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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 one’s 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 dentist’s
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.
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