John C. Chao, D.D.S.
Research Associate Professor, University at Buffalo, SUNY
Adjunct Assistant Professor, Ostrow School of Dentistry, USC
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COWARDS OR HIGHLY SENSITIVE PATIENTS ARE ESPECIALLY WELCOME AT ALHAMBRA DENTAL. Technological advances in dental anesthesiology have been integrated into Dr. Chao’s patient care, so that even the most sensitive and anxious patients, in a short time, actually look forward to and enjoy their visits with us. Total patient ease and comfort is the central theme of our practice. This theme extends to the way our staff answers your first call, the way you are warmly greeted, to the professionalism used to communicate with you regarding your needs and concerns.
OVERCOME DENTAL PHOBIA
By John Chao, DDS, MAGD
Faculty, Behavior Science Section
USC School of Dentistry
Since 1974 thousands of fearful patients have been successfully treated by mean of “iatro-sedation” at USC School of Dentistry, whose Behavior Science Section, under the direction and stewardship of the late Dr. Nathan Friedman, a pioneering periodontist and USC professor of dentistry developed this groundbreaking curriculum in the 1960’s aimed at helping apprehensive patients overcome their fear of dental treatment.
The following essay, based in part on ten years of experience in teaching iatrosedation in the Behavior Science Section at the USC School of Dentistry, is a unique, innovative presentation of this non-pharmaceutical approach to dental anxiety in that it is written from the standpoint of and for the benefit of the patient, rather than the doctor. It is written for dissemination to the general public in the hope that those who have high anxieties regarding dental treatment will know that there is a predictable, evidence-based method by which their fears associated with dental treatment can be dissolved and the quality of their lives can be dramatically improved as a result.
1. What is iatrosedation?
2. What is dental phobia?
3. How is dental phobia different from other phobia?
4. How prevalent is dental phobia?
5. How can I know how severe my condition is?
6. How does an individual become dental phobic?
7. You mentioned how one can “unlearn” the pattern of fear. But how does one “learn” dental phobia in the first place?
8. Does the doctor using the iatrosedative approach have a different take on the doctor-patient relationship when it comes to highly fearful patients?
9. What is the process I need to go through to overcome this phobia?
10. How can I find a dentist that will help me “un-learn” this fear pattern?
11. Why shouldn’t I just get “knocked out” for whatever dental treatment I need?
12. How can I prevent my children from getting dental phobia, like I did?
Iatrosedation is defined as an interpersonal-cognitive (doctor-patient) process by which patients suffering from dental phobia are calmed by the behaviors, attitudes, and communicative stance of the doctor. (i, ii) It is non-pharmaceutical. It is effective particularly in treating dental fears that originate as a consequence of one or more traumatic conditioning experiences. (iii) Thousands of dental patients with dental phobia or high anxiety levels have been successfully treated with iatrosedation at Herman Ostrow School of Dentistry of USC since the 1960’s. This proven fear-dissolving therapy, for the most part, is accomplished without the use of pharmaceuticals, such as general anesthesia, IV sedation or oral medication. After having treated thousands of highly anxious patients over twenty-five years I have observed that the dissolution of the phobia , without pharmaceuticals, becomes a mark of personal triumph and empowerment that reverberates through the personality of the patient in astonishing and remarkable ways.
A phobia is an intense and persistent fear of certain situations, activities, things, animals, or people. The main symptom of this disorder is the excessive and unreasonable desire to avoid the feared subject. (ii) Dental phobia may be described as excessive and unreasonable fear of dental treatment.
In contrast to many other phobias, sufferers subject themselves to regular and repeated exposure to threatening stimuli, or may be expected to do so. Dental phobia, compared to other specific phobias, avoiding the feared situation in many cases leads to significant negative consequences. For the truly phobic individual, it is common for a vicious cycle to develop in which fear leads to avoidance of dentists, resulting in neglected dental care, increased awareness of these unmet needs, and feelings of shame. These factors give rise to negative social effects and hence to increased anxiety, (iii) not to mention the added financial burden of deferred dental care.
Up to 40 percent of the adult population admits to being fearful of dental treatment, of which 3 to 5 percent can be said to be truly phobic or to have a debilitating high level of fear. (iv v vi vii viii ix) It is estimated that at least 20 million Americans suffer from dental phobia. (i)
There is The Corah Dental Anxiety Scale, developed in 1969, by Dr. Norman L. Corah, from the Department of Behavior Science, School of Dentistry, State University of New York, (x) that can help you assess your anxiety level. Fill out the following questionnaire then follow instructions on how to score this test.
- If you had to go to the dentist tomorrow, how would you feel about it?
a. I would look forward to it as a reasonably enjoyable experience.
b. I would NOT care one way or the other.
c. I would be a little uneasy about it.
d. I would be afraid that it would be unpleasant and painful.
e. I would be very frightened of what the dentist might do.
- 2. When you are waiting in the dentist’s office for your turn in the chair, how do you feel?
b. A little uneasy.
e. So anxious that I sometimes break out in a sweat or almost feel physically sick.
- When you are in the dentist’s chair waiting while he gets his drill ready to begin working on your teeth, how do you feel?
b. A little uneasy.
e. So anxious that I sometimes break out in a sweat or almost feel physically sick.
- You are in the dentist’s chair to have your teeth cleaned. While you are waiting and the dentist is getting out the instruments which he will use to scrape your teeth around the gums, how do you feel?
b. A little uneasy.
e. So anxious that I sometimes break out in a sweat or almost feel physically sick.
How to score this test: Add one point for each “a.” Add two points for every “b.” Add three points for every “c.” Add four points for every “d.” Add five points for every “e.” Total scores can range from 4 – 20. Average score is 8-9 and a high score typical of a dental phobic would be 17-20. (In one sample of 1,232 college students the mean score was 8.89, with a standard deviation of 2.99, whereas the median and mode were both 8.) (ix)
These scores are not diagnostic of your condition. Obviously a high score would suggest a need to look further into the possibility that you have a high level of anxiety or fear toward dental treatment. No matter what the score is, it is advisable for you to share the result of this test with your dentist.
Dental phobia may be described as excessive and unreasonable fear of dental treatment. The patient needs to consciously acknowledge that this fear is learned as a consequence of direct or indirect experience, and is not a congenital condition that should be accepted as immutable. A direct experience may be associated with a traumatic encounter in a dental office or a medical procedure. Even the memory of an experience not related to dentistry or medicine, e.g., a near-drowning experience, may be brought to reminiscence by dental treatment.
An indirect experience is one in which the fear is learned vicariously. Generally this is experienced through stories told by the parents or siblings, or observation of the after-effects of dental procedures. Other medium, such as TV and movies, may also be conditioning factors.
These experiences most frequently occur during childhood, although feelings associated with the memories may persist throughout life. Fortunately the ability to “unlearn” this “neuro-cognitive pattern” is resident in every individual.
One “learns” fear through a phenomenon called “classical conditioning.” Heightened fear of dental treatment can be described as a “conditioned response,” in a sense similar to the response in “Pavlovian classical conditioning.” Pavlov observed salivation (unconditioned response) when food was offered to the dogs. Then he rang a bell every time food was offered. Soon the dogs salivated (conditioned response) simultaneously with the sound of the bell.
Similarly, when a child experiences pain from a needle or drill, he/she associates the dentist with pain. The fear of the dentist then becomes the conditioned response and whenever he/she thinks of the dentist or actually goes in for a dental appointment it translates into fear.
This conditioned response may generalize from the original traumatic circumstances to other situations. For example, fear of injections for immunization or antibiotics may be generalized as a response to dental injections, or vice versa.
Conditioned responses may also be learned through “modeling.” Parents sharing their traumatic experiences with their child become a modeling experience for the child. The child learns a “conditioned response” as a result. Parents can ingrain the fear response by comments such as, “If you don’t behave, I’ll take you to the dentist.” No wonder the child becomes wild with fear at the dental chair. The child can also learn to fear dental treatment through the medium of television or movies.
Fearful patients require a specific kind of behavior from doctors, according to Dr. I.L. Janis, who conducted an extensive five-year study of psychological stress endured by patients preparing for and undergoing major and minor surgery, including operative dentistry. (xi) This study determined that doctors have a powerful influence on the patients’ fear and stress levels. Patients perceive the doctor in two important ways:
- A Danger Control Authority.
- A Protective Authority.
The doctor controls what the patient perceives as dangerous and is the one who can protect him from that danger. Because of this perception the doctor’s behavior and mannerism assume great significance in the mind of the patient. The patient is looking to the doctor to protect him/her from danger. This takes place through an interactive two-way dialogue (iatrosedative interview) during which a process takes place that results in the patient developing trust and confidence in the protective authority of the doctor. Having built up trust, the patient then can better cope with the stress of the surgery.
For this reason the doctor needs to find out during the iatrosedative interview:
- What do you perceive as threatening or dangerous?
- What can the doctor do to make you feel safe and protect from the danger?
A. This question will be answered in three parts. The first part consists of you doing some thinking about the problem before your first appointment.
1. You must recognize and accept the fact that you have an inordinate fear of dental treatment. Twenty million other adults have the same condition. You learned this conditioned fear response through no fault of your own. You have nothing to be ashamed of, nor to feel guilty about. It’s OK for you to be a “dental coward,” or “dental chicken.” Some of the bravest people, including decorated veterans, are also afflicted with this condition.
2. You might want to give thought to the following questions, if it doesn’t bother you too much.
- What exactly are you most afraid of? For example, is it the injection? Is it the fact that it wasn’t numb enough? It is the noise? The smell? Is it the numbness? Do you feel claustrophobic in the dental chair?
- Can you associate that with some experiences in the past? Was it an experience related to a dental appointment? Or a medical procedure? Was it a series of dental or medical experiences? Was it something that was not at all related to any dental or medical procedures?
- Was your fear response learned some other way, e.g., through you parents or siblings? Now that you have recognized, accepted and have some idea as to how you acquired dental phobia, you are now ready for your first meeting with the doctor.
B. Your first visit with the doctor is called the Iatrosedative Interview. This interview may proceed in different ways, but generally will move along in four segments.
1. You can expect that the doctor will verbally and non-verbally communicate understanding and acceptance of your expression of anxiety or fear. The doctor is well aware that fearful patients are very perceptive and sensitive to the doctor’s behavior and will do everything possible to reassure you.
2. The doctor will explore and identify the problem through the use of questioning and facilitation skills to determine:
- The specific fear and its intensity.
- The origin of the fear.
- The behavior of the doctor(s) or authoritative figure(s) that may have been involved in the traumatic conditioning that occurred.
By determining the specific fear and its origins the doctor will be better able to offer a specific solution and formulate a plan that would help you, the patient, to “un-learn” the conditioned response.
3. The doctor will explain his interpretation of your unique circumstance:
- How your fears were learned, whether this is apparent or not.
- How fears may be associated with helplessness, dependency and the unknown. The doctor may discuss with you the different ways in which you can exert control over your treatment and that you will participate in the choice of treatment, and have control during the treatment itself, such as stopping the procedure at any time. Having control over treatment will help alleviate feelings of helplessness and having knowledge of the treatment will help relieve the fear of the unknown.
- How you have the ability to unlearn the sense of danger and relearn a sense of safety. The doctor may share with you how other patients just like you have also relearned under his/her care.
4. The doctor will offer a solution to the problem:
- How the doctor will perform the procedure in a way that will bring about a totally different result.
- What kind of behavior the patient can expect from the doctor, such as taking every precaution to make the injection as painless as possible and that the tooth will have “absolute anesthesia” before procedure is begun.
- Offer of control so that the treatment will be stopped if the patient feels the need. The doctor may assure the patient even if the patient does not complain, the doctor will know through experience and observation when to stop and inquire.
- Patient will be kept informed as to what to expect as the treatment progresses (Preparatory communications).
- The doctor will keep a two-way line of communication open to the patient to answer questions or discuss the patient’s state of mind.
C. Iatrosedative Clinical Appointment. This is the appointment during which a dental procedure will be done for you. This is what you may expect the doctor to do to help you “relearn” the condition response of fear and anxiety:
1. Preparatory Interview: this is a brief two-way dialogue concerning the anticipated procedure. The doctor will want to find out two things:
- Have you ever experienced this particular procedure before?
- How do you feel about it?
The reason for this inquiry is to prepare you for the details, such as the kind of instruments to be used, so that potentially threatening perception of danger can be avoided and the doctor can take steps to make sure this time things will work out much better than the past.
2. Nonverbal Empathic Behavior. Without words the doctor exhibits these following traits:
- Attentiveness and concern.
- Acceptance of you and your problem.
- Involvement with the intent to help.
3. Physical attending skills. The experienced doctor will naturally exude the following characteristics:
The words that the doctor uses will be augmented with good eye contact, forward trunk lean, good body orientation and good distance so that the intent to communicate empathy is accomplished.
The experienced doctor is well aware that facial expression needs to convey warmth, interest and concern so that the words spoken will have the intended impact.
The voice is an important instrument in helping the highly anxious patient to relax and feel safe and protected. Generally the doctor will speak with moderate volume, pitch and resonance, such that the voice is consistent with the words and facial expression.
At the conclusion of the iatrosedative encounter you will have made significant progress in “unlearning” the neuro-cognitive response that has haunted all you life and relearning that dental treatment can be a pleasant, enjoyable experience surrounded by your doctor and staff who care about you.
It would be best if you can find a doctor who is trained and experienced with the iatrosedative approach. At the present there are no formal lists of doctors who by training, knowledge and experience are specially positioned to take care of phobic or highly anxious dental patients. However, it can be assumed that many graduates from the USC School of Dentistry have been trained in this method. Your inquiry may consist of whether the doctor you have been referred to is trained and experienced with this method.
It should be said that many dentists intuitively incorporate the principles of iatrosedation into their chairside manner and can attend to the needs of the highly anxious patient with predictable success. The best way to find someone like this is through word of mouth. You need to find a person with similar anxiety levels as you and who has been successfully treated by a doctor. You may ask your friend how the doctor was able to help him or her.
Once you have been given such a referral you may call the office and talk to the receptionist or office manager. Be frank and explain what your condition is and ask whether, in the opinion of the staff, whether this doctor is particularly suited to treat you. Feel free to tactfully ask for the doctor’s familiarity with the iatrosedative method or other non-pharmaceutical means of treating dental phobia or high anxiety. When you meet the doctor, feel free to be completely open about how you feel and what you expect the doctor will do for you. The experienced doctor will welcome such open communication and will be better able to help you.
Pharmacosedation is the medical terminology for being “knocked out” for a surgical procedure. It includes oral sedatives, nitrous oxide (laughing gas), IV conscious sedation and general anesthesia. Pharmacosedation is effective in enabling the highly fearful patient to receive needed urgent dental treatment. Apart from the cost of pharmacosedation, the disadvantage with this method is that the source of the anxiety is never dealt with. The phobia still dominates the life of the sufferer as it did before. It would be difficult for the patient to return regularly for maintenance care. What is most lacking with this method is that, because of the high level of anxiety, the patient may find it difficult to communicate with or bond with a particular doctor and his staff.
However pharmaceutical sedation as a means to reach the of goal of iatrosedation is an acceptable, and sometimes necessary method, for helping patients with high levels of fears and anxiety. It is debatable whether long-term dependency on pharmaceutical sedation alone without addressing the underlying causes of anxiety is necessarily the best course of treatment for all anxious patients.
Remember also that overcoming this phobia will empower you to live a better life in ways that you may not have considered before. Having a wonderful smile, with you teeth well taken care of, will likely give you an incredible sense of well-being and heightened self-regard.
If you feel a combination approach will help you, do not hesitate to discuss this with your doctor.
You can apply the initial steps of the iatrosedative method to alleviate your child’s anxieties regarding dental treatment. You should consider doing the following:
- Be positive yourself regarding dental treatment at all times. Sometimes that is all you need to do to instill confidence and trust of the child toward the dentist. Do not engage in negative talk about dentistry in front of your children.
- You should take your child for a routine checkup when she/he is two years old, according to the American Dental Association. This will allow the child to be comfortable with the dental environment and the doctor and the staff.
- If your child is especially fearful or anxious, acknowledge your child’s fear as real, whether you believe it is justified or not.
Accept your child’s fear and anxiety with understanding and empathy.
- Talk to your child about the possible sources of the anxiety/fear. Was there an unpleasant experience with a dentist? With a medical procedure? Did the child hear or see something that was frightening? Did the child adopt this anxiety vicariously from another member of the family?
- What specifically caused the fear/anxiety? The sight of the needle, the injection, the numbness, the bad taste of the anesthetic, the noise of drill, the tooth still hurt after injection, fear of the white coat, etc.
- Reassure your child you will see to it that this would not happen again. You might even visit the office and get an “office tour,” say hello to the doctor and perhaps ask some questions as to what the doctor thinks you should do to reassure your child. Then you have strong personal basis to reassure your child.
- During the office tour, you can inquire as to how the doctor handles difficult pediatric cases. Does the doctor typically use pharmacosedation? What medicine is used and what are its side effects? Does the doctor discourage or permit the presence of the parent in the operating room? Can you be there when your child comes out of sedation so that the child wakes out in your reassuring presence? Does the doctor typically use restraining devices, such as the papoose? How do you feel about restraining devices for your child? Does the doctor typically use iatrosedation, with no physical restrain or pharmaceuticals? This would be the best, if it is practicable for your child.
- You should book an appointment first thing in the morning, if possible. Be sure your child has gotten a good night’s sleep and a healthy breakfast. Your job is to make sure your child is happy at the first appointment.
- When you talk to the doctor about what is needed, give serious consideration to talking to the doctor away from the child. You can then share with the doctor your concerns and that of your child’s. Questions such as, “Should I stay with the child during the procedure?” How does the doctor treat an anxious child, such as yours? What pharmaceuticals, if any, will be used? You may discuss the possibility the pharmacosedation may be needed, at least in the beginning.
- You may reassure your child with positive reinforcement and strongly, positively express your trust and confidence in the doctor.
- When the appointment is over, praise your child regardless of how the appointment went. Smile when you see your child. Do not show a face that says, “ Poor baby, it might have been terrible.” Say something like, “I am so proud of you.” The doctor/nurse said you did great! You will be pleasantly surprised at how happy your child will be the next time.
i Friedman N. Psychosedation, part 2 –iatrosedation. In McCarthy FM (ed): Emergencies in Dental Practice. Philadelphia, WB Saunders Co. 1979.
ii Friedman N: Iatrosedation. The treatment of fear in the dental patient. J Dent Educ 47 (2): 91-95. 1983.
iii Friedman N. A dentist oriented fear reduction technique: The iatrosedative process. Compend Contin Educ Dent. Vol. X no2 113.
iv Hägglin C, Berggren U, Hakeberg M, Hallstrom T, Bengtsson C. Variations in dental anxiety among middle- aged and elderly women in Sweden: a longitudinal study between 1968 and 1996. J Dent Res 1999;78:1655-61.
v Hakeberg M, Berggren U, Carlsson SG. Prevalence of dental anxiety in an adult population in a major urban area in Sweden. Community Dent Oral Epidemiol 1992;20:97-101.
vi Milgrom P, Fiset L, Melnick S, Weinstein P. The prevalence and practice management consequences of dental fear in a major US city. J Am Dent Assoc 1988;116:641-7.
vii Moore R, Birn H, Kirkegaard E, Brodsgaard I, Scheutz F. Prevalence and characteristics of dental anxiety in Danish adults. Community Dent Oral Epidemiol 1993;21:292-6.
viii Stouthard ME, Hoogstraten J. Prevalence of dental anxiety in The Netherlands. Community Dent Oral Epidemiol 1990;18:139-42
ix Vassend O. Anxiety, pain and discomfort associated with dental treatment. Behav Res Ther 1993;3 1:659-66.
x Corah NL, Development of a Dental Society Scale, J Dent Rest 1969; 48: 596.
xi Janis IL, Psychological Stress, New York, Wiley, 1958.