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Adult Anxiety
LETTERS TO THE EDITOR THE JOURNAL devotes this section to comment by readers on topics of current interest to dentistry. The editor reserves the right to edit all comm unications to fit available space and requires that all letters be signed. Printed comm unications do not necessarily reflect the opinion or official policy of the Association. Your participation in this section is invited.
A d u lt an xiety □ The article “Psychological aspects of dental anxiety in adults” (January 1982) by Drs. Scott and Hirschman is interesting and revealing in its disclo sures concerning pain thresholds and methods to identify, and com part mentalize, the possibly nervous pa tient. From the practical standpoint, sim ply requesting patients to routinely complete an anxiety questionnaire in the waiting room would, by itself, tend to increase an already existing state of apprehension w hich all dental pa tients experience in varying degrees. To test this surmise, we handed each of one day’s eight patients a copy of the Dental State Anxiety Scale (photo copied from the article) to be filled out in the waiting room. Each patient’s blood pressure had been recorded dur ing his original office visit, a proce dure routinely performed for all new patients in my office. When the rec ordings of eight patients’ question naires were compared with those of their first visit, a significant rise in blood pressure, both systolic and dias tolic, occurred in each instance. From this experience I believe it is safe to conclude that the methodology de scribed in the article could be greatly improved. It is also noteworthy that no mention is made about the use of tranquilizing drugs as prem edication before any treatment that might conceivably by psychologically traumatic. The use of benzodiazepam derivatives, such as diazepam, 5 mg, while the patient is resting in the waiting room, before anesthesia, either local or general, is th e f in e s t and m o st p r e d ic ta b le method to help the fearful, tense, and apprehensive patient, who then be com es calm , cooperative, apprecia tive, and best of all even thankful and unapprehensive at his subsequent ap pointment. The psychological approaches re 432 ■ JADA, Vol. 104, April 1982
ferred to in the article still seem to be in the laboratory and nebulous stages, and appear generally unsuitable for the daily practice of dentistry. MONTAGUE A. CASHMAN, DOS WASHINGTON, DC
□ Author’scom ments.-Icom mendDr. Cashman for taking the time out of his p r a c t i c e to c o n d u c t a q u a s i experiment in which the blood pres sure of patients was measured on their first d ental v isit, p resum ably for evaluation, and a follow-up visit, pre sumably for treatment. Dr. Cashman concluded that the increased blood pressure (a possible index of anxiety) on the second visit was a result of ask ing patients about their dental anxiety. The problem with this conclusion is that the second-visit patients had two new experiences: They completed the dental anxiety questionnaire, and then were about to undergo treatment for the first time by a relatively unfamiliar dentist. Although I cannot be certain, I believe that the second factor caused patients’ blood pressure to rise more than the first factor. Had Dr. Cashman not given the questionnaire to another eight patients (randomly selected) on their return visit, and if he had found low er blood pressure than in the treatment group, the data would speak for itself. Benzodiazepam administered to the patient can help the dentist and the pa tient cope with dental anxiety. How ever, my personal view is that this fails to provide patients with their personal feelings of self-control, and it rein forces our culture’s (inappropriate) re liance upon psychoactive drugs. DONALD S. SCOTT, PhD MIAMI VALLEY HOSPITAL DAYTON, OHIO
□ In their article “Psychological as pects of dental anxiety in adults” (Jan uary 1982) Drs. Scott and Hirschman make interesting, but perhaps m is leading, comments regarding the use of nitrous oxide. They state, in part,
“ . . . . evidence suggests that nitrous oxide is not as potent an antianxiety agent as many have thought. Dworkin recently reported that, when subjects are given nitrous oxide and instruc tions to expect more pain, they report increased pain sensitivity.” N itro u s o x id e sh o u ld be u sed prim arily to facilitate verbal com munication between doctor and pa tient; the agent indirectly reduces anx iety by enhancing the suggestibility of the doctor’s anxiety-reducing com munication. But if the content of the message states that there will be in creased stress (as the authors para phrase Dworkin), then the patient’s heightened suggestibility w ill cer tainly reinforce this negative message. Certainly no dentist purposely uses nitrous oxide as an agent to reinforce negative, stress-inducing communica tions. The authors’ paraphrasing of Dworkin simply demonstrates that n i trous oxide does indeed heighten pa tient suggestibility. As a pedodontist, I cannot simply plug a patient into an inhalation sys tem and then ignore the principles of “Tell-Show -Do.” Nitrous oxide will help most anxious persons (young or old) to listen to a message, to learn its content, and then to be less anxious through the assimilation of their new found information. PHILIP SOKOLOFF, DDS, MSD HOFFMAN ESTA TES, ILL
Sealant survival? □ In his letter (February 1982), Dr. Pope’s contention that “partial loss of sealant may increase susceptibility to tooth d ecay” is incorrect. C linical studies have shown that areas from w hich sealant has been lost are not more susceptible to caries; on the con trary, some data indicate that the pro te ctiv e e ffe c t may co n tin u e even though the sealant may clinically ap pear to have been lost.
A d u lt an xiety □ The article “Psychological aspects of dental anxiety in adults” (January 1982) by Drs. Scott and Hirschman is interesting and revealing in its disclo sures concerning pain thresholds and methods to identify, and com part mentalize, the possibly nervous pa tient. From the practical standpoint, sim ply requesting patients to routinely complete an anxiety questionnaire in the waiting room would, by itself, tend to increase an already existing state of apprehension w hich all dental pa tients experience in varying degrees. To test this surmise, we handed each of one day’s eight patients a copy of the Dental State Anxiety Scale (photo copied from the article) to be filled out in the waiting room. Each patient’s blood pressure had been recorded dur ing his original office visit, a proce dure routinely performed for all new patients in my office. When the rec ordings of eight patients’ question naires were compared with those of their first visit, a significant rise in blood pressure, both systolic and dias tolic, occurred in each instance. From this experience I believe it is safe to conclude that the methodology de scribed in the article could be greatly improved. It is also noteworthy that no mention is made about the use of tranquilizing drugs as prem edication before any treatment that might conceivably by psychologically traumatic. The use of benzodiazepam derivatives, such as diazepam, 5 mg, while the patient is resting in the waiting room, before anesthesia, either local or general, is th e f in e s t and m o st p r e d ic ta b le method to help the fearful, tense, and apprehensive patient, who then be com es calm , cooperative, apprecia tive, and best of all even thankful and unapprehensive at his subsequent ap pointment. The psychological approaches re 432 ■ JADA, Vol. 104, April 1982
ferred to in the article still seem to be in the laboratory and nebulous stages, and appear generally unsuitable for the daily practice of dentistry. MONTAGUE A. CASHMAN, DOS WASHINGTON, DC
□ Author’scom ments.-Icom mendDr. Cashman for taking the time out of his p r a c t i c e to c o n d u c t a q u a s i experiment in which the blood pres sure of patients was measured on their first d ental v isit, p resum ably for evaluation, and a follow-up visit, pre sumably for treatment. Dr. Cashman concluded that the increased blood pressure (a possible index of anxiety) on the second visit was a result of ask ing patients about their dental anxiety. The problem with this conclusion is that the second-visit patients had two new experiences: They completed the dental anxiety questionnaire, and then were about to undergo treatment for the first time by a relatively unfamiliar dentist. Although I cannot be certain, I believe that the second factor caused patients’ blood pressure to rise more than the first factor. Had Dr. Cashman not given the questionnaire to another eight patients (randomly selected) on their return visit, and if he had found low er blood pressure than in the treatment group, the data would speak for itself. Benzodiazepam administered to the patient can help the dentist and the pa tient cope with dental anxiety. How ever, my personal view is that this fails to provide patients with their personal feelings of self-control, and it rein forces our culture’s (inappropriate) re liance upon psychoactive drugs. DONALD S. SCOTT, PhD MIAMI VALLEY HOSPITAL DAYTON, OHIO
□ In their article “Psychological as pects of dental anxiety in adults” (Jan uary 1982) Drs. Scott and Hirschman make interesting, but perhaps m is leading, comments regarding the use of nitrous oxide. They state, in part,
“ . . . . evidence suggests that nitrous oxide is not as potent an antianxiety agent as many have thought. Dworkin recently reported that, when subjects are given nitrous oxide and instruc tions to expect more pain, they report increased pain sensitivity.” N itro u s o x id e sh o u ld be u sed prim arily to facilitate verbal com munication between doctor and pa tient; the agent indirectly reduces anx iety by enhancing the suggestibility of the doctor’s anxiety-reducing com munication. But if the content of the message states that there will be in creased stress (as the authors para phrase Dworkin), then the patient’s heightened suggestibility w ill cer tainly reinforce this negative message. Certainly no dentist purposely uses nitrous oxide as an agent to reinforce negative, stress-inducing communica tions. The authors’ paraphrasing of Dworkin simply demonstrates that n i trous oxide does indeed heighten pa tient suggestibility. As a pedodontist, I cannot simply plug a patient into an inhalation sys tem and then ignore the principles of “Tell-Show -Do.” Nitrous oxide will help most anxious persons (young or old) to listen to a message, to learn its content, and then to be less anxious through the assimilation of their new found information. PHILIP SOKOLOFF, DDS, MSD HOFFMAN ESTA TES, ILL
Sealant survival? □ In his letter (February 1982), Dr. Pope’s contention that “partial loss of sealant may increase susceptibility to tooth d ecay” is incorrect. C linical studies have shown that areas from w hich sealant has been lost are not more susceptible to caries; on the con trary, some data indicate that the pro te ctiv e e ffe c t may co n tin u e even though the sealant may clinically ap pear to have been lost.