Pain Management.
Pain can be classified based on pain physiology, intensity, temporal charac-
teristics, type of tissue affected, and syndrome:
1) Pain physiology (nociceptive, neuropathic, inflammatory)
2) Intensity (mild-moderate-severe; 0-10 numeric pain rating scale)
3) Time course (acute, chronic)
4) Type of tissue involved (skin, muscles, viscera, joints, tendons, bones)
5) Syndromes (cancer, fibromyalgia, migraine, others)
Special considerations (psychological state, age, gender, culture)
Classification of Pain
Classification of pain: Classifying pain is helpful to guide assessment and
treatment. There are many ways to classify pain and classifications may overlap.
The common types of pain include:
Nociceptive: represents the normal response to noxious insult or injury of tis-
sues such as skin, muscles, visceral organs, joints, tendons, or bones.
Somatic: musculoskeletal (joint pain, myofascial pain), cutaneous; often well
localized
Visceral: hollow organs and smooth muscle; usually referred
6) Neuropathic: pain initiated or caused by a primary lesion or disease in
the somatosensory nervous system.
Sensory abnormalities range from deficits perceived as numbness to hyper-
sensitivity (hyperalgesia or allodynia), and to paresthesias such as tingling.
Examples include, but are not limited to, diabetic neuropathy, postherpetic
neuralgia, spinal cord injury pain, phantom limb (post-amputation) pain, and post-
stroke central pain.
7) Inflammatory: a result of activation and sensitization of the nociceptive
pain pathway by a variety of mediators released at a site of tissue inflammation.
The mediators that have been implicated as key players are proinflamma-
tory cytokines such IL-1-alpha, IL-1-beta, IL-6 and TNF-alpha, chemokines, reac-
tive oxygen species, vasoactive amines, lipids, ATP, acid, and other factors released
by infiltrating leukocytes, vascular endothelial cells, or tissue resident mast cells
Examples include appendicitis, rheumatoid arthritis, inflammatory bowel
disease, and herpes zoster.
Clinical Implications of classification: Pathological processes never occur in
isolation and consequently more than one mechanism may be present and more than
one type of pain may be detected in a single patient; for example, it is known that
inflammatory mechanisms are involved in neuropathic pain.
There are well-recognized pain disorders that are not easily classifiable. Our
understanding of their underlying mechanisms is still rudimentary though specific
therapies for those disorders are well known; they include cancer pain, migraine and
other primary headaches and wide-spread pain of the fibromyalgia type.
Pain Intensity: Can be broadly categorized as: mild, moderate and severe. It
is common to use a numeric scale to rate pain intensity where 0 = no pain and 10 is
the worst pain imaginable:
• Mild: <4/10
• Moderate: 5/10 to 6/10
• Severe: >7/10
Time course: Pain duration
• Acute pain: pain of less than 3 to 6 months duration
• Chronic pain: pain lasting for more than 3-6 months, or persisting be-
yond the course of an acute disease, or after tissue healing is complete.
• Acute-on-chronic pain: acute pain flare superimposed on underlying
chronic pain.
Pain management
The practice of various psychological, physical, and chemical approaches to
the prevention and treatment of preoperative, operative, and postoperative anxiety
and pain.
Methods of pain control:
Anesthetic agents
Inhalation sedation
Antianxiety agents
Intravenous sedation
General anesthesia
Anaesthetic agents.
Topical anesthesia provides a temporary numbing effect on nerve endings that
are located on the surface of the oral mucosa.
Supplied as:
Ointments
Liquids
Sprays
Local Anesthesia.
Criteria for use:
• Be nonirritating to the tissues in the area of the injection.
• Produce minimal toxicity.
• Be of rapid onset.
• Provide profound anesthesia.
• Be of sufficient duration.
• Be completely reversible.
• Be sterile.
Local anesthesia temporarily blocks the normal generation and conduction ac-
tion of the nerve impulses and is obtained by injecting the anesthetic agent near the
nerve in the area intended for dental treatment.
Vasoconstrictor prolongs the duration of an anesthetic agent by decreasing the
blood flow in the immediate area of the injection.
Types:
Adrenaline
Epinephrine
Norepinephrine
Ratio of vasoconstrictor to anesthetic solution:
• 1:20,000
• 1:50,000
• 1:100,000
• 1:200,000
Contraindications for the use of vasoconstrictors:
• Unstable angina
• Recent myocardial infarction.
• Recent coronary artery bypass surgery.
• Untreated or uncontrolled severe hypertension.
• Untreated or uncontrolled congestive heart failure.
Types of local anesthesia injections:
Infiltration is achieved by injecting the solution directly into the tissue at the
site of the dental procedure. Most frequently used to anesthetize the maxillary teeth.
Used as a secondary injection to block gingival tissues surrounding the mandibular
teeth.
Block anesthesia
• The solution is injected near a major nerve, and the entire area served
by that nerve is numbed.
• Type of injection required for most mandibular teeth.
Inferior alveolar nerve block
Obtained by injecting the anesthetic solution near the branch of the inferior
alveolar nerve close to the mandibular foramen. Type of injection for half of the
lower jaw, including the teeth, tongue, and lip.
Incisive nerve block
Injection is given at the site of the mental foramen and used when the mandibular
anterior teeth or premolars require anesthesia.
Local anesthesia setup
Aspirating syringe is used in dentistry to inject a local anesthetic. The aspirat-
ing syringe differs from most syringes in that it is designed to inject anesthetic from
a carpule. The parts of an aspirating syringe consist of a threaded tip where the nee-
dle attaches, a barrel where the carpule is placed, a piston rod (plunger) with a har-
poon attached that embeds itself into the rubber stopper of the carpule, a finger grip,
and a thumb ring.
The harpoon allows the dentist to aspirate (draw back) the injection site to see
if the needle tip is located in a blood vessel before injecting the anesthetic solution.
Once the harpoon is engaged into the rubber stopper of the anesthetic carpule, the
dentist can apply inward or outward pressure on the stopper by exerting pressure on
the thumb ring. Pulling the thumb ring outward also pulls the plunger outward pro-
ducing an aspirating effect; whereas, pushing inward forces the anesthetic solution
through the needle.
Anesthetic carpule care and caution of use:
• Cartridges should be stored at room temperature and protected from
direct sunlight.
• Never use a cartridge that has been frozen.
• Do not use a cartridge if it is cracked, chipped, or damaged in any way.
• Never use a solution that is discolored or cloudy or has passed the ex-
piration date.
• Do not leave the syringe preloaded with the needle attached for an ex-
tended period of time.
• Never save a cartridge for reuse.
Electronic Anesthesia is a noninvasive method to block pain electronically
by using a low current of electricity through contact pads that target a specific elec-
tronic waveform directly to the nerve bundle at the root of the tooth.
Benefits to the patient:
• No needles.
• No post-operative numbness or swelling.
• Chemical-free method of anesthesia.
• No risk of cross-contamination.
• Reduces fear and anxiety.
Antianxiety agents and sedatives
Criteria for use:
• Patients are very nervous about a procedure.
• Procedures are long or difficult.
• Mentally challenged patients.
• Very young children requiring extensive treatment.
Commonly prescribed:
• Secobarbital sodium (Seconal)
• Chlordiazepoxide HCl (Librium)
• Diazepam (Valium)
• Chloral hydrate (Noctec): For children
Intravenous Sedation
Antianxiety drugs that are administered intravenously continuously through-
out a procedure at a slower pace, providing a deeper stage I analgesia.
Patient assessment
• A health history, physical examination, and signed consent are per-
formed.
• Baseline vital signs are taken and recorded.
• Oximetry and electrocardiogram are completed and recorded.
• Weight taken and recorded for dose determination.
Patient monitoring requires physiologic measurements taken and recorded
every 15 minutes.
• Level of consciousness
• Respiratory function
• Oximetry
• Blood pressure
• Heart rate
• Cardiac rhythm
References:
1. Chapter 37. Anesthesia and Pain Control in Dentistry. Elsevier Science
(USA);Link:http://www.csi.edu/facutyAndStaff_/webTools/sites/Bowcut58/
courses/408/ch37.ppt
