The way we experience pain is complex. Whilst I cannot
go into an in-depth explanation about the physiology and psychology of pain in this short article, it is important to be aware of several aspects of both in order to understand why the CDIT works.
Our current theory of pain – The Gate Theory – stems from the neuroscientists Melzack and Wall in 1965, in which they attempted to explain how pain signals may be modulated. From your undergraduate training, you will remember that there are several different types of nerve fibres. They can be thin, thick, myelinated and non-myelinated.
A-alpha fibres are thick and myelinated and transmit signals of motor origin very quickly (touch, pressure, vibration). C-fibres, on the other hand, are thin and non-myelinated and transmit signals of nociception (pain, temperature, chemical) very slowly in comparison to A-alpha. The Gate Theory proposes that only one signal can pass through the dorsal horn of the spinal cord, where there is a synapse, enabling us to ‘close the gate’ to pain if we stimulate the faster signal of touch, vibration or pressure sensation. You already know this because we have all been in situations where we have hurt ourselves or others have, accidentally and our immediate response is to rub the painful area. This ‘rubbing’ sensation stimulates the faster fibres of touch, thus closing the ‘gate’ to pain. In practical terms, if we rub the area we are about to inject, stimulating A-alpha fibres we can close the gate to pain.
Equally, whilst we can modify the pain signal from the source ‘upwards’ to the cerebral cortex, we can also modify the pain signal from higher centres downwards. ‘Top down’ modification is best explained by an example of a footballer who breaks his leg during a game but is so focused on playing that it’s only after the game that he feels the pain or discovers the break.
Top down modification can dial the pain up or down! Memories can dial it up but our behaviour and our language can dramatically impact the perceived signal either way. For example, if we as Dentists are relaxed, in rapport and are careful with our words, we can easily dial down our patient’s perception of pain. Conversely, if we are careless, rushed or even stressed, we can influence our patient to perceive pain, even if we aren’t causing it.
Whilst words are just a small percentage of our communication (approximately 7%), our language and its effect on the subconscious mind is huge. In fact, one of the first things I learned about the language of was that our subconscious mind cannot process a negative. If I were to say to you, ‘Don’t think of a dental chair’, you have to imagine a dental chair in order NOT to think of a dental chair. Even for a brief, fleeting moment, you will have an internal representation (thought) of a dental chair.
When my daughter was young, and I hadn’t learnt this, I would say things like, ‘Sweetheart, don’t spill the juice’ or, ‘Careful, don’t trip’. Whilst I had a positive intent for her to keep the juice in the glass and for her to stay upright and not hurt her knees, I was increasing the likelihood of her spilling her juice or even falling over. Why? Because for her to understand and process what ‘not spilling her drink’ meant, she had to create a picture, sound or movie in her head (an internal representation) of spilling the drink. It was almost like a mini rehearsal for the main event that invariably resulted in me on my hands and knees mopping up juice and chastising her. Wow, what a situation; the poor child gets told off for doing exactly what I had, unintentionally, told her to do.
So, once I learnt this nugget of information, I would make every effort to catch myself from using a negative phrase and change it to a positive one before I spoke. For example, ‘Sweetheart, carry your glass really carefully’. I had the same positive intent and dramatically increased the likelihood of her keeping the liquid in the glass, because she had to create an ‘internal representation’ of carrying the glass carefully rather than spilling it. Make sense?
So, how can this be useful in our lives as dentists to benefit our patients? Let’s look at some of the things that you and your team say to patients every day that might be creating an Internal Representation of something that is negative. Firstly, a disclaimer; I know that you have a positive intent for your patients and with some practise and effort you will be able to influence them even better than you already do.
In my dental practice to reassure our patients, we used to say things like: