This document discusses the management of anxious dental patients. It begins by defining stress and outlining the stages of the stress response. It then discusses the scope of the problem, distinguishing between dental fear, anxiety, and phobia. Signs of acute anxiety are provided. The first consultation is emphasized as important for getting to know the patient, showing empathy, and taking a thorough medical history. Communication techniques like active listening and maintaining eye contact are recommended. Treatment approaches like iatrosedation, pre-medication, and vocal sedation during procedures are outlined. The importance of a comprehensive treatment plan and clear post-treatment instructions are also highlighted.

1. Management of the
anxious patients
Assist.Prof.Dr.Alper KAYA
RAK College of Dental Sciences
RAK Medical & Health Sciences University

2. Stress
 A physical, chemical or emotional factor that
causes bodily or mental tension and may be a
factor in disease causation
 Factors that tend to alter an existent equilibrium
 Cause of ¾ Medical Emergencies in Dentistry

3. Stages of Stress Response
Stage 1: One of the 5 senses sends stimuli to the brain
.

4. Stages of Stress Response
Stage 2: Brain analyzes it as a ‘Threat’ or ‘No Threat’

5. Stages of Stress Response
Stage 3: Body aroused until threat is over
.

6. Stages of Stress Response
Stage 4: Body returns to homeostasis (calm) once threat is gone.

7. Scope of the Problem
• Dental Fear
• Dental Anxiety
• Dental Phobia

8. Scope of the Problem
Dental Fear
• Fear is a natural, adaptive reaction and is supposed to protect
us against danger.
• Our response to the feeling of fear consist of three parts; a
physiologic, a cognitive and a behavioral component.

9. Scope of the Problem
Dental Fear
• The physiologic component consists of an activation of the
sympathetic nerve system with an increased adrenalin-level,
which can lead to sweating, increased heart beating and
stomach problems.
• The cognitive component involves negative thinking, like “this is
dangerous – I might die – I need to get away”,

10. Scope of the Problem
Dental Fear
• The behavioral part of the response will involve trying to
fight the situation or getting away from it.
• The fear is nevertheless controllable and the person is
capable of coping and thinking rationally.

11. Scope of the Problem
Dental Anxiety
• The anxiety response is almost identical to the fear response,
both having a physiologic, a cognitive and a behavioral
component.
• The main difference is the nature of the stimulus which will
trigger the reaction, and how powerful the reaction is to the
given threat.

12. Scope of the Problem
Dental Anxiety
• The anxious patient will still know that the anxiety is
an irrational and greatly exaggerated reaction, and
will often, despite of the anxiety, actually come to the
dental clinic

13. Scope of the Problem
Dental Phobia
• Phobia is a well-defined illness, and there are very
specific criteria of what is defined as odontophobia

14. Scope of the Problem
Dental Phobia
• Odontophobic persons will usually not go to a dental clinic at
all, or at the most only when they have an unbearable tooth
ache.
• Often they cease brushing their teeth, because looking at the
teeth is a constant reminder of not going to the dentist –a
feeling which gives them great discomfort.

15. Scope of the Problem
Dental Phobia
• Not going to the dentist often gives an increased treatment
need, and hence their anxiety and shame increase even more.
• Often they evolve a social phobia as well, because of their bad
tooth condition or –function, and their phobia affects their
everyday life to a great degree.

16. Anxiety
 Release of epinephrine, nor-epinephrine
 ⇧ HeartRate
 ⇧ Blood Flow
 ⇧ Respiration
 Vasodilatation in the periphery (arms and legs)
 ⇧ Serum Glucose Level

17. Signs of Acute Anxiety
 Cold, sweaty palms or forehead
 Flushing of face
 Altered facial expression such as bulging eyebrows
 Dry mouth orincrease in salivation
 Bruxism or clenching of teeth
 Increased need to urinate
 Unnaturally stiff posture

18. Signs of Acute Anxiety
 Inability to sit still
 Trembling or tremors
 Fiddling with items in his/her hands
 White-knuckle syndrome
 Tapping feet or fingers
 Crying out or moaning
 Hyperventilation, syncope, nausea or vomiting
 Increased respiration, blood pressure, and heart rate

19. First Consultation
 Get to know the patient
 Try to be friend him/her
 Medical History
 Discuss likes and dislikes, acknowledge feelings
Empathy
 Understand him/her well-it’s a long term affair...

20. Medical History
 Written, signed and verbal
 Categorization as per ASA PS Score
 Check vitals

21. Communication
 Let them talk
 Be a good listener
 Show interest in their conversation
 At an eye level
 Away from the equipment

22. Iatrosedative Technique
 “Making the patient calm by the dentist’s behavior,
attitude, and communicative stance “
 A dentist can use to achieve this include making efforts
to avoid pain, giving the patient control and keeping the
patient informed of what the dentist is planning to do, and
what sensations the patient may experience

23. Iatrosedative Technique
 The dentist should have some flexibility in the choice of
language, speed and attitude in order to adapt the
communication to the individual patient.
 Full clarity about the expectations and demands placed
on the patient at any time, is also necessary and helpful
for the patient

24. AnxiousPatient
 Short morning appointment followed by a good morning
breakfast
 Pre-medication with Lorazepam 1mg (check interaction
with other drugs) night before sleep followed by 90
minutes prior to procedure
• No driving
• Need to be accompanied by friend/relative etc.
 Extremely short or no waiting time in the waiting area

25. Diagnosis and Treatment Plan
Try to find the cause of the problem and discuss with
patient rather than just trying to pick up that handpiece
Make a preventive programme for the patient
Make a comprehensive treatment plan in phases
Emergency
Stabilization
Maintenance
Definitive

26. During the treatment
 Duration, only as much as patient can tolerate
 Making sure patient feels he/sheis in command
 Better to have a short and simple procedure first
to gain patient’s confidence
 Pain free
Topical gel
Local anesthesia; Buffered, warm, slow, 30G needle

27. Vocal Sedation
“I will be careful.”
“You may feel a slight sting.”
“I will make the area numb so that it is comfortable for
both, you and me.”
“I will apply this strawberry surface anesthetic first and
youwill hardly feel anything.”
“I am slowly putting some solution inside so that you
will not feel a thing.”

28. Vocal Sedation
• Avoid “needle”, “hurt”, “sharp”
• Talk to them as you go through the procedure.
• It will make them feel more relaxed and compliant.
• Don’t forget smiling

29. Post Treatment
 Clear verbal and writteninstructions
 Pain control medications
 Phone number of the treating doctor (to call in case
of emergency)
 Protocol for referral if needed