LA Theory - part 2 PDF - Local Anaesthetics, Dental Training, FCSP LSBU

Local Anaesthe-cs Theory – part 2 Tutor: Lucy Harrison Module: FCSP, Year 1 Key GDC learning outcomes 1.1.5 1.1.8 Describe relevant and 1.1.6...

Local Anaesthe-cs Theory – part 2 Tutor: Lucy Harrison Module: FCSP, Year 1 Key GDC learning outcomes 1.1.5 1.1.8 Describe relevant and 1.1.6 Describe the properties of appropriate dental, oral, Describe relevant and relevant medicines and craniofacial and general appropriate physiology and therapeutic agents and anatomy and explain their explain its application to discuss their application to application to patient patient management patient management management 1.7.4 Manage patient anxiety and 1.7.5 pain through effective Manage patient pain through communication, reassurance the appropriate use of and relevant behavioural analgesia techniques Aims and Objec-ves Deliver safe and e-ec/ve local Describe and iden/fy related oral anaesthesia to pa/ents anatomy and nerve supplies To relate how to safely deliver in:ltra/ons and IDBs Inves/gate the legal framework for LA delivery in den/stry Highlight the poten/al complica/ons of LA delivery Nerve supply Mandibular branches into Inferior alveolar nerve, lingual and buccal nerve Maxillary branches into superior alveolar nerve (Posterior 6-7) (Middle 4-5 and MB root 6’s) (Anterior 3-3) Pa-ent prepara-on  Legal Valid prescription Any contraindications Medical History Has patient taken their medication Previous reactions to LA Has patient eaten as usual? Food Vaso-vagal attack prevention Why using LA- comfort/efficiency Explain Sensation Procedure LA anxiety/phobia PatientCalm atmosphere Distraction techniques Appropriate language Operator Positioning Visibility LA equipment What can aLect the pa-ents pain threshold?  Anxiety  Psychological makeup  Previous experience  Physical environment  Culture  Emo/onal state  Age  Distraction Hypnosis Gate Control Alternative theory stimulus Calm atmosphere InOltra-ons  What nerves are we wanting to anaesthetise? Anterior = 3-3 Middle = Pre-molars and MB root first molar Posterior = Molars but NOT MB root first molar Pterygopala-ne nerves Posi-oning Pa/ent supine, comfortable and well supported Pa/ent at correct height for operator Light directed into sulcus area Applica-on of topical anaesthe-c agent Apply on Leave for Dry a cotton 2-3 mucosa wool roll minutes  Buccal inOltra-on technique 1. Es/mate posi/on of apex of the tooth 2. Pull surface mucosa taut Good Retraction Poor Retraction  Buccal inOltra-on technique Short 3. Insert needle through mucosa at 25 degrees to the bone 4. Aim for the apex of the tooth 5. Keeping roughly parallel to long axis of tooth Buccal inOltra-on technique 6. Smoothly allow needle to glide through taut mucosa Avoid contac/ng bone, if contacted withdraw 1-2mm Needle should be bevel to bone Buccal inOltra-on technique 7. Aspirate, especially if injec/ng around upper second/third molars Check cartridge Buccal inOltra-on technique 8. Deliver solu/on gently and low S 9. Very liXle pressure required on the plunger 10. Withdraw needle smoothly 11. Make needle safe Buccal inOltra-on technique 0.5ml - 1ml of solu/on per site for in:ls for perio work 2.2ml of solu/on for restora/ons Pulpal analgesia should be established within 2-5 minutes So\ /ssue analgesia 1-2 minutes WAIT Buccal inOltra-on technique Par-cular care required: Labial aspect of upper incisors – VERY SENSITIVE (use lots of topical and inject very slowly) Labial aspect of lower incisors – aXachment of mentalis and depressor labii inferioris muscles Buccal inOltra-on video Supplementary Injec-ons  Palatal in:ltra/ons  Lingual in:ltra/ons  Intrapapillary  Palatal InOltra-on 1. Topical applica/on/pressure on area :rst 2. In:ltrate the palatal mucosa of the appropriate tooth 3. Inject at 90 degrees to the mucosa at about 1-1.5cm from gingival margin half way between gingival margin and midline of palate 4. Considerable resistance IT CAN HURT A LOT 5. Deposit 0.2 ml of solu/on Palatal inOltra-on Used for:  Deep restora/ons  Subgingival PMPR (Professional Mechanical Plaque Removal)  Extrac/ons of deciduous maxillary den//on Palatal inOltra-on video Intrapapillary Injec-on Useful for achieving palatal analgesia in children and nervous pa/ents 1. Direct needle at right angles to interdental papilla 2. Insert needle into centre of papilla at level of aXachment to periosteum 3. Deposit 0.25ml of solu/on 4. Check palatal mucosa has blanched Inferior Dental Block (IDB) Inferior dental/ alveolar nerve Long Buccal Lingual Mental Innerva-on of mandible Basic anatomy of the mandible RETROMOLAR FOSSA The pterygomandibular space  The facial nerve If needle goes in too deeply analgesic solution is deposited outside the pterygomandibular space in the deep lobe of the parotid gland. Facial nerve is blocked causing paralysis of the facial muscles Temporary facial palsy On which side of the mouth was the IDB administered?  Left side IDB 11’oclock IDB Technique Right side IDB 8-9 o’clock 1. Pa/ent can be supine or upright (if large tongue or obese pa/ent, try upright posi/on) 2. Need good ligh/ng 3. Ideally use topical analgesia 4. Pa/ent’s mouth should be wide open to allow good visualisa/on of the anatomical landmarks 5. Sit in appropriate posi/on to pa/ent IDB Technique Select long needle 35 mm, 27 gauge  IDB Technique (1) and palpate external 6. Use :nger or thumb to locate the retromolar fossa oblique ridge 7. Iden/fy pterygomandibular raphe: (2) with :nger or thumb (3) Look for ‘crease’ in mucosa between 1 and 2 (4) Point of entry is + IDB Technique 8. Posi/on barrel of syringe over contra-lateral premolars. Correct level for mandibular foramen is iden34ed by bisec3ng the thumb/4ngernail and drawing an imaginary line 1cm above occlusal plane. IDB Technique 9. Insert needle smoothly and slowly into the pterygomandibular space, aiming for the mandibular foramen 10. Inject to a depth of 2.0-2.5 cm 11. Do NOT insert the full needle – 5mm of needle must ALWAYS be visible. 12. If mandibular bone is contacted, withdraw needle 1 mm and aspirate IDB Video IDB Technique- posi-ve aspira-on  If blood present upon aspira/on  Withdraw needle 1 or 2 mm  Aspirate again  If no blood, con/nue with injec/on  If posi/ve again, reposi/on and repeat aspira/on IDB Technique 13. Once you are sure that the /p of the needle is not in a vein, then slowly deliver the anaesthe/c solu/on 14. Withdraw needle quickly and smoothly and re-sheath needle to make it safe 15. Sit pa/ent up for a rinse IDB makes yellow area numb.  Anatomical varia-ons Bone struck too soon – withdraw, swing needle round to midline, advance for 7 mm, swing back to original posi/on and proceed Electric shock sensa/on in tongue or lip means lingual nerve or mandibular nerve respec/vely touched by needle – must withdraw 1-2mm from mandibular nerve Incisive and Mental Block Useful if you want anaesthesia of several anterior teeth (incisors, canine and 6rst premolar) Aim for mental foramen (between apices of 6rst and second premolar) May provide unreliable anaesthesia for central incisor and may still need a lingual in6ltration  Incisive and Mental block procedure 1. Check posi/on of mental foramen on radiograph (if one available) 2. Pa/ent ideally supine, good ligh/ng 3. Apply topical LA 4. Ask pa/ent to open wide 5. Unsheathe needle (30 gauge short) 6. Place /p of needle in rehec/on of buccal sulcus between root apices of LL4 and LL5 7. Aspirate- if not posi/ve. Slowly inject at least 1ml solu/on 8. Withdraw needle and re-sheath safely  Do not give Ar-caine For IDBs OR Incisive and Mental block Needle s-ck injury Before contact with pa-ent… No transfer of infec/on can occur if the needle has not contacted the pa/ent  Double lock cover on needle  Remove gloves, wash with soap and dress wound if necessary  Inform senior tutor on clinic  New syringe/needle/cartridge and holder  New gloves No addi/onal repor/ng needs to happen A`er contact with pa-ent… Poten/al transfer of infec/on from pa/ent to operator from the needle  Double lock cover on needle  Gloves o- and WASH the wound under running water or rinse mucous membranes appropriately  Report to senior tutor on clinic  Check medical history to con:rm if known blood-borne virus  Contact Occupa/onal Health or A&E (out of hours) for advice  Pa/ent blood sample  Record in notes  Da/x incident report Link to Ac-on Plan for a Sharps/Needles-ck Injury Health and Safety Representa/ve(s) (uclh.nhs.uk) Legal framework Who can change the LA agent? LA is a Prescrip-on Only Medicine (POM) Need a wriXen prescrip/on for each speci:c agent from a recognised prescriber- a den/st The Human Medicines Regula3ons 2012 Pa-ent group direc-ve (PGD) – gives a legal framework that allows registered health professionals – including Dental Hygienists and Therapists to administer speci:ed medicines without the need for a prescrip/on What Cons-tutes a Prescrip-on (Rx) for LA? Type of LA Route of Dosage Date Eg: Administra-on Eg: Check the Rx is Eg: One Cartridge in date for each Lidocaine In:ltra/ons 2.2 ml etc course of tx. Ar/caine IDB No-ce to dental therapists and dental hygienists: legal change eLec-ve 26 June 2024 From 26 June 2024, an amendment to the Human Medicines Regula/ons made it possible for dental hygienists and therapists to supply and administer certain prescrip/on-only medicines (POMs) under exemp/ons, without the need for a prescrip/on from a den/st or a pa/ent group direc/on (PGD). While speci:ed medicines can legally be supplied and administered under exemp/ons, dental hygienists and dental therapists must undertake the appropriate training to ensure they are competent to use this new mechanism. There is no obliga/on for dental hygienists and dental therapists to administer and supply these medicines under exemp/ons. The changes do not give any prescribing powers to hygienists or therapists, or Post opera-ve Post-injec-on precau-on Never leave your pa-ent alone a`er an injec-on A reac/on may occur at any /me  Including faint  Anaphylaxis Post- Opera-ve Instruc-ons Dura-on of Anaesthesia Usually, a few hours Avoid Hot food/drinks, bi/ng lips/cheeks Do not poke/prod area With :nger/tongue No smoking For dura/on of LA  Documenta-on of LA A dated signed entry must be made on the pa/ent’s record every /me LA is given:  Type of LA agent and vasoconstrictor  Amount of solu/on administered BN?  not exp and Site of injec/on  Any unusual e-ects  Post opera/ve instruc/ons given verbally POIV LA - 2ml lidocaine 2% with epinephrine 1: 80,000, buccal in4ltra3on UL7, UL4, UL2. POIGV Complica-on of LA Unwanted eLects may occur as a result of:  Injec/ng an inappropriate solu/on  Injec/ng too much solu/on  Injec/ng into the wrong site Complica/ons can be divided into: 1. Local 2. General Local complica-ons Failure to go numb Most common complica/on  Flaccid Pain during injec/on Site of Too much No topical LA Blunt needle Too fast Too hot/cold Psychological mucosa injec/on solu/on Bleeding into the /ssues following puncture of the Haematoma forma-on blood vessel May cause pain, trismus May become infected Intravascular injec-on systemic toxic e-ects failure of analgesia Skin blanching Due to vasospasm of artery Bleeding At point of injec/on Stops by itself Other Infec/on Lip/so\ /ssue trauma Trismus Visual disturbances Local complica-ons Prolonged impairment of sensa-on SERIOUS COMPLICATION 1 in 14,000 IDBs cause permanent injury Seek help immediately Facial paralysis (IDB) Needle breakage Post anaesthe-c reac/va/on of herpes simplex virus General complica-ons  Psychogenic  Toxicity of LA agent  Overdose  Reduced tolerance  Intravascular adrenaline  Allergy- anaphylaxis  Drug interac/ons  Bleeding risk  ID blocks and lingual in:ltra/ons may be contraindicated or used with cau/on depending on bleeding risk.  Risk relates to the act of injec3on, not the LA agent. Examples include pa/ents with gene/c bleeding disorders e.g. haemophilia  Pa/ents taking an/coagulants or an/platelet drugs e.g. warfarin, clopidogrel  Alcoholics (reduced liver func/on)  Pa/ents with liver disease.  Failure of anaesthesia  Too long a delay before commencing treatment  Too liXle solu/on administered  Intravascular injec/on (aspirate)  Inaccurate placement of needle point (IDBs)  Anatomical varia/ons  Incorrect choice of technique  Anxiety/fear/nega/ve experience  Poor storage of LA (too hot/ in sunlight) Presence of infec-on Never inject into an area of ingamma-on/infec-on Inject mesial and distal to the area If LA fails… Don’t overdose Get advice Summary Today we have…  Described and iden/:ed related oral anatomy and nerve supplies  Understand how to safely deliver in:ltra/ons and IDBs  Inves/gated the legal framework for LA delivery in den/stry  Highlighted the poten/al complica/ons of LA delivery Any ques-ons? Reference List Evers, H. (1990) Introduc3on to Dental Local Anaesthesia. 2nd Edi/on. Switzerland: Mediglobe SA. Yapp, K.E., Hopcra\, M.S. and Parahos, P., (2011) Ar3caine: a review of the literature, Bri3sh Dental Journal volume, 210, pp. 323–329. Available from: hXps://www.nature.com/ar/cles/sj.bdj.2011.240 [Accessed on 5th January 2023].