COMPLEMENTARY AND ALTERNATIVE LOCAL ANESTHESIA BEYOND THE BASIC TECHNIQUES KATHY BASSETT BSDH, RDH, MED COURSE CONTENT MAY INCLUDE ANY FOLOW8 OF THE FOLOWING NOTE: New materials may be added, while other content removed from this presentation after submission of the handout and therefore are not aligned to this handout. Anatomy Factors Nerve Pathways Leveraging the Dental Plexus Features of the Maxilla Bone Density Maxillary Plexus Features of the Mandible Mandibular Foramen Retromolar Region Mandibular Plexus ett Injections & Devices The Mandibular Blocks: Traditional IA High Block vs Gow-Gates Short Needle IA Akinosi PDL-IA Rescue Injection Retromolar Injections (Inferior r alveolar, Lingual, Mylohyoid) Mandibular Tips AMSA Block Maxillary Tips 8 Pharmacology Buffering Dosages: Revised MRDs Pediatric Obesity Non-Pharmacological Non-Injectable Local Anesthesia Compounded Topicals Medical Cannabis People Factors DQAC Rules 2017 Injection Fluid Dynamics Relaxation Breathing Cognitive Distraction Ergonomics CCLAD vs Manual Devices Operatory Set-up & Habits Kathy BSDH, RDH, MEd Copyright
WAC 246-817-730 Local anesthesia. Local anesthesia shall be administered only by a person qualified under this chapter and dental hygienists as provided in chapter 18.29 RCW. (1) All offices must comply with the requirements listed in WAC 246-817-724. (2) A permit of authorization is not required. [Statutory Authority: RCW 18.32.640 and 18.32.0365. WSR 09-04-042, 246-817-730, filed 1/30/09, effective 3/2/09. Statutory Authority: RCW 18.32.035. WSR 95-21-041, 246-817-730, filed 10/10/95, effective 11/10/95.] New and revised rules (WAC 246-817-550 & 560) went into effect on January 13, 2017 that allow dental hygienists licensed in Washington to administer local anesthesia under general supervision for adults when treatment planned and approved by the supervising dentist. The new language Administer local anesthetic agents and adjunctive procedures clarifies that dental hygienists can administer currently available agents such as buffered anesthetic, reversal agents, and nasally delivered topical. Further this language allows for the inclusion of new and evolving forms of local anesthetic administration as they are developed. The following conditions must be met to delegate e administration local anesthesia under general supervision: 2of o The patient is at least 18 years of age o The patient has been examined by the delegating dentist within the previous twelve (12) months o There has been no change in the patient s medical history since the last examination. If there has been a change in the patient s medical history within that time, the dental hygienist must consult with the dentist before administering local anesthetics. o The delegating dentist who performed the examination has approved the patient for the administration of local anesthetics by a dental hygienist under general supervision and documented this approval in the patient s record. Dental hygienists in supervised settings continue to be allowed to administer local anesthesia to patients less than 18 years of age as long as it is under close supervision and they may use adjunctive procedures including local anesthetic reversal agents and buffered anesthetic. WAC 246-817-560, which is the rule that allows dental hygienists to administer nitrous oxide analgesia and place antimicrobials under close supervision, clarifies this. NOTE: the rules for dental hygienists when practicing in unsupervised settings (056) have NOT changed. These direct access settings as specified in RCW 18.29.056 (certain health care facilities and senior centers) and RCWB RCW 18.29.220 (community-based sealant programs) have a very limited scope of practice and the B. procedures allowed have not changed. set f 18 COPYRIGHT KATHY BASSETT BSDH, RDH, MEd 2
MANDIBULAR BLOCK TECHNIQUE VARIATIONS: Location of Mandibular Foramen Penetration site standard Halsted block criteria? Actual location of mandibular foramen 1 O ~84% of the time > 10 mm above occlusal table O ~96% of the time > 15 mm above occlusal table Depositing solution higher is more likely to place it above the foramen (Dr. GG referenced the lingula) Indirect Blocks O Retromandibular injections O Short Needle IANB O PDL IANB O The indirect IANB is a variation of the direct technique [halstad] and will be discussed here as a version of the Short Needle IA. The depth of penetration [distance] from the oral mucosa at the pterygotemporal depression [depth of pterygomandibuar sulcus], at the narrowest anteroposterior osterior width of the ramus [depth of coronoid notch], to the inferior alveolar nerve [at mandibular foramen] was routinely ~21 mm +/- 1 mm. O Short needles (or shallow penetrations) ns) at this location may actually place solution closer to IA nerve trunks O It was easier to estimate the depth of penetration tio with a short needle than with a long needle. A short needle also was less likely to go too deep and deviate from its course than was a long needle. 2,3 Retromandibular Zone O Nerves with possible sible innervation through the retromolar bone: inferior alveolar, lingual, mylohyoid, buccal O Retromolar foramen O Retromolar canal O Retromolar innervation supports retromolar infiltration 3 Rooted Molars O High instance of mylohyoid intervention O High instance in Alaska native and some South American populations PDL Inferior Alveolar Block O At four aspects of mandibular 2 nd molar (MB, DB, ML, DL) o 1 stopper (0.2 ml) per site Maxillary Plexus Factors o Success of AMSA Injections High Block vs Gow Gates A Picture Is Worth a Thousand Words (YouTube) O Gow Gates o AMSA COPYRIGHT KATHY BASSETT BSDH, RDH, MEd 3
Individual Ergonomics o CCLADs Computer Controlled Local Anesthesia Delivery The Wand Computer Assisted Anesthesia System Wand handpiece Dynamic Pressure Sensing Technology o Benefits Injection comfort (patients & clinicians) Accurate and reliable aspiration Controlled injection fluid dynamics Controlled flow rates Decreased inflammatory response Ergonomic advantage o Impact of Fluid Dynamics 5 Drip vs Burst Flow Rates Injection Hydraulics 25 and 27 gauge needles are associated with lower fluid pressures at needle tips when compared to 30 gauge ge needles Smaller gauge needles (25ga, 27ga) are associated with reduced post injection pain and et edema, which appears ars to contradict beliefs that 30 gauge needles are less traumatic 6 o Flow Rates & Fluid Pressures sures Reference 7 Type 1 Type 2 Type 3 Density Compliance Tissue Examples low-density tissues moderate-density tissues high tissue compliance ce moderate tissue compliance most adaptive less adaptive buccal mucosa, attached gingiva retro-molar fossaes fossae palatal tissues high-density tissues very low tissue compliance minimal adaptive capacity periodontal ligaments set Flow Rates > 0.005 cc/sec ~ 0.005 ml/sec 0.005 ml/sec < 0.03 ml/sec slower rates than Tye 1 requires a fixed slow rate PressuresB< 9 psi to 12 psi 50 psi to 75 psi 225 psi to 350 psi COPYRIGHT KATHY BASSETT BSDH, RDH, MEd 4
Ergonomics 8,9,10 o Work Related Musculoskeletal Disorders o Cumulative Trauma Disorders o Aspiration Pressures 11 CCLAD vs Manual Devices o Aspiration, grasp Individual Ergonomics o Basic elements for good ergonomics Do not twist truck Bend from hips Keep wrists at a neutral angle Do not raise arms > 30 degrees Do not extend the neck > 30 degrees forward O Non-dominate hand injections, opposite side approach ach Relaxation Breathing O Conventional mouth breathing increases sympathetic nervous system activity, while decreases parasympathetic system activity O During nasal breathing reduces sympathetic nervous system activity to only 50% of its capacity, while increases calming parasympathetic system stem activity by 50%! O When mouth breathing brain waves rev up into a very fast and stressed state of beta brain wave activity o While nose breathing brain waves became calm and coherent, the brain goes into an alpha state, which is seen in deep relaxation states like meditation Buffering o ph of local anesthetics, impact of multiple cartridges on ph o Remember it is the base form (RN) of the drug that moves through the nerve membrane. o Principles of Buffering Acid hurts (burning & stinging); decreased acidity may result in increased comfort Increase in ph of one point represents an exponential decrease in hydrogen ions (acid) A higher her ph promotes neutral base molecules; more base molecules can lead to a faster onset Lidocaine HCL is non-lipid soluble (99% RNH+) at 3.5 ph, 0.004% in lipid soluble form (RN) Buffer the bodies ph closer to 7.35 7.45 before the drug is effective Sodium bicarbonate interacts with hydrochloric acid to form CO 2, potentiates the action of lidocaine HCL, and yields an immediate, independent depressive effect on the nerve Buffering elevates extracellular ph Potential use of buffering o THEORY - Alcohol and Alcoholics: Patients under the influence of large amounts of alcohol (as well as recovering alcoholics) can be quite difficult to anesthetize. High alcohol intake produces a state of metabolic acidosis (due to lactic acidosis, ketoacidosis and acetic acidosis). An acidic environment at the site of the injection reduces the ability of the anesthetic to cross the cell membrane limiting its effects. COPYRIGHT KATHY BASSETT BSDH, RDH, MEd 5
Buffering Systems o Orapharma s Onset - single cartridge system o Anutra - multi-dose system, disposable syringe http://anutramedical.com/buffering/ Dosages: o FDA Approved Adult MRDs MRDs are weight based for all patients Standardizes adult dosages nationwide Drug* mg/lb MRD* Articaine 4% 3.2** Bupivacaine 05%*** 0.9 90 mg Lidocaine 2% 3.2 500 mg Mepivacaine 2% 3.0 400 mg Prilocaine 4% 4.0 600 mg Weight dependent ** Vasoconstrictor does dependent *Note: "per appt." values represent dosages for healthy adults..va Values may need to be adjusted for children, elderly, and medically compromised individuals. duals. ** MRD of Articaine weight related, no absolute maximum given *** No U.S. recommendations ns are available Source: FDA 2013; ADA/PDR A/PDR 5e; 2009; Malamed, 6e, 2013; Local Anesthesia for Dental Professionals 2e, 2015. Pediatric Dosages o The American Academy of Pediatric Dentists, 2009 Guideline on Use of Local Anesthesia for Pediatric Dental Patients maintains the previous lower values. Pediatric Obesity o Body Mass Index Calculator o http://www.nhlbi.nih.gov/health/educational/lose_wt/bmi/bmicalc.htm ssed 6e g2mg2 500 mg20 tt 018 18 COPYRIGHT KATHY BASSETT BSDH, RDH, MEd 6
Pediatric Drug Dosages * mg/lb MRD* Articaine 4% 3.2 500 mg Bupivacaine 0.5% 0.6 90 mg Lidocaine 2% 2.0 300 mg Mepivacaine 2% 2.0 300 mg Prilocaine 4% 2.7 400 mg *Note: "per appt." values represent dosages for healthy children. Values may need to be adjusted for children, elderly, and medically compromised individuals. Source: AAPR, 2009;; ADA/PDR 5e; 2009; Malamed, 6e, 2013; Local Anesthesia for Dental Professionals 2e, 2015. Medical Cannabis 12 o Can elicit variable parasympathetic effects, which h in association with a stress response, such as a visit to the dentist, t, may be associated with syncopal episodes. o [in the presence of] epinephrine phrine may seriously prolong tachycardia already induced by an acute dose of cannabis. o For those who experience erience cannabis-induced anxiety disorder, this may exacerbate dental fears. Non-Pharmacological al o Topical - Gebauer s PainEase TM o Gate Control 13 Gate control is pain relief by causing sensations other than pain, and then sending them down the same pathway. Using the body s own nervous system, transmit cold and vibration senses to block the final common pathway for sharp pain to the brain. Stimulating C [cold] and A-beta [vibration] fibers prior to sticking with a needle can decrease pain. DentalVibe Buzzy DistrACTION Cards o Cognitive Distraction 14,15 Neurocognitive models of pain demonstrate that young children benefit more from interactive distraction than passive. Actions vs Words Interactive vs passive an intentional effort aimed to interrupt and capture attention Age appropriate child must be competent enough at the skill to sustain attention 201 COPYRIGHT KATHY BASSETT BSDH, RDH, MEd 7
Non-Injectable Local Anesthesia o Kovanaze Nasal Mist Topical Anesthetic o Oraqix Periodontal Gel Contains poliaximers which set up at body temperature Formulated for use in the pocket o Cetacaine Topical Anesthetic o All of these pose a risk for methemoglobinemia REFERENCES 1. Gow-Gates, G.A.E. (1983) A new mandibular block technique using extra-oral al and intra-oral landmarks, A thesis, presented to the Faculty of Dentistry, University of Sydney for the Master of Dental Surgery. 2. Menke, R.A., Gowgiel, J.M. (1979). Short-needle block anesthesia sia at the mandibular foramen, Journal of the American Dental Association, 99(1), 27-30. 3. Khoury, J., Townsend, T. (2011) neural blockade anaesthesia esia of the mandibular nerve and its terminal branches: rationale for different anaesthetic techniques including their advantages and disadvantages. Anesthesiology Research and Practice, Vol. 2011, Article ID 307423, 7 Pages. DOI:10.1155/2011/307423 4. Galdames, S., López, M.G., Matamala, Z. (2008) 08) Inferior alveolar nerve block anesthesia via the retromolar triangle, an alternative for patients ts with blood dyscrasias. as. Med Oral Patol Oral Cir Bucal. Jan1;13(1):e43-7. 5. Kudo, M. (2005). Initial injection pressure for dental local anesthesia: effects on pain and anxiety, anesthesia progress. 52:95 101. 6. Diggle, L., Deeks, J.J., Pollard, A.J. (2006). Effect of needle size on immunogenicity and reactogenicity of vaccines in infants: randomized controlled trial, British Medical Journal, 333(7568):571-578. 7. Hochman, M. N., Friedman, M. J., Williams, W., Hochman, C. B. (2006). Interstitial tissue pressure associated with dental injections, ns, Quintessence International. 37:469 476. 8. Guignon A.N. (2013). Less strain, less pain, Rdh Magazine. (7) 60-61 9. Kaufman K.R., An K.N., Litchy W.J., Cooney W.P., Chao E.Y. (1999) in-vivo function of the thumb muscles, Clinical l Biomechanics. 14(2):141-50. 10. Tzafalia, M., Sixou, J.L. (2001). Administration of anesthetics using metal syringes. An Ex Vivo Study, Anesthesia Progress. 58(2): 61 65. 11. Kuscu, O. O., Akyuz, S. (2008). Is it the injection device or the anxiety experienced that causes pain during dental local anaesthesia? International Journal Of Paediatric Dentistry. ISSN 2321-547X, 001-006. 12. CHO CM 1, HIRSCH R, JOHNSTONE S. GENERAL AND ORAL HEALTH IMPLICATIONS OF CANNABIS USE. AUST DENT J. 2005 JUN;50(2):70-4. PMID: 16050084 [PUBMED - INDEXED FOR MEDLINE] 13. Canbulat, at, N., Ayhan, F., Inal. S. (2014). Effectiveness of external cold and vibration for procedural pain relief during peripheral intravenous cannulation in pediatric patients. Pain Management Nursing, jun 6 S1524-9042.N=176. 14. Wohlheiter, KA., Dahlquist, LM. (2013). Interactive versus passive distraction for acute pain management in young children: the role of selective attention and development. J Pediatr Psychol.;38(2):202-212 15. Cohen LL, Blount RI, Cohen RJ, Schaen ER, Zaff JF. Comparative study of distraction versus topical anesthesia for pediatric pain management during immunizations. Health Psychol 1999;18(6):591-8. COPYRIGHT KATHY BASSETT BSDH, RDH, MEd 8
WEB LINKS 1. Dr. Murph: Inferior Alveolar Nerve Block Technique (Short Needle IA) YouTube: https://www.youtube.com/watch?v=7owclxgckb4 2. A Picture Is Worth A Thousand Words (YouTube) - Gow Gates CHAIRSIDE LIVE EPISODE 80: YOU CAN TEACH AN OLD DOC NEW TRICKS! HTTP://WWW.YOUTUBE.COM/WATCH?V=L1RDSOMXCMM 3. A Picture Is Worth A Thousand Words (YouTube) - AMSA CHAIRSIDE LIVE EPISODE 81: OLD DOC NEW TRICKS: PART DEUX HTTP://WWW.YOUTUBE.COM/WATCH?V=I07PYCE2Z74 4. Body Mass Index Calculator http://www.nhlbi.nih.gov/health/educational/lose_wt/bmi/bmicalc.htmhtm 5. Anutra Buffering System - http://anutramedical.com/buffering/ 6. St. Renatus, Use and Training - http://www.kovanaze.com/use-and-training/ /use-and-training/ 7. WACs > Title 246 > Chapter 246-817 > Section 246-817-550 http://apps.leg.wa.gov/wac/default.aspx?cite=246-817-55050 COPYRIGHT KATHY BASSETT BSDH, RDH, MEd 9