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An agoraphobic patient with dental anxiety: report of case
. iA ' \Q )A \ C L I N I C A L
R E P O R T S
An agoraphobic patient with dental anxiety: report of case Edward L. H erod, MS, D DS
A 46-year-old woman made an appoint ment for dental therapy. The patien t’s agoraph o b ia and d en tal anxiety p re sented a d ifficu lt treatm ent situation. An open dialogue between patient and dentist along with a flexible treatment plan and unhurried appointments con trib u ted to the success o f the d en tal rehabilitation.
A
goraphobia was first described by W estphal1 in 1871. Agoraphobia . can be described e ith e r as “staying-at-home” behavior or as avoid ance of v enturing o u t.2 An open envi ronm ent causes anxiety for these people. S uperm arkets, freeways, theaters, and dental appointm ents can produce anxiety severe eno u g h to substan tially disable persons w ith agoraphobia. The fear of h a v in g an an x iety a ttack w hile away from fa m ilia r s u rro u n d in g s restricts activities. This often results in infrequent dental visits. T he literature discussing agoraphobia is e x ten siv e .1-10 A lth o u g h actu al case re p o rts in v o lv in g d e n ta l anxiety are numerous, those involving agoraphobia in relation to the dental patient are few. M artin an d N u sb ach er3 presented the only know n case rep o rt th a t connects agoraphobia and dental treatment. These authors discussed the causes and medical 860 ■ JADA, Vol. 116, June 1988
treatment of this phobia and illustrated the extrem e patience req u ired when treating a dental patient with agora phobia. T he follow ing case involves a p a tie n t receiving restorative dentistry that presented unique problems. Report of case A 46-year-old white married female came to the office for a consultation. Her health history appeared norm al, but she said she was agoraphobic. Sitting in the dental ch air sideways, she w ould not perm it the assistant to place an apron on her. T h e p a tie n t stated th a t she had only made the appointm ent to meet the dentist, discuss her previous agoraphobic expe riences an d d e n ta l h isto rie s, an d to determine if she felt comfortable in the office environment. The patient discussed her agoraphobia openly. She had recently moved from her lifetime home in the Midwest to the Southeast w ith her husband and two children. She reported never having been far from her family and friends, and that the an ticip ated move had precipitated the a g o ra p h o b ic response. Also, she reported feeling secure and emotionally stable before the move. Personality changes were recognized; the family physician referred the patient to a behavioral therapist. Reportedly, the psychologist helped her to ‘'under sta n d ” the phobia, and she gradually became desensitized and more confident
in dealing w ith the disabling phobia. Relating that she was making progress, she acknowledge some anxieties. It was im portant to feel free to leave any given situation at any time, she said, no matter how in n o cu o u s the en vironm ent may ap p ear. P resently, she was no longer under the care of anyone for her ago raphobic condition. T he p atien t’s dental history was dis cussed. She believed that her m outh was in poor health because her teeth were sensitive to hot and cold and she could see decay. She was wearing an ill-fitting “flipper” to temporarily replace missing m andibular incisors. The patient wanted all teeth removed, but knew, in reality, this w o u ld not be the best. She had received some dental treatment that was interrupted by the agoraphobic attacks. T h e p a tie n t’s former dentist replaced the m issing four m an d ib u lar incisors w ith a fixed p a rtia l d en ture, b u t the p a tie n t was un ab le to to lerate this confinem ent psychologically. T he den ture was rem oved and the tem p o rary “flipper” was constructed. T he history was confirmed w ith dental records. The patient wanted to continue dental treatment. The ideal arrangement would have in c lu d e d a b eh av io ral th e ra p ist w orking w ith the dentist and patient, but the patient was reluctant to continue such therapy. The patient agreed, how ever, to be receptive to psychological care should the anxiety become a problem during treatment.
CLINICAL
After the in itia l consultation, the patient did not immediately reschedule. She did, however, bring in her two children for dental examinations. After several weeks, the patient scheduled another appointment. At the appoint ment the patient was still apprehensive; a full-mouth series of radiographs were taken, and an oral exam ination per formed. Her oral hygiene was poor. In addition to the problems previously m entioned, the patient had moderate gingival inflammation. Generalized cal culus and gingival bleeding were seen, but the bone level and tissue pocket depths appeared normal. The patient had extensive decay although no peri apical radiolucent areas were present, but endodontic therapy seemed likely. The m andibular left first molar and maxillary right and left first molars were missing. Several treatment plans were discussed; the patient said that she did not want endodontic therapy, crowns, or partial dentures, and was even distressed at the thought of having large amalgam res torations. A scaling and oral hygiene instruction appointment was scheduled. The periodontal therapy was performed without incident. During these appoint ments, considerable time was spent discussing alternative treatment plans. Verbal com m unication between the patient and dentist seemed an effective form of anxiety control. R elaxation techniques involving controlled brea thing exercises were also used to help reduce anxiety. The treatment plan avoided dealing with the worst teeth first, which is custom ary, but started with the less involved restorations to help the patient gain confidence. Several single surface restorations were placed. The patient reported that psychological stress occurred for the first day or two after the procedure but that the anxiety gradually lessened. N ext, a severely decayed m axillary second premolar needed a crown. Extrac tion was considered; however, if the tooth could be saved, the patient’s smile would look better and she could masticate adequately without a partial denture. The patient refused partial dentures. If necessary, a partial denture could be placed at a later date. After the tooth was prepared, a temporary crown was fabricated. The patient tolerated it with great difficulty. Telephone discussions occurred daily, and only because the temporary was removable was it possible
to endure. The permanent crown was in itia lly cemented, w ith a temporary cement, so the patient could become used to it. The patient liked the new crown but refused to have it permanently cemented. She needed to know that it could be easily removed if an anxiety crisis occurred. At that time, the patient was becom ing more comfortable with each visit, and less time was needed in relaxation conversations. Crowns were also placed on the man dibular left and right canines with temporary cement. A mandibular partial denture was rejected by the patient. A partial denture was made to replace the missing mandibular teeth. The patient finally consented to having the crowns perm anently cemented, but only one crown per appointm ent, on alternate weeks. Both patient and dentist were pleased to see the treatment period end. It was timeconsuming and mentally exhausting for both parties, although also satisfying as the feeling of accomplishment was gratifying. In the year since the work was com plete, the patient reported insomnia with tremendous anxiety con cerning her teeth. A recurrence of symp toms is possible, and further treatment may be required. The suggestion was offered that she continue with psycho logical therapy, but she declined. Discussion
Agoraphobia is considered the most common adult phobia.4 Approximately half of all patients with phobic disorders have the agoraphobic syndrome.5 It has been established that most agoraphobic patients are female6 and the symptoms typically affect young adults.7 Studies8 have shown that the onset of agoraphobia usually occurs after a period of stress or an identifiable precipitant. Patients w ith agoraphobia usually come from stable family environments.9 The syn drome is characterized by a cluster of phobias centering around goin g into public places and is often accompanied by other nonphobic symptoms such as mild depression, depersonalization, mild obsessions, and compulsions.6 A survey of agoraphobic patients in B ritain10 showed that dental visits invoked fear and it is probable that individuals with agoraphobia, like patients with dental phobia, do not receive adequate dental care. The patient in this case report displayed many symptoms of dental anxiety. Fear
REPORTS
of losing control, inability to sleep, and various levels of nervousness were related to her dental appointm ents. An open dialogue discussing these anxieties with flexib ility in treatment p lan n in g in addition to unhurried appointm ents contributed to the success of treating this patient with agoraphobia. T ech niques useful in relaxing other patients with dental phobia were used successfully in this case, as well. Summary
The special care needed when treating the patient with agoraphobia and dental anxiety is reported. T he dental reha bilitation was accom plished w ithout concurrent psychological therapy, but the coordination o f dental care and psychological treatment was and should always be considered a viable option. Considerable chairside time was required. Successful techniques reported in the literature to work with dental phobics were used. As patients with agoraphobia frequently have periods of remission and relapse, further problems may occur and without special treatment, oral health may be compromised.
------------------ J'AOA -----------------T h e a u th o r th an k s L a u ra A. H erod for assistance in pre p a ra tio n of the m anuscript. D r. H e ro d is in p riv a te p ra c tic e , 1001 S L o o p B lvd, L e h ig h A cres, F L 33936. A ddress re q u e sts for re p rin ts to Dr. H erod.
1. W e s tp h a l, C. D ie a g o r a p h o b ie . A rc h iv fu r P s y c h ia trie a n d N e rv e n tz ra n tz tre ite n . 3:138, 219, 1871-72. 2. H a llm a n , R.S. A gorap h o b ia: a critical review of the concept. B r J Psychiatry 133:314-319, 1978. 3. M a r tin , M .D ., a n d N u s b a c h e r, C .J . T h e a g o ra p h o b ic d e n ta l p a tie n t: re p o rt of case. JA D A 109(l):53-56, 1984. 4. M ark s, I.M . C la s s ific a tio n o f p h o b ia s . B r J Psychiatry 116:377-386, 1970. 5. A g ra s, S., a n d o th e rs . T h e e p id e m io lo g y o f c o m m o n fears a n d p h o b ia . C o m p r P s y c h ia try 10(2): 151-156, 1969. 6. M ark s, I.M . A g o ra p h o b ic s y n d ro m e (p h o b ic anxiety state). A rch G en Psychiatry 23:538-553, 1970. 7. M arks, I.M ., an d G elder, M .G. D ifferent onset ages in v a rie tie s of p h o b ia . Am J P s y c h ia try 123(2):218-221, 1966. 8. T e a m a n , B .H ., a n d others. Etiology a n d onset of agoraphobia: a critical review. C o m p r Psychiatry 25(l):51-62, 1984. 9. B urns, L.E., and T h o rp e , G .L . T h e epidem iology of fears a n d p h o b ia s (w ith p a rtic u la r reference to th e n a tio n a l survey o f a g o ra p h o b ic s ). J I n t M ed Res 5 (S uppl 5): 1-7, 1977. 10. M arks, I.M ., a n d H e rst, E. T h e o p e n do o r: a survey of agoraphobics in B ritain. Soc Psychiatry 1:16-24,1970.
Herod : AGORAPHOBIC PATIENT WITH DENTAL ANXIETY ■ 861
R E P O R T S
An agoraphobic patient with dental anxiety: report of case Edward L. H erod, MS, D DS
A 46-year-old woman made an appoint ment for dental therapy. The patien t’s agoraph o b ia and d en tal anxiety p re sented a d ifficu lt treatm ent situation. An open dialogue between patient and dentist along with a flexible treatment plan and unhurried appointments con trib u ted to the success o f the d en tal rehabilitation.
A
goraphobia was first described by W estphal1 in 1871. Agoraphobia . can be described e ith e r as “staying-at-home” behavior or as avoid ance of v enturing o u t.2 An open envi ronm ent causes anxiety for these people. S uperm arkets, freeways, theaters, and dental appointm ents can produce anxiety severe eno u g h to substan tially disable persons w ith agoraphobia. The fear of h a v in g an an x iety a ttack w hile away from fa m ilia r s u rro u n d in g s restricts activities. This often results in infrequent dental visits. T he literature discussing agoraphobia is e x ten siv e .1-10 A lth o u g h actu al case re p o rts in v o lv in g d e n ta l anxiety are numerous, those involving agoraphobia in relation to the dental patient are few. M artin an d N u sb ach er3 presented the only know n case rep o rt th a t connects agoraphobia and dental treatment. These authors discussed the causes and medical 860 ■ JADA, Vol. 116, June 1988
treatment of this phobia and illustrated the extrem e patience req u ired when treating a dental patient with agora phobia. T he follow ing case involves a p a tie n t receiving restorative dentistry that presented unique problems. Report of case A 46-year-old white married female came to the office for a consultation. Her health history appeared norm al, but she said she was agoraphobic. Sitting in the dental ch air sideways, she w ould not perm it the assistant to place an apron on her. T h e p a tie n t stated th a t she had only made the appointm ent to meet the dentist, discuss her previous agoraphobic expe riences an d d e n ta l h isto rie s, an d to determine if she felt comfortable in the office environment. The patient discussed her agoraphobia openly. She had recently moved from her lifetime home in the Midwest to the Southeast w ith her husband and two children. She reported never having been far from her family and friends, and that the an ticip ated move had precipitated the a g o ra p h o b ic response. Also, she reported feeling secure and emotionally stable before the move. Personality changes were recognized; the family physician referred the patient to a behavioral therapist. Reportedly, the psychologist helped her to ‘'under sta n d ” the phobia, and she gradually became desensitized and more confident
in dealing w ith the disabling phobia. Relating that she was making progress, she acknowledge some anxieties. It was im portant to feel free to leave any given situation at any time, she said, no matter how in n o cu o u s the en vironm ent may ap p ear. P resently, she was no longer under the care of anyone for her ago raphobic condition. T he p atien t’s dental history was dis cussed. She believed that her m outh was in poor health because her teeth were sensitive to hot and cold and she could see decay. She was wearing an ill-fitting “flipper” to temporarily replace missing m andibular incisors. The patient wanted all teeth removed, but knew, in reality, this w o u ld not be the best. She had received some dental treatment that was interrupted by the agoraphobic attacks. T h e p a tie n t’s former dentist replaced the m issing four m an d ib u lar incisors w ith a fixed p a rtia l d en ture, b u t the p a tie n t was un ab le to to lerate this confinem ent psychologically. T he den ture was rem oved and the tem p o rary “flipper” was constructed. T he history was confirmed w ith dental records. The patient wanted to continue dental treatment. The ideal arrangement would have in c lu d e d a b eh av io ral th e ra p ist w orking w ith the dentist and patient, but the patient was reluctant to continue such therapy. The patient agreed, how ever, to be receptive to psychological care should the anxiety become a problem during treatment.
CLINICAL
After the in itia l consultation, the patient did not immediately reschedule. She did, however, bring in her two children for dental examinations. After several weeks, the patient scheduled another appointment. At the appoint ment the patient was still apprehensive; a full-mouth series of radiographs were taken, and an oral exam ination per formed. Her oral hygiene was poor. In addition to the problems previously m entioned, the patient had moderate gingival inflammation. Generalized cal culus and gingival bleeding were seen, but the bone level and tissue pocket depths appeared normal. The patient had extensive decay although no peri apical radiolucent areas were present, but endodontic therapy seemed likely. The m andibular left first molar and maxillary right and left first molars were missing. Several treatment plans were discussed; the patient said that she did not want endodontic therapy, crowns, or partial dentures, and was even distressed at the thought of having large amalgam res torations. A scaling and oral hygiene instruction appointment was scheduled. The periodontal therapy was performed without incident. During these appoint ments, considerable time was spent discussing alternative treatment plans. Verbal com m unication between the patient and dentist seemed an effective form of anxiety control. R elaxation techniques involving controlled brea thing exercises were also used to help reduce anxiety. The treatment plan avoided dealing with the worst teeth first, which is custom ary, but started with the less involved restorations to help the patient gain confidence. Several single surface restorations were placed. The patient reported that psychological stress occurred for the first day or two after the procedure but that the anxiety gradually lessened. N ext, a severely decayed m axillary second premolar needed a crown. Extrac tion was considered; however, if the tooth could be saved, the patient’s smile would look better and she could masticate adequately without a partial denture. The patient refused partial dentures. If necessary, a partial denture could be placed at a later date. After the tooth was prepared, a temporary crown was fabricated. The patient tolerated it with great difficulty. Telephone discussions occurred daily, and only because the temporary was removable was it possible
to endure. The permanent crown was in itia lly cemented, w ith a temporary cement, so the patient could become used to it. The patient liked the new crown but refused to have it permanently cemented. She needed to know that it could be easily removed if an anxiety crisis occurred. At that time, the patient was becom ing more comfortable with each visit, and less time was needed in relaxation conversations. Crowns were also placed on the man dibular left and right canines with temporary cement. A mandibular partial denture was rejected by the patient. A partial denture was made to replace the missing mandibular teeth. The patient finally consented to having the crowns perm anently cemented, but only one crown per appointm ent, on alternate weeks. Both patient and dentist were pleased to see the treatment period end. It was timeconsuming and mentally exhausting for both parties, although also satisfying as the feeling of accomplishment was gratifying. In the year since the work was com plete, the patient reported insomnia with tremendous anxiety con cerning her teeth. A recurrence of symp toms is possible, and further treatment may be required. The suggestion was offered that she continue with psycho logical therapy, but she declined. Discussion
Agoraphobia is considered the most common adult phobia.4 Approximately half of all patients with phobic disorders have the agoraphobic syndrome.5 It has been established that most agoraphobic patients are female6 and the symptoms typically affect young adults.7 Studies8 have shown that the onset of agoraphobia usually occurs after a period of stress or an identifiable precipitant. Patients w ith agoraphobia usually come from stable family environments.9 The syn drome is characterized by a cluster of phobias centering around goin g into public places and is often accompanied by other nonphobic symptoms such as mild depression, depersonalization, mild obsessions, and compulsions.6 A survey of agoraphobic patients in B ritain10 showed that dental visits invoked fear and it is probable that individuals with agoraphobia, like patients with dental phobia, do not receive adequate dental care. The patient in this case report displayed many symptoms of dental anxiety. Fear
REPORTS
of losing control, inability to sleep, and various levels of nervousness were related to her dental appointm ents. An open dialogue discussing these anxieties with flexib ility in treatment p lan n in g in addition to unhurried appointm ents contributed to the success of treating this patient with agoraphobia. T ech niques useful in relaxing other patients with dental phobia were used successfully in this case, as well. Summary
The special care needed when treating the patient with agoraphobia and dental anxiety is reported. T he dental reha bilitation was accom plished w ithout concurrent psychological therapy, but the coordination o f dental care and psychological treatment was and should always be considered a viable option. Considerable chairside time was required. Successful techniques reported in the literature to work with dental phobics were used. As patients with agoraphobia frequently have periods of remission and relapse, further problems may occur and without special treatment, oral health may be compromised.
------------------ J'AOA -----------------T h e a u th o r th an k s L a u ra A. H erod for assistance in pre p a ra tio n of the m anuscript. D r. H e ro d is in p riv a te p ra c tic e , 1001 S L o o p B lvd, L e h ig h A cres, F L 33936. A ddress re q u e sts for re p rin ts to Dr. H erod.
1. W e s tp h a l, C. D ie a g o r a p h o b ie . A rc h iv fu r P s y c h ia trie a n d N e rv e n tz ra n tz tre ite n . 3:138, 219, 1871-72. 2. H a llm a n , R.S. A gorap h o b ia: a critical review of the concept. B r J Psychiatry 133:314-319, 1978. 3. M a r tin , M .D ., a n d N u s b a c h e r, C .J . T h e a g o ra p h o b ic d e n ta l p a tie n t: re p o rt of case. JA D A 109(l):53-56, 1984. 4. M ark s, I.M . C la s s ific a tio n o f p h o b ia s . B r J Psychiatry 116:377-386, 1970. 5. A g ra s, S., a n d o th e rs . T h e e p id e m io lo g y o f c o m m o n fears a n d p h o b ia . C o m p r P s y c h ia try 10(2): 151-156, 1969. 6. M ark s, I.M . A g o ra p h o b ic s y n d ro m e (p h o b ic anxiety state). A rch G en Psychiatry 23:538-553, 1970. 7. M arks, I.M ., an d G elder, M .G. D ifferent onset ages in v a rie tie s of p h o b ia . Am J P s y c h ia try 123(2):218-221, 1966. 8. T e a m a n , B .H ., a n d others. Etiology a n d onset of agoraphobia: a critical review. C o m p r Psychiatry 25(l):51-62, 1984. 9. B urns, L.E., and T h o rp e , G .L . T h e epidem iology of fears a n d p h o b ia s (w ith p a rtic u la r reference to th e n a tio n a l survey o f a g o ra p h o b ic s ). J I n t M ed Res 5 (S uppl 5): 1-7, 1977. 10. M arks, I.M ., a n d H e rst, E. T h e o p e n do o r: a survey of agoraphobics in B ritain. Soc Psychiatry 1:16-24,1970.
Herod : AGORAPHOBIC PATIENT WITH DENTAL ANXIETY ■ 861