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BDS2 CDS Paedriatric > Dental fear & Anxiety > Flashcards

Dental fear & Anxiety Flashcards

1
Q

dental fear

A

a normal emotional reaction to one or more specific threatening stimuli in the dental environment
- something specific they perceive as threatening e.g. needle, drill, chair

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2
Q

dental anxiety

A

a sense of apprehension that something dreadful is going to happen in relation to dental treatment, coupled with a sense of losing control
- general dread. In dentist chair loss of control

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3
Q

dental phobia

A

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.

  • Affecting their life, unable to walk past surgery
  • Child may refuse to open mouth, run to the toilet
  • Need specialist care initially to help control

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

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4
Q

5 top stressors for dentists in dentistry

A
  • Running behind schedule
  • Causing pain
  • Heavy workload
  • Late patients
  • Anxious patients
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5
Q

how can dentists reduce the feeling of mortification for patients?

A

acknowledge fear

  • Appreciate it hard and genuine fear
  • Will work through step by step at a comfortable pace for you
  • Don’t belittle them - very daunting for them
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6
Q

5 different aetiology sources for dental anxiety

A
  • Negative medical and dental experiences e.g. “painful”, “frightening” or “embarrassing”
  • ‘influenced’ by family and peers
  • media representations of dentistry
  • expectation of pain and discomfort
  • poor knowledge of modern analgesia
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7
Q

how can negative medical and dental experiences be an aetiology of dental anxiety

A

e.g. “painful”, “frightening” or “embarrassing”

Multiple medical exposure is the precipitator
- E.g. emla cream left on hand for just 10 minutes when meant to be on for an hour prior to injection or IV

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8
Q

how can family and peer influences be an aetiology of dental anxiety and how can the dentist assess

A
  • Need to asses patient and understand their background

- DA is easily passed on from parent to child

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9
Q

why is media representation important for dental anxiety cases

A

dentistry is portrayed as a feared thing

- more likely to be anxious

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10
Q

what can the expectation of pain do for a patient in terms of dental anxiety

A

Most patients anticipate great pain when they go to the dentist – doesn’t help keep them calm
- Finger on hand Ok finger in mouth - pain (as of expectation of pain)

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11
Q

3 pathways for children to become dentally anxious

A
  • conditioning
  • modelling
  • information
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12
Q

conditioning pathway for child to be dentally anxious is

A

arising from objective dental pathology and subjective dental and medical experiences. The dentist’s personal sensitivity to children’s fears appears is also crucial.
- Past experience

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13
Q

modelling pathway for child to be dentally anxious is

A

children’s imitation of mother’s behaviour. Mothers of anxious children, higher in state anxiety and behave more variably during consultation than those of non-anxious children.

  • Mostly from mothers
  • Can be other anxious kids
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14
Q

information pathway fro child to be dentally anxious is

A

possibly through unwitting provision of frightening information, but more likely through absorbing mother’s attitudes to dentistry

  • Possibly the wrong information or told in the wrong manner
  • Be careful what you say - try and keep positive, not mention pain
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15
Q

characteristics of the anxious (6)

A
  • High neuroticism and trait anxiety
  • Pessimism & negative expectation
  • Proneness to somatisation (the manifestation of psychological distress by the presentation of physical symptoms)
  • Low pain threshold anticipation
  • Co-morbid anxiety disorders diagnosed
  • Co-morbid depressive disorders
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16
Q

what are likely thoughts for the anxious and neurotic thinking?

A
  • Fear of negative evaluation
  • Pessimistic and vulnerable
  • Catastrophic
  • Over-inclusive negativity –“life is a disaster / risky / failure/ pointless…”
  • Worry as a habit
  • Can have other mental health illnesses going on
    (Be aware of them - May need to talk with GP regarding it)
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17
Q

what is mood congruency effect?

A

Neuroticism and clinical depression tend to negatively bias recall about personal information and events

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18
Q

what is important to remember about how dental anxious patients when treating them and post treatment

A

avoidant and fearful dental patients have inaccurate memories for treatment experiences and also benign experiences are recalled negatively, and hence are consistent with a pessimistic and fearful “schema” (negative ways of thinking) about dental treatment
- Can go away from a decent appointment with negative thoughts

Reflection - find out what they didn’t enjoy need to categorise and discuss with them

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19
Q

steps in managing an anxious dental patient

A

Listen to what your patient is saying to you……..
- False reassurance isn’t helpful

Ask the right questions…………

What is their goal?
- Patients main concern – address that whilst also addressing yours too

What do they want to achieve?
- Phrase in a positive way not negatively what they want (E.g. ‘feel calmer’ not ‘ I don’t want to be anxious’)

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20
Q

assessment of dental anxiety adults

A

The Dental Anxiety Scale (DAS) (Corah, 1969) and its derivatives,
- the DAS-R (Ronis, Hansen & Antonakos, 1995) and the MDAS (Humphris, Dyer & Robinson, 2009) are all widely used in the literature.

4 or 5 item questionnaires which can be given to patients to complete.

Scoring instructions are also provided.

  • Diagnostic cut offs are provided 19>/25 then phobic
  • Might score less than 19 but score 5/5 may qualify as phobic

Both the DAS-R and the MDAS are available freely on the web

21
Q

MDAS

A

modified dental anxiety scale

22
Q

what features must be in a dental anxiety assessment for children and young adults?

A

measure should assess specific triggers of dental anxiety or unhelpful thoughts

age taken into account
- picture tests good for younger age groups

23
Q

Venham Picture scale

A

shows 8 pairs of boys, one with and anxious and one with a non-anxious facial expression and the child is asked to point to the figure they feel most like.
- 4-11 years

Criticisms;

  • all figures are male
  • some of the facial expressions are ambiguous
24
Q

the facial image scale (FIS)

A
  • Children are asked to point at the face they most feel like.
  • Measure of ‘state anxiety’ or may even be measuring the child’s mood that day
  • Significantly correlates with Venham Picture Scale
25
Q

what is a factor that could impact child anxiety assessments?

A

could be that the child has had a bad day and nothing to do with dental treatment
- easily impacted

26
Q

MCDASf

A

Modified Child Dental Anxiety Scale (faces version)

  • age 8 to 16
  • 8 Qs
    Ask about extraction, GA, gas and air (feel comfortable; laughing gas; IS)
  • 9th Q hand camultation - medical and dental needle phobia
27
Q

CEDAM

A

Child Experience of Dental Anxiety Measure
- age 9 to 16

Asks children how they feel about dentistry - would they avoid going to treatment; tell parents not want to go
- Behaviours, physiological, thoughts assessed

Boys tend to not admit anxious they just say not bother
- Not shaky or scared or embarrassed but angry and frustrated

28
Q

3 treatment strategies for mild/moderate dental anxiety

A
  • General attitude and the application of a general anxiety reducing treatment style
  • pharmacological support
  • teach coping strategies
29
Q

treatment strategy of General attitude and the application of a general anxiety reducing treatment style involves

A
  • Explain the “fight and flight” system to them, let them know they can take control
  • Acknowledge patient’s feeling of anxiety
    (Tell them what it is - shaky, inc HR, not good recall. Normal as adrenaline pumping through body)
  • Engender a trusting relationship
  • Provide realistic information
  • Provide control
  • Agreed stop signal
  • Provide a high level of predictability (agree the appointment goals and plans at the start; introduce next appointment at end)
30
Q

treatment strategy of pharmacological support involves

A

if necessary liaise with GMP regarding prescribing oral sedation prior to treatment (adults), use nitrous oxide sedation.

31
Q

treatment strategy of teaching coping strategies involves

A

relaxation and distractions

32
Q

ways to give control to patients in dental treatment (4)

A
  • stop signals
  • rest signals
  • proceed signals
  • provide options
    ‘What do you want to happen?”
    “Which tooth will we restore first?”
    Allows apparent control but all treatment will still be done
33
Q

stop signals

A

gives control over pace of the procedure

  • helps coping
  • “place your left hand straight in the air if you want me to stop”.
34
Q

rest signals

A

allows the patient to stop with the understanding that the treatment is not finished yet.
- Good for if they have reached their limit for the day – don’t over push them

35
Q

proceed signals

A

open your mouth when you are ready to start”

- E.g. for Gag reflex patients – when they are ready and comfortable, in the zone

36
Q

relaxation training involves

A

Teaching patient how to do in the chair
- e.g. breathing techniques, Progressive muscle relaxation techniques

Breathe in for 3 and out for 3
- Stick chin in the air (don’t mention tongue but by default will be lower

  • Patient and dentist previous experiences should be considered
  • may have done before
37
Q

what has relaxation therapy been proven to do for dental anxious patients?

A

reduce anxiety

music works less effectively in children than adults in reducing anxiety

38
Q

distraction involves

A

Thinking pleasant and relaxing thoughts

  • Needs cognition
  • Discuss with them what they suit

Imagine somewhere real or imaginary where you can relax and put aside the cares of the world
- Hypnosis like

Do puzzles in your head

  • word (anagrams)
  • number games (counting backwards in 2 from 100)

What makes you happy?
- Think of 5 things

Simple things can be very effective at distracting

39
Q

what is the consensus for treatment of moderate/severe dental anxiety and phobic patients?

A

to opt for exposure-based treatment programme, such as systematic densensitisation.

40
Q

what is systematic desensitisation?

A

Patient first trained in relaxation.

After this they are encouraged to expose themselves to a hierarchy of fearful situations

This procedure can be carried out individually or in a group setting using imagined, video, computer-based or real-life confrontation.

  • Work with patient at exposure of things that cause anxiety (e.g. 3 in 1 cold air can cause pain so want LA first)
  • What’s important and comfortable to patient
  • Can be in clinic or psychologist
41
Q

simple desensitisation step by step approach

A
  • Relaxation training – teach how to stay relaxed
  • Give control in a calm manner – calm, progressive coping manner exposed to people
  • Fear hierarchy
  • Successive approximations
42
Q

what is simple desensitisation good for?

A

needle desensitisation

use of real-life dental situations or video images produces the greatest effect

43
Q

what may happen if patient is a more complex case?

A

preferable for treatment to be carried out by clinical psychologist in close cooperation with the dentist.
- Use anxiety questionnaire to assess

but Dentists are well-placed to carry out exposure therapy for those with uncomplicated specific fears

44
Q

what is exposure therapy often combine with?

A

teaching the patient cognitive treatment strategies

45
Q

cognitive treatment strategies involve

A
  • 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”

e.g. Thought Diaries

46
Q

what is an effective verbal strategy of tackling dental anxious patients?

A

challenging their fears and support their successes

e.g.
Belief - “I have never coped well with pain and I am prone to fail”
- Challenge: What about when your child was born?
- Response: I got through it pretty well, I only asked for gas if I needed it.

47
Q

symptoms of a panic attack

A
  • Hot or cold flushes
  • Fear of dying
  • Feeling lightheaded/faint
  • Choking feeling
  • Trembling, shaking
  • Upset stomach
  • Racing heart
48
Q

when to refer a dental anxious patient on?

A
  • Where the dental anxiety may be a manifestation of underlying emotional problems or more serious mental difficulties, referral to a clinical psychologist, psychiatrist or specialist dental clinic may be needed.
  • Where there is high treatment need, but the psychological consequences would be too overwhelming or demanding for the patient, such that the patient is unwilling to have the treatment then a pharmacological approach in the form of a general anaesthetic or intravenous sedation may be appropriate

Don’t tell patient you are referring on until patient accepted
- rejected can make worse for patient
Need good relationship with referral team

49
Q

optimal interventions for dental anxiety treatment

A
  • Phobic avoidance needs desensitisation – refer to local clinical psychology service
  • Information-giving improves knowledge and dispels fears, hence reducing uncertainty and anxiety. Combining sensory and procedural information appears to be the most effective approach
  • Simple desensitisation can be carried out in the clinic
  • Inappropriate beliefs can be evaluated, challenged and restructured

BDS2 CDS Paedriatric (7 decks)

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