Treating Dental Fears; "My Choice or My Obligation?"
A Look at the Management and Treatment of Dental Anxiety
James H. King, D.D.S., B.C.E.T.S.



In this ultra-modern, high-tech age of dentistry, the problem of dental phobia still exists. Despite the fact that good dental hygiene and maintenance are becoming of increasing importance in today's health-oriented culture, over half of the American population suffers from dental phobia or related anxieties. The stirring technological advances which have propelled dental science into an art form have not quelled the worries of an anxious population.

Poor dental maintenance in early years has created a rift between the family and the family dentist. The dentist is an unknown quantity and his machines appear intrusive and dangerous. Therefore, the personal touch that a dentist cultivates becomes one of his most important tools.

Easing anxiety lies not only in creating the initial reassuring atmosphere, but in individual care and attention to detail. The dentist must emulate the family doctor of old, a true family friend. Treating dental fears is rapidly approaching the publicity level of other medical problems such as various cancer threats, sickle cell anemia, alcoholism, etc. As a matter of fact, this author recently viewed a news program dedicated to dental phobia. The program addressed the trend of modern-day dentists who specialize in treating fearful or anxious patients. It offered various techniques for relieving stress such as the having the dentist just talk with the patient for a period; informing the patient about the upcoming treatment; allowing the patient to relax and not just telling him or her "I am going to do this to you, to get this result" but instead giving the patient options on the treatment plan and personal input on what is preferred. Obviously, this plan is not unique: some dentists through the years have worked very hard to get patients to relax through the use of radios during the treatment, conscious sedation, and even hypnosis, but the fact that the media is broadcasting this information indicates an increase in attention.

The modern dentist is faced with the questions of ethics: is it ethical to refuse to treat or refer patients with dental phobia to save time and increase productivity or is it oneís duty as a dentist to treat every patient with a dental related problem even it means foregoing additional income? In the April 1989 issue of The Journal of the American Dental Association, the question of ethics and patient initiative is addressed. The issue concluded that many chairside ethical dilemmas arise that have no clear-cut solutions that everyone (the dentists, staff, patients, or the larger community) is likely to agree upon on. One set of questions concerned how much control the doctor or patient has over the treatment to be performed and how it should be delivered. A second set of questions concerned money. The article left an open question for the reader as to what exactly is ethical and in the future plans to publish responses. I think this is the perfect opportunity for such a response.

I feel that every dentistís primary professional obligation should be service to the public, competent and timely delivery of quality care, with due consideration to the needs and desires of the patient. This opinion is not an attempt to appear idealistic or even naive, but clearly rules out prejudice against patients with special problems. It is not my view alone but is restated in the section on principle in the American Dental Association's Principles of Ethics and Code of Professional Conduct. Maybe I'll have to drive a Chevette instead of a Corvette, but I honestly cannot visualize turning away patients in need, if I am qualified to serve them.

Regarding the various methods of treating dental fears, it appears nitrous oxide/oxygen inhalation is the treatment of choice. Nitrous oxide/oxygen sedation is recommended for both its analgesic and anxiolytic properties. With respect to pain control, studies proved that analgesic effects were heightened with higher concentration of nitrous oxide in gas mixture. Nonetheless, individual differences in pain control are considerable, wide variations from patient to patient have been reported at the same nitrous oxide concentrations. In addition, it was shown that psychological variables can influence the analgesic properties of the inhalation procedure. Nitrous oxide produces a state of consciousness similar to an hypnotic state, with an emphasis on heightened patient responsiveness. Weinstein indicates that nitrous oxide is a more effective anxiolytic for children than a placebo gas, but also reports that strategies used by the dentist modified the effectiveness of the inhalation agent. From the various clinical trials, it appears nitrous oxide alone works best in mildly anxious patients whose major concern is adequate pain control. For patients that were afraid of the syringe and injection procedure or of the dental drill, the use of nitrous oxide by itself is unpredictable and often unsuccessful. Often the patients would become upset, even when 50% nitrous oxide was used, and refused to allow the dentist to proceed. Even if treatment was initiated, the disruption caused by the patient anxiety dramatically reduces the efficiency the dentist tried to attain by using the drug initially. Regardless of this point, in some instances nitrous oxide can be used effectively as an anxiolytic. The challenge for the dentist is to maximize its useful effects.

Regarding behavioral treatment of dental fear, a number of clinical studies have shown the effectiveness of treatment related to fear of dental drills and needles.

The results of studies of systematic desensitization were very encouraging. It appears the treatments succeed because they carefully expose patients to dental procedures and teaches them a coping strategy.

The process to systematic desensitization has three conceptual components. First, the patient is given relaxation training in which they are provided with a coping response "antagonistic to the anxiety response." Progressive muscle relaxation, where after vigorous muscle groups are identified, the patient practices tensing and relaxing the muscles until they are able to demonstrate mastery of them. Other coping devices, such as, deep breathing and imagery, have also been used with much success.

Second, a fearful stimulus is generated. The clinician makes a list of the various steps in receiving care (making an appointment, sitting in the waiting room, etc.) and the patient i~ asked to rate his fearfulness based on the items on the list. Therefore, it is possible to judge the degree to which individuals are fearful of various procedures.

Finally, the clinician presents each stimulus in order, first in an exercise in imagination and later clinically. At each step, the patient practices the relaxation technique while the feared stimulus is presented. Patients that were not tense were better able emotionally to handle the fearful stimuli. Using this approach, the anxiety level remained manageable. The clinicians and patients did not proceed to the next step until the less fearful step was mastered, in that way, the patients anxiety never rose above the manageable level. The manageable level is defined as when the patient reports anxiety reduced to near zero and shows neither behavioral indications of fear, such as hypervigilance and extreme muscle tension, nor cardiopulmonary indications of intense arousal.

Although this specialized behavioral treatment is successful, few dentists are familiar with it and it is believed that few would be willing to invest the time involved to administer it. It is recommended that screening of patients and the usual precautions should be taken in the administration of any inhalation agent. It has been proven that Nitrous Oxide / Oxygen sedation is a safe procedure that is well tolerated by a wide range of patients. Polyphobic individuals, especially those who are claustrophobic, may not be good candidates. Patients that are afraid of using inhalation drugs and those with medical conditions that conflict with the use of Nitrous Oxide, such as respiratory disease or pregnancy should be excluded.

All patients should be evaluated using three systems: behavioral, verbal, and physiological. The fear response may be manifested in one or all of these systems, thus, failure to monitor anyone of these systems can lead to misleading results. For instance, a patient may not indicate fear behaviorally or verbally, while his heart rate increases to 120 beats per minute. On the other hand, patient verbalizations may provide the only warning that a patient is becoming anxious.

Behaviors, such as "white knuckles", or averting the head are typically displayed by fearful dental patients. Verbal assessment can be a simple comfort thermometer in the form of a card on which the patient is presented with a self-rating scale at regular intervals. Physiological assessment should be a simple and noninvasive measurement of heart or respiration rate. These indicators should be recorded at baseline before treatment and during and after each phase of desensitization.

In regards to practice management, this procedure can be administered by the dentist or a well trained auxiliary in places where the use of nitrous oxide by para-professionals is consistent with state laws. A flat hourly rate can be established to cover costs that will probably not be covered by dental insurance. The establishment of a fixed price per case may relieve the patient of additional worry that the cost is open-ended. Although nitrous oxide is commonly used in dental practice, it is often used indiscriminately and without carefully preparing the patient. If the clinician and his staff use the combined behavioral-pharmacological treatment mentioned previously, special expertise in behavioral therapy is not required. The methods carefully prepare the patient for treatment. The appropriate level of nitrous oxide is established before actual treatment begins, trial and error in trying to locate a comfortable level of nitrous oxide is not accepted practice. Also trying to tell the patient to relax or distract himself when he is frightened is not a reliable method of instruction. Nitrous oxide typically requires one or two appointments for moderate levels of fear and three or four appointments for high levels of fear.

Patient compliance in performing coping procedures at home is important to the success of this treatment method. Patients are encouraged to practice coping responses on a daily basis; those who practice appear to progress more rapidly.

There is reason to believe that this behavioral-pharmacological procedure can be an advantage when desensitization is combined with oral, intramuscular, or intravenous administration of benzodiazepines. No research is presently available on this topic, but it appears to be successful with patients who are uncooperative when only drug therapy is used. Such approaches may reduce required drug dosages and improve other risks associated with such treatment.

As Franklin Roosevelt said, "There is nothing to fear but fear itself." It could be added that the greatest fear is the fear within.

The challenge is set, the dental professional must become part of the family. This challenge also extends to the office staff where imparting information and a friendly atmosphere is not only part of a good dental practice but makes excellent business sense.

A good personality coupled with good techniques will lead the dental professional on the road to a healthy practice, with well informed, secure patients.

References

1. The Journal of the American Dental Association. April, 1989, p. 414.

2. Dental Code of Ethics and Conduct, Ed.

3. Berger, D.E. Assessment of the analgesic effects of Nitrous Oxide on the primary dentition. J Dent Child, 39: 265-268, 1972.

4. Emmersten, E. The treatment of children under general analgesia. J Dent Child, 2:123-124, 1965.

5. Hogue, D., Ternisky, M., and Inranpour, B. The responses to Nitrous Oxide analgesia in children. J Dent Child, 39: 129-133, 1971.

6. Dworkin, S.F., et al. Analgesic effects of Nitrous Oxide with controlled painful stimuli. JADA, 107: 581-585, 1983.

7. Hallonsten, A.L. Nitrous Oxide/Oxygen sedation in dental care. Community Dent and Oral Epidemiol, 1: 347-355, 1983.

8. Benedetti, C., et al. Effects of Nitrous Oxide concentration on event-related potentials during painful tooth stimulation. Anesthesiology, 56: 360-364, 1982.

9. Dworkin, S.F., et al. Cognitive modification of pain. Information in combination with N20. Pain, 19: 339-364, 1982.

10. Dworkin, S.F., et al. Cognitive reversal of expected Nitrous Oxide analgesia for acute pain. Anesth Analg 62: 1073-1077, 1983.

11. Weinstein, P., Domoto, P., and Holleman, E. The use of Nitrous Oxide in the treatment of children: Results of a controlled study. JADA, 112: 325-331, 1986.

12. Milogrom, P. Behavioral methods and research issues in the management of the adult dental patient. In: Hhopt, M., Moore, P., and Weinstein, P. (eds.). Progress in pain and anxiety control. Anesthesia Progress, 33: 5-9, 1986.

13. Smith, T., Milogrom, P., and Weinstein, P. Evaluation of treatment at a dental fears research clinic. Spec Care Dentist, 7(3): 130-134, 1987.

14. Gale, E.N., and Ayer, W.A. Treatment of dental phobias. JADA, 73: 1304-1307, 1969.

©1997 by The American Academy of Experts in Traumatic Stress, Inc.