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Bruce Peltier, Ph.D., M.B.A. and
Paul Glassman, D.D.S., M.A., M.B.A. |
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Dentist - Psychologist Collaboration: The Case of the Anxious Patient
There are many areas in dentistry in which psychology can make a significant contribution, an obvious one being the treatment and management of anxious patients. Fearful dental patients are common, and they are problematic to the dentist for at least three reasons: First, they make optimal treatment more difficult and less likely to happen. It is easier to perform a complex dental procedure when a patient is able to sit still and “open wide” for long periods of time. Treatment planning is difficult and often disrupted when patients squirm and withdraw. Problems left untreated are subsequently more difficult to make right. Second, anxious patients make dentists anxious or even angry (as they do to nearly everyone they meet). And third, anxious patients slow things down and no-show at a higher rate than other patients. Dentists are time conscious, and some even hire management consultants to teach them how to work efficiently and maximize profit. A related problem is that dentists typically feel that they are in the business of helping people, performing an important health care function, and are doing it in the most comfortable way that they can. They are sensitive about they way that they are perceived by the public, and many get their feelings hurt when people are fearful of them. Dentists feel helpless when they cannot help.
Dental fear is an even greater problem for patients, in that it causes them to skip treatment that they really need and to suffer when they eventually present themselves for care. Some people worry about dental problems even when they don’t have any.
As psychologists know, anxiety disorders are the most prevalent disorders in the general population, and specific phobias are widespread (Maxmen, 1986; DSM IV, 1994). Anxiety about dental treatment is extremely common, and studies have noted that anywhere from 46% to 75% of the population suffers at least some dental anxiety, while 6 - 14% of the population never go to the dentist because of fear (Robbins, 1962; Milgrom, et. al., 1988). Among those who do not see their dentist regularly, 90% report that the reason is dental fear (Agras, et. al., 1969). Most people can relate to this problem at some level.
What do people fear?
There is a long list and it is clear that psychology has much to offer in each of these areas.
- Fear of pain. This is a very commonly expressed fear, and, to some extent is “objectively” justifiable. Dentistry is rarely totally comfortable although, increasingly, dentists are finding ways to make visits nearly or completely pain-free. Public perception has not kept up with dental advances, and many people recall early or previous experiences with the dentist which seemed quite painful.
- Fear of being out of control. People don’t know and can’t see what dentists are doing in the very private oral cavity. Many people are sensitive about their mouth, and analytic or dynamically trained psychologists immediately understand. This is a situation where you, as a patient, simply must lay back and let someone else take complete charge. This is extremely difficult for many people. Some patients have experienced sexually difficult or abusive experiences, and this situation triggers frightening memories. Some patients are also afraid of how they, themselves, will behave, and do not want to embarrass themselves or do something embarrassing in the dentist’s office. They then become afraid of their own potential reactions.
- Fear of dentists. An associated set of fears evolves when patients perceive that the dentist doesn’t empathize or understand or care about them. This is a serious problem for dentists who lack good interpersonal skills. Dentists who really care about their patients are often misjudged because they move too fast or don’t appear to listen. Dentists are sometimes viewed as sadistic, even though they are not. On the other hand, some dentists really don’t care all that much about patient comfort. They entered dentistry to get control or to make money and have a nice lifestyle. Patient concerns are secondary to “production.”
- Fear of strange equipment or smells. The dental office is a strange and unfamiliar place for most people, and although modern offices are becoming more and more patient-friendly, it is impossible to turn a dental office into a living room.
- Fear of X-rays. People are increasingly wary of the dangers in our environment, and television documentaries on the dangers of X-rays have not made dental radiography any easier. Dentists and assistants routinely field questions about the safety of essential diagnostic “pictures.”
- Fear of specific procedures. Some patients have irrational ideas about root canals, for example, when endodontic procedures are essentially pain-free, once anesthesia is working. It is rare to read a single newspaper without some reference to how something is as terrible as a root canal. (It is analogous to psychologists putting up with media references to a “schizophrenic foreign policy.”)
- Fear of gagging or choking. For some patients this is a difficulty, and, while it can be substantially ameliorated, many procedures in dentistry require that patients relax under stressful circumstances. Again, some patients unfortunately associate these sensations with previous sexual abuse.
- Fear of numbness. There are patients who simply cannot stand the idea that their mouth or lips will be numb. They are afraid that , when numb, they will not be able to breathe or swallow, or that they will spill their drink or talk funny and embarrass themselves later in the day. They would much prefer simple pain to anesthetic numbness. (Some of these patients are good hypnotic subjects.)
What can psychologists do?
Dentists are aware of the problem of dental anxiety, and some have studied the problem, read dental journals, and a few have taken specific additional training (although there is not much training offered to them in this area). However, many dentists inaccurately assess their own ability to deal with anxious patients, as they feel that they already possess the skills necessary to deal with any kind of patient who comes through the door. Some dentists don’t think much about communication skills, and others have never gotten around to developing or enhancing their interpersonal skills. Dental students are not typically selected on the basis of social skills, and, unless they are confronted with educational experiences, many dentists will never become proficient with anxious patients. Some, as a defense, will even blame patients for their fears. Because patients who have a negative experience with a dentist typically disappear (rather than confront this imposing figure) the dentist never receives essential disconfirming evidence.
We teach dentists and patients several simple (but not always easy) approaches to the problems of dental anxiety.
- Learn modern injection procedures. Dentists can learn to give injections which are (believe it or not) essentially pain-free. They are not as comfortable as, say, a massage, but they really aren’t “painful” for most people. The downside, if there is one, is that they take a few moments longer than a quick injection might. The benefits to dentists and patients are, of course, huge. Some dentists figure this out for themselves; others can be taught.
- Slow everything down. Dentists are constantly taught and reinforced for time-efficiency. Time is money, and all that. But a speeding dentist communicates all the wrong things to many patients (while other patients actually prefer a quick appointment), so dentists need to figure out who’s-who and adjust accordingly. Most dentists can move through their day very, very quickly. Dentists get paid on a “piece-work” basis. They are not accustomed to charging for their time or their expertise or their judgment, and are reluctant to do so. Slowing them down is not easy, especially when they are paying large fees to consultants who teach them to become more efficient.
- Learn active listening. This simple and powerful Rogerian skill makes a big difference in dentistry. Dentists are willing and able to learn practical skills that they can apply in the office. Staff members (dental assistants and hygienists) are essential and even more eager students of effective listening skills than dentists themselves, even though it is the dentist who uses the sharp and dangerous instruments. Nonetheless, an empathic dental assistant can smooth over lots of interpersonal rough spots, while a poorly communicating assistant can ruin the best dentist’s efforts. This even applies to receptionists and front office staffs, and it includes the way that they communicate with patients over the telephone.
- Yield control. Whenever possible, we teach dentists to give control to patients, even if (especially if) the matter is not central to treatment. Let patients choose as much as they can. This includes the choice of treatment options and is related to the overall pattern of autonomy in the doctor-patient relationship. Some dentists have difficulty with this change from older paternalistic practice patterns, but younger dentists are taught a collaborative approach these days in dental school. Dentists must ensure that patients know that they can stop the dentist during any procedure, at any time, when they signal the dentist to do so. Specific signals are set up and practiced in advance.
- Develop scripts and hypnotic language. As any psychologist knows, words are powerful. (Recall Kipling: “Words are the most powerful drug.”) They can frighten and they can soothe, and one’s choice of words can change the world. Psychologists can help dentists learn specific ways to speak with anxious patients. Language has hypnotic and persuasive qualities, and psychologists can teach dentists about Ericksonian ways.
- Teach hypnosis. Patients and dentists benefit greatly from trance based hypnosis. Every dentist is at least obliquely aware of other dentists who report on the powerful potential of hypnosis in dentistry. Some patients (good subjects who are highly motivated) are able to accomplish virtual miracles with hypnosis. Simple progressive relaxation can be of great benefit to many anxious patients (and dentists, for that matter) (Benson, 1975).
- Educate patients. This, too, takes time, but the benefits to patients and dentists can be substantial, especially if the dentist is inclined to establish life-long relationships with patients in the community. The effective dental office is an educational institution, and education is woven into all aspects of care. Dentists are well aware of the value of patient self-care.
As a consultant to the dental practice, psychologists can team with dentists to help develop a “People Centered Dental Practice,” and all parties can benefit. Fear reduction is taught to patients, stress management to dentists, and communication skills are learned and practiced by all members of the dental team. Dentists are highly motivated learners (under the right circumstances) and the potential benefits of dentist-psychologist collaboration are increasingly clear. As can be seen, psychologists possess a set of skills uniquely positioned to help in this important aspect of dental practice.
References
Agras, S., Sylvester, D., & Oliveau, D. (1969). The epidemiology of common fears and phobias. Comprehensive Psychiatry, 10 (2), 151-156.
American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders.
Benson, Herbert (1975). The relaxation response. New York: Morrow Company.
Maxmen, Jerrold. (1986). Essential psychopathology. New York: WW Norton.
Milgrom, P., Fiset, L., Melnik, L. & Weinstein, P. (1988). The prevalence and practice management consequences of dental fears in a major U.S. city. JADA, 116, 641-647.
Robbins, P.R. (1962). Some explorations into the nature of anxieties relating to illness. Genet Psychol Monogr, 66, 91-144.
Dr. Peltier is Associate Professor of Psychology at the University of the Pacific School of Dentistry in San Francisco and is a licensed clinical psychologist and licensed marriage and family therapist. His E-mail address is bpeltier@uop.edu.
Dr. Glassman is Professor of Dental Practice at the University of the Pacific and is Director of the Advanced General Dentistry Residency program and Director of the Special Needs Program. He is also Director of Information and Educational Technology at the dental school. His E-mail address is pglassma@uop.edu |
