Jenny sat in the dental office only because the nurses insisted at her intake physical exam that she do so. She had entered the state corrections system taking antibiotics and NSAIDs prescribed in the county jail to treat several necrotic teeth and abscesses. She had a history of methamphetamine use that had contributed to widespread severe dental decay. She also acknowledged that a high level of dental anxiety had caused her to avoid dental treatment in the past.

Dental anxiety is common among Americans, with about half experiencing at least moderate anxiety and 10% in the “severe” category. Among prison inmates, however, the rate of severe anxiety soars, reaching 80% for women in Oregon prisons, according to an informal review of that population.

It makes perfect sense: Patients who report high dental anxiety describe a sense of personal space infringement while in a prone and vulnerable position, unable to communicate orally while an authority figure with sharp metal instruments hovers above inflicting discomfort and lecturing about dental hygiene.

Nearly all dental phobia stems from traumatic experiences such as not being listened to in the dental chair, especially if not numb enough; being pushed around psychologically; and being given no control over the experience.

Stressful enough in the general population, such circumstances are even more upsetting for inmates and especially female inmates, many of whom have a history of physical or sexual abuse. In fact, recent studies confirm a connection between such history and extreme dental anxiety.

Such intense anxiety has negative consequences. Patients are more likely to miss appointments, and if they do show up, they are tense and difficult to treat, taking up to 20% more chair time. They have negative attitudes about dentistry and convey these attitudes in and out of the dental office. Incidentally, the dental staff absorb some of this stress and negativity.

More detrimental, phobic patients may self-medicate with marijuana, narcotics or other substances to deal with their dental pain or with the appointment itself.

This leads to a vicious cycle given that current and recovering substance abusers are likely to have severe dental disease. Abuse of drugs such as methamphetamine, cocaine, tobacco and opiates causes decreased saliva production, and is often associated with high sugar intake, poor oral hygiene and high incidence of caries and periodontal disease.

Measuring Anxiety
Models of human conditioning tell us that things learned in times of intense emotion are profoundly felt and difficult to “unlearn” without dealing with that gut-level feeling.

But to manage gut-level phobia, it first has to be recognized, and that’s where dentists sometimes come up short. Studies have shown that trained observers, including dentists, failed to recognize high anxiety in patients more than 50% of the time.

Fortunately, a number of tools exist that can help them to gauge their patients’ anxiety. These include patient questionnaires, the Dental Anxiety Scale (DAS) and the Dental Concerns Assessment (DCA) (see citations below). (Download the tools here.)

These tools produce reliable results. Used alone, simple patient questioning and the DAS each have about 80% accuracy, and this figure increases when both are used together. They also are easy to use. The DCA, for example, takes 5 to 10 minutes to do, while the DAS can be completed in about a minute.

Use of these standardized instruments not only quantifies the patients’ anxiety, it also opens the door to discussion about it. In some cases, that’s all that is needed to temper their anxiety.

Jenny and I agreed that this would be a get-acquainted appointment. She was asked to complete two written instruments, the Dental Anxiety Scale and the Dental Concerns Assessment. We then discussed her responses to these questionnaires.

As we talked about her anxiety, I asked Jenny what she had been doing about the pain, and she replied sheepishly, “That’s why I’m here.” She had been seeking Vicodin through illegal means to relieve her intense dental pain. Finally, she felt comfortable enough and reassured to agree to return to have the three necrotic teeth removed.

Managing Anxiety
Not every case of dental anxiety is so easily resolved, however. When more concrete anxiety management is needed, relaxation training may be a useful approach. This encompasses behavioral techniques such as controlled abdominal breathing (slow and deep); meditation, suggestive relaxation therapy or self-hypnosis; and biofeedback. Environmental comfort can be enhanced by providing a neck pillow and music or relaxation recordings.

This will have a soothing effect on autonomic nervous system pathways by lowering heart rate, pulse, adrenalin levels and breathing rate while improving blood flow to the body surface and to the digestive tract.

Another approach, known as cognitive restructuring training, aims to help patients identify and correct errors in thinking that generate anxiety and depression.

If necessary, anxiety can be managed pharmacologically. Drugs that might be appropriate for this purpose include Vistaril, Buspar, benzodiasepines such as Triazolam and Valium, and antidepressants such as Zoloft and Trazodone.

For patients who suffer from the highest levels of anxiety/phobia (a score of 15 to 20 on the 20-point Dental Anxiety Scale), even medications might not suffice. In 2% to 3% of cases the help of a mental health therapist might be required. This is seen most often when the patient cannot or will not talk about the fear, is extremely difficult or hostile, has unmanaged panic attacks or anxiety disorder, or has a history of abuse.

Respect and Empathy
It’s important not to blame the victim. After all, many people who suffer from anxiety then become anxious about being anxious! Instead, dentists should recognize their own role in causing dental anxiety.

It is imperative that dentists believe patients who say they are not numb, and that dentists be resourceful and skillful in administering supplemental local anesthesia injections, particularly of the mandible.

Further, by using the dental anxiety instruments, which enable patients to articulate their fears, and by treating them with respect and empathy, allowing a measure of control, we can facilitate their learning coping skills that will continue after their release.

Bettina sent a standard inmate request form to the dentist stating that a tooth had fractured. She was called to the clinic for an evaluation a few days later, and we had time to fill the fractured tooth with a silver amalgam overlay. Bettina mentioned that she would be released soon and had feared that the tooth might have become painful had we not restored it. She also said she had worried that, to treat the pain, she might have relapsed in her recovery from heroin. As she left the clinic, she thanked us.

Citations
• Dental Anxiety Scale-Revised (DAS-R): Corah, 1969
• Dental Concerns Assessment: Clarke, 1993, revised 1998