A 51-year-old male patient, weighing 64 kg, visited our outpatient department with the chief complaint of redness and swelling on the right side of the face that had occurred 3 h after a tooth extraction at another dental clinic. Furthermore, the patient complained of continuous throbbing pain associated with difficulty in chewing food and reduced mouth opening. There was no history of systemic illness. On examination, his vitals were stable; extra-orally, diffuse swelling was noted on the right side of the face along with erythema involving the right cheek, chin, and neck region (). The patient had no other symptoms except for mild itching associated with the erythema. Intra-orally, edema was noted around the unhealed socket of 48. Cone-beam computer tomography revealed a 48 root stump. Considering the patient’s history and examination findings, he was transferred to the Department of Dermatology to rule out any allergic reaction/allergen sensitivity before commencing any definitive treatment (surgical extraction of 48) under local anesthesia.\nSkin prick and intradermal tests were performed using the HollisterStier grading system (Allergy Skin Test Guide/HollisterStier - Sliding Guide Miles []) with five LAs: lidocaine, procaine, articaine, bupivacaine, and ropicaine. Wheel-and-flare reaction was noted only to lidocaine (). Therefore, procaine, with a duration of action shorter than that of lidocaine, was used as the LA for performing the surgical extraction of 48. Continuous monitoring of all vitals was performed for 3 h, and no signs of hypersensitivity were noted. Patient was discharged few hours after the procedure; he was instructed to self-monitor the symptoms and report to the emergency department in case of any symptoms or discomfort.
A 54-year-old female patient, weighing 77 kg, experienced various symptoms such as clouding of consciousness, hearing impairment, and chills during dental treatment for periodontal disease using a local anesthetic. Under the assumption that these adverse effects were attributable to the use of lidocaine, the patient was transferred to the Department of Allergy to determine whether local anesthesia with bupivacaine would be possible.\nThe Department of Allergy performed skin prick and intradermal tests to test for reactivity to bupivacaine, and the patient tested negative in the skin prick test. In the skin provocation test, when administered an intradermal injection of 0.1 cc bupivacaine diluted to 1:100, the patient complained of listlessness and drowsiness beginning 30 s after the injection. Following an intradermal injection of 0.1 cc bupivacaine diluted to 1:10, the patient's symptoms of listlessness and drowsiness became more severe from 30 s after the injection. When administered an intradermal injection of 0.1 cc of undiluted bupivacaine, the patient was placed in a recumbent position on a bed owing to complaints of listlessness and heavy eyes at approximately 50 s after the injection. Subsequently, the patient showed symptoms of shivering, which eventually became uncontrollable, and she had difficulty keeping her eyes open. As a result, the patient was given 2 doses of 0.5 mg Ativan. Afterward, the patient appeared to be more stable, but began showing symptoms of shaking her chin and one of her arms, for which 0.5 ampule of Demerol™ was administered, after which her condition began to improve. The testing was completed within 20 min and the patient was discharged after a 5 h observation period. The patient was diagnosed with bupivacaine intolerance, meaning the appearance of adverse effects even with small amounts of the medication, and the dental treatment was subsequently performed under general anesthesia since local anesthesia was determined to be impossible.