Lecture 9 (10/17) Flashcards by Abagayle Moody

Profound anesthesia in endo is an:

absolute essential

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“painless” injections and considerate, caring manner are the ____ of modern dental practice and are your ____

cornerstone; greatest practice builders

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Learning to achieve ____ in all cases and doing so as comfortable as possible can MAKE or BREAK you practice

profound anesthesia

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T/F: RCT is possible without profound LA

FALSE- impossible

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T/F: Patients routinely select a particular dentist based solely upon the comfort level of injections given

True

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List the steps for atraumatic anesthetic injections: (3)

Dry mucosa
Apply topical anesthetic (let sit for 60 seconds at least)
Use injection distraction tactics (shake or squeeze lip)
Slowly inject (should take 60 seconds to inject)
Continue to talk to patient to keep occupied

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For atraumatic anesthetic injections, you should dry the mucosa and then apply:

topical anesthetic

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How long should you let topical anesthetic sit prior to giving the injection?

at least 60 seconds

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Vigorously shaking or gently squeezing the lip or cheek while injecting is a ____ technique thought to activate the faster Alpha fibers to “_____”

distraction; “close the gate”

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Vigorously shaking or gently squeezing the lip or cheek while injecting is a distraction technique thought to activate faster ______ to “close the gate”

Alpha fibers

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How long should you take to inject the patient? (actual injection)

60 second- SLOW

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Any MAXILLARY molars, premolars, or anterior teeth may have ____ injections also, for maximum anesthetic effect

palatal

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What is one downfall to a palatal injection?

very painful

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How do you make a palatal injection less painful?

Pressure + Time

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Why are palatal injections more painful?

because this tissue is tight

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You should never use more than ___ carp on palatal injection because more than ____carp will slough the tissue

1/4 carp

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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

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For a palatal injection, when using endo-ice, you should:

hold q-tip 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 maintain palatal contact)

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What can you see visually when using q-tip and endo ice in accordance with the palatal injection?

frosted dimple

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Use no more than ____ on palatal injection

1/4 carpule

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Any ___ tooth may present problems in achieving adequate anesthesia

pulp inflamed tooth

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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

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Why is anesthesia more difficult with mandibular molar acutely inflamed pulpitis?

inherent inaccuracies of mandibular nerve blocks (however other problems are present)

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Remember “lip signs” do not necessarily indicate:

pulpal anesthesia

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Remember "lip signs" DO NOT necessarily indicate pulpal anesthesia and infiltration alone here is useless due to the:

density to the cortical plates

Ways to check for pulpal anesthesia include:

1. endo ice on cotton pellet 2. EPT

In _____ tissue, a ____ or pore in the nerve cell will be effectively blocked by LA resulting in inability to create a an action potential = no pain

non-inflamed; 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 the LEAST"

In clinical practice, local anesthesia may be influenced by the local availability of ___, as only the _____ can diffuse the neuronal membrane

free base; non-ionized portion (free base)

In clinical practice, local anesthesia may be influenced by the local availability of free base, as only the non-ionized portion (free base) can diffuse 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 and inflamed pulp have on the ability of a clinician to anesthetize that area?

makes tissue more acidic resulting in less release of free base = harder to anesthetize

Teeth with acute 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 and psychological 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 achieved (fat lip not tingly lip)

T/F: Profound pulpal anesthesia with local anesthetic agents can be achieved for a full clinic period

False- none of the local anesthetic solutions are available at UMKC will last for the duration of the typical 3 hour clinic 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 PDL injections?

15-30 minutes

Emotional considerations for RCT/ anesthesia:

1. Apprehension-Fear-Anxiety 2. Fatigue-Hyperglasia-Allodynia 3. Decreased Pain Threshold 4. History of Unsuccessful Anesthesia 5. Popularized Fear of RCT 6. Lack of Confidence in Provider

Emotional considerations all up to a unique and formidable challenge. ____ & ____ are equally important to a good result.

technique & patient management

What can we do to combat LA problems? (4)

1. anti-inflammatory drug 2. do everything you can to diminish the emotional component - (patient management) 3. ensure you have a good block (lip signs) 4. learn to effectively use supplemental anesthetic (following confirmed block)

Why does use of an anti-inflammatory prior to dental appointment help to combat LA problems? (3)

1. reduces inflammation 2. reverts pore size to normal 3. raises the patients 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 dx prior to telling the patient to take IBU prior to treatment because:

you CANNOT prescribe without a diagnosis or examination of patient

How do you diminish the emotional component (when trying to combat LA problems)?

1. establish rapport with patient 2. show patient you care- communicate in calm, convincing manner 3. inform before yo perform 4. give patient some control (raise ur left hand if you feel pain) 5. 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 (w/out 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 wait a few minutes to allow anesthesia in are of the IA injection - Go back and FEEL the Bone and painlessly inject the 2nd carpule where you KNOW you need to be fore an IA block - Wait for "lip signs" and check the tooth with percussion and/or cold to determine if you may need to do supplementary anesthesia

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 that you have a NUMB and FAT LIP

"Lip signs" are ____ 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 you BLOCK

what is shown in this image?

point of penetration for an IAN-L (inferior alveolar nerve block)

The point of penetration for an IAN-L (inferior alveolar nerve block) is:

just lateral to the pterygomandibular raphe at the height of the coronoid notch

This image shows correct placement for what type of block?

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)

1. Intra-ligamental (periodontal ligament= PDL) Injection 2. Intra-pulpal injection 3. intra-osseous injection

- intra-ligamental (PDL) injection - intra-pupal injection - intra-osseous injection These are all examples of:

supplemental anesthetic injections

Most LA agents have an onset of action between: ____ (WAIT and TEST)

1-20 minutes

_____ of the LA salutation available at UMKC will last for the duration of the typical 3 hr clinic session. You should plan on:

None; re-injecting in 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 clinic 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 unexpected tag of vital tissue), you will lose the most essential element of patient management which is:

the confidence of the patient

(in the case of forgoing anesthetics due to the unresponsiveness of the necrotic pulp)- If it hurts at all, the patient thinks you made in error in judgement and he/she is already looking for a new dentist. If they do stay with you they will be "_____"

forever waiting of 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 reaction - No longer in favor or commonly available in the U.S

Esters

Novacaine and Procaine are examples of:

Esters

Why are esters no longer in favor or commonly available in the U.S?

1. More side effects 2. Higher probability of allergic reaction

The readily available and preferred type of local anesthetic agent:

Amides

What are the durations of amides?

Short: less than 60 minutes Medium: 60-120 minutes Long: greater than 120 minutes

Give an example of short duration amide:

3% Mepivacaine (carbocaine)

Give some examples of medium duration amides:

Lidocaine & Articaine

Give an example of a long duration amide:

0.5% Bupivacaine w/ 1:200,000 epi (Marcaine)

The vasoconstrictor ratio seen in amide local anesthetic agents may be:

None 1:200,000 epi 1:100,000 epi 1:50,000 epi

What does aspirating repeatedly when injecting a patient ensure?

That you are avoiding intra-vascular injection

Although the duration of pulpal anesthesia ranges form 30-90 minutes, most pulpal anesthesia will be lost after:

45 minutes

Allows the articaine to penetrate the cortical bone plates:

Thiophene ring

What does a Thiophene ring allow for?

allows for Articaine to penetrate the codicil bone plates

In patients with symptomatic irreversible pulpitis (a systemic review and meta-analysis)

NOT FINISHED

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