Disease/Medical Condition ANXIETY AND

ANXIETY DISORDERS Date of Publication: Jan. 31, 2019

(Anxiety disorders include “generalized anxiety disorder”; “social anxiety disorder” [formerly known as “social phobia”]; “separation anxiety disorder”; “selective mutism”; “agoraphobia”; “substance abuse/medication-induced anxiety disorder”; “specific phobias” [also known as “simple phobias”, which include claustrophobia, blood phobia, needle phobia, and dental phobia1]; and “panic disorder”.)

Is the initiation of non-invasive dental hygiene procedures* contra-indicated? No, unless the patient/ client displays signs/symptoms of anxiety or an anxiety disorder that pose a risk to himself/herself or the dental hygienist during procedures (e.g., markedly elevated heartrate with comorbid heart disease, inability to sit still, etc.).

 Is medical consult advised? — No, if anxiety disorder has been previously diagnosed and is well controlled. — Yes, if anxiety disorder is newly suspected or poor control of previously diagnosed anxiety disorder is suspected. — Yes, if severe xerostomia is suspected to be related to antidepressant or benzodiazepine use (which may improve if an alternative medication is a consideration).

Is the initiation of invasive dental hygiene procedures contra-indicated?** No, unless the patient/ client displays signs/symptoms of anxiety or an anxiety disorder that pose a risk to himself/herself or the dental hygienist during procedures (e.g., markedly elevated heartrate with comorbid heart disease, inability to sit still, etc.).

 Is medical consult advised? ...... See above.  Is medical clearance required? ...... No, unless: — a panic attack has previously occurred in the dental/dental hygiene setting; or — severe leukopenia (i.e., reduced white blood cell count, and hence immunosuppression) is suspected with tricyclic antidepressant (TCA) or monoamine oxidase inhibitor2 (MAOI) medication use. [This would be a rare situation in the dental hygiene office setting.]  Is antibiotic prophylaxis required? ...... No (in the absence of immunosuppression).  Is postponing treatment advised? ...... No, unless: — medical clearance is pending regarding possible immunosuppression associated with TCA or MAOI use; — the patient/client appears drowsy and/or confused (which may be side effects of benzodiazepine use); — the patient exhibits signs/symptoms of anxiety or an anxiety disorder (e.g., a panic attack) that may pose risk during, or cause inability to perform, procedures, in which case medical intervention may first be needed; or — severe signs/symptoms of anxiety (e.g., a panic attack) exist, in which case, attainment of better anxiety control may be indicated to alleviate patient/client’s distress before attempting elective dental hygiene treatment.

Oral management implications

 Patients/clients with anxiety disorders directly related to, or exacerbated by, dental or dental hygiene procedures may delay seeking treatment due to dental fear. Thus, they may present with advanced disease.  A history of emergency dental care only and/or cancelled appointments for non-emergency treatment potentially indicates moderate to severe dental anxiety.  Caffeine should generally be avoided by anxious patients/clients proximate to a dental hygiene appointment, because it can worsen signs/symptoms of anxiety.

1 Dental phobia is also known as “odontophobia” and “dentophobia”. 2 MAOIs are generally not first-line choices for the medicinal management of anxiety disorders due to their side effect and drug interaction profiles. However, they are used in the management of panic disorder and some other anxiety disorders when first-line antidepressants are ineffective.

cont’d on next page... Disease/Medical Condition ANXIETY AND ANXIETY DISORDERS

(Anxiety disorders include “generalized anxiety disorder”; “social anxiety disorder” [formerly known as “social phobia”]; “separation anxiety disorder”; “selective mutism”; “agoraphobia”; “substance abuse/medication-induced anxiety disorder”; “specific phobias” [also known as “simple phobias”, which include claustrophobia, blood phobia, needle phobia, and dental phobia]; and “panic disorder”.)

Oral management implications (cont’d)

 The dental hygienist should be cognizant of the patient/client’s ability to tolerate the stress of the appointment, which is aided by appropriate history-taking (e.g., any history of dental phobia/anxiety, agoraphobia, claustrophobia, panic disorder, or separation anxiety) and direct observation of signs related to anxiety. Intensified anxiety related to dental and dental hygiene procedures can exacerbate an underlying anxiety disorder, as well as precipitate or worsen medical problems such as hyperventilation, syncope, angina, myocardial infarction, stroke, asthma, and seizures.  Because some patients/clients underestimate or do not want to acknowledge dental anxiety or anxiety disorders, direct observation of signs and symptoms is important.  Severely anxious patients/clients may show the following: appearance of uneasiness; increased blood pressure and heart rate; sweating; dilatation of pupils; and trembling. In the dental chair, signs include overly quick answers, unnaturally stiff posture, nervous play with a tissue or other object, and perspiration on forehead and hands.  Stress reduction protocols, possibly in conjunction with premedication with a sedative/anxiolytic and/or conscious sedation during therapy, may effectively manage a moderately anxious patient/client. A severely anxious patient/client may require either intravenous (IV) sedation or general anaesthetic for dental treatment and, on occasion, invasive dental hygiene procedures.  A patient/client’s anxiety can often be reduced by scheduling the appointment in the morning; minimizing the waiting time; using reassuring, calm communication; informing the patient/client that he/she can stop the procedure by raising a hand during treatment; and avoiding triggers (i.e., sights, sounds) associated with previous negative experiences. Adequate pain control during dental procedures and postoperatively should be achieved.

Oral manifestations

 Burning mouth syndrome is associated with higher anxiety scores, particularly in generalized anxiety.  Xerostomia, dysgeusia (altered sense of taste), bruxism, stomatitis, sialadentitis, and tongue edema or discolouration can result from antidepressant use. Xerostomia can also result from benzodiazepine use.

Related signs and symptoms

 Anxiety is a sense of psychological distress that may involve one or more of: an internal psychological conflict, an environmental stress, a physical disease state, or a drug effect. It can be experienced as a primarily psychological experience with few physical manifestations, or it can be experienced primarily as a physical phenomenon.  Physiologic reactions to anxiety are similar to those of fear3, being mediated through the autonomic nervous system. Such signs and symptoms include: tachycardia, palpitations, shortness of breath, sweating, dilated pupils, muscle tension, chest pain, headaches, dry mouth, indigestion, diarrhea, and urinary frequency. Manifestations may also include feeling “on edge”, exaggerated startle response, difficulty concentrating, irritability, and insomnia.  While nearly everyone periodically experiences anxiety, its signs and symptoms are typically short-lived and do not cause significant problems. By contrast, anxiety disorders are persistent conditions where the cognitive, physical, and behavioural signs/symptoms are severe and out of proportion to real events, and which cause substantial distress that adversely affects functioning on an ongoing basis. The causes of anxiety disorders are incompletely understood, but likely result from a combination of genetic, environmental, psychological, and developmental factors4.

3 Fear is the emotional response to a real or perceived threat, whereas anxiety is anticipation of a threat. The two states overlap. 4 Management for most anxiety disorders usually involves psychotherapy (including cognitive behavioural therapy), counselling, self-help strategies (e.g., stress management and relaxation techniques), and/or medications. Commonly used medications are anxiolytic drugs (e.g., benzodiazepines [lorazepam, diazepam, triazolam, alprazolam, etc.], which are generally intended to be prescribed for a short period of time) and antidepressants. Beta-blockers (such as propranolol and atenolol), which are also used in the management of hypertension), are sometimes used to control physical symptoms of anxiety, such as rapid heart rate, trembling, and blushing.

cont’d on next page... 2 Disease/Medical Condition ANXIETY AND ANXIETY DISORDERS

(Anxiety disorders include “generalized anxiety disorder”; “social anxiety disorder” [formerly known as “social phobia”]; “separation anxiety disorder”; “selective mutism”; “agoraphobia”; “substance abuse/medication-induced anxiety disorder”; “specific phobias” [also known as “simple phobias”, which include claustrophobia, blood phobia, needle phobia, and dental phobia]; and “panic disorder”.)

Related signs and symptoms (cont’d)

 Anxiety disorders in aggregate are the most common of mental health conditions, affecting 10% to 12% of Canadians. Children, adolescents, and adults are affected, with prevalence somewhat higher in women than in men.  Common to all anxiety disorders are:  excessive and irrational fear;  tense and apprehensive feelings; and  difficulty managing daily or specific tasks and/or distress related to such tasks.  Types of anxiety disorders include:  generalized anxiety disorder (affecting about 2% of adults in any given year, with lifetime prevalence of about 5% to 6%), which is excessive worry around a variety of everyday problems that interferes with daily activities for more than 6 months, and which is often accompanied by physical symptoms such as restlessness, feeling on edge or easily fatigued, difficulty concentrating, problems sleeping, and muscle tension;  social anxiety disorder (a complex phobia affecting about 7% of adults in any given year), which involves intense fear of social situations, including fear of being embarrassed, humiliated, rejected, or evaluated negatively by others, with resultant avoidance of social situations (such as public speaking, meeting new people, or eating/drinking in public) and interference with daily functioning for more than 6 months;  separation anxiety disorder (affecting 1% to 2% of adults in any given year), in which the patient/client is excessively anxious or fearful about separation from those with whom he or she is attached, beyond what is appropriate for the person’s age, and which persists (for at least 4 weeks in children and 6 months in adults) and causes problems functioning (e.g., reluctance to leave home without ‘attached’ person, as well as physical symptoms of distress);  agoraphobia (a complex phobia affecting about 2% of adults in any given year), which involves fear of situations where escape may be difficult or embarrassing or help might not be available in the event of panic symptoms; this fear is disproportionate to the actual situation and may manifest as fear of being in open or enclosed spaces, using public transportation, or being outside the home alone);  specific phobias (affecting about 8% of adults in any given year, with lifetime prevalence of 25%), which involve excessive and persistent fear of a specific object, situation, or activity, and which cause such distress that some patients/clients go to extreme lengths to avoid what they fear; include claustrophobia [extreme and irrational fear of confined spaces] and dental phobia [extreme and irrational fear of dental examinations and procedures]); and  panic disorder (affecting 2% to 3% of adults in any given year, with lifetime prevalence of about 4%), which involves recurrent and unexpected panic attacks with an overwhelming combination of psychological and physical distress (e.g., feelings of choking, dizziness, light-headedness, shortness of breath, smothering sensation, and/or detachment or unreality; fear of losing control or dying; palpitations, pounding heart, or rapid heart rate; sweating; shaking or trembling; chest pain; numbness or tingling; chills or hot flashes; and nausea and/or abdominal pain). Because symptoms are so severe, the patient/client experiencing a panic attack may believe he/she is having a myocardial infarction or other life-threatening illness. Affected persons often try to avoid places where panic attacks have occurred in past. Mean age of onset of panic disorder is about 22 years.  Some other mental illnesses are no longer classified as anxiety disorders, although anxiety is a major part of the conditions5. Anxiety is also often part of the clinical picture for persons with depression, bipolar disorder, dementia, eating disorders, psychosis, and other psychiatric disorders or withdrawal states.

5 These illnesses include obsessive-compulsive disorder (OCD, in which unwanted thoughts, images, or urges cause anxiety [i.e., obsessions] resulting in repeated actions intended to reduce that anxiety [i.e., compulsions]), as well as post-traumatic stress disorder (PTSD, which involves reliving a traumatic event — such as an accident, natural disaster, or abuse — through flashbacks or nightmares, in addition to avoiding reminders of the traumatic event; lifetime prevalence is 5% to 10%).

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Disease/Medical Condition ANXIETY AND ANXIETY DISORDERS

(Anxiety disorders include “generalized anxiety disorder”; “social anxiety disorder” [formerly known as “social phobia”]; “separation anxiety disorder”; “selective mutism”; “agoraphobia”; “substance abuse/medication-induced anxiety disorder”; “specific phobias” [also known as “simple phobias”, which include claustrophobia, blood phobia, needle phobia, and dental phobia]; and “panic disorder”.)

References and sources of more detailed information

 College of Dental Hygienists of Ontario http://www.cdho.org/Advisories/CDHO_Advisory_Anxiety_Disorders.pdf  Davies SJC, Underhill HC, Abdel-Karim A, et al. Individual oral symptoms in burning mouth syndrome may be associated with depression and anxiety. Acta Odontologica Scandinavica. 2016;74(2):155-160. https://www.ncbi.nlm.nih.gov/pubmed/26494262  Centre for Addiction and Mental Health http://www.camh.ca/en/hospital/health_information/a_z_mental_health_and_addiction_information/anxiety_disorders/ Pages/Anxiety_Disorders.aspx  Institute for Clinical Evaluative Sciences https://www.ices.on.ca/Publications/Atlases-and-Reports/2017/MHASEF The Mental Health of Children and Youth in Ontario: 2017 Scorecard  Health Canada https://www.canada.ca/en/health-canada/services/healthy-living/your-health/diseases/mental-health-anxiety- disorders.html  Canadian Mental Health Association https://cmha.ca/wp-content/uploads/2016/02/Anxiety-MI-NTNL-brochure-2014-web.pdf  National Institute of Mental Health, National Institutes of Health https://www.nimh.nih.gov/health/topics/anxiety-disorders/index.shtml  American Psychiatric Association https://www.psychiatry.org/patients-families/anxiety-disorders/what-are-anxiety-disorders https://dsm.psychiatryonline.org/doi/10.1176/appi.books.9780890425596.dsm05  Darby M (ed.) and Walsh M (ed.). Dental Hygiene: Theory and Practice (4th edition). St. Louis: Elsevier Saunders; 2015.  Little JW, Falace Da, Miller CS and Rhodus NL. Dental Management of the Medically Compromised Patient (8th edition). St. Louis: Elsevier Mosby; 2013.

* Includes oral hygiene instruction, fitting a mouth guard, taking an impression, etc.

** Ontario Regulation 501/07 made under the Dental Hygiene Act, 1991. Invasive dental hygiene procedures are scaling teeth and root planing, including curetting surrounding tissue.

Date: February 18, 2018

www.cdho.org 4