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
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
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.
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.
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
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
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
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
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.
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.
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American Academy of Experts in Traumatic Stress,