Midterm Ch. 1-5 Flashcards
Identify providers of dental local anesthesia in North America.
In most states and provinces, dentists and dental hygienists provide dental local anesthesia. In some, mid-level and/or expanded function providers are also allowed to administer dental local anesthesia.
Identify the fundamentals of pain management
The fundamentals of pain management include conducting comprehensive assessment, recognizing and responding to patient factors, integrating evidence-based knowledge, and understanding relevant drugs and their effects, indications, and contraindications. Fundamentals also include developing clinical decision-making skills and mastering a wide variety of techniques and appropriate modifications.
Define the term troubleshooting as it relates to the administration of local anesthesia.
Troubleshooting is the ability to critically assess and resolve anesthesia inadequacies in order to provide comfortable patient care.
How does the International Association for the Study of Pain define pain?
The International Association for the Study of Pain defines pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.”
Identify variables that contribute to an individual’s experience of pain.
Pain is influenced by many variables that contribute to an individual’s experience of pain. The sex of an individual provides genetic and hormonal influence. Gender also adds numerous complex components that include an array of socially constructed roles and relationships, personality traits, attitudes, behaviors, values, relative power, and influence that society ascribes based on a differential basis. Other factors, such as age, physical health, mental health, emotional status, expectations, previous experiences, learned responses, and ethnic and cultural norms also impact the pain experience.
Discuss pain as a protective response.
As a physiological response to our environment, pain is a protective response. Physiological pain serves to protect us from harmful experiences. This protective response is a rapid, reflexive, subconscious reaction. However, a less emergent painful annoyance may elicit a slower, conscious-level reaction. Without the protective pain response, the ability to maintain a healthy body would be seriously compromised.
Define pain threshold.
Pain threshold is the point at which a stimulus begins to produce a sensation of pain. It is highly reproducible in the same individual and among different individuals.
Define pain tolerance.
Pain tolerance is an individual’s reaction to a painful stimulus. A common experience of pain produces a highly variable reaction from one individual to another.
Define acute pain.
Acute pain usually lasts for a few seconds to not more than six months, depending on the causative factors. It is generally caused by tissue damage from an injury or disease.
Define chronic pain.
Chronic pain is long-term pain that persists for more than six months, with or without an identifiable cause. The longer an acute pain continues the more likely the pain will become a chronic pain experience.
Name the three broad classifications of pain.
Pain is generally considered in three broad classifications: nociceptive pain, neuropathic pain, and pain disorders. Subclassifications exist within these broad categories.
Define nociceptors.
Nerve fibers have specialized endings to detect and transmit information to the central nervous system. For pain, the receptor fibers are known as nociceptors. Nociceptors are unique because they are polymodal, meaning they respond to all types of stimuli: mechanical, thermal, and chemical.
Explain the difference between pain and nociception.
Pain and nociception are not synonymous. Nociception is the body’s neurophysical detection of tissue trauma by nociceptors and the process of transmission of signals of the tissue injury within the nervous system. Nociception is not a conscious process. The process of nociception is influenced by an individual’s age, general health, and genetics. An individual must have conscious awareness to experience pain. Pain cannot exist apart from consciousness and cannot be objectively measured.
Define nociceptive pain.
Nociceptive pain is caused by injury or disease in body tissues. Pain may be constant or intermittent and often escalates with movement.
Define somatic and visceral pain.
Somatic nociceptive pain occurs on superficial structures such as skin and muscles and is caused by traumatic injuries. The resulting pain may be sharp, aching, or throbbing. Visceral nociceptive pain occurs in internal body cavities and is caused by compression, expansion, stretching, and/or infiltration of internal organs. It usually produces squeezing or gnawing sensations.
Define neuropathic pain.
Neuropathic pain is caused by nerve tissue injury or dysfunction of the sensory nerves in central or peripheral nervous systems. There are numerous neuropathic pain types.
Define pain disorders with psychological factors.
Pain disorders are related to mental or emotional problems that affect the experience of pain. Pain disorders with psychological factors are diagnosed after other causes of physical pain have been eliminated.
What physiological responses occur as a result of the sympathetic nervous system?
Heart rate and contractions increase, blood pressure increases, and pupils dilate. Bronchodilation and vasodilation of skeletal muscle arterioles occur along with vasoconstriction of mesenteric circulation.
What percentage of patients report fear as the main reason for avoiding dental appointments?
It has been reported that the main reason individuals avoid dental appointments is fear. About 40% of patients report some level of anxiety related to dental treatment and roughly 5% avoid dentistry because of fear of injections. Patients experience fear on a continuum ranging from mild anxiety to phobia.
How can clinicians create an environment that encourages patients to discuss their dental fears?
To create an environment that encourages patients to discuss their fears, deliberate behavior on the part of clinicians can be helpful in developing successful patient experiences. For example, using controlled, calm speech and a positive demeanor convey comfort and instill confidence. Signs of impatience or disapproval from the clinician should be avoided.
Give examples of the PREP strategies that help patients manage anxiety and fear.
PREP strategies help patients cope with anxiety and fear:
Prepare by utilizing relaxation techniques such as deep breathing, distraction such as music or visualization, and muscle relaxation.
Rehearse procedures allowing patients to practice control and self-calming techniques.
Empower patients with strategies that give them control during procedures such as raising a hand to ask the clinician to stop.
Praise patients for using specific coping techniques that are helpful to them.
What is the debriefing process?
The debriefing process allows for discussion periods at the end of appointments to provide patients an opportunity to relate which aspects of treatment and which approaches to treatment went well and which did not.
Give examples of pharmacological interventions that may be helpful and necessary in providing care for fearful patients who avoid dental treatment.
For some patients, pharmacological intervention may be helpful and necessary. Nitrous oxide-oxygen sedation, oral conscious sedation, intravenous sedation, and general anesthesia should be discussed with patients as the situation warrants. Pharmacological solutions are especially helpful for anxious patients who avoid dental treatment and present only for emergent care.
Discuss strategies and provide examples that enhance positive communication with patients.
Strategies and examples that will enhance positive communication with patients include:
• Display a genuinely warm and caring attitude.
• Review treatment plan, addressing fears, including fears of the unexpected and of loss of control.
• Obtain permission to begin, addressing fear of loss of control if necessary.
• Establish patient control strategy (time-out signal such as raising hand to stop).
• Direct the focus on positive outcomes (“You may feel a bit of pressure.”).
• Acknowledge and compliment success (“You did great with the anesthesia today!”).
• Create positive expectations (“That went well today and I expect your next appointment will too.”).
Discuss examples of distraction techniques.
Examples of distraction techniques include:
• Light, casual conversation or guided relaxation
• Gate control strategies and devices
• Pressure applied with cotton swab to palatal tissues
• Gentle lip shaking during needle insertion
• The use of vibration devices
• Audio devices with headphones for music or audio books (selected by patient)
• Television, video devices, and audiovisual glasses (not for highly anxious)
Discuss the relaxation response and its relationship to the parasympathetic nervous system.
The relaxation response is a restful state that modifies physical and emotional responses to stress. Parasympathetic pathways that allow recovery from stress (fight or flight) are activated by this response that lowers heart and respiratory rates, blood pressure, and muscle tension.
Discuss the link between hypnosis and the physiology of pain.
Growing evidence suggests a strong link between hypnosis and the physiology of pain for effective management of pain and anxiety. When in a state of hypnosis, patients usually feel calm and relaxed and are able to concentrate intensely on a specific thought, memory, feeling, or sensation while blocking out distractions.
Name the four structural areas of neurons.
All neurons have four structural areas: the dendritic zone, axon, cell body, and terminal arborization.
What is the composition and function of the neurolemma?
Nerve membranes, called neurolemmas, are bilayered phospholipid membranes. The function of a bilayered membrane is to act as a barrier. Lipid membranes are composed of phospholipids having both lipophilic (“fat-loving”) and hydrophilic (“water-loving”) ends. The membranes are held together by the attraction of the lipophilic ends at their centers.
What is the function of Schwann cells?
Schwann cells, which produce myelin, are specialized connective tissue cells that surround and protect peripheral nerves. Schwann cells insulate and protect the nerve membranes from their surrounding environments. Axons and their associated Schwann cells are collectively referred to as nerve fibers.
Describe the significance of the nodes of Ranvier in the administration of local anesthesia.
Local anesthetic solutions cannot diffuse through myelinated nerves except in areas where they come into direct contact with the membrane at the nodes of Ranvier.
Define saltatory conduction.
Saltatory conduction is the term for the process by which impulses are more rapidly conducted along myelinated nerves.
Which two layers within the fasciculi are the most significant barriers to the diffusion of anesthetic solutions?
The two most significant barriers to the diffusion of anesthetic solutions within the fasciculi are the perilemma and the perineurium, with the perilemma posing the greatest obstacle to diffusion.
What is the electrical potential of the nerve axoplasm in the resting state?
The electrical potential of nerve axoplasm in the resting state is approximately -70 mV.
Which ions bind to specific protein receptor sites within the ion channels of the nerve membrane in its resting state?
In the resting state, Ca+2 ions bind to specific protein receptor sites in the nerve membrane ionic channels. This causes the channels to be closed or gated by the Ca+2 ions.
Describe what occurs to create a firing threshold and impulse generation.
When a nerve is stimulated, the ion channels respond by releasing the gate keeper calcium ions. The channels are then wide enough to allow the positively charged, hydrated Na+ ions to begin to enter through the channels into the more negatively charged axoplasm. The initial influx of positively charged Na+ ions causes, at first, a slow depolarization process. Once there are sufficient Na+ ions in the axoplasm to reduce the electrical potential by approximately 15–20 mV, more Na+ ions flood the axoplasm. When the electrical potential reaches -50 to -55 mV, an impulse is generated.
Compare the conduction speeds of Aδ and C nerve fibers.
The Aδ fibers convey more rapid information on sharper pain. C fibers convey information more slowly on duller, aching pain. Both A and C fibers have been found in the dental pulp with a greater distribution of C fibers than A
Define refractory state and absolute refractory state.
The inability to successfully restimulate a section of membrane after impulse generation and conduction is known as the refractory state. Initially, the membrane is absolutely refractory to stimulation, and the previously fired section of membrane cannot be restimulated no matter how great the stimulus.
How does repolarization occur?
During rapid depolarization, the nerve axoplaxm has attained an electrical potential of +40mV. At this point the influx of Na+ ions is prevented and the Na+ ions begin to return to the extracellular environment through the ion channels. Additionally, sodium ion pumps enhance the movement of sodium from the axoplasm. The reversal of the ion concentration in the recovery phase is called repolarization.
How long does the process of depolarization to repolarizion take?
This process may seem long and tedious. In reality, however, it requires only one millisecond for a nerve membrane to react and recover after a successful impulse-generating stimulation.
Define impulse extinction related to the use of local anesthetic drugs.
Upon administration of local anesthetic drugs, Na+ ion influx through the nerve membrane is blocked and sodium-dependent depolarization is prevented. Both the generation and conduction of nerve impulses can be inhibited by local anesthetic drugs. Decreased responsiveness to stimuli and the failure to transmit an impulse toward the CNS are direct consequences of impulse extinction due to local anesthetic drugs.
Which structures do core and mantle bundles innervate?
Nerve fibers housed in mantle bundles tend to innervate structures in close proximity to them. Fibers housed in core bundles tend to innervate structures at some distance away from them. For example, in the case of the inferior alveolar nerve, fibers from the mantle layer tend to innervate the molar region, while fibers from the core layer tend to innervate the anterior mandible including the chin and lips.
Explain why the core bundles that innervate the anterior mandible can be more difficult to anesthetize.
Core bundles which innervate the anterior mandible can be more difficult to anesthetize because the anesthetic solution reaches them only after the solution has penetrated through the mantle layer. It takes longer to reach the core, and the solution does so in a diluted form primarily because of the binding of drug molecules to receptor sites in the mantle bundles. Once at the core, there are fewer molecules remaining to bind to sites in the core
Define local anesthesia.
Local anesthesia may be defined as a temporary loss of sensation in a specific, usually small area of the body. A primary distinction between local and general anesthesia is that when local anesthesia alone is in effect, the patient remains conscious.
Explain how local anesthetics work.
Local anesthetic drugs all work similarly. Local anesthetic molecules have a greater affinity for protein receptor sites within the nerve membrane compared to Ca+2 ions and they subsequently displace them. Different local anesthetic drugs have varying affinities for these receptor sites, which account for clinically significant differences in drug action.
Are both sensory and motor nerves anesthetized by local anesthesia?
Local anesthetic drugs are effective on both sensory and motor nerves. They typically anesthetize smaller nerves before larger nerves and sensory nerves before motor nerves
Although the desired effects of local anesthetic drugs are local, what other parts of the body are affected by the drug?
Although the desired effects of these drugs are localized, their inevitable systemic absorption exposes other tissues to their potentially toxic actions, including the central nervous system (CNS), the cardiovascular system (CVS), and skeletal muscle.
What is the objective in using local anesthetic drugs in dental treatment?
The objective in using local anesthetic drugs in dental treatment is to produce anesthesia for a specific area and, in some instances, to reduce localized bleeding.
What is the primary benefit of local anesthesia?
The primary benefit of local anesthesia is that pain sensations can be suppressed without significant central nervous system depression. This allows the majority of dental procedures, for example, to be performed under local anesthesia without exposing patients to the risks of general anesthesia.
What are the legal and ethical requirements for all health professionals administering local anesthesia drugs?
A sound knowledge of local anesthetic drugs and techniques is crucial to safe and successful administration. An understanding of the influences of compromised physiologic function, susceptibility to adverse reactions, and awareness of all drugs the patient may be using whether prescribed or not are equally important. Legal and ethical principles mandate that practitioners licensed to inject drugs into the human body are responsible for these considerations and, ultimately, their consequences.
Name two primary routes of delivery of dental local anesthetic drugs
There are two primary routes of delivery of dental local anesthetic drugs: topical and submucosal injection.
