15
Psychiatric Disorders
15.1 Anxiety and Phobia
Section I: Clinical Scenario and Dental Considerations
Clinical Scenario
A 31‐year‐old female presents to the dental clinic with acute pain from her lower left third molar of 2 months’ duration. The pain is triggered by cold and hot stimuli, lasts hours and is now extremely painful with associated sleep disturbance.
Medical History
- Recently diagnosed mixed anxiety‐depressive disorder presented with panic attacks
- History of Bell palsy (left side) 1 year ago; linked to episode of extreme stress; 6‐month recovery period
- Fatty liver (non‐alcoholic fatty liver disease)
- Overweight (BMI = 26 kg/m2)
Medications
- Sertraline
- Clonazepam (taken intermittently)
Dental History
- Dental phobia
- Mother has dental phobia too which the patient believes is the cause of her own phobia
- Irregular dental attender (only attends when in extreme pain); last visit 5 years ago
- Previous dental treatment provided under general anaesthesia (multiple fillings, extractions); sedation has also been used for emergency dental treatment
- Anxiety starts from the day before and increases with prolonged waiting time
- History of leaving the dental practice before entering the dental surgery because of the unbearable anxiety
- Fear of both high‐ and low‐speed dental handpieces (sound and vibration)
- High levels of anxiety assessed on different scales
- Modified Dental Anxiety Scale (MDAS): 20 points
- Revised Dental Belief Survey (R‐DBS): 53 points
- Brushes twice a day but has struggled when the Bell palsy was present
- Highly cariogenic diet
Social History
- Lives with partner who often works away from home
- Two daughters (7 and 10 years old)
- Occupation: secretary, but at the moment is on medical leave (due to the mixed anxiety‐depressive disorder)
- Less than 2 units of alcohol a week but when very anxious can binge drink and consume 10–12 units the day before a dental appointment to help her to sleep
- Habits: nail biting (onychophagia) and nocturnal bruxism
Oral Examination
- Hypertrophic bilateral masseters
- Scalloping/traumatic bite marks on the tongue (Figure 15.1.1)
Figure 15.1.1 Scalloped tongue due to bruxism/tongue biting.
Figure 15.1.2 Poor oral health with associated gingivitis.
Figure 15.1.3 Lower incisors: calculus and lingual recession.
Figure 15.1.4 Multiple restorations; #25 caries; #24 disto‐occlusal defective restoration.
- Presence of soft and hard deposits (Figure 15.1.2)
- Calculus and recession lingual to lower incisors (Figure 15.1.3)
- Heavily restored dentition (Figure 15.1.4)
- Caries in #17, #24 (root filled), #25 and #38
- #38 with tenderness to percussion
- Probing depth 3.5–5.5 mm in relation to the upper posterior teeth and all the lower teeth
Radiological Examination
- Long cone periapical radiographs undertaken
- #38 caries extending into dentine, no apical lesion, mesiobuccal root close to inferior dental nerve canal
- #17 cusp fracture, temporary restoration in situ
- #24 endodontic treatment, no apical lesion, occlusodistal cavity
- #25 mesial caries extending into dentine
Structured Learning
- What aspect of this patient’s behaviour is a feature of dental phobia rather than dental anxiety?
- This patient exhibits classic avoidance behaviour
- She only goes to the dentist when she is experiencing extreme dental pain
- What are anxiety scales?
- Anxiety scales are questionnaires that have been developed to assess whether a patient has a higher level of dental anxiety than an average patient (see Section II)
- They can be helpful to identify specific triggers or just as a conversation starter
- What do this patient’s anxiety scores tell you about her degree of dental anxiety?
- This is a highly anxious patient, with signs of dental phobia
- The patient also reports that her mouth can feel very dry – what factors could be contributing to this?
- Anxiety, particularly when acute, can cause sympathetic stimulation which results in a dry mouth
- Sertraline is a selective serotonin reuptake inhibitor associated with a common side‐effect of a dry mouth
- Clonazepam is a benzodiazepine and can also cause a dry mouth
- What factors do you need to consider in your risk assessment for the management of this patient?
- Social
- Availability/suitability of escort as partner works away from home and mother also has dental anxiety
- Impact of binge drinking prior to dental visits on attendance and ability to proceed with dental treatment, especially sedation, and ability to provide informed consent
- Panic attacks (unbearable anxiety)
- Currently unemployed – cost of dental treatment may have an impact
- Medical
- Consider impact of fatty liver/liver cirrhosis (see Chapter 6.1) and raised BMI on the delivery of care (see Chapter 16.4)
- Bell palsy (rarely may recur during stressful periods)
- Dental
- Dental phobia – only seeks dental input when she is in pain; in view of this she may not return once she is pain free
- Presenting with acute infection in relation to apical periodontitis of #38; need to provide urgent intervention (e.g. antibiotics and/or dental extraction with sedation)
- High caries risk: highly cariogenic diet, xerostomia, negative impact of Bell palsy on access for toothbrushing, irregular dental attender
- Periodontal disease at an early age with spacing and recession in relation to the lower incisors; ideally needs more regular dental visits to stabilise this
- Patient has allowed an oral examination, radiographs and photographs; hence acclimatisation for dental visits may be possible
- Social
- The patient requests that all dental treatment, including extraction of #38, fillings and scaling, is undertaken under a general anaesthetic procedure. What are the benefits and drawbacks of this approach for this patient?
- Benefits
- May be an advantage if #38 requires surgical extraction
- Multiple dental treatments required and can be completed in a single session
- Allows to ‘buy time’ to do adaptation at a later stage
- Disadvantages
- No learning from the experience
- Incorrectly reinforces to the patient that general anaesthesia is the normal setting for dental treatment; this may then be also assumed by daughters if they need dental treatment in the furture
- Risks of complications higher than with local anaesthesia, especially as there are additional comorbidities to consider such as raised BMI and fatty liver disease
- Dental treatment options may be limited due to limits of operating time (e.g. may not be possible to undertake root canal treatment on posterior teeth)
- Increases cost (patient may need to pay for this in some countries)
- Benefits
General Dental Considerations
Oral Findings
- Neglect – dental fear impacts on dental health. This commonly manifests as extensive oral needs that tend to require invasive dental treatment, which further reinforces the dental fear
- Dry mouth – secondary to sympathetic stimulation or some medications prescribed for anxiety management
- Bruxism
- Lip chewing/tongue biting
- Increased gag reflex
- Atypical facial and oral pain
- Burning mouth syndrome
- Cancer phobia
Dental Management
- According to the General Dental Council (United Kingdom) all dentists have a duty to provide adequate pain and anxiety control
- Each patient will require careful assessment to ensure that the most appropriate supportive approach is implemented (Table 15.1.1)
Section II: Background Information and Guidelines
Definition
Dental anxiety or ‘odontophobia’ is the fifth most common cause for anxiety. It is an emotional state marked by fear of the dental environment or treatment, which is perceived as a threat. Dental phobia corresponds to an irrational and overwhelming fear of dental treatment, where the patient understands that their response is not proportional to the situation. It is characterised by avoidance behaviour. In the United Kingdom, it has been reported that 36% of patients have moderate dental anxiety, while 12% reported extreme dental fear. Both entities can be associated with stigma, which impacts on deterioration in the oral health of these individuals.
It is also important to consider if there are any additional anxieties/phobias which may impact on the provision of care, such as:
- Claustrophobia – fear of closed spaces, probably the most common phobic disorder
- Agoraphobia – fear of being in public places from which escape might be difficult or help unavailable
- Social phobia – overwhelming anxiety and excessive self‐consciousness in normal social situations
Table 15.1.1 Considerations for dental management.
Risk assessment - History of failed appointments
- Patient may either appear withdrawn or talk incessantly
- Unexpected movements
- More likely to have associated comorbidities such as alcohol or drug dependence
- Risk of vasovagal syncope
Criteria for referral - Patients with mild anxiety can be seen by general dentists
- Referral will depend on the dentist’s level of competence and resource availability within the health service
- The Indicator of Sedation Need (IOSN) may be used to categorise patient complexity and determine suitability for referral (Table 15.1.3)
- Patients who are not able to accept dental treatment with behavioural management techniques alone may need referral for more specialised management, sedation or general anaesthesia (Table 15.1.4)
Access/position
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