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OLD DOMINION UNIVERSITY
SCHOOL OF DENTAL HYGIENE
DNTH317
Local Anesthesia and Nitrous Oxide Analgesia
Credit Hours: 2 credits
Course Hours: August 11-15, 2008, Lecture 8 am-12 noon; Lab/Clinic 1 pm-5 pm
Curriculum Level: Summer Semester, First-Year
Course Instructor:
Name and Title: Deborah B. Bauman, Course Coordinator
Office Location: Dentist/Lecturer-TBA
Dr. Rod Rogge
E-mail Address: [email protected]
Telephone Number(s): 683-3338
Fax Number: 683-5239
Office Hours: August 4-8, 10 am-noon
Course Description: DNTH317. Local Anesthesia and Nitrous Oxide Analgesia. Lecture 15
hours; lab 30 hours; 1 week; 2 credits. Clinical experience in the on campus supervised clinic.
Prerequisites: DNTH305, 306, 307, 309 and 316. Introduction of principles of local anesthesia
injections and nitrous oxide analgesia administration, neurophysiologic considerations and
laboratory application of techniques. Five hours of lecture will be on Blackboard. (Offered
summer) (Qualifies as a CAP experience)
Required Texts:
1. Malamed, S.F. (2004) Handbook of Local Anesthesia, 5th ed. Mosby ISBN: 0-32302449-1.
2. Malamed (2003). Sedation: A Guide to Patient Management, 4th ed., Mosby ISBN:
032301226-4.
Supplemental Texts:
1. Darby, M. & Walsh, M. (2003). Dental Hygiene Theory and Practice, 2nd ed. Saunders
ISBN: 0-7216-2966-0.
2. Haveles, Elena B. (2007). Applied Pharmacology for the Dental Hygienist, 5th ed.,
Mosby ISBN: 978-0-323-04874-3.
3. Fehrenbach, M & Herring S. (2007) Illustrated Anatomy of the Head & Neck, 3rd ed.,
Saunders, ISBN:13978-1-4160-3403-2.
1
Method of Delivery: Lectures, seminars, small group work, self study, assigned readings, learning
activities online, quizzes final exam, laboratory clinical instruction and clinical competence exams.
Students will work in groups of three and administer local anesthesia on each other.
Course Requirements: Complete and deliver assigned readings, learning activities and online
assignments by Thursday, August 7 at midnight.
Method of Evaluation:
1.
2.
3.
4.
5.
6.
7.
Learning Activities
30%
Quizzes
20%
Participation
NA\
Final Exam Written
30%
Final Clinical Exam, (IA, PSA)
20%
Clinical Laboratory Exercises:
All students must perform 2 each of the following injections:
S/U
PSA, MSA, ASA, GP, NP, IA, Buccal, Incisive
Failure to perform all injections satisfactory will result in a 5% reduction of final grade.
Session Attendance (Absence & Tardiness) effects grade (see below).
Session Absence Grading Effects
One percentage point will be deducted from the final course average for each absence for each 50
minutes of a lecture and/or a laboratory session.
Session Tardiness Grading Effects
Students are expected to report to lectures and to laboratories at the assigned time. Accumulated
tardiness will be treated in a manner parallel to absences; thus, for each 50 minutes of lecture
tardiness, one percentage point will be deducted from the course average.
Grade Scale:
93 – 100% = A
85 – 92% = B
77 - 84% = C
70 - 76% = D
Below 69 = F
Note: Students must attain a “C” grade in this course to be eligible for continuance in the Dental
Hygiene Program.
2
Attendance:
Attendance is mandatory for all classroom, laboratory and clinical instruction. Students must attend
all sessions due to accelerated pace and detailed content present in the course.
Participation: Students are expected to
 prepare and participate during the entire course.
 be organized and on time.
 complete all required assignments.
 demonstrate responsibility as a team player
 adhere to clinical dress code and infection control policies
Outside Study Time: Approximately 2 hours per day is required for studying material.
GENERAL PROCEDURES
Prior to class, students will receive assigned reading, learning activities and a quiz which are to be
completed prior to and submitted no later than Thursday, August 7 at midnight. The class will meet
during the summer for five days and will involve lecture and laboratory. In the laboratory the
students will administer injections of local anesthesia to a laboratory partner. Competency
evaluations will be utilized in the laboratory.
CLASS ATTENDANCE/CONDUCT/DRESS POLICY
General Remarks
Each student is expected to attend all lectures and laboratory sessions. The student is also expected
to prepare for the laboratory by completing the injection study guide(s) specific to that laboratory
session (sample attached). If the study guide is incomplete, it must be completed before the student
is allowed to practice the particular injection technique on a laboratory partner. Also, students are
to prepare for laboratory sessions by providing a sterile armamentarium.
Conduct Dress
The student will follow department guidelines regarding dress for each laboratory session.
DUE DATES/DEADLINES
All competency evaluations, exams, and course requirements must be completed before 5 p.m.,
August 15, 2008.
3
SCHOOL OF DENTAL HYGIENE AND DENTAL ASSISTING
OLD DOMINION UNIVERSITY
STATEMENT OF STUDENT RESPONSIBILITIES AND ACCOUNTABILITIES
Attendance Due to the unique responsibilities associated with becoming a competent professional
person and provider of health care, and the progressive nature of the curriculum and its importance
to the provision of quality oral health services, attendance and class participation are required.
Should an absence be necessary, the student should contact the course instructor immediately. Only
an excused absence can be made up. A note from a physician, student health center nurse or other
appropriate individual must be submitted to constitute an excused absence. Late arrivals to class are
considered to be unexcused absences. Each unexcused absence will result in a grade penalty of one
percentage point reduction from the final grade.
Make-up exams for unexcused absences will not be given. . Makeup examinations for excused
absences may be given at the ODU Learning Assessment Center on the first Saturday at 8:30AM
following the missed class. Failure to do so will result in a zero on that particular activity.
Meeting Established Deadlines. All course related assignments are to be submitted to the course
instructor on the established due dates. Work submitted after the established deadlines will be
penalized by the grade. Students are encouraged to keep a duplicate copy of all written assignments
submitted. Assignments not handed in by the deadline will be penalized according to the syllabus
Honor Code By attending Old Dominion University you have signed a pledge accepting the
responsibility to abide by the following Honor Code: "We the students of Old Dominion
University, aspire to be honest and forthright in our academic endeavors. Therefore, we will
practice honesty and integrity and be guided by the tenets of the Monarch Creed. We will
meet the challenge to be beyond reproach in our actions and our words. We will conduct
ourselves in a manner that commands the dignity and respect that we also give to others."
This is an institutional policy approved by the Board of Visitors. The University Honor Code
applies to all assignments.
Plagiarism. All academic work submitted to fulfill a course requirement is expected to be result of
each student’s own thought, research and self-expression. A student will have committed
plagiarism if he or she reproduces someone else’s work without acknowledging its source; or if a
source is cited which the student has not cited or used. Examples of plagiarism include: submitting
a research paper obtained from a commercial research service, the Internet, or from another student
as if it were original work; making simple changes to borrowed materials while leaving the
organization, content, or phraseology intact; or copying material from a source, supplying proper
documentation, but leaving out quotation marks. Plagiarism also occurs in a group project if one or
more of the members of the group does none of the group’s work and participates in none of the
group’s activities, but attempts to take credit for the work of the group.
Code of Student Conduct. All students are expected to abide by the Student Code of Conduct as
found in the Old Dominion University Student Handbook and University Catalog.
Students’ papers and projects may be used anonymously for necessary review.
4
Learning Objectives:
1.
2.
3.
4.
5.
Conduct a complete health history interview
Perform a patient physical and psychological assessment
Evaluate the patient’s current health status to determine if any conditions exist that would
alter dental hygiene treatment
Demonstrate proficiency in obtaining and monitoring vital signs (pulse, blood pressure,
respirations).
Examine the mental and physical status of individual patients to determine the indication
for the use of local anesthesia and oxygen analgesia.
Local Anesthesia
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
Articulate the importance of adequate pain control as a prelude to providing quality dental
care.
Describe the physiological mechanism of nerve conduction, the origin of pain, and how
local anesthetic agents prevent impulse transmission.
Identify/describe the pharmacology of the commonly used local anesthetic agents and
vasoconstrictors.
Describe the neuroanatomy of the trigeminal nerve.
Describe the techniques for obtaining local anesthesia for all areas of the dentition.
Identify and describe the signs and symptoms of reactions to local anesthetic agents and
describe or demonstrate emergency protocol to manage these reactions.
Identify common complications encountered in the administrations of local anesthesia.
Identify the anatomical landmarks on a patient for the following injections: ASA, MSA,
PSA, GP, NP, IA nerve block, Buccal, Mental and Incisive.
Identify which nerves, teeth, and soft tissue structures are anesthetized with each of the
above injections.
Name and locate landmarks associated with the administration of the ASA, MSA, PSA, GP,
NP, B, M, IA and single tooth infiltration injections.
Differentiate between pain perception and pain reactions.
List the areas enervated by the following nerves: anterior superior alveolar, posterior
superior alveolar, middle superior alveolar, infraorbital, greater palatine, nasopalatine,
inferior alveolar, incisive, mental, lingual and buccal.
Recognize disease conditions and medications that may alter or contraindicate the use of
local anesthetic agents or nitrous oxide.
Recognize disease conditions and medications that may alter or contraindicate the use of
vasoconstrictors.
Document local anesthetic administration appropriately in the dental record.
Recognize signs and symptoms of local and systemic complications associated with the
administration of local anesthetic agents.
Discuss the management of local and systemic complications associated with the
administration of local anesthetic agents.
Identify the properties of an ideal local anesthetic.
Explain the role of the autonomic nervous system in anxiety.
List non-pharmaceutical approaches to anxiety control.
5
26.
27.
28.
29.
Calculate anesthetic dosages for adult and pediatric patients.
Explain why local anesthetics may not be as effective in an area of injury (infection).
Differentiate between the various types of anesthetics commercially available.
Identify the armamentarium for local anesthesia.
Nitrous Oxide
30.
31.
32.
33.
34.
35.
36.
37.
38.
39.
40.
41.
42.
43.
Explain the pharmacology, indications and contraindications for use of nitrous oxide-oxygen
analgesia.
Discuss the benefits of using nitrous oxide-oxygen analgesia for dental hygiene treatment.
Explain the procedure and signs and symptoms of nitrous oxide-oxygen analgesia to the
patient.
Identify the equipment utilized for nitrous oxide-oxygen analgesia and explain the function
of each part of the equipment.
Demonstrate knowledge in operating the equipment used for nitrous oxide-oxygen
analgesia.
Demonstrate knowledge in the effective administration of nitrous oxide-oxygen analgesia to
laboratory patients at appropriate analgesia levels.
Demonstrate knowledge in returning the patient to pre-analgesia status.
Describe adverse reactions and emergencies related to nitrous oxide-oxygen analgesia and
management of these situations.
Define analgesia, the stages of anesthesia and diffusion hypoxia
Describe interactions of nitrous oxide with dental drugs.
List, recognize and describe complications of OSHA guidelines to nitrous oxide use.
Discuss and describe the medical and legal aspects of nitrous oxide complications.
Discuss appropriate pre- and post-operative patient instructions
Describe the management of medical emergencies.
6
SCHEDULE
DAY
UNIT/LAB
TOPIC
Monday, 8/11/08
8:00 a.m.-12:00 p.m.
Unit 1, 2
Introduction to course and to
local anesthesia.
Neurophysiology and the pain
mechanism.
Armamentarium
1:00-4:00 p.m.
4:00-5:00 p.m.
Labs 1, 2 & 3
Unit 3
Head and neck anatomy Review
& Armamentarium
Tuesday, 8/12/08
8:00-9:00 a.m.
Lecture Unit 4, 6
Overview of pharmacology
9:00-12:00 a.m.
Lecture
Pharmacology of local anesthetics
Pharmacology of vaso constrictors
Quiz
1:00-1:45 p.m.
Lecture/
Video
Maxillary Injection Techniques
1:45-3:00 p.m.
Lab 4
Anterior and Middle superior alveolar
injection
3:00-5:00 p.m.
Labs 5, & 6
Maxillary injections
techniques-posterior superior
alveolar, greater palatine, and
nasopalatine injections.
Wednesday, 8/13/08
8:00-9:00 a.m.
Quiz
9:00-10:00 a.m.
Unit 5
Local complications
10:00-12:00 P.M.
Lecture/Video
Mandibular Injection TechniquesInferior Alveolar, Buccal, Incisive
11:00-12:00 p.m.
Lecture/
Video
Maxillary injection
techniques-posterior superior
alveolar, greater palatine, and
nasopalatine injections.
7
1:00-5:00 p.m.
Labs 7 & 8
Thursday, 8/14/08
8:00-9:00 a.m.
Mandibular Injection TechniquesInferior Alveolar, Buccal, Incisive
Quiz
9:00-12:00 a.m.
Unit 11
Nitrous Oxide Administration
Technique
Patient Assessment
Pharmacology of Nitrous Oxide
1:00-2:00 p.m.
Unit 11
Medical Emergencies with Nitrous
Oxide Administration
Nitrous oxide analgesia administration
Friday, 8/15/08
8:00-9:30 a.m.
Unit 7
Systemic complications and emergency
management of local anesthesia
Quiz
9:30-12:00 p.m.
Units 8, 9, 10
Local anesthesia and the law,
Pedodontic anesthesia, PDL injection.
1:00-3:00 p.m.
Clinical Exam
3:00-5:00 p.m.
Written Exam
8
DNTH-317
Learning Activities
NOTE: These readings and learning activities must be completed by August 7, 2008. Email
or hand deliver or fax your assignment to Ms. Bauman, [email protected], no later than
August 7, 2008 at midnight.
FAX (757) 683-5239
Health Sciences Bldg., @2011 (deliver by 4 pm 8/7/08)
9
DNTH-317
Learning Activity#1
THESE PAGES MUST BE COMPLETED PRIOR TO AUGUST 11 PORTION OF THE
COURSE.
Reading Assignment
Online:
History of Local Anesthesia (www.emedicine.com/ent/topic20.htm)
Blood-Borne Pathogen (www.cdc.gov) click on the following:
1.
2.
3.
4.
5.
Workplace safety and health
NIOSH homepage
NIOSH Site Index-click B
Click on Blood Borne Pathogens
Click on Exposure to Blood: What
Healthcare Personnel Need to Know
Answer these QUESTIONS:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
Define anesthesia.
How do local anesthetics produce anesthesia?
What are the basic classes of local anesthetics?
List 3 common amides.
What is the easy way to remember if a drug is an amide or an ester?
What is the physiologic pH of human tissue?
What is considered normal blood pressure?
What blood borne pathogens are healthcare workers at risk for?
How should needles be disposed?
If a needle stick occurs what is the first thing the health care worker should do?
Why is reporting the exposure essential?
What is the average risk of HIV after a needle stick exposure to HIV infected blood?
Is there a vaccine against Hepatitis C?
Explain postexposure prophylaxis.
What specific drugs are recommended for post exposure treatment for HIV if the patient’s
status is unknown?
How soon after exposure to a blood borne pathogen should treatment start? HBV? HIV?
What are the side effects associated with the antiviral drugs associated with HIV?
Can pregnant healthcare workers take the drugs recommended for post exposure?
10
DNTH-317
Learning Activity#2
Reading Assignment: Malamed, Chapter 1, Wilkins; pp. 583-586.
Answer these questions:
1.
Define local anesthesia.
2.
Assess the significance of the presence of notes of Ranvier to salutatory nerve conduction.
How does this effect anesthetic coverage of the nerve?
3.
Describe the mode and site of action of local anesthetics.
4.
Discuss the kinetics of local anesthesia, onset and duration of action.
11
DNTH-317
Learning Activity#3
Reading Assignment: Malamed, Chapter 12
Answer these questions:
1.
Which nerve contains the Ophthalmic, Maxillary and Mandibular Divisions?
2.
On pg. 172 (Malamed, Handbook of Local Anesthesia), locate the trigeminal nerve.
Following the mandibular nerve through the foramen ovale. Now, follow the lingual nerve
as it runs anterior and medial to the inferior alveolar nerve.
3.
On pg. 172, follow the inferior alveolar nerve as it enters the Mandibular canal. Turn to pg.
183 and observe the inferior alveolar nerve as it passes through the mandibular canal. When
the inferior alveolar nerve exits the mental foramen, it separates into the incisive nerve and
the mental nerve.
4.
5.
a.
What does the incisive nerve innervate?
b.
What does the mental nerve innervate?
On pg. 172, locate the maxillary nerve as it passes through the foramen rotundum. Turn to
pg. 177 and observe the path of the maxillary nerve as it branches into the posterior superior
alveolar nerve, the infraorbital nerve, the greater palatine nerve and the nasopalatine nerve.
a.
What does the posterior superior alveolar nerve innervate?
b.
What does the greater palatine nerve innervate?
c.
What does the nasopalatine nerve innervate?
On pg. 180, locate the infraorbital nerve. Follow it as it branches into the middle superior
alveolar branch and the anterior superior alveolar branch.
a.
What does the middle superior alveolar branch innervate?
b.
What does the anterior superior alveolar nerve innervate?
12
DNTH-317
Learning Activity#4
Armamentarium
Reading Assignments: Malamed, Chapter 5-9
Answer these questions:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
List advantages and disadvantages of reusable metal syringes.
Describe why it is important to be able to aspirate with syringes used to administer local
anesthetics in a dental setting.
Describe how the Astra self-aspirating syringe works, and relate the aspirating pressure to
drawback of an engaged plunger.
List the parts of the Astra self-aspirating syringe.
List the parts of a disposable needle.
Discuss the standard needle gauges and lengths used in dentistry.
Discuss the proper care and handling of cartridges and presterililzed, disposable needles.
List the parts of a dental cartridge and the functions of each.
List the 3 basic local anesthetic armamentarium (pg. 123)?
What is an added to prepare for an emergency?
What is added to these to provide topical anesthesia?
Which end of the cartridge is inserted first? Where is it placed?
What recapping technique is recommended?
13
DNTH-317
Learning Activity#5
Reading Assignment: Malamed, Chapters 10 & 11, Darby, pp. 702-705, Tables 34-8, 9 & 10
Answer these questions:
1.
Which steps in the injection technique will ensure the patient’s comfort and safety?
2.
Which medical contraindications, which influence administration of local anesthetics?
3.
List local and systemic complications, which can arise due to local anesthetic
administration.
4.
What is the proper physiologic position for the patient and operator for all injection
techniques?
5.
List the steps in the injection procedure using correct aseptic techniques.
6.
What patient responses should the clinician observe before, during and after injection
technique?
7.
What information is recorded in the patient’s chart relating to performance of any injection
technique?
8.
List at least 3 reasons why a patient should not be given an anesthetic injection. (relevant to
their medical history)
9.
What is the recommended cardiac dose of epinephrine?
10.
Explain what is meant by using a “cocktail” approach for local anesthesia?
11.
What would be the best anesthetic solution to use on a woman who is breastfeeding due to
its half life? When will this drug be removed from breast milk?
Online Assignment:
Blood pressure guidelines (www.americanheart.org)
1.
Disease and conditions
2.
About High Blood Pressure
Answer these questions:
1.
2.
Define hypertension
How is blood pressure measured?
14
DNTH-317
Learning Activity #6
Reading Assignment: Malamed, Chapters 2 and 4.
Answer these questions:
Discuss the pharmacologic actions of local anesthetics.
1.
Describe the alteration of the function of cells due to the presence of local anesthesia.
2.
Assess the actions of local anesthetics other than their action on the peripheral nervous
system.
3.
What is the difference between the actions of ester and amide local anesthetics due to their
pharmacologic differences?
4.
Discuss the distribution, absorption, metabolism and excretion of local anesthetics.
5.
What potential for drug interactions can occur in individuals in clinical applications of local
anesthetics?
Evaluate criteria for selection of local anesthetics.
1.
Which variables influence the depth and duration of the action of a drug.
2.
Determine the influence on drug action as a result of individual patient’s responses to drug
dosage.
3.
What is the calculation for maximum safe dosages of specific anesthetic agents expressed in
dose per unit of body weight.
4.
List agents classification, potency, metabolism, excretion, vasodilating properties, pKa,
onset of action and concentration for Lidocaine, Carbocaine and Septocaine.
5.
Which medical conditions contraindicate specific local anesthetic agents.
15
DNTH-317
Learning Activity #7
Reading Assignment: Malamed, Chapter 3.
Answer these questions:
1.
Why is a vasoconstrictor added to anesthetic solution? Provide 2 reasons.
2.
What synthetic vasoconstrictor is contraindicated with tri-cyclic antidepressants?
3.
List two vasoconstrictors.
4.
Describe the mode of action of vasoconstrictors.
5.
List the concentrations of vasoconstrictors used in clinical settings.
6.
List systemic actions, termination and elimination the pharmacology of specific
vasoconstrictor agents.
7.
Select the appropriate vasoconstrictor for use with a local anesthetic based on duration of
procedure.
8.
Describe the four major functions of vasoconstrictors relative to their use in local anesthesia.
16
DNTH-317
Learning Activity #8
Reading Assignment: Malamed, Chapter 17
Answer the following questions:
Local complications:
Identify the cause, problem, prevention and management of:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
Broken needle
Pain on injection
Burning on injection
Persistent anesthesia; paresthesia
Trismus
Hematoma
Infection
Edema
Sloughing of tissue (necrosis)
Self-trauma
Facial (VII) nerve paralysis
Systemic Complications
1.
2.
3.
4.
5.
6.
7.
8.
Describe predisposing factors that can lead to systemic toxicity of local anesthetics.
List three precautionary steps that can minimize the risk of systemic toxicity of local
anesthetics.
Describe the clinical manifestations of local anesthetic overdose.
Outline management of a patient experiencing a local anesthetic overdose. (Mild, Severe,
Rapid or Slow onset)
Recognize clinical manifestations of vasoconstrictor overdose.
Outline 5 steps in managing overdose of vasoconstrictor.
Describe acute allergic reaction (anaphylaxis) signs, symptoms and treatments.
Describe management of patient who notes “allergic reaction to dental anesthetic” on the
medical history questionnaire.
17
DNTH-317
Learning Activity #9
Local Anesthesia and the Law
Reading Assignment:
Chapter 19 Malamed
Please answer these questions:
1.
2.
3.
4.
5.
6.
7.
8.
Recognize several sources of our laws.
Describe the unique characteristics of the state dental practice act.
Define or describe:
a.
Dentist/Patient relationship
b.
Obligations of treatment
c.
Consent
d.
Malpractice-elements of malpractice
e.
Standard of Care
f.
Res ipsa loquitor
g.
Vicarious and Primary Liability
List five practice “pitfalls”.
Recognize importance of office records-three entries regarding drug administration.
Describe what malpractice insurance does.
Describe what to do if sued.
List nine practices that will minimize lawsuits.
Anesthesia Relative to the Pedodontic Patient
Reading Assignment: Malamed, p. 271-275
Please answer the following questions:
1.
2.
3.
Discuss local anesthesia overdose specific to the child patient.
Describe complications of local anesthetics relative to the pedodontic patient.
Discuss maxillary and mandibular anesthesia technique and modifications necessary when
administering anesthesia to the child patient.
The Periodontal Ligament Injection
Reading Assignment: Malamed, p. 255-260
Please answer the following questions:
1.
2.
Discuss indications and contraindications of the PDL technique as well as advantages and
disadvantages.
Describe the mechanism by which anesthesia is achieved using the PDL technique.
18
3.
4.
5.
Discuss the technique of PDL injection.
List precautions to take when administering local anesthesia via the PDL route.
List causes of failure of PDL injections and possible complications.
19
DNTH-317
Learning Activity #10
Nitrous Oxide
Reading Assignment: Please read the following Chapters in Sedation: A Guide to Patient
Management.
1.
2.
3.
4.
5.
6.
7.
8.
Introduction to sedation
Spectrum of pain and anxiety control
Physical and psychological evaluation – only pp. 48-54
Monitoring during sedation thru p. 71
Pharmacosedation: rationale
Techniques of administration
Complications
Practical considerations
No questions assigned.
20