Injection mLs and Sites Flashcards
Long Buccal Nerve Block Technique
Insertion = mucous membrane distal and buccal to most distal molar tooth in arch
Parallel but lateral to occlusal plane
Penetrate 2-4 mm
Mental Nerve Block
Gets buccal mucous membranes of anterior teeth and skin of lower lip/chin
Insertion = Mucobuccal fold between apices of 1st/2nd premolar
Gow-gates
True complete mandibular block - contact bone
Insertion = intertragic notch to distal of maxillary 2nd molar, place needle tip below mesiopalatal cusp of 2nd molar
Target = lateral side of condylar neck
Vazirani Akinosi Technique
Closed mouth V3 block when trismus (relieves trismus = V3 provides muscle innervation)
Vazirani Akinosi Technique Insertion
Medial border of ramus, at height of mucogingival junction adjacent to maxillary 3rd molar
No bone contact
Posterior Maxilla Primary Techniques
PSA, MSA infiltration
W/ or w/o palatal injection
Consider using 2 cartridges
Posterior Maxilla Secondary Techniques
PDL and Intraosseous Injection
Anterior Maxilla Primary Technique
ASA/infraorbital area infiltration
Consider using two cartridges
Infiltrate midline for centrals
Anterior Maxilla Secondary Technique
PDL and intraosseous injection
Mandible Primary Technique
IAN/Lingual, Buccal injections
Second cartridge not routinely useful
Reinjection after 5 mins may be useful
Mandible Secondary Techniques
Gow-gates
PDL/intraosseous
Deep local infiltration
Anterior Mandible Secondary Techniques
Anterior Infiltration
Mental/Incisive Block
PDL Injection
Large Areas or Remote Injections
Maxilla -> V2 block via greater palatine foramen
Mandible -> no special technique
Dosing Calculation
Each cartridge -> 1.7 mL
Each 1 percent of local anesthetic = 10 mg/mL
Concentration of Vasoconstrictors
Given as ratio
1:100,000 solution contains 0.01 mg/mL = 10 mcg
1 cc = 1 mL
3% mepivacaine w/o vasoconstrictor Max safe dose
Adult = 400 mg Pediatric = 6.6 mg/kg ST = 30-60 mins Pulpal = 20-40 mins
2% lidocaine w/ 1:100,000 epi
Adult = 500 mg Pediatric = 7 mg/kg ST = 2-4 hrs Pulpal = 60-90 mins
4% articaine w/ 1:100,000 epinephrine
Adult = 500 mg Pediatric = 7 mg/kg ST = 2-4 hrs Pulpal = 60-90 mins
0.5% bupivacaine w/ 1:200,000 epi
Adult = 90 mg Pediatric = 2 mg/kg ST = 4-10 hrs Pulpal = 90-180 or less
Epinephrine dosing
Healthy adult = 0.2 mg
Cardio Adults = 0.04 mg
Children rarely at risk
Anesthetic Selection
Drug of Choice = Lidocaine 2% w/ 1:100,000 epi
Epi sensitive = Limit lidocaine, Mepivacaine 3% w/o vasoconstrictor
Long-term soft tissue Anesthesia
Bupivacaine 0.5% w/ 1:200,000 epi
Difficulty achieving local anesthesia
Articaine 4% w/ 1:100,000 epi
Not used for mandibular blocks
Intra-osseous Anesthesia
Deposition of LA into cancellous bone of supporting tooth.
Includes = PDL injection, Intra-septal, intra-osseous
Intra-pulpal Anesthesia
Deposition of LA + pressure into coronal portion of pulp chamber
PDL Injection (Interligamentary Injection)
Not really used maxillary, best for mandible for localized area instead of whole quadrant.
Area = bone + soft tissue + apical and pulpal tissues
PDL Technique
AoI = Long axis of the tooth, bevel on root (each root), advance till resistance
0.2mL/20 sec = thickness of rubber stopper
Success = resistance to deposition, blanching of soft tissue
PDL Indications
Need for anesthesia of 1-2 teeth
Isolated teeth in both mandible quadrants
Children
Risky IAN block (hemophilia)
PDL Contraindications
Infection or sever inflammation at injection site
Presence of primary teeth = hypoplasia
PDL Advantages
Prevent unnecessary numbness of whole quadrant
Small dose = .2mL/root
Alternative to partially successful LA
30 sec onset
PDL Disadvantages
Difficult needle placement
Leakage = bad taste
Excessive pressure = break glass
Discomfort/tissue damage
Tooth extrusion
Intra-septal injection Technique
Target Area = base/center of interdental papilla equidistant from adjacent teeth
Angle = 45 degrees to LA of tooth and 90 degrees to soft tissue
Bevel face apex of tooth
Depth 1-2 mm
0.2-0.4mL/20 sec
Intra-septal injection Advantages
Unnecessary lip/tongue numbness
Minimum volume of anesthesia
Hemostasis
Atraumatic
30sec onset
Useful in perio involved teeth
Intra-osseous Injections
Deposit LA solution into interproximal bone between two teeth
Nerves = terminal nerve endings
Area = bone, soft tissue, root structures
Pulpal anesthesia 15-30 mins
Intra-osseous Injections Complications
Palpitations Post injection Pain Fistula Instrument Break Perforation of lingul plate
Failure of Intra-osseous
Infected/inflamed tissues
Inability to perforate cortical bone > 2 sec.. change site
Intra-pulpal injection
Deposit LA + pressure
RCT
Minimal volume/immediate onset
Intra-pulpal injection technique
Wedge needle into pulp chamber/canal
Resistance
Bend needle for accessibility
30 sec onset
Mandibular Infiltration
Simple, hemostasis, avoid damage to nerve trunks, less intravascular injection, safe for patients w/ clotting disorders
Mandibular Infiltration - Articaine (1.5x more potent than lidocaine)
Has amide and thiophene ring (solubility) and contains extra ester - only amide type w/ ester
7 mg/kg
Metabolized = 90-95% PEH, 5-10% liver
Confirmation of Anesthesia Clinically
Question Patient
Soft tissue testing
Commence w/ treatment
Testing for Pulpal Anestheisa
Electric Pulp test
Cold Refrigerant = Endo-Ice
Local Complications of Anesthesia
Needle break Prolonged anesthesia or parasthesia Faical nerve paralysis Trismus Soft tissue injury Hematoma Infection
Needle Breakage
Usually IAN or PSA blocks
Causes: Hubbing needle 30 gauge short needle Intentional bending Unexpected movements Forceful bone contact (litigation)
Prolonged Anesthesia or Parasthesia
Main cause of dental practice litigations
Cause = needle injury to nerve -> electric shock feeling
Contaminated LA solution
LA solution itself (Articaine)
Facial Nerve Paralysis
Introduction of LA into capsule of parotid gland usually during IANB or Akinosi
Prevention of Facial Nerve Paralysis
IAN = bone contact at medial side of ramus before injection
Akinosi: Avoid over-insertion of needle
Trismus
Can last average of 6 weeks
Causes:
Trauma to muscles
Contaminated solutions
Hemorrhage
Infection
Trismus Management
Heat therapy Warm saline Analgesics Muscle relaxants Antibiotics
Facial Nerve Paralysis Management
Remove contact lenses till return muscle movement
Eye patch
Prolonged Anesthesia or Parasthesia Management
Refer to OMFS if not improving within 2-3 weeks
Needle Breakage Management
Dont panic
Refer to OMFS
Document incidence
Soft tissue injury
Most common = self inflicted trauma
Warn patient/guardian
Manage = analgesics, ABX, saline mouth rinse, petroleum jelly
Hematoma
Effusion of blood into extravascular space
Prevent = minimize number of needle penetration, dont probe tissue with needle
Hematoma Management
Direct pressure
Analgesics for pain
Abx for infection
Discoloration gradually rseolves
No heat for 4-6 hrs
Ice application immediately
Infection
Extremely w=rare
Cause = needle/cartridge contamination
Prescribe antibiotics if confirm
Refer to OMFS if needed
Overdose Causes
Total dose too large Absorption Rapid Intravascular Injection Bio-transformed too slow Eliminated too slow
Biotransformation
Esters hydrolyzed in plasma and liver by pseudocholinesterase (6-7% abnormal patients) into PABA
Amides by microsomal enzymes in liver
Prevention of Intravascular Injection (IAN most common)
Use aspirating syringe
25 gauge or larger
Aspirate in 2 planes
Inject slowly
Minimal to moderate overdose
Talkativeness Excitability Metallic Taste Twitching Elevated BP Nausea
Moderate to High overdose
Generalized tonic-clonic seizure activity followed by:
Generalized CNS and CVS depression, depressed respiratory rate
Mild reaction - slow onset
Stop treatment! Administer O2 Monitor vital signs Consider IV anticonvulsant Get help
Severe reactuib
Stop all treatment
Place in supine, feet up
Establish airway, give O2
Consider anticonvulsant drugs and vasopressors
Epinephrine Overdose
Sharply elevated systole
Increased heart rate/palpitations
Cardiac tachyarrhythmia
Allergens in LA
Esters -> usually to PABA product
Na Bisulfite/metabisulfite = found in anesthetics as preservative for vasoconstrictors
Methylparaben = no longer used
Allergy signs
Urticaria
Angioedema
Laryngeal edema
Cyanosis
Anaphylaxis Progression
Cardivascular collapse
Delayed Allergy Skin reaction management
Benadryl - 50 mg stat @ Q6h 3-4 days
Immediate Skin Reaction
Epi 0.3 mg IM or SC
Benadryl - 50 mg IM
Bronchial Constriction Management
02
Albuterol - B2 agonist
EPI 0.3 mg IM or SC
Benadryl - 50 mg IM
Laryngeal Edema
Place supine, 02 Epi 0.3 mg IM or SC Maintain Airway Benadryl - 50 mg IV or IM Hydrocortisone - 100 mg IV or IM
Preform cricothyroidotomy
