Practical Approaches to Managing Apprehensive Patients

By Larry J. Sangrik, DDS

Dental fear remains as a leading cause of why patients avoid seeing a dentist. It is estimated that at least 75% of adults describe dental care as an anxiety-producing experience.

Overwhelmingly, dentists and the team members that surround them are caring, compassionate individuals. They consistently seek to allay their patient’s fears. However, it is discouraging when the technique that benefits one patient, fails so dramatically on another.

If only there were a technique to identify and classify a patient’s fear and then respond accordingly. Actually there is…

Almost all dental practices have some type of initial interview for new patients. Typically, it involves a review of the medical and dental histories. Although some practices delegate this task to a team member, I believe it so important that I personally do the interview myself.

In an old ballad, Rod Stewart said his “ad lib lines were well rehearsed.” While many dentists may be “gun-shy” to broach the subject of dental fear with an individual they just met, I believe it is during the dental history a dentist should seamlessly direct the conversation toward a discussion of the patient’s fears through a guided conversation.

During our discussion I am seeking answers to three specific questions.

1. Why is this patient fearful of dentistry? Decades ago two researchers, Milgrom and Getz (University of Washington), postulated there are four causes. While I concur with much of what they discovered, I found the need to be refined into the following four areas.

    • Specific Fears (whether they be physical, procedural or abstract)
    • Loss of Control
    • Fear of Catastrophe
    • Generalized Anxiety (by far the largest percentage of patients)

2.  How frightened is this patient? Within any of the four categories, the magnitude of the patient’s fear is critical. Surprisingly, patients are very open to discussing the severity of their fears. More importantly, in addition to being forthcoming, we have found they are extremely accurate in self-assessing the intensity of their fear.

3.  Finally, what kind of personality does this patient display? I have found the DISC™ personality profile to be extremely useful in understanding a patient’s behavior in relation to their fear. The DISC™ system examines two attributes of a person: 1) extrovert versus introvert and 2) analytical versus intuitive. These attributes provide four possible combinations

    • D for Dominant: analytical, extrovert
    • I for Influential: intuitive, extrovert
    • S for Steady: intuitive, introvert
    • C for Conscientious: analytical, introvert

Long-term research has shown that each of these personality styles exhibit certain characteristics, including behaviors under various circumstances such as stress and fear.

With a well-planned interview that includes the medical/dental histories and explores the patient’s fears, a “three dimensional” portrait of the patient can be drawn, usually within 10 minutes.

As the dental exam progresses, we now consider not only what dental procedures are necessary but also what fear-management strategies are appropriate.

Fear-management encompasses two broad areas: patient-mediated techniques and dentist mediated techniques.

Patient-mediated techniques include: 1) physical strategies such as patterned breathing and muscle relaxation, 2) physiological strategies such as biofeedback and 3) cognitive strategies such as redefining success, distraction, and guided imagery.

While it can be argued that patient-mediated techniques are the “best” apprehension management approach because the patient actually conquers their fears; they are not without significant limitations.

We live in a “quick-fix” culture and many of these techniques rely on the patient investing time to master the skill involved. Overwhelmingly, patients would choose to invest dollars instead of hours to address their fears.

This, then, brings us to dentist-mediated fear management techniques. For an outside party, such as a dentist, to overcome a person’s fears, they need to rely on medications.

Dentists essentially have four options, with increasing levels sedation and corresponding levels of training and monitoring skill.

  1. Nitrous oxide sedation
  2. Oral sedation coupled with nitrous oxide sedation
  3. Moderate anesthesia care
  4. Deep sedation / general anesthesia

While the first three are considered forms of conscious sedation, the fourth category renders the patient into a state of unconsciousness.

While merely being compassionate toward fearful patient has value, at some point dental practices must accept that in training to both identify fear and offer appropriate modalities.

Using the patient-portrait generated by answers to our three questions, we now have predictable insights into which technique would best meet a particular patient’s apprehension-management needs.


L Sangrik Dental Speaker

Contributor:

Larry J. Sangrik, DDS is a 1979 graduate of The Ohio State University College of Dentistry.

For over 20 years Dr. Sangrik has been a well-known national dental CE lecturer. His lecture topics include medical emergency preparedness, understanding dental fear, use of conscious sedation in dentistry and patient monitoring. In addition to two appearances at ADA Annual Sessions, Dr. Sangrik has been featured at virtually all of the nation’s major dental meetings and five US dental schools.

In addition to actively practicing dentistry, Dr. Sangrik has also conducted research and written for various dental publications on his areas of expertise.

View Dr. Sangrik’s full bio