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Intro to Oral Surgery & Pain Management > Comprehensive Study Guide > Flashcards

Comprehensive Study Guide Flashcards

1
Q

Label whether the following ions are intra- or extra-cellular:

  1. K+
  2. Na+
  3. Cl-
  4. Proteins
  5. HCO3-
A
  1. ICF
  2. ECF
  3. ECF
  4. ICF
  5. ECF
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2
Q

Intracellular ions=

A

K+ and proteins (more negative)

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3
Q

Extracellular ions=

A

Na+, Cl-, HCO3- (more positive)

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4
Q

Where do local anesthetics exert their pharmacological action on the nerve?

A

Nerve membrane

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5
Q

How do local anesthetics work?

A

Specific receptor theory- local anesthetic binds to specific receptor on the Na+ channel

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6
Q

What does the specific receptor theory state?

A

States that the local anesthetic binds to a specific receptor on the Na+ channel to prevent the channel from opening (therefore no action potential and no pain)

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7
Q

Which ion channel does the local anesthetics bind to ?

A

specific receptors of the na+ channel

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8
Q

Speed of conduction of a myelinated nerve:

Speed of conduction of an unmyelinated nerve:

A

myelinated: 120 m/sec

unmyelinated: 1.2 m/sec

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9
Q

Where do local anesthetics work at the myelinated nerve?

A

local anesthetics work at the nodes of ranvier (an abundance of sodium channels here)

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10
Q

In order for local anesthetic to work on a myelinated nerve, it needs to block:

A

2-3 nodes (8-10mm of nerve)

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11
Q

Drug: Lidocaine
Onset:
Half-Life:
Mg/Kg of max dose:

A

onset: 2-3 min
half-life: 1.6 hrs
(1hr of pulpal and 3-5 hrs of soft tissue for 2% solution)
Mg/Kg of max dose: 4.4 mg/kg (300mg)

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12
Q

Drug: Prilocaine
Onset:
Half-Life:
Mg/Kg of max dose:

A

Drug: Prilocaine
Onset: 2-4 min (slightly slower)
Half-Life: 1.6 hrs
Mg/Kg of max dose: 6 mg/kg (400 mg)

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13
Q

Drug: Mepivacaine
Onset:
Half-Life:
Mg/Kg of max dose:

A

Drug: Mepivicaine
Onset: 1.5-2 min (rapid!)
Half-Life: 1.9 hrs
(20-40 minutes of pulpal and 2-3 hrs of soft tissue)
Mg/Kg of max dose: 4.4mg/kg

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14
Q

Drug: Bupivacaine
Onset:
Half-Life:
Mg/Kg of max dose:

A

Drug: Bupivacaine
Onset: 6-10 min (longer)
Half-Life: 2.7 hours (long!)
Mg/Kg of max dose: 1.3 mg/kg (90mg)

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15
Q

What drug would be used when more than 90 minutes of pulpal anesthesia is needed and is also used to reduce post-op pain?

A

Bupivacaine

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16
Q

Drug: Articaine
Onset:
Half-Life:
Mg/Kg of max dose:

A

Drug: Articaine
Onset: 1-2 min (rapid)
Half-Life: 0.5 hours (short!!)
(0.5hrs of pulpal and 3-5 hours of soft tissue for 4%)
Mg/Kg of max dose: 7mg/kg (500mg)

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17
Q

Drug: Cocaine
Onset:
Half-life:

A

Drug: Cocaine
Onset: immediate- 1 min
Half-life: 1-1.5 hrs

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18
Q

What is the onset of Procaine?

A

6-10 min (a little slower than lidocaine)

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19
Q

List the following anesthetics in order of fastest to slowest onset:

  • Bupivacaine
  • Articaine
  • Prilocaine
  • Procaine
  • Cocaine
  • Mepiivocaine
  • Lidocaine
A

(Fastest)
1. Cocaine
2. Articaine
3. Mepivacaine
4. Lidocaine
5. Prilocaine
6. Bupivacaine
7. Procaine
(Slowest)

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20
Q

List the following anesthetics in order of longest to shortest duration:

  • Bupivacaine
  • Articaine
  • Prilocaine
  • Procaine
  • Cocaine
  • Mepiivocaine
  • Lidocaine
A

(Longest)
1. Bupivacaine
2. Mepivacaine
3. Lidocaine & Prilocaine (equal)
4. Cocaine
5. Articaine

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21
Q

For maximum recommended dose (MRD) what guidelines do we follow?

A

ADA & USPC guidelines (NOT manufacturer)

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22
Q

How does low tissue pH influence local anesthesia?

A

Low tissue pH (high acidity/H+) is HARDER to anesthetize (usually associated with inflamed tissues)

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23
Q

How does low anesthetic pH lead influence local anesthesia?

A

Low anesthetic pH leads to higher effective shelf life

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24
Q

is the average pH of local anesthetics?

A

5.5-7.0

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25
Q

If the pH of the environment does not allow the ___ of the anesthetics to exist, numbing will NOT occur.

A

free base form

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26
Q

In order for the local anesthetic to work, the pH of the environment:

A

must allow the free base form to exist

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27
Q

What is the free base form of the local anesthetic?

A

What enters the nerve membrane

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28
Q

The further the pH Is from the ideal for that specific anesthetic, the:

A

lower the percentage of that local anesthetic will be present in the free base form

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29
Q

Is local anesthetic hydrophilic or hydrophobic?

A

amphipathic (both hydrophilic and hydrophobic)

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30
Q

What is the exception to local anesthetic being amphipathic?

A

Benzocaine; doesn’t have a hydrophilic group so it is good for topical but not for injections

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31
Q

_____ determines the ease for nerve blockade

A

extracellular pH

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32
Q

Inflamed or infected tissue is
much more difficult to get adequate anesthesia because:

A

of increased H+ or lower pH

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33
Q

RNH+ Breaks down into:

A

Rn (free base) and H+

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34
Q

The low pH in an anesthetic allows for:

A

increased shelf life

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35
Q

RNH+ —> RN + H+ describes:

A

the dissociation of local anesthesia

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36
Q

RNH+ —> RN + H+

What does RN represent?

A

free base

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37
Q

RNH+ —> RN + H+

What does RNH+ represent?

A

cation

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38
Q

RNH+ —> RN + H+

In this reaction, if there’s excess H+, the equilibrium will shift to the:

A

left (RNH+ side)

this means that if there is an acidic environment (example- a really infected tooth with lots of bacteria = very acidic) it will be harder to anesthetize because there is less of the free base form RN which is what actually enters the nerve membrane

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39
Q

Only the _____ of the anesthetic can enter the nerve, which is important because the sodium channel must be blocked ____

A

free base form (“ninja”); from the inside

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40
Q

Anesthesia is injected as a ___ that ___

A

ionized cation; that cannot cross the nerve cell membrane (until broken down into free-base form)

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41
Q

The anesthesia that is injected must break down from its _____ form into ____ form, which can diffuse into the membrane

A

ionized cation; non-ionized free-base

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42
Q

Once in the nerve, the free base can become the ionized version again and bind to the specific receptor to:

A

prevent sodium channel from opening

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43
Q

Once the free base form of the local anesthetic is diffused, it must _____ in order to bind to the receptor

A

dissociate back into the cationic form

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44
Q

Once the free base form of the local anesthetic is diffused, it must dissociate back into the cation form in order to bind to the receptor- what does this binding t the receptor cause?

A

prevents sodium channel from opening

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45
Q

Describe the relationship of pKa vs. local anesthesia:

A

high pKA: slow onset (few free bases available)

low pKA: rapid onset

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46
Q

Local anesthesia are _______- They combine with acids to form local anesthetic salt (HCl)

A

weak base compounds

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47
Q

pKA influences:

A

onset; inversely related

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48
Q

Describe why a high pKA would have slower onset?

A

because there are fewer free bases to diffuse (fewer ninjas without their backpacks that can get through, most ninjas have their backpacks on so they can’t cross to bind)

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49
Q

How does lipid solubility influence local anesthesia?

A

With increased lipid solubility, the drug is more potent.
With decreased lipid solubility, the drug is less potent.

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50
Q

The relationship of pKA to onset is ____.

The relationship of lipid solubility to local anesthesia potency is ___

A

inverse; direct

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51
Q

The nerve membrane is ____% Lipid

A

90%

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52
Q
  1. What influences the ONSET of local anesthesia?
  2. What influences the POTENCY of the local anesthesia?
  3. What influences the DURATION of the local anesthesia?
A
  1. pKA
  2. lipid solubility
  3. protein binding
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53
Q

With increased protein binding, the local anesthetic has:

A

longer duration

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54
Q

With decrease protein binding, the local anesthetic has:

A

shorter duration

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55
Q

The nerve membrane is ____% protein

A

10%

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56
Q

With increased lipid solubility, the drug is:

A

more potent

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57
Q

With decrease lipid solubility, the drug is:

A

less potent

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58
Q

With a high pKA, the onset of the local anesthesia is:

A

slow (few free bases available)

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59
Q

With a low pKA, the onset of the local anesthesia is:

A

rapid

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60
Q

Most local anesthetics have a ____ effect

A

vasodilation

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61
Q

Which local anesthetic has the most profound vasodilation effect?

A

Procaine

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62
Q

The only local anesthetic to have a vasoconstrictive effect

A

cocaine

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63
Q

Cocaine is vasoconstrictor (meaning its alpha-1) and works by:

A

Inhibition of catecholamine re-uptake

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64
Q

Alpha 1 =

A

vasoconstriction

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65
Q

Beta 2=

A

vasodilation

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66
Q

What agent has the most potent vasodilation properties?

A

procaine

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67
Q

The most commonly used vasoconstrictor:

A

epinephrine

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68
Q

“I” comes before “Caine” if the agent is:

A

an amide

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69
Q

_____ are readily hydrolyzed in aqueous solutions

A

esters

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70
Q

List examples of esters (6)

A
  1. procaine
  2. propoxycaine
  3. tetracaine
  4. cocaine
  5. benzocaine
  6. dyclonine
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71
Q

_____ resist hydrolysis and get excreted in urine as an unchanged form

A

Amides

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72
Q

List examples of amides (6)

A
  1. lidocaine
  2. etidocaine
  3. mepivocaine
  4. bupivocaine
  5. prilocaine
  6. articaine
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73
Q

What are the two different classes of local anesthesia?

A

Amides & Esters

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74
Q

How do amides metabolize in the body?

A

The liver is the primary biotransformation site

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75
Q

Metabolism of what type of anesthetic can cause cirrhosis/CHF or hypotension?

A

amides

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76
Q

How are esters metabolized in the body?

A

Hydrolyzed in plasma by pseudocholinesterase into paraaminobenzoic acid (PABA)

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77
Q

What is a substance in local anesthetic that individuals commonly have a reaction to? Is this in amide anesthetics or ester anesthetics?

A

PABA; Esters

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78
Q

What is the relationship between cirrhosis patient and metabolism of local anesthetics?

A

Liver function/hepatic perfusion influence biotransformation

(1) Cirrhosis → Late stage of scarring (fibrosis) of
the liver

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79
Q

When is local anesthetics a contraindication for patients with liver issues?

A

ASA IV to V for patients with liver
dysfunction (or heart failure)

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80
Q

How do cirrhosis and/or CHF interfere with the amounts of your local anesthesia injection?

A

Amide LAs are chemically modified (metabolized) in the body in the liver, so since the liver is not functioning well (does have full metabolic capacity), then less LA should be administered

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81
Q

If a patient has cirrhosis and/or liver failure, do you give them more or less local anesthetic when injecting?

A

LESS

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82
Q

Does a patient who has cirrhosis and/or CHF increase the availability of the amide local anesthetic or decrease the availability of the local anesthetic?

A

Increases the availability because the amide is not being metabolized as quickly and more is left in the body for longer periods of time

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83
Q

Which organ in the body (largest mass and tissue in the body) has the greatest concentration of local anesthesia?

A

skeletal muscle

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84
Q

What is tachyphylaxis?

A

The increase in tolerance to drug after repeated administration

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85
Q

Explain how to calculate elimination half-life

A

Take percentage of leftover, divide that in half, and add it on to what has been eliminated thus far.

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86
Q

What does elimination half life describe?

A

The amount of time needed for 50% reduction in blood level

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87
Q

List the percentages of elimination of the following elimination half life:

1st half life: 50% eliminated
2nd half life:
3rd half life:
4th half life:

A

1st half life: 50% eliminated
2nd half life: 75% eliminated
3rd half life: 87.5% eliminated
4th half life: 94% eliminated

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88
Q

DO all local anesthetics readily cost the BBB and placenta?

A

yes

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89
Q

What is the cause for local anesthesia overdose/ toxicity?

A

over injection or repeated injections into the bloodstream and systemic circulation

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90
Q

To prevent local anesthesia overdose/toxicity it is important to:

A

aspirate

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91
Q

What are the initial signs of local anesthesia overdose/toxicity?

A

Initially: Causes excitatory response (numbness of tongue and circumoral region slurred speech, shivering, AV disturbances, tremor and etc.)

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92
Q

If you ignore the initial signs of local anesthesia overdose/toxicity, what may occur?

A

patient may go into a seizure and if you continue loading them up with more local anesthesia they will stop breathing

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93
Q

What are the later signs/stages of local anesthesia overdose/toxicity?

A

Depressive response on CNS with a lesser CV effect as well as agitation, confusion, dizziness, drowsiness, dysphoria, auditory changes, tinnitus, perioral numbness, metallic taste, etc.)

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94
Q

Causes excitatory response (numbness of tongue and circumoral region slurred speech, shivering, AV disturbances, tremor and etc.)

A

Initial stage of local anesthesia overdose/toxicity

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95
Q

Depressive response on CNS with a lesser CV effect as well as agitation, confusion, dizziness, drowsiness, dysphoria, auditory changes, tinnitus, perioral numbness, metallic taste, etc.)

A

Later stage of local anesthesia overdose/toxicity

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96
Q

The initial signs/symptoms of CNS toxicity are:

A

excitatory

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97
Q

Higher levels of initial toxicity from local anesthetic may result in:

A

tonic-clonic convulsion (seizure)

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98
Q

In later stages of toxicity or where their is further increases in anesthetic beyond the initial symptoms, there will be:

A

cessation of seizure activity –> respiratory depression —> respiratory arrest

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99
Q

Catecholamines include:

A

epinephrine, norepinephrine and dopamine

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100
Q

Non-catecholamines include:

A

amphetamine, ephedrine, and methanphetamine

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101
Q

Epinephrine, Norepinephrine and dopamine are ____ catecholamines

A

natural

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102
Q

Isoproterenol and levonordefrin are ____ catecholamines

A

synthetic

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103
Q

Contain hydroxyl group on benzene ring and work directly on adrenergic receptors (alpha 1, 2 and beta 1, 2)

A

Catecholamines

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104
Q

Do not contain hydroxyl group on benzene ring

A

non-catecholamines

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105
Q

Catecholamines work directly on:

A

adrenergic receptors (alpha 1 & 2 and beta 1 & 2)

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106
Q

What is more concentrated

1:100,000 or 1:200,000

A

1:100,000 because this is equal to 1G or 1000mg/100,000ml of solution

versus

1:200,000 is equal to 1G or 1000mg/200,000ml of solution

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107
Q

Calculate the mg/ml of solution for a 1:300,000 dilution:

A

1G = 1,000 mg

1000mg/300,000ml = 0.0033mg/ml

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108
Q

The maximum dose of epinephrine in a healthy patient is:

A

0.20mg (200mcg)

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109
Q

The maximum dose of epinephrine in an unhealthy/cardiac patient is:

A

0.04mg (40mcg)

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110
Q

If you have a 1.7ml solution of the 1:100,000 dilution of epinephrine, how much epi is present per ml?

A

1.7 x.01 = .017mg/ml

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111
Q

Which agent (catecholamine) lacks significant b2 actions thus produces intense peripheral vasoconstriction with possible dramatic elevation of BP and is associated with a side effect ratio 9x higher than that of epinephrine? (a big reason that this agent is NOT available in the US)

A

Norepinephrine (EXCESSIVE vasoconstriction)

112
Q

Closely resembles norepinephrine:

A

Levonodefrin

113
Q

Contraindications for vasoconstrictor administration includes: (6)

A
  1. Blood pressure in excess of 200mmHg systolic or 115mmHg diastolic
  2. Uncontrolled hyperthyroidism
  3. Severe cardiovascular disease
  4. Undergoing general anesthesia with halogenated agents
  5. Patients receiving nonspecific B-blocker, MAOi, tricyclic antidepressants
  6. Patients in categories 1 to 3a through 3d are classified as ASA4 risks and NOT normally considered candidates for elective or emergency dental treatment in the office
114
Q

Contraindications for vasoconstrictor administration includes patients with severe cardiovascular disease such as: (6)

A
  1. Acute MI within past 6 months
  2. Cerebrovascular accident within past 6 months
  3. Cardiac dysrhythmias despite appropriate therapy
  4. Daily exposure of angina pectoris or unstable angina
  5. Post-coronary artery bypass surgery within last 6 months
115
Q

Do patient OD if you exceed MRD?

A

No- remember bell-shaped curve.

Multiple factors to consider, but exceeding MRD does increase chances of overdose

116
Q

What are contributing factors to local anesthetic overdose:

A
  1. accuracy of deposition
  2. tissue status
  3. anatomical variation
  4. type of injection
117
Q

Can a patient overdose if given under MRD?

A

YES

118
Q

What categories of patient might you want to decrease the MRD on? Why?

A

medically compromised, debilitated, and elderly patients; these disadvantaged patients are slower in metabolizing these drugs

119
Q

Do we need to decrease the MRD on medically compromised, debilitated, and elderly patients? Why or why not?

A

Yes because they are unable to metabolize anesthetic as efficiently

120
Q

What is the most common cause of failure to achieve adequate anesthesia?

A

anatomic variation and faulty technique

121
Q

Articaine is ____% concentration

A

4%

122
Q

What are contraindications for articaine use?

A
  1. patient allergic to amide anesthesias
  2. Sulfite sensitivity
  3. Hepatic disease
  4. Patient with impairments in cardiovascular function
  5. Children under age of 4
123
Q

Why should you not use articaine on children under 4 years old?

A

due to insufficient data

124
Q

Has the potential for neurotoxicity, resulting in more non-surgical paresthesia’s than all of local anesthetics (despite fewer injections given):

A

Articaine

125
Q

The smaller the gauge;

A

the bigger the diameter

126
Q

Which has a greater internal diameter? A 25 gauge or a 30 gauge?

A

25 gauge

127
Q

A ____ gauge needle results in less deflection, and greater accuracy in injection as well as less chance for the needle to break and easier aspiration

A

30 gauge

128
Q

Name four positive qualities of a 30 gauge needle:

A
  1. Less deflection
  2. Greater accuracy
  3. Less chance of needle break
  4. Easier aspiration
129
Q

A total of 4ml of 3% Mepivacaine without epinephrine has been used. What is the total mg used in this case?

The MRD for mepivicaine is 4.4mg/kg

A

4ml x 0.03% = 0.12
0.12x 1000= 120mg

3% is equal to 30mg/ml

130
Q

Billy Jean is going through a special diet and after 2 months she only ways 20kg. She is at UMKC for some dental work. You pick 2% lidocaine with epinephrine 1:100,000 as your anesthetic agent (because it has red label on it). What is the maximum mg that you can give for her.

A
  • We know that MRD for lidocaine is 4.4mg/kg

4.4mg/kg x 20kg= 88 mg

131
Q

Can a needle be used on more than one patient?

A

No

132
Q

When not in use, the needle should be:

A

covered with protective sheath

133
Q

T/F: You should use both hands to recap the needle:

A

FALSE! use scoop technique

134
Q

What technique should be used to recap the needle?

A

scoop technique

135
Q

T/F: The needle should be bent for difficulty access blocks due to curves and different contours of the facial skeleton

A

False- absolutely no

136
Q

Where should you dispose the needle after use?

A

sharps and biohazard containers

137
Q

Which agent is bacteriostatic and was removed from local anesthesia cartridge in 1984 due to reported allergic reactions?

A

methylparaben

138
Q

______ was replaced by lidocaine (back in the day)

A

novocaine

139
Q

When discussing the “care & handling of the cartridge”, there is no manufacture claim:

A

sterility of exterior surface of cartridge

(bacterial culture test failed to produce growth)

140
Q

When discussing the “care & handling of the cartridge”, it cannot:

A

withstand extreme temps

141
Q

Due to a cartridge being unable to withstand extreme temps, No _____ especially with plastic cartridge.

A

autoclaving

142
Q

Due to a cartridge being unable to withstand extreme temps, when heated, ____ are ____

A

vasopressors are destroyed

143
Q

How should you store cartridges?

A

store at room temp in a dark space

144
Q

T/F: A study showed benefits of using a cartridge warmer

A

False- study showed NO BENEFITS

145
Q

In regard to cartridges, DO NOT soak in:

A

alcohol or “cold sterilizing solution”

146
Q

Why should you NEVER soak cartridges in alcohol or “cold sterilizing solution”?

A

The semipermeable diaphragm permits diffusion of these solutions

147
Q

What should you read in regard to cartridges?

A

drug insert

148
Q

The rubber diaphragm of a cartridge can be wiped with:

A

alcohol wipes moistened with undiluted 91% isopropyl alcohol or 70% ethyl alcohol- BUT DO NOT SOAK

149
Q

What are some problems that can occur with cartridges? (6)

A
  1. bubble in cartridge
  2. corroded cap
  3. rust on cap
  4. leakage during injection
  5. broken cartridge
  6. burning on injection
150
Q

What is the size considered a “small bubble” in a cartridge and what is the cause?

A

Small bubble= 1-2 mm

Usually just nitrogen gas

151
Q

What is the size considered a “large bubble” in a cartridge and what is the cause?

A

large bubble = greater than 2 mm

Occurs due to extruded stopper or frozen cartridge

152
Q

When might a cap of a cartridge become corroded?

A

If immersed in disinfection solution

153
Q

The only sterilization needed for a cartridge is to rub the cap only (rubber diaphragm) with:

A

91% isopropyl alcohol or 70% ethyl acohol

154
Q

Why night the cap of a cartridge rust?

A

From “tin” container

155
Q

Leakage from the cartridge during injection may occur with:

A

eccentric needle puncture of diaphragm

156
Q

What should you do with a broken cartridge?

A

return damaged box upon receiving

157
Q

When might a cartridge shatter?

A

occurs due to improper loading & bent harpoons

158
Q

Why might burning on injection occur?

A

due to mishandled or defective cartridges (1. pH, 2. alcohol, 3. heat, 4, expired)

159
Q

What are the most common psychogenicallly induced reactions people have upon local anesthetic injection?

A

Most common: vasodepressor syncope & hyperventilation

Others (less common) include: tonic clonic convulsions, brochospasms, and angina pectoris

160
Q

What does relative contraindication to local anesthetic mean?

A

means that caution should be used when two drugs or procedures are used together (its acceptable if the benefits outweigh the risk)

161
Q

What does absolute contraindication to local anesthetic mean?

A

means that event or substance can cause a life-threatening situation

162
Q

List the RELATIVE contraindications to local anesthetic administration: (5)

A
  1. pregnant women (in first trimester)
  2. malignant hyperthermia
  3. Cimetidine + ASA III CHF patient
  4. ASA III or IV with CHF
  5. Methemoglobinemia to prilocaine
163
Q

Why is an ASA III patient with CHF taking Cimetidine a relative contraindication to local anesthetic?

A

Because Cimetidine increases the half-life of circulating LA

164
Q

Why is an ASA III or IV patient with CHF considered a relative contraindication to local anesthetic?

A

Because this patient may demonstrate decreased liver perfusion and increase half-life

165
Q

List the ABSOLUTE contraindications to administrations to local anesthesia: (3)

A
  1. ASA IV cardiovascular risk patient
  2. Tricyclic antidepressant (TCAs)
  3. Cocaine abuser
166
Q

Why is an ASA IV cardiovascular risk patient an ABSOLUTE contraindication to local anesthetic?

A

Because an ASA IV Cardiovascular risk patient is not a candidate for vasopressors or elective dental care.

Specifically recent MI (less than 6 months ago) or repeated MIs increase risk during dental care or local injection

167
Q

Specifically what classifies someone as an ASA IV cardiovascular risk patient? (making them an ABSOLUTE contraindication to local anesthetic)

A

Specifically recent MI (less than 6 months ago) or repeated MIs increase risk during dental care or local injection

168
Q

Why are patients taking Tricyclic antidepressants (TCAs) and ABSOLUTE contraindication to local anesthetic?

A

TCAs enhance cardiovascular action to exogenously administered vasopressors

169
Q

List the statistical risk associated with TCAs enhancing cardiovascular action to exogenously administered vasopressors: (3)

A

A) 5-10x increase with levonordefrin and Norepi
B) 2x increase with epinephrine
C) Hypertensive crisis –> death

170
Q

List the reasons a cocaine abuser is an ABSOLUTE contraindication for local anesthetic:

A
  1. Cocaine stimulates norepinephrine please and inhibits re-uptake
  2. 72hrs is needed for cocaine clearance
  3. Epinephrine impregnated gingival retraction cord is absolutely contraindicated
171
Q

What should you do if you suspect cocaine usage within 24hrs of dental treatment?

A

postpone

172
Q

Since cocaine stimulates norepinephrine release and inhibits uptake, what may occur?

A

Tachycardia/Hypertension leading to increased myocardial oxygen requirement leading to cardiac ischemia and eventually myocardial infarction

173
Q

What is ABSOLUTELY contraindicated for a cocaine user?

A

epinephrine-impregnated gingival retraction cord

174
Q

How long do you need to leave topical in the mouth for it to be effective?

A

apply topical for 2 minutes

175
Q

Where should the bevel of a needle be placed during and LA injection?

A

place the bevel of the needle on tissue in the direction you want to go (towards bone)

176
Q

When MUST you aspirate when giving local anesthetic injections?

A

for PSA and Inferior Alveolar Nerve blocks

177
Q

What does aspirating when giving an injection do?

A

makes sure you are not in a blood vessel

178
Q

When giving an LA injection, you should: (technique)

A

twist the needle as you insert it to keep the needle from deflection in one direction

179
Q

How do you avoid deflection in one direction when giving LA injections?

A

twist the needle as you insert

180
Q

Finger rest or chest/body rest?

A

finger rest

181
Q

What are the three branches of the trigeminal nerve?

A

V1- ophthalmic
V2- maxillary
V3- mandibular

182
Q

Where do the following branches of the trigeminal nerve enter/exit the cranium?

  1. V1- ophthalmic:
  2. V2- maxillary:
  3. V3- mandibular:
A
  1. superior orbital fissure
  2. forman rotundum
  3. foramen ovale
183
Q

Name whether each branch is sensory or motor of the trigeminal nerve:

  1. V1- ophthalmic:
  2. V2- maxillary:
  3. V3- mandibular
A
  1. sensory
  2. sensory
  3. motor & sensory
184
Q

One of the branches of the V2 (trigeminal nerve) upon exiting cranial base makes a quick 180 degree turn back into the cranium. This nerve provides sensory innervations to the dura mater.

A

Middle meningeal nerve

185
Q

Which division of the trigeminal nerve is sensory and motor?

A

Mandibular branch (V3)

186
Q

Type of injection that numbs one tooth:

A

local infiltration

187
Q

Type of injection that numbs about two teeth:

A

field block

188
Q

Type of injection that numbs the entire area as you are injecting the nerve bundle:

A

Nerve block

189
Q

When you inject a nerve bundle you are performing a:

A

nerve block

190
Q

What type of LA injection is seen in the photo below?

A

local infiltration

191
Q

What type of LA injection is seen in the photo below?

A

field block

192
Q

What type of LA injection is seen in the photo below?

A

nerve block

193
Q

Infiltration is considered a _____ injection

A

supraperiosteal

194
Q

Infiltration is performed if you are numbing:

A

one tooth

195
Q

How is the needled entered when performing an infiltration injection (one tooth)

A

needle is entered adjacent to bone and apical to apex

196
Q

Describe how infiltration kind of works:

A

maxillary labial bone is porous, and allows infiltration of anesthetic (anesthetic diffuses into the bone)

197
Q

Infiltration is commonly done with:

A

premolars

198
Q

List the areas anesthetized by infiltration:

A
  1. single tooth
  2. buccal periodontite & bone
  3. labial/buccal mucosa
199
Q

PSA:

A

posterior superior alveolar nerve block

200
Q

What type of LA injection is seen in the following photos?

A

posterior superior alveolar nerve block (PSA)

201
Q

How is the needed entered for a posterior superior alveolar nerve block? (PSA)

A

needle is entered into the height of the vestibule at a 4 degree angle to the occlusal plane

(needle is inserted about 16mm and you MUST aspirate)

202
Q

How far is the needle inserted in a posterior superior alveolar nerve block?

A

16 mm

203
Q

What is the aspiration rate for a posterior superior alveolar nerve block?

A

3%

204
Q

If there is a positive aspiration with a PSA, what may occur?

A

hematoma

205
Q

List the areas anesthetized with a PSA:

A
  1. maxillary molar tooth pulps
  2. MB root of 1st molar (72%)
  3. buccal periodontium and bone (not palatal)
206
Q

During an infiltration injection (supraperiosteal I injection) the syringe is held ______ and the anesthetic is placed ____.

A

parallel to the long axis of the tooth; apical to apex of tooth

207
Q

Given the anesthetized areas, what type of injection was given?

  • tooth
  • buccal peridontium and bone
  • labial or buccal mucosa
A

infiltration (supreperiosteal injection)

208
Q

What tooth root has special innervation?

A

1st molar MB root

209
Q

Which injection is most likely to give you the ugly hematoma?

A

PSA

210
Q

Given the anesthetized areas, what type of injection was given?

  • maxillary molar tooth pulps
  • MB root of 1st molar (72%)
  • Buccal periodontite and bone
A

Posterior superior alveolar nerve block (PSA)

211
Q

What type of injection was given if the yellow portion is the area anesthetized?

A

PSA

212
Q

What type of injection was given if the yellow portion is the area anesthetized?

A

MSA

213
Q

Describe the position of the needle when injection an middle superior alveolar nerve block:

A

needle is injected well above premolar apices (bevel facing the bone)

214
Q

List the areas anesthetized during an MSA:

A
  1. maxillary premolars
  2. MB root of 1st molar (28%)
  3. Buccal periodontium and bone (NOT palatal)
215
Q

According to the image what type of injection is being given?

A

Middle superior alveolar nerve block (MSA)

216
Q

Given the anesthetized areas, what type of injection was given?

  • maxillary premolars
  • MB root of 1st molar (28%)
  • Buccal periodontium and bone (not palatal)
A

MSA

217
Q

Describe the needle placement in an anterior superior alveolar nerve block (ASA):

A
  1. Needle contacts roof of infraorbital foramen (which is located about 16mm above vestibule)
  2. Insert needle about 1/2 length
  3. Orient bevel towards bone and insert until bone is contacting needle
  4. Maintain pressure during injection and 1 min aftr
218
Q

In an ASA nerve block, the anesthetic is directed into:

A

canal

219
Q

List the areas anesthetized during an ASA nerve block:

A
  1. maxillary central incisor through canine
  2. premolars
  3. MB root of first molar (28%)
  4. buccal periodontium and bone
  5. lower eyelid, side of nose, and upper lip
220
Q

Given the following anesthetized areas, what type of injection was given?

  • maxillary central incisor through canine
  • premolars
  • MB root of first molar (28%)
  • buccal periodontium and bone
  • lower eyelid, side of nose, and upper lip
A

Anterior superior alveolar nerve block (ASA)

221
Q

The following images depict what type of injection?

A

ASA

222
Q

Am anterior superior alveolar nerve block (ASA) may also be called:

A

infraorbital nerve block

223
Q

What should be located before an ASA and how?

A

locate foramen by palpation

224
Q

For a greater palatine injection, where is the needle aiming?

A

Needle is aiming for greater palatine foramen area and contacts bone (NOT into the foramen)

225
Q

What type of injection is seen in the following images?

A

greater palatine injection

226
Q

What type of injection is seen in the following image?

A

nasopalatine injection

227
Q

List the areas anesthetized with an greater palatine injection:

A
  1. posterior portion of hard palate (canine to last molar)
  2. overlying soft tissue

(NO anesthesia of teeth)

228
Q

Where its he boundary of anesthetize for greater palatine vs. nasopalatine on the palate?

A

Greater palatine- distal to the 2nd maxillary molar

229
Q

How can the greater palatine foramen be located?

A

Can be identified by finding the junction of molars 2 &3 and then moving the needle 1cm medially

230
Q

Can be identified by finding the junction of molars 2 &3 and then moving the needle 1cm medially

A

greater palatine foramen

231
Q

If the following areas are anesthetized, what type of injection was given?

  • posterior portion of hard palate
  • overlying soft tissues
  • NO teeth anesthetized
A

greater palatine

232
Q

Where is the injection area of a greater palatine injection?

A

midway between midline and free gingival border (10mm from palatal midline)

233
Q

Where does the needle need to contact with a nasopalatine injection?

A

Needle contacts bone lateral to incisive papilla

234
Q

Given the image, what type of injection was given?

A

greater palatine injection

235
Q

Given the image, what type of injection was given?

A

nasopalatine injection

236
Q

Describe the steps to giving a nasopalatine injection:

A
  1. needle contact bone lateral to incisive papilla
  2. bevel against tissue and bow the needle
  3. straighten needle and advance
237
Q

What is alternative approach for a nasopalatine injection?

A

trans-papillary approach

(insert needle through papilla between 8&9 towards palate)

238
Q

List the areas anesthetized during a nasal palatine injection:

A
  1. anterior portion of hard palate (canine to canine)
  2. both hard and soft tissues

(no anesthesia of teeth)

239
Q

The following image depicts what type of injection?

A

buccal nerve block

240
Q

The following image depicts what type of injection?

A

mental nerve block

241
Q

The following image depicts what type of injection?

A

inferior alveolar nerve block

242
Q

The following image depicts what type of injection?

A

Gow-Gates (true mandibular) nerve block

243
Q

The following image depicts what type of injection?

A

Vazirani-Akinosi nerve block _closed mouth mandibular nerve block

244
Q

Use a 25 gauge long needle, stretch tissue and contact periosteum.

(large area of nerve coverage, just need to aim in general area)

A

Buccal nerve block

245
Q

What gauge of needle should be used for a buccal nerve block?

A

25 gauge

246
Q

What is the only block to anesthetize the buccal mucosa of molars?

A

buccal nerve block

247
Q

T/F: A lot of anesthesia is needed to anesthetize the buccal mucosa of molars (buccal nerve block)

A

true

248
Q

List the areas anesthetized with a buccal nerve block:

A
  1. gingival buccal to molars
  2. retromolar pad mucosa
  3. buccal mucosa in molar areas

(NO hard tissue anesthetized)

249
Q

Given the following image, what type of injection was given?

A

buccal nerve block

250
Q

The mental nerve (targeted in a mental nerve block) exits out of the:

A

mental foramen

251
Q

How should you locate the site of injection for a mental nerve block?

A

palpate the mental foramen near the premolars to determine site of injection and inject into tissue over foramen

252
Q

There is risk of possible _____ with a mental nerve block. What is the aspiration rate?

A

hematoma; 5.7%

253
Q

List what become anesthetized with a mental nerve block:

A
  1. mucosa anterior to foramen
  2. skin of the lower lip
  3. chin
254
Q

If the following areas are anesthetized following injection, what injection was given?

  • mucosa anterior to foramen
  • skin of lower lip
  • chin
A

mental nerve block

255
Q

The largest branch of the posterior division protected by the sphenomandibular ligament:

A

inferior alveolar nerve

256
Q

The inferior alveolar nerve is protected by:

A

sphenomandibular ligament

257
Q

What injection is being given in the following scenario:

Syringe directed across the arch (from contralateral side) at level of coronoid notch. Place finger on notch to locate it and determine height of injection.

  • Needle penetrated buccinator muscles and is lateral to pterygomnaidbular raphe
  • contacts bone
  • must aspirate
A

Inferior alveolar block

258
Q

As what level is a inferior alveolar block given?

A

level of the coronoid notch

259
Q

With an inferior alveolar block, the needle penetrates _____ and is lateral to ____

A

buccinator muscle; pterygomandiblar raphe

260
Q

Do you contact bone in an inferior alveolar nerve block?

A

yes

261
Q

What nerves are anesthetized with an inferior alveolar block?

A
  1. inferior alveolar
  2. incisive
  3. mental
  4. lingual (usually)
262
Q

What areas and nerves are anesthetized with an inferior alveolar block?

A
  1. Nerves- inferior alveolar, incisive, mental and lingual
  2. entire unilateral side from midline
  3. lingual mucosa
  4. tongue
  5. teeth
263
Q

According to the following image, what injection was given?

A

inferior alveolar block

264
Q

” A true mandibular nerve block”

A

Gow-gates block

265
Q

What injection is being described?

  • Needle contacts neck of condyle
  • patient opens wide so condyle moves forward
  • must aspirate
A

Gow-gates block

266
Q

What are the extraoral landmarks for a gow-gates block?

A
  1. inter tragic notch
  2. corner of mouth
267
Q

When doing a gow-gates block, what should you tell the patient to do?

A

open wide so condyle moves forward

268
Q

What nerves are anesthetized with a gow-gates block?

A
  1. inferior alveolar
  2. lingual
  3. mylohyoid
  4. auriculotemporal
  5. buccal (75%)
269
Q

A closed mouth mandibular nerve block may also be called:

A

Vazirani-akinosi nerve block

270
Q

The height of injection of a Vazirani-Akinosi nerve block is:

A

maxillary muco-gingival line

271
Q

How far is the needle inserted in a Vazirani-Akinosi nerve block?

A

35 mm

272
Q

When giving a Vazirani-Akinosi nerve block the path of insertion is:

A

parallel to the ramus

273
Q

Should you contact bone with a Vazirani-Akinosi nerve block?

A

NO

274
Q

What nerves are anesthetized with a Vazirani-Akinosi nerve block?

A
  1. inferior alveolar
  2. lingual
  3. mylohyoid
275
Q
A

Intro to Oral Surgery & Pain Management (4 decks)

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