Lecture 8 (10/17) Flashcards
Profound anesthesia in endo is an:
absolute essential
“Painless” injections and considerate, caring manner are the ______ of modern dental proactive and are your _____
cornerstone; your greatest practice builders
Learning to achieve ____ in all cases and doing so as comfortably as possible can MAKE OR BREAK your practice
profound anesthesia
T/F: RCT is possible without profound LA
FALSE
T/F: patients routinely select a particular dentist based solely upon the comfort level of injections given
True
List the steps for atraumatic anesthetic dental injections: (3)
- dry mucosa
- apply topical anesthetic (let sit for 60 sec at least)
- Use injection distraction tactics (shake or squeeze lip)
- slowly inject (should take 60 sec)
- continue to talk to patient to keep occupied
For atraumatic anesthetic injections, you should dry the mucosa and then apply:
topical anesthetic
How long should you allow topical anesthetic sit prior to giving the injection?
60 sec at least
Vigorously shaking or squeezing the lip or cheek while injecting is considered a _____ technique thought to faster activate the alpha fibers to “______”
distraction; “close the gate”
Vigorously shaking or squeezing the lip or cheek while injection is considered a distraction technique thought to activate _____ faster to “close the gate”
alpha fibers
How long should you take to inject the patient? (actual injection)
60 seconds
Any MAXILLARY molars, premolars or anterior teeth may have ______ injection also, for maximum anesthetic effect
Palatal
What is one downfall to the palatal injection?
Very painful
How do you make a palatal injection less painful?
Pressure & time
Why are palatal injections more painful?
Because this tissue is tight
You should never use more than ____ carp on palatal injection, because more than ____ carp will slough the tissue
1/4 carp
T/F: Use of a refrigerant (like endo ice) as a pre injection anesthetic was more effective compared with a topical gel in reducing pain by patients receiving a palatal injection
True
For a palatal injection, when using endo ice, you should:
Hold Q-tip in place on palate with endo ice; slide Q-tip to the side while maintaining contact with palate and then inject (while Q-tip is still to the side and maintaining palatal contact)
What can you see visually when using Q-tip & endo ice in accordance with palatal injection?
Frosted dimple
Use no more than _____ on palatal injection
1/4 carpule
Any _____ tooth may present problems in achieving adequate anesthesia
pulp inflamed tooth
Although any pulp inflamed tooth may present problems in achieving adequate anesthesia, your biggest challenge will probably present as:
Mandibular molar with acutely inflamed pulpitis
Why is anesthesia more difficult with mandibular molar acutely inflamed pulpitis?
Inherent inaccuracies of mandibular nerve blocks (however other problems are also present)
Remember “lip signs” do not necessarily indicate:
Pulpal anesthesia
Remember “lip sings” DO NOT necessarily indicate pulpal anesthesia and infiltration alone here is useless due to the:
Density of the cortical plates
Ways to check for pulpal anesthesia include:
- endo ice on cotton pellet
- EPT
In ______ tissue, a ______ or pore in the nerve cell will be effectively blocked by LA resulting in inability to create an action potential= no pain
non-inflamed tissue; normal gate channel
(This is NOT a tooth with acute pulpitis- its a normal tooth)
Murphy’s law as applied to dentistry states:
“local anesthetic is MOST effective when the need for it is LEAST”
In clinical practice, local anesthesia may be influence by the local availability of _______, as only the _______ (____) can diffuse through the neuronal membrane
free base; non-ionized portion (free base)
In clinical practice, local anesthesia may be influence by the local availability of free base, as only the non-ionized portion (free base) can diffuse through the neuronal membrane
Thus, local anesthetics are relatively ineffective when injected into tissues with an _____ which is presumably due to ________
Acidic pH (e.g. pyogenic abscess, inflamed pulp); reduced release of free base
What effect do conditions like pyogenic abscess & inflamed pulp, have on the ability of a clinician to anesthetize that area?
Makes tissue more acidic resulting in less release of three base= harder to anesthetize
Teeth with acutely inflamed tissues are often ______ to local anesthetic
VERY RESISTANT
If you can inadequately anesthetize the inflamed tooth tissues, you are now presented with both:
physiological & psychologic challenge (due to the pain)
After a local anesthetization of a mandibular 1st molar with acute SIP, when can you proceed with buccal infiltration with Articaine?
After profound lip anesthesia is achieve
(fat lip not tingly lip)
T/F: propound pulpal anesthesia with local anesthetic agents can be achieved for a full clinic period
False- none of the local anesthetic solutions available at UMKC will last for the duration of the typical 3 hour clinical session- plan on re-injecting in clinic
T/F: A good way to test for profound pulpal anesthesia is to poke with an explorer on the buccal & lingual gingiva:
False
How long is anesthesia achieved with periodontal ligament (PDL) injections?
15-30 minutes
Why are local anesthetics relatively ineffective when injected into infected and inflamed tissues?
Acidic pH of tissue & reduced release of free base (non-ionized)
Emotional considerations for an RCT/anesthesia include:
- apprehension-fear-anxiety
- fatigue-hyperalgesia-allodynia
- decreased pain threshold
- history of unsuccessful anesthesia
- popularized fear of RCT
- lack of confidence in provider
Emotional considerations all add up to a unique and formidable challenge. ______ & ______ are equally important to a good result.
Technique & patient management
What can we do to combat local anesthesia problems?
- anti-inflammatory drug
- do everything you can to diminish the emotional component (patient management)
- ensure you have a good block (lip signs)
- learn to effectively use supplemental anesthetic techniques (following confirmed block)
Why does the use of an anti-inflammatory drug prior to the dental appointment help to combat LA problems?
(3)
- reduces inflammation
- reverts pore size to normal
- raise the patient’s pain threshold
What is a simple & inexpensive way to combat LA problems?
Use of an anti-inflammatory drug 1 hour prior to appointment
Dosage and time frame of anti-inflammatory drug prior to treatment:
IBU 600 mg one hour prior
How effective is IBU 600 mg one hour prior to treatment to combat LA problems:
78% effective
You must have ALREADY seen the patient, taken history and obtained radiographs, clinical testing, and made your diagnosis prior to telling the patient to take IBU before their treatment because:
you CANNOT prescribe without a diagnosis or examination in patient
How do we diminish the emotional component in order to combat LA problems?
- Establish rapport with patient
- show them you care-communicate your concerns in a calm, convincing manner
- inform before you perform
- give patient some control (raise your left hand if you feel pain)
- consider pre-op anti-inflammatory &/or anti-anxiety drugs
If you do a good IA block, you should have:
lip signs
If you include any buccal infiltration anesthesia initially (without waiting for “lip signs”) you won’t know if the “lip signs” are from:
the block or the infiltration
How should you ensure that you do a good IA block?
-Do initial IA and then wait a few minutes to allow anesthesia in area of IA injection
-Go back and FEEL the BONE and painlessly injection the 2nd carpal where you KNOW you need to be for an IA block
- wait for “lip signs” & check tooth with percussion and/or cold to determine the need for supplementary anestheisia
How should you check to determine if you need any supplementary anesthesia following proper administration on an IA block?
Check tooth with percussion and/or cold
When should you use buccal infiltration for endo treatment?
ONLY AFTER you are POSITIVE you have a numb and fat lip
“lip signs” are a ______ NOT a _____
Fat lip; tingly lip
T/F: It is acceptable to proceed to supplemental techniques before you have confirmed your block
False- DO NOT proceed to any supplemental anesthesia techniques until you have CONFIRMED your block
What is the point of penetration to an Inferior alveolar nerve (IAN-L) block?
Just lateral to the pterygomandibular raphe at the height of coronoid notch
What is shown in this image?
Point of penetration for an IAN-L (inferior alveolar nerve block)
The following image shows he correct for an:
IAN-L (inferior alveolar nerve block)
It is important to learn to effectively use ______ if necessary following confirmed block
Supplemental anesthetic techniques
List some supplemental anesthetic techniques: (3)
- intra-ligamental (periodontal ligament=PDL) injection
- intra-pupal injection
- intra-osseous injection
- Intra-ligamental (PDL) injection
- Intra-pulpal injection
- Intra-osseous injection
These are all examples of:
Supplemental anesthetic injections
Most LA agents have an onset of action between:
1-20 minutes
____ of the LA solutions available at UMKC will last for the duration of the typical 3 hr clinic session. You should plan on:
None; re-injecting in the clinic
Effective pulpal anesthesia will be routinely gone in _____. This is why you should:
30-90 minutes; get pulp OUT while numb
T/F: It will be necessary to monitor the patient and re-inject during the course of MOST or ALL clinical sessions
True
Just because there is a well developed P/A lesion and both teeth test necrotic (non-responsive); don’t begin ANY treatment without LA. Always use:
LA for every case at every appointment
If you encounter ANYTHING that hurts (rubber 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
(in the case of forgoing anesthetics due to the unresponsiveness of the necrotic tooth) If it hurts at all, the patient thinks you made an error in judgement and he/she is already looking for a new dentist. If they do stay with you they will be “_____”
Waiting for the other shoe to drop
Play it safe; give adequate LA ______ you enter the tooth. If anything hurts:
EVERY TIME; IMMEDIATELY STOP and give additional LA
What are the two basic types of local anesthetic agents?
Esters & amides
-more side effects
-higher probability of allergic reactions
-no longer in favor or commonly use in U.S.
Esters- Novacaine & Procaine
Why are esters no longer in favor or commonly available local anesthetic agents in the U.S.? (2)
- more side effects
- higher probability of allergic reaction
Novocaine & Procaine are examples of:
Esters
The readily available & preferred type of local anesthetic agents:
Amides
What are the durations of amides?
Short: less than 60 min
Medium: 60-120 min
Long: More than 120 min
Give an example of short duration amide:
Mepivacaine (Carbocaine)
Give an example of a medium duration amide:
Lidocaine & Articaine
Give an example of a long duration amide:
0.5% Bupivacaine with 1:200,000 epi (Maracaine)
The vasoconstrictor ratio seen in amide local anesthetic agents may be:
None
1: 200,000
1: 100,000
1: 50,000
When injecting local anesthetic what MUST be done to avoid intra-vascular injection?
Aspirate (Repeatedly)
What does aspirating repeatedly when injecting a patient do ensure?
That you are avoiding intra-vascular injection
Although duration of pulpal anesthesia ranges from 30-90 min, most pulpal anesthesia will be lost after:
45 min
Allows Articaine to penetrate the cortical bone plates:
Thiophene ring
What does a Thiophene ring allow for?
Allows Articaine to penetrate the cortical bone plates
(According to a systematic review and meta-analysis) In patients with symptomatic irreversible pulpits
