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Is My Patient’s Hematoma Related to a PSA injection?

One of my patients underwent replacement of occlusal amalgams on #3 and #4 with recurrent decay using a resin restorative material. The patient complained of swelling and bruising the length of her mandible that lasted about 2 weeks, along with irritation inside her cheeks and lips.

 One of my patients underwent replacement of occlusal amalgams on #3 and #4 with recurrent decay using a resin restorative material. One carpule of articaine HCl 4% (40 mg/mL) with epinephrine 1:200,000 was administered. The patient complained of swelling and bruising the length of her mandible that lasted about 2 weeks, along with irritation inside her cheeks and lips. The patient had no history of any allergies and she underwent several dental procedures in the past. Is it possible this is related to the anesthesia injection?

Yes, it is likely the injection resulted in a hematoma. The question does not state if a posterior superior alveolar (PSA) injection was administered to anesthetize tooth #3, but a hematoma most frequently occurs with PSA injections and may also happen with the inferior alveolar and mental/incisive injections.

A hematoma develops when a blood vessel (artery or vein) is inadvertently injured by the needle. If the injury is minor or the tissue is dense, a hematoma is unlikely to be noticeable extraorally. If an artery or vessel is injured in a vascular area, such as the pterygopalatine or infratemporal fossa, a more dramatic response of swelling and bruising may occur. It is not unusual for swelling and bruising to manifest in the mandibular area following a PSA injection. Bruising can last up to 14 days depending on the amount of bleeding that occurs. The swelling may have led to the irritation intraorally.

Treating a hematoma involves discontinuing the procedure and applying pressure and ice at the first indication of swelling and bruising. A quick response can limit swelling and bleeding. Ice can be applied intermittently for up to 6 hours, and patients should be advised to avoid any anticoagulant pain relievers such as aspirin. The patient is likely to experience soreness and limited ability to open his or her mouth. Heat or a moist warm towel can be applied the following day to minimize the discomfort of muscle trismus. A patient should not be dismissed until the bleeding is stopped. Practitioners should inform the patient of the occurrence and assure him or her that the bruising will heal in 7 days to 14 days with no additional treatment required.

The patient must be advised to notify you immediately if signs of infection appear. Follow-up with the patient to ensure healing occurs is considered best practice.

The Ask the Expert column features answers to your most pressing clinical questions provided by Dimensions of Dental Hygiene’s online panel of key opinion leaders, including: Jacqueline J. Freudenthal, RDH, MHE, on anesthesia; Nancy K. Mann, RDH, MSEd, on cultural competency; Claudia Turcotte, CDA, RDH, MSDH, MSOSH, on ergonomics; Van B. Haywood, DMD, and Erin S. Boyleston, RDH, MS, on esthetic dentistry; Michele Carr, RDH, MA, on ethics and risk management; Erin Relich, RDH, BSDH, MSA ,on fluoride use; Kandis V. Garland, RDH, MS, on infection control; Mary Kaye Scaramucci, RDH, MS, on instrument sharpen­ing; Kathleen O. Hodges, RDH, MS, on instrumentation; Karen Davis, RDH, BSDH, on insurance coding; Cynthia Stegeman, EdD, RDH, RD, LD, CDE, on nutrition; Olga A.C. Ibsen, RDH, MS, on oral pathology; Michael W. Roberts, DDS, MScD, on pediatric dentistry; Timothy J. Hempton, DDS, on periodontal therapy; Ann Eshenaur Spolarich, RDH, PhD, on pharmacology; and Caren M. Barnes, RDH, MS, on polishing. Log on to dimensionsofdentalhygiene.com/​​asktheexpert to submit your question.

From Dimensions of Dental Hygiene. March 2020;18(3):46.

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