Dental pain control beyond anaesthesia - a fear-aware approach
For dentists, this has important implications: pain is not just something we block, it is something we influence.
Dental pain control is often approached as a purely technical task, selecting the right anaesthetic, technique, and adjuncts to eliminate nociceptive input. While this remains essential, it is only one part of how patients experience pain. Contemporary research shows that pain is a biopsychosocial experience, influenced not only by tissue damage but also by psychological factors such as anxiety, expectation, memory, and context (Loggia et al., 2008).
For dentists, this has important implications: pain is not just something we block, it is something we influence.
Pain is processed in the brain
Patients do not experience pain directly in their teeth, they experience it in their brains. While peripheral nerves transmit signals, the brain interprets these signals and determines whether they are perceived as pain.
This interpretation is heavily influenced by psychological state. Studies show that anxiety significantly increases pain perception, even when the stimulus itself is unchanged (Loggia et al., 2008; Turturica et al., 2025). In dentistry, this is reflected in everyday clinical scenarios, such as patients flinching before contact or reporting discomfort in the absence of a clear stimulus.
Dental anxiety has also been shown to correlate with higher reported pain intensity during treatment, reinforcing the relationship between emotional state and sensory experience (Abedi et al., 2025; Maggirias & Locker, 2002).
Contemporary research shows that pain is a biopsychosocial experience, influenced not only by tissue damage but also by psychological factors such as anxiety, expectation, memory, and context
The limitation of a purely physiological approach
Traditional pain control focuses on:
Local anaesthesia
Pharmacological adjuncts (e.g. NSAIDs)
Mechanical techniques such as pressure or vibration (gate control theory)
These remain fundamental. Effective anaesthesia, delivered slowly and predictably, is critical. Adjuncts such as pre-operative analgesia and multi-sensory distraction are also well-supported.
However, research suggests that psychological factors may influence pain perception as much as, or more than, the physical stimulus itself (Turturica et al., 2025).
This explains why:
Some patients remain uncomfortable despite adequate anaesthesia
Others tolerate complex procedures with minimal distress
The same procedure can feel very different between patients
The role of expectation and suggestion
One of the most powerful modulators of pain is expectation.
Pain perception can be significantly altered by what patients are told to expect. Studies in pain neuroscience demonstrate that expectation of pain relief activates endogenous analgesic pathways, reducing perceived pain (Loggia et al., 2008).
Conversely, negative expectations increase pain intensity.
In dentistry, this translates directly to language.
Negative suggestions such as:
“This might hurt”
“Sharp scratch”
“You’ll feel pain”
Prime the brain to interpret sensations as threatening.
Positive, reframed suggestions such as:
“You may feel some pressure or vibration”
“I’m applying numbing gel to make this more comfortable”
“I’ll do this very gently for you”
Reduce anticipatory anxiety and alter how sensations are interpreted.
These are not simply communication preferences, they are neurobiological interventions that influence pain processing.
Reducing uncertainty improves pain tolerance
Uncertainty is a key driver of anxiety, and anxiety amplifies pain.
Evidence shows that patients who are given clear, realistic expectations of sensory experiences report lower pain levels than those who are not (Loggia et al., 2008).
Importantly, this is not about overloading patients with information, but about removing ambiguity.
Instead of:
“You won’t feel anything”
Use:
“You’ll likely feel some pressure and vibration”
Providing timeframes further improves tolerance:
“This will take about 10 seconds”
“You’ll feel this for a short period”
This is particularly important for patients with sensory sensitivities or neurodivergence, where predictability significantly improves coping.
Perceived control reduces pain and distress
Another key factor in pain modulation is control.
Studies show that increasing a patient’s perceived control reduces both emotional distress and pain perception (Loggia et al., 2008).
In practice, this can be achieved through simple strategies:
Agreeing on a stop signal
Asking permission before starting
Using invitational language
For example:
“Would you like me to start now?”
“You can let me know at any time if you want to stop”
These small changes shift the patient from a passive recipient to an active participant, reducing perceived threat and improving tolerance.
Integrating physiological and psychological approaches
The most effective pain control comes from combining both domains.
Physiological
Effective local anaesthesia
Slow, controlled delivery techniques
Pre-operative analgesia
Gate control (pressure, vibration)
Distraction (multi-sensory engagement)
Psychological
Positive suggestion
Predictable sensory guidance
Clear timeframes
Patient control and autonomy
Together, these approaches:
Reduce perceived pain intensity
Improve cooperation and efficiency
Decrease reliance on sedation
Enhance patient experience
Pain, memory, and future behaviour
Pain is not only experienced, it is remembered.
Memory research shows that experiences are not recorded accurately but are constructed, influenced by interpretation and emotion. This has significant implications for dentistry, as remembered pain strongly influences future attendance.
The Peak-End Rule (Kahneman) suggests that patients judge experiences based on:
The most intense moment
The end of the experience
This means that how pain is managed during key moments — particularly injections and the conclusion of treatment — disproportionately shapes memory.
Simple reinforcement at the end of treatment:
“That was better than you expected, wasn’t it?”
Encourages patients to form more positive memories, reducing future anxiety and perceived pain.
Clinical implications
Pain control should no longer be viewed as purely technical.
A modern approach recognises that:
Pain is influenced by psychological state
Language directly affects perception
Predictability reduces anxiety
Control improves tolerance
This represents a shift from:
“Blocking pain”
to
“Shaping the experience of pain”
Key takeaway
Effective pain control is not just about eliminating nociception, it is about reducing perceived threat.
By combining strong clinical technique with intentional communication and patient-centred strategies, dentists can significantly reduce pain without increasing treatment time.
Ultimately, this approach not only improves comfort in the moment, but also reshapes how patients remember dental care, breaking the cycle of fear and improving long-term outcomes.
References
Abedi, S. (2025). Relationship between dental anxiety and pain perception. Journal of Dental Sciences.
Loggia, M. L., et al. (2008). The role of psychological factors in pain perception. Pain, 136(1–2), 168–176.
Maggirias, J., & Locker, D. (2002). Psychological factors and perceptions of pain associated with dental treatment. Community Dentistry and Oral Epidemiology, 30(2), 151–159.
Turturica, N. C., et al. (2025). Psychological influences on pain perception during dental procedures. Dentistry Journal, 13(12), 597.
Written by Dr Trent Davidson and Dr Helen Fisher from Mindset Dental in Brisbane, Australia 2026