Anxious or Phobic Dental Patients

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The Body's Response To Pain And Fear


t is valuable to compare the physical response of pain in the body to the relaxation response of the body. (Kroeger 1987)



The stressful situation activates two systems:

The relaxation response produces the opposite effects.

System 1

hypothalamus to anterior pituitary to adrenal cortex

  • adrenal cortex produces steroids

  • inactivates lymphoid tissues

  • stimulates glucose production

  • irritates G.I. tract lining

  • stimulates kidney to produce renin

System 1

hypothalamus to anterior pituitary to adrenal cortex

System 2

hypothalamus to sympathetic division of the autonomic nervous system, sympathetic nerve endings secrete norepinephrine and epinephrine

System 2

hypothalamus to sympathetic division of the autonomic nervous system

  • deactivates sympathetic system

    • decreases

      • epinephrine production

      • blood pressure

      • blood glucose

  • activates parasympathetic system

    • constricts pupils

    • increases salivation

    • decreases respiration

    • decreases heart activities

Gate Control Theory

The Gate Control Theory postulates that the body cannot produce a stress response and a relaxation response at the same time. Presented in 1965 by Melzack and Wall, it shows a correlation between the emotional and cognitive state of the patient and the degree of response to pain stimuli. Though controversial with respect to its physiological basis, the pain research community widely supports its findings.

As a pain impulse is generated in the receptor cell it goes through the spinal cord to the brain where it is interpreted as painful or not painful. The spinal cord is referred to as the "gate." The signal is sent to the brain from the gate. Simultaneously a signal is sent from the brain to the gate to either open or close the gate. This action modifies the intensity of the pain response. If the patient experienced fear during a dental appointment in the past, and if they are expecting pain, their brain signals the gate to be wide open. Thus, the patient will react to the smallest pain impulse.

The theory states that if a patient can learn effective relaxation methods, have confidence in the dentist and staff, and use positive self-talk, then he or she can make their brain signal the gate to be closed. If the patient is relaxed during a procedure, the anesthetics can be more effective. If the anesthetics are more effective, the patient will not respond to minor impulses from the area being treated.

The Gate Control Theory has had a tremendous impact on the way pain is defined. The anatomical and physiological responses to stimuli are influenced by the mental and emotional state of the individual. Current expectations, experiences, and distractions all play a role in the pain experience.

Assessment Techniques

The phobic patient can sometimes be identified during their first phone call to the office to schedule an appointment. Therefore, it is important that the receptionist not only be thorough, but compassionate when dealing with potential patients.

To assist with the identification of a phobic or anxious patient the receptionist should include the following questions in the first conversation with the patient:

  • When was your last dental visit?

  • What was the procedure?

  • How did it make you feel?

  • Are you concerned about any aspect of the dental office?

    If the responses indicate anxiety, the receptionist can reassure the patient that the entire dental staff is very interested in working with individuals and their dental fears. He or she can stress that dental anxiety is normal and that the dental staff has measured success (if applicable) with treating patients with similar fears. Since most dental phobics don't come to their scheduled appointments, this initial reassurance may be necessary for the patient to have the bravery needed to walk through your office's front door.

The receptionist should take note of the patient's responses and inform the dentist before the patient's arrival. This will enable the dentist to structure the first visit differently if anxiety is suspected. It will also allow the dentist to allow more time for the initial visit.

It is important to remember that someone on the dental team may need to approach the patient regarding fear and anxiety. Particularly in adults, the patient may mask his or her behavior making assessment difficult. Additionally, the patient may be too embarrassed to initiate discussion about his or her fears.

It may be beneficial to utilize health history forms which include questions such as: "Have you ever had a bad experience in the dental office?" or "Are you afraid of dental treatment?" Space should be given for the patient to write additional comments about specific fears. Simply spending time at the initial treatment planning appointment and identifying the patient's fears can be rewarding. Such simple actions reassure the patient that the dental staff cares about their emotional state as well as the condition of their teeth.

If the dental staff determines that the patient has a dental phobia, an assessment tool such as the Corah Anxiety Scale can be very useful. This scale "kills two birds with one stone" and completes the patients medical history while determining the extent of his or her fears. Sometimes just the action of writing out the fears can produce a catharsis or purging effect, helping the patient better understand his or her fears.

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