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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.
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.
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.
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.
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.
Answer: A
Objective: 2
6) Dentists have been able to deliver local anesthetic drugs in cartridge form since 1884.
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.
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.
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.
Answer: A
Objective: 3
Multiple choice
1) The fundamentals of pain management include all of the following except
Answer: C
Objective: 1
2) The fundamentals of pain management include
Answer: A
Objective: 1
3) Local anesthetics have been available in dentistry since
Answer: D
Objective: 1
4) Which situations best demonstrate the fundamentals of pain management?
Answer: C
Objective: 1
Short answer/essay
1) Discuss a providers 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
AU: Question 5 and answer to question 4 are identical; is this intended?
Chapter 3
The Neuroanatomy and Neurophysiology of Pain Control
Match the following
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.
Answer: A
Objective: 1
2) The strength of nerve impulses weakens as the energy transfers from one section of nerve membranes to the next.
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.
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.
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.
Answer: A
Objective: 3
6) The electrical potential of a nerve axoplasm in the resting state is approximately -70 mV.
Answer: A
Objective: 3
7) Depolarization refers to a potential change across a nerve membrane from -70 mV to +40 mV.
Answer: A
Objective: 3
8) Depolarization is a reversal of ion concentrations in the recovery phase.
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.
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.
Answer: B
Objective: 3
11) Schwann cells release neurotransmitters when stimulated by impulses.
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.
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.
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.
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.
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.
Answer: B) C fiber impulses travel in a range of 0.52.3 m/sec and A fibers at 15100 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.
Answer: A
Objective: 6
18) A fibers are the most numerous of the fiber types. They are nonmyelinated and transmit sharp pain sensations.
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.
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.
Answer: A
Objective: 11
Fill in the blank
1) The four structural parts of the neuron are the ________, ________, ________, and ________.
Answer: dendritic zone, axon, cell body, terminal arborization
Objective: 1
2) Sensory neurons carry impulses to the ________ for processing.
Answer: central nervous system (CNS)
Objective: 1
3) Motor nerves carry impulses away from the CNS to ________ and ________.
Answer: effector cells (muscles), tissues and organs
Objective: 1
4) Lipophilic membranes are described as ________.
Answer: fat loving
Objective: 1
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 ________ and are bilayered phospholipid membranes.
Answer: neurolemmas
Objective: 2
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 membranes 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 (A)
Objective: 7
14) The two most significant ________ of local anesthetic solutions are the perilemma and the perineurium.
Answer: barriers to diffusion
Objective: 9
15) Mantle fibers within the inferior alveolar nerve innervate the ________ region.
Answer: molar
Objective: 10
Multiple choice
1) Which description of nerve membranes is correct?
Answer: B
Objective: 2
2) Which statement is not accurate when describing nerve impulses?
Answer: D
Objective: 2
3) Which statement accurately describes the process known as saltatory conduction?
Answer: A
Objective: 2
4) Saltatory conduction is defined as the
Answer: D
Objective: 2
5) The axoplasm of a nerve at rest:
Answer: B
Objective: 2
6) In the resting state, a nerve membrane has an electrical potential of:
Answer: D
Objective: 2
7) Which two ions are responsible for the uninterrupted maintenance of the resting potential across the nerve membrane?
Answer: A
Objective: 2
8) Which positively charged ion functions as a gatekeeper in ion channels?
Answer: A
Objective: 2
9) Which of the following does not occur upon rapid depolarization?
Answer: A
Objective: 3
10) Which of the following sequences best describes the events in a successful impulse generation?
Answer: B
Objective: 3
11) Which statement describes slow depolarization?
Answer: C
Objective: 3
12) Which statement best describes rapid depolarization?
Answer: B
Objective: 3
13) Which statement best describes the relative refractory state when the membrane has not fully returned to its resting state?
Answer: D
Objective: 3
14) Which statement best describes the repolarization process?
Answer: D
Objective: 3
15) Which of the following is correct when a nerve is in the resting state?
Answer: C
Objective: 3
16) The process of sequential impulse generation to the CNS is called:
Answer: D
Objective: 3
17) Myelin is composed of:
Answer: A
Objective: 4
18) Which cells produce myelin?
Answer: D
Objective: 4
19) Nerve impulses travel rapidly on myelinated nerves because:
Answer: C
Objective: 4
20) What are the functions of Schwann cell sheaths?
Answer: C
Objective: 4
21) What is the correct relationship of Schwann cells to the nodes of Ranvier?
Answer: C
Objective: 4
22) In myelinated nerves, local anesthetic molecules are effective:
Answer: D
Objective: 4
23) Which statement correctly describes sensory and motor neurons?
Answer: B
Objective: 5
24) Which statement correctly describes the cell bodies of sensory and motor neurons?
Answer: C
Objective: 5
25) Nerve impulses are initiated in the:
Answer: A
Objective: 5
26) All oral cell bodies of sensory nerves are located in the:
Answer: C
Objective: 5
27) Which statement inaccurately describes nerve fiber types?
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?
Answer: A
Objective: 7
29) What is the function of the endoneurium?
Answer: A
Objective: 9
30) What is the function of the perineurium?
Answer: B
Objective: 9
31) Which nerve layers represent the most significant barriers to the diffusion of anesthetic solutions and the development of anesthesia?
Answer: C
Objective: 9
32) What are three divisions of the dental plexus?
Answer: D
Objective: 10
33) The aromatic, lipophilic portion of an anesthetic molecule allows the anesthetic solution to:
Answer: A
Objective: 11
34) With which ion does the local anesthetic molecule compete within the nerve membrane?
Answer: B
Objective: 11
35) Which statement is true regarding the specific protein receptor theory?
Answer: B
Objective: 11
36) Local anesthetics block pain impulses by:
Answer: D
Objective: 11
37) Which of the following is not directly related to impulse extinction caused by local anesthetics drugs?
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)?
Answer: C
Objective: 11
39) Which statement does not describe the typical onset of anesthesia?
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 13
Injections for Palatal Pain Control
True or false
1) The nasopalatine nerve is a terminal and short branch of the PSA nerve.
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.
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.
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 non-nociceptive fibers.
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.
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.
Answer: A
Objective: 2
7) For palatal injections, if swelling or blanching occurs, withdraw the needle and choose another penetration site.
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.
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.
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.
Answer: A
Objective: 3
11) A P-ASA injection requires a 27 gauge long needle due to the increased depth of insertion.
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.
Answer: A
Objective: 3
13) The rate of deposition of anesthetic solution is the same for the NP and P-ASA injections.
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.
Answer: A
Objective: 3
15) The rate of deposition for an AMSA injection is 0.4 mL over 40 seconds.
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).
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.
Answer: A
Objective: 3
18) The needle pathway for a GP nerve block is 6 to 8 mm through dense mucosal tissue.
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.
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 ________ depth of anesthetic penetration.
Answer: 4 to 6 mm
Objective: 2
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 ________ is reduced.
Answer: rate of deposition
Objective: 2
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?
Answer: C
Objective: 2
2) Which statement correctly describes one precaution when using 4% local anesthetic drugs for palatal injections?
Answer: B
Objective: 2
3) The most common cause of failure of palatal nerve blocks is:
Answer: A
Objective: 2
4) Which of the following nerve branches anesthetizes the upper lip and skin of the cheek?
Answer: C
Objective: 2
5) Which of the following statements is true of the NP nerve block?
Answer: C
Objective: 3
6) Which one of the following is not anesthetized by a nasopalatine nerve block?
Answer: C
Objective: 3
7) Which location represents the correct penetration site for a nasopalatine nerve block?
Answer: A
Objective: 3
8) Which of the following represents the correct penetration depth for a nasopalatine nerve block?
Answer: B
Objective: 3
9) Which statement describing the injection steps for a nasopalatine nerve block is not correct?
Answer: B
Objective: 3
10) What is the most likely cause of unilateral failure of a nasopalatine nerve block?
Answer: C
Objective: 3
11) Which of the following is the best indication of a P-ASA nerve block?
Answer: C
Objective: 3
12) Which structures are not anesthetized by the P-ASA nerve block?
Answer: B
Objective: 3
13) Which statement best describes the needle pathway for a P-ASA nerve block?
Answer: D
Objective: 3
14) What is the correct penetration depth for a P-ASA nerve block?
Answer: D
Objective: 3
15) Which needle is commonly used for a P-ASA nerve block?
Answer: C
Objective: 3
16) What is the correct deposition rate for the P-ASA nerve bock?
Answer: A
Objective: 3
17) What is the typical minimum volume of anesthetic solution deposited for P-ASA nerve blocks?
Answer: C
Objective: 3
18) What nerve branch can provide assessory innervation causing incomplete anesthesia following a P-ASA nerve block?
Answer: D
Objective: 3
19) Which of the following best describes the nerves anesthetized by the AMSA nerve block?
Answer: D
Objective: 3
20) Which of the following is not a clinical advantage of the AMSA nerve block?
Answer: B
Objective: 3
21) The field of anesthesia for an AMSA nerve block includes:
Answer: D
Objective: 3
22) What is the optimum site of penetration for an AMSA nerve block?
Answer: D
Objective: 3
23) What is a typical minimum volume of anesthetic solution deposited for an AMSA nerve block?
Answer: C
Objective: 3
24) What is the correct deposition rate for an AMSA nerve block?
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?
Answer: C
Objective: 3
26) Terminal fibers of the GP nerve overlap the:
Answer: B
Objective: 3
27) What is the penetration site for a GP nerve block?
Answer: A
Objective: 3
28) What is the approximate depth of penetration for a GP nerve block?
Answer: C
Objective: 3
29) What is a typical minimum dose of anesthetic solution deposited for GP nerve blocks?
Answer: B
Objective: 3
30) What is the recommended maximum dose of a 4% anesthetic solution for a GP nerve block?
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 pain-transmitting (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
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