Main types of pain management
Modern dental practice is unthinkable without adequate protection of the patient from pain. The technique is chosen individually, taking into account the functional status and concomitant pathologies.
Broadly speaking, there are three main approaches:
- Local anesthesia — performed directly by the attending physician (dentist, pediatrician, or general practitioner). The primary requirement is continuous monitoring of the patient's well-being.
- General anesthesia — induction of a state of reversible CNS depression.
- Combined anesthesia — a multimodal approach combining different techniques. For example, local anesthesia is actively combined with classical general anesthesia, neuroleptanalgesia, or ataralgesia.
General anesthesia and its components
This state is achieved through the use of pharmacological, physical, or psychological factors. Comprehensive general anesthesia achieves several goals at once: suppresses pain perception, induces unconsciousness, provides myorelaxation (muscle relaxation) and neurovegetative blockade. It is critically important to maintain adequate gas exchange, circulation, and regulate metabolic processes during this time.
Based on the route of administration, general anesthesia is classified into:
- Inhalation. Anesthetics enter the body via the respiratory system. Physicians value this method for its good controllability. Liquid vaporous substances (e.g., halothane, diethyl ether, chloroform) and anesthetic gases (nitrous oxide, cyclopropane) are used. The mixture is delivered via a mask, nasopharyngeal, or endotracheal tube.
- Non-inhalation. Drugs are administered intravenously or rectally (sodium thiopental, sodium oxybutyrate, hexobarbital, ketamine).
Depending on the number of agents used, a distinction is made between mononarcosis (only one drug is used) and combined anesthesia (polynarcosis, combining two or more medicinal substances).
Specific and alternative methods
In addition to classical general anesthesia, specific drug combinations and non-pharmacological techniques are used in dental clinics and hospitals:
- Neuroleptanalgesia. Provides protection against surgical trauma without inducing unconsciousness. A potent analgesic (e.g., fentanyl) and a neuroleptic (droperidol) are administered intravenously. The patient remains conscious but experiences psychic indifference and motor quiescence.
- Ataralgesia. A variation of the previous method utilizing sedative tranquilizers (diazepam) and analgesics. Often combined with local anesthesia while spontaneous breathing is preserved. If unconsciousness is required, small doses of nitrous oxide may be added.
- Central analgesia. Involves the administration of high doses of narcotic analgesics. Pain sensitivity disappears completely without the onset of full general anesthesia.
- Audioanalgesia. Stimulation of the auditory analyzer with specific sound signals. This creates a focus of excitation in the cerebral cortex, provoking diffuse inhibition in its other areas.
- Hypnosis. Psychotherapeutic intervention used for persistent facial pain (prosopalgia) and occasionally during tooth extractions.
- Acupuncture analgesia (electroacupuncture). Mechanical or electrical stimulation of biologically active points. Well-suited for pain relief in the postoperative period.
Specifics of anesthesia in maxillofacial surgery (MFS)
Working in the maxillofacial region is associated with serious anesthetic challenges. First, there is a high risk of respiratory failure. Edema of the tongue tissues and the floor of the mouth, accumulation of wound secretions, and anatomical alterations can obstruct the upper airway. Second, the maxillofacial region is richly supplied with blood, creating a threat of massive blood loss. Mechanical hemostasis is often insufficient; it is essential to strictly monitor circulating blood volume and electrolyte balance.
An additional difficulty lies in the inability to monitor the depth of anesthesia via ocular reflexes, as the patient's face is covered with a sterile surgical drape.
Combined endotracheal anesthesia is indicated for lengthy surgeries (resections of the jaws, tongue, plastic surgery on the neck). The tube reliably protects the trachea from the aspiration of saliva or blood and guarantees oxygen delivery. At the same time, it is strictly not recommended to use anesthetics that increase reflex excitability of the mucous membranes (chloroform, ketamine), as during manipulations in the oropharynx, they can provoke life-threatening laryngospasm or bronchospasm.
Briefly: answers to topical questions
What types of local anesthesia are used in dentistry?
Local anesthesia in dentistry is subdivided into non-injection (topical) and injection methods. Injection methods include:
- Infiltration anesthesia — direct and indirect.
- Conduction anesthesia — blocking nerve trunks.
- Periodontal methods — intraligamentary, intraseptal, and intraosseous.
- Endodontic methods — intrapulpal and intracanal.
- Specialized types — submucosal and subperiosteal infiltration anesthesia.
What local complications can occur during injection anesthesia?
The literature describes the following local complications of injection anesthesia:
- Vascular complications — vessel damage, hemorrhage, hematoma formation, accidental intravascular injection of the anesthetic, appearance of skin ischemia zones; epistaxis is possible during incisive anesthesia.
- Neurological complications — injury to the nerve trunk with the development of neuritis, facial muscle paresis.
- Muscular complications — damage to the medial pterygoid muscle, leading to the development of lower jaw contracture.
- Other complications — numbness of pharyngeal tissues; toxic reaction possible during incisive anesthesia if the pack is left in place for an extended period.
Which nerves are blocked during mandibular anesthesia?
During mandibular anesthesia, depending on the technique, the following are blocked:
- Inferior alveolar nerve — in Yegorov's mandibular anesthesia and via the extraoral approach from the submandibular region.
- Lingual nerve — usually blocked together with the inferior alveolar nerve; Yegorov's method blocks the inferior alveolar and lingual nerves, and less frequently, the buccal nerve.
- Buccal nerve — blocked in torus anesthesia and Gow-Gates anesthesia; additional infiltration anesthesia may be required for complete pain relief in the area innervated by the buccal nerve.
To remember the goals of general anesthesia, use the phrase "Sleepy Bear Forgot Pain, Breathes Even": Consciousness (loss of), Myorelaxation (relaxation), Pain (suppression), Breathing (maintenance), Regulation of metabolism.
Class and exam questions
Who is authorized to administer general anesthesia during a dental appointment?
Any type of general anesthesia (narcosis) may be administered exclusively by an anesthesiologist. A dentist is only permitted to perform local anesthesia.
What is the difference between ataralgesia and neuroleptanesthesia?
Neuroleptanalgesia uses a combination of a potent analgesic and a neuroleptic. In ataralgesia, the analgesic is combined with tranquilizers (sedatives), achieving a state of ataraxia and relaxation.
Why is endotracheal anesthesia frequently used in maxillofacial surgeries?
It ensures a secure airway in the presence of edema or anatomical alterations of the mouth, and also eliminates the risk of accidental aspiration of blood, saliva, or foreign bodies into the trachea and bronchi.
What else to study on this topic
- Indications and contraindications for endotracheal anesthesia in a dental hospital setting
- Mechanisms of action of drugs for inhalation and non-inhalation general anesthesia
- Postoperative complications in maxillofacial surgery
- Specifics of performing ataralgesia and neuroleptanalgesia in outpatient settings
- Methods of non-pharmacological pain relief: audioanalgesia and electronarcosis
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