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Oral Medicine > Local + Nitrous SG > Flashcards

Local + Nitrous SG Flashcards

1
Q

three parts of local anesthesia

A
  1. aromatic group
  2. intermediate linkage
  3. amine group
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2
Q

aromatic group

A

confers lipophilic properties

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3
Q

intermediate linkage

A

supplies spacial separation between lipophilic and hydrophilic ends and connects them with either an ester or amide linkage

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4
Q

amide group

A

secondary or tertiary

affects pka, lipid vs water solubility, and influences speed of onset

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5
Q

ester

A

union of a carboxylic acid and alcohol

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6
Q

amide

A

union of a carboxylic acid and an amine (peptide bone is an amide)

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7
Q

except for ______, the injectable dental locals are ______

A

procaine
amides

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8
Q

the topicals are mostly _______ (esters or amides)

A

esters

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9
Q

list the amides

A

lidocaine (xylocaine)
mepivicaine (carbocaine)
articaine (septocaine)
buprivacaine (marcaine)
etidocaine (duranest)
prilocaine (citanest)

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10
Q

list the esters of benzoic acid

A

butacaine
cocaine
benzocaine
hexlycaine
piperocaine
tetracaine (pontocaine)

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11
Q

list the esters of para aminobenzoic acid

A

chloroprocaine
procaine (novocaine)
proxycaine

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12
Q

what is the only injectable ester?

A

procaine (novocaine)

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13
Q

another name for lidocaine

A

xylocaine

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14
Q

another name for mepivicaine

A

carbocaine

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15
Q

another name for articaine

A

septocaine

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16
Q

another name for buprivacaine

A

marcaine

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17
Q

another name for etidocaine

A

duranest

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18
Q

another name for prilocaine

A

citanest

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19
Q

another name for tetracaine

A

pontocaine

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20
Q

another name for procaine

A

novocaine

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21
Q

the amine portion is a _____ (acid / base)

A

base

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22
Q

only _____ can cross cell membranes, so onset of action is faster for ____ (low / high) pKa because they give up their protons more easily and become uncharged “free bases”

A

free bases
low

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23
Q

pKa

A

how strongly the organic portion of the local anesthetic molecule holds onto its proton

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24
Q

drugs with a high pKa are _____(weak / strong) acids.

A

weaker acids (stronger. bases)

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25
Q

Do weak acids hold on to their protons tightly? what does this mean for onset?

A

weak acids / strong bases hold their proton more tightly, remaining positively charged, and cross cell membranes poorly

thus they have a slower onset

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26
Q

drugs with low pKa are _______ (weak / strong) acids

A

strong acids (weak bases)

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27
Q

do strong acids hold on to their protons tightly? what does this mean for onset?

A

strong acids / weak bases shed their proton more easily, become non-ionized free bases and cross membranes more easily

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28
Q

acidic environments like inflamed tissue have ____ (slow / fast) onset

A

slow onset

since the base remains protonated in the low pH environment

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29
Q

locals ______ membranes and prevent ________

A

stabilize
rapid sodium influx

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30
Q

why are the pharmacokinetics of locals unique?

A

they become ineffective when absorbed by the system

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31
Q

what happens when locals are redistributed?

A

effects wear off

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32
Q

metabolic half life is not related to ______ but is related to _____

A

duration of anesthesia
toxicity

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33
Q

half life

A

the rate at which a local anesthetic drug is removed from the blood

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34
Q

does half life impact toxicity?

A

yes

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35
Q

can local anesthetic agents cross the BBB?

A

yes

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36
Q

can local anesthetics cross the placenta?

A

yes (and get into breast milk)

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37
Q

why does metabolism affect overall toxicity?

A

because it is the balance between rates of absorption at the injection site and the removal from the blood that determines the levels in the tissues

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38
Q

duration of action is related to ______ of the local

A

protein bonding

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39
Q

is duration of action related to metabolic transformation?

A

no

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40
Q

all locals are (vasodilators / vasoconstrictors)

A

vasodilators

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41
Q

which local is a vasoconstrictor?

A

cocaine

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42
Q

Why are vasoconstrictors added to most LAs?

A

because LAs are vasodilators, blood washes them away. need something to balance this so they stay in desired area longer

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43
Q

with vasodilation, there is (2 things)

A
  1. an increased rate of absorption
  2. decreased duration and level of pain control
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44
Q

an increase in the anesthetic in the blood will lead to _______

A

overdose

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45
Q

vasoconstrictors are needed for _________

A

slow redistribution

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46
Q

why use vasoconstrictors?

A

because local anesthetics possess vasodilation properties

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47
Q

what are vasoconstrictors?

A

drugs that constrict blood vessels and there by control tissue perfusion

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48
Q

which vasoconstrictor is used most often?

A

epinephrine

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49
Q

epinephrine effects

A

alpha
beta 1
beta 2

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50
Q

small amounts of urine are excreted in ______

A

urine unchanged

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51
Q

soft tissue anesthesia

A

always develops before pulpal
5 hours

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52
Q

pulpal anesthesia

A

relatively short window
60 minutes

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53
Q

does nerve block or infiltraiton last longer?

A

nerve block

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54
Q

primary metbaolism of esters

A

plasma hydrolysis by the enzyme pseudocholinesterase

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55
Q

cocaine is metabolized primarily in

A

liver

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56
Q

amides are metabolized in

A

liver

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57
Q

the status of liver function is a factor in

A

toxiity

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58
Q

relative contraindications in terms of metabolism of amides

A
  1. liver failure
  2. heart failure resulting in lower liver perfusion
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59
Q

articaine (septocaine) is metbaolized primarily by

A

plasma carboxyesterase

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60
Q

accumulation of biotransformation product _______ in the blood can produce _____

A

orthotoluidine
methemoglobin

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61
Q

what two LAs produce methemoglobin?

A

prilocaine
articaine

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62
Q

methemoglobin is produce in hemoglobin in which the iron ion has been oxidized to the _____ instead of ____ state

A

ferric (fe+3)
ferrous (fe+2)

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63
Q

if a significant percent of the total hemoglobin is affected, it can result in _____

A

poor oxygen delivery to tissues

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64
Q

methemoglobin can be reversed rapidly with ____-

A

IV methylene blue

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65
Q

why is pulse oximetry unreliable with methemoglobin?

A

methemoglobin has absorption frequency that draws the pulse oximeter to 85%

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66
Q

excretion of local anesthetics

A

kidney for local anesthetic agents and metabolites

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67
Q

when do local anesthetics lose their effect?

A

when absorbed into the blood stream

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68
Q

the rate at which a local is removed from the plasma is expressed as its…

A

metbaolic half life

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69
Q

duration of local anesthetics from shortest to longest

A

carboxaine
xylocaine
septocaine
marcaine

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70
Q

which anesthetic is not recommended in pedo or in cognitively impaired adults?

A

marcaine

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71
Q

max dose for lidocaine with epinephrine

A

4.4

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72
Q

max dose for mepivicaine

A

4.4

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73
Q

max dose for bupivicaine

A

1.3

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74
Q

max dose for septocaine

A

7

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75
Q

epinephrine’s effects on the myocardium

A
  1. increased cardiac output
  2. increased stroke volume
  3. increased oxygen consumption
  4. decrease overally efficiency of the myocardium
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76
Q

when does LA become toxic?

A

when the tissue levels int he CNS or heart become too high

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77
Q

maximum recommended doses of drugs should be calculated by…

A

body weight (and not exceded)

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78
Q

why could manifestations of toxicity occur well after the appointment is over?

A

LA tissue levels in the CNS or heart may rise slowly as the drug is absorbed over time

79
Q

mild symptoms of LA toxicity

A

sedation
drowsiness
transient anxiety

80
Q

moderate / severe symptoms of LA toxicity

A

dysphoria
anxiety
nausea
confusion
semiconscious / unconscious
tonic-clonic seizures

81
Q

severe symptoms of LA toxicity

A

respiratory and cardiovascular collapse

82
Q

signs of excessive vasoconstrictor dose

A

CNS: increased fear and anxiety, tension, restlessness, throbbing headache, tremors, weakness, dizziness, pallor, respiratory difficulty, palpations

increased blood levels: cardiac arrhythmias, ventricular fibrillation, increased BP, angina, cerebral hemorrhage

83
Q

local complications of injections

A

-pain on injection or burning on injection
-needle breakage
-persistent anesthesia or paresthesia
-trismus, hematoma, infection, edema
-sloughing of tissues
-facial nerve paralysis
-post-anesthetic intraoral lesions

84
Q

systemic complications of injections

A

-no drug ever exerts a single action
-no clinically useful drug is entirely devoid of toxicity
-toxicity caused by direct extension of the usual pharmacological effect of the drug (ex. side effect)
-toxicity caused by alteration in the recipient (ex. emotional disturbances)

85
Q

3 topical anesthetics you should know

A

benzocaine
lidocaine
cocaine

86
Q

benzocaine

A

ester type local anesthetic
poor absorption
localized allergic reactions reported
inhibits antibactieral actions fo sulfonamides

87
Q

lidocaine

A

poorly soluble in water

primarily used to paliate painful oral ulcerations, HSV, mucositis form chemo / radiation therapy

88
Q

cocaine (as topical)

A

-rapid onset of topical
-duraiton up to two hours
-metbaolism in liver, excreiton in urine
-produces vasoconstriction
-exellent agent for nasal trauma / surgery

89
Q

3 divisions of the trigmeinal nerve

A

v1 - opthalmic
v2 - maxillary
v3 - mandibular

90
Q

pulpal anesthesia can usually be achieved with ____ in the maxilla

A

infiltration

91
Q

why can anesthesia be achieved with infiltration in the maxilla?

A

cortical plate is not very dense; bone is highly vascular

92
Q

pulpal anesthesia for all lower teeth occurs where?

A

on the side injected

93
Q

why does infiltration not work in the mandible?

A

cortical bone too dense for infiltration

94
Q

landmark for common infiltration

A

mucobuccal fold (vestibular sulcus) at / above apex of root

95
Q

how much LA should be used per tooth?

A

1/3 carpule per tooth

96
Q

landmarks for PSA nerve block

A
  1. zygomatic buttress (injection point is posterior to it)
  2. depth of vestibule
  3. tuberosity of maxilla
97
Q

direction of PSA nerve block

A

posterior, medial, and superior

98
Q

ASA nerve block landmarks

A
  1. medial aspect of the pupil
  2. infraorbital notch
  3. depth of the mucobuccal fold
  4. 5mm lateral to long axis of 1st PM
99
Q

greater palatine nerve block landmarks

A
  1. midline of palate
  2. 2nd maxillary molar
  3. greater palatine foramen at junction of maxillary alveolar process and palatine bone
100
Q

incisive canal nerve block landmarks

A
  1. incisive papilla
101
Q

second division block landmarks

A
  1. zygomatic buttress
  2. depth of vestibule
  3. tuberosity of maxilla
102
Q

direction of second division block landmarks

A

direction is posterior, medial, and superior

103
Q

second division block is ____ and ____ than a PSA (requires a ______)

A

higher
deeper
long needle

104
Q

inferior alveolar. nerve block landmarks

A
  1. depth of the coronoid notch
  2. pterygomandibular rapphe
  3. contra lateral premolars
  4. bisection of thumbnail lying in coronoid notch (or higher)
  5. occlusal plane
  6. contact bone with needle almost fully in tissue
105
Q

long buccal nerve block landmarks

A
  1. anterior, lateral border of the ramus
  2. superficial
106
Q

location of anesthesia for posterior superior alveolar nerve block (PSA)

A

pulpal and lateral gingival anesthesia to (but not including) the mesiobuccal cusp of the first molar

no palatal anesthesia

107
Q

anterior alveolar nerve block (ASA / infra orbital nerve block)

A

not frequenlty used, but useful when infiltration not practical due to localized infection

108
Q

location of anesthsia for greater palatine nerve block

A

posteiror hard palate and soft palate to midline

109
Q

location of anesthesia for incisive canal block

A

anterior hard palate (pre-maxilla) which includes the four maxillary incisors

usually requires greater palatine block as well

110
Q

location of anesthesia for second division block

A

all upper teeth and buccal / palatal mucosa on injected side (and lateral alar rim)

good injection when area of infiltraiton is involved in infection

111
Q

location of anesthesia for inferior alveolar nerve block

A

pulpal anesthesia for all lower teeth on side injected

does not provide lingual anesthesia, although the lingual nerve is usually anesthetized at same time

does not anesthetize posterior lateral gingival tissue (long buccal)

112
Q

location of anesthesia for long buccal nerve

A

lateral gingival anesthesia in posterior mandible

extraction, surgery, rubber dam clamp

113
Q

gow gates will anesthetize _____-

A

entire 3rd division of CN V

114
Q

success rate of gow gates

A

95% with experience (Compared to 80% for traditional IANB)

115
Q

gow gates landmarks

A
  1. lower border of tragus
  2. corner of mouth
  3. needle tip jsut below ML cusp maxillary seocnd molar
  4. penetration soft tissue just distal to maxillary second molar
  5. contact with neck of condyle must be made
116
Q

in tracheal mucosa, uptake of topical anesthetics is _____

A

almost as rapid as with IV administration

117
Q

length of time for application for topical anesthetics in mucosal sites

A

2-3 minutes

118
Q

penetration of topical anesthetics in mucsal sites

A

2-3mm

119
Q

types of tissue that topical anesthetics can penetrate

A

mucosa or damaged skin only

120
Q

are deep tissues anesthetized by topicals?

A

no

121
Q

two types of bases for topical anesthetics

A
  1. alcohol propylene glycol
  2. polyethylene bases
122
Q

3 types of topicals

A
  1. benzocaine
  2. lidocaine (xylocaine)
  3. cocaine
123
Q

benzocaine is a _____ type local

A

ester

124
Q

absorption of benzocaine?

A

poor

125
Q

localized ______ have been reported with benzocaine as local

A

allergic reactions

126
Q

benzocaine inhibits ______ action of _______

A

antibacterial
sulfanamides

127
Q

lidocaine is used as a ____% concentraiton in locals

A

5

128
Q

is lidocaine soluble in water?

A

no

129
Q

what type of lidocaine solution penetrates tissues better than the base form

A

when acidified, lidocaine hydrochloride water soluble 2% concentraiton

130
Q

what is lidocaine topical primarily used for?

A

paliate painful oral ulcerations

HSV, mucositis from chemo therapy

131
Q

lidocaine topical is a _____ type anesthetics

A

amide

132
Q

maximum dose of lidocaine

A

4.4 mg / kg

133
Q

pKa of lidocaine

A

7.9

134
Q

onset of action for lidocaine topical

A

2-3 minutes

135
Q

duration of cocaine topical

A

2 hours

136
Q

cocaine is metabolized in the

A

liver

137
Q

cocaine is excreted in the

A

urine

138
Q

Is nitrous metabolized by the body?

A

no

139
Q

Does nitrous have any adverse effects on liver, brain, kidney, respiratory system?

A

no

140
Q

rapidly is nitrous absorbed into respiratory circulation?

A

1000 ml may be absorbed per minute

141
Q

nitrous replaces the _____ in the blood

A

nitrogen

142
Q

how does nitrous impact body cavities?

A

may increase volume in body cavities (such as bowel, pleural space, middle ear)

143
Q

how is primary saturation of the blood and brain accomplished? (nitrous)

A

displacement of nitrogen

144
Q

how long does it take for equilibration for nitrous to occur at any concentraiton?

A

3-5 minutes

145
Q

how long should the patient remain at given concentration to assess effect of dose?

A

3-5 minutes

146
Q

what tissues will reach concentration faster?

A

tissues with greater perfusion (brain, heart, liver, kidney)

147
Q

pressure in cylinders of nitrous

A

745 psig (pounds per square inch guage)

148
Q

connection and office setup for nitrous

A

DISS (diameter index safety system) scavenger system

149
Q

percentage of nitrous / oxygen at various flows

A

4:2 (67% nitrous oxide)

150
Q

overview of diffusion hypoxia

A
  1. patient switches from N2O / O2 to room air
  2. N2O rapidly leaving the circulation dilutes the other gases in the lungs
  3. there is a fall in O2 concentraiton in alveoli resulting in hypoxia
151
Q

what is the alveolar O2 concentration during diffusion hypoxia?

A

10% alveolar O2 concentraiton

152
Q

symptoms of diffusion hypoxia

A

headache
nausea
lethargy

153
Q

prevention of diffusion hypoxia

A

100% oxygen at end of case for 5 minutes

this also ensures that the N2O in the patient’s system is scavenged and not exhaled into the room

154
Q

physical properties of nitrous

A

nonirritating
sweet smelling
colorless gas
nonflammatbale
non-explosive
least potent of anesthetic gases

155
Q

is nitrous stable under pressure at room temperature?

A

yes

156
Q

how would nitrous support combustion in a fire?

A

at temperature >450 deg C forms nitrous and oxygen

delivered with oxygen

157
Q

N2O analgesic effect at therapeutic levels

A

10-15mg of morphine

158
Q

gas source of nitrous

A

oxygen and nitrous oxide are delivered either from portable tankes attached to anesthesia machine or thorugh central machine

159
Q

color code of oxygen and nitrous oxide

A

oxygen is green

nitrous oxide is light blue

160
Q

set up of nitrous

A

central system installation must be done by a dental supplier and plumber qualified as competent in the installation process (medical gas certified)

161
Q

what organization is dedicated to educating users about proper installation?

A

PIPE (piping, industry, progress, and education)

162
Q

how many tanks of each gas are connected in portable tank systems?

A

two (four tanks total)

one in use, other is backup

163
Q

when in the in-use tank is empty…

A

opening the valve on the back-up maintains gas flow

164
Q

if both tank valves are accidentally opened…

A

the machine will run off both simultaneously, and when empty there is no backup

165
Q

parameters of control of nitrous

A
  1. total flow of gases, measured in livters per minute
  2. the mix (percent of O2 and N2O)
    the scavenger)
166
Q

when scavenging rate is too slow…

A

may allow expired N2O to enter the room
(ball falls below the green zone)

167
Q

when scavenging rate is too fast…

A

wastes agent… as faster gas flows will be needed to keep up with scavenger
(ball rises above the green zone)

168
Q

fixed percentage (definition)

A

all patients receive the same concentration

169
Q

ratio for fixed percentage

A

usually 40-50% throughout the procedure

170
Q

fixed percentage is ineffective in ____ of cases

A

15%

171
Q

how do patients often feel during fixed percentage?

A

uncomfortable
dislike procedure (probably over-sedated)

172
Q

overview of titration technique

A
  1. patient / dose specific
  2. higher success rate
  3. less nausea, vomiting, headache, and adverse behavior
173
Q

if the total gas flow is less than the patient’s minute volume…

A

the patient will obtain the rest of their volume through the small relief valve in the max, diluting the mix with room air

this is not harmful, but patient is not breathing concentration of N2O that you think they are

174
Q

if total gas flow is above the patient’s minute volume…

A

they are breathing the correct. mix (but you are wasting agents)

175
Q

steps for titration technique

A
  1. begin and end with 100% oxygen
  2. 4-6 L starting flow rate is adequate
  3. 20% nitrous oxide is a good starting point with 10% increase every 60-120 seconds
  4. when the procedure is completed, 100% oxygen is administered for 5 minutes
176
Q

flow rate for titration

A

4-6 liters

177
Q

good starting point for titration

A

20% nitrous oxide with 10% increases ever 60-120 seconds

178
Q

signs of anesthesia by nitrous

A
  1. first clinical sign is lightheadedness
  2. dizziness is usually transient and should disappear quickly
  3. tingling in the extremities with paresthesia in the face and oral cavity
  4. feelings of warmth, floating, or heaviness
  5. altered perceptions of sound, vision dims
179
Q

signs of over sedation with nitrous

A
  1. nausia
  2. sleepiness; failure to respond to verbal commands; uncooperative patient; incoherent speech
  3. laughing and giddiness
  4. mouth breathing / closing
180
Q

indications of using nitrous

A
  1. primarily to manage fear and anxiety
  2. optimize care for medically compromised patients
  3. management of gagging
181
Q

nasal mask may increase the _______ phenomenon

A

claustrophobia

182
Q

cardiovascular disease + nitrous

A

-nitrous has analgesic properties diminishing pain, sedative properties aiding relaxation, reducing the the workload of the myocardium (providing increased blood O2 levels)

titrate carefully to avoid inadvertent overdose
consider heart rate

183
Q

what is most important to remember with cardiovascular patients and nitrous?

A

these patients do not tolerate low oxygen levels in the blood

184
Q

respiratory disease and nitrous

A

N2O is a non-irritating vapor that doesn’t precipitate bronchospasm or asthmatic attachs

concerns with COPD / hypoxic drive (blue bloaters). respiratory drive needs to be monitored

N2O may expand an emphysematous bleb

185
Q

nitrous and hepatic disease

A

N2O doesn’t undergo biotransformation anywhere in the body

186
Q

nitrous and epilepsy / seizure

A

condition may be exacerbated with anxiety, fear, pain, and low O2 levels

nitrous oxide may elevate seizure threshold (favorable)

187
Q

nitrous use in pregnancy

A

N2O adverse effects only for chornic exposure; no harm for controlled, managed usage

-medical consulatation is advised
-maintain good oxygenation
-does not cross placenta / BBB
-found in same concentration in unborn as mother
-some recommend avoiding in first trimester

188
Q

contraindications of nitrous - closed gas spaces

A

~can expand a closed gas space~

  1. when gas has. been injected intraocular for treatment of retinal detachment
  2. thoracic trauma with possibility of peumothorax
  3. surgical procedures associated with risk fo air emboli
  4. open abdominal procedures / bowel obstruction
  5. scuba in previous 24 hours
189
Q

other contraindications of nitrous use

A
  1. COPD
  2. claustrophobic patients
  3. children with severe behaviorla probelms
  4. patients with personality disorders
  5. patients with compulsive personality
  6. upper respiratory infection
  7. pregnancy and spontaneous abortion
190
Q

advantages of nitrous oxide in dental practice

A
  1. titration possible
  2. onset of action is more rapid than oral, rectal, or IM routes
  3. depth of sedation may be altered from moment to moment
  4. more forgiving than IV (can decrease if desired)
  5. duration of sedation is variable at the discretion. of the administrator
  6. rapid recovery time
  7. no adverse effects on liver, kidney, brain, CV system, or respiratory system
  8. not metabolized - recovery time not dependent on liver or kidney
  9. no injection required
  10. use is safe and very few side effects
191
Q

disadvantages of nitrous oxide in dental practice

A
  1. not potent agent
  2. in some cases, will fail to produce the desired affect at fail safe levels of no less than 30% O2 concentrations
  3. failure is linked primarily to lack of potency
  4. degree of cooperation required from patient
  5. costs (equipment, installation, maintenance, continued rental of tanes)
  6. mandatory training in most states
  7. chronic exposure of trace amounts may be deleterious to health of personnel
  8. essential that proper scavenging of waste gas to outside occurs
192
Q

which methods of conscious sedation can be titrated to patient’s needs and are controlled by the dentist?

A

inhalation and IV

193
Q

range of safety FBS casual random BG

A

start procedure with FBS of <70 mg / dL for 3 hour appointment

MU OS > 90%, <300

194
Q

range of safety for INR

A

2.0-3.5 greater than 3.5 manage warfarin

Oral Medicine (2 decks)

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