- compassionate and truly empathetic approach, understanding of patients expectations
- acclimatization and ‘non-clinical initial appointment can help a lot in non-urgent cases.
- detailed discussion of available options, explanations re: DGA should be as a last resort option
- MDAS scale to assess level of anxiety – no ideal as does not contain the question about dental extractions and other surgical procedures ! If > 16 score – indications for sedation/DGA
- women twice anxious than men
- gradual confidence build up, gradual acclimatization
- multiple appointments, regular familiarization
- Do not be so serious! good sens of humor helps!
- BM and CBT works well for carefully selected patients
- non-pharmacological iatrosedation does work !
- Tell-Show-Do approach for small children and phobic adults
- the use of ‘non-suggesting’ expressions: ‘water pistol’, ‘a bit scratchy’, ‘a bit pinchy’ etc., avoid words like ‘needle’, ‘injection’, etc.
- high anxiety can be reflected also by history of substance misue (alcohol, drugs) and these patient can be really phobic
- if eg. extraction of deeply buried roots necessary – do not force patient to go ahead with this, sometimes better to postopne and mintor till patient decides on his/her own and make trully independent decision.
- caution before any invasive procedure as increased risk of prolonged bleeding due to eg. liver malfunction
- some unmanageable without sedation
- long discussion to acclimatize the patient
- acclimatization, CBT and desensitization if possible
- to start from simple, achievable and non-invasive procedures first to make the treatment tolerable
- to avoid expressions like: ‘needle’, always can be replaced with another
- engage with the phobic patients: look in the eye not teeth, say simple Hello, listen to them, write down and use in future some things about the patient – favourate things, holidays, etc., voice control, positive images, modeling, utilising plastic memory
- distraction techniques very useful! eg. slow and deep breathing, ask to concentrate on chest/belly movements, ask to wiggle fingers and toes the same time, ideally the opposite sites, ask to clench hands, feet, etc.
- verbal relaxation: “your shoulders sinking into dental chair”, “you are getting light now”, “your muscles getting relaxed and calm”, etc.
- lots of reassurance, ‘gentle’ approach, CBT and acclimatization- anxious patient needs to trust you
- topical anaesthetic very helpful
- a finger pressure within the injected areas, eg. palatally
- avoid palatal infiltration if not necessary
- warm up anaesthetic solution before administration – ideally: specifically designed electric heaters for cartridges
- The Wand for children
- oral pre-medication with midazolam/temazepam of justified
- transmucosal sedation with bolus of midazolam
- RA for young patients and adults with mild and moderate phobia
- IV sedation for patients above 12 years old with severe phobia
- GA as a last resort
Case:
Female patient, entering surgery shaking and saying: ” I am terrified”. Offered to sit in normal chair, a slight break without any conversation to allow patient’s get some rest , patient is breathing rapidly. Start off with easy questions about non-dental aspects, eg. how pt managed to get to dentist, by car or public transport, how long did it take?, etc., keep smiling Then, to figure out why pt is so anxious, any bad experience from the past? without any personal judgment. Basic and general questions about dental problems, what is pt’s main concern, what we can do for pt re: long term tx plan, eg. dentures?. If pt has a severe phobia with physiological symptoms (being sweaty, shaky etc) – to postpone even dental check up and arrange new one, the most convenient for the patient time and day.