Preventing Dental Phobia
This summary is based on information found in Cognitive Behaviour Therapy for Dental Phobia and Anxiety (Wiley Publishing, 2013)
Since it is usually nearly impossible to change the personal and external/social factors (vulnerability) of the patient, the dental factors should be adapted to the level of this vulnerability since they represent a potential for prevention of behaviour management problems, dental fear and anxiety and dental phobia.
The Dentist’s Behaviour: Establishing Rapport
- A trusting relationship between the patient and the dental personnel is basic both for prevention and treatment of dental phobia.
- The Four Habits Model: a guide for the interview with the dental patient:
- Invest in the beginning;
- Elicit the patient’s perspective;
- Demonstrate empathy; and
- Invest in the end.
Meeting the Child and the Parent in the Waiting Room
A good practice is for the dentist or the hygienist to meet every new patient in the waiting room, depending on who is going to do the dental exam. If the new patient is a child, he/she should be met with the same respect and the same principles as for an adult patient.
Child and Parent in the Dental Clinic
- The conversation must include both the child and parent in order to establish a trusting relationship with both of them.
- If the dentist has established an excellent communication with the child, but has neglected proper exchange of ideas with the parent, a possible negative attitude may be communicated from the parent to the child either during or after the session and the good relationship between dentist and child may be reduced.
- There are, however, cases where it is preferable to dismiss the parents, for example when parents are interfering negatively with the treatment process. It is important that this is done according to the rules of good etiquette in order to prevent the parent ruining a good relationship between dentist and child by negative communication with the child after the session.
- Behaviour shaping should be introduced early and if possible during sessions of preventive dentistry where no invasive treatment is yet needed. Positive experiences in the dental chair seem to be make children able to cope with more unpleasant and painful experiences later (Davey 1989).
- The behaviour shaping must aim at introducing the child to actual treatment needs, including how the instruments work and their purpose.
Cognitive Behavioural Therapy in Fearful Children and Adolescents
- Cognitive behavioural therapy (CBT) is a treatment approach shown to be very effective in treatment of dental phobia in adults and the basic principles of CBT may also be useful for prevention of dental phobia in clinical practice.
- A good outcome of CBT in children depends on the child’s own motivation for being treated for the fear and thereby being able to cope with ordinary treatment.
Exploring the child’s’ negative thoughts
- It is important for the dentist to explore the patient’s thoughts in the situation: what is the specific problem?
- Whatever the negative beliefs, they are never tested, and over time the avoidance makes the beliefs gradually stronger.
Explaining the fear and the principles of gradual exposure
- One of the goals is to conclude a session at a step where the patient, the parent and the therapist are happy because of the improvement that has been achieved, even if the progress is ‘minimal’.
- The focus on teamwork between child and dentist is generally a good approach for children and to ‘play’ together and to help each other to reach small goals that qualify for praise and feeling of coping.
- For the child patient different techniques aimed at reducing the physiological activity should be used, e.g. blowing a ‘windmill’ and distraction techniques like singing, telling stories and playing with toys.
The Complexity of Pain
- Pain is a subjective experience: the goal is not necessarily a totally pain-free treatment, but that the pain experience is within the individual patient’s own coping ability.
- Introducing LA to children in order to make them confident with the technique is important for pain control during invasive dental treatment.
- Children need some kind of information before an injection, but this must be adapted to their age and maturity.
- The use of a topical analgesic agent is extremely important in reducing the pain of the penetrating needle.
Local Anaesthesia in Children with Blood-Injury-Injection (BII) Phobia Activation
- Paediatric dentists should be aware that children with a genetic predisposition of BII phobia may experience an injection as very unpleasant because of the characteristic vasovagal response (decrease of blood pressure). They may therefore need adjusted behaviour management techniques aimed at compensating for the reduction in blood pressure, for example the muscle tension technique (Öst and Sterner 1987).
- The concept could be divided into 4 categories:
- Informational control: the description of details, e.g. anatomy of the mouth, jaws and teeth; treatment procedures and instruments etc.
- Cognitive and behavioural control: cognitive control is the control of negative thoughts starting before the appointment and will influence the anticipatory anxiety. Behavioural control is the opportunity to influence and control the procedures, e.g. to stop the treatment by raising one hand, including the patient’s control over the treatment options.
- Retrospective control: the patient understands what and why things happened.
- The major indications for conscious sedation as a supplement to the psychological treatment methods are uncooperative patients in need of acute dental treatment and/or extensive and complicated dental treatment needs. The aims of this combination is to enable the patient to cope with future dental treatment.