Therapeutic intervention for Dental Phobia
23rd August, 2010
Fear, anxiety and phobias are very common reasons why a person will not attend a dental practice on a regular basis, if at all. Levels of anxiety are very much linked to our memories of experience and how we rationalise them into our current lives. You, the dentist, are well aware that the level of life threatening treatments and surgeries you will undertake is virtually zero. However, you also accept that there is a level of discomfort in certain invasive surgical techniques in the mouth, an area that is very sensitive and strongly linked with painful and pleasurable life memories. The risk of a patient choking in your surgery is tiny but to a claustrophobic patient, the thought of a rubber dam suffocating them may be enough to trigger a panic attack.
I conducted an exercise in 2007 where patients of 5 dental practices were asked a series of questions aimed at identifying the levels of fear and comfort that they experience before, during and after dental treatment. Upon further questioning, the majority who felt anxious put this down to either an early life trauma, usually the school dentist, or from the myths they had assimilated into fact. While others had specific triggers such as the noise of the dental drill, the smell of the sanitised surgery or potential pain.
A phobia is an abnormal fear linked to a particular being or situation as the fear is out of proportion to the demands of the situation. A dental phobic patient not only has difficulty in coming to see you for dental treatment but very often when they do get through the door their increasing anxiety and anticipation alone can increase their level of perceived pain if you go anywhere near a nerve ending thus making your treatment time run longer and with less chance of successful completion on time.
So when someone is dental phobic how have they been conditioned to accept this abnormal fear and what can be done to lower its potency? I am sure that most of you have heard of Pavlov’s work in classical conditioning. The reflex response to a stimulus that if repeated enough times will produce an unconscious response, a response that occurs regardless of logic. It is important to separate anxiety based upon a previous traumatic experience with phobias that, similar to the bell in Pavlov’s experiments, are indirect to the stimulus. The highly phobic patient may find watching an actor on the TV brushing their teeth as too traumatic as experience for them to keep watching.
The use of relaxation sessions is effective in the treatment of phobias. Desensitisation is a preferred technique as it is a permissive process, which allows the patient to move at a comfortable pace with reassurance that they are always in a safe environment. Joseph Wolpe pioneered the use of desensitisation in the treatment of anxiety and phobias. Wolpe used more assertive techniques successfully but found that a process of general relaxation was more beneficial where the stimulus was not literally present i.e. person will have a fear of dental treatments even if there are no dentists readily to hand, no surgeries in view etc. Wolpe discovered that if a person is in a relaxed state and repeatedly imagines a weakly anxiety provoking situation, the stimuli (fear of dentists and treatment) would progressively diminish in terms of its potential to generate anxiety. The objective was to establish an alternative, more appropriate positive response to the stimuli. This could take the form of a change in potential pain expectation and perception of treatment comfort. Wolpe developed the SUDS scale (Subjective Units of Disturbance Scale). This allows the categorisation of anxiety on a sliding scale. Zero being totally relaxed, 100 being total anxiety. Through this the therapist can reach and push the threshold of tolerance of the phobia through the patient in a relaxed state. This process is a form of reciprocal inhibition which is defined as a method of inhibiting one response (fear) by the occurrence of another state mutually incompatible to it (relaxation). In other words you cannot be anxious and relaxed at the same time!
During the patient consultation the SUDS scale is incorporated to ascertain the level of anxiety to a stimulus (construct the hierarchy). During practice I worked with someone with a non specific fear of dental treatment. From this I ascertained the following;
The case history and SUDS must be as thorough as possible using the patient’s words;
10%-I barely give it a thought, as long as I am on time.
20%-I get butterflies in my stomach but I am comfortable in the dental chair.
30%-I can flinch and pull away if the dental drill slips but remain composed.
40%-The anticipation of the drill, probe or needle makes me feel anxious.
50%-The sound of the dental drill frightens me.
60%-I feel sick and feel like running out of the surgery.
70%-I need reassurance as I sit in the waiting room.
80%-I find excuses to cancel my appointment.
90%-I cannot go into a dental surgery without reassurance.
100%-I panic at the thought of a dentist, treatments, hands in my mouth
The hypnotic process for a patient with a high level of dental phobia is based upon getting them to stop focussing on their fear internally. The majority of hypnotic therapies that I undertake start with an induction which is a combination of distraction and focus on an external object such as a pen or even their hand. The induction process includes elements of suggestion of relaxation and quite quickly the patients eyes will close, their breathing will slow as well as their pulse. The next stage is deepening, where the patient is taken into a deeper trance. Some patients respond quicker than others and the therapists use of language and timing is imperative to allow the patient to trust that they can go deeper into trance. Once in the deepened trance, the therapist takes the patient up through their levels of disturbance asking them to imagine the feelings surrounding each level until a level is reached that the patient cannot tolerate. At this time the therapist takes the patient back a level and then attempts the higher level again. Through this the fear diminishes as the patient , who is relaxed, will begin to associate more what they can tolerate as they are calm rather than what they cannot when anxious.
It is worth noting that a condition cannot be reached where a patient is totally oblivious to fear regardless of the clinical and personal skills of their dentist because through hypnosis the patient has been able to rationalise their own conscious beliefs. There is much conjecture surrounding the hypnotic phenomenon, some say it is an act that the patient ‘agrees’ to, others the ability to get in touch with what Jung described as the ‘Collective Unconscious’. The scientific and spiritual viewpoints must be respected and whatever, at this time, is nearer to the truth, the benefits of relaxation in reaching internal objectivity are clear.
A key consideration in the treatment of anxiety is the risk of abreaction. This is where the patient may revivify a previous traumatic experience and may start to relive the emotional and physical pain. Under hypnosis it is imperative to establish a safe and secure ‘place’ for the patient that they can freely explore their deeper memories with out fear. A significant advantage of hypnosis is the very relaxed state, a patient in a relaxed state is far more suggestible and open to new ideas of thinking. The very nature of a hypnosis session is beneficial for the calm state it creates allowing the subject in some way to ‘work out’ their phobia anxiety
So in this instance the patient recorded their threshold of anxiety at between 80-90%. Through the use of hypnodensitisation this is reduced to 20-30%. The patient was able to attend appointments and remain calm. This can then be reinforced with teaching the patient a short self hypnosis script based upon what calmed them most that they could activate when in the dental chair.
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