stimulus to the next until the patient no longer fears the stimulus. Systematic desensitization entails four steps: 1. Identifying the issue. 2. Training the patient to relax. 3. Constructing a hierarchy of fear-producing stimuli related to the patient’s main fear. 4. Introducing each stimulus in turn to the relaxed patient. (Oliver & Manton, 2015) Progressive muscle relaxation is a technique of stress management that involves alternately tensing and relaxing different muscle groups in a specific sequence. It may require multiple training sessions to master. Regardless of the specific sequence that is followed, the overall process is the same. First, the patient tenses each muscle for 5 to 10 seconds, generally at 75% of full tension. Then the patient relaxes those muscles for approximately 10 seconds. During this process, the patient should focus on the sensations of muscle tension and then relaxation (Armfield, 2016). This type of progressive muscle relaxation has been shown to be effective not only in managing general anxiety but in combating dental anxiety in particular (Appukuttan, 2016). For scientific research on the relaxation response, see the groundbreaking work of Herbert Benson, M.D. environment that are the source of their anxiety (Rosiak & Szymanska, 2018). Unlike the images portrayed in movies and television, a hypnotized individual has the complete ability to make their own decisions and is not subject to the controlling influence of the hypnotist (Allison, 2015). Hypnosis places the dental patient in a state of deep relaxation, which reduces their anxiety related to dental treatment and also decreases the perception of pain during a dental procedure with the proviso that the patient must be willing to undergo hypnosis (Rosiak & Szymanska, 2018). Some authorities distinguish between light and deep hypnosis, with the latter taking more induction time and the former being easier and faster in the achievement of a hypnotic state, which is more appropriate in the dental setting (Allison, 2015). Hypnosis used in dentistry has a low risk of adverse side effects and may be used as a safe alternative to conscious sedation or general anesthesia, which may also be used to treat anxious or phobic dental patients (Ravalia, 2017). can also act as an adjunct for achieving anesthesia during dental procedures and has the potential of producing antianxiety and other therapeutic effects (Dentistry Today, 2018). Acupressure applied with thumb pressure to the P-6 Neikuan pressure point on the wrist has also been shown to significantly reduce the gag reflex (Eachempati et al., 2019; Rohmetra et al., 2017). in the level of dental anxiety (Premkumar, 2019; Venkataramana et al., 2016). Aromatherapy with the use of an orange fragrance has also been shown to reduce anxiety among patients related to surgical removal of impacted mandibular third molars (Minja & Kahabuka, 2019). Although there is a reduced state of anxiety with the use of aromatherapy, it does not influence the patient’s dental anxiety related to thoughts of future dental visits. auditory or visual signals that can be noted by the patient. The information (feedback) is then used to help patients modify undesirable physiological changes. The disadvantage of this approach is that effective implementation requires investment in biofeedback equipment as well as training for the dental practitioner (Appukuttan, 2016). In offices in which this technology is implemented, the dentist or assistant would assume the role of a coach by explaining the feedback information, offering encouragement, and helping the patient to learn desired behavior.
4. Throughout the session, continue assessing the patient’s state of relaxation and, if necessary, gently remind the patient to focus on breathing and relaxation to reassure the patient that he or she is in control. 5. After the treatment is completed, the patient should be complimented on doing well and encouraged to continue practicing the newly learned relaxation technique. For success with this technique, a calm, attentive chairside manner is essential. Suggestions must be given in a soothing, unhurried voice, using nonthreatening words. Other common relaxation techniques include systematic desensitization, progressive muscle relaxation, and hypnosis. All are more time consuming than rapid relaxation and are best reserved for more seriously anxious patients. Muscle relaxation techniques can also be used with proper breathing techniques as a combined modality to further decrease the patient’s anxiety (Apple, 2019). Systematic desensitization involves first teaching the patient to relax. A series of progressively stronger stimuli related to the main fear are then gradually introduced to the relaxed patient in small increments, progressing from the least fear-producing Hypnosis Hypnosis produces an altered state of mind in which the subject can accept suggestions more readily and act upon them more powerfully. Posthypnotic suggestion can be used for positive reinforcement, possibly reducing stress on subsequent dental visits (Appukuttan, 2016). In fact, in one meta-analysis, 75% of the patients reported pain reduction after hypnosis (Appukuttan, 2016.) Clinical hypnosis has been shown to reduce dental anxiety during the appointment and can decrease the dental anxiety for follow-up appointments (Ravalia, 2017). Hypnosis is rarely used in dental practice as there is a lack of dentists who are appropriately trained in this discipline (Ravalia, 2017). Usually hypnosis is thought of as a trance state. However, hypnosis is considered a modified state of consciousness in which there exists a high degree of susceptibility to outside influences and in which there is increased attention to suggestion (Allison, 2015). In dentistry, the goal of hypnosis is to have the patient focus on their internal feelings and thus eliminate the influence of external stimuli within the dental Acupuncture and acupressure Dentists wishing to incorporate acupuncture into their practice need special training. This technique has not been widely used in dentistry, although it has been proved successful for control of the gag reflex and dental pain. After using acupuncture point CV-24 (center of the mentolabial groove directly below the lip), the gag reflex during impression taking was reduced significantly (Anand et al., 2015; Daneshkazemi et al., 2016). Acupuncture Aromatherapy Aromatherapy is a form of alternative medicine that uses plant materials and aromatic plant oils, including essential oils and other aromatic compounds, for altering one’s mood or cognitive, psychological, or physical well-being. The oils can be diffused in the atmosphere to produce a calming effect for the anxious patient. A significant decrease of anxiety among dental patients has occurred with the use of an ambient scent of both lavender and rose oil, but lavender oil has produced a higher reduction Biofeedback Biofeedback, a mind-body technique that uses specific instruments to monitor the physiological processes of the patient being monitored (Appukuttan, 2016; Matsuoka et al., 2017), has been shown to reduce dental anxiety. Biofeedback devices monitor subtle physiological changes, including muscle activity. This information is then conveyed to the patient to help the patient learn how to modify undesirable activities such as muscle tensing. Biofeedback devices range from relatively simple monitors to quite complex, computer-based systems. The information being monitored is displayed by means of
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