1. MANAGEMENT OF PAIN IN
OPERATIVE DENTISTRY

2. INTRODUCTION:-
• Although pain is an important
motivating factor for patients to visit
the dentist, fear of pain is a major
reason for delaying dental
treatment..
• A caring & sympathetic attitude &
gentle handling of patient will itself
to a major extent relax them..

3. Method to control pain
in operative dentistry
1.local anaesthesia
2.alternative methods to control pain
- premedication with antianxiety
agents or sedatives
-inhalation sedation
-hypnosis
-electronic dental anaesthesia

4. 1.LOCAL ANAESTHESIA
• Most common used method
Indication:-
• Patient with hypersensitive
dentin
• Patients who are tense
• Painful procedures

5. Local anaesthesia

7. Before administering LA certain
patient factors have to be
assessed.these include:
• Systemic health
• Allergy
• psychology

8. Systemic health :
• Dentist should enquire about the
health status of the patient especially
regarding the cardiovascular
system,central nervous
system, liver, kidneys, thyroids, etc....
• Eg.in a hypertensive patient,the use of
LA with a vasoconstrictor should be
avoided as it can cause a rise in the
blood pressure & increased heart rate
• Overdose of anaesthetic agents can
depress the central nervous &
respiratory systems..

9. • Allergy:
• Patient having “sensitivity” or
“reaction” are contraindicated for
LA..anaphylactic shock can
occur..which may be immediate &
fatal..
• Psychology:
• Dental patient are usually tense about
receiving intraoral injection.a
confident,positive approch by tha
dentist can improve patient co-
operation & comfort.

10. • LOCAL ANAESTHETIC AGENTS:
• Amide type local anaesthetics are
commonly used in operative dentistry as
they produse less allergic reaction.
• 1.lidocaine 2% +
epinephrine1:50,000
• 2.lidocaine 2% +
epiinephrine1:100,000
• 3.bupivacaine 0.5% +
epinephrine1:200,000
• A vasoconstrictor like epinephrine is
added to prolong the action of the
anaesthetic by decreasing the rate of
absorption of tha anaesthetic into the
blood.

11. COMPOSITION :
• 2% lidocaine hydrochloride
- local anaesthetic agent.
• 1:80,000- 1:100,000 epinephrine
- vasoconstrictor.
• Sodium metabisulfite
- oxidizing agent.
• Methyl paraben
- preservative.
• Thymol
- antifungal.
• Distilled water
- solvent.

13. • TECHNIQUES OF LA :
• i) infiltration anaesthesia
• ii) regional block anaesthesia
• i)infiltration anaesthesia consists of
supraperiostial injection where the
anaesthetic is deposited near the nerve
endings in the operating site.usually
employed in maxillary teeth.
• ii) regional block anaesthesia consists of
a nerve block where the anaesthetic
solution is deposited near a nerve trunk
at a distance from the operating
site.usually employed in mandibular
teeth.

14. • TOPICAL ANAESTHESIA:
• Prior to administering the
anaesthesia,a topical
anaesthesic such as benzocaine
or lidocaine gel or spray must
be applied over the mucosa to
minimize the discomfort due to
needle pennetration.

17. • PRECAUTION DURING INJECTION:
• The patient should be kept in a supine or
semi-supine position.this will prevent
syncope by maintaining the blood supply &
blood pressure to the brain.
• The solution should be deposited slowly to
minimize pain
• Injection into infected tissues should be
avoided as this will spread the infection
• The syringe should have an aspirating
feature.the needle should be 27 gauge
needle.
• Only the smallest volume that will provide
effective anaesthesia should be deposited

18. • ADVANTAGES OF LA:
• Patient co-operation: once the LA has
become effective,the patient is more
relaxed & co-operative due to the
absence of pain.
• Control of saliva: complete
anaesthesia of all tissues in the
operating site controls salivation.
• Reduced blood flow: the
vasoconstrictor in the local
anaesthetic reduces blood flow in the
operating site thus controlling gingival
bleeding in the arae.
• Operator efficiency: due to the above
mentioned factors,the operator’s
efficiency is greatly enhanced.

19. 2.ALTERNATING METHODS
OF CONTROL PAIN
• I) pre-medication with antianxiety agents or sedative:
• This technique can be employed as an adjunct to local
anaesthesia in order to calm the patient during the
dental treatment.one precaution while prescribing
these drugs is that the patient should not come
unaccompanied during the dental appointment as his
reflexes would be depressed.
• The agents used are:
A.diazepam (benzodiazepine derivative)
administered orally in a dose of 2 to 10 mg one hour
prior to the dental appiontment
B.alprazolam
0.25 to 0.5 mg one hour prior to the dental
appointment.
C.midazolam
2 to 5 mg one hour prior to the dental appointment.

22. • ii) INHALATION SEDATION:
• Many patient with mild to moderate
fear of dental treatment can benefit
from conscious sedation with nitrous
oxide and oxygen.in this 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 anaesthesia..

25. • iii) HYPNOSIS:
• This is another adjunct to LA &
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 & co-operative.

27. • iv) ELECRONIC DENTAL
ANAESTHESIA(EDA):
• Recently available technique
• 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” , “pulsing” , “twitching”.
• EDA acts by stimulating the larger diameter
A-fibers which transmit the sensation of
touch,pressure & temperature.this will
inhibit the transmission of pain impulses
produced by the high-speed drill which are
transmitted by the small A-delta and C-
fibers. when the pain impulses fails to reach
the brain, the sensation of pain does not
occur.

28. • Another mechanism which occurs
during high frequency stimulation is
that the blood levels of serotonin &
endorphins are increased.they play a
secondary role in controlling pain
during dental treatment.
• EDA is as successful as LA during
restorative procedures with patients
reporting no soreness or discomfort
soon after the treatment

31. • Indications :
Needle phobic patient
Patient allergic to LA
Pain control prior to administration of
LA,especially for palatal injection.
• Contraindication :
Patient with cardiac pacemakers.
Patient with neurological disorders like
epilepsy.
Very young and very old patients
pregnancy

32. • Advantages:
No need for injection.
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.

33. CARE DURING OPERATIVE
PROCEDURES
• An extremely gentle & careful approch
• Use of mouth mirrors to provide proper
retraction of tongue, checks & lips
• Application of rubber dam to ensure protection
of the gingiva & adjacent hard & soft tissues.
• Avoiding the use of slow-speed drill for gross
removal of tooth structure,as it can be time
consuming,& produces heat & 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.

37. • 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 & prevent pulp exposure & pain associated
with it.
• Mastery over proper insrument grasps , rests ,
& guards is necessary to prevent accidental
damage to adjacent hard & soft tissues.
• Avoiding dessication of cavity preparation by
blowing air from the air-water syringe. A rapid
blast of air from the 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 gingival will protect the gingival
tissues.
• Proper use of pulp protective agents like
varnish, sealants, liners and bases during
restorative procedures will help to preserve
pulp vitality & prevent postoperative pain.

38. Thank you…….