This document discusses sedation and pain control in dentistry. It covers strategies for managing pain before, during, and after dental procedures. For pre-operative pain control, it recommends oral sedation with benzodiazepines or barbiturates and preoperative analgesics like NSAIDs. During procedures, it suggests IV sedation with benzodiazepines, nitrous oxide, and local anesthesia. Post-operatively, analgesics like opioids and NSAIDs may be prescribed. The document provides details on specific drugs, techniques, and managing failures of local anesthesia. It also discusses approaches for non-odontogenic pain conditions like trigeminal neuralgia, TMJ pain, and atypical facial pain.

1. Sedation and Pain Control in
Dentistry
Iyad Abou Rabii
DDS. OMFS. DU. MRes. PhD

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Welcome
Bienvenue
Willkommen
Benvenuto
Bienvenida
yôkoso
tervetuloa
welkom

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Please mute
Your cell!

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Are we doing our best to help
our patients to
get red of their pain?
Can we do more?

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DATE Duration
Slides
49 1 hour
Let us try to answer this
16/11/2010

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Yes or No
The Dentist is the best judge of pain.
A person with pain will always have obvious signs such as moaning,
abnormal vital signs, or not eating.
Addiction is common when opioid medications are prescribed.
Morphine and other strong pain relievers should be reserved for the late
stages of dying.
Morphine and other opioids can easily cause lethal respiratory
depression.
Pain medication should be given only after the resident develops pain.

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Yes or No
The Dentist is the best judge of pain.
A person with pain will always have obvious signs such
as moaning, abnormal vital signs, or not eating.
Addiction is common when opioid medications are
prescribed.
Morphine and other strong pain relievers should be
reserved for the late stages of dying.
Morphine and other opioids can easily cause lethal
respiratory depression.
Pain medication should be given only after the resident
develops pain.
No
No
No
No
No
No

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Sarah has presented at your office
reporting severe pain that kept her
awake all night. She denies any
contraindications to NSAIDs.
After examination, you find the
patient is suffering from
irreversible pulpitis with acute
apical periodontitis, and a root
canal procedure is initiated.
This patient may will experience
some post-appointment pain due
to continued inflammation of the
periapical tissues.

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• NO apparent factors for
odontogenic pain,
• No consistent relief of pain by
local anesthetic.
• Bilateral pain or multiple painful
teeth.
• Pain that occurs with a
headache.
• Increased pain associated with
palpation of trigger point or
muscles, emotional stress,
physical exercise, head
position, etc.
• Presence of etiologic factors
for an odontogenic origin, (e.g.
Caries, leakage of
restorations, trauma, fracture).
• Responsive to dental
treatment
• Pain reduction by local
anesthetic.
• Unilateral and localized pain.
• Sensitivity to temperature.,
percussion , and digital
pressure.
Pain in dental clinic
Non-odontogenic
Odontogenic

22. During
Intervention
Preoperative
Pain
Post-Operative
Pain Control Strategy

23. Pain
Preoperative
During
Intervention
Post-Operative
Pain Control Strategy

24. Pre-operative
 Oral Sedation
 Preoperative Analgesics
SCENE
Pain Control Strategy

25. During the Intervention
• IV Sedation
• Nitrous Oxide
• Local Anesthesia
SCENE
Pain Control Strategy

26. Post-opertaive
• Analgesic Prescription
• Opioids
• Non-opioids
SCENE

27. Pre-operative procedures

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Oral Sedation
 Happy pills
 Before the appointment,

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Oral Sedation : Drugs Used
 Anti-Anxiety Pills (Benzodiazepines or "Benzos")
 "Sleeping pills" (Barbiturates)
 Antihistamines

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Preoperative Analgesics
 Pre-treating patients with NSAID's
delays the onset of post-operative
pain and reduces its magnitude
when it does occur.
 Pretreatment with
acetaminophen is not effective.
 Aspirin in not used for this
purpose since it can increase
bleeding.

31. During Surgical or Dental
Intervention

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IV Sedation
 Anti-anxiety variety, is administered into the blood system during dental
treatment
 Safe
 The drugs which are usually used for IV sedation are not painkillers

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IV Sedation : Drugs Used
– benzos
– Barbiturates(sleep-inducing drugs)
– Opioids
– Propofol

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IV Sedation : Caution and Contraindication
– contraindications include pregnancy, known allergy to benzos, alcohol
intoxication, CNS depression, and some instances of glaucoma.
– Cautions include psychosis, impaired lung or kidney or liver function, and
advanced age. Heart disease is generally not a contraindication

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Nitrous Oxide
 Referred to as laughing gas or
sweet air
 Useful for fearful patients as well as
young children
 After the patient is relaxed and
sedated, the dentist can
comfortably give the injection or
proceed to dental treatment

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Nitrous Oxide: Contraindications
– Some chronic obstructive pulmonary diseases
– Severe emotional disturbances or drug-related dependencies
– First trimester of pregnancy
– Treatment with bleomycin sulfate

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Local Anesthesia

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Local Anesthesia : Choice of Drug and Technique
 1-According to procedure (expected duration, the surgical procedure
tissue’s implication)
 2- According to the patient physiological and pathological situation

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Failure of Anesthesia
Pathological causes
Psychological causes
Anatomical causes
Operator dependent

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Failure of anesthesia
 Psychological causes of failure
 Pathological causes of failure of anesthesia
– Factors precluding access
– Inflammation

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Failure of anesthesia
 Anatomical causes of failure of anesthesia
– Soft-tissue analgesia is more easily obtained, needing a lower degree of
penetration of solution into nerve bundles, than does analgesia from pulpal
stimulation.
– A numb lip does not indicate pulpal anaesthesia.
– Accessory nerve supply
– Barriers to anaesthetic diffusion
– Dense compact bone can prevent a properly given infiltration from working.
Counter by using intraligamentary or regional LA.

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Accessory nerve supplies

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Failure of anesthesia
 Operator dependent causes of failure of Anesthesia
– Choice of LA
– Poor technique
• inadequate volume of LA.
• Injection into a muscle (will result in trismus which resolves spontaneously).
• Injection into an infected area (which should not be done anyway as this
risks spreading the infection).
• Intravascular injection; clearly of no analgesic benefit. Small amounts of
intravascular LA cause few problems.

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Management of failure of Anesthesia
 A technique suggested for patients who have experienced local anesthetic
failure in the mandible is
Intraligamentary injection of 0.2ml lignocaine with adrenaline per root.
Buccal and lingual infiltrations adjacent to the tooth of interest using around 1.0
ml of lignocaine and adrenaline
Repeat inferior alveolar and lingual block injection using 3% prilocaine with
0.03IU/ml felypressin
Conventional inferior alveolar and lingual block with lignocaine and adrenaline
(1.5ml), followed by long buccal nerve block with remainder of cartridge.

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Failure Management : Mandible

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Management of failure of Anesthesia
 A technique suggested for patients who have experienced local anesthetic
failure in the maxilla is
Intraligamentary injection of 0.2ml lignocaine with
adrenaline per root.
Nerve bloc : posterior superior, infraorbital
Buccal and palatal infiltration
Buccal infiltration

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Failure management : Maxilla

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Important general points
 Nerve trunks Thickness
 In nerve trunks autonomic functions are blocked first, then sensitivity to
temperature, followed by pain, touch, pressure, and motor function.
 Soft tissue anesthesia is reached before the levels needed for pulpal
anesthesia, which takes several minutes and will wear off first

49. Post-operative procedures

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Analgesic Prescription
 Ceiling effect
– The term ceiling effect has two distinct meanings, referring to the level at
which an independent variable no longer has an effect on a dependent variable
– In case of Analgesics, a ceiling effect in treatment, is pain relief by some kinds
of Analgesics drugs, which have no further effect on pain above a particular
dosage level

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Types of Analgesics
– Opioid
• Morphine
• Tramadol
– Non-opioids
• acidic analgesics
– Salicylic acid derivatives
– Acetic acid derivatives
– Propionic acid derivatives
– Anthranilic acid derivatives
• non-acidic analgesics
– Aniline derivatives
– Pyrazolone derivatives

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Types of Analgesics
 COX-2 selective NSAIDs
 Nimesulide
 Celecoxib
 Etoricoxib
 Parecoxib
 Valdecoxib
 Rofecoxib

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Types of Analgesics

54. Non-odontogenic Pain

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Trigeminal Neuralgia
– Non-analgesic drug (Carbamazepine) give excellent results in
the treatment of Trigeminal Neuralgia
– Dose
• 100 mg twice daily
• No improvement: the dose is increased to 200 mg four time a
day
• No improvement : Dose can be augmented until 1600 mg a day
with (monitoring of plasmatic concentration of the drug should be
achieved regularly)
– If with such dose there is no improvement then Phenytoin
is used (150 to 300 mg daily)

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TMJ Pain
 Diazepam has both sedative and muscle relaxant effects, so it is helpful if
the origin of the trismus is psychotic
 In other cases the use of Paracetamol 250 mg in combination with
Chlorzoxzson (muscle relaxant ) 300 mg is recommended 4 times daily.

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atypical facial pain
 The use of Tricyclic antidepressant looks helpful (Amitriptyline)
 Anyway the prescription of such drugs should not be done by a dentist

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1
2
3
Long acting local anesthetics
Precise estimation of the pain
Use the right analgesic
Conclusion
6
5
4
Profound local Anesthesia
Removal of the cause
Accurate Diagnostic

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Pain management schema

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What about Sarah ?

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Thank you for
your attention!
Any Questions?

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Contact Details
Dr. Iyad Abou Rabii
+33612198442
+966532758000
www.facebook.com/iarabii
www.Twitter.com/iarabii
www.Scribd.com/iyad abou rabii
Email
iyad@wanadoo.fr
Iyad.abou.rabii@qudent.edu.sa