ENDODONTIC PAIN MANAGEMENT

Perception is not always reality. Pain is often associated with root canal therapy by the media and public. Every one has heard jokes about root canals and how much they hurt. However , in a survey conducted by AAE , people who had actually experienced root canal therapy were three times more likely to describe it as “painless” than those who had never had the procedure.

PATHWAYS OF FEAR IN DENTISTRY- WHY PAIN??

extreme dental fear avoid the dentist

 learn to fear from dental phobic elders, negative connotations and friends with personal negative experiences.

fears are reactions to stressful experiences

 “word of mouth” information

 mother’s dental fear

DIAGNOSTIC CONSIDERATIONS??

Is the pain of odontogenic or non-odontogenic origin? Is the tooth vital or non-vital? Is the pain due primarily to an inflammatory or

infectious process? Is the pain of pulpal or periradicular origin or both? Is there a periodontal component?

CLINICAL STRATEGIES FOR MANAGING ENDODONTIC PAIN

A pulpotomy is often performed in cases of acute pain of pulpal origin when there is insufficient time to do pulpectomy.

The goal of the pulpotomy is to remove the coronal pulp tissue in the chamber without penetrating pulpal tissue in the root canal systems.

The pulpotomy, including sealing of sedative and antibacterial dressings in the pulp chamber

The removal of caries, pulpotomy, and sealing of the cavity was found to be a reliable means to relieve pain

PULPOTOMY

The biological basis for the high level of success associated with the pulpotomy procedure is probably associated with alteration of pulpal hemodynamics and interstial fluid pressure.

PULPECTOMY

Pulpectomy is the course of treatment often used in patients who present with symptoms of irreversible pulpitis, or pulp necrosis with or without swelling.

Since it is impossible for the clinician to precisely determine the apical extent of pulpal pathosis, a pulpectomy offers the advantage of complete removal of the pulp.

TREPHINATION

Trephination is the surgical perforation of the alveolar cortical plate over the root end of a tooth to release accumulated tissue exudate that is causing pain

The procedure has been recommended for patients with severe recalcitrant periradicular pain of endodontic origin

The mucosa is retracted with a tissue retractor, and a number six round bur is used to penetrate the cortical bone

An endodontic file has also been suggested to create a path through the cancellous bone toward the periradicular lesion, avoiding contact with the root structure or adjacent teeth

It is presumed that if apical trephination is successful, its success it based on the establishment of drainage, relief of pressure and the removal of inflammatory mediators from the periradicular tissues

INCISION AND DRAINAGE

Pulpal necrosis may result in a periradicular abscess with swelling

A serious diffuse swelling is characterized by its spread through adjacent soft tissues, dissecting tissue spaces along fascial planes. Such a swelling is called a cellulitis

The goal of emergency treatment for patients with swelling is to achieve drainage

The objective of drainage is to evacuate pus from the tissue spaces.

In endodontic cases, drainage is best achieved through a combination of canal instrumentation and when there is a fluctuant swelling incision and drainage

CELLULITIS I&D

Even in cases where an incision and drainage is to be implemented, the canal should be accessed, instrumented, irrigated, medicated and closed as soon as active drainage stops

OCCLUSAL REDUCTION

The value of reducing occlusion to prevent pain after endodontic instrumentation had been a source of controversy

Conditions evaluated included the presence or absence of pulp vitality, preoperative pain, percussion sensitivity, a periradicular radiolucency, a stoma, swelling and a history of bruxism – need occlusal reduction

Occlusal adjustment reduces mechanical stimulation of sensitized nociceptors

ANXIETY AND PAIN MANAGEMENT

The greater the anxiety, the more likely we are to interpret the sensation as pain

Highly fearful patients are more sensitive to pain in general and those who are dentally anxious are more sensitive to dental pain specifically

High levels of stress, anxiety or pessimism in preoperative patients predict poor outcomes

It has also been shown that more highly anxious patients report greater pain during dental procedures than normal controls

EFFECTIVE MANAGEMENT OF ACUTE PAIN

1. Diagnose and treat the cause of pain 2.Use a flexible analgesic prescription strategy 3.Pretreat with NSAID 4.Acheive profound anesthesia

DIAGNOSE AND TREAT THE CAUSE OF PAIN

In most of cases dental treatment alone results in substantial pain relief

Drug therapy is only adjunct to dental treatment

Accurate diagnosis

Effective treatment

Pain management

USING A FLEXIBLE ANALGESIC PRESCRIPTION STRATEGY

PRETREATING WITH NSAIDS

Pre treatment with NSAIDS delays the onset of post op pain

NSAIDS inhibit the production and release of chemical mediators of inflammation

Aspirin is not used prior to surgical procedures

SEDATION THERAPY

BARBITURATES- ANXIETY RELIEF

Depress all areas of CNS but reticular activating system is most sensitive. They can impair learning, short term memory and judgement.

SA Barbiturates Butobarbitone Secobarbitone Pentobarbitone

BENZODIAZEPINES

Antianxiety benzodiazepines Diazepam Chlordiazepoxide Oxazepam Lorazepam Alprazolam

USING LONG ACTING LOCAL ANESTHESIA

Adequate anesthesia not only ensures comfortable treatment but also reduces post treatment pain

Etidocaine and bupivacaine are effective in reducing pain

Etidocaine have faster onset of anesthesia

MANAGEMENT OF FEAR IN ENDODONTICS

Pretreatment anxiety questionnaire Individual systematic desensitization and group

therapy Individual systematic desensitization (ISD) is a

behavioral therapy whereby individuals are gradually exposed or incrementally exposed to fearful stimuli.

In this process, the individual must first identify and accept the fear-related stimulus

Second, the individual must learn to employ a relaxation or coping technique

Finally, the individual must utilize the learned relaxation or coping strategy to react and overcome the fearful stimulus.

Flooding/implosion Flooding is a form of desensitization for treating

phobias when the patient has a directly conditioned origin of fear.

In flooding therapy, the patient is subjected to repeated exposure of fear-inducing stimuli until they no longer show a fear response

Cognitive behavioral therapy Cognitive behavioral therapy (CBT) is a

psychotherapeutic approach to address dysfunctional emotions and negative behaviors and cognitions using a series of goal-oriented sessions

FLOODING/IMPLOSION

RELAXATION THERAPY

Relaxation therapy is a diverse set of practices aimed at eliciting a relaxation response, including a reduction in overall physical arousal symptoms. The phobic individual implements a particular mental relaxation technique (e.g., slow breathing, counting, relaxation swallowing) to reduce stress

Computer-assisted relaxation learning A recent development in the treatment of dental fear,

computer-assisted relaxation learning (CARL) is a self-paced treatment for dental phobic individuals for treating needle phobia. The program begins by introducing its purpose, followed by activities and videos on how to cope with their fear