What vascular tissue may be injured in a PSA injection?
Pterygoid Plexus of veins
What cranial nerves are involved in taste?
Glossopharyngeal (IX), Vagus (X), and Facial (VII)
The second part of the trigeminal nerve is…
What nerve supplies the maxillary central incisors?
What nerve supplies the mucosa of the lower lip?
What nerve supplies the palatal gingiva of the maxillary central incisors?
What supplies taste sensation to the anterior 2/3 of the tongue?
Which cranial nerve passes through both the internal acoustic meatus and the stylomastoid foramen to leave the skull?
Which nerve is the terminal branch of the inferior alveolar nerve that continues forward within the mandible anterior to the mental foramen?
Which injection is likely to encroach on the buccinator muscle?
Nodes of Ranvier….
Are not covered by Schwann cells Allow nerve impulses to “Hop” over lengths of the fiber Are part of the axon
A (alpha) and C peripheral nerve fibers carry pain, temperature, and pressure sensations. True or False
Tetracaine, Procaine, Novocaine, and Benzocaine. Which anesthetic is an ester?
All are esters
Which topical anesthetic has the lowest solubility in water?
Which anesthetic has such outstanding diffusion that if injected via buccal infiltration in the maxilla, would anesthetize the palatal gingiva also?
Anesthetics “numb” in the area of deposition by?
Making the nerve membrane lass permeable to Na+
What does Action Potential refer to?
The depolarization and repolarization of the nerve membrane
What is the normal pH of intercellular fluids?
In infected tissue (inflammation is present)….
pH of tissue will be lower than in normal tissue pH of tissue will be more acidic than normal anesthetics will be less effective anesthetics will exist more in the ionized form
Lidocaine, Mepivacaine, Citanest, and Etidocaine. Which one are primarily metabolized in the liver?
All of them
The excretion of unchanged local anesthetics and their metabolites is through the kidneys. True or False
Which end of an anesthetic molecule helps in diffusion of the anesthetic across the membrane?
The lipophilic end
In which pH listed below would an anesthetic most likely lose its efficacy? 7.0, 9.0, 7.6, 6.7, & 9.3
pKa of an anesthetic…..
Defines the anesthetic disassociation propensity Is directly proportional to its rate of onset (the lower pKa the faster the onset) Is the pH at which 50% of the anesthetic is in the base form and 50% is in the ionized form.
One anesthetic has a pKa of 7 and another has a pKa of 20. Which will have the faster onset?
What is true for Benzocaine (pKa 3)?
The anesthesia will have a fast onset The anesthetic will be rapidly absorbed by the blood stream There is more likelihood of an allergic reaction from this anesthetic than from an amide with a pKa of 3. The anesthetic has a low solubility in water.
The topical Dyclone (diclonine) is what type of anesthetic?
The hydrophilic portion of the anesthetic molecule..
Contributes to the affinity of the molecule for the nerve membrane
The reason that esters have more allergenicity is because one of the metabolites (breakdown products) is PABA (para-amino-benzoic acid). True or False
Which pair(s) of anesthetics are not correct? 1. lidocaine-Xylocaine 2. procaine-Novocaine 3. etidocaine-Duranest 4. bupivacaine-Marcaine 5. tetracaine-Pontocaine 6. benzocaine-Hurricaine 7. mepivicaine-Citanest 8. prilocaine-Carbocaine
7 & 8
Which of the following is incorrect for max safe dose? A. lidocaine: 2mg/lb B. etidocaine: .04mg/lb C. bupivicaine: .6mg/lb D. mepivicaine: 2mg/lb E. prilocaine: 2.7mg/lb
B. etidocaine: .04mg/lb
The correct ratio of lbs to kg is….
1kg = 2.2lbs
The maximum safe dose for epinephrine is what?
.2mg for a healthy client and .04mg for a cardiac risk client
The amount of epinephrine in a 1:100,000 solution is 1/100=.01 mg/ml. True or False
The treatment choice for the emergency that can occur from vasoconstrictors will include delivery of diazepam (Valium) IV. True or False
Which of the following positive notations on the medical history would NOT be cause for more than usaual judiciousness in using a vasopressor? a. MAOI b. TCA c. APC (atypical plasma cholinesterase) d. Beta blockers e. ASA Class III
e. ASA III
Concern for use of amides (prilocaine and articaine) would be necessary if a positive notation of what was on the Medical history?
A client who has had a myocardial infarction in the last 3 months is in ASA Class ___, and should be scheduled for routine scaling until it has been ___ months post MI.
A client who has been having a seizure every week for the past month and for whom the physician has just changed medications is an ASA Class what?
The needle has broken off within the tissue while you were doing an infiltration in the PSA region and it cannot be seen. What should you do?
Send the client to the oral maxillofacial surgeon
What is the correct treatment for someone who experiences syncope?
Place in the supine position and administer oxygen
For a mild allergic skin reaction, what is the treatment of choice?
What is the first step, after BLS in anaphylaxis?
Epinephrine administered either sublingually or IM in the arm
True or False. The management of a hematoma includes pressure applied to the site and ice; an antibiotic should always be prescribed for 10 days after the incident.
True or False. An inadvertent intravascular injection is one of the most common reasons for an overdose.
When comparing a 27 gauge short needle and a 25 gauge short needle, the 27 gauge needle is ___ in length and ___ in bore than the 25 gauge.
The bevel of the needle should be oriented toward the bone to prevent a position aspiration. True or False
An aspiration check should be performed upon initial insertion and at anytime that the needle is advanced or redirected. True or False
A positive aspiration requires that the clinician withdraw the needle and change to a new cartridge. True or False
Anesthetic solutions no longer contain methylparaben as a preservative. True or False
True or False. Anesthetic solutions that contain epinephrine will have sodium bisulfite as a preservative and might cause a bronchospasms in asthmatic clients.
Salt (sodium chloride) is in the anesthetic solution to make them more isotonic to the body. True or False
In an infiltration, What is the average depth that a clinician will penetrate the tissue?
In an infiltration for scaling and root planing of 3, 4, and 5, the least amount of injections the clinician will give will be __ injections and will deposit approximately __ carpule at each site.
Your client needs the maxillary and mandibular right quadrants scaled and root planed and is particularly sensitive around #31, where there is a small periodontal abscess. The best treatment plan is what?
Have your dentist give a mandibular block and the appropiate maxillary field blocks. or You give the maxillary infiltrations and begin working on the maxillary quadrant until the dentist arrives to do the mandibular block.
Inability to achieve profound anesthesia might be due to what?
Low pH Too little anesthetic deposited Anesthetic deposited short of the root apices Needle orientation too lateral into the buccal tissue
Soft tissue anesthesia with 3% Carbocaine will last about __ hours and will last __ hours with 3% Carbocaine, 1:20,000 Neocobefrin.
True or False. Pulpal anesthesia will last longer than soft tissue anesthesia.
How can you achieve a nerve block for the mandibular incisors?
By anesthetizing the incisive nerve through massage of anesthetic back into the mental foramen.
What fibers do nerves impulses travel faster on?
Myelinated A fibers
True or False. A concentration of 1:100,000 epinephrine means 1mg/cc of epinephrine is in the anesthetic.
Depolarization of the axon during the generation of the action potential occurs due to the influx of what?
At which pH would the greatest concentration of Xylocaine be needed? 7.8, 7.6, 7.4, 7.2
Where does lidocaine metabolize?
Which anesthetic has the breakdown product known as PABA?
What do vasoconstrictors cause?
The duration of the local anesthetic to increase.
Four carpules of 2% lidocaine would exceed the toxic dose for a 31 kg person. True or False
True or False. Benzocaine should never be used as a topical.
Myelinated nerves are easier to anesthetize than nonmyelinated nerves. True or False
True or False. Local anesthetics are weak acids.
Topical tetracaine must be used in low concentrations because of high solubility in water and possible overdose. True or False
What is the maximum number of carpules of 2% lidocaine that should be used in 20kg child.
During the provision of local anesthesia via infiltration, which is not a protocol?
Anesthetics should be warmed to body temperature of 98.6 F.
Pain during injections is most likely due to what?
The injection of the fluid.
Why is aspiration performed?
To avoid injection into a blood vessel
You have anesthetized the maxillary left area for scaling #9-15. You notice an immediate swelling in the cheek. What is the most likely cause?
You have traumatized the pterygoid plexus.
You have given 2% Carbocaine with Neocorbefrin to a 30 year old client. The client stated that it really burned and there is an ashen gray spot beneath his eye that is about the size of a dime. What is the most likely cause?
Vasonconstrictor infarct of the t. facial artery.
True or False. Anesthetic carpules should be stored in 91% isopropyl alcohol for one week to achieve disinfection.
Gluteraldhyde should not be used to soak LA. True or False.
True or False. One of the first steps in managing an acute asthmatic attack would be to place the client in a supine position.
The Trigeminal nerve has both motor and sensory function. Which division of the trigeminal has both of these functions?
Which nerve runs just medial to the mandible at the place where the 3rd molar roots are?
In order to achieve a nerve block, on should enter the foramen with the needle. True or False
Name the three branches of the trigeminal nerve:
Opthalmic V1 Maxillary V2 Mandibular V3
Which of the following arteries supply blood to the face? A. Lingual B. Maxillary C. Palatal D. Mental E. All of the above
E. All of the above
Which nerve is the nerve supply to the palatal gingiva of the maxillary central incisors?
What is a Hematoma?
Effusion of blood into extra vascular spaces
Definition: Motor disturbance of the trigeminal nerve.
What is parestesia?
Loss of sensation in nerve fiber
Definition: Ischemia resulting from use of local anesthesia with vasoconstrictor.
True or False. A 30 guage needle has a smaller internal diameter than a 25 gauge needle.
An anesthetic cartridge contains ___ ml of solution.
A long needle is approximately __ long.
How should topical anesthetic be stored?
At room temperature
What will not increase the duration of anesthesia?
Infiltration anesthetic technique
Which injection would anesthesize the facial gingiva only of teeth #25 and 26?
What blood vessel(s) are a potential for causing a hematoma when administering the PSA?
Pterygoid venous plexus
What is the most common reason for unsuccessful nerve block of the inferior alveolar nerve?
Given a 140 lb patient with no known contraindications to local anesthetic agents or vasoconstrictors, what is the maximum mg of lidocaine 2% with epinephrine 1:100,000 you may safely administer? How many cartridges can this patient receive?
280 mg and 7.7 cartridges
What is the needle penetration for the PSA nerve block injection?
During the long buccal injection which fibers will the needle pass through?
After giving a right posterior superior alveolar injection, you find that there is still sensitivity while root planing tooth #3. Teeth numbers one and two exhibit adequate anesthesia. What is the most likely cause?
After performing the inferior alveolar injection, you find the mandibular first molar is not completely anesthetized. What is most likely the cause?
Accessory innervation from the mylohyoid nerve
If one of your patients reports limitation of movement of the mandible and pain upon opening the day following an inferior alveolar nerve injection, what would you recommend to that patient for their trismus?
Heat therapy An analgesic such as aspirin Physiotherapy (No cold packs)
If a hematoma should begin to develop immediately following an incisive nerve block, what would you do?
Apply pressure to the area immediately for at least one minute and then give the patient an ice pack to hold over the area
What is the most significant factor in the prevention of intravascular injection of the anesthetic?
Aspiration at the point of deposition
What would minimize the chances of toxic overdose reaction if the needle is inserted into the lumen of a blood vessel during an injection?
Slow (min of 60 sec per cartridge) deposition of anesthetic solution
After performing a left inferior alveolar injection, it is found that the left mandibular central and lateral incisors are still sensitive to root planing but the rest of the quadrant exhibits adequate anesthesia. What is most likely the cause?
Accessory innervation from the right incisive nerve
To avoid injection of anesthetic solution into the medioposterior aspect of the parotid gland during the inferior alveolar nerve injection, what should the operator do?
Contact the bone before deposition
Which injections will completely anesthetize the pulp of the maxillary first molar?
MSA and PSA
Positive aspiration while performing the PSA injection can occur when the needle enters what?
Pterygoid venous plexus or the Maxillary artery
What is the recommended physiological position for administration of local anesthesia?
The position of the barrel of the syringe during a PSA injection should be…
45 degrees to the midsagital plane and 45 degress to the occlusal plane
What is the penetration site for the middle superior alveolar nerve block at the height of the mucobuccal fold?
Over the maxillary second premolar.
What is the point of insertion for the inferior alveolar nerve block?
At the level of the coronoid notch
The barrel of the syringe during the inferior alveolar injection and the lingual injection should be positioned..
Over the [premolars of the opposite side
The deposition site for the anterior superior alveolar nerve block is…
Over the apex of the maxillary canine
To anesthetize the pulps of the mandibular molars and the buccal and lingual mucosa adjacent to them, which injections would be needed?
Inferior alveolar Long buccal Lingual
What is the recommended needle size for the IA injection for an average size adult?
What is the recommended needle size for the PSA injection?
25 g short
What blood pressure levels would a patient be considered unsuitable for elective dental care with a local anesthetic agent?
200(or greater)/115(or greater)
What is the most common reason syncope occurs?
Six steps in the universal treatment of emergencies
Recognize Activate Position Evaluate Diagnose EMS
What is the correct number of compressions per minute for CPR?
80 – 100
Your patient presents for root planing and gingival curettage. You find that his blood pressure is 195/121. The patient reports that he is taking his “blood pressure pills” What should you do?
No elective treatment should be performed
Your patient reports a history of rheumatic fever and heart murmur. You plan to use local anesthesia. What should you know?
Vasocontrictors are contraindicated for patients with a heart murmur.
Your patient reports a history of epilepsy and is taking his medication. You are planning root planing and curettage. What should you know?
Adequate pain control is essential thus local anesthesia is indicated
Which of following is false about the trigeminal nerve? A. Largest cranial nerve B. Has motor and sensory fibers C. Has three major branches D. Exits the cranium at the pons E. All are true
D. Exits the cranium at the pons
What does the long buccal nerve innervate?
Skin of the cheek and gingiva of mandibular molars
Conduction blockage of which nerve would anesthetize the pulp of the mandibular canine?
What should you do to assist your client who is having a seizure?
Lower the chair and clear the area
What is considered to be chest pain that is relieved by nitroglycerin?
What is the depth of compression for an adult in CPR?
1 1/2 to 2 inches
For which situation is additional oxygen NOT part of the recovery management?
True or False. During the clonic phase of a grand mal seizure it is important to physically restrain the patient to avoid injury.
The most common reason for inability to ventilate a patient sufficiently in CPR is due to inadequate patient head tilt. True or False
True or False. Never administer insulin to a diabetic patient in emergency distress.
Headache, confusion, dizziness, varied respiration, distorted speech are signs and symptoms of a stroke. True or False
Xylocaine Greatest vasodilatory effects Tagamet and antacids should only get half of the dose 2% Safe Dose: 2 mg/lb or 4.4 mg/kg MRD: 300 mg
Carbocaine Least vasodilatory effects 3% plain, 2% 1:20,000 levonordefrin Safe Dose: 2 mg/lb or 4.4 mg/kg MRD: 300 mg
Novocaine Ester Metabolized in plasma Can cause Atypical plasma cholinesterase
Citanest Metabolized by Lungs, Kidneys, then Liver May cause paresthesia very low vasodilation, least toxic May produce Methemoglobinemia 4% Safe Dose: 2.7 mg/lb or 6 mg/kg MRD: 400 mg
Septocaine, Articadent, or Ultracaine Metabolized in plasma and liver 4% Safe Dose: 3.2 mg/lb or 7 mg/kg MRD: 500mg 1.7 ml in a cartridge
Marcaine, Sensorcaine Most potent and toxic amide Half life 3 1/2 hours 0.5% Safe Dose: .06 mg/lb or 1.3 mg/kg MRD: 90 mg
Primary effects of local anesthesia are during what phase?
What are the 3 components of an anesthetic molecule?
Lipophilic aromatic ring (for lipid solubility) Intermediate hydrocarbon chain (Determines ester or amide) Hydrophilic terminal amine (dissociation and H+ pick up)
The greater the lipid solubility = ?
The greater the potency
Which part loses local anesthetic first?
Mantle bundles then core bundles
A buffer that creates an isotonic solution
A buffer that alkalizes and adjusts the pH between 6-7
Acts directly on adrenergic receptors
Acts by releasing norepinephrine from adrenergic nerve terminals