Fear of pain at the dentist
What paralyses a patient most before a visit to the dentist? It is the fear of pain that can appear during various procedures in the practice – when preparing a defect, in endodontic treatment or extraction. It is precisely because of pain that patients often come too late, when the treatment options are considerably more limited than in the case of detecting, for example, decay at an earlier stage. Despite numerous ways of coping with pain during and after the procedure, patients still often feel uncertain before a visit.
What is pain?
Pain is a sensory modality that constitutes an unpleasant and emotional experience. The sensation of pain is subjective and, at the same time, essential for survival – it is a warning signal and the reaction of damaged tissue in the body. The orofacial area consists of the mouth (teeth, gums and mucosa), the face, the jawbone and the temporomandibular joint. The physiology of the orofacial pain pathways includes the primary afferent neurons, pathological changes in the trigeminal ganglion, the nociceptive neurons of the brainstem and the higher brain functions regulating orofacial nociception.
Fighting pain in dentistry
Since we now know what pain is and which elements of the orofacial area it involves, we can focus on the ways of combating it. Let us begin with the well-known and commonly used non-steroidal anti-inflammatory drugs, specifically ibuprofen. According to studies, ibuprofen significantly relieves and quickly reduces procedural pain in over 90% of patients and post-procedural pain in over 70% of patients, reduces the post-procedural need for medication and also minimises anxiety about anaesthesia and endodontic treatment. In the case of teeth with irreversible pulpitis it significantly increases the effectiveness of the inferior alveolar nerve block by local anaesthetics. Ibuprofen is used both as a drug relieving pain of dental origin and in the treatment of chronic toothache. Dosage and contraindications are decided each time by the doctor.
Local anaesthesia – ways of relieving pain
Another way of relieving pain during a procedure is local anaesthesia, performed using a cartridge syringe or a syringe and a thin needle. It can be infiltration (we anaesthetise directly the area of the root apex of the tooth concerned by the procedure) or conduction (an injection in the area of the nerve, e.g. the inferior alveolar, and the deposition of the agent, which anaesthetises all the teeth innervated by that branch). The most common agents include: 2% lidocaine with epinephrine 1:100,000, 3% mepivacaine, 4% prilocaine, 4% prilocaine with epinephrine 1:200,000, 4% articaine with epinephrine 1:100,000 and 4% articaine with epinephrine 1:200,000.
Adding a vasoconstrictor (e.g. epinephrine) to the anaesthetic prolongs the action of the anaesthetic and reduces its toxic effect by delaying absorption into the bloodstream. A problem can be the unpleasant sensation when the needle is inserted and the so-called "feeling of pressure" when the agent is administered. To reduce discomfort at the injection, a 2% lidocaine gel can be applied to the injection site on the mucosa – applied for at least 1–2 minutes it gives an effect lasting 3–6 minutes. The "feeling of pressure" depends on the speed of administering the agent and the associated pressure, as well as on the temperature and pH of the fluids. When administered too quickly, the pressure of the anaesthetic exceeds the intratissue pressure, which causes mechanical damage to the tissue and an increase in pain. That is why slow administration is recommended, at a speed of about 15 s for every 0.5 cm³. Devices have been created that allow control of speed and pressure (e.g. Injex or Wand); studies on a group of 50 dentists showed that the discomfort associated with administering the agent with an injection device was rated as 2–3 times lower than with a traditional syringe.
Summary
Today there are many measures and methods that make it possible to manage pain before, during and after a procedure. An appropriately chosen agent and method make it possible to achieve the effect of full analgesia and mean that a visit to the dentist does not have to be associated with pain. More about comfortable methods in our offer of pain-free treatment and inhalation sedation.
Studies
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Evidence-based clinical practice guideline for the pharmacologic management of acute dental pain in adolescents, adults, and older adults
Carrasco-Labra A., Polk D. E., Urquhart O., Aghaloo T., Claytor J. W., Dhar V., Dionne R. A., Espinoza L. i wsp. (2024) · The Journal of the American Dental Association · clinical practice guideline based on a systematic review
In acute dental pain in adults, anti-inflammatory drugs, alone or with paracetamol, are usually the first-choice treatment. Opioids should be the exception, at the lowest effective dose and for the shortest possible time.
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Analgesics for the management of acute dental pain in the pediatric population
Miroshnychenko A., Azab M., Ibrahim S., Roldan Y., Diaz Martinez J. P., Tamilselvan D., He L., Urquhart O. i wsp. (2023) · The Journal of the American Dental Association · systematic review and meta-analysis
In children and adolescents after dental procedures, ibuprofen and some paracetamol regimens effectively reduced pain. Dosing has to take account of age, body weight, contraindications and other medication.
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Pain perception following computer-controlled versus conventional dental anesthesia: randomized controlled trial
Attia S., Austermann T., May A., Mekhemar M., Conrad J., Knitschke M., Böttger S., Howaldt H. P., Riad A. (2022) · BMC Oral Health · randomised controlled trial
Computer-controlled delivery of local anaesthetic reduced pain during the injection and during delivery compared with a traditional syringe. The technology can help anxious patients but does not replace conversation and good technique.