Dental phobia = patient abuse

Dec. 1, 2001
When it comes right down to it, what happens in your treatment room with a fearful child can make or break that child's dental future.

When it comes right down to it, what happens in your treatment room with a fearful child can make or break that child's dental future.

When I first started practicing hygiene, I took a job with a temporary agency. Every day, I was treated like special company. People were so happy and relieved to see me. For the most part, I was treated like a savior. I also got to see it all and I mean all.

One episode still haunts me. I do not know the circumstances of the treatment or why it was delivered that way, but it still bothers me 16 years later. The patient, a young boy, was screaming at the top of his little lungs, fighting the entire time. I know you are thinking to yourself, so what? Little kids cry in my chair all the time! But I will never forget how that hygienist yelled back at the boy while continuing treatment. Fighting and screaming, the little boy had his teeth polished. Finally, the appointment was completed.

I realized I had observed a dental phobia in the making. I vowed never to work on a screaming child ... and I've kept that vow.

Let's look at the word phobia. It is defined as a persistent, abnormal, or irrational fear. Yet, the fear instilled into that child that day should not be categorized as either abnormal or irrational. He earned it and he'll probably carry it with him for the rest of his life!

How about the numerous patients you see every year who are fearful of dental treatment? If you start asking general questions about their anxiety, you undoubtedly will discover that your patient had a traumatic experience with a previous dentist, not an irrational fear.

Children, as late as the 1970s, were sometimes slapped by dentists, or drilled on without the benefit of an anesthetic more powerful than willpower — the dentist's willpower! They were often belittled for being afraid or made fun of for crying. Sometimes, just being in the proximity of another crying child, sibling, or parent will set up the fear factor. Listen to your patients tell of their past dental experiences. You will be horrified and embarrassed at the treatment that these patients received at the hands of a dental care provider. These patients are not true dental phobics; their fears are well-founded! To call it a phobic condition belittles them once again.

Always assess the level of fear that your patients may have. Did they have their spouse drive them to your office? Did they spend the night or the last week dreading their visit? Did they come in on a spur of the moment just to talk? (If they did, you or another staff member better find the time to talk to these patients immediately!) Do they keep canceling their appointments? Have you had patients who tried to fortify themselves with a drink before the appointment? Do they tremble, do they complain about every little thing, or are they belligerent? Are they insulting? Do they try to rattle you? Do they talk incessantly, so that you cannot get into their mouth to work? These are all possible manifestations of fear of dental treatment.

So now you have a fearful patient in your chair. You have assessed the level of this patient's fear and now you're afraid. You know that no matter what you do for that patient, no matter what you say, or how you approach this person, there's trouble ahead. If patients are overly sensitive to stimuli, they will be jumpy and you may end up hurting them. If they manifest their fear as aggression (that's the hardest one!), you may go home in tears. Once you recognize this trait, slide your chair back and talk to them. Have the patient seated upright in the chair while you discuss their concerns. Some clinicians feel an urgency to get the patients like this in and out of the office quickly. That may not be the best way. Ask these phobic patients what you can do to make the appointment easier, so they aren't afraid to come back again. Offer suggestions of options available to minimize their fears, from headphones to pharmacological support.

Medications are wonderful and patients really like them. We have a wide range of medications available to us, from nitrous oxide sedation to Valium and its cousins, to unconscious sedation. But, hygienists cannot write prescriptions. That's not the only drawback to pharmacological support. Some patients, who fear loss of control, may not find medications to be an acceptable solution for them. You may need to help that patient work through their fear with desensitization or another anxiety-relieving technique.

In the book, The Anxiety and Phobia Workbook, the author gives step-by-step directions to mastering relaxation, coping with panic, overcoming negative self-talk, and other time- honored procedures for managing fear. It may not be within our scope of practice to bring fearful patients around, but offering a book like this one may help that person get a handle on addressing the problem. In addition, numerous entries about dental fears and anxieties can be found in many publications aimed at dental-care providers.

A research paper in General Dentistry last summer discussed what dental personnel do to increase anxiety in patients. The number one situation with which patients reported elevated fear — even over the rushed appearance of the provider — was the lack of neatness on the part of the dentist and staff. Wow! What's up with that? The patients assumed or worried that the instruments were not properly sterilized or disinfected if dental team members did not project a neat appearance in their dress. The third way dental staff increase patient anxiety was to fail to demonstrate concern for the patient's feelings. How's that for a wake-up call? Maybe ironing scrubs isn't such a bad idea!

Between medications and behavior management, most patients will be able to work through their fears. Obviously, it's much better to establish a protocol to ensure that a person never has to go through a fear-producing event. Take care of the "little people." Remember, dental hygienists often are the first dental staff members that young patients come in contact with. It's really up to us to make sure the visit goes smoothly.

When it comes right down to it, what happens in your treatment room with a fearful child can make or break that child's dental future. See children at an early age — and maybe often — to get them acclimated to dental procedures. If they're having a bad day, don't try to treat them. Don't give them a toy or toothbrush. A gift may be construed as a reward for poor behavior. Have the child return another day. Give these fearful young patients a time frame that they can count on. Reinforce this by saying to them when they leave, "See you around Valentine's Day" or "See you in two weeks."

If children with dental phobias ask if something will hurt, tell them it may feel "weird." Sometimes, just giving them an alternate word for "hurts" — like "weird" — allows them the freedom to use a more appropriate word for an unfamiliar feeling. It's helpful to tell them that some people don't think it hurts and some do. Ask them to tell you if it does or does not hurt. Work to make that patient want to come back and see you. Your goal should be to make sure that this phobic patient will never leave your practice to be fearful in someone else's.

For adult patients, acknowledge their effort. Thank them for coming in; tell them you know it was hard for them and you appreciate their confidence in you. Whatever else you do, do not act hurried! They need all the time in the world to become confident and less fearful. Move slowly and deliberately. Understanding that the fear is real and earned, not irrational, will remind you to alter your approach. You can offer anxious patients a number of options to help reduce their fears. They may never come to you anxiety-free; but, as long as they come to you, it doesn't matter!

If nothing else, remember this: We can either pass through a patient's personal space barrier and enter into their body, or we can breach their personal space and violate their body and soul. Phobias are perpetuated in a person's mind out of nothing; dental fear comes from an uncaring, hurried dental problem-maker with a college degree.

Shirley Gutkowski, RDH, BSDH, has been a full time practicing dental hygienist in Madison, Wis., since 1986. Ms. Gutkowski is published in print and on Internet sites, and speaks to groups through Cross Links Presentations. She can be contacted at [email protected].