Lecture 2 ‫ انس فالح مهدي‬.‫د‬.

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Pain Control in Endodontic

Pain:
It is unpleasant and distressful body sensation which could be resulting from injury or disease.
Noxious stimuli in teeth are transmitted in primary afferent “nociceptive” (pain-detecting)
sensory neurons located in the trigeminal ganglion and their nerve axons terminated in the
dental pulp. Regardless of the nature of the sensory stimulus (i.e., thermal, mechanical,
chemical, electric), almost all afferent impulses generated from pulp tissue result in the
sensation of pain.
The tooth is innervated by a large number of myelinated (mainly Aδ (delta)) and
unmyelinated (C fibers) sensory axons. Both fiber types are nociceptors. C fibers in dental
pulp are generally 3 times higher in numbers that A fibers.
Aδ fibers are myelinated and larger in diameter, principally concentrated near pulp-dentin
complex and they can transmit sharp, instant and intermittent pain feeling.
C-fibers are unmyelinated smaller in diameter, distributed within the pulp with higher
concentration near pulp-dentin complex. Pain transmitted by these fibers is characterized by
burning, and aching sensation.

*Samir et al (2023)
In addition, these fibers can be stimulated during inflammation to release neurotransmitters
such as substance P and calcitonin gen related peptide (CGRP). These neurotransmitters can
cause vasodilatation which increase the pulp volume and this can increase the pressure on the
nerve ending intensifying the pain sensation. This process is called neurogenic inflammation.
The pain reaction threshold (PRT) is that point at which a person can feel pain. With
endodontic therapy hyperresponse to stimulation is significantly increased.
Factors that lower the PRT include:
1- Presence of pain in the beginning of treatment.
2- Fatigue.
3- Fear and anxiety.
By increase of pain sensation, blood level of catecholamine suddenly elevates with an
increase in blood pressure and heart rate. This might induce fainting, angina pectoris, asthma
and psychiatric reactions. To reduce the possibility of such conditions happening the
anesthesia has to be introduced slowly and in supine position.
Correct diagnosis of the etiological factors of pain and proper treatment of the problem
relieves pain in many cases.

Local anesthesia
It is the temporary loss of sensation or pain in a certain part of the body produced by a
topically applied or injected agent without depressing the level of consciousness. Prevention
of pain during dental procedures eliminates fear and anxiety.
Knowledge of the anatomy prevents problems during anesthetic injection such as muscle
trismus, hematoma and intravascular injection.
There are 2 general types of local anesthetic chemical formulations:
1- Esters as procaine, benzocaine.
2- Amides as lidocaine, mepivicaine, prilocaine and articaine.

Mechanism of action:
The primary action of the local anesthetic agent is to decrease the nerve permeability to
sodium (Na+) ions, thus preventing the inflow of Na+ ions into the nerve. This interferes with
sodium conductance and inhibits the propagation of impulse along the nerve fibers.
Movement of Na+ ions is permitted through Na channels which are called voltage-gated
sodium channels (VGSCs). Therefore, the local anaesthesia molecules block VGNCs on the
nerve membrane and prevent the generation and conduction of nerve action potential.
Local anesthetics are vasodilators, absorbed in the circulation and have a systemic effect
directly to the blood plasma level. Vasoconstrictors in the local anesthetic constrict the blood
vessels to lower the local absorption into the blood stream to prolong the anesthetic effect in
the working area and decreasing the possibility of toxicity. It is also used to decrease the
bleeding by infiltration of few drops in the bleeding area.
The condition of patients with hyperthyroidism, cardiovascular disease, diabetes and having
drugs as tricyclic antidepressants and MAO inhibitors need a consultation with the physician
before injection with a local anesthetic having vasoconstrictor.
If the local anesthetic is injected in an infected area, its onset will be delayed. The
inflammatory process in an area of infection lowers the pH of the extracellular tissue from its
normal value to 5-6 or lower. This low pH inhibits anesthetic action because little of the free
base form of the anesthetic is allowed to cross into the nerve sheath to prevent conduction of
nerve impulses. In addition, inserting a needle into an active site of infection may spread the
infection. Therefore, alternative nerve block injections can be used to prevent this
complication.
Traditional methods of confirming anesthesia usually involve questioning the patient, probing
the soft tissue, and/or starting treatment and waiting for the patient’s reaction. These
approaches may not be effective for determining pulpal anesthesia. The effective way to
detect onset of pulpal anesthesia is by doing pulp testing. The negative response means
positive pulpal anesthesia
Topical anesthesia:
It is effective to minimize surface discomfort of injection of the needle (2-3 mm in depth).
This anesthetic is composed of benzocaine (up to 20%) or lidocaine as solution or ointment
(5%) or spray (up to 10%).

Techniques for mandibular anesthesia

1- Inferior alveolar nerve block.
The site of deposition is near the mandibular foramen before the entry of the inferior alveolar
nerve. It anesthetizes the mandibular teeth on the side of injection. The lingual nerve also can
be anesthetized in the same injection with their innervated regions (lingual mucosa and
tongue). However, the buccal mucosa cannot be anesthetized.
Administration of a conventional IAN block to asymptomatic patients using 1.8 mL of 2%
lidocaine with 1:100,000 epinephrine would provide pulpal anesthesia within 15 minutes that
lasts for 1 hour.
Research also found that administration of a two-cartridge volume was significantly better for
avoiding a missed block than a one-cartridge volume in asymptomatic subjects.

Fig1: Inferior alveolar nerve block

2- Mandibular nerve block.
It is a V3 (mandibular) nerve block anesthetizing all the mandibular teeth in the region with
the buccal and lingual soft tissues. It also provides sensory anesthesia of the buccal and
mylohyoid nerves. In most of the cases V3 block should be combined with inferior alveolar
nerve block to ensure pulpal anasthesis.
There are two injection techniques for (V3) nerve block; Gow-Gates technique can be
performed by laying the patient in a supine position and the mouth to be open wide. The
dentist aims to administer local anesthetic just anterior to the neck of the condyle in proximity
to the mandibular branch of the trigeminal nerve after its exit from the foramen ovale.

Fig 2: Gow-Gates mandibular nerve block.

The second technique is Akinosi-Vazirani technique, which is used when there is limited
mouth opening to assist with further opening. The site of injection is the height of the
mucogingival junction of the maxillary third molar near the maxillary tuberosity.

Fig 3: Akinosi-Vazirani mandibular nerve block

4- Incisive nerve block (mental nerve block).

The site is buccaly between the mandibular two premolars. It provides anesthesia to the the
lower lip, buccal mucosa, and skin of the chin ventral to the mental foramen, in addition to
premolars and anterior teeth in the region.
 Fig 4: Incisive nerve block

Techniques for maxillary anesthesia:

The most commonly used injection for anesthetizing maxillary teeth is infiltration with a
cartridge of 2% lidocaine with 1:100,000 epinephrine. Infiltration results in a fairly high
incidence of successful pulpal anesthesia (around 87% to 92%). Pulpal anesthesia usually
occurs within 3 to 5 minutes. However, the duration of pulpal anesthesia is a problem with
maxillary infiltrations. Pulpal anesthesia of the anterior teeth my last till 30 minutes, while in
premolar region until about 40 to 45 minutes and then it starts to decline. Therefore,
additional local anesthetic should be administered depending on the duration of the procedure
and the tooth group affected.
Block anaesthesia for the maxillary teeth including posterior superior alveolar, anterior
middle superior alveolar, palatine-anterior superior alveolar, infraorbital, and second division
nerve blocks. All these are not required for routine restorative and endodontic procedures.

Fig 5: Trigeminal nerve branches

Supplemental injection techniques

1- Periodontal ligament (PDL) injection.
This technique is used when no other technique can be used. It can induce local anesthesia
in either maxillary or mandibular teeth. The needle is inserted between the tooth and PDL
with bevel of needle toward the root. Anesthetic solution of 0.2 ml is placed per root.
Onset of anesthesia is immediate but duration is variable. This technique required high
injection pressure to force the local anesthetic solution through the PDL into the
cancellous medullary bone surrounding a tooth. Therefore, high-pressure dental syringes
such as the Peripress Pen (Panadent, Kent, England) and Ligmaject (Henke-Sass, Wolf,
Tuttlingen, Germany) can be used. In addition, special motor driven anesthetic device
such as STA (single tooth anesthesia, Milestone Scientific, USA) has been also developed
for painless PDL anesthesia.

Fig 6: PDL injection

Fig 7: STA device

2- Intraosseous anesthesia.
It is particularly useful in conjunction with an inferior dental block when it is likely that
supplemental anesthesia will be necessary (e.g., in mandibular second molar teeth).
The Stabident IO system (Fairfax Dental Inc., Miami, FL) utilizes a slowspeed,
handpiece-driven perforator and a solid 27-gauge beveled wire that drills a small hole
through the cortical plate (Fig. 8 A). The anesthetic solution is delivered into cancellous
bone through a 27-gauge ultrashort needle placed into the perforation made by the
perforator (Fig. 8 B).
Fig 8: A- handpiece-driven perforator, B- Intraosseous injection delivered anaesthesia
to cancellous bone through a needle placed into the hole made by the perforator

3- Intrapulpal anesthesia.
When full anesthesia is not gained by other techniques, intrapulpal approach is used
especially in cases of irreversible pulpitis. The needle is inserted directly in the pulp and
LA introduced with force. This injection controls pain, by both applying pressure and
utilizing the pharmacologic action of local anesthetic agent. A profound and rapid onset
anesthesia can be obtained.
The major drawback of the IP injection technique is that the needle and injection are made
directly into vital and very responsive pulp tissue; this injection is quite often moderately
to severely painful.
Another disadvantage of the technique is the duration of pulpal anesthesia (15 to 20
minutes). The pulpal tissue must be removed quickly and completely to prevent a
recurrence of pain during instrumentation.

Fig. 9: For intrapulpal injection, needle is bent to gain access into the canal.
 Dental and referred pain.
Most of oral and dental pain can be traced to its source. There are cases whereby pain
might be experience away from its source as the same side but other jaw, ears, eyes and
sinus. Careful diagnosis reveals the affected tooth or related anatomic structure (in non
dental pain).

References:
1- Berman L H, Hargreaves K M, Rotstein I. Cohen’s Pathways of the Pulp. Elsevier,
12th ed. 2021.
2- Garg N, Garg A. Textbook of Endodontics. Jaypee Brothers Medical Publishers
(P) Ltd, 4th ed. 2019.
3- Samir et al 2023. ‘A Correlation between Clinical Classification of Dental Pulp and
Periapical Diseases with its Patho Physiology and Pain Pathway’ Int J Clin Pediatr
Dent; 16(4): 639–644.

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