Pain control

Copyright 2003, Elsevier Science (USA). All rights reserved.
ABDUL VAJID M
Final year [part- 1]
PAIN CONTROLIN
OPERATIVEDENTISTRY

INTRODUCTION
• Dental treatment is often perceived
as a painful experience.
• With emphasis on prevention, minimal
intervention & modern atraumatic
treatment this is not necessarily true.
• There are several methods available
now to control pain and trauma in
operative dentistry.

METHODS TO CONTROL PAIN
1. LOCAL ANAESTHESIA
2. PREMEDICATIONS
3. INHALATION SEDATION
4. HYPNOSIS
5. ELECTRONIC DENTAL ANAESTHESIA (EDA)

LOCAL ANAESTHESIA
• Most commonly used method.
• Patients with hypersensitive dentin and who are
tensed may require LA.
• LA injections are used to deposit the anaesthetic
solution close to the specific nerve fibers.
• Most procedures in operative dentistry are
performed either under a regional nerve block or
a local infiltration anaesthesia which blocks the
pathways of painful impulses.

Patient factors
• It includes :
Systemic health
Allergy
Psychology

Continued………
• Systemic health
dentists should enquire about the health status of the patient
especially regarding CVS, CNS, liver, kidneys, thyroid etc…. to
elicit any abnormalities in these systems . Overdose of LA
agents can depress the systems.
• Allergy
when a patient gives a history of “sensitivity” or “reaction”
to LA, its use is contraindicated. Although allergic reactions
are rare, when they occur cause anaphylactic shock which
may be immediate and fatal.
• Psychology
dental patients are usually tense about receiving intraoral
injections . A confident , positive approach by the dentist can
improve patient’s -operation and comfort.

• Agents most frequently used for pain control
in dentistry.
• Criteria for use:
– Be nonirritating to the tissues in the area of the
injection.
– Produce minimal toxicity.
– Be of rapid onset.
– Provide profound anesthesia.
– Be of sufficient duration.
– Be completely reversible.
– Be sterile.
Local Anesthesia

LOCAL ANAESTHETIC AGENTS
Amide type of local anesthetics are commonly
used.
AGENTS used are
1.Lidocaine 2% + Epinephrine (1:50,000)
2.Lidocaine 2% + Epinephrine (1 :100,000)
3.Bupivacaine 0.5% +Epinephrine (1: 200,000)
A vasoconstrictor like epinephrine is added
to prolong the action
of LA to the blood.

• Local anesthesia temporarily blocks the
normal generation and conduction action of
the nerve impulses.
• Local anesthesia is obtained by injecting the
anesthetic agent near the nerve in the area
intended for dental treatment.
• Induction time is the length of time from the
injection of the anesthetic solution to
complete and effective conduction blockage.
Method of Action

• Length of time from induction until the
reversal process is complete.
• Short-acting:
– Local anesthetic agent lasts less than 30 minutes.
• Intermediate-acting:
– Local anesthetic agent lasts about 60 minutes.
• Long-acting:
– Local anesthetic agent lasts longer than 90
minutes.
Duration

• Infiltration is achieved by injecting the
solution directly into the tissue at the site of
the dental procedure.
– Most frequently used to anesthetize the maxillary
teeth.
– Used as a secondary injection to block gingival
tissues surrounding the mandibular teeth.
Types of Local Anesthesia Injections

• Block anesthesia
– The solution is injected near a major nerve, and
the entire area served by that nerve is numbed.
• Type of injection required for most mandibular
teeth.
– Eg: Inferior alveolar nerve block
• Obtained by injecting the anesthetic solution near the
branch of the inferior alveolar nerve close to the
mandibular foramen.
– Type of injection for half of the lower jaw, including the teeth,
tongue, and lip.
Types of Local Anesthesia Injections− cont’d

• Eg: Incisive nerve block
– Injection given at the site of the mental foramen.
• Used when the mandibular anterior teeth or
premolars require anesthesia.
• Intraligamentry
– Alternative infiltration anesthesia method by
which the anesthetic solution is injected directly
into the periodontal ligament and surrounding
tissues.
Types of Local Anesthesia Injections− cont’d

DISPOSIBLE NEEDLE

ANESTHETIC SYRINGE

PRECAUTIONS DURING INJECTION:
The patient should be kept in supine or semi
supine position for preventing syncope by
maintaining the blood supply & pressure to
the brain.
The solution should be deposited slowly to
minimize pain.
Injection into infected tissues be avoided as
this will spread infection.
Syringe should have an aspirating feature.
Needle should be 27 gauge needle.

ADVANTAGES OF ANESTHESIA
• Patient’s co-operation: once LA is effective,
patient becomes co-operative due to absence
of pain.
• Control of saliva: anaesthesia of all tissues in
operating site controls saliva.
• Reduced blood flow: action done by
vasoconstrictor thus controls gingival
bleeding.

Advantages cont’d………….
• Operator’s efficiency: due to the above
mentioned factors, the operator’s efficiency is
greatly enhanced.

• Nitrous oxide/oxygen (N²O/O²) is a combination of these
gases that the patient inhales to help eliminate fear and
to help the patient relax.
• History
– Dates back to 1844.
– Dr. Horace Wells first used it on his patients.
• Effects
– Non addictive.
– Easy onset, minimal side effects, and rapid recovery.
– Dulls the perception of pain.
Inhalation Sedation

• Pregnancy: First trimester
• Nasal obstruction: Problems inhaling
through the nose
• Emphysema
• Emotional stability: Altered perception of
reality
Contraindication of Using N
²
O/O

• For the relief of anxiety.
• Sedatives
• Criteria for use:
– Patients are very nervous about a procedure.
– Procedures are long or difficult.
– Mentally challenged patients.
– Very young children requiring extensive
treatment.
Antianxiety Agents

SEDATIVES
A. DIAZEPAM: administrated orally. Dose- 2 to 10 mg 1
hour prior to dental appointment.
B. ALPRAZOLAM: 0.25 TO 0.5mg 1 hour prior to dental
appointment.
C. MIDAZOLAM: 2 TO 5 mg 1 hour to dental
appointment.

HYPNOSIS
• Another adjunct to local anaesthesia.
• Used to control the tense pain.
• Through hypnosis , patient can be made more
relaxed & co-operative.

ELECTRONIC DENTAL ANAESTHESIA
• Recently available technique to control pain during dental
procedures.
• Used at a high frequency of more than 120Hz, EDA produces a
sensation that may be described as “vibrating”, “throbbing’,
“pulsing" or “twitching.”
• EDA acts by stimulating the larger diameter A-fibers which
transmit the sensation of touch, pressure& temperature.
• This will inhibit the transmission of pain impulses produced by
high speed drill which are transmitted by smaller A-delta &C
fibers
• When the pain impulses fail to reach the brain ,the sensation
of pain does not occur

EDA cont’d………….
• Another mechanism which occurs during high
frequency stimulation is that the blood levels
of serotonin & endorphins are increased. They
play a secondary role in controlling pain
during dental treatment.
• EDA is as successful as LA during restorative
procedures with patients reporting no
soreness or discomfort soon after the
treatment.

EDA

ELECTRONIC DENTAL ANAESTHESIA
INDICATIONS
• Mainly for needle phobic
patients.
• Patients allergic to LA.
• Pain control prior to
administration of local
anaesthesia, especially for
palatal injections.
CONTRAINDICATIONS
• Patients with cardiac
pacemakers.
• Patients with nuerological
disorders like epilepsy.
• Very young &very old
patients.
• Pregnancy.

EDA
ADVANTAGES
• No need for injections.
• Anaesthetic effect only for
required time; doesn’t last
longer.
• Residual analgesic effect
lasts for several hours.
DISADVANTAGES
• High cost of the unit.
• Intraoral electrodes are a
weak link in the system.

CARE DURING OPERATIVE PROCEDURES
 An extremely gentle & careful approach during treatment goes a
long way in preventing pain and trauma to the patient
 The following measures will ensure proper care during operative
procedures:
1.Use of mouth mirrors to provide proper retraction of tounge ,
cheeks& lips
2. Application of rubber dam to ensure protection of the gingiva
and adjacent hard and soft tissues.
3. Avoid use of slow speed drill for gross removal of tooth
structure, as it is time consuming & produces heat & vibrations that
are traumatic to patient.
4. Use of airotor with coolant for initial cavity preparation
stage.

Cont’d…………
5.While treating deep carious lesions use of slow speed , round steel
burs or spoon excavators to remove soft caries will provide a better
tactile feel & prevent pulp exposure.
6.Use of gingival retraction cords while working close to the gingiva
will protect gingival tissues.
7.Proper instrument grasps, rests & guards will prevent accidental
damage to hard& soft tissues.
8.Avoid rapid blast of air from air water syringe as it can induce a
painful response & in deep caries produce pulpal inflammation.
9.Proper use of pulp protective agents like varnishes, sealants, liners&
bases during restorative procedures will help to preserve pulp
vitality & prevent postoperative pain.

CONCLUSION
• Dentists should employ many ways to ensure that
treatment is comfortable &relatively free of pain.
• Pleasant surrounding & pleasing chairside manners can
contribute greatly in relaxing the tense patients.
• Use of standard methods like LA, EDA & even concious
sedation is effective in reducing pain.
• Furthermore, reducing postoperative pain helps to allay
the patient’s fear regarding dental treatment
• Avoiding rough handling of lips& oral soft tissues, reducing
pulpal damage during restorative procedures, reducing
periodontal damage due to high spots on restoration are all
important factors in this regard.

THANK
YOU

Pain control

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