Anxiety in Dental Care PDF

Anxiety in Dental Care Intended learning outcomes After this session students should be able to:  Recognise signs of dental anxiety and describe its impact  Acknowledge sources/origins (aetiology) of anxiety and fear  Describe methods to assess dental anxiety  Outline management strategies...

Anxiety in Dental Care Intended learning outcomes After this session students should be able to:  Recognise signs of dental anxiety and describe its impact  Acknowledge sources/origins (aetiology) of anxiety and fear  Describe methods to assess dental anxiety  Outline management strategies for dental anxiety 2 Assessment Formative  Discussion on moodle  Patient care Summative  Clinical practice record Future  Effective clinical practice and patient care 3 Definitions, prevalence and impact CONTEXT 4 Definitions  Dental anxiety – as for anxiety, dental anxiety is an emotional state (feelings of apprehension, uneasiness or dread) that precedes a dental encounter or dental- related threatening stimuli, it can range from mild to severe and be related to specific or general situations.  Dental fear – a reaction to threatening stimuli in dental situations – fight or flight responses.  Dental phobia – stronger, persistent and intense fear, an extreme form of dental anxiety and recognized as a condition that can be diagnosed and managed. Often the terms dental fear and dental anxiety are used interchangeably and relate closely to each other. 5  Dental anxiety components  Physiological – how the body changes  Increased heart rate, sweating, raised blood pressure, palpitations, nausea, muscle tension Physiological  Behavioural – what we do  Avoid dental care, cancel visits last minute, reduce time in dental chair, meticulous oral hygiene to avoid care  Cognitive – how and what we think Behavioural Cognitive  Thoughts about the situation, reduced concentration, poor memory 6  12 Prevalence of dental anxiety % ext Adult dental health survey 2009 was the first time dental anxiety was measured. Included a re sample of the population using the Modified me Dental Anxiety Score:  No to low levels of anxiety = score 5-9 an  Moderate anxiety levels = score 10-18 36% xie  Extreme anxiety levels =score 19+ moderate ty anxiety Dental anxiety is common, it affects all ages, with females likely to be dental phobic. 51% no or low anxiety 7  Origins of dental anxiety Dental anxiety is multi-factorial and can include factors related to: Personal:  Negative or traumatic experiences (especially in childhood)  Triggers – sounds (of the drill, screams), sights (of the injection), smells (materials, infection), feelings (of numbness, vibrations)  Loss of control  Coping abilities  Medical history Social:  Family members or friends' experiences  Cost of care or worries about costs  Social circumstances  Negative media perceptions Extract demonstrating negative media headlines related to dentistry. Source: Daily 8 Impact of dental anxiety on oral health Avoid Associations attendance not causations Increased Poorer oral treatment health… need Oral health Remember the vicious cycle of dental fear impacts (Armfield et al 2007) – delay visit, dental problem, symptom driven Reduced Higher treatment reinforces quality of caries dental fear. life rates 9 Signs and assessment HOW TO IDENTIFY AND MEASURE? 10  Signs of dental anxiety Think about how anxiety may present.. Appukuttan D. P. (2016) identified in a literature review these signs: Physiologica  Behaviour – irritation, panicky, l  Emotions – outbursts, worrying,  Psychophysiological – posture, sweating, pulse, clearing throat, breathing  ….everyone is different Behaviour Cognitive (emotions) (emotions) Observe your patient for signs even when you greet them in the reception area. 11  Measures of dental anxiety The most suitable and accepted tools:  Modified Dental Anxiety Score (MDAS) is a valid and reliable measurement tool (Humphris et al 1995, 2006)  Visual Analogue Scale (VAS) is a modified version for children (Wong et al 1998) These are intended for use with patients who may be anxious about dental care or show signs of dental anxiety. It is recommended that each patient is asked verbally whether they are anxious about visiting the dentist. The MDAS is effective in reducing anxiety when completed prior to dental care, shared and discussed with their clinician. 12  Modified Dental Anxiety Score (MDAS) Asks patients to rate their level of anxiety from 1 (not anxious) to 5 (extremely anxious) for 5 aspects of dental care in the boxes below: 1 Not anxious 2 Slightly anxious 3 Fairly anxious 4 Very anxious 5 Extremely anxious Teeth scaled Local Treatment Waiting Tooth drilled and anaesthetic tomorrow room polished injection 13  Modified Dental Anxiety Score (MDAS) Scores are added up to determine level of anxiety: High 19+ Moderate Low 5-9 10-18 14 MDAS (left) VAS (right) Source: SCDEP 15 Strategies and referral HOW TO MANAGE? 16 Interventions for Management Non- Refer Pharmacological pharmacological Communication Anaesthesia skills All patients Conscious Behaviour sedation modification Psychotherapeutic Medication - s - Cognitive analgesia behavioural Refer therapy 17 Flow chart for management Source: Newton et al 18 Memory reconstruction When anxious, often recall negative or unpleasant aspects Help patient to recall positive aspects and remind them how they managed. Examples:  Images of smiling  Remember positive feelings,  Take photos This Photo by Unknown Author is licensed under CC BY-SA-NC Source: http://addbcdbimages.s3.amazonaws.com/pixar/Incredibles-nemo1.jpg? Implemented after a visit, and u= Image from the Finding Nemo dentist reception before or at the next visit. area – remember from the video excerpt the screams they hear might create unpleasant memories so it would be helpful to remind them 19 of the pleasant experiences too.  Environmental Change Smells, sounds, visuals:  Smell of lavender helps decrease anxiety  Soothing music  Positive imagery  … Remember the video clip from Finding Nemo shown in Non-pharmacological interventions lecture reflecting the Source: https://www.publicdomainpictures.net/pictures/100000/velka/lavender- environment. field.jpg 20 Provision of preparatory information Patients with moderate levels of anxiety can benefit from information about:  Procedure  Sensations to expect  Behaviours to help Should be tailored to patients' needs. Extract from a patient information leaflet for Intranasal Sedation Dental treatment at the RNENTED. Source: ULCH intranet 21 Cognitive Behavioural Therapy (CBT) CBT is a brief psychological intervention combining behavioural and cognitive therapy aiming to modify maldaptive beliefs and behaviours. It uses systematic desensitization where Thoughts patients are gradually exposed to fearful situations or objects from least to most over Behaviours time, often 6-10 sessions. Referral to GP, dental psychological services or clinician with specialist training. 22 Pharmacological interventions  Referral to specialist  General anesthesia  Conscious sedation – inhalation or intravenous  Medication prescriptions for pain management or relaxation Extract from a patient information leaflet for Intravenous Sedation Dental treatment at the RNENTED inserting a canula. Source: ULCH intranet 23  Services at the RNENT&EDH Special Care Dentistry Department:  Referrals for patients with anxiety for management Clinical psychologists:  Facial pain service  Pain management Extract from patient information leaflet. Source: UCLH website 24  NHS Dental Psychology Service - Referral https://www.guysandstthomas.nhs.uk/our- services/dental-psychology-service/ overview.aspx 25 Summary Definitions, prevalence and Signs and aetiology impact Dental Anxiety Identification and Management measurement strategies 26  References  Appukuttan D. P. (2016). Strategies to manage patients with dental anxiety and dental phobia: literature review. Clinical, cosmetic and investigational dentistry, 8, 35–50. https://doi.org/10.2147/CCIDE.S63626  Armfield JM, Stewart JF, Spencer AJ. The vicious cycle of dental fear: exploring the interplay between oral health, service utilization and dental fear. BMC Oral Health. 2007 Jan 14;7:1. doi: 10.1186/1472-6831-7-1. PMID: 17222356; PMCID: PMC1784087.  SCDEP Guidance Oral Health Assessment and Review Version 1, 2012, available online: https://www.sdcep.org.uk/published-guidance/oral-health-assessment/  https://files.digital.nhs.uk/publicationimport/pub01xxx/pub01086/adul-dent-heal-surv-summ-them-the8-2009-re10.pdf  Hakeberg M, Wide U. General and oral health problems among adults with focus on dentally anxious individuals. Int Dent J. 2018 Dec;68(6):405-410. doi: 10.1111/idj.12400. Epub 2018 Apr 11. PMID: 29638007.  Heidari, E., Banerjee, A. & Newton, J. Oral health status of non-phobic and dentally phobic individuals; a secondary analysis of the 2009 Adult Dental Health Survey. Br Dent J 219, E9 (2015). https://doi.org/10.1038/sj.bdj.2015.853  Newton T, Asimakopoulou K, Daly B, Scambler S, Scott S. The management of dental anxiety: time for a sense of proportion? Br Dent J. 2012 Sep;213(6):271-4. doi: 10.1038/sj.bdj.2012.830. PMID: 22996472. 27