High anxiety in the dental office

It's not all in their head ... but most of it is

By Cathleen Terhune Alty, RDH, BA

A patient comes in with a full sleeve tattooed on his arm and proceeds to confide his fear of dental needles and instruments. Another patient asks you to "please be gentle," as if your name badge proclaims you are "The Butcher." The nervous businessman insists on nitrous oxide and continually asks you to "turn it up" like it's a radio he can't quite hear.

If you've been in dentistry at least five minutes, you've met one of these anxious patients. Whereas a dental phobic may be so panicked and full of dread he or she can't even think about entering a dental office, an anxious patient is uneasy or fearful and probably has unfounded or exaggerated concerns about the appointment.

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What are they so afraid of? Studies say that most patients are afraid of three things at the dental office -- fear of loss of control, fear of embarrassment, or fear of pain. Loss of control is when they can't see what we're doing to them, can't help us to do it, or can't anticipate what will happen next. They have fear of embarrassment because we work inches away from patients' faces and are in their personal space. Some people lack self-confidence or are ashamed of how their teeth look, and they're afraid they'll be judged or ridiculed.

Fear of pain is probably the most common issue that keeps people from the dental office. A study at the University of Toronto, Canada, gathered data about patients' pain expectation when they're having dental treatment. The report says that sensation of pain was more likely to be reported by people who had painful dental experiences or who felt anxious about treatment, expected it to be painful, or felt they had little control over the treatment process. Those who reported pain more often were youths and those with higher education levels. The report concluded by stating that pain is as much a cognitive and emotional experience as a physiological experience.

The anticipation of pain, whether realized or not, is a powerful motivator. What do hygienists think about patients who are anxious about having their teeth cleaned? Here are some of the sentiments that I've heard expressed:

"Yes, it hurts. So do mammograms and other preventive procedures. People complain about the pain of these other preventive procedures, but they do them anyway for the sake of their health. Dentistry is no different."
"Treatment hurts if someone's oral hygiene has been less than stellar. If someone doesn't floss or brush enough, maybe the person deserves a little pain to be taught a lesson."
"I want the cleaning to be as comfortable as possible, but when I see a lot of inflammation, I know it's not going to feel too great. I'm conflicted about warning the patient or just jumping in and getting through it."

While there is a degree of truth to all of these statements, sometimes the anxiety has nothing to do with what we are physically doing. Yes, it hurts more when the tissue is not healthy. No matter how badly you want a patient to be comfortable, there are no pain control methods that are effective on every patient all the time. Unfortunately, pain and a patient's anticipation of pain are real, and we need to learn how to manage the effects.

Pain control begins outside of the office

We have many pain control analgesics and anesthetics at our disposal. But pain management really begins before patients step into the office. A patient's state of mind is important. If someone is anxious before they even enter the office, our job becomes more difficult.

Thankfully, putting patients at ease just takes a bit of foresight and some stand-in-their-shoes roleplaying. Think about every contact people have with the office before they come in. How are the phones answered? Is it a friendly but calm voice that greets them, or a machine with a barely audible message? Are printed or emailed materials designed with a patient's anxiety in mind? What about the office's outside environment? Are trees, bushes, and other greenery trimmed and tidy? Other environmental aspects include having enough space for patients to park with no stress. Is the front door clean and dirt free? Other things that help reduce anxiety levels are a comfortable reception room, smiling faces at the front desk, a warm greeting from the staff member who guides the patient to the back office, pleasant nondental smells, and no instruments in patient view.

Think about other preliminary steps before the patient enters the office. Consider discussing particular needs that someone may have with the rest of the staff before patients come in for their appointments to determine what pain management protocols may be required. Does the patient have any health issues that might interfere with any comfort protocol, such as pregnancy, certain medications, and more? Continuing education is another great preliminary step. There are many live and online CE courses about pain management to help keep team members up to date. Make sure you're certified (if required), and comfortable to administer any of the products prior to using them on a patient.

Consider the procedure that will be performed and begin with the end in mind. What comfort protocols or pharmacologic agents are applicable to the treatment? What is the working time -- is there time to use it and still get the procedure completed? How long will the effects last versus the anticipated length of the appointment? For example, don't have choices for a 90-minute film if the appointment is 45 minutes, or a long-acting anesthetic for a short appointment.

Having all supplies ready to use before the appointment keeps the dental team on schedule and relaxed with their preparation. Offering patients comfort choices upfront, explaining in a nontraumatic way what procedures will be done, what comfort plans are available if needed, and how someone can indicate if they need the operator to stop are all things that need to be discussed.

A comfortable appointment

Of course we are all familiar with local anesthetic and topical rinses, liquids, sprays or subgingivally applied gels. If you're using a pharmacologic agent, remember to review its safety and contraindications for use. Check the maximum dose for a patient and in what time frame it is to be used. Check how easy it will be to use on a patient. How quick is the onset? Is it a one-time or multiple-use product? How effective is the particular product for the particular procedure? Will you achieve tissue analgesia or profound anesthesia? Is it short, long, or intermediate acting?

Nonpharmacological choices include noise canceling headphones, video on demand at the chair, relaxation music, a warm blanket, aromatherapy, homeopathic remedies for dental treatment, a relaxed environment, pleasing fragrances or relaxing essential oils, acupuncture or acupressure, distraction, desensitization, mental imaging, breathing exercises, a TENS unit, biofeedback, bite block, warm or cold gel packs, self-hypnosis, and reflexology, to name a few.

When the appointment is over, sit the patient up so he or she can look you in the eye as you explain what might happen posttreatment. Suggesting warm saltwater rinses, OTC pain medications, or a prescription medication from the doctor if needed keeps patients from panicking if they experience postoperative pain. Having information in writing for patients to take with them is better than verbal instructions alone.

From front desk staff to back office, every interaction a patient has adds up. To reduce the anxiety before, during, and after a dental appointment, patients learn to be confident about their dental treatment. Reducing dental anxiety can profoundly reduce someone's pain threshold and lead to greater trust of their dental care providers, and a more positive outlook toward dentistry as a whole.

Fatter paycheck if certified?

Should you expect a raise if you get your certification in local anesthetic? Don't count on it. Of course, some states require local anesthesia certification to get a dental hygiene license, but those who decide to become certified probably shouldn't expect a fatter paycheck for their effort. The current job market basically demands that we improve in our clinical skills just to keep the jobs we have.

Taking CE to improve our skills makes us better clinicians, but doesn't always positively affect our finances. Being certified in local anesthesia means no waiting for the dentist to come in and do it and more variety in the day, and it may help you get that next hygiene position. Some employers may pay for the training, but be aware that they might feel they can expand your job to anesthetizing other patients in the office, not just the ones in your schedule.

Better to discuss the ramifications before taking the test in order to avoid surprises.

Cathleen Terhune Alty, RDH, is a frequent contributor who is based in King George, Va.