pain management in dentistry

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ComplianceTrainingPartners.com

888.388.4782

20793 Farmington Road, Suite LL,

Farmington Hills, MI 48336

PAIN MANAGEMENT IN DENTISTRY

KARSON CARPENTER, D.D.S.


888.388.4782

20793 Farmington Road, Suite LL, Farmington Hills, MI 48336

2.

IASP defines pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.”

The North American Nursing Diagnosis Association defines that pain is a state, in which an individual experiences and reports severe discomfort or an uncomfortable sensation

Medical dictionary by Farlex: Pain is defined as an unpleasant feeling that is conveyed to the brain by sensory neurons. The discomfort signals actual or potential injury to the body. However, pain is more than a sensation or the physical awareness of pain; it also includes perception, the subjective interpretation of the discomfort

DEFINITION OF PAIN


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Nociceptive pain occurs when nociceptors in the body detect noxious stimuli that have the potential to cause harm to the body

Neuropathic pain is caused by damage to the neurons that are involved in the pain signaling pathways in the nervous system. It arises from damage to the nervous system itself, central or peripheral. Example: chronic trigeminal neuropathy, burning mouth syndrome. The pain is often stabbing, firing, electrical, burning, tingling. More likely to lead to chronic pain. It does not serve any biological function

TYPES OF PAIN

Nociceptive PainNociceptor• A sensory nerve cell, a receptor for painful stimuli.• Intense chemical, mechanical, or thermal stimulation of nocicep-

tors produces a signal that travels along a chain of nerve fibers via the spinal cord to the brain

Nociception• The sensory nervous system’s response to harmful or potentially

harmful stimuli• The input to the brain from the tissues, the process of transmitting

information


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DENTAL PAIN

Nociceptive Acute Pain

Mechanism of Dentinal Sensation

• The A delta fibers are faster conducting and are responsible for localized, sharp dentinal pain. The C fibers are slower conducting fibers and are considered responsible for dull throbbing pain

• The pain receptors transmit their message to the central nervous system at different rates depending upon size, diameter and coating of the nerves

• Noxious stimuli stimulate the C-fibers in the pulp to produce dull, vague and unlocalized type of pain (pulpal pain)

• Non-noxious stimuli stimulate dentinal pain (A-delta fibers)

• Odontoblastic Receptor Theory• The odontoblastic processes act as sensory

receptors and transmit sensory sensation through odontoblasts to the underlying nerve endings in the cell free zone


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DENTAL PAIN

Acute Pain

Chronic Pain

• Usually comes on suddenly and is caused by something specific

• It is sharp in quality• Usually does not last longer than six months• It goes away when there is no longer an underlying

cause• Causes of acute pain includes surgery, tooth

fracture, broken bones• After acute damage goes away, a person can

usually go on with life as usual. Reversible. Complete healing

• Is usually ongoing and lasts longer than six months• Can continue even after the injury or illness that caused it

has healed or gone away• Pain signals remain active in the nervous system for

weeks, months, or years• Some people suffer chronic pain even when there is no

past injury or apparent body damage• Chronic pain is linked to conditions including: Headache,

Arthritis, Cancer, Back Pain, TMJ• Can have physical effects that are stressful on the body,

like a limited ability to move around• Emotional effects include depression, anger, anxiety, and

fear of re-injury. Such a fear might limit a person’s ability to return to their regular work or leisure activities


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DENTAL PAIN

Service Dogs Can Help With Chronic Pain• According to the HeartMD Institute, research

supports the use of service dogs to help manage pain

• One study in particular, showed that people have less shoulder pain when service dogs pull manually operated wheelchairs

• Adopting a calm, well-adjusted dog can help reduce pain. The simple act of petting a dog can release endorphins in the brain, which soothe pain

• The gentle cardiovascular activity of walking a dog is good for you, too. Not only does it get your blood flowing, but it forces you to move stiff joints and muscles, which (though counterintuitive) is one of the best ways to manage pain


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OROFACIAL PAIN DISORDERS

Arthrogenous TMJ & surrounding tissues- radiating to the ear region. Pain aggravated during loading and functioning of joint.

Myogenus Regional pain disorder characterized by localized muscle tenderness and limited range of motion. Defined by presence of myofascial trigger points. Masticatory muscle involvement can be a source of tooth pain

Neuropathic Trigeminal NeuralgiaAffects CN V which carries sensation from face to brain. Even mild stimulation (brushing teeth or putting make-up) may trigger a jolt of excruciating pain

Analgesics- Drugs that achieve relieve from pain• Salicylates (aspirin)• Acetaminophen• NSAIDS (Ibuprofen, Naproxen)• Ketorolac (Toradol)

Muscle Relaxants- Drugs that decrease muscle tone• Cyclobenzaprine (Flexeril)• Methocarbamol (Robaxin)

Corticosteroids- Drugs that regulate inflammation, stress and immune responses• Dexamethasone• Prednisone

Antispasmodics- Drugs that suppress muscle spasms• Botulinum Toxin - Botox

Mechanism of Action of Pharmacotherapeutics for Orofacial Pain


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ASPIRIN

• Indication: For the temporary relief of minor pain due to headache, arthritis, muscle pain or toothache

• Mechanism of action:• Inhibits the activity of the enzyme

cyclooxygenase (COX-1) which leads to the formation of prostaglandins (PGs) that cause inflammation, swelling, pain & fever

• PGs protect the stomach mucosa from damage by hydrochloric acid, maintain kidney function and aggregate platelets when required

• Therapeutic dose: 500-1000 mg Q4-6 HRS, Max 4000 mg/day

• Dosage strengths: 81 mg, 325 mg & 500 mg• Adverse effects: Epigastric distress, nausea, ulcers,

vomiting• Contraindications: Liver disease, GI ulcer,

concurrent use of anticoagulant medication, vitamin K deficiency, hemophilia


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NSAIDS

• Great for inflammatory pain• Mechanism of action: Inhibit prostaglandin

synthesis by reducing cyclooxygenase enzyme activity (COX-1 and/or

• COX-2). Both enzymes produce prostaglandins that promote inflammation, pain, and fever.

• Only COX-1 produces prostaglandins that activate platelets and protect the stomach and intestinal lining.

• The more an NSAID blocks COX-1, the greater is its tendency to cause ulcers and promote bleeding.

• Indications: headache, musculoskeletal pain, acute TMJ, osteoarthritis, internal derangement, all acute disease pains, postoperative analgesic, chronic pain.

• Adverse effects: gastropathy, renal dysfunction


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IBUPROFEN

• For the relief of mild to moderate inflammatory Pain including dental.

• Analgesic, anti-inflammatory, antipyretic.• Side effects: Nausea, vomiting, tinnitus• Dosage strengths: OTC: 200 mg. Prescription 800

mg• Dosage 200-800 mg every 4-6 hours• Max dosage:• 3200 mg/day (prescription strength)• 1200 mg/day (OTC)


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NAPROXEN

• For the relief of mild to moderate pain. Great anti-inflammatory

• The strongest pain reliever currently available without a prescription. Stronger dose, increased risk of side effects

• Dosage strengths• 220 mg OTC• 250 mg, 275 mg, 375 mg, 500 mg, 550 mg, 750 mg• Initial loading dose 500 mg, then 250 mg every 6-8

hours, or 500 mg q12hr• Max 1250 mg/day


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ACETAMINOPHEN

• Potent anti-pyretic and analgesic, weak anti-inflammatory

• Fast onset of action• Good for those intolerant to NSAIDS• Mechanism of Action: Weak inhibitor of COX-1 &

COX-2. Inhibition of prostaglandin synthesis in the CNS. Acts on hypothalamus to reduce fever

• Dosage strengths: 325 mg, 500 mg, 650 mg• Therapeutic dose 325-600 mg Q4-6 HRS or 1000

mg 3-4 times per day• Maximum dose: 4000 mg per day allowed (better

to stay closer to 3,000 mg per day)• Adverse reactions hepatotoxicity


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KETOROLAC (TORADOL)

• For moderate to severe acute pain requiring analgesia at opioid level

• Used for short-term treatment of moderate to severe pain in adults, less than a days

• It is usually used before or after medical procedures or after surgery

• Prescription needed• Dosage strengths: 10 mg tablets, 1V/IM 15 mg/mL ,

30 mg/mL• Always begin with parental IV/IM 20 mg, then 10

mg tablets q4-6 hr.• Side effects: Headache, abdominal pain, nausea,

diarrhea, hypertension


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SKELETAL MUSCLE RELAXANTS

• Drugs that are used to relax and reduce tension in muscles. Often used for TMJ/Bruxism pain

• Some work in the brain or spinal cord to block/dampen excessively stimulated nerve pathways

• For short-term use (no more than 3 weeks)• Indicated for muscle spasm, hyperactivity, trismus

Cyclobenzaprine (Flexeril)• 5 mg 3 times a day, could be increased to 10 mg• Drowsiness, constipation, urinary retention and dry

mouth

Methocarbamol (Robaxin)• Blocks nerve impulses that are sent to the brain• 1500 mg qid for 2-3 days, then 750 mg qid• Drowsiness, dizziness, fast heartbeat, headache• Reduced sedation compared to Flexeril


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CORTICOSTEROIDS

• Steroid- hormones produced by the body or man-made

• Synthetic corticosteroids - treat diseases of immunity, inflammation or salt and water balance

• Glucocorticoids reduce pain by inhibiting prostaglandin synthesis, which leads to inflammation, and reducing vascular permeability that results in tissue edema

• Systemic corticosteroids - orally or by injection (epidural, joint, peripheral nerve and soft tissue injections)

• Dexamethasone is the most common• Prednisone or prednisolone can also be

used

• Inflammatory TMJ pain (capsulitis, arthritis)• Triamcinolone (glucocorticoid) 10-20 mg mixed with local anesthetic (2% lidocaine

without epinephrine)• Dexamethasone 4 mg• Target the superior joint space• No more than 1 injection every 6 months• Hyaluronic acid injections once a month for patients that do not respond to

corticosteroids

Injectable Corticosteroids


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TRIGGER POINTS

• Areas in muscle that are very irritable• When pressed produce a twitch within the

affected muscle• May produce also pain in a distant area -

referred pain• May develop because of trauma, injury,

inflammation, or other factors• Can cause headache by themselves -

myofascial pain• Can be present in patients with migraine,• tension-type, post-traumatic, and other

headache disorders

• A procedure where a medication, usually a local anesthetic, with or without a steroid medication is injected into the painful muscle to provide relief

• If steroid medication is used, it reduces the inflammation and swelling of tissue around the nerves, which may help reduce pain

• Provide pain relief in affected muscle and area of referred pain• They block pain receptors within the nerves surrounding the muscle and reduce the

pain signals sent to the brain• Very helpful for immediate relief for severe pain in patients with an individual headache

or migraine attack, or an exacerbation

Trigger Point Injections


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OCCIPITAL NERVE BLOCKS TO SUPPRESS CHRONIC HEADACHE

• An injection around the greater and lesser occipital nerves that are located on the back of the head just above the neck area

• Irritation/inflammation of those nerves may cause occipital neuralgia

• Pain relief can occur within 15 minutes of the block(s). The duration of the therapeutic response varies widely: a day, weeks or even months


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BOTOX (BOTULINUM TOXIN) INJECTIONS

A drug made from a toxin produced by the bacterium Clostridium botulinum. It’s the same toxin that causes a life-threatening type of food poisoning called botulism. Doctors use it in small doses to treat health problems, including:

• Temporary smoothing of facial wrinkles• Severe underarm sweating• Cervical dystonia - a neurological disorder that causes

severe neck and shoulder muscle contractions• Blepharospasm - uncontrollable blinking• Strabismus - misaligned eyes• Chronic migraine FDA Approved when migraines occur

15 or more days a month

Botox injections (anti-spasmodic) work by weakening or paralyzing certain muscles or by blocking certain nerves. The effects last from three to twelve monthsIt should not be used when pregnant or while breastfeeding

• Off-label use for primary and secondary masticatory and facial muscle spasm, severe bruxism, chronic myofascial pain, masseter hypertrophy, neuropathic pain.

• It is injected superficially on masseter, anterior temporalis

• 20-40 units per muscle• Controversial studies about its effectiveness for

reducing bruxism or myofascial pain

Botox Injections


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ORTHOTICS/OCCLUSAL GUARDS TO MANAGE PAIN

• Mouth guards for TMJ problems are used to hold the jaw in the correct position

• Prevent pain by keeping patient from clenching or grinding their teeth together, reducing further attrition and dentinal exposure

• Help the jaw and facial muscles relaxed, which reduces muscle spasms and reduces pain

• Reduce pressure on sore teeth• Reduce clenching induced pain in head, neck,

shoulders, ears


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WHEN DID OPIOIDS BECAME POPULAR TO TREAT PAIN?

• Insurance companies and hospitals offered patient satisfaction as an element of quality of care, hidden incentives for doctors, 1999-2010

• In the late 1990s, pharmaceutical companies reassured the medical community that patients would not become addicted to prescription opioid pain relievers

• Healthcare providers began to prescribe them at greater rates for the management of pain

• Chronic Pain. Rx opioids, patients happy and satisfied!

• As access increased-- increase in abuse and misuse

• Opioids depress the central nervous system, reducing the perception of pain

• The chronic use of opioids is associated with an elevated risk of misuse

• The longer patients take an opioid, the higher their tolerance becomes, requiring more of the drug to achieve the same effect

Opioids Mode of Action


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THE OPIOID CRISIS

• Both legal and illegal opioids— a growing public health problem across the United States, affecting the health, social, and economic well-being of many Americans.

• Opioids are a type of powerful pain reliever that impact the nervous system. They include legal prescription pain medications, such as oxycodone, hydrocodone, codeine, morphine, and fentanyl, as well as illegal drugs, such as heroin.

• The only natural opioid is derived from the resin of the opium poppy. It is used in the manufacturing of morphine and codeine.

• All other opioids are either synthetic or semi-synthetic, including hydrocodone, oxycodone, heroin, methadone, and fentanyl. These drugs can be ingested in pill form, snorted, injected intravenously, or smoked. The drugs most commonly associated with overdose are hydrocodone, oxycodone, and heroin.

Opioids


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DOCTORS CONCERN WITH PATIENT SATISFACTION

• Led to widespread diversion and misuse of these medications before it became clear that these medications could indeed be highly addictive. Opioid overdose rates began to increase.

• Percocet: Oxycodone 5mg and acetaminophen 325 mg in one capsule, 60 capsules copay 20 dollars. Take the powder, water and inject it-- cheap!

• Patients made money by selling the drug• In 2010 they reformulated OxyContin - can’t dissolve it, addicted moved to heroin,

cheaper and more available-- now a heroin problem.• Awareness programs started. Once patients were no longer able to access prescription

opioid medications, they resorted to using street drugs, like heroin, to satisfy their addiction.


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PUBLIC HEALTH CRISIS

• Because of increases in opioid misuse and related overdoses

• Rising incidence of neonatal abstinence syndrome due to opioid use and misuse during pregnancy

• Neonatal abstinence• syndrome (NAS). A group of conditions

caused when a baby withdraws from certain drugs exposed to in the womb. ... When drugs are taken during pregnancy, they can pass through the placenta and cause serious problems for the baby

• The increase in injectable drug use has also contributed to the spread of infectious disease including HIV and Hepatitis C


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NATIONAL DRUG OVERDOSE DEATHS

National Drug Overdose

Deaths—Number Among All Ages, by Gender, 1999-2017. More than 70,200 Americans died from drug overdoses in 2017, including illicit drugs and prescription opioids—a 2-fold increase in a decade. The figure aside is a bar and line graph showing the total number of U.S. overdose deaths involving all drugs from 1999 to 2017. Drug overdose deaths rose from 16,849 in 1999 to 70,237 in 2017. The bars are overlaid by lines showing the number of deaths by gender from 1999 to 2017 (Source: CDC WONDER)


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NATIONAL DRUG OVERDOSE DEATHS INVOLVING

PRESCRIPTIONS

National Overdose Deaths Involving Prescription Opioids—Number Among All Ages, 1999-2017. The figure aside is a bar and line graph showing the total number of U.S. overdose deaths involving prescriptions opioids (including methadone) from 1999 to 2017. Since 2016, however, the number of deaths have remained stable. The bars are overlaid by lines showing the number of deaths involving prescription opioids in combination with other synthetic narcotics (mainly fentanyl) and without other synthetic narcotics from 1999 to 2017. The number of deaths involving prescription opioids in combination with synthetic narcotics has been increasing steadily since 2014 and shows that the increase in deaths involving prescription opioids is driven by the use of fentanyl (Source: CDC WONDER).


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DRUG AND OPIOID-INVOLVED OVERDOSE DEATHS

• In 2017, among 70,237 drug overdose deaths, 47,600 (67.8%) involved opioids, in multiple states

• From 2013 to 2017, synthetic opioids contributed to increases in drug overdose death rates in several states. From 2016 to 2017, synthetic opioid-involved overdose death rates increased 45.2%

The US has the highest rates of opioid use, USA represents 5% of the world population but consumes 99% of hydrocodone and 83% of oxycodone of the global totals

• 21-29 % of patients prescribed opioids for chronic pain misuse them

• 8-12% develop an opioid use disorder• 4-6% who misuse prescription opioids transition to heroin• 80% of people who use heroin, first misused prescription opioids• Opioid overdoses increased nationally 30% from 07-16 to 9-17• The Midwestern region: opioid overdoses increased 70% 7-16 to 17• Opioid overdoses accounted for:

• 42,000 deaths in 2016-- 40% of those involved a prescription opioid• 70,200 deaths in 2017--192 a day• 83,000 deaths in 2018; 228 a day 2018; one death every 6 minutes; 1600 a week!

United States, 2013–2017CDC Weekly / January 4, 2019

National Statistics


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THE TREND

• After natural opioids (morphine), heroin (semi-synthetic) was developed, then fentanyl (synthetic) which is cheaper and more potent.

• Fentanyl is 50-100 times more potent than morphine. 2-3 mg of Fentanyl can induce respiratory depression, arrest and death. 2-3 mg of fentanyl is about the same as 5-7 individual grains of table salt!

• Fentanyl is cheaper and easier to obtain than heroin and is often used as a cutting agent or filler for heroin. Mix it with heroin-- less heroine needed making it cheaper and more profitable!

• Carfentanil… terrifying! To sedate elephants: one grain needed. Prisoners used to get it in the mail, now they get photocopies of their mail. Touching it may be enough to kill you. 10,000 times as potent as morphine

• Dentistry Today 2019. NSAIDs are effective for relieving postoperative pain. Opioids are associated with high incidences of adverse effects such as nausea, vomiting, constipation and opioid abuse.

• There have been cases where OTC NSAIDs such as ibuprofen and naproxen sodium, performed better than opioids for postoperative pain relief!

• JAMA study 15,000 concluded that ~6% of people between 16-25 who received an initial opioid prescription, were diagnosed with opioid abuse within one year. A similar group that was not prescribed opioids had an abuse rate of just 0.4%.

• Advil & Tylenol are equally effective, less expensive, less toxic and less addictive. There will always be situations where opioids are the best option, but in many cases, OTC drugs are an effective and far less dangerous alternative.

Articles, articles, articles…


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IN THE NEWS

• In many cases, a wisdom tooth extraction can be the first exposure to an opioid.• Brains are at a critical stage of development• The ADA recommends dentists use nonsteroidal anti-inflammatory drugs as a first-line

therapy for managing acute pain• OMFS prescribe opioids 85% of the time:

• hydrocodone 5 mg,7.5 mg/acetaminophen 300 mg (Vicodin) preferred• ~20 tabs average but 8-40 tabs range

• Percocet (Oxycodone/acetaminophen) is 1.5 more potent than Vicodin/Norco – same as Vicodin but 325 acetaminophen

Addressing acute Pain in Teens & Young Adults ADA News April 15, 2019


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ULTRAM

• Ultram is a drug that contains the active ingredient tramadol. It’s a Schedule IV controlled substance, and it’s prescribed to relieve pain

• Tramadol is an opioid narcotic• Does not cause bleeding in the stomach and intestines, or kidney problems.

• It may not decrease swelling• It is less addictive than oxycodone but less effective


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THE ROLE OF THE DENTIST IN THE OPIOID CRISIS

• Adolescents and wisdom teeth• Dentists and Oral Surgeons often prescribe opioid analgesics to adolescents and

young adults for the first time in their lives• Brains developing, not wired right yet• There are other options

• Acute toothache, drug shopping (doctor shopping)• Prescription Drug Monitoring Programs, PDMP’s forces people to identify

themselves• In Michigan, MAPS

• Written consent should be signed• Use education pamphlet/video – document usage, risks, interaction, storage, disposal

and penalties for diversion• ~6% of immediate-release opioids are prescribed by dentists, and only ~20 tabs per RX,

compared to other healthcare professionals• Primary care providers prescribe the most opioids• Extended release opioids should not be used to treat acute pain


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SCREENING FOR OPIOID MISUSE IN THE DENTAL OFFICE

• Opioids decrease pain perception, elicit moderate levels of sedation, and produce euphoria

• Patients may present with constricted pupils, depressed respiration, and drowsiness• Anorexia and constipation are common side effects of opioid use• Patients using opioids are at risk for orthostatic hypotension due to the peripheral

vasodilation• Dental disease in this population is typically the result of poor oral hygiene and

xerostomia. Patients may present with high amounts of plaque and calculus. The risk of bruxism is also increased in this population

• Prescription Monitoring Programs


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POST-OPERATIVE STRATEGIES TO CONTROL PAIN

• Pre-operative NSAID’s (Naproxen sodium 550 mg or ibuprofen 600 mg)• Long acting local anesthetics (Marcaine – bupivacaine 0.5% with 1:200,000

epinephrine)• Corticosteroids

• Decadron (dexamethasone 8 mg I.M or I.V.) as an anti-inflammatory agent-- limits trismus and swelling

• Solu-Medrol or Medrol dose packs should also be considered.• Ice, soft diet and rest• NSAID’s analgesics as the first line of therapy for postoperative pain per ADA• Motrin primary control 3200 mg/day max--600 mg is as effective as 800 mg for

analgesia• Combination of Ibuprofen 400 mg and acetaminophen 500 mg as an opioid

alternative• Acetaminophen secondary control 3000 mg/day max• A 2-3 day supply of opioids is usually enough

• First time use of opioids?• Warn about the problems of abuse!


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GUIDELINES FOR MANAGEMENT OF ACUTE POSTOPERATIVE PAIN

• Mild Pain• Ibuprofen 200-400 mg• q 4-6 hours

• Mild-Moderate Pain• Ibuprofen 400-600 mg• q 4-6 hours: fixed interval for 24 hours

• Moderate-Severe Pain• Ibuprofen 400-600 mg plus Acetaminophen 500 mg• q 6 hours: fixed interval for 24 hours

• Severe Pain• Ibuprofen 400 mg plus Vicodin (hydrocodone 5 mg/Acetaminophen 300mg)• q 6 hours: fixed interval for 24-36 hours


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THE ROLE OF THE HYGIENIST IN THE OPIOID CRISIS

• Due to the growing number of Americans misusing opioid medications, dental hygienists should be prepared to screen for opioid misuse, offer resources for treatment, as well as provide effective oral health care to this population.

• A thorough medical and social history should be taken on every patient at each appointment, including a question on the use of illicit or prescription medications for nonprescription use.

• Misuse of drugs may be related to psychological factors such as depression; self-medication; personality disorder; and poor coping skills.

• Social behaviors related to misuse may have cultural, societal, and interpersonal influences.

The National Institute on Drug Abuse provides a guideline for the quick screening of drug use, which follows the protocol used in tobacco cessation:• Ask, Advise, Assess, Assist, and Arrange• Ask the patient if it is ok to talk about drug use• Advise the patient he or she may be at risk for SUD (Substance Use Disorder)• Assess the patient’s readiness to quit• In the dental office, assist and arrange would be covered by referring the patient to his

or her primary care physician for help


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DENTAL FEAR, ANXIETY AND PAIN

• Dental fear is defined as an unpleasant mental, emotional, or physiologic sensation derived from a specific dental–related stimulus

• Dental anxiety is non-specific unease, apprehension, or negative thought about what may happen during a dental appointment

• As pain increases, anxiety increases; as anxiety increases, pain becomes enhanced and therefore less tolerable

• Dental fear and anxiety can come from different sources, but are often from a previous bad dental experience, hearing of bad experiences from family or friends, or a general fear of needles

• Anxiety and fear management will lead to PAIN MANAGEMENT!• Antianxiety medications for patient to take before dental appointment:

• Valium 5 or 10 mg (Diazepam)• Xanax 1-2 mg

• Oral & IV Sedation/General Anesthesia

By observing the patient’s physical symptoms, such as dilated pupils, elevated blood pressure, heart rate, respiration and increased salivation.

These physical effects are a result of the sympathetic nerve endings producing epinephrine and are difficult for the patient to control.

Other non-verbal indicators may include “white–knuckling” the arms of the dental chair and missing or being late for dental appointments.

How Can We Identify Patient’s Fear?


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PAIN AND ANXIETY MANAGEMENT TOOLS

Traditional methods:• Topical aneshetics• Dentinal desensitizers• Flouride varnish• Local Anesthetics• Periodontal anesthetic gel (Oraqix™)• Nitrous oxide

• Benzocaine: FDA-approved drug. In 20% concentration, benzocaine gel is the most used topical anesthetic in dentistry, with an onset time of 30 seconds and duration of five to 15 minutes

• Lidocaine is another FDA-approved topical anesthetic that is available in various concentrations and over-the counter agents. The typical onset time for 2% topical lidocaine is three to five minutes, and its duration is 15 minutes

• Compounded Anesthetic Gel 30 gms tube. Each mL contains:• Lidocaine…….100 mg• Prilocaine ……100 mg• Tetracaine …… 40 mg

• Profound Gel is comprised of lidocaine, prilocaine & tetracaine. Edge Pharma offers Profound Gel in a 30-gram jar without requiring patient names. The raspberry marshmallow flavor is popular due to its effectiveness in masking the inherent bitterness of oral anesthetics. Mint is also available.

Topical Anesthetics


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PAIN AND ANXIETY MANAGEMENT TOOLS

• GLUMA (Hurriseal, Super Seal) Desensitizer & Desensitizer PowerGel

• An aqueous and viscous gel of Glutaraldehyd, HEMA, colloidal silica and pigments

• It achieves its effect by precipitation of plasma proteins, which reduces the dentinal permeability and occludes the peripheral dentinal tubules

• Apply GLUMA Desensitizer locally on the exposed dentine in the cervical tooth area

• Apply GLUMA Desensitizer and GLUMA Desensitizer PowerGel for an application time of 30 – 60 seconds

• Air dry the liquid GLUMA Desensitizer until the gloss of the liquid disappears

• Patients may use their whitening tray to apply the viscous gel directly onto the teeth for maximum coverage and extended wear-time

• The human body’s strongest material, hydroxyapatite (HAp) is a mineral that is naturally found in enamel and dentin. When applied to the dentin and/or enamel surface, TEETHMATE

• DESENSITIZER creates HAp, sealing dental tubules and cracks in the enamel

• Indicated to prevent a variety of dentinal sensitivity challenges, such as cervical sensitivity (exposed dentin), before/after bleaching, scaling or root planning and underneath restorations

• It is highly biocompatible• It is free of gum irritants such as glutaraldehyde or

methacrylates• Results are immediate and last long lasting and there is no

interference with adhesives

Dentinal Desensitizers

Teethmate Desensitizers


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38.

FLUORIDE VARNISH

• Dentinal sensitivity is reported to occur in 20 to 30 percent of adults with exposed dentin

• Short, exaggerated, painful response when exposed dentin is subjected to certain thermal, mechanical, or chemical stimuli

• The cause of the sensitivity is due to the exposure of the dentin due to gingival recession, abrasion, erosion, periodontal therapy, and/or defective restorations

• Fluoride varnish is a resin-based fluoride containing a 5 percent sodium fluoride.• The “varnish” is painted directly onto the tooth• It has been approved by the Food and Drug Administration (FDA) as a treatment

for dentinal sensitivity• The mechanism of action is the deposition of calcium fluoride on the tooth surface,

with the formation of fluoroapatite.• This mineral is able to seal completely dental tubules and to promote a secondary

dentin surface• When the proper application protocol is followed, the fluoride varnish remains on the

teeth for a number of hours, releasing fluoride into the immediate environment• (especially the interproximal and cervical areas where it is most needed)• For those patients with continued dentinal sensitivity, reapplication can occur every six

months


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PROTOCOL FOR 5% SODIUM FLUORIDE VARNISH

1. Prophylaxis of surface to be treated2. Rinse with water3. Remove excess water and saliva4. Dispense fluoride varnish as per manufacturer’s

instructions for use (Remember to look for material that has a unit-dose dispensing system)

5. Paint a thin layer approximately .5mm thick of varnish directly on the teeth using a disposable applicator brush. • Note that the varnish sets as soon as it comes in contact with saliva. It will leave a fluoride-rich layer adjacent to the tooth surface

6. Instruct patients to avoid brushing their teeth and eating for two hours after treatment


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40.

LOCAL ANESTHETICS

Lidocaine

• Marketed in 1948• First amide local anesthetic and a great improvement

over the ester agents previously available• It remains the gold standard by which all others are

judged and holds 49% of the U.S. market share• It is compounded with epinephrine as 2% lidocaine,

1:100,000 epinephrine and 1:50,000 epinephrine

Mepivacaine

• Marketed in 1960, it is available as 2% mepivacaine, 1:20,000 levonordefrin and 3% mepivacaine (plain)

• Mepivacaine has a milder vasodilatory effect than most other amides and so it may be useful with patients for whom vasoconstrictor is contraindicated and cannot receive 4%prilocaine plain

Prilocaine

• Marketed in 1965, is less toxic and less potent than lidocaine or mepivacaine and provides a slightly longer duration of action

• It is available as 4% prilocaine 1:200,000 epinephrine and 4% prilocaine (plain)

• It can be a good choice for patients for whom vasoconstrictor is contraindicated


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ARTICAINE

• It has been available in Europe since 1976 but was not marketed in the United States until 2000

• It is the second most popular local anesthetic in the U.S., currently holding 35.6% of the U.S. market share, and is the leading dental anesthetic in Canada and Europe

• Its popularity has been attributed to higher injection success rates related to increased lipid solubility and faster diffusion through hard and soft tissues. Reports also indicate more profound and longer duration of anesthesia

• It is 1.5 times more potent than lidocaine and has similar toxicity

• In the U.S., it is compounded with epinephrine as 4% articaine, 1:100,000 epinephrine & 4%articaine, 1:200,000 epinephrine

• The elimination half-life (time required for 50% of a drug to be removed from the blood), as reported by manufacturers, is only 44 minutes, more than twice as fast as all other amide agents, resulting in a decreased risk of system toxicity

• Stanley Malamed feels damage to the inferior alveolar nerve is caused more by mechanically injuring the nerve than anesthetic itself

***In court cases, awards have been lower if parasthesia resulted from lidocaine instead of articaine


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ORAQIX

• Mixture of local anesthetics (EMLA): 2.5% lidocaine & 2.5% prilocaine

• Approved by the FDA for subgingival application• A liquid-to-gel system that changes from a liquid at

room temperature to a gel when placed subgingivally• The max dose is five carpules for adults, not

recommended for patients under 18 years of age• The onset time is 30 seconds and it has a 20-minute

duration subgingivally• Contraindications: allergy to amides or any

component of the product Possible adverse reactions: edema, abscess, irritation, pain and ulceration


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NITROUS OXIDE

• Combination of inhaled nitrous oxide and oxygen - a safe and effective means of managing pain and anxiety in dentistry

• Nitrous oxide has the fastest onset among inhalation agents and is transported in blood as free gas; it does not combine with hemoglobin, and it does not undergo biotransformation. Systemic elimination occurs with pulmonary exhalation; its low solubility allows nitrous oxide to be removed rapidly from the body

• After the procedure, deliver 100% oxygen to the patient for 5 minutes before removing the mask. This will purge the system of any residual nitrous oxide and will help the patient clear the drug

• The American National Standards Institute (ANSI) recommends quarterly testing of nitrous oxide levels in your facility


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PAIN AND ANXIETY: ALTERNATIVE METHODS

Techniques that require no specialized training including:

• Stress-reduction techniques• Music therapy• Aromatherapy• Behavioral modeling• Distraction & deep breathing• Guided imagery• Progressive relaxation

*Examples of alternative techniques that do require specialized training or education include meditation, yoga, hypnosis and acupuncture


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STRESS-REDUCTION TECHNIQUES

• Relaxation therapy can include any variety of techniques designed to trigger the body’s relaxation responses (decreased muscle tension, heart rate, blood pressure, and respiration).

• Most hygienists and doctors use relaxation techniques every day, whether consciously or unconsciously, on their patients, their children, and even themselves.

• Deep breathing can help prevent hyperventilation and syncope, which can occur in anxious patients

• Instruct patients to take slow, deep breaths through the nose and exhale slowly which may stimulate the relaxation response

Deep Breathing


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• Simple and inexpensive relaxation technique• Research has shown that music can be a significant

mood–changer and stress reliever and suggests that the rhythm may allow for synchronization of the right and left-brain hemispheres, which leads to a more relaxed and contented state.

• Music has also been found to reduce pain during dental procedures

• Music that contain drums and flutes are examples of music that lead to relaxation

• Patients experience an increase in deep breathing, an acceleration in the production of serotonin, a lowering of the heart, pulse, and breathing rates, and a slight increase in body temperature

• Dental equipment noise, particularly the “drill,” can be an audio sensory cue that patients relate to pain. The use of music with headphones helps drown out these noises

• It is recommended to have a set of headphones for each operatory

Music Therapy


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• The art of using essential plant oils to promote and maintain health and vitality

• Essential plant oils are extracted through a chemical process of distillation from aromatic plants, flowers, herbs, woods, and fibers

• There are approximately 70 essential oils used in aromatherapy, each with its own characteristic odor and therapeutic effect

• Some essential oils claim to have analgesic effects. The pharmacology behind the actions of many essential oils remains undefined and more research is needed

• Current research in aromatherapy is underway. Lavender & Lemon, have shown to reduce dental anxiety.

• For Inflammation: Oregano, Peppermint, Frankincense, Melaleuca, Eucalyptus

• For pain, mixtures of Oregano, Marjoram, Incense, Eucalyptus, Frankincense

• Toothache: Clove

Aromatherapy


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TOP 5 ESSENTIAL OILS FOR WISDOM TOOTH PAIN

• Clove has long been known as a reliever of toothache and an analgesic and pain reliever. It contains a chemical called Eugenol which not only diminishes pain but fights infections and helps to relieve mouth sores safely. It also controls the number of bacteria that naturally occur in your mouth.

• Peppermint is a great cooling soother of sore and inflamed gums. Rub it directly onto the gum for instant relief or soak a cotton wool ball with oil to create a compress and tuck it into the space at the back of your mouth where the wisdom tooth is erupting or next to the troublesome tooth.

• Eucalyptus proven to be a comforting elixir. Dip a cotton swab in one of these mixtures and apply it to your tooth and gums.

• Myrrh is excellent at promoting the healing of mouth sores and canker if your pain originates from one of these rather than a sore or infected tooth.

• Tea tree is so useful for numerous health conditions. Tea tree oil will kill bacteria in your mouth and fight infection with anti-inflammatory and anti-microbial properties.


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SEVERE TOOTHACHE BLEND FOR ADULTS

Ingredients:

• 4 drops clove essential oil• 3 drops cinnamon essential oil• 1 teaspoon coconut oil

Directions:

• Mix the ingredients in a small glass container• Use a cotton swab to apply to the tooth or gums to

relieve pain• Try not to swallow immediately; the essential oils are

safe to ingest, but you want them to be absorbed by the tooth or gingiva for maximum pain relief


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TOOTH PAIN MOUTH RINSE

Ingredients:

• 5 drops tea tree essential oil• 4 drops spearmint essential oil• 3 cups of water• 3 2-inch segments of ginger root

Directions:

• Peel the ginger and slice into paper-thin slices.• Add the ginger to the water and boil until the

liquid is reduced by about half• Strain out the ginger from the water and discard,

saving the water• Cool the water to room temperature and add the

essential oils• Rinse the mouth with this mixture every 2 hours,

holding it in the mouth as long as possible to relieve pain and inflammation


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BEHAVIORAL MODELING

• A common method of behavior modification used by dental professionals who deal with children

• The child watches another person undergo a dental procedure and is encouraged to model the behavior

• Takes the patient’s mind off the dental treatment and allows it engage it in something else--conversation, television, or a poster

• This is an effective technique for short–term procedures such as radiographs, taking an impression, or a fluoride treatment

Distraction


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GUIDED IMAGERY

• It can be accomplished when the hygienist helps patients take a “mental vacation”

• Patients should be encouraged to close their eyes to block out negative visual sensory cues, to choose a place where they feel safe and secure, and to concentrate on that place through mental images

• Guided imagery tapes and CDs are also available


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ACUPUNCTURE IN DENTISTRY

• An alternative and complimentary therapy to traditional Western medicine

• Triggers the nervous system by activating various points on the body, originally by using needles

• Modern theories suggest it affects the body’s pain signal receptors while releasing endorphins and serotonin, which are natural painkillers, into the nervous system

• Dental Pain• Dental Anxiety• Gag Reflex• TMJ pain or TMD• Chronic Muscle Pain or spasm• Atypical Facial Pain• Headache

Conditions Treated With Acupuncture

• Xerostomia• Nerve Pain• Sjögren’s syndrome• Burning mouth syndrome• Pain Management method during and

after surgery


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SUPPLEMENTS REFERENCE MATERIAL


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QUESTIONS

KARSON L. CARPENTER, [email protected]

pain management in dentistry

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