Managing the fearful dental patient

Fear is something we are faced with every day. In fact I would wager that the majority of patient harbour some fear of the dentist. In some cases this fear is overcome by logic and reason and these patients present with the desire to avoid future problems. However in the sadder cases fear leads to avoidance of treatment and dental neglect and they often present for emergency treatments only. Obviously when they are in pain the appointment becomes a lot more difficult and this perpetuates the idea that all dental visits are painful and reinforces avoidance behaviour. Far down the line, after much pain and suffering, the patient is rendered edentulous with reduced function, self esteem and capacity for healthy lifestyle. Much of this reaction lies in the patient's childhood experiences which also determines their personality and how they cope with adversity. When attempting to manage these patients we must take special care. In clinical practice, depending on how we react to the challenge, they can be our greatest triumph or our saddest failures. We must consider what they are afraid of, address their fear and expectations and implement strategies to manage these fears. We can very rarely eliminate their fear but we may be able to modulate it to a stage where the patient is comfortable to receive the treatment that they require on an ongoing basis.

What are patients afraid of? Despite what they may think, most dental phobic patients are afraid of procedures, not operators. The classic line of "I hate the dentist" is somewhat misdirected as what they hate is what the dentists are doing not the dentists themselves. However for most purposes this proxy is accurate enough to reflect what the patient feels. Patients can have fear of pain both during and after the procedure, unpleasant sensations, fear due to past traumatic experiences, fear of costs and fear of the unknown.

Pain is something we are intimately aware of. From the moment we are thrust into this world we are bombarded with sights, smells and other stimuli each of which are the most overwhelming thing we have ever encountered. We are expected to emerge from this fragile state to make sense of this chaos and learn to deal with it. The way we respond to this stimuli is mostly learned and neuroplasticity plays the defining role in the behaviours we express in response to stimuli. This plasticity continues into adulthood which implies that such behaviours and cognitive associations can be changed albeit not without difficulty. An important distinction in pain psychology is the difference between nociception and pain. Nociception refers to the nerve impulses that convey the detection of noxious stimulus to the brain. The way that this is processed in the brain and the resulting experience is known as pain. The behaviours that are associated with this experience e.g physical withdrawal, foetal position, verbal responses are known as pain behaviours.

If it is accepted that pain is not the transmission of "pain signals" but the experience resulting from the processing of noniceptive signals then it stands to reason that pain is hugely subjective as every individual will process identical stimuli differently. This assumption is generally true as the same stimulus e.g an icecube held in the hand could be perceived differently in any population e.g some may find it a mild discomfort or some as intense pain. There is huge variation in the display of pain behaviours from the same stimulus. Similarly in dentistry, identical local anaesthetic protocols will produce a range of reactions from surprise that they have been given anaesthetic to feelings of pressure only to expressions of intense emotional pain.

Much of the neuroplastic changes that lead to learned behavioural responses to pain are rooted in childhood. As we are growing, we are constantly learning and much of our behaviours are mimicked from our parents. For example, we are not intrinsically afraid of spiders. If a mother sees a spider and reacts alarmedly, a child will see this and associate the visual stimulus of a spider to fear and danger. Similarly, if a parent is anxious with their child in the dentist's chair because of their own deep seated fears the child will tend to mirror this, become closed off and protective and associate the dentist office with danger. They may look to their parent for support and exhibit pain behaviours e.g crying a reaching for their mother. More blatantly, if a parent tells their children stories of the dental visits to scare them into submission the imagination of a child will amplify this trusted account and fear can emerge before exposure to the actual stimulus. Painful dental appointments are perhaps the most powerful negative learning behaviour as there is direct nociception. Late attendance to first dental visits after the child has experienced significant dental disease can cause life long psychological damage if treatment is performed without some form of sedation. At the best of times with adults, the sensation involved in dental treatment is uncomfortable. In the immature mind of a child, the discomfort of injection, numb feeling and forces involved in restorative work or exodontia is generally intolerable. Bad experiences as a child are amplified over time and can manifest as irrational fears in adulthood. Everything is bigger and scarier as a child and memory recall serves to exacerbate bad memories and leads to dental avoidance down the line. To avoid this we must educate parents to not scare their child by providing too much information before a dental visit. To bring their child in for timely checkups and council them on ideal hygiene and dietary advice to minimise the risk of dental disease in their child. they must know that their behaviour reflects in the learning of their child. As dentists we have a responsibility to make their first visits as fun and positive as possible but it is the parent's responsibility to ensure their child has positive habits and diet to avoid the need for dental intervention. In the end, the best treatment is no treatment at all.

Traumatic experiences in adulthood also cause similar neuroplastic changes however the effect tends to be less severe. Traumatic extractions or inadequate anaesthesia in the past will inevitably breed fear of recurrence. History of dominant, or abusive sexual relationships has been demonstrated to cause oral avoidance stemming from either the actual act of oral abuse, memories of trauma in the supine position or the power imbalance reflected in dentist-patient interactions. Reaction to adulthood trauma will either result in strict adherence to oral hygiene practices and dental appointments to avoid future dental disease or more severely will cause oral avoidance similar to childhood traumas.

Pain experiences in these populations are altered. Patients who expect pain will exhibit behaviours such as muscle tensing and guarding.  They tend to be highly strung, stressed individuals and may exhibit more severe parafunction that can ironically exacerbate dental pain. Patients who tend to catastrophise and have depressive tendancies will react more strongly to noxious stimulus and are at higher risk of developing chronic pain. Muscle tensing during local anaesthetic will reduce the loose tissue spaces for anaesthetic and may result in more pain during local anaesthetic administration. As their learned experiences are indicating they should feel pain they are more likely to report pain during procedures. They will have more difficulty distinguishing between somatic sensations such as pressure and pain. As a result, as these individuals are more fearful, they are more likely to have fear inducing experiences. These patients deserve our utmost attention and compassion during their care. Their behaviour should not be considered an irrational reaction to an innocuous stimulus but an irrational reaction to a noxious stimulus. We do have to remember as dental professionals we put patients through painful and uncomfortable procedures in a very intimate and guarded part of their body. We should not aim to remove pain entirely but to reduce the discomfort of the procedure and modulate their fear and expectation to a level that is tolerable for them.

Fear of the unknown can be found in patients who tend to be meticulous and controlling. they may want to know all facets of treatment before agreeing to a treatment plan. During treatment they may be apprehensive because things are going on that that are unaware of. Their imagination may start to take over and they may fear the worst. Fear of the unknown can overlap with fear of pain from childhood or adult experiences but along with management of those fears, these patients may require a running commentary of what you are doing so there aren't any surprises.

Costs are a big motivating factor for some patients to avoid or defer dental treatment. Often they will avoid a routine examination because they know it will expose the need for a large treatment plan. Unfortunately in private dental practice in a capitalist society not much can be done to address the root of their fears. Instead it is up to the operator if they feel kind enough to discount fees etc. Be sure to be upfront and honest about your fees before treatment. If patients are motivated enough to improve their dental health for whatever reason (avoid pain, improve function) and they can afford treatment then they will pay for it. Have confidence in your skills and treatment planning and give them multiple tiers of options that can be more affordable and provide a satisfactory result. Proper financial consent is absolutely important in these patients. If they aren't suitable for treatment you want to know beforehand rather than after starting. Be upfront with them; it is not insulting to ask what their budget is. If you project honesty and ethics then they will reflect that. If they give you an idea of their budget you can work your treatment plan to fit their situation. Many patients who say they can't afford a particular treatment have the money but not the will to spend it as they may not value the outcome. If you approach it from the right angle, you may be able to make them see the benefit of intervention be it improved aesthetics, function, prevention of pain or preservation of the dentition for the remainder of their life.

The management of anxious patients is difficult but not impossible. In some patients, their fear is so deep seated that treatment with a psychologist or psychiatrist is warranted. Some patients may require urgent intervention and there may not be the time to prepare them for procedures under local anaesthetic. Additionally, some patients may be refractory to therapy and would benefit from IV sedation or general anaesthetic for their dental work. Adjuncts such as nitrous oxide or oral sedation can be relax those who force themselves to tolerate conscious dental procedures but are not anxious enough to consider deeper sedation.

As dental professionals we can employ aspects of psychology to manage these patients in our day to day practice:

• Identify their fear: Most patients will tell us outright if they are anxious. We know the dialogue. Some will not however and it is up to us to recognise the non verbal cues. Avoidance of eye contact, hunched shoulders, closed posture, muscle guarding and withdrawal are some good examples. Some more frank signs are shivering, crying, reflex jerks of the head when you work and refusal to open their mouth for examination. If you are unsure then ask. Say something like "I'm unsure but I'm getting the feeling that you are anxious or afraid." If they are then they may admit to it but sometimes we may be confusing their non verbal cues for other emotions such as distraction or worrying about costs. If this is the case then they will correct us. People love to correct other people and it is a good way to force them to open up about their feelings.
• Acknowledge their fear: One possible outcome of addressing that their fear is that they may become embarrassed and more withdrawn. If their pain outweighs their fear, you may be able to get through the appointment and achieve whatever task is required. However by not addressing the fear you aren't allowing them to heal and you are unlikely to increase the chance that that they return for follow up visits. You aren't given the chance to address and modulate their fears and therefore your job during the appointment is made more difficult. Starting the conversation means starting the process of alleviating their concerns.
• Avoid treatment at the first visit: It is very difficult to manage patient's fears in the short appointments we generally have. Even if you start the process of changing their mind about you, immediately starting invasive procedures is a good way to change their mind and perpetuate their fear.
• Be non confrontational: Noxious stimulus in dentistry is physical. Patient's fear level will rise the closer we are to them. Keep a distance farther than the socially acceptable point. You may even want to meet the patient in a consultation room separate from the surgery room to remove all associations of dentistry. Having a conversation isn't scary to most people and it can often allow them to release much of the built up anxiety that they have worked up before the appointment. You want them to leave the first encounter hopeful that you are different to the dentists in the past. You may not be superior in skill but you must approach their case with superior tactics. Be kind, be empathetic and be understanding.
• Discuss their fear: Get to the root of their fear and attempt to rationalise it. If they can confront their fear then they can begin to reduce it. Ask them if they have had a bad experience in the past. They may give you a history of a bad extraction or painful procedure. They will give you valuable information about what strategy you need to employ during your treatment such as painless injection, ensuring effective local anaesthetic or the need for sedation during extractions. Some patients will be apologetic and embarassed about their fear. They will feel as though it is a barrier to their health and is making your life difficult. It is paramount that you dismiss this and reinforce that their fear is understandable and not at all irrational. You must tell them that the procedures done in dentistry are very unnatural and done in a very intimate zone. They must know that they are not alone in their fear but most fearful people can overcome fear and tolerate dentistry. You must ensure they know that you will work with them to get through this as well as you can. At this point, the majority of patients relax and will open up. They may say that not many dental professionals are willing to address fear and spend the extra time with them to work through fear and they appreciate this. The patients refractory to this reasoning are generally on the severe end of phobia, of paranoid or distrustful persona or have heard someone else say the same thing but hurt them anyway. When you are allowing patients to explore their fear: Be quiet. Let them talk and express themselves. Often the best communicators are the ones that let the other person talk. As health professionals we are trained to hone in on the fine details and in this quest for knowledge we often cut the patient off with short, close ended questions. If you keep silent for long enough, most people will keep talking. Make a game out of it and see how long you can be quiet after asking a question. When they finish their story, reflect a summary back to them. Patient will usually feel as though you truly understand them when really you are just repeating what they just said.
• Admit that you can't cure their fear: We can't cure fear. We are only dentists in the end. Patients may appreciate this humility. That isn't our job after all. Despite this truism, patient fear is a barrier to best practice. We can't provide the highest quality dentistry if we are afraid the patient will get up and run away midway though the appointment. It is in our scope to provide the right referrals or the right conditions for them to tolerate our work and this is often the best that we can do.
• Desensitise them to stimulus: In psychology, an effective method to manage fear is desensitisation. Exposing the patient to stimulus of increasing intensity works to build their confidence. Think of it as walking up a flight of stairs, you can't jump from the first story to the second but you can take small steps at a time. The key to desensitisation is to make sure they are comfortable when they take the next step. For example, fear of spiders can be overcome by showing the patient a photograph of a spider from across the room. The patient may initially be afraid but when given enough time they will realise they are not in danger. This can take a few minutes to multiple sessions. The variability is massive. Moving closer and closer to the photograph will build up their confidence but they must be comfortable before they shift positions. Switching then to a real spider in a cage from across the room and when they are ready, physical contact with the spider. This ability of neuroplasticity allowing retraining of behaviours is amazing in itself but unlearning a behaviour proves to be much more difficult than learning one so patience is necessary. Remember, these patients need more help than most and you have the opportunity to make an actual difference in their lives. In a dental setting, seeing them in a consultation room and avoiding treatment on the first visit is the first step in desensitisation. Building up their confidence with dialogue to the point where they can tolerate an examination is the next step. Clinical photographs and OPG can be useful to shorten your exam time in a non invasive way. Most patients will tolerate photographs better than a "metal hook" scraping around their teeth. These records can also come in handy with the patients who require in depth explanations before any treatment is done. Don't be afraid of showing them the condition of their teeth. They already know how bad things are. They must understand what you are trying to do for proper informed consent. You do have to be careful in how you manage their reaction however. You have to assure them that all their problems are lingering from their past habits and you will work with them to take steps forward and get them back on track.
• Take your time: These patients need longer appointments than most. This is mostly due to their unpredictable nature. They may have good days where you get through the work quickly but it just as easily may take much longer. It is imperative that you have the time scheduled to account for this. If you are stressed because the waiting room is filling up you will be more likely to cut them off in conversation, rush procedures, be rough and work with inadequate anaesthesia. Every facet of our work suffers when we are rushed.
• Allow them time to think and reflect: Just like we aim to have an atraumatic first dental visit for children, we have hopefully achieved this with our anxious adult patient. If they are given time to reflect on the appointment they will hopefully note that it was not in line with the experiences they have had in the past. They will be unlikely to be ready for treatment at that point but it is the first step towards accepting dentistry. Make yourself available to discuss treatment with them further and tell them to write down any questions or concerns they have. Make an appointment to talk further if they do not feel as though they are ready for treatment. Those who are ready for treatment can proceed. Those who are unsure can be offered oral sedation or relative analgesia to attempt a simple procedure to desensitise them further.
• Start simple: Find the simplest procedure you can do and start with that. If they need a prophy, give them a prophy, if they need a simple filling, start there. Sometimes there are only difficult things to do and we are afraid that we might lose the patient's compliance if we don't address their concerns. In this case consider stabilising them under IV sedation or GA to and bring them back for proper desensitisation
• Debrief at the end of the appointment: It is important for the patient to realise they are making progress or they will lose motivation. Praise them when appropriate and summarise the treatment you have completed. Contradict their previous expectations with "You didn't think you could do that did you?" or "well i'm glad we're improving". Learning is a continual process and if you allow them to form their own conclusions they may end up feeling they did not perform as required. It is your responsibility to convince them they are improving.
• Manage post operative pain: Those patients who are afraid of post operative pain may be discouraged from accepting treatment plans or returning for further treatment. For elective dentistry this is acceptable but dentistry to stabilise a neglected mouth is not elective and post operative discomfort is an inevitable consequence that must be accepted in the name of progress. It is important that you are honest with these patients when post operative pain is expected. Dishonesty in the name of getting treatment acceptance will breed distrust. If the procedure is necessary and post operative pain will occur then tell them. There are no ifs and buts. In the grand scale of things, the majority of surgical procedures we perform are relatively minor. Even difficult surgical extractions are nothing compared to a knee replacement for example. What is significant is the innervation of the oral cavity and importance of the mouth in day to day function. Oral post operative pain can have a significant short term impact on their lives but they must understand that their body will heal and they will recover. It is usually unfeasible in our pain control regiment to aim for zero pain. Remember that pain is an experience. We should manage patient's expectations to a stage where they understand that discomfort will be present and pain relief is there to reduce it to tolerable levels. 

The management of the fearful patient is a massive topic and highly subjective. Every practitioner will have their own strategies many of which may be very effective. What is necessary is a targeted approach to each individual patient. We must attempt to understand the depth of their pain and suffering and target our approach to their needs. At all costs we must avoid belittling or ignoring their concerns. Dismissing these patients makes sense form a purely business point of view but turning their situation around can have countless rewards both for personal satisfaction and business reputation. In our daily practice we have the opportunity to make a true difference to these people and we should relish the opportunity to do so.