Iatrosedation by Dr Nathan Friedman

Iatrosedation on the “Firing Line”

The patient whose iatrosedative interview revealed she feared painful injections is now on the “firing line” – the first clinical encounter in which the injection will be given.

Doctor: “How are you feeling this morning?”

Patient: “Fine, thank you… I’m a lot less nervous about the shot than I was before we talked, but I’m still somewhat nervous.”

Doctor: “Well, I would expect that… but I think you will learn today to be a lot less nervous than you are now. As I told you I am confident that I can give you an anesthetic with very little, if any, pain. Should you feel anything I think it will be something you will be able to handle very well. I will keep you informed as we go along as to what you can expect… I will be responding to you and between us I feel sure you will develop a new set of feelings. Okay?”

Patient: “Okay.”

Doctor: “Is there anything else you would like to talk about?”

A combination of manual and communicative techniques are involved in order to carry out, as succinctly as possible, the promise of an atraumatic experience with this injection. Although we are using the injection as a model, this concept should be carried out in all aspects of clinical treatment. Each doctor must develop his own style of iatrosedative behavior.

The Manual Component (Infiltration)

The syringe is prepared beforehand with a needle that has been tested for sharpness and a warm cartridge. It is kept out of sight behind the patient, to be passed over the shoulder below the line of vision. The objective of penetrating the tissue noiselessly and painlessly (or with the minimum amount of pain) is achieved by:

  1. painting a topical at the site of penetration (in this case the reflection of the alveolar mucosa);
  2. making the mucosa as taut as possible by pulling the lip or cheek out without discomfort;
  3. establishing a firm finger or hand rest to provide maximum stability and control of the syringe;
  4. delicately penetrating the taut mucosa, the bevel toward the tissue, to the depth of the bevel (1-2mm) only;
  5. very slowly injecting a drop or two of anesthetic. After a few moments, penetrate 1-2mm and deposit a few more drops. Move slowly into an anesthetized area until the target area is reached.

This manual technique is combined with preparatory communication in the following manner:

I am going to put a surface anesthetic on your gum to numb it so that you will be more comfortable.

– This is said as you approach with the topical. The mucosa is pulled taut with syringe poised to penetrate.

I don’t expect you to feel this.

– The needle is inserted to the depth of the bevel, stopped and a few drops injected.

Do you feel it?

– If the patient indicates that he does not, the doctor answers:

Good, I will be injecting very slowly… it may take longer than usual. I won’t be using any more than the normal amount, but it will be easier for you. Do you feel anything?

– If the patient indicates “No”, reply:


If the patient indicates in any way that she does feel something it is wise to respond by saying,

I’m sorry, but I don’t think you will feel anything from now on. I will be going very slowly.

– This is not said defensively, but merely to let the patient know that you care.

These simple preparatory communications carry much more weight for the patient than one would suspect. An interpretation of what they may mean follows:

  1. Using a topical anesthetic communicates the concern of the doctor and the wish to minimize pain.
  2. “I don’t expect you to feel this” states, “I am about to inject and will do all I can to do it without pain”.
  3. “Did you feel it?” I have already started injecting and I want to know how it is with you. This is a continuing involvement and I want feedback from you.
  4. “I will be injecting slowly, no more than usual… etc.” I am keeping you informed, explaining in case you get upset because you may think I am using too much anesthetic, etc.

Communications of this kind should be used consistently with all operative procedures. The above interpretation of the doctor’s preparatory communications is based on feedback from patients with whom these kinds of exchanges have taken place. A patient who had stated that she was no longer fearful was asked why she felt this had occurred:

Doctor: “What is it that permitted you to overcome your fear?”

Patient: “Well, I think when you first saw me I had this tremendous fear built up because of my past experiences. I’d heard so many stories about the amount of pain I would suffer with your work… but I have to have it done. I’ve suffered so greatly with other dental work, surely I’ll have mountains of pain with this. By the time I came to you and with my own frightening experiences, the thing that calmed me was your ability to work psychologically with me. (Expertise and Recognition) First, knowing my tremendous fear. I had made just a couple of comments, you know, about one dentist and how I should have been here many years ago. (“Hearing” and responding to critical cues during the interview.) The method you used to tranquilize me by words (Interpretation, explanation, suggestion and commitment) logically, something for me to accept within my fear, so strong that I automatically began to relate and listen to what you had to say instead of closing my mind; logically you approached me and tranquilized me… I don’t know how else to explain it. In other words, the very words that you used put me at ease enough to say, ‘listen, maybe he is telling the truth…’ and I gained more confidence as you talked to me… as you explained. (Trust developing) I felt very confident; then when I came in for the surgery, I only had a slight apprehension. (Iatrosedative interview dropped fear level, but was still higher than normal) Yet I figured I might suffer the tortures of the damned…but I felt no pain whatsoever.”

Doctor: “Well, you were very apprehensive predicated on past experiences. You say the words that I used … what words?”

Patient: “You were willing to go out on a limb in telling me what to expect from what you were doing. (He made clinical preparatory iatrosedation communications so that she would know what sensations she may feel, thus minimizing the fear of helplessness and the unknown.) You have a habit of saying in advance “You may feel this, but it will not be very much if anything”, “you will feel pressure but no pain.” This in itself, when the surgery began, is the thing that puts your patients at ease… because every time a dentist picks up an instrument, just like everybody else, they want to run away… because he sees you picking up all kinds of things. He doesn’t know what you are going to do… and it’s the not knowing that upsets the patient.” (“Knowing” lessens the fear of the unknown.)

Doctor Statements:

  • “I can understand why you would be afraid of injections …” Support, respect, empathy.
  • “It seems to me that you couldn’t trust that doctor to protect you from pain. You were depending on him but he didn’t seem to want to help you. These feelings still exist within you and you are still feeling today the same terror and distress you felt as a child.” Interpretation and explanation of why the patient is still fearful years after the original events.
  • “But you can unlearn and learn a new set of feelings based on our relationship.” Suggestion and a promise of a new and different kind of relationship.
  • “Let me tell you how I think things will go. First, I am confident that I can give you an injection with very little, if any, pain. If there is some, it will not be enough to be upsetting.” Beginning of the commitment. This offer is based on the ability to give injections in that way. To promise what you cannot deliver would be disastrous.
  • “I will keep you informed at all times …” This to dispel the fear of the unknown.
  • “If you feel any concern or discomfort I will stop. I will not do any treatment until you are ready and the area is numb.” This to dispel the fear of helplessness and dependency and to create some sense of control for the patient … as well as a sense of trust.
  • “I know from past experiences that you can learn not to be afraid.” Suggestion that the patient can learn not to be afraid is coupled with the assurance of the doctor’s knowledge and expertise.