Pain & Pain Control

Ashraf
Refai
BDS MSc DD HMD
Lecturer of Endodontics
Al-Azhar University
ashraf_refai@hotmail.com
Ashraf Samir Refai
www.arefai.edublogs.org
www.idclinics.com
+20101434323

Advanced Endodontic
Training Crouse
Pain & Pain Control

What is Pain???
“A more or less localized sensation of discomfort,
distress, or agony resulting from the stimulation of
specialized nerve endings”
Dorland’s Medical Dictionary

Another Defenition…
“An unpleasant sensory and emotional experience
associated with actual or potential tissue
damage, or described in terms of such damage”

Pain…
Is Learned Through
Experiences
Maybe
Psychological
Is Subjective
Is An Emotional
Experience
Is Unpleasant
Pain is Pain if the
Patients Says it is
Pain…

The Two Faces of Pain…
Pain Perception
&
Pain Reaction
Pain is Complex & Difficult to Quantify

The Neurophysiology of Pain
A-Delta Fibers (Myelinated)
C-Fibers (Non-Myelinated)

The Way Up…

The Process of Pain…
Transduc
tion
Transmis
sion
Modulati
on
Perceptio
n

Transduction…
Electrical
Thermal
Mechanical

What Else Causes Transduction…
Prostaglandins
Leukotrines
Arachidonic
Acid
A lot of other Stuff…

What do these Chemicals do???

What do these Chemicals do???
Allodynia:
Response to Normally Non-Painful
Stimulus
Hyper Algesia:
Exaggerated Response to Painful
Stimulus

Transmission…
• Stimulus reaches dorsal horn of spinal cord
• Repetitive &/or intense stimulation of C-Fibers results
in a buildup of chemicals in the dorsal horn which
results in:
“Wind Up”
• Increase in the response of dorsal horn neurons
• Temporal summation: Repeated stimulus results in
an increase in the intensity of the perceived pain

Modulation…
Pain Stimulus Reaches
the Brain
Release of Serotonin &
Norepinephrine
Activation of Descending
Inhibitory Pathways
Pain Modulation &
Suppresion

Modulation…
Central Modulation also
Occurs in the Brain
Endogenous
Opiods
Reduce Pain
Transmission From
Nerve Terminals
Pain Modulation &
Suppresion

Perception…
It is not really known which part of the brain is
actually responsible for the perception of pain but it
has been narrowed down to the:
Thalamus & Cortex
It is different from one person to the other from
one time to the other because there are two
aspects to pain perception
Sensory & Emotional

Review Up Till Now…
• Definition of Pain
• The Two Faces of Pain
• The Process of Pain
Ø Transduction
Ø Transmission
Ø Modulation
Ø Perception
• Prostaglandins & Arachnadonic Acid

Endodontic
Therapy
Can be
Painful!!!

When does pain occur???
Pre-operative
Intraoperative
Post Operative

Patient Perception is Everything…
Root Canals Hurt
The ‘’Shot” hurts
The “Drill” hurts
Everything Hurts!!!
Pain Reaction Threshold (PRT)

PRT (Pain Reaction Threshold)
70% of Patients
Will Respond Appropriately

15% of Patients
Hypo-responders

15% of Patients
Hyper-responders
Endodontic
Patients

The Pain Reaction Threshold…
I am Worried
I am Exhausted
I am Afraid
I
I am in Pain
PRT

Some Interesting Statistics…
• 54.9% of Medical
emergencies in
the Dental
Environment
Occurred During
Administration of
Anesthetic
• 22% During Dental
Treatment Beyond the basics: emergency
medicine in dentistry
Malamed SF
J Am Dent Assoc 1997

During Treatment
• 38.9% of Medical
emergencies
Occurred During
Extirpation
• 26.9% During
Extraction
Beyond the basics: emergency
medicine in dentistry
Malamed SF
J Am Dent Assoc 1997

Seizures
Angina Pectoris
Strokes
Syncope
Hyperventilation

Clinical Tips: Atraumatic Anesthesia
• Use a sharp
needle
• Check the flow of
local anesthetic
• Warm the
anesthetic
cartridge
• Place patient in
Supine position

• Apply topical
antiseptic
• Communicate with
the patient
• Establish a firm
hand rest
• Make the tissues
taut

• Keep syringe out
of the patient’s line
of sight
• Slowly advance
the needle toward
target.
• Deposit several
drops of local
anesthetic before
touching
periosteum.

• Aspirate
• Slowly deposit the
solution.
• Slowly withdraw
the Syringe

Conscious Sedation…
• Inhalation Conscious Sedation (N2O–O2)
• Intravenous Conscious Sedation
(Diazepam (Vallium) – (Midazolam)
= No Conscious Sedation

Local Anesthesia Statistics…
• 47% Walton &
Abbot 1981
• 91% Malamed SF
1997
The Cause of Failure During
Administration of Local Anesthesia is
Attributed to the Mandibular rather than
the Maxillary Teeth
Why?

Complete Anesthesia is
not
Optional!!!

Local Anesthesia Techniques…
• Mandibular
Techniques
Ø IANB
Ø Gow Gates
Ø Akinosi
Ø Mental (Incisive)
• Supplemental
Techniques
Ø Intraperiodontal
Ø Intraosseous
Ø Intrapulpal
• Maxillary
Techniques
Ø Infiltration
Ø Posterior
Superior Alveolar
Ø Middle Superior
Alveolar
Ø Anterior Superior
Alveolar
(Infraorbital)

Mandibular Techniques…
Inferior Alveolar Nerve Block (IANB)
• Most Commonly Used Technique
• Buccal Nerve NOT anesthetized
• Successful only 85% of the time
• Failure Due to Administration Lower than the
Mandbiluar Foramen
• 1% of Mandibular Teeth are Innervated by the
Mylohyoid

Gow Gates Technique
• True Mandibular Nerve Block
• Given at the Neck Lateral Aspect of the Neck of
the Condyle
• Just as Mandibular Nerve Exits Foramen Ovale
• Steep Learning Curve
• Will Anesthetize Mylohyiod & Buccal Nerve
(75%)

Akinosi Technique (Closed Mouth):
• Useful when there is Unilateral Trismus
• Anesthetizes Similar to the IANB
• There is no Touch of Bone

Maxillary Techniques…
• Used when
Infiltration Won’t
Work
• Localized Infection
in the Area of
Administration

Maxillary Techniques…
Posterior Superior Alveolar Block (PSA)
• Not Touch of Bone
• Less Painful Technique
• MB Canal of #6 May Not be Anesthetized

Supplemental Techniques…
Intraperiodontal
Intraosseous
Intrapulpal

Allergic Potential
Metabolism in Liver & Kidneys
Choice of Anesthetic Agent
Amides & Esters

The Importance
Of
Vasoconstrictor

An Alternative???
Hypnodontics

Uses of Hypnosis in Endodontics…
• Obtaining relaxation &
Ensuring Co-operation
• Reduction of Anxiety
and Fear
• Preparation of the
patient for local
anaesthesia
• Production of
analgesia & Amnesia

Uses of Hypnosis in Endodontics…
• Control of bleeding
• Control of salivation
• Induction of muscular
rigidity of the jaw and
neck
• Extension of the
period of analgesia

Review Up Till Now…
• Pain Reaction Threshold
• Clinical Tips: Atraumatic Anesthesia
• Different Local Anesthetic Techniques
• Conscious Sedation (Lack of Use)
• Hypnodontics

Analgesic Drugs…
Non-Narcotic Drugs
Nonsteroidal Anti-
inflamatory Drugs
(NSAID)
Nonanti-inflamatory
Antipyretic Drugs
Narcotic Drugs
Agonists Agonist/Antagonists

Mechanisms of Action
• Central (Narcotics)
Ø Acts on the Brains
Ø Three Different Types
(Kappa, Delta & Mu)
Ø Pain Reaction is Affected
• Peripheral (NSAID)
Ø Cyclooxygenase Enzyme
(1 & 2)
Ø Inhibition of Prostaglandin
Production
Ø Pain Perception is Affected

Non-Narcotic Drugs
(Nonsteroidal Anti-Inflamatory Drugs)
Salicylates (Asprin)
Indoles
Propionic Acid Derivatives (Ketoprofen & Ibuprofen)
Fenamates
Pyrazolones
Oxicams (Proxicam)

Non-Narcotic Drugs
Analgesic
Anti-pyretic
Anti-inflamatory

Non-Narcotic Drugs
Mechanism of Action
Most of the Effects and Side Effects of NSAID are
Attributed to the Inhibition of Prostaglandin Synthesis by
Acting on the Cyclooxygenase-1 Enzyme (Cox1)
Cox-1 is found in the stomach and kidneys
The Anti-pyretic Action

Non-Narcotic Drugs
Adverse Drug Reactions (ADRs)
Gastrointestinal Irritation
Topical
Ulcerative
Renal Toxicity
Aspirin Issues
Irreversible Bonding to Cox-1 on Platelets
Aspirin Allergy

Non-Narcotic Drugs
Cox-2 Inhibitors
Vioxx
Celebrex
They Inhibit Cox-2 Instead of Cox-1
They Have Serious Gut & Kidney Side Effects

Non-Narcotic Drugs
(Non-antiinflamatory Anti-Pyretic Drugs)
Acetaminophine
Panadol
Tylenol
No Anti-inflamatory Effect
No GIT Irritation
Less Adverse Effects than NSAID
Mode of Action is Central

Analgesic Drugs…
Non-Narcotic Drugs
Nonsteroidal Anti-
inflamatory Drugs
(NSAID)
Nonanti-inflamatory
Antipyretic Drugs
Narcotic Drugs
Agonists Agonist/Antagonists
X

Narcotic Drugs
(Pharmacological Effects…)
Analgesia
Drowsiness
Sedation
Urinary Retention
Constipation
Cough Suppression
Respiratory Depression
Addiction
Narcotic Drugs are Derived from Morphine

Narcotic Drugs
Agonists vs Antagonists??
Medial Thalamus
Types of Receptors in the Brain

Narcotic Drugs
(Mechanism of Action…)
Central
Interfere with Pain
Transmission
Alter Emotional
Response to Pain

Narcotic Drugs
Mild Narcotic Drugs
• Codeine
Ø Addictive
Ø Causes GIT Irritation
Ø Most Commonly Used in Dentistry
Ø Breaks Down into Morphine (2-12%)
• Hydrocodone (Vicodin)
Ø Less Irritant to the GIT

Narcotic Drugs
Strong Narcotic Drugs
• Oral Morphine
(Oramorph)
Ø Larger Doses than IV
Because it is Metabolized
in the Liver
Ø Reserved for Serious
Dental Pain
• Oxycodone
Ø Cousin of Hydrocodone
Ø Combined with Asprin (Percocet)
• Pethidine (Demerol)

Final Word…
Combinations of Non-Narcotic and Narcotic
Drugs are Used to Get the Optimum
Analgesia Required and to Minimize the
Negative Effects of Narcotic Drugs
Vicoprofen
Percodan
Empirin

Final Review…
• Different Type of Analgesic Drugs
• Mode of Action
Ø Peripheral
Ø Central
• Aspirin is a NSAID
• Narcotic Drugs
Ø Agonists
Ø Antagonists
• Narcotics Alter Pain Perception & Pain Reaction

Pain & Pain Control

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