EARN This course was written for dentists, 3 CE dental hygienists, CREDITS and dental assistants.

© Tetyana Afshar | Dreamstime.com The dental practitioner’s ultimate guide to adult patient fear, , and

A peer-reviewed article written by Lisa Dowst-Mayo, MHA, BSDH, RDH

PUBLICATION DATE: JUNE 2021

EXPIRATION DATE: MAY 2024

SUPPLEMENT TO ENDEAVOR PUBLICATIONS EARN 3 CE CREDITS

This continuing education (CE) activity was developed by Endeavor Business Media with no commercial support. This course was written for dentists, dental hygienists, and dental assistants, from novice to skilled. Educational methods: This course is a self-instructional journal and web activity. Provider disclosure: Endeavor Business Media neither has a leadership position nor a commercial interest in any products or services discussed or shared in this educational activity. No manufacturer or third party had any input in the development of the course content. Requirements for successful completion: To obtain three (3) CE credits for this educational activity, you must pay the required The dental practitioner’s fee, review the material, complete the course evaluation, and obtain an exam score of 70% or higher. CE planner disclosure: Laura Winfield, Endeavor Business ultimate guide to adult patient Media dental group CE coordinator, neither has a leadership nor commercial interest with the products or services discussed in this educational activity. Ms. Winfield can be reached at lwinfield@ fear, anxiety, and phobia endeavorb2b.com. Educational disclaimer: Completing a single continuing education course does not provide enough information to result Abstract in the participant being an expert in the field related to the course topic. It is a combination of many educational courses and clinical The American Dental Association reports 22% of adult Americans avoid the experience that allows the participant to develop skills and dentist due to fear and anxiety, which equates to one in five.1 Fifty-nine per- expertise. Image authenticity statement: The images in this educational cent of Americans cite cost as the top reason they do not visit the dentist activity have not been altered. more frequently.1 Patient anxiety etiologically can be psychological, finan- Scientific integrity statement: Information shared in this CE course is developed from clinical research and represents the most cial, physical, or a combination of these. The anxious patient presents with current information available from evidence-based . significant challenges to rendering care in the dental environment. This Known benefits and limitations of the data: The information presented in this educational activity is derived from the data and course takes a practical approach in the dental management of fearful, anx- information contained in the reference section. ious, and/or phobic patients that can be incorporated into even the busiest Registration: The cost of this CE course is $59 for three (3) CE credits. offices. Multimodal, evidence-based, nonpharmacological, and pharmaco- Cancellation and refund policy: Any participant who is not logical approaches to anxiety management are summarized to assist dental 100% satisfied with this course can request a full refund by contacting Endeavor Business Media in writing. practitioners in successfully treating these patients and improving their oral Provider information: health and overall quality of life. Dental Board of California: Provider RP5933. Course registration number CA code: 03-5933-21029. Expires 7/31/2022. “This course meets the Dental Board of California’s requirements for Educational objectives three (3) units of continuing education.” At the conclusion of this course, dental practitioners will be able to: Endeavor Business Media 1. Incorporate an anxiety management plan that best fits their is a nationally approved PACE program provider for FAGD/MAGD credit. patient population. Approval does not imply acceptance 2. Identify dentally fearful, anxious, or phobic patients and apply correct by any regulatory authority or AGD endorsement. management techniques. 11/1/2019 to 10/31/2022. Provider ID# 320452 3. Provide more pleasant and relaxed appointments to improve both the AGD code: 153 patient and provider experience.

Endeavor Business Media is designated as an approved Provider by the American Academy of Dental Hygiene, Inc. #AADHPNW (January 1, 2021-December 31, 2022). Approval does not imply acceptance by a state or provincial Board of Dentistry. Licensee should maintain this document in the event of an audit.

Endeavor Business Media is an ADA CERP–recognized provider. ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of dental continuing education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry. Concerns or complaints about a CE provider may be directed to the provider or to ADA CERP at ada.org/cerp.

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Introduction ranging from 3%–5% to 3%–16%.3,5,6 third (table 2). Women reported significantly Three terms have been used in dentistry Patients with dental fear, anxiety, or pho- higher fear of dental treatment while there concerning patients’ aversion and appre- bia are less likely to remain compliant were no statistical differences in gender hension to treatment. with regular follow-up appointments, skip reported for phobia of dental treatment.5 1. Dental fear: Actual response to or cancel appointments, and be reluctant a dental object or situation that to make upcoming appointments.7 Highly Etiology induces an emotional and/or physical anxious patients are likely to have avoided Dental fear, anxiety, and phobia are mul- response to a perceived threat.2,3 dental care for at least two years.7 tidimensional phenomena with complex 2. Dental anxiety: An emotional state A study published in European Journal etiology combining psychological, physi- that precedes an encounter with a of Oral Sciences assessed 1,959 partici- cal, and financial facets. feared object or situation.2 pants for fears and .5 The study Psychological: Psychological fear can 3. Dental phobia: Dental phobia is found that 20.4% of participants had no manifest into psychosomatic effects (physi- specified in the DMS-5 (Diagnostic fear, and 79.6% reported being fearful of cal illness caused by a mental factor such and Statistical Manual) under “Spe- at least one object or situation. The most as internal conflict or stress). There are cific Phobias,” defined as fear, anx- common fears identified were to snakes, many psychological fears or phobias that iety, and avoidance of situations heights, physical injury, dental treatment, afflict dental patients. Patients may fear lasting more than six months, which spiders, and injections. The least com- a loss of control, and the supine/semisu- cannot be attributed to another men- mon fears were flying, thunder, blood, pine positioning used in the dental chair tal health disorder, substance abuse, and darkness (table 1). can lead to feelings of powerlessness and or medical condition.4 The dental The study also found that the most com- submission. Patients may have comorbid phobic situation almost always pro- mon phobias were dental treatment first, underlying psychological conditions such vokes immediate fear or anxiety and and then heights and spiders second and as obsessive-compulsive disorder, depres- is out of proportion to the actual sion, or post-traumatic stress disorder that danger posed, which leads to feel- may be a manifestation of previous sexual, 5 ings of dread and panic. Patients will TABLE 1: Fear physical, or psychological or adult actively avoid the dental environment Prevalence abuse. Dental providers need to remind Object or situation or endure the situation with intense of fear these individuals they are in a safe space fear and anxiety that can cause clini- and be mindful of the fact that they are in Snakes 34.8% cal distress or impairment.4 Specific a patient’s personal and intimate space. phobias typically develop between Heights 30.8% The study of how space is used in com- ages 7 to 11, with many patients Physical injury 27.2% munication is termed “proxemics,” and it unable to identify the reason their identifies four distances maintained dur- Dental treatment 24.3% phobia developed.4 ing human communication8,9 (table 3). Patients who suffer from dental fear, anx- Spiders 23.3% Dental health providers invade patients’ iety, or phobia will delay or avoid needed Injections 16.1% culturally derived boundaries of personal procedures, which leads to poor dental and intimate space without warning and Flying, thunder, health outcomes and quality of life. When 8.3-12% many times without permission from the blood, darkness they do seek treatment, they typically patient, which can invoke tension and present with more complex and expen- anxiety.8 Dental professionals can cre- sive treatment plans. Their fear, anxiety, TABLE 2: Phobia5 ate safer and more secure spaces while or phobia causes behavioral challenges in increasing the patient’s sense of control Prevalence the dental environment, and if not handled Object or situation with an understanding, mindfulness, and of fear correctly, can lead to an unpleasant expe- respect for this concept of proxemics. rience for both the patient and provider. Dental treatment 3.7% A recent systematic review published This course will present dental fear, anxi- Heights 3.1% in the Journal of Advanced Nursing in ety, and phobia statistics and etiology, and 2019 found that 20%–30% of young adults Spiders 2.7% offer helpful tips and tricks for managing have a fear of needles that interferes with these patients in the dental environment. Snakes, physical injury, needed treatment.10 One in four adults injections, flying, thunder, 0.6-1.6% report a clinically significant fear of dental blood, darkness Statistics injections.11 Those fearful will subjectively The American Dental Association reports Spiders 23.3% report higher pain during injections due 22% of adult Americans avoid the dentist Injections 16.1% to psychosomatic manifestation of the due to fear and anxiety, which equates to cognitive fear. Other than desensitization 1 Flying, thunder, one in five. Literature reports vary for the 8.3-12% methods, whereby patients are introduced blood, darkness percentage of those with dental phobia, to the feared object in a gradual manner,

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there is also a computerized program that practitioners can utilize to assist those TABLE 3: Proxemics8,9 with needle fear, anxiety, or phobia. CARL Distance Description Examples (computer-assisted relaxation learning) between people aims to reduce fear of dental injections Public No physical contact; very Shopping centers; city sidewalks; through two-to-four-minute video seg- 12-25 feet space little eye contact is possible public speaking distances ments that provide patients cognitive and physical coping strategies and tools with Information and formal business Social No physical contact; and social relationships; the goal to alleviate the fear, anxiety, or 4-12 feet 11 space eye contact is possible distance where people set phobia of dental injections. up tents on a beach Patients may be fearful of germs. This topic is of increased relevance during People at arm’s length just outside Personal the SARS-CoV-2 pandemic with mask- 1.5-4 feet the “touching” zone; Meeting rooms wearing recommendations for laypeople, space distance where personal social distancing, and constant news discussions take place coverage that can present inconsistent Direct contact; humans or conflicting information. only allow their most Intimate Lovemaking; wrestling; crowded Given the digital age and easy access Contact-18 inches intimate associates space elevator; dental procedures to information, patients can be negatively into this space (family influenced through social media or blog members, spouse, etc.) posts about painful dental experiences or gain access to unreliable or uncred- when they are introduced to that trigger treatment and places an undue burden on ited sources of information that adds to during an appointment. an already overworked health-care system. their anxiety. Some patients have a fear Lastly, patients may have internal Financial limitations to dental treat- of being judged or ridiculed when they issues with trusting health-care practi- ment are common sources of anxiety visit an oral health professional. This psy- tioners. These patients may come across in the United States due to the lack of chological aversion leads to avoidance of as argumentative, confrontational, and resources available to pay for treatment. dental care for fear of embarrassment. combative.2 They may use sarcasm such In 2016, 46% of dental expenditures came Twenty-three percent of Americans avoid as, “I guess I’m paying for the doctor’s from private insurance, 40% was out-of- the dentist, and one in four avoid smiling family vacation with all this work you pocket, and 12% was from CMS programs due to embarrassment about their teeth.1 say I need.” These patients may threaten (Medicare, Medicaid).14 Only 45%–57% of Unconscious physiological responses to get a second opinion from another den- adult Americans ages 18-64 have dental that involve the limbic system and olfac- tal office. The dentist should encourage insurance, and in 2018, 14%–29% did not tory nerves can lead to dental fear, anxiety, the second opinion and offer a no-charge utilize their benefits.15 In 2019, the United or phobia. The human limbic system is the copy of the patient’s radiographs. Lengthy States spent 17% of GDP (gross domestic part of the brain involved with behavior, explanations of treatment needs with product) dollars on health services, with emotions, and memory. It regulates auto- the added use of scanners, 3-D imaging, only 4% on dental expenditures.16 Until nomic and endocrine function in response and intraoral camera photos will assist changes are made at the national level, to emotional stimuli.12 The limbic sys- in managing this type of dental anxiety. this source of dental anxiety will continue tem hippocampus and amygdala are Ask the patient’s permission prior to per- for many US citizens. involved in emotional regulation of anx- forming an examination, and ensure all Physical: There are many physical iety, aggression, and fear. The amygdala probable outcomes are discussed to avoid fears associated with the dental assigns emotional meaning to memories, changing treatment in the middle of an environment that lead to fear, anxiety, and the hippocampus forms the sensory appointment. or phobia. Fear of gagging, choking, memory of the experience and converts it Financial: A very real source of dental not becoming numb, or an inability to from short-term to long-term memory.12 anxiety is related to the cost and extent breathe when instruments are in the For example, every time I smell apples, of needed treatment. Fifty-nine percent mouth are common triggers. Patients I remember a pleasurable experience of of Americans cite cost as the top reason can be fearful or anxious of being hurt, visiting an apple orchard as a child on a they do not visit a dentist more frequently.1 especially those with low pain thresholds. school field trip, and I feel a rush of happi- Nationally, the number of emergency Sensory-sensitive patients may struggle ness and calmness. For some, their limbic department visits with pain of an oral with anxiety to sounds (drill, ultrasonics, system has programmed them to associ- origin have doubled in the last 10 years to scraping), taste, and the smell of dental ate specific dental sensory stimuli (sight, $2.2 million (1.65%) and are responsible for products or blood. Patients may report sound, smell, taste, feel) with a negative $1.7 billion in lost revenue.13 Dental finan- adverse reactions to local anesthetic such emotion, which increases anxiety and fear cial anxiety leads to avoidance of needed as adrenaline rushes. Do not downplay or

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dismiss this concern but explain typical typical and expected responses because information they want to know about versus atypical physiological reactions patients with fear, anxiety, or dental pho- procedures. For some, more information to vasoconstrictors used in dentistry bia will present along a vast continuum about procedures is helpful, but for oth- (epinephrine and levonordefrin) so the from mild to debilitating with multi- ers, information is counterproductive. If patient better understands his or her ple etiologies. a patient is anxious of sensory stimuli, body’s reaction2 (table 4). When practitioners utilize a multi- then it is prudent to describe what they modal approach in their management will see, smell, feel, taste, and hear. of anxious patients, more pleasant expe- Communication plays one of the most TABLE 4: Reactions to vasoconstrictors (epinephrine riences for both patients and staff will important roles in reducing patient fear, and levonordefrin)17 occur. Providers should access the degree anxiety, or phobia and these approaches of impact of the patient’s fear, anxiety, or need to be taken by all staff members who Increased heart rate and force of contraction phobia and ascertain their anticipated interact with the patient in the office. Do Changes in degree of cooperation to determine which not downplay patients’ anxiety. Acknowl- interventions will lead to a successful visit. edge their concerns and analyze their non- Increased fear or anxiety Pharmacological and nonpharmacological verbal language. Reluctance to sit in the Tension, restlessness approaches to anxiety management are dental chair, fidgeting, lack of eye contact, Headache available, and both may be needed dur- increased breathing/heart rate/blood ing appointments. Since dentally anxious pressure, talking excessively, or lack of Bronchodilation patients are more likely to report negative responses to questions are all cues of an perceptions of their dentist and work ren- anxious patient. Dental management techniques dered, it is imperative that interventions Listen intently to patient responses Screening: The first step in successfully are utilized to increase satisfaction.7 and sit eye-to-eye with them. If you treating fearful, anxious, or phobic dental Nonpharmacological approaches: stand while speaking with your patient patients is to identify them and then seek Nonpharmacological approaches to in a reclined chair position, you unknow- the source of their fear. Screening tools are managing dental fear, anxiety, or phobia ingly place yourself in a position of author- available for the dental practitioner and include good communication, desensiti- ity and intimidation. Sitting at the same have been demonstrated not to increase zation, paced breathing, distraction, and level as your patient when communicat- a patient’s anxiety2 (table 5). olfactory stimulation. ing gives the nonverbal impression you are Dental providers should ask patients if Communication: Good communica- willing to listen and will not rush through they can identify what makes them anx- tion is at the heart of any nonpharmaco- their appointment time.8 Be friendly, ious. Some patients can identify exactly logical anxiety management plan. Setting empathetic, and use calm tones in your what they are afraid of, such as injections, appropriate expectations from the get-go voice. Make eye contact with patients sounds, or gagging, while others will be for patients and providers will go a long even if they are avoiding your eyes. Offer unable to identify their trigger and will way to ease stress and fear. The level of a multiple reassurances that they are in simply say that everything about the den- patient’s anxiety (mild/moderate/high/ a safe place and that their comfort is of tal environment bothers them. These are severe/debilitating) will dictate how much utmost concern. During and after treatment, offer posi- TABLE 5: Dental anxiety screening tools tive reinforcement and moral support in a noncondescending and genuine way so as Screening tool Details not to sound fake or put-on.2 Congratulate 4-item questionnaire with 5 possible answers to identify a Corah’s Dental Anxiety Scale them on taking control of their oral health patient’s anxiety level as mild, moderate, high, severe, or phobic and offer praise. Give them a voice and Modified Dental Anxiety ability to communicate with you, even Scale (MDAS) during active treatment. Building posi- Modification of Corah’s 5-item questionnaire to identify mild, tive and trusting relationships between Dental Anxiety Scale18 moderate, or phobic patient patient and provider will lead to better satisfaction, lower fear, and more pleas- 4-item questionnaire using Likert scale 5-25 to identify Dental Anxiety Scale (DAS) patients from “no anxiety” to “extreme anxiety” ant experiences. Desensitization: Desensitization 20-item, 5-point scale with 3 dimensions measured: Dental Fear Survey (DFS) involves exposing the individual to aspects avoidance, physiological arousal, fears of specific stimuli19 of dentistry they find frightening in small, 3 modules to measure dental phobia, feared dental manageable doses, and then increasing the Index of Dental Anxiety stimuli, and an 8-item dental anxiety and fear module to exposure as the patient develops coping and Fear (IDAF-4C+) assess emotional, behavioral, physiological, and cognitive mechanisms.2 For example, if the source of components of the anxiety and fear response20 the anxiety is a negative physical response

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to dental local anesthetic, then the prac- waiting rooms lowered patient anxiety and • This population is more likely to can- titioner could start with administering a improved their mood.24,25 cel or no-show appointments due to vasoconstrictor-free solution for the first Appointment tips and tricks: Other their anxiety. Requiring prepayment for appointment and then gradually switch to appointment tips and tricks to better appointment times will assist patients a vasoconstrictor solution. manage fearful, anxious, or phobic den- in not cancelling and will maintain the Paced breathing: Paced breathing is a tal patients include: office daily production. technique used for adults and children to • Use the explain–ask permission–show– Pharmacological approaches: Den- ease anxiety and relax the individual. The do–follow-up approach. Explain what tal fear, anxiety, or phobias have a wide technique involves inhaling through the needs to be done, ask permission to do spectrum from mild to debilitating, and nose and holding for five seconds before it, show the patient how it will be car- their level dictates the management exhaling through the mouth slowly and ried out, do the action, and then follow approach. Patients’ dental anxiety or steadily over a two-to-four-minute time up with the patient immediately to see phobia can be so severe that they enter period. Paced breathing will reduce a per- how the person is feeling.2 a sympathetic fight-or-flight response son’s heart rate and can assist with avoid- • Give the patient a stress ball or fidget or during a visit, which can ing an anxiety attack. Smartwatches have device to hold during procedures. lead to a dental emergency (tables 6 and built-in alerts that instruct people to per- • Use weighted blankets to provide a 7). These patients may best be served form paced breathing when an increased sense of security. with pharmacological approaches. The heart rate is detected. The paced breath- • Schedule appointment times first thing use of pharmacological agents does raise ing technique can be used anytime the in the morning so the patient does not the cost of treatment, so their use as a patient is feeling anxious, during dental stress all day about the upcoming first-line management approach may injections, or in gagging management. appointment or talk themselves out of not be practical for all patients. While Distraction: Distraction techniques can keeping the appointment. pharmacological agents allow for den- be both auditory and visual. Visual dis- • Avoid keeping the anxious patient in tal procedures to take place, they do tractions commonly used in dentistry are the waiting room because this gives not teach patients coping strategies for TV, 3D video glasses, and visualization them time to think about what is to future visits. exercises, such as having patients picture come and get worked up. themselves at the beach when a feared trig- • Offer and encourage rest breaks before TABLE 6: Fight-or-flight ger is about to occur. Most dental offices the patient has an anxiety meltdown. body reactions12 use ambient background music as an audi- Anxious patients need mental breaks to tory distraction, although its effectiveness calm themselves, collect their thoughts, Increased heart rate and force of contraction 21 on highly anxious patients is minimal. and reset their sensory system. Allow Increased pulse rate Highly anxious or phobic patients are bet- them time to stand up, use the rest- ter served exploring music therapy, which room, or make a phone call to a loved Bronchodilation and more rapid breathing has been used for decades to reduce anxiety one. Dental providers need to recog- Mydriasis (dilated pupils) to increase sight and increase pain thresholds in patients. nize the cues their patient is getting Heightened sensory system Multiple Cochrane Reviews present music worked up and overly anxious and offer therapy as having a positive effect on anxi- the break before a breakdown occurs. Increased glucose in blood circulation ety reduction prior to medical procedures, Once the patient reaches their maxi- 21-23 examinations, and surgeries. mum anxiety threshold, completing the TABLE 7: Panic attack symptoms26 Olfactory stimulation: Olfactory stimula- appointment may not be possible, and tion has been useful in the management of getting them back for another appoint- Shortness of breath a multitude of disorders. Humans associate ment will be compromised. Dizziness, unsteady feeling, faintness odors with memories as dictated by their • Allow the patient the ability to signal Trembling limbic system. Odors can elicit a response you when something is bothering them. of calmness or anxiety depending on the Let them know that, once signaled, the Sweating patient’s previous experience with the scent. actions of the provider will be immedi- Choking Aromatherapy is a holistic healing treat- ately stopped as long as cessation does ment that uses plant extracts and essential not cause harm. This will build a sense Nausea or abdominal stress oil scents to promote health, increase calm of trust and provide the patient with a Paresthesia and relaxed feelings, and decrease anxiety sense of control over the situation. Flushing or chills and pain. The most common scents used are • Schedule more time for anxious patients. lavender, chamomile, clary sage, mandarin, If they feel rushed or that their provider Chest pain or discomfort and orange blossom. Two separate publica- is more concerned with how fast proce- Fear of dying tions in Physiology & Behavior found the dures are completed versus how they are Fear of losing control use of lavender and orange scents in dental feeling, trust will be broken.

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Pain is a physical process with psy- propofol (Diprivan), ketamine (Ketalar), with irreversible pulpitis. BMC Oral Health. chological components. Dentally anxious (Versed), and dexmedetomi- 2018;18(101):106. doi:10.1186/s12903-018-0563-x patients have exaggerated pain responses dine (Precedex), which all cause vary- 7. Hmud R, Walsh LJ. Dental anxiety: Causes, and perceptions, which leads to overesti- ing degrees of sedation and amnesia.29 complications and management approaches. Int . 2009;9(5):6-14. mation of pain experienced during pro- Adverse effects such as respiratory depres- Dent cedures.6,7 Pharmacological interventions sion, cardiovascular depression, or pulmo- 8. Haddad AM, Doherty RF, Purtilo RB. Health . 9th ed. such as medications (antianx- nary aspiration are possible.27,29 Professional and Patient Interaction Elsevier;2019. iety agents), inhalation sedation, mini- General : General anesthe- 9. Gordon NJ, Fleisher WL. mal/moderate/deep sedation, or general sia is a drug-induced loss of consciousness Effective Interviewing and Interrogation Techniques. 4th ed. Elsevier;2019. anesthesia may be required to produce whereby the patient cannot be aroused, 10. McLenon J, Rogers MAM. The fear of needles: A effective anesthesia, analgesia, and avoid even with painful stimuli.28 Patients may systematic review and meta-analysis. J Adv Nurs. emergencies during procedures. need assistance maintaining an air- 2019;75(1):30-42. doi:10.1111/jan.13818 Anxiolytic medications: Patients can be way and cardiovascular function may 11. Heaton LJ, Leroux BG, Ruff PA, Coldwell SE. so anxious that they are unable to sleep be impaired.28 Computerized dental fear treatment: a the night before an appointment, which randomized clinical trial. J Dent Res. 2013;92(7 increases their anxiety and worry. Benzo- Conclusion Suppl):37S-42S. diazepines are a class of drugs that can This course has shown it is possible to 12. Hitner H, Nagle B. Pharmacology: An Introduction. 6th 27 ease anxiety and improve sleep. Exam- have pleasant and productive dental vis- ed. McGraw-Hill;2010. ples of commonly used its for fearful, anxious, or phobic patients. 13. Dental-related ER visits rising in the US. American in dentistry are (Valium), mid- Utilizing multimodal approaches of both Dental Association. July 2, 2013. https://www.ada. azolam (Versed), (Xanax), and nonpharmacological and pharmacologi- org/en/press-room/news-releases/2013-archive/july/ (Ativan), given either the night cal origins will assist dental practitio- ada-dental-related-er-visits-rising-in-the-us 27 before and/or day of the appointment. ners in successfully treating the 22% of 14. U.S. dental expenditures, 2017 update. American Inhalation sedation: - Americans who are dentally anxious. This Dental Association. 2017. https://www.ada.org/~/ oxygen sedation is an inhalation method population deserves oral health providers media/ADA/Science%20and%20Research/HPI/ of sedation that provides some degree who are knowledgeable and willing to Files/HPIBrief_1217_1.pdf?la=en of analgesia, reduces anxiety, raises work alongside their individual needs to 15. Blackwell DL, Villarroel MA, Norris T. Regional pain thresholds, and increases feelings achieve oral and general health. Through variation in private dental coverage and care among of relaxation in clinical outpatient den- cooperation and understanding between dentate adults aged 18-64 in the United States, tistry.26 It is intended for patients with provider and patient, pleasant and pro- 2014-2017. National Center for Health Statistics. mild to moderate anxiety and those ductive appointments can be rendered. Centers for Disease Control and Prevention. May 2019. https://pubmed.ncbi.nlm.nih.gov/31163015/ with strong gag reflexes. Debilitating or severely anxious patients may not REFERENCES 16. The nation’s health dollar ($3.8 trillion), calendar year 2019: where it came from and where it went. Centers respond to this form of conscious seda- 1. Oral health and well-being in the United States. for Medicare and Medicaid Services. 2019. https:// tion and may need more advanced phar- American Dental Association. Health Policy Institute. www.cms.gov/files/document/nations-health-dollar- macological approaches. 2015. https://www.ada.org/en/science-research/ health-policy-institute/oral-health-and-well-being where-it-came-where-it-went.pdf Minimal/moderate/deep sedation: th 2. Armfield JM, Heaton LJ. Management of fear and 17. Malamed SF. Handbook of Local Anesthesia. 7 ed. These forms of sedation are indicated for Elsevier:2020. uncooperative anxious or phobic patients anxiety in the dental clinic: A review. Aust Dent J. 2013;58(4):390-407. doi:10.1111/adj.12118 18. Giri J, Pokharel PR, Gyawali R, Bhattarai B. who are unable to tolerate dental pro- Translation and validation of modified dental cedures through any other method dis- 3. White AM, Giblin L, Boyd LD. The prevalence of dental anxiety in dental practice settings. J Dent Hyg. anxiety scale: The Nepali version. Int Sch cussed in this course. This level of sedation 2017;91(1):30-34. Res Notices. 2017;Article ID 5495643:1-5. has allowed many patients to receive den- doi:10.1155/2017/5495643 4. Center for Behavioral Health Statistics and Quality. tal treatment for conditions that would Impact of the DSM-IV to DSM-5 changes on the 19. Oliveira MA, Vale MP, Bendo CB, et al. Dental fear have otherwise been left untreated. In National Survey on Drug Use and Health. Substance survey: A cross-sectional study evaluating the minimal and moderate sedation, a patient Abuse and Mental Health Services Administration. psychometric properties of the Brazilian Portuguese is able to maintain their airway indepen- June 2016:95-96. version. Scientific World Journal. August 11, 2014. doi:10.1155/2014/725323 dently, can respond to verbal commands, 5. Oosterink FMD, de Jongh A, Hoogstraten J. Prevalence 28 but has impaired cognitive function. of dental fear and phobia relative to other fear and 20. Armfield JM. Development and psychometric In deep sedation, the patient cannot be phobia subtypes. Eur J Oral Sci. 2009;117(2):135-143. evaluation of the index of dental anxiety and fear easily aroused but can respond to pain- doi:10.1111/j.1600-0722.2008.00602.x (IDAF-4C+). Psychol Assess. 2010:22(2):279-87. 28 doi:10.1037/a/0018678 ful stimuli. Assistance may be required 6. Dou L, Vanschaayk MM, Zhang Y, et al. The for maintaining their airway.28 The drugs prevalence of dental anxiety and its association 21. Bradt J, Teague A. Music intervention for dental used for these levels of sedation vary, but with pain and other variables among adult patients anxiety. Oral Dis. 2018;24:300-306. doi:10.1111/ odi.12615 commonly used agents in dentistry are

60 DentalAcademyofCE.com DENTAL ACADEMY OF CONTINUING EDUCATION

22. Bradt J, Dileo C, Shim M . Music interventions for 26. Boyd LD, Mallonee LF, Wyche CJ, Halaris JF. Wilkins’ LISA DOWST-MAYO, MHA, preoperative anxiety. 2013. Cochrane Database Syst Clinical Practice of the Dental Hygienist. 13th ed. BSDH, RDH, graduated magna Rev. 2013;6:CD006908. Wolters Kluwer:2020. cum laude with a bachelor’s degree in dental hygiene from 23. Bradt J, Dileo C. Music interventions for mechanically 27. Haveles EB. Applied Pharmacology for the Dental Baylor College of Dentistry and a ventilated patients. 2014. 8th ed. Elsevier:2020. Cochrane Database Syst Hygienist. master’s degree in health-care Rev. 2014(12):CD006902. 28. Guidelines for the use of sedation and general administration from Ohio 24. Lehrner J, Eckersberger C, Walla P, et al. Ambient anesthesia by dentists. American Dental Association. University. She is currently odor of orange in a dental office reduces anxiety and Oct. 2016. http://www.ada.org/~/media/ADA/ enrolled in a PhD program with Franklin University for health-care administration. She improves mood in female patients. Physiol Behav. 29. Education%20and%20Careers/Files/anesthesia_ works as a professor of dental hygiene at Texas A&M 2000;71(1-2):83-86. use_guidelines.pdf University College of Dentistry in Dallas, Texas. 25. Lehrner J, Marwinski G, Lehr S, et al. Ambient 30. Yoon JY, Kim EJ. Current trends in intravenous Dowst-Mayo is an international CE speaker, having odors of orange and lavender reduce anxiety and sedative drugs for dental procedures. J Dent Anesth taught more than 200 programs both in-person and improve mood in a dental office. Physiol Behav. Pain Med. 2016;16(2):89–94. doi:10.17245/ livestreaming. She has published more than 46 2005;86:92-95. jdapm.2016.16.2.89 peer-reviewed courses and articles since 2006 and can be contacted through her website at lisamayordh.com.

ONLINE COMPLETION QUICK ACCESS code 21029 Use this page to review questions and answers. Visit dentalacademyofce.com and sign in. If you have not previously purchased the course, select it from the Online Courses listing and complete your online purchase. Once purchased, the exam will be added to your Archives page, where a Take Exam link will be provided. Click on the Take Exam link, complete all the program questions, and submit your answers. An immediate grade report will be provided. Upon receiving a grade of 70% or higher, your verification form will be provided immediately for viewing and printing. Verification forms can be viewed and printed at any time in the future by visiting the site and returning to your Archives page.

QUESTIONS

1. What percentage of Americans avoid 5. According to a study published in the 9. Which of the following is a psychological visiting the dentist due to dental fear or European Journal of Oral Sciences, of the fear patients with dental anxiety may have? anxiety? following listed, which had the highest A. Fear of loss of control A. 12% percentage of participant fear? B. Fear of injections B. 22% A. Blood C. Fear of germs C. 35% B. Dental treatment D. All of the above D. 55% C. Thunder D. Flying 10. Which of the following structures of the 2. Which of the following terms describes a brain is a part of the limbic system that person’s response to a dental object or 6. According to a study published in the converts sensory memory from short-term situation that induces an emotional and/or European Journal of Oral Sciences, which of to long-term memory? physical response to a perceived threat? the following had the highest percentage of A. Thalamus A. Dental fear participant phobia? B. Hippocampus B. Dental anxiety A. Dental treatment C. Hypothalamus C. Dental phobia B. Snakes D. Medulla oblongata D. None of the above C. Spiders D. Blood 11. According to the Journal of Advanced 3. Which of the following terms describes an Nursing, in 2019, what percentage of young emotional state that precedes an encounter 7. In the study of proxemics, what space adults had a fear of needles that interfered with a feared object or situation? distance describes humans that are less with their receiving needed treatment? A. Dental fear than 18 inches away from one another and A. 2%-10% B. Dental anxiety where dental procedures take place? B. 10%-20% C. Dental phobia A. Public space C. 20%-30% D. None of the above B. Social space D. 75%-100% C. Personal space 4. Which of the following terms is described in D. Intimate space 12. What percentage of Americans cite cost as the DMS-5 as fear, anxiety, and avoidance the top reason they do not visit a dentist of a situation lasting more than six months, 8. In the study of proxemics, what space more frequently? which cannot be attributed to another distance describes humans that are A. 12% mental health disorder, substance abuse, or 12-25 feet apart, such as public speaking B. 22% medical condition? distance? C. 45% A. Dental fear A. Public space D. 59% B. Dental anxiety B. Social space C. Dental phobia C. Personal space D. None of the above D. Intimate space

DentalAcademyofCE.com 61 DENTALDENTAL ACADEMY ACADEMY OF OF CONTINUING CONTINUING EDUCATION EDUCATION ONLINE COMPLETION QUICK ACCESS code 21029 Use this page to review questions and answers. Visit dentalacademyofce.com and sign in. If you have not previously purchased the course, select it from the Online Courses listing and complete your online purchase. Once purchased, the exam will be added to your Archives page, where a Take Exam link will be provided. Click on the Take Exam link, complete all the program questions, and submit your answers. An immediate grade report will be provided. Upon receiving a grade of 70% or higher, your verification form will be provided immediately for viewing and printing. Verification forms can be viewed and printed at any time in the future by visiting the site and returning to your Archives page.

QUESTIONS

13. Nationally, how much money is spent on 20. Which of the following is not a 25. Which of the following is a reaction that emergency department visits for patients nonpharmacological approach to managing occurs during a sympathetic fight-or-flight presenting with pain of an oral origin? a dental patient’s anxiety? response? A. $100,000 A. Good communication A. Increased pulse rate B. $500,000 B. Desensitization B. Decreased heart rate C. $1.1 million C. Utilization of nitrous oxide-oxygen sedation C. Bronchoconstriction D. $2.2 million D. Distraction D. Decreased glucose in blood circulation 14. In the US, what percentage of dental 21. Which dental screening tool is a four- 26. Which of the following is a symptom of a expenditures came from private insurance item questionnaire using Likert scale 5-25 panic attack? resources in 2016? to identify patients from “no anxiety” to A. Shortness of breath A. 12% “extreme anxiety”? B. Chest pain or discomfort B. 46% A. Modified Dental Anxiety Scale (MDAS) C. Fear of dying C. 80% B. Dental Anxiety Scale (DAS) D. All of the above D. 90% C. Dental Fear Survey (DFS) D. Index of Dental Anxiety and 27. Which of the following anxiolytic drug 15. In the US, what percentage of dental Fear (IDAF-4C+) classes is used to assist patients in expenditures came from CMS programs in sleeping the night before an appointment 2016? 22. Which dental screening tool has three and easing anxiety either the night before A. 12% modules to measure dental phobia, or day of the appointment? B. 50% feared dental stimuli, and an eight-item A. Benzodiazepines dental anxiety and fear module to assess B. Minimal sedation C. 60% emotional, behavioral, physiological, and D. 75% cognitive components of the anxiety and C. Nitrous oxide-oxygen sedation fear response? D. General sedation 16. What percentage of adult Americans ages 18-64 had dental insurance in 2018? A. Modified Dental Anxiety Scale (MDAS) 28. Which of the following is a A. 5%-15% B. Dental Anxiety Scale (DAS) used in dentistry to ease anxiety? B. 45%-57% C. Dental Fear Survey (DFS) A. Diazepam (Valium) C. 80%-90% D. Index of Dental Anxiety and B. Propofol (Diprivan) Fear (IDAF-4C+) D. 90%-100% C. Ketamine (Ketalar) 23. Which of the following scents was found to D. Dexmedetomidine (Precedex) 17. What percentage of GDP dollars was spent lower patient anxiety and improve mood in on dental expenditures in 2019? dental waiting rooms as published in the 29. Which of the following is used in dentistry A. 4% Journal of Physiology & Behavior? as a minimal/moderate/deep sedation agent B. 60% that causes amnesia and varying degrees of A. Lavender sedation? C. 90% B. Orange A. Alprazolam (Xanax) D. 100% C. Menthol B. Hydrocodone 18. Which of the following is a typical response D. Both A & B C. Propofol (Diprivan) to vasoconstrictors used in dentistry? 24. Which of the following is recommended in D. Morphine A. Increased heart rate and appointment planning for the anxious dental force of contraction patient? 30. In which of the following forms of B. Increased fear or anxiety sedation does a patient completely lose A. Schedule appointments first consciousness, cannot be aroused even C. Headache thing in the morning. with painful stimuli, and airway assistance D. All of the above B. Allow extra time for appointments. is necessary with possible cardiovascular C. Encourage rest breaks during treatment. function impairment? 19. Which of the following are physical triggers that can induce anxiety in patients? D. All of the above A. Minimal sedation A. Gagging B. Moderate sedation B. Choking C. General anesthesia C. Inability to breathe when D. Inhalation sedation instruments are in the mouth D. All of the above

62 DentalAcademyofCE.com PUBLICATION DATE: JUNE 2021 ANSWER SHEET EXPIRATION DATE: MAY 2024

The dental practitioner’s ultimate guide to adult patient fear, anxiety, and phobia

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