Pediatric pain control involves quick thinking to put kids at ease
BY Cathy Hester Seckman, RDH
The five-year-old in my chair was staring into space, fairly vibrating with nervous tension. His mother, standing alongside, had her teeth clenched and forehead furrowed. OK, I thought, this isn't good.
"What's going on, Branton?" I asked casually. "You look nervous. Are you worried about me?"
"He doesn't like coming here," his mother blurted.
Oh, good, I thought, she's making it worse.
"Let's see what he thinks," I suggested. "Branton?" In the split second when he darted his eyes toward me, I said, "Tell me why you're nervous."
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Deciding to be brave, Branton forced himself to reveal his deepest fear. "Is it gonna hurt?"
"No," I said calmly. "I won't hurt you, but when I polish your teeth it might tickle. Will you be okay if it tickles?"
He shrugged, unable to admit anything might be okay.
"You must not be worried about tickling then. The first thing I'm going to do is use my mirror and my tooth checker - see, remember the tooth checker? - to count your teeth."
Hesitation can be fatal for a pediatric hygienist, so without any delay I placed the ring finger of my left hand on an upper cuspid for a fulcrum.
"Ow, ow, ow, ow!" Branton shrieked, pulling away in a panic.
Sigh. Did Branton really think my fulcrum was painful? Was he trying to stop me in my tracks, hoping to get out of the appointment? Was he having an extra dramatic day? Was he pretending because he thought it would be funny? Or was he just trying to get sympathy from his mother? Any of those scenarios might have been the right answer, but it's also very possible that Branton really thought I had hurt him. He expected pain, he perceived pain, and so he experienced pain.
Managing a patient's actual or perceived pain is difficult enough, but pediatric pain management takes that difficulty to a whole new level. We all know there's very little a hygienist can do to a child that causes actual pain. We might pinch a lip once in a while, accidentally put pressure on a loose tooth, or even slip with a scaler. Probably the most uncomfortable thing we do to our little patients is asking them to close on a bitewing tab.
Let's talk about actual pain first. In continuing education courses, I've heard speakers say over and over that the first rule in dealing with patients is, "Don't hurt them!" The American Academy of Pediatric Dentistry agrees with this statement. Their 2012 policy statement on pain management begins with these two recommendations:
• Recognize and assess pain, documenting in the patient's chart.
• Use nonpharmacologic and pharmacologic strategies to reduce pain experience preoperatively.1
Nervous little Branton deserved my recognition of his frantic, "Ow, ow, ow, ow!" even if there was a good chance he was faking it. If I said, "Oh, no, what happened?" that would give him an opportunity to explain. Maybe I really was pinching his lip without knowing it, or maybe he was just trying to delay the inevitable. Either way, I needed to assess the reason for his reaction and decide how to handle it.
If his lip was being pinched, it could be because his mouth is very small, in which case I needed to adjust my approach. Or it could be because I was in a hurry and was not paying attention. In that case I needed to apologize, admit it was an accident, explain how it happened, and promise not to do it again.
This is where mindfulness can be an asset in your practice. As an attribute of consciousness, mindfulness is defined as "where conscious attention and awareness are actively cultivated," and as a state of "being attentive to and aware of what is taking place in the present."2
How mindful are you on an average day at work? It's impossible, of course, to always stay present in the moment, but we can make an extra effort during direct patient care, when the patient's well-being and safety are concerned. Interestingly, mindfulness has been positively associated with our own well-being,2 which can make our day less stressful and more enjoyable.
The second recommendation of the AAPD - to use nonpharmacologic and pharmacologic strategies to reduce pain preoperatively - can also address actual and perceived pain.
What are some nonpharmacologic strategies for actual pain? If a loose tooth is tender, concentrate on mindfulness and find another fulcrum. I can't count the number of times I've acknowledged a loose tooth, only to fulcrum on it later, which tells me I really need to work on that mindfulness.
Pediatric dentists' methods of pain control
Beyond the hygiene appointment, pediatric dentists manage the pain of operative treatment in various ways. Local anesthetic, preceded by a good topical anesthetic, can take care of simple dental procedures. Most children who have asked me about shots seem to take the idea in stride.
I usually shrug my shoulders and say, "You've had shots at the doctor's office, right? It pinches and stings, and then it's over. It's like that here, too, except the shot goes beside your tooth to make it go to sleep." Controlled delivery systems can make injections even easier.
Sedation is an option frequently used in pediatric dentistry. Conscious sedation, for instance, can be defined as a state of anesthesia in which the patient is conscious but rendered free of fear and anxiety.5 One of the specific goals of conscious sedation is to reduce the perception of pain and discomfort while enabling the child to be alert enough to respond to a directive such as, "Stay open." Conscious sedation is typically administered as a mix of different drugs delivered as a flavored drink. If a child won't drink the liquid, even after being allowed to choose a flavor, a large syringe can be used to squirt the liquid toward the back of the mouth. The drugs can also be delivered in rectal or nasal preparations.
Intravenous sedation provides more profound sedation while still allowing the child to breathe independently. Inhalation sedation is most commonly delivered by nitrous oxide and oxygen.6 I've heard kids describe this type of sedation as, "really cool - you just float around and don't care." All of these types of sedation, of course, are surrounded by rules and regulations to protect both patients and practitioners.
For traditional bitewings, I typically roll a corner of the film under without creasing it to keep the corner from digging into the floor of the mouth. You can also try using a Snap-A-Ray so the child doesn't have to bite down so far. Even pediatric film can be folded a fraction of an inch on a short side so that it doesn't extend too far into a tiny mouth. Put the folded side into the hinge of the Snap-A-Ray, and you'll still get a readable diagnostic film.
If the child has a lot of calculus and/or stain to deal with, get out the ultrasonic scaler (be sure to give a thorough explanation to the patient) and proceed at a low setting. You can also use an always-sharp instrument such as an American Eagle XP or Hu-Friedy Ever-Edge. Polishing with mixed dry pumice and hydrogen peroxide is an old but still very effective way to remove even black-line stain effortlessly.
What are some pharmacologic options for actual pain? For the pain of a sharp film corner, try a topical or spray anesthetic. For a cold sore that's hard to avoid, coat it with a product such as Orabase, Zilactin, or Anbesol, if the child is older than age 2. For a child older than 12, Abreva might be a good choice. Dry, chapped lips can also be painful during hygiene treatment, so be sure to coat them with a petrolatum-free product such as Lubricoat from Dux or Burt's Bees lip balm.
In my experience, children rarely have general sensitivity, but if that's the case, prepolishing with a product such as Colgate Sensitive Pro Relief can take care of the problem.
Now let's consider perceived pain and options to control it. If I'm skeptical about Branton's "Ow, ow, ow, ow!" reaction, I can try to pry the truth out of him with a tell-show-do exercise. "Well," I might say, "all I did was put a finger on one tooth. Did you know that's all I was doing?" His mother can confirm my action. "Branton, I'm going to put my finger on your tooth again. Here's a mirror, so you can watch me do it. See how my finger is right next to your tooth? Now I'm going to touch your tooth the same way I did before, and you can tell me what it feels like."
It might take a few tries, but by being patient and repetitive, I can get Branton to admit that, no, my fulcrum isn't actually causing him any pain.
Working in pediatric dentistry, I've noticed children aren't always able to distinguish between sensation, the touch of my finger, and perception, receiving that touch as pain. Sometimes it helps to offer scenarios. For instance, "Branton, if I touch your arm like this with my finger, it doesn't hurt, does it? But what if I made a fist and pounded on your arm really hard? That would hurt, wouldn't it? So if I touch your tooth with my finger the same way I did on your arm, will it hurt the way it would hurt to pound the tooth with my fist?"
A five-year-old can easily accept the logic that helps him or her understand the difference between sensation and perception. It also helps, especially with boys, to inject some silliness. My boss used to demonstrate a pounding motion with wild waving of his hands and a loud, "Bam! Bam! Bam!"
Dental fear and anxiety (DFA) can result in very real perceptions of pain, so helping a child deal with that can remove the perception. Research shows that children can successfully employ coping strategies in situations where they experience DFA.3,4
Coping strategies can be internal or external. External strategies depend on cultural factors and the influence of others. Internal strategies include thinking patterns, beliefs, self-talk, and a child's sense of control over the situation. Coping strategies have common elements, according to Casamassimo et al. These elements include assessment of the problem by the child, a reframing or reconstruction of the child's viewpoint, development of mechanisms such as muscle relaxation, and recognizing success.4
One form of coping is called modeling. If a child can watch a parent or sibling calmly receive dental treatment and then get up and walk away, that gives the child a model to follow. Distraction is another good coping mechanism and can be contingent upon good behavior. Allowing children to watch cartoons (if the office has a TV) or listen to music over headphones can distract them just enough that they don't fuss over water spray, strange tastes, or unfamiliar sensations.
Patience is the key. If you stay mindful, use all the tools at your disposal, employ lots of tell-show-do, and don't mind repeating yourself, any actual or perceived pain can be kept to a minimum. Both you and your little patient can relax and enjoy - or at least put up with - a good hygiene appointment. RDH
Cathy Hester Seckman, RDH, has worked in pediatric dentistry for 12 years. She is a frequent contributor to dental magazines, works part-time as an indexer, and is the author of two novels and more than a dozen short stories.
2. Brown and Ryan. The benefits of being present; mindfulness and its role in psychological well-bring. Journal of Personality and Social Psychology, 2003, vol. 84, no. 4, 822-848.
3. Van Meurs et al. Child coping strategies, dental anxiety and dental treatment: the influence of age, gender and childhood caries prevalence. Eur J Paediatr Dent. 2005 Dec;6(4):173-8.
4. Casamassimo H et al. Pediatric Dentistry: Infancy through Adolescence. 2013, Elsevier Health Services.
6. Koch G, Poulsen S. Pediatric Dentistry: A Clinical Approach. Blackwell Publishing 2009.