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Pain Management for Anxious Patients

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.

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. 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. 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. Clinicians will likely need extra time to have these conversations and allow for pauses in treatment.

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Topical Anesthetics

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. 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. 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.

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Mouthrinse and Nasal Mist

Dyclonine hydrochloride (HCl) is a ketone-based topical anesthetic rinse that provides widespread topical anesthesia throughout the oral cavity. 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. An intranasal mist is available 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.

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Anxiety and Injections

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 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.

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Distraction and Computer-Controlled Local Anesthesia Delivery

Distraction methods are also helpful in delivering a comfortable injection. Vibration has been suggested as an effective method of distraction. There are dental syringe vibrators and vibrating retractors available to make this distraction technique simple. 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 devices can reduce patient discomfort during injections.

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Buffering and Sedation

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. Buffering systems include buffering solutions and mixing devices. Some patients may be candidates for sedation. In many states, dental hygienists can administer nitrous oxide/oxygen sedation. This method is effective for patients with mild to moderate anxiety. Nitrous oxide also has the ability to increase the pain threshold, which can be very effective during the administration of local anesthesia injections.

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