Dental Implants Singapore- is it painful?

Dentistry has often been associated with pain. And Hollywood has contributed significantly to this perception. My first encounter with Hollywood Dentistry came in the form of Dr Christian Szell in “Marathon Man” back in 1976, drilling Dustin Hoffman’s character to extract information. I believe that scene scared the living daylights out of many kids and deterred an entire generation from seeing the dentist. Fast forward to 1986, when I was in dental school and one day after exams, a few of us went to catch a movie which was none other than “Little Shop of Horrors” where Steve Martin played a sadistic dentist, albeit in a comical role. So, if drilling teeth is associated with so much pain, it is little wonder that many patients think that placing a metal screw in the jaw bone must be even worse! Fortunately, real life is nothing like reel life.

What is pain?

The International Association for the Study of Pain defines pain as “ an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.” Pain can be felt even when there is only potential tissue damage ie no real damage. It is also not a purely sensory experience but an emotional one as well. With that understanding, pain can be minimized by controlling both the sensory and emotional stimuli.

Local anesthesia

Contrary to what some may imagine, dental implant surgery is not any more painful than any other minor surgery, be it in the mouth or other parts of the body. Surgery today is almost always done with anesthesia. I say almost always because there are some patients who refuse anesthesia but that’s another story. Local anesthesia numbs the area of surgery without the patient losing consciousness and is sufficient to block the sensation of pain. Local anesthesia involves the injection of an anesthetic solution into the area of surgery to block the transmission of any painful stimuli to the brain. In the case of dental implants, injection only needs to be done in the immediate vicinity of the area where the implant is to be placed. If a lot of implants are needed, a nerve block can be done instead of multiple injections into all the implant sites. A nerve block is done by injecting the local anesthetic solution further back near where the main nerve enters the jawbone. Blocking the transmission of nerve signals further back can block the entire area that is supplied by that nerve. Injections into the gums can be rather painful but that can be significantly negated by the use of topical anesthetic gel prior to numb the superficial gum. The use of modern computerized injectors also helps to minimize the pain of injection. This works by controlling the speed and force of injection. One of the common cause of painful injection is the sudden pressure on the gums during an injection done by hand as the human hand cannot maintain a constant speed and force of injection. By using a machine, the speed and force is calibrated and kept constant. Hence the combination of applying a topical anesthesia and use of computerized injectors can alleviate much of the discomfort of dental injections.

Sedation

However, local anesthesia does not take away the emotional part of the experience. To that end, sedation can be used to relieve the anxiety associated with surgery. Dental implants surgery involves the use of a wide range of instruments and drills. The sight of these instruments and the sound of the drills creates fear in some patients that reduces the threshold for pain, thereby rendering the experience more traumatic than the physical sensation would cause. Sedation can be used to supplement local anesthesia to help relieve the emotional component of pain sensation. Sedation can be administered by various means.

      Inhalational sedation

The traditional laughing gas which is so commonly portrayed in the movies is an inhalational sedative. Nitrous oxide is mixed with oxygen and delivered via a mask over the patient’s nose. This form of sedation is also call relative anesthesia as it does not alter pain sensation but renders the mind more indifferent to the pain. This form of sedation is very commonly practiced among pediatric dentists. However, it is less common outside a pediatric dental clinic as it requires additional facilities to ensure proper scavenging of the waste gases. In addition, the sedative effect on adult patients is also less consistent than in children.

       Oral sedation

An alternative is to take a sedative pill orally one hour before the surgery. This can create some degree of anti-anxiety to calm the patient down. However, this form of sedation is not titratable, meaning, the dosage cannot be adjusted to suit the needs of the patient in real time. This can sometimes result in over or under-sedation.

       Intravenous sedation

Another method of sedation is intravenous sedation. This involves injecting a sedative drug into a vein. The effect of the sedative is felt in about two minutes. The dosage can be titrated in accordance to the response of the patient. Some patients require a higher dose while others require a lower dose. A small initial dose is given and the patient’s response is observed over the first two minutes. If the desired level of sedation is reached, the surgery can proceed, if not, additional doses can be given till the desire effect is achieved. The pulse rate, oxygen saturation of the blood and blood pressure is monitored continuously during intravenous sedation, ensuring that the patient is well oxygenated throughout.

General anesthesia

General anesthesia is sometimes used for dental implant surgery as well. General anesthesia renders a patient completely unconscious and major surgery can be carried out. I use general anesthesia for two categories of dental implant patients. The first group comprises patients who need major reconstructive jaw surgery along with the dental implants. These patients have lost a lot of bone either through trauma or natural resorption to the point that the jaw bone is not big enough to have dental implants placed. For this group, bone is harvested from the hip bone and grafted onto the jaw to expand the bone mass for implant placement. Again, this description similarly sends shivers down some spine. The need for a general anesthetic in such cases is not because the surgery is more painful than routine dental implant surgeries but because adequate local anesthesia cannot be established in the hip bone area. Such cases do not require overnight stay in the hospital. The surgery is done as a day surgery and the patient goes home about three hours after the surgery. Feedback from patients is that it is not that painful. The use of long-acting local anesthetic in such cases also serves to minimize discomfort significantly in the post general anesthetic phase. The second group of patient who requires general anesthesia for dental implants is the extremely fearful patients. Fortunately, there are not many people like that. For this group, general anesthesia is not for pain control but rather for control of fear.

In my practice the vast majority of dental implant surgeries are done under local anesthesia with intravenous sedation. This combination minimizes the pain of surgery significantly and makes the overall experience much more comfortable. The sedative drug also have a bit of anterograde amnesia, which means that the patient does not remember much of what happened between the onset of the sedation till the time the effect of the sedative wears off. By having an intravenous access established, the effect of the sedative can be reversed by injecting an antidote. While this is not usually necessary, some patients may experience a more lingering effect of the sedative even after the surgery is over. For this group, having an antidote that can reverse the effect of sedative within a minute or two is very useful.

Pain control at home

Postoperatively, when the local anesthesia wears out and the sedative or general anesthetic effects are gone, there will be some degree of pain. Such pain is usually easily managed using painkillers. In my practice, I usually prescribed two types of painkillers. One is a new generation non-steriodal anti-inflammatory (NSAID) such as eticoxib which the patient is instructed to take once daily for the first three days, regardless of whether there is any pain. These drugs work better as “pain-preventers” than pain “killers”. In addition, I will also add on another painkiller such as codeine combined with paracetamol to be used on a “when necessary” basis. This combination of an NSAID with a narcotic type painkiller has been reported by my patients as very effective.

Overall, dental implant surgery is ranked quite low on the pain scale of surgeries. The use of good anesthetic technique and post-operative painkillers can make dental implant surgery almost pain-free for the vast majority of patients.