PM final Flashcards
Nerve block injection
Disposition near a major nerve trunk at a greater distance from the area of treatment, which provides wider areas of anesthesia
PDL injection
And intraosseous injection technique for single tooth, for supplemental anesthesia of individual teeth and other techniques have failed to provide profound anesthesia, when widespread anesthesia is contra indicated, and when total doses need to be minimum
Interseptal technique
The interseptal technique provides pain management for the periodontium lingual to a tooth and can be particularly useful when palatal tissues require anesthesia and clinicians and or patients wish to avoid palatal injections
Infiltration injection
The disposition of local anesthetic drug directly at or near small terminal nerve endings in the immediate area of treatment
Diffusion hypoxia
Decreased O2 saturation levels in the blood caused by the rapid exit of nitrous on its termination
Partial pressure gradients
Inhaled agents act on the body by moving across partial pressure gradients
Move from a higher to a lower pressure gradient
The difference between the partial pressure of a gas any liquid indicated how quickly the agent crosses the pulmonary membrane and enters into the bloodstream (blood-gas partition coefficient)
Anxiety
An emotional response to a threat or danger that is not immediately present or is unclear
Fear
An emotional response to an immediate threat or danger
Phobia
A persistent, irrational fear of a specific object or situation the results in a compelling desire to either avoid the situation or to endure it with dread
Sensoring neurons
Carry incoming signals (impulses) from the body to the central nervous system for processing
Motor neurons
Carry impulses from the central nervous system to cells, tissues, and organs
Dendritic zones
Sites of nerve impulses initiation of sensory neurons in response to stimulation
Axons
Terminal zones of nerve axons (synapse) contain organelles that release neurotransmitters that send information to tissues
Terminal arborizations
Impulses are transmitted to processing nuclei called ganglia
What are nerve membranes composed of
A bi- layered phospholipid membrane that functions as a barrier
What are lipid membrane is composed of
Phospholipids having both lipophilic and hydrophilic ends. The membranes are held together by the attraction of the lipophilic ends at the center
Myelin
A protective covering for nerves produced by Schwan cells. The primary function of myelin it to provide electrical insulation to nerves to increase their conduction efficiency
Schwann cells
Produce myelin. Function to protect the neuron and facilitate healing in the event of an injury. Composed a lipid, protein, carbohydrates
C fibers
Most numerous of peripheral nervous system, nonmyelinated, conduct more slowly. Provide sensation of dull and aching pain
A fibers
Lately myelinated, conduct more rapidly. Provide sensation of sharp, stabbing pain
What are the two most significant barriers to the diffusion of anesthetic solution in the development of anesthesia
Perilemma and the perineurium
Maxillary plexus
Derives from terminal branches of the second division of the trigeminal nerve
Mandibular plexus
Derives from the terminal branches of the third division of the trigeminal nerve
What is the difference in the electrical charge across the membrane
-70 mV (resting state electrical potential)
What happens when the nerve is stimulated
The ion channels open their gates in response to it.
Calcium ions
Slow depolarization
Occurs until the axoplasm as depolarized approximately: 15-20mV, From -70 to somewhere between -55 to -50 mV = the firing threshold!!!!
Repolarization
Recovery phase
Refractory state
Following a nerve impulse generation, a subsequent impulse generation is either temporarily impossible or more difficult
What kind of nerves do local anesthetic drugs work on
Sensory and motor
What nerves, sensory or motor, are lost first
Loss of sensory nerves before loss of motor nerves
Child does for local anesthetic
Adult dose X Child’s age / (12+child’s age)
Child dose for nitrous
4-5 L/min
Tidal flow
Refers to the automatic, regular ad and flow movement of air – similar to the ocean tide
The amount of gas in the lungs – title volume – depends on the physical size and fitness of the person
Male lung volumes are about 25% greater than females
What is the largest and most complex cranial nerve
The trigeminal nerve. It has three major branches; opthalmic, maxillary, mandibular
Mandibular is the largest
ASA is the terminal brands of the maxillary division of the trigeminal nerve
Accessory nerve
A cranial nerve that controls the sternocleidomastoid and trapezius muscles. It is considered the 11th cranial nerve.
Aberrant nerve
Nerve fibers, blood vessels, or lymphatic which follow a usual route deviating from what is normal or typical. Most failures due to aberrant innervations result in a complete lack of anesthesia of the targeted tissues.
Nociceptive pain
Caused by injury or disease in the body tissues. Can be constant or intermittent and can increase with movement
Two categories of nociceptive pain
Somatic and visceral
Somatic pain
Occurs in superficial structures like skin or muscles and is caused by traumatic injuries. Pain is sharp, aching, or throbbing
Visceral pain
Occurs in internal body cavities and is caused by compression, expansion, stretching, infiltration. Pain is a squeezing or nawing sensation
What are nocicptors
Sensory receptors that detect injury
They are unique in that they never adapt to stimulation. This is the key aspect in the protective response to pain
PSA penetration site
Height of the mucobuccal fold, distal to the zygomatic process of the maxilla, above the maxillary second molar. Generally superior to the distal buckle root of maxillary second molar
MSA penetration site
Height of the mucobuccal fold over the second premolar
ASA penetration site
Height of the mucobuccal bold just mesial to the canine. The height of the mucobuccal fold anterior to the canine eminence. Area called the canine fossa
Supraperiosteal penetration site
Height of mucobuccal fault, above the apex of the tooth to be anesthetized
IO penetration site
Height of the musical buckle fold directly over first bicuspid. Locating infra orbital Freeman: move finger downward into the concave area of that infra orbital Freeman. Apply gentle pressure, feel that outline of the Freeman
NP penetration Saint
Palatal mucosa lateral to the midline of the insides of papilla
GP penetration site
Soft tissue slightly anterior to the greater palatine Freeman. To locate Palitine freeman, please cons wobble at the junction of maxillary alveolar process and hard palate just distal to the first molar. Move swab posteriorly until it falls into greater Palatine foremen usually just lingual to the second molar
IA penetration site
Medial to internal oblique Ridge, lateral to pterygoimandibular raphe at or above the height of the coronoid notch
LB penetration site
Buckle fold just distal and buckle to the most posterior molar for which soft tissue anesthesia is required
Mental and incisive penetration site
Miko buckle fold just superior to the mental foramen. Depth of mucobuccal fold superior to foramen
Infiltration penetration site
At the height of the mucobuccal fold near the apex of a single tooth. Visualize the long axis of the tooth and locate the apex for the penetration site. Use radiographs as a guide
Gow gates penetration site
Established using extra in intro oral landmarks. In mucobuccal membrane, directly posterior to maxillary second molar at the level of the mesial lingual cusp
Vazirani akinosi penetration site
Used for a closed mouth technique. Soft tissue medial to the Remus, directly adjacent to maxillary tuberosity. At height of mucogingival Junction a maxillary molars
What kind of fibers have been found in dental pulps
A and C fibers
Which fibers, a or C, are greater distributed
C fibers
Minimal sedation (anxiolysis)
Drug-induced state where patient responds normally to verbal commands. Seen with nitrous concentrations less than 50%. Cognitive functions and coordination may be impaired. Breathing in cardiovascular functions are unaffected
Moderate sedation
Drug induced depression of consciousness during which patients respond purposely to verbal commands. Airway and cardiovascular function maintained. Achieved with nitrous concentrations over 50%
Deep sedation
Drug induced depression of consciousness during which patients cannot be easily roused respond purposefully after repeated or painful stimulation. Independent airway maintenance may be impaired. Cardiovascular function maintained
Conscious sedation
Induced state of sedation characterized by a minimally depressed consciousness such that the patient is able to continuously and independently maintain a patent airway, retain protective reflexes, and remain responsive to verbal commands and physical stimulation
General anesthesia
Drug-induced loss of consciousness during which patients are not arousable even buy painful stimulation. Independent airway maintenance may be impaired in patient requires assistance to keep a patent airway and need positive pressure ventilation
Titration
Prices of administering a drug incrementally to a specific level or endpoint of sedation. Allows for the exact amount of the drug necessary to be delivered to every patient at every appointment
Where are amides metabolized
In the liver
Where are esters metabolized
Cholinesterase
Where are ketones of metabolized
They are not oxidized in the liver, but are carried to the skeletal and cardiac muscles where, under normal circumstances, they are rapidly metabolized
Where is nitrous metabolized
99% of nitrous is eliminated due to long without biotransformation and is not metabolized through the liver. .004% metabolized in the G.I. tract by the anaerobic bacteria pseudomonas
Soluble drugs
Defuse immediately into the blood and gets distributed throughout the body.
Blood – gas partition will be high
More drug and/or more time will be needed to achieve equilibrium
Blood brain barrier will be crossed rapidly
Onset of clinical action is rapid
Insoluble drugs
nitrous which is a relatively insoluble drug.
It remains unchanged in the blood and does not combined with any other blood elements
Onset is slow and blood brain barrier is crossed slowly
Less time will be needed to achieve equilibrium
Blood-gas partition will be low
Nitrous effects on the cardiovascular system
Blood pressure affects maybe does related, can see a decrease in blood pressure
Nitrous effects on the respiratory system
If a patient has a condition where it is hard to breathe out of the nose, insufficient amounts of nitrous will enter respiratory system.
For those with other deliberated respiratory conditions, nitrous may be considered a relative contraindication
Nitous effects on the central nervous system
Has the ability to depress the central nervous system. Evidence to injury to the central nervous system with chronic exposure.
Can be used on patients that have a history of stroke, seizure disorder, and Parkinson’s disease
Nitrous effects on the hematopoietic system
Megaloblastic bone marrow changes have been found in patients exposed to high concentrations over a prolonged period
Nitrous effects on the gastrointestinal system
If you’re patient suffers from a bowel obstruction, postpone nitrous due to the risk of expansion, pressure and discomfort
Nitrous effects on the reproductive system
Do not use in the first trimester of pregnancy, it crosses the placental barrier
Nitrous effects on the neuromuscular system
Nitrous does not provide direct skeletal muscle relaxation. Gives muscles rigidity with higher levels.
Can be used safely with patients with multiple sclerosis, muscular dystrophy, cerebral palsy, myasthenia gravis
Nitrous effects on mind altering conditions
Patients should be able to understand the procedure and it’s effects. Discretion should be taken when using with a recovering addict or mental illness. Severe phobics may not benefit from it, can make the situation worse
Malignant hyperthermia
A disease passed down through families that cause a fast rising body temperature snd severe muscle contractions when the affected person gets general anesthesia
Life threatening condition
Importance of obtaining health histories
Comprehensive patient assessment is necessary in order to minimize adverse events related to receiving local anesthesia
Relative contraindications for nitrous
Dry air asthma, substance abuse, alcoholism, claustrophobia, post dramatic stress disorder, Leap text sensitivity, current CNS depressant use, patients with colostomy vague or bowel obstruction, cystic fibrosis, autism, pregnancy in the second and third trimesters
Absolute contraindications for nitrous
Hypoxic – driven, advanced chronic obstruction pulmonary disease, active respiratory infections, first trimester pregnancy, intraocular gas injection within 8 to 12 weeks, severe psychosis, latex allergy if non-latex nitrous sedation systems are unavailable, recent typanic membrane graphing, treatment involving the injection of gases into any body cavity
Armamentarium
Refers to all equipment, materials, devices, and method is used during the delivery of local anesthetic agents
What is the most important step in the delivery of local anesthetic
Aspirating
What is the second most important step in delivering local anesthetics
Slow delivery
ASA I
A normal, healthy patient
ASA II
Patient with mild systemic disease
ASA III
A patient with severe systemic disease, or more likely to experience adverse events
May still be considered for elective dental procedures with local anesthetic. Modify treatment for safety.
ASA IV
A patient with severe systemic disease that is a constant threat to life
Elective dental care is contra indicated for these patients
Local complications
Ocher more frequently than systemic complications. Examples are:
Post operative soreness, prolong anesthesia, soreness at area of injection, syncope, pain from self injury, mild inflammation following muscle penetrations
Systemic complications
Toxicity: occur less frequently but are generally more serious. Examples are:
Overdose, allergy, idiosyncratic response
Hematoma complication
Form when a blood vessel gets nicked during injections in blood leaks into the surrounding tissue
Development can be rapid in dramatic, most common site is the PSA, avoid by aspirating, keeping needle straight, minimizing needle penetrations, avoiding moving needle around in tissues, discontinue treatment, apply pressure in ice, tell patient to avoid aspirin, advise patient of what to expect
Trismus
Motor disturbance of the trigeminal nerve – inability to open mouth
Most frequently occurs in the medial pterygoid muscle, followed by the lateral pterygoids and the temporalis
Causes of trismus
Tetanus-lock jaw-, tumors, bony ankylose, foreign bodies, fracture, facial space infections, in large coronoid processes, hemorrhage in muscle trauma following injection, drama to Needle movements, local anesthetic toxicity,
Prevention of trismus
Minimize the number of needle penetrations, change needles frequently, endure needle contamination does not occur
Management of trismus
Apply hot, moist towel for 20 minutes every hour, use analgesics as needed, open/close mouth gradually/repeatedly, monitor for signs of infection, if signs/symptoms worsen, contact oral surgeon or position
Causes a needle fractures
Unexpected movements, too small of lumen, bending needle at the hub, inserting needle too far, all the needles, excessive force and repositioning, excessive number of penetrations with the same needle
Management of needle fractures
Have sterile forceps nearby, do not allow patient to close mouth, if needle is visible remove with a hemostat, if needle isn’t visible inform impatient, immediately referred to an oral surgeon and keep a detailed record
Paresthesia
And altered sensation and/or persistent partial or complete numbness. Occurs most frequently in the lingual nerve
Hyperesthesia
Increased sensitivity to stimuli following nerve injury
Dysesthesis
The sensation of pain from non-noxious stimuli that may follow local anesthetic procedures
Ageusia
Absolute loss of ability to perceive sweet, sour, bitter or salt substances due to chorda tympani injury
Hypogeusia
Relative loss
Possible causes a paresthesis
Direct trauma from surgery or injury, drug-induced – neurotoxicity –, detergent effects of drugs, pressure from localized Adema, hire local anesthetic drug concentration, vascoconstrictors and their preservatives
Prevention of paresthesia
Slow disposition, reduce volumes for 4% drugs by 50%, for articaine, use my block techniques – GG or VA –, in pallet, limit volumes to less than .9 mL, examine your needle for barbs
Managing paresthesia
Speak with the patient personally, reassure the patient, schedule to evaluate the patient ASAP, document the conversation, determine a record the extent and degree, diagram field of altered sensation, explain that it may last a while, update map at follow up appointments
Allergy
Can be local or systemic reactions, systemic allergic reactions can be life-threatening, can be an allergy to and amide or the sulfite preservative for Vascoconstrictors
Angioedema
Localized swelling brought about by the rapid release of histamine’s
The pathway of biotransformation in the liver is known as what
Hepatic p450 isoenzyme system
Metabolism in the blood by enzymes is called what
Cholinesterase or plasma Cholinesterase
Eutectic mixtures
Provide more rapid onset, greater depth of penetration on skin and mucous membranes,
Anxiolytic
Sedative effects
Ability to cope with the procedure depends on factors such as age, gender, previous experiences and personality characteristics
Amnestic
Patients often state they cannot recall the severity of their pain or anxiety or its duration. Patient receives the time passed quickly
Analgesic
Pain control. Reduces fear which can help reduce pain
A mixture of 20% nitrous to 80% oxygen has the same analgesics as what
15 mg of morphine
