Tim Newton was a speaker at the 2012 YDC conference.
The Adult Dental Health Survey provides information on the common reasons for members of the public avoiding dental treatment...
...and qualitative research such as that conducted by Helen Finch (1980) has identified commonly-perceived problems with dental treatment among members of the general public. The following themes consistently emerge:
fear of dental treatment
fear of pain
negative images of dentistry and the dental team
concern about costs.
Let us explore these elements in more detail.
Fear of dental treatment and fear of pain
Fear of dental treatment itself is often, but not always, associated with a fear of pain. Patients may become anxious that the state of their mouth will be viewed judgementally by the dentist, or fear that they will not be able to cope and behave in an embarrassing way. Furthermore, as an individual becomes more and more anxious, they are increasingly sensitised to the experience of pain. Anxiety therefore increases pain experience, while interventions aimed at decreasing anxiety will also generally tend to decrease pain.
A fear of dentistry in children may be related to a negative experience in the dental setting, so primary prevention would seek to ensure that children enjoy positive experiences. By ensuring that children have exposure to fluoride and advice is given to parents on how to maintain healthy teeth, a child's first visits are less likely to be invasive. Dentists should also consider offering acclimatisation visits where children can attend and spend time in the surgery becoming accustomed to the setting. As far as possible the environment of the surgery should be inviting and friendly.
Where anxiety is established the level of intervention should be tailored to the degree of anxiety (see Table 1).
Table 1: Interventions for fear of dental treatment, according to level of fear
| Low level interventions |
- Voice control
- Distraction
- Positive reinforcement
- Tell-Show-Do
- Enhancing sense of control
- Stop signal
- Allowing choices
- Memory reconstruction
- Environment change
|
| Medium level interventions |
As above, plus:
- Preparatory information
- Modelling
|
High level interventions
(May require specialist referral) |
As above, plus:
- Sedation
- General anaesthetic
- Systematic desensitization
|
Low level interventions
Voice control
The use of a loud voice and deeper pitch has been found to decrease disruptive behaviour in children. Interestingly those children who receive loud commands report more pleasure in the interaction than the control group.
Distraction
Shifting the attention of the anxious patient away from the anxiety provoking stimulus is a technique which many patients report using spontaneously. Several types of distraction have been reported in the literature, including the use of cartoon films, audio-taped stories and video games.
Cognitive distraction
In which the patient is encouraged to think about something other than the dental situation, has been shown to be effective in adults. Evidence suggests that the technique is only useful if the patient is informed that it is likely to reduce anxiety.
Positive Reinforcement
Based upon psychological theories of learning, positive reinforcement refers to the use of rewards to increase compliant behaviour. Positive reinforcement as a management strategy is commonly used. It is intuitively simple and familiar from everyday life. Where the technique appears to be ineffective, this may be related to the common problems outlined below:
Identification of reinforcers. There are few things which are inherently rewarding. The choice of reward should be based on the individual child. Parents are a good source of information about what children like, and what can be used to reward the child.
Reward saliency. A child may find something (for example stickers) rewarding in some contexts but not others. The severity of the child's fear may block the effectiveness of a weak reinforcer. For example a child may not be prepared to risk dental treatment 'just' for a sticker.
Reward fade. If a child receives the same reward too often then the power of that reinforcer will fade, for example a child can only eat so many sweets, and after a while stickers will start to lose their attraction. Using praise and attention as rewards will generally insure against reward fade.
Contingency management. In order to be most effective, rewards should be closely associated with the behaviour which they are trying to change. The association of reward and behaviour should be readily apparent. Rewards which are far removed from the behaviour are generally more difficult for younger children to understand.
Tell-show-do
A commonly used and popular method, 'tell-show-do' is recommended as a technique for introducing children to dental equipment and procedures. The procedure takes place in three phases: the 'tell' phase involves an age-appropriate explanation of the equipment and/or procedures; the 'show' phase is used to demonstrate the procedure up to the point where the instrument is actually used (this may involve using an inanimate object to substitute for the child or a part of the child for example 'polishing' a model tooth); the 'do' phase follows. It has been suggested that for maximum anxiety reduction the time lapse between 'show' and 'do' should be brief.
Enhancing the patient's sense of control
Stop signals, which are commonly used by general practitioners, refer to the use of some agreed signal (usually raising the hand) to indicate that the patient would like the dentist to take a break from treatment. The technique has been shown to be effective in reducing patients' experience of anxiety even where patients do not actually use the signal.
Similarly a patient's sense of control over the situation may be enhanced by involving them in simple decisions (for example whether to take upper or lower impressions first).
Memory reconstruction
A study by Pickrell et al investigated the effect of the use of a memory reconstruction technique for anxious children. Children attending the dentist had a photograph of themselves taken at the appointment. They were encouraged to smile for the photograph. Prior to their next appointment the children were sent a note together with the picture to remind them of their previous visit. By showing them a positive image of themselves in the surgery, children were found to be subsequently less anxious at the second appointment.
Environment change
A small number of studies have explored the effect of providing a more positive dental environment on anxiety levels in children. Generally changes suggested include: using warm colours, replacing fluorescent tube lighting with bulbs and playing music. Fox & Newton (2002) found a beneficial effect of showing children positive images of the dentist prior to their appointment.
Modelling
The technique of modelling assumes that individuals learn about their environment through observation, in particular that learning can occur through observing the behaviour of others and the consequences of their behaviour. This approach is used to reduce disruptive or anxious behaviour through encouraging the child to learn the appropriate response to the dental situation by observing another person undergoing treatment. Modelling is most effective if:
the observed model shares important characteristics with the target child (for example The model should be the same gender and a similar age)
The model is observed to enter, complete and exit treatment without adverse consequence
The model is rewarded for their behaviour (material rewards such as stickers or toys, or by praise from the dentist)
The model appears to be mildly anxious but who 'copes' rather than being completely unafraid.
Modelling may take many forms. The model may be real, that is actually in the surgery with the anxious child or virtual, for example observed on film or videotape. Virtual models are generally less effective than real models.
Systematic desensitisation
For the patient with severe dental anxiety, associated with avoidance and extreme distress, psychological approaches based on the systematic introduction of the feared stimulus may be appropriate. Systematic desensitisation is a proven approach to phobic anxiety which has been adapted to a great many fears and phobias, and for both children and adults. The method works on the principle of graded exposure to the feared stimulus, together with training in relaxation.
Negative images of dentistry and the dental team
Qualitative research conducted by Helen Finch and her colleagues suggests that the dental surgery is often associated with pain and is perceived as impersonal. Dentists and the dental team are sometimes viewed as treating the patient as 'a mouth', and only interested in money. While dentists and other members of the dental team often feel that they are trapped on a conveyor belt of treatment, patients often share that feeling as many report that they had felt that they had been "rushed through". Research on the communication processes that take place in dental consultations by Wanless & Holloway (1994) supports these perceptions – only 56% of dentists gave a verbal greeting to their patient, and 70% failed to say 'goodbye' to their patient.
In order to tackle this the dental team and the dentist leading the team, should take the time to discuss how they wish the team to work, and their core values, then work as a team towards these values. The values of the practice and the team should be communicated to patients and the public through written information and supported by the behaviour of the entire team.
Concern about costs
While it is often difficult to be exact about treatment costs, it is perhaps easier to give clarity about the basis of charging, and to provide estimated costs in writing for patients to consider. Flexible payment schemes may be attractive to patients undertaking extensive restorative work.
Further reading
Finch H, Keegar J, Ward K, Sanyal Sen B. Barriers to the receipt of dental care. British Dental Association. London. 1988
Newton T (2003) 'Patient motivation and communication'. In A clinical guide to periodontology RM Palmer and PD Floyd London, BDJ Books pp 21-25.
Wanless MB, Holloway PJ. An analysis of audio-recordings of general dental practitioners' consultations with adolescent patients. British Dental Journal 1994 177: 94-98.