Anxious or Phobic Patients

42 Pages·2009·0.43 MB·English

The Academy of Dental Learning & OSHA Training

1101 Sibley Memorial Hwy Ste. 211
St. Paul, MN 55118

(800) 522-1207

[email protected]

Anxious or Phobic Patients:
Best Treatment Practices
Updated 2012

6 credit hours (6 CEs)

Mary Oeding, R.D.H., M.Ed.

Publication Date: October 2012
Expiration Date: September 2015
Academy - Dental Learning & OSHA Training is an ADA CERP Recognized provider. Provider Disclosure: Dental Learning or its authors have no
commercial interest in the content of this educational activity.
ADA CERP is a service of the American Dental Association to assist dental professionals in
identifying quality providers of continuing dental education. ADA CERP does not approve or Cancellation/Refund Policy: Any participant not 100% satisfied
endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards with this course may request a full refund by contacting:
of dentistry.
The Academy of Dental Learning & OSHA Training
Concerns or complaints about a CE provider may be directed to the provider or to ADA CERP at [phone] or [email protected]
www.ada.org/cerp.
Academy of Dental Learning & OSHA Training

Click here to take
COURSE AND EXAMINATION INSTRUCTIONS the online test.
1. Review the Objectives
Objectives provide an overview of the entire course and each chapter. Read the Course Description and
focus on the Learning Objectives listed.

2. Study the Chapters in Order
Each chapter contains information essential to understanding subsequent sections. Keep your
learning ‘programmed’ by reviewing the materials in order.

3. Complete the Post-Examination Online or by Fax
After studying the course take the test. You can access the exam by clicking on the red exam
box which is located in the upper right corner of this page and at the end of the last chapter.
Answer each questin b cclcclnn in he uuin cirreseinolnn i he cirrec answere Acc questins
mus e answereo efire he es can e nraoeoe There ls ni tme clml in he es e iu mab refer
acc i he ciurse a anb tme wl h he acc arriw in biur riwsere
You may also choose to print the exam and complete it manually. If you choose this option,
please FAX your answer sheet to [phone].

4. Grade the Test
If you completed the test online, click on ‘Grade Test’. You will then have the option to
Register your name and license number or Login if you have previously registered. Finally, you
will be required to provide a credit card number for secure transmission to pay the exam
processing fee.
If you completed the test manually and faxed it to us, someone from our office will grade it and
contact you with the results and your certificate.
A score of 70% or more is required to pass the test. If your score is less than 70%, you may try
again.

5. Fill out the Evaluation Form
Your opinion matters! After you pass the online test our evaluation form will be displayed on-
screen. Please answer the questions, enter the amount of time spent completing the entire
course and post-examination, and submit the form.

6. CE Certificate
Your CE Certificate will be displayed for you to print for your records.

THANK YOU FOR CHOOSING THE DENTAL LEARNING NETWORK!
If you have any questions, please email us at [email protected]
or call our friendly customer service department at 1-800-522-1207
Table of Contents
Instructions ........................................................................................................... 4
Table of Contents .................................................................................................. 5
Objectives .............................................................................................................. 6
Introduction ........................................................................................................... 7
Definitions ....................................................................................................................................... 7
The Body's Response To Pain And Fear ............................................................ 9
Gate Control Theory ..................................................................................................................... 10
Assessment Techniques .................................................................................... 11
The Corah Anxiety Scale17 ........................................................................................................... 12
Children ............................................................................................................... 16
The Child’s First Appointment ...................................................................................................... 16
Children’s Fears ........................................................................................................................... 17
Behavior ....................................................................................................................................... 17
Voice Control ................................................................................................................................ 18
Tell-Show-Do ................................................................................................................................ 18
Restraint ....................................................................................................................................... 18
Medication .................................................................................................................................... 19
Socio-Legal Concerns .................................................................................................................. 19
How Do Dentists Treat Anxious Patients?........................................................ 20
The Role of the Dental Staff ............................................................................... 21
Actions to Avoid ............................................................................................................................ 23
Intervention Strategies ....................................................................................... 25
The Latrosedative Process ........................................................................................................... 25
The Dental Fears Control Program .............................................................................................. 27
Deep Breathing ............................................................................................................................. 29
Modeling ....................................................................................................................................... 29
Pharmacological Sedation Techniques ............................................................ 30
Referral to a Mental Health Specialist ............................................................... 32
University Dental Fears Clinics .................................................................................................... 32
Conclusion .......................................................................................................... 33
Test ...................................................................................................................... 34
Bibliography and Suggested Reading List ....................................................... 38
5
Objectives
Upon completion of this course, the student should be able to:
• Define fear, anxiety, phobia, and pain. Describe how they are related.
• List some of the methods of assessment of dental fear or phobia.
• Describe the physiological reactions to fear stimuli.
• List common reasons for patient's fear of dentistry.
• List some current methods used by dentists to reduce the anxiety of their patients.
• Describe the role of the dental staff in reducing patient anxiety.
• List actions that experts recommend avoiding in order to reduce patient anxiety.
• Describe ways of teaching the patient to relax during dental treatment.
• Describe some current methods of anesthesia.
• List the conditions when is it appropriate to refer the patient to a mental health
professional or a dental fears treatment clinic associated with a dental school.

6
Introduction
Many patients only visit the dentist for emergency situations or when the pain of a dental
problem becomes so severe that they can't stand it anymore. Why don't these people
seek treatment when they first notice the symptoms? Why aren't they scheduling routine
maintenance visits?
Some people can't face dental treatment because it terrifies them. They would rather live
with the pain or poor esthetics caused by lack of dental care. A study by Dr. Scott in 1984,
shows that dental fear affects as much as eighty percent of the United States population
to some degree. Current data shows that up to twenty-percent of those needing dental
care avoid the dentist due to fear and anxiety. In fact, dental phobias are one of the most
common types of phobias around the world.
Many of those patients experiencing dental phobia seek a referral for IV sedation or
general anesthesia for dental procedures, but does sedation really help the patient
overcome his or her fears? Many experts agree that medication for sedation will only
propagate the cycle of emergency treatment and avoidance of routine care. (Kroeger
1988)
Additionally, dental professionals agree that anxious patients can be difficult to manage
and treat. In addition to taking up to twenty-percent more appointment time (Jepsen
1992), the anxious patient is more likely to be late and three times more likely than any
other patient to not show up for their appointment at all (Mendola 1991). Many dental
professionals experience feelings of frustration or inadequacy leading to increased stress
when treating anxious patients (Glassman 1993). While treating an anxious patient can be
difficult, exceptional care may lead to more referrals for the dental office that is willing to
take the time to treat the patient's anxiety.
The key to treating patients who experience dental fear and anxiety lies in a concept as
simple as compassion. In addition to common techniques that can ease pain during dental
procedures, this manual will provide helpful assessment techniques and revisit the idea of
a compassionate and caring dental team.
Definitions
Fear is a learned reaction characterized by physiological symptoms such as
quickened heart rate, nausea, sweating, muscular tension, and increased respiration. The
response is initiated by a real or imagined threat to one's safety. The patient poises in a
fight or flight stance ready to either escape the stimulus or stand and defeat it.
Anxiety is a different type of disturbed emotional state. Usually associated with
dangerous or unpredictable situations, the physiological symptoms include sweating,
increased heart rate, pounding chest, dry mouth, diarrhea, muscle tension, and
hyperventilation. The patient may have a sense of impending doom. Unlike fear, where
the source is easily identifiable, when a patient is questioned about the stimulus for
anxiety, the source is not easily identifiable.
7
Phobia is an irrational fear reaction. It is excessive, persistent, and exaggerated.
The physiological reactions are the same as anxiety, but the phobic state is beyond
conscious control. Reason or explanation cannot comfort the phobic. Often a dental
phobic feels as though no one understands his or her problem. They are usually
embarrassed and ashamed of their fears and may be concerned that they are mentally
unstable.
Pain is an anatomical and physiological reaction to a stimulus. The thoughts and
emotions of the patient as well as previous experiences, expectations, and distractions
can influence the patient’s perception of pain. The physiological and emotional symptoms
are very similar to those of anxiety. Often anxiety and pain occur at the same time.
8
The Body's Response To Pain And Fear
It is valuable to compare the physical response of pain in the body to the relaxation
response of the body. (Kroeger 1987)
STRESSFUL RESPONSE RELAXATION RESPONSE
The stressful situation activates two The relaxation response produces the
systems: opposite effects.
System 1 System 1
hypothalamus to anterior pituitary to hypothalamus to anterior pituitary to adrenal
adrenal cortex cortex

• adrenal cortex produces steroids • adrenal cortex is deactivated
• inactivates lymphoid tissues • decreases steroid production
• stimulates glucose production (syntoxic)
• irritates G.I. tract lining
• stimulates kidney to produce
renin
System 2 System 2
hypothalamus to sympathetic division of hypothalamus to sympathetic division of the
the autonomic nervous system, autonomic nervous system
sympathetic nerve endings secrete
norepinephrine and epinephrine
• deactivates sympathetic system
• adrenal medulla produces o decreases
epinephrine (cid:131) epinephrine production
o increases (cid:131) blood pressure
(cid:131) blood pressure (cid:131) blood glucose
(cid:131) heart rate • activates parasympathetic system
(cid:131) blood glucose o constricts pupils
(cid:131) blood cholesterol o increases salivation
(cid:131) respiration o decreases respiration
• irritates G.I. tract o decreases heart activities
• decreases salivation
• dilates pupils

9
Gate Control Theory
The Gate Control Theory postulates that the body cannot produce a stress response and
a relaxation response at the same time. Presented in 1965 by Melzack and Wall, it shows
a correlation between the emotional and cognitive state of the patient and the degree of
response to pain stimuli. Though controversial with respect to its physiological basis, the
pain research community widely supports its findings.
As a pain impulse is generated in the receptor cell it goes through the spinal cord to the
brain where it is interpreted as painful or not painful. The spinal cord is referred to as the
"gate." The signal is sent to the brain from the gate. Simultaneously a signal is sent from
the brain to the gate to either open or close the gate. This action modifies the intensity of
the pain response. If the patient experienced fear during a dental appointment in the past,
and if they are expecting pain, their brain signals the gate to be wide open. Thus, the
patient will react to the smallest pain impulse.
The theory states that if a patient can learn effective relaxation methods, have confidence
in the dentist and staff, and use positive self-talk, then he or she can make their brain
signal the gate to be closed. If the patient is relaxed during a procedure, the anesthetics
can be more effective. If the anesthetics are more effective, the patient will not respond to
minor impulses from the area being treated.
The Gate Control Theory has had a tremendous impact on the way pain is defined. The
anatomical and physiological responses to stimuli are influenced by the mental and
emotional state of the individual. Current expectations, experiences, and distractions all
play a role in the pain experience.

10
Assessment Techniques
The phobic patient can sometimes be identified during their first phone call to the office to
schedule an appointment. Therefore, it is important that the receptionist not only be
thorough, but compassionate when dealing with potential patients.
To assist with the identification of a phobic or anxious patient the receptionist
should include the following questions in the first conversation with the patient:
• When was your last dental visit?
• What was the procedure?
• How did it make you feel?
• Are you concerned about any aspect of the dental office?

If the responses indicate anxiety, the receptionist can reassure the patient that the entire
dental staff is very interested in working with individuals and their dental fears. He or she
can stress that dental anxiety is normal and that the dental staff has measured success (if
applicable) with treating patients with similar fears. Since most dental phobics don't come
to their scheduled appointments, this initial reassurance may be necessary for the patient
to have the bravery needed to walk through your office's front door.

The receptionist should take note of the patient's responses and inform the dentist before
the patient's arrival. This will enable the dentist to structure the first visit differently if
anxiety is suspected. It will also allow the dentist to allow more time for the initial visit.
It is important to remember that someone on the dental team may need to approach the
patient regarding fear and anxiety. Particularly in adults, the patient may mask his or her
behavior making assessment difficult. Additionally, the patient may be too embarrassed to
initiate discussion about his or her fears.
It may be beneficial to utilize health history forms which include questions such as: "Have
you ever had a bad experience in the dental office?" or "Are you afraid of dental
treatment?" Space should be given for the patient to write additional comments about
specific fears. Simply spending time at the initial treatment planning appointment and
identifying the patient's fears can be rewarding. Such simple actions reassure the patient
that the dental staff cares about their emotional state as well as the condition of their
teeth.
If the dental staff determines that the patient has a dental phobia, an assessment tool
such as the Corah Anxiety Scale can be very useful. This scale "kills two birds with one
stone" and completes the patients medical history while determining the extent of his or
her fears. Sometimes just the action of writing out the fears can produce a catharsis or
purging effect, helping the patient better understand his or her fears.
11
The Corah Anxiety Scale17
The Corah Anxiety Scale
1. If you had to go to the dentist tomorrow, how would you feel about it?
a. I would look forward to it as a reasonably enjoyable experience.
b. I wouldn’t care one way or the other.
c. I would be a little uneasy about it.
d. I would be afraid that it would be unpleasant and painful.
e. I would be frightened at what the dentist might do.
2. When you are waiting in the dentist office for your turn in the chair how do
you feel?
a. relaxed
b. a little uneasy
c. tense
d. anxious
e. so anxious I sometimes break out in a sweat or almost feel physically
sick.
3. When you are in the dentist chair waiting while he gets the drill ready to
begin working on your teeth, how do you feel?
a. relaxed
b. a little uneasy
c. tense
d. anxious
e. So anxious I sometimes break out in a sweat or almost feel physically
sick.
4. You are in the dentist chair to have your teeth cleaned, while you are
waiting the dentist is getting out the instruments he will use to scrape
your teeth around the gums, how do you feel?
a. relaxed
b. a little uneasy
c. tense
d. anxious
e. So anxious I sometimes break out in a sweat or almost feel physically
sick.

This survey can easily be tailored to each dental office. Use the responses from such a
survey to identify what the patient is most afraid of and address it at the first meeting.
Since the signs of fear can present in many ways, it is important to focus your full
attention on the patient. The anxious patient will sometimes exhibit signs of fear that are
verbal, behavioral, or somatic (physical).
12