LA (finish with nerve anatomy)

Question 1

Explain what you would do before performing LA

Answer 1

1. Introduce yourself
   I’d begin the session by introducing myself to the patient and asking them how they’re feeling today
2. Explain treatment
   I’d next explain to the patient what we were going to do in the session and why, so that they know what to expect. So I’d say that in order to do the treatment we need to numb the area with some local anaesthesia, which will make it much more comfortable for them. I’d tell them that I’d put some gel on the area first to make the top part numb and then to expect some pulling on the cheek whilst I insert the LA. I’d say it will start to tingle. I’d say that if they wanted me to stop at any time, the patient could raise their hand and I would stop immediately.
3. Gain informed consent
   I’d then gain consent by asking if the patient is happy for me to go ahead with the anaesthetic
4. Double check medical history
   Before I started I’d double check that the patient doesn’t have a latex allergy as the lidocaine bungs can contain latex (Citanest alternatively). Id also confirm that the patient doesn’t have any heart problems, because if this were the case I wouldn’t use adrenaline (citanest with felypressin or Scandanest plain alternatively). I’d confirm they aren’t pregnant, as I would then need to avoid using felypressin as it has similarities to ocitocin which can induce labour.
5. Mask, visor, wash/dry hands, gloves
6. Select needle
   For an ID block, I would use the 27G long needle, which is the yellow one
   For others, I would use the 30G shorter needle, which is the blue one
7. Select cartridge most appropriate for patient’s medical history
8. Check expiry date and concentration
   I would check the expiry date of the cartridge and that it’s the correct concentration
9. Check that the cartridge isn’t damaged; air bubbles, cracks etc
   I’d also check that there is no damage to the cartridge
10. Assemble needle
11. Apply topical gel and explain why
    I would dry the area and apply topical anaesthesia and explain that this will numb the very superficial layers of the tissues to make the process more comfortable for the patient. I would leave this for 2-3 minutes and look for the tissue going dry and wrinkly to see that this is working in the required area.

Question 2

ID block

Answer 2

• Identify the landmarks
• Palpate external oblique ridge with thumb
• Roll forward and feel for the internal oblique ridge
• Identify pterygomandibular raphe
• Come from opposite side of mouth in the region of the premolars with the needle
• 1cm above and parallel to occlusal plane
• insert the needle medial to the internal oblique ridge and lateral to the pterygomandibular raphe
• Insert 2/3 of needle until hit bone
• Retract 1mm and aspirate to check not in a blood vessel. If this were the case, I would expect to see backflow of blood into the needle after which I would retract 1mm further and aspirate again to see that I had come out of the vessel

Question 3

Mental block

Answer 3

• Hold needle in long axis of tooth
• Insert into muco-buccal fold between apices of 4/5
• Insert 3-4mm until hit bone and then retract 1mm
• Aspirate to check not in a blood vessel. If this were the case, I would expect to see backflow of blood into the needle after which I would retract 1mm further and aspirate again to see that I had come out of the vessel
• Deposit solution slowly to make more comfortable for patient
• Massage solution downwards because sometimes there is a lip of bone overlaying the foramen

Question 4

Long buccal nerve block

Answer 4

• Approach from same side
• Insert needle distal and buccal to most posterior molar

Question 5

Infiltration

Answer 5

• Insert needle 5mm slightly distal to the tooth at the point of the tooth’s apex roughly
• Aspirate
• Insert about 1ml
• Pull on the buccal tissues and rub once deposited

Question 6

Palatal

Answer 6

• Half way between gingival margin and midline
• Until it blanches

Question 7

What would you do after LA

Answer 7

13. Remove needle – make sure I’ve written down the batch code and expiry date
14. Double click the needle
15. Put in sharps bin
16. Remove gloves
17. Alcohol gel hands
18. Give post-operative advice – expect to have a numb lip for 2-3hrs, avoid biting in the area or drinking hot drinks because we don’t want you to burn your numb mouth. tingling sensation is quite normal during this time.