13: Pain and Anxiety Control

CHAPTER 13 Pain and Anxiety Control

Chapter Points

• This chapter covers the requirements of the NEBDN syllabus Section 13: Pain and anxiety control in dentistry. The chapter is highly relevant in the day-to-day situation you will face in a dental surgery or other dental environment.

Introduction

Any patient can become anxious or experience pain in a dental environment. They are managed accordingly by using different methods of anxiety and pain control. Patients who are very anxious may need sedation. As a dental nurse student, you are not permitted to assist in conscious sedation (CS) but, once you have qualified, you may consider doing a post-qualification course in dental sedation nursing. This will involve completing a record of experience in the workplace and sitting an examination.

Key Point

The most important aspect of pain and anxiety control is a calm, confident and reassuring manner by the dental staff including the dental nurse.

The mental state can significantly influence our level of anxiety and pain perception. Most patients are able to accept non-invasive dental treatments with simply sympathetic management. However, operative treatments, especially those involving cutting or removing soft or hard tissue (surgery, implantology, endodontics, much conservative dentistry and some periodontology) can cause significant discomfort. In these situations, drugs may be needed for analgesia, sedation or anaesthesia. Orofacial pain is discussed in Chapter 5. Analgesic medications are discussed in Chapter 12.

Some practitioners use hypnosis or other techniques in an effort to help. Physical interventions (restraint, holding still or containing) must only be considered if alternative approaches have been considered and are not possible.

Precautions in use of drugs for anxiety and pain control

It is important always to take a full medical and drug history, since the medical status or medications a person may already be taking can influence the choice of drugs (see Chapters 2 and 6). Certain drugs may need to be avoided or doses reduced in specific conditions. It is particularly important to ensure there is no history of allergy or untoward effect from the drug being considered.

The clinician can check drug doses, contraindications, interactions and adverse reactions in the British National Formulary (BNF) or the special dental version called the Dental Practitioners’ Formulary (DPF).

If aspirin or paracetamol is indicated, it should be given at least 30 minutes before food, since the absorption of these drugs is otherwise delayed.

Special Situations

In general, drug doses will need to be reduced in:

• Children
• Older people
• Liver disease
• Kidney disease.

Pregnancy

In relation to pain and anxiety control drugs should be avoided where possible in pregnancy, in case they affect the fetus.

Children

The following drugs should be avoided:

• Aspirin – it can cause a serious liver problem (Reye syndrome; see Chapter 12)
• Diazepam (Valium) – it may have unwanted effects, causing overactivity rather than sedation
• Tetracyclines – they may discolour the teeth (see Chapter 5).

Key Point

Always check: (i) that the correct drug (and solvent) is used; this is particularly important if another person makes up the drug; and (ii) that the drug expiry date has not passed.

Anaesthesia and sedation

Definitions

• Analgesia – the inability to feel pain while still conscious (from the Greek an-, ‘without’, plus algesis, ‘sense of pain’).
• Anaesthesia – loss of bodily sensation with or without loss of consciousness (from Greek anaisthe-sia, ‘lack of sensation’).
• Local anaesthesia (LA) – loss of feeling in a part of the body such as a tooth or an area of skin without affecting consciousness.
• Topical anaesthesia – loss of feeling in a part of the body such as an area of mucosa or skin, produced by a locally applied drug; there is no effect on consciousness.
• Regional anaesthesia – numbness of a larger part of the body, also without affecting consciousness.
• General anaesthesia (GA) – numbness of the body, with loss of consciousness and protective reflexes (e.g. cough reflex).
• Sedation – depression of a patient’s awareness to the environment and reduction of their responsiveness to external stimulation. Achieved by the administration of drugs. Often given to facilitate a procedure under local anaesthesia. Consciousness and protective reflexes (e.g. cough reflex) are retained.
• Conscious sedation (CS) – a state of sedation in which the patient remains aware of his or her person, surroundings and conditions, but without experiencing pain or anxiety. Consciousness and protective reflexes (e.g. cough reflex) are retained.
• Relative analgesia (RA) – the relief of pain without loss of consciousness or protective reflexes (e.g. cough reflex). This is inhalation sedation.

There are two types of anaesthetic used in medicine:

• Local – used only in a specific area
• General – has an effect on the whole body.

Local anaesthesia (or local analgesia) is required for many dental procedures. Thousands of patients are treated successfully using LA, without any problem. Some people, however, cannot accept injections and others have a pronounced gag reflex or fear of ‘the drill’. In these patients LA cannot be used or will not help. Such patients may benefit from using CS.

CS can be induced through several routes:

• Oral
• Inhalational (nitrous oxide or ‘laughing gas’) – also called ‘relative analgesia’ or RA, or inhalational sedation
• Intravenous or IV (usually midazolam)
• Intra-nasal.

In extreme cases where the patient is unable to co-operate, or in major procedures such as maxillofacial surgery, GA is indicated. However, GA can be potentially dangerous and life-threatening. Therefore GA must be given in a hospital with critical care facilities.

Term to Learn

Critical care: the care provided to patients who are critically ill and who usually require very intensive monitoring, e.g. patients in an intensive care unit (ICU or ITU for short).

Local anaesthesia

Local anaesthesia is generally a very safe procedure. It is made safer by ensuring that:

• Any medical problems or previous untoward reactions are noted while taking the history
• The patient has eaten meals as normal
• The injection is not given intravenously by accident
• The correct dose is given
• The patient is lying back when the injection is given.

Types of Local Anaesthesia

Surface or topical anaesthesia

This is the application of LA spray, solution, gel or cream to the skin or a mucous membrane which has a short-lasting effect restricted to the area of contact. For example:

• Paste (e.g. benzocaine (Ultracare)) and spray formulations or a tablet which is sucked (lidocaine/benzocaine) can be used before giving LA injections or before taking an impression or radiograph to prevent retching
• Gel (Oraquix, which is a lidocaine plus prilocaine periodontal gel) formulations can be applied to the gingiva before scaling
• Cream (e.g. EMLA, which is lidocaine plus prilocaine), gel (e.g. Ametop, which is tetracaine) and medicated plaster (e.g. Rapydan, which has lidocaine plus tetracaine) formulations can be applied to the skin before injections.

Ethyl chloride is a highly volatile liquid spray which evaporates and produces a near freezing temperature that causes numbness. This can be used before a minor procedure such as the quick incision of an abscess or extraction of a neo-natal tooth. It is flammable.

Term to Learn

Neo-natal tooth: a tooth that erupts in the first month of life. Rarely, a child is born with a tooth already erupted – this is called natal tooth.

Injected local anaesthesia

The preferred method of dental and oral pain control is often injected LA, since it is very safe and is adequate for most procedures. When LA is injected it blocks transmission in the nerve that is in that area. This allows patients to undergo procedures without pain. It is also used in most cases where CS or GA are used. LA is given with an aspirating syringe to prevent the accidental injection of the LA agent into a vein or artery, which could cause the patient to collapse. Disposable needles are used (and never re-used; Figure 13.1) to avoid any risk of transmitting infections. Needlestick injuries must be avoided (see Subchapter 1.2).

image

FIGURE 13.1 (A) Self-aspirating syringe; (B) dental needle; (C) non-aspirating syringe; (D) dental needle; (E) Jenker needle guard/holder; (F) local anaesthetic cartridges.

Types of Injection

There are several ways in which LA can be given by injection. The most common techniques used in dentistry are: infiltration, regional block and intraligamentary injection. Following infiltration and regional block anaesthesia there is not much systemic absorption of the drug, that is, it does not get distributed in the entire body.

• Infiltration anaesthesia – this is injection of LA into the tissue alongside the tooth to be anaesthetised. It can be effective for deciduous teeth, permanent anterior teeth or maxillary premolars and molars. This is because the bone surrounding these teeth is thin enough to allow the solution to diffuse through the porous alveolar bone to the dental nerves of one or two teeth. This injection rarely works for the posterior teeth in the mandible as the bone is denser, but can be used to aid haemostasis.
• Regional block anaesthesia – this is injection of LA into the tissue in the vicinity of a major nerve to anaesthetize that nerve’s area of innervation. Thus a regional block of the inferior alveolar nerve (inferior dental block or ID block) will anaesthetise the lower teeth and gingiva on that side (plus chin and lower lip). The ID block is given at the back of the oral cavity so as to deposit the LA at the site of the mandibular foramen where the inferior alveolar nerve enters the mandibular bone (see Chapter 4). The injections block the incoming impulses from all surrounding nerve branches, producing a wide area of anaesthesia. It is used during fillings, endodontics and surgical procedures in the mandible. The posterior superior alveolar nerve block will do the same in the upper jaw (anaesthetise the upper teeth and gingiva on that side).
• Intraligamentary anaesthesia – this is given directly into the periodontal ligament through the gingival sulcus for small fillings or extraction of a single tooth.

Term to Learn

Nerve’s area of innervation: the part of the body supplied by a particular nerve.

In addition:

• Intra-osseous anaesthesia – is given directly into the bone via an access hole (only rarely used).

Local Anaesthetic Solutions

The main LA solution that is used in the dental workplace is lidocaine (formerly called lignocaine). It belongs to a class of drugs called amides. Other commonly used amides for dental procedures are prilocaine, articaine and mepivacaine. See also Table 13.1.

TABLE 13.1 Commonly Used Local Anaesthetics

image

The majority of LA dental cartridges also contain a vasoconstrictor. The vasoconstrictor used in dental LA is either adrenaline (epinephrine) or felypressin (Table 13.1).

• Adrenaline is a naturally occurring hormone which makes the heart beat faster and harder to supply the muscles with more blood during exercise (see Chapter 4). Thus it is not used for patients with angina and high blood pressure.
• Felypressin is a hormone that constricts the blood vessels but does not make the heart beat faster, so it can then be used in place of adrenaline.

Term to Learn

Vasoconstrictor: these substances help constrict blood vessels, which reduces the bleeding in the operative field and concentrates the anaesthetic in the area (there is reduced absorption by blood), thus increasing its effect and making it last for longer.

Contents of a Local Anaesthetic Cartridge

Local anaesthetic is supplied sterile for dental use in a glass cartridge (Figure 13.1). This contains (Table 13.1):

• Local anaesthetic agent (mainly lidocaine 2% or prilocaine 3% or mepivacaine 3% or articaine 4%)
• Vasoconstrictor (adrenaline or felypressin)
• Saline solution
• Additives:

image Buffer to control pH level (acidity)
image Antiseptics
image Preservatives.

Key Point

LAs have a limited shelf-life so you should always check before use that it has not expired.

Dental Local Anaesthetic Syringes

A dental syringe (Figures 13.1 and 13.2) is a hand-held device that carries the LA cartridge for injection of LA. The major problem with most syringes is that the needle has to be removed from the syringe prior to sterilisation. This puts the operator at increased risk of injury (sharps or needlestick injury) during the dismantling process. The rising awareness of infection control is also putting increased pressure on manufacturers to introduce fully disposable instruments. These issues have led to the development of dental safety syringes. The types of safety systems include:

• Aspirating syringes – the clinician pulls back on the thumb grip to see whether a blood vessel has been penetrated
• Self-aspirating syringes – aspiration occurs automatically after the clinician stops giving the injection; nowadays self-aspirating syringes should be used
• Wand system – has a ‘computer-controlled local anaesthetic delivery’ (C-CLAD) system for the improved and painless delivery of local anaesthetic
• Safety system – constructed in such a way as to avoid needlestick injuries; it is disposable.
• SafetyWand system – like the Safety system, it has sharps protection features to aid in the prevention of needlestick injuries and also C-CLAD.
image

FIGURE 13.2 (A) Non-aspirating syringe; (B) aspirating syringe; (C) self-aspirating syringe; (D) intraligamentary syringe.

Find Out More

Does your workplace have a Safety or SafetyWand system? If not, type ‘safety wand syringe’ into a search engine such as Google and check out the results.

With regard to loading a cartridge, syringes may be:

• Breach loading – in this the plunger is pulled against the spring so the end can be turned sideways. This opens the barrel to allow the LA cartridge to slide in.
• Side loading – this has a spring-loaded collar at the plunger end. This is pulled back by the plunger to allow the cartridge in.

Loading an LA Syringe

1. Always check with the clinician which LA, syringe and needle they require:

• Sterile syringe type – self-aspirating or non-aspirating
• Sterile needle type – short needles of size 30G (where the G stands for ‘gauge’) are usually used for infiltration injections for anterior teeth and all maxillary teeth. Long needles of size 27G are usually used for ID block injections, which anaesthetise a whole side of the mandible
• Sterile cartridge type (usually lidocaine, prilocaine or articaine).

2. Check for:

• Correct anaesthetic
• Whether the solution is discoloured
• The expiry date
• Cracks or breaks
• The correct type of bung (stopper) – with or without indentation.

3. Setting up:

• Always put the needle in the />

Related posts:

  1. 16: Dental Emergencies
  2. 12: Dental Drugs, Materials, Instruments and Equipment
  3. 4: Anatomy and Physiology
  4. 2: Medical Emergencies and First Aid in the Dental Surgery
  5. 10: Surgical Procedures
  6. 17: Human Diseases and Health Promotion

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Jan 8, 2015 | Posted by in Dental Nursing and Assisting | Comments Off on 13: Pain and Anxiety Control

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