The Dentist-Patient Relationship II

13. How can the dentist help the patient to relate more information or to talk about a certain issue in greater depth?

A communication technique called facilitation by reflection is helpful. One simply repeats the last word or phrase that was spoken in a questioning tone of voice. Thus when a patient says, “I am petrified of dentists,” the dentist responds,

“Petrified of dentists?” The patient usually elaborates. The goal is to go from generalization to the specific fear to the origin of the fear. The process is therapeutic and allows fears to be reduced or diminished as patients gain insight into their feelings.

14. How should one construct suggestions that help patients to alter their behavior or that influence the outcome of a command?

Negatives should be avoided in commands. Positive commands are more easily experienced, and compliance is usually greater. To experience a negation, the patient first creates the positive image and then somehow negates it. In experience only positive situations can be realized; language forms negation. For example, to experience the command “Do not run!,” one may visualize oneself sitting, standing, or walking slowly. A more direct command is “Stop!” or “Walk!”

Moreover, a negative command may create more resistance to compliance, whether voluntary or not. If you ask someone not to see elephants, he or she tends to see elephants first. Therefore, it may be best to ask patients to keep their mouth open widely rather than to say, “Don’t close,” or perhaps to suggest, “Rest open widely, please.”

A permissive approach and indirect commands also create less resistance and enhance compliance. One may say, “If you stay open widely, I can do my procedure faster and better,” or “By flossing daily, you will experience a fresher breath and a healthier smile.” This style of suggestion is usually better received than a direct command.

Linking phrases—for example, “as,” “while,” or “when”—to join a suggestion with something that is happening in the patient’s immediate experience provides an easier pathway for a patient to follow and further enhances compliance.

Examples include the following: ‘as you lie in the chair, allow your mouth to rest open. While you take another deep breath, allow your body to relax further.” In each example the patient easily identifies with the first experience and thus experiences the additional suggestion more readily.

Providing pathways to achieve a desired end may help patients to accomplish something that they do not know how to do on their own. Patients may not know how to relax on command; it may be more helpful to suggest that while they take in each breath slowly and see a drop of rain rolling off a leaf, they can let their whole body become loose and at ease. Indirect suggestions, positive images, linking pathways, and guided visualizations play a powerful role in helping patients to achieve desired goals.

15. How do the senses influence communication style?

Most people record experience in the auditory, visual, or kinesthetic modes.

They hear, they see, or they feel. Some people use a dominant mode to process information. Language can be chosen to match the modality that best fits the patient. If patients relate their problem in terms of feelings, responses related to how they feel may enhance communication. Similarly, a patient may say, “Doctor, that sounds like a good treatment plan’ or “I see that this disorder is relatively common. Things look less frightening now.” These comments suggest an auditory mode and a visual mode; respectively responding in similar terms enhances communication.

16. When is reassurance most valuable in the clinical session?

Positive supportive statements to the patient that he or she is going to do well or be all right are an important part of treatment. Everyone at some point may have doubts or fears about the outcome. Some patients as insincerity or as trivializing their problem may interpret reassurance given too early, such as before a thorough examination of the presenting symptoms.

The best time for reassurance is after the examination, when a tentative diagnosis is reached. The patient best receives the support at this point.

17. What type of language or phrasing is best avoided in patient communications?

Certain words or descriptions that are routine in the technical terminology of dentistry may be offensive or frightening to patients. Cutting, drilling, bleeding, injecting, or clamping may be anxiety-provoking terms to some patients.

Furthermore, being too technical in conversations with patients may result in poor communication and provoke rather than reduce anxiety. It is beneficial to choose terms that are neutral yet informative. One may prepare a tooth rather than cut it or dry the area rather than suction all of the blood. This approach may be especially important during a teaching session when procedural and technical instructions are given as the patient lies helpless, listening to conversation that seems to exclude his or her presence as a person.

18. What common dental-related fears do patients experience?

• Pain

• Drills (e.g., slipping, noise, smell)

• Needles (deep penetration, tissue injury, numbness)

• Loss of teeth

• Surgery

19. List four elements common to all fears.

• Fear of the unknown • Fear of loss of control

• Fear of physical harm or bodily injury • Fear of helplessness and dependency

Understanding the above elements of fear allows effective planning for treatment of fearful and anxious patients.

20. During the clinical interview, how may one address such fears?

According to the maxim that fear dissolves in a trusting relationship, establishing good rapport with patients is especially important. Secondly, preparatory explanations may deal effectively with fear f the unknown and thus give a sense of control. Allowing patients to signal when they wish to pause or speak further alleviates fears of loss of control. Finally, well-executed dental technique and clinical practices minimize unpleasantness.

21. How are dental fears learned?

Most commonly dental-related fears are learned directly from a traumatic experience in a dental or medical setting. The experience may be real or perceived by the patient as a threat, but a single event may lead to a lifetime of fear when any element of the traumatic situation is re-experienced. The situation may have occurred many years before, but the intensity of the recalled fear may persist. Associated with the incident is the behavior of the past doctor. Thus, in diffusing learned fear, the behavior of the present doctor is paramount.

Fears also may be learned indirectly as a vicarious experience from family members, friends, or even the media. Cartoons and movies often portray the pain and fear of the dental setting. How many times have dentists seen the negative reaction of patients to the term “root canal,” even though they may not have had one?

Past fearful experiences often occur during childhood when perceptions are out of proportion to events, but memories and feelings persist into adulthood with the same distortions. Feelings of helplessness, dependency, and fear of the unknown are coupled with pain and a possible uncaring attitude on the part of the dentist to condition a response of fear when any element of the past event is re-experienced. Indeed, such events may not even be available to conscious awareness.

22. How are the terms generalization and modeling related to the conditioning aspect of dental fears?

Dental fears may be seen as similar to classic Pavlovian conditioning. Such conditioning may result in generalization, by which the effects of the original episode spread to situation with similar elements. For example, the trauma of an injury or the details of an emergency setting, such as sutures or injections may be generalized to the dental setting. Many adults who had tonsillectomies under ether anesthesia may generalize the childhood experience to the dental setting, complaining of difficulty with breathing or airway maintenance, difficulty with gagging, or inability to tolerate oral injections. Modeling is vicarious learning through indirect exposure to traumatic events through parents, siblings, or any other source that affects the patient.

23. Why is understanding the patient’s perception of troll of fear and stress?

According to studies, patients perceive the dentist as both the controller of what the patient perceives as dangerous and as the protector from that danger.

Thus the dentist’s behavior and communications assume increased significance.

The patient’s ability to tolerate stress and to cope with fears depends on the ability to develop and maintain a high level of trust and confidence in the dentist.

To achieve this goal, patients must express all the issues that they perceive as threatening, and the dentist must explain what he or she can do to address patient concerns and protect them from the perceived dangers. This is the purpose of the clinical interview. The result of this exchange should be increased trust and rapport and a subsequent decline in fear and anxiety.

24. How are emotions evolved? What constructs are important to understanding dental fears?

Psychological theories suggest that events and situations are evaluated by using interpretations that are personality-dependent (i.e., based on individual history and experience). Emotions evolve from this history. Positive or negative coping abilities mediate the interpretative process (people who believe that they are capable of dealing with a situation experience a different emotion during the initial event than people with less coping ability). The resulting emotional experience may be influenced by vicarious learning experiences (watching others react to an event), direct learning experiences (having one’s own experience with the event), or social persuasion (expressions by others of what the event means).

A person’s coping ability, or self-efficacy, in dealing with an appraisal of an event for its threatening content is highly variable, based on the multiplicity of personal life experiences. Belief that one has the ability to cope with a difficult situation reduces the interpretations that an event will be appraised as threatening, and a lower level of anxiety will result. A history of failure to cope with difficult events or the perception that coping is not a personal accomplishment (e.g., reliance in external aids, drugs) often reduces self-efficacy expectations and interpretations of the event result in higher anxiety.

25. How can learned fears be eliminated or unlearned?

Because fears of dental treatment are learned, relearning or unlearning is possible. A comfortable experience without the associated fearful and painful elements may eliminate the conditioned fear response and replace it with an adaptive and more comfortable coping response. The secret is to uncover through the interview process which elements resulted in the mal-adaptation and subsequent response of fear, to eliminate them from the present dental experience by reinterpreting them for the adult patient, and to create a more caring and protected experience. During the interview the exchange of information and the insight gained by the patient decrease levels of fear, increase rapport, and establish trust in the doctor-patient relationship. The clinician needs only to apply expert operative technique to treat the vast majority of fearful patients.

26. What remarks may be given to a patient before beginning a procedure that the patient perceives as threatening?

Opening comments by the dentist to inform the patient about what to expect during a procedure—e.g., pressure, noise, pain—may reduce the fear of the unknown and the sense of helplessness. Control through knowing is increased with such preparatory communications.

27. How may the dentist further address the issue of loss of control?

A simple instruction that allows patients to signal by raising a hand if they wish to stop or speak returns a sense of control.

28. What is denial? How may it affect a patient’s behavior and dental treatment-planning decisions?

Denial is a psychologic term for the defense mechanism that people use to block out the experience of information with which they cannot emotionally cope.

They may not be able to accept the reality or consequences of the information or experience with which they will have to cope; therefore, they distort that information or completely avoid the issue. Often the underlying experience of the information is a threat to self-esteem or liable to provoke anxiety. These feelings are often unconsciously expressed by unreasonable requests of treatment.

For the dentist, patients who refuse to accept the reality of their dental disease, such as the hopeless condition of a tooth, may lead to a path of treatment that is doomed to fail. The subsequent disappointment of the patient may involve litigation issues.

29. Define dental phobia.

A phobia is an irrational fear of a situation or object. The reaction to the stimulus is often greatly exaggerated in relation to the reality of the threat. The fears are beyond voluntary control, and avoidance is the primary coping mechanism. Phobias may be so intense that severe physiologic reactions interfere with daily functioning. In the dental setting acute syncope episodes may result.

Almost all phobias are learned. The process of dealing with true dental phobia may require a long period of individual psychotherapy and adjunctive pharmacologic sedation. However, relearning is possible, and establishing a good doctor-patient relationship is paramount.

30. What strategies may be used with the patient who gags on the slightest provocation?

The gag reflex is a basic physiologic protective mechanism that occurs when the posterior oropharynx is stimulated by a foreign object; normal swallowing does not trigger the reflex. When overlying anxiety is present, especially if anxiety is related to the fear of being unable to breathe, the gag reflex may be exaggerated.

A conceptual model is the analogy to being “tickled.” Most people can stroke themselves on the sole of the foot or under the arm without a reaction, but when someone else does the same stimulus, the usual results are laughter and withdrawal. Hence, if patients can eat properly, put a spoon in their mouth, or suck on their own finger, usually they are considered physiologically normal and may be taught to accept dental treatment and even dentures with appropriate behavioral therapy. In dealing with such patients, desensitization becomes the process of relearning. A review of the history to discover episodes of impaired or threatened breathing is important. Childhood general anesthesia, near drowning, choking, or asphyxiation may have been the initiating event that created increased anxiety about being touched in the oral cavity. Patients may fear the inability to breathe, and the gag becomes part of their protective coping. Thus, reduction of anxiety is the first step; an initial strategy is to give information that allows patients to understand better their own response. Instruction in nasal breathing may offer confidence in the ability to maintain a constant and uninterrupted airflow, even with oral manipulation. Eye fixation on a singular object may dissociate and distract the patient’s attention away from the oral cavity. This technique may be especially helpful for taking radiographs and for brief oral examinations. For severe gaggers, hypnosis and nitrous oxide may be helpful; others may find use of a rubber dam reassuring. For some patients longer-term behavioral therapy may be necessary.

31. What is meant by the term anxiety? How is it related to fear?

Anxiety is a subjective state commonly defined as an unpleasant feeling of apprehension or impending danger in the presence of a real or perceived stimulus that the person has learned to the response may be grossly exaggerated. Such feelings may be present before the encounter with the feared situation and may linger long after the event. Associated somatic feelings include sweating, tremors, palpations, nausea, difficulty with swallowing, and hyperventilation.

Fear is usually considered an appropriate defensive response to a real or active threat. Unlike anxiety, the response is brief, the danger is external and readily definable, and the unpleasant somatic feelings pass as the danger passes. Fear is the classic “fight-or-flight” response and may serve as an overall protective mechanism by sharpening the senses and the ability to respond to the danger.

Whereas the response of fear does not usually rely on unhealthy actions for resolution, the state of anxiety often relies on non-coping and avoidance behaviors to deal with the threat.

32. How is stress related to pain and anxiety? What are the major parameters of the stress response?

When a person is stimulated by pain or anxiety, the result is a series of physiologic responses dominated by the aut000mic nervous system, skeletal muscles, and endocrine system. These physiologic responses define stress. In what is termed adaptive responses, the sympathetic responses dominate (increases in pulse rate, blood pressure, respiratory rate, peripheral vasoconstriction, skeletal muscle tone, and blood sugar; decreases in sweating, gut motility, and salivation). In an acute maladaptive response the parasympathetic responses dominate, and a syncope episode may result (decreases in pulse rate, blood pressure, respiratory rate, muscle tone; increases in salivation, sweating, gut motility, and peripheral vasodilatation, with overall confusion and agitation). In chronic maladaptive situations, psychosomatic disorders may evolve. The accompanying figure illustrates the relationships of fear, pain, and stress. It is important to control anxiety and stress during dental treatment. The medically compromised patient necessitates appropriate control to avoid potentially life-threatening situations.

33. What is the relationship between pain and anxiety?

Many studies have shown the close relationship between pain and anxiety.

The greater the person’s anxiety, the more likely it is that he or she will interpret the response to a stimulus as painful. In addition, the pain threshold is lowered with increasing anxiety. People who are debilitated, fatigued, or depressed respond to threats with a higher degree of undifferentiated anxiety and thus are more reactive to pain.

34. List four guidelines for the proper management of pain, anxiety, and stress.

1. Make a careful assessment of the patient’s anxiety and stress levels by a thoughtful inter view. Uncontrolled anxiety and stress may lead to maladaptive situations that become life threatening in medically compromised patients.

Prevention is the most important strategy.

2. From all information gathered, medical and personal, determine the correct methods for control of pain and anxiety. This assessment is critical to appropriate management. Monitoring the patient’s responses to the chosen method is essential.

3. Use medications as adjuncts for positive reinforcement, not as methods of control. Drugs circumvent fear; they do not resolve conflicts. The need for good rapport and communication is always essential.

4. Adept control techniques to fit the patient’s needs. The use of a single modality for all patients may lead to failure; for example, the use of nitrous oxide sedation to moderate severe emotional problems.

35. Construct a model for the therapeutic interview of a self-identified fearful patient.

1. Recognize a patient’s anxiety by acknowledgment of what the patient says or observation of the patient’s demeanor. Recognition, which is both verbal and nonverbal, may be as simple as saying, “Are you nervous about being here?” This recognition indicates the dentist’s concern, acceptance, supportiveness, and intent to help.

2. Facilitate patients’ cues as they tell their story. Help them to go from generalizations to specifics, especially to past origins, if possible. Listen for generalizations, distortions, and deletions of information or misinterpretations of events as the patient talks.

3. Allow patients to speak freely. Their anxiety decreases as they tell their story, describing the nature of their fear and the attitude of previous doctors.

Trust and rapport between doctor and patient also increase as the patient is allowed to speak to someone who cares and listens.

4. Give feedback to the patient. Interpretations of the information helps patients to learn new strategies for coping with their feelings and to adopt new behaviors by confronting past fears. Thus a new set of feelings and behaviors may replace maladaptive coping mechanisms.

5. Finally the dentist makes a commitment to protect the patient—a commitment that the patient may have perceived as absent in past dental experiences. Strategies include allowing the patient to stop a procedure by raising a hand or simply assuring a patient that you are ready to listen at any time.

36. Discuss behavioral methods that may help patients to cope with dental fears and related anxiety.

1. The first step for the dentist is to become knowledgeable of the patient and his or her presenting needs. Interviewing skills cannot be overemphasized. A trusting relationship is essential. As the clinical interview proceeds, fears are usually reduced to coping levels.

2. Because a patient cannot be anxious and relaxed at the same moment, teaching methods of relaxation may be helpful. Systematic relaxation allows the patient to cope with the dental situation. Guided visualizations may be helpful to achieve relaxation. Paced breathing also may be an aid to keeping patients relaxed. Guiding the rate of inspiration and expiration allows a hyperventilating patient to resume normal breathing, thus decreasing the anxiety level.

37. What are common avoidance behaviors associated with anxious patients?

Commonly, putting off making appointments followed by cancellations and failing to appear are routine events for anxious patients. Indeed, the avoidance of care can be of such magnitude that personal suffering is endured from tooth ailments with emergency consequences. Mutilated dentition often results.

38. Whom do dentists often consider their most “difficult” patient?

Surveys repeatedly show that dentists often view the anxious patient as their most difficult challenge. Almost 80% of dentists report that they themselves become anxious with an anxious patient. The ability to assess carefully a patient’s emotional needs helps the clinician to improve his or her ability to deal effectively with anxious patients. Furthermore, because anxious patients require more chair time for procedures, are more reactive to stimuli, and associate more sensations with pain, effective anxiety management yields more effective practice management.

39. What are the major practical considerations in scheduling identified anxious dental patients?

Autonomic arousal increases in proportion to the length of time before a stressful event. A patient left to anticipate the event with negative self-statements and perhaps frightening images for a whole day or at length in the waiting area is less likely to have an easy experience. Thus, it is considered prudent to schedule patients earlier in the day and keep the waiting period after the patient’s arrival to a minimum. In addition, the dentist’s energy is usually optimal earlier in the day to deal with more demanding situations.

40. What behaviors on the dentist’s part do patients specify as reducing their anxiety?

• Explain procedures before starting.

• Give specific information during procedures.

• Instruct the patient to be calm.

• Verbally support the patient: give reassurance.

• Help the patient to redefine the experience to minimize threat.

• Give the patient some control over procedures and pain.

• Attempt to teach the patient to cope with distress.

• Provide distraction and tension relief.

• Attempt to build trust in the dentist.

• Show personal warmth to the patient.

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