Treating the Apprehensive Dental Patient ________________________________________________________
possibly due to memories of previous dental appointments with inadequate anesthesia and/or pain. The vibrations of the hand pieces against the surface of the tooth can also be a source of anxiety, even if profound local anesthesia has been achieved. The combined aerosolized mixture of water, cari- ous and non-carious tooth structure, and residual restorative materials can create an odor that may concern a patient and generate fear and anxiety during the procedure. Because a relatively large volume of water must be used with high-speed hand pieces to prevent the generation of potentially damaging heat, some water may accumulate in the patient’s mouth, even with suction evacuation. For some patients, this will trigger a fear of choking or drowning or of an inability to communi- cate needs to the dental staff. This same concern may arise in response to the use of water in conjunction with ultrasonic scaling devices used during dental prophylaxis. Other patients may fear that the high- or low-speed hand piece will slip and cause an injury to the adjacent teeth and/or soft tissues, par- ticularly for patients who have sustained this type of injury in the past. While nothing can completely eliminate iatrogenic injuries during dental procedures, fears can be allayed by a dentist-patient relationship based in mutual trust and respect and by meticulous attention to detail by the entire dental staff. GAGGING Another common fear among dental patients is of uncontrol- lable gagging, which can lead to nausea, vomiting, choking, or swallowing dental materials or instruments. Gagging is a protective reflex that is meant to prevent the aspiration or ingestion of foreign bodies. The degree of stimulation required to initiate this response and the intensity of the response vary considerably among patients. In the oral cavity, the areas most likely to stimulate a gag response are the soft palate, the lateral surfaces of the posterior border of the tongue, and the dorsum of the tongue. However, even minimal stimulation of any intraoral surface can initiate a gag reflex in patients who are hypersensitive. Most commonly, a tactile sensation against susceptible intraoral tissues during dental treatment initiates the gag reflex, but visual, auditory, and/or olfactory stimuli can also induce this response [18]. For susceptible patients, obtaining impressions for fixed or removable prostheses may be difficult. Impression materials are viscous but can still flow toward the soft palate (in the case of maxillary impressions) or toward the posterior borders of the tongue (in the case of mandibular impressions). Patients may also fear that the flow of the impression material will extend into the pharynx and compromise their ability to breathe. Patients who have experienced problems with the impression procedure in the past may begin to gag at the sight of the impression tray. Even the particular fragrance or taste of an impression material may trigger an excessive gag reflex. Numer- ous impression materials are available with varying complete polymerization times, and the option with the shortest set time should be selected for these patients. Vomiting or premature removal of the impression tray will ruin the impression and
THE MOST COMMON STRESSORS DURING DENTAL TREATMENT
As noted, no single theory can explain the etiology of appre- hension among dental patients. Likewise, there is not one dental instrument, situation, or procedure that is the source of fear, anxiety, or phobia among dental patients. In general, potentially stressful dental stimuli are characterized as one of the four S’s: sights, sounds, smells, or sensations [3]. Any or all of the four S’s can trigger a response of fear or anxiety in susceptible patients. Even the suspense of the initial waiting period in the dental reception area can be anxiety provoking [16]. An extended waiting time provides an opportunity for the patient to reflect on the nature of the treatment and any associated fears. Some patients may also become concerned that the extended wait time is a sign of clinician incompetence. NEEDLE AND INJECTION PHOBIA In the dental setting, needles (mainly used for the injection of local anesthetics) and high- or low-speed hand pieces are the instruments most likely to induce fear or anxiety. Injection of a local anesthetic is indispensable when providing painless dental care. Most patients have a certain degree of fear of the injection process but can tolerate the procedure without event. However, approximately 10% of the population has belone- phobia, a phobia of needles and injections [17]. Clinically, needle phobia is grouped with phobias of blood, injections, and/or trauma in the blood-injection-injury phobia category. There is some evidence that this type of phobia is or may be partially inherited, with higher concordance rates among first- degree relatives [17]. Fear of needles may be related to the pain during injection or the effects of the local anesthetic. Patients with needle phobia may describe the needle’s length or diameter in exaggerated terms, in accordance with their experience of the object or another person’s description of the needle. Patients with these fears may express concern about the possibility of tissue trauma, breakage of needles (perhaps requiring additional procedures to repair), or failure of the anesthetic. Acute, exaggerated parasympathetic nervous system activity with exposure to needles, blood, and/or injections can cause fainting (vasovagal syncope), and this reaction is experienced by up to 80% of people with blood-injection-injury phobia [50]. HAND PIECES AND DRILLING Hand pieces are an essential tool in restorative dentistry. The high-speed hand piece may also be used during oral surgery for the removal of bone and for sectioning roots during sur- gical extractions. In recent years, lasers have replaced hand pieces for some restorative procedures, but while their use has decreased, high-speed and low-speed hand pieces are still commonly encountered. Both the sight and the sound of the high- and low-speed hand pieces can evoke fear and anxiety,
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