PAIN

Tuesday, 31 January 2023 7:08 pm PAIN DURATION

INTRODUCTION
• Pain control with minimal discomfort remains a significant concern
of dental practitioners
• Pain is one of the primary concern among dental practitioners
• We have to deal with pain and manage it
○ It is a part of our practice, profession
Pain Intensity:
○ It is always present in the performance of our practice
○ We have to accept the phenomenon of pain as future dentists
○ Psychological aspect of pain and physical aspect of pain
• The injection of local anesthetic is perhaps the greatest source of
patient's fear
○ When there is pain, there is a way to manage it or mitigate it
○ The problem is for you to administer the anesthetic solution,
you need to perform injection
▪ With injection, there is fear
• Acute pain: pain of less than 3 to 6 months duration
○ Persistent pain.
• Chronic pain: pain lasting for more than 3-6 months, or persisting
beyond the course of an acute disease, or after tissue healing is
complete.
• Acute-on-chronic pain: acute pain flare superimposed on underlying
chronic pain.
• Can be broadly categorized as: mild, moderate and severe.
○ Asking information from the patient if the pain is mild, moderate
or severe
○ However, pain intensity differs from every person
▪ It would be best to have a better understanding of the
patient to exactly gauge the intensity of the pain according
to the patient
▪ Use visual analogue scale

Local anesthesia has been the cornerstone of modern day pain-free • It is common to use a numeric scale to rate pain intensity where 0 =
dental practice no pain and 10 is the worst pain imaginable:
• cornerstone
○ Important in the delivery of our pain free dental practice
○ If we want to be able to achieve pain free dental practice the
only way is to be good with anesthesia
○ The only solution in the management of pain is administration
of anesthetic

However, the practitioners limitations in updating about newer drug ○ The numbers 0-10 should be divided into 3:
formulation available and newer techniques to administer the drugs has, ▪ Score lesser than 4 = mild
still not made the goal of pain-free dentistry a reality ▪ 5-6 = moderate
○ In todays practice there are a lot of dentists around who hardly ▪ Score more than 7 = severe
update themselves on newer techniques with regards how to do ○ The objective is to have an exact measurement on how the
pain-free dentistry patient gauge the pain
▪ That is what should be recorded and have
The availability and cost factors are not excuses not to adapt newer ○ Another technique:
proven methods, when the benefits outweigh the shortcomings
▪ Make visual analogue scale and ask the patient to mark
○ We have to improve our traditional injection technique
where does the pain scale belong
There is a need in the current evidence-based era of dental practice for
us to constantly update, evaluate and incorporate newer drugs and
techniques into daily practice to provide our patients the best care of all
times
○ Evaluating your modern techniques.
▪ Example: 20 years back the dental needle is not recyclable,
whereas in ancient times they sharpen the needle and use it to
the next patient but now the needle is disposable and should
be discarded.

The achievement of good local anesthesia requires: ○ Most commonly used

1. Knowledge of the agents being used ▪ Ask the patient to check (give you the idea) where is the
2. Neuroanatomy involved scale of the pain is
3. Best techniques and devices available ▪ You can device your own way of measuring the pain
intensity being reported by patient
The agents and anesthetic delivery available today provide the Physiology of pain
practitioner an array of options to effectively manage the pain ○ Normally occurring in the body.
associated with dental procedures • Nociception
○ refers to the sensory process that is triggered
Vibrotactile device ▪ Sensation = nerves
• Suggests that pain can be reduced by simultaneous activation of • Anesthesia is always associated with nerve / sensation
nerve fibers through the use of vibration
▪ Triggered – there is stimulus
○ Incorporate vibration as we delivery injection
• The nerve ending is stimulate / initiated
• VibraJect
○ Small battery operated attachment that snaps on to the
• The neural processes underlying the encoding processing of
standard dental syringe
noxious stimuli
▪ Use: will help you to provide a pain free or less discomfort
○ Stimuli / sensory = nerves
anesthesia procedure
▪ Designed to be attached to the syringe.
○ Pain, nerve, sensation, and stimulus are the keywords for
anesthesiology

• Pain – refers to the perception of a feeling or sensation

○ ○ Feeling – all about nerve
○ Interpreted by patient as: (which is described variably)
• Accupal ▪ Irritating
○ Cordless device that used both vibration and pressure to ▪ Sore
precondition the oral mucosa ▪ Stinging
○ The needle is place through the hole in the head of the ▪ Aching
disposable tip of the motor ▪ Throbbing

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 ▪
▪ Unbearable
○ These are connotation of pain

DUAL NATURE OF PAIN

1. Pain Perception
○ Physioanatomical process whereby an impulse is
generated
○ Takes place in the brain
▪ After talking about injection, the patient might think not to
take the injection because of pain perception
▪ Patient may think twice whether or not to accept the
injection

• DentalVibe
○ Cordless, rechargeable, hand held device that delivers
soothing, pulsed, percussive micro-oscillation to the site where
and injection is being administered.
▪ Micro-oscillation: principle of vibrasion.
○ ▪ Reaction is individualized
• Computer-controlled local anesthetic delivery systems
○ In the mid-1990s, work began on the development of local
anesthetic delivery systems that incorporated computer
technology to control the rate of flow of the anesthetic solution
through the needle.
○ Ex. The Wand
MICROSCOPE DENTISTRY
Comfort control syringe
• is a pre-programmed anesthetic delivery device that controls the
flow of anesthetic into your tissues.
• injection at an extremely slow rate and then gradually increasing the
flow, pain is managed and patients experience little to no discomfort
• ensures that each patient receives the optimal dose of anesthetic at
the optimal flow rate so that each injection is comfortable every
2. Pain Reaction
○ Dual nature of pain
▪ Pain starts as perception, then reaction
▪ After sensing the stimulus, there would be reaction
• Reaction after stimulus
○ Process that represents the individual's overt manifestation of
the unpleasant perceptual process that just occurred
• It differs from one person from another
▪ Example:
• You injected your patient (infiltration), the reaction of
the patient will vary
○ Macho effect – okay lang; doesn’t hurt
○ Some will smile
○ Some will react violently to the stimulus given
(injection)
▪ varies markedly from one individual to another and from
day to day in the same individual.
• Yesterday, extraction was performed with anesthetics
○ After a week, the effect of anesthetic solution
starts to wear

Pain reaction threshold is commonly interpreted as being inversely

proportional to pain reaction.
• a pt. who is hyporeactive is considered to have high pain threshold,
○ The patient could bear/accept the pain because he/she is
hyporeactive (not reacting)
• and a pt. who has low threshold hyperreacts in response to noxious
stimulus
○ Px is hyperactive
○ Pain reaction varies from one individual to another

Factors affecting individual's pain threshold

Jet Injectors Emotional states
• based on the principle of using a mechanical energy source to • The pain threshold of individuals depends to a great degree on their
create a release of pressure to push a dose of liquid medication attitude toward the procedure, the operator, and the surroundings.
through a very small orifice, creating a thin column of fluid with • Emotionally unstable individuals has increased pain reaction
enough force that it can penetrate soft tissue into the subcutaneous ○ Big factor: relationship with the patient; how you explain
without a needle. procedures to patient affects their pain threshold.
• Jet injectors are believed to offer advantages over traditional needle ○ Do not mention "masakit" because you are introducing pain into
injectors by being fast and easy to use, with little or no pain, less the patient's mind/emotion.
tissue damage, and faster drug absorption at the injection site. ○ Substitute instead
○ Use art of semantics
Safety dental syringes ▪ Mararamdaman mo lang
• recent years there has been a move toward the development and ▪ Kiliti lang
introduction of 'safety' syringes both medicine and dentistry. ▪ Keri lang (luh)
• use of a safety syringe minimizes the risk of accidental needle-stick ○ Downplay the pain
injury occurring to a dental health provider with a contaminated ○ PX EMOTIONAL STATE IS DIRECTLY RELATED TO THE
needle after the administration of LA. PAIN SENSATION.
PAIN Fatigue
• PAIN is defined as an 'unpleasant sensation that occurs from • pt. who are well rested and who have a good night's sleep will have
imminent tissue damage'. (WHO) much higher pain reaction threshold

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 needle after the administration of LA. PAIN SENSATION.
PAIN Fatigue
• PAIN is defined as an 'unpleasant sensation that occurs from • pt. who are well rested and who have a good night's sleep will have
imminent tissue damage'. (WHO) much higher pain reaction threshold
• IASP definition: An unpleasant sensory and emotional experience ○ Appoint patient in the morning
associated with actual or potential tissue damage, or described in
• Very reason that it is always good to appoint patient in the morning;
terms of such damage
px is fresh from the bed and not tired
• From a physiological perspective, pain is a warning system ○ Px is from rest; best to appoint procedure in AM especially
• during dental treatment, patients will experience pain as something medically compromised px, extraction cases, old age
unpleasant • Sets in at the end of the day
• Do not schedule px at the end of the day; long procedure
Classification of Pain
Pain is generally classified according to:
Age
• Location
• older individual tends to tolerate pain and thus have a higher pain
○ Head
reaction threshold.
○ Back • Older has higher tolerance of pain than pediatric patients
○ Stomach ○ Adult > pediatric
• Duration • Early stage of clinic exposure for pediatric patients compared to
○ How long you experience the pain adult patients that could tolerate emotional factors
• Underlying cause
Racial and Nationality characteristics
• Intensity - pain intensity is different from one another • Culture
○ Severe pain ○ Each country has own culture
○ Moderate pain ○ E.g px. Comes from country who has higher pain tolerance
○ Mild pain then it would manifest
• frequency • Px who comes from countryside would have higher tolerance than
px who are from highly urbanized place who have lesser exposure
Classification of pain is thus complicated and can be a source of from painful situation
confusion for many clinicians. • Those in highly urbanized areas have lower tolerance to pain

Sex
• it is generally considered that men have a higher pain reaction
threshold than woman
○ In reality more men pass out compared to female
• "macho effect" culture - people believe men have higher pain
threshold

Fear and Apprehension

• pain reaction threshold is lowered as fear and apprehension
increase
• Individual accommodates pain
• If you fear something - you would be hyperreacting
• If px is apprehensive
○ threshold would be directly affected
• E.g px needle phobia/fear

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