chapter 3 The Spectrum of Pain and Anxiety Control
A variety of techniques are available to dental and medical professionals to aid their management of a patient’s fears and anxieties regarding dental care and surgery. To some this statement may be self-evident; however, to others the availability of a variety of techniques may come as something of a surprise. The aim of this chapter is to introduce the concept of the spectrum of pain and anxiety control. This spectrum, which is presented graphically in Figure 3-1, demonstrates that there are indeed quite a number of techniques available to manage patients’ fears and anxieties. This chapter introduces the various techniques included in this spectrum, and subsequent chapters and sections describe them in depth.
The vertical bar about three quarters of the way across the spectrum in Figure 3-1 denotes a very significant barrier: the point at which consciousness is lost. Techniques to the right of the bar fall under the heading of general anesthesia, whereas techniques to its left may be termed psychosedation, sedation, conscious sedation, or as recently redefined: minimum, moderate, or deep sedation.1–3
Techniques of sedation may further be divided into those requiring the administration of drugs to achieve a desirable clinical effect and those that do not. The former are termed pharmacosedation techniques, the latter iatrosedation techniques. These terms are further defined elsewhere in this text.
The bar representing the point at which unconsciousness occurs is significant in that it identifies a level of training that must be achieved by the dentist before various techniques can even be considered for use. Without elaborating at this point (educational requirements for specific techniques are discussed in the appropriate sections of this book), it may be stated that the absolute minimum of training recommended for the use of general anesthesia is 2 full years in an accredited residency program. These guidelines for general anesthesia and those for techniques of sedation have been accepted by the American Dental Association, the American Dental Society of Anesthesiology, and the American Dental Education Association.2,3
The duration of time required to adequately prepare the dentist to use the various techniques of sedation safely and effectively will vary from technique to technique and from dentist to dentist. Many dentists and dental hygienists are fully prepared upon graduating from dental school to enter into private practice knowledgeable in the safe and effective use of some of these techniques. Many others, however, will not have obtained this ability, and for these health care professionals, continuing education courses are available.4 In the United States for inhalation sedation with nitrous oxide (N2O) and oxygen (O2), a minimum course of 14 hours, including patient management, is recommended; for intravenous (IV) moderate sedation, a minimum of 60 hours, including patient management, is required.3
In recent years, outpatient surgery in the practice of medicine has greatly increased in popularity. Minor surgical procedures on the limbs, trunk, and face are easily completed with the administration of local anesthetics by general surgeons, dermatologists, cosmetic, and plastic and reconstructive surgeons.5–8 Until recently, however, little consideration was given to the degree of patient anxiety toward this type of surgical procedure. The patient faces these nondental surgical procedures with the same dread as may be seen in dental patients. The techniques and concepts discussed in this book are as appropriate for nondental surgery as they are in dentistry.
Many techniques of pain and anxiety control are available to the health care professional. Which ones, if any, are used is a very personal choice. Some dentists are comfortable using a technique that others might be uncomfortable using. Having several techniques available at his or her disposal enables the dentist to tailor the appropriate sedation technique to a given patient. There is no panacea, nor is any one technique always indicated or always effective. To rely solely on one technique for moderate sedation is to invite the occasional failure.
The extreme left-hand portion of the spectrum of pain and anxiety control (see Figure 3-1) comprises a small group of patients who require absolutely no sedation or local anesthesia during their dental treatment. Although quite rare, it is probable that a dentist or hygienist will be called upon to treat one or more of these persons at some time. For whatever reason—anatomic, physiologic, psychological, cultural, or religious—these patients either do not feel pain or do not react to it, and they are able to tolerate any form of dental treatment without the need for any sort of drug intervention.
Although such patients may not feel any pain in the course of their treatment, such may not be the case with the dentist or hygienist asked to treat them. The following incident actually took place: The patient, a pleasant 26-year-old woman requiring periodontal surgery (soft tissue), requested that the dentist not use any drugs at all during her treatment because she did not require them. After a futile attempt to dissuade the patient from what was assumed to be a foolhardy course, the dentist agreed to begin the surgical procedure without local anesthesia only if the patient would consent to receive it if at any time during the surgery pain was present. The surgical procedure required approximately 45 minutes to complete during which time the patient displayed absolutely no evidence of discomfort to the complete amazement of the (numerous) dental personnel who had gathered around to watch. Vital signs (blood pressure, heart rate, and rhythm) monitored during the procedure demonstrated essentially no deviation from baseline values. Not so with the dentist and assistant. Following the procedure, which proceeded uneventfully, they were bathed in perspiration. The dentist commented that he felt quite uncomfortable throughout the procedure because he knew that the patient should be in pain. Indeed, he stopped many times to ask the patient how she was feeling. He also said that he could almost feel the pain for the patient. “I was uncomfortable for the patient,” he said. At the next surgical appointment, the dentist and assistant were quite pleased when the patient consented to their request to give her local anesthesia for the surgery. When asked why she had changed her mind, the patient stated that she did it for the sake of the dentist and the assistant. She had noticed their discomfort at the prior visit and, although she still did not require the pain-controlling drug, thought it prudent to receive it to allow the dentist to be more relaxed during her treatment.
It is important to separate this small group of patients who truly do not require anesthetics from those patients who similarly request that they not receive local anesthesia because they are quite fearful of injections. It is somewhat easier to recognize such a patient before starting the planned procedure. However, if the dentist is unable to recognize the patient’s anxiety and proceeds to dental treatment, it usually becomes painfully obvious, to both the dentist and the patient, to which group the patient truly belongs.
Iatrosedation, defined as the relief of anxiety through the dentist’s behavior, is the building block for all other forms of psychosedation. The term and the technique of iatrosedation were created many years ago by Dr. Nathan Friedman, then chairman and founder of the Department of Human Behavior, University of Southern California School of Dentistry.9 Discussed in depth in Chapter 6, iatrosedation may briefly be described as a process involving several steps: recognition by the dentist of the patient’s anxieties toward dentistry, management of the information gathered by the dentist from the patient, and a commitment by the dentist to aid the patient during dental treatment.
Simply stated, iatrosedation is a technique of communication between the dentist and the patient that creates a bond of trust and confidence. Patients possessing trust and confidence in their health care provider (physician, dentist, or other health care professional) are well on their way to being more relaxed and cooperative, without the need for supplemental pharmacosedation.10
Another important benefit of the use of iatrosedation in the practice of medicine and dentistry is the prevention of possible medicolegal complications. Lack of effective communication between the health care professional and patient is a leading cause of suits brought against medical and dental professionals. In some estimates, up to 37% of all malpractice actions are a result of a lack of communication and trust between the doctor and patient.11
In some situations, iatrosedation alone may remove all of a patient’s fears and anxieties concerning the treatment, permitting treatment to proceed in a “normal” manner, without the need for pharmacosedation. More often, however, iatrosedation will produce a decrease in the patient’s level of anxiety to the point where the use of supplemental pharmacosedation will enable the patient to more readily accept and tolerate the planned treatment.
Hypnosis has been used for many years for the management of both pain and anxiety. When employed by a trained hypnotherapist, in the proper clinical environment, and on the appropriate patient, hypnosis has proved to be a highly effective means of achieving both a relaxed and a pain-free treatment environment.12
Other nondrug techniques for achieving pain and anxiety control are available. Some are not new, having been introduced to the medical and dental professions years ago. Interest in these techniques has waxed and waned over the years. They may prove to be effective in the hands of some medical and dental practitioners. Textbooks that provide in-depth coverage of these potentially valuable procedures are available and recommended.
Nondrug techniques are mentioned here for the sake of completeness. Developments in this field are occurring so rapidly that it is virtually impossible to include all of them in our compendium of available techniques. Nondrug techniques for the management of either pain or anxiety, or both, include acupuncture,13 acupressure, audioanalgesia,14 biofeedback,15 electroanesthesia (transcutaneous electrical nerve stimulation [TENS], electroanesthesia [EA], electronic dental anesthesia [EDA]),16 and electrosedation.
To this point in discussing the management of treatment-related anxiety, we have not yet employed any technique that requires administration of a drug. Sedation produced without administration of drugs is termed iatrosedation. The use of drugs to control anxiety is termed pharmacosedation. Iatrosedation by itself will allow us to manage but a small percentage of our fearful patients. One advantage possessed by iatrosedative techniques is their ability to increase the effectiveness of any drugs that might be needed for the definitive management of the patient’s dental fears. Even though we may have to turn to pharmacosedation, the great majority of patients in whom iatrosedation has been used will require smaller doses of the drug(s) to bring about a comparable degree of moderate sedation.17
There are many routes through which drugs may be administered (Table 3-1). The first 13 of these routes are used within the practice of medicine, with the first 10 used in dentistry. The intraperitoneal route is used in veterinary medicine. These routes are as follows:
The oral route is the most common route of drug administration. It possesses advantages over parenteral routes of administration that make it useful in various situations involving the management of pain and anxiety. This route, however, has several significant disadvantages that must also be considered. Advantages include an almost universal acceptance by patients, ease of administration, and relative safety. Patients today are accustomed to taking drugs by mouth. It is quite rare to come upon an adult patient who objects to the oral route of administration. The younger child, however, often proves to be an unwilling recipient of orally administered drugs. Unwanted drug effects, such as overdosage, idiosyncrasy, allergy, and drug side effects, may occur whenever any drug is administered by any route, but such reactions are less likely to be noted when a drug is administered orally. When they do occur, they are normally less intense than those reactions that develop following parenteral administration. This is not meant to imply that life-threatening situations do not arise following oral drug administration. Indeed, cardiac arrest and anaphylaxis after oral drug administration have been reported.18,19
Disadvantages of oral drug administration include a long latent period, unreliable drug absorption, an inability to easily achieve a desired drug effect (titration is not possible), and a prolonged duration of action. These are significant disadvantages that serve to limit the clinical use of the oral route in the management of pain and anxiety.
Orally administered drugs must reach the stomach and small intestine, where most absorption into the circulatory system occurs. For most drugs, the onset of clinical effectiveness is not noted for approximately 30 minutes, the latent period. Drug absorption continues, and a peak plasma concentration, equivalent to the greatest degree of clinical effectiveness (pain or anxiety relief), is reached. With most orally administered drugs, this maximal clinical effect develops approximately 60 minutes after administration. Because of this slow onset of action and the delay in reaching maximal effect, it is impossible to titrate via the oral route. Titration is defined as the administration of small incremental doses of a drug until a desired clinical action is observed. The ability to titrate endows the administrator with control over a drug’s actions and its ultimate effect. Titration eliminates the need to make an educated “guesstimate” of the appropriate dose of a drug for a patient. The lack of ability to titrate via the oral route of administration is a considerable handicap to the effective use of this technique when central nervous system (CNS)–depressant drugs are administered. The clinician must administer a predetermined dose to the patient. This dose w/>