Treating and Managing Dental Anxiety Lecture Notes PDF

Treating and Managing Dental Anxiety Dr. Laura Dempster DEN308Y Behavioural Science 2024-2025 Questions from last week? Dentally Anxious Patient Stories? Measuring Dental Anxiety  Modified Dental Anxiety Scale (Humphris, Morrison, Lindsay, 1995)...

Treating and Managing Dental Anxiety Dr. Laura Dempster DEN308Y Behavioural Science 2024-2025 Questions from last week? Dentally Anxious Patient Stories? Measuring Dental Anxiety  Modified Dental Anxiety Scale (Humphris, Morrison, Lindsay, 1995) 1 2 3 4 5 not slightly fairly very extremely anxious anxious anxious anxious anxious How would you feel … If you went to your dentist for treatment tomorrow? If you were sitting in the waiting room (waiting for treatment)? If you were about to have a tooth drilled? If you were about to have your teeth scaled and polished? If you were about to have a local anesthetic injection in your gum, above an upper back tooth? Modified Dental Anxiety Scale (Humphris, Morrison, Lindsay, 1995) Self report questionnaire Assesses anxiety about specific procedures Scoring: 1 (not anxious) – 5 (extremely anxious) Dental anxiety based on sum score /25 Score Interpretation: >15 dentally anxious; >19 highly anxious Also anxious if score of 5 on any question  Dental Fear and Avoidance Scale (Dempster et al., 2011) Rate your fear of dental treatment on the following scale 1 2 3 4 5 6 7 8 9 10 no moderate extreme fear fear fear Rate the degree to which you avoid (for whatever reason) going to the dentist? 1 2 3 4 5 6 7 8 9 10 no moderate extreme avoidance avoidance avoidance Dental Fear and Avoidance Scale (Dempster et al., 2011) Self report questionnaire Dental anxiety based on fear and avoidance scores Scores reported separately Scoring and interpretation: 1-4 : no/low fear/ avoidance 5-7: moderate fear/avoidance 8-10: extreme fear/ avoidance  Dental Belief Survey (Milgrom et al., 1985) Self report questionnaire Assesses patient attitude/ beliefs about dental care and their providers 3 dimensions - professionalism, communication and lack of control # of questions varies: 14-28 Reliable and valid Scoring: 1 (never) – 5 (nearly always) Sum score reported - range: 24 - 120 Score interpretation: 24 (highly +ve). –120 (highly -ve) beliefs  Dental Belief Survey – sample Qs (Milgrom et al., 1985) How do you feel about the following: I am concerned that dentists recommend work that is not really needed I am concerned that dentists do not provide all the information I need to make good decisions about my treatment When a dentist seems in a hurry I worry that I'm not getting good care Dentists focus too much on getting the job done and not enough on the patient's comfort I have had dentists not believe me when I said I felt pain Dental professionals say things to make me feel guilty about the way I care for my teeth When I am in the chair I don’t feel like I can stop the appointment for a rest if I feel the need Once I am in the chair I feel helpless (that things are out of my control)  Index of Dental Fear and Anxiety (Armfield, 2011) Self report questionnaire Potential anxiety-inducing stimuli or situations Specific concerns related to dental visit Scored: 1/not at all – 5/very much Score interpretation: higher score = more anxiety  Index of Dental Fear and Anxiety (Armfield, 2011) To what extent are you anxious about the following things when you go to the dentist Painful or uncomfortable procedures 1 2 3 4 5 Feeling embarrassed or ashamed 1 2 3 4 5 Not being in control of what is happening 1 2 3 4 5 Feeling sick, queasy or disgusted 1 2 3 4 5 Numbness caused by the freezing 1 2 3 4 5 Not knowing what the dentist is going to do 1 2 3 4 5 The cost of dental treatment 1 2 3 4 5 Needles or injections 1 2 3 4 5 Gagging or chocking 1 2 3 4 5 Having an unsympathetic or unkind dentist 1 2 3 4 5 State-Trait Anxiety Inventory (STAI-State) (Spielberger et al., 1970) Self report measure of state (vs trait) anxiety emotional state; feelings of tension, apprehension and nervousness; Assesses impact of situational factors upcoming surgery; stressful even on anxiety levels Asks how patient feels at this moment/right now 20 questions Scored: 1/not at all -4/very much; range 20-80 Score interpretation: > 46 = anxious Score quantifies intensity of current anxiety level  Amsterdam Preoperative Anxiety and Information Scale (APAIS) (Moerman er at., 1996 Self report questionnaire Measures preoperative anxiety and need for information in order to address patient concerns and improve experience 6 Questions: Anxiety about anaesthesia (2Qs) Anxiety about surgery/treatment (2Qs) Desire for information (2Qs) Scored: 1/not at all – 5/extremely; range: 6-30 Score Interpretation: >11= significant preop anxiety Highly correlated with State-Trait Anxiety Inventory (STAI-State)  Visual Analogue Scale (VAS) (Hayes & Patterson; 1921) Measures pain/pain expectations/pain intensity plus other characteristics/attitudes that cannot be directly measured Widely used; simple and easy Reliable and valid Scale: 100 mm; 0=no pain to 100=worse pain imaginable Scored by demarcation on 100 mm line distance from left end of scale to mark by patient Score interpretation: higher scores=more severe pain Recognizing the Dentally Anxious Patient Recognizing Behavioural indicators the Physiological indicators Dentally Cognitive indicators No outward signs Anxious Combination of indicators Patient Behavioural indicators Behavioural indicators Physiological indicators Physiological indicators Cognitive indicators Cognitive indicators  Low fear Low avoidance Combination Low physiological response of Components  High fear High avoidance Combination Physiological response of Components  Low fear High avoidance Combination Physiological response of Components  High fear Combination Low avoidance of Physiological response Components  Treatment Strategies Educational strategies Behavioural strategies Cognitive strategies Physiological strategies Pharmacological interventions Hypnosis Educational Strategies  Educational Strategies Communication component critical Most effective with low-moderate anxiety Patient education Preparatory information - sensory vs procedural Brochures Internet  Sensory (SI) vs Procedural (PI) Information Study Purpose: to evaluate the effect of sensory and procedural information and dental anxiety status on patients’ preoperative anxiety and pain expectations and experiences N=121 patients; 46.6% male; mean age 52 years Protocol: baseline Q’aire – watch video – 2nd Q’aire – extraction – reported pain Random assignment to SI, PI or control group Measured Dental anxiety (MDAS; DFAS), preop anxiety (APAIS); pain expectations/experience (VAS)  Sensory (SI) vs Procedural (PI) Information Study Preparatory info lowered preop DA (SI+PI grps) compared to control NSD in pain experience b/n in prep info groups (SI/PI),but SD in pain reduction from pre to post op measurements DA patients expected more preop pain than non-DA patients Significant reduction in anxiety between pre- and post-video for SI and PI groups vs control Potential alternative to conventional pharmaceutical approaches to manage DA Behavioural Strategies  Behavioural Strategies Use will depend on level of patient anxiety Time consuming Modelling behaviour Exposure to feared object/situation Tell-show-do techniques Single or multiple sessions (2-3 hrs+) Significant improvement in majority Cognitive Strategies  Cognitive Strategies Restructuring of thoughts and self-instructional training ✓replace negative thoughts with more realistic thinking Often combined with exposure therapy Distraction ✓best results with heightened physiological activity Control ✓perceived or real Physiological Strategies Physiological Strategies Relaxation Paced respiration Pharmacological Interventions Pharmacological Interventions Adjunct to other tx strategies Range of sedation Minimal, moderate, deep, GA Delivery modes Oral medication Nitrous oxide IV Conscious sedation Deep sedation General anaesthesia  Hypnosis Long history in Altered state of Limited use in medicine in pain consciousness; more dentistry control positive, less stressful because of lack experience of experienced clinicians  Depends on patient and level of anxiety Important to: Combined Give realistic assessment of role of drugs Approach Ensure understanding that drugs do not remove necessity to learn to cope Support patient in coping with dental treatment Treatment Considerations Patient assessment Clinician role  Patient assessment Severity of anxiety Referral to psychologist Referral to dental anaesthetist Treatment Severity not linked with tx success Considerations Components of anxiety Cognitive (fear) Behavioural (avoidance) Physiological response Contributing factors  Clinician Role Initial interview Patient centered approach Empathy and understanding Eliciting information Share information  Clinician Role Clinical examination Patient centered approach Empathy and understanding Eliciting information Share information  Clinician Role Dental treatment Provide continuous verbal support during tx Be vigilant for patient discomfort/anxiety Respond immediately to discomfort/anxiety Provide continuous information to reduce uncertainty Transfer control to patient Gradually exposure patient to procedures Use distraction techniques Shape patient interpretation of sensations using non-threatening terms Use count down technique  Relapse of Anxiety  anxiety over short term = less relapse +ve cognitive change = less relapse Clinician/patient relationship = critical to success Further dental tx = best indicator of success  Challenges Patients who are not honest about being anxious Building trust after a past negative experience Slow progress in extinguishing anxiety Managing patient tactics ✓Talking, avoidance, stalling treatment  Provide a positive experience Convey understanding and acceptance Essential Develop trust Principles in Reduce uncertainty Patient Enhance patient control Modify patient’s perception of pain Management Communication is key Overall Considerations for Treatment of Dental Anxiety Appropriate patient assessment “Best fit” for patient; meet specific patient needs Multidimensional approach Referral if necessary Follow-up Time and cost effective Decreased anxiety and pain = increased patient satisfaction with treatment  In Summary … Complex condition that affects a significant % of population Important to resolve anxiety from both patient and clinician perspective Signs/symptoms may not be obvious Multiple contributing factors Large individual variation Decision re: treatment options depends on nature and severity of anxiety and individual patient Multiple strategies often needed; Start with simple techniques/strategies Expect slow progress; be patient Clinician plays a role key in treatment  Next Lecture September 19, 2024 Dental Anxiety Patient Stories