Lisa J. Heaton

Management of fear and anxiety in the dental clinic: a review

People who are highly anxious about undergoing dental treatment comprise approximately one in seven of the population and require careful and considerate management by dental practitioners. This paper presents a review of a number of non-pharmacological (behavioural and cognitive) techniques that can be used in the dental clinic or surgery in order to assist anxious individuals obtain needed dental care. Practical advice for managing anxious patients is provided and the evidence base for the various approaches is examined and summarized. The importance of firstly identifying dental fear and then understanding its aetiology, nature and associated components is stressed. Anxiety management techniques range from good communication and establishing rapport to the use of systematic desensitization and hypnosis. Some techniques require specialist training but many others could usefully be adopted for all dental patients, regardless of their known level of dental anxiety. It is concluded that successfully managing dentally fearful individuals is achievable for clinicians but requires a greater level of understanding, good communication and a phased treatment approach. There is an acceptable evidence base for several non-pharmacological anxiety management practices to help augment dental practitioners providing care to anxious or fearful children and adults.

Dentin Hypersensitivity and Oxalates a Systematic Review

Treatment of dentin hypersensitivity with oxalates is common, but oxalate efficacy remains unclear. Our objective was to systematically review clinical trials reporting an oxalate treatment compared with no treatment or placebo with a dentin hypersensitivity outcome. Risk-of-bias assessment and data extraction were performed independently by two reviewers. Standardized mean differences (SMD) were estimated by random-effects meta-analysis. Of 677 unique citations, 12 studies with high risk-of-bias were included. The summary SMD for 3% monohydrogen-monopotassium oxalate (n = 8 studies) was -0.71 [95% Confidence Interval: -1.48, 0.06]. Other treatments, including 30% dipotassium oxalate (n = 1), 30% dipotassium oxalate plus 3% monohydrogen monopotassium oxalate (n = 3), 6% monohydrogen monopotassium oxalate (n = 1), 6.8% ferric oxalate (n = 1), and oxalate-containing resin (n = 1), also were not statistically significantly different from placebo treatments. With the possible exception of 3% monohydrogen monopotassium oxalate, available evidence currently does not support the recommendation of dentin hypersensitivity treatment with oxalates.

The effects of dental anxiety and irregular attendance on referral for dental treatment under sedation within the National Health Service in London

OBJECTIVE To investigate whether the relationship between dental anxiety and referral for treatment under sedation is explained by attendance patterns and oral health. METHODS Structural Equation Modeling was used on the covariance matrix of the covariates to test hypothesized inter-relationships. Subsequently, we modeled the probability of referral for treatment under sedation with a multiple logistic regression taking into account inter-relationships between the independent variables. RESULTS A direct significant association of referral with dental anxiety and attendance patterns was detected, but not with oral health status. However, oral health and anxiety were highly correlated. Also signaled were correlations between age and education and between gender and bad past experience. CONCLUSION Referral for treatment under sedation appears to be motivated by both fear and irregular patterns of attendance. Coupled with behavioral treatments to address dental fear and attendance, sedation can be an important part of comprehensive care where curative treatments are long or unpleasant for patients.

Computerized Dental Injection Fear Treatment A Randomized Clinical Trial

One in four adults reports a clinically significant fear of dental injections, leading many to avoid dental care. While systematic desensitization is the most common therapeutic method for treating specific phobias such as fear of dental injections, lack of access to trained therapists, as well as dentists’ lack of training and time in providing such a therapy, means that most fearful individuals are not able to receive the therapy needed to be able to receive necessary dental treatment. Computer Assisted Relaxation Learning (CARL) is a self-paced computerized treatment based on systematic desensitization for dental injection fear. This multicenter, block-randomized, dentist-blind, parallel-group study conducted in 8 sites in the United States compared CARL with an informational pamphlet in reducing fear of dental injections. Participants completing CARL reported significantly greater reduction in self-reported general and injection-specific dental anxiety measures compared with control individuals (p < .001). Twice as many CARL participants (35.3%) as controls (17.6%) opted to receive a dental injection after the intervention, although this was not statistically significant. CARL, therefore, led to significant changes in self-reported fear in study participants, but no significant differences in the proportion of participants having a dental injection (ClinicalTrials.gov, NCT00609648).

Psychometric properties of Spanish-language adult dental fear measures

BackgroundIt would be useful to have psychometrically-sound measures of dental fear for Hispanics, who comprise the largest ethnic minority in the United States. We report on the psychometric properties of Spanish-language versions of two common adult measures of dental fear (Modified Dental Anxiety Scale, MDAS; Dental Fear Survey, DFS), as well as a measure of fear of dental injections (Needle Survey, NS).MethodsSpanish versions of the measures were administered to 213 adults attending Hispanic cultural festivals, 31 students (who took the questionnaire twice, for test-retest reliability), and 100 patients at a dental clinic. We also administered the questionnaire to 136 English-speaking adults at the Hispanic festivals and 58 English-speaking students at the same college where we recruited the Spanish-speaking students, to compare the performance of the English and Spanish measures in the same populations.ResultsThe internal reliabilities of the Spanish MDAS ranged from 0.80 to 0.85. Values for the DFS ranged from 0.92 to 0.96, and values for the NS ranged from 0.92 to 0.94. The test-retest reliabilities (intra-class correlations) for the three measures were 0.69, 0.86, and 0.94 for the MDAS, DFS, and NS, respectively. The three measures showed moderate correlations with one another in all three samples, providing evidence for construct validity. Patients with higher scores on the measures were rated as being more anxious during dental procedures. Similar internal reliabilities and correlations were found in the English-version analyses. The test-retest values were also similar in the English students for the DFS and NS; however, the English test-retest value for the MDAS was better than that found in the Spanish students.ConclusionWe found evidence for the internal reliability, construct validity, and criterion validity for the Spanish versions of the three measures, and evidence for the test-retest reliability of the Spanish versions of the DFS and NS.

Development of labeled magnitude scales for the assessment of pain of dentin hypersensitivity.

AIMS To develop and test labeled magnitude (LM) scales that are sensitive to variations in pain associated with dentin hypersensitivity (DH). METHODS Qualitative methods were used first to obtain words that describe the pain of DH. Magnitude estimation was then used to determine the position of these descriptive terms by relative magnitude along four vertical LM scales. To assess their DH, patients used the four LM scales following dentin stimulation with 4°C and 25°C water. The LM scales were then compared to visual analog scale (VAS) ratings by using eight pain scenarios of varying severity. Finally, participants with DH completed the four horizontal LM scales and VAS after dentin stimulation with 4°C and 25°C water. Within-subject t tests were used for comparisons between scales and water temperatures, and between-subject t tests were used for comparisons between participants with and without DH. RESULTS Participants showed comparable differentiation between 4°C and 25°C water on VAS and three of the LM scale measures. Responses on the fourth LM scale showed better differentiation than VAS between the two water temperatures. Participants used a greater portion of the LM scales than VAS when rating low-level pain scenarios. CONCLUSION LM scales were shown to provide some advantages compared to standard VAS when used to evaluate DH-associated pain. These advantages may be generalized to other low-level pain conditions.

Predictors of Unmet Dental Need in Children With Autism Spectrum Disorder: Results From a National Sample

OBJECTIVE Unmet dental need in children with autism spectrum disorder (ASD) is common. We tested hypotheses that lacking a medical home or having characteristics of more severe ASD is positively associated with having unmet dental need among children with ASD. METHODS Using data from the 2009 to 2010 National Survey of Children with Special Health Care Needs, we analyzed 2772 children 5 to 17 years old with ASD. We theorized that unmet dental need would be positively associated with not having a medical home and having characteristics of more severe ASD (eg, parent reported severe ASD, an intellectual disability, communication, or behavior difficulties). Prevalence of unmet dental need was estimated, and unadjusted and adjusted odds ratios, 95% confidence intervals, and P values were computed using survey methods for logistic regression. RESULTS Nationally, 15.1% of children with ASD had unmet dental need. Among children with ASD, those without a medical home were more apt to have unmet dental need than those with a medical home (adjusted odds ratio, 4.46; 95% confidence interval, 2.59-7.69). Children with ASD with intellectual disability or greater communication or behavioral difficulties had greater odds of unmet dental need than those with ASD without these characteristics. Parent-reported ASD severity was not associated with unmet dental need. CONCLUSIONS Children with ASD without a medical home and with characteristics suggestive of increased ASD-related difficulties were more apt to have unmet dental need. Pediatricians might use these findings to aid in identifying children with ASD who might not receive all needed dental care.

Behavioral Interventions May Reduce Dental Anxiety and Increase Acceptance of Dental Treatment in Dentally Fearful Adults

Article title and bibliographic information Psychological treatment of dental anxiety among adults: a systematic review. Wide Bowman U, Carlsson V, Westin M, Hakeberg M. Eur J Oral Sci 2013; 121(3 Pt 2):225-34 . Reviewer Lisa J. Heaton, PhD Purpose/Question Are behavioral and cognitive-behavioral treatments for dental anxiety more effective in decreasing dental anxiety compared to receiving information about dental care, completing dental treatment under sedation or general anesthesia, or placebo/no treatment in dentally fearful adults? Source of funding Information not available Type of study/Design Systematic review with meta-analysis of data Level of evidence Level 2: Limited-quality, patient-oriented evidence Strength of recommendation grade Grade B: Inconsistent or limited-quality patient-oriented evidence

Communicating with Patients with Special Health Care Needs

People with special health care needs (PSHCN) often have difficulty communicating with providers in health care settings, including dental practices. This difficulty can affect access to care as well as the quality of care received. This article provides practical tips and tools dental professionals can use to facilitate communication for a diverse population of PSHCNs. The article discusses communication needs of patients with communication disorders; augmentative and alternative communication; and communication for patients with intellectual disability, psychiatric conditions; and dental fears. Examples are given of communication breakdowns, and descriptions of how communication challenges can be resolved.

What happens after referral for sedation

Objective To follow up 100 referrals to the sedation clinic, examining dental anxiety and background of patients, and to assess how many patients attended for treatment planning, initial treatment and how many completed treatment, and describe the characteristics of each. For those who attended for initial treatment, to investigate which type of sedation they received and the level of clinician they saw.Design Descriptive, cross-sectional survey and review of case notes.Subjects and methods Subjects were 100 consecutive new patients to the Department of Sedation and Special Care Dentistry at Guys and St Thomas NHS Foundation Trust. The notes were analysed by an experienced member of staff (CAB) and data entered into an Excel spreadsheet and an SPSS data file created. These data were merged with a dataset containing their responses to the initial questionnaire and medical history for analysis.Results Of the 100 patients initially referred, 72 attended the treatment planning session, 66 of the 72 (92%) attended for initial dental treatment, and 33 of 66 (50%) completed treatment. Dental Fear Survey (DFS) scores were related to attendance at the initial treatment visit but not to completion of treatment. Only 33 of 100 referred patients completed treatment.Conclusions Attendance for treatment planning and initial treatment was high. Attendance is related to fear and mental health. Overall completion of treatment from referral was 33%.