Pain control

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Pain control

  1. 1. Copyright 2003, Elsevier Science (USA). All rights reserved.ABDUL VAJID MFinal year [part- 1]PAIN CONTROLINOPERATIVEDENTISTRY
  2. 2. Copyright 2003, Elsevier Science (USA). All rights reserved.INTRODUCTION• Dental treatment is often perceivedas a painful experience.• With emphasis on prevention, minimalintervention & modern atraumatictreatment this is not necessarily true.• There are several methods availablenow to control pain and trauma inoperative dentistry.
  3. 3. Copyright 2003, Elsevier Science (USA). All rights reserved.METHODS TO CONTROL PAIN1. LOCAL ANAESTHESIA2. PREMEDICATIONS3. INHALATION SEDATION4. HYPNOSIS5. ELECTRONIC DENTAL ANAESTHESIA (EDA)
  4. 4. Copyright 2003, Elsevier Science (USA). All rights reserved.LOCAL ANAESTHESIA• Most commonly used method.• Patients with hypersensitive dentin and who aretensed may require LA.• LA injections are used to deposit the anaestheticsolution close to the specific nerve fibers.• Most procedures in operative dentistry areperformed either under a regional nerve block ora local infiltration anaesthesia which blocks thepathways of painful impulses.
  5. 5. Copyright 2003, Elsevier Science (USA). All rights reserved.Patient factors• It includes :Systemic healthAllergyPsychology
  6. 6. Copyright 2003, Elsevier Science (USA). All rights reserved.Continued………• Systemic healthdentists should enquire about the health status of the patientespecially regarding CVS, CNS, liver, kidneys, thyroid etc…. toelicit any abnormalities in these systems . Overdose of LAagents can depress the systems.• Allergywhen a patient gives a history of “sensitivity” or “reaction”to LA, its use is contraindicated. Although allergic reactionsare rare, when they occur cause anaphylactic shock whichmay be immediate and fatal.• Psychologydental patients are usually tense about receiving intraoralinjections . A confident , positive approach by the dentist canimprove patient’s -operation and comfort.
  7. 7. Copyright 2003, Elsevier Science (USA). All rights reserved.• Agents most frequently used for pain controlin dentistry.• Criteria for use:– Be nonirritating to the tissues in the area of theinjection.– Produce minimal toxicity.– Be of rapid onset.– Provide profound anesthesia.– Be of sufficient duration.– Be completely reversible.– Be sterile.Local Anesthesia
  8. 8. Copyright 2003, Elsevier Science (USA). All rights reserved.LOCAL ANAESTHETIC AGENTSAmide type of local anesthetics are commonlyused.AGENTS used are1.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 addedto prolong the actionof LA to the blood.
  9. 9. Copyright 2003, Elsevier Science (USA). All rights reserved.• Local anesthesia temporarily blocks thenormal generation and conduction action ofthe nerve impulses.• Local anesthesia is obtained by injecting theanesthetic agent near the nerve in the areaintended for dental treatment.• Induction time is the length of time from theinjection of the anesthetic solution tocomplete and effective conduction blockage.Method of Action
  10. 10. Copyright 2003, Elsevier Science (USA). All rights reserved.• Length of time from induction until thereversal 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 90minutes.Duration
  11. 11. Copyright 2003, Elsevier Science (USA). All rights reserved.• Infiltration is achieved by injecting thesolution directly into the tissue at the site ofthe dental procedure.– Most frequently used to anesthetize the maxillaryteeth.– Used as a secondary injection to block gingivaltissues surrounding the mandibular teeth.Types of Local Anesthesia Injections
  12. 12. Copyright 2003, Elsevier Science (USA). All rights reserved.• Block anesthesia– The solution is injected near a major nerve, andthe entire area served by that nerve is numbed.• Type of injection required for most mandibularteeth.– Eg: Inferior alveolar nerve block• Obtained by injecting the anesthetic solution near thebranch of the inferior alveolar nerve close to themandibular foramen.– Type of injection for half of the lower jaw, including the teeth,tongue, and lip.Types of Local Anesthesia Injections− cont’d
  13. 13. Copyright 2003, Elsevier Science (USA). All rights reserved.• Eg: Incisive nerve block– Injection given at the site of the mental foramen.• Used when the mandibular anterior teeth orpremolars require anesthesia.• Intraligamentry– Alternative infiltration anesthesia method bywhich the anesthetic solution is injected directlyinto the periodontal ligament and surroundingtissues.Types of Local Anesthesia Injections− cont’d
  14. 14. Copyright 2003, Elsevier Science (USA). All rights reserved.DISPOSIBLE NEEDLE
  15. 15. Copyright 2003, Elsevier Science (USA). All rights reserved.ANESTHETIC SYRINGE
  16. 16. Copyright 2003, Elsevier Science (USA). All rights reserved.PRECAUTIONS DURING INJECTION:The patient should be kept in supine or semisupine position for preventing syncope bymaintaining the blood supply & pressure tothe brain.The solution should be deposited slowly tominimize pain.Injection into infected tissues be avoided asthis will spread infection.Syringe should have an aspirating feature.Needle should be 27 gauge needle.
  17. 17. Copyright 2003, Elsevier Science (USA). All rights reserved.ADVANTAGES OF ANESTHESIA• Patient’s co-operation: once LA is effective,patient becomes co-operative due to absenceof pain.• Control of saliva: anaesthesia of all tissues inoperating site controls saliva.• Reduced blood flow: action done byvasoconstrictor thus controls gingivalbleeding.
  18. 18. Copyright 2003, Elsevier Science (USA). All rights reserved.Advantages cont’d………….• Operator’s efficiency: due to the abovementioned factors, the operator’s efficiency isgreatly enhanced.
  19. 19. Copyright 2003, Elsevier Science (USA). All rights reserved.• Nitrous oxide/oxygen (N²O/O²) is a combination of thesegases that the patient inhales to help eliminate fear andto 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
  20. 20. Copyright 2003, Elsevier Science (USA). All rights reserved.• Pregnancy: First trimester• Nasal obstruction: Problems inhalingthrough the nose• Emphysema• Emotional stability: Altered perception ofrealityContraindication of Using N²O/O
  21. 21. Copyright 2003, Elsevier Science (USA). All rights reserved.• 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 extensivetreatment.Antianxiety Agents
  22. 22. Copyright 2003, Elsevier Science (USA). All rights reserved.SEDATIVESA. DIAZEPAM: administrated orally. Dose- 2 to 10 mg 1hour prior to dental appointment.B. ALPRAZOLAM: 0.25 TO 0.5mg 1 hour prior to dentalappointment.C. MIDAZOLAM: 2 TO 5 mg 1 hour to dentalappointment.
  23. 23. Copyright 2003, Elsevier Science (USA). All rights reserved.HYPNOSIS• Another adjunct to local anaesthesia.• Used to control the tense pain.• Through hypnosis , patient can be made morerelaxed & co-operative.
  24. 24. Copyright 2003, Elsevier Science (USA). All rights reserved.ELECTRONIC DENTAL ANAESTHESIA• Recently available technique to control pain during dentalprocedures.• Used at a high frequency of more than 120Hz, EDA produces asensation that may be described as “vibrating”, “throbbing’,“pulsing" or “twitching.”• EDA acts by stimulating the larger diameter A-fibers whichtransmit the sensation of touch, pressure& temperature.• This will inhibit the transmission of pain impulses produced byhigh speed drill which are transmitted by smaller A-delta &Cfibers• When the pain impulses fail to reach the brain ,the sensationof pain does not occur
  25. 25. Copyright 2003, Elsevier Science (USA). All rights reserved.EDA cont’d………….• Another mechanism which occurs during highfrequency stimulation is that the blood levelsof serotonin & endorphins are increased. Theyplay a secondary role in controlling painduring dental treatment.• EDA is as successful as LA during restorativeprocedures with patients reporting nosoreness or discomfort soon after thetreatment.
  26. 26. Copyright 2003, Elsevier Science (USA). All rights reserved.EDA
  27. 27. Copyright 2003, Elsevier Science (USA). All rights reserved.EDA
  28. 28. Copyright 2003, Elsevier Science (USA). All rights reserved.ELECTRONIC DENTAL ANAESTHESIAINDICATIONS• Mainly for needle phobicpatients.• Patients allergic to LA.• Pain control prior toadministration of localanaesthesia, especially forpalatal injections.CONTRAINDICATIONS• Patients with cardiacpacemakers.• Patients with nuerologicaldisorders like epilepsy.• Very young &very oldpatients.• Pregnancy.
  29. 29. Copyright 2003, Elsevier Science (USA). All rights reserved.EDAADVANTAGES• No need for injections.• Anaesthetic effect only forrequired time; doesn’t lastlonger.• Residual analgesic effectlasts for several hours.DISADVANTAGES• High cost of the unit.• Intraoral electrodes are aweak link in the system.
  30. 30. Copyright 2003, Elsevier Science (USA). All rights reserved.CARE DURING OPERATIVE PROCEDURES An extremely gentle & careful approach during treatment goes along way in preventing pain and trauma to the patient The following measures will ensure proper care during operativeprocedures:1.Use of mouth mirrors to provide proper retraction of tounge ,cheeks& lips2. Application of rubber dam to ensure protection of the gingivaand adjacent hard and soft tissues.3. Avoid use of slow speed drill for gross removal of toothstructure, as it is time consuming & produces heat & vibrations thatare traumatic to patient.4. Use of airotor with coolant for initial cavity preparationstage.
  31. 31. Copyright 2003, Elsevier Science (USA). All rights reserved.Cont’d…………5.While treating deep carious lesions use of slow speed , round steelburs or spoon excavators to remove soft caries will provide a bettertactile feel & prevent pulp exposure.6.Use of gingival retraction cords while working close to the gingivawill protect gingival tissues.7.Proper instrument grasps, rests & guards will prevent accidentaldamage to hard& soft tissues.8.Avoid rapid blast of air from air water syringe as it can induce apainful 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 pulpvitality & prevent postoperative pain.
  32. 32. Copyright 2003, Elsevier Science (USA). All rights reserved.CONCLUSION• Dentists should employ many ways to ensure thattreatment is comfortable &relatively free of pain.• Pleasant surrounding & pleasing chairside manners cancontribute greatly in relaxing the tense patients.• Use of standard methods like LA, EDA & even concioussedation is effective in reducing pain.• Furthermore, reducing postoperative pain helps to allaythe patient’s fear regarding dental treatment• Avoiding rough handling of lips& oral soft tissues, reducingpulpal damage during restorative procedures, reducingperiodontal damage due to high spots on restoration are allimportant factors in this regard.
  33. 33. Copyright 2003, Elsevier Science (USA). All rights reserved.THANKYOU

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