Fear of injection is a significant factor for those who avoid dental treatment. Emotion is a major component in how we perceive pain. Particularly of interest to dental professionals are the emotions associated with local anesthesia injections. In anatomy, we learn the limbic system, prefrontal cortex and anterior cingulate gyrus control emotion. A 1991 study in the Journal of Neuropsychiatry, Neuropsychology and Behavior Neurology, found cancer patients with these areas of the brain removed perceived pain differently.
A 2003 paper for the Emergency Medical Clinics of North America titled “The Psychology of Pain”, reported on perception and pain tolerance. It focused on four main criteria: attention, anxiety, expectations and learned pain.
- Attention – Concentrating on pain increases its severity. In 2002, the Emergency Medical Journal noted that being over vigilant about a bodily sensation can amplify it. This amplification was often to the point of pain. On the other hand, distractions are effective in reducing pain. In 2001, the Clinical Journal of Pain published a study showing this. Burn patients reported less pain when using a virtual reality device during the treatment.
- Anxiety – Fear and a loss of control both contribute to patient suffering. Involving patients in their treatment helps them assume control. Using euphemistic vocabulary, like “prepping” not “drilling” and “mild discomfort” not “pain” can limit anxiety.
- Expectations – Preconceptions about how much pain a person should have, influences how much pain they feel. Additionally, it influences their response to treatment and whether or not the condition becomes chronic. According to a 1994 article in the Journal of the American Medical Association, pain experience in minor whiplash injuries, differed based on geographic location. This has been attributed to the local cultures and expectations. Communicating to patients they have a debilitating injury may contribute to deconditioning, worsening their pain. For instance, a person told they have an ankle sprain may develop a limp. Prescribing medications may lead a person to believe that they should be feeling pain. Alternatively, patients without sick leave that are told to ‘‘act as usual’’ have better outcomes.
- Learned Pain – Social modeling has an influence on the perception of pain. Watching another person experience a stimulus can influence the viewer’s physical perception of the stimulus. In 1984, a study in the Postgraduate Medical Journal demonstrated this phenomenon. Subjects were shown models demonstrating varying pain tolerance to a stimulus. Some subjects observed a high pain tolerance, while other subjects observed a low tolerance model. The subjects that observed high tolerance required 3.48 times greater stimulus before it was painful. Only three percent of the tolerant model patients reported pain to a slight electrical shock. Whereas seventy-seven percent of the low tolerance subjects reported pain.
Studying the psychological aspects contributing to avoiding dental treatment can help manage patients. Proper management can decrease acute pain sensitivity, alleviate inhibitory concerns and effectively involve patients. There is no standard way to treat the anxious dental patient. Management may involve combinations of emotional support, pharmaceuticals or psychological intervention. It is important to treat each patient as an individual to help them feel comfortable in the dental chair.
~Dustin Ruspini, Pacific ’19