Thoughts from Year One: The Pain Management Conundrum

“No pain, no gain.” Like many, I heard this phrase hundreds of times while growing up. The simplicity and motivational overtone of this impactful catch phrase can easily be applied to almost any difficult situation. Ironically, I have never heard it used while at the dental office. As a practicing dentist, I now understand why.

Using “the P word” loosely around the office can have the same effect on patients that severe turbulence has on airline passengers: increased heart rate, rapid breathing, white knuckles gripping armrests, and darting eyes looking for the nearest emergency exit. Yet, inflicting and managing pain is an innate part of the dental profession whether we like it or not.

In an attempt to navigate this unavoidable aspect of practicing dentistry, I began to experience pain of my own. While this pain was emotional, at times, it felt just as physically painful as anything else I’ve experienced in my life. To overcome these feelings, I purposefully sought out insight from colleagues, educators, and behaviorists/psychologists.

When patients present with physical pain it is often accompanied with an emotional counterpart: anxiety. These simple tricks seem to help make the appointment easier for the patient as well as myself:

1. Patient interview. I always start the appointment by conducting a patient interview with both the patient and myself in a seated position. I raise the dental chair so that the patient’s eye level is slightly above my own, which subconsciously makes the patient feel like they are in a position of power rather than vulnerability. I purposefully speak slowly, with minimal gesturing, and a slightly quieter tone to convey calmness, empathy, and a gentle demeanor.

2. Explanation of process. While still seated, I briefly describe the type of evaluation/examination process that I would like to complete. I also let the patient know that as we go through the examination process, I will show them what I am testing for in an area of the mouth that is not experiencing pain. This not only gives me baseline information and a control for the testing that I am doing, but it also lets the patient know that what I am doing does not cause harm or pain to an area that is healthy. I also customize my testing methods based on the patient’s responses in the interview. For example, if a patient tells me that breathing in cold air causes pain, I’m going to start my vitality testing with air from the air water syringe rather than endo-ice. I have found that these techniques minimize the frequency of a painful surprise that may cause the recurrence of anxiety or possibly a reason to become distrustful.

3. Imaging review. Lastly, I make sure that I review any imaging (radiology or intraoral photography) with the patient in a manner that promotes co-diagnosis between the patient and myself. I believe that engaging the patient in this part of the examination empowers them to make rational, rather than emotional, treatment decisions. It also develops trust that will carry over into the treatment phase.

After going through this process, my anxiety is usually reduced, patient trust/confidence is gained, and an easier treatment appointment lies ahead. I am also able to tell if the patient is a better candidate for some type of sedation or referral, both of which can be valuable resources to minimize my own anxieties about working with the patient in the future.
When addressing pain experienced during injection of anesthetic, intraoperatively, or postoperatively, I attempt to make peace with the fact that no matter how hard I try, these experiences are often unavoidable. The only things I can do to mitigate them is to minimize patient anxiety (with or without anxiolytic agents), attempt to manage the expectations of the patient with appropriate communication, and use the best technique possible/available. My personal techniques related to these encounters simply involve topical anesthetic, extremely slow advancement of the needle with concurrent aspiration/injection, intraoperative monitoring and communication, and personally delivering thorough postoperative instructions. I also prefer to personally follow up with my patients by phone 1 to 2 days after their treatment. This call adds a nice personal touch that communicates empathy, conveys accountability, and further develops trust. For me, the postoperative phone call is one of the most valuable components of my practice philosophy and also for my mental/emotional well being. In the end, as ridiculous as it may sound, we must actively remind ourselves that our actions are not malicious, and we only want what is best for our patients.

Even after incorporating all of this advice, I have experienced suboptimal outcomes and encounters that tested my mental and emotional fortitude. These encounters can come from patients, co-workers, colleagues, labs, or managers. During my first year of practice, I was fortunate to experience all of the above. I can say that it was fortunate now that I am standing on the other side, but in those moments, the emotional pain that I experienced was all-consuming. In those moments, the voice in the back of my head told me to quit, give up, and run away. Sometimes it felt like the only thing that made me go back to the office the next day was my student loan debt. I leaned heavily on my family, my girlfriend, my counselor, and my colleagues to help me get through it, and each time I emerged a little bit smarter, stronger, and more humble. For that, I am grateful.

Through all of these experiences, I believe that I, along with many of my patients and co-workers, have been able to gain insight into what makes a dentist-patient relationship and the clinic-patient relationship successful, mutually beneficial, and hopefully a little less painful.