Endo Anesthesia Flashcards
• \_\_\_\_\_\_ and considerate, caring manner are the cornerstone of modern dental practice and are your greatest practice builders
“Painless” injections
T/F: RCT is impossible without
profound LA *
True
The mucosa for an injection should be ____
Dry
T/F: Vigorously shaking or gently squeezing the lip or cheek while injecting is a distractiontechnique thought to activate the faster Alpha fibers to “close the gate”*
True
Should the injection be done fast or slow?
Slow
_____ inection is very painful
Palatal
Use _____ to help alleviate the pain of the palatal injection before
Endo ice
No more than ___/____ a carpule on palatal injection
1/4 carpule
Are lip signs enough to do RCT?
No; need lip to feel thick and fat
Although any pulp inflamed tooth may present problems in achieving adequate anesthesia, your biggest challenge will probably present as a _____ with _____
mandibular molar with acutely inflamed pulpitis*.
In clinical practice, local anesthesia may be influenced by the
local availability of free base, as only the non-ionized portion
______ can diffuse through the neuronal membrane.
(free base)
Thus, local anesthetics are relatively ineffective when injected
into tissues with an ______ pH (e.g. pyogenic abscess, inflamed
pulp) which is presumably due to reduced release of free base *
acid pH
First, use an ________ drug in an effort to
reduce inflammation, revert the pores to normal &
raise the patient’s pain threshold. Such an inexpensive
& simple benefit.
anti-inflammatory drug
Should you give buccal infiltration to mand tooth before or after lip signs?
After lip sings
What lip signs should you have for a IA block?
Thick and fat lip on that side to midline
How many carpules should you use for a IA block for endo?
2
IA block should occur ___ - ___ mm above occlusal plane
6-10 mm
IA block should go _____ to pterygomandibular raphe
Lateral
How long will effective pulpal anesthesia last?
30-90 mins
How long does local anesthesia take to start acting?
1-20 mins
T/F: It WILL be necessary to monitor the patient and RE-INJECT during the course of MOST or ALL Clinic Sessions.*
True
If pulp is necrotic, should you give LA?
Yes; always give it for endo
___ is more successful to use for buccal infiltration
Articaine
___ LA type:
Esters = (Novacaine, Procaine) more side effects, higher
probability of allergic reaction, no longer in favor or
commonly available in U.S.
Esters
____ LA type:
= all the rest, available & preferred.
• Duration:
– Short ( < 60 min.) 3% Mepivacaine (Carbocaine®)
– Medium (60-120 min.) Lidocaine, Articaine
– Long (> 120 min.) 0.5% Bupivacaine w/ 1:200,000 epi. (Marcaine®)
(probably is LEAST profound LA»Gross, R etal ….Double Blind comp
of Bupivicaine/Lido ….JOE, Sep ’07 33(9)pp1021-4)
• Vasoconstrictor (None, 1:200,000, 1: 100,000, 1:50,000)
• Aspirate (REPEATEDLY) to AVOID INTRA-VASCULAR injection*
– Amides
What technique was mentioned to give another IA block option?
Gow-Gates
If IA and buccal infiltration don’t accomplish full anesthesia, what is the next option to anesthetize?
PDL injections
FIRST CHOICE: IF regional block or infiltration prove insufficient . . . THE INTENT: to FORCE anesthetic solution down along the PDL and through the cribriform plate to reach apical neural elements in the medullary space . . . Wedge needle as deeply into PDL as possible. Start at DB. Warn patient of pain at injection. Use @% Lidocaine w/ 1:100,000 epi. Duration of anesthesia = 15-30 min. only (get the pulp OUT ASAP) No Waiting -Can use ligajet -Must have back pressure -Inject at 4 line angles
PDL ligament injections
Last choice– (painful and ultra short acting but immediate relief)
a. Use 30 gauge needle (#25 file) wedged as far in canal as possible.
b. Must bind tightly in canal
c. Warn patient –Injection Must hurt –twice . . . Most painful of injections
d. Duration: minutes only (extirpation only –will not last for shaping or obturation) get pulp out NOW
e. Do NOT count on repeating this injection
f. Do distal canal of lower molar first
Intrapulpal injections
When is it acceptable to inject into swelling tissue?
NEVER
_____ swelling is pointing
and may soon drain spontaneously. The patient
is probably not running a fever and is able to
open fully. Acceptable to infiltrate apically and
laterally or do infra-orbital block or both.
Debride the pulpal spaces and consider Incise
& Drain.
Localized swelling
\_\_\_\_ swelling: Patient here is seriously ill, running a fever and probably cannot open her mouth sufficiently to debride pulpal spaces. I&D, drain & antibiotics may need to precede Pulpal Extirpation.
Generalized swelling/cellulitis
\_\_\_\_\_ of a Cellulitis such as this is a very serious, life-saving procedure best accomplished in the hospital under the supervision of an oral surgeon or MD. The FIRST thing to do here is REFER * I.V. Antibiotics + I&D will follow Either the tooth is removed or the pulp extirpated as soon as patient is stabilized and able to open the mouth. This patient has a life threatening infection requiring immediate care. Sub-lingual, Sub- Mental, Sub- mandibular Spaces
Drainage
Local anesthetics cause _____ interruption of the
conduction of impulses in peripheral nerves by causing a
local decrease in the rate and degree of depolarization of the
nerve membrane such that the threshold potential for
transmission is not reached when everything goes well.
reversible
These effects are due to blockade of _____ channels,
thereby impairing ion flux across the membrane
resulting in disruption of impulse conduction.
Na channels
Most local anesthetic agents are tertiary amine bases that are
administered as water soluble hydrochlorides . After injection, the
tertiary amine base is liberated by the relatively _____ pH of normal
tissue fluids:
alkaline
In tissue fluid the local anesthetic will be present in both an ionized and
non-ionized form ; their relative proportions depend on the ___ in the
area*
pH
Only the _____ base then diffuses through the nerve sheath, peri-
neuronal tissues and the neuronal membrane, to reach the axoplasm.
non-ionized
Most common LA
– Safe & Effective Drug. Derivative of Xylidine (1.7ml/carpule)
– Each carp. contains 34 mg. of anesthetic.
– Max. safe adult dosage = 8 carpules (272 mg.)
– Detoxified primarily in LIVER (beware severe LIVER disease)
– No solution proven to be superior for pulpal anesthesia
– Not contraindicated in patients with heart disease (monitor
closely)
– Not contraindicated in pregnant women (after 1st trimester)
– Not contraindicated in nursing mothers
– Because of epinephrine content, should not be routinely used
in patients on MAO inhibitors or tricyclic antidepressants.
Probably best choice for routine RCT at UMKC
2% Lidocaine with 1:100,000 epi. (Xylocaine®)
Most controversial
(Septocaine®)
– Safe & Effective Drug. Contains both amide and ester linkage
– Each carp. contains 68 mg. of anesthetic.(twice as toxic as
Lidocaine)
– maximum safe adult dosage = 4 carpules (272 mg.)
– Also contains a unique Sulfur molecule (Sulfur allergy
problems?)
– Mel Hawkins, U/Toronto says no as S molecule is bound.
– Reputation of providing superior anesthetic effect (NOT
proven)
– Potential to cause neuropathies: paresthesia rare but 5
times as likely as with lidocaine or mepivicaine. Lawyers
know this! Be Safe! Avoid N. Blocks with Articaine*
– No known incident at UMKC in past decade.
– Drug interactions with MAO inhibitors, tricyclic
antidepressants and phenothiazides.
• 4% Articaine with 1:200,000 epi.
Delays systemic absorption which increases the
duration AND increases the effectiveness of the LA. Also
retards bleeding (surgery).
Epi
T/F: You must get your pt. “numb” or abort the
procedure.
True
However, if after ___-____ carps, pt. still isn’t “numb”, seriously
consider re-scheduling with sedation
3-4 carps
What are the 4 Solutions to hot maxillary tooth?
PSA
2nd Div Block
Infraorbital block
Palatal block
What is the solution for hot. max tooth?
Gow-Gates block
