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*
