INTRODUCTION
Dental anxiety is a common phenomenon. In a recent Canadian survey, 5.5% of respondents reported being “very afraid or terrified” of dental visits, and a further 9.8% were “somewhat afraid”.1 Dental anxiety prevalence, of a clinical significance, varies based on criteria used to measure it and the population studied. In general, worldwide estimates range from about 4% to over 20%.2,3 A larger number report feeling anxious of seeing the dentist. Many Canadians reported being at least “a little afraid” of dental care and endodontic treatment (36% and 61.2%, respectively).1 It is clear that dental anxiety is present to some degree in a majority of patients, and therefore should be considered by the treatment team.
WHAT IS ANXIETY?
Anxiety is a natural response to stressful situations. It is adaptive and advantageous when it enables us to be vigilant and ensure we accomplish our goals, such as complete a speech, or perform endodontic treatment. However, it can be disabling when it is excessive and inappropriately directed. It becomes a disorder when there is functional impairment. Although anxiety disorders can be classified into several types, it is out of the dentists’ scope of practice to make specific diagnoses. However, it is helpful to note that many of the anxiety disorders have common features, and generally respond well to behavioural and pharmacological management. These management techniques will be discussed in the context of the dental office.
Anxiety disorders are on a spectrum from mild to severe, and from normal to abnormal. They range from generalized anxiety, where the central theme is excessive anxiety and worry, to specific phobias, such as a fear of snakes, or a needle phobia.4
Dental anxiety has been variously called dental phobia, odontophobia, dentophobia, or dental fear in the literature. Fear is aroused by a real, specific stimulus (i.e. needle), whereas anxiety can be thought of as anticipatory in nature. Regardless of classification, a person’s response is similar in both situations.5
CAUSES OF DENTAL ANXIETY
A negative dental experience is a strong predictor of dental anxiety. In a random general population sample, people who had a painful, embarrassing, and frightening dental experience were over 22 times more likely to have dental anxiety.6 Extreme helplessness and a lack of control during dental treatment, and a lack of understanding from the dentist are highly correlated with dental anxiety.7 Experiencing extreme pain after dental work is amongst the most prevalent distressing life experiences, and can trigger psychological trauma and a persistent fear of the dentist.8 Similar to the anxiety disorders, dental fear has been found to be heritable.9
Dental anxiety can be problematic to the dental office. It is important to remember anxious patients can present as avoidant. This can result in missed or cancelled appointments. A Canadian survey found 49.2% in a high fear group had ever avoided a dental appointment, whereas only 5.2% had avoided from the no or low fear group.1 Anxious patients can present as irritable and uncooperative, and if not appropriately identified and treated can engender a negative reaction by office staff (thus self-fulfilling the patient’s negative expectation).10 Patients who experience a higher level of anxiety will tend to have a greater pain response. This can lead to increased anxiety amongst dental staff, and the potential for making mistakes.11 Given these issues, it is clear dentists should aim to alleviate anxiety to successfully help treatment, but also to reduce risks for further dental anxiety, and to help reduce avoidance behaviour.
RECOGNIZING ANXIETY USING DENTAL FEAR INSTRUMENTS
A number of dental fear measures have been developed to recognize the anxious patient. The most commonly used instrument according to the literature is the Dental Anxiety Scale (DAS), a four-item questionnaire about different dental situations. Each question is scored from 1 (not anxious) to 5 (extremely anxious). The DAS has been modified to include a question on local anaesthesia.12 The Dental Fear Survey is another questionnaire, utilizing 20-items. It aims to assess avoidant behaviour, fear, and physiological responses.13
Although these instruments are useful, they may be overly time-consuming to be used as screening instruments by busy dentists. Shorter instruments are available. Milgrom’s single-item scale uses a 5 item self-response to rate dental anxiety: from not at all afraid, a little afraid, somewhat afraid, very afraid, and terrified. The last two items have been shown to correlate well with patient’s who score highly on the DAS and DFS.2
THE SHORT DENTAL FEAR QUESTION (SDFQ) IS A SINGLE QUESTION ASKING:
Last time you visited your dentist, how did it go?
The answers range from 1-4 on a likert scale (with clinical classification in italics).
1. I was totally relaxed during the treatment. (“relaxed”)
2. I was nervous but, nevertheless, the treatment was carried out successfully. (“slightly frightened”)
3. I was nervous; the treatment could only just be carried out (“moderately frightened”)
4. I was so frightened and nervous that
a) Treatment was difficult. (“severely frightened”)
b) The treatment didn’t succeed. (“severely frightened”)
c) I totally missed my appointment. (“severely frightened”)
This question can help guide treatment. For example, slightly frightened patients may not exhibit outward signs of anxiety, but may need some extra reassurance. Moderately frightened patients may need to take a break now and then. Severely frightened patients may be avoiders (4c), or may have extreme difficulty coping with treatment (4a, b). This is a patient with extreme dental anxiety.14
To quickly screen for anxious patients, a single question measure, such as the SDFQ or Milgrom’s, can be easily incorporated into a dental questionnaire. If patients are screened as anxious, a more comprehensive assessment tool may be helpful to further understand the presenting anxiety.
OFFICE BEHAVIOURAL MANAGEMENT TECHNIQUES
Specific treatment modalities, such as Cognitive Behavioural Therapy (CBT), or Exposure Therapy are beyond the scope of this article (and beyond the scope of practice of a busy dentist). However, a number of techniques gleaned from these treatments can be utilized in the dental office to help alleviate anxiety, and will be outlined below. For patients who are screened as highly anxious, it would be worthwhile to ask them if they have considered seeing a mental health professional, such as a psychologist or psychiatrist. Anxious patients, possibly from stigma, embarrassment, or even avoidance (as part of the illness itself), may be unable to fully utilize mental health resources.
Anxious patients tend to worry more that dentists may say things to try to trick them, may not take their fears seriously, or may recommend unnecessary work. Given that loss of control, embarrassment, and lack of understanding are associated with anxiety, it is important to use strategies to combat these issues.15 An empathic and understanding approach must be taken. Taking the time to inquire and listen about fears is productive as it sets the tone that you are interested in understanding the patient’s anxiety. Praise the patient often, especially when they challenge their anxiety. Avoid phony reassurances such as “there’s nothing to be afraid of”, since it tends to minimize anxiety. Normalizing anxiety is supportive, such as saying “many people have concerns similar to yours”.
Communication strategies are also important. Using positive sentence structure is preferable to negative phrasing. For example, “you may feel a twinge” is better than “you will not feel pain”. Avoid certain words such as
hurt, shot, or needle, if possible. Patients appreciate clear, honest, and straightforward communication. Resistance may be sidestepped by indirectly suggesting something good will happen. A patient fearful of pain may be told “you may not have experienced the various ways we now use to get people numb”.
Simple changes to the office environment can be accommodating, such as offering to change the room temperature to the patient’s liking. A blanket can be soothing. Inquire if there is anything you can do to make the visit more comfortable. Although it may take an investment in time in the short run, in the longer term such changes will reduce anxiety and tend to speed up the treatment process.
When patients are given some control, they may feel much less fearful. Creating a signal system, whereby patients can let you know when they require a break can be calming. It is important to honour the system and try not to make promises you cannot keep; such as saying the procedure will not be long. Distraction techniques such as music, movies, having the patient count or track objects in the room, or recall a hobby are beneficial.10
The Tell-Show-Do technique is used by many paediatric professionals, but also can be used effectively with adults. The first part entails verbal explanation of procedures (“tell”). “Show” involves demonstrating the visual, auditory, olfactory, and tactile aspects of the procedure. The last part is completing the actual procedure (“do”). Use positive reinforcement to desensitize the patient to the experience.16
Relaxation strategies that can be easily employed include breathing strategies, such as ‘boxed breathing’, and progressive muscle relaxation. Boxed breathing, sometimes called square breathing, involves utilizing diaphragmatic breathing to expand the stomach and not the chest. Use the rules of 4 to remember this technique. Have the patient count to 4 as they inhale, hold their breath for 4 seconds, exhale to a count of 4, and hold their breath to a count of 4. Tell the patient to try this technique for 4 minutes. Progressive muscle relaxation involves helping the patient relax the entire body by tensing and relaxing muscle groups sequentially, usually tensing for 10 seconds, relaxing for 20 seconds, then moving to the next muscle group. To perform this, ask the patient to start at the top or bottom of their body. If they start at the top, ask them to tense (10 seconds), and then relax (20 seconds) their head, neck, shoulders, chest, biceps, etc. in a sequential fashion.10
Cognitive behavioural therapy (CBT) helps patients link thought patterns with emotions, and behaviours. Understanding these themes will allow the patient to arrive at the underlying core issues of the anxiety. CBT utilizes various strategies to combat anxiety. Cognitive restructuring involves identifying problematic cognitions known as “automatic thoughts” that are the instantaneous thought patterns of anxiety. Identifying cognitive distortions in these thoughts is informative, for example a patient may automatically think something severely bad will happen (even though they can acknowledge that it is highly unlikely). Helping the patient process these distortions can enable them to dispute these thoughts, and balance them with a more realistic thought. When the patient develops a trusting relationship, it may be useful to explore some of the core beliefs, automatic thoughts, and cognitive distortions in an effort to alter them.17 CBT can utilize exposure to a feared context without any danger in order to overcome the pattern of avoidance that strengthens the fear response. For example, if someone has a fear of heights, they may progressively start standing at higher levels, according to how well they can tolerate a mild level of anxiety. Dentists can use exposure techniques by progressively increasing treatment. An anxious patient may not tolerate having all of their restorations completed at once, but may tolerate a simple procedure (such as a hygiene appointment) to gain trust in the dental office and reduce anxiety. With an anxious patient, find out what will cause a minimal level of anxiety, and start from there.
A combination of behavioural strategies can be used to greatest effect for the mild or moderately anxious patient. Severely anxious patients may be too anxious to respond only to behavioural treatments, and may require pharmacologic management. Some patients may prefer a combination of behavioural and pharmacologic treatment. No matter the level of anxiety, some form of behavioural strategies should be incorporated in a dental practice, and should be tailored to suit the level of comfort of the patient (and the dentist).
PHARMACOLOGIC MANAGEMENT
Sedation can be an effective way to alleviate a patient’s stress and anxiety during dental treatment, enabling work to be undertaken more comfortably.
Patients with a mild to moderate fear or anxiety will respond quite well to minimal and moderate forms of conscious sedation. A minimal sedation can be achieved easily with an oral administration of a sedative agent (most commonly benzodiazepines), nitrous oxide with oxygen, or a combination of both. Moderate sedation can be attained via the administration of multiple sedative agents with or without nitrous oxide and oxygen, or by parenteral administration of a sedative drug.
Nitrous oxide is easy to use, well tolerated by patients, and safe. The onset of action is very rapid, as is recovery. Along with producing sedation, nitrous oxide also provides the added benefit of mild analgesia.
Benzodiazepines are ideal agents for use in dentistry due in part to their anxiolytic, sedative, and amnestic qualities. They can be administered orally or parenterally. Benzodiazepines have a wide margin of safety and the advantage of a specific antagonist, flumazenil, for emergency reversal of an accidental overdose.
For patients with a significant fear or phobia, treatment rendered under deep sedation or general anesthesia would be more suitable. In these cases, the patient will be in a drug-induced state of unconsciousness while the dentistry is completed. Working with a trained medical or dental anaesthesiologist will ensure this treatment is undertaken safely and effectively.
SUMMARY
Dental anxiety is a common presentation that can be treated. It is important to be able to recognize anxious patients, who may present as avoidant or irritable. It is useful to screen for anxiety: a simple one-question questionnaire can be effective. There are multiple behavioural techniques that can be incorporated into a dental office, including (but not limited to): staff factors such as empathy and inquisition, a relaxing office environment, signal systems to allow patients to have greater control, distraction techniques, the Tell-Show-Do methodology, boxed breathing, progressive muscle relaxation, and cognitive strategies. Pharmacologic management can be highly effective for anxiety management. A dentist should tailor strategies according to individual patient need. OH
Robert McMaster, MD, Resident Physician, Department of Psychiatry, University of Toronto.robmcmaster@gmail.com
Dr. Gabriella Garisto is an assistant professor in the Discipline of Anaesthesia at the Faculty of Dentistry, University of Toronto and also maintains a mobile dental anaesthesia practice. gabriella.garisto@gmail.com
Oral Health welcomes this original article.
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