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Y3 OMS > Local Anesthesia > Flashcards

Local Anesthesia Flashcards

1
Q

Definition of Local Anesthesia

A

Loss of sensation in a circumscribed area of the body caused by depression of excitation in nerve endings or an inhibition of the conduction process in peripheral nerves

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2
Q

Name the 4 purposes of LA

A

1) Decrease intraoperative and postoperative pain
2) Decrease amount of general anesthetics used in the operating theatre
3) Increase patients cooperation
4) Diagnostic testing/examination (to detect location of pain)

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3
Q

What are the 4 methods of administration of LA?

A

Topical, infiltration, regional nerve block, intra-ligamentary injection

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4
Q

Describe the path of the trigeminal nerve and its branches

A

V1: Opthalmic (enters superior orbital fissure)
- nasociliary
- frontal
- lacrimal

V2: Maxillary (enters pterygopalatine fossa via foramen rotundum)
- sensory
1) posterior superior alveolar nerve -> enters body of maxilla into maxillary sinus
2) middle superior alveolar nerve (via infra orbital canal) -> enters maxillary sinus
3) anterior superior alveolar nerve -> via anterior wall of max sinus
* superior dental plexus formed via PSA/MSA/ASA
4) infraorbital nerve

V3: Mandibular (enters infratemporal fossa via foramen ovale)
- mixed nerve
- main trunk: meningeal nerve, nerve to medial pterygoid muscle
- small anterior trunk: buccal nerve (sensory), muscles of mastication (lateral pterygoid nerve, ant. & post. deep temporal nerves & massesteric nerve) (motor)
- large posterior trunk: lingual nerve (sensory) -> joined by chorda tympani (branch of facial nerve), inferior alveolar nerve -> splits to mylohyoid nerve, mandibular canal branch and mental nerve, auriculotemporal nerve (enters mandibular canal)

Buccal nerve:
- Sensory nerve
- Skin, mucous membrane of cheek, buccinator muscle

Masseteric nerve:
- also supplies TMJ

Lingual nerve:
- gingiva of mandible
- floor of mouth
- anterior 2/3 of tongue

Mylohyoid nerve:
- molars, premolars and adjacent gingiva
- branch to mylohyoid muscle
- branch to ant. Belly of digastric

Mandibular canal branch:
- supplies lower teeth and gum

Mental nerve:
- skin and mucosa of lower lip
- skin of chin

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5
Q

Describe the nerve supply of the tongue

A

Anterior 2/3 sensory: lingual nerve
Posterior 1/3: glossopharyngeal nerve
Taste: chords tympani branch of facial nerve
Motor: hypoglossal nerve

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6
Q

Describe the shape and the structures around the pterygomandibular space

A
  • Triangular
  • medially: medial pterygoid
  • cranially: lateral pterygoid
  • laterally: mandibular ramus
  • posterior: parotid gland
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7
Q

Name the 7 factors of an ideal LA

A
  • Water soluble and readily undergoes bio transformation
  • non-irritating to nerve
  • non allergic (esters cause more allergic reactions)
  • low systemic toxicity
  • no post anesthetic side effects
  • short induction period
  • adequate duration of action
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8
Q

What’s the difference between esters and amides?

A

Method of metabolism

1) Amide
- majority of drug metabolised in liver
- liver disease (use lower dose)

2) Esters
- metabolised in plasma by pseudocholinesterase
- PABA is a major metabolite of ester metabolism (known allergen, DO NOT USE)
- Atypical pseudocholinesterase deficiency (cannot metabolise leading to toxicity, DO NOT USE)

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9
Q

Name 4 amides and 2 esters

A

Amides:
- articaine, bupivacaine, lidocaine, mepivacaine (Class C Pregnancy)

Esters:
- (of Benzoic acid): benzocaine (topical), tetracaine (topical)
- (of paraaminobenzoic acid): procaine

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10
Q

Describe the MOA of LA

A
  • Resting potential: High conc of Na+ outside nerve membrane and high conc of K+ inside
  • Nerve excitation causes increased permeability of nerve membranes to Na+ -> Na+ rush into axon and cause depolarisation
  • LA blocks Na channels by binding to specific sites on channel protein
  • Prevents formation of open channel inhibiting influx of Na+ ions into neuron -> reduce depolarisation in response to action potential -> prevent propagation of action potential
  • reversible
  • blocks generation and propagation of electrical impulses in excitable tissue
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11
Q

What is the DOA of different types of LA?

A
  • time from induction to completion of reversal process
  • short acting: 1-3h
  • intermediate: 2-4h
  • long acting: 4-9h
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12
Q

What are the maximum safe doses of LA in adults?

A

Amides:
Articaine: 500mg
Bupivacaine: 90mg
Lidocaine: 500mg, 300mg (plain)
Mepivacaine: 300mg

Esters:
Procaine: 500mg
Tetracaine: 100mg (topical)

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13
Q

How does LA enter the nerve?

A
  • Injectable LA are weak bases
  • LA is neutralise when injected into tissue and part of ionised form is converted to non-ionised
  • Non-ionised base diffuses into the nerve and forms the ionised form responsible for action
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14
Q

Is an acidic environment more or less effective for LA?

A
  • less effective
  • infected tissue = lower pH and more acidic
  • according to Henderson hasselbach (HH) equation, less of the non-ionised form of the drug crosses into nerve
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15
Q

What are the 3 factors affecting LA action?

A

1) Lower pKa of LA-> stronger acid -> more dissociation -> more rapid onset (more LA in non-ionised form to diffuse through)
2) Increased lipid solubility of LA-> increased potency
3) Decreased pH of tissues-> less effective

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16
Q

What are the 3 main purposes of vasoconstrictors?

A
  • prolong length of action and increase depth of action of LA
  • reduce toxicity of LA (delays absorption into the bloodstream)
  • haemostatic effect (slows down bleeding by decreasing blood flow in injected area)
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17
Q

Which is the most potent vasoconstrictor used in dentistry? Describe it.

A

Epinephrine
- natural cathecholamine produced by supra renal medulla
- concentrations of 1:50,000 to 1:200,000 in dental cartridges (1g in 50,000ml)

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18
Q

What is the maximum dose of vasoconstrictors in healthy patients/patients with significant cardiovascular history?

A

Healthy: 0.2mg
Cardiovascular history: 0.04mg (divide by 5 from healthy)

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19
Q

What is the maximum number of carpules that can be administered to healthy/cardiovascular history patients? (With ref to epinephrine)

A

Max cartridges: 0.04/0.022 = 1.8 carpules (cardiovascular)
Max cartridges: 0.2/0.022 = 9.1 carpules (healthy)

1 carpule = 2.2ml
Epinephrine - 1:100,000 = 0.00001g/ml = 0.01mg/ml
1 carpule contains: 0.01 x 2.2 = 0.022mg

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20
Q

What are the systemic effects of adrenaline?

A
  • Increases systolic and diastolic BP
  • Arrythmias
  • Fear
  • Sweating
  • Anxiety
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21
Q

What are the 5 contraindications to using vasoconstrictors?

A

1) unstable angina (chest pain due to reduced blood flow)
2) recent myocardial infarction
3) recent coronary artery bypass surgery
4) untreated or uncontrolled severe hypertension
5) untreated or uncontrolled congestive heart failure

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22
Q

What is the dose (mg) of LA in one single cartridge?

A

44mg (2% mepivacaine/lidocaine)
88mg (4% articaine)

1 cartridge = 2.2ml
2% LA = 2g/dL = 20g/L = 20mg/ml
1 cartridge = 20 x 2.2 = 44mg of LA

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23
Q

What is the max dose of LA per kg?

A

7mg/kg

LIDOCAINE (safe max dose 500mg)
500mg/44mg = 11.4 cartridges
500mg/7mg = 71kg (any weight above does not increase dosage)

MEPIVACAINE (safe max dose = 300mg)
300mg/44mg = 6.8 cartridges
300mg/7mg = 42kg (any weight above does not increase dosage)

Alternative Mepivacaine (safe max dose = 400mg)
400mg/44mg = 9.1 cartridge
Max dose 6.6mg/kg -> 60kg (400mg)

*Lidocaine = 2% but articaine = 4% (conc doubled = half the max dosage, assuming 2.2ml per cartridge)

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24
Q

Whats the units for 1:10,000 vs 1%

A

1:10,000 = 1g/10,000ml (g/ml)
1% = 1g/dL = 10mg/ml

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25
Q

Which is the max dosage you should follow? Epinephrine or LA (2%) ?

A

Epinephrine:
- 9.1 cartridges: healthy
- 1.8 cartridges: cardiovascular history patient

LA (lidocaine):
- dependent on weight
- 57kg: 9.1 cartridges (same as epinephrine dose)
- max safe dose 500mg (70kg) -> 11.1 cartridges
7mg x weight / 44mg = max number of cartridges

LA (mepivacaine):
- max safe dose 300mg -> 6.8 cartridges (equivalent to 42kg)

  • assume LA is 2%
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26
Q

Name the 5 parts of a syringe (top to bottom)

A
  • needle adapter
  • piston with harpoon (sharp)
  • syringe barrel (surrounding the piston and harpoon)
  • finger grip
  • thumb ring
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27
Q

What are the steps to injecting LA?

A
  • check flow of LA solution
  • position patient
  • dry tissue with gauze
  • apply topical anesthesia (see wrinkled area)
  • establish hand rest
  • make tissue taut
  • ensure bevel can be seen from position of needle
  • advance needle slowly while injecting solution
  • aspirate
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28
Q

What is the purpose of topical anesthesia?

A
  • provides a temporary numbing effect on nerve endings located on the surface of oral mucosa
  • supplied as ointments, liquids and sprays
  • must be in contact for sufficient duration
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29
Q

What is EMLA?

A
  • eutectic mixture of LA
  • cream formed from 2.5% lidocaine and 2.5% prilocaine
  • penetrates skin to 5mm within 1h
  • permits superficial procedures
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30
Q

How should you apply topical anesthesia?

A
  • dry mucous membranes first
  • 2-3 minutes for greater effect
  • most commonly 20% benzocaine (Ester)
31
Q

What is xylocaine? Describe its conc, onset, half life, metabolism, elimination, max dose w/wo vasoconstrictor

A
  • brand of lidocaine (amide)
  • 2% conc
  • onset of action is 2-4 mins
  • half life = 1.6 hours
  • metabolised through microsomal oxidation in the liver
  • elimination through kidneys
  • max dose 7mg/kg with VC max 500mg
  • max dose 4.4mg/kg w/o VC
32
Q

Describe mepivacaine (conc w/wo VC, half life, max dose/kg, max safe dose, onset)

A
  • 2% w VC, 3% without VC
  • half life = 1.9 hours
  • max dose = 6.6mg/kg (max 400mg) -> 60kg
  • onset = 1.5-2 mins
33
Q

Describe Bupivacaine (type, max dose/kg, max dose, metabolism, half life, risk)

A
  • marcaine: 0.5% bupivacaine with 1:200,000 epinephrine
  • max dose = 1.3mg/kg, total max = 90mg
  • metabolised in liver by amidases
  • half life = 2.7h (for lengthy dental procedures & post-op pain)
  • risk: most cardiotoxic -> must aspirate
34
Q

What is infiltration? When and where is it used?

A

Injecting the solution directly into tissue at the site of dental procedure
- more frequently to anesthesise maxillary teeth
- injected near apex of tooth (extraction) -> diffuse through bone to affect periapical nerves and nerves serving PDL, bone and soft tissues
- injected at interproximal papilla (root planing)
- used as secondary injection to block gingival tissues surrounding mandibular teeth

35
Q

What is block anesthesia?

A

Injecting near a major nerve bundle/trunk, with the entire area served by that nerve being numbed
- required for most mandibular teeth
E.g. posterior superior alveolar, inferior dental nerve block (include lingual nerve)

36
Q

Name the 6 types of maxillary injection techniques

A

1) Local infiltration

2) Nasopalatine nerve block
- upper incisors and canines mucosa palatally

3) Greater palatine nerve block
- upper premolars and molars mucosa palatally
- in 1 quadrant

4) Anterior Superior Alveolar nerve block
- upper anteriors and mucosa above the teeth

5) Middle Superior Alveolar nerve block
- upper premolars and buccal tissues

6) Posterior superior alveolar nerve block
- upper molar teeth and buccal tissues
- in 1 quadrant

37
Q

What are the considerations for infiltration for incisors and canines?

A
  • thin and porous maxillary cortical bone -> infiltration spreads easily
  • ASA runs from high lateral to low medial (apply infiltration laterally just above apex)
38
Q

Which dental procedures use LA? And where?

A

1) Cavity preps/endodontic treatment
- buccal infiltration

2) wedges/ crown preps
- buccal & palatine infiltration

3) surgical procedures
- buccal and palatal regional anesthesia/ field block

39
Q

Describe the infiltration technique for buccal and palatal

A

Buccal anteriors:
- parallel to long axis of tooth
- needle inserted 3-5mm
- avoid contact with periosteum or bone
- pierce mucosa of buccal fold above apex of tooth
- 1ml

Palatal:
- tangentially
- 0.25ml

40
Q

What does the PSA nerve block? Where’s the insertion?

A
  • pulpal anesthesia for 1st, 2nd, 3rd molars
  • required for procedures involving 2 or more molars
  • sometimes anesthesia of 1st molar require block of MSA nerve
  • associated buccal periodontium over molars
  • harmless tingling or numbness
  • insertion 45 degrees to occlusal plane and 45 degrees to long axis of 2nd molar
  • height of muco buccal fold above maxillary 2nd molar
  • bevel towards bone
  • 16mm penetration: aspirate
41
Q

Where do you administer a MSA block?

A

MSA nerve at apex of maxillary 2nd premolar

42
Q

Where do you administer the ASA block?

A

Apex of the maxillary canine

43
Q

Describe the ASA block

A
  • considered local infiltration
  • ASA nerve can cross the midline onto the opposite side
  • used in procedures involving anterior teeth and their facial tissues
  • blocks pulp tissue + gingiva, PDL and alveolar bone
  • OD and perio
44
Q

Describe the Infraorbital nerve block (where it numbs, where to inject)

A
  • Anesthesises both MSA and ASA
  • used for anterior teeth and premolars (indicated when more than one premolar or anterior teeth to be treated)
  • numbs gingiva, PDL and alveolar bone
  • numbs lower eyelid, side of nose and upper lip

Where to inject:
- apex of 1st premolar (mucobuccal fold)
- palpate for the IO foramen along the IO rim (move slightly down 10mm to feel the depression)

45
Q

Describe the greater palatine block (uses, where it numbs, area of injection)

A
  • used in procedures involving more than 2 maxillary posterior teeth or palatial tissues distal to canine
  • anesthesises posterior portion of hard palate from 1st premolar to molars and medically to the palate midline
  • DOES NOT provide pulpal anesthesia
  • targets greater palatine nerve at the junction of maxillary alveolar process and hard palate at 2nd or 3rd molar
  • midway between median palatine suture and lingual gingival margin of molar
  • inserted 90 degrees to palate
46
Q

Describe the nasopalatine nerve (use, where is numbs, injection area)

A
  • used for anesthesia of bilateral portion of hard palate from mesial of max right 1st premolar to the left mesial 1st premolar
  • for palatal soft tissue anesthesia
  • targets both left and right nerves as they enter incisive foramen
  • injection site lateral to incisive papilla, 45 degrees about 6-10mm gently contact maxillary bone and withdraw 1mm before administering
  • most painful
47
Q

List the 6 LA technqiues given to the mandible

A

1) Local infiltration
2) Inferior alveolar nerve block
3) Lingual nerve block
4) Long buccal nerve block
5) Mental nerve block
6) Mandibular nerve block

48
Q

What other LAs is inferior alveolar nerve block complemented by?

A

Buccal nerve block for soft tissue anesthesia in the buccal posterior region

OR also

Infiltration for lower incisors due to cross inner action from opposite site

49
Q

Which area does IAN anesthesise?

A
  • Mandibular teeth until midline
  • Body of mandible
  • Buccal mucoperiosteum anterior to mental foramen
  • lingual nerve: anterior 2/3 of tongue, floor of mouth, lingual soft tissues and periosteum
50
Q

List the advantage and 5 disadvantages of IAN block

A

Advantage: single injection for adequate anesthesia

Disadvantage:
- wide area not necessary for local procedures
- high rate of failure
- inconsistent landmarks
- high rate of positive aspiration (10-15%)
- discomforting soft tissue anesthesia (lip and tongue)

51
Q

Describe the technique of giving IAN block (area of injection, how to locate site of injection, method of injection)

A
  • Insert into mucous membrane on medial side of ramus
  • Target IAN before it enters Mandibular foramen

Height:
- locate coronoid notch (bone lingual to teeth)
- pull laterally to taut skin
- place finger over occlusal surface of lower teeth
- visualise pterygomandibular raphe

Antero-posterior position:
- penetration 3/4th distance from coronoid notch to deepest part of raphe
- triangle formed between raphe and finger over coronoid notch

Method of injection:
- advance needle till bone is contacted then retract 1mm
- aspirate
- 20-25mm penetration
- if bone contacted early (before 3/4 needle) -> tip is too anterior -> withdraw needle and turn barrel laterally towards premolars
- if no bone contact -> needle is too posterior -> risk of injecting into parotid gland

52
Q

Signs and symptoms of IAN block (subjective and objective)

A

Subjective:
- tingling or numbness of lower lip and anterior 2/3 of tongue

Objective:
- instrumentation to demonstrate absence of pain sensation

53
Q

List the 6 possible complications of IAN block

A

1) Hematoma
2) Trismus
3) Facial paralysis
4) Paraesthesia
5) Needle breakage
6) Patient-inflicted trauma (e.g. lip biting)

54
Q

What are the possible wrong structures anesthesised due to wrong positioning of needle?

A

Too medial: medial pterygoid muscle
Too posterior: facial nerve (parotid gland), external carotid artery

55
Q

Describe the buccal nerve block (which branch, where it supplies, area of injection)

A
  • branch of anterior division of V3
  • innervates buccal soft tissues adjacent to mandibular molars
  • buccal nerve readily located on surface of tissue and not within bone
  • very high success rate
  • Inject into mucous membrane disto-buccal to most distal tooth in the arch
  • Landmark: mucobuccal fold, mandibular molars
  • 0.2-0.3ml
56
Q

Describe Mental Nerve block (which nerve branch, where it innervates)

A
  • Terminal branch of IAN
  • Exits mental foramen near apices of mandibular premolars
  • Supplies buccal soft tissue anterior to foramen and soft tissues of lower lip and chin
57
Q

Describe mental nerve block (site of injection, technique)

A
  • mucobuccal fold between 1st and 2nd premolar
  • use a short needle and inject 1/3 to 1/2 cartridge
  • retract lip and buccal tissues laterally
  • penetrate till mental foramen is reached
58
Q

Describe the Gow-Gates Technique - most of mandibular nerve (area of injection and injection technique)

A
  • aim for neck of the condyle, mesio palatal cusp of maxillary second molar
  • direct long needle from corner of mouth of opposite site
  • advance till bone is contacted
59
Q

Which areas are anesthesised from Gow-Gates technique?

A
  • Blocks IAN, mental, incisive, mylohoid, auriculotemporal and buccal nerves
  • Blocks buccal and lingual soft tissue from most distal molar to midline + anterior 2/3 tongue and floor of mouth
  • Blocks mandibular teeth to midline
  • Blocks body of mandible, inferior portion of ramus
  • Skin over zygoma, posterior portion of cheek and temporal regions
  • ## less incidence of positive aspiration
60
Q

What is akinosi technique?

A
  • closed mouth technique
  • does not rely on a hard-tissue landmark
  • parallel to occlusal plane, height of mucogingival junction
  • advanced until hub is level with distal surface of maxillary second molar
  • delayed onset of anesthesia
  • mandibular quadrant anesthesia
  • less pain but slower onset
61
Q

Describe the steps to take if anesthesia fails

A

1) Topical anesthesia
2) Re-test pain using patient’s chief complaint
3) Inject again (higher/more LA/ nerve to mylohyoid)
4) Consider PDL/intraosseous anesthesia
5) Consider intrapulpal anesthesia
6) It hurts…

62
Q

What are some precautions to take note of for LA?

A

1) wait 3-5 mins post LA for dental procedures
2) failure of LA requires re-administration using another method
3) never re-administer using the same method
4) keep in mind the total number of injections and dosages
5) nerve inject into an area with an abscess or other types of abnormality

63
Q

List 5 types of adjunctive strategies

A

1) Additional anesthetic
- higher injection, gow gates, akinosi, nerve to mylohyoid
2) PDL injection
3) Intraosseous injection
4) Intrapulpal injection
5) Different anesthetic

64
Q

Describe how to anesthesise the nerve to mylohyoid

A
  • Deposit 1/4 cartridge of LA on lingual surface of tooth in alveolar mucosa
  • Goal is to bathe the nerve as branches of it enter lingual surface of mandible
65
Q

Describe the PDL injection technique

A
  • needle inserted into gingival sulcus at 30 degrees angle towards the tooth
  • bevel placed towards bone
  • advanced until resistance felt
  • anesthetic injected with continuous force for 15 seconds
  • 0.2ml of solution
66
Q

Describe the intraosseous injection technique (purpose, types)

A
  • technique for mandibular infiltration
  • perforate cortical plate to introduce LA in medullary bone
  • stabident or x-tip
67
Q

What other anesthetic should you use if LA fails?

A

Articaine
- Reputation for improved local anesthetic effect -> short linear molecule
- Amide local, contains thiophene ring instead of benzene ring
- Partial hydrolysis by plasma esterases
- 4% solution (concern with toxicity)
- potential methemoglobinemia
- NO evidence found it to be more effective

68
Q

What are the common reasons for mandibular anesthesia failure?

A

1) Operator inexperience
2) Deflection of needle tip (armamentarium)
3) Patient factors
- variations in anatomy
- accessory innervation
- unpredictable spread of LA
- Local infection
- pulpal inflammation
- psychological issues

69
Q

What are the systemic effects of LA?

A

1) CVS (happens later)
- reduces excitability & force of contraction of heart muscles
- vasodilation of arterioles

2) CNS (happens first)
- restlessness, tremor
- respiratory depression esp with increased dose

70
Q

List the complications of LA

A

1) Fainting (fearful)
- minimised by giving LA with patient lying down
2) Interaction (uncommon)
3) Cross infection
- minimised by using disposable needle
4) allergy (uncommon)
5) cardiovascular collapse
- stress related
- arrhythmia or fibrillation of heart, previously diseased
6) failure to achieve LA
- often due to ‘hot pulp’ or acute apical abscess
7) haematoma
- aspiration during block injection
8) trismus
- haematoma in medial pterygoid muscle
- too fast and too low IAN block
9) facial paralysis
- complication of IAN block (1h)
10) needle fracture
- should not be bent

71
Q

Describe allergy to LA

A
  • Ester LA may produce allergic reactions typically manifested as skin rashes or bronchospasm
  • May be as severe as anaphylaxis
  • Due to metabolism to p-aminobenzoic acid (PABA)
72
Q

Describe the symptoms of CNS toxicity

A
  • tinnitus
  • lightheadedness, dizziness
  • numbness of mouth and tongue, metal taste in mouth
  • muscle twitching
  • irrational behaviour and speech
  • generalised seizures
  • coma
73
Q

Describe the symptoms of CVS toxicity

A
  • depressed myocardial contractility
  • systemic vasodilation
  • hypotension
  • arrhythmias, ventricular fibrillation

Y3 OMS (14 decks)

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