The Combined Treatment
During my first 10 years as a dentist in the public dental service and my next 10 years in private practice, I spent a lot of time working with fearful dental patients in all age groups. I enjoyed this work, as dentists do if they manage to help these patients to gradually cope with ordinary dental treatment. However, since I had no specific qualifications in behavioural science, I did not know which of the factors in my fear treatment contributed most to my successes and failures. The treatment approach in the beginning was based on my own intuition and then on what the patients gradually taught me. I think this is a typical story for dentists who are interested in this area.
My interest and clinical experience finally brought me into the academic field. During the years at the Center for Odontophobia, University of Bergen, Norway and in the Dental Fears Research Clinic, University of Washington, Seattle, USA, I had the privilege to work with competent colleagues and psychologists in this field and gradually learned the empirically based treatment approaches for dental phobia. I was thereby also able to evaluate and understand why I as a general dentist had some success, but also why other cases failed. The important factor contributing to my success, at least in my mind, was first of all my genuine interest in factors related to patients’ lack of coping with dental treatment. This made me an empathic listener who showed respect for the patient’s problem with the ability to establish a trusting alliance. I gradually learned that the patient’s problem had something to do with individual differences in perception of pain and lack of control, factors that today have comprehensive empirical support (Bergius et al. 1997; Law, Logan and Baron 1994; Litt 1996; Logan et al. 1991; Milgrom, Vignehsa and Weinstein 1992; Skaret et al. 1998; Vassend 1993). As a clinician I am still convinced that these factors are among the ‘key’ factors for successful prevention and treatment of anxiety. However, because of the complexity of anxiety and phobia the knowledge about purely these factors is not sufficient for a successful treatment outcome in phobia treatment.
A third step in my career as a dental phobia therapist started when I gained the opportunity to work with Lars-Göran Öst. He taught me how to practise cognitive behavioural therapy (CBT) in both multiple and one-session formats. I realized and learned how my treatment could be more effective. The main change in my treatment approach was that I learned to do effective exposure therapy. Three important factors in my approach were changed.
First of all I was no longer ‘afraid’ of the patient’s high anxiety and, except for children, I stopped telling the patient to pause to avoid the increase in anxiety. When I did that earlier I confirmed the patient’s dysfunctional thoughts about a possible catastrophe if the anxiety was too high. The gradual repetitive exposure under control teaches the patient that high anxiety is unpleasant but not dangerous.
The second important change was that I did not accept behaviour like closing the eyes, looking away and thinking about other things during the exposure. These safety behaviours represent escape from the situation and this is not effective exposure. Either the patient has learned by experience that it is helpful to try to ‘escape’, or the behaviour is introduced by the dentist. The patient can manage to do it under specific conditions and will establish well-anchored beliefs that this will not work if the safety behaviour is removed. This patient is not effectively treated for the phobia and will have coping problems when referred to another dentist. Other examples are further explained later in this chapter.
The third change in my approach was that I tried to talk less during exposure. When the rationale for CBT is explained to the patient the importance of the establishment of teamwork is emphasized. The therapist knows how to do the treatment, but the patient is the expert on his/her cognitions and emotions. The therapist should not tell the patient his opinion about the level of anxiety. The patient is concentrating on what happens in the body and needs time to do the ‘work’ himself, without being interrupted. Then the therapist should ask the patient about the thoughts and feelings during the gradual hierarchical exposure (see Chapter 9).
The description of the combined dental and anxiety treatment in this chapter is based on our CBT studies in patients fulfilling the criteria for specific phobia (dental phobia and intra-oral injection phobia, DSM-IV 300.29) (APA 1994) in one and five sessions, as delineated by Öst (see Chapter 9). The effects of CBT have been tested in many randomized controlled trials (RCT) and CBT is shown to be very effective for treatment of specific phobias (Öst 2008) (see Chapter 9), including dental phobia (Haukebo et al. 2008) and intra-oral injection phobia (Vika et al. 2009). However, the principles described for treatment of patients fulfilling the criteria for specific phobia will apply for any level of dental anxiety. The expression dental phobia (DP) will in this chapter therefore include the different levels of anxiety, independent of whether or not the DSM-IV criteria for specific phobia are fulfilled.
Characteristics of the Dental Treatment Situation
Compared to other specific phobias DP has specific characteristics that makes this phobia challenging. The dental patient has well-anchored beliefs about dental treatment as a situation for potential experiences of pain. The patient is lying down partially covered by the bodies of a dentist and the dental assistant. The mouth is filled with different instruments and the patient often has insufficient knowledge about why they are used and for how long they need to be there. These factors represent a risk of claustrophobic feelings. Patients try to behave in a polite way and want to contribute to avoid a delay in the dentist’s busy schedule. The dentist’s non-verbal signals about the busy schedule make it difficult to express a possible feeling of being trapped. These different characteristics are all possible risk factors for feelings of lack of control and helplessness: potential risk factors for dental anxiety (Logan et al. 1991; Oosterink, De Jongh and Aartman 2009).
In contrast to patients with other phobias, dental phobics report painful dental experiences as a main aetiological factor (Lundgren, Berggren and Carlsson 2004; Milgrom et al. 1992; Skaret et al. 1998). The experience of pain is individual and subjective and influenced by the level of dental anxiety. The unpleasant bodily feelings experienced by a fearful patient may be reported as pain and the level of dental anxiety will influence both the anticipatory pain before treatment and the self-report of pain during treatment (Litt 1996). A typical potential risk situation is when the patient reports pain and the dentist concludes that the effect of the local anaesthesia (LA) should be reasonably good (‘Your lip is numb, isn’t it?’). Who knows the truth? Only the patient knows the truth. How can this situation be solved? The most important way to react is to show respect for the patient’s pain report. Then the therapist should offer more LA (same injection or supplemental injections in the local area).
For the anxious patient who is saying:
P: I always feel pain even if I have an injection.
D: So you have experienced pain even if you had LA. I suggest that you come back another day. Then we will give you a strong ‘pain killer’ that you take one hour before your next appointment. Then we will give you LA again and test if the effect is better. Does that make sense to you?
P: Yes, I am glad you take my problem seriously.
The clinical experience is that this treatment is good. Why is the effect of the LA often very good at the next appointment? Because of the additional effect of the medication or because of the respect we showed the patient? Since the individual experience of pain is produced from the output of the brain, not from the sensory signal (Eli 2010), it could be one or the other or both.
Often the busy dentist is unaware of the patients’ different non-verbal signals of anxiety and discomfort. This is often a question about insufficient knowledge of the normal and functional fear response. Of the three fear response components – the physiological (sympathetic activation), the cognitive evaluation (negative thoughts) and the behavioural response (escape or avoidance) – the first one starts even before the patient is aware of the fear-provoking stimuli (LeDoux 1998). This immediate response is functional and helps the patient to be aware of potential harmful situations that should be avoided. When the dentist is saying: ‘Just relax, I’ll be careful. This will go well’ it will have a limited effect on the automatic physiological activation.
The Dentist as Therapist
The treatment approach presented here is based on our research model with cooperation between a clinical psychologist and a dentist. Psychologists have the competence for being phobia therapists, whereas dentists are licensed to perform dental treatment. To achieve cooperation, both participants need to acquire a new competence. The psychologist needs to have specific and rather detailed knowledge about the dental treatment situation, whereas the dentist needs to be specially trained in CBT for DP, in addition to be generally experienced in clinical dentistry. In the model presented the psychologist performs the diagnostic interview and develops a plan for the in vivo treatment in cooperation with the dentist. The in vivo exposure to test catastrophic beliefs is carried out by the dentist. The general principle behind exposure in vivo is the hierarchical structure of tasks in the real situation. For the dental phobic the psychologist can only do part of the in vivo exposure and there is therefore a major advantage of using the dentist as the anxiety therapist for DP. Since the CBT is characterized by being relatively brief and time-limited, with a structured, directive and problem-oriented procedure, it is possible for a dentist to learn and follow the basic principles of CBT. The disadvantage with the dentist as therapist is the need for a resource-demanding course to obtain sufficient knowledge and training in CBT.
Changing the focus of the treatment
The general dentist has his/her main focus on the patient’s dental treatment needs. To be a DP therapist implies an important change in focus from the dental treatment needs to the fear treatment, e.g. how and when to introduce dental procedures as part of the anxiety treatment. When a dentist without sufficient knowledge about anxiety treatment has a fearful patient in the dental chair, the focus on the dental work will soon bring the two of them into a situation where they are trying to do the dental work, even if the patient’s behaviour and signals about lack of coping indicate that this will not be successful. The dentist is too soon trying to carry out the dental treatment, because that is the main focus, but also because he/she does not know how to handle the fear. The patient feels the pressure, is ashamed of being so ‘stupid’ and is struggling to cope with the situation. The result will often be a sort of adapted treatment ending up with temporary and low quality solutions. The criterion for success here is that the patient is able to cope with the temporary or adjusted dental treatment. The dentist needs more competence and training to be able to carry out a combined psychological and dental treatment where the criterion for success is a patient who is able to cope with ordinary dental treatment procedures, also in the future.
The fearful patient often carries out many different kinds of safety behaviours, like keeping the eyes closed, listening to music, having things done as quickly as possible (hoping to ‘survive’) and trying to ‘hide’ the negative automatic thoughts that pop up.
Sometimes the safety behaviour is introduced by the dentist. Let’s take as an example a phobic patient whose catastrophic belief was being choked by the rubber dam clamp. The problem was ‘solved’ by having dental floss tied from the rubber dam clamp to his/her finger, in case the clamp should jump off the tooth and be stuck in the throat. This method will reinforce the patient’s belief about the high risk that this may happen (‘Since the dentist taught me to do this, the likelihood that the catastrophe will happen must be high’).
Another well-known example is the patient who has experienced rapid increase in blood pressure (BP) and pulse rate caused by the adrenaline in the local anaesthesia (LA) solution when the injection accidentally ends up intravasally. This normal physiological response caused by the adrenaline may be misinterpreted as a sort of allergic reaction. When the patient tells a new dentist that ‘I think I am allergic to LA’, the response from the dentist, who is unsure about how to respond and is focusing on the dental treatment needs, may be like this: ‘Ok, but then we can give you another type of LA that your body will accept much easier’ (not including adrenaline). The dentist has now reinforced the patient’s belief about the allergy.
When the catastrophic beliefs are confirmed and never tested whether they are true or false, the patient believes that the treatment should only be carried out as long as the safety behaviour is maintained. He/she is still struggling with the anxiety, with a risk of future avoidance of care. Safety behaviour is functional as long as the patient is feeling the normal unpleasantness of the fear response and has experienced that e.g. listening to music reduces the unpleasant bodily feelings and increases the feeling of coping. This way of using distraction – altering the patient’s attention from the negative thoughts to the music – is okay as long as the dental anxiety is not too high and the patient has no tendency of avoidance of dental care. For a patient with high dental anxiety, it is important that the dental treatment is put out of focus while sufficient time is spent on the exploration of the patient’s level of anxiety and why it is difficult to cope with the treatment.
CBT in the Dental Chair
As for the CBT treatment of other phobias, the catastrophic belief that maintains the avoidance of treatment is an important focus for the gradual exposure. Gradual and repeated exposure for the most fear-provoking procedures is effective in the way that the beliefs about the catastrophe are tested in the real situation. The dentist’s reassurance is not effective. For dental phobia, as for other phobias, the most effective way to get rid of the negative beliefs is by testing it repeatedly in the real situation. If the patient’s catastrophic beliefs are completely removed, then the patient no longer has a phobia.
Establish mutual trust
The exposure is founded on teamwork between the patient and the therapist. In the model presented here the psychologist carries out the interview and has time to communicate and to establish rapport. Then the dentist is introduced to start the CBT. No person wants to try out procedures that are both anxiety provoking and potentially painful, without knowing that the therapist is trustworthy and will never do anything that the patient has not approved of. The establishment of a trusting relationship is fundamental to the exposure therapy and when the dentist starts the first session he/she also needs some time to establish a mutual trust in the team.
The establishment of the relationship between the patient and the therapist starts during the first few seconds when the dentist meets the patient in the waiting room. The basic principles in clinical communication, respect, emphatic response and active listening are key factors in the establishment of a trusting relationship (see Chapter 14). The establishment of trust during the start of the first part of the session does not necessarily need to be time consuming, since the establishment of trusting teamwork permeates the whole CBT session(s).
Patients with many years of avoidance of care feel shame, believe their oral health is a disaster and are afraid of judgement from the dentist (Berggren 1984). When the session starts this will be the focus of the patient: ‘The dentist will be shocked when he/she looks in my mouth’. It is therefore important to start with having a look at the radiographs together. Taking an orthopantomogram (OPG) before the session is most often acceptable to the phobic patient. The OPG gives an overview of the jaws, teeth and other anatomical structures intra and extra orally. The information based on the radiographs should be short and not detailed and the dentist should emphasize the positive aspects and conclude that the oral health status can be completely restored after the anxiety treatment is finished.
Then the team will go through the summary from the psychologist’s interview. This gives the dentist the opportunity to confirm that he/she knows what the patient and the psychologist have emphasized as important regarding the anxiety treatment, and to show respect for the patient’s previous experiences and that the avoidance of care makes sense based on the strong conviction of the catastrophe. Sometimes the catastrophic beliefs are not completely explored in the psychologist’s interview, but will become clearer during the gradual exposure in the dental surgery.
The functional fear response
The therapist then starts to explain the nature of the fear response, the maintenance factors and the rationale for the treatment (see Chapter 9). The patient needs to understand that the unpleasant fear response is normal, functional and not harmful, and that the patient in that perspective is completely normal. Drawing the anxiety curve (see Chapter 9) and then using this as a reference during the exposure will help the patient to see how the anxiety is increasing each time a new step is introduced and to confirm how the fear will decrease during the repetitions.
Gradual exposure to the fear-provoking dental treatment procedures
When the treatment principles and the anxiety curve have been explained (see Chapter 9), then the exposure should start. Before the exposure the patient knows only one way to get rid of the unpleasant anxiety, namely avoidance or escape from the fear-provoking situation. Now the patient will experience that gradual exposure in a controlled way will decrease the anxiety across repetitions. The patient learns a new way of getting the anxiety under control. If the patient is saying ‘no’ to the next step the therapist will suggest a new one in between the one he/she has just suggested and the already completed step. The patient is asked to rate the level of anxiety at different steps of the procedure. This will confirm that the anxiety really is decreasing by doing the repetitions. The therapist should remind the patient about the important principle that nothing will be done without having verbal or non-verbal acceptance from the patient, but also that the more the patient is ‘saying’ yes, the more effective the anxiety treatment will be.
Catastrophic beliefs in the dental situation
Some examples of catastrophic beliefs reported by patients with DP are:
- After the LA injection my tongue swells and fills my throat completely (I will be choked)
- My jaw will fracture during a tooth extraction and I will have permanent injury
- Injection in my mouth makes my head anaesthetized
- The pain will be so strong that I will panic and force my way out of the dentist’s office
- The needle fractures and the end of it will move inside my body and end up in my heart or lungs
- The needle will get stuck in the jawbone
- I will faint and never wake up again
- I will faint and lose some of my memory
- The dentist will turn crazy
There will often be several procedures that make the patient fearful. Focusing on the catastrophic beliefs makes the treatment more effective. Exposure to things that the patient is not so afraid of is a waste of time. You can do some exposure to minor fear-provoking procedures later, if necessary. When the patient is able to cope with the most anxiety-provoking procedure, then the rest will often be easy. Flexibili/>