Treating the Apprehensive Dental Patient ________________________________________________________
require that the process be repeated. Further, incompletely set impression materials can cling to teeth and soft tissues, and removing the residual materials can also stimulate a sensitive gag reflex. While there are no universal solutions to eliminate the gag reflex and related problems, techniques have been developed to minimize a gagging response. Most dental procedures are accomplished with the patient in a supine position, but moving the patient to an upright position with his or her head tilted toward the floor will decrease the flow of impression mate- rial toward the posterior of the oral cavity. When possible, impressions may be taken with a quadrant tray rather than a full arch tray to minimize the amount of impression material introduced into the oral cavity. Local anesthetic sprays may be applied to the mucosal tissues prior to taking an impression in an effort to decrease the gag reflex. However, these formulations should be used with cau- tion, because if the spray is inadvertently directed into the pharynx, it can lead to laryngospasm. Placement of salt on the tip of the tongue stimulates taste receptors whose ascending neural pathways lead to the hypo- thalamus, the part of the brain that also receives neural input for the gag reflex [19]. The presence of this competing stimu- lus can dampen the gag reflex. A similar diversion technique can be employed by having the patient lift his or her legs off the chair; the flexing of muscles can also provide enough of a distraction to reduce the intensity of the gag reflex. When these or similar techniques are not adequate, nitrous oxide sedation or anxiolytic medications may be required. When pharmacotherapy is used, a responsible adult driver should be present to transport the patient home. These are among the most common situations that may cause a dental patient to develop apprehension about dental treat- ment, but it is not an all-inclusive list. Some patients will have very specific fears—of masks, being touched, or even certain lighting. When combined with the fear of pain and/or loss of control, these situations can become an obstacle in the abil- ity to provide dental treatment. All dental clinicians should maintain an open dialogue with patients about situations that stimulate fear, anxiety, or phobias and pursue options to ameliorate them.
words, expressions, and/or body language characterize an apprehensive dental patient, there are cues that should trigger dental staff to inquire further about the patient’s anxiety and ability to move forward with treatment. Verbal signs of dental fear and anxiety include the actual words spoken, but also the manner and inflection of the speech. Speech cues that suggest underlying fear or anxiety include a trembling lip, variances in speech tone or inflection (e.g., vocal tremors), an atypically loud or silent demeanor, and a very rapid or very slow rate of speech [20]. Statements that reflect strong negative feelings about previous dental encounters may also be an indicator and include comments about hating dentists, hating to go to the dentist, fainting at the sight of a needle or after receiving an injection, having difficulty achiev- ing local anesthesia, or being hurt during a previous dental encounter. Similarly, patients who speak with little or no eye contact may also have an undisclosed fear and/or anxiety of dental treatment. Behavioral signs and body language may also be signals of a patient’s dental apprehension. Being startled or jumping when a staff member enters the room, places an instrument or an x-ray film in the mouth, applies a topical anesthetic, or administers a local anesthetic are all potential signs of fear [21]. Strongly grasping the dental chair (e.g., “white knuckle”) is a classic presentation of an apprehensive dental patient. Patients who sit with their arms and/or legs crossed tightly, fidget or are generally uncooperative, shut their eyes tightly, hold their breath, have pronounced tension and flexion of the facial musculature, or require excessive breaks during a dental procedure are likely expressing stress and anxiety. Again, this is not an exhaustive list, but it reflects some of the more com- mon physical manifestations of dental fear and anxiety. The greater the degree of underlying fear and anxiety, the greater the tendency to display these verbal and nonverbal signs. Consideration should also be given to the verbal and non- verbal signs the dental staff provide as they interact with the apprehensive patient. Tension and animosity can manifest in hurried, abrupt, apathetic, or rude interactions with patients. Dental staff members who are immersed in their own concerns may ignore those of the patient and further perpetuate fear and anxiety. Dental professionals should not provide care to patients unless they have the patience and empathy to do so appropriately. BEHAVIOR MODIFICATION TECHNIQUES Behavior modification techniques should be the first-line treatment for patients with dental fear or anxiety, before phar- macotherapy (e.g., oral, intravenous, or inhalation sedation) is employed. If behavior modification techniques are embraced by the patient, they have the potential to improve adherence to dental follow-up and prophylaxis appointments and reduce or even eliminate the need for sedation. However, it is important
VERBAL AND NONVERBAL SIGNS OF FEAR AND ANXIETY
The ability to detect varying degrees of patient apprehension can allow dental staff to address patients’ concerns so treat- ment can be completed in a safe and comfortable atmosphere. Patients who are fearful or anxious about dental treatment may exhibit verbal and nonverbal signs of their discomfort. Some patients will not admit to feelings of fear and anxiety, but their behavior may indicate an underlying anxiety. While no single
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