The Anxious Patient

Pain is a subjective experience and the threshold for experiencing discomfort is unique to each individual. Age, gender, race/ethnicity, and psychosocial factors all influence the way people experience pain.^1,2 Many patients avoid seeking dental treatment because they are afraid of pain. A vast percentage of these dental phobic patients fear dental hygiene-related procedures such as periodontal probing, scaling, root planing, and flossing.³ Approximately, 10% of the population experiences such a high level of anxiety and fear that they avoid any kind of dental treatment.³ Milgrom et al discuss four dimensions of fear: general fear of dental anesthetic injection, fear related to local anesthesia, fear of acquired disease, and fear of physical injury.⁴ General fear of injections and fear of bodily injury ranked the highest. Fear of dental injections was also associated with avoidance of dental treatment.⁴

The role of the dental hygienist is continually evolving. Currently, dental hygienists are permitted to administer local anesthesia in 40 states and nitrous oxide in 26 states.⁵ As the dental hygiene scope of practice continues to expand, the dental hygienist’s administration of pain control modalities during nonsurgical periodontal therapy will increase.

METHODS OF PAIN CONTROL

Dental hygienists can minimize pain during treatment by observing the patient’s personality, using a combination of topical and injectable agents, and employing cognitive behavioral management or relaxation.

Since most dental patients fear intraoral injections, the need for an effective fast-acting topical anesthetic is essential. A 2.5% lidocaine and 2.5% prilocaine periodontal gel* was introduced last year and is a new category of local anesthetic that is noninjectable. This local noninjectable anesthetic gel is administered subgingivally to the periodontal pocket using a blunt tip applicator. At room temperature the periodontal gel is a low viscosity fluid, allowing it to flow directly into the instrumentation site. Once in the oral cavity, the anesthetic sets into an elastic gel that keeps the anesthetic in the periodontal pocket.

Within 30 seconds a dental hygienist can commence scaling and root planing. The effects of noninjectable anesthetic last for about 20 minutes. The application of 2.5% lidocaine and 2.5% prilocaine gel is similar to subgingival irrigation and delivery of subgingival antibiotics. Due to the similarities, this mode of applying anesthesia can be quickly adapted by the dental hygienist.⁶

When using the noninjectable periodontal gel, sometimes rescue anesthesia may be necessary if its effects are not profound enough. A study of patients undergoing periodontal therapy found that rescue anesthesia—either by nerve block or infiltration—was needed after applying the periodontal gel in patients who were extremely sensitive.⁷ Out of 112 subjects, 17 required rescue anesthesia.

INJECTABLE OPTIONS

Injectable local anesthesia is still the anesthetic option of choice for profound pain relief in scaling and root planing procedures.⁸ Since 1971, dental hygienists in an increasing number of states have been permitted to deliver local anesthesia. A study indicated that when hygienists completed didactic and clinical coursework, they were able to successfully administer local anesthesia.⁹ Scheduling, productivity, and the quality of hygiene care also improved when this service was administered by dental hygienists.⁹

Injectable local anesthetics can provide pulpal anesthesia from 30 to 60 minutes and soft tissue anesthesia from 1 to 8 hours depending on the drug formulation used. Even with its desirable numbing qualities, injectable local anesthesia is not without disadvantages, which include pain associated with needle insertion; long periods of numbness to tongue, lip, and cheek; trismus; paresthesia; and potential for avoidance of dental care due to fear.⁸

USING TOPICAL ANESTHESIA

Topical anesthesia may assist the hygienist by decreasing patients’ anxiety, however, it will not necessarily deliver profound pain relief. Topical anesthesia—in either a gel or spray form—is placed at the work site of the oral mucosa during scaling and root planing. The main disadvantages include inadequate depth of penetration, short duration of action, poor taste, and difficulties of administration.¹⁰

Dental hygienists should not apply large amounts of topical anesthesia alone for nonsurgical periodontal therapy due to its high concentrations of anesthetic agents (14% benzocaine, 2% tetracine/2% butamben formulation) and the risk of absorption. The most common application of topical anesthesia is in combination with injectable anesthesia. When swabbed or sprayed prior to injection, topical anesthesia decreases the pain of needle insertion.⁶

NITROUS OXIDE

Nitrous oxide is an inhalation anesthetic agent that is delivered through the patient’s nose in combination with oxygen. It is commonly referred to as “laughing” or “sleeping” gas by patients due to its euphoric effects. Nitrous oxide-oxygen sedation may calm the anxious patient without producing a loss of consciousness. This inhalation anesthetic develops its analgesic properties within 2-3 minutes and is eliminated from the body within 3-5 minutes after the gas is no longer administered. If there is too high a concentration of nitrous oxide, side effects may include nausea, hallucinations, and dizziness.

Inhalation sedation units are required to possess a number of safety mechanisms designed to prevent the delivery of too little oxygen. When nitrous oxide-oxygen is used, an increase in the patient’s pain threshold occurs. Nitrous oxide-oxygen sedation can be used alone or in combination with local anesthesia to manage the needle phobic patient.¹¹

BEHAVIOR MANAGEMENT

Cognitive behavioral management techniques are used to address patients’ thoughts, beliefs, and mental processes. Studies support alternative behavioral techniques that include relaxation.^12,13 Relaxing the anxious dental patient may relax the nervous system and mental process, thus encouraging a greater compliance with periodontal treatment.

Various types of relaxation techniques are available that the dental hygienist can incorporate to treat the fearful patient, such as guided imagery, distraction techniques, slow abdominal breathing, and systematic desensitization. Guided imagery is a technique that allows patients to imagine themselves in a tranquil setting. Distraction techniques, either audio or visual, remove the patient’s focus from the offending stimulus. Slow abdominal breathing engages the physical being, forcing patients to relax their bodies.

Systematic desensitization is a technique that involves slowly exposing the patient to the offending stimulus. During this technique, patients are educated about the procedure and encouraged to ask questions.¹⁴ Educating the patient reduces anticipatory stress and enhances feelings of perceived control, likely influencing their pain experience. Research indicates that providing patients with perceived control over pain increases pain tolerance.¹³

When implementing cognitive behavioral techniques, patients do not necessarily experience less pain. However, they may consider the experience less painful and, therefore, less negative.¹³

CONCLUSION

For many patients, even the most compliant, nonsurgical periodontal therapy is considered painful and undesirable. Understanding the dental patient’s personality and the appropriate selection or combination of pain reduction modalities will allow the dental hygienist to successfully treat the anxious patient. With periodontal maintenance and recall appointments, dental hygienists often encounter the fearful patient, which places them in an ideal position to alleviate pain.

REFERENCES

1. The Influence of Gender and Ethnicity on Management of Chronic Pain Disorders. Available at: www.medscape.com/viewarticle/416595. Accessed March 13, 2007.
2. Pickering G, Jourdan D, Eschalier A, Dubray C. Impact of age, gender and cognitive functioning on pain perception. Gerontology. 2002;48:112-1128.
3. Cohen BE. Use of aromatherapy and music therapy to reduce anxiety and pain perception in dental hygiene. Access. 2001;15:34-35.
4. 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.
5. States Where Dental Hygienists May Administer Local Anesthesia. Available at: www.adha.org/governmental_affairs/downloads/localanesthesiamap.pdf. Accessed March 13, 2007.
6. Niessen LC, George MD. Anesthetic options for nonsurgical periodontal therapy. The Journal of Practical Hygiene. 2005;14:1:35-37.
7. Jeffcoat MK, Geurs NC, Magnusson I, et al. Intrapocket anesthesia for scaling and root planing: results of a double-blind multicenter trail using lidocaine prilocaine dental gel. J Periodontol. 2001;72:895-900.
8. Magnusson I, Geurs NC, Harris PA, et al. Intrapocket anesthesia for scaling and root planing in pain-sensitive patients. J Periodontol. 2003;74:597.
9. Anderson JM. Use of local anesthesia by dental hygienists who completed a Minnesota CE course. J Dent Hyg. 2002;76:35-46.
10. Friskopp J, Nilsson M, Isacsson G, et al. The anesthetic onset and duration of a new lidocaine/prilocaine gel intrapocket anesthetic (Oraqix) for periodontal scaling/root planing. J Clin Periodontol. 2001;28:453.
11. Cooper MD. Nitrous oxide/oxygen sedation in dentistry. Contemporary Oral Hygiene. 2006;12:24-29.
12. Aartman IH, de Jongh A, Makkes PC, Hoogstraten J. Treatment modalities in a dental fear clinic and the relation with general psychopathology and oral health variables. Br Dent J. 1999;186:471.
13. Carroll D, Seers K. Relaxation for the relief of chronic pain: a systematic review. J Adv Nurs. 1998;27:476-487.
14. Slovin M. Managing the anxious and phobic dental patient. NY State Dent J. 1997;63:36-40.

From Dimensions of Dental Hygiene. July 2007;5(7): 24, 27.