Future Trends In Pain Control

1. Presented by: Stéphanie Chahrouk

2. Introduction
Although local anesthesia remainsthe backboneof pain controlin dentistry,
research continues in both medicine and dentistry with the goalof improving all
areas of the localanesthetic experience, from that of the administrator to that of
the patient.
Much of this research hasfocused on improvements in the area of local
anesthesia—safer needles and syringes; moresuccessful techniques of regional
nerve block, such as the anterior middle superior alveolar (AMSA) and palatal
anterior superior alveolar (P-ASA)); and newer drugs, such as articaineHCl.
intraosseousanesthesia ,self-aspirating, pressure, and safety syringes and
computer-controlled localanesthetic delivery (C-CLAD) systems; and articaineHCl.
These drugs, devices, and techniques are nowa part of the mainstream of pain
controlin the world.

3. Buffered Local Anesthetics (The local anesthetic “on” switch)
With the introduction of the first amide local anesthetic (LA), lidocaine HCl, in 1948,
providing profound anesthesia of long duration became almost a certainty. Other
amides introduced since 1948 include mepivacaine HCl, prilocaine HCl, bupivacaine
HCl, etidocaine HCl, and articaine HCl (the latter is considered an amide, although
technically it is a hybrid drug, possessing both amide- and ester-type characteristics).
Onset of pulpal anesthesia commonly occurs within 5 to 10 minutes and persists for
approximately 60 minutes with articaine HCl, lidocaine HCl, mepivacaine HCl, and
prilocaine HCl formulations containing a vasopressor (epinephrine or levonordefrin).
Local anesthetics work. They represent the safest and most effective drugs in
medicine for the prevention and management of pain. If deposited in close proximity to
a nerve, they will block nerve conduction.

4. Recent Findings—Mandibular Infiltration With Articaine
HCl
Since the introduction of articaine HCl 4% with epinephrine 1:100,000 in the United
States in June 2000, numerous anecdotal reports have been received from doctors
claiming that they no longer needed to administer the IANB to work in the adult
mandible painlessly. They claimed that mandibular infiltration with articaine HCl was
uniformly successful.
I-ARTICAINE:
Advantages
Fasteronset &longerduration ofaction
Highersuccess rate
Systemic intoxicationis low
Increaseddiffusioninto tissuesincludingbone
Volume = 1.7 times> volume needed to that of
4% articaine comparedto 2% lignocaine
Disadvantages
Cause methemoglobinemia &neuropathies
High incidence of paresthesia{mostlywith
lingualnerve}
Ocularcomplications{forInfra OrbitalNerve
Block}
Belongs to amide
group of LA
Consists of
thiophene ring
Half life = 20mins
Metabolism : liver
& plasma{plasma
esterase}

5. II-Centbucridine (a quinoline derivative)
 “It has proved to be five to eight times as potent a local anesthetic as lidocaine,
with an equally rapid onset of action and an equivalent duration.”
 “Of potentially great importance is the finding that it does not adversely affect the
CNS or CVS, except in very high doses.”
 It’s a quinolone derivative

Advantages
0.5% Concentration[4-5timespotent
than 2% lignocaine]iseffective for
infiltration,nerve blockandspinal
anaesthesia
Longerdurationof action
Its topical actionisconcentration
dependent
Disavantages
failure indental uses

6. III-PHENTOLAMINE MESYLATE
 Phentolamine mesylate is an alpha-adrenergic antagonist
o that, when injected into the site where local anesthetic with vasopressor
was previously deposited, produces vasodilation, increasing blood flow
through the area, increasing the speed with which the local anesthetic drug
diffuses out of the nerve.
 The duration of residual soft tissue anesthesia is significantly reduced.
 Phentolamine mesylate has been approved by the Food and Drug Administration
(FDA) for use in patients 6 years of age and older and weighing more than 15 kg
Used for reversalof effects of LA
solution
Itis a non selective alpha adrenergic
blocking agent
Half life = 2-3 hrs Peak concentration
0.4mg/1.7ml[after
20mins]

7. Disadvantages
• Diarrhea,
• facial swelling
• hypertension
• jaw&oral
pain,tenderness,vomitting
Advantages
• Prevent post-operative
anaesthesia induced
injuries

8. NEWER DRUG
DELIVERY
SYSTEMS FOR
LOCAL
ANAESTHESIA
Electronic
Dental
Anesthesia-
EDA
Intra-oral
Lignocaine
Patch-
Dentipatch
Jet Injection
IontophoresisEMLA
Computer
Controlled
Local
Anesthetic
Delivery
Devices –
CCLAD
Intra-osseous
Systems –IO
systems

9. This technique involves the use of the principle
ofTranscutaneous Electrical Nerve Stimulation
(TENS) which has been used for the relief of pain
Used as a supplement to conventional local
anesthesia
ElectronicDental
Anesthesia
Increased salivary flow and
inability to usemetal
instruments freely
Limitations:
Heart disease, seizures,
neurological disorders, brain
tumors, patients wearing
pacemakers and cochlear
implants
CONTRAINDICATIONS:

10. A patch that contains 10-20% lidocaine is placed on the dried
mucosa for 15 minutes.
Hersh et al (1996) studied the efficacy of this patch and
recommended it for use in achieving topical anesthesia for
both maxilla and mandible
(Dentipatch):

11. Jet injection is based on the principle that liquids forced through very small openings, called
jets, at very high pressure can penetrate intact skin or mucous membrane (visualize water
flowing through a garden hose that is being crimped).
small amount of local anesthetic is propelled as a jet
into the submucosa without the use of a hypodermic
syringe/needle from a reservoir
This technique is particularly effective for palatal
injections
Jet Injection:

12. This technique first introduced in 1993 is a
suitable alternative for application of drug in
achieving surfaceanesthesia
It is a painless modality of
administrating anesthesia
Iontophoresis

13. EMLA (eutectic mixture of local anesthetics)
 It is a combination of lidocaine and prilocaine,
 designed to provide cutaneous anesthesia before venipuncture,
 has been employed in dentistry with some degree of success
It contains a mixture of lignocaine and prilocaine bases, which
forms an oil phase in the cream and passes through the intact
skin
Clarke et al in 1986 suggested the use of EMLA
cream for anesthetizing the skin prior to needle
insertion as this reduces the incidence of injection
pain
It is used more often for skin than intra
orally
EMLA

14. Small battery-operated attachmentthat snaps on to the
standard dentalsyringe
Vibraject

15. It is a cordless, rechargeable, hand held device that delivers
soothing, pulsed, percussive micro-oscillations to the site where an
injectionbeingadministered.
Stimulates the sensory receptors at the injection site,
effectively closing the neural pain gate, blocking the painful
sensation.
DentalVibe

16. C-CLAD Systems (Computer Controlled Local Anesthesia Delivery System):
 C-CLAD systems represent a significant change in the manner in which a local anesthetic
injection is administered.
 The operator is now able to focus attention on needle insertion and positioning, allowing
the motor in the device to administer the drug at a preprogrammed rate of flow.
 It is likely that greater ergonomic control coupled with fixed flow rates is responsible for
the improved injection experience demonstrated in many clinical studies conducted with
these devices in dentistry.

Cordlessdevice thatusesbothvibrationandpressureto
preconditionthe oral mucosa.
Accupal providespressure andvibratesthe injectionsite 360°
proximal tothe needle penetration,whichshutsthe “pain
gate.”
Accupal

17. Milestone Scientific introduced the first CCLAD system in 1997 and
was termed the “WAND” and the subsequent versions were renamed
as “WAND PLUS” and “COMPUDENT”.
In 2001, DENTSPLY International introduced the “Comfort Control
Syringe – CCS” and similar devices originating outside USA were;
“Quick Sleeper, Sleeper & One from France, “Anaeject” and
“Orastar” from Japan.
CCLAD Systems (Computer Controlled
Local Anesthesia Delivery System):

18. Base unit, Foot pedal and DisposableHandpiece
assembly.
•Base unit consists of a microprocessorand connects to the footpedal
and Handpiece assembly that accepts the LA cartridge.
•LA solution fromthe cartridgepasses through the microboretubing in
the Handpiece assembly and attached needle into the target tissue.
“Wand” has 3 components:

20. Introduced by MilestoneScientific in
2007.
“SingleTooth Anesthesia
System – STA System”
The STA System device with dynamic pressure-sensing technology
provides an objective means by which to identify the correct target
location to perform a PDL injection, improving the predictability of
this injection when compared with previous techniques and
instruments.
uses a controlled low-pressure fluid dynamic to reduce
the risk of tissue injury and to minimize subjective pain
responses.
allows a greater volume of anesthetic solution
(0.45 mL to 0.90 mL) to be safely administered,
thereby increasing the effective working time of
this PDL injection (30 to 45 minutes).
The STA System device with dynamic pressure-
sensing technology can detect local anesthetic
solution leakage into the patient's mouth, avoiding
an unpleasant taste
The STA System device with dynamic pressure-
sensing technology can detect excessive
pressure and can safeguard patient and
operator from glass cartridge breakage.
Dynamic Pressure Sensing – DPS‟
which provides continuous feedback
to the user about the pressure at the
needle tip to identify the ideal
needle placementforPDLinjections.
Advantages Of The
STA System device

21. Rate of Injection of STA
 3 modes to control the rate of injection :
Failure of anesthesia: Inability to generate STA System in the
high yellow or green LED zone. In this case, remove and reenter
at a different site(s) until the STA System can generate and
maintain the proper DPS outcome.
Requires the use of a specialized C-CLAD instrument and
associated costs of purchase and use
Requires additional training
Disadvantages of STA
1. STA mode:Single,slow
rate of injection
2. Normal mode:emulates
the Compudentdevice
3.Turbo mode:fasterrate of
injection –0.06ml/s

22. Consistsof twocomponents;base unitandsyringe.
The most importantfunctionsof the unit(injectionand
aspiration) canbe controlleddirectlyfromthe syringe.
USES: restorations,pulpaltherapies&extractionsinpediatric
dentistry.
Comfort Control Syringes

23. Intraosseous Anesthesia
 IO anesthesiainvolvesthe depositionof local anestheticsolutionintothe cancellousbone that
supportsthe teeth.
 Althoughnotnew(IOanesthesiadatesbackto the early1900s), a resurgence of interestinthis
technique indentistryhasoccurredoverthe past 15 years.
 the use of intraosseousanesthesiagreatlyincreasessuccessratesinmandibularmolars.
 Newtechniquesare nowavailable

The use of motor drivenperforatortopenetrate the buccal
gingivaandbone can be consideredasthe firstmoderntechnique
of IOanesthesia.
The devicesusedforthistechnique,injectthe solutionintothe
cancellousbone adjacenttothe rootapex.
Intra-Osseous Anesthesia:
i.Stabident
ii. X –Tip
iii. Intraflow
Commonly used
devices are:

24. Stabident:
It includes a solid 27 gauge perforator needle with a beveled
tip and a plastic base which fits a latch type slow speed
contra-angle handpiece.
This perforator creates a small tunnel through attached
gingiva, periosteum and alveolar bone.
The angle of perforation is usually directed apically in the
mandibular incisor region whereas a more perpendicular angle is
advantageous in the molar region
Later a 27 gauge ultra-short needle is used to deposit the local anesthetic solution.

25. X –Tip:
This system consists of three parts; the drill/perforator, 25 gauge guide
sleeve that fits over 27 gauge drill and ultra-short 27 gauge needle.
The drill leads the guide sleeve through the cortical plate into the
cancellous bone.
The drill portion is removed, leaving the guide sleeve in place, which directs
the needle into the cancellous bone to deposit the LA solution.
Later the guide sleeve is removed with a hemostat.
Intraflow:
“ALL IN ONE”SYSTEM that allows the operator to
perforate the bone and deposit the anesthetic
solution inasingle step.
The device is a dental handpiece equipped with an injection
systembuiltintoitsbody.
A 24 gauge hollow perforator is used to penetrate the bone and infuse
the LA solution.
The anesthetic solution from the cartridge is routed to the perforator by a disposable
transfuser that also serves to cover the switch used to select between the perforator
rotationand anestheticinfusionmodes.

27. Clinical uses of IO Anesthesia:
Most common application is for Single tooth anesthesia.
It can also be used as a primary method of pain control or
as a supplementary technique in refactory cases.
These systems help to achieve profound anesthesia in cases of
irreversible pulpitis of lower molar teeth.
It also helps in treating children and adolescents due to its quick onset
of action, limited duration and minimal collateral anesthesia
Side effects and Complications of Intra Oral Anesthesia:
1.Tachycardia,hencethis should be avoided in patients at risk of cardiovascular
diseaseparticularly when used with a vaso-constrictor
2. Separation of perforator drill / needle from its plastic holder.Thishappens
when the perforation is difficultor the drill heats up from overuse
3. Overheating of bone and maceratingof overlyingsofttissuemay causepain,
swellingand localized injections
4.Post injection hyper-occlusion,pain and chewingsoreness areother symptoms
reported
5.Dentinal tooth damage and osteonecrosis of bone may rarely occur after IOA injection.

28. NEWER METHODSOF SEDATION
Used for dental implantationwith screw implants orforthe
alveolar ridge augmentation with biocompatible materials
A total of 90% of the patients experienced no pain duringthe
operation(rated at 1 point)

29. 1-Needleless Internasal Spray
It isformulatedinapre-filled,single-use nasal sprayer:6mg tetracaine HCl and 0.1 mg
oxymetazolineHCl (equivalentto5.27 mg tetracaine and0.088 mgoxymetazoline) ineach0.2 mL
spray.
Patientsnoticedthattheirupperteethfeltnumb,whichledtointerestforapplicationof thistype
of anesthesiafordentistry.
2-Syringe MicroVibrator(SMV)
Thisdevice isa promisingbreakthroughinpainandanxietymanagement
and maydeliversolutionforcliniciansplaguedwithpatientpainphobia
By creatingmicrovibration,thisdevice wouldbe effectiveinreducingthe pain
and anxietyconfrontedwithmosttypesof intraoral injectionsaspalatal,
mandibularblock,intraligamental andlocal infiltration
It isalso more useful forpediatricpatientsandthose whohave aphobiaof
intraoral injectionorpain

30. Components:
a) stainless steel shell containing motor and eccentrically
weighted plate
b) power switch
c) stainless steel cap
d) four flexible attachment arms for firm attachment and
shell concavityforwell adaptation on syringe barrele)

31. References:
 HANDBOOKof Local Anesthesia6th
edition
 HANDBOOKOF Local Anesthesia.5thedition
 TEXT BOOKOF MEDICINE:DAVIDSON
1. Acupuncture
2. Placebos
3. Ultrasound
4. Deep heat
5. Massage
6. Hypnosis
7. Physical activity
8. Exercises
9. Counselling
•A doctor should be aware of the physiological and psychological
aspects of pain and anxiety as it applies to the patient.
•Adequate clinical assessment and diagnosis are the keys to
successfully managesuch painfulconditions.