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Pain Management > Test 2 > Flashcards

Test 2 Flashcards

1
Q

What do vasoconstrictors oppose in local anesthetics?

A

Oppose rapid uptake

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2
Q

Specific protein receptor theory

A

The binding of local anesthetic molecules to structural proteins known as specific protein receptor sites. Temporarily transform nerve membranes to nonexcitability.

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3
Q

2 primary routes of delivery

A

Topical

Submucosal injection

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4
Q

Topical route of delivery

A

Effective on mucosa due to ease of penetration through mucosal barriers

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5
Q

Submucosal injections route of delivery

A

Allows for direct placement of drug close to nerves

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6
Q

Desirable properties of local anesthetics (3)

A

Biocompatibility, safety and efficacy, and pKa and pH.

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7
Q

Biocompatibility

A

Nonirritable, nontoxic to tissues, nonallergenic, biotransformable, completely reversible, no systemic effects

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8
Q

Safety and efficacy

A

Effective in tissues and mucous membranes, rapid onsets and no residual effects, therapeutic durations, adequate potency, sterilizable, patient remains conscious.

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9
Q

pKa and pH

A

Relevance of pKa (the dissociation constant) and pH. When pKa=pH, there is an equal distribution of cations and unchanged base molecules in solution

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10
Q

Clinical application of pKa

A

Local anesthetics have pKa range from 7.7-8.1. Determine onset of local anesthetics

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11
Q

Primary benefit of local anesthetic

A

Suppression of pain sensations without significant central nervous system depression. Allows for the majority of dental procedures to be performed under local anesthesia without exposing patients to the risks of general anesthesia

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12
Q

Biotransformation

A

Metabolism of local anesthetic drugs, reduces or eliminates their toxicity. Breaks down the drug into its components called metabolites. Process occurs primarily through one of two pathways, the liver or in the blood.

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13
Q

Liver pathway

A

Hepatic p450 isoenzyme system

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14
Q

Metabolism in the blood is by what?

A

Pseudocholinesterase

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15
Q

What is an enzyme responsible for

A

Breaking down esters

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16
Q

Biotransformation of amides

A

Amides are bupivscaine, lidocaie, and mepivacaine.
In the liver by hepatic p450 isoenzymic system. In addition to the liver, prilocaine is biotransformed in the kidneys and lungs with very little excreted unchanged

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17
Q

Biotransformation of esters

A

Esters include benzo cane, procaine, tetracaine. Biotransformed in the blood by pseudochlorinesterase

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18
Q

Elimination half-life

A

The rate at which a drug is removed from the system execution. The time necessary to metabolize and secrete 50% of a drug. Shorter half-life drugs may be readministered sooner with less risk of overdose. Consideration should be made with nursing mothers. Articaine has the shortest half-life of all amides

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19
Q

Shortest to longest half-life of amides

A 
Articaine equals .75 hours. 
Prilocaine equals 1.6 hours. 
Lidocaine equals 1.6 hours. 
Mepivacaine equals 1.9 hours
Bupivicaine equals 3.5 hours
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20
Q

Nasopalatine landmark

A

Incisive foramen

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21
Q

Risks for nasopalatine

A

Minimal risk. Post op pain injection. Hematoma rarely. Postop edema

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22
Q

Indication for nasopalatine

A

Palatal soft and osseous tissue in the anterior third of the palate: canine to canine

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23
Q

Landmarks for palatal anterior superior alveolar

A

Nasal Palantine canal in the incisive papilla

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24
Q

Risks for the palatal anterior superior alveolar

A

Risk is minimal. Postop pain injection site. Hematoma rarely. Post op edema. Risk of necrosis with use of epi-

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25
Q

Indications for palatal anterior superior Alveolar nerve

A

Pain management of the maxillary anterior sextons in is especially useful in cosmetic procedures that involve smile lines

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26
Q

Landmarks for the anterior middle superior alveolar nerve block

A

Between the premolars. Junction between the vertical Alveolar process and horizontal palatal process

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27
Q

Risks for the anterior middle superior alveolar

A

Risk is minimal. Some patients experience a burning at site of injection. Postop pain at injection site. Hematoma rarely. Postop edema. Risk of the necrosis increases with the use of epi-

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28
Q

Indication of anesthesia for the anterior middle superior alveolar

A

Pain management of the incisors, canine, and premolars on the anesthetized side as well as palatal tissue from the midline through the molars in the buccal periodontium of the pulpally affected teeth

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29
Q

Landmarks for a greater palatine

A

Greater palatine formation is found palatal to the apices of the second and third maxillary molars

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30
Q

Risks for greater Palantine

A

Post procedural heretic lesions are more common in palatal injections. Caution with epi to prevent palatal necrosis. Hematoma rarely. Post op edema

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31
Q

Indications for greater Palatine

A

Pain management of the palatal soft in osseous tissues distal to the canine in one quadrant

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32
Q

Landmarks for that inferior alveolar

A

Pterygomandibular raphae. Coronoid not on the anterior border of the Ramis of the mandible. Internal oblique Ridge on the medial surface of the molars and continuing posteriorly.

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33
Q

Risks for the inferior alveolar

A

Trismus: post injection soreness or limitation. Paresthesia: nerve injury/prolong anesthesia. Post operative soft tissue injury – biting of lip, cheek or tongue

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34
Q

What injection has the highest failure rates in dentistry

A

Inferior alveolar. This is due to anatomical variations, need for deeper penetration, depositing too far from foramen and accessory innervation from other nerves

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35
Q

What are alternative injections for the inferior alveolar

A

Gow gates, vazirani-akinosi, intraosseous injections including periodontal ligament.

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36
Q

Landmarks for lingual nerve block

A

Same as inferior alveolar- Pterygomandibular Rafe, coronoid not on the anterior border of the ramus of the mandible, internal oblique ridge of the medial surface of the mandible

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37
Q

Risks for the lingual nerve block

A

Lingual nerve is one of the most frequent injured nerves during dental injections. Symptoms range from transient “electric shock” to permanent paresthesia

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38
Q

Alternative injections for lingual nerve block

A

GG nerve block. Multiple infiltrations

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39
Q

Landmarks for buccal nerve block

A

Buccal fold just distal and buccal to the most posterior roller for which soft tissue anesthesia is required.

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40
Q

Risks for buckle nerve block

A

Rare: bleeding and hematoma

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41
Q

Alternative injections for buckle nerve block

A

Rarely needed. Multiple infiltrations

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42
Q

Key landmarks for mental/incisive nerve block

A

Depth of mucobuccal fold superior to mental foramen. Or just anterior to the mental foramen. Berries with location of the mental foramen: locate the foramen prior to penetration and use radiographs or your finger

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43
Q

Risks for mental/incisive nerve block

A

Bleeding, hematoma, postoperative discomfort

44
Q

Alternative injections for mental/incisive nerve block

A

Multiple infiltrations

45
Q

Landmarks for incisive nerve block

A

Same as mental nerve block: depth of mucobuccal fold superior to foramen. Or just anterior to the mental foramen

46
Q

Risks for incisive nerve block

A

Bleeding, hematoma, postoperative discomfort

47
Q

Alternative injections for incisive nerve block

A

Multiple infiltrations

48
Q

Risks for Gow gates

A

Injection into temporomandibular joint or optic ganglion. Temporary paralysis of cranial nerves – three, four, and five. Hematoma

This is a true mandibular block

49
Q

PDL indications

A

Used when other injections have failed. When widespread anesthesia is contra indicated. For patients with bleeding disorders in highly vascular areas.

50
Q

PDL technique

A

Enter the Saugus then penetrate the junctional epithelium. Advanced within the PDL to a point of resistance. Look for blanching in the attached gingiva of the tooth. Can bend the needle in the middle to gain access to the area you want to numb

51
Q

Intra septal injection

A

Provides anesthesia to the periodontium lingual to a tooth. Inject through the soft tissue until the bone is contacted

52
Q

Intra pulpal

A

Used when the pulp is inflamed. Non-intraosseous. Penetrate directly into vital pulpal tissues

53
Q

Administration related factors

A

Device related factors. Needle bevel considerations- orientation recommendations. Needle deflection consideration- gauge of needle. Quality of cartridge contents – damage to solutions during shipping and handling. Clinical judgment – adequate volumes of solution

54
Q

Volume considerations for troubleshooting in adequate anesthesia

A

Volume must be adequate to flood targeted neural membranes. This must be according: anatomy, individual responses – previous history of responses to anesthetic, Length of anticipated treatment

55
Q

Physiological barriers for troubleshooting in adequate anesthesia

A

Phobias of needles, fear of insufficient anesthesia, hating the feeling of being numb

56
Q

Physical barriers for troubleshooting in adequate anesthesia

A

Bony prominences, shallow vestibules, die lacerations, small foramens

57
Q

Chemical barriers for troubleshooting inadequate anesthesia

A

Inflammation, infection, vascular injury

58
Q

Tachyphylaxis

A

Refers to the failure of subsequent administrations of local anesthetic – in the same appointment – to prolong the duration, extent, and intensity of the anesthetic effect. Causes can be tissue edema, localized hemorrhaging, decreases in tissue pH, clot formation

59
Q

Accessory (expected) innervations

A

Typical, and expected, deviations

60
Q

Aberrant (unexpected) innervations

A

Unexpected variations, highly unusual. Majority of abarrant innervation failures can be addressed with PDL injections

61
Q

Atypical innervation for posterior superior Alveolar block

A

PSA injection may require greater Palatine block or a PDL as a supplement

62
Q

Atypical innervation for middle Superior alveolar block

A

MSA nerves are missing in a significant percentage of the population. Clinicians can infiltrate as needed

63
Q

Atypical innervation for anterior superior alveolar block

A

Crossing novation from the contralateral side ASA nerve. Phone in the anterior maxilla is unusually dense. The vestibule has little vertical height. Maxilla has an exaggerated curvature over the roots of the teeth

64
Q

Atypical innervation for palatal innervations of maxillary central incisors

A

May need supplemental injections with nasal Palantine nerve or a PDL injection

65
Q

Atypical innervation for inferior alveolar nerve block

A

IA Nerve block has a relatively high incidence of in adequate anesthesia. Can pause assessor he innervation from: mylohyoid nerves – incidence of 60% –, buckle nerves, lingual nerve, contralateral incisive and mental nerves, sensory fibers traveling with motor fibers, bifid IA nerves, branches from the cervical plexus – to the anterior teeth –

66
Q

Atypical innervation of intravascular injection

A

Intravascular injections take solution away from the target site and distributed throughout the body

67
Q

Atypical innervation for inflammation

A

Performing nerve blocks away from the side of information can help. Local anesthetic drugs are package primarily in cationic form; as they diffuse through healthy tissue with pH values near 7.4

68
Q

Local complications

A

Occur more frequently then systemic complications. These include: postoperative soreness, prolong anesthesia, soreness at area of injection, syncope, pain from self injury, mild inflammation following muscle penetrations

69
Q

Systemic complications

A

(Toxicity) occur less frequently but are generally more serious. These include: overdose – peripheral nerve blocks; associated with the highs incident of systemic toxicity-, allergy, idiosyncratic response.

70
Q

Hematoma

A

Form when a blood vessel get snipped during injections and blood leaks into the surrounding tissue. Development can be rapid and dramatic. Most common site is the PSA – close proximity to the pterygoid Plexes –. Avoid by aspirating, keeping needle straight, minimizing needle penetrations, avoiding moving needle around in the tissue. Discontinue treatment, apply pressure and ice. Tell patient to avoid aspirin, advised patient of what to expect

71
Q

What does trismus include

A

Motor disturbance of the trigeminal nerve. Most frequently occurs in the medial pterygoid muscle, followed by the lateral pterygoid and the temporalis. Causes include: tetanus (lock jaw), tumors, bony ankyloses, foreign bodies, fracture, fascial space infections, in large coronoid processes, hemorrhage and muscle trauma following injection, drama to need a movement,

72
Q

Prevention of trismus

A

Minimize the number of needle penetrations, change needles frequently, I sure needle contamination does not occur. THIS IS MOST IMPORTANT TO MINIMIZE CONTACT WITH A STERILE NEEDLE

73
Q

Management of trismus

A

Apply hot, moist towels for 20 minutes every five hours – five minutes on, 10 minutes off –, use analgesics as needed, Open/close mouth gradually/repeatedly, monitor for signs of infection, if signs/symptoms worsen, contact oral surgeon or position

74
Q

Causes a needle fracture

A

Use proper gauge and link needles to avoid broken needles
Causes include: unexpected movements, too small of lumen, bending needles at the hub, inserting needle too far, faulty needles, excessive force and repositioning, excessive numbers of penetrations with the same needle

75
Q

Management a needle fracture

A

Have sterile hemostat/forceps nearby, do not allow patient to close mouth, if needle is visible, remove with hemostat, if needle isn’t visible: inform patient, IMMEDIATELY referred to oral surgeon, keep detailed records – location, size, patient communication log –

76
Q

Self injury

A

Inform patient and/or caregivers of risk of self injury following anesthesia

Injuries include: tongue, lips, cheek biting. Burning of mouth via food/drinks.

77
Q

Management of self injury

A

Palliative therapy; such as over-the-counter preparations for protection of oral sores and pain relief

78
Q

OraVerse

A

Agent that can help reverse- of soft tissue – anesthesia

79
Q

Where does paresthesia most frequently occur

A

In the lingual nerve

80
Q

Paresthesia

A

And altered sensation and/or persistent partial or complete numbness. Has the potential to affect taste if the chorda tympani is involved.

81
Q

Hyperesthesia

A

Increased sensitivity to stimuli following nerve injury

82
Q

Dysesrhesia

A

Sensation of pain from non-noxious stimuli that may follow local anesthetic procedures

83
Q

Ageusia

A

Absolute loss of ability to perceive sweet, sour, bitter or solid substances due to chorda tympani injury

84
Q

Hypogeusia

A

Relative loss

85
Q

Possible causes a paresthesia

A

Direct trauma from surgery or needle, drug-induced=neurotoxicity, detergent effects of drugs, pressure from localized Adema, hire a local anesthetic drug concentrations, that’s vascoconstrictor and their preservatives

86
Q

Prevention of Paresthesia

A

Slow disposition, reduce volumes for 4% drugs by 50%, for articaine, use high block techniques, in pallet, limit volume to

87
Q

Paresthesia response/management

A

Speak with the patient personally, reassure the patient, schedule to evaluate the patient as soon as possible, document the conversation, determine and record the extent in degree, diagram field of altered sensation,

88
Q

Allergy

A

A major difference between overdose and allergy is that allergies are not dose-dependent. Can be local or systemic reactions, systemic allergy reactions can be life-threatening, can be an allergy to and amide or the sulfite preservative in the vasoconstrictor.

89
Q

Localized allergy reactions

A

Most frequent after topical anesthesia contact, usually limited to, respond well to antihistamines, majority of contact allergies due to the metabolic byproduct of esters

90
Q

How to respond to allergy

A

Rapid recognition and response. Removal of remaining traces of topical drugs

91
Q

Prevention of allergy

A

Avoid: medications that have induced allergy in the past, same – glass topicals that produced hypersensitivities, consult with previous providers whenever patient reports past allergic experiences, referred for allergy testing to confirm reports, document in the chart

92
Q

Management of delayed reactions to allergies

A

Schedule ASAP to evaluate post operative allergic lesion/reactions, recommend over-the-counter Benadryl or prescribe diphenhydramine as appropriate

93
Q

Systemic allergic reaction

A

Less frequent than local, yet far more serious. May occur due to: local anesthetic drugs themselves, sulfite preservatives with vasoconstrictors, even after, to the byproduct of hydrolysis

94
Q

Symptoms of systemic reactions

A

Skin reactions, G.I./GU reactions, respiratory, CVS,

95
Q

Management of systemic reactions

A

Administer oxygen, administer epinephrine: adult .3 mg intramuscularly or subcutaneously, child .15 mg. administer diphenhydramine: adult 50 mg intramuscularly or subcutaneously, child 25 mg

96
Q

Fear

A

An emotional response to immediate threat or danger; that’s that something bad might happen; heart rate increases, sweating, hyperventilation, nausea; shaking, pacing, rapid speech

97
Q

Anxiety

A

An emotional response to a threat or danger that is not immediately present or is unclear; can occur hours or days before the appointment

98
Q

Phobia

A

Persistent, irrational fear of a specific object or situation that results in a compelling desire to either avoid the situation or two endured with dread; phobias interfere with the person’s ability to function; interfere with oral health, resulting in pain

99
Q

Behavioral overt signs for phobia

A

Pacing the waiting room, visiting, ringing hands, gripping the arms of chairs

100
Q

Physiological signs of phobias

A

Perspiration, changes in respiration, shallow breathing, increased heart rate, increased blood pressure

101
Q

Three concepts to consider when treating fearful patients

A
  1. The patient clinician relationship. 2. The patient sense of control over a potentially threatening environment. 3. The patient’s ability to cope with a stressful situation
102
Q

Informational control

A

Emphasis on the sensations that the patient will experience, the steps involved, and time expected for treatment

103
Q

Behavioral control

A

Allows patients to take actions to lesson, shortening, or terminate stressful situations; example: raise left-hand during procedure

104
Q

Cognitive control

A

Mental maneuvers through which patients can lessen their Feafel, negative thoughts in their reactions to these thoughts; distraction strategies of listening to music or watching TV

105
Q

pKa

A

Dissociation constant

Pain Management (3 decks)

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