Less Painful Dentistry

Synopsis–Must have confidence of patient. Not difficult to secure it. Some general rules. Cheerful pictures and attractive literature. How to use the children. Should go at it systematically and thoughtfully. How to control mental attitude. How we hear through the teeth. Noise not pain. Must tell when hurt. Never deceive. May cause loss of all teeth. Give children reason for acts. Explain germ theory. Value of pictures. Most pain preventing methods apply to children. Importance of correct diagnosis. How to use cold water. Automatic heater important. Let gentle test precede extreme. Treat with galvanic current. The value of X-ray pictures. Never mallet the chisel. Campho phennique and cocaine. Study to avoid use of rubber. Adrenalin chloride used. Saliva ejector. Use of flexible cushion rest. Combination cheek depressor and saliva ejector.

 

In continuing the discussion of this subject as promised, we will do so from the standpoint of the technique and methods necessary for accomplishing it.

To render entirely comfortable service to his patients, the dentist must of necessity have their confidence, and even though he is not hurting them they may be suffering much mental discomfort until they have come to this attitude of confidence. This relation can only be secured by either starting with the patients as children before they have been seriously hurt or frightened, or by proving ability to make the necessary operations without any considerable discomfort and yet thoroughly. It is not usually difficult to secure the entire confidence of either the children or adults though the methods may differ in some details. Some general rules will apply to both, viz., the office arrangement and furnishings must be bright, cheerful and absolutely free from suggestions of discomfort. On the contrary, have as strong as possible suggestions of comfort and gladness and entertainment. These features must also always characterize the manner and disposition of the dentist and his assistants.

The office should have besides good and cheerful pictures and decorations, the most attractive current literature, and the writer uses for the entertainment of the children a music chair which plays when occupied, a group of bears old and young carved from wood, life size, forming a hall tree, rugs of skins of wild animals, etc., etc., and a little art gallery carefully selected and arranged on the ceiling over the dental chair. This latter is invaluable for taking the attention of both the little and big folks. It is used in several ways, to entertain or divert and hold the attention of the smaller children and keep their head in position, which will be described later.

The getting of the confidence of the patients old or young is of so much importance that the operator should go about it systematically and thoughtfully. The first thing to do with the small child after getting acquainted is to teach them that they can hear with their teeth almost as plainly as with their ears, a fact that not a few adults have to be taught and even some dentists. Since we cannot work upon the teeth without considerable jar and vibration, the interpretation of this is of the greatest importance, for the mental attitude towards this sensation determines largely the kind and extent of reflex it produces. After asking the child if he knows that he can hear with his teeth, take two knurled metal handled instruments and rub them lightly together and ask him if he hears it, then do it again while distinctly, then explain that every time you touch his teeth he will hear it and each kind of instrument will make a different sound or noise, some of those that go round make a noise like a dog growling and some like a street car going over a bridge, etc., and he will want to hear it. Have him understand thoroughly that noise is not pain, and take great care by the methods. following or others not to produce pain along with the necessary noise, and he will soon relax and become quite indifferent to the noise.

Next, before starting to work, have a complete understanding with him that if anything you do hurts him he must let you know at once and you will stop and then keep your agreement. If you need to hurt a little, tell him so first or tell him you do not know whether it will hurt or not. Never for any cause or under any circumstances deceive a child; leave the practice of dentistry rather than do so. By that crime, some dentists have ruined more teeth than they ever saved, for by destroying the confidence of the children they cause them thereby, through fear of dentists, to neglect all the rest of their teeth which they otherwise would have cheerfully had taken care of. I believe it were better for a dentist to have a mill-stone tied about his neck and be cast into the sea, than to deceive innocent children. The operation he may do on any one tooth is absolutely insignificant beside the influence he may have in determining that child’s attitude towards the care of the balance of the teeth throughout the rest of his life. There are members of our profession who have ravaged and cursed more lives by deception and needless brutality than they could atone for by one hundred life times at hard labor, and our profession can never be freed from these infamous co-workers until public sentiment or college consciences compels the dental colleges to stop cursing the public by turning loose simply for their money this army of low murder unprofessional would be dentists.

Next remember that a child’s mind is continually a question mark, and they must have a satisfactory reason in their mind for everything. Explain in language suited to the age, how these holes or cavities were made in his teeth by little germs that have made their homes there, and that you must brush them out by putting something in the hole to stop it up and explain what will happen to that tooth, both if you do and if you do not so fix it. He will be interested in having them brushed and washed out and sent off on that long dark journey through the big pipes under the city streets out into the lake for the fish to get. It becomes real and interesting to him. Then having gotten the mind satisfied (if they are small and restless and impatient and afraid), divert their mind by securing a keen interest in something like the finding of a certain picture or a certain object in a picture in the picture gallery on the ceiling. Any child can be interested in finding two puppy dogs trying to get a little boy’s dinner away from him, one pulling him away while the other gets his dinner, etc. Reward him by giving him a penny or a brownie if he finds it before you get the cavity prepared, or get the filling in. A variety of fascinating prizes can be gotten for a penny each and less. It not only takes their attention but induces them to hold their heads back and unconsciously hold them still. They will not emphasize the discomforts under these conditions and will not dread going to the dentist, but will frequently say frankly, that they do not mind it a bit or even enjoy it and prove it in many ways. The writer has many dozens of children patients who come with real pleasure and apparently no fear or hesitation, largely because they have absolute confidence, and have never been seriously hurt and never once were deceived, and their teeth are thoroughly filled. Many of them come to call and look at the pictures when they have no appointment, and several times have feigned a toothache to get permission to come. Although most of the general methods for preventing pain in cavity preparation will apply to children’s teeth as well as adults. There are some that are specially suitable and will be considered specially.

With adults as well as children, have a very distinct and thorough understanding always in force, that if you hurt them or if anything is uncomfortable they will let you know and you will stop, and if you think best to hurt them a little or think you may, you will first let them know. Under these conditions and these only can both the operator and patient relax, and hence they become absolutely essential as a basis of mutual confidence.

Now, how can the operator proceed without surprising and hurting his patient, and do good and thorough work without deliberately hurting him?

First is diagnosis, and it must be done correctly and without pain for two reasons, for the general comfort of the patient and to establish confidence. There is practically no dental lesion but can be diagnosed without pain. Do not go prowling around with a sharp explorer in search and location of toothache. Find out the condition as far as possible by questioning the patient regarding responses and symptoms; for example, do hot or cold and sweet or sour agents irritate it? If the patient is not sure do not throw a stream of cold water into a suspected cavity to see, but start with water at blood heat; if it responds it will be from pressure of the stream on an exposed or nearly exposed pulp which you would have severely hurt had you used your inquisitive explorer or cold water; and just here I must say that some kind of an automatic heater that keeps the water at just the right temperature every minute of the day is absolutely indispensable to the least painful operator. There are several splendid electrical makes and some for gas.

If the cavity or tooth does not respond to the warm water, reduce the temperature just a little, which will be sufficient to locate an acute pulpitis; and cold water would produce extreme pain. Reduce the temperature gradually. Perhaps the patient will report that the cool water stops the pain, which may tell the whole story. Try real warm water and then if no response warmer still, and if the heat increases the pain and the cool water decreases it, most will recognize at once mechanical pressure within the pulp chamber usually due to gas from separation, and which pain will be relieved as soon as the confined pus or gas is allowed to escape.

If the condition is pulpitis with exposure it will almost invariably be determined, and without producing pain, by simply having the patient make suction upon it. Do not use extreme tests until gentle ones have been tried. If the symptoms are of a pericemental lesion with perhaps several teeth sensitive to percussion, do not go drilling into them to see which one is the worst, etc.; tests with a galvanic current to find the dead tooth, which is done by placing an insulated electrode upon the fillings of the suspected teeth and note how much current they will take before responding. If from one half to one milamphere, the pulp is quite surely dead, if only one tenth or less it is surely alive. This will almost always tell the whole story as to which tooth is the cause. If several teeth are dead and all tender, take an X-Ray picture which will give full particulars without any pain or discomfort whatever. Space will not permit of a further discussion of diagnosis. Having found a sensitive cavity proceed carefully, not ploughing into it with a burr or excavator until the patient rebels or breaks down. Keep in mind continually the mental attitude of your patient and keep the patient comfortable there, as well as in the tooth. You can remove the thin enamel margins without pain, and so explain and proceed to do it very carefully either with a very sharp chisel or sharp cross cut bur, but never use a mallet to hit the chisel–use it by hand. Remove the food and debris and soft decay if you can without discomfort, but as soon as the cavity becomes sensitive, stop until you have relieved it by some of the following or other effective methods. There are conditions under which the discomfort caused by proceeding without any remedial methods may be justifiable, but they are exceedingly rare, for even where the sensitiveness is only slight it will be very easily and entirely relieved by a local application of warm campho phennique, in which is about two per cent of cocaine and a few drops of oil of cloves. Do not ever proceed to dehydrate a sensitive tooth with alcohol or other such volatile agent until you have first saturated the cavity with the above or some mendicant of similar effect. I believe this one remedy would relieve at least twenty per cent of the discomfort of dental operations if properly used. It is perfectly harmless and acts very promptly, both on the mucous membranes and on inflamed or sensitive dentine or pulp tissue, to stop pain or permit of minor operations. Use it on sensitive gums when cleaning the teeth or adjusting the rubber, and for any condition of pain of the dentine or pulp, though it will not desensitize deeply.

Before adjusting the rubber cloth, which is generally quite disagreeable, and often exceedingly so, study to see if you can avoid using it. Many of the cavities that used to be the most difficult and distressing both for the patient and the writer have become very easy for both by improved technique. For example, those cervical cavities which extend under the free margin of the gum, making the adjustment of the rubber cloth exceedingly difficult and painful and sometimes injurious to the gum tissue. Very many of these cavities are filled now with gold without the rubber cloth by blanching the gum tissue in the immediate vicinity with adrenalin chloride solution, thus rendering it temporarily as dry and harmless as a piece of dry leather while placing the gold beneath it. Of course using at the same time a piece of bibulous paper to keep the lip or cheek away and the saliva ejector to keep the patient free from the discomfort of its accumulation. The apparently small or secondary discomforts attending dental operations are often exceedingly trying to the patient such as the accumulation of saliva, the crowding down of the clamps, the stretching of the corners of the mouth with the rubber cloth, the tiring of the muscles of the face from holding the mouth open, etc., all of which can be quite entirely relieved or prevented. Every dentist, whether he has running water or not, should have a saliva ejector. If he has no running water he can accomplish the result splendidly by means of a rubber ejector bulb operated by the patient. The crowding down of the clamp can be prevented by placing a loop of ligature silk across the top of the tooth for molars, or by placing a couple or three turns of it around the neck of the tooth before adjusting the clamp, or by twisting a small soft wire tightly about the neck of the tooth. The tiring of the muscles is relieved by a flexible cushioned rest placed between the patient’s teeth, which no dentist would be without if he knew by personal experience their great comfort. Other cases in which to dispense with the use of the rubber cloth are the many cervical and labial cavities that are much better filled with porcelain inlays than with gold or anything else. It makes a much more comfortable operation besides being a much better one in these cases. Still another variety of cases where the uncomfortable rubber cloth can be dispensed with, and with advantage to both the patient and operator, are all those relatively short operations on the lower teeth, especially the molars, but where dryness is essential such as treatments, small fillings, setting bridges or crowns, etc. Instead of the rubber cloth in these cases, we use a combination cheek and tongue depressor and saliva ejector all in one piece which the writer has devised. It is not one tenth as uncomfortable or objectionable as the rubber cloth, and as quickly placed as any saliva ejector, and is held either by the patient or the assistant. With this simple device the writer has frequently inserted gold fillings in the buccal surfaces of the lower molars even to the third molar. Small children do not object to its use where the rubber would be out of the question.

 

To be continued in the April number.