Dentally-anxious patients —— a study of secondary care referrals in Scotland

Key Points

In brief

• Psychological treatments for dental anxiety are a feasible option that some patients prefer when given a choice.

• Dentists have a duty to discuss the full range of treatment options for dental anxiety with patients and, where necessary, refer to specialist dental and clinical psychology services.

• Stronger links between general and specialist dental and psychology services will improve service provision for patients with dental anxiety.

Abstract

Objectives

This study aimed to determine the methods suggested by general dental practitioners for management of patients with dental anxiety whom they refer to a dental hospital setting, the treatment modalities eventually used with such patients and the relationship between patient's previous sedation experience and the current referral.

Methods

Consecutive referral letters (n=125) for management of patients with dental anxiety over a 16 month period were analysed for content, including reason for referral and suggested treatment modalities. Patient records were also examined for previous sedation experience.

Results

From 115 referrals eligible for analysis, the dentists requested management of anxiety using pharmacological methods in 113 referrals with only two referrals mentioning psychologically-based treatments. In secondary care, 29% of the adult referrals opted for dental treatment using psychological techniques alone.

Conclusions

In spite of the efficacy of psychological treatments for dental anxiety, primary and secondary care dentists appear not to be suggesting or promoting their use for patients with dental anxiety. Further research into the availablility of, and barriers to accessing the full range of services for those with dental anxiety, including patient perspectives, needs to be undertaken.

Main

Referrals to a secondary care dental clinic for anxious adult patients: implications for treatment by P. McGoldrick J. Levitt A. de Jongh A. Mason and D. Evans Br Dent J 2001; 191: 686–688

Comment

This study, based in Scotland, identifies a common problem that occurs between the primary and secondary care systems. That is, the requests from the primary care service for a particular type of specialist treatment to be delivered by a hospital do not necessarily match.

McGoldrick and her team present the details of 125 referral letters made over a 14 month period to a specialist service for dentally anxious patients. The majority of these referrals (67%) were received from general dental practitioners. Only two of the patients who attended their first appointment (n = 115) had referral requests for non-pharmacological treatment.

The authors then reviewed the treatment provided. It was found that only 70% received pharmacological assisted treatments including: intravenous or inhalation sedation, and general anaesthesia, whereas 30% approximately were managed with behavioural techniques.

The paper points out that there is now good evidence that patients can be effectively treated with the aid of formal psychological approaches. Not only can the current episode of dental treatment be completed successfully but also the prospect of maintaining a reduced level of anxiety with future dental visits may be expected as shown, for instance, by the classic study by Berggren.¹

On enquiring about the past experiences of patients, from their dental records, it was found that there was a relatively strong association between previous pharmacological history for dental treatment and the current episode under investigation. The interpretation of this finding was that inertia in the management of dentally anxious patients could occur.

The authors alert readers to the usual limitations of retrospective local surveys, however important issues are raised. First, from a patient-centred perspective, what are the expectations of patients? Would they prefer pharmacological assistance in order to 'get the job done', or do they look beyond the short-term? Second, to what extent do primary care practitioners discuss their referral decisions with their patients? If patients were aware of some of the range of services, including psychological, would referral patterns change?

Finally, the role of general dental practitioners would appear to be vital, not only in their assessment of the patient (perhaps more formally with the use of standardised rating scales) but also in the professional relationship that they strike with the patient. Some evidence suggests that patients remain in the system of regular dental care or fall outside depending on the quality of the communication between dentist and patient.²

In conclusion, McGoldrick et al. recommend educational and service developments to improve treatment for dentally anxious patients and research into patient preferences.