This document provides information on pain and anxiety control in endodontics. It discusses the importance of managing patient pain and anxiety, outlines various local anesthetic techniques including infiltration, nerve blocks, and additional methods. It also covers selecting the appropriate local anesthetic based on factors like duration of treatment, contraindications, and provides expected durations of different local anesthetics. The document emphasizes the importance of psychological preparation of anxious patients and obtaining profound anesthesia before beginning endodontic procedures.

1. 8/15/2020
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2. PAIN & ANXIETY
CONTROL IN
ENDODONTICS
Prepared by,
Dr.Sachin Sunny Otta
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3. CONTENTS
• INTRODUCTION
• PATIENT PREPARATION
Initial management
- Psychological
- Painless injection
- When to anesthetize
• LOCAL ANESTHETICS : DRUGS
• LOCAL ANESTHETIC TECHNIQUES
Infiltration
Regional nerve block
Maxillary nerve block
- PSA
- ASA
- GP
- NP
Mandibular anesthesia
- IANB
- Incisive
- Gow gates
- V-A
Additional techniques
- PDL
- IS
- IO
- IP
• ADDITIONAL CONSIDERATIONS
• PAIN CONTROL : EMERGENCY PATIENT
• INADEQUATE ANALGESIA
• SEDATION/GENERAL ANESTHESIA
Oral sedatives
• ANXIETY CONTROL
Recognition of anxiety
Management of anxiety
- Iatrosedation
- Pharmacosedation
- Oral sedation
- IM
- Inhalational
- IV
- Combination
• PRE TREATMENT STRATEGIES TO IMROVE
IANB
• STRATEGIES TO REDUCE PRE OP & POST OP
PAIN
• STRATEGIES TO REDUCE INTRA OP & POST
OP PAIN
• FLEXIBLE PAIN CONTROL STRATEGIES
• STRATEGIES TOWARDS HOT TOOTH
• PAIN MANAGEMENT CONTROL
PROTOCOL
• CONCLUSION
• BIBLIOGRAPHY 8/15/2020
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4. INTRODUCTION
“Pain is not a sensation,
it is an experience”.
Dr Welden. E.Bell
• MONHEIMS: An unpleasant emotional experience usually initiated by
a noxious stimulus and transmitted over a specialized neural network
to the central nervous system where it is interpreted as such.
• International Association for the Study of Pain: An unpleasant sensory
and emotional experience associated with actual and potential tissue
damage or described in terms of such damage.
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5. • “When a tooth is loose or painful is to be extracted, the nose of the patient
should be rubbed with brown sugar, ivy and green oil; he is advised to hold
his breath, a stone is then placed between his teeth, and he is made to
close his mouth. The fluid, which causes the pain, is then seen to flow from
the mouth in such quantity as frequently to fill three pots; after having
cleansed the nose with pure oil, and rinsed the mouth with wine, the tooth is
no longer painful, and may easily be extracted”.
SCRIBONIUS, AD 47
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6. • This historic anecdote illustrates Scribonius description of a method of
obtaining “anesthesia”. He was convinced that he would perform painless
extractions using what was apparently a rather crude technique of pressure
anesthesia.
• Our concern for the patient continues: How are adequate levels of
anesthesia attained to keep our patients relatively comfortable during
endodontic procedures? Obtaining profound anesthesia for the endodontic
patient is difficult and challenging.
• Many patients recount vivid (and often valid) accounts of painful
experiences. Although routine anesthetic techniques may be effective in
operative dentistry, endodontic procedures present special situations that
require additional techniques and special approaches.
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7. • Reduced to its simplest form pain is the sensation that occurs when it hurts!
• Humans suffer pain throughout their lifetime. It is not unusual to experience
unprovoked fleeting pains in the body that most people tend to ignore.
• However, because highly charged emotions are associated with the mouth,
people react more strongly to any form of oral pain.
• Clinically, endodontic pain (the most frequent type of oral pain) can be
approached on several levels.
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8. • Usually patients have been preconditioned to, and echo, the unfounded
myths that perpetuate the unwarranted stigma of pain related to root canal
treatment.
• It is common for patients to challenge the dentist with phrases such as , “ I
hate being here,” “I hate needles,” “I hate Novocain” “ My friend said that
this is really painful” etc….
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9. • The dentist should not loose patience or become irritated. It is up to him or
her to neutralize the patient’s fears by showing concern and offering
assurance that everything possible will be done to make the visit
comfortable.
• The dentist must convey understanding of the patients’ fears and
reassurance that they will be catered to.
• A light remark can ease the tension, for example, “There will be very little
discomfort with the procedure”, adding jokingly, “Probably the fee will hurt
the most”.
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10. • The key to successful patient relations is profound anesthesia.
• One should NOT commence treatment until one is unequivocally certain
that the anesthetic has achieved the greatest depth possible.
• Even then, the patient may experience unexpected pain. One should be
continually aware of the facial and body movements of the patient during
the initial access.
• Patients find it reassuring if the dentist stops periodically to ask if it hurts.
Postoperative instructions include words of advice, caution, and again
reassurance. Inform the patient to expect a few days of some discomfort or
mild pain that will gradually subside. This alerts the patient about what to
expect and defuses alarm if there is a little protracted pain.
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11. • At the start of endodontic therapy, local anesthesia is used to manage
patient’s pain and anxiety.
• Studies have demonstrated that fear of pain is one of the major reasons for
adults not seeking dental care.
• Fear keeps some patients from visiting the dentist until they experience
excruciating dental pain. This pain they experience has been shown to be a
significant factor in increasing the incidence of life threatening medical
emergencies arising during dental treatment, because it is clinically more
difficult to obtain profound pulpal anesthesia when pain or infection has
been present for a prolonged period of time.
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12. • Data obtained from 4,309 dentists in independent surveys by Fast and
Malamed reported that an array of 30,608 emergency situations arising in
their practices over a ten-year period.
• Emergencies ranged from benign (eg: syncope) to the catastrophic (eg:
cardiac arrest).
• 75% of the emergencies listed may have been precipitated, in part, by the
increase stress (fear or pain) that is so frequently associated with dental
treatment.
• Syncope alone accounted for 50.43% of the reported emergencies.
• Other potentially “stress-induced” problems included angina pectoris,
seizures, acute asthmatic attacks, hyperventilation, cardiac arrest,
myocardial infarction, acute pulmonary edema, cerebrovascular accident,
acute adrenal insufficiency, and thyroid storm.
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13. • Fear and pain are associated with an increase occurrence of emergency
situations, as was further confirmed by Matsuura, who reported that 77.8% of
life-threatening systemic complications in the dental office developed either
during or immediately after the administration of local anesthesia or during
the ensuing dental treatment.
• Of those emergencies arising during dental treatment, 38.9% developed
during extraction of teeth and 26.9% occurred during pulpal extirpation (two
procedures where adequate pain control is frequently difficult to obtain).
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14. • It appears that the occurrence of sudden and unexpected pain can induce
profound changes in the cardiovascular, respiratory, endocrine, and central
nervous systems which may lead (in certain situations) to a potentially
significant medical emergency.
• The problems of the management of pain and anxiety are closely related.
• Pain produced by dental treatment can usually be minimized or entirely
prevented through thoughtful patient management and judicious use of the
techniques of pain control, especially local anesthesia. Unlike most types of
General surgery dentist often involves recurring treatment. Consequently, it
is desirable that comfortable anesthesia be provided to patients to reinforce
their motivation to return for future care.
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15. LOCAL ANESTHETICS: DRUGS
The following are the local anesthetic drugs that are currently used in dentistry:
1. Lidocaine
2. Mepivacaine
3. Prilocaine
4. Bupivacine
5. Etidocaine
6. Articaine
• With this availability in various combinations (with and without vasopressors), it is now
possible to select a drug possessing the specific properties required by the patient
for a given dental procedure.
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16. Other agents used in the past for extirpating pulp painlessly include:
1. Arsenic
2. Paraformaldehyde
3. Diathermy
• These methods are inadequate and time consuming.
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17. FACTORS AFFECTING THE DURATION
OF ANESTHESIA
• Factors that affect both the depth and the duration of a drug’s anesthetic
action, either prolonging or decreasing it are:
1. Individual variation in response to the drug administered.
2. Accuracy in administration of the drug.
3. Status of the tissues at the site of drug deposition (i.e., Vascularity, pH)
4. Anatomic variation
5. Type of injection administered (i.e.: Supraperiostal, nerve block)
• The duration of anesthesia is presented as a range. Eg: 40-60 minutes.
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18. SELECTION OF LOCAL
ANAESTHETIC
• The selection of local anesthetic should be based on the following criteria:
1. Duration of dental procedure
2. Requirement of hemostasis.
3. Requirement for post-surgical pain control
4. Contra-indication to the selected anesthetic drug or vasoconstrictor.
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19. DURATION OF LOCAL ANESTHETICS
• Expected Duration of Pulpal Anesthesia:
Short-Duration Pulpal Anesthesia (< 30 minutes)
• Mepivacaine – 3% (20-40 min)
• Prilocaine – 4% (5-10 min) via infiltration
Intermediate-Duration Pulpal Anesthesia (About 60 minutes)
• Articaine 4% + Epinephrine 1:100,000+1:200.000
• Lidocaine 2% + Epinephrine 1:50,000, 1:100,000
• Mepivacaine 2% +Epinephrine 1:20,000
• Prilocaine 4% via nerve block ( 40- 60 minutes)
• Prilocaine 4% + Epinephrine 1:200,000 ( 60-90 min)
Long- Duration Pulpal Anesthesia ( >90 minutes)
• Bupivacaine 0.5% + Epinephrine 1:200,000
• Etidocaine 1.5% + Epinephrine 1:200,000 via nerve block.
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20. PATIENT PREPARATION
• Local anesthetic administration should always be preceded by a thorough medical,
dental and anesthetic history as well as the psychologic preparation of the patient.
1. The patient in acute pain may be frightened, exhausted, hypoglycemic,
dehydrated and even angry. Psychologic support may consist of attentive
listening, a drink of dextrose in water, a blanket for patient’s comfort and verbal or
non-verbal suggestions of care, concern and understanding.
2. Pre-operative administrations of drugs to relieve anxiety have also proved
effective.
3. Anti-anxiety exercises (deep rhythmic breathing) and using TLC (Tender Loving
care) are also very effective.
4. Providing uncomplicated explanation of the situation, along with one’s
expectation of a successful outcome, is most supportive.
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21. • Speed and haste must be avoided when treating an anxious person in
acute pain, especially during administration of anesthesia. Quiet, smooth,
preplanned efficiency is invaluable.
• Before proceeding, it may be kinder and more appropriate to prescribe
antibiotic and analgesic medication, allowing acute pain and infection to
subside.
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22. INITIAL MANAGEMENT
• Psychological Approach: this involves the four C’s: Control, Communication,
Concern, and Confidence.
• Control: of the situation is important and is achieved by obtaining and
maintaining the upper hand.
• Communication: is accomplished by listening and explaining what is to be
done and what patient should expect.
• Concern: is shown by verbalizing awareness of the patient’s apprehensions.
• Confidence: is expressed in the body language and in professionalism, giving
the patient confidence in the management, diagnostic, and treatment skills
of the dentist.
• Management of the four C’s effectively calms and reassures the patient,
thereby raising the pain threshold.
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23. • Painless injections:
• They can be achieved by following:
1. Obtaining patient confidence.
2. Application of topical anesthesia.
3. Solution warming: it is a common belief that an anesthetic solution warmed to or
above body temperature is better tolerated and results in less pain during injection.
However clinical trials and studies have shown that patients are unable to differentiate
between pre-warmed and room temperature anesthetic solutions.
4. Needle insertion: insert the needle gently into the mucosal tissues.
5. Slow injections: this is a very effective method of decreasing patient discomfort during
injection. Slow deposition of solution permits its gradual distribution into the tissues
without painful pressure.
6. Two stage injection: consists of initial slow administration of approximately quarter
cartridge of anesthetic solution under the mucosal surface; this will be nearly painless.
After some regional numbness occurs, additional anesthetic solution is given to the full
depth at the target site, usually with minimal pain.
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24. • When to anesthetize:
1. Preferably anesthesia should be given at each appointment.
2. There is a common belief that canals with necrotic pulps and periradicular lesions
may be instrumented painlessly without anesthesia. Even if the majority of the pulp
is necrotic, vital tissue exists peri-apically and often in the apical few millimeters of
the canal. This inflamed tissue contains nerves and is sensitive. Not only is the vital
tissue contacted during instrumentation, but also pressure is created and dentin
filings may be forced out of the apex. This may cause discomfort if the patient is
not anesthetized.
3. Another misconception is that once canals have been cleaned and shaped, it is
not necessary to anesthetize the patient at the obturation appointment. However,
during obturation pressure is created and small amounts of sealer may be
extruded beyond the apex. This may be quite uncomfortable. Many patients (as
well as dentists) are more at ease if regional hard and soft tissue anesthesia is
present.
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25. LOCAL ANESTHETICS: TECHNIQUES
• Fortunately many techniques are available to aid in obtaining clinically
adequate pain control during virtually all-endodontic procedures, even in
the presence of acute or chronic localized tissue changes.
1. Supraperiosteal injection (Local Infiltration)
2. Regional Nerve block
3. Periodontal Ligament Injection (PDL)
4. Intraseptal Injection
5. Intra-osseous anesthesia
6. Intra pulpal Injection
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26. SUPRA-PERIOSTEAL INJECTION
(LOCAL INFILTRATION)
• Supraperiosteal anesthesia is described as a technique in which anesthetic is
deposited into the “area” of treatment.
• Small, terminal nerve endings in the area are rendered incapable of
transmitting impulses.
• Infiltration anesthesia is commonly used in maxillary teeth because of the
ability of the anesthetic solution to diffuse through periosteum and the
relatively thin cancellous bone of the maxilla, this technique provides
effective pain control in maxillary endodontic procedures in the absence of
infection.
• Very often, however, where infection is present at the onset of an
endodontic case, infiltration proves ineffective and other anesthetic
techniques must be relied on initially.
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27. • Infiltration anesthesia is rarely effective in the adult mandible because of the
inability of the anesthetic to penetrate the more dense cortical plate of
bone.
• Teeth anesthetized Vol. of anesthetic Recommended needle
One maxillary tooth 0.6ml 27 gauge short
• The anesthetic solution should be deposited near the apex of the tooth to
be treated. Approximately 3- 5 minutes are allowed to elapse before
starting the procedure.
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28. REGIONAL NERVE BLOCK
• In the event that infiltration anesthesia proves ineffective in providing
clinically adequate pain control, regional nerve block anesthesia is
recommended
• Regional Nerve Block- is defined as a method of achieving regional
anesthesia by depositing a suitable local anesthetic close to a main nerve
trunk, preventing afferent impulses from travelling centrally beyond that
point.
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29. MAXILLARY ANESTHESIA
• Maxillary nerves that can be anesthetized and are of importance in
endodontic procedures are:
1. The maxillary nerve (V2)
2. Posterior Superior Alveolar (PSA) nerve
3. Anterior Superior Alveolar (ASA) nerve
4. Greater Palatine nerves
5. Nasopalatine nerves
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30. • PSA nerve block provides pulpal anesthesia to the three maxillary molars and
their overlying buccal soft tissues and bone.
• Anesthetic is deposited into the pterygomaxillary space located superior,
distal and medial to the maxillary tuberosity.
• In 28% of patients the mesiobuccal root of the first molar receives innervation
from the middle superior alveolar nerve, in which case an additional volume
of 0.6ml should be infiltrated high into the buccal fold, just anterior to the first
maxillary molar.
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31. • Teeth Anesthetized Vol. f Anesthetic (ml) Recommended Needle
  
Maxillary 1st, 2nd, 0.9 25 or 27 gauge short
3rd molars
• In addition, palatal infiltration may be required for anesthesia of the palatal
soft tissues for placement of the rubber dam clamp
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32. • ASA Nerve Block
• It is an easy injection to administer, providing anesthesia of
1. Infra-orbital nerves
2. ASA nerves
3. MSA nerves
• By depositing local anesthetic outside the infra-orbital foramen anesthesia
of:
• Maxillary premolars
• Anterior teeth
• and their overlying soft tissues and bone is obtained.
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33. • Additionally, soft tissues of the lower eyelid, lateral portion of the nose and
upper lip are anesthetized (Infra-orbital nerve).
• An important requirement for successful ASA nerve block is the application
of finger pressure over the injection site for a minimum of 2 minutes after
deposition of the anesthetic.
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34. • Teeth anesthetized Vol.of anesthetic Recommended Needle
  
Maxillary incisors, 0.9 ml 27 gauge long
Canine, premolars
• Deposition of 0.3 ml of anesthetic by infiltration into the palatal gingiva 3 to 5
mm below the gingival margin provides adequate anesthesia.
• Larger areas of palate rarely need to be anesthetized for endodontic
procedures, but when necessary two nerve blocks are available.
1. The greater palatine
2. Naso palatine
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35. • Greater Palatine Nerve Block
• It provides anesthesia to both the palatal hard and soft tissues ranging from
the distal of the third molar as far anterior as the medial aspect of the first
premolar.
• At the first pre-molar soft tissue anesthesia may only be partial because of
overlap from the nasopalatine nerve.
• Area Anesthetized Vol. of anesthetic Recommended Needle
  
Soft tissues palatal to 0.45 ml 27 gauge long
teeth
• Maxillary premolars & Molars.
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36. • Naso Palatine Nerves:
• They enter the palate through the incisive foramen, located in the midline just
palatal to the central incisors and directly beneath the incisive papilla.
• They provide sensory innervation to the hard and soft tissues of the pre maxilla as far
distal as the mesial aspect of the first premolar, where fibers from the greater
palatine nerve may be encountered.
• Area Anesthetized Vol. of Anesthetic Recommended Needle
  
Soft tissues palatal 0.45 ml 27 gauge, Long
to teeth
• Maxillary incisors, canine
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37. • Palatal anesthesia can be achieved with a minimum of discomfort if care is
taken throughout the procedure to ensure the following:
1. Adequate topical anesthesia
2. Adequate pressure anesthesia
3. Slow penetration of tissues
4. Continual, slow deposition of anesthetic
5. Injection of not more than 0.45 ml of solution
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38. • Maxillary Or Second Division Nerve Block
• Should be considered when other techniques of pain control prove
ineffective because of infection accompanied by inflammation.
• Area anesthetized Vol. of anesthetic Recommended Needle
  
Pulps of all maxillary teeth
overlying buccal s/t bone 1.8 ml 27 gauge long teeth on side of
injection
• Palatal hard and soft tissues on the injection side
• Upper lip, cheek, side the nose and lower eyelid
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39. Two intra-oral approaches are available for maxillary nerve block:
• The High Tuberosity Approach: Follows the same path as the PSA nerve
block except that the depth of the needle penetration is greater (i.e. 30 mm
Vs 16 mm in the PSA)
• The Greater Palatine Approach: involves entering the greater palatine
foramen, usually located palatally between the second and the third
maxillary molars at the junction of the alveolar process and the palatal
bone. A 27 gauge long needle is carefully inserted into the foramen to a
depth of 30 mm before 1.8 ml of anesthetic is deposited.
•
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40. • MAXILLARY TECHNIQUE BY FRIEDMAN & HOCHMAN
• This new technique called anterior middle superior alveolar nerve block
(AMSA), is best administered with a computer-controlled anesthetic delivery
system (Eg: The want). But, can be administered successfully with the
traditional syringe and needle system.
• It is administered on the palate at a point midway between the two
premolars and the midline of the palate.
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41. • Teeth Anesthetized Vol.of Anesthetic Recommended Needle
  
Maxillary incisors, 1.35 ml 27 gauge short
Canine, Premolars
• AMSA does not produce anesthesia of the face and muscles of expression.
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42. MANDIBULAR ANESTHESIA
Inferior Alveolar Nerve Block:
• Pulpal anesthesia of mandibular teeth is traditionally obtained through the
IANB.
• Teeth Anesthetized Vol. of Anesthesia Recommended Needle
  
Mandibular incisors, 1.5 ml 25 or 27 gauge long
Canine, Premolars,
Molars
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43. • Incisive Nerve Block:
• The incisive nerve provides sensory innervation to the pulps of the premolars,
canine, incisors and the bone anterior to the mental foramen.
• Anesthetic is placed outside the mental foramen, with finger pressure
applied at the injection side for a minimum of 1 min (2min is preferred) to
ensure entry of anesthetic into the mental foramen and mandibular canal.
• Teeth anesthetized Vol.of anesthetic Recommended Needle
  
Mandibular incisors, 0.6 ml 27 gauge short
Canine, Premolars
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44. • MANDIBULAR BLOCK: GOW-GATES TECHNIQUE
• This technique, first described by Australian George
Gow-Gates in 1973, provides adequate anesthesia of all
sensory portions of the mandibular nerve. (i.e.,: buccal,
inferior alveolar lingual, mylohyoid).
• The injection is given with the patient supine, his head
extended and his mouth opened widely.
• The syringe is aligned with a plane extending from the
lower border of the intertragic notch of the ear although
the corners of the mouth.
• Laterally, the syringe is aligned with the flare of the
tragus of the ear to the face and usually lies over the
mandibular canine or premolars on the opposite site.
• The needle puncture point is just medial to the deep
tendon of the temporalis muscle and as “close to the
cusps” of the “maxillary’” second molar as the syringe
will allow.
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45. • After the buccinator muscle is penetrated, the needle is advanced
effortlessly until a “definite bony stop” is detected, usually at a depth of 25 to
27 mm. This places the target area at the lateral aspect of the neck of the
condyle, below the attachment of the lateral pterygoid muscle.
• Teeth Anesthetized Vol.of Anesthetic Recommended Needle
  
Mandibular incisors, 1.8 – 3.0 ml 25 gauge long
Canines, premolars &
Molars
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46. • MANDIBULAR BLOCK: CLOSED-MOUTH
TECHNIQUE:
• This technique was described by Akinosi in
1977, and is indicated primarily when
mandibular opening is limited, owing to
infection, trauma or trismus.
• The Akinosi- Vazerani technique uses a 27
gauge long needle held in the maxillary
buccal fold on the side of injection at the
height of he mucogingival junction of the
most posterior maxillary tooth.
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47. • Needle insertion occurs into the soft tissues on the lingual aspect of the
mandibular ramus immediately adjacent to the maxillary tuberosity. Needle
is advanced as parallel as possible to the ramus to a depth of 25 mm.
• Disadvantage: Absence of a bony landmark before injection of the
anesthetic.
• Teeth Anesthetized Vol.of anesthetic Recommended Needle
  
Mandibular incisors, 1.8 ml 27 gauge long.
Canine, Premolars &
Molars
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48. ADDITIONAL LOCAL ANESTHETIC
PROCEDURES
1. PDL injection
2. Intraseptal injection
3. Intra-osseous injection
4. Intra-pulpal injection
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49. • PDL INJECTION:
• PDL injection or intraligamentary injection (ILI) may be used alone to achieve
brief, profound pulpal anesthesia in a single tooth.
• Indicated when no nerve block technique has proven to be effective.
• Mode of administration : Standard dental anaesthetic syringe, Computer
controlled anesthetic delivery systems (The wand or Single tooth anesthesia)
• Advantage: Profound anesthesia with minimal volume of anesthetic (0.2 to
0.4 ml) and the absence of lingual and lower lip anesthesia.
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50. • Technique: A 27 gauge short needle or a 30 gauge ultra short needleis firmly
placed into the periodontal space between the root of the tooth and
interseptal bone. A volume of 0.2 ml of anesthetic is “slowly” deposited on
the distal of each root of the tooth.
Successful PDL injection is indicated by:
• The presence of resistance to anesthetic deposition (back pressure).
• Ischemia (i.e.: blanching) of the soft tissues in the immediate area on
injection of the anesthetic.
• Teeth anesthetized Vol. of anesthetic
 
One Tooth 0.2 ml/root
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51. • INTRASEPTAL INJECTION:
• Intraseptal anesthesia described by Saadoun & Malamed is a variation of the IO
technique.
• A 27 gauge, short needle is inserted firmly into the cortical plate of bone, the soft
tissues having been anesthetized (either by infiltration or topical application) before
needle insertion.
• Because of decreased bone density, intraseptal anesthesia is more successful in
younger patients.
• Teeth Anesthetized Vol. of anesthetic Recommended Needle
  
One tooth 0.3 – 0.5 ml 27 gauge short
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52. • INTRA-OSSEOUS ANESTHESIA:
• The intraseptal & PDL injections are modifications of true IO anesthesia.
• IO anesthesia has been repopularised since the introduction of the stabident
local anesthesia system (Fainfax Dental, Miami, FL). It consists of a perforator,
a solid needle that perforates the cortical plate of bone with a conventional
slow speed, contra angle hand pipe, an 8 mm long, 27 gauge needle that is
inserted into this predrilled hole for anesthetic administration.
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53. • Advantage: Extremely effective in providing pulpal anesthesis in the “hot”
mandibular molar, immediate onset
• Disadvantage : transient increase in heart (Stabident & X-tip)
• Teeth Anesthetized Vol.of anesthetic Recommended Needle
  
One or two teeth 0.45 to 0.6 ml 27 gauge, short
• Recommended distal to the tooth to be anesthetised
• Mode of administration : Stabident system, X-tip system, Intra flow handpiece
• Duration of anesthesia : 45 min
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54. • Difficulty of locating the hole made by the perforator:
1. When handpiece is removed, clinicians should not take their eyes of the
perforation site until the needle has been inserted into the hole.
2. After perforating, stop the hand piece, detach the perforator and leave it
in the hole until the syringe and needle are lined up for inserted.
3. The X-tip has a cannula in place and remains in the hole after a perforation
is made. Now the needle is simply inserted into the cannula, which guides
it directly into the perforation.
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55. • INTRA-PULPAL INJECTION:
• A 27 gauge short needle is inserted into the pulp chamber or specific root
canal. The needle is firmly wedged into the chamber or canal and the
solution inserted under pressure.
• Anesthesia is produced both by the action of the local anesthetic and the
applied pressure.
• Teeth Anesthetized Vol.of anesthetic Recommended Needle
  
One tooth 0.2 to 0.3 ml 27 gauge, short
• Short duration of action (15-20 min)
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56. PAIN CONTROL: ADDITIONAL
CONSIDERATIONS
• In the overwhelming majority of endodontic procedures, if there is difficulty-
controlling pain at all, this happens only at the first appointment. Once the
canals have been located and the pulp extirpated, the requirement for pain
control becomes minimal.
1. Soft-tissue anesthesia may be necessary for rubber dam application.
2. Instrumentation within a thoroughly debrided canal seldom requires
anesthesia.
3. In the filling of canals, considerable pressure may be exerted during
compaction of the filling material and may produce discomfort and pain.
Local infiltration anesthesia should be considered before this procedure is
started.
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57. PAIN CONTROL: SUGGESTED
PROTOCOL FOR THE EMERGENCY
PATIENT
• Dentists contacted by a patient who is in acute pain have used the following
protocol (with considerable success) to provide comfortable treatment in an
endodontic emergency.
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58. • When initially contacted by telephone the dentist determines whether the
patient has taken oral analgesic medication.
• Most often the patient has, but if not, NSAID therapy is started. Preferably the
patient has taken two oral doses before the scheduled appointment.
• Treatment should not be delayed, however, if this cannot be done, the initial
goal is to relieve the patient’s acute problem: the pain.
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59. • On the arrival in the dental office the patient should be seen as soon as
possible after completion of appropriate records (including a health history
questionnaire). The dentist identifies the offending tooth and administers the
appropriate anesthetic injection technique to provide rapid onset of pain
relief.
• Radiographs can be obtained after successful administration of the local
anesthetic. The patient, no longer in pain, can return to the reception area, if
necessary, to await definitive treatment. Because the pain cycle has been
interrupted, the patient is able to relax, perhaps for the first time in days.
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60. • Before the start of definitive endodontic treatment, it is suggested that the
patient be reanesthetized, even if the original injection is still effective. All too
often the use of a high-speed hand piece evokes even more intense pain
than was present when the patient entered the office (i.e. the so called
“anesthetic window”). Readministration of the local anesthetic at this time
serves to reinforce the initial block, perhaps providing additional RN
molecules to diffuse into the neuronal tissues.
• If the patient still experiences pain, intraligamentary anesthesia should be
administered along with inhalation sedation. Nitrous oxide at 35%
concentration is equianalgesic to 10 mg morphine or 50 mg meperidine. In
most cases it does not completely eliminate pain, but it does alter the
patient’s perception of pain, making it more tolerable.
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61. • However in some few cases (most likely in mandibular molars) adequate
pain control may still be unattainable even with the combined use of local
anesthesia and inhalation sedation. In such situations the use of IO
anesthesia should be considered. IO anesthesia has achieved high success
rates in clinical situations. The IO technique is especially recommended in
cases of difficult to anesthetize mandibular molars.
• When the emergency treatment is completed, and if the dentist thinks there
may be considerable post-treatment pain, the patient should be
reanesthetized, with a long acting local anesthetic (etodocaine or
bupivacaine), providing that the dose of the local anesthetic thus far has
been small enough to permit it’s administration. This can ensure upto 10 to 12
hours of post-treatment pain relief.
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62. • The dentist should also reaffirm the importance of continued use of the oral
analgesic medication, as directed, even though the patient may still be
comfortable. It is easier to keep a patient free of pain than it is to eliminate
pain once it recurs.
• Again it is helpful to telephone later the same day to determine how the
patient is keeping.
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63. INADEQUATE ANALGESIA
In spite of normal dosage and technique, inadequate analgesia is obtained.
The main reasons for this are as follows:
❖Pulpal inflammation in the affected tooth produces hyper excitability of the
nerve fibers, particularly C fibers, such that the local anesthetic solution is
unable to block the conduction of all these impulses.
❖There is usually increased vascularity of the tissues in the region of the
inflamed tooth and hence the local anesthetic may be more rapidly
removed by the blood stream, shortening its period of duration.
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64. SEDATION OR GENERAL ANALGESIA
• There are rare and exceptional cases where the use of relative analgesia, IV
sedation or G.A is the only way that a vital pulp can be extirpated or an
abscess drained.
• Generally the reasons are not related to the effectiveness of L.A, but to the
attitude of the patient.
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65. ORAL SEDATIVE DRUGS
Benzodiarepines:
• Alprazolam – 0.25 – 0.50 mg
• Diazepam - 2-10 mg
• Flurazepam – 15 – 30 mg
• Lorazepam – 1- 3 mg
• Triazolam – 0.125 – 0.250 mg
Chlorahydrate – 500-1500 mg
Hydroxyzine – 50-100 mg
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66. ANXIETY CONTROL
• There are many causes of anxiety related to dentistry. Most frequently
encountered is the fear of pain, and in no specialty of dentistry is the
problem of pain control more acute than in endodontics.
• Because of this many patients are apprehensive when faced with the need
for endodontic treatment.
• Many adult patients do not openly admit their fears to the doctor. Rather
they sit in the dental chair, undergo dental care, and suffer in silence.
Suppression of these anxieties is not always innocuous.
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67. • Approximately 75% of the emergency situations reported may have been a
result of increased anxiety and dental related stress. The effect of
unrecognized and untreated anxiety on medically compromised patients is
even more significant.
• Patients with cardiovascular, respiratory, neurologic, and other metabolic
disorders (e.g. thyroid disease, diabetes mellitus, adrenal disorders) are
considered to be stress intolerant, representing an increase risk during dental
care if they become apprehensive or experience pain.
• Bennett has stated that “the greater the medical risk of the patient, the
more important it is to achieve adequate control of both pain and anxiety”.
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68. RECOGNITION OF ANXIETY
• Many fearful adult patients do not admit to being apprehensive about their
pending dental treatment. Therefore the task of exposing their fears
becomes a form of detective work, with the dentist and members of the
office staff seeking clues.
• The patient’s dental history can aid in this regard. Fearful patients may
exhibit a pattern of cancelled appointments, with a number of excuses for
this happening. A dental history of appointments for emergency treatment
of painful situations should also be suspect. Once the emergency is
alleviated (i.e. extraction, pulpal extirpation), the patient does not return until
their next episode of dental pain.
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69. • On arriving in the dental office, the patient often sits in the reception area
and discusses his or her fears of dentistry with other patients or with the office
receptionist. The receptionist must be conscious of the statements made by
patients concerning their attitude towards dentistry. The receptionist should
advise chair side personnel (i.e. dental assistant, hygienist, dentist) about
such patients.
• In the dental chair the dentist must spend some time at each visit speaking
with the patient. This allows the patient to “open-up”.
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70. ✓TOUCH THE PATIENT: The feel of the skin of the apprehensive patient when you shake
hands can tell much. Cold, wet palms usually indicate trepidation.
✓WATCH THE PATIENT: Apprehensive patients do not stop watching the dentist. They
are afraid that they will be “snuck up on” and unpleasantly surprised with a syringe
or some other instrument.
Nonfearful patients look comfortable in the chair, whereas fearful patients appear stiff,
unrelaxed, and on the verge of bolting from the chair.
Their hands may firmly grip the armrest of the chair in what is known as the “white
knuckle syndrome”.
They may clutch a handkerchief or shred a paper tissue without being aware of it. The
forehead and arms of nervous patients may be bathed in perspiration, despite
effective air-conditioning. Patients may even complain about the warmth of the
room.
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71. • The ideal time to detect anxiety is before the start of dental treatment. The
medical history questionnaire may be used to assist in fear recognition
before the start of dental treatment. Corah and Gale devised an anxiety
questionnaire to help determine the degree of a patient’s anxiety:
1. Do you feel very nervous about having dental treatment?
2. Have you ever had an upsetting experience in the dental office?
3. Has a dentist ever behaved badly towards you?
4. Is there anything else about having dental treatment that bothers you? If
so please explain.
• These questions permit patients to express their feelings about dentistry,
perhaps for the very first time. Many patients who would never verbally
admit to anxiety answer these questions honestly
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72. MANAGEMENT OF ANXIETY
• A variety of techniques for the management of anxiety in dentistry are
available. Together these techniques are termed a spectrum of pain and
anxiety control. They represent a wide range, from nondrug techniques
through general anesthesia. Although general anesthesia has a useful place
in this spectrum, its use today is quite limited. Two reasons for the decreased
reliance on general anesthesia as a means of anxiety control have been:
1. The introduction and acceptance of the concept of conscious sedation in
dentistry
2. The development in the past two decades of more highly effective drugs
for the management of anxiety.
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73. • From a practical point of view, conscious
sedation techniques present relatively safe,
reliable, and effective methods of
controlling anxiety with little or no added
risk to the patient.
• Conscious sedation is defined as “ a
minimally depressed level of consciousness
that retains the patient’s ability to
independently and continuously maintain
an airway and respond appropriately to
physical stimulation and verbal command
and that is produced by a pharmacologic
or non- pharmacologic method or
combination thereof”.
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74. • There are two major types of sedation:
• Iatrosedation: Techniques that do not necessitate the administration of drugs
for the control of anxiety (e.g. hypnosis, biofeedback, acupuncture, electro
anesthesia, and the clinically important “chair side manner”). This term,
introduced by Dr. Nathan Friedman is defined as “relaxing the patient
through the doctor’s behavior”.
• Pharmocosedation: Techniques that require drug administration.
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75. Iatrosedation
• The techniques of iatrosedation form the building blocks from which all
pharmacosedative techniques arise.
• A relaxed dentist-patient relationship favorably influences the action of the
sedative drugs.
• Patients who are comfortable with their dentist either require a smaller dose
of a given drug to achieve a desired effect or respond more intensely to the
usual dose. This is in contrast to patients who are uncomfortable with their
dentist.
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76. Pharmacosedation
• Although iatrosedation is the starting point for all sedative procedures in the
dental office, the level of anxiety present in many patients may prove too
great to allow dental care to proceed without pharmacological
intervention.
• Fortunately several techniques are available to aid in relaxing the
apprehensive patient.
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77. • The following goals are to be sought whenever pharmacosedation is
considered:
1. Patient’s mood must be altered.
2. Patient must remain conscious.
3. Patient must be cooperative.
4. All protective reflexes must remain intact and active.
5. Vital signs must be stable and within normal limits.
6. Patient’s pain threshold should be elevated.
7. Amnesia may be present.
• Drug administration in dentistry must never become an excuse for inferior-
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78. Oral Sedation
• The oral route is the most frequently used technique of pharmacosedation.
• It is recommended that oral sedation not be used to achieve deep levels of
sedation. Other, more controllable (i.e. titratable), techniques should be
used to achieve these levels.
• There are two recommended uses of oral route of conscious sedation:
1. If anxiety is severe the evening before dental treatment, the patient should
take an oral sedative 1 hour before going to sleep.
2. If anxiety is severe the day of the dental treatment, the patient should take
an oral sedative 1 hour before the scheduled appointment to lessen the
preoperative anxiety.
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79. • Many drugs are available for oral administration.
• In clinical experience the following drugs have proven to be the most
effective: Benzodiazepines (e.g. diazepam, oxazepam, triazolam,
flurazepam, midazolam).
• An additional advantage of oral midazolam is the occurrence of amnesia
(i.e. lack of recall of events) in a significant percentage of patients.
• Clinicians must remember that patients receiving oral sedatives must not be
permitted to drive a motor vehicle to or from dental office.
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80. Intramuscular sedation
• Intra-muscular (IM) sedation is infrequently used in dental practices, however
it remains an effective method of anxiety control in certain situations.
• Like the oral route the IM route lacks a degree of control that would be
desirable. Therefore the level of sedation sought with IM sedation should
remain light to moderate.
• Only doctors trained in this technique of drug administration and in airway
management should consider sedation via the IM route.
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81. • The most effective IM sedative has proven to be the water soluble
Benzodiazepine, midazolam. Its IM use is frequently associated with the
occurrence of amnesia, which is a welcome happenstance because the
patient has a lack of recall of events occurring during the dental procedure.
• IM sedation is not contraindicated in endodontics, however if a radiograph
unit is not readily available chair side, the clinician should remember that the
patient will need to walk to the radiograph unit (perhaps several times)
during the appointment. Patients who receive an IM injection may require
assistance doing this.
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82. Inhalation sedation
• Nitrous oxide and oxygen inhalation sedation is a remarkably controllable
technique of pharmacosedation. Because of its advantages over other
routes of drug administration, inhalation sedation is usually the method of
choice when sedation is required.
• Approximately 70% of patients receiving nitrous oxide and oxygen are ideally
sedated between 30% and 40% nitrous oxide. Fifteen percent require less
than 30% nitrous oxide, whereas 15% require in excess of 40%. Of this last 15%,
it may be said that some 5% to 10% are unsedatable with any level of nitrous
oxide less than 70%.
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83. • Inhalation sedation is entirely compatible with endodontic treatment.
Indeed, use of rubber dam converts most patients into nose breathers,
facilitating the administration of nitrous oxide and oxygen.
• Inhalation sedation with nitrous oxide and oxygen is a highly effective, easy-
to-use, and safe technique of pharmacosedation.
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84. IV Sedation
• The goal in the administration of any drug (except obviously, local
anesthetics) is to achieve a therapeutic level of that drug in the blood
stream.
• The direct administration of a drug into the venous circulation results in a
much more rapid onset of action and a greater degree of control than are
found with other pharmacosedative techniques.
• Only inhalation sedation (in which the inhaled gases rapidly reach the alveoli
and capillaries) has an onset of action approaching that of IV sedation. A
drop of blood requires between 9 and 30 seconds to travel from the hand to
the heart and then to the cerebral circulation.
• Titration is possible with IV drug administration.
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85. • Many techniques of IV sedation are available. Most involve sedative drugs
administrated alone or in conjunction with opioids. One can administer
benzodaizepine, either midazolam or diazepam, or in some cases, both a
benzodaizepine and an opioid analgesic.
• The use of propofol, a rapid acting, short-duration nonbarbiturate sedative-
hypnotic, or ketamine, a dissociative anesthetic, should not be considered
for IV conscious sedation use by dentists not trained in and permitted to use
general anesthesia.
• IV conscious sedation, particularly with the short acting benzodaizepines,
midazolam and diazepam, or either in combination with an opioid, such as
meperidine or fentanyl, are ideally suited for endodontic therapy.
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86. Combined techniques:
• On occasion it may be necessary to consider combining several of the
techniques just described.
• Quiet frequently a patient who requires either inhalation of IV sedation is
apprehensive enough to also need oral sedation, either the night before or
the day of the dental appointment.
• There is no contraindication to this practice, provided the level of oral
sedation in not excessive and the inhalation or IV drugs are carefully titrated.
Because a blood level of oral sedative already exists, the requirement for
other CNS depressants is usually decreased.
• If “average” doses of inhalation or IV drugs are used without titration, an
overdose is more likely to develop. Titration is an important safety factor.
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87. PRE-TREATMENT STRATEGIES TO
IMPROVE IANB
1. Oral premedication : Acetaminophen or Acetaminophen+ibuprofen
2. IO injection of 40mg methylprednisolone (Depo-Medrol)
3. Sublingual triazolam : 0.25mg oral 30 min before treatment
4. Conscious sedation
With conscious sedation, profound pulpal anesthesia was still required to
eliminate pain during endodontic therapy.
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88. STRATEGIES TO REDUCE PRE, INTRA
& POST OPERATIVE PAIN
• Pretreatment with either ibuprofen (800mg) or flurbiprofen (100mg)
• Patients not tolerant to NSAIDS : Acetaminophen 1000mg
• Injectables NSAIDS (Intra oral/Intra muscular)
• Ibuprofen liquid gel form (Advil liquid gel)
• Timing of drug administration : should be prescribed ‘by the clock’ not SOS –
q6h or q8h for first few days
• Long acting anesthetics
• IO Injection
• Occlusal reduction
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89. • The patient suffering from pulpitis most likely has taken oral analgesics before
the initial endodontic visit. The dentist should confirm by asking the patient
whether he or she is taking medication, such as NSAID’s. A therapeutic blood
level should be attained before the initial endodontic visit. Ideally two oral
doses have been taken by this time.
• The patient should continue to take the NSAID’s after treatment for a period
of time determined by the treating dentist (1 or 2 days, depending on
probable post-treatment discomfort.
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90. • A telephone call to the patient from the dentist in the early evening after
treatment is valuable in minimizing post-treatment complications that may
develop in the late evening or early next morning.
• It is helpful to determine how the patient is doing, to repeat post-operative
instructions, and to reaffirm the importance of a patient’s continuing to take
prescribed medications (e.g. antibiotics, analgesics) as directed.
• Psychologically, such calls provide a tremendous boost to the patient in the
immediate post-treatment period.
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91. FLEXIBLE PAIN CONTROL
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92. LOCAL ANESTHETIC STRATEGIES
FOR HOT TOOTH
Evidence based technical considerations:
• Change the LA solution : but clinical studies failed to show any superior analgesia for
3% mepivacaine or 4% articaine with 1:100000 epinephrine over 2% lidocaine with
1:100000 epinephrine
• Change injection technique : Gow gates & V-A techniques did not improve success
in attaining pulpal anesthesia compared with IANB
• Needle & bevel placement : medical ultrasound guided block that it do not affect
anaesthetic rate of IANB
• Accessory nerve block : incisive nerve block at mental foramen + IANB = Effective in
first molars and premolars. Mylohyoid nerve block + IANB = Not much effective
• Volume of LA : no influence
• Concentration of epinephrine : no influence
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93. Why Is It So Difficult To Achieve
Adequate Pulpal Anesthesia In
Mandibular Teeth, Even If Patient Is
Asymptomatic?Central core theory:
• Outer nerves of IAN bundle supply molar teeth
• Nerves for anterior teeth lie deeper
• Anesthetic solution currently used cannot diffuse into nerve trunk to reach all
nerves, which explains difficulty in achieving successful anesthesia for
mandibular anterior teeth
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94. • Inflamed tissue has low pH that reduces the amount of base form (active
form) of the LA to penetrate the nerve sheath
• Less ionized form of anesthetics
Then Why Is there additional Difficult To
Achieve Adequate Pulpal Anesthesia In
Teeth with Irreversible pulpitis?
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95. • Nerves arising from inflamed tissue have altered resting potential & reduced
threshold of excitability
• LA was not able to prevent transmission of nerve impulse because of
lowered excitability threshold of inflamed nerves.
• Anaesthetic resistant sodium channels
• Upregulation of sodium channels in pulps diagnosed with irreversible pulpitis
But Why Does IANB Fail When Given
At A Site Away From Site Of
Inflammation?
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96. THE ROLE OF SUPPLEMENTAL
INJECTIONS
1. Intraligamentary (Periodontal ligament injection)
2. Intraosseous injection
3. Mandibular buccal infiltration injection with 4% Articaine
4. Intrapulpal injection
5. Pre-treatment strategies
• Supplemental technique are used best after attaining a clinically successful
IANB (lip numbness)
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97. PAIN MANAGEMENT CONTROL
1. Preoperative oral NSAID, 1 hour before start of treatment.
2. L.A of choice for pain control during surgery.
3. Bupivacaine administration at end of procedure immediately prior to
dismissal of patient.
4. Continue oral NSAID’s on timed basis (ie: bid, tid, qid) for a number of days
deemed appropriate.
5. Postoperative telephone calls evening of appointment.
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98. CONCLUSION
• The integration of clinical and pharmacological strategies for developing
effective pain management plans for treating the endodontic pain patient.
• The importance of a proper diagnosis cannot be over-emphasized. Along
with definitive therapy, it should reduce the need for controlled drugs with
attendant side-effects.
• A flexible prescription plan has been presented, with appropriate
pharmacological recommendations.
• To consider : Pain before the treatment, Fatigue, Fear & anxiety of the
patient
Successful therapy is achieved by treating the source of pain, not the site of
pain
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99. BIBLIOGRAPHY
1. Cohen pathways of Pulp – first south east Asian edition
2. Endodontic Pain – Paul.A.Rosenberg
3. Building effective strategies for the management of endodontic pain KARL
KEISER & KENNETH M. HARGREAVES
4. Hargreaves KM, Keiser K. Local anesthetic failure in endodontics.
Mechanisms and management. Endod Topics 2002: 1: 26–39.
5. Medical Neurosciences an Approach to Anatomy, Pathology, and Physiology by
systems and levels - Eduardo E, Benarroch et al 4th edition
6. Relief of pain in clinical practice – Sampson Lipton
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