Cognitive Behavioural Therapy for Dental Fear, Anxiety and Phobia

Question 1

Why are both pharmacological and psychological techniques important for anxiety management?

Answer 1

• pharmacological provides immediate results
• psychological is effective long term

Question 2

What guidance is available surrounding management of patients with anxiety about dental treatment?

Answer 2

• GDC Standards for the Dental Team
• Standards for Conscious Sedation in the Provision of Dental Care
• SDCEP Conscious Sedation in Densitry

Question 3

How is CBT relevant to IV sedation?

Answer 3

• CBT can complement sedation
• preparation for sedation
• patient provided with tools to manage anxiety

Question 4

What is cognitive behavioural therapy?

Answer 4

• brief psychological therapy
  
  • talking therapy
• useful for a range of problems
  
  • anxiety
  • depression
  • PTSD
  • specific phobias
    - dental phobias
• thoughts, feelings and behaviours linked
• psychoeducation and behaviour modification
  
  • cognitive restructuring
  • challenge unhelpful beliefs and behaviours

Question 5

What is dental anxiety?

Answer 5

a general type of fear which occurs without a present triggering stimulus, emotional response to an unknown danger of perceived threat, anticipatory due to previous negative experience

Question 6

What is dental fear?

Answer 6

an intense biological response to immediate danger which is specific, encourages caution and safety

Question 7

What is dental phobia?

Answer 7

overwhelming and debilitating fear of an object or place which interferes with daily life

Question 8

What is the aetiology of dental fear, anxiety and phobia?

Answer 8

• direct experiences
  
  • painful injection
  • extraction
  • ACE/trauma
• observations
  
  • seen family members at dentist
• told
  
  • friends and family
  • media
• personality
  
  • some traits more susceptible
• genes
  
  • can run in families
  • not born with phobia
  • more prone to developing one

Question 9

What are possible triggers of dental fear, anxiety and phobia?

Answer 9

• fear of specific stimuli
  
  • injections
  • smell of practice
  • drill
    
    • sound
    • sight
  • dental setting
• fear of medical catastrophe
  
  • something happens at appointment
  • medical emergency occurs
    
    • faint
      -allergy
    • choking
• generalised dental anxiety
  
  • significant anxiety
  • cannot identify a single trigger
  • likely has other worries
    
    • heights
    • flying
    • exams
• mistrust of dental personnel
  
  • not being in control
  • loss of self esteem
  • fear of judgement
    
    • OH
      -diet

Question 10

What is trauma?

Answer 10

an event or actual extreme threat of physical or psychological harm which an individual experiences as traumatic, and which has long-lasting effects

Question 11

Why may past traumas cause dental fear and anxiety?

Answer 11

• lack of control
• authority figure
• things being done
• full consent not given
• smells
• noises
• sensations
• unexpected
• unable to say no

Question 12

What is universal precaution?

Answer 12

• treating all patients the same
  
  • e.g. all are dentally anxious
• provides safety and empowerment

Question 13

What is commonly used to measure dental anxiety and what are the threshold scores?

Answer 13

• Modified Dental Anxiety Scale
  
  • MDAS
• > 16 years old
• scores from 5-25
  
  • severe anxiety/phobia
    
    • > 19
    • 5/5 on LA question

Question 14

What fears are contraindications to IV sedation?

Answer 14

• needle phobia
  
  • cannulation required
• loss of control

Question 15

What is commonly used to measure dental anxiety in children and what are the threshold scores?

Answer 15

• Modified Child Dental Anxiety Scale-faces version (MCDASf)
• 8-15 years old
• scores from 9-45
  • > 27 is severe DFA/phobia

Question 16

What can a patient expect from CBT?

Answer 16

• collaboration with clinical for a personalised plan
• understating the ability to test their negative thinking
• psychoeducation and learn coping skills to allow behavioural exposure
• encouraged to participate in ‘homework’
• learn to face anxiety and disengage from avoidance
• challenge anxiety and learn to reduce reliance on cyclical treatment under sedation

Question 17

What are the 5 components of fear and anxiety?

Answer 17

• situation
• thoughts and images
• body/physical sensations
• moods/emotions
• behaviours

Question 18

What does the emotional component of fear and anxiety include?

Answer 18

• anxiety
• fear
• shame
• guilt
• anger

Question 19

What does the physiological component of fear and anxiety include?

Answer 19

• increased heart rate
• dry mouth
• increased perspiration
• butterflies in stomach
• flushed face
• increased muscle tension
• fight/flight/freeze

Question 20

What does the cognitive component of fear and anxiety include?

Answer 20

• expectation of failure
• catastrophising
• fortune telling
• magnifying and minimising

Question 21

What does the behavioural component of fear and anxiety include?

Answer 21

• avoidance
• disruptive behaviour
  
  • especially children
• increased muscle tension
• safety behaviours
  
  • hold water bottle
    
    • fear of choking
    • problem if forgets to bring

Question 22

Describe the cycle of fear and avoidance

Answer 22

• encounter fear
• thing about what could happen
• feel afraid
• avoid and move away
• feel immediately relieved
• beliefs about fear remain the same

Question 23

How can the cycle of fear and anxiety be broken?

Answer 23

• breathing control
  
  • deep, controlled breaths
    
    • reduces autonomic
    • increases parasympathetic
• relaxation
  
  • progressive muscle relaxation
    
    • tensing and relaxing
    • systematically
    • good for refocussing
• this will pass
• stepping back
• grounding
  
  • 5, 4, 3, 2, 1
  • stress ball
  • essential oils
• STOPP

Question 24

What happens during the fight/flight/freeze response?

Answer 24

• brain hijacked
• eyes widen
  
  • vision improves or blurs
• mouth dries
• body heats and sweats
• heart rate increases
  
  • blood pressure increases
• hands tingle and legs tremble
• bladder relaxes
• stomach churns
• fast and shallow breathing
• head dizzy

Question 25

What 3 steps can be used to change thoughts and break the fear and anxiety cycle?

Answer 25

1. catching the thoughts
   
   • notice unhelpful thoughts
   • understand unhelpful thinking
   • keep a thought diary
2. challenge the thoughts
   
   • evidence?
   • worth?
   • say to someone else?
3. find alternative thoughts
   
   • balanced alternatives

Question 26

What is a feared hierarchy and how can it be used to help fear and anxiety?

Answer 26

• creation of a fear ladder
  
  • provide fear rating of 1-10
  • place in order
• plan to expose patient
  
  • start with low level anxiety
  • gradually work up

Question 27

What are the 4 grades of exposure?

Answer 27

1. graded
2. prolonged
3. repeated
4. no distraction

Question 28

What resources are available for patient self help?

Answer 28

• self help booklet
• message to dentist
• child experience of dental anxiety measure
  
  • CEDAM