The document discusses future trends in pain control in dentistry. It covers new local anesthetic drugs like articaine that have a faster onset and longer duration than lidocaine. It also discusses newer drug delivery systems for local anesthesia like electronic dental anesthesia, intra-oral lidocaine patches, and jet injection. Overall, the document focuses on advances in local anesthesia to improve pain management for dental procedures.

1. FUTURE TRENDS IN PAIN
CONTROL

2. CONTENTS
INTRODUCTION
PAIN - CLASSIFICATION
PAIN PERCEPTION -THEORIES
TRADITIONAL CONCEPTS IN PAINCONTROL
PREOPERATIVEADMINISTRATIONOF NSIADS
POST PROCEDURAL PAIN MANAGEMENT
FUTURETRENDS IN PAINCONTROL
OTHERADJUVANTTHERAPIES
REFERENCES
CONCLUSION

3. The management of pain in dentistry encompasses a number of
procedural issues, including the delivery of anesthetic and the
management of postprocedural pain, as well as pain diagnosis,
management strategies for orofacial conditions that cause pain
in the face and head.
INTRODUCTION:

4. It is defined as an unpleasant sensational experience initiated
by noxious stimulus & transmitted over a specialized neural
network to CNS where it is interpreted as such feeling
PAIN – DEFINITION:
PAIN (LATINWORD:PEONA) – PUNISHMENT OR PENALTY
PAIN is one of the most commonly
experienced symptoms in dentistry

5. Depending on experience, pain can be classified as :
1. Experimental
2. Acute
3. Chronic
PAIN – CLASSIFICATION:
< 6 MONTHS
> 6 MONTHS

6. Experimental
• Noxious stimuli
causes a mild
uncomfortable or
painful sensation
Acute
Pathological Pain
• Elicits a psychological or
behavioral reaction
• The cause of this
continuous pain is often
unknown to patient
• May create anxiety,
anger, physical gesture
• Usually alleviated with
the help of professional
care
Chronic
Pathological Pain
• Complicated physical,
behavioral and
psychological problem
• Experience of persistent
pain that last many months
to years
• Little apparent cause & not
self limiting
• Pain often increases over
time & is aggravated by
many factors
• Response is persistent
anxiety, confusion, sleep
disturbances, depression,
disability

7. Associated with:
Anesthetic injection
Restorative treatment
Periodontal procedures
Implant placement,
Tooth extraction
PROCEDURAL PAIN

8. A. Avoid accidental trauma
B. Good suturing
C. Proper injection technique including:
1. slow delivery of the drug
2. selection of the proper needle size
D. Topical anesthesia
E. Local anesthesia
CONTROL OF PROCEDURAL PAIN:

9. Thresholds for Sensation and Pain
 Three thresholds for sensation and pain help in understanding the
experience of pain :
1. Sensory threshold
2. Pain threshold
3. Pain tolerance/response threshold
PSYCHOLOGICALFACTORSMODYFYINGPAIN

10. PAIN PERCEPTION –THEORIES:
 SPECIFICITYTHEORY:
 Provided by Descartes in 1644
 Pain system - a straight through channel
Von Frey developed the “concept of specific cutaneous receptors for the
mediation of touch,heat,cold and pain”
 Free nerve endings were implicated as pain receptors
This theory was responsible for the development of several surgical
approaches to the management of chronic pain by cutting straight-through
tracts

11.  PATTERNTHEORY:
 In 1894,Goldscheider was the first to propose that stimulus intensity and
central summation are the critical determinants of pain
The theory states that “particular patterns of nerve impulses that evoke
pain are produced by the summation of sensory input within the dorsal horn
of the spinal column”
 Pain results when the total output of the cells exceeds a critical level.
 Eg : touch + pressure + heat = PAIN

12. GATE CONTROLTHEORY:
 Proposed by Melzack and Wall in 1965
 Postulates:
 Information about the presence of injury is transmitted to the CNS by small
peripheral nerves
 Cells in the spinal cord or nucleus of the fifth cranial nerve,which are excited by
theseinjury signals,are also facilitated or inhibited by other large peripheral nerves that
also carry information about inocuous events (temperature,pressure)
 Descending control systems originating in the brain modulate the excitability of
cells that transmit information about injury
Therefore,the brain recieves messages about injury by way of the gate control
system,which is influenced by 1)injury signals,2)other types of afferent impulses and
3)descending control

14. PHYSIOLOGY OF PAIN

15. CONTROL OF PAIN
It is one of the most important aspects of the practice of dentistry
Pain in many instances is considered as a necessary element of
everyday living because it is a warning of trouble.
METHODS:
 Removing the cause
 Blocking the pathway of painful
impulses
 Raising the pain threshold
 Preventing pain reaction by cortical
depression
 Using psychosomatic methods

16. LOCAL ANAESTHESIA
Transient 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
 The most commonly used local anesthetic is lidocaine HCL (also called
xylocaine or lignocaine) with a half-life of 1.5-2 hours
 It is considered as GOLD STANDARD
 It is least allergic and least toxic
 The best formulation for injection pain control is the gel
or paste topical anesthetic. These include
 Lidocaine or benzocaine in ointment – 3 mins
Tetracaine+benzocaine in spray form – 1 min

17.  Supra periosteal infiltration
 Regional nerve block :depositing suitable local anesthetic solution
close to a main nerve trunk preventing afferent impulses from
traveling centrally beyond that point
LOCAL ANAESTHETIC PROCEDURES
Maxillary Anesthesia
 Posterior superior alveolar nerve
 Anterior superior alveolar nerve
 Greater palatine
 Nasopalatine
Mandibular Anesthesia
 Inferior alveolar nerve block
 Incisive nerve block
 Mandibular block
 VasiraniAkinosi technique (closed
mouth technique)

18. Additional Local Anesthetic Procedures
 Intra Osseous Anesthesia
 Intra LigamentaryAnesthesia
 Intra Septal Anesthesia
 Intra PulpalAnesthesia
o Other local anesthetic agents in current use include articaine (also called
septocaine or ubistesin), bupivacaine (a long-acting anesthetic),
and mepivacaine
o Also, most agents come in two forms: with and without epinephrine(adrenaline)
or other vasoconstrictor

19.  Giving lornoxicam oral medication prior to nerve block, significantly improved the
efficacy of the procedure in comparison to placebo, suggesting that pre-
administration of this NSAID may be useful in establishing good anesthesia in patients
with irreversible pulpitis .
Preoperative administration of NSAIDS
Post-procedural Pain management
Analgesics
 The most commonly used drugs for relief of toothache or pain
 NSAIDs , Paracetamol(acetaminophen) , aspirin
Ibuprofen , naproxen , Aspirin
 Work by blocking the action of both COX -1 and COX-2 thus inhibits
prostaglandin synthesis
 Ibuprofen occasionally causes xerostomia (dry mouth) that may increase
oral plaque and dental caries

20.  A number of drug/dose combinations were found to have demonstrated over 50%
reduction in postprocedural pain including:
1. ibuprofen 400 mg,
2. diclofenac 50 mg,
3. etoricoxib 120 mg, (Longest half-life >8 hours)
4. codeine 60 mg plus paracetamol 1000 mg,
5. celecoxib 400 mg,
6. and naproxen 500 mg.
 In patients with GI or kidney problems, a Cox-2 inhibitor such as Celebrex can
be prescribed to reduce potential adverse effects.
 Moderate postprocedural pain may necessitate the prescription of an opioid
drug or tramadol combined with an acetaminophen or a NSAID.

21.  Preoperative oral NSAID, one hour before start of treatment
 Local anesthetic of choice for pain control during surgery
 Bupivacaine or etidocaine HCL administration at END of procedure immediately
prior to dismissal of patient
 Continue oral NSAIDs on timed basis for number of days deemed appropriate
 Postoperative telephone call evening of appointment
Pain Management Protocol

22. FUTURETRENDS
NEWER LOCAL ANAESTHETIC DRUGS
1.ARTICAINE:
 Belongs to amide group of LA
 Consists of thiophene ring
 Half life = 20mins
 Metabolism : liver & plasma{plasma esterase}
 Advantages :
Faster onset & longer duration of action
Higher success rate
Systemic intoxication is low
Increased diffusion into tissues including bone
Volume = 1.7 times> volume needed to that of 4% articaine compared
to 2% lignocaine
 Adverse effects :
Cause methemoglobinemia & neuropathies
High incidence of paresthesia{mostly with lingual nerve}
Ocular complications{for Infra Orbital Nerve Block}

23. 2.CENTBUCRIDINE:
 LA molecule synthesized at the centre for drug research of India{Lucknow}
 Its a quinolone derivative
 Advantages:
0.5% Concentration [4-5 times potent than 2% lignocaine] is effective
for infiltration,nerve block and spinal anaesthesia
Longer duration of action
Its topical action is concentration dependent
 Uses : Ophthalmology and other medical specialities
 Disadvantages : Failure in validation of its use in controlling pain in
dental procedures
3.PHENTOLAMINE MESYLATE:
Used for reversal of effects of LA solution
It is a non selective alpha adrenergic blocking agent
Half life = 2-3 hrs
Peak concentration – 0.4mg/1.7ml [after 20mins]
Adverse effects :Diarrhea,facial swelling,hypertension,jaw&oral
pain,tenderness,vomitting
Advantages : Prevent post-operative anaesthesia induced injuries

24. NEWER DRUG DELIVERY SYSTEMS FOR LOCAL ANAESTHESIA
1. Electronic Dental Anesthesia – EDA
2. Intra-oral Lignocaine Patch- Dentipatch
3. Jet Injection
4. Iontophoresis
5. EMLA
6. Computer Controlled Local Anesthetic
Delivery Devices – CCLAD
7. Intra-osseous Systems – IO Systems
Electronic Dental Anesthesia:
This technique involves the use of the principle ofTranscutaneous Electrical Nerve Stimulation
(TENS) which has been used for the relief of pain
 Used as a supplement to conventional local anesthesia
 LIMITATIONS: Increased salivary flow and inability to use metal instruments freely
 CONTRAINDICATIONS: Heart disease, seizures, neurological disorders, brain tumors, patients
wearing pacemakers and cochlear implants

25. (Dentipatch):
 A patch that contains 10-20% lidocaine is placed on the dried
mucosa for 15 minutes.
 Hersh et al (1996) studied the efficacy of this patch and
recommended it for use in achieving topical anesthesia for both
maxilla and mandible.
Jet Injection:
 A small amount of local anesthetic is propelled as a jet into the submucosa without the use of
a hypodermic syringe/needle from a reservoir
This technique is particularly effective for palatal injections

26. Iontophoresis:
This technique first introduced in 1993 is a suitable
alternative for application of drug in achieving surface
anesthesia.
 It is a painless modality of administrating anesthesia.
EMLA – Eutectic Mixture of Local Anesthetics:
 It contains a mixture of lignocaine and prilocaine bases, which
forms an oil phase in the cream and passes through the intact skin
 Clarke et al in 1986 suggested the use of EMLA cream for
anesthetizing the skin prior to needle insertion as this reduces the
incidence of injection pain
 It is used more often for skin than intra orally

27. Vibroject :
 Small battery-operated attachment that snaps on to the standard dental syringe.
 It is a cordless, rechargeable, hand held device that delivers soothing, pulsed, percussive
micro-oscillations to the site where an injection being administered.
 Stimulates the sensory receptors at the injection site, effectively closing the neural pain gate,
blocking the painful sensation.
Dental vibe :

28.  Cordless device that uses both vibration and pressure to precondition the oral
mucosa.
 Accupal provides pressure and vibrates the injection site 360° proximal to the needle
penetration, which shuts the “pain gate.”
Accupal :
CCLAD Systems (Computer Controlled Local Anesthesia Delivery System):
 Milestone Scientific introduced the first CCLAD system in 1997 and was termed the “WAND” and
the subsequent versions were renamed as “WAND PLUS” and “COMPUDENT”.
 In 2001, DENTSPLY International introduced the “Comfort Control Syringe – CCS” and similar
devices originating outside USA were; “Quick Sleeper, Sleeper & One from France, “Anaeject” and
“Orastar” from Japan.

29. “Wand” has 3 components: Base unit, Foot pedal and Disposable Handpiece assembly.
 Base unit consists of a microprocessor and connects to the foot pedal and Handpiece assembly
that accepts the LA cartridge.
 LA solution from the cartridge passes through the microbore tubing in the Handpiece assembly
and attached needle into the target tissue.
“SingleTooth Anesthesia System – STA System”
Introduced by Milestone Scientific in 2007.
 Advantages :Dynamic Pressure Sensing – DPS‟ which provides continuous feedback to the user
about the pressure at the needle tip to identify the ideal needle placement for PDL injections.
Rate of Injection: 3 modes to control the rate of injection
1. STA mode: Single, slow rate of injection
2. Normal mode: emulates the Compudent device
3.Turbo mode: faster rate of injection – 0.06ml/s

30. “Comfort Control Syringes”
Consists of two components; base unit and syringe.
The most important functions of the unit (injection and aspiration) can be controlled
directly from the syringe.
Advantages of CCLADs:
1) Administer small quantities of LA solution continuously during needle insertion
2) Steady infusion of the anesthetic solution at the target site reduces the discomfort associated
with less controlled injections.
USES: restorations, pulpal therapies & extractions in pediatric dentistry.

31. Intra-Osseous Anesthesia:
The use of motor driven perforator to penetrate the buccal gingiva
and bone can be considered as the first modern technique of IO
anesthesia.
The devices used for this technique, inject the solution into the
cancellous bone adjacent to the root apex.
 Commonly used devices are:
i. Stabident
ii. X –Tip
iii. Intraflow
Stabident:
It includes a solid 27 gauge perforator needle with a beveled tip
and a plastic base which fits a latch type slow speed contra-angle
handpiece.
This perforator creates a small tunnel through attached gingiva,
periosteum and alveolar bone.
The angle of perforation is usually directed apically in the
mandibular incisor region whereas a more perpendicular angle is
advantageous in the molar region
 Later a 27 gauge ultra-short needle is used to deposit the local
anesthetic solution.

32. X –Tip:
This system consists of three parts; the drill/perforator, 25 gauge guide
sleeve that fits over 27 gauge drill and ultra-short 27 gauge needle.
The drill leads the guide sleeve through the cortical plate into the
cancellous bone.
The drill portion is removed, leaving the guide sleeve in place, which
directs the needle into the cancellous bone to deposit the LA solution.
Later the guide sleeve is removed with a hemostat.
Intraflow:
 “ALL IN ONE”SYSTEM that allows the operator to perforate the
bone and deposit the anesthetic solution in a single step.
The device is a dental handpiece equipped with an injection
system built into its body.
 A 24 gauge hollow perforator is used to penetrate the bone and
infuse the LA solution.
The anesthetic solution from the cartridge is routed to the
perforator by a disposable transfuser that also serves to cover the
switch used to select between the perforator rotation and
anesthetic infusion modes.

33. Clinical uses of IO Anesthesia:
Most common application is for Single tooth anesthesia.
 It can also be used as a primary method of pain control or as a supplementary technique in
refactory cases.
These systems help to achieve profound anesthesia in cases of irreversible pulpitis of lower
molar teeth.
 It also helps in treating children and adolescents due to its quick onset of action, limited
duration and minimal collateral anesthesia
Side effects and Complications of Intra Oral Anesthesia:
1.Tachycardia, hence this should be avoided in patients at risk of cardiovascular disease
particularly when used with a vaso-constrictor
2. Separation of perforator drill / needle from its plastic holder.This happens when the
perforation is difficult or the drill heats up from overuse
3. Overheating of bone and macerating of overlying soft tissue may cause pain, swelling and
localized injections
4.Post injection hyper-occlusion, pain and chewing soreness are other symptoms reported
5.Dentinal tooth damage and osteonecrosis of bone may rarely occur after IOA injection.

34. A total of 90% of the patients experienced no pain during the operation (rated at 1 point)
NEWERMETHODSOF SEDATION
Used for dental implantation with screw implants or for the alveolar ridge augmentation
with biocompatible materials

35. It is formulated in a pre-filled, single-use nasal sprayer: 6 mg tetracaine HCl and 0.1 mg
oxymetazoline HCl (equivalent to 5.27 mg tetracaine and 0.088 mg oxymetazoline) in each
0.2 mL spray.
Patients noticed that their upper teeth felt numb, which led to interest for application
of this type of anesthesia for dentistry.

36. This device is a promising breakthrough in pain and anxiety management and may
deliver solution for clinicians plagued with patient pain phobia
By creating micro vibration, this device would be effective in reducing the pain and
anxiety confronted with most types of intraoral injections as palatal, mandibular block,
intraligamental and local infiltration
It is also more useful for pediatric patients and those who have a phobia of intraoral
injection or pain.
a) stainless steel shell containing motor and eccentrically
weighted plate
b) power switch
c) stainless steel cap
d) four flexible attachment arms for firm attachment and
shell concavity for well adaptation on syringe barrele)

37. 1. Acupuncture
2. Placebos
3. Ultrasound
4. Deep heat
5. Massage
6. Hypnosis
7. Physical activity
8. Exercises
9. Counselling
OTHER ADJUVANT THERAPIES

38.  Pain is a diagnostic challenge. A doctor should be aware of the physiological
and psychological aspects of pain and anxiety as it applies to the patient.
 Adequate clinical assessment and diagnosis are the keys to successfully
manage such painful conditions.
CONCLUSION

39.  MALAMED SF. HANDBOOK OF Local anesthesia.5th edition. St.Louis, Mo:CV
Mosby;2004:274-2754TH .
 TEXT BOOK OF MEDICINE :DAVIDSON
 TEXT BOOK OF ENDODONTICS : INGLE
 PATHWAYS OF PULP : COHEN
 MONEIHM’s LOCALANESTHESIA : C R BENNET
 ESSENTIALSOF MEDICAL PHYSIOLOGY : K. SEMBULINGAM
REFERENCES