Anesthetic Flashcards
MARTIN & RAMSAY 1994
anesthetic
Patients who believe they are receiving 20% topical benzocaine gel anticipate significantly less pain during dental injection
Who said Patients who believe they are receiving 20% topical benzocaine gel anticipate significantly less pain during dental injection
Martin and Ramsay 1994
MCLEAN & READER 1993
different types of anesthetic in asymptomatic teeth
No significant difference in asymptomatic teeth between 4% prilocaine, 3% mepivicaine and 2% lidocaine (with 1:100K epi) in onset, success and failure of IAN blocks. Three solutions are equivalent for IAN block of 50 minutes.
Who said No significant difference in asymptomatic teeth between 4% prilocaine, 3% mepivicaine and 2% lidocaine (with 1:100K epi) in onset, success and failure of IAN blocks
McLean and REader 1993
AGGARWAL 2012
for IAN blocks
For irreversible pulpitis, IAN blocks using lido with 1:200K epi have a higher success rate with 3.6 mL (54%) compared to 1.8 mL (26%)
Who said For irreversible pulpitis, IAN blocks using lido with 1:200K epi have a higher success rate with 3.6 mL (54%) compared to 1.8 mL (26%)
Aggarwal 2012
HAASE & READER 2008
efficacy of supplemental infiltration
in ASYMPTOMATIC teeth, Following 4% septocaine block, buccal infiltration is more successful with 4% septocaine (88%) than with 2% lidocaine (71%) for mandibular first molars.
Who said : Following 4% septocaine block, buccal infiltration is more successful with 4% septocaine (88%) than with 2% lidocaine (71%) for mandibular first molars.
Haase and Reader 2008
Which article to use to support supplemental infiltration for irreversible pulpitis? for asymptomatic teeth?
irreversible pulpitis? Aggarwal 2009 (B and L), Matthews (B) 58%
Asymptomatic teeth? Haase and Reader 2008
Who said that following a 2% lido with 1:200K epi IAN block, a buccal and lingual infiltration of 2% lidocaine or 4% articaine increases anesthetic efficacy in irreversible pulpitis from 33 to 47 to 67%?
Aggarwal 2009
Aggarwal 2009
efficacy of supplemental infiltration?
in IRREVERSIBLE pulpitis, following a 2% lido with 1:200K epi IAN block, a buccal and lingual infiltration of 2% lidocaine or 4% articaine increases anesthetic efficacy from 33 to 47 to 67%
Who said that in irreversible pulpits, NSD in anesthetic success of PSA, buccal infiltration and buccal plus palatal infiltration using lido w/ 1:200K epi?
Aggarwal 2011
Aggarwal 2011
best method for max posterior injections?
in irreversible pulpits, NSD in anesthetic success of PSA, buccal infiltration and buccal plus palatal infiltration using lido w/ 1:200K epi
Who said pre-op admin of NSAIDs has no effect on efficacy of lido IAN block in irreversible pulpiits?
NSAID plus APAP -NSD?
Aggarwal 2010
Simpson 2011
Who said a labial and lingual infiltration with 4% septo w/ 1:100K epi is more effective than just a labial infiltration (in asymptomatic teeth)?
Nuzum 2010
Nuzum 2010
best for mandibular incisors?
a labial and lingual infiltration with 4% septo w/ 1:100K epi is more effective than just a labial infiltration (in asymptomatic teeth) 76 to 98%
Mason 2009
1:50K epi
Increasing epinephrine from 1:100k to 1:50k decreased pulpal anesthesia of short duration for the lateral incisor but not the molar (asymptomatic)
Who said: Increasing epinephrine from 1:100k to 1:50k decreased pulpal anesthesia of short duration for the lateral incisor but not the molar (asymptomatic)
Mason 2009
Who said that the use of topical anesthetic reduces pain of needle insertion for maxillary anteriors but not maxillary posteriors or IAN block?
Nusstein 2003
Nusstein 2003
topical
the use of topical anesthetic reduces pain of needle insertion for maxillary anteriors but not maxillary posteriors or IAN block?
Who said that 3.6 mL of lidocaine 1:100K provides a statistically longer duration of pulpal anesthesia than 1.8 mL for maxillary infiltrations? (asymptomatic)
Mikesell 2008
Mikesell 2008
Is more lido better for max?
3.6 mL of lidocaine 1:100K provides a statistically longer duration of pulpal anesthesia than 1.8 mL for maxillary infiltrations? (asymptomatic)
(But doesn’t affect onset or success97-100%)
Who said depositing 3.6 mL lidocaine is not significantly more painful than depositing 1.8 mL?
Mikesell 2008
Who said 3.6mL of lidocaine decreases non-continuous anesthesia compared to 1.8mL for max first molar (asymptomatic)?
Mikesell 2008
Who said pulpal anesthesia with lidocaine does not last as long in maxillary anteriors as maxillary posteriors?
Mikesell 2008
Evans 2008
is septo better?
asymptomatic: 4% articaine improved anesthetic success compared to 2% lidocaine for lateral incisors (88% v. 62%), but not for first molars (78% v. 73%)
who said in asymptomatic teeth : 4% articaine improved anesthetic success compared to 2% lidocaine for lateral incisors (88% v. 62%), but not for max first molars (78% v. 73%)
Evan 2008
Who said: IAN block is similar to the Gow-Gates and Vazirani-Akinosi techniques regarding anesthetic success of ant and post mandibular teeth, but has a faster onset of pulpal anesthesia (asymptomatic)
Goldberg 2008
Goldberg 2008
best technique for mandibular injections?
IAN block is similar to the Gow-Gates and Vazirani-Akinosi techniques regarding anesthetic success but has a faster onset of pulpal anesthesia (asymptomatic)
Who said: in mand post teeth with irreversible pulpits, a supplemental infiltration with 4% septocaine with 1:100K (after lido IAN block) is successful only 58% of the time
Matthews 2009
Matthews 2009
supplemental buccal infiltration?
In mand post teeth with irreversible pulpits, a supplemental infiltration with 4% septocaine with 1:100K (after lido IAN block) is successful only 58% of the time
who said For mandibular posterior teeth with irreversible pulpitis, a supplemental intraosseous injection of 3% mepivacaine increased anesthetic success from 25% to 80%. A second intraosseous injection, when necessary, further improved success to 98%.
Reisman 1997
Reisman 1997
Does intraosseous work?
For mandibular posterior teeth with irreversible pulpitis, a supplemental intraosseous injection of 3% mepivacaine increased anesthetic success from 25% to 80%. A second intraosseous injection, when necessary, further improved success to 98%.
Who said no difference in intrapulpal anesthesia using sterile saline or 2% lidocaine with1:50 or 1:100K (works because of pressure)
Birchfield 1975
who found: patients who receive an IO injection of the 2% lidocaine-epinephrine solution experience a transient increase in heart rate. No significant increase in heart rate was seen with the i.o. injection of 3 percent mepivacaine
Replogle 1999
Replogle 1999
intraosseous
patients who receive an IO injection of the 2% lidocaine-epinephrine solution experience a transient increase in heart rate. No significant increase in heart rate was seen with the i.o. injection of 3 percent mepivacaine
How much lidocaine is in a 2% solution?
20 mg/mL
Maximum recommended dose of septo? bupiv? lido? mepiv?
septo: 500 mg, bupiv: 90 mg, lido: 300 mg, mepiv: 300 mg
Who said patients with irreversible pulpitis who receive 0.5% bupivicaine w/1:200K epi have significantly less post op pain at 6 and 12 hours compared with patients who receive 2% lido w/ 1:80K epi?
Parirokh, Abbot 2012 JOE
Parirokh, Abbot 2012
bupivicaine?
patients with irreversible pulpitis who receive 0.5% bupivicaine w/1:200K epi have significantly less post op pain at 6 and 12 hours compared with patients who receive 2% lido w/ 1:80K epi
Basically, how do local anesthetics work?
They block voltage gated sodium channels, partitioning into the uncharged basic form (RN) which crosses cell membranes, and the charged acid form (RNH+) which binds to the inner pore of the sodium channel.
How many different voltage gated sodium channels? How do they differ(3)?
- Expression pattern, biophysical properties, and roles in mediating peripheral pain.
What are VGSC’s resistant to tetrodotoxin called?
Where are they found? Two facts about them?
TTX-R channels
Nocicepters (Wells 07)
Relatively resistant to local anesthetics(Reemers 08)
Sensitized by prostoglandins (Gold 96)
What happens when TTX-R VGSG are near prostaglandins?
Prostaglandings sensitize TTR-X channels, leading to depolarization at lower levels of stimulus strengths.
Two parts of a VGSC?
Alpha and Beta subunits. The alpha subunit is a voltage sensor that leads to channel activation and Na ion passage when the channel detects an electric field.
What is a second mechanism by which local anesthetics may help with odontogenic pain?
L.A.s modulate certain G protein-coupled receptors.
What are G protein-coupled receptors?
Major class of cell membrane receptors that many dental drugs and endogenous mediators produce their effects by activating specific ones.
Is bupivicaine long duration? Says who?
For IAN block, yes (Fernandez 05). For anterior infiltration, no (shorter duration than lido) (Gross 07)
Fernandez 2005
bupivicaine
For IAN blocks, Pulpal anesthesia averaged 4 hr for bupivacaine versus 2 hr and 24 min for lidocaine
Gross 2007
bupivicaine
For maxillary infiltrations, bupivicaine has a lower success rate in the anteriors than 2% lido, and the duration for maxillary teeth is less than 60 minutes for lido and bupiv
Reasons not to receive epinephrine in L.A. and consult physician instead:
unstable angina, history of MI or stroke in last 6 months, severe HTN, uncontrolled congestive heart failure, or heart transplant. (Naftalin 2002)
Who said any of the commonalty available local anesthetics are safe for use in pregnant or lactating women?
Haas 2007
Two changes in inflamed dental pulp that could make L.A. less effective?
More TTX-R sodium channels, more sodium channels in general (Warren 2008)
What is oraverse?
Phentolamine mesylate-shortens duration of soft tissue anesthesia
Cohen 1993
For irreversible pulpitis, 3% mepivacaine and 2% lidocaine with 1:100K epinephrine were equivalent for IAN blocks (success measured using DDM)
who said For irreversible pulpitis, 3% mepivacaine and 2% lidocaine with 1:100K epinephrine were equivalent for IAN blocks (success measured using DDM)
Cohen 1993
Claffey 2004
NSD in success rate of 4% articaine compared to 2% lidocaine for IAN blocks
Who said NSD in success rate of 4% articaine compared to 2% lidocaine for IAN blocks
Claffey 2004
who said The incisive nerve block at the mental foramen is successful for anesthetizing mandibular premolars, but not incisors?
Nist 1992
Nist 1992
Incisive nerve block at mental foramen?
The incisive nerve block at the mental foramen is successful for anesthetizing mandibular premolars, but not incisors?
Who said: A slow injection (60 seconds) does not increase success compared to a fast injection (15 seconds) for incisive nerve block at mental foramen
Whitworth 2007
Whitworth 2007
speed of injection
A slow injection (60 seconds) does not increase success compared to a fast injection (15 seconds) for incisive nerve block at mental foramen but is more comfortable
Meechan 2002
mandibular anterior anesthesia
A combo of labial and lingual infiltration of lidocaine significantly increases success in mandibular anterior teeth
Who said: A combo of labial and lingual infiltration of lidocaine significantly increases success in mandibular anterior teeth
Meechan 2002
who said…The mylohyoid nerve is the accessory nerve most often cited as a cause of failure of mandibular anesthesia.
Frommer 1970
Fromer 1970
leading cause of failure of mandibular anesthesia?
Mylohyoid nerve
who said: a slow IAN block injection (60 sec) resulted in higher success rates (using EPT) than a rapid injection (15 sec)
Kanaa 2006
Kanaa 2006
a slow IAN block injection (60 sec) resulted in higher success rates (using EPT) than a rapid injection (15 sec)
What best explains why IAN block failure occurs? Says who?
Central core theory (DeJong 1997)
who said: The use of 3% mepivacaine as a supplemental intraosseous injection after IAN block significantly increased the success of pulpal anesthesia for 30 minutes
Gallatin 2000
Gallatin 2000
intraosseous?
The use of 3% mepivacaine as a supplemental intraosseous injection after IAN block significantly increased the success of pulpal anesthesia for 30 minutes
who said: For maxillary anesthesia, pulpal anesthesia usually occurs within 5 to 7 minutes, but slow onset occurs 20% of time
Gross 2007
Gross 2007- how long for pulpal anesthesia to occur using lido in maxillary infiltrations?
5-7 minutes
When does pulpal anesthesia start to decline in maxillary anteriors? maxillary posteriors?
Anteriors: 20-30 min
Posteriors: 30-45 min
Meechan 2002
intraligamentary injection
Intraligamentary injection is not successful in mandibular anterior teeth
How does the intraligamentary injection work?
It forces anesthetic solutions through the cribiform plate into the marrow spaces around the tooth. It is not via the PDL, and it’s not the result of pressure anesthesia. It should be considered intraosseous.
Possible downsides to intraligamentary injections?
small risk of peril abscess and bone loss. localized areas of root resorption
Two most common intraosseous systems
Stabident and X-tip
Replogle 1999
No significant tachycardia occurs when 3% mepivacaine is used for IO anesthesia
Which teeth are most difficult to anesthetize during irreversible pulpits?
mandibular molars, then mand/max premolars, then maxillary molars, then mandibular ant, then max ant.
Can intraosseous be used for necrotic painful teeth?
Can intrapulpal?
Unknown.
No, it could force bacteria apically
Why not inject into site of swelling (inject on either side instead?)
Very painful and not that effective.
who said irreversible pulpitis pulpotomies restored with IRM or GI-pain present in 10% of people at 6 mos.
Malamed 2000
Malamed 2000
pulpotomies?
irreversible pulpitis pulpotomies restored with IRM or GI-pain present in 10% of people at 6 mos.
Onset time for IAN in Mand 2nd molars? Mand first molars? Mand premolars? Mand anteriors?
Mand 2nd molars: 6 minutes
Mand 1st molars: 10 minutes
Mand premolars: 10 minutes
Mand anteriors 19 minutes
who said: primary intraosseous injection of 2% lidocaine with 1:100,000 epinephrine is more successful and results in a longer duration of pulpal anesthesia as compared with 3% mepivacaine in noninflamed mandibular first molars (30 min 3% mepiv, 60 min 2% lido)
Replogle 1997
Replogle 1997
Duration and efficacy of intraosseous with lido v. mepiv
Primary intraosseous injection of 2% lidocaine with 1:100,000 epinephrine is more successful and results in a longer duration of pulpal anesthesia as compared with 3% mepivacaine in noninflamed mandibular first molars (30 min 3% mepiv, 60 min 2% lido)
Who showed that the electric pulp tester can be a valuable tool in predicting potential anesthetic problems in operative (restorative) dentistry
Archer and Certosimo 1996
Also supported the central core theory–that it’s harder to get anterior teeth numb…?
How much lidocaine and epi are in one 1.7 mL carpule of 2% lido with 1:100K epi?
34 mg lidocaine and .017 mg epi
How much septocaine and epi are in one 1.7 mL carpule of 4% lido with 1:50K epi?
68 mg septocaine and .034 mg epi
Percentage of nociceptive fibers in the pulp?
A fibers (20%) (90% A delta, 10% A beta) C fibers (80%)
what is oraverse?
L.A. reversal agent. Phentolamine mesylate.
Guglielmo 2011
palatal injection increases pulpal anesthesia for maxillary posterior teeth
If someone is allergic to local anesthetic, what are they probably allergic to? Says?
methylparaben (preservative in esther local anesthetic)
Max dose of local anesthetic?
4.4 mg/kg (Malamed’s conservative dose.) True dose is 7 mg/kg.
How to do gow gates?
Inject needle just inferior to ML cusp of 2nd maxillary molar, and direct towards the neck of the condyle, just under the insertion of the lateral pterygoid.
What does the gow gates anesthetize?
Almost the entire mandibular division of the trigeminal nerve (IAN, lingual, mylohyoid)
Hillerup 2011
Most nerve damage is caused by the percentage of L.A. (so consider not using 4% solutions for IAN blocks)
Who said that most nerve damage is caused by the percentage of L.A. (so consider not using 4% solutions for IAN blocks)?
Hillerup 2011
Three parts of a local anesthetic
- lipophilic aromatic residue, 2. hydrophilic amino group 3. intermediate hydrocarbon chain
At rest, which ions are outside of the nerve membrane? Inside?
Na and Cl outside. K inside
What is the resting potential of nerve membranes? How is it created?
-70 to -90 mV. The Na pump maintains the resting potential by pumping Na from inside to outside.
What happens to the ions when a stimulus is produced?
Na moves in and K moves out, causing a depolarization, producing an action potential that travels down the nerve membrane.
how do local anesthetics interfere with the ions involved in depolarization?
LAs competitively displace Ca from nerve membranes. Because Ca exerts a regulatory effect on the active transport of Na out, this interferes with conduction.
Why is HCl added to anesthetics?
LA’s are weakly basic and poorly soluble in water. They are combined with HCl to form hydrochloride salts that are more soluble in water.
what is pKa
the pH value at which there are equal parts of uncharged ion and charged cation.
pKa of lidocaine? mepivacaine?
what is tissue pH
what happens to tissue pH during infection?
7.85, 7.6
7.4 (so there are more cations of L.A. in tissue).
pH 5.5–> increases cationic form to 99%
Three reasons LA don’t work in infection
pH of tissues, dilution by blood or fluids, too rapid absorption into systemic circulation.
Order of loss of function to local anesthetics (PTTPS)
Pain, temp, touch, proprioception, skeletal muscle tone
metabolism of amides?
hydrolyzed in liver by microsomal enzymes, excreted by kidney.
metabolism of esters?
hydrolyzed in plasma by pseudocholinesterase. excreted by kidney
Three things in lidocaine besides anesthetic and epi?
Na metbisulfate (0.9 mg), Citric acid (preservative), Sodium chloride (preservative)
most common cause of death with local anesthetic
respiratory depression
Who showed that 4% local anesthetics are more likely to cause paresthesia?
Haas 1995
What did Haas 1995 show about paresthesia?
4% L.A. more likely to cause paresthesia
How does epi work to help with vasoconstriction?
stimulates gamma1 receptors in mucous membranes (from Haas 2002 review)
Who described articaine, a new amide local anesthetic?
Malamed 2000
Two studies that show articaine and lidocaine are equally effective for IAN blocks?
Claffey 2004 and Mikesell 2005
Who looked at FDA records and found paresthesia occurs more commonly after the use of 4% L.A. solutions
Garisto 2010
What did Garisto 2010 find about L.A.?
ooked at FDA records and found paresthesia occurs more commonly after the use of 4% L.A. solutions
Who found that for PDL injections, injecting under back pressure produced the greatest frequency of success?
Smith, Walton 1983
What did Smith, Walton 1983 say about PDL injections?
injecting under back pressure produced the greatest frequency of success
