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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
clinical technique for how gates
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
What are the literature ranges for gow gates success
35-91 | not significant improvement
27
Indication for akinosi block
Infection Trismus Trauma Closed mouth technique
28
What are landmarks for akinosi block
Occlusal plane of occluding teeth Mucogingival junction of maxillary molars Anterior border of ramus
29
Akinosi technique
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
Akinosi advantages
Anesthesia obtained with limited opening | 2% positive aspiration
31
disadvantages of akinosi
Absence of a bony landmark | Unexpected side effects
32
Akinosi success rates
77-85%
33
does lingual infiltration help
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
When should you consider a 2nd IAN, Gowgates, or akinosi
when initial block fails to produce a positive lip sign.
35
How does a PDL injection spread
mesial and distal Primarily pulp of tooth anesthetized Pulps of 2 adjacent teeth mesial and distal to point of injection
36
PDL landmarks
Periodontal ligament space Line angles of tooth Crestal bone
37
PDL clinical technique
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
Advantages of PDL injection
Increases success of IAN anesthesia Minimal damage to periodontium No special instruments
39
Disadvantages of PDL injection
Short duration | Mild discomfort
40
Adverse effects of PDL injection
``` 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
Indications and contraindications for PDL injection
Indications Failed IAN block As a primary in hemophilia patient Contraindications Restorative
42
PDL success rates
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
What are two types of intraosseous injection
Stabident | Xtip
44
For stabident where should the perforation site be
Perforation site – 2 mm below intersection of a line along gingival margin & line bisecting the papilla Needle perpendicular to cortical plate
45
How should you drill for the stabident
Light pressure at full speed with pecking motion | 2-5 seconds
46
Injecting with stabident
Align needle into perforation – ‘pen grasp’ Slowly inject over 1-2 minutes 0.9-1.8 cc Should not have resistance or backflow
47
What differentiates tip from stabident
2 piece system internal perforator and external guide sleeve tip is also longer
48
Contraindication for intraosseous
root proximity per disease local infection
49
Advantages of intraosseous
Acts quickly excellent plural anes fairly easy to use
50
Dis of intraosseous
difficulty inserting the needle short duration 15-45 min
51
IO injection and systemic effects with lido
HR increase 12-32 ppm lasting 4 mins in 46-90% of pts perceived 60-75% rate increase NO affect on BP
52
IO injection and systemic effect with 3% Mepi without epi
none
53
Adverse effects of IO injection
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
IO injection success
``` 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
Intrapulpal injection
``` Assumes an endodontic procedure Advise patient – “sharp sensation” Use as last resort 27- or 30-gauge short needle Tight fit ```
56
whats the key to success of intrapulpal injection
``` 0.2 – 0.3 cc over 10 seconds Backpressure is KEY to SUCCESS Birchfield & Rosenberg J Endodon 1975 Solution used is not important Vasoconstrictor is not critical ```
57
how often is intrapulpal injection needed
5-10% of time in iR pulpitis

Endodontics (9 decks)

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