Treating the Apprehensive Dental Patient ________________________________________________________
Fear Fear is an emotional reaction to real or imagined imminent danger or pain. A certain degree of fear provides a protective mechanism against environmental dangers, but some fears, such as those that pertain to dental care, are learned and exceed the level warranted by the actual threat [2]. The exact number of patients who are fearful of dental treatment is unknown, because research is complicated by the large and diverse patient population, lack of universal definitions, and reluctance of patients to admit to fears. Dental fear is generally considered to be a less severe reaction than clinical anxiety disorder and specific phobia, but it can vary from mild to severe. Anxiety and Specific Phobia Anxiety is defined as a psychological distress reaction that develops in anticipation of a future threat. Severe, acute anxiety may manifest as a panic attack, a fear response experienced by many patients with anxiety disorders [49]. Patients with anxiety may also rely on avoidance of triggering situations. Anxiety is experienced as a prolonged sense of intense apprehension and uneasiness that can manifest as physical symptoms, including skeletal muscle tension, gastrointestinal disturbances, sleep disruption, hypertension, myalgia, neuralgia, and tension headaches [4]. Fear and anxiety can co-occur. Anxiety disorders are the most commonly diagnosed psychi- atric disorders in the general population, and specific phobia is the most commonly identified anxiety disorder [5]. Specific phobia is characterized by persistent (longer than six months), marked anxiety about a specific object or situation (e.g., fly- ing, spiders, blood, dentistry) to the extent that the trigger is avoided or endured with severe fear or anxiety [49]. Patients with specific phobia will go to extremes to avoid the situation or the object that is the basis of their phobia. In dentistry, needle phobia can make the administration of a local anes- thetic virtually impossible unless the patient has received some level of sedation. Claustrophobia, or the fear of being enclosed in and unable to escape from small spaces, may be triggered by coverings or masks (e.g., rubber dams) on the face, being surrounded by dental professionals during procedures, and/ or small dental treatment rooms. Some objects or situations that are the basis for a person’s phobias can be avoided. For example, a person can opt to drive or take a train rather than fly. However, there is no substitute for routine dental care, and avoiding it will increase the risk for the development of periodontal disease and carious lesions. These conditions will become more expensive to treat and more symptomatic with the passage of time, which can exacerbate the phobia. As with any description of human behavior, the boundaries between fear, anxiety, and phobia are not absolute, and each patient’s issues should be assessed on an individual basis. Co- existing psychiatric problems, such as depression, bipolar disor- der, and schizophrenia, can further decrease a patient’s ability to withstand dental treatment. It may be necessary for dental clinicians to consult with the patient’s physician, psychiatrist, and/or psychologist before initiating dental treatment.
INTRODUCTION Patients exhibit varying emotional and psychological responses as they prepare for an appointment for dental assessment and treatment. Some patients remain relaxed before and through- out dental treatment or may experience a minor degree of apprehension but can complete treatment with minimal emo- tional and psychological stress. However, for some patients, apprehension about dental treatment can progress to a degree that varying forms of sedation must be used to complete a dental procedure. Some people become so apprehensive about dental treatment that they cannot even make an appointment, forfeiting the benefits of preventive dental care and assuming an increased risk for dental caries, periodontal disease, acute pain, and infections of odontogenic origin [1]. Ironically, the pain and swelling that can accompany an emergency dental problem tend to make these patients even more apprehensive about seeking dental care. Needless suffering, cosmetic and functional problems that develop from the loss of teeth, absences from work, decreased self-esteem, and a diminished quality of life are among the problems attributable to the avoidance of dental care by apprehensive patients. This course will provide information about the varying levels of dental apprehension and common sources of their origin. Procedures and situations considered to be sources of stress among dental patients and the common verbal and nonverbal signs that patients exhibit during these situations will be dis- cussed, as will methods that the dental team can use to allay dental fear and phobia, including behavior modification, phar- macologic agents, and alterations in dental treatment. Finally, the emotional and psychological effects dental team members may experience as they provide treatment for apprehensive patients will be addressed.
AN OVERVIEW OF DENTAL APPREHENSION
Each person’s unique physical, emotional, psychological, and spiritual history contributes to how he or she views life events and handles perceived stress. The same dental procedure per- formed by the same clinician may be considered uneventful by one patient but can cause enough apprehension in another patient that the procedure cannot be completed without the assistance of sedating agents. These responses represent oppo- site ends of the spectrum of dental apprehension, between which there are many increments of dental apprehension. DEFINITIONS Many terms are used to describe dental apprehension, each with a different connotation and associated severity level. The most common terms used to describe dental apprehension are dental fear, dental anxiety, and dental phobia. These terms pro- vide general guidelines for the degree of dental apprehension but should not be construed as absolute and rigid definitions.
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