Dental Pain Perception Management – From Neglect to Prevention
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– Dr Diksha Tahilramani Batra

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Dentistry is one of the only medical faculties that has been infamously linked or associated with pain in the patients’ mind, even though several other specialties like obstetrics come with higher amounts of risks and assured pain, yet we commonly hear people saying –

I’d rather experience any pain except tooth ache."”

The age old portrayal of dental appointments and dentists even in the media or as we hear it from our family & friends, reeks of horror stories and weapons of torture, but just like everything else has transformed in this day and age, dentistry has not been left behind either. The advent of technology has made almost all procedures supremely comfortable and that is something that we must communicate unanimously as a fraternity, to allow more patients to avail the quality care that we have to offer.

For years, we as dental professionals have identified the biggest challenge to treating our patients has been this all-encompassing fear of going to the dentist that prevents so many people from seeking care at the right time, this in fact makes the occurrence of dental pain a definite reality.

It is important to acknowledge and understand this barrier of perceived pain, from a psychological as well as technological stand point, that will help us create awareness for a better patient experience among our patient populations.

Patient perception of a dental experience – discomfort vs anxiety vs fear vs phobia

In our practices we come across patients who feel no hesitation in receiving dental care or the other end of the spectrum are those that cannot even bear the thought of the dental chair. Somewhere in between are many more who avoid till they could, but still are a bit uncomfortable or anxious. It becomes important to identify where a patient lies on this spectrum in order for us to be able to manage them well as each level of perception requires a different approach by the caregiver as well as the entire dental team.

Mild – Dental Discomfort

It’s a mild degree of an unpleasant sensation that can be endured but not enjoyed. For many patients, a dental appointment is something that they “must” or “have” to do rather than they “want” to do.

These patients have not been scarred by a bad experience and are easiest to manage with routine protocols, however at this stage it’s still important to not create any negative association of dentistry in the patients mind. Effective communication to set expectations, adequate anesthesia and raising awareness about prevention can ensure a successful result so the patient doesn’t experience pain. The aim here should be to replace Discomfort with Delight (a willingness to voluntarily make an appointment for routine follow ups and partner in oral hygiene maintenance)

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Moderate – Dental Anxiety

Dental anxiety is defined as an abnormal fear or dread of visiting the dentist for preventive care or therapy and unwarranted anxiety over dental procedures.

It is a slightly more heightened response than mere discomfort. Patients with anxiety do manage to battle this feeling and show up for their appointment but definitely imagining unpleasant scenarios and are cautious with procedures that involve long treatments and instruments. It is the most common since most people don’t know what will happen at the appointment and it heightens their “fear of the unknown”.

Most of these patients are cooperative to tolerating basic dental treatments that they may have experienced before but dental anxiety is the reason why these patients don’t convert to recieve complex or elaborate treatments like implants or smile makeovers immediately and like to think over and return. If we can eliminate this anxiety by treating these patients with effective means of “tell show do” ensuring they understand the procedure, see what will be used and even experience it to some mild degree before committing to it we can see their anxiety reducing with trust and acceptance increasing. Such a patient should never be forced into an elaborate treatment or subjected to multiple procedures in one session or it can compound their anxiety significantly.

Severe – Dental Fear

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Dental Fear is a reaction to a known danger (“I know what the dentist is going to do, been there, done that – I’m scared!!”), which involves a fight-or-flight response when confronted with the threatening stimulus.

It’s source lies in the conscious mind and creates definite physical responses. Dental fear is when your anxiety is unmanageable and is now definitely leading to avoidance of dental care. Anxiety when finally progresses to an established feeling of dread that creates physical inaction is dental fear but it is still different from phobia which leads to avoiding dental care at all costs. A fearful patient will approach dental care cautiously and maybe even reluctantly but may not avoid it completely, this can be the initial stages of a developing phobia if not managed.

The main difference you will see in these patients clinically is multiple dental procedures done and degree of neglect is lesser than that in a phobic patient, these procedures may even be attempted and not completed. Many patients with dental fear describe the helplessness and pain they may have been subjected to which caused them to not go back to complete their treatment.

These patients need to be handled with patience and understanding as they may have had several bad dental experiences with multiple providers at different stages in their life. If they have opted to come and see us, then we have the added responsibility to perform beyond expectation or we push them into a complete phobia. An integral part of the treatment is to hear about their bad experiences and ensure that anything we do should not remind them of the same.

The main modality in treating these patients is to give them back power to make decisions and stay in control of the treatment , this reduces their feeling of helplessness and increases their acceptance gradually. Taking their consent at each stage of treatment is imperative and be careful not to start procedures you can’t finish in the same session as they can discontinue treatment again if they feel the threat return.

Extreme – Dental Phobia

Phobia is defined as a “marked and persistent fear that is excessive or unreasonable”.

It is basically the same as fear, only much stronger (“I know what happens when I go to the dentist – there’s no way I’m going back if I can help it. I’m so terrified I feel sick”). The fight-or-flight response occurs when just thinking about or being reminded of the threatening situation.

Someone with a dental phobia will avoid dental care at all costs until either a physical problem or the psychological burden of the phobia becomes overwhelming.

Phobia leads to avoidance of care to a point where it can damage or cause severe harm due to heightened neglect.

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Modification of Extreme Type – Specific Phobia

The biggest cause of varying unpleasant feelings is usually an experience – direct or related – that a patient may have seen or heard of and it has now formed their reality of what they believe is going to happen to them in the dental chair.

To name a popular few stimuli that cause a phobia

  • Fear of the injection/needle
  • Fear of the drill
  • Fear of the blade
  • Fear of the dental chair itself
  • Fear of choking/gagging when something is placed in your mouth

These patients needless to say are the hardest to manage and must be treated very carefully as any negligence or failure to identify and address their needs will further push them back into neglect. Phobias no matter how prolonged or severe can be managed meticulously given adequate time and the right approach. The management of these patients must be staged to employ different measures, such as:

1. Good psychological management including communication focused on listening about their bad dental experience, relationship building progressing to trust, at this point refrain from starting any procedures.

2. A predictable treatment with a short session can now be carried out with advanced technology which remarkably improves the patients perception of the overall dental experience in comparison to what they had experienced earlier.

3. At this stage, dealing with the patients specific challenge or phobia maybe beneficial, like a fear of needles – then let them experience a different type of anesthesia without any additional procedure being done just ridding them of their specific fear is the aim at this stage

4. The next step is to start employing sound pain management principles with effective anesthesia and preventive medication starting with short and easy appointments but for some serious dental work.

Once the patient reaches this stage and accepts the first proper dental treatment completely, then they have overcome the phobia which may come back unless the good experience is reinforced repeatedly in a short time frame. Each of these stages can last for multiple appointments or may progress smoothly in consecutive sessions.

Painfree Experiences – a hallmark of quality practices

Man being a pleasure-seeking organism definitely does not want to ever encounter pain or danger. We are built to avoid that which is unpleasant. Most patients only report to the dental office once the pain is unbearable and these numbers are proportional to the level of awareness that a person has about the latest experience and technology in dentistry.

If they have been exposed to a bad experience before and haven’t been to the dentist in decades, seeing how much things have changed increases the otherwise avoidable anxiety (of the unfamiliar) that adds to the pain. Patients rarely know what to expect in a normal dental appointment.

In my years in dentistry and establishing a quality practice for my patients, my team and I have followed certain disciplines to ensure that we can predictably deliver a painfree experience every single time. It all starts with identifying patients depending on their dental behaviour and following a systematic protocol to deal with their specific patterns and to consistently make sure that the end result is always a memorable experience that the patient looks forward to.

References

1.Dental anxiety. Assessment, reduction and increasing patient satisfaction.NL Corah – Dental Clinics of North America, 1988 – europepmc.org

2.The prevalence of dental anxiety across previous distressing experiences G Humphris, K King – Journal of anxiety disorders, 2011 – Elsevier

3.Negative dental experiences and their relationship to dental anxiety. D Locker, D Shapiro, A Liddell – Community dental health, 1996 – europepmc.org

4.Dental Anxiety: Fear of Going to the Dentist Isador H. Coriat, M.D. Coriat, I.H. (1946). Dental Anxiety: Fear of Going to the Dentist. Psychoanal. Rev., 33(3):365-367.

5. Appukuttan DP. Strategies to manage patients with dental anxiety and dental phobia: literature review. Clin Cosmet Investig Dent. 2016;8:35-50. Published 2016 Mar 10. doi:10.2147/CCIDE.S63626

Dr Diksha Batra
Dr Diksha Tahilramani Batra is a prosthodontist & implantologist, book author, and founder of ‘ Angel Dentists Network’, India’s first all-dental NGO.

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