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ANATOMY/LA > LOCAL ANAESTHETIC > Flashcards

LOCAL ANAESTHETIC Flashcards

1
Q

What 5 main different types of LA do we have

A
  • lidocaine/adrenaline - GOLD STANDARD
  • prilocaine - alternative
  • mepivicaine - least vasodilatory
  • bupivacaine - high protein binding, long acting
  • articaine (IF IDB DOESNT WORK carry out articaine infils?)
  • topical analgesics - lidocaine is the only really useful topical analgesic among those just listed. Used either as a gel or spray on the mucosa prior to the site being injected. Has many other uses too
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2
Q

What do we mean by anaesthesia ?

A

LOSS OF ALL SENSATION

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3
Q

what do we mean by analgesia

A

LOSS OF PAIN SENSATION

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4
Q

what is LOCAL anaesthesia

A

a method of anaesthesia that acts in a local/specific area of the body and does not result in a loss of consciousness

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5
Q

Under GDC standards for dental team, what do patients expect regarding LA

A

Patients expect: that their dental pain and anxiety will be managed APPROPRIATELY

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6
Q

what is the scope of dental local anaesthesia (what can it do)

A
  • pain control: during a procedure and post op
  • diagnosis
  • haemostasis (due to adrenaline being a vasoconstrictor)
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7
Q

what are the 2nd and 3rd branches called of the trigeminal nerve

A

MAXIILLARY DIVISION
MANDIBULAR DIVISION

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8
Q

Describe the branches involved in the MAXILLARY division of the trigeminal nerve.

A
  • Posterior superior alveolar nerve
  • Middle superior alveolar nerve
  • Infraorbital nerve
  • Anterior superior alveolar nerve
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9
Q

What is the DENTAL (tooth) innervation of the maxillary arch?

A

Anterior superior nerve supplies the upper incisors and canines

Middle superior nerve supplies the upper premolars and the MESIO-BUCCAL ROOT OF UPPER 1ST MOLAR

Posterior superior alveolar nerve supplies the second and third molars and 2/3 roots of the upper first molar

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10
Q

on the hard palatal surface, what 3 pairs nerves are located and what is eaches mucosal innervation?

A

INCISIVE branch of nasopalatine nerve (through the nasopalatine foramen)- (anterior aspect of palate - canine to canine)
GREATER palatine nerve (middle palate - supplies the soft tissues up until the midline on one side of the hard palate )
LESSER palatine nerve (soft palate area)

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11
Q

Describe the maxillary and palatal mucosal innervation that LA provides

A

Anterior superior alveolar nerve - supplies LABIAL mucosa
Middle superior alveolar nerve - supplies BUCCAL tissues adjacent to the teeth supplied by that nerve
Posterior superior alveolar nerves - supplies BUCCAL tissues adjacent to the teeth supplied by that nerve

Greater palatine nerve - supplies ALL soft tissues on palate adjacent to all posterior teeth
Incisive branch of nasopalatine nerve - supplies hard palate just behind 3-3
Infra-Orbital nerve - supplies some of the tissues high up in sulcus
Lesser palatine nerve - supplies the soft palate

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12
Q

what are the 3 different LA techniques

A

-topical
- infiltrations
- regional block

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13
Q

list some of the supplementary LA techniques we have(5)

A
  • intra-osseous
  • intra-ligamentary
  • intra-papillary
  • intra-pocket
  • computer controlled
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14
Q

list some uses of topical (surface) anaesthesia

A
  • aid to pain free injections
  • very minor surgical procedures
  • abscess incision
  • rubber dam clamps
  • impressions ie place on palate
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15
Q

Describe some advantages/disadvantages of infiltrations (7)

A
  • easy
  • safe
  • low risk of IV administration
  • low risk of nerve damage/injury
  • local haemostasis
  • local diffusion required
  • acts on NERVE endings rather than trunk
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16
Q

Describe some advs/dis of doing an IDB(7)

A
  • can be difficult - people have different anatomy
  • less safe
  • higher risk of IV administration
  • higher risk of nerve injury
  • acts on nerve trunk
  • widespread effect from single injection
  • can deposit away from INFECTED AREAS.
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17
Q

what is an infiltration useful for?

A

pulpal anaesthesia for MOST upper teeth and soft tissue anaesthesia for where you put it eg buccally or pal.

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18
Q

where can an infiltration be difficult to achieve anaesthesia and why?

A

PULPAL ANAESTHESIA OF THE UPPER 1ST MOLARS - due to the zygomatic process (thicker bone)
can be placed buccally/palatally

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19
Q

Describe the technique carrying out an infiltration

A

Medical History
Equipment - short needle, lidocainew/adrenaline (normally)

Identify injection site
Dry with 3 in 1
Apply topical gel
Remove cotton wool roll
Retract tissues
Bevel must be facing bone (45 degs to bone)
gently insert needle until bone is contacted
withdraw needle by 1mm and ASPIRATE - if clear inject slowly into area!

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20
Q

What is aspiration?

A

a technique to reduce the risk of Intravascular injection

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21
Q

what different branches of nerves come off of the 3rd branch (mandibular nerve) of the trigeminal nerve

A

Lingual, long buccal, inferior alveolar, mental, incisive

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22
Q

What is the dental innervation of the mandibular arch

A

inferior alveolar nerve supplies 3 molars and the 5
incisive nerve supplies the 2 incisors, canine and 4

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23
Q

what nerves give mucosal innervation to the mandible?

A

lingual nerve (lingual sts)
long buccal (buccal gingivae/tissues on posterior area)
mental supplies the labial soft tissues

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24
Q

Where does the inferior alveolar nerve pass through/enter?

A

the MANDIBULAR FORAMEN

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25
Q

How do we have a pt sitting when giving an IDB and why

A

SUPINE less likely of a vasovagal (faint) or upright for anatomical reasons - gravity will allow anatomical features to naturally relax ?

26
Q

describe the technique for an IDB

A
  • mouth open wide to identify the pterygo-mandibular raphe
  • place supporting thumb in coronoid notch of anterior border of ramus
  • identify injection point
  • insert needle at angle of the first premolar until bone is touched
  • withdraw needle by 1-2mm then ASPIRATE
    • if none, then start to slowly inject
27
Q

What is the KEY SIGN an IDB has worked

A

Numb lower lip (IAN nerve)
Numb tongue (lingual nerve)
Either of these signs shows us roughly where our needle was placed.

28
Q

During an IDB we like to catch the lingual nerve too, how do we do this?

A

withdraw needle slightly just before taking needle out of injection site and should just catch the lingual nerve, the key sign to this is an IPSILATERAL NUMB TONGUE

29
Q

where do we inject a long buccal

A

POSTERIOR and BUCCAL to the last molar tooth (comes across the coronoid notch)

30
Q

how do we do a mental nerve block

A

mental nerve emerges from the mental foramen lying APICAL to and between the first and second mandibular premolars - MENTAL NERVE SUPPLIES INNERVATION TO LABIAL MUCOSA AND GINGIVA - NOT TEETH - this is the incisive nerve

31
Q

what is the GOLD standard LA

A

LIDOCAINE with adrenaline

32
Q

List some of the CAUSES of failure in LA(5)

A
  • poor technique and inadequate VOLUME of LA
  • injection into a MUSCLE (can result in trismus)
  • injection into an infected area (due to the pH being decreased in infected area, LA is ionised/charged meaning it will be less likely to enter the cell membrane)
  • IV injection - no analgaesic benefit
  • DENSE COMPACT bone can prevent a properly given infiltration from working
33
Q

How can we get facial palsy from injecting LA

A

can be caused by incorrect distal placement of the needle tip allowing LA to permeate the capsule of the parotid gland affecting the facial nerve. the palsy lasts for the duration of the LA - until numbness wears off.

34
Q

What is in a LA cartilage (5)

A
  • LA agent
  • epinepherene - adrenaline, vasoconstrictor
  • solvent
  • water
  • fungacide
35
Q

what does the choice of LA technique depend on? (3)

A

patient
nature, location and duration of the planned treatment
LA drug!

36
Q

Why is a palatal injection uncomfortable

A

due to the keratinised MASTICATORY mucosa which is tightly bound to the hard palate - once blanched, we know when to withdraw the needle

37
Q

where do we aim to deposit the LA in an IDB

A
  • CLOSE to the IAN
  • BEFORE it enters the mandible
38
Q

How does LA work?

A

essentially keeping the sodium channels CLOSED hence no increased sodium permeability - no sodium into cell therefore no depolarisation.

in other words: Blocking Sodium Channels: Anaesthetic molecules enter the nerve cells and block the sodium channels. These channels are like gates that allow sodium ions to flow into nerve cells, which is NECESSARY for nerve signalling/pain to brain. When the channels are blocked, the nerve cannot send pain signals so therefore analgesia is achieved.

39
Q

what are the 2 theories on how LA works

A

membrane expansion theory:
LA diffuses into an axon membrane and prevents sodium channels from opening
specific receptor theory:
LA binds to the sodium channel, inactivating the sodium channel

40
Q

in terms of nerve size, what nerves are easier to block?

A

SMALL due to the lack of myleination. the block usually lasts longer too

41
Q

what does the absorption of LA depend on? (4)

A
  • dose
  • vasoactivity of the drug
  • vascularity of the tissue
  • vasodilator effect vs use of vasoconstrictors
42
Q

Where is LA metabolised? (3)

A

in the liver, lungs (prilocaine), plasma (articaine)

43
Q

what/why should we avoid prilocaine with felypressin (only form it comes in) in pregnancy

A
  • mild oxytocic effect
  • interferes with placental circulation and uterine tone (can cause contractions)
  • dose in dentistry is small (need 100 carts to induce labour, but should just avoid in practice)
44
Q

What is the purpose of a vasoconstrictor in LA? (3)

A
  • advantagous as there is less flow of blood in/out of area
  • holds the LOCAL solution where we need it
  • haemostasis - stops blood blowing into area (particularly useful for moisture control of restorations!)
45
Q

What are the LEAST vasodilatory LOCAL ANAESTHETICS (2)

A
  • prilocaine
  • mepivicaine
46
Q

What post op advice would we give our patients after administrating LA once they leave the surgery(6)

A

Avoid Eating or Drinking anything too hot until Numbness Wears Off: Patients should avoid eating or drinking until the numbness in the treated area has completely worn off to prevent accidental injury to the soft tissues.

Be Cautious When Chewing: Once the numbness has resolved, patients should be cautious when chewing to avoid biting their lips, cheeks, or tongue until normal sensation returns.

Take Pain Medication as Directed: If necessary, patients may be advised to take over-the-counter pain medication, such as ibuprofen, to manage any discomfort or soreness following the procedure. Patients should follow the dosage instructions provided by their dentist.

Apply Ice Packs: Applying an ice pack to the outside of the face in the area of the treated tooth or injection site can help reduce swelling and alleviate discomfort.

Maintain Good Oral Hygiene: Patients should continue to brush and floss their teeth as usual, being careful around the treated area to avoid causing irritation or injury.

47
Q

What determines the effectiveness of an infiltration anaesthesia ?

A
  • effectiveness is determined by the PERMEABILITY of the tissues (especially bone) through which the solution has to pass!
48
Q

List the nerves commonly blocked when doing a regional (block) anaesthesia

A

Nerves commonly blocked:
- IAN
- Mental and Incisive
- Lingual
- Long buccal

  • greater palatine
  • naso-palatine
49
Q

As a Dental Therapist what can we do regarding LA

A

IF we are TRAINED, COMPETENT AND INDEMNIFIED: give infiltration and inferior dental block analgesia

50
Q

Why are communication skills important in pain management ?

A
  • good communication skills - it is integral to developing RAPPORT with your patient
51
Q

What about a good relationship with patients, why is this important?

A
  • patients trust and have confidence in the dentist and treatment proposed - effective at relieving pain
  • good relationship with patients predicts attendance at appointments
52
Q

What are 5 techniques used to help patients cope with pain (and anxiety)

A
  • Build a TRUSTING RELATIONSHIP with the patient
  • predictability and controllability for the patient (reduces pain anxiety and fear)
  • relaxation techniques (ask if your patient is familiar with any techniques - breathing/muscle relaxation techniques)
  • distraction (cognitive coping strategy)
  • desensitisation - phases into treatment (reduce anxiety)
53
Q

What types of roots do we have on the trigeminal nerve?

A

2 ROOTS: sensory and motor

54
Q

what techniques can we do to achieve a painless injection?

A
  • topical anaesthetic
  • taught tissue - quick, precise needle penetration
  • slow injection - 1ml/min - DRIZZLE!
  • 2 stage injection for upper anteriors
55
Q

why is the mandibular occlusal plane an important reference point regarding IDBs

A

due to the mandibular foramen (where IAN enters) being IN LINE with the occlusal plane - can try direct our needle in line with this to catch BEFORE the IAN which is an ideal aim for an IANB

56
Q

What are the 5 BOUNDARIES of the pterygomandibular space (lateral, medial, posterior, anterior, superior) - COULD BE AN EXAM QUESTION SO KNOW WELL

A

LATERAL - ramus of mandible - clinically important as it is the only one of the structures we can feel with the needle or touch
MEDIAL - medial pterygoid raphe - v uncomfortable if we gave pt injection here - tend to avoid this
POSTERIOR - Parotid gland and its capsule and within capsule we have facial nerve - clinically important as if we depos anaesthetic too far posterior within space and into capsule we can have an affect of facial nerve which includes the motor function. Cause drooping of the muscles on that side. Rare ish complication
ANTERIOR - buccinator - structure we put the needle through
SUPERIOR - lateral pterygoid muscle

57
Q

How do we do a long buccal nerve block (3)

A
  • comes across the coronoid notch
  • can use a short needle, however, this is usually done straight after an IDB/lingual block
  • raphe not an important landmark here
58
Q

What is the general rule of thumb for an effective MANDIBULAR infiltration?

A
  • If we infiltrate on lowers, splitting the dosage on either surface 50/50 we get a 90% success rate.
59
Q

What is the MAX dose of lidocaine

A

0.22ml to 1KG of bodyweight, so that means 2.2ml would do 10kg of bodyweight - 1 cartridge to 10kg of bodyweight!

60
Q

How much Lidocaine and Adrenaline is there in a standard 2.2 ML cartridge ?

A

So, for every 1ml of solution (liquid) in the cartridge, there is:
- 20 MILLIGRAMS of lidocaine hydrochloride
- 12.5 MICROGRAMS of epinepherene

SO, if we work this out in a 2.2ML cartridge we just multiply! :
- 2.2 times by 20 = 44mg of lidocaine hydrochloride in 2.2ml cartridge
- 12.5 times by 2.2 = 27.5 mcg epinepherene

ANATOMY/LA (2 decks)

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