CHAPTER 14 Pain Management
Anxiety is the feeling of apprehension and fear characterized by physical symptoms such as palpitations, sweating, feelings of stress. Anxiety keeps many people from receiving necessary dental treatment because of fear of pain or discomfort. Fear is excessive apprehension or anxiety. Understanding dental fear can help in selecting appropriate methods for alleviating patient discomfort. Anxiety and fear are common occurrences in the dental office and can be managed by a variety of techniques. Sometimes fear can become excessive and involve a phobia, which promotes inaction (failure to seek necessary dental treatment).
Scenario: A 35-year-old woman has not been to the dentist’s office for 10 years. During her last dental experience, she had two third molars extracted and the local anesthetic initially used did not provide pulpal anesthesia. Repeated injections did not improve the situation but did make her more anxious and uncomfortable, and the extraction proceeded without anesthesia for the patient. Lately her gums have been bleeding and sore. Her husband persuaded her to have a thorough exam and cleaning. After diagnosis of generalized chronic periodontitis, her treatment plan suggests nonsurgical periodontal therapy by quadrant dental hygiene using local anesthesia of the involved regions. On the day of her appointment with the dental hygienist, the patient calls and cancels.
Peripheral nervous system (PNS) comprises sensory (afferent) nerves that carry sensations of pain to central nervous system (CNS), and motor (efferent) nerves that transmit messages from CNS to muscles and glands. Understanding of sensory nerve anatomy and physiology and action of local anesthetics is essential to pain management. Sensory nerves are afferent nerves that carry sensations of pain to the CNS.
Dental patients can benefit from removal of pain during dental procedure with local anesthesia, as well as hemorrhage control from use of a vasoconstrictor, along with use of topical anesthesia. Can be used alone or with a combination of nitrous oxide sedation, which alone does NOT replace local anesthesia for pain control, since it is an analgesic and not an anesthetic. Local anesthesia administration by dental hygienists is allowed in only some states and usually under the supervision of a dentist.
The CORRECT administration of local anesthesia involves understanding nerve anatomy and physiology, pharmacology, armamentarium, technique, and possible complications. Action of local anesthetic agent depends on chemical structure and pH of the solution and body tissues.
Understanding the metabolism, action, dosage calculations, and specific functions of topical and local anesthetic agents and vasoconstrictors helps the clinician to request and use these agents more safely and efficiently. Clinician MUST prevent an overdose (OD) situation, which is an accidental or intentional use of a drug in an amount higher than is normally used.
Local anesthetic is an anesthetic drug that induces local anesthesia by inhibiting nerve excitation or conduction. These agents also have effects on central nervous system (CNS), cardiovascular system (CVS), respiratory system.
Dosage calculations for local anesthetics are based on the size and general health of patient and on type and concentration of the anesthetic agent and vasoconstrictor. The maximum recommended dose (MRD) is the dose established by manufacturer (in milligrams per pound).
Vasoconstrictors and local anesthetic agents must be chosen carefully, based on the medical concerns and type of dental procedure to be performed. Anesthetic is selected based on whether its duration is appropriate to procedure being performed.
Topical anesthetics are useful for providing light, localized anesthesia to the first 2 to 3 mm of the oral mucosa as a preinjection agent. May also be used alone before procedures involving soft tissues (nonsurgical periodontal therapy). Must be placed on oral mucosa for 2 to 3 minutes per Materials Safety Data Sheet (MSDS).
Preparing the armamentarium for delivery of local anesthetic involves knowledge of the syringe, needle, cartridge, proper setup procedures, care of equipment, safe handling, and prevention and management of associated problems. Aspiration is the process of removing fluids (or gases) from the body with a suction device (syringe with piston). It allows the clinician to know if the needle tip is in a blood vessel to prevent an intravascular injection.
|Anatomy anesthetized||Pulpal and soft tissue and nerve endings in area of injection|
|Needle gauge and length||27-gauge; short, extra short, or ultra short or CLAD|
|Depth of penetration||Base of pocket until resistance is met|
|Landmarks||Pocket area, mesial of distal root|
|Site of penetration||Long axis of root on mesial or distal with bevel toward root|
|Deposition site||Base of pocket|
|Cartridge amount (1.8 mL/cartridge)||0.2 mL|
|Advantages||Minimal dose required; no unnecessary structures anesthetized; works better with CLAD|
|Disadvantages||Leakage of anesthetic; difficult to deposit with nonpressure syringe; not with inflammation or primary teeth present|
Scenario: During an initial dental hygiene appointment with new patient, the dental hygienist observes blood in a cartridge (positive aspiration) during administration of an inferior alveolar nerve (IA) nerve block (2% lidocaine with 1:100,000 epinephrine). A 25-gauge long needle is being used. A large amount of blood fills the cartridge quickly. The patient with generalized moderate chronic periodontitis reports no medical conditions and exhibits no significant need for dental restoration.