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Intro to Oral Surgery & Pain Management > Comprehensive Study Guide > Flashcards

Comprehensive Study Guide Flashcards

1
Q

Label water the following ions are intra- or extra-cellular:

  1. K+
  2. Na+
  3. Cl-
  4. proteins
  5. HCO3-
A
  1. ICF
  2. ECF
  3. ECF
  4. ICF
  5. ECF
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2
Q

Intracellular ions=

A

K+ & proteins (More negative)

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3
Q

Extracellular ions=

A

Na+, Cl-, HCO3-

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4
Q

Where do local anesthetics exert their pharmacological action on the nerve?

A

nerve membrane

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5
Q

How do local anesthetics work?

A

Specific receptor theory- local anesthetic binds to specific receptors on the Na+ channel

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6
Q

What does the specific receptor theory state?

A

The local anesthetic binds to a specific receptor on the Na+ channel to prevent the channel from opening (therefore no action potential & no pain)

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7
Q

Which ion channel do local anesthetics bind to?

A

Specific receptors on the Na+ channel

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8
Q

Speed of conduction of a myelinated nerve:

Speed of conduction of an unmyelinated nerve:

A

myelinated: 120 m/s

unmyelinated: 1.2 m/s

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9
Q

Where do local anesthetics work at the myelinated nerve?

A

Local anesthetics work at the nodes of ranvier (abundance of sodium channels here)

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10
Q

In order for local anesthetic to work on a myelinated nerve it needs to block:

A

2-3 nodes (8-10mm of the nerve)

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11
Q

Drug: Lidocaine
Onset:
Half-Life:
Mg/Kg of max dose:

A

Onset: 2-3 min
Half-life: 1.6 hrs
(1 hr of pulpal, 3-5 hrs of soft tissue for 2% solution)
Mg/Kg of max dose: 4.4 mg/kg (300mg)

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12
Q

Drug: Prilocaine
Onset:
Half-Life:
Mg/Kg of max dose:

A

Onset: 2-4 min (slightly slower)
Half-Life: 1.6 hrs
Mg/Kg of max dose:6.0 mg/kg (400mg)

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13
Q

Drug: Mepivacaine
Onset:
Half-Life:
Mg/Kg of max dose:

A

Onset: 1.5-2 min (rapid!)
Half-Life:1.9 hr
(20-40 min of pulpal. 2-3 hrs of soft tissue anesthesia)
Mg/Kg of max dose: 4.4mg/kg (300 mg)

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14
Q

Bupivacaine:
Onset:
Half-Life:
Mg/Kg of max dose:

A

Onset: 6-10 min (longer)
Half-Life:2.7 hrs (long!)
Mg/Kg of max dose: 1.3 mg/kg (90 mg)

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15
Q

What drug would be used when more than 90 min of pulpal anesthesia is needed and is also used to reduce post-op pain?

A

Bupivacaine

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16
Q

Drug: Articaine
Onset:
Half-Life:
Mg/Kg of max dose:

A

Onset: 1-2 min (rapid!)
Half-Life: 0.5 hrs (short!)
(0.5 hrs of pulpal and 3-5 hrs of soft tissue for 4%)
Mg/Kg of max dose: 7 mg/kg (500 mg)

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17
Q

Drug: Cocaine
Onset:
Half-Life:

A

Onset: immediate-1 min
Half-Life: 1-1.5 hours

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18
Q

Drug: Procaine
Onset:

A

Onset: 6-10 min

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19
Q

List the following anesthetics in order of fastest to slowest onset:

-Bupivacaine
-Articaine
-Prilocaine
-Procaine
-Cocaine
-Mepivacaine
-Lidocaine

A

(Fastest)
1. Cocaine
2. Articaine
3. Mepivacaine
4. Lidocaine
5. Prilocaine
6. Bupivacaine
7. Procaine
(Slowest)

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20
Q

List the following anesthetics in order of longest to shortest duration:

-Bupivacaine
-Articaine
-Prilocaine
-Procaine
-Cocaine
-Mepivacaine
-Lidocaine

A

(Longest)
1. Bupivacaine
2. Mepivacaine
3. Lidocaine = Prilocaine
4. Cocaine
5. Articaine

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21
Q

For maximum recommended dose (MRD) what guidelines do we follow?

A

ADA & USPC guidelines (NOT manufacturer)

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22
Q

How does low tissue pH influence local anesthesia?

A

Low tissue pH (high acidity (H+) is harder to anesthetize (usually associated with inflamed or infected tissues)

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23
Q

How does low anesthetic pH influence local anesthesia?

A

Low anesthetic pH leads to higher effective shelf life

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24
Q

What is the average pH of local anesthetics?

A

5.5-7.0

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25
Q

If the pH of the environment does not allow the ________ of anesthetic to exist, numbing will NOT occur

A

free base form

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26
Q

In order for the local anesthetic to work, the pH of the environment:

A

must allow the free base form to exist

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27
Q

What is the free base form of the local anesthetic?

A

what enters the nerve membrane

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28
Q

The further the pH is from the ideal for that specific anesthetic, the:

A

lower the percentage of that local anesthetic will be present in free base form

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29
Q

Is local anesthetic hydrophilic or hydrophobic?

A

amphipathic (both hydrophilic and hydrophobic)

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30
Q

What is an exception to local anesthetic being amphipathic?

A

Benzocaine; doesn’t have hydrophilic group - good for topical but not good for injections)

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31
Q

_____ determines the ease for the nerve blockade

A

extracellular pH

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32
Q

Inflamed or infected tissue is much more difficult to get adequate anesthesia because:

A

of increased H+ or lower pH

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33
Q

RNH+ —> RN + H+ describes:

A

The dissociation of local anesthesia

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34
Q

RNH+ —> RN + H+

What does the RN represent?

A

Free base

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35
Q

RNH+ —> RN + H+

What does the RNH+ represent?

A

Cation

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36
Q

RNH+ —> RN + H+

In this reaction, if there’s excess H+, the equilibrium will shift to the _____

What is the significance of this?

A

Left (RNH+ side)

this means that if there is an acidic environment (example- really infected tooth with lots of bacteria is very acidic) it will be harder to anesthetize because there is less of the free base form (RN) which is what actually enters the nerve membrane

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37
Q

Only the _______ of the anesthetic can enter the nerve, which is important because the sodium channel must be blocked ________

A

free base form (ninja); from the inside

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38
Q

Anesthesia is injected as an ______ that _______

A

ionized cation; cannot cross the nerve cell membrane

(until broke down into free-base form)

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39
Q

The anesthesia that is injected must break down from its _____ form into ______ form in order to diffuse into the nerve cell membrane

A

ionized cation; non-ionized free-base

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40
Q

Once in the nerve, the free base can become the ionized version again and bind to the specific receptor to:

A

prevent sodium channel from opening

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41
Q

Once the free base form of the local anesthetic is diffused. it must ____ in order to bind to the receptor

A

dissociate back into the cationic form

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42
Q

Once the free base form of the local anesthetic is diffuse, it must dissociate back into the cationic form in order to bind to the receptor- what does this binding to the receptor cause?

A

Prevents Na channel from opening

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43
Q

Describe the following relationships between pKA vs local anesthesia:

  1. High pKA:
  2. Low pKA:
A
  1. slow onset (few free bases available)
  2. rapid onset
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44
Q

Local anesthesia are _______- They combine with acids to form local anesthetic salt (HCl)

A

weak basic compounds

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45
Q

pKA influences _______

A

onset (inverse relationship)

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46
Q

Describe why a high pKA would have a slower onset:

A

because there are fewer free bases to diffuse (fewer ninjas without their backpack that can get through- most ninjas still have their backpack on so they cannot cross inside the nerve cell membrane)

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47
Q

How does lipid solubility influence local anesthesia?

A

With increased lipid solubility, the drug is more potent

With decreased lipid solubility, the drug is less potent

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48
Q

The relationship of pKA to onset is ______

The relationship of lipid solubility to local anesthesia potency is _____

A

inverse

direct

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49
Q

The nerve membrane is ____% lipid

A

90%

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50
Q
  1. What influences the ONSET of local anesthesia?
  2. What influences the POTENCY of local anesthesia?
  3. What influences the DURATION of local anesthesia?
A
  1. pKA
  2. Lipid solubility
  3. protein binding
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51
Q

With increased protein binding the drug has _________

A

longer duration

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52
Q

With decreased protein binding the drug has ______

A

shorter duration

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53
Q

The nerve membrane is _____% protein

A

10%

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54
Q

With increased lipid solubility, the drug is:

A

more potent

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55
Q

With decreased lipid solubility, the drug is:

A

less potent

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56
Q

With a high pKA the onset of local anesthesia is:

A

slow (less free base form available)

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57
Q

With a low pKA the onset of local anesthesia is:

A

rapid

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58
Q

Most local anesthetics have a ______ effect

A

vasodilation

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59
Q

Which local anesthetic has the most profound vasodilator effect?

A

Procaine

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60
Q

The only local anesthetic with a vasoconstrictor effect?

A

Cocaine

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61
Q

What is used with local anesthetics that has a vasoconstrictive effect?

A

epinephrine

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62
Q

Cocaine is a vasoconstrictor (meaning its alpha-1) and works by:

A

inhibition of catecholamine re-uptake

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63
Q

Alpha-1 =

A

vasoconstriction

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64
Q

Beta-2 =

A

vasodilation

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65
Q

What agent has the most potent vasodilation properties?

A

Procaine

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66
Q

“I” comes before the “Caine”if the agent is:

A

an amide

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67
Q

_____ agents are easily hydrolyzed in aqueous solutions

A

esters

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68
Q

List some examples of local anesthetics that belong to the ester class: (6)

A
  1. Procaine
  2. Propoxycaine
  3. Tetracaine
  4. Cocaine
  5. Benzocaine
  6. Dyclonine
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69
Q

____ agents resist hydrolysis & get excreted in urine as an unchanged form

A

amides

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70
Q

List some examples of local anesthetics that belong to the amide class: (6)

A
  1. Lidocaine
  2. Etidocaine
  3. Mepivocaine
  4. Bupivocaine
  5. Prilocaine
  6. Articaine
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71
Q

what are the two different classes of local anesthesia?

A

amides & esters

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72
Q

How do amides metabolize in the body?

A

The liver is the primary biotransformation site

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73
Q

Metabolism of what class of local anesthetic may lead to cirrhosis/CHF or hypotension?

A

Amide metabolism

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74
Q

How do esters metabolize in the body?

A

Hydrolyzed in the plasma by pseudocholinesterase into paraaminobenzoic acid (PABA)

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75
Q

What is a substance in local anesthetics that individuals commonly have a reaction to? Is this in amide anesthetics or ester anesthetics?

A

PABA; Esters

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76
Q

What is the relationship between cirrhosis patient and metabolism of local anesthetics?

A

Liver function/hepatic perfusion influence biotransformation

(1) cirrhosis –> late stage of scaring (fibrosis) of the liver

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77
Q

When is local anesthetics a contraindication for patients with liver issues?

A

ASA IV to V for patients with liver dysfunction (or heart failure)

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78
Q

How do cirrhosis and/or CHF interfere with the amounts of your local anesthesia injection?

A

Amide LAs are chemically modified (metabolized in the body in the liver, so since the liver is not functioning well (doesn’t have full metabolic capacity) then less LA should be administered

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79
Q

If a patient has cirrhosis and/or liver failure, do you give them more or less anesthetic when injecting?

A

less

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80
Q

Does a patient who has cirrhosis and/or liver failure increase or decrease the availability of the amide local anesthetic? Explain:

A

Increases Thea availability because the amide is not being metabolized as quickly more is left in the body for longer periods of time

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81
Q

Which organ in the body has the greatest concentration of local anesthesia?

A

skeletal muscle

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82
Q

What is tachyphylaxis?

A

the increase in tolerance to drug after repeated administration

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83
Q

Explain how you calculate elimination half-life:

A

Take percentage of leftover, divide that in half, them add it on to what has been eliminated thus far

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84
Q

what does elimination half life describe?

A

the amount of time needed for 50% reduction in the blood level

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85
Q

list the percentages of elimination of the following elimination half-lifes:

1st half life: 50% eliminated
2nd half life:
3rd half life:
4th half life:

A

1st half life: 50%
2nd half life: 75%
3rd half life: 87.5%
4th half life: 94%

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86
Q

Do all local anesthesia readily cross the BBB and placenta?

A

yes

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87
Q

What is the cause of local anesthesia overdose/toxicity?

A

over injection or repeated injections in the blood stream & systemic circulation

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88
Q

To prevent local anesthesia overdose/toxicity it is important to:

A

aspirate

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89
Q

What are the initial signs of local anesthesia overdose/toxicity?

A

Initially causes excitatory response (numbness of tongue and circumoral region slurred speech, shivering AV disturbances. tremor, etc.)

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90
Q

If you ignore the initial signs of local anesthesia overdose/toxicity, what may occur?

A

patient an go into a seizure and if you continue loading them up with more local anesthesia they will stop breathing

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91
Q

What are the later signs/stages of local anesthesia overdose/toxicity?

A

Depressive response on CNS with a lesser CV effect as well as agitation, confusion, dizziness, drowsiness, dysphoria, auditory changes, tinnitus, perioral numbness, metallic taste, etc.

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92
Q

Causes excitatory response (numbness of tongue and circumoral region slurred speech, shivering AV disturbances. tremor, etc.)

A

Initial stage of local anesthesia overdose/toxicity

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93
Q

Depressive response on CNS with a lesser CV effect as well as agitation, confusion, dizziness, drowsiness, dysphoria, auditory changes, tinnitus, perioral numbness, metallic taste, etc.

A

Later stage of local anesthesia overdose/toxicty

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94
Q

The initial clinical signs/symptoms of CNS toxicity are:

A

excitatory

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95
Q

Higher levels of toxicity from local anesthesia may result in:

A

tonic-clonic convulsion (seizure)

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96
Q

In the later stages of toxicity, or where there is further increases in anesthetic beyond the initial symptoms, there will be:

A

cessation of seizure activity –> respiratory depression –> respiratory arrest

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97
Q

Catecholamines include:

A

epinephrine, norepinephrine, dopamine

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98
Q

Non-catecholamines include:

A

amphetamine, ephedrine, methamphetamine

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99
Q

Epinphrine, norepinephrine & dopamine are all categorized as:

A

natural catecholamines

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100
Q

Isoproterenol & levonordefrin are both categorized as:

A

synthetic catecholamines

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101
Q

Contain hydroxyl group on benzene ring and work directly on adrenergic receptors (alpha 1,2 and beta 1,2)

A

Catecholamines

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102
Q

Do not contain hydroxyl group on benzene ring:

A

Non-catecholamine

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103
Q

Catecholamines work directly on:

A

adrenergic receptors (alpha 1,2 and beta 1,2)

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104
Q

What is more concentrated?

1:100000 or 1:200000

A

1:10000 because this is equal to 1G or 1000mg/100000 ml

whereas 1:200000 is equal to 1G or 1000mg/200000 ml of solution

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105
Q

Calculate the mg/ml of solution for a 1:300000 dilution:

A

1G = 1000 mg

1000mg/ 300000 ml = 0.0033 mg/ml

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106
Q

The maximum dose of epinephrine in a healthy patient is:

A

0.20 mg (200 mcg)

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107
Q

The maximum dose of epinephrine in an unhealthy/cardiac patient is:

A

0.04. mg (40 mcg)

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108
Q

If you have a 1.7ml solution of the 1:100000 dilution of epinephrine, how much epi is present per ml?

A

(1.7 x .01) = 0.017 mg/ml

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109
Q

Which agent (catecholamine) lacks significant b2 actions thus produces intense peripheral vasconstriction with possible dramatic elevation of blood pressure and is associated with a side effect ratio 9x higher than that of epinephrine

(a big reason that this agent is NOT available in the U.S)

A

Norepinephrine (EXCESSIVE Vasoconstriction)

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110
Q

Closely resembles norepinephrine:

A

Levonordefrin

111
Q

Contraindication for vasoconstrictor administration includes: (6)

A
  1. Blood pressure in excess of 200mmHg systolic or 115 mmHg diastolic
  2. uncontrolled hyperthyroidism
  3. severe cardiovascular disease
  4. undergoing general anesthesia with halogenated agents
  5. Patients receiving nonspecific B-blocker, MAOi, tricyclic antidepressants
  6. patients in categories 1-3a through 3d are classified as ASA 4 RISKS and NOT normally considered candidates for elective or emergency dental treatment in the office
112
Q

Contraindication for vasoconstrictor administration includes patients with severe cardiovascular disease such as: (6)

A
  1. acute MI within past 6 months
  2. cerebrovascular accident within past 6 months
  3. cardiac dysrhythmias despite appropriate therapy
  4. daily exposure of angina pectoris or unstable angina
  5. post-coronary artery bypass surgery within last 6 months
113
Q

Do patients overdose if you exceed MRD?

A

No- remember bell-shaped curve, multiple factors involved, but does increase chances of overdose

114
Q

What are contributing factors to local anesthetic overdose?

A
  1. accuracy of deposition
  2. tissue status
  3. anatomical variation
  4. type of injection
115
Q

Can a patient overdose if given under the MRD?

A

yes

116
Q

What categories of patients might you want to decrease the MRD on? Why?

A

Medically compromised, debilitated & elderly patients; these disadvantaged patients are slower in metabolizing these drugs

117
Q

Do we need to decrease the MRD on medically compromised, debilitated and elderly patients? Why or Why not?

A

Yes because they are unable to metabolize anesthetic as efficiently

118
Q

What is the most common cause of failure to achieve adequate anesthesia?

A

Anatomic variation & faulty technique

119
Q

Articaine is _____% concentration

A

4%

120
Q

What are contraindications for Articaine use?

A
  1. patient allergic to amide anesthesias
  2. sulfite sensitivity
  3. hepatic disease
  4. patient with impairments in cardiovascular function
  5. children under age of 4
121
Q

Why should you not use Articaine on children under age of 4 years old?

A

due to insufficient data

122
Q

Has the potential for neurotoxicity, resulting in more nonsurgical paresthesias than all of local anesthetics (despite fewer injections given)

A

Articaine

123
Q

The smaller the gauge:

A

The bigger the diameter

124
Q

Which has a greater internal diameter?

25 gauge or 30 gauge

A

25 gauge

125
Q

A ____ gauge needle results in less deflection, greater accuracy in injection, and less chance for the needle to break along with easier aspiration

A

30 gauge

126
Q

Name four positive qualities of a 30 gauge needle:

A
  1. less deflection
  2. greater accuracy
  3. less chance of needle break
  4. easier aspiration
127
Q

A total of 4ml of 3% mepivacaine without epinephrine has been used. What is the total mg used in this case?

The MRP for Mepivacaine is 4.4 mg/kg

A

4ml x 0.03% = 0.12

0.12 x 1000 = 120 mg

3% is = to 30mg/ml

128
Q

Billy Jean is going through a special diet, and after two months she only weighs 20kg. She is at UMKC for some dental work. You pick 2% Lidocaine with epinephrine 1:100,000 as your anesthetic agent (because it has red label on it). What is the maximum mg that you. can give for her?

A

We know that MRD for lidocaine is 4.4mg/kg

4.4 mg/kg x 20kg = 88 mg

129
Q

Can a needle be used on more than one patient?

A

No

130
Q

When not in use the needle should be:

A

Covered with protective sheath

131
Q

T/F: You should use both hands to recap the needle

A

False- use scoop technique

132
Q

What technique should be used to recap the needle?

A

scoop technique

133
Q

T/F: The needle should be bent for difficult access blocks due to curves and different contours of the facial skeleton

A

False- absolutely not

134
Q

Where should you dispose of the needle after use?

A

Sharps and in biohazard containers

135
Q

Which agent is bacteriostatic and was removed fro local anesthesia cartridge in 1984 due to reported allergic reactions?

A

Methyparaben

136
Q

_______ was replaced by lidocaine (back in the day)

A

Novacaine

137
Q

When discussing the “care & handling of cartridge” there is no manufacturer claim of:

A

sterility of the exterior surface of cartridge

(bacterial culture test failed to produce growth)

138
Q

When discussing the “care & handling of cartridge” it cannot:

A

withstand extreme temperatures

139
Q

Due to a cartridges inability to withstand extreme temps, no ______ especially with plastic cartridge

A

autoclaving

140
Q

Due to a cartridges inability to withstand extreme temps, when heated _____ are _____

A

Vasopressors are destroyed

141
Q

How should you store cartridges?

A

At room temp in a dark space

142
Q

T/F: studies showed benefits of using a cartridge warmer

A

False- studies showed NO BENEFITS of using a cartridge warmer

143
Q

in regards to cartridges, do NOT soak in:

A

alcohol or “cold sterilizing solution”

144
Q

Why should you NEVER soak cartridges in alcohol or “cold sterilizing solution”?

A

The semipermeable diaphragm permits diffusion of these solutions

145
Q

What should you read in regards to cartridges?

A

Drug insert

146
Q

What can you wipe the rubber diaphragm of a cartridge with?

A

Alcohol wipes moistened with undiluted 91% isopropyl alcohol or 70% ethyl alcohol - but do NOT soak

147
Q

What are some problems that can occur with cartridges? (6)

A
  1. bubble in cartridge
  2. corroded cap
  3. rust on cap
  4. leakage during injection
  5. broken cartridge
  6. burning on injection
148
Q

What is the size considered a “small bubble” in cartridge and what is the cause?

A

Small bubble = (1-2mm)

Usually just nitrogen gas

149
Q

What is the size considered a “large bubble” in a cartridge and what is the cause?

A

Large bubble= greater than 2mm

Occurs due to extruded stopper or frozen cartridge

150
Q

When might the cap of cartridge become corroded?

A

If immersed in disinfection solution

151
Q

The only sterilization needed for a cartridge is to rub the rubber diaphragm only with:

A

91% isopropyl alcohol or 70% ethyl alcohol

152
Q

Why might the cap of a cartridge rust?

A

From “tin” container

153
Q

Leakage from the cartridge during injection may occur if:

A

eccentric needle puncture of diaphragm

154
Q

What should you do with a broken cartridge?

A

return damaged box upon receiving

155
Q

when might a cartridge shatter?

A

shatter cartridge occurs due to improper loading & bent harpoons

156
Q

A bent harpoon may result in:

A

a shatter cartridge

157
Q

Why might burning on injection occur?

A

Due to mishandled or defective cartridges
1. pH
2. Alcohol
3. heat
4. expired

158
Q

What are the most common psychogenically induced reactions people have upon local anesthesia injection?

A

most common: Vasodepressor syncope & hyperventilation

Others (less common) include: Tonic clonic convulsions, bronchospasm, and angina pectoris

159
Q

What does relative contraindication to local anesthetic mean?

A

Means that caution should be used when two drugs or procedures are used together (it is acceptable if the benefits outweigh the risk)

160
Q

What does absolute contraindication to local anesthetic mean?

A

Means that event or substance can cause a life-threatening situation

161
Q

List the RELATIVE contraindications to local anesthetic administration: (5)

A
  1. pregnant women in first trimester
  2. Malignant hyperthermia
  3. Cimetidine + ASA III CHF patient
  4. ASA III or IV + CHF
  5. Methemoglobinemia to Prilocaine
162
Q

Why is an ASA III CHF patient taking cimetidine a relative contraindication to local anesthetic?

A

Because cimetidine increases the half life of circulation LA

163
Q

Why is an ASA III or IV patient with CHF considered an relative contraindication to local anesthetic?

A

Because this patient may demonstrate decreased liver perfusion and increase half-life

164
Q

List the ABSOLUTE contraindication to administration to local anesthesia: (3)

A
  1. ASA IV Cardiovascular risk patient
  2. Tricyclic antidepressant (TCAs)
  3. Cocaine abuser
165
Q

Why is an ASA IV cardiovascular risk patient an ABSOLUTE contraindication to local anesthetic?

A

Because an ASA IV cardiovascular risk patient is not a candidate for vasopressors or elective dental care

Specifically recent MI (less than 6 months ago) or repeated MIs increase risk during dental care or local injection

166
Q

Specifically what classifies someone as an ASA IV cardiovascular risk patient (Making them an ABSOLUTE contraindication to local anesthetic)

A

Specifically recent MI (less than 6 months ago) or repeated MIs increase risk during dental care or local injection

167
Q

Why are patients taking Tricyclic antidepressants (TCAs) an ABSOLUTE contraindication to local anesthetic?

A

TCAs enhance cardiovascular action to exogenously administered vasopressors

168
Q

List the statistical risks associated with TCAs enhancing cardiovascular action to exogenously administered vasopressors:

A

(a) 5-10x increase with levonordefrin and norepinephrine

(b) 2x increase with epinephrine

(c) hypertensive crisis –> death

169
Q

List the reasons a cocaine abuser is an ABSOLUTE contraindication to local anesthesia: (3)

A
  1. cocaine stimulates norepinephrine release and inhibits reuptake
  2. 72 hours is needed for cocaine clearance
  3. epinephrine-impregnated gingival retraction cord is absolutely contraindicated
170
Q

What should you do if you suspect cocaine usage within 24 hours of dental treatment?

A

Postpone

171
Q

Since cocaine stimulates norepinephrine release and inhibits reuptake, what may occur to the patient?

A

Tachycardia/HTN leading to increased myocardial oxygen requirement leading to cardiac ischemia and eventually myocardial infarction

172
Q

What is ABSOLUTELY contraindicated for a cocaine user?

A

Epinephrine-impregnated gingival retraction cord

173
Q

How long do you need to topical in the mouth to be effective?

A

Apply topical for 2 min

174
Q

Where should the bevel of the needle be placed during a LA injection?

A

Place the bevel of the needle on the tissue in the direct you want to go (towards bone)

175
Q

When MUST you aspirate when giving local anesthetic injections?

A

For PSA and inferior alveolar nerve blocks

176
Q

What does aspirating when giving an injection do?

A

Makes sure you are not in a blood vessel

177
Q

When giving an LA injection you should: (technique)

A

twist the needle as you insert it to keep the needle from deflection in one direction

178
Q

How do you avoid deflection in one direction when giving LA injections?

A

Twist the needle as you insert

179
Q

Finger rest or chest/body rest?

A

finger rest

180
Q

What are the three branches of the trigeminal nerve?

A

V1: opthalmic
V2: Maxillary
V3: Mandibular

181
Q

Where do the following branches of the trigeminal were enter/exit the cranium?

  1. V1- opthalmic:
  2. V2- maxillary
  3. V3: mandibular
A
  1. V1- opthalmic: superior orbital fissure
  2. V2- maxillary: foramen rotundum
  3. V3: mandibular: foramen ovale
182
Q

Name whether each branch of the trigeminal nerve is sensory or motor:

  1. V1- opthalmic:
  2. V2- maxillary
  3. V3: mandibular
A
  1. V1- opthalmic: sensory
  2. V2- maxillary: sensory
  3. V3: mandibular: sensory & motor
183
Q

One of the branches of the V2 (trigeminal nerve) upon exiting cranial base makes a quick 180 degree turn back into the cranium. This nerve provides sensory innervation to the dural mater. Its the _____ nerve

A

middle meningeal nerve

184
Q

Which division of the trigeminal nerve is sensory and/or motor?

A

Mandibular branch (V3)

185
Q

Type of injection that numbs one tooth:

A

local infiltration

186
Q

Type of injection that numbs about two teeth:

A

field block

187
Q

Type of injection that numbs the entire area as you are injection the nerve bundle:

A

nerve block

188
Q

When you inject a nerve bundle, you are performing a:

A

nerve block

189
Q

What type of LA injection is seen in the photo below?

A

Local infiltration

190
Q

What type of LA injection is seen in the photo below?

A

Field block

191
Q

What type of LA injection is seen in the photo below?

A

Nerve block

192
Q

Infiltration is considered a _____ injection

A

supraperiosteal

193
Q

Infiltration is performed if you are numbing:

A

one tooth

194
Q

How is the needle entered when performing infiltration injections?

A

Adjacent to bone, apical to apex

195
Q

Describe how infiltration kind of works:

A

Maxillary labial bone is porous and allows infiltration of anesthetic (anesthetic diffuses into bone)

196
Q

Infiltration is commonly done with:

A

premolars

197
Q

List the areas anesthetized by infiltration:

A
  1. single tooth
  2. buccal periodontium & bone
  3. labial/buccal bucosa
198
Q

PSA:

A

Posterior superior alveolar nerve block

199
Q

What type of LA injection is seen in the following photos?

A

Posterior superior alveolar nerve block (PSA)

200
Q

How is the needle entered for a posterior superior alveolar nerve block (PSA)?

A

Needle is entered into the height of the vestibule at a 45 degree angle to the occlusal plane

Needle is inserted about 16mm and you MUST aspirate

201
Q

How far is the needle inserted in a posterior superior alveolar nerve block?

A

16mm

202
Q

What is the aspiration rate for a posterior superior alveolar nerve block?

A

3%

203
Q

If there is a positive aspiration with a PSA what may occur?

A

hematoma

204
Q

List the areas anesthetized with a PSA:

A
  1. Maxillary molar tooth pulps
  2. MB root of 1st molar (72%)
  3. buccal periodontium & bone (NOT palatal)
205
Q

During an infiltration injection (supraperiosteal) the syringe is held ______ and the anesthetic is placed ______

A

parallel to the long axis of the tooth; apical to apex of tooth

206
Q

Given the anesthetized areas, what type of injection was given?

-tooth
-buccal periodontium
-labial/buccal mucosa

A

Infiltration (supraperiosteal)

207
Q

What tooth root has special innervation?

A

1st molar MB root

208
Q

What injection is most likely to give you an ugly hematoma?

A

PSA

209
Q

Given the anesthetized areas, what type of injection was given?

-maxillary molar tooth pulps
-MB root of 1st molar (72%)
-buccal periodontite and bone

A

Posterior superior alveolar nerve block (PSA)

210
Q

What type of injection was given if the yellow portion is the area anesthetized?

A

PSA

211
Q

What type of injection was given if the yellow portion is the area anesthetized?

A

MSA

212
Q

Describe the position of the needle when injecting a middle superior alveolar nerve block (MSA):

A

Needle is injected well above premolar apices; bevel facing the bone

213
Q

List the areas anesthetized during an MSA:

A
  1. Maxillary premolars
  2. MB root of 1st molar (20%)
  3. Buccal periodontal & bone (NOT palatal)
214
Q

According to the image, what type of injection is being given?

A

Middle superior alveolar nerve block (MSA)

215
Q

Given the anesthetized areas, what type of injection was given?

-maxillary premolars
-MB root of 1st molar (28%)
-Buccal periodontite & bone

A

MSA

216
Q

Describe the needle placement in an anterior superior alveolar nerve block (ASA):

A
  1. Needle contacts roof of infraorbital Forman (which is located about 16mm above vestibule)
  2. Insert needle about 1/2 length
  3. orient bevel towards bone and insert until bone is contacting needle
  4. maintain pressure during injection and about 1 min after
217
Q

In an ASA nerve block, the anesthetic is directed:

A

into canal

218
Q

List the areas anesthetized by an ASA:

A
  1. maxillary central incisor through canine
  2. premolars
  3. MB root of first premolar (28%)
  4. buccal periodontite & bone
  5. Lower eyelid, side of nose, upper lip
219
Q

Given the following anesthetized areas, what type of injection was given?

-maxillary central incisor through canine
-premolars
-MB root of first molar in 28%
-Buccal periodontite & bone
-lower eyelid, side of nose, upper lip

A

Anterior superior alveolar nerve block (ASA)

220
Q

The following images depict what type of injection?

A

ASA

221
Q

An anterior superior alveolar nerve block (ASA) may also be called:

A

infraorbital nerve block

222
Q

What should be located before an ASA and how?

A

Locate foramen by palpation

223
Q

For a greater palatine injection, where is the needle aiming?

A

Needle is aiming for greater palatine foramen area & contacts bone (not into the foramen)

224
Q

What type of injection is seen in the following images?

A

Greater palatine

225
Q

What type of injection is seen in the following images?

A

Nasopalatine

226
Q

List the areas anesthetized with a greater palatine infection:

A
  1. posterior portion of hard palatine (canine to last molar)
  2. overlying soft tissue

(NO anesthesia of teeth)

227
Q

Where is the boundary of anesthesia for greater palatine vs. nasopalatine on the palate?

A

Greater palatine is distal to 2nd maxillary molar

228
Q

How can the greater palatine foramen be located?

A

Can be identified by finding the junctions of molars 2&3 and then moving the needle 1cm medially

229
Q

Can be identified by finding the junctions of molars 2&3 and then moving the needle 1cm medially:

A

Greater palatine foramen

230
Q

If the following areas are anesthetized what type of injection was given?

-posterior portion of hard palate
-overyling soft tissues

(no teeth anesthetized)

A

Greater palatine

231
Q

Where is the injection area of a greater palatine injection?

A

Midway between midline and free gingival border (10mm from palatal midline)

232
Q

Where does the needle need to contact with a nasopalatine injection?

A

Needle contacts bone lateral to incisive papilla

233
Q

Given the image, what type of injection was given?

A

Greater palatine

234
Q

Given the image, what type of injection was given?

A

Nasopalatine

235
Q

Describe the steps to giving an nasopalatine injection:

A
  1. needle contacts bone lateral to incisive papilla
  2. bevel against tissue and bow the needle
  3. straighten needle and advance
236
Q

What is an alternative approach for a nasopalatine injection?

A

Trans-papillary

Insert needle through papilla between 8&9 towards palate

237
Q

List the areas anesthetized during a nasopalatine injection:

A
  1. anterior portion of hard palate (canine to canine)
  2. both hard and soft tissues
    (no anesthesia of teeth)
238
Q

The following image depicts what type of injection?

A

Buccal nerve block

239
Q

The following image depicts what type of injection?

A

Mental nerve block

240
Q

The following image depicts what type of injection?

A

Inferior alveolar nerve block

241
Q

The following image depicts what type of injection?

A

Tow-gates block (true mandibular nerve block)

242
Q

The following image depicts what type of injection?

A

Vazirani-akinosi nerve block (closed mouth mandibular nerve block)

243
Q

Use a 25 gauge long needle, stretch tissue, and contact periosteum. (Large area of nerve coverage, just need to aim in general area)

A

buccal nerve block

244
Q

What gauge of needle should be used for a buccal nerve block?

A

25 gauge

245
Q

What is the only block to anesthetize the buccal mucosa of molars?

A

Buccal nerve block

246
Q

T/F: a lot of anesthetic is needed to anesthetize the buccal mucosa of molars (buccal nerve block)

A

true

247
Q

List the areas anesthetized with a buccal nerve block:

A
  1. gingival buccal to molars
  2. retromolar pad mucosa
  3. buccal mucosa in molar areas

(no hard tissue anesthetized)

248
Q

Given the following image, what type of injection was given?

A

Buccal nerve block

249
Q

The mental nerve (targeted in a mental nerve block) exits out of the:

A

mental foramen

250
Q

How should you locate the site of injection for a mental nerve block?

A

Palpate the mental foramen (near the premolars) to determine site of injection

Inject into tissue over foramen

251
Q

There is risk of possible _____ with a mental nerve block

What is the aspiration rate?

A

Hematoma; 5.7%

252
Q

List what becomes anesthetized with a mental nerve block:

A
  1. mucosa anterior to foramen
  2. skin of the lower lip
  3. chin
253
Q

If the following areas are anesthetized, what injection was given?

-mucosa anterior to foramen
-skin of lower lip
-chin

A

mental nerve block

254
Q

The largest branch of the posterior division protected by the sphenomandibular ligament:

A

Inferior alveolar nerve

255
Q

The inferior alveolar nerve is protected by:

A

sphenomandibular ligament

256
Q

What injection is being given in the following scenario:

Syringe is directed across the arch (from contralateral side) at level of coronoid notch. Place finger on notch to locate it and determine height of injection. Needle penetrated buccinator muscle and it is lateral to pertygomadibular raphe- contacts bone and must aspirate

A

Inferior alveolar nerve block

257
Q

At what level is an inferior alveolar nerve block given?

A

Level of the coronoid notch

258
Q

With an inferior alveolar nerve block, the needle penetrates _____ and is lateral to ____

A

buccinator muscle; pterygomandibular raphe

259
Q

Do you contact bone in an inferior alveolar nerve block?

A

yes

260
Q

What nerves are anesthetized with an inferior alveolar block?

A
  1. inferior alveolar
  2. incisive
  3. mental
  4. lingual (usually)
261
Q

What areas and nerves are anesthetized with an inferior alveolar nerve block?

A
  1. Nerves- inferior alveolar, incisive, mental, lingual
  2. entire unilateral side from midline
  3. lingual mucosa
  4. tongue
  5. teeth
262
Q

According to the following image, what injection was given?

A

Inferior alveolar nerve block

263
Q

Considered a “true mandibular nerve block”

A

Gow-gates block

264
Q

What injection is being described:

Needle contacts neck of condyle, patient opens wide so condyle moves forward; must aspirate:

A

Gow-gates block

265
Q

What are the extra oral landmarks for a Gow-gates block:

A

Intertragic notch & corner of mouth

266
Q

When doing a Gow-gates block, what should you have the patient do?

A

Open wide so condyle moves forward

267
Q

What nerves are anesthetized with a Gow-gates block?

A
  1. inferior alveolar
  2. lingual
  3. mylohyoid
  4. auriculotemporal
  5. buccal (75%)
268
Q

A closed mouth mandibular nerve block may also be called:

A

Vazirani-akinosi nerve block

269
Q

The height of injection of a Vazirani-akinosi nerve block is:

A

maxillary muco-gingival line

270
Q

How far is the needle inserted in a Vazirani-akinosi nerve block?

A

35 mm

271
Q

When giving a Vazirani-akinosi nerve block, the path of insertion is:

A

Parallel to ramus

272
Q

Should you contact bone with a Vazirani-akinosi nerve block?

A

No

273
Q

What nerves are anesthetized with a Vazirani-akinosi nerve block?

A
  1. inferior alveolar
  2. lingual
  3. mylohyoid
274
Q
A

Intro to Oral Surgery & Pain Management (2 decks)

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