Treating the Apprehensive Dental Patient ________________________________________________________
with the patient in a supine position, with the dentist and assistant in a position above them. These positions can make some patients feel that they have relinquished control and that they are defenseless to communicate any degree of pain or discomfort to the dental staff. The introduction of unfamiliar dental procedures or instruments, unanticipated problems with the actual procedure, and prolonged treatment times may exacerbate these fears. An inability to see and understand the specifics of the dental procedure and the dental terminology being used between the attending staff members can create a feeling of isolation between the patient and staff, amplifying the patient’s perception of loss of control. The use of medications adjunctive to dental treatment can also contribute to patients’ perception that they are not in control of their immediate situation. Sedation can depress neuromuscular reflex activity and make patients feel that they are in a vulnerable position. Most local anesthetics contain a vasoconstrictor (e.g., epinephrine) to prolong the effect of the anesthetic and facilitate the coagulation process after oral or periodontal surgery. Epinephrine is a catecholamine with a stimulant effect on the sympathetic nervous system. If a local anesthetic with epinephrine is inadvertently injected directly into an artery or a venous plexus, this can cause untoward effects. An intravascular bolus of epinephrine can increase heart rate, respiratory rate, and blood pressure, with patients experiencing heart palpitations and tightness in the chest that can mimic or precipitate a panic attack. An intravascular injection of the local anesthetic itself can have adverse effects on cardiac tissue and cerebral tissue, inducing syncope and seizures. Patients who have experienced these incidents can develop fear, anxiety, or phobia of local anesthetic. It is impor- tant to note that the apprehension these patients develop is not generally related to a phobia of needles but is related to the potential adverse effects of the local anesthetic. Another possible source of dental apprehension is excessive or aggressive criticism regarding patients’ neglect of their oral health and presentation with advanced periodontal disease and widespread carious lesions. Fear of reprimand prevents some patients from seeking preventive dental care, creating a cycle of worsening oral health and increasing embarrassment and fear. Clinicians who strongly scold patients may increase patients’ dental apprehension and construct another obstacle to needed dental treatment. As a corollary, some patients who have not sought dental treat- ment for a long period of time and are aware of large carious lesions, fractured teeth, teeth with advanced mobility, gingival bleeding, and halitosis may believe that restoring their oral health is either hopeless or cost prohibitive. Similarly, some patients without symptoms of oral health problems may fear that a comprehensive dental examination will reveal problems they do not want to deal with, including caries, periodontal
disease, impacted wisdom teeth, and benign or malignant oral lesions. The predominant concern for these patients is that the diagnosis of these conditions will require additional dental treatment and related costs and potential pain. Distressing life experiences may also impact patients’ approach and response to dental treatment. Studies indicate that victims of sexual assault are 2.5 times more likely to report high levels of dental anxiety than individuals who have not been sexu- ally assaulted. Victims of sexual assault may feel particularly vulnerable when they are in a supine position in the dental chair. Patients who have been sexually abused are also more likely to have a heightened gag reflex and related fear and anxiety [10; 11]. In some patients, dental treatment fear may be related to a fear of contracting diseases such as hepatitis, herpes, or human immunodeficiency virus (HIV) directly from dental staff or indirectly from insufficiently disinfected or sterilized instru- ments or environmental surfaces. This fear is not necessarily unfounded, as there have been cases of disease transmission linked to dental care. The first widely publicized cases occurred in the late 1980s, when Dr. David Acer, an HIV-positive general dentist from Florida, allegedly infected six of his patients with the virus, although the mode of transmission is unknown [12]. More recently, in 2001, hepatitis B was transmitted from one patient to another in an oral surgery practice due to a breakdown in clean-up procedure. In 2009, five patients who attended a two-day portable dental clinic in West Virginia developed hepatitis B. A retrospective analysis revealed several breaches in the infection control regimen, any of which could have facilitated the outbreak [13]. In 2013, a documented case of the transmission of hepatitis C between two patients from an oral surgery practice in Oklahoma occurred, again due to a lapse in the infection control regimen [14]. Despite rare breaches, disease transmission in the dental setting is uncommon, particularly when infection control standards are followed. The best way to allay patient fear is to practice appropriate infection control procedures without fail after each patient encounter. Staff members should also be prepared to answer patients’ questions about the facility’s infection control standards. It is clear that a variety of factors, exogenous and endogenous, contribute to the development and maintenance of dental fear and anxiety. It is good practice to include questions that focus on the patient’s perceived level of dental apprehension, trau- matic dental events of the past, and concerns about continued dental treatment in each medical history. A discussion between the dentist and the patient about these concerns before the initiation of dental treatment can assist in establishing an atmosphere of mutual trust and respect, which can provide the critical first step in addressing (and hopefully minimizing) fears and providing the necessary dental treatment.
68
EliteLearning.com/Dental
Powered by FlippingBook