Pain Control in Dentistry

[sushantpatel_doc]

Dental Pain is one of the most common reasons driving patients to seek help from a dentist.

Pain can also arise from non dental sources such as myofunctional pain dysfunctional syndrome, maxillary sinusitis, migraine, neuralgias.

The cause of Pain should be diagnosed, followed by the appropriate dental treatment with drugs playing a secondary supporting role.

Analgesics and Non steroidal anti-inflammatory drugs (NSAID’s) are commonly and routinely prescribed to combat dental pain, with Ibuprofen and Paracetmol being the most common. They are known to block the synthesis of Prostaglandins and inhibit Cyclooxygenase. Preoperative administration of NSAID’s may reduce the need for analgesics postoperatively since they are more effective preventing the synthesis of prostaglandins rather than dealing with pain once prostaglandins are already formed.

To diagnose pain, a detailed history of chief complaint backed by clinical examination (presence of caries/swelling) and investigations (like radiographs) is mandatory.
Pain can be caused by Caries, broken tooth, fractured fillings, exposed dentin, cracked cusp, periapical infection, pocket, sinusitis, pericoronitis, impacted food, acute necrotizing ulcerative gingivitis, dry socket, temporomandibular joint disorders.

SHARP, SHORT, SHOOTING PAIN –
Can be caused usually by fluid movement through open dentinal tubules or initial pulpal inflammation due to caries, dentin exposure due to attrition or recession, fractured cusps, fractured restoration, trauma to tooth.
Pain will be associated with hot, cold or sweet stimuli, pain on eating, pain at night, pain on heat/hot, pain relieved only by medications, pain lasting for few minutes or few hours.
Generalized pain could be generalized dentin sensitivity and hence should be investigated accordingly.
Intermittent sharp, shooting pains could be diagnostic of trigeminal neuralgia.

DULL, TRHOBBING, PERSISTENT PAIN –
Such pain can be due to pocket, food impaction, pericoronitis, temporomandibular joint disorders, maxillary sinusitis, acute necrotizing ulcerative gingivitis.

Journey of Dental Decay and Dental Pain –

Decay or caries generally occurs when food remains embedded inside the tooth for a sufficient period of time to enable bacteria present in the mouth to convert it into acids. Once the decay reaches the inner layer of the tooth i.e. dentin, it gives rise to pain and the patient becomes symptomatic. As the decay travels to the pulp, pulp gets inflamed, pain becomes more pronounced and may manifest as sharp, shooting or dull, throbbing caused by a stimulus or spontaneous. Heat or lying down may aggravate such type of pain.

REVERSIBLE PULPITIS –
Initially decay entering the pulp leads to pulpal inflammation and a condition called as reversible pulpitis. Pain which is reversible on withdrawal of the stimulus causing it, is termed as reversible pulpitis. Such pain lasts only for few seconds. Stimulus elicitating such type of pain is generally cold water or cold food items, sweet foods. It can also be transient sensitivity after scaling or dentin hypersensitivity.

IRREVERSIBLE PULPITIS –
Reversible pulpitis if left untreated can progress to irreversible pulpitis which is a severe inflammation of the dental pulp. Such pain is spontaneous, is more severe, acute and is still persistent even after withdrawal of the causative stimulus. It is only relieved by medication. It lasts for few minutes to few hours or may be present throughout the day and night. Present as pain on eating hot or cold food. Tooth may become sensitive to percussion.

PULP NECROSIS –
Irreversible pulpitis may lead to pulpal necrosis (death of the dental pulp). Thus the patient becomes asymptomatic despite having decay persisting in the dental pulp.

ABSCESS –
Pulpal necrosis can lead to an abscess (localized collection of pus) usually around the apex of the tooth. Such tooth may be slightly extruded and becomes slightly mobile. Also it becomes sensitive to percussion and patient may have pain on chewing on such a tooth. An abscess can also be accompanied by a swelling and/or draining fistula. If left untreated can spread to surrounding tissues and cause cellulitis.

PERIODONTAL DISEASE –
Periodontal pocket can lead to an itchiness feeling in the gingiva (gums) or a dull, throbbing type of pain.
Treatment includes pocket elimination through non surgical or surgical means.
Periodontal Abscess may also be formed, causing tooth mobility, throbbing pain, swelling of gingiva, suppuration, inflamed gingiva, erythema, tenderness to percussion.
Abscess should be drained through the sulcus or through an external incision followed by administration of systemic antibiotics and analgesics.

PERICORONITIS –
Pericoronitis is inflammation around the crown of a partially erupted tooth most commonly the mandibular third molar tooth. Pericoronitis is a painful condition and there may be pain while eating, pain on closing the jaws when the opposing jaw may traumatize the operculum further, tenderness, halitosis and suppuration. It can also lead to a pericoronal abscess, regional lymphadenopathy, cellulitis and trismus.
Operculectomy (removal of the overlying flap – operculum) or extraction of the indicated tooth are treatment options dictated by the pattern of eruption and possibility of further eruption of the tooth in its functional position.

MOUTH ULCERS –
The most common type is apthous ulcers. Ulcers can be painful especially while eating food. Pain can be acute especially when it comes in contact with hot or spicy foods. It may result from infections, trauma, orthodontic trauma, minor burns or stress.
Ulcers are usually symptomatically treated with ulcer anesthetic gels, antibiotics, analgesics and vitamin supplements.

TRAUMA –
Trauma usually resulting from injuries sometimes iatrogenic in origin can result in sharp, shooting type of pain.
Cracked tooth syndrome – a condition in which there is sharp pain in the tooth on chewing on certain parts of the tooth, pain on biting, pain on applying slight pressure. Can be diagnosed by making the affected tooth bite an instrument or bite on a rubber disc.

BARODONTOLGIA –
This condition results in tooth pain in environments where there may be extreme changes of pressure. Examples include pilots in unpressurized cabins and scuba drivers. The cause is hypothesized to suggest that tiny air bubbles trapped under a filling or adjacent to dentin expand and contract causing the sharp, shooting type of pain on changes in pressure.

REFERRED DENTAL PAIN –
Symptoms of non dental origins of pain include –
Spontaneous multiple toothaches without obvious causes, stimulating, burning, constant, unremitting toothache, persisting, recurrent, failure to respond to local anesthetic action when injected adjacent to the indicated tooth, failure of toothache to respond to indicated dental treatment.
Migraine can lead to toothache. Jaw/ tooth pain can also be caused by trigeminal neuralgia. Maxillary sinusitis can lead to dull, throbbing type of pain in maxillary teeth. Pain can also arise from temporomandibular joint disorders.

POST-OPERATIVE PAIN –
Pain can be due to inflammation post – surgery. Also some patients report of pain following endodontic treatment. Iatrogenic damage during dental treatment can lead to post-operative pain for the patient.

DRY SOCKET –
This deep aching type of painful condition results when the blood clot present in an extraction socket gets accidentally dislodged through mechanical trauma, or dislodged by the brush, finger or tongue resulting in exposure of the alveolar bone to the oral environment.

DIAGNOSIS OF DENTAL PAIN –
Patients chief complaint and history of dental pain along with clinical examination and investigations (pulp vitality tests, radiographs) are important parameters to diagnose dental pain. Attempts should be made to reproduce the pain and localize it. Dental causes of pain should be eliminated before attributing the pain to non dental origins.

MANAGING DENTAL PAIN –
The successful treatment of any condition depends on the cause. The cause should be identified and treated accordingly instead of just administering analgesics routinely. Analgesics have been accorded an adjunctive or supporting role in the treatment of dental pain. The first line of managing dental pain is diagnosis and administering indicated dental treatment followed by employing analgesics. Analgesics are also used to control post-operative pain.
Analgesics include non-steroidal anti-inflammatory drugs(eg. Ibuprofen) or opoids (Narcotics). Paracetamol is an analgesic with little anti-inflammatory actions. NSAIDS are potent analgesics as well as anti-inflammatories. Opoids are powerful analgesics but with significant side effects.
Common analgesics include Ibuprofen and Paracetamol.

NONOPOID ANALGESICS –
Useful and most routinely employed to manage dental pain and reduce inflammation. Nonopoid analgesics used include Acetaminophen, Ibuprofen, Diclofenac.

PARACETAMOL –
Paracetamol/ Acetaminophen is an analgesic and antipyretic but poor anti-inflammatory action. Generally used for mild to moderate dental pain and dental post-operative pain, but preferably combined with another analgesic.
Paracetamol is believed to interrupt the influence of prostaglandins within CNS pathways. Inhibits prostaglandin synthesis within the central nervous system. Paracetamol dose of 500 milligrams is usually used. Paracetamol’s site of action differs from other NSAID’s. Paracetamol’s analgesic effect enhances effectively when combined with another NSAID.

NSAIDS –
They are even today considered to be the gold standard for managing mild, moderate and severe dental pain and inflammation. They have a potent analgesia and anti-inflammatory action. Pre-operative administration and then continuing the NSAID pos-operative is more effective in minimizing pain and inflammation. Also are relative safe compared to opoids.
NSAIDS inhibit cyclooxygenases (COX-1 and COX-2) that catalyze the synthesis of prostaglandins. However they cannot be used in patients with allergies to this group, peptic ulcers, pregnancy, hepatic/ renal disease.

IBUPROFEN –

Ibuprofen is commonly used in association with Paracetamol for dental pain relief as an analgesic and an anti-inflammatory. In a number of studies and trials this drug has proved its effectiveness in managing dental pain, post-operative pain, apicoectomy, biopsies, etc.

DICLOFENAC –
Diclofenac is a NSAID with potent analgesia and anti-inflammatory action. Some trials have suggested that diclofenac inhibits the lipoxygenase pathway, reducing formation of leukotrienes. Also it has been speculated that diclofenac may inhibit phospholipase A2 as part of its mechanism of action.

ACECLOFENAC –
Aceclofenac is an NSAID that is effective in the management of painful inflammatory diseases and provides effective analgesia in dentistry. Aceclofenac has been shown to elicit preferential inhibition of COX-2. Aceclofenac has shown more biocompatibility and tolerance with lower gastrointestinal side effects.

COMBINATION ANALGESIC THERAPY –
Single analgesics have proved their efficacy in effectively managing dental pain. However for additive and synergistic action, a combination analgesic therapy with different mechanisms of actions and acting on different inflammatory pathways may be employed to lower doses but improving analgesia thus reducing the side – effects. Paracetamol or Acetaminophen are routinely employed along with Diclofenac/Ibuprofen/ Aceclofenac to produce more effective analgesia but with little side – effects.

SUMMARY –
Dental pain is one of the most severe types of pain and can unsettle the patient. Patients may find it difficult to eat, sleep till it is correctly treated. Most common reasons of dental pain include dental caries and periodontal disease. Managing dental pain effectively is the cornerstone to successful dental treatment. Dental pain can have dental origins or non-dental origins as has been discussed above. A patient’s pain history along with clinical examination and investigations play an important role in planning treatment. The key to management is proper diagnosis of pain, administering the required dental treatment with drugs playing an effective adjunctive role. NSAID’s block the synthesis of prostaglandins thereby providing pain relief and minimize inflammation. For mild pain, paracetamol can provide relief. However for moderate to severe dental pain, ibuprofen, diclofenac or Aceclofenac should be administered in combination with Paracetamol to provide synergistic effective analgesic action. The ultimate goal of dental treatment is to provide pain relief to the patient thereby influencing him positively and making him comfortable.

        

[divyanshee]

Non pharmacological approaches have to be considered in the management of chronic orofacial pain

        

[Drsumitra]

 Trauma to the teeth can be transmitted to the supporting structures, which get damaged. This can cause mobility of the teeth. Such mobile teeth may require splinting for a specified period of time till the supporting tissues heal and the tooth becomes stable.

Splinting is a procedure where the teeth are supported in its position for a period of time. This is done to teeth that are traumatized or teeth whose supporting structures are affected by disease, which prevents them from supporting the teeth. Splinting involves binding a group of teeth together so that the biting forces are shared by a large number of teeth instead of being born by the affected tooth.

Extremely thin fiber-glass band (0.05 mm / .0019") to be used with our Fiber-Bond or any light-cured bonding agents. The band is 4mm wide, which gives 30% more adhesion power to the interdental area. Indicated for periodontally loosened teeth, post-traumatic mobility, surgical reimplantation, or even to reinforce temporary bridges. It can also be used as splinting material for orthodontic stabilization. Strength with a certain degree of flexibility and “tooth hugging” quality combine for an overall aesthetic and functional result. Minimum tooth preparation.
High patient acceptance.

 

        

[Drsumitra]

The ideal sedative for oral surgery should make the patient comfortable during the surgery and should wear off quickly enough that the patient can leave the dental chair soon after the procedure. Finding the best plan of anesthetic treatment is essential to the success of dental procedures such as the extraction of wisdom teeth.
A study in the journal Anesthesia Progress compares two drug combinations for use as deep sedation during oral surgery. Patients in a control group received a continuous intravenous infusion of propofol-remifentanil, while those in an experimental group received a continuous intravenous infusion of propofol-ketamine. This was a double-blinded study — neither patients nor surgeons were aware of which treatment was given.
Oral surgery to extract third molars, also known as wisdom teeth, is a common dental procedure routinely performed with local anesthesia and moderate or deep sedation. This procedure is typically performed in the dental office, not a hospital setting, so there are not extensive facilities and personnel to assist in recovery. Rapid recovery for safe discharge is therefore an important component of dental anesthesia.
In the current study, 37 patients were monitored while sedated for respiratory, heart rate, and blood pressure stability. Emergence from the effects of anesthesia and total recovery time were recorded. Both patients and surgeons were asked to rate their satisfaction with the anesthetic treatments.
Patients who received the ketamine treatment took longer to emerge from the effects of the anesthesia. Their average emergence time was 13.6 minutes compared with 7.1 minutes for patients in the remifentanil group. The recovery period for ketamine patients was 42.9 minutes compared with 24.5 minutes for those who received remifentanil.
Both groups showed similar levels of sedation. However, an increase in heart rate was noted among patients receiving the ketamine treatment. Both patients and surgeons indicated they were very satisfied with either treatment.
While ketamine provides a more cost-effective alternative for dental sedation — remifentanil is more expensive — it requires a longer patient recovery time. This study found that the more rapid recovery from the propofol-remifentanil combination makes it a more ideal deep sedative for dental office third molar surgery.

 

        

[Drsumitra]

A new study comparing the effectiveness of propofol-remifentanil and propofol-ketamine combinations for the removal of all four third molars found that the latter is a less-than-perfect alternative to the former, primarily due to recovery times (Anesthesia Progress, Fall 2012, Vol. 59:3, pp. 107-117).
The prospective, randomized, double-blinded controlled study was performed by researchers from Indiana University (IU); University of California, Los Angeles; and Ohio State University (OSU).

"The biggest difference that we found was that the group that received ketamine and propofol as an infusion took basically twice as long to emerge from anesthesia," Kyle Kramer, DDS, a visiting professor at the department of oral surgery and hospital dentistry at IU’s School of Dentistry, said in an interview with DrBicuspid.com. "And it took patients twice as long to recover fully and meet discharge criteria."

“It took patients twice as long to recover fully and meet discharge criteria.”
— Kyle Kramer, DDS, Indiana University
Recovery time was the primary difference noted in the measured outcomes tracked by the researchers. Other measured outcomes included various sedation parameters, hemodynamic and respiratory stability, patient and surgeon satisfaction, postoperative course, and associated drug costs.

"What we found is that the operating conditions were pretty similar," Dr. Kramer said. "There weren’t a lot of differences interoperatively."

‘Remarkable stability’

The study’s 37 participants were men and nonpregnant women between the ages of 18 and 40 who were active patients in the department of oral and maxillofacial surgery at OSU’s College of Dentistry. Due to the possible psychotomimetic effects of ketamine, patients with a history of psychiatric or psychological conditions were excluded. Prior to receiving one of the two sedative combinations, each patient was given midazolam (0.03 mg/kg) to achieve baseline sedation.

Those that received propofol-remifentanil in ratios of 20 mg of propofol to 5 µg of remifentanil per milliliter served as the control group. The experimental group was given a combination of propofol-ketamine in a ratio of 10 mg of propofol to 2.5 mg of ketamine per milliliter; both were given at an initial propofol infusion rate of 100 µg/kg/minute.

After the extractions were performed and the infusions terminated, clinicians tried to revive patients by gently shaking their shoulder and asking the patients to open their eyes every minute until there was a response. This determined the emergence time. Recovery time was qualified by the patients’ ability to complete the same Trieger connect-the-dots test and 30-second one-leg standing test they completed prior to the surgery.

Surgeons were asked to rate their satisfaction immediately after the surgery, while patients were contacted by phone the following day. The patients were also asked about postoperative nausea and vomiting (PONV) during the call.

The researchers found no statistical difference in the mean infusion times or rates.

"Both groups demonstrated similar sedation parameters and hemodynamic and respiratory stability," they wrote.

Drug shortages and recalls

However, the ketamine group had prolonged emergence (13.6 ± 6.6 versus 7.1 ± 3.7 minus, p = 0.0009) and recovery (42.9 ± 18.7 versus 24.7 ± 7.6 minutes, p = 0.0004) times.

The researchers found no statistical differences in patient or surgeon satisfaction, postoperative oral analgesic requirements, or PONV between the two groups. They also found "remarkable hemodynamic and respiratory stability" for both groups.

Kenneth K. Lee, DDS, a Los Angeles practitioner who has written about propofol, agreed with the study findings and highlighted aspects of it that are relevant to the typical practitioner.

"The conclusions are valid; ketamine is a longer-acting drug, hence you will get longer recovery time," Dr. Lee stated in an email to DrBicuspid.com. "For a busy office, this fact alone would probably preclude its use."

However, forces outside dentists’ control may lead to them to consider using a propofol-ketamine combination.

"In these days of drug shortages and recalls, it is prudent for practitioners to have a variety of techniques in their armamentarium," Dr. Lee explained. "Both techniques are good ones but are only viable for those that carry a general anesthesia permit or who have completed an oral and maxillofacial surgery or dental anesthesiology residency."

Given the environment of cost-conscious healthcare, the relatively high cost of remifentanil compared with that of ketamine may favor the use of ketamine as a more cost-effective anesthetic alternative to remifentanil while still allowing for good sedation quality and recovery parameters, the researchers noted.

 

        

[Drsumitra]

German researchers have found a way to add a light-sensitive moiety to propofol that could control its effect on humans with light (Angewandte Chemie International Edition, October 15, 2012, Vol. 51:42, pp. 10500-10504).
In their study, the researchers from Ludwig Maximilian University (LMU) of Munich effectively anesthetized and revived tadpoles when irradiated with violet light. The tadpoles returned to their anesthetized state when the light was switched off, suggesting a reversible light-dependent effect.

Propofol’s effectiveness lies in its interaction with receptors on neural cell membranes that typically bind the inhibitory neurotransmitter gamma-aminobutyric acid (GABA), the study authors noted. While propofol has been studied since its discovery in 1980, there are persistent gaps in the knowledge of its function, they added.

"The analysis of their exact binding sites at a molecular level has been complicated by a lack of detailed structural data," they wrote. The data from their study suggest new ways to harness propofol’s functionality.

"[We learned] that GABA receptors, which control inhibitory input in the brain and retina, can be controlled with light," study author Dirk Trauner, PhD, a professor of chemical biology and genetics at LMU, wrote in an email to DrBicuspid.com. Trauner, specializes in enabling "blind" nerve cells to react to light stimulation, according to an LMU press release.

Azobenzene derivatives of propofol

Trauner and his fellow researchers from the U.S. and Switzerland designed a series of azobenzene derivatives of propofol, called azo-propofols, that allow the action of the GABA receptor to be regulated by light.

One of the azo-propofols in particular, called AP2, had favorable pharmacological and photochemical features. Additionally, the molecular switch that was attached to the azo-propofol actually made it a more potent anesthetic in the dark.

The researchers established that AP2 had an impact on GABAA receptors, pentameric ligand-gated ion channels that are activated by GABA, and moved forward to investigate the light dependency of the current potentiation. They used pocket lights of different wattages to test egg yolk cells where GABA was coapplied with AP2 with promising results. "The current amplitude decreased rapidly and increased again upon turning off the light source," the researchers wrote.

Afterward, they tested the anesthetic activity and photoreversability of propofol and AP2 in animal models using tadpoles. The researchers noted that light "induced vigorous swimming activity in unanesthetized tadpoles," suggesting that it is a noxious stimulus. They places groups of the animals in solutions containing propofol or AP2 and tested them every five minutes for loss of righting reflexes (LORR), which is a standard assay for anesthesia, the researchers noted.

More research needed

The animals exposed to propofol were anesthetized as anticipated. In AP2, the animals expressed similar EC50 value (a measure of a drug’s potency) to propofol, but light changed the value considerably.

"Propofol produced LORR in all tadpoles with or without light, whereas in AP2, all animals showed LORR without light and all spontaneously righted themselves during illumination with UV light," the researchers wrote. The demonstration supports a hypothesis of the researchers that "anesthesia caused by AP2 and propofol is largely mediated by GABAA receptors."

While the study’s results are intriguing, considerable work needs to be done before dentists use a type of light-controlled propofol in their practices, Trauner noted.

"I think controlling the human brain and consciousness with light would be illusionary at this stage," he told DrBicuspid.com.

He was more optimistic that the data could be applied to vision restoration in the near future. In the next phase of his research, he said that he will apply their compounds to the retina to restore vision and see whether certain brain nuclei in rats can be made light-sensitive.

 

        

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