Dental anesthesia in molars with irreversible pulp inflammation is a challenge in clinical practice due to the difficulties in its complete realization. The following are tips for performing it more effectively.
In Ricardo Machado. Biological and Technical Principles, Ed. Gen, 2022:
Introduction
Nowadays, it is unacceptable to accept that patients feel, tolerate, or endure any type and intensity of pain during dental treatment, regardless of the specialty in question.
According to the International Association to Study of Pain (IASP), "pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage, and can be described either in terms of this damage or by both characteristics". It is considered a personal and subjective experience and its perception is characterized in a multidimensional way, diverse both in sensory quality and intensity, being further affected by affective-emotional variables.
In this definition, a passage draws special attention: "sensory and emotional experience. Pain has its sensory phase (the same in all human beings in which the anesthetic technique and solution have a direct action) and emotional phase (changeable from human being to human being and in the human being itself depending on the situation at the time or experiences previously lived related to fear and anxiety - called "affective-emotional variables"). Therefore, for total pain control, mastery of both phases is necessary. Otherwise, it will be compromised.
To control the sensorial phase, the dental surgeon uses injections of anesthetic solutions with analgesic properties through specific anesthesia techniques. To act in the emotional phase, the professional must be able to condition his patient and even employ alternative means of controlling fear and anxiety (oral or inhalational sedation techniques and/or hypnosis).
The dismemberment of the word "anesthesia" corresponds to the suppression of all forms of sensation (pain, pressure, and touch) with loss of consciousness, but in outpatient dentistry the dental surgeon has the condition to remove only the painful symptom, which nominally corresponds to an analgesia (elimination of the painful symptom without loss of consciousness). For a better understanding of this chapter, the similarity between the terms: analgesia ≈ anesthesia ≈ pain control.
Dental anesthesia is divided into two main types - local and general; the former occurs on an outpatient basis, and the latter in a hospital setting.
Regarding general anesthesia, the dental surgeon should know when and how to use it. Not that he cannot perform procedures indicated under general anesthesia (cases in which local anesthesia is contraindicated and major surgeries, such as orthognathic and facial trauma surgeries), but it is understood that there is a medical specialty to apply it and, thus, it must be performed in a hospital regime with the proper monitoring and care.
Before starting any procedure and after performing the anesthetic technique, professionals must wait for what is known as the latency period (time needed for the onset of the anesthetic effect) and check the symptoms to be sure of success.
After the local anesthesia has set in, signs and symptoms are observed, which are subdivided into subjective and objective. The subjective ones portray what the patient reports (such as numbness, tingling, "swelling" sensation, etc.), and the objective ones, in turn, depend on the professional's instrumentation at the site (performing the treatment without painful symptoms). The signs (visually observed by the professional, such as lip and eyelid droop) are of little interest for the demonstration of dental anesthesia, since they represent the action of the local anesthetic on muscular and non-sensorial nerve fibers responsible for dental innervation.
In summary, it is important to understand that this chapter approaches dental anesthesia far beyond the techniques of anesthetic injections, but rather a sum of attitudes such as pain control, in which it is important not only the correct injection, but also the psychological conditioning of the patient for perfect operative silence.
The dental surgeon must not forget that the ambulatory patient can perceive everything around him (including touch and pressure), and if he is not well conditioned psychologically, his brain will induce him to think that he was not anesthetized, and no matter how much the anesthesia is repeated, adding more anesthetic, it will not be possible to "control" this sensation.
Requirements for the anesthetic technique
Before any anesthetic procedure and/or the adoption of anxiety control methods, the dental surgeon should obtain important information, by means of a questionnaire with appropriate language, about his patient and his complete health history, with details about his current, past, and family history (anamnesis).
Anamnesis must be done exclusively by the dental surgeon, and not by another auxiliary professional, who is restricted to asking preliminary questions, such as name, age, gender, occupation, etc. During the anamnesis, the following factors must be carefully observed:
-Physical and psychological condition of the patient
-History of any previous unpleasant experience with dental treatment
-Sensitivity to some type of medication
-Cardiovascular status
-Respiratory disorders
-Central nervous system (CNS) disorders
-Metabolic deficiencies and endocrine disorders
-Hematological or pathological alterations
-Pulse acquisition and recording of its frequency, volume and rhythm
-Pressure recording
-Frequency and characteristic of breathing.
Mandibular anesthesia
Mandibular anesthesia is undoubtedly the most difficult. The lower teeth and their adjacent tissues receive innervation from the 3rd branch of the 5th cranial pair - the mandibular branch - which despite having a mixed constitution (motor and sensory), the greatest interest lies on the sensory fibers, which in the region of the internal face of the mandibular branch, are divided and originate the inferior alveolar, lingual and buccal nerves. In the region of the mental foramen, the inferior alveolar is subdivided into the mentonian and incisor nerves.
It is important to know the nerve pathway, since, in the case of inflammation and/or infection, for example, it is necessary to use several anesthetic techniques.
Inferior alveolar nerve (intraosseous)
It descends behind and slightly lateral to the lingual nerve, between the two pterygoid muscles, and continues its path until it reaches the inner surface of the mandible, where it enters the inferior alveolar canal through a foramen delimited by an anatomical structure called lingula (Spix's spine). It has no contact with the mandible above the inferior alveolar canal and is responsible for the innervation of the inferior molars and premolars, as well as the mandibular bone tissue and periosteum (both buccal and lingual). It traverses the mandibular canal and, in the premolar region (usually between the second and first), divides into two asymmetrical terminal branches: the incisor nerve and the mentonian nerve.
Dental anesthesia.
