Ways of Tackling Dental Fears

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Ways of Tackling Dental Fears

In the What Can Help section, you can find information on the three main things that can help with overcoming dental phobias and fears:

1. psychological – the way the dentist acts and communicates, and specific techniques dentists can use to help

2. technology and gadgets – new and not-so-new inventions which can make dental treatment more enjoyable

3. sedation – using drugs to make you feel relaxed.

For dentists, there is also a fourth way, and that is local anaesthesia technique (giving comfortable and effective numbing).

The way you tackle your fears needs to be tailored to you as an individual. But generally speaking, we can look at tackling fears (or “dental anxiety management” in dentist-speak) as being a bit like a pyramid:



The Environment

The dental environment, despite being of such huge importance, is often overlooked when it comes to dental anxiety. The environment sets the tone for the whole dental experience – first impressions do count! While we cannot do away with modern dental equipment, many people with dental fears find it really important that the rest of the room doesn’t have a “clinical” feel to it. This means, for example, instruments being hidden from sight as much as possible, artwork instead of photos of smile makeovers, friendly colour schemes, music playing in the background, dentists and staff not dressing in traditional medical outfits, and doing away with the “typical” smells associated with dentistry as far as possible.

Communication

The foundation of the pyramid is communication. This means the way your dentist interacts with you (and the way you interact with your dentist). You need to feel at ease with your dentist if you want to overcome your fears, and your dentist needs to know what you fear and how they may be able to help you. Communication also means things like rapport, body language, and using non-threatening language that you can understand. Rapport (a harmonious connection) also implies a relationship of equals, where you don’t perceive your dentist as a threatening or a condescending figure, but as a partner in your care. Communication means that you do things together with your dentist, rather than your dentist doing things to you.

You should only move on to more concrete techniques and options once rapport has been established.

The least invasive approach – that is, psychological techniques – should be considered and tried first.

Psychological Approaches

Psychological approaches include techniques such as tell-show-do, structured time, desensitisation, and other options which you can read about on this site (see the right navigation box). In dentist-speak, these are referred to as behaviour management. While “behaviour management” may sound ominous, it simply means that your dentist will let you gradually get used to new, unfamiliar things, take things slowly, explain things to you, let you know what s/he is doing and what to expect, and so forth.

An integral part of this approach is that any treatment is delivered comfortably and gently.

Inhalation Sedation

If psychological techniques alone do not help you enough, there are then various sedation options. Inhalation sedation (laughing gas) is great for making you feel more relaxed, and it is very much a “participation technique” suited to people who like to feel in control of situations.

IV Sedation

On the other hand, IV (intravenous) sedation may be better suited to those who are more willing to entrust control to another person. It can produce a level of sedation so deep that you may not remember much, or even nothing at all, of what happens during treatment.

IV sedation can also be a good option if you need lots of work doing and you are really worried about it. In this case, you might be better served getting things under control using IV sedation, and then experiment with other methods when you require just a bit of maintenance work. Having said that, if you find yourself a really good dentist, he or she might be able to treat you using other techniques alone, which will be less expensive.

Remembering the treatment and having positive experiences will help you build confidence.

Technology and Gadgets

Also, there have been some exciting technological advances and innovations which can really help with specific fears. For example, the wand has been a real blessing for people with needle phobia, who in the past might have opted for sedation. Handpieces (“drills”) have become quieter, and there is even a device now which allows people to literally stop the handpiece at the press of a button (although it isn’t widely available yet) – ideal for the many people who fear loss of control. Minimally invasive methods such as air abrasion and ozone therapy also hold much promise for delivering gentle care and ensuring that children do not grow up to develop dental fears.

You can find out more about these technologies, as well as about psychological and sedation approaches, by exploring the pages in the right navigation box.

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Psychological Approaches for Tackling Dental Fears

Dentists often adapt approaches from children’s dentistry when helping adult phobic patients. And although they were originally invented with children in mind, there’s nothing intrinsically childish about them.

Baby Steps or Giant Strides?

Frequently used techniques include:

the use of non-threatening language (and body language)
interactive approaches based on tell-show-do techniques (direct interaction)
structured time (taking frequent breaks)
positive reinforcement (making positive comments)
Desensitisation and rehearsals are also frequently used, both in formal and in informal ways.

What all these approaches have in common is that they are based on rapport and interactivity. They’re aimed at building confidence and trust. They are about putting you in control.

By going slow and taking baby steps, many people find that they make giant strides and gain confidence quite rapidly!

Blue is the new white

The physical environment also plays an important role in easing fears. For example, the dental team wearing non-clinical clothes instead of the “white coat”, getting rid of the smells traditionally associated with dentistry, and playing music in the background can all help people by removing and replacing frightening stimuli. Some people also enjoy more obvious distraction techniques such as watching movies or listening to their own music during treatment.

It’s a kind of magic…

More specialised methods of help include hypnosis and systematic desensitisation. Systematic desensitisation is not used all that often by dentists because of the amount of time it can take and the additional training required. For hypnosis, the dentist needs special training, so it is quite rare to actually be offered this. But informal hypnosis is quite commonly used, often without the dentist even realising they’re using hypnosis.

There are other ways of making people feel at ease – for example, using humour or being particularly calm and confident. These are to some extent dependent on personality characteristics though and not always techniques that can be learned. Another major factor is trust – dentists who strongly believe in your ability to cope well are likely to be much more successful using psychological approaches. Trust begets trust. And although trust is a very powerful technique, again it takes a special kind of personality to put deep trust into another person’s ability to cope.

Relaxation and Systematic Desensitisation

Much of what has been written in journals and books on helping adults with dental fears is about using relaxation techniques such as belly breathing, or behavioural techniques like systematic desensitisation, or thought-based techniques such as cognitive restructuring (that is, challenging your thoughts about dentists and dentistry).

In practice, some of these techniques can be quite cumbersome and slow (this website is an example of an attempt at cognitive restructuring – and note how long it takes to read it!). They can take weeks or months to have an effect. Not surprisingly, not many dentists use them on a regular basis.

Even when a “traditional” cognitive-behavioural approach is used, rapport, confidence, trust and control is what it boils down to:

“It is interesting to take into account the views of people who have been provided with behavioural treatments for dental fear. From a psychologist’s perspective, techniques such as graded exposure, relaxation techniques or challenging catastrophic thinking are important. However, Gerry Kent, a clinical psychologist from the University of Sheffield UK, notes that from the patient’s perspective, interventions can be conceptualized quite differently. He argues that high levels of anxiety or phobia should not be considered as residing simply within the individual or in the individual’s perceptions of dental care, but more within the relationship with the dentist. For example, when patients who had successfully completed a cognitive-behavioural programme were asked what had helped them to tolerate treatment, they mentioned factors such as the provision of information, the time taken, being put in control by the dentist, and the dentist understanding and listening to their concerns. Such findings suggest that an interpersonal model of anxiety and anxiety-reduction is useful when trying to understand and treat dental fears.” (from Wikipedia – Dental Fear)

You can find more information on all of these psychological techniques for overcoming dental phobia in this section (see the right navigation box for a list of links!). Each page also includes practical tips for dentists, which can be used straight away.



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Dental Phobia and Dental Anxiety
Direct Interaction based on Tell-Show-Do Techniques

“It is by having hands that man is the most intelligent of animals.” (Anaxagoras)

The tell-show-do technique was developed as a means of helping apprehensive children receive dental care. However, it works just as well with many nervous (or even terrified) adults.

As the name suggests, it involves:

Tell: the dentist explaining to you what they’d like to do
Show: showing you what is involved (e. g. showing the equipment and demonstrating it on a finger)
Do: performing the procedure
Other ingredients…

Underpinning the technique are rapport and control.

Rapport is established before everything else, and also, the tell-show-do technique itself is a great way of establishing rapport, as it is very much an interactive and communicative approach.

To put you into the driving seat and hand control over to you, your dentist asks your permission before each new step. You may also want to agree on a stop signal and practice this together, until you are confident that you are in control and can stop at any time.

Tell-show-do is used in conjunction with non-threatening, everyday language.

Tell-Show-Do is a great technique for anyone who fears loss of control – one of the most common dental fears!

Why and how does Tell-Show-Do work?

The tell-show-do technique can be viewed as a rapid form of desensitisation, where anxiety is reduced by a gradual acclimatisation to the object which causes fear. In contrast to systematic desensitisation, the tell and show phases are not repeated.

A crucial factor which explains why tell-show-do works so well may be the tactile interaction with the environment. Touch and interaction are central to the tell-show-do technique, providing a sense of control which cannot be obtained by “just looking”. In fact, tell-show-do can work well even if a person chooses to keep their eyes closed:

“When I get treatment, or even just a check-up, I have my eyes tightly shut through the whole thing but I am told exactly what is about to happen and always asked if I would like to feel it on my hand first – which I usually do. So without having to see the “scrapey thing”, I can feel it pulled along the back of my hand or have a puff of air blown onto it so there is no surprise when I feel exactly the same sensation a moment later on my gums/teeth. Sometimes being told is just not enough.”

A better term for the technique might be Direct Interaction, as it is the direct interaction with your dentist and with the environment which fosters a sense of control and predictability, and reduces or removes the fear factor.

Also, the very fact that the dentist is taking time to explain things and acknowledge any anxieties or fears their patient has, the more relaxed they will become.

In the following article, dentist Fraser Hendrie explains the direct interaction / tell-show-do technique and gives some examples of how it can be used to tackle dental fears.

Tell-Show-Do – It’s not just for Children!

by Fraser Hendrie BDS MFGDP

A dentist named Harold Addleston coined the phrase Tell-Show-Do more than 40 years ago. Tell-Show-Do is a technique used by dentists to help children work through their fears and curiosities in a new situation, be it a simple dental examination or something more detailed. The theory behind this is simply that children are great little lie detectors and will be more anxious if they sense they are being deceived. So we should be honest and upfront with them, describing things in a truthful yet non threatening way. In time, this rigorously honest approach with them helps them to grow in trust and confidence.

While Tell-Show-Do is an oversimplification of things on many levels, a version of this technique is very helpful for adult patients who suffer from dental fear. The variant that I favour most for adults is more Explain-Ask-Show-Do.

In the past, dentists got a reputation for “doing things to their patients” with the old medical approach of “we know best.” A more modern and enlightened approach is one of mutual co-operation. So Tell-Show-Do in my practice has actually been Explain-Ask–Show–Do for a long time.

This works on the basis that we do not have your agreement to do anything at all until you specifically agree to it. The aim here is to put you as the patient back in control of the situation. So at each key stage we explain what we would like to happen / suggest a next step in your care, we answer any questions that you may have and then, once you are in possession of all of the information that you need, we ask your permission to proceed. The exact stages where we Ask if it is ok to do something will vary from person to person, depending on what we discussed during our initial chat about your fears and phobias.

So if, for example, you are someone who has a phobia about sharp metal objects in your mouth I would want to avoid using a probe or anything like it initially. I might ask if it is ok for me just to look around your mouth with a mirror. I would then Show you the mirror and explain that this was all I would like to use today. I would demonstrate that the mirror was all that I was holding / had within reach. To further show that this is all that we were going to use, I would also keep my hands in plain view the whole time. I would then keep exactly to my promise and use just the mirror for a preliminary look around. This is the Do part of the process.

Now, different dentists will handle this approach at different levels. A thorough discussion with you beforehand should help your dentist get a pretty good idea where the “stress points” are going to come for you in the visit. Your stress levels will vary within the visit from moment to moment. Some dentists will intuitively be better at sensing this than others. It is fair to say however that none of us get this right 100% of the time, so please don’t be afraid to ask questions or let us know how you are doing.

The overall aim is to gradually help your to decrease your stress levels and increase your confidence.

So coming back to our example, at a first visit we may not even get to using a probe, if that is your fear or phobia. What we may do instead (if you agree) is have a conversation about it, and describe and reframe for you how and why it will be used. Very often, explaining the most up-to-date information about what we do and the equipment we use to provide care can help to re-frame and thus reduce your fear too. By this, I mean it may help to balance what your mind tells you happens with this object and bring it closer to what will actually happen. The ultimate aim being over time to bring your internal dialogue or imagery about your dental fears closer to the current reality of modern dental care delivered by a caring dental team.

In this example, I would Explain that probes are no longer used to vigorously “test” teeth for decay as they were years ago – generally they only lift away any little bits of plaque or trapped food or are used to touch the gum and assess its health. Further on I may even Ask if you would like to hold a probe and feel that the tip of it is specially rounded to make it safe and comfortable (Show) . Assuming this all goes well we may then get to the stage where we simply use the probe to lightly touch the teeth once or twice. (Do)

There is no one magic solution to using this technique. As a dentist, I am trying to balance your fears and phobias against your desire to make progress while respecting where you are currently at both physically and emotionally. It is a balancing act that with practice (on both parts) you become better at as the balance is different for every single person.

Successful easing of dental fears comes when you form a partnership to tackle your fears with your dentist. With trust, time and honesty many patients successfully eliminate their fear altogether.

I firmly believe that as dentists, we need to earn this trust through care, honesty and doing what we say we will. In terms of honesty I do not mean telling patients how dreadful their dental situation is or how bad things are because these are opinions rather than facts. What I mean is simply keeping our promises and doing what we say we will. You can help us to help you by telling us as much detail about your dental fear as possible in advance, or as it comes to your mind, so that we can tailor that care exactly to you.

This approach can work for a number of scenarios, here is one other example. Your dentist simply needs to work out what you need to know, see and experience to help you move forwards. So for someone who tells me they are terrified of getting a “scale and polish” we might just start with the polish part and look at that…

Getting your teeth polished, it is really no different to using a toothbrush, the paste we use is just a little better at removing stains than regular toothpaste (Explain). It can be likened to polishing the bonnet of a car, or polishing up a piece of furniture in so far as the aim is to allow the naturally glossy appearance to shine through. We can check and if you are ok with it (Ask), the polishing brush can be demonstrated on a finger nail (Show). You can hold it and examine it if you like as it is similar to a regular toothbrush. Assuming this is ok, we can then check and if you feel up to it we can move on and polish an individual tooth.

The approach has thousands of variations and can be varied to suit your fear: the more your dentist knows, the more creative they can be in helping you to find a way past your individual “stress / fear points.” The examples here are just 2 common examples that spring to mind. Most dental professionals who are interested in helping patients with dental fear will be happy to flex what is their usual routine, if it helps to make life easier for you. Ultimately, there are some things in dentistry that we cannot change, but with empathy and in investment of time, I have met only a very few patients who cannot be helped past these hurdles.

For example, we know that a dentist cannot do their job thoroughly unless you are sitting in the dental chair, but if this is where your fear lies, do we really need to do a first examination in the dental chair? An examination in a regular chair may be an initial compromise but if both you and your dentist recognise that this is a compromise and commit towards working to the ideal solution then this means progress is being made.

Explain-Ask-Show-Do is a versatile tool that is limited only by the imagination and creativity of the people using it. While not a panacea for dental fear it is one of the major planks on which we can build a foundation to help overcome it.

Fraser works at Craigentinny Dental Care Edinburgh. Outside work, he is being kept busy by his 2 young children and interest in any sport involving water. Fraser has been helping patients overcome their fears for more than 15 years.

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Structured Time

“To help my patients feel in control, I usually tell them to count to 10 (internally) then we’ll stop on some agreed signal, then a count to 20 and so on.”

Structured Time means breaking up a procedure into manageable chunks, and/or taking frequent breaks.

Many people feel overwhelmed by the prospect of dental treatment because they are worried they won’t be able to cope. But often, you may find that you are able to cope if a procedure is broken up into short time segments.

Structured time:

means you only have to deal with the situation for a short, finite period of time, and won’t feel overwhelmed.
gives you a chance to check out what a piece of equipment is like and what sensations and sounds to expect for a few seconds at a time. It can hugely increase your confidence that you’ll be able to handle the situation.
means that even if you feel unable to give a stop signal, you know that you will be able to take a break shortly.
is useful if you are worried about panic attacks – panic attacks are usually about anticipatory anxiety (“what might happen if…”). If the time frame is short enough to prevent anticipatory thoughts from happening, then this lessens the chances of experiencing panic.
Structured time can be used in several ways:

If you are unfamiliar with a dental procedure, your dentist can count, or let you count internally, in intervals of seconds (e.g. to the count of 3). Once you are confident that you can handle the situation or the sensations, and you feel more relaxed, the interval can be extended (for a real-life demonstration, see the Tell-Show-Do video example).
It can be used to practice the stop signal (see quote at the beginning of this page), and put you in control of the situation.
It can be used for longer time segments (e. g. your dentist stopping every 5 minutes), to ensure that you can take a break without having to ask for one, and to let your dentist know if everything is going ok for you. It also gives you a chance to just chill, have some water, blow your nose, or just sit up and regain your composure if needed.