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  1. Pain control and isolation in Operative Dentistry & Endodontics Class by Dr. Honap Manjiri Nagesh Department of Conservative Dentistry and Endodontics
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  3. Classified as Business What is pain?
  4. Classified as Business 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
  5. Classified as Business 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
  6. Classified as Business Analgesics • When definitive care cannot be delivered immediately, oral analgesics offer convenient and effective means to relieve even severe dental pain.
  7. Classified as Business 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.
  8. Classified as Business 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.
  9. Classified as Business 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.
  10. Classified as Business 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.
  11. Classified as Business 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.
  12. Classified as Business 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.
  13. Classified as Business 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
  14. Classified as Business 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.
  16. Classified as Business 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
  17. Classified as Business Available LA agents
  18. Classified as Business 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.
  19. Classified as Business 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
  20. Classified as Business • Objectively testing the treatment tooth with an electric pulp tester before and after administering local anaesthesia to determine if pulpal anaesthesia has been achieved.
  21. Classified as Business 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.
  22. Classified as Business 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.
  23. Classified as Business 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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  25. Classified as Business 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.
  26. Classified as Business 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.
  27. Classified as Business 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. 27
  28. Classified as Business • PRESSURE SYRINGE : Used in IL injection techniques, especially in mandibular teeth (types: pistol-grip, pen-grip). 28
  29. Classified as Business 29 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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  33. Classified as Business 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.
  34. Classified as Business Intraligamentary (Periodontal Ligament) Injection Intraosseous Injection Mandibular Buccal Infiltration Injection with Articaine Intrapulpal Injection
  35. Classified as Business 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
  36. Classified as Business 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
  37. Classified as Business 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.
  38. Classified as Business 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.
  39. 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.
  40. ISOLATION OF OPERATING FIELD Dr. Manjiri Honap Department of Conservative Dentistry & Endodontics
  41. Classified as Business Flowchart • Introduction • Goals of isolation • Advantages of isolation • Methods of isolation Direct methods Indirect methods • Conclusion
  42. Classified as Business Methods of isolation Direct method : • Rubber dam • Cotton rolls & cellulose wafers • Dri-angle • Gauze piece • Suction devices • Gingival retraction cords • Mouth props • Mouth mirror
  43. 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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  45. 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 45
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  48. Classified as Business CONTRAINDICATION
  49. Classified as Business Rubber dam Forceps Rubber dam retainer/Clamp Rubber dam punch Rubber dam Frame Rubber dam sheet Rubber dam armamentarium
  50. Classified as Business 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 50
  51. Classified as Business 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:
  52. Classified as Business Rubber dam punch:
  53. Classified as Business Dam forceps:
  54. Classified as Business Rubber dam retainer/ clamp: 4 prongs 2 jaws 1 bow Clamps for the front teeth. Clamps for the premolars Clamps for the molars
  55. Classified as Business Wingless clamp: Winged clamp:
  56. Classified as Business 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 56
  57. Classified as Business Rubber dam frames:
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  59. Classified as Business Lubricant/petroleum jelly Dental floss Wedgets Rubber dam napkin Accessories:
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  63. Classified as Business Step 1: Testing and lubricating the proximal contacts Dental floss Wedge 63
  64. Classified as Business Step 2:Punching the holes
  65. Classified as Business Methods 65 1.One step technique /All in one technique 2.Two step technique • Rubber dam clamp first method • Rubber dam first method
  66. All in one technique:
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  69. Classified as Business Dam first method: 69
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  71. 71 Rubber dam clamp first method:
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  73. Classified as Business 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: 73 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.
  74. Classified as Business Removal of Dam: Step 1: cutting the septa 74
  75. Classified as Business Step 2: removing the retainer
  76. Classified as Business Step 3: removing the dam 76
  77. Classified as Business Step 4: wiping the lips
  78. Classified as Business Step 5: rinsing the mouth and massaging the lips 78
  79. Classified as Business Step 6: Examining the dam 79
  80. Classified as Business 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
  81. Classified as Business Errors in Rubber dam placement: Off center arch form
  82. Classified as Business Improper distance between the holes
  83. Classified as Business Clamps for the front teeth. 83 Clamps for the premolars Clamps for the molars Incorrect choice of retainer:
  84. Classified as Business Torn rubber dam Retainer pinched tissue
  85. Classified as Business 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.
  86. Classified as Business 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:
  87. Classified as Business 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
  88. Classified as Business 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
  89. Classified as Business 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.
  90. Classified as Business 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.
  91. Classified as Business 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
  92. Classified as Business 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
  93. Classified as Business 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
  94. Classified as Business 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
  95. Classified as Business 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
  96. Classified as Business 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
  97. Classified as Business TYPES OF SALIVA EJECTOR • Metallic – • Autoclavable • Rubber tip to avoid irritating delicate tissues on floor of the mouth • Plastic – Disposable & inexpensive
  98. Classified as Business 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)
  99. Classified as Business 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
  100. Classified as Business MOUTH PROP • Can be potential aid for lengthy appointment on posterior teeth • Should maintain suitable mouth opening Types – • Block • Ratchet
  101. Classified as Business INDIRECT METHODS • Local anaesthesia Drugs – • Anti sialogogues (Atropine) • Anti anxiety ( Diazepam) • Local anaesthetics
  102. THANK YOU

Notas do Editor

  1. Ibuprpfen The maximum recommended dosage of ibuprofen is 3200 mg/day, with common dosages ranging from 400 mg to 800 mg every 4 to 8 hours.2 Major side-effects include gastrointestinal upset and are dose dependent; thus, the lowest effective dosage should be utilized.3
  2. Nonetheless, risks of misuse and addiction, and resultant rules and regulations limiting their use, suggest avoidance of these medications whenever possible.
  3. Often, the only determination made to confirm if a patient is properly anesthetized is the subjective anesthesia level, as reported by the patient. traditionally been confirmed by asking the patient if their lip feels numb, probing or sticking the gingiva around the mandibular tooth to be treated, or simply starting treatment and waiting for a patient response.
  4. In addition to verbal communication, written instructions can effectively help manage patient expectations and clearly define normal and abnormal conditions that may warrant contacting an available emergency provider.
  5. Better longevity of restorations Ergonomics Aerosol control Soft tissue protection Better RCT survival Medico legal ingestion of instrumnets