Chapter 11 - Fundamentals for LA Administration

Question 1

1. A technique that deposits anesthetic solution near larger terminal nerve branches for treatment near the site of an injection is called:
   a. infiltration injection
   b. ligamental injection
   c. field block injection
   d. nerve block injection

Answer 1

c. field block injection

Question 2

2. Which ONE of the following describes the target site for LA solutions?
   a. needle pathway
   b. deposition site
   c. penetration site
   d. aspiration site

Answer 2

b. deposition site

Question 3

3. The first step in the administration of LA solution is to:
   a. assemble the armamentarium
   b. obtain informed consent
   c. assess the patient before proceeding
   d. make sure that solution is able to exit the needle

Answer 3

c. assess the patient before proceeding

Question 4

4. A primary benefit of orienting the needle bevels toward bone during injections is that it:
   a. reduces trauma to the periosteum when bone is contacted
   b. deflects the needle away from the bone during penetration
   c. prevents false negative aspirations within a vessel
   d. reduces discomfort from the advancing needle

Answer 4

a. reduces trauma to the periosteum when bone is contacted

(reduces discomfort and trauma to periosteum when bone is contacted; w/ inadvertent contact, the needle tends to glance off the bone rather than pierce the periosteum)

Question 5

5. Which ONE of the following is the most appropriate LA patient record entry?

a. 10/21/2015: Review hx, PB 1220/80, 2 cartridges 2% lidocaine, 1:100,000 epi, no complications

b. Review hx, BP 120/80, 2 cartridges 2% lidocaine, 1:100,000 epi (0.036 mg, Rt IA, LB, (+) aspiration

c. Review HX, BP 120/80, 72mg of 2% lidocaine, 0036mg 1:100,000 epi, IA, LB

d. 10/21/2015: Review hx, PB 1220/80, 2 cartridges (3.6mL) 2% lidocaine (72mg), 1:100,000 epi (0.036mg), Rt IA, LB, (-) aspiration. No adverse reactions

Answer 5

d. 10/21/2015: Review hx, PB 1220/80, 2 cartridges (3.6mL) 2% lidocaine (72mg), 1:100,000 epi (0.036mg), Rt IA, LB, (-) aspiration. No adverse reactions

Question 6

6. When is it safe to deposit LA solution?
   a. after a (-) aspiration, where no blood is drawn into the cartridge
   b. after a (-) aspiration, following a (+) aspiration where blood was visible in the cartridge only as a small trickle of blood, or a “worm like” thread
   c. following a positive aspiration that obscures the results of subsequent aspirations
   d. A & B

Answer 6

d. A & B

Question 7

7. The MOST important safety step(s) during LA injections is/are:
   a. aspirate before depositing
   b. administer LA slowly
   c. direct bevel away from bone
   d. aspirate before depositing and to administer drugs slowly

Answer 7

d. aspirate before depositing and to administer drugs slowly

Question 8

8. Upon completion of an injection, the most important SUBSEQUENT step is to:
   a. rinse the patient’s mouth
   b. calculate the volume of drug delivered
   c. make the needle safe with a one-handed technique
   d. determine if the patient experienced discomfort

Answer 8

c. make the needle safe with a one-handed technique

Question 9

Q11-1: Name the three basic types of intraoral injections frequently used in dentistry.

Answer 9

A11-1: The three basic types of injections frequently used in dentistry include local infiltration, field block, and nerve block injections.

Question 10

Q11-2: Define infiltration injections.

Q11-3: Define field block injections.

Q11-4: Define nerve block injections

Answer 10

A11-2: Infiltration: deposition directly at or near small terminal nerve endings in the immediate area of treatment

A11-3: Fields blocks: deposition near larger terminal nerve branches; tx of areas near or a small distance away; commonly referred to as infiltrations a/o supraperiosteal injections.

A11-4: Nerve blocks: depositions near primary nerve trunks at greater distances from the areas of treatment -> provide wider areas of anesthesia.

Question 11

Q11-5: Define penetration site.

Q11-6: Define needle pathway.

Q11-7: Define deposition site

Answer 11

A11-5: The penetration site is the specific location where a needle first enters the mucosa.

A11-6: Needle pathway refers to the route a needle travels as it advances to a target site.

A11-7: The deposition site may be defined as the anatomical location at which a drug is deposited.

Question 12

Q11-8: How is needle deviation prevented from the penetration site to the deposition site?

Answer 12

A11-8:
- the greater the distance (penetration to deposition site), the greater the potential for deviation

• Close attention to proper landmarks and maintaining appropriate syringe barrel angles during injection will reduce these deviations.

Question 13

Q11-9: What elements should be included in an informed consent?

Answer 13

A11-9:
1. Appropriate language
2. Provide opportunities to ask questions
3. Explain recommended procedures and the need for each
4. Clarify the risks & rewards of recommended treatment, including the risks of failing to treat
5. Provide acceptable alternatives to the recommended treatment

Question 14

Q11-10: Explain the importance of properly loading and fully engaging the rubber stopper into the cartridge.

Answer 14

A11-10: harpoon fully engaged into the rubber stopper allows piston to be retracted when performing aspiration tests.

Question 15

Q11-11: Explain why it is important for the cartridge to remain fully visible when loaded into the syringe barrel.

Answer 15

A11-11:
- to re-confirm that the correct drug has been loaded - to confirm results of aspiration tests
- to monitor drug doses and rates of delivery

Question 16

Q11-12: What is the final step in armamentarium preparation?

Answer 16

A11-12:
- confirm that all safety controls are in place (incl. appropriate PPE for clinicians and patients)
- focus special attention on the safe handling of needles.

Question 17

Q12-13: Explain the importance of patient positioning during injections.

Answer 17

A11-13:
-Ideally, direct vision of the penetration site
-Placing a pt’s head at same level as heart is reco’d
-principles of proper ergonomics should be applied for all injections

Question 18

Q11-14: Why is effective soft tissue retraction necessary?

Answer 18

A11-14:
-provide clear visibility of the penetration site
-allow view of needle throughout the injection

Question 19

Q11-15: Why is it important to dry the soft tissue prior to placing topical anesthetic at the penetration site?

Answer 19

A11-15:
- reduces dilution and spread of the topical agent
- improves uptake into mucosal tissue
- serves as a debridement of gross & microscopic debris from the site

Question 20

Q11-16: Which grasp on the syringe provides the most stability?

Answer 20

A11-16: “palm up” grasp
-stability can be increased with the index finger extended onto the barrel for support

Question 21

Q11-17: Why is it important to have a good fulcrum and stabilization throughout an injection?

Answer 21

A11-17: The goals of fulcruming and stabilization are to maintain constant control of the syringe and a position that supports musculoskeletal health.

Question 22

Q11-18: What is the initial penetration depth into the mucosa?

Answer 22

A11-18: The initial penetration depth is 1–2 millimeters (approximately the length of the bevel).

Question 23

Q11-19: Explain the purpose of an aspiration test.

Answer 23

A11-19: An aspiration test reduces the risk of inadvertent deposition of a drug directly into the blood stream.

Question 24

Q11-20: How is an aspiration test performed?

Answer 24

A11-20: Once the needle is advanced to the appropriate deposition site for a specific injection and prior to depositing solution, perform an aspiration test by applying gentle, brief back pressure on the upper inside surface of the thumb ring. This action changes the pressure inside the cartridge from positive to negative.

Question 25

Q11-21: How can a “false negative” aspiration be prevented?

Answer 25

A11-21:
- Causes for false negative: bevel is in contact with a vessel wall, negative pressure of aspiration can retract the vessel wall into lumen and blocking it
- To check for false negative responses, rotate the syringe slightly; this will reposition bevels away from vessel walls. This step is encouraged for all injections in which there are greater risks of positive aspiration.

Question 26

Q11-22: What is the correct procedure to follow if a small trickle or “worm like” thread of blood enters the cartridge following an aspiration test?

Answer 26

A11-22: If clear vision of a subsequent aspiration will not be obstructed, the needle can be repositioned slightly and aspiration can be repeated.
After a second test is negative, the clinician may continue with the injection and deposit the drug.

Question 27

Q11-23: Discuss appropriate steps to take following any positive aspiration.

Answer 27

A11-23:
-injection site should be evaluated immediately after completion for local complications (e.g, swelling)
- remain alert to S/S of possible intravascular inject.
- If there are no immediate complications, continue tx
- advise pts according to the significance of the situation and monitored post-tx as indicated
- If there are repeated positive aspirations at the same injection site, rescheduling should be considered.

Question 28

Q11-24: What is the most important step in the administration of a safe and comfortable injection at the optimum deposition site? Why?

Answer 28

A11-24:
= rate of delivery
- Slow delivery reduces the risk of OD & complications if inadvertent intravascular injection after false negative aspiration

Question 29

Q11-25: What is considered a safe and more comfortable rate of deposition?

Answer 29

A11-25: A safe and more comfortable rate of deposition allows for the delivery of 1 mL of solution per minute, which means it requires about 2 minutes to deposit a 1.8 mL cartridge of anesthetic drug; however, 60 seconds is more common.

Question 30

Q11-26: What is the final safety step following an injection?

Answer 30

A11-26: properly manage and recap the needle

Question 31

Q11-27: What are the key elements to include in a patient’s medico-legal treatment record following an injection procedure?

Answer 31

A11-27: The patient’s record must include:
1. Date of administration
2. Type of drug(s) administered (both topical and injectable)
3. Injection(s) administered (or area of delivery when topical alone is used)
4. Total volume of drug(s) administered
5. Results of aspiration recorded as positive (+) or negative (-)

Question 32

Q11-28: Discuss the basic principles of ergonomics related to the administration of injections.

Answer 32

A11-28: consider non-traditional approaches to reduce twisting the trunk, hyperextending the neck, angling the wrist in an awkward manner, and reaching over the patient.

Question 33

Q11-29: Provide five basic elements for good ergonomics during the administration of local anesthesia injections.

Answer 33

A11-29: To maintain good ergonomic position and balance:
1. Do not twist from the trunk.
2. Bend from the hips.
3. Keep wrists at a neutral angle.
4. Do not raise arms >30 degrees.
5. Do not extend the neck >30 degrees forward.