Options to manage young patients’ pain

Successful procedural outcomes depend on effective pain management; it is especially relevant when providing treatment to children.  Pain is the response to nociceptive stimuli.  The response to a stimulus varies greatly from one child to another child. The delivery of quality dental treatment relies heavily on the ability to prevent and RELIEF pain.

Controlling pain is critical to a successful dental treatment. It was not too long ago that many in the dental and medical community doubted that children were susceptible for pain. Pediatric patients may not be able to provide a very detailed description of the pain, including the intensity.  Fortunately, there are several pain scales that can be used with children to estimate the intensity and severity of the pain.

Different options to help with the pain are available to the dentists who provide care to children.

These options include:

✓ Behavioral management

✓ The use of local anesthetics (like articaine)

✓ Nitrous oxide (if available in your country)

✓ Analgesics

✓ Bioactive dental materials like Biodentine^™

Behavioral management, local anesthetics & Nitrous oxide

The use of behavior management techniques when treating young patients is the key to pain control in the dental office. “Tell-Show-Do” is the core approach for behavior management. The correct use of local anesthesia is also a fundamental component in the algorithm to control pain in children.  A good understanding of the pharmacology of the local anesthetics and the specific techniques for children are critical in the successful use of the anesthesia. Along with the basic behavior management techniques and the use of local anesthesia, is the correct use of nitrous oxide (if available in your Country). Without any question, the key to successful use of nitrous is patient selection.  The ideal pediatric patient is slightly anxious and old enough to wear the nasal hood.

Treatment with Biomaterials

The use of biomaterials is a recent and highly effective strategy to decrease pain, especially in the post-operative phase. Biodentine^™ is a calcium-silicate based material that became commercially available in 2009.  The material is specifically designed as a “dentin substitute”.  The spectrum of applications of Biodentine^™ is wide and includes endodontic repair, indirect pulp cap, direct pulp cap, liner and dentin replacement in restorative dentistry.

The composition of Biodentine™ consists on a powder (tricalcium silicate, dicalcium silicate, calcium carbonate, oxide filler, iron oxide shade, and zirconium oxide) and a liquid (calcium chloride and hydrosoluble polymer).  One of the main advantages of Biodentine^™ is the setting time, which is around 9-12 minutes.  There is a significant difference in the setting time compared with other similar cements (like MTA).  The compression strength of Biodentine^™ is similar to the dentin.  The use of etch over Biodentine^™ does not affect the compressive strength of the material.  A critical factor of Biodentine^™ is the porosity.  Because of the low content of water of Biodentine^™ the porosity of the material is lower compared with other materials.  This is a significant benefit when a perfect seal is mandatory, like in direct pulp cap treatment.  The radiopacity of Biodentine^™, thanks to the content of zirconium is ideal and allows the practitioner to visualize the material on the radiographs.  The antibacterial property of Biodentine^™ is attributed to the high pH of the material. The high alkalinity has inhibitory effect on the growth of microorganisms.

The biocompatibility of Biodentine^™ is outstanding and has been probed in multiple studies when the material is placed with fibroblasts from the pulp. According to the American Association of Endodontics, full pulpotomy involves the removal of the coronal portion of the vital pulp as a means of preserving the vitality of the remaining radicular portion.  It may be performed as an emergency procedure for temporary relief of pain, and this is a critical advantage of Biodentine^™ in front of other materials that can be placed in direct contact with the pulp. The presence of spontaneous or severe pre-operative pain does not always indicate that the pulp is not capable to repair.

Vital pulp therapy with Biomaterials

Several recent clinical studies reported a successful medium to long term outcome of vital pulp therapy in teeth with PAIN, particularly young or immature teeth. The mechanisms of interaction of Biodentine^™ with the dental hard tissues, explain, at least in part, the post-operatory pain control with Biodentine^TM The material provides a micro-mechanical retention by infiltrating the dentin tubules.  Furthermore, Biodentine^™ induces the formation of tertiary dentin synthesis with provides protection to the pulp. These two combine effects might be responsible for the ABSENCE of pain and hypersensitivity.

Reducing inflammation & post-operative pain

Another critical report found that the application of Biodentine^™ reduces both TRPA1 pain receptor expression and function. More importantly, when applied on odontoblast-like cells, Biodentine^™ decreases pro-inflammatory TNF-a secretion.  This indicates that in addition to the roles of Biodentine^™ mentioned in the first paragraph, its application onto the dentin-pulp reduces the inflammation and consequently the post-operative pain.

References:

– Malkondu O, Kazandag M, Kazazoglu E. A review on Biodentine®, a contemporary dentin replacement and repair material. Biomed Research International 2014.

– Kaur M, et al. MTA vs. Biodentine®: Review of literature with a comparative analysis. J Clin Diagn Res 2017; 11(8): 01-05

– Imad A. Biodentine: from biochemical and bioactive properties to clinical applications. Giornale Italiano di Endodinzia 2016; 30: 81-88