lecture 6 Flashcards
4 factors affecting endodontic anesthesia
- apprehension and anxiety
- fatigue
- tissue inflammation
- previous unsucessful anesthesia
what phase of treatment is most important
initial management
RCT is impossible without profound
LA- local anesthesia
what is important in the initial management?
psycological approach this involves the 4C’s
- control
- communication
- concern
- confidence
atraumatic anesthetic injections:
- dry mucosa- then topical anesthetic- let it soak in at least 60 seconds
- vigourously shaking/squeeing lip or cheek while injecting is a distraction technique
- SLOW and gentle (take 60 seconds to injection)
- talk to pt constantly
- keep patient occupied
for any maxillary molars, PM or anterior
- may have palatal injection also for max anesthetic effect
- palatal very painful though
- use small quantity of LA on palatal tissue which is tight and painful. too much (more than 1/4 carp) may slough tissue
use of what as pre-injection anesthetic is more effective compared with topic gel in reducing pain in palatal injection
use of refrigerant (endo ice)
+ pressure
+ time
using refrigerant as pre-injection for palate, you direct the needle top ______to the frosted dimple and use NO MORE than ____carpule on palatal injections
perpendicular to the frosted dimple
no more than 1/4 carpule
why is local anesthetic less effective in acute inflammation?
and where will biggest challenge be located at?
the HOT pulpitis
mandibular molar with acutely inflamed pulpitis
why is anesthesia difficult in mand molar with acute inflamed pulpitis
due to inherent inaccuracies of mandibular Nerve blocks and other problems
______do not necessarily indicate PULPAL anesthetia and infiltration alone here is useless due to the density to the cortical plates
lip signs
teeth with _____are often very resistant to LA
so bottom line is, less effective anesthesia is resultant and a whole lot more pain is perceived
acutely inflamed tissues
these are equally important to a good result
technique and patient management
what can we do to combat LA problems?
- use anto-inflammatory drug in effort to reduce inflammation, revert the pores to normal and raise the patient’s pain threshold. such an inexpensive and simple benefit
IBU 600 mg one hour prior = ___% effective
78%
you cannot prescribe w/o a DX or w/o examining pt so must
have already seen the patient, taken history, obtained radiographs, clinical testing and made your Dx
to combat LA problems, do everything you can to diminish the
emotional components
diminish emotional components by:
- establish rapport with the patient. show then you CARE
- communicate your concern for the pt in a calm, convincing and confident manner
- inform before you preform
do initial LA and wait few minutes to allow anesthesia in area of LA injection. then, go back and
feel the bone and painlessly inject the 2nd carpule where you know you need to be for the LA block
then wait for lipsigns and check tooth with percussioin and or cold to determine if you need to do supplementary anesthesia
only after you are positive that you have a numb and fat lip, do you use any ____ anesthesia
buccal
- intra-ligamental (PDL injection)
- intra-pulpal injection
- intra-osseous
what are supplemental anesthetic techniques that can confirm block
5 basic mandibular techniques
- inferior alveolar nerve (IAN)
- lingual nerve (L)
- buccal infiltration
- gow-gates
- incisive nerve block/infiltration at the mental foramen
inferior alveolar nerve and lingual nerve anatomy
- mand nerve V3
- all descend on medial side of ramus
- lingual nerve is just anterior to IAN
- IAN will enter the mand foramen
deposition site “target” for IAN
superior to mandibular foramen
target site for lingual nerve
withdrawl needle slightly
3 things for IAN and lingual nerve before you deposit
- aspirate
- stabilize
- distraction
IAN and L point of penetration
just lateral to pterygomandibular raphe at the height of coronoid notch
IAN and L injection at height of:
coronoid notch
6-10mm above occlusal plane
IAN and L insertion path has barrel of syringe parallel with:
and barrel of syringe is over:
mand occlusal plane
over opposite premolars
IAN and L insertion path
advance~ ___mm or __inch needle in
20-25mm or 1 inch
what is the most common method for mandibular
IAN
lip numb 5-7 mins
pulpal anesthesia 10-15 mins
success more in molars and premolars
duration of IAN
2 1/2 hours
labial and lingual infiltration injections alone (are/aren’t) effective for pulpal anesthesia in mandible
are not
what carpal is significantly better for first mand molar
articaine over lidocaine
for gow gate, the target is
neck of condyle
steps for gow gate
- have pt open as wide as possible
- position syringe over the contralateral premolars
- insert the needle into mucosa distal to the max 2nd molar until the neck of condyle is contacted
- imagine needle tip is aimed for the external auditory meatus
incisive nerve block at the
mental foramen
incisive nerve block successful for what teeth
for premolar teeth but not for central or lateral incisors
branches for IAN above the mand foramen and might innervate first molar
mylohyoid
mylohyoid can deliver anesthetic into the mucosal tissue apical and distal to the
first molar
5 techniques for maxillary
- infiltration
- anterior superior alveolar (ASA)
- middle superior alveolar (MSA)
- posterior superior alveolar (PSA)
- infraorbital block
max palatal anesthesia nerves
- greater-palatine GPB
- naso-palantine (NPB)
anesthesia is more successful in (maxilla/mandibular)
maxilla
with maxilla, pulpal anesthesia onset is:
lip numbness:
duration:
lip numbness few mins
pulpal: 3-5 mins
duration anterior teeth 30-60 mins
premolars and molars 45-60 mins
anterior superior alveolar (ASA)
numbs the maxillary anterior teeth (incisors and canines) and the associated soft tissue
where to inject for anterior superior alveolar (ASA)
anesthetic is typically injected near the apex of the maxillary canine or incisor
target area for middle superior alveolar MSA
premolars (first and second) and may also include the mesiobuccal root of the maxillary first molar, as well as the surrounding gingival and buccal tissues
middle superior alveolar MSA technqiue
near max second premolar, targeting the MSA nerve which is branch of max nerve
posterior superior alveolar (PSA) target area
maxillary molars (typically the first, second, and sometimes third molars) and the associated buccal soft tissues
technique for posterior superior alveolar
injected near posterior superior alveolar foramen, which is located on the maxilla, usually above the molar roots.
needle is typically inserted at 45 degree angle to reach nerve
infraorbital block target area
max anterior teeth (incisors and canines), premolars, and sometimes mesiobuccal root of max first molar. it also affects the buccal soft tissues, upper lip, and sometimes the nasal region
infraorbital block technique
injected near infraorbital foramen, located just below the infraorbital rim
greater palatine target area
numbs soft and hard tissues of posterior hard palate, usually from the second molar to the midline, affecting the greater palatine nerve
greater palatine technique
injected at the greater palatine foramen, located on the hard palate usually about 1-2mm medial to the second molar.
needle gently advanced into the foramen
nasopalatine target area
numbs anterior hard palate, particularly the area around the maxillary incisors (central and lateral incisors) and the associated gingival tissues
nasopalatine technique
injected at nasopalatine foramen, located just behind max central incisors
done by inserting the needle into midline of anterior palate, often requiring gentle aspiration to avoid blood vessels
most LA agents have onset of action between
1-20 mins
wait and test
___of LA solutions available at umkc will last for entire 3 hour duration
NONE
plan on reinjecting
effective pulpal anesthesia will be routinely gone in ______mins. get pulp OUT while numb!
30-90 mins
two basic types of LA agents
esters and amides
novacaine, procaine
-more side effects, higher probability of allergic reaction, no longer in favor or commonly available in US
esters
all rest, available, and preferred agents
amides
(lidocaine)
most pulpal anesthesia will be lost after
45 mins
amides short duration <60 mins [carbocaine]
mepivacaine
amides medium duration 60-120 mins
lidocaine and articaine
amides long duration >120 mins
0.5% bupivacaine w/ 1:200,000 epi [marcaine]
____REPEATEDLY to avoid intravascular injection
aspirate
many hot IP cases will require one or more supplemental anesthetic technique in addition to basic regional blocks and necessary infiltration:
after buccal infiltration, use PDL on hot mand molar when block is confirmed
- PDL injection
- intra-pulpal injection
- intra-osseous injection
needle wedged between root and bone
key is achieving back pressure
achieves rapid onset but can be uncomfortable to the pt and short in duration
PDL injection
can get you into pulp but cant get you into the canal
-want to get into canal
-last choice
-painful and ultra short acting, but immediate relief
intra-pulpal injection
use what needle with intra-pulpal injection and wedge how
30 gauge (#25 file)
wedge as far in canal as possible
*must bind tightly in canal
how to complete intra-osseous injection
- distal to target tooth
- 2mm apical to CEJ
- stay in attached gingiva
- avoid roots, mental foramen, sinus
a ____is rotated in the handpiece following soft tissue anesthesia to create hole (path) thru cortical bone into medullary spaces
radiograph with cannula(needle) in place and remove at end of visit
perforator for intra-osseous injection
*not used at UMKC
x-tip used for intra-osseous injection parts
perforator and cannula (needle)
*not used at umkc
x-tip designed to be placed here:
2mm inferior to the intersection of horizontal line paralleling B-G margins and a vertical line bisecting the interdental papilla distal to the tooth to be anesthetized
this is usually necrotic pulp so not IP problem, but probably very sens to palpation and percussion.
never a good idea to inject into swollen tissue
refer serious case
cellulitis
general considerations with cellulitis
- do regional block AWAY from inflamed area
- increase dose of LA
- change anesthetic?
- supplemental anesthetic techniques
- pre-med with anti-anxiety agents [valium or nitrous oxide/oxygen sedation]
- strongly consider REFERRAL for initial cellulitis treatment
drainage of cellulitis is very serious. best thing to do it
- refer
I.V. antibiotics and I&D (incision and drainage)
as soon as pt stabilized and able to open mouth, tooth reomved or pulp extirpated
do not add any buccal infiltration until you have
thick and fat lip
(not just tingling)
local anesthetics cause____________ 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 interruption of the conduction of impulses in peripheral nerve
LA effects are due to blockade of _____, thereby impairing sodium ion flux across the membrane resulting in
sodium channels
disrupting 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:
depends on the pH in the area
Only the (ionized/non-ionized) 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 :
1
2
- occludes the channel
- combines with a specific receptor within the channel that results in channel blockade
most commonly used LA agent
(best choice for routine RCT at umkc)
2% lidocaine with 1:100,00 (xylocaine)
each lidocaine carp contains
34 mg of anesthetic
max safe adult dosage of lidocaine
8 carps (272mg)
since lidocaine has epinephrine, should not be routinely used in patients in
MAO inhibitors or tricyclic antidepressants
most controversial LA agent
4% lidocaine with 1:200,000 epi (septocaine)
contains both ester and amide linkage
4% lidocaine with 1:200,000 epi (septocaine) each carp contains _____mg of anesthetic (twice as toxic as lidocaine)
68 mg
maximum safe adult dosage for 4% articaine with 1:200,000 epi
4 carpules
what has the potential to cause neuropathies paraesthesia
articaine
5x as more likely than with lidocaine. or mepivicaine
what is the purpose of epinephrine in LA
Delays systemic absorption which increases the duration AND increases the effectiveness of the LA. Also retards bleeding (surgery).
potential danger with epi
in a pt with elevated BP is an untoward further increase in BP (esp. w/ intravascular inj.)
if pt is stressed how does this effect epi
normal pt around 70kg will produce endogenous epi at 0.007mg-0.014mg per minute at rest.
exogenous epi ranging from 0.018mg-0054mg (1-3 carps)
thus, a pt at rest produces almost 1 carp of LA epi/min
and if pt is STRESSED, not number, they will produce endogenous epi at 0.28mg per min!!! 10 carps of la epi/min
1-2 carps of 1/100k is generally
of little consequence
3-4 carps and pt still isnt numb
consider rescheduling with sedation
unless pt in severe pain, then consider IV sedation unless contraindicated if faculties and services available
solution to hot max tooth
use regional block (infraorbital block or palatal infiltration/2nd division block)
PSA
2nd division block
LA should not be injected directly into swelling before incision for draining because
swelling has increased blood supply so they anesthetic is transported quickly into systemic circulation diminishing the effect in the local tissues
solution to hot tooth mand
- gow gate injection -designed to include the high rising mylohyoid nerve
