Control Of Anxiety And Pain In Dentistry
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- CONTROL OF ANXIETY AND PAIN IN DENTISTRY By: Shabeel P.N Ist
batch
- INTRODUCTION
- Most common complaint in dental treatment & is defined as
an unpleasant sensational experience initiated by noxious stimulus
& transmitted over a specialised neural network to CNS where it
is interpreted as such.
- Specificity theory ,Pattern theory , Gate control theory
(Melzak & Wall).
- Theories of Pain
- Both Specificity and Pattern theories are used to help explain
how different kinds of pain can occur.
- Specificity theories consider pain as an independent sensation
with specialised peripheral sensory receptors [nociceptors], which
respond to damage and send signals through pathways (along nerve
fibres) in the nervous system to target centres in the brain. These
brain centres process the signals to produce the experience of
pain.
- Pattern theories consider that peripheral sensory receptors,
responding to touch, warmth and other non-damaging as well as to
damaging stimuli, give rise to non-painful or painful experiences
as a result of differences in the patterns [in time] of the signals
sent through the nervous system.
- The gate control theory of pain , put forward by Ronald Melzack
and Patrick Wall in 1962 , and again in 1965 ,is the idea that
physical pain is not a direct result of activation of pain receptor
neurons , but rather its perception is modulated by interaction
between different neurons.
- Control of Pain:
- 1.Before treatment
- Find out the cause pain and eliminate it.
- Thermal changes without protective base.
- High points in restoration.
-
- Deep caries excavation and use of cements.
- Pulp capping procedures in deep cavities.
- In case of deep cavities with amalgam restoration .So a
protective base should be used for mental restoration.
- Articulating paper should be used to check
- Attend to the traumatic injury and do the needful
- Find the cause of referred pain & treat the cause.
- 2.During Treatment.
- Use high speed instrumentation with
- water coolants: Decrease heat & pain.
- Small bur size: Decreases heat, Intermittent cutting is
preferred.
- Minimal pressure: Use high speed sharp instruments.
- Condensation pressure: 4-5 pounds.If increased pain.
- Burnishing & carving after initial set:
- Polishing should be done in a wet medium.
- 3.After Treatment
- High speed cutting without coolant.
- High points in restoration.
- Deep cavity restored without base.
- Pain due to pulpal involvement.
- Remove the restoration & place temporary sedative dressing
with ZOE.
- Place base & apply cavity varnish.
- If pain persist ,do pharmacological treatment with analgesics ,
anti-inflammatory agents , sedatives & anaesthetics.
- Some common techs of pain control
- It is defined as elimination of sensation espescially pain in
one part of the body by the topical application or by regional
injection of drug.
- Free nerve endings are anesthetized.
- Small nerve endings in the area of surgery are floaded with LA
.
- Depositing LA solution in the proximity to large terminal
branches.
- Depositing LA in close proximity to main nerve trunk
- LA injected to periodontal ligament space.
- LA injected to crestal bone.
- Apprx.Duration of action of LA
- Prilocaine 4% (infiltration)
- Articaine 4% + Epinephrine 1:100,000.
- Lidocaine 2% + Epinephrine 1:500,000.
- Bupivacaine 0.5% + Epinephrine 1:200,000
- Etidocaine 1.5% + Epinephrine
- General considerations:
- American society of anesthetology classified the patients into
:
- A.Normal healthy individual.
- B.Patient with mild to moderate systemic disease.
- C.Patient with severe systemic disease that limits the activity
but is not incapacitating
- D.Patient with severe systemic disease that limits the activity
& is a constant threat to life.
- E.Moribund(Dying) Pt not expect to survive 24 hours
with/without operation.
-
- CVS:- Since adrenalin is a vasoconstrictor it should be avoided
in hypertensive patients.
- Anesthetics drugs may cause decreased BP.
- In cardiac patients, use LA without adrenalin.
- CNS:- Therapeutic dose may cause depression. High dose Tonic
clonic seizures, decreased BP & Respiratory arrest death.
- Hepatic:-In hepatic dysfunction biotransformation cannot take
place properly.
- Renal Dysfunction: No extra problems.
- Thyroid diseases: In uncontrolled hyperthyroidism patient
exhibit increased response to adrenalin.
-
- In very young & extremely old patients low dose should be
given.
- During first trimester surgical dental procedures are
contraindicated.Minimal dose LA is adviced during pregnancy.
- Proper history of allergy should take to avoid anaphylactic
shock.
- Use of a kind & gentle approach.
- Genuine concern for the patients problem.
- Avoiding harsh words like inject, sting , hurt etc.
- Keeping the syringe & needle away from the patients
view.
- Constant reassurance during the injection
- Precautions & Steps
- Patient should be in supine position-good blood supply &
pressure.
- Syringe aspiration:To prevent intravenous injection 7 toxic
effect.
- Should not inject into iflamed and infected tissue:- Spread of
infection, LA wont work in iflamed areas due to acidic media.
- Disposable needle & syringe of appropriate length &
gauge should be used.
- Before loading syringe the temperature of the solution should
be brought to body temp. to make injection painless.(Confirm the
expiry)
-
- Before injecting LA clean the surface with cotton & apply
topical LA(benzocaine or lidocaine).
- Needle should be inserted at the junction of alveolar mucosa
& vestibular mucosa.And angle of needle should not be parallel
to long axis of the tooth.-(less pain)
- LA solution is injected slowly (1ml/min)-proper diffusion.If
there is resistance, withdrawn the needle and redirect it.
- 2 min after the injection the effect of LA should check before
starting the procedure.
-
- Pt should be carefully watched during & after LA for half
an hour for any delayed reactions.
- Needle and syringe should be discarded in leak proof hard
walled containers.
- This tech can be employed as an adjunct to LA inorder to calm
an anxiety patient.
- A.Diazepam (Benzodiazepine derivative):
- B.Alprazolam (Benzodiazepine derivative):
- III.Inhalation sedation
- Used for patients who has a low threshold of pain & are
very apprehensive. Nitrous oxide oxygen are administered. It gives
a sedative and euphoric effect.
- State of mind in which critical faculty of mind has been
bypassed & selective thinking is
-
- Also called white noise.It causes stimulus distraction.
Eg:-soft music like constant rainfall.
- VI.Electronic dental anesthesia(EDA)
- Also called transcutaneous electronic nerve
stimulation.(TENS).
- It work on gait control theory, with use of high frequency
greater than 120 Hz by producing sensations like vibrating ,
thrombing, Pulsing or twitching.
- It act by stimulating a larger diameter A delta fibres which
transmit the sensation of touch pressure & temperature. This
will inhibit transmission of pain impulses produced by high speed
drill which is transmitted by smaller A delta & C fibres.
- This high frequency stimulations increase blood level of
serotonin & endorphin- control pain.
-
- Mainly for needle phobic patients.
- Pain control prior to administration of LA espescially for
palatal injections.
- Patients with cardiac pace makers.
- Patient with neurological disorders like epilepsy.
- Very young & very old patients.
-
- Anaesthetic effect only for the required time; does not last
longer.
- Residual analgesic effect lasts for several hours.
- Intraoral electrodes are a weak link in the system.
- VII.Accupuncture
- Acupuncture (from Lat. acus, "needle" (noun), and pungere,
"prick" (verb) is a technique of inserting and manipulating
filiform needles into " acupuncture points " on the body. According
to acupuncture theory, this will restore health and well-being, and
is particularly good at treating pain . The definition and
characterization of these points is standardized by the World
Health Organization (WHO) [1] . Acupuncture is thought to have
originated in China and is most commonly associated with
Traditional Chinese medicine (TCM).
- VIII.GENERAL ANAESTHESIA
- It is only required when all the above methods fail or the
mouth opening is poor.
- CARE DURING OPERATIVE PROCEDURES:
- Use of mouth mirror to provide retraction of tongue cheeks
& lips.
- Application of rubber dams to ensure protection of gingiva
& adjacent tissues.
- Use airotor with a coolant with intermittent cutting with light
stroke.
- Use spoon excavator to remove soft caries better tactile
sensation.
- Use instrument grasps , finger rests & guards.
- Rapid blast of air from airway syringe can induce a painful
response & pulpal inflammation .It should be avoided.
- Use gingival retraction cords while working close to
gingiva.
- Use pulp protective agents like varnishes ,Sealants ,liners
& bases.
- BIBLIOGRAPHY:
- Art & Science of operative dentistry
- Clinical Operative Dentistry (Principles&Practice)
- -Remya raghu & Raghu srinivasan
- Textbook of operative dentistry:
- -Satish chandra & shaleen chandra.
- http:// www.rcoa.ac.uk/docs/dental.pdf . (Royal college of
anesthetics)
-