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Endodontics > Anesthesia > Flashcards

Anesthesia Flashcards

1
Q

In pt with positive lip signs how successful was man 1st molar block? 1st premolar? Lat incisor?

A

Molar 53%
1st premolar 60%
Lat incisor 40%

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2
Q

How successful are IAN blocks in teeth with irreversible pulpitis

A

20-70%

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3
Q

Teeth with inflamed pulps are how many times more likely not to achieve plural anesthesia

A

8x

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4
Q

Describe Aβ

nerve fibers

A

The largest are the A- beta, heavily myelinated and responsible for touch and pressure, fastest

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5
Q

Describe Aδ

fibers

A

Then there are the A-delta fibers, a little smaller in diameter and with a slower conduction velocity. These fibers are responsible for pain, temperature and touch. They are also myelinated.

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6
Q

Describe C fibers

A

small, unmyelinated C-fibers responsible for the throbbing pain associated with tissue injury, slowest conduction speed

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7
Q

A delta pain description

A

Temperature sensitive
- Often sharp
Short Duration

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8
Q

C fiber pain description

A

Temperature sensitive
- Often sharp
Short Duration

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9
Q

Compare nerve fiber sensitivity to lido

A

Aβ > Aδ > C

Therefore – if your patient has a numb lip (Aβ), then the pulp is not necessarily anesthetized

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10
Q

Two important points about c fibers

A

C fibers are the hardest to anesthetize

C fibers are the most resistant to necrosis (irreversible pulpitis)

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11
Q

What are some anatomical mechanisms of IAN failure

A 
Needle placement
Accessory nerves
Size of the nerve
Length of nerve exposed
Type of sodium channel
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12
Q

What are some inflammatory mechanisms of failure for IAN blocks

A 
Local pH
Inflammatory mediators
Sprouting 
Central sensitization
Neuropeptides
Local blood flow
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13
Q

How many nodes of ranvier need to be blocked for nerve blockade

A

Initially thought to be 3 now believed to be 4

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14
Q

What are TTX-r sodium channels

A

New Sodium Channel discovered that is resistant to local anesthetic
Tetrodotoxin resistant sodium channel (TTX-r)
Takes 4 x more anesthetic to block action potential

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15
Q

what form of the anesthetic can diffuse through the membrae

A

non ionized form

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16
Q

What is the average pH of the extracellular space

A

7.4

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17
Q

Which form of the anesthetic blocks the channel

A

ionized

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18
Q

How does PGE2 affect ability to anesthetize

A

Sensitizes neurons Mense Brain Research 1981
Doubles the activity of TTX-resistant (TTX-r) sodium channels
alter structural properties of nociceptors
-nerves sprout into areas of inflammation
-greater field, spatial summation of stimuli, activation

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19
Q

what is central sensitization

A

Barrage of afferent impulses

Exaggerated response to gentle peripheral stimuli

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20
Q

Does anxiety play a part in anesthesia

A

Anxious patients reported greater pain
Prior painful treatment or anxiety about treatment led to an increase in reported pain
Different procedures caused more anxiety

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21
Q

Does a 2nd IAN block increase success if positive lip sign already present

A

no

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22
Q

What are some advantages of a low gates nerve block

A 
True V3 block
Inferior alveolar
Buccal
Lingual
Mylohyoid
Low positive aspiration rate (1.8%)
Constancy of landmarks
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23
Q

What are some disadvantages of a cow gates

A

Slower onset

Provider anxiety during learning phase

24
Q

What are the landmarks for the low gates

A

Anterior border of ramus
Corner of mouth
Intertragic notch

25
Q

clinical technique for how gates

A

Patient supine with mouth wide open
Thumb in anterior border of ramus and finger in meatus of ear
Insertion below the ML cusp of maxillary 2nd molar aim toward finger
Depth of penetration 25mm (contact bone)
Deposit 1.8ml and keep patient open

26
Q

What are the literature ranges for gow gates success

A

35-91

not significant improvement

27
Q

Indication for akinosi block

A

Infection
Trismus
Trauma
Closed mouth technique

28
Q

What are landmarks for akinosi block

A

Occlusal plane of occluding teeth
Mucogingival junction of maxillary molars
Anterior border of ramus

29
Q

Akinosi technique

A

Patient gently occludes with muscles relaxed
Reflect soft tissues laterally
Position barrel of syringe
Parallel with maxillary occlusal plane
Needle at the level of the mucogingival junction of max 2nd molar
Direct needle posteriorly and laterally
Bevel of needle away from mandibular ramus so needle deflection is toward ramus
Patient can move mandible to the side of the injection for better access
Advance needle approximately 25mm
Aspirate and deposit entire carpule

30
Q

Akinosi advantages

A

Anesthesia obtained with limited opening

2% positive aspiration

31
Q

disadvantages of akinosi

A

Absence of a bony landmark

Unexpected side effects

32
Q

Akinosi success rates

A

77-85%

33
Q

does lingual infiltration help

A

IAN block alone (73%) or with mylohyoid block (83%) – no significant difference in anesthesia success Clark et al OOOOE 1999
Technique addresses only one mechanism of failure

34
Q

When should you consider a 2nd IAN, Gowgates, or akinosi

A

when initial block fails to produce a positive lip sign.

35
Q

How does a PDL injection spread

A

mesial and distal
Primarily pulp of tooth anesthetized
Pulps of 2 adjacent teeth mesial and distal to point of injection

36
Q

PDL landmarks

A

Periodontal ligament space
Line angles of tooth
Crestal bone

37
Q

PDL clinical technique

A

27 - 30 gauge short or ultra-short needle
Needle type not critical, but back pressure is (to force solution into bone)
Insert into PDL space
Bevel facing bone
All four line angles of tooth
Inject 0.3 ml with pressure

38
Q

Advantages of PDL injection

A

Increases success of IAN anesthesia
Minimal damage to periodontium
No special instruments

39
Q

Disadvantages of PDL injection

A

Short duration

Mild discomfort

40
Q

Adverse effects of PDL injection

A 
HR increase 10-20%
	Smith & Pashley Oral Surg 1983
Decreases pulpal blood flow Kim et al. J Dent Res 1984
9.6% at 5 minutes
65.3% at 65 minutes
41
Q

Indications and contraindications for PDL injection

A

Indications
Failed IAN block
As a primary in hemophilia patient

Contraindications
Restorative

42
Q

PDL success rates

A

63-81% on first attempt
83-92% if second injection needed
NOTE: only 3.8% pulpal anesthesia when 3% mepivacaine used as a primary injection

43
Q

What are two types of intraosseous injection

A

Stabident

Xtip

44
Q

For stabident where should the perforation site be

A

Perforation site – 2 mm below intersection of a line along gingival margin & line bisecting the papilla
Needle perpendicular to cortical plate

45
Q

How should you drill for the stabident

A

Light pressure at full speed with pecking motion

2-5 seconds

46
Q

Injecting with stabident

A

Align needle into perforation – ‘pen grasp’
Slowly inject over 1-2 minutes 0.9-1.8 cc
Should not have resistance or backflow

47
Q

What differentiates tip from stabident

A

2 piece system
internal perforator and external guide sleeve
tip is also longer

48
Q

Contraindication for intraosseous

A

root proximity
per disease
local infection

49
Q

Advantages of intraosseous

A

Acts quickly
excellent plural anes
fairly easy to use

50
Q

Dis of intraosseous

A

difficulty inserting the needle
short duration
15-45 min

51
Q

IO injection and systemic effects with lido

A

HR increase 12-32 ppm lasting 4 mins in 46-90% of pts
perceived 60-75% rate increase
NO affect on BP

52
Q

IO injection and systemic effect with 3% Mepi without epi

A

none

53
Q

Adverse effects of IO injection

A

Perforator breakage
Rarely separates from plastic
Injection discomfort
Low; may increase with irreversible pulpitis
Postoperative problems
None to mild pain
<5% develop exudate +/or localized swelling
Pressure; thicker bone; larger perforators
Resolve over 3-4 weeks on their own

54
Q

IO injection success

A 
90-95% for 2% lidocaine w/1:100K epi
Uninflamed and inflamed pulps
Fairly similar rates for 3% mepivacaine
Only with an IAN block (45% as primary)
Duration not as long
Two IO injections increased success to 98%
                                                            Reisman et al. OOOOE 1997
Long-acting anesthetics not recommended
Heart muscle toxicity
55
Q

Intrapulpal injection

A 
Assumes an endodontic procedure
Advise patient – “sharp sensation”
Use as last resort
27- or 30-gauge short needle
Tight fit
56
Q

whats the key to success of intrapulpal injection

A 
0.2 – 0.3 cc over 10 seconds
Backpressure is       KEY to SUCCESS
	       Birchfield &amp; Rosenberg J Endodon 1975
Solution used is not  important
Vasoconstrictor is not critical
57
Q

how often is intrapulpal injection needed

A

5-10% of time in iR pulpitis

Endodontics (9 decks)

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