Spring 2017

The Patient Whisperers

Every dentist can learn to put the anxious and the fearful at ease. It’s not magic; it simply takes time and effort.

By Julie Flaherty

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Illustration: Hanna Barczyk

Fear of the dentist is not just a funny movie trope. Studies show that up to 40 percent of people have some level of dental anxiety, from mild to disabling. Advances in sedation, including nitrous oxide and oral or intravenous drugs, have made treating fearful patients much easier and allowed more people to get the care they need. But are drugs the only solution?

“Many dentists focus primarily on pharmacologic treatments, such as the short-term use of sedatives, but there are many nonpharmacologic, behavioral approaches that I believe are underutilized in the dental setting,” said Ellen Patterson, director of interprofessional education at Tufts School of Dental Medicine. In a course called “Introduction to the Dental Patient,” Patterson, a health communications specialist and former psychiatrist, helps students learn to manage fearful patients—using skills that can benefit all of their patients, and ultimately their practices.

We asked Patterson and other Tufts faculty and alumni for their best advice for treating anxious patients. Here are some of their tips:

Anyone Can Do It

Does it seem that some dentists are just inherently better at calming frightened patients than others? With a soothing chairside manner, gentle hands and a face that lends itself to concern, they seem to know just what to say and how to say it.

“This comes more naturally to some,” Ellen Patterson acknowledges. But the story doesn’t have to end there. “Anyone can be taught to recognize less obvious signs of anxiety and to respond to them in effective ways,” she said.

Creating an empathetic connection with a patient is important for building a trusting relationship, Patterson said. “I think it really has to do more with the practitioner’s decision to take the time and energy to create a patient-centered environment that respects and honors each patient’s needs rather than any innate talent.”

Never Make Assumptions

What does it mean to be “afraid of the dentist?” The nervousness some people experience when they go to the dentist—or just think about going—can be categorized in three ways. Dental fear, the most common, is relatively mild, transient and usually manageable with everyday coping strategies. Dental anxiety is worse—patients may be too overwhelmed by fear to handle it on their own. When the patient is not just anxious, but utterly panic-stricken, it is dental phobia.

Dental phobia is a relatively rare but very real illness that is listed as a specific phobia in the Diagnostic and Statistical Manual of Mental Disorders. “People with dental phobia will likely need specialized interventions by their health-care providers in order to tolerate dental care,” Patterson said.

Dental fear can also be quite specific—one patient may fear the needle; another may worry that the anesthetic won’t work and a third can’t stop imagining the drill slipping and cutting her cheek. In her book, Have No Fear of the Dental Chair, Susan Cushing, D81, lists 47 common dental fears that she has observed in her own practice.

By asking open-ended questions, dentists can gently explore a patient’s dental history and narrow in on specific anxiety triggers. Is it the sound of the drill they hate? Explain that the noise is just the sound of air being forced through the handpiece. Does the thought of the needle piercing the gums upset them? Demonstrate the effectiveness of topical anesthetic.

“If somebody’s anxious in the chair, there’s got to be a reason for it,” Cushing said. “We just need to take the time.”

Understanding the specifics of the fear is important, but so is understanding how that fear fits into the rest of the patient’s life.

“An individual with a coexisting depression, substance use disorder, anxiety disorder or a history of trauma may have very different needs than an individual who has fear based solely on a difficult or painful past dental experience,” said Patterson. “When it comes to dental fear, one size does not fit all.”

Listen First

When Iqbal Singh, a professor of preclinical studies, first meets an anxious patient, he never jumps right into the exam. He takes a seat close enough to talk, but without crowding the patient. He looks the patient in the eye and opens his ears instead of his mouth.

“I have to listen to them, rather than me talking to them,” he said.

This is the chance for the patient to talk about that time he didn’t get numb at the dentist, or the smell of the operatory that reminds him of an unpleasant hospital experience. A first step in allaying those fears may be to simply repeat what the patient says back to him: I hear you’re telling me that…

“Sometimes all you have to say is, ‘I understand. I know what you mean,’ ” Singh said.

All of this takes time, of course, but for Singh it has meant that he has had patients who have stayed faithful to his practice for decades. As Patterson noted, “The skill to form a strong and trusting bond with your patient is the most valuable tool that any clinician can have, and well executed, it is the one skill that the patient will remember long after the dental procedure is over.”

Be Honest

Telling a patient, “This won’t hurt at all,” might seem like a reassuring thing to say, but it can easily backfire if the patient does experience pain. Trust in the dentist flies out the window.

Susan Cushing still remembers how, as a young girl, she believed her mother’s promise that the dentist would not use a needle on her, only to be held down by the dentist’s assistant while he gave her an injection.

 

 

 

The experience traumatized her. “When you lie to someone, right away you broke rapport; you broke the bond,” she said. It took her many years and good visits with other, very caring dentists to overcome her dread.

When Cushing became a dentist, she was determined to make promises she could keep, such as: I promise to do my best not to hurt you. But there may be a pinch or things that are uncomfortable, and I need you to help me make it easy for you.

Look for Nonverbal Cues

Sometimes the most fearful patients are reluctant to talk about their anxiety. “It is not unusual for some people—men as well as women—who pride themselves on being tough to want to maintain that image in spite of their fears,” said Anthony Silvestri Jr., E69, a clinical professor at the dental school. “If I see a rugged-looking patient sitting in my air-conditioned operatory with beads of sweat emanating from the upper lip, I have a pretty good idea what lies behind that sweat.”

Behavior and body language can be important clues. Is the patient pacing the waiting room? Does he frequently get up from his seat, as if about to leave? Is she shaking or white-knuckling the arms of the chair? When you talk about the procedure, does he appear frustrated or unsure?

“If the clinician picks up these clues, it becomes an opening to compassionately explore those clues while building a sense of trust with the patient,” Patterson said. “For example, an individual with a history of physical or sexual trauma may be very reluctant to share that information openly, but may suddenly become very anxious or panicky when placed in a vulnerable and prone position in the dental chair.”

Sometimes fear can masquerade as other emotions, said Mary Jane Hanlon, D97, interim associate dean of clinical affairs. “Some patients come in angry, and that is their fear: Don’t touch me. I’m going to be a bear, because I’m afraid,” she said.

If the patient’s demeanor changes during the visit—becoming less relaxed, less responsive to questions—it could be a sign that you have hit upon a trigger and should try a different approach. In short, don’t assume a quiet patient is a happy patient, Hanlon said. “If something is off, you’ve got to listen to your gut instincts.”

Explain As You Go

Most dentists have good success with tell-show-do: Telling the patient what the procedure will involve, showing them the tools and materials involved and finally doing the procedure. For some patients, the “show” may include letting them handle the tools, or dragging a probe against the back of the hand so they can see what it feels like before it goes in the mouth.

Give Them a Sense of Control

For some, getting into the dental chair can feel like being locked into a roller coaster—once the car starts up that hill, there’s no way to stop the ride.

Giving patients a sense of control can go a long way in allaying their fears. That might mean asking permission each step of the way: Can I look in your mouth with the mirror? Can I apply the topical to the gums?

“Once you’ve established that trust, you would be amazed at how much patients will push themselves to help you.”

And if you promise you will stop at their signal, be sure to do it, even if you think finishing the procedure quickly will make the patient happier.

“Patients will test you,” Hanlon said. “You must stop.” It’s time consuming, but the payoff is big. “Once you’ve established that trust, you would be amazed at how much patients will push themselves to help you,” she said.

In his book, The Fearful Dental Patient, longtime faculty member Arthur Weiner, now retired, writes that ceding some control to the patient shows that you respect her wishes more than your own agenda. That’s why if a fearful patient came to Weiner’s office for a chipped front tooth but had more serious issues in his molars, he would do the small cosmetic repair first. “Do something that shows [an improvement] and fulfills the patient’s primary reason for seeking treatment,” he wrote. “This provides the patient with the perception of having some degree of control over his or her care.”

Neutralize Sensory Overload

The sound of the drill, the smell of the antiseptic, the sight of the dental instruments—a dental office is an assault on the senses filled with potential fear triggers. Some patients benefit from having other things to focus on, such as headphones with their favorite music (or soothing music, if their favorite is too pulse-quickening) or a gently spinning mobile above the dental chair. Cushing finds that some patients need to hold onto something for comfort and stress release. It could be a slinky, silly putty, a stress ball or just their cell phone. Cushing has kept an assortment in her office over the years. Distracting conversation can also help, but be sure to watch the patient for signs that the witty banter isn’t adding to the patient’s stress.

Take Baby Steps

A common treatment for phobias is to gradually expose people to the things they fear. A needle-phobic patient may start by being in the same room as the needle, then handling the needle, then sticking it in an orange. The psychiatric term is “systematic desensitization.” Gina Terenzi, director for Advanced General Dentistry Residency Programs at Tufts, calls it “baby steps.”

Terenzi used the approach with a patient who had been physically abused. The patient needed crowns on all her teeth, but she felt claustrophobic whenever a dentist stood over her.

 

 

 

“She didn’t like to be laid back in the chair—it meant something to her,” Terenzi said. “We tried nitrous oxide, but she couldn’t stand having her face covered with the mask.”

So Terenzi started the treatment with the chair upright, and then over time, and with the patient’s permission (“Do you think you could sit back a little more?”) she lowered it bit by bit. Oral sedation helped the patient tolerate the procedure. The patient’s fear is far from cured, but because of the care her dentists have shown, she is dedicated to completing the treatment.

Be Flexible

Singh recalls the mother of a nervous young patient who took him aside before the first appointment. “Do me a favor and don’t wear your white jacket. That’s what she doesn’t like.” Singh complied, and the visit went smoothly.

By compromising his usual workflow, a dentist shows that he is listening. The hope, of course, is that the patient will then be more willing to change his behavior. For example, a dentist can’t work effectively without the use of a dental chair. But for a patient who dreads sitting in the dental chair, conducting the very first examination in a regular chair might be the concession that gets the patient into the chair next time.

If a patient feels claustrophobic at the thought of a dental dam, “maybe figure out how to work without a dam,” Terenzi said. “In real life you have to be flexible.”

In his book, Weiner suggests doing things out of the usual order as a nod to the patient’s priorities. For a patient who does not trust that he will get numb, restore the smallest cavities first, to show that the anesthetic works. For the patient afraid of needles, use a topical anesthetic and pick an easy site like the tissue above a premolar to show how painless the injection can be.

Weiner writes about a former Green Beret who told him he didn’t want anesthetic, because he could withstand a lot of pain. Weiner agreed to skip the needle, just to show that he was willing to change his behavior for the patient—even though he expected the patient to change his mind once the procedure got going.

Make Friends with a Psychiatrist

As part of the course “Introduction to the Dental Patient,” Patterson gives presentations on the wide range of mental health conditions that can predispose a person to dental fear, such as depression, anxiety disorders, substance-use disorders and psychological trauma. But she also tells students that sometimes a patient’s fear is just too severe or too entwined with other psychiatric illness for a dentist to address on her own, and that’s OK. That’s why Patterson recommends that all dentists have a mental health colleague they can ask for advice. “Reaching out to and working actively with other providers and specialists—interprofessional collaborative care—is often the best way to provide optimal treatment for the complex patient,” she said.

But if mental health is the psychiatrist’s domain, why should a dentist get involved in the first place? Patterson points to the growing body of research showing the connection between psychological health and physical health. “There is also a very important component of healing in all clinical settings, dentistry included, that relates to the patient’s perception of the connection and caring he or she feels from the provider. We can’t separate how a patient feels about his or her health or health care from the patient’s objective experience of receiving that health care.”

Whether it is acknowledged or not, Patterson said there will always be a psychological component to every encounter with a health-care provider. “It is up to the provider to make that experience as positive as it can be,” she said. It takes time, but in the end, it can earn you a loyal—and less fearful—patient for years to come.

Contact Julie Flaherty at julie.flaherty@tufts.edu.

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