Management of dental anxiety

Introduction

Despite the efforts required by dental phobics to attend for treatment, it is not unusual for them to flee from the waiting room as their appointment time approaches.

Dentists have a duty to provide and patients have a right to expect adequate pain and anxiety control. Pharmacological methods of pain and anxiety control include local anaesthesia and conscious sedation techniques. (From Maintaining standards; General Dental Council, 2001.)

The avoidance of dental care due to fear of dentistry is a well known barrier to oral health. Many anxious or phobic patients will accept dental treatment if managed by sympathetic staff with the assistance of psychological therapies. A proportion of the population will, however, require sedation to help them accept dental treatment. It should be remembered that whilst fear of dentistry is commonplace there are other reasons why patients may refuse dental care: the patient may have behavioural problems or lack the capacity to understand the proposed treatment. When managing patients who are reluctant to have dental treatment it is important to understand the difference between anxiety and phobia.

Phobia

Phobia: an irrational fear of a particular object or situation – the fear response is excessive and disproportionate to the threat posed.

• The stimulus is comparatively small compared to the severity of the reaction

• This is a lasting abnormal fear that is usually deep rooted in a patient's emotions and often its origin cannot be explained, although this is not always the case

• The patient has little or no control over the phobia and logical thought is not a feature

• A phobia can significantly change a patient's behaviour

• Embarrassment and shame are often present.

Anxiety

Anxiety: a human emotion which causes feelings of apprehension, tension and discomfort and is associated with increased activity of the sympathetic nervous system.

• Anxiety is a learnt response

• Anxiety can be beneficial (eg it is often anxiety that precipitates a candidate to study for examinations), but anxiety is not always a helpful state to be in

• An anxious patient is in a state of unease

• Anxiety can be measured by using self-reported questionnaires such as the Modified Dental Anxiety Scale

(Fig. 1).^1,2

Figure 1

Modified Dental Anxiety Scale^1,2

Dental anxiety has implications for both the patient and the dental team. A variety of studies have shown that the prevalence of dental anxiety is high, affecting up to one third of the UK population. The 1998 Adult Dental Health Survey identified that 32% of dentate patients in the UK population ‘always feel anxious about going to the dentist’. This figure rises to 46% in dentate patients who only attend when they have some trouble with their teeth. It is interesting to note that 59% of dentate patients reported that they attended for regular dental check-ups. Anxiety therefore remains a barrier to dental care in a significant proportion of the population. Approximately 10% of the population avoids dental care because dental treatment provokes overwhelming feelings of anxiety which exceed the sufferer's ability to cope; such patients have dental phobia. Dental anxiety and phobia can be distinguished by the intensity of anxiety experienced and the patient's ability to cope with the anticipated anxiety of dental treatment. It is not unusual for a phobic patient to seek help for a dental problem from their doctor, rather than a dentist, in the hope of being prescribed painkillers or antibiotics. Many anxious/phobic patients will only seek a dental appointment when in severe or chronic pain; some are forced to do so by a friend or relative. Despite the efforts required by dental phobics to attend for treatment, it is not unusual for them to flee from the waiting room as their appointment time approaches. It is therefore not surprising that there is an association between high anxiety and missed or delayed dental appointments.

Spectrum of symptoms

Patients who are anxious or phobic about dental treatment may have generalised concerns about many aspects of dentistry or they may have very specific worries, such as a fear of injections. Other patients have a fear of the unknown or feel that they may lose control. Anticipation of pain during dental treatment is a frequently reported reason for dental anxiety and fear. Anxiety may be based around one or more previous distressing experiences, such as pain, but it is not always possible to identify specific traumatic life events. Some adults who have accepted routine dental treatment in the past may develop dental anxiety for no obvious reason. Patients may become anxious because of incidents portrayed by family, friends and the media; this is known as vicarious learning. Not surprisingly, patient's beliefs (cognitions) about dental treatment vary considerably as does their response to stress-provoking situations. Children respond quite differently from adults. Patients with psychological or psychiatric problems may respond unpredictably to stressful situations. Some patients will experience anxiety only on the day of the appointment or when they enter the dental surgery. Other patients will start to exhibit symptoms of stress as soon as they receive the dental appointment, experiencing several sleepless nights prior to the visit. The spectrum of symptoms varies from mild psychological symptoms to physical (somatic) signs and symptoms such as those listed in Table 1.

Table 1 Signs and symptoms of anxiety

Impact on quality of life

Anxious patients should always be given a stop signal as this transfers an element of control to the patient. The dental team must always respond appropriately to such signals. The trust of a patient can take a long time to build up but can be very quickly undermined or destroyed.

Research has shown that many patients who have high levels of dental anxiety also display other fears or psychological problems and these may adversely influence treatment outcome.

Dental anxiety can have a profound detrimental impact on the quality of life of the sufferer. One study by Cohen et al.³ has shown that the impact of dental anxiety on people's lives can be divided into the five categories outlined below:

• Physiological disruption – eg dry mouth, increased heart rate, sweating

• Cognitive changes – eg negative and even catastrophic thoughts and feelings, unhelpful beliefs and fears

• Behavioural changes – eg alteration of diet, attention to oral hygiene, avoidance of dental environment, crying, aggression

• Health changes – eg sleep disturbance, acceptance of poor oral health

• Disruption of social roles – eg reduced social interactions and adverse affects on performance at work. Family and personal relationships can also be adversely affected.

Anxiety management

The management of anxious/phobic patients is dependent upon the severity of the condition and the treatment that needs to be undertaken. The medical history of the patient also influences management. It is important to control anxiety in patients who have systemic disease that is aggravated or triggered by stress, for example hypertension, epilepsy or asthma. The spectrum of patient management varies from psychological or behavioural approaches to the use of pharmacological agents such as anxiolytic drugs or general anaesthesia (GA). The spectrum of management strategies for the anxious patient are outlined in Table 2 and range from behaviour management to local anaesthesia, sedation and general anaesthesia.

Table 2 Methods of reducing anxiety

Not everybody can be managed by sedation. GA is the method of choice for the pre-co-operative child and for many patients with profound learning or physical disabilities.

It is important to appreciate that the use of an anxiolytic drug is not a replacement or substitute for behavioural management of an anxious patient. The use of effective and persuasive communication techniques are still required when managing a patient under sedation.

Behavioural techniques

Behavioural techniques are employed as a matter of routine by many dentists, and are perhaps most evident when children are being treated. Positive reinforcement is frequently used as shown by the delivery of praise to an appropriately behaved patient. The age and emotional development of a child must always be taken into account when deciding upon which techniques to use. Anxious patients should always be given a stop signal as this transfers an element of control to the patient. A commonly used signal is simply raising a hand and it can be helpful for the patient to rehearse this briefly before treatment. The dental team must always respond appropriately to such signals. The trust of a patient can take a long time to build up but can be very quickly undermined or destroyed.

A review of Advanced dental nursing, 2nd edition can be found on page 8.

Behavioural management can be time consuming and expertise is required. Dentists who have access to a clinical psychologist are very much at an advantage. Patients with needle phobias can often be cured of their phobia by employing a systematic desensitisation programme. Desensitisation is a graded introduction to the feared experience/treatment – starting with the least frightening. The patient learns to cope with this before progressing onto the next stage. Finally, the patient is exposed to the most threatening situation. A long-term aim in the management of anxious/phobic patients is to modify their behaviour in order that some or all future dental treatment may be accepted without the assistance of sedation.

Some clinicians find it useful to categorise anxious patients into four types (Table 3); this is because the patient category influences the choice of behavioural management strategy. It should be appreciated that whilst this classification can be helpful, patients may have features of anxiety that belong to more than one category and several management strategies are sometimes required for one patient.

Table 3 Management strategies for anxious patients according to anxiety type