Pain Management 101

Pain is an unpleasant sensation, with both physical and emotional components. Physical pain is a response to nerve stimulus, and the characterization of pain can vary over time. For oral health professionals, the delivery of quality oral health care — and the key to successful dental treatment — hinges on their ability to prevent and relieve pain.

It wasn’t long ago that many in the medical community doubted that children, particularly infants, were susceptible to pain.1 This notion has been disproven and recent studies suggest that children begin to show developmental changes in response to painful stimuli early in infancy.2 When treating adult patients, clinicians rely on reported symptoms and detailed descriptions of pain quality and intensity. Pediatric patients — particularly preschool-age children and those with special health care needs — may not be able to provide such descriptions. For this reason, clinicians may employ one of several pain scales that can be used by patients to report pain. One such example is the Wong-Baker pain scale — a series of faces from which patients can choose to reflect their perceived level of pain.3

The potential effects of emotion on pain perception are sometimes overlooked. Anxiety and emotional distress can decrease a patient’s pain threshold, thereby increasing the magnitude of a patient’s reaction to a painful stimulus.4 Oral health professionals are more likely to be able to deliver pain-free dentistry when the patient is calm, which is guided by parental/caregiver emotional response.5,6

BEHAVIOR MANAGEMENT

Oral health professionals use basic behavior management techniques for controlling dental pain among their patients. While myriad behavior management options exist, the majority of patients respond well to the use of simple requests and commands. “Tell-show-do” is the bedrock approach for behavior management in children.7 Explaining what is about to happen, what will be used, and then proceeding with the treatment as described allows practitioners to treat most children with a high level of success.

Another simple and vital part of behavior management is word choice. Using words that conjure positive thoughts and happy emotions can go a long way toward decreasing anxiety.

Unfortunately, many children view a visit to the dentist as a frightening experience.8 Numerous items in a dental office may prove challenging, including: a startling noise from a scaler, the sharp hook on an explorer, and a bright glare from the overhead light. Informed sales reps can speak to providers about how these objects and stimuli may be seen in the eyes of anxious patients in order to minimize patient anxiety.

LOCAL ANESTHESIA

Many of the tasks performed in dentistry have the potential to cause discomfort. Local anesthesia blocks nerve impulses, thereby potentially altering the perception of pain (see “Blocking Pain with Local Anesthesia”sidebar).9 The administration of local anesthesia can be a frightening experience for patients of all ages. Many individuals have a fear of needles, whether due to the past experience of a painful injection or feelings related to stories shared by family or friends. Whatever the cause, fear of local anesthesia is legitimate and should be treated as such.10,11

The first step to providing local anesthesia is the use of a topical anesthetic to dry the mucosa in the area where the injection will take place. It is important that the tissue be dry to ensure the anesthetic is absorbed in the tissue — ideally, for at least 1 minute prior to injection. The second step is to ensure the patient does not see the syringe.

In order to avoid needle separation, the needle must not be placed too deeply into the soft tissue upon injection. Sales reps are behooved to know that clinicians should always be able to see a segment of the needle outside of the soft tissue; that way, if the needle separates, it can be retrieved. Controlling the patient’s head movement and remaining aware of needle placement will help prevent needle separation or other soft tissue trauma caused by sudden movements.

The anesthetic technique used for children is different from the one designed for adults — primarily due to the difference in the landmarks used when performing inferior alveolar nerve (IAN) blocks, which provide pulpal anesthesia to a mandibular quadrant. If a block is unsuccessful, clinicians should be advised to insert the needle higher on the ramus than the previous attempt, keeping in mind maximum dosages (based on patient’s weight) to prevent an overdose.12

The most commonly used local anesthetic agent in children is
2% lidocaine with epinephrine 1:100,000.13 This anesthetic has a long track record of safe and effective use in pediatric dental populations. The vasoconstrictor, epinephrine, is added to cause constriction of the blood vessels in the area where the injection occurs, thereby keeping more of the anesthetic solution localized and slowing the systemic uptake of the solution. This provides longer anesthesia in the area while reducing the risk of overdose.14 Other agents used for local anesthesia in children include 4% articaine with epinephrine and 3% mepivacaine without vasoconstrictor. Mepivacaine plain (without vasoconstrictor) is not recommended when treating multiple areas in pediatric patients because the lack of a vasoconstrictor increases the likelihood of overdose, and the duration of pulpal anesthesia is very brief (5 minutes to 10 minutes).


 

BLOCKING PAIN WITH LOCAL ANESTHESIA

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Local anesthesia blocks nerve impulses, thereby potentially altering the perception of pain. To review, a noxious stimulus (such as an injection through the skin or mucus membranes) activates A-delta and C fibers. Such fibers may be sensitive to nerve stimulation, and the impulses transmitted along these fibers, when integrated with other sensory input and psychic phenomena in the central nervous system, may cause pain. When a local anesthetic is delivered, it diffuses into the extensions of nerve cells and temporarily interrupts the conduction of action potentials by preventing the inflow of sodium ions.9 The smaller fibers are shut down before the larger fibers, so the sensation of pain is blocked first, with the sensation of pressure being blocked last, if at all, as this is carried by a larger fiber. This explains why some patients will still feel the pushing sensation during dental work, even when the pain sensation is blocked.

 


In recent years, the use of 4% articaine has grown in popularity. Many dental professionals claim this drug works faster than lidocaine and provides more profound anesthesia. There are concerns, however, because articaine has a higher rate of persistent paresthesia when used for IAN blocks.15 Avoiding block anesthesia with 4% articaine may be prudent, but there are other uses for the drug in pediatric dentistry.9 The use of 4% articaine may eliminate the need to provide block anesthesia in some instances, reducing the risk of soft tissue trauma. It has been reported that mandibular buccal infiltration in children (age 3 to 9) was as effective as IAN blocks for all restorative situations, with the exception of a pulpotomy on a second primary molar.16 This anesthetic technique should be used with caution because the likelihood of successful local anesthesia decreases as a child grows older. Studies have also shown that local infiltration of 4% articaine can improve the effectiveness of IAN blocks.17

Clinicians understand that the administration of local anesthesia is not without risk — the most serious being the possibility of overdose in pediatric dental patients. Knowing each patient’s weight and calculating a maximum dosage of local anesthetic prior to treatment is important. The large body mass of adults reduces the risk of overdose in this population, but it is much easier to reach local anesthetic maximums in children.

Another major concern regarding local anesthetic use in pediatric patients is post-operative complications, as children are not used to the feeling of being numb and may respond by chewing or biting on their lips. When children traumatize their lips following a dental procedure, the swelling and irritation can be misinterpreted by parents and medical providers as an infection or allergic reaction to local anesthetic and may be inappropriately treated.18

To help combat this, a drug was recently introduced in the United States that shortens the duration of soft tissue anesthesia.19 Early studies have shown that the drug, phentolamine mesylate, is successful in reversing the effects of anesthesia and shortening the duration of time that lips, tongue, and cheeks are numb following local anesthesia.19 This is a potentially useful drug that can aid in patient comfort and limit the possibility of trauma caused by involuntary lip biting. Dental sales reps should advise their customers, however, that this drug is not approved for use on children younger than 6 due to lack of research among this age group.

NITROUS OXIDE SEDATION

Along with the basic behavior management techniques, many oral health professionals use pharmacological methods of managing behavior and preventing pain. The most commonly used anti-anxiety medication for pediatric dental patients is nitrous oxide. Nitrous oxide is safe, easy to administer, and provides some anti-anxiety effects. Its use, however, can cause nausea and vomiting.20 The desired effect is that the patient is content, comfortable, and has somewhat blunted sensation, making the injection easier to accomplish.21

The key to the successful use of nitrous oxide is patient selection. Patients must be willing to wear the nasal hood and to breathe through their nose to achieve the desired effect. For patients with claustrophobia or those with a history of abuse, the wearing of the nasal hood may increase agitation and anxiety. Rather, the ideal pediatric patient for nitrous oxide is a slightly anxious child who is old enough to comfortably wear the nasal hood, who can breathe freely through his or her nose, and who requires a mild level of anxiety relief to complete the desired treatment.


 

ALTERNATE DELIVERY METHODS

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The introduction of computer-controlled local anesthesia delivery (CCLAD) has simplified pain management in the dental setting. Ensuring patient comfort is integral not only to treatment outcomes but also in creating a positive dental experience for patients, to support compliance and their return for follow-up care. CCLAD devices provide local anesthetic drugs in a slow and controlled manner compared with traditional manual syringes. They help improve patient comfort during local anesthesia administration and can be especially helpful for patients with a fear of injections, as the needle is less visible than in manual syringes. For sales reps, CCLAD represents an opportunity to generate incremental sales.

The US Food and Drug Administration (FDA) recently approved the first dental anesthesia administered via nasal spray. Intended for dental use as a topical anesthetic (tetracaine hydrochloride [HCI] and oxymetazoline HCl), it is designed to provide pulpal anesthesia for restorative treatment. This nasal spray is indicated for regional anesthesia when performing restorative procedures on teeth #4 to #13 and A to J in patients weighing 88 pounds or more.


ANALGESICS FOR CHILDREN

Discomfort following a dental visit is relatively common and parents are likely to administer analgesics to their child as a result.22 A 2011 study found that 33% of pediatric dental patients reported pain following a restorative visit and most were given over-the-counter pain medications by their parent/caregiver.23

The drugs prescribed for pain control in children are generally limited to acetaminophen and ibuprofen, both of which are analgesic and fever-reducing agents — with the latter also acting as an anti-inflammatory agent when prescribed in higher doses. Alternating between these two drugs should be sufficient in managing pain resulting from routine restorative and hygienic dental procedures, though clinicians should remain aware of daily maximum dosages.

Aspirin is not recommended for use in children because of its association with viral illnesses and the development of Reye syndrome. Narcotics, such as acetaminophen with codeine, are of limited value for pediatric patients and should be reserved for the rare circumstances where a child is in moderate to severe pain, such as following an extensive surgical procedure. If acetaminophen with codeine is utilized, the maximum amount of acetaminophen should never be exceeded due to the risk of liver damage. Codeine is also a respiratory depressant, and clinicians should be advised that the US Food and Drug Administration released a statement on April 20 advising against the use of codeine in children due to the risk of breathing problems.24 Therefore, the value of using this drug for children should be carefully weighed against its serious risks.

GAIN CONTROL

Pain control is a broad term that encompasses many aspects of patient care. Sales reps should know that emotional pain mitigation begins prior to the patient ever entering the dental practice. And savvy dental sales reps will partner with their customers not only to help offer pain control products, but to ensure that the dental office is a welcoming, bright, and positive atmosphere — which goes a long way with patients’ overall experience.

Prevention and management of pain are important to patients, regardless of their age. Successful sales reps will be able to offer suggestions in anesthetics that will assist clinicians in gaining control of pain — and perhaps even the chance to gain patient trust.

Featured photo by MEDIAPHOTOS/ISTOCK/GETTY IMAGES PLUS

References

  1. Schechter NL. The under-treatment of pain in children: An overview. Pediatr Clin North Am. 1989;36:781–794.
  2. Walker SM. Biological and neurodevelopmental implications of neonatal pain. Clin Perinatol. 2013;40:471–491.
  3. Barretto EPR, Ferreira EF, Pordeus IA. Evaluation of toothache severity in children using a visual analog scale of faces. Pediatr Dent. 2004:26:485–491.
  4. Peters ML. Emotional and cognitive influences on pain experience. Mod Trends Pharmacopsychiatri. 2015;30:138–152.
  5. Kim JS, Boynton JR, Inglehart MR. Parents’ presence in the operatory during their child’s dental visit: a person-environmental fit analysis of parents’ responses. Pediatr Dent. 2012;34:407–413.
  6. Karibe H, Aoyagi-Naka K, Koda A. Maternal anxiety and child fear during dental procedures: a preliminary study. J Dent Child. 2014;81:72–77.
  7. Law CS, Blain S. Approaching the pediatric dental patient: A review of nonpharmacologic behavior management strategies. J Calif Dent Assoc. 2003;31:703–713.
  8. Doerr PA, Lang WP, Nyquist LV, Ronis DL. Factors associated with dental anxiety. J Am Dent Assoc. 1998;129:1111–11119.
  9. Malamed SF. Handbook of Local Anesthesia. 6th ed. St. Louis: Mosby; 2013.
  10. Leal AM, Serra KG, Queiroz RC, Araújo MA, Maia Filho EM. Fear and/or anxiety of children and parents associated with the dental environment. Eur J Paediatr Dent. 2013;14:269–272.
  11. Milgrom P, Coldwell SE, Getz T, Weinstein P, Ramsay DS. Four dimensions of fear of dental injections. J Am Dent Assoc. 1997;128:756–762.
  12. Benham NR. The cephalometric position of the mandibular foramen with age. J Dent Child. 1976;43:233.
  13. Cheatham BD, Primosch RE, Courts FJ. A survey of local anesthetic usage in pediatric patients by Florida dentists. J Dent Child. 1992;59:40–407.
  14. Malamed SF. Pharmacology of vasoconstrictors. In: Handbook of Local Anesthesia. 6th ed. St. Louis: Mosby; 2013:124–156.
  15. Garisto GA, Gaffen AS, Lawrence HP, Tenenbaum HC, Haas DA. Occurrence of paresthesia after dental local anesthetic administration in the United States. J Am Dent Assoc. 2010;141:836–844.
  16. Sharaf AA. Evaluation of mandibular infiltration versus block anesthesia in pediatric dentistry. ASDC J Dent Child. 1997;64:276–281.
  17. Kanaa MD, Whitworth JM, Corbett IP, et al. Articaine buccal infiltration enhances the effectiveness of lidocaine inferior alveolar nerve block. Int Endod J. 2009;42:238–246.
  18. Chi D, Kanellis M, Himadi E, Asselin M. Lip biting in a pediatric dental patient after dental local anesthesia: a case report. J Ped Nurs. 2008:23:490–493.
  19. Prados-Frutos JC, Rojo R, González-Serrano J, et al. Phentolamine mesylate to reverse oral soft-tissue local anesthesia: A systematic review and meta-analysis. J Am Dent Assoc. 2015;146:751–759.
  20. Kupietzky A, Tal E, Shapira J, Ram D. Fasting state and episodes of vomiting in children receiving nitrous oxide for dental treatment. Pediatr Dent. 2008;30:414–419.
  21. Levering NJ, Welie JVM. Current status of nitrous oxide as a behavior management practice routine in pediatric dentistry. J Dent Child. 2011;78:24–30.
  22. Vernacchio L, Kelly JP, Kaufman DW, Mitchell AA. Medication use among children younger than 12 years of age in the United States: Results from the Slone Survey. Pediatrics. 2009;124:446–454.
  23. Staman NM, Townsend JA, Hagan JL. Discomfort following dental procedures for children. Pediatr Dent. 2013;35:52–54.
  24. United States Food and Drug Administration. Codeine and Tramadol Can Cause Breathing Problems for Children. Available at: fda.gov/ForConsumers/ConsumerUpdates/ucm315497.htm. Accessed May 11, 2017.

From MENTOR. June 2017;8(6):18-20, 22-23.

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