| 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. |
