Management of the anxious patients

Assist.Prof.Dr.Alper KAYARAK College of Dental SciencesRAK Medical & Health Sciences University

Stress A physical, chemical or emotional factor that

causes bodily or mental tension and may be a factor in disease causation

Factors that tend to alter an existent equilibrium

Cause of ¾ Medical Emergencies in Dentistry

Stages of StressResponse

Stage 1: One of the 5 senses sends stimuli to the brain

.

Stages of StressResponse

Stage 2: Brain analyzes it as a ‘Threat’ or ‘No Threat’

Stages of StressResponse

Stage3: Bodyaroused until threat is over

.

Stages of StressResponse

Stage 4 : Body returns to homeostasis (calm) once threat is gone.

Scope of the Problem

• Dental Fear

• Dental Anxiety

• Dental Phobia

Scope of the Problem

Dental Fear

• Fear is a natural, adaptive reaction and is supposed to

protect us against danger.

• Our response to the feeling of fear consist of three

parts; a physiologic, a cognitive and a behavioral

component.

Scope of the Problem

Dental Fear

• The physiologic component consists of an activation of

the sympathetic nerve system with an increased

adrenalin-level, which can lead to sweating, increased

heart beating and stomach problems.

• The cognitive component involves negative thinking, like

“this is dangerous – I might die – I need to get away”,

Scope of the Problem

Dental Fear

• The behavioral part of the response will involve

trying to fight the situation or getting away from it.

• The fear is nevertheless controllable and the

person is capable of coping and thinking rationally.

Scope of the ProblemDental Anxiety

• The anxiety response is almost identical to the fear

response, both having a physiologic, a cognitive and a

behavioral component.

• The main difference is the nature of the stimulus which will

trigger the reaction, and how powerful the reaction is to the

given threat.

Scope of the Problem

Dental Anxiety

• The anxious patient will still know that the

anxiety is an irrational and greatly exaggerated

reaction, and will often, despite of the anxiety,

actually come to the dental clinic

Scope of the Problem

Dental Phobia

• Phobia is a well-defined illness, and there are

very specific criteria of what is defined as

odontophobia

Scope of the ProblemDental Phobia

• Odontophobic persons will usually not go to a dental clinic at

all, or at the most only when they have an unbearable tooth

ache.

• Often they cease brushing their teeth, because looking at

the teeth is a constant reminder of not going to the dentist –

a feeling which gives them great discomfort.

Scope of the ProblemDental Phobia

• Not going to the dentist often gives an increased treatment

need, and hence their anxiety and shame increase even

more.

• Often they evolve a social phobia as well, because of their

bad tooth condition or –function, and their phobia affects

their everyday life to a great degree.

Anxiety Release of epinephrine, nor-epinephrine

⇧ Heart Rate

⇧ Blood Flow

⇧ Respiration

Vasodilatation in the periphery (arms and legs)

⇧ Serum Glucose Level

SignsofAcute Anxiety Cold, sweaty palms or forehead

Flushing of face

Altered facial expression such as bulging eyebrows

Dry mouthor increase in salivation

Bruxism or clenching of teeth

Increased need to urinate

Unnaturally stiff posture

Signs of Acute Anxiety

Inability to sit still

Trembling or tremors

Fiddling with items in his/her hands

White-knuckle syndrome

Tapping feet or fingers

Crying out or moaning

Hyperventilation, syncope, nausea or vomiting

Increased respiration, blood pressure, and heart rate

First Consultation Get to know the patient

Try to be friend him/her

Medical History

Discuss likes and dislikes, acknowledge feelings

Empathy

Understand him/her well-it’s a long term affair...

Medical History

Written, signed and verbal

Categorization as per ASA PS Score

Check vitals

Communication Let them talk

Be a good listener

Show interest in their conversation

At an eye level

Away from the equipment

Iatrosedative Technique

“Making the patient calm by the dentist’s behavior,

attitude, and communicative stance “

A dentist can use to achieve this include making efforts to

avoid pain, giving the patient control and keeping the

patient informed of what the dentist is planning to do, and

what sensations the patient may experience

Iatrosedative Technique

The dentist should have some flexibility in the choice of

language, speed and attitude in order to adapt the

communication to the individual patient.

Full clarity about the expectations and demands placed

on the patient at any time, is also necessary and helpful

for the patient

Anxious Patient Short morning appointment followed by a good morning

breakfast

Pre-medication with Lorazepam 1mg (check interaction with other drugs) night before sleep followed by 90 minutes prior to procedure

• No driving

• Need to be accompanied by friend/relative etc.

Extremely short or no waiting time in the waiting area

Diagnosis andTreatment Plan

Try to find the cause of the problem and discuss with patient rather than just trying to pick up that handpiece

Make a preventive programme for the patient

Make a comprehensive treatment plan in

phases

Emergency

Stabilization

Maintenance

Definitive

During the treatment

Duration, only as much as patient can tolerate

Making sure patient feels he/she is in command

Better to have a short and simple procedure first to gain patient’s confidence

Pain free

Topical gel

Local anesthesia; Buffered, warm, slow, 30G needle

VocalSedation“I will be careful.”

“You may feel a slight sting.”

“I will make the area numb so that it is comfortable forboth, you and me.”

“I will apply this strawberry surface anesthetic first andyouwill hardly feel anything.”

“I am slowly putting some solution inside so that youwill not feel a thing.”

VocalSedation• Avoid “needle”, “hurt”, “sharp”• Talk to themas you go through the

procedure.• It will make them feel more relaxed and

compliant.• Don’t forget smiling

Post Treatment Clear verbal and written instructions

Pain control medications

Phone number of the treating doctor (to call in caseof emergency)

Protocol for referral if needed