Comprehesive course on local anesthesia

1. Dental Pain
Islam Kassem,BDS,MSc,FDS RCS
Consultant Maxillofacial Surgeon

2. Patient’s idea about dentistry
• Usually it starts few days before visiting
the dental office , and all the information
since childhood are collected and
processed , but luckily the latest
experiences are easier to appear in
memory

3. Patient’s idea could be :
• Fearful place
• Professional group
• They know what to do
• I am different than others
• Painful
• Expensive , do I have to sell my car
• Will not feel me

4. Fearful place

5. Professional group

6. They know what to do

7. I am different than others

8. Expensive !

9. • Pain is definitely the most but not the
only factors that causes worries to dental
patient

10. • So every patient
has a separate
personality and
thus there is no
standard
psychological
approach for all the
patients , but here
are some of the
suggested
approaches that
can work with most
of the patients and
can ease your
practice

11. Starting point , what happened that
patient chose your ADD.
• Patient is coming to your dental office
through different possible routes :
• - friends experience
• -suggested by another doctor in different
specialty
• Had read your ADD
• Or , lets try

12. • If the patient is referred to you by other
doctor or he was a call of friend
suggestion , so its expected that he is
easier to manage
• Patients come from Adds or general
suggestion might require extra
psychological care

13. A moment of call or arrival

14. Analyzing vs. fear
• Even patient might be afraid upon his
arrival , but he or she will still try to have
close-look of the place and do
unconscious analysis of the current
situation including :
• Cleanliness
• Price

16. Some suggestions for first inquiry
• In my presentation I would suggest to :
• Not let the receptionist wear surgical
scrub as it might be too early for the
patient to get ready mentally for the ideal
of medical or dental care , instead you
can use professional suits or casual
clothes but not too casual

17. • The second suggestion is to remove the
trash can from any visible place in the
reception , instead let him keep any
wastes or have him assisted by the
receptionist to put in her trash can .
• The trash can could have ( even if its
closed) some negative visual effect that
could be better skipped

18. ??

19. What patient observes in your banner
please don’t use obvious Photoshop
• Results , ,,,, and results

20. Thanks God,it’s not painful

21. Don’t tell , let him observe

22. First time appointment
• It’s the most
important
appointment , it’s
the key for building
confidence and
future trust
between patient
and dental team
• Patient’s fear might
be due to :
• Personal factors :
1-age
2-temper
3-other problems :
DAMP or AD

23. • External factors :
1-personality
2-social experience
3-family or background
**
Dental factors :
Mostly pain and related issues

24. Elegancy but !!

28. The written questionnaire
• should be simple and away from
complicated words
• Should be free of serious medical terms
• I suggest not to mention the method of
payment
• Should not be too personal

29. A big warm caring smile will break the
fear chain

30. Dental cabinet suggestion
shelf everything !

31. Busy cabinet gives chances to thoughts

32. Provocative things that might affect
negatively the patient psychology

35. Meet the patient
• The first step of psychological
management attempt is to call the
patient by his first name
don’t use alternatives , family names only
or other names , its important to establish
feeling of closeness and comfort

36. Welcome , don’t jump to treatment
• Its important to ask the patient simple
questions like :
1- how are you today ?
2- how are we doing today ?
if you were many staff and wearing similar
clothes he should know who is in charge

37. Where to seat the patient
• my suggestion is to let him sit directly on
the dental chair , and have him speak
about his problem while you are still far ,
this will get him used to the environment
faster and feels more comfortable to the
surgical environment

38. Repeat medical history but be careful
with your words
• Start gradually by asking do you have any
health problem?
• Are you taking any medication ?
• Then increase gradually to specify some
expected health problem , don’t use you
have diabetes but use did you even suffer
from diabetes or high blood sugar , do you
suffer from elevated blood pressure

39. Listen to the chief complaint but !!
• You should carefully listen
to patient chief complaint
, understand his problem
and his needs
• If patient is explaining
more , he might be afraid
to start dental treatment
and trying to consume
more time
• Give time for chief
complaint but control you
time by interrupting when
unnecessary details are in
subject

40. • Ask questions and be
careful with your words
• After you listen to patient
chief complaint never jump
into clinical examination
without repeating patients
own chief complaint for
two reasons :
• 1- to make sure you’ve
understand it
• 2-to let him feel that
you’ve understand it and
know what he wants
exactly

41. Clinical examination
• The movement toward dental chair should
be gentle , wear your mask , gown ,
gloves gently , if the patient is a child I
would suggest to explain what you are
doing , like :
• I am wearing this so I can see you
• I will wear the mask so I can get close to
you , or not cough directly to you

42. Comfort zone
• Its about 40 cm around patient face ,
getting closer than that suddenly might
let him feel that dentist in invading his
comfort zone
Too farToo close

43. •Be careful , the
patient is checking
your teeth

44. • Open the instruments in front of patient ,
I suggest mirror alone or first
• Start your examination by dental mirror
only , avoid touching the teeth
• Then go with your dental probe
(explorer ) gently , do not check caries
with your probe

45. Supine position
• I suggest to put the patient in
45 degrees position for few
second before you move to
supine position
• Say I will put the chair down
and it will stop alone
• Don’t use the sentences :
open your mouth but use
could you open , or can I
see , can I have it wider ?
• In children reinforce the
behavior by asking about the
secret of good behavior

46. Explaining treatment
• Again use simple words , away
from medical terms as possible
use to words :
• Anesthesia … instead of
injection
• Gel …instead of topical
anesthesia
• Use we ,,, not I ,, it gives more
professional team feeling
• Don’t jump to price till it’s the
end

47. Show don’t just explain

48. • Show the
patient what
he cannot see

49. Why you will change filling

50. • Why
extraction?

51. • Share your
findings

52. improvement

53. Anesthesia
• Gel in always
preferable than spray in
topical anesthesia
• Use good expensive one
, its your business
capital
• 2 minutes at least for
the topical to work ,
most dentists rush and
don’t wait !
• Use it in cotton stick
( bud ) preferably white
• Start with the palatal
topically to ensure
more contact time

54. Spend money on painless injection
its your asset
• But I
recommend not
using vibration
even it shows
good results in
some studies ,
but its still
uncomfortable
by patient
• Technologies are
variable :

55. Please do not show the patient your scary
instruments , don’t cause him panic twice

56. The blind spot
??

57. • Its important to not to show the needle
while injecting , the blind spot can serve
to help this problem in both child and
adult
• I don’t recommend taking it from the
right of the patient even if its hidden as
its still in his anxious spot

58. Utilizing the blind spot

59. Was it easy ? Right?

60. Avoid looking at patient eyes while in
dental chair
• In my opinion eye contact is important
prior sitting in dental chair , after sitting
direct eye contact might cause little
discomfort or fear to the patient , so try
to avoid it unless it deemed necessary

61. Bringing patient into the middle
• Patient might be father acting personality
or demanding
• Or young passive child personality ,
responding
• Or in-between
• Your job is to bring him into the middle ,
so he will understand and share with you
the treatment plan with trust to your
professional knowledge and experience

62.
don’t say “NO”
use alternative
• If you were asked any request by the patient and
you don’t have or you can not do this service
don’t answer by the word NO , instead use other
phrases to divert the request to the other options
• Example : ( patient has no infection but worried )
Patient : doctor , can you prescribe me antibiotics
Doctor : your teeth are fine there is no infection
Patient : but I guess I might need it
Doctor : ok , I prescribe you pain killer for the pain

63. • Notice the treatment
conversation went smooth
without saying the word no
• Other example :
Patient : doctor , can you do
me two teeth on time today
I really want to finish my
dental work as early as
possible
Doctor : I will do one tooth
for you today so we can have
better result
Again the conversation went
to the required direction
without saying NO , you
actually said it but didn’t
pronounce it

64. • Don’t confirm easy or difficult
extraction , just say let’s hope its easy
This way you involve him in the process
After extraction its better not to mention
“ its finished “ let it after biting on the
gauze , this way he will feel sudden
positive psychological impact

65. Patient who starts his story taking about
other doctor’s bad work
• This patient might have criticizing personality or
bad experience ,listen to him first to exclude
bad experience , if it was only method of
criticizing so you have to be careful when
suggesting treatment plan , it should be clear ,
sign consent form if possible and all expectation
and complication should be explained clearly

66. Obsessive and paranoid patient

67. Which type ?
Happy or miserable ?
OCD patient is excused and should not be
blamed

68. Gradual exposure is a successful method
to manage mild OCD in dental clinic

69. Management of patient with extra-
involvement in details
• Patient has the right to know the
details of his general dental
treatment , more questions can be
searched online or asked
separately .
• All the procedures must be
explained in clear straight way with
minimal scientific terms if possible .
• But in some cases extra-details are
been asked in every step , like
number on the bur and size of the
tip.
• These patients must be guided to
read further if they want but must
also informed about time constrains
and necessity to achieve proper
dental work

70. Failure

71. Failure management psychology
• One of the hardest
things is to manage the
anger or the blame of
the patient in case of
failure
• Its important to prepare
and inform about
possible complications
before starting up the
treatment , but one
should understand that
failure is a normal thing
that can happen to
every one , this is how
we learn

72. Failure to extract tooth after long time
trying
• This is one of the
common failures ,
especially with
fresh graduates ,
but it could
happen to any one.
• The most thing
that patient
worries is what will
happen during that
time till he sees
surgeon , and
mostly pain

73. Patient Waiting long time
• This patient usually is angry and
has lack of patience , I suggest to
smile nicely at the beginning of
treatment
• If the patient has nothing to do , do
anything even if its polishing but he
is expected treatment after this
waiting time

75. Tissue injury produces a biphasic
response
•Peripheral sensation
•Excitatory neurotransmitters
•Chemical mediators of the
inflammatory response
(substance P, prostaglandins,
leukotrienes, bradykinin,
serotonin and histamine)
• Central sensation
• Afferent traffic from the
site of injury and
activation of excitatory
amino acid NMDA
receptors in the spinal
cord

78. Morphine
Codeine
Hydrocodone
Oxycodone
Propoxyphene
“Caine Drugs”
Aspirin
Ibuprofen
Naproxen
COX-2s

79. Construction in Mouth

80. Erythoxylum Coca Shrub

81. NE
NE
NE
α1
β1
NE
Cocaine
End Result: Accumulation of Norepinephrine,
Sensitization of receptors,
CNS Stimulation, Vasoconstriction,
Tachycardia, Increased Contraction Force,
Avoid Epinephrine
NE
NE
NE
NE
NE
NE
COM
T
Inactive
Inactive
MAO

82. DA
DA
DA
β1
DA
Cocaine
End Result: Dopamine Accumulation,
Receptor sensitization,
Euphoria, Physical and
Psychological Dependence,
Cardiac Stimulation
DA
DA
DA
COMT
Inactive
MAO
Inactive

83. Cocaine + Vasoconstrictors =

84. NSAIDS
•largely due to the inhibition of cyclooxygenase
which prevents the formation of prostglandins
and thromboxanes
•COX -1 present in all tissues
•COX- 2 produced primarily at the ssite of
inflamation

86. central sensitization
• afferent traffic from the site of injury and
activation of excitatory amino acid NMDA
receptors in the spinal cord
• amplification of afferent nocioceptive input by
expansion of receptive fields with in the CNS

88. • mixed nerves that contain both
afferent and efferent fibers
• each axon is surrounded by
endoneurium -non neural glial cells
• individual nerves are bundled into
fascicles and and surrounded by
perineurium -connective tissue
• the entire peripheral nerve is
wrapped in epineurium composed of
dense connective tissue
the anatomy

90. nerve fiber classification
•size
•conduction velocity
•function
•the more myelin and the bigger the nerve the
faster the conduction velocity

91. nerve diameter myelin conduction location function
A-alpha,
A-beta 6-22 + fastest a/e joints,
muscles
muscles and
propriocepti
on
A-delta 1-4 +
6x
slower
afferent
sensory
nerves
pain, touch,
temp
B <3 +
1.5 x
slower
sympathetic auto
C
0.3-
1.3
-
5-10x
slower
sympathetic
auto,
pain,
temper

93. resting membrane
potential
• resting memnrane potential of most
nerve cells is - 60 to -90 mV.
• cells at rest are more permeable to
K+ ions and because the
concentration of K+ is about 30 x
greater inside the cell than outside

94. depolarization
• when the cells are active, Na+ channels
are openedand the Na+ permeability
increases so the membrane potential
becomes less negative
• if the membrane potential increases
enough additional Na+ channels open
and a wave is propagated along the
axon

95. action of LA
• local anesthetics prevent the opening
of Na+ channels and prevent the
membrane potential from increasing
sufficiently to open additional Na+
channels

96. The problem is that the Na channels
need to be blocked from inside the
cell!

97. acidic alkaline
influenced by pH of
surroundings
LA H + LA + H+
lipid insoluble
do not cross cell membranes
lipid soluble

98. pKa
the pH at which the ratio of ionized to non-ionized
molecules is 1:1
dissociatic constant

99. ambient pH <
pKa
ambient pH>
pKa
weak acid more unionized
more ionized
(lipid insoluble)
weak base
more ionized
(lipid insoluble)
more unionized

100. local anesthetics
• poorly soluble weak bases with pKa> 7.4 ( ie predominantly
ionized at a neutral pH
• consist of a hydrophobic portion ( tertiary amine) and
hydrophobic portion (unsaturated amine ring) linked by ester
or amide
• modification of the chemical structure alter potency, rate of
metabolism and duration of action