Chairside Techniques for Reducing Dental Fear
- Dental fear contributes greatly to avoidance of dental care.
- Discussing a patient’s fear actually helps reduce their anxiety.
- Four A’s of interacting with an anxious patient: Ask, Assess, Acknowledge, Address.
- Chairside behavioral techniques have been shown to be effective in reducing dental fear and anxiety for many apprehensive patients.
- A brief progressive relaxation procedure which combines progressive relaxation with guided imagery and suggestion is described and the actual procedure is included.
- Extremely anxious dental patients may require referral to a mental healthcare provider for more complex behavioral interventions.
- Ethical issues associated with addressing dental fear are examined.
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.
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.
These quotes from two different dental patients, while perhaps somewhat extreme, are not uncommon. As authors of other chapters in this book have shown, dental fear is probably one of the most prevalent problems that dentists face in treating patients. Dental fear contributes greatly to avoidance of dental care (Morse, 2002), and if sought, makes the experience trying for the patient, staff, and dentist alike (Moore & Brodsgaard, 2001), and can impact the patient’s life negatively (Cohen, Fiske, & Newton, 2000; Locker, 2003). While practitioners and their staff may feel that avoiding the issue and just working fast to get the patient out of the chair is the best approach, not resolving a patient’s anxiety can lengthen appointments, exacerbate pain perception, and reinforce negative attitudes, making subsequent appointments even worse.
The purpose of this chapter is to serve as a “reader’s guide” to performing a few of the many different behavioral techniques that can help reduce patient fear. One approach to categorizing the various behavioral interventions is according to the role that relaxation plays in each. Thus, one can identify (a) non-relaxation-based techniques, (b) “quasi-relaxation”-based techniques, and (c) relaxation-based techniques.
Non-relaxation-based techniques are those that employ intervention strategies that do not utilize relaxation types of procedures (directly or indirectly) in their implementation. Examples of procedures of this type would include communication skills (including the redefining of sensations), distraction, behavior modification, modeling, cognitive restructuring or cognitive behavior modification, stress inoculation, iatrosedation, and acupressure. Quasi-relaxation-based techniques are those that achieve relaxation indirectly, without employing a formal progressive muscle relaxation procedure. Examples are guided imagery, paced breathing, biofeedback, graduated exposure, and meditation. Relaxation-based techniques incorporate progressive relaxation-type procedures directly as part of the intervention. Included in this category would be progressive relaxation, systematic desensitization, and hypnosis.
These techniques vary in terms of both expediency and the level of training needed to use them effectively, with hypnosis requiring the most formal training to be both safe and effective. It should be noted that the techniques described can be effective when performed by dental practitioners in their offices. However, despite a dentist’s best behavioral management efforts, there are some apprehensive patients that would benefit from referral to a mental health practitioner. These referrals need to be made in a sensitive, empathetic, and supportive fashion to encourage the patient to obtain the help needed. Many dentists are uncomfortable making mental health referrals, but dental anxiety problems can be successfully managed (Kvale, Berggren, & Milgrom, 2004), and requests for consultation are appropriate and welcomed by mental health professionals. Similar to a general dentist referring a patient to a dental specialist, collaboration with a mental health practitioner allows the opportunity for dentists to provide patient-centered care for their most anxious patients in a team approach. Good partnerships between dentists and mental health specialists can help patients develop long-lasting solutions to problems caused by dental anxiety (Donate-Bartfield, Spellecy, & Shane, 2010).
Because the degree of complexity varies for the aforementioned approaches that the dental practitioner can utilize, the techniques chosen to be used should reflect the degree of fear the patient is experiencing. For mild anxiety, simple non-relaxation procedures such as distraction may be adequate (Corah, Gale, & Illig, 1979). In general, complexity increases from non-relaxation-based techniques to relaxation-based techniques. In addition, relaxation-based techniques, while effective for all levels of patient anxiety, would usually be more appropriate for moderate to high levels of fear than mild levels of fear. For example, using a relaxation procedure on a patient who feels mildly apprehensive would be effective, but would not be an efficient use of either the patient’s or practitioner’s time. Because of space limitations, only a few representative and relatively easily implemented interventions will be discussed here.
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/>