Pain Management LA

bisulfite preservatives; absolute

Allergies to specific local anesthetic drugs or to ___________ are (relative/absolute) contraindications.

Absolute Contraindication

Allergy

C) Cardiac compromise

For an uncontrolled diabetic patient, which factor is the most critical to consider when planning to use a local anesthetic with epinephrine? A) Appointment time B) Blood sugar level C) Cardiac compromise D) Meal time

Depressants

Local anesthetics are central nervous system (stimulators/depressants)

No; they might need antibiotic prophylaxis

Should patients experiencing a Sickle Cell Anemia crisis receive local anesthetic?

Deposition site

anatomical location at which a drug is deposited

Field block

injections involve deposition of anesthetic drugs near larger terminal nerve branches near or a small distance from the site of the injection and areas of treatment

Local infiltration

injections involve the deposition of local anesthetic drug directly at or near small terminal nerve endings in the immediate area of treatment

ASA

physical status classification

Needle Pathway

route a needle travels as it advances to a target site.

relative contraindication

somewhat inadviseable

Penetration site

the specific location where a needle first enters the mucosa

All

(All/Some/No) local anesthetic drugs with vasoconstrictors contain bisulfite preservatives

1,000

A dilution ratio of 1:1000 epinephrine is equivalent to one gram in one liter. So a dilution of 1:100,000 is equivalent to _______________________ mg/mL

ASA IV

A patient with chronic obstructive pulmonary disease (COPD) requiring oxygen is classified as what ASA?

ASA II

A patient with well controlled, noninsulin-dependent diabetes is classified as what ASA?

Levonordefrin is one sixth as poten

Compare the potency of levonordefrin to the potency of epinephrine.

Positive Aspiration

Blood visible within the cartridge

No

Can patients with ASA III blood pressure receive local anesthetic?

Infiltration injection

Deposition of local anesthetic directly at or near small terminal nerve endings in the immediate area of treatment.

Nerve Block injection

Deposition of local anesthetic near the primary nerve trunk a greater distance away from the areas of treatment, providing a wider area of anesthesia.

concomitant

Drugs used together

absolutely contraindicated_

Epinephrine is __________________ in patients with poorly controlled or uncontrolled hyperthyroidism!!!!!

Relative

Epinephrine is a (relative/absolute) contraindication for patients who have had a stroke.

uncontrolled hyperthyroidism

Epinephrine is contraindicated in a patient with _______________________

COMT & MOA

Epinephrine is metabolized by

The needle should be withdrawn, the cartridge replaced, and the needle flushed or replaced before re-initiating the injection

Explain what should be done for a burst of blood, creating a "cloudy and reddened" solution in the cartridge

the needle can be repositioned slightly and aspiration can be repeated

Explain what should be done for a small trickle or "worm like" thread of blood?

reversal of generalized anaphylaxis and bronchospasm

For what other medical conditions can epinephrine be used for?

C) Hives

From the choices below, which one would NOT be exhibited during an overdose reaction to a vasoconstrictor? A) Racing heart B) Intense anxiety C) Hives D) Hyperventilation

*efficient re-uptake in synapses *the rapid removal and biotranformation of any residual portions that enter the bloodstream

Give two reasons why most adverse events associated with the use of vasoconstrictors are short-lived?

IV; no

If a patient experiences angina while at rest or sleep, what ASA class are they? Can they receive dental treatment?

epinephrine

If hypertension, myocardial infarction, cardiac arrhythmia, or comorbidity is present, caution with ___________ is indicated.

.04 mg

In ASA Class III and IV patients, what is the maximum dose for epinephrine?

anesthetic drugs into vessels

In areas where local anesthetic drugs with vasoconstrictors are deposited, the slowing of vascular uptake allows what?

*constrict local vessels *increasing safety by slowing systemic absorption *prolongs the local actions of the drugs *provides hemostasis *increases profoundness of anesthesia

In what ways to vasoconstrictors enhance local anesthetic drugs?

Yes

Is it possible to have an allergy to epinephrine?

Yes

Is levonordefrine a better homeostatic agent than epinephrine?

_1/6th____

Levonordefrin has ___________ the potency of epinephrine, therefore more concentrated dilutions are needed.

COMT primarily

Levonordefrin is biotransformed by ____________

3 to 10 minutes

Onset of anesthesia will usually occur within ______________ minutes.

Depression

Overdose reactions from lidocaine topical are similar to injectable forms with progression to CNS ________ without the initial excitation phase.

Depression

Patient who have taken narcotic drugs prior to injections of local anesthetics are at risk due to the risk for additional CNS _____.

myocardial infarctions; cerebrovasular accidents

Patients who have experienced recent _________________ or ______________ may need to delay elective dental treatment.

hemophilia; clotting disorders; warfarin

Patients with ___________, _____________, and on blood thinning medications such as ___________, may require modifications.

amide

Patients with compromised liver function may not be able to metabolize ________ local anesthetic drugs efficiently.

Epinephrine

Patients with poorly controlled diabetes may have a relative contraindication to the use of ______________

IV; NO

Symptomatic congestive heart failure is what ASA?______ Should they be seen for dental treatment? _____

True

T/F A patient who is taking Timolol can safely receive epinephrine.

True

T/F A patient with severe systemic disease is classified as ASA IV.

FALSE Allergic reactions to ESTER topicals are rare, but not impossible. Allergies to AMIDE topicals have been described as virtually unknown

T/F Allergic reactions to amide topicals are rare, but not impossible. Allergies to ester topicals have been described as virtually unknown.

True

T/F Allergic responses to epinephrine is nearly impossible.

False

T/F Atypical plasma cholinesterase is a relative contraindication to amide type anesthetics

True

T/F Benzocaine topical can induce methemoglobinemia

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.

False

T/F Local anesthetics are CNS stimulants and should be used with caution when patients have taken large doses of narcotics.

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

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 20%, which will provide a 30 second onset of anesthesia with peak effectiveness in approximately 2 minutes.

.04 mg

The maximum dose of epinephrine allowed for a patient with cardiovascular compromise is ________

epinephrine & levonordefrin

The two vasopressors routinely included in dental local anesthetic drugs in North America are _______________ & _________________

Uncompensated peripheral vasoconstriction

There is a concern about vasoconstrictors when nonselective beta-blocking agents such as propranolol are taken to control hypertension or prevent migraines. What could this lead to?

digoxin; Preticipate arrhythmias

Vasoconstrictors should be avoided, if possible, in patients taking ____________ for heart failure. What could happen?

arrhythmias

Vasoconstrictors should be used with caution and at low concentrations in patients prone to ___________.

III

What ASA category does a person have to have regarding a liver or kidney condition being a relative contraindication for local anesthetic?

Articaine

What anesthetic might you want to use on such as patient with seriously compromised livers?

BP over 180/110 mm Hg Angina during rest ASA IV Allergy to esters or amides

What are some absolute contraindications to LA?

ASA III Pt taking narcotic medications Atypical plasma cholineterase Signigicant liver or kidney dysfunction (ASA III) Use Articaine Pregnancy

What are some relative contraindications?

nausea, restlessness, heart racing, weakness

What are some signs and symptoms of transient high plasma levels of vasoconstrictors?

Lathargy, cyanosis and respiratory difficulty

What are some signs of methemoglobinemia?

Allergy to sulfites uncontrolled hyperthyroidism pheochromocytoma (tumor of the adrenal medulla)

What are the absolute contraindication for vasoconstrictor?

reduces the risk of overdose and complications even if inadvertently injected into the bloodstream after a false negative aspiration.

What are the advantages of slow delivery of anesthetic solution?

with the administration of local anesthesia

What are the majority of medical emergencies in the dental office associated to?

D) an aspiration test and slow delivery of anesthetic

What are the two most important safety steps when delivering anesthesia? A) informed consent and cooperative patient B) armamentaria in good working order and a thorough understanding of head and neck anatomy C) a thorough health history review and a list of all medications D) an aspiration test and slow delivery of anesthetic

1:50,000, 1:100,000, and 1:200,000

What concentrations is epinephrine added to local anesthetics in North America?

dental cartridges

What dental solution has levonordefrin in it?

14% benzocaine; 2% tetracaine; 2% butamben 45 mins

What drugs are in Cetacaine? How long does the numbness last?

Lidocaine Prilocaine; "intrapocket" use

What drugs are in Oraqix? Where is it suggested to use?

myocardium- increased cardiac output and heart rate Coronary arteries - increase coronary artery blood flow CVS -Decreased cardiac efficiency the uncontrolled diabetic- elevated blood sugar levels

What effects do vasoconstrictors have on myocardium? Coronary artieries ? CVS? The uncontrolled diabetic?

*myocardium- increased cardiac output and heart rate but less than epinephrine *Coronary arteries - increased coronary artery blood flow but less than epinephrine *Blood pressure - increased systole but less than epinephrine. Decreased diastole, except increased in higher doses

What effects does levonordefrin have on myocardium? Coronary arteries? Blood pressure?

MAO

What enzyme biotransmforms levonordephrine?

COMT

What enzymes are responsible for the biotransformation of unrecycled epinephrine?

Syncope

What is a common emergency situation associated with the injection process?

Hydrochloric Acid

What is added to anesthetic solutions to increase its tissue absorption?

the delivery of local anesthetic agents is the aspiration test

What is one of the most important safety steps in the delivery of local anesthetic?

To prevent insertion into standard syringes and inadvertent submucosal injection

What is the "safety collar" on the cartridge for?

5 cartridges per appointment

What is the MRD for Oraqix?

.2

What is the maximum dose of epi for a healthy individual in dentistry?

.2 mg

What is the maximum dose of epinephrine allowed for a healthy adult?

.04 mg

What is the maximum recommended dose of epinephrine for patients in category ASA III with cardiovascular disease?

1.8 per minute

What is the minimum recommended rate of injection?

Deposition too low below mandibular foramen

What is the most common error when giving an IANB?

Metabolic issues; scheduling appointments in the morning

What is the most common medical emergency that occurs in diabetics? How might this be avoided?

Articaine

What is the preferred anesthetic for a patient regarding a liver or kidney condition

Trauma to periosteum is lessened if bone is inadvertently contacted

What is the primary reason it is recommended to orient needle bevels toward bone during infiltration injections?

it increases the risk of hypertensive crisis stroke and myocardial infarction

What is the risk in giving a person epinephrine who has consumed cocaine or methamphetamine within 24 hours?

3% mepivacaine

What local anesthetic can a patient with a LA/bisulfite allergy receive without concern?

Acetaminophen & sulfonamides & some additives & dyes

What medications might put a patient at risk of methemoglobinemia?

Mild CNS Depression; Restlessness; agitation; increased heart rate

What might be some signs of overdose reactions to topical anesthetics?

A consultation with a physician is indicated

What should be done for patients with seriously compromised livers?

dry the tissue with gauze

What should you do before applying topical anesthetic that reduces dilution and inadvertent spread of the topical agent, and removes any gross or microscopic debris for the site?

establish effective soft tissue retraction

What should you do to increase visibility of the injection and allow you to view the needle throughout the injection?

gently pull the mucosa "taut"

What should you do to the oral mucosa that will ease needle penetration?

Inferior alveolar nerve block and the buccal block

What two injections are most often used to anesthetize a mandibular quadrant?

Emphysema & COPD or Ones who smoke

What underlying conditions could predispose a patient to methemoglobinemia?

Ephasema/ COPD

What underlying conditions may predispose a patient to methemoglobinemia?

Local effects: ischemia and necrosis Systemic effects: changes in arterial blood pressure, palpitations, dysrhythmias, and even permanent injury or death due to ventricular fibrillation, heart attack, or stroke

What undesirable local and systemic effects might aderenergic vasoconstrictors produce?

complementary and alternative medicine

When interviewing patients, it is also important to inquire about the use of what kinds of medicines?

Non-selective beta blockers (propanolol) Digoxin Glaucoma

When should you avoid epinephrine?

2 Seconds

When using spray preparations of Benzocaine, a spray should never exceed how much time?

C) 2% mepivacaine; 1:20,000 levonordefrin

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

1:50,000

Which has the greater concentration? 1:50,000, 1:100,000, and 1:200,000

A) Primary action on alpha receptors causes contraction of smooth muscles in blood vessels.

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) Antibiotic premedication

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) Typical pulpal anesthesia

Which of the following is not a benefit of eutectic mixtures of anesthetic drugs for use in dentistry? A) Typical pulpal anesthesia B) Increased therapeutic range C) Higher concentrations of base forms of anesthetics D) Greater depth of penetration on mucosa

D) None of the above

Which of the following is not a local adverse reaction to topical agents? A)tissue sloughing B)edema C) redness and pain burning D)None of the above

C) Bronchospasm

Which of the following is not a sign or symptom of an epinephrine overdose reaction? A) Nausea B)Heart racing C) Bronchospasm D)Weakness

A) Bradycardia

Which of the following is not a sign or symptom of methemoglobinemia? A) bradycardia B) lethargy C) cyanosis D) respiratory difficulty

A) Talkativeness and nervousness

Which of the following is not a typical sign of CNS toxicity related to overdoses of topical anesthetic drugs? A) Talkativeness and nervousness B) Decreased myocardial contraction C) Loss of consciousness D) Restlessness and agitation

D) Providing vasodilatation following treatment

Which of the following is not an indication for the use of a vasoconstrictor? A) Reducing the risk of toxicity of local anesthetic drugs B) Prolonging the duration of local anesthetic drugs C) Providing hemostasis D) Providing vasodilatation following treatment

D) Sedation

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

C) Recapping the needle with a one-handed technique

Which of the following is the most important safety step following an injection? A) Rinsing the patient's mouth B) Assessing the patient for adverse reactions C) Recapping the needle with a one-handed technique D) Making a complete chart entry

B) Lidocaine

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

Liver Disease

Which of the following medical conditions does not require precautions when using vasoconstrictors? A) Liver disease B) Diabetes with significant cardiovascular disease C) Radiation therapy of the jaws D)Cerebrovascular accident/stroke

C) Benzocaine

Which of the following topical anesthetic MRD is unknown? A) Tetracaine B) lidocaine C) benzocaine D) dyclonine

Epinephrine

Which of the vasoconstrictors is the most useful in providing hemostasis?

C) All injectable local anesthetics with vasoconstrictors

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

B) Rotate the syringe a quarter turn then reaspirate to release the bevel from a vessel wall

Which statement describes how to avoid a false-negative aspiration? A) Withdraw the syringe slightly and reaspirate to release the bevel from a vessel wall B) Rotate the syringe a quarter turn then reaspirate to release the bevel from a vessel wall C) Apply greater force on the thumb ring to permit blood to enter cartridge D) Avoid injections in highly vascular areas

A) Toward the clinician to permit visibility throughout the injection

Which statement describes the correct positioning of the long window of the syringe? A) Toward the clinician to permit visibility throughout the injection B) Away from the patient to block visibility throughout the injection C) Toward the patient to permit assessment of the duration of the injection D) Either toward or away from the clinician because both sides of the syringe have an opening

Toward the bone

Which way should the needle bevel be turned?

out of concern that respiration might be compromised when managing medial emergencies in dental settings.

Why is it preferred to have the patients head level with their heart, instead of lower than their heart?

considered to be equal in both clincal and systemic effects to 2% lidocaine, 1:100,000 epinephrine

Why is levonordefrin formulated in dilutions of 1:20,000?

Thick cortical bone, unreliable location of landmarks and nerves, potential for accessory enervation and the depths of soft tissue penetration required to reach the target

Why is the adult mandible more challenging to anesthetize than anywhere else in the mouth?

Yes, because of their influence on the efficiency, metabolism, and/or elimination of anesthetic drugs

Will concomitant drugs influence the choice of local anesthetics? Why?

Benzocaine

_____________, an ester, is one of the most widely used topical anesthetic agents.

concomitant drug

drugs that are in a patient's system when local anesthetics are administered

Nerve block

generally characterized as depositions near primary nerve trunks at greater distances from the areas of treatment, which provide wider areas of anesthesia.

adverse reaction

unwanted outcome

II, I, III

what ASA class would a patient whose blood pressure is 148/92 be? How about 135/89? What about a patient who has stable angina?