CONTROL OF ANXIETY CONTROL OF ANXIETY AND PAIN IN DENTISTRYAND PAIN IN DENTISTRY

By:By:Shabeel P.NShabeel P.N

Ist batchIst batch

INTRODUCTIONINTRODUCTIONPAINPAINMost common complaint in dental Most common complaint in dental

treatment & is defined as an unpleasant treatment & is defined as an unpleasant sensational experience initiated by sensational experience initiated by noxious stimulus & transmitted over a noxious stimulus & transmitted over a specialised neural network to CNS where specialised neural network to CNS where it is interpreted as such.it is interpreted as such.

Theories:Theories:Specificity theory ,Pattern theory , Gate Specificity theory ,Pattern theory , Gate

control theory (Melzak & Wall).control theory (Melzak & Wall).

Theories of PainTheories of Pain Both Both Specificity Specificity and and PatternPattern theories are used to help theories are used to help

explain how different kinds of pain can occur.explain how different kinds of pain can occur. SpecificitySpecificity theories consider pain as an independent theories consider pain as an independent

sensation with specialised peripheral sensory receptors sensation with specialised peripheral sensory receptors [nociceptors], which respond to damage and send signals [nociceptors], which respond to damage and send signals through pathways (along nerve fibres) in the nervous through pathways (along nerve fibres) in the nervous system to target centres in the brain. These brain centres system to target centres in the brain. These brain centres process the signals to produce the experience of pain.process the signals to produce the experience of pain.

Pattern Pattern theories consider that peripheral sensory theories consider that peripheral sensory receptors, responding to touch, warmth and other non-receptors, responding to touch, warmth and other non-damaging as well as to damaging stimuli, give rise to non-damaging as well as to damaging stimuli, give rise to non-painful or painful experiences as a result of differences in painful or painful experiences as a result of differences in the patterns [in time] of the signals sent through the the patterns [in time] of the signals sent through the nervous system.nervous system.

The The gate control theory of paingate control theory of pain, put forward by , put forward by Ronald Ronald MelzackMelzack and Patrick Wall in 1962 , and again in 1965 ,is the and Patrick Wall in 1962 , and again in 1965 ,is the idea that physical idea that physical painpain is not a direct result of activation of is not a direct result of activation of pain receptorpain receptor neuronsneurons, but rather its perception is , but rather its perception is modulated by interaction between different neurons.modulated by interaction between different neurons.

Control of Pain:Control of Pain:3 Phases:3 Phases:1.1. Before treatment.Before treatment.2.2. During treatment.During treatment.3.3. After treatment.After treatment.

1.Before treatment1.Before treatment Find out the cause pain and Find out the cause pain and

eliminate it.eliminate it.Pulpal Pain:Pulpal Pain:1.1. Deep cariesDeep caries2.2. Thermal changes without protective Thermal changes without protective

base.base.3.3. High points in restoration.High points in restoration.4.4. Traumatic injuriesTraumatic injuries

Treatment:Treatment:1.1. Deep caries excavation and use of Deep caries excavation and use of

cements.cements.2.2. Pulp capping procedures in deep cavities.Pulp capping procedures in deep cavities.3.3. In case of deep cavities with amalgam In case of deep cavities with amalgam

restoration .So a protective base should restoration .So a protective base should be used for mental restoration.be used for mental restoration.

4.4. Articulating paper should be used to Articulating paper should be used to check check

5.5. Attend to the traumatic injury and do the Attend to the traumatic injury and do the needfulneedful

6.6. Find the cause of referred pain & treat Find the cause of referred pain & treat the cause. the cause.

2.During Treatment.2.During Treatment.Use high speed instrumentation with Use high speed instrumentation with water coolants: Decrease heat & water coolants: Decrease heat &

pain.pain. Small bur size: Decreases heat, Small bur size: Decreases heat,

Intermittent cutting is preferred.Intermittent cutting is preferred. Minimal pressure: Use high speed Minimal pressure: Use high speed

sharp instruments.sharp instruments. Condensation pressure: 4-5 Condensation pressure: 4-5

pounds.If increased –pain.pounds.If increased –pain. Burnishing & carving after initial set:Burnishing & carving after initial set: Polishing should be done in a wet Polishing should be done in a wet

medium.medium.

3.After Treatment3.After Treatment Causes:Causes: High speed cutting without coolant. High speed cutting without coolant. High points in restoration.High points in restoration. Deep cavity restored without base.Deep cavity restored without base. Pain due to pulpal involvement.Pain due to pulpal involvement. Treatment:Treatment: Remove the restoration & place temporary Remove the restoration & place temporary

sedative dressing with ZOE.sedative dressing with ZOE. Reduce high points .Reduce high points . Place base & apply cavity varnish.Place base & apply cavity varnish. If pain persist ,do pharmacological If pain persist ,do pharmacological

treatment with analgesics , anti-inflammatory treatment with analgesics , anti-inflammatory agents , sedatives & anaesthetics.agents , sedatives & anaesthetics.

Some common tech’s of pain controlSome common tech’s of pain controlI. Local anesthetics:I. Local anesthetics:

It is defined as elimination of sensation It is defined as elimination of sensation espescially pain in one part of the body by the espescially pain in one part of the body by the topical application or by regional injection of topical application or by regional injection of drug.drug.

Techniques:Techniques:1.1. Topical anesthesiaTopical anesthesia Free nerve endings are anesthetized.Free nerve endings are anesthetized. LA gel or spray.LA gel or spray.2.2. Local infiltration:Local infiltration: Small nerve endings in the area of surgery are Small nerve endings in the area of surgery are

floaded with LA .floaded with LA .3.3. Field block:Field block: Depositing LA solution in the proximity to large Depositing LA solution in the proximity to large

terminal branches.terminal branches.4.4. Nerve block:Nerve block: Depositing LA in close proximity to main nerve Depositing LA in close proximity to main nerve

trunktrunk5.5. Intra ligamentary:Intra ligamentary: LA injected to periodontal ligament space.LA injected to periodontal ligament space.6.6. Intra crestal:Intra crestal: LA injected to crestal bone.LA injected to crestal bone.

Apprx.Duration of action of Apprx.Duration of action of LALA

Short Duration:Short Duration: Lidocaine 2%Lidocaine 2% Prilocaine 4% (infiltration)Prilocaine 4% (infiltration) Intermediate duration:Intermediate duration: Articaine 4% + Epinephrine Articaine 4% + Epinephrine

1:100,000.1:100,000. Lidocaine 2% + Epinephrine Lidocaine 2% + Epinephrine

1:500,000.1:500,000. Long duration:Long duration: Bupivacaine 0.5% + Bupivacaine 0.5% +

Epinephrine 1:200,000Epinephrine 1:200,000 Etidocaine 1.5% + Epinephrine Etidocaine 1.5% + Epinephrine

1:200,000(nerve block)1:200,000(nerve block)

General considerations:General considerations: Patient factors:Patient factors:1.1. Systemic healthSystemic health:: American society of anesthetology classified American society of anesthetology classified

the patients into :the patients into :A.Normal healthy individual.A.Normal healthy individual.B.Patient with mild to moderate systemic disease.B.Patient with mild to moderate systemic disease.C.Patient with severe systemic disease that limits C.Patient with severe systemic disease that limits

the activity but is not incapacitatingthe activity but is not incapacitatingD.Patient with severe systemic disease that limits D.Patient with severe systemic disease that limits

the activity & is a constant threat to life.the activity & is a constant threat to life.E.Moribund(Dying) Pt not expect to survive 24 E.Moribund(Dying) Pt not expect to survive 24

hours with/without operation. hours with/without operation.

CVS:- Since adrenalin is a vasoconstrictor it CVS:- Since adrenalin is a vasoconstrictor it should be avoided in hypertensive patients.should be avoided in hypertensive patients.

Anesthetics drugs may cause decreased BP.Anesthetics drugs may cause decreased BP.In cardiac patients, use LA without adrenalin.In cardiac patients, use LA without adrenalin.

CNS:- Therapeutic dose may cause depression. CNS:- Therapeutic dose may cause depression. High dose – Tonic clonic seizures, decreased BP High dose – Tonic clonic seizures, decreased BP & Respiratory arrest – death.& Respiratory arrest – death.

Hepatic:-In hepatic dysfunction Hepatic:-In hepatic dysfunction biotransformation cannot take place properly.biotransformation cannot take place properly.

Renal Dysfunction: No extra problems.Renal Dysfunction: No extra problems. Thyroid diseases: In uncontrolled Thyroid diseases: In uncontrolled

hyperthyroidism patient exhibit increased hyperthyroidism patient exhibit increased response to adrenalin.response to adrenalin.

2.2. Age:Age: In very young & extremely old patients In very young & extremely old patients

low dose should be given.low dose should be given.3.3. Pregnancy:Pregnancy: During first trimester surgical dental During first trimester surgical dental

procedures are contraindicated.Minimal procedures are contraindicated.Minimal dose LA is adviced during pregnancy.dose LA is adviced during pregnancy.

4.4. Allergy:Allergy: Proper history of allergy should take to Proper history of allergy should take to

avoid anaphylactic shock.avoid anaphylactic shock.5.5. Psychology:Psychology: Use of a kind & gentle approach.Use of a kind & gentle approach. Genuine concern for the patient’s Genuine concern for the patient’s

problem.problem. Avoiding harsh words like “inject”, Avoiding harsh words like “inject”,

”sting” , ”hurt” etc.”sting” , ”hurt” etc. Keeping the syringe & needle away from Keeping the syringe & needle away from

the patient’s view.the patient’s view. Constant reassurance during the Constant reassurance during the

injectioninjection

Precautions & StepsPrecautions & Steps Patient should be in supine position-Patient should be in supine position-

good blood supply & pressure.good blood supply & pressure. Syringe aspiration:To prevent Syringe aspiration:To prevent

intravenous injection 7 toxic effect.intravenous injection 7 toxic effect. Should not inject into iflamed and Should not inject into iflamed and

infected tissue:- Spread of infection, infected tissue:- Spread of infection, LA won’t work in iflamed areas due LA won’t work in iflamed areas due to acidic media.to acidic media.

Disposable needle & syringe of Disposable needle & syringe of appropriate length & gauge should appropriate length & gauge should be used.be used.

Before loading syringe the Before loading syringe the temperature of the solution should temperature of the solution should be brought to body temp. to make be brought to body temp. to make injection painless.(Confirm the injection painless.(Confirm the expiry) expiry)

Before injecting LA clean the surface with Before injecting LA clean the surface with cotton & apply topical LA(benzocaine or cotton & apply topical LA(benzocaine or lidocaine).lidocaine).

Needle should be inserted at the junction of Needle should be inserted at the junction of alveolar mucosa & vestibular mucosa.And alveolar mucosa & vestibular mucosa.And angle of needle should not be parallel to angle of needle should not be parallel to long axis of the tooth.-(less pain)long axis of the tooth.-(less pain)

LA solution is injected slowly (1ml/min)-LA solution is injected slowly (1ml/min)-proper diffusion.If there is resistance, proper diffusion.If there is resistance, withdrawn the needle and redirect it.withdrawn the needle and redirect it.

2 min after the injection the effect of LA 2 min after the injection the effect of LA should check before starting the procedure. should check before starting the procedure.

Pt should be carefully watched during & Pt should be carefully watched during & after LA for half an hour for any delayed after LA for half an hour for any delayed reactions.reactions.

Needle and syringe should be discarded Needle and syringe should be discarded in leak proof hard walled containers.in leak proof hard walled containers.

II. Sedatives.II. Sedatives.This tech can be employed as an adjunct This tech can be employed as an adjunct

to LA inorder to calm an anxiety patient.to LA inorder to calm an anxiety patient.DRUGS:DRUGS:A.Diazepam (Benzodiazepine derivative):A.Diazepam (Benzodiazepine derivative): 2-10mg 1hr prior 2-10mg 1hr prior B.Alprazolam (Benzodiazepine derivative):B.Alprazolam (Benzodiazepine derivative): 0.25-0.5mg 1 hr prior0.25-0.5mg 1 hr priorC.MidazolamC.Midazolam 2-5mg 1hr prior. 2-5mg 1hr prior.

III.Inhalation sedationIII.Inhalation sedation Used for patients who has a low threshold of pain & Used for patients who has a low threshold of pain &

are very apprehensive. Nitrous oxide oxygen are are very apprehensive. Nitrous oxide oxygen are administered. It gives a sedative and euphoric effect.administered. It gives a sedative and euphoric effect.

IV.HypnosisIV.HypnosisState of mind in which critical faculty of mind has been State of mind in which critical faculty of mind has been

bypassed & selective thinking isbypassed & selective thinking is re-established.re-established.

Advantges:Advantges:1.1. Total relaxation.Total relaxation.2.2. Analgesia.Analgesia.3.3. Decrease gagging.Decrease gagging.4.4. Controls saliva.Controls saliva.5.5. Controls haemorrhage.Controls haemorrhage.6.6. Controls fainting.Controls fainting.

V.Audio analgesiaV.Audio analgesia::Also called white noise.It causes stimulus Also called white noise.It causes stimulus

distraction. Eg:-soft music like constant distraction. Eg:-soft music like constant rainfall.rainfall.

VI.Electronic dental VI.Electronic dental anesthesia(EDA)anesthesia(EDA)

Also called transcutaneous Also called transcutaneous electronic nerve stimulation.(TENS).electronic nerve stimulation.(TENS).

It work on gait control theory, with It work on gait control theory, with use of high frequency greater than use of high frequency greater than 120 Hz by producing sensations like 120 Hz by producing sensations like “vibrating” , “thrombing”, “vibrating” , “thrombing”, ”Pulsing” or “twitching”.”Pulsing” or “twitching”.

It act by stimulating a larger It act by stimulating a larger diameter A delta fibres which diameter A delta fibres which transmit the sensation of touch transmit the sensation of touch pressure & temperature. This will pressure & temperature. This will inhibit transmission of pain inhibit transmission of pain impulses produced by high speed impulses produced by high speed drill which is transmitted by smaller drill which is transmitted by smaller A delta & C fibres.A delta & C fibres.

This high frequency stimulations This high frequency stimulations increase blood level of serotonin & increase blood level of serotonin & endorphin- control pain.endorphin- control pain.

IndicationsIndications

Mainly for needle Mainly for needle phobic patients.phobic patients.

Patients allergic to Patients allergic to LA.LA.

Pain control prior to Pain control prior to administration of LA administration of LA espescially for palatal espescially for palatal injections.injections.

Contra indicationsContra indications

Patients with cardiac Patients with cardiac pace makers.pace makers.

Patient with Patient with neurological disorders neurological disorders like epilepsy.like epilepsy.

Very young & very old Very young & very old patients.patients.

PregnancyPregnancy

ADVANTAGESADVANTAGES No need for injections.No need for injections.

Anaesthetic effect Anaesthetic effect only for the required only for the required time; does not last time; does not last longer.longer.

Residual analgesic Residual analgesic effect lasts for several effect lasts for several hours.hours.

DISADVANTAGESDISADVANTAGES High cost of the High cost of the

unit.unit.

Learning curveLearning curve

Intraoral electrodes Intraoral electrodes are a weak link in are a weak link in the system.the system.

VII.AccupunctureVII.Accupuncture AcupunctureAcupuncture (from Lat. (from Lat. acus,acus,

"needle" (noun), and "needle" (noun), and pungere,pungere, "prick" (verb) is a technique of "prick" (verb) is a technique of inserting and manipulating inserting and manipulating filiformfiliform needles into "needles into "acupuncture pointsacupuncture points" " on the body. According to on the body. According to acupuncture theory, this will acupuncture theory, this will restore health and well-being, and restore health and well-being, and is particularly good at treating pain. is particularly good at treating pain. The definition and characterization The definition and characterization of these points is standardized by of these points is standardized by the World Health Organization the World Health Organization (WHO)[1]. Acupuncture is thought (WHO)[1]. Acupuncture is thought to have originated in China and is to have originated in China and is most commonly associated with most commonly associated with Traditional Chinese medicine Traditional Chinese medicine (TCM). (TCM).

VIII.GENERAL ANAESTHESIAVIII.GENERAL ANAESTHESIA It is only required It is only required

when all the above when all the above methods fail or the methods fail or the mouth opening is mouth opening is poor.poor.

CARE DURING OPERATIVE CARE DURING OPERATIVE PROCEDURES:PROCEDURES:

Use of mouth mirror to provide retraction of Use of mouth mirror to provide retraction of tongue cheeks & lips.tongue cheeks & lips.

Application of rubber dams to ensure Application of rubber dams to ensure protection of gingiva & adjacent tissues.protection of gingiva & adjacent tissues.

Avoid slow speed drills.Avoid slow speed drills. Use airotor with a coolant with intermittent Use airotor with a coolant with intermittent

cutting with light stroke.cutting with light stroke. Use spoon excavator to remove soft caries – Use spoon excavator to remove soft caries –

better tactile sensation.better tactile sensation. Use instrument grasps , finger rests & guards.Use instrument grasps , finger rests & guards. Rapid blast of air from airway syringe can Rapid blast of air from airway syringe can

induce a painful response & pulpal induce a painful response & pulpal inflammation .It should be avoided.inflammation .It should be avoided.

Use gingival retraction cords while working Use gingival retraction cords while working close to gingiva.close to gingiva.

Use pulp protective agents like Use pulp protective agents like varnishes ,Sealants ,liners & bases. varnishes ,Sealants ,liners & bases.

BIBLIOGRAPHY:BIBLIOGRAPHY: Art & Science of operative dentistryArt & Science of operative dentistry

-Sturdevant-Sturdevant Endodontic practice:Endodontic practice:

-Grossman-Grossman Handbook of LAHandbook of LA

-Stanley melamed-Stanley melamed Clinical Operative Dentistry (Principles&Practice)Clinical Operative Dentistry (Principles&Practice)

-Remya raghu & Raghu srinivasan-Remya raghu & Raghu srinivasan Textbook of operative dentistry:Textbook of operative dentistry:

-Satish chandra & shaleen chandra.-Satish chandra & shaleen chandra. Practical Dentistry:Practical Dentistry:

-Balwant rai-Balwant rai WWW:WWW:

www.wikipedia.comwww.wikipedia.comwww.medscape.comwww.medscape.com

http://www.rcoa.ac.uk/docs/dental.pdf. (Royal college of anesthetics)http://www.rcoa.ac.uk/docs/dental.pdf. (Royal college of anesthetics)

THANK UTHANK U