Pain management

Chapter 9

Pain management

With the collaboration of Richard Steffen

Therapy of already existing pain or elimination of potential pain as part of dental treatment are fundamental requirements for successful management of children who have molar incisor hypomineralization (MIH)-affected teeth.

In addition to the classic posteruptive breakdowns, molars affected by MIH can also show strongly hypersensitive reactions. The occurrence of such hypersensitivities does not necessarily have to be linked to the presence of an enamel breakdown.

Children with painful MIH teeth require special behavioral management and pain control. Adequate anesthetic technique plays an important role, especially if more invasive interventions are necessary. Only if the right analgesic is used, pain control can work even with chronic inflammatory irritated MIH molars.1 In the meantime, there are good treatment approaches, which are described below.

9.1 Pain perception in children

Children of all ages feel pain.1 The assumption that their pain perception is reduced and thus there is a lower need for anesthetics and analgesics is not correct.2

Children react to acute pain events even more strongly than adolescents or adults. This is due to the connection of the pain with a causal event and its transient nature, which is not recognizable to children. It is also due to the fear of pain, which is still difficult to control.3 The patient must first learn to deal with pain and to differentiate between real pain and merely unpleasant sensations.

Another influencing factor is that children have a limited ability to communicate in the perception of pain, depending on their age and mental development, and cognitive difficulties in attributing pain. Furthermore, they may encounter an incomprehensible and unsupportive social environment.1,4 Children lack the experience that pain in the dental context is generally limited in time. Here, excessive pain expectations and a focus on the negative aspects of the treatment situation can significantly influence the experience of pain. Thus, in acute pain situations, the child’s organism can only fall back on already learned coping strategies. Only the increasing age-appropriate familiarity with pain leads to an increase in pain tolerance.5

In addition, the experiences of parents, siblings, or friends shape a child’s perception of pain. Gender, culture, and personality also have an influence. Boys and girls, for example, are probably equally sensitive but express their feelings differently.2,6

9.2 Pain originating from MIH

Hypersensitivity represents the second key symptom of MIH in addition to posteruptive enamel breakdown (Chapters 2 and 6) (Fig 9-1). Some children report more or less severe chronic pain sensations already with the beginning of eruption (especially of the molars).

Fig 9-1 Hypersensitive MIH molar: plaque accumulation can be seen, which indicates a lack of oral hygiene due to pain.

The reason for this pain is probably due to the penetration of oral bacteria through the hypomineralized enamel into the dentinal tubules, which can cause inflammatory reactions in the pulp. This seems to be possible even in teeth with intact surfaces and means that even MIH-affected teeth without enamel breakdown must be well examined clinically and checked regularly.7

Children with MIH teeth have a twofold deficit when hypersensitivity is present:

  • Acute hypersensitivity/pain: Pain in MIH teeth often leads to considerable restrictions in oral hygiene as well as problems with the intake of cold and warm food. Hypersensitive teeth are more susceptible to the development of caries as a result of this restricted oral hygiene, especially if an MIH-related substance defect also occurs at the same time. In severe cases, spirals of destruction can be observed here, which can lead to the complete destruction of such teeth in a few months.
  • Chronic hypersensitivity/pain: Sensitization to pain stimuli is considered a central mechanism of chronic pain.

In children with hypersensitive MIH teeth, chronic pain-anxiety conditions and, at the same time, a clearly limited willingness to cooperate with the dentist are very common.1 Likewise, the development of a pain memory can be observed in children suffering from recurrent pain episodes.8 Such a pain memory can trigger intense pain sensations even without direct stimuli, only by experiencing situations possibly associated with pain.

The treatment of acute MIH-induced pain differs substantially from that of chronic MIH pain. Figure 9-2 illustrates this.

Fig 9-2 MIH pain mapping showing various parameters of MIH pain (source: Richard Steffen).

9.3 Child-friendly treatment

Child-friendly treatment protocols, confidence-building activities, and appropriate communicative behavioral guidance generally form the basis for successful dental treatment of children. There are various interactional possibilities and techniques for this. In addition to fear-avoiding conversation and the tell-show-do technique (Fig 9-3), these are primarily methods of influencing the child’s psyche, such as conditioning, positive reinforcement, distraction, and attention control, as well as systematic desensitization and cognitive modeling. However, all these ways of working are very sensitive to external influences.1

Fig 9-3 Tell-show-do technique. a) Tell. b) Show. c) Do.

9.4 Pain control

Due to the described problem of chronic pain conditions in MIH teeth, pain control is of the highest importance to guide affected children through dental treatment.

9.4.1 Investigation

Examining and treating children with MIH requires a high level of attention and empathy. Painless examinations are top priority. Often, classical examination methods, such as the use of an air blower or the switch-on of a warming surgical lamp, have to be modified and replaced by other aids. Since even the use of a saliva ejector can be painful, drainage with cotton rolls is recommended for chronic MIH-pain-affected children. Parotid patches can also be used. Small cotton balls or compression caps can likewise be applied to briefly dry the tooth during the diagnostic examination (Fig 9-4). In addition, flexible and elastic cheek retractors provide a comfortable fit and make it easier for the patient to keep the mouth open (Fig 9-5).

Fig 9-4 Tools for intraoral inspection: cotton rolls, cotton balls, and parotid patches.

Fig 9-5 Flexible and elastic cheek retractors as additional tools (source: Richard Steffen). a) Optragate (Ivoclar Vivadent, Schaan, Liechtenstein). b) Isolite (Zyris, Santa Barbara, USA).

9.4.2 Local anesthesia

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Aug 22, 2023 | Posted by in General Dentistry | Comments Off on Pain management

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