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BDS2 - LA symposium > overview of LA techniques > Flashcards

overview of LA techniques Flashcards

1
Q

what procedures is LA commonly used for

A
  • extractions
  • implants
  • RCT
  • restorations
  • scaling
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2
Q

why do we use LA

A
  • would be horrendously painful if we didn’t
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3
Q

what is the definition of pain

A
  • an unpleasant sensory and emotional experience associated with actual or potential tissue damage
  • emotional = can leave imprint on us from past experience -
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4
Q

what is pain

A
  • it is the body’s way of saying we are being harmed and need to do something
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5
Q

what are injections referred to as in Glasgow

A
  • jag
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6
Q

what is the anxiety for LA often for

A
  • the anxiety is often due to the needle rather than the injection itself
  • need to use behavioural and physical techniques to help patient manage anxiety
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7
Q

how many types of LA are there

A
  • 2 types
  • esters and amides
  • have different chemical structures from one another
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8
Q

which type of LA is more common

A
  • more amides
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9
Q

what can LA also help control

A
  • haemostasis/bleeding which is good for surgical and restorative points of view
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10
Q

what do LA also have in them

A
  • vasoconstrictors = although not all of them

- adrenaline or felypressin

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11
Q

what do the vasoconstrictors in LA do

A
  • causes blood vessel to constrict which is advantageous as it means that the LA can stay in the area for a longer time
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12
Q

what is the benefit of using adrenaline instead of felypressin

A
  • adrenaline prolongs the effect of LA more than felypressin
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13
Q

who can’t you use felypressin in

A
  • pregnant individuals
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14
Q

what can be a side effect of adrenaline

A
  • can make patients feel funny
  • if it has been placed in a blood vessel then the patient can get an increased heart rate as adrenaline has been sent into the blood vessel
  • these patients may say they are allergic to La but they re not
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15
Q

what are the two types of preservatives in LA

A
  • bisulphate and propylparaben
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16
Q

what can parabens cause

A
  • problems with allergy

- not a true allergy though but some people may be allergic to certain ones so can’t use LA with that type in it

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17
Q

how are patients with a true allergy to LA treated

A
  • they will be assessed and referred to West of Scotland clinic of Glasgow Royal Infirmary
  • it is really important that these patients are managed very specifically
  • quite uncommon
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18
Q

what are the 2 types of LA injection

A
  • infiltration

- block

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19
Q

what is infiltration LA

A
  • local anaesthetic is deposited around the terminal branches of nerves
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20
Q

what is block LA

A
  • anaesthetic deposited beside the nerve trunk
  • trunk of the nerve has LA deposited at it and so all fibres distal to that are blocked
  • reduces pain and better for haemostat issues and good for those scared of needles
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21
Q

what are infilatration LA used for

A
  • used to anaesthetise soft tissues
  • used to produce pulpal anaesthesia where alveolar bone is thin = maxilla and lower anterior teeth, not posterior of mandible as too thick
  • most used in maxilla and anteriorly in mandible for soft tissue biopsies
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22
Q

why must infiltration LA be used in thin bone areas

A
  • the La needs to be able to get through the bone to get to pulps and roots of teeth sit through bone
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23
Q

what is block LA used fro

A
  • used to produce soft tissue anaesthesia
  • used where bone is too thick for infiltration = mandible
  • used when working on multiple teeth or a large area = instead of puncturing the mucosa a lot, can just do it once with this
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24
Q

how do you anaesthetise the dental pulp in maxilla

A
  • buccal infiltration
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25
Q

how do you anaesthetise the buccal gingiva in maxilla

A
  • buccal infiltration
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26
Q

how do you anaesthetise the palatal gingiva in the maxilla

A
  • palatal infiltration/injection
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27
Q

how do you anaesthetise the dental pulp in the mandible for lower molars and second premolar

A
  • inferior alveolar Neve block (IAN)
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28
Q

how do you anaesthetise the dental pulp in the mandible for lower premolars and canines

A
  • mental (incisive) nerve block
  • depends where it is located and how many teeth it will get with the mental nerve
  • can palpate for mental nerve to feel where nerve it to deposit
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29
Q

how do you anaesthetise the dental pulp in the mandible for lower canine and incisors

A
  • buccal/labial infiltration
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30
Q

how do you anaesthetise the buccal gingiva in the lower molars and second premolar

A
  • long buccal infiltration

- these teeth are also supplied by the buccal nerve so need this injection as well as IAN block

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31
Q

how do you anaesthetise the buccal gingiva for lower premolar and canines

A
  • infiltration of long buccal or mental nerve block
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32
Q

how do you anaesthetise the buccal gingiva for lower incisors and canines

A
  • buccal/labial infiltration
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33
Q

how do you anaesthetise the lingual gingiva for mandible

A
  • lingual infiltration
  • secondary part of IAN block = when give IAN initially you are aiming for the IAN but if you withdraw 2-3mm you can also hit the lingual nerve for the tongue on that side and it is beneficial to give this injection as you only need to do it once
  • sometimes for end, there is a supply to the molars from the nerve to mylohyoid so need to give that injection to
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34
Q

what tissues do you need to anaesthetise for restoration of tooth

A
  • dental pulp as want to anaesthetise the tooth
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35
Q

what tissues do you want to anaesthetise for extraction

A
  • pulp and gingiva
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36
Q

what tissues do you need to anaesthetise for scaling

A
  • gingiva or pulp and gingival

- need pulp too if root planing on dentine

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37
Q

what is he equipment to give LA

A
  • syringe handle and bung
  • syringe barrel = contains needle as well
  • cartridge = can get a couple different types
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38
Q

what sizes of needles can you get

A
  • long = 35mm

- short = 25mm

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39
Q

what must you do when you get a cartridge

A
  • check the expiry date and batch

- needs to be recorded in clinical notes for traceable reasons

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40
Q

how are things packaged

A
  • the handle and bung come together in a packet and ned to be careful when opening it as bung can fall out
  • needles are packaged individually as they are single use items
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41
Q

what cartridge does lignocaine come in

A
  • 2.2ml solution

- 1:80,000 adrenaline

42
Q

what cartridge does articaine come in

A
  • 1:100,000 or 1:200,000 adrenaline
43
Q

when do you use articaine

A
  • has increased ability to diffuse through bone so may not need to give IAN block in mandible with this
44
Q

when can’t articaine be used

A
  • shouldn’t give IAN block with this as it can damage IAN from the needle and damage to this nerve can be life-limiting
45
Q

what is good about articaine

A
  • it is not processed in the liver which is good for those with liver disease
46
Q

what is Citanest

A
  • it doesn’t contain adrenaline in it= this LA has felypressin
47
Q

where does the needle pierce the cartridge

A
  • the gold tips on cartridges have a little piece of non-rubber that is pierced with the needle
48
Q

what do you do with the sticker on the packet from the equipment

A
  • need to put in in the patients notes
49
Q

how do you assemble the handle

A
  • slide the chunky part onto the longer part = chunky part is where you place your fingers and loop is where your thumb goes
  • put bung on with the thicker end towards the handle = if on the other way then the cartridge can get stuck in the barrel
50
Q

how is the cartridge inserted

A
  • insert gold end of cartridge into the needle barrel itself and press down until the little piece of plastic punctures
51
Q

what do the safety plus syringes look like

A
  • blue plastic shield over needle with clear plastic shield on top
52
Q

how is the needle exposed

A
  • take back the outer clear shield, hold the barrel with the blue end pointing away from you and pull clear shield down and clip it into the handle
  • then take off blue shield and this can now be put in the bin
53
Q

how do you ensure needle is safe before putting it down

A
  • pull clear outer shield down to cover needle until you hear one click
  • if you double click it then it becomes locker and can no longer be used
  • it is good practice to only do a single click during procedures as patient may need another injection
  • at the end of the procedure you need to double click and put it in sharps bin
54
Q

why must you check patients medical history before giving LA

A
  • for example, you cannot give haemophiliacs IAN block in routine dental practice
55
Q

what is the position of the patient in the chair when giving LA

A
  • usually dependant on the type of LA you are giving
  • IAN often in sitting up position as can feel the anatomy better
  • main justification for lying the patient back is that if the patient become hypertensive and faints then they are already lying down
56
Q

why do you need to dry the mucosa -

A
  • if using topical and put it on a wet mucosa then it will dilute a little and be less effective
57
Q

how long does topical need to be applied for

A
  • 1-2 minutes
  • place a pea sized amount on cotton wool roll
  • its a gel
  • it gives some LA before using needle
  • can either hold it on or put in on a roll and let cheek hold it in place
  • good to use for infiltration LA but makes no difference for block
58
Q

what are the 2 main types of topical

A
  • one is minty flavoured and the other is bubblegum
59
Q

what type of atmosphere would you want for giving LA

A
  • tranquility
  • those who are stressed are more likely to feel pain so need patient to be nice and clam and get them to focus on something else
60
Q

how can breathing help when giving LA

A
  • takes patients mind off of what’s happening

- focus on breathing and relaxing muscles

61
Q

why is confidence of the dentist important

A
  • not over confident
  • if the dentist is visibly nervous then the patient can pick up on this and become more anxious as well so we need to look confident
  • need to know what you are doing and how much you are going to give
62
Q

what is the injection technique

A
  • remove topical
  • stretch mucosa
  • place needle over the site you want to go
  • puncture mucosa quickly = distraction for patient
  • position needle tip at target point
  • aspirate = safety plus system does this itself which is beneficial
  • inject slowly = no less than 30 seconds, do not force it in as this will cause pain
63
Q

how do you stretch the mucosa

A
  • need to pull it as tight as you can

- do with fingers initially but will eventually use a mirror so you are less likely to puncture yourself

64
Q

what is the correct bevel orientation of the needle

A
  • needle has bevel on it and you want the most advanced surface of the bevel facing away from the tissue
  • bevel towards you during needle placement = lumen unobstructed
  • incorrect = bevel facing away from you = lumen obstructed
65
Q

what is the role of the bevel of the needle

A
  • the role of the bevel is the provide a cutting surface that offers little resistance to mucosa as the needle penetrates and withdraws from the tissue
66
Q

why do you want the bevel facing you

A
  • as if the most pointy bit enter first then you are more likely to puncture the periosteum which is painful
  • have most pointy part reversed
67
Q

what is the needle position for infiltration

A
  • bevel away from bone
  • if the bevel is towards the bone, the edge of the needle is likely to penetrate the periosteum
  • periosteal injections are more likely to evoke a painful response
68
Q

what is the needle position for IAN block

A
  • makes no statistical difference or clinical difference
69
Q

what happens if you get blood in the cartridge after aspiration

A
  • means you have hit a blood vessel and you need to stop and come out and change the cartridge and go back in
  • aspiration is caused by pulling back on the plunger of the handle on the safety plus needles
70
Q

how must you administer the LA

A
  • need to drip it in
  • very slowly and very gently
  • it is not an opportunity to fire in as much as quickly as you can at a high volume = it is very sore for patient at high pressure and volume
71
Q

what are some myths about LA

A
  • needle length influences discomfort = makes no difference
  • needle diameter influences discomfort
  • temperature influences discomfort = some believe that if you warm it up then it makes it more comfortable but others say patients can’t tell the difference between 15 and 37 degrees
72
Q

what are some specific injections

A
  • buccal infiltration
73
Q

how is buccal infiltration administered

A
  • stretch cheek = pull skin taught and identify position
  • puncture mucosa with correct bevel of needle
  • advance needle until over the apex of the tooth
  • if contact bone, withdraw slightly
  • aspirate = if negative then carry on slowly, if positive, reposition and repeat
  • for molars, when doing extraction and filling, give 3/4 cartridge buccally and 1/4 palatally = some say anaesthetise roots separately on buccal or can just go in middle
  • remove syringe from mouth
  • slide sheath down to hear first click
  • replace cartridge if need be
  • massage LA into tissues
  • wait for 2 mins
  • test
74
Q

how do you identify injection site

A
  • in reflection of mucosa below apex of tooth
75
Q

how do you replace a cartridge

A
  • pull handle off and with it should come the cartridge and can then insert a new one
76
Q

how do you test if LA has worked

A
  • if removing a tooth then stick probe down the PDL

- f doing a restoration then use a probe and check around area but don’t stick down PDL

77
Q

what are the limitations of infiltration anaesthesia

A
  • pulpal anaesthesia limited to one or two teeth
  • infection = if have infection present then won’t achieve full pulpal anaesthesia, and if inject into infected area will just push infection and spread further
  • dense bone = may not get anaesthesia if the bone is too dense
78
Q

what are the positives of infiltration anaesthesia

A
  • high success rate = works really well
  • technically easy
  • atraumatic
79
Q

what are blocks used in the maxilla

A
  • posterior superior alveolar nerve block
  • middle superior alveolar nerve block
  • anterior superior alveolar nerve block
  • need to be aware that different parts of superior alveolar nerve supply different teeth
80
Q

how is posterior superior alveolar nerve block given

A
  • effective in achieving pulpal anaesthesia for the first, second and third molars
  • MB on first maxillary molar is not reliable
  • insert needle MB fold over maxillary 2nd molar
  • upward 45 degrees to occlusal plane, inward medial toward midline 45 degrees to occlusal plane and backward direction of needle 45 degree to occlusal plane
  • needle inserted around 16mm
  • quite complicated
81
Q

how is middle superior alveolar nerve block given

A
  • advanced technique
  • this nerve is only present in about 28% of population
  • MB of 1st maxillary molar, premolars and canine
  • MB fold over the 2nd premolar
82
Q

how is the anterior superior alveolar nerve block given

A
  • successful anaesthesia of maxillary incisors and canine on side of delivery
  • MB fold over 1st premolar target is the infraorbital foramen
83
Q

how do you dispose of sharps

A
  • pull plastic up to cover needle till hear double click
  • take everything apart and use sharps bins
  • place needle in sharps bin = orange
  • if LA cartridge is completely empty then place in orange sharps bin
  • if LA cartridge has some left in it then place in blue sharps bin = but procedure on that changes
  • always shut the bin over
  • need to take handle apart and it goes to dirty room/box
  • rubber bung is put in clinical waste as it doesn’t go through sterilisation = red bin
84
Q

what LA injections are performed as buccal infiltrations

A
  • mental block

- buccal injection

85
Q

how is mental block given

A
  • between apices of lower premolars
  • do not try to put needle in foramen as could damage the nerve
  • massage the LA
  • this gives aneasthetic pulpally for 4321 and sometimes you can get crossover anteriorly with nerve so might need top up as could still be some innervation
86
Q

how is buccal injection given

A
  • lower buccal gingiva
  • administer slightly distal to the tooth to be treated
  • need buccal nerve block as well as IAN as its not enough alone for mandible molars
87
Q

how is IAN block given

A
  • need to get mouth as wide open as possible
  • prepare equipment = saem as for infiltration but use 35mm needle instead
  • identify site for LA
  • need patient to open wide = wide stretch so it is easier to see landmarks
88
Q

what are the important landmarks

A
  • coronoid notch
  • pterygomandibular raphe
  • posterior border of mandible
  • lower premolar teeth of the opposite side = barrel is going here when approaching
89
Q

what is the position for your hand (if RH) giving IAN block

A
  • stand in front of patient and feel the coronoid notch with left thumb and have fingers on posterior border of mandible
  • thumb goes at coronoid notch of the mandibular ramus which is the greatest depression
  • coronoid notch give vertical and horizontal reference points
  • see pterygomandibular raphe at the midline
90
Q

where is the site of anaesthetic deposition for IAN block

A
  • in the region of the mandibular foramen

- aiming for the mandibular foramen

91
Q

what is the approach of IAN

A
  • thumb on coronoid notch
  • fingers on posterior aspect of the mandible = posterior border of the mandible is highlighted by raphe
  • this positioning gives the point of puncture
  • deepest point of raphe is insert point
  • vertical plane is 6-10mm above lower teeth
  • barrel of syringe is above premolar teeth on opposite side
92
Q

what are the limitation if give IAN too inferior

A
  • increased onset time
  • increased lingual nerve injury
  • no change in intravascular injection
  • if too low, then will not get nerve numb
93
Q

what is the injection site for IAN

A
  • vertical position 1cm above lower teeth
  • horizontal plane going 3/4 back from where thumb and raphe are is where injection goes
  • keep advancing needle until you hit bone
  • needle entry junction of buccal pad of fat and pterygomandibular raphe
  • syringe lies over contra lateral 5 and 6
  • when in correct position withdraw from bony contact slightly
  • need to aspirate
94
Q

how much of the needle should be inserted with IAN block

A
  • 3/4 of needle should disappear into tissue
  • if only 1/4 goes then you are too far anterior so need to bring barrel towards midline
  • if you don’t reach a bony contact then reposition syringe distally, and if too soon contact then reposition mesially
  • 1cm of needle should be visible once reach bony contact
95
Q

how do you inject the lingual nerve after IAN block

A
  • once hit bone withdraw a couple mm to inject 3/4 of cartridge then retract 2-4mm to give lingual nerve bock where you deposit the remaining 1/4 or 1/3 of the cartridge while withdrawing
96
Q

how should the patient feel after anaesthesia

A
  • rubbery
  • numb
  • swollen/fat lips
  • should reassure that is is temporary
97
Q

what will patient still feel after IAN

A
  • still be able to feel pressure but not pain and you should reassure them of this
98
Q

how will patient feel after IAN block

A
  • tongue and lower lip extending to the mid-line on that side should feel different
99
Q

how should you test for anaesthesia if doing extraction or surgical procedure

A
  • consider testing the mucosa with a probe to ensure anaesthesia
100
Q

is there one way to give LA

A
  • no, success is technique dependant

BDS2 - LA symposium (3 decks)

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