Dental Local Anesthesia and Ehlers Danlos Syndrome

Ehlers Danlos Syndrome is a group of similar inherited disorders that adversely affect the connective tissue. Patients with this disease experience problems in the skin, joints, blood vessels, and other areas. In addition, some disorders within the syndrome also make the individual resistant to local anesthesia.

Unfortunately very few dentists are aware of this phenomenon. And in addition, there are patients out there with undiagnosed Ehlers Danlos, as well as patients with EDS who are not aware of the issues with local anesthesia. What happens? The patient ends up having a very unpleasant time at the dentist with both the dentist and patient trying to figure out what is going on!

About Ehlers Danlos Syndrome

Ehlers Danlos and dental local anestheticIt is not the point of this blog post to talk about the Syndrome in great detail. There are plenty of other sites out there that accomplish this. However, to understand how this affects dentistry and the dreaded “novocaine shot,” you need to know a bit about the disease.

Ehlers Danlos affects connective tissue. Connective tissue is basically the “glue” that holds other tissue and organs together. Specifially, there are defects with the production of collagen, which is the major protein in connective tissue. While there are six major types of EDS, they are all generally characterized by hypermobile joints (joints that can move way beyond what would be considered normal), joint pain, fragile and easily bruised skin, and other findings.

Not all of the genes responsible for Ehlers Danlos are known and there is active research into all parts of this syndrome.

Why Does Local Anesthesia Not Always Work?

First, it needs to be mentioned that not all of the six types of EDS make the patient resistant to dental local anesthetic. Based on research (here and here), it appears that Type III – Hypermobility is the one in which this phenomenon is seen.

dental injections don't always work in Ehlers Danlos

For those with some types of Ehlers Danlos, you will need MANY injections of very specific anesthetics for effective local anesthesia.

Unfortunately, the mechanism behind why the local anesthesia is less effective is not well understood. The current theory focuses on the “looseness” of the connective tissue. Since the connective tissue is defective, it is very easy for the local anesthetic to quickly move away from the site that is being anesthetized. Stated another way, the connective tissue barriers that hold the local anesthesia in place for the duration of the dental procedure are weak and easily broken.

The end result is that the patient is not sufficiently numb for the dental procedure, leading to pain. Patients get confused, discouraged, angry, and ultimately avoid the dentist, which then makes things even worse down the road.

What Should Dental Patients Do?

Ehler Danlos hypermobility which can affect dental local anesthesia

If you can do this with your thumb, you may have Ehlers Danlos.

As a dentist who treats patients in private practice, I am disappointed that this issue is not well known in the dental community. Ask most dentists and unfortunately, most will not be aware of this. In fact, in what is considered the bible of dental local anesthesia (A Handbook of Local Anesthesia by Stanley Malamed), there is no mention of phenomenon (I searched the 6th edition).

Here are some tips:

  1. Find a dentist who has experience with Ehlers Danlos. There is nothing wrong with calling an office and asking if the dentist is familiar with EDS and this local anesthetic phenomenon.
  2. Identify yourself early on as having Ehlers Danlos to the hygienist and dentist.
  3. Find an opportunity to meet with the dentist in advance of any procedure requiring local anesthetic to review the plan (remember that the office may have to order a special type of local anesthetic).
  4. Consider taking a medication beforehand to relax you.
  5. Be ready for a longer than normal appointment.
  6. At the completion of the appointment, especially if it was successful, ask the dentist for detailed records on the local anesthesia (what local anesthetic, how much administered, where administered, etc.)

In some cases, nitrous oxide and/or IV sedation may be necessary to complement the local anesthesia.

My own experience treating patients with Ehlers Danlos has shown that most of the time, we can achieve local anesthesia. I attribute my success to knowing the pharmacology of local anesthetics as well as other injection techniques. To use a pun based on EDS, with a little “flexibility” in selecting local anesthetics and injection sites, we can nearly always succeed!


  1. Joanne McKenzie says

    I read about Ehlers Danlos syndrome in your blog. I think this is a really informative blog. Every time what a local anesthesia do does not work because they use local product. A dental patients always follow the instruction what his/her doctor instruct to do. For more information you can follow our website.

  2. Elizabeth Darden says

    Ehlers Danlos syndrome (EDS) is the name for a group of rare inherited conditions that affect connective tissue. Connective tissues provide support in skin, tendons, ligaments, blood vessels, internal organs and bones. Some times the dentists use less quantity for local anesthesia so the procedure don’t work properly. Specially the quality of the products make difference in the procedure.

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  4. Alisha Franco says

    I had a tooth pulled about 5 years ago before I knew I had ehlers Danlos syndrome Hypermobility and the dentist had to give me 4 shots before I could no longer feel anything. He was very mad at me and saying that I didn’t feel anything and it was in my head. I was crying and so scared. He said I was just feeling pressure but no pain. I knew I was feeling pain and I finally screamed and was feeling like II got pass out. My fave was so numb it was sagging when we were all done.
    Horrible experience!

    • Jennifer Duncan says

      Alisha Franco…That is so my story too. I was ten and had to have 7 teeth extracted (3 were baby teeth ) and the anaesthetic worked for a bit but not for long. For the last three teeth I was not numb at all. The dentist was yelling at me, telling me I wasn’t in pain, just feeling pressure. And kept threatening me saying that he could give me another shot but it would have to go in my upper pallet and did I remember how much that hurt? Sometimes npvacane works for me and sometimes it doesn’t. Same dentist later had to fill a cavity for me and after two shots and I wasn’t numb, he grudgingly gave me a third. He didn’t put anything on topical on the gum. When he injected ,I screamed, and he said “You weren’t kidding, you really weren’t numb!”. This man put me off dentists for years!

      Finally found a dentist who worked well with me. She wasn’t familiar with EDS but before my first official appointment she learned about it and how it affected my oral health. Such a different experience!

  5. This is my entire dental experience life. I was diagnosed with type iii at the age of 34. You are. Genius

  6. Im not scared or anxious of dentists per se, but the reason I do get anxious is because I have never had a visit to the dentist where the injection has fully taken first time. And it usually wears off fast. Same with painkillers, I need a lot to even touch pain. Must be the way my liver metabolises things. I do have psoriasis and autoimmune issues and wonder if that has something to do with it. When I go to a new dentist it is always the same, they never listen and don’t believe me so Ihave to go through it all again each time. I have had to move around a lot you see and reliant upon NHS so if Im out of the catchment area I cannot keep the same dentist. Sigh… it is horrible having to feel pain every time. Sadly I don’t get a lot of choice on NHS – and too many of them are far from humble or nice.

  7. E. J. Chithalen says

    So, what local anaesthetic have you found most successful?

    • I am assuming you are a dentist. I like to use several. The most common is 4% articaine with 1:100K epi. I buffer all my local anesthetics. Note that buffered septocaine is not FDA approved for sale – but Onset is doing it – but if you buffer it yourself you are not breaking any rules. By buffering, you are making the local more available to cross into the neuron much more quickly before it can “leak” away through poorly formed connective tissue. Is there research to back this up? No. Should someone be researching this? Yes. My observations are anectdotal at best but you can’t argue with success. Sometimes also 2% lido with 1:50K epi as the extra epi decreases the distribution of the local away from the site.

      • Leslie Hilton says

        Thank you SO much for this blog! I recently read an interesting article about injectable diphenhydramine being an alternate option for local anesthesia in emergency medicine. Could this translate over to dentistry? If viable, I’m wondering if this option might work better than any of the “caines” + epi for providing numbness to EDS + POTS patients who are sensitive to the effects of the epi? Have you had any experience with this?

      • PJ Langhoff says

        I have tremendous issues with dental work and respond well with shots that do not contain epi, which makes my head feel like a snow globe by the way, as well as cause my heart rate to soar. I require a bit extra shot-wise and have suffered much pain even with laser procedures because of sensitivity. But if I get enough numbing agent, I manage to make it through about 30 minutes without squirming too much, although I am still highly reactive to anything beyond 1% of phosphate etch, which still causes reactions when it gets on mucous membranes (flushing, heart rate increase, panic attack) but with good suction and water rinses, subdues. ALSO taking lemon water and swishing in my mouth 1/2 hour prior to dentistry work HELPS to significantly moderate the reactions….so consider that for it raises the acid content of the mouth and this helps for some reason. IF ONLY I can get to the bottom of the phosphate reactions, because that restricts my diet so so much (anaphylactoid-type reactions). Any help on this is most welcome.

    • Trina Saice says

      Personally, I have found that Marcaine (so?) works well for me. I have hEDS and mild hemophilia B. I have had many dental procedures (root scaling, root canals, extractions and re-shaping of my gums) done with little to no anesthesia (not due to lack of trying) and when I was Dx’d with the EDS I was doing research and read that Marcaine had much better results even with stitches and other injuries.

      • Trina,

        Thank you for your comment. There is no good research in any of the dental journals on the “best” local anesthetics for EDS patients. Through anecdotal evidence, marcaine does appear to be superior. Marcaine has the highest protein binding of all the local anesthetics – which is why the duration is long.

        Not all dentists keep marcaine in stock so always be sure to ask your dentist in advance.

  8. Elizabeth says

    Have you had any patient with EDS Type 3 who exhibited extreme hypersensitivity to local anesthetic?
    Based on the likely mechanism of action, this seems possible, but I haven’t found anything in the literature.

    • I have not experienced this, but I have not had the opportunity to treat as many EDS patients as I would like. Can you define hypersensitivity? Such as the duration of the numbness?

      • Elizabeth says

        Thanks. It’s me. I’m also a nurse practitioner with EDS.
        I achieve full numbness with, as my dentist described it, 1/10th the dose. If I get more than a micro dose, then I have profound numbness and early lidocaine toxicity (ringing ears, circumoral numbness, tunnel vision. The numbness has spread so much it will be in my throat and I feel like I am choking (because I can’t really swallow)
        Similar (but much worse) reaction during epidural during childbirth on 1/6 the dose. So they had to d/c the epidural. (Bradycardia of mom and baby, severe hypotension)
        And I tend to do other procedure without any lidocaine. I never connected this with my EDS until I read your posting! Thorough literature review does not show EDS with hypersensitivity. I’m pretty certain my daughter has EDS, but she’s never had lidocaine.

        • tommy Newill says

          your reaction sounds less EDS related and more MCAS have you looked into this possibility ? I have hEDS, vEDS POTS , and MCAS so sometimes it can all get confused but as a zebra i am sure you know that we are very prone to about 40 other disorders i would look into the MCAS i gt very similar reactions sometimes but its form the MCAS

        • C Weaver says

          That is the opposite of the normal Zebra reaction. It takes far more local anesthesia to work for most of us. I don’t get numb at the dentist without about 3 times as much as usual and it took 3 tries for the anesthesiologist to get me numb with my epidural. She said if that third try didn’t work she would have to do a block because she couldn’t give me any more. Luckily it did finally make it so I couldn’t still lift my legs up off of the table!

  9. I just experienced this at the dentist today–several attempts had to be made to numb me up. I’ve had all kinds of weird things happen though. The previous time, the anesthesia paralyzed my eye for a while. I suspect that it just passes through tissue more easily and tends to travel more. I also struggle with implants falling out or succumbing to repeated infections even though I keep them clean. The dentist finally said that he believed that my gums may not be sealing around the implants normally due to EDS. I agree that I wish it were better studied. My daughters both have EDS as well, and my oldest always has trouble getting her mouth numb enough. She says it seems like it all just drains to the back of her mouth and numbs up the wrong area.

  10. Heidi Hawkins says

    To complicate matters even further, EDS patients are also much more likely to have some type of dysautonomia or POTS. (Postural Orthostatic Tachycardia Syndrome) It’s rare to have EDS alone, there will usually be accompanying issues such as autoimmune conditions, mitral valve prolapse. A common combination is EDS, POTS and Mast Cell Activation Disorder. These patients may have adverse reactions to Epi or other vasoconstrictors. So it’s a dilemma: Local anesthetic will wear off very quickly and Epi will cause cardiovascular side effects. In addition, these patients often have a genetic profile that makes them a poor risk for nitrous oxide. It’s no wonder that these patients develop dental phobias! Here is some more info:

    • Leslie Hilton says

      Heidi, this is interesting. Can you point me to more info explaining how EDS and POTS genetics make patients apt to nitrous oxide intolerance? I am 38 yo and I was just recently diagnosed with EDS-HM and POTS. I have both a long history of poor response to dental anesthesia and history of poor response to nitrous oxide (high fever and hallucinations.)

    • Yessssss! Thank you! My heart races when I get the novocaine because of the epinephrine in it. There have been times when I have almost passed out getting up after a procedure just from the epinephrine. And I need about 3 times the shots to get numb. I have EDS type 3 and MCAD and POTS. It’s a lot. On top of the fact that we have crappy enamel and get cavities so we’re there all the time!
      Great awareness here tho!

  11. Isaiah McLain says

    I am not sure if i have EDS or not i had an appointment for a filling today first numb i could not feel anyhting for 3 mins they i could numbed me 3 more times and i could still feel it dentist finished even though i was in pain lip was numb af teeth-gums not at all. -Isaiah-

  12. This is interesting. I have never been diagnosed with Ehlers-Danlos but according to Brighton and Beighton scores — could very well be. I have difficulty with dental anesthesia. A very strange thing happens that NO ONE has been able to explain. When I get anesthesia on the RIGHT side, it temporarily paralyzes the muscles in my LEFT eye and I cannot move my eye. Also can systemically make me weak. The last time, I thought I was getting away without this happening but 12+ hours after the dental anesthesia was administered on the RIGHT, I developed blurriness and pain in my LEFT eye which lasted until that evening. Also didn’t feel numbness until after my appointment was over — so it was a delayed reaction.

  13. Thank you for this… I wake during anesthesia.. it’s awful.

  14. I have POTS and EDS, NOW it makes perfect sense why seeing dentist is miserable. THANK YOU for this blog, Also as with lots POTS patients teeth rot away from excess saliva, curious to know if all on 4 implants would last longer?

    • Every case is different. But the bacteria and factors that cause tooth decay will not compromise implants. Implants can fail as well, but typically for other reasons. It is worthwhile to consider implants given your situation.

  15. I was recently diagnosed with EDS type 3 AND also have a bleeding disorder as a result…I WISH I could say that lack of freezing in a dental chair was the worst thing…which I have had numerous times…HOWEVER, having a spinal epidural wear off, before my c-section was completed…by FAR tops ALL of my dental nightmares combined!
    I can leave you to imagine what it feels to have your abdomen sliced open from one end to the other…not only being awake, but having no one believe your screams of pain…therefore NOT topping up the anesthesia…all the while having the doctor panicking because your bleeding out in front of their eyes, repeatedly telling the others to hurry up what they were doing because I was losing too much blood! I lost over half my blood volume that time. I DO remember a feeling of drifting off to somewhere peaceful.

  16. Kathy Villarreal says

    I would like to share that the skin/tissue inside of my mouth is loose, and every time I brush my teeth or eat something tissue comes off. You could put your finger in my mouth, move it around and tissue comes off (yes I have EDS type 3). I also have bumps all around my mouth as well. My dentist reminds me to stop sucking on the inside of my mouth, and I always tell him I don’t and I honestly think it’s some how EDS related. I am just wanting to know do other EDS patients have this problem and if so what do I do about it?

  17. C Weaver says

    The other thing that makes this situation even more difficult is that it is also common for hEDS patients to have heart arrythmias or tachychardias. Epinephrine, if it is injected in the wrong spot can cause a very uncomfortable complication. It is a catch 22. Epi keeps the anesthetic localized so it doesn’t wear off as fast, but the epi can also cause heart palpitations. I’ve had horrible dental phobia my whole life from a dentist I had as a child that didn’t believe me when I said I could still feel it. They thought I was just being dramatic. Please educate dentists! Doctors are also a problem. No one has heard of or really understands what this syndrome does. Thank you for this article!

  18. Heather Grace says

    I’ve actually become so fearful of dentists, I haven’t been seeing anyone. My teeth are a mess & I know it’s harming me medically. Happened several yrs ago, when a dentist was pulling off a very stuck(messed up) bridge that’d been put in just 6yrs earlier. Was told I needed a bridge. Knew it was true. But the immense pain I was caused made it impossible to drive away when I got to my car. I just sat there & sobbed. It was traumatic—tho far from the 1st time I’ve been in severe pain in a dental chair. Now I need REAL HELP but have no idea where to go/how to get it. It’d be amazing if a dentist who’s somewhat of an expert in EDS could help me… especially if they could fund it in their hearts to help me pro bono.

    I know I got myself in this mess. Tho in truth, a portion of the yrs I went w/o care, I couldn’t really have seen a dentist easily if I wanted to. Was focused on caring for family member w/dementia & had essentially NO BACKUP. Had just 1 fam member who was able to give me a break 1nite/wk for <2hrs.

    Can’t keep ignoring this SERIOUS problem—already have compromised immune system, allergic to the world essentially. And it’s gotten *MUCH* WORSE in the last 6mos. If anyone knows of anybody who may be able to help in So Cal, pls let me know!

  19. Kristin Langdon says

    I am a patient with EDS. The geneticists have diagnosed us as having EDS Classical or Hypermobile. We are still doing more genetic testing. I have this condition. From a patient standpoint, I cannot thank you enough. I’ve had to endure trauma for years because the dentists wouldn’t believe me. I was actually held down by one last year while another proceeded to yank my tooth out and broke it on the way out. The pain was so tremendous I could t talk about it for weeks. I have two broken teeth that need pulling and I’m so scared. Petrified I won’t be believed again.


  1. […] off this blog post to give your dentist so they can have an understanding of how EDS may affect your appointment. […]