INTRODUCTION:-• Although pain is an important motivating factor for patients to visit the dentist, fear of pain is a major reason for delaying dental treatment..• A caring & sympathetic attitude & gentle handling of patient will itself to a major extent relax them..
Method to control painin operative dentistry1.local anaesthesia2.alternative methods to control pain - premedication with antianxiety agents or sedatives -inhalation sedation -hypnosis -electronic dental anaesthesia
1.LOCAL ANAESTHESIA• Most common used methodIndication:-• Patient with hypersensitive dentin• Patients who are tense• Painful procedures
Before administering LA certain patient factors have to be assessed.these include:• Systemic health• Allergy• psychology
Systemic health :• Dentist should enquire about the health status of the patient especially regarding the cardiovascular system,central nervous system, liver, kidneys, thyroids, etc....• Eg.in a hypertensive patient,the use of LA with a vasoconstrictor should be avoided as it can cause a rise in the blood pressure & increased heart rate• Overdose of anaesthetic agents can depress the central nervous & respiratory systems..
• Allergy:• Patient having “sensitivity” or “reaction” are contraindicated for LA..anaphylactic shock can occur..which may be immediate & fatal..• Psychology:• Dental patient are usually tense about receiving intraoral injection.a confident,positive approch by tha dentist can improve patient co- operation & comfort.
• LOCAL ANAESTHETIC AGENTS:• Amide type local anaesthetics are commonly used in operative dentistry as they produse less allergic reaction.• 1.lidocaine 2% + epinephrine1:50,000• 2.lidocaine 2% + epiinephrine1:100,000• 3.bupivacaine 0.5% + epinephrine1:200,000• A vasoconstrictor like epinephrine is added to prolong the action of the anaesthetic by decreasing the rate of absorption of tha anaesthetic into the blood.
• TECHNIQUES OF LA :• i) infiltration anaesthesia• ii) regional block anaesthesia• i)infiltration anaesthesia consists of supraperiostial injection where the anaesthetic is deposited near the nerve endings in the operating site.usually employed in maxillary teeth.• ii) regional block anaesthesia consists of a nerve block where the anaesthetic solution is deposited near a nerve trunk at a distance from the operating site.usually employed in mandibular teeth.
• TOPICAL ANAESTHESIA:• Prior to administering the anaesthesia,a topical anaesthesic such as benzocaine or lidocaine gel or spray must be applied over the mucosa to minimize the discomfort due to needle pennetration.
• PRECAUTION DURING INJECTION:• The patient should be kept in a supine or semi-supine position.this will prevent syncope by maintaining the blood supply & blood pressure to the brain.• The solution should be deposited slowly to minimize pain• Injection into infected tissues should be avoided as this will spread the infection• The syringe should have an aspirating feature.the needle should be 27 gauge needle.• Only the smallest volume that will provide effective anaesthesia should be deposited
• ADVANTAGES OF LA:• Patient co-operation: once the LA has become effective,the patient is more relaxed & co-operative due to the absence of pain.• Control of saliva: complete anaesthesia of all tissues in the operating site controls salivation.• Reduced blood flow: the vasoconstrictor in the local anaesthetic reduces blood flow in the operating site thus controlling gingival bleeding in the arae.• Operator efficiency: due to the above mentioned factors,the operator’s efficiency is greatly enhanced.
2.ALTERNATING METHODSOF CONTROL PAIN• I) pre-medication with antianxiety agents or sedative:• This technique can be employed as an adjunct to local anaesthesia in order to calm the patient during the dental treatment.one precaution while prescribing these drugs is that the patient should not come unaccompanied during the dental appointment as his reflexes would be depressed.• The agents used are: A.diazepam (benzodiazepine derivative) administered orally in a dose of 2 to 10 mg one hour prior to the dental appiontment B.alprazolam 0.25 to 0.5 mg one hour prior to the dental appointment. C.midazolam 2 to 5 mg one hour prior to the dental appointment.
• ii) INHALATION SEDATION:• Many patient with mild to moderate fear of dental treatment can benefit from conscious sedation with nitrous oxide and oxygen.in this method,the patient’s pain threshold is elevated while he is conscious of his surroundings.Though the initial cost to install the equipment is high,this technique is a safe alternative to general anaesthesia..
• iii) HYPNOSIS:• This is another adjunct to LA & may be used to control the tense patient.the dentist should be familiar with the principles of hypnosis.through hypnosis,the patient can be made more relaxed & co-operative.
• iv) ELECRONIC DENTAL ANAESTHESIA(EDA):• Recently available technique• It works on the gate control theory of pain transmission.used at a high frequency of more than 120Hz,EDA produces a sensation that may be described as “vibrating” , “throbbing” , “pulsing” , “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 the high-speed drill which are transmitted by the small A-delta and C- fibers. when the pain impulses fails to reach the brain, the sensation of pain does not occur.
• 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
• Indications : Needle phobic patient Patient allergic to LA Pain control prior to administration of LA,especially for palatal injection.• Contraindication : Patient with cardiac pacemakers. Patient with neurological disorders like epilepsy. Very young and very old patients pregnancy
• Advantages: No need for injection. Anaesthetic effect only for the required time; does not last longer. Residual analgesic effect lasts for several hours.• Disadvantages: High cost of the unit. Learning curve. Intraoral electrodes are a weak link in the system.
CARE DURING OPERATIVE PROCEDURES• An extremely gentle & careful approch• Use of mouth mirrors to provide proper retraction of tongue, checks & lips• Application of rubber dam to ensure protection of the gingiva & adjacent hard & soft tissues.• Avoiding the use of slow-speed drill for gross removal of tooth structure,as it can be time consuming,& produces heat & vibrations which may be traumatic to the patient.• Use of airotor with coolant for the initial cavity preparation stage.intermittent cutting with light strokes is most comfortable for the patient.this will also avoid excessive cutting of tooth structure.
• 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 & pain associated with it.• Mastery over proper insrument grasps , rests , & guards is necessary to prevent accidental damage to adjacent hard & soft tissues.• Avoiding dessication of cavity preparation by blowing air from the air-water syringe. A rapid blast of air from the air-water syringe can induce a painful response and in deep caries produce pulpal inflammation.• Use of gingival retraction cords while working close to the gingival will protect the gingival tissues.• Proper use of pulp protective agents like varnish, sealants, liners and bases during restorative procedures will help to preserve pulp vitality & prevent postoperative pain.