Introduction

Pain and Anxiety Control in Dentistry -- This Is No Humbug

Tim Silegy, DDS

Copyright 2003 Journal of the California Dental Association.

Contributing Editor

Tim Silegy, DDS, is a diplomate of the American Board of Oral and Maxillofacial Surgery. He maintains a private practice in Long Beach, Calif.

Pain and suffering are an unfortunate part of human experience. It is also perhaps dentistry’s greatest paradox.

Patients will refrain from seeing the dentist for years fearing the relatively minor discomfort of the dental injection. They will reject even the simplest of treatment plans stating, “If my tooth doesn’t hurt, Doc, why bother?”

Paradoxically, the pain of a toothache (avoidable with regular preventive care) is frequently what drives our patients to see us.

For many, “pain” and “dentistry” are synonymous, so much so that this association has been incorporated into our popular vernacular.

A daunting task is “like pulling teeth,” a difficult decision, akin to a root canal.

John Patrick’s play The Teahouse of the August Moon chronicles the struggles of Okinawan villagers during the Second World War. The play ends with the protagonist making this statement. “Pain makes man think. Thought makes man wise. Wisdom makes life endurable.”

I saw the play almost 20 years ago, and this closing statement has stayed with me ever since.

I am reminded of it almost daily, as I induce general anesthesia in an apprehensive patient for third-molar removal, see the look of relief in the eyes of a toothache patient after having received a mandibular block, witness the blank stare of a pediatric patient breathing nitrous oxide who was crying only moments before, or explain to a patient with facial pain that in spite of what others may think her pain is real and she is not crazy.

As dentists, we are judged not by our ability to carve tertiary anatomy into a shiny new amalgam, but rather by our ability to make the procedure painless.

It is appropriate, then, that we dedicate this issue of the Journal of the California Dental Association to pain and anxiety control in dentistry.

* Dentists utilize local anesthesia more than any other health professionals do. Dr. Alan Budenz reviews basic concepts of local anesthesia, introduces new agents and armamentaria, and gives protocols for managing the hard-to-numb patient.

* Drs. Stanley Malamed and Morris Clark review nitrous oxide and address myths that may be preventing its more frequent use. They make the case that with proper administration and well-maintained equipment, the nitrous oxide-oxygen technique has an extremely high success rate and a very low rate of adverse effects.

* Dr. Roger Kingston and I discuss the principal pharmacologic modalities that appropriately trained dentists can use to manage pain and anxiety in apprehensive dental patients.

* Dr. Scott Jacks and I review oral conscious sedation and demonstrate that it can be a safe and cost-effective alternative to intravenous sedation and general anesthesia for children who could otherwise not be treated.

* Dr. John Yagiela challenges traditional assumptions about the appropriate management of acute and postoperative dental pain by reviewing the literature on currently available oral analgesics used in dentistry.

* Patients suffering from chronic pain and headache can be found in all dental practices. Dr. Steven Graf-Radford reviews current methods of diagnosing chronic pain and discusses the physical, pharmacologic, and behavioral interventions currently used to manage it.

The work of these individuals reflects dentistry’s ongoing commitment to reducing and, it is hoped, one day eliminating pain and anxiety in our patients.

It is a noble cause now, as it was 150 years ago when, in amazement, Dr. John Warren uttered, “Gentlemen, this is no humbug!” after having painlessly removed a tumor from a patient under the effects of ether anesthesia administered by, none other than a dentist, William T.G. Morton, DDS.