Armamentarium Flashcards by Caleb Houghton

 Aspirating:

 with harpoon, it engages thick silicone rubber stopper at the tail end of the cartridge
 Negative pressure will cause blood (if there) to be visible in the cartridge

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Caring for Your Instruments
washing?
lubrication?
harpoon?
piston and harpoon replacement?

Wash the syringe after each use
Dismantle and lubricate every 5 autoclavings
Clean Harpoon with brush after use
Replace piston and harpoon on regular basi

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needle anatomy
factors of the shaft?
greater bevel=?

 Bevel, shaft, the hub, and cartridge penetrating end
 Shaft has two important factors
• Diameter (gauge)
• Length (from tip to the hub)
 Greater angle the bevel, greater the degree of deflection

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needle gauge

 Diameter of the lumen of the needle
 Smaller the gauge #, Greater the diameter
• Example 25-gauge has greater internal than 30-gauge internal diameter

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are smaller needles less painful?

 This assumption is unwarrnated !!!
 Hamburg (1972) demonstrated that patient is unable to differentiate among 23-, 25-, 27-, and 30-gauge needle.
 Bottom line
 Patients feel the same regardless of gauges of needle

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Advantage of Larger Gauge Needle
defelction?
accuracy?
breaks?
aspiration?
pt comfort?

Less deflection, as needle advances through tissues
Greater accuracy in injection
Less chance of needle breakage
Easier aspiration
No perceptual difference in patient comfort

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when should larger gauge needles be used

Larger-gauge needles should be used when there is a
greater risk of positive aspiration

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colors of gauges

 Red: 25- gauge
 Yellow: 27- gauge
 Blue: 30- gauge

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Deflection of needle

Deflection
 Deflection of needle will differ according to gauges
 Deflection becomes important when needle must penetrate a greater thickness of tissue

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Conventional Dental Needle

 Needle tip is at the lower edge of the needle shaft, deflection

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Nondeflecting Needle

 The tip of needle is at the center of the shaft
 But over years of use, dentists become accustomed to deflecting needle

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needle length
weakest portion?
should entire needle ever be completely injected?

 Long and short
 Average short needle is 20mm
 Average long needle is 32mm
 Weakest portion of the needle is at the hub
 Needles should not be inserted into tissues to their hub unless it is absolutely necessary for the success of the injection

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Handling of Needle
Never used on?
Change after?
Must cover?
Pay attention to?
Proper disposal?
 Recapping?

Never used on more than one patient
Change after 3 or more tissue penetration
Must cover in protective sheath when not
use
Pay attention to the position of uncovered
needle tip
Proper disposal is necessary
 Recapping using “Scoop” technique

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 Pain on insertion due to

dull needle

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Breakage of needle

 Do not bent needle if to be inserted into >5mm soft tissue depth
• Most commonly “bent needle” procedures are
 Inferior alveolar nerve block
 Posterior superior alveolar nerve block
 Intrapulpal injection
 PDL injection and Intraosseous injection

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changing needle direction in tissue?

Don’t change direction of a needle when its embedded in tissue

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Pain on withdraw may caused by?

Pain on withdraw may caused by “fishhook” barb on the tip

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cartridge overview
holds what V?
reffered to as?
some made of?

 The glass cylinder can hold 2ml of solution
 U.S. dental cartridge contains 1.8ml of local anesthetic solution
 Dental cartridge is commonly referred as “carpule”
 Some cartridge are made of plastic cylinder instead of glass
 Plastic cylinder isn’t able withstand extended force and will leak

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Cartridge Contents
 Calculation of mg of drug in the cartridge

Local anesthetic drug is the main player !!
 Calculation of mg of drug in the cartridge
• Example: 2% lidocaine in a cartridge (1.8ml)
2% = 20mg/ml and we have 1.8ml so
20 mg/ml X 1.8 ml = 36 mg
this means we have 36mg of lidocaine in a cartridge
• How about 3% Mepivacaine in a cartridge
3% = 30mg/ml and we have 1.8ml so

possible add in for cartridges

May have Vasopressor
 Sodium bisulfite (antioxident)
 Sodium bisulfite oxidize to Sodium bisulfate
NaCl
 make solution isotonic with tissue
Distilled water

how can cartridge be cleaned?

no soaking, use of a moistened wipe with 91% ispropyl or 70% ethyl

Care and Handling of cartridges

 No manufacturer claim of sterility about exterior surface of the cartridge
 Bacterial culture tested fail to produce any growth
 Cannot withstand extreme temperature
 No autoclaving especially plastic cartridge
 When heated, vasopressors are destroyed
 Store in room temperature in a dark place
 Study showed no benefit of using cartridge warmer
 Do NOT soak cartridge in alcohol or “cold sterilizing solution”
 Semipermeable diaphragm permits diffusion of these solution
 Read the drug package insert

Problems with cartridges bubble? extruded stopper? how to fix?

 Bubble in the cartridge- Small bubble 1-2 mm are usually nitrogen gasand Large bubble with extruded stopper  Extruded Stopper- >2mm bubble due to frozen cartridge or If no bubble, may caused by diffusion of other agent through diaphragm • Wescott demonstrated measurable alcohol in cartridge after only one day of immersion in alcohol solution

Corroded Cap

 If immersed in disinfecting solution  Only sterilization needed are • 91% isopropyl alcohol • 70 % ethyl alcohol

Burning on injection due to

 pH, alcohol, heat, expiration date..

cartridge use on more than one? stored at what temp? warm before use? expiration date? check for?

 Dental cartridges must never be used on more than one patient  Cartridges should be stored at room temperature  It is not necessary to warm cartridges before use  Cartridges should not be used beyond their expiration date  Cartridges should be checked carefully for cracks, chips and integrity of the stopper and cap before use

 Topical antiseptics before injection optional)

 Betadine  Chlorhexidine

 Topical anesthetic prior to injection

 Placed directed with applicator for 1 min • Stern and Giddon demostrated topical to mucous membrane for 2-3 mins leads to profound soft-tissue analgesia  Benzocaine > Lidocaine topical (reduced overdose potential)  Off label use of EMLA but its biter  Unmetered spray is not recommended

Preparing of the Armamentarium steps

retract piston insert cartidge Engage the harpoon in plunger with GENTLE finger pressure Plastic hubbed needle is screwed onto the syringe Scoop the needle cap unload and retract the piston

Costly Mistake with post injection

When discarding needle, make sure metal needle adaptor is not discarded

Most common psychogenic reactions

 Vasodepressor syncope  Hyperventilation

Medical History Questionnaire Update every? allergies? bleeding? avoid techniques that? HF?

Update every 6 months Allergy -True, documented, and reproducible allergy to amide is virtually nil -Epinephrine allergy most likely due to exaggerated physiological response Bleeding problems (Coagulopathies)  Avoid techniques with ↑ chance of + aspiration -Use supraperiosteal, PDL, Intraosseous Heart Failure -CHF with disability (ASA III or ASA IV) may demonstrate ↓ liver perfusion ↑ t ½ amide local anesthesia

 ASA IV cardiovascular risk pt is not a candidate for?

 ASA IV cardiovascular risk pt is not a candidate for vasopressors or elective dental care -Recent (< 6 months) or repeated MI increases risk during dental care or local injection

 Judicious use of vasopressors in L.A. is __________ in stable angina

 Judicious use of vasopressors in L.A. is not contraindicated in stable angina (Unstable angina = ASA IV)

 AIDS, Hepatitis A,B, Jaundice... increase half time of?

 AIDS, Hepatitis A,B, Jaundice... ↑ t ½ amide

Seizure  Causes?  Stress Reduction?

 Causes • Stress / Anxiety • Hypoglycemia • Hyperventilation  Stress Reduction protocol is needed

Pregnancy and injections

 Relative contraindicated especially at 1st trimester  Consultation with OB-GYN is needed

TCAs and LA type on contraindication?

Tricyclic Antidepressant (TCAs) - Enhance cardiovascular action to exogenously administered vasopressors • 5 -10 X increase with levonordefrin and Nore-epi • 2 X increase with epinephrine --What’s the big deal ?!=Hypertensive crisis =death

Drug-Drug Interactions Cimetidine?  H2 receptor blocker?  Cimetidine + ASAIII CHF = ? what sort of contrainidcation?

Cimetidine ↑ t ½ of circulating local anesthesia  H2 receptor blocker compete with lidocaine for hepatic oxidative enzyme  Cimetidine + ASAIII CHF = relative contraindication for amide local anesthesia

other relative contraindications of LA?

Malignant Hyperthermia and Methemoglobinemia (to Prilocaine)

cocaine drug to drug interaction contraindication type?

 Cocaine stimulate nore-epi release and inhibit reuptake  Tachycardia / hypertension = ↑ myocardio O2 requirement = Cardiac ischemia = MI 72 hrs is needed for Cocaine clearance Dental correlation:  Epinephrine-impregnated gingival retraction cord is absolutely contraindicated in the cocaine abuser  Postpone dental treatment, if suspected cocaine usage within 24 hours

reuse needles?

covered with sheath when not in use?

yes

how to recap needle

one handed scoop

should needles be bent in cases where if it difficult to access for a block

what bacteriostatic agent was removed from cartridges?

methylparaben

bevel angle importance

greater angle means more deflection

bevel bone relation

towards bone, prevent periosteum from being punctured