Online support groups Millions of people access online support groups for information on various disorders, illnesses, and phobias. These individuals are eager for information. They may also derive comfort from knowing that others share their problem and that help is available. One such group, http://www.dentalfearcentral.org, addresses dental anxiety. In a recent study, Coulson and Buchanan (2008) investigated the efficacy of this support group. Ninety- one individuals who had accessed the Dental Fear Central website bulletin board during an 8-week period completed an online questionnaire. Respondents provided background demographic information and their own evaluation of the efficacy of the support group. They also completed a modified dental anxiety scale (Corah’s Dental Anxiety Scale, http://www. dentalfearcentral.org/media/dental_anxiety_scale.pdf). Sixty percent of respondents reported that participation in the support group had “somewhat” or “greatly” lessened their anxiety. The authors of the study compared Dental Fear Central with an earlier face-to-face dental anxiety dentist-led support group in England composed of anxious adults who were avoiding dental care. Although members of the British support group stated that participation had helped them gain confidence and enabled them to seek dental treatment, the group disbanded, citing time conflicts and dependence on the dentist as a group leader. These findings are supported by a more recent study examining the effectiveness of peer-to-peer online support groups (Harding & Chung, 2016). The authors surveyed users of the Big White Wall site (https://www.bigwhitewall.com). The site is not specific to dental anxiety but rather targets anxious or “down” (depressed) individuals. Thirty-one percent of those who responded reported improvement in their anxiety levels. Many anxious and phobic patients are embarrassed to admit to their problem in public. An online support group may help them face their fears while giving them the anonymity they need. NONPHARMACOLOGICAL GUIDANCE TECHNIQUES FOR USE WITH GAGGING PATIENTS
can drown out the sound of a drill, and perfume can disguise certain dental office smells. Management of gagging requires a sympathetic but firm and confident approach. According to Lineberry (2018), useful nonpharmacological strategies, similar to those used successfully for guiding patients with other dental fears, include: ● Rhythmic breathing. ● Behavioral and psychological therapies. ● The use of local or topical anesthetics. ● The use of nitrous oxide inhalation sedation. It may take a combination of these treatment modalities to assist patients with a hypersensitive gag reflex. Advocates of desensitization claim that this technique is preferable to distraction because the positive results are often permanent, whereas the results achieved with distraction are temporary. Using a different approach, acupuncture or acupressure may be an adjunctive means of controlling the gag reflex (Eachempati et al., 2019). The dentist may modify various procedures in an effort to reduce gagging. A rubber dam may help reduce gagging triggered by contact with air spray or water. With a dam, there is no need to suction water from the back of the mouth. ● Relaxation. ● Distraction. ● Desensitization. Dentures and denture construction are especially problematic for patients with a strong gag reflex. The following modifications of prosthetic procedures may be helpful: ● Perforated impression trays should be avoided because exuded impression material can come in contact with the tongue or soft palate. ● A boxing wax or putty posterior dam can be constructed on stock trays to help prevent impression material from escaping the back of the tray, which is not overloaded and uses a rapid setting impression material (Benting, 2018). The use of cotton tip applicators to remove excess, which oozes beyond the posterior border of the impression tray, can decrease the tendency for gagging. A staff member must remain in the room to continuously monitor the patient and remove the impression tray as soon as the material polymerizes.
Dental care for a patient with a strong gag reflex poses an enormous challenge for both the patient and the dentist. Fear of gagging can be a major impediment to providing or receiving dental care. For a patient with a strong gag reflex, the fear of choking is very real, which increases the patient’s dental anxiety. In the worst-case scenario, the problem may appear insurmountable and result in the patient avoiding all dental care. As is the case with other extremely fearful patients, the patient’s avoidance of dental care often leads to complex oral health problems. Eventually, treatment may be compromised because of gagging, and teeth may be lost. This compounds the problem further because for many patients with a strong gag reflex, wearing dentures may be intolerable. When treating a gagging patient, the dentist must have a complete history and assessment. Preferably the gagging history should detail previous gagging experiences, triggers, and successful strategies that have been used in the past. Although the patient may be embarrassed, providing this information allows the practitioner to assess the severity of the problem, including limitations it may place on future treatment. Discovering the etiology of the patient’s gagging is helpful when designing a treatment plan. Different etiologies may call for different approaches (Ahmad et al., 2015; Lineberry, 2018). To elicit the necessary information, a simple request, such as, “Describe the problems you have had with gagging during dental treatment” may elicit enough information to enable the dentist to gauge the extent and nature of the problem. According to Ahmad and colleagues (2015), gagging may be caused by: ● Local factors (e.g., nasal obstruction, constricted airways). ● Systemic disorders (e.g., certain medical conditions, smoking). ● Psychological factors (e.g., fear, anxiety, psychological issues). ● Latrogenic factors (e.g., instrumentation). ● Prosthetic factors (e.g., poor retention of complete or partial dentures). ● A hypersensitive gag reflex. If the problem is purely psychogenic, a referral to an appropriate counseling service may be warranted. However, because gagging problems are commonly multifactorial, a multifactorial solution is most likely to succeed (Ahmad et al., 2015). Certain sounds, smells, or sights may trigger psychogenic gagging. If possible, such stimuli must be avoided or disguised. Music
NONPHARMACOLOGICAL BEHAVIOR GUIDANCE FOR FEARFUL PEDIATRIC PATIENTS The American Academy for Pediatric Dentistry (AAPD) has produced behavior guidelines for pediatric dental patients that include many of the nonpharmacological techniques and strategies already discussed for adult fearful patients (AAPD, 2016a). These strategies must be tailored to the specific needs of each child. The parents’ attitudes and concerns must also be considered. Parents share in the decision-making process regarding treatment of their children. They must be informed about the nature, risks, and benefits of the technique to be used and about any professionally recognized or evidence- based alternatives. Informed consent should be obtained for all techniques other than communication and should be consistent with AAPD guidelines for informed consent and applicable state laws.
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