The fear factor

A FEAR OF going to the dentist is generally regarded as a trivial problem and patients who can’t cope with treatment often think they are being silly or stupid. But such fear can have serious implications.

Studies show that a significant percentage of the UK population remain anxious about treatment despite advances in the delivery of dental care – and some of these patients display a genuine phobia of the dental chair. A phobia is defined as an “irrational and uncontrollable fear… related to a specific object or situation… that is persistent… and has a direct effect on the patient’s lifestyle”. Avoiding dental treatment out of fear can have a clear impact on general health. There has been considerable debate regarding the relationship between gum disease and ischaemic heart disease.

Avoidance of dental care can also mean patients are not regularly screened for diseases including oral carcinoma. A more extreme example is the recent wellpublicised case of an eight-year-old girl in Cornwall who starved herself to death because she was afraid of dental treatment. Such stories are rare but not unheard of.

Dental phobic patients

There is no stereotypical anxious or phobic dental patient. Some practitioners report seeing more phobic women than men, but it’s thought female patients are more likely to present for treatment and admit their anxiety. I have provided sedation for patients from all backgrounds, including medical consultants from varying specialties (including an anaesthetist), lawyers and accountants. Patients who are anxious regarding dental treatment can show a number of signs. The most obvious include shaking, sweating (having cold clammy hands), looking very pale, having dilated pupils or gripping the armrests of the chair.

Other less obvious signs are:

• Fainting at the time of injection. Often patients will blame the contents of the injection rather than admit they are frightened.
• Aggression. Fear is marked by an excessive secretion of epinephrine which is part of the fight or flight response. It is quite common for frightened patients to become aggressive, particularly when they don’t get what they want.
• Repeated missed appointments. The “regular irregular attenders” visit the dentist when in pain but don’t complete courses of treatment. They attend every few years when the next problem can’t be ignored.
• Over-eager responses. Some anxious patients will try to shorten the time they are in the dental environment by attempting to answer questions rapidly or by giving the response that they feel that the dentist wants.
• Conversation in the waiting room. Discussions about how quick or painful the dental treatment may be are signs of anxiety.

Treating anxious patients The most common complaint GDPs have about treating anxious patients is the wasted surgery time and lost income caused by failed appointments. Other common problems include:

• Failure to understand the explanations that are given to them. Stressed patients often don’t assimilate information as clearly and this may lead to claims that treatment consent was not informed.
• Breakdown of the patient–dentist relationship. This can be a particular problem when the patient’s anxiety manifests as aggression. A judgement needs to be made as to whether the patient is genuinely aggressive or just frightened.
• Prolonged treatment times. Anxious patients are more likely to take a break, sit up and spit out, or otherwise interrupt treatment. This can irritate the dental team.

The most important thing with anxious patients is to recognise the anxiety. Over 50 per cent of patients cite fear as the major barrier to receiving dental care. In the USA, recent publicity associated with Root Canal Awareness Week suggested over half the population avoid attending due to fear while some degree of fear affects up to 80 per cent. We should, therefore, expect to encounter such patients on a daily basis.

Fear of the unknown is a basic human trait. A good explanation in advance of the treatment will often help reassure patients with mild to moderate anxiety. Tell–show– do is the model approach. Patients should also be given a stop signal, so that they can request a break. This allows a feeling of control, but be sure to act upon such a signal. Many anxious patients describe situations with a dentist where “he said he would stop, but he didn’t”.

Anxiety management

There are two basic approaches to anxiety management in seriously phobic patients. The first allows the patient to have their dental treatment carried out in a stress-free manner, but does not address the underlying problem. The second “treats” the anxiety.

Conscious sedation techniques are the cornerstone of the first strategy. This temporarily relieves the patient’s anxiety and allows the dental procedures to be carried out with reduced stress levels for both patient and dental team. The other major advantage is that once the patient knows there is a way of having treatment carried out without stress they are more likely to attend for check-ups. Sedation may encourage patients to attend more regularly and complete treatment.

The second approach employs psychological treatments, usually involving behavioural therapies or cognitive behavioural therapy (CBT).

The behavioural approach takes the patient through a structured, graded exposure to an event or experience. The process starts with the least stressful part of the process and culminates in the most stressful. The patient is given relaxation techniques to use and repeats each stage until they can go through it stress-free.

Cognitive behavioural therapy is the term for a number of therapies that are designed to help solve problems in people's lives. CBT works on the premise that your problems are often created by you. It is not the situation itself that is making you unhappy, but how you think about it and how you react to it. Patients are taught to re-evaluate the way they think about a problem.

One example would be a man going through a divorce who feels that he has failed as a husband, which makes him depressed. The depression makes him tired and lack energy. This leads to him spending all his time at home and avoiding family and friends. The CBT approach would tackle this by firstly dealing with the thoughts: in this case that divorce is common. The breakup usually relates to faults on both sides. It is time to move on, learning from the mistakes. As this is addressed it will help the emotional and physical symptoms. The last step is to integrate this into a change of behaviour.

In common with conscious sedation, these techniques would require postgraduate training for a dental professional. But there is no reason why dentists can’t be effective at providing such treatments, given appropriate training and experience.

Hypnosis can also be used as a vehicle for psychotherapy, and its main benefit is to increase the efficacy. Particularly in combination with the behavioural approach, hypnosis can make it possible to move through graded exposures more rapidly. The technique can also be used to help with immediate treatment, producing a state of non-pharmacological sedation.

Mutual stress

Dealing with anxious patients is among the factors dentists report as being most stressful in their working environment.

When both dentist and patient are stressed, there are high levels of adrenaline circulating. Both experience the fight-orflight reaction. The dentist will not have the flight option, and thus it is important for him to be aware of, and avoid, potential confrontation.

Dentists should only manage situations they are trained and competent to deal with. If a patient’s anxiety is beyond the scope of a dentist’s management techniques, they should refer to an appropriate colleague.

Dr Nigel Robb is a senior lecturer in sedation in relation to dentistry at Glasgow Dental Hospital and School and an Honorary Consultant in Restorative Dentistry