Dental fear and anxiety Flashcards
What is dental fear
a normal emotional reaction to one or more specific threatening stimuli in the dental environment
What is dental anxiety
a sense of apprehension that something dreadful is going to happen in relation to dental treatment, coupled with a sense of losing control
What is dental phobia
a severe type of dental anxiety manifested as a marked and persistent anxiety in relation to clearly discernible situations or objects e.g. use of drill or to the dental situation in general
What is required for a diagnosis of dental phobia
there must be either complete avoidance of necessary dental treatment or endurance of treatment only with dread and in a specialist treatment situation
What is the UK prevelence of dental anxiety
11.6% adults, 4 times greater in 18-39 years old v 60+
Describe the cycle of dental fear and anxiety
- fear/ anxiety
- avoidance
- deterioration in dental status
- feelings of shame and inferiority
- fear/ anxiety etc
A good thing to say to a dentally anxious patient
‘we’re going to take this step by step’
What causes dental anxiety?
- negative medical and dental experiences
- influenced by family and peers
- media representations of dentistry
- expectation of pain and discomfort
- poor knowledge of modern analgesia
What are the 3 pathways identified which make children dentally anxious
Conditioning
- arising from objective dental pathology and subjective dental experiences.
Modelling
- children’s imitation of mother’s behaviour
Information
- unwitting provision of frightening info
- absorbing mother’s attitudes to dentistry
Characteristics of the anxious
- high neuroticism and trait anxiety
- pessimism and negative expectation
- proneness to somatisation (manifestation of psychological distress by the presentation of physical symptoms)
- low pain threshold (they are expecting pain)
- co-morbid anxiety disorders
- co-morbid depressive disorders
- fear of negative evaluation
- pessimistic and vulnerable
- catastrophic
- over-inclusive negativity
- worry as a habit
What are examples of anxious and neurotic thinking
- fear of negative evaluation
- pessimistic and vulnerable
- catastrophic
- over-inclusive negativity “life is a disaster/ failure/ pointless etc”
- worry as a habit
How do a patients negative thoughts impact their memories of treatment experience
inaccurate memories
benign experiences are recalled negatively
what are the 3 provoking factors to fear/ avoidance/safety-seeking/ anticipating disaster
bad experience
high neuroticism
depression and anxiety
what are the 3 maintaining factors to fear/ avoidance/safety-seeking/ anticipating disaster
selective memory and attention
high neuroticism
biased judgement
how is dental anxiety assessed in adults
The modified dental anxiety scale (MDAS) and the DAS-R
what is the diagnostic cut off for the MDAS
19/25
how is dental anxiety assessed in children
picture tests (for young children and adolescents)
child experience of dental anxiety measure (CEDAM) for age 9-16
modified child dental anxiety scale (faces version) MCDASf for age 8-16
What are the treatment strategies for Mild/moderate dental anxiety
- general attitude and the application of a general anxiety reducing treatment style
- pharmachological support
- teach coping strategies
What should the general attitude and application of a general anxiety reducing treatment style be like?
explain the ‘fight and flight’ (how they can take control)
- acknoledge patient’s anxiety
- build trusting relationship
- give realistic information
- provide control e.g. agreed stop signal
- provide high level of predictability (tell them at the start what you’re planning on doing and introduce the next appointment the same day)
What pharmachological support can be used for treatment
nitrous oxide sedation (if necessary liaise with GMP regarding prescribing oral sedation prior to treatment)
what coping strategies can be taught
relaxation and distraction
What control signals can be used by the patient
Stop signals - gives control over the pace of the procedure
Rest signals - allows the patient to stop with the understanding that the treatment is not finished yet
Proceed signals - just as important
Provide options e.g. which tooth will we restore first?
An example of a relaxation exercise
breathe in for 2 and out for 3 - helps lower tongue in place too
How effective is music at relaxing a patient
not effective with children
effective with adults
What ways can someone distract themselves
- think pleasant and relaxing thoughts
- do puzzles in their head (anagrams/ number games)
- think of 5 things which makes them happy
What are the behavioural treatment strategies for mod/severe dental anxiety/phobia
exposure-based treatment programme e.g. systematic desensitisation:
- trained in relaxation
- then encouraged to expose themselves to a hierarchy of fearful situations
(can be individual or group setting using imagined, video, computer based or real life confrontation)
For more complex cases, treatment could be carried out by a clinical psychologist in close cooperation with dentist
What is the fear hierarchy
sitting in the waiting room seeing the needle holding the needle feeling the needle on the gum intra-oral injection
What is involved in simple desensitisation
- relaxation training
- give control in a calm manner
- fear hierarchy
- successive approximations
What are cognitive treatment strategies
- using pleasant and positive imagery
- identifying challenging and modifying negative and unhelpful thoughts and replacing these with more positive and realistic thoughts
- use of coping statements e.g. I can and I will
How could you challenge evidence supporting negative thoughts
e.g. Belief: I have never coped well with pain and am prone to fail
What about when your child was born
What about your marriage
How are you enjoying your work
Why is it helpful for highly anxious patients to have their fears challenged
when highly anxious patients have to come up with facts that do not confirm their fears, there is a subsequent decline in their perception of risk
When might it be appropriate to refer an anxious patient on?
- where dental anxiety may be a manifestation of underlying emotional problems or more serious mental difficulties
- where there is a high treatment need, but the psychological consequences would be too overwhelming/ demanding for the patient. GA or IV sedation may be appropriate
What are the optimal interventions
- phobic avoidance needs desensitisation
- giving info improves dispels fears (v effective)
- simple desensitisation can be carried out in the clinic
- inappropriate beliefs can be evaluated, challenged and restructured
- severe cases of anxiety plus high need for treatment/ pain = maybe offer sedation
How common is dental anxiety
1/10 patients will have high levels
What provokes fearful behaviour
- traumatic experiences
- inappropriate beliefs/ expectations
- neurotic traits
What is better, behaviour management or managing behaviour
behaviour management (it’s about reducing the underlying fear and anxiety)
