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Dental Hygiene Local Anesthesia Study Boards

Terms in this set (419)

pain perception
fear of pain, keeps seeking dental care
What are 2 ways we control pain in dentistry?
1. Behavioral Method
2. Pharmacological Method
What is behavioral Method?
breathing exercise, meditation, acupuncture
What are some pharmacological methods?
1. LA
2. Inhalation (nitrous)
3. sedation oral premedication (valium)
4. conscious sedation
5. IV sedation
6. general anesthesia
Local anesthesia is for?
pain control
Inhalation sedation is for ?
help control fear
what is armamentarium and the components?
equipment to administer LA
1. syringe
2. needle
3. cartridge
4. topical
type of syringes?
1.non disposable
2. disposable
3. safety
4. intraosseous systems
5. computer controlled LA delivery system
What are the 5 types of NON DISPOSABLE SYRINGES?
1. breech loading metallic cartridge, aspirating
2. Breech loading, plastic cartridge, aspirating
3. breech loading metallic cartridge, self aspirating
4. pressure
5. jet injector
in SCCC we use which type of syringe?
breech loading metallic cart. aspirating
breech loading means?
cartridge isolated from the side
there are 5 components of a syringe what are they?
1. Needle adapter
2. syringe barrel
3. piston and harpoon
4. finger grip
5. thumb ring
The thumb ring traps and controls the syringe as well as ?
move the piston
the finger grip is for what?
grasp and control syringe
the piston connects what two things?
thumb ring and harpoon
The harpoon allows for what kind of pressure within cartridge? to check what?>
negative pressure to check location of lumen of needle
5 advantages of breech loading metallic cart. aspirating syringe?
1. visible cart
2. one hand aspirating
3. autoclavable
4. rust resistant
5. long lasting
what are disadvantage of breech loading metallic cart, aspirating syringe?
1. weight 2. too big 3. infection if improper care
should a non aspirating syringe be used?
never
a non aspirating syringe has risk for?
intravascular drug administration
what type of syringe is the standard of care?
aspirating
what are the type of needle lengths in dentistry? 3 types and mm length?
LONG which is 32mm
Short 25mm and
ultrashort is 12 mm only in 30 gauge
5 parts to a needle?? draw and label
Bevel
shaft
hub
syringe adapter
cart penetration end
2 factors to consider about shaft?
diameter lumen
length from point to hub
what is a gauge?
diameter of lumen. smaller greater diameter
colors of needles? 25? 27? 30? which is largest lumen?
25 red is the largest
27 yellow
30 blue
which needle is recommended for inj posing high risk positive aspiration?
red 25 gauge
which needle recommended for injection where positive aspiration is low and tissue penetration is minimal?
yellow 27 guage
4 advantage of using larger gauge?
1. less deflection
2. greater accuracy
3. less chance breakage
4. aspiration easier and more reliable
what is deflection?
needle deflects away target area, from bevel
larger needles less deflection more accuracy
change the needle after how many penetrations?
3-4
draw and name parts of cartridge?
cylindrical glass tube
plunger
Aluminum cap
neck
diaphragm
which component of cart is made of latex?
diaphragm
what are the components of a cartridge?
local anesthetic drug
Vasoconstrictor
Preservative for vaso
sodium chloride
distilled water
each cart is made of how much soln?
1.8ml or 1.8cc
packaging of cart can come in 2 types and number in each?
vacuum sealed*50
sealed blister 10
cart should store in light or dark place? why?
dark cause deterioration mainly vaso. decrease duration of anesth
can you immerse cart in disinfectant? why?
never, contamination and corrode cap
topical effective into how much tissue?
2-3 mm not deep or hard tissue
what causes leakage during injection?
off center perforation of diaphragm
what causes broken cart?
worn syringe, bent harpoon
excess force
needle bend not engaged
what causes disengagement of harpoon?
dull harpoon
excess force during aspiration
what happens if piston doesn't move?
at syringe end, needle no perforated to diaphragm
pain on insertion due to?
dull needle change 3-4 times
pain on withdraw due to?
fishhook barbs caused by manufacturing, or contact bone
what causes injury to pt or operator?
sudden unexpected movement pt
There is a small bubble in cartridge. What is the bubble made of and result of it? can we use?
nitrogen gas
manufacturing process
yes
What do large bubbles in cart indicate? can we use and why?
was frozen
can't use, not sterile
what does a extruded stopper with large bubbles indicate?
soln frozen, soln not sterile
what does extruded stopper without bubbles indicate?
contaminated in disinfectant soln
what does a corroded cap indicate?
immersion in disinfectant soln that contain ammonium salts
what does rust on cap indicate?
one of carp leaked
sticky stoppers were common when manufactures used what to lubricate stopper? and now we use what?
paraffin wax
silicone
what are 4 reason it may burn on inj?
1. normal response pH
2. contain sterilizing soln
3. over heart cart
4. vaso
how to position pt at an inj?
head and heart parallel to floor, feet slt. elevated
supine position helps prevent ______. which is also the most common medical emergency with injections
syncope (or fainting)
local infiltration is?
small nerve endings, interproximal papilla
field block is an injection of where? also called two other names?
is injection above apex also called infiltration and supraperiosteal inj
A nerve block, anesthetizes what?
main nerve trunk
Draw and name the nerve origin starting from the Central nerve?
CN V : trigeminal
opthalmic maxilary mand
PSA pterygpalatine IO
GP NP MSA ASA
the maxillary division of central nerve #?
5 trigeminal
CN V then exits through the _______ _____ which is located in the _______ _______ of ________ bone
foramen rotundum
greater wing of sphenoid bone
supraperiosteal or field block .. numbs the region innervated by the terminal branches of the _____ _____ including: (what does it anesthetize?)
dental plexus
including: pulp and root area of specific tooth, buccal periodontium tissues, mucous membrane
when to use field block?
1-2 teeth
contraindications for field block?
inflammation or infection dense bone over apex
what is site of deposition for field block?
apex tooth, height muccobuccal fold, tip at apex
ASA innervates? (what it anesthetizes)
pulp max central, lateral, and canine
buccal periodontium
PDL and overlying bone
upper lip and lower nose
can ASA cross the midline and innvervate opposite side?
yes
what % of population can ASA originate premolars and MB root of max 1st molar. but not be numbed in those teeth
72%
contraindication of ASA?
infection or acute inflammation
what gauge use for ASA and area to inject?
27 short or 25 short
in canine fossa
between lateral and canine height muccobuccal fold
needle parallel to long axis of canine, follow contour maxilla bone
depth of insertion of ASA?
3-6mm
Site of deposition of ASA?
well above apex canine in canine fossa
deposit how much for ASA?
0.9-1.2 ml soln
The IO inj anesthetizes which nerves?
ASA MSA
MSA anesthetizes?
pulp 1st and 2nd premolar and MB root first molar
buccal periodontium
overlying bone
MSA use what gauge and area of injection?
27 short or 25 short
above 2nd premolar at height muccobuccal fold
If patient has 1 premolar where do u do a MSA?
apex of that premolar
depth of insertion for MSA?
5-8mm
Deposit how much for MSA?
0.9-1.2ml
Amides metabolizes in what?
liver
Esters metabolizes in the ?
plasma
what are the 5 types of amide LA? and which is gold standard?
articane
bupivacaine
Lidocaine** gold standard
Mepivacaine
Prilocaine
what are the 2 esters of LA? no longer used
procaine (novocane) and propoxycaine
what is important to know about LA agents prior to administer them to patient?
duration of action
MRD
contrindications
short duration lasts how many min? and which LA are included?
less than 30 pulpal
Lido 2%
Mepivacaine 3%
Prilocaine 4% (infiltration)
all plain.. no epi
Intermediate duartion is __min pulpal?
60
long duration is how many min pulpal? which LA?
90 +
Bupivacaine .5% 1:200,000 epi
when a lot of s0ft tissue must be penetrated to get to the nerve it is harder to maintain accuracy of deposition which can INCREASE OR DECREASE the duration??
decrease
inflammation, infection or pain INCREASES OR DECREASES duration anest.?
decreases
increased vascularity decreases the duration because?
drug absorbed rapidly
Lidocaine onset of action
2-3 min
duration of lido plain..pulpal and soft tissue
5-10 min pulpal
1-2 hrs soft tissue
duartion lido 2% 1:50,000 epi
60 min pulap
3-5 hrs soft tissue
duration lido 2% 1:100,000 epi
60 min pulpal
3-5 hrs soft tissue
mepivacaine 3% plain
onset?
duartion?
onset 1.5-2 min
20-40 in pulpal
2-3 hrs soft tissue
which anesth recc for pt when a vaso is not indicated? and the least vasodialating
mepivacaine
prilocaine plain onset?
2-4 min
prilocaine plain duration for field block?
10-15 min pulpal
1.5-2hrs soft tissue
prilocaine plain duration nerve block ?
40-60 min pulpal
2-4 hrs soft tissue
prilocaine 1:200,000 epi duration?
60-90 min pulpal
3-8 hr soft tissue
Which LA does metabolism occur in both the plasma and liver?
Articaine
Articaine onset?
1-3 min
articaine 4% 1:200,000 epi duration?
45-60 min pulpal
2-5 hr soft tissue
articaine 4% 1:100,000 epi duration?
60-75 min pulpal
3-6 hr soft tissue
DO NOT use articaine on patients with what kind of sensitivities?
SULFITE
Bupivacaine .5% 1:200,000 onset and duration?
onset 6-10 min
90-180 min pulpal
4-9 hr soft tissue
which LA is the most toxic and most vasodialating of the amides???
bupivacaine
For palatine injection place topical for a full __ min?
2
for palatine injections do you use pressure anesth. before or during injection?
both
The GP anesth which areas?
posterior hard palate
overlying soft tissues
premolar region
medial to midline palate
what are contraindications of GP?
inflammation or infection
smaller areas of therapy
What gauge do you use for GP? and area to insert?
27 short
palatal soft tissue anterior greater palatal foramen
What is path of insertion for GP?
syringe from opposite side of mouth at right angle target area
the GP foramen is usually located distal to the ?
max 2nd molar
what is the depth of insertion and amount of LA for a GP?
4-6mm and .45-.6 ml
true or false? in order to give an accurate injection of GP you need to enter th GP foramen?
false. very painful
Gp has what % success rate?
95%
with a GP anesthesia of the palatal area of the ___ ____ may be inadeq. due to the NP fibers overlapping
1st premolar
what are some complications with a GP?
ischemia ( lack blood supply) causing necrosis when highly concentrated vasoconstrictors are used over long period
* necrosis. will look like ulceration heal in 2 wks
Nasopalatine area to anesthetize?
anterior hard palate and overlying tissues,
mesial of right 1st premolar and mesial left 1st premolar
yes or no NP has pulpal anesth?
no
yes or no hemostasis for np?
no
NP gauge? and area of insertion?
27 short
palatal mucosa lateral incisive papilla
how much deposit on a NP?
0.45 ml
Local anesthesia is the ____ of _______ in an area of the body caused by a ______ of _______ in nerve endings or an inhibition of the conduction of a nerves ________
loss of sensation
depression of excitation
impulse
neurophysiology is a roadblock of the source of the impulse and the _____, preventing the ________ of ______
brain, interpretation of pain
A nerve impulse or neuron carries messages from one part of the body to ____? These messages are called?
to another
called, electrical action protentials or impulses
A neuron or nerve cell are??
the structural unit of the neuron system
There are 2 basic neurons that are present. Name the 2 types:
sensory or afferent neurons
motor or efferent neurons
The sensory or afferent neuron conduct impulses from the ____ to the ______
periphery to the CNS
The motor neuron conducts impulses from the ____ to the _____
CNS
periphery
Draw and label the structure of a sensory neuron
dendritic zone in the periphery
axon
cell body or soma
terminal arborization for the synapse with the CNS
Draw and label parts of the motor or effect neuron
cell body axon dendritic zone
true or false.. sensory nerves are afferent, going from the CNS to periphery
false. periphery to CNS
Peripheral nerves are made up of many axons bundled together in groups called??
fasciculi
The outer region of the nerve is called?
mantle
the fasciculi in the mantle are called the?
mantle bundles
the center portion of the nerve is called? which contains the ____ _____ of the fasciculi
core
core bundles
peripheral nerve anatomy: the fibers of the mantle innervate areas _____ to them while the fibers of core innervate sites _____ _____
close
further away
A nerve that carries messages from one part of the body to another in form of impulses are called??
action potential
action potential:
depolarization of the nerve membrane results from a _____ in the membrane permeability to ___ and ____
increase
potassium and sodium
what 4 stimuli initiates a IMPULSE?
chemical stimuli
thermal stimuli
mechanical
electrical
What are the 3 phases of a nerve conduction?
resting state
depolarization
repolorization
which phase of the nerve conduction is the non conducting nerve occur?
resting state
which phase of nerve conduction does the membrane excitation occur?
depolorization
Name 2 parts of the repolarization phase
absolute refractory period
relative refractory period
A negative electrical potential ___mv exits across the nerve membrane . this is produced by differing concentrations of ions on either side of membrane
-70mv
the interior of the is ____ relative to the exterior. negative or positive??
negative
during the resting state the nerve membrane is slightly permeable to _____
freely permeable to ___ and ___
sodium
potassium and chloride
DEPOLORIZATION:
stimulus excites the nerve causing more permeability to ___
*influx of ___ causes nerve to undergo depolarization
depolarization results in initiation and spread of an impulse along the nerve to the _____
Na
Na
CNS
depolarization begin slow/fast?
slowly
depolarization:
______ ______ occurs when the nerve membrane changes by 15mv
then ____ _____ is now -50 to -60mV
firing potential
membrane potential
depolarization:
In a normal nerve the ____ ____ remains constant?
firing thershold
exposure to a local anesthetic raises/lowers? a nerves firing thershold
raises because a lot Na+ pass membrane to decrease to a level where depolarization occurs
depolarization:
firing potential is reached, nerve is more freely permeable to?
* ___ begin to diffuse out
*the influx of Na ions cause the nerve to undergo ____ _____
* at the end of depolarization the transmembrane electrical potential is ___mv
Na
K+
rapid depolarization
+40
which phase?
action potential is terminated when the membrane ______
caused by an inactivation to sodium
*nerve returns to resting state
repolarization
repolarization: SODIUM PUMP
the ____ ions remain in axoplasm (inside cell)
the ____ ions remain in extracellular fluid
*metabolic activity begins:
sodium pump moves remaining __ out of nerve
sodium pump moves __ from the outside to inside cell
Na
K+
Na
k
what period of repolarization phase?
nerve is unable to respond to a stimulus regardless of its strength?

time when a new impulse can be initiated but only by a stronger than normal stimulus ?
absolute refractory period
relative refractory period
sensory neurons are myelinated, not unmyelinated. t/f?
false they are both
myelinated neurons are what type of delta fibers?
is it a sharp, bright pain or slow burning pain?
A delta fiber
sharp bright pain
unmyelinated neurons are what type fiber?
sharp, bright pain or slow burning pain?
c fibers
slow burning pain
A delta fibers and C fibers are responsible for transmitting ____ input from the dental and periodontal tissues. Both are in pump, there is more __ fibers than _ fibers
sensory
c
a
what are nodes of ranvier?
allow nerve impulse to go much faster in comparison to unmyelinated nerve
In a myelinated nerve the impulse leaps from node to node. What is this called?
salutatory conduction
When the nerve is myelinated, conduction more rapid and energy efficient. Greater the ____ of the axon, thicker the myelin sheath. therefore salutatory conduction occurs more rapidly in thicker axon
diameter
______ fiber which is myelinated. transmit a sharp stabbing type pain while the unmyelinated ___ fiber transmit slow, burning pain
A delta
C
Local anesthesia is a ___ of sensation in a circumscribed area of the body caused by a _________ of excitation in nerve endings.
Loss
Depression
What is is called when local anesthetics achieve their effects by binding to specific receptors within the sodium channels of a nerve thereby altering nerve condution.
Conduction blockage
How much of the nerve should local anesthetic cover to ensure its effects?
8-10mm
In a myelinated nerve, the anesthetic must block the action potential in at least how many nodes of ranvier?
2-3 consecutive nodes
What are some properties of an ideal anesthetic?
Sterile
Non-irritating to tissues
Reversible (it will wear off)
Low systemic toxicity
Effective when injected as well as topically
Quick onset
Sufficient duration
Non-Allergenic
Readily metabolized
Adequate potency without use of harmful concentrations
What is the composition of an anesthetic carpule?
Vasoconstrictor (optional)
-Epinephrine
-Levonordefrin

Antioxidant/preservative (sodium sulfite)
-only present when there's a vasoconstrictor

Alkalining agent- adjusts the pH & makes solution more basic

Sodium chloride- makes solution isotonic for surrounding tissue

Sterile water- provides volume to solution (main component)
What are the two categories of local anesthetics?
Esters (mainly used as topical)
Amides
Why aren't esters used as an injectable drug in the US?
They are associated with a higher risk for allergies
The three components of local anesthetics are:
Lipophilic
Intermediate chain
Hydrophilic
True/False: local anesthetics either have a liphophilic component or a hydrophilic component, but not both.
False- Local anesthetics contain both lipophilic and hydrophilic components.
Esters and amides are classified according to its __________.
Chemical linkage
____________ ________ determines the classification.
Intermediate chain
Local anesthetics must diffuse through ______ __________ and ________.
Nerve Membrane
Tissue
True/False: Local anesthetics can either be lipid or water soluble.
False- it must be both.
Lipid soluble- gets through the membrane
Water soluble- gets through the tissues
Lipophilic component contains a _________ _____ which enables penetration of lipid-rich nerve sheath and is responsible for lipid solubility.
Benzene ring
Lipid solubility of the local anesthetic is determined by __________.
it's potency
Hydrophilic component, when combined with __________ _____, allows anesthetic to diffuse through _________ _______ in the tissues to reach the nerve.
Hydrochloric acid (HCl)
Interstitial fluid
What is an esters mode of biotransformation?
Metabolized in the plasma
What is an amides mode of biotransformation?
Metabolized in the liver
Esters were developed first but mainly used as _________ and it's name is _________.
topical
Benzocaine
Amides are commonly used in dentistry. What are the names of anesthetics that contain amides?
Lidocaine
Mepivacaine
Prilocaine
Bupivacaine
Etidocaine
Articaine
In their original form, local anestetics are basic compounds that are poorly ________ in water, ________ to air, and not clinically valuable. When combined with ___________ _____, they form local anesthetic salts that are ________ in water (sterile saline). This makes anesthetic stable and clinically effective.
soluble
unstable
Hydrocholic acid
soluble
How many ionic forms does local anesthetic salts have and what are they?
2
RN
RNH+
The RN ionic form is the _____ and is uncharged. It is ______-soluble and enables diffusion through the nerve sheath. The RNH+ ionic form is the _______ and is charged. It _____ to receptors sites in _______ channels, blocking nerve conduction.
base
lipid
cation
binds
sodium
Each ionic form of local anesthetic is dependent on the _____ and ____ of the solution or surrounding enviornment.
pKa
pH
What is pKa?
dissociation constant. It's the molecule's affinity for hydrogen atoms.
Drug with high pKa has affinity for hydrogen atoms & water soluble
Drug with low pKa does not have affinity for hydrogen atoms & fat soluble
In order for a drug to be both water and fat soluble, it must have two separate forms. What are they?
RN (base) fat soluble form
RNH+ (cation) water soluble form
For the amount of RN and RNH+ to balance, what does it depend on?
pH
What is the pH of normal tissue
pH 7.4
Why are anesthetics more acidic than normal tissue?
In order for anesthetics to get through soft tissue, there's a need for more RNH+ (water solubility).
At the nerve sheath, only ___ molecules go through the lipid membrane. Inside the neuron, the ___ molecules change to the ____ for; the _____ ions block the sodium channels. Gradually, most of the ____ form outside the nerve changes to the ___ form allowing passage through the nerve sheath.
RN
RN
RNH+
RNH+
RNH+
RN
What is the pH of inflamed tissue?
pH 5-6
Inflammation makes the tissues have a lower pH than normal. the LA solution will have less available RN base form to go through the nerve sheath. Will the anesthetic solution penetrate the nerve membrane and why?
Because inflamed tissues are more acidic, the RNH+ does not convert into RN which is why there isn't much RN available to penetrate the nerve membrane.
Inflamed tissue has more ______ blood vessels causing absorption and uptake of the LA.
dilated
What are some characteristics of local anesthetics with epinephrine?
Have low pH (anything with a vasoconstrictor)
Makes it burn on injection
Slower onset (more acidic, basic LAs work faster)
What causes inadequate concentrations of LA in nerve fibers?
Inaccurate site of deposition
Rapid absorption of solution in blood stream (due to inflammation)
Decreased pH of tissues surrounding the nerve (due to inflammation)
What are factors that influence blood levels of LA?
Uptake
Distribution and redistribution
Metabolism of ester linked anesthetics
Metabolism of amide linked anesthetics
Excretion
The rate of LA is related to __________ of tissues. Route of administration ______ rate of absorption. Absorption is governed by _________ injected regardless of concentration.
Vascularity
alters
quantity
Once absorbed into the blood, LA is distributed to all body tissues such as:
brain
lung
liver
kidney
muscle
fat
bone
tissues with higher blood content have higher blood levels of LA
Blood levels of anesthetic reflects:
The rate at which the drug is absorbed in the CVS
The rate at which the drug is distributed to the tissue and
The elimination of the drug through metabolism or excretion
The rate that the drug is removed from the blood is the ___________ _____-______. It tells you how long a drug stays in your system.
Elimination half-life
________ binding may prolong the time that the drug is in the blood.
Protein
(other drugs a person may be taking)
Metabolism of an ester and hydrolysis occurs in the plasma through _________________.
Pseudocholinesterase
True/False: Allergy of esters are related to para-aminobenzoic acid (PABA) which is why ester injectable anesthetics are no longer common.
True
Metabolism of an amide is primarily metabolized by ________ _________.
Microsomal enzymes
True/False: Both prilocaine and articaine are metabolized in the liver and lungs.
False:
Prilocaine is metabolized in the liver and lungs
Articaine is metabolized in the liver and blood
Hepatic dysfunction or hepatic disease cause the inability to metabolize _______ at a normal rate.
Amides
Which organ is a primary excretory organ of both esters and amides?
Kidney
What are patients with kidney problems at risk for when given LA?
Toxicity because the drug is not excreted as effectively and the drug stays in the blood longer.
True/False: Both esters and amides cross the placenta in significant quantity.
True
Be careful with pregnant patients
What are some factors that influence toxicity?
Type of drug
Concentration
Route of administration
Vascularity of tissue
Vasoconstrictor
Weight of patient
Rate of metabolism and excretion
What are some adverse effects of LA?
Administration into vascular tissue (injecting into a blood vessel)
Giving too high a dosage
Giving the anesthetic too quickly
Poor drug clearance from the body (people with poor liver/kidney problems)
Why is it important to aspirate?
The higher the blood level, the greater the chance for systemic toxicity.
At toxic levels, the CNS pharmacological action is __________ and things slow down.
depression
True/False: Toxic or overdose levels of LA present CNS depression and tonic-clonic episodes.
True
Seizures are primary clinical manifestation
What can happen to the CVS when toxicity occurs?
Decrease electrical excitability of myocardium and electrical conduction rate and form of contraction.
Hypotension at overdose levels
Complete collapse of cardiovascular system at lethal levels (stops heart)
Allergic reactions are rare with LA that contain amides, but what are signs of an allergy? What causes the reaction?
Mild rash to anaphylaxis
Sulfites
How deep into the tissue can topical take its effects and aids in comfortable needle penetration?
2-3mm into tissue
Topical anesthetics aid in a _________ injection.
comfortable
Topical gel contains what kind of anesthetic?
Benzocaine
True/False: Topical anesthetic anesthetizes deep tissue or hard tissues.
False- it only anesthetizes 2-3 mm of tissues
Topical anesthetics come in ______ concentration thatn local anesthetic to facilitate _________ of the drug.
Higher
Diffusion
True/False: Topical anesthetics have a greater chance for toxicity than injectable anesthetics and cause most cases of toxicity.
First statement is true, Second statement is false.
Though topical anesthetics have a greater chance for toxicity, it is poorly absorbed in the CVS in topical forms.
Topical anesthetics do not contain _____________ and are rapidly absorbed into the bloodstream and have vasodilating properties.
vasoconstrictors
True/False: It's okay to administer topical gel to patients with ester allergies because it's not absorbed systemically and doesn't cause any reaction.
False: it is not okay to administer topical anesthetic to patients who have ester allergies. It causes a localized allergic response such as blister/hive at the spot applied.
What types of topical are available?
Gel
Ointment
Liquid
Spray
Bioadhesive Matrix
Topical anesthetic sprays should be metered spray dose. If the spray is unmetered, the risk of _________ is much greater. A problem with sprays is keeping the nozzle _______.
overdose
sterile
Topical anesthetic bioadhesive matrix contains 46.1mg of __________ and last for ___ mins. It helps prevent ______ by keeping blood concentrations very low.
lidocaine
30
toxicity
What are some precautions to topical anesthetics?
Place topical at injection site only
Apply to no more than 3 teeth at a time
Full quadrant application not indicated and could lead to an overdose
Spray forms doses cannot be monitored
What is the procedure for placing topical?
Explain what and why
Dry site
Apply to site and do not rub (causes sloughing and higher dosage)
Wipe off excess after 1-2 mins
What are the major differences between benzocaine and lidocaine as topical anesthetics?
Benzocaine: Higher incidence of localized allergy, not suitable for injection
True/False: Most undesirable reactions to LA are a response to the drugs itself and not the act of getting an injection.
False- Most undesirable reactions to LA are response to the ACT of getting an injection and not the drug itself.
What are the two common undesirable reactions to LA?
Vasodepressor syncope
Hyperventilation
What should be done prior to treatment?
Determine patients tolerance
Make modifications as necessary
Review medical history
Take vital signs
Review dental questionnaire
A medical/dental questionnaire should be done. What are some things that should be known about a patient?
Presence of pain
Anxiety
Past dental experiences
Hospitalization
Under care of physician
History of bleeding
History/presence of medical condition
Allergic reactions to medication
Allergic reaction to other substances
Medications or drugs taking now or previously
A patients ____ status determine any modifications to treatment. _____ status I-III may receive vasoconstrictors in LA.
ASA
ASA
True/False: ASA IV Cardiovascular risk patient are good candidates for elective dental treatment.
False- ASA IV and beyond are not good candidates for dental treatment. They are too compromised.
Patients who are ASA III-IV with congestive heart failure (choose all that apply):
a) have decreased liver perfusion
b) do not metabolize the anesthetic as readily
c) increase the half-life of amide anesthetics
d) increased risk of overdose
e) should not have a medical consult
f) stress reduction protocol with nitrous oxide
g) modification of positioning- risk of orthopnea
All EXCEPT E.
The patient SHOULD have a medical consult.
Myocardial infarction during the past 6 months is considered ASA ___. Elective dental treatment is ___________. After 6 months, ASA status is considered ASA ____. Vasoconstrictors are ______ after 6 month period.
IV
contraindicated
III
limited
Vasoconstrictors are ok when angina is ______. Anxiety may precipitate an attack. Unstable angina represents ASA ____ and cannot be treated. Medical consult may be ________.
stable
IV
indicated
Blood pressure should be take at _______ appointment. With mild to moderate elevated BP, clinician should ________ vasoconstrictors.
Every
limit
Patients with heart operation, heart murmur, congenital heart lesion, rheumatic fever, and scarlet fever should all get what before dental treatment?
Medical consultation- determination of antibiotic premedication
Guidelines say that these cases still need antibiotic premedication. Which are they:
a) artificial heart valves
b) history of infective endocarditis
c) mitral valve prolapse
d) certain, specific, serious congenital heart conditions
e) cardiac transplant that develops a problem in a heart valve
d) bicuspid valve disease
a, b, d, e
Mitral valve prolapse
bicuspid valve disease
rheumatic heart disease
calcified aortic stenosis
heart pacemakers
congenital heart conditions such as ventricular septal defect, atrial septal defect and hypertrophic cardiomyopathy
no longer need antibiotic premedication
Cardiovascular- compromised patient can have ____mg of epinephrine per appointment. The maximum catridges of 4ml of a 1:100,000 is ___ or 8ml of a 1:200,000 is ___.
.04mg
2 cartridges
4 cartridges
Acetaminophen can _______ methemoglobin levels and is a relative contraindication to what type of anesthetic?
elevate
Articaine (lower amount)
Cimetidine (Tagamet and Peptol) increase the ____-____ of amide anesthetics. It is only an issue if a patient is ASA ____ and has congestive heart failure. __________ dose of amides should be used.
half-life
III
Minimal
What should be done with non-selective beta blockers
Monitor heart rate, rhythm and BP
Strictly limit vasoconstrictors
Limit usage of lidocaine
Patients taking Tricyclic Antidepressants, avoid ____________: tricyclics can increase the vasoconstricting properties by 5-10 times. Limit _____________: tricyclics can increase vasopressor effects by 2x.
levenordefrin
epinephrine
Phenothiazines can decrease vasopressor effects and create hypotension if injected intravascularly. Limit usage of ____________.
Vasoconstrictors
If a patient is using cocaine, what can it do?
CNS & CVS stimulant
If vasoconstrictor is given, can cause significant dysrhythmias, myocardial infarction, or cardiac arrest
Reschedule if taken within 24 hours
If a patient is using methamphetamine, what can it do?
If vasoconstrictor is given, it can cause heart attack, stroke, hypertensive crisis.
Reschedule if taken within 24 hours
If a patient is using marijuana, what may happen when given LA?
It will be harder for the patient to receive the benefits of anesthetic.
True/False: Giving a patient with a sodium bisulfite or metabisulfite allergy a carpule of lidocaine with epinephrine is the best decision.
False: Epinephrine is the vasoconstrictor. Anesthetics with vasoconstrictors contain sulfite as its preservative. Patients with sulfite allergies can only receive plain anesthetics.
A patient who is allergic to methylparaben (PABA) should ________ the use of an ester topical.
Avoid
True/False: Patients with latex allergies should not be given anesthetics because of the latex diaphragms.
False: Theoretically is it a contraindication, but there are no cases reported of an allergic reaction due to the latex diaphragm.
Where does the Mental Nerve Exit?
Mental Foramen
Where is the Incisive nerve located and what does it innervate?
Continues a long in the Mandibular Canal and innervates the premolars and anteriors.
TRUE/FALSE :Incisive nerve block is a bilateral injection.
FALSE: It is a unilateral injection meaning that it will only anesthetize the area being injected.
What teeth are anesthetized with the Incisive nerve block?
-Mandibular 1st and 2nd premolar, canine, lateral incisor, and central incisor.
What area of the Gingiva is anesthetized with Incisive nerve block?
Mandibular buccal gingiva from the mental foramen to the midline.
What other areas are anesthetized with Incisive nerve block?
-PDL from 2nd premolar to central incisor
-bone overlying these teeth
-Mandibular Buccal Mucosa
-lower lip and skin of chin to midline.
What is being anesthetized in a Incisive nerve block? (Nerves)
-Incisive and Mental nerve
TRUE/FALSE: The lingual tissue will not get numb with the Incisive block.
TRUE: only the IABL anesthetizes the lingual nerve.
What are contraindicatoins with Incisive nerve block?
-Infection or Inflammation
What are some advantages/disadvantages for the Incisive Nerve block?
Advantages: Highly Successful
-Provides pulpal and hard tissue without having the tongue numb

Disadvantages:
-No lingual anesthesia
What is the percentage aspiration for the Incisive nerve block?
5.7 %
What are some complications with this injection?
-Hematoma
-Trauma to the nerves if the needle enters the foramen
What are reasons why the Incisive nerve block will lack pulpal anesthesia?
-Inadequate solution in the mental foramen
-Not enough extra oral pressure
What is needed to provide pulapal anesthesia?
Anesthetic needs to enter the foramen, by achieving this pressure must be applied to the area for 2 minutes. Do not rub the area.
Where is the mental foramen Located?
-Can visually be seen in radiographs in between the 1st and 2nd premolar.
How can you locate the mental foramen?
Palpation
What gauge is used for the Incisive nerve block and what area?
25 or 27 gauge short
Muccobuccal fold in the area between the 1st and 2nd premolar.
Depth of Penetration?
5-6mm
deposit of solution for incisive?
0.6-0.9ml
What happens if pressure is not provided after the injection?
You will only give a mental nerve block and will only get soft tissue numb.
What nerve is the largest of the Trigeminal Nerve?
Mandibular Nerve
TRUE/FALSE: Mandibular nerve only has sensory roots.
FALSE: Mandibular nerve consist of both sensory and motor roots
Where does the mandibular nerve exit?
Foramen Ovale
What are the muscles of the anterior division (motor branches) that innervate the muscles of mastication?
Masseter
Temporalis
Lateral Pterygoid
What are the sensory nerves of the posterior division?
Auriculotemporal nerve
Lingual nerve
Inferior alveolar nerve
Incisive and mental nerve
What nerve is the largest branch of the mandibular nerve?
Inferior Alveolar Nerve
TRUE/FALSE: The IA is the most used injection in dentistry.
TRUE
What other nerve are also Anesthetized besides the IA?
Lingual and Buccal Nerve
What is the clinical failure rate for the IABL?
15-20%
Teeth anesthetized for IABL?
From the mandibular molars to the midline anteriors
Structures that are anesthetized for IA/Lingual?
Anterior 2/3 of tongue
Lingual soft tissue from molar to midline
Buccal gingiva anterior to 1st molar
What are indication for the IABL?
Dental procedure requiring multiple teeth in one quadrant
Lingual soft tissue anesthesia is required
What are some contraindications for IABL?
Infection or inflammation of tissue
Hemophiliacs
Patient at risk for self injury
Hemostasis, rather than pain control, is needed
disadvantages for IABL?
Anatomy is not consistent
High failure rate 15-20%
What is the percentage of positive aspiration?
10-15% highest of all injections
What are complication associated with the IABL?
Trismus
Hematoma
Transient Facial Paralysis
Electric Shock due to contact with lingual nerve
What is Trasient Facial Paralysis and why does it occur?
Occurs when the needle is over inserted and solution is deposited in the parotid gland which causes numbness of the facial nerve. This happens when bone is not contacted and the solution is deposited.
Alternative techniqes for IABL?
Gow Gates Nerve block
Mental/Incisive Nerve block
What gauge is used?
25 gauge long
Anatomical landmarks for the IABL?
Coronoid Notch
Pterygomandibular Raphe
What is the Coronoid Notch?
Where the external oblique ridge begins to curve upward. Also lined up with the mandibular foramen. Allow operator to inert at a site higher than the foramen which will anesthetize around the nerve before entering the foramen.
What is the pterygomandibular raphe?
Band of attachment of the buccinator muscle to the superior constrictor muscle of the pharynx
Where is the height of the injection?
Slightly superior to the apex of the raphe triangle or 2 to 3 mm higher than the level of the coronoid notch.
6-10 mm above the occlusal plane of the mandibular molars
1/2 to 2/3 of the raphe
Where is the syringe placed?
At the corner of the mouth on the opposite side that is being injected over the contralateral premolars.
Depth of Penetration and how much of needle should be visible?
20-25mm depth of penetration
7-12 mm of needle should be showing
How much solution should be administered for the IA, Lingual, and Buccal?
IA: 1.5mL
Lingual: 0.2 cc
Buccal: 0.2-0.3 cc
What happens when you are too shallow and how do you correct it?
You hit bone too early and the needle is located too anteriorly on the ramus. To correct move the syringe more anterior over the canine. Once depth has been reach move syringe back over premolars.
How do you correct if you are too deep?
Withdraw the needle slightly and leave about 5mm of needle in tisssue and reposition barrel over the molar and continue until bone is contacted.
After the IA has been given, the Lingual block is given next. How many mm of the needle is withdrawed from the tissue?
About half way
8-10 mm of the needle should be left in tissue.
TRUE/FALSE: When giving anesthetic to the lingual, no need to aspirate since the injection site is the still the same.
FALSE: Aspiration is always done even with slight movement.
What areas does the buccal nerve anesthetize?
Buccal gingiva and periosteum of the mandibular molars
Skin of the cheek
Mucosal membranes in the area of the mandibular molars
Syringe alignment for the Buccal nerve?
Parallel to the occlussal plane
Distal and buccal to the last molar
Depth of penetration for the buccal nerve?
3-4mm
What are complications for this injections?
Minimal positive aspiration
Hematoma may occur
Should topical be placed at different times?
No, topical should be placed at the same time for both injections since recapping is not necessarry to give both the IA/L and buccal
What are some useful tips for pediatric anesthesia?
-Never lie to the child
-Tell them what to expect
-Make sure child know you are in charge
-Use topical
-Do not show needle
-Avoid palatal injections
-Give slow injections
TRUE/FALSE: The depth of penetration is not less in children.
FALSE: The depth of penetration is less since the bone in less dense and more porous.
*Short needles should be used for both arches
Why are PDL injections contraindicated in primary teeth?
Enamel Hypolplasia can be caused on the underlying permanent teeth.
What can help prevent Toxicity?
Use LA with vasoconstrictor when treating more than one quadrant.
LA without vaso can be used if appointments are short and confined
Why is the PSA not necessary?
Zygomatic process closer to maxilla in children ( a risk for hematoma)
Infiltration will be very effective
When is the ASA necessary?
Multiple restorations are needed
The depth of penetration is just slightly deeper than infiltration
TRUE/FALSE: Is the Nasopalatine done the same way as an adult
TRUE, but palatal injections not recommended unless necessary
Where is the Greater Palatine located?
Visualize imaginary line from most posterior erupted tooth to the midline. If 1st permanent molar is not erupted penetrate 10 mm behind the last primary molar.
How are papillary injections done in children?
Similar to adults, insert horizontally into buccal papilla and advance needle towards palatal side
Why are infiltrations effective in mandible?
Less dense and more porous.
When child gets older the bone becomes dense.
What makes the Inferior Alveolar very successful in children?
The mandibular foramen lies distal and inferior to the occlusal plane.
When the child ages, about how much does the foramen move?
About 7mm
Where is the syringe barrel placed for the IA in children?
Over the primary molars on the opposite side of the mouth.
IA depth penetration and needle used for kids?
Depth: 15 mm
Needle: 25 or 27 gauge short
Don't forget to evaluate the size of the child and mandible
Buccal is done the same as adults
What will the mental/incisive anesthetize?
All 5 primary teeth in a quadrant
Where is the mental foramen located in children?
In between the two primary molars
What are sign and symptoms of overdose toxicity?
-Restleness
-Tremors
-Sweating
-V omitting
-Decrease in BP and cardiac output
-CNS and CVS depression
How to prevent Overdose?
-Inject slowly
-Aspirate
-a needle that reliably aspirates
-use LA with vaso
Clarks Rule
Child Weight in lbs x Adult MRD = Child Dose
-------------------------------------------
150
How many carpules of 2% lidocaine with 1:100,000 epinephrine can safely be administered to a 50 lb child?
2.5 carpules
How many carpules of 3% Mepivicaine without a vasoconstrictor can safely be administered to a 50 lb child?
1.5 carpules
How to avoid injuries?
-Watch for cheek biting
-select appropriate anesthetic for duration procedures
-advise patient and guardian
-put a warning sticker on forehead or hand
-use cotton roll to protect lip
When discovered nitrous oxide?
Joseph Priestly in 1772
What year was it first used in dentistry?
1844
In _________ it was combined with __________ for use in pain control.
1868
oxygen
What are the reasons for use?
Helps patients relax
Provides pain control for procedures that are slightly moderate to painful.
Nitrous Oxide is a ________ anesthetic but _________ analgesic.
weak
strong
TRUE/FALSE: Nitrous oxide does not raise a person's threshold.
FALSE
What are the goals of N2O Sedation?
-Relieves anxiety and fear
-Stress reduction
-Reduce pain Perception
-Amnesia and analgesia effects
-Light sedation and mood alteration
-Patient remains conscious with protective reflexes intact
What are the advantages of N2O?
-Simple and Safe
-No allergies
-Reduction in gag reflex
-Onset & recover are fast
-Time and perception can be altered
What are the disadvantages of N2O?
-Vertigo, nausea, vomitting
-Extreme behavior problems
-Equipment is cubersome
-Mask gets in the way
-Long term exposure may cause health problems
What are some indications for patients?
-Asthma
-Epilepsy
-Cardiovascular or cerebrovascular disease
-Parkinson's disease
Cerebral palsy, Multiple Sclerosis, Muscular dystrophy
-Fainting Spells
What are some contraindications?
- Communication and cooperation difficulty
-COPD (Emphysema, Bronchitis)
-Nasal Obstruction (cold, allergies, sinus infection)
-Patient don't want N2O
-Middle ear disturbances (increase pressure on tympanic membrane)
-Pregnancy (N2O crosses the Placenta, avoid 1st trimester)
-Personality disorder and emotional instability
-Claustrophobia
-Sever behavior problems
-May need a medical consultant with physician to determine whethere there is a sensitivity to N2O.
Can you use Nitrous on a patient with a cold?
No, obstruction not able to breath in and out.
Your patient had a stroke 12 months ago. Can you safely administer Nirtous Oxide?
Yes
Does Nitrous Oxide lower a patient's threshold for pain?
No, it raises it.
Will nitrous help reduce gagging?
Yes
Nitrous is stored as a ____________ and is delivered as a ___________. Oxygen is strored as a Gas.
Liquid
Gas
TRUE/FALSE: Both oxygen and nitrous are colorless and odorless.
FALSE Nitrous is colorless, but it has a sweet odor.
Nitrous is stored in a __________cylinder and oxygen is stored in a _________ cylinder.
Blue
Green
Full tank is nitrous is at ______ psi and oxygen is at _______psi.
750
2100
Nitrous is relatively ________ in blood and is rapidly eliminated from blood to __________.
insoluble
lungs
Will nitrous have an effect on blood pressure, hear rate, liver or kidney function?
No, it will not just as long as there is an adequate amount of oxygen that is administered at the same time.
Nitrous has affects on sensations as ________, _________, ____________, and _____________.
hearing, touch, pain, warmth
Nitrous is a ________ depressant. It affects the _________, __________, __________, and ____________.
cerebral cortex, thalamus, hypothalamus, reticular activating system.
TRUE/FALSE: Pain perception is blocked, LA is not needed to manage pain
FALSE, anesthetic is needed to help reduce pain.
What happens when there is too much nitrous oxide and not following up with proper oxygenation?
Diffusion Hypoxia
TRUE/FALSE: Nitrous oxide administration can increase a patient's blood pressure.
FALSE, it does not have an effect
What is stage I?
Analgesia/Sedation: Patient feels pain but does not care
What is stage II?
Excitement/Delirium: Hyper responsive to stimuli, exaggerated response, loss of conciousness
What is stage III?
Surgical Anesthesia: Oral Surgery
What is stage IV?
Medullary Paralysis/Death: Major surgery in a hospital setting
What are sign and symptoms of early to ideal sedation?
-Facial muscl relax
-light- headedness
-Tingling/numbness
-light or floating feeling
-mouth remains opened
-Vital signs are normal
-Regular Breathing
-Skin has a slight flush
What are sign and symptoms of heavy sedation to slight overdose?
-Hearing acute
-Visual images confused
-Sleepiness
-Laughing, crying, dreaming
-Nausea
-Mouth tends to close
-Less likely to respond
What are signs and symptoms of over sedation?
-Nausea/vomiting
-Mouth breathing
-Patient is uncomfortable
-Uncooperative
-Uncoordinated movements
-Patients responds irrationally
What are the management of over sedation?
reduce N2O by 1 lpm. Use 100% of O2 flush if necessary, turn off N2O, use basic life support and call 911 if needed.
What to do when a patient vomits?
Turn the patients head to the side to help clear the pharynx, turn off nitrous, and give 100% oxygen for 5 minutes.
Concentration of ____ to ____ % will have a response of body warmth, tingling of hands, and feet.
10 to 20%
Concentration of _____ to ____% will have a response of cummoral numbness and numbness of the thighs.
20 to 30 %
What is the ideal level of sedation (% percentage) and the responses?
20 to 40 %
Numbness of tongue, hands and feet
Mild sleepiness
Analgesia
Euphoria
Feeling of heaviness or lightness of body
What are adverse reactions and side effects to N2O?
-Diffusion Hypoxia
-Nausea and Vomiting
-Corneal Irritation
-Behavioral Problems
What causes Corneal Irritation?
Leakage of gas from mask, causes dry eyes.
If patient has contact lenses ask them to remove or keep their eyes clothes.
What will cause equipment malfunction?
-ill-fitting mask
-faulty conduction tube
-poor scavenger system
-inadequate ventilation
What have studies have shown of hazards to personnel?
-spontaneous abortions
-birth defects
-bone marrow suppression
-anemia
-hepatic and renal diseases
-cancer
How to reduce N2O concentration?
-use a well fitting mask
-discourage talking
-use a fan
-have proper ventilation
-open a window
-wear a badge
What is scavengin?
Removes excess nitrous oxide and minimizes the trace amounts of nitrous before, during, and after use.
What happens when the patient does not breath through their nose?
Nitrous is not getting into their system and nitrous ends up in the atmosphere where it is unscavenged.
What are indications that your patient has reached an undesirable level of nitrous oxide sedation include which of the following:
a) flushing of the skin
b) slight dizziness
c) uncontrollable laughing
d) mild perspiration
C) uncontrollable laughing
Patient was on N2O for 45 minutes. At the end of the appointment, the patient complains of headache and nausea. What is the cause of this?
a) received nitrous too long
b) did not receive 100% O2 for sufficient time after nitrous
c) received too much 100% oxygen after nitrous
d) it has nothing to do with administration of N2O
b) did not receive 100% O2 for sufficient time after nirtous
The ideal stage of sedation for dental hygiene care is :
a) stage I
b) stage II
c) stage III
d) stage IV
a) stage I
Your patient complains of a " hung over" feeling following of N2O administration. What is the cause?
a) nausea
b) corneal irritation
c) diffusion hypoxia
d) scavenger system
c) diffusion hypoxia
What are the 5 parts of the equipment?
-Flow meter
-Pressure gauge
-Yoke
- Gas Hole
- Reservoir Bag
What is needed to in order to prevent leakage of nitrous?
Appropriate mask size
The sterilized nose mask connects to two hoses. The larger adaptor connects to the __________ and the smaller adaptor connects to the the _______________.
Gas hose
high-speed suction system
TRUE/FALSE: The clinician should always check and record health history, blood pressure, and pulse of the patients before proceeding.
TRUE
TRUE/ FALSE: If a patients has been on substance for the past 48 hours a clinician can give nitrous to the patient.
FALSE
What is the total tidal volume?
6 L/min
When should you place a gauze on the area?
-If the mask is too big
-when mask is impinging on a sensitive area of the face
If patient feels that he/she is short of breath ______ the volume of oxygen. If patient feels that there is too much air coming into the mask ________ the oxygen volume.
Increase
Decrease
What is the average adult tidal volume?
6-8 liters
When should you check with the patient after adjusting the tidal volume?
Every 90 seconds
TRUE/ FALSE: If nitrous volumes goes up, oxygen volume must go down.
TRUE
If patient is not at ideal sedation after 90 seconds, how much should you adjust?
1/2 a liter after every 90 seconds
What is titration?
When the flow of nitrous has reached the patients ideal sedation.
At what level should a clinician never reduce oxygen below while in use?
2-3 Liters
What is the ideal level of sedation for 70% of people?
30 to 40 %
What is the maximum level of Nitrous should not go over?
42%
How long should the patient be on 100% oxygen after their treatment?
For every 15 minutes on N2O the patient should receive 5 minutes of oxygen.
TRUE/FALSE: After treatment nitrous oxide needs to be turned off and oxygen needs to be turned back up to 6 lpm.
TRUE
Why is it important to administer oxygen for at least 5 minutes to a patient following N2O sedation?
To prevent diffusion hypoxia
What is the percentage of N2O if N2O is 1.5 lpm and O2 is 4.5 lpm?
25%

1.5 /6 = 25% N2O
What properties does all injectable local anesthetic have?
Vasodilating properties
Which LA have the least vasodilation?
Mepivacain plain
What are the benefits for vasoconstrictors?
1. Decrease blood flow to site of injection (vasoconstrict vessels)
2. Slows absorption of local anesthetic into CVS
3. Decreases blood level = lower toxcicity
4. LA remains around nerve longer (prolongs)
5. Smaller amount of LA can be used
6. Provides hemostasis (controls bleeding)
Vasoconstrictors are what kind of drugs?
Sympathomimetic or Adrenergic Drugs

(it "mimics" the action of "sympathetic" nervous system mediators)
What are sympathomimetic drugs termed?
CATECHOLAMINES
What are the two vasoconstrictors currently used?
Epinephrine and Levonordefrin
Epinephrine is a synthetic drug, Levonordefin is a natural drug. True or false?
Both are false
What are the two main receptors for LA
Alpha and Beta (B1 and B2)
Alpha receptors produces _____ through ______ of smooth muscle in blood vessles. It helps ______.
1. Vasoconstrictors
2. Contractions
3. Hemostasis
B2 receptors produces what through smooth muscle relaxation?
Vasodilation and bronchodilation
B2 produces what?
Cardiac stimulation (increases heart rate and strength of contraction)
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