Emergency Treatment and Pain Control Flashcards
What causes oral pain problems most commonly?
Caries
Bacteria within teeth (cracks, restorations breaking down, etc)
Pulp pathosis
Periapical conditions
Periodontal diseases
How are pre-operative and post operative pain related? What does this tell us about pain?
Strong relationship between pre-op and post-op pain. (if moderate to severe pre-op pain 5x more likely to have moderate to severe post-operative pain)
Patient’s psychological profiles for coping with pain modulates their perception of post-operative pain.
What factors complicate pain?
Lack of sleep
New patient
New dentist
What are the 3 Ds for managing dental pain?
Diagnosis
Dental treatment
Drugs
What are the principles to follow when dealling with dental pain?
Take a thorough history to come up with a provisional diagnosis (Take into consideration the pulp/root canal status and periapical status)
Thorough clinical examination (Tests - palpation, percussion, periodontal probing, mobility, pulp sensibility tests, radiographs)
Examination, tests, radiograph to: Confirm diagnosis, confirm which tooth, and help decide the cause)
Determine the management options and help to assess the prognosis.
How does dental treatment affect pain?
Most patients have marked or total pain relief within 24 hours following dental treatment. Antimicrobials alone are poor at controlling pain.
What are the principles of management?
Remove cause: All restorations to assess tooth for future restoration and its long term prognosis. (Access to caries, cracks, and marginal breakdown)
Remove the pulp/debris from canals using a barbed broach (If possible and with care)
Provide drainage (Only if required via canal or soft tissue incision)
Medication-intracanal
Interim restoration
How does pain during treatment impact post-op pain?
Pain during treatment significantly impacts on the amount of post-op pain. Adequate pain control is essential.
What are the goals of local anaesthesia?
3 goals:
Anaesthesia during treatment
Haemostasis during treatment
Prolonged post-operative pain control
How is pain control from LA achieved?
Direct: Block discharges from peripheral nerves. Duration: Minutes -> Hours
Indirect: Prolonged blocking of peripheral input reduces central sensitization
What happens if there is inadequate local anaesthesia?
Pain during treatment
More post-operative pain (Prolonged exposure to sensory input increases allodynia and hyperalgesia)
What is allodynia and hyperalgesia?
Allodynia: Pain from non-injuries stimuli
Hyperalgesia: Exaggerated sense of pain
Why does LA not work with acute irreversible pulpitis?
Various theories have been proposed but non proven, most commonly discussed are:
Inflammation activates nociceptors and associated central pain mechanisms
Inflammatory mediators reduce threshold of nociceptor activation
Mediated by prostaglandins
Prostaglandins sensitize nerve endings
Inflamed pulps have high levels of both prostaglandins and arachidonic acid
These theories are incomplete and do not explain why LA doesn’t work.
What stages of treatment can pain be felt?
Pre-operative
Dentine
Pulp
How can acute irreversible pulpitis pain be managed?
Pre-empt the difficult situation (Diagnosis)
Consider pre-medication with ibuprofen
Test tooth: Triplex air + percussion during exam
Give Gow-gates block
Re-test with triplex air and percussion (Pain = give IAN block + Buccal infiltration, no pain = place rubber dam and re-test)
Allow more time for LA to work
Place rubber dam using cuff technique
Re-test again with triplex air and percussion (No pain = proceed with treatment. Pain = Give PDL injection and test again)
If pain felt on reaching the dentin (PDL injection)
If pain felt on reaching the pulp (Intrapulp injection)
If still pain: Pulpotomy only -CS-AB dressing and reappoint 3 - 4 weeks later
What kind of pain is seen in acute irreversible pulpitis? (Order from least to most severe)
Pain with cold stimuli
Pain with head
Above 2 lead to short, very sharp pain followed by lingering ache/throb
Pain is spontaneous
Pain lying down
Pain wakes the patient up. Intense throbbing/aching pain; continuous or may come and go.
Where should the Gow-Gates mandibular block be done?
Lateral region of the neck of the condyle just below the insertion point of the lateral pterygoid muscle.
Entry point is medial to the deep tendon of the temporalis muscle and slightly below the palatal cusp of the upper second molar
What external landmarks are used for the gow gates mandibular block?
Apex of the intertragic notch and the lower border of the tragus through the opposite corner of the mouth
What are the advantages and disadvantages to the gow-gates mandibular block?
Advantages:
High success rate (92 - 99%) compared to IAN (65 - 85%)
Complete mandibular nerve (V3) block
No supplementary injections needed (No need for long buccal or lingal nerve injections)
Less muscle involved
Less painful (even though needle used is larger @ 25 guage)
Safer technique
Less blood vessels at the injection site (Positive aspiration rate is negligible)
No vaso-constrictor required
Is a buccal infiltration necessary when giving an IAN block?
There is a significant improvement in pain reduction following combination of IAN block + Buccal infiltration for acute irreversible pulpitis in lower molars.
However, some patients will STILL have pain
What supplementary injections can be provided for increased pain relief?
Labial infiltration for lower anterior teeth
Palatal infiltration for upper molars
Palatal for upper premolars and anterior teeth (Anterior middle superior alveolar nerve block)
What are the advantages to using the rubber dam cuff technique?
Enables PDL injections if required
Full access to the entire tooth
Better vision
Can antibiotics be prescribed for pulpitis?
NO
They are unnecessary, contra-indicated, not pain relieving, and do not help treat inflammation.
Pulpitis is not a bacterial infection (It is caused by bacterial presence in the tooth but not an infection itself)
What local drugs are used for pain management?
Local anaesthetic - long acting
Intra-canal medicaments
