CONTROL OF ANXIETY AND PAIN IN DENTISTRY By: Shabeel P.N Ist batch

INTRODUCTION

• PAIN

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

• Theories:

• Specificity theory ,Pattern theory , Gate control theory (Melzak & Wall).

Theories of Pain

• Both Specificity and Pattern theories are used to help explain how different kinds of pain can occur.

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

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

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

Control of Pain:

• 3 Phases:

• Before treatment.

• During treatment.

• After treatment.

1.Before treatment

• Find out the cause pain and eliminate it.

• Pulpal Pain:

• Deep caries

• Thermal changes without protective base.

• High points in restoration.

• Traumatic injuries

• Treatment:

• Deep caries excavation and use of cements.

• Pulp capping procedures in deep cavities.

• In case of deep cavities with amalgam restoration .So a protective base should be used for mental restoration.

• Articulating paper should be used to check

• Attend to the traumatic injury and do the needful

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

2.During Treatment.

• Use high speed instrumentation with

• water coolants: Decrease heat & pain.

• Small bur size: Decreases heat, Intermittent cutting is preferred.

• Minimal pressure: Use high speed sharp instruments.

• Condensation pressure: 4-5 pounds.If increased pain.

• Burnishing & carving after initial set:

• Polishing should be done in a wet medium.

3.After Treatment

• Causes:

• High speed cutting without coolant.

• High points in restoration.

• Deep cavity restored without base.

• Pain due to pulpal involvement.

• Treatment:

• Remove the restoration & place temporary sedative dressing with ZOE.

• Reduce high points .

• Place base & apply cavity varnish.

• If pain persist ,do pharmacological treatment with analgesics , anti-inflammatory agents , sedatives & anaesthetics.

Some common techs of pain control

• I. Local anesthetics:

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

• Techniques:

• Topical anesthesia

• Free nerve endings are anesthetized.

• LA gel or spray.

• Local infiltration:

• Small nerve endings in the area of surgery are floaded with LA .

• Field block:

• Depositing LA solution in the proximity to large terminal branches.

• Nerve block:

• Depositing LA in close proximity to main nerve trunk

• Intra ligamentary:

• LA injected to periodontal ligament space.

• Intra crestal:

• LA injected to crestal bone.

Apprx.Duration of action of LA

• Short Duration:

• Lidocaine 2%

• Prilocaine 4% (infiltration)

• Intermediate duration:

• Articaine 4% + Epinephrine 1:100,000.

• Lidocaine 2% + Epinephrine 1:500,000.

• Long duration:

• Bupivacaine 0.5% + Epinephrine 1:200,000

• Etidocaine 1.5% + Epinephrine

• 1:200,000(nerve block)

General considerations:

• Patient factors:

• Systemic health :

• American society of anesthetology classified the patients into :

• A.Normal healthy individual.

• B.Patient with mild to moderate systemic disease.

• C.Patient with severe systemic disease that limits the activity but is not incapacitating

• D.Patient with severe systemic disease that limits the activity & is a constant threat to life.

• E.Moribund(Dying) Pt not expect to survive 24 hours with/without operation.

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

• Anesthetics drugs may cause decreased BP.

• In cardiac patients, use LA without adrenalin.

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

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

• Renal Dysfunction: No extra problems.

• Thyroid diseases: In uncontrolled hyperthyroidism patient exhibit increased response to adrenalin.

• Age:

• In very young & extremely old patients low dose should be given.

• Pregnancy:

• During first trimester surgical dental procedures are contraindicated.Minimal dose LA is adviced during pregnancy.

• Allergy:

• Proper history of allergy should take to avoid anaphylactic shock.

• Psychology:

• Use of a kind & gentle approach.

• Genuine concern for the patients problem.

• Avoiding harsh words like inject, sting , hurt etc.

• Keeping the syringe & needle away from the patients view.

• Constant reassurance during the injection

Precautions & Steps

• Patient should be in supine position-good blood supply & pressure.

• Syringe aspiration:To prevent intravenous injection 7 toxic effect.

• Should not inject into iflamed and infected tissue:- Spread of infection, LA wont work in iflamed areas due to acidic media.

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

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

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

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

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

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

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

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

• II. Sedatives.

• This tech can be employed as an adjunct to LA inorder to calm an anxiety patient.

• DRUGS:

• A.Diazepam (Benzodiazepine derivative):

• 2-10mg 1hr prior

• B.Alprazolam (Benzodiazepine derivative):

• 0.25-0.5mg 1 hr prior

• C.Midazolam

• 2-5mg 1hr prior.

III.Inhalation sedation

• Used for patients who has a low threshold of pain & are very apprehensive. Nitrous oxide oxygen are administered. It gives a sedative and euphoric effect.

• IV.Hypnosis

• State of mind in which critical faculty of mind has been bypassed & selective thinking is

• re-established.

• Advantges:

• Total relaxation.

• Analgesia.

• Decrease gagging.

• Controls saliva.

• Controls haemorrhage.

• Controls fainting.

• V.Audio analgesia :

• Also called white noise.It causes stimulus distraction. Eg:-soft music like constant rainfall.

VI.Electronic dental anesthesia(EDA)

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

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

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

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

• Indications

• Mainly for needle phobic patients.

• Patients allergic to LA.

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

• Contra indications

• Patients with cardiac pace makers.

• Patient with neurological disorders like epilepsy.

• Very young & very old patients.

• Pregnancy

• ADVANTAGES

• No need for injections.

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

• Residual analgesic effect lasts for several hours.

• DISADVANTAGES

• High cost of the unit.

• Learning curve

• Intraoral electrodes are a weak link in the system.

VII.Accupuncture

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

VIII.GENERAL ANAESTHESIA

• It is only required when all the above methods fail or the mouth opening is poor.

CARE DURING OPERATIVE PROCEDURES:

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

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

• Avoid slow speed drills.

• Use airotor with a coolant with intermittent cutting with light stroke.

• Use spoon excavator to remove soft caries better tactile sensation.

• Use instrument grasps , finger rests & guards.

• Rapid blast of air from airway syringe can induce a painful response & pulpal inflammation .It should be avoided.

• Use gingival retraction cords while working close to gingiva.

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

BIBLIOGRAPHY:

• Art & Science of operative dentistry

• -Sturdevant

• Endodontic practice:

• -Grossman

• Handbook of LA

• -Stanley melamed

• Clinical Operative Dentistry (Principles&Practice)

• -Remya raghu & Raghu srinivasan

• Textbook of operative dentistry:

• -Satish chandra & shaleen chandra.

• Practical Dentistry:

• -Balwant rai

• WWW:

• www.wikipedia.com

• www.medscape.com

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

• THANK U