This document discusses the management of endodontic pain. It defines pain and related terms like hyperalgesia. It describes the pathways of pain transmission, including the gate control theory. It discusses factors that affect a patient's pain threshold like fear. It outlines the types of dental pain and the nerves involved in transmitting pain signals. Finally, it discusses various clinical strategies for managing endodontic pain, including pulpotomy, pulpectomy, incision and drainage, and occlusal reduction. It also covers effective medical management using analgesics and anxiolytics.

1. MANAGEMENT OF ENDODONTIC
PAIN
Aaron Sarwal, MDS 2nd Prof

2. PAIN
 An unpleasant sensory or emotional
experience resulting from a noxious stimulus,
usually associated with actual or potential
tissue damage. (WHO)
 It is the body’s protective response against
noxious stimulus, it is associated with reflex
withdrawal which is protective.

3. PAIN RELATED TERMS
Sr.
No.`
Term Definition
1. Nociceptor
A high-threshold sensory receptor of the peripheral
somatosensory nervous system that is capable of
transducing and encoding noxious stimuli
2. Hyperalgesia
Increased pain from a stimulus that normally provokes
pain
3.
Neuropathic
pain
Pain caused by a lesion or disease of the somatosensory
nervous system
4. Allodynia
Pain due to a stimulus that does not normally provoke
pain
5. Sensitization
Increased responsiveness of nociceptive neurons to their
normal input, and/or recruitment of a response to

4. FACTORS AFFECTING PAIN
THRESHOLD

5. FEAR AND PAIN
 It is and emotion
stemming from the
lack of knowledge.
 Patients are
apprehensive and
fearful because they
do not know.
 It is not a physical
phenomenon.
 It is the body’s natural
response to a noxious
stimulus.
 It is a safety
mechanism that
prevents us from
inadvertently hurting
our bodies.
 It is a physical
FEAR PAIN

6. Pain Reaction

8. PATHWAYS OF FEAR IN
DENTISTRY

9. ANXIETY AND PAIN
MANAGEMENT

10. PATHWAY OF DENTAL
PAIN
•Neurons communicate via an electro-
chemical process:
•ELECTRICAL: Resting potential, action
potential and refractory period.
•CHEMICAL: When the action potential
reaches the terminal buttons on the ends
of the terminal branches, it causes the
synaptic vesicles to
release neurotransmitters into the
synapse. Eg. Acetylcholine, Dopamine.

11. PAIN RECEPTORS IN THE PULP
 Aδ fibres are lightly
myelinated and smaller
diameter, and hence
conduct more slowly than
Aβ fibres.
 They respond to
mechanical and thermal
stimuli.
 They carry rapid, sharp
pain and are responsible
for the initial reflex
 C fibres are unmyelinated
and are also the smallest
type of primary afferent
fibre.
 Hence they demonstrate
the slowest conduction.
 C fibres are polymodal,
responding to chemical,
mechanical and thermal
stimuli.
 C fibre activation leads to
Fast Response Fibers - Aδ
Fibers
Slow Response Fibers – C
Fibers

12. TYPES OF DENTAL PAIN
 Short, sharp pain, following
thermal, mechanical or
chemical stimulus.
 The hydrodynamic theory -
fluid movement within
dentine tubules activates
intradental A-delta nerve
fibres.
 Greatest pain sensation on
outward flow of fluid.
 Exacerbated by patent
 Typically resulting in
spontaneous prolonged
intractable poorly
localised pain
 C-fibres are activated
directly by local
inflammatory mediators
D
Dentine Sensitivity Pulpal inflammation

13. NERVOUS
PATHWAY OF
DENTAL PAIN
 The trigeminal nerve is the 5th
cranial nerve and it is the largest
of the twelve cranial nerves.
 It contain both sensory and
motor fibers.
 The nerve is attached to the
lateral wall of the pons by two
roots, large sensory and small
motor.
 The nerve passes forward and
at the apex of the petrous part of
the temporal bone the large
sensory root expands to form

14. NEURAL THEORY OF PAIN
TRANSMISSION
 Given by Fields in 1987. Later modified by others.
 Processing of pain from the stimulation of primary
nociceptors to the subjective experience of pain into 4
steps:
 Transduction
 Transmission
 Modulation
 Perception

15. THEORIES OF PAIN
TRANSMISSION
 Specificity Theory
 Pattern Theory
 Gate Control Theory

16. SPECIFICITY THEORY

17. PATTERN THEORY

18. GATE CONTROL THEORY
Ronald Melzack and Patrick Wall proposed the Gate Control Theory in
1965.

19. HOW DOES GATE CONTROL THEORY
WORK?
 The SG has both excitatory and inhibitory synapses with the
T cells.
 Three kinds of neurons send signals to the SG. Two of them
(A-delta and C) are slow conducting and transmit pain
signals; the third (A-beta) inhibits the transmission of pain
signals.Pain Signal ---> Excites the SG+ --->Opens Gate ---> T-cells fire ---> Pain signal
sent
Non-painful Stimulus ---> Excites the SG - --->Closes Gate ---> T-cells inhibited
--->

20. DIAGNOSTIC CONSIDERATIONS
 Is the pain of odontogenic
or non-odontogenic origin?
 Is the tooth vital or non-
vital?
 Is the pain due primarily to
an inflammatory or
infectious process?
 Is the pain of pulpal or
peri-radicular origin or
both?

21. SIGNS AND SYMPTOMS OF PAIN
 PULPAL PAIN
 Patient not able to
localize the pain.
 Sharp, electric shock
like sensation.
 Tooth suffering from
strictly pulpal pain is not
tender to percussion.
 Pain can be elicited by
probing the cavity.
 Pain relived on
removing the stimulus
 PERIODONTAL PAIN
 Patient is able to identify
the offending tooth.
 Tooth is usually tender.
 Laterally or apically
 Pain is sharp but
doesn’t relive
completely on removing
stimulus.
 It is possible for a non-
vital tooth to be tender
on percussion.

22. Methods of Pain Control
 As pain is divided into two phases:
 Pain perception
 Pain reaction
 Methods of pain control affect either one of the
two phases.

23. • Removing the cause of pain prevents the initiation of the painful
impulse.
Removing the cause of
pain
• A suitable drug possessing local analgesic properties is injected
into the tissue in proximity to the nerve involved.
Blocking the pathway of
the impulse
• Certain drugs that have analgesic properties which result in
raising the pain threshold centrally and thus interfere with the
pain reaction phase.
Raising the pain
threshold
• Eliminating pain by this method is within the scope of general
anaesthesia. The anaesthetic agent by its increasing depression
of the central nervous system prevents any conscious reaction
to a painful stimuli.
Preventing pain reaction
by cortical depression
• This method depends for its effectiveness on putting the patient
in proper frame of mind. One of the most important factors in
this method is the honesty and sincerity toward the patient.
Using psychosomatic
method

24. CLINICAL STRATEGIES:
PULPOTOMY
 A pulpotomy is often performed in cases of
acute pain of pulpal origin when there is
insufficient time to do pulpectomy.

25. CLINICAL STRATEGIES:
PULPECTOMY
 Since it is impossible for the
clinician to precisely determine
the apical extent of pulpal
pathosis, a pulpectomy offers
the advantage of complete
removal of the pulp.
 Pulpectomy is the course of
treatment often used in
patients who present with
symptoms of irreversible
pulpitis, or pulp necrosis with
or without swelling. All Pulp Removed And Replaced
With Medicated Filling

26.  Trephination is the surgical
perforation of the alveolar
cortical plate over the root
end of a tooth to release
accumulated tissue exudate
that is causing pain.
 The mucosa is retracted with
a tissue retractor, and a
number six round bur is used
to penetrate the cortical
bone.
CLINICAL STRATEGIES:
TREPHINATION

27.  It is presumed that if
apical trephination is
successful, its
success it based on
the
establishment of
drainage, relief of
pressure and the
removal of
inflammatory
mediators from the
periradicular tissues
CLINICAL STRATEGIES:
TREPHINATION

28.  A serious diffuse swelling is characterized by its
spread through adjacent soft tissues, dissecting
tissue spaces along fascial planes. Such a swelling
is called a cellulitis
 In endodontic cases, drainage is best achieved
through a combination of canal instrumentation and
when there is a fluctuant swelling incision and
drainage.
CLINICAL STRATEGIES: INCISION AND
DRAINAGE

29. CLINICAL STRATEGIES: INCISION AND
DRAINAGE

30. CLINICAL STRATEGIES: INCISION AND
DRAINAGE
SUTURING AFTER INCISION AND

31. CLINICAL STRATEGIES: INCISION AND
DRAINAGE

32. CLINICAL STRATEGIES: OCCLUSAL
REDUCTION
 The value of reducing occlusion to prevent pain
after endodontic instrumentation had been a
source of controversy
 Occlusal adjustment reduces mechanical
stimulation of sensitized nociceptors.

33. CLINICAL STRATEGIES: OCCLUSAL
REDUCTION

34. EFFECTIVE MEDICAL MANAGEMENT OF
ACUTE PAIN
 Diagnose and treat
the cause of pain
 Use a flexible
analgesic
prescription strategy
 Pretreat with NSAID
 Acheive profound
anesthesia

35. DIAGNOSE AND TREAT THE CAUSE
OF PAIN
 In most of cases
dental treatment
alone results in
substantial pain relief.
 Drug therapy is only
adjunct to dental
treatment.

36. A FLEXIBLE ANALGESIC PRESCRIPTION
STRATEGY: ASPRIN-LIKE DRUGS ARE INDICATED
• 200 to 400 mg ibuprofen or 650 mg asprinMild Pain
• 600 to 800 mg ibuprofen
• 400 mg ibuprofen plus non-narcotic / narcotic
combination analgesic equivalengt to 60 mg codeine
Moderate
Pain
• 600 to 800mg ibuprofen plus non-narcotic/ narcotic
combination analgesic equivalent to 10mg
oxycodeine
Severe Pain

37. A FLEXIBLE ANALGESIC PRESCRIPTION
STRATEGY: ASPRIN-LIKE DRUGS ARE
CONTRAINDICATED
• 650 to 1000mg ibuprofen
acetaminophenMild Pain
• 600 to 1000mg acetaminophen and
narcotic equivalent to 60mg codeine
Moderate
Pain
• 1000mg acetaminophen and narcotic
equivalent to 10mg oxycodeineSevere Pain

38. PRETREATING WITH NSAIDS
 Pre treatment with
NSAIDS delays the
onset of post op pain
 NSAIDS inhibit the
production and release
of chemical mediators of
inflammation
 Aspirin is not used prior
to surgical procedures

39. BARBITURATES- ANXIETY
RELIEF
 Depress all areas of CNS but reticular activating
system is most sensitive. They can impair
learning, short term memory and judgement.
 Short acting barbiturates
 Butobarbitone
 Secobarbitone
 Pentobarbitone

41. BARBITURATES
 If there are other medications involved, like if a person is
taking antihistamines, cold medicines, muscle relaxants, OTC
pain relievers or if a person is drinking alcohol, be careful.
 The combined effects of barbiturates and these other drugs
and substances on the central nervous system can be very
dangerous and may lead to unconsciousness or even death.
 Anyone who experiences symptoms of an adverse reaction to
barbiturates or a possible overdose should seek emergency
medical assistance immediately.

42. BENZODIAZEPINES
 Antianxiety benzodiazepines
 Diazepam
 Oxazepam
 Lorazepam
 Alprazolam

44. BENZODIAZEPINES

45. USING LONG ACTING LOCAL
ANESTHESIA
 Adequate anesthesia not only ensures
comfortable treatment but also reduces post
treatment pain.
 Etidocaine and bupivacaine are effective in
reducing pain.
 Etidocaine has faster onset of anesthesia.

46. MANAGEMENT OF FEAR IN
ENDODONTICS
 Pretreatment Anxiety Questionnaire
 Individual Systematic Desensitization And
Group Therapy:
 Individual systematic desensitization (ISD) is a
behavioural therapy whereby individuals are
gradually exposed or incrementally exposed to
fearful stimuli.
ACCEPT LEARN UTILIZE

47.  Flooding/Implosion
 Flooding is a form of
desensitization for treating
phobias when the patient has
a directly conditioned origin of
fear.
 In flooding therapy, the patient
is subjected to repeated
exposure of fear-inducing
stimuli until they no longer
MANAGEMENT OF FEAR IN
ENDODONTICS

48.  Cognitive Behavioral
Therapy
 Cognitive behavioral
therapy (CBT) is a
psychotherapeutic
approach to address
dysfunctional emotions and
negative behaviors and
cognitions using a series of
goal-oriented sessions
MANAGEMENT OF FEAR IN
ENDODONTICS

49.  Relaxation therapy is a diverse set of practices
aimed at eliciting a relaxation response,
including a reduction in overall physical
arousal symptoms.
 The phobic individual implements a particular
mental relaxation technique (e.g., slow
breathing, counting, relaxation swallowing) to
MANAGEMENT OF FEAR IN
ENDODONTICS

50.  Computer Assisted Relaxation Learning
 A recent development in the treatment of dental
fear, computer-assisted relaxation learning (CARL)
is a self-paced treatment for dental phobic
individuals for treating needle phobia.
 The program begins by introducing its purpose,
followed by activities and videos on how to cope
with their fear.
MANAGEMENT OF FEAR IN
ENDODONTICS

51. KEY POINTS
1. The pain experienced by patients is a result of the
interaction between sensory and emotional
experiences.
2. Aδ fibres transmit rapid, sharp, localised pain.
3. C fibres transmit slow, diffuse, dull pain.
4. Pain transmission can be modulated at a number of
levels, including the dorsal horn of the spinal cord
and via descending inhibitory pathways.

52. CONCLUSION
 Pain is both a sensory and emotional experience, and
patients past experiences, fears and anxieties can
play an important role.
 Pain transmission is a result of complex peripheral
and central processes.
 These processes can be modulated at different levels
and pain perception is a result of the balance between
facilitatory and inhibitory interactions.