Dental Anxiety

Question 1

What is the difference between anxiety and fear?

Answer 1

Anxiety is non-specific

Question 2

What is a phobia?

Answer 2

It is a marked, persistent and irrational fear which interferes with normal life

Question 3

What is a method of measuring anxiety?

Answer 3

The MADS – using the physiological, cognitive, behavioural, health and social impacts.

Question 4

Why is paying attention to anxiety?

Answer 4

Anxiety affects the behaviour of our patients, thus those patients are more likely to suffer from greater dental problems. They also may not come to their appointments, which creates stress for the health system.

Question 5

How do people become dentally anxious/fearful? What theoretical explanations have been proposed?

Answer 5

1. Behavioural learning theories - conditioning
2. Social learning theory – observing leads to imitation
3. Cognitive learning theories – thoughts about experience produces fear

Question 6

What is classical conditioning?

Answer 6

Stimulus lead to response. Association pairing.

Question 7

What is operant conditioning?

Answer 7

It is conditioning of a voluntary behavioural response as a result of associating the behaviour with its consequences. Use of positive and negative reinforcement.

Question 8

How to measure anxiety and fear?

Answer 8

Using different scales:

Dental anxiety question

Dental anxiety scale

Modified dental anxiety scale – includes dental injections

Dental fear survey

Index of Dental Anxiety and Fear

Question 9

How do we approach dental anxiety and fear?

Answer 9

Use a preventive approach

1. Prevent anxiety/fear acquisition
2. Prevent anxiety/fear maintenance
3. Prevent transmission to children

Question 10

What are the methods to help with dental anxiety?

Answer 10

1. Tailor to the needs of the patient
2. Effective communication
3. Ask patient
4. Planning gradual Tx increments
5. Use relaxation methods – progressive muscle relaxation or controlled breathing
6. Tell-show-do
7. Behavioural modelling
8. Control enhancement

Question 11

What do dental anxiety and dental fear refer to?

Answer 11

Dental anxiety refers to feeling worried about a dentist visit. It’s a general sense of unease. You anticipate something unpleasant. The threat isn’t immediate. For example, you might dread an upcoming appointment.

Dental fear is a strong, specific reaction to a dental procedure. It brings physical and emotional responses. You feel a fight-or-flight urge. The threat seems present or imminent. For instance, you might panic during a drill or local anesthesia.

Question 12

What are the practical usefulness of the distinction between dental fear and anxiety for you?

Answer 12

The distinction helps me understand your emotional state. Anxiety points to general worry about a future visit. I can suggest calming strategies like deep breathing or scheduling tips. Fear indicates a specific, immediate reaction during a procedure. I can recommend real-time coping methods like distraction or communication with the dentist. It tailors my advice to your needs. It ensures I address the right emotion effectively.

Question 13

What is phobia and what potential impacts does it have on pt?

Answer 13

A phobia is a marked, irrational fear of a specific object or event. It’s persistent and disrupts normal life. Exposure causes immediate anxiety. This creates a strong urge to avoid the feared item. For example, a dental phobia might lead to avoiding checkups.

For a patient, the impacts are serious. They might skip essential dental care. This can worsen oral health issues. Problems like cavities or gum disease can develop. Anxiety may trigger physical symptoms like panic attacks. Over time, it can lower their quality of life. They might feel isolated or ashamed of their fear.

Question 14

What impacts does dental anxiety/fear have?
- What impact does it have on patients, on practitioners, and the health system?
- Why is it a problem?

Answer 14

A phobia is a marked, irrational fear of a specific object or event. It’s persistent and disrupts normal life. Exposure causes immediate anxiety. This creates a strong urge to avoid the feared item. For example, a dental phobia might lead to avoiding checkups.

For a patient, the impacts are serious. They might skip essential dental care. This can worsen oral health issues. Problems like cavities or gum disease can develop. Anxiety may trigger physical symptoms like panic attacks. Over time, it can lower their quality of life. They might feel isolated or ashamed of their fear.

Question 15

How do we understand the literature on dental anxiety/fear?
- What do epidemiological studies tell us re severity, prevalence and demographic patterns?

Answer 15

Epidemiological studies on dental anxiety and fear focus on key areas. They record severity and prevalence through surveys. They examine demographic patterns like age, gender, or socioeconomic status. They assess care-seeking behaviors and oral health status. Objective measures include clinical assessments like the Dental Fear Survey. Subjective measures use self-reports, such as OHstatus or perceived treatment needs. They also study psychological impacts using scales like OHIP14. These scales measure pain, discomfort, and disability. The Oral Health-Related Quality of Life Scale evaluates broader effects. Together, they show how widespread dental anxiety is. They reveal who is most affected and how it impacts care access. They highlight links to poorer oral health outcomes.

Question 16

What impacts does dental fear have?

Answer 16

Dental fear has five key impacts. Physically, it causes acute stress responses. You might feel tense in the waiting room or during surgery. Cognitively, it leads to constant worrying. You may stress before, during, and after about others’ judgments or feel “silly.” Behaviorally, it changes your habits. You might avoid oral hygiene, dental visits, or self-medicate. Health-wise, it disrupts sleep, especially the night before. It can also worsen oral health issues, causing pain. Socially, it affects work roles and relationships. You might avoid social support due to embarrassment.

Question 17

Why is dental fear a problem?

Answer 17

Dental fear is a problem for population health. Patients with high fear have worse oral health. They need more care due to neglect. They often have more missing teeth. They have fewer filled teeth as well. They report more pain and discomfort. They experience functional issues and poor appearance. Dissatisfaction with their oral health is common. They recall and expect more pain during treatments. On a broader level, dental fear impacts mental health. It affects psychosocial well-being and self-esteem. It leads to lifestyle changes like missing work. Overall, it worsens oral and general health outcomes.

Question 18

Why is dental phobia a problem?

Answer 18

Dental phobia causes care-seeking avoidance. Patients miss treatments, worsening oral health. This leads to severe health issues. Treatment becomes resource-intensive. Some may need general anesthesia (GA). This strains healthcare systems. It also increases costs and risks.

Question 19

Why is dental fear a problem for children?

Answer 19

Dental fear in children causes visiting delays. They become non-cooperative or disruptive. Many refuse treatment entirely. This leads to distress for the child. It also complicates dental care delivery. Untreated issues worsen over time. Long-term oral health suffers.

Question 20

Why is dental fear a problem for population health and care

Answer 20

Dental fear leads to care avoidance. Poor oral health (OH) results in fearful patients. This requires more resource-intensive OH care. Time and treatment extent increase. Many skip regular dentist visits. Some only go every 10 years or less. Fearful patients often cancel or delay appointments. This causes resource waste. Dental anxiety passes across generations. Parents’ fear affects children. Children grow up avoiding care. The cycle continues. Population health declines. Care systems face ongoing strain.

Question 21

Why is dental fear a problem in behaviour?

Answer 21

Dental fear disrupts care-seeking behavior. It causes delays and avoidance. Patients cancel or miss appointments (FTAs). This creates a treatment-seeking “episodic” pattern. The “vicious cycle” worsens the issue. Fearful patients avoid care, leading to worse oral health. Poor oral health increases dental problems. More problems heighten fear. The cycle repeats, perpetuating avoidance. This impacts overall health trends. Fearful patients remain trapped in this loop. Armfield, Stewart & Spencer (2007) highlight this pattern.

Question 22

How do people become dentally anxious / fearful? What theoretical explanations have been proposed?

Answer 22

There are two main theories that explain the causative factors of dental anxiety / fear:
1. Behavioural learning theory (classical conditioning, operant conditioning, and social learning theory)
2. Cognitive learning theory

Question 23

What are the pros and cons of various explanations for causative factors of dental fear?

Answer 23

Behavioral theories (classical and operant conditioning) are strong in explaining direct learning and have practical applications but overlook cognitive processes. Social learning theory highlights social influences but is less comprehensive for direct experiences. Cognitive theories address mental processing but are less focused on observable behaviors. Combining these theories provides a more holistic understanding of dental fear.

Question 24

How do these theories inform clinical practice?

Answer 24

In practice, clinicians often combine these approaches. For example, a dentist might use desensitization (classical conditioning), reward attendance with praise (operant conditioning), model calm behavior (social learning), and provide clear explanations to reduce perceived threat (cognitive). The document emphasizes that learned fearful behaviors can be replaced by new, non-fearful learning (Page 5), supporting interventions like systematic desensitization, positive reinforcement, and cognitive-behavioral therapy.

Question 25

Describe Classical Conditioning

Answer 25

Dental fear can develop through associations between a neutral stimulus and an unconditioned stimulus (UCS) that naturally elicits fear. For example, a dental drill (neutral stimulus) paired with pain (UCS) can lead to the drill alone (conditioned stimulus, CS) triggering fear (conditioned response, CR). This is similar to Pavlov’s dogs learning to salivate to a bell sound after it was paired with food

Question 26

Describe Operant Conditioning

Answer 26

Fearful behaviors can be reinforced by consequences. For instance, avoiding dental visits (fearful behavior) may be rewarded by temporary relief from anxiety (positive or negative reinforcement), thus maintaining the fear. Conversely, attending dental appointments may be punished by negative experiences like pain, reinforcing avoidance

Question 27

Describe Social Learning Theory

Answer 27

Dental fear can be learned through observing others, particularly role models like parents or peers. If a child sees a parent displaying fear during dental visits and this behavior is reinforced (e.g., by sympathy or attention), the child may imitate the fearful behavior

Question 28

Describe Cognitive Learning Theory

Answer 28

Dental fear arises from how individuals process and interpret dental experiences. Cognitions, such as perceiving a dental procedure as highly threatening or uncontrollable, can lead to anxiety. For example, expecting pain or believing one has no control over the procedure can amplify fear

Question 29

What are the pros and cons of Classical Conditioning?

Answer 29

Pros: - Well-supported by research, with clear examples like Pavlov’s experiments. - Explains involuntary fear responses triggered by specific stimuli (e.g., the sound of a dental drill). - Practical applications in desensitization techniques, where new associations replace fearful ones. Cons: - Not all individuals who experience an aversive dental event develop fear, suggesting individual differences or other factors (e.g., cognition) play a role. - Overlooks the role of thoughts and feelings, focusing only on stimulus-response associations. - Limited in explaining why fear generalizes to other dental contexts (Page 16).

Question 30

Discuss the pros and cons of operant conditioning

Answer 30

Pros: - Explains how consequences (rewards or punishments) maintain or reinforce fearful behaviors, such as avoidance. - Supported by research and applicable in clinical settings (e.g., rewarding non-fearful behaviors like attending appointments). - Accounts for voluntary behaviors, unlike classical conditioning. Cons: - Fails to explain why some individuals continue attending despite negative consequences, indicating other influences (e.g., motivation or cognition). - Ignores cognitive processes, limiting its ability to address how perceptions shape behavior. - Over-simplifies complex emotional responses to dental experiences.

Question 31

Discuss the pros and cons of Social Learning Theory

Answer 31

Pros: - Explains how fear can be acquired indirectly through observation, especially in children observing role models. - Accounts for social influences, such as family or cultural attitudes toward dentistry. - Supported by Bandura’s research on observational learning and applicable in preventing fear by modeling positive behaviors. Cons: - Limited in explaining why only some observers imitate fearful behaviors, suggesting cognitive or individual factors are involved. - Less focus on direct experiences compared to conditioning theories. - Reinforcement of observed behavior is not always clear in dental contexts.

Question 32

Discuss the pros and cons of the Cognitive Learning Theory

Answer 32

Pros: - Emphasizes the role of thoughts and perceptions, addressing gaps in behavioral theories. - Explains why individuals interpret the same dental experience differently (e.g., perceiving a procedure as threatening vs. manageable). - Supported by research (e.g., Armfield, 2010) and applicable in cognitive-behavioral interventions to modify fearful thoughts. Cons: - Less focus on direct learning experiences compared to behavioral theories. - Cognitive processes are harder to measure and quantify than observable behaviors. - May not fully explain involuntary fear responses triggered by conditioning.

Question 33

Discuss the clinical application and examples of classical conditioning.

Answer 33

Clinical Application: Desensitization techniques, such as gradual exposure to dental stimuli (e.g., sitting in the dental chair without treatment), can weaken the association between dental stimuli (CS) and fear (CR). For example, pairing the dental environment with relaxation techniques can create new, non-fearful associations. Example: A patient afraid of the dental drill sound can be exposed to the sound in a controlled, non-threatening setting until the fear response diminishes.

Question 34

Discuss the clinical application and examples of operant conditioning

Answer 34

Clinical Application: Reinforce non-fearful behaviors with rewards to encourage attendance and cooperation. For instance, praising or providing small rewards (e.g., stickers for children) for attending appointments can reinforce positive behavior. Conversely, minimizing negative consequences (e.g., pain through effective anesthesia) reduces punishment for attending. Example: A child who attends a dental visit without distress could receive verbal praise or a small toy, increasing the likelihood of future attendance. Caution: Punishment (e.g., scolding for fear) should be avoided, as it may reinforce avoidance (Page 20).

Question 35

Discuss the clinical application and examples of Social Learning Theory

Answer 35

Clinical Application: Use positive role models to demonstrate non-fearful behavior. For example, showing videos of calm patients or having parents model relaxed behavior during dental visits can encourage imitation. Dentists can also act as positive models by displaying empathy and confidence. Example: A child observing a sibling comfortably undergoing a dental check-up may be more likely to emulate that behavior, especially if the sibling is rewarded (e.g., with praise).

Question 36

Discuss the clinical application and examples of Cognitive Learning Theory

Answer 36

Clinical Application: Cognitive-behavioral techniques, such as cognitive restructuring, can help patients reframe fearful thoughts. For instance, teaching patients to view dental procedures as low-threat or controllable can reduce anxiety. Providing information about procedures to reduce uncertainty also helps. Example: A patient who perceives a dental visit as highly dangerous can be guided to focus on their ability to control aspects of the visit (e.g., signaling to pause the procedure), reducing fear.

Question 37

Direct Question Assessment

Answer 37

A single question ("Are you afraid of going to the dentist?") with graded responses to quickly identify levels of dental fear.

Question 38

Dental Anxiety Scale (DAS)

Answer 38

A standardized questionnaire measuring dental anxiety through multiple items to quantify fear levels.

Question 39

Modified Dental Anxiety Scale (MDAS)

Answer 39

An updated DAS with five items, including a dental injection question, scored 1–5 to assess anxiety severity (0–25 range).

Question 40

Dental and Social History (DHx & SHx)

Answer 40

A non-questionnaire approach using detailed patient history to qualitatively assess dental anxiety through conversation.

Question 41

Compare and Contrast teh methods for a questionare

Answer 41

The direct question assessment is a quick, simple method to gauge dental fear but lacks depth for nuanced understanding. The Dental Anxiety Scale (DAS) offers a standardized, multi-item questionnaire for reliable anxiety measurement, though it may miss specific triggers like injections. The Modified Dental Anxiety Scale (MDAS) improves on the DAS by including a dental injection question and clear scoring (0–25), making it more precise for identifying high (≥15) or severe (≥20) anxiety. In contrast, the Dental and Social History (DHx & SHx) approach relies on qualitative patient interviews, providing rich, contextual insights but requiring more time and skill to interpret effectively. Each method balances speed, specificity, and depth differently, suiting varied clinical needs.

Question 42

Discuss how to Manage Dental Anxiety

Answer 42

Adopt a preventive approach to avoid anxiety/fear acquisition, maintenance, and transmission to children (e.g., through positive role-modeling). Build a trusting dentist-patient relationship with effective communication as the cornerstone. Use tailored management methods matched to patient concerns, such as: Treatment planning in increments. Relaxation techniques. Distraction (momentary or sustained). Behavioral modeling. Control enhancement (e.g., giving patients a sense of control). Guided imagery. Positive reinforcement. Be flexible in approach, adapting to situational factors (e.g., time constraints, patient changes). Acknowledge that while fear may not be "cured," treatment can proceed successfully, and fear can be reduced.

Question 43

What Does 4As Mean? What Does It Do?

Answer 43

The 4As framework is an approach to preventing and managing dental anxiety: Ask: Actively listen and observe the patient to understand their anxiety/fear. Acknowledge: Validate the patient’s feelings and concerns before and after treatment. Assess: Evaluate the level of anxiety, fear, or phobia using observations or tools like questionnaires. Address: Implement tailored strategies to manage anxiety during and after treatment. It ensures a structured, patient-centered approach to reduce anxiety and improve treatment outcomes.

Question 44

Approach to Preventing/Managing: 4As

Answer 44

Before Treatment: Communicate effectively, acknowledge patient fears, and assess their dental/psychosocial history. During Treatment: Assist patients in feeling in control and achieving success (e.g., adapt techniques to their specific concerns, such as fear of needles or drills). Use methods like relaxation, distraction, or control enhancement to manage anxiety. After Treatment: Debrief with the patient (e.g., ask, “How was that for you?”) to address what worked or needs adjustment. Aim to prevent fearful cognitions that could reinforce anxiety. Emphasizes flexibility and tailoring methods to the patient’s needs within a strong dentist-patient relationship.

Question 45

What Does Empathy Mean? Why Is It Important? Core Elements of Empathy

Answer 45

Definition: Empathy is understanding and sharing the feelings of the patient, fostering a trusting relationship. Importance: It builds trust, reduces patient anxiety, and improves cooperation and treatment outcomes. Core Elements: Actively listening to the patient’s concerns. Observing verbal and non-verbal cues. Validating the patient’s emotions (e.g., acknowledging their fear without judgment). Responding with compassion and understanding to create a supportive environment.

Question 46

How Might Anxiety/Fear Manifest?

Answer 46

Signs of Anxiety/Fear: Physiological: Increased heart rate, sweating, trembling (acute stress response). Cognitive: Negative thoughts, fear of pain, or catastrophic thinking. Affective: Feelings of panic, dread, or embarrassment. Behavioral: Avoidance, fidgeting, or reluctance to proceed with treatment. Manifestation in Patients: Adults may appear tense, avoid eye contact, or express concerns verbally. Children may cry, cling, or refuse to sit in the dental chair.

Question 47

Impacts of Dental Anxiety

Answer 47

Dental Attendance: Irregular or avoided appointments, as revealed by patient records or history. Oral Health: Poor oral hygiene, untreated dental issues, or advanced dental disease due to avoidance. Examination may show signs of neglect; history may reveal pain or prior negative experiences.

Question 48

Explanations for the Origins of Dental Anxiety/Fear

Answer 48

Previous Experiences: Traumatic dental visits, pain, or perceived lack of control (revealed through careful dental/social history). Limitations of Dental History: May not capture psychological or social factors fully, requiring broader inquiry. Conditioned Responses: Fear from past negative experiences or learned from others (e.g., parents). Other Factors: General anxiety disorders, cultural influences, or misinformation about dental procedures.

Question 49

Specific Aversive Aspects of Dentistry

Answer 49

Treatment-Related: Fear of drills, needles, or local anesthesia. Sensory Triggers: Sounds (e.g., drill noise), sights (e.g., instruments), or smells (e.g., clinical odors). Psychological Factors: Embarrassment, fear of being scolded, or feeling judged for poor oral health.

Question 50

Aversive Reactions to Dental Treatment (Physical/Medical or Psychological):

Answer 50

Physical/Medical: Gagging, choking, nausea, or fainting. Pain or discomfort from procedures or perceived allergic reactions to local anesthesia. Psychological: Panic, embarrassment, or feeling overwhelmed. Fear of loss of control or helplessness in the dental chair.

Question 51

Loss of Control; Helplessness:

Answer 51

Patients may feel vulnerable due to: The reclined position in the dental chair. Lack of control over procedures or outcomes. Dependence on the dentist’s actions. Contributes to anxiety, especially in patients with a history of trauma or general anxiety.

Question 52

Acknowledge Response

Answer 52

Before Treatment: Validate patient concerns (e.g., “I understand needles can be scary”). After Treatment: Debrief by asking, “How was that for you? Can we change anything?” to address concerns and prevent reinforcing fear. Helps build trust and encourages open communication.

Question 53

Assess: Measuring Anxiety, Fear & Phobia

Answer 53

Methods: Observe behavioral and physiological signs (e.g., fidgeting, sweating). Use patient history or interviews to identify triggers. Consider validated questionnaires (e.g., Dental Anxiety Scale) to quantify anxiety levels. Clinical Relevance: Questionnaires can be useful but are not always necessary; clinical judgment and patient dialogue are key. Assessing anxiety helps tailor interventions and monitor progress.

Question 54

What is the chairside mthod?

Answer 54

- relationship and communication - ask your patient how they cope with other fearful situations - treatment planning increments - relaxation - tell-show-do - behavioural modelling - control enhancement (predictability/ reducing uncertainty: information / time-markers + increasing sense of control: hand signal) - Guided imagery - Distraction (momentary sustained) - Positive reinforcement

Question 55

What is iatrosedation?

Answer 55

Calming the aptient as a direct reesult of the dntis's actions e.g., attitudes, communication style

Question 56

Relaxation methods

Answer 56

Relaxation methods include progressive muscle relaxation and controlled diaphragmatic breathing, both aimed at countering tension associated with arousal or stress. Progressive muscle relaxation involves tensing and releasing muscle groups to reduce stress over time, encouraging patients to practice at home for better adaptation to shorter methods, such as focusing on tense upper body, holding, and releasing. Controlled breathing, on the other hand, helps manage tension by avoiding breath-holding and can be effectively applied in clinical settings with demonstrations to ensure proper technique.

Question 57

Tell-show-do

Answer 57

The "Tell-Show-Do" technique, often used with children, involves three steps to reduce anxiety and enhance sensory control: first, verbally explaining what will happen (e.g., "I'm going to get the germs out of your tooth"); second, demonstrating the procedure outside the mouth, such as showing the noise and spraying water while allowing the child to feel it (e.g., "Listen and feel the water when I spray"); and third, performing the procedure in the mouth without rushing (e.g., "Now I'm going to do the same thing to get those germs out of your tooth"). This method helps manage expectations, reduces anxiety, and alters negative sensory perceptions.

Question 58

Behavioural imagery

Answer 58

The Behavioural Modelling technique, rooted in social learning theory (vicarious learning by observation), involves a child observing a suitable model being treated, with the model demonstrating appropriate coping and cooperative behaviour. The process includes the child watching the model, the operator positively reinforcing the model's actions, making the desired behaviour explicit for the observer, and subsequently reinforcing the child's own coping and cooperation. This method leverages observation to shape the child's behaviour and expectations through the model's actions and their consequences.

Question 59

Control Enhancement

Answer 59

Control enhancement techniques focus on improving predictability and perceived control to address anxiety and fear caused by uncertainty or lack of control. This includes providing informational control with predictable onset, offset, duration, and intensity of procedures or sensations, as well as perceived control through knowledge. Predictability is enhanced with patient signals (e.g., stop, suction), which also increases the patient’s actual control over dental treatment, thereby reducing stress and reappraisal by improving their ability to understand or predict the threatening situation.

Question 60

Guided Imagery

Answer 60

Guided imagery involves the patient choosing a pleasant image they can comfortably evoke in a dental setting, with the operator guiding them through the imagery before and periodically during treatment, while positively reinforcing the patient for focusing on the image and maintaining cooperative behaviour. This technique acts as a distraction, promotes relaxation, and counter-conditions a new response in place of fear.

Question 61

Positive reinforcement

Answer 61

Positive reinforcement, using operant principles to manage fearful or non-fearful behaviours, involves immediately increasing specific desirable behaviours while avoiding punishment, whether deliberate or inadvertent. This approach focuses on identifying the behaviour(s) to reinforce, determining the consequence(s) that might encourage those behaviours, and applying operant conditioning principles to support and sustain non-fearful behaviour effectively.

Question 61

Distraction

Answer 61

Distraction techniques redirect the patient’s attention away from dental treatment using physical activities or mental exercises, such as momentarily wiggling toes, or sustained methods like listening to a story, music, watching a movie, or using virtual reality. By selectively shifting focus from the feared stimulus, these methods reduce anxiety and fear during the procedure and help lower subsequent anxiety or fear.

Question 61

Systematic de-sensitisation

Answer 61

Systematic de-sensitisation, typically used by psychologists or trained therapists for phobias and severe fears when specific stimuli are identified, involves the patient constructing a hierarchy of fearful stimuli and subjective anxiety scales, learning relaxation techniques, and gradually exposing themselves to increasingly anxiety-provoking stimuli while monitoring their response against the scale. Initially done away from surgery and later repeated in the surgical setting, this method uses counter-conditioning to replace the fear response with relaxation.

Question 62

How to reduce anxiety?

Answer 62

According to a 1986 study by O'Shea et al., patients’ advice for reducing anxiety during medical procedures includes providing an initial explanation of planned procedures, describing each step as it happens, instructing patients to remain calm, warning about potential discomfort, offering support through concern and reassurance, reframing the experience to focus away from pain, teaching coping mechanisms like controlled breathing, providing distractions, building trust, showing warmth, and starting with minor procedures first.