PAIN IN OPERATIVE DENTISTRY
Professor jabbar hussein
4 t h grade Conservative dentistry-441
First semester
Week 3
Date
Outline
◦ General causes of pain in operative dentistry.
◦ Different stimuli that my cause pain.
◦ Control of pain.
Objectives
◦How to avoid different stimuli that my cause pain in
operative dentistry .
◦Control of pain in operative dentistry.
Definition:
Simply, pain is an unpleasant sensation usually associated with
tissue damage.
Classification of pain:
1) Pre-operative pain.
It derives the patient to seek for dental treatment (resulted mostly from
caries and soft tissue lesions).
2) Pain during operative procedure.
Due to instrumentation and restorative procedures.
3) post- operative pain.
it may result from trauma during cavity preparation
and /or failure of restorations.
General causes of pain.
1) Hard dental tissue lesions.
2) Soft tissues lesions .
3) Instrumentation.
4) Physical and chemical irritations.
Pathological attrition causing pulp
exposure.
1) Hard dental tissue lesions: .
- Caries → The pain is coming from irritation of pulp
by acid, bacteria and their toxin.
- Erosion → The pain is result from chemical
stimuli on dento - pulpal organ.
- Abrasion → The pain is result from mechanical
wearing of enamel and exposed dentin.
- Attrition → In sever case ( pathological
attrition), may cause pulp exposure .
- Fractured or cracked tooth→ pain is result
from movement of the dentinal fluids along the
crack.
2) Soft tissue lesions :
e.g.: Ulcers, abscess, vesico-bollus lesions and gingivitis.
3) Instrumentation:
a- Hand cutting instruments.
Dull inst. require greater force applied on the tooth
structure, which will give greater compression on dentin.
Also, the area of contact will be more wide.
So, greater pressure + greater area→ more pain .
• b) Rotary instruments:
• Cutting of dentin will cause direct
cutting of viable odontoblastic process
which result in pain.
• Heat Generation→ blunt burs produce
more friction with the tooth structure and
will generate more heat → pain.
• Vibration : is an unpleasant sensation
experienced by the patient which lowers
the pain threshold .’
• → patient can tolerate vibrations of 150- 200
cycle/sec
→ vibration above 560 cps can not be tolerated.
→ vibration with high speed may cause localized
necrosis in pulp ( rebound response ).
.
4) Physical and chemical irritations:
a- Excessive dryness of the cavity may
cause dehydration, which result in
migration of odontoblastic nuclei into
the proximal ends of dentinal tubules,
and causing pain.
b- Also, heat generation during cutting will cause dryness of the
dentinal surface.
c- Any irritant antiseptics during cleaning
of the cavity will causing pain.
Different stimuli that may cause pain:
- Mechanical stimuli.
- Thermal stimuli.
- Chemical stimuli.
- Galvanic stimuli.
- Osmotic stimuli.
- Microbial stimuli.
• Chemical stimuli: results from using of chemical irritants for cleaning the cavity or from
restorative materials.
• Mechanical stimuli: are usually result from direct cutting of dento-pulpal organ and
direct impact of food on pulp or indirectly on high flexibility of remaining dentin
thickness.
• Thermal stimuli: Temperature fluctuation more than 85- 135◦F ( 26◦- 47◦ c) causes
pain as it decreases viscosity of dentinal fluid and change in hydrodynamic phenomena.
• Osmotic stimuli : Different in osmotic pressure will cause movement of the dentinal
fluid with pain production.
• Galvanic stimuli: Direct contact between two dissimilar metallic restorations will result
in galvanic shock and cause pain.
• Microbial stimuli : result from dental caries.
Diagnosis of pain :
The main goal of diagnosis is to identify the
cause of discomfort or pain. This can be
achieved by collecting subjective (symptoms)
information from the patient and objective
(signs) from the clinical examination of oral
cavity with appropriate tests . After taking the
personal data and medical review the patient
should be asked about : -------------------
1) the onset and duration of pain.
2) the stimuli that cause pain.
3) the spontaneity of the pain.
4) the character of pain.
5) factors that relief the pain.
Examples :
- pain with thermal stimuli specially with cold, disappearing
after remove of stimulus, indicate pulp hyperemia
(reversible pulpitis).
- on the other hand if it continuous more than 2 minutes, it
indicate acute pulpitis
• Preliminary diagnosis can develop from the previous
information. To confirm diagnosis the following tests may
done:
- Percussion test : give idea about the condition of the
periodontal ligaments.
- Palpation test : To determine any tenderness in the
apical region.
- Vitality pulp testing: ( electric & thermal):
determine that tooth is a vital or not.
- Cavity test : when prepared the cavity without anesthesia,
and the patient no felt pain
.
Control Of Pain
Techniques of pain reduction:
1- Surface anesthesia.
2- Local anesthesia.
3- Sedation.
4- Hypnosis.
5- General anesthesia
1- Surface anesthesia :
Used with very apprehensive patient which may be fear even from the
needle puncture itself
*Management of such apprehensive patient:
In the first visit the following stages should be done :
- Encourage the patient to site on the dental chair.
- Examination without instruments.
- Examination of teeth using mirror.
- Polishing of teeth by soft rubber cup.
- Examination by probe.
- Local anesthesia in area that has relatively less sensation.
2- Local anesthesia.
Is the safest and most effective way in achieving painless procedures.
Contraindications:
1- Cardiovascular disease: →The vaso-constrictor in anesthetic
solution should be kept to minimum or completely eliminated.
2- Hyperthyroidism: → anesthesia without vaso-constrictor.
3- Allergies: → un-commonly, some patients has allergy
to anesthetic drugs.
4- Emotional instability and past history of unpleasant
experience. Premedication should be required and patient
confidence should be gained.
5- Trismus and hand-capped patient: → G.A. is usually indicate.
N.B.: Infiltration anesthesia is contraindicate with periodontitis,
acute suppurative infections and periapical acute lesions. Because
injection may aggravate this condition.
3) Sedation:
- As mentioned, sedation is useful for management of
apprehensive and uncooperative
patients.
Routes of administration:
→ 1- orally. 2- Intra-venous. 3- Inhalation.
4) Hypnosis.
5) General anesthesia: used to control
behavioral problems of some local or systemic
conditions.
