Treatment of Anxious Patients and Patients with Dental Phobia
A Main Focal Point of Our Occupation
Edvard Munch: "The Scream"
Dental phobia or the fear of seeking dental care is a widespread phenomenon. Even if the predominant part of the population regularly sees a dentist, between five and ten per cent suffer from such a strong fear of the dental office, that they only attend when the pain becomes too much to bear. This pronounced form of anxiety is known as dentophobia or dental phobia. Symptoms observed during dental treatment are tachycardia (rapid heartbeat), trembling, excessive sweating, choking, nausea, dropping blood pressure, to the point of circulatory collapse.
It may only be a small minority who suffer from this extreme form of anxiety. Nonetheless, according to surveys, almost 70% of the total population report having a distinctive fear of the dental office.
Potential sources of dental phobia
- Traumatising experiences during childhood or adolescence
- Scaring narrations from others, often from own parents
- General fear of pain
- Needle phobia (fear of injections)
- Fear of losing control
- Shame about the condition of the teeth
- Strong gag reflex during dental treatment (e.g. impression taking)
- Generalised phobias, psychosis and anxiety disorders
Frequently, no specific reason for the dental phobia can be established. Then it is the matter of a primordial fear like the fear of spiders (arachnophobia).
Consequences of dental anxiety
NLZ article on dental anxiety
from February 9th 2004
(PDF, 270 kB, German)
Dental fear often has a disastrous effect on both oral and general health. Inflammation and pain in teeth, gums, and jaw can undermine masticatory and digestive functions. One's appearance also suffers and many dental phobia sufferers are ashamed of their poor teeth and the bad breath they cause. The patient's often already damaged self-confidence takes a further blow. It is more than likely they cannot talk openly about their anxiety, having been laughed at in the past by friends or even the dentist. This creates a vicious circle that just makes the situation worse.
Our strategy in the fight against dental phobia:
- Reduction of psychological stress
- Gentle, painless treatment
- Laughing gas treatment
- Conscious sedation treatment
- Treatment under general anaesthesia
At our dental office, we try in a multitude of ways to find solutions to the problems presented here. Our primary concern is the early recognition and consistent treatment of dental phobia patients.
Gentle treatment - painless anaesthetic
A stress-free, relaxed atmosphere before, during, and after treatment plays an important role here. That includes preventing unnecessary waiting times, a comprehensive and interesting range of reading material in the waiting room, unobtrusive music in a bright, modern surgery, where the typical smell of "dentist" is nowhere to be found.
When treating pronounced dentophobia patients, it makes sense to carry out early counselling in a neutral conference room without the presence of dental equipment, rather than in the surgery itself.
Of course, a gentle, pain-free treatment technique is vital. And so it is that we dispensed with the traditional anaesthetic needle for treating individual teeth (fillings, crowns). Instead, the tooth is anaesthetized using the modern intraligamentary (Peripress) technique. Advantage for the patient:
- No inserting needles into the oral tissue
- Nearly painless administration
- Immediate effect
- Lips, cheeks and tongue remain unanaesthetized
These measures alone are not enough to overcome the anxiety that many patients have built up over the years. Despite positive experiences ("it really doesn't hurt"), the nightmare of a visit to the dentist still holds much of its horror.
Therefore, our dental office has facilities that provide anxiety-free treatment even in more difficult cases.
Nitrous oxide analgesia (conscious sedation) - the renaissance of a proven method
The analgetic (painkilling) and sedative (calming) effect of laughing gas (chemical formula N2O, dinitrogen monoxide, nitrogen oxide) was discovered in the Nineteenth Century. It has since been used million-fold as an anaesthetic. Before introducing routine local anaesthetics, the analgetic effect of laughing gas was in the foreground. Today, its sedative anxiolytic (anxiety reducing) characteristic makes it an excellent tool for treating anxious patients. In the US and many other countries (England, Australia, Scandinavia), over 50% of all dentists regularly use laughing gas.
How does conscious sedation with nitrous oxide work?
Completely relaxed thanks to laughing gas -
Dr. Schulte treating a dental phobia patient
A small nasal mask releases a mix of oxygen and laughing gas. The effect begins after just a few breaths: From a feeling of lightness and relaxation, the patient drifts into a comfortable, trance-like state. Constantly addressable and in charge of the senses, the patient feels a desire to close the eyes. Anxiety and tension make way to a relaxed feeling of security. The custom-made headphones dampen the sound of the surgery. Suggestive, relaxing music supports and intensifies the hypnotic effect of the laughing gas. The patient is able to let go and follow pleasant thoughts. Time flies by.
At the same time, sensitivity to pain ebbs away, as does anxiety. Injecting anaesthetic in the mouth, for many patients otherwise a nightmare, is hardly felt any more. The typical feeling of nausea (gag reflex) experienced by many anxious patients (for example during impression taking) and the strong reflex to swallow, which often make treatment more difficult, are forgotten under sedation with nitrous oxide.
The dentist can vary the depth of sedation, adjusting to suit each patient individually. After treatment, the patient breathes pure oxygen for around 5 minutes. The effect of laughing gas is reversed and the patient leaves the dental office alone with a clear head. This ideal controllability gives laughing gas a decisive advantage over other sedation methods (oral or intravenous).
Also ideal for treating children
Parents and dentist alike are faced consistently with the problem of children reluctant to have dental treatment. Many adults, even if they should know better, avoid essential dental appointments because of dental phobia; so how can appealing to a child's reason be successful?
Small patients - large anxiety
Laughing gas makes things better
Laughing gas is an ideal tool in treating anxious children. However, the child must consciously be able to breathe through the nose (upward of six-seven years) and the nasal passage must be free. Furthermore, children treated with nitrous oxide should be reasonable enough to understand the necessity of their dental treatment. Thanks to the strong relaxing and anxiety-reducing effect of nitrous oxide, around 80% of children who would otherwise refuse normal dental treatment, can now be treated. Reducing gag reflex, nausea and the reflex to swallow while keeping complete receptiveness means treatment (for example fillings) can be carried out thoroughly. This is not always possible, especially with non-cooperative children (defensive reactions, persistently closing the mouth.). Often, the reliable laughing gas method can prevent the need for treatment under general anaesthesia.
Risks and side effects
Laughing gas analgesia is an extremely safe method: With millions of recorded applications in the US, where around fifty-percent of all dentists use laughing gas, not one single serious incident has been reported. This method is not recommended, however, for patients with impeded nasal respiration, children under the age of three years or mentally handicapped people who cannot consciously breathe through the nose. In some rare cases, nausea or vomiting may occur as a side effect. Laughing gas is administered in our dental office under pulse oxymetric measuring. With this method, a finger sensor constantly measures the patients pulse and arterial oxygen saturation, as an extra safety precaution.
There are many orally administered medications (tablets, drops) or intravenous injections, which have a strong calming (sedative) effect. The main agent used today belongs to the Benzodiazepine family (for example Valium®, Dormicum®).
With these drugs, depending on the dose, a sedation can be achieved ranging from mild relaxation to a deep twilight sleep. A welcome side effect is that normally patients have little memory of the procedure after it is over.
Controlling the dosage of these sedatives requires special experience as the individual dosage can vary tremendously. The dosage needed to put some patients into a relaxed state can be enough to anaesthetize others. Unlike the conscious sedation with nitrous oxide, the sedative effect usually lasts longer than the treatment itself. The patient is not able to leave the dental office alone, and always needs the help of a companion.
The use of sedative medication in our dental office is restricted to surgical interventions as well as anxious patients for whom laughing gas is not effective enough.
The methods against dental phobia described in this section are proven succesfull. Nevertheless, there are patients that want to have no conscious knowledge of their treatment: Information on treatment under general anaesthesia.