Chapter 5

Understanding and Finding Solutions: The Dentally Anxious Patient

Aim

To outline the development of dental anxiety, its assessment and management in adult dental services.

Outcome

The reader will be able to explain the major factors responsible for patients becoming dentally anxious. In addition the reader will be able to state various methods of assessing dental anxiety. Finally, the reader will be conversant with a number of behavioural management techniques for the dentally anxious patient.

Dental Anxiety: A Perpetual Problem?

It is not an exaggeration to argue that dental anxiety is the most important psychological factor dental staff will meet in practice. Dental anxiety is that feeling of apprehension experienced by an individual when confronted with matters that are dentally related. It is commonly described as having physiological, cognitive and behavioural aspects. Hence, patients who describe themselves as dentally anxious may complain of raised heart rate (physiological), imagining painful consequences of dental treatment (cognitive) and preferring to delay making a dental appointment (behavioural).

The prevalence of dental anxiety has been studied over the past 50 years. Levels of self-reported dental anxiety appear to be remarkably stable when comparing representative samples from a single culture (USA) over a time span of 34 years (1967–2001) and using identical measures (Corah’s Dental Anxiety Scale). This may appear to be disappointing, especially when attempts are being made to make dental treatment more comfortable. Repeated surveys in the UK, however, suggest that dental anxiety prevalence has fallen due to procedures that have assisted in reducing anxiety. These include use of preventive treatments, lasers, new dental materials for fixing restorations, and use of written and computer-assisted information systems. The falling levels of dental anxiety may be something of a success story for the dental profession, considering there has been a definite rise of general anxiety levels in the population over the past 50 years.

From this optimistic standpoint, it is still disappointing that approximately 30% of the adult population continue to feel nervous about visiting the dentist. In a large Dutch representative sample it was found that 36% of respondents ‘dreaded’ visiting the dentist. Hence nervousness may not seem too important until it is realised that about one in five respondents delay making a dental appointment because of their anxiety. Dental anxiety promotes avoidance. So ubiquitous is the ‘condition’ of dental anxiety that the experienced practitioner with large numbers of patients, many of whom will be dentally anxious, is able to manage the vast majority of patients with quick and simple procedures that are learnt from observing or copying other colleagues, training courses and general clinical experience. Some patients present, however, with either unusual features that may not respond quickly to the dental practitioner’s standard procedure or with such intensity that at first sight the anxiety cannot be challenged in order to diminish it. This group are sometimes classified, rather punitively, as ‘difficult’ patients. The term indicates that their treatment cannot be delivered in the normal way but special procedures are indicated. However, ‘difficult’ could be interpreted to mean that the patient has a choice over whether to volunteer his/her feelings. S/he might have made a hedonistic decision to receive special attention and extra time from the dental team. Evidence would appear to indicate the reverse. Most dentally anxious patients are acutely embarrassed to admit to their difficulty and would gladly prefer, if at all possible, to hide their feelings and attempt to cope without any special arrangements and procedures. The more intense the quality and quantity of anxiety felt by the patient, the greater the sense of shame and need to avoid any exposure to the dentist or dentally related stimuli. Therefore a distinction needs to be made between those patients who attend despite of their intense fear (dentally anxious) and those who avoid dental treatment (dentally phobic).

Individuals who avoid dental care at all costs are best described as dentally phobic, which is distinct and separate from dental anxiety. While dentally anxious patients can link their fear to specific frightening dental experiences, the same is not the case for those who are dentally phobic. Dentally phobic patients tend to displace or foist frightening experiences from outside the dental surgery onto dental treatment. The resulting anxiety is unbearable, and they avoid the situation that evokes such a magnitude of fear – that is dental treatment. Therefore dental phobia is a condition with discrete features, which can be a symptom of a psychological disorder and as such may require referral for secondary-level care.

Dental anxiety develops in a variety of ways as follows:

• a direct traumatic dental experience, such as a painful injection or exposure to insensitive dental staff

• an indirect traumatic dental experience, such as hearing negative stories about dental procedures in the family, school playground or articles in magazines, books and the media

• a direct traumatic medical experience, such as lumbar puncture or tonsillectomy conducted at an early age.

These various traumatic experiences are interpreted by the individual under a number of conditions that have a bearing on the strength and stability of dental anxiety, including:

• the vulnerability of the individual concerned. Patients with multiple mental health problems or a generally anxious disposition may be more prone to developing dental anxiety

• the timing of the experience. Patients who encounter a dental (or perhaps medically-related) traumatic experience at an early age (under five years of age) are more likely to exhibit dental anxiety

• the frequency and intensity of the dental traumatic experience. Repeated unpleasant experiences or a single very intense experience (dental or medical) may be foisted or displaced upon the dental situation and generate profound dental anxiety

• the sequence of events. If the first visit to the dentist by a child patient is frightening and traumatic then the chances of dental anxiety developing is significantly greater compared to a child who has had a number of pleasant experiences prior to an unpleasant, say painful, experience. The coping abilities of the patient to help the child and for the experience to be labelled as non-threatening is partially dependent on reviewing the wider motives for visiting the dentist (maintaining dental health) and the attitudes of the dental team (sensitive and caring staff).

Dental anxiety is reported more strongly in women than men, in younger rather than older people and in those with greater untreated dental disease. People who are dentally anxious tend not to have an extensive past dental treatment history, as shown by a limited number of filled tooth surfaces but more teeth missing for non-orthodontic reasons. Surprisingly, dental anxiety does not necessarily decrease when all teeth are lost. There is some evidence that amongst the edentulous there is a greater proportion of very anxious people compared with the dentate. This may be due to patients who have been very dentally anxious at a younger age, opting to have a clearance to reduce the need to visit the dentist. Their dental anxiety remains high. The expected relief from dental anxiety for this anxious group does not occur, as they do not need to challenge their anxiety any longer and cannot find reassurance that might have been possible from successful treatment visits. Dentally anxious patients are more likely to state they are experiencing dental symptoms such as sore gums, toothache and bad breath. The explanation of this effect is probably not straightforward. A dentally anxious person may avoid the dentist and delay attention, thereby allowing disease levels to increase. Alternatively, these patients may be generally more concerned about their well-being and volunteer their problems more readily. Another clear feat/>

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