Anxious or Phobic Dental Patients



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Voice Control


Voice control is one of the methods that can be successful in calming a child who is out of control. Sometimes, it may be necessary for the dentist to raise his or her voice level to assert authority over a misbehaving child. It is important to convey that the dentist is not angry with the child, but that the child's behavior is unacceptable. It is important for the dentist to remember that as soon as the child’s attention is regained, he or she should immediately change back to a normal, soft, friendly tone of voice. Give positive reinforcement and start talking about something that has been determined to interest the child such as Mickey Mouse (or the latest movie hero) to get the child’s mind back on a positive track.

Tell-Show-Do


Children, like most people, have a fear of the unknown. A particular instrument can be threatening until the child is introduced to it. Show the child the instrument, tell them what it does, and use the instrument to perform the procedure on an alternative subject such as a stuffed animal (it may be helpful to keep one on hand for such demonstrations). Many times the child just wants to hold or touch the instrument. As long as it’s safe and doesn’t compromise the sterility of the procedure, it may be helpful to let the child touch the instrument. Be certain to inform the child when it is acceptable to touch the dental instruments and when they should keep their hands to themselves.

Restraint


It is dangerous for a child to squirm or grab at instruments while they are being treated. It is important for the dentist to explain to the child that grabbing is unacceptable and that if they are unable to follow directions and remain calm during a procedure, they may be restrained. If a child requires restraint during a procedure, a practice that is considered controversial, it may be helpful to "ease" into full restraints. If a child is simply a bit squirmy during an injection, the assistant or parent can hold the patient’s hand while the injection is performed. If the child becomes out of control, it may be necessary to use more powerful restraints, such as a Papoose Board, to safely treat the child. A Papoose Board consists of a firm backing with cloth ties or Velcro used to snugly wrap the child’s arms, legs, and stabilize the head to the board. It is suggested that if the use of such restraint becomes necessary the parent should not only be consulted, but should assist in placing the child in the device. It is essential that prior to use, the dentist or dental assistant explain the procedure and benefits of using such a method of restraint.

Medication


There are many different medications that can assist with calming children for dental procedures. It is suggested that medications that allow for conscious sedation be used so an anxious child learns to cope with the procedures over time, thus enabling the child to have a dental procedure without medication.

The most common conscious sedative used in dentistry is Diazepam. Diazepam is often given to the patient prior to the arrival to the dental office as the onset of action for an oral dose is 45 to 90 minutes and it’s duration is from 2 to 4 hours. It has a long half-life (20 to 100 hours) so it is not desirable for short procedures. It is taken in a pill form, so can be easily administered in children.

Studies also show good results with Midazolam. It is absorbed rapidly (within 10 minutes if administered nasally, 1 hour orally), has a short duration of action and has few side effects. It can also be administered intravenously if necessary.



Nitrous oxide/oxygen sedation is also effective in calming pediatric patients, but is typically a last resort.

If the child is too disruptive in the general practice setting, consider referral to a Pedodontist. Pedodontists specialize in working with children and are trained in behavioral management techniques and have offices specially designed for children.


Socio-Legal Concerns


In recent years, there is significant public concern over matters of child abuse in the dental setting. While the procedures covered here are considered acceptable, it is important to use any means of restraint or medication in a professional way that is in the best interest of the child. In all instances that restraint or medication is used, it is necessary to obtain a specific informed consent from the parent. (Braham et al, 1994) It is also necessary that a witness present (the assistant) at all procedures involving children.

Parents may find some behavior techniques unacceptable, even if they are commonly accepted in dentistry. Informed consent must include the nature of the intended treatment, the benefits and risks of the treatment, alternate methods of treatment, and the benefits and risks of not receiving treatment. It can no longer be assumed that the parent gives full consent to any type of treatment if they have not signed a written, detailed consent form.




How Do Dentists Treat Anxious Patients?


W

hile much of what a dentist can do to treat an anxious patient may seem like common sense, it is important to remember that it only takes one bad experience to deter an anxious patient from returning for dental treatment. It is up to the dentist and his or her staff to ensure that the patient not only receives exceptional dental care, but compassionate care as well. According to Dr. Josh Bernstein in his April 2008 article, Your Patient's Wow Experience – don't hurt them!, he emphasizes that dentists simply need to revisit the basic principles of comfortable dentistry to ensure relief for the anxious patient.

Dr. Bernstein focuses on making a patient as comfortable as possible during each visit. He believes that the most important step toward making a patient comfortable with all dental procedures begins with a painless injection. The most important step in administering a painless injection is to take the time necessary to allow the anesthetic to work. It takes up to five minutes for a topical and ten minutes for an injection to take effect. Once the dentist has established trust with the patient through a simple procedure such as an injection, the patient will be more agreeable when it is time for longer and more involved procedures. Dr. Bernstien also suggests that both the dentist and his staff be up to date on the most recent equipment, techniques, and materials used on a day-to-day basis. Greater knowledge and understanding of dentistry provides a patient with confidence that the dentist and his staff are knowledgeable and reliable.

Some surveys conducted in recent years have shown that in addition to painless injections, it is important to spend time explaining the procedure to the patient and giving the patient an opportunity to signal for a rest during the procedure if necessary . Patients have also benefited from music distraction, relaxation therapy, and nitrous oxide-oxygen conscious sedation.



A study published in 1991 (Smith, Kroeger, Mullins) provides more ideas to assist with managing patient anxiety.

  • Be friendly to the patient

  • Show that you pay attention to what the patient says

  • Be calm and patient

  • Reassure the patient during the procedure

  • Make the patient feel welcome

  • Show that you take seriously what the patient has to say

  • Show that you understand what the patient is feeling

  • Use understandable words in talking about the patient's care

  • During the procedure, ask if the patient is having any discomfort

  • Encourage the patient to ask questions about the treatment

  • Say what you are going to do before starting

  • Give moral support during the procedure

Some dentists also suggest using humor, giving a reassuring touch, employing a well-trained and empathetic staff, and generally conveying a sincere concern for the patient's well being.


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