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Mind Over Matter

 

Effective psychological pain and anxiety management techniques can help patients who are averse to needles and injections receive the dental treatment they need. By Arthur C. DiMarco, DMD; Kathy Bassett, RDH, MEd; and Jackie Foskett, RDH, BA, CH

 

It's difficult to imagine performing dental and dental hygiene therapies without local anesthesia. The local anesthetic injection that allows for comfortable treatment, however, is often what patients fear most. They may be afraid of the depth of injections or uneasy about giving up control. These perceptions and fears should not be ignored.1,2 For patients who refuse local anesthesia or its use is contraindicated, psychological strategies may be effective in pain prevention and management.

PREP

Implementing a positive communication strategy, such as prepare, rehearse, empower, and praise (PREP), can be a valuable tool for reducing patient anxiety. Designed to improve patients' coping skills and minimize their anxiety, PREP recommends a sequence of relaxation and distraction techniques (prepare) and allows patients to practice these techniques before being challenged (rehearse). Building coping skills allows patients to have significant control during appointments (empower). Finally, PREP applauds patients for coping with their dental anxieties and fears (praise). As patients realize they can exert at least some control over their situations, they are better able to relax and trust their clinicians.3 

Table 1. Tips for Positive Communication

After reading this course, the participant should be able to:

  • Display a warm and caring attitude 
  • Explain treatment plan for appointment (addresses fear of not knowing what to expect and loss of control)
  • Obtain patient's permission to begin (addresses fear of loss of control)
  • Communicate how the patient can participate (eg, raising hand to stop)
  • Choose words that direct the focus on positive outcomes ("This gel will get the area nice and numb first," "You may experience a bit of pressure")
  • Set positive expectations for future visits ("That went very well today, didn't it? Now you can expect the same or even better next time")
 

DEBRIEFING

Debriefing provides patients with an opportunity for a focused discussion at the end of an appointment, to report which aspects of treatment went well and which did not, and how to modify those aspects as needed. Patients feel empowered when they play an active role in determining future strategies.3 

Debriefing after appointments can be critically important for fearful patients because it helps them to develop trust in clinicians and it sets the stage for success during subsequent visits.

CARL

The Computer Assisted Relaxation Learning (CARL) program, developed at the University of Washington, is an in-office computerized exposure therapy designed to treat dental injection fear. CARL relies on systematic desensitization to help fearful dental patients tolerate different aspects of their appointments, including syringes and needles. CARL is especially well-suited for phobic dental patients.3–8 

Assessment tools such as the Corah Dental Anxiety Scale, Corah's Dental Anxiety Scale, Revised, Modified Dental Anxiety Scale, and Dental Fear Survey are useful for identifying patient fear and anxiety.3–8 

NITROUS OXIDE

When desensitization and relaxation strategies are not sufficient to control patient anxiety before and during local anesthetic procedures, pharmacological strategies can be useful. Nitrous oxide inhalation analgesia can increase patients' tolerance for local anesthetic procedures, even in the absence of coping strategies. Nitrous oxide is not a last resort. It should be used at the start of the appointment, not after other efforts to control fear have failed.3 

PULP TESTING TO CONFIRM ADEQUATE ANESTHESIA

Pulp testing the teeth that will be worked on prior to performing any therapy can reassure both patients and clinicians that they are in fact "numb." If the test indicates that more profound anesthesia is necessary, it can be administered before procedures are started and discomfort can be minimized. Pulp testing will not reveal all occurrences of inadequate anesthesia, but it can certainly decrease its incidence and it is one of the easiest ways to reassure patients that treatment will be comfortable.3 

Table 2. Common Distraction Techniques

  • Conversation 
  • Lip shaking while inserting needle 
  • Gate control strategies and devices (ie, pressure applied with cotton swab to palatal tissues)
  • Television 
  • Use of headsets or CD players with music, audio books, or guided relaxation, all selected by the patient  
  • Audiovisual glasses (for patients who are not highly anxious)9 
 

POWER OF SUGGESTION

The power of suggestion can be profound. Both pediatric and adult patients can ascribe unique interpretations to the terminology used during injections. Choosing words carefully can reduce the imagery that may be associated with poorly-chosen terms such as "poke," "pinch," "sting," and "burn," for example.

Positive communication and establishing trust are important with all patients, but especially when treating anxious or fearful patients (Table 1). Trust provides a foundation for relieving anxiety and fear in order to better support patients.1,3 

DISTRACTION

Distraction shifts the focus from the procedure to something else. Milgrom et al rank distraction as one of the easiest coping strategies and one that is most familiar to dental professionals. 1 Distraction works best on mildly to moderately anxious patients and for procedures of short-duration. It may not be as effective during the administration of local anesthetics as it is for other procedures. Table 2 lists some common distraction techniques.1,9 

VISUALIZATION

Visualization, or guided imagery, is a cognitive strategy to help patients reduce their fear of dental procedures that can be especially beneficial for "needle" fears. Visualization often accompanies physical relaxation, a behavioral strategy. Patients who are both physically and mentally relaxed do not usually experience the same levels of discomfort as those who are tense.

Tension can result in an insufficient supply of air reaching the lungs. Improperly oxygenated blood contributes to anxiety and stress, as well as fatigue and depression. Focused breathing can help patients relax their muscles. Guided imagery can distract patients from procedures and can provide the necessary relaxation needed in order to cope with physical discomfort or the expectation of pain.1,10–13 

RELAXATION RESPONSE

The relaxation response activates parasympathetic pathways that allow recovery from stress. Biochemical release lowers heart and respiratory rates, blood pressure, and muscle tension. Physiologic relaxation promotes relaxation further by adding support to patient coping skills when using visualization techniques.

Explaining the impact of relaxation to patients is an important part of this strategy because when patients are informed, better stress management often follows. Securing patient permission and consent prior to guiding them through a relaxation process is essential (Table 3).

Visualization usually starts with guided physical relaxation or focusing patients on their "inner world" of thoughts and feelings. In this technique, the clinician guides the patient to focus on a scenario of choice. The clinician supports the patient's guided imagery by verbally cueing him or her with details of the images, such as colors, sounds, and textures. This helps to engage the imagination while allowing patients a pleasant inner experience, away from the currently stressful one. Speaking in a slow, soft voice can enhance the relaxation response.

Clinicians can preface relaxation exercises by informing patients that they are going to take a different approach to help them feel more at ease. Visit the web version of this article to view tips for visualization and a guided relaxation and visualization sample script.10 

Table 3. Tips For Preparing Patients for Guided Relaxation and Visualization

  • Act confident, even if you feel awkward or new at using these tools. 
  • Invite patient to bring their attention to breathing: "(Patient name), I'd like to invite you right now to bring your attention to your breathing."
  • Explain how slow breathing allows more oxygen to get into lungs. 
  • Detail how oxygen allows the muscles to relax better, releasing tension. 
  • Discuss how, when muscles are relaxed, the whole body can begin to relax easier, heart rate slows, breathing slows, and the mind and body calm. 
  • Use your voice as a tool: talk slowly, softly (patience and calmness should prevail in your voice).
 

HYPNOSIS

Images of hypnotically-induced, unnatural behaviors continue to fuel misconceptions about hypnosis. In reality, hypnosis and hypnotherapists do not make individuals do anything that is contrary to their values. Hypnosis is an effective technique for managing pain and anxiety, as there is a strong link between hypnosis and the physiology of pain.19 

When under hypnosis, patients usually feel calm and relaxed, and are able to concentrate intensely on a specific thought, memory, feeling, or sensation while blocking out distractions. In this state, individuals are more open to suggestion and become more aware of their inner worlds. Thoughts and images from this inner world can be used to create a sense of comfort and pleasure, and to help reduce fears and anxiety.10–19 

Although the formal practice of hypnosis requires specialized training and certification, clinicians can use suggestive words to help promote positive experiences. Equally important is the avoidance of words that may focus patients' attention on the anticipation of pain. As an alternative to pharmacological approaches, patients with unmanageable levels of anxiety can also be referred to qualified hypnotherapists who can help them overcome their fears. The benefits of hypnosis for both patients and clinicians prior to and during local anesthetic administration may include decreasing anxiety and stress, enhancing pain management, reducing the degree of salivation, and reducing the gag reflex.20 In addition to hypnotherapy sessions, self-hypnosis is usually taught for patients to use at future dental appointments.

SUMMARY

There are a variety of approaches to help patients manage their pain and anxiety including physiological, procedural, and pharmacological strategies. For those averse to needles or injections or who prefer more holistic approaches, psychological strategies should be considered. Dental treatment need not be a negative experience, and by reducing patient anxiety and providing effective pain management, clinicians can ensure patients receive the oral health care services they need in a positive environment.

 


Bonus Content

Table 4: Tips for Guided Visualization

  • Inform patients what they'll be doing. "I'm going to help you relax by guiding you in a simple relaxation and visualization process"
  • Ask patients if they have a favorite place to go on vacation or where they would want to go, if they could anywhere just to relax.
  • Invite patients to begin focusing on breathing to begin to relax
  • Encourage them to close their eyes for better focus on their breathing and imagery
  • Talk in a calm and soothing voice…using their favorite place, embellish it with relaxing images, sounds, fragrances and positive feelings.
  • When completing, suggest to patients that they can use this favorite place anytime they want to feel more relaxed and calm.
 


Table 5: Guided Relaxation and Visualization Practice Script20

First, preface your relaxation exercise with a statement that you are going to do something different today to help them relax. Next, asking permission from the patient to proceed, "Is that ok?"

Once permission is granted, guide the patient as follow:
I'd like to invite you, (NAME), to simply bring your attention to your breath…..
When you bring your attention to your breath, you begin to naturally bring in more oxygen, which then circulates through your body to your muscles. Your muscles will begin to relax, release and let go. That's a good thing because as your muscles begin to soften and let go, you feel more relaxed, and when you feel relaxed, everything else shifts to help you relax more deeply … even if just a little bit. So, simply by breathing a little deeper, down into your belly, now … you may notice how your belly expands when you inhale … and then notice how as you exhale, it seems as if your naval is falling toward your back … that's all you have to do right now … simply notice your breath … notice the rise and fall of your abdomen. That's it … good … (as you watch their abdomen rise and fall).

If they haven't already closed their eyes, guide them by saying:
If you are comfortable, and when you are ready, you may simply close your eyes, allowing you to focus even more on your breathing. You may even notice how comfortable it feels now to simply let go … sink into the chair, allowing the chair to fully support you. As the dental chair supports you now, you can continue to keep your focus on your breathing … noticing how natural and easy it is now … each breath allowing you to relax into your body … each and every exhale allows any tension, any worries, any concerns … to simply be released.

Now, you may imagine a beautiful place in nature, someplace you've been to (you may ask about a favorite vacation spot before you begin) … or simply create a place now in your own mind. As your body further relaxes, your imagination becomes fluid … allowing you to create a place in your mind.

This is a place where you feel very safe, secure and strong … a place where you can be alone and yet never feel lonely … a place where you feel very calm and peaceful. Simply imagine being there now … notice the colors here, notice any sounds you might hear in this beautiful place, and notice how the air feels on your skin ... you may notice aromas or smells … especially notice now, how calm and peaceful you feel being here, in this beautiful place.

Simply allow yourself to be there … completely …
I'm going to be quiet now … as you keep your focus on this beautiful place … where you feel so calm … so relaxed … so peaceful … If the patient has told you beforehand about their scene, you may keep talking and describing all the aspects they've told you, or simply repeat:
"… feeling calm, feeling peaceful, feeling relaxed".
When you're ready to complete, begin again with suggestions that "anchor" their pleasant relaxed experience to the dental chair, the dental office, and the dental procedures.

So, (NAME), we're almost finished for today … you can simply keep your focus on your breathing for now … in a few moments, I'm going to simply ask you to come back into alertness … but for now, simply focus on your breathing … as you remember this pleasant experience today … remembering now that it was different, better, easier than ever before … remembering now, every time you think about our dental office, you'll be reminded of this relaxing experience … every time you are driving on your way to our office, you'll again be reminded of this pleasant experience … and even when you put your hand on the doorknob, you'll be reminded of your pleasant experience today.

And when you see any of the staff, you immediately think about and also feel this very pleasant experience … it feels good now … when you sit in the dental chair, so supporting, so relaxing, so pleasant … as you imagine your beautiful place. So now, every time you even make a dental appointment, you remember and feel this pleasant experience … you remember it's easier now … every time you sit or lie back in this chair, it reminds you to relax, release and let go … you remember it is safe to relax, release and let go … and you do.

Now I am going to ask you to simply began to wiggle your toes, wiggle your fingers – stretch - and when you are ready, open up your eyes gently … GREAT!!! Anchor in the relaxation by commenting on how "soft" and relaxed their face looks. Acknowledge them for experiencing something different, and again remind them:
"Now, every time you sit or lie down in the dental chair, you are reminded to relax and let go, and your beautiful place will be here for you." Acknowledge them for trusting you:
"Wow…great job!", "That's awesome", "Thank you for trusting me",
(a gentle exclamation to acknowledge their coping, trust and success)

Calming Dental Anxiety: Relaxation Script, JM Foskett. Modified by KB Bassett (2012)

 

References

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From Dimensions of Dental Hygiene. July 2012; 10(7): 24-27. 

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