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.     

Relaxation and complementary therapies: an alternative approach to managing dental anxiety in clinical practice

Dental anxiety is a widespread problem and has a significant impact on the provision of dental care for the general population. Anxiety leads to avoidance of dental treatment and increased stress for dental practitioners. Traditionally, dental anxiety has been managed using pharmacological techniques. This article reviews alternative treatment approaches, including psychological and complementary therapies which can be used in managing dental anxiety and facilitating dental treatment. Many of these approaches are currently being used within the dental profession. Others are gaining a wider acceptance as to their usage. Where available, the evidence of their efficacy will be reviewed.     

Dental anxiety: differentiation, identification and behavioral management.

Dental anxiety has always been and still is a major impediment to regular dental care for a significant proportion of the general public. In years past, dental professionals could afford, by and large, to ignore this problem. Practices could flourish based on their technical virtuosity, and fearful or anxious patients might be considered a burden rather than a concern. Today, however, the laws of supply and demand are causing dentists to pay increased attention to aspects of the profession that extend beyond the science of clinical technique. A successful practice now depends on interpersonal as well as technical skills, particularly the ability to manage dental anxiety. Despite this, most dentists admit to a surprising lack of confidence when it comes to understanding the nature of anxiety and the modern methods advocated for its everyday management, which generally rely on behavioral modes of intervention. This paper is designed to familiarize practitioners with some of the basic elements of dental fear and anxiety, and their day to day management.     

Music interventions for dental anxiety

Anxiety is a significant issue in the dental care of adults and children. Dental anxiety often leads to avoidance of dental care which may result in significant deterioration of oral and dental health. Non‐pharmacological anxiety management interventions such as music listening are increasingly used in dental care. Although efficacy for music's anxiolytic effects has been established for pre‐operative anxiety, findings regarding the use of music listening for dental anxiety are inconclusive, especially for children. The use of music for passive distraction may not be adequate for children and highly anxious adults. Instead, interventions offered by a trained music therapist may be needed to optimize music's anxiolytic impact. Music therapy interventions are individualized to the patient's presenting needs and geared at enhancing patients’ active engagement in the management of their anxiety. Interventions may include (i) active refocusing of attention, (ii) music‐guided deep breathing, (iii) music‐assisted relaxation, and (iv) music‐guided imagery. In addition, music therapists can teach patients music‐based anxiety management skills prior to dental treatments, offer them the opportunity to express emotions related to the upcoming procedure, and help them gain a sense of control and safety. Clinical guidelines for the use of music listening by dental practitioners are offered.     

Childhood fear and anxiety states in relation to dental treatment

Five years experience by the authors in organizing a dental psychology clinic has impressed on them that many excessively fearful child patients have a history of untoward dental and medical experiences which might have been prevented. A background to an understanding of fear and anxiety in children is presented, and two cases are described to illustrate straight-forward behavior modification techniques which can be used to help the fearful or excessively anxious child cope with dental treatment.     

Dental anxiety in Iceland: an epidemiological postal survey

In this study, we examined the prevalence of specific (dental) phobia among a sample of the Icelandic population. In addition to dental anxiety we explored factors that could be related to dental anxiety. In the period 1972–73, a stratified sample of 1641 schoolchildren in Reykjavík was selected for a study on malocclusion, dental maturation and other factors. Twenty‐two years later (1995), a postal survey conducted in this group looked at many variables relating to oral health, including orofacial pain, functional oral disorders, self‐perception of dental and general appearance and need for orthodontic treatment. Out of 1529 individuals contacted, 1192 completed questionnaires were returned (response rate 78%). Questions based on DSM‐IV criteria of specific (dental) phobia (DP) were included. Ninety‐six participants reported that they had avoided dental treatment during the previous 6 months. Twenty‐one respondents fulfilled DSM‐IV criteria for specific (dental) phobia (DP) and 75 admitted to many symptoms of dental anxiety (DA). Specific (dental) phobia (DP) was more prevalent among women than among men. The divorced or widowed were most at risk, as were non‐salaried respondents. Most respondents attributed the onset of their phobias to a specific painful or fearful experience. There was a significant difference between the total dentally anxious (TDA = DA+DP) and the not dentally anxious (NDA) with regard to sex (women‐higher TDA) and marital status (divorced or widowed‐higher TDA). The TDA had statistically fewer teeth than the NDA and received dental treatment less frequently.     

New guidelines for cardiac risk assessment prior to non‐cardiac surgery

To cite this article:
Int J Dent Hygiene
DOI: 10.1111/j.1601‐5037.2009.00427.x
Pickett FA. New guidelines for cardiac risk assessment prior to non‐cardiac surgery. Abstract: The European Society of Cardiology (ESC) has established guidelines to determine the risk for non‐cardiac procedures, such as oral procedures, when individuals have experienced severe cardiac disease, including myocardial infarction. This is the first time the ESC has developed consensus guidelines to assist practitioners in managing care for cardiac patients receiving medical or dental procedures. Factors for risk assessment are described and management for oral care is discussed.     

What dental phobics say about their dental experiences

Previous surveys have indicated that there is a substantial proportion of dentally anxious individuals in the general population. Many of these individuals avoid contact with dentistry as much as possible, while fearful individuals who present themselves for treatment are probably too uncomfortable or too afraid to make their views known. Consequently, a study of the feelings and attitudes of a group of dental phobics was carried out as part of a larger study of the efficacy of psychological treatments for excessive dental anxiety. The subjects were recruited by means of a newspaper advertisement and asked to complete a questionnaire designed to obtain information regarding their dental experiences and attitudes. Twenty-three individuals provided enough data for analysis. They were distributed widely in terms of age, education, income levels, and general fearfulness. They reported less satisfaction with the level of understanding or acceptance found in the last dentist they had seen than with the dentist's level of technical competence and the diagnostic information they received. Dental phobics who had been to a dentist in the past year were generally more satisfied with their dentist than those who had not. It is suggested that a good dentist-patient relationship based on understanding and acceptance is an important factor in overcoming the avoidance of fearful patients.     

Referrals to a secondary care dental clinic for anxious adult patients: implications for treatment.

OBJECTIVES: This study aimed to determine the methods suggested by general dental practitioners for management of patients with dental anxiety whom they refer to a dental hospital setting, the treatment modalities eventually used with such patients and the relationship between patients previous sedation experience and the current referral. METHODS: Consecutive referral letters (n = 125) for management of patients with dental anxiety over a 16 month period were analysed for content, including reason for referral and suggested treatment modalities. Patient records were also examined for previous sedation experience. RESULTS: From 115 referrals eligible for analysis, the dentists requested management of anxiety using pharmacological methods in 113 referrals with only two referrals mentioning psychologically-based treatments. In secondary care, 29% of the adult referrals opted for dental treatment using psychological techniques alone. CONCLUSIONS: In spite of the efficacy of psychological treatments for dental anxiety, primary and secondary care dentists appear not to be suggesting or promoting their use for patients with dental anxiety. Further research into the availablility of, and barriers to accessing the full range of services for those with dental anxiety, including patient perspectives, needs to be undertaken.     

Dental anxiety and symptoms of general anxiety and depression in 15‐year‐olds

Abstract: Objectives: The objective of the study was to analyse the relationship between dental anxiety and symptoms of general anxiety and depression among 15‐year‐old individuals. Methods: The sample analysed included 221 randomly selected 15‐year‐old individuals living in the city of Jönköping, Sweden. One questionnaire captured sociodemography and dental history, while dental anxiety was assessed by the Dental Fear Survey (DFS) and symptoms of general anxiety and depression by the Hospital Anxiety and Depression Scale (HADS). Results: About 6% of the adolescents were classified as dentally anxious. Symptoms of general anxiety and depression were significantly correlated with dental anxiety in both the bivariate and multivariate analyses. The latter analyses were adjusted for gender and previous painful experiences of dental care. Individuals with high dental anxiety showed general anxiety scores on a clinical level (mean = 9.8, SD = 4.3). Conclusions: Symptoms of general anxiety and depression were shown to be significantly correlated with dental anxiety among 15‐year‐old individuals.     

Dental fear in children and adolescents: a comparison of forms of anxiety management practised by general and paediatric dentists

International Journal of Paediatric Dentistry 2011; 22: 60–67 Background. About 11% of children and adolescents suffer from dental fear. These young people run an increasing risk of undergoing more invasive treatments. Aim. We researched the management of dental anxiety in young patients by general and paediatric dentists as well as by trained and untrained dentists. Design. Eight hundred dentists in Germany were interviewed via e‐mail regarding their experience, treatment techniques, information material and complications during the treatment of fearful children. We also examined how difficult dentists judge the treatment of anxious children and how often they participate in continuing education courses. Results. Paediatric dentists applied a greater spectrum of management techniques than general dentists. They used more often psychotherapeutic interventions and anxiety assessment questionnaires. Dentists who frequently attend in continuing education courses judged the treatment to be less difficult and also used psychotherapeutic interventions more often. Conclusions. German paediatric dentists and dentists who take continuing education courses utilise a broader range of techniques to manage dental anxiety. They may be eminently suited to treat children with severe forms of anxiety. Therefore, dentists who treat young patients should participate in education programmes so as to reduce both the anxiety of their patients and their own anxiety.     

Clinical correlates of dental anxiety among older adults

Most studies of the relationship between dental anxiety and oral health status have used subjective rather than clinical indicators of oral health. In this paper we examine differences between older adults who are and are not dentally anxious using a broad range of clinical measures. The data show that dentally anxious individuals were more likely to be edentulous, and among the dentate, had more missing and fewer filled teeth. As a result, dentally anxious dentate subjects were more likely to need prosthodontic treatment. They were also more likely to need immediate treatment for the relief of pain and infection and periodontal care. There was evidence to suggest differences in patterns of dental treatment between those who were and were not dentally anxious and some evidence consistent with the hypothesis that aging influences the relationship between dental anxiety and oral health status.     

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.     

A comparison between audio and audiovisual distraction techniques in managing anxious pediatric dental patients

Pain is not the sole reason for fear of dentistry. Anxiety or the fear of unknown during dental treatment is a major factor and it has been the major concern for dentists for a long time. Therefore, the main aim of this study was to evaluate and compare the two distraction techniques, viz, audio distraction and audiovisual distraction, in management of anxious pediatric dental patients. Sixty children aged between 4-8 years were divided into three groups. Each child had four dental visits--screening visit, prophylaxis visit, cavity preparation and restoration visit, and extraction visit. Child's anxiety level in each visit was assessed using a combination of four measures: Venham's picture test, Venham's rating of clinical anxiety, pulse rate, and oxygen saturation. The values obtained were tabulated and subjected to statistical analysis. It was concluded that audiovisual distraction technique was more effective in managing anxious pediatric dental patient as compared to audio distraction technique.     

Psychosocial consequences of dental fear and anxiety

OBJECTIVES: The aim of this study was to examine the negative psychosocial impacts of dental anxiety in a sample of dentally fearful and anxious individuals recruited from the general population. The associations between psychosocial impacts, dental anxiety scale (DAS) scores and other severe fears were explored. METHODS: One hundred and thirty-five subjects who were anxious or fearful about dental treatment were divided into low and high general fear groups based on the number of other severe fears they reported. Negative psychosocial impacts were assessed using a modified form of the scale developed by Kent et al. (1996). This consisted of three dimensions: psychological reactions, social relationships and avoidance/inhibition. Other measures included self-ratings of oral, general and emotional health and scales to assess self-esteem and morale. RESULTS: Overall, 93.1% of subjects reported one or more impacts. Those in the high-fear group had higher psychosocial impact scores than those in the low-fear group (means of 4.19 vs. 2.85; P < 0.05). Differences were most marked with respect to psychological consequences and avoidance/inhibition. The high-fear group had scores indicative of lower self-esteem and lower morale. Forward stepwise linear and logistic regression analyses indicated that both dental anxiety and general fearfulness contributed to these negative outcomes. However, the latter was a more consistent predictor in that it entered six of seven models generated while the former entered only four. CONCLUSION: The study indicated that dental fear and anxiety have pervasive psychosocial consequences, and that these are more marked among subjects with high levels of general fearfulness. It also provided evidence of the validity of a modified form of the psychosocial impact scale developed by Kent et al. (1996).     

The Monitor Practice Program: implications for dentistry and dental education

The restorative model of care, known colloquially as drilling and filling, has been challenged on the basis of its inappropriateness. The Caries Management System protocol was developed as an evidence‐based strategy for non‐surgical treatment of caries lesions and the Monitor Practice Program was designed to test the hypothesis that use of the protocol would reduce risk of dental caries experience. After 7 years, patients attending intervention practices, compared with those attending control practices, needed: 30%–50% fewer restorative interventions; 55% fewer first time restorative interventions; 32% fewer repeat restorative interventions; and were only 23% as likely to be classified as high risk. The outcome was cost‐effective and patients attending intervention practices highly valued non‐invasive care, and intervention dentists derived professional satisfaction from non‐surgical caries management. The implications of the program are that the general public will likely embrace the benefits of non‐invasive caries management, as will many current and future dental practitioners. This calls for dental practice reform including: the establishment of a clinical discipline in cariology; cariology curriculum development; revised accreditation regulations for cariology programs in dental schools; advanced training in clinical cariology leading to a specialty; support from the dental profession; and public health advocacy.     

Treatment outcome in subgroups of uncooperative child dental patients: an exploratory study

Objectives. The principal aims of this study were to evaluate the treatment outcome in subgroups of uncooperative child dental patients and to test the validity of these subgroups, which were based on fear and personality characteristics. Design. An exploratory, intervention study using quantified questionnaire, interview and observation data. Sample and methods. Eighty‐six 4 to 12‐year‐old uncooperative child dental patients (of whom 81 were divided retrospectively into four subgroups) and their accompanying parents were followed up during treatment at a specialist paediatric dental clinic in Sweden. Treatment was based on behaviour management techniques, supported by nitrous oxide/oxygen sedation if necessary. At baseline, parents answered a questionnaire including questions on child dental and general fear, temperament and behaviour, and parental dental fear, emotional stress, locus of control, parenting efficacy and attitudes to dental care, some of which were repeated post‐treatment. The treating dentist rated child behaviour according to the acceptance of a maximum of 14 treatment steps at each visit. Results. Approximately 90% of all children managed to undergo the dental treatment. Child dental fear and parental emotional stress decreased during treatment. Externalizing, impulsive children showed lower acceptance. In fearful, inhibited children, integrated use of sedation appeared to facilitate acceptance. Validity of the subgroups characterized as ‘fearful, extrovert, outgoing’, ‘fearful, inhibited’ and ‘externalizing, impulsive’ was supported, while heterogeneity within the group of ‘non‐fearful, extrovert, outgoing’ children made validation difficult. Conclusion. Fear and personality characteristics may serve as diagnostic aids when planning treatment of uncooperative child dental patients. Controlled outcome studies using differentiated treatment methods for children with different fear and personality profiles are needed.     

Full-arch implant-retained prosthetics in general dental practice

The loss of all teeth from one or both dental arches is a significant disability affecting self-confidence, communication, masticatory function and aesthetics. Whilst missing teeth cannot be restored to the natural state, the development of a prosthetic dentition has been a goal of dental science throughout the centuries. Contemporary techniques allow for the replacement of missing dentition with fixed or removable solutions, solving many of the problems. Implant dentistry has transformed this area of medicine. This article provides dental practitioners with an overview of this important area of patient care. CLINICAL RELEVANCE: Dental practitioners in clinical practice will frequently see edentulism; a good understanding of the available options for rehabilitation is essential.     

Psychological disorders and dental anxiety in a young adult population

OBJECTIVES: It has been suggested that some individuals who are fearful or anxious about dental treatment have a constitutional vulnerability to anxiety disorders as evidenced by the presence of multiple fears, generalized anxiety or panic disorders. This paper compares the prevalence of psychological disorders among dentally anxious and non-anxious groups drawn from the general population. METHODS: Data were obtained as part of a birth cohort study when study members were aged 18 years. They were assessed using the Dental Anxiety Scale (DAS) and the Diagnostic Interview Schedule (DIS). The disorders diagnosed by the DIS were major depressive episode, dysthymia, generalized anxiety disorder, panic disorder, agoraphobia, social phobia, simple phobia, obsessive compulsive disorder, conduct disorder, cannabis and alcohol dependence. RESULTS: Overall, 12.5% of study members had DAS scores of 13 or more and were considered to be dentally anxious. Those who were dentally anxious were more likely than the non-anxious to be diagnosed with one or more psychological disorders (55.0% vs. 42.3%). However, those with DAS scores of 13 or 14 (moderately dentally anxious) were broadly similar to the non-anxious in terms of their psychological profile. This excess prevalence of psychological disorder was largely accounted for by high rates of disorder among those with DAS scores of 15 or more (highly dentally anxious). The highly anxious were more likely than the non-anxious to have a diagnosis of conduct disorder, agoraphobia, social phobia, simple phobia or alcohol dependence. Odds ratios ranged from 2.8 to 5.0 after controlling for the effects of gender. The data also suggested that dentally anxious individuals with psychological disorders were more likely to maintain their anxiety over time. CONCLUSIONS: In this population of young adults, high rates of psychological disorder were characteristic of those with high levels of dental anxiety. Psychological disorder was related to the maintenance of dental anxiety over time.