Dental anxiety? Let’s tackle this

Link to source

16th Jan 2013

Diana Woodward examines how we can help patients with the age-old problem

A 35-year-old female attended the practice, recommended all teeth to be taken out and to have a set of dentures instead. She indicated that she hadn’t seen a dentist for 20 years and she had not used a toothbrush for the same time interval. She said: ‘The last time I saw a dentist he was trying to squash that air mask on my face.’
She scored 25 (the highest score) on the Modified Dental Anxiety Scale (MDAS). An examination revealed very poor dental status with pocket depth of more than 5mm and teeth mobility ranging from grade 1 to grade 3, no dental fillings or missing teeth but four decayed teeth. A brief, relaxing discussion was undertaken and the patient agreed to have some treatment done. She had supra and sub gingival scaling under audio distraction and was given all control on when she would like treatment to start and stop (perceived control).
Treatment was very successful and the patient was very co-operative. Dental health education was given and the importance of oral hygiene was reinforced. On several appointments, her dental status has improved and would have partial dentures constructed once her periodontal status is stabilised. After three months of the first appointment her MDAS score dropped to 14.
Survey
According to a report from the Adult Dental Health Survey carried out in 2009 by the NHS Information Centre for health and social care  in England and published in 2011,   just over half of adults (51%) who had ever been to a dentist had an MDAS score of between 5 and 9, indicating low/no dental anxiety. Over a third of adults (36%) had an MDAS score of between 10 and 18 indicating moderate dental anxiety, and a further 12% had a score of 19 or more, which suggests extreme dental anxiety. The prevalence of dental anxiety was higher in women and lower socioeconomic groups. Twenty percent of the patients were not satisfied with their most recent dental visit and showed the longest gaps in dental appointments and hence had the highest scores on MDAS.
Discussion
Dental anxiety is very common but the degree of dental anxiety varies considerably between patients. Reasons include previous traumatic dental experience, fear of needles, fear of the drill, fear of the sounds, fear of the smells, fear of feeling helpless, etc. The key for successful management of these patients is good communication between the dentist and the patient – allowing plenty of time for the consultation and building rapport with the patient is essential. Regaining confidence in the dentist is the key. Showing empathy and respect is the only way to gain the patient’s confidence and cooperation during treatment.

Anxiety busters
•    Show positive images instead of neutral
•    Use images or videos to help explain the procedure
•    Seat patients upright so they feel less helpless
•    Relaxation techniques help reduce stress
•    Audio and visual distraction techniques can divert anxiety
•    If trained, hypnotic therapy is useful.

How to help your patients
There are many ways to help your patient relax in the dental surgery. These include changing the environment, such as positive images instead of neutral images as well as lavender scent. The benefit of the treatment should be explained to the patient and images or videos can be used to achieve that. Tell-show-do technique and modelling, which was initially used in paediatric patients, has demonstrated to be successful in anxious adults.
Seating the patient in a slightly upright position and allowing them to control the pace of the treatment (perceived control) helps to reduce the feeling of helplessness in the dental chair. Relaxation techniques such as deep breathing can be successful and gradual exposure to the stimulus that cause dental anxiety –such as the needle or the drill – has been very effective.
Audio and visual distraction techniques are simple and very helpful in mild to moderate cases. More recent and promising techniques such as the use of virtual reality are used to grab the patient’s attention, maximising the distraction away from the ‘real world’ allowing the patient to tolerate dental procedures.   
Hypnotic therapy is an also a useful tool in patient management provided that the dentist is adequately trained and the patient appropriately selected. Cognitive behavioural therapy is a brief and effective psychological therapy that could help the patient to realise that the feared stimulus is not harmful.
In extreme cases, referral to psychotherapists has been shown to increase some patients’ acceptance of dental treatment and decreases dental anxiety with successive visits.
Most of the patients suffering from dental anxiety would like to be ‘knocked out’ for their treatments. Dentists should always consider the above simple but effective techniques before resorting to pharmacological sedation.  
References
1.    N. Nuttall, R. Freeman, C. Beavan-Seymour, K. Hill.        Access and barriers to care - a report from the Adult         Dental Health Survey 2009 by The NHS Information         Centre is England’s central, authoritative source of health         and social care information.www.ic.nhs.uk/... Care/        Dentistry/dentalsurvey09/AdultDentalHealthSu...
2.    C L. Frere, R Crout, J Yorty, D W. McNeil. Effects of         Audiovisual Distraction During Dental Prophylaxis         The Journal of the American Dental Association 2001;         132: 1031-1038 L
3.    W. Jerez, C. Hopper, M. Kumar, T. Pile, G. Midland,         S. Newman & C. Feynman Psychological intervention         in acute dental pain: review British Dental Journal         2007; 202: 337 - 343
4.    Sullivan C. Schneider PE. Mussel man RJ. Dimmitt CO         Jr. Gardiner D. The effect of virtual reality during dental         treatment on child anxiety and behaviour. Journal of         Dentistry for Children. 2000; 67:193-6, 160-1   
5.    Hoffman HG. Garcia-Palacios A. Patterson DR. Jensen         M. Furness T 3rd. Ammos WF Jr. The effectiveness of         virtual reality for dental pain control: a case study.         Cyber psychology & Behaviour. 2001; 4:527-535.

Diana Woodward qualified as a dental hygienist in 1971 during a four-year engagement in the WRNS. She has worked mainly in the NHS, but also in private practices, hospital and community, dental health education and with special needs. She gained the Certificate in Health Education at Gloscat in 1986. Diana enjoys writing and has had several non-fiction articles published.