VERIFIABLE CPD PAPER

Oral Medicine CLINICAL

Functional neurologic disorder as a rare complication

of dental local anaesthetics: two contrasting cases
Alastair Goss1

Key points
To provide knowledge that systemic adverse Outlines the responsibilities of the dentist who Suggests medical management of these systemic
reactions can occur following dental local performed the injection. reactions.
anaesthetic injection.

Abstract
Adverse reactions to dental local anaesthetics are fortunately rare. However, when they occur, they can be severe and
debilitating to the patient. Adverse reactions may be either prolonged anaesthesia, with or without dysaesthesia, or
systemic reactions. Although these systemic reactions are commonly thought to be allergies, this is rarely the case.
Much more commonly, these adverse systemic reactions are either cardiovascular or from the central nervous system.
This paper describes two contrasting cases of functional neurologic disorder which illustrates the consequences and
appropriate management. The responsibilities of the dentist who injected the local anaesthetic are outlined.

Introduction treatment. This has been summarised in Box 1. The treating dentist liaised with the hospital
Most are acute and if correctly managed will staff who were uncertain as to the nature of the
Fortunately, adverse reactions to dental local resolve promptly. One central nervous system reaction. Jointly, they contacted the author for
anaesthetics are rare. However, when they condition which may continue is characterised advice on how to proceed.
occur, they can be severe and debilitating to the as a functional neurologic disorder (FND). The patient was discharged from hospital
patient and they require appropriate action by FND is described as ‘a medical condition in on antihypertensives and antineuralgics for
the dentist involved. Adverse reaction to dental which there is a problem with the functioning the continued peripheral burning sensations.
local anaesthesia may be either alteration of the nervous system and how the brain and On advice, a specialist physician review was
in sensation to the involved nerve1,2 or be body send or receive signals, rather than a arranged. Allergy testing was performed at
systemic.3 structural disease process such as multiple one month, negative to all the local anaesthetic
In a review of severe systemic reactions sclerosis or stroke’. FND can encompass a wide agents used.
reported to the Office of Product Review overlap with other problems, such as chronic Neurologic review was negative for
of the Therapeutic Goods Administration pain and fatigue.4 multiple sclerosis and other neurologic
of Australia, the most common reactions This paper described two cases of FND with conditions and a diagnosis of FND was
were syncope (27%), central nervous system different management and outcomes. made. The peripheral burning sensations
(16%) and cardiovascular system (9%). True persisted for several months but settled with
allergy was very rare (1%), although often, Case 1 pregabalin twice daily and amitriptyline at
the reporting dentist and patient thought night. The patient has since fully recovered
the adverse reaction was an ‘allergy’. The key A 60-year-old, otherwise fit and well and had further routine dental treatment
with these systemic reactions is to promptly woman, living in rural South Australia, had with lignocaine local anaesthetic without
recognise and arrange appropriate first line a mandibular block with lignocaine 2% with problems.
1:80,000 adrenaline followed by an infiltration
of articaine 4% with 1:100,000 adrenaline for Case 2
1
Emeritus Professor of Oral and Maxillofacial Surgery,
restoration of a molar in 2020. She suffered
Oral and Maxillofacial Surgery Unit, Faculty of Health and
Medical Sciences, The University of Adelaide, Adelaide, immediate burning sensations in the scalp, The patient was a fit and well, 55-year-old
South Australia. face, hands and feet but no rash. She collapsed woman, resident in Northern England, with no
Correspondence to: Alastair Goss
Email address: [email protected] and was taken by ambulance to a peripheral previous history of psychological disturbance
Refereed Paper.
hospital. She had marked hypertension which or epilepsy and with an active business career.
Submitted 30 March 2023 was promptly controlled with antihypertensive In June 2020, she presented to the dentist with
Revised 12 August 2023 medication. She continued to be confused but toothache in the right mandibular first molar.
Accepted 22 August 2023 had a normal brain computerised tomography The area was anaesthetised with prilocaine
https://doi.org/10.1038/s41415-023-6690-z
(CT) scan and electrocardiogram (ECG). 3% with felypressin 0.03 international units/

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© The Author(s) under exclusive licence to the British Dental Association 2024.
 CLINICAL Oral Medicine

ml, later supplemented with 4% articaine

with 1:100,000 adrenaline. The tooth was Box 1 Actions in the event of systemic reactions to dental local anaesthetics
uneventfully removed but ten minutes later, 1. Seek urgent medical advice (full work up, including CT/MRI, ECG, blood tests)
the patient collapsed into semiconsciousness 2. Seek expert advice concerning adverse reactions to dental local anaesthetics
with a seizure in the dental clinic car park. 3. Specialist medical investigations (allergy, cardiovascular, neurologic)
Another dentist from the practice came out 4. Medical treatment as indicated (antihypertensives, antineuralgics, antidepressants)
to the car park and an ambulance was called. 5. Monitor
Paramedics stabilised her, but as the COVID- 6. If further dental treatment indicated:
19 pandemic was at its height, did not take her º Be fully aware of the history and don’t dismiss
to hospital. However, over the next few days, º Review results of medical investigations
she suffered hypertension, multiple seizures, º Preventative management by frequent dental review rather than await emergencies
weakness and loss of consciousness, so was º Use single LA agent based on allergy testing.
hospitalised. The staff doctors were unsure
as to what it was, but the patient was briefly
seen by a neurologist. A diagnosis of FND twice daily. She was also put on an NHS At 36 months after the main incident and
was made. Category 2 waiting list for allergy outpatients. 48 months after the initial event, the patient
Her treating dentist denied any responsibility She was advised that the current wait time was remains incompletely investigated and thus at
and her general medical practitioner (GP) was two years. risk if further LA is required. She continues to
unsure what had happened. Antihypertensives At six months, after the 2020 event, as the live with symptoms of FND and continues to
were prescribed to normalise her blood seizures continued, the author facilitated a be on 250 mg pregabalin twice daily.
pressure. telehealth review with a London-based oral
The patient on her own initiative did a medicine specialist. Allergy testing to the Discussion
literature search, found some papers,1,2,3 and local anaesthetic was suggested, but with the
contacted the author via Zoom and email. She COVID-19 lockdown, it was not possible, FND is reported to occur in a range of
was advised that she had had a known but as the patient lived in North West England. anaesthetic procedures, both local and
rare complication and advised what would be Helpful preventative dental advice was general.5 It has also been previously reported
done in Australia. This advice however did not provided. following dental local anaesthesia.6 Several
consider the effect of the COVID-19 pandemic The symptoms progressively lessened but possible mechanisms have been suggested,
on the NHS. still lingered in the background. This resulted mainly excessive dose or intravascular
At the initial Zoom telehealth consult, it was in a change in lifestyle and her business. injection. There is often a strong implication
established that this was not the first such event. At two years, she was having some beauty of a psychogenic reaction. All of these types
In January 2019, the same tooth had required treatment in preparation for her daughter’s of FND are of short duration as the overdose
endodontic treatment, but this attempt had wedding. The therapist applied an unknown is eliminated or the underlying psychological
failed, hence the extraction in 2020. Here, cream to her face before injecting. There was abnormality is revealed.
2% lignocaine with 1:80,000 adrenaline, later an immediate adverse reaction where she Both the cases presented in this paper
supplemented by 4% articaine with 1:100,000 started to feel paralysis in her tongue, her lasted for a long time, indeed, in Case 2, the
adrenaline, was used in 2019. After an hour, lips drooped and she suffered slurred speech. symptoms are still unresolved after four years.
she became hypertensive, confused and with This was much less powerful but similar to Neither of these patients had underlying
left-side weakness. Emergency services were the seizures she had first experienced. The psychologic, allergic or epileptic conditions
called but despite having the classic features therapist then advised that the cream was in before the injection. The burning sensations
of a transient ischaemic attack/cerebrovascular fact a 7% lignocaine ointment which had been in Case 1 began following known dermatomes
accident (CVA), was not investigated or imported from China. and in Case 2, the seizures were documented
admitted. Not long after the beauty treatment, the NHS by ECG.
Ongoing slurring of speech became Allergy Clinic contacted her by Telemed. After These two cases illustrate the spectrum of
problematic and the patient insisted her GP a full discussion, including the recent reaction FND. The first case, which may have been less
refer her to a neurologist, who dismissed her to 7% lignocaine, they advised that they could severe, was swiftly and effectively managed
symptoms and thought that menopause was a see ‘no indication’ from allergy testing. and did settle after a few months. Although
more likely factor. Acting on the London oral medicine it occurred in a time of COVID-19 shutdown
In 2020, she told the treating dentist of this specialist’s advice, she was referred to a local in Australia, her symptoms were recognised
event, but again the history was dismissed. The teaching hospital clinic for a dental check, as severe, so she was admitted to hospital
multiple seizures, up to 12 per day, continued but they couldn’t see the indication for and promptly had full investigations and
for 12 months and thereafter, a few a week for treatment, so she was declined. She returned specialist management. The second case was
a further year. These were triggered by loud to her original dental clinic and had a filling not identified as severe, despite having the full
noise and stress. performed without local anaesthetic (LA). This features of a CVA, followed by multiple seizures
After some months, a neurologist did not exacerbate her neuralgic symptoms or with varying degrees of unconsciousness.
commenced a low dose of 100 mg pregabalin result in seizures, but it was, however, a painful There seemed an unwillingness to accept that
twice daily, subsequently increased to 250 mg experience. this could be the result of a dental procedure.

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 Oral Medicine CLINICAL

It is accepted, however, that the effect of the (conversion reaction).7,8 Certainly, both of Ethics declaration
COVID-19 pandemic in the UK had profound these patients were psychologically sound, The author declares no conflicts of interest.
adverse effects on the NHS.5 well-functioning people before the adverse Written consent to publish has been obtained from
B oth cases initially had marked reaction. It is more likely that there is an the patients in Cases 1 and 2.
hypertension, which may be a response to alteration in chemical brain functioning which
the adrenaline. Certainly, in Case 1, testing causes the abnormal neuralgic symptoms.6 This References
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