Caroline Holland on the Health Psychology Service and how dental nurses can help anxious patients.
The stage is set for dental care professionals (DCPs) to be more involved in the management of anxious patients. This is the result of the work undertaken by Professor Tim Newton, the UK's only Professor of Psychology as applied to dentistry, and his colleagues at King's College London (KCL) Dental Institute.
Since it was established in 2008, the Health Psychology Service for Adults with Dental Anxiety has run a weekly clinic. The clinic uses cognitive behaviour therapy (CBT) and based on the success of their work, they have produced a manual to support dental teams: C1ognitive behaviour therapy for adults with dental anxiety: a toolkit. Professor Newton hopes that dental nurses can be involved in developing services around the UK.
Most of the patients treated by the Health Psychology Service have been referred to the Dental Institute for sedation. Dental nurses offer patients the opportunity to go to the psychology service instead. Professor Newton says: ‘If people have sedation every time they need treatment they will not have the opportunity to address the thoughts and behaviours that underlie their phobia. As healthcare professionals we should encourage them to seek help.’
Initially the patient has between three and five CBT sessions with a psychologist. These take place away from a surgery setting and involve discussing the person's anxieties. The aim is to help the patient understand their fear and by finding an explanation for their often extreme behaviour, they can modify it. Relaxation and desensitisation techniques are used to help the patient face their fear rather than run away.
Desensitisation involves graded exposure to the feared situation. So, the patient who is fearful of injections will be given increasing exposure to a syringe. Initially, they will be shown the syringe but as time wears on, the syringe will be placed in a closer position until after a few weeks, the patient feels able to tolerate the syringe near to them. This allows them to understand that the thing which makes them feel so anxious is not doing them any harm.
Relaxation and desensitisation techniques are used to help the patient face their fear rather than run away.
It's also about shattering preconceptions. According to Professor Newton, anxious patients commonly confuse pain with pressure. Phobics frequently say that injections don't work and they feel pain. In fact, they are feeling the pressure of the drill so they don't believe they are numb and this induces panic.
But there are preconceptions on the part of dentists too, says Professor Newton. ‘They underestimate the patient's experience. Dentists really think that treatment is pain free whereas 95% of patients think treatment is painful. They can't both be wrong.’
CBT works in a collaborative way with the therapist supporting the patient with tasks such as goal-setting. Homework is a key aspect and allows the patient to apply what they have learned in their everyday lives. Then, at the next session they can discuss their progress with the therapist.
Gradually, by the sixth session, the patient feels able to sit in the dental chair and have a scale and polish without sedation. Beforehand, the dentist will make it clear to the patient that treatment can stop anytime if they feel anxious. A signal is agreed, such as raising a hand.
Professor Newton recalls one patient who was very keen to have a scale and polish but she would raise her hand as soon as the dentist started treating her. He suggested that they change the system so that she indicated her declining tolerance. She would gradually raise each finger on one hand and when she reached the last finger, the dentist had to stop.
‘By changing the system and allowing the dentist to do a little work, progress was made and trust was built up. More importantly, the patient felt in control, which is important when you feel anxious.’
With more time and commitment dedicated to the support of anxious and phobic patients, Professor Newton believes that a significant number of people who avoid the dentist would eventually seek an appointment and the number of people requiring sedation could be reduced.
One of the biggest psychological hurdles for the anxious patient is root canal treatment. Professor Newton says that it is not the treatment per se but the combination of injection and drilling. These are the two most feared aspects of dental treatment. He is a supporter of the Saving Teeth Awareness Campaign, launched last year to change attitudes.
‘People who are anxious will often avoid dental treatment, and when they do attend often make decisions which they might not make if they were less anxious – for example to have teeth extracted rather than have to attend for more appointments for treatment to restore their teeth. By addressing their anxiety and helping them to find ways to cope with their fear, we aim to help them enjoy teeth for life.’
One of the founders of the campaign was the Harley Street Centre for Endodontics. Debra Hackshaw, the practice manager and a dental nurse, said a common problem for their patients was the comments of friends which made them anxious.
Debra encourages patients to avoid sedation where possible. “I tell them that times have changed and they can bring their own iPod and relax - amazingly some will even fall asleep!”
‘Their friends quote their own experiences but these stories can be out-of-date or irrelevant. What we do is encourage patients to come here and meet the clinician. Once the patient knows the endodontist and realises they will be doing everything they can to make the root canal pain free, attitudes change.’
Debra says she encourages patients to avoid sedation where possible. ‘I tell them that times have changed and they can bring their own music or story on an iPod and relax for an hour and a half – and amazingly some will even fall asleep!’
So, for a patient who is nervous, as opposed to phobic, time and communication can make all the difference. This is where dental nurses have a role as they are usually better at chatting to patients and putting them at their ease.
Following the strong supporting role that dental nurses who work at KCL have played in his work, Professor Newton is an advocate for dental nurses acquiring CBT skills. ‘Dental nurses are suitable and reliable,’ he says, ‘and although there are initial upfront costs in training dental nurses, this is in the long-term a cost-effective approach to getting more people dentally fit.’
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Facing up to fear & phobia. Vital 9, 20–21 (2012). https://doi.org/10.1038/vital1518