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