anxiety and pain management exam 3

palatal nerve blocks

• the greater palatine (GP) nerve block

• nasopalatine (NP) nerve block

• pressure anesthesia utilizing a cotton tipped applicator in the area of needle insertion is recommended to maximize patient comfort

indication for greater palatine nerve block

• recommended when lingual soft tissue anesthesia is needed distal to the canine

indication for nasopalatine block

• is recommended when lingual soft tissue anesthesia is needed from canine to canine

greater palatine nerve block

• innervates greater palatine nerve

• no teeth anesthetized

• consider overlap of nasopalatine nerve in palatal area of maxillary first premolar

areas anesthetized by greater palatine nerve block

• lingual gingival tissue of maxillary premolars and molars

• posterior hard palate in one quadrant

• no teeth anesthetized

technique for greater palatine nerve block

• 27 gauge short needle is used and inserted in soft tissue slightly anterior to the greater palatine foramen

• advance syringe from opposite side of mouth at right angle to target area

• locate greater palatine foramen and place cotton swab at junction of maxillary alveolar process and hard palate in which it will fall into the depression

• prepare tissue 1-2 mm anterior to greater palatine foramen

• clean and dry with gauze, apply topical, apply considerable pressure with cotton swab over foramen and note ischemia

• apply pressure for 30 seconds and while doing this direct syringe into mouth from opposite side with needle approaching injection site at a right angle

• place bevel of needle against previously blanches tissue

• apply enough pressure to bow needle slightly and deposit a small volume of anesthetic then straighten needle and permit bevel to penetrate mucosa

• deposit small volumes of anesthetic throughout procedure and slowly advance needle until palatine bone is gently contacted at a depth of 5 mm

• aspirate then slowly deposit 0.25-0.3 mL anesthetic for a minimum of 30 seconds

landmarks for greater palatine nerve block

• greater palatine foramen and junction of maxillary alveolar process and palatine bone

• foramen most frequently located distal to the maxillary second molar but may be located anterior or posterior

greater palatine inadequate anesthesia complications

• caused by injecting too far anterior to greater palatine foramen

• crossover innervation from nasopalatine nerve for maxillary first premolar

• after reinsertion, direct needle more posteriorly toward GP foramen and administer nasopalatine block

greater palatine gagging feeling complication

• caused by soft palate anesthesia due to inadvertently anesthetized lesser palatine nerve

• can be fixed by reassuring patient and having patient avoid swallowing until anesthesia wears off

greater palatine anatomy complication

• large midline palatal torus

• high vaulted palate

• can be fixed by attempting to maintain the perpendicular angle (90 degrees) to the palatal tissues with the needle bowing slightly

nasopalatine

• block recommended when lingual soft tissue anesthesia is needed from canine to canine, including the palatal bone and lingual gingival tissue

• both the right nasopalatine nerve and left nasopalatine nerve are anesthetized by this block so only one injection is needed for both sides

nasopalatine technique

• 27 gauge short

• incisive foramen beneath incisive papilla

landmark for nasopalatine injection

• central incisors and incisive papilla

nasopalatine block technique variation

• topical applied to mucosa of frenum

• first injection: into labial frenum with bevel angled toward the bone

• second injection: interdental papilla between central incisors

• third injection: place needle into soft tissue adjacent to diamond shaped incisive papilla, aiming toward most distal portion of papilla

nasopalatine first injectiion

• clean and dry tissue with gauze and place topical for 1 minute

• retract upper lip to stretch tissue and improve visibility

• gently insert needle into frenum and deposit 0.3 mL in 15 seconds (tissue may balloon)

• anesthesia of sift tissue develops immediately

• aim is to anesthetize interdental papilla between two central incisors

nasopalatine second injection

• penetration through labial aspect of papilla between maxillary incisors toward incisive papilla

• retract upper lip and hold needle at a right angle to interdental papilla, insert into papilla just above level of crestal bone

• care must be taken to avoid needle puncturing through papilla on palatal side (use finger of opposite hand to stabilize syringe)

• aspirate when needle tip becomes visible just beneath tissue surface then deposit 0.3 mL in 15 seconds

• anesthesia within distribution of right and left nasopalatine nerves usually develops in a minimum of 2-3 minutes

nasopalatine third injection

• place needle into soft tissue adjacent to diamond shaped incisive papilla, aiming toward most distal portion of papilla

• advance needle until contact is made with bone, withdraw needle 1 mm to avoid subperiosteal injection

• aspirate and deposit 0.3 mL in 15 seconds

inadequate anesthesia nasopalatine complication

• of maxillary first premolar or canine is caused by crossover innervation from greater palatine nerve

• administer greater palatine injection

anesthetic solution around penetration site nasopalatine complication

• caused by density of tissue and constricted area for anesthetic deposition

• inject slowly and rinse patients mouth following safe capping of needle

denser; less

• overall, mandible is _ and _ porous than the maxillary especially within mandibular posterior sextant. therefore nerve blocks are preferred in most parts of the mandible

extent of procedure and structures needing to be anesthetized

• mandibular nerve of fifth cranial nerve (trigeminal) and its branches can be anesthetized in a number of ways for pt pain management with hemostatic control depending on:

not

• a supraperiosteal (infiltration) injection of the mandible is _ as effective as maxillae

mandibular nerve blocks

• inferior alveolar nerve block (IA)

• buccal block

• mental block

• incisive block

• Gow-Gates mandibular block

• Vazirani-Akinosi mandibular block

inferior alveolar (IA) block

• is recommended for anesthesia of the mandibular teeth, their associated periodontium, and the lingual soft tissue to the midline, plus the facial soft tissue anterior to the mandibular first molar.

reasons for lower mandibular injection success rates

• buccal alveolar plate is much more dense

• access to inferior alveolar is limited

• wide variation in patients anatomy

• for IA, must deposit within 1 mm of target nerve

inferior alveolar nerve block

• most commonly preformed technique

• has highest failure rate (15-20%)

• success depends on depositing solution within 1 mm of nerve trunk

• not a complete mandibular nerve block

• requires supplemental buccal nerve block

• may require infiltration of incisors or mesial root of first molar

• bilateral not recommended due to higher change of self injury

areas anesthetized by alveolar nerve block

• mandibular teeth to midline

• body of mandible, inferior ramus

• buccal mucosa anterior to mental foramen

• anterior 2/3 tongue and floor of mouth

• lingual soft tissue and periosteum

indications for inferior alveolar nerve block

• multiple mandibular teeth

• buccal anterior soft tissue

• lingual anesthesia

contraindications for inferior alveolar nerve block

• infection/ inflammation of injection site

• patients at risk for self injury (children)

disadvantages of inferior alveolar nerve block

• wide area for localized procedures

• intraoral landmarks not consistent

• rate of failure

• highest change of positive aspiration (10 to 15%)

• lingual and lower lip anesthesia

fulcrum for IA block

• pinky finger of dominant hand resting on patients chin for right side

• pinky finger of dominant hand resting on patients chin for left side

if bone is not contacted for IA

• needle is placed too far posteriorly

  • withdraw needle but do not takeout

  • reposition needle over molars

  • continue insertion until bone is contacted

if bone is contacted too soon for IA block

• needle is placed too far anteriorly

  • withdraw needle but do not take out

  • move the syringe toward the midline

landmark and target for IA injection

• target is inferior alveolar nerve, near mandibular formane

• landmarks are

  • coronoid notch

  • pterygomandibular raphe

  • occlusal plane of mandibular posteriors

parameter for IA block

• height of injection

• anteroposterior position of injection

• depth of penetration

inferior alveolar nerve block technique

• practice actual injection pathway using cotton tip applicator which is usually superior to the mandibular second premolar with it resting on the contralateral corner of the mouth and parallel and superior to the mandibular occlusal plane

• palpate the anterior border of the ramus with thumb, find concavity which is the coronoid notch

• palate pterygomandibular fold and approach injection site from premolar on the opposite site level with occlusal plane (1 cm above or 6-10 mm)

• place topical on injection site and using a 25 gauge long needle with bevel toward the bone and with large window of the syringe toward the clinician direct the syringe over the contralateral corner of the mouth parallel and superior to the mandibular occlusal plane

• establish fulcrum and use needle tip with slight pressure into deepest part of depression created by pterygomandibular space and the intersection of these two imaginary lines

• insert needle just medial to thumb ¾ posterior from coronoid notch to pterygomandibular raphe

• advance needle into soft tissue until gentle contact of bone (2/3-3/4 of long needle or 20-25 mm)

• aspirate then slowly deposit 1/8 mL over 60 seconds

• recap and place patient upright

pterygomandibular fold

• the tissue that extends from behind the most distal mandibular molar and retromolar pad and horizontally to the posterior border of the mandible

aspirating during inferior alveolar block

• aspirate within 3 planes to insure bevel of needle is not abutted against the interior of a blood vessel, providing a false aspiration

• first aspirate as usual at depth of insertion and if negative rotate syringe barrel toward clinician and respirate then rotate again

• aspirate in one plane after each fourth of carpule is administered

if bone is not contacted

• DO NOT inject if

• avoid forceful bone contact

failure of anesthesia complication for IA block

• injection too low

• injection too anterior

• accessory innervation

  • mylohyoid nerve

  • contralateral incisive nerve innervation

transient facial paralysis complication IA block

• to prevent always contact mandible before depositing agent

• caused by administration of anesthetic into the parotid salivary gland containing facial nerve

• inability to close the eyelid and the drooping of the lips on the affected side

lingual shock complication inferior alveolar nerve block

• happens as a result of moving needle through tissue and past lingual nerve

• reaction is only momentary and unavoidable

hemotoma complication with IA nerve block

• highest positive aspiration rate

• apply pressure with firm, sterile gauze to area if needed

• important to educate patients: let them see the bruising and give clear postanesthetic directions

• reassure patient

true mandibular block

• Auriculotemporal nerve

• Inferior alveolar nerve

• Mylohyoid nerve

• Lingual nerve

• Long buccal nerve

• Mental nerve

• Incisive nerve

gow gates mandibular block

• is recommended for extensive procedures during quadrant dentistry or with failure of IA block

• true mandibular block

vazirani-akinosi mandibular block

• nerves anesthetized include the IA, lingual, mental, incisive, and mylohyoid within the pterygomandibular raphe space as well as long (buccal) nerve approximatley 75% of the time

• closed mouth mandibular block

• useful when soft tissue structures persistently obstruct the view of the necessary intraoral landmarks used in the IA block

buccal nerve block

• provides buccal soft tissue anesthesia adjacent to mandibular molars

• indicated immediately after IA nerve block to complete quadrant anesthesia

• not required for most restorative procedures

areas anesthetized by buccal nerve block

• long buccal nerve

• buccal gingival tissue of mandibular molars

landmarks for buccal nerve block

• mandibular molars

• mucobuccal fold

universal contraindication to buccal nerve block

• infection/inflammation at injection site

technique for buccal nerve block

• 25 gauge long needle is used

• orient bevel to bone with large window toward clinician and apply topical to injection site

• insert in mucosa distal and buccal to most distal molar in the arch and penetrate 2-4 mm into tissue

• aspirate and inject half carpal of solution slowly

leakage of solution complication with buccal block

• caused by bevel of needle only partially in the tissue

• correct by deeper penetration on reinsertion

ballooning of tissue complication with buccal block

• caused by rapid deposit of solution

• correct by slowing down the injection

cheek biting complication with buccal nerve block

• correct by educating patient

mental nerve block

• recommended for anesthesia of the facial gingival tissue (usually of the anterior teeth and premolars) anterior to the mental foramen

• location is usually between the apices of first and second premolars

• mucobuccal fold at or anterior to mental foramen

horizontal approach of mental block

• retract lip, locate mental foramen, and place topical anterior to mental foramen at depth of mandibular mucobuccal fold

• use 27 gauge short needle, orient bevel to bone and large window toward clinician

• direct syringe from anterior of mouth to posterior in a horizontal manner with syringe barrel resting on lower lip and index finger or thumb of retration hand

• insert needle at depth of mandibular mucobuccal fold, directing needle to mental foramen 5-6 mm or ¼ short needle

why horizontal method is preferred for mental block

• although both techniques provide necessary anesthesia, it keeps syringe out of patient’s sight and offers a direct view of large window during aspiration and less risk of puncturing through lower lip when advancing the needle

mental block vertical approach

• establish fulcrum and direct syringe vertically with patients cheek toward the needle insertion site anterior to the mental foramen

• insert needle 5-6 mm into tissue

• aspirate in two planes

• slowly deposit 0.6 mL or 1/3 cartridge over 20 seconds. if tissue balloons, clinician is injecting too rapidly and should stop deposition, remove needle, and massage area

• carefully withdraw the syringe and recap needle using scoop method

• place pt upright, rinse mouth and wait 3 minutes before starting tx

hematoma complication mental block

• rarely occurs even though positive aspiration is the second most frequently used of all the block injections

• adjust technique and apply pressure with gauze to the area and reassure pt

incisive block

• is recommended for anesthesia of the teeth, periodontium, and facial soft tissue anterior to the mental foramen, usually the anterior teeth and premolars

• useful when there is a crossover of the contralateral incisive nerve and there is still discomfort on the mandibular anterior teeth after giving an IA nerve block

• useful for nonsurgical periodontal therapy or routine maintenance of sensitive anteriors

• deposit just outside mental foramen and directed into formane

mental vs incisive nerve block

• incisive block anesthetizes teeth

• same needle gauge and length

• same operator position

• same syringe stabilization

• same landmarks

• same needle insertion point, penetration, and location

• same amount of anesthetic

• same length of time to deposit

inadequate anesthesia incisive nerve block

• caused by inadequate volume of anesthetic or inadequate duration of pressure over mental foramen

• reinject in correct location and apply firm pressure to deposition site for minimum of 2 minutes

hematoma incisive nerve block complication

• same percentage as for mental block; rare occurrence

• apply pressure with gauze to the area and reassure patient

• not

incisive nerve block is _ necessary when IA is successful

areas anesthetized by incisive nerve block

• premolars, canine, laterla, and central incisors

• buccal soft tissues and bone

adverse drug reactions

1. toxicity caused by direct extension of the usual pharmacological effect of drug

2. toxicity caused by alteration in the recipient of the drug

3. toxicity caused by allergic responses to the drug

examples of toxicity caused by alteration in the recipient of the drug

• a disease

• genetic aberration

• emoitions

overdose reactions

• the most common of all true adverse drug reactions associated with administration of local anesthetics

• administration of too large a local anesthetic dose in relation to age and weight of patient is most common cause

patient factors of overdose

• age

• weight

• other drugs

• sex

• presence of disease

• genetics

• mental attitude and environment

predisposing factors of overdose

• patient factors

• drug factor

drug factors of overdose

• vasoactivity

• concentration

• dose

• route of administration

• vascularity

• presence of vasoconstrictor

cause of overdose

• biotransformation of the drug is unusually slow

• the unbiotransformed drug is too slowly eliminated from body

• too large a total dose is administered

• absorption from the injection site is unusually rapid

• inadvertent intravascular administration occurs

prevention of intravascular injection

• use an aspirating syringe

• use a needle no smaller than a 25 gauge

• slowly inject the anesthetic - 1.8 mL cartridge per 60 seconds

• aspirate in at least two planes before injecting

child patient overdose epidemiology

• most occur in children ages 2-6 years old from 15-40 kg

prevention of child patient overdose

• Use a plain local anesthetic when treatment is limited “plain” local anesthetic when treatment is limited to one quadrant.

• Two or more quadrants ,use a local anesthetic with a vasoconstrictor

• Do not use more than 2 cartridges

• Death is usual consequence when 5 or more cartridge are administered

clinical manifestation in CNS of overdose

• is extremely sensitive to the action of local anesthetics

• Signs of toxicity-generalized cortical sensitivity, agitation, talkativeness, irritability.

• Tonic-clonic seizures occur at levels greater than 7.5 micrograms

• Blood levels greater will result in generalized depression and death

clinical manifestations in CVS of overdose

• CVS is less sensitive to the action of local anesthetics

• Increased levels(5 to 10 micrograms/ml) cause minor myocardial depression, peripheral vasodilation, decreased cardiac output

• Above 10 microgram/ml cause massive peripheral vasodilation, marked reduction in myocardial contractility, severe bradycardia, and possible cardiac arrest

mild overdose signs and symptoms

• retention of consciousness, talkativeness, agitation, and increased heart rate, blood pressure respiration rate

mild overdose management

• most local anesthetic overdose reactions are self-limiting

• follow algorithm used in management of all medical emergencies

  • P - position

  • A - airway

  • B - breathing

  • C - circulation

  • D - definitive care

• reassure patient everything will be all right, monitor and record vitals, permit patient to recover as long as necessary

slow onset

• = or > 5 minutes after administration

• caused from rapid absorption or too large dose

slower onset

• = or > 15 minutes

management of moderate overdose reaction

• P-A-B-C of medical emergencies protocol

• definitive care

• reassure patient, administer oxygen, monitor vital signs, administer anticonvulsant, summon medical assistance, examined by physician

rapid onset

• within 1 minute of administration

• caused by intravascular injection

management of severe overdose reaction

• P-A-B-C medical emergencies protocol

• definitive care: tonic-clonic convulsion

• protect arms, legs, head

• summon emergency medical assistance

• basic life support

• anticonvulsant

severe overdose post seizure phase management

• P-A-B-C-D- of basic life support

• additional management such as vasopressor for hypotension

• allow patient to rest

• patient evaluated in emergency of hospital

slow onset severe overdose reaction

• 5 to 15 minutes

• possible causes are too large a total dose, rapid absorption, abnormal biotransformation and renal dysfunction

epinephrine

• is the vasoconstrictor in local anesthetics in united states

• use of 1:50,000 is not recommended for pain control

• 1:50,000 and 1:100,000 can be used to control bleeding at surgical site

• overdose is more common after its use in gingival retraction cord

• ada recommended not to use it in retraction cord

epinephrine overdose signs and symptoms

• sharp elevation of blood pressure, elevated heart rate, cardiac dysrhythmias

• fear, anxiety, restlessness, tremor, perspiration, dizziness, weakness, pallor, palpitations, throbbing headache, respiratory difficulties

epinephrine overdose management

• Terminate procedure

• If possible, remove source of epinephrine

• P-A-B-C management of medical emergencies protocol

• Definitive care-reassure patient, monitor vital signs, allow patient to recover before dismissal

allergy

• is a hypersensitive state, acquired through exposure to a particular allergen

type I hypersensitivity reaction

• anaphylactic

• time of reaction is seconds to minutes

type II hypersensitivity reaction

• cytotoxic

• antimembrane

type III hypersensitivity reaction

• immune complex

• serum sickness like

• 6 to 8 hours

type IV hypersensitivity reactions

• cell mediated-time of reaction is 48 hours

much more freuqent

• hypersensitivity to ester-type local anesthetics

• procaine, benzocaine, tetracaine

very rare

• toxic reaction to amino amide local anesthetic

local anesthetic allergy

• do not administer local anesthetics until allergy has been disproved

• if allergy to an ester is determined, use an amine anesthetic

• if a certain amide is determined to be allergic to patient use another amide anesthetic- no cross allergies between amides