- Pharmacological management of pain and anxiety - G. J. Roberts
and M. T. Hosey
4.1 INTRODUCTION
Effective pain management of a child, especially an anxious one, is a challenge to
every dentist. The need for good management of anxiety and pain in paediatric
dentistry is paramount. A common cause of complaint from parents and their children
is that a dentist 'hurt' unnecessarily. Such a complaint can jeopardize access to life-
long dental care.
Children are anatomically and physiologically different from adults. The anatomy of
the airway means that breathing is through a narrower, more fixed 'wind pipe'.
Physiologically, a child is less capable of taking in a bigger volume of air even when
urgently required. Coupled with this, both the demand for oxygen (consumption) and
the incidence of periodic breathing and apnoeas are higher compared to adults. These
differences mean that a child can become hypoxic more easily.
4.2 CHILDREN'S PERCEPTION OF PAIN
A child's perception of pain is purely subjective and varies widely, particularly with
age. Infants up to about 2 years of age are unable to distinguish between pressure and
pain. After the age of approximately 2 and up to the age of 10, children begin to have
some understanding of 'hurt' and begin to distinguish it from pressure or 'a heavy
push'. The problem is that it is not always possible to identify which children are
amenable to explanation and who will respond by being co-operative when
challenged with local anaesthesia and dental treatment in the form of drilling or
extractions. Children over the age of 10 are much more likely to be able to think
abstractly and participate more actively in the decision to use local anaesthesia,
sedation, or general anaesthesia. Indeed, as children enter their teenage years they are
rapidly becoming more and more like adults and are able to determine more directly,
sometimes aggressively, whether or not a particular method of pain control will be
used. The response is further determined by the child's coping ability influenced by
family values, level of general anxiety (trait), and intelligence.
Key Points
- Children are anatomically and physiologically different from adults this results in
them becoming hypoxic more easily. - Children's response to pain is influenced by age, memory of previous negative
dental experience, and coping ability.
4.3 CONSENT
Before you can do anything to a patient, even a simple examination, consent must be
obtained. Consent may be implied, verbal, or written. The main purpose of written
consent is to demonstrate post hoc, in the event of a dispute, that informed consent
was obtained. It has the considerable advantage of making clinicians and patients
pause to consider the implications of what is planned and to weigh the advantages and
disadvantages so that a reasoned and informed choice can be made. The responsibility
for informed consent is often shared between the referring primary care dentist and