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An Update on Pain Control in Conservative Dentistry and Endodontics: A

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 The Indian Journal of Nutrition and Dietetics
ISSN: 0022-3174; eISSN: 2348-621X
DOI:10.21048/IJND.2022.59.1.28600
www.ijndonline.org

An Update on Pain Control in Conservative Dentistry

and Endodontics: A Review
Mehrukh Zehravi1, Mudasir Maqbool2 and Irfat Ara3
(1. Department of Clinical Pharmacy Girls Section, Prince Sattam Bin Abdul Aziz
University Alkharj, Saudia Arabia 2. Department of Pharmaceutical Sciences,
University of Kashmir, Srinagar, Jammu and Kashmir, India 3. Regional Research
Institute of Unani Medicine, Srinagar, Jammu and Kashmir, India)
e-mail: bhatmudasir92@gmail.com

(Received 9th September, 2021)

Abstract

Any healthcare professional must be able to understand pain in order to better

manage it. Dental pain can be caused by a variety of things and can manifest itself in many
ways. Getting an appropriate diagnosis is the first step in dealing with tooth discomfort.
Pain is evaluated using rating tools such as the Visual Analog Scale and questionnaires.
Following a diagnosis, a variety of strategies for pain management can be utilized alone or
in combination. None of the pain-relieving approaches will work until the underlying source
of the pain is addressed. Dental pain can be relieved using a variety of pharmacological
and non-pharmacological methods. Patients with dental anxiety may have a decreased
pain tolerance, which should be addressed with behavioral treatment. Premedication
prior to anaesthetic administration has also been found to improve pain management.
Analgesics like NSAIDS, aspirin and a few opioids like morphine are the cornerstones
of pain management. Anaesthetics, which can be applied topically or in injectable forms,
are another regularly utilized approach. Dental phobia can be overcome with analgesia or
conscious sedation, which is commonly used in youngsters. Hypnosis, acupuncture and
audio-analgesia have all been shown to be effective in the treatment of pain. Lasers have
recently been investigated for the treatment of pain. Virtual reality has also been proven
to be successful as a distraction tool. Pain can also be managed with a variety of tried-
and-true home treatments. As a result, it’s crucial to recognize that pain treatment is a
multifaceted process.

Keywords: Pain Management, home remedies, analgesics, dental pain, anaesthetics

114 The Indian Journal of Nutrition and Dietetics, Vol. 59 (1), January - March 2022
 An Update on Pain Control in Conservative Dentistry and Endodontics: A Review

Introduction will induce the dentinal fluid to migrate in

directions, inwards and outwards. A heat
Pain can be frightening and lead to
stimulus causes an inward flow, whereas
fear. This pain is what typically prompts a
a cold stimulus causes an outward flow4.
patient to seek treatment from a dentist,
The stimulation is delivered to the pulp via
with the goal of receiving instant pain relief.
odontoblasts or nerve terminals in close
“An unpleasant sensory and emotional
proximity to the odontoblasts. Pain signals
experience connected with existing or
are transmitted by fast conducting A-fibres
potential tissue damage, or defined in
and slow conducting C-fibres in the strongly
terms of such harm,” is according to the
innervated tooth pulp. This transmission
International Association for the Study of
occurs from primary sensory neurons in the
Pain. Acute, subacute, or chronic pain;
spinal cord to secondary order neurons in
inflammatory, nociceptive, or neuropathic
the thalamus, where next order neurons
pain; slow or quick pain; odontogenic or
emerge and terminate in the SI and SII
non-odontogenic pain; or referred pain
areas of the cerebral cortex. Chemical
is only few of the numerous forms of
mediators such as neuropeptides have
pain. Developmental factors such as age
also been found in the cell bodies of these
and sex, physiological factors such as
nerve fibres. Substance P is one of the
genes, neurological function, and fatigue,
most important mediators, and calcitonin
social factors such as attention, previous
experience, family and social support, – gene related peptide is another. Both

spiritual factors, psychological factors play key roles in modulating two essential

such as anxiety, fear, apprehension, components of neurogenic inflammation,

coping styles, and the patient’s emotional namely vasodilation and vascular
status are just some of the factors that can permeability. After irreversible pulpitis,
influence pain1-3. immune-histochemical examination shows
an increase in their levels. Upon a low-
Dental pain: Its physiology and causes
intensity injury, the primary afferent fibres
As dental caries progresses, the pulp have been found to increase in number
become inflamed, resulting in a toothache, within the pulp, a phenomenon known as
also known as odontalgia. Trauma, sprouting, which returns to normal after
damaged restorations, parafunctional the stimuli is removed. Because the pulp is
behaviours, poor oral care and other encased inside the hard tooth structure, it
factors can all contribute to a toothache. is difficult to expand, increasing intrapulpal
Dentine tubules that are exposed might pressure and lowering the nerve fibres’
cause tooth pain. External stimulation pain threshold. Pain and inflammation

The Indian Journal of Nutrition and Dietetics, Vol. 59 (1), January - March 2022 115
 Mehrukh Zehravi, et al.
have also been linked to endogenous
chemical mediators such as histamine,
prostaglandins and bradykinins4, 5. There
are three types of endodontic tooth pain:
pain before, pain during and pain after
treatment. Pre-endodontic pain has
been explored in terms of its causes and
mechanisms. Inter-appointment endodontic
pain can be caused by mechanical,
chemical, or microbiological root canal
injury, which can result in significant pain
and swelling. Over instrumentation and
over-extended filling materials are the
most common causes of mechanical injury,
while irrigants or intracanal medicaments
extruded apically can cause chemical
harm. Inter-appointment endodontic
discomfort has been linked to bacteria
like Porphyromonas endodontalis,
Porphyromonas gingivalis and Prevotella
species. Post-endodontic discomfort is the
most prevalent consequence of endodontic
treatment. Unistrumented remnants of
pulp tissue, inappropriate or insufficient
irrigation, missing canals, working length
misdetermination, extrusion of debris
beyond the apex, and even the type of
obturation technique used, such as lateral
condensation, can all contribute to post
endodontic pain6.
Evaluation of pain
The first stage in managing dental
pain is gaining a thorough awareness of the
patient’s symptoms, which necessitates a
precise diagnosis. Certain aspects of pain
116 The Indian Journal of Nutrition and Dietetics, Vol. 59 (1), January - March 2022
should be evaluated before a diagnosis can
be made. In addition to this, a family history,
drug history and prior and current medical
history should be collected. Extraoral
and intraoral examinations, as well as
the necessary investigations, should be
performed. Because pain is subjective,
it can be assessed using questionnaires
and rating scales. Different types of rating
scales can be employed, such as numeric
rating scales, visual analogue scales,
categorization scales and so on. The Visual
Analogue Scale (VAS) is the most often
used scale among these. A 10-centimeter
line on the VAS scale indicates the severity
of pain in numbers ranging from 0 to 10,
with 0 representing no pain and 10 being
the greatest pain possible. The first pain
assessment instrument, brief pain inventory
and McGill pain questionnaire are further
tools for assessing pain based on more
information7.
Pain management in dentistry
Pain is complex and as a result, there
are a variety of solutions or combinations
of options for pain management. If the
underlying source of pain is not addressed,
none of the pain management techniques
will be effective. As a result, accurate
diagnosis is critical. The nerve terminals will
not be activated if the stimuli are removed
and hence no impulses will be generated.
Pain management would involve
pharmaceutical and non-pharmacological
therapies, as well as emotional and stress
 An Update on Pain Control in Conservative Dentistry and Endodontics: A Review
management for the patient7. The following
are some pain-relieving measures to
consider:
Behavioral management
Anxiety, needle phobia, previous
unpleasant dental experiences, and so on
all have an impact on the patient’s pain
experience. In some people, lowering their
anxiety can help them boost their pain
threshold. Providing a compassionate
clinical environment, as well as guarantees
for the patient’s comfort when offered
confidently and softly, can aid to acquire
a more compliant patient. The dentist’s
pledge to prevent discomfort aids in anxiety
reduction. Because anxiety is a result
of ambiguity, offering knowledge about
the process and increasing the patient’s
sense of control can assist lessen anxiety.
Encouraging the patient to shift his or her
focus of thought to something else can also
assist. Changes in the environment, such as
a lavender scent at the dental office, have
also been shown to help patients overcome
their fears. If the patient is a youngster,
rapport-building techniques such as voice
control, distraction, modelling and memory
reconstruction should be used8.
Premedication
Premedication is the process of
delivering a medication before to a therapy
or procedure, and it is commonly done
before giving anaesthesia for any surgery.
The usual approach is intramuscular,
The Indian Journal of Nutrition and Dietetics, Vol. 59 (1), January - March 2022
although for premedication, the oral route is
preferred. It should be given 20 minutes to
3 hours before surgery. Various medicines
are utilized for premedication depending on
the treatment, the patient and the aesthetic
method. Anxiety, sedation and amnesia
are all things that can happen. Anxiety
relief, light sedation and anterograde
amnesia are all frequent uses for short-
acting benzodiazepines (e.g. Temazepam).
Alternatives include lorazepam, midazolam,
clonidine and dexmedetomidine. Opioids
like morphine and fentanyl can be used in
the same way. Premedication analgesia
is usually achieved with opioids, NSAIDs,
or paracetamol. Antimuscarinics are
less routinely used now, but they were
once widely used to dry up secretions
in the mouth and minimise bradycardia
and hypotension. Hyoscine or atropine,
for example pre-operatively, antiemetics
and anti-acidity medications such as H2
receptor antagonists, sodium citrate and
antihistamines can be administered to
decrease anaesthetic adverse effects
(emetic)9.
Analgesics
Analgesics, which attempt to make
pain acceptable for the individual, are
the most commonly used medicine for
pharmacological pain management.
Opioids and non-opioids, traditionally
known as narcotic and non-narcotic
analgesics, are two types of analgesics.
Non-opioid analgesics like NSAIDS and
117
 Mehrukh Zehravi, et al.
aspirin include anti-pyretic, anti-platelet
and anti-inflammatory activities in addition
to analgesic properties. These forms
of analgesics do not cause physical
dependence or addiction. They have a
ceiling effect where the analgesic effect
does not rise. Their doses should be
delivered at regular intervals, as determined
by the clock. NSAIDS function by blocking
the cyclo-oxygenase enzyme, which
reduces the formation of prostaglandins . 10
The safest NSAIDS are ibuprofen 400 mg
and ibuprofen 800 mg. However, NSAIDS
can have negative side effects, such as
gastrointestinal toxicity. In addition, NSAIDS
block platelet cyclooxygenases, lowering
the production of thromboxane A2, which
is responsible for platelet aggregation.
Patients with bleeding problems and those
using anticoagulant drugs should avoid
NSAIDS. Because prostaglandins maintain
the patency of the ductusarteriosus
during foetal development, NSAIDS
should be avoided in pregnant people . 11
Acetaminophen is an alternative to aspirin
in circumstances where it is contraindicated.
The most serious side effect is known to be
hepatotoxicity. Because acetaminophen’s
mechanism of action differs from that of
NSAIDs, it can be taken with them for a
synergistic effect. Other than Ibuprofen,
dentists regularly prescribe Diclofenac
potassium 50 mg, Naproxen sodium
500/550 mg, etoricoxib 120 mg, and other
NSAIDS for pain . The delivery of NSAIDs
12
118 The Indian Journal of Nutrition and Dietetics, Vol. 59 (1), January - March 2022
via a relatively painless transmucosal or
transdermal route would be a step forward.
Ketorolac Tromethamine (KT) in a bucco
adhesive film applied to the oral mucosa,
for example, maintains therapeutic levels
for at least 6 hours13. Opioids Morphine and
morphine-like substances are analgesics.
They work as agonists at opioid receptors
to deliver therapeutic effects. Opioids
have a higher efficacy when the dose
is increased, as opposed to non-opioid
analgesics, which have a ceiling effect.
However, they should not be used as the
first line of treatment for tooth discomfort.
Opioids are most commonly used to treat
severe acute dental pain. When the dose of
NSAIDs and/or acetaminophen has been
optimised but the pain still persists, opioids
may be used. Morphine inhibits the release
of bradykinin when it is mediated by neural
processes. It works by acting as an agonist
on the kappa and mu receptors, resulting
in analgesia. Opioid analgesics cause
dependency and addiction and patients
may experience withdrawal symptoms.
This can be avoided by reducing the doses
gradually. The analgesia and side effects
of 10 mg morphine, 120 mg codeine and
75 mg meperidine are all similar. Tramadol
is another medication that decreases
serotonin and norepinephrine reuptake.
The activity of tramadol is shown on the
mu receptors, delivering about 60 mg
of codeine efficacy. Opioids should be
avoided during pregnancy since they
 An Update on Pain Control in Conservative Dentistry and Endodontics: A Review
raise the chance of major brain, heart and
spine birth abnormalities. As a result, the
doctor should devise a number of safe and
effective analgesic regimens based on the
anticipated pain severity, all of which should
be founded on sound pharmacological
principles14.
Anaesthetics
Anaesthetics can be used to treat
pain as well as diagnose it. It’s offered
as a topical cream and as an injectable.
Sprays, solutions and ointments are
available as topical anaesthetics. Gel or
paste formulations are ideal for topical
anaesthesia. Topical anaesthetics act by
modifying pain thresholds by blocking
impulses sent from peripheral nerve fibres
in the mucosa’s surface layers. Topical
anaesthetics are used in dentistry to
conceal injection discomfort, to reduce
pain during operative dental treatments,
and to ease any pain caused by superficial
mucosal lesions such as ulcers15. The
anaesthetics with higher concentrations
and no vasoconstrictors have improved
mucosal permeability. Lidocaine or
benzocaine, at doses ranging from 7.5 per
cent to 20%, provides surface numbness
in about 3 minutes. To limit the region of
application, the chosen mucous membrane
or patch of skin is dried before applying the
gel with a cotton swab. Topical anaesthetic
is effective for about 10 minutes. Other
topical anaesthetics include EMLA cream,
a eutectic mixture of 2.5 per cent lidocaine
The Indian Journal of Nutrition and Dietetics, Vol. 59 (1), January - March 2022
and 2.5 per cent prilocaine and Ametop, a
tetracaine-based 4 per cent water-in-water
gel. The latter has been demonstrated to
be more effective at reducing discomfort
following needle insertions. Recently, a
patch combining 70 mg lidocaine and 70 mg
tetracaine has been proposed as an
alternative for a speedier start of action.
Topical anaesthetic does not have many
side effects; however it can cause a brief
change in taste and tissue stimulation.
Prior to using local anaesthetics, the
patient should be tested for allergies to
them16. An successful local anaesthetic
is the cornerstone of pain management.
Local anaesthetics act by stopping neural
transmission by reducing sodium ion
influx through channels within neuronal
membranes. The effectiveness of local
anaesthetics is determined by a number
of factors, including the precision of the
injection, the relative acidity of the injected
tissue, the type of anaesthetic used,
bone density, nerve architecture and the
patient’s stress levels. The most prevalent
type of injectable local anaesthetic is
amides. Depending on the length of action,
there are three forms of L.A.: short (30
minutes), moderate (60 minutes) and
long (>90 minutes)17, 18. Vasoconstrictors,
such as epinephrine, are used to prolong
anaesthesia. So, with epinephrine,
anaesthesia would last roughly 40-60
minutes, whereas without it, anaesthesia
would only last 5-10 minutes. Nerve blocks,
field blocks and local infiltrations are just a
119
 Mehrukh Zehravi, et al.
few of the injectable treatments that can be
used. The most widely used anaesthetic
solution is 2% lidocaine with 1:100000
epinephrine. Mepivacaine 3%, Prilocaine
4%, Articaine 4% and Bupivacaine 0.5 per
cent are some of the others. Articaine has
been shown in several tests to be superior
to traditional anaesthetics. In comparison
to maxillary nerve blocks, mandibular nerve
blocks have been found to be less effective.
For a more strong control of pain and in cases
of anaesthetic failures, these nerve blocks
can be reinforced with intraligamentary,
intraosseous, intrapulpal and infiltration
injection procedures. A computer-controlled
local anaesthetic administration system
that regulates the rate of injection has also
been found to be effective in lowering pain
from LA injections. The type of solution
utilised, needle size and injection speed
are all aspects that influence injection pain
reduction. A good rule of thumb is to use
a 27-gauge needle to give anaesthetic at
a rate of 1ml per minute. In an attempt to
lessen injection pain, some dentists prefer
to use a 30-gauge needle. While this is
possible, there may be issues such as
not enabling aspiration or deviating during
injection. Patients with stage 2 or higher
hypertension, as well as those who have
a known allergy to LA, should avoid local
anaesthesia. It is important to avoid taking
too much LA. CNS toxicity, cardiovascular
toxicity, neurotoxicity, methaemoglobinemia
and other side effects of local anaesthetic
are all possible19,20. Malamed recommends
120 The Indian Journal of Nutrition and Dietetics, Vol. 59 (1), January - March 2022
a maximum safe dose of 4.4 mg/kg
(2 mg/lb) with an absolute maximum intake
of 300 mg. To have a good chance of
success, any difficulties must be dealt with
right away. In the event of an emergency,
the patient would be placed in a supine
position, medical aid would be summoned,
vital signs would be monitored and basic
life support would be administered if
necessary19.
Analgesia (Conscious sedation)
Conscious sedation is a drug-induced
state of consciousness in which the
patient can respond to spoken directions.
Inhalation sedation can be combined with
anaesthesia to raise the pain threshold
in apprehensive patients with a low pain
threshold. It comes in a variety of forms,
including oral, intramuscular, intravenous
and inhalational. Nitrous oxide and oxygen,
as well as benzodiazepines, are often
used sedatives. Analgesic, sedative and
hypnotic effects are all properties of nitrous
oxide. 30-50 per cent concentrations are
required and the patient can stay at this
level for 5 minutes before administering LA.
The patient will be placed on 100% oxygen
for 5 minutes after the procedure. The
analgesic effect of nitrous oxide is thought
to be due to the production of endogenous
opiate peptides and the activation of
opioid receptors, according to research.
Inhibition of the N-methyl-D-aspartate
glutamate receptors is also observed.
Hypoventilation, apnea, laryngospasm,
 An Update on Pain Control in Conservative Dentistry and Endodontics: A Review
respiratory obstruction and cardiovascular
changes are all possible side effects
of sedation. Analgesia administration
necessitates specialised training. For
conscious sedation, benzodiazepines such
as diazepam and midazolam, as well as
ketamine, propofol and a few opioids, may
be administered in addition to nitrous oxide.
Conscious sedation should only be used to
treat dental phobia, not as a substitute for
good local anaesthesia21, 22.
Hypnosis
Hypnosis has a long history of usage
in anaesthesia and pain management.
Hypnosis might be able to help you
overcome your phobia of dental procedures.
It’s called hypnodontia when it’s employed
in dentistry. The patient is more comfortable
during hypnosis since it involves learning
how to use one’s thoughts to control stress.
It is divided into four stages: induction,
deepening, suggestions and debriefing.
These techniques assist the patient in
shifting his or her attention away from the
discomfort and toward something more
calming. Some patients have described this
as a trance-like state. Hypnosis can improve
the efficacy of other well-established pain
therapies when used in conjunction with
them. Hypnosis can assist modify mental
states and increase cognition, as well as
change pain perception and relieve tension.
It can also modulate neurovegetative
reactions such as heart rate, blood pressure
and gag reflex. As a result, hypnosis can be
The Indian Journal of Nutrition and Dietetics, Vol. 59 (1), January - March 2022
perceived as a pleasurable experience in
which the individual is more focused and
absorbed in their experience, as well as
more comfortable and calm23, 24.
Acupuncture
Acupuncture or needle puncturing
can be used in dentistry to treat orofacial
pain. Acupuncture offers new hope to some
patients who have been unable to find relief
from traditional therapy options. It works by
stimulating the nerve system by stimulating
certain spots. Pain conduction is inhibited
when nerve fibres such as the A delta and
C fibres are activated with a needle. When
the needle is put into the point, a sensation
known as De qui is felt, which can manifest
as numbness, discomfort, or distention
surrounding the insertion site. This triggers
a minor inflammatory response, releasing
neurotransmitters such as histamine and
bradykinin. Acupuncture is a safe practise
when conducted by someone who has
received sufficient training. It’s a pain
reliever that also works as a symptomatic
treatment for dental pain25.
Audio analgesia
Gardner and Licklider coined the term
“audio analgesia,” which refers to the use
of music and noise to relieve pain. Patients
are provided earphones and a control box
with which to control the audio stimulation.
During therapy, if the patient has any
discomfort or agony, they can increase the
music volume to a maximum of 116 decibels
121
 Mehrukh Zehravi, et al.
above 0.0002 microbar. A sound similar
to that of a waterfall can be heard, which
has a relaxing effect. This music can help
people relax by removing the conditioned
anxiety they experience while hearing a
dental drill. Audio analgesia has long been
a mysterious phenomenon. If adequate
sound intensity limits and durations are
observed, it appears to have no harmful
side effects26.
Lasers
Maiman was the first to employ lasers
in dentistry, and they have subsequently
been used for a variety of purposes.
Lasers have recently been discovered
to help with acute inflammatory pain.
This is caused by decreased amounts of
prostaglandins, interleukin, TNF alpha
and other inflammatory mediators. Lasers
have been shown to block nociceptive
signals in peripheral nerves, as well as
to reduce oedema. It can also improve
lymphatic drainage and enhance histamine
production. In endodontics, lasers have
also been shown to minimize postoperative
discomfort. For pain relief, diode lasers with
low-level laser therapy have been found to
be effective. For the same, wavelengths
ranging from 600 to 950 nm are employed.
Photobiomodulation is another name for this
process. The use of lasers as an additional
therapy for momentarily decreasing pain
has been approved. More research into the
mechanism of action and the application of
lasers to relieve dental pain is needed27, 28.
122 The Indian Journal of Nutrition and Dietetics, Vol. 59 (1), January - March 2022
Virtual reality
Virtual reality is a revolutionary
approach for providing diversion during
dental procedures. Virtual reality is a three-
dimensional universe created by computer
technology that immerses the viewer in
enticing and interactive environments. It
has been demonstrated to be an excellent
distraction method for patients during dental
treatment, lowering discomfort and anxiety
while also enhancing cooperation. Virtual
reality has been demonstrated in studies
to be more enticing to youngsters than to
adults. Although successful, assessing
efficacy when using virtual reality is
relatively tricky. The bulky equipment may
obstruct the dentist’s job and restrict his
operating space. More research is needed
to determine the role of virtual reality in pain
and anxiety management29.
Home remedies for pain management
Pain can be effectively treated with
heat and cold. Ice can be applied after
surgery to help slow blood flow, which
in turn lessens inflammatory discomfort.
Osmosis is reversed and inflammation is
reduced by rinsing with warm seawater.
The higher the saline content, the more
the fluid in the oedema leaks out of the
cells. Eugenol, which contains clove/clove
oil at concentrations of 80-90 per cent, is
also useful for numbing pain and lowering
inflammation. The discomfort will be relieved
in 10 minutes. Clove gel has also been
 An Update on Pain Control in Conservative Dentistry and Endodontics: A Review

shown to be as effective as benzocaine gel or non-pharmacological techniques,

on the skin. Tannic acids in black tea bags
can also aid to relieve pain and swelling.
For pain relief, it is recommended that you
keep the bag in your mouth and bite on it
for 15 minutes. Because ginger may reduce
inflammation and swelling and cayenne
pepper contains capsaicin, which is widely
used in pain management, making a paste
with ginger and cayenne pepper is also
useful. Chewing on a garlic clove is also a
tried-and-true method of pain relief30, 31.
Conclusion
Pain is the most common phenomenon
that has unpleasant implications that
affect people’s quality of life. As a result, a
multifaceted strategy to pain management
is required. To arrive at a good diagnosis,
a thorough examination of pain should be
carried out. Pain management requires a
thorough understanding of pain. Pain can
then be controlled with pharmacological
or by combining them for a synergistic
effect. Non-narcotic analgesics (e.g., non-
steroidal anti-inflammatory medications,
paracetamol, etc.) and opioids are
both used to treat pain (i.e., narcotics).
Because of their anti-inflammatory and
analgesic properties, Non-Steroidal Anti-
Inflammatory medicines (NSAIDs) provide
good pain relief. Aspirin and ibuprofen are
the most often used NSAIDs. Although
paracetamol is a powerful analgesic, it has
little anti-inflammatory properties. Opioids
are potent analgesics, but they have a lot
of negative effects, therefore they should
only be used for severe pain. Codeine is
the most often prescribed opioid, which
is usually combined with paracetamol.
Corticosteroids can also be used to treat
inflammation; however they are only utilized
in dentistry in a few extremely restricted
circumstances.

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