November 1, 2005
by Trina Ghauri, Ph.D.
Dental fear and anxiety is a common problem that many patients and dentists must deal with on a regular basis. Without adequate resources, it can be one that tries the patience of the most professional and compassionate of dentists, often creating an aversion to working with such patients. Considering the high percentage of individuals who suffer from this type of fear, an aversion can have a harsh impact on one’s practice.
Every person working in the dental profession has encountered patients with dental fear. Some fears are mild and tolerable, while others are extreme and can create severe physical reactions. The latter is a situation that can be difficult for any professional to deal with, especially when it interferes with treatment and risks the patient’s health and your mental health. A stressful situation is not the ideal when attempting to perform delicate restorative dentistry. Nor is having to medicate patients who experience dental fear, as this creates additional potential complications, especially in a person who’s body is having a stress reaction such as high blood pressure and irregular breathing. Fortunately, medication is only one means of alleviating fear and anxiety in the dental chair. In order to understand some other methods, it is important to first gain a better understanding of fear and its mind and body connection.
UNDERSTANDING DENTAL FEAR
Each emotion a person experiences acts as a signal, attempting to tell that person something about his environment and experiences and his interpretation of them. Interpretation of events is a key element in how one responds or reacts to a situation, because it is ones interpretation that gives specific meaning to the event. Human beings experience the world through their senses, visual, auditory, kinaesthetic, gustatory, and olfactory. Each second we have two million bits of information coming at us, but can only pick out 126 bits of that information to process.1 This means that much of the stimuli in our world is deleted, distorted, and generalized in order to fit into 126 bits that we can comprehend. So the question is, what is one focusing on in choosing which bits of information to grab from the millions going by?
An individual who enjoys dental visits may be choosing to focus on her health, feeling good about smiling, friendly people in the office, pleasant music, the taste of cherry flavoured fluoride, a comfortable relaxing chair, and the new toothbrush she will take home. Whereas someone who experiences fear might focus on feelings of losing control and not being able to speak as someone works in his mouth, vulnerability, the potential of needles, the smell of burning teeth, gagging, blood, and pain. These are two very different experiences about a dental visit because of varying interpretation of the situation.
Fear is an emotion that is useful when a person is in danger. It assists them to choose safe appropriate action and to carry it out. For example, if one were in a life-threatening situation, the feeling of fear would be a signal to that person that something is hazardous and he needs to either remove himself or deal with the situation immediately. This is known as the flight or fight response. However, fear is also an emotion that appears when one begins to focus on and expect the worst, consciously, or unconsciously. That is to say that the individual may be aware of what they are thinking that is having them feel fearful, or the reason may be deeply unconscious and out of their mental awareness.
Whether the situation that a person fears is real or imagined, the body responds in the same way. Some physical responses to fear are chest tightness, breathing fluctuations, sweating, seizures, hypertension, nervous stomach, and nausea. It has been suggested that fear is an acronym for: false expectations appearing real. Which essentially means that what a person creates in his mind (through pictures, sounds, feelings, etcetera), his interpretation, if held strongly, can manifest itself in that person’s life as being real.
For example, Jonathan has never had a painful experience in a dental chair. When he was fourteen years old he began to worry about upcoming trips to the dentist. One day during practice, a soccer team mate told a story of having to have a tooth removed after one of his teeth was so badly decayed that no tooth structure would remain after caries removal. The boy embellished the story, making sure to add many gruesome details to impress his friends. One such exaggeration was that he had to be held down by several people when he tried to jump out of the chair because of the excruciating pain and in doing so sprayed blood everywhere.
Jonathan was worried by this story as he had a dental examination the following week. He knew that he was long overdue for the appointment, and let his mind wonder as to the build up of decay he might have himself. “What if I have to have a tooth removed too?” he thought. Similar thoughts cycled through his mind over the week along with images of his own worst-case scenario experience in the dental chair. Each time he thought of this he suffered from tightness in his stomach, sweaty hands, and shallow breathing.
The night before his appointment, he could not sleep anxiously thinking about what could happen at the dentist the next day. In the morning, he told his mother that he was not feeling well and asked her to cancel his appointment. He continued to postpone rescheduling and in doing so, built up the fear even more, thinking about the additional decay that was occurring. Jonathan had created fear and anxiety without ever having any “real” experience to support this fear. For him, it was just as real as if he had had a previous negative dental encounter.
The reason a person can experience something as being real even if it had not occurred is linked to ones interpretation and the unconscious mind. Remember that humans process their experience through their senses. It is with these same senses that a person imagines. For example, a person who had a real negative dental experience will recall that experience through either pictures, sounds, feelings, tastes, and smells or some combination of these senses. This will invoke the fear.
A second individual who is afraid of dentists, yet has never had a negative dental experience, will imagine a trip to the dentist through his senses, in the same way as the previous example. Once again, this will cause the fear to arise. Both situations will initiate physiological responses to the fear, which is a very authentic experience for that individual. Because of this, it is important to honour each person’s experience of fear, as it is real to him or her.
Along with one’s interpretation of a situation, his previous life experiences can also play a role in having dental fear and anxiety. Some such experiences and conditions include, but are not limited to claustrophobia, sexual, physical or mental abuse, panic attacks, agoraphobia, medical trauma, emotional childhood wounds, and of course a distressing dental encounter.
As previously stated, a person may or may not make a conscious connection between a past experience or condition and their dental fear. In fact, many times a patient will know that her fear is irrational and unwarranted, yet still have the emotion and responses because it has a connection at the unconscious level to a previous experience. For this reason, only addressing the dental fear without deeper exploration into its origins may sometimes prove to have little effect.
An example of this is Mary, who is a childhood sexual abuse survivor. During Mary’s childhood experience she was gagged so she could not call out for help and felt helpless and vulnerable. When Mary began visiting the dentist the feeling of work being done in her mouth triggered her unconscious mind to generalize the sensation and link it to the abuse. This led her to feel helpless and vulnerable at the dentist, especially because of the reclined position of the chair.
When Mary was in her teens, her dental fear had intensified, so her parents sent her for professional help. The practitioner who saw her, although well intentioned, only focused on the dental fear, which had a minimal effect on her dental experience. A few years later, Mary went to another professional. This time, the sexual abuse was revealed and the connection with the dental visits explored. After a few sessions, she no longer experienced the fear and in fact viewed the office as a safe place where people were helping her.
For other patients, focusing on the fear of the dental visit is effective. Jonathon, the boy who developed fear and anxiety after hearing his teammate’s embellished dental story, was one such patient. His fear was based on creating an unsupportive belief for himself. When he finally made an appointment to see the dentist, he expressed his fear to the receptionist, who recommended he visit the office a few times prior to having treatment.
During these preliminary visits, Jonathon was led on a tour of the office where he was able to meet the staff, sit in the chair without having work done, touch the dental implements, familiarize himself with his surroundings and watch an educational video explaining how a cleaning is performed. He noticed that when other patients would come to reception upon completion of their treatment, they were smiling and relaxed. Even the girl who just had a major procedure, seemed in good spirits despite her swollen mouth.
Jonathon soon realized that his fear was unfounded and was ready for his appointment. This example illustrates some simple steps that any dental practice can incorporate to assist their patients in being at ease.
TOOLS & RESOURCES
Although the causes for dental fear are varied and sometimes complex, requiring outside help, there are steps that every dental office can take to help alleviate at least some if not all of the fear. The first and most important thing one can do is to withhold judgement of a fearful patient, and instead approach him or her with understanding and compassion. Developing this type of relationship assists the patient in building trust and creating a safe place.
One way to do this is to ask questions. Find out what specifically causes the patient to feel fearful. If they are aware and feel comfortable with you, they will tell you. It could be something as simple as finding the bright lights startling, so suggesting they wear sunglasses to the appointment would help. Address your patient by name, and ask them how you and your staff can help them to feel relaxed. Then do your best to accommodate this request. If it is a request that interferes with treatment, explain the reason why it cannot be fulfilled and work together to find an alternate solution. Cooperating in this way also lets the patient know that they too have a responsibility and ability to help themselves.
This relationship begins with the first communication the patient has with your office, usually with the receptionist. Therefore it is essential that each member of your staff be trained in proper communication and techniques for dealing with fearful patients. Knowing what to say and what not to say is significant. For example, using words such as pain, and hurt, trigger the patient to think about those sensations. Instead, of saying, “The procedure will not hurt,” one could say, “So you will find the experience to be quick and relaxing, you can even listen to your favourite music!” The second means of communication is the intake form, so include questions that assess the patient’s fear level and a space for them to let you know if they are aware of anything that helps them relax.
The office environment must be pleasant, comfortable, and friendly. This begins with the waiting room experience. A well-equipped waiting room can go a long way in making patients feel at ease. Access to a variety of reading material is important.
Some suggestions are educational materials about various procedures in easy to understand, non-threatening terms, current magazines, tips for improving oral health at home, testimonials from happy patients for reassurance, mind-challenge puzzle books, simple relaxation breathing exercises posted, and children’s books about visiting the dentist and teeth care (if the office accepts children). A small television showing information about the office, resources, up-to-date educational information about oral care, etc. is useful, as long as the volume is at a comfortable level for those who are not interested.
Music is another element that can add to the nature of the environment, as is cheerful artwork, and colour scheme. Offer office visits to familiarize the patient with the space so that they can feel comfortable in the environment when they return for the treatment. Provide tools for the patient to use at home to prepare for the appointment such as visualizations, breathing techniques, and hypnosis CD’s (which work with the unconscious mind) to release dental fear and promote relaxation.
Be diligent about explaining the procedure prior to and during treatment, so that the patient knows what is happening. After the explanation of each step, ask the patient if that is okay with them. Get a verbal agreement or hand signal, as this reassures them that they will still have control. Thus, it is helpful to set up hand signals for “okay” and “stop” to use when treatment is in progress. Provide periodic time estimations so that they know what to expect, and when they are nearing completion.
Where possible, allowing the patient to handle the suction themselves helps with feelings of being in control and participating rather than having something “done to” them.
When sedation is being used, the patient may feel more comfortable having a friend or family member in the room. This is not always possible, so find out what you can do alternatively to help them feel safe. For many, having the choice of music through headphones or watching television during the procedure is a great method of distraction and relaxation. Remember that ones focus plays a significant role in their interpretation of a situation, so diverting their attention to something entertaining can be beneficial.
Dental fear and anxiety can range from tolerable, though uncomfortable, to severe where dental work is impossible without treatment. The good news is that there are many options for treatment that do not include medication, only some were outlined here.
Understanding patients’ dental fear combined with incorporation of the above resources will have your practice function much more productively. With the percentage of dental fear being so high, it is the professional’s responsibility to either educate themselves and their staff as to how to deal with such patients, or have a referral base in which to send them, especially if the fear is deeply rooted in more complex issues.
Some offices specialize in working with fearful patients, as they realize the vastness of this problem in the population. These professionals have learned how to handle the situation so as to alleviate the stress for their patients and for them selves.
Trina Ghauri, Ph.D. works with individuals, assisting them with identifying and resolving mental and emotional challenges. She has developed specialized trainings for dental practices in patient-care management and communication, as well as hypnosis CD’s to promote relaxation, inner peace, and support the elimination of dental fear. E-mail: trina@ necessaryelements.com
Oral Health wecomes this original article.
1.Csikszentmihalyi, Mihalyi. Flow New York: Harper Perennial, 1991.