Advice for Anxious Patients

Feeling anxious about going to the dentist is normal!!

This seems a funny statement to make on a page trying and reduce anxiety. But it is true, and a truth that most extremely anxious patients may find incomprehensible. In reality almost every patient we see is anxious to a degree, but this can vary from slight feelings of discomfort to panic attacks. There are two important differences between the patients that we see every day and treat successfully and the ones who feel too anxious to attend:

1. The level of anxiety felt by the patient – more info
2. (most importantly) The coping strategies employed by the patient – more info

That’s right! It is not that the patients we see are not anxious, it is just that they have found ways to deal with their anxiety. We will come back to the above points in detail below. Click on the links to jump ahead. First, however, we need to touch briefly on a separate entity that is often confused with anxiety:

Phobia

Phobias and anxiety are different. Anxiety is a feeling of nervousness. A tension that is in fact a normal body defence mechanism to a stressful situation. It is the preparation of the body for what is called the ‘fight or flight’ response, i.e. if the situation gets worse, you are ready to defend yourself or leg-it!

Phobias are an irrational fear, although they will be a cause of anxiety, it is theirrationality that sets it apart. It makes them difficult to justify, or sometimes even vocalise, and they are more difficult to cope with.

As an example, lots of people are afraid of flying, which is a phobia because it is irrational. There is no need to be scared of flying as it is much safer than most other forms of travel, but being scared of crashing… that is a rational fear!

Phobias can be considered like a short circuit in the brain. They are a connection between a stimulus, often harmless, like sitting in a plane, and a panic reaction. They self-feed and progress so that without any added negative input, each time the degree of panic will increase.

Phobias can be dealt with in different ways to over come the fear. The most common, and often the easiest way to try and do this is with hypnotherapy, although other techniques are used. Theresa Parnell, a qualified hypnotherapist, cognative behavioural therapist and thrive councillor, works from BPDS, please visit her site for more details of the treatments she offers

Degrees of anxiety

As stated above, nearly all patients are anxious when it comes to seeing the dentist. Even a person who says they do not mind will probably feel a small amount of anxiety when they actually walk in, but dismiss it out of hand.

In the middle ground we have patients who are quite put out by their visit, but they manage. They perhaps have a sleepless night, or skip lunch because they don’t feel hungry. However when the time comes, they get in the car, drive to the surgery, and they go through their appointment and are relieved when it is over. These are the patients who have coping strategies to deal with their visit, although they may not realise it. The very fact that they can come in is fantastic. There may be better ways for them to deal with their anxiety, but they are most of the way there already.

The final group of people are the ones who cannot face the dentist. Either they don’t book an appointment, in denial, or they book and then never make it into the surgery for one reason or another. Something can always crop up if needed. Surely all the people who are in this group know what I mean! These are the people who need to, AND CAN, develop coping strategies.

To add to the problems, most patients who have any significant degree of anxiety, are acutely embarrassed by this fact, confounded by the lack of rational explanation for their degree for anxiety. As already stated, the anxiety felt is normal, and dentist are used to dealing with it on a daily basis, and expect patients to be anxious and embarrassed. The realisation that these feelings are normal, and an understanding or how many thousands of people share these feelings, should help you to accept that being anxious is nothing to be embarrassed about!

There are three further points that you need to take away from this section:

1. This is not a fixed scale. There will be a full spectrum of individuals between the three groups mentioned.
2. Your level is not fixed. It is perfectly normal for your anxiety levels to fluctuate, depending on the treatment you are receiving, how tired you are, how your day has gone, or any number of other factors.
3. Most importantly. The difference between the people who attend, and the people that can’t is NOT the level of anxiety. There will be people who attend regularly who are more anxious then some who have never been. The difference is the coping strategies that are employed. We frequently see patients who we would assess as being exceedingly anxious, but between us and them, we cope.

Coping Strategies

There are countless different methods used to deal with the stress levels. Some better than others. But no two people are the same, so what works for one may be totally useless for another. Below are some of the common ones that we see. This is not an exhaustive list, just some known techniques.

Internal Techniques

The best methods are those that you, the individual, have control over.

• Self control – for many people it is as simple as mind over matter. For patients with low anxiety this is very easy to do. There are some patients with quite high levels of anxiety that mange this way, simply because they reach a stage where they decide their teeth need sorting out
• Co-dependence – Some people cannot manage on their own, however they manage with a second person. This can take the form of:
  • Moral support
  • A dominant companion to encourage
  • A distraction
  • A shared anxiety
• Rapport with the dentist – a good relationship with your dentist can be all it takes to help you through a course of treatment. This is a personal relationship that will always have to be lead by the patient, although they may not be aware that they are leading, as the dentist will normally try and take cues as to how the patient will react best without open discussion.Unfortunately there are two people in this relationship, and as well as needing the right patient, you also need the right dentist. This is not to say that there are good and bad dentists, just that people click differently and a dentist that one patient may love, may be hated by another. If you find your dentist a little difficult to get on with, it is perfectly acceptable to ask to swap dentist. This will not be seen as a slight, simply as a personal preference. When ever possible we will aim to accommodate a preference to see another dentist.It is worth noting at this stage, one of the key differences between private and NHS treatments is the time that can be allowed for an appointment. This extra time will make it easier to build up a good rapport and discuss your anxieties if needed. If you are particularly anxious it would be worth considering if you would benefit from that extra attention.
• Distraction and ‘Trance-like-state’ – these are both semi-hypnotic approaches (see below), which many people use automatically to different degrees. In simple terms these are ways of focusing your attention away from what is actually happening.

External techniques

These are techniques that can be used by a dentist or other professional to help an anxious patient accept treatment. Ideally it is best to find ways of helping a person cope with their anxieties and the ultimate goal of good treatment provided with sedation or hypnosis is to aid a person to accept routine treatment in the future.

• Hypnosis and relaxation – hypnotic relaxation and ‘trance-like-states’ are a good middle ground between internal techniques and truly external techniques. By going through some simple hypnotic relaxation exercises the degree of anxiety for treatment can be greatly reduced. This can be taken further to a trance-like state that can be maintained through treatment for a truly relaxed visit.The real benefit of the relaxation exercises is once you have been shown them, you can then use them to great effect on yourself with a little practice.In effect, this is a way of teaching a person to achieve the distraction and trance-like state that some anxious patients will use naturally.Theresa Parnell, working from BPDS, offers councelling, hypnosis and congnitive behavioural therapy covering all areas. Able to help control anxitety with dental treatment, details of treatments are availalbe through Theresa’s dedicated website tp-hypnotherapy.com

• Conscious Sedation – Sedation is administrated by a dentist with specialised experience in specific clinics. Our nearest clinic is in Abergavenny and we refer there for intravenous and inhalation sedation. In skilled hands sedation is extremely effective in dealing with anxieties and can be used to build a patient towards routine care.Inhalation sedation is the use of Nitrous oxide mixed with oxygen. These are the same gases used for mothers in labour. By using variable concentrations combined with other relaxation techniques a very profound level of sedation can be achieved. This technique is most often used on children but can be equally successful with adults.The biggest advantages of this technique are:
  • That the sedative has to be constantly inhaled to be active. It is cleared from the system in a few breaths so there is no special after care needed and a patient can immediately drive themselves home
  • There are no injections needed to achieve the sedation (although anaesthetic will normally be used once the patient is sedated)

  Intravenous sedation uses an injection, usually placed in the back of the hand, to administer a strong sedative that can leave a patient heavily sedated, lasting normally for about 45 minutes of treatment time. Although the sedation is very profound, and has some degree of amnesia (loss of memory) with it, the sedative remains in the system for 24hrs so a patient undergoing this technique will need to be cared for over that period and have a chaperone at home.

• General Anaesthetic – General anaesthesia is a technique which is used less and less in modern dentistry. Although it does allow treatment on patients that may not otherwise except treatment, the vast majority of patients can be dealt with using one or a few of the above techniques. The negative points of general anaesthesia are:
  • Although small and well managed, there is a risk each time a patient is given a general anaesthetic of complications
  • It is very costly to provide
  • It is very time consuming
  • Low volumes of patients can be treated
  • Waiting lists tend to be long
  • There is no progression towards routine treatment. Patients treated with general anaesthetic tend to always need a general anaesthetic

  In Monmouthshire we are unable to refer for a general anaesthetic without first trying conscious sedation on a patient.