Sedation and Pain Control in

Dentistry

Iyad Abou Rabii

DDS. OMFS. DU. MRes. PhD
 Willkommen Bienvenue
Welcome
yôkoso welkom
Benvenuto
Bienvenida tervetuloa

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 Please mute
Your cell!

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Are we doing our best to help
our patients
Can we do more? to
get red of their pain?

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 Let us try to answer this

DATE Slides Duration

49 1 hour
16/11/2010

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 Yes or No

The Dentist is the best judge of pain.

A person with pain will always have obvious signs such as moaning,
abnormal vital signs, or not eating.

Addiction is common when opioid medications are prescribed.

Morphine and other strong pain relievers should be reserved for the late
stages of dying.

Morphine and other opioids can easily cause lethal respiratory

depression.

Pain medication should be given only after the resident develops pain.

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 Yes or No
The Dentist is the best judge of pain. No

A person with pain will always have obvious signs such

as moaning, abnormal vital signs, or not eating. No

Addiction is common when opioid medications are

prescribed. No

Morphine and other strong pain relievers should be

reserved for the late stages of dying. No

Morphine and other opioids can easily cause lethal

respiratory depression. No

Pain medication should be given only after the resident

develops pain. No

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 Sarah
Sarah has
has presented
presented at at your
your office
office
reporting
reporting severe
severe pain
pain that
that kept
kept her
her
awake
awake all
all night.
night. She
She denies
denies any any
contraindications
contraindications to to NSAIDs.
NSAIDs.
After
After examination,
examination, you you find
find the
the
patient
patient is
is suffering
suffering from
from
irreversible
irreversible pulpitis
pulpitis with
with acute
acute
apical
apical periodontitis,
periodontitis, and and aa root
root
canal
canal procedure
procedure is is initiated.
initiated.
This
This patient
patient maymay will
will experience
experience
some
some post-appointment
post-appointment pain pain due
due
to
to continued
continued inflammation
inflammation of of the
the
periapical
periapical tissues.
tissues.

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Pain in dental clinic

Odontogenic
Odontogenic Non-odontogenic
Non-odontogenic

•• Presence
Presence of of etiologic
etiologic factors
factors •• NO
NO apparent
apparent factors
factors for
for
for
for an
an odontogenic
odontogenic origin,origin, (e.g.
(e.g. odontogenic
odontogenic pain,
pain,
Caries,
Caries, leakage
leakage of of •• No
No consistent
consistent relief
relief of
of pain
pain by
by
restorations,
restorations, trauma,
trauma, fracture).
fracture). local
local anesthetic.
anesthetic.
•• Responsive
Responsive to to dental
dental •• Bilateral
Bilateral pain
pain oror multiple
multiple painful
painful
treatment
treatment teeth.
teeth.
•• Pain
Pain reduction
reduction by by local
local •• Pain
Pain that
that occurs
occurs with
with aa
anesthetic.
anesthetic. headache.
headache.
•• Unilateral
Unilateral and
and localized
localized pain.
pain. •• Increased
Increased pain
pain associated
associated withwith
•• Sensitivity
Sensitivity to
to temperature.,
temperature., palpation
palpation of
of trigger
trigger point
point or
or
percussion
percussion ,, and
and digital
digital muscles,
muscles, emotional
emotional stress,
stress,
pressure.
pressure. physical
physical exercise,
exercise, head
head
position,
position, etc.
etc.
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Pain Control Strategy

During
Preoperative
Intervention

Pain

Post-Operative
Pain Control Strategy

During
Preoperative
Intervention

Pain

Post-Operative
Pain Control Strategy SCENE

Pre-operative
Pre-operative
 Oral
Oral Sedation
Sedation

 Preoperative
Preoperative Analgesics
Analgesics
Pain Control Strategy SCENE

During
During the
the Intervention
Intervention
•• IV
IV Sedation
Sedation

•• Nitrous
Nitrous Oxide
Oxide

•• Local
Local Anesthesia
Anesthesia
 SCENE

Post-opertaive
Post-opertaive
•• Analgesic
Analgesic Prescription
Prescription

•• Opioids
Opioids

•• Non-opioids
Non-opioids
Pre-operative procedures
Oral Sedation

 Happy pills

 Before the appointment,

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Oral Sedation : Drugs Used

 Anti-Anxiety Pills (Benzodiazepines or "Benzos")

 "Sleeping pills" (Barbiturates)

 Antihistamines

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Preoperative Analgesics

 Pre-treating patients with NSAID's

delays the onset of post-operative
pain and reduces its magnitude
when it does occur.
 Pretreatment with
acetaminophen is not effective.
 Aspirin in not used for this
purpose since it can increase
bleeding.

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During Surgical or Dental
Intervention
IV Sedation

 Anti-anxiety variety, is administered into the blood system during dental

treatment

 Safe

 The drugs which are usually used for IV sedation are not painkillers

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IV Sedation : Drugs Used

– benzos
– Barbiturates(sleep-inducing drugs)
– Opioids
– Propofol

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IV Sedation : Caution and Contraindication

– contraindications include pregnancy, known allergy to benzos, alcohol

intoxication, CNS depression, and some instances of glaucoma.

– Cautions include psychosis, impaired lung or kidney or liver function, and

advanced age. Heart disease is generally not a contraindication

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Nitrous Oxide

 Referred to as laughing gas or

sweet air
 Useful for fearful patients as well as
young children
 After the patient is relaxed and
sedated, the dentist can
comfortably give the injection or
proceed to dental treatment

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Nitrous Oxide: Contraindications

– Some chronic obstructive pulmonary diseases

– Severe emotional disturbances or drug-related dependencies

– First trimester of pregnancy

– Treatment with bleomycin sulfate

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Local Anesthesia

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Local Anesthesia : Choice of Drug and Technique

 1-According to procedure (expected duration, the surgical procedure

tissue’s implication)
 2- According to the patient physiological and pathological situation

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Failure of Anesthesia

Psychological causes

Pathological causes
Anatomical causes

Operator dependent
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Failure of anesthesia

 Psychological causes of failure

 Pathological causes of failure of anesthesia
– Factors precluding access
– Inflammation

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Failure of anesthesia

 Anatomical causes of failure of anesthesia

– Soft-tissue analgesia is more easily obtained, needing a lower degree of
penetration of solution into nerve bundles, than does analgesia from pulpal
stimulation.
– A numb lip does not indicate pulpal anaesthesia.
– Accessory nerve supply
– Barriers to anaesthetic diffusion
– Dense compact bone can prevent a properly given infiltration from working.
Counter by using intraligamentary or regional LA.

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Accessory nerve supplies

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Failure of anesthesia

 Operator dependent causes of failure of Anesthesia

– Choice of LA
– Poor technique
• inadequate volume of LA.
• Injection into a muscle (will result in trismus which resolves spontaneously).
• Injection into an infected area (which should not be done anyway as this risks
spreading the infection).
• Intravascular injection; clearly of no analgesic benefit. Small amounts of
intravascular LA cause few problems.

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Management of failure of Anesthesia

 A technique suggested for patients who have experienced local

anesthetic failure in the mandible is

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Failure Management : Mandible

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Management of failure of Anesthesia

 A technique suggested for patients who have experienced local

anesthetic failure in the maxilla is

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Failure management : Maxilla

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Important general points

 Nerve trunks Thickness

 In nerve trunks autonomic functions are blocked first, then sensitivity to

temperature, followed by pain, touch, pressure, and motor function.

 Soft tissue anesthesia is reached before the levels needed for pulpal
anesthesia, which takes several minutes and will wear off first

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Post-operative procedures
Analgesic Prescription

 Ceiling effect

– The term ceiling effect has two distinct meanings, referring to the level at
which an independent variable no longer has an effect on a dependent variable

– In case of Analgesics, a ceiling effect in treatment, is pain relief by some kinds

of Analgesics drugs, which have no further effect on pain above a particular
dosage level

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Types of Analgesics

– Opioid
• Morphine
• Tramadol
– Non-opioids
• acidic analgesics
– Salicylic acid derivatives
– Acetic acid derivatives
– Propionic acid derivatives
– Anthranilic acid derivatives
• non-acidic analgesics
– Aniline derivatives
– Pyrazolone derivatives

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Types of Analgesics

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Types of Analgesics

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Non-odontogenic Pain
Trigeminal Neuralgia

– Non-analgesic drug (Carbamazepine) give excellent results in

the treatment of Trigeminal Neuralgia
– Dose
• 100 mg twice daily
• No improvement: the dose is increased to 200 mg four time a
day
• No improvement : Dose can be augmented until 1600 mg a day
with (monitoring of plasmatic concentration of the drug should be
achieved regularly)
– If with such dose there is no improvement then Phenytoin
is used (150 to 300 mg daily)

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TMJ Pain

 Diazepam has both sedative and muscle relaxant effects, so it is helpful if

the origin of the trismus is psychotic

 In other cases the use of Paracetamol 250 mg in combination with

Chlorzoxzson (muscle relaxant ) 300 mg is recommended 4 times daily.

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atypical facial pain

 The use of Tricyclic antidepressant looks helpful (Amitriptyline)

 Anyway the prescription of such drugs should not be done by a dentist

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Conclusion

1 Accurate Diagnostic

2 Removal of the cause

3 Profound local Anesthesia

4 Long acting local anesthetics

5 Precise estimation of the pain

6 Use the right analgesic

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Pain management schema

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 What about Sarah ?

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 Thank you for
your attention!
Any Questions?

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 Contact Details

Dr. Iyad Abou Rabii

+33612198442
+966532758000
www.facebook.com/iarabii
www.Twitter.com/iarabii
www.Scribd.com/iyad abou rabii
Email
iyad@wanadoo.fr
Iyad.abou.rabii@qudent.edu.sa

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