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Pain and anxiety are natural physiological and psychological responses. Pain is a direct response to an adverse stimulus that has occurred; anxiety is the unpleasant feeling, the worry that something unpleasant might occur. Pain and anxiety are often intertwined, especially in the dental setting. The best way to manage child dental anxiety is to avoid its occurrence in the first place through prevention of dental disease, good behaviour management, pain-free operative care, and treatment planning that is tailored to the needs and developmental stage of each individual child. These issues are detailed in the previous chapters. This Chapter specifically focuses on pharmacological pain and anxiety control and explores the roles of conscious sedation and general anaesthesia (GA) as adjuncts to behaviour management. A child’s perception of pain is subjective and varies widely, particularly with age. Infants up to about 2 years of age are believed to be unable to distinguish between pressure and pain. Older children begin to have some understanding of ‘hurt’ and begin to distinguish it from pressure or ‘a heavy push’. It is not always possible to identify which children are amenable to explanation and will respond by being cooperative when challenged with local anaesthesia (LA) and dental treatment in the form of drilling or extractions. Children over 10 years of age are much more likely to be able to think abstractly and participate more actively in the decision to use LA, sedation, or GA. As children enter their teenage years they are rapidly becoming more and more like adults and are able to determine more directly, sometimes emphatically, whether or not a particular method of pain control will be used. The response is further determined by the child’s coping ability influenced by family values, level of general anxiety and intelligence. There is a strong relationship between the perception of pain experienced and the degree of anxiety perceived by the patient. Painful procedures cause fear and anxiety; fear and anxiety intensify pain. This circle of cause and effect is central to the management of all patients. Good behaviour management reduces anxiety, which in turn reduces the perceived intensity of pain, which further reduces the experience of anxiety.

It is essential that dental students and practitioners understand the structure and function of the temporomandibular joints and the muscles of mastication and other muscle groups that move them. The infratemporal fossa and pterygopalatine fossa are deep to the mandible and its related muscles; many of the nerves and blood vessels supplying the structures of the mouth run through or close to these areas, therefore, knowledge of the anatomy of these regions and their contents is essential for understanding the dental region. The temporomandibular joints (TMJ) are the only freely movable articulations in the skull together with the joints between the ossicles of the middle ear; they are all synovial joints. The muscles of mastication move the TMJ and the suprahyoid and infrahyoid muscles also play a significant role in jaw movements. The articular surfaces of the squamous temporal bone and of the condylar head (condyle) of the mandible form each temporomandibular joint. These surfaces have been briefly described in Chapter 22 on the skull and Figure 24.1A indicates their shape. The concave mandibular fossa is the posterior articulating surface of each squamous temporal bone and houses the mandibular condyle at rest. The condyle is translated forwards on to the convex articular eminence anterior to the mandibular fossa during jaw movements. The articular surfaces of temporomandibular joints are atypical; they covered by fibrocartilage (mostly collagen with some chondrocytes) instead of hyaline cartilage found in most other synovial joints. Figures 24.1B and 24.1C show the capsule and ligaments associated with the TMJ. The tough, fibrous capsule is attached above to the anterior lip of the squamotympanic fissure and to the squamous bone around the margin of the upper articular surface and below to the neck of the mandible a short distance below the limit of the lower articular surface. The capsule is slack between the articular disc and the squamous bone, but much tighter between the disc and the neck of the mandible. Part of the lateral pterygoid muscle is inserted into the anterior surface of the capsule. As in other synovial joints, the non-load-bearing internal surfaces of the joint are covered with synovial membrane.