Dental fear & Anxiety Flashcards
dental fear
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
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
- general dread. In dentist chair loss of control
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.
- 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
5 top stressors for dentists in dentistry
- Running behind schedule
- Causing pain
- Heavy workload
- Late patients
- Anxious patients
how can dentists reduce the feeling of mortification for patients?
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
5 different aetiology sources for dental anxiety
- 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
how can negative medical and dental experiences be an aetiology of dental anxiety
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
how can family and peer influences be an aetiology of dental anxiety and how can the dentist assess
- Need to asses patient and understand their background
- DA is easily passed on from parent to child
why is media representation important for dental anxiety cases
dentistry is portrayed as a feared thing
- more likely to be anxious
what can the expectation of pain do for a patient in terms of dental anxiety
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)
3 pathways for children to become dentally anxious
- conditioning
- modelling
- information
conditioning pathway for child to be dentally anxious is
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
modelling pathway for child to be dentally anxious is
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
information pathway fro child to be dentally anxious is
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
characteristics of the anxious (6)
- 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
what are likely thoughts for the anxious and neurotic thinking?
- 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)
what is mood congruency effect?
Neuroticism and clinical depression tend to negatively bias recall about personal information and events
what is important to remember about how dental anxious patients when treating them and post treatment
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
steps in managing an anxious dental patient
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’)
assessment of dental anxiety adults
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
MDAS
modified dental anxiety scale
what features must be in a dental anxiety assessment for children and young adults?
measure should assess specific triggers of dental anxiety or unhelpful thoughts
age taken into account
- picture tests good for younger age groups
Venham Picture scale
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
the facial image scale (FIS)
- 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
what is a factor that could impact child anxiety assessments?
could be that the child has had a bad day and nothing to do with dental treatment
- easily impacted
MCDASf
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
CEDAM
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
3 treatment strategies for mild/moderate dental anxiety
- General attitude and the application of a general anxiety reducing treatment style
- pharmacological support
- teach coping strategies
treatment strategy of General attitude and the application of a general anxiety reducing treatment style involves
- 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)
treatment strategy of pharmacological support involves
if necessary liaise with GMP regarding prescribing oral sedation prior to treatment (adults), use nitrous oxide sedation.
treatment strategy of teaching coping strategies involves
relaxation and distractions
ways to give control to patients in dental treatment (4)
- 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
stop signals
gives control over pace of the procedure
- helps coping
- “place your left hand straight in the air if you want me to stop”.
rest signals
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
proceed signals
open your mouth when you are ready to start”
- E.g. for Gag reflex patients – when they are ready and comfortable, in the zone
relaxation training involves
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
what has relaxation therapy been proven to do for dental anxious patients?
reduce anxiety
music works less effectively in children than adults in reducing anxiety
distraction involves
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
what is the consensus for treatment of moderate/severe dental anxiety and phobic patients?
to opt for exposure-based treatment programme, such as systematic densensitisation.
what is systematic desensitisation?
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
simple desensitisation step by step approach
- Relaxation training – teach how to stay relaxed
- Give control in a calm manner – calm, progressive coping manner exposed to people
- Fear hierarchy
- Successive approximations
what is simple desensitisation good for?
needle desensitisation
use of real-life dental situations or video images produces the greatest effect
what may happen if patient is a more complex case?
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
what is exposure therapy often combine with?
teaching the patient cognitive treatment strategies
cognitive treatment strategies involve
- 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
what is an effective verbal strategy of tackling dental anxious patients?
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.
symptoms of a panic attack
- Hot or cold flushes
- Fear of dying
- Feeling lightheaded/faint
- Choking feeling
- Trembling, shaking
- Upset stomach
- Racing heart
when to refer a dental anxious patient on?
- 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
optimal interventions for dental anxiety treatment
- 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
