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Local Anesthesia For Dental Professionals

2nd Edition By Bassett, DiMarco &


Naughton – Test Bank
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Local Anesthesia For Dental Professionals 2nd Edition By Bassett, DiMarco & Naughton –
Test Bank

Sample Questions

Chapter 6

Vasoconstrictors in Dentistry

Match the following


1. A) Adrenaline
2. B) Mimics sympathetic mediators
3. C) Smooth muscle relaxation
4. D) Vasoconstrictor not used in dentistry
5. E) Tissues or cellular receptors that respond to adrenaline
6. F) Synthetic catecholamine
7. G) Cardiac stimulation
8. H) Adrenal gland neurotransmitters
9. I) Epinephrine and norepinephrine
10. J) Smooth muscle contraction

1) Adrenergic

Objective: 1

2) Alpha receptor

Objective: 1

3) Beta1 receptor

Objective: 1

4) Beta2 receptor

Objective: 1

5) Catecholamines

Objective: 1

6) Epinephrine

Objective: 1
7) Levonordefrin

Objective: 1

8) Norepinephrine

Objective: 1

9) Sympathomimetic

Objective: 1

10) Vasopressors

Objective: 1

Answers: 1) E 2) J 3) G 4) C 5) H 6) A 7) F 8) D 9) B 10) I

True or false

1) Epinephrine, levonordefrin, and phenylephrine are catecholamines.

1. A) True
2. B) False

Answer: B

Explanation: B) Epinephrine and levonordefrin are catecholamines. Phenylephrine is a


noncatecholamine.

Objective: 2
2) All vasoconstrictors in dentistry stimulate adrenergic receptors.

1. A) True
2. B) False

Answer: A

Objective: 2

3) Epinephrine and norepinephrine are indirect-acting sympathomimetic drugs.

1. A) True
2. B) False

Answer: B

Explanation: B) Both epinephrine and norepinephrine are direct-acting vasopressors.

Objective: 2

4) Epinephrine provides almost equal alpha and beta effects; however, beta effects initially
predominate to vasoconstrict vessels.

1. A) True
2. B) False

Answer: B

Explanation: B) Epinephrine provides almost equal alpha and beta effects; however, alpha
effects initially predominate to vasoconstrict vessels.

Objective: 2

5) All vasopressors stimulate adrenergic receptors.

1. A) True
2. B) False
Answer: A

Objective: 2

6) Vasoconstrictors speed the absorption of local anesthetic drugs.

1. A) True
2. B) False

Answer: B

Explanation: B) Vasoconstrictors slow the absorption of local anesthetic drugs.

Objective: 3

7) Signs and symptoms of epinephrine overdose include confusion and drowsiness, and are short
lived due to the efficiency of epinephrine metabolism.

1. A) True
2. B) False

Answer: B

Explanation: B) Signs and symptoms of epinephrine overdose include nausea, restlessness, a


racing heart, severe headaches, palpitations, tremors, and shakiness. Confusion and drowsiness
may be related to an overdose of the local anesthetic drug. Reactions to epinephrine overdose are
typically short due to the efficiency of epinephrine metabolism.

Objective: 4

8) Vasoconstrictors have been associated with more drug interactions than any other drugs in
dentistry.

1. A) True
2. B) False

Answer: A

Objective: 4
9) Most adverse effects with the use of vasoconstrictors are short lived and easily managed.

1. A) True
2. B) False

Answer: A

Objective: 4

10) High blood pressure is always a contraindication to the use of vasoconstrictors in dentistry.

1. A) True
2. B) False

Answer: B

Explanation: B) Avoiding vasoconstrictors based on their impact on blood pressure alone may be
misguided. Use of a local anesthetic drug without a vasoconstrictor may not provide profound or
durable anesthesia. The lack of profound anesthesia can result in unmanageable pain, which, in
turn, can lead to a spike in blood pressure due to the release of endogenous epinephrine in
response to the pain. This endogenous release may be greater than administered doses of
epinephrine.

Objective: 4

11) Epinephrine may be contraindicated for patients with a previous history of stroke, radiation
therapy, or brittle diabetes.

1. A) True
2. B) False

Answer: A

Objective: 4

12) Levonordefrin is one-tenth as potent as epinephrine.

1. A) True
2. B) False
Answer: B

Explanation: B) Levonordefrin is approximately one-sixth as potent as epinephrine.

Objective: 5

13) Cardiac stimulation from levonordefrin is less compared to epinephrine.

1. A) True
2. B) False

Answer: A

Objective: 5

14) Levonordefrin is a stronger vasoconstrictor compared to epinephrine because its primary


action is 75% alpha.

1. A) True
2. B) False

Answer: B

Explanation: B) Levonordefrin is a weaker vasoconstrictor compared to epinephrine. Although


its primary action is 75% alpha, it has only one-sixth the potency of epinephrine.

Objective: 5

15) Levonordefrin is less potent than epinephrine therefore it is formulated as 1:20,000.

1. A) True
2. B) False

Answer: A

Explanation: A) Levonordefrin is less potent than epinephrine therefore it is formulated as


1:20,000.

Objective: 5
Fill in the blank

1) The two vasopressors routinely used in dental local anesthetic drugs in North America are
________ and ________.

Answer: epinephrine, levonordefrin.

Objective: 2

2) Epinephrine is an example of a ________ sympathomimetic drug.

Answer: direct-acting

Objective: 2

3) ________ receptors are responsible for smooth muscle contraction in peripheral arteries and
veins.

Answer: Alpha1

Objective: 2

4) ________ receptors are responsible for cardiac stimulation.

Answer: Beta1

Objective: 2

5) ________ receptors are responsible for smooth muscle relaxation such as bronchodilation and
vasodilatation.

Answer: Beta2

Objective: 2
6) Two receptors contribute to the potential for cardiac dysrhythmias. They are ________ and
________.

Answer: beta1, beta2

Objective: 2

7) When vasoconstrictors are used, care should be taken to avoid ________ or injection into
vessels.

Answer: intravascular injection

Objective: 2

8) The maximum dose of epinephrine for a healthy adult is ________ per appointment.

Answer: 0.2 mg

Objective: 4

9) The maximum dose of epinephrine for a patient with cardiovascular compromise is ________
per appointment.

Answer: 0.04 mg

Objective: 4

10) Norepinephrine has a greater tendency to induce tissue necrosis compared with epinephrine
and levonordefrin, especially on the ________.

Answer: palate

Objective: 5

Multiple choice
1) Which of the following best explains why vasoconstrictors are effective in increasing
durations for local anesthesia?

1. Primary action on alpha receptors causes contraction of smooth muscles in blood vessels
2. Primary action on alpha and beta receptors causes contraction of smooth muscles in blood
vessels
3. Primary action of beta receptors causes initial contraction of smooth muscles in blood vessels
followed by vasodilation of blood vessels
4. Primary action on alpha receptors causes initial vasodilation of the smooth muscle
5. Answer: A

Objective: 2

2) Which formulation of local anesthetic drug with levonordefrin is available in the United States
today?

1. A) 2% lidocaine; 1:20,000 levonordefrin


2. B) 4% prilocaine; 1:20,000 levonordefrin
3. C) 2% mepivacaine; 1:20,000 levonordefrin
4. D) 3% mepivacaine; 1:20,000 levonordefrin

Answer: C

Objective: 2

3) Which statement correctly describes the adrenergic actions of levonordefrin?

1. A) 50% alpha, 50% beta


2. B) 75% alpha, 25% beta
3. C) 25% beta, 75% alpha
4. D) 90% alpha, 10% beta

Answer: B

Objective: 2

4) Epinephrine is metabolized by:

1. A) COMT and MOA


2. B) hepatic enzymes
3. C) renal isoenzymes
4. D) COMT only
Answer: A

Objective: 2

5) Levonordefrin is biotransformed by:

1. A) COMT and MOA


2. B) hepatic enzymes
3. C) renal 450 isoenzymes
4. D) COMT primarily

Answer: D

Objective: 2

6) A one-hour root planing appointment is planned for a patient with significant cardiovascular
compromise. Which of the following drugs would be safest and still have adequate duration?

1. A) 3% mepivacaine plain
2. B) 4% prilocaine, 1:200,000 epinephrine
3. C) 2% lidocaine, 1:50,000 epinephrine
4. D) 2% mepivacaine, 1:20,000 levonordefrin

Answer: B

Objective: 3

7) Which of the following is not an indication for the use of a vasoconstrictor?

1. A) Reducing the risk of toxicity of local anesthetic drugs


2. B) Prolonging the duration of local anesthetic drugs
3. C) Providing hemostasis
4. D) Providing vasodilatation following treatment

Answer: D

Objective: 4

8) Which of the following vasoconstrictors is the most useful in providing hemostasis?

1. A) Levonordefrin
2. B) Felypressin
3. C) Epinephrine
4. D) Phenylephrine

Answer: C

Objective: 4

9) What is the maximum dose of epinephrine per appointment for a healthy adult?

1. A) 1.8 mg
2. B) 0.2 mg
3. C) 0.4 mg
4. D) 4.0 mg

Answer: B

Objective: 4

10) What is the maximum dose of epinephrine a patient with significant cardiovascular disease
should receive in an appointment?

1. A) 1.8 mg
2. B) 0.2 mg
3. C) 0.04 mg
4. D) 0.004 mg

Answer: C

Objective: 4

11) Which of the following drugs would be the safest for a patient with cardiovascular disease?

1. A) 4% articaine, 1:200,000 epinephrine


2. B) 2% mepivacaine,1:20,000 levonordefrin
3. C) 2% lidocaine, 1:50,000 epinephrine
4. D) 4% prilocaine plain

Answer: D

Objective: 4
12) Which of the following medical conditions does not require precautions when using
vasoconstrictors?

1. A) Liver disease
2. B) Diabetes with significant cardiovascular disease
3. C) Radiation therapy of the jaws
4. D) Cerebrovascular accident/stroke

Answer: A

Objective: 4

13) Which of the following is not a sign or symptom of an epinephrine overdose reaction?

1. A) Nausea
2. B) Heart racing
3. C) Bronchospasm
4. D) Weakness

Answer: C

Objective: 4

14) Which vasoconstrictor should be considered for a patient with diabetes and poorly-controlled
blood sugar levels when hemostasis is not needed?

1. A) Epinephrine 1:50,000
2. B) Epinephrine 1:100,000
3. C) Levonordefrin 1:20,000
4. D) Felypressin

Answer: C

Objective: 4

15) A crown preparation for tooth #19 is planned for a patient who takes a tricyclic
antidepressant. Which of the following drugs represents the best choice for this procedure?

1. A) 4% prilocaine, 1:200:000 epinephrine


2. B) 4% articaine, 1:100,000 epinephrine
3. C) 2% mepivacaine, 1:20,000 levonordefrin
4. D) 0.5% bupivacaine, 1:200,000 epinephrine

Answer: A

Objective: 4

16) Which one of the following patients has a relative contraindication for vasoconstrictor?

1. Heart attack 2 years ago with no current complications


2. Controlled hyperthyroid condition
3. Non-selective beta blocker medication
4. Controlled blood sugars

Answer: C

Objective: 4

17) Compare the potency of levonordefrin to the potency of epinephrine.

1. A) Levonordefrin is one fourth as potent


2. B) Levonordefrin is one sixth as potent
3. C) Levonordefrin is twice as potent
4. D) Levonordefrin is six times as potent

Answer: B

Objective: 5

Short answer/essay

1) A patient calls approximately six hours after a tooth extraction to report an increase in
bleeding. What is a likely cause of the increased bleeding?

Answer: Epinephrine provides nearly equal α and β effects; however, not at the same time. Initial
α vasoconstriction of peripheral vasculature allows time for the anesthetic drugs to bind to
receptor sites. Later, β2 vasodilatation predominates. This has been observed before and after
surgery when epinephrine has been administered. Initially, the α effect enhances profound,
durable anesthesia and reduces hemorrhaging at surgical sites. Postoperatively, the dominant β2
effects can result in increased bleeding approximately six hours after surgery.
Objective: 2

2) How do vasoconstrictors enhance the effects of local anesthetic drugs?

Answer: Vasoconstrictors enhance local anesthetic drugs by constricting local vessels, slowing
systemic absorption, and prolonging the local actions of the drugs. These combine to increase the
profoundness and durations of the drugs.

Objective: 3

3) Explain why the avoidance of vasoconstrictor may cause increase risk for a patient with high
blood pressure?

Answer: The lack of profound anesthesia can result in unmanageable pain that in turn can lead to
unpredictable spikes in blood pressure due to the endogenous release of epinephrine. The impact
of the potential endogenous release is far less predictable due to the difficulty in anticipating
quantities that might be released. This release can compound the adverse adrenergic effects of
exogenous (injected) epinephrine.

Objective: 4

4) Explain why the lack of profound anesthesia can result in a spike in blood pressure?

Answer: The lack of profound anesthesia can result in unmanageable pain which, in turn, can
lead to a spike in blood pressure due to the release of endogenous epinephrine in response to the
pain. This endogenous release may be much greater than typical doses of administered
epinephrine (exogenous).

Objective: 3

Chapter 7

Dose Calculations for Local Anesthetic Solutions

Match the following


1. A) MRD 90 mg
2. B) MRD 0.04 mg
3. C) 3.2 mg/lb
4. D) 3.6 mg/lb
5. E) MRD 500 mg
6. F) 54 mg/cartridge
7. G) Based on child’s weight
8. H) 1.8 ml
9. I) MRD 1.0 mg
10. J) Based on child’s age

1) Articaine

Objective: 1, 3, 5

2) Bupivacaine

Objective: 1, 3, 5

3) Cardiac dose

Objective: 1, 3, 5

4) Cartridge volume

Objective: 1, 3, 5

5) Clark’s rule

Objective: 1, 3, 5

6) Levonordefrin
Objective: 1, 3, 5

7) Lidocaine

Objective: 1, 3, 5

8) Mepivacaine

Objective: 1, 3, 5

9) Prilocaine

Objective: 1, 3, 5

10) Young’s rule

Objective: 1, 3, 5

Answers: 1) C 2) A 3) B 4) H 5) G 6) I 7) E 8) F 9) D 10) J

True or false

1) The maximum recommended dose for each solution is dependent on the drug that limits the
total volumes that may be delivered.

1. A) True
2. B) False

Answer: A

Objective: 2
2) In solutions containing both a local anesthetic and a vasoconstrictor drug, the maximum
recommended dose of the local anesthetic is usually the limiting drug.

1. A) True
2. B) False

Answer: B

Objective: 3

3) The maximum safe dose of 1:50,000 epinephrine per appointment for a healthy adult is 0.2 mg
or 5.5 cartridges.

1. A) True
2. B) False

Answer: A

Objective: 3

4) At a concentration of 4%, the amount of drug in a 1.8 ml cartridge is 7.2 mg.

1. A) True
2. B) False

Answer: B

Explanation: B) At a concentration of 4%, the amount of drug in a 1.8 ml cartridge is 72 mg 4%


solution = 40 mg/ml x 1.8 = 72 mg/cartridge

Objective: 4

5) At a concentration of 0.5%, the amount of drug in a 1.8 ml cartridge is 9 mg.

1. A) True
2. B) False

Answer: A

Objective: 4
6) To calculate the milligrams of drug delivered, multiply the total number of cartridges by the
total milligrams of drug in each cartridge.

1. A) True
2. B) False

Answer: A

Objective: 4

7) When two different drugs are injected, the total of the MRDs for both drugs is the maximum
number of milligrams of drugs the patient may receive.

1. A) True
2. B) False

Answer: B

Explanation: B) When multiple drugs are administered with different MRDs, the lowest MRD
(most toxic drug) is applied when calculating total drug doses.

Objective: 5

8) Calculations of maximum safe doses for vasoconstrictors are determined by mg/lb or mg/kg.

1. A) True
2. B) False

Answer: B

Explanation: B) Calculations of vasoconstrictor doses are different compared to those used to


determine local anesthetic drug doses. The main differences are that vasoconstrictors are
expressed as dilution ratios rather than concentration percentages and maximum doses of
vasoconstrictors are not weight dependent.

Objective: 5

9) The maximum safe dose of 1:200,000 epinephrine per appointment for a patient with ischemic
heart disease is 0.4 mg or 1.1 cartridges.
1. A) True
2. B) False

Answer: B

Explanation: B) The maximum safe dose of 1:200,000 epinephrine per appointment for a patient
with ischemic heart disease is 0.04 mg or 4 cartridges (about 4.4, rounded down for safety to 4).

Objective: 5

10) Clark’s rule for determining pediatric drug doses is based on a child’s weight divided by 150
to get the approximate fraction of the adult dose.

1. A) True
2. B) False

Answer: A

Objective: 5

Fill in the blank

1) The maximum recommended dose per appointment for bupivacaine is ________.

Answer: 90 mg

Objective: 3

2) The maximum recommended dose per appointment for lidocaine is ________.

Answer: 500 mg

Objective: 3

3) The maximum mg/lb of mepivacaine per appointment is ________.


Answer: 3.0

Objective: 3

4) The maximum mg/lb of prilocaine per appointment is ________.

Answer: 3.6

Objective: 3

5) A 10% solution contains one tenth of a milligram per milliliter or ________ mg/ml.

Answer: 100

Objective: 5

6) A 2% solution of lidocaine contains ________ mg/ml.

Answer: 20

Objective: 5

7) A 2% solution of lidocaine contains ________ mg/cartridge.

Answer: 36

Objective: 5

8) A 3% solution of mepivacaine contains ________ mg/ml.

Answer: 30

Objective: 5

9) A 3% solution of mepivacaine contains ________ mg/cartridge.


Answer: 54

Objective: 5

10) Ralph weighs 175 lb. He has received 72 mg of 2% lidocaine. Ralph can receive a maximum
of ________ mg additional lidocaine.

Answer: 428

Objective: 5

11) Susan is a healthy patient and weighs 130 lb. She has received 54 mg of 3% mepivacaine.
She could receive a maximum of _________ mg of 4% prilocaine, 1:200,000 epinephrine.

Answer: 336

Objective: 5

Multiple choice

1) The MRD for bupivacaine is:

1. A) 200 mg
2. B) 90 mg
3. C) 300 mg
4. D) 500 mg

Answer: B

Objective: 3

2) Which of the following information for MRD is not correct?

1. A) Bupivacaine = 90 mg
2. B) Lidocaine = 500 mg
3. C) Mepivacaine = 300 mg
4. D) Prilocaine = 600 mg

Answer: C

Objective: 3

3) What is the MRD of vasoconstrictor for 2% lidocaine, 1:100,000 epinephrine for a healthy
patient?

1. A) 0.02 mg
2. B) 2.0 mg
3. C) 1.0 mg
4. D) 0.2 mg

Answer: D

Objective: 3

4) What is the MRD in cartridges for 4% prilocaine, 1:200,000 epinephrine for a healthy 150
pound patient?

1. A) 5
2. B) 6
3. C) 8
4. D) 11

Answer: C

Objective: 3

5) How many milligrams of epinephrine 1:50,000 are available in one cartridge?

1. A) 0.018 mg
2. B) 0.050 mg
3. C) 0.036 mg
4. D) 0.2 mg

Answer: C

Objective: 3
6) How many milligrams of epinephrine 1:200,000 are available in two cartridges?

1. A) 0.018
2. B) 0.18
3. C) 0.036
4. D) 0.016

Answer: A

Objective: 3

7) Which of the following pieces of information is not usually required in order to calculate safe
doses for local anesthetics and vasoconstrictors?

1. A) Patient factors such as height, weight, and age


2. B) Standard cartridge volume and dilution percentages
3. C) Maximum recommended dose and patient weight
4. D) Concentration of drug and dilution percentages

Answer: A

Objective: 4

8) A 150-pound patient has received two cartridges of 2% lidocaine, 1:100,000 epinephrine.


How many additional cartridges with the same drugs can be administered before reaching the
MRD?

1. A) 5
2. B) 6
3. C) 9
4. D) 11

Answer: C

Objective: 5

9) A 120-pound patient has received three cartridges of 4% prilocaine, 1:200:000 epinephrine.


How many more milligrams of prilocaine can this patient receive before reaching the MRD?

1. A) 72 mg
2. B) 216 mg
3. C) 432 mg
4. D) 600 mg

Answer: B

Objective: 5

10) A healthy 160-pound patient has received three cartridges of 2% lidocaine, 1:50,000
epinephrine during an oral surgical procedure. How many more cartridges with the same drug
could this patient receive before reaching the MRD?

1. A) 2
2. B) 5
3. C) 8
4. D) 10

Answer: A

Objective: 5

11) A patient has received four cartridges of 4% articaine, 1:200,000 epinephrine. How many
milligrams of vasoconstrictor has the patient received?

1. A) 0.018
2. B) 0.036
3. C) 0.072
4. D) 0.36

Answer: B

Objective: 5

12) A 180-pound patient has received three cartridges of 2% lidocaine, 1:100,000 epinephrine.
How many additional milligrams of 4% articaine, 1:200,000 epinephrine can be administered
before reaching the MRD?

1. A) 72 mg
2. B) 192 mg
3. C) 228 mg
4. D) 392 mg

Answer: D
Objective: 5

13) A 120-pound patient has received 2 cartridges of 2% mepivacaine, 1:20,000 and does not
remain adequately numb during the procedure. How many additional cartridges of 2% lidocaine,
1:100,000 epinephrine may the patient receive before reaching the MRD?

1. A) 6
2. B) 9
3. C) 11
4. D) 13

Answer: B

Objective: 5

14) What is the MRD of levonordefrin for a 210 pound male patient with ischemic heart disease?

1. A) 0.02 mg
2. B) 0.2 mg
3. C) 0.04 mg
4. D) 0.4 mg

Answer: B

Objective: 5

15) A patient with cardiovascular disease has received one cartridge of 2% lidocaine, 1:100:000
epinephrine. How many milligrams of vasoconstrictor has this patient received? How many
additional milligrams of vasoconstrictor can the patient receive before reaching MRD?

1. A) 0.018 mg received; 0.022 mg additional


2. B) 0.009 mg received; 0.391 mg additional
3. C) 0.36 mg received; 0.4 mg additional
4. D) 0.18 mg received; 0.22 mg additional

Answer: A

Objective: 5
16) A patient with cardiovascular disease has received two cartridges of 4% articaine, 1:200:000
epinephrine. How many milligrams of vasoconstrictor has this patient received? How many
additional cartridges of the same drug solution can the patient receive?

1. A) 0.009 mg received; two additional cartridges


2. B) 0.018 mg received; two additional cartridges
3. C) 0.18 mg received; no additional cartridges
4. D) 0.036 mg received; no additional cartridges

Answer: B

Objective: 5

17) Using Clark’s rule, calculate the milligrams of 2% lidocaine an 8-year old, 60 pound child
can receive before reaching MRD.

1. A) 60 mg
2. B) 120 mg
3. C) 200 mg
4. D) 300 mg

Answer: C

Objective: 5

18) Using Clark’s rule, a 12-year old, 90 pound child has received two cartridges of 2%
lidocaine. How many more cartridges of lidocaine can this child receive before reaching MRD?

1. A) 3
2. B) 6
3. C) 7
4. D) 8

Answer: B

Objective: 5

19) Using Clark’s rule, calculate the maximum number of milligrams of 3% mepivacaine a 5-
year old, 40-pound child can receive before reaching the MRD?

1. A) 40 mg
2. B) 80 mg
3. C) 106 mg
4. D) 117 mg

Answer: C

Objective: 5

20) Using Young’s rule, calculate the mg of 2% lidocaine a 10-year old, 60-pound child can
receive before reaching the MRD?

1. A) 125 mg
2. B) 136 mg
3. C) 200 mg
4. D) 227 mg

Answer: D

Objective: 5

Short answer/essay

1) What is the MRD of 4% prilocaine plain for a healthy 205 pound male patient?

Answer: The MRD for prilocaine plain is 3.6 mg/lb, with a maximum of 600 mg per
appointment. Based on 3.6 mg/lb a 205 lb patient the MRD would be 656 mg, however the 600
mg per appointment should not be exceeded.

Objective: 3

2) What factors are needed to calculate the local anesthetic drug dose delivered for a given
patient?

Answer: The following factors are needed: number of milligrams of drug delivered, number of
cartridges delivered, MRD for the drug delivered, and weight of the patient.

Objective: 4
3) A 140-pound patient received 144 mg of 2% lidocaine plain. How many more milligrams of
the same drug can the patient receive without exceeding the MRD? Provide mathematical
formulas required to calculate the correct answer.

Answer: The MRD for 2% lidocaine plain is 3.2 mg/lb with a maximum of 500 mg per
appointment. This patient can receive a total of 3.2 mg/lb which equals 448 mg maximum per
appointment. (3.2 x 140 = 448). Next, subtract mg of drug received from MRD (448 – 144 = 334
mg). The patient can receive an additional 334 mg of 2% lidocaine plain.

Objective: 4

4) A 180-pound patient received 108 mg of 3% mepivicaine. How many cartridges were used?
Provide mathematical formulas required to calculate the correct answer.

Answer: A 3% solution ml/cartridge equals 30 mg/ml. Compute the mg of 3% mepivicaine in


one cartridge by multiplying 30 ml/cartridge by ml in one cartridge (30 x 1.8 = 54 mg). Next
divide 108 mg received by mg/ml in each cartridge of 3% mepivicaine (108 ÷ 54 = 2). A total of
two cartridges of 3% mepivicaine were received.

Objective: 4

5) A 120-pound patient received 108 mg of 2% lidocaine. How many mg of 4% articaine can this
patient receive? Provide mathematical formulas to calculate the correct answer.

Answer: The MRD for 2% lidocaine is 3.2 mg/lb with a maximum of 500 mg per appointment.
The MRD for 4% articaine is 3.2 mg/lb with no determined maximum per appointment. When
considering the MRD for more than one drug, the lowest MRD should be used in calculating the
second drug’s MRD. In this case the MRD is the same for both drugs therefore, 284 mg is the
MRD. (3.2 x 120 = 284). Next subtract mg of 2% lidocaine received from MRD (284 – 108 =
176). The patient can receive 176 mg of 4% articaine.

Objective: 5

6) Complete the missing information in the table below.


Maximum
Recommended
Dose per
Appointment

Based on Local
Anesthetic Drug
ONLY*

Drug mg/lb mg/kg mg per appt.*

Articaine 3.2 7.0 –

Bupivacaine 0.9** 2.0** ____mg

Lidocaine _____ 7.0 500 mg

Mepivacaine 3.0 6.6 ____mg

Prilocaine _____ 8.0 600 mg

*Note: “per appt.” values represent dosages for healthy individuals, Values must be adjusted for
children, elderly, and medically compromised individuals.

** Canadian recommendations. No U.S. recommendations are available

Source: FDA, ADA/PDR, 5th ed., 2009; Malamed, 6th ed. 2013.

Answer: See bold numbers in table below


Maximum
Recommended
Dose per
Appointment

Based on Local
Anesthetic Drug
ONLY*

Drug mg/lb mg/kg mg per appt.*

Articaine 3.2 7.0 –

Bupivacaine 0.9** 2.0** 90 mg

Lidocaine 3.2 7.0 500 mg

Mepivacaine 3.0 6.6 400 mg

Prilocaine 3.6 8.0 600 mg

*Note: “per appt.” values represent dosages for healthy individuals, Values must be adjusted for
children, elderly, and medically compromised individuals.

** Canadian recommendations. No U.S. recommendations are available

Source: FDA, ADA/PDR, 5th ed., 2009; Malamed, 6th ed. 2013

Objective: 3

AU: Explanation needed here?

Chapter 11

Fundamentals for Administration of Local Anesthetic Agents

Match the following

1. A) Bevel contacts vessel wall


2. B) Piercing point
3. C) Near nerve endings
4. D) Target
5. E) Delivery rate
6. F) Supraperiosteal
7. G) Near nerve trunk
8. H) Passageway
9. I) PREP
10. J) Blood in cartridge?

1) Aspiration test

Objective: 1

2) Deposition site

Objective: 1

3) False-negative aspiration

Objective: 1

4) Field block injection

Objective: 1

5) Infiltration injection

Objective: 1

6) Needle pathway

Objective: 1
7) Nerve block injection

Objective: 1

8) Penetration site

Objective: 1

9) Speed and volume

Objective: 1

10) Supportive communication

Objective: 1

Answers: 1) J 2) D 3) A 4) F 5) C 6) H 7) G 8) B 9) E 10) I

True or false

1) Informed consent should be obtained from a patient or guardian prior to administering


injections.

1. A) True
2. B) False

Answer: A

Objective: 2

2) The deposition site for a nerve block injection is at a greater distance from the penetration site
than for a field block or infiltration injection.

1. A) True
2. B) False

Answer: A

Objective: 6

3) The greater the distance from penetration to deposition site, the greater the potential for
deviation of the needle.

1. A) True
2. B) False

Answer: A

Objective: 6

4) False-negative aspirations typically occur when a clinician has failed to develop adequate
negative pressure with the thumb ring.

1. A) True
2. B) False

Answer: B

Explanation: B) False-negative aspiration occurs when a bevel is in contact with a vessel wall.
The negative pressure retracts the vessel wall into the lumen of the needle, blocking the flow of
blood through the needle into the cartridge.

Objective: 7

5) The two most important patient safety steps during an injection are locating the penetration
site and deposition sites.

1. A) True
2. B) False

Answer: B

Explanation: B) The two most important patient safety steps of an injection are slow
administration and aspiration.
Objective: 7

6) The first step of the Standard Operating Procedure for all injections is locating and preparing
armamentarium.

1. A) True
2. B) False

Answer: B

Explanation: B) Thorough patient evaluation is the first step in the Standard Operating
Procedures for all injections. After consideration of all precautions, contraindications, and
necessary modifications, appropriate injection techniques and anesthetic drugs are selected.

Objective: 7

7) A patient’s head should be in a position higher than the heart for comfort during injections.

1. A) True
2. B) False

Answer: B

Explanation: B) Placing patients in supine positions during injections provides physiological


support during stress and is recommended for the management of medical emergencies.

Objective: 7

8) Most topical anesthetic agents will reach peak effectiveness in about 5 minutes.

1. A) True
2. B) False

Answer: B

Explanation: B) Most topical anesthetic agents will reach peak effectiveness in about 1 minute.

Objective: 7
9) Gently pulling the mucosa taut will ease penetration of the needle and establish a point of
stability for the syringe.

1. A) True
2. B) False

Answer: A

Objective: 7

10) Regardless of the amount of blood in a cartridge following positive aspiration, the best
practice is to withdraw the needle and reinject.

1. A) True
2. B) False

Answer: B

Explanation: B) If an aspiration test results in a small trickle of blood or “wormlike” thread into
the cartridge and does not obstruct clear vision of a subsequent aspiration, the needle can be
repositioned slightly and aspiration can be repeated.

Objective: 7

11) If there are repeated positive aspirations at the same injection site, rescheduling should be
considered.

1. A) True
2. B) False

Answer: A

Objective: 7

12) The safest rate of deposition of local anesthetics allows for the delivery of approximately1.0
mL of solution per minute.

1. A) True
2. B) False
Answer: A

Objective: 7

13) The most stable position when using a syringe is palm up.

1. A) True
2. B) False

Answer: A

Objective: 7

14) Resting an elbow on a patient’s shoulders or chest during injection creates good stabilization
and is a safe ergonomic practice.

1. A) True
2. B) False

Answer: B

Explanation: B) Establishing syringe stability on a patient’s shoulders or chest can create


stability for the syringe but increases the risk of trauma should the patient move unexpectedly.

Objective: 8

15) A clinician should not stand during the administration of local anesthesia injections.

1. A) True
2. B) False

Answer: B

Explanation: B) Standing up during the administration of some local anesthetic injections can
facilitate good ergonomic balance especially when patients cannot be positioned easily.

Objective: 8

Fill in the blank


1) The ________ refers to the specific location where a needle first pierces mucosa.

Answer: penetration site

Objective: 1

2) The ________ refers to the route a needle travels as it advances to the deposition site.

Answer: needle pathway

Objective: 1

3) The ________ is defined as the anatomical location at which a drug is deposited.

Answer: deposition site

Objective: 1

4) The two most important safety steps in the delivery of local aesthetic agents are ________.

Answer: aspiration and slow administration

Objective: 3

5) ________ tests reduce the risk of inadvertent deposition of drugs into the bloodstream.

Answer: Aspiration

Objective: 3

6) A ________ aspiration can occur when a bevel is in contact with a vessel wall.

Answer: false negative

Objective: 3
7) An ________ injection deposits local anesthetics directly at or near small terminal nerve
endings.

Answer: infiltration

Objective: 3

8) Efforts to reduce stress from the beginning to the end of an injection are enhanced by
maintaining positive, ________ with the patient.

Answer: supportive communication

Objective: 4

9) The greater the distance from penetration site to deposition site, the greater the potential for
________ of the needle tip.

Answer: deflection or deviation

Objective: 5

10) A ________ injection deposits local anesthetics near larger terminal nerve branches.

Answer: field block

Objective: 6

11) A ________ injection deposits local anesthetic near major nerve trunks at a greater distance
from the area of treatment, which provides wider areas of anesthesia.

Answer: nerve block

Objective: 6
12) Drying tissue with gauze can reduce ________ of topical agents and improve their uptake
into mucosa.

Answer: dilution and spread

Objective: 7

13) Most topical anesthetic agents will reach peak effectiveness in about ________ minute(s).

Answer: 1

Objective: 7

14) The final safety step during an injection procedure is to properly ________ the needle prior
to disposal.

Answer: recap

Objective: 7

Multiple choice

1) Which of the following is not an element of informed consent in local anesthesia?

1. A) Discussing risks
2. B) Providing alternatives
3. C) Providing information in a language patients understand
4. D) Explaining the costs of procedures

Answer: D

Objective: 2

2) What are the two most important safety steps during a local anesthetic injection?

1. A) Aspiration before depositing and recapping needles


2. B) Slow administration and recapping needles
3. C) Patient evaluation and aspiration
4. D) Aspiration before depositing and administering drugs slowly

Answer: D

Objective: 3

3) Which of the following is important but is not a recommended step in the PREP strategy?

1. A) Prepare patient
2. B) Rehearse injection
3. C) Empower patient
4. D) Plan debriefing

Answer: D

Objective: 4

4) Supportive communication includes all of the following, except:

1. A) It should begin during the pre-injection period


2. B) It should involve positive comments focusing on patient behavior during injections
3. C) It lets patients know that injections will be more comfortable compared to previous injections
4. D) It includes rehearsing injections and providing ways for patients to communicate with
clinicians during injection

Answer: C

Objective: 5

5) An injection technique that deposits anesthetic solution near terminal nerve endings is called:

1. A) A periodontal ligament injection


2. B) A field block injection
3. C) An infiltration injection
4. D) A nerve block injection

Answer: C

Objective: 6
6) An injection that deposits anesthetic solution near a major nerve trunk is called:

1. A) A periodontal ligament injection


2. B) A supraperiosteal injection
3. C) A field block injection
4. D) A nerve block injection

Answer: D

Objective: 6

7) A field block injection is also called:

1. A) A superperiosteal injection
2. B) A periodontal ligament injection
3. C) A nerve block injection
4. D) An interpapillary injection

Answer: A

Objective: 6

8) Which of the following describes the penetration site?

1. A) Needle pierces mucosa


2. B) Needle pierces the muscle
3. C) Needle pierces a vessel
4. D) Anesthetic solution is deposited

Answer: A

Objective: 7

9) Which of the following describes the target site for local anesthetic solution?

1. A) Penetration site
2. B) Needle pathway
3. C) Aspiration site
4. D) Deposition site

Answer: D

Objective: 7
10) What is the first step in preparation for local anesthesia injections?

1. A) Obtain informed consent


2. B) Prepare the armamentarium
3. C) Make sure solution will flow through the needle
4. D) Assess the patient

Answer: D

Objective: 7

11) What is the primary reason it is recommended to orient needle bevels toward bone during
infiltration injections?

1. A) Needles should be angled away from bone during penetration


2. B) Trauma to periosteum is lessened if bone is inadvertently contacted
3. C) False aspirations can be prevented
4. D) Discomfort from needles is reduced

Answer: B

Objective: 7

12) Which of the following is the most appropriate documentation following local anesthesia
injections?

78. A) 03/03/2014: Review health history. BP 115/78. Two cartridges of 4% prilocaine (144 mg)
w/epi 1:100,000 (0.036 mg), benzocaine topical, Rt PMC, MMC, GP, (-) aspiration. No adverse
reactions.
79. B) Review health history. BP 120/70. Three cartridges 3% mepivacaine w/1:20,000
levonordefrin. No adverse reactions.
80. C) 05/03/2014: Review health history. Two cartridges 2% lidocaine w/epi, (-) aspiration.
81. D) 07/07/14: Review health history. BP normal. One and a half cartridges (27 mg) of 2% lido
w/1:100:00 epi, Left IA and buccal, (-) aspiration. No adverse reactions.

Answer: A

Objective: 7
13) Which of the following is the most important safety step following an injection?

1. A) Rinsing the patient’s mouth


2. B) Assessing the patient for adverse reactions
3. C) Recapping the needle with a one-handed technique
4. D) Making a complete chart entry

Answer: C

Objective: 7

14) Which statement describes the correct positioning of the long window of the syringe?

1. A) Toward the clinician to permit visibility throughout the injection


2. B) Away from the patient to block visibility throughout the injection
3. C) Toward the patient to permit assessment of the duration of the injection
4. D) Either toward or away from the clinician because both sides of the syringe have an opening

Answer: A

Objective: 7

15) Which statement best describes why retraction of tissue keeping the tissue taut is important
during injections?

1. A) The patient’s mouth is open and it improves visibility for the clinician.
2. B) It eliminates the need for stabilization of syringe and fulcrum.
3. C) It allows better identification of landmarks.
4. D) It allows for ease of needle penetration and establishes a point of stability for the syringe.

Answer: D

Objective: 7

16) What is the minimum recommended rate of injection?

1. A) 0.5 mL per minute


2. B) l.8 mL per minute
3. C) 1.0 mL per two minutes
4. D) 3.0 mL per minute
Answer: B

Objective: 7

17) Which statement describes how to avoid a false-negative aspiration?

1. A) Withdraw the syringe slightly and reaspirate to release the bevel from a vessel wall
2. B) Rotate the syringe a quarter turn then reaspirate to release the bevel from a vessel wall
3. C) Apply greater force on the thumb ring to permit blood to enter cartridge
4. D) Avoid injections in highly vascular areas

Answer: B

Objective: 7

18) Which of the following procedures represents the correct response following a positive
aspiration when a small wormlike thread enters the cartridge?

1. A) Withdraw the syringe and reinject


2. B) Reposition the syringe away from the area of the positive aspiration, and deposit solution
following a negative aspiration
3. C) Withdraw the syringe, change the cartridge, clear the needle of blood and reinject
4. D) Rotate the syringe a quarter turn, reaspirate and continue to deposit solution

Answer: B

Objective: 8

19) What is the most important goal of ergonomic positioning?

1. A) Prevention of cumulative trauma disorders


2. B) Stabilization of the syringe
3. C) Prevention of patient injury
4. D) Patient comfort and safety

Answer: A

Objective: 8

20) Which of the following is not a basic element of good ergonomic positioning?
1. A) Keep wrists at a neutral angle
2. B) Bend from the waist
3. C) Bend from the hips
4. D) Do not raise arms more than 30 degrees

Answer: B

Objective: 8

Short answer/essay

1) What elements are included in an informed consent?

Answer: Informed consents include:

1. Discussion in a language a patient can understand


2. Provide patients with opportunities to ask question
3. Explain the procedures that have been recommended and explain the need for each
4. Clarify the risks and rewards of the recommended treatment including the risks of failing to
treat
5. Provide acceptable alternatives to the recommended treatment

Objective: 2

2) Explain how an aspiration test performed?

Answer: Once the needle is advanced to the appropriate deposition site for a specific injection,
and before depositing solution, perform an aspiration test by applying gentle, brief back pressure
on the upper inside surface of the thumb ring. This action changes the pressure inside the
cartridge from positive to negative. If the needle has entered a vessel, blood will be drawn into
the cartridge, referred to as a “positive aspiration.” No drug should be deposited in the specific
location of a positive aspiration.

Objective: 7

3) Discuss management of a positive aspiration.

Answer: A positive aspiration in which blood is visible in the cartridge requires an immediate
response. If the aspiration test results in a small trickle of blood or “wormlike” thread into the
cartridge and does not obstruct clear vision of a subsequent aspiration, the needle can be
repositioned slightly and aspiration can be repeated. After a second test that is negative, the
clinician may continue with the injection and deposit the drug. If the aspiration test results in a
burst of blood, creating a “cloudy and reddened” solution in the cartridge or if the clinician, for
any reason, is concerned about the ability to see subsequent aspiration results clearly, the needle
should be withdrawn, the cartridge replaced, and the needle flushed or replaced before
reinitiating the injection.

Objective: 7

4) What is a false-negative aspiration and how can it be prevented?

Answer: Despite performing aspiration tests correctly, it is still possible to have “false-negative”
aspirations at times. This can occur when a bevel is in contact with a vessel wall. During an
aspiration test, negative pressure can retract the vessel wall into the lumen of the needle blocking
the flow of blood through the needle into the cartridge. To check for false-negative responses,
rotate the syringe slightly, and reposition the bevel away from the vessel wall. This step is
encouraged for all injections in which there is a greater risk of positive aspiration.

Objective: 7

5) What information is documented in a patient record for local anesthetic injections? Provide an
example.

Answer: The patient’s record includes:

1. Date of administration
2. Type of drug(s) administered (both topical and injectable)
3. Injection(s) administered (or area of delivery when topical alone is used)
4. Total volume of drug(s) administered
5. Result of aspiration, recorded as positive (+) or negative (-)

Sample documentation:

02/14/14 20% benzocaine topical, R-PES, MES, AES, two cartridges (3.6 mL) 2% lidocaine (72
mg) w/epi 1:100,000 (.036 mg), (-) aspiration, no complications

Objective: 7

6) Discuss the basic elements of good ergonomic position and balance.

Answer: To maintain good ergonomic position and balance:

1. Do not twist from the trunk


2. Bend from the hips
3. Keep wrists at a neutral angle
4. Do not raise arms more than 30 degrees
5. Do not extend the neck more than 30 degrees forward

Objective: 8