The Willies

Aug. 1, 1997
Anxiety about the dental experience interferes with the patient?s life. Skills such as touch, empathy, active listening, open

Anxiety about the dental experience interferes with the patient?s life. Skills such as touch, empathy, active listening, open

communication and asking questions diminish the fear.

Debora Bale-Griffeth, BA, RDH

As dental professionals, we all work one-on-one with every patient who comes to our office. While addressing their immediate dental health-care needs is the major priority, we also are called upon to comfort and console our patients in times of stress ? the stress brought on by the dental visit and the stress caused by outside sources.

During my many years of professional practice, I have dealt with parents of children who committed suicide, adults who have lost their spouses to illness or accidents, patients who have been diagnosed with life-threatening illnesses, people with depression and other mental-health problems, and patients who are extremely anxious, fearful, or phobic about dental treatment.

Our education in dental hygiene often does not adequately prepare us for the many diverse communication challenges that we encounter. We are sometimes left to develop our own communication skills and understanding of human behavior and motivation. Anxious, fearful, or phobic patients are among the most challenging, and they require all of our good communication skills and our understanding.

What is the difference in the terms Oanxiety,O OfearO and Ophobia?O Many research studies and books use the words OfearO and OanxietyO synonymously. However, it may be useful to distinguish between the two when working with patients. Fear and anxiety basically are the same emotions, behaviors, and thoughts that occur in response to a specific stimulus, but they occur at different times.

The fear response toward dentistry can be conceptualized as the unpleasant emotions and thoughts, physiological reactions (increased heart rate, perspiration, gastrointestinal upset, changes in breathing, muscle tension, etc.) and overt behaviors (shaking, pacing, and escape or avoidance) that happen in response to the here and now experience of dentistry. Anxiety, on the other hand, is the same fear response (emotions, behaviors and thoughts), but it can be thought of as the response to dentistry that will happen in the future or Oanticipatory anxiety.O Anxiety is the feeling of dread we feel about an upcoming event.

Anxiety about the future and fear during a present dental experience can become so overwhelming that it begins to interfere with a patient?s life (the patient avoids going to the dentist or hygienist, for example, until the pain is so bad he or she is forced to make an appointment). The patient may even be so fearful that he or she can?t even walk in the door to take the children in for their appointment.

According to the Diagnostic and Statistical Manual of Mental Disorders, 1994, a specific phobia, such as a dental phobia, can be diagnosed if:

* A person has a striking and persistent fear that is thought to be excessive or unreasonable, and the fear is initiated by the presence (fear response) or anticipation (anxiety response) of a specific object or situation.

* Exposure to the phobic stimulus almost always provokes an immediate fear response, which may take the form of a panic attack.

* The person recognizes the fear as excessive or unreasonable.

* The situation or stimulus/stimuli that provokes the fear is avoided or else is endured with intense distress.

* The avoidance, anxiety, or distress interferes significantly with the person?s normal routine, occupational, or academic functioning, social activities or relationships or the person is highly distressed about having the phobia.

Anxiety and fear run on a continuum from the very mild to the extreme phobic response. If you have been in practice long enough, you probably have seen patients from one extreme (no fear at all) to the other (severe physiological, emotional, and avoidance reactions).

What do our patients fear?

Study after study has shown that the specific dental stimuli most people fear are the needle (seeing and feeling it) and the drill (feeling, seeing, and hearing it). Although there have been countless studies of dental fear, little research has been done on fear of dental hygiene.

In a 1988 article published in the Journal of the American Dental Association, researchers reported that, in a group of high dental-fear participants, 20 percent listed prophylaxis on their list of worrisome dental procedures. Many steps go into a prophylaxis. So what exactly do patients fear about what we do?

One research project I conducted showed the highest fear levels overall were brought on by seeing, hearing, and feeling the scraping of our scaling instruments. Because pain is a factor in negative reactions to dentistry, it was theorized that people might experience similar fear and anxiety about the potential for pain from procedures performed by a dental hygienist. It was not surprising, then, that the dental-hygiene stimuli that produced the most fear for the participants was the dental scaler.

Another study found that pain sensitivity was predictive of perceived drill pain and drill pain was predictive of avoidance behavior. A dental scaler is one of the instruments that dental hygienists use that produces pain for some patients, and thus creates the most fear. Because drill pain has been associated with avoiding the dentist, scaling pain may result from avoiding the dental hygienist. How many of us have had hypersensitive, fearful patients walk out the door after their initial appointment, never to return?

Although one of the few published research projects done on the fear of dental hygienists found that the majority of participants in the study (71 percent) reported no difference in fear levels between seeing a dentist or dental hygienist, and 17 percent felt more at ease seeing a dentist, I found higher levels of fear toward dentists than dental hygienists in my own research.

Over the years, I have seen many patients who want to come in regularly for their dental-hygiene appointments, but will put off seeing the dentist for years. On the other hand, the dentist sees many patients who put off seeing the dental hygienist. The point here is that every patient you see will have different fears and concerns about dental treatment. If you can discern a patient?s fears and concerns, you then can assist that patient in overcoming them.

According to the marvelous book, Treating Fearful Dental Patients: A Patient Management Handbook, there are many reasons people fear coming to the dental office. Patients fear our unprofessional behavior, such as yelling, being too rough, and not listening to them. They also fear some of our personal characteristics, such as being impersonal, mean, uncaring, or cold. The anticipation of negative comments ? Oyou have the worst overbite I?ve ever seen,O or Oyou haven?t been flossing and your gums look terribleO ? produces more anxiety than receiving an injection! Our patients fear being embarrassed and belittled.

Patients also can fear being vulnerable and losing control. Because we so often are in the Odriver?s seatO for the duration of a patient?s appointment, it is easy to lose sight of how it feels to the patient. Imagine for a minute what it must be like to be a patient. You find yourself in an unfamiliar setting, you can view the Oinstruments of tortureO when you walk into the operatory. You are reclined in a chair in such a position that it is difficult to escape. You have a dental provider hovering close to your body with mask and gloves on, and you are unable to speak during treatment while there are instruments in your mouth. It is a highly unnatural and restrictive situation, and it is not surprising that our patients feel as if they have no control over the situation.

Even the term OpatientO implies a subservient position where the health-care provider is perceived to be the Oexpert.O Many studies have shown that if a person is perceived to be an Oexpert,O it makes it difficult for the other person to make requests of this authority figure. So, many patients might not even voice their thoughts on ways you could increase their comfort and give them a small sense of control over the situation. Not a pleasant position to be in!

Assessing fear in our patients

Now that we know what people fear when they come to the dental office, how do you recognize and assess fear in your dental patients? If you are lucky, some patients actually may come right out and tell you that they are afraid of seeing the dentist or hygienist and then go into an exact listing of what they are afraid of and what caused it. However, many patients adopt the OmartyrO position and never tell you or show you that they are afraid. Without verbal cues, we often rely solely on visual cues of fear (shakiness, hyperventilation, sweating, Owhite knuckles,O etc.) which may or may not alert us to the fear some of our patients are experiencing.

It might be more productive for your office to use an established verbal interview or a pencil and paper questionnaire that could be included in your medical-dental history. You might tailor an interview or questionnaire to suit the specific needs of your dental office. Let all members of the dental staff provide input. If a verbal interview is to be conducted, the administrator of the interview must be selected from among the staff, a place must be chosen and time must be scheduled. This may be difficult to accomplish in a busy dental office, so it may be easier and more time-efficient to construct a written questionnaire.

However, you may find the information gathered from a written questionnaire may not be as complete as that gleaned from a verbal interview. Pencil and paper-assessment tools are available in the Treating Fearful Dental Patients: A Patient Management Handbook. The book can be purchased by contacting the University of Washington, Dental Fears Research Clinic, Box 3557475, Seattle, Washington 98195-7475. The fax number is (206) 685-4528.

Working with the fear

Over the years, I have had the opportunity to work with many patients who experience high levels of dental fear and anxiety. I also have had the opportunity to observe other dental providers (hygienists, dentists and assistants) attempting to manage these patients. For many dental providers, tools for the management of dental fear generally are limited to verbal encouragement and sometimes touch.

I distinctly remember one poor fellow who came to an office with a severely abscessed tooth that had been keeping him awake for many nights. After finally building up enough nerve to come to the dentist, he emphatically instructed the dentist to Ojust pull itO (the classic picture of a dental phobia). He was not interested in ways in which the tooth might be saved, especially if the treatment involved coming back to the office for another appointment.

During the extraction, he was the picture of fear: white-knuckled, tense muscles, sweating, and moaning. During the loudest moan, the assistant patted him on the hand and said, OYou?re doing OK.O In actuality, the patient was anything but OOK,O and the assistant?s attempt to allay his fears only served to discount or deny his experience and probably reinforced his beliefs that dentistry was painful. Although inadequate as an attempt to reduce the patient?s fear, it was the only thing the assistant knew how to do.

What could the assistant have done to validate his experience and decrease his fear? Several communication skills can be useful when working with the anxious or fearful dental patient. These skills include touch, empathy, active listening, open communication and asking questions. Behavioral techniques that can be very effective in diminishing fear include providing control to the patient, teaching relaxation breathing and distraction.

Expressing empathy

How could the assistant have expressed her concern in a more meaningful way? How could she have been more empathetic? Empathy can be defined as the ability to understand people from their frame of reference, rather than your own, or to be able to feel and experience what another person is feeling and experiencing. Responding to a patient empathetically may be Oan attempt to think with, rather than for or about, the patient.O Empathy functions to help build rapport and elicit information from others. Empathy can be conveyed by both verbal and nonverbal means. Nonverbal empathy includes direct eye contact, facing the patient and touch.

I often use touch with my patients. A brief touch on the shoulder with an inquiry into their well-being (OAre you doing OK?O) seems to assure my patients that I care. Touch is the nonverbal language that we use to show our feelings to demonstrate to others that they are loved, cared for and/or appreciated. It is an integral part of the human experience.

There have been innumerable studies conducted in the area of touch. One medical study discovered that patients denied skin contact during treatment reported feeling immensely isolated. On the other side of the coin, a separate study found that patients who were touched during treatment, even if only for a brief second, perceived the provider as more kind and likable than those providers who did not touch their patients. Other studies have shown that hospitalized patients who are touched routinely by nurses heal faster and return home earlier than those patients who are not touched. So, the assistant?s touch, at some level, was somewhat comforting to the very fearful patient.

We can express nonverbal empathy with touch. How can we best express verbal empathy? Verbal empathy usually is conveyed by paraphrasing or repeating OfeelingO statements to the patient.

An example would be a patient who tells you, OI?m really afraid of the needle!O

The common replies ? OIt will only hurt for a minute,O OIt just feels like a mosquito bite,O or OIt won?t hurt a bitO ? are all examples of responses that are not empathetic.

OYou seem really concerned about this shot,O or OI can tell you are very worried about the shot,O are examples of replies that are empathetic. These statements mirror back to the patient what was said and make that person feel like you are listening.

The empathetic response from you may lead to more information from the patient as he continues to tell you exactly what he is afraid of. It then opens the door for the dental provider to ask such questions as, OWhat can I do to make it more comfortable for you?O OIs there a way to make this less stressful for you?O When you add direct eye contact and/or a touch to the hand or shoulder of the patient during emphatic statements and questions, you are well on the road to building rapport and establishing a trusting relationship with this person.

Active listening

To be empathetic to our patients, we must first listen to what they are saying. One of the most basic and important of all communication skills is the art of listening. It is amazing what a profound effect just OlisteningO can have on a patient! Listening to the patient means listening well to what is said and also to what is unsaid. You can do that by listening carefully to cues indicating the patient is suppressing, ignoring, or just not mentioning certain emotions. When you listen to your patients, you listen to:

* Their experience or what they see happening to them (OThe last time I went to the dentist, I had a horrible time with the shot.O).

* Their behaviors, or what they do or fail to do (OI fainted.O).

* The feelings and emotions that come from their experience and behaviors (OI felt really embarrassed and scared.O).

* Their point of view in talking about their experience, behavior, and feelings (OI?m really afraid I?m going to faint again, and I might die!O).

Active listening is part of empathy, because it involves comprehension of the patient?s innermost thoughts and perspectives, even when these are unspoken and implicit. If the patient is afraid of the needle, find out why he is afraid. Is it the pain, or are there some other fears going on? Perhaps the patient is afraid of fainting and embarrassing himself or perhaps this individual is afraid of the needle.

A patient may have even heard a story of someone dying after receiving an injection in a dental office. Don?t assume you know what the patient is afraid of. Asking questions to comprehend the patient?s concerns is very useful to you as the provider of dental services and also is useful to the patient. Patients will start to feel as if you really care about what they feel and want.

Behavioral skills

Feelings of control, according to Milgrom, Weinstein and Getz, can be provided through three routes:

* Informational control.

* Behavioral control.

* Retrospective control or debriefing.

Informational control involves discussing salient parts of the procedures with the patient, emphasizing safety, comfort and control. Some patients like a lot of information, while others prefer little or no information. It is very important to ask each patient how much information is wanted.

Behavioral control during the dental appointment can be encouraged by letting the patient know he can signal at any time if a rest is needed or a procedure is uncomfortable (for example, the patient can be told that the injection will take 10 seconds and to signal to stop at any time during those 10 seconds if he becomes uncomfortable).

Scheduled rest breaks also are helpful. A patient who knows he only has to OendureO the scaling for five minutes before there is a break will have a greater sense of control over what is taking place.

Retrospective control involves talking with the patient after a procedure to establish what went right and what can be done at the next appointment to make the patient even more comfortable.

One of the most important skills you can teach your patients to do is the technique of relaxation breathing. It is simple to learn and very effective. Have the patient slowly inhale to the count of five, hold for one second and then OsighO or exhale slowly. Repeat the breathing exercise for four to five breaths. Using relaxation breathing during scheduled rest breaks can be very effective in relieving muscle tension and stress.

Some patients handle stress more effectively when they can be distracted with music or some other visual or auditory input (television or video monitors). For others, distraction just serves to heighten their distress. Make sure you ask before using auditory or visual distractions with your patients. If music works to distract your patient, either have a headset available for such occasions or have the patient bring in his personal stereo. Suggest the patient bring music that is soothing to him, rather than choosing something yourself that might not have the desired effect.

One side note: Studies have shown that the perception of pain is heightened when people shut their eyes, so it is important for patients to keep their eyes open during dental treatment.

Other behavioral techniques

What further skills can be used by dental providers to assist them in the management of dental fear/anxiety? Behavioral techniques such as relaxation training, biofeedback, guided imagery, implosion therapy, systemic desensitization, and modeling are suggested. Although these behavioral techniques have been shown to be effective in the treatment of specific phobias, such as dental phobia, it might be difficult to use these techniques during office hours. The techniques could be better handled by trained behavioral therapists.

Over the past decade, specialized dental-fear clinics have been organized throughout the United States. When necessary, it would be prudent to refer a highly fearful and phobic patient to one of these clinics. If a dental-fear clinic is unavailable to your patients, it might be useful to connect them with a psychotherapist in your area who specializes in one of the behavioral techniques listed above.


Dentists have at their disposal the use of one or more pharmacological interventions (nitrous-oxide analgesia, anti-anxiety medications, general anesthesia, and intravenous sedation) to relieve dental fear/anxiety. In some states, dental hygienists are trained to administer nitrous-oxide analgesia for the reduction of anxiety, fear, and pain in their patients.

These pharmacological approaches to dental fear, while beneficial in the short run because they allow needed treatment to be performed, do not address the root of the fear, and tend to make patients reliant on some form of sedation almost every time they come to the dental office.

Improved communication skills between health providers and their patients can lead to better health-care outcomes, increased compliance with the treatment plan, low job- burnout rate, less litigation, relationship satisfaction, increased demand for services and reduced levels of stress for both the provider and the patient. When we provide our patients with the basics of good communication skills, empathy, active listening and questions, everyone benefits.

Other useful resources

The Anxiety and Phobia Workbook by Edmund Bourne (1995), New Harbinger Publications ? This book would be helpful for patients interested in learning how to treat themselves and for the dental hygienist as an instruction manual in some of the behavioral techniques used in the treatment of specific phobias. It is readily available at most book stores.

Oral Self Care: Strategies for Preventive Dentistry by Philip Weinstein, Tracy Getz and Peter Milgrom (1991), University of Washington ? This book addresses many communication skills and techniques for helping dental patients build and maintain preventive habits. It can be obtained from the address listed earlier in this article.

Other resources and skills can be learned at your local university, community college or at continuing education seminars. I encourage you to take a class in paraprofessional counseling, counseling skills or communication skills. The skills learned in these classes can benefit you not only at work, but with all of your interpersonal interactions.

Debora Bale-Griffeth, RDH, BA is a clinician and occasional adjunct faculty of the dental hygiene program at the University of Alaska at Anchorage. She is currently completing her MS degree in clinical psychology.

Better questions to ask than, OWhat are you so nervous about??

What kind of questions would be helpful in establishing your patient?s unique fears and concerns? The following questions could serve as a guide for an interview or written questionnaire:

What brings you to our office today? Is this a regular checkup and prophylaxis, or has the patient been suffering with a toothache for the past week without calling a dentist? Is this patient interested in regular care or just emergency care to relieve pain? This simple question can give you cues about the continuum of fear and anxiety for the patient.

When was the last time you visited a dental office? What was done at that time? Was it six months ago for an exam and cleaning or six years ago for a root canal or extraction? If it has been a long time, you might inquire why this patient hasn?t been to the dentist for so long. Many people avoid dentistry for reasons other than fear. These reasons may include physical illness or a lack of time, money, insurance or transportation.

Have you had any difficult or uncomfortable experiences with dentists or dental hygienists? If so, what made it difficult or uncomfortable for you? This question will give you some insight into what the patient fears about dentistry. Was it difficult because of pain, or was the patient made to feel belittled or embarrassed? Did the patient feel the dental professional ignored his/her fears and concerns?

Have you had any good experiences with dentists or dental hygienists? If so, could you explain what made it a good experience for you? If you haven?t had a good experience, what would a good experience be like for you? If you know what makes the patient feel comfortable, then you can repeat the experience and help build his confidence and give that individual a sense of control over the dental experience. If a patient has never had a good experience with the dentist or dental hygienist, knowing the things that would make that person?s visit more comfortable would be very useful.

How do you feel when you have a scheduled dental appointment next week? In a couple of days? Tomorrow? These questions address the anxiety a patient feels before an appointment. The higher the anxiety, the more likely it will be that the patient will cancel his appointment or be a no-show. That?s why it is even more important for you to find out what you can do to make the patient more comfortable before and/or during the appointment. If the patient?s anxiety is lowered, the fear response during the appointment also may be lowered.

Do you notice any changes in your heart rate, your breathing, or do you sweat when you see the dentist? The dental hygienist? If so, when has a dental appointment not caused these symptoms? By finding out if the patient has a fear response during dentistry, you can learn to work with that person to reduce these bothersome and sometimes embarrassing symptoms. If the patient has had a good experience once, how can you help the patient repeat it?

All of us experience fear and anxiety at times. How do you normally cope with stress? People cope with stress in their life in many different ways (meditation, deep breathing, avoidance, Ogrinning and bearing it,O listening to music, etc.). By asking patients their unique ways of dealing with stress, it may give you ideas on how to help them through their dental fear and anxiety.

A Ohip,? yet expensive, fear

A common and generally acceptable fear in our society is the fear of dentistry. Many people, if asked, would admit to some level of anxiety or fear about dentistry. Most people pity and console others who have the OmisfortuneO of having to go to a dental appointment. So, what are the problems associated with this common and generally accepted fear of the dentist?

Cancellations and no-shows for appointments leading to reduced production are the major problems that anxiety and fear may cause. For the patient, putting off that much needed root-planing appointment or crown prep because of anxiety and fear can lead to major dental and physical-health problems.

However, the most salient problem caused by anxiety and fear is the total avoidance of dental care. Different studies of dental fear have established:

* Somewhere between 6 to 14 percent of the population in the United States avoid seeking out dental services because of severe fear and anxiety (dental phobics).

* Approximately 50 percent of Americans go to the dentist yearly and 20 to 30 percent go only occasionally because of their fear, distrust, and/or dislike.

* An estimated 30 million people are so fearful of dentistry that they couldn?t make an appointment to see a dentist under any circumstances!

As you can see by the statistics, dental anxiety and fear impact our practice and the health of our patients in many ways.

What is the cost to us personally? After working on a highly stressed and fearful patient, I feel almost as exhausted as they do. I also feel as relieved as they do when the appointment is over! Fearful patients possibly can lead to high burnout, high stress, and fatigue. Just imagine what you would feel like after a whole day of working on patients who were hypersensitive and fearful.