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80 Cards in this Set
- Front
- Back
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Pain Perception Threshold & Pain reaction threshold
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Perception threshold stimulus is similar in most people.
Pain Reaction threshold is variable according to pain tolerance, emotional state, fatigue, age, sex, past exp, medications |
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Nerve fibers
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Type A fibers are myelinated & fast conduction
a,b,gamma - Tactile & proprioceptive delta - Fast pricking pain, touch, warmth, cold Type C fibers - Smaller diameter, unmyelinated, slow burning pain, itch, warmth, cold, mechanical & chemoreceptive |
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Chemoreceptors
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C fibers that respond to inflammatory mediators like bradykinin.
Prostaglandins increase perception of pain |
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Free nerve endings
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Adelta & C fibers transmitted to CNS
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Gate control theory
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Large diameter fibers open or close gate to modulate impulses from small diameter nociceptive fibers.
Gate is in substantia gelatinosa in dorsal horn or CN V nucleus caudalis Also descending control from cortex & Limbic system |
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EOP
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Endogenous opioid peptides
endorphins, dynorphins, enkephalons activated by pain or stress |
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Two types of tooth pain
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Odontogenic - Dentinal pain, short duration stimulated by sweets & extreme temperatures
Pulpal Pain - Severe long lasting pain, percussion sensitivity. |
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Migraines
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Migraine with Aura
Migraine without Aura Ophthalmoplegic migraine Basilar Migraine Periodic Migrainous Neuralgia |
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Migraine with aura
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Classic migraine - Starts as ache then pulsatile. 1-4 per month & Preceded and/or accompanied by scotomata, tunnel vision, nausea, vomiting, diarrhea, chills, photophobia, phonophobia, tremors, fatigue etc
Occipital cortex ischemia causes visual hallucinations to remain with eyes closed. Fluid retention before, then polyuria, possibly premenstrual, possible nasal stuffiness & secretion while subsides |
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Migraine without Aura
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Common Migraine - Same as classic but without aura. More frequent
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Ophthalmoplegic Migraine
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Migraine with orbital & periorbital pain.
Ipsilateral Ptosis & CN 3 Palsy |
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Basilar Migraine
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Usually with menstruation & 10-30 minutes of blindness, vertigo, ataxia, dysarthria, Tinnitus, periorbital paresthesias.
Possibly lose consciousness & then severe throbbing headache, usually occipital May get typical migraines between attacks, probably caused by brainstem ischemia. |
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Periodic Migranious Neuralgia
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Cluster headache
- Severe pain around one side of face, that lasts minutes to hours. Often same time of day or night around REM. - Unilateral Flushing or blanching of face & conjunctiva that affects mostly men. |
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Etiology of migraines
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Classic vascular theory - Extracranial vasodilation cause headache while intracranial vacoconstriction causes neurologic symptoms
Neuronal phenomenon theory - Slow moving depression of cortical activity preceded by a wavefront of increased metabolic activity spreading over cortex. Studies whow wave of cortical hypoperfusion for 4-6 hrs. |
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Treatment of Migraines
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Prophylactic - Beta blockers, Ca+ channel blockers, antidepressants etc
Attack aborting - Cerebral vasoconstrictor abortive angents Ergotamine/caffine, dihydroergotamine, triptans. Non vasoconstrictive abortive agents butorphanol tartrate nasal spray |
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Coital headache
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Severe occipital headache around orgasm more often for men.
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Atypical Odontalgia
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Variant of cluster headache with crawling, exploding or pressure pain in tooth
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Eagle's syndrome
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Elongated styloid process or calcified stylohyoid ligament resulting in pain in neck & throat.
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Trigeminal Neuralgia
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Usually unilateral shocking pain due to possible compression of rootlets of CN V by superior cerebellar artery.
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Glossopharyngeal Neuralgia
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Shock like pain in throat & ear often triggered by cold drink. Possibly caused by compression of CN 9 rootlets by inferior cerebellar artery.
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TMJ Joint Pain
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Due to internal derangements, dislocation, arthritides or trauma
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Preparation of Local anesthetic
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Generally weak base unstable in air & poorly soluble in water.
Combine with acid to form salt which is hydrophilic and stable Dissolved in water or saline to form injectable solution |
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Anesthesia mechanism of action
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- Displace calcium from receptor site
- Antagonize receptor site - Blockade of sodium channel to depress rate of depolarization to subthreshold level. |
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Anesthesia structure/activity considerations
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Aromatic ring - Lipid solubility
Intermediate chain Ester: Plasma Cholinesterase Amide: Metabolized in hepatic Terminal amine: Tertiary - Neutral, lipid soluble Quaternary - Ionized, water soluble |
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pKa of anesthetic
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pH at which 50% are ionized
Since local anesthetics are basic, pH below pKa will result in more than 50% ionization |
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Onset of action & Duration of action
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Both depend on Concentration & Lipid solubility
Onset: Diffusion to site, Nerve morphology, tissue pH, pKa of drug Duration: Diffusion from site, Protein binding |
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1% Solution & 1:100,000 solution
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1% solution = 10mg/ml
1:100,000 solution = .01mg/ml |
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Methemoglobinemia
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Reduced amount of hemoglobin available for oxygen transport due to oxidation to methemoglobin.
- Look for cyanosis of nail beds & lips Treat with methylene blue 1-2mg/kg Weight administered via IV over 5 minutes. |
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Prilocaine considerations
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Low systemic toxicity, however metabolite o-toluidine can cause methemoglobinemia
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Aderenergic receptor function
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Alpha: Vasoconstriction
Beta2: Vasodilation, Bronchodilation Beta1: Cardiotropic |
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Needle Gauges used in dentistry
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Red - 25
Yellow - 27 Blue - 30 |
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Long vs short needle
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Long:
Inferior alveolar block Infraorbital nerve block PSA block V2 block |
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Sulfur allergy
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Asthmatic patients may be allergic to Sulfur dioxide or Sulfite antioxidants like Sodium metabisulfite used to improve shelf life.
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Sulfonamides
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Antimicrobial agents with high incidence of allergenicity/cross-allergenicity with high requently reported reactions.
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Articane characteristics, mechanism of action, metabolism & Special
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Amide group local anesthetic with an ester group on highly lipid soluble thiophene aromatic ring
- Sodium channel blocker - 90% inactivated by plasma cholinesterase & only 10% by hepatic enzymes. Ester hydrolysis component provides rapid metabolism which prevents toxocity * Not been associated with increased allergenicity due to presence of ester linkage on thiophene ring. * 27min Half life. So can administer half of original loading dose after 27min |
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Local Anesthetics & Cell necrosis
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<1% Lidocaine does not injure neurons
>2.5% cause calcium conc to rise & cell death to occur 5% showed immediate irreversible effect |
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Salicylates characteristics, mechanism, side effects
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Analgesic but non narcotic
Antipyretic Anti-inflammatory - All accomplished by inhibiting formation of prostaglandin synthesis Inhibits prostaglandin synthesis by inhibiting COX action on arachidonic acid. GI: Nausea, vomiting, gastric ulcers. Prostaglandins inhibit acid secretion & promote gastric mucous secretion Hemostasis: Inhibits platelet aggregation by preventing formation of Thromboxane A2 Increased respiration resulting in respiratory alkalosis |
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Para-aminophenol derivatives, actions, side effects
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Phenacetin & Acetaminophen - Active metabolite of phenacetin is acetaminophin
- Analgesic, antipyretic, weak anti-inflammatory Side effects: - Allergic reactions like rash - Rare neutropenia - No gastric irritation & weak effect on platelets |
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Acetaminophen dosing & overdose
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325mg tablet most common with 500mg extra strength
- 650mg every 4 hours as needed with 4000mg/day max Overdose: 10-15 grams resulting in potentially fatal hepatic necrosis. Treat with Acetylcysteine (Mucomyst) |
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Salicylate dosing & overdose
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325mg tablets
- Normal adult dose is 650mg every 4 hrs as needed. 4000mg/day max Overdose: Headache, dizziness, tinnitus, confusion, acid-base disturbance |
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NSAIDs families
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Salicylic acid derivatives
Propionic acid derivatives Pyrrolo-pyrrole group COX-2 Inhibitors |
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Ibuprofen family, Dosing
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Propionic Acid derivatives - Motrin, Advil, Nuprin
Prescription 400mg,600mg,800mg Non prescription only 200mg Usual adult dose is 100mg/hour every 4,6,8 hrs 2400mg/day maximum |
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Opium constituents, effects
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Alkaloids
- Morphine, Codeine, Thebaine - Papaverine, Noscapine:antitussive Effects: Analgesic, Antidiarrhea, Antitussive CNS - miosis, respiratory depression from unreponse to CO2 levels, Nausea, Vomiting, Mood changes CV - Peripheral arteriolar & venous dilation due to histamine release, lack of CO2 vasoconstriction reflex GI - Decrease secretions & motility throughout GI. Constipation |
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Opioid receptors
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Mu - euphoria & physical dependence
Kappa - Miosis, sedation, spinal analgesia Delta - Dysphoria, hallucinations, respiratory & vasomotor stimulation |
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Pentazocine
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Opioid agonist/antagonist
Analgesic with little or no abuse potential |
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Acetaminophen or Asprin(Empirin) with Codeine dosing & maximum
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#1 - 325mg, 7.5mg
#2 - 325mg, 15mg #3 - 325mg, 30mg #4 - 325mg, 60mg #'s1,2,3: 1-2 tablets every four hours as needed #4: 1 tablet every 4 hours as needed Daily Max Codeine: 360mg Acetaminophen: 4000mg |
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Tylenol with Codeine elixer
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Codeine phosphate: 12mg/5cc
Acetaminophen: 120mg/5cc 3-6yr - 1tsp(5cc) 3-4 times a day 7-12 - 2tsp(10cc) 3-4 times a day adults - 1tablespoon (15cc) every 4 hours as needed |
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Oxycondone family
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Percodan
Percodan - demi Percocet Tylox Roxicet Roxicodone |
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Percodan & -demi tablets, usual adult dose
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Percodan tablets
Oxycodone HCL - 4.5mg Oxycodone Terephthalate - 0.38mg Asprin - 325mg Percodan - Demi tablets Oxycodon HCL - 2.25mg Oxycodon Terephthalate 0.19mg Asprin - 325mg Usual Adult dose Percodan: 1tab/6hr as needed Percodan-demi: 1-2tab/6hr as needed |
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Percocet tablets & usual adult dose
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Oxycodone HCL - 5mg
Acetaminophen - 325mg Usual adult dose 1tab/6hr as needed |
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Tylox
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Same as Percocet but in capsule & 500mg Acetaminophen
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Roxicet
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Same as Percocet & Tylox with 5:325 & 5:500
Oral solution Oxycodone HCL 5mg/5cc Acetaminophen 325mg/5cc |
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Hydrocodone family, tablets, dosing, max
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Vicodin
- Hydrocodone Bitartrate 5mg, 500mg Acetaminophen - 1-2tab every 4-6hrs as needed - Max 8/day Vicodin ES - Hydrocodone Bitartrate 7.5mg, 750mg Acetaminophen - 1tab every 4-6hrs as needed -Max 5/day Vicodin HP - Hydrocodone Bitartrate 10mg, 660mg Acetaminophen - 1tab every 4-6hrs as needed - Max 6/day |
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Vicoprofen
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Hydrocodone 7.5mg
Ibuprofen 200mg 1tab every 4-6hrs as needed |
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Butalbital
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Anxiolytic & muscle relaxant
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Benzodiazepines
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Diazepam (Valium)
Anxiolytic Sedative/hypnotic Anterograde anmesia Muscle relaxant Anticonvulsant NOT analgesics |
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Drug schedules
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I - No current medical use
II- Opioids like morphine, codeine, eprcodan, meperidine, amphetamines, etc III - Compounds containing opioids tylenol with codeine, vicodin, etc IV - certain barbiturates & Benzodiazepines like valium V - Moderate amts of opioids with antitussive & antidiarrheal use |
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Local anesthesia general steps
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Relaxed atmosphere
Study Injection site Palpate area Wipe with Gauze Apply topical for 3 min Wipe with gauze **Inject slowly (1 cartridge/min) & Aspirate! |
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Supraperiosteal Injection sites, position, & steps
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Pulpal anesthesia of maxillary teeth & variable mandibular incisors.
Also Buccal soft tissue & bone. Semi reclining or Supine position - Stretch cheek outwards, jiggle, Penetrate at mucobuccal fold, slowly advance till slightly apical to apex often only a few mm, aspirate, deposite 0.6cc of solution. |
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Middle superior Alveolar Nerve Block sites, position, & steps
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Pulpal anesthesia of both maxillary premolars & MB root of maxillary first molar, unless innervated by PSA nerve.
Also anesthetizes buccal soft tissue & bone Semi reclining or supine position Stretch lip & cheek, jiggle, penetrate at height of mucobuccal fold opposite maxillary second premolar, advance slightly past apex, aspirate, inject slowly 0.9-1.2cc. |
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Infraorbital block sites, position, & steps
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Pulpal anesthesia to:
Central & Lateral incisors Canines Premolars & MB root of M1 if no MSA nerve & for MB root if not innervated by PSA Also anesthetizes Labial soft tissue & bone, and anesthetizes extra oral soft tissue of infraorbital & lateral nasal regions Semi-reclining or supine position Locate infraorbital foramen by palpating infraorbital notch & then sliding finger downard. Place Index finger over foramen, & use thumb to lift lip & cheeck out & up Penetrate at mucobuccal fold parallel to long axis of first premolar & jiggle Advance slowly towards finger until contact with roof of foramen 16mm avg adult Apply firm pressure over foramen with finger Aspirate & inject 0.9 to 1.2cc slowly. Maintain finger pressure for 1 minute |
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For infraorbital block, when needle is in place it is:
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Beneath infraorbital head of quadratus labia superioris & above origin of canis
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PSA Block sites, position, & steps
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Pulpal anesthesia for maxillary molars but possibly only Palatal & DB roots of M1
Also anesthetizes buccal soft tissue & bone Semi-reclining or supine position Open mouth partially & shift mandible toward side of injection to move coronoid process out of way Insert at height of mucobuccal fold opposite M2 upward, inward & backward 45degs appx 16mm Aspirate & inject 1.8cc |
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Greater Palatine Nerve Block sites, position, steps
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Anesthetize palatal soft tissue from first bicuspid to 3rd molar regions
Supine position Locate foramen distal to M2 at junction of alveolus & palate Directed from opposite side perpendicular to injection site Penetrate mucosa & deposit a few drops & withdraw to wait 30 seconds Reenter same site & advance to bone then withdraw needle 1mm Aspirate & deposit 0.45-0.6cc solution |
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Nasopalatine Nerve Block Sites, Position, Steps
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Anesthesia of soft tissue & bone in anterior palate from canine to canine
Supine position Insert needle just lateral to incisive papilla Penetrate mucosa & deposite a few drops, withdraw & wait 30 sec Reenter same site & advance 6-10mm at 30deg angle & progress to foramen Contact bone & withdraw 1mm Aspirate & slowly deposite 0.45cc of slution |
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V2 block site, position, steps
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Pulpal anesthesia of all unilateral maxillary teeth, buccal & palatal soft tissue & bone, extraoral soft tissues of infraorbital & lateral nasal regions
Diagnostic block Higher tuberosity approach - Same as PSA but advance 30mm with 1.8cc of solution Greater Palatine approach - Same as GP block but advance 30mm into foramen using needle to locate & inject 1.8cc |
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IAB sites, steps
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- Pulpal & mandibular bone anesthesia of all ipsilateral mandibular teeth.
- Soft tissue anesthesia of labial & buccal soft tissue anterior to first molar & lower lip & chin Retract cheek with thumb & index finger on coronoid notch & posterior border Study site Palpate Wipe with gauze Apply topical for 3 min Wipe Patient opens wide Position barrel over contralateral premolars at height indicated by coronoid notch Punture mucosa just lateral to raphe & deposite a few drops of solution & wait Advance till bone then pull back 1mm & aspirate Inject 1.4cc of solution slowly |
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Position of Needle during IAB
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Superior to:
Inf alveolar vessels & nerve Insertion of medial pterygoid Mylohyoid vessels & nerve Medial to: Ramus of Mandible Anterior to: Deep part of parotid Lateral to: Lingual nerve Medial Pterygoid muscle Sphenomandibular ligament |
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Lingual nerve Block
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Anesthetizes
Anterior 2/3 of tongue Floor of mouth Lingual soft tissues After IAB, withdraw needle halfway & inject remaining 0.4cc solution. |
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Trouble shooting IAB
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Succesful anesthesia of lip/chin
- Possible accesory innervation from cervical branches or Mylohyoid nerve Partial anesthesia of lip/chin Additional volume Alter injection site No lip/chin anesthesia Additional volume Alter location of injection |
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Hitting bone too soon
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Minor:
Withdraw most of way Swing barrel anteriorly Major Withdraw needle completely Reinsert needle several mm superiorly |
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Not hitting bone at full depth
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Minor correction
Withdraw needle most of the way Swing barrel posteriorly Major Withdraw needle all the way Reinsert several mm inferiorly |
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Long Buccal Block
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Anesthesia of buccal soft tissue in mandibular molar region
Pull Buccal tissues laterally Bold syringe parallel to occlusal plane Penetrate 1-2mm distal & buccal to last molar till contact bone Withdraw half way & aspirate Inject about 0.3cc solution |
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Mental vs Incisive block
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Both:
Soft tissues of lower lip, chin, labial mucosa anterior to mental foramen Incisive: Pulpal for mandibular centrals to +/- second premolar |
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Mental or incisive block steps & precautions
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Pull tissues laterally to make area taut
Orient bevel towards bone Penetrate close to foramen & advance slowly Aspirate 0.6ml solution for mental block 0.6ml-0.9ml of solution for incisive block * Maintain finger pressure 1-2min after needle is removed * Do not enter mental foramen |
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Gow- Gates block
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Anesthetize inferior alveolar, lingual, mylohyoid, auriculotemporal, buccal in 75%
Pt open wide to bring condyle closer to nerve trunk Penetrate distal to M2 & Advance to contact neck of condyle |
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Akinosi Block
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Used on Pts with limited opening
Anesthetizes: Inferior alveolar Lingual Mylohyoid Possibly Buccal Bevel away from ramus & point at level of Mucogingival junction of Max molars. |
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Clark's Rule
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Child's weight(lbs) /150 x Max adult dose
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Max number of cartriages for Lido's, Mepivicaine, Articaine & Prilocaine, bupivacaine, Etidocaine
Absolute Max |
2% Lido with 1:100k epi - 10
2% Lido with 1:50k epi - 5.5 3% Mepivacaine - 5.5 4% Articaine 1:100k Epi - 7 4% Articaine 1:200k Epi - 7 4% Prilo with or w/o 1:200k Epi - 5.5 0.5% bupivacaine with 1:200 - 10 1.5% Etidocaine with 1:200 - 15 Lidocaine & Articaine 500mg Mepivacaine & Prilocaine 400mg |
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Naloxone
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Narcan - Reverse morphine like opioid agonists
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