Procedural and postoperative pain in paediatric dentistry

Abstract: Tooth extraction is one of the most commonly performed dental treatments and there is always a risk of pain during and after this procedure. Pain is a major contributor to the development of dental fear and anxiety(DFA) and dental behaviour management problems (DBMP) in children and adolescents. These, in turn, are two of the most common reasons for referrals to specialist in paediatric dentistry. DFA and DBMP lead to reduced oral health and possibly suffering for the individual, as well as huge costs for society as a whole. It is therefore of uttermost importance that all dental treatments be performed with the aim of avoiding or minimising pain. The aims of this thesis were to (i) investigate how and to what extent Swedish dentists (both general dental practitioners and specialists inpaediatric dentistry) use different pain management strategies when treating children and adolescents, (ii) explain the natural course of pain after uncomplicated bilateral extractions of maxillary premolars in children between the ages of 10 and 15, (iii) systematically evaluate the effect of postoperatively administered over-the-counter oral analgesics as a means to minimise postoperative pain after oral surgery in children between the ages of 0 and 18, and finally (iv) gain greater insight into how children between the ages of 10 and 16 perceive the whole process of tooth extraction (during the procedure and after extraction) as part of orthodontic treatment. In the first study, a postal survey was sent to all active general dental practitioners (GDPs) in Skåne County, and to all specialists in paediatric dentistry (SPDs) in Sweden. The main findings were that pain management strategies differ between the two groups; in addition, GDPs used different strategies depending on whether primary or permanent teeth were being treated. In general, the survey found an underuse of local anaesthesia by general dentists. This calls for guidelines on pain management strategies in paediatric dental care. In the second study, pain intensity was measured at 14 different time points after tooth extraction performed prior to orthodontic treatment, in a sample of 31 children 10 to15 years of age. Pain intensity after extraction of an upper tooth was generally mild to moderate. The natural course of pain intensity followed the same pattern regardless of how the data were analysed. Pain peaked at 2 hours after treatment, then decreasing rapidly until the next measurement that took place 4 hours after treatment. There was no difference between the first and second extraction, indicating that this model is an excellent one for further research on pain management strategies, with no carryover effect. The third study was a systematic review(SR) and health technology assessment (HTA). A systematic review regarding preoperatively administered oral analgesics has been previously published, but it does not present any scientific evidence showing their administration as providing additional pain relief in children after dental treatment. An SR/HTA looked at postoperatively administered oral analgesics with the goal of minimising postoperative pain after oral surgical therapies in children. This SR/HTA yielded an empty review. As of today, there is no scientific evidence for the effectiveness of the administration of oral analgesics postoperatively in order to minimise postoperative pain after oral surgical therapies in children aged 0–18 years. Neither is there any evidence to reject this strategy. This highlights the need for well-designed primary studies on this topic. In the fourth and final study of this thesis, children’s perception of tooth extraction and the postoperative period was investigated in order to better understand the child’s perspective regarding this treatment. A qualitative research approach, using grounded theory, was used. Although the subjects were a bit anxious before the procedure, they all managed to handle the treatment using different types of coping strategies. One central theme that emerged from analysing the interviews was the importance of getting proper information from dental staff, at the right time. Children who received adequate information were able to withstand some pain and discomfort. Having some form of control over the situation also emerged as a coping strategy.ConclusionsAmong Swedish dentists (both GDPs and SPDs), there seems to be uncertainty regarding pain management strategies in children and adolescents in terms of the use of local anaesthetics and oral analgesics. There are differences in pain management strategies between GDPs and SPDs. The majority of the participants perceived pain intensity after tooth extraction due to orthodontic indication to be mild to moderate. These types of extractions can serve as a good model for future pain research. The amount of pain research on paediatric populations in dentistry is scarce. We need more well-designed primary studies before guidelines on pain management strategies for paediatric dental care can be formulated. When given proper and honest information at the right time, children are able to cope with dental treatments, even if they are a bit anxious beforehand and even if they perceive pain or discomfort during and after treatment.