Knowledge and practice of behavioral management principles among dentists treating adults with learning disabilities

This study investigated U.K. dentists’ knowledge and practice of behavioral management principles (BMPs) as applied to adults with learning disabilities (AWLD). A postal questionnaire enquired into the dentists’ experience in managing AWLD, utilization of behavioral management techniques, and knowledge of BMPs. The response rate was 41% (N = 53). Two groups were investigated: specialists (dentists registered on the Special Care Dentistry specialists’ list, n = 37) and nonspecialists (dentists not on the list, n = 16). Although specialists treated more AWLD than nonspecialists, both groups of dentists reported they felt highly confident in managing AWLD. However, all dentists’ knowledge of the principles of nonpharmacological BMPs was low. Specialists had a tendency to use a greater range of nonpharmacological behavioral management techniques compared to non‐specialists. These results suggest that dental team members need more training in the theory and practice of BMPs, which might lead to less reliance on costly pharmacological interventions and a clinical experience that is more respectful of the dignity and independence of AWLD.     

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 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.     

Factors influencing the use of behavioral management techniques during child management by dentists

Dental anxiety develops from a vicious cycle of bodily arousal from dental stimuli, cognitive interpretation and ineffective coping all working in a runaway feedback loop. Behavioral management strategies (BMT) aim at cognitive reorientation, which results in better compliance with instruction. This paper therefore tried to find out possible factors that influence the effective use of BMT during child dental management during treatment by dental operators in Nigeria. The levels of anxiety pre and post treatment were assessed using the short form of the dental version of the Child Fear Survey Schedule. Also, the type of treatment given to the child, the types and number of behavioral strategies employed during dental management as well as the gender and age of the child were noted. The professional status of the attending dental operator was also noted. Prior to the commencement of the study, the five students in the final year, who were to attend to the children in this study received one week training on the psychological management of dental anxiety in children. Results obtained from the dental operators were compared. The type of treatment received by the child did not significantly affect the dental anxiety score. The number of techniques combined by house officers and senior registrars were significantly higher than would be expected by chance (chi2=16.030, P=0.0001 and chi2=9.000, P=0.0001 respectively). Combination of techniques was also more frequent during invasive procedures and when dental anxiety levels were high. Combining techniques also tended to decrease dental anxiety more significantly than otherwise. Training has a role to play in the basic and efficient use in the management of the child dental patient. The training of dentists should thus entail the full spectrum (content and instructional effectiveness) of all psychological techniques.     

Anxiolysis in dental practice: a report of three cases

While general dentists have used many modalities to reduce fear and anxiety in the dental office, including iatrosedation (calming words), distraction techniques, conditioning techniques, and empathy, there still are patients who need pharmacologic management of fear and anxiety to receive dental care. Anxiolysis, the lightest level of sedation, can be employed by all dentists and is safe and effective when used properly. This article presents three cases to introduce the anxiolysis technique as an in-office sedation procedure that can be used by all general dentists.     

Applied behavior analysis: behavior management of children with autism spectrum disorders in dental environments

BackgroundThere are a limited number of studies addressing behavior management techniques and procedural modifications that dentists can use to treat people with an autism spectrum disorder (ASD).MethodsThe authors conducted a search of the dental and behavioral analytic literature to identify management techniques that address problem behaviors exhibited by children with ASDs in dental and other health-related environments.ResultsApplied behavior analysis (ABA) is a science in which procedures are based on the principles of behavior through systematic experimentation. Clinicians have used ABA procedures successfully to modify socially significant behaviors of people with ASD. Basic behavior management techniques currently used in dentistry may not encourage people with cognitive and behavioral disabilities, such as ASD, to tolerate simple in-office dental procedures consistently. Instead, dental care providers often are required to use advanced behavior management techniques to complete simple in-office procedures such as prophylaxis, sealant placement and obtaining radiographs. ABA procedures can be integrated in the dental environment to manage problem behaviors often exhibited by children with an ASD.ConclusionsThe authors found no evidence-based procedural modifications that address the behavioral characteristics and problematic behaviors of children with an ASD in a dental environment. Further research in this area should be conducted.Clinical ImplicationsKnowledge and in-depth understanding of behavioral principles is essential when a dentist is concerned with modifying behaviors. Using ABA procedures can help dentists manage problem behaviors effectively and systematically when performing routine dental treatment. Being knowledgeable about each patient’s behavioral characteristics and the parents’ level of involvement is important in the successful integration of the procedures and reduction of in-office time.     

Brief relaxation versus music distraction in the treatment of dental anxiety: a randomized controlled clinical trial

BACKGROUND: Dental anxiety is a significant cause of poor dental health. Because patients often prefer nonpharmacological interventions, the clinical effectiveness of clearly structured approaches is of particular interest. METHODS: This prospective randomized controlled study compares a brief relaxation method (BR) with music distraction (MD) and with a control group (C). The authors randomly assigned 90 patients with dental anxiety to BR, MD or C groups. They assessed the outcomes by means of the state anxiety subscale of the State-Trait Anxiety Inventory. RESULTS: Both BR and MD reduced dental anxiety significantly. In contrast, patients in the C group did not exhibit a significant change in their anxiety level. BR was significantly superior to MD. Stratification according to the patient's general level of dental anxiety revealed that BR also was particularly effective in highly anxious subjects, whereas MD did not have a clinically relevant effect on these subjects. CONCLUSIONS: BR appears to be a safe, economically sound and effective nonpharmacological approach to the short-term reduction of dental anxiety. Additional investigations are needed to validate these findings in a larger clinical trial and to determine the long-term effects of this intervention. CLINICAL IMPLICATIONS: Relaxation techniques are a pragmatic, effective and cost-saving method of facilitating dental treatment in anxious patients.     

Mentoring. A quality assurance tool for dentists. Part 1: the need for mentoring in dental practice

This paper introduces the concept of mentoring and its use in dental practice. It explains how there has been a drive for quality in all areas of healthcare in the United Kingdom (UK), and that clinical audit and clinical governance are two of the quality assurance tools that have been developed. It suggests that the most important factor in the provision of quality care is the dentist and that it is therefore essential that dentists are given support and encouragement by their peers, together with recognition of good performance. The next section of the paper considers factors that hinder a dentist's quality of performance. It explains that there are multiple stresses in dental practice and, if they are not managed and controlled, that they can lead to professional burnout, anxiety and depression. One of the most important stressors that can impact on the quality of patient care is the constraint of time, which can frequently result from pressure from third parties such as managers and administrators. Dentists often feel isolated. The final section of the paper describes how dentists may be supported. Techniques include developing special interests within oral healthcare, career development, good human resource management, peer review and study groups, and coaching and mentoring. The nature of these last two techniques is discussed and the authors conclude that the best tool for supporting the quality of performance of dentists is mentoring.     

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.     

Techniques for reducing anesthetic injection pain: an interdisciplinary survey of knowledge and application

BACKGROUND: The authors conducted a study that considered family physicians' and dentists' knowledge and application of techniques to reduce the pain associated with anesthetic injections. They also assessed practitioners' discomfort with patients' injection pain and needle anxiety/phobia. METHODS: The authors designed a questionnaire about awareness and use of 10 techniques for reducing pain of anesthetic injection and mailed it to 2,000 randomly selected family physicians and general dentists. They analyzed the data to examine differences between disciplines regarding awareness and use of techniques, reasons for not using techniques, number of injections given per week, and predictive value of certain demographic variables on reported use of individual techniques and on practitioner reactions to patients' pain and anxiety. RESULTS: The response rate was 35 percent. The authors used the chi2 test for differences between disciplines' awareness of and use or nonuse of techniques, Wilcoxon testing to assess differences between disciplines' median values of number of weekly injections and logistic regression to study demographic variables' predictive values (P = .01). General dentists give more injections than do family physicians. Differences existed between disciplines' awareness and use of eight of 10 techniques. Disciplines reported cost and time issues as reasons for not using some techniques. Number of years in practice and age were associated with use of six techniques. Dentists reported feeling greater personal effects of patients' pain and needle anxiety/phobia than did family physicians. CONCLUSIONS: Those not using pain-lessening techniques inaccurately identified time and cost as problems, suggesting that respondents may be less familiar with these techniques than otherwise reported. Further study is recommended. CLINICAL IMPLICATIONS: Pain reduction techniques for anesthetic injection cost little to implement, are not time liabilities, and can lessen avoidable pain and reduce the incidence of needle phobia.     

Perceptions of dentists, dentistry undergraduate students, and the lay public about dental sedation

Sedation is an option for controlling fear and anxiety related to a visit to the dentist. The goal of this study was to capture, by means of a questionnaire, the perceptions of twenty dentists, twenty dental students and twenty lay people concerning the use of sedatives in a dental environment. The responses were evaluated using the quantitative-interpretative method. Dentists: 75% had knowledge of sedatives in a dental setting, but their actual use was mentioned by only three. As far as the use of sedatives by dentists is concerned, one considered it "risky" and 19 were favorable. Two affirmed that sedation does not present risks. Eighteen said they would be able to react to a medical emergency. Dental students: 60% said they were aware of the topic, in theory. Nineteen expressed interest in the topic. Fifteen claimed there were risks associated with the technique. Twelve (60%) have the theoretical knowledge to deal with a medical emergency in the dental office. Lay public: Seven (35%) responded that they felt some discomfort during dental treatment, because of fear (n=6) and equipment noise (n=2). Five said they would go to the dentist more often if there was a way to reduce the discomfort. Half of those interviewed indicated that they knew what sedation was. Sixteen favored using it for dental treatment. Seven thought that there were no risks when sedation is carried out. It was concluded that few participants in any of the three categories felt confident about the topic, though they demonstrated interest. The population in general felt optimistic, while practicing dentists and dental students complained of a lack of exposure to the subject at dental school.     

Challenges and dilemmas in behaviour guidance of the pediatric dental patient

In addition to the pressures of providing a high quality of dental care for children, dentists practising pediatric dentistry are faced with some legal and ethical concerns regarding the use of behaviour management techniques. The following article will discuss some of the pressures and ethical dilemmas facing dentists treating children. Strategies for making the dental appointment more humane for child, parent and dentist are suggested. The most perplexing issues in pediatric dentistry today are related to the management of patients. In addition to questions regarding clinical management, dentists treating children have to make careful judgements concerning management of patient's behaviour. The following scenarios are a few examples of the situations that often arise during the dental treatment of child and adolescent patients: "I really had to raise my voice to Jamie today and use a lot of physical restraint to administer the local anesthetic. I was not happy about being so aggressive, but it was important to get that filling done. I wonder, though, how he is going to feel about going to the dentist now?" "I feel frustrated that I did not get any work done on that four-year-old today, but I did not want to use undue force. Maybe I should have been more forceful; hand-over-mouth-exercise might have worked, but I always feel uncertain about using that technique and I wonder what the parents will think if I use it."     

Long-term management of the fearful adult patient using behavior modification and other modalities.

This paper reviews reports on the treatment of fearful adult dental patients with special emphasis on behavioral and cognitive methods and long-term followup. A number of such treatment methods are available that can be used by dentists for the alleviation of fear and anxiety in their patients. At an "intuitive" level, many dentists probably use these methods frequently as a comprehensive part of everyday praxis. Considering the high number of fearful individuals visiting dentists regularly, a better knowledge of such methods would improve dental care for the majority of these patients. It would also help prevent aggravation of fears among individuals at risk. However, despite the success of treatment methods performed by specially trained dentists, it seems reasonable that there should be limits to what can be expected of a dentist in terms of psychological, diagnostic, and therapeutic competence. Dental phobia may constitute a complex psychological and odontological problem with far-reaching consequences for a relatively large proportion of fearful individuals. It therefore seems likely that optimal care of such patients can best be achieved by cross-disciplinary efforts involving both dentists and psychologists.     

The acceptability of the use of sedation in the management of dental anxiety in children: views of dental students

The aim of the present study was to determine the views of dental students concerning the acceptability of the use of sedation in the management of dentally anxious children. Dental students in Trinidad (n = 100) were asked to rate the acceptability of vignettes describing the management of a young teenager with dental anxiety. The vignettes varied systematically along two dimensions: nature of intervention for anxiety (sedation vs. the use of relaxation training and rewards) and outcome of the intervention (good vs. poor). Ratings of acceptability were made using a standardized questionnaire measure. The data were analysed using analysis of variance (ANOVA). There were significant main effects of nature of intervention (F = 5.54; P < 0.05) and outcome of intervention (F = 298.01; P < 0.001), though the students' year of study did not influence ratings. None of the interaction terms were significant. Sedation was viewed as a less acceptable intervention than relaxation and rewards. Interventions associated with good outcomes were seen as more acceptable than interventions associated with poor outcomes. It is concluded that dental students' perceptions of the acceptability of interventions for use with dentally anxious patients are related to the effectiveness of the intervention. Sedation, regardless of the outcome, is seen as less acceptable than the use of rewards and relaxation.     

Clinical trials in dental primary care: what research methods have been used to produce reliable evidence?

OBJECTIVE: To identify controlled clinical trials done exclusively in dental primary care and to classify the research according to design. Details of any procedures used to recruit general dental practitioners and any special organisational arrangements were also collected. DESIGN: A scoping literature review. SETTING: Dental primary care defined as general dental practice, community and school dental settings. PARTICIPANTS: Published randomised controlled trials using randomised or quasi randomised approaches and controlled clinical trials were considered for inclusion in the review. Reports were excluded if they did not describe either a randomised controlled trial or a controlled trial. Studies were excluded if the setting was not primary dental care or the intervention was for non-dental conditions. Conference abstracts without a full report and trials published in a language other than English were also excluded. MAIN OUTCOMES: Experimental and quasi-experimental designs, clinical areas and different kinds of strategies used to recruit dentists, any organisational arrangements made to support research in dental primary care. RESULTS: The search of the Cochrane Oral Health Group Controlled Trials Register found 174 articles. Forty-three randomised controlled trials met the inclusion criteria. Trials to evaluate the effects of interventions for types of anaesthesia, periodontal diseases, smoking cessation techniques, dental materials, organisational aspects of dental care, patient anxiety, post extraction healing rates, antibiotics were identified. All were done in general dental practice. Trials in school and community settings were also included. CONCLUSIONS: Practice-based research needs to be encouraged to provide dental primary care with relevant evidence upon which effective treatment can be based. This review shows there are few trials done in dental primary care to inform clinical practice, most of which have been reported since 1997. The range of trial designs shows that this method of evaluation can be used to evaluate dental primary care interventions and this is promising for those with an interest in improving dental patient outcomes. More research on how to recruit dentists into clinical trial research must be done.     

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.     

Revisiting comfort: strategies observed in the direct observation study

The Surgeon General's 2000 report on oral health found that one-third of adults in the U.S. had not visited a dentist in the previous year. Fear of treatments received during a dental encounter can create a barrier to patients receiving care. Most studies of dental anxiety have focused on phobic patients; relatively few studies have explored attempts to provide comfort and alleviate anxiety among everyday patients. This study describes comforting strategies that were performed by dentists, dental assistants, and hygienists for their patient population as a whole. As part of the Direct Observation Study, 120 dental practices in Ohio were observed over a four-day period by trained research hygienists. Researchers observed and recorded 3,800 patient interactions with dentists and hygienists at 30-second intervals using 24 behavior-specific codes. In addition, observers composed qualitative notes detailing the patient visits and recorded in their notes specific comforting techniques performed by dentists, hygienists, and dental assistants.     

儿童口腔科患者就诊配合度的影响因素

儿童口腔科最常见的问题是患儿由于牙科焦虑或者行为管理问题不能配合治疗,对口腔诊疗的正常进行造成极大的影响。本文将从医护、患儿、监护人3个方面对可能造成患儿就诊不合作的因素进行综述,以期为临床工作中了解患儿不配合的原因提供参考。