Pediatric Dental Procedure-Related Pain Assessment Practices in a Rural Alaskan Healthcare Organization: A Qualitative Study

Abstract

Purpose:

Acute pain experienced during dental procedures can lead to distress, difficulty with behavior guidance, and dental fear/avoidance. This study explored dental providers’ perceptions of pediatric procedure-related pain and acute pain assessment practices.

Methods:

Fifteen dental providers (53% female; 9 dentists, 3 dental therapists, 3 dental hygienists) currently/formerly employed by a single rural Alaskan healthcare organization were interviewed using a semi-structured guide. Recorded interviews were transcribed, verified, and coded using inductive qualitative analytic methods.

Results:

Six providers suggested that pediatric procedure-related pain is rarely encountered. Providers who reported encountering it rely on observation of body language, facial expression, behavior, crying, and verbalization to know whether a child is experiencing procedural pain. Few Even when available, only four interviewees reported using standardized pain scales.

Conclusions:

Dental providers have mixed perceptions about whether they encounter pediatric procedure-related pain. There is high variability in how providers assess procedural pain, and approaches often are non-standardized.

Introduction

After disease and injury, routine medical and dental procedures are the most common cause of acute pain in children.¹ One-in-three children ages 6–14 years report experiencing pain during dental procedures (e.g., prophylaxis, local anesthetic injections, restorations, extractions).² Procedural pain is distressing for children, parents, and providers.³ Inadequate management of such pain also can make behavior guidance challenging, resulting in lengthier procedures and subsequent provider uneasiness and reluctance to treat children.^4,5 Moreover, pain encountered during dental procedures is the primary pathway in the etiology of dental fear, which can have lifetime impact on dental care utilization and oral, systemic, and emotional health.⁶

The first step of evidence-based pain management is the assessment of pain presence and intensity, applied consistently and repeatedly within and between patients.⁷ The American Academy of Pediatric Dentistry describes pain assessment as “integral,” suggesting the use of standardized and validated pain assessment tools as part of regular clinical practice.⁸ Though understudied in dentistry, research from medicine demonstrates that proper use of these tools results in improved pain management outcomes and patient/parent and provider satisfaction.⁹ Consistent use of pain assessment tools may also prevent underestimation of pediatric pain, which studies have found is common among dentists.^10,11

There is a gap between evidence-based recommendations for pain assessment and current clinical practice in pediatric dentistry. Only 57% of U.S. pediatric dentistry residency directors report that pain is routinely assessed using quantifiable scales at all types of appointments in the training clinics they oversee.¹² It is unknown how often pain is measured during procedures, versus only during review of symptoms. Pain assessment behaviors by dentists in clinical practice have not been comprehensively described in the literature, but there likely is even less consistency than observed in training settings.¹³ For instance, even with respect to non-standardized and informal (versus structured, evidence-based) assessment of pain during treatment, a survey of dentists suggests that they may encourage children to report pain if it is experienced, but routine querying is uncommon.¹⁴

To understand the evidence-practice gaps in procedural pain assessment in pediatric dentistry, the goal of this study was to explore dental providers’ perceptions about dental procedure-related pain and their approaches to pain assessment in a clinic where a standardized pain assessment tool is known to be readily available.

Methods

Participants and Setting

Participants were dental providers currently or previously employed by a healthcare organization in rural Alaska. Providers were eligible to participate if they were a dentist, dental therapist (whose scope of practice includes restorative treatment and extractions of primary teeth, simple restorations and extractions of permanent teeth, and preventive care, all under the general supervision of a dentist), or dental hygienist (who primarily deliver prophylaxis and hygiene instruction, but whose scope of practice includes scaling and root planning and local anesthetic administration). Children account for a majority of the patient population in the healthcare organization from which participants were recruited, in part because: (a) there are high caries rates among children in the region; (b) prioritizing the treatment of children is an organizational goal; and, (c) Medicaid pays for comprehensive dental services for children but not adults in the state.¹⁵ Consistent with internal policies of the healthcare organization, a copy of the Universal Pain Assessment Tool (which simultaneously presents multiple validated pain assessment instruments) is available in every dental operatory.¹⁶

Study Design and Procedures

This was an interview-based qualitative study. A semi-structured interview guide was developed by a pediatric dentist and a clinical health psychologist as part of a larger script. The guide included three open-ended questions, and associated follow-up probes, about pediatric procedure-related dental pain assessment: (1) “How much of a problem is procedural pain for the children you treat?,” (2) “When pain is a problem, how can you tell?,” and (3) “Is there anything you use to measure their pain?” Dental providers who were participating in a qualitative program evaluation about the care delivery system in their healthcare organization were invited to answer these additional interview questions about pain assessment; all agreed. We obtained verbal consent, and a single interviewer administered all interviews individually by telephone. Each interview lasted 10–20 minutes. Participants received two continuing education credits as a thank you for completing the interviews. Data were collected between September 2017 and April 2018. The study was approved by the University of Washington IRB, the University of Alaska Fairbanks IRB, and the healthcare organization’s Human Studies Committee.

Data Management and Analysis

Interviews were audio recorded and transcribed verbatim; transcripts were verified for accuracy. A single coder analyzed the transcripts using inductive content analytic methods.¹⁷ Responses, unitized by noun-verb phrases, were categorized into non-overlapping groupings of similar concepts based on the manifest meaning of the words; all units were coded. The categories were labeled using participants’ words. Results are organized by question/probe below, and subheadings represent the category labels generated from participant responses.

Results

We enrolled 15 participants (53% female; 9 dentists, 3 dental therapists, 3 dental hygienists). All dentists were general dentists when they worked for the healthcare organization; two had subsequently specialized by the time of the interview. For each question/probe, categories are presented below, and for each category, representative quotes are provided in Table 1.

Table 1.

Pediatric Dental Procedure-Related Pain Assessment Practices: Categories with Sample Verbatims

Category	Sample Verbatim(s)
The Problem of Pediatric Acute Procedure-Related Pain
Not thinking there is much pain	“I would think that there’s not a whole lot of pain associated with what I’m doing.” (dental hygienist, female) “A majority of my kids weren’t in excruciating amounts of pain.” (dentist, male) “It (procedural pain) shouldn’t be a problem to be able to get anesthesia. If they’re in pain, there would be an injection.” (dentist, male)
Talking to the child about the pain beforehand	“If I know it’s gonna hurt, I talk about it…I like to let [the child] know it may hurt a little bit.” (dental therapist, female)
Believing most procedural pain is caused by injections	“Mostly every time we have pain is from injections. When you can minimize the pain associated with an injection.they’re much more likely to accept the care.” (dentist, male)
Believing pressure is pain	“You can still feel that sensation of a tooth being removed.it doesn’t take away that pressure. I constitute that as pain…if the [pressure] sensation is upsetting to you, that’s maybe pain.” (dentist, male)
Knowing when a Child is Experiencing Acute Procedure-Related Pain
Seeing that the patient is swollen or looking sick	“If they have a blatant abscess.you know.that has to hurt.” (dental hygienist, female) “You can see that their cheek is swollen.” (dentist, male)
Seeing the way the patient acts	“Their eyebrows or the movements of their feet [tell me they are in pain].” (dental therapist, female) “It’s just about their facial expression and how they are interacting with you, how they’re responding to questions, how open they are to accepting care and following directions.” (dentist, male) “Their reaction, if they flinch, if their eyes open really big [you know they are in pain].” (dentist, female) “They would let you know with classic social keys, or squinting their eyes or guarding or, you know, closing their mouth.” (dentist, male)
Hearing the patient’s cry	“Patients can be crying because they’re scared. But if you do something that could be painful and their cry changes, then you know that that hurt.” (dentist, female) “You’d have to tell stoic kids that you could see that they were crying, or just maybe tearing up or a drip down underneath their shades.” (dentist, male)
Patients verbalize their pain	“Some of them (children) can verbalize it (their pain) for sure.” (dental hygienist, female) “Maybe [patients are] describing it if they’re an older child.” (dentist, female)
Believing it is not always easy to tell if a child is in pain	“A lot of times it was hard to tell if the kid was in pain.” (dentist, male)
Acute Pain Measurement During the Pediatric Dental Visit
Doing a pre-treatment assessment	“[Assessing] when they first come in, yeah.” (dental therapist, female)
Using a pain scale	“We had, like, a picture, the scale of one through ten with a picture that they would point to, like the happy face or sad face or whatever.” (dental hygienist, female) “If they’re old enough then.you can explain the pain scale to them.” (dentist, female) “[I] use a pain scale [every time] to formally or informally assess pain. A lot of people just say ‘10’ and so it makes it not that useful, [but] kids sometimes will point to a face and that works a little bit.” (dentist, male) “I don’t stop in the middle of a procedure to [use a pain scale].” (dentist, female)
Offering a comparison	“Maybe comparing it to something else they’ve experienced.” (dentist, female)

The Problem of Pediatric Acute Procedure-Related Pain

With regard to encountering procedural pain in pediatric clinical practice, data were summarized into four categories: not thinking there is much pain; talking to the child about the pain beforehand; believing most procedural pain is caused by injections; believing pressure is pain.

Not thinking there is much pain.

Six participants (three dentists) described not encountering significant procedure-related pain when working with children. Two dental hygienists and one dental therapist suggested the procedures they do are not painful. The dentists did not describe a complete absence of procedure-related pain, but suggested it was not encountered frequently or intensely, or that it wasn’t experienced as long as pre-operative analgesia could be achieved.

Talking to the child about the pain beforehand.

A dental therapist recalled telling patients that procedure-related pain might be experienced during the visit.

Believing most procedural pain is caused by injections.

Participants suggested injections are the main source of procedure-related pain.

Believing pressure is pain.

A dentist indicated that, even when analgesia is achieved, a pressure sensation might be experienced as pain.

Knowing when a Child is Experiencing Acute Procedure-Related Pain

Responses about how providers know whether a child is experiencing procedural pain were grouped into five categories: seeing that the patient is swollen or looking sick; seeing the way the patient acts; hearing the patient’s cry; patients verbalize their pain; believing it is not always easy to tell if a child is in pain.

Seeing that the patient is swollen or looking sick.

Participants reported that observing swelling or other symptoms of dental disease can indicate a child is experiencing pain.

Seeing the way the patient acts.

Eight participants (six dentists, one dental therapist, one dental hygienist) described using observations of “facial expression,” “body language,” and/or behavioral “reactions” to know when a child is experiencing pain.

Hearing the patient’s cry.

Participants—all of whom dentists—indicated they can tell a child is experiencing pain during a dental procedure based on the presence and tone of crying.

Patients verbalize their pain.

Participants reported that some children will tell their provider when they are experiencing pain.

Believing it is not always easy to tell if a child is in pain.

Participants described some uncertainty or difficulty in knowing whether a child is in pain.

Acute Pain Measurement During the Pediatric Dental Visit

With regard to measuring pain, provider’s responses were summarized into three categories: doing a pre-treatment assessment; using a pain scale; offering a comparison.

Doing a pre-treatment assessment.

A dental therapist suggested pain measurement occurs not during dental procedures but at the beginning of the visit.

Using a pain scale.

Four providers described measuring pain intensity with a validated pain scale. One of these providers indicated they do not interrupt a procedure to do so, and another suggested they use the scale only if the child is old enough. Only one provider, a dentist, reported using a pain scale with every patient.

Offering a comparison.

To measure pain, a dentist suggested using comparison to previous pain.

Discussion

In this study, we interviewed dental providers from one healthcare organization about procedure-related pain and its assessment. Findings are mixed with regard to whether providers working with children believe they encounter procedural pain in their clinical practice. Provider type may account for some of this variability, as three of six non-dentists, but only three of nine dentists, described not encountering procedural pain. Findings suggest that few providers in the study healthcare organization use a standardized pain assessment tool. Instead, providers more commonly monitor pediatric patients’ facial expressions, body language, crying, and behavior to determine whether procedure-related pain is being experienced. These results are congruent with data indicating inconsistent use of pain assessment tools by dental providers treating pediatric patients.^12,13 Most interesting is the main finding that providers’ approaches to pain assessment are informal and unique to each provider even in a clinic where a standardized pain scale is available in all operatories.

Participants viewed acute procedure-related pain as something encountered toward the beginning of a procedure and primarily from injections. Assessment of such pain is essential to guide its management, but because pain can be experienced dynamically throughout a procedure, repeated assessment is needed for real-time management of pain.⁷ Moreover, routine use of standardized tools can protect against inconsistent pain management and associated disparities resulting from implicit biases related to patient/provider characteristics and environmental constraints.^10,18 Thus, though providers may attend to potential indicators of procedure-related pain, as our participants reported doing, best practices would include consistent use of an evidence-based assessment tool multiple times throughout a procedure. For example, during a longer procedure, a provider might use the same validated self-report pain scale to query pain ratings before and immediately following an injection as well as during drilling, placement of a filling, and after the procedure is complete.

There are many reasons providers may not use validated, standardized pain assessment tools, including inadequate dissemination of evidence-based tools.¹⁹ As suggested by our data, just having access to such tools does not ensure use—providers may be aware of these tools but not know how to best implement them. Future research should identify how providers learn to assess procedure-related pain and the barriers to consistent use of validated tools in independent practice. The pediatric setting is particularly important for implementation of evidence-based pain assessment tools given that approximately three-fourths of adults with dental fear, often with pain-related etiology, report childhood or adolescent onset.²⁰

This is an initial investigation of dental providers’ pediatric procedure-related pain assessment practices. Due to interview length constraints, the interview guide was non-comprehensive. Future work should identify a more detailed understanding of provider practices for a more nuanced conceptualization. Given its focus on assessment, the interview guide offered only a brief opportunity for participants to describe pain management practices, without follow-up probing. Future research should thoroughly address management and provider perspectives about the assessment-management link. Additionally, because participants were recruited from a single healthcare organization, results may not be generalizable. Last, the participant sample was heterogenous with respect to provider type. Future studies may reveal differences by clinician type and training level, offering information to tailor implementation strategies aimed at improving assessment practices.

Conclusions

1. Results of this preliminary qualitative study indicate that some pediatric dental providers perceive encountering procedure-related pain more often than others, possibly a function of provider type.

2. Pain assessment practices are largely non-standardized and based on individual provider preferences, even when tools are available.

3. Enhanced integration of evidence-based pain measurement could improve pediatric dental care and prevent dental care-related fears.