CHAPTER 13 Pain and Anxiety Control
Any patient can become anxious or experience pain in a dental environment. They are managed accordingly by using different methods of anxiety and pain control. Patients who are very anxious may need sedation. As a dental nurse student, you are not permitted to assist in conscious sedation (CS) but, once you have qualified, you may consider doing a post-qualification course in dental sedation nursing. This will involve completing a record of experience in the workplace and sitting an examination.
The mental state can significantly influence our level of anxiety and pain perception. Most patients are able to accept non-invasive dental treatments with simply sympathetic management. However, operative treatments, especially those involving cutting or removing soft or hard tissue (surgery, implantology, endodontics, much conservative dentistry and some periodontology) can cause significant discomfort. In these situations, drugs may be needed for analgesia, sedation or anaesthesia. Orofacial pain is discussed in Chapter 5. Analgesic medications are discussed in Chapter 12.
Some practitioners use hypnosis or other techniques in an effort to help. Physical interventions (restraint, holding still or containing) must only be considered if alternative approaches have been considered and are not possible.
It is important always to take a full medical and drug history, since the medical status or medications a person may already be taking can influence the choice of drugs (see Chapters 2 and 6). Certain drugs may need to be avoided or doses reduced in specific conditions. It is particularly important to ensure there is no history of allergy or untoward effect from the drug being considered.
The clinician can check drug doses, contraindications, interactions and adverse reactions in the British National Formulary (BNF) or the special dental version called the Dental Practitioners’ Formulary (DPF).
Local anaesthesia (or local analgesia) is required for many dental procedures. Thousands of patients are treated successfully using LA, without any problem. Some people, however, cannot accept injections and others have a pronounced gag reflex or fear of ‘the drill’. In these patients LA cannot be used or will not help. Such patients may benefit from using CS.
In extreme cases where the patient is unable to co-operate, or in major procedures such as maxillofacial surgery, GA is indicated. However, GA can be potentially dangerous and life-threatening. Therefore GA must be given in a hospital with critical care facilities.
Ethyl chloride is a highly volatile liquid spray which evaporates and produces a near freezing temperature that causes numbness. This can be used before a minor procedure such as the quick incision of an abscess or extraction of a neo-natal tooth. It is flammable.
The preferred method of dental and oral pain control is often injected LA, since it is very safe and is adequate for most procedures. When LA is injected it blocks transmission in the nerve that is in that area. This allows patients to undergo procedures without pain. It is also used in most cases where CS or GA are used. LA is given with an aspirating syringe to prevent the accidental injection of the LA agent into a vein or artery, which could cause the patient to collapse. Disposable needles are used (and never re-used; Figure 13.1) to avoid any risk of transmitting infections. Needlestick injuries must be avoided (see Subchapter 1.2).
There are several ways in which LA can be given by injection. The most common techniques used in dentistry are: infiltration, regional block and intraligamentary injection. Following infiltration and regional block anaesthesia there is not much systemic absorption of the drug, that is, it does not get distributed in the entire body.
The main LA solution that is used in the dental workplace is lidocaine (formerly called lignocaine). It belongs to a class of drugs called amides. Other commonly used amides for dental procedures are prilocaine, articaine and mepivacaine. See also Table 13.1.
Vasoconstrictor: these substances help constrict blood vessels, which reduces the bleeding in the operative field and concentrates the anaesthetic in the area (there is reduced absorption by blood), thus increasing its effect and making it last for longer.
A dental syringe (Figures 13.1 and 13.2) is a hand-held device that carries the LA cartridge for injection of LA. The major problem with most syringes is that the needle has to be removed from the syringe prior to sterilisation. This puts the operator at increased risk of injury (sharps or needlestick injury) during the dismantling process. The rising awareness of infection control is also putting increased pressure on manufacturers to introduce fully disposable instruments. These issues have led to the development of dental safety syringes. The types of safety systems include: