Cynthia R. Biron, RDH
A 31-year-old female arrived in a general dentist`s office as a new patient who had not seen a dentist in 10 years. Her medical history was unremarkable, and her chief complaint was pain in the mandibular right first molar. After filling out the usual paperwork necessary for the patient record, Molly began pacing the floor of the reception area, wringing her hands in nervous anticipation of going into the dental operatory.
Finally, the dental assistant came into the reception area and called out Molly`s name, since the doctor was ready for the appointment. The dental assistant, Debra, cheerfully exchanged pleasantries in an attempt to get Molly to relax. As soon as Molly sat down in the dental chair, Debra placed the patient napkin across Molly`s upper chest, securing the napkin with the alligator clips. Molly began breathing rapidly in a quiet, unnoticeable sort of way as she gripped the arms of the dental chair and eyed Debra`s every move. Debra sat down too and suddenly Molly began to breathe faster, exclaiming that her chest hurt and she couldn`t breathe.
Debra activated a light switch that signaled a patient was in emergency distress. Within a few seconds, Dr. Johnson entered the operatory and immediately went to Molly`s side, introducing himself. He asked Molly about her symptoms.
"I can`t breathe," Molly gasped, "and my chest hurts. I must get some fresh air!"
Dr. Johnson directed Debra to get the oxygen, and she did so in a matter of seconds. He then told Molly, "Let me give you some oxygen, and you`ll breathe easier."
Dr. Johnson placed the nasal cannula on Molly and began to administer oxygen. Molly said her chest pain was getting worse and began to perspire heavily. Dr. Johnson instructed the receptionist to call EMS. Suddenly, Molly appeared to be rigid as if she were frozen in her seated position in the chair. Her eyes fixated on the wall in a blank stare. It was as if she were catatonic or simply scared stiff.
EMS arrived and, when they lifted Molly to place her on the stretcher, she remained stiff as a board and could not be made to lie down on the stretcher. The paramedics carried her out in a seated position and placed her in the ambulance.
After consulting with the on-call emergency physician, they removed the oxygen delivery system and continued to monitor Molly`s vital signs. While en route to the hospital they continued to comfort her and communicate with her. Before they reached the hospital, Molly began to move and talk to the paramedics. She told them she was scared to death to have the dentist touch her tooth and that she couldn`t breathe. When she felt the pain in her chest, she became so frightened that she couldn`t move.
The consultation with the emergency room physician revealed that Molly had a panic attack. The hyperventilation had worsened to a physical state of parasthesia and tetany. Molly had never experienced a panic attack before, and now she feared going back to the dentist was going to prompt another panic attack.
What is a panic attack?
A panic attack may be described as "an instantaneous alarm reaction that peaks in three to five minutes. It is initiated by a sudden surge in heart rate, an abrupt autonomic surge, and hyperventilation that leads to a drop in arterial CO2 pressure." Patients who have experienced a panic attack describe the episode as "fear of dying, going crazy, losing control, paresthesia, dizziness, faintness, unreality, and shortness of breath."
All panic attacks include hyperventilation, regardless of differences between types of panic attacks. Whether or not the hyperventilation leads to profound physiologic changes of stiffness or tetany is dependent on the management of the episode of hyperventilation and the degree of anxiety and fear experienced by the patient.
An individual may experience one isolated panic attack in a lifetime or a series of attacks that are cued or uncued. An attack in the dental office is definitely cued as the fear of dental treatment brings on the anxiety. People who have uncued panic attacks cannot link the onset of the attack with a situation or environment.
When a situation that initiates panic attacks is avoided, the patient is said to have agoraphobia. Having a history of avoiding situations that cause panic attacks - such as crowds, shopping malls, dental offices, beauty salons - is typical of the individual who has agoraphobia.
People whose panic attacks are not associated or triggered by certain situations are said to have Panic Disorder (PD). Although one isolated incident of cued panic is not the marker of diagnosis for PD, an anxiety-prone individual must have experienced at least one uncued panic attack in order to be categorized as having a panic disorder. Individuals who are frequently anxious and noticeably nervous and tense are not necessarily panickers as they are simply expressing their nervousness. On the other hand, many PD sufferers hide their fears. Such suppression leads to the emotional explosion known as a panic attack.
The best resource for information about PD is The Diagnostic and Statistical Manual of Mental Disorders by the American Psychiatric Association, Fourth Edition (DSM-IV). The manual defines PD as "Panics not associated with a situational trigger." Criterion A of DSM-IV states, "Recurrent, unexpected panic attacks, followed by a month or more of persistent concerns about having additional attacks, worry about the implications of the attack and its consequences, or significant change in behavior related to the attacks."
This criterion would not necessarily suggest that an apprehensive dental patient who experiences a panic attack has PD. Most anyone could have a panic attack if frightened enough from a previous painful and traumatic experience. So it would be incorrect to assume that patients who have panic attacks in the dental office also have the condition known as panic disorder.
It is correct, however, to assume that patients who tell you they have PD - and are apprehensive about dental treatment - are at high risk for a panic attack in the dental office. How well we assess patients and implement stress reduction protocols can play a major role in preventing panic attacks.
Which patients are prone to panic attacks?
Dental patients between the ages 15-40 are the most prone to panic attacks. They also attempt to hide their dental fears. Several questionnaires are considered reliable measures in determining the likelihood of panic attacks in an individual, including the:
- Anxiety Sensitivity Index. The ASI determines anxiety sensitivity by asking questions such as, "When my heart begins to race I am frightened." Each statement is ranked on a 0-4 Likert scale. The higher the total ranking, the higher the anxiety sensitivity of the individual being tested.
- Agoraphobic Cognitions Questionnaire. The ACQ as-sesses an individual`s catastrophic thoughts during anxiety.
- Body Sensations Question-naire. The BSQ measures an individual`s fear of bodily sensations such as breathlessness, dizziness, and rapid heart rate.
- Anxiety Disorders Interview Schedule Revised. The ADIS-R is used to diagnose PD by asking questions such as, "Have you ever felt a sudden rush of fear and sense of impending doom?" Another question is, "Did the feeling come from out of the blue, or when you were home alone, or in an unexpected situation?"
Psychologists and psychiatrists use these questionnaires to measure anxiety and add to their evaluation tools for diagnosing PD. Some dental offices use similar anxiety questionnaires to assess patients as part of the initial medical history questionnaire.
What are the treatments for PD?
Initial treatments for PD usually include the benzodiazepine alprazolam (Xanax). Recent studies indicate Xanax has been prescribed quite freely and its addictiveness coupled with various adverse effects have given it an infamous reputation for being misused.
Most psychiatrists prescribe Xanax for immediate relief of panic attacks and anxiety, but they prescribe an antidepressant to treat an underlying depression or mood disorder that is ultimately the cause of the anxiety that triggers panic attacks. The brain activity that suddenly causes abrupt autonomic surges is believed to be altered by serotonin and dopamine. Antidepressants can increase circulating blood levels of these neurotransmitters, and, in doing so, anxiety and panic attacks are eliminated.
As soon as there is an adequate blood level of the antidepressant, the psychiatrist will wean the patient off the Xanax. Psychotherapy alone and in conjuction with drug therapy can help patients learn to work through their anxiety and stress situations. Behavior modification teaches patients to face the condition and develop coping skills to effectively deal with day-to-day stress and crisis situations that have resulted in separation and loss. The separation and loss phenomona seems to be a significant association with agoraphobia and situation panic attacks.
Preventing panic attacks
We try to assess patients during an examination only, making sure the patient understands that there will not be any painful procedures performed. As a result, there is no need to be anxious about the appointment.
With this plan, the dentist can consult with the patient and develop a rapport so that the patient`s fears can be brought out into the open and discussed. Active listening and open-ended questions are the keys to effectively dealing with patient anxiety before appointments that involve procedures. Questions that can be answered with a yes or no are not conducive to patients admitting to fears. Questions such as, "What effects have you had from local anesthesia, if any?" will be much more likely to get to the common fears of local anesthesia than asking, "Have you ever had local anesthesia?"
When the dentist has determined that the patient is extremely anxious about dental treatment, a stress-reduction protocol must be employed. Prescribing anti-anxiety drugs such as benzodiazepines the night and morning before the appointment can prevent an episode of hyperventilation. Scheduling the patient for the first appointment in the morning also reduces the buildup of anxiety.
How to handle a panic attack
When a patient tells us they can`t breathe and feel chest pain, we assume they are really in respiratory distress or they may be having a heart attack. A careful assessment of Molly`s emotional state, as well as her capability of overbreathing easily, would have en-abled the dental team to recognize the hyperventilation syndrome.
Giving oxygen to a hyperventilating patient does not cause the situation to get worse. It merely slows the process of returning the blood gases to normal. During hyperventilation, an inadequate level of carbon dioxide is in the blood, and the patient is in respiratory alkalosis. To reverse the condition, it is necessary to explain to patients that they are overbreathing.
Most emergency manuals recommend having a patient breathe into a paper bag to reverse respiratory alkalosis by breathing their own carbon dioxide. While the remedy is effective, the practice is risky. Patients who actually are having difficulty breathing may be in respiratory acidosis, which is the case of patients experiencing an asthmatic episode or patients with Kussmaul breathing associated with diabetic coma. If such a patient is mistakenly diagnosed as hyperventilating (and given a paper bag to breathe into to reverse alkalosis), their true condition of acidosis is worsened.
It is less of a risk to give oxygen to a hyperventilating patient than to give a paper bag to someone who seems to be overbreathing but is actually not getting a good oxygen air exchange.
The need to help patients with a phobia about dental treatment is of paramount importance. Stress-reduction protocols that include premedication, hypnosis, and even acupuncture have enabled patients to receive dental care and keep their natural teeth.
Cynthia R. Biron, RDH, is chair of the dental hygiene program at the Tallahassee Community College. She is also a certified emergency medical technician.
Management of hyperventilation
- Recognize overbreathing in a healthy young individual
- Terminate dental treatment
- Immediately tell patient - no more treatment today
- Position patient seated upright
- Explain hyperventilation
- Ask patient to hold breath to the count of 10
- If hysteria or symptoms worsen call EMS
- Provide Basic Life Support while awaiting EMS arrival