TEST BANK for Local Anesthesia For Dental Professionals 2nd Edition by Bassett, DiMarco, Naughton

Local Anesthesia For Dental Professionals 2nd Edition Bassett Test Bank Chapter 1 Perspectives on Local Anesthesia for Dental Professionals True or false 1) Troubleshooting is the ability to critically assess and resolve anesthesia inadequacies in order to provide comfortable patient care.

A) True B) False Answer: A Objective: 1 2) Dental hygienists and mid-level providers in all states and provinces receive the same education, and require the same level of supervision for administering local anesthesia.

A) True B) False Answer: B Explanation: B) Specific requirements for dental hygienists and mid-level providers vary regarding the type, degree, or extent of injections, as well as the required extent of supervision, education, and examination. Clinicians must be knowledgeable regarding the specifics of the practice acts governing their particular practice locations.

Objective: 1 3) Dentists are the only providers of local anesthesia in dentistry in North America.

A) True B) False Answer: B Explanation: B) In most states and provinces, dental local anesthesia providers include dentists, dental hygienists, and in some states and provinces, mid-level and/or expanded function clinicians.

Objective: 2 4) The first state to license dental hygienists to deliver local anesthetic agents was California in 1975.

A) True B) False Answer: B Explanation: B) The first state to license dental hygienists to deliver local anesthetic agents was Washington in 1971.

Objective: 2 5) The first state to license dental hygienists to deliver local anesthetic agents was Washington in 1971.

A) True B) False Answer: A

Objective: 2 6) Dentists have been able to deliver local anesthetic drugs in cartridge form since 1884.

A) True B) False Answer: B Explanation: B) Dentists have been able to deliver local anesthetic drugs in cartridge form since 1921.

Objective: 2 7) Troubleshooting anesthesia inadequacies always requires referral to a dental specialist.

A) True B) False Answer: B Explanation: B) Every dental professional who administers local anesthesia can and should have ready troubleshooting skills, and familiarity with pain control alternatives.

Objective: 3 8) Only a dentist can assess and resolve anesthesia inadequacies.

A) True B) False Answer: B Explanation: B) Every dental professional who administers local anesthesia can and should have ready troubleshooting skills, and familiarity with pain control alternatives.

Objective: 3 9) Mastering a wide variety of techniques is critical to safe and effective pain control.

A) True B) False Answer: A Objective: 3 Multiple choice 1) The fundamentals of pain management include all of the following except A) Comprehensive assessment B) Knowledge of drug effects C) Periodontal assessment D) Mastering multiple injection techniques Answer: C Objective: 1 2) The fundamentals of pain management include A) Administering drugs that provide the shortest period of anesthesia possible B) Patient safety C) Integrating evidence based knowledge in clinical decisions D) Knowledge in a wide variety of techniques

Answer: A Objective: 1 3) Local anesthetics have been available in dentistry since A) 1971 B) 1948 C) 1906 D) 1884 Answer: D Objective: 1 4) Which situations best demonstrate the fundamentals of pain management?

A) A clinician assesses the patient, including taking vital signs. The patient receives the same dose of drug that has always been effective. Today the patient is not adequately numb and he is asked to reschedule an appointment for another day.

B) A clinician assesses the patient and determines there is no physical reason the patient could not receive anesthesia for periodontal maintenance. The patient reports she always has difficulty getting numb therefore the patient is referred to a periodontist for treatment.

C) A clinician assesses the patient and readies the patient for treatment. The patient mentions that he was not numb enough at his last appointment. It is decided that another drug and technique will be tried at this appointment.

D) A clinician asks the patient if she has had any difficulty with anesthesia in the past. The patient indicates she has never had any problem and always gets really numb; therefore treatment is provided without difficulty.

Answer: C Objective: 1 Short answer/essay 1) Discuss a provider’s responsibility for troubleshooting local anesthesia inadequacies.

Answer: Every provider of local anesthesia should have confidence in his or her pain control strategies, have ready troubleshooting skills, and familiarity with alternate techniques to provide successful anesthesia.

2) Discuss the responsibility of local anesthesia providers.

Answer: Providing safe, effective, and appropriate pain control is a responsibility of all dental local anesthesia providers. This requires knowledge of and competency with the fundamentals of pain management.

Objective: 3 3) Discuss the fundamentals of pain management.

Answer: The fundamentals of pain management include conducting a comprehensive patient assessment, recognizing and responding to patient factors, integrating evidence-based knowledge, and understanding relevant drugs, their effects, indications, and contraindications.

Fundamentals also include developing clinical decision-making skills and mastering a wide variety of techniques and appropriate modifications.

Objective: 1

Chapter 2 Fundamentals of Pain Management Match the following A) Internal squeezing or gnawing sensation B) Sympathetic nerve responses C) Individual reaction to painful stimuli D) Caused by injury to nerve tissue E) Postoperative discussion with patient F) Rapid, reflexive, subconscious reaction G) Innate ability to detect painful stimuli H) Thermal, mechanical, chemical receptors I) Postoperative dental pain J) Detects tissue injury 1) Acute pain Objective: 1 2) Debriefing Objective: 1 3) Fight or flight Objective: 1 4) Neuropathic pain Objective: 1 5) Nociceptors Objective: 1 6) Pain threshold Objective: 1 7) Pain tolerance Objective: 1 8) Polymodal Objective: 1 9) Protective response Objective: 1 10) Visceral pain Objective: 1

Answers: 1) I 2) E 3) B 4) D 5) J 6) G 7) C 8) H 9) F 10) A Fill in the blank 1) Pain is highly variable and may vary from one individual to another.

Answer: tolerance Objective: 1 2) The three classifications of pain are ; ; and .

Answer: nociceptive; neuropathic; pain disorders associated with psychogenic factors Objective: 4 3) Nociceptive pain is caused by Answer: injury Objective: 4

or disease in body tissues.

4) pain is caused by nerve tissue injury or dysfunction of the sensory nerves in the central or peripheral nervous systems.

Answer: Neuropathic Objective: 4 5) Pain disorders associated with psychogenic factors are related to mental or problems that affect the experience of pain.

Answer: emotional Objective: 4 6) pain usually lasts for a few seconds to not more than six months. It is generally caused by tissue damage from an injury or disease.

Answer: Acute Objective: 5 7) pain is long-term pain that persists for more than six months with or without an identifiable cause.

Answer: Chronic Objective: 5 8) Nociceptors are unique because they respond to Answer: mechanical Objective: 7

, thermal, and chemical stimuli.

9) Physiological responses that occur as a result of the sympathetic nervous system's reaction to pain include an in heart rate, heart contractions, and blood pressure.

Answer: increase Objective: 7 10) To help patients cope with anxiety and fear, the four PREP steps are ; and .

;

;

Answer: prepare; rehearse; empower; praise Objective: 9 11) Visualization is an example of a dental treatment.

Answer: cognitive Objective: 9

distraction to help a patient reduce stress during

12) The response is a restful state that modifies physical and emotional responses to stress.

Answer: relaxation Objective: 9 Multiple choice 1) Which of the following statements related to an individual's response to a pain experience is not correct?

A) It is complex and includes both physiological and psychological factors.

B) It is not influenced by an individual's gender and physical health.

C) It is proportionate to the intensity of physical injury and degree of harm.

D) It is affected by attitudes and learned responses.

Answer: B Objective: 2 2) Which statement best describes pain as a protective response?

A) Pain is a physiological, conscious reaction.

B) Pain is a rapid, reflexive, unconscious reaction.

C) Pain is a psychological reaction based on blood flow to the injured site.

D) Pain is a slow, deliberate reaction to avoid further tissue injury.

Answer: B Objective: 2 3) Which statement correctly describes pain threshold?

A) It is an individual's reaction to a painful stimulus.

B) It indicates the amount of pain an individual is able to endure.

C) It is altered by environmental, personal, and social attitudes.

D) It is identified when a stimulus begins to produce pain.

Answer: D Objective: 3 4) Which statement correctly describes pain tolerance?

A) It is an individual's reaction to a painful stimulus.

B) It is consistent among all individuals.

C) It is innate and highly reproducible.

D) It is identified when a stimulus begins to produce pain.

Answer: A Objective 3

5) Which of the following is classified as nociceptive pain?

A) Trigeminal neuralgia B) Phantom limb pain C) Chronic muscle pain D) Traumatic tooth fracture Answer: D Objective: 4 6) Which statement correctly describes chronic pain?

A) It follows a period of acute pain that persists for more than six months.

B) It follows inception of nociceptive processes.

C) It always has an identifiable cause and duration.

D) It responds well to pain medication and limited interventions.

Answer: A Objective: 5 7) Which is true regarding nociception?

A) Pain perception and nociception are synonymous B) Trigger muscular neurons C) Activated without conscious awareness D) Deactivated by stimuli to minimize pain perception Answer: C Objective: 6 8) In response to pain from injection, the CNS activates the sympathetic nervous system to: A) Stimulate the adrenal medulla to release serotonin B) Increase heart rate, blood pressure, and skeletal muscle vasculature C) Increase mesenteric vessel blood flow to digestive organs D) Depress the psychological state of a patient Answer: B Objective: 7 9) Which statement is true regarding fear and local anesthesia?

A) Fear can be a barrier to obtaining adequate anesthesia.

B) Fear causes little concern over dental treatment.

C) Fear of injections causes over 40% of patients to avoid treatment.

D) Fear is an insurmountable problem for most patients who experience fear of injections.

Answer: A Objective: 8 10) Which of the following strategies helps patients cope with anxiety and fear?

A) Avoid discussions about anxiety and fear.

B) Only the dentist should ask about anxiety and fear to avoid patient embarrassment.

C) Assure the patient that difficulties during past dental visits could not have been avoided.

D) Prepare, rehearse, empower, and praise patients to reduce anxiety and fear.

Answer: D Objective: 9 11) Which one of the following is not helpful in the process of debriefing?

A) Patients relate which aspects of treatment did and did not go well.

B) Patients provide input for subsequent appointments.

C) Clinicians select strategies for appointments according to their observations of patient behavior.

D) Clinicians listen carefully and consider patient input in planning next appointments.

Answer: C Objective: 9 12) Which statement best describes the hypnosis?

A) Hypnosis is most effective in conjunction with oral sedation.

B) Hypnosis causes the inability to concentrate.

C) Hypnosis reduces anxiety, stress, salivation and gag reflex.

D) Hypnosis induces calmness, relaxation and amnesia Answer: C Objective 9 Short answer/essay 1) Discuss the value of pain as a protective response.

Answer: As a physiological response to environment, pain is a protective response. Physiological pain serves to protect against harmful experiences. This protective response is a rapid, reflexive, and subconscious reaction. A less emergent painful annoyance, however, may elicit a slower, conscious level reaction. Without the protective pain response, the ability to maintain a healthy body would be seriously compromised.

Objective: 2 2) Discuss variables that contribute to an individual's experience of pain.

Answer: Pain is influenced by many variables that contribute to an individual's experience of pain. The sex of an individual provides genetic and hormonal influence. Gender adds numerous complex components that include an array of socially constructed roles and relationships, personality traits, attitudes, behaviors, values, and relative power and influence. Other factors, such as age, physical health, mental health, emotional status, expectations, previous experiences, learned responses, and ethnic and cultural norms also impact the pain experience.

Objective: 3 3) Differentiate between acute and chronic pain.

Answer: Acute pain usually lasts for a few seconds to no more than six months depending on the causative factors. It is generally caused by tissue damage from an injury or disease. Chronic pain is long-term pain that persists for more than six months with or without an identifiable cause.

The longer an acute pain continues, the more likely the pain will become a chronic pain experience.

Objective: 5

4) Explain the difference between pain and nociception.

Answer: Pain and nociception are not synonymous. Nociception is the body's neurophysiologic detection of tissue trauma by nociceptors and the process of transmission of signals of the tissue injury within the nervous system. Nociception is not a conscious process. The process of nociception is influenced by an individual's age, general health, and genetics. An individual must have conscious awareness to experience pain. Pain cannot exist apart from consciousness and cannot be objectively measured.

Objective: 6 5) Provide examples of the PREP strategies that help patients manage anxiety and fear.

Answer: To help patients cope with anxiety and fear: Prepare by utilizing relaxation techniques such as deep breathing, distraction such as music or visualization, and muscle relaxation.

Rehearse procedures allowing patients to practice control and self-calming techniques.

Empower patients with strategies that give them control during procedures such as raising a hand to ask the clinician to stop.

Praise patients for using specific coping techniques that are helpful to them.

Objective: 9 6) Discuss strategies and provide examples that enhance positive communication with patients.

Answer: Display a genuinely warm and caring attitude.

Review the treatment plan addressing fears, including of the unexpected and of loss of control.

Obtain patient’s permission to begin treatment and address fear of loss of control if necessary.

Establish patient control strategy (time-out signal such as raising hand to stop.)

Direct the focus on positive outcomes (“You may feel a bit of pressure.”)

Acknowledge and compliment success (“You did great with the anesthesia today!”)

Create positive expectations (“That went well today and I expect your next appointment will too.”)

Objective: 9

Chapter 3 The Neuroanatomy and Neurophysiology of Pain Control Match the following A) Water loving B) Passage through nerve membrane C) Nerve bundle of nerve fibers D) Nerve membrane E) Covering on nerve membrane F) Forms myelin layer G) Ionic activity on nerve membrane H) Area of synapses I) Little or no stimulation on nerve J) Gap in sheath 1) Dendritic zone Objective: 1 2) Depolarization Objective: 1 3) Fasciculi Objective: 1 4) Hydrophilic Objective: 1 5) Ion channel Objective: 1 6) Impulse Objective: 1 7) Myelination Objective: 1 8) Neurolemma Objective: 1 9) Node of Ranvier Objective: 1 10) Schwann cells Objective: 1

Answers: 1) H 2) I 3) C 4) A 5) B 6) G 7) E 8) D 9) J 10) F True or false 1) The epineurium surrounds all of the fasciculi, their associated supporting connective tissue including blood vessels and lymphatics, and the perineuria.

A) True B) False Answer: A Objective: 1 2) The strength of nerve impulses weakens as the energy transfers from one section of nerve membranes to the next.

A) True B) False Answer: B Explanation: B) Impulses do not lose any of their strength in the transfer of energy from one section of membrane to the next. Current flow at successive areas of a nerve membrane actually exceeds that which is necessary to fire nerve impulses.

Objective: 2 3) Saltatory conduction is the term for the process by which impulses are slowly conducted along nonmyelinated nerves.

A) True B) False Answer: B Explanation: B) Saltatory conduction is the term for the process by which impulses are more rapidly conducted along myelinated nerves.

Objective: 2 4) In response to stimulation, calcium ions release from the receptor sites, allowing an influx of sodium ions into the axoplasm.

A) True B) False Answer: A Objective: 2 5) There are more positively charged ions outside the depolarized nerve cell than inside because the nerve membrane is relatively impermeable to sodium.

A) True B) False Answer: A Objective: 3 6) The electrical potential of a nerve axoplasm in the resting state is approximately -70 mV. A) True B) False

Answer: A Objective: 3 7) Depolarization refers to a potential change across a nerve membrane from -70 mV to +40 mV. A) True B) False Answer: A Objective: 3 8) Depolarization is a reversal of ion concentrations in the recovery phase.

A) True B) False Answer: B Explanation: B) The reversal of ion concentrations in the recovery phase is called repolarization.

Objective: 3 9) A relative refractory period occurs when a nerve fiber can only be restimulated by a much stronger stimulus than the initial stimulus.

A) True B) False Answer: A Objective: 3 10) An absolute refractory period occurs when a nerve fiber can be restimulated only by a much stronger stimulus than the initial stimulus.

A) True B) False Answer: B Objective: 3 11) Schwann cells release neurotransmitters when stimulated by impulses.

A) True B) False Answer: B Explanation: B) Organelles are located in the terminal zones of nerve axons and release neurotransmitters when stimulated by impulses. Schwann cells produce myelin, a specialized connective tissue that surrounds and protects peripheral nerves.

Objective: 4 12) Nodes of Ranvier are small, raised areas on the neurolemma that permit ions to pass into the axoplasm.

A) True B) False Answer: B Explanation: B) Nodes of Ranvier are minute gaps on myelinated nerves between adjacent Schwann cells.

Objective: 4

13) Local anesthetic drugs are effective only at the nodes of Ranvier and in order to be effective, multiple nodes must be exposed to the drug to block impulses.

A) True B) False Answer: A Objective: 4 14) Due to the effectiveness of local anesthetic drugs, exposure of a 1 to 3 millimeter section of nerve membrane to an anesthetic solution is adequate to ensure profound anesthesia.

A) True B) False Answer: B Explanation: B) Eight to ten millimeters of the nerve membrane must be flooded by an anesthetic solution in order to achieve anesthesia in larger, heavily myelinated nerves, such as the inferior alveolar nerve.

Objective: 4 15) All cell bodies of sensory nerves that innervate oral tissues are located in the trigeminal ganglia and participate in impulse transmission.

A) True B) False Answer: B Explanation: B) All cell bodies of sensory neurons that innervate oral tissues are located in the trigeminal ganglia and provide metabolic support to the cell. The cell bodies are located away from the axon, and therefore do not participate in impulse transmission.

Objective: 5 16) The minimal threshold stimulus required to stimulate a C fiber will be sufficient to stimulate an A fiber.

A) True B) False Answer: B) C fiber impulses travel in a range of 0.5–2.3 m/sec and A fibers at 15–100 m/s.

Objective: 6 17) Nonmyelinated C fibers are the most common nerve fiber types on peripheral nerves and conduct slowly producing a sensation of dull and aching pain.

A) True B) False Answer: A Objective: 6 18) A fibers are the most numerous of the fiber types. They are nonmyelinated and transmit sharp pain sensations.

A) True B) False Answer: B Explanation: B) C fibers are the most numerous of the fiber types. They are nonmyelinated,

conduct more slowly, providing the sensation of dull and aching pain.

Objective: 7 19) The mantle bundles are located on the outer area of the nerve membrane and the core bundles are located in the central area. Both have significance in the order of anesthesia development.

A) True B) False Answer: A Objective: 11 20) Local anesthetic molecules have a greater affinity for protein receptor sites within the nerve membrane compared to calcium ions; therefore, they displace the calcium ion and block impulse transmission.

A) True B) False Answer: A Objective: 11 Fill in the blank 1) The four structural parts of the neuron are the , Answer: dendritic zone, axon, cell body, terminal arborization Objective: 1 2) Sensory neurons carry impulses to the Answer: central nervous system (CNS) Objective: 1

, and

.

for processing.

3) Motor nerves carry impulses away from the CNS to Answer: effector cells (muscles), tissues and organs Objective: 1 4) Lipophilic membranes are described as Answer: fat loving Objective: 1

,

and

.

.

5) Nerves are classified as myelinated or nonmyelinated according to the extent of the tissue that encloses them.

Answer: connective Objective: 1 6) Nerve membranes are called Answer: neurolemmas Objective: 2

and are bilayered phospholipid membranes.

7) The process of sequential impulse generation to the CNS is referred to as Answer: propagation

.

Objective: 2 8) The ion is the gatekeeper in the nerve membrane's resting state.

Answer: calcium Objective: 2 9) The inability of a nerve membrane to be restimulated following impulse generation and conduction is known as a .

Answer: refractory state Objective: 3 10) Specialized connective tissue cells that surround and protect peripheral nerves are called .

Answer: Schwann cells Objective: 3 11) Myelinated nerves have minute gaps consisting of unprotected nerve membranes between adjacent Schwann cells called .

Answer: nodes of Ranvier Objective: 3 12) is a process by which impulses are rapidly conducted along myelinated nerves.

Answer: Saltatory conduction Objective: 3 13) fibers are lightly myelinated and primarily provide a sharp pain sensation.

Answer: A delta (Aδ) Objective: 7 14) The two most significant perineurium.

Answer: barriers to diffusion Objective: 9

of local anesthetic solutions are the perilemma and the

15) Mantle fibers within the inferior alveolar nerve innervate the Answer: molar Objective: 10

region.

Multiple choice 1) Which description of nerve membranes is correct?

A) Trilayered sandwich-like membranes B) Bilayered phospholipid membranes C) Hydrophilic ends facing inward D) Have fatty cores that allow large hydrophilic molecules to pass into the axoplasm Answer: B Objective: 2

2) Which statement is not accurate when describing nerve impulses?

A) Electrical in nature B) Depend on ionic activity on nerve membranes C) Require firing threshold to transmit to CNS D) Successive impulses decrease in size Answer: D Objective: 2 3) Which statement accurately describes the process known as saltatory conduction?

A) Impulses are rapidly conducted along myelinated nerves.

B) Impulses are slowly, uniformly conducted along nonmyelinated nerves.

C) Impulses are conducted only through the nodes of Ranvier on myelinated nerves.

D) Impulses are conducted through the Schwann cells and axoplasmic membrane to the CNS. Answer: A Objective: 2 4) Saltatory conduction is defined as the A) Slow transmission of a nerve impulse due to diffusion of sodium across nerve membrane B) Rapid diffusion of sodium chloride into the nerve cell during impulse conduction C) Slow conduction of an impulse along a nonmyelinated nerve at the nodes of Ranvier D) Rapid transmission of nerve impulses along a myelinated nerve fiber Answer: D Objective: 2 5) The axoplasm of a nerve at rest: A) Is electrically positive at +70 mV. B) Is electrically negative compared to the extracellular environment.

C) Contains more sodium ions than the extracellular environment.

D) Contains less calcium ions than the extracellular environment.

Answer: B Objective: 2 6) In the resting state, a nerve membrane has an electrical potential of: A) -40 mV to +40 mV. B) +40 mV. C) +70 mV to +90 mV. D) -70 mV. Answer: D Objective: 2 7) Which two ions are responsible for the uninterrupted maintenance of the resting potential across the nerve membrane?

A) K+ and Na+ B) K+ and ClC) Ca+ and NaD) H+ and Cl-

Answer: A Objective: 2 8) Which positively charged ion functions as a gatekeeper in ion channels?

A) Calcium B) Sodium C) Potassium D) Hydrogen Answer: A Objective: 2 9) Which of the following does not occur upon rapid depolarization?

A) Calcium rapidly floods into the axoplasm B) Sodium rapidly floods into the axoplasm C) Electrical potential of the axoplasm is +40 mV D) Absolute refractory state Answer: A Objective: 3 10) Which of the following sequences best describes the events in a successful impulse generation?

A) Stimulation, firing threshold, rapid depolarization, slow repolarization, resting state B) Stimulation, slow depolarization, firing threshold, rapid depolarization, recovery C) Resting state, stimulation, slow depolarization, rapid depolarization, firing threshold D) Resting state, stimulation, slow depolarization, rapid depolarization, slow depolarization Answer: B Objective: 3 11) Which statement describes slow depolarization?

A) Allows dehydrated sodium ions to enter the negatively charged axoplasm causing the threshold for firing threshold B) Allows release of the sodium ions from the receptor sites in the ion channels allowing negative ions to enter the axoplasm C) Occurs until the axoplasm has depolarized 15 to 20 mV to reach -50 to -55 mV, which is the firing threshold D) Occurs until the calcium ions rebind with the receptor sites to reach firing threshold at -50 to 55 mV Answer: C Objective: 3 12) Which statement best describes rapid depolarization?

A) The membrane rapidly depolarizes at the site of stimulation causing a firing threshold that is followed by displacement of the calcium ions.

B) The membrane rapidly depolarizes once the firing threshold has been achieved allowing a flood of sodium ions into the axoplasm.

C) The membrane rapidly depolarizes along the entire nerve until the strength of the stimulus increases enough to cause an impulse.

D) The membrane rapidly depolarizes following the refractory resting state.

Answer: B Objective: 3 13) Which statement best describes the relative refractory state when the membrane has not fully returned to its resting state?

A) The same strength of a single stimulus can create a firing threshold.

B) No amount of stimulus relative to the previous impulse will produce a firing threshold.

C) Rapid repetition of the same strength stimulus will create a firing threshold.

D) A larger stimulus than the previous stimulus can produce a firing threshold.

Answer: D Objective: 3 14) Which statement best describes the repolarization process?

A) The nerve membrane has reestablished a potential of +70 mV. B) Positively charged sodium ions return to the axoplasm due to the negative charge of the axoplasm during polarization.

C) Positively charged sodium, calcium, and potassium ions are actively transported from the axoplasm to the extracellular environment.

D) Calcium ions re-bind to the receptor sites to ensure that Na+ will not continue to depolarize the axoplasm.

Answer: D Objective: 3 15) Which of the following is correct when a nerve is in the resting state?

A) Na+ concentration is the highest inside the axoplasm B) Nerve membrane is more negative on the extracellular side C) Nerve axoplasm is approximately -70 mV D) Nerve membrane will respond to any stimulus Answer: C Objective: 3 16) The process of sequential impulse generation to the CNS is called: A) Impulse generation B) Firing potential C) Firing threshold D) Propagation Answer: D Objective: 3 17) Myelin is composed of: A) Connective tissues B) Fatty tissues C) Neuron tissues D) Phospholipid tissue Answer: A Objective: 4

18) Which cells produce myelin?

A) Sensory neurons B) Myelinated neurons C) Schwin cells D) Schwann cells Answer: D Objective: 4 19) Nerve impulses travel rapidly on myelinated nerves because: A) Myelin allows for a consistent incremental impulse over the membrane surface B) Impulses travel through the membrane, generating new impulses at each node C) Impulses bypass nodes and travel up to 8–10 mm to subsequent nodes, decreasing the length of nerve over which impulses must be generated D) Transmit rapidly because they are small nerves Answer: C Objective: 4 20) What are the functions of Schwann cell sheaths?

A) Protection and insulation for cell bodies B) Protection for the nodes of Ranvier and neurons C) Protection and insulation for the neurons D) Produce Schwann cells and cell membranes Answer: C Objective: 4 21) What is the correct relationship of Schwann cells to the nodes of Ranvier?

A) Schwann cells are located in the nodes of Ranvier.

B) Schwann cells are twice as thick as the nodes of Ranvier.

C) Nodes of Ranvier are gaps between Schwann cells.

D) Nodes of Ranvier are wrapped around the Schwann cells.

Answer: C Objective: 4 22) In myelinated nerves, local anesthetic molecules are effective: A) As they diffuse through the myelin sheath.

B) As they diffuse at the synapse.

C) Only at the cell body.

D) Only at the Nodes of Ranvier.

Answer: D Objective: 4 23) Which statement correctly describes sensory and motor neurons?

A) Sensory neurons are efferent and conduct impulse away from the CNS. B) Sensory neurons are afferent and conduct impulses toward the CNS. C) Motor neurons participate in impulse conduction toward the CNS. D) Motor neurons and sensory neurons have cell bodies that participate in the conduction of nerve impulse transmission.

Answer: B Objective: 5 24) Which statement correctly describes the cell bodies of sensory and motor neurons?

A) Motor neuron cell bodies are located away from the axon.

B) Sensory neuron cell bodies participate in impulse transmission.

C) Sensory neuron cell bodies do not participate in impulse transmission.

D) Motor neuron cell bodies do not participate in the impulse transmission.

Answer: C Objective: 5 25) Nerve impulses are initiated in the: A) Dendritic zone B) Axon.

C) Cell body.

D) Terminal arboration Answer: A Objective: 5 26) All oral cell bodies of sensory nerves are located in the: A) Axon B) Dendrite zone C) Ganglia D) Nerve membrane Answer: C Objective: 5 27) Which statement inaccurately describes nerve fiber types?

A) Dental pulp has more A than C nerve fiber types.

B) C fibers are more numerous in the peripheral nervous system.

C) A delta fibers are lightly myelinated and are responsible for the sensation of sharp pain.

D) C fibers are nonmyelinated and are responsible for the sensation of dull and aching pain.

Answer: D Objective: 6 28) The immediate painful sensation from a traumatic injury to the lip is transmitted to the brain by which nerve fiber type?

A) A delta fibers B) C delta fibers C) B fibers D) A and C fibers Answer: A Objective: 7 29) What is the function of the endoneurium?

A) Insulates the electrical activity of individual nerve fibers B) Bundles nerve fibers into fasciculi

C) Is the inner layer of the perineurium D) Provides metabolic support for the neuron membranes Answer: A Objective: 9 30) What is the function of the perineurium?

A) Forms the epineural sheath B) Bundles nerve fibers into fasciculi C) Produces connective tissues that insulate nerves D) Forms a sheath around Schwann cells Answer: B Objective: 9 31) Which nerve layers represent the most significant barriers to the diffusion of anesthetic solutions and the development of anesthesia?

A) Perilemma and fasciculi B) Fasciculi and epineurium C) Perilemma and perineurium D) All neuromembranes present a significant barrier to diffusion.

Answer: C Objective: 9 32) What are three divisions of the dental plexus?

A. Interdental, interradicular, and periodontal B. Inner dental, interradicular, and dental C. Inner dental, interradicular, and periodontal D. Interdental, interradicular, and dental Answer: D Objective: 10 33) The aromatic, lipophilic portion of an anesthetic molecule allows the anesthetic solution to: A) Diffuse through the nerve membrane B) Bind at the receptor site C) Diffuse through the interstitial tissues D) Be more effective in the presence of inflammation Answer: A Objective: 11 34) With which ion does the local anesthetic molecule compete within the nerve membrane?

A) Sodium B) Calcium C) Potassium D) Hydrogen Answer: B Objective: 11 35) Which statement is true regarding the specific protein receptor theory?

A) Local anesthetic molecules compete with sodium ions for receptor sites.

B) Local anesthetic molecules displace calcium ions at receptor sites.

C) It explains why local anesthetic molecules affect only sensory nerves.

D) It blocks proteins that cover specific protein receptors on Schwann cells.

Answer: B Objective: 11 36) Local anesthetics block pain impulses by: A) Preventing repolarization of the nerve membrane B) Preventing diffusion of the free base molecules C) Decreasing the absolute refractory period between impulses D) Preventing depolarization of the nerve membrane Answer: D Objective: 11 37) Which of the following is not directly related to impulse extinction caused by local anesthetics drugs?

A) Drug classification B) Volume delivered C) Drug concentration D) Length of nerve exposed to the drug Answer: A Objective: 11 38) Local anesthetic molecules have a greater affinity for protein receptor sites within the nerve membranes compared to which ion(s)?

A) Chlorine and hydrogen B) Hydrogen and sodium C) Calcium D) Sodium Answer: C Objective: 11 39) Which statement does not describe the typical onset of anesthesia?

A) Anesthesia will affect smaller nerves before larger nerves.

B) Anesthesia will affect sensory nerves before motor nerves.

C) Mantle bundles will be anesthetized before core bundles.

D) Onset is faster on incisors, soft tissues of chin, and labial tissues.

Answer: D Objective: 11 Short answer/essay 1) What is the composition and function of the neurolemma?

Answer: Nerve membranes, called neurolemmas, are bilayered phospholipid membranes. The function of a bilayered membrane is to act as a barrier. Lipid membranes are composed of phospholipids having both lipophilic ("fat-loving") and hydrophilic ("water-loving") ends.

Membranes are held together by the attraction of the lipophilic ends at their centers.

Objective: 2 2) Explain the structure and function of Schwann cells and nodes of Ranvier.

Answer: Schwann cells are specialized connective tissue cells that produce myelin. Myelin forms extensive sheaths around axons that insulate and protect the nerve membranes from their surrounding environments. Axons and their associated Schwann cells are collectively referred to as nerve fibers. Local anesthetic solutions cannot diffuse through myelinated nerves except in areas where they come into direct contact with the membrane at the nodes of Ranvier.

Objective: 4 3) Describe the process of firing threshold and impulse generation.

Answer: When a nerve is stimulated, the ion channels respond by releasing the gatekeeper calcium ions. The channels are then wide enough to allow the positively charged, hydrated Na+ ions to begin to enter through the channels into the more negatively charged axoplasm. The initial influx of positively charged Na+ ions causes a slow depolarization. Once there are sufficient Na+ ions in the axoplasm to reduce the electrical potential by approximately 15 to 20 mV, extracellular Na+ ions flood the axoplasm.

Objective: 3 4) Define local anesthesia.

Answer: Local anesthesia may be defined as a loss of sensation in a usually small area of the body that is temporary. A primary distinction between local and general anesthesia is that when local anesthesia alone is in effect, the patient remains conscious.

Objective: 11 5) Explain how local anesthetics work.

Answer: Local anesthetic drugs all work similarly. Local anesthetic molecules have a greater affinity for protein receptor sites within the nerve membrane compared to Ca+2 ions and subsequently displace them. Different local anesthetic drugs have varying affinities for these receptor sites, which account for clinically significant differences in drug action.

Objective: 11

Identify the structures indicated on the figure below

1) Identify A. Answer: axon Objective: 2 2) Identify B. Answer: cell body Objective: 2 3) Identify C. Answer: Schwann cell Objective: 2 4) Identify D. Answer: dendritic zone Objective: 2 5) Identify E. Answer: terminal aborization Objective: 2

Identify the structures indicated on the figure below

1) Identify A. Answer: fasciculi Objective: 7 2) Identify B. Answer: perilemma Objective: 7 3) Identify C. Answer: perineurium Objective: 7 4) Identify D. Answer: Schwann cells Objective: 7 5) Identify E. Answer: axon Objective: 7 Use the information provided in the Case Study below to answer the questions that follow.

Case Study An injection has been completed on the right side of the mandible. The patient, Ralph, tells the clinician that his back teeth are numb; however, his lower lip and chin are not very numb.

1) Taking into consideration the sensory neuron structure, are the mantle bundles or the core bundles more affected by the anesthetic drug?

Answer: The mantle bundles are more effectively anesthetized.

Objective: 11 2) Provide two reasons Ralph does not feel as numb in the anterior area.

Answer: The anesthetic solution reaches the core bundles only after the solution has penetrated through the mantle bundles. It takes longer for the anesthetic solution to reach the core bundles.

There is a diluting effect on the solution due to the binding of the drug molecules to receptor sites in the mantle bundles. Once at the core, there are fewer anesthetic molecules remaining to bind to the receptor sites in the core.

Objective: 11 3) After waiting several more minutes, Ralph is not yet numb in the anterior region. Explain why this may occur.

Answer: There are actually several reasons the lower anterior region is not as numb as the posterior region. Impulse extinction is directly related to the volume of anesthetic solution administered, the concentration of the drug, and the length of nerve that was exposed to the solution. One other possibility could be the presence of accessory innervations in the anterior

region.

Objective: 11

Chapter 4 Pharmacology Basics Match the following A) Contains a nitrogen atom B) Identifies chemical nature of local anesthetic drug C) Uncharged molecule D) Effect of local anesthetic drug on nerve membrane E) Restricts vascular flow F) pKa G) Removal of drug by kidneys H) 50% of drug is removed from circulation I) Positively charged ion J) Body's management of a drug 1) Amide Objective: 1 2) Biotransformation Objective: 1 3) Cation Objective: 1 4) Dissociation constant Objective: 1 5) Elimination Objective: 1 6) Elimination half-life Objective: 1 7) Intermediate chain Objective: 1 8) Neutral base Objective: 1 9) Specific receptor theory Objective: 1 10) Vasoconstrictor Objective: 1

Answers: 1) A 2) J 3) I 4) F 5) G 6) H 7) B 8) C 9) D 10) E Multiple choice 1) Which of the following is not a desirable characteristic of local anesthetic drugs?

A) Biotransformable and easily eliminated B) Nonirritable C) Nontoxic to neural structures D) Easily distributed Answer: D Objective: 2 2) Which of the following local anesthesia drugs is available without a vasoconstrictor?

A) Lidocaine B) Articaine C) Bupivacaine D) Procaine Answer: A Objective: 2 3) Which of the following is not a trade name for lidocaine?

A) Xylocaine B) Octocaine C) Lignocaine D) Carbocaine Answer: D Objective: 2 4) Trade names for prilocaine include: A) Zorcaine and Citanest B) Citanest and Citanest forte C) Isocaine and Carbocaine D) Octocaine and Marcaine Answer: B Objective: 2 5) Which of the following local anesthetic drugs is available in a 0.5% concentration?

A) Prilocaine B) Mepivacaine C) Articaine D) Bupivacaine Answer: D Objective: 2 6) Which statement is false regarding the intermediate chain of local anesthetic drugs?

A) Affects the method of biotransformation B) Separates an aromatic end and a secondary or tertiary amine C) Contains a nitrogen atom in amides

D) Contains both lipophilic and hydrophilic properties Answer: D Objective: 2 7) Which form(s) of a local anesthetic drug is (are) responsible for the actions of the drug on nerve membranes?

A) Cation and neutral base B) Ester and amide C) Positive cation D) Neutral base Answer: A Objective: 2 8) Which statement is false regarding the vasoactivity of local anesthetic drugs?

A) All local anesthestic drugs are peripheral vasodilators.

B) It is not a desired characteristic C) It affects both duration and efficacy D) Their vasoactivity decreases toxicity Answer: D Objective: 2 9) Approximately what percentage of the action of local anesthetic drugs is due to cation binding at specific protein receptor sites?

A) 100% B) 90% C) 10% D) 4% Answer: B Objective: 3 10) During normal nerve function, which ion is displaced when a membrane is stimulated?

A) Sodium B) Calcium C) Potassium D) Neutral salt Answer: B Objective: 3 11) Which one of the following local anesthetic ions binds to specific receptor sites?

A) NA+ B) NAC) CA+2 D) K+ Answer: C Objective: 3

12) Which portion of a local anesthetic molecule passes through nerve membranes?

A) Base B) Cation C) Hydrophilic base D) Base and cation Answer: A Objective: 3 13) Which portion of local anesthetic molecules binds to receptor sites within nerve membranes, preventing depolarization?

A) Lipophilic base B) Neutral base C) Sodium cation D) Cation Answer: D Objective: 3 14) What factor influences the shift of the neutral base (RN) molecule to the cation (RNH+) within the axoplasm?

A) Lower pH of axoplasm than extracellular fluid B) Fewer H+ ions available in axoplasm C) Sufficient H+ ions available in axoplasm at pH of 7.4 D) Higher number of base molecules within the axoplasm due to inflammation Answer: C Objective: 3 15) Which of the following best explains the membrane expansion theory?

A) Membrane ion channels narrow due to diffusion of local anesthetic molecules into lipophilic regions of the membranes B) Membrane ion channels narrow due to diffusion of local anesthetic molecules into hydrophilic regions of the membranes C) Diffusion of local anesthetic molecules bind in the nerve channels causing a narrowing of lipophilic ion channels D) Dissociation of local anesthesia molecules narrows membrane channels blocking influx of sodium and calcium ions Answer: A Objective 3 16) Approximately what percentage of the action of local anesthetic drugs is due to the membrane expansion theory?

A) 90% B) 60% C) 10% D) 5% Answer: C Objective 3

17) What factor decreases the effectiveness of local anesthesia when tissues are inflamed?

A) An increase in the pH of surrounding tissues B) A decrease in the pH of surrounding tissues C) An increases in the number of base molecules D) A decrease in the number of H+ ions available to form base molecules Answer: B Objective: 4 18) Why do manufacturers alter the pKa of local anesthetic drugs?

A) Increase the duration of anesthesia B) Decease the duration of anesthesia C) Provide useful onset time of anesthesia D) Provide more profound anesthesia Answer: C Objective: 5 19) What is the clinical effect of a local anesthetic drug solution with a higher pKa? A) Increased base molecule concentration and thereby slower onset of anesthesia B) Increased cation molecule concentration and thereby faster onset of anesthesia C) Increased base molecule concentration and thereby faster onset of anesthesia D) Decreased base molecule concentration thereby slower onset of anesthesia Answer: C Objective: 5 20) Which statement is false regarding the absorption and distribution of local anesthetic drugs?

A) Once absorbed into the systemic circulation the drugs are distributed throughout the body.

B) The lungs, brain, heart, and kidneys will receive more drug because they are highly perfused with blood.

C) Injection into highly vascular regions will result in faster absorption and distribution.

D) Bone and epithelium will receive more drug.

Answer: D Objective: 6 21) Which body system (by mass) receives the highest concentration of anesthetic drugs?

A) Liver B) Skin C) Muscle D) Bone Answer: C Objective: 6 22) Biotransformation of current local anesthetic drugs occurs primarily through: A) Liver or blood B) Liver and intestines C) Kidney and blood D) Liver and kidney

Answer: A Objective: 6 23) Most amide local anesthetics are biotransformed in the: A) Blood by P450 isoenzymes B) Liver by P450 isoenzyme C) Blood by pseudocholinesterase D) Kidneys and liver by P450 isoenzymes and pseudocholinerase Answer: B Objective: 6 24) Prilocaine is biotransformed by the: A) Liver B) Liver and blood C) Liver, kidneys, and lungs D) Liver, lungs, and large intestines Answer: C Objective: 6 25) Ester-type local anesthestic drugs are biotransformed in the: A) Liver by hepatic enzymes B) Kidney by cholinesterase C) Blood by the isoenzyme system D) Blood by pseudocholinesterase Answer: D Objective: 6 26) CNS toxicity occurs due to: A) Normal function of nerve cells B) Nerve damage during injection C) Compromised vascular supply D) Inadequate amount of local anesthesia Answer: A Objective: 7 27) Which of the following signs and symptoms are not signs of CNS overdose toxicity?

A) Apprehension, excitedness, talkativeness B) Bilateral numbness of tongue, perioral numbness C) Muscle twitching, tremors D) Hypotension, lower pulse, slower breathing Answer: D Objective: 7 28) Which of the following signs and symptoms are not signs of CVS overdose toxicity?

A) Depression of myocardial conduction rate B) Vasoconstriction of peripheral vasculature

C) Hypotension D) Depression of force of myocardial contraction Answer: B Objective: 8 29) Which local anesthetic drug can be harmful at higher blood levels however useful in treating cardiac arrhythmias?

A Bupivacaine and procaine B) Procaine and prilocaine C) Lidocaine and procaine D) Lidocaine and prilocaine Answer: C Objective 8 30) Elimination half-life refers to the time it takes for half of a drug to be: A) Metabolized B) Out of the lungs C) Out of the circulation D) Out of half of the circulation Answer: C Objective: 9 31) What is the half-life of lidocaine?

A) 6.25 hours B) 1.6 hours C) 50% D) 3.5 hours Answer: B Objective: 9 32) If the fourth half-life of lidocaine is 12.5%, what is the fifth half-life?

A) 50% B) 1.8% C) 0.32% D) 6.25% Answer: D Objective: 9 33) Which local anesthetic drug has the shortest half-life?

A) Articaine B) Prilocaine C) Mepivacaine D) Bupivacaine Answer: A Objective: 9 34) Which drug could be a good choice for a nursing mother who plans to nurse her child soon

after an appointment?

A) Bupivacaine B) Mepivaciane C) Prilocaine D) Articaine Answer: D Objective: 9 35) What is the half-life of bupivacaine?

A) 0.75 hours B) 3.5 hours C) 1.6 hours D) 1.9 hours Answer: B Objective: 9 Short answer/essay 1) What is the primary benefit of local anesthesia?

Answer: The primary benefit of local anesthesia is that pain sensations can be suppressed without significant central nervous system depression. This allows the majority of dental procedures, for example, to be performed under local anesthesia without exposing patients to the risks of general anesthesia.

Objective: 2 2) Discuss the ideal properties of local anesthetic drugs used in dentistry.

Answer: An ideal local anesthetic drug would have the following specific properties: a high level of biocompatibility with no systemic effects; a rapid onset; no damage to tissue including nerve tissue; and a therapeutic duration and potency without inducing hypersensitivity or unconsciousness. It would also be sterilizable, readily biotransformed, and provide excellent topical effects at low concentrations.

Objective: 2 3) How does the vascularity of an injection site affect the absorption and distribution of a local anesthetic drug?

Answer: Injection into highly vascular areas will result in faster absorption and distribution away from sites of deposition. In contrast, less vascular areas with slower vascular uptake prolong the local actions of drugs.

Objective: 2 4) How does tissue inflammation affect local anesthetic drug efficacy?

Answer: When tissues are inflamed at the deposition sites, the lowered pH suppresses the production of base molecules. This suppression may result in insufficient numbers of base molecules (RN) penetrating nerve membranes. Profound anesthesia may become difficult to achieve or, if initially achieved, to sustain. In addition to the increase in hydrogen ions due to the inflammatory response, localized edema and increased circulation may also contribute to failure of profound anesthesia in this situation by decreasing drug concentrations at the delivery site.

Objective: 4 5) Discuss factors that can precipitate toxic overdose from local anesthetic drugs.

Answer: Factors that can precipitate toxic overdose from local anesthetic drugs include excessive doses, rapid absorption, intravascular administration, or slower than normal biotransformation or elimination. Other factors include an individual's age, weight, health status, and the speed and route of administration.

Objective: 6

Chapter 5 Dental Local Anesthetic Drugs Match the following A) Ester-type anesthetic B) First amide available C) Long-acting anesthetic D) Available in 4% solution E) Established safe dose guideline F) Vasoconstrictor G) Available 1:20,000 H) Nerve damage I) Available in 3% solution J) Sulfur atom in ring structure 1) Articaine Objective: 1 2) Bupivacaine Objective: 1 3) Epinephrine Objective: 1 4) Levonordefrin Objective: 1 5) Lidocaine Objective: 1 6) MRD Objective: 1 7)Mepivacaine Objective: 1 8) Paresthesia Objective: 1 9) Prilocaine Objective: 1 10) Procaine Objective: 1

Answers: 1) J 2) C 3) F 4) G 5) B 6) E 7) I 8) H 9) D 10) A Match the following A) Intermediate B) Long C) Short 1) Articaine Objective: 2 2) Bupivacaine Objective: 2 3) Lidocaine plain Objective: 2 4) Lidocaine Objective: 2 5) Mepivacaine plain Objective: 2 6) Mepivacaine Objective: 2 7) Prilocaine plain Objective: 2 8) Prilocaine Objective: 2 9) Procaine Objective: 2 Answers: 1) A 2) B 3) C 4) A 5) C 6) A 7) C 8) A 9) C True or false 1) Lidocaine was the first amide local anesthetic drug developed by Lofgren in 1943.

A) True B) False Answer: A Objective: 2 2) Mepivacaine was prepared as an alternative to lidocaine by Lofgren in Sweden, in 1957.

A) True

B) False Answer: B Explanation: B) Mepivacaine was prepared as an alternative to lidocaine by A. F. Eckenstam in Sweden in 1957.

Objective: 2 3) Prilocaine was first prepared by Lofgren and Tegner in 1953 and approved by the FDA in 1965.

A) True B) False Answer: A Objective: 2 4) Articaine was synthesized in 1969 by H. Rusching and is the most recently approved dental injectable local anesthetic drug in North America.

A) True B) False Answer: A Objective: 2 5) Articaine is metabolized primarily in the liver.

A) True B) False Answer: B Explanation: B) Articaine is metabolized primarily by plasma cholinesterase.

Objective 2 6) The drug of choice for a patient with significant liver disease is articaine because it is metabolized primarily by plasma cholinesterase.

A) True B) False Answer: A Objective: 4 7) The best local anesthesia drug choice for a nursing mother is prilocaine.

A) True B) False Answer: B Explanation: B) The best local anesthesia drug choice for a nursing mother is articaine because it has a half-life of 45 minutes.

Objective 4 8) 3% mepivacaine plain is a better drug choice than 2% lidocaine when a vasoconstrictor is contraindicated because its higher drug content increases the duration of pulpal anesthesia.

A) True B) False Answer: B

Explanation: B) 3% mepivacaine plain is a better drug choice than 2% lidocaine when vasoconstrictor is contraindicated because it is a weak vasodilator, not because it has higher drug content. It provides 20 to 40 minutes pulpal anesthesia compared to 2% lidocaine which provides 5 to 10 minutes of pulpal anesthesia without a vasoconstrictor.

Objective: 7 9) 2% lidocaine with 1:50,000 epinephrine provides excellent hemostasis for periodontal surgery.

A) True B) False Answer: A Objective: 4 10) Prilocaine can reduce the blood’s oxygen carrying capacity which may lead to methemoglobinemia.

A) True B) False Answer: A Objective: 5 11) The higher the pKa of a local anesthetic solution, the slower the onset on anesthesia.

A) True B) False Answer: B Explanation: B) Local anesthesia drugs with a higher pKa provide a more rapid onset of anesthesia because greater numbers of the anesthetic molecules are in the base form.

Objective: 4 12) Allergic reactions to lidocaine have been documented and the drug shows cross-allergenicity with other currently available amides.

A) True B) False Answer: B Explanation: B) Allergic reactions to lidocaine have not been documented and the drug shows no cross-allergenicity with other currently available amides.

Objective: 5 13) Prilocaine has demonstrated a higher than typical incidence of inducing methemoglobinemia due to its metabolite, ortho-toluidine.

A) True B) False Answer: A Objective: 5 14) Bupivacaine's high pKa translates into a slow onset time, which explains why it is a longacting anesthetic.

A) True

B) False Answer: B Explanation: B) Bupivacaine's high pKa does translate into a slow onset time. This has nothing to do with bupivacaine's duration, however, which is related to the strength of its protein receptor binding in sodium ion channels.

Objective: 5 Multiple choice 1) Lidocaine is not available in which of the following formulations?

A) 2% lidocaine, 1:20,000 levonordefrin B) 2% lidocaine plain C) 2% lidocaine, 1:100,000 epinephrine D) 2% lidocaine, 1:50,000 epinephrine Answer: A Objective: 2 2) The anesthetic duration of lidocaine plain is: A) 60 minutes pulpal; 60 to 120 minutes soft tissue B) 10 to 30 minutes pulpal; 60 to 120 minutes soft tissue C) 5 to 10 minutes pulpal; 180 to 300 minutes soft tissue D) 5 to 10 minutes pulpal; 60 to 120 minutes soft tissue Answer: D Objective: 2 3) The maximum recommended dose for lidocaine is: A) 5 mg/lb B) 500 mg per appointment C) 4.4 mg/lb D) 2.0 mg/kg Answer: B Objective: 2 4) Which local anesthetic is not available in the United States with 1:200,000 epinephrine?

A) Prilocaine B) Articaine C) Lidocaine D) Bupivacaine Answer: C Objective: 2 5) The potency of lidocaine as compared to other local anesthetic drugs in dentistry is: A) Twice as potent as procaine B) Equal potency to procaine C) One half potency of bupivacaine D) One half potency of mepivacaine Answer: A

Objective: 2 6) What is the primary site of biotransformation of lidocaine?

A) Kidney B) Liver C) Lungs D) Blood Answer: B Objective: 2 7) What percentage of lidocaine is excreted by the kidneys unchanged?

A) 0% B) 5% C) 10% D) 20% Answer: C Objective: 2 8) What is the maximum recommended dose of mepivacaine?

A) 0.5 mg/lb B) 1.8 mg/lb C) 3.0 mg/lb D) 600 mg per appointment Answer: C Objective: 2 9) Mepivacaine is available in the following formulation: A) 2% plain B) 3% plain C) 1% with 1:20,000 levonordefrin D) 3% with 1:20,000 levonordefrin Answer: B Objective: 2 10) The correct pKa of lidocaine is: A) 6.5 in lidocaine plain B) 8.1 in lidocaine with epinephrine C) 2.4 in lidocaine plain D) 2.3 to 8.1 in lidocaine with epinephrine Answer: A Objective: 2 11) Which of the following is the correct onset of action for mepivacaine?

A) 0.5 to 2 minutes B) 1 to 2 minutes C) 4 to 6 minutes D) 6 to 0 minutes

Answer: A Objective: 2 12) What is the maximum recommended dose per appointment for prilocaine?

A) 200 mg B) 300 mg C) 400 mg D) 600 mg Answer: D Objective: 2 13) Which of the following is available in North America?

A) 4% prilocaine, 1:200,000 epinephrine B) 3% prilocaine, 1:20,000 levonordefrin C) 4% prilocaine plain D) 3% prilocaine, 1:100,000 epinephrine Answer: A Objective: 2 14) Name the atom present in the ring structure of articaine that helps to make it more lipophilic.

A) Sulfur B) Calcium C) Sodium D) Nitrogen Answer: A Objective: 2 15) Which formulation of articaine is correct?

A) 2% articaine with 1:50,000 epinephrine B) 2% articaine with 1:100,000 epinephrine C) 4% articaine with 1:100,000 epinephrine D) 4% articaine plain Answer: C Objective: 2 16) Which one of the following drugs used in dentistry is the least toxic to the CNS and CVS? A) Lidocaine B) Mepivacaine C) Prilocaine D) Bupivacaine Answer: C Objective: 3 17) What is the FDA pregnancy category for mepivacaine?

A) A B) B C) C

D) A, if minimal doses are administered Answer: C Objective: 4 18) The correct onset of action for lidocaine is: A) 30 seconds to 1 minute with vasoconstrictor B) 2 to 3 minutes C) 5 to 7 minutes D) 6 to 10 minutes Answer: B Objective: 4 19) What is the clinically safest available dilution of vasoconstrictor with lidocaine?

A) 1:50,000 B) 1:100,000 C) 1:200,000 D) 1:1,000,000 Answer: B Objective: 4 20) The elimination half-life of lidocaine is: A) 6 minutes B) 16 minutes C) 96 minutes D) 300 minutes Answer: C Objective: 4 21) What is the elimination half-life of mepivacaine?

A) 0.5 hours B) 1.0 hours C) 1.6 hours D) 1.9 hours Answer: D Objective: 4 22) Which of the following drugs has the shortest duration of action?

A) Mepivacaine 3% B) Bupivacaine 0.5%, 1:200,000 epinephrine C) Prilocaine 4%, 1:200,000 epinephrine D) Lidocaine 2%, 1:100,000 epinephrine Answer: A Objective: 4 23) Which of the following drugs has the shortest duration of action?

A) Mepivacaine 3% plain B) Bupivacaine 0.5%, 1:200,000 epinephrine

C) Prilocaine 4%, 1:200,000 epinephrine D) Lidocaine 2% plain Answer: D Objective: 4 24) Which anesthetic provides pulpal anesthesia for 10 minutes for an infiltration technique and 60 minutes for a block injection?

A) Lidocaine B) Mepivacaine, 1:20,000 levonordefrin C) Prilocaine plain D) Prilocaine, 1:200,000 epinephrine Answer: C Objective: 4 25) What is the clinical significance of prilocaine's pKa of 7.9?

A) Stronger vasodilator than mepivacaine B) Slightly slower onset compared to lidocaine C) Less toxicity compared to lidocaine D) Higher risk of methemoglobinemia Answer: B Objective: 4 26) What is the duration of action of articaine with 1:200,000 epinephrine?

A) 30 to 45 minutes pulpal anesthesia B) 45 to 60 minutes pulpal anesthesia C) 60 to 90 minutes pulpal anesthesia D) 120 to 300 minutes of pulpal anesthesia Answer: B Objective: 4 27) The correct maximum recommended dose for articaine is: A) 3.2 mg/lb B) 4 mg/kg C) 7 mg/lb D) 400 mg per appointment Answer: A Objective: 4 28) What is the clinical significance of the rapid half-life of articaine?

A) There is half the risk for a lingual paresthesia to occur.

B) There is a low allergy potential.

C) Half of its metabolites are excreted unchanged; therefore, there is less risk of toxicity.

D) It can be reinjected sooner than the other dental injectable drugs due to its rapid half-life.

Answer: D Objective: 4 29) Which local anesthetic drug is appropriate for extended periods of postoperative pain

control?

A) Bupivacaine B) Mepivacaine C) Lidocaine D) Prilocaine Answer: A Objective: 4 30) What is the absolute maximum recommended dose of bupivacaine?

A) 25 mg B) 35 mg C) 45 mg D) 90 mg Answer: D Objective: 4 31) What are the two key considerations that determine the duration of action of bupivacaine?

A) Biotransformation and elimination B) Distribution and volume C) Receptor binding strength and vasoactivity D) Receptor binding and biotransformation Answer: C Objective: 4 32) What is the FDA pregnancy category of lidocaine?

A) A B) B C) C D) B or C depending on dose administered Answer: B Objective: 5 33) Which drug can reduce the blood's oxygen-carrying capacity, which may lead to a specific anemia known as methemoglobinemia?

A) Lidocaine B) Bupivicaine C) Mepivacaine D) Prilocaine Answer: D Objective: 5 34) The risk of methemoglobinemia may be precipitated by which one of the following drugs?

A) Mepivacaine B) Lidocaine C) Bupivacaine D) Prilocaine Answer: D

Objective: 5 35) Which local anesthestic drug is the best choice for a nursing mother?

A) Lidocaine B) Articaine C) Mepivacaine D) Prilocaine Answer: B Objective 5 36) Which is the best reason why articaine is the local anesthetic drug of choice for a nursing mother?

A) It is quickly biotransformed in the liver by hepatic enzymes B) It is quickly biotransformed by pseudocholinesterase C) It is not available in breast milk D) It has a half-life of approximately 3 hours Answer: B Objective 5 37) What is the best choice of drug(s) for a patient taking a beta blocker for hypertension that will provide the longest duration of action?

A) 2% lidocaine B) 2% mepivacaine, 1:20,000 levonordefrin C) 3% mepivacaine D) 4% articaine; 1:200,000 epinephrine Answer: C Objective 5 38) Which one of the following explains why mepivacaine is capable of providing 20 to 40 minutes of pulpal anesthesia without a vasoconstrictor?

A) Low percentage of drug in the cartridge B) Strong vasodilation activity C) Weak vasodilation activity D) Greater potency Answer: C Objective: 6 39) Which of the following explains why mepivacaine is effective for short durations without a vasoconstrictor?

A) Strong vasodilator property B) Strong protein binding capacity C) Weak vasodilator property D) Equal in potency to lidocaine Answer: C Objective 6 40) Mepivacaine is similar to lidocaine although its chemical structure more closely resembles

A) Prilocaine B) Procaine C) Articaine D) Bupivacaine Answer: D Objective: 7 41) Which of the following drug choices would provide the most vigorous hemostasis for a periodontal surgical procedure?

A) 4% articaine, 1:100,000 epinephrine B) 2% lidocaine, 1:50,000 epinephrine C) 2% mepivacaine, 1:20,000 levonordefrin D) .5% bupivacaine, 1:200,000 epinephrine Answer: B Objective: 8 42) Which of the following drugs is most appropriate for a patient with significant liver and cardiovascular compromise for a root planing procedure in the lower right quadrant?

A) 4% articaine, 1:200,000 epinephrine B) 3% mepivacaine, 1, 20, 000 levonordefrin C) 3% mepivacaine plain D) 4% articaine, 1:100,000 epinephrine Answer: A Objective: 8 Diagram/figure identification 1) Identify the following local anesthetic drug.

Answer: Lidocaine Objective: 2 2) Identify the following local anesthetic drug.

Answer: Procaine Objective: 2

3) Identify the following local anesthetic drug.

Answer: Prilocaine Objective: 2 4) Identify the following local anesthetic drug.

Answer: Bupivacaine Objective: 2 5) Identify the following local anesthetic drug.

Answer: Articaine Objective: 2

6) Identify the following local anesthetic drug.

Answer: Mepivacaine Objective: 2

Chapter 6 Vasoconstrictors in Dentistry Match the following A) Adrenaline B) Mimics sympathetic mediators C) Smooth muscle relaxation D) Vasoconstrictor not used in dentistry E) Tissues or cellular receptors that respond to adrenaline F) Synthetic catecholamine G) Cardiac stimulation H) Adrenal gland neurotransmitters I) Epinephrine and norepinephrine J) Smooth muscle contraction 1) Adrenergic Objective: 1 2) Alpha receptor Objective: 1 3) Beta1 receptor Objective: 1 4) Beta2 receptor Objective: 1 5) Catecholamines Objective: 1 6) Epinephrine Objective: 1 7) Levonordefrin Objective: 1 8) Norepinephrine Objective: 1 9) Sympathomimetic Objective: 1 10) Vasopressors Objective: 1

Answers: 1) E 2) J 3) G 4) C 5) H 6) A 7) F 8) D 9) B 10) I True or false 1) Epinephrine, levonordefrin, and phenylephrine are catecholamines.

A) True B) False Answer: B Explanation: B) Epinephrine and levonordefrin are catecholamines. Phenylephrine is a noncatecholamine.

Objective: 2 2) All vasoconstrictors in dentistry stimulate adrenergic receptors.

A) True B) False Answer: A Objective: 2 3) Epinephrine and norepinephrine are indirect-acting sympathomimetic drugs.

A) True B) False Answer: B Explanation: B) Both epinephrine and norepinephrine are direct-acting vasopressors.

Objective: 2 4) Epinephrine provides almost equal alpha and beta effects; however, beta effects initially predominate to vasoconstrict vessels.

A) True B) False Answer: B Explanation: B) Epinephrine provides almost equal alpha and beta effects; however, alpha effects initially predominate to vasoconstrict vessels.

Objective: 2 5) All vasopressors stimulate adrenergic receptors.

A) True B) False Answer: A Objective: 2 6) Vasoconstrictors speed the absorption of local anesthetic drugs.

A) True B) False Answer: B Explanation: B) Vasoconstrictors slow the absorption of local anesthetic drugs.

Objective: 3

7) Signs and symptoms of epinephrine overdose include confusion and drowsiness, and are short lived due to the efficiency of epinephrine metabolism.

A) True B) False Answer: B Explanation: B) Signs and symptoms of epinephrine overdose include nausea, restlessness, a racing heart, severe headaches, palpitations, tremors, and shakiness. Confusion and drowsiness may be related to an overdose of the local anesthetic drug. Reactions to epinephrine overdose are typically short due to the efficiency of epinephrine metabolism.

Objective: 4 8) Vasoconstrictors have been associated with more drug interactions than any other drugs in dentistry.

A) True B) False Answer: A Objective: 4 9) Most adverse effects with the use of vasoconstrictors are short lived and easily managed.

A) True B) False Answer: A Objective: 4 10) High blood pressure is always a contraindication to the use of vasoconstrictors in dentistry.

A) True B) False Answer: B Explanation: B) Avoiding vasoconstrictors based on their impact on blood pressure alone may be misguided. Use of a local anesthetic drug without a vasoconstrictor may not provide profound or durable anesthesia. The lack of profound anesthesia can result in unmanageable pain, which, in turn, can lead to a spike in blood pressure due to the release of endogenous epinephrine in response to the pain. This endogenous release may be greater than administered doses of epinephrine.

Objective: 4 11) Epinephrine may be contraindicated for patients with a previous history of stroke, radiation therapy, or brittle diabetes.

A) True B) False Answer: A Objective: 4 12) Levonordefrin is one-tenth as potent as epinephrine.

A) True B) False

Answer: B Explanation: B) Levonordefrin is approximately one-sixth as potent as epinephrine.

Objective: 5 13) Cardiac stimulation from levonordefrin is less compared to epinephrine.

A) True B) False Answer: A Objective: 5 14) Levonordefrin is a stronger vasoconstrictor compared to epinephrine because its primary action is 75% alpha.

A) True B) False Answer: B Explanation: B) Levonordefrin is a weaker vasoconstrictor compared to epinephrine. Although its primary action is 75% alpha, it has only one-sixth the potency of epinephrine.

Objective: 5 15) Levonordefrin is less potent than epinephrine therefore it is formulated as 1:20,000.

A) True B) False Answer: A Explanation: A) Levonordefrin is less potent than epinephrine therefore it is formulated as 1:20,000.

Objective: 5 Fill in the blank 1) The two vasopressors routinely used in dental local anesthetic drugs in North America are and .

Answer: epinephrine, levonordefrin.

Objective: 2 2) Epinephrine is an example of a Answer: direct-acting Objective: 2

sympathomimetic drug.

3) receptors are responsible for smooth muscle contraction in peripheral arteries and veins.

Answer: Alpha1 Objective: 2 4) receptors are responsible for cardiac stimulation.

Answer: Beta1 Objective: 2 5)

receptors are responsible for smooth muscle relaxation such as bronchodilation and

vasodilatation.

Answer: Beta2 Objective: 2 6) Two receptors contribute to the potential for cardiac dysrhythmias. They are .

Answer: beta1, beta2 Objective: 2 7) When vasoconstrictors are used, care should be taken to avoid vessels.

Answer: intravascular injection Objective: 2 8) The maximum dose of epinephrine for a healthy adult is Answer: 0.2 mg Objective: 4

and

or injection into

per appointment.

9) The maximum dose of epinephrine for a patient with cardiovascular compromise is per appointment.

Answer: 0.04 mg Objective: 4 10) Norepinephrine has a greater tendency to induce tissue necrosis compared with epinephrine and levonordefrin, especially on the .

Answer: palate Objective: 5 Multiple choice 1) Which of the following best explains why vasoconstrictors are effective in increasing durations for local anesthesia?

A) Primary action on alpha receptors causes contraction of smooth muscles in blood vessels B) Primary action on alpha and beta receptors causes contraction of smooth muscles in blood vessels C) Primary action of beta receptors causes initial contraction of smooth muscles in blood vessels followed by vasodilation of blood vessels D) Primary action on alpha receptors causes initial vasodilation of the smooth muscle E) Answer: A Objective: 2 2) Which formulation of local anesthetic drug with levonordefrin is available in the United States today?

A) 2% lidocaine; 1:20,000 levonordefrin B) 4% prilocaine; 1:20,000 levonordefrin C) 2% mepivacaine; 1:20,000 levonordefrin D) 3% mepivacaine; 1:20,000 levonordefrin

Answer: C Objective: 2 3) Which statement correctly describes the adrenergic actions of levonordefrin?

A) 50% alpha, 50% beta B) 75% alpha, 25% beta C) 25% beta, 75% alpha D) 90% alpha, 10% beta Answer: B Objective: 2 4) Epinephrine is metabolized by: A) COMT and MOA B) hepatic enzymes C) renal isoenzymes D) COMT only Answer: A Objective: 2 5) Levonordefrin is biotransformed by: A) COMT and MOA B) hepatic enzymes C) renal 450 isoenzymes D) COMT primarily Answer: D Objective: 2 6) A one-hour root planing appointment is planned for a patient with significant cardiovascular compromise. Which of the following drugs would be safest and still have adequate duration?

A) 3% mepivacaine plain B) 4% prilocaine, 1:200,000 epinephrine C) 2% lidocaine, 1:50,000 epinephrine D) 2% mepivacaine, 1:20,000 levonordefrin Answer: B Objective: 3 7) Which of the following is not an indication for the use of a vasoconstrictor?

A) Reducing the risk of toxicity of local anesthetic drugs B) Prolonging the duration of local anesthetic drugs C) Providing hemostasis D) Providing vasodilatation following treatment Answer: D Objective: 4 8) Which of the following vasoconstrictors is the most useful in providing hemostasis?

A) Levonordefrin B) Felypressin

C) Epinephrine D) Phenylephrine Answer: C Objective: 4 9) What is the maximum dose of epinephrine per appointment for a healthy adult?

A) 1.8 mg B) 0.2 mg C) 0.4 mg D) 4.0 mg Answer: B Objective: 4 10) What is the maximum dose of epinephrine a patient with significant cardiovascular disease should receive in an appointment?

A) 1.8 mg B) 0.2 mg C) 0.04 mg D) 0.004 mg Answer: C Objective: 4 11) Which of the following drugs would be the safest for a patient with cardiovascular disease?

A) 4% articaine, 1:200,000 epinephrine B) 2% mepivacaine,1:20,000 levonordefrin C) 2% lidocaine, 1:50,000 epinephrine D) 4% prilocaine plain Answer: D Objective: 4 12) Which of the following medical conditions does not require precautions when using vasoconstrictors?

A) Liver disease B) Diabetes with significant cardiovascular disease C) Radiation therapy of the jaws D) Cerebrovascular accident/stroke Answer: A Objective: 4 13) Which of the following is not a sign or symptom of an epinephrine overdose reaction?

A) Nausea B) Heart racing C) Bronchospasm D) Weakness Answer: C Objective: 4

14) Which vasoconstrictor should be considered for a patient with diabetes and poorly-controlled blood sugar levels when hemostasis is not needed?

A) Epinephrine 1:50,000 B) Epinephrine 1:100,000 C) Levonordefrin 1:20,000 D) Felypressin Answer: C Objective: 4 15) A crown preparation for tooth #19 is planned for a patient who takes a tricyclic antidepressant. Which of the following drugs represents the best choice for this procedure?

A) 4% prilocaine, 1:200:000 epinephrine B) 4% articaine, 1:100,000 epinephrine C) 2% mepivacaine, 1:20,000 levonordefrin D) 0.5% bupivacaine, 1:200,000 epinephrine Answer: A Objective: 4 16) Which one of the following patients has a relative contraindication for vasoconstrictor?

A) Heart attack 2 years ago with no current complications B) Controlled hyperthyroid condition C) Non-selective beta blocker medication D) Controlled blood sugars Answer: C Objective: 4 17) Compare the potency of levonordefrin to the potency of epinephrine.

A) Levonordefrin is one fourth as potent B) Levonordefrin is one sixth as potent C) Levonordefrin is twice as potent D) Levonordefrin is six times as potent Answer: B Objective: 5 Short answer/essay 1) A patient calls approximately six hours after a tooth extraction to report an increase in bleeding. What is a likely cause of the increased bleeding?

Answer: Epinephrine provides nearly equal α and β effects; however, not at the same time. Initial α vasoconstriction of peripheral vasculature allows time for the anesthetic drugs to bind to receptor sites. Later, β2 vasodilatation predominates. This has been observed before and after surgery when epinephrine has been administered. Initially, the α effect enhances profound, durable anesthesia and reduces hemorrhaging at surgical sites. Postoperatively, the dominant β2 effects can result in increased bleeding approximately six hours after surgery.

Objective: 2

2) How do vasoconstrictors enhance the effects of local anesthetic drugs?

Answer: Vasoconstrictors enhance local anesthetic drugs by constricting local vessels, slowing systemic absorption, and prolonging the local actions of the drugs. These combine to increase the profoundness and durations of the drugs.

Objective: 3 3) Explain why the avoidance of vasoconstrictor may cause increase risk for a patient with high blood pressure?

Answer: The lack of profound anesthesia can result in unmanageable pain that in turn can lead to unpredictable spikes in blood pressure due to the endogenous release of epinephrine. The impact of the potential endogenous release is far less predictable due to the difficulty in anticipating quantities that might be released. This release can compound the adverse adrenergic effects of exogenous (injected) epinephrine.

Objective: 4 4) Explain why the lack of profound anesthesia can result in a spike in blood pressure?

Answer: The lack of profound anesthesia can result in unmanageable pain which, in turn, can lead to a spike in blood pressure due to the release of endogenous epinephrine in response to the pain. This endogenous release may be much greater than typical doses of administered epinephrine (exogenous).

Objective: 3

Chapter 7 Dose Calculations for Local Anesthetic Solutions Match the following A) MRD 90 mg B) MRD 0.04 mg C) 3.2 mg/lb D) 3.6 mg/lb E) MRD 500 mg F) 54 mg/cartridge G) Based on child's weight H) 1.8 ml I) MRD 1.0 mg J) Based on child's age 1) Articaine Objective: 1, 3, 5 2) Bupivacaine Objective: 1, 3, 5 3) Cardiac dose Objective: 1, 3, 5 4) Cartridge volume Objective: 1, 3, 5 5) Clark's rule Objective: 1, 3, 5 6) Levonordefrin Objective: 1, 3, 5 7) Lidocaine Objective: 1, 3, 5 8) Mepivacaine Objective: 1, 3, 5 9) Prilocaine Objective: 1, 3, 5 10) Young's rule Objective: 1, 3, 5

Answers: 1) C 2) A 3) B 4) H 5) G 6) I 7) E 8) F 9) D 10) J True or false 1) The maximum recommended dose for each solution is dependent on the drug that limits the total volumes that may be delivered.

A) True B) False Answer: A Objective: 2 2) In solutions containing both a local anesthetic and a vasoconstrictor drug, the maximum recommended dose of the local anesthetic is usually the limiting drug.

A) True B) False Answer: B Objective: 3 3) The maximum safe dose of 1:50,000 epinephrine per appointment for a healthy adult is 0.2 mg or 5.5 cartridges.

A) True B) False Answer: A Objective: 3 4) At a concentration of 4%, the amount of drug in a 1.8 ml cartridge is 7.2 mg.

A) True B) False Answer: B Explanation: B) At a concentration of 4%, the amount of drug in a 1.8 ml cartridge is 72 mg 4% solution = 40 mg/ml x 1.8 = 72 mg/cartridge Objective: 4 5) At a concentration of 0.5%, the amount of drug in a 1.8 ml cartridge is 9 mg.

A) True B) False Answer: A Objective: 4 6) To calculate the milligrams of drug delivered, multiply the total number of cartridges by the total milligrams of drug in each cartridge.

A) True B) False Answer: A Objective: 4 7) When two different drugs are injected, the total of the MRDs for both drugs is the maximum

number of milligrams of drugs the patient may receive.

A) True B) False Answer: B Explanation: B) When multiple drugs are administered with different MRDs, the lowest MRD (most toxic drug) is applied when calculating total drug doses.

Objective: 5 8) Calculations of maximum safe doses for vasoconstrictors are determined by mg/lb or mg/kg.

A) True B) False Answer: B Explanation: B) Calculations of vasoconstrictor doses are different compared to those used to determine local anesthetic drug doses. The main differences are that vasoconstrictors are expressed as dilution ratios rather than concentration percentages and maximum doses of vasoconstrictors are not weight dependent.

Objective: 5 9) The maximum safe dose of 1:200,000 epinephrine per appointment for a patient with ischemic heart disease is 0.4 mg or 1.1 cartridges.

A) True B) False Answer: B Explanation: B) The maximum safe dose of 1:200,000 epinephrine per appointment for a patient with ischemic heart disease is 0.04 mg or 4 cartridges (about 4.4, rounded down for safety to 4).

Objective: 5 10) Clark's rule for determining pediatric drug doses is based on a child's weight divided by 150 to get the approximate fraction of the adult dose.

A) True B) False Answer: A Objective: 5 Fill in the blank 1) The maximum recommended dose per appointment for bupivacaine is Answer: 90 mg Objective: 3 2) The maximum recommended dose per appointment for lidocaine is Answer: 500 mg Objective: 3 3) The maximum mg/lb of mepivacaine per appointment is Answer: 3.0 Objective: 3

.

.

.

4) The maximum mg/lb of prilocaine per appointment is Answer: 3.6 Objective: 3

.

5) A 10% solution contains one tenth of a milligram per milliliter or Answer: 100 Objective: 5 6) A 2% solution of lidocaine contains Answer: 20 Objective: 5

mg/ml.

7) A 2% solution of lidocaine contains Answer: 36 Objective: 5

mg/cartridge.

8) A 3% solution of mepivacaine contains Answer: 30 Objective: 5

mg/ml.

9) A 3% solution of mepivacaine contains Answer: 54 Objective: 5

mg/cartridge.

mg/ml.

10) Ralph weighs 175 lb. He has received 72 mg of 2% lidocaine. Ralph can receive a maximum of mg additional lidocaine.

Answer: 428 Objective: 5 11) Susan is a healthy patient and weighs 130 lb. She has received 54 mg of 3% mepivacaine.

She could receive a maximum of mg of 4% prilocaine, 1:200,000 epinephrine.

Answer: 336 Objective: 5 Multiple choice 1) The MRD for bupivacaine is: A) 200 mg B) 90 mg C) 300 mg D) 500 mg Answer: B Objective: 3 2) Which of the following information for MRD is not correct?

A) Bupivacaine = 90 mg B) Lidocaine = 500 mg

C) Mepivacaine = 300 mg D) Prilocaine = 600 mg Answer: C Objective: 3 3) What is the MRD of vasoconstrictor for 2% lidocaine, 1:100,000 epinephrine for a healthy patient?

A) 0.02 mg B) 2.0 mg C) 1.0 mg D) 0.2 mg Answer: D Objective: 3 4) What is the MRD in cartridges for 4% prilocaine, 1:200,000 epinephrine for a healthy 150 pound patient?

A) 5 B) 6 C) 8 D) 11 Answer: C Objective: 3 5) How many milligrams of epinephrine 1:50,000 are available in one cartridge?

A) 0.018 mg B) 0.050 mg C) 0.036 mg D) 0.2 mg Answer: C Objective: 3 6) How many milligrams of epinephrine 1:200,000 are available in two cartridges?

A) 0.018 B) 0.18 C) 0.036 D) 0.016 Answer: A Objective: 3 7) Which of the following pieces of information is not usually required in order to calculate safe doses for local anesthetics and vasoconstrictors?

A) Patient factors such as height, weight, and age B) Standard cartridge volume and dilution percentages C) Maximum recommended dose and patient weight D) Concentration of drug and dilution percentages Answer: A Objective: 4

8) A 150-pound patient has received two cartridges of 2% lidocaine, 1:100,000 epinephrine.

How many additional cartridges with the same drugs can be administered before reaching the MRD? A) 5 B) 6 C) 9 D) 11 Answer: C Objective: 5 9) A 120-pound patient has received three cartridges of 4% prilocaine, 1:200:000 epinephrine.

How many more milligrams of prilocaine can this patient receive before reaching the MRD? A) 72 mg B) 216 mg C) 432 mg D) 600 mg Answer: B Objective: 5 10) A healthy 160-pound patient has received three cartridges of 2% lidocaine, 1:50,000 epinephrine during an oral surgical procedure. How many more cartridges with the same drug could this patient receive before reaching the MRD? A) 2 B) 5 C) 8 D) 10 Answer: A Objective: 5 11) A patient has received four cartridges of 4% articaine, 1:200,000 epinephrine. How many milligrams of vasoconstrictor has the patient received?

A) 0.018 B) 0.036 C) 0.072 D) 0.36 Answer: B Objective: 5 12) A 180-pound patient has received three cartridges of 2% lidocaine, 1:100,000 epinephrine.

How many additional milligrams of 4% articaine, 1:200,000 epinephrine can be administered before reaching the MRD? A) 72 mg B) 192 mg C) 228 mg D) 392 mg Answer: D

Objective: 5 13) A 120-pound patient has received 2 cartridges of 2% mepivacaine, 1:20,000 and does not remain adequately numb during the procedure. How many additional cartridges of 2% lidocaine, 1:100,000 epinephrine may the patient receive before reaching the MRD? A) 6 B) 9 C) 11 D) 13 Answer: B Objective: 5 14) What is the MRD of levonordefrin for a 210 pound male patient with ischemic heart disease?

A) 0.02 mg B) 0.2 mg C) 0.04 mg D) 0.4 mg Answer: B Objective: 5 15) A patient with cardiovascular disease has received one cartridge of 2% lidocaine, 1:100:000 epinephrine. How many milligrams of vasoconstrictor has this patient received? How many additional milligrams of vasoconstrictor can the patient receive before reaching MRD? A) 0.018 mg received; 0.022 mg additional B) 0.009 mg received; 0.391 mg additional C) 0.36 mg received; 0.4 mg additional D) 0.18 mg received; 0.22 mg additional Answer: A Objective: 5 16) A patient with cardiovascular disease has received two cartridges of 4% articaine, 1:200:000 epinephrine. How many milligrams of vasoconstrictor has this patient received? How many additional cartridges of the same drug solution can the patient receive?

A) 0.009 mg received; two additional cartridges B) 0.018 mg received; two additional cartridges C) 0.18 mg received; no additional cartridges D) 0.036 mg received; no additional cartridges Answer: B Objective: 5 17) Using Clark's rule, calculate the milligrams of 2% lidocaine an 8-year old, 60 pound child can receive before reaching MRD. A) 60 mg B) 120 mg C) 200 mg D) 300 mg Answer: C

Objective: 5 18) Using Clark's rule, a 12-year old, 90 pound child has received two cartridges of 2% lidocaine. How many more cartridges of lidocaine can this child receive before reaching MRD? A) 3 B) 6 C) 7 D) 8 Answer: B Objective: 5 19) Using Clark's rule, calculate the maximum number of milligrams of 3% mepivacaine a 5year old, 40-pound child can receive before reaching the MRD? A) 40 mg B) 80 mg C) 106 mg D) 117 mg Answer: C Objective: 5 20) Using Young’s rule, calculate the mg of 2% lidocaine a 10-year old, 60-pound child can receive before reaching the MRD? A) 125 mg B) 136 mg C) 200 mg D) 227 mg Answer: D Objective: 5 Short answer/essay 1) What is the MRD of 4% prilocaine plain for a healthy 205 pound male patient?

Answer: The MRD for prilocaine plain is 3.6 mg/lb, with a maximum of 600 mg per appointment. Based on 3.6 mg/lb a 205 lb patient the MRD would be 656 mg, however the 600 mg per appointment should not be exceeded.

Objective: 3 2) What factors are needed to calculate the local anesthetic drug dose delivered for a given patient?

Answer: The following factors are needed: number of milligrams of drug delivered, number of cartridges delivered, MRD for the drug delivered, and weight of the patient.

Objective: 4 3) A 140-pound patient received 144 mg of 2% lidocaine plain. How many more milligrams of the same drug can the patient receive without exceeding the MRD? Provide mathematical formulas required to calculate the correct answer.

Answer: The MRD for 2% lidocaine plain is 3.2 mg/lb with a maximum of 500 mg per appointment. This patient can receive a total of 3.2 mg/lb which equals 448 mg maximum per

appointment. (3.2 x 140 = 448). Next, subtract mg of drug received from MRD (448 - 144 = 334 mg). The patient can receive an additional 334 mg of 2% lidocaine plain.

Objective: 4 4) A 180-pound patient received 108 mg of 3% mepivicaine. How many cartridges were used?

Provide mathematical formulas required to calculate the correct answer.

Answer: A 3% solution ml/cartridge equals 30 mg/ml. Compute the mg of 3% mepivicaine in one cartridge by multiplying 30 ml/cartridge by ml in one cartridge (30 x 1.8 = 54 mg). Next divide 108 mg received by mg/ml in each cartridge of 3% mepivicaine (108 ÷ 54 = 2). A total of two cartridges of 3% mepivicaine were received.

Objective: 4 5) A 120-pound patient received 108 mg of 2% lidocaine. How many mg of 4% articaine can this patient receive? Provide mathematical formulas to calculate the correct answer.

Answer: The MRD for 2% lidocaine is 3.2 mg/lb with a maximum of 500 mg per appointment.

The MRD for 4% articaine is 3.2 mg/lb with no determined maximum per appointment. When considering the MRD for more than one drug, the lowest MRD should be used in calculating the second drug's MRD. In this case the MRD is the same for both drugs therefore, 284 mg is the MRD. (3.2 x 120 = 284). Next subtract mg of 2% lidocaine received from MRD (284 – 108 = 176). The patient can receive 176 mg of 4% articaine.

Objective: 5 6) Complete the missing information in the table below.

Maximum Recommended Dose per Appointment Based on Local Anesthetic Drug ONLY* Drug

mg/lb

mg/kg

mg per appt.*

Articaine

3.2

7.0

-

Bupivacaine

0.9**

2.0**

mg

Lidocaine Mepivacain

3.0

7.0

500 mg

6.6

mg

8.0

600 mg

e Prilocaine

*Note: “per appt.” values represent dosages for healthy individuals, Values must be adjusted for children, elderly, and medically compromised individuals. ** Canadian recommendations. No U.S. recommendations are available Source: FDA, ADA/PDR, 5th ed., 2009; Malamed, 6th ed. 2013.

Answer: See bold numbers in table below Maximum Recommended Dose per Appointment Based on Local Anesthetic Drug ONLY* Drug

mg/lb

mg/kg

mg per appt.*

Articaine

3.2

7.0

-

Bupivacaine

0.9**

2.0**

90 mg

Lidocaine

3.2

7.0

500 mg

Mepivacain

3.0

6.6

400 mg

3.6

8.0

600 mg

e Prilocaine

*Note: “per appt.” values represent dosages for healthy individuals, Values must be adjusted for children, elderly, and medically compromised individuals. ** Canadian recommendations. No U.S. recommendations are available Source: FDA, ADA/PDR, 5th ed., 2009; Malamed, 6th ed. 2013 Objective: 3

Chapter 8 Topical Anesthetics Match the following A) Formulated B) Benzocaine, butamben, and tetracaine C) Common ester D) Preservative E) Ketone F) Air propelled G) Most potent topical H) Subgingival placement I) Metabolite J) Common amide 1) Benzocaine Objective: 1 2) Cetacaine Objective: 1 3) Compounded Objective: 1 4) Dyclonine Objective: 1 5) Jet injector Objective: 1 6) Lidocaine Objective: 1 7) Methylparaben Objective: 1 8) Oraqix Objective: 1 9) Para-aminobenzoic acid Objective: 1 10) Tetracaine Objective: 1

Answers: 1) C 2) B 3) A 4) E 5) F 6) J 7) D 8) H 9) I 10) G True or false 1) The variety of application methods for topical anesthetic drugs complicates the safety of their use.

A) True B) False Answer: A Objective: 2 2) Benzocaine topical exists nearly 100% in the base form and is poorly absorbed into the systemic circulation.

A) True B) False Answer: A Objective: 3 3) The most common concentration of benzocaine topical is 20%, which will provide a 30 second onset of anesthesia with peak effectiveness in approximately 2 minutes.

A) True B) False Answer: A Objective: 3 4) Compared to injectable local anesthetic drugs, topical products do not require MRDs because they are potentially less toxic.

A) True B) False Answer: B Explanation: B) MRDs do not exist for many topical products. Since they are formulated in concentrations exceeding those approved for use in injectable local anesthetic drugs, topical preparations are potentially more toxic.

Objective: 4 5) Benzocaine topical can induce methemoglobinemia.

A) True B) False Answer: A Objective: 5 6) Precautions for toxicity increase when topical anesthetic is applied to abraded tissue.

A) True B) False Answer: A

Objective: 5 7) Cetacaine is a eutectic mixture of lidocaine, butamben, and tetracaine.

A) True B) False Answer: B Explanation: B) Cetacaine is a eutectic mixture of benzocaine, butamben, and tetracaine.

Objective: 6 8) The advantages of Cetacaine are its low risk of allergy, rapid onset, and long duration of anesthesia.

A) True B) False Answer: B Explanation: B) The advantages of Cetacaine are its rapid onset and long duration. Cetacaine is formulated with benzocaine, tetracaine, and butamben. All three drugs are esters. The potential for allergy to para-aminobenzoic acid (PABA), a metabolite of benzocaine, does exist.

Objective: 6 9) Compounding rules for topical anesthetics allow multidose packaging for use with multiple patients.

A) True B) False Answer: B Explanation: B) The compounded product must be individually prescribed for an identified patient. It is contrary to the act to acquire a multidose package intended for patients yet to be identified.

Objective: 7 Fill in the blank 1) Topical anesthetics are most commonly used Answer: prior to needle insertion Objective: 2 2) The onset of action for benzocaine is Answer: 30 seconds Objective: 2 3) The duration of action for benzocaine is up to Answer: 15 minutes Objective: 2

.

.

.

4) A topical anesthetic is a liquid at room temperature and a gel when placed in the gingival sulcus.

Answer: two-phase

Objective: 2 5) Benzocaine is available in a range of Answer: six, twenty Objective: 3

to

6) The FDA pregnancy category for benzocaine is Answer: C Objective: 3

% formulations.

.

7) Overdose reactions from lidocaine topical are similar to injectable forms with progression to CNS without the initial excitation phase.

Answer: depression Objective: 5 8) A combination of anesthetic drugs is known as a Answer: eutectic mixture Objective: 6

.

9) Three ester drugs, benzocaine, butamben, and tetracaine are formulated together in topical anesthetic.

Answer: Cetacaine Objective: 6 Multiple choice 1) Which of the following is not an indication for topical anesthetic drugs in dentistry?

A) Needle penetration B) Radiographic film placement C) Periodontal evaluation D) Sedation Answer: D Objective: 2 2) Which of the following application methods are considered safest when preventing toxicity?

A) Metered sprays and single dose application systems B) Patches and metered sprays C) Gels and liquids D) Swabs and two-phase applications Answer: B Objective: 2 3) Which of the following does not contribute to the toxicity risk of topical anesthetic drugs?

A) Hydrophilic properties B) Higher concentrations C) Total applied dose

D) Application method Answer: A Objective: 3 4) Why do topical anesthetics require a higher concentration of drug than the same drug used as an injectable local anesthetic?

A) More base molecules of drug are needed to diffuse through membranes barriers B) They are less likely to produce toxicity when applied topically C) Decreased amounts are applied topically than when locally injected D) They do not contain vasoconstrictors Answer: A Objective: 4 5) Which of the following is not a typical sign of CNS toxicity related to overdoses of topical anesthetic drugs?

A) Shaking and agitation B) Talkativeness and excitedness C) Disorientation and drowsiness D) Loss of consciousness Answer: B Objective: 5 6) Which of the following topical anesthetic drugs is a eutectic mixture?

A) Dyclonine hydrochloride B) Benzocaine C) Cetacaine D) Butamben Answer: C Objective: 6 7) Which of the following eutectic mixtures is available as an intrapocket topical anesthesia?

A) Lidocaine B) Oraqix C) Cetacaine D) EMLA Answer: B Objective: 6 8) Which of the following is not a benefit of eutectic mixtures of anesthetic drugs for use in dentistry?

A) Greater depth of penetration on mucosa B) Higher concentrations of base forms of anesthetics C) Increased therapeutic range D) Typical pulpal anesthesia Answer: D Objective: 6

9) Oraqix is a eutectic mixture of which anesthetic drugs?

A) Benzocaine and lidocaine B) Lidocaine and cetacaine C) Prilocaine and lidocaine D) Prilocaine and benzocaine Answer: C Objective: 6 10) All of the following statements are true regarding compounded drugs, except: A) Compounded drugs are formulated for individuals for whom they are prescribed.

B) Compounded drugs may be used on other individuals as long as the use is the same as the original use.

C) Compounded drugs may contain much larger quantities of drug compared to multiuse commercial preparations.

D) Compounded topicals are dispensed by prescription.

Answer: B Objective: 7 Short answer/essay 1) List uses for topical anesthetic drugs in dentistry.

Answer: Topical anesthetic agents have many uses in dentistry. The most common is penetration site anesthesia prior to needle insertion. They are also useful for discomfort related to radiographic film placement, periodontal evaluation and treatment, procedures confined to superficial mucosa, the placement of retraction cord and rubber dams (when anesthesia has not been established prior to placement), and controlling gag reflexes.

Objective: 2 2) Why it is difficult to determine the administered dose of topical anesthetics drugs?

Answer: Unlike their injectable counterparts, maximum dose recommendations for many topical products do not exist. Even when manufacturers provide MRD information, clinicians often have difficulty determining how much was dispensed or absorbed. Compared to injectable administrations with calibrated cartridges containing specific concentrations of drugs, tracking topical dosages can be problematic. Patches and metered sprays offer more precise calculations as do some single-dose application systems. Liquids and gels in multiuse containers and nonmetered sprays present problems even if maximum doses are known because there is no easy way to determine how much was dispensed or how much was absorbed before being washed away in saliva.

Objective: 4 3) Describe the local adverse reactions to topical local anesthetic agents.

Answer: Local reactions with topical agents include tissue sloughing, delayed hypersensitivity, redness, pain, and burning at the sites of application.

Objective: 5

4) Identify symptoms of a systemic overdose of topical anesthetic drugs.

Answer: Overdoses may manifest as mild CNS depression (restlessness, agitation, and increased heart rate) or more severe CNS and CVS depression (unconsciousness, convulsions, decreased force of myocardial contraction, respiratory collapse, and cardiovascular collapse).

Objective: 5 5) Discuss the safety features of Oraqix.

Answer: The safety features of Oraqix include: 1. Low systemic toxicity with only 20 to 40% of the dispensed drug available systemically.

2. Ease of dose tracking compared to multidose packaging common with other topicals.

(Standard calculation methods can be used with the 1.7 mL fcartridges.)

3. A specialized safety collar prevents accidental placement of the cartridge into standard aspirating syringes, avoiding accidental submucosal injection of the drugs.

Objective: 6

Chapter 9 Local Anesthetic Delivery Devices Match the following A) Winged or wingless B) Angled tip of needle C) Penetrating end of piston D) Glass cylinder E) 32 mm F) Hollow part of needle G) 22 mm H) Aluminum cover on cylinder I) Hub J) Internal diameter of needle 1) Bevel Objective: 1 2) Cartridge Objective: 1 3) End cap Objective: 1 4) Finger grips Objective: 1 5) Gauge Objective: 1 6) Harpoon Objective: 1 7) Long needle Objective: 1 8) Short needle Objective: 1 9) Lumen Objective: 1 10) Needle adaptor Objective: 1 Answers: 1) B 2) D 3) H 4) A 5) J 6) C 7) E 8) G 9) F 10) I

True or false 1) The most common type of syringe used in dentistry is a disposable, breech-loading, selfaspirating, cartridge device.

A) True B) False Answer: B Explanation: B) The most common type of syringe used in dentistry is a nondisposable and sterilizable, breech-loading, manual aspiration, cartridge-type device.

Objective: 3 2) The large window of the syringe barrel should be positioned away from the clinician throughout the injection to prevent injury in the event the cartridge shatters during injection.

A) True B) False Answer: B Explanation: B) The large window of the syringe barrel should be positioned toward the clinician throughout the injection to provide for direct visibility of the cartridge throughout the injection procedure.

Objective: 4 3) The purpose of the harpoon on the piston is to engage the rubber stopper during injection to create a slightly positive pressure inside the cartridge during the aspiration test.

A) True B) False Answer: B Explanation: B) The purpose of the harpoon on the piston is to engage the rubber stopper during injection to create a slightly negative pressure inside the cartridge during the aspiration test.

Objective: 4 4) A 25 gauge needle has a larger internal diameter than a 30 gauge needle.

A) True B) False Answer: A Objective: 5 5) Dental cartridges in the United States contain a volume of 1.8 ml of solution, which means each stopper width displaces 0.2 ml of solution.

A) True B) False Answer: A Objective: 8 6) Large air bubbles in a cartridge of anesthetic solution are a normal result of the manufacturing process and pose no risk for use.

A) True

B) False Answer: B Explanation: B) Large bubbles can result when solutions have been frozen or contaminated.

Cartridges should be discarded when larger bubbles are noted below the cap when held vertically.

Objective: 8 7) Anesthetic cartridges containing vasoconstrictors should be stored in the dark.

A) True B) False Answer: A Objective: 8 8) Sodium chloride is added to local anesthetic solutions as a preservative for the vasoconstrictor drug.

A) True B) False Answer: B Explanation: B) A sulfite preservative is added to local anesthetic solutions that contain vasoconstrictors. Sodium chloride is used in all solutions to provide for isotonic tissue compatibility.

Objective: 8 9) Sulfite is added to local anesthetic solutions as a preservative for the vasoconstrictor drug.

A) True B) False Answer: A Objective: 8 10) Sodium chloride is added to local anesthetic solutions as a preservative for the anesthetic drug.

A) True B) False Answer: B Explanation: B) Sodium chloride is used in all solutions to provide for isotonic tissue compatibility. A sulfite preservative is added to local anesthetic solutions that contain vasoconstrictors.

Objective: 8 11) The shelf life of a local anesthetic solution without a vasoconstrictor is approximately 24 months.

A) True B) False Answer: A Objective: 8 12) The shelf life of a local anesthetic solution without a vasoconstrictor is approximately 12

months if stored in a dark container.

A) True B) False Answer: B Explanation: B) The shelf life of a local anesthetic solution without a vasoconstrictor is approximately 24 months. Storage in the dark is recommended.

Objective: 8 13) The required color-coding band for lidocaine with 1:100,000 epinephrine is red and the band for lidocaine with 1:50,000 epinephrine is green.

A) True B) False Answer: A Objective: 9 Fill in the blank 1) The term refers to all equipment, materials, and devices used during the delivery of local anesthetic agents.

Answer: armamentarium Objective: 1 2) The most common syringe design used in dentistry is the sterilizable, breech-loading, cartridge-type, syringe.

Answer: aspirating Objective: 3 3) Pistol grip and pen-type syringes are used for Answer: periodontal ligament Objective: 3

injections.

4) A device is a preprogrammed, electronic delivery system for the administration of local anesthetic injections.

Answer: Computer Controlled Local Anesthetic Delivery (CCLAD) Objective: 3 5) The is the part of the piston inside the syringe barrel that penetrates the stopper.

Answer: harpoon Objective: 4 6) Clinicians hold the syringe with the index and middle fingers on the finger grip to balance and control the of the syringe.

Answer: movement Objective: 4 7) Needles used in dentistry are identified by length and internal diameter, also called the of the needle.

Answer: gauge Objective: 5 8) Long needles in dentistry average Answer: 32 mm or 1.5 inches Objective: 5

in length.

9) Short needles in dentistry average Answer: 25 mm or 1 inch Objective: 5

in length.

10) Extra short needles in dentistry average Answer: 12 mm or 0.5 inch Objective: 5

in length.

11) Extra-short needles can be used when penetrations are shallow such as in injections.

Answer: palatal Objective: 6 12) Long needles are used when sites are a greater distance from the penetration site such as with mandibular (IA or GG) nerve block injections.

Answer: deposition Objective: 6 13) Cartridges in the United States contain a volume of Answer: 1.8 ml Objective: 7 14) Sodium chloride provides for Answer: isotonic Objective: 1 15) Distilled water is a solutions.

Answer: diluent Objective: 8

tissue compatibility in anesthetic solutions.

and serves as the majority component of local anesthetic

16) 4% prilocaine with 1:200,000 epinephrine has a Answer: yellow Objective: 9 17) 2% lidocaine plain has a Answer: light blue Objective: 9

of solution.

color-coded band on the cartridge.

color-coded band on the cartridge.

18) The standard aspirating syringe is designed to provide Answer: negative pressure

for aspiration.

Objective: 4 19) Local anesthetic solutions with vasoconstrictors should be stored in the Answer: dark Objective: 8

.

20) The shelf life of a local anesthetic solution without a vasoconstrictor is Answer: 24 months Objective: 8

.

21) The shelf life of a local anesthetic solution with a vasoconstrictor is Answer: 18 months Objective: 8

.

Multiple choice 1) Which of the following is not a feature of all CCLAD devices?

A) Precisely controls the rate of delivery of solutions B) Correctly identifies the deposition site C) Helps to reduce patient discomfort for palatal injections D) Can reduce the incidence of adverse tissue reactions Answer: B Objective: 3 2) Which of the following statements is correct?

A) The standard aspirating syringe is designed to provide negative pressure on aspiration unlike the self-aspirating syringe.

B) The standard aspirating syringe is designed to provide negative pressure on aspiration similar to the self-aspirating syringe.

C) The standard aspirating syringe is designed to provide positive pressure on aspiration unlike the self-aspirating syringe.

D) Neither the standard nor the self-aspirating syringes provides negative pressure on aspiration.

Answer: B Objective: 4 3) Which statement describes the correct method to ensure that the harpoon is seated in the stopper?

A) Press on the finger ring to ensure solution passes through the needle.

B) Pull back on the thumb, then the rubber stopper will retract.

C) Use firm hand pressure against the syringe ring.

D) Apply pressure on the needle cap.

Answer: B Objective: 4 4) Which statement does not accurately describe a needle used for dental local anesthesia?

A) Sterile stainless steel for single-patient use

B) Identified by length and diameter C) Plastic needle caps with standard color coding D) Available in 25, 27, and 30 gauge Answer: C Objective: 5 5) Which of the following needles gauges has the smallest lumen?

A) 23 B) 25 C) 27 D) 30 Answer: D Objective: 5 6) Which of the following needle gauges used in dentistry has the largest lumen?

A) 23 B) 25 C) 27 D) 30 Answer: B Objective: 5 7) Which of the following statements best describes the appropriate choice of needles for local anesthetic injections?

A) Use higher-gauge needles for injection techniques that require deep penetrations because the flexibility will allow for repositioning around soft tissue obstructions.

B) Use smaller gauge needles for injections that require deep penetrations because they are less flexible and the larger lumen provides for ease and accuracy of aspiration.

C) Use smaller gauge needles because they will cause less discomfort during injection compared to larger gauge needles.

D) All needles will work equally well for all injection techniques.

Answer: B Objective: 6 8) Which of the following is not correct when comparing a 25 gauge needle with a 30 gauge needle?

A) Permits better aspiration B) Has the same comfort level C) Has a smaller internal diameter and breaks more easily D) Allows less deflection during deeper penetrations Answer: C Objective: 6 9) What is the most likely cause of an extruded stopper on a cartridge?

A) Freezing during shipping or storage B) Pressure and expansion caused by overheating C) Cartridge was overfilled during manufacturing

D) Oxidation of sodium bisulfate creating gas in the cartridge Answer: A Objective: 7 10) How much anesthetic solution is delivered when four stopper widths are deposited?

A) 0.4 ml B) 0.6 ml C) 0.8 ml D) 7.2 ml Answer: C Objective: 7 11) What is the amount of anesthetic solution delivered in two stopper widths?

A) 0.4 ml B) 0.6 ml C) 0.8 ml D) 7.2 ml Answer: A Objective: 7 12) Small bubbles visible in cartridges of local anesthetic are the result of: A) Air bubbles trapped during manufacturing B) Overheating in cartridge warmers C) Contamination from storing cartridges in antiseptic solutions D) Oxidation of the vasoconstrictor in solutions Answer: A Objective: 7 13) A local anesthetic solution that has been overheated during shipping and handling will: A) Have small and large bubbles from the gas produced by heating B) Appear cloudy and/or sediment may be visible C) Have incompletely filled cartridges due to evaporation D) Have mostly broken cartridges in the container Answer: B Objective: 7 14) Which of the following contents in the cartridge is the preservative for epinephrine?

A) Sodium chloride B) Nitrogen gas C) Methylparaben D) Sodium bisulfite Answer: D Objective: 8 15) Which of the following contents in the cartridge provides isotonic tissue compatibility?

A) Sodium chloride

B) Distilled water C) Preservative D) Sodium bisulfite Answer: A Objective: 8 16) Which cartridge has a green band in the required ADA color-coding system?

A) 3% mepivacaine plain B) 4% prilocaine, 1:200,000 epinephrine C) 2% lidocaine plain D) 2% lidocaine, 1:50,000 epinephrine Answer: D Objective: 9 17) Which cartridge has a yellow band in the required ADA color-coding system?

A) 3% mepivacaine, 1:20,000 levonordefrin B) .5% bupicavaine, 1:200,000 epinephrine C) 4% articaine, 1:100,000 epinephrine D) 4% prilocaine, 1:200,000 epinephrine Answer: D Objective: 9 18) Which of the following does not meet OSHA standards to prevent needlestick injuries?

A) Placing needle in a cap in a cardboard card B) One-handed scoop into needle cap C) Passing the syringe to an assistant to cap D) Capping a needle in an upright holder Answer: C Objective: 10 Identify the labeled components for the devices shown in the figures below 1) Components of a syringe

A. B. C. D. E. F. G. H. Answer: A. Thumb ring B. Finger grip C. Spring D. Guide bearing E. Piston F. Harpoon G. Syringe barrel H. Needle adaptor Objective: 4 2) Components of a needle

A. B. C. D. E. F. Answer: A. Needle shaft B. Beveled tip C. Cartridge penetrating end D. Syringe adaptor E. Hub F. Needle cap Objective: 5 3) Components of a dental local anesthetic cartridge

A. B.

C. D. Answer: A. Cylindrical glass tube B. Stopper C. Aluminum cap D. Diaphragm Objective: 7 Short answer/essay 1) List the armamentarium appropriate for dental local anesthesia injections.

Answer: 1. Mouth mirror 2. Devices for safe needle recapping and disposal 3. Syringe devices 4. Cotton pliers or hemostat 5. Gauze squares for drying tissues and enhancing retraction 6. Cotton swabs for application of topical anesthetic agents and predetermination of penetration sites and angles 7. Needles of appropriate gauge and length 8. Cartridges of drugs 9. Topical anesthetic agents Objective: 2 2) Discuss advantages of CCLAD devises for local anesthesia.

Answer: Key advantages of CCLAD devises include the ability to precisely control the rate of delivery of anesthetic solutions. The initial phase of the injection can start at a very slow rate of delivery for a given period of time. The rate can then be increased to a predetermined rate based on the injection technique selected. These devices can maintain a specified rate and controlled pressure that can eliminate patient discomfort, and adverse tissue reactions when injections are needed in dense tissues, such as the palate, attached gingiva, or periodontal ligament. Greater volumes of solution can be deposited at controlled lower rates of pressure when compared to other PDL devices and standard syringes.

Objective: 3 3) What are the factors that clinicians use to determine the selection of needles for local anesthetic injections?

Answer: Factors impacting clinician choice are related to needle deflection, ease and accuracy of aspiration, and patient comfort.

Objective: 6 4) What information is listed on the mylar label of a cartridge?

Answer: Each label lists which local anesthetic and vasoconstrictor drug (when present) are contained in the cartridge. Both trade and generic drug names are provided, along with drug concentrations and dilutions of vasoconstrictor, the manufacturer, an expiration date, a local anesthetic drug color code band, and the lot number and bar code.

Objective: 7 5) What is the OSHA standard for the prevention of needlestick injuries?

Answer: "Recapping or needle removal must be accomplished through the use of a mechanical device or a one-handed technique," therefore clinicians are prohibited from managing needles with two-handed manual recapping techniques. Only one-handed methods of recapping may be employed.

Objective: 10 6) What is the appropriate response if a needlestick or other puncture injury occurs?

Answer: If a needlestick occurs, all anesthetic procedures and treatment should be terminated and the injured tissues immediately and thoroughly washed with soap and water. The facility's exposure manager should be notified while appropriate first aid is initiated. According to CDC guidelines, postexposure management should include documentation in both the patient's chart and the exposed individual's health record.

Objective: 10 Use the information provided in the Case Study below to answer the questions that follow.

Case Study The clinician has reached the deposition site for an inferior alveolar injection. In order to perform an aspiration test, the clinician pulls backwards with his or her thumb and is unable to aspirate.

The clinician tells the patient that he or she needs to withdraw the syringe and then carefully withdraws.

1) What is the first thing the clinician needs to do after withdrawing the syringe to ensure safety?

Answer: The clinician should safely recap the needle using a one-handed technique or a mechanical recapping device.

Objective: 3 2) Provide possible reasons the clinician was unable to aspirate.

Answer: The clinician neglected to seat the harpoon in the rubber stopper. The clinician did not ensure that the harpoon was seated in the rubber stopper before beginning the injection. The harpoon was dull and did not seat firmly in the rubber stopper and disengaged when pressure was applied to the thumb ring. The cartridge was loaded backwards in the barrel. The clinician pulled too firmly on the thumb ring and dislodged the harpoon from the stopper.

Objective: 3

Chapter 10 Patient Assessment for Local Anesthesia Match the following A) ASA B) Somewhat inadvisable C) Ibuprofen D) Amoxicillin E) Allergy F) Drugs used together G) Permission to treat H) Objective evaluation I) Reduced oxygen carrying capacity J) Unwanted outcome 1) Absolute contraindication Objective: 1 2) Adverse reactions Objective: 1 3) Antibiotic premedication Objective: 1 4) Anti-inflammatory premedication Objective: 1 5) Concomitant Objective: 1 6) Informed consent Objective: 1 7) Methemoglobinemia Objective: 1 8) Physical status classification Objective: 1 9) Relative contraindication Objective: 1 10) Risk assessment Objective: 1

Answers: 1) E 2) J 3) D 4) C 5) F 6) G 7) I 8) A 9) B 10) H True or false 1) A patient with severe systemic disease is classified as ASA IV. A) True B) False Answer: B Explanation: B) A patient with severe systemic disease is classified as ASA III. Objective: 3 2) If a patient is described as ASA III due to blood pressure levels, recommended dental treatment may be initiated provided that intraoperative monitoring of blood pressure is considered and patients are referred to physicians within one month.

A) True B) False Answer: A Objective: 3 3) A score of 18 on Corah's Dental Anxiety Scale indicates mild fear.

A) True B) False Answer: B Explanation: B) A score of 18 on Corah's Dental Anxiety Scale indicates phobia.

Objective: 4 4) Abnormally slow or fast breathing can be an indicator of disease or anxiety, or both.

A) True B) False Answer: A Objective: 4 5) A pulse oximeter attached to a patient's finger may detect the presence of methemoglobinemia.

A) True B) False Answer: A Objective: 4 6) Most local anesthetic injections through tissue are considered invasive and require premedication for at-risk patients.

A) True B) False Answer: B Explanation: B) Most local anesthetic injections through tissue are considered to be noninvasive and do not require premedication.

Objective: 6

7) Patients with hemophilia do not require antibiotic premedication for injections of local anesthesia.

A) True B) False Answer: A Objective: 6 8) Metabolism of both amide and ester-type local anesthetics may be compromised in patients with serious liver dysfunction.

A) True B) False Answer: A Objective: 6 9) Atypical plasma cholinesterase is a relative contraindication to amide type anesthetics.

A) True B) False Answer: B Explanation: B) Atypical plasma cholinesterase is a relative contraindication to ester-type anesthetics. Amide metabolism is not affected by the condition.

Objective: 6 10) Patients with artificial heart valves placed more than two years ago do not require antibiotic premedication.

A) True B) False Answer: B Explanation: B) Patients with artificial heart valves are at risk of developing infective endocarditis. Antibiotic premedication is advised by the American Heart Association guidelines.

The date of placement of the valve is not a factor in this determination.

Objective: 7 11) Patients diagnosed with congestive heart failure (CHF) should not be placed in a supine position because this can quickly lead to serious pulmonary edema.

A) True B) False Answer: A Objective: 7 12) Local anesthetics are CNS stimulants and should be used with caution when patients have taken large doses of narcotics.

A) True B) False Answer: B Explanation: B) Local anesthetics are CNS depressants. When patients have taken large doses of narcotics prior to anesthetic administrations, the local anesthetics can have a more profound

effect on the CNS. Objective: 7 13) Articaine may be the anesthetic drug of choice for a patient with liver dysfunction because only 5 to 10 % is metabolized in the liver.

A) True B) False Answer: A Objective: 7 14) Epinephrine is an absolute contraindication for patients with poorly controlled or uncontrolled hyperthyroidism.

A) True B) False Answer: A Objective: 7 15) Epinephrine can cause dangerous elevations in blood sugar in patients with cardiac compromise and severe diabetes.

A) True B) False Answer: A Objective: 7 Fill in the blank 1) Drugs that are in a patient's system when local anesthetics are administered are referred to as .

Answer: concomitant Objective: 1 2) Making a determination of a patient's ability to withstand local anesthetic procedures prior to initiating them is called .

Answer: risk assessment Objective: 1 3) According to the American Society of Anesthesiologists, the most important goal in the delivery of anesthesia is .

Answer: patient safety Objective: 2 4) ASA II describes a patient with Answer: mild systemic disease Objective: 3

.

5) ASA IV describes a patient with .

Answer: severe systemic disease that is a constant threat to life

Objective: 3 6) A patient with asthma is classified as ASA type Answer: II Objective: 3

.

7) A patient with congestive heart failure is classified as ASA type .

Answer: III Objective: 3 8) Objective information about a patient's physical condition can be obtained from an evaluation of his or her .

Answer: vital signs (blood pressure, pulse, respiration, and weight) Objective: 4 9) Normal respirations range from Answer: 12 to 20 Objective: 4

breaths per minute.

10) Normal pulse rates range from health and fitness.

Answer: 50 to 70 Objective: 4

beats per minute depending on a person's general

11) A genetic or acquired condition that reduces the oxygen-carrying capacity of the blood is called .

Answer: methemoglobinemia Objective: 6 12) Patients with poorly controlled diabetes may have a relative contraindication to the use of .

Answer: epinephrine Objective: 6 13) Patients who have taken narcotic drugs prior to injections of local anesthetics are at risk due to the risk for additional CNS .

Answer: depression Objective: 6 14) According to the American Heart Association, antibiotic premedication is indicated for patients with exceptional risks of developing .

Answer: infective endocarditis Objective: 7 15) Patients with congestive heart failure should be placed in a pulmonary edema.

Answer: supine Objective: 7

position to avoid

Multiple choice 1) Which of the following is not one of the six elements of the ASA Medical Components of Care associated with regional anesthesia?

A) Pre-anesthetic evaluation of the patient B) Prescription of the anesthetic plan C) Remain present during the course of the anesthesia D) Tooth charting and periodontal evaluation to determine treatment plan Answer: D Objective: 2 2) A patient with chronic obstructive pulmonary disease (COPD) requiring oxygen is classified as: A) ASA II B) ASA III C) ASA IV D) ASA V Answer: C Objective: 3 3) A patient with well-controlled, noninsulin-dependent diabetes is classified as: A) ASA I B) ASA II C) ASA III D) ASA IV Answer: B Objective: 3 4) Which of the following, when considering patient evaluation, is the least pertinent when obtaining local anesthetic informed consent?

A) Specific risks of procedure in light of medical status B) Benefits of the procedure C) Identifying a surrogate to provide health information D) The timing of appointments and cost Answer: D Objective: 5 5) Which one of the following drugs is absolutely contraindicated for patients with bisulfite sensitivity?

A) All injectable local anesthetics with amides B) All injectable local anesthetics with esters C) All injectable local anesthetics with vasoconstrictors D) All topical anesthetics Answer: C Objective: 6

6) For an uncontrolled diabetic patient, which factor is the most critical to consider when planning to use a local anesthetic with epinephrine?

A) Appointment time B) Blood sugar level C) Cardiac compromise D) Meal time Answer: C Objective: 6 7) Epinephrine is contraindicated in a patient with: A) Uncontrolled hyperthyroidism B) Diabetes C) Heart disease D) Asthma Answer: A Objective: 6 8) According to the 2007 American Heart Association guidelines, which of the following conditions does not require antibiotic premedication for the prevention of infective endocarditis?

A) Previous endocarditis B) Prosthetic heart valve C) Hemophilia D) Congenital heart disease Answer: C Objective: 7 9) Which of the following is not a consideration for patients with hemophilia for local anesthetic injections?

A) Antibiotic premedication B) Types of injections C) Types of drugs D) Doses of local anesthesia Answer: A Objective: 7 10) Which of the following local anesthetic drugs may represent a relative contraindication for patients with compromised liver function?

A) Levonordefrin B) Benzocaine C) Lidocaine D) Epinephrine Answer: C Objective: 7 11) What is the maximum recommended dose of epinephrine for patients in category ASA III with cardiovascular disease?

A) 1.8 mg B) 0.4 mg C) 0.2 mg D) 0.04 mg Answer: D Objective: 7 12) Following a myocardial infarction, what is the current guideline recommended when considering elective dental treatment?

A) A minimum of 4weeks delay, following appropriate consultation and risk analysis B) A minimum of 3 months delay, following appropriate consultation and risk analysis C) A minimum of 6 months delay, following appropriate consultation and risk analysis D) A minimum of 12 months delay, following appropriate consultation and risk analysis Answer: A Objective: 8 13) Following a CVA, TIA, or RIND, how long should elective dental treatment be delayed?

A) 1 to 6 months, following appropriate consultation and risk analysis B) A minimum of 3 months, following appropriate consultation and risk analysis C) A minimum of 6 months, following appropriate consultation and risk analysis D) A minimum of 12 months, following appropriate consultation and risk Answer: A Objective: 8 14) Which local anesthetic drugs would it be advisable to avoid when a patient is taking significant amounts of acetaminophen?

A) Prilocaine and benzocaine B) Lidocaine and mepivacaine C) Bupivacaine and benzocaine D) Procaine and cocaine Answer: A Objective: 7 15) Which one of the following activities does not describe an activity to meet the 4 MET level?

A) Walk one block on level ground at 4 mph B) Play golf C) Walk up a hill D) Ski down hill Answer: D Objective: 9 16) Which one of the following activities describes an activity that meets the 1 MET level?

A) Walk one block on level ground at 2 mph B) Run a short distance C) Walk up a hill D) Ski downhill Answer: A

Objective: 9 17) Which one of the following conditions does not indicate the need to limit the dose of vasoconstrictors?

A) Patient taking digitalis gylcosides for heart failure B) Patient prone to arrhythmia C) Patient with cardiovascular disease and controlled hypothyroidism D) Patient taking nonselective beta-blockers Answer: C Objective: 10 18) Which of the following are initial signs and symptoms of methemoglobinemia?

A) Dizziness and headache B) CNS depression and seizures C) Gray cyanosis of mucous membranes, lips, nail beds D) Flushed, clammy skin Answer: C Objective: 11 Short answer/essay 1) Provide four reasons why it is important for a clinician to know which concomitant drugs a patient is taking prior to the administration of local anesthetics.

Answer: 1. They may influence the choice of local anesthetic drug and quantity administered.

2. They may affect the efficacy, metabolism, and elimination of a local anesthetic drug.

3. They may potentiate the actions or delay the metabolism of local anesthetic drugs.

4. They may be affected by the local anesthetic drugs.

Objective: 6 2) Discuss situations that require a medical consultation prior to treatment.

Answer: In order to optimize safety, consultation with a patient’s physician is sometimes needed prior to local anesthesia. Medical consultation may be considered when a patient has symptoms of undiagnosed disease and/or has not had regular medical exams. It may also be considered when there are gaps in information provided, when pregnant, or when other concerns suggest follow-up is necessary. Medical conditions that suggest a need for consultation include cardiovascular conditions, recent surgeries, uncontrolled hypertension, psychological conditions that may influence oral procedures, compromised liver and/or kidney function, immune system compromise, and any concerns regarding local anesthesia and/or treatment. A consult with a patient’s physician is also recommended in order to clarify details and, in some cases, to ensure safety during anesthetic procedures. This is especially true if patients are unable to recall or appear to be withholding important details about medical conditions or current medications. An incomplete understanding of health status can result when there is no history of recent medical care.

Objective: 8 3) Explain the risks associated with the concomitant use of local anesthetic drugs and cocaine.

Answer: Cocaine is a strong CNS depressant and local anesthetics can compound any existing CNS depression. Cocaine is also a vasoconstrictor. Administration of other vasoconstrictors in addition to cocaine significantly increases the risk of hypertensive crisis, stroke, or myocardial infarction. Do not administer local anesthetics with vasoconstrictors for 24 hours after cocaine use and patients should be monitored for local anesthetic drug overdose.

Objective: 6 4) Explain the risks associated with the concomitant use of local anesthetic drugs and methamphetamine.

Answer: Methamphetamine is an indirect-acting, sympathomimetic amine. Administration of vasoconstrictors in the presence of methamphetamine may result in hypertensive crisis, stroke, or myocardial infarction. Do not administer local anesthetics with vasoconstrictors for a minimum of 24 hours after methamphetamine use.

Objective: 6 5) Define and discuss methemoglobinemia.

Answer: Methemoglobinemia is a genetic or acquired condition that reduces the oxygen carrying capacity of blood. Acquired methemoglobinemia has been reported following the administrations of benzocaine topical and injectable prilocaine. It is also possible when using articaine. Clinical anoxia may result from methemoglobin levels as low as ten percent, at which point signs of reduced oxygenation and cyanosis may develop.

Objective: 6 Use the information provided in the Case Study below to answer the questions that follow.

Case Study Tucker Johnson is a 49-year-old male who recently moved to the area to search for a new job. He says he has not had dental care for several years because nothing hurts. His chief complaint is stained teeth and bad breath. His medical history is positive for smoking. He takes acetaminophen for stress-induced headaches most days of the week. Vital signs are: blood pressure 155/92, respiration 20, and weight 215 pounds. Intraoral findings include the presence of periodontal infection and six teeth in need of restorations.

1) Considering the factors presented, what is Mr. Johnson's ASA physical classification?

Answer: Mr. Johnson is ASA II. His health status and vital signs indicate the presence of mild systemic disease.

Objective: 3 2) Are any precautions necessary given Mr. Johnson's blood pressure of 155/92?

Answer: Mr. Johnson's blood pressure is less than 160/100 and should not present contraindication to treatment however medical evaluation should be recommended if he is not currently monitored. Base line blood pressure should be obtained prior to administering local anesthetics and vasoconstrictors, and used as a comparison should adverse events develop after drugs are administered. Vasoconstrictor concentrations should be limited when hypertension suspected. Stress reduction protocol may be indicated.

Objective: 7 3) What local anesthetics should be avoided in light of his frequent use of acetaminophen? Why?

Answer: Benzocaine, prilocaine, and articaine in conjunction with the use of acetaminophen may induce methemoglobinemia. Smoking is also a mild contraindication to these drugs due to the potential for impair oxygenation. Smoking cessation programs should be recommended.

Objective: 7 4) What is the significance of Mr. Johnson's weight related to the maximum recommended dose of local anesthetic drugs?

Answer: Mr. Johnson’s weight computed by milligram per pound will exceed the maximum dose per appointment for all local anesthetic drugs (except articaine which has no established maximum dose per appointment, however articaine is not recommended for Mr. Johnson.) The MRD per appointment should not be exceeded for Mr. Johnson.

Objective: 7

Chapter 11 Fundamentals for Administration of Local Anesthetic Agents Match the following A) Bevel contacts vessel wall B) Piercing point C) Near nerve endings D) Target E) Delivery rate F) Supraperiosteal G) Near nerve trunk H) Passageway I) PREP J) Blood in cartridge?

1) Aspiration test Objective: 1 2) Deposition site Objective: 1 3) False-negative aspiration Objective: 1 4) Field block injection Objective: 1 5) Infiltration injection Objective: 1 6) Needle pathway Objective: 1 7) Nerve block injection Objective: 1 8) Penetration site Objective: 1 9) Speed and volume Objective: 1 10) Supportive communication Objective: 1

Answers: 1) J 2) D 3) A 4) F 5) C 6) H 7) G 8) B 9) E 10) I True or false 1) Informed consent should be obtained from a patient or guardian prior to administering injections.

A) True B) False Answer: A Objective: 2 2) The deposition site for a nerve block injection is at a greater distance from the penetration site than for a field block or infiltration injection.

A) True B) False Answer: A Objective: 6 3) The greater the distance from penetration to deposition site, the greater the potential for deviation of the needle.

A) True B) False Answer: A Objective: 6 4) False-negative aspirations typically occur when a clinician has failed to develop adequate negative pressure with the thumb ring.

A) True B) False Answer: B Explanation: B) False-negative aspiration occurs when a bevel is in contact with a vessel wall.

The negative pressure retracts the vessel wall into the lumen of the needle, blocking the flow of blood through the needle into the cartridge.

Objective: 7 5) The two most important patient safety steps during an injection are locating the penetration site and deposition sites.

A) True B) False Answer: B Explanation: B) The two most important patient safety steps of an injection are slow administration and aspiration.

Objective: 7 6) The first step of the Standard Operating Procedure for all injections is locating and preparing armamentarium.

A) True

B) False Answer: B Explanation: B) Thorough patient evaluation is the first step in the Standard Operating Procedures for all injections. After consideration of all precautions, contraindications, and necessary modifications, appropriate injection techniques and anesthetic drugs are selected.

Objective: 7 7) A patient's head should be in a position higher than the heart for comfort during injections.

A) True B) False Answer: B Explanation: B) Placing patients in supine positions during injections provides physiological support during stress and is recommended for the management of medical emergencies.

Objective: 7 8) Most topical anesthetic agents will reach peak effectiveness in about 5 minutes.

A) True B) False Answer: B Explanation: B) Most topical anesthetic agents will reach peak effectiveness in about 1 minute.

Objective: 7 9) Gently pulling the mucosa taut will ease penetration of the needle and establish a point of stability for the syringe.

A) True B) False Answer: A Objective: 7 10) Regardless of the amount of blood in a cartridge following positive aspiration, the best practice is to withdraw the needle and reinject.

A) True B) False Answer: B Explanation: B) If an aspiration test results in a small trickle of blood or "wormlike" thread into the cartridge and does not obstruct clear vision of a subsequent aspiration, the needle can be repositioned slightly and aspiration can be repeated.

Objective: 7 11) If there are repeated positive aspirations at the same injection site, rescheduling should be considered.

A) True B) False Answer: A Objective: 7 12) The safest rate of deposition of local anesthetics allows for the delivery of approximately1.0

mL of solution per minute.

A) True B) False Answer: A Objective: 7 13) The most stable position when using a syringe is palm up.

A) True B) False Answer: A Objective: 7 14) Resting an elbow on a patient's shoulders or chest during injection creates good stabilization and is a safe ergonomic practice.

A) True B) False Answer: B Explanation: B) Establishing syringe stability on a patient's shoulders or chest can create stability for the syringe but increases the risk of trauma should the patient move unexpectedly.

Objective: 8 15) A clinician should not stand during the administration of local anesthesia injections.

A) True B) False Answer: B Explanation: B) Standing up during the administration of some local anesthetic injections can facilitate good ergonomic balance especially when patients cannot be positioned easily.

Objective: 8 Fill in the blank 1) The refers to the specific location where a needle first pierces mucosa.

Answer: penetration site Objective: 1 2) The refers to the route a needle travels as it advances to the deposition site.

Answer: needle pathway Objective: 1 3) The is defined as the anatomical location at which a drug is deposited.

Answer: deposition site Objective: 1 4) The two most important safety steps in the delivery of local aesthetic agents are Answer: aspiration and slow administration Objective: 3

.

5) tests reduce the risk of inadvertent deposition of drugs into the bloodstream.

Answer: Aspiration Objective: 3 6) A aspiration can occur when a bevel is in contact with a vessel wall.

Answer: false negative Objective: 3 7) An injection deposits local anesthetics directly at or near small terminal nerve endings.

Answer: infiltration Objective: 3 8) Efforts to reduce stress from the beginning to the end of an injection are enhanced by maintaining positive, with the patient.

Answer: supportive communication Objective: 4 9) The greater the distance from penetration site to deposition site, the greater the potential for of the needle tip.

Answer: deflection or deviation Objective: 5 10) A injection deposits local anesthetics near larger terminal nerve branches.

Answer: field block Objective: 6 11) A injection deposits local anesthetic near major nerve trunks at a greater distance from the area of treatment, which provides wider areas of anesthesia.

Answer: nerve block Objective: 6 12) Drying tissue with gauze can reduce into mucosa.

Answer: dilution and spread Objective: 7

of topical agents and improve their uptake

13) Most topical anesthetic agents will reach peak effectiveness in about Answer: 1 Objective: 7 14) The final safety step during an injection procedure is to properly to disposal.

Answer: recap Objective: 7 Multiple choice

minute(s).

the needle prior

1) Which of the following is not an element of informed consent in local anesthesia?

A) Discussing risks B) Providing alternatives C) Providing information in a language patients understand D) Explaining the costs of procedures Answer: D Objective: 2 2) What are the two most important safety steps during a local anesthetic injection?

A) Aspiration before depositing and recapping needles B) Slow administration and recapping needles C) Patient evaluation and aspiration D) Aspiration before depositing and administering drugs slowly Answer: D Objective: 3 3) Which of the following is important but is not a recommended step in the PREP strategy?

A) Prepare patient B) Rehearse injection C) Empower patient D) Plan debriefing Answer: D Objective: 4 4) Supportive communication includes all of the following, except: A) It should begin during the pre-injection period B) It should involve positive comments focusing on patient behavior during injections C) It lets patients know that injections will be more comfortable compared to previous injections D) It includes rehearsing injections and providing ways for patients to communicate with clinicians during injection Answer: C Objective: 5 5) An injection technique that deposits anesthetic solution near terminal nerve endings is called: A) A periodontal ligament injection B) A field block injection C) An infiltration injection D) A nerve block injection Answer: C Objective: 6 6) An injection that deposits anesthetic solution near a major nerve trunk is called: A) A periodontal ligament injection B) A supraperiosteal injection C) A field block injection D) A nerve block injection Answer: D

Objective: 6 7) A field block injection is also called: A) A superperiosteal injection B) A periodontal ligament injection C) A nerve block injection D) An interpapillary injection Answer: A Objective: 6 8) Which of the following describes the penetration site?

A) Needle pierces mucosa B) Needle pierces the muscle C) Needle pierces a vessel D) Anesthetic solution is deposited Answer: A Objective: 7 9) Which of the following describes the target site for local anesthetic solution?

A) Penetration site B) Needle pathway C) Aspiration site D) Deposition site Answer: D Objective: 7 10) What is the first step in preparation for local anesthesia injections?

A) Obtain informed consent B) Prepare the armamentarium C) Make sure solution will flow through the needle D) Assess the patient Answer: D Objective: 7 11) What is the primary reason it is recommended to orient needle bevels toward bone during infiltration injections?

A) Needles should be angled away from bone during penetration B) Trauma to periosteum is lessened if bone is inadvertently contacted C) False aspirations can be prevented D) Discomfort from needles is reduced Answer: B Objective: 7 12) Which of the following is the most appropriate documentation following local anesthesia injections?

A) 03/03/2014: Review health history. BP 115/78. Two cartridges of 4% prilocaine (144 mg) w/epi 1:100,000 (0.036 mg), benzocaine topical, Rt PMC, MMC, GP, (-) aspiration. No adverse

reactions.

B) Review health history. BP 120/70. Three cartridges 3% mepivacaine w/1:20,000 levonordefrin. No adverse reactions.

C) 05/03/2014: Review health history. Two cartridges 2% lidocaine w/epi, (-) aspiration.

D) 07/07/14: Review health history. BP normal. One and a half cartridges (27 mg) of 2% lido w/1:100:00 epi, Left IA and buccal, (-) aspiration. No adverse reactions.

Answer: A Objective: 7 13) Which of the following is the most important safety step following an injection?

A) Rinsing the patient's mouth B) Assessing the patient for adverse reactions C) Recapping the needle with a one-handed technique D) Making a complete chart entry Answer: C Objective: 7 14) Which statement describes the correct positioning of the long window of the syringe?

A) Toward the clinician to permit visibility throughout the injection B) Away from the patient to block visibility throughout the injection C) Toward the patient to permit assessment of the duration of the injection D) Either toward or away from the clinician because both sides of the syringe have an opening Answer: A Objective: 7 15) Which statement best describes why retraction of tissue keeping the tissue taut is important during injections?

A) The patient's mouth is open and it improves visibility for the clinician.

B) It eliminates the need for stabilization of syringe and fulcrum.

C) It allows better identification of landmarks.

D) It allows for ease of needle penetration and establishes a point of stability for the syringe.

Answer: D Objective: 7 16) What is the minimum recommended rate of injection?

A) 0.5 mL per minute B) l.8 mL per minute C) 1.0 mL per two minutes D) 3.0 mL per minute Answer: B Objective: 7 17) Which statement describes how to avoid a false-negative aspiration?

A) Withdraw the syringe slightly and reaspirate to release the bevel from a vessel wall B) Rotate the syringe a quarter turn then reaspirate to release the bevel from a vessel wall C) Apply greater force on the thumb ring to permit blood to enter cartridge D) Avoid injections in highly vascular areas

Answer: B Objective: 7 18) Which of the following procedures represents the correct response following a positive aspiration when a small wormlike thread enters the cartridge?

A) Withdraw the syringe and reinject B) Reposition the syringe away from the area of the positive aspiration, and deposit solution following a negative aspiration C) Withdraw the syringe, change the cartridge, clear the needle of blood and reinject D) Rotate the syringe a quarter turn, reaspirate and continue to deposit solution Answer: B Objective: 8 19) What is the most important goal of ergonomic positioning?

A) Prevention of cumulative trauma disorders B) Stabilization of the syringe C) Prevention of patient injury D) Patient comfort and safety Answer: A Objective: 8 20) Which of the following is not a basic element of good ergonomic positioning?

A) Keep wrists at a neutral angle B) Bend from the waist C) Bend from the hips D) Do not raise arms more than 30 degrees Answer: B Objective: 8 Short answer/essay 1) What elements are included in an informed consent?

Answer: Informed consents include: 1. Discussion in a language a patient can understand 2. Provide patients with opportunities to ask question 3. Explain the procedures that have been recommended and explain the need for each 4. Clarify the risks and rewards of the recommended treatment including the risks of failing to treat 5. Provide acceptable alternatives to the recommended treatment Objective: 2 2) Explain how an aspiration test performed?

Answer: Once the needle is advanced to the appropriate deposition site for a specific injection, and before depositing solution, perform an aspiration test by applying gentle, brief back pressure on the upper inside surface of the thumb ring. This action changes the pressure inside the cartridge from positive to negative. If the needle has entered a vessel, blood will be drawn into the cartridge, referred to as a "positive aspiration." No drug should be deposited in the specific

location of a positive aspiration.

Objective: 7 3) Discuss management of a positive aspiration.

Answer: A positive aspiration in which blood is visible in the cartridge requires an immediate response. If the aspiration test results in a small trickle of blood or "wormlike" thread into the cartridge and does not obstruct clear vision of a subsequent aspiration, the needle can be repositioned slightly and aspiration can be repeated. After a second test that is negative, the clinician may continue with the injection and deposit the drug. If the aspiration test results in a burst of blood, creating a "cloudy and reddened" solution in the cartridge or if the clinician, for any reason, is concerned about the ability to see subsequent aspiration results clearly, the needle should be withdrawn, the cartridge replaced, and the needle flushed or replaced before reinitiating the injection.

Objective: 7 4) What is a false-negative aspiration and how can it be prevented?

Answer: Despite performing aspiration tests correctly, it is still possible to have "false-negative" aspirations at times. This can occur when a bevel is in contact with a vessel wall. During an aspiration test, negative pressure can retract the vessel wall into the lumen of the needle blocking the flow of blood through the needle into the cartridge. To check for false-negative responses, rotate the syringe slightly, and reposition the bevel away from the vessel wall. This step is encouraged for all injections in which there is a greater risk of positive aspiration.

Objective: 7 5) What information is documented in a patient record for local anesthetic injections? Provide an example.

Answer: The patient's record includes: 1. Date of administration 2. Type of drug(s) administered (both topical and injectable) 3. Injection(s) administered (or area of delivery when topical alone is used) 4. Total volume of drug(s) administered 5. Result of aspiration, recorded as positive (+) or negative (-) Sample documentation: 02/14/14 20% benzocaine topical, R-PES, MES, AES, two cartridges (3.6 mL) 2% lidocaine (72 mg) w/epi 1:100,000 (.036 mg), (-) aspiration, no complications Objective: 7 6) Discuss the basic elements of good ergonomic position and balance.

Answer: To maintain good ergonomic position and balance: 1. Do not twist from the trunk 2. Bend from the hips 3. Keep wrists at a neutral angle 4. Do not raise arms more than 30 degrees 5. Do not extend the neck more than 30 degrees forward Objective: 8

Chapter 12 Injections for Maxillary Pain Control Match the following A) Near nerve endings B) Swelling C) Opening through bone D) Nerves around teeth E) Bony protrusion F) Bruising G) Area numbed H) Passageway I) Piercing point J) Target 1) Dental plexus Objective: 1 2) Deposition site Objective: 1 3) Edema Objective: 1 4) Eminence Objective: 1 5) Field of anesthesia Objective: 1 6) Foramen Objective: 1 7) Hematoma Objective: 1 8) Infiltration Objective: 1 9) Needle pathway Objective: 1 10) Penetration site Objective: 1

Answers: 1) D 2) J 3) B 4) E 5) G 6) C 7) F 8) A 9) H 10) I Fill in the blank 1) The group of nerves innervating the pulp of the tooth, facial areas of the gingiva, periodontal ligament, and alveolus is called the .

Answer: dental plexus Objective: 1 2) Field block or injections are indicated when procedures are confined to one or two teeth or to tissues in limited area.

Answer: infiltration Objective: 2 3) The facial bone of the maxilla is relatively local anesthetics.

Answer: thin and permeable Objective: 2

which allows for ease of diffusion of

4) The optimum site of penetration for infiltration injections is at the Answer: height of the mucobuccal fold Objective: 2 5) A bony ridge or Answer: eminence Objective: 2

.

can be palpated overlying the facial roots of maxillary teeth.

6) The ASA nerve is a branch of the Answer: maxillary or second Objective: 2

division of the trigeminal nerve.

7) An anatomical variation that can complicate an MSA injection is the presence of a large .

Answer: zygomaticoalveolar crest Objective: 2 8) The PSA nerve branches from the maxillary nerve in the infraorbital canal.

Answer: pterygopalatine Objective: 2 9) The pathway of the needle Answer: parallels Objective: 3

fossa prior to entering the

the long axis of the tooth in an infiltration injection.

10) The deposition site for an infiltration injection is at the Answer: apex Objective: 3

of the tooth.

11) The optimal site of penetration for an ASA injection is at the height of the mucobuccal fold to the canine eminence.

Answer: anterior Objective: 3 12) The depth of penetration for an ASA injection ranges from mm.

Answer: 3 to 6 Objective: 3 13) A minimum volume (in milliliters) of anesthetic solution needed to achieve anesthesia with an ASA injection is typically mL. Answer: 0.9 Objective: 3 14) The needle pathway of an MSA injection parallels the long axis of the Answer: second premolar Objective: 3

.

15) The nerve block is indicated for pain management of anterior and premolar teeth in one quadrant.

Answer: infraorbital Objective: 3 16) The needle pathway for an IO injection has been described as oriented along a line parallel to the .

Answer: pupil of the eye Objective: 3 17) The PSA injection is indicated for pain management of Answer: multiple molars Objective: 3

in one quadrant.

18) The optimum depth of insertion for a PSA injection is Answer: 16 Objective: 3

mm.

19) The angle of insertion for the PSA injection is table and the midsagittal planes.

Answer: 45 Objective: 3

degrees to the maxillary occlusal

20) Soft tissue retraction for a PSA injection is both Answer: outward and downward Objective: 3

to allow for good visibility.

21) The correct depth of penetration for a V2 injection is Answer: 30 Objective 3

mm.

22) The optimum depth of insertion for a V2 injection is Answer: 30 Objective: 3

mm.

Multiple choice 1) Which of the following best explains why infiltration techniques are highly successful in the maxilla?

A) Minimal penetration depths B) Ease of diffusion through bone C) Multiple nerves in the dental plexus D) Volumes of anesthetic delivered Answer: B Objective: 2 2) Which of the following is a possible anatomical barrier to the success of an infiltration technique?

A) Root angulations B) Syringe angulations C) Frenal attachments D) Large exostoses Answer: D Objective: 2 3) Which of the following best explains the needle choice for an infiltration of a maxillary lateral incisor?

A) 30 gauge long for patient comfort and to assure deposition of solution near the apex B) 30 gauge short for patient comfort and high risk of positive aspiration C) 27 gauge short based on the low risk of positive aspiration D) 25 gauge extra short due to shallow root depth Answer: C Objective: 3 4) What is a typical minimum volume of anesthetic solution necessary for an infiltration of tooth number 7?

A) 0.4 mL B) 0.6 mL C) 1.8 mL D) 9.0 mL Answer: B Objective: 3 5) What is the typical minimum volume of anesthetic solution necessary for an infiltration of a maxillary central incisor?

A) 0.4 mL B) 0.6 mL

C) 1.8 mL D) 9.0 mL Answer: B Objective: 3 6) When an infiltration injection is unsuccessful, it may be helpful to: A) Visualize and re-inject with a longer needle B) Visualize, palpate, check radiographs and reassess the technique C) Establish contact with bone before administering additional anesthetic D) Repeat the same injection and deposit more solution Answer: B Objective: 3 7) Which of the following injections is not an alternate for an unsuccessful infiltration on a maxillary canine?

A) IO B) ASA C) MSA D) PASA Answer: C Objective: 3 8) Which one of the following injections is the best alternative for an unsuccessful infiltration of a maxillary first molar?

A) PSA B) MSA C) IO D) AMSA Answer: A Objective: 3 9) Which injection will most easily remedy cross-over innervation to a central incisor?

A) Infiltration over the same side central incisor with a larger volume of solution B) Infiltration over the opposite side central incisor C) ASA nerve block D) Bilateral AMSA nerve blocks Answer: A Objective: 3 10) Which of the following describes the ASA nerve?

A) Terminal branch of the maxillary nerve exiting the infraorbital foramen to supply sensation to the upper lip, lower side of the nose, and dental plexus of the canine and incisors B) Terminal branch of the maxillary nerve branching from the infraorbital nerve within the infraorbital canal 6 to 10 mm prior to the infraorbital foramen to supply sensation to the dental plexus of the canine, central and lateral incisors C) Descends along the external surface of the maxilla and supplies sensation to the dental plexus of the canine, central and lateral incisors

D) Descends through anterior wall of the maxillary sinus to supply sensation to the dental plexus of the premolars, canine, lateral and central incisors Answer: B Objective 2 11) The field of anesthesia of an ASA nerve block includes each of the following except A) Upper lip, cheek, lower nose B) Pulps of the maxillary central incisor through canine C) Facial periodontium of central incisor through canine D) Lingual periodontium of central incisor through canine Answer: D Objective: 2 12) Which of the following is an anatomical landmark for an ASA injection?

A) Mucobuccal fold mesial to the first premolar B) Canine fossa distal to the canine eminence C) Canine fossa anterior to the canine eminence D) Mucobuccal fold superior to the canine eminence Answer: C Objective: 2 13) What is the depth of penetration for an ASA nerve block?

A) 1 to 3 mm B) 3 to 6 mm C) 6 to 9 mm D) 9 to 12 mm Answer: B Objective: 3 14) What is an accepted minimal volume of anesthetic solution for an ASA nerve block?

A) 0.6 mL B) 0.9 mL C) 0.9 mL to 1.8 mL D) 1.2 to 1.6 mL Answer: B Objective: 3 15) Which is the best explanation for incomplete anesthesia of the central incisor following an ASA nerve block?

A) Cross-innervation from the opposite side of injection B) Inadequate depth of penetration C) Poor angulation of the needle D) Accessory innervation of the MSA nerve Answer: A Objective: 2 16) Studies have demonstrated the absence of the MSA nerve in:

A) 10% to 28% of individuals B) 15% to 50% of individuals C) 28% to 52% of individuals D) 50% to 72% of individual Answer: D Objective: 2 17) What anatomical feature may restrict the penetration site for an MSA injection?

A) Canine eminence B) Low mucogingival junction C) Maxillary tuberosity D) Zygomaticoalveolar crest Answer: D Objective: 2 18) In the absence of an MSA nerve, which of the following two nerves may innervate the premolars and the mesiobuccal root of the first molar?

A) Infraorbital and posterior superior alveolar B) Infraorbital and anterior Superior alveolar C) Anterior superior alveolar and posterior superior alveolar D) Anterior superior alveolar and greater palatine Answer: C Objective: 2 19) Which of the following correctly describes the needle pathway for an MSA injection?

A) The needle advances distal to the second premolar through thin mucosal tissue to superficial fascia consisting of dense connective tissue, microvasculature, and nerve endings.

B) The needle advances parallel to the long axis of the first premolar through thin mucosal tissue to superficial fascia consisting of loose connective tissue, microvasculature, and nerve endings.

C) The needle advances parallel to the long axis of the second premolar through thin mucosal tissue to superficial fascia consisting of loose connective tissue, microvasculature, and nerve endings.

D) The needle advances perpendicular to the long axis of the second premolar at the height of the mucobuccal fold through thin mucosal tissue to superficial fascia consisting of loose connective tissue, microvasculature, and nerve endings.

Answer: C Objective: 3 20) What is the depth of penetration for a MSA nerve block?

A) 1 to 3 mm B) 3 to 6 mm C) 5 to 8 mm D) 9 to 12 mm Answer: C Objective: 3 21) What is an adequate range of volumes for MSA nerve blocks?

A) 0.4 to 0.9 mL B) 0.9 to 1.2 mL C) 1.2 to 1.8 mL D) 1.6 to 1.8 mL Answer: B Objective: 3 22) In a typical adult, how far below the inferior orbital ridge is the IO deposition site located?

A) 8 to 10 mm B) 6 to 12 mm C) 2 to 4 mm D) 1to 2 mm Answer: A Objective: 2 23) The field of anesthesia of an IO nerve block includes the: A) Pulps of maxillary central incisors through canine, and upper lip, side of nose, and lower eyelid B) Pulps and periodontium of maxillary central incisors through canine and premolars, mesial buccal root of the first molar, upper lip, side of nose, and lower eyelid C) Pulps of maxillary incisors, canine and premolars, upper lip, and side of nose D) Pulps and maxillary periodontium of incisors, canine, premolars Answer: B Objective 2 24) Which of the following teeth are anesthetized by an IO injection technique?

A) 8, 9, 10, 11, 12, 13 B) 6, 7, 8, 9, 10, 11 C) 8, 9, 10, 11, 12, 13, and sometimes the MB root of 14 D) 8, 9, 10 Answer: C Objective: 3 25) Which of the following provides the most accurate description of the field of anesthesia for an IO injection?

A) Pulps of the maxillary first and second premolars and their facial gingiva, the periodontal ligament, alveolar bone, and in some individuals, the mesiobuccal root of the first molar B) Pulps of the maxillary central incisors through the canines, premolars, and their facial periodontium; the lower eyelid, lateral aspect of nose, and upper lip; and in some individuals, the mesiobuccal root of the maxillary first molar C) Pulps of the maxillary central incisor through the canines on the injected side and their facial periodontium, and due to diffusion of anesthetic solution some terminal branches of the facial nerve D) Pulps of the maxillary first and second molars and their facial gingival, periodontal ligament, and alveolar bone Answer: B Objective: 3

26) What is a minimal volume of anesthetic solution deposited for an IO nerve block?

A) 0.6 mL B) 0.9 mL C) 0.9 mL to 1.8 mL D) 1.2 to 1.6 mL Answer: B Objective: 3 27) The PSA nerve branches from the maxillary nerve within the: A) Temporomandibular fossa B) Maxillary tuberosity C) Infraorbital canal D) Pterygopalatine fossa Answer: D Objective: 2 28) Small PSA foramina are located on the A) Posterior surface of the maxillary tuberosity B) Medial surface of the maxillary tuberosity C) Distal wall of the pterygopalatine fossa D) Inferior surface of the zygomatic arch Answer: A Objective 2 29) What is the correct deposition site for a PSA nerve block?

A) Anterior to the zygomatic process of the maxilla B) Posterior to the zygomatic bone of the maxilla C) Posterior surface of the maxillary tuberosity D) Superior to the apex of the mesial buccal root of the maxillary second molar Answer: C Objective: 3

30) What is the optimum depth of penetration for a PSA nerve block?

A) 6 mm B) 9 mm C) 16 mm D) 22 mm Answer: C Objective: 3 31) Which nerve may provide accessory innervation to the palatal roots of the maxillary molars and to the premolars?

A) MSA B) IA C) GP D) IO

Answer: C Objective: 2 32) Which of the following maxillary injection techniques has the highest risk of hematoma?

A) ASA B) IO C) AMSA D) PSA Answer: D Objective: 3 33) What is the most common cause of failure of a PSA nerve block?

A) Deposition of solution too far away from the PSA foramina B) Incorrect needle length and gauge C) Inadequate volume of solution D) Intravascular injection Answer: A Objective: 3 34) The PSA injection technique may be contraindicated in patients with: A) Clotting disorders due to risk of hematoma B) Diabetes due to high risk of infection C) TMD because of difficulty opening the mouth wide D) Missing maxillary second molars due to difficulty locating the posterior aspect of the tuberosity Answer: A Objective: 3 35) The maxillary nerve block provides unilateral anesthesia to the following except A) pulps and periodontium of maxillary teeth B) soft and hard palatal tissues C) upper and lower lips, cheek, upper and lower eyelids D) upper lips, cheek, lower eyelids, lateral aspect of nose Answer: C Objective: 3 36) Which maxillary nerve block technique has the highest risk of hematoma formation?

A) High-tuberosity B) Greater palatine C) Extra oral approach D) Pterygopalatine canal Answer: A Objective: 3 37) What is the correct penetration depth for a maxillary nerve block for a palatal approach?

A) 16 mm B) 20 mm

C) 30 mm D) 32 mm Answer: C Objective: 3 38) What is the preferred needle length and gauge for maxillary nerve block with a palatal approach?

A) Short, 25 gauge B) Short, 30 gauge C) Long, 27 gauge D) Long, 25 gauge Answer: D Objective: 3 39) Which of the following describes the penetration site for a facial approach to a maxillary nerve block?

A) Height of the mucobuccal fold over the distobuccal aspect of the maxillary second molar B) Height of the mucobuccal fold distal to the zygomatic process C) Lateral to the height of the mucobussal fold posterior to the zygomatic bone of the maxilla D) Lateral to the height of the mucobuccal fold over the mesiobuccal aspect of the maxillary second molar Answer: A Objective 3 40) Which of the following maxillary injection techniques has the highest risk of hematoma?

A) IO B) AMSA C) PSA D) V2 Answer: D Objective: 3 Short answer/essay 1) Describe the field of anesthesia for the infraorbital (IO) nerve block.

Answer: The IO nerve block will affect structures innervated by the anterior and middle superior alveolar and IO nerves. Areas anesthetized include the pulps of the maxillary central incisors through the canines, premolars, and their facial periodontium; and the lower eyelid, lateral aspect of nose, and upper lip. In some individuals, the mesiobuccal root of the maxillary first molar is also anesthetized.

Objective: 3 2) Describe the field of anesthesia for the PSA nerve block.

Answer: Anesthesia will affect the structures innervated by the PSA nerve, including pulps of the maxillary first, second, and third molars; and the facial periodontium on the injected side. In some individuals, the mesiobuccal root of the maxillary first molar will not receive its entire innervation, or any innervation, from the PSA nerve and a PSA block would not provide

profound anesthesia for the entire tooth.

Objective: 3 3) Discuss techniques factors that increase the risk of hematoma in PSA injections.

Answer: The risk of hematoma is increased if needles are over-inserted into the pterygopalatine fossa beyond the optimum depth of 16 mm; or when needle penetrations are located too posterior to the deposition site on the posterior surface of the maxilla. PSA injections may be contraindicated in patients with clotting disorders or on anticoagulant therapy. Alternate techniques, such as multiple infiltrations may be safer in these situations.

4) Discuss possible complications of the tuberosity-approach maxillary nerve block.

Answer: The tuberosity-approach maxillary nerve block injection has the highest risk of periinjection hematoma formation, due to its proximity to the pterygoid plexus of veins and maxillary arteries. Possible risks with the greater palatine foramen approach include: displacement of orbital structures, diplopia (anesthesia of the sixth cranial nerve), retrobulbar block (mydriasis, anesthesia of the cornea, ophthalmoplegia), optic nerve block (transient loss of vision in that eye is possible), penetration into the nasal cavity. Maxillary injection techniques are contraindicated in patients with clotting disorders or on anticoagulant therapy. Alternate techniques should be used in these instances.

5) Color in the field of anesthesia and list the structures anesthetized by an infiltration of #7.

Answer:

Objective: 3

6) Color in the field of anesthesia and list the structures anesthetized by an ASA nerve block.

Answer:

Objective: 3

7) Color in the field of anesthesia and list the structures anesthetized by an MSA nerve block.

Answer:

Objective: 3

8) Color in the field of anesthesia and list the structures anesthetized by an IO nerve block.

Answer:

Objective: 1

9) Color in the field of anesthesia and list the structures anesthetized by a PSA nerve block.

Answer:

Objective: 3

Use the information provided in the Case Study below to answer the questions that follow.

Case Study 1 The treatment plan for Marjorie Dickens includes restorations for #11D and #12MO. 1) Which injection(s) is/are needed for pulpal anesthesia of teeth #11 and #12 with the least number of needle penetrations?

Answer: Left IO Objective: 3 2) What other injection(s) can be considered if needle penetrations are not limited?

Answer: infiltrations #11 and #12; or Left ASA and MSA Objective: 3 3) Which needle length and gauge is typically used for injection(s) of #11 and #12?

Answer: short 25 or 27 gauge Objective: 3 Use the information provided in the Case Study below to answer the questions that follow.

Case Study 2 The treatment plan for Florence Anderson includes restoration of teeth #6, #7, and #8.

1) Which injection(s) is/are needed for pulpal and facial soft tissue anesthesia for #6, #7, and #8 with the least number of needle penetrations?

Answer: right ASA Objective: 3 2) Which other injection(s) can be considered if needle penetrations are not limited?

Answer: infiltrations #6, #7, #8 Objective: 3 3) Which needle length and gauge is typically used for injection(s) of #6, #7, and #8?

Answer: short 25 or 27 gauge Objective: 3 Use the information provided in the Case Study below to answer the questions that follow.

Case Study 3 The treatment plan for Jim Martin includes an MOD restoration on tooth #14.

1) Which injection(s) is/are needed for pulpal anesthesia of #14?

Answer: infiltration #14; or left PSA and MSA Objective: 3 2) Which needle length and gauge is typically used for injection(s) of #14

Answer: short 25 or 27 gauge Objective: 3 Use the information provided in the Case Study below to answer the questions that follow.

Case Study 4 The treatment plan for Ralph Cooper includes a DO restoration for #6, and an MO for #3. His medical assessment indicated he takes warfarin, an anticoagulant medication.

1) Which injection(s) presents the least risk for Mr. Cooper? Why? Answer: Infiltration injections for both #3 and #6 are the safest choice of injections for treatment of #3 and #6 due to the minimal risk of vessel injury. PSA nerve blocks should be avoided because the pterygoid plexus and maxillary artery can be nicked during this injection with excessive bleeding possible due to warfarin’s anticoagulant properties.

Objective: 3 2) Which needle length and gauge are used for injection(s) of #6 and #3?

Answer: short 25 or 27 gauge Objective: 3 3) What volume of solution is recommended for anesthesia of #6 and #3?

Answer: 0.6 mL (1/3 of a cartridge) per tooth Use the information provided in the Case Study below to answer the questions that follow.

Case study 5 Jana Adams is a semi-retired 65 year-old. She is a routine patient and reliable historian. She reports no change in her health and takes a daily multi-vitamin with minerals. Her blood pressure is 126/80 today, pulse 76, and respiration 14 breaths per minute. She is 5’ 1” and weighs 130 pounds. Ms. Adams is scheduled for the replacement of two discolored restorations on the facial aspects of #7 and #8. She has had no past difficulties with local anesthesia and tolerated the injection procedure today. The preparation of #7 is completed in comfort however shortly after the preparation of tooth #8 begins Ms. Adams reports the tooth is painful.

1) What initial injection technique(s) will provide pulpal and facial gingival anesthesia with the least penetrations?

Answer: right ASA Objective: 3 2) Which needle length and gauge is used for injection(s) of #7 and #8?

Answer: short 25 or 27 gauge Objective: 3 3) What is the most likely cause of the pain experienced during the preparation of #8?

Answer: Cross-innervation of the terminal fibers of the left ASA nerve is suspected.

4) What additional injection(s) provide(s) the best option for profound anesthesia of #8?

Answer: Infiltration #8.

Objective: 3

Chapter 13 Injections for Palatal Pain Control True or false 1) The nasopalatine nerve is a terminal and short branch of the PSA nerve.

A) True B) False Answer: B Explanation: B) The nasopalatine nerve is a terminal and longest branch of the PSA nerve.

Objective: 2 2) Excessive blanching more commonly occurs when administering solutions that contain vasoconstrictors.

A) True B) False Answer: A Objective: 2 3) The GP nerve branches from the maxillary nerve within the pterygopalatine fossa and is anesthetized by a GP nerve block just prior to its entrance to the pterygopalatine canal.

A) True B) False Answer: B Explanation: B) The GP nerve branches from the maxillary nerve within the pterygopalatine fossa and is anesthetized by a GP nerve block after it exits through the greater palatine foramen on the hard palate of the maxilla.

Objective: 2 4) The gate control theory suggests that pressure anesthesia blocks the stimulation of nonnociceptive fibers.

A) True B) False Answer: B Explanation: B) In dentistry, the gate control theory suggests that by stimulating non-nociceptive fibers of other nerves, pressure anesthesia blocks the stimulation of nociceptive fibers and related pain sensations from the teeth and their supporting structures.

Objective: 2 5) The rate of deposition of solution for all palatal injections should be 0.4 mL over 40 seconds.

A) True B) False Answer: B Explanation: B) The rate of deposition varies for palatal injections based on the location of the injection site and the need for comfort and risk of tissue damage due to trauma and/or ischemia.

Objective: 2

6) It should take twice the time to deposit a cartridge of a 4% local anesthetic solution compared to a 2% solution.

A) True B) False Answer: A Objective: 2 7) For palatal injections, if swelling or blanching occurs, withdraw the needle and choose another penetration site.

A) True B) False Answer: B Explanation: B) If either swelling or blanching occurs, continue with the deposition only after pausing to allow for diffusion and absorption of the solution from areas of swelling and for the mucosa to return to normal coloration.

Objective: 2 8) A nasopalatine nerve block will anesthetize palatal soft and osseous tissue in the anterior third of the palate, from canine to canine.

A) True B) False Answer: A Objective: 3 9) The optimum penetration site for the NP nerve block is adjacent to the narrowest portion of the incisive papilla to facilitate ease of insertion.

A) True B) False Answer: B Explanation: B) The optimum penetration site for the NP nerve block is adjacent to the widest anteroposterior aspect of the incisive papilla.

Objective: 3 10) The P-ASA injection successfully anesthetizes bilateral nasopalatine and ASA nerves.

A) True B) False Answer: A Objective: 3 11) A P-ASA injection requires a 27 gauge long needle due to the increased depth of insertion.

A) True B) False Answer: B Explanation: B) A short needle has adequate length for a P-ASA injection.

Objective: 3 12) The field of anesthesia for a P-ASA injection includes the same structures that are innervated

by the right and left NP and anterior branches of the ASA nerves.

A) True B) False Answer: A Objective: 3 13) The rate of deposition of anesthetic solution is the same for the NP and P-ASA injections.

A) True B) False Answer: B Explanation: B) The rate of deposition of anesthetic solution for the NP is 0.4 mL over 40 seconds compared to the slower rate of deposition for the P-ASA injection, which is 0.5 mL over 60 seconds.

Objective: 3 14) The AMSA injection does not anesthetize labial tissues.

A) True B) False Answer: A Objective: 3 15) The rate of deposition for an AMSA injection is 0.4 mL over 40 seconds.

A) True B) False Answer: B Explanation: B) The rate of deposition for an AMSA injection is 0.5 mL (or less) over 60 seconds.

Objective: 3 16) The penetration site for a GP injection is in the fossa located anterior to the GP foramen (also referred to as the anterior depression).

A) True B) False Answer: A Objective: 3 17) Anesthesia of the soft palate is common because the lesser palatine nerve and foramen are located immediately posterior to the greater palatine foramen.

A) True B) False Answer: A Objective: 3 18) The needle pathway for a GP nerve block is 6 to 8 mm through dense mucosal tissue.

A) True B) False Answer: A

Objective: 3 19) An extra short needle is not used for GP nerve blocks due to the penetration location at a more posterior position in the palate.

A) True B) False Answer: B Explanation: B) A 27 or 30 gauge short or x-short needle is commonly used.

Objective: 3 Fill in the blank 1) The two-step method for pre-anesthesia for palatal injections includes a one-minute application of topical anesthesia and .

Answer: one minute of pressure anesthesia Objective: 2 2) Topical anesthetic patches may provide a Answer: 4 to 6 mm Objective: 2

depth of anesthetic penetration.

3) The nasopalatine nerve is the longest branch of the posterior superior nasal branch of the nerve.

Answer: maxillary Objective: 2 4) The theory explains why pressure anesthesia is effective in palatal nerve blocks.

Answer: gate control Objective: 2 5) In order to avoid discomfort during palatal injections, the Answer: rate of deposition Objective: 2

is reduced.

6) Computer-controlled local anesthetic devises (CCLAD) are ideal for palatal nerve blocks because they provide electronically regulated recommended for all palatal injections.

Answer: slow rates of deposition Objective: 2 7) P-ASA and AMSA nerve blocks are advantageous for cosmetic procedures because anesthesia of the is typically avoided.

Answer: labial tissue (upper lip) Objective: 2 8) Rapid deposition of anesthetic solutions containing vasoconstrictors should be avoided to prevent .

Answer: ischemia

Objective: 2 9) The use of 4% anesthetic solutions in the palate should be accompanied by very depositions.

Answer: slow Objective: 2 Multiple choice 1) Which one of the following is the most important consideration for palatal local anesthetic procedures?

A) Apply topical anesthetic for one to two minutes B) Use ester topical anesthetic drug C) Administer solution slowly D) Withdraw the needle if swelling and ischemia occur Answer: C Objective: 2 2) Which statement correctly describes one precaution when using 4% local anesthetic drugs for palatal injections?

A) Deposit 0.4 mL over forty seconds B) Deposit approximately twice as slowly as for 2% solutions C) Use a 4% solution without a vasoconstrictor D) Do not use 4% local anesthetic drugs for palatal injections Answer: B Objective: 2 3) The most common cause of failure of palatal nerve blocks is: A) Solution deposited too far from deposition site B) Solution deposited too rapidly and it backflows into the mouth C) Vasoconstrictor constricts the vessels preventing the flow of solution to the nerve D) Inadequate topical and pressure anesthesia prevent adequate penetration depth Answer: A Objective: 2 4) Which of the following nerve branches anesthetizes the upper lip and skin of the cheek?

A) Facial nerve B) Trigeminal nerve, division 1 C) Trigeminal nerve, division 2 D) Trigeminal nerve, division 3 Answer: C Objective: 2 5) Which of the following statements is true of the NP nerve block?

A) Provides highest rate of positive aspiration of palatal injections B) Provides more durable anesthesia than other palatal injections C) Provides bilateral anesthesia

D) Contact with bone should be avoided Answer: C Objective: 3 6) Which one of the following is not anesthetized by a nasopalatine nerve block?

A) Soft tissues of the anterior one third of the palate B) Lingual gingiva, canine to canine C) Maxillary incisors and canines D) Incisive papilla Answer: C Objective: 3 7) Which location represents the correct penetration site for a nasopalatine nerve block?

A) Palatal mucosa lateral to the widest anteroposterior dimension of the incisive papilla B) Palatal mucosa at the base of the incisive papilla on the right or left side of the incisive papilla C) Midline in the incisive papilla at the widest anteroposterior dimension of the incisive papilla D) Perpendicular to the incisive papilla at the widest dimension Answer: A Objective: 3 8) Which of the following represents the correct penetration depth for a nasopalatine nerve block?

A) 2 to 3 mm B) 4 to 7 mm C) 6 to 12 mm D) 10 to 16 mm Answer: B Objective: 3 9) Which statement describing the injection steps for a nasopalatine nerve block is not correct?

A) Use a two-step pre-anesthesia method B) Penetrate parallel to the incisive canal until bone is contracted C) After contacting bone, withdraw 1 mm D) Deposit solution at a rate of 0.4 mL over forty seconds Answer: B Objective: 3 10) What is the most likely cause of unilateral failure of a nasopalatine nerve block?

A) Use of an extra-short needle B) Inadequate volume of anesthesia C) Opposite wall of canal is not contacted with needle D) Backflow of solution along the needle pathway Answer: C Objective: 3 11) Which of the following is the best indication of a P-ASA nerve block?

A) Pain management of palatal tissue

B) Pain management for extensive restorative therapy C) Pain management for cosmetic dental procedures D) Pain management for anterior facial and lingual soft tissues Answer: C Objective: 3 12) Which structures are not anesthetized by the P-ASA nerve block?

A) Facial and palatal soft and hard tissues associated with the teeth and the pulps of the teeth canine to canine B) Structures anesthetized by right and left MSA nerve blocks C) Structures innervated by the right and left nasopalatine nerves D) Structures innervated by the right and left anterior branches of the ASA nerves Answer: B Objective: 3 13) Which statement best describes the needle pathway for a P-ASA nerve block?

A) Advance needle to a depth of 6 to 10 mm in the center of the canal B) Advance needle to a depth of 4 to 6 mm within the canal C) Advance needle parallel to the long axis of the central incisors to a depth of 6 to 10 mm into the canal D) Using the wall of the canal as a guide, advance needle parallel to the long axis of the central incisors to depth of 6 to 10 mm into the canal Answer: D Objective: 3 14) What is the correct penetration depth for a P-ASA nerve block?

A) 2 to 6 mm B) 2 to 10 mm C) 4 to 6 mm D) 6 to 10 mm Answer: D Objective: 3 15) Which needle is commonly used for a P-ASA nerve block?

A) 25 gauge short B) 27 gauge long C) 27 gauge short D) 25 gauge extra short Answer: C Objective: 3 16) What is the correct deposition rate for the P-ASA nerve bock?

A) 0.5 mL over 60 seconds B) 0.5 mL over 90 seconds C) 1.8 mL over 1 minute D) 1.8 mL over 2 minutes Answer: A Objective: 3

17) What is the typical minimum volume of anesthetic solution deposited for P-ASA nerve blocks?

A) 0.5 to 1.0 mL B) 0.9 to 1.8 mL C) 1.4 to 1.8 mL D) 1.0 mL Answer: C Objective: 3 18) What nerve branch can provide assessory innervation causing incomplete anesthesia following a P-ASA nerve block?

A) Facial nerve branch B) Nasal nerve branch C) MSA nerve D) Greater palatine Answer: D Objective: 3 19) Which of the following best describes the nerves anesthetized by the AMSA nerve block?

A) GP, MSA, NP B) NP, ASA, MSA C) NP, ASA, MSA, PSA D) ASA, MSA, NP, GP Answer: D Objective: 3 20) Which of the following is not a clinical advantage of the AMSA nerve block?

A) No anesthesia of associated labial tissues for cosmetic procedures B) Profound pulpal anesthesia of maxillary first molar C) Less total drug volume administered D) Requires one needle penetration Answer: B Objective: 3 21) The field of anesthesia for an AMSA nerve block includes: A) Pulps of central and lateral incisors, canine, premolars, and molars on the anesthetized side B) Pulps of central and lateral incisors, canine, and premolars, and upper lip and facial gingival tissues on the anesthetized side C) Pulps and lingual gingival of the central and lateral incisors, canine, premolars, and molars bilaterally D) Pulps of the central and lateral incisors, canine, and premolars, and palatal tissues from the central incisors through the second molar on the side of injection on the anesthetized side Answer: D Objective: 3 22) What is the optimum site of penetration for an AMSA nerve block?

A) Mucogingival junction between the maxillary premolars B) Junction between the vertical and horizontal aspects of the palate at an imaginary line drawn from the gingival margin between the maxillary second premolar and the first molar C) Between the premolars along an imaginary line drawn from the base of the interdental papilla D) Junction between premolars approximately halfway from the median palatine raphe to the gingival margin Answer: D Objective: 3 23) What is a typical minimum volume of anesthetic solution deposited for an AMSA nerve block?

A) 0.2 to 0.6 mL B) 0.6 to 1.8 mL C) 0.9 to 1.2 mL D) 1.2 to 1.8 mL Answer: C Objective: 3 24) What is the correct deposition rate for an AMSA nerve block?

A) 0.5 mL over 60 seconds B) 0.3 mL over 40 seconds C) 0.5 mL over 30 seconds D) 1.2 mL over 90 seconds Answer: A Objective: 3 25) Which of the following statements is the most accurate description of the field of anesthesia for a greater palatine nerve block?

A) Soft and hard palatal tissues unilaterally from the midline B) Soft and hard palatal tissues bilaterally from the midline C) Soft and hard palatal tissues unilaterally distal to the canine D) Soft and hard palatal tissues unilaterally from the canine to the molars Answer: C Objective: 3 26) Terminal fibers of the GP nerve overlap the: A) Lesser palatine nerves B) Nasopalatine nerves C) Anterior superior alveolar nerves D) Opposite greater palatine nerve Answer: B Objective: 3 27) What is the penetration site for a GP nerve block?

A) Slightly anterior to the greater palatine foramen B) Greatest depression of the greater palatine foramen C) Junction of the maxillary and palatal bones medial to an imaginary line drawn between the

maxillary first and second premolars D) Slightly distal to the greater palatine foramen Answer: A Objective: 3 28) What is the approximate depth of penetration for a GP nerve block?

A) 2 mm B) 2 to 6 mm C) 6 to 10 mm D) 9 to 12 mm Answer: C Objective: 3 29) What is a typical minimum dose of anesthetic solution deposited for GP nerve blocks?

A) 1 stopper width (0.2 mL) B) 2 to 3 stopper widths (0.4 – 0.6 mL) C) 0.9 to 1.2 mL D) One-half of a cartridge Answer: B Objective: 3 30) What is the recommended maximum dose of a 4% anesthetic solution for a GP nerve block?

A) 0.3 mL B) 0.6 mL C) 0.9 mL D) 1.2 mL Answer: A Objective: 3 Short answer/essay 1) What are the two most important considerations for patient comfort for all palatal local anesthetic procedures?

Answer: The two most important considerations for patient comfort for all palatal local anesthetic procedures are use of a two-step pre-anesthesia technique consisting of a 1-minute topical anesthesia application followed by an additional minute of pressure anesthesia, and the slow administration of anesthetic solutions never exceeding 1.8 mL over 2 to 3 minutes.

Objective: 2 2) Explain the gate control theory of pain perception related to the use of pressure anesthesia for palatal injections.

Answer: The gate control theory of pain perception suggests that there are neurological gates that can block signals to the brain. This theory asserts that the perception of physical pain is not based solely on the activation of nociception. The experience of pain is a modulation between activation of large non-pain-transmitting (non-nociceptive) nerve fibers and small paintransmitting (nociceptive) nerve fibers; the activation of large non-nociceptive fibers can interfere with signals from small nociceptive fibers; and the stimulation of non-nociceptive fibers

is greater than the stimulation of nociceptive fibers causing pain to be inhibited or blocked.

The stimuli of pressure anesthesia therefore blocks the pain stimuli caused by the penetration of the needle.

Objective: 2 3) Describe the two-step method of topical anesthesia.

Answer: The two-step method of topical anesthesia includes application of a topical anesthetic for one minute followed by one minute of pressure applied with a cotton swab or a smooth, blunt-ended instrument handle until the site blanches.

Objective: 2 4) Discuss the procedural modification necessary if excessive tissue blanching and bulging occur when depositing anesthetic solutions for palatal nerve blocks.

Answer: If either excessive tissue blanching or bulging occurs, continue with the deposition only after pausing to allow for diffusion and absorption of the solution from areas of swelling, and for tissue coloration to return to normal. This will reduce tissue damage from stretching and will allow normal blood flow to return to the area. In either instance, when deposition proceeds it should occur at an even slower rate (less than one cartridge per three minutes).

Objective: 2 5) Explain the advantages of using P-ASA and AMSA nerve block techniques.

Answer: The P-ASA and AMSA nerve block reduce the total number of injections necessary and therefore the total volumes of solution necessary to achieve the same field of anesthesia as traditional approaches. The labial tissues are not anesthetized with these techniques; therefore, they work especially well for cosmetic procedures that involve assessment of the patient "smile lines" and for ease in speaking.

Objective: 3 6) Color in the field of anesthesia and list the structures anesthetized by a nasopalatine nerve block.

Answer:

Objective: 3 7) Color in the field of anesthesia and list the structures anesthetized by a P-ASA nerve block.

Answer:

Objective: 3 8) Color in the field of anesthesia and list the structures anesthetized by an AMSA nerve block.

Answer:

Objective: 3

9) Color in the field of anesthesia and list the structures anesthetized by a GP nerve block.

Answer:

Objective: 3

Use the information provided in the Case Study below to answer the questions that follow.

Case Study 1 The treatment plan for Marjorie Dickens includes crown preparations for teeth #7, #8, and #9.

1) Which injection(s) is/are needed for pulpal, facial, and palatal soft tissue anesthesia for #7, #8, and #9 with the least number of needle penetrations planned?

Answer: P-ASA Objective: 3 2) Which other injection choice(s) can be considered if needle penetrations are not limited?

Answer: infiltrations #7, #8, #9, NP Objective: 3 3) Which needle(s) should be used?

Answer: short 25 or 27 gauge Objective: 3 Use the information provided in the Case Study below to answer the questions that follow.

Case Study 2 The treatment plan for Jim Martin includes an MOD restoration on tooth #14 requiring rubber dam placement on tooth #15.

1) Which injection(s) is/are needed for pulpal and soft tissue anesthesia?

Answer: left PSA, MSA, and GP Objective: 3 2) Which needle(s) should be used?

Answer: short 25 or 27 gauge Objective: 3 3) The gingivopalatal aspect of #14 and #15 has failed to be anesthetized. What is the most common cause(s) for failure of anesthesia following a GP injection?

Answer: The most common causes of anesthetic failure following a GP nerve block include deposition of solution that is too shallow, too lateral, or too medial to the foramen as well as inadequate volumes of solution.

Objective: 3

Chapter 14 Injections for Mandibular Pain Control Match the following A) Medial border of retromolar triangle B) Mental nerve block target C) Anterior border of ramus D) IA target E) Persistent anesthesia F) True mandibular block G) Requires post-injection pressure H) Bony obstruction I) Muscle soreness J) Closed mouth technique 1) Akinosi (VA) nerve block Objective: 1 2) Coronoid notch Objective: 1 3) Gow-Gates nerve block Objective: 1 4) Incisive foramen Objective: 1 5) Incisive nerve block Objective: 2 6) Internal oblique ridge Objective: 2 7) Mandibular foramen Objective: 2 8) Paresthesia Objective: 2 9) Premature contact Objective: 2 10) Trismus Objective: 2

Answers: 1) J 2) C 3) F 4) B 5) G 6) A 7) D 8) E 9) H 10) I True or false 1) The inferior alveolar nerve is the largest branch of the anterior division of the mandibular nerve.

A) True B) False Answer: B Explanation: B) The inferior alveolar nerve is the largest branch of the posterior division of the mandibular nerve.

Objective: 2 2) The IA nerve traverses lateral to the sphenomandibular ligament.

A) True B) False Answer: A Objective: 2 3) The IA artery branches from the maxillary artery and descends through the pterygomandibular space.

A) True B) False Answer: A Objective: 2 4) The three key landmarks for the IA nerve block are the pterygomandibular raphe, the coronoid notch, and the external oblique ridge.

A) True B) False Answer: B Explanation: B) The three key landmarks for the IA nerve block are the pterygomandibular raphe, the coronoid notch, and the internal oblique ridge.

Objective: 2 5) The deposition site for an IA nerve block is superior to the mandibular foramen on the medial surface of the ramus.

A) True B) False Answer: A Objective: 3 6) The IA injection has a 10 to 15% positive aspiration rate.

A) True B) False Answer: A Objective: 3

7) The lingual nerve is usually anesthetized along with the IA nerve when an IA nerve block is administered.

A) True B) False Answer: A Objective: 2 8) The buccal nerve is anesthetized by an IA nerve block.

A) True B) False Answer: B Explanation: B) The buccal nerve is rarely anesthetized during an IA nerve block. The buccal nerve can be anesthetized using a separate injection, the buccal nerve block.

Objective: 2 9) Profound anesthesia of the incisive and mental nerves is achieved by a mental nerve block.

A) True B) False Answer: B Explanation: B) Profound anesthesia of the incisive nerve is typically not achieved unless finger pressure is applied at the site of injection following the deposition of solution, which forces the anesthetic through the mental foramen. This is referred to as a mental incisive or incisive nerve block rather than a mental nerve block.

Objective: 2 10) The Gow-Gates nerve block will achieve buccal and lingual anesthesia.

A) True B) False Answer: A Explanation: A) The Gow-Gates nerve block will achieve anesthesia of the lingual nerve (all of the time) and the buccal nerve (the majority of the time).

Objective: 3 Fill in the blanks 1) A needle is recommended for an inferior alveolar nerve block.

Answer: 25 gauge long Objective: 3 2) The penetration site for an inferior alveolar nerve block is slightly pterygomandibular raphe.

Answer: lateral Objective: 3 3) The largest branch of the mandibular division of the trigeminal nerve is the Answer: inferior alveolar nerve Objective: 2

to the

.

4) A minimum of mL of anesthetic solution is required for an inferior alveolar nerve block due to the large diameter of the nerve.

Answer: 1.5 Objective: 3 5) The lingual nerve is usually located Answer: medial and anterior Objective: 2

to the inferior alveolar nerve.

6) The buccal nerve crosses the coronoid notch of the ramus at the level of the Answer: occlusal plane Objective: 2

.

7) The deposition site for a buccal nerve block is at the buccal aspect of the ramus, lateral to the as the nerve passes over the anterior border of the ramus.

Answer: external oblique ridge Objective: 3 8) The mental nerve typically exits the mandible between the Answer: apices of the first and second premolars Objective: 2

.

9) The depth of insertion for a mental nerve block is typically Answer: 4 to 6 Objective: 3

mm.

10) A typical minimum recommended volume of anesthetic solution for a mental nerve block is mL. Answer: 0.6 Objective: 3 11) The field of anesthesia for an incisive nerve block includes the buccal mucous membrane and skin of the lower lip and chin, and the anterior to the mental foramen, to the midline.

Answer: pulps and periosteum of the teeth Objective: 3 12) Following the deposition of anesthetic solution for an incisive nerve block, applied directly and steadily over the mental foramen.

Answer: pressure Objective: 3

is

13) A nerve block anesthetizes an entire mandibular quadrant.

Answer: Gow-Gates Objective: 3 14) The deposition site for a Gow-Gates nerve block is often

mm from the inferior

alveolar nerve.

Answer: 5 to 10 Objective: 3 15) Deposit a recommended minimum of nerve block.

Answer: 1.8 Objective: 3

mL of anesthetic solution for a Gow-Gates

16) Crucial to the success of Gow-Gates nerve blocks, patients must remain in a position throughout the procedure for up to 2 minutes following deposition of anesthetic solution.

Answer: wide open Objective: 17) The needle pathway is to the posterior segment of the maxillary occlusal plane during a Vazirani-Akinosi nerve block.

Answer: parallel Objective: 3 18) Deposit a minimum of block.

Answer: 1.8 Objective: 3

mL of anesthetic solution for a Vazirani-Akinosi nerve

19) A Vazirani-Akinosi nerve block is also called the Answer: closed mouth Objective: 3

technique.

20) Prolonged anesthesia following local anesthetic procedures is called Answer: paresthesia Objective: 3

.

Multiple choice 1) Which of the following vessels is not located within the infratemporal and pterygomandibular spaces?

A) Maxillary artery and vein B) Middle meningeal artery and vein C) Inferior alveolar artery and vein D) Facial artery and vein Answer: D Objective: 2 2) Which teeth and soft tissues are innervated by the inferior alveolar nerve?

A) Mandibular molars and premolars, and buccal gingiva B) Mandibular teeth from the premolars to the incisors and buccal soft tissues

C) Mandibular teeth to the midline and the buccal soft tissues D) Mandibular teeth to the midline and buccal soft tissue from premolars to the midline Answer: D Objective: 2 3) Which of the following reasons best describes why it is advantageous to use a 25 gauge long needle for an IA nerve block?

A) Greater depth of penetration, less needle flexibility when contacting bone to determine deposition site, high risk of positive aspiration B) Ease of penetration through fibrous submucusal tissues, greater depth of penetration, low risk of positive aspiration C) Greater depth of penetration, greater accuracy of aspiration outcomes, less needle deflection D) Comfort level during penetration, greater depth of penetration, low risk of negative aspiration Answer: C Objective: 3 4) Which of the following best describes the correct syringe position for an IA nerve block?

A) Over the canine on the contralateral side of the mouth above the occlusal plane B) Over the premolars on the contralateral side of the mouth angled 45 degrees from the occlusal plane C) Over the premolars on the contralateral side of the mouth above and parallel to the occlusal plane D) At the labial commissure over the molars on the contralateral side of the mouth Answer: C Objective: 3 5) Which of the following is not a helpful landmark to identify the penetration site for an inferior alveolar nerve block?

A) Mandibular occlusal plane B) Pterygomandibular raphe C) Maxillary occlusal plane D) Internal oblique ridge Answer: C Objective: 2 6) Which of the following correctly describes the needle pathway for an IA nerve block?

A) Lateral to the pterygomandibular raphe, into the pterygomandibular space; passing lateral to the medial pterygoid muscle, lingual nerve, and sphenomandibular ligament; and superior to the lingula and mandibular foramen B) Lateral to the pterygomandibular raphe, into the pterygomandibular space; passing medial to the medial pterygoid muscle; posterior and medial to the lingual nerve, lateral to the sphenomandibular ligament; and superior to the lingula and mandibular foramen C) Medial to the pterygomandibular raphe, into the infratemporal space; passing lateral to the medial pterygoid muscle, lingual nerve, and sphenomandibular ligament; and superior to the lingula and mandibular foramen D) Medial to the pterygomandibular raphe, into the pterygomandibular space; passing lateral to the medial pterygoid muscle, lingual nerve, and sphenomandibular ligament; and superior to the

lingula and mandibular foramen Answer: A Objective: 3 7) Which of the following statements best describes the technique error(s) that results in premature contact with bone immediately after penetration for an IA nerve block?

A) Penetration too high and too lateral to pterygomandibular raphe B) Penetration too low and too lateral to pterygomandibular raphe C) Penetration too medial to the internal oblique ridge in relationship to the pterygomandibular raphe D) Angle of the syringe was anterior to the premolars Answer: B Objective: 3 8) Which anatomical structure should be medial to the needle at the IA deposition site?

A) Pterygomandibular raphe B) Hylomandibular ligament C) Stylomandibular ligament D) Spenomandibular ligament Answer: D Objective: 3 9) What is the recommended volume of local anesthetic solution for an inferior alveolar nerve block for an adult?

A) 0.6 to 1.0 mL B) 0.9 to 1.5 mL C) 1.2 mL D) 1.5 to 1.8 mL Answer: D Objective: 3 10) The typical rate of positive aspiration for an IA nerve block is: A) 5% to 15% B) 10% to 15% C) 10% to 20% D) 15% to 25% Answer: B Objective: 3 11) What is the most probable IA nerve block penetration error when immediate premature contact is made with bone?

A) Too low and/or too lateral to the pterygomandibular raphe B) Too low and/or too medial to the pterygomandibular raphe C) Too high and/or too lateral to the sphenomandibular ligament D) Too low and/or too medial to the sphenomandibular ligament Answer: B Objective: 3

12) What is the best correction to make during an IA injection when premature bony contact is met immediately after penetration?

A) Reposition syringe toward the mandibular incisors B) Reposition syringe toward the contralateral canine C) Reposition syringe toward the first molar D) Withdraw the syringe Answer: D Objective: 3 13) What is the best correction to make during an IA injection when premature bony contact is met at less than one half of the penetration depth?

A) Reposition syringe toward the contralateral canine and re-advance the needle until bony contact is met.

B) Partially withdraw the needle, reposition syringe over the contralateral canine and re-advance the needle until bony contact is met.

C) Partially withdraw the needle, reposition syringe over the contralateral canine, advance needle to clear resistance, then reposition the syringe over the premolars, and re-advance the needle until bony contact is met.

D) Withdraw the syringe to minimize tissue trauma and reinject.

Answer: C Objective: 3 14) What is the best correction to make during an IA injection when no bony contact is met at target depth?

A) Reposition the syringe over the contralateral canine and re-advance the needle until bony contact is met.

B) Withdraw the needle at least half way, reposition the syringe over the molars, re-advance the needle until bone is met.

C) Aspirate in two plane to assure negative aspiration and inject 1.8 mL. D) Withdraw the needle and select an alternate technique.

Answer: B Objective: 3 15) Which of the following is a possible complication of an IA nerve block when penetration is too deep?

A) Piercing the parotid gland and numbing the hypoglossal nerve B) Piercing a vessel in the pterygoid plexus increasing potential of hematoma C) Piercing the parotid gland and numbing the facial nerve D) Piercing the external carotid artery causing a severe hematoma Answer: C Objective: 3 16) Which of the following injections is not an alternate for an unsuccessful anesthesia of a mandibular first molar?

A) Incisive nerve block B) Akinosi nerve block C) Gow-Gates nerve block D) Periodontal ligament injection Answer: A Objective: 3 17) What is the position of the lingual nerve in relation to the inferior alveolar nerve?

A) Anterior and lateral B) Inferior and lateral C) Anterior and medial D) Posterior and medial Answer: C Objective: 2 18) What is minimum recommended volume of anesthetic solution administered for a lingual nerve block?

A) 0.2 mL B) 0.6 mL C) 0.9 mL D) 1.5 mL Answer: A Objective: 3 19) Which of the following nerve block injections is safest when avoiding the risk of lingual nerve injury when a procedure requires lingual anesthesia?

A) Incisive B) Inferior alveolar C) Vazirani-Akinosi D) Gow-Gates Answer: D Objective: 3 20) Which of the following correctly describes the buccal nerve pathway?

A) Crosses the coronoid notch and innervates the medial pterygoid and buccinator muscles B) Crosses the coronoid notch at the level of the mandibular occlusal plane C) Crosses at the height of the coronoid notch and divides into several branches that innervate the buccal mucosa and gingival D) Divides into several branches and crosses the coronoid notch and innervates the buccinators muscle, mucosa and gingiva of the mandibular molars Answer: B Objective: 2 21) Which of the following describes the field of anesthesia for the buccal nerve block?

A) Facial mucosa, gingiva and pulps of mandibular molars B) Facial and lingual mucosa and gingiva of mandibular molars C) Facial soft tissue and periodontium of mandibular molars

D) Facial soft tissue and periodontium of mandibular molars to the midline Answer: B Objective: 2 22) What is the insertion depth for a buccal nerve block?

A) 2 mm B) 3 to 4 mm C) 6 mm D) 4 to 8 mm Answer: B Objective: 3 23) What is minimum recommended volume of anesthetic solution administered for a buccal nerve block?

A) 0.2 to 0.3 mL B) 0.6 mL C) 0.9 mL D) 1.0 to 1.5 mL Answer: A Objective: 3 24) Which of the following procedures would not require a buccal nerve block?

A) Periodontal surgical procedure for teeth #27 to 29 B) Placement of a rubber dam on #31 C) Root planning of teeth #18 to 20 D) Crown preparation of tooth #30 Answer: B Objective: 3 25) The mental nerve is a terminal branch of the A) Cervical nerve B) Inferior alveolar nerve C) Incisive nerve D) Mylohyoid nerve Answer: B Objective: 2 26) The mental foramen can typically be palpated A) At the facial apices of the mandibular first or second premolar B) Between the facial apices of the mandibular first molar and second premolar C) Between the apices of the mandibular first premolar and the canine D) It is best to identify the location on a radiograph as it is difficult to palpate Answer: A Objective 2 27) What is the correct depth of penetration for a mental nerve block?

A) 2 to 4 mm

B) 4 to 6 mm C) 4 to 10 mm D) 6 to 10 mm Answer: B Objective: 3 28) What is the correct volume of anesthetic solution for a mental nerve block?

A) 0.4 mL B) 0.4 mL C) 0.6 mL D) 1.0 mL Answer: C Objective: 3 29) The incisive nerve is a terminal branch of the A) Mental nerve B) Mylohyoid nerve C) Inferior alveolar nerve D) Cervical nerve Answer: C Objective: 2 30) What is the correct depth of penetration for an incisive nerve block?

A) 2 to 4 mm B) 4 to 6 mm C) 4 to 10 mm D) 6 to 10 mm Answer: B Objective: 3 31) Which of the following represents the recommended volume of anesthetic solution and depth of penetration for an incisive nerve block?

A) 2 to 4 mm; 0.4 mL B) 4 to 6 mm; 0.4 mL C) 4 to 6 mm; 0.6 mL D) 6 to 10 mm; 0.9 mL Answer: C Objective: 3 32) Which of the following is the recommended clinician position when administering an incisive nerve block using a vertical syringe approach?

A) 6 o'clock B) 8 o'clock C) 10 o'clock D) 12 o'clock Answer: D Objective: 3

33) Which of the following best describes the nerves anesthetized by a Gow-Gates nerve block?

A) Inferior alveolar, incisive, mental, lingual, buccal B) Inferior alveolar, lingual, mylohyoid, auriculotemporal, buccal C) Inferior alveolar, mylohyoid, auriculotemporal, zygomaticofacial D) Inferior alveolar, incisive, mental, lingual, buccal, zygomaticofacial Answer: B Objective: 2 34) Which of the following lists describes the correct inferior to superior deposition locations of the mandibular nerve block techniques within the pterygomandibular space?

A) IA, Gow-Gates, Akinosi B) IA, Akinosi, Gow-Gates C) Gow-Gates, IA, Akinosi D) Akinosi, IA, Gow-Gates Answer: B Objective: 3 35) What is the minimal volume of anesthetic solution recommended for a Gow-Gates nerve block?

A) 0.9 mL B) 1.5 mL C) 1.8 mL D) 3.6 mL Answer: C Objective: 3 36) Which of the following is not a helpful landmark when determining the penetration site and needle pathway for a Gow-Gates nerve block?

A) Depth of the coronoid notch B) Flare of the tragus of the ear C) Labial commissure D) Mesiolingual cusp of the maxillary second molar Answer: A Objective: 3 37) Which of the following statements best explains the need to reposition a patient upright with the mouth remaining wide open for up to two minutes after the completion of a Gow-Gates injection?

A) An open mouth allows access to safely remove the syringe and bite block from the mouth, and provides time to rinse and suction the area of injection while preventing aspiration risk in an upright position B) An upright, open mouth position allows gravity to improve the flow of solution toward the IA nerve, which is located 5 to 10 mm from the deposition site C) An open mouth allows the condyle to remain fully translated over the articular eminence, preventing the diffusion of solution away from the IA nerve; the upright position facilitates diffusion toward the IA nerve

D) An open mouth allows withdrawal of the syringe without contacting the mandibular occlusal plane; the upright position improves diffusion of the solution toward the IA nerve Answer: C Objective: 3 Short answer/essay 1) What are the three key intraoral landmarks for inferior alveolar nerve blocks?

Answer: The three key intraoral landmarks for inferior alveolar nerve blocks are the pterygomandibular raphe, the coronoid notch on the anterior border of the ramus of the mandible, and the internal oblique ridge on the medial surface of the mandible close to the molars and continuing posteriorly.

Objective: 2 2) Discuss technique errors that lead to failure of anesthesia of the inferior alveolar nerve.

Answer: Technique-related errors that lead to failure of anesthesia of the inferior alveolar nerve occur when deposition is too: 1. Shallow (less than 20 to 25 mm for a typical adult) 2. Low (solution diffuses below the foramen due to gravity) 3. Medial (the sphenomandibular ligament forms a soft tissue barrier to diffusion) 4. Posterior (risks depositing into the parotid gland) Objective: 3 3) Explain why the lingual nerve is usually anesthetized when an IA nerve block is administered.

Answer: When IA nerve blocks are administered, the lingual nerve is usually anesthetized along with the inferior alveolar nerve. This occurs because the lingual nerve is typically located medial and anterior to the inferior alveolar nerve and is therefore along the pathway of the needle as it approaches the IA nerve. The small drops of anesthetic solution deposited ahead of the needle and diffusion from the site of deposition of the IA block are usually sufficient to anesthetize the lingual nerve.

Objective: 3 4) Identify and explain the significance of the intraoral and extraoral landmarks for a Gow-Gates nerve block in relationship to the penetration site, needle pathway, and deposition site.

Answer: There are two key landmarks to observe when performing a Gow-Gates nerve block.

Intraorally, the height or most occlusal aspect of the mesiolingual cusp of the second molar will identify the penetration site. Extraorally, a line visualized from the intertragic notch to the labial commissure will establish the angle of the syringe barrel for penetration and provide the upward orientation angle for the syringe and needle pathway. Use of these landmarks assists in correctly locating the deposition site at the anterolateral surface of the neck of the condyle.

Objective: 3 5) Discuss the indications for a Vazirani-Akinosi nerve block.

Answer: Vazirani-Akinosi nerve blocks are ideal for pain management of the mandibular teeth in a single quadrant when the ability to open the jaw is limited, either due to physiologic, pathologic, or phobic circumstances.

Objective: 3

6) Color in the field of anesthesia and list the structures anesthetized by an inferior alveolar nerve block.

Answer:

Objective: 3

7) Color in the field of anesthesia and list the structures anesthetized by a lingual nerve block.

Answer:

Objective: 3

8) Color in the field of anesthesia and list the structures anesthetized by a buccal nerve block.

Answer:

Objective: 3

9) Color in the field of anesthesia and list the structures anesthetized by a mental nerve block.

Answer:

Objective: 3

10) Color in the field of anesthesia and list the structures anesthetized by a Gow-Gates nerve block.

Answer:

Objective: 3

11) Using the figure below, identify the structures related to the needle pathway for the IA nerve block.

Answer: A. Parotid gland B. Masseter muscle C. Ramus of mandible D. Medial pterygoid muscle E. Buccinator muscle F. Pterygomandibular raphe G. Superior constrictor muscle H. Sphenomandibular ligament I. Lingual nerve J. Inferior alveolar nerve K. Inferior alveolar artery/vein Objective: 3

12) Using the figure below, describe the penetration site and needle pathway for an IA nerve block in relation to the surrounding anatomical structures.

Answer: The penetration point is lateral to the pterygomandibular raphe (F); the needle pathway is into the pterygomandibular space (between C and D), lateral to the medial pterygoid muscle (D), lingual nerve (I), and sphenomandibular ligament (H), and superior to the lingula and mandibular foramen.

Objective: 3 Use the information provided in the Case Study below to answer the questions that follow.

Case Study 1 The treatment plan for Robert Jones includes #26D, 29MOD, 30MO. A rubber dam will be placed for all the restorations.

1) Which injection(s) are needed for pulpal anesthesia, facial soft tissue anesthesia, and the least amount of lingual anesthesia?

Answer: right incisive or PDL #26; left IA, left buccal Objective: 3 2) Which needle should be used?

Answer: 25 or 27 gauge long needle may be used for all injections in this case.

Objective: 3 3) Tooth #26 fails to be adequately anesthetized. What other injection(s) may be considered?

Answer: Infiltration #26 or a PDL injection of #26. Cross-over innervation from the right IA should not be a consideration, as a right IA would be administered for teeth #29 and 30.

Objective: 3

Use the information provided in the Case Study below to answer the questions that follow.

Case Study 2 The treatment plan for Sam Babbitt included one and one-half hours for scaling and root planning on the mandibular left quadrant. The dental hygienist completed the injections with one cartridge of lidocaine with 1:100,000 epinephrine. After testing for adequate anesthesia, scaling and root planning started on the left molars, then the premolars, and lastly the lower incisors. Mr. Babbitt originally said everything felt numb. When the dental hygienist began to root plane #24 he complained that the lower left front teeth did not feel very numb anymore and the gum really hurt right where she was working. The dental hygienist told Mr. Babbitt he needed additional anesthesia. Mr. Babbitt was not very happy because he did not want his tongue to be numb for a long time because he has a meeting later in the day.

1) Which injection(s) did the dental hygienist most likely administer initially to achieve pulpal and facial and lingual anesthesia for the lower left quadrant?

Answer: left inferior alveolar, lingual, and buccal nerve blocks Objective: 3 2) Explain the most likely cause of anesthesia reversal of the incisors but not the soft tissue except on #24.

Answer: Pulpal anesthesia for lidocaine with 1:100,000 epinephrine is sixty minutes with three to five hours of soft tissue anesthesia. After an hour, the effect of pulpal anesthesia is diminished.

Objective: 3 3) Explain the most likely cause of incomplete anesthesia of the facial tissues of tooth #24.

Answer: The terminal ends of the right mental nerve likely cross over at the midline, providing sensation to the facial gingiva of tooth #24.

Objective: 3 4) What injection would provide anesthesia on the facial gingiva of tooth #24?

Answer: infiltration #24 Objective: 3 5) What injection other then repeating the left IA nerve block, could be given to regain anesthesia of the left mandibular incisors?

Answer: A left incisive nerve block will provide pulpal and soft tissue anesthesia for the left premolars and incisors without adding additional anesthesia to the left side of the tongue.

Objective: 3

Chapter 15 Supplemental Techniques and Adjunctive Strategies Match the following A) Appears pale pink to white B) Dense layer of bone C) Single tooth injection D) Penetrates into bone E) Used in endodontic procedures F) Reverse movement of solution G) Compressible osseous tissue H) Buffering system I) Peridental injection J) Alternative to palatal injections 1) Backflow Objective: 1 2) Blanching Objective: 1 3) Cortical plate Objective: 1 4) Intraligamentary Objective: 1 5) Intraosseous Objective: 1 6) Intrapulpal Objective: 1 7) Intraseptal Objective: 1 8) Onset Objective: 1 9) Periodontal ligament Objective: 1 10) Spongy bone Objective: 1

Answers: 1) F 2) A 3) B 4) I 5) D 6) E 7) J 8) H 9) C 10) G True or false 1) Aspiration for PDL injections is unnecessary because there is no significant risk of intravascular injection with the technique.

A) True B) False Answer: A Objective: 2 2) Anesthetic solution deposited in PDL injections diffuses through the periodontal ligament and alveolar bone to the apical region of the tooth.

A) True B) False Answer: B Explanation: B) Anesthetic solution will not diffuse through the dense, fibrous periodontal ligament with a PDL injection. It diffuses through the porous layer of alveolar bone proper and the underlying spongy bone surrounding the ligament and tooth.

Objective: 2 3) An intraseptal injection is commonly used for single tooth anesthesia.

A) True B) False Answer: B Explanation: B) A periodontal ligament injection is commonly used for single tooth anesthesia, including pulpal. An intraseptal injection does not usually provide pulpal anesthesia.

Objective: 3 4) A PDL injection for tooth #19 requires four separate penetrations.

A) True B) False Answer: B Explanation: B) Four may be necessary; two to three sites may be sufficient.

Objective: 3 5) If a decision is made to bend a needle to improve access during an injection, the needle should be bent to a 45-degree angle and as close as possible to the hub.

A) True B) False Answer: B Explanation: B) If it is decided to bend a needle, the bend should be made near the center of the needle shaft, not at the hub/shaft interface, in order to create a 45-degree angle and to avoid undue stress and increased risk of breakage.

Objective: 3 6) Intraosseous injections should never be used for patients taking anti-clotting medications.

A) True B) False Answer: B Explanation: B) A benefit of intraosseous injection technique includes minimized bleeding when there are increased risks such as for patients taking anticlotting medications.

Objective: 3 7) Intraosseous injection techniques are used more frequently on the mandible due to increased bone density.

A) True B) False Answer: A Objective: 3 8) Intraseptal injections are useful for anesthesia of palatal and pulpal tissues for one or two teeth.

A) True B) False Answer: B Explanation: B) Intraseptal injections are useful for anesthesia of the palatal tissues for one or two teeth. Pulpal anesthesia is usually not present or unreliable and it is short term.

Objective: 3 9) Intrapulpal injections provide anesthesia only in teeth with endodontic access already accomplished.

A) True B) False Answer: A Objective: 3 10) An intense pain associated with an intrapulpal injection indicates that pre-intrapulpal anesthesia was inadequate.

A) True B) False Answer: A Explanation: A) An initial intense pain is often associated with intrapulpal injections because the teeth involved were not able to be anesthetized profoundly using other techniques. If teeth are profoundly anesthetized prior to an intraosseous injection, the intraosseous injection is not necessary.

Objective: 3 11) OnPharma’s sodium bicarbonate buffering system reduces the acidity of local anesthetic solutions which reduces pain on injection and improves the onset time of anesthesia.

A) True B) False Answer: A Objective: 5

12) The active ingredient in OraVerse counters the effects of the local anesthetic drug allowing a faster recovery from the soft tissue symptoms of anesthesia.

A) True B) False Answer: B Explanation: B) OraVerse is a nonselective alpha-adrenergic blocking agent that counters the effects of the epinephrine in local anesthetic solutions on tissues causing vasodilation which allows for an increase in the elimination and clearance of local anesthetic from the deposition site.

Objective: 6 13) Phentolamine mesylate is added to local anesthetic solutions to enhance the depth of pulpal anesthesia.

A. True B. False Answer: B Phentolamine mesylate, known by the trade name of OraVerse reverses the anesthesia of soft-tissue anesthesia.

Objective: 6 Fill in the blank 1) Periodontal ligament injections are commonly used when other injection techniques have .

Answer: failed to provide adequate anesthesia Objective: 3 2) If it is deemed necessary to bend a needle, it should be bent at a 45-degree angle near the of the shaft of the needle.

Answer: center Objective: 3 3) The deposition site for a PDL injection is any point at which the tip of the needle is wedged between the root of a tooth and within the .

Answer: periodontal ligament Objective: 3 4) It is important to observe pale pink tissue blanching for reliable success during PDL injections because blanching indicates .

Answer: soft tissues are saturated with solution and solution is subsequently diffusing through bone Objective: 3 5) OSHA regulations prohibit the bending of medical or dental rationale for doing so.

Answer: contaminated

needles, except when there is compelling

Objective: 3 6) Penetration sites for PDL injections are usually easiest and most effective from the aspects of mandibular teeth.

Answer: lingual Objective: 3 7) should be avoided or limited with intraosseous injections.

Answer: Vasoconstrictors Objective: 3 8) Intraseptal injections can be useful to avoid Answer: palatal Objective: 3 9) Intraseptal injections provide significant Answer: hemostasis Objective: 3

injections.

if vasoconstrictors are administered.

10) An intrapulpal technique is frequently used to anesthetize teeth requiring treatment.

Answer: endodontic Objective: 3 Multiple choice 1) Which of the following is a recommended deposition rate for PDL injections?

A) 0.1 mL over 20 seconds or slower B) 0.1 mL over 30 seconds or slower C) 0.2 mL over 20 seconds or slower D) 0.2 mL over 40 seconds or slower Answer: C Objective: 3 2) Which of the following statements is true regarding PDL injections?

A) The solution diffuses through the periodontal ligament to the dental plexus.

B) The solution diffuses through alveolar bone to the dental plexus.

C) The technique is useful only when other techniques have failed.

D) The orientation of the bevel is critical to the success of the procedure.

Answer: B Objective: 3 3) Which of the following factors accurately describes recommendations for safety in bending needles?

A) Never bend a needle with one hand.

B) Make the bend at a 45-degree angle at the hub/shaft interface.

C) Always bend the needle at a 90-degree angle for minimal risk.

D) Bend a needle only when there is minimal risk it will be lost in tissue.

Answer: D Objective: 3 4) Which of the following guidelines correctly recognizes the importance of ease of access as well as ergonomics when administering PDL injections?

A) For maxillary teeth, select sites on the lingual because the embrasures are larger.

B) For mandibular teeth, select sites on the facial for better access.

C) Prevent blanching whenever possible to relieve hand stress.

D) When blanching is observed circumferentially around the tooth, no more penetrations are necessary.

Answer: D Objective: 3 5) Which statement describes why aspiration is not required for PDL injections?

A) There is no significant risk of intravascular deposition with this technique.

B) Special syringes used for PDL injections are self-aspirating.

C) It is impossible to aspirate with a bend in a needle.

D) The position of the syringe prohibits the ability to aspirate.

Answer: A Objective: 3 6) Which of the following represents the best indication for an intraosseous injection?

A) As an alternative to PDL injections B) To provide anesthesia to maxillary molars C) To provide anesthesia when large amounts of drugs are needed D) To provide anesthesia when other techniques have failed Answer: D Objective: 3 7) Which of the following devices is not used for intraosseous injections?

A) X-tip B) Stabident C) CCLAD D) IntraFlow Answer: C Objective: 3 8) The optimal penetration site for an intraosseous injection is the: A) Apical extent of the free gingival margin between adjacent teeth.

B) Apical extent of the attached gingiva between adjacent teeth.

C) Apical extent between the intrapapillary margins.

D) Apical extent of the attached gingival on the long axis of tooth.

Answer: B Objective: 3 9) Which of the following techniques does not provide reliable pulpal anesthesia?

A) PDL B) Intraseptal C) Intraosseous D) Intrapulpal Answer: B Objective: 3 10) Intraseptal injections provide: A) Pulpal anesthesia to the teeth adjacent to the area penetrated.

B) Anesthesia to the tooth mesial to the area penetrated.

C) Significant hemostasis without a vasoconstrictor.

D) An alternative to palatal injection techniques.

Answer: D Objective: 3 11) Which of the following statements describes the needle pathway for an intraseptal injection?

A) Advances through the interdental papilla within the attached gingiva until bone is contacted and then forced deeper into the interdental bone B) Advances through the free gingiva of the interdental papilla until bone is contacted C) Advances from the mucogingival margin below the interdental papilla until bone is contacted D) Advances from the mucogingival margin below the interdental papilla and then is forced deeper into the facial bone to deposit solution in the spongy bone adjacent to the apex of the teeth Answer: A Objective: 3 12) What is a minimum recommended volume of anesthetic administered for an intraseptal injection?

A) 0.9 to 1.2 mL B) 0.6 to 1.0 mL C) 0.4 to 0.6 mL D) 0.2 to 0.4 mL Answer: D Objective: 3 13) Which factor is most reliable when selecting the needle for an intrapulpal injection?

A) Narrow enough to fit into the pulp chamber or canals B) Long enough to reach the apex of the root without exiting the canal C) Wide enough to prevent breakage in the canal D) As narrow as possible to prevent discomfort in the chamber or canal Answer: A Objective: 3 14) Which of the following will minimize backflow of anesthetic solution in a PDL injection?

A) Reduce the depth and pressure of penetration to avoid backflow away from the bone.

B) Increase the depth of penetration to block the flow of solution away from the deposition site.

C) Use a shorter needle and insert to the hub.

D) Use a 30 gauge needle to control the rate and amount of solution deposited under pressure in tight spaces.

Answer: B Objective: 3 15) Which of the following complications is most often related to supplemental injection techniques?

A) Trismus and infection B) Hematoma and heart palpitations C) Damage to cortical bone and infection D) Pain at the injection site and surrounding area Answer: D Objective: 3 16) Which of the following anesthetics is recommended for use with OnsetTM ?

A) 4% prilocaine plain B) 4% Articaine with 1:200,000 epinephrine C) 2% Lidocaine with 1:100,000 epinephrine D) 2% mepivacaine with 1:20,000 levonordefrin Answer: C Objective: 7 17) Which of the following is not a potential benefit of OnsetTM? A) Increases duration time of anesthesia B) Decreases the onset time of anesthesia C) Decreases tissue irritation D) Produces carbon dioxide which has an anesthetic effect on tissues Answer: A Objective: 5 18) How many mg of phentolamine mesylate are contained in one cartridge of OraVerse?

A) 0.2 mg B) 0.4 mg C) 0.8 mg D) 1.8 mg Answer: B Objective 7 19) What is the maximum recommended dose of OraVerse for a child age 8 who weighs 54 lbs?

A) 1/4 cartridge B) 1/2 cartridge C) 1/3 cartridge D) 2 cartridges Answer: B Objective: 7 20) Which of the following statements best describes the pharmacological action of OnsetTM?

A) It reduces the effects of local anesthesia by reversing the buffering effects of the drug solution within tissues.

B) It reduces the effects of local anesthesia by altering the pKa of the solutions in the cartridge.

C) It is a nonselective alpha-adrenergic blocking agent that counters the effects of epinephrine on tissues.

D) It is a nonselective beta blocking agent that counters the beta effects of epinephrine on smooth muscle linings of vessels.

Answer: C Objective: 4 Short answer/essay 1) List indications for periodontal ligament (PDL) injections.

Answer: PDLs are indicated as a primary method of anesthesia for single teeth, for supplemental anesthesia of individual teeth when other techniques have failed to provide profound anesthesia, when widespread anesthesia is contraindicated, and when total doses need to be minimized. The PDL technique can also be beneficial for individuals with bleeding disorders and when needle insertions into vascular regions may be a risk.

Objective: 3 2) When is an intrapulpal injection technique used?

Answer: An intrapulpal technique can deliver effective anesthesia when the degree of inflammation in the pulp renders other, more common injection methods ineffective. An endodontic opening through the crown of the tooth is necessary to allow injection access to the pulpal tissue.

Objective: 3 3) Explain safety factors required for bending needles.

Answer: For optimal safety, commercially designed syringe adaptors with 45-degree angles are available and recommended. If an adaptor is not available, a sterile hemostat or locking pliers should be used. The bend should be made near the center of the needle shaft, not at the hub/shaft interface. OSHA regulations relating to workplace safety do not prohibit bending sterile needles.

Bending of contaminated needles, however, is prohibited except under compelling circumstances.

Objective: 3 4) Discuss the potential benefits of phentolamine mesylate (OraVerse) for post-anesthetic care for children.

Answer: OraVerse (phentolamine mesylate), an injectable formulation by Novalar Pharmaceuticals, is the first pharmaceutical agent available for the reversal of soft-tissue anesthesia which often interfere with speaking, eating, and drinking. Additionally, there is early evidence that OraVerse may reduce the risks of postoperative soft tissue injury occurring during and after local anesthesia, especially in children.

Objective 7 Use the information provided in the Case Study below to answer the questions that follow.

Case Study Tom Reynaldo is scheduled for restorations for recurrent decay on #18 and #19. He has received two IA nerve blocks without profound anesthesia of tooth #19. The surrounding teeth and soft tissues are very numb. He says he is usually numb for hours after the many injections he typically receives but he notes that one tooth, #19, never gets numb enough.

1) Which nerve likely provides accessory innervation to tooth #19?

Answer: mylohyoid Objective: 2 2) Which alternate injections can be considered to provide anesthesia for the accessory innervation?

Answer: mylohyoid, Gow-Gates, Vazirani-Akinosi, PDL, intraosseous Objective: 3 3) Explain why the alternate injections were selected.

Answer: The mylohyoid nerve may provide accessory innervation to tooth #19. A mylohyoid injection would provide anesthesia of the mylohyoid nerve. Gow-Gates and Vazirani-Akinosi injections both provide anesthesia of the mylohyoid nerve. A PDL injection or intraosseous injection can also be considered.

Objective 3 4) What drug can be suggested to Mr. Reynaldo that will shorten his recovery from profound soft tissue anesthesia?

Answer: Phentolamine mesylate (OraVerse), a vasodilator, will reverse the effects of local anesthesia in approximately half the time of typical recovery.

Objective 6 5) What is the appropriate dose of drug that will shorten Mr. Reynaldo’s recovery from profound soft tissue anesthesia?

Answer: Phentolamine mesylate solution is injected into the mucosa at the end of the dental procedure at the same location, volume, and with the same injection techniques as the local anesthetic injections. Assuming he received 2.5 cartridges of local anesthetic the same dose of phentolamine mesylate would be administered.

Objective 7

Chapter 16 Troubleshooting Inadequate Anesthesia Match the following A) Response to drug based on time of day B) Allows diffusion into spongy bone C) Soft tissue restriction to flow of anesthesia D) Expected variation E) Accessory to mandibular incisors F) Drug tolerance G) Divided nerve H) Unexpected variation I) Hard tissue restricting flow of anesthesia J) Accessory innervation to mandibular teeth 1) Aberrant innervation Objective: 1 2) Accessory innervation Objective: 1 3) Bifid Objective: 1 4) Cervical nerve plexus Objective: 1 5) Dense bone Objective: 1 6) Diurnal body rhythms Objective: 1 7) Fascial planes Objective: 1 8) Intraosseous injection Objective: 1 9) Mylohyoid nerve Objective: 1 10) Tachyphylaxis Objective: 1

Answers: 1) H 2) D 3) G 4) E 5) I 6) A 7) C 8) B 9) J 10) F True or false 1) Devices used for delivery of local anesthetic solutions have very little impact on local anesthesia failure.

A) True B) False Answer: A Objective: 2 2) Needle bevel orientations are not considered critical to the success of any injection.

A) True B) False Answer: A Objective: 2 3) A 25 gauge needle has less potential for deflection than a 27 gauge needle, although deflection is not a common cause of anesthetic failure.

A) True B) False Answer: A Objective: 2 4) A pH below 3.3 can lead to failure of anesthesia because the solution is too acidic.

A) True B) False Answer: A Objective: 2 5) Dental hygiene procedures require less duration of anesthesia than restorative procedures.

A) True B) False Answer: B Explanation: B) The duration of anesthetic required is based on the type of procedure and the time required for the procedures.

Objective: 2 6) Nerve blocks typically require similar volumes of anesthetic solution to achieve profound anesthesia.

A) True B) False Answer: B Explanation: B) Some nerve blocks require a far greater volume of anesthetic solution to achieve profound anesthesia.

Objective: 2

7) Inferior alveolar nerve blocks may be unsuccessful when the needle penetration is made lateral to the sphenomandibular ligament.

A) True B) False Answer: B Explanation: B) Inferior alveolar nerve blocks may be unsuccessful when the needle penetration is medial to the sphenomandibular ligament.

Objective: 3 8) Aberrant innervations are unexpected anatomical variations.

A) True B) False Answer: A Objective: 3 9) Fibers from the greater palatine nerve may provide accessory innervation to the palatal roots of maxillary molars.

A) True B) False Answer: A Objective: 3 10) PDL injections can overcome nearly all of the challenges that occur due to accessory and aberrant innervation.

A) True B) False Answer: A Objective: 5 Fill in the blank 1) The term referring to the lack of redevelopment of profound anesthesia when subsequent injections in the same appointment are administered is called .

Answer: tachyphylaxis Objective: 1 2) The term is frequently used to describe the variable response to drugs during different times of a day.

Answer: diurnal rhythm Objective: 2 3) The higher the gauge of a needle, the greater its Answer: flexibility Objective: 2

and deflection in tissues.

4) A cartridge of anesthesia with a vasoconstrictor should have a pH of no less than Answer: 3.3

.

Objective: 2 5) The injection technique requires penetration through the periosteum and cortical plate before injecting anesthetic solution.

Answer: intraosseous Objective: 3 6) Initial recommended volumes of local anesthetic solution are affected by the nerve membrane to be anesthetized.

Answer: size Objective: 3

of the

7) Dense bony prominences, shallow vestibules, dilacerations, and ligaments create barriers to the success of anesthesia.

Answer: physical Objective: 3 8) Tachyphylaxis is most likely to occur once anesthetized tissues have returned to levels of sensation.

Answer: normal Objective: 3 9) can deflect anesthetic solution away from ideal deposition sites, resulting in inadequate anesthesia.

Answer: Fascial planes Objective: 3 10) The term that is used to describe failure of mandibular anesthesia due to innervation from cervical nerve fibers is called an innervation.

Answer: aberrant Objective: 3 Multiple choice 1) Inadequate anesthesia may typically be caused by all of the following, except A) Volume of solution B) Presence of inflammation C) Quality of manufactured solutions D) Anatomical variations Answer: C Objective: 2 2) Which of the following factors is most likely to correspond to anesthetic failures?

A) Delivery devices B) Needle bevel orientation C) Needle deflection D) Physical barriers

Answer: D Objective: 2 3) Which of the following does not typically have an effect on the ability to achieve profound anesthesia?

A) Anatomical barriers B) Choice of anesthetic C) Volume of anesthetic administered D) Psychological barriers Answer: B Objective: 2 4) Inadequate anesthesia in the maxillary incisors is least likely to be caused by: A) Crossover innervation from the contralateral ASA nerve B) Nasopalatine innervation C) Bony obstructions D) Facial nerve innervation Answer: D Objective: 3 5) Which of the following nerves is often considered the most likely source of accessory innervation of the mandibular first molar?

A) Mylohyoid B) Buccal C) Lingual D) Cervical Answer: A Objective: 3 6) Which of the following injections would most likely solve inadequate anesthesia on the palatal root of tooth #3?

A) Facial infiltration B) MSA C) Greater palatine D) PSA Answer: C Objective: 4 7) Which of the following is the best option to assure anesthesia in the presence of inflammation?

A) Administer a larger volume of anesthetic in the same location B) Select an injection that will provide anesthesia of the nerve trunk medial to the area of inflammation C) Administer infiltrations in several locations around the tooth to provide anesthesia D) Choose a different anesthetic drug Answer: B Objective: 4

8) The Gow-Gates is successful in providing anesthesia of mandibular molars in the presence of accessory innervation from the mylohyoid or lingual nerves because A) An increased volume of solution is administered and the mouth is maintained in an open position following injection.

B) The deposition site is lower on the inferior nerve; therefore, it is closer to the mylohyoid and lingual nerves.

C) The IA nerve trunk is anesthetized higher on the inferior nerve.

D) A long, 25 gauge needle is used.

Answer: C Objective: 4 9) Mepivacaine plain solutions may be useful for reinjection following the use of lidocaine 2% with epinephrine for all of the following reasons except A) There is 50% more drug per volume.

B) It raises the pH at the deposition site.

C) Duration is enhanced by the presence of previously injected vasoconstrictor.

D) It is a strong vasodilator.

Answer: D Objective: 4 10) Which statement is true regarding tachyphylaxis?

A) It is most likely to occur once sensation has returned to normal levels.

B) It is least likely to occur when effective anesthesia was initially achieved.

C) It is well understood as a problem related to inadequate local anesthesia.

D) It is related to the high pH of tissues in the presence of inflammation.

Answer: A Objective: 4 Short answer/essay 1) Explain the difference between suspected aberrant and accessory innervations.

Answer: Most failures due to aberrant innervations result in a complete lack of anesthesia of the targeted tissues. The presence of accessory innervations will commonly result in incomplete anesthesia of the targeted tissues.

Objective: 3 2) What is recommended to avoid failed anesthesia and an increased risk of toxicity due to intravascular injection?

Answer: Intravascular injection can contribute to failed anesthesia because the solution is deposited directly into a vessel and then distributed throughout the body, away from intended local areas. Performing multiple aspirations and aspirations in more than one plane will minimize this possibility.

Objective: 4 3) Following a PSA nerve block of tooth #2 it is determined that the palatal root is inadequately anesthetized. Discuss two possible causes and three possible solutions the clinician should consider.

Answer: Two possible causes of inadequate anesthesia of the palatal root include the existence of potential accessory innervation by a branch of the greater palatine nerve, or that the anesthetic solution did not diffuse adequately to reach the palatal nerve. Administration of a GP nerve block to anesthetize the palatal root is often effective in this situation. PDL injections may also be effective. It has also been suggested by some that articaine allows more effective diffusion.

Objective: 5 4) Identify and discuss inadequate anesthesia following IA injections and suggest alternative injections to achieve anesthesia.

Answer: IA nerve blocks have a relatively high incidence of inadequate anesthesia. Possible reasons include accessory innervation to the pulps from any of the following nerves: mylohyoid, buccal, lingual, contralateral incisive and mental nerves, sensory fibers traveling with the motor fibers of the muscles of mastication, and bifid inferior alveolar nerves or branches from the cervical plexus to the anterior teeth. Alternate injection techniques may include: mylohyoid, PDL, Gow-gates, Vazirani-Akinosi or intraosseous injections.

Objective: 5 Use the information provided in the Case Study below to answer the questions that follow.

Case Study 1 The treatment plan for Clare Ross included an MODL restoration on tooth #3. A right PSA, MSA, and intraseptal injection (to avoid a palatal injection) were administered with 2% lidocaine with 1:100,000 epinephrine. During cavity preparation, Clare jumped when the bur neared the palatal root.

1) Explain two possible reasons for inadequate anesthesia of the palatal root.

Answer: Some branches of the PSA nerve enter the maxilla medial to the common location and innervate the palatal roots of molars. Solution from PSA blocks and infiltrations does not always penetrate to these branches. Fibers from the greater palatine nerve can also provide similar accessory innervation.

Objective: 3 2) What other injection(s) should be considered to anesthetize the palatal root?

Answer: A greater palatine nerve block would solve either of these possible accessory innervations. PDL injections with at least one site located on the palatal aspect of the tooth will also provide anesthesia.

Objective: 5 3) What other anesthetic drugs may be considered and why?

Answer: Articaine reportedly provides greater diffusion capabilities in some situations.

Objective: 5 Use the information provided in the Case Study below to answer the questions that follow.

Case Study 2

The treatment plan for Ralph Cook includes a restoration for tooth #12. There is a large, bony exostosis on the facial aspect that extends from the canine to the first molar. An MSA was attempted however failed to achieve adequate anesthesia.

1) What is the likely cause of inadequate anesthesia?

Answer: Dense bone covering the facial surface of #12 prevented adequate diffusion of solution to the apex of the tooth.

Objective: 3 2) What other injection technique(s) should be considered?

Answer: An AMSA or PDL injection can avoid the anatomic barrier encountered in an MSA nerve block because the penetration sites avoid the dense, bony barrier.

Objective: 5 Use the information provided in the Case Study below to answer the questions that follow.

Case Study 3 Anita Mendoza presents with a large failing #30 MOD amalgam with distal lingual cusp fracture.

She says she hated to have the tooth “worked on again because it’s the only tooth that never gets numb no matter what they try.” It is determined that a crown is the appropriate treatment for #30.

She is assured that the tooth will be numb before treatment. IA, lingual and buccal nerve blocks are administered with a total of 1.5 cartridges of lidocaine with 1:1,000,000 epinephrine. She reports the “tooth and all around it feel numb,” however when a pulp tester is applied to #30 she jumps with discomfort. Pulp testing on tooth number 29 and 31 are negative. The IA injection site is carefully re-evaluated and an IA injection is repeated with a second cartridge of the same drugs. An identical response to the pulp tester follows.

1) What are the possible causes for inadequate anesthesia of tooth #30?

Answer: Because Ms. Mendoza reports repeated experiences of inadequate anesthesia with #30, accessory innervation should be considered. It is not likely that the lingual or buccal nerve provide accessory innervation because these nerves have been anesthetized. The mylohyoid nerve should be considered because it is not anesthetized by an IA nerve block. Other considerations could be a bifid inferior alveolar nerve however is not likely because pulp testing on #29 and #31 was negative. Innervation by sensory fibers of the muscles of mastication is possible however less probable.

Objective: 3 2) What other injection techniques should be considered to provide profound anesthesia?

Answer: A supplemental mylohyoid nerve block administered distal to tooth #30, PDL injections at four sites on #30, a Gow-Gates, Vazirani-Akinosi or intraosseous injection should be considered.

Objective: 5

Chapter 17 Local Anesthesia Complications and Management Match the following A) Causes CNS and CVA depression B) Blood leakage into tissue C) Low oxygen-carrying capacity D) Undesired response to drug E) Localized swelling F) Inability to open mouth G) Sensation of pain from non-noxious stimuli H) Follows needle breakage I) Adverse reaction with no known etiology J) Requires very low drug dose to cause overdose reaction K) Allergy L) Increased sensitivity to stimuli following nerve injury M) Requires very high drug dose to cause overdose reaction N) Altered taste sensation 1) Adverse reaction Objective: 1 2) Ageusia Objective: 1 3) Angioedema Objective: 1 4) Dysesthesia Objective: 1 5) Hematoma Objective: 1 6) Hyperesthesia Objective: 1 7) Hyper-responder Objective: 1 8) Hyper-responder Objective: 1 9) Hypersensitivity Objective: 1

10) Idiosyncratic Objective: 1 11) Overdose Objective: 1 12) Trismus Objective: 1 13) Embedded needle Objective: 1 14) Methemoglobinemia Objective: 1 Answers: 1) D 2) N 3) E 4) G 5) B 6) L 7) J 8) M 9) K 10) I 11) A 12) F 13) H 14) C True or false 1) Local complications occur more frequently than systemic complications following injections of local anesthetic.

A) True B) False Answer: A Objective: 1 2) Hematomas are local complications occurring most frequently after inferior alveolar nerve blocks.

A) True B) False Answer: B Explanation: B) Hematomas are local complications occurring most frequently after posterior superior alveolar nerve blocks.

Objective: 2 3) Hematomas on the palate are generally well-confined due to the tight tissue covering the bone.

A) True B) False Answer: A Objective: 2 4) As a consequence of local anesthetic, the primary causes of trismus are hemorrhage and muscle trauma following injection.

A) True B) False Answer: A Objective: 2

5) In the event a needle breaks and embeds in the tissue, it should be removed as soon as possible to avoid infection.

A) True B) False Answer: B Explanation: B) In the event a needle breaks and embeds in the tissue, the patient should be referred to an oral surgeon for evaluation. Surgical removal may not be indicated due to the potential for extensive tissue damage that is possible during removal. Retaining needle fragments might ultimately cause less tissue damage than removal although most embedded needles are removed.

Objective: 2 6) Lip biting following local anesthesia is not uncommon in children even when both patient and parent are warned of the risk.

A) True B) False Answer: A Objective: 2 7) The lingual nerve is most frequently involved in paresthesias following dental injections.

A) True B) False Answer: A Objective: 2 8) Signs and symptoms of local anesthetic overdose are those of CNS and CVS depression.

A) True B) False Answer: A Objective: 3 9) Local anesthetic overdose and allergy are both dose dependent and can be prevented by adhering to MRD guidelines.

A) True B) False Answer: B Explanation: B) A major difference between overdose and allergy is that allergies are not dose dependent. MRD guidelines should be adhered to for overdose prevention.

Objective: 8 10) Minimizing the number of needle penetrations is the least effective way to avoid hematomas.

A) True B) False Answer: B Explanation: B) Minimizing the number of needle penetrations is the most effective way to avoid hematomas.

Objective: 8

Fill in the blank 1) An adverse reaction to a drug with no known etiology is called an Answer: idiosyncratic Objective: 1

reaction.

2) Undesired events that occur in response to the pharmacologic actions of a drug are called reactions.

Answer: adverse Objective: 1 3) A patient who requires very low drug doses in order to experience an overdose is referred to as a .

Answer: hyper-responder Objective: 1 4) A patient who requires a high drug dose in order to experience an overdose is referred to as a .

Answer: hypo-responder Objective: 1 5) A partially altered taste sensation is referred to as Answer: hypogeusia Objective: 1

.

6A is formed by the leaking of blood from vessels into surrounding tissues.

Answer: hematoma Objective: 1 7) is defined as a motor disturbance of the trigeminal nerve and an inability to open the mouth.

Answer: Trismus Objective: 1 8) The recommended treatment for trismus includes the application of every hour.

Answer: hot, moist towels Objective: 4

for 20 minutes

9) A recommended treatment for hematomas includes the immediate application of pressure and .

Answer: ice, if available Objective: 4 10) In the event a needle becomes embedded in the tissue and cannot be retrieved, the patient should be informed that a needle has broken off and embedded in the tissue and it is necessary for the patient to see an oral surgeon for .

Answer: evaluation Objective: 4 11) A drug called limits the duration of soft tissue anesthesia and may reduce the potential for post-injection self-injury.

Answer: OraVerse Objective: 4 12) An altered sensation and/or a persistent partial or complete numbness is referred to as .

Answer: paresthesia Objective: 4 13) Systemic complications from local anesthetics occurs local complications.

Answer: less Objective: 5 14) Allergy may occur due to the inclusion of containing solutions of local anesthetic drugs.

Answer: sulfite Objective: 5

frequently compared to

preservatives in vasoconstrictor-

15) The occurrence of trismus and hematoma can be minimized by needle penetrations.

Answer: decreasing Objective: 8

the number of

Multiple choice 1) The most common adverse events related to local anesthetic include all of the following except A) Syncope B) Postoperative discomfort C) Self-injury D) Anaphylaxis Answer: D Objective: 2 2) A patient calls the office and complains of sloughing of the mucosal tissue on the side of the mouth that was treated. What is the most likely cause?

A) Mucosa was dried too vigorously B) The patient used too much salt when rinsing post-operatively C) The patient chewed their check while still numb D) Topical anesthetic was in contact with a large area of mucosa for too long Answer: D Objective: 2

3) What is the main cause of hematoma?

A) Poor operator technique B) Failure to aspirating C) Tearing a blood vessel D) Anatomical anomalies Answer: C Objective: 2 4) Which of the following statements is true when considering hematoma formations following inferior alveolar nerve blocks?

A) Outward or intraoral signs of hematoma occur immediately during or following injections because the blood leakage quickly follows the facial planes.

B) Outward signs of hematoma are uncommon during or immediately following injection because the pterygomandibular space accommodates large quantities of blood medial to the ramus.

C) Outward signs of hematoma are immediately noticeable under the mandible due to the large unrestricted areas of soft tissue.

D) Hematoma is very rare following inferior alveolar nerve blocks because the venous plexus is located superior to the IA nerve.

Answer: B Objective: 2 5) Which of the following muscles experiences trismus more frequently?

A) Medial pterygoid B) Lateral pterygoid C) Masseter D) Buccinator Answer: A Objective: 2 6) Which of the following nerve blocks is most frequently associated with hematoma formation?

A) Inferior alveolar B) Greater palatine C) Gow-Gates D) Posterior superior alveolar Answer: D Objective: 2 7) Three days after receiving an inferior alveolar block, a patient calls and complains that the numbness has not worn off and she is experiencing sharp pains in her lower jaw on the same side as the numbness. Which of the following describes what she is experiencing?

A) Paresthesia and dysesthesia B) Persistent anesthesia and hypoesthesia C) Paresthesia and anesthesia D) Paresthesia and an idiosyncratic reaction Answer: A Objective: 2

8) Which of the following local anesthetic drugs is a concern for patients with atypical plasma cholinesterase?

A) Lidocaine B) Prilocaine C) Dyclonine hydrochloride D) Benzocaine Answer: D Objective: 3 9) Which of the following local anesthetic drugs is safest to use in the case of a known family history of methemoglobinemia?

A) Benzocaine B) Prilocaine C) Tetracaine D) Lidocaine Answer: D Objective: 3 10) The day after a dental hygiene procedure, a patient calls to report the right side of his mouth is sore and he is having difficulty opening. Which of the following should be recommended first?

A) Monitor for increased discomfort and call again if pain worsens B) Open and close the mouth to regain flexibility of the muscles C) Apply hot, moist towels for 20 minutes every hour D) Recommend an analgesic for discomfort Answer: C Objective: 4 11) What is the correct dose of OraVerse following the administration of two cartridges of a local anesthetic drug?

A) Two cartridges or 0.8 mg B) One cartridge or 1.8 mg C) One-half cartridge or 0.8 mg D) Two cartridges or 36 mg Answer: A Objective: 4 12) The recommended first step in paresthesia management is A) Explain that most paresthesias resolve over time B) Diagram the extent and degree of sensory deficit C) Speak personally with and reassure the patient D) Schedule an appointment to evaluate the paresthesia Answer: C Objective: 4 13) Which of the following injection technique errors can cause facial nerve paralysis following an IA nerve block?

A) Penetration into the medial pterygoid muscle B) An overdose of anesthetic drug C) Overinsertion into the capsule around the deep lobe of the parotid gland D) Overinsertion into the capsule around the TMJ Answer: C Objective: 4 14) Allergies to topical anesthetic drugs that manifest in mucosal signs and symptoms hours or days after application: A) Are usually an indication of allergy to amide type anesthetics and all amide drugs should be avoided in the future B) Are considered delayed hypersensitivity reactions however the drug type should be avoided in the future C) Have a high potential to progress to anaphylaxis D) Usually occur due to secondary infections from needle penetrations Answer: B Objective: 4 15) During an inferior alveolar block, a patient makes a sudden movement in response to needle contact with bone. The needle bends and breaks off at the hub. The broken shank of the needle is visible. Which of the following is a recommended first response?

A) Gently remove the needle with gloved fingers B) Contact an oral surgeon and transport the patient to the oral surgeon's office C) Ask the patient to keep the mouth open and attempt to remove the needle with a hemostat D) Take a radiograph to determine if the needle remains in contact with bone. If not, remove the needle with a sterile hemostat Answer: C Objective: 4 16) Which of the following local anesthetic complications occurs most frequently?

A) Overdose B) Allergy C) Idiosyncratic reaction D) Dysesthesia Answer: A Objective: 5 17) Which of the following patient factors is not a predisposing factor in overdose reactions?

A) Allergy B) Age C) Disease status D) Concomitant medications Answer: A Objective: 5 18) Which of the following initial signs and symptoms should alert the clinician to a potential overdose reaction?

A) Itching and hives B) Tremors and seizures C) Metallic taste and circumoral tingling/numbness D) Visual hallucinations and confusion Answer: C Objective: 5 19) Which of the following signs and symptoms should alert the clinician to a potential vasoconstrictor overdose?

A) Intense anxiety and nausea B) Bradycardia and hypotension C) Itching and hives D) Visual hallucinations and confusion Answer: A Objective: 5 20) A clinician has administered an injection for a restorative procedure. The patient immediately becomes anxious and restless, clutching his chest. The clinician reassures the patient in a calm voice after which the patient's breathing slows and he feels calmer. Which of the following describes what has likely occurred?

A) Local anesthetic overdose B) Vasoconstrictor overdose C) Hypersensitivity reaction to the sulfite preservative D) Mild myocardial infarction Answer: B Objective: 5 21) A patient is experiencing initial signs and symptoms of a mild overdose of a local anesthetic drug. Which of the following correctly describes the next step?

A) Administer oxygen, then dismiss the patient and refer to a physician for follow-up evaluation B) Administer oxygen and diazepam to prevent seizures C) Adminsiter oxygen, then dismiss the patient and reschedule the appointment D) Administer oxygen, observe, and monitor Answer: D Objective: 6 22) A patient is experiencing moderate signs and symptoms of an overdose of a local anesthetic drug and office emergency protocol has been activated. Which of the following correctly describes the next step?

A) Perform CPR B) Reassure, observe, and monitor the patient C) Administer oxygen D) Administer diazepam to prevent seizures Answer: C Objective: 6 23) Which of the following is the correct response for the management of a severe systemic

allergic reaction?

A) 100 mg oral Benadryl B) 25 mg Benadryl IM C) 0.3 mg epinephrine IM or subcutaneous D) 1000 mg epinephrine IM or subcutaneous Answer: C Objective: 6 24) Which statement describes the best management protocol for a suspected idiosyncratic reaction to a local anesthetic drug?

A) Immediately stop procedures and transport the patient to ER B) No response will be adequate because the reaction to treatment will be idiosyncratic C) Respond appropriately to whatever signs and symptoms develop D) Respond the same as for an existing overdose of a drug Answer: C Objective: 7 25) Which of the following is the most important consideration when preventing overdoses of local anesthetic drugs?

A) Calculating safe doses B) Aspiration C) Slow administration D) Identifying allergies Answer: C Objective: 8 26) Which of the following is the most important precaution in order to avoid hematoma formation?

A) Avoid PSA nerve blocks because infiltrations are safer injections B) Avoid using large gauge needles that are flexible and can unknowingly pierce vessels C) Avoid multiple needle penetrations D) Never inject before carefully assessing the anatomy in the area of the injection Answer: C Objective: 8 27) Avoiding PSA nerve blocks is a prudent practice A) Because infiltrations are always much safer B) For patients on anticoagulant therapy C) For patients with diabetes D) Because they require a high degree of clinical skill to administer without causing hematoma formation Answer: B Objective: 8 Short answer/essay 1) Explain the anatomical factors that limit the extent of hematoma formation.

Answer: Hematomas are limited by the degree of flexibility of the tissues into which the blood is emptying. For example, where the tissues are less flexible, such as in the palate, hematoma sizes tend to be more limited.

Objective: 2 2) What are the first two protocols in the recognition and management of hematomas?

Answer: Early recognition and rapid response to hematomas include being alert to the possibility of their formation and discontinuing treatment, and applying pressure (and ice, when available) to create an opposing force allowing clot formation.

Objective: 4 3) Discuss possible causes of pain on injection.

Answer: There are many possible causes of pain on injection. Needle penetrations of wellinnervated anatomic structures can cause pain. Rapid deposition of solution can distend tissues, causing pain. Pain can occur due to the irritating and acidic nature of local anesthetic solutions, and can also occur if solutions are too cold or too hot compared to oral temperature.

Objective: 2 4) What strategies are effective for reducing the risk of tissue necrosis following injection?

Answer: Four strategies are effective in reducing the risk of tissue necrosis following injections.

They include: 1. Avoid epinephrine concentrations of 1:50,000, especially in confined tissues.

2. Avoid excessive durations of topical anesthetic contact as recommended in the product instructions.

3. Avoid excessive blanching by allowing sufficient time for solution to diffuse into tissue during deposition; tissues should not turn "stark white" in appearance.

4. Avoid extensive distention of tissues by allowing sufficient time for solution to diffuse while depositing; tissues should not bulge or “balloon” with too much solution.

Objective 8 5) What guidelines are recommended in order to prevent local anesthetic overdose?

Answer: The following guidelines are recommended to prevent local anesthetic overdose: 1. Establish maximum doses based on weight and health status, prior to injection.

2. Aspirate whenever there is a possibility of intravascular deposition.

3. Administer all doses slowly.

4. Re-aspirate throughout injections.

Objective: 8 Use the information provided in the Case Study below to answer the questions that follow.

Case Study 1 A clinician administered a PSA injection with a short, 27 gauge needle, bent at the hub to improve access around the maxillary tuberosity. The penetration site was determined and the needle was inserted to the hub contacting bone. The patient quickly jerked his head causing breakage of the needle. The clinician attempted to remove the needle fragment, probing with a gloved finger and a sterile forceps without success. A radiograph was taken showing the needle

against the posterior wall of the tuberosity. He explained to the patient that the needle could remain in place because the body would “wall off” the needle and it would not cause any problems, and that trying to remove the needle would cause unnecessary trauma.

1) What needle choice and technique error(s), if any, was/were made prior to the injection?

Answer: The needle length and gauge were appropriate for the planned injection. It is not necessary to bend needles to gain access to the posterior tuberosity. If it is determined that bending is appropriate, needles should never be bent at the hub.

Objective: 4 2) What injection techniques errors, if any, were made during the injection?

Answer: The insertion was too deep for a PSA block. The optimum insertion depth for a PSA is 16 mm in typical adults, which is 5 mm from the hub of a 21 mm (short) needle. By bending the needle, the penetration and needle pathway were too close to the tuberosity. Contact with the tuberosity is not desirable in PSA injections.

Objective: 4 3) Was the clinician correct in attempting to remove the needle? Why or why not?

Answer: If a needle is completely embedded in tissue, no attempt at removal should occur.

Attempting to remove an embedded needle can negatively impact the needle's position. The patient should be referred to an oral surgeon for evaluation.

Objective: 4 4) Was the patient given adequate advice regarding the broken needle?

Answer: When a needle breaks and the shank is not visible, it is best to inform the patient that a needle has broken and that a segment that is not visible is embedded in the tissue. Referral to an oral surgeon for evaluation is recommended.

Objective: 4 Use the information provided in the Case Study below to answer the questions that follow.

Case Study 2 A clinician administered an IA nerve block with a long, 25 gauge needle. Although no contact with bone was made, she was certain that the penetration depth was adequate because only 3 mm of the needle was visible. She confirmed negative aspiration in two planes and deposited one cartridge of 2% lidocaine with 1:100,000 epinephrine. After several minutes, the patient's teeth were not numb however the side of their face, including the lower eyelid, around the mouth and chin, were extremely numb.

1) What was the most important technique error made by this clinician?

Answer: The clinician failed to make gentle contact with bone in IA nerve blocks which would have confirmed the correct deposition site for an IA nerve block.

Objective: 2 2) Why was the depth of insertion an indicator of a potential problem?

Answer: The typical depth of insertion for an IA nerve block is two thirds to three quarters of a long needle. Inserting needles to within 3 mm of the hubs is rarely necessary.

Objective: 4 3) Describe the correct procedure to follow when bone is not contacted in an IA nerve block.

Answer: When failure to contact bone at the anticipated target occurs, withdraw the needle at least halfway and reposition the syringe over the molars. Re-advance the needle until bone is contacted.

Objective: 4 4) If bone is not contacted after repositioning the needle, what is the appropriate procedure?

Answer: If bone is not encountered after adjusting the syringe over the molars, do not deposit anesthetic. Withdraw the needle and consider alternate techniques to achieve inferior alveolar nerve anesthesia.

5) What structure did the needle penetrate and what nerve was anesthetized causing anesthesia of the side of the face, the lower eyelid, and around the mouth and chin?

Answer: The needle entered the capsule surrounding the deep lobe of the parotid gland providing anesthesia to the facial nerve as it travels through the parotid gland resulting in anesthesia of the side of the face, the lower eyelid, and around the mouth and chin?

Objective 4 Use the information provided in the Case Study below to answer the questions that follow.

Case Study 3 Marion Orson came to a dental appointment accompanied by her daughter, Joan. Mrs. Orson, 73, was recently diagnosed with dementia and is experiencing memory loss. Today a restoration is planned for #30. She tolerated the IA and buccal nerve block anesthesia, and placement of the restoration well. When Mrs. Orson arrived home she was tired and ready for a nap. When Mrs. Orson woke up, Joan, she was concerned because her mother’s lower lip was bleeding. She called the office immediately.

1) What was the most likely cause of the bleeding?

Answer: Mrs. Orson likely chewed on her lip causing a self-inflicted injury.

Objective: 2 2) How should the lip injury be treated?

Answer: A cold pack should be applied to the injured tissue to reduce swelling. If it is determined the injury is extensive Mrs. Orson should be seen in the office for evaluation.

Application of 0.2% chlorhexidine solution to the traumatized tissues with cotton-tipped applicator may improve healing.

Objective: 4 3) What could have been done to help prevent the risk of injury?

Answer: The clinician should have discussed the risk of self-injury with Mrs. Orson and her daughter. Mrs. Orson also needed continued observation at home to prevent the injury.

Objective: 8

4) What drug may have been considered before Mrs. Orson following treatment that would have reduced the length of soft tissue anesthesia.

Answer: Phentolamine mesylate (OraVerse), an anesthesia reversal agent may have limited the risk of self-inflicted injury by reducing the length of soft tissue anesthesia.

Objective: 8

Chapter 18 Insights for the Fearful Patient Match the following A) Proficiency acquired or developed through training or experience B) Opportunity to practice new skill C) Plan of action to accomplish a specific goal D) Reply or answer to stimulus E) Bodily response to stimuli F) Coping technique to control respiration G) Redirecting anticipatory anxieties H) Apprises patient of injection progress I) Emotional response to immediate danger J) Persistent, irrational fear of object or situation K) Modification of physiological responses L) Relieves tension M) Unpleasant sensory and emotional experience N) Emotional response to threat not immediately present O) Creating pleasant mental scenes 1) Anxiety Objective: 1 2) Biofeedback Objective: 1 3) Deep breathing Objective: 1 4) Fear Objective: 1 5) Focusing attention Objective: 1 6) Guided imagery Objective: 1 7) Muscle relaxation Objective: 1 8) Pain Objective: 1 9) Phobia

Objective: 1 10) Reaction Objective: 1 11) Rehearsals Objective: 1 12) Response Objective: 1 13) Skill Objective: 1 14) Strategy Objective: 1 15) Time structuring Objective: 1 Answers: 1) N 2) K 3) F 4) I 5) G 6) O 7) L 8) M 9) J 10) C 11) B 12) D 13) A 14) E 15) H True or false 1) Approximately 20% of all patients presenting for dental care experience some level of anxiety related to appointments.

A) True B) False Answer: B Explanation: B) Approximately 40% of all patients presenting for dental care experience some level of anxiety related to appointments.

Objective: 2 2 Fear is an emotional response to an immediate threat or danger.

A) True B) False Answer: A Objective: 2 3) A phobia is an emotional response to a threat not immediately present.

A) True B) False Answer: B Explanation: B) A phobia is a persistent, irrational fear of objects or situations.

Objective: 2 4) Fearful patients are often not aware of the benefits of oral health due to past fearful

experiences.

A) True B) False Answer: B Explanation: B) Many fearful patients are aware of the benefits of oral health, but the prospect of good oral health, alone, is not sufficient to enable them to tolerate treatment.

Objective: 3 5) Fear is innate and will develop in response to pain, regardless of the manner in which a clinician manages a patient's reaction to pain.

A) True B) False Answer: B Explanation: B) The manner in which a clinician manages a patient's emotional reaction to pain (or the anticipation of pain) is a more important determinant of whether or not dental fear develops.

Objective: 3 6) Self-report is the only method for obtaining reliable information about a patient's fear.

A) True B) False Answer: B Explanation: B) Self-report is one of the three primary sources for assessing patient anxiety and fear. Behavioral indicators and physiological signs provide important clues for clinicians when evaluating patients.

Objective: 4 7) When a patient feels they have control over a situation, they can increase their level of pain tolerance.

A) True B) False Answer: A Objective: 5 8) Patients need to have a sense of control throughout an appointment or they will worry that the procedures will be more than they can endure.

A) True B) False Answer: A Objective: 6 9) Focused attention is a cognitive control method whereby patients are guided to think of pleasant scenes or scenarios.

A) True B) False Answer: B Explanation: B) Focusing attention is a technique used to prevent what are known as anticipatory

anxieties or thoughts of what might happen during treatment. Guided imagery provides patients with active roles and greater control over recurring negative thoughts by replacing them with mental images of pleasant scenes or scenarios.

Objective: 7 10) Muscle relaxation techniques are helpful in reducing the likelihood of a startle reaction.

A) True B) False Answer: A Objective: 8 11) Deep breathing and muscle relaxation give patients an active role during administration of local anesthetic drugs, enhancing cognitive control over negative thoughts.

A) True B) False Answer: A Objective: 8 12) N2O-O2 sedation is a substitute for good behavioral management.

A) True B) False Answer: B Explanation: B) While nitrous oxide/oxygen sedation is sometimes used for fearful and anxious patients, it is not a substitute for good behavioral management practices.

Objective: 10 13) It is important when using a time-structuring strategy during an appointment to tell patients when needle penetrations are occurring, deposition sites have been reached, and injections are nearly finished.

A) True B) False Answer: B Explanation: B) When using time structuring, patients are continually apprised of injection progress by stating when the injection is one-fourth complete, one-third complete, three-quarters complete, and finished.

Objective: 11 14) Electric pulp testing (EPT) devices can be a reliable method to reassure patients that adequate anesthesia has been established prior to initiating treatment.

A) True B) False Answer: A Objective: 12 15) Confirming anesthesia with an EPT is contraindicated because this causes pain and induces unnecessary fear and anxiety in patients.

A) True

B) False Answer: B Explanation: B) Using an EPT can be a reliable method to reassure patients that adequate anesthesia has been established prior to initiating treatment. It is not unusual for anxious patients to request an EPT prior to every treatment.

Objective: 12 Short answer/essay 1) Provide examples of behavioral indicators of dental fear.

Answer: Behavioral indicators of fear include such overt signs as pacing in the waiting room, fidgeting, wringing hands, or gripping the arms of chairs until knuckles turn white. Patients may talk incessantly to avoid beginning treatment. Often, however, the signs of fear in the operatory are the opposite of the excessive movement seen in the waiting room. Patients may become quiet and slow to respond or nonresponsive, especially prior to beginning treatment.

Objective: 4 2) Explain one of the two muscle relaxation techniques.

Answer: The clinician explains and demonstrates the muscle relaxation technique prior to practicing with the patient. Instruct the patient to: 1. Inhale and tense up the leg muscles 2. Exhale while releasing the leg tension 3. Inhale and tense the arm and hand muscles 4. Exhale and release the hand and arm tension, allowing them to go limp This can be repeated for the head, neck, and shoulders Another method is to: 1. Ask the patient to inhale deeply to the count of five and squeeze and tense all body muscles 2. Upon initiation of exhalation ask patients to release tension in all muscles as their bodies sink into the chairs Objective: 9 3) What postoperative anesthetic recovery instructions are important for fearful patients?

Answer: Provide patients a realistic expectation for recovery from their local anesthesia experience. For example, an area may be sore where a substantial number of penetrations or relatively large volumes of local anesthetic were administered. When patients are informed and given instructions to take anti-inflammatory medications prior to anesthesia wearing off, or given pain medications prior to leaving, they will more likely assume that these sensations are normal.

Knowing what is normal is always an important point for fearful patients. They can continue to take recommended pain medications until fully recovered.

Objective: 9 Use the information provided in the Case Study below to answer the questions that follow.

Case Study The receptionist receives a call from a prospective patient who states that she has not been to the dentist for years and knows that she needs treatment. The receptionist makes an appointment for

her; however, the patient later decides she cannot make it that day and another appointment is scheduled for the following month. The next day, the patient calls again saying she is not able to make the second appointment, either. After speaking with the receptionist, she decides to reschedule for an earlier appointment because her tooth is starting to hurt.

1). What clues suggest this patient might be fearful of dentistry?

Answer: There are at least four clues that alert the receptionist that this patient is fearful of dentistry. She admits to having had no recent dental experience and continues to delay care by changing her appointments. She finally agrees to keep her appointment because of pain but only after having called a second time to cancel her appointment.

Objective: 4 2) Given this scenario, do you suspect this patient is fearful, anxious, and/or phobic? Why? Answer: At the least, this patient is anxious and fearful of dental care. She is aware that she needs care, yet she has avoided it. She also has features of phobia in that she is persistent in her practice of avoiding dental care to the point that her oral health has declined. She admits a tooth is hurting and she has likely endured suffering to avoid dental care.

Objective: 2 3) What is the most important first step in providing dental care for her?

Answer: The most important first step in providing care for this patient is to treat the fear first. It is important that all dental personnel remain alert to identifying fear as early as possible. Studies have demonstrated that dental personnel who recognize fear and anxiety in patients often do not address the problem in order to avoid making matters worse. Acknowledging and treating fear with well-researched methods is necessary to empower this patient to overcome her fears and willingly accept dental care.

Objective: 5 4) Explain three concepts to consider when developing strategies for treating her. Provide examples.

Answer: The three concepts to consider when developing strategies for treating this patient are: 1. Establish a patient-clinician relationship that builds trust through interpersonal rapport, open two-way communication, empathy, and professional competence.

2. Develop a sense of control over the potentially threatening environment. For example, before treatment, provide simple informational descriptions that emphasize the sensations that she will experience. Encourage behavioral control such as raising her hand when she feels anxious, or needs to swallow or rest. Teach and practice cognitive skills such as controlling negative thoughts, and provide positive distractions through guided imagery and music. After the appointment, spend time to retrospectively evaluate her successes.

3. Assess her knowledge and use of coping skills in other stressful situations. Teach new skills that will be helpful for her, such as deep breathing and progressive muscle relaxation.

Objective: 5

Chapter 19 Insights from Pedodontics Match the following A) Words children understand B) Prevents body movement C) Used to demonstrate and explain D) Praise for specific good behavior E) Keeps focus on clinician's voice F) Post-injection trauma G) Terms that may induce fear H) Dose adjustment based on child's age I) Controlled body language and silence J) Dose adjustment based on child's weight 1) Age-appropriate terminology Objective: 1 2) Clark's rule Objective: 1 3) Lip chewing Objective: 1 4) Parent guidelines Objective: 1 5) Passive restraint Objective: 1 6) Positive feedback Objective: 1 7) Show-tell-do Objective: 1 8) Trigger words Objective: 1 9) Vocal distraction Objective: 1 10) Young's rule Objective: 1 Answers: 1) A 2) J 3) F 4) I 5) B 6) D 7) C 8) G 9) E 10) H

True or false 1) MRDs for obese children should be strictly adhered to because of incomplete development of internal organs.

A) True B) False Answer: B Explanation: B) There are no MRDs or proven maximum safe dose standards for obese children.

Due to incompletely developed organs and organ functions, it is recommended that the MRD for an adult with similar weight be divided by two.

Objective: 2 2) Vasoconstrictors can be helpful or harmful when used in local anesthetic injections in pediatric dentistry.

A) True B) False Answer: A Objective: 2 3) Children have thinner cortical plates and more porous bone, which allow for ease of diffusion; therefore, infiltration techniques are more reliable in children than adults.

A) True B) False Answer: A Objective: 5 4) The primary advantage when administering mandibular infiltrations on children is the small volume of anesthetic needed to achieve profound anesthesia.

A) True B) False Answer: B Explanation: B) The primary advantage of mandibular infiltrations in children is that anesthesia of large areas of the lip and tongue can be avoided.

Objective: 5 5) The advantage of using articaine for children is its ability to diffuse through bone; however, an increase in anesthetic volume is needed for infiltration injections compared to nerve block techniques in children.

A) True B) False Answer: B Explanation: B) Articaine is believed by some to be more effective in its ability to diffuse through bone compared to other amide anesthetic solutions. Articaine is available only in a 4% concentration. It is twice as concentrated when compared to 2% lidocaine. An appropriate volume reduction is required to avoid toxicity. The consideration is identical regardless of the

technique, infiltration versus nerve block.

Objective: 5 Fill in the blank 1) The MRD for 2% lidocaine for a child weighing 30 pounds is Answer: 96 Feedback: 96 mg; 3.2 mg/lb × 30 = 96 mg Objective: 2

mg.

2) The number of cartridges of 2% lidocaine that can be administered to a child weighing 30 pounds is .

Answer: 2.6 Feedback: 2.6 cartridges; 3.2 mg/lb × 30 = 96 mg; 96 mg ÷ 36 = 2.6 cartridges Objective: 2 3) The MRD for 2% lidocaine for a child weighing 40 pounds is Answer: 128 Feedback: 128 mg; 3.2 mg/lb × 40 = 128 mg Objective: 2

mg.

4) The number of cartridges of 2% lidocaine that can be administered to a child weighing 40 pounds is .

Answer: 3.5 Feedback: 3.5 cartridges; cartridges; 3.2 mg/lb × 40 = 128 mg; 128 ÷ 36 mg = 3.5 cartridges Objective: 2 5) The MRD for 2% lidocaine for a child weighing 75 pounds is Answer: 240 Feedback: 240 mg; 3.2 mg/lb × 75 = 240 mg Objective: 2

mg.

6) The number of cartridges of 2% lidocaine that can be administered to a child weighing 75 pounds is .

Answer: 6.6 Feedback: 6.6 cartridges; 3.2 mg/lb × 75 = 240 mg; 240 ÷ 36 mg = 6.6 cartridges Objective: 2 7) The MRD for 4% articaine for a child weighing 35 pounds is Answer: 112 mg Feedback: 112 mg; 3.2 mg x 35 = 112 mg Objective: 2

mg.

8) The number of cartridges of 4% articaine that can be administered to a child weighing 35 pounds is .

Answer: 1.5 Feedback: 1.5 cartridges; cartridges; 3.2 mg/lb × 35 = 112 mg; 112 ÷ 72 mg = 1.5 cartridges

Objective: 2 9) The MRD for 4% articaine for a child weighing 58 pounds is Answer: 185 Feedback: 185 mg; 3.2 mg x 58 = 185 mg Objective: 2

mg.

10) The number of cartridges of 4% articaine that can be administered to a child weighing 58 pounds is .

Answer: 2.5 Feedback: 2.5 cartridges; 3.2 mg x 58 = 185 mg; 185 ÷ 72 mg = 2.5 cartridges Objective: 2 11) The MRD for 4% articaine for a child weighing 70 pounds is Answer: 224 Feedback: 224 mg; 3.2 mg/lb × 70 = 224 mg Objective: 2

mg.

12) The number of cartridges of 4% articaine that can be administered to a child weighing 70 pounds is .

Answer: 3.1 Feedback: 3.1 cartridges; 3.2 mg/lb × 70 = 224 mg; 224 mg ÷ 72 mg = 3.1 cartridges Objective: 2 13) The mandibular foramen in children is located Answer: inferior Objective: 1

to its position in adults.

14) Administering vasoconstrictors to children increases the risk of Answer: self-induced trauma Objective: 5

after injections.

15) On the other hand, administering vasoconstrictors to children minimizes the risk of the anesthesia during treatment.

Answer: wearing off Objective: 3 16) The process of keeping a child focused on a clinician's voice rather than a dental procedure is called .

Answer: verbal distraction Objective: 3 17) A technique called allows a dental assistant to minimize unwanted movements by gently protecting children during injections.

Answer: passive restraint Objective: 1

18) Trauma resulting from lip chewing may be treated by applying a swelling.

Answer: cold pack Objective: 6

to reduce tissue

Multiple choice 1) What is the most critical risk factor for toxicity of local anesthetics in pediatric patients?

A) Children react differently to local anesthetic agents than adults B) Children are less able to metabolize local anesthetics than adults C) Appropriate anesthetic agents for children are different than for adults D) Children typically weigh less than adults Answer: D Objective: 2 2) Which of the following anesthetic drugs is associated with a higher number of toxicity reports compared to the others?

A) Articaine B) Lidocaine C) Mepivacaine D) Bupivacaine Answer: C Objective: 2 3) Why is 3% mepivacaine plain associated with a higher number of local anesthetic toxicity reports in children compared with other agents?

A) Lack of vasoconstrictor B) Higher content of anesthetic drug than lidocaine C) Longer duration of action than lidocaine D) More difficult for children to metabolize than other anesthetic drugs Answer: A Objective: 2 4) Which of the following is not a special consideration when administering anesthetic drugs to obese children?

A) Excess adipose tissue in the oral cavity impedes visibility B) Excess adipose tissue in the oral cavity makes it difficult to identify intraoral anatomical landmarks C) Obesity alters the distribution and elimination of anesthetic drugs D) Obesity may require administration of greater volumes of anesthetic for effectiveness Answer: D Objective: 2 5) Which of the following is the best management technique for children?

A) Cover the mouth and nose to stop a child from screaming B) Use of physical restraint

C) Use of vocal distraction and positive feedback D) Explain exactly what the child will feel during the injection Answer: C Objective: 3 6) Which of the following is an age appropriate explanation for a three year old child?

A) Hold real still and you will not feel this B) Your lip will feel fat and sleepy C) The anesthetic will wear off in just a little while D) Your teeth will feel numb Answer: B Objective: 4 7) Why is 4% articaine used with frequency in pediatric care?

A) Less risk of paresthesia B) Ease of biotransformation C) More effective in its ability to diffuse through bone D) Longer duration than mepivicaine Answer: C Objective: 5 8) Which of the following anatomical variations affects the choice of injection technique for children?

A) The inferior alveolar foramen is more superior in children than adults.

B) The cortical plate is thinner and more porous in children than in adults.

C) The roots of primary teeth are approximately the same length as permanent teeth roots.

D) The maxillary tuberosity is less prominent in children than adults.

Answer: B Objective: 5 9) Shortly after returning home, a mother calls to report that her child has bitten his lower lip causing redness and swelling. What is the appropriate treatment?

A) Return to the office immediately for evaluation B) Apply benzocaine topical to reduce pain C) Apply a cold pack to reduce swelling D) Apply heat to increase circulation, and to reduce swelling and pain Answer: C Objective: 6 10) A father takes his son back to a dental office two days after a filling was placed. He is concerned because the lip is red, swollen, and sore. What is the appropriate treatment?

A) Refer the child to a physician B) Apply heat to increase circulation and reduce swelling C) Apply a cold pack to reduce swelling and pain D) Prescribe antibiotics to prevent infection Answer: B

Objective: 6 Short answer/essay 1) Discuss appropriate behavioral guidelines for parents in dental clinics.

Answer: If parents wish to observe treatment, they need to be silent observers, allowing the child's attention to be focused on the clinician. Calm, neutral expressions convey important visual messages that all is going well. Slow, measured movements are equally important because they arouse fewer negative responses. Gentle touches on the shoulders by the parent or guardian are reassuring, as is gentle hand holding (as opposed to tight gripping), and gentle ankle stroking.

All of these nonverbal cues enhance a child's sense of comfort and safety.

Objective: 7 2) What is the primary focus of an assistant during injection procedures?

Answer: The primary focus of an assistant during injection procedures must be the safety of the child. The clinician administering the injection cannot control gross body movements of the child while injecting. The assistant must respond to any quick and unexpected movements that occur in order to ensure the safety of the child. This can be accomplished through gentle use of passive restraint. The assistant places one hand over the child's hands (which should be placed on their stomach). The other hand is placed on the child's forehead.

Objective: 7 3) Discuss a reported advantage of administering bilateral mandibular nerve blocks in children.

Answer: A recent study found that the incidence of postoperative lip biting actually decreased in children who received bilateral mandibular blocks compared to those who received unilateral blocks. It was speculated that, following a unilateral mandibular block, children are more inclined to test the funny side by chewing their lips.

Objective: 5 Use the information provided in the Case Study below to answer the questions that follow.

Case Study Sophia is a healthy 3 year old weighing 36 pounds. This is her first visit to the dental office. She is cooperative and climbs into the chair without hesitating. With only slight encouragement she opens her mouth. The dentist determines she has two teeth with small areas of decay, M and D, and two teeth with large areas of decay, S and T. Her mother requests as few appointments as possible because she relies on a neighbor for transportation. The dentist decides to restore S and T today and M and D on a subsequent visit. 2% lidocaine with 1:100:000 epinephrine is selected for anesthesia.

1) Why did the dentist choose to restore the mandibular teeth first?

Answer: Beginning treatment on the mandible will provide reliable anesthesia for a first-time experience. This area is also in the greatest need of treatment.

Objective: 3

2) What injection technique should be considered to provide anesthesia for S and T? Why? Answer: An IA will provide profound pulpal anesthesia and soft tissue anesthesia for clamp placement.

Objective: 3 3) What is the MRD for 2% lidocaine for Sophia?

Answer: Sophia’s weight is 36 pounds. She may receive a maximum of 115 mg.

(3.2 mg/lb x 36 = 115 mg) Objective: 2 4) What number of cartridges of 2% lidocaine does this represent?

Answer: 2 cartridges of 2% lidocaine.

(3.2 mg/lb x 36 = 115 mg; 115 mg ÷ 36 = 3 cartridges) 5) How will you explain the anesthesia experience to Sophia? Provide a sample explanation.

Answer: This is Sophia’s first dental and anesthesia experience. It is important to use ageappropriate terms. For example, “I am going to put some sleepy jel on your gum” and when the topical is effective, “Now I’ll use some sleepy juice. Your lip and tongue will feel sleepy and kind of fat.”

Objective: 4 6) What two behavior management techniques are useful during dental procedures? Why? Answer: Two useful behavior management techniques are vocal distraction and positive feedback. Vocal distraction will keep Sophia focused on the clinician’s voice rather than on procedures. Using a calm, reassuring narrative that is continuous throughout the procedure is important. Positive feedback for specific desirable behaviors, for example “Sophia, thank you for holding your head still” will help Sophia learn good behaviors and feel rewarded for her cooperation.

Objective: 5 7) How can the dental assistant help Sophia during the injection procedure?

Answer: The dental assistant uses passive restraint by putting Sophia’s hands on her stomach with her hands over Sophia’s. The assistant’s other hand is placed on Sophia’s forehead to guard against sudden or unexpected movements during the procedure.

Objective: 7

Chapter 20 Insights from Specialties: Oral Surgery, Periodontics, and Endodontics Match the following A) Closed-mouth injection technique B) Anxiolytic drugs C) Technique used exclusively in endodontics D) Provides deep topical anesthesia E) Alternate when true anesthetic allergy is present F) Long-acting anesthetic G) Technique used to anesthetize lingual tissues H) Spread along injection pathway I) Guide sleeve for intraosseous injection J) Penetrates efficiently through bone 1) Akinosi Objective: 1 2) Articaine Objective: 1 3) Benadryl Objective: 1 4) Benzodiazepines Objective: 1 5) Bupivacaine Objective: 1 6) Interpapillary Objective: 1 7) Intrapulpal Objective: 1 8) Needle tract infections Objective: 1 9) Stabident Objective: 1 10) Tetracaine Objective: 1

Answers: 1) A 2) J 3) E 4) B 5) F 6) G 7) C 8) H 9) I 10) D Multiple choice 1) Which of the following represents a reasonable rationale for the concurrent use of lidocaine and bupivacaine in oral surgery cases?

A) Rapid onset of lidocaine and long duration of bupivacaine B) Ease of diffusion of lidocaine and low potency of bupivacaine C) Slow onset of lidocaine and high potency of bupivacaine D) Rapid onset of lidocaine prevents the high toxicity risk of bupivacaine Answer: A Objective: 1 2) Rationale for selecting a 25 gauge long needle for oral surgical procedures includes which one of the following?

A) There is a frequent need to avoid areas of infection.

B) The risk of patient movement is higher given the increased potential for pain.

C) The depth of most injections requires a long needle to reach the deposition site.

D) Long needles allow all types of injections to be administered without changing needles.

Answer: D Objective: 2 3) Which of the following is not a reason geriatric patients are more susceptible to local anesthetic toxicity?

A) Slower rate of metabolism and excretion B) Underlying complicating medical conditions C) Concomitant use of medications that may have effect on drug metabolism or clearance D) Risk of hematomas Answer: D Explanation: D) Hematomas are not complications of drug toxicity.

Objective: 3 4) Which of the following is not a local anesthesia consideration in oral and maxillofacial surgery when treating an infected patient?

A) Use a greater amount of local anesthetic to help overcome acidity created by the infection.

(Make sure maximum doses are not exceeded.)

B) Use a regional nerve block away from the area of inflammation.

C) Discard the needle after injecting in or near an area of inflammation/infection.

D) Use a local anesthetic agent with a lower pH. Answer: D Explanation: D) In an area of infection, an anesthetic with a low pH has a decreased ability of providing adequate anesthesia compared to one with a higher pH. Objective: 4 5) Which class of drugs decreases the toxic threshold for any local anesthetics administered?

A) Antibiotics B) Benzodiazepines

C) Antihistamines D) Vasodilators Answer: B Objective: 11 6) All of the following are local anesthetic considerations when treating a patient with an oral infection, except A) Selection of anesthetic technique B) Increased amount of anesthetic drug C) Use of anesthetic drug with a higher pH D) Always premedicate with antibiotics Answer: D Objective: 4 7) Which of the following additives to local anesthetic solutions increases the effectiveness of a local anesthetic by raising the pH when an infection is present?

A) Methyparaben B) Sodium bicarbonate C) Vasoconstrictor D) Cocaine Answer: B Objective: 4 8) Which of the following is not an option for treatment of patients with true local anesthetic allergies?

A) Use of an alternate local anesthetic B) 1% Benadryl (diphenhydramine hydrochloride) C) 0.09% benzyl alcohol D) 0.1% sodium benzoate Answer: D Objective: 5 9) Which of the following represents a plausible explanation for the occurrence of lingual paresthesia?

A) The lingual nerve is not usually in the pathway of the needle during the IA injection.

B) The lingual nerve is a large nerve therefore more easily encountered.

C) The lingual nerve is attached to the interpterygoid fascia and does not slide away when encountered.

D) A small but significant anatomical anomaly exists where the lingual nerve is attached to the IA nerve in the pterygomandibular space.

Answer: C Objective: 7 10) Why is caution recommended when considering vasoconstrictors for intraosseous injection techniques?

A) Vasoconstrictors will stop the flow of blood into a viable tooth.

B) Vasoconstrictors produce rapid CVS effects including a rapid heartbeat.

C) The duration of anesthesia is not critical, as the endodontic procedure quickly stems the firing ability of the nerve.

D) Vasoconstrictors increase the risk of post-treatment necrosis in the surrounding tissues.

Answer: B Objective: 16 11) Intrapulpal techniques require all of the following, except A) endodontically prepared tooth B) use of any local anesthetic is equally effective C) use of pressure anesthesia created by the volume of solution D) wide opening through the crown to permit access to the large volume of anesthetic required for success Answer: D Objective: 15 12) Which injection technique can be used to provide lingual anesthesia of the mandibular premolars and incisors following a mental incisive nerve block without inducing widespread anesthesia of the tongue?

A) Mylohyoid nerve block B) Akinosi nerve block C) Interpapillary infiltration D) Bilateral lingual nerve block Answer: C Objective: 9 13) The AMSA injection technique is used in procedures involving maxillary anteriors and premolars because the field of anesthesia includes A) lingual and facial soft tissues and pulps of incisors and premolars on the injected side, minimizing the number of palatal and facial injections B) facial soft tissues and pulps of incisors and premolars on the injected side, minimizing the number of facial injections C) lingual soft tissues on the injected side, minimizing the number of palatal injections D) facial soft tissue and pulps of the incisors and premolars on the injected side, minimizing the need for two injections on the palate and the infraorbital on the facial Answer: A Objective: 10 14) Which of the following is a reason vasoconstrictors are usually required in periodontal procedures?

A) Only short durations are required B) Increased risk of toxicity C) Hemostasis D) Vasodilating properties Answer: C Objective: 11 15) Which concentration of epinephrine is usually adequate for periodontal surgeries?

A) 1:50,000 B) 1:20,000 C) 1:200,000 D) 1:100,000 Answer: D Objective: 11 Short answer/essay 1) Discuss specific challenges encountered in the administration of local anesthesia in oral maxillofacial practice settings.

Answer: Specific challenges encountered in OMFS local anesthesia administration include safe management of patients of all ages with diverse medical backgrounds who may require extensive treatment (e.g. full mouth extractions). Minor to life-threatening infections may be encountered.

Achieving adequate local anesthesia in the presence of these infections while limiting the potential for needle tract infections (infections spread along needle pathways) and compensating for anatomic difficulties (with associated trismus and airway patency concerns) are serious and significant challenges encountered by OMF surgeons.

Objective: 2 2) Why is local anesthesia administered in addition to the use of inhalation, intravenous, and general anesthesia in OMFS practices?

Answer: Although the use of inhalation and intravenous sedation, as well as general anesthesia, is common in OMFS, effective local anesthesia plays an important supplemental role, assisting in providing effective intraoperative pain management and allowing for lighter general anesthesia and sedation. Local anesthetics with vasoconstrictors also provide hemostasis while longer-acting local anesthetics provide postoperative pain control and a more comfortable transition to oral and intravenous analgesics.

Objective: 2 3) Why are geriatric patients generally at greater risk of local anesthetic toxicity?

Answer: Geriatric patients generally metabolize drugs at a slower rate. In addition, they often have underlying complicating medical conditions, or take other medications that may have an effect on drug metabolism or clearance. For example, propranolol (InderalTM), a beta-adrenergic blocker, can reduce both hepatic blood flow and renal clearance.

Objective: 3 4) Why is it easier to exceed recommended doses of local anesthetics in pediatric patients?

Answer: It is easier to exceed maximum doses of local anesthetics in children due to their generally smaller body masses.

Objective: 3 5) Explain the risks associated with the use of cocaine and methamphetamine with vasoconstrictors in local anesthetic drugs.

Answer: Cocaine potentiates the effects of vasoconstrictors. The dysrhythmic results of this interaction can be life threatening, especially if the cocaine use is recent. Recommendations for avoiding local anesthetics with vasoconstrictors range from a minimum of 6 hours to a maximum

of 24 hours after cocaine use, although a 24 waiting period is recommended. A similarly abused drug, methamphetamine, requires a minimum waiting period of 24 hours after use before vasoconstrictors can be administered.

Objective: 3

Use the information provided in the Case Study below to answer the questions that follow.

Case Study 1 Susan Johnson is scheduled for an endodontic procedure on tooth #12. She is nervous because she never had a “root canal”; however, she knows she cannot stand the pain any longer and does not want to lose the tooth. She has no medical complications. The only medication she is currently taking is amoxicillin, prescribed for her 2 days ago. Obvious redness and swelling remain around #12.

1) Why is it important to address Ms. Johnson’s nervousness before treatment?

Answer: Anxiety can intensify typical levels of fear, particularly when root canals and injections are necessary. It is important to address her fear to ease her anxiety and increase the success of local anesthesia.

Objective: 4 2) What is the first consideration in the choice of injection technique for Ms. Johnson?

Answer: Injection procedure(s) that deposit anesthetic solution away from the inflamed area are recommended when inflammation and infection are present.

Objective: 4 3) What nerve block injection technique(s) are good choices for #12 after noting that observable redness and swelling remain? Which injections are not likely good choices? Explain each choice.

Answer: An IO nerve block could provide soft tissue and pulpal anesthesia for tooth #12 provided the inflammation does not extend to the penetration site. An AMSA can provide soft tissue and pulpal anesthesia of #12 the inflammation does not extend to the AMSA penetration site on the palatal aspect of the premolars. If either of these choices proves inadequate, an intraosseous technique would provide predictable profound anesthesia when there is considerable inflammation and infection present in the tissues surrounding a tooth. An infiltration is contraindicated in most instances because solution would be deposited into the inflamed area which could impact anesthesia success and infiltrations through inflamed or infected tissues risks the possibility of deeper, needle track spread of infection.

Objective: 4 4) During the root canal procedure it is determined that the tooth is not profoundly nesthetized.

What additional injection technique should be considered? Explain this choice.

Answer: An intrapulpal injection is used exclusively in endodontic procedures when a tooth is inadequately anesthetized.

Objective: 4 Use the information provided in the Case Study below to answer the questions that follow.

Case Study 2 Barbara Jones, age 72 arrives for a morning appointment for periodontal surgery on teeth #3, 4, 5, and 6. She has a history of heart disease with a single stent placed two years ago, as well as hypertension. She reports she sees her physician regularly. Her medications include atorvastatin (40 mg daily) and metoprolol (50 mg twice daily). Her blood pressure is 145/92 and her heart rate is 84.

1) Identify and discuss Ms. Jones’ medical conditions and current medications related to the planned treatment and the use of local anesthesia.

Answer: Ms. Jones has a history of heart disease with stent placement 6 years ago. She is treated for hypertension with metoprolol 50 mg twice daily. Her blood pressure is above 120/80; however, it is less than 160/100 and therefore does not represent a contraindication to treatment.

Her pulse is slightly elevated but is not a contraindication to treatment, either. It is important to confirm that Ms. Jones has taken her blood pressure medications as scheduled. Stress reduction protocols should be considered for her.

Objective: 10 2) Identify and discuss appropriate drug choice or limitations for the planned treatment for Ms. Jones.

Answer: Ms. Jones has a history of heart disease and uses metoprolol, a beta-adrenergic antagonist, to manage her hypertension. Adverse reactions can occur when administering vasoconstrictors in the presence of heart disease. Providing profound anesthesia, including a local anesthetic with sufficient amounts of a vasoconstrictor, is important for her planned periodontal surgery. Epinephrine provides excellent hemostasis and durable pain control for surgery. Solutions containing no more than a 1:100,000 epinephrine dilution or 1:20,000 levonordefrin dilution are sufficient to accomplish the necessary anesthesia. The total dose of epinephrine should limited to no more than 0.04 mg of epinephrine or 0.2 mg of levonordefrin.

Objective: 9, 10 3) Identify and explain what maxillary injection(s) should be considered for the planned surgery given the limit of 2 cartridges with vasoconstrictor?

Answer: Two alternatives may be considered. First, a maxillary block (division 2 block) can be accomplished with a single injection to provide anesthesia to the hemi-maxillary soft tissues and tooth pulps with one cartridge (1.8 mL) of anesthetic with vasoconstrictor. A second alternative requires three injections including a PSA and an infiltration for the mesiobuccal root of #3 to provide pulpal and facial soft tissue anesthesia for tooth #3; and an AMSA to provide pulpal and soft tissue anesthesia for teeth 4, 5, 6, and the lingual soft tissue for #3 with a total of 1.5 to 2 cartridges (2.4 mL to 3.6 mL).

Objective: 9, 10

Chapter 21 Fundamentals for the Administration of N2O-Oxygen Sedation True or False 1) The specific gravity of N2O is 1.53 and its molecular weight is 44, making it heavier than both air and oxygen.

A) True B) False Answer: A Objective: 2 2) The nitrous tanks will last significantly longer than oxygen tanks due in part to their gaseous content and the fact that typical administrations deliver only 30% N2O. A. True B. False Answer: B Explanation: B) The nitrous tanks will last significantly longer than oxygen tanks due in part to their liquid content and the fact that typical administrations deliver only 30% N2O. Objective: 2 3) N2O tanks maintain a constant pressure of approximately 1100 psi until all the liquid has evaporated, making residual volume difficult to determine.

A. True B. False Answer: B Explanation: B) N2O tanks maintain a constant pressure of approximately 745 psi until all the liquid has evaporated, making residual volume difficult to determine Objective: 3 4) N2O is stored primarily as an oxidizing gas with a small portion of liquid N2O at the bottom of the cylinder.

A) True B) False Answer: B Explanation: B) N2O is stored as a liquid with a small oxidizing gaseous content above the liquid.

Objective: 3 5) At least one clinician must remain in a treatment room to monitor a patient during N2O sedation, and at least one additional, appropriately trained professional should be nearby and within view.

A) True B) False Answer: A Objective: 4

6) Pin index safety systems are used only for portable equipment.

A) True B) False Answer: A Objective: 4 7) In the United States oxygen is stored in blue cylinders, and it is odorless, colorless and tasteless.

A) True B) False Answer: B Explanation: B) In the United States oxygen is stored in green cylinders, and it is odorless, colorless and tasteless.

Objective: 4 8) Oil, grease, or lubricants can be used on tanks, piping, and regulators during routine maintenance.

A) True B) False Answer: B Explanation: B) No combustible material, such as oil, grease, or lubricants, should be used on tanks, piping, or regulators. If these materials enter the orifices of tanks, piping, or regulators, they increase the odds of tank ignition. Only certified technicians should perform maintenance and repairs on central supply delivery systems.

Objective: 4 9) Excessive exposure to N2O may occur as a result of leaks from the anesthetic delivery system during administration.

A) True B) False Answer: A Objective: 4 10) Average adult tidal volume is 500 mL based on an average of 6–7 liters/minute.

A) True B) False Answer: A Objective: 5 11) The pre-induction of sedation begins with establishing tidal volume of 100% oxygen for two minutes.

A) True B) False Answer: A Objective: 5

12) The incremental induction of N2O should never exceed 5% per three minutes.

A) True B) False Answer: B Explanation: B) The incremental induction of N2O is 10% for 1 minute¸ 20% for one minute, 25% for 1 minute, and then up by 5% each minute until mild sedation level is achieved.

Objective 5 13) Pre-sedation preparation includes confirming the proper function of the scavenging system by delivering 45% N2O according to the manufacturer’s instructions.

A) True B) False Answer: B Explanation: B) Pre-sedation preparation includes confirming the proper function of the scavenging system by delivering 100% oxygen according to manufacturer instructions.

Objective: 5 14) Nitrous oxide-oxygen sedation has a positive effect on myocardial ischemia due to its provision of supplemental oxygen, sedative properties, and tendency to dilate peripheral vessels.

A) True B) False Answer: A Objective: 6 15) Nitrous oxide can also enhance the CNS depressant effects of agents such as barbiturates, tranquilizers, narcotics, and recreational drugs.

A) True B) False Answer: A Objective: 9 16) During minimal sedation patients are able to independently and continuously maintain airways; however, they frequently respond slowly to tactile stimulation and verbal commands.

A) True B) False Answer: B Explanation: B) During minimal sedation patients are able to independently and continuously maintain airways, and respond normally to tactile stimulation and verbal commands.

Objective: 10 17) Patient mouth breathing not only increases the amount of N2O that is available for sedation but also allows N2O to be exhaled into the environment.

A) True B) False Answer: B Explanation: B) Breathing through the mouth decreases the amount of N2O that is available for

sedation.

Objective: 10 18) The benefits of N2O-O2 sedation include easy titration of gases, rapid onset of sedation, and short recovery time should overdose occur.

A) True B) False Answer: A Objective: 11 19) Breathing N2O directly from pressurized tanks can cause frostbite to noses, lips, and intraoral tissues.

A) True B) False Answer: A Objective: 13 20) The National Institute for Occupational Safety and Health (NIOSH) set the maximum exposure limit for N2O concentration to 25 ppm for dental personnel.

A) True B) False Answer: A Objective: 15 Multiple choice 1) Which of the following are properties of N2O? A) Odorless, blue colored gas that is flammable B) Sweet smelling, colorless gas that supports combustion C) Odorless, colorless gas that supports combustion D) Sweet tasting; colorless gas that is flammable Answer: B Objective: 2 2) Nitrous oxide is manufactured from: A) Ammonium dioxide B) Ammonium chloride C) Ammonium nitrate D) Ammonium chlorohydrate Answer: C Objective: 2 3) Which of the following are properties of oxygen?

A) Odorless, colorless, tasteless gas that supports combustion B) Odorless, colorless, sweet tasting gas that is flammable C) Sweet smelling, colorless gas that is supports combustion D) Sweet smelling, colorless gas that is flammable

Answer: A Objective: 2 4) What will the gauge on an oxygen tank read when it is full?

A) 2200 psi B) 1100 psi C) 750 psi D) 32 psi Answer: A Objective: 3 5) Which of the following is not a purpose of a manifold in central supply delivery systems?

A) Allows connections for multiple tanks in up to 10 rooms B) Connects the gas supply to a central system C) Allows full tanks to be accessed once other tanks are empty D) Provides a scavenger system for up to 10 rooms Answer: D Objective 3 6) Which component of a N2O-O2 delivery system reduces gas pressures from tanks before delivery into tubing and pipes?

A) Regulator B) Manifold C) Pin index safety system D) Flow meter Answer: A Objective: 3 7) What color is a N2O tank in the United States?

A) White B) Blue C) Green D) Gray Answer: B Objective: 3 8) What does the reservoir bag monitor?

A) Patient’s respirations B) Flow of N2O C) Flow of oxygen D) Total flow of nitrous and oxygen Answer: A Objective: 3 9) What would the gauge read on a half full cylinder of oxygen?

A) 500 psi B) 750 psi

C) 1100 psi D) 2000 psi Answer: C Objective: 3 10) Which of the following is a safety feature of a central supply delivery system?

A) Sterile plastic tubing B) Diameter-Index System C) Pin index system D) Non latex nasal hoods Answer: B Objective 4 11) Which of the following reduces gas pressures from the tanks before any gas is delivered into the tubing and pipes?

A) Pin index system B) Flow meter C) Reservoir bag D) Regulator Answer: D Objective: 4 12) Which of the following explains why copper tubing is required in central supply delivery systems?

A) It reduces the overall cost of installation B) It is color coded to prevent accidental connection to the nitrous cylinders C) It does not support combustion D) It avoids the necessity of certified technicians to perform maintenance Answer: C Objective: 4 13) What is the approximate constant pressure of a N2O tank until all the liquid has evaporated?

A) 745 psi B) 700 psi C) 695 psi D) 445 psi Answer: A Objective: 4 14) How many hours should children avoid food before planned N2O-O2 sedation?

A) One B) Two C) Three D) Four Answer: B Objective: 5

15) What is the recommended liter flow rate of oxygen prior to the induction of N2O? A) 2 B) 4 C) 6 D) 8 Answer: C Objective: 5 16) Which of the following is not included in the pre-sedation preparation?

A) Seat patient in semi-supine position B) Place nasal hood C) Explain procedure to patient D) Establish tidal volume at 100% oxygen Answer: D Objective: 5 17) Which is the correct sequence of administration of N2O-O2 sedation?

A) Pre-sedation preparation, patient assessment, obtain consent, assemble armamentarium, initiate sedation, establish tidal volume, complete sedation, documentation B) Patient assessment, assemble armamentarium, pre-sedation preparation, establish tidal volume, initiate sedation, monitor patient recovery, documentation C) Patient assessment, obtain consent, assemble armamentarium, pre-sedation preparation, establish tidal volume, initiate sedation, monitor sedation, completion of sedation, documentation D) Patient assessment, obtain consent, pre-sedation preparation, establish tidal volume, assemble armamentarium, initiate sedation, monitor recovery, documentation Answer: C Objective: 5 18) Which is the correct initial percentage and time interval to begin N2O-O2 sedation?

A) 5% for one minute B) 10% for one minute C) 10% for two minutes D) 20% for two minutes Answer: B Objective: 5 19) What is the first thing to do when a patient reports feeling no sedation effects with 50% N2O flow?

A) Check the patient’s breathing B) Check the fit of the nose hood C) Replace the empty N2O tank D) Increase the flow of N2O by 5% until optimum sedation is established Answer: A Objective: 5

20) How long is oxygen administered at the completion of sedation?

A) 1 minute B) 2 to 5 minutes C) 3 to 5 minutes D) 5 to 8 minutes Answer: C Objective: 5 21) Which level of sedation is the desired and appropriate level with N2O-O2?

A) Local B) Minimal C) Moderate D) General Answer: B Objective: 6 22) Which of the following best describes the patient’s vital signs at an appropriate level of N2O sedation?

A) Pulse is accelerated; respiration and blood pressure remain unchanged B) Pulse, respiration and blood pressure remain within normal range C) Pulse, respiration and blood pressure are all lowered significantly D) Pulse is reduced; blood pressure and respiration remain unchanged Answer: B Objective: 6 23) Which of the following is not an indication for use of N2O-O sedation in dentistry?

A) Anxious patient B) Patient with a gag reflex that interferes with treatment C) Patient in the first trimester of pregnancy D) Cooperative child undergoing a lengthy procedure Answer: C Objective: 7 24) Which of the following conditions contraindicates the use of N2O-O2 sedation?

A) Anemia B) Diabetes C) Ear infection D) High blood pressure Answer: C Objective: 8 25) Which of the following conditions does not contraindicate the administration of N2O? A) Chronic obstructive pulmonary disease B) Hypertension or cardiovascular disease C) Gastrointestinal obstructions D) Psychiatric disorders Answer: B Objective: 8

26) Which of the following contraindicates the use of N2O sedation?

A) Sinus infection B) Cancer C) Cerebrovascular accidents D) Parkinson’s disease Answer: A Objective: 8 27) Which of the following does not contraindicate the use of N2O-O2 sedation?

A) Recovering alcoholic B) CNS sedative use C) Emphysema D) Fear Answer: D Objective: 8 28) Which of the following patient conditions is not an absolute contraindication for the use of N2O-oxygen sedation?

A) Recovering alcoholic B) Acute respiratory infection C) Severe chronic obstructive pulmonary disease D) Severe psychosis Answer: A Objective: 8 29) Which of the following best explains the analgesic effect of N2O-O2 sedation?

A) Atropic B) Adrenergic C) Opioid D) Steriodal Answer: C Objective: 9 30) Which of the following describes an advantage of N2O over opioids?

A) Cost B) Effects quickly diminish when inhalation is discontinued C) Provides post-operative pain management D) Safe for use in all patients Answer: B Objective: 9 31) How many liters of air does a healthy adult inhale per minute?

A) 2–3 B) 3–5 C) 5–7 D) 9–12

Answer: C Objective: 10 32) Which of the following is not a result of N2O-O2 sedation?

A) Mild analgesia B) Perception of longer appointment time C) Mild amnesic effect D) Anxiolytic effect Answer: Objective: 10 33) Which of the following patient reactions indicate that a patient is not maintained at an appropriate level of relative analgesia?

A) Giggling B) "Floating" feeling C) Slight ringing in the ears D) Dilated pupils Answer: D Objective: 10 34) Which of the following should you do first when a patient at the 50% level of N2O-O2 sedation tells you they are not feeling much?

A) Make sure the nitrous tank is not empty B) Increase the level of N2O by 10% per minute C) Check the scavenging system for proper function D) Check the nose piece seal for leakage Answer: D Objective: 10 35) Most patients will achieve the desired clinical level of sedation at what percent of N2O? A) 10 – 20 % B) 15–20% C) 15–40% D) 50–70% Answer: C Objective: 10 36) Why is oxygen delivered to patients for 3–5 minutes after sedation is completed?

A) Prevent diffusion hypoxia B) Prevent nausea and vomiting C) Determine how long it takes the patient to return to normal wakefulness D) Provide time for reflexes to return to normal Answer: D Objective: 10 37) The volume of each breath is known as the: A) Induction volume B) Minute ventilation

C) Vital capacity D) Tidal volume Answer: D Objective: 10 38) Which of the following adverse events does not occur during N2O-O2 sedation?

A) Nausea and vomiting B) Sweating C) Unresponsiveness D) Constricted pupils Answer: D Objective: 10 39) What is the leading cause of patient dissatisfaction with N2O administration?

A) Inadequate anesthesia B) Nausea and vomiting C) Diffusion hypoxia D) Headache Answer: B Objective: 10 40) Which of these symptoms is not a sign of over-sedation?

A) Giddiness B) Loss of consciousness C) Rigid movements D) Dizziness Answer: A Objective: 11 41) Which of these symptoms is a possible sign of over-sedation?

A) Frequent closing of mouth B) Sweating C) Nausea D) Feeling of heaviness of the extremities Answer: D Objective: 11 42) What is the first step a clinician should take when mild over-sedation is observed?

A) Check for properly functioning equipment B) Remove the nasal hood C) Decrease the N2O concentration D) Check the oxygen tank to be sure it has an adequate supply of oxygen Answer: C Objective: 11 43) Which is the correct calculation to determine the percentages of N2O delivered to a patient per minute?

A) Divide the liters of N2O per minute by the total liters of flow of N2O and O2 per minute

B) Divide the minutes of N2O use by the total liters of N2O delivered C) Divide the liters of oxygen flow per minute by the liters of N2O flow per minute D) Divide the remaining liters of N2O by the remaining liters of oxygen Answer: A Objective: 12 44) Which is the correct calculation to determine the percentage of oxygen delivered to a patient per minute?

A) Multiply the liters of oxygen being delivered per minute by the total liters gas delivered per minute B) Multiply the liters of oxygen being delivered per minute by the total liters of N2O per minute C) Divide the liters of oxygen being delivered per minute by the total liters of flow per minute D) Divide the liters of oxygen being delivered per minute by the total liters of N2O per minute Answer: C Objective 12 45) What is the percentage of N2O a patient receives when 2 liters of N2O are delivered per minute with a total flow rate of 6 liters per minute?

A) 3% B) 12% C) 33% D) 50% Answer: C Objective: 12 46) What is the percentage of N2O a patient receives when 1.5 liters of N2O are delivered per minute with a total flow rate of 5 liters per minute?

A) 3% B) 7.5% C) 12% D) 30% Answer: D Objective: 12 47) What is the percentage of oxygen a patient receives when 4 liters of oxygen and 2 liters of N2O are delivered per minute?

A) 6% B) 16% C) 50% D) 66% Answer: D Objective 12 48) What is the percentage of oxygen a patient receives when 5.5 liters of oxygen and 3 liters of N2O are delivered per minute?

A) 6.4% B) 15%

C) 47% D) 64% Answer: D Objective: 12 49) Which of the following is not a potential symptom of chronic N2O abuse?

A) Vitamin D deficiency B) Neurologic disorders C) Megablastic anemia D) Reproductive difficulty Answer: A Objective: 13 Use the information provided in the Case Study below to answer the questions that follow.

Case Study 1 John Smith is a 64-year-old patient appointed for extraction of #14. He is very anxious but does not want to take any oral sedatives because he has to drive home after the procedure. He mentions that his son had N2O-O2 sedation when his wisdom teeth were removed and he thinks he would like to try it. His health history is significant for heavy smoking over the last 40 years, advanced COPD, hypertension, and diabetes. He walks to the operatory slowly, breathing with great difficulty.

1) What medical condition(s) would contraindicate the use of N2O-O2 sedation?

Answer: Although Mr. Smith has a number of health problems, advanced COPD is an absolute contraindication for the use of N2O-O2 sedation.

Objective: 8 2) What is the most likely complication of N2O-O2 sedation for Mr. Smith?

Answer: Mr. Smith has advanced COPD. His breathing is regulated by the drive to breathe when hypoxia is present. The use of N2O-O2 sedation could cause him to cease breathing.

Objective: 8 Use the information provided in the Case Study below to answer the questions that follow.

Case Study 2 A 31-year-old female presented to the emergency room with a 4-month history of imbalance, limb weakness, and numbness and tingling from her toes to her waist as well as in the hands. She desired immediate medical attention after awakening with complete numbness from the chest to the toes. Physical examination showed decreased pinprick and light touch response from her waist to her toes as well as to her hands. Vibration sensation was also diminished in the feet and hands. Motor examination demonstrated generally decreased strength in all extremities.

Magnetic resonance imaging (MRI) revealed no abnormalities although the posterior spinal columns demonstrated increased signal. Standard lab values were normal. The patient did not immediately disclose N2O abuse; however, prior to additional testing the patient admitted to regularly abusing N2O via a N2O machine. Over the last 2 years, she admitted to using N2O for 1–2 hour sessions several times a week.

1) Discuss signs that could have alerted colleagues that this individual might have been abusing nitrous-oxide in the office.

Answer: Clinicians or employees who are often found in the facility after hours, or are noticed to frequently lose their balance might be abusing N2O. Objective: 13 2) Explain the likely cause of the symptoms experienced by this individual.

Answer: Chronic abuse of N2O can lead to neurologic disorders due to the reduction in active vitamin B12, possibly through cobalamin inactivation.

Objective: 13 3) What is the recommended treatment for this individual?

Answer: This individual should be treated with B12 injections to rectify the vitamin deficiency.

Additionally she should receive counseling for substance abuse.

Objective: 13