PAIN MANAGEMENT IN PAEDIATRIC DENTISTRY.pptx

PAIN MANAGEMENT IN PAEDIATRIC DENTISTRY.pptx

1. I. PREMEDICATION AND PAIN CONTROL AGENTS II. COMMON DRUGS USED IN PAIN CONTROL III. LOCAL ANAESTHESIA TECHNIQUES GROUP C 12/02/2024

2. PAIN MANAGEMENT IN PAEDIATRIC DENTISTRY contents definition causes of pain impacts of dental pain pain assesment pain management dosage calculations LA

3. definiton An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.” According to the International Association for the Study of Pain (IASP) in 1986. An unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage. According to the International Association for the Study of Pain (IASP) 2020.

4. causes of pain in paediatric dentistry Dental caries especially deep lesions Tooth eruption Trauma to the teeth Dental abscess Bruxism Loose teeth Gum disease

5. Impacts of dental pain difficulty in sleeping difficulty eating difficulty in brushing teeth concentrating in activities school absenteeism negatively affected their families i.e. disruption in physical activities (e.g., performing household activities), social activities (e.g., visiting friends and relatives), psychological activities (e.g., waking up at night, emotional stability, family relationship), and economic impacts (e.g., work loss, effect on family budget due to expenditure on pain relief)

6. Pain assessment Difficulty in identifying and assessing pain in children is one of the barriers to its management. use of pain evaluation tools which differ according to the age of the child ,is generally necessary to confirm the existence of pain, assess its intensity, determine the analgesic means required, and evaluate the effectiveness of the treatment instituted. pain evaluation in children can be done using various scales i.e. Visual Analogue Scale (VAS),Wong-Baker Face Pain Rating Scale( WBFPS),Children's Hospital of Eastern Ontario Pain Scale (CHEOPS). A systematic review of the literature on face scales (Self-evaluation scale) concluded that children preferred the WBFPS scale because the faces used are close to those of children, which further promotes their cooperation. (Elasmar, M. (2021). Evaluation and management of dental pain in children Motivating emergency consultation at the Dental Consultation and Treatment Center of Casablanca. Journal of Pediatric Dentistry. https://doi.org/10.14744/jpd.2021.06_36)

7. (Wong-Baker FACES Foundation. (2020, April 28). Home - Wong-Baker FACES Foundation. https://wongbakerfaces.org/)

8. pain management range from nonpharmacologic modalities to pharmacological treatment. Nonpharmacologic therapy calm environment encouraging deep breathing employing guided imagery distraction, play therapy hypnotherapy virtual reality, other (e.g.,acupuncture, transcutaneous nerve stimulation)

9. pharmacological consist of administration of topical and local anesthesia, analgesic medications, and/or mild,moderate, or deep sedation regimens. Analgesic selection depends on the individual patient, the extent of treatment, the duration of the procedure, psychological factors, and the patient’s medical history. therapeutics available for the prevention of pain include acetaminophen,nonsteroidal anti-inflammatory drugs(NSAIDs) and opioids. A guideline panel determined that, when used as directed, acetaminophen alone, NSAIDs (like ibuprofen) alone or acetaminophen in combination with NSAIDS can effectively manage a child’s pain after a tooth extraction or during a toothache when dental care is not immediately available. (ADA Media Relations. (n.d.). New guideline details dental pain management strategies for pediatric patients. American Dental Association. https://www.ada.org/en/about/press-releases/new-guideline-details-dental-pain-management-strategies-for-pediatric-patients)

10. Acute dental pain Evidence-Based Clinical Practice Guideline for the Management of Acute Dental Pain: Postoperative Pain after 1 or More Simple or Surgical Tooth Extractions in Children 1 . For the management of acute postoperative dental pain in children undergoing 1 or more simple or surgical tooth extractions, the guideline panel suggests initiating the pain management scheme using ibuprofen alone, naproxen (>2 years) alone, OR either of the two in combination with acetaminophen over the use of acetaminophen alone. 1.1. If postprocedural (that is, simple or surgical tooth extraction) pain control using NSAIDs alone is inadequate, the guideline panel suggests the addition of acetaminophen 1.2. When NSAIDs are contraindicated, the guideline panel suggests the use of acetaminophen alone. . 2. For the management of acute postoperative dental pain in children undergoing 1 or more surgical tooth extractions, the panel will not formulate recommendations for or against corticosteroids due to a paucity of evidence. Carrasco-Labra A, Polk DE, Urquhart O, Aghaloo T, Claytor JW Jr, Dhar V, Dionne RA, Espinoza L, Gordon SM, Hersh EV, Law AS, Li BS, Schwartz PJ, Suda KJ, Turturro MA, Wright ML, Dawson T, Miroshnychenko A, Pahlke S, Pilcher L, Shirey M, Tampi M, Moore PA. Evidence-based clinical practice guideline for the pharmacologic management of acute dental pain in children: A report from the American Dental Association Science and Research Institute, the University of Pittsburgh School of Dental Medicine, and the Center for Integrative Global Oral Health at the University of Pennsylvania. J Am Dent Assoc. 2023 Sep;154(9):814-825.e2. doi : 10.1016/j.adaj.2023.06.014. PMID: 37634915.

11. Carrasco-Labra A, Polk DE, Urquhart O, Aghaloo T, Claytor JW Jr, Dhar V, Dionne RA, Espinoza L, Gordon SM, Hersh EV, Law AS, Li BS, Schwartz PJ, Suda KJ, Turturro MA, Wright ML, Dawson T, Miroshnychenko A, Pahlke S, Pilcher L, Shirey M, Tampi M, Moore PA. Evidence-based clinical practice guideline for the pharmacologic management of acute dental pain in children: A report from the American Dental Association Science and Research Institute, the University of Pittsburgh School of Dental Medicine, and the Center for Integrative Global Oral Health at the University of Pennsylvania. J Am Dent Assoc. 2023 Sep;154(9):814-825.e2. doi : 10.1016/j.adaj.2023.06.014. PMID: 37634915.

12. paediatric pulpitis Recommendations and good practice statements for the temporary pharmacologic management of toothache in children with no immediate access to definitive dental treatment. 1. For the temporary management   of toothache (symptomatic pulpitis [that is, reversible or symptomatic irreversible pulpitis with or without symptomatic apical periodontitis or symptomatic periapical or furcation involvement] or pulp necrosis with symptomatic apical periodontitis or periapical or furcation pathosis , or acute apical abscess) before definitive dental treatment in children,    the guideline panel suggests the use of ibuprofen alone,   naproxen (> 2 years)   alone,or either of the 2 in combination with acetaminophen   When nonsteroidal anti-inflammatory drugs are contraindicated,   the guideline panel suggests the use of acetaminophen alone . ∗These recommendations are applicable only to settings in which definitive dental treatment is not available. Definitive dental treatment includes pulpectomy , nonsurgical root canal treatment, incision for drainage of abscess, and tooth extraction. Patients or their caregivers should be instructed to call if their pain fails to lessen over time or to call if the referral to receive definitive dental treatment within 2 through 3 days is not possible. These pharmacologic strategies will alleviate dental pain temporarily until a referral for definitive dental treatment is in place. According to the US Food and Drug Administration, codeine and tramadol are contraindicated  ¶ in children younger than 12 years. In addition, topical benzocaine should not be used in infants or young children owing to the high risk of methemoglobinemia . Carrasco-Labra A, Polk DE, Urquhart O, Aghaloo T, Claytor JW Jr, Dhar V, Dionne RA, Espinoza L, Gordon SM, Hersh EV, Law AS, Li BS, Schwartz PJ, Suda KJ, Turturro MA, Wright ML, Dawson T, Miroshnychenko A, Pahlke S, Pilcher L, Shirey M, Tampi M, Moore PA. Evidence-based clinical practice guideline for the pharmacologic management of acute dental pain in children: A report from the American Dental Association Science and Research Institute, the University of Pittsburgh School of Dental Medicine, and the Center for Integrative Global Oral Health at the University of Pennsylvania. J Am Dent Assoc. 2023 Sep;154(9):814-825.e2. doi : 10.1016/j.adaj.2023.06.014. PMID: 37634915.

13. opioids effective for moderate to severe postoperative pain potential adverse effects (e.g., nausea, emesis, constipation, sedation, respiratory depression) and diversion has steadily deacreased its dispensation in paediatrics. a combination of acetaminophen and ibuprofen provided effective analgesia without the adverse side effects associated with opioids. In 2017, the United States Food and Drug Administration (FDA) issued a warning to restrict the use of codeine and tramadol in children and breastfeeding mothers. (ADA Media Relations. (n.d.). New guideline details dental pain management strategies for pediatric patients. American Dental Association. https://www.ada.org/en/about/press-releases/new-guideline-details-dental-pain-management-strategies-for-pediatric-patients)

14. Dosage calculations when giving a drug to a child it may be required that you adjust the dosage based on how much they weigh, as assigning a dosage based on age could result in the child taking too much or too little of the drug. Dosages may not necessarily be given per day. They could be per hour, or any time frame. About yorksj.ac.uk/media/content-assets/study-skills/Maths-and-statistics/Nursing-maths/Dosage-Calculations-per-KG-Factsheet.docx - Google Search. (n.d.). https://www.google.com/search?q=About+https://www.yorksj.ac.uk/media/content-assets/study-skills/maths-and-statistics/nursing-maths/Dosage-Calculations-per-kg-Factsheet.docx&tbm=ilp&sa=X&ved=2ahUKEwiM2sbdkreEAxWGygIHHV93AIIQv5AHegQIABAD

15. Example A patient is prescribed a drug. The dosage of the drug is 3mg/kg of body weight/day, and the patient weighs 40kg. The drug comes in liquid form with a concentration of 2mg/ml. What volume of the drug should the patient be given in a single dose if they must take the drug 2 times per day?

16. OUTLINE; DEFINITION TOPICAL ANESTHESIA; - Formulations - Techniques - Types; Benzocaine, Lidocaine, EMLA - Recent Advances; Dentipatch 3. REGIONAL ANESTHESIA; - Types - Recent Advances - Complications

17. DEFINITION; A loss of sensation in a circumscribed area of the body caused by a depression of excitation in nerve endings or an inhibition of the conduction process in peripheral nerves. ( Malamed, 1980)

18. LOCAL ANAESTHETIC AGENTS; Esters; Esters of Benzoic Acid; Cocaine, Butacaine, Benzocaine, Tetracaine Esters of Para Aminobenzoic Acid; Procaine, Chloroprocaine , P ropoxycaine Amides; Bupivacaine, L idocaine, A rticaine , P rilocaine, Mepivacaine, Ropivacaine Quinolones; ( not used anymore) Centbucridine

19. TOPICAL ANESTHESIA; Available in different forms: Gel; Benzocaine 20% ( most effective type). Liquid Spray; Lidocaine 15%

20. Gel is the most desired; i . Easy to control application to the oral mucosa ii. Most of the have pleasant flavours Benzocaine liquid, ointment, or gel preparations are best suited for topical anesthesia; They offer a more rapid onset Longer duration of anesthesia than other topical agents Not known to produce systemic toxicity; low aqueous solubility making its absorption slow

21. TECHNIQUE; The mucosa at the site of the intended needle insertion is dried with gauze. A small amount of the topical anesthetic agent is applied to the tissue with a cotton swab. Topical anesthesia should be produced in 30 seconds. The dentist should prepare the child for the injection Mucosa should appear white and wrinkled Effective to a depth of 2-3 mm .

22. BENZOCAINE; Formulations; Solutions, Sprays; 5%, 10%, 20% Oral preparations; 7.5% – 20% Most widely used; Fast action Acceptable taste Lack of systemic absorption

23. INDICATIONS; Oral ulcers, mucositis Pain during teething Periodontal irritation Reduce discomfort caused by the needle Orthodontic banding CONTRAINDICATIONS; Pts with congenital methemoglobinemia Pts with deep wounds, injuries, severe burns Pts allergic to benzocaine

24. ADVERSE EFFECTS; Methemoglobinemia when high concentrations are used; Cyanosis, Hypoxia, Dyspnea CVS; Hypotension, Bradycardia, Cardiac arrest CNS; Seizures, Drowsiness, Dizziness Allergic reactions

25. LIDOCAINE; Formulations; i . Gel, patches; 2-5 % ii. Ointment; 5% iii. Spray; 10% ADVANTAGES; High safety margin before reaching its toxic levels DISADVANTAGES; Has an unpleasant taste Only relieves pain caused by needle insertion but not the injection itself

26. INDICATIONS; To reduce the discomfort of the initial penetration of the needle into the mucosa. Oral ulcers Orthodontic banding During teething

27. EUTECTIC MIXTURE OF LOCAL ANESTHESIA; Oil in water emulsion of 2.5% lidocaine an 2.5% prilocaine Available in concentration of 2.5 -5% Duration of action of 2-10 minutes Available in; Foams Ointments Pastes Gels Creams Patches

28. INDICATIONS; Small mucosal biopsies During placement of orthodontic spacers Children with needle phobia When elastomeric orthodontic separators are to be used DISADVANTAGES; Don’t provide sustained action due to their short retention time Act on non targeted parts; numbness of the mouth and throat, choking

29. RECENT ADVANCES; DentiPatch ( Noven Pharmaceuticals, Inc., Miami, Fla), a lidocaine transoral delivery system. This system seems to be designed primarily for situations in which superficial oral tissue anesthesia is desired for several minutes rather than the shorter time required for local anesthetic injections. Use of this product has not yet been shown to be convenient or efficacious in young children

30. REGIONAL ANESTHESIA; There are two basic differences in the craniofacial complex of children when compared to adults: 1. The jawbones are less dense 2. The smaller size of oral structures in children 3. Position of the mandibular foramen

31. TYPES OF REGIONAL LA; Nerve block: Depositing the LA solution within close proximity to a main nerve trunk. Field block: Depositing LA in proximity to the larger nerve branches. Local infiltration : Small terminal nerve endings are anaesthetized.

32. COMMONLY USED LA AGENTS;

33. MANDIBULAR ANESTHESIA; INFERIOR ALVEOLAR NERVE BLOCK; Provides anesthesia to; IAN and its terminal branches Lingual nerve Long buccal nerve TECHNIQUES; Conventional IANB Vazirani- Akinosi Technique Gow-Gates Technique

34. The mandibular foramen is situated at a level lower than the occlusa l plane of the primary teeth of the pediatric patient. The injection must be made slightly lower and more posteriorly than for an adult patient. BELOW 6 YEARS 6 – 12 YEARS ABOVE 12 YEARS

35. Areas anesthetized; Mandibular teeth of the injected side. Body of the mandible, inferior portion of the ramus. Buccal mucoperiosteum, mucous membrane anterior to the mandibular 1 st molar. Anterior 2/3 rd of tongue and floor of the mouth. Lingual soft tissue and periosteum. Indications; M ore than 1 tooth filling, extraction P ulp therapy Difficulty in achieving a mental block due to infection.

36. MENTAL NERVE BLOCK; Provides anesthesia to; Labial mucous membrane Pulpal tissues from the first premolar to the midline Periodontium Skin of lower lip, chin

37. LONG BUCCAL NERVE BLOCK; Site Of Injection; Mucous membrane distal and buccal to the most distal molar tooth in the arch. Area Anesthetized; Soft tissue and periosteum buccal to the mandibular molar teeth.

38. INFILTRATION FOR MANDIBULAR INCISORS ; The terminal ends of the inferior alveolar nerves cross over the mandibular midline slightly and provide conjoined innervation of the mandibular incisors. The labial bone overlying the mandibular incisors is usually thin enough for supraperiosteal anesthesia techniques to be effective.

39. SUPRAPERIOSTIAL TECHNIQUE (LOCAL INFILTRATION) Most frequently used for obtaining pulpal anesthesia in maxillary teeth. Indicated whenever dental procedures are confined to only one or two teeth. Landmark: I nsertion at 45 to the long axis of the tooth Mucobuccal fold. Crown of the tooth. Root contour of the tooth.

40. Areas Anesthetized; 1. Pulp and root area of the tooth. 2. Buccal periosteum. 3. Connective tissue. 4. Mucous membrane.

41. GREATER PALATINE NERVE BLOCK: Anesthetizes the mucoperiosteum of the palate from the tuberosity to the canine region and from the median line to the gingival crest on the injected side.

42. NASOPALATINE NERVE BLOCK; Palatal soft and osseous tissue management from canine to canine bilaterally

43. OTHER NERVE BLOCKS; 1. Posterior Superior Alveolar NB; Management of several molar teeth in one quadrant 2. Middle Superior Alveolar NB; Management of premolars in one quadrant 3. Anterior Superior Alveolar NB; Management of anterior teeth in one quadrant

44. SUPPLEMENTAL INJECTION TECHNIQUES; 1. PERIODONTAL LIGAMENT INJECTION; The needle is placed in the gingival sulcus, and advanced along the root surface until resistance is met. Then approximately 0.2 mL of anesthetic is deposited into the periodontal ligament. Pressure is necessary ( by the injection) to express the anesthetic solution. Indications; In single tooth procedures In bleeding disorders In young handicapped patients where lip biting may be a problem

45. Advantages of Periodontal Ligament Anesthesia: It provides reliable pain control rapidly and easily. It provides pulpal anesthesia for 30 to 45 minutes. It is no more uncomfortable than other local anesthesia techniques. It is completely painless if used adjunctively. It requires very small quantities of anesthetic solution. It does not require aspiration before injection. It may be performed without removal of the rubber dam. It may be useful in patients with bleeding disorders that contraindicate use of other injections. It may be useful in young or disabled patients in whom the possibility of postoperative trauma to the lips or tongue is a concern.

46. 2. INTRASEPTAL; Used to reinforce analgesia produced by infiltration and is primarily used for mandibular primary molars Technique; Give a submucosal injection buccally When the soft tissue anaesthesi is effective, inject LA through the interdental papilla into the interdental bone mesially and distally and deposit about 0.1 ml of the LA

47. 3. INTRAPULPAL; Indicated in pulp therapy when other techniques of la have failed The needle is bent and deposited into the pulp tissue

48. 4. INTRAPAPILLARY; Produces analgesia of palatal and lingual tissues to avoid more painful injections.

49. RECENT ADVANCES; JET INECTOR; Based on the principle of using a mechanical energy source to create a pressure sufficient to push a liquid medication through a very small orifice, that it can penetrate into the subcutaneous tissues without a needle.

50. Advantages; Painless technique Less tissue damage Faster injection iv. Faster rate of drug absorption into the tissues Disadvantages; i . It cannot be used for nerve blocks, only infiltration and surface anesthesia are possible

51. 2. COMPUTER CONTROLLED ADMINISTERING OF LA; These devices consist of an electronic unit, a footswitch (The Wand-STA™, Sleeper One™, CCS™), or a hand switch ( Dentapen ™), needing a needle (specialized or not) connected to the device (. Fig. 7.3). Pen-shaped C-CLAD injectors (The Wand-STA™, Sleeper One™, CCS™, Dentapen ™) allow good support points.

52. Advantages; It allows a drop-by-drop delivery during the first seconds of injection which is very difficult to perform using traditional syringes [32]. Injection is continuous and stable or increases slowly after the first seconds: it therefore avoids pulses of anesthetics that are associated to high intratissular pressure around the needle and therefore to pain. The different appearance of the needle and syringe, when pen-shaped, appears to reduce fear and pain in patients Disadvantages; Using C-CLAD devices takes more time than regular anesthesia It comes at a higher cost, so much as to initial purchase as to buying specific consumables

53. 3. VIBROTACTILE DEVICES; These devices work on the principle of 'gate control' theory thereby reduces pain It acts based on the fact that the vibration message is carried to brain through insulated nerves and pain message through smaller uninsulated nerves. The insulated nerves overrule the smaller uninsulated nerves. The devices are: VibraJect , Dental Vibe, Accupal

54. 4. COMFORT CONTROL SYRINGE; This syringe (Dentsply) is an electronic pre programmed anesthesia delivery device that uses a a-stage delivery rate. The rate of injection varies based on the injection technique chosen. It begins with as low rate; the flow the increases to a pre programmed technique-specific rate selected by the dentist. The operation of this syringe (initiation and termination of the injection, controlled aspiration and flow rate) is controlled by a button on the handpiece. A disposable cartridges heath is required for each patient, but a standard dental needle and anesthetic cartridge can be used

55. COMPLICATIONS OF LA; ANAESTHESIA TOXICITY Young children are more likely to experience toxic reactions because of their lower body weight. It is most important for dentists who treat children to be acutely aware of the maximum recommended dosages of the anesthetic agents they use, because allowable dosages are based on the patient’s weight LA toxicity causes suppression of cardiovascular and central nervous system. Symptoms include tremors, shivering, spasms, suppression of breathing, and even fainting

56. 2. SOFT TISSUE TRAUMA; The children should be observed carefully so that they will not purposely or inadvertently bite the tissue especially the lip, tongue, or inner surface of the cheek. In some cases, the child chews the area, and the result 24 hours later is an ulceration, often termed a traumatic ulcer Management; The child should be seen in 24 hours, and a warm saline mouth rinse is helpful in keeping the area clean.

57. 3. NEEDLE BREAKAGE; A particularly rare occurrence The main cause of this complication is a sudden movement from the patient as the needle bores the muscular substrate or is in contact with the periosteum. Thinner needles are more sensitive as are those which have been previously bent by the dentist. Prevention; Changing needle direction should be avoided once it is inside the tissues, while the hand holding the syringe should remain stable Management; Have the patient keep opening wide and remove it if visible If not visible clinically, locate the retained fragment through computed tomographic scanning

58. 4. PAIN & A BURNING SENSATION ; Prevention; Use of topical anesthesia and slow injection of the anesthetic solution are essential. LA Solution should be between room and environmental temperature 5. PARASTHESIA; In rare instances, in infiltration techniques, prolonged anesthesia relating to burrowing of the nerve by the needle (felt as an electric shock in the neural region) or hemorrhaging around the nerve can occur This usually recedes within 2 months.

59. 6. HEMATOMA; Causes; A hematoma is created intraorally from extravasation of blood due to injury caused by the needle. It rarely causes any problems beyond a change in color of the mucosa. Management; Direct pressure applied to the hemorrhaging area helps control the extent of the hematoma, which usually recedes without intervention within 7–14 days. The use of analgesics to control pain is advised, Avoidance of hot foods several hours post op

60. 7. TRISMUS; Causes; Muscle and vessel trauma, low-level infections, multiple needle insertions, and large doses of anesthetic Management ; Heat therapy, warm saline rinses, analgesics, muscle relaxants Diazepam (muscle relaxant)10mg twice daily Chewing gum (lateral movement of temporomandibular joint) Referred to oral surgeons for evaluation.

61. REFERENCES; Alvarez, G. G., Romero, C. C., Gonzalez, G. I., Hernanadez , G. R., Morteo , L. T., Reyes, L. P., . . . Soto, J. M. (2022). Topical Anesthetics in Pediatric Dentistry; A Literature Review. International Journal of Applied Dental Sciences, 8 (3), 283-286. doi:https ://doi.org/10.22271/oral.2022.v8.i3c.1604 Dean, J. A. (2016). McDonald and Avery's Dentistry for the Child and Adolescent (10 ed.). Elsevier Inc. Kotsanos , N., Sarnat , H., & Park, K. (Eds.). (2015). Textbooks in Prosthetic Dentistry: Pediatric Dentistry (11th ed.). Thessaloniki: Fylatos Publishing. doi:https ://doi.org/10.10007/978--030-78003-6 Tandon, S. (2018). Shoba Tandon Pediatric Dentistry (3rd ed., Vol. 2). Paras Medical Publisher.

62. Thank You!