Pain Management II (weekly quizzes and study guide)
T/F Local anesthetics are CNS stimulants and should be used with caution when patients have taken large doses of narcotics
False; depressors
T/F Atypical plasma cholinesterase is a relative contraindication to amide type anesthetics.
False; ester
Which of the following local anesthetic drugs may represent a relative contraindication for patients with compromised liver function? a. Levonordefrin b. Lidocaine c. Benzocaine d. Epinephrine
Lidocaine
ANTERIOR SUPERIOR ALVEOLAR (ASA) area (maxillary)
MAXILLARY canine, lateral central
Which of the following is the most important safety step following an injection?
Recapping the needle with a one-handed technique
Which statement describes how to avoid a false-negative aspiration?
Rotate the syringe a quarter turn then reaspirate to release the bevel from a vessel wall
What is a hematoma?
Rupturing a blood vessel during insertion
Which of the following is NOT a consideration for patients with hemophilia for local anesthetic injections? a. Antibiotic premedication b. Types of injections c. Types of drugs d. Doses of local anesthetic
a. Antibiotic premedication
Which of the following is NOT a sign or symptom of methemoglobinemia? a. bradycardia b. lethargy c. cyanosis d. respiratory difficulty
a. bradycardia
Which of the following is not a benefit of eutectic mixtures of anesthetic drugs for use in dentisty? a. typical pulpal anesthesia b. increased therapeutic range c. higher concentrations of base forms of anesthetics d. greater depth of penetration on mucosa
a. typical pulpal anesthesia
target of ASA
above apex of maxillary canine
Inferior alveolar (IA) teeth anesthetized MANDIBULAR
all teeth in quad and all periodontium, buccal mucosa premolars to midline, floor of mouth and 1/2 tongue in quad(not soft tissues buccal to molars) MANDIBULAR
Gow-Gates (GG) teeth anesthetized
all teeth in quad, all periodontium soft tissues, buccal mucosa premolars to midline, floor of mouth to 1/2 tongue in QUAD
What are the two most important safety steps when delivering anesthesia?
an aspiration test and slow delivery of anesthetic
Cause of Postanesthetic mucosal lesions
an infectious or suspected immune response resulting from direct injury to mucosa.
Local infiltration injections anesthetized area (maxillary)
at injection site
Benzocaine topical can induce methemoglobinemia
true
Which of the following is NOT a typical sign of CNS toxicity related to overdoses of topical anesthetic drugs? a. restlessness and agitation b. talkativeness and nervousness c. decreased myocardial contraction d. loss of consciousness
b. talkativeness and nervousness
Cause of self injury
biting cheek, tongue, lip, etc while still numb.
S&S of hematoma during IA
bruising around submandibular angle
Which of the following topical anesthetic drugs is a eutectic mixture? a. dyelonine hydrochloride b. benzocaine c. oraqix d. butamben
c. Oraqix
Which of the following topical anestheric MRD is unknown? a. tetracaine b. lidocaine c. benzocaine d. dyclonine
c. benzocaine
MxNB target
close proximity to the maxillary nerve trunk within pterygopalatine fossa
maxillary nerve block high tuberosity approach penetration site
height of vestibule opposite the DB cusp of the maxillary 2nd molar.
Cause of allergies
hypersensitivity to LA or preservatives within anesthetic solutions. Allergies AREN'T DOSE RELATED, overdoses are.
S&S of tissue necrosis
large open sores at side of palatal injection
GG target
lateral side of condylar neck
MxNB needle size
long 25 gauge
GG needle size
long 25/27 gauge
posterior superior alveolar (PSA) teeth anesthetized
maxillary molars except mesiobuccal root of first molar and buccal to affected teeth
S&S of hematoma during PSA
may not be noticeable until 1-2 days later, bruising around cheek area
IA penetration site
medial to internal oblique ridge, lateral to pterygomandibular raphe, at or above height of coronoid notch
Buccal nerve block penetration size
mucous membrane distal and lateral to most posterior molars
YES/NO MxNB toward bone?
no
YES/NO max nerve block high tuberosity approach toward bone?
no
Buccal nerve block (Mandibular) teeth anesthetized
none, soft tissue: buccal to molars
MRD for articaine
not provided
S&S of hematoma during Mental or infiltration injection
noticeable right away due to shallowness of the injection
Avoidance of self injury
patient/ caregiver education -visual reminders for children
INFRAORBITAL (IO) teeth anesthetized
premolars, canine, lateral, central, buccal to affected teeth
S&S of syncope
pt loses consciousness
S&S of pain on injection
pt says "ouch"
Target of Local infiltration injections
selected soft tissue, gingival or apex of tooth
Local infiltration injections target
selected soft tissue, gingival or apex of tooth.
ANTERIOR SUPERIOR ALVEOLAR (ASA) needle size
short 25/27 gauge
M and I needle size
short 25/27 gauge
PSA needle size
short 25/27gauge
buccal nerve block needle size
short* or long** 25/27 gauge, -->* when given alone, **when given following IA
M and I target
slightly superior to mental foramen,
relative contraindication
somewhat inadvisable
Avoidance of syncope
supine position to restore circulation (unless prego- semi supine, rolling on their side)
S&S of allergies
systemic: respiratory and/or cardiac arrest. Epi pen may be administered as in anaphylaxis. Localized: occur mostly to topical anesthetics
Cause of overdose
too much LA
IO penetration site
height of vestibule above first premolar
PSA site of penetration
height of vestibule above second premolar
MSA penetration site
height of vestibule above second premolar. MAXILLARY
Mental (M) and Incisive (I) teeth anesthetized MANDIBLE
(M) pulpal limited to tooth at site of infiltration/ (I) premolars to midline SOFT TISSUES: premolars to midline
Relative contraindications...
-ASA III patients depending on their condition -Patients taking narcotic medications. -Pt with untreated or uncontrolled hypothyroidism -Atypical plasma cholinesterase -Significant liver or kidney dysfunction (ASA III) (Articaine is better) -Pregnancy -A TIA or CVA within 6 mths to 1 year (medical consult) -Anxiolytics (limit dosages) -Phenothiazines (antipsychotic/antiemetic/neuroleptics—thorazine)
Absolute contraindications for vasoconstrictors...
-Allergy to sulfites -Pt with poorly controlled or uncontrolled hyperthyroidism -Pt with pheochromocytoma (tumor of the adrenal medulla)
Avoidance of allergies
-Amide drugs have a very low allergic potential -Most allergies are due to preservatives. -If pt is allergic to sulfites, don't use anesthetics with vasoconstrictors. TAKE A GOOD HEALTH HISTORY!!!
S&S of postanesthetic mucosal lesions
-Herpetic looking lesions at site of injection -occurs mostly with palatal injections -manifests a few days later.
Avoidance of Trismus
-Limit # of injections -changed needle if it becomes barbed -apply hot compress alternating 20 min on/off. -Use analgesics for pain
S&S of paresthesia
-Lingual nerve is most effected -Pt may complain of partial numbness in tongue -Altered taste -Increased sensitivity to stimuli
Avoidance of facial paralysis
-Observe recommended insertion depths -confirm bony contact prior to depositing anesthetic -discontinue tx if it happens.
Avoidance of overdose
-PROPER CALCULATONS -ASPIRATE -ADMINISTER SOLUTIONS SLOWLY
Absolute Contraindications to LA...
-Pt who have angina that occurs during rest or sleep (ASA IV) -HBP >180/110 mm Hg -ASA IV patient depending on their condition -Pts having a sickle cell enemia crisis. -Allergy to specific local anesthetic (If they are allergic to amines, then an ester can be used, if they are allergic to esters, then all esters are to be avoided) -Cocaine or meth within the last 24 hours -Pt with poorly controlled or uncontrolled hyperthyroidism
S&S of trismus
-cant open more than few centimeters shortly after LA. - is transient and will clear up in a week or two
Avoidance of paresthesia
-change barbed needles -aim on the high side when doing an IA injection
Cause of tissue necrosis
-lack of blood supply to tissue -occurring where palatal injections were given -result of extended interruption of blood supply to area often due to vasoconstrictor
S&S of broken needle
-use hemostat to remove partially protruding broken needle - take xray and call dr and keep pt mouth in position if it is fully inserted into the tissue
Avoidance of pain on injection
-use topical anesthetic -pull tissue taught when penetrating needle -administer at slow rate of 1 carpule/min
The maximum dose of epinephrine allowed for a patient with cardiovascular compromise is
0.04 mg
What is the maximum recommended dose of epinephrine for patients in category ASA III with cardiovascular disease?
0.04 mg
NOTE: GG nerve block, patient should keep mouth open for _______ minutes after injection, __________ ______ recommended
1-2, mouth prop
What is the minimum recommended rate of injection?
1.8 mL per minute
When using spray preparations of Benzocaine, a spray should never exceed how much time?
2 seconds
IO needle size
25/27 gauge short or long
MRD for mepivacaine
400mg
MRD for lidocaine
500mg
MRD for prilocaine
600mg
MRD for bupivacaine
90mg
Which formulation of local anesthetic drug with levonordefrin is available in the United States today? A. 2% lidocaine; 1:20,000 levonordefrin B. 4% prilocaine; 1:20,000 levonordefrin C. 2% mepivacaine; 1:20,000 levonordefrin D. 3% mepivacaine; 1:20,000 levonordefrin
A. 2% lidocaine; 1:20,000 levonordefrin
Which statement best describes why retraction of tissue keeping the tissue taut is important during injections? A. It allows for ease of needle penetration and establishes a point of stability for the syringe. B. The patient's mouth is open and it improves visibility for the clinician. C. It eliminates the need for stabilization of syringe and fulcrum. D. It allows better identification of landmarks.
A. It allows for ease of needle penetration and establishes a point of stability for the syringe.
Which of the following best explains why vasoconstrictors are effective in increasing durations for local anesthesia? A. Primary action on alpha receptors causes contraction of smooth muscles in blood vessels. B. Primary action on alpha and beta receptors causes contraction of smooth muscles in blood vessels. C. Primary action of beta receptors causes initial contraction of smooth muscles in blood vessels followed by vasodilation of blood vessels. D. Primary action on alpha receptors causes initial vasodilation of the smooth muscle.
A. Primary action on alpha receptors causes contraction of smooth muscles in blood vessels.
What is the primary reason it is recommended to orient needle bevels toward bone during infiltration injections? A. Trauma to periosteum is lessened if bone is inadvertently contacted B. Needles should be angled away from bone during penetration C. False aspirations can be prevented D. Discomfort from needles is reduced
A. Trauma to periosteum is lessened if bone is inadvertently contacted
What is the Physical status classification
ASA
A patient with well controlled, noninsulin-dependent diabetes is classified as
ASA II
A patient with chronic obstructive pulmonary disease (COPD) requiring oxygen is classified as
ASA IV
Allergy
Absolute contraindication
Which one of the following drugs is absolutely contraindicated for patients with bisulfite sensitivity? a. All injectable local anesthetics with amides b. All injectable local anesthetics with esters c. All injectable local anesthetics with vasoconstrictors d. All topical anesthetics
All injectable local anesthetics with vasoconstrictors
Cause of paresthesia
Altered sensation or numbness in previously anesthetized tissue that lasts longer than expected caused by damage to the nerve.
Local infiltration injections MANDIBULE teeth anesthetized
At injection site both teeth and soft tissue
Compare the potency of levonordefrin to the potency of epinephrine A. Levonordefrin is one fourth as potent B. Levonordefrin is one sixth as potent C. Levonordefrin is twice as potent D. Levonordefrin is six times as potent
B. Levonordefrin is 1/6th as potent
Drugs used together
Concomitant
S&S of overdose
Biphasic response 1st phase, complain of ringing in ears, metallic taste, increased anxiety and tingling or numbness of the lips. 2nd phase may result in slurred speech, twitching or tremors, fatigue, unconsciousness and seizures. Could progress to coma, respiratory or cardiac arrest
Which of the following is not a sign or symptom of an epinephrine overdose reaction?
Bronchospasm
Which anesthetic is LONG acting?
Bupivacaine
How are esters and Articaine metabolized?
By cholinesterase
Which of the following vasoconstrictors is the most useful in providing hemostasis? A. Levonordefrin B. Felypressin C. Epinephrine D. Phenylephrine
C. Epinephrine
Supportive communication includes all of the following, except: A. It should begin during the pre-injection period B. It should involve positive comments focusing on patient behavior during injections C. It lets patients know that injections will be more comfortable compared to previous injections D. It includes rehearsing injections and providing ways for patients to communicate with clinicians during injection
C. It lets patients know that injections will be more comfortable compare to previous injections.
What is added to anesthetic solutions to increase its tissue absorption? A. Levonordefrin B. Felypressin C. Hydrochloric Acid D. Phenylephrine
C. hydrochloric acid
For an uncontrolled diabetic patient, which factor is the most critical to consider when planning to use a local anesthetic with epinephrine?
Cardiac compromise
Medical consultations urged for patients with...
Cardiovascular conditions, recent surgeries, uncontrolled hypertension, compromised liver and/or kidney function, immune system compromise, and any concerns regarding LA and/or treatment.
Anatomical location at which a drug is deposited.
Deposition Site
Patient who have taken narcotic drugs prior to injections of local anesthetics are at risk due to the risk for additional CNS _____.
Depression
Avoidance of Hematoma
Don't penetrate too deep for PSA's. Don't give PSA's to pt on blood thinners or with clotting disorders. Minimize # of injections needed for all.
What underlying conditions may predispose a patient to methemoglobinemia?
Emphysema/COPD
Patients with poorly controlled diabetes may have a relative contraindication to the use of
Epinephrine
MxNB penetration size
GP foramen
Deposition of local anesthetic directly at or near small terminal nerve endings in the immediate area of treatment.
Infiltration injection
What is the purpose for aspiration?
It reduces the risk of inadvertent deposition of a drug directly into the bloodstream
IA needle size
LONG 25/27 gauge
S&S of self injury
Lacerated oral tissues.
What causes Trismus (inability to open mouth all the way)
Muscle trauma, usually the pterygoid muscle, while giving an IA injection.
YES/ NO PSA toward bone?
NO
YES/NO GG toward bone?
NO
Route a needle travels as it advances to a target site
Needle Pathway
Deposition of local anesthetic near the primary nerve trunk a greater distance away from the areas of treatment, providing a wider area of anesthesia.
Nerve Block injection
Avoid EPINEPHRINE...
Non-selective Beta Blockers (propranolol). Use levonordephrine in cardiac doses. Digitalis glycosides (digoxin) glaucoma
Cause of pain on injection
OBVIOUS
IA target
On medial surface of ramus, slightly superior to mandibular foramen.
Cause of facial paralysis
Over inserting a long needle when giving an IA injection and inadvertently anesthetizing the facial nerve
What is the MOST common injection resulting in hematomas? Second most common?
PSA IA
Use epi with caution (use cardiac dosages)...
Patients prone to arrhythmis Poorly controlled diabetics with cardiac compromise CVD and controlled hyperthyroidism Tricyclic antidepressants (avoid levonordefrine) Certain antidepressants
Specific location where a needle first enters the mucosa
Penetration site
Which anesthetic is SHORT acting?
Polocaine
Blood visible within the cartridge
Positive aspiration
Where are amides metabolized?
Primarily in the liver
Which of the following is not an indication for the use of a vasoconstrictor?
Providing vasodilatation following treatment
Which statement describes the correct positioning of the long window of the syringe?
Toward the clinician to permit visibility throughout the injection
T/F A patient with severe systemic disease is classified as ASA IV.
True
T/F Allergic responses to epinephrine is nearly impossible.
True
T/F Epinephrine can cause dangerous elevations in blood sugar in patients with cardiac compromise and severe diabetes.
True
T/F Epinephrine is an absolute contraindication for patients with poorly controlled or uncontrolled hyperthyroidism.
True
T/F Gently pulling the mucosa taut will ease penetration of the needle and establish a point of stability for the syringe.
True
T/F If a patient is described as ASA III due to blood pressure levels, recommended dental treatment may be initiated provided that intraoperative monitoring of blood pressure is considered and patients are referred to physicians within one month.
True
T/F Metabolism of both amide and ester-type local anesthetics may be compromised in patients with serious liver dysfunction.
True
T/F Patients diagnosed with congestive heart failure (CHF) should not be placed in a supine position because this can quickly lead to serious pulmonary edema.
True
Epinephrine is contraindicated in a patient with
Uncontrolled hyperthyroidism
YES/ NO Local infiltration injections toward bone?
YES
YES/NO IA to bone?
YES
YES/NO IO needle toward bone?
YES
Which of the following is NOT an indication for topical anesthetic drugs in dentistry a. needle penetration b. radiographic film placement c. periodontal evaluation d. sedation
d. Sedation
Allergic reaction to amide topicals are rare, but not impossible. Allergies to ester topicals have been described as virtually unknown. a. The first statement is true and the second statement is false. b. the first statement is false and the second statement is true c. both statements are true d. both statements are false
d. both statements are false
Overdose reactions from lidocaine topical are similar to injectable forms with progression to CNS_______ without the initial excitation phase
depression
GG penetration site
distal to maxillary second molar at height of mesiolingual cusp
Avoidance of tissue necrosis
don't deposit too much anesthetic drug during a palatal injection
Avoidance of broken needle
don't insert needle all the way to the hub, stick with 25 or 27 gauge needles
Which of the following is NOT a local adverse reaction of topical agents? a. tissue sloughing b. edema c. redness and pain d. burning e. none of the above
e. none of the above
Maxillary nerve block palatal tuberosity approach (MxNB) teeth anesthetized
entire hemi maxilla
Local infiltration injections needle size
extra short or short 25/27/30 gauge
Local infiltration injections Needle size
extra short-short 25/27/30 gauge
MIDDLE SUPERIOR ALVEOLAR (MSA) anesthetized area
facial to affected teeth
Cause on syncope
fear or stress
NOTE: for incisive nerve block, keep pressure over ________ for _____ minute after injection
foramen, 1
S&S of facial paralysis
half the pt face doesn't move
Local infiltration injections penetration site
height of vestibule (buccal) to tooth. MAXILLARY
ASA penetration site
height of vestibule above canine. MAXILLARY
T/F Benzocaine topical can induce methemoglobinemia
true
T/F Precautions for toxicity increase when topical anesthetic is applied to abraded tissue
true
T/F The most common concentration of benzocaine topical is 2%, which will prove a 30 second onset of anesthesia with peak effectiveness in approximately 2 minutes
true
Adverse reaction
unwanted outcome
Cause of broken needle
usually "hubbing" the needle (patient jerks)
M and I penetration size
vestibule at or just anterior to mental foramen
Local infiltration injections penetration size
vestibule to tooth
YES/ NO ANTERIOR SUPERIOR ALVEOLAR (ASA) toward bone?
yes
YES/ NO M and I toward bone?
yes
YES/NO ANTERIOR SUPERIOR ALVEOLAR (ASA) toward bone?
yes
YES/NO Buccal nerve block toward bone?
yes
YES/NO Toward bone during Local infiltration injections?
yes
