Dental phobia affects about 4% of the population, while dental anxiety affects one in five.
Our dental professions can profoundly help these people. However, our professions also have the power to profoundly wound them, with indifference and inconsideration. We have all heard of the ‘the butcher’ dentist in our patients’ stories. Of course, in the stories that each of us hear, this character is always played by another dentist. But if you really think about it, many of us must have featured in stories told in other clinics. This is, of course, not to say that we are deserving of this inglorious position. Perhaps we are remembered unfairly? After all, the stories of dentists having a knee on a patient’s chest are ergonomically questionable. However, we need to recognise that dental anxiety promotes the construction of such memories, among many other negative outcomes. Regardless of historical fact, the distress that such memories bring is real and crippling. Dental anxiety also breeds catastrophisation and causes exaggerated, but actual, increases in pain. These real-life implications are deserving of both our consideration and our respect. In this clinical feature, we share advice on how to avoid four common traps that lie before dental professionals when treating people with severe dental anxiety so we can avoid becoming the protagonist in future stories.
Not setting the team’s expectations It can be difficult to keep our cool when under extreme pressure. While our responses are mostly rational and help keep us safe, sometimes they are out of kilter. Just like our reactions to threat, patients with dental anxiety may naturally react to dental encounters with ‘fight or flight’. So when an anxious patient seems irrationally ‘needy’ or argumentative (fight), or cancels last minute (flight), we need to understand that this is simply the physiology of fear and not a purposeful or intentional trespass! The team’s natural responses to such interactions tend to be negative by meeting emotion with emotion (fight) or begrudging the lost clinical capacity (flight). One crucial feature of fear response that is often overlooked is its crippling effect on communication. Patients may come across as inattentive, rude or short. If our whole team understands that this is a fear response rather than an intention, it takes away a lot of the negative emotion that these interactions elicit.
Our advice is to have a team discussion about intention and reaction so everyone, especially the person answering the phones, understands that anxious patients do not choose their responses, rather they suffer them. Merely phoning to make a dental appointment can be the equivalent of a rollercoaster ride for people with dental phobia. They are facing physiological and psychological challenges that demand understanding and patience from the whole team. Simply having this discussion can make dental anxiety encounters so much better for the team and patients. It lets the team understand how they can be proactive in supporting patients with dental anxiety. When will you have yours?
Not sending the right message The team must be conscious of the message that patients may take from their interactions. Patients can be reassured with the right message. These messages can be generic like: ‘You are in control’ or ‘You are in the right place’. When done well, we can meet the patient’s specific needs so they can see and feel that their issue has been addressed. If you are unsure of the patient’s specific needs, ask. This information is gold dust. Table 1 summarises actual feedback from patients who felt their specific needs were met, with suggestions for how to elicit this experience.
Avoiding the issue In general, anxious patients will benefit greatly from knowing that we recognise their fear and take it seriously. Opening a conversation is key. This lets patients know we take their concerns seriously. It lets them share their needs and preferences, shaping our response. However, it can be difficult to know how to elicit this information and build rapport. We share the questions we ask our dentally anxious patients in Table 2 to help. You can copy and paste these six questions into your dental anxiety interview.
Not reacting proportionately Dental anxiety is not uniform in aetiology, presentation or severity. Rather, it represents a spectrum, particularly regarding severity. It is crucial to get a sense of how anxious a patient is. This can easily be quantified using the MDAS score. Newton’s article can help you to find out how.3 Patients should be treated proportionally to their level of anxiety: mild, moderate or severe. Patients with mild anxiety can be supported using relaxation and distraction-based techniques, among others. These are easily provided by general dentists. People with higher levels of anxiety will more likely need pharmacological or psychological intervention.
Cognitive behavioural therapy (CBT) is a talking therapy provided by psychologists or trained dental professionals. Studies have shown substantial rates of reduction in dental anxiety resulting in long-term benefits.4 There is no doubt that this multidisciplinary approach should be utilised a lot more than it currently is. If you search for CBT therapists in your area you will find them. Why not drop them a line? Wouldn’t it be wonderful to offer a successful outlet to that group of phobic patients whose oral care is otherwise so unpredictable?
Sedation and general anaesthesia are alternative options that are suitable for urgent care and high treatment needs in patients with high levels of dental anxiety. Their down side is that they fail to actually ‘fix’ the problem and are probably best considered a work around rather than a solution. Having said that, access to such services is crucial so ensure that you are appropriately endowed with access to these vital options.
Treating people with dental anxiety presents many challenges. However, if managed effectively there are many positives – this group has high treatment need, is incredibly loyal, acts as a practice builder and provides powerful testimonials. Above all, there is no greater professional satisfaction than observing the gradual transformation of a person’s whole life simply by overcoming severe dental anxiety. Try it!
1. Oosterink, F.M.D., de Jongh, A., Hoogstraten, J. Prevalence of dental fear and phobia relative to other fear and phobia subtypes. European Journal of Oral Sciences 2009; 117 (2): 135-143.
2. Brady, P., Dickinson, C., Whelton, H. Dental anxiety prevalence and surgery environment factors: a questionnaire-based survey of attenders in Ireland. 2012. Available from: https://cora.ucc.ie/handle/10468/638.
3. Newton, T., Asimakopoulou, K., Daly, B., Scambler, S., Scott, S. The management of dental anxiety: time for a sense of proportion? British Dental Journal 2012; 213 (6): 271-274.
4. Gordon, D., Heimberg, R.G., Tellez, M., Ismail, A.I. A critical review of approaches to the treatment of dental anxiety in adults. Journal of Anxiety Disorders 2013; 27 (4): 365-378.
Caoimhin Mac Giolla Phadraig
Assistant Professor in Public Dental Health and Dental Science, School of Dental Science, Trinity College Dublin, and Dublin Dental University Hospital
BDS Dip Con Sed Boyne Dental, practice limited to dental anxiety
Hillmorton Hospital, Christchurch, New Zealand
BA BDentSc FFGDP (UK) PhD FFPHM FHEA Professor in Special Care Dentistry and Dental Science, School of Dental Science, Trinity College Dublin, and Dublin Dental University Hospital
Corresponding author: Caoimhin MacGiolla Phadraig, Dublin Dental University Hospital, Lincoln Place, Dublin 2. T: 01-612 7303