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Pulpectomy is a very painful procedure, which should not be undertaken without proper anesthesia. Routine procedures, including local infiltration or regional blocs, to be followed and, as a rule, is sufficient. However, pulp anesthesia sometimes fails and you find that the tissue can still be a very sensitive and cannot be touched, not causing intense pain, even if the injection was given properly. This complication is more common in the side of the lower jaw teeth, than in the maxillary teeth, where infiltration anesthesia, as a rule, are effective (65). This is a common clinical data, especially in patients with painful pulpitis that full anesthesia may be difficult to achieve. Provided that the injection properly and at the proper doses, several mechanisms may be prosecuted:
  1. Afferent nerve fibers derived from the inflamed tissues sites may have changed recreation potentials and low excitability thresholds, which are not limited only locally, but also extend throughout the affected nerve.
    Anesthetic is therefore unable to avoid the complete impulse transmission (52, 85).
  2. Patients under stress and anxiety have a low pain threshold.
  3. Accessory innervation, for example. nervus mylohyoideus can send branches mandibular molars. Frequency is estimated to be about 20% (78).
In case of insufficient pulp anesthesia, one or more additional measures can be implemented:
  1. Repeat injections and wait another 5-10 minutes
  2. If not effective, join regional block anesthesia with infiltration. For example, on the lower jaw blocks combine with infiltration into the bottom of the mouth distal to the tooth to stifle potential additional nerve supply nervus mylohyoideus. The needle must be placed close to the bark of the lower jaw. Combine infiltration of the maxillary Tusk with a Deposit into the depths of the nasopalatine channel to catch nerve branches.
  3. If you still are not effective, the so-called periodontal ligament injection or intraosseous injection (Clinical procedure 4.2).
  4. As a last, desperate step may be forced to make a shot right in the flesh (intrapulpal injection) (Clinical procedure 4.2). It is important that such a measure is carried out only in full compliance with the patient. In fear, or highly anxious patient procedure should be avoided. It is recommended to postpone treatment and reschedule the patient recipe for sedation. Different schemes can be used in practice including combining oral administration of nonsteroidal anti-inflammatory drugs and benzodiazipine in appropriate dosages. After treatment, the patient must be accompanied by adult.
Previously, when pain control may not be obtained in these extreme situations, the tooth pulp devitalization was used. The procedure involved the use of highly fabric of toxic substances, for example. formaldehyde, open cellulose. Such material will fix tissue and make it necrotic within 1 week. In this regard, endodontic procedure may be performed. This method is not currently used due to a strong risk of leakage of temporary filling limit periodontal where serious tissue destruction may lead..
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