Managing the fear factor

Robert Elsenpeter;

Managing the fear factor

January 24, 2019

Dental Products Report, Dental Products Report February 2019, Volume 53, Issue 2

How putting patients at ease can make their (and your) life better.

For some patients, sitting in the dental chair can feel a lot like being questioned by Laurence Olivier in the 1976 movie “Marathon Man” with his character uttering the famous phrase, “Is it safe?” That comparison is more than a little hyperbolic, of course, but some level of fear and trepidation is a real concern for most patients.

Easing dental anxiety is a two-way street. While the patient should take the initiative to ameliorate his or her own angst, which may begin by telling the dentist these feelings exist, the dentist can also strive to minimize patient anxiety and fears.

Patients’ main concerns include:

Fear of pain

Fear of local anesthetic injection or that the local anesthetic won’t work, necessitating repeated injection

Fear of local anesthetic side effects

Fear of helplessness or loss of control

Embarrassment and loss of personal space

No matter the reason, putting them at ease makes a better experience for patient and doctor alike.

Fear hurts the patient and the dentistry

It isn’t just patient comfort levels that are a concern. If that anxiety gets out of hand, it can have a negative effect on the dentistry too.

“From a procedure standpoint, an anxious patient can be much more difficult to work on,” says Dr. Jennifer Sanders, DMD, a general dentist in Frenchtown, Montana. “If you’re trying to keep them comfortable, some people’s fear is that they feel like they can’t breathe or that they’re drowning, and that means you’re needing to get them a lot more breaks and stop more often.It can make the procedure a lot more difficult, or you’re trying to keep the composite dry, and they’re freaking out. But that’s how they feel. You want to try and work with them, but it can be difficult to have the best conditions for your materials to work well.”

A trust-based relationship is necessary for overall patient well-being.

“Trust is to be a big part of whatever we do,” says Dr. Jason Goodchild, DMD, director of clinical affairs for Premier Dental Products Company. “So, if I can talk to patients about what’s going on, I can talk to them about the need to do something and the consequences of not doing something, and then I can talk to address any fears that could stand in our way, that’s a huge part of even getting them into the chair.

“Now, when we just get in the chair, people need to hold still and they need to open wide,” Dr. Goodchild continues. “So, all those things can be troublesome for the very fearful or anxious. They want to move or not open their mouth very wide. We do our best to work around that stuff when they’re actually in the chair and still provide treatment. Hopefully we’ve got a lot of their concerns under control by this point because the highly fearful patients will just try to avoid even getting into the dental chair.”

Ease the pain

There are things the clinician can do to put the patient at ease from the moment he or she sets foot in the office.

“First and foremost, just setting the stage with a calm and comfortable office goes a long way with a lot of people,” says Dr. Rebekah Lucier-Pryles, DMD, an endodontist in White River Junction, Vermont. “We chose our décor strategically to make sure that it was a calm and comfortable environment that patients would walk into knowing that they were going to be cared for. Even just the way that our staff interacts with the patient is important from the beginning, just to let them know that we care about them and their concerns. We answer their questions and start to develop that relationship from the get-go.

“We work really hard to address patient concerns at the beginning,” she continues. “Maintaining open and honest communication about what exactly it is are you nervous about can go a long way to alleviate a lot of that treatment anticipation. It’s really environmental and relationship building from the beginning, and it can set the stage for an anxiety-free procedure, at least for us.”

While a trip to the general dentist can cause some measure of anxiety, specialists - like endodontists, for instance - have to deal with even more intense feelings of fear and dread.

“Anxiety is a really common issue that most endodontists deal with on a day-to-day basis,” Dr. Lucier-Pryles explains. “Root canals have a bad reputation. We’ve all heard the expression, ‘I’d rather have a root canal, than [do something].’ Most of our patients come in with, at least to some degree, anxiety or concern about what’s going to happen. General dentists have the added benefit of a longer-term relationship with most patients, so they have an ability to build up trust over a long period of time. Patients are referred to us, and they don’t know us from any other person that they’ve recently met, so we have to work really hard and really quickly to make sure we have proven to them that we are trustworthy. So much of that is our staff setting the bar for that relationship. It’s just coming into it as kind and considerate individuals to alleviate some of that anxiety right from the beginning.”

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What patients need

Managing patient stress involves the whole team.

“It starts with an acknowledgement that almost every single person that walks in the office is nervous about what’s going to happen, sort of handling that from the jump - meaning everyone on the team is sympathetic, empathetic and ready to help the patient any way they can,” Dr. Goodchild says. “And that could be just by a friendly person talking with them, building rapport and trust. It could be making sure that your office is clean, looking good, things are working and up to date.”

Patient anxiety can stem from any number of things, so mitigating as many potential causes as possible is a great start.

“The source of nervousness or anxiety or fear could be lots of different things,” Dr. Goodchild explains. “It could be the needle, it could be the drill, it could be the post-op pain, it could be just the smell of the dental office. Even something like making sure that your office is clean and following strict infection control procedures.”

Further, he illustrates just how important it is to look at the experience through the patient’s eyes.

“In this day and age, that really is a huge part of it,” Dr. Goodchild says. “Sit in the dental chair, yourself, and look around, from the patient’s perspective, to see what they see and the perspective they have. Everything is potentially anxiety-producing for these patients. It could be even the cost of treatment. The unknown of, ‘What am I getting myself into? Is the dentist going to suggest expensive treatments that I can’t afford?’ One of the things that’s really worked for me is looking people in the eyes, shaking their hand, greeting them, and sometimes not even using the word doctor - just saying, ‘Hi, I’m Jason Goodchild. How can I help you?’”

Naturally, it isn’t just the doctor’s job to put patients at ease. The whole team must be involved.

“That culture has to be through every member of the team,” Dr. Goodchild says. “When it’s a team thing, then you have a good place to start. There’s this term, the idea of that ‘dental home,’ and home should feel like a safe place. And when you can do that, all else kind of becomes secondary.”

Some very basic, simple techniques might be all that it takes to take off the edge.

“I’ll try to talk to the patient, get them to take some deep breaths, get them to wiggle their toes, just try to get them back into their body and not focusing on their fear and anxiety, not focusing on what I’m doing, distracting them, but then also having them calm down,” Dr. Sanders says. “Something as simple as taking really good deep breaths can help them bypass that fight-or-flight reaction until the person calms down.”

Ultimately, it comes down to good old-fashioned communication.

“Talk to the patient,” Dr. Sanders says. “Take some time to listen to them. If people feel heard, if they tell you they’re anxious and you actually spend a couple of minutes talking to them about why and what you can do, that helps a lot, instead of just pushing the next thing in their face. It’s not exactly comfortable to have somebody that you don’t know working in your face and putting sharp things in your mouth.”

Communication is a good way to get started, but where the clinician goes from there depends on the patient and his or her unique needs.

“I have patients who want to be talked through the procedure and know exactly what’s happening as it’s happening,” Dr. Lucier-Pryles says. “That’s a really nice tool that we endodontists can use to let the patients know what’s occurring in their mouths and to have a better idea of not only what’s happening but how long it’s expected to take, etc. It really sets the stage from the beginning to have conversations about what we’re doing and why - it goes a long way to help patient anxiety.”

“All people are unique,” Dr. Goodchild adds. “I find that, for most of my patients, they do really well with just some coaching. For those who require more, it’s really drawing on their past experience. Some have taken oral anti-anxiety medication before and know that it works well for them. Some have used nitrous oxide and oxygen sedation in the past and know that it works well. There are those who say, ‘I used both of these and it’s not been effective.’ It’s really important to maintain open communication with people to understand what makes them anxious and how we can best help them and get them through comfortably.

“I wish I could say that I had a magic bullet, and I don’t think I do really,” he continues. “Just like everybody’s mouth and teeth, and every one of the thousands and thousands of carious lesions we treat or crowns we make, everyone is different. Every patient is different in that regard. I think everyone needs a little something different. Asking people what they want has been successful for me so that we can tailor the approach. We do make notes in the treatment record about what we’ve done from the local anesthesia we’ve used, or nitrous oxide, or oral medications, or things that may help us with treatment from appointment to appointment. Sometimes the patient doesn’t want the radio on and prefers a quieter environment, or the patient wants a particular TV channel on, or the patient doesn’t like to hear ‘dental speak,’ or clinical language. We make notes about what management strategies the patient prefers so that we can be consistent.”

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Stay vigilant

Managing patient stress is an ongoing process. It starts as soon as the patient arrives at the office but continues throughout the visit.

“It’s a matter of looking from the second they walk in the door,” Dr. Sanders says. “You see that person that comes to the front desk and either they won’t talk or they just won’t be quiet. They just talk constantly. They’re asking the front desk 50 million questions, or they just kind of go hide in a corner of the room and they won’t say anything. And it’s the same thing when they come back in there chatting with the assistant before getting started.

“Then you get the opposite end of the spectrum where they just seem really rude, but it’s just that they’re afraid,” she continues. “Keep in mind that a lot of these people who come in and they seem like they’re just not the nicest person, it’s really just that they’re afraid. They’re anxious, and they’re just afraid do it.”

Don’t leave it to the patient to indicate that he or she is stressed. The way in which you discover the apprehensive patient will differ from person to person.

“Identify the anxious patient,” Dr. Sanders says. “Some of them are going to walk in and tell you they’re terrified, or that they hate you, but some of them are not. Just reading that body language and realizing that they are anxious and you have to be a little bit more gentle with them. After that, I try to find out what they want. Not everybody’s going to have the same reaction or the same thing that’s going to make them comfortable. I like to find out if they like a lot of information. Will it make them feel better if I try to tell them everything I’m doing? Do they just want to zone out?

“And the other thing is, what makes them anxious?” she continues. “For some people, it’s the whole experience. For other people, it’s only the anesthetic. Other people, it’s just a noise. If it’s just the noise, then just give them some noise-cancelling headphones and help them relax. If it’s the anesthetic, then I know to focus on talking to them through that. I definitely use a good amount of topical gel, let that sit in, and then just use a very gentle injection technique so that they’re feeling it as minimally as possible.”

It’s better to find out sooner rather than later that a patient is feeling anxious.

“By the time you see outward signs, sometimes the game is over,” Dr. Goodchild says. “One of the things that I’ve done is to talk to patients about the things that make me nervous. And one of the things that makes me nervous is flying. I would say something like, I don’t like to fly, but one of the things that always makes me feel better is when the captain comes on and says, ‘We are going to have a little bit turbulence here, but don’t worry.’ Or they say, ‘We are going to start to land soon.’ I really like to use that analogy in the dental office. It’s like the update from the cockpit. What is the patient going to feel next? What’s coming next? How much longer is this going to last? Those little updates as the procedure is going on can really help because the fear of the unknown is really what a lot of people are nervous about.

“Sometimes I’ll say to patients, ‘Hey, what would you like me to do here?’” he continues. “‘Do you want me to give you updates every so often of where we are in the procedure? Do you not want me to talk? Do you want me to just kind of roll, trying to get through it as quickly as I can? How do you want me to do this?’ That gives the patient some control as well. There are so many facets to dentistry, but it’s very personal and patients - because of that personal nature, and you’re working in a very personal space - the idea of giving up some control sometimes is difficult for patients. Reminding patients that they are in control or understanding that when you say, ‘I need a break,’ that you get a break, or if ‘it hurts,’ it hurts. My philosophy for the patient is, ‘How can we make this better for you?’ and then listening to what they need so that it can be addressed upfront has been hugely successful for me.”

Keep checking in on patients to ensure that their stress levels remain manageable.

“I and my assistant both check in with patients regularly during treatment,” Dr. Lucier-Pryles says. “We’re not waiting to see signs of distress. I’m asking constantly, ‘Are you comfortable?’ ‘How are you feeling?’ ‘Is there anything I could explain differently for you?’ ‘How’s everything going on your end?’ and the assistants are checking in similarly as well. So, we don’t wait for things to get out of hand before we manage them. We’re trying to preempt it as much as we can.”

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The environment

What patients’ senses encounter are very influential factors in their stress level. Paying attention to that detail can have hugely beneficial effects.

“I think what we’re talking about is distraction,” Dr. Goodchild says. “We’ve had TVs on the wall, TVs on the ceiling. I know a lot of dentists will put up calming kinds of pictures. I know some dentists who, when they build a new office, try to have a lot of windows with nice views. You don’t want dental posters up. If you are going to have posters or pictures on the walls, you want them to be nonclinical and pleasant. You want people thinking about other things that could take their mind off dental treatment. You may have calming music. You may have something that generates a nice smell. I know offices that have more like a spa environment, which I think is really effective.”

“The whole environment should be right,” he continues. “From the moment they walk in, it should feel like a really nonthreatening place, and that’s why a lot of dental offices prefer something called an ‘open concept’ where you don’t have treatment rooms with doors, you have sort of half walls and multiple exits, so it works against the claustrophobia of the dental experience. There’s a method to the madness, even going back to the office design, in the way that the flow of the office is set up, not just for patient comfort but also for efficient treatment delivery.”

Dr. Lucier-Pryles designed her practice with patient comfort in mind.

“When we were developing our vision for the office, we practice in Vermont, so it’s cold for a lot of the year,” Dr. Lucier-Pryles says. “We placed a fireplace in our waiting room and made sure the furniture was really comfortable and had water available to patients and had a nice selection of magazines to set the stage from the beginning that it was a comfortable place.

“We chose tones that were kind of cool and relaxed - on purpose - to help keep everybody’s blood pressure down,” she adds. “In the treatment rooms in the back, we kept with that same color palette and also had some really nice local artists develop some pieces that were really pleasing to look at. Also, within the treatment rooms, we have a lot of the equipment hidden, so patients aren’t walking into the room seeing all sorts of intimidating dental implements. That way we can kind of take things out as we need them, but we’re not going to scare people from the beginning with what’s out there.”

Relaxing outside the box

Responding to patient cues, relaxation and soothing environments are easy, effective places to start, but what if that just isn’t enough? Some practices have successfully used therapy dogs, acupuncture and hypnotism. More commonly, pharmaceutical interventions can be effective.

“I’ve always used traditional methods,” Dr. Goodchild says. “That would include oral anti-anxiety medications, like oral benzodiazepines. We use nitrous oxide and oxygen as well. Local anesthesia is a huge part of it, even with sedation techniques, and all the things we talked about thus far. Without good local anesthesia, you really can’t do anything. It goes back to that notion of just being aware of what the patient needs.”

“We’ve kind of stuck with pharmacology for those patients who don’t respond well to other things,” Dr. Lucier-Pryles adds. “Everything from oral anxiolytic medications like benzodiazepine to nitrous oxide. We actually have an anesthesiologist who comes in from the hospital for patients that even need additional anxiolysis, so we actually can provide our patients with an IV sedation, in the most severe cases.”

If patients need that extra help, especially if they’re being referred by another doctor, then the more notice, the better.

“Communication is so important in a specialty practice,” Dr. Lucier-Pryles says. “We rely on our referring doctors to say, ‘Hey, this is a patient who is really anxious about upcoming treatment. Perhaps you should schedule a consultation with them to talk about how you want to manage this moving forward.’ And, again, most of it is just being open with those patients to say, ‘Hey, here’s your pathology. Here’s what we have to do about it. We want to make this as easy on you as possible. Here are the ways that we can go about doing that.”

“Marathon Man” was just a movie, but paying attention to patients’ anxiety can make them know you’re there to help - not to inflict torture.

Download Issue: Dental Products Report February 2019