Pain-free dentistry The unattainable Holy Grail? by Dr. Don In 1844 Dr. Horace Wells, a dentist, had a wisdom tooth extracted by his colleague Dr. John Riggs under the pain controlling effect of Nitrous Oxide. He thought that the era of pain-free dentistry had arrived. Since then dentists have been claiming to provide "Painless dental treatment", usually in an effort to encourage patients to visit them. Despite the great advances that have been made in the intervening 155 years patients are often let down and the claim of painless treatment proves to be false. In 1999 there is no longer any excuse for inflicting pain in the dental surgery! With modern techniques and local anaesthetic solutions all dentists should be capable of delivering a painless injection which produces adequate local anaesthesia. In the few cases where heightened anxiety makes this difficult sedation facilities to relieve their anxiety should be available in the practice or on referral. When new patients visit a dentist for the first time they are frequently worried that treatment will hurt. The reassurance from the dentist is usually viewed very sceptically. Previous dentists have also reassured them that "this won't hurt" and then proceeded to do just that. Why should they believe a new dentist? After all, all dentists are the same - aren't they? If you want a patient to believe you, you must earn their trust. This is not something that is lightly given and once earned the trust must be built on and protected. You only have to imagine the scenario where a patient has finally found a dentist who not only claims to provide pain-free treatment but actually does. What happens if that patient who is now relaxed and trusts this dentist is hurt by him or her? Why should they ever trust another dentist again? Even if they have many more pain-free sessions they will always be expecting to be hurt. Many hours can be spent telling patients that treatment will not be uncomfortable - a much better word than painful! Far better to acknowledge the patient's reservations and doubt then start the treatment. Some patients will be very reluctant to let you start because of fear of pain. Reassurance that at worst it will become slightly uncomfortable coupled with a promise to stop at any time the patient wishes gives the patient the feeling of control over the session. You must stop immediately at the patient's request! If there are any instances when you know that there is a possibility of causing discomfort, tell the patient. If you do this and it does not hurt you have done no harm. If you do not and hurt them you have lost their trust. If you tell them and then do cause discomfort you will increase their trust in you. If you have informed them of times that could be uncomfortable they are more likely to believe you when you tell them "this won't hurt". Never lie to a patient. It is unfortunate that many dentists still believe that pain-free dental care is unattainable. This is a problem that must be addressed before the profession can attempt to tackle the public's perception of dental treatment being painful. The starting point of treatment is with the injection. Topical anaesthetic should always be applied. This should be left in place for two minutes but with good injection technique less time is necessary in some areas of the mouth. The topical anaesthetic provides you with about two millimetres of depth of anaesthetised tissue. Providing the tip of the needle stays within this anaesthetised tissue and a slow injection is given no pain should be felt by the patient. The choice of anaesthetic solution is not automatic. Different solutions have different properties and the most appropriate should be used in each instance. Very occasionally despite good topical anaesthetic a slight 'sting' is felt on first injecting. This is caused by the vasoconstrictor and is eliminated by first giving a plain solution such as mepivacaine plain. Such a solution is also useful prior to a block injection. There are many courses and textbooks to instruct dentists on correct technique. What is not so easily learnt is the patience and understanding that is required to truly empathise with our patients. Building a relationship based on trust takes time, not just at one chairside session but over many sessions. Once built such patient relationships will generate a rapidly expanding list of relaxed, appreciative patients who are not only happy to recommend you buy positively expound your virtues to all and sundry - and quite rightly so! The golden rules. Trust must be earned. Once earned don't loose it. Only claim to be painless if you are. If, despite everything, you are going to cause pain - tell the patient in advance. Give the patient perceived control of the treatment session. Always use topical anaesthetic. Treat your patients as you would wish to be treated. Visit Dr Don's website