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LA Toxic effects
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LA Toxic effects
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Local Anesthesia Allergic shock
§ Esters are highly allergenic, their use should be avoided and restricted to
special cases after allergy test.
§ There has never been a true, documented allergic reaction to an amine
anesthetic.
§ a patient may in fact be allergic only to the bisulfite preservative used to
stabilize the vasoconstrictor.
§ If the allergic reaction was not too serious, it may be worth trying again
with either mepivicaine or prilocaine without vasoconstrictor.
Anesthetic manufactures do not use preservatives in carpules that do not
also contain vasoconstrictor.
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Testing for anesthetic allergy using skin test
T.R.U.E. Test®
§ This is a patch test that applies 23 allergens to the skin contained in 12
polyester patches. One of the patches contains a mixture of several
anesthetics and is used to test for allergy to local anesthetics in general.
The mixture used includes two ester based anesthetics and one amine
based anesthetic. This mixture of anesthetics is called the "Caine Mix"
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Signs and symptoms of anesthetics allergic reaction
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Anaphylactic shock
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Psychological causes
Pathological causes
Anatomical causes
Operator dependent
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Failure of anesthesia
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Failure of anesthesia
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Accessory nerve supplies
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Failure of anesthesia
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Pain on injection
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Other problems with LA administration
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LA Hazards Management
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Management of anaphylactic shock : 1
§ Position the patient on his or her back with the feet elevated.
§ Maintain an airway
§ If the patient is not breathing on his own, use rescue breathing like you
learned in CPR class. Thanks for Dr. Yasser
§ Check the carotid artery for heartbeat and use chest compressions if
necessary.
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Management of anaphylactic shock : 2
§ The two drugs that you must have on hand to stabilize a patient in
anaphylactic shock are as follows:
– Epinephrine (adrenalin) 1:1000 subcutaneous injection. It opens the bronchioles allowing free breathing, increases
the blood pressure counteracting shock and evens out and intensifies the heart beat. Its effects are drastic, but short
lived. The standard dose is 1 mg given in three doses five minutes apart.
– Benedryl (diphenhydramine) 25-50 mgm injectable. This is an antihistamine and can also be taken in pill form an
hour before the procedure to help prevent serious allergic reaction before it begins. Injectable diphenhydrimine which
can be administered either subcutaneously, or in the buccal fold if the dentist is more comfortable with that route.
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Management of anaphylactic shock : 3
§ The following drugs are of little use to the dentist during the initial stages
of the emergency since they are generally used by EMS personnel
– Aminophylline This drug opens blocked breathing passages.
– Solu-cortef IV injection. This drug is a corticosteroid and reduces the generalized allergic inflammatory reactions on a
longer term basis. It will not act rapidly enough to reverse anaphylaxis immediately, but is more of a long term remedy.
– Wyamine injection. This drug is used to counteract hypotension (low blood pressure and shock) on a prolonged
basis.
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Management of failure of Anesthesia
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Failure Management : Mandible
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Management of failure of Anesthesia
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Failure management : Maxilla
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Pain on injection ; reduction
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Other Hazards
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Paresthesia
f the needle passes through a nerve in the area of injection, it may damage
the nerve and cause paresthesia. The injury is usually not long term or
permanent.
Make a note in the chart if the patient reports a shooting feeling during the
injection that would indicate needle contact with the nerve.
A local anesthetic that has been contaminated by alcohol or a sterilizing
solution may cause tissue irritation and edema, which will in turn constrict
the nerve and lead to paresthesia.
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Paresthesia (Prevention and Management)
Proper injection protocol and care of the dental cartridges will reduce the
incidence of paresthesia, but it can still occur.
If the patient calls reporting paresthesia, explain to them that it is not an
uncommon result of an injection and make an appointment for
examination.
Make a note of the conversation in the patient's chart.
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Paresthesia (Prevention and Management)
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Hematoma
§ The needle can nick vessels as it passes through highly vascular tissues.
A nicked artery will usually result in a rapid hematoma, while a nicked vein
may or may not result in a hematoma.
§ Hematomas most often occur during a posterior superior alveolar or
inferior alveolar nerve blocks.
§ Use a short needle for the PSA and be conscious of depth of penetration
for these injections.
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Hematoma (Prevention and Management)
§ Use a short needle for the PSA and be conscious of depth of penetration
for these injections.
§ If the hematoma develops during an inferior alveolar nerve block, apply
pressure to the medial aspect of the mandibular ramus. The
manifestations will usually be intraoral.
§ If the hematoma develops during an infraorbital nerve block, apply
pressure to the skin directly over the infraorbital foramen. The
discoloration will be below the lower eyelid.
§ If the hematoma develops during a mental or incisive nerve block apply
pressure over the mental foramen. The skin will discolor over the mental
foramen and swelling will occur in the mucobuccal fold.
§ If the hematoma occurs during a posterior superior
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Hematoma (Prevention and Management)
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Trismus
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Trismus (prevention)
Use of
– disposable needles,
– antiseptic cleansing of the injection site,
– aseptic technique,
– and atraumatic injection technique
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Trismus (Management)
§ Recommended treatment for trismus includes heat therapy with moist hot
towels 20 minutes every hour, analgesics, and muscle relaxants if
necessary.
§ The patient should be instructed to exercise the area by opening, closing,
and lateral excursions of the mandible for 5 minutes every 3 to 4 hours.
§ The patient can chew sugarless gum to facilitate lateral movement of the
TMJ.
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Trismus (Management)
§ Continue therapy until the patient has no symptoms. If the pain continues
over 48 hours, an infection may be present.
§ Antibiotic therapy for 7 full days is indicated. If there is no improvement
after 2 to 3 days without antibiotics or 7 to 10 days with antibiotics, refer
the patient to an oral surgeon for evaluation.
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Infection (Prevention)
§ Infection from a dental injection has become rare due to the use of sterile
disposable needles and one-patient use cartridges.
§ The needle will always be contaminated when it comes in contact with the
patient's mucosa.
§ Proper tissue preparation and sterile technique will virtually eliminate
infection at the injection site.
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Infection (Management)
§ The patient reports post injection pain and dysfunction one or more days
following treatment,
§ manage as with trismus. If the symptoms do not resolve within three days,
prescribe a seven day course of antibiotic therapy. (Usually 500 mg.
penicillin V immediately then 250 mg. four times a day or erythromycin if
the patient is allergic to penicillin.)
§ Record the incident and treatment in the patient's chart.
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Broken Needles
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Broken Needles (Prevention)
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Broken Needles (Management)
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General points
§ Thick nerve trunks require more time for penetration of solution and more
volume of LA.
§ In nerve trunks autonomic functions are blocked first, then sensitivity to
temperature, followed by pain, touch, pressure, and motor function.
§ Soft tissue anesthesia is reached before the levels needed for pulpal
anesthesia, which takes several minutes and will wear off first (usually
within an hour of a standard lidocaine/adrenaline LA).
§ Disinfection of mucosa prior to LA is not required in reality; however,
sterile disposable needles are absolutely mandatory due to risks of cross-
infection.
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Dr Iyad Abou Rabii
Iyad.abou.rabii@qudent.edu.sa
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