Dental fear and anxiety

Question 1

What is dental fear

Answer 1

a normal emotional reaction to one or more specific threatening stimuli in the dental environment

Question 2

What is dental anxiety

Answer 2

a sense of apprehension that something dreadful is going to happen in relation to dental treatment, coupled with a sense of losing control

Question 3

What is dental phobia

Answer 3

a severe type of dental anxiety manifested as a marked and persistent anxiety in relation to clearly discernible situations or objects e.g. use of drill or to the dental situation in general

Question 4

What is required for a diagnosis of dental phobia

Answer 4

there must be either complete avoidance of necessary dental treatment or endurance of treatment only with dread and in a specialist treatment situation

Question 5

What is the UK prevelence of dental anxiety

Answer 5

11.6% adults, 4 times greater in 18-39 years old v 60+

Question 6

Describe the cycle of dental fear and anxiety

Answer 6

• fear/ anxiety
• avoidance
• deterioration in dental status
• feelings of shame and inferiority
• fear/ anxiety etc

Question 7

A good thing to say to a dentally anxious patient

Answer 7

‘we’re going to take this step by step’

Question 8

What causes dental anxiety?

Answer 8

• negative medical and dental experiences
• influenced by family and peers
• media representations of dentistry
• expectation of pain and discomfort
• poor knowledge of modern analgesia

Question 9

What are the 3 pathways identified which make children dentally anxious

Answer 9

Conditioning
- arising from objective dental pathology and subjective dental experiences.

Modelling
- children’s imitation of mother’s behaviour

Information

• unwitting provision of frightening info
• absorbing mother’s attitudes to dentistry

Question 10

Characteristics of the anxious

Answer 10

• high neuroticism and trait anxiety
• pessimism and negative expectation
• proneness to somatisation (manifestation of psychological distress by the presentation of physical symptoms)
• low pain threshold (they are expecting pain)
• co-morbid anxiety disorders
• co-morbid depressive disorders
• fear of negative evaluation
• pessimistic and vulnerable
• catastrophic
• over-inclusive negativity
• worry as a habit

Question 11

What are examples of anxious and neurotic thinking

Answer 11

• fear of negative evaluation
• pessimistic and vulnerable
• catastrophic
• over-inclusive negativity “life is a disaster/ failure/ pointless etc”
• worry as a habit

Question 12

How do a patients negative thoughts impact their memories of treatment experience

Answer 12

inaccurate memories

benign experiences are recalled negatively

Question 13

what are the 3 provoking factors to fear/ avoidance/safety-seeking/ anticipating disaster

Answer 13

bad experience
high neuroticism
depression and anxiety

Question 14

what are the 3 maintaining factors to fear/ avoidance/safety-seeking/ anticipating disaster

Answer 14

selective memory and attention
high neuroticism
biased judgement

Question 15

how is dental anxiety assessed in adults

Answer 15

The modified dental anxiety scale (MDAS) and the DAS-R

Question 16

what is the diagnostic cut off for the MDAS

Answer 16

19/25

Question 17

how is dental anxiety assessed in children

Answer 17

picture tests (for young children and adolescents)

child experience of dental anxiety measure (CEDAM) for age 9-16

modified child dental anxiety scale (faces version) MCDASf for age 8-16

Question 18

What are the treatment strategies for Mild/moderate dental anxiety

Answer 18

1. general attitude and the application of a general anxiety reducing treatment style
2. pharmachological support
3. teach coping strategies

Question 19

What should the general attitude and application of a general anxiety reducing treatment style be like?

Answer 19

explain the ‘fight and flight’ (how they can take control)

• acknoledge patient’s anxiety
• build trusting relationship
• give realistic information
• provide control e.g. agreed stop signal
• provide high level of predictability (tell them at the start what you’re planning on doing and introduce the next appointment the same day)

Question 20

What pharmachological support can be used for treatment

Answer 20

nitrous oxide sedation (if necessary liaise with GMP regarding prescribing oral sedation prior to treatment)

Question 21

what coping strategies can be taught

Answer 21

relaxation and distraction

Question 22

What control signals can be used by the patient

Answer 22

Stop signals - gives control over the pace of the procedure

Rest signals - allows the patient to stop with the understanding that the treatment is not finished yet

Proceed signals - just as important

Provide options e.g. which tooth will we restore first?

Question 23

An example of a relaxation exercise

Answer 23

breathe in for 2 and out for 3 - helps lower tongue in place too

Question 24

How effective is music at relaxing a patient

Answer 24

not effective with children

effective with adults

Question 25

What ways can someone distract themselves

Answer 25

- think pleasant and relaxing thoughts - do puzzles in their head (anagrams/ number games) - think of 5 things which makes them happy

Question 26

What are the behavioural treatment strategies for mod/severe dental anxiety/phobia

Answer 26

exposure-based treatment programme e.g. systematic desensitisation: - trained in relaxation - then encouraged to expose themselves to a hierarchy of fearful situations (can be individual or group setting using imagined, video, computer based or real life confrontation) For more complex cases, treatment could be carried out by a clinical psychologist in close cooperation with dentist

Question 27

What is the fear hierarchy

Answer 27

``` sitting in the waiting room seeing the needle holding the needle feeling the needle on the gum intra-oral injection ```

Question 28

What is involved in simple desensitisation

Answer 28

- relaxation training - give control in a calm manner - fear hierarchy - successive approximations

Question 29

What are cognitive treatment strategies

Answer 29

- using pleasant and positive imagery - identifying challenging and modifying negative and unhelpful thoughts and replacing these with more positive and realistic thoughts - use of coping statements e.g. I can and I will

Question 30

How could you challenge evidence supporting negative thoughts e.g. Belief: I have never coped well with pain and am prone to fail

Answer 30

What about when your child was born What about your marriage How are you enjoying your work

Question 31

Why is it helpful for highly anxious patients to have their fears challenged

Answer 31

when highly anxious patients have to come up with facts that do not confirm their fears, there is a subsequent decline in their perception of risk

Question 32

When might it be appropriate to refer an anxious patient on?

Answer 32

- where dental anxiety may be a manifestation of underlying emotional problems or more serious mental difficulties - where there is a high treatment need, but the psychological consequences would be too overwhelming/ demanding for the patient. GA or IV sedation may be appropriate

Question 33

What are the optimal interventions

Answer 33

- phobic avoidance needs desensitisation - giving info improves dispels fears (v effective) - simple desensitisation can be carried out in the clinic - inappropriate beliefs can be evaluated, challenged and restructured - severe cases of anxiety plus high need for treatment/ pain = maybe offer sedation

Question 34

How common is dental anxiety

Answer 34

1/10 patients will have high levels

Question 35

What provokes fearful behaviour

Answer 35

- traumatic experiences - inappropriate beliefs/ expectations - neurotic traits

Question 36

What is better, behaviour management or managing behaviour

Answer 36

behaviour management (it's about reducing the underlying fear and anxiety)