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Mental-Health Informed Dental Care

Access to care is a popular topic of discussion in the United States, often focusing on the financial barriers that inhibit patients from seeking and receiving proper healthcare. In dentistry, these financial barriers are valid and important to unpack in order to improve the overall health of our modern society.

Further, through the elucidation of additional and rarely recognized barriers, dental clinicians can expand their ability to improve community access for patients who have a propensity to postpone or avoid care due to fear and anxiety. Studies have indicated that the prevalence of moderate to high dental anxiety was present in 19% of the population sampled while 8.4% reported missing prior appointments for dental care due to anxiety.1 Mental-health informed dental care is a treatment philosophy designed specifically to address anxiety induced barriers that exist in one out of every five members of communities served.

Standard practice for managing the anxious patient in dentistry is one of a reactive nature and rarely proactive. New patient intake forms at dental practices usually includes a question inquiring if one has a history of dental anxiety. This question
provides an opportunity for the clinician to discuss reactive measures to reduce a patients anxiety prior to commencing any invasive dental procedure. These measures are primarily pharmaceutical based for sedation and include: Inhaled nitrous oxide and oxygen and/or dose(s) of benzodiazepine, a potent anxiolytic. For patients requiring more potent pharmaceutical intervention, IV sedation may be necessary. The aforementioned sedative methods can be quite effective for delivering care to the anxious patient without complication; however, the benefit of reduced anxiety does not extend after the procedure is completed and has little effect on the psychological barriers for future dental appointments.

Conversely, the philosophy of mental-health informed dental care is one of a proactive nature. The objective is to deliberately create awareness by obtaining a thorough history of a patient’s specific anxieties. Utilizing intake questionnaires, dental providers are able to identify the particular areas of past dental experiences that continue to cause a patient distress while visiting the dentist. This detailed history is further expanded by the use of a Subjective Units of Distress Scale which measures (from 0 to 10) the subjective severity of disturbance or distress currently experienced by an individual. Patients are presented questions such as, “On a scale from 0 to 10, with 10 being the most severe, please rate your level of distress when thinking about having a root canal procedure done.” Through this detailed history specific to each patient, providers can customize the patient experience to help alleviate their anxieties. For example, if a patient notates that their distress was high during prior dental procedures due to feeling “out of control”, providers can preemptively discuss helpful techniques such as allowing patients to provide hand signals to alert the dental provider to stop. The intake questionnaire can also identify a subset of anxious patients who have experienced acute trauma from an unpleasant dental experience as a child. These patients, among others, would be best served by collaborative care with a psychotherapist specializing in trauma.2 In addition to a detailed history of a patient’s anxiety, it is also important that dental offices implement measures to improve the environment of their office to minimize distress.

Staff should receive training and encouragement to be aware of the office environment in order to take appropriate actions to reduce patient anxiety. Such considerations include comprehensive sensory awareness from the time a patient enters the office until they exit: what a patient smells, hears, sees, feels, and tastes. More specific items include: establishment of rapport, ambient room temperature, perceived privacy in the clinical setting, infection control protocols, lighting, disposition of staff, eye contact, cleanliness, sound of instruments/hand pieces, feeling heard and not rushed, and time taken to explain financial responsibilities. It is up to the providers and staff to determine which areas of consideration are most important to their patients. Patient comforts and distraction techniques can be utilized to improve the patient experience as well. Some examples include: weighted blankets, pillows, ceiling mounted televisions, painless injection techniques, aromatherapy, guided breathing, noise canceling headphones, and bilateral stimulation wristbands.

The above mentioned methods outline the general philosophy of mental-health informed dental care, a treatment philosophy that empowers patients to develop and utilize tools to manage their anxious symptoms rather than immediately resorting to sedative medication. Care provided in this fashion positively affects the patient experience while conveying a sense of understanding and acceptance towards the anxious patients that their feelings are valid and worthy of consideration. Therefore, it is imperative that patients do not feel judged in a dental setting as this could strengthen their psychological barrier towards dental care. Through the use of thorough intake questionnaires, detailed attention to the dental office environment, and implementation of patient comforts and distractions, dental providers can significantly improve access to dental care for those in the community who suffer from dental anxiety and fear.

1 Angela White RDH, MS, Lori Giblin, RDH, MS, The Prevalence of Dental Anxiety in Dental Practice Settings, Journal of Dental Hygiene Vol.91, Issue 1, Feb 2017

2 Doering S. Ohlmeier MC, Efficacy of a trauma-focused treatment approach for dental phobia: a randomized clinical trial. European Journal of Oral Sciences 2013; 121: 584-593

Written by Jeremy Silverman, DMD & Elissa Silverman, LCSW

Dr. Silverman and Elissa Silverman are the co-founders of Peace of Mind Dental Studio–a family dental practice specializing in the care of mental and physical wellbeing alongside oral health.