- Email: [email protected]
Managing anxious or fearful patients
high risk of caries. The variable most closely associated with the high risk of caries was being an evening type person, with the risk for an evening person nearly 4 times higher than the risk for a morning person.
encouraged to not let breakfast or oral hygiene habits slip because of morning tiredness. In addition, oral health education programs for adolescents should include information about circadian rhythms so that all youth are made aware of the effect these natural fluctuations can have on their oral health.
Discussion.—Circadian rhythm, caries risk, toothbrushing frequency, and breakfast habits were correlated in these adolescents. Morning and neutral type people were more likely to be at low risk for caries; evening people were more likely to be at high risk.
Clinical Significance.—The effect of circadian rhythms on young people’s oral health can be significant. Dentists should include questions about being tired in the morning or alert at night in forms to be completed by their adolescent patients. Those who are evening types may be
€ €nsson B: Do adolescents who are night Lundgren A-M, Ohrn K, Jo owls have a higher risk of dental caries? – a case-control study. Int J Dent Hygiene 14:220-225, 2016 €nsson, The Public Dental Health Service Reprints available from B Jo Competence Ctr of Northern Norway, PO Box 2406, N-9271 Tromsø, Norway; fax: þ47 77690114; e-mail: [email protected]
Dental Fear/Anxiety Managing anxious or fearful patients Background.—Dental anxiety, fear, and phobia contribute significantly to an avoidance of dental care. Dental anxiety is an emotional state that occurs before the encounter with the dentist and can be directed at threatening stimuli or at an unidentified cause. Dental fear is a reaction to a known or perceived threat or danger and leads to a fight-or-flight response. Dental phobia, also termed odontophobia, is a persistent, unrealistic, intense fear that leads to complete avoidance of dental care. This overwhelming fear causes hypertension, terror, trepidation, and unease and is an identified phobic disorder. Physical, cognitive, emotional, and behavioral responses are evoked by each of these states. As a result, the individual reacts with avoidance of dental care, leading to poor dental health until an emergency situation develops, when complex, highly traumatic treatments may be needed, further reinforcing the fear and perpetuating the cycle. Dental practitioners should quickly identify dentally anxious or fearful individuals and alleviate these feelings while positively motivating them with the goal of achieving long-term results. The causes of dental anxiety, identification of anxious or phobic individuals, and management of these individuals in the dental office were explored.
personality characteristics such as being self-conscious or neurotic; not understanding; seeing frightening portrayals of dentists in the media; having poor coping skills; experiencing altered body image perceptions; and feeling vulnerable when considering lying back in a dental chair. Sensory triggers can also contribute to fear. These include the sight of needles, the sounds of drilling, the smell of eugenol, or the sensation of drilling vibrations.
Causes.—Multiple factors play a role in the development of dental anxiety and fear. These include having a previous traumatic experience, especially during childhood; seeing family members or peers who are anxious; having
Dentists can try to identify which dental situations cause a patient fear and anxiety through a calm, uninterrupted conversation. The dentist should ask a few open-ended questions to guide the discussion and identify why the
226
Dental Abstracts
Fears that give rise to dental anxiety include a fear of pain, of blood, of betrayal, of being ridiculed, of the unknown, of depersonalization in the eyes of the dentist, of exposure to radiation or mercury poisoning, of choking or gagging, or of lack of control over the situation. Anxious persons can be classified using the Seattle system as influenced by specific dental stimuli, by distrust of dental personnel, by a generalized sense of fear of dentistry, or by fear of catastrophe. Identification.—Dentists can often identify dentally anxious or phobic individuals through their first interactions with them. However, it is also possible to identify these individuals using questionnaires or objective measures.
patient came for treatment, what he or she has experienced previously in a dental setting, what causes him or her anxiety or fear, and what expectations the patient has for the visit. If the dentist identifies the dental anxiety as part of a broader psychological disorder, the patient can be referred for psychological help. Often the dentist and psychologist/ psychiatrist can work together to alleviate the patient’s anxiety. Dentists should not rely solely on clinical judgment. Self-reporting questionnaires can also help to identify patients with anxiety or fear related to the dental setting. These include multi-item scales such as Corah’s Dental Anxiety Scale (CDAS), Modified Dental Anxiety Scale (MDAS), Spielberger State-Trait Anxiety Inventory, Dental Fear Survey (DFS), Dental Anxiety Inventory, and fear scales. Single-item dental anxiety-and fear questionnaires can also be used. The tools most often used are the CDAS, MDAS, and DFS. Using these questionnaires, patients can be identified has having mild anxiety, moderate anxiety, or extreme anxiety or phobia. Among the objective measures used to identify anxious patients, the galvanic skin response may be the most accurate. Other objective measures include blood pressure, pulse rate, pulse oximetry, and finger temperature. Management.—Once the patient has been properly evaluated and the source and level of their anxiety or fear identified, an appropriate treatment plan can be formulated. The broad categories of interventions are psychotherapeutic methods, pharmacologic interventions, or a combination of psychotherapy and pharmacologic agents. Both psychological and pharmacologic interventions can be effective in reducing anxiety and phobia. Among the psychotherapeutic interventions are behavioral or cognitive approaches, along with the use of cognitive behavior therapy (CBT), which has proved highly successful for extremely anxious and phobic persons (Table 2). However, behavioral and cognitive therapies require multiple sessions to achieve a response, although the response tends to be maintained once it has developed. Pharmacologic aids provide either sedation or general anesthesia and usually are effective only on a short-term basis. These agents should be used only when the patient cannot respond and cooperate well with psychotherapeutic interventions, is unwilling to undergo a psychotherapeutic treatment approach, or is considered dental phobic. This can include patients with special needs. Before resorting to pharmacologic measures the dentist should weigh the risks in relation to behavioral versus pharmacologic approaches; the evidence when selecting agents to use; the
Table 2.—Psychotherapeutic Interventions Communication skills, rapport, and trust building: iatrosedative technique Behavior-management techniques Relaxation techniques: deep breathing, muscle relaxation Jacobsen’s progressive muscular relaxation Brief relaxation or functional relaxation therapy Autogenic relaxation Ost’s applied relaxation technique Deep relaxation or diaphragmatic breathing Relaxation response Guided imagery Biofeedback Hypnotherapy Acupuncture Distraction Enhancing control ‘‘Tell-show-do’’, signaling Systematic desensitization or exposure therapy Positive reinforcement Cognitive therapy Cognitive behavioral therapy (CBT) (Courtesy of Appukuttan DP: Strategies to manage patients with dental anxiety and dental phobia: Literature review. Clin Cosmetic Invest Dent 8:35-50, 2016.)
extent of the patient’s dental needs as well as the severity of the anxiety or fear; the patient’s cognitive and emotional needs, along with his or her personality; the practitioner’s skill, training, and experience; if proper equipment is available along with appropriate monitoring devices; and the cost involved. A sedation needs tool has been developed to help clinicians determine the need for conscious sedation, which is defined as the use of a drug or drug combination to depress the central nervous system and reduce the patient’s awareness of his or her surroundings. Sedation can be conscious, deep, or general, but it does not control pain or replace the use of local anesthetics. When the patient is under general anesthesia, he or she cannot be aroused, even by painful stimuli. Ventilatory function can be impaired, and help may be required to maintain a patent airway, maintain ventilation, or support neuromuscular or cardiovascular function. General anesthesia is used for patients who are phobic, have severe learning difficulties, have severe anxiety, suffer from severe psychiatric disorders, have physical disabilities or movement disorders, or have significant comorbid conditions. Sedation is generally not considered safe for these patients, and perioperative monitoring is required. Environmental Measures.—While psychotherapeutic and pharmacologic measures are highly useful, the dentist can also address issues related to the dental office environment and communication approaches. Often the
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Issue 4
2017
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patient becomes anxious just entering the dental environment. Therefore receptionists, dental nurses, and dental hygienists should help to create a soothing atmosphere. This includes providing positive, caring interactions and using a concerned but calm tone when obtaining information. The addition of soft music, the avoidance of bright lights, providing a slightly cooler room temperature, and having posters and pictures on the walls as well as magazines and books in the waiting area can contribute to a calm atmosphere. Sounds of instruments should be muted in the waiting area, and the patient should not have to wait long. Pleasant ambient odors can be used to mask clinical smells and provide a calming effect. Aromatherapy has been useful in managing moderate but not severe anxiety. The scent of lavender has been shown to reduce salivary cortisol and chromogranin levels, lower serum cortisol levels, increase blood flow, and decrease galvanic skin conductance and systolic blood pressure. A sensory-adapted dental environment (SDE) may also prove useful and is especially helpful with children and those with developmental disabilities. The dentist should also establish two-way communication with the patient, conversing personally before the clinical portion of the visit. He or she should maintain a calm, composed, and nonjudgmental demeanor, listening closely to what the patient has to say. Patients should be encouraged to ask questions about all aspects of the visit. The dentist should continue to (1) ask the patient if he or she is experiencing any discomfort, (2) provide moral support, and (3) reassure the patient during the procedure. These approaches will help to cement a rapport with the patient that can increase the patient’s confidence in the dentist. It can be important to normalize the patient’s anxious feelings and avoid negative phrasing. Nonverbal communication should be in line with what is being said. Patients respond well to touch to convey comfort and provide control. Dentists should seek to maintain eye contact with the patient when possible and continually observe the patient’s responses throughout the procedure. The dentist should avoid rapid movements, provide empathy, and try to make the patient feel welcome. These patients need to feel the dentist is their friend, someone who is sensitive to their needs and sympathetic to their struggles.
Technologic Aids.—In addition to making the environment comforting and providing support therapy as indicated, the dentist can make use of various technologies that have the ability to reduce anxiety. These include computer-controlled local anesthetic delivery, electronic dental anesthesia, and computer-assisted relaxation learning. During restorative treatments, patients can be managed by eliminating the primary sensory triggers for dental anxiety (sight, sounds, sensations, and smells). Among the newer methods for reducing pain or discomfort associated with dentistry are atraumatic restorative treatment, air abrasion using alumina powder streams, ultrasonic tips coated with diamond particles, chemomechanical caries removal, and lasers for cavity preparation.
Clinical Significance.—Quality of life is impaired by dental anxiety or fear, so the dentist should take seriously any patient who comes for treatment with these conditions. Overcoming fear and anxiety related to the dental experience will allow the patient to obtain and maintain good oral health. Therapy should be tailored to the specific patient and based on the results of a proper evaluation, the dentist’s expertise and experience, the degree of anxiety and fear, the patient’s mental capability and age, the degree of cooperation that can be achieved, and the clinical situation. Good communication is essential in allaying fear and allowing the patient to relax and experience reduced stress. Success in treatment will require a trusting dentist-patient relationship.
Appukuttan DP: Strategies to manage patients with dental anxiety and dental phobia: Literature review. Clin Cosmetic Invest Dent 8:35-50, 2016 Reprints available from DP Appukuttan, Dept of Periodontics, Sri Ramakrishna Mission Dental College and Hosp, Bharathi Salai, Ramapuram, Chennai, Tamil Nadu 600 089, India; e-mail: [email protected]
Emergency Room Follow-up Dental clinic use after nonemergency hospital visits Background.—Both emergency and nonemergency dental care is being sought increasingly at hospital
228
Dental Abstracts
emergency departments (EDs). A disproportionate number of these visits are from low-income families who often
encouraged to not let breakfast or oral hygiene habits slip because of morning tiredness. In addition, oral health education programs for adolescents should include information about circadian rhythms so that all youth are made aware of the effect these natural fluctuations can have on their oral health.
Discussion.—Circadian rhythm, caries risk, toothbrushing frequency, and breakfast habits were correlated in these adolescents. Morning and neutral type people were more likely to be at low risk for caries; evening people were more likely to be at high risk.
Clinical Significance.—The effect of circadian rhythms on young people’s oral health can be significant. Dentists should include questions about being tired in the morning or alert at night in forms to be completed by their adolescent patients. Those who are evening types may be
€ €nsson B: Do adolescents who are night Lundgren A-M, Ohrn K, Jo owls have a higher risk of dental caries? – a case-control study. Int J Dent Hygiene 14:220-225, 2016 €nsson, The Public Dental Health Service Reprints available from B Jo Competence Ctr of Northern Norway, PO Box 2406, N-9271 Tromsø, Norway; fax: þ47 77690114; e-mail: [email protected]
Dental Fear/Anxiety Managing anxious or fearful patients Background.—Dental anxiety, fear, and phobia contribute significantly to an avoidance of dental care. Dental anxiety is an emotional state that occurs before the encounter with the dentist and can be directed at threatening stimuli or at an unidentified cause. Dental fear is a reaction to a known or perceived threat or danger and leads to a fight-or-flight response. Dental phobia, also termed odontophobia, is a persistent, unrealistic, intense fear that leads to complete avoidance of dental care. This overwhelming fear causes hypertension, terror, trepidation, and unease and is an identified phobic disorder. Physical, cognitive, emotional, and behavioral responses are evoked by each of these states. As a result, the individual reacts with avoidance of dental care, leading to poor dental health until an emergency situation develops, when complex, highly traumatic treatments may be needed, further reinforcing the fear and perpetuating the cycle. Dental practitioners should quickly identify dentally anxious or fearful individuals and alleviate these feelings while positively motivating them with the goal of achieving long-term results. The causes of dental anxiety, identification of anxious or phobic individuals, and management of these individuals in the dental office were explored.
personality characteristics such as being self-conscious or neurotic; not understanding; seeing frightening portrayals of dentists in the media; having poor coping skills; experiencing altered body image perceptions; and feeling vulnerable when considering lying back in a dental chair. Sensory triggers can also contribute to fear. These include the sight of needles, the sounds of drilling, the smell of eugenol, or the sensation of drilling vibrations.
Causes.—Multiple factors play a role in the development of dental anxiety and fear. These include having a previous traumatic experience, especially during childhood; seeing family members or peers who are anxious; having
Dentists can try to identify which dental situations cause a patient fear and anxiety through a calm, uninterrupted conversation. The dentist should ask a few open-ended questions to guide the discussion and identify why the
226
Dental Abstracts
Fears that give rise to dental anxiety include a fear of pain, of blood, of betrayal, of being ridiculed, of the unknown, of depersonalization in the eyes of the dentist, of exposure to radiation or mercury poisoning, of choking or gagging, or of lack of control over the situation. Anxious persons can be classified using the Seattle system as influenced by specific dental stimuli, by distrust of dental personnel, by a generalized sense of fear of dentistry, or by fear of catastrophe. Identification.—Dentists can often identify dentally anxious or phobic individuals through their first interactions with them. However, it is also possible to identify these individuals using questionnaires or objective measures.
patient came for treatment, what he or she has experienced previously in a dental setting, what causes him or her anxiety or fear, and what expectations the patient has for the visit. If the dentist identifies the dental anxiety as part of a broader psychological disorder, the patient can be referred for psychological help. Often the dentist and psychologist/ psychiatrist can work together to alleviate the patient’s anxiety. Dentists should not rely solely on clinical judgment. Self-reporting questionnaires can also help to identify patients with anxiety or fear related to the dental setting. These include multi-item scales such as Corah’s Dental Anxiety Scale (CDAS), Modified Dental Anxiety Scale (MDAS), Spielberger State-Trait Anxiety Inventory, Dental Fear Survey (DFS), Dental Anxiety Inventory, and fear scales. Single-item dental anxiety-and fear questionnaires can also be used. The tools most often used are the CDAS, MDAS, and DFS. Using these questionnaires, patients can be identified has having mild anxiety, moderate anxiety, or extreme anxiety or phobia. Among the objective measures used to identify anxious patients, the galvanic skin response may be the most accurate. Other objective measures include blood pressure, pulse rate, pulse oximetry, and finger temperature. Management.—Once the patient has been properly evaluated and the source and level of their anxiety or fear identified, an appropriate treatment plan can be formulated. The broad categories of interventions are psychotherapeutic methods, pharmacologic interventions, or a combination of psychotherapy and pharmacologic agents. Both psychological and pharmacologic interventions can be effective in reducing anxiety and phobia. Among the psychotherapeutic interventions are behavioral or cognitive approaches, along with the use of cognitive behavior therapy (CBT), which has proved highly successful for extremely anxious and phobic persons (Table 2). However, behavioral and cognitive therapies require multiple sessions to achieve a response, although the response tends to be maintained once it has developed. Pharmacologic aids provide either sedation or general anesthesia and usually are effective only on a short-term basis. These agents should be used only when the patient cannot respond and cooperate well with psychotherapeutic interventions, is unwilling to undergo a psychotherapeutic treatment approach, or is considered dental phobic. This can include patients with special needs. Before resorting to pharmacologic measures the dentist should weigh the risks in relation to behavioral versus pharmacologic approaches; the evidence when selecting agents to use; the
Table 2.—Psychotherapeutic Interventions Communication skills, rapport, and trust building: iatrosedative technique Behavior-management techniques Relaxation techniques: deep breathing, muscle relaxation Jacobsen’s progressive muscular relaxation Brief relaxation or functional relaxation therapy Autogenic relaxation Ost’s applied relaxation technique Deep relaxation or diaphragmatic breathing Relaxation response Guided imagery Biofeedback Hypnotherapy Acupuncture Distraction Enhancing control ‘‘Tell-show-do’’, signaling Systematic desensitization or exposure therapy Positive reinforcement Cognitive therapy Cognitive behavioral therapy (CBT) (Courtesy of Appukuttan DP: Strategies to manage patients with dental anxiety and dental phobia: Literature review. Clin Cosmetic Invest Dent 8:35-50, 2016.)
extent of the patient’s dental needs as well as the severity of the anxiety or fear; the patient’s cognitive and emotional needs, along with his or her personality; the practitioner’s skill, training, and experience; if proper equipment is available along with appropriate monitoring devices; and the cost involved. A sedation needs tool has been developed to help clinicians determine the need for conscious sedation, which is defined as the use of a drug or drug combination to depress the central nervous system and reduce the patient’s awareness of his or her surroundings. Sedation can be conscious, deep, or general, but it does not control pain or replace the use of local anesthetics. When the patient is under general anesthesia, he or she cannot be aroused, even by painful stimuli. Ventilatory function can be impaired, and help may be required to maintain a patent airway, maintain ventilation, or support neuromuscular or cardiovascular function. General anesthesia is used for patients who are phobic, have severe learning difficulties, have severe anxiety, suffer from severe psychiatric disorders, have physical disabilities or movement disorders, or have significant comorbid conditions. Sedation is generally not considered safe for these patients, and perioperative monitoring is required. Environmental Measures.—While psychotherapeutic and pharmacologic measures are highly useful, the dentist can also address issues related to the dental office environment and communication approaches. Often the
Volume 62
Issue 4
2017
227
patient becomes anxious just entering the dental environment. Therefore receptionists, dental nurses, and dental hygienists should help to create a soothing atmosphere. This includes providing positive, caring interactions and using a concerned but calm tone when obtaining information. The addition of soft music, the avoidance of bright lights, providing a slightly cooler room temperature, and having posters and pictures on the walls as well as magazines and books in the waiting area can contribute to a calm atmosphere. Sounds of instruments should be muted in the waiting area, and the patient should not have to wait long. Pleasant ambient odors can be used to mask clinical smells and provide a calming effect. Aromatherapy has been useful in managing moderate but not severe anxiety. The scent of lavender has been shown to reduce salivary cortisol and chromogranin levels, lower serum cortisol levels, increase blood flow, and decrease galvanic skin conductance and systolic blood pressure. A sensory-adapted dental environment (SDE) may also prove useful and is especially helpful with children and those with developmental disabilities. The dentist should also establish two-way communication with the patient, conversing personally before the clinical portion of the visit. He or she should maintain a calm, composed, and nonjudgmental demeanor, listening closely to what the patient has to say. Patients should be encouraged to ask questions about all aspects of the visit. The dentist should continue to (1) ask the patient if he or she is experiencing any discomfort, (2) provide moral support, and (3) reassure the patient during the procedure. These approaches will help to cement a rapport with the patient that can increase the patient’s confidence in the dentist. It can be important to normalize the patient’s anxious feelings and avoid negative phrasing. Nonverbal communication should be in line with what is being said. Patients respond well to touch to convey comfort and provide control. Dentists should seek to maintain eye contact with the patient when possible and continually observe the patient’s responses throughout the procedure. The dentist should avoid rapid movements, provide empathy, and try to make the patient feel welcome. These patients need to feel the dentist is their friend, someone who is sensitive to their needs and sympathetic to their struggles.
Technologic Aids.—In addition to making the environment comforting and providing support therapy as indicated, the dentist can make use of various technologies that have the ability to reduce anxiety. These include computer-controlled local anesthetic delivery, electronic dental anesthesia, and computer-assisted relaxation learning. During restorative treatments, patients can be managed by eliminating the primary sensory triggers for dental anxiety (sight, sounds, sensations, and smells). Among the newer methods for reducing pain or discomfort associated with dentistry are atraumatic restorative treatment, air abrasion using alumina powder streams, ultrasonic tips coated with diamond particles, chemomechanical caries removal, and lasers for cavity preparation.
Clinical Significance.—Quality of life is impaired by dental anxiety or fear, so the dentist should take seriously any patient who comes for treatment with these conditions. Overcoming fear and anxiety related to the dental experience will allow the patient to obtain and maintain good oral health. Therapy should be tailored to the specific patient and based on the results of a proper evaluation, the dentist’s expertise and experience, the degree of anxiety and fear, the patient’s mental capability and age, the degree of cooperation that can be achieved, and the clinical situation. Good communication is essential in allaying fear and allowing the patient to relax and experience reduced stress. Success in treatment will require a trusting dentist-patient relationship.
Appukuttan DP: Strategies to manage patients with dental anxiety and dental phobia: Literature review. Clin Cosmetic Invest Dent 8:35-50, 2016 Reprints available from DP Appukuttan, Dept of Periodontics, Sri Ramakrishna Mission Dental College and Hosp, Bharathi Salai, Ramapuram, Chennai, Tamil Nadu 600 089, India; e-mail: [email protected]
Emergency Room Follow-up Dental clinic use after nonemergency hospital visits Background.—Both emergency and nonemergency dental care is being sought increasingly at hospital
228
Dental Abstracts
emergency departments (EDs). A disproportionate number of these visits are from low-income families who often