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General Complications ofDental Local Anesthesia
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General or systemic complications are less common during
dental treatment than local complications, and it is estimated that fewer than 1% of patients treated are affected (see
Tables23.1 and23.2). General complications or systemic
toxicity can result in serious harm or even death, but fortunately most cases are of little consequence. Approximately
75% of cases are caused or associated with dental local anesthesia (Table23.3), and it has been observed that there are
situations in which the frequency of general complications
is increased, as follows:
● After multiple administrations of local anesthetic in the
same patient (Persson1969).
● Failure of local anesthetic (Persson1969).
● Patients with a history of complications during adminis-
tration of local anesthetic (Persson1969).
● Patients at risk (ASA III) when treatment takes more
than 30
minutes, especially patients with cardiovascular conditions (Hughes et al. 1966; Daubländer
etal.1997).
● Endodontic treatment and extractions increase the risk
(Matsuura1989; Malamed1993).
Table23.1 Vasovagal syncope asa percentage ofgeneral
complications that appear during dental treatment.
Complications
Reference Origin
Fast etal.
(1986)
United
States
observed
16.773 10 67
Matsuura1989 Japan — 5 63
Malamed
(1993)
Girdler and
United
13.835 10 30
States
UK 814
Smith (1999)
Mean 58 ≈ 60
Years of
study
Vasovagal
syncope (%)
1 73
Table23.2 Percentage ofpatients who experience vasovagal
syncope inthe office, excluding patients aged <14
No. of cases
Reference
Sample
size
of vasovagal
syncope
years.
Cases of
vasovagal
syncope (%)
First part, pre- 1980
Moose (1959) 1636 25 1.5
Hannington- Kiff
3000 60 2
(1969)
McGimpsey (1977) 9513 100 1.1
Edmondson etal.
6265 135 2.2
(1978)
Mean 1.7 ≈ 1.5
Second part, post-
1980
Lemay etal. (1984) 108 1 0.9
Meechan and Blair
440 1 0.2
(1989)
Hidding and
1518 12 0.8
Khoury (1991)
Salins etal. (1992) 1500 10 0.7
D’Eramo (1992) 199 045 278 0.4
Daubländer etal.
2731 12 0.4
(1997)
D’Eramo (1999) 158
Lustig and
061 1114 0.7
1007 1 0.1
Zusman (1999)
Kaufman etal.
179 1 0.6
(2000)
Moore etal. (2006) 187 1 0.5
Mean 0.53 ≈ 0.5
Many patients in the first part (pre- 1980) were treated while
seated in the chair, therefore we took the values in the second
part because patients were lying back in the dentist’s chair
(leading to fewer cases). The second part (post- 1980) is the
current data.
Local Anesthesia in Dentistry: A Locoregional Approach, First Edition. Jesús Calatayud and Mana Saraghi.
© 2024 John Wiley & Sons Ltd. Published 2024 by John Wiley & Sons Ltd.
Companion website: www.wiley.com/go/Calatayud/local
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Table23.3 Percentage ofgeneral complications during dental
treatment caused by or associated withdental local anesthesia.
Percentage of complications during
Local
Reference
Hannington- Kiff
(1969)
Edmondson etal.
(1978)
Matsuura1989 55 23 78
Malamed (1993) 55 22 77
anesthesia (%)
36 48 84
45 22 67
Dental
treatment (%)
Mean 76.5
Rounded mean 75
Total
(%)
The two main causes or triggers of complications associated with local anesthetic are as follows: (i) psychogenic
reaction because of anxiety and needle phobia, and (ii)
adverse reactions to the components of the local anesthetic
solution.
Death is the most severe complication that can arise in
the dentist’s office. Dental local anesthesia has proven to
be very safe. Table 23.4 shows that when dental local
anesthesia is administered with a minimum standard of
recommended care, mortality is one case in 100 million
injections, whereas with general anesthetic or deep sedation it is one case in 500
000, that is, a 200- fold greater risk.
Furthermore, death during general anesthesia is recorded
mainly in healthy patients graded as ASA I or II, whereas
cases of death as a result of dental local anesthesia usually involve patients graded as ASA III or IV (Driscoll1974).
Finally, general complications, especially those caused by
local anesthesia in the dental clinical setting are as
follows:
1) Psychogenic reaction:
● Vasovagal syncope.
● Hyperventilation syndrome.
● Allergic- like reactions.
2) Toxicity induced by sympathomimetic vasoconstrictors
(epinephrine and norepinephrine).
3) Systemic toxicity induced by local anesthetics.
4) Toxic methemoglobinemia caused by some local
anesthetics.
5) Allergic reactions to components of local anesthetic
solutions.
Table23.4 Frequency ofdeath after dental local anesthesia andgeneral anesthesia anddeep sedation indentistry.
Frequency of
Reference Origin Study period Deaths/patients
Local anesthesia
Selding and Recant (1955) USA 1943–1952 2/90million 1/45million
Cawson etal. (1983) UK 1970–1979 10/700million 1/70million
Matsuura1989 Japan 1984–1985 9/300million
Perea etal. (2014) Spain 2000–2010 1/385million
Mean 1/130million
Rounded mean 1/100million
General anesthesia and deep sedation
Driscoll (1974) USA — 11/5 285 750 1/480 000
Tomlin (1974) UK 1963–1968 26/7 956 000 1/300 000
Coplans and Curson (1982) UK 1970–1979 99/15
Lytle and Stamper (1989) USA 1968–1988 7/4 700 000 1/670 000
Nkansah etal. (1997) Canada 1990–1995 4/2 830 000 1/700 000
D’Eramo (1992,1999),
D’Eramo etal. (2003)
a
The data for Japan are estimated based on double the population of the UK since Japan has twice as many inhabitants. The
data for Spain are based on 35million cartridges per year (Rosso2015). The figures for Japan may be underestimated and
those for Spain may be overestimated, therefore we established the figure of 1/100million.
USA 1984–1999 8/5 377 000 1/670 000
Mean 1/495 000
Rounded mean 1/500 000
a
a
168 000 1/150 000
death
1/33million
1/385million
a
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Preventive Measures
The main preventive measures we can take when administering local anesthetic in the office are as follows:
1) A complete clinical history and health questionnaire to
obtain information about the patient’s illnesses (e.g.
diabetes, hypertension, history of myocardial infarction), current medications (e.g. betainsulin, tricyclic antidepressants), or general reactions
to previous local anesthetics that the patient has experienced and require anesthetic techniques or solutions to
be modified or reactions that simply contraindicate
local anesthetic (Chapters8–10).
2) Reassure the patient (Abasi1987). The methods for
administering local anesthetic are discussed in the
chapter on basic injection techniques (Chapter 13).
Itis important to remember the repercussions of anxiety (Annex 17). Other techniques (e.g. pharmacologic therapy, hypnosis) in patients with considerable
anxiety or medical problems are beyond the scope of
this book.
3) Prevent pain (Abasi1987), both during administration
of the local anesthesia and during the dental procedure
(in cases where deep anesthesia is necessary). It is
important to remember the repercussions of pain
(Annex 17).
4) Aspirate before the injection to prevent inadvertent
intravascular injection of solution entering the
bloodstream (Chapter 13). Although some authors
have not found an association between positive and
negative aspirations and systemic reactions
(Forrest 1959; Goldman and Gray 1963; Persson
etal.1974; Blair and Meechan1985; Lipp etal.1988),
possibly because toxic reactions to anesthetics are
often confused with other types of reaction (e.g. vasovagal syncope), there is general consensus that
aspirating reduces the risk of intravascular injection
(Malamed2004; Horowitz etal.2005). Furthermore,
aspiration is recommended at each stage to prevent
intravascular injection (Lloyd1992). It is important
to remember that intravascular injection can sometimes increase toxicity by up to 200- fold (Meechan
and Rood1992).
To ensure correct aspiration, it is very important to
use 25G or 27G needles (25G is better) since they enable
evaluation of the blood that colors the cartridge; this is
not possible with 30G needles because the smaller
lumen of the needle makes detection of aspiration unreliable and difficult, thus little blood enters the cartridge
(see Chapter11).
5) The injection should be administered slowly. The cur-
rently recommended rate is 1.8 ml in 40–60 seconds
(Chapter13), which enables us to reduce the toxicity
blockers, digoxin,
of the anesthetic solution since fast injections can lead
to rapid increases in plasma levels, especially in the
case of inadvertent intravascular injections (Adriani
and Campbell1956; Adriani etal.1959; Campbell and
Adriani1958; Scott and Hirschman1982). Slow injections enable the anesthetic solution to dilute in the
bloodstream (Adriani and Campbell 1956; Campbell
and Adriani1958; Forrest1959), in turn enabling the
lungs to retain some of the drug and attenuate the
toxic effect (Tucker and Mather 1979; Scott 1986).
Some authors consider slow injections to be the most
important factor for preventing adverse reactions in
dental local anesthesia, even more than aspiration
(Malamed2004).
6) Do not exceed the maximum dose for dental treatment.
Remember the patient’s weight and height, especially
in preschool children and children younger than
6–8
years (Annex 10) and in low- weight adults with
reduced body mass, who are very often elderly, to
minimize the risk of overdose (Goodson and
Moore1983; Hersh etal.1991; Virts1999). It is also
important to remember that topical anesthesia contributes to the dose administered and should be added
to the total dose (Cannell1996; Meechan1998). It is
very useful to keep the empty cartridges until the procedure has finished to know at all times the dose
administered, especially in the case of repeated
injections.
Basic Management ofComplications
This book does not address the management of general
complications in the office: the reader can consult the several excellent texts available (Bennett and Rosenberg2002;
Malamed2007; Grimes2013) and guidelines such as those
of the European Resuscitation Council (Monsieurs
etal.2015; European Resuscitation Council2020) and the
American Heart Association (Panchal etal.2020; Topjian
et al. 2020). However, we do wish to provide accepted
guidelines on how to manage general complications.
Initial Measures
The steps to be taken in the case of a general complication
associated with local anesthesia are as follows:
1) Suspend the dental treatment being administered to
address the complication that has arisen.
2) Patient position.
● If the patient is conscious and is having difficulty
breathing and/or shows signs of chest discomfort or
is anxious or nervous, the best approach is to allow
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P: Posture
The approach described is for a patient who reports dizziness, lightheadedness, or feeling faint, among other signs
of impending unconsciousness, namely, lying down with
the feet raised 15–30°. If the patient does not recover consciousness after a few seconds with this maneuver, then
we should suspect a more severe underlying condition
(i.e. arrhythmia, myocardial infarction, cerebrovascular
accident, hypoglycemia) (Greenwood 2008; Sambrook
etal.2011).
)
Figure23.1 (a) Patient lying in the horizontal position (supine
decubitus). (b) Patient in the Trendelenburg position. (c) Correct
position, horizontal with the legs raised.
him/her to find a position that is comfortable. This
generally involves the patient sitting up.
● If the patient becomes dizzy and it seems that he/she
is going to lose consciousness, the best position is
lying down (supine decubitus), with the head at the
same height as the rest of the body and heart, to help
blood reach the brain. In addition, the legs should be
raised 15–30° to favor venous return of the peripheral
blood to the heart (Figure23.1c).
● Two important observations about posture:
○ Do not place the patient in the Trendelenburg posi-
tion, with the whole body in a straight line with the
head pointing downwards (Figure23.1b). In this
posture, even though the head is lower than the
heart, the abdominal organs exert pressure on
the diaphragm, which in turn exerts pressure on
the lungs, thus restricting respiration.
○ Pregnant women in the third trimester should not
be placed horizontally face up, since the gravid
uterus exerts pressure on the inferior vena cava,
which ascends pressing against the spinal column,
leading to aortocaval compression syndrome. In
these cases, the best approach is to place the
patient in the left lateral recumbent position
(McGimpsey1977).
3) Loosen tight clothing such as belts, ties, and shirt col-
lars so as not to interfere with blood flow (Edmonson
etal.1978; Kuster and Udin1985).
Unconscious Patient
A loss of consciousness indicates a more dangerous phase,
when we should adopt the PABC approach (Malamed2007;
Haas2010) or the PCAB approach (Field etal.2010).
A: Airway
1) Remove any apparatus from the mouth, for example
gauze, cotton rolls, removable dental prosthesis, removable orthodontics devices, rubber dam, clamps, etc.
2) Clear the airway of obstruction by soft tissue, mainly a
closed tongue, which falls backwards. Leave the patient’s
head in a horizontal position by removing the extra head
supports before performing the following maneuvers:
● Head tilt- chin lift maneuver (standard maneuver)
(Figure23.2).
○ The dentist places him/herself to the side of the
patient’s head and, with the palm of the hand on
the forehead, pulls downward. With the index and
middle finger of the other hand placed on the symphysis menti, the dentist pulls upward until the
imaginary line that joins the earlobe with the chin
is perpendicular to the floor. Thus, the head is
turned backward and the neck extended.
○ During this maneuver, we should ensure that the
patient’s mouth is not fully closed and that the full
extension of the neck does not obstruct the airway.
● Jaw- thrust technique (Figure 23.3). Sometimes, the
previous technique may not be sufficient to clear the
upper airway. The head tilt-
chin lift maneuver may
not be applicable if the patient has a limited range of
motion, such as one acquired by having a cervical spinal fusion or cervical disc herniation. The jaw-
thrust
technique allows manipulation of the airway without
movement of the head or cervical spine. The technique is as follows:
● The dentist places him/herself behind the patient’s
head and places his/her index and middle fingers
behind the posterior border of the mandibular
ramus, with one hand on each side, and pulls the
mandible upward.
● The lower lip can be pulled back with the thumbs to
help the patient exhale through the mouth and nose.
● This maneuver is uncomfortable. However, any
audible complaint from the patient is a positive
sign because it shows that the degree of unconsciousness is not so deep.
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Figure23.4 With the patient in the head tilt- chin lift position,
the dentist places his/her head with the ear approximately 2 cm
from the patient’s nose and mouth, with the face looking toward
the patient’s chest.
Figure23.2 Head tilt- chin lift maneuver, used to open the
airways: (a) airway closed and (b) airway open.
Figure23.3 Jaw- thrust technique, used to open the airways.
B: Breathing
1) With the hands on the patient’s face to maintain the
head tilthead with the ear approximately 2
chin lift position, the dentist places his/her
cm from the patient’s
nose and mouth and with the face looking toward the
patient’s chest. This position enables the following
(Figure23.4):
● The dentist can hear and feel air entering and leaving
the patient’s nose and mouth (very reliable).
● The dentist can see the movements of the patient’s
chest. This is not as reliable since, while it shows that
the patient is trying to breathe, it does not guarantee
that gas exchange is taking place (as the diaphragm
may be working against an obstructed upper airway).
Sometimes, the patient’s clothing prevents the dentist
from observing the movement of the chest.
2) A bubbling/gurgling noise indicates that the airway is
partially obstructed by blood, saliva, water, secretions,
or vomit and should be cleared. The approach to adopt
is as follows:
● The dentist positions the head downward and places
the patient’s head turned to one side to facilitate
expulsion and prevent the aspiration of liquids
and debris.
● The dentist opens the patient’s mouth with the index
and middle finger and inserts an aspirator to suck out
liquids and debris. The cannula can even be
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inserted – carefully – in the posterior part of the
mouth and lower pharynx to remove any remaining
debris. The cannular should be plastic (not metal) so
as not to further damage soft and hard tissue.
3) If the patient is not breathing and there is no debris, the
dentist should undertake artificial respiration maneuvers (not covered in this book). Please consult guidelines such as those of the European Resuscitation
Council and the American Heart Association.
C: Circulation
At this point, the most important action is to palpate the
carotid artery. With the patient in the low head tilt-
chin lift
position, remove the hand from the chin and, as the patient
has his/her neck stretched, palpate the thyroid cartilage
(Adam’s apple). The carotid pulse is checked by placing the
index and middle fingers between the thyroid cartilage and
the sternocleidomastoid muscle.
If the pulse is weak but present, maintain the position
until the patient recovers or until the emergency services
arrive (see below) in the case of a patient whose condition
remains unchanged or worsens.
If no pulse is felt for 10
seconds, start cardiopulmonary
resuscitation. These maneuvers are beyond the scope of
this book, although they are very well explained in other
books and guidelines (Bennett and Rosenberg 2002;
Malamed2007; Monsieurs etal.2015; Panchal etal.2020;
Topjian etal.2020).
Note: The assistant can place a stethoscope on the
patient’s chest to evaluate the heart rate and take the
patient’s blood pressure with a sphygmomanometer. If
the situation persists, the patient should be assessed
every 5
minutes (heart rate, blood pressure, and breath-
ing rate).
Routes ofAdministration ofDrugs
Specific maneuvers may be necessary depending on the
complication, and it may even be necessary to administer
drugs. We can make a series of comments on the routes of
administration:
● Intravenous route. While this route is the fastest, it also
requires specific training. It is necessary to apply a tourniquet and to find the appropriate vein in the arm, hand,
forearm, or antecubital fossa.
● Sublingual route (Mercurio 1967). The drug is injected
into the floor of the mouth underneath the tongue if the
injection is intraoral (Figure23.5a); if the injection is
extraoral, the submental technique is used (Figure23.5b).
This technique has somewhat slower onset than the
intravenous technique, although it is faster than the
intramuscular technique (Sklar and Schwartz 1965;
Nichols and Cutright1971). In some cases, it may be a
good alternative to the intravenous technique for dentists who find it difficult to insert an intravenous line.
One important caveat to this is that injecting into a
highly vascular area, such as the floor of the mouth, can
result in a hematoma that can worsen an already
obstructed airway (Weaver2011).
● Intramuscular route. This route is slower than the oth-
ers. The drug can be injected into the deltoid muscle
(shoulder), gluteus muscle (upper lateral quadrant so as
not to inject the sciatic nerve or the vessels of the leg), or
the vastus lateralis muscle of the leg (medial-
lateral area
of the thigh), which is the preferred route in children.
This route is one of the best for dentists.
● Subcutaneous route. This is the slowest route.
Parenteral injection techniques are addressed in various
texts (Bennett and Rosenberg2002; Malamed2007).
Figure23.5 Sublingual injection techniques. (a) Injection into the floor of the mouth under the tongue if the drug is administered
intraorally. (b) Submental approach if the drug is injected extraorally.
Adam’s apple
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Calling theEmergency Services
If the dentist observes that (i) the patient does not improve
and the situation does not resolve, (ii) the patient’s condition worsens, or (iii) his/her instinct indicates that the
course of the complication is problematic, then the emergency services should be called so that the patient can be
treated in situ by specialized staff with specialized equipment or taken to a hospital. The emergency telephone num-
ber is 911in the United States, 112in the European Union,
and 999in the UK.
Psychogenic Reactions
Psychogenic, or psychosomatic, reactions are the most frequent general complications and can be classified into
three types:
1) Vasovagal syncope: the most common.
2) Hyperventilation syndrome.
3) Allergic- like reaction: this is exceptional.
General Causes
In all of the psychogenic reactions to be discussed, we can
identify two key factors:
1) The emotional situation of anxiety, tension, fear, or
panic. This is the basic factor.
2) The onset of intense and unexpected pain. This factor is
closely associated with the first one because it triggers
the emotional situation by creating a profound emotional experience of anxiety (McGimpsey 1977;
Edmondson etal.1978; Salins etal.1992).
Anxiety is such an important factor that it is worth point-
ing out some associated characteristics:
● People who are naturally anxious. Approximately 10% of
people have high levels of anxiety and fear when receiving dental treatment and a further 5% suffer from a phobia (Table8.1, Chapter8).
● Dental local anesthesia is the factor related to dental
treatment that causes the highest levels of anxiety. Seeing
the syringe and needle and feeling the prick of the needle
generate the most anxiety (Chapter8).
● It is difficult to differentiate between the behavior of
anxious and non- anxious adults in the office
(McGimpsey 1977; Kleinknecht and Bernstein 1978;
Ayer et al. 1983; Scott et al. 1984), therefore the health
questionnaire should contain a direct question on fear of
dental treatment, which could be classified into five categories (from none to considerable fear) to identify the
most anxious patients and to consider the risk of general
complications and the need for concomitant treatment
to sedate the patient and control anxiety (Kleinknecht
and Bernstein 1978; Scott and Hirschman 1982; Ayer
etal.1983).
It is interesting to highlight how nervousness before dental treatment can induce vasovagal syncope, even before
the treatment is administered (D’Eramo1999).
Vasovagal Syncope
Vasovagal syncope (neurocardiogenic syncope) is defined
as a sudden and marked drop in blood pressure (hypotension) and heart rate (bradycardia) caused by anxiety, fear,
and pain that is accompanied by weakness, sweating, and
pallor. In its most severe form it involves a sudden, transitory loss of consciousness (syncope or faint) due to the
drastic reduction in blood flow to the brain.
Vasovagal syncope is the most common complication
during administration of dental anesthesia and dental
treatment, accounting for 60% or more of all general com-
plications (Table 23.1) and affecting 0.5% of patients
treated (one in every 200) (Table 23.2). Other authors
report a frequency of one case every 6
months (Girdler
and Smith1999).
It is important to draw attention to the fact that this type
of reaction is easily confused with toxic reactions to local
anesthetics or vasoconstrictors and with allergic reactions
(Verrill 1975; McCarthy 1982; Milgrom and Fiset 1986;
Daubländer etal.1997; Batinac etal.2013).
Pathophysiology
The severe emotional reaction induced by anxiety leads to
three types of reaction:
1) Severe hypotension. This is the main type of syncope.
The emotional reaction and pain activate the parasympathetic nervous system in the brain (cholinergic),
which acts via the vagus nerve (cranial nerve X), leading
to the following:
● Dilation of the vessels of the abdominal viscera
(splanchnic circulation) (Bourne1980).
● Dilation of the vessels of the skeletal muscles in the
absence of physical activity due to the lack of a fight
or flight reaction (Harrison 1973; Edmondson
etal.1978; Bourne1980).
● Reduction in heart rate (bradycardia).
These factors in turn lead to a severe reduction in blood
pressure and therefore a reduction in blood flow to the
brain. Curiously, the effect of this reaction can be triggered by stimulation of the autonomic nervous system
(Taggart etal.1976).
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