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131 Cards in this Set
- Front
- Back
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Which type of peripheral nerve fibers are myelinated?
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A and B fibers. C fibers are NOT myelinated
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What is a type of slow-conducting unmyelinated fibers. These fibers are the most numerous in the PNS.
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C fibers
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Which type of fibers are the largest thus mkost rapidly conducting axons?
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A fibers
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Which types of fibers conduct pressure and motor sensations?
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A fibers
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This type of A fivers are primarily in the skin and mucous membranes and are responsible for the conduction of sharp, bright dental pain.
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A Delta
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What other major fiber group is myelinated and closely resembles A delta fibers except they're not responsible for dental pain.
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B fibers
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These types of fibers carry dull or burning dental pain
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C fibers
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Which type of fibers are more easily blocked by anesthetics. Why? Why when patients are anesthetized can they often still feel pressure and mobility?
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C fibers are easily blocked due to the lack of myelin sheath. Pts can still feel these sensations because they are carried by A fibers (myelinated) which are often unblocked even when dental pain from C fibers is blocked.
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Which of the A fibers is the largest, fastest and responsible for muscle movement and light touch? These are EFFERENT fibers.
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A alpha
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Which A fibers are afferent and register pain, cold, temp, tissue damage?
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A delta
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Which A fibers are afferent, innervate muscle are are responsible for touch sensation, pressure sensation and proprioception?
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A Beta
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Which type of A fibers are efferent, responsoble for muscle spindle tone and also touch and pressure.
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A gamma
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Which of the main types of fiber groups are found abundantly in the oral cavity? Which require more anesthetic volume to block?
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A and C fibers, C fibers greater distribution. A fibers have a larger diameter so require more anesthetic to block.
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Which positive ions are predominantely in the extracellular fluid? Intracellular? What else in intracellular? What does this mean for the electro-charge on each side of the cell membrane in a resting state?
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Sodium is extracellular and posassium is mainly intracellular. Negatively charted protein and nucleic acid molecules are also insode the cell are because they are large don't diffuse across the membrane. Therefore, the inside is negative in relation to the outside.
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Which negatively charged ion is mainly extracellular?
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Chloride ions
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What is the resting potential of a nerve
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-70mV -40 to -95
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In its resting state the nerve cell is said to be _______.
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polarized
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The resting membrane potential of a cell is altered when which two mechanisms are altered.
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Sodium potassium pumps OR permeability characteristics.
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How do local anesthetics work?
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they inhibit sodium influx through sodium specific ion channels in the neuronal cell membrane (voltage gated sodium channels). An action potential can't arise without the influx of sodium. The receptore site is on the cytoplasmic/inner portion of the sodium channel.
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True or False: Local anesthetic drugs bind more easily to activated sodium channels?
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True-the onset of neuronal blockade is faster in neurons that are rapidly firing. "State dependent blockade"
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Which are more sensitve to local anesth. Large or small fibers?
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small.
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Five the order in which local anesthtics block conduction (myelinated vs. non, large vs. small)
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1. small myelinated axons (nociceptive impulse carriers) 2. nonmyelinated axons 3. Large myelinated (therefore size/diameter is more of a factor than presence on myelin)
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Which nerve blocks need more anesthetic and why?
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IA and PSA need more than a supraperiosteal, because these are large diameter nerve fibers and therefore need more to prevent depolarization (note-at least 2-3 adjacent nodes must be blocked to block the nerve--b/c lost of excess current in saltatory conduction)
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What are some properties of the ideal local anesthetic?
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potent, reversible, absence of local or systemic or allergic reactions, rapid onset, satisfactory duration, adequate tissue penetration, low cost, stability in solution, sease of metabolism and excretion.
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What is the clinical significance between esters and amides?
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Potential for allergy (esters higher potential-high incidence of cross hypersensitivity) and route of biotransformation (esters are hydrolizedin the plasma by pseudocholinesterase; amides are biotransformed in the liver)
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What are the three components of the local anesthetic molecule?
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1. lipophilic aromatic ring (improveds lipid solubility of the molecles-fascilitates penetration through membrane and relates to the potentcy of the drug). 2. Intermediate hydrocarbon (ester or amide-predetermines course of biotransfermation) 3. Hydrophilic terminal amine ( acts as on-off switch, allows local to exist in either lipid soluble (tertiary amine) or water soluble (quaternary amine) configurations--once injected into tissue, quaternary amine dissociates into uncharged tertiary amine base and a hydrogen ion so that it can penetrate the nerve membrane)
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Why is there a higher risk for toxicity if large amounts of topical are applied to a limited area?
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Topical agents have a higher concentration to allow them to diffuse through the mucous membranes. However, submucosal injections, although not as concentrated are more effective due to delivery in close proximity of target nerves.
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What is pKa? How does this relate to number of free base molecules and onset of action.
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the pH at which 50% of the molecules exist in the lipid soluble tertiary form (free base, non-protonated) and 50% in the quaternary, water soluble (salt, protonated) form. It's the proportion of cation to base molecules when manufactured. Higher pKa=fewer free base molecules=slower onset; Lower pKa=more free base=fast onset
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Local anesthetics are weak ________(acids/bases), and when in the dental cartridge exist in the ____________ form.
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bases. In the cartridge they exist in the quaternary water soluble state.
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True or False: ALL anesthetic solutions are acidic before injection
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TRUE
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True or False: Preparations with vasoconstrictors are usually more acidic than plain formations. Explain.
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TRUE-preps with vasoconstrictors contain the preservative sodium bisulfite. The pH ranges from 3.5-5.5
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pKa is also known as the?
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dissociation constant
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which form is the anesthetic in when it binds to the receptor site?
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quaternary form (once the tertiary form passes into the cell and makes it to the axoplasm it gains an H+ ion and turns back into the quaternary form which can attach and inhibit the Na channels from opening)
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If the normal pH of the body is 7.4 but most local anesthetics have pKa values over 7.5, what does this mean for the proportion of free base when it's delivered to the tissues?
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Less than 50% will be in the free base form. The ideal anesthetic would have a pKa of 7.4.
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What is the only local anethetic that has a pKa of less than 7.5?
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topical benzocaine-3.5
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What is the pH of most plain solutions? With vasoconstrictors?
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5-6, lower with vasoconstrictors.
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The concentration of local anesthetic affects?
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diffusion and onset. Higher concentration=more molecules diffuse through the nerve=rapid onset
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The pKa affects?
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Onset: lower pKa=more rapid onset of action (more RN-free base molecules present to diffuse through the derve)
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Lipid solubility affects?
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potency. More lipid soluble increases diffusion allows for a lower effective dose
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protein binding of an anesthetic affects
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duration. More cations can bind to the receptor sites within the sodium channels prolonging the presence of anesthetic at the site of action. (Bupivicaine has very good protein binding).
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Perineurium thickness
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Onset: thicker perineurium the slower the rate of diffusion and onset of action.
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Diffusibility of nonnervous tissue affects?
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Onset: increased diffusibility=decreased time of onset
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vasodilator activity affects?
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Anesthetic potency and duration (NOT onset). Greater vasodilator activity=increased blood flow to region=rapid removal of anesthetic molecules from injection site-decreases potency and duration.
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During what phase of the nerve impulse generation does the local anesthetic act?
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During depolarization. It binds to the structural proteins "specific receptors on the sodium channel. There fore the rate of depolarization is reduced ad the firing potential is never reached.
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Local anesthetics compete with which ion to bind to ion channels and thus slow depolarization?
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Ca++. Calcium being displaced from ion channels during depolarization is the most significat factor responsible for the influs of sodium.
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what is the primary factore that determins the onset of action of a local?
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pKa value. Lower pKa increases tissue penetration and shorten sonset of action. (more lipid-soluble un-ionized particles). Lipid solubility (more soluble-faster onset) and administration site (smaller diameter nerve trunks-faster onset) also influence onset.
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What factors influence induction time or the time interval between the initial deposition at the nerve site and complete conduction blockade?
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Concentration of local anesthetic, pKa, lipid solubiolity, protein binding, perineurium thickness, nonnervous tissue diffusibility, vasodilator activity.
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Which bundles are faster to be anesthetized and also lose anesthesia faster?
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Mantle bundles
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When administering the IA which teeth will become numb first? Which will start to regain feeling first?
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The molars because they are innervated by mantle bundles.
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Tachyphylaxis means?
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increased tolerance to a drug that's administered repeatedly. If mantle and core fibers fully recover, reinjection will be ineffective.
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The duration of local anesthetics is influenced by?
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protein binding, vascularity of the injection site, presence or absense of a vasoconstrictor.
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The rate of systemic absorption is dependent on?
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total dose and concentration, route of admin., vascularity of the tissues at the admin site, and presence or absence of a vasoconstrictor.
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True or False, all anesthetics are vasodilators?
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TRUE
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Highly vascular organs have higher concentrations of local anesthetic (brain, heart, liver, kidneys, lungs), why do we care?
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Toxicity is related to the amount of accumilation in these tissues.
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What are 4 beneficial effects of vasoconstrictors?
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1. decrease blood flow (less anesthetic needed to produce effect) 2. Increase duration of anesthetic 3. Reduce systemic toxicity (increased duration means less needs to be given) 4. Hemostasis
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Which patients should NOT receive anesthetic with a vasoconstrictor?
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Recent MI, coronary bypass surgery, or cerebrovascular accident within the past 6 months. Uncontrolled hypertension, angina, arrhythmias, diabetes and hyperthyroidism.
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If a pt notes an allergy to an amide, what is the pt likely allergic to? What should be done?
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Likely allergic to the preservative sodium bisulfite added to solutions with vasoconstrictors. Do not give them anesthesia that contains a vasoconstrictor (3% Mepivacaine and 4% Prilocaine).
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Why can mepivacaine and prilocaine be used more easily without a vasoconstrictor
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Both only produce minor vasodilation
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How many generic locals are available in the US?
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5-Lidocaine, Mepivacaine, Prilocaine, Articain and Bupivacaine
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When choosing an anesthetic, what should be considered? (5 things)
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1. duration of pain control 2. need for post-tx pain control 3. health assessment and medications 4. Allergy (local, sodium bisulfite or metabisulfite) 5. need for hemostasis
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What determins an anesthetic's duration of action?
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Lipid solubility and protein-binding ability. Lipid solubility also determine's its potency. Vasodilating properties also play a rol in potency and duration of action (Mepivacaine and Prilocaine have less vasodilating effects so they can be used without a vasoconstrictor).
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Why does bupivacaine have such a long duration of action?
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Highest percentage of protein binding and is the most lipid-soluble. It is also therefore the most potent (.5% formulation) BUT it has the highest pKa so SLOWEST onset.
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Which of the anesthetics are considered short acting?
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All the plain formulations (30 mins of pulpal anesthesia and no vasoconstrictors): 2% Lido, 3% Mepiv., 4%Prilocaine
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Which anesthetics are intermediate acting and what does this mean?
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Pulpal aneshtesia of about 60 mins, contain a vasoconstrictor: Lidocaine 2%, 1:100,000 and 1:50,0000 epi, Mepivacaint 2%, 1:20,0000 Levo, Prilocaine 4% plain when used for a nerve block, Prilocaine 4%, 1:200,000 epi, Aricaine 4% 1:100,000 and 1:200,000.
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Which are the long-acting and what does that mean?
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90 mins of pulplal anesthesia and has a vasoconstrictor: Bupivacaine 0.5%, 1:200,000 epi
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What factors affect the difference patients experience in the duration of anesthesia (when given the same formulation/type)?
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1. Individual response-normal, hyper and hypo-responders. 2. Accuracy of anesthetic admin. 3. vascularity of tissue (more if inflamed) 4. variation of anatomic structure and injection technique
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Which population has a high incidence of allergies to bisulfites?
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Asthmatics (severe bronchospasms can occur)
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What is the mechanism of action of topical anesthetics
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blocks nerve conduction at the surface of the skin or mucous membrane. Permeability of sodium ions to the nerve cell is decreased-decreased depolarization and increased exictability threshold that blocks the conduction of the nerve impulse. Produces reversible loss of sensation.
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Most common dental concentration of Benzocaine
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20%
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Onset and duration of Benzocaine
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30sec-2min onset, 5-15 minutes (NO MRD)
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What is the only topical that is a FDA pregnancy cat B?
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Lidocaine…the rest are cat C. Oraquix (Lidocaine/prilocaine) is category B.
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Which is the most potent topical? How is it commonly prepared?
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Tetracaine Hydrochloride. Usually combined with other drugs. Has slow onset (up to 20 mins) but lasts 45 mins
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What types of anesthetic is used in Oraquix?
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2.5% Prilocaine/ 2.5% Lidocaine (5% gel). The MRD is 5 cartridges per tx.
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What is the onset and duration of action for Oraquix?
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onset-30 secs. Duration-20 mins (14-31)
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Which nerve blocks should be avoided in pts with bleeding disorders?
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PSA, IO, IA due to higher risk of excessive bleeding and hematoma. Supraperiosteal and PDL injections are "safer".
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Signs of modearate anxiety
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stiff posture, nervous play, white-knuckles, perspiration, overwillingness to cooperate, nervouse conversation, quick answers.
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Effects of stress on body
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dilated pupils, decreased salivation, chest pain, high BP, shortness of breath, increased hr, increased blood cholesterol and glucose, GI upset, headache, back and neck ache, clenching jaws, grinding of teeth, indigestion, perspiration, insomnia, weight change, hives, dry mouth, decreased immune response.
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True or False: Most people benefit from the use of a vasoconstrictor.
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True.
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What is the cardiac dose for epi and Levonordefrin? Mg and carpules
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Epi-.04mg 2.2cartridges of 1:100,000 or 4.4 of 1:200,000. Levo-.2mg
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For patients weighing more than 90lbs, what is the limiting drug in 2% 1:50,000 Lidocaine? How many carps can be given?
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Epi is the limiting drug in this case. 5 carps is the max that can be given.
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What should you do if a pt is taking tricyclin antidepressants and why?
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Interaction with epi and levonordefrin may cause hypertension and dysrhythmia. Levonordefrin to a greater degree. Avoid levo, limit epi to cardiac dose and don't use 1:50,000 form
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What if a patient is taking a nonselective beta blocker?
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There increase hypertension resulting in rebound bradycardia and potential for cardiac arrest. Limit vasoconstrictors to cardiac dose and don't use 1:50,000 epi.
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What considerations should be made for a patient with diabetes?
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Vasoconstrictors oppose the effect oninsulin. Limit the dose of vasoconstrictors for patients with UNCONTROLLED or brittle diabetes. Normal amounts used in dentistry should not affect a controlled diabetic. Also schedule apts in the morning after a meal.
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What if your patient has Graves disease?
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Hyperthyroidism leads to an increased sensitivity to vasoconstictors. Use the minimal effective dose.
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What is the drug-drug interaction for phenothiazines and vasoconstrictors?
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These may antagonize the peripheral vasoconstrictive effects of epi and may reverse the pressor effect resulting in increased risk of hypotension. Limit to cardiac dose and don't use 1:50,000 epi
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How do digitalis glycosides interact with epinephrine?
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Epi increases risk of cardiac arrhythmias. Med consult with MD before use of epi.
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For a healthy patient what is the absolute max number of carps of 2% Lido 1:100,000?
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8.3 (300mg-anesthetic is the limiting drug)
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What are the absolute contraindications for use of a vasoconstrictor? (10)
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MI withing 6 months, Coronary bypass within 6 months, Uncontrolled high BP, uncontrolled angina, uncontrolled arrhythmia, sulfite allergy, Pheochromocytoma (catecholamine producing tumors of adranal gland), Uncontrolled hyperthyroidism, cocaine or meth abusers, Glaucoma (increases ocular pressure)
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What kind of topical should be used on a patient taking sulfonamides and why?
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Esters undergo hydrolysis to PABA. Sulfonamides competitively inhibit PABA. PABA derivatives may antagonize the antibacterial activity of sufonamides and reder them ineffective. DO NOT give them an ester topical, instead use topical lidocaine.
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Most drug interactions with amide anesthetics manifest how?
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delaying the metabolism of the local and thus increasing the risk of systemic toxicity/overdose.
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What should you do if a pt is taking H2-receptor blocker cimetidine (Tagamet)?
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These reduce the metabolism of amides particularly lidocaine. Reduce the dosage (very important in patients with CHF)
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How do propranolol and metoprolol affect amides?
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Inhibit metabolism especially of lidocaine, reduce dosage.
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What is needed if your patient has malignant hyperthermia?
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Med consult before treating.
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What two anesthetics should be avoided if a patient has methemoglobinemia?
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Prilocaine and benzocaine
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Which injections should be avoided in those with blood clotting disorders and why?
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PSA, IA, and IO blocks should be avoided due to greater risk of positive aspirations/hematoma formation etc.
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True or false local anesthetics are teratogenic and pose danger to the fetus.
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False. Lidocaine is category B and safe during lactation. Prilocaine is B but unknown lactation category.
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If Prilocaine and Bupivacaine contain epi what is the concentration? Articaine?
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1:200,000. Articaine has 1:100,000 and 1:200,000 formulations
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What causes burning on injections?
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pH of the drug (acidic-5-6), Vasoconstrictor (lower pH due to sodium bisulfite 3.8-5), overheated carps, expired solutions, Contamination-with disinfecting solution this can also cause paresthesia and edema-don't put in disinfectant)
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List/explain the 9 steps to preparing a syringe
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1. Med history, armamentarium (PPE, syringe, cartridge, needle-proper length and guage, topica antiseptic, topical anesthetic, gauze, cottong-tip applicator, hemostat/cotton pliers 2. Evaluate cap (proper drug, expiration date, large bubbles, extruded stopper, corrosion on cart., fractures) 3. wipe rubber diaphragm with disinfectant 4, retract piston by puling back on thumb ring 5. insert carp with rubber stopper soing into the syringe first towards piston 6. engage harpoon into plunger with gentle finger pressure on thumb ring 7. Attach needle (harpoon is too difficut to engage winto rubber stopper when needle is in place) 8. uncap and expel a few drops to ensure flow 9. racap into protective shild using single handed scoop.
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Name and explain the 8 cartridge problems
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1. Large bubbles (anesthetic has been frozen-more than 2mm-discard), small bubbles-N2 gas harmless. 2. Extruded stopper (with bubble-frozen, without-placed in disinfectant-don't use) 3. sticky stopper-paraffin-store at room temp 4. burning during injection (expired or contaminated with disinfecting soln) 5. Corroded cap (placed in disinfectant) 6. rust on cap (seal has been broken-discard and evaluate all others for rust) 7. leakage during injection (off center perforation of needle into rubber diaphragm) 8. Broken cartridge (shipping, excessive force during harpoon engagement, bent needle-not properly penetrating diaphragm)
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How long is a short needle? Long?
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20mm from hub to tip. Long-32mm
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True or False the patient can discern between guages of needles, so the smallest (30g) should be used when possible?
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False. The 25 G is safer for the patient because it provides easier access for blood to enter the carp during aspiration.
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How is guage selection determined?
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by depth of tissue penetration and risk of intravascular injection (25g used for areas of high risk for positive aspiration-IA and PSA)
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What are the advantages of a larger gauge?
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Less deflection, greater accuracy, increased success of injection, less chance of need breakage, aspiration is easier and more reliable, no difference in pt. comfort
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When should you change a needle?
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after 3-4 stabs
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Which blocks have the highest aspiration rates? Which has the highest risk of hematoma formation and why?
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1st: IA 10-15%, hematomas may occur. 2nd highest: mental block-aspiration 5.7%, 3rd highest: PSA -3%. The PSA has the highest risk of hematomas due to the proximity of the pterygoid plexus. The IA and Mental blocks can also cause hematomas. They are least likely following palatal blocks.
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True or False, positive aspirations lead to hematoma aspirations and there can't be a hematoma without a positive aspiration.
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Both are false. Positive aspirations usually don't produce hematomas. Hematomas can occusr without a positive aspiration by nicking a blood vessel during penetration/removal.
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Hematoma from the PSA manifests _____orally, whereas they occur ____orally from the IA
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extraorally; intraorally
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What's the best way to avaoid hematomas
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know your anatomy, use a short needle for the PSA, minimize number of insertions, use good technique
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Which injection could cause facial paralysis if administered incorrectly?
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IA, if needle tip is too far posterior (correction would be to move barrel posterior and needle tip anterior), anesthetic could be deposited in the parotid and the facial nerve could become anesthetized. Loss of motor function of muscles of facial expression, can't close eyelid, drooping corner of lip. Should fade within a few hours-have pt remove contacts and close eyelid manually. Document
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A persistent anesthesia beyone the expected duration, or an altered sensation such as tingling or itching that is beyond a normal level.
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Paresthesia.
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What can cause paresthesia? How can it be avoided?
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1. irritation of nerve due to contaminated solution 2. edema places pressure on nerve 3. trauma to nerve sheath/electrical shock (lingual nerve during IA/L injection) 4. Hemorrhage around nerve sheath . Higher concentrations of solutions may increase risk (possibly why reports of increase paresthesia with use of Articaine-4%). Can also be from spread of dental infection or trauma from extraction AVOID: Properly store cartridges, avoid placing in disinfectant, Use proper technique-don't move needle around in deep tissue, change directions. If it happens: reassure pt, arrange exam with DDS, consult with OS, recod and inform insurance carrier of incident.
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Normal reasons for burning during injection are? Abnormal burning is caused by?
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Normal: pH of the local/vasoconstrictor. Abnormal: contaminate solns, heated cartridges, expired solutions, rapid deposition.. Can result in trismus, edema, and paresthesia. Prevent: don't put in disinfection solns, check expiration dates, don't use cartridge warmers, inject slowly.
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Which nerves is paresthesia most common?
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Lingual and IA
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What is OraVerse (Phentolamine Mesylate) and how does it work?
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used to reverse local anesthetics with vasoconstrictors. It's and alpha-adrenergic recpetor antagonist and competes for the receptor sites of the vasoconstrictor encouraging faster metabolic reuptake of the local due to increased vasodilation.
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What's the best way to avoid systemic complications?
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Preanesthetic patient assessment and by strictly following administration guidelines.
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Which branch of the trigeminal nerve is the maxillary nerve? Where does it enter the skull? What does the maxillary branch split into (what other nerves). Is the maxillary afferent or effernt?
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second division. Enters through foramen rotundum of sphenoid. Then it enters the trigeminal ganglion. It splits into the zygomatic nerve (zygomaticofacial and zygomaticotemporal), infraorbital (ASA , MSA), PSA, Greater and Lesser palatine, and NP.
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Which nerve is afferent nerve that serves the maxillary sinus?
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PSA
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Where does the mandibular nerve enter the skull and which division of the trigeminal nerve is it?
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V3, enters through the foramen ovale of the sphenoid.
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Which division of the trigeminal nerve is the largest?
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V3-mandibular
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Which division of the trigeminal nerve carries both efferent and afferent nerves?
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Mandibular
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Topical provides what type of anesthesia
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Surface anesthesia. Anesthetizes the free nerve endings supplying the mucosal surfaces. (short lasting and limited to direct area of contact)
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If a small area of soft tissue needs to be anesthetized or bleeding control is desires for a small area which type of technique can be used?
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Local infiltration-deposit solution close to the smaller terminal nerve endings providing relief only in the area of diffusion
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Anesthesia that involves pulpal and soft tissue of a single tooth is called? This is also often referred to as a supraperiosteal injection.
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Field block
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Type of injection that deposits solution in the vicinity of a major nerve trunk at a greater distance from the area of treament.
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Nerve block
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What's the most common emergency in the dental office that often is linked to admin of local anesthetic?
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vasodepressor syncope. Prevent: effective commiunication and psychological support.
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True or False. At some point the administration of local ansthetics should become routine
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FALSE! Never let it become routine.
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What 6 things should be considered when selecting an anesthetic?
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1. physical status 2. duration of tx and postop pain control 3. volume of anesthetic 4. need for hemostasis 5. possiblity of self-mutilation 6. MRD
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What order should you admin injections for MX Quad tx? MN?
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MX: PSA, MSA, ASA, GP, NP. MN: IA, B
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For half mouth tx what order should you admin injections?
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IA, B, PSA, MSA, ASA, GP, NP
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According to the book, what 8 things should be documented when administering local anesthetic?
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1. date 2. drug and concentration 3. vasoconstrictor 4. amount of drug and vasoconstrictor administered in mg 5. gauge and type of needle 6. injections given 7. time of administration 8. pt reactions
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