anesthesiology midterm reviewer

7/29/2019 Anesthesiology Midterm Reviewer

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ANESTHESIOLOGY MIDTERM REVIEWER

MANDIBULAR DIVISION

Gasserian Ganglion/ Semilunar Ganglion Foramen

Ovale Infratemporal Fossa (ITF) Mandibular

Foramen Mandibular Canal (3rd M to 2nd PM)

Inferior Alveolar Nerve (between 1st & 2nd PM on

buccal side)

LONG BUCCAL NERVE

o Innervates mucosa on posterior part on

surface of the mandible up to the 2nd PM

INCISIVE NERVE

o Innervates teeth from 1st PM to Central

Incisors

o Innervates bone on the Labial/Facial side

MENTAL NERVE

o Innervates lip and mucosa on the facialsurface

LINGUAL NERVE

o Innervates the anterior 2/3 of the tongue

INFERIOR ALVEOLAR NERVE BLOCK

Anesthetizing lingual nerve, inferior alveolar nerve

and occasionally the long buccal nerve

Anesthetizes half of the lower jaw

METHODS OF ANESTHETIZING THE INFERIOR ALVEOLARNERVE

HOW TO PALPATE:

o RETROMOLAR FOSSA/RETROMOLAR

TRIANGLE

Bounded by external oblique ridge,

internal oblique ridge and distal

side of 3rd molar

o Use index finger to palpate starting from the

bicuspid area to the deepest curvature at

the ascending portion of the mandible and

feel the triangular fossa

o The tip of the index finger should be at the

internal oblique ridge

o inch from the internal oblique ridge is the

point of puncture

o LINGULA

Leads anesthetic agent into the

foramen

DIRECT METHOD

o The syringe should be straight at the

occlusal plane of the bicuspids crossing

from the opposite side

o Deposit of the content of the cartridge

slowly (for the inferior alveolar nerve)

o Withdraw of the needle then deposit of

the content slowly (for the lingual nerve)

INDIRECT METHOD


occlusal plane coming from the same side

o Insert of the needle and deposit of the

cartridge then move lateral (for lingual

nerve)

o Move to the other side then insert of the

needle and deposit of the content slowly

(for inferior alveolar nerve)

DIRECT INDIRECT METHOD


occlusal plane of the bicuspids crossing

from the opposite side

o Insert of the needle and deposit of the

content slowly (for inferior alveolar nerve)

o Withdraw of the needle and deposit of

the content slowly (for lingual nerve)

o Move to the same side and deposit

INFILTRATION TECHNIQUES:

SOFT TISSUE INFILTRATION

o supraperiosteal or paraperiosteal

o periodontal or intraligamentary

o intrapulpal or pressure

o subperiosteal

o submucosal

o circular

o topical

BONY TISSUE INFILTRATION

o Intraosseous

o Intraseptal

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PREPARATION OF SOFT TISSUES

Do oral prophylaxis

Ask the patient to rinse

Apply antiseptic solution

Apply topical anesthetic

Check for numbness

SUPRAPERIOSTEAL TECHNIQUE

Landmark: MUCOBUCCAL/MUCOLABIAL

Lift the lip, retract the corner of the mouth

Insert the needle at the center following the

curvature of the bone

Insert 1/3 to of the needle cartridge slowly

Apply soft pressure on the area to facilitate diffusion

of the anesthetic solution

Most commonly used technique

PERIODONTAL TECHNIQUE

A.k.a. INTRALIGAMENTARY TECHNIQUE

Anesthesia in the periodontal space (thin, minute

space)

Danger: may destroy the periodontal ligaments

Only a supplementary technique

Pressure syringe: using ultra thin, ultra fine needle

4 point of puncture for posterior

Use only for extraction of the tooth

INTRAPULPAL TECHNIQUE

A.k.a. PRESSURE TECHNIQUE

Only indicated for vital teeth

Supplementary technique

Insert the needle into the root canal then deposit the

anesthetic solution slowly

Pressure applied contributes to the numbness

SUBPERIOSTEAL TECHNIQUE


Point of Puncture: Bisect the root of the tooth,

insert the needle (bevel facing the bone)

A very painful technique

SUBMUCOSAL TECHNIQUE

Most superficial aside from topical anesthesia

Indicated for Frenectomy

CIRCULAR TECHNIQUE

Deposit around the area (incisive papilla)

INTRAOSSEOUS TECHNIQUE


Open-flap technique to expose the bone

Involves the bone

INTRASEPTAL TECHNIQUE

Good technique done with children due to the

porosity of their bone

Deposited in between two incisors

INCISIVE NERVE BLOCK

Deposited into the incisive foramen to anesthetize

both incisive and mental nerve

Anesthetizes first premolar to central incisor

INFRAORBITAL NERVE BLOCK

From central incisor to the first molar (lingual and

buccal root)

Facial surface and not palatal

PAIN PHYSIOLOGY

PAIN

One of the most commonly experienced symptoms in

dentistry

A major concern to the dentist

Protective mechanism usually manifested when

an environmental change occurs that causes injury

to responsive tissue

NERVE CONDUCTION

Self-propagated passage of an electrical current

along nerve fibers

Nerve Cell Membrane

o a thin elastic covering composed of a layer

of lipid between two layers of protein

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o membrane contains many minute pores

through which ions can diffuse under the

proper circumstances

electrolytic solutions containing an equal

concentration, approximately 155 mEq, of anions

and cations are present on both sides of the cell

membrane

RESTING STATE

nerve is at rest: greater number of anions (-) are

present inside the cell membrane; equal number of

cations (+) are gathered outside the membrane

potassium ions concentrated inside

sodium and chloride ions concentrated outside

membrane potential can develop by the creation

of an ionic imbalance and can be accomplished by:

o an active diffusion of ions through the

membrane

o a diffusion of ions across the membrane

because of a gradient difference

electrochemical gradient approximately -70 to

-90 mv

o indicates that the inside of the membrane

becomes 70 to 90 mv more negative than

the outside

o membrane is polarized with the inside

electrically negative relative to the outside

polarized membrane is a potential source of

energy

resting potential of the nerves is assumed to

result from and be maintained by

o the relative permeability of the cell

membrane to potassium

o the relative permeability to sodium ions

potassium remains within the axioplasm

o positively charged potassium ions are

retained by the electrostatic attraction of

the negatively charged nerve membrane

chloride remains outside the nerve membrane

o as a result of the opposing electrostatic

influence forcing outward migration

o no chloride diffuses into the nerve

membrane

SODIUM PUMP

o An active mechanism resulting to the

maintenance of the resting potential which

moves the sodium from the area of lesser

concentration inside the nerve to that of

greater concentration outside

o Greater concentration inside: 142 mEq

o Lesser concentration outside: 10 mEq

o Sodium tends to diffuse back across the

membrane into the nerve as it is being

pumped out

Relative impermeability of the nerve

membrane during the resting state

o Prevents a massive influx of this ion

o Polarization of the membrane will continue

as long as the nerve remains undisturbed

DEPOLARIZATION

Initiation of changes in membrane permeability

to sodium

o Occurs as a result of displacement of

calcium ions from a phospholipid-binding

state

Alteration in the permeability of the cell membrane

that is initiated after an adequate stimulus is applied

o Acetylcholine a transmitter substance

that is liberated at the site of stimulation

Passage of the impulse/speed of the action

potential

o Result a continuing stimulation or chain

reaction, with each area generating its own

potential by the alteration of the

permeability of the membrane to the inward

passage of sodium followed by the outward

passage of potassium

SALTATORY CONDUCTION

o Jumping of the impulse from node to node

through the surrounding interstitial tissue

o Explains the greater rate of speed at which

impulses are conducted by myelinatednerves

REPOLARIZATION

Permeability of the nerve membrane again

decreases while high permeability to potassium is

restored

Potassium moves freely out of the cell

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o Restoring the original electrochemical

equilibrium and resting potential

Relative refractory period

o When the normal ionic distribution pattern

begins to return, the nerve can be

stimulated but only by a stimulus greater

than usual

Membrane is normally polarized and will react

to a stimulus of normal intensity

o When the pre-impulse concentration

gradients of potassium inside the nerve and

of sodium outside are reached following a

relative refractory period

o However, certain minimal stimulus is

necessary to provoke a sufficient ionic

interchange to create an impulse

ALL OR NONE LAW OF NERVE ACTION

o Amplitude of electrical change as well as the

speed of nerve conduction remains constant

regardless of the quality or intensity of

stimulus applied

PAIN THEORIES

SPECIFICITY THEORY

o DESCARTES (1644) pain system as a

straight-through channel from skin to the

brain

o MULLER (1900) theory of information

transmission only by way of sensory nerves

o VON FREY concept of specific cutaneous

receptors for touch, heat, cold and pain

PATTERN THEORY

o GOLDSHEIDER (1894) stimulus intensity

and central stimulation are critical

determinants

GATE CONTROL THEORY

o MELZACK & WALL regulation of pain

along the pathway it travels

Pain is influenced by:

o Injury signal

o Other types of afferent impulses

o Descending control

*NOTE: please read the handouts for the rest of the topics

good luck to us! Thanks

-Rosette Go 013110

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anesthesiology midterm reviewer

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