Alkattan, Dakila; (2023) Non-procedural Pain Management in Paediatric Dental Patients. Doctoral thesis (D.Dent), UCL (University College London).

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Abstract

Introduction: Efforts to improve pain management in children have included approaches to standardize and advance the use of validated pain measurement tools and encourage comprehensive assessment. The discrepancy between improvements in pain assessment practices and pain management outcomes suggests that translation into clinical practice may have failed. Non-procedural pain management approaches are not standardized, or individualized. Even though there are different validated tools to scale and assess pain, these tools are not serving their main purpose, which is giving better outcomes in pain management practices, especially in a time where management of non-procedural pain is paramount. Aims and objectives: The first part of this project consisted of a scoping review on the non-procedural pain management in paediatric patients; to establish how non-procedural pain is managed in paediatric patients, reflect on the research and literature gaps that could be considered as an opportunity for future exploration and studies. Moreover, we aimed to explore how non-procedural pain is managed in different healthcare settings and how these practices can be applied and employed in the paediatric dental setting. The second part of this project involved qualitative interviews to understand the views of paediatric dentists on non-procedural pain assessment and management. Methodology: The eligibility criteria for the scoping review on non-procedural pain management in paediatric patients was based on Participants, Concept, and Context (PCC) between 2015 – 2022. Participants were healthcare workers caring for children under the age of 17 years, and studies included children under the age of 17 with non-procedural pain. The scoping review focused on the assessment and management of pain before delivering any treatment (medical or dental) in children. A qualitative study was conducted in 2023, investigating the views of paediatric dentists on non-procedural pain assessment and management,. The participants included consultants, specialists, registrars, speciality trainees The exclusion criterion were dentists with less than a year of previous experience in delivering dental care to paediatric patients. The 14 participants who were asked questions addressed the following themes: the dentist’s perception of the need and the importance of a baseline pain assessment prior to dental treatment, challenges in obtaining an appropriate non-procedural pain assessment, challenges in decision making of non-procedural pain management practice, and perception on how well parents/carers are managing pain at home. Results: The scoping review resulted in 15 titles eligible for this review. Five studies were conducted in the UK, 4 studies in Italy, 2 in the US, 2 in India, 1 in Germany, and 1 in Canada. Included studies ranged from reviews, retrospective studies, clinical trials, retrospective observational study, exploratory study, cross sectionals, and pilot studies. The qualitative interviews reflected the different layers of the perception and management of the paediatric dentist in practice. They are aware of how important and effective non-procedural pain assessment and management can be with children and their caregivers yet face different challenges in real life practice due to the subjective nature on non-procedural pain. This research aims to improve the care and management of pain in children before they receive actual treatment by emphasising the need for an individualised patient-centred care that will focus on every child’s need and their parents. Discussion and Conclusion: the scoping review highlighted the scarce literature on non-procedural pain management in children. Different approaches were proposed in different domains to manage non-procedural pain, including two pilot studies with unclear results, and a randomised clinical trial with no results provided. Policies and frameworks trialled to lessen visits to emergency departments by better managing non-procedural pain. Pharmacological and non-pharmacological management were also considered effective, with non-pharmacological management being more effective on decreasing the level of anxiety than the intensity of pain. It has been shown that tele-dentistry can be used as a valuable patient management strategy. The qualitative study reflected that paediatric dentists were not interested to use any of the current validated pain assessment tools with children in exception to the Numeric pain Rating Scale (NSR). The overall perception was that pain was subjective and it is challenging for children to express pain accurately. Moreover, pain assessment is a holistic approach of pain history, clinical presentation, clinical and radiographic examination. Paediatric dentists are familiar with the practice of giving patients and their parents non-procedural pain management such as instructions of how to manage pain at home with diet, hygiene, pharmacological management, behaviour management, and/or exercises that will help to ease pain. More studies are needed on the effectiveness of these instructions and how to improve them to better assess the validity of non-procedural pain management.

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