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886Nonpharmacologic Issues inPain Perception and ControlStephen WilsonThe English word pain is derived from an ancient Greekword meaning “penalty” and a Latin word meaning“punishment” as well as “penalty.” When the term pain isused in clinical dentistry or medicine, it is synonymous withstrong discomfort. It is important to realize that despite thedistress experienced by the person in pain, pain has auniquely purposeful and necessary function. Pain signalsreal or apparent tissue damage that thereby energizes theorganism to take action in relieving or alleviating its pres-ence. In this sense, it is a desirable experience for maintain-ing and guiding the activities in life.It is important to understand that pain is more thanjust a sensation and a consequential response. It is a highlycomplex, multifaceted interaction of physical, chemical,humoral, affective (emotional), cognitive, psychological,behavioral, and social elements. Certainly, the determinantsof how an individual interprets and reacts to pain are notclearly understood. However, the body of knowledge sur-rounding the understanding of pain recently has begun toevolve and is accelerating rapidly into a scientiﬁc and usefuldiscipline.An interesting and clinically relevant parallel experienceto pain is the presence of anticipatory responses secondarilyacquired from the pain experience. These are conceptualizedand broadly referred to as “stress” and “fear.” Children andadults can be profoundly inﬂuenced by the processes attend-ing many events perceived as fearsome, stressful, or both,including various dental procedures. For example, the2-year-old child who presents with painful, abscessed maxil-lary anterior teeth due to nursing bottle caries and poorlyendures the injection of local anesthesia and extractionswhile restrained in a papoose board will most likely developstrong disruptive and avoidance behaviors. Such behaviorsmay include crying with or without tears, placing hands overthe mouth, refusing to open the mouth, kicking, screaming,shaking the head, spitting, and biting. These may manifestduring subsequent dental appointments.Likewise, adult patients who have been hurt either as achild or as an adult by a dentist who was not considerateor empathetic may have difﬁculty making and keepingappointments.Deﬁnition of PainPain is a highly personalized state attending tissue damagethat is either real (e.g., skin laceration) or apparent (e.g.,excess bowel distention) as a result of an adequate stimulus.Under normal circumstances, the state of pain implies thatthere is a simultaneous activation of cognitive, emotional,and behavioral consequences that provides both motivationand a direction to action.Pain can ﬂuctuate in intensity and quality as a conse-quence of the passage of time. This may be as signiﬁcant totheindividualastheoriginalinsult.Forinstance,theintenselysharp, shooting pain in the lower back of a person who usedan improper weight-lifting technique may change over time(and therapies) to an intermittent deadening, dull ache thatmay signiﬁcantly interfere with a routine lifestyle.OUTLINEDeﬁnition of PainTheories of Pain Perception: Why and How It IsExperiencedSpeciﬁcityPatternGate Control TheoryNeuromatrixCentral Nervous System Effects on PainPerception and ControlCognitive Elements of Pain PerceptionEmotional Elements of Pain PerceptionChildren and PainBehavior Management TechniquesShort- and Long-Term Consequences of BehaviorManagement
CHAPTER 6 Nonpharmacologic Issues in Pain Perception and Control 89large-diameter neurons servicing the area, whereas a hotthermistor (warming element) may cause an initial burstfollowed by a steady discharge of action potentials in smallerneurons.It was theorized that the recognition of painful stimuli bythe individual was based primarily on the pattern of nervousactivity that entered the CNS. Again, this theory was inade-quate to explain the complexity of the pain experience, butit contributed signiﬁcantly to the advancement of knowledgeabout pain mechanisms.4,5GATE CONTROL THEORYThe gate control theory of pain (Figure 6-1) was developedby Melzack and Wall in 1965 and has been the most inﬂu-ential, comprehensive, and adaptive conceptualization ofpain and its consequences to date. The essence of the theoryproposes that various “gates” controlling the level of noxiousinput via small-ﬁber neurons to the spinal cord can be mod-ulated by other sensory, large-ﬁber neurons; higher CNSinput; or both. Postulated mechanisms for the gates includepresynaptic inhibitory effects on secondary transmissioncells in the spinal cord. In essence, this implies that largeﬁbers (e.g., those for touch) can cause partial depolarizationof the nerve terminals of small ﬁbers (e.g., for pain) thatinnervate transmission cells in the spinal cord. This resultsin the release of fewer “packets” of neurotransmitter mole-cules and a decreased likelihood that transmission cells willsummate and ﬁre.A simplistic example would be the ameliorative inhibi-tory effect of the parent rubbing a“bumped”area of the kneeimmediately following a toddler’s fall. The light rubbingPhysiologically, pain involves neural signals that aretransmitted over a multitude of pathways involving neuronsthat are specialized in space, biochemistry, size, and shape.These signals induce a host of secondary responses that maybecome organized in a hierarchy of systems involving por-tions of the central nervous system (CNS).At the physiologiclevel, some of these responses involve further transmissionof neural signals and the release of neurochemicals andhumorally active chemicals (e.g., γ-aminobutyric acid andendogenous opioids). Other systems within this responsehierarchy include those that activate motor activities for pur-poseful escape; still others result in emotional and cognitiveappreciation of the pain experience.Research is showing that the emotional and cognitive ele-ments in the pain process have critical roles in the degreeof pain awareness and, possibly more importantly, in theindividual’s ability to induce self-control while enduringthe suffering or its consequences.1For instance, cognitivemechanisms (e.g., cognitive dissociation) that reduce theperceived quality and quantity of discomfort can be effec-tively taught to a patient before the experience of clinical orlaboratory-induced pain. Children, through the process ofsuggestion, can be taught (to varying degrees) to ignore orto inhibit responsiveness to painful stimuli during cancertherapies.2,3Theories of Pain Perception:Why and How It Is ExperiencedSPECIFICITYIn the late 19th century, it was believed that the pain experi-ence was merely a function of activating a particular set ofneurons that resulted, metaphorically speaking, in a “ringingof the bell” at higher levels of the CNS signifying discom-fort.4,5The neural receptors (i.e., free nerve endings) andtheir pathways were considered to be specialized for theprocess of pain, just as other elements and pathways wererigidly designed as passages for other sensory information(i.e., pressure sensation).Portions of this theory are reasonably accurate descrip-tions and therefore remain prominent in our understandingof the pain mechanism, but the simplicity of the theoryis inadequate to explain the multifaceted nature of thepain experience (e.g., the phantom pain experienced by anamputee in the missing limb).PATTERNA slightly more sophisticated model of pain mechanismsarose as a consequence of the technological ability to recordstimulus-induced activity within neural pathways. Neuralactivity recorded and ampliﬁed on an oscilloscope allowedsome appreciation of the changes in timing and groupingof nerve action potentials as a consequence of modiﬁcationin stimulus parameters. A light stroking across a patch ofskin may provoke one or two isolated action potentials in■ FIGURE 6-1 The gate control theory of pain. (From deWit SC:Medical-surgical nursing: concepts and practice, St Louis, 2009,Saunders.)Gate openGate closedSpinal cordBrainSmall-diameter fiberPain sensation
90 PART 1 Fundamentals of Pediatric Dentistryfew side effects. SPA of the periaqueductal gray area has beenshown to inhibit jaw-opening reﬂexes due to tooth pulpstimulation in cats.12NEUROMATRIXIn more recent years the CNS, and more speciﬁcally thosecomponents of the CNS we generally refer to as higher levelsof CNS functioning (i.e., above the midbrain), has becomea popular focus of pain research. In one theory, a highlycomplex neuronal network or matrix purportedly exists andis referred to as the neuromatrix (Figure 6-2). The neuro-matrix is thought to have some genetic basis but can beinﬂuenced by the internal and external environment.13Theuniqueness of the genetic makeup of the neuromatrix andits ultimate functional identity may aid in distinguishingeach individual’s “body-self.” It is through this neuromatrixthat cyclical processing and synthesis of neuronal activitymay result in a characteristic pattern known as a neurosigna-ture. It has been theorized that neurosignatures can helpexplain complicated states like pain in individuals who expe-rience a speciﬁed set of symptoms that have environmental,situational, or other inﬂuential mediators (e.g., emotions).This abstract model undoubtedly will stimulate a focus offuture research to aid in diagnosing, understanding, andexplaining many clinical conditions.Central Nervous System Effectson Pain Perception and ControlAn endogenous opioid system that is both complex in func-tion and widespread throughout the mammalian CNS hasbeen partially characterized and described.14Endogenousopioids are peptides that are naturally synthesized in thebody and cause effects similar to those of opiates (e.g.,disproportionately activates greater numbers of large ﬁbersthat inhibit previously activated small ﬁbers. In dentistry, ashaking of the lip during insertion of the needle and deliveryof local anesthesia is commonly believed by many to distractor lessen the associated discomfort.Transcutaneous electrical nerve stimulation (TENS), orthe use of low-intensity electrical stimulation at peripheralsites, has been shown to relieve pain.6Although the mecha-nism for TENS-mediated pain relief is not known, it hasbeen suggested that its segmental effects may be due to acti-vation of large-diameter, primary afferent ﬁbers that in turninhibit small-ﬁber transmission as predicted by the gatetheory. A similar mechanism may account for the effects ofacupuncture. TENS has been shown to produce partial anal-gesia to electrical tooth pulp stimulation in school-agedchildren.7Proportionately more emphasis has been placed on therole and inﬂuence of higher CNS modulation of pain per-ception and reactivity.1,8,9This reorientation is partially theresult of more sophisticated studies suggesting the need fora more comprehensive explanation of cognitive, behavioral,and emotional inﬂuences in pain perception and control.10Discoveries of endogenous opioids, widespread locations ofopioid receptors throughout the CNS, and unnatural (i.e.,electrical) stimulation of CNS sites resulting in pain thresh-old elevations also have sparked renewed interest in painresearch.In addition, animal studies have documented the pres-ence and inﬂuence of descending supraspinal mechanismson modulating painful input at the level of the spinal cord.11Interestingly, a phenomenon called stimulation-producedanalgesia (SPA) has been demonstrated in both humans andanimals. SPA results in speciﬁc inhibition of pain or avoid-ance behaviors during electrical stimulation of discrete brainsites (e.g., periaqueductal gray area of the medulla) and has■ FIGURE 6-2 The neuromatrix. (Redrawn from Melzack R: Pain and the neuromatrix in the brain, J Dent Educ 65:1378, 2001.)BODY-SELFNEUROMATRIXINPUTS TO BODY-SELFNEUROMATRIX FROM:COGNITIVE-RELATED BRAIN AREASMemories of past experience,attention, meaning, anxietySENSORY SIGNALING SYSTEMSCutaneous, visceral,musculoskeletal inputsEMOTION-RELATED BRAIN AREASLimbic system and associatedhomeostatic/stress mechanismsTIME TIMESTRESS-REGULATION PROGRAMSCortisol, noradrenalin, andendorphin levelsImmune system activityACTION PROGRAMSInvoluntary and voluntaryaction patternsPAIN PERCEPTIONSensory, affective, andcognitive dimensionsCSAOUTPUTS TO BRAIN AREASTHAT PRODUCE:
CHAPTER 6 Nonpharmacologic Issues in Pain Perception and Control 91Coping strategies may include hypnosis and relaxationtechniques, imagery, modeling, distraction, and reconceptu-alization. Typically, therapeutic coping strategies of painmanagement have a number of common elements, including(1) an assessment of the problem, (2) reconceptualization ofthe patient’s viewpoint, (3) development of appropriateskills (e.g., breathing and relaxation), (4) generalization andmaintenance of those skills in preventing relapse, and (5)measurement of therapeutic success.16Evidence supports the notion that coping skills in thecontext of pain and anxiety can be taught even to children,and the effectiveness of cognitive training can be evaluatedthrough self-report, physiologic, or behavioral measures. Inone study, children who were undergoing restorative proce-dures were taught distraction and self-support techniquesbefore undergoing dental procedures and subsequently com-pared with a group of children who were read stories. Self-report of anxiety for speciﬁc procedures (e.g., the injection)was less in those who received the cognitive training than inthose who did not.17This lends credence to the idea thatschool-aged children who have had opportunities to exerciseself-control in anxiety-provoking circumstances may dobetter if they know that they are to receive an injection aspart of their treatment rather than to proceed without anyforewarning. This forewarning permits the child to invokehis or her own personalized coping skills in preparation forthe “dreaded event.”However, knowing ahead of time about impending dis-comfort can have a detrimental effect under certain condi-tions. For instance, the less time between informing a youngchild who cognitively is incapable of signiﬁcant copingstrategies (i.e., 3 years or less) of a procedurally relatedpainful stimulus (e.g., injection) and doing it allows corre-spondingly less time for interference behaviors to occur. It iseven possible that the length of emotional outburst beforeand following the procedure may be reduced under thesecircumstances.Some studies indicate that adults who are led to believethat they have some control over impending discomfort doexhibit more tolerance of painful stimuli.1However, a strongbelief in their ability to gain self-control is apparently animportant factor in modulating the degree of discomfort.Those who lack this ability may place more trust in others(e.g., physician) and “suffer less” under their care.Cognitive development and maturation are keys to thesuccess of cognitive strategies. There is evidence that anxietyreduction can be attained in the medical and dental environ-ment as a function of age in school-aged cohorts. The extentto which these strategies can be successfully applied to pre-schoolers is yet to be determined. However, younger childrenare capable of signiﬁcant pain modulation through processesresembling cognitive strategies. In one study, play therapywith needles and dolls before venipuncture resulted in asigniﬁcantly more rapid return of heart rate and less bodymovement within 5 minutes of blood drawing comparedwith controls. This ﬁnding was interpreted as evidence ofreduced anxiety in the children.18morphine). β-Endorphin is one of the most potent peptidesand has an N terminal identical to that of met-enkephalin,which was one of the ﬁrst opioid peptides isolated.The active opioid peptides are cleaved from larger precur-sors and act at various CNS opioid receptor sites, includingthe spinal cord. The peptides are not equally potent, but allare inactivated by naloxone, a narcotic antagonist, and eachmay contribute to selective and specialized mechanismsunderlying the pain perception process.Correspondingly, there have been at least four opiatereceptors characterized (μ, δ, κ, and nociceptin) throughoutthe CNS. However, the contribution of each in producinganalgesia is not clear. Opioid ligands that bind to μ receptorsproduce potent analgesia when injected into the periaque-ductal gray (PAG) area of the medulla. Other sites, extendingfrom the hypothalamus to the rostral ventromedial medullaincluding the PAG, produce analgesia when properly stimu-lated electrically or by opiates. Curiously, the analgesic effectsof nitrous oxide are believed to be partially mediated byendogenous opioid ligands, or it is able to directly activateopiate receptors.15Theoretically, this system could mediate changes in theappreciation, motivation, and reactive processes of pain per-ception at higher levels of the CNS. In addition, spinal cordinﬂuences in terms of either synaptic effectiveness or neuro-nal sensitivity are possible.There is evidence to suggest that this system developsearly in the CNS and thus should be functional in youngerchildren. The extent of its inﬂuence and the conditions nec-essary for its activation are not understood. Future studiesprobably will underscore the means and usefulness of acti-vating this system in addressing clinical pain states.Cognitive Elements ofPain PerceptionCognition is a complex process resulting in an appreciationand often subsequent recognition of potential consequencesas a function of “knowing.” Knowing involves a multitude ofprocesses including, but not limited to, perceiving, organiz-ing, judging, meaning, reasoning, and responding.Cognition implies an awareness of internal and externalenvironmental inﬂuences on oneself. It also insinuatesthat steps can be taken for one to gain control over thoseinﬂuences and use the control to alter one’s response (e.g.,coping). For instance, one may be experiencing some dis-comfort but can possibly diminish the degree of discomfortby practicing mental processes (e.g., imagining pleasantevents or counting holes in a ceiling tile).A person can cope with a variety of conditions, includingstressful environments, depending on his or her perceptionof the situation. Factors such as consequences and repercus-sions of the situation, its timing, and individual resourcesapparently are important to the outcome of coping strate-gies. Coping, whether realized or not, is a statement of per-sonal success that is most rewarding.
92 PART 1 Fundamentals of Pediatric Dentistryof age.22As a child matures, develops a broader vocabulary,and witnesses a variety of environments, his or her ability tocommunicate feelings becomes increasingly sophisticated.Paralleling and reﬂecting the child’s cognitive developmentare signs manifesting the evolution of coping skills.23Ingeneral, the pain threshold tends to decline and the self-management of pain becomes more effective with increasingage.24Similar self-management trends are noteworthy in theyoung dental patient.25This phenomenon undoubtedlyresults from the interactions of multiple factors, includingthe maturation of coping skills, appreciation of self-control,and social inﬂuences.The pain associated with dental or other medicallyimposed procedures might be instrumental in invoking theopportunity for the development and testing of certain self-control and coping mechanisms.26Many children are efﬁ-cient with their coping skills and tolerate mild discomfortwith little overt expression. A few lack good coping skills anddisplay hysterical behaviors (e.g., extreme panic, screaming,and struggling) in anticipation of or during minor discom-forts. Consequently, any assessment of a child’s behavioraland cognitive responses to the dental environment shouldbe considered in light of age-appropriate expressions, spe-ciﬁc procedures, and the use of cognitive probes.It may appear difﬁcult to measure the degree of pain ordiscomfort in a young child, especially preschool children,because of their level of cognitive and language develop-ment. Several tools have been developed for this purpose,including nonverbal self-report techniques. Thus the inten-sity of pain may be represented by the number of poker chipsselected, the ranking of variable expressions on happy-sadfaces, the rating along a “pain thermometer” scale, and colorselections.An accumulation of evidence indicates that the visualanalog scale (VAS) is one of the most reliable and validmeasurement tools for self-report of pain in children. Typi-cally, a VAS is a line approximately 100 mm in length witheach end anchored by extreme descriptors (e.g., “no pain”versus “worst pain imaginable”) or happy-sad faces. Thepatient indicates the degree of perceived pain by making amark on the line. The length of the line from the left-handmargin to the mark determines the magnitude of pain forthat individual (Figure 6-3). Certain physiologic measure-ments, especially heart rate, in conjunction with self-reportof discomfort are thought to add another important dimen-sion to the characterization of response speciﬁcity to painfulstimuli.27Family and cultural elements are apparent in the media-tion of pain-related expressions and their effects. An infant’scry may elicit protective and indulging types of behavior or,sadly, abusive behaviors in adult caretakers. Family membersmay respond differentially to a child’s painful expressions,with females being more supportive and soothing and malesmore coarse and distracting. Some societies are highly sensi-tive to infant distress whereas others are less sensitive.In summary, many factors may contribute to a child’sperception of pain. McGrath and colleagues28have listedEmotional Elementsof Pain PerceptionAlthough pain and the anticipation of painful stimuli (i.e.,anxiety) invoke a personalized emotional experience, mosthumans have a common understanding of the attendantemotions of such experiences. Certainly, we are adept atrecognizing another’s suffering and possibly even betterattuned to appreciating another person’s anticipation ofdiscomfort.The expression of emotional content during or precedingpainful experiences is most likely a complex combination ofa partially inherited yet learning-tempered phenomenonthat occurs early in life. An infant’s expression of discomfortresulting from inoculations changes with aging from a morediffuse, crying, and reﬂexive response to one of anticipation,attentiveness toward the noxious object, and sometimesexpression of anger.19,20An injured child may not be overly upset until she or henotices an adult’s emotional outpouring over her or his con-dition. This is an important consideration when allowingparents to observe injections, extractions, and other treat-ment procedures. Careful assessment by the practitioner ofthe parent’s concerns and likely response mode is mostimportant. If one anticipates that the parent will not be stoicor supportive of the procedure, it may be advisable for theparent to leave the area or have the “more stoic” parent staywith the child.The social response to pain can be a commanding andattention-gathering entity.21For example, the toddler whoskins a knee during a fall initially may not react as if in painuntil the parent secondarily reacts to the injury. Dependingon the parental response, the child may burst into tears if theparent looks upset or “toughen up” with the support of theparent’s verbal encouragement.Although one might conceive of the emotional elementsof pain as being secondary to the pain itself, the emotionalovertones may act in concert to modulate painful experi-ences. Indirect and anecdotal evidence suggests that certainpharmacologic agents (e.g., nitrous oxide and benzodiaze-pines) act on areas of the CNS responsible for emotionalinﬂuence. A person feels the pain but is not particularlyannoyed by it.In contrast, emotional distress in anticipation of discom-fort is known to lower pain thresholds and increase reactiv-ity. Cognitive strategies designed to elicit positive emotionalstates can be effective in reducing anxiety and the degree ofresponsiveness to painful stimuli.Children and PainSurprisingly little is known about children and pain. Studiessuggest that the developmental changes in response topainful stimuli occur early in infancy. In fact, anticipatoryfears of sharp objects can be seen in children around 1 year
CHAPTER 6 Nonpharmacologic Issues in Pain Perception and Control 93special patients. That publication includes deﬁnitions, ratio-nales, and descriptions of techniques that are commonlyused to manage the behavior of these patients (Table 6-2).The list of techniques is not exhaustive but representsthe major body of empirically and scientiﬁcally derivedknowledge presently available on patient management. It isprobable that newer techniques as well as reﬁnementsof those presently in existence will be developed with thegoal of providing both a pleasant experience and positivelearning. Some of these techniques are discussed further inChapter 23.Behavioral and physiologic ﬁndings suggest that the threemost feared or anxiety-producing stimuli in the dental oper-atory are the injection of local anesthesia, application of therubber dam, and initiation of tooth preparation with thehigh-speed handpiece.30-33Knowledge of these ﬁndingsshould prepare the dentist and staff to anticipate and managedisruptive behaviors that may accompany these procedures.For instance, the dental assistant should passively place hisor her arms slightly above the torso and arms of the patientduring the injection. In this fashion, assistants are preparedto intercept the child’s hands if she or he attempts to grabthe dentist’s hands. Otherwise, the patient may inadvertentlyfactors that tend to exacerbate the pain in children withcancer and suggest developmental considerations for quan-tiﬁcation of pain (Box 6-1 and Table 6-1).Behavior Management TechniquesA variety of techniques can be used to manage the behaviorof a child in the dental environment. The establishmentof communication combined with a caring attitude is thekey building block for developing sound rapport with anypatient. Consequently, the great majority of children requireminimal management efforts other than providing informa-tion on what is going to happen (e.g., tell, show, and do). Animportant caveat is that every child responds to his or herenvironment with an individualized style. Practitioners mustbe perceptive and ﬂexible with the use of their managementtechniques and optimize the likelihood of a successfulencounter by matching their selection of techniques to thatof the patient’s style of interaction.The American Academy of Pediatric Dentistry29has pub-lished guidelines on the clinical management of children and■ FIGURE 6-3 An example of a visual analog scale that can be used to measure the degree of discomfort in children. Note that the line is100 mm long and is anchored at the left end by a happy face and at the right end by a sad face. The child is instructed to make a mark on theline that best describes how much pain he or she is having. The distance from the left end bar to the mark made by the child is the measure ofdiscomfort for the child.FACTORS EXACERBATING CHILDREN’S PAINIntrinsic FactorsChild’s cognitive development, anxiety, depression, and fearPrevious experience with inadequately managed pain (child’slack of control)Experience of other aversive symptoms (nausea, fatigue, anddyspnea)Child’s negative interpretation of situationExtrinsic FactorsAnxiety and fears of parents and siblingsPoor prognosisInvasiveness of treatment regimenParental reinforcement of extreme underreaction (stoicism)or overreaction to painInadequate pain management practices of health care staﬀBoring or age-inappropriate environment■ BOX 6-1 ■ TABLE 6-1Age and Measures of Pain IntensityAgeSelf-ReportMeasuresBehaviorMeasuresPhysiologicMeasuresBirthto 3yearsNot available Of primaryimportanceOf secondaryimportance3 to 6yearsSpecialized,developmentallyappropriatescales availablePrimary ifself-reportnotavailableOf secondaryimportance>6 years Of primaryimportanceOf secondaryimportanceOf secondaryimportanceFrom McGrath PJ, Beyer J, Cleeland C et al: Report of the Subcommittee onAssessment and Methodologic Issues in the Management of Pain in ChildhoodCancer, Pediatrics 86:814–817, 1990.
96 PART 1 Fundamentals of Pediatric Dentistryavailable to satisfactorily deﬁne this issue, but considerationsof lifestyle, personality development, and extenuating cir-cumstances should be addressed before any signiﬁcant con-clusions are drawn.As for short-term effects, positive reinforcement has beenshown to produce decreased disruptive behavior within atreatment session in children who have variable levels ofbaseline disruptive behaviors. Positive reinforcement mayinclude patient praise, tokens or stickers, and privilegedsocially related events (e.g., gaining the opportunity to watcha sibling or friend undergo dental treatment).Time out (i.e., separating the child from the social envi-ronment or procedure that provokes disruptive behavior)appears to decrease patient disruptiveness in selected cases.The degree of success of time out varies, and factors such asthe time-out period and the frequency of applied time-outepisodes are important considerations. Apparently, if timeout is to be effective, it should be short and only used onceor twice in attempts to gain the acceptable behavior. Longerperiods and numerous uses on any given child doom thetechnique to failure.Variables such as parenting style, personality, tempera-ment, and sociability have not been studied systematically.Nonetheless, it is recognized that each child is unique in“how” he or she responds and has a distinguishable back-ground; thus future studies will no doubt prove the impor-tance of these variables in the child’s behavior.34It should be emphasized that the great majority of pedi-atric dental patients can be managed with simple, nonag-gressive techniques. However, even the use of tell-show-do,which is perceived as the most innocuous technique, is noguarantee that the patient will not become a dental phobicor that parents won’t react strongly to its use on their childif described as a “technique.” It is the wise and competentpractitioner who knows children’s behaviors and parents’expectations.Chapter 23 discusses behavior management in terms ofverbal and nonverbal techniques, predictors of child misbe-havior, and related themes.REFERENCES1. Weisenberg M: Cognitive aspects of pain. In Wall PD, Melack R,editors: Textbook of pain, New York, 1989, Churchill Livingstone.2. Weisenberg M: Pain and pain control, Psychol Bull 84:1008–1041,1977.3. Zeltzer L, LeBaron S: Hypnosis and nonhypnotic techniques forreduction of pain and anxiety during painful procedures in childrenand adolescents with cancer, J Pediatr 101:1032–1035, 1982.4. Melzack R, Wall PD: Pain mechanisms: a new theory, Science150:971–979, 1965.5. Sternbach R: Pain: a psychophysiological analysis, New York, 1968,Academic Press.6. Woolf C: Segmental afferent ﬁbre-induced analgesia: transcutaneouselectrical nerve stimulation (TENS) and vibration. In Wall PD,Melzack R, editors: Textbook of pain, New York, 1989, ChurchillLivingstone.7. Abdulhameed SM, Feigal RJ, Rudney JD et al: Effect of peripheralelectrical stimulation on measures of tooth pain threshold and oralsoft tissue comfort in children, Anesth Progr 36:52–57, 1989.cause trauma to themselves or the dental staff. (See Chapter28, Figure 28-2, for an example of this procedure.)Natural fears of bright lights, loud noises, sudden move-ments, and strange environments are easily aroused in andproduce the most overt expressions of anxiety during theﬁrst 3 years of a child’s life. These stimuli are found in everydental operatory! Consequently, the dentist and assistantshould anticipate disruptive behaviors in very young chil-dren. Taking time for development of rapport and trust,using instruments that are familiar to these patients (e.g.,toothbrush), and allowing a child to use them initially isa fairly successful method for gaining a young child’sconﬁdence.Nitrous oxide/oxygen (N2O/O2) can be effective for chil-dren who are mildly to moderately anxious, can respond toguidance, and have no medical contraindications to N2O/O2administration. In sedative concentrations (30% to 45%),the patient can derive from N2O/O2 both a calming effectand some analgesia (although local anesthesia is usuallyrequired). Key elements to improve the effectiveness of N2O/O2 include proper patient selection, maximizing nasalbreathing, minimizing oral shunting of air during cryingepisodes, snug ﬁt of the nasal hood over the nose, soft ﬂexiblerubber hoods that adapt to the young child’s face, adequatetitration, and clinical monitoring.Nitrous oxide is not without its perils. Results of labora-tory studies as well as prolonged continuous clinicalexposure or recreational abuse have been associated withsigniﬁcant sequelae, including bone marrow depression;teratogenic, mutagenic, and carcinogenic effects; spontane-ous abortions; and neuropathies.15The immediate and long-term goals for the use of anybehavioral management technique are to provide as pleasantan experience as possible for the patient, instill the under-standing of the attainment and maintenance of a positiveoral health attitude, and promote and foster lifelong care-seeking and preventive behaviors. Hence, the dentist’s atti-tudes and demeanor toward his or her patients are mostcritical to the development of a positive attitude about den-tistry in those patients.Short- and Long-TermConsequences ofBehavior ManagementUnfortunately, few well-controlled studies have addressedthe impact of behavioral management techniques used inchildhood on behaviors later exhibited in the adult patient.Anecdotally, it has been noted that some aggressive tech-niques do not interfere with a patient’s seeking of future care,especially if the child was relatively young when the tech-nique was used. On the other hand, more aggressive tech-niques applied in childhood have been implicated as beingprominent factors in the behavior of adult patients withdental phobias. Frankly, there is not enough information
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