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80 Cards in this Set

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Pain Perception Threshold & Pain reaction threshold
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
Nerve fibers
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
Chemoreceptors
C fibers that respond to inflammatory mediators like bradykinin.

Prostaglandins increase perception of pain
Free nerve endings
Adelta & C fibers transmitted to CNS
Gate control theory
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
EOP
Endogenous opioid peptides
endorphins, dynorphins, enkephalons

activated by pain or stress
Two types of tooth pain
Odontogenic - Dentinal pain, short duration stimulated by sweets & extreme temperatures

Pulpal Pain - Severe long lasting pain, percussion sensitivity.
Migraines
Migraine with Aura
Migraine without Aura
Ophthalmoplegic migraine
Basilar Migraine
Periodic Migrainous Neuralgia
Migraine with aura
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
Migraine without Aura
Common Migraine - Same as classic but without aura. More frequent
Ophthalmoplegic Migraine
Migraine with orbital & periorbital pain.

Ipsilateral Ptosis & CN 3 Palsy
Basilar Migraine
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.
Periodic Migranious Neuralgia
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.
Etiology of migraines
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.
Treatment of Migraines
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
Coital headache
Severe occipital headache around orgasm more often for men.
Atypical Odontalgia
Variant of cluster headache with crawling, exploding or pressure pain in tooth
Eagle's syndrome
Elongated styloid process or calcified stylohyoid ligament resulting in pain in neck & throat.
Trigeminal Neuralgia
Usually unilateral shocking pain due to possible compression of rootlets of CN V by superior cerebellar artery.
Glossopharyngeal Neuralgia
Shock like pain in throat & ear often triggered by cold drink. Possibly caused by compression of CN 9 rootlets by inferior cerebellar artery.
TMJ Joint Pain
Due to internal derangements, dislocation, arthritides or trauma
Preparation of Local anesthetic
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
Anesthesia mechanism of action
- Displace calcium from receptor site
- Antagonize receptor site
- Blockade of sodium channel to depress rate of depolarization to subthreshold level.
Anesthesia structure/activity considerations
Aromatic ring - Lipid solubility
Intermediate chain
Ester: Plasma Cholinesterase
Amide: Metabolized in hepatic
Terminal amine:
Tertiary - Neutral, lipid soluble
Quaternary - Ionized, water soluble
pKa of anesthetic
pH at which 50% are ionized

Since local anesthetics are basic, pH below pKa will result in more than 50% ionization
Onset of action & Duration of action
Both depend on Concentration & Lipid solubility

Onset: Diffusion to site, Nerve morphology, tissue pH, pKa of drug

Duration: Diffusion from site, Protein binding
1% Solution & 1:100,000 solution
1% solution = 10mg/ml

1:100,000 solution = .01mg/ml
Methemoglobinemia
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.
Prilocaine considerations
Low systemic toxicity, however metabolite o-toluidine can cause methemoglobinemia
Aderenergic receptor function
Alpha: Vasoconstriction
Beta2: Vasodilation, Bronchodilation
Beta1: Cardiotropic
Needle Gauges used in dentistry
Red - 25
Yellow - 27
Blue - 30
Long vs short needle
Long:
Inferior alveolar block
Infraorbital nerve block
PSA block
V2 block
Sulfur allergy
Asthmatic patients may be allergic to Sulfur dioxide or Sulfite antioxidants like Sodium metabisulfite used to improve shelf life.
Sulfonamides
Antimicrobial agents with high incidence of allergenicity/cross-allergenicity with high requently reported reactions.
Articane characteristics, mechanism of action, metabolism & Special
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
Local Anesthetics & Cell necrosis
<1% Lidocaine does not injure neurons

>2.5% cause calcium conc to rise & cell death to occur

5% showed immediate irreversible effect
Salicylates characteristics, mechanism, side effects
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
Para-aminophenol derivatives, actions, side effects
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
Acetaminophen dosing & overdose
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)
Salicylate dosing & overdose
325mg tablets
- Normal adult dose is 650mg every 4 hrs as needed. 4000mg/day max

Overdose:
Headache, dizziness, tinnitus, confusion, acid-base disturbance
NSAIDs families
Salicylic acid derivatives
Propionic acid derivatives
Pyrrolo-pyrrole group
COX-2 Inhibitors
Ibuprofen family, Dosing
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
Opium constituents, effects
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
Opioid receptors
Mu - euphoria & physical dependence

Kappa - Miosis, sedation, spinal analgesia

Delta - Dysphoria, hallucinations, respiratory & vasomotor stimulation
Pentazocine
Opioid agonist/antagonist

Analgesic with little or no abuse potential
Acetaminophen or Asprin(Empirin) with Codeine dosing & maximum
#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
Tylenol with Codeine elixer
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
Oxycondone family
Percodan
Percodan - demi
Percocet
Tylox
Roxicet
Roxicodone
Percodan & -demi tablets, usual adult dose
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
Percocet tablets & usual adult dose
Oxycodone HCL - 5mg
Acetaminophen - 325mg

Usual adult dose
1tab/6hr as needed
Tylox
Same as Percocet but in capsule & 500mg Acetaminophen
Roxicet
Same as Percocet & Tylox with 5:325 & 5:500

Oral solution
Oxycodone HCL 5mg/5cc
Acetaminophen 325mg/5cc
Hydrocodone family, tablets, dosing, max
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
Vicoprofen
Hydrocodone 7.5mg
Ibuprofen 200mg

1tab every 4-6hrs as needed
Butalbital
Anxiolytic & muscle relaxant
Benzodiazepines
Diazepam (Valium)

Anxiolytic
Sedative/hypnotic
Anterograde anmesia
Muscle relaxant
Anticonvulsant
NOT analgesics
Drug schedules
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
Local anesthesia general steps
Relaxed atmosphere
Study Injection site
Palpate area
Wipe with Gauze
Apply topical for 3 min
Wipe with gauze

**Inject slowly (1 cartridge/min) & Aspirate!
Supraperiosteal Injection sites, position, & steps
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.
Middle superior Alveolar Nerve Block sites, position, & steps
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.
Infraorbital block sites, position, & steps
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
For infraorbital block, when needle is in place it is:
Beneath infraorbital head of quadratus labia superioris & above origin of canis
PSA Block sites, position, & steps
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
Greater Palatine Nerve Block sites, position, steps
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
Nasopalatine Nerve Block Sites, Position, Steps
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
V2 block site, position, steps
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
IAB sites, steps
- 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
Position of Needle during IAB
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
Lingual nerve Block
Anesthetizes
Anterior 2/3 of tongue
Floor of mouth
Lingual soft tissues

After IAB, withdraw needle halfway & inject remaining 0.4cc solution.
Trouble shooting IAB
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
Hitting bone too soon
Minor:
Withdraw most of way
Swing barrel anteriorly

Major
Withdraw needle completely
Reinsert needle several mm superiorly
Not hitting bone at full depth
Minor correction
Withdraw needle most of the way
Swing barrel posteriorly

Major
Withdraw needle all the way
Reinsert several mm inferiorly
Long Buccal Block
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
Mental vs Incisive block
Both:
Soft tissues of lower lip, chin, labial mucosa anterior to mental foramen

Incisive:
Pulpal for mandibular centrals to +/- second premolar
Mental or incisive block steps & precautions
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
Gow- Gates block
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
Akinosi Block
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.
Clark's Rule
Child's weight(lbs) /150 x Max adult dose
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
Naloxone
Narcan - Reverse morphine like opioid agonists