Fifth-year dental students Operative dentistry first semester

1. ALPINE SKI HOUSE
Dr. Inas Ayoub Elalem
inas.alalem@gmail.com
00970599448344
1
Operative Dentistry IV

2. ALPINE SKI HOUSE
Control of Dental Fear &
Pain During Operative
Procedures
2

3. Dental fear
refers to the fear of dentistry and of receiving
dental care. Dental fear is not an unusual
condition, and may be a significant obstacle to
effective dental care. Painful, traumatic or
negative dental experiences, especially in
childhood, are important determinants of
dental fear

4. • Incidence:
Many dentally fearful people will only seek
dental care when they have a dental emergency,
such as a toothache or dental abscess. People
who are very fearful of dental care often
experience a “cycle of avoidance” in which they
avoid dental care due to fear until they
experience a dental emergency requiring
invasive treatment, which can reinforce their fear
of dentistry.

5. • Women tend to report more dental fear than
men, and younger people tend to report being
more dentally fearful than older individuals.
People tend to report being more fearful of more
invasive procedures, such as oral surgery, than
they are of less invasive treatment, such as
professional dental cleanings, or prophylaxis.

6. • Causes of dental fear:
1. Direct experiences.
2. Indirect experiences.

7. • Causes of dental fear:
1. Direct experiences:
Direct experience is the most common
way people develop dental fears. Most of the
people report that their dental fear began
after a traumatic, difficult, and/or painful
dental experience. However, painful or
traumatic dental experiences alone do not
explain why people develop dental phobia.

8. • The perceived manner of the dentist is an
important variable. Dentists who were
considered “uncaring” or “uninterested” were
found to result in high dental fear in patients,
even in the absence of painful experiences.

9. 2. Indirect experiences:
 Learning: Dental fear may develop as
people hear about others’ traumatic
experiences or negative views of dentistry.
 Mass media: The negative portrayal of
dentistry in mass media and cartoons may
also contribute to the development of
dental fear.

12. Stimulus generalization: Dental fear may
develop as a result of a previous traumatic
experience in a non-dental context. For
example, bad experiences with doctors or
hospital environments may lead people to fear
white coats and antiseptic smells. This is one
reason why dentists nowadays often choose to
wear less “threatening” apparel.

14. Causes of operative pain:
I. Instrumentation.
II. Physical and chemical irritation.
III. Miscellaneous.

15. Causes of operative pain:
I. Instrumentation:
A. Hand cutting instruments:
Dull instruments produce more pain
than sharp one as they need greater force to
be applied to the tooth structure. This insult
will be transmitted to the contents of the
dentinal tubules and produce pain
according to the hydrodynamic theory of
pain.

16. B. Rotary cutting instruments:
They can produce pain through heat
generation and vibration.
i. Heat generation:
Instruments with rotary speed of 10.000
rpm can produce a rise in the temperature
during the cutting at micro-contact area up
to l000 °C. The rise in the temperature is
limited to the contact points of the metallic
blades with the dentin. This temperature is
sufficient to cause pulp damage.

17. • Therefore, the usage of coolant is essential
and it is preferable to be in the form of air
water spray. High speed cutting device with
coolant have decreased but not completely
abolished pain due to multiple and repetitive
cutting of dentinal tubules.

18. • Blunt rotary instruments produce more friction
with the tooth substance thus, more heat and
consequently more pain. The pain produced
during cavity preparation is due to both heat
and the cutting of a large number of dentinal
tubules.

19. ii. Vibration:
Vibration occurs due to eccentricity and run-
out of rotary instrument , it causes Annoyance
and discomfort to the patient.

20. ii. Vibration:
It is unpleasant sensation experienced by
the patient that lowers the pain threshold. It is
caused by the rotation of the instruments. Most
patients can tolerate vibrations of 150-200
cycles per second, while if the vibration
exceeds 560 cps it will not be tolerated.
Vibration is absent in high speed devices and
this is considered as one of its advantages.

21. II. Physical and chemical irritation:
1) Dehydration of cavities
If an air jet is used alone, even for a
relatively short period, it will produce an
effect on the pulp that detected
histologically as migration of the
odontoblastic nuclei into the proximal ends
of the dentinal tubules (desiccation).
2) Strong drugs
As disinfectants which are
contraindicated in deep cavities nowadays.

22. III. Miscellaneous:
Certain procedures during tooth
preparation and restoration produce an un-
pleasant sensation instead of pain. Such as
placing the wedge to stabilize a matrix.
They are practically unnoticed when the
patient is under the influence of the local
anesthesia.

24. • Likewise, such procedures as the placement of
a rubber dam clamp, packing of the gingival
retraction cords prior to an impression of a
prepared tooth and the actual taking of an
impression that may require pressure or the
utilization of materials requiring temperature
changes. The elimination of such unpleasant
sensation is almost as important to many
patients as the elimination of pain.

26. • Treatment of dental fear and operative pain
Treatments include a combination of
behavioral and pharmacological techniques.
Behavioral techniques
Behavioral strategies used by dentists
include positive reinforcement (e.g. praising the
patient), the use of non-threatening language,
and tell-show-do techniques. The tell-show-do
technique was originally developed for use in
pediatric dentistry, but can also be used with
nervous adult patients.

27. • The technique involves verbal explanations of
procedures in easy-to-understand language
(tell), followed by demonstrations of the sights,
sounds, smells, and tactile aspects of the
procedure in a non-threatening way (show),
followed by the actual procedure (do).

28. Certain aspects of the physical environment also
play an important role in alleviating dental fear.
For example, getting rid of the smells
traditionally associated with dentistry, the dental
team wearing non-clinical clothes, or playing
music in the background can all help patients by
removing and replacing stimuli which can trigger
feelings of fear.

29. Some anxious patients respond well to more
obvious distraction techniques such as listening
to music, watching movies, or even using virtual-
reality headsets during treatment. This technique
can also be referred as audio-visio analgesia.

31.  Pharmacological techniques
Pharmacological techniques to manage
operative pain can be achieved by profound
anesthesia. But in the case of apprehensive
patients it ranges from mild sedation to general
anesthesia, and are often used by dentists in
conjunction with behavioral techniques.

32. A. Surface anesthesia:
This is achieved by the application of
creams or sprays to the dried mucosa before
the injection is given. If a suitable period of
time is allowed to elapse after application,
anesthesia of the superficial tissues will be
produced so that the patient does not feel the
initial entry of the needle. These agents do not,
however, prevent discomfort from the passage
of the needle into the deeper tissues or the
sensation associated with the discharge of the
local anesthetic solution.

34. B. Local anesthesia:
It is the most satisfactory method to
eliminate pain and to establish a good dentist
patient relationship. Unfortunately, there is
wide spread fear of injection which may be
associated with child hood experiences.

35.  Advantages of local anesthesia:
1) Elimination of pain.
2) Elimination of apprehension associated with
anticipation of pain.
3) Allows patient to relax thus relieves muscle
tension facilitating retraction of lips, cheeks
and tongue thus improving access and
visibility.
4) Allows patient to tolerate extended
procedure thus saves time.
5) Allows operator to work in a relaxed
atmosphere.

36.  Contraindications of local anesthesia:
1) Cardio-vascular diseased patient: anesthesia
should be free of vasoconstrictor.
2) Hyperthyroidism: same as cardiac patient.
3) Allergies: rare but does exist, one should use
another group of LA.
4) Local conditions: e.g. acute suppurative
infection in the area of injection may be
aggravated.

37. Procedure for administration of LA:
Explain to the patient where the injection is
to be administered and the degree of
discomfort anticipated.
Carefully dry the intra-oral injection site
with germicidal solution before application
of topical anesthetic.

38. Collect the syringe by working outside the
patients line of vision.
The solution should be preheated to body temp
to reduce discomfort.
Gently stretch the mucosa through which the
needle is to pass for smoother penetration.
Bring the syringe into position and gently
penetrate the mucosa.

39. Avoid any fast or sudden movements and
maintain a steady flow of talk with the patient
during this stage.
Apply light pressure to the plunger as soon as
the needle penetrate the tissues so that a very
small quantity of solution is ejected ahead of
the needle.

40. Advance the needle slowly behind this shield
of anesthetic solution until the tip reaches the
desired position then deposit the appropriate
amount slowly and gently into the tissues.
Remove the needle gently.
Check objective and subjective symptoms
before proceeding any further.

41. C. Electronic anesthesia:
This may be used as an alternative to
uncomfortable injections of local anesthetic.
The dentist puts electrodes on the cheeks,
which transmit a numbing electrical current
into the jaw. Some patients report that
electronic anesthesia is more effective than
medications.

44. E. Acupuncture and Acupressure:
Originating in China more than 4,000 years
ago, acupuncture is a form of medicine that
involves inserting needles into certain locations,
called acupoints, on the body. Research has
shown that acupuncture may trigger the body to
release pain-relieving chemicals in the body
called endorphins. A related technique is
acupressure, in which pressure is applied to the
acupoints instead of needles. Acupuncture is
becoming more common in general medicine,
but for now, it's something of a rarity among
dentists.

46. F. Sedation
 Oral sedation
Unlike analgesics, which block pain,
sedatives such as diazepam (Valium) relax the
central nervous system and help people feel
calmer and more relaxed. Dentists often avoid
oral sedatives because they typically take
about 30 minutes to work, and the side effects,
such as drowsiness, may last for hours.

47. Intravenous sedation
This technique usually is reserved for
patients who are undergoing extensive dental
procedures, although it can be used for those
who are simply too anxious to have dental
treatment done otherwise. A tranquilizer is
injected into a vein in the hand or arm.

48. Inhalation sedation
Nitrous oxide (laughing gas)
This is one of the most common forms
of in-office pain control. The gas helps
people feel relaxed or even euphoric
(laughing gas), and the effects wear off
quickly once the gas is turned off. Nitrous
oxide generally is used as a supplement to
other drugs, not as a replacement.

49. G. General anesthesia
This involves putting the patient to "sleep"
for the duration of the procedure. Some
dentists have the equipment and staff to
perform general anesthesia in the office, but
it's often done in a hospital setting. Because of
the risks of side effects, including drops in
blood pressure or heartbeat irregularities
(arrhythmias), general anesthesia should be
only used when other forms of sedation or
pain control aren't enough.

50. Laser drills
Some dentists are now using lasers to remove decay within a
tooth and prepare the surrounding enamel for placement of the
filling.
Lasers may cause less pain in some instances and result in a
reduced need for anesthesia.

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