Pain Control

By : Dr.Zoha Wisal Khan

Hot tooth management
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
Anesthetizing the tooth
 The use of an electric pulp tester (EPT) and/ or the
application of a cold refrigerant have been shown
to accurately determine pulpal anesthesia in teeth
with a normal pulp before treatment.
 However, in teeth diagnosed with a hot irreversible
pulpitis, a failure to respond to the stimulus may
not necessarily guarantee pulpal anesthesia. The
patient may still report pain during treatment.
. Teeth with necrotic pulp chambers but whose
root canals contain vital tissue may not be tested
using the before mentioned means. In these cases,
testing for pulpal anesthesia of the neighboring
teeth may give the clinician an indication of the
anesthetic status of the tooth to be treated
 the case of a severe irreversible pulpitis in which
the conventional IANB using 2% lidocaine with
1:100,000 epinephrine achieves lip numbness but
not pulpal anesthesia; changing the LA or the inj
technique donot guarentee success
 Inaccuracy of the IANB injection has been cited as
a contributor to failed mandibular pulpal
anesthesia. But needle deflection, direction of the
needle bevel,inc volume of LA,presence of an
accessary nerve do not have any affect on success
or failure of Pulpal anesthesia
 Slow speed of inj however has better results than
fast speed but not in the case oh hot tooth
 The central core theory states that the outer nerves
of the inferior alveolar nerve bundle supply the
molar teeth, whereas the nerves for the anterior
teeth lie deeper. Anesthetic solutions that are
currently used may not be able to diffuse into the
nerve trunk to reach all the nerves and provide an
adequate block, which explains the difficulty in
achieving successful anesthesia for mandibular
anterior teeth
Hot tooth and difficulty in
achieving anesthesia
 One theory to explain this is that the inflamed tissue
has a lowered pH, which reduces the amount of the
base form of anesthetic needed to penetrate the nerve
sheath and membrane. Therefore, there is less ionized
form of the anesthetic within the nerve to produce
anesthesia. This theory may explain only the local
effects of inflammation on the nerve and not why an
IANB injection is less successful when given at a
distance from the area of inflammation (the hot tooth).
 Another theory is that the nerves arising from the
inflamed tissue have altered resting potentials and
reduced thresholds of excitability. It was shown
that anesthetic agents were not able to prevent the
transmission of nerve impulses because of the
lowered excitability thresholds of inflamed nerves
 Other theories have looked at the presence of
anesthetic-resistant sodium channels and the
upregulation of sodium channels in pulps
diagnosed with irreversible pulpitis.
Supplemental injections
Intraosseous anesthesia:

 Placement of LA directly in the cancellous bone

adj to the tooth
 Only when supplemental anesthesia is necessary
 Quicker onset, shorter affect.
 Lido+mepivacaine+vasoconstrictors (60mins)
 3% mepivacaine results in shorter anesthetic
duration and doesn’t inc HR
 Bupivacaine doesn’t increase duration of pulpal
anesthesia, just IAN
 Inj given on the distal side except max and mand
molars
 IO inj causes tachycardia which comes to baseline
in 4 mins
 Inj should be given slow to avaid massive increase
in HR
 Stabident system vs X-tip ; attached gingiva vs
alveolar mucosa

 Post operative problems

X-Tip
Failure due to:
 Backflow of LA from the perforation site
 Constricted cancellous spaces may limit LA
distribution around apices of teeth
 Excessive torquing of the perforator may result in
breakage
Intraligamentary Anesthesia

 An IL inj forces LA through the cribriform plate into

marrow spaces around tooth, it should be considered
an IO inj
 Given If conventional method is unsuccessful
 Inject with strong back pressure
 Success rates are lower in anteriors
 Duration of anesthesia is approx 10-20 mins
 A vasoconstrictor increses its efficacy
 A computer assisted LA delivery system is introduced
to minimize the inj discomfort and ensure an exact
known amount of LA delivered fast
rate(1.4ml/min)

slow rate(0.3ml/min)

o Anesthesia slowly decreases over 60 mins

o PostOp – tooth feels ‘high’ in occlusion
o IL inj doesn’t increase HR
Adverse effects:

o Small clinical risk of periodontal abcess formation

o Deep pocket formation
o Localized areas of root resorption
 Pain management strategies
Considerations for effective ‘three D’ pain control:
1. Diagnosis
2. Definative dental treatment
3. Drugs
 Pretreat with NSAIDS or acetaminophen
 Use long lasting LA when indicated
 Use a flexible prescription plan
 Prescribe ‘by the clock’rather than as needed
THANKYOU!