_______________________________________________________ Treating the Apprehensive Dental Patient
to remember that, despite best intentions, dental patients with extreme fear, anxiety, or phobia usually require some level of sedation in order to undergo dental treatment. CLINICIAN-PATIENT RAPPORT Establishing rapport with patients during initial and subse- quent encounters is a critical step in the provision of dental care. A relationship founded in trust and mutual respect will allow the dental professional to be cognizant of a dental patient’s fears and concerns and to respond to them appropri- ately. This simple practice can easily be overlooked in a busy clinical schedule that is production-oriented, but it is the basis for all other behavior modification techniques. DISTRACTION Distraction can work for patients who display mild fear and anxiety about their dental treatment. Techniques for proce- dures of minimal duration, such as applying pressure or vigor- ously rubbing mucosal tissue that is about to be anesthetized, can be useful for patients with fear of injections. Distraction techniques for procedures of longer duration include the use of handheld electronic devices or intra-operatory televisions to listen to music, watch movies, or participate in interactive games. GUIDED IMAGERY AND BREATHING EXERCISES In guided imagery, the clinician walks the patient through visualization of him- or herself in a soothing place or having a pleasant experience. The purpose of guided imagery as a coping exercise is to provide the patient with a safe, healthy mental escape that he or she can access when needed. At first, the clinician’s voice is the guide to take the patient to this place. If a clinician feels uncomfortable developing guided imagery scenarios, there are many good free scripts available online, including hundreds of variations on the standard calm, happy, or safe place [15]. Patients who can develop and maintain a strong and detailed visualization will have a higher degree of distraction from their dental treatment. Progressive relaxation can be particularly effective in patients who somatize stress into physical tension. This form of therapy involves tensing and relaxing individual muscle groups while breathing deeply, starting from the toes, working progressively through the calves, thighs, stomach, shoulders, hands, arms, and neck, and ending with the facial muscles [22]. Deep breathing exercises use slow, controlled breaths (while counting) to “quiet” racing thoughts. The influx of oxygen has a relaxing effect on the body [23]. Breathing exercises are particularly beneficial for patients who hold their breath when they develop fear or anxiety during a dental procedure. If a patient stops normal breathing, blood oxygenation is decreased, which can cause fatigue and anxiety and increase the apprehension experienced by the patient [24]. Good breath regulation is also necessary to gain the maximum benefit from guided imagery experiences.
Three basic breath exercises that may be incorporated into a treatment plan are diaphragmatic breathing, complete breath- ing, and ujjayi breathing: • Diaphragmatic breathing (or belly breathing): Instruct the patient to breathe in through the nose and out through the mouth, focusing only on the rise and fall of the belly (not the whole rib cage). Challenge the patient to expand the belly as far as possible as he or she inhales. It may help for the patient to put his or her hand on the belly to concentrate on this motion. • Complete breathing: For this exercise, the patient
should begin with the belly breath. When the stomach expands as far as it will go, teach the patient to inhale through the nose again and concentrate on the air coming into and fully
expanding the rib cage. There are two variations on the release: either a slow, steady release, which helps promote tranquility and mindfulness, or a sudden, rapid release, which can help the patient experience how good “letting go” can feel. • Ujjayi breathing (“ocean breathing” or “Darth Vader breathing”): This breath, which is effective as an affect regulator during moments of high stress or intensity, is a noisy in-through-the-nose, out-through- the-nose technique. This allows for a greater flow of oxygen into the lungs, which can stimulate a relaxation response. For patients who are not used to mindful breathing, it is especially important to start slow with this exercise, doing no more than five breaths at a time. Let the patient know that the louder this breath sounds (even if he or she feels self-conscious at first), the better it is likely to work. These techniques have the best chance of success among patients who have mild-to-moderate dental fear or anxiety; they will have little benefit for those with dental phobias. Clinicians should be willing to learn about these techniques and spend the additional time required to implement them, when necessary, into their practices. Some techniques may be combined to maximize the benefit. PHARMACOLOGIC MANAGEMENT OF DENTAL FEAR AND ANXIETY Patients who are unable to undergo dental treatment due to excessive fear, anxiety, or phobias and who do not respond to dental behavior modification techniques require phar- macotherapy. Oral, inhalation, or intravenous sedation can help these patients receive dental care. The use of sedation medications should only be employed to the extent that they are compatible with the patient’s medical history and will not cause adverse drug interactions with any other prescription or over-the-counter medication used by the patient. Patients
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