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What are the benefits to doing a nerve block?
- decreases the amount of injectable and gas inhalants needed
- lower cost
- increase patient safety since lower levels of general anes are needed
- decreased recover time
- greater patient comfort
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With decreased recovery time, what else does it decrease?
decreased risk of hypertension, tachycardia, and tachypnea due to decreased oral pain
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What are the risks of using dental nerve blocks?
- injection into circulation could cause myocardial depression and cardiac dysrhythmia
- ocular damage caused by improper infraorbital nerve block technique
- cheek or tongue damage during recovery
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What are the different types of local anesthetics used in dentistry?
- infiltration anesthesia
- splash technique
- regional nerve block
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What does infiltration anesthesia involve?
applying small amounts of local anesthesia into the gingiva, mucosa, periodontal ligament space/alveolar periosteum
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When would you use infiltration anesthesia?
used only for small number of teeth that need to be blocked or as adjunct to intraorbital blocks
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How do we do the splash technique?
anesthetic agent is dropped onto or into area being treated
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Is the splash technique as successful as infiltration or regional nerve blocks?
no
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What are regional dental nerve blocks not indicated for?
routine dental cleaning procedures
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When should we use regional dental nerve blocks?
for all painful oral surgeries and should be preceded by regional nerve blocks
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What are considered painful oral surgeries?
- tumor resection
- biopsy
- reconstruction surgery
- oral lacerations, foreign bodies
- jaw fractures
- fractured teeth
- root canals
- pulptomies
- extractions
- flap surgery and root planning
- oral resorptive lesions
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How do we do regional nerve blocks?
local anesthetic agent is injected just into the foramen
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What are the different foramens that we can inject regional nerve blocks into?
- inraorbital foramen
- palatine/maxillary foramen
- inferior alveolar foramen (mandibular block)
- mental foramen
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What kind of equipment do we need for nerve blocks?
- drugs
- 25 - 22g needles with 5/8 - 1 inch length
- 1 - 3 cc syringes
- surgical scrub
- dog and cat skulls for anatomical guidance
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What is the onset time for lidocaine?
5 - 10 minutes
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What is the duration of lidocaine?
60 - 90 minutes
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What is the dose for lidocaine?
2% lidocaine 2 mg/kg
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How much lidocaine would we use for a 4 lb animal? 5 lbs? 10 lbs?
- 4 lbs: 0.18 ml
- 5 lbs: 0.22 ml
- 10 lbs: 0.45 ml
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How can we expand the volume of lidocaine we need to use?
add it to saline
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How can we reduce the stinging of lidocaine?
and 1/10 of volume as sodium bicarbonate (example - if using 1 ml of lidocaine add 0.1 ml of sodium bicarbonate)
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What is the onset time of bupivicaine?
15 - 30 minutes
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What is the duration of bupivicaine?
4 - 8 hours
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What is the dose for bupivicane?
0.5% bupivicaine 2 mg/kg
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How much bupivicaine would we use for a 4 lb animal? 5 lbs? 10 lbs? 50 lbs?
- 4 lbs: 0.72 ml
- 5 lbs: 0.90 ml
- 10 lbs: 1.8 ml
- 50 lbs: 9 ml
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How can we expand the volume of bupivicaine?
mix with saline
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How can we reduce the sting of using bupivicaine?
add 1/10 volume as sodium bicarbonate (example: is using 1 ml of bupivicaine add 0.1 ml of sodium bicarbonate)
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If we are using lidocaine and bupivicaine, what should we do?
cut doses in half
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What is the average dose of bupivcaine for dogs?
- 0.5 - 1.0 ml per site in dogs
- the cumulative dose during any procedure should not exceed 2 mg/kg
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What is the average dose of bupivicaine for cats?
- 0.01 - 0.3 ml per site
- the cumulative dose during any procedure should not exceed 2 mg/kg
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What is the onset of mepvacaine?
quick onset
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What is the duration of mepivacaine?
2 - 2.5 hours
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What is the dose of mepivacaine for dogs? cats? maximum dose?
- dogs: 0.25 - 1 ml depending on size
- cacts: 0.25 - 0.5 ml depending on size
- maximum dose: 2 mg/kg
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Is mepivicaine less toxic than lidocaine and bupivicaine?
yes
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What is the onset when mixing lidocaine and bupivicaine? Duration?
- onset: 5 - 10 minutes from the lidocaine
- duration: 4 - 6 hours from bupivicaine
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What is the duration when mixing lidocaine and bupivicaine?
4 - 6 hourse
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Why do we mix lidocaine and bupivicaine?
for balanced anesthesia
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How much lidocaine and bupivicaine should we use for dogs? Cats & small dogs?
- dogs: 0.1 - 1.0 ml per site
- cats & small dogs: 0.1 - 0.3 ml per site
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What does epinephrine do to the drugs?
lengthens the effects of the agents by 50%
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All of the drugs are _____, especially to cats?
cardiotoxic
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What can be fatal if even a little bit gets administer IV to cats?
bupivicaine
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What are the steps to performing regional nerve blocks?
- locate the foramen
- insert the needle bevel down (towards the bone)
- aim to insert the needle just to or slightly into the canal
- aspirate
- rotate the needle 1/4 a turn
- aspirate again
- rotate the needle 1/4 a turn
- aspirate the needle a third time to be sure you are not in a blood vessel
- slowly inject
- place a finger over the foramen for 20 - 30 seconds after withdrawing the needle
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What does the infraorbital nerve block anesthetize?
- upper lip
- nose
- roof of nasal cavity
- skiin ventral to the infraorbital foramen
- maxillary incisors, canine, and first 2 premolars
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How do we do an infraorbital nerve block?
- lift lip and palpate foramen
- insert needle through buccacl mucosa where it forms a crease
- direct needle (bevel down?) toward the floor of the foramen in a rostrocaudal direction, just at the foramen
- aspirate and rotate three times
- inject and hold pressure on foramen
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What does a palatine block/maxillary nerve block anesthetize?
- maxillary 4th premolars
- molars
- hard tissue caudal to the maxillary 4th premolar (hard and soft palate)
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Where do we do the palatine block/maxillary nerve block?
- visualize the midline of the palate and the palatal root of the 4th premolar
- draw an imaginary line for each
- halfway across the line is the opening of the major palatine foramen
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Should we enter the actual foramen for the palatine block?
no because of large vessels in the foramen
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How do we find where to do the maxillary nerve block?
with the patient's mouth open, palpate the notch at the rostral ventral aspect of the zygomatic arch as it meets the bone surrounding the last maxillary molar
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How do we do a maxillary nerve block?
- insert the needle perpendicular to the horizonal line of the palate directly adjacent to the bone at the ventral border of the zygomatic arch
- walk the needle slightly cranially along the cranial side of the maxilla to a level just beyond the root tips of the last molar
- aspirate 3 times
- apply digital pressure 30 - 60 seconds
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Whats another name for the inferior alveolar foramen?
mandibular block
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What does the inferior alveolar foramen nerve bloc, anesthetize?
- blocks all teeth in the mandible
- also blocks soft and hard tissues
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Where do we anesthetize for the mandibular block?
located on the lingual surface of the mandible, halfway between the caudal curve of the mandible and the angular process
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What are the 2 different types of mandibular blocks can we do?
extra-oral and intra-oral
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How do we do the extra-oral approach to the mandibular block?
- clip and prep a small area at the angle of the mandible
- slide your finger inside the mouth until you feel an indentation
- from the outside, insert the needle through the skin until the needle hits the mandibular notch
- aspirate three times and inject
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How do we do the intra-oral mandibulad block?
- place the animal lateally so the side you want to block is down
- palpate the foramen on the down side
- direct the syringe across the tongue from the up side of the mouth
- aspirate 3 times and inject
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What does the mental nerve block aneathetize?
- 1st and 2nd premolars
- canines
- incisors
- soft and hard tissues of the mandible rostral to the 2nd premolar
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How many foramens are there for the mental foramen block and which one do we use?
there are 3 and we use the middle one
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How do we do a mental nerve block?
- insert needle bevel down into the submucosa in a rostral to caudal direction and advance just to the entrance of the foramen
- aspirate 3 times
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How long should we use post operative analgesia?
3 -7 days
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