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How do I manage paresthesia caused by a needle injury?

Woman Holds Her Cheek, ToothacheThis question was submitted by a general dentist: How do I manage paresthesia caused by a needle injury? The patient felt an electric shock on his tongue while I was inserting the needle for the block.  I had not injected anything yet.  Is there a different way to manage the paresthesia if you know it is from trauma or from anesthetic toxicity?

Dr. Dan Haas, Dean of the Faculty of Dentistry at the University of Toronto and Dr. Suham Alexander provided this quick initial response

 

Paresthesia is defined as a persistent anesthesia or altered sensation that extends beyond the expected duration of anesthesia. It is usually an unpreventable complication in patients undergoing oral surgical procedures including implant placement; however, it is also a common issue cited in dental malpractice litigation.

The sensation of the “electric shock” is caused by needle contact with the nerve, and may be all that is required to produce paresthesia. It is uncommon for nerves to be severed during local anesthetic injection given the small gauge needles used in dentistry. The definitive cause of paresthesia following local anesthetic injection is not known with certainty, but there has been the suggestion that it is more common following blocks using 4% local anesthetic solutions. Most cases of paresthesia will spontaneously resolve within days, weeks, or months. Those that last beyond 6 to 9 months are considered permanent.

If it is determined that paresthesia is due to surgical trauma, then consultation with an oral and maxillofacial surgeon should be considered to help determine if a surgical approach to repair is warranted. If it is determined that paresthesia is due to local anesthetic injection, then consider the following.

Patient Management  

1. Reassure patient

  • Practitioner should speak to the patient personally
  • Explain how paresthesia occurs and expected timeframe for resolution
  • Book an examination appointment with the patient
  • Record incident in the dental record

2. Patient examination

  • Discuss phenomenon of paresthesia with patient
  • Explain paresthesia may take time to resolve and can take months, although rarely it may persist indefinitely
  • Determine degree and extent of paresthesia patient is experiencing
  • Record examination findings in the chart

3. Follow-up with patient

  • Re-examine patient within one month, and then in 1 – 2 month intervals, or more often if appropriate, for as long as the paresthesia persists. An improvement in the signs and symptoms, however gradual, is often a promising sign of eventual complete resolution.
  • If paresthesia persists at this first follow-up appointment, offer to refer the patient to an oral and maxillofacial surgeon or other appropriate specialist for an assessment.

4. Dental Treatment

  • Dental treatment may continue in other areas of the mouth
  • If further treatment is required in the area of the sensory deficit, avoid injecting local anesthetic into this region – consider alternative techniques to deliver anesthetic

References 

  1. Malamed SF. Handbook of Local Anesthesia. 2013. Elsevier Mosby. St. Louis, Missouri.
  2. Moore PA and Haas DA. Paresthesias in Dentistry, Dental Clinics of North America 2010;54(4): 715-730

 

13 Comments

  1. Dr.R.Orawiec October 7, 2014

    I had recent experience of a ‘chef’ claiming parasthesia as well as loss of taste. I am being sued for $750,000. I am sure this patient would rather have a mandibular block than proceeding without local anasthesia for this procedure. While the risk is small, unforeseen events happen.To my knowledge there is no reason to obtain consent for local anasthesia, there is no need to explain the risk as it is minimal. We do not get to sign a release when we board a plane as risk is there but minimal as well. Most dentists will administer approximately 1800 mandibular blocks and get some reports of nerve damage. Prilocaine and Articane 4% solutions are recently suspect. What are your recommendations ?

    Reply
    1. Anonymous October 8, 2014

      Switch to lidocaine from articaine. Less likely for lidocaine to cause nerve damage

      1. David Wilkie October 14, 2014

        More risk from articaine? The ONE study on this was questionable at best. Anecdotally, I’ve used articaine almost exclusively since the mid-80’s and never had an anaesthetic-related paraesthaesia (though I DID see it once in a very deep 3rd molar exo, a complication that I related to surgical technique rather than anaesthetic complications.) The whole “articaine induced paraeshesia” thing is getting a bit tiresome.

  2. Dr Sheryl P Lipton October 7, 2014

    Is the use of steroid therapy appropriate? Are there studies to support it’s use in reducing paraesthesia?

    Reply
  3. Dr J. Marcoe October 8, 2014

    ” , but there has been the suggestion that it is more common following blocks using 4% local anesthetic solutions.”

    If possible please clarify the suggestion.

    Reply
    1. Robert Kaufmann October 9, 2014

      If you go to : http://www.endoexperience.com/library_2.html#4

      you will find an extensive section on LA and specifically the “Articaine and/or 4% solution” controversy.

  4. Julie-Claude Leblanc October 8, 2014

    Où dois-je cliquer pour avoir une version en français?
    Mon personnel souhaiterait le lire.

    Reply
  5. VR October 10, 2014

    Thanks for a very concise and useful explanation!

    Reply
  6. Bernd Jäkel October 13, 2014

    I practised in Europe for 20 years and used 4% Articaine exclusively. My experience does not in any way support the claim that 4% anesthetic solutions or Articaine increase the likelihood for paresthesia, even if used for mandibular blocks. This hype is turning dentists away from an excellent anesthetic. Studies are one thing, but my experience lets me sleep quite well on this particular issue.

    Reply
    1. Dr. Sheryl P. Lipton October 14, 2014

      Wow!! Dr. Jakel, you say that you’ve used articaine for many years and never had a problem!! That’s like saying that you smoked your whole life and never got cancer so smoking must be ok!!
      Studies are done on huge numbers of statistically significant populations.
      It’s wonderful that you didn’t have a problem with articaine, but I will believe the RCDSO and the studies that show otherwise. Of course, articaine appears to be not a problem for local infiltration, but I wouldn’t use it for mandibular blocks.
      Respectfully,

      Sheryl Lipton

      1. Anonymous October 14, 2014

        Dr. Lipton: your analogy doesn’t quite fly! We surely agree that smoking has absolutely nothing positive about it, except perhaps being a good tax source. Articaine, on the other hand, is an excellent material with some contrversy regarding its use in mandibular blocks. This controversy, however, is not significant enough to warrant the manufacturer to contra-indicate Articaine for blocks. That says something in a litigious environment like North America!
        I think that the bottom line is to stay within your own comfort zone.
        Regards, Bernd Jakel

  7. Dr Gilles Leblanc November 3, 2014

    j’AIMERAIS BIEN LIRE LES ARTICLES EN FRANÇAIS PARTICULIÈREMENT POUR MON PERSONNEL. OÙ PUIS-JE AVOIR LES TEXTES EN FRAÇAIS

    Reply
  8. Anonymous December 24, 2014

    What would a referral to an Oral Surgeon accomplish? I do not believe there is any technology or treatments available to repair damaged nerves. If I am right, why tie up an Oral Surgeon’s schedule with something he can do nothing about? If the only reason is to continue to reassure an upset patient, the the referring dentist needs to work on his communication techniques. The extremely small risk of permanent nerve damage following a nerve block needs to be made clear to the patient as part of an initial general release. I also think that the people who make local anaesthetics should fund a large scale study to put the 4% controversy to bed once and for all. I have experienced approximately 3 temporary paraesthesias in my 28 year career, all of them using 4% Articaine.

    Reply

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