Pain control and isolation in
Operative Dentistry &
Endodontics
Class by
Dr. Honap Manjiri Nagesh
Department of Conservative Dentistry and Endodontics

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What is pain?

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Pain
control
Preoperative
Fear alleviation
Non opioid drugs
Opioid drugs
Intra operative
Local Anaesthesia
Pulpectomy/Pulpotomy/ Occlusal reduction/
Trephination/I&D
Post operative
Pharmacological agents

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Pre - operative
considerations
Fear alleviation
Many patients enter the dental office in
such a state of nervousness that they
even find taking radiographs
unbearable!
Anxiety is believed to play a role in
lowering pain thresholds

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Analgesics
• When definitive care cannot be delivered
immediately, oral analgesics offer convenient
and effective means to relieve even severe
dental pain.

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NSAIDs &
acetaminophen
• Convenient dosing, high safety profile,
and ready availability
• Functions by blocking the
cyclooxygenase (COX) 1 and 2
enzymes to prevent production of
prostaglandins involved in both pain
transmission and inflammation.

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Acetaminophen • Block prostaglandin synthesis
peripherally and interacts with
cannabinoid and serotonergic receptors
centrally.
• The manufacturer's maximum
recommended dosage of
acetaminophen is 3000 mg/day.
• Given the risk of hepatoxicity
associated with acetaminophen, the
lowest effective dosage is
recommended.

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Corticosteroids • Shown efficacy in treating severe dental
pain,
• corticosteroids like prednisalone and
dexamethasone have a higher side-
effect profile than NSAIDs
• Possess cross-reactivity when patients
are sensitive to these drugs.
• Their use is not routinely
recommended.

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Opioid class drugs • complexes of codeine, hydrocodone,
oxycodone, and tramadol.
• Act centrally on mu and kappa receptors to
alter pain perception.
• Though not as effective as the pain
relievers, these drugs produce feelings of
euphoria and reduce anxiety; thus, patients
in severe pain can rest and oftentimes
escape notice of their severe pain.

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Antibiotics ? • Antibiotics are not effective pain
relievers.
• Providers should limit their prescription
to situations with uncontrolled, systemic
spread of infection, or where medical
compromise warrants their use
prophylactically.

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Intraoperative
/
perioperative
pain
control
• Perioperative pain management in
endodontics centers around the achievement
of profound local anesthesia.
• It is paramount for the clinician to obtain
profound anaesthesia when providing
endodontic treatment.

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Local anaesthetic Definition of LA
Nerve conduction
MOA of LA
Available LA agents
Clinical Anaesthesia objective tests
Various routes/ supplemental techniques
Topical anaesthetics
Adjusts to potentiate the LA
Recent advances in delivery of LA

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Definition • Local anaesthesia is defined as a loss of
sensation in a circumscribed area of
the body caused by depression of excitation
in nerve endings or an inhibition of the
conduction process in peripheral nerves.

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Nerve
conduction
THE FUNCTION OF A NERVE
IS TO CARRY MESSAGES
FROM ONE PART OF THE
BODY TO BRAIN AND BACK.
THESE MESSAGES, IN THE
FORM OF ACTION
POTENTIALS ARE CALLED
IMPULSES.
ACTION POTENTIALS ARE
TRANSIENT MEMBRANE
DEPOLARIZATIONS
FROM A BRIEF INCREASE IN
THE PERMEABILITY OF THE
MEMBRANE TO SODIUM

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MOA of LA
Local anaesthetic agent interferes with
excitation process in a nerve membrane
in one of the following ways:
• Altering the basic resting potential of nerve
membrane
• Altering the threshold potential
• Decreasing the rate of depolarization
• Prolonging the rate of repolarization

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Available LA agents

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Clinical
Anaesthesia –
objective tests
• A common mistake is not objectively
testing if pulpal anaesthesia has been
achieved prior to initiating therapy.
• IANB with irreversible pulpitis had only
a 55% incidence of profound pulpal
anesthesia, even in the presence of
100% lip numbness, as reported by the
patient.

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Objective tests for
anaesthesia
• Objective tests - better assess the level of
pulpal anesthesia for all teeth.
• With a preoperative baseline of the pulp
sensibility level, the use of an electric pulp
tester (EPT) and/or the application of a cold
refrigerant

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• Objectively testing the treatment tooth
with an electric pulp tester
before and after administering local
anaesthesia to determine if pulpal
anaesthesia has been achieved.

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Clinical techniques • The literature supports specific techniques for
achieving pulpal anesthesia in teeth with
symptomatic irreversible pulpitis. Successful
pulpal anesthesia
• Maxillary teeth - infiltrations on the buccal
surfaces alone. No gains in anesthesia success
are obtained through the addition of a posterior
superior alveolar nerve block or palatal
anesthesia.
• Mandibular teeth - complex.
• Mandibular anterior teeth -infiltrations alone
• Premolars - combination of mental and inferior
alveolar nerve blocks (IANBs).
• Mandibular molars require block anesthesia,
usually with the addition of an adjunctive
anesthetic technique.

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Supplementary
anaesthetic
technique
Intraligamentary and
intraosseous anesthesia
(anaesthetic solution
directly into the cancellous
space), are also effective.
When all else fails, or
when breakthrough
sensitivity occurs mid-
procedure, intrapulpal
anesthesia may be used.

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Intraosseous
• The point of penetration is
identified. It should lie in attached
gingiva and is determined by
imagining two lines perpendicular
to one another. The horizontal line
passes along the buccal gingival
margins of the teeth. The vertical
line bisects the distal interdental
papilla of the tooth that is being
anaesthetised. The site of
perforation is 2 mm apical to the
intersection of these lines

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Adjuncts to LA • Local anesthesia alone may be insufficient for
perioperative pain control in some patients.
• Additional pharmacologic agents - increase its
efficacy.
• Nitrous oxide - itself acts as an analgesic and
can improve the efficacy of local anesthetic
solutions.
• Preoperative use of oral analgesics, including
dexamethasone, NSAIDs, and tramadol, may
improve effectiveness of IANB injections in
patients with symptomatic irreversible pulpitis,
although controversy exists.
• Benzodiazepines, however, do not potentiate
the effects of local anesthetics, and should only
be expected to reduce procedure-related
patient anxiety.

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Topical anaesthetics
• Ointments, gels, pastes, sprays
• Local anesthetics are absorbed at different rates
after application to mucous membranes, in the
mucosa uptake is as rapid as with intravenous
administration.
• Eutectic mixture of local anesthesia (EMLA) has
been developed to provide surface anesthesia for
intact skin.
surface anesthesia
for intact skin.

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Recent
advances
of
LA
delivery
• DentiPatch (lidocaine transoral delivery
system)
• Preinjection – 10- 15 minutes exposure prior
to injection - Root scaling/planing – apply 5-
10 minutes prior to beginning procedure.
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• PRESSURE SYRINGE :
Used in IL injection techniques,
especially in mandibular teeth
(types: pistol-grip, pen-grip).
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Jet injection works by forcing anaesthetic through mucosa under
pressure. The head of the device is placed firmly against mucosa and
then the trigger released. This forces the solution through mucosa to
produce anaesthesia.

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Management of hot tooth
The term ‘‘hot’’ tooth
generally refers to a pulp
that has been diagnosed
with irreversible pulpitis,
with spontaneous,
moderate-to-severe pain.
A classic example of one
type of hot tooth is a
patient who is sitting in the
waiting room, sipping on a
large glass of ice water to
help control the pain.

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Intraligamentary (Periodontal Ligament)
Injection
Intraosseous Injection
Mandibular Buccal Infiltration Injection with
Articaine
Intrapulpal Injection

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Treatment itself
Performing treatment for
hypersensitivity/
endodontic treatment and/
or Pulpotomy/ Occlusal
reduction/ Trephination/I&D
Treatment can significantly
reduce pre-treatment
odontogenic pain due to
acute pulpal inflammation
and / or trauma from
occlusion/ hypersensitivity

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Post
operative
pain
control
• The most consistent predictive factor for
postoperative endodontic pain is the presence
of preoperative hyperalgesia (i.e.,
spontaneous pain, reduced pain threshold
and/or increased perception to noxious
stimuli).19

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Post-operative
pain control
• The definitive treatment of endodontic
pathology is the optimal means to alleviate
severe pain, some degree of postoperative
discomfort is normal.
• Since postoperative pain is common and to
be expected, clinicians need to warn
patients to anticipate its presence and arm
them with strategies to minimize its impact.

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Post-operative
pain control
• Oral medications, including combination
therapy with ibuprofen and acetaminophen,
are most appropriate for the management
of postoperative pain.
• Opioid class drugs are less effective and
should be avoided if possible.
• Long-acting anaesthetics like bupivacaine
are useful adjuncts to ensure pain relief
through the acute postoperative period
when pain can be most severe.
• Bupivacaine possesses properties to
provide extended analgesia even beyond
its half-life, according to studies in the
medical literature.

Conclusion
Appropriate pain
management in operative
& endodontic therapy
requires clinicians to have
a good understanding of
local anesthesia,
conventional endodontic
treatment and clinical
pharmacology. Equipped
with these clinical skills,
the dentist or specialist
will be positioned to
successfully manage the
pain reported by their
endodontic patient.

ISOLATION OF OPERATING
FIELD
Dr. Manjiri Honap
Department of Conservative Dentistry &
Endodontics

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Flowchart
• Introduction
• Goals of isolation
• Advantages of isolation
• Methods of isolation
Direct methods
Indirect methods
• Conclusion

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Methods of isolation
Direct method :
• Rubber dam
• Cotton rolls & cellulose wafers
• Dri-angle
• Gauze piece
• Suction devices
• Gingival retraction cords
• Mouth props
• Mouth mirror

What is Rubber dam
Indication/Contraindication
Armamentarium
Placement of Rubber
dam
Removal of rubber dam
Maintenance of
Clamp/Retainer
Errors in Rubber dam
placement
Few recent advances

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Rubber dam is a flat thin sheet of latex
or non latex that is held by a clamp
and a frame which is perforated to
allow the teeth to protrude through the
perforation while all other teeth are
covered and protected by the sheet.
Johannes Müller, Norman Tischer 2006 Quintessenz Verlags GmbH, Berlin
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CONTRAINDICATION

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Rubber dam Forceps
Rubber dam
retainer/Clamp
Rubber dam punch
Rubber dam Frame
Rubber dam sheet
Rubber dam armamentarium

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T
emplate:
Inked rubber stamp which helps in marking the dots on
the sheets according to the position of the tooth.
Holes should be punched according to
the arch and the missing tooth
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THIN 0.15mm/ 0.006inch
MEDIUM 0.2mm/ 0.008inch
HEAVY 0.25mm/ 0.010 inch
EXTRA HEAVY 0.30mm/ 0.012inch
SPECIAL HEAVY 0.35mm/ 0.014inch
Rubber dam sheet:

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Rubber dam punch:

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Dam forceps:

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Rubber dam retainer/ clamp:
4 prongs
2 jaws
1 bow
Clamps for the front teeth.
Clamps for the premolars
Clamps for the molars

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Wingless clamp: Winged clamp:

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Retainers with serrated jaws : tiger clamps
Stabilization of broken down teeth
S-G Silker Glickman clamp
Anterior extension allows retraction of dam around a severely
broken down teeth
Clamp is placed on a tooth proximal to one being
treated
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Rubber dam frames:

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Lubricant/petroleum
jelly
Dental floss
Wedgets Rubber dam napkin
Accessories:

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Step 1: Testing and lubricating the proximal contacts
Dental floss
Wedge
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Step 2:Punching the holes

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Methods
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1.One step technique /All in one technique
2.Two step technique
• Rubber dam clamp first method
• Rubber dam first method

All in one technique:

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Dam first method:
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Rubber dam clamp first method:

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Everting the margins:
a) The rubber dam is lying on the tooth surface and may
allow leakage.It should be everted into the gingival
crevice by the following ways:
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b) stretching the rubber away from the tooth and drying the
mucosa with a stream of cold air, before
c) using a flat plastic
instrument to tuck the
rubber into the crevice.

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Removal of Dam: Step 1: cutting the septa
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Step 2: removing the retainer

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Step 3: removing the dam
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Step 4: wiping the lips

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Step 5: rinsing the mouth and
massaging the lips
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Step 6: Examining the dam
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Cleaning of clamps after use:
Cleaning:
• Clamps should be rinsed & cleaned immediately after the procedure
• Failure to clean will decrease the life of clamp & can result in staining & corroding
• Rinse & remove excess material before ultrasonic cleaning
Allow clamps to dry
Sterilization:Important to remove excess restorative material from the clamp before sterilization as it
may damage the clamp
Autoclave – 15 min at 130°C/266°F
Inspect the clamp for wear, distortion or damage
Discard if distorted

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Errors in Rubber dam placement:
Off center arch form

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Improper distance between
the holes

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Clamps for the front teeth.
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Clamps for the premolars
Clamps for the molars
Incorrect choice of
retainer:

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Torn rubber dam
Retainer
pinched
tissue

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Split dam technique:
In this technique two holes
are punched in the dam
atleast 5mm apart that
corresponds to teeth anterior
and posterior to the teeth in
question.
The dam is then stretched
over the clamped tooth and
to the anterior tooth where
the dam is stabilized with the
wedjets.
• The dam between the holes is then
cut with scissors.

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In case of crowded teeth there is no enough space to
place the clamp in position, in such a situation rubber
dam is placed on to the tooth which is teased beneath
the contact area with the help of a floss and is
stabilized by two fragments of the dam instead of the
clamp.
Wedgets can also be used in place of dam.
Isolation for Crowded teeth:

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Modifications in designs:
Insti dam
• Natural latex dam with pre punched
holes and built in rubber frame
• Its compact size is just the right size
to fit outside the patient’s lips
• Radiographs may be taken without
removing the dam

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Handidam:
Has a built in foldable radiolucent frame and a plastic
tube inserted in prepared holes in rubber dam material to
keep the dam open.
Available in one size only

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Dry dam:
Dry Dam is a rubber dam laminated with paper on both
sides and attached straps.
Marked punch spots and the sturdy built in paper frame
makes it simple and fast to apply.
The patients lips and cheeks are protected by the moisture
absorbing paper reducing the risk of allergic reaction.

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Optra gate:
• Exclusively for isolating the upper and
lower anterior regions.
• It works by applying only lip and cheek
retraction, quadrant based.
• The device comes in three sizes and easily
placed to hold the mouth open providing
optimal anterior access.

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Cotton
rolls &
cellulose
wafers
• Available in different diameters, cut to
variant lengths & have plain or woven
surfaces
• Stabilized & held sublingually with
specific holders or with an anchoring
rubber dam clamp
• lateral to salivary gland orifices
• Cellulose wafers provide additional
absorbency

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Cotton rolls & cellulose wafers
Advantage – Slight retraction of cheeks aiding in visibility &
access
Precaution:
• Moisten the cotton rolls & cellulose wafers while removing to
prevent inadvertent removal of epithelium from cheeks, floor
of mouth or lips

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Gauze
piece or
throat
shields
• Indicated when there is danger of aspirating or
swallowing small objects, when rubber dam is
not being used
• Used in pieces of 2”x2” or larger
• Particularly important when treating teeth in
maxillary arch

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Gauze piece or throat
shields
• Gauze sponge unfolded & spread over the tongue&
posterior part of the mouth
Advantage –
• Better tolerated by delicate tissues
• Less adherence to dry tissues compared to cotton

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DRI-ANGLE
• A thin, absorbent, cellulose triangle
• Unique replacement on the cotton roll in the
parotid area
• Covers the parotid or Stensen's duct and
effectively restricts the flow of saliva
• Provides the required Dry-Field for Composites,
Bonding, Cementing

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SALIVA EJECTOR
• Saliva ejector prevents pooling of saliva
in the floor of the mouth
High volume evacuating
• equipment removes solid debris along
with water
HIGH VOLUME EVACUATOR

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TYPES OF SALIVA EJECTOR
• Metallic –
• Autoclavable
• Rubber tip to avoid irritating delicate tissues on floor of the
mouth
• Plastic – Disposable & inexpensive

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GINGIVAL RETRACTION CORD
• Used for isolation & retraction in direct
procedures of treatment of accessible sub
gingival area
• Diameter of cord should be selected such
that it is gently inserted into gingival
sulcus,
• Cord may be moistened with a non caustic
styptic before insertion (Hemodent)

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ADVANTAGES
• Help restrict excessive restorative materials from entering
the gingival sulcus
• Provide better access for contouring & finishing the
restorative material
• Prevent abrasion of gingival tissue during tooth preparation
• Used primarily to push the gum tissue away from the
prepared margins of the tooth, in order to create an accurate
impression of the teeth

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MOUTH PROP
• Can be potential aid
for lengthy
appointment on
posterior teeth
• Should maintain
suitable mouth
opening
Types –
• Block
• Ratchet

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INDIRECT METHODS
• Local anaesthesia
Drugs –
• Anti sialogogues (Atropine)
• Anti anxiety ( Diazepam)
• Local anaesthetics

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