Local Complications
Content
LOCAL COMPLICATIONS
I. Attributed to the Solution Used Overdose/Toxicity
Cause
Management
Prevention
-Too large dose of LA -Unusually rapid absorption of drug (intravascular injection) -Unusually slow biotransformation, elimination or redistribution
-Based on severity of reaction -Mild & transitory reaction require little or no specific -Severe reaction require prompt therapy (Convulsions- diazepam, Phenobarbital, succinylcholine)
Allergic Reactions
- specific antigen-antibody reaction in a patient who had previously been sensitized to a particular drug
-According to the symptoms present -ABC -Antihistamine -Isoproterenol/epinephrine inhalants -Epinephrine
-Administer the smallest clinical effective dose -Deposit solution very slowly (1 cartridge/min) -Use most effective weakest concentration -Aspirate before injection -Use solution with vasoconstrictor -Pre-anesthetic evaluation -Consider the patient allergic to the drug until proven otherwise -Do not test the patient yourself
II. Attributed to Needle Injection Syncope
- Anxiety + redistribution of blood to the skeletal muscles - Pooling of blood in the extremities leads to decrease in venous return to the heart and cardiac output -Weakening of needle by bending it before insertion -Sudden movement by the patient as the needle penetrates the muscle or the periosteum -Smaller needles are more likely to break -Defective manufacturing of needles
-Place the patient in semi-reclining position: lower chair back, elevate legs slightly
-Detect early symptoms (weakness, light headedness, dizziness, nausea, pallor, palpitation, white knuckles) -Relief of anxiety
Needle breakage
-Keep calm -Instruct patient not to move and keep mouth open -Remove fragment if visible (use hemostat) -Do not attempt to remove if fragment is deeper in location and is difficult to locate -Refer to oral maxillofacial surgeon -Inform patient and record incident on the chart
-Use larger needle (at least gauge 25) for techniques requiring soft tissue penetration -Never force needle against resistance - Use long needles for penetration of greater soft tissue depth -Never insert the needle up to its hub -Once the needle is inserted into tissues, withdraw it almost completely before redirecting it -Strict adherence to injection protocol -Proper care and handling of dental cartridges
Paresthesia
-Trauma to the nerve sheath by the needle during insertion -Injecting contaminated LA solution causing nerve irritation -Hemorrhage in and around the nerve sheath causes increased pressure on the nerve -Controversy that says there is higher incidence of paresthesia with the use of Articaine - Poor technique – introduction of LA into capsule of parotid gland
- Usually resolves approximately within 8 weeks -If sensory deficits persist after 1 yr, consult neurologist -Recall patient every month or every 2 months as long as the sensory deficit persists -Avoid administration of anesthesia into the same region
Facial Nerve Paralysis
Trismus
Dentistry 151- Javier
- Irritating LA solution -Trauma to muscles or blood vessels in the infratemporal fossa
- Reassure the patient that condition is transient - Defer further dental care at this appointment - No contraindication for reanesthetizing to achieve mandibular anesthesia -Prescribe muscle relaxant for initial phase of muscle spasm -Prescribe analgesic for managing
- Follow protocol with IAN - A needle tip should contact bone before depositing anesthesia - When utilizing Akinosi technique, over insertion of needle more than 25 mm should be avoided. -Use sharp, sterile, disposable needle -Proper care for and handle of
-Hemorrhage -Low grade infection within muscle
pain and inflammation - Application of warm moist compress -Let the patient rinse with warm saline solution -Physiotherapy by opening, closing and lateral excursions of the mandible -Antibiotics -Avoid dental treatment until symptoms resolve -Apply pressure on the area of insertion -Will resolve within 7-14 days, with or without treatment -Manage associated conditions as they occur -Cold/warm compress -No management necessary -Steps should be taken to prevent recurrence of pain associated with injection of LA
dental cartridge -Discard contaminated needles immediately -Practice atraumatic insertion and injection techniques -Avoid of repeat injections and multiple insertions into the same area -Use of minimum effective volume of LA
Hematoma
-Improper technique
-Knowledge of normal anatomy -Modify injection technique as dictated by patient’s anatomy
Pain on Injection
- Careless injection technique -Dull needle -Rapid deposition of anesthetic solution -Needles with barbs
-Atraumatic injection technique -Use of topical anesthetic before needle insertion -Use sharp needles -Avoid multiple injections -Use of sterile LA agents -Inject slowly -Avoid excessive volumes -Use solutions close to body temperature - Use sterile disposable needles -Properly care for and handle needles & cartridges -Properly prepare tissues before penetration
Infection
Edema
-Contamination of needle before administration of anesthetic solution -Improper handling of LA equipment and improper tissue preparation for injection -Injecting solution into infected area -Trauma during injection -Infection -Hemorrhage -Injection of irritating solution
-Heat and analgesic -Muscle relaxant if needed -Antibiotics
-Prescribe analgesics for pain -Antibiotic therapy
-Properly care for and handle the LA armamentarium -Atraumatic injection technique -Complete an adequate medical evaluation of the patient before drug administration
SYSTEMIC COMPLICATIONS
Cardiovascular Status
Angina Pectoris
Symptoms
-chest pain (substernal) -sudden onset of heavy weight on chest -pain radiating to the left arm
Management
-Nitroglycerin tablets (0.6 mg)sublingual -Amyl nitrite ampule – broken near nose
Remarks
-Due to transient ischemia of heart muscle -Short duration -Usually following stress (exertion, excitement or sudden exposure to cold environment) -Atherosclerosis is an underlying factor
Coronary Occlusion
Dentistry 151- Javier
-chest pain -feeling that the chest is about to
-Administer oxygen (because coronary artery is blocked)
Congestive Heart Failure
explode -may also radiate to left arm up to the left jaw -digestive crisis (long duration) -mild chest pain -shortness of breath -fatigability -ankle edema in the afternoon -coughing spells (in the morning) -Tachycardia (over 100 bpm) -Bradycardia (below 40 bpm)
-Morphine (8-15 mg) or meperidine (50-100 mg) IM to relieve pain
-Administer oxygen - Morphine (8-15 mg) or meperidine (50-100 mg) IM to relieve pain
-Slow progressing
Cardiac arrhythmias
-Depends on symptoms -Rest -Oxygen -Stress management protocol
-Heartbeat having no rhythm Normal heart beat: 60 to 80 bpm
Hypertension
-not a disease, but a symptom
Respiratory Status
Emphysema
-coughing spell (asthma-like attack) -Bronchodilator sprays (1:1000 epinephrine or 1:200 isoproterenol) -Late appointments- more time for patient to clear trachea bronchial tree since coughing spells usually occur in the morning -If the foreign material is still in pharynx, patient should be instructed to hold the mouth open and refrain from swallowing. Attempt to retrieve foreign body with a suitable instrument. Induce patient to cough forcefully to expel object. -If foreign material gets lodged at the glottal opening, take the patient to the nearest hospital. -Never hesitate to perform cricothyrotomy -If foreign object gets lodged at the main bronchus, tell the patient what happened and take him/her to hospital - Abnormal dilation of the alveoli and the distal bronchioles with associative destructive changes -May be acute or chronic
Mechanical Respiratory Embarrassment
Nervous System Disorders
Epilepsy
a. Petit mal – loss of consciousness, lasts only a short while, patient reacts w/o aftereffects b. Grand mal – excessive muscular activity, loss of consciousness, muscle rigidity, after the attack, patient may exhibit headache, vomiting and muscle soreness - nausea - dizziness - unconsciousness -Maintain patent airway -Make sure patient is breathing adequately -Prevent any bodily injury during convulsion. Put patient on the floor. -Before impending attacks, barbiturates may be given to the patient for calming effects
Syncope
- ventilation -oxygen
Metabolic Diseases
Diabetes
Dentistry 151- Javier
a. Diabetic coma – may be due to hypoglycemia, hyperglycemia or
- Slow onset, no necessary treatment
Cholinesterase inactivity (Plasma cholinesterase deficiency)
ketoacidosis, thirsty, nausea, shortness of breath, warm dry skin, sleepiness b. Insulin shock – due to hypoglycemia, occurs only in patients injecting insulin, hunger, weakness, irritability, disorientation, cold perspiration - no overt sign
-Lumps of sugar -Cola drink -Glucagon hydrochloride (0.5 to 1.0 mg) with 5% dextrose solution -Barbiturates -Emergency occurs when LA used is an ester type
Endocrine Malfunction
Hypothyroidism
-cretinism -myxedema - mentally dull -drowsy -fatigued -tremors -exophthalmia -intolerance to heat - sweating - increased BMR -increased pulse rate -hypertension - adrenal shock -hypotension -Managed accordingly -lower basal metabolic rate makes the patient more prone to toxic drug reactions
Hyperthyroidism
- prevention -sedation -stress reduction protocol -oxygen -cold packs – to normalize body temp
Adrenal insufficiency
- support blood circulation -Hydrocortisone succinate (100200mg) -Dexamethasone (4 – 12mg) -Oxygen
-Usually occurs in patients who have been taking steroid hormones or ACTH and have discontinued drug sometime before a traumatic or stressful experience
CPR (Cardiopulmonary resuscitation) A= airway Establish a patent airway Remove prosthesis, food, saliva, etc. that are obstructing airway Tilt the victim’s head backward (head extension) to its fullest The neck should NOT be arched Lift the chin while tipping the head backward o These maneuvers lift the tongue away from the posterior pharyngeal wall B= breathing Deliver 4 successive air blows on the mouth of the patient o The brain can only last 7 to 15 mins without oxygen and it will lead to permanent brain damage o Brain oxygen supply is dependent on the pumping of the heart Pinch nose to prevent air leakage Ensure full mouth coverage One can readily determine if the air is reaching the patient’s lungs by observing the rise and fall of the chest wall C= circulation Let the patient lie down on a hard flat surface Palpate for the most inferior rib Locate the inferior border of the sternum Put the ball of your hand 2 fingers ABOVE the styloid process Place other hand on top Lock elbow (do not bend), square shoulder
Dentistry 151- Javier
Thrust straight down, perpendicular to sternum 5 cm or 2 inches displacement of the sternum must be observed o Compresses heart forcing blood from it into systemic circulation Ratio: Normal (in normal people) o Normal heart rate: 60 bpm o Normal breathing rate: 12 breaths per min Pair o Cardiac: 1 per second; The one doing the cardiac massage is usually the one counting o Breathing: every 4 to 5 seconds Solo o Cardiac: 80 per minute o Breathing: 60 per minute Choking Backslap – in the area bet 2 shoulder blades, 4 successive blows Heimlich maneuver – Position yourself behind the person and reach your arms around his/her waist. Place your fist, thumb side in, just above the person’s navel and grab fist tightly with the other hand. Pull fist abruptly upward and inward to increase airway pressure and expel the foreign object. Tracheostomy/ Cricothyrotomy – no nerves or blood vessels on the area of incision
I. Attributed to the Solution Used Overdose/Toxicity
Cause
Management
Prevention
-Too large dose of LA -Unusually rapid absorption of drug (intravascular injection) -Unusually slow biotransformation, elimination or redistribution
-Based on severity of reaction -Mild & transitory reaction require little or no specific -Severe reaction require prompt therapy (Convulsions- diazepam, Phenobarbital, succinylcholine)
Allergic Reactions
- specific antigen-antibody reaction in a patient who had previously been sensitized to a particular drug
-According to the symptoms present -ABC -Antihistamine -Isoproterenol/epinephrine inhalants -Epinephrine
-Administer the smallest clinical effective dose -Deposit solution very slowly (1 cartridge/min) -Use most effective weakest concentration -Aspirate before injection -Use solution with vasoconstrictor -Pre-anesthetic evaluation -Consider the patient allergic to the drug until proven otherwise -Do not test the patient yourself
II. Attributed to Needle Injection Syncope
- Anxiety + redistribution of blood to the skeletal muscles - Pooling of blood in the extremities leads to decrease in venous return to the heart and cardiac output -Weakening of needle by bending it before insertion -Sudden movement by the patient as the needle penetrates the muscle or the periosteum -Smaller needles are more likely to break -Defective manufacturing of needles
-Place the patient in semi-reclining position: lower chair back, elevate legs slightly
-Detect early symptoms (weakness, light headedness, dizziness, nausea, pallor, palpitation, white knuckles) -Relief of anxiety
Needle breakage
-Keep calm -Instruct patient not to move and keep mouth open -Remove fragment if visible (use hemostat) -Do not attempt to remove if fragment is deeper in location and is difficult to locate -Refer to oral maxillofacial surgeon -Inform patient and record incident on the chart
-Use larger needle (at least gauge 25) for techniques requiring soft tissue penetration -Never force needle against resistance - Use long needles for penetration of greater soft tissue depth -Never insert the needle up to its hub -Once the needle is inserted into tissues, withdraw it almost completely before redirecting it -Strict adherence to injection protocol -Proper care and handling of dental cartridges
Paresthesia
-Trauma to the nerve sheath by the needle during insertion -Injecting contaminated LA solution causing nerve irritation -Hemorrhage in and around the nerve sheath causes increased pressure on the nerve -Controversy that says there is higher incidence of paresthesia with the use of Articaine - Poor technique – introduction of LA into capsule of parotid gland
- Usually resolves approximately within 8 weeks -If sensory deficits persist after 1 yr, consult neurologist -Recall patient every month or every 2 months as long as the sensory deficit persists -Avoid administration of anesthesia into the same region
Facial Nerve Paralysis
Trismus
Dentistry 151- Javier
- Irritating LA solution -Trauma to muscles or blood vessels in the infratemporal fossa
- Reassure the patient that condition is transient - Defer further dental care at this appointment - No contraindication for reanesthetizing to achieve mandibular anesthesia -Prescribe muscle relaxant for initial phase of muscle spasm -Prescribe analgesic for managing
- Follow protocol with IAN - A needle tip should contact bone before depositing anesthesia - When utilizing Akinosi technique, over insertion of needle more than 25 mm should be avoided. -Use sharp, sterile, disposable needle -Proper care for and handle of
-Hemorrhage -Low grade infection within muscle
pain and inflammation - Application of warm moist compress -Let the patient rinse with warm saline solution -Physiotherapy by opening, closing and lateral excursions of the mandible -Antibiotics -Avoid dental treatment until symptoms resolve -Apply pressure on the area of insertion -Will resolve within 7-14 days, with or without treatment -Manage associated conditions as they occur -Cold/warm compress -No management necessary -Steps should be taken to prevent recurrence of pain associated with injection of LA
dental cartridge -Discard contaminated needles immediately -Practice atraumatic insertion and injection techniques -Avoid of repeat injections and multiple insertions into the same area -Use of minimum effective volume of LA
Hematoma
-Improper technique
-Knowledge of normal anatomy -Modify injection technique as dictated by patient’s anatomy
Pain on Injection
- Careless injection technique -Dull needle -Rapid deposition of anesthetic solution -Needles with barbs
-Atraumatic injection technique -Use of topical anesthetic before needle insertion -Use sharp needles -Avoid multiple injections -Use of sterile LA agents -Inject slowly -Avoid excessive volumes -Use solutions close to body temperature - Use sterile disposable needles -Properly care for and handle needles & cartridges -Properly prepare tissues before penetration
Infection
Edema
-Contamination of needle before administration of anesthetic solution -Improper handling of LA equipment and improper tissue preparation for injection -Injecting solution into infected area -Trauma during injection -Infection -Hemorrhage -Injection of irritating solution
-Heat and analgesic -Muscle relaxant if needed -Antibiotics
-Prescribe analgesics for pain -Antibiotic therapy
-Properly care for and handle the LA armamentarium -Atraumatic injection technique -Complete an adequate medical evaluation of the patient before drug administration
SYSTEMIC COMPLICATIONS
Cardiovascular Status
Angina Pectoris
Symptoms
-chest pain (substernal) -sudden onset of heavy weight on chest -pain radiating to the left arm
Management
-Nitroglycerin tablets (0.6 mg)sublingual -Amyl nitrite ampule – broken near nose
Remarks
-Due to transient ischemia of heart muscle -Short duration -Usually following stress (exertion, excitement or sudden exposure to cold environment) -Atherosclerosis is an underlying factor
Coronary Occlusion
Dentistry 151- Javier
-chest pain -feeling that the chest is about to
-Administer oxygen (because coronary artery is blocked)
Congestive Heart Failure
explode -may also radiate to left arm up to the left jaw -digestive crisis (long duration) -mild chest pain -shortness of breath -fatigability -ankle edema in the afternoon -coughing spells (in the morning) -Tachycardia (over 100 bpm) -Bradycardia (below 40 bpm)
-Morphine (8-15 mg) or meperidine (50-100 mg) IM to relieve pain
-Administer oxygen - Morphine (8-15 mg) or meperidine (50-100 mg) IM to relieve pain
-Slow progressing
Cardiac arrhythmias
-Depends on symptoms -Rest -Oxygen -Stress management protocol
-Heartbeat having no rhythm Normal heart beat: 60 to 80 bpm
Hypertension
-not a disease, but a symptom
Respiratory Status
Emphysema
-coughing spell (asthma-like attack) -Bronchodilator sprays (1:1000 epinephrine or 1:200 isoproterenol) -Late appointments- more time for patient to clear trachea bronchial tree since coughing spells usually occur in the morning -If the foreign material is still in pharynx, patient should be instructed to hold the mouth open and refrain from swallowing. Attempt to retrieve foreign body with a suitable instrument. Induce patient to cough forcefully to expel object. -If foreign material gets lodged at the glottal opening, take the patient to the nearest hospital. -Never hesitate to perform cricothyrotomy -If foreign object gets lodged at the main bronchus, tell the patient what happened and take him/her to hospital - Abnormal dilation of the alveoli and the distal bronchioles with associative destructive changes -May be acute or chronic
Mechanical Respiratory Embarrassment
Nervous System Disorders
Epilepsy
a. Petit mal – loss of consciousness, lasts only a short while, patient reacts w/o aftereffects b. Grand mal – excessive muscular activity, loss of consciousness, muscle rigidity, after the attack, patient may exhibit headache, vomiting and muscle soreness - nausea - dizziness - unconsciousness -Maintain patent airway -Make sure patient is breathing adequately -Prevent any bodily injury during convulsion. Put patient on the floor. -Before impending attacks, barbiturates may be given to the patient for calming effects
Syncope
- ventilation -oxygen
Metabolic Diseases
Diabetes
Dentistry 151- Javier
a. Diabetic coma – may be due to hypoglycemia, hyperglycemia or
- Slow onset, no necessary treatment
Cholinesterase inactivity (Plasma cholinesterase deficiency)
ketoacidosis, thirsty, nausea, shortness of breath, warm dry skin, sleepiness b. Insulin shock – due to hypoglycemia, occurs only in patients injecting insulin, hunger, weakness, irritability, disorientation, cold perspiration - no overt sign
-Lumps of sugar -Cola drink -Glucagon hydrochloride (0.5 to 1.0 mg) with 5% dextrose solution -Barbiturates -Emergency occurs when LA used is an ester type
Endocrine Malfunction
Hypothyroidism
-cretinism -myxedema - mentally dull -drowsy -fatigued -tremors -exophthalmia -intolerance to heat - sweating - increased BMR -increased pulse rate -hypertension - adrenal shock -hypotension -Managed accordingly -lower basal metabolic rate makes the patient more prone to toxic drug reactions
Hyperthyroidism
- prevention -sedation -stress reduction protocol -oxygen -cold packs – to normalize body temp
Adrenal insufficiency
- support blood circulation -Hydrocortisone succinate (100200mg) -Dexamethasone (4 – 12mg) -Oxygen
-Usually occurs in patients who have been taking steroid hormones or ACTH and have discontinued drug sometime before a traumatic or stressful experience
CPR (Cardiopulmonary resuscitation) A= airway Establish a patent airway Remove prosthesis, food, saliva, etc. that are obstructing airway Tilt the victim’s head backward (head extension) to its fullest The neck should NOT be arched Lift the chin while tipping the head backward o These maneuvers lift the tongue away from the posterior pharyngeal wall B= breathing Deliver 4 successive air blows on the mouth of the patient o The brain can only last 7 to 15 mins without oxygen and it will lead to permanent brain damage o Brain oxygen supply is dependent on the pumping of the heart Pinch nose to prevent air leakage Ensure full mouth coverage One can readily determine if the air is reaching the patient’s lungs by observing the rise and fall of the chest wall C= circulation Let the patient lie down on a hard flat surface Palpate for the most inferior rib Locate the inferior border of the sternum Put the ball of your hand 2 fingers ABOVE the styloid process Place other hand on top Lock elbow (do not bend), square shoulder
Dentistry 151- Javier
Thrust straight down, perpendicular to sternum 5 cm or 2 inches displacement of the sternum must be observed o Compresses heart forcing blood from it into systemic circulation Ratio: Normal (in normal people) o Normal heart rate: 60 bpm o Normal breathing rate: 12 breaths per min Pair o Cardiac: 1 per second; The one doing the cardiac massage is usually the one counting o Breathing: every 4 to 5 seconds Solo o Cardiac: 80 per minute o Breathing: 60 per minute Choking Backslap – in the area bet 2 shoulder blades, 4 successive blows Heimlich maneuver – Position yourself behind the person and reach your arms around his/her waist. Place your fist, thumb side in, just above the person’s navel and grab fist tightly with the other hand. Pull fist abruptly upward and inward to increase airway pressure and expel the foreign object. Tracheostomy/ Cricothyrotomy – no nerves or blood vessels on the area of incision
