14: Pain Management

CHAPTER 14 Pain Management


Pain is sum total of responses (behavioral, emotional, motivational, psychological) to actual or impending tissue damage from noxious stimulus.

Anxiety 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.

Sensory Innervation

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.

See Chapters 3, Anatomy, Biochemistry, and Physiology: nervous system anatomy and physiology; 4, Head, Neck, and Dental Anatomy: trigeminal nerve.

Figure 14-1 Structure of a neuron and relationship with other neuron (and muscle tissue).

(From Bath-Balogh M, Fehrenbach MJ: Illustrated dental embryology and anatomy, ed 2, Philadelphia, 2006, Saunders/Elsevier.)


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.

D. Dissociation of local anesthetics: ability of a local anesthetic to dissociate, indicated by pKa number.

Pharmacology of Local Anesthetics and Vasoconstrictors

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.

See Chapter 9, Pharmacology: local anesthetic and vasoconstrictor pharmacology.

Local Anesthetic Agent Action

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.

See Chapter 10, Medical and Dental Emergencies: local anesthesia emergency protocol in a dental setting.

Vasoconstrictor Action

Vasoconstrictors if used in local areas cause constriction of the arterioles and capillaries. Vasoconstrictors act on alpha (α) and/or beta (β) receptors, depending on the body tissues.

D. Inclusion of vasoconstrictors:

Dosage Calculations

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).

Local Anesthetic Agents and Vasoconstrictors

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.

Local Anesthesia Armamentarium

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.

B. Needles: stainless steel, disposable, presterilized, sharp to decrease potential for cross-contamination (Figure 14-6):

C. Cartridges: cylindrical tube of agent, color-coded by manufacturer to distinguish types, holds 1.8 mL of anesthetic (Figure 14-7):

Table 14-4 Periodontal ligament injection technique

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
Complications Pain
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

See manufacturer’s directions for use of pressure syringe (Ligmaject); dental hygienists may not be allowed to perform intraosseous injections in some states.

Jan 1, 2015 | Posted by in Dental Hygiene | Comments Off on 14: Pain Management
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