IT SEEMS never a day goes by without at least one patient reminding you how much they loathe injections, fillings or root canal treatments and bringing up that time the dentist had his knee on their chest to complete an extraction. While I have yet to meet a member of the profession with such remarkable flexibility, it is commonplace to have to manage patients’ misconceptions or misgivings about dental treatment.
There are many reasons why such ideas are formed by patients, but often they stem from feelings of fear or anxiety. It is important for any dentist to be aware of the extent of these feelings and to be able to distinguish between a patient who is mildly anxious or one suffering from a more serious and deeprooted phobia. There are various approaches to dealing with these issues as I have discovered in exploring this topic for SoundBite and through my own practice. Finding the right approach for each patient requires gaining an understanding of their fears through good communication skills.
The presentation of anxiety
Identifying an anxious patient is not always easy. Some may be more than happy to recount their fears and previous bad experiences at length, but for others the signs may be more difficult to detect. You might notice that a patient is unusually quiet and unwilling to talk about their concerns, perhaps due to embarrassment. You might notice their hands shaking or sweating or that they look pale. If you suspect a patient is feeling anxious then it is useful to enquire in a non-threatening way if there is anything they would like you to clarify before the examination or treatment begins.
You can also take the opportunity to ease their anxiety during the consent process by giving them a step-by-step account of the different stages of the proposed treatment. As well as reassuring the patient about each stage, it is important to judge how much information a patient wants to know. You must give enough information to ensure valid consent but giving a graphic account of a surgical extraction, for example, is certainly not going to alleviate fears of an already anxious patient and will likely make the ensuing half hour stressful for both parties. It can also be helpful to agree a stop signal with the patient so that they can request a break. This gives the patient a feeling of control over their treatment, so be sure to obey the signal.
Some patients who are reluctant to discuss their dental anxiety may already have coping mechanisms in place which means they can normally deal with most aspects of treatment with simple reassurance and empathy. However, for other patients the problem can be more severe.
One indication that a patient is not coping with their anxiety is repeated missed appointments or short-notice cancellations. These patients tend to visit the dentist in pain but don’t complete courses of treatment. From personal experience, I have found that by telephoning patients you suspect to be staying away for this reason, you can help identify the anxious from the disorganised. Showing anxious patients that you are concerned about their fears can help establish trust between the dentist and patient and hopefully facilitate successful future treatment. It is far better to take the time to try and ensure these patients attend than face the alternative of them presenting as emergencies when you not only have to deal with their pain, but also their heightened sense of anxiety.
From an early stage in undergraduate clinical years, we experience a multitude of patients with odontogenic pain, which can occasionally elicit uncharacteristically aggressive behaviour. Again, this may be due to the anxiety surrounding treatment or possible worries about not achieving anaesthesia. In more extreme cases, a patient may not have slept or eaten for days and it is important to bear this in mind when communicating with them.
By empathising with their situation and again taking the time to reassure these patients, the majority will begin to calm and in turn allow treatment to be undertaken. But it is also important to remember to warn patients whose aggressive behaviour – whether verbal or physical – is escalating that it will simply not be tolerated. You should never put yourself or members of the dental team in a position that threatens your safety.
Good communication is one of the fundamental principles of alleviating anxiety and by identifying patients’ specific fears you can devise a treatment plan that will help build their confidence. Needle phobias, for example, are a common cause of concern to patients. The various approaches to needle desensitisation are covered in the undergraduate curriculum, but the time some of these techniques take to implement in general practice can be a deterrent for clinicians. It is worth choosing and practising a sequence where you can put the patient at ease in a time-efficient manner.
Factoring in any possible dental anxiety in your treatment planning can also help increase compliance and instil patient trust in your ability to perform procedures relatively painlessly. For example, when undertaking a restorative treatment it is wise to start with short appointments for small restorations in the upper posterior region if possible. This allows almost painless infiltrations, if given slowly following topical anaesthesia, and can build patient confidence to a level where they feel able to embark upon more complex and time-demanding procedures.
It is also vital that you know your clinical limitations and don’t attempt treatment beyond your capabilities, especially on anxious patients. A bad experience is likely to compound negative attitudes towards treatment. If you feel that a patient’s clinical or behavioural needs are best met in a specialist setting, you should refer the patient appropriately. Prior to referral, a patient should be made aware of the various sedation techniques available to them, which include inhalation sedation, intravenous sedation and general anaesthetic. It is vital that you inform them of the likely sedative effects these induce and also the associated risks and consequences. This enables the patient to attend an assessment clinic with an informed idea of what is realistically possible.
Oral sedation can be prescribed in general practice, but I have personally had limited success with this method. This may have been due to the fact that I was only using it in cases of moderate to severe anxiety, but patients who felt an alleviation of fears attributed it more to pre-operative communication than the actual sedative effect of diazepam. A secondary care setting may also be able to refer a patient to see a clinical psychologist in particularly severe cases.
Something I was not aware of until recently was that some abuse victims can have real difficulty in dealing with dental treatment. This can be due to a number of reasons, including the feelings of vulnerability and loss of control. It is unlikely that you would find this information from any dental, medical or social history you would take as part of a routine exam but it is important to be sensitive to any other signs of abuse or neglect (see feature Protecting the Vulnerable in this issue).
All of this means it is important not to dismiss behaviours which you may find unusual as there may be a deep-seated physiological problem at play. Dealing with anxious patients can often be frustrating, but the satisfaction from helping a patient conquer their fears can be extremely rewarding. Dental anxiety will remain a daily occurrence throughout your working career, and by dedicating time and developing methods to help those in need, you will begin to establish a content and loyal patient base.
Martin Nimmo is an SHO in oral and maxillofacial surgery and is editor of SoundBite