Anxious or Phobic Dental Patients



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Actions to Avoid


Experts warn against ignoring the patient's signals of anxiety and discomfort. Stern commands and excessive restraint may result in traumatizing the patient even more.

A significant number of dental professionals report treatment of the anxious patient causes them to become anxious as well. Patients in turn pick up on the anxiety and interpret it as either incompetence or animosity. The operator must recognize his or her own tension level and control it to decrease the patient’s anxiety level.

The words the dental staff uses can reduce or increase the anxiety of the patient from the initial treatment planning appointment. Milgrom (1985) offers an excellent example:

"A dentist after the initial examination might say the following: 'The primary problem is this tooth that hurts. It looks like you will need a root canal, which is a procedure where we take out the nerve and replace it with an inert plug. You have two new cavities that need to be filled, and a few old fillings that should be replaced. You also have moderate periodontal disease which will require treatment. This may sound like a lot of work, but it is all pretty routine dentistry, and everything should turn out 'O.K.' by the time we finish.'"

Though the approach is straightforward enough, the primary focus is negative. The first thing mentioned is a root canal therapy: one of the most dreaded procedures a patient may encounter. Once the fear of the procedure begins, the patient may not pay attention to the remainder of the treatment plan. Instead of focusing on the negative, say:

"Let me begin by saying that most of your teeth are in good shape. You have two kinds of problems, both of which can be successfully treated. I'm glad you came in now, rather than waiting longer. We can make you healthy again. The problem I am most concerned with is the infection in your gums. It is the infection that makes your teeth so sensitive, and can eventually cause more problems. The second problem involves your teeth. There are two new cavities and two to three old fillings that need to be repaired. All of them involve routine patch work and they will be 'good as new' after we're done. The last tooth I want to discuss is the one that you pointed out as bothering you. Although I need to do some more tests, it looks as though that tooth will need more complicated treatment, which I will explain in detail later. It too should turn out fine. I want to give you some antibiotics to reduce the infection in that tooth which will also help the gums. Also, I'd like to start with some simpler procedures so that I can get to know how you react to treatment, and you have a chance to get to know me. Do you have any questions?"



Consider taping yourself during interaction with patients. Do you find any mediocre communication skills in your conversation? Do you emphasize the negative without any positive comments? What is your body posture telling your patients? What do your facial expressions portray?

Some dental schools place a relatively small emphasis on the behavioral sciences as they pertain to the dental experience. Some dental professionals possess little knowledge, experience, or confidence to execute behavioral or psychological techniques in their everyday method of treatment. A happy, relaxed patient is usually a loyal, referring patient. No promises are being made for perfect patient compliance every time. Behavioral techniques deserve at least a brief summary and possibly further independent study, because of their potential to ease stress and anxiety not only for the patient, but for the dental professional as well.



Behavioral management techniques in conjunction with adequate local anesthesia can often provide a comfortable and pleasant experience for the patient receiving dental treatment. All the following behavioral management techniques must be used along with local anesthetics, not in place of them.

Intervention Strategies

T

he Latrosedative Process


The Iatrosedative process, developed by Dr. Nathan Friedman of The School of Dentistry at The University of Southern California, is a technique that is dentist directed through verbal and non-verbal cues from the dentist. Latrosedation is "the act of making calm by the doctor's behavior." This process eliminates or at least significantly reduces the patient’s fears by relearning. The latrosedative process is successful because it gives the Dentist control of the situation and gives the patient a sense of safety.

The process consists of two steps:

  • The Iatrosedative Interview where the dentist focuses on recognizing, analyzing and interpreting the patient's fear and

  • The Iatrosedative Clinical Encounter which specifically deals with the specific fear.

The dentist directs the interview by asking the patient open-ended question such as “Are you having any difficulties?” Giving the patient the opportunity to express concerns enables the Dentist to collect and analyze the symptoms and concerns of the patient. If the patient responds with “I’m afraid of the dentist” or “My teeth are in terrible shape, I’ve neglected them.” then the dentist can begin the latrosedative process and focus in on the concerns of the patient immediately.

It is important that the patient be open and honest for the latrosedative process to work. Since the success of the process relies on the dentist determining the root of the problem, the questions should be open ended at first, then more direct as he or she zeroes in on the cause of the fear. The give and take during the interview serves multiple purposes, the dentist gains the information he or she needs to properly treat the patient while the patient establishes a sense of trust in the dentist. This gives the patient a sense of security while under the dentists care. Once the patient determines the root cause, he or she should outline the dental plan so the patient and the dentist can work through potential fears before the procedure. Consider the following dialogue from “Emergencies in Dental Practice” by F. McCarthy, Chapter 7, written by Dr. Nathan Friedman:

Dr: “Are you having any difficulties?” (An open ended question allows the patient to establish their priorities.)

Patient: “Doctor, I’m terribly afraid of anything to do with by teeth.” (The patient expresses fear and now the Dentist must respond with recognition and acceptance of the problem and follow up questions that will help determine the specific fear.)

Dr: “What is it that you are afraid of?”

Patient: “I hate needles.” (More specific but still desire more information.. There are many reasons patients fear needles including: deep penetration, pain, and body damage.)

Dr: “What is it about injections that bother you?”

Patient: “It’s the pain of the shot that bothers me” (This is the specific threat. Now the questions can be directed toward revealing the origin of the fear and the behavior of the past doctor that may be responsible for this learning.)

Dr: “Have you had painful injections in the past?” (This is a precise question, repeating the word “pain” to get to the origin.)

Patient: “Yes, I have...many times and I’m really afraid of them.” (Sometimes the patient will continue the story, particularly if facilitation is used by nodding the head. If not, then--)

Dr: “Can you tell me what happened?” (This brings the patient closer to explaining the origin.)

Patient: “As a child I had shots for fillings and the needle hurt a lot...they were awful...” (This pairing of pain with injections may be traumatic enough to set up a conditioned response, but if the doctor’s behavior caused fear as well the threat increases.) I cried and squirmed and they got angry which frightened me more...” (The sense of helplessness is magnified here, the danger is intensified by the doctor; he offers this patient no protection... the distrust is compounded by the dentist's anger.) “It got worse because sometimes the shots didn’t take, but he drilled anyway... it was terrible!” (The fear of the unknown is added to the other fears—the patient did not know if he or she would have protection from the pain or not... again compounded by the doctor’s lack of concern.)

Now the dentist can shift his or her strategy from gathering information to giving information. The elements of conditioning for this patient are painfully clear: the pain, the distress, the fear of helplessness and the unknown coupled with a particularly uncaring and uncompassionate dentist. The dentist now begins rebuilding the patients trust in dentists with an empathetic statement of support. This statement should be followed by an interpretation of the patient’s reason for his or her fears then an explanation of how you will assist the patient with eliminating his or her fear. The dentist will state: 1) How he or she will behave, 2) What he or she will do, and 3) How he or she will do it.



Dr: “I can understand why you would be afraid of injections...” (Support, respect and empathy) “It seems to me that you learned you couldn’t trust that particular doctor to protect you from pain.” (This helps show interpretation and explanation of why the patient is still fearful years after the original events.) “You were depending on him but he didn’t seem to want to help you. These feelings still exist within you and you are still feeling today the same terror and distress you felt as a child. But you can unlearn those fears and learn a new set of feelings based on our relationship.” (Suggests and stirs up hope for a new and different kind of relationship.) “Let me tell you how I think things will go. First, I am confident that I can give you an injection with very little, if any, pain. If there is some pain, it will not be enough to be upsetting. (Marks the beginning of the commitment. This is based on the ability to give injections as painlessly as possible. To promise what you cannot deliver would be disastrous.) “I will keep you informed of what I am doing at all times...” (This is to dispel the fear of the unknown.) “If you feel any concern or discomfort I will stop. I will not do any treatment until you are ready and the area is numb…” (To dispel the fear of helplessness and dependency and to create some sense of control for the patient... as well as establish a sense of trust.) “I know from past experiences that you can learn not to be afraid.” (Suggestion that she can learn not to be afraid is coupled with the assurance of the doctor’s knowledge and expertise.)

It is very important to remember that each patient is an individual, so the techniques used on one patient may not work for another. It is also necessary to avoid jumping to conclusions during the interview as each person’s experience is unique. Take the time and really listen to the patient and what he or she is saying. Try to pinpoint what caused their fears. Address the fears specifically, and make a commitment to act differently, fairly, and in the patient’s best interest to build trust and security.

During the second phase of the Latrosedative Clinical Encounter, the Dentist shows that he or she is more than empty promises. The Dentist must focus on every aspect of the appointment, how he or she handles the patient, both through verbal and non-verbal communications and especially and how gently the dental processes are carried out. Tactile behavior must convey concern and competence and must be gentle yet purposeful. Communicate with the patient continuously so the patient is not taken by surprise. Language used by the Dentist should be non-technical and non-threatening. During the entire appointment, the Dentist must convey a sense of concern about the patient’s fears, acknowledge that the patient's fear is not unusual, and vow to help them overcome the fear. Patients should be treated with respect and dignity and they should be able to signal the Dentist to stop at any time if they feel discomfort.

Even though the interview and clinical encounter takes up space in writing, it is actually accomplished in as little as thirty to forty minutes. Data shows that patients with fear and anxiety respond well to this technique.


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