How, when, or why it happened is a mystery to me, but somehow I’ve developed a dental phobia so extreme as to keep me away from a dental office most of my adult life. Just mentioning the word “dentist” made me cringe. Hearing an orthodontic or toothpaste commercial on radio or TV made me run from the room.

[Adult female]

I don’t know, just the word “dentist” does something to me. So after I got in the chair, I asked the dentist if I could go to the bathroom. He said “yes,” so I went to the waiting room, grabbed my hat and coat, and ran out.

[Adult male]

Communication

First (and foremost) on the list of intervention techniques is that of communication (van der Molen, Klaver, & Duyx, 2004). Two studies of fearful dental patients reported that dentist’s attitudes or comments regarding the patient’s oral state were one of the situations they feared the most (Gale, 1972; Stouthard & Hoogstraten, 1987). When an anxious patient who has avoided dental treatment does present to a dental provider, it is imperative that rather than condemn their poor oral health, the dentist should commend the patient on taking the first step toward dental health by actually arriving at the dental office to seek help. This initial encounter can provide cues to the patient’s avoidance and potential dental fears. The dentist who takes the time and listens to the patient will learn the most about their concerns.

Listening skills are the basis for effective communication and are actually a foundation skill for all of the other techniques. In interpersonal communication, it is not only critical that the listener does indeed listen, but that the speaker also feels heard. One common cue that the patient is not feeling heard or understood is that their statements continue to be repeated. Techniques such as paraphrasing and reflective listening, which are discussed later, are useful tools for helping the patient to feel understood.

Before discussing some specific communication skills, the question of whether or not to even communicate needs to be addressed. Some practitioners hold the belief that discussing fear with the patient “will make it worse,” including concern over employing questionnaires such as Corah’s Dental Anxiety Scale (Corah, 1969). Humphris, Clarke, and Freeman (2006) have examined this issue and found that completing a variation of Corah’s Dental Anxiety Scale (Modified Dental Anxiety Scale) before dental treatment did not have a negative impact on patients’ anxiety levels. Furthermore, Dailey, Humphris, and Lennon (2002) assessed the impact of patients completing the Modified Dental Anxiety Scale and then sharing the results with the dentist. The results clearly showed that patients preferred to have their dentist aware of their fear. Thus, the problem is generally not with patients expressing their fears, but what the practitioner does with that information.

The practitioner or staff will commonly attempt to “reassure” the patient by stating something along the lines of, “Don’t worry; everything will be fine,” or “There’s nothing to be afraid of.” Although well-intentioned, reassurance is ineffective, causing the patient to feel that their concerns are being dismissed or diminished (Chambers & Abrams, 1992). A “quick affirmation” of this concept can be experienced by the reader by simply taking a couple of minutes to reflect on something they consider very threatening and then imagining someone saying, “Don’t worry; everything will be alright,” and seeing how much it diminishes the perceived threat. Instead of attempting to directly reassure the patient, it is more effective to listen empathetically and teach interventions that resolve the patient’s apprehension. In other words, reassurance is the outcome, not the intervention.

The first step in communicating with patients about their fears is to determine whether or not the patient is fearful. As mentioned earlier, patients who are fearful want the dentist to know how they feel. While many different assessment tools exist for this task, formal quantification is more critical for research purposes than for clinical treatment. The practitioner will usually find it sufficient to simply ask each patient, “How apprehensive or fearful are you about having dental work done?” If the patient answers, “Not at all,” nothing else needs to be discussed on this topic, and the patient will appreciate the practitioner being sensitive and caring enough to ask. If the patient answers anything greater than that, even “A little,” then the practitioner needs to gather additional information regarding what types of things bother the patient, how anxious each activity makes them, share with the patient what the practitioner has heard the patient say, and then let the patient know that there are a number of things that the practitioner can do to help the patient feel more comfortable. This discussion should normally be part of the initial diagnostic interview with each patient.

It is important in the preceding discussion that the practitioner state clearly to the patient that he/she understands the patient’s fears rather than evaluate their “validity.” This is simply accomplished by stating “I understand,” and then stating back to the patient what they understand the patient to be saying. This reflection can include both the content and feelings that the practitioner understands the patient to be expressing.

There may not always be concordance among the various ways that fear can be expressed (verbal, behavioral, physiological), called “response desynchrony.” A patient may say that they are relaxed, yet be gripping the chair, tense, sweating profusely, and/or breathing shallowly. The opposite could also occur, in that the patient may say that they are anxious, but show no other signs of fear. A simple rule of thumb is to address any messages that might be associated with apprehension, whether they are verbal, behavioral, or physiological. A simple method to remember the above-mentioned communication points is to think about them as the “Four A’s of Anxiety”: (1) Ask how anxious they are, (2) Assess the causes, (3) Acknowledge what you have heard, and (4) Address their fears by offering solutions.

Other communication guidelines include the careful choice of terms used. Anxiety-producing terms or phrases such as “give a shot,” “cut down a tooth,” “pull your tooth,” “have a root canal,” or “This may hurt a bit,” should be avoided. Instead, terms such as “get the area numb,” “shape the tooth,” “remove the tooth,” “endodontic treatment,” or “pinch or sting a little,” are preferable. In addition, avoid describing the instruments used. Telling a patient about using needles, syringes, files, scalpels, or forceps is not going to comfort them. Finally, only make promises that can be backed. While this may seem obvious, it is not uncommon to hear the following statement, “Before we start, we will numb you up so you won’t feel anything.” Local anesthesia rarely renders the patient devoid of sensation. As a result, the sensations that are perceived (e.g., movement, pressure) are often interpreted by the patient as indicating insufficient anesthesia, and therefore often perceived as painful. Instead, let the patient know what sensations will be perceived following anesthesia (e.g., “You will feel pressure and vibration”). In addition, it has been shown that providing highly anxious patients with information regarding the dental procedure and recovery reduces their anxiety levels (Ng, Chau, & Leung, 2004).

A final communication “rule” to be mentioned is to ensure that the patient has a means of communicating while the practitioner is working and the patient’s mouth is open. In spite of the recurring comic parodies of a dentist conversing with a patient whose mouth is open and full of instruments, patients at times feel reduced to this form of “communication.” A more effective way for the patient to “communicate” when verbal methods are limited is to tell the patient to signal the practitioner when the discomfort gets too great, or if he/she wishes the practitioner to stop. This approach has the added benefit of giving the patient the perception o/>