Pain management in dentistry – a hygienist’s refresher

pain managementAdam Obermuller believes pain shouldn’t have a place in dentistry if clinicians use the correct clinical pain management techniques.

Pain, unfortunately, is all about perspective. There is no single way to determine every individual’s pain threshold. Or the outcome of that unique feeling.

As clinicians, I’m sure we all have our own experiences of the boy who cried wolf; your mirror in hand, not yet in contact with any oral tissue yet an overwhelming pain overcomes the patient before you. Or you’re faced with a frosty reception from ‘that’ patient as they recoil from the mere sight of you. Naturally followed by a small insult of hatred for all dentists – ‘no offence’ – of course.

A colleague of mine once said: ‘…and the patient complained she [the hygienist] had been really painful. But I knew that meant she’d done a good job.’

This remark from a dentist who was practising for more than 15 years absolutely astounded me.

Pain should never be the marker of a good clinician. And anyone hoping to provide excellent care – and maybe even receive some positive reviews – should employ techniques to effectively manage the experience.

Unfortunately the longer I have worked, the more common this complaint has become. Many patients attribute pain to a visit with the hygienist.

So it’s worth discussing what we can do to change those perspectives and help make a difference in improving our patients experience.

For this we will cover:

  1. A definition of pain
  2. Clinical pain management techniques – a short refresher
    1. Local anaesthetic
    2. Correct application of non-surgical instrumentation
  3. The clinical environment.

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What is pain?

Pain is a general term. We often use it to describe an unpleasant physical and mental experience linked with tissue damage.

With this in mind, our objectives from a pain management perspective are always to work in an atraumatic fashion.


  • The amount of dentine exposure (recession)
  • Whether you are working supragingival or subgingival
  • Tissue distinctions such as oedematous and erythematous
  • Your patient’s anxiety levels.

There is a strong relationship between pain and anxiety. Fear, or the apprehension of an associated action or experience, can greatly influence the perception of pain.

Always take a moment to get to know your patient – a good rapport builds trust and confidence in your actions. This helps early on to somewhat alleviate the stress of a complete stranger peering into their mouth.

Clinical pain management techniques

A big factor in pain relief is the use of local anaesthetics. Both therapists and hygienists alike should feel comfortable giving infiltration and ID block injections for their patients if necessary.

As I’m sure we are all aware, hygienists are not on the prescribers list. This means you need to have communication with the rest of dental team. Ensure the prescription is signed off by a referring dentist. Hopefully this inconvenience will change soon!

Alternatively, have a patient group direction (PGD) in place.

This allows the administration of named medicines in an identified clinical situation without the need for the referring dentist to provide an individual written prescription.

For further information on PGDs see

If you’re looking to improve your local anaesthetic technique – before administering your local anaesthetic, try drying the injection site with a gauze or cottonwool roll.

Allow a topical anaesthetic at least one minute to effect the peripheral tissue. This will improve patient comfort from the actual injection.

A slower injection is also much more comfortable than rushing! This lets the tissue expand at a reduced rate, rather than forcing the issue.

Tip: remember, retraction of the soft tissues with a mirror will help avoid unnecessary exposure to a needle stick injury.

Topical anaesthetic can often provide enough pain relief on its own for many situations. Even if some of the impact is that of a placebo.

Non-surgical instrumentation

I can understand the temptation for clinicians to always want to reach for power-driven scalers. But not all patients are comfortable with the sensation or accompanying water.

So using the correct instrument for the task at hand is imperative in providing a pain-free experience.

Sickle scalers are not designed to be used subgingivally. To do so can result in extensive trauma to the tissues.

I know some curettes have been sharpened so far they no longer resemble a curette at all. The tip of a curette should not be pointed! If this is the case, it’s time for new instruments!

Keep nagging your practice manager or principal for safe and effective equipment.

Equally, area-specific curettes (such as Gracey Curettes) must be adapted correctly to the tooth surface to function as intended. The cutting edge must be identified (there’s only one) and inserted below the gum line at a closed angle. The terminal shank should be parallel to the surface you intend to scale, with the instrument cutting edge then opened to 70o for effective calculus removal in the stroke.

Severe cases

For those with truly crippling anxiety toward dental procedures, the options for conscious sedation remain viable. Although they are much more limited in their supply with fewer surgeries offering this option.

We should avoid general anaesthesia in almost every situation. Although it does have its place within hospital settings, we must not forget the small but significant risk to life with such a procedure.

The clinical environment

Often the make or break of an appointment comes down to how we can manage our patients’ anxiety.

Everything from your initial greeting to your final goodbye needs tailoring to your patient.

I wouldn’t attempt to micromanage your appointment through a short article. But I would encourage you to consider the entire patient journey.

Consider their whole environment, from start to finish and also how it would make you feel if you were a nervous patient. Conceal any needles or syringes. Have tidy work surfaces. Gentle music can also help the surgery feel less sterile, and a positive encouraging attitude can go a long way.

Essentially, treat others how you would wish to be treated. Even if it is 8am on a cold Monday morning.

I hope this short overview can help provide a small refresher for everyone.

Together we can change perceptions and get some positive reviews!

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