Monthly Archives: September 2011

How can pain and anxiety be managed successfully and safely in the dental office?

Pain associated with dental treatment is managed effectively through the administration of local anesthetic drugs prior to the start of treatment.  These chemicals prevent passage of the nerve impulse beyond the site at which they are received.  Although the tooth or soft tissues have recieved a noxious stimulus, the nerve implulse will stop at the site where the local anesthetic drug was deposited.  The action potential on the nerve axon is blocked, the impulse is terminated and the patient feels no discomfort.

Dental anxiety can be managed by inducing a state of consciousness (or, more precisely, altered consciousness) in which a person is more relaxed and carefree than previously.  Over the years many names have been given to this state.  Names such as chemamnesia, sedamnesia, twilight sleep, relative analgesia and comedication have been used to describe the state of consciousness that is now called sedation.

                                                                                                              Basic Fears

What are the causes of our patients’ fear of the dentist?  Most persons harbor five universal fears:

1.  Fear of pain

2.  Fear of the unknown

3.  Fear of helplessnes and dependency

4.  Fear of bodily change and mutilation

5.  Fear of death

Each of the above fears may easily be transferred into the dental situation. 

The fear of pain is the most significant fear barbored by the typical dental patient.  How often do I hear, “Is it going to hurt?” from a paient just before a procedure is to start?  In fact, how do most patients select their  dentist?  Because of the superior quality of dental care or because the doctor has a repution for being “painless” and caring?  I have heard “Its nother personal Doc, but I don’t like dentists” many times. 

Fear of the unknown is present in varying degrees whenever a person is confronted with a new situation, be it attempting to cross a furnished room for the first time in the dark or facing anew and theatening dental procedure.  Fortunately, this fear can be effectively diminished or or eliminated by the dentist by “preparatory communication.”  Preparatory communication is when the dentist discusses the planned procedure with the patient, describing in nontechnical terms the nature of this planned procedure. 

The fear of helpnessness and dependency is, unfortunately, more difficult to eliminate in dentistry.  Because of the nature of dental care, the patient is both unable to observe the treatment and is usually placed in a very vulnerable position – the supine position.  Most persons will experience a feeling of unease at this time, especially when they are receiving treatment from a stranger – a dentist or hygienist with whom they are not well aquainted.  As the patient becomes more familiar with the dentist or hygienist, this feeling of helplessness should resolve.

The fear of bodily change or mutilation is common in all aspects of medicine but is especially evident in dentistry.  The oral cavity is both a richly innervated and a psychologically improtant region of the body.  All aspects of dental care have potentially great psychological overtones.  Changes in the size and shape or configuration of the body may have a profound effect on the patient’s overall outlook and attitude.  The loss of teeth, for example, in today’s society may represent the process of growing old, a situation that could prove to be extremely disturbing psychologically to the patient.

The fear of death is also ever present.  Placed in a vulnerable position in the dental chair, patients next have a multitude of hands and instruments placed into their mouth.  Drugs are injected that remove the patient’s ability to feel, and then a high-speed handpiece is placed in the mouth, with a bur rotating several hundred times per minute.  Many sensations and feelings race through the patient’s mind at this time: Can I breathe with all this equipment and these hands in my mouth?  Will I move my tongue too close to the drill and have it injured?  Will the dentist slip and injure me?

Although I do treat many patients with severe dental anxiety, the vast majority of my patient population is the patient who does not harbor any irrational fears of dental treatment.  However this patient does experience a degree of heightened anxiety as the scheduled dental appointment nears.  This apprenhension over dental treatemt does not prevent the patient from appearing in the office, for this patient is genuinely concerned about maintaining oral hygiene and does not want to experience the pain of a toothache.  This patient will be categorized as having low to moderate anxiety and will appear on a regular basis for scheduled dental care because such a patient knows that avoiding needed dental treatment will only lead to more significant (and painful) problems later.  While in the dental office this patient may have sweaty palms and a more rapid heartbeat, and would admittedly much rather be somewhere else.

Dentistry has indeed been at the forefront in the fight against pain.  In the current age virtually all dental procedures may be sucessfully completed in the absence of any patient discomfort through the administration of local anesthetics and or other techniques.  However, the dental patient, our consumer, may not be aware of this, or they may consider that the injection of a local anesthetic is the most traumatic part of the entire procedure.  How then are we to manage these patients?

As dentistry developed, dentists gained the reputation of being tooth “doctors.”  Dental education was for many years pedicated on the fact that the dentist was responsible for the oral cavity of the patient, and dental school cirricula illustrated this.  Early dentists were trained to manage their patients’ dental requirements only.  the possible interaction between dental treatment and the overall health of the patiet was either unknown or ignored.

As medicine became more sophisticated, it became very apparent that dental care could and indeed does have a significant impact on the overall health of patients.  Dental schools amended their curicula, adding courses in medicine and physical evaluation.  The dentist bcame even more alert to the fact that treatment in the oral cavity could profoundly influence a patient’s well being and conversely that the patient’s health could significantly affect the type of dental treatment offered.  The use of the patient-completed medical history questionaire became a standard in the 1950′s.  The direction today, in the 2000′s is  toward a more in-depth understanding of the relationships between oral and systemic health and disease, ie periodontal disease, heart attack, diabetes, stroke.

The words “fear,” “anxiety,” and “pain” have long been associated with dentistry.  Throughout the years the public has thought that dentistry hurts.  The public’s image of the dentist has borne this out.  Surveys have consistently shown that although dentistry as a profession is highly respected by the public, the image of the dentist as one who enjoys hurting people is still retained by many people.  In a survey of the most common fears of adults, fear of going to the dentist ranked second only to the fear of public speaking.

Is this image of the dentist justified?  I do not think so.  Unfortunately, however, our predecessors in dentistry did not have at their disposal the array of equipment and medications for the management of pain and anxiety that are available today.  History has recorded that members of the dental profession have consistently been in the forefront in the research and development of new techniques and medications for the management of pain and anxiety.  Horace Wells (a dentist) and William T.G. Morten (dentist and physician), in the 1840′s were the founders of anesthesia and the first to employ nitrous oxide (Wells) and either (Morton) for the management of pain during  dental or surgical procedures.  Prior to this time dental care primarily consisted of the removal of root tips without any form or anesthetic, except for alcohol, which was frequently used preoperatively.  Surgery, prior to the introduction of anesthesia, consisted almost exclusively of the amputation of limbs that had become infected and gangrenous.  As in dentistry, these procedures were of necessity performed without the aid of ANY form of anesthesia.

In the area of intravenous (IV) medications and outpatient general anesthesia the dental profession again led the way.  With the introduction of the IV barbiturates in the late 1930′s, Victor Goldman and Stanley Drummond-Jackson in England and Adrian Hubbell in the United States pioneered the techniques of IV General anestisia for ambulatory oral surgery patients.  It was not until the 1970′s that the medical profession, realizing the merits of short-stay surgery, becgan to use the same techniques.