Almost 90% of the Indian population is dealing with anxiety problems.
Today, if we talk about this issue, then we can easily observe around us that not only teenagers and old age groups have become its prey, but even kids are suffering from the same difficulty. Anxiety exists everywhere, whether its workplace or home. It’s everywhere!
Patient’s anxiety causes stress to the dentist
A dentist has to tackle so many things in clinics and hospitals, and one of them is patient’s anxiety on dental chair. Dental anxiety and phobia result in avoidance of dental care. It is a frequently encountered problem in dental offices. Formulating acceptable evidence-based therapies for such patients is essential, or else they can be a considerable source of stress for the dentist. These patients need to be identified at the earliest opportunity and their concerns addressed.
Anxiety is often closely linked to painful stimulus and increased pain perception, and thus these patients experience more pain that lasts longer; moreover, they also exaggerate their memory of pain.1 Treating such anxious patients is stressful for the dentist, due to reduced cooperation, requiring more treatment time and resources, ultimately resulting in an unpleasant experience for both the patient and the dentist.2 The practitioner should aim at alleviating the anxiety and fear in such a way that these patients are positively motivated on a long-term basis for future dental visits.
Next are top 10 strategies to manage dental anxiety patients:
1. Relaxation techniques – Jacobsen’s progressive muscular relaxation
A relaxation response is the opposite of a stress response, and when practiced regularly it not only lowers stress and anxiety levels, but also enables an individual to cope with the symptoms of anxiety. This can be achieved by both deep breathing and muscle relaxation. Once a person is physically relaxed, it is difficult to be psychologically upset at the same time. Anxiety-provoking stimuli give rise to physical tension, which in turn increases the person’s perception of anxiety.
Jacobsen’s progressive muscular relaxation: The most common technique taught to the patient is Jacobsen’s progressive muscular relaxation. This involves tensing specific muscle groups for 5–7 seconds, followed by 20 seconds of relaxation. The method can be demonstrated chair-side, and should be practiced and rehearsed by the patient at home. Four major muscle groups are commonly tensed and relaxed. These are:
- feet, calves, thighs, and buttocks
- hands, forearms, and biceps
- chest, stomach, and lower back
- head, face, throat, and shoulders.
Allow 15–20 minutes to practice the relaxation technique.3
2. Guided imagery
Guided imagery has been defined as a directed, deliberate daydream that uses all the senses to create a focused state of relaxation and a sense of physical and emotional well-being. It is a mind–body exercise, wherein patients are taught to develop a mental image of a pleasant, tranquil experience that consciously guides their attention to achieve relaxation, thereby reducing anxiety. There are generally three stages to guided imagery:
- positive suggestion. 4
Imagery can be a pleasant place such as a beach, mountains, lake, or a safe place, and should be engaging and customized to each patient. Patients can be allowed to choose their own mental image or they can be guided by using scripts by the dentist. It is relatively easy to learn, teach, and use in practice. It can be performed by an adequately trained dentist or with the use of audio recordings, and can be performed daily or as needed by the patient.
3. Caring and communication
For patients with dental anxiety, empathy and understanding go a long way. Taking time to listen to patients voice their fears and concerns can make them feel welcome and, ultimately, relaxed.
The most important thing about being a good dentist is being comforting and being a good communicator. A patient’s relationship with his/her dentist and dental team is just like any other—it benefits from open, honest communication.
When speaking to patients, normalizing anxious feelings and avoiding negative phrasing is beneficial. Furthermore, patients should be encouraged to ask questions, and they should be kept informed throughout the dental procedure.5
Acupuncture is a technique, wherein a disease is treated by inserting needles at various points on the body, known as acupuncture points.6 It has been reported that acupuncture is effective in treating dental problems such as
- temporomandibular dysfunction syndrome,
- pain, and
- Sjögren’s syndrome.
It is a simple, inexpensive treatment modality that requires special training before it can be incorporated into practice. Reports on the use of auricular acupuncture for treating chronic and acute anxiety have shown promising results.7
The term ‘hypnosis’ denotes an interaction between one person – the ‘hypnotist’ – and another person or people – the ‘subjects’. In this interaction, the hypnotist attempts to influence the subjects’ perceptions, feelings, thinking, and behavior by asking them to concentrate on ideas and images that may evoke the intended effects. The verbal communications that the hypnotist uses to achieve these effects are termed ‘suggestions’. Suggestions differ from everyday kinds of instructions in that they imply that a ‘successful’ response is experienced by the subject as having a quality of involuntariness or effortlessness.8 It is inexpensive, and has a very low risk of side effects.
The technique needs to be avoided in those with mental health problems, personality disorders, and neurodegenerative disorders. Dentists require special training before they can practice hypnotherapy.
In a meta-analytic review, it was shown that 75% of subjects experienced pain reduction following hypnosis. Studies have also shown effectiveness in anxiety reduction, allowing people to handle stressful dental treatments.9
6. Enhancing control by Tell-Show-Do
Loss of control over the treatment procedure is a significant cause for anxiety, and hence providing control is very essential. Tell-show-do is a behavior-shaping technique that reduces uncertainty and increases predictability in the clinical setting.10 This technique can be used for both child and adult patients. It involves
- verbal explanations of procedures in phrases appropriate to the developmental level of the patient (tell);
- demonstrations for the patient of the visual, auditory, olfactory, and tactile aspects of the procedure in a carefully defined, unthreatening setting (show);
- and then, without deviating from the explanation and demonstration, completion of the procedure (do).
The tell-show-do technique is used with communication skills (verbal and nonverbal) and positive reinforcement.11 This could reduce anxiety due to “fear of the unknown”, and demonstrates to the anxious patient what is considered appropriate behavior in the dental setting and what can be expected in the upcoming treatment session.
7. Computer-assisted relaxation learning
Computer-assisted relaxation learning is a program developed to reduce fear of dental injections. It is a computer-based application utilizing principles of cognitive behavior therapy.
In computer-assisted relaxation learning, individuals view a series of videos in which a fearful patient is taught coping skills and then taken through the gradual steps of a dental injection.
A systematic review by Patel et al indicated that the overall quality of evidence for psychological treatment for injection fear or phobia is poor, and outcome measures need consensus and further development.12 Jet injections and vibrotactile devices are other modern gadgets available for local anesthetic administration. Whether these devices are efficient in alleviating anxiety and phobia needs more exploration with randomized controlled clinical trials.
8. Electronic dental anesthesia
This technique is used to produce dental anesthesia by using the principle of transcutaneous electric nerve stimulation. By means of electrodes, electric flow from the stimulation unit is converted into an ionic current flow in the living tissue and anesthesia is produced, offering pain control without needles, based on the gate-control theory of pain. Electrodes can be placed either extra-orally or intraorally.
Advantages of electronic dental anesthesia are as follows:
- there is no need for a needle
- no need for injection of drugs
- limited soft-tissue anesthesia
- the residual analgesic effect remains for several hours
- it is suitable for the needle-phobic, and
- there is no residual anesthetic effect at the end of the procedure.
- the high cost of the unit
- it is not suitable for all patients and all treatments
- efficacy is not as predictable as with other methods of anesthesia
- it requires training and there is a learning curve, whereby initially the success rate may be low but then it increases with experience.13,14
9. Positive reinforcement
Positive reinforcement is an effective technique to reward desired behaviors and thus strengthens the recurrence of those behaviors. Reinforcers include
- positive voice modulation,
- facial expression,
- verbal praise, and
- appropriate physical demonstrations of affection by all members of the dental team.
These should be individualized, frequently provided, and varied over time.15
10. Communication skills, rapport, and trust building
A good patient–dentist relationship is crucial for the management of anxiety. Communication strategies are very important. There should always be two-way communication. The dentist should first introduce themselves and personally converse with the patient in their office, and listen carefully in a calm, composed, and nonjudgmental way.16
11. Bonus tip – Anxiolytic medications & conscious sedation
Patients who are extremely anxious or phobic typically require a combination of treatments. Anxiolytic medications or conscious sedation may be required on rare occasions. There is a significant risk associated with pharmacological therapies, hence it is essential that the dentist and dental team follow proper protocols, be adequately trained, and have suitable infrastructure before pharmacological interventions can be implemented.
Dental Anxiety 101
Dental anxiety and phobia can have a negative impact on a person’s quality of life, so it’s critical to identify and address these significant roadblocks in order to improve a person’s oral health and overall well-being. It is also the dentist’s duty and responsibility to give quality dental treatment to these patients with special mental needs. Managing these patients should be an integral part of clinical practice because a large portion of the population suffers from anxiety and fear.
Following a thorough evaluation, therapy should be tailored to each individual, based on the dentist’s experience, expertise, level of anxiety, patient cognition, age, cooperation, and clinical situation. The dentist should interact with the patient and discover the root of their fear and anxiety, using self-reporting anxiety and fear scales to categorize the patient as having mild, moderate, or severe anxiety or being dental-phobic.
- Patients who are mildly to moderately worried can often be controlled with psychosocial therapies, while anxiolytic medications or conscious sedation may be required on rare occasions.
- Patients who are extremely anxious or phobic typically require a combination of treatments.
To alleviate the emotional, cognitive, behavioral, and physiological aspects of dental anxiety and fear, a variety of psychological therapies are used. These therapies are effective over time and have favorable impacts on patients, allowing them to seek dental care in the future, which should be the dental team’s primary emphasis.
All successful treatment relies on the cooperation of the dentist and the patient, and a relaxed patient will, unsurprisingly, result in a less stressful environment for the dental team and better treatment outcomes.
- Weisenberg M, Aviram O, Wolf Y, Raphaeli N. Relevant and irrelevant anxiety in the reaction to pain. Pain. 1984; 20(4): 371–383.
- Moore R, Brødsgaard I. Dentists’ perceived stress and its relation to perceptions about anxious patients. Community Dent Oral Epidemiol. 2001; 29(1): 73–80.
- Jacobson E. Progressive Relaxation. Chicago: University of Chicago Press; 1938.
- Hofmann SG, Sawyer AT, Witt AA, Oh D. The effect of mind-fulness based therapy on anxiety and depression: a meta-analytic review. J Consult Clin Psychol. 2010; 78(2): 169–183.
- Appukuttan DP. Strategies to manage patients with dental anxiety and dental phobia: literature review. Clin Cosmet Investig Dent. 2016; 8: 35–50.
- Wolpe J. Reciprocal inhibition as the main basis of psychotherapeutic effects. AMA Arch Neurol Psychiatry. 1954; 72(2): 205–226.
- Ernst E, Pittler MH. The effectiveness of acupuncture in treating acute dental pain: a systemic review. Br Dent J. 1998; 184(9): 443–472.
- Montgomery GH, DuHamel KN, Redd WH. A meta-analysis of hypnotically induced analgesia: how effective is hypnosis? Int J Clin Exp Hypn. 2000; 48(2): 138–153.
- Flammer E, Bongartz W. On the efficacy of hypnosis: a meta-analytic study. Contemp Hypn. 2003; 20(4): 179–197.
- American Academy of Pediatric Dentistry. Special issue: Proceedings of the conference on behavior management for the pediatric dental patient. Pediatr Dent. 2004; 26(2): 110–183.
- Allen KD, Stanley RT, McPherson K. Evaluation of behavior management technology dissemination in pediatric dentistry. Pediatr Dent. 1990; 12(2): 79–82.
- Patel MX, Baker D, Nosarti C. Injection phobia: a systematic review of psychological treatments. Behav Cogn Psychother. 2005; 33(3):343–349.
- Yap AU, Henry CW. Electronic and local anesthesia: a clinical comparison for operative procedures. Quintessence Int. 1996; 27(5): 549–553.
- Dhindsa A, Pandit IK, Srivastava N, Gugnani N. Comparative evaluation of the effectiveness of electronic dental anesthesia with 2% lignocaine in various minor pediatric dental procedures: a clinical study. Contemp Clin Dent. 2011;2(1):27–30.
- Roberts JF, Curzon ME, Koch G, Martens LC. Review: behaviour management techniques in paediatric dentistry. Eur Arch Paediatr Dent. 2010;11(4):166–174.
- Cermak SA, Stein Duker LI, Williams ME, et al. Feasibility of a sensory-adapted dental environment for children with autism. Am J Occup Ther. 2015;69(3):1–10.
Author – Dr Madhulika Banerjee