Endodontic Anesthesia Flashcards
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(2) are the cornerstone of modern dental practice and are your greatest practice builders
“Painless” injections and considerate, caring manner
RCT is impossible without
profound LA *
Patients routinely select a particular dentist based solely upon the comfort level of injections given.
If they like you,
they may tell 3 or 4 friends about you. If they DON’T like you they will tell 15 people
Atraumatic anesthetic injections (5)
Dry mucosa - then Topical Anesthetic - let it soak in at least 60sec.
Vigorously shaking or gently squeezing the lip or cheek while injecting is a distraction technique thought to activate the faster Alpha fibers to “close the gate”*
Sloooooooooooooow and gentle (Take 60 sec. to inject)
Talk to patient constantly
Keep patient occupied *
May have — injection also, for maximum anesthetic effect*
However, the — injection can be very painful!
palatal
Use small quantity of LA on palatal tissue which is TIGHT and Painful. Too much –
more than 1/4carp may slough tissue.
“Comparison of a refrigerant/topical anesthetic gel as pre inj anesthetics” - Kosaraju A, Vandewalle K; JADA 2009: 68-72
Use of a refrigerant as a pre-injection anesthetic was more effective compared with a topical gel in reducing pain by patients receiving a palatal injection*
Direct the needle tip perpendicular to
the
frosted dimple
Use NO MORE than — Carpule on palatal injection
¼
Although any pulp inflamed tooth may present problems in achieving adequate anesthesia, your biggest challenge will probably present as a
mandibular molar with acutely inflamed pulpitis*.
Although any pulp inflamed tooth may present problems in achieving adequate anesthesia, your biggest challenge will probably present as a mandibular molar with acutely inflamed pulpitis*.
Anesthesia is difficult here at best due to the
inherent inaccuracies of mandibular N. blocks but other problems are also present.
Remember “lip signs” do not necessarily indicate
pulpal anesthesia and infiltration alone here is useless due to the density to the cortical plates**
In non-inflamed tissue, a normal gate channel or pore in the nerve cell will be effectively blocked by a LA resulting in
inability to create an action potential = no pain.
Murphy’s Law as applied to Dentistry:
“Local Anesthetic is most effective when the need for it is the least”
In clinical practice, local anesthesia may be influenced by the local availability of free base, as only the — can diffuse through the neuronal membrane.
non-ionized portion (free base)
Thus, local anesthetics are relatively ineffective when injected into tissues with
an acid pH (e.g. pyogenic abscess, inflamed pulp) which is presumably due to reduced release of free base *
Instead of getting what you want, you may get this - even AFTER your BEST attempt to anesthetize the painful tooth.
Therefore: Teeth with acutely inflamed tissues are often VERY resistant to
LA.
Bottom line: LESS EFFECTIVE anesthesia is resultant and
a whole lot more PAIN is perceived
You have both a physiological and a psychological challenge**
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Emotional Considerations
(7)
Apprehension-Fear-Anxiety
Fatigue-Hyperalgesia-Allodynia
Decreased Pain Threshold
History of Unsuccessful Anesthesia
Popularized Fear of RCT
Lack of Confidence in Provider
Lack of Confidence by Provider
It all adds up to a unique & formidable challenge. (2) are equally important to a good result*
Technique and Patient Management
- What can we do to combat LA problems?
A. First, use an anti-inflammatory drug in an effort to reduce inflammation, revert the pores to normal & raise the patient’s pain threshold. Such an inexpensive & simple benefit.
You must have already seen the patient, taken history, obtained radiographs, clinical testing and made your DX* (Cannot prescribe w/o a DX or w/o examining pt.)
IBU 600 mg one hour prior= —% effective
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B. Do everything you can to diminish the Emotional Component: (Patient Management)
(5)
Establish rapport with the patient. Show them you CARE*
Communicate your concern for the patient in a calm, convincing and confident manner.
“Inform before you Perform” – Wayne Harvey DDS
“We want your visit to be as pleasant as possible and we will do everything we can to make you comfortable. If you feel discomfort, raise your hand and I will stop at once” (giving the patient - some control) –Jim Dryden, DDS
Consider pre-op Anti inflammatory &/or Anti-anxiety Drugs (Anxiolytics: another Lecture)
Be CERTAIN you have a good —
BLOCK
If you do a good IA block, you should have
“lip signs”.
If you include additional any BUCCAL anesthesia initially (w/o waiting for “lip signs”),
you won’t know if the “lip signs” are from the BLOCK or the infiltration.
Do initial IA and wait a few minutes to allow anesthesia in area of IA injection. Then go back and
FEEL the BONE and painlessly inject the 2nd carpule where you KNOW you need to be for the IA BLOCK.
Then wait for “lip signs” and check the tooth with (2) to determine if you may need to do SUPPLEMENTARY anesthesia.
percussion and/or cold
ONLY AFTER YOU ARE POSITIVE that you have a NUMB and FAT LIP, do you use ANY
buccal anesthesia
Do NOT proceed to any supplemental anesthesia techniques until you have
CONFIRMED your BLOCK
IAN-L – Point of Penetration
Just lateral to pterygomandibular raphe at the height of coronoid notch
Correct Placement – IAN
Watch angle of retracting thumb / finger on Coronoid Notch
D. Learn to Effectively Use Supplemental Anesthetic Techniques if necessary following CONFIRMED BLOCK
(3)
Intra-ligamental (Periodontal Ligament=PDL ) Injection
Intra-pulpal Injection
Intra-osseous Injection
Most LA agents have an onset of action between — minutes. Wait and TEST*
1-20
None of the LA solutions available at UMKC will last for the duration of the typical 3 hr. Clinic Session* Plan on re-injecting in Clinic*
Effective Pulpal Anesthesia will be routinely gone in
30-90 minutes.* Get pulp OUT while numb***
It WILL be necessary to monitor the patient and — during the course of MOST or ALL Clinic Sessions.*
RE-INJECT
Just because there is a well developed P/A lesion and both teeth test necrotic (Non-responsive ); don’t begin ANY treatment w/o
LA. Always use LA for every case at every appointment*
If you encounter ANYTHING that hurts (R. Dam Clamp, pressure, or an unexpected tag of vital tissue, you will lose the most essential element of patient management
(the confidence of the patient)
If it hurts at all, the patient thinks you made an error in judgment and he/she is already looking for a new dentist. If they do stay with you . . . They will forever be “waiting for the other shoe to drop”.
Play it safe; give adequate LA . . . EVERY TIME you enter the tooth. If ANYTHING hurts . . .
IMMEDIATELY STOP and give additional LA.
LOCAL ANESTHETIC AGENTS
Two basic Types: (2)
Esters and Amides
Esters = (Novacaine, Procaine)
(Novacaine, Procaine)
more side effects, higher probability of allergic reaction, no longer in favor or commonly available in U.S.
Amides =
all the rest, available & preferred.
Amides
Duration:
(3)
Short ( < 60 min.) 3% Mepivacaine (Carbocaine®)
Medium (60-120 min.) Lidocaine, Articaine
Long (> 120 min.) 0.5% Bupivacaine w/ 1:200,000 epi. (Marcaine®)
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)
Amides
(2)
Vasoconstrictor (None, 1:200,000, 1: 100,000, 1:50,000)
Aspirate (REPEATEDLY) to AVOID INTRA-VASCULAR injection*
NO L.A. AGENT CAN BE EXPECTED TO REMAIN EFFECTIVE FOR THE 3 HR. CLINIC PERIOD. YOU MUST
RE-INJECT***
— allows Articaine to penetrate cortical bone plates
Thiophene ring
If you have a compromised “brittle” patient (ASA III or IV) or any serious medical concern
be certain to contact the patient’s physician for advice on anesthesia and other drugs planned for patient.
Best to fax, email or otherwise contact physician to obtain their input in writing.
the biggest problem to get predictable anesthesia
Lower Molar Pulpitis
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Mandibular teeth
Lower Molar Pulpitis = the biggest problem to get predictable anesthesia*
(6)
Pre-medication with NSAIDS, Anti-anxiety meds p.r.n.
Gow-Gates Block for mandibular teeth
mylohyoid nerve & buccal infiltration(ONLY after Lip Signs proven)
Supplementary injections may be necessary
Change anesthetic ?
Use greater volume of anesthetic (within safe limits)
Supplementary injections may be necessary
(3)
Intra-ligamental injection (PDL)
Intra-osseous injection
Intra-pulpal injection
Mandibular molar (hot IP) is the major problem*. (start with — carpules initially)
(2)
2
Gow-Gates may be superior to IA (?)
VIP!! Be certain of IA or Gow-Gates effectiveness before progressing to buccal infiltration or supplemental injections (test with cold for IP)
Mand. Anteriors require
IA/GG (not just Mental)
Overlap of N. Fibers in midline
> 2 injections, (one infiltration)
MANY or MOST HOT IP cases will require
one or more supplemental anesthetic techniques in addition to basic regional blocks and necessary infiltration. After buccal infiltration use PDL on HOT mandibular molar when block is confirmed.*
A. Periodontal Ligament (PDL) Injections
B. Intra-pulpal Injection . . . or . . .
C. Intra-osseous Injection
A. Periodontal Ligament (PDL) Injections
FIRST CHOICE: IF
IF regional block or infiltration prove insufficient . .
A. Periodontal Ligament (PDL) Injections
THE INTENT:
to FORCE anesthetic solution down along the PDL and through the cribriform plate to reach apical neural elements in the medullary space . . .
— needle as deeply into PDL as possible. Start at DB. — patient of pain at injection.
Wedge
Warn
?
Use @% Lidocaine w/ 1:100,000 epi.
?
Duration of anesthesia =
15-30 min. only (get the pulp OUT ASAP) No Waiting
Ligajet:
easy to apply pressure & barrel covers carpule & protects & contains glass if carpule breaks.
Must have — when injecting (tissue blanching is possible without achieving sufficient back pressure)
back pressure
Inject at all – line angles
4
Will hurt patient at proper injection and be sore later
Questionable in perio cases ?
The PDL injection may get you into the pulp but maybe NOT
the canals.
Next Choice:
Intra-pulpal Injection : Last choice– (painful and ultra short acting but immediate relief)
Intra-pulpal Injection : Last choice– (painful and ultra short acting but immediate relief)
(6)
Use 30 gauge needle (#25 file) wedged as far in canal as possible.
Must bind tightly in canal
Warn patient – Injection Must hurt – twice . . . Most painful of injections
Duration: minutes only (extirpation only – will not last for shaping or obturation) get pulp out NOW
Do NOT count on repeating this injection
Do distal canal of lower molar first
Needle should be wedged in canal as deeply as possible. You are trying to
force solution out apex.
A “perforator”
is rotated in the handpiece following soft tissue anesthesia to create a hole (path) through the cortical bone into the medullary spaces.
“X-tip”
2 parts: perforator
Cannula (needle)
“Stabident”
2 separate pieces
— is not used nor suggested @ UMKC
X-Tip
Some use X-Tip distal to 2nd Molar
(2)
Radiograph with cannula in place
Remove cannula at end of visit
X-Tip
Beware:
do not (4)
do (1)
Do NOT drill into the roots of a tooth.
Do NOT break the perforator
Do NOT allow the cannula to be aspirated or swallowed
Do Not leave the cannula in place
Do watch for infection at perforation of Bone.
X-Tip: Intra-osseous Injection
Designed to be placed here:
2mm inferior to the intersection of a horizontal line paralleling B-G margins &
A vertical line bisecting the interdental papilla distal to the tooth to be anesthetized.
- Cellulitis: Another Challenge
(4)
Usually necrotic pulp so no IP problem but probably very sensitive to palpation & percussion*
Never a good idea to inject into swollen tissue
Localized swelling vs. cellulitis
Referral of serious case
Localized swelling
Localized swelling as shown here 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.
Generalized Swelling: Cellulitis
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.
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General Considerations:
(4)
Do a regional block away from inflamed area
Increase dose of LA
Change anesthetic ?
Supplemental anesthetic techniques
PRE MED w/Anti-anxiety agents
PRE MED w/Anti-anxiety agents
(2)
Liquid valium in pineapple juice: 0.25 mg/kg
Nitrous oxide/oxygen sedation
Strongly Consider — for initial treatment of cellulitis
REFERRAL
A Dental Cellulitis: “Ludwig’s Angina”
This patient has a life threatening infection requiring immediate care.
Sub-lingual, Sub-Mental, Sub-mandibular Spaces
Drainage 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.
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4. How do we combat LA problems?
C. Perfect your LA Technique:
Use an effective, safe & appropriate LA agent
Practice & use the most effective N. Block technique
Utilize Alternative Injection Locations as applicable
Wait until effective to start TX (check with Percussion, EPT or Endo ice – whatever had caused the pain prior to anesthesia)
Continue to demonstrate concern for the patient:
Use topical anesthetic (effective or not)
Use Endo-Ice for palatal injections
Employ “Gate Theory” when injecting
SLOW injection – reassure patient
27 gauge needle OK (30 gauge is NOT less pain – unless the patient thinks so – then use it)
Local anesthetics cause — by causing a local decrease in the rate and degree of depolarization of the nerve membrane such that the —
reversible interruption of the conduction of impulses in peripheral nerves
threshold potential for transmission is not reached when everything goes well.
Local anesthetics cause reversible 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.
These effects are due to blockade of sodium channels, thereby impairing
sodium ion flux across the membrane resulting in disruption of impulse conduction.
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 alkaline pH of normal tissue fluids:
In tissue fluid the local anesthetic will be present in both an ionized and non-ionized form ; their relative proportions depend on the
pH in the area*
Only the —- base then diffuses through the nerve sheath, peri-neuronal tissues and the neuronal membrane, to reach the axoplasm.
non-ionized
In the non- ionized form , the local anesthetic enters the sodium channel (from the interior of the nerve fiber) and either occludes the channel or combines with a specific receptor within the channel that results in
channel blockade (IF sufficient LA reaches the channel to be effective)
Most commonly used: LA AGENT
2% — with 1:100,000 epi. (Xylocaine®)
Safe & Effective Drug. Derivative of Xylidine (1.7ml/carpule)
Each carp. contains – mg. of anesthetic.
Max. safe adult dosage = – carpules (272 mg.)
Detoxified primarily in — (beware severe LIVER disease)
No solution proven to be superior for pulpal anesthesia
Lidocaine
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LIVER
2% Lidocaine with 1:100,000 epi. (Xylocaine®)
Safe & Effective Drug. Derivative of — (1.7ml/carpule)
Each carp. contains – mg. of anesthetic.
Max. safe adult dosage = – carpules (272 mg.)
Detoxified primarily in — (beware severe LIVER disease)
No solution proven to be superior for pulpal anesthesia
Xylidine
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8
LIVER
2% Lidocaine with 1:100,000 epi. (Xylocaine®)
no contraindication in
(3)
Not contraindicated in patients with heart disease (monitor closely)
Not contraindicated in pregnant women (after 1st trimester)
Not contraindicated in nursing mothers
2% Lidocaine with 1:100,000 epi. (Xylocaine®)
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®)
4% — with 1:200,000 epi. (Septocaine®)
Safe & Effective Drug. Contains both amide and ester linkage
Also contains a unique — molecule (Sulfur allergy problems?)
Mel Hawkins, U/Toronto says no as S molecule is bound.
Reputation of providing superior anesthetic effect (NOT proven)
No known incident at UMKC in past decade.
Articaine
Sulfur
4% Articaine with 1:200,000 epi. (Septocaine®)
Each carp. contains — mg. of anesthetic.(twice as toxic as Lidocaine)
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4% Articaine with 1:200,000 epi. (Septocaine®)
maximum safe adult dosage = — carpules (272 mg.)
4
4% Articaine with 1:200,000 epi. (Septocaine®)
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*
4% Articaine with 1:200,000 epi. (Septocaine®)
Drug interactions with
MAO inhibitors, tricyclic antidepressants and phenothiazides.
Epinephrine
Purpose:
Delays systemic absorption which increases the duration AND increases the effectiveness of the LA. Also retards bleeding (surgery).
Epinephrine
Potential danger:
w/ epi. in a pt with elevated BP is an untoward further increase in BP (esp. w/ intravascular inj.)
Epinephrine
If the concern is with exogenous epi ranging from
.018mg-.054 mg (1-3 carps of 1/100K epi)
Epinephrine
VIP to remember that a 70kg adult will produce endogenous epi. @
.007mg -.014mg /min at rest
Epinephrine
rest vs stressed patient
Thus A patient at rest produces almost I carp of LA epi/min.
IF a pt is stressed, (ie) not “numb”; they will produce endogenous epi @ .28mg. per min! (10 carps of LA epi./min.)
MAJOR HEALTH CONCERN IS MAINTAINING PROFOUND ANESTHESIA TO MAINTAIN COMFORT AND REDUCE STRESS THEREBY
REDUCING EPI.
A systematic lit. review on effects of epi on >BP pts concluded:
“… the risk for adverse events among uncontrolled >BP pts was low & the # of adverse events associate w/ use of epi was minimal.”
— carps of 1/100K is generally of little consequence
1-2
You must get your pt. “—” or abort the procedure.
numb
However, if after — carps, pt. still isn’t “numb”, seriously consider re-scheduling with sedation
3-4
UNLESS pt. is in severe pain, then consider
IV sedation unless contraindicated if faculties & services available.
Solutions to hot maxillary tooth
Use a Regional Block
PSA
2nd Div. Block
Solutions to hot maxillary tooth
Regional Blocks
Infraorbital block
An anesthetic agent should not be injected directly into a swelling before an incision for drainage because the swelling has increased blood supply so the anesthetic is transported quickly into systemic circulation diminishing the effect in the local tissues.
Or…..
Solutions to hot maxillary tooth
Regional Blocks
Palatal infiltration/2nd division block
Solutions to hot tooth (mandible)
Gow-gates injection (designed to include the high rising mylohyoid nerve)
-Walton and Abbott found —% failure of inferior alveolar nerve block
-Malamed’s study claims —% success with the Gow Gates blcok?
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