management of endodontic pain SANDEEP.pptx

PAIN MANAGEMENT IN ENDODONTICS

1. Aaron Sarwal, MDS 2 nd Prof Pain management in endodontics RAGHAVAN R PG 1 ST YEAR DEPARTMENT OF CONSERVATIVE DENTISTRY AND ENDODONTICS DR.SANDEEP M 1 ST YEAR MDS DEPARTMENT OF CONSERVATIVE DENTISTRY AND ENDODONTICS GDC CUDDALORE

2. PAIN An unpleasant sensory or emotional experience resulting from a noxious stimulus, usually associated with actual or potential tissue damage. (WHO) It is the body’s protective response against noxious stimulus, it is associated with reflex withdrawal which is protective.

3. PAIN RELATED TERMS Sr. No.` Term Definition 1. Nociceptor A high-threshold sensory receptor of the peripheral somatosensory nervous system that is capable of transducing and encoding noxious stimuli 2. Hyperalgesia Increased pain from a stimulus that normally provokes pain 3. Neuropathic pain Pain caused by a lesion or disease of the somatosensory nervous system 4. Allodynia Pain due to a stimulus that does not normally provoke pain 5. Sensitization Increased responsiveness of nociceptive neurons to their normal input, and/or recruitment of a response to normally subthreshold inputs

4. FACTORS AFFECTING PAIN THRESHOLD 1 Emotional Status 2 Fatigue 3 Age 4 Gender 5 Fear and Apprehension

5. FEAR AND PAIN FEAR It is an emotion stemming from the lack of knowledge. Patients are apprehensive and fearful because they do not know. It is not a physical phenomenon. PAIN It is the body’s natural response to a noxious stimulus. It is a safety mechanism that prevents us from inadvertently hurting our bodies. It is a physical phenomenon .

6. Pain Reaction The patient’s reaction to pain differ from patient to patient and from time to time in the same patient. Pain reaction threshold inversely proportionate with pain reaction. The higher the pain threshold the less is the pain reaction. Patients manifes­tation to pain include facial expressions, crying out, tapping feet, etc.

7. Perception is not always reality. Pain is often associated with root canal therapy by the media and public. Every one has heard jokes about root canals and how much they hurt. However , in a survey conducted by AAE , people who had actually experienced root canal therapy were three times more likely to describe it as “painless” than those who had never had the procedure.

8. PATHWAYS OF FEAR IN DENTISTRY

9. ANXIETY AND PAIN MANAGEMENT The greater the anxiety, the more likely we are to interpret the sensation as pain. Highly fearful patients are more sensitive to pain in general and those who are dentally anxious are more sensitive to dental pain specifically. It has also been shown that more highly anxious patients report greater pain during dental procedures than normal controls.

10. PAIN RECEPTORS IN THE PULP Fast Response Fibers - A δ Fibers Aδ fibres are lightly myelinated and smaller diameter, and hence conduct more slowly than Aβ fibres. They respond to mechanical and thermal stimuli. They carry rapid, sharp pain and are responsible for the initial reflex response to acute pain. Slow Response Fibers – C Fibers C fibres are unmyelinated and are also the smallest type of primary afferent fibre. Hence they demonstrate the slowest conduction. C fibres are polymodal , responding to chemical, mechanical and thermal stimuli. C fibre activation leads to slow, burning pain.

11. NEural PATHWAY OF DENTAL PAIN The trigeminal nerve is the 5th cranial nerve and it is the largest of the twelve cranial nerves. It contain both sensory and motor fibers. The nerve is attached to the lateral wall of the pons by two roots, large sensory and small motor. The nerve passes forward and at the apex of the petrous part of the temporal bone the large sensory root expands to form the trigeminal ganglion.

12. NEURAL THEORY OF PAIN TRANSMISSION Given by Fields in 1987 . Later modified by others. Processing of pain from the stimulation of primary nociceptors to the subjective experience of pain into 4 steps: Transduction Transmission Modulation Perception

13. THEORIES OF PAIN TRANSMISSION Specificity Theory Pattern Theory   Gate Control Theory

14. SPECIFICITY THEORY Specificity theory is one of the first modern theories for pain .  It holds that specific pain receptors transmit signals to a "pain center " in the brain that produces the perception of pain. This theory is correct in that separate fibers for pain do carry pain signals to the brain eventually. However, the theory does not account for the wide range of psychological factors that affect our perception of pain. For example, soldiers may report little or no pain in relation to a serious wound in war time that would otherwise be excruciating.

15. PATTERN THEORY Pattern theory  holds that pain signals are sent to the brain only when stimuli sum together to produce a specific combination or pattern. The theory does not posit specialized receptors for pain nor does it see the brain as having control over the perception of pain. Rather, the brain is merely viewed as a message recipient. Despite its limitations, the Pattern Theory did set the stage for the Gate Control theory that has proved the most influential and best accepted pain theory so far.

16. GATE CONTROL THEORY Ronald Melzack and Patrick Wall proposed the Gate Control Theory in 1965. The theory can account for both "top-down" brain influences on pain perception as well as the effects of other tactile stimuli (e.g. rubbing a banged knee) in appearing to reduce pain. It proposed that there is a " gate " or control system in the dorsal horn of the spinal cord through which all information regarding pain must pass before reaching the brain. The  Substantia Gelatinosa  ( SG ) in the dorsal horn controls whether the gate is open or closed. An "open gate" means that the  transmission cells  (i.e.,  t-cells ) can carry signals to the brain where pain is perceived; a "closed gate" stops the t-cells from firing and no pain signal is sent to brain.

17. HOW DOES GATE CONTROL THEORY WORK? The SG has both excitatory and inhibitory synapses with the T cells. Three kinds of neurons send signals to the SG. Two of them (A-delta and C) are slow conducting and transmit pain signals; the third (A-beta) inhibits the transmission of pain signals. Pain Signal ---> Excites the SG +  --->Opens Gate ---> T-cells fire ---> Pain signal sent Non-painful Stimulus ---> Excites the SG  -  --->Closes Gate ---> T-cells inhibited ---> Reduces pain signal

18. DIAGNOSTIC CONSIDERATIONS Is the pain of odontogenic or non- odontogenic origin? Is the tooth vital or non-vital? Is the pain due primarily to an inflammatory or infectious process? Is the pain of pulpal or peri-radicular origin or both? Is there a periodontal component ?

19. SIGNS AND SYMPTOMS OF PAIN PULPAL PAIN Patient not able to localize the pain. Sharp, electric shock like sensation. Tooth suffering from strictly pulpal pain is not tender to percussion. Pain can be elicited by probing the cavity. Pain relieved on removing the stimulus PERIODONTAL PAIN Patient is able to identify the offending tooth. Tooth is usually tender. Laterally or apically Pain is sharp but doesn’t relieve completely on removing stimulus. It is possible for a non-vital tooth to be tender on percussion.

20. Methods of Pain Control As pain is divided into two phases: Pain perception Pain reaction Methods of pain control affect either one of the two phases.

21. CLINICAL STRATEGIES: PULPOTOMY A pulpotomy is often performed in cases of acute pain of pulpal origin when there is insufficient time to do pulpectomy.

22. CLINICAL STRATEGIES: PULPECTOMY Since it is impossible for the clinician to precisely determine the apical extent of pulpal pathosis, a pulpectomy offers the advantage of complete removal of the pulp. Pulpectomy is the course of treatment often used in patients who present with symptoms of irreversible pulpitis, or pulp necrosis with or without swelling. All Pulp Removed And Replaced With Medicated Filling

23. CLINICAL STRATEGIES: TREPHINATION Trephination is the surgical perforation of the alveolar cortical plate over the root end of a tooth to release accumulated tissue exudate that is causing pain. The mucosa is retracted with a tissue retractor, and a number six round bur is used to penetrate the cortical bone.

24. CLINICAL STRATEGIES: TREPHINATION It is presumed that if apical trephination is successful, its success is based on the establishment of drainage, relief of pressure and the removal of inflammatory mediators from the periradicular tissues

25. CLINICAL STRATEGIES: INCISION AND DRAINAGE A serious diffuse swelling is characterized by its spread through adjacent soft tissues, dissecting tissue spaces along fascial planes. Such a swelling is called a cellulitis In endodontic cases, drainage is best achieved through a combination of canal instrumentation and when there is a fluctuant swelling incision and drainage.

26. CLINICAL STRATEGIES: INCISION AND DRAINAGE

27. CLINICAL STRATEGIES: INCISION AND DRAINAGE SUTURING AFTER INCISION AND DRAINAGE

28. CLINICAL STRATEGIES: INCISION AND DRAINAGE

29. CLINICAL STRATEGIES: OCCLUSAL REDUCTION The value of reducing occlusion to prevent pain after endodontic instrumentation had been a source of controversy Occlusal adjustment reduces mechanical stimulation of sensitized nociceptors .

30. CLINICAL STRATEGIES: OCCLUSAL REDUCTION Conditions including the presence or absence of pulp vitality, preoperative pain, percussion sensitivity, a periradicular radiolucency, a stoma, swelling and a history of bruxism – need occlusal reduction

31. EFFECTIVE MEDICAL MANAGEMENT OF ACUTE PAIN Diagnose and treat the cause of pain Use a flexible analgesic prescription strategy Pretreat with NSAID Acheive profound anesthesia

32. DIAGNOSE AND TREAT THE CAUSE OF PAIN In most of cases dental treatment alone results in substantial pain relief. Drug therapy is only adjunct to dental treatment.

33. A FLEXIBLE ANALGESIC PRESCRIPTION STRATEGY: ASPRIN-LIKE DRUGS ARE INDICATED

34. A FLEXIBLE ANALGESIC PRESCRIPTION STRATEGY: ASPRIN-LIKE DRUGS ARE CONTRAINDICATED

35. PRETREATING WITH NSAIDS Pre treatment with NSAIDS delays the onset of post op pain NSAIDS inhibit the production and release of chemical mediators of inflammation Aspirin is not used prior to surgical procedures

36. BARBITURATES- ANXIETY RELIEF Depress all areas of CNS but reticular activating system is most sensitive. They can impair learning, short term memory and judgement. Short acting barbiturates Butobarbitone Secobarbitone Pentobarbitone

37. BARBITURATES If there are other medications involved, like if a person is taking antihistamines, cold medicines, muscle relaxants, OTC pain relievers or if a person is drinking alcohol, be careful. The combined effects of barbiturates and these other drugs and substances on the central nervous system can be very dangerous and may lead to unconsciousness or even death. Anyone who experiences symptoms of an adverse reaction to barbiturates or a possible overdose should seek emergency medical assistance immediately .

38. BENZODIAZEPINES Antianxiety benzodiazepines Diazepam Oxazepam Lorazepam Alprazolam

39. BENZODIAZEPINES Physiological and psychological dependence can result from benzodiazepine misuse depending on the drug’s potency, its dosage and the length of time it is taken. For example, alprazolam is highly potent and if taken at high doses, dependence can develop in as short as 2 months. With certain other benzos, tolerance occurs at around 6 months of use.

40. USING LONG ACTING LOCAL ANESTHESIA Adequate anesthesia not only ensures comfortable treatment but also reduces post treatment pain. Etidocaine and bupivacaine are effective in reducing pain. Etidocaine has faster onset of anesthesia.

41. MANAGEMENT OF FEAR IN ENDODONTICS Pretreatment Anxiety Questionnaire Individual Systematic Desensitization And Group Therapy : Individual systematic desensitization (ISD) is a behavioural therapy whereby individuals are gradually exposed or incrementally exposed to fearful stimuli.

42. MANAGEMENT OF FEAR IN ENDODONTICS Flooding/Implosion Flooding is a form of desensitization for treating phobias when the patient has a directly conditioned origin of fear. In flooding therapy, the patient is subjected to repeated exposure of fear-inducing stimuli until they no longer show a fear response

43. MANAGEMENT OF FEAR IN ENDODONTICS Cognitive Behavioral Therapy Cognitive behavioral therapy (CBT) is a psychotherapeutic approach to address dysfunctional emotions and negative behaviors and cognitions using a series of goal-oriented sessions

44. CONCLUSION Pain is both a sensory and emotional experience, and patients past experiences, fears and anxieties can play an important role. Pain transmission is a result of complex peripheral and central processes. These processes can be modulated at different levels and pain perception is a result of the balance between facilitatory and inhibitory interactions.

45. REFERENCES Cohen, pathways of pulp, 12 th edition Di Spirito F, Scelza G, Fornara R, Giordano F, Rosa D, Amato A. Post-Operative Endodontic Pain Management: An Overview of Systematic Reviews on Post-Operatively Administered Oral Medications and Integrated Evidence-Based Clinical Recommendations. Healthcare (Basel). 2022 Apr 19;10(5):760. doi : 10.3390/healthcare10050760. PMID: 35627897; PMCID: PMC9141195. Jayakodi H, Kailasam S, Kumaravadivel K, Thangavelu B, Mathew S. Clinical and pharmacological management of endodontic flare-up. J Pharm Bioallied Sci. 2012 Aug;4( Suppl 2):S294-8. doi : 10.4103/0975-7406.100277. PMID: 23066274; PMCID: PMC3467928.

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