 An “anesthetic complication” may be

defined as any deviation from the

normally expected pattern during or
after the securing of regional analgesia.
CLASSIFICATION
LOCAL COMPLICATIONS SYSTEMIC COMPLICATIONS

 Needle breakage  Adverse drug reaction

 Paresthesia  Overdose
 Facial Nerve Paralysis
 Allergy
 Trismus
 Soft-tissue injury  Malignant hyperthermia
 Hematoma
 Pain on injection
 Burning on injection
 Infection
 Edema
 Sloughing of tissues
 Post anaesthetic intraoral lesions
NEEDLE BREAKAGE
CAUSES
 Weakening of the dental needle by
bending it before its insertion into the
patient’s mouth.
 Sudden unexpected movement by the
patient as the needle penetrates muscle
or contacts periosteum.
 Smaller needles are more likely to break
than larger needles.
 Needles may prove to be defective in
manufacture.
PROBLEM
 A Magill intubation forceps or hemostat
can be used to grasp the visible
proximal end of the needle fragment
and remove it from the soft tissue.
PREVENTION
 Use long needles for injections requiring
penetration of significant (>18mm) depths of
soft tissues.
 Do not insert a needle into tissues to its hub.
 Do not redirect a needle once it is inserted into
tissues.
 Excessive lateral force on the needle is a factor
in breakage.
 Withdraw the needle almost completely
before redirecting it.
MANAGEMENT
 When a needle breaks, remain calm, do not
panic, instruct patient not to move, if the
fragment is visible, try to remove with a small
hemostat or a Magill intubation forceps.
 When the needle breaks, consideration should
be given to its immediate removal under the
following conditions: * The needle is superficial
and easily located through radiological and
clinical examination, removal by a competent
dental surgeon is possible. *
 The needle is located in deeper tissues or hard
to locate, it should be permitted to remain
without an attempt at removal.
PARESTHESIA
CAUSES
 Trauma to any nerve.
 Injection of a LA solution contaminated by alcohol
or sterilizing solution near a nerve produces
irritation, resulting in edema and increased pressure
leading to paresthesia.
 Trauma to the nerve sheath can be produced by the
needle during injection.
 Injection of a needle into a foramen, as in the II
division nerve block via the greater palatine foramen,
also increases the likelihood of nerve injury.
 Hemorrhage into or around the neural sheath.
 Bleeding increases pressure on the nerve, leading to
paresthesia.
PROBLEM
 Persistent anesthesia can lead to self-
inflicted injury.
 Biting or thermal or chemical insult can
occur. Sense of taste also may be
impaired when the lingual nerve is
involved.
PREVENTION
 Strict adherence to injection protocol and
proper care and handling of dental
cartridges.

MANAGEMENT

 Resolves within 8 weeks without treatment.

FACIAL NERVE PARALYSIS
CAUSES
 Commonly caused by the introduction
of local anesthesia into the capsule of
the parotid gland, which is located at the
posterior gland, which ramus, clothed by
the medial pterygoid and masseter
muscle.
PROBLEM
 Loss of motor function to the muscles
of facial expression produced by
deposition of local anaesthetia is
normally transitory. Unilateral paralysis.
 Unable to voluntarily close one eye.
 Protective lid reflex of eye is abolished.
 Winking and blinking becomes
impossible.
PREVENTION
 Adhere to protocol Needle tip in
contact with bone

MANAGEMENT

 Reassure the patient. An eye patch

should be applied to the affected eye
until muscle tone returns.
TRISMUS
CAUSES
 Trauma to muscles or blood vessels in the infra
temporal fossa
.
 Local anesthesia solutions into which alcohol or
cold sterilizing solutions have diffused, produce
irritation of tissues potentially leading to
trismus.

 Local anesthesia has slight mycotoxic properties

leading to a rapidly progressive necrosis of the
exposed muscle fibres
 Hemorrhage.
 Low grade infection after injection.
 Multiple needle penetrations.
 Excessive volume of solution deposited into a
restricted area produces distention of tissues
which leads to trismus

PROBLEM

 Pain produced by haemorrhage leads to

muscle spasm and limitation of movement.
PREVENTION
 Use a sharp sterile disposable needle.
 Proper care and handle dental LA
cartridges. Use aseptic technique.
 Practice atraumatic insertion and
injection techniques.
 Avoid repeated injections and multiple
injections.
 Use minimum effective volumes of LA.
 MANAGEMENT
 Heat therapy, warm saline rinses,
analgesics and muscle relaxants to
manage the initial phase of muscle
spasm.
 Initiate physiotherapy consisting of
opening and closing of mouth as well as
lateral excursions of the mandible for 5
minutes every 3 to 4 hours.
 Chewing gum.
SOFT-TISSUE INJURY
CAUSE
 Primary cause – soft tissue anesthesia
lasts longer than pulpal anesthesia.

PROBLEM
 Trauma can lead to swelling and
significant pain when the anaesthetic
effects resolve.
 PREVENTION
 LA of appropriate duration should be selected.
 Cotton rolls can be placed between the lips
and teeth if they are still anaesthetized.
 Secure the roll with dental floss wrapped
around the teeth.
 Warn the patient and guardian against eating,
drinking hot fluids and biting on the lips and
tongue to test for anesthesia.
 A self adherent warning sticker may be used in
children.
MANAGEMENT
 Analgesics for pain.
 Antibiotics.
 Lukewarm saline rinse to aid in
decreasing swelling.
 Petroleum jelly or other lubricant to
cover a lip lesion and minimize irritation.
HEMATOMA
CAUSE
 Arterial or venous puncture after PSA or
IANB.
 Blood effuses from vessels until
extravascular exceed intravascular
pressure or clotting occurs.
 IANB hematoma – visible intra orally.
 PSA hematoma – visible extra orally.
PROBLEM
 Bruise, trismus and pain. Swelling and
discoloration subside within 7 to 14
days.
PREVENTION
 Knowledge of the normal anatomy
involved in the proposed injection.
 Modify the injection technique as
dictated by the patient’s anatomy.
 Use a short needle for the PSA nerve
block to decrease the risk of hematoma.
 Minimize the number of needle
penetration into tissue.
 Never use a needle as a probe in tissues.
MANAGEMENT
 Immediate: direct pressure should be
applied to the site of bleeding for not
less than 2 minutes.
 Subsequent: analgesics, ice Tincture of
time is the most important element in
managing a hematoma.
PAIN ON INJECTION
CAUSES
 Careless injection technique and callous
attitude.
 Using a needle which is dull due to
multiple injections.
 Rapid deposition.
 Needles with barbs.
PROBLEM
 Increase in patient anxiety.
 Sudden unexpected movement.
 Increasing the risk of needle breakage.
PREVENTION
 Adhere to proper techniques of injection
both anatomical and psychological.
 Use sharp needles.
 Use topical anaesthetic properly before
injection.
 Use sterile local anaesthetic solutions.
 Inject local anaesthetic slowly.
 Be certain that the temperature of the
solution is correct.
MANAGEMENT
 No management is necessary
BURNING ON INJECTION
CAUSES
 pH of the solution.
 Rapid injection.
 Contamination of cartridge.
 Solutions warmed to normal body
temperature.
PROBLEM
 Tissue may be damaged with
subsequent development of other
complications such as post anaesthetic
trismus, edema or possible paresthesia.
PREVENTION
 Ideal rate of injecting : 1ml/min.
Cartridge of anesthetic should be stored
at room temperature in a container or in
a container without alcohol or other
sterilizing agents.
MANAGEMENT
 Formal treatment is not indicated.
 In few situations in which post injection
discomfort, edema or paresthesia
becomes evident, management of a
specific problem is indicated.
INFECTION
CAUSES
 Contamination of a needle before
administration of the anaesthetic.
 Improper technique in the handling of
the LA equipment and improper tissue
preparation for injection.
PROBLEM
 Low grade infection.
 Trismus.

PREVENTION

 Use sterile disposable needles.

 Properly care for and handle needles and dental
cartridges
 Properly prepare the tissues before penetration.
MANAGEMENT
 Immediate treatment used to manage
trismus : Heat therapy, analgesic, muscle
relaxant and physiotherapy.
 Penicillin V(250mg) 500mg immediately
and 250mg x4 times a day. Erythromycin
as a substitute.
EDEMA
CAUSES
 Trauma during injection.
 Infection.
 Allergy.
 Hemorrhage.
 Injection of irritating solutions.
 Hereditary angioedema.
PROBLEM
 Pain.
 Dysfunction.
 Angioneurotic edema.
PREVENTION
 Properly care for and handle the LA
armamentarium.
 Use atraumatic injection techniques.
 Complete an adequate medical
evaluation of the patient before drug
administration.
MANAGEMENT
 Allergy induced edema: intra muscular
and oral histamine blocker
administration.
 Compromises breathing: Supine
position, basic life support, epinephrine,
histamine blocker, corticosteroid.
 Total airway obstruction:
Cricothyrotomy.
SLOUGHING OF TISSUES
CAUSES
 Epithelial desquamation : Application of
a topical anaesthetic to the gingival
tissues for a prolonged period.
 Heightened sensitivity of the tissues to a
LA. Reaction in an area where a topical
has been applied.
 Sterile abscess: Secondary to prolonged
ischemia . Develops on a hard palate.
PROBLEM
 Pain.
 Infection.

PREVENTION

 Topical anaesthetics : Allow the solution to

contact mucous membrane for 1 to 2 mins.
Nor ephinephrine : produces ischemia.
MANAGEMENT
 For pain , analgesics (aspirin and
codeine). Topically applied ointment.
(Orabase).
POST ANAESTHETIC
INTRAORAL LESIONS
CAUSES
 Recurrent aphthous stomatitis or Herpes
simplex Trauma to tissues by a needle.


PROBLEM

 Acute sensitivity in ulcerated area. Risk

of secondary infection is minimal.
PREVENTION
 Antiviral drugs

 MANAGEMENT

 Reassure the patient. Topical LA.

Orabase without Kenalog. Tannic acid
prep (Zilactin).
ADVERSE DRUG REACTION
CAUSES OF ADVERSE DRUG
REACTIONS
TOXICITY CAUSED BY DIRECT EXTENSION OF THE USUAL
PHARMACOLOGICAL EFFECTS BY DRUG
 1. Side effects
 2. Overdose
 3. Local toxic effects

TOXICITY CAUSED BY ALTERATION IN THE RECIPIENT OF THE

DRUG
 1. A disease process
 2. Emotional disturbance
 3. Genetic aberrations
 4. Idiosyncrasy

TOXICITY CAUSED BY ALLERGIC RESPONSES TO THE DRUG

 Overdose reactions are those clinical signs and
symptoms that manifest as a result of an absolute or
relative over-administration of a drug.

 Allergy is a hypersensitive state acquired through

exposure to a particular allergen, re-exposure to
which brings about a heightened capacity to react.

 Idiosyncrasy , the third category of true adverse

drug reactions, is a term used to describe a
qualitatively abnormal, unexpected response to a
drug, differing from its pharmacological actions and
thus resembling hypersensitivity.
CLINICAL ALLERGY OVERDOSE
RESPONSE
Dose Non-dose related Dose related

Signs & symptoms Similar regardless of Related to

allergin pharmacology of
drug administered
Management Epinephrine, Specific for drug
histamine blockers administered
LOCAL ANAESTHETIC OVERDOSE
PREDISPOSING FACTORS
Patient factors: Drug factors

 Age  Vaso-activity
 weight  Concentration
 Dose
 other drugs
 route of administration
 sex  rate of injection
 presence of disease  vascularity of injection
 genetics site
 mental attitude  presence of
vasoconstrictors
CAUSES
 Unusually slow biotransformation.
 Slowly elimination
 Large dose Unusually rapid absorption .
 Inadvertent intravascular administration.
MANAGEMENT
 Position
 Airway
 Breathing
 Circulation
 Definitive care
LOCAL ANAESTHESIA OVER
DOSE
 CONSCIOUS  UNCONSCIOUS
PATIENT PATIENT
Semi sitting Horizontal
position position
Reassure & Assess ABC
Hyperventilate Activate EMS
Give Diazepam
10mg slowly if
needed.
 PATIENT HAS LA
INDUCED SEIZURE

STOP ALL
ADMINISTRATION OF LA ADMINISTER O2 ENSURE
THAT IV IS RUNNING

ENSURE AIRWAY OF THE

PATIENT IS PATENT &
DONOT INSERT A BITE
OXYGENATING &
VENTILATING BLOCK

RESOLVED

ADMINISTER
MIDAZOLAM 0.05mg-
0.1mg/kg

RESOLVED

ADMINISTER
PHENOBARBITAL
20mg/kg
ALLERGY
DEFINITION
 It is a hypersensitive state, acquired
through exposure to a particular
allergen, re-exposure to which produces
a heightened capacity to react.
 GELL & COMB’S CLASSIFICATION OF ALLERGIC DISEASES
ANAPHYLACTIC
I
CYTOTOXIC
II
IMMUNE COMPLEX
III
CELL MEDIATED / TUBERCULIN TYPE RESPONSE
IV
IDIOPATHIC
V
TYPE MECHANISM PRINCIPAL TIME OF EXAMPLE
ANTIBODY REACTION
I Anaphylactic Anaphylaxis
(immediate, IgE Sec to min Allergic rhinitis
antigen- Hay fever
induced, Utricaria
antibody
mediated)
II Cytotoxic ( anti Transfusion
membrane) IgG ------ reactions
IgM Good pauster’s
syndrome
Haemolytic
anaemia
III Immune IgG 6 to 8 hours Serum
complex sickness
(serum Viral hepatitis
sickness like)
IV Cell mediated ------ 48 hours Graft rejection
Infective
granulomas
Chronic
 CAUSES: The primary cause of allergic reactions is a
specific antigen-antibody reaction, where the
patient has been previously sensitized to a particular
drug or a chemical agent.

 SIGNS & SYMPTOMS: Skin rashes Utricaria Pruritis

Edema Erythema Wheezing

 PREVENTION: Proper pre-anesthetic evaluation:

Proper personal history , Interrogation into past
dental history and drug history

 MANAGEMENT: Antihistamines –
diphenhydramine (Benadryl) 20-50mg Epinephrine
0.5ml Administer O 2 , if necessary.
ANAPHYLAXSIS
MANAGEMENT
 Initial Therapy : 1. Stop Administration of
the Antigen and Minimize [Inhaled
Anaesthetics].
 2. Call for Help ; Stop Surgery.
 3. Endotracheal Intubation and 100%
O2.
 4. Volume Expansion – Leg Elevation.
 5. Adrenaline : 5-100 µg IV ;
 Closed Chest Cardiac Compressions.
 Secondary Therapy :
 1. Histamine 1 Receptor Antagonists :
Promethazine 50 mg IM.
 2. Histamine 2 Receptor Antagonists :
Ranitidine 50 mg IV.
 3. Catecholamine Infusions.
 4. Nebulization of Bronchodilators.
 5. Corticosteroids : Hydrocortisone 5 mg/kg
IV.
 6. Airway Evaluation before Extubation
 Any reaction to a LA agent or any other drug
that cannot be classified as allergic or toxic
reaction is often called as idiosyncrasy

 PREVENTION: Pre-anesthetic evaluation

Precautions to the patients from injuring Proper
and adequate pre-medication.

 MANAGEMENT: Supine position with legs

slightly elevated Maintenance of airway
Adequate O 2 supply Evaluate circulation
Administer parenteral fluids*
MALIGNANT HYPERTHERMIA
 Malignant hyperthermia Also known as
hyperpyrexia.
 Malignant hyperthermia (MH; hyperpyrexia) is
a pharmacogenic disorder in which a genetic
variant in the individual alters that person’s
response to certain drugs.
 Acute clinical manifestations of MH :
tachycardia, tachypnea, unstable blood
pressure, cyanosis, respiratory & metabolic
acidosis, fever, muscle rigidity & death.
 Mortality: 63% - 73%
EARLY SIGNS LATE SIGNS

 Inc end tidal co2  Cardiac arrest

 Skeletal muscle rigidity  DIC
 Muscle spasm  Myoglobnurea
 Tachycardia  Elevated temp
 Tachapnea  Hypo/hyper calcemia
 Sweating
 Metabolic & respiratory
acidosis
REFERENCES
 Handbook of local anesthesia – Stanley F
Malamed – 6th edition.
 Textbook of Oral & Maxillofacial Surgery-
Laskin Vol-1.
CONCLUSION
 ‘’ Donot Ever Panic, By Seeing The
Situation, Every Problem In The World
Have A Solution & Only Thing Is The
Method We Select To Overcome Is
Important’’