Going to the dentist is anxiety-inducing for many patients who are apprehensive about needles, drills and other triggers. A recent survey by the market research platform DentaVox found that more than 60% of respondents experience dental fear: 24% say visiting the dentist is scarier than being in a room with a snake, and an astounding 4% have never visited a dentist. To help patients, dental practitioners need to contend with both the physiology and the psychology of pain. “Pain receptors and pain stimuli create a chain reaction,” says Dr. Robert M. Peskin, a general dentist, dental anesthesiologist and speaker of the House of Delegates for several organizations, including the Academy of General Dentistry, the American Dental Society of Anesthesiology and the New York State Dental Association. “When pain messages come into the spinal cord and nervous system, they can be amplified or turned down before they even get to the brain. This is a crucial concept to understanding the pain experience — and how we can relieve it.” There are a number of techniques that can be used to reduce discomfort and stress for patients. A holistic pain management approach takes into account:
As local anesthetics have evolved, new products have emerged to help minimize the discomfort associated with injection. The syringes that were created decades ago have been upgraded with new devices that can minimize the speed in which the anesthetic is administered. Septodont, for example, offers a series of syringes with different ring sizes that are adaptable to individual practitioners’ hands. Self-aspirating syringes (which allow for aspiration by using counter pressure) also offer a greater degree of control. “Aspiration is key to avoiding intravascular injections, which can have side effects such as seizures or cardiovascular issues, so I recommend aspirating with whichever syringe you use,” says Dr. Peskin. Modern electronic syringe systems have been developed to provide a smooth, pain-free injection. These systems improve upon the traditional self-administered syringes, which can cause patient discomfort when anesthetics are injected too quickly. Electronic syringes help eliminate human error, creating a more consistent injection. Sleeker-designed products, like the Milestone Scientific® Wand Single Tooth Anesthesia® System, provide dynamic pressure sensing technology, while devices like the lightweight Dentapen by Septodont, a Computer-Controlled Local Anesthetic Delivery System (CCLAD), allow for a virtually pain-free injection. This portable device can be used universally with other needles on the market. “Once the Dentapen system is in the proper place, I can keep my hand steady and the injection takes place all on its own,” says Dr. Peskin. “Most patients can’t even tell I’m administering the local anesthetic.” Needle selection is also key to pain reduction.
In addition to needle choice, another area where practitioners can improve patient comfort is in the selection of local anesthetic agents. Articaine, for instance, has a favorable pKa, which provides for a short onset and better penetration into the nerve cell. A study published in the Journal of the American Dental Association found that when performing infiltration anesthesia on first molars, the onset of pulpal anesthesia is more profound and more rapid with articaine versus lidocaine. Another advantage of articaine is that it is the only molecule that contains an ester function, which degrades in the blood by esterases into inactive form. 95% of articaine is degraded in this way, making it easier for the liver to process it (lidocaine is the opposite, with 95% deactivated in the liver). Articaine is very potent, so there’s less volume required to anesthetize the patient. It has a more favorable pKa than lidocaine and acts more quickly. Another advantage is that due to its chemistry, it is well tolerated systemically. “Articaine has the shortest half-life, making its safety profile better,” says Dr. Peskin. “If you need to readminister it, you have far less likelihood of approaching toxicity.” Not all articaine-based cartridges are identical, notes Dr. Peskin. It has been available with different epinephrine concentrations in the U.S. for many years, but the dosage may vary depending on the patient profile. Articaine with 4% epinephrine 1:200,000 may be preferable for patients with cardiac disease. In addition to selecting the right syringe and anesthetic agent, dental practitioners can ease patient discomfort by buffeting their local anesthesia. By using sodium bicarbonate mixed together with lidocaine prior to injection, the dentist can neutralize the acid in the anesthesia agent. This improves injection comfort and hastens the onset of anesthesia.
For dental practitioners who have the capabilities to do so, offering nitrous oxide can be advantageous for certain patients, particularly if they arrive already in pain or dealing with anxiety about the procedure. “Nitrous oxide provides an effective and relatively easy way to relax the patient,” says Dr. Peskin. “For this depth of sedation, it’s easy to turn on and off. You put a nasal hood on the patient’s face, turn on the nitrous oxide and within a relatively short time, they start to feel the effects and are much more comfortable.” Once the procedure is finished, 100% oxygen is administered for three to five minutes to allow the patient to equilibrate, and then they are ready for discharge. Beyond the selection of tools used to administer anesthesia, dentists and their team can adapt their practices in other ways to help allay patients’ fears.
“There are all kinds of sounds and smells that get accelerated and accentuated when you’re sitting in the dental chair,” Dr. Peskin says. “When we consider pain, it isn’t limited to the physical sensation, because there is both a physiological as well as a psychological component that comes into play. It’s our job to do this in a way that’s as courteous and as compassionate as possible.” With that in mind, establish a dental team that’s warm, professional and exudes caring about whatever procedure the patient is going through. Explain to patients in the most understandable terms not only what will happen when they come to the office but what to expect in terms of how they’ll feel when they go home. Be a good listener. Creating a physically relaxing environment is also worthwhile. Patients who feel at ease will be more likely to return, and to refer their friends and family. Design a space that’s appealing to the senses. This may include choosing comfortable chairs, fresh flowers, soothing pictures instead of clinical ones, as well as sound reduction so patients don’t have to hear the drill while they’re in the waiting room.
Don’t underestimate patients’ anxiety. Their impression of the practice setup and their stress level plays a major role in their perception of pain. There are many products available today that enhance pain control and efficiency, leading to a better experience for patients. Taking pain management seriously improves the practice and helps build a reputation as a caring practitioner.
To learn more about this topic and other integrated solutions for health care professionals, click here.