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doi: 10.1007/s13258-019-00824-8 262 KhayyalMTKreuterMHKemmlerMAltmannPAbdel-NabyDHEl-GhazalyMA

Oral anaerobes generate volatile sulfur compounds (VSCs) such as hydrogen sulfide and methanethiol, which may modulate inflammatory signaling and epithelial integrity within the respiratory mucosa 195 , while organic acids and tryptophan-derived metabolites produced by oral commensals may further alter microbial colonisation patterns and host immune responses in the airways 196

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Having said that, there are some things that one can do that may reduce the likelihood of progressing to toxic levels: Ultrasound guidance may reduce the incidence, as one can more precisely target (and avoid vasculature) Use the lowest effective dose of local anesthetic (dose = volume x concentration) Incremental injection of local anesthetics, pausing between each injection (one circulation time) Aspirate before each injection (bear in mind there is a 2% false-negative rate for this diagnostic intervention) When injecting potentially toxic doses of local anesthetic, one can use of an intravascular marker