Deck 16: Troubleshooting Inadequate Anesthesia

Question 1

Match the following:

-Aberrant innervation

A) Response to drug based on time of day
B) Allows diffusion into spongy bone
C) Soft tissue restriction to flow of anesthesia
D) Expected variation
E) Accessory to mandibular incisors
F) Drug tolerance
G) Divided nerve
H) Unexpected variation
I) Hard tissue restricting flow of anesthesia
J) Accessory innervation to mandibular teeth

Answer 1

Unexpected variation

Question 2

Match the following:

-Accessory innervation

A) Response to drug based on time of day
B) Allows diffusion into spongy bone
C) Soft tissue restriction to flow of anesthesia
D) Expected variation
E) Accessory to mandibular incisors
F) Drug tolerance
G) Divided nerve
H) Unexpected variation
I) Hard tissue restricting flow of anesthesia
J) Accessory innervation to mandibular teeth

Answer 2

Expected variation

Question 3

Match the following:

-Bifid

A) Response to drug based on time of day
B) Allows diffusion into spongy bone
C) Soft tissue restriction to flow of anesthesia
D) Expected variation
E) Accessory to mandibular incisors
F) Drug tolerance
G) Divided nerve
H) Unexpected variation
I) Hard tissue restricting flow of anesthesia
J) Accessory innervation to mandibular teeth

Answer 3

Divided nerve

Question 4

Match the following:

-Cervical nerve plexus

A) Response to drug based on time of day
B) Allows diffusion into spongy bone
C) Soft tissue restriction to flow of anesthesia
D) Expected variation
E) Accessory to mandibular incisors
F) Drug tolerance
G) Divided nerve
H) Unexpected variation
I) Hard tissue restricting flow of anesthesia
J) Accessory innervation to mandibular teeth

Question 5

Match the following:

-Dense bone

A) Response to drug based on time of day
B) Allows diffusion into spongy bone
C) Soft tissue restriction to flow of anesthesia
D) Expected variation
E) Accessory to mandibular incisors
F) Drug tolerance
G) Divided nerve
H) Unexpected variation
I) Hard tissue restricting flow of anesthesia
J) Accessory innervation to mandibular teeth

Question 6

Match the following:

-Diurnal body rhythms

A) Response to drug based on time of day
B) Allows diffusion into spongy bone
C) Soft tissue restriction to flow of anesthesia
D) Expected variation
E) Accessory to mandibular incisors
F) Drug tolerance
G) Divided nerve
H) Unexpected variation
I) Hard tissue restricting flow of anesthesia
J) Accessory innervation to mandibular teeth

Question 7

Match the following:

-Fascial planes

A) Response to drug based on time of day
B) Allows diffusion into spongy bone
C) Soft tissue restriction to flow of anesthesia
D) Expected variation
E) Accessory to mandibular incisors
F) Drug tolerance
G) Divided nerve
H) Unexpected variation
I) Hard tissue restricting flow of anesthesia
J) Accessory innervation to mandibular teeth

Question 8

Match the following:

-Intraosseous injection

A) Response to drug based on time of day
B) Allows diffusion into spongy bone
C) Soft tissue restriction to flow of anesthesia
D) Expected variation
E) Accessory to mandibular incisors
F) Drug tolerance
G) Divided nerve
H) Unexpected variation
I) Hard tissue restricting flow of anesthesia
J) Accessory innervation to mandibular teeth

Question 9

Match the following:

-Mylohyoid nerve

A) Response to drug based on time of day
B) Allows diffusion into spongy bone
C) Soft tissue restriction to flow of anesthesia
D) Expected variation
E) Accessory to mandibular incisors
F) Drug tolerance
G) Divided nerve
H) Unexpected variation
I) Hard tissue restricting flow of anesthesia
J) Accessory innervation to mandibular teeth

Question 10

Match the following:

-Tachyphylaxis

A) Response to drug based on time of day
B) Allows diffusion into spongy bone
C) Soft tissue restriction to flow of anesthesia
D) Expected variation
E) Accessory to mandibular incisors
F) Drug tolerance
G) Divided nerve
H) Unexpected variation
I) Hard tissue restricting flow of anesthesia
J) Accessory innervation to mandibular teeth

Question 11

Devices used for delivery of local anesthetic solutions have very little impact on local anesthesia failure.

Question 12

Needle bevel orientations are not considered critical to the success of any injection.

Question 13

A 25 gauge needle has less potential for deflection than a 27 gauge needle, although deflection is not a common cause of anesthetic failure.

Question 14

A pH below 3.3 can lead to failure of anesthesia because the solution is too acidic.

Question 15

Dental hygiene procedures require less duration of anesthesia than restorative procedures.

Question 16

Nerve blocks typically require similar volumes of anesthetic solution to achieve profound anesthesia.

Question 17

Inferior alveolar nerve blocks may be unsuccessful when the needle penetration is made lateral to the sphenomandibular ligament.

Question 18

Aberrant innervations are unexpected anatomical variations.

Question 19

Fibers from the greater palatine nerve may provide accessory innervation to the palatal roots of maxillary molars.

Question 20

PDL injections can overcome nearly all of the challenges that occur due to accessory and aberrant innervation.

Question 21

The term referring to the lack of redevelopment of profound anesthesia when subsequent injections in the same appointment are administered is called ________.

Question 22

The term ________ is frequently used to describe the variable response to drugs during different times of a day.

Question 23

The higher the gauge of a needle, the greater its ________ and deflection in tissues.

Question 24

A cartridge of anesthesia with a vasoconstrictor should have a pH of no less than ________.

Question 25

The ________ injection technique requires penetration through the periosteum and cortical plate before injecting anesthetic solution.

Question 26

Initial recommended volumes of local anesthetic solution are affected by the ________of the nerve membrane to be anesthetized.

Question 27

Dense bony prominences, shallow vestibules, dilacerations, and ligaments create ________ barriers to the success of anesthesia.

Question 28

Tachyphylaxis is most likely to occur once anesthetized tissues have returned to ________ levels of sensation.

Question 29

________ can deflect anesthetic solution away from ideal deposition sites, resulting in inadequate anesthesia.

Question 30

The term that is used to describe failure of mandibular anesthesia due to innervation from cervical nerve fibers is called an ________ innervation.

Question 31

Inadequate anesthesia may typically be caused by all of the following, except

A) Volume of solution
B) Presence of inflammation
C) Quality of manufactured solutions
D) Anatomical variations

Question 32

Which of the following factors is most likely to correspond to anesthetic failures?

A) Delivery devices
B) Needle bevel orientation
C) Needle deflection
D) Physical barriers

Question 33

Which of the following does not typically have an effect on the ability to achieve profound anesthesia?

A) Anatomical barriers
B) Choice of anesthetic
C) Volume of anesthetic administered
D) Psychological barriers

Question 34

Inadequate anesthesia in the maxillary incisors is least likely to be caused by:

A) Crossover innervation from the contralateral ASA nerve
B) Nasopalatine innervation
C) Bony obstructions
D) Facial nerve innervation

Question 35

Which of the following nerves is often considered the most likely source of accessory innervation of the mandibular first molar?

A) Mylohyoid
B) Buccal
C) Lingual
D) Cervical

Question 36

Which of the following injections would most likely solve inadequate anesthesia on the palatal root of tooth 3?

A) Facial infiltration
B) MSA
C) Greater palatine
D) PSA

Question 37

Which of the following is the best option to assure anesthesia in the presence of inflammation?

A) Administer a larger volume of anesthetic in the same location
B) Select an injection that will provide anesthesia of the nerve trunk medial to the area of inflammation
C) Administer infiltrations in several locations around the tooth to provide anesthesia
D) Choose a different anesthetic drug

Question 38

The Gow-Gates is successful in providing anesthesia of mandibular molars in the presence of accessory innervation from the mylohyoid or lingual nerves because

A) An increased volume of solution is administered and the mouth is maintained in an open position following injection.
B) The deposition site is lower on the inferior nerve; therefore, it is closer to the mylohyoid and lingual nerves.
C) The IA nerve trunk is anesthetized higher on the inferior nerve.
D) A long, 25 gauge needle is used.

Question 39

Mepivacaine plain solutions may be useful for reinjection following the use of lidocaine 2% with epinephrine for all of the following reasons except

A) There is 50% more drug per volume.
B) It raises the pH at the deposition site.
C) Duration is enhanced by the presence of previously injected vasoconstrictor.
D) It is a strong vasodilator.

Question 40

Which statement is true regarding tachyphylaxis?

A) It is most likely to occur once sensation has returned to normal levels.
B) It is least likely to occur when effective anesthesia was initially achieved.
C) It is well understood as a problem related to inadequate local anesthesia.
D) It is related to the high pH of tissues in the presence of inflammation.

Question 41

Explain the difference between suspected aberrant and accessory innervations.

Question 42

What is recommended to avoid failed anesthesia and an increased risk of toxicity due to intravascular injection?

Question 43

Following a PSA nerve block of tooth 2 it is determined that the palatal root is inadequately anesthetized. Discuss two possible causes and three possible solutions the clinician should consider.

Question 44

Identify and discuss inadequate anesthesia following IA injections and suggest alternative injections to achieve anesthesia.

Question 45

The treatment plan for Clare Ross included an MODL restoration on tooth #3. A right PSA, MSA, and intraseptal injection (to avoid a palatal injection) were administered with 2% lidocaine with 1:100,000 epinephrine. During cavity preparation, Clare jumped when the bur neared the palatal root.

-Explain two possible reasons for inadequate anesthesia of the palatal root.

Question 46

The treatment plan for Clare Ross included an MODL restoration on tooth #3. A right PSA, MSA, and intraseptal injection (to avoid a palatal injection) were administered with 2% lidocaine with 1:100,000 epinephrine. During cavity preparation, Clare jumped when the bur neared the palatal root.

-What other injection(s) should be considered to anesthetize the palatal root?

Question 47

The treatment plan for Clare Ross included an MODL restoration on tooth #3. A right PSA, MSA, and intraseptal injection (to avoid a palatal injection) were administered with 2% lidocaine with 1:100,000 epinephrine. During cavity preparation, Clare jumped when the bur neared the palatal root.

-What other anesthetic drugs may be considered and why?

Question 48

The treatment plan for Ralph Cook includes a restoration for tooth #12. There is a large, bony exostosis on the facial aspect that extends from the canine to the first molar. An MSA was attempted however failed to achieve adequate anesthesia.

-What is the likely cause of inadequate anesthesia?

Question 49

The treatment plan for Ralph Cook includes a restoration for tooth #12. There is a large, bony exostosis on the facial aspect that extends from the canine to the first molar. An MSA was attempted however failed to achieve adequate anesthesia.

-What other injection technique(s) should be considered?

Question 50

Anita Mendoza presents with a large failing #30 MOD amalgam with distal lingual cusp fracture. She says she hated to have the tooth "worked on again because it's the only tooth that never gets numb no matter what they try." It is determined that a crown is the appropriate treatment for #30. She is assured that the tooth will be numb before treatment. IA, lingual and buccal nerve blocks are administered with a total of 1.5 cartridges of lidocaine with 1:1,000,000 epinephrine. She reports the "tooth and all around it feel numb," however when a pulp tester is applied to #30 she jumps with discomfort. Pulp testing on tooth number 29 and 31 are negative. The IA injection site is carefully re-evaluated and an IA injection is repeated with a second cartridge of the same drugs. An identical response to the pulp tester follows.

-What are the possible causes for inadequate anesthesia of tooth #30?

Question 51

Anita Mendoza presents with a large failing #30 MOD amalgam with distal lingual cusp fracture. She says she hated to have the tooth "worked on again because it's the only tooth that never gets numb no matter what they try." It is determined that a crown is the appropriate treatment for #30. She is assured that the tooth will be numb before treatment. IA, lingual and buccal nerve blocks are administered with a total of 1.5 cartridges of lidocaine with 1:1,000,000 epinephrine. She reports the "tooth and all around it feel numb," however when a pulp tester is applied to #30 she jumps with discomfort. Pulp testing on tooth number 29 and 31 are negative. The IA injection site is carefully re-evaluated and an IA injection is repeated with a second cartridge of the same drugs. An identical response to the pulp tester follows.

-What other injection techniques should be considered to provide profound anesthesia?