Introduction
Oral surgical procedures require administering anesthesia and the type of anesthesia varies depending on the specific procedure and the location in the mouth where treatment is needed. Palatal anesthesia is given for the extraction of upper teeth and surgical procedures involving the maxillary teeth.
A common anesthesia technique in dentistry is palatal infiltration, with a high success rate and without adverse reactions. But, complications can arise either during the procedure or in the postoperative phase. These complications may include needle breakage, hematoma (blood collected outside the blood vessels), postoperative paraesthesia (persistent anesthesia), edema, and, rarely, necrosis or intraoral lesions after anesthesia.
It is important to note that local anesthesia, when improperly administered, can lead to the development of a necrotic ulcer, an exceedingly rare complication. It occurs due to improper injection technique involving traumatic needle penetration and a pressurized release of the anesthetic solution.
What Is Palatal Anesthetic Necrotic Ulcer?
In dental surgery, a rare complication known as an anesthetic necrotic ulcer can occur on the palate after local anesthesia (LA). This ulcer usually happens in patients with risk factors like poor blood supply to the hard palate followed by a local anesthetic injection.
The ulcers are often deep and can heal on their own after treatment. In immunocompromised patients, healing may be delayed. If these palatal lesions are not treated, the necrotic spots on the palate can extend into the bone, leading to sequestrum (fragment of bone separated from healthy bone tissue) formation. This, in turn, may result in palatal perforation, causing severe, life-threatening complications like orofacial infections. Early and proper treatment is crucial to prevent these serious consequences.
What Are the Risk Factors for Anesthetic Necrotic Ulcer?
The palate is a common site for various soft-tissue issues, cysts, drug-induced lesions like phosphonate-induced osteonecrosis of the jaw , and oral cancers in individuals. The anesthetic necrotic ulcer is a less common but documented condition, on the palate that has several potential factors. These factors can contribute to decreased blood supply or a complete cut-off (tissue ischemia) to the palate, eventually leading to the formation of ulcers or lesions. The risk factors include:
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Direct effects of the anesthetic drug leading to ulceration.
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Tissue blanching during injection.
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Reduced or poor blood supply to the palate (a significant patient-related factor causing ulcers).
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Possible reactivation of latent forms of the herpes virus.
How to Manage Anesthetic Necrotic Ulcer of the Palate?
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Treating these lesions often involves reassuring the patient and using a conservative approach.
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Conservative management may include applying anesthetic-antiseptic gel.
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Surgical intervention is necessary if the underlying bone is involved.
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Most lesions heal spontaneously within three to four weeks with simple conservative care.
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Careful infiltration of local anesthesia is crucial to avoid or minimize ischemia-induced palatal ulcers.
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Anesthetic solutions without epinephrine are recommended, especially for minor surgical cases like simple extractions.
What Are the Advancements in Local Anesthesia Techniques?
In dental practice, it is standard and necessary to use local anesthesia for effective pain control during oral surgeries and procedures. Achieving proper local anesthesia is important for patient cooperation, especially in minor procedures like extractions, wisdom tooth removal, root canals, cyst removal surgeries, and major surgeries like tumor resections, fracture repairs, and facial reconstructions.
With modern dentistry techniques, such as the popular CCLAD technique (computer-controlled local anesthetic delivery), painless and error-free injections have become common. This advancement ensures a comfortable experience for patients and eliminates potential mistakes made by the dental operator. Even for experienced oral surgeons, the current dosing and composition of local anesthesia make it a reliable and painless way to induce effective anesthesia during dental procedures.
How Allergic Reactions Can Be Minimized?
In dental practice, there have been rare cases of allergic reactions commonly seen in individuals with a history of anesthesia allergies. These reactions can show up as specific lesions, or they may be linked to the pharmacological agents used. However, allergic reactions to local anesthetics, especially amide ones like Lidocaine (the most widely used dental anesthetic), have significantly decreased.
All modern local anesthetics, including Lidocaine, are considered safe and cause minimal irritation to oral tissues. Mepivacaine can be used as an alternative to Lidocaine. Mepivacaine has a less vasodilative effect on the palate compared to Lidocaine and Prilocaine. Using a three percent Mepivacaine solution without a vasoconstrictor is considered a suitable approach for achieving effective palatal anesthesia without causing any palatal or soft tissue necrosis.
How to Prevent Anesthetic Necrotic Ulcer of the Palate?
Dental practitioners must follow the following protocols to prevent anesthetic necrotic ulcers:
Dosing and Application:
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Limit the application of topical anesthetics to less than one to two minutes to minimize toxicity.
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Follow the manufacturer's instructions for dosage to ensure maximum efficacy.
History of Infection and Medical History:
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Take proper medical and medication histories from patients undergoing surgical procedures requiring local anesthesia.
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Be particularly vigilant in cases of recurrent aphthous stomatitis, herpes simplex, or mucormycosis, as these conditions can increase the risk of anesthetic necrotic ulcers.
Minimizing or Avoiding Vasoconstrictor in LA Solution:
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Exercise caution when using anesthetic solutions with high concentrations of epinephrine (e.g., 1:50,000; 1:30,000).
Previous Dental or Anesthetic History:
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Confirm the diagnosis of anesthetic necrotic ulcers and differentiate them from other palatal lesions.
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Collect information about the patient's medical and dental history, especially any previous extractions or local anesthesia administration at the trauma site.
Avoiding Trauma or Pressure on the Palate:
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Exercise care to avoid excessive pressure on the palate during local anesthesia administration, as the palate is a soft tissue firmly attached to the underlying bone.
Conclusion
It is essential to recognize that not all palatal ulcers following anesthesia are caused by the anesthetic itself. Those induced by palatal trauma or anesthetic allergy specifically fall under the category of anesthetic necrotic ulcers. The prevention of these ulcers involves the timely diagnosis and precautionary pre-procedural measures taken by oral surgeons. While it is an uncommon complication, anesthetic necrotic ulcers can be severe when trauma to the palate occurs due to anesthetic agents.
Modern anesthetics, along with strategies such as minimizing the use of vasoconstrictors in local anesthesia solutions or opting for alternative agents like three percent Mepivacaine, contribute to reducing the risk of developing this type of ulcer. This shows the importance of informed and careful procedural management to ensure patient safety and well-being.
