Pain control in restorative procedure
- 1. PAIN CONTROL IN RESTORATIVE PROCEDURE Submitted by: Dany Biju Philip Roll no: 12
- 2. Contents Introduction Nerve fibres for different sensation Pain pathway Theories of pain Management of pain in restorative procedures Conclusion
- 3. Introduction Definition of pain: An unpleasant sensation associated with actual or potential tissue damage and mediated by specific nerve fibers to the brain, where its conscious appreciation is modified International Association for the Study of Pain (IASP –WHO) Dental treatment is often perceived as a painful experience by patients. However, with emphasis on prevention, minimal intervention and modern atraumatic treatment this is not necessarily true. A caring and sympathetic attitude and gentle handling of patients will in itself to a major extent relax the patientand reduce their anxiety.
- 4. Nerve fibres for different sensations Neuron is the structural and functional unit of the nervous system Consists of : • Dendrites • Cell body • Axon
- 5. Nerve Conduction: Resting state / Polarized Depolarization Repolarization Saltatory Conduction
- 6. Sensory Receptors: Exteroceptors Proprioceptors Interoceptors
- 7. Pain receptors in the skin and other tissues are all free nerve endings – Nociceptors Pain arises by 4 processes: • Transduction • Transmission • Modulation • Perception A –delta- fibers – large myelinated fibers (fast pain) C – fibers – small unmyelinated fibers.(slow pain) Both respond to pain,pressure and temperature
- 8. Pathways of pain : Neospinothalamic tract
- 9. Pathways of pain : Paleospinothalamic tract
- 11. Theories of Pain Specifity theory Pattern theory Gate control theory
- 12. Specificity Theory: Von Frey developed this concept. Specific cutaneous receptors are there for the mediation of touch, heat, cold and pain. Free nerve endings are implicated as pain receptors. A pain centre was thought to exist in the brain, which is responsible for the manifestation of unpleasant experience. Pattern Theory: By Goldscheider in 1894 Proposes that stimulus intensity and central stimulation are critical determinants of pain Theory suggest that particular patterns of nerve impulses that evoke pain are produced by the summation of sensory input within the dorsal horn of the spinal column. Pain results when the total output of the cells exceeds a critical level.
- 13. Gate Control Theory: Proposed by Melzack and Wall in 1965. Information about the presence of injury is transmitted to the central nervous system by small peripheral nerves These small peripheral nerves are facilitated or inhibited by large peripheral nerves which also carry information about innocuous events The theory proposes that large diameter fiber input has the ability to modulate synaptic transmission of small diameter fibers within the dorsal horn. Large diameter fibers transmit impulses at a greater rate of speed than small diameter fibers. Large fibers transmit signals that are initiated by pressure, vibration, and temperature. Small fibers transmit noxious or painful sensations. Intentional stimulation of large fibers results in the inhibition of synaptic transmission by smaller fibers.
- 14. Management of Pain during Restoration Removing the cause Blocking the pathway of painful impulses Raising the pain threshold Preventing pain reaction by cortical depression Using psychosomatic methods
- 15. Management of pain during: Restoration involving enamel and dentin Restoration involving pulp tissue •Case history •Motivation •Inhalation sedation •Premedication •Hypnosis •Electronic Dental Anaesthesia •Proper Clinical Procedure •Local Anaesthesia •Case history •Motivation •Premedication •Local Anaesthesia •Clinical procedure
- 16. Case history To understand the patient and patient’s attitude towards treatment. If it is his or her 1st dental visit or any past dental history Motivation A caring and sympathetic attitude and gentle handling of patients will in itself to a major extent relax them and reduce their anxiety. Premedication Pre-medication with antianxiety agents or sedatives as an adjunct to local anesthesia in order to calm the patient during the dental treatment. The agents used are: • Diazepam(Benzodiazepine derivative) administered orally in a dose of 2 to 10 mg one hour prior to the dental appointment • Alprazolam(Benzodiazepine derivative)0.25 to 0.5 mg one hour prior to the dental appointment • Midazolam 2 to 5 mg one hour prior to the dental appointment.
- 17. Inhalation sedation • Many patients with mild to moderate fear of dental treatment can benefit from conscious sedation with nitrous oxide and oxygen. • In the method, the patient’s pain threshold is elevated while he is conscious of his surroundings. • Though the initial cost to install the equipment is high, this technique is a safe alternative to general anesthesia. Hypnosis • This is another adjunct to local anesthesia and may be used to control the tense patient. • The dentist should be familiar with the principles of hypnosis. • Through hypnosis, the patient can be made more relaxed and co-operative.
- 18. Electronic Dental Anesthesia(EDA) This is a recently available technique to control, pain during dental procedures. It works on the gate control theory of pain transmission. • Used at a high Frequency of more than 120Hz, EDA produces a sensation that may be described as “vibrating”,”throbbing”,”pulling” or “twitching”. • It acts by stimulating the large diameter A- fibers which transmit the sensation of touch, pressure and temperature . • This will inhibit the transmission of pain impulses produced by the high speed drill which are transmitted by the smaller A-delta and C-fibers . • When the pain impulses fail to reach the brain, the sensation of pain does not occur
- 19. Local Anaesthesia Patient factors: Before administering local anesthesia, certain patient factors have to be assessed. These include: Systemic Health Allergy Techniques of local anesthesia: The techniques of local anesthesia commonly used in operative dentistry are: • Topical anaesthesia • Infiltration anaesthesia • Regional block anaesthesia • Intra pulpal and Intra ligament LA
- 20. The agents used are: Lidocaine 2% + Epinephrine 1:50,000 Lidocaine 2% + Epinephrine 1:100,000 Bupivacaine 0.5% + Epinephrine 1:200,000 A vasoconstrictor like epinephrine is added to prolong the action of the anaesthetic by decreasing the rate of absorption of the anesthesia into the blood.
- 21. Advantages of local anesthesia • Patient co-operation: Once the local anesthesia has become effective, the patient is more relaxed and co-operative due to the absence of pain. • Control of saliva: Complete anesthesia of all tissues in the operating site controls salivation. • Reduced blood flow: The vasoconstrictor in the local anesthesia reduces blood flow in the operating site thus controlling bleeding in the area. • Operator efficiency : Due to the above mentioned factors , the operator’s efficiency is greatly enhanced
- 22. CARE DURING OPERATIVE PROCEDURES An extremely gentle and careful approach during treatment goes a long way in preventing pain and trauma to the patient. The following measures will ensure proper care during operative procedures: Use of mouth mirrors to provide proper retraction of tongue, cheeks and lips. Application of rubber dam to ensure protection of the gingiva and adjacent hard and soft tissues. Avoiding the use of slow speed drill for gross removal of tooth structures it can be time consuming and produces heat and vibrations which may be traumatic to the patient. Use of airotor with coolant for the initial cavity preparation stage. Intermittent cutting with light strokes is most comfortable for the patient. This will also avoid excessive cutting of tooth structure.
- 23. While treating deep carious lesions use of slow speed, round steel burs, or spoon excavators to remove soft caries will provide a better tactile feel and prevent pulp exposure and pain associated with it. Mastery over proper instrument grasp, rests and guards is necessary to prevent accidental damage to adjacent hard and soft tissues. Avoiding desiccation of cavity preparations by blowing air from the air water syringe. Rapid blast of air from air water syringe can induce a painful response and in deep caries produce pulpal inflammation. Use of gingival retraction cords while working close to the gingiva will protect the gingival tissue. Proper use of pulp protective agents like varnishes,sealants,liners and bases during restorative procedures will help to preserve pulp vitality and prevent post operative pain.
- 24. Conclusion The skill of the dentist in minimizing pain is an important consideration for many patients. The dentist has an obligation to the patient to perform operations with as little discomfort and pain as possible.
- 25. Bibliography Bell’s Orofacial pain, Jeffery P. Okeson DMD Clinical Operative Dentistry Principles and Practice, Ramya Raghu, Raghu Srinivasan