Posted by: The Probe 19th May 2020
Advances in treatment and techniques and a greater understanding about the value of oral health haven’t eliminated dental anxiety. Estimated figures put extreme dental phobia at affecting 12 per cent of the UK adult population (excluding Scotland) and moderate anxiety, 36%.[i] The reality is likely to be higher, though.
Treating an anxious patient can be a stressful experience for a clinician and the practice, “due to reduced cooperation, requiring more treatment time and resources”.[ii] But although highly phobic patients have poorer oral health than those with no fear, a study published in the BDJ last year found that, for its sample, dental anxiety had no impact on care planning.[iii] If a patient needs root canal therapy, for example, a phobic status would not affect this recommendation. However, one of authors commented that, “it is still important to consider patients’ anxiety and its management in the treatment plan… (an) important component in their care would be to address dental phobia”.[iv]
To address dental phobia at treatment stage is an opportunity to help patients break free from a fear that, at best, means they have avoided preventive check-ups. Often starting in childhood, dental phobia can be attributed to a negative past experience which becomes forever associated with and triggered by sensory stimuli present in the dental practice – the smells, sights and sounds. Or, a child might have inherited their fear from a parent because they harbor distressing memories of Mum or Dad being upset before or after a dental appointment. But memories lose clarity over time and the procedure may have been remembered as being more far painful or upsetting than it actually was.
Every phobia has an element of the irrational; in the case of dental phobia, it’s the fear that something terrible will happen. Phobic patients think: “When the dentist looks in my mouth, I’ll struggle to breathe!” Then there are patients who are concerned they’ll be humiliated when they find out how poor their oral health is. Other reasons for anxiety include worrying about how much it’s going to cost and having the dentist working in close proximity to their face, invading their personal space. Humans have a “fight or flight” response to any situation that they perceive is a “threat” or could be “harmful”. This isn’t always a bad thing, either. This natural, hormone-based surge of adrenalin will often help them to get through something that they’ve been dreading and then feel proud that they survived it. The next time, it probably won’t seem so bad. Also, there are many parents who will admit that the prick of fear their children get when they visit the dentist is far more effective at encouraging them to brush properly and to not demand sweet treats than any daily nagging.
There is no one-size-fits-all approach for dental anxiety because every case, like every patient, is unique. Trust in the dental team is imperative, but the reality is that the dentist is often a stranger. Extreme phobia will require multi-agency support, with cognitive-based therapies regularly and successfully used. Other methods include hypnosis, acupuncture and distraction techniques, such as listening to music through headphones. Cognitive-behavioural interventions require a patient’s co-operation and when this hasn’t been achieved, sedation or anaesthetic may be required.
Even for people who are not normally dentally anxious, oral pain and particular treatments can suddenly trigger a fearful response. Research from 2018 found dental anxiety to be prevalent for people with irreversible pulpitis, which, according to the authors, had a strong association with “pain at the most recent dental visit and during endodontic treatment”.[v] Effective pain management in endodontics is necessary for successful outcomes and for calming dental anxiety. Looking for a way to make a procedure like root canal therapy – that does have a bad reputation, despite high success rates – less traumatic, is essential.[vi] As well as a high level of technique and good communication about the benefits of treatment, efficient endodontic procedures which have been simplified in their delivery is key. COLTENE’s HyFlex™ EDM file sequence, which includes the Glidepath file 15/.03 for the preparation of curved and narrow canals, offers flexibility in a range of situations. Clinicians report that they only need to use one or two files to complete treatment successfully and efficiently, for a pain-free long-term outcome that shows patients they had nothing to be afraid of.
Accepting dental anxiety and phobia is important. Understanding its complex, fluid nature, and how patient responses can change over time, especially when faced with procedures that have a scary reputation is essential. Gold-standard, holistic care would be incorporating a strategy for the management for dental anxiety into and alongside a treatment plan. An example of this would be endodontic treatment that also takes into account the patient’s anxiety, so that the end result is not just successful root canal therapy, but also an individual who is less fearful at every subsequent appointment.
Author: Mark Allen, General Manager at COLTENE
[i] BSDHT. Reducing anxiety in adult dental patients. Link: http://www.bsdht.org.uk/mag/reducing-anxiety-in-adult-dental-patients (accessed December 2019).
[ii] Appukuttan DP. Strategies to manage patients with dental anxiety and dental phobia: literature review. Clinical, Cosmetic and Investigational Dentistry. 2016; 8: 35.
[iii] Heidari E, Newton JT, Andiappan M, Banerjee A. The impact of dental phobia on care planning: a vignette study. British Dental Journal. 2019 Apr; 226 (8): 581.
[iv] King’s College London, 26 April 2019.
[v] Dou L, Vanschaayk MM, Zhang Y, Fu X, Ji P, Yang D. The prevalence of dental anxiety and its association with pain and other variables among adult patients with irreversible pulpitis. BMC Oral Health. 2018 Dec; 18 (1): 101.
[vi] British Endodontic Society. Link: https://britishendodonticsociety.org.uk/patient-public/further-information/ (accessed December 2019).
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