April / May 2005

Join AHP to receive the complete Perspective Magazine by mail!

THERE IS MORE TO LIFE THAN DENTAL FEAR

— Cor W. Anneese

Despite the fact that, from the point of view of technology, dentistry is a highly developed discipline, more than half of the American population is afraid to be treated by the dentist. Five to fifteen per cent of the population simply never consults a dentist. The most important reason is fear of the possible pain to be inflicted.

There is probably no other medical healthcare context in which the connection between pain and anxiety is so conspicuous as with dentistry, and this is why most patients step into the waiting room trembling with fear.

Several causes appear to play a role in the development of fear of the dentist. A patient recounts how a molar broke off during a treatment session. She was immediately referred to a dental surgeon to have the roots removed. After that, she was too scared to go back.

Young children are often afraid of the dentist, particularly when one or both parents share the same fears. Studies have shown that 60% of school dentists are concerned about the sometimes harsh way in which dentists approach the behavior of young children, which undermines the treatment provider’s professional functioning. Authoritarian or socially inept behavior on the part of the dentist often causes substantial anxieties in the later stages of a child’s life. Behavioral therapists find that often problematical situations are not due to the child, but rather to the dentist himself, who, with a lack of adequate knowledge of educational psychology, is unable to make a correct assessment of an emotional problem.

Patients suffering from agoraphobia, social fear, or panic disorders may show reluctance to make a dental appointment. I once treated a young woman for erythrophobia who would not go to a dentist. Her neglected teeth filled her with embarrassment.

However, there are many variations of dental fears. One person panics at the drill, another becomes giddy or nauseous after treatment, while others turn pale at the sight of a syringe. Dentists are also familiar with the fear of treatment. In fact, one-third of dentists are afraid of the dentist.

Click ad to go to www.selfhelpwriter.com

LIMITATIONS IN DENTAL TREATMENT

On close inspection, a patient lying passively in a dentist’s chair reminds me of the setup for Pavlov’s dog trial. Of course, the dental patient is not rigged up to a harness, and the dentist does not put meat powder into his mouth, but he does put a drill in there, and a needle, cooling water, absorbent cotton, and much more! Such unpleasant surprises in the patient’s private space generate socalled unconditioned pain stimuli, which, in their turn, generate conditioned stimuli in the form of frightening thoughts. The naive patient often has no idea what the dentist is going to do. He or she is physically being exposed to unpleasant triggers, but is incapable of doing anything about it. This passive situation is the perfect breeding ground for the conditioning of dental fears in a patient’s mind. As soon as the patient lies back in the chair and the dentist starts drilling, the urge to escape springs into action at the first signs of pain. A local anesthetic should make pain impossible, and even though it usually does, previous negative experiences can cause irrational thoughts and fears.

In the 1960s, the psychologist Martin Seligman carried out extensive research into the behavior of dogs that were exposed to electroshocks, from which they were unable to escape. It eventually turned out that, even when later they were able to escape from the shocks, they no longer tried. This shows that, irrespective of a change in conditions, acquired helplessness can persist.

Once afraid of the drill, patients simply cannot rid themselves of their acquired helpless behavior; for this, a change in the treatment conditions would in fact be required. According to the principle of stimulus generalization, such fears will spread to other medical situations. Because the avoidance of situations contaminated by pain comes naturally to both humans and animals, long-term avoidance is not advisable, which is why, for example, after an accident, pilots will be advised to board an airplane immediately for another flight.

A great many patients also appear to attribute negative qualities to the waiting room. This is because, both in time and space, the waiting room is the gateway to the dentist’s surgery. Indeed, the dogs in Seligman’s study also refused to escape to the shock-free areas of the shuttle box. After their aversive conditioning, they behaved as helplessly in the safe area, where no electroshocks had been administered, as in the dangerous area of the shuttle box, where they had been regularly submitted to electroshocks. This learning principle also applies to nervous dental patients, who are sometimes even more anxious in the waiting room than in the dentist’s surgery itself. At first glance, nothing is happening in the waiting room, and yet . . . one patient is sighing, another is looking regularly at his watch, while a third, seemingly nonchalantly, is leafing through The Washington Post without reading a word.

From the point of view of psychology, a frightened patient is caught up in vicious circles of thoughts and emotions that mutually reinforce each other. Can we escape from these? We can, in fact, but we rarely do. A dentist once told me the following anecdote: “I have a patient who felt locked in during treatment. I told him: ‘Get out of the chair then!’ I didn’t have to say it again, because, with his back rigid against the leather upholstery, the patient slid out of the chair and onto the floor, where he crawled to one of the empty chairs. From there, he stared at the dentist’s chair and said: ‘How can that happen! I was totally caught up inside myself!’ ‘Then please sit down in the chair again,’ I said. A moment later, the patient was back in the treatment chair, more quietly than ever before. And he stayed that way.”

Click to go to www.saybrook.edu

THE USELESS PURSUIT OF SELF-CONTROL

Those who glance through psychology books in search of the meaning of the concept of selfcontrol could easily become confused. Not only does self-control correspond with the concept of self-restraint (of emotions), but it is also related to the concept of self-guidance, which is mainly about a person’s own behavior. Those who think that, with the help of thinking, breathing, or relaxation exercises, they will stay fresh and relaxed during treatment will be disappointed. Reflexes definitely cannot be controlled by exercises. Jacobson’s recommended relaxation exercises can hardly be carried out during treatment, let alone make you be able to press your tongue against the roof of your mouth or flex your lips with your mouth open while in the dentist’s chair. Such notions of self-control are highly misleading. We can therefore better abandon our persistent pursuit of selfcontrol in the sense of selfrestraint. The same applies to breathing through your nose while the dentist is drilling a molar or tooth: You are lying with your mouth wide open, trying to breathe as calmly as possible. But all this trying works in the wrong way, and before you know it, you are hyperventilating. What should you do then? Rather than making a vain attempt to control your body and mind, you could simply gesture to the dentist that you would like to take a short break.

Simple research has shown that real self-control only works optimally when dental patients can effectively influence the course of treatment. In this connection, the British psychologist W. G. Cumberbatch carried out an experiment with test subjects who could stop the drill immediately by pressing a button. The results were impressive! Nearly all of the subjects only pressed the button once or twice early in the drilling session, but after that no more. On further inquiry, these patients turned out to perceive the awareness that they could stop the drill as a pleasant sensation of control. In dental practices, the above-mentioned button is replaced by a gesture from the patient, upon which the dentist immediately stops drilling. From a psychological point of view, this mainly enhances cooperation between dentist and patient.

Real self-control is a kind of autonomy, in that the patient himself can direct his own behavior, and can start to break out of the acquired behavior of helplessness. The test subjects were totally independent of the dentist. Indeed, they themselves decided when and how often they made use of the button, and they could intervene at any given time. In her book Let the Patient Control the Procedure, Lorand Borland wrote:

Many patients have remarked to me about the intolerable lack of control which they feel during the dental procedures, saying that the pain and discomfort are not so unbearable in themselves but only become so as a result of feeling “there is nothing which one can do about it.”

Click to go to www.altjn.com

IMPROVING PRECONDITIONS IN THE PATIENT’S INTEREST

Experts believe dentists should provide their patients with more concrete information on what they intend to do at each treatment session and the time it will take.

As early as the 1980s, Professor P. M. Milgrom from the University of Washington advocated improvement in patient-oriented care in dentistry. He also emphasized the detrimental effects of dentists with an authoritarian attitude. As a reaction to authoritarian behavior, patients showed a tendency to avoid treatments, which resulted in the dentist becoming irritated and eventually in a vicious circle of mutual misunderstanding between patient and dentist. According to Milgrom, it is possible to realize a well-balanced cooperation between dentist and patient, with the objective of “making the treatment easier for the patient, so that pain and fear can be reduced to a minimum.”

With the “tell-show-do-method,” the dentist explains, for example, how the drill works, after which the patient is allowed to hold the drill himself for a moment. Solving riddles during the “biting” procedure for making an impression of a patient’s teeth also appears to be an excellent method of distracting someone from an unpleasant situation. “Procuring information in advance,” “sitting up straight if a patient starts to retch,” “practicing autogenously training” (imagining that your body feels warm and heavy), and “learning to think differently” are all important exercises that patients can carry out at home. It is important that the patient takes part in the treatment procedure actively and assertively.

Fortunately, there are more dentists who explain in advance what they are intending to do at each treatment session, and how long it will take, so that their patients start to feel safer and more secure. I advise anxious patients to ask the dentist to restrict treatment sessions to a half hour maximum each time. The so-called “exposure technique,” by which, early on in the treatment, patients are briefly exposed to frightening stimuli (such as drilling), is often effective. Good cooperation between dentist and patient can only be realized when the dentist is prepared to stimulate the greater involvement of his patients in the treatment. Examples are: giving advice, coming to agreements, giving instructions, and encouraging patients to be more assertive.

FROM JUDGMENT TO RESPECT AND COOPERATION

Research has shown that test subjects who are relatively seriously afraid of the dentist express more criticism of the dentist personally and of his professional functioning than those who are less frightened. How does a patient actually feel about his dentist if he fills in a questionnaire with “he is nasty,” “disinterested,” and “mean”? And how much confidence does a patient have in his dentist if he describes his professional functioning as: “He is incompetent,” “rough,” and “cool”? Anxious patients attribute relatively more negative qualities to a dentist than less anxious patients. This certainly suggests that the degree of fearfulness a patient has is voiced in his judgment of the dentist.

If patients are truly prepared to look fears in the eye, they will also become aware of what the dentist does for them. Only then will we discover that she helps us to keep our teeth healthy [contributing to overall health] and recognize the aptness of the following words: Better cooperation leads to less fear and more self-confidence.

COR ANNEESE is a Dutch psychologist, behavior therapist, and trainer, and author of diverse political, spiritual, and psychological articles as well as poems. He treated phobic patients for many years. In the 1990s, he coauthored the book Banish your Phobia with journalist Tino Pol, which was popular in The Netherlands and Germany. Recently he wrote a book about the psychological implications of dental treatments. Cor Anneese believes that specific balanced training programs help people to overcome their fears and anxieties. www.selfhelpwriter.com

First Cover Story

Interview with George Leonard
. . . Kathleen Erickson