42 Questions
What should be the initial approach when a patient claims to be allergic to a local anesthetic?
Believe the patient and avoid using any form of local anesthetic on the patient until a definitive allergy is determined
Why is intravascular administration of local anesthetics considered dangerous?
The rate of injection may be overly rapid, leading to adverse effects
Are all currently available local anesthetic formulations extremely safe and effective when used properly?
Yes, all local anesthetic formulations are extremely safe and effective when used properly
What did the 2011 review of articaine literature conclude?
Articaine has no conclusive evidence demonstrating neurotoxicity or significantly superior anesthetic properties compared to other local anesthetics
Why are amide local anesthetics preferred to ester local anesthetics?
Because of their decreased incidence of allergy
What factors should be considered when selecting an appropriate local anesthetic for a patient and procedure?
Duration of pain control required and the patient’s physical status
What is the recommended minimum application time for topical anesthetics on mucous membranes?
1 minute
Why are topical anesthetics containing benzocaine considered to have minimal risk of overdose?
They are not absorbed into the cardiovascular system
In which situations is it recommended to restrict the use of rapidly absorbed topically applied local anesthetics like lidocaine?
At the site of needle puncture before injection
Which of the following is a contraindication to the use of vasoconstrictors in dental patients?
a and c
Which of the following conditions is a contraindication for the use of vasoconstrictors in dental patients?
a and c
Which of the following scenarios is a contraindication for the use of vasoconstrictors in dental patients?
Patients receiving nonspecific β-blockers
What is the maximum recommended dose of epinephrine for a cardiac risk patient?
0.04 mg
In which scenario should the use of epinephrine be avoided?
Cardiac risk patients with unresponsive cardiac rhythm abnormalities
Which local anesthetic, via nerve block, can provide up to 60 minutes of pulpal anesthesia?
4% prilocaine
What is a must for a syringe for local anesthetic administration?
Must be capable of aspiration
Do computer-controlled local anesthetic delivery (C-CLAD) systems work well enough to justify their purchase?
Yes, they enable pain-free local anesthesia
What gauge needle is recommended for posterior superior alveolar nerve blocks?
27-gauge needle
Which nerve blocks in adults require the use of a long dental needle?
Inferior alveolar and anterior superior alveolar
Why should local anesthetic cartridges not be stored in alcohol or cold sterilizing solution?
Alcohol or cold sterilizing solution diffuses into the cartridge, causing burning, irritation, or paresthesia upon injection
Why do some patients complain of a burning sensation when a local anesthetic is injected?
The acidic pH of the local anesthetic may cause a slight burning sensation during injection
Are cartridge warmers effective in making local anesthetic solutions more comfortable on injection?
No, most cartridge warmers make the local anesthetic solution too warm, leading to increased discomfort on injection and possible destruction of the heat-sensitive vasoconstrictor.
Why is autoclaving of glass cartridges not recommended?
Autoclaving destroys the seals of glass cartridges
What causes local anesthetic solution to run down the outside of the needle into a patient’s mouth?
Improper preparation of the armamentarium
What does not cause cartridges to break during injection?
Improper preparation of the armamentarium
What should always be done before local anesthetic administration in a patient?
Review of the patient’s medical history questionnaire and a physical examination, including vital signs and visual inspection
Is any specific chair position best for administration of local anesthetics?
Yes, the position of choice is with the patient’s chest and head parallel to the floor with the feet slightly elevated
Why do you recommend regional anesthesia in the maxilla instead of infiltration?
To minimize tissue penetrations and reduce the risk of postinjection soreness, systemic reactions, and to ensure adequate anesthesia
What is not done to reduce pain on palatal injection?
Applying ice to the injection site
Why might there be a higher failure rate with inferior alveolar nerve blocks?
a and b
What are the special concerns involved with local anesthesia in pediatric dentistry?
a and c
In which type of legal suit can a health care professional be accused of guaranteeing a result related to treatment?
Contract law suit
In criminal law, what trend is being followed regarding the requirement of proof of criminal mens rea?
Not requiring proof of criminal mens rea
In the context of local anesthesia administration, who is ideally trained to handle untoward reactions during local anesthetic administration?
A responsive team trained to handle such events
What is the recommended unit for recording doses of local anesthetic drugs administered to patients?
Milligrams
In what scenario would an inability to properly dose most patients lead to provision of health care below the standard of care?
Overdose
What type of manifestation is an allergic reaction to local anesthetic administration?
Non-dose-dependent
What would be considered a breach of duty in relation to the control of a syringe during local anesthetic administration?
Inability to control the syringe due to an ill-fitting thumb ring
What is the primary concern with local anesthetic cartridges?
Chemical leaching and temperature extremes
What is the potential consequence of a court's decision being reversed?
It may be reversed due to a new fact pattern or reevaluation under different legal formulae
What is the constant expectation from health care practitioners in relation to the standard of care?
To be informed about the current standard of care and optimize decision making
What is the potential consequence of needle breakage, bending, or contamination?
Local reactions to local anesthetic administration
Study Notes
Local Anesthesia
- When a patient claims to be allergic to a local anesthetic, the initial approach is to take their claim seriously and consider alternative anesthetics.
Dangers of Local Anesthesia
- Intravascular administration of local anesthetics is considered dangerous because it can lead to systemic toxicity.
Efficacy and Safety of Local Anesthetics
- Not all local anesthetics are extremely safe and effective when used properly; some may have adverse reactions.
- A 2011 review of articaine literature concluded that it is a safe and effective local anesthetic.
Selecting Appropriate Local Anesthetics
- Factors to consider when selecting a local anesthetic for a patient and procedure include the patient's medical history, allergies, and the type of procedure.
- Amide local anesthetics are preferred over ester local anesthetics due to their faster metabolism and lower risk of allergic reactions.
Topical Anesthetics
- The recommended minimum application time for topical anesthetics on mucous membranes is 2-5 minutes.
- Topical anesthetics containing benzocaine have a minimal risk of overdose due to their low absorption rate.
- Rapidly absorbed topically applied local anesthetics like lidocaine should be restricted in situations where overdose is a concern.
Vasoconstrictors
- Contraindications for the use of vasoconstrictors in dental patients include hypertension, cardiovascular disease, and thyroid disease.
- The maximum recommended dose of epinephrine for a cardiac risk patient is 0.04mg.
Nerve Blocks
- Lidocaine, via nerve block, can provide up to 60 minutes of pulpal anesthesia.
- Syringes for local anesthetic administration must be specifically designed for the procedure.
Local Anesthetic Administration
- Computer-controlled local anesthetic delivery (C-CLAD) systems are not justified for purchase due to their high cost and limited benefits.
- A 27-gauge needle is recommended for posterior superior alveolar nerve blocks.
- Long dental needles are required for nerve blocks in adults.
- Local anesthetic cartridges should not be stored in alcohol or cold sterilizing solution to prevent degradation.
Patient Comfort
- Some patients may experience a burning sensation during local anesthetic injection due to the pH of the solution.
- Cartridge warmers are effective in making local anesthetic solutions more comfortable on injection.
- Autoclaving of glass cartridges is not recommended as it can cause them to break.
Safety Precautions
- Before local anesthetic administration, the patient's medical history and allergy status should always be reviewed.
- No specific chair position is recommended for the administration of local anesthetics.
- Regional anesthesia is recommended in the maxilla instead of infiltration due to its higher success rate.
- Palatal injection should be done slowly to reduce pain.
- Inferior alveolar nerve blocks may have a higher failure rate due to anatomical variations.
- Pediatric dentistry requires special considerations due to the patient's age and size.
Legal Aspects
- A health care professional can be accused of guaranteeing a result related to treatment in a negligent misrepresentation lawsuit.
- In criminal law, the trend is to require proof of criminal mens rea (guilty mind).
- A dentist should be trained to handle untoward reactions during local anesthetic administration.
- The recommended unit for recording doses of local anesthetic drugs is milligrams (mg).
- An inability to properly dose patients can lead to provision of health care below the standard of care.
- An allergic reaction to local anesthetic administration is a type of type I hypersensitivity reaction.
Liability and Breach of Duty
- A breach of duty in relation to the control of a syringe during local anesthetic administration can lead to liability.
- The primary concern with local anesthetic cartridges is the risk of breakage or contamination.
- A court's decision can be reversed, leading to a change in the standard of care.
- Health care practitioners are expected to maintain the standard of care in their profession.
- Needle breakage, bending, or contamination can lead to significant consequences, including infection and harm to the patient.
Test your knowledge of the safety considerations and best practices for intravascular administration of local anesthetics with this quiz. Explore the factors that contribute to the perceived danger of intravenous lidocaine administration, including patient physical status, the form of lidocaine used, and the rate of injection.
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