FEAR OF dental pain is so common that it affects people even before they have their first experience with a dentist. Drilling on teeth is intrinsically unpleasant, much like the screeching of chalk on a slate board. Even if treatment is relatively painless, it is still generally unpleasant. I know, because I visit my dentist in Miami twice a year for a checkup and cleaning, and although it’s routine, I still feel somewhat anxious in his chair. Most people are able to overcome their fears and accept periodic dental care, although it may take repeated positive experiences before the anxiety is significantly reduced. Extremely frightened children and adults with anxieties at the level of phobia should be introduced to treatment slowly. In extreme cases, the child’s first appointments may be only visits to meet the doctor and ‘nurses’, and to observe the tranquility of the dental office. But sooner or later, one must experience the real thing. Then it takes a gentle but firm control of the situation by the dentist to overcome the patient’s anxieties, and to prove that fear of the dentist was unwarranted. Once encouraged past this point, the patient enjoys a sense of great accomplishment; of having overcome a major hurdle in the path to self-control and maturity. The effect is the same in both adults and children.

Overcoming fear of the dentist does not mean there will never be some anxiety of dental treatment. It means that the anxiety will be minimal and not directed at the dentist — who is there to help. Besides, a good local anesthetic injection is all that is necessary to provide virtually painless treatment. Most dental injections amount to no more than the tiny pinprick of the needle, and do not hurt. However, if anesthetic solution is injected too rapidly, with too much force, the pain is unnecessarily severe. A good dental injection takes about 30 seconds to be completed, and will be fully effective in 3 to 5 minutes. The extraction may be done hours after. Patients frequently complain of the lingering numbness afterward, but it is a small discomfort compared to the pain that otherwise would be experienced.

Pain associated with dental conditions ranges from mild sensitivities, to hot and cold temperatures, to the severe pain of toothaches and acute infections of the gums. Analgesics, such as aspirin, are usually sufficient to alleviate mild aches and discomfort. Narcotics are prescribed for more severe pain. As with antibiotics, drugs to relieve pain and reduce anxiety should be used sparingly. The choice of drug should always be based on the principle of adequacy, the least amount of the least powerful substance sufficient for the purpose.

Generic drugs have a distinct advantage over proprietary brand-name drugs: They are cheaper. They are also just as effective. Although manufacturers suggest that their brands are of a superior quality, the active chemical ingredients are the same. There is no reason to pay for higher-priced brand-name drugs, unless one believes the hype of advertisements.

Analgesics are medicines that usually relieve pain without entirely depressing the central nervous system. The popular analgesics are aspirin (acetylsalicylic acid) and acetaminophen. These are often combined with other analgesics, such as phenacetin and caffeine, to potentiate the effect. Aspirin is the first choice for the relief of dental pain; it is inexpensive, non addictive, and well tolerated by most people. And for some, it is just as effective as codeine. Aspirin should always be swallowed to relieve pain; it should never be placed directly on the gum, where it causes ulceration and sloughing of the mucosa. An aspirin burn looks worse than it really is, and the mucosa heals uneventfully, once the irritant is removed.

Aspirin should not be used by patients with a history of peptic ulcers. To avoid the risk of Reye’s syndrome, a rare but serious illness that may result in mental retardation or death, children recovering from chicken pox or flu should not be given aspirin. Many aspirin alternatives are available, such as acetaminophen (Datril, Percogesic, Phenaphen, and Tylenol), propoxyphene (Darvon), and ibuprofen (Advil, Motrin, and Nuprin). These have analgesic and antipyretic (fever-reducing) qualities similar to aspirin’s. They may be tolerated better by those who experience gastrointestinal side effects with aspirin. As with aspirin, prolonged use of ibuprofen can cause stomach ulcers and prolonged bleeding.

Codeine is a commonly prescribed narcotic in dentistry, usually in combination with aspirin, acetaminophen or other analgesics. Patients should first try aspirin alone, since it may be quite adequate. Percodan, a synthetic narcotic, is more potent. Percodan contains aspirin, and therefore should be avoided by those who have aspirin sensitivity. Demerol is another morphine-type narcotic sometimes prescribed for the relief of pain; however, it works much more effectively when given by injection than when taken orally. It is more likely to be used in dentistry as a pretreatment sedative.

Since narcotics are addictive, they should be taken no longer than required for relief of pain. Codeine is the least addictive, which makes it the first choice for those who can tolerate it. Other narcotics such as opium, heroin, and morphine are either too potent or too addictive for routine dental use.

Narcotics relieve pain by depressing the central nervous system. An overdose produces unconsciousness, stupor, coma, and death. Even an average small dose is likely to reduce alertness and induce drowsiness. To avoid injury to themselves and others, narcotized patients should not drive automobiles, and should avoid work that requires alertness.