This scenario is familiar to many people. The mere act of making a dental appointment requires greater courage than they can summon up, and except when oral pain becomes unbearable, pursuing dental treatment is out of the question.
Many fears are regarded as socially unacceptable. Dental fear, however, is widely accepted and carries little social stigma. Several studies have confirmed that dental anxiety and fear are common among the general U.S. population and are a worldwide problem. About 50% of adults in the United States report some dental fear, and 8% to 12% are fearful enough that simply making a dental appointment is problematic. Although women account for more than half of fearful patients, clinicians should not assume that the men they treat as patients are without dental fear and anxiety. Men may not express their fears as openly as women, but exaggerated emotions, such as anger or impatience, may be masking their dental fear. As the fictional scenario demonstrates, many clinicians have attempted to make their practices inviting by presenting a warm and friendly image to the patient who calls. Yet data show that in the United States, the rate of dental anxiety or fear has remained stable during the past 50 years.
Worldwide, the prevalence of dental phobia (an extreme form of fear) is also common. In Australian adults, the level of dental fear ranges from 10% to 14%, whereas in Iceland, Taiwan, and Japan, the percentages of adult respondents who reported at least some dental fear were 21%, 50%, and 82%, respectively. Studies of children have shown considerable global variation in the prevalence, with some estimates as high as 43%. Given the international prevalence and universal acceptance of dental fear and anxiety, it is impossible for any clinician to avoid fearful patients. Consequently, it is worth the clinician’s time and energy to understand the nuances of dental fear and anxiety. This chapter presents general information about fear and anxiety, including proposed mechanisms, and highlights individual differences in response and management strategies. It begins with a section describing the biologic and psychological characteristics of anxiety and fear.
Anxiety and Fear
Anxiety and fear play an adaptive role as an alarm in response to danger. Both are crucial and adaptive components of the overall behavioral and autonomic stress response. In response to dangerous situations that threaten to disturb homeostasis, some biologic systems are activated and others are inhibited in a largely predictable manner. A short-term reaction proportional to the challenge elicits an appropriate response (often escape and avoidance) and is of fundamental importance as a survival strategy. However, this survival strategy taxes the patient’s resources, and stress-induced dysregulation may result in a diverse set of health risks ranging from increased susceptibility to viral infection and activation of latent virus to impaired wound healing after surgery and increased mortality.
Anxiety and fear lie at the interface of neurobiology and psychology and are controlled by a highly complex system of both inhibitory and facilitatory mechanisms. These stress mechanisms are dynamic and redundant. Their purposes include maintaining an appropriate degree of emotion under nonthreatening conditions; efficiently responding to potential threats; producing behavioral responses, such as “fight or flight”; and, finally, allowing the patient to rapidly return to “baseline” after the danger has passed. Authors have attempted to make a distinction between anxiety and fear, and for the purposes of this chapter, those distinctions may be helpful in understanding dental patients’ responses to actual and potential treatment.
Fear is described as an individual’s physiologic and emotional response to a perceived immediate and identifiable threat or danger. It is accompanied by an unpleasant cognitive or affective state of impending doom marked by physiologic changes involving the sympathetic branch of the autonomic nervous system (e.g., hyperventilation, enlarged pupils, gastrointestinal upset, changes in salivary flow, elevated catecholamines) and overt behavior that may involve pacing, shaking, combativeness, or attempts to escape the situation.
Anxiety may or may not differ in the degree of physiologic and emotional arousal compared with fear, but the source of the threat is typically ambiguous, ill defined, and not immediate. Using this paradigm, the emotional and physiologic response a patient reports when imagining a dental appointment would be classified as anxiety, whereas the elevated psychological and physiologic arousal of a patient receiving an injection of local anesthetic while seated in a dental chair would be characterized as fear.
Dental phobia is a special case of dental fear, characterized as a consistent and persistent fear that interferes with a person’s social life or role functioning and often leads to avoidance of dental treatment of almost any type. Although the distinction between anxiety, fear, and phobia is useful to consider, most patients do not make such a distinction; consequently, the clinician should be aware that the terms are often used interchangeably.
For most people, the level of anxiety and fear expressed is commensurate with the level of danger or threat present, and the individual quickly adapts to the threatening event, either through reassessment of the level of danger or development of more effective coping skills. For most dental patients, the level of threat from treatment is balanced by the potential to benefit from maintaining good oral health, leading the patient to seek and receive treatment. For others, the fear may be disproportionate to the level of threat, and the individual’s behavior is perceived by an outsider to be maladaptive (avoiding treatment until the last moment). For still others, the anxiety experienced is paralyzing with respect to the stimulus and persists in the absence of threats, producing high levels of intrusive thoughts and memories. At its most extreme, this reaction qualifies as a phobia, and the avoidance is of such a proportion that it produces extreme distress and may provoke an immediate and intense anxiety response at the mere mention of the word dental .
The paradox, that the systems activated by stress-inducing stimuli cannot only protect and facilitate, but also damage the body, was recognized nearly 70 years ago. Since that time, the interactive roles of the autonomic nervous system, the hypothalamic-pituitary-adrenal axis, and the cardiovascular, metabolic, and immune systems during stressful responses have been documented, and the price of the continual accommodation to stress has been characterized.
The stress system coordinates the generalized stress response, which has both central nervous system and peripheral components. The main elements of the stress system’s central components, which are located in the brainstem and the hypothalamus, include the arginine vasopressin neurons of the paraventricular nuclei of the hypothalamus; the parvocellular neurons of corticotrophin-releasing hormone; the corticotrophin-releasing hormone neurons of the paragigantocellular and parabrachial nuclei of the medulla and the locus ceruleus; and other, largely noradrenergic cell groups in the medulla and pons (LC/NE). (The reader is referred to an excellent paper by Charmandari et al. for details of the endocrinology of the stress response.)
Intervariability and Intravariability in Responses
Variability in Stress Response
The stress system receives and integrates a diversity of inputs; these arrive through distinct pathways arising from the individual’s unique biology, psychology, and environment. Activation of the stress system is remarkably similar across species, but individual differences do exist that arise from variations in genetics and individual experiences. The knowledge resulting from research into the effects of stressful responding is far-reaching and shows associations across a broad range of health conditions, including wound healing ; the severity of infectious diseases ; inflammatory response ; chronic diseases such as cancer ; and pain levels.
For instance, psychological stress has been shown to impair human wound healing in a number of well-controlled studies. In one study, the investigators placed 3.5-mm punch biopsy experimental wounds on the arms of chronically stressed caregivers of patients with Alzheimer’s disease, in addition to well-matched controls, to study dermal wound healing. In the Alzheimer caregivers group, healing of standardized wounds took an average of 24% longer, with group differences in wound size appearing within the first week of healing. The ability to mount an inflammatory response was tested using an ex vivo endotoxin-stimulated interleukin 1 beta (IL-1 β ) gene expression assay in whole blood. Alzheimer caregivers produced significantly less IL-1 than did the controls. These results indicate that stress begins to have an impact in the early phases of wound repair, specifically the inflammatory phase, resulting in delayed wound closure. In an oral wound model, with wounds placed 3 days before examinations, dental students healed an average of 40% slower than did the same students with wounds made during summer vacation, and the differences were quite reliable. No student healed as rapidly during examinations as during vacation. These data show that an event as transient, predictable, and relatively benign as examination stress may have significant consequences for wound healing, even in young adults.
It seems quite likely that similar phenomena would be found in fearful dental patients after surgery, but no study to date has tested the question. It is beyond the scope of this chapter to review this important body of work, * but two important factors largely determine individual responses to potentially stressful situations: the way a person perceives the situation and the person’s general state of health, which is influenced by both genetic factors and lifestyle. Under this paradigm, it is not surprising that both interindividual and intraindividual differences exist in response to potentially aversive stimuli. Nowhere are variations in an individual’s response to a stressor more apparent than in a dental office. The following section describes one highly relevant dental outcome that has been shown to be influenced by fear, anxiety, and stress and that exhibits remarkable interindividual variability.
* References .
Variability in Pain Response
Two patients with comparable dental disease may report vastly different levels of pain associated with their disease and treatment. One patient may be distressed and report high levels of pain. The other may seem less bothered by the problem and report low to moderate levels of pain. Is one patient an outlier and the other typical? Or are both legitimate expressions of the individual’s experience?
The role of these individual differences in the response to stress is complex, and the part these differences play in pain perceptions is only partially understood. Investigators showed that experimentally induced anxiety led to increased pain reactivity, whereas high levels of fear led to decreased pain. Whether the dental setting produces fear or anxiety is not clear, but within the dental care context, patients may have worried for days about a scheduled treatment, resulting in elevated levels of autonomic arousal and high levels of anxiety. This elevated arousal may produce heightened levels of plasma catecholamines, which in laboratory studies have been shown to lower the pain threshold and tolerance. It is not surprising that many highly anxious patients show elevated levels of pain reactivity during dental treatment compared with less anxious patients. Therefore, clinicians should anticipate that anxious patients will have more sensory and affective distress during dental treatment than less anxious patients and treat them accordingly.
A body of literature shows that pain is strongly influenced by factors that include the person’s affective, cognitive, and psychosocial history and social learning (see also Chapter 4 ). One study demonstrated that patients’ perception of pain was associated with the amount of personal control they believed they would have during dental treatment, coupled with the amount of control they wished to have. Dental patients with the largest discrepancy between the amount of control they desired and the amount they believed was available were at greatest risk for elevated levels of expected, experienced, and recalled pain during dental treatment. Catastrophizing, a form of coping characterized by expecting the worst, predicts greater severity of postoperative pain; it has been linked with both experimental pain sensitivity and clinical pain symptoms. In addition, negative mood predicts greater severity of acute pain and is related to greater pain sensitivity.
Negative mood also influences the level of pain that is recalled. Overall, pain is remembered inaccurately and becomes exaggerated over time, with the amount of exaggeration strongly influenced by the intensity of the negative emotions at the time of the painful encounter. Moreover, the elevated recall of pain influences the level of pain experienced at a second painful encounter, such as in dental treatment. These research findings reinforce the significance of efforts to reduce a patient’s level of negative emotion before dental treatment.
Increasing evidence indicates that women with high levels of dental fear are more likely to have a history of sexual or physical abuse (or both) than other women. The current estimate of childhood sexual abuse in the general U.S. population is 5.8% to 34% for women and 2% to 11% for men, which is considered by many to be a conservative estimate. The sheer number of patients who have experienced sexual abuse strongly suggests that clinicians frequently treat sexually abused patients, and a greater understanding of the impact of abuse on dental attitudes and reactions may help both the patient and clinician to form an effective treatment partnership.
A study of sexually abused European women who were categorized by whether they had been exposed to sexual touching, intercourse, or oral penetration showed that women in the oral penetration group scored significantly higher on dental fear than women in the other two groups. In addition, women with a history of childhood sexual abuse and high levels of dental fear considered interpersonal factors related to the clinician as more important than did women with high levels of dental fear but without a history of childhood sexual abuse. These important interpersonal factors included not feeling that the clinician could be trusted and not feeling in control. It is not hard to understand the parallel between some elements of abuse and receiving dental care, including discomfort and pain, in addition to a reluctance by abused patients to believe that the clinician can be trusted.
From a more general perspective, one study found that a self-reported history of physical or sexual abuse among a nonclinical sample was associated with increased pain complaints and lower perceived health status. Not surprisingly, health care utilization and psychological distress, including the tendency to catastrophize about upcoming events, was greater among women with an abuse history compared with other women. The clinical implications of the association between sexual abuse and dental fear are that clinicians should be prepared to talk to their patients about sexual and physical abuse and the influence of that abuse on receiving dental care.
Fear of pain differs greatly among dental patients and is associated with elevated levels of anxiety. Of particular concern to the clinician is the finding that anxious patients tend to be more fearful of dental pain after they experience a procedure than before, whereas less anxious patients tend to report less fear of pain after the procedure has been experienced. For highly anxious dental patients specifically, experiencing treatment tends to make their fear of pain even greater. Individual differences in pain response may correlate to individual biological changes, which may be evaluated objectively using techniques such as functional magnetic resonance imaging (fMRI). Using neural imaging, researchers in one study found that fear of pain predicted activation of the right lateral orbital prefrontal cortex during a heat pain task. This region of the brain has been linked to attempts by fearful individuals to regulate pain by determining how much threat the stimulus represents. This phenomenon of assessing the primary threat level, in conjunction with the coping resources available, is well documented in dental patients and, in conjunction with recent research using fMRI, provides biologic evidence to support behavioral observation that differences in pain perception are true representations of the individual’s experience.
Although a variety of cultural, psychological, and physiologic factors contribute to variability in both clinical and experimental contexts, the role of genetic factors in human pain sensitivity is increasingly recognized. The most dramatic manifestation of individual variations in pain response is congenital insensitivity to pain, caused by single mutations of the NTRK1 gene. This well-documented genetic defect, which causes pain insensitivity by influencing tyrosine kinase, the receptor for nerve growth factor, underscores the role of individual genes in the reaction to painful stimuli.
One study evaluated genetic influences on variability in human pain sensitivity associated with gender, ethnicity, and temperament. Loci in the vanilloid receptor subtype 1 gene (TRPV1), delta opioid receptor subtype 1 gene (OPRD1), and catecholamine O -methyltransferase gene (COMT) were genotyped using 5′ nuclease assays. These researchers demonstrated that gender, ethnicity, and temperament contribute to individual variation in thermal and cold pain sensitivity by interacting with TRPV1 and OPRD1 single-nucleotide polymorphisms. Another study found that the COMT gene was related to experimental pain sensitivity and the risk of developing temporomandibular pain and disease (TMD).
In a fascinating study, 207 cancer patients receiving morphine treatment were genotyped with respect to the Val158Met polymorphism. The study compared the morphine doses, serum concentrations of morphine, and morphine metabolites between the genotype groups. Patients with the Val/Val genotype (n = 44) needed more morphine (155 mg ± 100 mg/24 h; n = 96) and the Met/Met genotype (95 ± 99 mg/24 h; n = 67) ( P = 0.025). This difference was not explained by other factors, such as the duration of morphine treatment, performance status, time since diagnosis, perceived pain intensity, adverse symptoms, or time until death. These results show that genetic variation in the COMT gene may contribute to variability in the efficacy of morphine in cancer pain treatment.
Further evidence has emerged of a genetic basis for differences in patients’ response to pain control agents. One study demonstrated a significant link between the melanocortin-1 MC1R gene sequence, pain tolerance, and the efficacy of morphine-6-glucuronide in both humans and laboratory animals. In addition, the distinctive molecular processes associated with different types of pain and changes in gene expression over time support the idea that heterogeneous responses to pain stimulus are typical, and “one size fits all” attempts at pain management are unrealistic. It follows that failure to achieve anesthesia in some dental patients may reflect real anatomic and genetic differences. Limited research on the effectiveness of local anesthetic agents has been conducted in the past 50 years, and almost none has focused on individual differences in genetic composition and anatomic structure. One in seven patients reports inadequate anesthesia when the teeth are stimulated with a drill, even after administration of local anesthetic ; therefore, it may be time to launch research into the impact on drug efficacy of individual differences in genetic composition.
Brain imaging studies provide additional support for the need to adapt to individual differences in pain mechanism. One study used fMRI to evaluate cerebral responses and, through this approach, confirmed that identical experimental pain stimuli produced different activation in pain-related regions of the cortex. These differences systematically varied in subjects who were sensitive to the pain and those who were not. This study provides additional and persuasive evidence that individual differences in pain responses reflect actual variability in the experience of pain. Incorporating pain management strategies into dental treatment, with the understanding that individual differences in pain response are rooted in true biologic, psychological, and social differences, will lead to better outcomes for patients and less stress for clinicians.
Considerable evidence has been presented supporting the existence of differences among individuals in their responses to dental treatment. It follows that a single management approach for anxious patients is less effective than adapting the strategy to the needs of the individual patient. In the next section, a few selected strategies are outlined, with special emphasis on tailoring communication to the fearful patient.
Management of Pain and Anxiety
Individualizing clinician-patient communication, so as to identify, acknowledge, and reassure a distressed patient, is one of the most effective anxiety-reducing strategies available to the dental team. This is a three-pronged strategy involving (1) establishment of rapport with the patient, (2) use of a standard interview protocol, and (3) use of effective nonverbal communication. Each of the prongs of communication requires a dialog with the patient, rather than either of two extremes—one-sided listening to the patient, or a monologue by the clinician that does not provide opportunities for the patient to comfortably speak up. For most patients, having the clinician listen attentively sets a context for building a trusting clinician-patient relationship.
Fearful patients often cite poor communication with the clinician as a factor in maintaining anxiety. In particular, patients report that they do not believe their clinician adequately listens to their concerns. Accurate diagnostic information is the foundation of any treatment, but to obtain that information, the clinician must first develop a trusting relationship with the patient so that a free exchange of information is possible. The first step in building a trusting relationship with a fearful patient is to develop rapport.
Rapport development can begin in the first few minutes of getting acquainted. In fact, because many first impressions are unconsciously made, the clinician may be wise to carefully consider patients’ first impressions of the dental provider and his or her staff. There is probably no better way to make a positive first impression than to demonstrate a sincere and genuine interest in the patient. What is the first question the patient is asked by the staff? Often, it concerns the payment policy of the practice and how the patient will be paying. Although it is essential to know about the patient’s financial status, making that the first question the patient hears may immediately set an impersonal tone. Research shows that the clinician who initially talks about nondental topics is more likely to be perceived by the patient as friendly, and friendly clinicians are more likely to have satisfied patients . An important exception to the use of nondental topics to establish rapport is the patient who immediately initiates conversation about dental-related issues associated with his or her fear. Failing to respond to such an initiative may suggest to the patient that the clinician is avoiding the topic of fear or lacks compassion.
The clinician should also be aware of the impression he or she is making when addressing the patient. The use of a first name assumes or implies a familiarity not all patients are comfortable with. Because the manner in which we address each other frequently sets the context for future interactions, dental providers and their staff should be cautious and sensitive to the individual needs of the patient. Addressing the patient as Mr., Mrs., or Ms. demonstrates respect, and this form of address should be used unless the patient has expressed a preference for use of his or her first name. Older patients and fearful patients may be offended if younger clinicians or staff members address them by their first name. Developing rapport and trust may require additional time and attention with the fearful patient, who is already on guard. It is worth the effort, however, because satisfied, formerly fearful patients become excellent ambassadors for the dental practice. Another effective tool with anxious patients is active and engaged listening. In the following paragraphs, the challenge of listening to a distraught patient in a busy practice is discussed.
Listening is sometimes viewed as analogous to sending an audio signal to a receiver that faithfully reproduces the signal as it was transmitted; however, listening is not a passive act. Anxious and fearful patients may express their feelings to the clinician or staff in the form of anger and blame. Rather than reacting to the patient’s anger, the clinician should show reflective listening. Reflective listening is an effective way to respond to anger, often defusing the exchange regardless of the cause of the anger. When people are angry, one of their primary goals is to convey their feelings to the listener. If a patient is expressing strong emotions, he or she cannot listen very well, so it is best not to offer advice at that moment. Both patients and clinicians listen through a filter of biases and prejudices that influence their interpretation of what is being said. In this kind of interaction, it is especially important that the clinician not assume that he or she understands what the patient is saying or how the patient “feels.” Clinicians should encourage the patient to explain expressed fear with statements such as, “It sounds like you have very strong feelings about what happened. I want to be sure that I understand. Please go on.” This gives the patient an opportunity to clarify, and the clinician has demonstrated that the emotional content or tone of the concern is being heard.
Strong feelings do not vanish just because they are ignored; they do diminish in intensity and lose their sharp edges when the listener accepts them with respect and understanding and allows the patient to express these feelings. Often the best initial step for either the clinician or the staff member is to LISTEN! Once the nature of the problem has been clarified and the patient’s strong emotions have diminished, the usual techniques for effective communication can be used, such as open-ended questions with appropriate follow-up questions based on the content and tone of the message. Developing a dialog of trust between the clinician and the patient is necessary and cannot be delegated to a staff member .
Fearful patients are sensitive to any communication that can be interpreted as belittling or disrespectful. This includes dental jargon the patient does not understand or terms the clinician or staff members do not clearly explain. Fearful patients may be insulted by a statement such as, “There is no reason for you to be afraid,” when the patient is convinced there are abundant reasons for fear. The more empathetic the clinician can be, the more likely it is that the fearful patient will accept treatment. The term empathy refers to the capacity and willingness to understand a situation from the other person’s point of view and communicate that understanding to the person. This is not the same as sympathizing, which can widen the gap between patient and provider and has been shown to be counterproductive in establishing a therapeutic alliance. Instead, reflecting back but not parroting what the patient has said can help the clinician show empathy. For example, if the patient says that he or she hates going to the dentist, a reflective statement might be, “Sounds like you have had some unpleasant experiences with dentists in the past.” The patient may elaborate, and at the appropriate time, the clinician can offer reassurance by saying that he or she will do whatever can be done to make the treatment as comfortable as possible. Once a clinician has developed a good rapport with the patient, the rest of the patient’s visit is more likely to go smoothly. The clinician will also find that a good rapport with the patient facilitates a smooth standard interview and future treatment. After a trusting relationship has been established, the patient is more likely to accept the moments in which the clinician is distracted as a forgivable event and not take it as a personal insult or lack of interest.
Demonstrating clinical empathy can be more of a challenge in a diverse society. Clinicians frequently treat patients from ethnic, racial, and cultural groups different from their own. It is unreasonable to expect that clinicians can identify or understand what it is like to be from another ethnoracial cultural group. It is still possible, however, to demonstrate clinical empathy if empathy is understood as a feedback loop much like hypothesis testing. Successive cycles of conversation establishing what the patient believes about the nature of dental disease and what needs to be done can allow the patient and clinician to move closer to a shared understanding about an acceptable course of treatment. If nothing else, the clinician’s honest attempt to understand the patient’s perspective facilitates trust. Trust cannot be earned if the patient feels a lack of concern from the clinician.
Using a Standard Interview Protocol
The use of a standard interview protocol facilitates the dialog with distressed patients. Not infrequently, the anxious patient becomes sidetracked by the emotion-driven recollection of past dental experience, and the responses to questions in the patient history meander, lacking logic and clarity. To keep the interview on track and in professional focus, the clinician may need to gently, smoothly, and efficiently return to the standard protocol and format for the information-gathering process. This may be accomplished by using a statement such as, “I am very interested in that part of your experience, but to be sure we have enough time, please tell me about … Remind me later, and we will return to what you were starting to tell me.” Similarly, it may become necessary to pause and deal with the patient’s fear in the middle of the interview.
The use of a standard set of questions allows the clinician to concentrate on the patient and the response to each verbal question, confident that all relevant information will be gathered. Depending on the patient’s comfort level and curiosity, it is often useful for the clinician to provide a rationale for particular questions or requests for specific information. The rationale need not be long or detailed but should clearly establish, in lay language, why obtaining the information is in the patient’s best interest. Stressed or fearful patients are frequently not attentive to the details of a message, so it is a good practice for the clinician to verify clarity and understanding by summarizing each phase of the interview. The clinician may wish to say, “Sometimes my statements are pretty confusing. [A little personal joke can help make the point, such as a reference to the clinician trying to clarify with his or her teenager what time to come home.] Because much of what we are going to talk about is important if I am to provide optimum care for you, I may ask you to repeat what you think I said just to reassure myself that I am being clear.” Patients usually respond positively to such an approach.
Another helpful portion of the standard interview protocol is a question already established on most patient medical/dental health history questionnaires, which is, “Are you anxious about receiving dental treatment?” The question provides two benefits for the patient: It allows the patient to verbalize his or her anxieties, and it also reassures the patient that the clinician is aware he or she may be anxious about the visit. The answer to the question also provides a benefit to the clinician; if the patient responds positively, a series of follow-up questions regarding the patient’s perception of the cause or causes of the anxiety can lead to fruitful revelation of specific adverse issues, materials, and techniques. This knowledge can then be very helpful in strategizing how treatment will be planned and carried out to mitigate the patient’s aversion and anxiety.
The type of questions the clinician uses in talking with a fearful patient can influence the degree of satisfaction with the interaction for both. For example, if the fearful patient is not talkative, the clinician should consider whether responses could be encouraged through use of more open-ended questions. If the patient is talking excessively, closed questions help the clinician control the interview. Incomplete or inaccurate information may result from questions that lead patients to an answer they believe the clinician is seeking. For example, “I don’t suppose there have been any changes in your medications,” may suggest to the patient that the clinician does not want to be bothered with any new information. A mix of open and closed questions produces the most effective interview and facilitates an ongoing dialog. Effective communication, however, is not based solely on words. Nonverbal communication can be an effective strategy in building an empathetic and effective relationship with a patient. The following section describes an approach many clinicians find helpful, beginning with silence, which is rarely thought of as an important communication tool.
Using Nonverbal Strategies
There is a strong tendency in the commercial model of health care to think that giving advice and providing treatment is the sole task of the clinician. Periods of silence are often avoided, but silence can be a useful tool when listening to any patient, especially a frightened one. Conversely, good care cannot be provided without spending the time to build a trusting relationship between the patient and the clinician. The silence may feel a bit clumsy or uncomfortable, but patients often report that they are not given adequate time to respond to the clinician’s questions. This is especially true with older patients who may need a bit more time to understand what is being said or asked of them. Giving the patient adequate time to collect his or her thoughts and avoiding the tendency to comment too quickly gives the impression that the patient is the focus of attention at that moment. It also helps if eye contact is maintained with the patient; a nod of the head shows that the message is being heard and is important. Permitting the silence to continue may encourage the patient to provide additional relevant information that would have otherwise been missed. Within limits, the clinician should encourage the fearful patient to talk more rather than less.
The clinician’s physical orientation toward the patient also provides important messages about the level of interest in what the patient is saying. It is unlikely the patient will continue talking if the clinician appears not to care about what is being said. Making direct eye contact and nodding as the patient speaks can be affirming and can serve as encouragement for more conversation. During the interview, it is most effective for the clinician to face the patient, with the chair at about the same level as the patient’s chair. These initial moments are often the time when the fearful patient assesses the clinician’s trustworthiness and the extent to which expressed concerns are being taken seriously.
In Western culture, eye contact is the principal means of demonstrating involvement with another human being. Eye contact should be steady and frequent (without staring). Glancing elsewhere is acceptable, but the patient’s face should be the focus of the clinician’s attention. The clinician may take notes, but it is important to reestablish eye contact after each note is taken to convey the impression that what the patient is saying is important. Showing care in this way is one avenue of demonstrating clinical empathy. Patients are very sensitive to discordant messages between our words of caring and aspects of nonverbal communication, such as eye contact. Maintaining eye contact until the patient has stopped speaking provides a powerful statement of respect and concern.
The fearful patient is best served if the context in which care is received is based on mutual respect and concern. Many fearful patients have not received routine preventive care and may have extensive treatment needs, including some requiring complex, invasive treatment. If so, the patient will need reassurance that the clinician will make every effort to provide comfortable treatment.
No promises should be made that the treatment will be painless or free of discomfort. Pain-free dentistry is not a promise that can always be kept. It is also important to acknowledge the patient’s feelings. Acknowledgment does not represent endorsement; it simply confirms that what the patient said was heard. During treatment, frequently expressing sincere interest in the patient’s level of comfort and keeping the patient informed of progress helps relieve anxiety. The expression of concern should be sincere, not automatic.
As part of the framework for care of a fearful patient, the clinician should work quickly and systematically without appearing hurried. Planning ahead and informing the patient about the next step can be reassuring. Keeping promises made to the patient maintains the patient’s trust. Such promises may include the length of the appointment or the frequency of breaks. Being honest about what is and is not realistic helps both the clinician and the patient. Fearful patients appreciate a frequent review of what has been accomplished, what remains to be completed, and any unanticipated deviations from the original plan. Setting a context of predictability is important to most patients, but with fearful patients, the appearance of predictability projects organization and control. The basis of trust often rests in the patient’s sense of personal control.
Research has shown that fear about dental care increases when the fearful patient wants control during treatment and believes he or she will not have it. A sense of personal control can be provided through information, predictable sequences, and choices about the treatment and the treatment process. One strategy that returns some level of control to the patient involves inviting the individual to raise a hand when he or she would like to take a timeout. It should not be surprising if a patient tests the clinician’s willingness to give up control during the treatment by frequently raising a hand. Other options may include giving patients a choice of music to listen to during treatment, which implies control over the environment. (See de Jongh et al. and Logan and Marek for reviews of individualized dental anxiety management strategies.)
Patients who manage their apprehension about dental treatment often have identified coping strategies that have worked well for them in the past. Fearful patients may not have such well-defined strategies. Asking about preferred coping strategies and helping the patient identify one that usually works has proven useful in reducing anxiety. Dental anxiety can also be managed with conscious sedation techniques, but it is important to remember that these agents do not treat anxiety, they only facilitate treatment. When conscious sedation techniques are used, they are most effective when combined with behavioral interventions. (See de Jongh et al. for a review of individualized management strategies for dental anxiety.)
In short, if anxiety reduction is to be possible, a trusting relationship needs to be in place whereby (1) the patient’s feelings of anxiety are acknowledged, (2) a safe and secure environment is in place, and (3) the patient believes that nothing will happen that the patient and clinician have not agreed on. In addition to the strategies described before, numerous other behavioral interventions are available. Although no one strategy has emerged as best, most have shown that dental anxiety is treatable, and the effects of the behavioral treatment are long lasting. Next, four interventions with particular relevance to dental care are highlighted in somewhat greater detail.
Distraction as an anxiety-reducing strategy has broad appeal because of the ease of use. Music represents one of the simplest distraction techniques to use and is particularly effective if the patient selects the music and listens over individual headphones. Regardless of their anxiety level, patients often report that they prefer to have music in the background because music makes them more comfortable. In a randomized clinical study, patients who listened to music during dental treatment reported less pain, less discomfort, and a greater sense of personal control. Thus music can be both distracting and, under certain conditions of choice, provide the patient with a sense of control.
Portions of the office environment can also divert a patient’s attention. It has often been reported that interesting artwork, decor, and tropical fish tanks are useful in distracting the patient from feared stimuli. Some clinicians have used video games or a television set in the operatory as an effective and comforting distraction for anxious patients. Manual distraction-stimulating devices have also been used during injection of dental anesthetics to reduce dental anxiety. The clinician should be aware that simple distraction techniques may be ineffective if the perceived intensity of dental pain is too high. Distraction is largely effective in the short-term management of anxiety but less effective for long-term behavior change.
The goal of relaxation is to achieve both muscular and mental relaxation. Research shows that relaxation is an effective method of reducing patient anxiety. Deep breathing coupled with muscle relaxation can be effective in stress reduction. Many fearful adults tend to hold their breath during basic procedures such as applying a rubber dam, giving injections, or forming impressions. When the person’s blood becomes poorly oxygenated because of an insufficient amount of fresh air entering the lungs, states of anxiety, depression, and fatigue arise, contributing to the already stressful situation. Deep breathing exercises to help reduce this unwanted stress can consist of as little as 2 to 4 minutes of breathing in deeply, holding the breath, and then exhaling completely. Demonstrating for patients that deep breathing is something they can do on their own provides a new sense of control, in addition to the calming effects from the breathing techniques. It may even be helpful to attach a heart rate monitor so that both clinician and patient can assess this aspect of stress arousal and success in controlling it.
Pausing during the procedure and suggesting that the patient briefly repeat the deep breathing techniques can be helpful. Muscle relaxation is also very useful in calming the patient. This method includes repeated tensing and relaxing of specific muscle groups in the body. Breathing and muscle techniques can be combined by tensing the muscles while breathing in and relaxing them while breathing out. Practicing this rhythmic coordination of relaxation techniques quickly and effectively improves the patient’s ability to relax. Periodic reinforcement of muscle relaxation during treatment helps the patient regain composure. Pausing during the procedure and suggesting that the patient take several slow, deep breaths can also be useful. For some fearful patients, the mere act of deeply inhaling and exhaling completely can help dispel negative reactions to receiving care. Some caution should be used in attempting to combine music and relaxation therapy because some types of music may have unanticipated effects on the patient and may actually increase autonomic arousal.
Hypnosis and Guided Imagery
Hypnosis is a guided, self-controlled state of mind in which concentration and focus are directed inward. An altered level of consciousness is reached, similar to “zoning out” while daydreaming or reading a book. Guided imagery is a form of mild hypnosis that can be useful with fearful patients. It produces a light trance from which patients easily awaken, and the procedure is less time-consuming for the clinician than guiding patients into a deep hypnotic state. Asking the patient to focus on a place in which he or she feels very relaxed, comfortable, or safe is a good starting point for guided imagery and can be effectively combined with relaxation training. Information about appropriate images can be gathered during the examination process. Current research shows that patients have reduced pain and distress when they themselves choose the place to be imagined. The patient should be asked to choose imagery that is associated with little movement so that movements do not interfere with the provision of care. During guided imagery, the patient achieves an altered state similar to daydreaming or focused attention. By focusing on a calm and safe scene, positive emotions are elicited that can block or mitigate the anxiety arising from the dental treatment. An analysis of imagery topics chosen by patients shows that the topics were highly individual; this further supports the efficacy of guiding patients to a “safe and comfortable place” of their own choosing. Guided imagery is effective in managing pain during outpatient procedures and can be delivered by the dental team without disrupting the workflow in the patient care setting.
In the past, the success of hypnosis was believed to depend on the hypnotizability of the subject and was associated with a specific “phobic” portion of the population. More recently, researchers have shown that nearly all patients are equally able to engage in imagery during invasive outpatient procedures, and the imagery has resulted in reduced pain and anxiety. Although nearly all patients are equally susceptible to hypnotism, their attitudes, motivations, and fears from common misconceptions may interfere with or impede their willingness to engage in a hypnotic state. The most successful conditions involving hypnotism in the clinical setting include a well-trained hypnotherapist and a patient who is highly motivated to overcome a problem. For most mildly or moderately anxious patients, the most effective management strategy for the clinician is taking time, actively listening to the patient’s concerns and fears, and emphasizing the building of a trusting relationship between the patient and the clinician.
For more serious cases, deep breathing techniques and hypnosis or guided imagery are among the most useful. The effectiveness of hypnosis in treating dental fear has been demonstrated. Hypnosis, however, requires specialized training and experience, so a brief “how to” belies the complexity of the strategy. For clinicians who are interested in training in hypnosis, resources can be accessed through the Internet or through other printed materials. Information about training in the specific area may be available through the local dental society or mental health center.
Referral to a Mental Health Professional
In extreme cases, refining the dialog and using previously mentioned strategies are inadequate to reduce the patient’s distress and fear. The clinician may want to exercise the option to refer a fearful patient to a mental health worker for professional counseling and therapy. This decision may depend on the clinician’s own skills and interests in working with fearful patients. One criterion used for referral is whether the fear imposes a significant barrier to successful completion of care. If this is the case, referral may be warranted. If a therapist’s name is not readily available, a call to a county or state psychological or psychiatric association will yield the names of professionals who specialize in anxiety disorders. If the patient is currently in therapy, it is appropriate to ask the patient’s permission to speak with the therapist. If the patient gives permission to contact the therapist, the clinician should consider maintaining an ongoing dialog with the therapist during the course of dental treatment. The following are questions the dental provider and the therapist may discuss.
Do adjustments need to be made in the sequence of the dental treatment plan?
Do adjustments need to be made in the anxiety management strategies as the treatment progresses?
Should new anxiety treatments be tried?
Based on the conversation with the therapist, the clinician can decide whether further referral is necessary or if the patient is being treated adequately for his or her dental fear. If the patient’s dental fear and anxiety do not subside, other measures may be needed, including pharmacotherapy. As with all treatment, careful documentation of the anxiety treatment is important. The dental team should be reminded to assiduously adhere to the standards established by the Health Insurance Portability and Accountability Act (HIPAA) in discussing the patient’s care among themselves and in sharing information unless directly relevant to provision of dental care.