This qualitative study, using grounded theory, explored children’s and adolescents’ experiences of procedural and postoperative pain connected to tooth extractions. Despite a great deal of uncertainty in terms of what to expect for procedural and postoperative pain, they went through with having their teeth extracted. By using different types of coping strategies, they were handling the unavoidable unknown. All informants showed a great deal of courage by having teeth extracted (on orthodontic indications) without knowing what to expect from the treatment itself or the postoperative period, including some level of anxiety prior to treatment.
The present study shows that although the children and adolescents have different experiences from previous dental treatments, there are similar traits. These are described in the five categories (clinging to what I can trust, clinging to earlier experience, striving to be in control, longing to get it over with, and looking forward to a treat), all representing different ways of coping with the tooth extractions.
Wanting more information emerged as a central part for the informants in the present study, as an aid to cope with the tooth extractions since information given appropriately makes the procedure understandable, lowering levels of fear and anxiety. In this study, the participants expressed thoughts about the information given in conjunction with treatment. The amount of information was described as sufficient; still, informants were anxious during and after treatment. We interpret this as there being a continuous need for information, which must come at an appropriate time. The relationship between dental anxiety and pain experiences, both dental and everyday pains, is well established (15) and individually tailored information about treatment should always be a first step in the prevention of both (16). Information has to be age appropriate as well as be continuously provided throughout the whole treatment procedure. Within dental care, the ‘tell-show-do’ procedure is commonly practiced. When the child/adolescent is guided and gradually exposed to a procedure, this will aid future cooperation with dental treatment. Problems in a dental scenario are most likely to be prevented if time and awareness are devoted (17). Based on the present study’s findings, this is important to stress. A child’s first treatment must be handled with empathy and understanding from the dental/medical health personnel. Being empathetic to the patient’s needs and preferences may be a key factor in establishing an effective working relationship (18) and is likely to lead to future medical/dental care being characterised by cooperation rather than by conflict from the child’s perspective (19). With this also comes the patient’s right not to know. We as dentists have to take notice of patients’ preferences of receiving or not extensive information. Some children said in their interviews that they did not want too much information as it would lead to more worrying. In such cases, it is crucial to be aware that it is not only verbal communication that matters. Non-verbal communication also aids children visiting the dentist (20).
Previous experiences from dental visits are used by the child as a model to predict future treatments (21). In this study, the informants seemed to have had positive to neutral experiences. The first visit within this study seemed to have a positive conditioning effect on the second visit, which has been reported by Hembrecht et al. (22), who stated the consecutive dental treatments seem to have a conditioning effect. This is supported in a study of pain’s natural course after tooth extractions (on orthodontic indication) where there were no differences in pain profiles after first and second extractions (1). Dental pain and dental fear and anxiety are often seen as closely rated and intertwined and in children, cognitive and emotional development will affect the child’s understanding of both as well as the ability to differentiate between them. If a child has an experience with a dental procedure that was perceived as traumatic and/or frightening, future events will be coloured by that. This first experience may also be generalised so that all coming events that remotely resemble the first frightening episode, may cause fear and anxiety (23). Having many non-traumatic dental visits is an important factor in avoiding development of dental fear and anxiety, according to the theory of latent inhibition (24–26). Exposure to several repeated successful and pain-free dental visits leads to ‘vaccination’ (latent inhibition). If the patient later meets a negative dental experience the likelihood of developing dental fear and anxiety is lower than if this negative experience occurs during one of the first dental visits (24, 25).
Being in control of the situation is an important coping strategy. This can be achieved by having the opportunity to pause the treatment with a stop signal, like raising the hand (20). The participants in the present study mentioned this repeatedly. The possibility of stopping the treatment gave the informants a feeling of control. Some tested it, even though they really did not have to. Doing so can be interpreted as them not feeling totally secure in the situation, but when they noticed that the stop hand worked, they felt safer in the situation, having better control. A stop signal is very favourable for the patient and can be easily employed in practice, leading to a lowered reported stress level even if the child does not use the stop signal (20). In a study by Rodd et al. (27), children also stated that they hoped that the dental team would listen to them and tell them what was happening. Within the theme of good communication, children wanted to feel in control, by asking the dentist to cease treatment when necessary (27).
The fourth category, longing to get it done with, is a theme that has been described in other studies as well. For example, Davies & Buchanan (20) reported that children aged 9–11 preferred getting the treatment over and done with, compared to having a pause, which would prolong the treatment.
The fifth category, looking forward to a treat, points out that motivation can make the child accept the treatment although sometimes painful/unpleasant. The informants in the present study defined a treat in different ways. For some it was watching Netflix, while for others it could be having more quality time with their parents. It could also be an eagerness to have braces, because that meant their teeth would be aligned and aesthetically appealing. This motivator to accept treatment has been shown in other studies; for example, van Meurs et al. (28) found that 92% of the children used a strategy called ‘I tell myself I have to do this because it is good for my teeth’.
A strength with the present study is that the same person performed all of the interviews and transcriptions. By this measure, a deepened acquaintance and close knowledge of the data was achieved. Also, having a multidisciplinary team reading the transcripts and participating in analyses is a strength as it warranted different views of the information, and led to picking up nuances in the participants’ stories that otherwise might have been missed (29, 30).
The outbreak of Covid-19 led to delay in recruitment of informants. However, re-interviewing of three earlier informants plus inclusion of a new twelfth informant were conducted a few months later than originally planned. This is a verification strategy called ‘member checking’. The goal is not to make a data check, rather it is a way to perform analysis at a more abstract, and higher position in the process, make a validation of concepts and their components. This leads to a completion of data collection, and this is also ensuring commitment to the data and the analysis being made (31, 32). From interviews of the 12 informants and 3 re-interviews, we could clearly see that saturation was reached for each category, thanks to all interviews being lengthy and rich in information. Those who analysed the data, individually, concluded this.
In general, the pain in conjunction with tooth extraction seems to be manageable. The informants were motivated to go through with the treatment despite some pain and discomfort. Their stories instead focused on the importance of not forgetting the basis in non-pharmacologic pain treatment, namely accurate and individually tailored information about treatment as well as possible pain and discomfort both during extractions and postoperatively. It may be beneficial if more detailed information about dental extraction was already provided at the orthodontist’s. Information about the postoperative period also needs more focus from the dentist performing the extractions. Today many children/adolescents have limited experience of invasive dental treatments, due to good oral health. Tooth extraction prior to orthodontic treatment might therefore be a totally novel experience for the patient. This is perhaps the very first invasive treatment, encounter with local anaesthesia, and possible dental pain for many patients in an otherwise dentally healthy population. It is also important to remember that children are not porcelain figurines. They need to be equipped for reality without sugar coating, instead being honest and preparing them the best way possible.
There was in general a very low demand for pharmaceutical aid to cope with pain. Instead, prevention of pain seems to be the main theme based on data in this study. When formulating guidelines, focus should lie on psychological care.