but I hate coming here!
Written by Dr Jeffrey M Kestenberg MDSc LDS FRACDS , Dentist
(Some readers may find this article confronting)
How many times have I heard these words?
Several times a week I meet patients with obvious dental anxiety. Most people have some degree of apprehension about visiting the dentist or the doctor but extreme dental fear affects approximately one in six Australian adults and about one in ten children. One’s education and socioeconomic status make no difference. Going to the dentist can be scary. Fear of a needle, the drill, the smell, concern about possible pain, a strong gag reflex, or the sight of blood is all real issues for many people. So what is it and can we overcome this?
What are the consequences of dental anxiety?
People with high dental fear are much more likely to delay or avoid dental visiting and as a result, they don’t receive preventative care and are then more likely to require more extensive treatment. It becomes a vicious circle as the patient’s dental health deteriorates and the degree of fear escalates with the patient realizing that a lot of dental treatment may be needed.
Why are some patients afraid of the dentist?
A bad experience in the past especially as a child or a perception that something bad might happen are the two main factors that contribute to dental fear. A lack of control over the whole situation, lying back and opening your mouth wide and the perceived unpredictability of the whole situation makes people feel susceptible to danger. In addition, the dentist is literally poking around inside the patient’s mouth and at the same time invading the patient’s personal space. That will make anyone feel uncomfortable.
And there will be differences in the willingness of patients to discuss these issues. It is embarrassing and confronting so many people try to hide their feelings. That’s never a good idea (and I’m talking about life in general).
Symptom of another condition
Avoiding a dental visit might also be an indication of another condition, such as fear of social evaluation (as in social phobia and being judged by others), fear of germs (as in obsessive-compulsive disorder) or fear of being away from the safety of your home (as in a panic disorder) or agoraphobia. More recently, patients have had fearful concerns about coming to the dentist during the COVID-19 pandemic.
Other psychological conditions, such as depression, might also be related to reduced dental visiting and increased dental need.
I’ve been abused
There is also a strong association between dental fear and having been the victim of past sexual abuse, especially where the victim’s abuse has involved the mouth. This is such a difficult topic to discuss with the dentist so it’s important to find a compassionate dentist who will sit down with you to discuss the issues. It is not unreasonable to request a private meeting with the dentist to have this discussion and request that the patient’s treatment record not include this information.
While some patients have little hesitation in identifying themselves as anxious or phobic, other patients may be very reluctant to bring up the issue of their dental anxiety and this may be for any number of possible reasons. But as a dentist has a responsibility to the patient, the patient should make sure that the dentist is fully informed.
Good communication and establishing a working relationship with the dentist are critical in these circumstances.
Unfortunately, some people might feel that they will be ridiculed, that their fears might be dismissed out of hand, or that they will appear weak or cowardly. They may be embarrassed or upset by their fears. They may even have previously had a negative experience with a dental practitioner when discussing their concerns.
Some dentists find it difficult to broach the subject of dental fear and anxiety but someone needs to and perhaps that should be you so that the discussion can take place under your terms. That’s why you need to find a compassionate and understanding dentist who is not judgmental.
Good communication involves establishing an effective two-way conversation with listening and understanding to build trust with the dentist genuinely acknowledging any patient concerns, accurate reflection of what the patient has said, demonstrating empathy, and using appropriate voice and tone. This is crucial for a productive and effective dentist-patient relationship that results in competent clinical care that lives up to your expectations.
Take little steps
It is better to tell the dentist that you are anxious than to ignore the fear or try to hide it. Dentists are not psychologists. They studied psychology for one or two semesters way back in first-year university so they’re not going to treat your anxiety but they have a variety of ways of helping you get through your dental visit.
As a first step, I would suggest making an appointment with a dentist for a consultation only. If you are particularly concerned about even attending the dentist’s office, you could start with a virtual consultation via Zoom, Facetime or a similar platform. This has become more popular since the need for virtual consultations for all health care providers during the COVID-19 pandemic.
During this consultation, the dentist and patient should discuss the issues, and possible strategies to achieve the desired outcome of a future visit.
I’m ready for treatment but I’m still scared
Ultimately, a treatment plan for dentally anxious patients should be flexible and reflect the patient’s desires. For example, the order of treatment should be determined by what the patient fears and what he or she considers most important. Treatment can be thought of in phases. An initial phase might involve getting the patient used to the clinic – the smell, the noises, the staff, establishing rapport, and talking through issues and concerns with the patient. An anxious patient may or may not be ready to undergo any procedures at this point so a second visit might need to be scheduled for an examination including x-rays.
Either the dentist or patient may choose to have a break during a procedure. It is not wise to continue with a procedure until you “can’t bear it any longer”. This makes it much more difficult for the fearful patient overall. When the patient initiates a rest break, being able to pause the procedure with a simple hand signal can increase the patient’s sense of control over treatment. Being able to signal for the dentist to stop treatment is a key component of building communication and trust between the patient and dentist.
Some patients, particularly children find it helpful to have distractions in the dental clinic. Several options are available ranging from background music to television sets to computer games to 3D video glasses for watching movies.
How can we overcome the fear?
Given that most people have some anxiety related to dental visits, the management will vary greatly from person to person. Some people will be able to control their fear with simple techniques such as relaxation techniques including meditation, slow deep breathing, distraction techniques, self-hypnosis, or yoga. Others will seek professional help from a psychologist to help achieve the desired results with these methods or systematic desensitization where the patient is progressively exposed to increased fear generating actions in conjunction with a relaxation strategy.
I need to be asleep
Despite all the best intentions some patients need to be sedated or have a general anaesthetic.
Many patients find that sedation is very effective in reducing anxiety and allowing the patient to have dental treatment in a relaxed manner. The three types of sedation are inhalation sedation such as laughing gas, oral sedation, primarily through the use of a tablet, which acts as a sedative and/or anti-anxiety drugs, and intravenous (IV) sedation, which involves administering a drug to produce deep sedation.
A general anaesthetic, where the patient is totally asleep, can be particularly useful if a lot of treatment is required and there is some urgency to have the treatment done all at once, if the patient doesn’t wish to be conscious during treatment or if other techniques have not been successful. We call this ‘sleep dentistry” A general anaesthetic is usual administered by a medically qualified specialist anaesthetist in a hospital, day surgery centre or some dental clinics where the appropriate facilities are provided.
We have often found that patients who have had ‘sleep dentistry’ return to have small treatments such as a cleaning while they are awake or lightly sedated.
There is a way and there is hope to have dental treatment for everyone.
Any surgical or invasive procedure carries risks. Before proceeding, you should seek a second opinion from an appropriately qualified health practitioner
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