Definition and etiology of pain Control of pain Methods of pain control Latest advances

What is Pain?

-Pain is defined as an unpleasant sensory and emotional experience resulting from a stimulus causing, or likely to cause, tissue damage or expressed in terms of that damage.

1)Firstly the Patient Pain being a highly subjective and individualistic response, the patient plays a major role in how much pain is felt. Stoic, controlled patients may bear even the most unpleasant procedures quietly while highly hysteric patients might jump even if you dont touch them. Hence, patient conditioning is such an integral and vital part of pain management. 2)Second are the instruments, materials and armamentarium used in dentistry Rotary instrumentation, caustic chemicals, improperly handled hand instruments and ironically the anesthetic needle itself are associated with pain responses. Heat and pressure play an important role in these mechanisms. 3)The Pulp- Dentin Organ Enamel is sensationless. Any procedure performed purely on enamel is incapable of causing pain. However, procedures that involve the dentin and pulp elicit only pain as a response; if any. The various theories of pain transmission of pain in dentin and pulp are still exploring the exact cause but sensitivity is an integral part of the dentinal response. 4)Improper handling of tissues Careless and insensitive handling of the oral tissues may result in operative or post operative discomfort and pain. Hence, delicate management of oral tissues is a must.

3 Phases 1)Before

treatment (pre operative) 2) during treatment (operative) 3) after treatment (post operative)

Cause of pain Deep caries Adjacent Soft tissue involvement( damage) Trauma from occlusion Traumatic injury Tretment Deep caries excavation and use of cement. Pulp caping procedure in deep cavities. Find the cause refered pain and treat the cause.

Cause High speed bur without coolent LA failure Extra excavation of cavity Pathological pain ( false pain) Tretment Use of high speed instrument Water coolent: decrease heat and pain. Small bur size: decrease heat. Minimal pressure: use high speed sharp instrument. Condensation pressure: 4-5 pounds, if increased then pain. Burnishing and carving after initial set.

Cause High speed cutting without coolent. High point restoration. Deep cavity restored without base. Pain due to pulpal involvement. Tretment Remove restoration and place temporary sedative dressing with ZOE. Reduce high point Place base and apply cavity varnish. If pain persist, do pharmacological treatment with analgesic, anti-inflamatory agent, sedatives and anesthetics.

These can be broadly described under 1)Gaining the confidence of the patient. 2)Ideal instrumentation and proper implementation. 3)Use of cooling devices. 4)Use of palliative drugs and obtundants. 5)Dessication of dentin. 6)Pressure anesthesia with cocaine. 7)Local anesthesia. 8)Use of inhalation sedation or nitrous oxide sedation 9)Hypnosis and psychotherapy. 10)General anesthetics.

The first axiom is Treat the individual, not just the tooth. A patient is an individual just like us with his / her own complexes, beliefs and fears. The correct psychological approach will help us not only to understand their needs but also alleviate any apprehension skillfully.

Instrumentation can be either

Hand cutting Rotary instrumentation Slow speed or High speed. Hand cutting instruments: The thinner the cross section, the more sharper the instrument and hence the more efficient it is. Dull or blunt instruments require more pressure to cut the tooth structure which also causes more frictional heat thus eliciting pain. Rotary instruments: Rotary instrumentation can govern the presence or absence of pain through 1)Speed 2) Pressure 3) Heat production and 4) Vibration all of which are inter related.

To overcome the disadvantages of low speed, high and ultrahigh speed instrumentation was introduced into dentistry. These rotate at speeds above 45,000 to 1,50,000 rpm. Advantages: 1)Efficient rapid cutting. 2)Convenient to operator and patient. 3)Minimal vibration. 4)Low frictional heat with coolants. 5)Longevity of cutting instruments. 6)Less pressure and sensitivity -low speed (25lb), high speed (1lb), ultrahigh (1-4 ounces). Disadvantages: 1)Overcutting. 2)Visibility is hampered. 3)Lesser tactile sensation. A major advancement with high speed cutting was the introduction of coolants to lower the frictional heat and enhance efficiency and comfort.

Coolants minimize pain and maximize efficiency with high speed. The commonly used coolants are: a)Air. b)Water. c)Combination of both which is the most popular and highly effective. Also, the use of chilled burs is said to diminish pain. CO2 and ethyl chloride have also been experimented with.

Here, soothing and palliative type of cements or medicaments are used on dentin. Desensitizing agents like ZnCl2, Ag(NO3)2, Ferric oxalates can minimize dentinal sensitivity. Commonly used obtundant is ZOE which can be placed over cut dentin as an intermediate dressing in patients having severe sensitivity.

Dessication is drying of dentin by a blast of warm air gives relief from sensitivity and subsequent pain. Over dessication should be avoided so as to prevent the fluid movement inside the dentinal tubules, which causes pain, as hypothetized by the hydrodynamic theory. Even during cavity cleansing, a 3-way syringe should be used taking advantage of both air and water.

This method is particularly effective in anesthetizing the pulp of deciduous and young permanent teeth but not effective in areas of secondary dentin and carious areas. It is quite effective for a short duration procedure. The solution used has the following ingredients: a)Cocaine 25% b)Ether 10% c)Chlorophenol 15% d)Alcohol 50%. Technique: Access should be gained to the dentin cutting through enamel with a 1mm inverted cone bur. The opening is enlarged, changing it to the form of a section of a conewith the larger end at the surface. A very small bit of cotton pledget (1mm) should be moistened with the solution and placed at the bottom of the opening. A slightly larger piece of unvulcanized rubber should then be placed over the cotton and pressure, at first light and gradually increased to heavy is applied in a series of thrusts using a round, flat faced condenser about 1 to 2mm in diameter. This forces the solution through the dentinal tubules to anesthetize the pulp. This must be done in a dry field.

It is the most widely used and popular technique of effective pain control It is defined as a transient regional loss of sensation to a painful or potentially painful stimulus resulting from a reversible interruption of peripheral conduction along a specific neural pathway to its central integration and perception in the brain. Cavity preparation and Endodontic procedures may be painlessly carried out after securing anesthesia by infiltrating the apical tissues or by nerve blocking with one of the LA solutions. It reduces pain as well as permits the dentists to work faster and save time. One should operate just as carefully when preparing cavities in teeth with anesthetized pulps as though they are not anesthetized.

LA techniques: 1.Local infiltration (supraperiosteal infiltration) Supraperiosteal anesthesia is described as a technique in which anesthetic is deposited into the area of treatment (0.6-0.9ml). Small terminal nerve fibres in the area are blocked and thus rendered incapable of transmitting impulses. This is commonly employed in maxillary teeth because of the ability of anesthetic solutions to diffuse through periosteum and relatively thin cancellous bone. 13 2.Regional nerve block: Nerve block is defined as a method of achieving regional anesthesia by depositing a suitable local anesthetic solution close to a main nerve trunk, preventing afferent impulses from traveling centrally beyond that point.

1)Maxillary nerve blocks

Maxillary nerves that can be anesthetized include PSA block or the zygomatic or tuberosity block Anterior superior alveolar block, Infraorbital nerve block greater palatine block, the nasopalatine block and the second division of the trigeminal or maxillary block

MAXILLARY NERVE BLOCK

NASOPALATINE NERVE BLOCK

GREATER PALATINE NERVE BLOCK

ANTR. SUPERIOR ALVEOLAR BLOCK

INFRAORBITAL NERVE BLOCK

POST. ALVEOLAR NERVE BLOCK

2)Mandibular anesthesia
the inferior alveolar nerve block. lingual nerve block the buccal nerve block Incisive or mental nerve block Mandibular nerve block: Gow Gates techniques Akinosi or closed mouth techniques

INFER. ALVEOLAR NERVE BLOCK

BUCCAL NERVE BLOCK

MENTAL NERVE BLOCK

MANDIBULAR NERVE BLOCK

1)Periodontal ligament injection: The PDL injection is frequently used when isolated areas of inadequate anesthesia are present. It is also indicated to achieve anesthesia in a single mandibular and / or maxillary tooth. Advantages include adequate pulpal anesthesia with a minimal volume of solution (0.2-0.4ml) and absence of lingual and lower lip anesthesia. 2)Intraseptal infiltration (variation of intraosseous) Here the 27-gauge 1-inch needle is inserted into the interseptal tissue in the area to be anesthetized. Its success rate is not so high. It is relatively more successful in young patients due to decreased bone density.

INTRASEPTAL INFILTRATION
PERIODONTAL LIGAMENT INJECTION

This technique can be employed as an adjunct to LA in order to calm an anxiety patient. DRUG: A) Diazepam: (benzodiazepine derivative) 2-10 mg 1hr prior B) Alprazolam (benzqdiazepine derivative) 0.25- 0.5 mg 1 hr prior C) Midazolam 2-5 mg 1hr prior

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