Anesthesia Chapter 17

Infection causes:

-postinjection infection is contamination of needle before administration -contamination of needle always occurs when the needle touches mucous membrane (not significant because the normal flora of the oral cavity does not lead to tissue infection) -improper technique of handling local anesthetic, and improper tissue preparation can cause infection -anesthetic is less effective when injected into infected tissue, deposited under pressure as the periodontal ligament injection, the force might transport bacteria into adjacent healthy tissue, spreading infection

Problems with anesthetic?

- self-injury of soft tissue (biting, thermal or chemical) -if the lingual nerve is involve taste can be impaired (chorda tympani nerve) -loss of sensation (Paresthesia), hyperesthesia (pain) & dysesthesia (numbness)

Management of soft tissue injury?

-Analgesics for pain -Antibiotics if necessary -lukewarm saline rinse to decrease swelling -Petroleum jelly or other lubricant to cover lip lesion and minimize irritation

Prevention of needle breakage?

-Do not use short needles for inferior alveolar nerve block in adults or large children -Do not use 30-gauge needles for inferior alveolar nerve blocks in adults or children -Do not bend needles -Do not insert a needle into soft tissue to its hub, unless absolutely essential for the injection -Use extra caution when inserting needles into children or phobic adults

Facial Nerve Paralysis

-Facial Nerve (VII) carries motor impulses to the muscles of the facial expression, paralysis of some of its terminal branches can occur whenever an infraorbital nerve block is administered or when maxillary canines are infiltrated -muscle droop is observed when motor fibers are anesthetized by inadvertent deposition of local anesthetic into their vicinity. This may occur when anesthetic is introduced into the deep lobe of the parotid gland, which terminal portions of the facial nerve extend

Prolonged anesthesia

-Hyperractor: may experience prolonged soft tissue anesthesia after local anesthesia that persists for many hours longer than expected -This is not a problem -When anesthesia persists for day, weeks or months potential for the development of problems is increased -Paresthesia or persistent anesthesia is a disturbing yet often-times unpreventable complication of local anesthetic administration -Paresthesia is one of the most frequent causes of dentist malpractice litigation

Management of the Hematoma?

-Immediate: when swelling is evident after injection, pressure should be applied to the site of bleeding for a least 2 mins to effectively stop the bleeding -Inferior Alveolar Nerve Block: pressure applied to medial aspect of ramus, hematoma visible intraoral, discoloration and swelling on the lingual side of the ramus -Anterior Superior Alveolar (infraorbital) Nerve Block: Pressure applied directly over infraorbital foramen, discoloration of the skin below the lower eyelid, unlikely to occur with ASA, pressure is applied during injection (usually prevents hematoma) -Incisive (mental) Never Block: Pressure over mental foramen, externally on skin, discoloration of skin of the chin area and swelling in the muccobuccal fold in region of mental foramen, pressure applied during INCISIVE injection (usually prevents hematoma) but not mental -Buccal/Palatal: place pressure at site of bleeding, usually visible within the mouth -Superior Alveolar Nerve Block: PSA produces larges most esthetically unappealing hematoma, infratemporal fossa into which bleeding occurs, can accommodate large volume of blood, colorless swelling around TMJ (a few minutes after injection), usually seen on lower region of the cheek, difficult to apply pressure to the Posterior Superior Alveolar Artery (primary source of bleeding), facial arter, pterygoid plexus of veins. Located posterior, superior, medial to maxillary tuberosity, digital pressure can be applied to the mucobuccal fold as distally as tolerable, medial & superior direction. Use an icepack -Resorbs over 7-14 days, do not apply heat to area for 4-6 hours, heat=vasodilation, heat can be applied the next day, increase the rate in which blood elements are resorbed, heat 20 mins every hour -Ice applied directly after analgesic and vasoconstrictor minimize the size

Needle Breakage:

-Less breakage due to non-reusable stainless steel needles being used -1 in 14 million at risk (inferior alveolar nerve block) -1951-2001 reported 26 cases of needle breakage, 15 were Inferior Alveolar Nerve Block (IANB), 5 Posterior Alveolar Nerve Block (PSA) -PSA cases were all adults -IANB 9 of the 15 were children -11 needles were 30 gauge short -30 gauge ("hubbing the needle or inserting all the way) -All cases involved the IANB or PSA -No evidence of manufacturing defects

Localized complications of local anesthesia?

-Needle breakage -Prolonged anesthesia or paresthesia (sensation of tingling, tickling, pricking, or burning of a person's skin with no apparent long-term physical effect) -Facial nerve paralysis -Trismus (lockjaw) -Soft tissue injury -Hematoma -Pain on injection -Burning on injection -Infection -Edema -Sloughing of tissues -Intraoral lesions When patient experiences any complications a note needs to be made in the chart, if the conditions if chronic the note should be permanent

Management of Trismus?

-Patients reports pain and some difficulty opening mouth on day after dental treatment (PSA, IANB) -Occurs 1-6 days after treatment -Mild pain prescribe heat therpy, warm saline rinses, analogies and muscle relaxants -Heat treatment: hot moist towel approximately 20 minutes every hour -Saline rinse: teaspoon of salt is added to a 12-ounce glass of warm water the rise is held in mouth on side effected -Anti-inflammatory: diazepam or benzodiazepine -opening and closing the mouth as lateral excursion of the mandible, 5 min every 3-5 hours -gum chewing -Vazirani-Akinois nerve block can provide relief of motor function -improvement 48-72 hours, beyond 48 could be a an infection -recovery could take 6 weeks -2-3 days without antibiotics, 5-7 with antibiotic with no improvement send to oral surgeon

Burning on Injection causes:

-Primary cause is the pH of the solution, pH of plain (no vasopressor) 6.5, solution with vasopressor more acidic at 3.5 -Bupivacaine with epi reported more pain -Rapid injection (especially in denser areas palate) produces burning -Contamination of local anesthetic cartridges when they are stored in alcohol or sterilizing solution, which diffuse into the cartridges -no warming to body temp (too hot for patient)

Trismus:

-Prolonged tetanic spasm of jaw muscles by which the normal opening of the mouth is restricted (locked jaw) -chronic complications to manage

What to do if a needle does break?

-Refer to specialist (oral or maxillofacial surgeon) -Panoramic image often taken or computer tomographic (CT) scanning -3 dimensional CT scanning has been recommended to identify the location of the needle -Surgeon will remove needle while patient is under local anesthesia

Edema

-Swelling of tissues is not a syndrome, but a clinical sign of the presence of a disorder

Cause of Facial Nerve Paralysis?

-Transient facial nerve paralysis commonly caused by the introduction of local anesthetic into the capsule of the parotid gland, which is located posterior border of the mandibular ramus, clothed by the medial pterygoid and masseter muscle -Directing needle posteriorly to the posterior direction during an IANB or inserting the needle into the parotid gland, if local anesthetic is deposited, transient paralysis can result -Facial paralysis not being able to close eye or drooping of lip

Cause of Hematoma

-because of the density of the hard palate and its firm adherence to the bone, hematoma rarely develop after a palatal injection -large hematoma can develop from an arterial or venous puncture after a PSA or inferior alveolar never block, tissue surrounding these vessels more readily accommodate significant volumes of blood -the blood effuses from the vessel until extravascular exceeds intravascular pressure or until clotting occurs -can occur after inferior alveolar nerve block and usually visible only intraoral, PSA hematomas are visible extraorally

The cause of Paresthesia is?

-Trauma to a nerve that lead to Paresthesia -Paresthesia is a common complication of mandibular dental implants (poster operative lingual nerve and inferior alveolar never developed in patients under 20, from wisdom tooth extraction) and inexperience person giving injections -contamination of alcohol of sterilizing solution near the nerve cause edema and increase pressure leading to Paresthesia -alcohol is neurolytic and can produce long term trauma to a nerve (Paresthesia lasting for months or years) -Trauma to the nerve sheath during an injection can occur (electric shock), needle in contact with the nerve can cause Paresthesia -Insertion of the needle into a foramen, as the second division maxillary nerve block via the greater palatine foramen also increase the likelihood of nerve injury -Bleeding into the neural sheath can increase the pressure and cause Paresthesia -Can because purely by the local anesthetic, all cases involve the inferior alveolar nerve and lingual nerve -Paresthesia reported most commonly with 4% local anesthetic - prilocaine HCI and articaine -Paresthesia from local anesthetic only is 1:785,000 below 2% 1:1,25,000 for 3% 1:485,000 for 4% Articaine should not be used to the Inferior Alveolar never block 1 in 46 million

Causes of Trismus:

-Trauma to muscles or blood vessels in the infratemporal fossa is the most common causative factor -Alcohol or cold sterilizing solution can diffuse into the tissues (muscles) -Local anesthetic can be myotoxic to skeletal muscles -intramuscular or supramuscularly rapid progressive necrosis of exposed muscle fibers -hemorrhage causes trismus -infection after injection -every needle insertion produce some damage to the tissue through which is passes, multiple needle penetrations correlate with a greater incidence of postinjection trismus -Barbed needle increases the occurrence of damage to the lingual or inferior alveolar nerve (e.g. Paresthesia) and trismus -excessive volume of local anesthetic deposited into a restricted area (multiple IANB's)

Prevention of Trismus

-Use a sharp, sterile, disposable needle -proper care of anesthetic cartridges -Aseptic technique, contaminated needles needs to be changed -Atraumatic insertion and injection technique -Avoid repeat injection and multiple insertions into the same area by knowing anatomy and proper technique (use nerve block instead of local infiltration (supraperiosteal) wherever possible -Use effective volume of anesthetic -Trismus is not always preventable

What to do if patient experiences facial paralysis?

-Within seconds to minutes of local anesthetic into the parotid gland the patient can sense wreaking of muscles affected 1. Reassure patient, explain the situation is transient, will last for a few hours, and will resolve without residual effects. Produced by normal action of local anesthetic drugs on the facial nerve, which is a motor nerve to the muscles of facial expression 2. Contact lenses should be removed until muscular movement returns 3. Eye patch should be applied to affected eye until muscle tone return 4. Record incident in patients chart 5. No contradiction is known to reanesthetizing the patient to achieve mandibular anesthesia, may want to forego further dental care at this time

Problems of Postanesthetic Intraoral Lesions:

-acute sensitivity in the ulcerated area -tissue could become infected, secondary infection is minimal

Prevention of burning on injection

-buffering the local anesthetic solution to approximately pH 7.4 before injection -slow speed of injection do not exceed 1.8ml/min, recommend 1 ml/min -stored at room temperature -no alcohol or sterilizing agents should come in contact with it -usually transient and do no lead to prolonged tissue involvement

Paresthesia:

-clinical response to this can be varied including sensations of numbness, swelling, tingling, and itching -it is defined as persistent anesthesia beyond expected duration, altered sensation well beyond the expected duration of anesthetic -include hyperesthesia (pain) & dysesthesia (numbness)

Hematoma

-effusion of blood into the extravascular spaces can be caused by inadvertently nicking of a blood vessel -nicking of an artery usually increase rapidly in size until treatment is instituted because of the significantly great pressure of the blood within the artery -nicking of a vein may or may not cause a hematoma -denser tissue (palate) is less likely to develop a hematoma, looser tissue (infratemporal fossa) large volumes of blood may amass before a swelling is ever noted and therapy instituted

Postanesthetic Intraoral Lesions

-gen. reported after 2 days from an intraoral injection, ulceration develops in their mouth around the side of injection -pain usually intense in nature

Preventing problems with anesthetic and Paresthesia

-get as close to the nerve as possible without making contact

Problem with Pain on Injection:

-increase patient anxiety and lead to sudden movements, increasing risk for needle breakage, traumatic soft tissue injury, or needle-stick injury

Problem of Facial Nerve Paralysis?

-is almost always preventable by adhering to protocol with the inferior alveolar and Vazirani-Akinosi nerve blocks -in some situations the facial nerve branch may lie close to the site of local anesthetic deposition of IANB and Vazirani-Akinosi nerve block -needle tip that comes in contact with bone (medial aspect of the ramus) possibility for deposit being deposited in the parotid gland IANB -If the needle defects posteriorly during this block and bone is not contacted, the needle should be withdrawn almost entirely and directed more anterior -No contact with bone is made during the Vazirani-Akinosi nerve block over insertion of needle should be avoided

Prevention of Hematoma

-know anatomy, PSA most common, IANB (second) and mental/incisive (third when foramen is entered) -if you have a smaller patient decrease the depth of penetration for a PSA -use a short needle for PSA to decrease risk -minimize number of needle penetrations -don't use needle as a probe for tissue Hematoma is not always preventable whenever a needle is inserted into the tissue and cannot always be avoided

Problems with Edema?

-local anesthetic administration is seldom intense enough to cause airway obstruction -local anesthetic usually caused edema related to pain and dysfunction of the region and embarrassment for patient -Angioneurotic edema produce by topical can comprise airway, edema of tongue, pharynx or larynx may develop and represent a potentially life-threatening situation

Prevention of soft tissue injury?

-local anesthetic of appropriate duration should be selected for appt. -cotton roll can be placed between the lip and he teeth (should be wrapped with dental floss) -warn patient not to eat or drink hot fluids or bite on lips, or tongue (self warning sticker can be used on children)

Managing Paresthesia?

-most cases resolve within 8 weeks -only when damage to the nerve is sever will Paresthesia be permanent which is not likely with the size of the needle -in most situation paresthesia is minimal with the sensory function be retained to the area affect

Management of sloughing of tissues:

-no management for epithelial desquamation or sterile abscess -for pain they can have analgesics such as aspirin or other NSAIDs and a topically applied ointment -epithelial desquamation resolves within a few days; the course of a sterile abscess may run 7-10 days

Prevention of Postanesthetic Intraoral Lesions:

-no preventing intraoral lesions, extraoral herpes simplex my be prevented if treated in prodromal stage (mild burning or itching) -antiviral: acyclovir

Systemic complications of local anesthesia?

-overdose -allergy -Psychogenic reactions (mental reaction that can cause physical manifestations)

Problems with sloughing of the tissues:

-pain at times, due to epithelial desquamation or sterile abscess, remotely possible that infection can result from these

Management of Prevention of Postanesthetic Intraoral Lesions:

-pain is an initial symptom, exacerbation of a process that was present in latent form -topical solutions (viscous lidocaine) -Benadryl and milk of magnesia rinse coats ulcerations and provides relief -Orabase without kenalog -tannic acid (Zilactin) relief for 6 hours -ulceration usually last 7-10 days

Sloughing of Tissues:

-prolonged irritation or ischemia of gingival soft tissues may lead to a number of complication including epithelia desquamation and sterile abscess

Problems with Hematoma

-rarely produces significant problems aside from bruising -could include trismus and pain, swelling and discoloration of the region

Postanesthetic Intraoral Lesions cause:

-recurrent aphthous stomatitis or herpes simplex can occur after local anesthetic or trauma -recurrent aphthous stomatitis is the most common oral mucosal disease known to humans -Recurrent aphthous stomatitis is more frequently observed than herpes simplex gingival tissue not attached to bone (loose) -Herpes can develop intraorally manifests as small bumps on tissues that are attached to underlying bone (fixed) soft tissue of hard palate

Management of Edema?

-reduction of swelling as quickly as possible and identify cause of edema -may have to prescribe analgesics for pain of traumatic injection -Hemorrhage, edema resolve slowly 7-14 days -If symptoms of infection (pain, mandibular dysfunction, edema, warmth) do not resolve within 3 day, antibiotics should be started -allergy-induced edema is life threatening, degree and location are significant. Buccal (histamine blocker), determine precise cause of edema

Soft Tissue Injury

-self-infected trauma to the lips and tongue can be caused by patient -trauma usually caused with younger children, mentally or physically disabled children or adults and in older patients -primary reason is that the soft tissue anesthesia lasts longer than the pulpal dose

Problems with burning on injection?

-tissue irritation is occurring -if because of pH rapidly disappears because of the anesthetic action developed -when burning occurs because of rapid injection, contaminated solution, or being overly warmed tissue damage may have occurred and can cause (trismus, edema, paraesthesia)

Problems with soft tissue injury?

-trauma of anesthetized tissues can lead to swelling and pain when effects wear off -infection can develop in remote instances

Management of Infection

-treat patients with trismus with heat and analgesic if needed, muscle relaxant, physiotherapy. -patient take penicillin 500 mg immediately and 250 mg four times a day until all tables have been take, Erythomycin can be substituted for penicillin

Prevention of sloughing of tissues:

-use topical as recommended 1-2 minutes maximizes effectiveness and minimizes toxicity -norepinephrine is the agent most likely to produce ischemia to cause tissue damage and a sterile abscess -palatal tissue is a likely place for this to occur is (1:50,000) if reinjected over a long period of time

Prevention of Pain on Injection

1. Adhere to proper techniques of injection, both anatomic and psychological 2. Use sharp needles 3. Use topical anesthetic properly before injection 4. Use sterile local anesthetic solution 5. Inject local anesthetic slowly 6. Temperature of solution should be at room, 7. Buffered local anesthetic at pH of 7.4 make injection more comfortable

If a patient calls about Paresthesia?

1. Be reassuring 2. Speak with patient personally 3. Explain that Paresthesia is not uncommon after local injection 4. Arrange examination appt. 5. Record incident 6. Examine patient in person 7. Deter the extent of Paresthesia 8. Explain that is can happen and take up to 2 months to a year before resolution 9. Tincture Time: recommended treatment 10. Record all finds, using patient description (hot, cold, painful, tingling) 11. Suggestion observation for 1 -2 months and offer to send them to a oral surgeon 12. If surgery suggested get second opinion and a waiting period of 1-2 months is recommended 13. See paitient every 2 months as long of problem persists 14. Dental treatment may continue by avoid using anesthetic into region traumatized 15. Contact liability insurance if it persists

Pain on injection Causes:

1. Careless injection technique and callous attitude, (don't say always hurts), self-fulfilling prophesies 2. Needle is dull 3. Rapid deposit may cause tissue damage 4. Needle with bards (from impaling bone) produce pain when withdrawn

Reasons for needle breakage?

1. Intentional bending 2. Sudden movement by patient 3. Forceful contact with bone -Have access to a hemostat in case of breakage -Needle fragments can migrate if not removed

Edema that compromises breathing?

1. P (position) patient is place supine 2. A-B-C (airway, breathing, circulation): basic life support is administrated 3. D (definitive treatment): emergency medical services are summoned 4. Epinephrine is administered: .3mg (1:1000 epi) adult, .15mg (1:1000 epi), every 5 mins 5. Histamine blocker 6. Corticosteroid 7. Preparation is made for Cricothyrotomy total airway obstruction (emergency airway puncture) 8. Patients condition is evaluated before any other appointments are made

Prevention of Edema?

1. Proper handle and care of local anesthetic 2. Use atraumatic injection technique. 3. Complete an adequate medical evaluation before drug administration

Facial nerve and nerve branches

1. Temporal branches -Frontalis -Orbicularis Oculi -Corrugator Supercilii 2. Zygomatic branches -Orbicularis Oculi 3. Buccal Branches: region of inferior to the eye and around the mouth -Procerus -Zygomatcius -Levator Labii Superioris -Buccinator -Orbicularis Oris 4. Mandibular branch: supply muscles of the lower lip and chin -Depressor anguli oris -Depressor labii inferioris -Mentalis

Edema Causes:

1. Trauma during injection 2. Infection 3. Allergy: Angioedema response to ester-type topical (localized tissue swelling) 4. Hemorrhage: effusion of blood into soft tissue produces swelling 5. Injection of irritating solutions (alcohol or cold sterilizing agents) 6. Hereditary Angioedema: sudden onset of brawny nonpitting edema affecting face, extremities, and mucosal surface of the intestine and respiratory tract, often without obvious precipitating factors. Manipulation within the oral cavity, including local anesthetic administration may precipitate an attached. Lips, eyelids and tongue are involved. 15%-33% died from untreated angodenma form acute airway obstruction as a result of laryngeal edema

Prevention of infection?

1. use sterile needle 2. proper care and handle of needles, do not touch any surface avoid multiple injections with the same needle 3. Proper care of cartridges -one cartridges per patient -keep storage and cover before use -can clean diaphragm with alcohol 4. properly prepare tissue before penetration. Dry them and supply topical

Problems with infection?

Contamination of needle or solutions may cause a low grade infection, this can lead to trismus is not recognized

Causes of Sloughing of tissues:

Epithelial Desquamation: 1. application of topical anesthetic to the gingival tissues for prolonged period of time 2. Heightened sensitivity of the tissues to either topical or injectable local anesthetic 3. reaction in an area where a topical has been applied Sterile Abscess: 1. Secondary to prolonged ischemia resulting from the use of local anesthetic with vasoconstrictor (usually norepinephrine) 2. usually develops on the hard palate