Dentistry for the Faint of Heart
words by Merry Sue Baum / illustration by Eric Miller
Pain often brings people to the dentist;
it also keeps many away.
ccording to the American
Dental Association, 30 to 40 million adults put off dental visits because they are afraid. In fact, fear of going to the dentist is among the most common phobias, ranking right alongside of the fear of heights, spiders and public speaking. There are numerous triggers that can cause dental angst: the sight of the drill, a needle or a white uniform; the antiseptic smell of the dental office, or the thought of seeing blood. Some people feel they have no control of the situation and their personal space is being violated. And, for those who have put off going to the dentist, there’s the fear of being lectured for not brushing or flossing enough and for staying away too long.
Recognizing that the dentist’s behavior is vital to helping such patients, New Jersey Dental School gives several hours of instruction on Assessing and Dealing with Patient Fear and Anxiety. Taught by Joseph Holtzman, PhD, a professor in the Department of Community Health, the course looks at understanding the basis of fear and anxiety and teaches a variety of non-pharmacological cognitive methods to help patients cope. The students first learn that anxiety (defined as a general foreboding or worry) and fear (a reaction to triggers like seeing a needle or hearing the drill) are learned behaviors. “Images of fiendish dentists mistreating their patients pervade our society,” says Holtzman. “While they may be in jest, nevertheless, we see them on television, and kids see them in cartoons. Even the movies contain such grisly scenes. Take for example the films Little Shop of Horrors, Marathon Man, and even Finding Nemo. Adding to these subliminal messages are the tales friends and relatives tell of bad experiences in the dental chair. And often dentophobes, as they’re known, can trace their fears back to their own unpleasant childhood experiences.”
Understanding the origin of patients’ fears is only the first step, however. Determining who is dentophobic is next. Often patients will tell the dentist they are afraid, but what about those who are embarrassed and suffer in silence? They exhibit very specific, telling patterns, Holtzman says. If a patient is reluctant to make a subsequent appointment, repeatedly breaks appointments or simply doesn’t show up, even after receiving several reminders, chances are, he or she is harboring an irrational fear. The dentist can administer a written survey known as dental fear and anxiety scale to any known or suspected dentophobes. This quick, multiple-choice survey asks patients to check off how they feel when, for example, they know they have an appointment the next day; they are in the dentist’s waiting room; and when the dentist is preparing instruments and the drill. The answers help practitioners zero in on the triggers that may be avoided. A patient who becomes anxious at the sound of the drill, for instance, might be given ear plugs or advised to bring an iPod to the next appointment. Some dental offices have televisions, head phones and/or large, pleasant photos on the ceiling as distractions.
Holtzman recommends spending the first new patient visit talking in a location other than the operatory. “Sitting in the dentist’s private office, getting to know a patient and discussing his or her fears helps build a rapport and trust and lets the person feel more in control,” he says. “If the first visit is an emergency, the dentist should do only what’s necessary and not cram too much into one visit. In both cases, more time than usual should be scheduled for the next visit.”
When the actual work begins, Holtzman says the practitioner should explain, step by step, exactly what is going to happen, progress slowly, and interpret the process in a non-threatening way. “Instead of saying, ‘this may hurt,’ a better statement would be, ‘you may feel a little pressure or slight discomfort,’ ” says Holtzman. “It sounds so simplistic, but it can make a huge difference.”
Research has shown that physical tension and emotional stress, which can result from rapid breathing, holding one’s breath or tensing muscles, can heighten a person’s perception of pain. Simple deep breathing exercises may help. The dentist can suggest the patient breathe in slowly and count to five before exhaling. Progressive muscle relaxation — tensing and then releasing one group of muscles at a time — slows the heart rate and promotes whole-body relaxation. The dentist can follow a script to talk the patient through the exercise, starting with the feet and ankles. During the class, Holtzman has the students try the relaxation technique themselves and suggests they try it during their next exam.
Finally, a technique known as guided imagery has been known to lower blood pressure and focus the mind elsewhere. Again using a script, the dentist asks the patient to imagine all the details of a safe, comfortable place, such as a favorite beach or a garden and imagine being there. Some dentists give the patients a CD of the script so they can practice at home and/or allow them to listen to the CD in an empty operatory before the procedure begins.
Keeping children calm in a dental setting involves similar techniques, Holtzman says. Using a calm, soothing tone of voice, the dentist should bend down to the child’s level and talk to him or her before doing any procedures. Smiling often and praising the child for cooperating are also key to a good experience. A common pediatric technique is known as Tell-Show-Do. The dentist shows the patient the instrument and explains its use. He may then let the child hold it, or perhaps, use it to count the patient’s fingers, in a fun playful manner. Telling riddles and short stories or even playing tapes of children’s songs and stories helps distract the child. A child may want to bring a favorite toy or book to the appointment as well. “It’s always best to make kids’ appointments first thing in the morning, after they’ve had a good night’s sleep,” says Holtzman. “As a way of modeling, the dentist may want to ask if a parent or an unafraid sibling be treated first, while the youngster watches. And it’s good to give each child an inexpensive toy after the appointment. It will remind them of the good experience they had.”
For the majority of patients, any combination of these techniques generally helps, however, there are always patients who simply cannot relax enough to be treated. Holtzman says if all else fails, those patients may have to see a psychologist. “No one enjoys going to the dentist,” he says. “But by teaching our students these techniques, they can help make the experience as pleasant as possible, and that goes a long way.”