DH-215 Pain Control Final
How much are patients charged for N2O at SCC?
$30 hour/$15 per 30 minutes
What total dose of Lidocaine w/1:100K epi can be given to a 120 lb patient? What volume of 2% lidocaine? How many CRT is that?
*In class, we used 2.0 mg/lb value for this problem, but based on table, should be using 3.2, so that's what I did below. However, on boards, since you won't have a calculator, may want to eliminate the 2 very off answers, then do the math two ways: with 3.0 mg/lb and 2.0 mg/lb. Then, of the two remaining answers, pick the one that is closest to the answers you came out with. 2% Lido=20 mg/mL x 1.8 mL=36 mg in 1 cart 3.2 mg/lb for Lido 3.2 mg/lb = x/120 lb 3.2 x 120=384 x=384 mg < 500 mg MRD absolute Total dose: 384 mg 384 mg/36 mg in 1 cart of Lido=10.667=10 cart CRT: 10 Note that I rounded down to be cautious, since we are talking about LA, even though based on Sig Figs, you would usually round up. Concentration x volume=dose Concentration=20 mg/mL Dose/concentration=Volume 384 mg / (20mg/mL)=19.2 mL Volume=19.2 mL 1/100,000=.00001 x 1000=0.01 mg/mL 0.01 mg/mL x 1.8 mL x 10 cart = 0.18 mg epi. Healthy patient can have up to 0.2 mg epi. 0.2/0.18=1.1 cart epi SO Lidocaine is limiting factor, not epi.
Regulators
-Decrease pressure from cylinder to patient
Record all data of N2O in patients chart
-Dosage -Duration -Patient condition during and after
What is trismus? What causes it? Which injection most commonly results in it? How do you prevent it? How do you manage it?
-Inability to open the mouth Occurs during IA Causes: Physical and chemical trauma to muscle tissue (if not open wide enough during IAL--tell patient to open wide) Physical and chemical trauma to blood vessels Prevention: Minimize needle penetrations, change needles frequently & prevent needle contamination Management: Apply hot, moist towel (5 mins on, 10 mins off) Warm salt water rinses (1 tsp salt with 12 oz warm water) Use ibuprofen as needed Open & close mouth repeatedly and gradually (Open and close and lateral excursions of mandible for 5 min every 3-4 hours) Monitor for signs of infection Onset is usually 1-6 days after tx. If pain and dysfunction don't decrease in 48 hours, consider antibiotic to counteract possible infection Complete recovery takes 6 weeks or longer Document in patient's chart
When to use PDL injection, what it anesthetizes, needle type, where site is located on maxillary vs. mandibular teeth.
-On a single tooth -If IA has failed Allows pulpal, facial and lingual anesthesia without anesthesia of tongue or cheek Short or ultra-short 30 gauge needle Sites: -Maxillary: buccal sulcus -Mandibular: lingual sulcus Carmon said usually used on mandible Technique: Advance through PDL attachment but stop when resistance is met, watch for tissue blanching on buccal and lingual side (gone throughout entire pocket) and deposit 0.2 mL
N2O
-Stored as a liquid -delivered as a gas -colorless sweet odor -stored in a BLUE cylinder -full tank= 750 PSI
Tidal Volume-
-The amount of air needed for one respiration cycle. AVERAGE ADULT = 6-8 liters. Levels may vary from 5-9 liters.
Nitrous does effect:
-hearing -touch -pain -warmth -Background sounds are more distinct -Gag reflex
Nitrous does not affect:
-heart rate - blood pressure - pulse -respiration -liver -kidneys
Oxygen
-stored as a gas -colorless, odorless -stored in a GREEN cylinder -full tank= 2100 PSI
How to convert LA (say 0.5 Bupivacaine) to mg
0.5*10 =5 mg x 1.8 mL=9 mg
What amount of N2O do you start off giving a patient after determining tidal volume? How much do you increase by and how often?
1 lpm increase by 0.5 lpm increments after waiting 60-90 sec
What factors are needed to calculate the local anesthetic drug doses when two different drugs are used?
1.mg of the first drug delivered or to be delivered. 2.MRD of the first drug. 3.mg of the second drug delivered or to be delivered. 4.MRD of the second drug delivered.
How to convert vaso (say, 1:100,000 epi) to mg/carp
1/100000=0.00001 x 1000 (milli)=.01 mg x 1.8 mL = 0.018 mg/carp
How many cartridges of 2% Lidocaine with 1:100,000 epinephrine can safely be administered to a 50 lb child?
11 carps is adult dose 50 lbs/150 lbs=0.33 x 11 carps=3.63 carps
If a 150 lb patient has received 128 mg of 2% Lido, how many mg of 4% Prilo can be given?
2% Lido MRD absolute: 500 mg 4% Prilo MRD absolute: 600 mg 2% Lido MRD < 4% Prilo MRD, so use 500 mg 500 mg - 128 mg = 372 mg of 4% Prilo can be given
Determine the maximum dose for 2% lidocaine with epinephrine 1:100,000 for a 100-pound patient.
2% Lido=20 mg/mL 20 mg/mL
If MRD for 2% Lidocaine is 500mg: How much Lidocaine in mg/mL is in a carp?
2% solution=20 mg/mL 20 mg/mL x 1.8 mL = 36 mg/carp
2% Lidocaine in dose/volume
20 mg/mL
An operator delivered 3 cartridges of 2% lidocaine w. 1:100K epi. What dose of LA and VC was given?
20 mg/mL x (1.8 mL x 3 cart=5.4 mL) 20 mg/mL x 5.4 mL =108 mg LA LA: 108 mg 1/100,000=0.00001 x 1000=0.01 mg/mL epi x 1.8 mL=0.018 mg epi x 3 cart=0.054 mg epi VC: 0.054 mg
Operator first delivered 2 CRT of 2% lidocaine 1:100K epi for an IA block for a 140 lb patient. Patient's core bundles are not fully saturated with the anesthetic solution. Operator wants to switch to 4% articaine to achieve more profound anesthesia before proceeding with the periodontal procedure. What volume (and how many CRT) of 4% articaine can be given as a second injectable local anesthetic?
20 mg/mL x 1.8 mL=36 mg in 1 cart of Lido 40 mg/mL x 1.8 mL=72 mg in 1 cart of Art *As per Dr. Honey on 12/11/19, even though 3.2 mg/lb is value you should use for Lido & Articaine if given, when we did this problem for class, she used 2.0 mg/lb to be cautious since we are talking about LA. She said it's just a difference of values given, but if we are on the board, we won't have a calculator and multiplying by 3.2 may be hard/take too much time. So, she recommends you eliminate the two answers that look extreme off, and then do easy math by using 2 different values (if you aren't sure which mg/lb value is associated with each drug) to figure out which of the 2 remaining answers is right. So in her example to me, she did it 2 ways: Way 1: Calculate how much Lido was given to 140 lb patient: 3.0 mg/lb x 140 lb=420 mg MRD 36 mg per cart of Lido x 2 cart=72 mg in 2 carts of 2% Lido 1:100k epi 420mg MRD - 72 mg 2% Lido given already=348 mg remaining 348 mg/72 mg in 1 cart of Art=4.8 cart of Articaine left to give Vol=348 mg CRT: 4.8 Way 2: 2.0 mg/lb x 140 lb=280 mg MRD 36 mg per cart of Lido x 2 cart=72 mg in 2 carts of 2% Lido 1:100k epi 280 mg MRD - 72 mg 2% Lido given already=208 mg remaining 208 mg/72 mg in 1 cart of Art=2.8 cart of Art left to give Vol=208 mg CRT: 4.8 Then pick whichever answer of the 2 remaining (since multiple choice on the board) is closest to either of those. Also, remember to check vaso as limiting factor: 0.010 mg/mL x 1.8 mL x 2 cart=0.036 mg epi, which is < 0.2 mg epi max safe amount for healthy patient, so epi is not limiting factor in this situation
What total dose of mepivacaine can be given to a 120 lb patient? What volume of 3% mepivacaine? What volume of 2% mepivacaine? How many CRT is that of each?
3% Mepivacaine Plain: 30 mg/mL x 1.8 mL=54 mg in 1 cart 3.0 mg/lb=x/120 3 x 120=360 mg < 400 mg MRD absolute Total dose: 360 mg 360 mg/54 mg=6.6 cart (Rounded down to be cautious since talking about LA) CRT: 6.6 Concentration x volume=Dose Dose/concentration=volume 360 mg/(30 mg/mL)=12 mL Volume: 12 mL 2% Mepivacaine w/1:20k Levo: 20 mg/mL x 1.8 mL=36 mg in 1 cart 3.0 mg/lb=x/120 3x120=360 mg < 400 mg MRD absolute Total dose=360 mg 360 mg/36 mg=10 cart CRT: 10 360 mg/(20 mg/mL)=18 mL Volume=18 mL 1/20000=.0.00005 x 1000=0.05 mg/mL epi 0.05 mg/mL x 1.8 mL x 10 cartridges 2% Mepi =0.9 epi > 0.2 mg max safe dose of epi a healthy patient can have. So epi is limiting factor.
Determine the maximum dose for 3% mepivacaine for a 195-pound patient.
3% Mepivacaine=3.0 mg/lb 3.0 mg/lb=x/195 lb x=585 mg > 400 mg MRD, so answer is 400 mg
3% Mepivacaine in dose/volume
30 mg/mL
If patient has a tidal volume of 8, and was given 3 liters of nitrous, what percentage is that of nitrous? What percentage of oxygen?
37.5% (3/8) N2O 62.5% (5/8) O2
N2O
42% max here at school. Tidal volume: 6-8 max volume of the lungs. 3-5 min O2 flush to replace nitrous molecules that accumulated. Nausea and headache are common symptoms if flush does not occur. Reason to offer N2O to a pt: high fears, gag reflex, time perception alteration, for taking x-rays on a gagger.
0.5% Bupivacaine in dose/volume
5 mg/mL
An operator delivered 4 cartridges of 0.5% bupivacaine w 1:200K epi. What dose of LA and VC was given?
5 mg/mL x (1.8 mL x 4 cart=7.2) 5 mg/mL x 7.2 mL=36 mg LA LA: 36 mg 1/200,000=.000005 x 1000=0.005 mg/mL epi 0.005 mg/mL x (1.8 mL x 4 cart=7.2) 0.005 mg/mL x 7.2 mL=0.036 mg VC: 0.036 mg
How many cartridges of 3% Mepivacaine without a vasoconstrictor can safely be administered to a 75 lb child?
7 carps is adult dose 75 lbs/150 lbs=0.5 x 7 carps=3.5 carps
Advantages/Disadvantages of AMSA
Advantages: -Decreased amount of anesthetic solution -Decreased number of needle penetrations -Hemostasis of associated palatal tissues Disadvantages: -You must visually monitor the degree of tissue blanching...failure to do so could result in ischemia. -An ulcerative lesion may develop 24-48 hours following excessive ischemia.
Nitrous is a CNS depressant
Affects: -cerebral cortex -thalamus -hypothalamus -reticular activating system
What is paresthesia? What causes it? Which injection most commonly results in it? How do you prevent it? How do you manage it?
Altered sensation & or persistent partial or complete numbness. Most commonly associated with lingual nerve. Causes · The operator is very accurate (anatomically) and actually touches the nerve intended for anesthesia. The resulting trauma to the nerve sheath may result in paresthesia. · Severing of nerve fibers with a needle during routine intraoral injections will also cause paresthesia; however, such incidents are extremely rare. · The needle contacts a vessel and causes hemorrhage into the surrounding area and possibly into the neural sheath. Bleeding results in increased pressure on the nerve and thus the anesthesia effect is prolonged. · Administration of contaminated solution can produce irritation and edema which in turn leads to increased pressure in the region of the nerve and thus prolonged anesthesia. Prevention: -Follow all LA protocol -Avoid using Articaine for mandibular blocks (increases likelihood as per studies about it, although many DDS use it anyway) Management · Arrange an appointment to examine the patient. · Determine the degree and extent of paresthesia. · Schedule the patient for an examination every two months until the sensory deficit is no longer present. · If paresthesia continues for more than 12 months, refer the patient to an oral surgeon or neurologist for evaluation (per Malamed textbook). Additional Information · If the patient experiences an "electrical" sensation during the injection procedure, the operator should withdraw and move to a slightly different position. Tell patient to keep mouth open wide during IAL--keeps lingual nerve stretched out and away from needle. · When explaining what happened to the patient, state that paresthesia is a result of optimum accuracy in locating the nerve intended to be anesthetized. Inform the patient that s/he may experience some prolonged anesthesia but that it will gradually return to normal in most instances. Warn the patient about the possible increased risk of self-inflicted injury in the area. · Avoid redepositing local anesthetic solution at the site of the traumatized nerve. · In most cases, the area will gradually return to normal within 8 weeks. However, if the paresthesia lasts longer than 6 months it will most likely be permanent. · Document relevant information in the patient's chart.
ASA
Anterior Superior Alveolar -27 short, height of much buccal fold, distal of the canine, does not get palatal
Identify the types of anesthetic drugs available for use in the US. (not trade name).
Articaine (4% w/1:100K epi, 4% w/1:200K epi) Bupivacaine (0.5% w/1:200k epi) Lidocaine (2% w/1:50k epi, 2% w/1:100k epi) Mepivacaine (3% plain, 2% w/1:20k Levo) Prilocaine (not used as often): 4% plain, 4% w/1:200k epi
Is it better to do unilateral or bilateral IA injections on children as per Carmon?
Bilateral. When child has LA on one side, they will play with their tongue and cause trauma, but if bilateral, they wont' feel anything.
Pediatric Considerations for LA
Bone is less dense Penetration depth is less ALWAYS USE A SHORT NEEDLE Infiltrations are most effective for children, as they get older, they become less effective PSA: can be done when children have 1st permanent molars. ASA: same as an adult NP: same as an adult GP: If the child does not have their first permanent molar yet, penetrate ~10mm behind the last primary molar. IA: Place the barrel of the syringe over the primary molars on opposite side of the mouth, mandibular foramen lies inferior to the occlusal plane. As a child ages, the foramen moves up to where it should be as an adult. B: same as an adult Mental/Incisive: Anesthetizes all 5 primary teeth in a quadrant, foramen is between the two primary molars. Use pressure after administration. Minimal/Moderate Overdose Signs and Symptoms: restlessness, tremors, sweating, vomiting, elevated blood pressure, respiratory rate and heart rate. Moderate/high overdose: Tonic-clonic seizure followed by depression of CNS, depressed BP, HR and resp. rate. Inject slowly, aspirate, use a needle that will reliably aspirate. Clark's Rule: Child's weight in (Lbs/ 150) x adult dose= child dose
Onset and Oraverse: What is anesthetic buffering? How is it used? When do you use it? Biggest drawback? How do you use it? Is there an MRD for Oraverse and if so, what is it?
Buffering agent: Onset. Adding sodium bicarbonate to anesthetic (buffering agent) to increase pH of anesthetic (also adjust CO2 levels). Onpharma is a device to deliver a precise amount of sodium bicarb at the same time as it removes the same volume of anesthetic from the carp--mixes in 1-2 seconds, then about 6000 more of LA in base form (so more lipid soluble and allows more to get thorugh membrane). Reversal agent: Ora-Verse. Reverses affects of LA, but need another injection in same site. Helps speed up process of reversing effects, but isn't immediate. 0.4 mg/1. mL solution per carp. Dosing is 1:1 (1 carp of LA administered means you give patient 1 carp of OraVerse). MRD of Oraverse: -2 carps for 12yo+ -1 carp for 6-11 yo and weigh over 66 lbs -0.5 carp for 6-11 age and weigh 33-66 lbs DO NOT give to kids under 6 yo and weighing less than 33 lbs AND DO NOT give to pregnant women
Signs of LA Overdose (in CNS and Cardiovascular system), ways to prevent, and how to manage if overdose
CNS: Metallic taste, increased anxiety, dizzy, tinnitus (ringing in ear), confusion, circumoral numbness; muscle twitching, auditory & visual hallucinations; tonic-clonic seizures, unconciousness, and respiratory arrest Cardiovascular: Hypertension, tachycardia; Decreased contractility and cardiac output, hypotension; Sinus bradycardia (a regular but unusually slow heart beat of 50 beats/min or less), ventricular dysrhythmias (disturbance in the normal rhythm of the electrical activity of the heart, circulatory arrest Prevent: -Establish MRD for patient based on weight & overall health status prior to injection -Aspirate -Administer slowly The more delayed the onset, the less severe the reaction. -Mild overdose: Activate emergency protocols as needed, reassure patient, monitor, continue with tx if patient can tolerate, no need for escort if fully recovered. -Mod to severe: Activate emergency protocols, administer oxygen (to prevent seizure that can occur because of lack of Oxygen), perform CPR as needed, prevent patient injury due to seizures, monitor vitals, patient dismissal with escort or emergency transport as indicated
What causes facial nerve paralysis? Which injection most commonly results in it? How do you prevent it? How do you manage it?
Cause: Most common cause is injection of LA into the capsule of the parotid gland. Occurs if the needle is inadvertently positioned too posteriorly during the IA. The resulting loss of motor function to the muscles of facial expression will generally last no more than several hours. Prevention: Ensure that the needle contacts periosteum before depositing the anesthetic solution. Management: · Reassure the patient. · Discontinue tx · Remove contact lenses · Place patch on affected eye · Document incident · Follow up with patient
Facial Nerve Paralysis
Cause: Most common cause is injection of LA into the capsule of the parotid gland Prevention: Avoid depositing LA during IA nerve blocks unless bone is contacted Management: Discontinue treatment Remove contact lenses Place a patch of affected eye Document the incident Follow up with the patient Note: Facial paralysis can look similar to Bell's palsy
What is Clark's Rule?
Child's weight in (lbs/ 150) x adult dose= child dose
Contraindications for N2O
Communication and cooperation difficulty COPD (emphysema, chronic bronchitis) Nasal obstructions Patient doesn't want it Middle ear disturbances Pregnancy Personality disorders and emotional instability Claustrophobia Severe behavior problems Drugs or alcohol
CCLAD
Computer controlled local anesthesia device: Controls: -rate -pressure
Calculations
Concentration X Volume = Dose Concentration in mg/ml Volume in ml Dose in mg 2% Lidocaine= 20 mg/ml 0.5% Bupivacaine=5 mg/ml 3% Mepivacaine= 30 mg/ml
What is the basic formula to remember that results in dose in mg?
Concentration x volume = dose concentration=mg/mL volume=mg
Early to Ideal Sedation
Facial muscles relax Light headedness Tingling/Numbness-hands, feet, lips, oral cavity, etc. Wave of warmth Light or floaty feeling Heavy feeling Analgesia Mouth remains open Normal vital signs, Regular breathing Skin slightly flush Patient responds readily to commands Eyes will glaze over
GP
Greater Palatine -27-short -1-2 mm anterior to the greater palatine foramen, bevel towards the palatal tissue -0.4-0.6 ml
Maximum safe dose for: -Epi in a healthy patient? -Levo in a healthy patient? -Epi in a patient with heart disease: -Levo in a patient with heart disease?
Healthy: -Epi: 0.2 mg -Levo: 1 mg Heart disease: -Epi: 0.04 mg -LevoL 0.2 mg
Heavy Sedation to Slight OverdoseOver
Hearing acute Visual images confused -ceiling patterns move Sleepiness Laughing, crying, dreaming Less likely to respond to verbal commands Mouth tends to close Nausea Increased movement Nausea/vomiting Loss of consciousness, Patient responds irrationally Protective reflexes suppressed Responds sluggishly Uncooperative Uncoordinated movements
Hematoma
Hematoma: Nick of blood vessel during injection causes blood to leak from the vessel into the surrounding tissue. PSA: Most common injection resulting in a hematoma. This is due to proximity of the pterygoid plexus of veins & maxillary arteries. Management Immediately: Discontinue treatment and apply ice and pressure. Once hematoma has stopped expanding: Apply ice intermittently for next 6 hours Instruct patient to avoid aspirin which is a blood thinner Advice patient to call immediately if sign/symptoms of infection or limited jaw opening
Trismus
Inability to open the mouth Causes: -Physical and chemical trauma to muscle tissue -Physical and chemical trauma to blood vessels Prevention: -Minimize needle penetrations, change needles frequently & prevent needle contamination Management:Apply hot, moist towel (5 mins on, 10 mins off) Use ibuprofen as needed Open & close mouth repeatedly and gradually Monitor for signs of infection
Benefits of CCLAD
Increased patient comfort: -Less needle deflection in tissue -Increased technique safety -Decreases involuntary movement during aspiration Ergonomic benefits -Elimination of pressure on thumb -Reduction in hand and finger strain
IA:
Inferior Alveolar -25 long needle -look for raphe and pterygomandibular triangle -retract the raphe or you will contact too early. -Needle should be ⅔ of the way in for contact. -Does not anesthetize the buccal tissue of the molars.
Effectiveness of mandible infiltrations child vs. an adult Where is mandibular foramen located on a child?
Infiltrations are effective on mandible, but as child gets older bone gains density around age 12. Once have 12 YO molars, do IA, but use 25 or 27 short. Make sure syringe barrel is over PRIMARY MOLARS on contralateral side (where permanent premolars will be) and remember that as children age, foramen moves up to level of occlusion and then 7 mm above level of occlusion as adult; mandibular foramen is inferior to occlusal plane in kids.
If MRD for 2% Lidocaine is 500mg: Calculate how many cartridges of 2% Lido a healthy 150 lb patient can receive. What is the limiting factor, LA or vasocontrictor?
LA part: 2% solution=20 mg/mL 20 mg/mL x 1.8=36 mg/carp 500 mg MRD / 36 mg/carp = 13 carps Vaso part: 1/100,000=0.00001 x 1000 (milli) = .01 mg/mL 0.01 mg/mL x 1.8=0.018 mg Healthy patient can have 0.2 mg (Max Safe Dose) epi 0.2 mg/0.018 mg in 1 carp =11 carps Limiting factor=epinephrine (0.2 mg in healthy patient, 0.04 in heart patient), patient can have 11 cartridges
Diffusion Hypoxia
Lack of oxygen to tissues--too much nitrous was left in bloodstream after patient receives it -headache - feel groggy -nauseated -"hung-over" Prevent by properly oxygenating your patient At pt's next appt, ask them how they felt last time when they went home. If felt any of the ways above, needed oxygen after for longer. 3-5 minutes was needed, EVEN if patient says they are fine and want to go.
AMSA (Anterior Middle Superior Alveolar): Landmarks, amount deposited, teeth/soft tissue/nerves anesthetized, type of needle
Landmarks: -Point that bisects 1st & 2nd premolars and midpoint between crest of the lingual free gingival margin of these teeth -Bevel faces palatal tissues, needle is 45 degree angle to palatal tissues at site of penetration Amount: 1.2 cc Teeth/soft tissue anesthetized: -Pulpal anesthesia of maxillary incisors, canines and premolars -Buccal attached gingiva of same teeth -Attached palatal tissues from midline to free gingival margin on associated teeth Nerves: -ASA Nerve -MSA when present -As per Carmon in class, portion of GP -As per Carmon in class, NP Needle: 27 short
Systemic Allergic Reaction
Less frequent vs. localized reaction, but when it happens, it's more serious Can result from LA drugs or sulfite preservatives in solution Progression of signs/symptoms of generalized anaphylaxis Skin reactions-itching, flushing, hives GI reactions- cramps, vomiting, diarrhea, nausea Respiratory- chest tightness, cough, wheezing CVS- palpitations, dizzy, tachycardia, hypotension, unconsciousness
Calculate how many cartridges of 2% Lidocaine a healthy 150lb patient can receive. What is the limiting factor, LA or vasoconstrictor?
MRD for 2% Lido=500 mg 20 mg/mL x 1.8 mL=36 mg 500 mg/36 mg=13.89 round down to 13 carp to be cautious CRT: 13 1/100000=0.00001 x 1000=0.01 mg/mL 0.01 mg/mL x 1.8 mL=0.018 mg A healthy pt can have up to .2 mg of epi 0.2 mg/0.018 mg=11.1 so 11 cart Limiting factor=epi, patient can have 11 cartridges
Indications for N2O
Management of fear, anxiety, or mild apprehension Reduces stress for medically compromised patient Reduces gagging Refusal of anesthesia (general or local) Reduces pain sensation of dental procedures Most children with mild anxiety Long appointments Patient's with medical conditions Patients with: Asthma Epilepsy (seizure disorders) Cardiovascular or Cerebrovascular disease Parkinson's Disease CP, MS, MD Fainting spells
SYNCOPE
Management: Place Patient in a supine position Administer supplemental oxygen Monitor vital signs until baseline is achieved Clear area & make patient safe if convulsive activity occurs Observe for pallor, clamminess and weakness Dismiss with escort Document the incident
When to do Gow-Gates nerve block, advantages and indication. Technique.
Mandibular injection that targets main nerve trunk of mandibular nerve (higher up) vs. IA (which gets just inferior alveolar). 75% of the time when you do Gow-Gates you also get the buccal nerve, so no need to do buccal. Also hit auriculotemporal, and mylohyoid. When: if IA is unsuccessful. Anesthetizes buccal and lingual soft tissue just like with IA since getting buccal and lingual nerves. Contraindications: Limited mouth opening, kids, patients with disabilities (since will give profound anesthesia), anywhere there's infection Anesthetizes same areas as IA Advantages: Great success rate since higher up on ramus, low incidence of + aspiration, good option if IA won't get patient numb. Technique: -Use tragus of ear and line up w it. 25 gauge long needle -ML cusp of maxillary 2nd molar - intraoral landmark -Depositing near mandibular condyle -IF YOU DO NOT CONTACT BONE, DO NOT DEPOSIT ANESTHETIC! -After done depositing, ask patient to keep their mouth open really wide for 1-2 minutes.
Flowmeter
Measures liters per minute of gas
Mental Incisive
Mental only does tissue -nerve is on the surface. -For pulpal anesthetic, must hit the incisive nerve inside the canal, must use pressure to push it into the foremen. Administration: Use a 27-short needle. Depth of penetration: 5-6 mm. Administer: 0.6-0.9 ml of solution. Position either at 12 o'clock or 8 o'clock. Locate mental foramen on x-rays, between premolars, palapte. To achieve pulpal anesthesia after depositing pressure must be applied for 2 minutes. Other areas anesthetized: -PDL -Bone overlying the teeth -Mandibular buccal mucosa -Lower lip to the midline -Skin of the chin to the midline Indications: Use in place of IA, dental procedure of mandibular teeth anterior to the mental foramen.
MSA
Middle Superior Alveolar -27 short, height of much buccal fold, second premolar, numbs premolars and mesial buccal root of the first molar, 72% of people do not have the MSA nerve
What is Scavenging?
Minimizing trace amounts of nitrous oxide -before -during -after Scavenging nasal mask
Localized Allergic Reactions
Most common LA related allergic reaction is to topical anesthetic. Signs and symptoms usually appear within 30-60 minutes after contact. With topical allergy, will see sluffing of the tissue. Minimize that by not using a lot of topical and by not rubbing it into the tissue. Management: -Recommend OTC Benadryl -Refer for allergy testing -Document in the patient record
NP
Nasopalatine -27-short -Pressure anesthesia for 1 min prior -palatal mucosa just lateral to the incisive papilla at a 45 degree angle -0.3ml/ 15-30 seconds
IO nerve block
Nerves anesthetized: ASA and MSA Other areas it numbs: lower eyelid, lateral aspect of nose, and upper lip. Indications: Procedures involving 2 or more teeth Contraindicated to give infiltration 3. Ineffective infiltration Advantages: Less anesthetic, more effective, minimizes needle penetrations, less likely to get a positive aspiration.Armamentarium: 27 short needle (or long) Target area: Infraorbital foramen just below the infraorbital notch. Area of penetration: Height of the mucobuccal fold over first premolar. Needle parallel to the long axis of the tooth. 16mm for site of deposition. Deposit: 0.9-1.2 ml of solution. Maintain finger pressure for 1-2 minutes for diffusion of solution into the foramen. When administering: Make sure to contact periosteum, maintain finger over IO foramen, estimate depth before administering.
What is a hematoma? Which injection most commonly results in it? How do you manage it?
Nick of blood vessel during injection causes blood to leak from the vessel into the surrounding tissue. PSA: Due to proximity of the pterygoid plexus of veins & maxillary arteries. Prevention: Always aspirate, even if you move slightly Identify landmarks and follow appropriate injection methods Modify injection based on patient's individual anatomy (don't go as deep for smaller patient) Management Immediately: Discontinue treatment, sit patient up, and apply ice and pressure (intraoral and extraoral)/ Once hematoma has stopped expanding: -Apply ice intermittently for next 6 hours. -Tell patient not to apply heat to area for 4-6 hours. -Instruct patient to avoid aspirin which is a blood thinner (Advil good as anti-inflammatory) -Advise patient to call immediately if sign/symptoms of infection or limited jaw opening -Resolves in 7-14 days
Where is the mental foramen located on a child with only primary dentition? How many teeth/which ones does it numb in terms of primary teeth in a quad?
Point of ref: between 2 primary molars at mental foramen (perm PM are under those). Apply pressure 2 minutes. Mental/Incisive: Numbs all 5 primary teeth in a quad.
PSA
Posterior Superior Alveolar -25 short needle -¾ of the needle should be in -45 degrees to the sagittal plane and to the occlusal plane, distal buccal root of the second molar, the gushy part at the height of the muccal buccal fold.
How can you prevent broken needles? How do you manage it?
Prevention: Avoid inserting needle to the hub Use lower gauge needles Avoid excessive force on needles Management: If the needle is visible, remove with hemostat or locking forceps If the needle is not visible, immediately refer to oral surgeon
Why provide 100% O2 flush at the end?
Provides an O2 flush Prevents diffusion hypoxia
Q1: Determine the maximum dose for 2% lidocaine with epinephrine 1:100,000 for a 100-pound patient. Q2: How many cartridges can this 100 pound patient receive?
Q1: 2% Lido w/epi: 3.2 mg/lb 3.2 mg/lb = x mg/100 lb. x=320 mg < 500 mg MRD absolute, so answer is 320 mg Q2: 2% Lido=20 mg/mL 20 mg/mL x 1.8=36 mg 320 mg (previous answer)/36 mg=8.89, round down to 8 carts
Goals of N2O Sedation
Relieves anxiety & fear Stress reduction Reduce pain perception Amnesia & analgesia effects Light sedation & mood alteration Patient remains conscious with protective reflexes intact
Advantages of N2O
Simple and safe No allergies Reduction in gag reflex Onset & recovery are fast Time perception can be altered
When to use local infiltration or supraperiosteal injection, what it anesthetizes, indications and contraindications, deposition site
This anesthetizes one tooth's pulp and root area, buccal periodontal tissues, connective tissue and mucous membrane. •Supplemental injection to back up what you've already done. •If doing incisal filling on mandibular or maxillary tooth, could use this. Short procedure, not very invasive, so don't need the block. More commonly used on maxillary posterior tooth because bone isn't as dense, so LA diffuses through. Can also use on mandibular anteriors for the same reason. Indications: 1-2 teeth Contraindications: Infection or acute inflammation, dense bone (won't usually work for mandibular) Deposition site: At apex of tooth being treated.
What is the most common cause of LA overdose in kids? How do you prevent it?
Too large of doseage Aspirate, inject slowly, know child's weight
Nausea and Vomiting
Too much nitrous Eating a large meal before appointment "See-sawing" nitrous levels Take patient off N2O and administer 100% O2
True or False: The wand aspirates for you
True
Disadvantages of N2O
Vertigo, nausea, vomiting Extreme behavior problems cannot be managed well Equipment is cumbersome Mask gets in the way Long term exposure may cause health problems
Paresthesia
altered sensation &/or persistent partial or complete numbness Lingual nerve-most common nerve involved in paresthesias Prevention of Paresthesia- follow all LA protocol, but bottom line is, we don't know-Avoid using articaine for lower blocks Good news: most paresthesias resolve themselves within a few weeks
Nitrous Oxide
is a weak anesthetic but strong analgesic and raises a patients threshold for pain.
Pedo Anesthesia: How deep for penetration, needle size, rule associated with them, when can you give maxillary and mandibular injections (PSA ASA MSA NP GP IALB Mental/Incisive) vs. what's alternative used and why, what's max amount of carps given, which type of LA is recommended for what tx?
look at the size of the child, shallower depth, ALWAYS use short needle regardless of injection type, more vascular, so aspiration very necessary, use Clark's rule. Do not give a PSA because infiltrations are very effective. If tx perm. 1st molars, use PSA or 2 buccal infiltrations (one on mesial root and one on distal root) . Don't give ASA unless multiple restorations in same quadrant. Same with MSA, but local infiltrations are best. NP: Same technique as in adults. GP: Visualize imaginary line from most posterior erupted tooth to the midline of the palate. Insert the needle from the opposite side of the mouth and bisect that line. If the child does not have their 1st permanent molar in yet, penetrate approximately 10 mm behind the last primary molar. Kids when younger don't usually need a lot of profound anesthesia. Would do a palatal injection on a child for extraction or rubber dam. For rubber dam, can just do local infiltration. Infiltrations are effective on mandible, but as child gets older bone gains density around age 12. Once have 12 YO molars, do IA, but use 25 or 27 short. Make sure syringe barrel is over PRIMARY MOLARS on contralateral side (where permanent premolars will be) and remember that as children age, foramen moves up to level of occlusion and then 7 mm above level of occlusion as adult; mandibular foramen is inferior to occlusal plane in kids. Mental/Incisive: Numbs all 5 primary teeth in a quad. Point of ref: between 2 primary molars at mental foramen (perm PM are under those). Apply pressure 2 minutes. 3% Mepivacaine ok if appointment is short--more toxic in kids. But 0.5-1 carp ok to give. 2% Lido w/epi more beneficial if treating more than one quadrant because of vasoconstrictor slows systemic absorption and decreases total dose of drug administered so systemic toxicity is decreased.
To feel for the foramen:
look at x-rays or palpate.
Advantage and indication of Varikosi Akinosi nerve block
· Between IA and Gow-Gates · Closed mouth mandibular nerve block · Good for patients who can't open their mouth well and need to work on them · Arbitrary injection since no bony contact because it's all soft tissue. You're parallel to ramus, so only soft tissue. · Carmon has never seen this done
What causes postanesthetic mucosal lesions? Examples?
•Caused when depositing too fast—can cause ulceration. Carmon read you wouldn't use 1:50K vasoconstrictor on the palate because too much vaso and can cause trauma—constricting blood flow to the area. Examples: Aphthous Ulcer Herpetic lesion
When to use intraseptal injection, when know it's successful
•Go in interpapillary area until hit crestal bone. •Lots of resistance •See blanching on buccal, then see on lingual (so know it's getting in there) •If person has a lot of tissue inflammation, make sure have blanching—if not then not effective
The WAND
•Greater tactile sense and control •Pen like grasp and stable finger rest, twizzle (twist--slight rotating finger motion) it as advance to minimize discomfort •Allows for more efficient flow of anesthetic solution through tissues •Needle deflection - Minimizes tissue damage
How does childhood obesity factor into LA for pedo patients?
•Need to consider age, not just weight when determining MRD • •An obese 7 year-old, for instance cannot metabolize drugs as efficiently as a 20 year-old of same weight.
It has often been suggested that LA drugs without vasoconstrictors should be used to shorten the time of anesthesia in children to reduce the incidence of self-inflicted injuries and lip trauma. However, when selecting a LA drug without a vasoconstrictor, one should consider the following:
•Three carpules of 3% Mepivacaine would exceed MRD for children 30-50lbs. •If quadrant dentistry is performed, it is difficult to not exceed MRD • •A 50 lbs child can receive twice the amount of 2% Lidocaine than 3% Mepivacaine plain. THEREFORE It is often beneficial to use an anesthetic with a vasoconstrictor in small children. It will slow systemic absorption of the local anesthetic and should decrease the total dose of the drug administered, thereby decreasing systemic toxicity.