Pain Control Protocol

A Patients with poor periodontal health frequently require anesthesia to thoroughly scale and root plane each quadrant. To my knowledge, no state practice act specifies the legality of anesthetizing the entire mouth, but safety concerns do exist. When a dental hygienist administers both inferior alveolar nerve blocks, the teeth, lingual soft tissue, floor of the mouth, anterior two-thirds of the tongue, and buccal tissue are anesthetized. Maxillary injections that anesthetize the anterior area, upper lip, and palate have the greatest impact. Anesthetizing all four quadrants for full-mouth periodontal treatment can impact eating, drinking, and speaking, and increases the likelihood of soft tissue injury, temporomandibular joint discomfort, and muscle trismus, if multiple injections are required to obtain profound anesthesia. These complications typically require short-term sequela management and can occur any time local anesthesia is administered. Hemostasis is required in the majority of periodontal therapy cases, which necessitates the use of a vasoconstrictor. Intermediate-acting anesthetic agents contain a vasoconstrictor that provides the necessary hemostasis and pulpal anesthesia for approximately 60 minutes to 75 minutes and soft tissue anesthesia for 3 hours to 5 hours.¹ A thorough medical history review must be obtained and the maximum recommended doses (MRD) calculated prior to the administration of any local anesthetic to reduce the risk of an adverse medical event. Anesthetizing the entire mouth in one appointment requires that clinicians know the "per appointment" MRD for patients based on their medical status and weight. The MRD of the anesthetic needed to obtain adequate anesthesia must be considered when anesthetizing the entire mouth. According to Malamed's Handbook of Local Anesthesia, the administration of bilateral inferior alveolar nerve blocks are rarely indicated for dental treatment, other than for bilateral mandibular surgeries.² The most significant concern for patients who receive bilateral mandibular nerve blocks is the increased risk of self-injury. Additionally, discomfort from numbness of the tongue and floor of the mouth and difficulty swallowing and speaking should be considered. A comprehensive case presentation and informed consent are strongly recommended for this treatment protocol. The use of an anesthetic reversal agent, such as phentolamine mesylate, may decrease the length of soft tissue anesthesia and, therefore, the likelihood of self-injury. The American Dental Hygienists' Association Code of Ethics contains the core values that serve as a guide for clinicians in cases such as this.³ The three that are most relevant to this situation include:

• Individual autonomy and respect for human beings: Patients have the right to informed consent and full disclosure of all relevant information, so they can make informed choices about their care.
• Nonmaleficence: Dental hygienists have an obligation to provide services in a manner that protects patients and minimizes harm.
• Societal trust: Dental hygienists value patient trust and know that public trust in the profession is based on clinicians' actions and behavior.

The dental hygiene care plan should incorporate professional judgment and current evidence. This requires following the process of care model to determine safe and effective treatments that minimize patient discomfort and promote oral health and quality of life.

References

1. Bassett K, DiMarco A, Naughton D. Local Anesthesia for Dental Professionals. 2nd ed. Upper Saddle River, New Jersey: Pearson Education Inc; 2015.
2. Malamed SF. Handbook of Local Anesthesia. 6th ed. St Louis: Elsevier; 2013.
3. American Dental Hygienists' Association. Code of Ethics. Available at: adha.org/resources-docs/7611_Bylaws_and_Code_of_Ethics.pdf. Accessed December 9, 2014.