Pain Management For a Better Patient Experience
Effective pain management before, during, and after a dental procedure can significantly improve care and raise the bar for dentistry services provided in general practices.
The management of pain in dentistry encompasses a number of procedural issues, including the delivery of anesthetic and the management of post-procedural pain, as well as pain diagnosis, management strategies for orofacial conditions that cause pain in the face and head, and the management of pain in special populations.
Given the extensive nature of the topic, this article reviews pain definitions and mechanisms, acute versus chronic pain, and focuses on management strategies related to anesthetic delivery and the control of pain following dental procedures.
2) Acute Versus Chronic Pain
The mechanisms underlying acute and chronic pain are considerably different in terms of neurophysiology; hence, overall pain management needs to reflect these differences. The persistence of pain (greater than 3 months) sets into motion multiple changes in the functioning of the peripheral and central nervous system that, coupled with psychological and behavioral considerations, can make pain intervention more complex and difficult.
The delivery of anesthetic and the management of postprocedural pain in a normal patient is not likely to be impacted by peripheral and central neurophysiological plasticity. However, in the patient with a history of chronic nonfacial pain or in the fearful patient, brain neurophysiology may be altered so as to facilitate pain perception. Anxiety and fear is known to activate the pituitary-adrenal axis, leading to an increased experience of pain.
Thus, effective procedural pain control should include assessment and management of the patient's emotional state and relative stress level. The patient with multiple chronic pain problems may respond to dental treatment differently than the noninvolved patient.
3) Procedural Pain
Acute pain may be associated with dental procedures such as anesthetic injection, restorative treatment, periodontal procedures, implant placement, and tooth extraction. Pain associated with the injection of anesthetic can be modulated by co-administration of volatile agents such as nitrous oxide, intravenous drugs, and by the pre-application of topical anesthetic, proper injection technique including slow delivery of the drug, selection of the proper needle size, and the type of anesthetic selected for delivery.
Injection pain can also be reduced or eliminated via good patient management pre-injection by way of clinician patience, gentle patient management, assurance, and other behavioral techniques such as desensitization, hypnosis, and relaxation training.
4) Behavioral Management
Fear of the needle or dental treatment in general is common. Numerous factors are associated with dental anxiety, including the memory of prior painful dental experiences, conditioning, pain expectation, and other psychological factors. All may impact the pain experience. Reducing dental anxiety can profoundly reduce an individual's pain threshold.
Simple behavioral strategies for managing anxiety vary between children and adults but typically include the provision of a warm and caring clinical environment, assurance, an unhurried clinical atmosphere, slow introduction, and nontraumatic explanation of the anticipated procedures; for children, inclusion of a parent or guardian with hand-holding, if necessary can also help. Evidence even exists that pleasant ambient fragrances as well as musical intervention can alter dental fear.
Other fear-reducing and anxiety-reducing interventions include those used to manage pain patients generally, such as distraction, desensitization, and relaxation training with mental imaging. Limited research also suggests that biofeedback may help to reduce dental anxiety and improve the pain experience.
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