In: Dental treatment28 Mar 2010
Our results indicate that there is clinical meaningfulness for a variety of powerful psychosocial and cultural influences that come to bear on the perceived need for anesthetic in tooth drilling. Although gender and age affected Scandinavians to some degree, pain beliefs by ethnicity and differences in health-care systems were variables with predictable outcomes across ethnic groups. This implies that given anatomic similarities, expectations developed from a person’s upbringing and social environment about a clinical procedure such as tooth drilling can influence pain perception dramatically. Many Scandinavians and Chinese have been brought up to believe that tooth drilling does not hurt or that it is only minor pain. The opposite was found for the Anglo-Americans. This affects clinical decisions regarding the use of pain control.
There are also political-policy related incentives for or against using local anesthetic for such a procedure. Present results also have immediate policy implications in Denmark, where despite broad National Dental Health Insurance coverage, patients are required to pay for “pain free” fillings, unlike other nations in the study. Danish national insurance does, however, cover the use of local anesthetic in the cost of tooth extractions but not root canal therapy. A history of traditional nonuse of local anesthesia for dental fillings in Denmark indicates that the process of fee-schedule negotiations between the Danish Dental Association and officials representing the National Health Insurance provide economic reinforcements to maintain the current fee schedule. That some older patients in Sweden were under the impression that one still needed to pay for local anesthesia separately, despite a change in practice dating back to the late 1940s and early 1950s, indicates a need for direct verbal communication or printed information for older patients.
Because there are economic incentives for patients not to use local anesthetics for tooth drilling in Denmark, it is remarkable that it is also here that nonuse of anesthetic was also considered a “barometer of trust” in the dentist-patient relationship. Even though there is no previous literature directly linking trust in dentists with altered pain thresholds, it is possible that if a patient’s level of relaxation is increased the pain threshold can be modified, according to the Gate Control theory of pain. It is striking that almost all Scandinavian dentists chose local anesthesia for their own dental treatments, whereas only about one-half of their patients did. American and Chinese dentists more closely paralleled their patients’ preference or nonpreference for anesthetic. One might surmise that armed with knowledge about the possibility for pain-free treatment, and in the case of the Danes cost-free pain-free treatment, that patients might choose more often to be anesthetized. On the other hand, in Sweden, where there are no economic influences on choice of anesthetic, 34% of patients chose not to be anesthetized for routine fillings, which is evidence for Scandinavian pain beliefs that anesthetic is often not necessary. Still, Danes were three times less likely to use anesthetics than Swedes, which offers some evidence that public policy can have a very strong influence on pain treatment choice at the individual level.
Phenomena as described by the Chinese are also potentially important with regard to pain perception, the need for anesthetic, and the dentist-patient relationship. The Chinese concept of suan or “sourish” sensation in tooth drilling has previously been described, and it is usually thought of as tolerable. Thus, the Chinese concept of suan directly impacts the expected interactions between patients and dentists from within the cultural framework. Unless it is suantong, or sourish pain, most of the Chinese dentists describe tooth drilling as only “sourish,” whereas injections are usually described to patients by their dentists as outright “painful” (tong). There are no attempts to cognitively diminish the sensation of injections by Chinese dentists as the western dentists do when describing it only as a “pinch” or a quick, short “discomfort.” Our data are also in agreement with previous data, indicating that Mandarin Chinese do not require local anesthesia for tooth drilling and that injection pain is perceived as relatively more painful than tooth drilling pain. Studies of dental anxiety in Asiatic patients also suggest that communication between dentist and patients is “one way,” with dentists deciding when pain control is appropriate. Present data suggest that this one-way communication works for some patients but that undue fear of injections may be reinforced in other patients by Chinese dentists. There may be other cognitive mechanisms, such as trust in authority, working for Chinese patients that decrease pain perceptions, which need to be explored in future research.
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Cross-cultural interpretation of pain resulting from injections as worse than or producing more anxiety than tooth-drilling sensations indicates that the psychosocial component of pain perception is heavily tied to the patient’s expectations and gradients of anxiety, which are usually shaped by the social values and norms of the ways people expect to be treated and are expected to behave. The possibilities for learning anxiety or pain beliefs through social interactions with dentists or friends and family who express their own ways of thinking about pain and coping are enormous. Self-fulfilling prophecies or similar expectation phenomena are thus perhaps the mechanisms that drive cultural coping strategies, for better or worse. Encouraging a patient to express concerns or discomfort, whether about anxiety or pain, allows the practitioner to communicate without bias and in terms with which the patients feel most comfortable. This can improve the feeling of trust in the interaction, which can in itself have healing effects. However, when negative expectations hinder adequate care, specific psychosocial strategies must be employed to reframe the patients’ expectations of the event they perceive as painful or anxiety provoking, keeping in mind the patient’s cultural background and assumptions. If provided with adequate information and choices about local anesthesia, some patients might choose differently than their dentists or third-party insurers have come to expect from them.
Blog invites submissions of review articles, reports on clinical techniques, case reports, conference summaries, and articles of opinion pertinent to the control of pain and anxiety in dentistry.