NEEDLE BREAKAGE

 CAUSES
 Sudden unexpected movement
 Smaller needle gauge
 Previously needle bent
 defective needles
 PREVENTION:
 Use larger gauge needle for injection . 25 gauge needle
for IANB, PSA nerveblock
 Use longer needle
 do not insert to hub
 do not bend needle
 do not redirect needle when in deep tissue
 MANAGEMENT
 When needle breaks and visible
 Be calm , don’t panic
 Keep the mouth open and place biteblock
 Remove the needle end with a small hemostat.
 When needle breaks and can’t be retrieved
 Calmly inform pt & relieve his fears, apprehension
 Don’t attempt to remove if not visible
 Refer the pt to SURGERY for consultation
: when needle breaks, can be retrieved
- if needle breaks and it is superficial, easily located
by X- ray & clinical examination
-
PAIN ON INJECTION

 Pain is prevented by following basic rules of

ATRAUMATIC injection
 CAUSES :
 Careless injection technique
 Multiple injection with the same needle
 Rapid injection
 Using a barbed needle
 PREVENTION :
 Proper injection technique
 Use topical anesthetic
 Use sharp needles
 Use sterile LA solution
 Inject LA slowly
BURNING ON INJECTION
 CAUSES
 pH of the solution
 Rapid injection
 Contamination of LA cartridge’
 Temperature of solution
 Sequelae – greater tissue damage with post-anesthetic
trismus, edema, paresthesia
 PREVENTION
 Slow injection at the rate of 1.8ml/min
 Proper care & handling of LA cartridge without
contamination
PERSISTENT ANESTHESIA/ PARESTHESIA
 Paresthesia is defined as persistent anesthesia or
altered sensation well beyond the expected duration of
anesthesia

 CAUSES :
 Trauma to nerve / nerve sheath by needle in IANB,
Greater palatine nerve block
 Contaminated LA – edema & pressure on the nerve . For
example-alcohol is neurolytic
 Bleeding around the nerve sheath.
 PROBLEM :
 Biting / thermal / chemical insult to soft tissues
 Loss of taste sensation
 Local anesthetics are NEUROTOXIC to some extent , so
use of lesser conc of LA is adviced
 For eg , use 2% instead of 4 %
 MANAGEMENT :
 Usually resolves within 8 weeks
 Re-assurance :
 Speak and explain that paresthesia is not uncommon &
persists for 2 months before resolution, sometimes it may last
for year or Longer.
 Examine and determine the degree and extent of paresthesia
and Record it on dental chart.
 Reschedule the appointment for every 2 months
 If sensory loss persists even after a year , the consult with
neurologist
 TRISMUS
 Prolonged tetanic spasm of jaw muscles by which
normal mouth opening is restricted.
 CAUSES:
 Trauma to muscles / blood vessels in the infratemporal
fossa
 Contaminated LA cartrige
 LA have Myotoxic properties – accidental IM inj leads to
necrosis of muscle fibers
 Hemorrhage – extravascular blood lead to muscle
dysfunction
  Low grade infection after injection
 Multiple needle penetrations
 Excessive LA deposited in a small area, eg IANB
 PREVENTION:
 Use sterile sharp disposable needle
 Aseptic inj technique-cleanse the site of inj with
antiseptic soln
 ATRAUMATIC INJECTION TECHNIQUE
 Always use minimal amount of LA
 TRISMUS IS NOT ALWAYS PREVENTABLE
FACIAL NERVE PARALYSIS
 CAUSES:
 Transient facial paresis – deposition of LA in to
capsule/deep lobe of parotid gland , for eg , IANB /
VAZIRANI AKINOSI technique-.
 PROBLEM:
 Loss of motor function to muscles of facial expression
 Drooping of lip, inability to close eye, winking,
blinking.
 PREVENTION:
 Follow proper IANB, Vazirani akinosi injection
Technique
  Do not Over-insert the needle beyond 25 mm in
Vazirani inj technique
 Do not inject LA unless needle contacts the bone in
IANB
 MANAGEMENT :
 Reassurance:
 Eye protective patch, remove contact lens
 Record the incident on chart
SOFT TISSUE INJURY
 Self inflicted trauma to lips & tongue
 CAUSE :
 Prolonged soft tissue anesthesia
 PREVENTION:
 Cotton roll is placed between lips & teeth
 Warn the pt about eating, drinking , biting
 Adhesive warning sticker is placed on forehead
 “ WATCH ME, MY LIP AND CHEEKS ARE NUMB”
HEMATOMA
 The inadvertent nicking of a blood vessel, either artery
or vein during an injection of L.A
 CAUSES :
 Nicking of the vein may or may not cause
hematoma
 The density y of the tissue surrounding the injured
vessel will be a determining factor
 SEQUELAE :
 Pain , swelling & trismus
 Swelling subsides in 7 – 14 days
 PREVENTION :
 Know the normal anatomy of the proposed injection
 greater risk of hematoma in PSA nerve block & IANB
 Modify the injection technique -lessen the penetration
of posterior superior alveolar nerve block in pt with
smaller facial characteristics
 Never use needle as probe in tissues
 MANAGEMENT :
 IMMEDIATE :
 When swelling becomes evident Direct pressure should be
applied to the site of bleeding for not less than 60 sec. against
bone
 Inferior alveolar nerve block
 Pressure is applied to the medial aspect of the
mandibular ramus.
 Infra-orbital nerve block
 Pressure in applied to the skin directly over the infra-
orbital foramen
 Posterior superior alveolar nerve block
 the largest & most esthetically unappealing hematoma
 swelling appears on the side of the face progressing
inferiorly & anteriorly toward the lower anterior region
of the cheek.
 Bleeding normally halts when external pressure of blood
vessel exceed the internal one.
 Digital pressure can be applied to the soft tissues in the
muco-buccal fold as far as it can be tolerated by the pt.
without gagging.
 Apply pressure in a medial & superior direction
INFECTION
 extremely rare since the introduction of sterile,
disposable needles.

 Causes :
 contamination of the needle prior to administration of
the L.A.
 Improper technique in the handling of the L.A
armamentarium & improper tissue preparation for
injection.
 PREVENTION :
 Use disposable syringe

 Recap the needle when not in use to avoid

contamination through contact with non sterile
surfaces.
 Avoid multiple injections with the same needle.

 Properly prepare the tissues prior to penetration; dry

the tissue & apply topical anesthesia
SLOUGHING OF TISSUES
 Prolonged irritation to the soft tissue may lead to
epithelial desquamation & sterile abscess

 CAUSES :
 Epithelial desquamation
 Application of topical anesthesia agents to the gingival tissues for a
long period of time
 heightened sensitivity of tissues L.A

 Sterile abscess:
 secondary to prolonged ischemia resulting from the use of L.A
with vasoconstrictors
 PREVENTION :
 use topical anesthesia as recommended ; Allow the solution to contact mucous
membrane for 1-2 min
 When using vasoconstrictors , don't employ overly concentrated solutions
 MANAGEMENT :
 Symptomatic
 For pain - analgesic (aspirin , codeine 7 a topically applied
ointment such as Ora-base
 Epithelial desquamation will resolved within few days
 Sterile abscess run for 7-10 days
POST ANESTHETIC INTRAORAL LESIONS
 Recurrent apthous stomatitis &/or herpes simplex can
develop intraorally following L.A injection or any
traumatic insult
 CAUSES :
 Trauma to tissues by needle, L.A , cotton swab,
reactivate the latent form of the disease process that has
been present in the tissue prior to the injection
 PREVENTION :
 Extra oral herpes simplex can be prevented or minimizing its
manifestation if it's in its prodromal phase
 Topical acyclovir
 MANAGEMENT :
 topical anesthetic viscous lidocaine
 A mixture of equal amount of diphenhy dramine &
milk magnesia
EDEMA
 * Edema is the swelling of tissues

 CAUSES :
 Trauma during injection
 Infection
 hemoorhage
 Allergy
 Angioedema
 PROBLEM :
 Pain
 Angioedema of lip , tongue , larynx - Airway obstruction
 MANAGEMENT :
 Traumatic injection - resolve within 3 days – symptomatic Rx
 Hemorrhage – resolves in 2 weeks
 Infection - Antibiotics
 Allergy :
 Epinephrine 0.3 mg IM or IV
 Antihistamine IM or IV
 Corticosteroid IM or IV
 medical assistance
 Basic cardiac life support
 Crico-thyrotomy / tracheostomy