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BDS2 CDS Paedriatric > Child Management and Pain Control > Flashcards

Child Management and Pain Control Flashcards

1
Q

surface anaesthesia

A

anaesthesia of the surface tissue i.e. skin or mucous membrane

physical or pharmacological

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2
Q

uses of surface anaesthesia

A

to reduce pain of LA injection

to reduce discomfort of venepuncture

for superficial soft tissue manipulation

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3
Q

physical surface anaesthesia a.k.a

A

refrigeration anaesthesia

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4
Q

physical surface anaesthesia technique

A

By reducing the temperature

Ethyl chloride (rarely used as LA agent in children)
- Can be useful for quick topical if pt not using EMLA correcting

Difficult to direct stream of liquid accurately

Inadvertent contact with vital teeth produces discomfort

Inflammable – kept in yellow flammable cupboard

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5
Q

pharmacological surface anaesthesia

A

topical anaesthesia

  • intraoral topical agents
  • topical anaesthesia for skin
  • controlled release devices
  • jet injectors
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6
Q

intraoral topical agents

A

Will anaesthetise 2-3mm depth of tissue

Success is technique dependent:

  • Dry area (cotton wool roll)
  • Apply over limited area (use a cotton wool roll)
  • Apply for sufficient time: 2 mins

Different preparations:

  • Lidocaine: 2% gel; 10% spray & 5% ointment
  • Benzocaine: 20% gel (flavoured bubblegum, harder to find currently)
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7
Q

different preparations of intraoral topical anaesthesia

A
  • Lidocaine: 2% gel; 10% spray & 5% ointment

- Benzocaine: 20% gel (flavoured bubblegum, harder to find currently)

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8
Q

what is important to remember when calculating the dose given of anaesthesia to a child

A

always take in the dose of topical anaesthesia as well as local anaesthesia

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9
Q

importance of intraoral topical anaesthesia in practice

A

These are key to LA in children (and anxious pt of all ages) but take care to follow correct approach and timings

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10
Q

intraoral topical uses

A

Pre-injection

Rubber dam clamp

Placing matrix band

Suture removal

Exfoliating primary teeth

Subgingival scaling

Incision of abscess
- Harder to apply other LAs

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11
Q

2 types of topical anaesthetic for skin

A

EMLA cream

ametop gel

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12
Q

EMLA cream

A

5% eutectic mixture of prilocaine (amide) and lidocaine (amide)

Needs to be applied for at least 45 minutes

Useful prior to general anaesthesia or intravenous sedation (veneflow)

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13
Q

ametop gel

A

Tetracaine (amethocaine) 4% gel (esther)

Faster onset than EMLA

Not as widely used as EMLA

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14
Q

type of topical controlled release devices

A

patches

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15
Q

topical patches

A

Incorporation of local anaesthetic into materials that adhere to the mucosa and allow slow release

Decreases the chance of the anaesthetic moving away from the application site

  • helps keep topical injection at site
  • dry cotton wool roll with topical can be distributed around mouth or swallowed – cause numb throat and patient may be less compliant

Under investigation

  • Under development
  • patches can be coloured to allow a bullseye which the operator can use to apply injection to correct site
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16
Q

advantages topical jet injectors (4)

A

Allows anaesthesia up to 1cm

Bleeding diatheses (susceptibility to bleeding e.g. haemophilia, VW) where deep injections are contraindicated
- E.g. IV blocks – deep bleed, airway constriction etc

Sole means achieving LA depending on Tx

Prior to conventional techniques

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17
Q

disadvantages of topical jet injectors (4)

A

Could cause soft tissue damage if careless

Frightening sight and sound

Taste of solution

Expensive

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18
Q

2 types of non-pharmacological pain control

A

TENS (transcutaneous electrical nerve stimulation)

Hypnosis

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19
Q

TENS (transcutaneous electrical nerve stimulation)

A

blocks large myelinated nerve fibres and closes the gate to central transmission of smaller unmyelinated pain fibres

Controlled by patient (over 10yrs old)
- Early stages of labour

Uses: restorations, primary extractions, pre- LA (always need LA after)

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20
Q

hypnosis

A

An altered state of mind such that suggestions are accepted more readily and acted upon more powerfully

adjunct to LA by decrease pulse rate
- More powerful and work better
Decreases pulse rate, makes calmer

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21
Q

common LA solutions (4)

A

Lidocaine 2% with 1:80000 epinephrine/adrenaline (amide)

Lidocaine 2% plain (amide) (shorter acting as no vasoconstricter/adrenaline)

Prilocaine (Citanest®) 3% with felypressin (also known as octapressin) 0.03IU/ml (amide)

Articaine 4% (Septanest®) with 1:100 000 adrenaline (amide)

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22
Q

when might you use a LA without vasoconstrictor

A

Doesn’t stay in localised area for as long so is shorter acting - special need children

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23
Q

lidocaine

A

common local anaesthetic

anti-arrhythmic drug (supresses abnormal heart rhythms)

rapid onset of action

half life= 1.5-2hrs (time it takes to half concentration of drug in body – affected by vasoconstrictor)

suitable for infiltration, block, and surface anesthesia

addition of epinephrine (adrenaline) vasoconstricts arteries, reducing bleeding and also delays the resorption of lidocaine, almost doubling the duration of anaesthesia

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24
Q

4 contraindications of lidocaine

A

Heart block and no pace-maker

Allergy to LA (or to corn),

hypotension

impaired liver function

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25
Q

articaine

A

First produced in Germany 1969

Half life of 20 mins

Contains a thiophene ring instead of benzene

Additional ester group

Risk of systemic toxicity lower than others as it is hydrolised by blood quicker

More effective for mandibular infiltrations than lignocaine
- Usually for haemophiliacs where you are reluctant to do IDB

Lignocaine and articaine are equally effective as blocks.

Lignocaine drug of choice for block, as 4% solutions carry higher risk of non-surgical paraesthesia

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26
Q

contraindication of articaine

A

avoid in sickle cell patients (and other haemoglobinopathies)

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27
Q

4 effects of adrenaline

A

Avoid intra-arterial injection by careful technique
- aspirate prior to deposition to ensure not in BV

Adrenaline binds to alpha-receptors in the peripheral vasculature
- causing vasocontriction

Adrenaline binding with B1-adrenergic receptors in the heart wall.
- causes tachycardia (heart rate >100 bpm), due to

Increased HR in combination with peripheral constriction can lead to increased blood pressure.

However, it has been reported that there is no need to avoid adrenaline containing local (which is less effective) unless BP> 200mmHg (systolic) and/or (diastolic) >115mmHg

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28
Q

what should you consider when giving LA to pt with HBP

A

Have caution with patients on diuretics (“water tablet” used to decrease BP by flushing salt out of body
- use adrenaline free LA to avoid risk of reduction in potassium concentration) Meechan 92

Beta-Blocker (used to decrease blood pressure)
- less problematic

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29
Q

3 techniques of LA in children

A

infiltration

intraligamentary

regional block

30
Q

LA needle sizes

A

long
- ID block

short (regular)
- infiltration

ultra-short
- infiltration of intra-papilllary

31
Q

long LA needle use

A

ID block

32
Q

short LA needle use

A

infiltration

33
Q

ultra-short LA needle block

A

infiltration or intra-papillary

34
Q

LA infiltration uses (5)

A

Anaesthesia in primary teeth

Anaesthesia in maxillary permanent teeth

Anaesthesia in mandibular permanent anterior teeth

Prior to intrapapillary and then intraligamental anaesthesia in posterior permanent teeth

Prior to intrapapillary and palatal/lingual anaesthesia

Not mandibular molars – unless articaine infiltration in haemophiliac

35
Q

when is LA infiltration not used

A

mandibular molars – unless articaine infiltration in haemophiliac

36
Q

LA infiltration technique

A

Dry mucosa

Topical anaesthetic (2 mins)

Wipe off excess topical anaesthetic

Stretch mucosa until taught (make more comfortable)

Distract patient (gentle pressure or rubbing on lip can do this, talking, singing)

Insert needle (ultra short or normal 30 gauge)
Aspirate

Inject supraperiosteal as close as possible to apices of teeth
- Painful when on bone

37
Q

lingual/palatal anaesthesia technique

A

Ultra-short 90 degrees to surface
- Already put in infiltration – so numb of area ahead before you inject

Approach via anesthetised buccal interdental papilla

Advance when see palatal blanching
- Otherwise uncomfortable

38
Q

LA intraligamentary uses (2)

A

to supplement infiltrations

may eliminate need for block

39
Q

intraligamentary technique

A

Can be tender in child due to pressure
- get specialised syringes

Interosseous via cancellous space via PDL

0.2ml per root – beware excess dose

More successful with a vasoconstrictor

Ultra short 32 gauge needle

30 degree to long axis of tooth in mesiobuccal gingival sulcus
- advance until resistance

Specialised syringe measured dose
Conventional syringe – 0.2ml is width of bung (hard to do)

40
Q

syringes used for intraligamentary technique LA

A

Normal syringe with ultra short needle or Custom made syringes
- Peripass syringe – less pressure

41
Q

the wand

A

Method specialised intraligamental LA and conventional blocks

Uses computerised flow of local anaesthetic
- Computer can guide you if on bone

Can be used as a method of intraligamental LA for single tooth anaesthesia
- E.g. special need children – avoid biting on numb soft tissue

Can also be used for infiltration and block anaesthesia

42
Q

issue for the wand

A

not safety plus syringe system

  • cap goes at side of machine
  • cannot resheath it like normal conventional needle
  • use one hand to deposit and then place back in cap
43
Q

inferior alveolar and lingual nerve block in children

A

Mandibular foramen (smaller children)
- below occlusal plane
lower than in adults

Approach direct from primary molars of opposite side

Lateral to the pterygomandibular raphe and medial to ascending ramus

44
Q

mental block technique (long buccal, mental and incisive nerve s)

A

Advance needle in buccal sulcus toward region between apices of 1st and 2nd primary molars.

Mental foramen faces anteriorly in children

45
Q

advantage of mental block

A

very good soft tissue anaesthesia

46
Q

disadvantage of mental block

A

Incisive nerve anaesthesia not as reliable as IDB

Incisors may get crossover supply across midline so need a labial infiltration adjacent to tooth as well as this block

47
Q

nerves effected by mental block

A

long buccal
mental
incisive

48
Q

maxillary block technique

A

Direct block seldom used
- Surgery in area e.g Supernumerary tooth, ectopic canine

Greater palatine and nasopalatine blocks can be achieved by infiltrating LA through anaesthetised buccal papilla and ‘chasing’ the anaesthetic through to the palatal mucosa

49
Q

LA generalised compilations (5)

A

psychogenic (stress)

allergy

toxicity

drug interactions

infections

50
Q

allergy to LA

A

Anaphylaxis is very rare especially to amide group

Metabisulphite (E223) preservative, antiseptic

Latex – rubber bung cartridge

Methyl parabens Preservative, (E218) found in blueberries

51
Q

LA toxicity effect (4)

A

cardiovascular

  • low levels: stimulant
  • high levels: circulatory collapse

CNS
- depressant leading to unconsciousness and respiratory arrest

methaemoglobinaemia
- cyanosis associated with lethargy and respiratory diseases

reduced ability of RBC to release O2 to tissues
- prilocaine, articaine, benzocaine

52
Q

max safe dose of lidocaine 2% plain/with adrenaline

A

5mg/kg

53
Q

max safe dose of prilocaine 4% plain/3% with felypressin

A

8mg/kg

54
Q

max safe dose of mepivicaine 3% plain/2% with adrenaline

A

3mg/kg

55
Q

max safe dose of artiicaine 4% with adrenaline

A

7mg/kg

56
Q

max safe dose of 2% lidocaine in 20kg child

A

2% soln in 2.2ml cartridge contains 44mg

Max safe dose is 4.4mg/kg or 1/10th cart /kg

weight of a 5yr old child is 20kg

20kg x 4.4 = 88mg = 2 cartridges

57
Q

max safe dose of 3% prilocaine with felypressin in 20kg child

A

3% soln in 2.2ml cartridge contains 66mg

Max safe dose is 6mg/kg (1/11th of a cartridge per kg weight)

weight of a 5yr old child is 20kg

20kg x 6= 120mg so less than 2 cartridges (2 cartridges contain 132mg- so can only give 1 and 9/11ths of a cartridge)

58
Q

max safe dose of 4% articaine

A

4% soln in 1.8ml cartridge contains 72mg

Max safe dose is 5mg/kg (1/15th cart/kg)

Weight of 5 year old child is 20 kg

20kg x 5 = 100mg = 1 and 1/3 cartridge

59
Q

3 ways to prevent complication in LA administration

A

Aspiration

Slow injection
- Feels right – not depositing in wrong place, more comfortable for patient

Dose limitation

  • Give the lowest dose needed for Tx
  • Half cartridge sufficient then just use that
60
Q

LA toxicity Treatment

A 
Stop dental treatment
Provide basic life support
Call for medical assistance
Protect patient from injury
Monitor vital signs
61
Q

LA localised complications (6)

A

Self inflicted trauma – biting soft tissues

Oral ulceration

Long lasting anaesthesia

Trismus

Infection

Developmental defects

62
Q

early localised complications to LA

A

Pain:

  • intraepithelial; subperiosteal;
  • nerve trunk; intravascular

Intravascular injection:
- arterial; venous

Failure of LA:
- anatomy; pathology; operator technique

Motor nerve paralysis

Haematoma formation

63
Q

4 contraindications to LA

A

in bleeding disorders avoid IDB

allergy

acute infection

care in liver disease - amide dose reduction

64
Q

do nots in behaviour management

A 
bribe 
coax
shout
bully 
threaten 
humiliate 
lose your patience with the patient 
allow child to have all their own way
65
Q

how to be empathetic to child

A

create an environment in which the child feels safe

use a kind empathetic approach using directive guidance, and reinforcement to establish co-operation and obtain a rapport

  • praise specific behaviour – opening mouth wide, arms still
  • enforce specific behaviour

allow the child some control (e.g. hand signal, take seriously)

question for feeling (are you OK?)

66
Q

techniques is child behaviour management

A

Positive reinforcement

Tell, show, do

Acclimatisation

Desensitisation

Voice control

Distraction

Role modelling

children often focus on negative words like ‘pain; or ‘hurt’
- avoid them

67
Q

what is the safe max dose of ligocaine that can be given to child of 15kg

A

1.5 cartridges

Calculate 1/10th cartridge per kg weight

4mg/kg –> 75mg for 30kg

44mg/cartridge

75/44 = 1.7045 (so 1.5 cartridges)

68
Q

what is a safe and effective way to anaesthetise a lower permanent molar in a 12 year old child with mild haemophilia A

A

Single tooth anaesthesia using the wand system and articaine with adrenaline
- because nerve blocks should be avoided and buccal infiltration with lignocaine alone is less likely to be as effective

69
Q

what is the most common adverse effect when giving LA via an IA Nerve Block

A

Failure of local anaesthetic to anaesthetise the tooth sufficiently
- Although in most cases this should be avoided with careful technique. It can be more difficult to effectively anaesthetise teeth with irreversible pulpitis, periapical abscess or hypomineralised sensitive molars

70
Q

what is the max safe dose of articaine that can be given to a 30kg child

A

2 cartridges

4.3ml is max safe dose – 1/15 cartridge/kg

7mg/kg –> 210mg for 30kg

88mg/cartridge

210/88 = 2.3863 (so B 2 cartridges)

BDS2 CDS Paedriatric (7 decks)

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