Pain Management in Operative Dentistry.ppt

Pain Management in Operative Dentistry

1. Pain Management in
Operative Dentistry

2. Presentation on:
Pain Management in
Operative Dentistry
Prepared By:
Rufaida Rahman
BDS-2
Roll: 05
Seasson: 2016-2017
Dental Unit

Ibrahim Medical College

3. Topics
Introduction
Pharmacosedation
Iatrosedation
Pain Control

4. Introduction
Many patients enter in dental hospital in such a
state of nervousness or agitation that they even
find taking of radiographs almost unbearable. A
kind, supportive and understanding attitude
together with suggestion for control of such
feelings will be greatly appreciated and usually
yield acceptable response.

5. Introduction (Cont.)
A variety of techniques for management of
anxiety are available. Together these
techniques are termed as spectrum of pain
and anxiety control. They represent a wide
range from non-drug technique to general
anesthesia.

6. Introduction (Cont.)
On the whole there are two major types of
sedation.
First, requiring administration of the drugs
(pharmacosedation) and
Second, requiring no administration of drugs
(latrosedation).

7. Pharmacosedation
Sedatives and tranquilizers are drugs that are CNS
depressants and decrease cortical excitability. Both
have similar actions reducing abnormal and excessive
response to environmental situations that produce
agitation, tension and anxiety.
Short acting barbiturates and their substitutes are
excellent for use with dental treatment. Initial dose
should be given the night before the appointment to
ensure restful night, with another taken 30 min before
the patient is seated for the treatment.

8. Iatrosedation
It is a non-drug technique of causing
sedation. A relaxed and pleasant doctor
patient relationship has favorable influence
on action of these sadative drugs. A patient,
who is comfortable with doctor, responds well
to the drugs than to the patient who is
anxious about the doctor and treatment to be
done.

9. Pain Control
Pain control in conservative dentistry though is
not very difficult but sometimes it becomes
almost impossible to control pain.
Pain control can be achieved through:
- Opioid Drugs
- Non- Opioid Drugs
- Local anesthesia

10. Opioid Drugs
Generally narcotic (opioid) analgesics are
used to relieve acute, severe pain and slight
to moderate pain. The drugs used most often
are the mild, non-opioid analgesics.
The opioid receptors are located at several
important sites in brain and their activation
inhibits the transmission of nociceptive
signals from trigeminal nucleus to higher
brain regions. Opioids also activate
peripheral opioid receptors.

11. Non-opioid Drugs
These are weaker analgesics. They act
primarily on peripheral pain mechanism also
in CNS to raise pain to rise threshold.

12. Local Anesthesia
It is defined as a loss of sensation in a
circumscribed area of the body caused by
depression of excitation in nerve endings or
an inhibition of the conduction process in
peripheral nerves

13. Classification of Local Anesthetic Agents
All local anesthetics except cocaine are
synthetic. They are broadly divided into two
groups.

14. Based on chemical structure
Ester group
–Cocaine
–Benzocaine
–Procaine
–Tetracaine
Amide (Non-ester group)
–Lidocaine
–Mepivacaine
–Prilocaine
–Etidocaine
–Bupivaicaine

15. Based on duration of action
Short-acting
–Procaine
Intermediate-acting
–Lidocaine
Long acting
–Bupivaicaine

18. Following Factors should be Kept in Mind Prior to
Administration of Local Anesthesia
Age: In very young and extremely old persons, lesser therapeutic
dose should be given.
Allergy: Since it is life-threatening in most of the cases, proper
history about allergy should be taken before administering
local anesthesia.
Pregnancy: It is better to use the minimum amount of local
anesthetic drugs especially during pregnancy.
Thyroid disease: Since patients with uncontrolled hyper
­
thyroidism show increased response to the vasoconstrictor
present in local anesthetics, therefore, in such cases, local
anesthesia solutions without adrenaline should be used.

19. Precautions to be Taken before Administration of
Local Anesthesia
Patient should be in supine position as it favors good blood supply
and pressure to brain.
Before injecting local anesthesia, aspirate a little amount in the
syringe to avoid chances of injecting solution in the blood vessels.
Do not inject local anesthesia into theinflamed and infected
tissues as local anesthesia does not work properly due to acidic
medium of inflamed tissues.
Always use disposable needle and syringe in every patient. Needle
should remain covered with cap till its use.
To make injection a painless procedure, temperature of the local
anesthesia solution should be brought to body temperature.

20. Clean the site of inject ion with a sterile cotton pellet before injecting the local
anesthesia.
Insert the needle at the junction of alveolar mucosa and vestibular mucosa. If
angle of needle is parallel to long axis, it causes more pain.
In je ct local anesthesia solution slowly not more than 1 ml per minute and in
small increments to provide enough time for tissue diffusion of the solution.
Needle should be continuously inserted inside till the periosteum or bone is felt
by way of slight increase in resistance of the needle movement. The needle is
slightly with drawn and here the remaining solution is injected .
Check the effect of anesthesia two minutes after injection .
Patient should be carefully watched during and after local anesthesia for about
half an hour for delayed reactions, if any.
Discard needle and syringe in a leak-proof and hard
­ walled container after use.
Precautions to be Taken before Administration of
Local Anesthesia (Cont.)

21. Recent Advances in Local Anesthesia
Many advances have been tried for making the
experience of local anesthesia more comfo rtable
and less traum atic.
These advances are:
1.WAND system of local anesthesia
2.Comfort control syringe
3.TENS local anesthesia
4.Electronic Dental Anesthesia (EDA)
5.Needleless syringes.

22. 1. WAND system of local anesthesia
WAND local anesthesia system is computer-
automated injection system which allows precise
delivery of anesthesia at a constant flow rate despite
varying tissue resistance.

23. Method
Topical anesthetic is first applied to freeze the
mucosa and then a tiny needle is introduced through
the already numb tissue to anesthetize the
surrounding area. In this system, a disposable an
esthetic cartridge is placed in a disposable plastic
sleeve, which docks with the p um p that delivers
anesthetic solution through a micro intravenous
tubing attached to hand piece.

24. Advantages
Reduced pain and anxiety
More rapid onset of anesthesia
Considered as m ore accurate than standard aspirating syringe
Enables the operator to use pen grasp while injecting.

25. Disadvantages
Initial cost of the unit is expensive.
Longer injection time.
Due to longer tubing attached to hand piece, only 1.4 ml of
anesthetic solution is injected from cartridge.
System does require some time to get accustomed too.
System is operated by foot-pedal control and anesthetic
cartridge is not directly visible.

26. 2. Comfort Control Syringe (CCS)
Comfort control syringe has two-stage delivery
system in which injection begin s at a very slow rate
to decrease the discomfort associated with rapid
injection. After ten seconds, CCS automatically
increases injection rate for the technique which has
been selected. There are five different injection rates
to choose from that are pre-programmed into CCS
system.

27. Advantages
During the first-phase of injection, anesthetic is
delivered at very slow rate. This minimizes
pressure, tissue trauma and patient discomfort.
More rapid onset of anesthesia.
Enables the operator to use pen grasp while
injecting.
It has anesthetic cartridge directly behind the
needle, that as in traditional syringe and injection ,
controls are on finger tip rather than on foot-
pedal.

28. Disadvantages
Longer injection time.
Cost of the unit is expensive.
Hand piece is bulkier than WAND system.

29. 3. Transcutaneous Electrical Nerve
Stimulation (TENS)
This is non-invasive technique in which a low-
voltage electrical current is delivered through
wires from a power W1it to electrodes located on
the skin.

30. Mechanism of action
Release of endogenous opiates
Basedon Gate‘s control theory, which states that
stimulating input from large pain conducting nerve
fibers close s the gate on nociceptive sensory
phenomena from the A-delta and C-fibers. This
prevents descendent motor activity (tightening
up).

31. Indications
Most commonly used in temporomandibular
disorders (TMDs).
Restorative dentistry
In patients, allergic to local anesthesia
In patients having needle phobia.

32. Technique
Clean the surface by alcohol swab over the coronoid notch area.
Dry the area with gauze piece.
Apply electrode patches.
Make sure that TES unit is off.
Attach electrode leads from patch to TENS unit.
Adjust the timer.
Adjust the controls to high band width and high frequency.
Slowly adjust the amplitude so that patient feels a gentle pulsing
sensation.
Adjust pulse width and pulse rate.
Proceed with dental procedure in usual manner.
At the completion of the procedure, disconnect the leads and remove
the electrode patches from the patient.

33. 4. Electronic Dental Anesthesia (EDA)
Electronic dental anesthesia developed in mid -
1960s for management of acute pain, but the use
of electricity as therapeutic modality is not new
in the field of medical and dental sciences.

34. Indications
Most common use in temporomandibular
disorders (TMDs).
Restorative dentistry.
Patients with allergic to local anesthesia.
Patient having needle phobia.

35. Mechanism of EDA
Based on Gate Control's theory
Uses higher frequency to experience a sensation
Causes the patient to experience a sensation described as throbbing
or pulsing.
Causes stimulation of large diameter nerves (A-fibers) which inhibit
central transmission of effects of smaller nerve fibers basis.

36. Advantages
No fear of needle.
No fear for injection of drugs.
Noresidual anesthetic effectafterthe
completion of procedure.
Residual analgesic effects persists after completion
of procedure.

37. Disadvantages
Expensive
Technique sensitive- requires training.

38. 5. Needle-less Syringes
Needle less syringes are especially designed
syringes to administer anesthetic drugs
which shoot a pinpoint jet of fluid through the
skin at a high speed.