Written by Dana C. Ackley, PhD Tuesday, 31 December 2002 19:00
Patient fear creates problems for both patients and dentists. First, there is the emotional discomfort of your patient. And, because feelings are a bit contagious, their discomfort can influence your mood. Second, fear often interferes with people getting the needed treatment. It creates that “fight or flight” impulse. “Flight” from dentists is easy—just don’t go to them. The logical consequence is that teeth rot and fall out. Unfortunately, logic may have little impact on overwhelming fear. Third, for dentists, fear must get tiresome. You deal with the same kinds of irrational responses repeatedly. A 1998 study estimated that 45 million people have significant dental fear.1 Some days, maybe it seems as though all of them are on your schedule.
Finally, unrelenting patient fear may wear on your soul. Think of it this way: You have dedicated yourself to helping people. Because you can see yourself from the inside out, you know that’s who you are. Many patients, looking at you from the outside in, can only see someone whom they believe is going to hurt them. Such wariness, repeated so many times every day, can wear on professionals over time. It can even slowly erode our belief in ourselves. This is the result of a psychological law of nature: Our daily experiences strongly shape our view of who we are. If we encounter too many people who see us as someone to fear, the danger exists that we gradually may come to accept the majority view.
Let me share some psychological tools to help you help your patients reduce and control their fear. I don’t promise fear-free dentistry any more than I believe that pain-free dentistry is realistic. However, both fear and pain can be managed in reasonably comfortable ways. Also, you can’t control what patients do. No one can control anyone else’s feelings or behavior. You will never, ever, make anyone’s dental fear go away. What people feel (and do) comes from two sources, their personality and their circumstances. What you can do is create circumstances in your visits that strongly encourage patients to perceive that they can handle what they face. Then their fear will be manageable. Let’s talk about how to do that.
WHAT IS FEAR?
Understanding fear is your first tool. It will help you to know how to use the other tools. People talk about being afraid of the dentist (or of snakes, or heights, etc). Such expressions suggest that fear is situation-based, ie, it is the situation that causes fear. This is impossible. No situation, even a highly dangerous one, ever caused fear in the history of mankind. It is our perception of the situation that causes fear. The drunk driver going 110 miles an hour on a curvy dark road is not afraid. He should be, but he’s not. His perceptions are distorted, which eliminates the fear. The sober person coming the other way accurately perceives that the wild driver poses a threat, and the sober driver is afraid. For both people, fear is a matter of perception. Some perceptions are accurate and some are not. (We all have inaccurate perceptions sometimes.) From your perspective, patients have nothing to fear. Highly fearful patients do not share your perception.
People experience fear when they perceive, accurately or inaccurately, that they face a situation that they cannot handle. If you are swimming in the ocean and Jaws joins you, you will probably know fear because you (accurately) perceive that you are in a situation that you cannot handle.
People who fear dentists believe that they cannot handle the situation, for different reasons. Some people fear pain. Others fear being in any vulnerable situation in which they give up control to someone else. Still others are afraid of fear itself, that it will make them behave in some embarrassing fashion.
WHY NOT DRUG THEM?
Indeed, this has been a popular choice. It is quick and easy. A little Valium or Xanax seems to solve the problem. It does, but only temporarily. A recent study compared the efficacy of using benzodiazepines versus one session of psychological treatment on dental phobia for dental surgery.2 Drugs worked, but only for that one visit. Afterwards, the patients who took the tranquilizers found that their dental phobia came back. You may not see this because when the fear returns the patient does not; 80% of the patients in the study who took the tranquilizers did not return. Of those who had just one session of psychological treatment, 70% returned for the rest of their dental work.
The most powerful tool at your disposal is the relationship you establish with your patient. This goes beyond good chairside manner. A strong doctor-patient relationship is characterized by feelings of mutual respect and trust that must be earned. Your good intentions and professional expertise are not enough. Investment of a relatively small amount of time and listening will reward you handsomely, not only with less patient anxiety but also with: (1) better overall patient compliance; (2) more completed treatments; and (3) more patient referrals.
The Pankey Institute has tested this concept and demonstrated its power. The Institute teaches its students to begin every new patient relationship with an interview designed to give dentist and patient an opportunity to get to know each other as people, as the first order of business. For anxious patients, this has two huge advantages. First, it builds trust. The more a patient trusts you, the more pain they will tolerate without panic. Trust helps shift perception from “I can’t handle this” to “Dr. Jones will not ask me to do anything I can’t handle.” No frightened patient will ever trust you simply because you are a dentist. The initial interview gives them a chance to experience you as someone who is interested in listening to them and who values their feelings and ideas. This creates a foundation for trust.
Second, when you ask someone to come for an interview rather than for an examination or procedure, you arouse less anxiety. Fear can be estimated on a scale from 0 to 100 (0 = total peace; 100 = sheer panic). A typical first dental appointment may stimulate anxiety at 85 to 95 in a dental phobic. If they know that the first visit will be just talking, their anxiety may only reach 50, likely to be below their “flight” threshold. Thus, they keep the appointment. Once they spend some time talking with you, the thought of a gentle examination might only stimulate an anxiety level of 60, uncomfortable but manageable. Again, they show up. Next, if you ask them to engage in a simple dental procedure, they again may experience an anxiety level of 60, whereas before their fear would have been nearly 100, well beyond their flight threshold. Psychologists call this process desensitization. Instead of having to face the full force of a feared situation, they face smaller parts. As someone finds that they can handle each small part, they can imagine themselves handling each next step, which once seemed impossible.
Some dentists feel uncomfortable (fear?) doing interviews, and thus shy away. Let me assure you that the interview is a situation that you can learn to handle. There is a set of questions I recommend for these interviews that will give you a structure within which to work. These questions include but go beyond issues of anxiety. They will help you form a relationship with a firm foundation. Thus, your steps of interview desensitization might be:
(1) Discover the questions.
(2) Modify them to suit your own style.
(3) Get some lessons on how to ask them.
(4) Get some lessons on how to respond to different answers.
(5) Try them out with an easy patient.
Interviews will give you some understanding of the patient and their fear. With the patient in mind, you can now select from the following anxiety management techniques. Listen to your patients’ preferences because different people have success using different approaches.
Most dentists give patients a way to tell them to stop. This gives the patient control, which helps many patients perceive that they can handle the situation. It is a good technique but is not useful for everyone. Interestingly, not everyone wants control. A 1993 study,3 among others, found that patients fall into four groups with regard to control in the dental chair:
•High wish for control but low expectation they will have it
•High wish for control and high expectation they will have it
•Low wish for control and low expectation they will have it
•Low wish for control and high expectation they will have it.
The first group, who wish for control but don’t expect it, have more dental anxiety than the others. They benefit most from the control technique. Interestingly, this same study found that asking these patients to focus on the physical sensations during a root canal reduced their perception of pain. Giving them something to do may increase their sense of control, which may allow them to more realistically estimate the amount of pain involved.
CONTROLLING THE BODY
When we get anxious, it is natural for our breathing to become shallow and rapid and for our muscles to get tense. These are ways the body uses to prepare for physical danger. When they occur, we become anxious. Conversely, when people take control of their breathing and muscle tension, they can reduce their anxiety.
Teach patients how to breath in slowly, from the diaphragm. Do so first in your office, not the operatory. Ask them to place one hand on their upper chest and the other on their belly. Then ask them to breath and see which hand moves. If they report that the upper hand moves, talk about how that feeds anxiety. If the lower hand moves, congratulate them and tell them that breathing from the belly will help them control anxiety. Then ask them to breath so slowly that if there were a feather beneath their nose it would not move. Actually, this takes a good bit of practice. (Try it yourself.) Ask your patient to practice this for 5 minutes or so every day over the next week or two. These directions are really brief, because of space limitations. There are a variety of stress management books that can give you excellent instructions on how to teach breathing that calms your patients.
Imagine that you are running from a bear. Your muscles naturally get tense because that helps you escape. Sitting in the dental chair, tense muscles don’t help. They even increase the perception of pain. You can teach patients how to relax their muscles with a process called progressive deep muscle relaxation. (Saying “just relax” won’t succeed.) It goes like this:
(1) Explain the rationale for the procedure.
(2) Next, ask the person to make a fist and tighten their forearm gradually on your count of five. As you say each number, they should make their forearm increasingly tense, but not so much as to hurt themselves. Direct them to focus on the sensation of tension.
(3) Then have them progressively relax as you count backwards from five to one.
(4) Have them notice the difference between the experience of tension and relaxation. Chronically tense people have often lost their ability to know what relaxed feels like, which is why “just relax” fails.
(5) You can take them through the muscle groups throughout the body. It usually takes about an hour to teach someone this technique. Pay particular attention to muscle groups the patient associates with tension.
Again, these instructions are intended just to give you a picture. More detailed instructions can be obtained from any number of stress management books.
Have the patient first practice in your office. Next, have them practice in the chair when no other work is planned. Step three would be to have them practice in the chair just prior to an exam or procedure. Notice that this is a desensitization process. You are breaking the challenge into smaller, doable steps. I know, it looks time consuming; you may not have to do all steps with all patients, but it will take some time. Bill for it. Patients who need it will be grateful. They also will hang around to complete their work with you.
Some patients do well when they mentally take themselves to a place of peace and relaxation. It does not matter if it is a real place or one that they imagine. To train the patient to use imagery, ask the patient to sit quietly in your office, slow their breathing, and let their muscles go limp. (Obviously this works best if they have already mastered those techniques.) Then ask them to picture a place that they find particularly peaceful. Walk them through their senses. For example, suppose your patient mentions going to a beach. Using a calm, rhythmic voice, you could say:
(1) Sight. “Notice the beautiful blue sky with a few small white clouds just for decoration. You can see where the sky and sea meet at the horizon.” (Elaborate as your imagination allows.)
(2) Sound. “Listen to the rhythmic sound of the waves lapping on the shore. If you prefer to be on the beach alone, notice the absence of voices. If you prefer to have people around, listen to the excited sounds of children playing. You can hear the call of seagulls.”
(3) Touch. “Notice the temperature is perfect. You can feel the warmth of the sun, with just a slight breeze to provide a delightful contrast. As you lay on your towel, you can feel the warm sand beneath.”
(4) Smell. “You can notice the clean smell of the ocean breeze as it comes in off the water. Perhaps you can smell your sunscreen, reminding you of pleasant summer times.”
Meditation and Hypnosis
Diaphragmatic breathing, muscle relaxation, and imagery are parts of what often is done in meditation and hypnosis, which are two powerful techniques for controlling fear.
As indicated before, some people seem to do best when they focus on the physical sensations, even though it may seem counter-intuitive to us. Others do well when they can put their focus elsewhere, such as on imagery. Some dentists have had nice success in setting up their operatory with earphones and a radio. Another approach is to have a library of movies they can watch (and hear with earphones) while you are busy in their mouths. Do not use this approach with people who are more comfortable staying focused on what is happening in the visit.
Fear focuses our attention on the feared object. People who fear flying focus on plane crashes. They often get relief from their fear by changing their focus to what they will do after they arrive at their destination. Likewise, suggest to anxious patients that they focus on what they will be doing after the dental appointment. (Make sure it is not something that is also terrifying!) The logic of this procedure is that when they look into the future, they will picture themselves as comfortable, functional, and feeling better. It helps people remember that they can handle what you are doing.
All of the techniques described share the characteristic of giving the patient something constructive that they can do. This empowers people, giving them a sense of control. This helps those people who normally cope with life actively and who find passivity to be uncomfortable. Obviously they have to be physically passive, but mentally they can still “take charge.”
Some patients will find touch reassuring (and others won’t). Of course, you have to be careful not to touch in a suggestive way. However, a calming touch by you or your assistant on the shoulder or arm can often be quite reassuring. It helps patients feel human and cared for.
Some patients will find it comforting to know exactly what you are going to do and how long you estimate the procedure will take. For them, knowledge is power, which chases away anxiety. Other patients don’t want to know. They are uncomfortable picturing what you will be doing. Denial works better for them. There are times when denial is an excellent way to manage anxiety. It is easy to find out whether to give the patient information or not. Ask them: “Some people like to have the details of what we are going to do and other people do not. Which is your preference?”
For some procedures, many dentists like to use a local anesthetic with epinephrine added. Epinephrine creates physical sensations that mimic anxiety, which can create a problem. Suppose you have a patient who has struggled to master her anxiety. Then when you administer this anesthetic, she experiences those physical sensations without understanding where they come from. The patient is likely to conclude that she has lost control of her anxiety management skills, and then really will get frightened.
To prevent this, you can do one of two things. First, there may be times when you will be able to use alternative medications. Second, if you must use epinephrine, tell the patient ahead of time so that they can accurately interpret what they are experiencing.
There are many techniques you can use to help patients manage their anxiety. Taking the time to do so will pay off in many ways. The biggest barrier you may face is your own fear of relating to patients in these different ways. You can overcome that barrier by changing your perception of the situation. You have learned many complex procedures. You can learn these as well.
1. Rowe MM, Moore TA. Self-report measures of dental fear: gender differences. Am J Health Behav. 2000;22(4):243-247.
2. Thom JA, Sartory G, Jöhren P. Comparison between one-session psychological treatment and benzodiazepine in dental phobia. J Consult Clin Psychol. 2000;68(3):378-387.
3. Baron RS, Logan H, Hoppe S. Emotional and sensory focus as mediators of dental pain among patients differing in desired and felt dental control. Health Psychol. 1993;12(5):381-389.
Dr. Ackley is a consulting psychologist who enjoys working with dentists and their staffs to improve practice enjoyment and performance. He is a guest presenter at The Pankey Institute. He can be reached at (540) 774-1927.
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