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BDS2 LA Symposium > Overview of LA Techniques > Flashcards

Overview of LA Techniques Flashcards

1
Q

why do we need LA

A

Number of procedures

  • Dental implants
  • Extractions
  • Scaling
  • Rubber dam placement
  • Endodontics

Prevent pain during procedures

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2
Q

pain

A

An unpleasant sensory and emotional experience associated with actual or potential tissue damage

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3
Q

how can needle anxiety be managed

A

with technique practice

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4
Q

2 main types of LA

A

amides (more common) and esters

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5
Q

why are vasoconstrictors added to LA

A

Cause BV to constrict

Advantageous with LA keep LA in area for longer period of time

Control bleeding
- Help with haemostasis – scaling, subgingival restorations for crown (less interruption to placement procedure)

Prolongs for best length of time –

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6
Q

what is more effective vasoconstritor?

A

Adrenaline over Felypressin

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7
Q

when would felypressin be used as the vasoconstrictor in LA

A

Not as effective as adrenaline as vasoconstriction, cannot be used in pregnant

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8
Q

why are preservatives added to LA

A

prolong shelf life

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9
Q

risk of preservatives added to LA

A

Propylparaben – allergy risk

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10
Q

why is aspiration key to LA technique

A

Adrenaline in BV need to aspirate to ensure not placed needle in BV

If in BV with adrenaline containing LA will increase HR, dangerous complication

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11
Q

2 main types of LA injection

A

infiltration

nerve block

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12
Q

infiltration LA injection

A

Local anaesthetic solution deposited around terminal branches of nerves
- Only get nerves situated in that area

Used to anaesthetise soft tissues

Used to produce pulpal anaesthesia where alveolar bone is thin

  • Maxilla
  • Lower anterior teeth
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13
Q

how is pulpal anaethesia acheived

A

LA need to get through bone to achieve pulpal anaesthetise

Posterior mandible has thicker bone so infiltration not effective

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14
Q

sites where LA infiltration used

A

maxilla

anterior mandible for soft tissue biopsies

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15
Q

nerve block LA

A

Anaesthetic deposited beside nerve trunk

Abolishes sensation distal to site

  • All terminal end fibres from nerve trunk anaesthetised
  • Larger area

Used to produce soft tissue anaesthesia

Used where bone too thick to allow infiltration
- Mandible

Or working on multiple teeth and/or haemostatic worry

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16
Q

anaesthesia in the maxilla for dental pulp

A

buccal infiltration

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17
Q

anaesthesia in the maxilla for buccal gingivae

A

buccal infiltration

e.g rubber dam, scaling, extraction

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18
Q

anaesthesia in the maxilla for palatal gingivae

A

palatal injection

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19
Q

anaesthesia in the mandible for dental pulp of lower molars (and second premolars)

A

inferior alveolar nerve block (IAN/IDB)

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20
Q

anaesthesia in the mandible for dental pulp of lower premolars and canine

A

mental (incisive) nerve block

  • population dependent, Chinese further back in mandible effect aim and teeth effected, palpate for mental nerve
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21
Q

anaesthesia in the mandible for dental pulp of lower canine and incisors

A

buccal/labial infiltration

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22
Q

anaesthesia in the mandible for buccal ginigvae of lower molar and second premolar

A

(long) buccal infiltration

- additional injection to IDB

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23
Q

anaesthesia in the mandible for buccal gingivae of lower first premolar and canine

A

infiltration or long buccal or mental nerve block

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24
Q

anaesthesia in the mandible for buccal gingivae of lower incisors and canines

A

buccal/labial infiltration

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25
Q

anaesthesia in the mandible for lingual gingivae

A

secondary part of inferior alveolar end block if given

  • Anterior alveolar nerve targeted initially targeted in IDB, get lingual nerve by withdrawing 2-3mm - supplies tongue on that side
  • 2 nerves with one injection

Lingual infiltration

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26
Q

how to decide what tissues to anaethetise

A

depends on the procedure

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27
Q

what to anaesthetise when doing restoration

A

dental pulp

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28
Q

what to anaesthetise when doing extraction

A

pulp and gingivae

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29
Q

what to anaesthetise when doing scaling

A

pulp? or pulp and gingivae?

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30
Q

stages in LA technique

A

preparation of equipment

preparation of pt

injection technique

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31
Q

preparation of equipment for LA

A

Syringe handle and bung

Syringe barrel

  • Short 25 mm for infiltration
  • Long 35 mm for Inferior Alveolar Nerve Block

Cartridge
- CHECK EXPIRY DATE & BATCH – record in clinical notes, safety and traceability reasons

32
Q

what is a short syringe barrel used for

A

25mm used for infiltration

33
Q

what is a long syringe barrel used for

A

35mm for inferior alveolar nerve block

34
Q

what do you need to record from LA equipment

A

Cartridge EXPIRY DATE & BATCH – record in clinical notes, safety and traceability reasons

35
Q

how is LA equipment packaged

A

2 separate packages

  • syringe handle and bung in one
  • syringe barrel in another
36
Q

ligocaine

A

2.2ml barrels

contains adrenaline 1:80,000

37
Q

articaine

A

contains adrenaline
- 1:100,000 or 1:200,000

Increase ability to diffuse through bone
- Do not need to give IDB in lower molars potentially, may help minimise nerve damage

Not processed in liver – good or liver disease

38
Q

citanest

A

Alternative - no adrenaline

No vasoconstrictor plain form as well

39
Q

how to assemble syringe handle and bung

A

Slide chunkier part (finger rest) onto longer loop part (thumb)

Place bung on end
- with the thicker end towards the handle

40
Q

how to insert the syringe barrel to the handle

A

Pierce non rubber seal with needle

  • Gold end
  • Hear plastic puncture

Blue plastic shield with clear plastic shield on top
- Safety plus needle; Single use disposable

Take Back outer shield 
- Blue end away from you 
- Pull outer shield down 
- Clip onto handle
- Pull away from you 
- Dispose of blue tip 
Outer shield clicked into handle 
- Make safe by pulling outer shield down to cover the needle

One click – means can reuse, shield will slide back and forth
Double click – cannot reuse, locked

41
Q

one click of outer shield over needle

A

means can reuse, shield will slide back and forth

42
Q

double click of outer shield over needle

A

cannot reuse, locked

43
Q

preparation of pt

A

Check medical history

  • No contraindications
  • Haemophiliac – cannot give IDB in GDP

Position in chair
- Usually dictated by the type of treatment

Dry mucosa
- Moist will dilute topical LA

Apply topical for 1-2 minutes
- Pea size on cotton wool

Atmosphere

  • Tranquil - Stress will upregulate pain
  • Happy place – distract from pain

Breathing

Try to be confident
- Patients can feed off your anxiety

44
Q

injection of LA technique

A

Remove topical anaesthetic from mouth

Stretch mucosa
- Fingers or mirror

Puncture mucosa quickly
- (Use distraction)

Position needle tip at target point

Aspirate

  • Safety plus is self-aspirating
  • Pull back on plunger – active aspiration, good practice
  • Metal barrels are not self-aspirating
Inject slowly
- No less than 30 seconds
- “drip it in”
Slowly, gentle drops – like drizzle cake
Hurts for high pressure – tissue is tight
45
Q

needle shape

A

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

  • Important want to have the most advanced part of bevel away from tissue
  • —Most pointy part away
  • If enters first more likely to puncture periosteum – painful
46
Q

how should the needle enter the mucosa

A

Important want to have the most advanced part of bevel away from tissue

  • —Most pointy part away
  • If enters first more likely to puncture periosteum – painful
47
Q

needle position for infiltration

A

Bevel away from bone

If the bevel is towards the bone, the edge of needle is likely to penetrate the periosteum

Periosteal injections are more likely to evoke a painful response

48
Q

needle position for inferior alveolar nerve block

A

Makes no statistical difference or clinical difference

Important want to have the most advanced part of bevel away from tissue
—-Most pointy part away

49
Q

what is aspiration

A

Pull block with thumb

In BV see blood in cartridge
Stop, come out, change cartridge

50
Q

what to do if see blood in cartridge

A

In BV see blood in cartridge

Stop, come out, change cartridge

51
Q

3 common myths of giving LA

A

Needle length influences discomfort

Needle diameter influences discomfort

(Temperature influences discomfort)
- Patients cannot detect if between 15 and 37o

52
Q

how to identify injection site for buccal infiltration

A

in reflection of mucosa below apex of tooth with the mirror

53
Q

what is infiltration anaesthesia used for (2)

A

Pulpal anaesthesia limited to one or two teeth

Soft tissue anaesthesia

54
Q

2 limitations of infiltration anaesthesia

A

Infection

  • If infection present may not be able to achieve full pulpal anaesthesia
  • Some papers say push infections into space – encourage spread potentially

Dense bone
- e.g. More posterior parts of mandible

55
Q

3 positives of infiltration LA

A

High success rate

Technically easy

Atraumatic

56
Q

technique for buccal infiltration

A

Stretch cheek

Puncture mucosa with correct bevel of needle
- Pointiest away

Advance needle until over the apex of the tooth

If contact bone, withdraw slightly

Aspirate

  • If negative inject slowly (No blood)
  • If positive, reposition and repeat

Amount of LA

  • Molar teeth ¾ buccal ¼ palatially
  • —2 buccal roots – can anesthetise separately or mid buccal region

Remove syringe from mouth

Slide sheath down to first click

Can replace cartridge if need further injections
- Pull black handle, glass cartridge should come with

Massage local anaesthetic into tissues
- Increases spread and desensitise other nerves in the area

Wait for 2 minutes for anaesthesia

Test

  • Ask the pt
  • Place probe down PDL if extraction (will damage it)
57
Q

amount of LA for buccal infiltration of molar teeth

A

¾ buccal ¼ palatially

2 buccal roots – can anesthetise separately or mid buccal region

58
Q

3 types of maxilla blocks

A

posterior superior alveolar nerve PSA

mesial superior alveolar nerve MSA

anterior superior alveolar nerve ASA

  • different branches for different teeth
59
Q

Posterior superior alveolar nerve block

A

Effective in achieving pulpal anaesthesia for the first, second and third molars

MB (mesial buccal) on first maxillary molar not reliable anaesthetised

Insert needle MB fold over maxillary 2nd molar,

Upward (45 degree to occlusal plane) , Inward (medial toward midline 45 degree angle to occlusal plane) and backward direction of needle (45 degree angle to the occlusal plane)
- needle inserted around 16mm

60
Q

Mesial Superior Alveolar nerve block

A

MSAN present in only 28% of the population

MB of 1st maxillary molar, Premolars and maxillary canine

MB fold over the 2nd premolar

61
Q

Anterior superior alveolar nerve block

A

Successful anaesthesia a of maxillary incisors and canine on the side of delivery

MB fold over 1st premolar target is the infraorbital foramen

62
Q

how to dispose of LA sharps

A

Take everything apart - use gloves

Orange sharps bin for needle and LA cartridge if completely empty

Some LA still in need to go into the blue lidded bin

syringe handle goes to dirty room/box
- take apart and have tag with

rubber bund is in clinical waste (red stream)

63
Q

2 LA injection performed as buccal infiltrations

A

mental block

buccal injection

Cross over in midline of Inferior nerve with mental nerve - may need to top up

64
Q

mental block LA injection

A

Between the apices of lower premolars

Do not try to put needle in foramen

  • Sore when press on
  • If needle in can damage the nerve

Massage the LA

65
Q

buccal infiltration of LA

A

Lower buccal gingivae

Administer slightly distal to the tooth to be treated

66
Q

how to deliver inferior alveolar nerve block

A

Prepare the equipment and patient
- As for buccal infiltration, but use 35mm needle

Identify site for LA

Patient opens mouth

  • Wide stretch
  • Easier landmarks
  • Taut tissue
67
Q

what needle is used for IAN/IDB

A

longer 35mm

68
Q

important landmarks for IDB/IAN

A

Coronoid notch of the mandibular ramus

Posterior border of mandible

Pterygomandibular raphe
- Skin and connective tissue makes the fauces towards

Lower premolar teeth of the opposite side
- Where barrel of needle going to go

The site of anaesthetic deposition is in the region of the mandibular foramen - aim

Right-handed to anaesthetise the right inferior alveolar nerve stand in front of pt

  • Use left hand to feel coronoid notch with thumb (greatest depression on anterior ramus, in mouth)
  • — Horizontal plane is reference point to foramen
  • fingers on posterior border of mandible (outside mouth)
69
Q

right handed operator guidance for right IDB/IAN

A
  • Use left hand to feel coronoid notch with thumb (greatest depression on anterior ramus, in mouth)
  • — Horizontal plane is reference point to foramen
  • fingers on posterior border of mandible (outside mouth)
70
Q

limitation of inferior position of IDB injection (3)

A

Increased onset time

Increased lingual nerve injury

No change in intravascular injection

71
Q

coronoid notch

A

greatest depression on anterior aspect on ramus

vertical plane – 6-10mmmm above teeth

72
Q

where should the syringe barrel bne for IDB

A

barrel of syringe situated above premolars on opposite side

point of puncture in raphe

73
Q

how far should needle go in for IDB

A

Advance needle to contact bone
- ¾ needle in

Do not inject if no bone – too posterior

Too little of needle in – too anterior
- Replant by moving barrel to midline

Only inject if bone contacted

74
Q

step by step inferior alveolar nerve block

A

Thumb placed at anterior notch

Needle entry junction of buccal pad of fat/ pterygomandibular raphe

Syringe lies over contra lateral 5-6

Advanced to bony contact (1cm of needle visible), do not inject onto retract slight

  • If no bony contact reposition syringe distally
  • If bony contact too soon, reposition syringe barrel mesially

When in correct position withdraw from bony contact

Aspirate

Inject slowly
- For lingual anaesthesia withdraw 2-4mm then injection of last 1/4 of solution

75
Q

how to administer lingual anaesthesia after IDB

A

withdraw 2-4mm then injection of last 1/4 of solution

76
Q

ways of confirming anaesthesia

A

Ask the patient how it feels
- Reassure temporary sensation

Rubbery

Numb – block in mandible, stop at midline

Tingly

Swollen/ fat

77
Q

ways of confirming IDB/IAN

A

Tongue and lower lip extending to the mid-line on that side should feel different

Ability to sense pressure remain
- Confusing – pressure will remain but no pain

If carrying out an extraction or oral surgical procedure consider testing mucosa with a probe to ensure anaesthesia

BDS2 LA Symposium (4 decks)

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