Dental fear & Anxiety

Question 1

dental fear

Answer 1

a normal emotional reaction to one or more specific threatening stimuli in the dental environment
- something specific they perceive as threatening e.g. needle, drill, chair

Question 2

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
- general dread. In dentist chair loss of control

Question 3

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.

• Affecting their life, unable to walk past surgery
• Child may refuse to open mouth, run to the toilet
• Need specialist care initially to help control

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

Question 4

5 top stressors for dentists in dentistry

Answer 4

• Running behind schedule
• Causing pain
• Heavy workload
• Late patients
• Anxious patients

Question 5

how can dentists reduce the feeling of mortification for patients?

Answer 5

acknowledge fear

• Appreciate it hard and genuine fear
• Will work through step by step at a comfortable pace for you
• Don’t belittle them - very daunting for them

Question 6

5 different aetiology sources for dental anxiety

Answer 6

• Negative medical and dental experiences e.g. “painful”, “frightening” or “embarrassing”
• ‘influenced’ by family and peers
• media representations of dentistry
• expectation of pain and discomfort
• poor knowledge of modern analgesia

Question 7

how can negative medical and dental experiences be an aetiology of dental anxiety

Answer 7

e.g. “painful”, “frightening” or “embarrassing”

Multiple medical exposure is the precipitator
- E.g. emla cream left on hand for just 10 minutes when meant to be on for an hour prior to injection or IV

Question 8

how can family and peer influences be an aetiology of dental anxiety and how can the dentist assess

Answer 8

• Need to asses patient and understand their background

- DA is easily passed on from parent to child

Question 9

why is media representation important for dental anxiety cases

Answer 9

dentistry is portrayed as a feared thing

- more likely to be anxious

Question 10

what can the expectation of pain do for a patient in terms of dental anxiety

Answer 10

Most patients anticipate great pain when they go to the dentist – doesn’t help keep them calm
- Finger on hand Ok finger in mouth - pain (as of expectation of pain)

Question 11

3 pathways for children to become dentally anxious

Answer 11

• conditioning
• modelling
• information

Question 12

conditioning pathway for child to be dentally anxious is

Answer 12

arising from objective dental pathology and subjective dental and medical experiences. The dentist’s personal sensitivity to children’s fears appears is also crucial.
- Past experience

Question 13

modelling pathway for child to be dentally anxious is

Answer 13

children’s imitation of mother’s behaviour. Mothers of anxious children, higher in state anxiety and behave more variably during consultation than those of non-anxious children.

• Mostly from mothers
• Can be other anxious kids

Question 14

information pathway fro child to be dentally anxious is

Answer 14

possibly through unwitting provision of frightening information, but more likely through absorbing mother’s attitudes to dentistry

• Possibly the wrong information or told in the wrong manner
• Be careful what you say - try and keep positive, not mention pain

Question 15

characteristics of the anxious (6)

Answer 15

• High neuroticism and trait anxiety
• Pessimism & negative expectation
• Proneness to somatisation (the manifestation of psychological distress by the presentation of physical symptoms)
• Low pain threshold anticipation
• Co-morbid anxiety disorders diagnosed
• Co-morbid depressive disorders

Question 16

what are likely thoughts for the anxious and neurotic thinking?

Answer 16

• Fear of negative evaluation
• Pessimistic and vulnerable
• Catastrophic
• Over-inclusive negativity –“life is a disaster / risky / failure/ pointless…”
• Worry as a habit
• Can have other mental health illnesses going on
  (Be aware of them - May need to talk with GP regarding it)

Question 17

what is mood congruency effect?

Answer 17

Neuroticism and clinical depression tend to negatively bias recall about personal information and events

Question 18

what is important to remember about how dental anxious patients when treating them and post treatment

Answer 18

avoidant and fearful dental patients have inaccurate memories for treatment experiences and also benign experiences are recalled negatively, and hence are consistent with a pessimistic and fearful “schema” (negative ways of thinking) about dental treatment
- Can go away from a decent appointment with negative thoughts

Reflection - find out what they didn’t enjoy need to categorise and discuss with them

Question 19

steps in managing an anxious dental patient

Answer 19

Listen to what your patient is saying to you……..
- False reassurance isn’t helpful

Ask the right questions…………

What is their goal?
- Patients main concern – address that whilst also addressing yours too

What do they want to achieve?
- Phrase in a positive way not negatively what they want (E.g. ‘feel calmer’ not ‘ I don’t want to be anxious’)

Question 20

assessment of dental anxiety adults

Answer 20

The Dental Anxiety Scale (DAS) (Corah, 1969) and its derivatives,
- the DAS-R (Ronis, Hansen & Antonakos, 1995) and the MDAS (Humphris, Dyer & Robinson, 2009) are all widely used in the literature.

4 or 5 item questionnaires which can be given to patients to complete.

Scoring instructions are also provided.

• Diagnostic cut offs are provided 19>/25 then phobic
• Might score less than 19 but score 5/5 may qualify as phobic

Both the DAS-R and the MDAS are available freely on the web

Question 21

MDAS

Answer 21

modified dental anxiety scale

Question 22

what features must be in a dental anxiety assessment for children and young adults?

Answer 22

measure should assess specific triggers of dental anxiety or unhelpful thoughts

age taken into account
- picture tests good for younger age groups

Question 23

Venham Picture scale

Answer 23

shows 8 pairs of boys, one with and anxious and one with a non-anxious facial expression and the child is asked to point to the figure they feel most like.
- 4-11 years

Criticisms;

• all figures are male
• some of the facial expressions are ambiguous

Question 24

the facial image scale (FIS)

Answer 24

• Children are asked to point at the face they most feel like.
• Measure of ‘state anxiety’ or may even be measuring the child’s mood that day
• Significantly correlates with Venham Picture Scale

Question 25

what is a factor that could impact child anxiety assessments?

Answer 25

could be that the child has had a bad day and nothing to do with dental treatment - easily impacted

Question 26

MCDASf

Answer 26

Modified Child Dental Anxiety Scale (faces version) - age 8 to 16 - 8 Qs Ask about extraction, GA, gas and air (feel comfortable; laughing gas; IS) - 9th Q hand camultation - medical and dental needle phobia

Question 27

CEDAM

Answer 27

Child Experience of Dental Anxiety Measure - age 9 to 16 Asks children how they feel about dentistry - would they avoid going to treatment; tell parents not want to go - Behaviours, physiological, thoughts assessed Boys tend to not admit anxious they just say not bother - Not shaky or scared or embarrassed but angry and frustrated

Question 28

3 treatment strategies for mild/moderate dental anxiety

Answer 28

- General attitude and the application of a general anxiety reducing treatment style - pharmacological support - teach coping strategies

Question 29

treatment strategy of General attitude and the application of a general anxiety reducing treatment style involves

Answer 29

- Explain the “fight and flight” system to them, let them know they can take control - Acknowledge patient’s feeling of anxiety (Tell them what it is - shaky, inc HR, not good recall. Normal as adrenaline pumping through body) - Engender a trusting relationship - Provide realistic information - Provide control - Agreed stop signal - Provide a high level of predictability (agree the appointment goals and plans at the start; introduce next appointment at end)

Question 30

treatment strategy of pharmacological support involves

Answer 30

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

Question 31

treatment strategy of teaching coping strategies involves

Answer 31

relaxation and distractions

Question 32

ways to give control to patients in dental treatment (4)

Answer 32

- stop signals - rest signals - proceed signals - provide options 'What do you want to happen?” “Which tooth will we restore first?” Allows apparent control but all treatment will still be done

Question 33

stop signals

Answer 33

gives control over pace of the procedure - helps coping - “place your left hand straight in the air if you want me to stop”.

Question 34

rest signals

Answer 34

allows the patient to stop with the understanding that the treatment is not finished yet. - Good for if they have reached their limit for the day – don’t over push them

Question 35

proceed signals

Answer 35

open your mouth when you are ready to start” | - E.g. for Gag reflex patients – when they are ready and comfortable, in the zone

Question 36

relaxation training involves

Answer 36

Teaching patient how to do in the chair - e.g. breathing techniques, Progressive muscle relaxation techniques Breathe in for 3 and out for 3 - Stick chin in the air (don’t mention tongue but by default will be lower - Patient and dentist previous experiences should be considered - may have done before

Question 37

what has relaxation therapy been proven to do for dental anxious patients?

Answer 37

reduce anxiety music works less effectively in children than adults in reducing anxiety

Question 38

distraction involves

Answer 38

Thinking pleasant and relaxing thoughts - Needs cognition - Discuss with them what they suit Imagine somewhere real or imaginary where you can relax and put aside the cares of the world - Hypnosis like Do puzzles in your head - word (anagrams) - number games (counting backwards in 2 from 100) What makes you happy? - Think of 5 things Simple things can be very effective at distracting

Question 39

what is the consensus for treatment of moderate/severe dental anxiety and phobic patients?

Answer 39

to opt for exposure-based treatment programme, such as systematic densensitisation.

Question 40

what is systematic desensitisation?

Answer 40

Patient first trained in relaxation. After this they are encouraged to expose themselves to a hierarchy of fearful situations This procedure can be carried out individually or in a group setting using imagined, video, computer-based or real-life confrontation. - Work with patient at exposure of things that cause anxiety (e.g. 3 in 1 cold air can cause pain so want LA first) - What's important and comfortable to patient - Can be in clinic or psychologist

Question 41

simple desensitisation step by step approach

Answer 41

- Relaxation training – teach how to stay relaxed - Give control in a calm manner – calm, progressive coping manner exposed to people - Fear hierarchy - Successive approximations

Question 42

what is simple desensitisation good for?

Answer 42

needle desensitisation use of real-life dental situations or video images produces the greatest effect

Question 43

what may happen if patient is a more complex case?

Answer 43

preferable for treatment to be carried out by clinical psychologist in close cooperation with the dentist. - Use anxiety questionnaire to assess but Dentists are well-placed to carry out exposure therapy for those with uncomplicated specific fears

Question 44

what is exposure therapy often combine with?

Answer 44

teaching the patient cognitive treatment strategies

Question 45

cognitive treatment strategies involve

Answer 45

- 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” e.g. Thought Diaries

Question 46

what is an effective verbal strategy of tackling dental anxious patients?

Answer 46

challenging their fears and support their successes e.g. Belief - “I have never coped well with pain and I am prone to fail” - Challenge: What about when your child was born? - Response: I got through it pretty well, I only asked for gas if I needed it.

Question 47

symptoms of a panic attack

Answer 47

- Hot or cold flushes - Fear of dying - Feeling lightheaded/faint - Choking feeling - Trembling, shaking - Upset stomach - Racing heart

Question 48

when to refer a dental anxious patient on?

Answer 48

- Where the dental anxiety may be a manifestation of underlying emotional problems or more serious mental difficulties, referral to a clinical psychologist, psychiatrist or specialist dental clinic may be needed. - Where there is high treatment need, but the psychological consequences would be too overwhelming or demanding for the patient, such that the patient is unwilling to have the treatment then a pharmacological approach in the form of a general anaesthetic or intravenous sedation may be appropriate Don’t tell patient you are referring on until patient accepted - rejected can make worse for patient Need good relationship with referral team

Question 49

optimal interventions for dental anxiety treatment

Answer 49

- Phobic avoidance needs desensitisation – refer to local clinical psychology service - Information-giving improves knowledge and dispels fears, hence reducing uncertainty and anxiety. Combining sensory and procedural information appears to be the most effective approach - Simple desensitisation can be carried out in the clinic - Inappropriate beliefs can be evaluated, challenged and restructured