Community Dent Oral Epidemiol 2012; 40: 343350 All rights reserved

2012 John Wiley & Sons A/S

Predictors of pain associated with routine procedures performed in general dental practice
Tickle M, Milsom K, Crawford FIJ, Aggarwal VR. Predictors of pain associated with routine procedures performed in general dental practice. Community Dent Oral Epidemiol 2012; 40: 343350. 2012 John Wiley & Sons A/S Abstract Objectives: The objective of the study was to investigate factors that inuence pain intensities associated with routine dental procedures. Method: Four hundred and fty-one dental patients self-reported pain experienced during the procedure immediately after undergoing a variety of common dental interventions and 1 day after the completion of the procedure. Pain character was measured using the McGill short-form pain questionnaire and intensity using a numerical rating (NRS) scale. Information was collected on a number of factors that could inuence pain: dental anxiety was measured using the Corah Dental Anxiety Scale to categorize patients into four domains (fearless, some unease, nervous and very anxious). Dentists provided information regarding the type(s) of procedure and use of local anaesthetic (LA). Results: Seventy-ve percent of patients (339/451) reported no pain during their procedure when the data were collected immediately postoperatively (NRS score = 0). Univariate analyses showed that dental anxiety, LA use and type of procedure (extractions) were signicant (P < 0.05) predictors of reported intra-operative pain. However, when these factors were combined in a multivariate model, the strongest predictor of pain was dental anxiety [odds ratio (OR) = 4.98 (95% CI 1.4217.44)] and LA use [OR = 2.79 (95% CI 1.395.61)]. Although the strongest predictor of postoperative pain on the next day was pain reported during the procedure [OR = 5.85 (95% CI 2.71 12.64)], LA remained a signicant predictor of pain the day after the procedure [OR = 3.16 (95% CI 1.029.81)]. Conclusions: Dentists need to assess their patients both preoperatively for dental anxiety and intra-operatively for signs of suboptimal local anaesthesia so as to effectively align patient management and clinical techniques to control dental anxiety and produce adequate anaesthesia.

Martin Tickle, Keith Milsom, Fiona I. J. Crawford and Vishal R. Aggarwal

Manchester Academic Health Sciences Centre, School of Dentistry, University of Manchester Manchester, UK

Key words: anxiety; clinical research; pain Vishal R. Aggarwal, Oral Health Unit, School of Dentistry, University of Manchester, Oxford Road, Manchester M15 6FH, UK Tel.: 0161 275 6623 Fax: 0161 275 6299 e-mail: vishal.r.aggarwal@manchester.ac.uk Submitted 19 December 2010; accepted 10 January 2012

Historically, patients have perceived dental procedures as painful and uncomfortable (1), and this perception has continued (2). Psychological factors have an important inuence on pain perception, both in clinical and experimental settings, and negative emotions, like anxiety, are known to increase pain perception (2,3). In the 1998 Adult Dental Health Survey in the United Kingdom, one-third of the adult population reported being anxious when
doi: 10.1111/j.1600-0528.2012.00673.x

visiting the dentist (4). Despite the advances in pain control, dental anxiety remains a signicant barrier to access dental care (5). Societys perception of dental care being a painful experience, and therefore something to be fearful of, is constantly fuelled by negative stereotypes in the popular media. Little work has been published to quantify the intra-operative pain intensity of routine treatment

343

Tickle et al.

provided in general dental practice. This knowledge gap is surprising given that dental procedures are among the most frequently provided surgical interventions in healthcare, because of the high prevalence of dental disease and remuneration systems that incentivize treatment activity (6). A limited number of studies have investigated the incidence of pain during placement of a lling (7). A longitudinal populationbased study (2) reported that both psychological and intra-operative factors were important in the perception of pain associated with dental treatment and dental anxiety; the strongest predictor reported was the number of types of invasive treatment received. There is a growing body of evidence to show that perceived threat increases the likelihood of avoidance and that being aware of such a threat will lower pain tolerance (8). Given that a large number of patients who report anxiety associated with dental visits (4), it is entirely plausible that patient anxiety levels could inuence pain perception and reporting during operative procedures. Therefore, the aims of this study were to investigate in general dental practice settings: The inuence of patient and operative factors on immediate postoperative reporting of pain experience during commonly performed dental procedures. The inter-relationships between these factors whilst controlling for potential confounding. The longer-term (the day after the procedure) inuence of these factors.

of the study were sent to eligible patients prior to their appointment. On attendance, the patients dentist explained the study, answered any queries, obtained informed consent and carried out the treatment scheduled for the patient during the same visit. Based on previous literature (2) which reported a 16% absolute difference in pain between none and two invasive procedures, we needed to recruit a minimum of 468 patients to give the study a power of 90% to detect this difference in pain experience (signicance level 0.05, two-sided tests). A total of 881 patients in the eligible age group were contacted, and 508 (57.7%) patients were recruited into the study.

Study measures
Self-reported pain experienced by participants during the procedure (including administration of local anaesthetic LA) was the principal outcome measure. This was measured by asking patients to rate the intensity and character of the pain they experienced during the procedure immediately after the completion of the procedure once the participant had left the dental surgery. The term self-reported pain during the procedure is used as short hand for this measure throughout the paper. A number of self-report measures were used to measure pain intensity and character: The McGill short-form pain questionnaire (9): this categorizes degrees of sensory (11 questions) and affective (four questions) pain each with the options none, mild, moderate or severe and a scale for overall pain intensity options: no pain, mild, discomforting, distressing, horrible or excruciating, using descriptive phrases. This measure was used to describe self-reported pain during the procedure. A Numerical Rating Scale (NRS) based on a 010 scale, where 0 = no pain and 10 = worst possible pain. The numerical rating scale scores were used to categorize the study population into an overall measure of pain experience for the purposes of bivariate and multivariate analyses. Participants who scored 0 were categorized as no pain experience and participants with a score > 0 were categorized as experiencing pain during the procedure. Participants were asked to score the two pain scales at the same time to reect the pain they experienced during the procedure (whilst they were in the dental surgery). These data were collected immediately after receiving treatment in the dental surgery waiting room away from the inuence of the dentist. Patients were informed that all

Materials and methods

Study setting and population
This study was conducted within general dental practices located within Salford, Trafford and East Lancashire in the North West of England. Ethical approval was provided by the National Health Service (NHS) and the University of Manchester ethics committees, and research governance approval was provided by the NHS primary care trusts within which the study was conducted. All general dental practitioners (N = 300) in each of the three locations were invited to participate in the study; 50 agreed to participate, 12 dentists later withdrew, leaving 38 (12.7%) who participated in the study. These dentists were asked to recruit adult patients attending their practices for routine treatment. Letters and information sheets explaining the purpose

344

Predictors of pain associated with routine dental procedures

of their responses would be kept strictly condential and that individual responses would not be able to be identied by their dentists or the practice staff. The same measurements were undertaken the day after the procedure; participants were asked to complete the same questionnaires completed in the dental surgery at some point during day after the procedure and to send their completed questionnaires to the research team in a business reply envelope. Dental anxiety was measured preoperatively, again in the dental surgery waiting room using the Corah Dental Anxiety Scale (10) (CDAS).This measure uses four questions each with ve possible answers to describe domains of increasing levels of dental anxiety (45 = no anxiety; 610 = some unease; 1115 = anxious; and 1620 = very anxious). Factors that could potentially inuence or predict pain were also collected preoperatively by self-report questionnaire. These included demographic factors such as age and gender. Clinical/ operative factors such as type of procedure and use of LA were recorded separately by the dentists for each participant. Procedures were assessed in three groups: examinations and scaling and polishing were assessed as one group; the second group included restorative treatments such as llings, bridges, crowns, inlays, veneers, root-llings whilst dental extractions made up the third group.

Results
Demographics of the study population
Of the 508 patients who took part in this study, age data were available for 485 (95.5%) participants, while gender was recorded for all patients. Participants ages ranged from 15 to 87 years, with a mean age of 50 (SD = 14.8). A signicantly larger number of female (N = 288, 56.7%) than male (N = 220, 43.3%) patients took part in the study (chi-squared P = 0.003). A total of 314 [69.6% (denominator N = 451)] of participants returned a questionnaire assessing pain and dental anxiety the day after the procedure was performed.

Operative factors
The majority of patients (N = 418, 81.9%) underwent only one procedure, but patients had up to ve treatments during their visit to the dentist (Table 1). Two hundred and seven (45%) patients received LA for their dental procedure. Dentists use of LA did not appear to be inuenced by patient anxiety (chi-squared P = 0.078), but was signicantly associated with the type of procedure the patient was about to undergo (chi-squared P < 0.001); the more invasive the procedure, the more likely dentists were to prescribe LA. Patients who were given LA reported signicantly more pain than those who had no LA (chi-squared P < 0.001).

Statistical analysis
Frequency distributions from the responses to the McGill pain questionnaire were used to record the proportion of patients who reported pain and the quality of the self-reported pain during the procedure. For patients with multiple procedures, results were analysed with reference to the most painful procedure they had reported, which was identied from the frequency distributions of the whole study population. Of the 508 responders, NRS scores were available for 451 (89%), and this was the sample used for analysis. Chi-squared tests for categorical data and MannWhitney U- or KruskalWallis tests for ordinal data were used to compare the differences in proportions of the potential predictive factors between participants with and without reported pain. A multi-variate model using logistic regression was used to examine the strongest predictors of self-reported pain during the procedure and pain experienced the day after the procedure. All data were analysed in SPSS version 16 (SPSS, Inc., Chicago IL) and STATA version 9 (StataCorp, Texas, USA).

Dental anxiety prior to procedure

Most patients reported some unease on attending the dentist, with a median score of 8, on the CDAS scale, and 15 patients (3.4%) could be classed as very anxious. Women were slightly more anxious than men, with median anxiety scores of 8.5 and 7, respectively (MannWhitney U-test, P < 0.001). There was no association between age and dental anxiety (KruskalWallis test, P = 0.384), and the degree of dental anxiety induced by the prospect

Table 1. Number of treatments given during the dental appointment Number of individual treatments provided during the dental appointment 1 2 3 4 5 Total

Frequency, n (%) 416 (81.9) 63 (12.4) 19 (3.7) 6 (1.2) 4 (0.8) 508

345

Tickle et al.

of visiting a dentist was not signicantly inuenced by the procedure(s) which patients were about to undergo (KruskalWallis test, P = 0.944).

Self-reported pain during the procedure

Overall, NRS pain data were available for 451 patients. Of these, three-quarters (N = 339) felt no pain during their procedure. The McGill pain scale was used to descriptively capture self-reported pain during the procedure, and the results are presented in Table 2. The most commonly selected sensory term to describe self-reported pain during the procedure was tender, and this type of pain was experienced to some degree by 76 (17%) of patients who completed this part of the questionnaire. Sharp and shooting pain were the next most frequently used terms, chosen by 12.5% and 7% of dental patients. Affective pain terms were selected less often, with fearful or tiring pain being used by 7% and 8% of patients, respectively. There was no inuence of age and gender on selfreported pain during the procedure: the strongest predictors were as follows: Procedure: certain procedures were signicantly more painful than others (chi-squared P = 0.014); those having extractions experiencing most pain compared with those having examinations and scaling (OR = 3.31 95% CI 1.387.92) (Table 3).

Dental anxiety: those who were classed as very anxious had vefold increased odds (OR = 5.20 95% CI 1.5817.07) of reporting pain following the procedure when compared with those who were fearless. There were also increased odds of pain for nervous patients (OR = 3.71 95% CI 1.84 7.48) (Table 3). Local anaesthetic: those who had LA for the procedure had a twofold increased odds of reporting pain during the procedure (OR = 2.27, 95% CI 1.473.52) (Table 3). However, when these predictors were combined in a multivariate model, the risk associated with the type of procedure was no longer present, and the strongest predictors were dental anxiety (OR = 4.98, 95% CI 1.4217.44) and LA use (OR = 2.79 95% CI 1.395.61) (Table 3).

Pain the day after the procedure

Fewer patients (N = 42/272, 15%) suffered pain in the rst 24 h after their procedure than had done during the procedure. In addition, there were some associations with age and gender; a larger proportion of women reported pain although the difference was not statistically signicant (OR = 1.76 95% CI 0.883.53) and those in the older age group less likely to report pain (OR = 0.25 95% CI 0.06 1.02) (Table 4). However, the strongest predictors were similar to those of self-reported pain during the procedure although the inuence of procedure was greater, with those having extractions reporting a seven times increased odds of pain the day after the procedure (OR = 7.66 95% CI 2.0828.21) (Table 4). The association with LA administration was also greater (OR = 5.44 95% CI 2.5711.54) as were those of being very anxious (OR = 6.51 95% CI 1.2833.16) and nervous (OR = 3.95 95% CI 1.33 11.77) (Table 4). In addition, pain at baseline was also an important predictor [OR = 6.53 (3.28 13.00)]. However, the association with procedure was no longer present when we adjusted for confounding in a multivariate model and the strongest predictor was reported pain experience during the procedure (OR = 5.85 95% CI 2.7112.64) and the association with LA administration was still significant (OR = 3.16 95% CI 1.029.81) (Table 4).

Table 2. Sensory and affective score for self-reported pain during the procedure experienced by dental patients (recorded using the McGill pain scale) Pain description Sensory Tender Sharp Shooting Aching Stabbing Throbbing Heavy Cramping Gnawing Hot/ burning Splitting Affective Fearful Tiring Sickening Punishing/ cruel
a

Patients experiencing pain, N (row%)a None Mild Moderate Severe 3 (0.7) 2 (0.4) 2 (0.4) 1 (0.2) 0 (0.0) 2 (0.4) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 5 (1.1) 1 (0.2) 1 (0.2) 0 (0.0)

366 (79.9) 76 (16.6) 13 (2.8) 387 (84.5) 57 (12.5) 12 (2.6) 409 (89.5) 32 (7.0) 14 (3.1) 413 (90.2) 39 (8.5) 5 (1.1) 416 (90.8) 36 (7.9) 6 (1.3) 426 (93.0) 27 (5.9) 3 (0.7) 444 (96.9) 12 (2.6) 2 (0.5) 448 (97.8) 10 (2.2) 0 (0.0) 448 (97.8) 10 (2.2) 0 (0.0) 452 (98.7) 5 (1.1) 1 (0.2) 452 (98.7) 409 (89.3) 417 (91.1) 444 (97.0) 454 (99.1) 4 (0.9) 2 (0.4)

33 (7.2) 11 (2.4) 37 (8.1) 3 (0.6) 12 (2.6) 1 (0.2) 4 (0.9) 0 (0.0)

Discussion
This study involved a group of participants who are of major interest to both dental clinicians and

Totals are not the same because of missing values.

346

Predictors of pain associated with routine dental procedures Table 3. Factors associated with self-reported pain during the procedure Self-reported pain during the procedure recorded using a Numerical Rating Scale (NRS) Associated factors (N) Age range 1535 3650 5165 66+ Missing (9) Gender Male (194) Female (257) Local anaesthetic administration No (241) Yes (202) Missing (11) Procedure Examination and S&P (177) Restore (249) Extract (25) Dental anxiety Fearless (119) Unease (271) Nervous (86) Very anxious (14) Missing (15) S&P, Scale and Polish. * Chi-squared tests. Yes N = 112 (%) 26 (34) 26 (27) 35 (23) 7 (13) 1 (11) 50 (26) 62 (24) 44 (18) 68 (34) 0 (0) 34 (19) 67 (27) 11 (44) 15 (13) 59 (27) 30 (35) 6 (43) 2 (13) No N = 339 (%) 51 (66) 65 (73) 116 (77) 47 (87) 8 (89) 144 (74) 195 (76) 197 (82) 134 (66) 8 (100) 143 (81) 182 (73) 14 (56) 104 (87) 158 (73) 56 (65) 8 (57) 13 (87) P-value* 0.049 Bivariate analyses OR (95% CI) 1 0.72 (0.401.30) 0.59 (0.321.08) 0.29 (0.120.74) 1 0.92 (0.601.41) 1 2.27 (1.473.52) 1 1.55 (0.972.47) 3.31 (1.387.92) 1 2.59 (1.404.81) 3.71 (1.847.48) 5.20 (1.5817.07)

Multivariate analyses OR (95% CI) 1 0.85 (0.451.63) 0.67 (0.341.29) 0.38 (0.141.01) 1 0.81 (0.501.30) 1 2.79 (1.395.61) 1 0.72 (0.351.47) 1.23 (0.393.83) 1 2.42 (1.274.61) 3.13 (1.516.53) 4.98 (1.4217.44)

0.688 <0.001

0.014

0.001

the pain research community because of the frequency of the problem (visits to the dentist) and the virtual experiment nature of the problem (acute procedures that are perceived to involve pain or need pain relief). We found that dental anxiety, LA use and the nature of the procedure (extractions) were the strongest predictors of selfreported pain during the procedure. However, the increased risk from the dental procedure was no longer present when included in a multivariate model. Postoperatively, the strongest predictor was reporting experiencing pain during the procedure although the association with the use of LA was still signicant. Contrary to popular belief, the majority of commonly provided dental treatments are not painful, as 75% of participants reported no pain during the procedure. Not surprisingly, higher pain scores were recorded for more invasive procedures such as extractions and root canal therapy; however, many patients undergoing these more invasive procedures also reported experiencing no pain at all. Very few patients (15%) reported residual postoperative

pain the day after the procedure, and this was again more commonly experienced following invasive treatments such as extractions. There was no difference in pain experience by age or gender. This practice-based study had some limitations. Dentists are independent practitioners running small businesses, and there are many barriers to them engaging in research. As a result, a selfselecting group of practitioners and their patients were involved in the study, and only 57% of patients approached provided informed consent; further compromising external validity. It is unlikely that a truly representative sample of dentists or patients could ever be recruited to studies like this, and therefore, multiple studies of different populations are required to determine whether our results represent the usual situation in populations using general dental services. Given these concerns, the case mix within the study population is what one would expect an average dentist to see routinely on an average day in his or her practice. The strong association we found between reported pain experience during the procedure

347

Tickle et al. Table 4. Factors associated with pain the day after the procedure Self-reported pain during the procedure using a Numerical Rating Scale (NRS) Associated factors (N) Age range 1535 3650 5165 66+ Missing Gender Male (133) Female (181) Baseline pain No (239) Yes (75) Local anaesthetic administration No (180) Yes (132) Missing (2) Dental anxiety Fearless (81) Unease (156) Nervous (63) Phobic (10) Missing (4) Procedure Examination and S&P (125) Restore (173) Extract (16) *Chi-Square tests. Yes N = 42 8 (21) 14 (12) 17 (16) 3 (6) 0 (0) 13 (10) 29 (16) 17 (7) 25 (33) 10 (6) 32 (24) 0 (0) 5 (6) 21 (13) 13 (21) 3 (30) 0 (0) 7 (6) 30 (17) 5 (31) No N = 272 30 (79) 99 (88) 90 (84) 45 (94) 8 (100) 120 (90) 152 (84) 222 (93) 50 (67) 170 (94) 100 (76) 2 (100) 76 (94) 135 (87) 50 (79) 7 (70) 4 (100) 118 (94) 144 (83) 11 (69) P-value* 0.230 Bivariate analyses OR (95% CI) 1 0.53 (0.201.39) 0.71 (0.281.81) 0.25 (0.061.02) 1 1.76 (0.883.53) 1 6.53 (3.2813.00) 1 5.44 (2.5711.54) 1 2.36 (0.866.52) 3.95 (1.3311.77) 6.51 (1.2833.16) 1 3.54 (1.508.34) 7.66 (2.0828.21)

Multivariate analyses OR (95% CI) 1 0.81 (0.272.42) 1.16 (0.403.44) 0.52 (0.112.50) 1 2.01 (0.894.58) 1 5.85 (2.7112.64) 1 3.16 (1.029.81) 1 1.35 (0.444.11) 2.18 (0.657.25) 2.37 (0.3815.00) 1 1.87 (0.526.75) 2.47 (0.4115.06)

0.108 <0.001 <0.001

0.032

0.001

and higher levels of preoperative dental anxiety was expected. Maggirias and Locker (2) investigated participants recollections of pain experience associated with commonly provided dental treatments and reported that invasive treatment was the strongest independent predictor of pain. Pain was also more likely to be reported by those with previous painful experiences and those who were anxious about dental treatment. The results reported here using contemporaneous data collected in primary care broadly agree with these ndings although different methodologies and measures were used. The Maggirias and Locker (2) study was susceptible to recall bias as the selfreport measures used involved recall of previous dental experiences over 5 years. This risk of bias may explain the high levels of pain prevalence (approximately 75%) they reported compared with the low levels that we report among primary care patients. We also assessed dental anxiety scores within our study, and the prevalence of severe anxiety in our sample was 3.4% which is well below

recently reported population levels of 12% (11). This discrepancy can be explained by our study being conned to regularly attending patients who would be expected to have lower levels of anxiety than the general population. Hence, our ndings related to anxiety are likely to reect that the population general dental practitioners have to manage on a daily basis and will underestimate population dental anxiety prevalence. Local anaesthetic was strongly associated with reported pain. Patients who had LA for a procedure had a twofold increased odds of reporting pain during the procedure; a counter-intuitive nding given that the reason for prescribing LA is to prevent pain. A subanalysis was performed on patients who received restorative procedures only (N = 248) some of whom received LA, some of whom did not, to remove patients who had procedures not normally requiring LA (examinations and scale and polish) and patients who had extractions, all of whom had LA. LA administration still had a highly signicant association with pain,

348

Predictors of pain associated with routine dental procedures

when restorative procedures alone were examined, reinforcing the association between pain and LA, after controlling for procedure. Injections are anxiety inducing (12,13) increasing the likelihood of emotional enhancement of pain perception. The pain of the injection itself could also be responsible for the association; studies have shown that many patients nd an injection to be the most unpleasant aspect of dental treatment rather than the procedure itself (12). Another explanation could be that LA, like any other drug, varies in its effectiveness because of variation in patient response and operator technique (14). The drug will not perform optimally if the dosage is incorrect or if it is not delivered in exactly the right anatomical position (14). There is also evidence of a discrepancy between dentists perception of how painful a procedure is and the views of their patients (15). Another explanation of this nding could be selection bias. There is evidence from other pain studies that the level of pain at the start of a procedure is predictive of subsequent pain regardless of procedures and pain relief. Although all of the procedures in the study were elective, some participants may have had preoperative pain and would be more likely to request or be given LA. However, procedure and LA administration were controlled for in the models, and therefore, the invasive nature of procedures often required to resolve preoperative pain did not remove the association with LA. The availability of preoperative pain scores would resolve this question and is thus a weakness in the study design. Our nding that patients who had LA were more likely to experience pain the day after their treatment, even after procedure and dental anxiety were controlled for, is more difcult to explain. This is unlikely to be due to the after effects of the drug, such as numbness, which will have worn off. It could be due to recall bias; patients recollection of pain experienced during their treatment inuencing their pain scores the day after the procedure or possibly bruising of soft tissues from the injection itself or possibly rougher handling of soft tissues in anesthetized patients. Another explanation is that the results could have been affected by nonresponse bias. We conducted a nonresponse analysis, and we could nd no signicant differences between self-reported pain during the procedure scores and anxiety scores in responding and nonresponding populations, suggesting that nonresponse bias was an unlikely explanation of this nding.

This study has signicant implications for the clinical care of patients and for planning the delivery of services and future research. One interpretation of the ndings is that dentists are skilled at patient and pain management and provide treatments in such a way that pain is experienced infrequently and therefore dental treatment is not as bad as its reputation with the public suggests. The association between dental anxiety and pain experience during common dental procedures is the most robust nding of this study. Preoperative dental anxiety is a major predictor of pain experienced by dental patients. Accurate and formalized assessment of anxiety is not routinely undertaken by general dental practitioners. Our ndings suggest that preoperative assessment of anxiety and appropriate management of the anxious patient are key requirements for high-quality dental care. Currently, these competencies do not have a high priority in the undergraduate curriculum of most UK dental schools (16). Research is also needed to help dentists to provide optimal pain control. It is not sufcient that drugs and techniques alone are improved, holistic management of patients is key. Dentists must listen to, and be aware of, the responses of their patient and be prepared to administer more LA or use alternative techniques (17) to obtain effective anaesthesia so that procedures can be completed pain free. Other factors that inuence the approach taken to intra-operative anaesthesia such as ethnic differences in pain beliefs, the impact of different health-care systems, individual patient preferences about the tolerability of dental treatment, avoidance of numb feelings after dental procedures have been completed, and fear of injections has all been reported in the literature (18). The empathy a dentist has for his or her patients has also been reported as a determining factor in the prescription of LA (19). The important decision on when and how LA should be administered requires further investigation as it is not only an important predictor of postoperative pain, but also it may explain the relationship between intra-operative factors and pain that have been reported in previous studies (2). In conclusion, this study suggests that pain is infrequently associated with routine dental procedures and, if it is experienced, it is seldom severe. Dental anxiety, the nature of the procedure and use of LA are predictors of pain reported during dental procedures. To improve the quality of the care they provide, general practitioners need to

349

Tickle et al.

assess their patients preoperatively for dental anxiety and use appropriate patient management techniques based on the outcomes of the assessment. In addition, dentists need to monitor their patients intra-operatively for signs of suboptimal anaesthesia and act swiftly to ensure anaesthesia is effective.

Acknowledgements
The authors are grateful to the patients and practitioners who participated in the research and to Louise Morris for collection and cleaning of data. Vishal Aggarwal is funded by a National Institute of Health Research Clinician Scientist Award grant number CS/2008/08/001. The views expressed in this publication are those of the author(s) and not necessarily those of the NHS, the National Institute for Health Research or the Department of Health.

Conicts of interest
The authors have no conicts of interests to declare.

References
1. Bregstein SJ. When the patient says: ill think it over. Dent Manage 1965;34:3338. 2. Maggirias J, Locker D. Psychological factors and perceptions of pain associated with dental treatment. Community Dent Oral Epidemiol 2002;30:151159. 3. Loggia ML, Schweinhardt P, Villemure C, Bushnell MC. Effects of psychological state on pain perception in the dental environment. J Can Dent Assoc 2008;74:651656. 4. Nuttall NM, Bradnock G, White D, Morris J, Nunn J. Dental attendance in 1998 and implications for the future. Br Dent J 2001;190:177182. 5. Humphris GM, Dyer TA, Robinson PG. The modied dental anxiety scale: UK general public population norms in 2008 with further psychometrics and effects of age. BMC Oral Health 2009;9:20.

6. NHS Information Centre. NHS dental statistics for England 200809. 2009. 7. Rousseau WH, Clark SJ, Newcomb BE, Walker ED, Eleazer PD, Scheetz JP. A comparison of pain levels during pulpectomy, extractions, and restorative procedures. J Endod 2002;28:108110. 8. Van DS, Legrain V, Vogt J, Crombez G. Keeping pain in mind: a motivational account of attention to pain. Neurosci Biobehav Rev 2010;34:204213. 9. Melzack R. The short-form McGill pain questionnaire. Pain 1987;30:191197. 10. Corah NL. Development of a dental anxiety scale. J Dent Res 1969;48:596. 11. Adult Dental Health Survey (UK). Available at: http://www.ic.nhs.uk/webles/publications/ 007_Primary_Care/Dentistry/dentalsurvey09/ AdultDentalHealthSurvey_2009_Theme8_Barriersandaccesstocare.pdf [last accessed 24 May 2011]. 2011. 12. Humphris GM, Freeman R, Campbell J, Tuutti H, DSouza V. Further evidence for the reliability and validity of the Modied Dental Anxiety Scale. Int Dent J 2000;50:367370. 13. Moore R, Brodsgaard I, Mao TK, Kwan HW, Shiau YY, Knudsen R. Fear of injections and report of negative dentist behavior among Caucasian American and Taiwanese adults from dental school clinics. Community Dent Oral Epidemiol 1996;24:292295. 14. Blanton PL, Jeske AH. Avoiding complications in local anesthesia induction: anatomical considerations. J Am Dent Assoc 2003;134:888893. 15. Murtomaa H, Milgrom P, Weinstein P, Vuopio T. Dentists perceptions and management of pain experienced by children during treatment: a survey of groups of dentists in the USA and Finland. Int J Paediatr Dent 1996;6:2530. 16. General Dental Council. The rst ve years. Available at: http://www.dentpostgradwales.ac.uk/overseas/rst_ve_years.pdf [last accessed 24 May 2011]. 2008. 17. Blanton PL, Jeske AH. Dental local anesthetics: alternative delivery methods. J Am Dent Assoc 2003;134:228234. 18. Moore R, Brodsgaard I, Mao TK, Miller ML, Dworkin SF. Perceived need for local anesthesia in tooth drilling among Anglo-Americans, Chinese, and Scandinavians. Anesth Prog 1998;45:2228. 19. Milgrom P, Weinstein P, Golletz D, Leroux B, Domoto P. Pain management in school-aged children by private and public clinic practice dentists. Pediatr Dent 1994;16:294300.

350

This document is a scanned copy of a printed document. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material.