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Cover page of the Journal of Health Sciences


 
 Table of Contents  
CASE REPORT
Year : 2017  |  Volume : 10  |  Issue : 1  |  Page : 94-96

Palatal ulceration: A local anesthetic complication


Department of Pedodontics, Dr. HSJ Institute of Dental Sciences and Hospital, Chandigarh, India

Date of Web Publication18-Jan-2017

Correspondence Address:
Associate Prof. Urvashi Sharma
Department of Pedodontics, Dr. HSJ Institute of Dental Sciences and Hospital, Punjab University South Campus, Chandigarh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2349-5006.198598

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  Abstract 

The hard palate is one of the common sites of local complications following administration of local anesthetics. The hard, unyielding palatal tissues coupled with either forceful or excessive administration of solution, induction of trauma, use of contaminated solutions, or reactivation of latent viruses may present or aggravate local complications in the palatal area. Ulceration and necrosis is unusual and a rare complication of local anesthesia. Presented is such an uncommon case in a 16-year-old girl.

Keywords: Anesthesia, dental, necrosis, ulcer


How to cite this article:
Sharma U. Palatal ulceration: A local anesthetic complication. Indian J Health Sci Biomed Res 2017;10:94-6

How to cite this URL:
Sharma U. Palatal ulceration: A local anesthetic complication. Indian J Health Sci Biomed Res [serial online] 2017 [cited 2019 Oct 20];10:94-6. Available from: http://www.ijournalhs.org/text.asp?2017/10/1/94/198598


  Introduction Top


An anesthetic complication may be defined as "any deviation from the normally expected pattern during or after securing regional anesthesia."[1] Complications include syncope, muscle trismus, pain, edema, infections, broken needles, prolonged anesthesia, hematoma, sloughing, and bizarre neurological symptoms.[1]

The palatal tissues are susceptible to local complications on account of their dense, firm, and adherent nature. Local tissue changes can be produced or influenced by ischemia; osmotic pressure; pressure from injection; irritating effects of the vasoconstrictors, preservatives, and antioxidants; adventitious metal ions; or trauma.[1] Some of the reported local tissue changes after dental local anesthesia include ulceration,[2],[3] necrosis, and tissue slough.[4],[5]


  Case Report Top


A 16-year-old girl reported pain in the central part of the upper jaw. History revealed that she had visited a private practitioner a day before for correction of malaligned teeth. A visit to the local dentist revealed that she had been injected local anesthesia (2% lidocaine with 1:100,000 epinephrine) for extraction of an upper premolar for orthodontic purposes, which resulted in an almost immediate swelling of the tissues, resulting in deferral of extraction. The patient observed an increase in the swelling with the formation of an ulcer by the end of the day.

Medical and drug allergy history was noncontributory. An intraoral examination of the area revealed an edematous midline palatal swelling extending from the mesial aspect of the first premolar to the mesial aspect of the first permanent molar [Figure 1]. The swelling, with dimensions of about 13 mm by 9 mm, was fluctuant, tender, and erythematous and had well-defined margins. The central portion had an ovoid ulcer of dimensions 7.5 mm by 5 mm, covered with a necrotic grayish slough. The patient was prescribed an analgesic (nonsteroidal anti-inflammatory drug) and a topical obtundent gel. Healing was uneventful and occurred in around 10 days.
Figure 1: Palatal ulceration with a grayish necrotic slough

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  Discussion Top


Local anesthetics are defined as the agents which produce a temporary loss of sensation or pain in one part of the body without depressing the level of consciousness.[6] The main components of a local anesthetic cartridge are a local anesthetic agent, a vasoconstrictor, an antioxidant (bisulfites), and a preservative (paraben). The vasoconstrictor employed is usually epinephrine in a concentration ranging from 1:50,000 to 1:200,000. Vasoconstrictor prolongs the duration of anesthesia, decreases the rate of absorption from the local site, and reduces systemic toxicity.

Although the patient was advised to undergo a dermal patch test which turned out negative, skin tests to ascertain suspected allergy to local anesthetics are not always accurate.[7] Some of these could be attributed to a lack of appropriate knowledge of the precise antigens involved in true anesthetic allergy and a lack of proven reliable skin test reagents.[8]

Palatal tissues are relatively dense, confined, unyielding, and firmly adherent to the underlying bone. A high tissue pressure is created when the local anesthetic agent is administered rapidly and/or forcefully in the adherent palatal tissues causing pain and soreness in that area.[5] A misdirected needle because of an inadequate anatomic knowledge can also be a cause for local complications. Moreover, trauma induced either by insertion of the needle or the solution itself can lead to burning and swelling of the tissues which could reactivate latent viruses such as herpes simplex virus. In addition, an excessive concentration of a vasoconstrictor in a local anesthetic (1:50,000) or repeated injections in the same area at the same appointment also poses a greater risk.[9] The vasoconstrictor stimulates the α1 receptors of the peripheral blood vessels of mucous membranes leading to vasoconstriction, lowered tissue perfusion, and ischemia which may result in a trophic ulcer at the site of the administration of a local anesthetic.

A case of chronic nonspecific palatal ulceration after 5 days has been reported following greater palatine nerve block.[2] Yet another case reported one large and small palatal ulcerations, each covered by a necrotic slough after palatal injection.[3] Although not uncommon, a case of an inferior alveolar block resulting in a postanesthetic necrotic defect has also been reported.[4] The defect, in the latter case, was cylindrical with a deep punched-out lesion medial to the pterygomandibular fold following repeated doses of anesthesia given 2 months previously. It was attributed either to an excessive anesthetic solution containing epinephrine or a faulty technique. The development of such local palatal complications can best be avoided by slow deposition of the anesthetic agent (0.5 ml/min).[9] Knowledge of the proper anatomy of the area, before the administration of the anesthetic, is a must to avoid local complications. In the present case, a near midline ulcer was suggestive of an inappropriate injection site for palatal anesthesia. The thin and firmly adherent palatal mucosa in this site coupled with a likely rapid and/or forceful injection of the anesthetic or even, repeated injections at the same site at the same appointment could have formed a trophic ulcer secondary to ischemia.[9]

Although a topical anesthetic before the use of an injectable anesthetic was not used in the present case (confirmed from the practitioner), it is advisable that if used, it should be allowed to remain in contact with the mucous membrane for the recommended 1-2 min only. Local reactions such as epithelial desquamation, edema, ulceration, and probable tissue necrosis[10] are known to occur with prolonged periods or repeated use over the same area. Compared to an injectable local anesthetic agent, a topical anesthetic agent is of a higher concentration and with an absence of a vasoconstrictor, an easy diffusion, increased vascular absorption, and toxicity of the drug is facilitated.

Treatment of such local complications is usually conservative as the lesion usually heals without complications. Systemic analgesics and a topical obtundent can be recommended if pain continues in the localized area. Antibiotics are advised only if the lesion is secondarily infected.


  Conclusions Top


Care should be exercised when a topical or a local anesthetic agent is used. Knowledge of the palatal anatomy coupled with a slow deposition of the anesthetic solution; and a thorough knowledge of dental anesthetic dose will greatly help in minimizing local complications.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Bennett CR. Monheims Local Anaesthesia and Pain Control in Dental Practice. 1 st ed. Delhi: CBS Publishers and Distributors; 1990.  Back to cited text no. 1
    
2.
Hartenian KM, Stenger TG. Postanesthetic palatal ulceration. Oral Surg Oral Med Oral Pathol 1976;42:447-50.  Back to cited text no. 2
    
3.
Ghanem H, Suliman AM. Palatal ulceration: A complication of regional anesthesia of the oral cavity - A case report. Anesth Prog 1983;30:118-9.  Back to cited text no. 3
    
4.
Giunta J, Tsamsouris A, Cataldo E, Rao S, Schreier E. Postanesthetic necrotic defect. Oral Surg Oral Med Oral Pathol 1975;40:590-3.  Back to cited text no. 4
    
5.
Gogna N, Hussain S, Al-Rawi S. Case reports: Palatal mucosal necrosis after administration of a palatal infiltration. Br Dent J 2015;219:560-1.  Back to cited text no. 5
    
6.
American Academy of Pediatric Dentistry. Guideline on Use of Local Anesthesia for Pediatric Dental Patients. Clinical Guidelines, Reference Manual; 2009. Available from: http://www.aapd.org/media/policies_guidelines/g_localanesthesia.pdf. [Last accessed on 2010 May 08].  Back to cited text no. 6
    
7.
Ruzicka T, Gerstmeier M, Przybilla B, Ring J. Allergy to local anesthetics: Comparison of patch test with prick and intradermal test results. J Am Acad Dermatol 1987;16:1202-8.  Back to cited text no. 7
    
8.
Schwartz HJ, Sher TH. Bisulfite sensitivity manifesting as allergy to local dental anesthesia. J Allergy Clin Immunol 1985;75:525-7.  Back to cited text no. 8
    
9.
Malamed SF. Techniques of maxillary anaesthesia. In: Handbook of Local Anesthesia. 3 rd ed. St. Louis, MO: Elsevier Mosby; 2013.  Back to cited text no. 9
    
10.
Franz-Montan M, Ranali J, Ramacciato JC, de Andrade ED, Volpato MC, Groppo FC. Ulceration of gingival mucosa after topical application of EMLA: Report of four cases. Br Dent J 2008;204:133-4.  Back to cited text no. 10
    


    Figures

  [Figure 1]


This article has been cited by
1 Isolated Actinomycosis of the Hard Palate Incurred Subsequent to Local Anesthesia
Vugar Gurbanov,Damla Torul
Journal of Craniofacial Surgery. 2019; 30(7): e645
[Pubmed] | [DOI]



 

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