Tim Newton, leader of King's Health Psychology Service, talks to the BDJ about his views on UK health policy and tells us why a dentist's visit can still cause a lot of anxiety for patients.
Tim Newton is a professor of psychology as applied to dentistry at King's College London Dental Institute. Tim leads the environment and education research theme at King's, a group which is involved in cutting-edge research in the behavioural sciences as applied to dentistry, oral health services research and the development of new technologies in dental education. He has worked in the behavioural sciences in relation to dentistry for the last 18 years, and his particular interests include dental anxiety and fear, self-perceived oral health and the working life of the dental team. Tim also leads the King's Health Psychology Service which was launched in 2008. The service provides support for people with dental anxiety and is the first of its kind in the UK.
What attracted you to apply your psychology knowledge to dentistry?
My PhD was on the topic of the psychology of eating disorders (anorexia and bulimia) which involved a dental aspect. I was also really interested in communication, and dentistry involves a lot of interesting communication. Following my PhD 20 years ago, an exciting dentistry job came up at King's which offered me the opportunity to work with really good people, so I came down to London and I'm still here. I started on the 1st April and I remember going into the hospital on my first day and saying 'I'm the new psychologist in dentistry' and, as it was April Fool's Day, they all thought it must be a joke! At that time, in the dental school there was only me and a half-time sociologist and that was it. That is one of the things that has really changed in the last 20 years – there are now far more psychologists really interested in dentistry so I am now a bit of an old hand.
What are the differences in terms of the psychology of dentistry versus medicine?
There is a big overlap between dental and medical psychology; for example behaviour change, the principles, adherence and compliance etc are very similar. The specifically interesting elements of dentistry are anxiety (because it is such a common fear, even more common than a fear of flying) and communication. Communication for GPs and GDPs is very different. A visit to your dentist is more often than not much more invasive than just going to your GP; a GP is not likely to get into your space and look inside your mouth to that extent. Dentistry also has that whole reputation of being painful. People imagine it will be painful. So as a psychological topic to study, dentistry is really interesting.
What has most surprised you in the course of your research?
Many things but particularly that there isn't more overlap between dental and medical research. Just as dentistry is a really good model for human behaviour, the mouth and how it works is a really good model for other aspects of healthcare. Dentistry and medicine are currently somewhat separate, to the point where we have 'dental public health' covering only dentistry and 'public health' everything else! Why is that? It might be down to dentistry being separated somewhat from the general NHS system or because of the way it's delivered, for example a dentist is much more likely to 'do something' at an appointment.
What drives some people to be so afraid of dental treatment?
I think that it is partially the bad reputation of dentistry. Dental treatment is often a by-word for pain and nastiness. For example, people often mention the negative depiction of dentistry in films such as the 'Little shop of horrors' and 'Marathon man'. Generally the media portrayal of dentistry is really negative and that can become cultural. You get parents who, even if they are not actively negative about dentistry, might wince when mentioning the dentist and so it passes on down.
My son has been to the dentist a lot and so has become completely blasé about it. I have great video of him, which I use with anxious children, where he just pops in the dentist's chair and opens his mouth. Then he uses the stop signal to interrupt and the dentist takes the equipment out of his mouth and asks him what the matter is and my son says, 'I just wanted to let you know that I want them all cleaned.' It's a nice example which displays how to use the stop signal and he is also very positive about the whole thing.
One of the interesting things we will try to look at in the future is why some people can overcome a bad experience whereas it sticks with other people. Partly we know that's because they might have had good experiences in the past but it may also be due to aspects of the way in which they solve problems or cope with life that make them more vulnerable to learning from a bad experience.
How has the dental experience for children changed over the last 40 years?
I suspect that treatment is now much gentler with better pain control. One of my worries about the way the system currently works in the UK is that it is very treatment-focused when what children most need is probably just acclimatisation. They should be coming into the dental surgery at a young age to get used to being there as a safe place and have a play with the equipment etc but the renumeration system is not currently set up for that.
As a non-dentist working closely with the profession what do you feel is the biggest challenge facing dentists in the UK?
It's got to be the funding system. Because of the funding system it is becoming increasingly difficult to work in the NHS in a way that many dentists feel they want to. Therefore they are choosing to vote with their feet and find their own ways to deliver the care they wish to deliver.
Being in academia I also worry about what the system does to our students. In the future they will be leaving university having paid £45,000 in fees alone. So they will probably be in about £90,000 worth of debt before they have even started 'living' which puts them in a different place from dentists of ten years ago. Having said that, although fees are high, dentistry is still one of the most sought-after professions with a high employment rate and earnings potential. They may now largely be motivated first and foremost by the desire to pay off this debt and will want to work in a way that is going to help them to do this. If I was 18 again as things stand now I wouldn't have gone to university as there is no way we could have afforded for me to go. There have to be lots of kids who were like me who would now say 'why should I go to university if it costs so much?'
The nature of the Chief Dental Officer and dental public health roles (which have moved to civil service contracts) has also changed enormously. There no longer appears to be a 'voice of the profession' advocating for it which is really tricky. The BDA does a great job but often finds itself accused of doing what the government want them to do.
We have made a shift, which I think is a bad move, from a self-governing profession to being governed as if the default is that people are going to do wrong instead of expecting professional standards. People respond by losing their innate motivation to do things well. If you think that the only way to motivate someone is to give them external motivation they will respond to that. For example, doctors used to treat the job as a vocation and they would work whatever hours were required. Now if you ask a doctor to do something they may think 'will I get a programmed activity (PA) for that?' ie will I get paid? Some have lost that sense of vocation. The government must get back to the idea of working with the professions rather than the current dichotomy of expecting the profession to do wrong and the profession reacting against that.
In 2008 you established a Health Psychology Service for adults with dental anxiety – how is it doing?
It's doing well. We have had lots of people wishing to adopt a similar model. We now provide training courses for those people who want to come and be trained in the King's model.
We get referrals from GPs and GDPs as well as a lot of self-referral. Our average number of sessions (generally 45 minutes to an hour) to get someone with a phobia having some treatment is five. That early treatment is usually a scale and polish, something simple. If the patient only has a simple fear of needles then the average number of sessions required is three. The sessions are mostly about giving people information to help them to be realistic about what is going to happen, and techniques for improving their sense of control.
Why is cognitive behavioural therapy (CBT) so effective in helping adults overcome high levels of dental anxiety?
It's effective because it is a learning process. There are two elements: one involves very carefully breaking down the steps of dental treatment and doing those repeatedly until people feel confident. It's a bit like training for a marathon, so you might start off with walking a bit, then walking and running and gradually increasing your distance. The other element is educating to give people a greater sense of control – providing simple facts, about the structure of the mouth and how pain receptors work. For example, we have this simple technique where you ask people to write a letter to the dentist saying how they would like to be treated – what they would like to be called, whether they want the dentist to tell them everything about the treatment or nothing at all, do they want the dentist to talk to them while lying down or to sit them up.
Roughly half our patients are generally anxious (nature's worriers), of the other half about 25% have had a very bad experience and the other 25% are just scared about a particular thing, typically injections or drills. This latter group are really easy to treat and it's very rewarding. Our patients are mostly women, but that could be just because more women than men actually seek help. Gagging problems are a typical reason for male patients to attend the service.
We get a lot of people who come because they are in pain. Another common motivation for parents is the need to be able to take their own child to the dentist.
How can people be encouraged to take care of their teeth?
I would say that unfortunately the best way is to sell oral care as an aesthetic thing. We know that white, straight teeth are rated as being very attractive so we can buy into that to encourage people to keep their teeth healthy. Making oral care a habit is also key. A great tip I heard the other day is to do your flossing when you wash your hair as this ties oral care into habitual patterns.
Biggest breakthrough in dentistry in the last ten years as you see it?
Inevitably dentistry is very technical so most people would think about technical developments. But I have to say that the biggest breakthroughs. as I see it. have been two non-technical things:
The increasing interest in inequalities in oral care. The IADR under David Williams are just starting a whole programme looking at global oral health inequalities and I think that is great; we need to get this on the agenda
Linking up with social scientists (I would say this!).
What is your view on direct access?
I am against direct access because I think you need the reassurance of seeing someone who knows your whole person. Having said that I am against direct access I am pro dentists working like GPs and increasing the skill-mix but I don't think you should be able to skip seeing someone who knows the whole picture.
What is the future for patient-dentist relationships?
I think we are going to see patients more empowered in all areas of healthcare. One of my fears is that healthcare will move to a consumerist model in which patients feel as if they can buy whatever they want. I think this is inappropriate because the dentist knows so much more and has a body of knowledge enabling them to advise and suggest what is appropriate so that the patient can make a decision.
We are now entering a generation where having information is less important than the ability to use that information. To draw it together, critically appraise and apply it is the new skill. Patients often come and say that they have read an article about a particular technique. But though they can access the information easily what is more difficult is to say whether or not this info they found on the internet is a good and reliable source and as a dentist you need to be able to say genuinely and honestly what you think of it.
What are your top five tips for the dental team in dealing with patients' anxiety?
Expect some anxiety
Assess how anxious the patient is
Think about how you can make the whole journey through the surgery less anxiety provoking. It could be quite simple – what image does your surgery give when the patient arrives? Is it warm and welcoming? The key people are the receptionists and nurses
Think about any techniques that you could use to give the patient a little bit more control. Give them choices: 'Would you like me to do the upper or the lower impression first?' 'Will I do the front teeth or back teeth first?'
With children, get them in to acclimatise them.
Interview by Ruth Doherty BDJ Managing Editor
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Cite this article
Tim Newton: 'The government must get back to the idea of working with the professions'. Br Dent J 213, 423–425 (2012) doi:10.1038/sj.bdj.2012.977
British Dental Journal (2013)