Pain Control for Patients With Anxiety

Pain control is an important aspect of patient care. Most restorative procedures and nonsurgical periodontal therapy require pain management in some form. Many patients experience anxiety related to dental visits for reasons such as prior painful experiences or negative interactions with dental personnel.¹ For these patients, providing pain control can be challenging. For some, the administration of local anesthesia may be the most fear-inducing portion of the appointment. The purpose of this article is to provide strategies for providing pain control for patients with anxiety.

One of the most important aspects of working with anxious patients is communication. Fearful patients need the oral health professional to hear and understand their concerns, as well as respond in a meaningful way.² Rather than a quick dismissive response, the clinician must build trust by listening carefully to understand the nature of the patient’s anxiety and acknowledge his or her concerns.^2,3 If the clinician communicates in a calm and confident way, this can also reduce patient anxiety.³

Another helpful tip is to put patients in control by giving them the option of a hand raise on the side opposite the clinician if they need to have a pause in treatment. It is critical to stop if they raise their hand in order to build trust. By taking time to understand patients’ fears and giving them control of the situation, anxiety can be greatly reduced.³ Clinicians will likely need extra time to have these conversations and allow for pauses in treatment. Proceeding more slowly with fearful patients can reduce anxiety.³

NEEDLE-FREE PAIN CONTROL OPTIONS

Not all dental hygiene procedures require the use of injected local anesthesia. For many patients, soft tissue anesthesia is sufficient for providing nonsurgical periodontal therapy. Several options are available for topically delivered pain control.

There are two combination topical anesthetics commonly used for scaling and root planing. One is a 2.5% lidocaine/2.5% prilocaine combination that is delivered subgingivally using a blunt-tipped applicator. Once delivered into the sulcus, the liquid undergoes a thermosetting process becoming a gel form, and provides approximately 20 minutes of pain control. Onset is approximately 1 minute, and the maximum dose per appointment is five cartridges.^4–7 This agent is contraindicated in patients at risk for methemoglobinemia.

The second formulation is a combination of 14% benzocaine, 2% butamben, and 2% tetracaine. It is also applied subgingivally, and will provide 30 minutes to 45 minutes of soft tissue anesthesia.^8,9 Onset is approximately 30 seconds, and the maximum recommended dose is 0.4 mL. This combination topical gel is contraindicated in patients with allergies to esters and those at risk for methemoglobinemia. While studies have evaluated this formulation’s ability to get an area of tissue numb, its efficacy in providing pain control for dental hygiene procedures has not been studied.

Used to treat smaller areas, such as two teeth to four teeth at a time, these formulations can be good options for providing nonsurgical periodontal therapy for patients with anxiety.

Dyclonine hydrochloride (HCl) is a ketone-based topical anesthetic rinse that provides widespread topical anesthesia throughout the oral cavity.^4,10,11 Dyclonine is not necessarily a good option if periodontal pockets are deep. Because it is delivered as a rinse, subgingival anesthesia is not profound, so this is a better option for a patient with gingivitis or mild periodontitis. Dyclonine HCl is used in 0.5% and 1% concentrations, and can be obtained through compounding pharmacies. The United States Food and Drug Administration (FDA) has specific prescribing rules governing compounded prescriptions and clinicians should be aware of these regulations prior to using compounded prescriptions.^12,13

In 2016, the FDA approved an intranasal mist for maxillary anesthesia. The mist is a combination of 3% tetracaine HCl and 0.05% oxymetazoline HCl. The intranasal mist is used to provide anesthesia for teeth #4 to #13 and A through J in patients weighing more than 88 lbs.^14–16 This provides the clinician with the ability to treat maxillary teeth anterior to the molars with a needleless approach. This method provides pulpal anesthesia, which may be better suited than topical options if the patient has dentin hypersensitivity. Successful pulpal anesthesia is attained more often in the anterior teeth (88%) compared with premolars (60% to 66%), which may be due to the absence of the middle superior alveolar nerve in 28% of patients. There is a longer wait time after administration before dental procedures can begin with this method. The dose for an adult is two sprays in the nostril, administered 4 minutes to 5 minutes apart. Dental procedures can begin 10 minutes after the second spray.¹⁷ This mist will not anesthetize molars or mandibular teeth; therefore, it is not an ideal choice for quadrant dental hygiene therapy.

REDUCING PAIN AND ANXIETY DURING INJECTIONS

Topical anesthetics may not provide sufficient depth of anesthesia for all patients (eg, patients with dentin hypersensitivity not dulled by varnishes or pastes), and injectable local anesthetics may be needed. If a patient needs profound anesthesia, clinicians need to be able to deliver injected local anesthesia comfortably. There are several strategies that are helpful in providing quality, atraumatic injections in a calm manner.

Communication prior to and during the injection can reduce anxiety about the injection. The clinician should maintain a calm and quiet voice, and should structure any communication about possible discomfort using a positive sentence structure. For example, “You may feel a slight pinch” is preferable to telling patients they shouldn’t feel any pain.²

For patients with severe anxiety, behavioral management techniques can be helpful. They require a bit more time, but can drastically improve the patient experience. These include deep breathing, progressive relaxation, and guided imagery, performed with the patient’s eyes closed. Deep slow breaths have a calming effect on the body and mind. The clinician can guide the patient through deep, slow breathing using a calm and quiet tone to encourage initial relaxation. Progressive relaxation can follow guided deep breathing to further calm the patient. Progressive relaxation asks the patient to focus on each area of the body, moving from one end to the other (head to toe or vice versa), and releasing tension at each level as the patient slowly progresses from one area to the next. Finally, guided imagery can help the patient achieve a less fearful state prior to administering injections. In guided imagery, the clinician helps the patient focus on the image of something that is peaceful. The clinician then asks the patient to think about how each of the senses experiences this image. For example, if the patient finds the ocean calming, ask him or her to focus on how the ocean looks, how it sounds, how it smells, and then how it feels. During progressive relaxation and guided imagery, the patient may need reminders to breathe deeply and slowly. Part of the clinician’s job is to observe the patient to make sure he or she remains calm and that facial features are relaxed. At this point, the injections can be administered. Have patients maintain their focus on the image they have in their mind, and remind them to breathe in and out as the injection is administered. Training and using a script can reduce clinician stress during this phase. The textbook Behavioral Dentistry contains an appendix that presents a training guide and scripting for clinicians, which is clearly written and easy to understand.¹⁸

The application of topical anesthetic gel at the site of the injection can reduce the discomfort caused by the initial needle penetration. The tissue should be blotted dry with gauze prior to application of the gel, and the gel should be left in place for 1 minute to maximize efficacy.²

Distraction methods are also helpful in delivering a comfortable injection. Vibration has been suggested as an effective method of distraction.^2,3 There are dental syringe vibrators and vibrating retractors available to make this distraction technique simple. Research regarding the efficacy of vibration on pain reduction has been mixed, with some studies showing pain reduction on vibration,^19,20 and others demonstrating no statistically significant difference.^21,22 Other distractions that can be effective are music via headphones, videos, or audiobooks.^2,3

Some of the discomfort associated with local anesthetic injection is due to the rate at which the clinician delivers the anesthetic. If the speed of the anesthetic delivery is too fast, then the injection burns due to the pH difference between the local anesthetic agent (acidic) and the body tissues (close to neutral). Computer-controlled local anesthesia delivery (CCLAD) devices can reduce patient discomfort during injections. These devices use a computer to control the rate at which the anesthetic agent is injected, and have demonstrated improved patient comfort compared to a traditional syringe.^2,23

Buffering can reduce the pain of an injection, as the addition of sodium bicarbonate to the anesthetic solution raises the acidic pH to a more physiologic range.²³ Buffering systems include buffering solutions and mixing devices. With one system, the clinician uses a mixing pen to add sodium bicarbonate to a traditional dental cartridge. Another system uses large vials of lidocaine and sodium bicarbonate that are mixed in a cartridge contained inside a dispenser. There are no contraindications to buffering anesthetic solutions.

Some patients may be candidates for sedation. In many states, dental hygienists can administer nitrous oxide/oxygen sedation (N₂O/O₂). This method is effective for patients with mild to moderate anxiety.^2,24 Nitrous oxide also has the ability to increase the pain threshold, which can be very effective during the administration of local anesthesia injections. Patients who are truly phobic often do not benefit from N₂O/O₂. Correct administration technique is critical to a positive experience. Titration to the appropriate baseline concentration of nitrous oxide is the best approach to ensure anxiety reduction without progressing to oversedation.²⁴

CONCLUSION

Not all patients will be candidates for all options. A patient’s medical history should be closely reviewed prior to choosing topical anesthetic agents, sedation options, and methods of anxiety reduction. While conversation about the patient’s fears, deep breathing, relaxation, and guided imagery all take additional time, these methods can positively impact the fearful patient’s dental experience. This care and attention can be a practice builder, as patients who have good experiences will likely recommend the office to others.

REFERENCES

1. Slovin M. Managing the anxious and phobic dental patient. N Y State Dent J. 1997;63:36-40.
2. Weiner A. The Fearful Dental Patient: A Guide to Understanding and Managing. Ames, Iowa: Wiley-Blackwell; 2011.
3. Peltier B. Psychological treatment of fearful and phobic special needs patients. Spec Care Dent. 2009;29:51–57.
4. Bassett K, DiMarco A, Naughton D. Local Anesthesia for Dental Professionals. 2nd ed. Upper Saddle River, New Jersey: Pearson; 2015.
5. Jeffcoat MK, Geurs NC, Mangussion I, et. al. Intrapocket anesthesia for scaling and root planing: results of a double-blind multicenter trial using lidocaine prilocaine dental gel. J Periodontol. 2001;72:895–900.
6. Derman SHM, Lowden CE, Hellmich M, Noack MJ. Influence of intra-pocket anesthesia gel on treatment outcome in periodontal patients: A randomized controlled trial. J Clin Periodontol. 2014;41:481–488.
7. Antoniazzi RP, Cargnelutti B, Freitas DN, Guimaraes MB, Zanatta FB, Feldens CA. Topical intrapocket anesthesia during scaling and root planing: A randomized clinical trial. Braz Dent J. 2015;26:26–32.
8. Adriani J, Mehta D, Naraghi M. Mixtures of local anesthetics: the effectiveness of combinations of benzocaine, butamben, and tetracaine topically. Anesthesiol Rev. 1981;8:15–19.
9. Adriani J, Beuttler W, Brihmadesam L, Naraghi M. Topical anesthetics: use and misuse. South Med J. 1985;78:1224–1229.
10. Lexicomp Online for Dentistry. Dyclonine HCl. Available at: wolterskluwercdi.com/online-for-dentistry/. Accessed September 26, 2018.
11. Malamed S. Handbook of Local Anesthesia. Clinical action of specific agents. 6th ed. St. Louis: Elsevier Mosby; 2013:70.
12. Food and Drug Administration. Human Drug Compounding. Available at: fda.gov/Drugs/GuidanceComplianceRegulatoryInformation/PharmacyCompounding/default.htm. Accessed September 26, 2018.
13. Kravitz ND. The use of compound topical anesthetics: A review. J Am Dent Assoc. 2007;138:1333–1339.
14. Ciancio S, Marberger A, Ayoub F, et al. Comparison of 3 intranasal mists for anesthetizing maxillary teeth in adults: a randomized, double-masked, multicenter phase 3 clinical trial. J Am Dent Assoc. 2016;147:339–347.
15. Ciancio SG, Hutcheson MC, Ayoub F, et al. Safety and efficacy of a novel nasal spray for maxillary dental anesthesia. J Dent Res. 2013;92:S43–S48.
16. Hersh EV, Pinto A, Saraghi M, et al. Double-masked, randomized, placebo-controlled study to evaluate the efficacy and tolerability of intranasal K305 (3% tetracaine plus 0.05% oxymetazoline) in anesthetizing maxillary teeth. J Am Dent Assoc. 2016;147:278–287.
17. Lexicomp Online for Dentistry. Tetracaine and Oxymetazoline. Available at: wolterskluwercdi.com/online-for-dentistry/. Accessed September 28, 2018.
18. Botto R. Brief relaxation training procedure for use in dentistry. In: Mostofsky DI, Fortune F, eds. Behavioral Dentistry. 2nd ed. Ames, Iowa: John Wiley and Sons; 2014:389.
19. Nanitsos E, Vartuli R, Forte A, Dennison PJ, Peck CC. The effect of vibration on pain during local anaesthesia injections. Aust Dent J. 2009;54:94–100.
20. Ching D, Finkelman M, Loo C. Effect of the dentalvibe injection system on pain during local anesthesia injections in adolescent patients. Pediatr Dent. 2014;36:51–55.
21. Roeber B, Wallce D, Roethe V, Salama F, Allen K. Evaluation of the effects of the vibraject attachment on pain in children receiving local anesthesia. Pediatr Dent. 2011;33:46–50.
22. Raslan N, Masri R. A randomized clinical trial to compare pain levels during three types of oral anesthetic injections and the effect of Dentalvibe^® on injection pain in children. Int J Paediatr Dent. 2018;28:102–110.
23. Malamed S. Handbook of Local Anesthesia. The syringe. 6th ed. St. Louis: Elsevier Mosby; 2013:83–89.
24. Clark MS, Brunick A. Handbook of Nitrous Oxide and Oxygen Sedation. 4th ed. St. Louis: Elsevier Mosby; 2014.

From Dimensions of Dental Hygiene. October 2018;16(10):18,22,24.