Anxiety and Pain Control DH 301 Clinic V By Judy Valdez 3-13

Fear of Dentistry The fear of going to the dentist had remained un unchanged for the past 50 years. Dental anxiety hinders the dentist-patient relationship and impairs the treatment experiences. Approximately 23 million US adults in (2005) avoid seeking dental care due to fear. 75% of dentists see patient anxiety as a major barrier that prevents patients from receiving adequate dental care. Journal of American College Health, Woodmansey (2005) 3-13

Anxiety A negative, emotional response to an anticipated event, which the outcome is unknown. A learned response from personal experiences or from stories of others. Dental anxiety is more specific than general anxiety. Severe dental anxiety: irrational and disproportionate to the actual threat, yet the patient is unable to control his or her emotions and reactions. Severe dental anxiety also called dental phobia. Clinical Practice of the Dental Hygienist, Wilkins (2013), Journal of American College Health, Woodmansey (2005) 3-13

American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders (DSM IV) of the American Psychiatric Association defines phobia “a persistent and irrational fear of a specific object, activity, or situation that results in a compelling desire to avoid the dread object, activity, or situation.” Anxious dental patients tend to be young females, hold negative attitudes toward dental personnel and have poor oral hygiene. Journal of American College Health, Woodmansey (2005) 3-13

Reducing Dental Anxiety for mild to moderate Patients with anxiety that is mild to moderate, dentist can use stress reduction protocols as effective anxiolytic agents. Like: ▫Morning appointments when patient is more likely to be rested. ▫Also shortens the waiting time which helps decrease anxiety. ▫Keep treatment visits within the limits of the patient’s tolerance. ▫Empower patients with control over certain aspects of the dental visit. ▫Use adequate pain control measures during and after treatment. Journal of American College Health, Woodmansey, (2005) 3-13

Reducing Dental Anxiety for moderate to severe In moderate to severely anxious dental patients, pharmacological sedation may be required. Inhaled nitrous oxide and orally administered benzodiazepines are common dental sedatives. Journal of American College Health, Woodmansey, (2005) 3-13

Assessing dental anxiety Corah’s Dental Anxiety Scale (CDAS): the most widely used anxiety assessment. Standard to assessing dental anxiety since Patients rank their anxiety on a scale of 1-5 for each situational dental question. Scores of 4-7: low to no dental anxiety Scores of 8-11: mild anxiety Scores of 12-15: moderate anxiety Score of 16 or greater: severe anxiety=dental phobia. Journal of American College Health, Woodmansey, (2005) 3-13

Anxiety & Pain Control Dental hygienist care plan should include methods to recognizing and managing pain and anxiety. The decision to use pharmacological agents depends on: ▫Periodontal health status ▫Treatment being rendered ▫Patient’s pain threshold Clinical Practice of the Dental Hygienist, Wilkins (2013) 3-13

Pain A sensation in which a person experiences discomfort, distress, or suffering. Can vary in intensity from mild discomfort to intolerable agony. Pain threshold: the point when a sensation starts to be painful and a response results. Varies in patients based on the interpretation of the sensation. May be altered by drugs. ▫High pain threshold: greater than average tolerance to a painful stimulus. ▫Low pain threshold: strong or rapid reaction to a painful stimulus. Clinical Practice of the Dental Hygienist, Wilkins (2013) 3-13

Components of pain Pain Perception: ▫Physical process of receiving a painful stimulus and transmitting the message to the brain. ▫Brain interprets pain. ▫Little variability in pain perception between individuals with intact nervous systems. Clinical Practice of the Dental Hygienist, Wilkins (2013) 3-13

Components of Pain Pain Reaction: ▫Reaction is a combination of interpretations and the response to the pain message. ▫Reaction is highly variable between patients. ▫Factors that influence pain reaction: age, fatigue, emotional state, fatigue, cultural and ethnic learned behaviors. ▫Patients experiencing anxiety is predisposed to feel pain. ▫Patients with a strong or rapid reaction to pain have a low pain threshold. Clinical Practice of the Dental Hygienist, Wilkins (2013) 3-13

Pain Control Mechanisms Five pain control mechanisms. Can be combined for optimum effect. Anxiety and pain control management should be included in the dental hygiene care plan and noted in the patient’s chart. Important to match the pain control method to the patient’s treatment needs and medical status. Pain management works best when it is implemented prior to the patient experiencing pain. Clinical Practice of the Dental Hygienist, Wilkins (2013) 3-13

Pain control mechanisms 1. Remove the painful stimulus. ▫Patient avoids dental appts, clinician corrects faulty pain causing instrument technique. 2. Block the pathway of the pain message. ▫Use of local anesthetics, topical anesthetic 3. Prevent pain reaction by raising pain reaction threshold. ▫Use of nitrous oxide, or nonopioid analgesics like NSAIDS. Clinical Practice of the Dental Hygienist, Wilkins (2013) 3-13

Pain Control mechanisms 4. Depress central nervous system: ▫General anesthesia 5. Use psychosedation methods: ▫Nonpharmacologic technique that reduces patient anxiety, builds a trust relationship, lets the patient feel more in control. ▫Used alone or with pharmacologic pain management. ▫Ex. – Explain procedure carefully, allow patient to express concerns, use relaxing or distraction techniques. Clinical Practice of the Dental Hygienist, Wilkins (2013) 3-13

Nonopioid analgesics OTC medications for preventing or reducing mild to moderate discomfort. Drugs include: ▫Nonsteroidal anti-inflammatory (NSAIDS): the drugs of choice for dental pain. Ibuprofen, Advil ▫NSAIDS block prostaglandin synthesis at peripheral nerve endings to inhibit pain messages. ▫Suppresses onset of pain. ▫Decreases pain severity. ▫Used for mild to moderate pain during treatment and mild to moderate pain postoperatively. Clinical Practice of the Dental Hygienist, Wilkins (2013) 3-13

Anesthetics Block anesthetics: injecting the anesthetic close to a nerve trunk, may be at a distance from the area being treated. General anesthesia: elimination of all sensations, accompanied by a loss of consciousness. Infiltration anesthesia: injecting the anesthetic directly into or around the tissues to be anesthetized. Local anesthesia: loss of sensation, in an area without a loss of consciousness. Clinical Practice of the Dental Hygienist, Wilkins (2013) 3-13

Anesthetics… Noninjectable local anesthesia: anesthetic gel extruded into the periodontal pocket resulting in the loss of sensation to the adjacent soft tissues. Topical anesthesia: form of local anesthesia whereby free nerve endings in accessible structures are rendered incapable of stimulation by the application of an anesthetic drug directly to the surface of the area. Clinical Practice of the Dental Hygienist, Wilkins (2013) 3-13

Sedation A stage of anesthesia in which the patient is still conscious but is under the influence of a central nervous system depressant drug. Conscious sedation: calming of nervous excitement while maintaining a conscious state by pharmacologic, nonpharmacologic or combined methods. Iatrosedation: reduction of anxiety as a result of the clinician’s behavior or actions. Psychosomatic method of pain control. Clinical Practice of the Dental Hygienist, Wilkins (2013) 3-13

NSAIDS Onset: 30 minutes after administration. Peak onset: 2-3 hours after administration. Maintenance: second dose 4 hours after the initial dose. For treatment pain: take 2 hours before. Postoperative pain without local anesthetics: take immediately before treatment. Postoperative pain with local anesthetics: take at the completion of treatment. Clinical Practice of the Dental Hygienist, Wilkins (2013) 3-13