MANAGING DENTAL PATIENT ANXIETY
by Nicole Ellis

››››››››› Evidence of dentistry has dated back to ancient Egyptian and Babylonian times.›› In the 4th and 5th centuries B.C., toothache was believed to be a sign of divine displeasure.› Since there was no in depth study of the dentistry, no significant dentistry was performed during that time.› Relief had to be sought through prayers.› The skulls of Cro-Magnon people displayed evidence of tooth decay, as did the ancient Sumerians (5000 B.C.).› They believed that tooth worms caused tooth decay.› The worms developed from carious materials found in decayed teeth.› During the Middle Ages in Europe, dentistry became more available to the wealthy.› Physicians and surgeons that made house calls performed dental procedures, and they removed decay by rotating a metal rod between the palms.› This instrument was evidence of the earliest model of the Ždental drillŪ.› Dental practitioners migrated to the U.S. in the 1700s, and they focused on the removal of decayed teeth and the fabrication of artificial teeth.› By the late 1800s a man by the name of Greene Vardiman Black developed a foot engine to power the dental drill.›

››››››››› This historical overview of general dentistry gives us a basis for why some patients associate fear with dentistry.› If a person thinks dentistry is scary now, try living in The Middle Ages, where the dentist was also the local barber, embalmist or surgeon.› Mr. Black was successful in inventing foot motor for the dental drill, but he also needed to know how to cope with patient anxiety.› Presently, in the year 2000, dental practitioners have recognized that fear and anxiety associated with dental treatment undermines patient compliance.› I suggest that the most qualified of our dental community develop required courses that dental students receive during didactic and clinical training.› Most practitioners would agree that ž÷a successful practice now depends on inter personal as well as technical skills, particularly the ability to manage dental anxiety.Ó(1) The best place to learn patient anxiety management is in school, where the student has time to learn the proper tested methods of behavior management, instead of trial and error with their own patients in the Žreal worldŪ.› In a 1988 national survey of American adults, 27 percent of respondents delayed seeking treatment because of fear, and 54 percent said they were nervous about going to the dentist because of fear.› (Mendola et al. 444)›

››››››››› According to Dr. Arthur A. Weiner, who is clinical professor and director of the behavioral science course at Tufts School of Dental Medicine, believes that in treating dental anxiety, it should be categorized into two subgroups: (1)exogenous and (2) endogenous.› Exogenous dental anxiety patientsŪ etiology is situation-related.› Individuals experience moist palms, hand tremors, rapid heartbeat and fluttery stomach.› All of these signs are associated with the žfight or flightÓ response in the central nervous system, and are in response to external stimuli.› Endogenous generalized anxiety patients experience lightheadedness, difficulty breathing, hyperventilation and nervousness.› All of these symptoms are felt are very severe levels.› Because these symptoms mimic so many other medical disorders, it is recognized as a medical condition, and should be properly diagnosed.› Identifying between the two can be a difficult process, and since multiple methods of anxiety management are required, it is divided into three major categories:

1.     Observation and interaction

2.     Collection of information

3.     Environmental analysis

›››› Observation and interaction are initial ways of detecting dental anxiety in patients who do not readily express their feelings to the practitioner.› The practitioner as well as the office staff should observe the patientŪs verbal and non-verbal expressions.› Either the patientŪs choice of words when talking about past dental experiences, or the rate at which the patient is talking is an indication of dental anxiety.› Non-verbal expressions such as sitting position in the reception area, rubbing of hands or pacing are also strong signs of dental anxiety.› After determining if a patient does have dental anxiety, the next step is data collection.›

›››› This happens to be the most effective method of identifying and getting a general idea of how to treat each patientŪs dental anxiety.› Data collection is best achieved by providing the patient with anxiety questionnaires.› This should be done prior to patientŪs first visit with any practitioner, preferably a few days to a week before the appointment. (Table I)› The practitioner should follow up the questionnaire with a personal interview in the office.› The purpose of the patient questionnaire is to allow the patient to be a part of all phases of their dental treatment.› It also allows the practitioner and his/her staff to assess the level of anxiety that should be anticipated with each new patient.› The final phase of dental anxiety identification is environmental analysis.

› Viewing the surroundings of the dental office through the eyes of the phobic dental patient is quite significant.› Pamphlets and posters displayed in the reception area can have a negative affect on patients because of the grotesque monsters used on the posters or pamphlets.› Also, the arrangement of the equipment in the operatory, dental drills and all other instruments that could intimidate patients should be kept out of the sight of the phobic dental patient.› Sound is also a factor in the fear of dental patient.› The practitioner should try not to have the operatories too close to the reception area since the sound of dental drills will elevate the patientŪs already high anxiety levels.› Colors, like reds, blues and dark greens, create undesired feelings of arousal in the dental chair.› The practitioner would like the patient to remain as calm and relaxed as possible to ensure that dental treatment runs smoothly.› Another modality of behavior management is relaxation training.› Developed by Dr. Wolpe in the 1940s, ž÷he determined that a human cannot be tense in musculature and relaxed mentally at the same time.Ó(NYSDJ Aug/Sep p.38)› His method was basically to žunteachÓ patients that the situations that appeared to be threatening previously, were not really so, and if they were able to accept this education, then it would be easier for them to relax physically, thus relaxing mentally.› Easier said than done a patient has years of fear and bad experiences behind them.› This is why practitioners have developed new ways of treating the anxious dental patient with custom made treatment plans instead of the usual and customary order of treatment.

›››› According to Dr. Weiner, managing the behavior of a patient with dental anxiety can be achieved after proper identification of anxiety and their causes are established.› In the Journal of General Dentistry (Nov/Dec p.444), Dr. Pauline MendolaŪs questionnaire implied that practitioners learned how to cope and manage with dental anxiety, but much later in their careers.› IŪm sure if they learned in dental school, what took them 10-15 years to learn (by trial and error) while in practice, they would have helped many people with their anxiety toward dentistry, and have more of a patient roster.› Just think of how many patients were lost due to the practitionerŪs inexperience in dealing with dental anxiety.› Some of the questions on the surveys asked practitioners what they felt were the most effective ways of anxiety management.› The top answers ranged from being patient, explaining the dental procedure step by step, to being friendly and communicating to the patient that every measure would be taken to prevent pain. (Tables 2 & 3)› Dr. Mendola also surveyed 127 senior dental students as part of another research study, and they were asked essentially the same questions as the practitioners.› In Table 4 the contrast in their answers is shown, and the results were what the general practitioners rated as highly effective the senior dental students did not.› This proves that the need for patient anxiety education is imperative while dentists are still in school.› New students graduating from dental school will be more efficient in identifying and managing dental anxiety, as well as having a higher potential for a more profitable and distinguished practice.

››››››››› Dr. Jeffrey Gurian, who is faculty at New York University College of DentistryŪs oral medicine department, currently runs a medical facility known as the žHealing CenterÓ.› Dr. Gurian believes that, ževeryone has the capacity to heal other peopleÓ.› In other words, healing through touch.› This works by having someone trusted transfer positive energy from their body to the patientŪs, but the patient must be open-minded to receiving this positive energy or the procedure will not work.› Dr. Gurian says, žItŪs important for people to get in touch with the power that is within themselves.Ó› He also feels that, ž÷because our society doesnŪt understand the power of touch, because itŪs been so abused, that weŪre not more comfortable with the transfer of positive energy from one person to another.Ó› At the žHealing CenterÓ, Dr. Gurian has created an atmosphere or warmth and tranquility with the type of lighting, music, and incense used, which he says, aids in strengthening some of the chakras and allowing oneself ž÷to experience the beauty of touch.Ó› In combining Dr. GurianŪs practice of healing through touch and dentistryŪs clinical and technical procedures, fearful dental patients can adapt to a more modern and approachable method of dental treatment.› This is why I propose that patient anxiety management be incorporated into the dental school curriculum.

››››››››› It is shown in Dr. MendolaŪs study that dental studentsŪ responses to what is considered to be žvery effectiveÓ anxiety deterrents, differed greatly than the responses of the general practitioners.(Mendola, 446) Since the general practitioners who were surveyed, ž÷had been in practice for an average of 19.8 years and treated an average of 62.6 patients per week.Ó, I would consider their opinion to be more sound than that of the dental students.› It is for the following reasons that patient anxiety management should be included in dental schools and why future dentists should advocate it:

Ö        Develop interpersonal skills (behavioral intervention)

Ö        Increase patient confidence (patient compliance)

Ö        Increase office morale

Ö        Increase patient roster

Ö        Increase revenue

›››› In following these steps, a dentist is sure to succeed in comforting an anxious patient and building a prosperous practice.› But the foundation should be established while in school; the student will be aware that dental anxiety is a real problem that can have debilitating effects on a dental practice and its staff.

›››› I interviewed two people affiliated with the dental field.› One is a dental assistant, and the other is a› dental patient.› The dental assitant› which I interviewed has been an assistant at New York University College of Dentistry for three years, and the patient has been treated at NYUCD for approximately four years.› When asked what his methods are for calming an anxious dental patient, his response was, žWell, IŪll sit and talk to them, or reassure them that the faculty in the clinic are very experienced and the student working on them is very capable to do whatever procedure heŪs going to do.Ó› He also said that heŪd either hold the patientŪs hand or talk softly to them about the progress of the work being done.› This, he says, helps in distracting and calming the patient.› The second interview with the patient almost echoes what the dental assistant said.› This patient admits that she suffers from dental anxiety and believes that it is the role of the dental practitioner to establish trust between dentist and patient, and also to inform her of what will be done prior to starting the appointment.› According to her, žHe never prepared told me that I was going to be in the chair for eight hours at a time, never told me he was going to be grinding my teeth the whole day.› This caused me great anxiety, and I said to him after the first time that he needed to explain and prepare me for what you are going to do, so that when I sit in the chair, I know how long IŪll be here, IŪll know what the procedure is and that would help to alleviate my anxiety.Ó› When asked how she felt about including anxiety management in dental school curriculum, her response was, žItŪs part of patient management, and you put a lot of trust in this person to work on your teeth, and if they make a mistake, you donŪt have these teeth.› He needs to explain to me what my treatment plan is, how long it will take, how many appointments, and how much it will cost.› Money can also be very stressful because dental treatment is so expensive.Ó› These interviews show that personalizing and alleviating dental anxiety is beneficial for dental treatment.› It is also apparent that sharpening the interpersonal skills of the dentist and dental team can prove to be a huge asset in any dental setting.

›››› In conclusion, we all can agree that patient anxiety is a hindrance when trying to achieve and maintain optimum oral health.› With the statistics and information provided, education and patience prove to be our only solution for this dilemma.› Our first step in achieving this goal is to incorporate patient anxiety management into the dental schoolŪs curriculum as a solid foundation for patient compliance in dental treatment.