I recently finished a book called Cure: A Journey into the Science of Mind Over Body by Jo Marchant – it was on my reading list because I’m always on the lookout for anything that could help me improve my practice. In this instance, I wanted to see if I’d been missing something in those cases (and I’m sure we’ve all experienced at least one of them) where, despite every effort on my part, the patient simply doesn’t respond well to treatment, or is left with pain that is inexplicably resistant to the prescription of analgesics.
While thoroughly enjoyable, Marchant’s book did cover a lot of ground with which I’m already familiar. However, it did highlight some interesting points about the way we interact with and care for our patients, which I think could – and probably should – be integrated into dental care.
One of the problems we have as dentists is that we are often trained to take a solely scientific approach to treatment: we like measurable data and quantifiable results. We like conventional solutions. As such, we tend to disregard other avenues; homeopathy, for example, is treated with derision because we simply cannot compute its effectiveness – we say these treatments are all in the mind. And yet, we know first-hand how the mind can affect the body – we recognise the physical symptoms of stress and anxiety – and, even if we don’t always admit it, we understand and utilise the power of the placebo.
Marchant’s book delves deeply into the science of placebos, from how research has shown that a bigger pill will produce a greater effect – regardless of whether or not it actually does anything for the patient chemically – to the efficacy of sham surgical cases, where a patient believes they have undergone surgery when they haven’t. While we may be unable to quantify these responses, the case remains: they work. When we swallow a placebo, we’re not just swallowing a pill – we’re swallowing an idea. The idea of health and a cure.
So how does this apply to dentistry? Well, like I mentioned, we may use placebos without really admitting that’s what we’re doing. Take my beloved anaesthetic wand, for example. Unlike a traditional injection, the wand looks modern, hi-tech and elaborate and comes with the expectation of painless – so immediately the patient is at ease. From thereon in the question of whether or not the wand is actually better is completely moot; in reality it just forces me to give a very slow local. The same applies to topical gel – study after study has shown that there is no scientific benefit of applying this gel, but it makes patients feel better… and don’t get me started on bite raising appliances for TMJ pain!
Is this all a placebo? The point here is: does it really matter if these things are superfluous if they have a positive effect? I would say no, it doesn’t. In fact, I think we should harness it more. For example, we can look at pregnancy: the whole process now is very medicalised and expectant mothers are often subjected to long procedures or juggled between different carers. This has been shown to increase the need for caesareans or greater dependency on pain relief. On the other hand, Mothers who have been cared for by one person are shown to be happier, more comfortable and less likely to ask for more drugs. This simple paradigm shift shows that, physically, patients respond far better to more empathetic, targeted care. We can easily incorporate this idea into our practice, by just slowing down and showing our patients that rather than being shifted along the conveyor belt, they are being treated by someone who knows and cares for them.
Similarly, we can look at how burn victims are treated. These patients are often given a lot of painkillers, especially when they have their wounds debrided of damage and infected tissue. But a clinic in America has recently been giving patients virtual reality headsets and encouraging them to immerse themselves in videogames. The idea is that there is only so much information the brain can’t take in and they will be distracted from the pain. The results are staggering with marked reduction of both pain and the need for analgesics. For years my patients have been given video glasses and films to watch during their long endodontic procedures. This was part entertainment, part marketing and it helped stop them from fidgeting. Now I know that I was inadvertently making them more compliant and less in need of further pain control.
These approaches may not be conventional, or even as the chemical reaction of painkillers, but there is no denying their efficacy in a vast number of different scenarios. If we can relay positive messages to our patients, communicate with them in a more empathetic way – provide them with options that they think will help the, then we can give them a better, more painless service.
Of course, using drugs and medication may be quicker and less labour intensive, but do they really change a patient’s attitude to treatment or present a long term solution? Not reallu, they are just a quick fix – what we need to do is understand and appreciate the psychological state of our patients and act on this accordingly. Marchant herself sums it up far more succinctly than I could in her book: “taking account of the mind in health is actually a more scientific and evidence-based approach than relying every more heavily on physical interventions and drugs.”
This deceptively simple idea is one of the most powerful in the book: sometimes the difference between feeling well and feeling awful is simply a matter of where we direct our attention.