Chapter 18 - Fearful Patients

Question 1

Q18-1: What percent of people avoid dentistry because of fear of injections?

Answer 1

A18-1: One in twenty individuals (5%) avoids dentistry because of fear of injections.

Question 2

Q18-2: Define the term fear and give examples of a patient’s reaction to perceived danger.

Answer 2

A18-2: Fear is an emotional response to an immediate threat or danger and is often referred to as the fight or flight response. The reaction to the perceived danger includes:
1. Unpleasant cognition that something terrible will happen
2. Physiological changes (tachycardia, perspiration, nausea, hyperventilation)
3. Overt behavior such as shaking, pacing, and rapid speech

Question 3

Q18-3: Define the term anxiety.

Answer 3

A18-3: Anxiety is the emotional response to a threat or danger that is not immediately present or is unclear.

Question 4

Q18-4: Define the term phobia.

Answer 4

A18-4: Phobia is a persistent, irrational fear of a specific object or situation that results in a compelling desire to avoid it or to enduring it with dread.

Question 5

Q18-5: What is the most common cause of the development of dental fear?

Answer 5

A18-5: The most common cause of the development dental fear is direct negative experience, usually of pain or fright, to a perceived threat of harm.

Question 6

Q18-6: What are the three primary sources for assessing patient anxiety and fear before and during stressful dental experiences?

Answer 6

A18-6: The three primary sources for assessing patient anxiety and fear before and during stressful dental experiences are self-report, behavioral indicators, and physiological indicators.

Question 7

Q18-7: Provide examples of questions to use in one-on-one interviews or questionnaires that give patients the opportunity to express both negative and positive aspects regarding past dental experiences.

Answer 7

A18-7: Some example questions include:
How long has it been since your last dental visit?
What kind of treatment did you receive? How did it go?
Are there any concerns about receiving injections?
Is there anything that you would like to do or not do during today’s appointment?
What will make receiving an injection easier for you?

Question 8

Q18-8: Provide examples of behavioral indicators of dental fear.

Answer 8

A18-8: Behavioral indicators of fear include such overt signs as pacing in the waiting room, fidgeting, wringing the hands, or gripping the arms of the chair until the knuckles turn white. The patient may talk incessantly to avoid beginning treatment. Signs of fear in the operatory also include opposite responses such as quiet, nonresponsive postures.

Question 9

Q18-9: What are three concepts to consider in developing strategies for treating fearful patients?

Answer 9

A18-9: There are three concepts to consider in developing strategies for treating fearful patients: the patient-clinician relationship, the patient’s sense of control over a potentially threatening environment, and the patient’s ability to cope with a stressful situation.

Question 10

Q18-10: What are four methods for providing patients with control?

Answer 10

A18-10: Four methods for providing patients with control include informational, cognitive, behavioral, and retrospective.

Question 11

Q18-11: Define and discuss informational control.

Answer 11

A18-11: Informational control communicates to the patient what to expect of an imminent aversive procedure. The information is best delivered as a simple description immediately before treatment with the emphasis on the sensations that the patient will experience. For example, provide patients simple descriptions of the steps involved in procedures, sensations they can expect, estimates of the time allowed for each step, and suggestions as to ways in which they can participate in the process or at least speed it along. Limit rationale to the benefits of procedures. Provide detailed descriptions if a patient needs reassurance.

Question 12

Q18-12: Define and provide examples of cognitive control.

Answer 12

A18-12: Cognitive control involves mental maneuvers through which patients can lessen their fearful, negative thoughts and their reactions to these thoughts. It is sometimes referred to as relaxing the mind and includes distraction, guided visualization, focusing attention, and positive coping statements.

Question 13

Q18-13: Define and provide examples of behavioral control.

Answer 13

A18-13: Behavioral control allows the patient to take actions that will lessen, shorten, or terminate a stressful situation. One of the most familiar is the use of a hand signal to stop procedures. Fearful patients should be given permission to discontinue procedures for any reason. This same signal can be used as to indicate a willingness to proceed with treatment.

Question 14

Q18-14: Provide examples of questions used to survey a patient’s relaxation skills.

Answer 14

A18-14: The following questions are used to survey a patient’s relaxation skills.
1. Do you find it difficult to relax in the dental chair?
2. Do you find yourself tensed up and stiff during certain dental procedures?
3. If so, which specific procedures?
4. Do you have a problem with gagging while x-rays are taken, or during other procedures?
5. Do you find it difficult to breathe or swallow during an injection or other dental treatment?
6. Is there anything you can do to help yourself relax in the dental chair?

Question 15

Q18-15: Explain and demonstrate deep breathing techniques.

Answer 15

A18-15: The clinician explains to the patient that it is important not to hold his or her breath during procedures or injections. Proper breathing allows the anesthetic to be administered slowly, which is essential for comfort. Suggest practicing before proceeding with the injection. Say to the patient: I would like you to:
1. inhale slowly and deeply to the count of 5, filling the lungs with air
2. hold the breath for 1 second
3. slowly exhale to the count of 5, feeling the tension release while sinking into the dental chair.

Question 16

Q18-16: Explain one of the two muscle relaxation techniques.

Answer 16

A18-16: The clinician explains and demonstrates the muscle relaxation technique prior to practicing with the patient. Instruct the patient to:
1. inhale and tense up the leg muscles
2. exhale while releasing the leg tension
3. inhale and tense the arm and hand muscles
4. exhale and release the hand and arm tension, allowing them to go limp.
This can be repeated for the head, neck, and shoulders.

Another method is to:
1. have the patient inhale deeply to the count of 5 and squeeze and tense all the body muscles
2. on initiation of exhaling begin to release tension in all the muscles as the body sinks into the chair.

Question 17

Q18-17: What is the purpose of rehearsals after a patient is introduced to relaxation skills?

Answer 17

A18-17: The purpose of rehearsals is to provide opportunities to practice the new skills while simulating the steps involved in actual dental procedures. Rehearsals allow patients to master control over anxiety-provoking situations while relieving everyone of the burden of having to accomplish any treatment.

Question 18

Q18-18: Discuss biofeedback and its use in lowering patient anxiety.

Answer 18

A18-18: Biofeedback can be useful in addressing the physiological changes that occur during stressful situations, such as increases in heart rate. It has been used successfully in the past to modify these responses. Subjects have been able to lower their blood pressure by observing it on a monitor, for example, after having been given instructions to concentrate on lowering it, with no instructions on how to do so. A simple heart rate monitor can be used by patients to monitor their heart rate and anxiety. Patients may be entirely unaware of the effect of anxiety on their heart rates. The ability to visualize the effects of relaxation on their heart rates reinforces the effectiveness of coping mechanisms and their ability to compete with anxiety.

Question 19

Q18-19: When is the electronic pulp tester (EPT) particularly useful in testing for anesthesia?

Answer 19

A18-19: The EPT is highly effective when patients have reported a history of inadequate anesthesia.

Question 20

Q18-20: Discuss post-op anesthetic recovery for fearful patients.

Answer 20

A18-20: Dental fears patients need realistic expectations for postoperative periods. Soreness is not unusual, especially after generous amounts of anesthesia have been administered and when more than one technique was used. In order to provide these patients with control over the post-op recovery period, it is important for them to be prepared in advance with recommendations for handling pain from routine trauma and inflammation, including taking anti-inflammatory medications before the recovery of the tissues from anesthesia. In receiving the recommendation that they take these medications while the anesthetics are still in effect, patients can understand that postoperative sensations are normal and expected.

Question 21

Q18-21: What patient preparation is advised prior to the use of nitrous oxideoxygen sedation for fearful patients?

Answer 21

A18-21: Nitrous oxide-oxygen sedation is best introduced to fearful patients when they have time to become accustomed to its sensations and when it can be titrated to comfortable levels before commencing treatment.

Question 22

Q18-22: What is the CARL program?

Answer 22

A18-22: CARL is a computer-assisted relaxation learning program that provides a means for patients to begin to address their fear before presenting to the dental office. It uses systematic desensitization protocols that consist of three active components: coping responses such as deep breathing, muscle relaxation, guided imagery, and positive coping statements are provided; a hierarchy of fearful stimuli is generated; and the presentation of fearful stimuli in order of increasing aversiveness.

Question 23

1. New patient w/ clammy hands, perspiration on upper lip, appears stiff, responds only with “yes” or “no”. Most appropriate strategy:
   a. Try distraction by offering to watch movie/ listen to music
   b. Get N2O-O2 sedation ready just in case
   c. Check out observations by asking pt about any possible concerns
   d. Avoid saying anything about dental anxiety or fear because it might upset the pt and risk not being able to get the tx completed

Answer 23

c. Check out observations by asking pt about any possible concerns

Question 24

2. Establishing trust is espec. important for fearful pts b/c they need to learn:
   a. how to pay for services
   b. how to be assertive
   c. that clinicians will not recommend tx pats cannot tolerate
   d. that clinicians are professionals and know what is best for pts