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reduced by injecting 150 T.R.U. of hyaluronidase dissolved in 1 to 3 ml. of saline solution directly into the afflicted area and applying pressure packs immediately after the injection.

The perforation by a bur or implant through the labial, buccal, or lingual plate of the alveolar bone of either jaw will surely result in swelling and tenderness. In such a case, the instrument should be removed as soon as possible and implantation delayed. Also, puncture or proximity to the nasal vestibulum, maxillary sinus, or inferior alveolar canal by any of the implant insertion instruments will cause swelling.

Hemorrhage

Hemorrhaging must be controlled before continuing with the intervention to prevent postoperative complications, including pain and swelling.

If the bleeding results from a definite tissue wound, not from a defect in the clotting mechanism, the use of pressure bandages, sutures, and blood-coagulating drugs will be of aid. Sometimes styptic agents can be used directly over the injured areas. (Warning: blood coagulants should not be given until the patient's general condition is reevaluated. It is assumed, naturally, that a medical history was previously obtained and is readily available for study.) Usually pressing a gauze pad directly over the wound or on the nearest pressure point is sufficient. The patient can bite on the gauze to make it easier for the operator.

Hemorrhaging of the gingival tissues can be con-trolled by suturing the wound margins together with 000 silk ligature. Bleeding from the bone itself can be arrested by suturing closed the gingiva over the wound or by packing the socket with an absorbable gelatin sponge or oxidized cellulose and then closing the wound.

If the patient is pale, shows signs of shock, and has cold clammy skin, he should immediately be administered oxygen and covered with a blanket. A physician may have to be called.

Adverse reactions to anesthesia

Allergic reactions resulting from local anesthetics include rashes, edema, rhinitis, asthma, and urticaria. These usually occur almost immediately after administration of the anesthetic. Antihistaminic drugs are suitable for milder cases, while epinephrine injections are utilized for the more severe reactions.

Although anaphylactic shock is not a common complication of local anesthesia, the operator should be able to recognize the signs and know how to treat

it. Some of the symptoms appear almost immediately after insertion of the needle. These symptoms include circulatory collapse, impaired respiration, cold sweat, and shivering followed by perspiration. If these appear, the patient should immediately be placed in a horizontal position with his feet slightly elevated and covered. An immediate injection of 0.5 ml. of 1:1,000 epinephrine should be given sub-cutaneously and the area massaged to increase the absorption rate. The patient should be administered oxygen as quickly as possible. If the patient does not improve rapidly, epinephrine should be again injected in 5 to 15 minutes.

Paresthesia, usually affecting the inferior alveolar nerve, sometimes results postoperatively if the injection directly injured the nerve or the ganglion, if the needle caused a hemorrhage in the neural sheath, or if a contaminating agent was present in the anesthetic solution. Although no definite treatment has proved successful in eliminating paresthesia, the administration of vitamins B,p or B, intramuscularly three times a week sometimes hastens recovery. In any event, many times the paresthesia may disappear after a number of weeks or months. Some, however, never disappear. Therefore it is of the utmost importance to carefully inject the anesthetic and to avoid placing an implant too close to the inferior alveolar nerve. The patient also should be forewarned of any possibility of a paresthesia.

The anesthetic's penetration of the parotid gland can cause a facial paralysis characterized by an in-ability to close the eyelid and a drooping of the corner of the mouth. This type of paralysis usually disappears within a short period of time.

Temporary blindness, diplopia (double vision), hematoma, tissue blanching, sloughing, and ulceration may also result from local anesthesia. Most of these symptoms are only of a short duration. Trismus, a condition caused by a hemorrhage or spasm in the pterygoid muscle, may be caused by an inferior alveolar nerve block.

Sometimes severe swelling of the inside of the cheek or lower lip will appear after the operation. Close examination will many times reveal that the swelling was caused by the patient's biting the afflicted area while under the influence of the local anesthetic.

Bone fracture

Fracture of the alveolar process or of a maxillary tuberosity resulting from perforation by or the proximity of an implant is also possible. In those situations where the alveolar bone is still attached to the