Management of the petrified dental patient

Fear and anxiety are common responses to anticipated or actual dental treatment. This may range from slight feelings of unease during routine procedures, such as an injection or cavity preparation, to feelings of extreme anxiety long before treatment is happening. There is general agreement that anxiety constitutes a major problem for the dentist, and a barrier to optimal care for the patient, as one of the most significant consequences is avoidance of dental treatment. Common triggers include local anaesthetic injection and the dental drill. This paper uses the term anxiety to encompass both fear and anxiety and reviews current strategies for managing anxious people in the dental setting, with a focus on non-invasive operative techniques. CLINICAL RELEVANCE: Being able to recognize fear and anxiety in dental patients is an important part of overall patient management. Knowledge of various behaviour management techniques, and the use of less-invasive operative techniques, enable the clinician to treat a large proportion of anxious people and help them to cope with dental treatment in the primary care setting. Those who remain anxious and unable to cope in the dental setting may require pharmacological techniques, such as conscious sedation, to enable them to receive dental treatment. These techniques are not always readily available, require appropriate training, are more time consuming and costly. In extreme cases, general anaesthesia may be a last resort option.     

The use of dental anxiety questionnaires: a survey of a group of UK dental practitioners

AIM: To determine the frequency of use of dental anxiety assessment questionnaires and factors associated with their use in a group of UK dental practitioners. METHOD: A postal questionnaire to all 328 dentists whose names appear in the British Society for Behavioural Sciences in Dentistry Directory. Information collected for each practitioner included gender, year of qualification, type of practice in which anxious dental patients were treated, treatment used to manage anxious dental patients, type and frequency of use of dental anxiety assessment indices. RESULTS: Questionnaires were returned from 275 (84%) practitioners. 269 were analyzed. Only 54 practitioners (20%) used adult dental anxiety assessment questionnaires and only 46 (17%) used child dental anxiety assessment questionnaires. Male practitioners were more likely to report questionnaire use in comparison with females (P< 0.05), when treating dentally anxious adults (26% v 14%). In addition, practitioners providing intravenous sedation were more likely to use an adult dental anxiety questionnaire (P < 0.04) than those who did not use intravenous sedation (29% v 15%). The type of treatment provided had a significant association with the use of child dental anxiety. Those providing general anaesthesia (P = 0.03) and hypnosis (P = 0.01) for dentally anxious children were more inclined to use a questionnaire. CONCLUSION: The use of pre-treatment dental anxiety assessment questionnaires was low in this group of dentists. Male practitioners and those providing intravenous sedation, general anaesthesia or hypnosis seem more likely to use dental anxiety assessment questionnaires.     

Treatment modalities in a dental fear clinic and the relation with general psychopathology and oral health variables.

OBJECTIVE: To assess differences among highly anxious dental patients assigned to different treatment modes (i.e. behavioural management (BM), nitrous oxide sedation (NOS), intravenous sedation (IVS). Patients were compared with regard to psychological and dental variables before treatment (e.g. number of decayed teeth), and dental variables after treatment (e.g. number of fillings made). DESIGN: Dentists experienced in the treatment of highly anxious patients allocated patients to a treatment mode based upon their clinical judgement. SETTING: Centre for Special Dental Care, Amsterdam, The Netherlands. SUBJECTS: 211 patients from this dental fear clinic. MEASURES: General psychopathology, as measured by the Symptom Checklist 90 (SCL-90), and dental anxiety (DAS, S-DAI, 10-point scale) were measured prior to treatment. From the panoramic radiograph the following pre-treatment dental variables were assessed: number of teeth, number of decayed teeth, number of retained roots, and number of root-filled teeth. After treatment, number of fillings, extractions, endodontically treated elements, number of visits, and treatment duration, were determined from the patients' records. RESULTS: Of the 144 patients who received dental treatment at the clinic, 46.5% was treated using a BM approach, 27.8% with NOS, 22.9% with IVS, and 2.8% under GA. No differences among the treatment groups were found with regard to SCL-90 and dental anxiety. The results showed that patients in the IVS group had statistically significant more decayed teeth than patients in the BM group. Furthermore, more fillings were made in the IVS group than in the BM group. CONCLUSION: Since it appeared possible to treat a large proportion of patients by BM alone, training dentists in the application of psychological methods for the treatment of anxious patients should be stimulated. In addition, future research should seek for variables that, besides oral health, are better able to discriminate between groups of highly anxious patients than measures of dental anxiety and psychopathology.     

Emergency dental clinic patients in South Devon, their anxiety levels, expressed demand for treatment under sedation and suitability for management under sedation.

OBJECTIVE: To assess the anxiety levels of patients attending two salaried dental service emergency clinics, their expressed demand for treatment under sedation, and their medical suitability for dental sedation. DESIGN: A questionnaire survey, incorporating the Modified Dental Anxiety Scale (MDAS) and assessment of American Society of Anesthesiologists' (ASA) physical status classification, of all adult patients attending two emergency dental clinics in Torquay and Newton Abbot. RESULTS: 513 patients returned questionnaires. Only five declined to take part in the study. The mean MDAS for patients attending the two emergency dental clinics was 14.09 (SD 6.04) and 41.9% of patients were classified as dentally anxious (MDAS >15). A preference for treatment under sedation was expressed by 56.3%, of all patients, of whom 50.5% were classified as ASA 1 (without health problems) and would have been suitable for sedation in primary dental care. CONCLUSIONS: The reported dental anxiety levels of patients attending the two emergency dental clinics were found to be much higher than those found by previous studies in general dental practice and at dental school emergency clinics. There was a high expressed demand for treatment under sedation. Further studies are needed to assess the levels of dental anxiety seen at other dental emergency clinics and a health needs assessment to determine need as opposed to expressed demand.     

Use of nitrous oxide and oxygen for conscious sedation to manage pain and anxiety

A 13-item survey of dentist's views about approaches to pain and anxiety management was distributed in Atlantic Canada. Respondents indicated that about 50% had training in conscious-sedation techniques and 20% had learned to administer intravenous (IV) sedation. Sixty-nine percent of those responding had used oral sedatives to help manage fearful patients. Forty-six percent had referred anxious adult patients to specialists or other dentists, and 78% had made similar referrals for anxious children. Seventeen percent reported using conscious sedation, but they typically treated more than 20 anxious patients per year. Most (80%) believed that nitrous oxide and oxygen (N2O/O2) conscious sedation should be included in the treatments that a licensed practitioner can provide, and they were evenly divided in their opinion about the need for a separate licence for its use. However, only half of respondents believed that IV sedation should be included among a general practitioner"s treatment options, and over 70% said that this treatment should be subject to a separate licence. The implications of these findings for curriculum are discussed.     

A study to assess the validity of clinical judgement in determining paediatric dental anxiety and related outcomes of management

OBJECTIVE: The aim of the present study was to determine the validity of subjective anxiety assessment and the outcomes of management of children receiving operative dental treatment. SETTING: The study was conducted at the Departments of Sedation and Child Dental Health, Newcastle Dental Hospital, Newcastle upon Tyne, UK. SUBJECTS AND METHODS: One hundred children and adolescents aged between 8 and 15 years participated in the study. Clinicians subjectively allocated 50 children for treatment with local analgesia alone (low anxiety), and identified 50 children who had the potential to benefit from nitrous oxide and oxygen sedation (high anxiety). Participants then completed the State-Trait Anxiety Inventory for Children (STAIC), the Venham Picture Test (VPT) and the Child Fear Survey Schedule-Dental Subscale (CFSS-DS). A global rating scale classified behaviour during dental treatment. RESULTS: State anxiety and dental fear prior to treatment were significantly higher in children allocated to receive inhalation sedation (P = 0.004 and P = 0.005, respectively). There was no significant difference in trait anxiety or post-treatment state anxiety between the two groups (P = 0.69 and P = 0.06, respectively). Only 11% displayed 'negative' behaviour during treatment: 82% of this group represented those allocated to receive sedation. CONCLUSION: Children receiving inhalation sedation were significantly more anxious prior to treatment than children receiving treatment with local analgesia alone. The findings support the subjective assessment of anxiety in children; however, objective anxiety measures may assist clinicians in identifying specific fears, which may ultimately aid patient management.     

Dental fear among a young adult Saudian population

AIMS: To assess the prevalence of dental fear and reasons for irregular dental attendance among young adult university students; to describe the gender distribution of the dentally anxious population according to the perceived origins or sources of fear; to identify the time of fear development and preference for anaesthesia or sedation before dental treatment. METHOD: A questionnaire incorporating the Dental Fear Scale (DFS) with items related to sources of dental fear stimuli, together with the preference of anaesthesia or sedation before dental treatment and other characteristics. Approximately 500 questionnaires were distributed among Saudian undergraduate students. RESULTS: 368 questionnaires were completed and presented for statistical analysis. The sight and sensation of anaesthetic needles and the sight, sound and sensation of the drill were rated the most fear-eliciting stimuli. Also, females tended to be more anxious than males. Increased heart rate was the most common reported physiological response to fear resulting from dental treatment. The overall level of fear of dental work among the studied population was found to be about 39%.'Lack of time' and 'no need for treatment' were found to be the main reasons for irregular dental visits. Fear of pain and trauma were the major perceived sources of reported fear reactions and were developed mainly during childhood. About 63% of the subjects preferred to have local anaesthesia before dental treatment to prevent or ameliorate dental fear.     

Dental anxiety in a representative sample of residents of a large German city

In a demographic survey, 300 residents of a German city were questioned to determine the prevalence of dental anxiety. The correlation between the amount of dental anxiety and the age, sex, and education of the subjects was examined and the reasons for avoiding dentist’s appointments, the duration of this avoidance, and what the subjects desire from future dental treatment. The Hierarchical Anxiety Questionnaire (HAQ) was used to measure the amount of dental anxiety. The average level of anxiety was 28.8±10.1 according to the HAQ. Young people were more afraid than older people (p=0.007), and women were more anxious than men (p=0.004). Of the women, 72% go to the dentist regularly, but only 60% of the men do (p=0.020). A painful experience while receiving dental treatment was given by 67% as the main reason for their dental anxiety, followed by a fear of needles (35%). The people wished for the most accurate information available about the dental treatment they receive (69%), followed by a compassionate dentist (62%), and treatment that is free of pain (62%). Of the people, 11% [95% CI: (7.5%; 14.5%)] suffer from dental phobia. All dental phobics were able to state the cause of their fear and more urgently wished for help from the dentist in overcoming their anxiety than the non-phobics (p=0.030). To satisfy the needs of the phobic patients, it appears necessary to screen the phobics out of the group of all patients and then offer them adequate therapy, or refer these patients to specialised treatment centres.     

Strategies for combating dental anxiety

Dental anxiety and subsequent avoidance of dental care and deterioration of oral health pose a significant problem for the dental profession. In an attempt to elucidate preferences of anxious dental patients, we gathered survey data from 121 persons at a small, private liberal arts college in the mid-Atlantic region of the United States. Half of the respondents experienced dental anxiety, and most of these (66 percent) attributed anxiety to fear of anticipated pain. The majority of anxious patients preferred a dentist to be friendly (93 percent), talkative (82 percent), and to have an office with adorned walls (89 percent) and a slightly cool temperature (63 percent). Patients who identified themselves as anxious also indicated that music in the background (89 percent) and magazines and books in the dental office (75 percent) were helpful. Anxious patients were more likely than non-anxious patients to prefer a male dentist (77 percent versus 52 percent). This finding was especially marked among anxious male respondents, 93 percent of whom preferred a male dentist compared to 73 percent of anxious female respondents. These survey data may assist dental professionals in understanding and combating patients' dental anxiety, in order to increase the frequency of dental visits and to prompt a corresponding restoration or maintenance of oral health.     

Predicting anxiety during dental treatment using patients'self-reports: less is more

BACKGROUND: Self-reported dental fear measures seldom are used in clinical practice to assess patients' fears. This study examined how well dental fear measures predicted anxious behaviors displayed during dental treatment. METHODS: One hundred eight adult patients (54 percent female) in a periodontology clinic completed several paper-and-pencil demographic, dental fear and general anxiety measures before treatment. Dental practitioners, blinded to their patients' responses, rated their patients' anxiety during treatment on a series of 100-millimeter visual analog scales. RESULTS: Higher Dental Fear Survey scores, younger age, more invasive treatment type and previous avoidance of dental care because of a bad experience all were predictive of greater observed anxiety. Neither self-reported nor observed anxiety was affected by previous experience with a particular practitioner or treatment. CONCLUSIONS: Dentists may assess patients' anxiety quickly and accurately with the Dental Fear Survey or a similar measure, as well as by asking patients about their current dental attendance and previous dental experiences.     

Midazolam conscious sedation in a large Danish municipal dental service for children and adolescents

Objective.  The aim of this study was to describe the introduction and the first six years use of midazolam for conscious sedation in a municipal dental service in Denmark.
Methods.  In 1998, all dentists were introduced to midazolam conscious sedation. A sedation chart was filled in for each session, and parents' assessment was obtained. In 2004, all clinical materials were collected.
Results.  Six hundred and eighty sessions were performed; 63.7% of the children were between 2 and 6 years of age; 88.5% belonged to American Society of Anesthesiologists grade 1; 74.8% of the sedations performed used the oral route of administration. Restorations were performed during 60.3% of the sessions, and extractions during 38.4%. Complications during the sessions were rare, the most frequent being double vision (6.1%), hiccups (2.7%), and paradoxical reaction (2.0%). Using Wilton's sedation scale, 42.9% were calm and 27.7% were agitated during treatment, whereas after treatment 61.7% were calm; 80.4% of the parents were very positive towards this sedation method.
Conclusion.  Sedation with midazolam for dental treatment of children with dental fear and anxiety is a feasible and an efficient method with a low rate of complications. It can probably reduce the need for dental treatment under general anaesthesia.     

Comparing efficacy and safety of four intravenous sedation regimens in dental outpatients.

BACKGROUND: Management of patients' fear and anxiety during dental treatment is a primary concern of dental practitioners. Pharmacological strategies used in outpatient dental settings must be both safe and effective. Regimens of intravenously administered sedative drugs were evaluated in a collaborative, multicenter study of outpatients undergoing removal of impacted third molars. METHODS: A total of 997 patients randomly received one of five treatments: placebo; midazolam administered to a clinical endpoint of conscious sedation (mean dose, 8.6 milligrams); midazolam plus additional midazolam as needed during the procedure (mean total dose, 12.2 mg); fentanyl (1.4 micrograms/kilogram) plus midazolam to achieve the same endpoint of conscious sedation (mean dose, 5.7 mg); or fentanyl (1.4 (micrograms/kg), midazolam (mean dose, 5.8 mg) and methohexital as needed during the procedure (mean dose, 61.0 mg). RESULTS: Each drug regimen reduced anxiety during surgery in comparison with placebo, with the combination of midazolam, fentanyl and methohexital resulting in significantly less anxiety in comparison with the other treatment groups. Pain reports by patients during surgery also were reduced significantly by the combination of fentanyl, midazolam and methohexital. Patients' global evaluations of the efficacy of sedation ranked midazolam with supplemental midazolam and the combination of fentanyl, midazolam and methohexital as significantly more efficacious than the other two drug regiments. The authors noted transient respiratory depression in patients in the two opioid-treated groups, but no other physiological changes were detected. CONCLUSIONS: These data provide evidence that the drugs and doses evaluated resulted in therapeutic benefit to dental outpatients, with minimal incidence of potentially serious adverse effects. CLINICAL IMPLICATIONS: The results of this large-scale study provide assurance to both the public and the dental profession of the safety of parenteral sedation with these drugs and combinations of these drugs when titrated slowly in the recommended doses by appropriately trained dentists.     

Anxiety about dental hygienist treatment

Abstract – Although dental anxiety is a well investigated phenomenon in dental health care, remarkably little is known about anxiety reactions related to treatment carried out by the dental hygienist. In the present study anxiety reactions were measured among 101 patients attending the dental hygienist. General level of anxiety was assessed through the PAQ (Photo Anxiety Questionnaire; S touthard , D e J ongh & H oogstraten , 1991), whereas an additional questionnaire was used to obtain information about specific stimuli and situations that might provoke anxiety in the dental hygienist situation. The results indicated that during dental hygienist treatment only 15% of the patients experienced no feelings of anxiety. Another 15% of the patients reported that a visit to the dental hygienist was more distressing than dental treatment. The level of anxiety appeared to be strongly related to a number of stimuli and situations, with actual pain (78%) and expected pain (67%) major anxiety provoking factors. The relation between pain and anxiety was highly significant, with highly anxious patients having more fear for pain than their low anxious counterparts. Also feelings and sounds of instruments, patient's helplessness and perceived lack of control over what happens were identified as important contributors to anxiety for the dental hygienist treatment. The results of this study suggests that treatment by the dental hygienist is a distressing event for many patients.     

Dental caries, age and anxiety: factors influencing sedation choice for children attending for emergency dental care

OBJECTIVES: The aim of the study was to examine how physical (dental caries) and psychosocial (age, dental anxiety and dental health behaviour) factors, associated with child and parent, influenced dentists' sedation choice when a child presents in pain. METHODS: 600 parents whose children were aged between 5 and 11 years took part: 200 attended for routine dental care (RDC); the remaining 400 attended as emergency patients and were offered either dental general anaesthesia (DGA) or relative analgesia (RA). The subjects were approached and invited to take part. The researcher was blind as to the child's pattern of dental attendance and the type of sedation offered. All parents and children completed self-reported ratings of dental anxiety. The children's teeth were examined to determine past and present dental caries experience. RESULTS: The results showed that children who were offered DGA had greater experience of dentinal caries, were younger and dentally anxious. The children offered RA were older, had a higher frequency of brushing their teeth with fluoride toothpaste and were also dentally anxious. Discriminant analysis showed that 2 canonical functions provided clear categorisation of the three treatment groups. Function 1 was a physical (dental caries) factor, which was related to the child's experience of dentinal caries. Function 2 was a psychosocial factor, which was related to the child's age, dental anxiety and frequency of tooth brushing. A greater proportion of the variance in the treatment offered was explained by Function 1, suggesting that the most important factor in the decision to offer DGA was dentinal caries. Function 2 was of lesser importance. CONCLUSIONS: The findings have implications for the type of sedation offered to children presenting for emergency care. These children may not otherwise receive treatment and the need to provide less anxiety provoking forms of sedation must be promoted. By doing so, parents who have only brought their children when in pain may take advantage of RDC and the treatments offered to prevent and control dental caries and anxiety in their children.     

成人患者牙科畏惧症的临床调查及相关因素分析

目的探讨引发患者焦虑情绪的相关因素,为临床焦虑控制和制定干预措施提供较好的参考依据。方法深圳市第五人民医院口腔科门诊就诊的358名18～75岁的初诊患者,应用口腔焦虑量表和自编牙科畏惧细评表、人口统计学一般项目表进行调查。结果 84.1%的被试者呈现无畏惧或轻度畏惧状态,6.1%呈现中度畏惧,9.8%呈现重度畏惧。引发患者焦虑的前3位因素分别是疼痛（57.5%）、洗牙时的吱吱声（45.0%）、牙钻的声音和震动（37.5%）。结论针对疼痛、洗牙和钻牙的声音等相关因素的临床干预能够有效缓解畏惧情绪。     

氧化亚氮吸入清醒镇静在拔牙术中的止痛作用

实验组选取无笑气吸入禁忌证拔牙患者112例,随机分为60%笑气组61例,40%笑气组51例,在笑气吸入清醒镇静辅以局麻下拔牙;对照组53例,只在局麻下拨牙.结果表明:60%笑气组与40%笑气组的VAS疼痛评分大多较低,与对照组相比,在统计学上有非常显著性差异(P<0.001).提示笑气具有一定的镇静、止痛作用,联合局麻应用可以较好地控制患者焦虑与疼痛的复合状态.     

Experience with dental pain and fear of dental pain

Anxious people tend to overestimate the intensity of aversive events such as fear and pain. When an aversive event has been experienced personally, prediction is based on experience and is possibly less subject to bias due to anxiety. Therefore, it was hypothesized that subjects will overestimate fear of specific dental pains relative to subjects who experienced the pain or procedure personally. Samples of highly anxious dental patients (n=48), patients waiting for periodontal treatment (n=56), and psychology freshmen (n=262) completed a measure of dental anxiety and the Fear of Dental Pain (FDP) questionnaire. All FDP items were extended with the question whether the subject ever experienced the pain personally (yes or no). Less fear was reported when the pain had been experienced personally, with the exception of the sample of highly anxious dental patients. The results suggest that fear of dental pain is a highly important covariate in dental pain research.     

Conscious sedation with propofol in dentistry.

Propofol by continuous intravenous infusion was used as an alternative to nitrous oxide/oxygen for conscious sedation in 19 patients undergoing out-patient dental treatment. Patients were either extremely anxious or mentally and/or physically handicapped. Propofol was administered by a syringe pump at an initial rate of 3 mg/kg/hour. During the procedure the infusion rate was adjusted to attain and maintain the desired level of conscious sedation. The mean time from starting the propofol infusion until reaching the required level of sedation was 11.5 (SD 3.5) minutes. The mean infusion rate was 3.6 (SD 0.65) mg/kg/hour. The average duration of the dental procedure was 55.9 (SD 18.8) minutes. Sedation was satisfactory in all but two patients. There were no side-effects. Recovery was rapid after stopping the infusion. It is concluded that propofol is an acceptable alternative to nitrous oxide/oxygen for conscious sedation in the dental surgery.