Management of a nxiety
3. If you were about to have a TOOTH DRILLED, how would you feel?
Not
anxious ⵧ Slightly
anxious ⵧ Fairly
anxious ⵧ Very
anxious ⵧ Extremely anxious ⵧ 4. If you were about to have your TEETH SCALED AND POLISHED, how would you feel?
Not
anxious ⵧ Slightly
anxious ⵧ Fairly
anxious ⵧ Very
anxious ⵧ Extremely
anxious ⵧ 5. If you were about to have a LOCAL ANAESTHETIC INJECTION in your gum, above
an upper back tooth, how would you feel?
Not anxious ⵧ
Slightly anxious ⵧ
Fairly anxious ⵧ
Very anxious ⵧ
Extremely anxious ⵧ
_________________________________________________________________
Instructions for scoring (remove this section below before copying for use with patients)
The Modified Dental Anxiety Scale. Each item scored as follows:
Not anxious = 1 Slightly anxious = 2 Fairly anxious = 3 Very anxious = 4 Extremely anxious = 5
Total score is a sum of all five items, range 5 to 25: cut-off is 19 or above which indicates a highly dentally anxious patient, possibly dentally phobic.
Figure 4.1 The Modifi ed Dental Anxiety Scale (Humphris et al . 1995, 2000 ). Reproduced with permission.
respond unpredictably to stressful situations. Some patients will experience anxiety only on the day of the appointment or when they enter the dental surgery. Other patients will start to exhibit symptoms of stress as soon as they receive the dental appointment, experiencing several sleepless nights prior to the visit. The spectrum of symptoms varies
Table 4.1 Signs and symptoms of anxiety.
■ Clenched fi sts (white knuckles), sweaty hands ■ Pallor, sweating
■ Tense, raised shoulders, sitting upright unsupported in the chair, ill at ease ■ Fidgeting, nail biting, licking lips
■ Hypervigilance (constantly looking around, suspicious, extremely alert and conscious of environment)
■ Distracted, confused, unable to concentrate ■ Very quiet or extremely talkative
■ Breathlessness
■ Tachycardia (heart rate > 100 bpm), ■ Palpitations
■ Hypertension ■ Dry mouth
■ Frequent visits to the toilet ■ Feeling nauseous, light headed or
faint, vomiting, syncope, ‘ butterfl ies ’ , stomach pains
■ Tremors
■ Hyperventilation/panic attack bpm, beats per minute.
from mild psychological symptoms to physical (somatic) signs and symptoms such as those listed in Table 4.1 . Research has shown that many patients who have high levels of dental anxiety also display other fears or psychological problems and these may adversely infl uence treatment outcome.
Dental anxiety can have a profound detrimental impact on the quality of life of the sufferer. One study by Cohen et al . (2000) has shown that the impact of dental anxiety on peoples ’ lives can be divided into the fi ve categories outlined below.
■ Physiological disruption, e.g. dry mouth, increased heart rate, sweating.
■ Cognitive changes, e.g. negative and even catastrophic thoughts and feelings, unhelp- ful beliefs and fears.
■ Behavioural changes, e.g. alteration of diet, attention to oral hygiene, avoidance of dental environment, crying, aggression.
■ Health changes, e.g. sleep disturbance, acceptance of poor oral health.
■ Disruption of social roles, e.g. reduced social interactions and adverse affects on performance at work. Family and personal relationships can also be adversely affected.
Management of d ental a nxiety
The management of anxious/phobic patients is dependent on the severity of the condi- tion and the treatment that needs to be undertaken. The medical history of the patient also infl uences management. It is important to control anxiety in patients who have systemic disease that is aggravated or triggered by stress, for example hypertension, epilepsy or asthma. The spectrum of patient management varies from psychological or behavioural approaches to the use of pharmacological agents such as anxiolytic drugs or general anaesthesia (GA). The spectrum of management strategies for the anxious patient is outlined in Table 4.2 , and ranges from behaviour management to local anaesthesia, sedation and general anaesthesia. Not everybody can be managed by sedation ’ GA is the
method of choice for the pre - co - operative child and for many patients with profound learning or physical disabilities.
It is important to appreciate that the use of an anxiolytic drug is not a replacement or substitute for behavioural management of an anxious patient. The use of effective and persuasive communica- tion techniques is still required when managing a patient under sedation.
Behavioural t echniques
Behavioural techniques are employed as a matter of routine by many dentists, and are perhaps most evident when children are being treated. Positive reinforcement is fre- quently used, as shown by the delivery of praise to an appropriately behaved patient.
The age and emotional development of a child must always be taken into account when deciding on which techniques to use. Anxious patients should always be given a stop signal as this transfers an element of control to the patient. A commonly used signal is simply raising a hand and it can be helpful for the patient to rehearse this briefl y before treatment. The dental team must always respond appropriately to such signals. The trust of a patient can take a long time to build up but can be very quickly undermined or destroyed.
Behavioural management can be time - consuming and expertise is required. Dentists who have access to a clinical psychologist are very much at an advantage. Patients with needle phobias can often be cured of their phobia by employing a systematic desen- sitisation programme. Desensitisation is a graded introduction to the feared experience/
treatment – starting with the least frightening. The patient learns to cope with this before progressing to the next stage. Finally, the patient is exposed to the most threatening
Table 4.2 Methods of reducing anxiety.
■ Relaxation training breathing
progressive muscle relaxation ■ Positive reinforcement ■ Behaviour shaping ■ Distraction
story - telling music
■ Transfer of control to the patient stop signal
rehearsal sessions ■ Explanation and information
‘ tell, show, do ’ sequence modelling
permissible deception (being economical with the truth) ■ Negative reinforcement
■ Hypnosis
■ Systematic desensitisation ■ Biofeedback
■ Acupuncture ■ Sedation
■ General anaesthesia
These techniques must be carried out in a suitable environment. The operator should have a relaxed, positive and empathetic manner.
Table 4.3 Management strategies for anxious patients according to anxiety type.
Anxiety type Management strategy
Patients who fear specifi c stimuli e.g. needle phobics
Gradual exposure of patient to the feared stimulus (e.g. ‘ tell, show, do ’ , systematic desensitisation). This approach will work better with a patient stop signal. Coping strategies such as relaxation techniques are also helpful
Patients with free - fl oating anxiety or generalised anxiety
The patient fi nds many situations outside of dentistry stressful; often there will be no history of a precipitating event
The patient needs to develop coping strategies to reduce anxiety
Patients who have a fear of physical catastrophe
e.g. choking, retching, asphyxiating or death
Rehearsal and explanation of the patient ’ s psychosomatic reactions are helpful Systematic desensitisation, coping strategies and biofeedback can be benefi cial once the patient acknowledges the mind – body link to their reactions
Patients who are distrustful of dentists These patients may be confrontational in how they express their fears, e.g. the dentist was always in a rush and never asked how I felt; or always made me feel as if the problems were my fault
Listening to the patient ’ s fears and the transference of some control to the patient is helpful. Feedback must be sought from the patient throughout treatment. The
establishment of a dialogue in an unhurried, open and non - judgemental manner will help improve the patient ’ s confi dence and trust Adapted with permission from Naini et al . (1999) .
situation. A long - term aim in the management of anxious/phobic patients is to modify their behaviour such that some or all future dental treatment may be accepted without the assistance of sedation.
Some clinicians fi nd it useful to categorise anxious patients into four types (Table 4.3 );
this is because the patient category infl uences the choice of behavioural management strategy. It should be appreciated that whilst this classifi cation can be helpful, patients may have features of anxiety that belong to more than one category and several manage- ment strategies are sometimes required for one patient.
Conscious s edation
The term sedation has different meanings in medicine and dentistry and this can also vary internationally. Throughout this book the term conscious sedation will be used as this has widespread acceptance among dental sedationists in the UK and has a precise defi ni- tion. The defi nition that has been adopted by the General Dental Council (GDC), the Department of Health and other dental societies and advisory bodies such as the Dental
Sedation Teachers Group is that originally proposed in the Wylie Report in 1978 and is as follows:
A technique in which the use of a drug or drugs produces a state of depression of the central nervous system enabling treatment to be carried out, but during which verbal contact with the patient is maintained throughout the period of sedation.
The drugs and techniques used to provide conscious sedation for dental treatment should carry a margin of safety wide enough to render loss of consciousness unlikely.
It is imperative that the level of sedation is such that the patient remains conscious, retains protective refl exes and is able to understand and respond to verbal commands. In patients who are unable to respond to verbal contact even when fully conscious (e.g. patients with hearing impairment), the normal method of communicating with them must be maintained. The concept of sedation in which the criteria listed above are not fulfi lled is regarded as general anaesthesia by the GDC. When the term sedation is used in this chapter the authors are referring to conscious sedation .
In the UK, the main sedative agents used in dentistry are:
■ nitrous oxide (N 2 O) administered by inhalation ■ midazolam administered intravenously
■ a benzodiazepine administered orally (e.g. midazolam).
The use of other sedative drugs and multiple agents ( polypharmacy ) is only occasionally indicated and their use requires additional training and expertise because of the increased risk of adverse events, including respiratory depression.
Indications for s edation
Local anaesthesia remains the mainstay of pain control during dental treatment. However, in some patients conscious sedation can be an effective method of facilitating dental treatment and is normally used in conjunction with local anaesthesia as appropriate.
Sedation is a valuable tool in dentistry, it is not a therapy. Like local anaesthesia, it is an adjunct to patient management. There are some patients in whom sedation is contrain- dicated and in a small minority of patients it may prove to be unsuccessful. The indica- tions for sedation are as follows.
Psychological/social : Patients who have dental anxiety or phobia and are unable to accept treatment which they view as traumatic or distressing; sedation often allows the acceptance of such treatments. This heading would also include patients who routinely faint on dental injections or report that local anaesthetic is ineffective and therefore their previous dental treatment has been painful. While failure of local anaesthesia is often due to poor technique or failure to anaesthetise an accessory nerve supply, some patients do become fearful and anxious that local anaesthetic is not going to work and sedation is helpful in controlling anxiety associated with these patients.
Medical : This category consists of several different types of patients.
(i) Anxious patients with medical conditions that are precipitated or aggravated by stressful procedures can often benefi t from receiving sedation, indeed stressful treatment undertaken with sedation may be safer than carrying it out with local anaesthesia alone. Anxiety and pain can cause overactive sympathetic nervous activity (hypertension, tachycardia, arrhythmias). Normal physiological responses to anxiety and fear are not usually harmful; however, in a medically compromised patient they may present a risk to the patient ’ s health. Sedation reduces physiologi- cal responses to anxiety and fear. Epilepsy, asthma, hypertension, angina and psychiatric conditions are examples of systemic diseases that may be exacerbated by stress.
(ii) Patients who have involuntary movements due to neuromuscular disease (e.g.
cerebral palsy or Parkinson ’ s disease) may wish to have dental treatment but are unable to physically co - operate. It is diffi cult to treat patients with movement disorders safely, and sedation can facilitate dental management in this group of patients.
(iii) Patients with cognitive impairment, such as individuals with learning disabilities or dementia. This group of patients may not necessarily be anxious prior to dental treatment but they may become distressed during treatment, usually due to poor understanding of the procedures. Dementia patients will often forget why they are in the dental chair and are then unable to co - operate with treatment and commu- nication may be limited. Sedation can sometimes allow treatment to be undertaken in a non - threatening manner that the patient fi nds acceptable. Learning disabilities could quite rightly be seen as forming a category on its own rather than being viewed as a medical condition.
Dental : Patients who normally fi nd dental treatment acceptable may need sedation for procedures that they view as stressful. Oral surgery procedures (e.g. surgical removal of teeth or implant placement) under local anaesthesia are understandably viewed as unpleasant by many patients. Children may view certain procedures as unpleasant but their perceptions are likely to change as they mature. Sometimes a clinician may recom- mend sedation because the planned procedure is expected to be particularly traumatic or prolonged, the views of the clinician will have to take the patient ’ s wishes into account, and the threshold for this decision may change with the age of the patient. Patients who have a severe disruptive gag refl ex may be included in this indication, although some would say this is psychological in origin and should therefore be classifi ed in the psy- chological/social category.
General a naesthesia
General anaesthesia is a state of unconsciousness with complete loss of feeling and protective refl exes. In dentistry, GA is reserved for patients who cannot accept routine dental treatment, such as individuals with severe learning disabilities that prevent patient
co - operation. In addition, GA is used for procedures that are not amenable to local anaesthesia alone or with sedation. GA remains the preferred method of pain and anxiety control in the pre - co - operative child in the UK. Over recent years there has been a move away from the use of GA in dentistry. GA is subject to stringent regulations and when required for dental treatment it is provided under consultant care in a hospital.
The administration of general anaesthetics in primary care ceased following the implementation of A Conscious Decision (2000), a report by the Department of Health.
Recommended t asks
(1) Access on the Royal College of Surgeons of England website (i) the UK national clinical guidelines on the use of conscious sedation in paediatric dentistry (2002);
(ii) the guidelines on non - pharmacological behavioural management (2002).
You can obtain a copy of these guidelines from the RCSEng website: www.rcseng.
ac.uk/fds/clinical_guidelines .
(2) Read around the subject of dental anxiety and phobia. Journal publications such as Cohen et al . (2000) and Naini et al . (1999) will be helpful.
(3) Obtain a copy of A Conscious Decision from the Department of Health and learn more about why the use of GA has been restricted in dentistry. The full document or an executive summary may be obtained from the Department of Health website ( www.dh.gov.uk/en/healthcare/primarycare/dent ). Identify situations where general anaesthesia, rather than conscious sedation would be advisable for dental treatment.