Dental Phobia

Dentist have heard this common refrain from some patients: “Nothing personal but I don’t like you Dentists.” This is most honest confirmation of a patient dealing with Dental Phobia. Most people do very well to manage this fear on their own. I have seen children who are absolutely nonchalant in the face of impending dental treatment-some handle their plight much better than adults. And then there are those who don’t care to be numbed up for treatment as they would rather deal with the temporary discomfort the work entails rather than go through the process of receiving an injection and losing control of half their face for two to three hours!. (I am also prone to mild anxiety prior to undergoing any treatment.) So what is the source of this fear and how can it be managed?

Fear can be characterized as being of two kinds: Experienced or Informed Fear and Imagined Fear.

Informed fear is fear that develops after an encounter with an incident which caused some emotional and physical distraught. The unpleasantness followed by a visceral memory of the incident drives the trepidation in the individual. The first time one experiences a burn from contact with a hot object or fire will inform them of the dangers of getting too close to heat for the rest of their lives. Dental patients who have been through a traumatic experience will retain the memory of discomfort coupled with the hopelessness of the situation that they had found themselves in.

Imagined fear is one in which in the absence of information the mind begins to fill in the void with its own imagined scenarios. Since the fear feeds off of one’s imaginative abilities it can become quickly fairly debilitating. Children who have never been to a dentist will have a deep portents of impending pain and torturous experience either from hearsay from other kids or from a traumatic experience at another doctor’s office, albeit medical, and it is called the ‘white coat syndrome’.

In the dental field the patient anxieties are of a unique kind. People, to begin with, have mixed opinions on where to place the field of dentistry in their healthcare portfolio. Is it akin to medical practice or is it more in the realms of prosthesis services like eyeglasses, hearing aids, walkers etc. or is it more of a gadget intensive medically oriented repair shop?

Fear of Exposure and Loss of privacy:

Those who see dental service as akin to medical services are more likely to be accepting of some of the inconveniences that come with having to set up a relationship with a Dentist. These inconveniences involve divulging personal information, private information, employment information, financial status and insecurities associated with personal medical information including lifestyle indiscretions, past and present, all in the course of filling out paperwork for registering as a patient. Accepting as they might be of the need to divulge all of this information, still does not make it acceptable. This sense of loss of privacy is coupled with feeling of being vulnerable from exposure of ones deepest fears and secrets. For the others who view the dental service more as an outfit for custom prosthesis and ‘gadgety’ repair shops they will be more resistant to divulging too much of personal information. How many of us, for instance, would go to repair shop and be expected to hand over this much of personal information as a pre-condition for being provided the service?

Fear of Discomfort during Examination and Treatment:

The next layer of anxiety is that the examination and possible treatment occurs in a part of the body that is not viewable by the patient. The only input they have about what is happening within their mouths is what they can garner from touch, smell, sound senses and the visual cues they pick off the people around them. The absence of visual correlation with information from sensations emanating from the mouth can be overwhelming for some. The level of pain tolerance is another factor. In the heightened state of awareness that most patients find themselves in, every sensation becomes evaluated in the context of pain or approaching pain. In recent times to some extent this has been redressed in many offices, by the introduction of intraoral cameras for live viewing of the mouth conditions and also high fidelity intraoral photography. But even these cannot provide real time correlation for the sensations the patients feel when work is being done in the mouth. Live feed of examinations and treatment is a practical logistical problem for the operator namely the dentist, as his job is to get the best viewpoint of the area of the mouth and not to worry about the camera’s angles. Besides the operating field being small and dark it is difficult to fit too many tools and equipment in that small a space.

Another area of anxiety is that most of Dental work involves equipment that are sharp, pointed and appear to be designed to poke, penetrate or cut. All our life we have been trained to avoid getting intimately involved with sharp pointed objects and to handle such with great care and precaution and not to definitely place any of them in the mouth. In the dental office setting, while the patient is at their most vulnerable, they will be subjected to examination using similar instruments, a concept which is counterintuitive to their conditioning.

Furthermore anatomy of the head is unique in having all the organs of senses in close proximity to one another. The mouth is in itself a highly innervated sense organ. With so much of sensory overlap densely concentrated in a small area the sense perceptions are more enhanced. This results in precipitation of pain even with moderate forces which anywhere else in the body would be better tolerated. Hence the care that a dentist must show to prevent discomfort is critical in allaying the fear.

Finally there is the issue of the rationale behind committing to a process of dental information acquisition (dental examination) and potential treatment planning in the absence of any specific symptom that requires intervention. Most people who visit the dentist are motivated because of a problem area which needs looking into. The area requiring attention might have been developing as a silent condition for weeks or months before becoming symptomatic. When the first dental visit occurs, in these circumstances, there is more than a fair chance that the diagnosing dentist might find other similar silent conditions developing in other areas of the mouth. Most people of reasonable disposition will agree to proactively fix all the problem areas. Here is where the patient has to justify to themselves, the logic of subjecting themselves to the indignities and trauma accompanying the helpless state of losing control, to the treating dentist, of a part of their body, with no knowledge or guarantee of post-operative state of discomfort to the treatment. Add to this discomfort is also the pain of the financial burden that accompanies the treatment recommendations. Unlike the medical field where one might be blessed with a generous insurance coffer that might absorb the major chunk of the expenditure, in dentistry the onus of the financial burden falls largely on the patient’s shoulders.

Dental offices are all aware of these concerns and mental obstacles that patient have to surmount to initiate and agree to a relationship with a dentist. But in the routine of everyday practice it sometimes becomes difficult to be cognizant and empathetic to these concerns in an ongoing fashion and as a result all patients get treated with a single mode of approach. This lack of individualized attention and the inability to recognize the varying capacities of patients to deal with their fears makes the new, apprehensive patient even more apprehensive.

Fear management techniques:

These are as varied as the personalities of the Dentist and the Patient. In most instances it boils down to the Dentist being suitably sensitive and empathetic to the patient’s fears. The most common approach with consistent effectiveness is as simple as slowing down the procedure and explaining ahead of time what is to be expected at each stage. Some might even benefit from a running commentary of what is being done. A large part of the panic patient experience is from not knowing what is going on. When empowered with information a lot of patients can process the sensory feedback better. Anytime the process starts to overwhelm the patient the best thing is to stop and allow the patient to gain some sense of control. Patient feels less out of control especially if they know that they can stop the procedure at any stage with some pre-arranged signal communication like raising the hand.

In some patients this approach might be complicated by their general sense of revulsion about anything biological or medical. They might forewarn the Dentist that they would prefer to not know anything and will definitely not be willing to any visual information feedback. Fortunately, most of these patient have already dealt with their anxiety by blocking any thoughts about the process.

While in majority of cases these simple techniques will be sufficient there are the others who will be a challenge. Here it makes sense to figure out what is it that triggers their anxieties. In some instances it is something as simple as not having to see the needle. The need for the anesthetic injection is accepted at a rational level and they can handle the process as long as they don’t actually see the injection apparatus. In some it is the high pitched sounds of the drill and the sense of vibrations of the work being done on the teeth. Here again this can be sometimes countered by providing the patient a headset to listen to some audio distractions. In some patients it is the memory of a traumatic experience and if the dentist can isolate which part of the process was the traumatic one then they can work with the patient to deal through with it.

Then there are those who are absolutely incapable of confronting their fears. They require other forms of assistance. Usually this involves some form of chemical or pharmaceutical product.

Nitrous Oxide:

The most benign in this category is the one where fear management is done through the use of Nitrous Oxide aka laughing gas. The pros of this method is that it is relatively inexpensive and with hardly any dangerous side effects. Since the gas is almost 70-80 percent oxygen it is useful in patient with compromised heart conditions. The cons of this technique are that the effect is variable in individuals from mild anxiety relief to complete temporary loss of consciousness. It also triggers a dreamlike state in which patients have been known to fantasize. To prevent the potential for any misunderstandings in which the Dentist might be accused of inappropriate behaviors this technique is preferably done in the presence of other witnesses. The main negative from the dentist perspective is that the delivery device is through a nose piece and this sometimes makes it difficult for the doctor to work on the upper front teeth. Since this form of fear management is required in the minority of instances many offices do not invest in the equipment. The ROI (return on investment) is suspect and hence not available universally.

Anti-Anxiety Drugs:

The next most common form of fear management is by using prescription drugs which are designed to alleviate anxiety. Some like Benzodiazepine (Valium and Xanax) type are effective in reducing the pre appointment jitters and also the stress during procedures. But they have the side effect of making the patient drowsy and they will need to be transported to and from the office. These drugs also are not guaranteed to completely neutralize anxiety and fear. Besides these also have other side effects especially in interaction with other drugs and alcohol and also have the risk of becoming habit forming.

General Anesthesia:

The next level of fear management is having the patient completely go under. These require some potent tranquilizers and general anesthetics. If done properly this is a very safe method for getting a lot of dentistry done all at once while the patient is under. It is usually under the supervision and management of a trained anesthesiologist who at all times is monitoring the vitals. Unfortunately the cons of this technique is very apparent. It is an overkill for simple procedures like fillings, cleaning etc. It requires some preparation on the part of the patient and the patient will need post treatment care until they regain sufficient consciousness. It is more expensive as the procedure of the general anesthesia and the anesthesiologist time will be added cost. But it is worth it especially if it involves unmanageable apprehensive children with extensive dental work or in patients requiring extensive surgical treatment.

There is yet another method of fear management that most dental offices do not offer as they have not been trained in it. This is by far the safest method that can also be the most effective one – It is the technique of Hypnosis. The level of ignorance about this technique is just as profound in the dental practitioner community as amongst the lay public. I am now going to spend some time in laying the ground work for this technique and its details.

Hypnosis:

Trance like states is something we all self-induce regularly and sometimes daily. It is that state of absolute focus on one particular activity with the exclusion of awareness from everything else around. On a long drive along a familiar route unaware to our conscious mind we indulge in many minutia of conscious decisions pertaining to the drive. We do not pay much heed to this as our minds are pre-occupied by either the audio from the audio set or a conversation we engaged in with a fellow passenger. We call it zoning out. When engrossed in such intensely captivating activities we lose track of time and everything else that happened.

Another example for this state is the state of mind when watching a very engrossing movie. The more captivating it is the more you will end up zoning out all other sources of distraction. When you are completely immersed in the movie you are receptive to both the visual and audio signals, indicating that your senses are not compromised in favor of one over the other. This is an example of the mind selectively choosing, to switch off all the sensory signals it is constantly receiving, to focuses only on the ones that are pertaining to the movie.

It is difficult to become completely detached from everything around us during movie watching. We can tune out our attention from the surroundings but the moment someone yells out our name or we hear a loud unsettling noise we would quickly deflect our attention to that source. So while the movie watching example elaborates our ability to disconnect with the surroundings it is not exactly similar to a true hypnotic state. But for the sake of the debate let us assume that there was a way to increase the focus of the person to the movie with greater and greater disassociation with the surroundings then it is possible that as long as the movie is running and is continuing to be captivating the person can enter a temporary trance like state.

The previous two examples of mental focus during activities such as driving and watching movies are largely to show the ability of anyone to be awake, hyperaware yet capable of not responding to other forms of stimulations which the body is continuously receiving. The idea of hypnosis is a slight modification of this ability of ours to specifically have the mind trained to observe just one point of stimulation with the exclusion of all other sources of stimulation. On our own while we can enter into the trance state of heighten selective awareness, we cannot seem to be able to put ourselves into that state on demand. In hypnosis the individual is trained to be able to enter into the state of heightened uni-focus awareness by a set method of induction. Since it is impractical to depend on Driving and movie watching as the method for zoning out on a regular basis, there is the need for a practical predictable method of self-induction of a hypnotic state.

In the Dental practice context there are two areas where Hypnosis can play a significant role. 1) Perception Modification: Firstly in anxiety and fear management, secondly in pain perception, healing and anesthetic efficacy. 2) Behavior or Action Modification: Help in controlling or neutralizing Gagging, salivation, bleeding etc.

In reference to Dental Phobia we are interested in the Perception Modification benefits of Hypnosis. The drawback with this method is that for it be effective the dentist has to be trained in the art of Hypnosis induction and then they have to train the patient. This is the unpredictable link in the chain. Some are more easily trained than others, and some patients will be able to enter into their hypnotic state fairly easily while others might need more assistance. This makes scheduling for treatment with patients requiring Hypnotic help unpredictable.

Finally:

Fortunately for the vast majority of patients the fear management process is a relatively simple one. Because of this dentists might be remiss to discount individual anxieties as being not very important, and ignore them to their own detriment, in the establishment of a long term relationship with a patient. Attempting to deal with fear purely with logical reasoning will not only be ineffective but also be frustrating. Fear is an emotional response and it usually outranks rational thought. Especially fear in children cannot be combatted with trying to make the child think rationally. If talking to the patient, adult or child, through the process does not allay their fears, it is best to adopt one of the other methods mentioned earlier. It is important to try and avoid triggering a traumatic experience as this only reinforces the primary fear. Fear can also be handled with greater ease when the patient is confident of the skills of the dentist and has developed a trusting relationship.

One final consideration to keep in mind is that the patient and the doctor tend to pick up subliminal cues from one another. A fearful patient makes the dentist more diffident and uncertain and this in turn feeds the apprehension in the patient. A calm or calmed patient makes for a happier and more fruitful appointment.

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