1. Copyright © 2004 by Delmar Learning, a division of Thomson Learning, Inc. ALL RIGHTS RESERVED. 1 Chapter 16 Management of Pain and Anxiety

2. Copyright © 2004 by Delmar Learning, a division of Thomson Learning, Inc. ALL RIGHTS RESERVED. 2 Anesthetic Emergencies Studies show that more than half of all dental emergencies occur during or after giving anesthetic

3. Copyright © 2004 by Delmar Learning, a division of Thomson Learning, Inc. ALL RIGHTS RESERVED. 3 Techniques to Manage Pain Sedation –Oral sedation –Nitrous oxide gas Topical anesthetic Local anesthetic General anesthetic

4. Copyright © 2004 by Delmar Learning, a division of Thomson Learning, Inc. ALL RIGHTS RESERVED. 4 Sedation Used to relax the patient before anesthetic

5. Copyright © 2004 by Delmar Learning, a division of Thomson Learning, Inc. ALL RIGHTS RESERVED. 5 Types of Sedation Premedication –Liquid –Pill Nitrous oxide gas Used in conjunction with local anesthetic Patient requires supervision

6. Copyright © 2004 by Delmar Learning, a division of Thomson Learning, Inc. ALL RIGHTS RESERVED. 6 Nitrous Oxide Anesthetic agent Patient remains conscious Raises the pain threshold Used in conjunction with local anesthetic Patient is more receptive to treatment

7. Copyright © 2004 by Delmar Learning, a division of Thomson Learning, Inc. ALL RIGHTS RESERVED. 7 Indications for Nitrous Oxide Heart patients Patients that gag easily Fearful or stressed patients Longer appointments Patients able to breathe through nose easily

8. Copyright © 2004 by Delmar Learning, a division of Thomson Learning, Inc. ALL RIGHTS RESERVED. 8 Baseline The ratio that is most effective on patient Patient should be: –Cooperative –Conscious –Relaxed Record baseline on patient’s chart

9. Copyright © 2004 by Delmar Learning, a division of Thomson Learning, Inc. ALL RIGHTS RESERVED. 9 Topical Anesthetic Temporarily numbs nerve endings Application –Before local anesthetic injection –Reduces gagging sensation Impressions Radiograph Types –Ointments/gels –Liquids/mouth rinses –Sprays

10. Copyright © 2004 by Delmar Learning, a division of Thomson Learning, Inc. ALL RIGHTS RESERVED. 10 Placing Topical Anesthetic

11. Copyright © 2004 by Delmar Learning, a division of Thomson Learning, Inc. ALL RIGHTS RESERVED. 11 Topical Anesthetic May Cause Reaction Topical 5% to 10% anesthetic solution Local consists of 2% anesthetic solution Signs include: –Talkative –Apprehensive –Excited –Increased pulse and blood pressure –Patient becomes sleepy afterward

12. Copyright © 2004 by Delmar Learning, a division of Thomson Learning, Inc. ALL RIGHTS RESERVED. 12 Local Anesthetic Used routinely for pain management Intraoral injection administered Produces a pain-free area Sensory impulses are temporarily blocked from: –Pain –Touch –Thermal

13. Copyright © 2004 by Delmar Learning, a division of Thomson Learning, Inc. ALL RIGHTS RESERVED. 13 Determining Factors for Amount of Anesthetic Administered Age Weight Physical condition Liver function

14. Copyright © 2004 by Delmar Learning, a division of Thomson Learning, Inc. ALL RIGHTS RESERVED. 14 Overdose of Anesthetic Drop in blood pressure Nausea and vomiting Pallor Convulsions Muscular twitching Apprehension

15. Copyright © 2004 by Delmar Learning, a division of Thomson Learning, Inc. ALL RIGHTS RESERVED. 15 Possible Complications of Anesthetic Paresthesia: temporary numbness –Nerve sheath damage during injection –Hemorrhage: creating pressure on nerve –Contamination of anesthetic Patient may bite tongue, cheeks, lips Condition is rarely permanent

16. Copyright © 2004 by Delmar Learning, a division of Thomson Learning, Inc. ALL RIGHTS RESERVED. 16 Two Types of Anesthetic Solutions Amides –Lidocaine Ester –Benzocaine Patient may be sensitive to one and not the other

17. Copyright © 2004 by Delmar Learning, a division of Thomson Learning, Inc. ALL RIGHTS RESERVED. 17 Properties of Vasoconstrictors Decreases the risk of a toxic reaction by slowing the absorption of anesthetic into bloodstream Constricts the blood vessel, which in turn controls bleeding Prolongs the duration of anesthetic

18. Copyright © 2004 by Delmar Learning, a division of Thomson Learning, Inc. ALL RIGHTS RESERVED. 18 Epinephrine Added to local anesthetics as a vasoconstrictor Not used on heart patients Ratio of vasoconstrictor to anesthetic –1:50,000, 1:100,000, 1:200,000 E XAMPLE: 1 part epinephrine to 50,000 parts anesthetic

19. Copyright © 2004 by Delmar Learning, a division of Thomson Learning, Inc. ALL RIGHTS RESERVED. 19 Anesthetic Label

20. Copyright © 2004 by Delmar Learning, a division of Thomson Learning, Inc. ALL RIGHTS RESERVED. 20 How Nerves Innervate the Tooth Pulp horns Pulp chamber Pulp Pulp canal Cementum Enamel Dentin

21. Copyright © 2004 by Delmar Learning, a division of Thomson Learning, Inc. ALL RIGHTS RESERVED. 21 Anatomy Review of Maxillary Arch Incisive foramen Palatine process of the maxilla Median palatine suture Transverse palatine suture Horizontal plate of palatine bone Greater palatine foramen Lesser palatine foramina Maxillary tuberosity

22. Copyright © 2004 by Delmar Learning, a division of Thomson Learning, Inc. ALL RIGHTS RESERVED. 22 Maxillary Arch Injections Nasopalatine nerve block Middle superior alveolar nerve block Posterior superior alveolar nerve block Anterior superior alveolar nerve block (infraobital nerve block) Greater palatine nerve block (anterior palatine nerve block) Maxillary nerve block

23. Copyright © 2004 by Delmar Learning, a division of Thomson Learning, Inc. ALL RIGHTS RESERVED. 23 Anatomy Review of Mandibular Arch Condyle Mandibular (sigmoid) notch Ramus Mandibular angle External oblique ridge Border of the mandible Mental foramen Mental protuberance Submandibular fossa Mylohyoid line Retromolar area Coronoid process

24. Copyright © 2004 by Delmar Learning, a division of Thomson Learning, Inc. ALL RIGHTS RESERVED. 24 Anatomy Review of Mandibular Arch Coronoid process Mandibular foramen Submandibular fossa Lingual foramen Genial tubercles Mylohyoid groove Condyle Internal oblique ridge Sublingual fossa

25. Copyright © 2004 by Delmar Learning, a division of Thomson Learning, Inc. ALL RIGHTS RESERVED. 25 Mandibular Arch Injections Incisive nerve block Buccal nerve block Lingual nerve block Inferior alveolar nerve block (mandibular nerve block) Mental nerve block

26. Copyright © 2004 by Delmar Learning, a division of Thomson Learning, Inc. ALL RIGHTS RESERVED. 26 Types of Injections Local infiltration –Surrounding tissue or one tooth Field blocks –One or two teeth Nerve blocks –Entire quadrant

27. Copyright © 2004 by Delmar Learning, a division of Thomson Learning, Inc. ALL RIGHTS RESERVED. 27 Local Infiltration Injected into tissues at the end of the nerve branch 1 to 2 minutes until effective Used on procedures that involve soft tissue –Biopsy, gingivectomy, prophylaxis

28. Copyright © 2004 by Delmar Learning, a division of Thomson Learning, Inc. ALL RIGHTS RESERVED. 28 Field Block Used on procedures that involve the teeth and/or bone –Restorative Injection site is near the apex of tooth 2 to 3 minutes until anesthetic is effective Commonly used on maxillary arch –Absorbs well due to cancellous bone Used in anterior regions of both arches

29. Copyright © 2004 by Delmar Learning, a division of Thomson Learning, Inc. ALL RIGHTS RESERVED. 29 Nerve Block Injected near a main nerve trunk 4 to 5 minutes until effective Injected near foramen sites –Incisive –Mandibular –Mental

30. Copyright © 2004 by Delmar Learning, a division of Thomson Learning, Inc. ALL RIGHTS RESERVED. 30 Anesthetic Setup

31. Copyright © 2004 by Delmar Learning, a division of Thomson Learning, Inc. ALL RIGHTS RESERVED. 31 Syringe Aspirating syringe allows operator to verify that they have not penetrated a blood vessel. Harpoon of syringe is retracted; if blood appears in syringe then needle is repositioned.

32. Copyright © 2004 by Delmar Learning, a division of Thomson Learning, Inc. ALL RIGHTS RESERVED. 32 Aspirating Syringe

33. Copyright © 2004 by Delmar Learning, a division of Thomson Learning, Inc. ALL RIGHTS RESERVED. 33 The Needle Short: 1 inch –Used in infiltrations and field blocks –Periodontal ligament injections Long: 1-5/8 inch –Used for nerve blocks Maxillary and mandibular Reaches posterior areas –For areas that require penetration of thicker tissue

34. Copyright © 2004 by Delmar Learning, a division of Thomson Learning, Inc. ALL RIGHTS RESERVED. 34 Components of a Needle

35. Copyright © 2004 by Delmar Learning, a division of Thomson Learning, Inc. ALL RIGHTS RESERVED. 35 Needle Gauge Sizes – 25 gauge – 27 gauge – 30 gauge The smaller the gauge the larger the diameter of the needle

36. Copyright © 2004 by Delmar Learning, a division of Thomson Learning, Inc. ALL RIGHTS RESERVED. 36 Anesthetic Cartridge Components

37. Copyright © 2004 by Delmar Learning, a division of Thomson Learning, Inc. ALL RIGHTS RESERVED. 37 Retracting Harpoon

38. Copyright © 2004 by Delmar Learning, a division of Thomson Learning, Inc. ALL RIGHTS RESERVED. 38 Loading Cartridge into Syringe

39. Copyright © 2004 by Delmar Learning, a division of Thomson Learning, Inc. ALL RIGHTS RESERVED. 39 Engaging Harpoon

40. Copyright © 2004 by Delmar Learning, a division of Thomson Learning, Inc. ALL RIGHTS RESERVED. 40 Placement of Needle into Syringe

41. Copyright © 2004 by Delmar Learning, a division of Thomson Learning, Inc. ALL RIGHTS RESERVED. 41 Passing the Syringe

42. Copyright © 2004 by Delmar Learning, a division of Thomson Learning, Inc. ALL RIGHTS RESERVED. 42 Disassembling the Syringe

43. Copyright © 2004 by Delmar Learning, a division of Thomson Learning, Inc. ALL RIGHTS RESERVED. 43 Intraosseous Anesthesia Cancellous bone injected Requires special system Anesthetizes the following: –Bone –Soft tissue –Root –Teeth –Single or multiple teeth

44. Copyright © 2004 by Delmar Learning, a division of Thomson Learning, Inc. ALL RIGHTS RESERVED. 44 Periodontal Ligament Injection Often used with other types of injections Outcome: pulpal anesthesia Diagnosing abscessed teeth Technique –The needle is inserted into the gingival sulcus of the tooth –Requires special pressure syringes

45. Copyright © 2004 by Delmar Learning, a division of Thomson Learning, Inc. ALL RIGHTS RESERVED. 45 Periodontal Ligament Injection System

46. Copyright © 2004 by Delmar Learning, a division of Thomson Learning, Inc. ALL RIGHTS RESERVED. 46 Intrapulpal Injection Injection delivered directly into nerve chamber Used when unable to numb patient by traditional methods Procedures –Root canal therapy –Severe abscess

47. Copyright © 2004 by Delmar Learning, a division of Thomson Learning, Inc. ALL RIGHTS RESERVED. 47 General Anesthetic Reserved for extensive restorative procedures or surgeries

48. Copyright © 2004 by Delmar Learning, a division of Thomson Learning, Inc. ALL RIGHTS RESERVED. 48 General Anesthetic Patient becomes unconscious Nitrous oxide and intravenous (IV) drugs Patient must be monitored Used during – Extensive treatment – Surgeries – Uncooperative patients – Children

49. Copyright © 2004 by Delmar Learning, a division of Thomson Learning, Inc. ALL RIGHTS RESERVED. 49 Contraindications Blocked nasal passage Pregnancy Emotional instability –Alters perception of reality Emphysema Multiple sclerosis Street drug users Immune-compromised patients –Bone marrow suppression