Jason Lucas Ian Jun-Han Tan
You are required to administer the Corah’s Dental Anxiety Scale, Revised (DAS-R) to five subjects. The subjects cannot be dental students or dental professionals. Once you have scored the DAS-R, you are to choose one subject who exhibits signs of dental anxiety and arrange to interview them. You are then to write a 1000 word write a 1000 word reflection discussing aspects of dental anxiety that has been raised by the subject. Also, include suggestions as to ways that anxiety may be diminished.
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Dental anxiety is a common psychological response of fear which plagues many individuals ranging from different ages and backgrounds. Forms of dental anxiety can manifest in a myriad of forms such as feeling uneasy and worried on the days preceding a dental appointment, fidgeting/sweating whilst waiting for a dental appointment and attempting to distract the dentist to delay impending treatment etc. Although those who lack dental anxiety may perceive this form of anxiety as inconsequential, instead dismissing it as mere “common nervousness”; it has an ingrained presence in the lives of actual sufferers. Due to the reactive fear associated with dental treatment, patients with dental anxiety may seek to actively avoid treatment, be argumentative with their dentists and be physically uncooperative during dental treatment etc. This will eventuate in a tense clinical environment for the clinician and patient both, thus impeding the overall effectiveness of the patient’s oral health healthcare. Therefore, during the initial appointment for new patients, dental clinicians should utilise a myriad of questions and tools such as “Corah’s Dental Anxiety Scale, Revised (DAS-R)” to determine whether their patient have dental anxiety and if so, develop a variety of ways in which they can help their patients manage this anxiety.
Amongst the five subjects who answered the questions in Corah’s Dental Anxiety Scale, Revised (DAS-R), I have selected Vivian Cheng (a 17 year old Year 12 student) as my interviewee for this reflective piece. Vivian had a total score of 19/20 which translates to severe (dental) anxiety. Upon interviewing her, Vivian divulges that she has always had an “crippling fear” of dentists ever since she was young. Her first dental visit resulted in her getting 2 teeth extracted and she said she still remembers the sensation of the dentist “ripping and tugging at my two front teeth” whilst she was screaming and struggling to an extent where she had to be physically restrained by the dental nurses. She says this traumatising experience has stayed with her ever since, and she “can’t even sit on the dental chair now without breaking into a cold shivering sweat”.
During our interview, Vivian disclosed key aspects of her dental anxiety and her feelings/thoughts whilst receiving treatment. I have inserted abstracts of her comments below and also included my thoughts behind her anxiety as well as possible methods that could help Vivian circumvent her fear of “the pain doctors”:
1. “I hate how cold and to the point my first dentist was, he always said a simple ‘hi’ to me and went straight into my mouth and started prodding with his sharp pliers and mirrors without even waiting for me to answer or compose myself. It was awful!”
Vivian revealed to me that she felt her dentist was unfriendly and uninterested in her wellbeing, and this always aggravated her sense of anxiety and uneasiness towards going to the dentist. From personal experience, I feel that this is a trap that many dental students (and some clinicians) fall into, where we get so enthused with ‘getting right in there and fixing the teeth’ that we forget the quintessential fact that these teeth are connected to a living breathing individual who is possibly frightened and in need of our attention as well.
New patients with dental anxiety are undoubtedly intimidated by the notion that a ‘complete stranger’ could be causing them pain (with injections and extractions), which makes them subconsciously erect barriers of reservation against us and their treatment. Thusly it is our responsibility as clinicians to break down these walls by establishing a rapport with our patients, letting them know that we are ‘human’ as well, as oppose to ‘the bad guy in the white coat’. Ways to achieve this could be by asking patient’s open-ended questions such as “Tell me how your day was today.”, “That’s a nice watch, where did you get it?” etc. By actively engaging the patients in non-dental related conversations, we may be able to diminish the sensation that they are within a ‘dental’ environment thus allowing them to relax and feel less overwhelmed. Cracking jokes and laughing with patients may also visibly reduce their tension and anxiety, dispersing the conception that we are ‘stone-cold and just down for business’.
2. “As soon as I walk into the dental room, I immediately start trembling and sweating. I immediately become embarrassed and feel that everyone is judging me for being a coward. This makes me feel more anxious to a point where I sometimes just start bawling and have to go home. When this happens, I am too humiliated to go back”
I feel that Vivian experiences what many dental anxiety patients feel where upon being presented with a ‘sterile clinical’ environment, it invokes sensations of fear and a ‘fight-flight response’ of sorts which can take the forms of profuse sweating, trembling or feigning family emergencies to remove themselves from the confronting stimulus etc. When this happens, patients (especially males) are often too humiliated to return for subsequent treatment and it can take protracted periods of time before they summon up the courage to seek dental treatment again from a (new) dentist.
Therefore, in order to avoid this, clinicians must be pro-active in discerning visual and audio cues from their patients in regards to their mental and emotional state prior to the patient even sitting down on the dental chair. If the patient displays signs of dental anxiety, clinicians should gently remove them from the operating room, sit them down and inquire in a non-condescending tone as to whether they feel nervous or a bit uncomfortable. It is also important for the clinician to assure the patient that “nothing is wrong in being afraid” and generalise the patients reactions with statements such as “You are not the first person this happens to, it’s quite common for everyone!” Clinicians must also abstain from coercing the patients to continue with the appointment and should inform the patient that they are “free to leave whenever they want”, assuring them that they can come back for a subsequent appointment when they are more comfortable and ready.
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By affirming to the patient you acknowledge their apprehension and are here to support them rather than condemn them, clinicians may be able to reduce patient restlessness and impart a sense of assurance to the patient that their well-being is an essential priority for the clinician. Clinicians may also want to consider reducing “provoking” visual cues such as ‘confronting’ pictures or posters of gum disease or tooth cavities in their surgery and waiting room. The ambience of a ‘cold sterile hospital’ environment should also be diminished whenever possible with brightly coloured wall pastels, tranquil scenic photographs and cosy furniture which depict a warm homely environment at least in the waiting room, if not in the surgery.
3. “I hate the feeling of not knowing what’s going on when the dentist is working on me. The sounds of drilling and the feeling when he’s scraping your teeth. I am so scared he’s going to slip and cut my gums up. Whenever he tells me I am going to get an injection or filling, I just want to run out and tell Mum to drive off!”
Vivian and many other dental anxiety patients report a great sense of terror when their clinicians are carrying out routine cleans and filling procedures as they are oblivious of what is happening and feel helpless at being ‘subjugated’ at the complete mercy of someone else. This sense of insecurity and fear will be greatly exacerbated for patients who are victims of physical or sexual abuse as being in a physically vulnerable position (being reclined) may instigate sensations and memories of previous traumatic events. Thus it is important that clinicians facilitate a sense of security and control in their patients. This can be achieved by genially explaining to the patient the various steps involved in their respective procedure, possible sensations the patients may experience and the expected duration of said dental procedure and anaesthetic effects.
Dental clinicians should also always request patient consent prior to continuing any new component of the dental procedure as this enables the patient to have some degree of control over their treatment. Patients should also be presented with the option of giving a physical cue (i.e.: raising their hand, shaking their feet etc.) if they want a brief intermission of the procedure or if they are feeling any discomfort. This will allow the clinician to stop and impart reassurance and/or allow the patient to regain their composure. It is important that the clinician abide with the ‘brief break’ conditions previously agreed upon with their patients as not adhering to it will break the tenuous bridge of trust with their patient, resulting in the patient feeling deceived and potentially being aggressive/uncooperative with subsequent treatments.
Clinicians can also ‘walk with’ the patient throughout their treatment such as “counting down till the local anaesthetic is completely administered via needle (10 seconds)”, “amount of time it will take to finish a filling (announce progress at every 5 minute interval)” etc. Although, some patients may not want to be aware at all of what is transpiring and opt for auditory (headphone music) or visual (television) distractions instead as they want to be as ‘out of it’ as possible. Thus, it is important that the clinician is aware of the patient’s unique individual needs prior to treatment and tailor their provision of dental treatment accordingly.
However, some severe patients may still present with dental anxiety and be unwilling to give consent for ‘invasive’ procedures such as administering rubber dams or anaesthetic etc. In situations like these, the clinician may want to consider behavioural soothing techniques such as deep diaphragmatic inhalation/exhalation and progressive muscle relaxation. Cognitive strategies such as guided visualisation of pleasant scenery or recollecting fond memories may also serve to facilitate dwindling of patient dental anxiety.
Moreover, the dental clinician could also seek to use alternative forms of treatment such as using cotton rolls to isolate working areas or applying topical anaesthetic instead. If forms of patient-aversive treatments cannot be avoided, the clinician may want to consider sedation options such as nitrous oxide, general anaesthetic or oral sedatives etc. In severe cases, the treatment could be delayed till a later date and the patient referred for psychological conditioning/counselling until their dental anxiety is better managed. It is crucial that the patient is made to feel sufficiently comfortable to communicate their feelings and needs to the clinician at all times. This can ensure their procedure goes as expediently and pleasantly as optimally possible
In conclusion, I feel that dental anxiety is a common occurrence that afflicts many individuals at least at some point of their lives. From talking to friends and patients with dental anxiety, I know it can be a mentally-crippling fear that stops sufferers from receiving good oral healthcare as well as impart feelings of increased agitation, humiliation and guilt, further perpetuating a vicious cycle. However, I firmly believe that dental clinicians play a quintessential role in facilitating their patients’ management of dental anxiety. Patients with dental anxiety can display physical (trembling, sweating etc.) and emotional (fear, uneasiness etc.) signs and symptoms due to their fear of impersonal dentists, feelings of vulnerability and aversion to pain etc. This can have detrimental repercussions on the overall effectiveness of their treatment and create a strained relationship with their dentist, eventuating in a spiralling decline in their oral health levels. Thusly, it is of paramount important that dental clinicians endeavour to ensure their patients feel comfortable, validated, respected and supported from the instant the patient enters the clinic till the moment they leave the premises.
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