Psychological management of anxiety and pain during dental treatment

An exploratory study investigating children's perceptions of dental behavioural management techniques

BACKGROUND

Behaviour management techniques (BMTs) are utilised by dentists to aid children's dental anxiety (DA). Children's perceptions of these have been underexplored, and their feedback could help inform paediatric dentistry.

AIM

To explore children's acceptability and perceptions of dental communication and BMTs and to compare these by age, gender, and DA.

DESIGN

A total of sixty-two 9- to 11-year-old school children participated in the study. Children's acceptability of BMTs was quantified using a newly developed Likert scale, alongside exploration of children's experiences and perceptions through interviews. anova and t-tests explored BMT acceptability ratings by age, gender, and DA. Thematic analysis was used to analyse interviews.

FINDINGS

Statistical analyses showed no effect of age, gender, or DA upon BMT acceptability. Children generally perceived the BMTs as acceptable or neutral; stop signals were the most acceptable, and voice control the least acceptable BMT. Beneficial experiences of distraction and positive reinforcement were common. Children described the positive nature of their dentist's communication and BMT utilisation.

CONCLUSION

Dental anxiety did not affect children's perceptions of BMTs. Children were generally positive about dentist's communication and established BMTs. Children's coping styles may impact perceptions and effectiveness of BMTs and should be explored in future investigations.

Psychological intervention in acute dental pain: review

Acute dental pain is an unpleasant experience. This article studies acute dental pain and examines the role of psychological intervention. After identification of the psychological factors associated with dental pain we go on to assess the role of psychological interventions.

Reliability of a Questionnaire Assessing Experiences of Adolescents in Orthodontic Treatment

OBJECTIVE

To evaluate the reliability of a questionnaire that assessed the expectations and experiences of adolescent patients about orthodontic treatment.

MATERIALS AND METHODS

The study included two groups of patients: 30 consecutive patients (19 girls and 11 boys, mean age 14.6 years, SD 2.3 years) naïve to orthodontic treatment, and 30 consecutive adolescent patients (17 girls and 13 boys, mean age 15.1 years, SD 2.0 years) in active orthodontic treatment with fixed appliances in both jaws. A questionnaire comprising 46 items was developed, based upon focus group interviews and previous established questionnaires. The questionnaire covered the following domains: Treatment motivation; treatment expectations; pain and discomfort from teeth, jaws, and face; functional jaw impairment; and questionnaire validity. Internal consistency as well as temporal stability with the test-retest method was investigated.

RESULTS

A majority of the questions exhibited acceptable test-retest reliability, and composite scores yielded excellent reliability for all domains. Internal consistency was acceptable and good face validity was found for all domains.

CONCLUSION

The questionnaire can be recommended for use in the assessment of expectations and experiences of orthodontic treatment.

Clinical management of dental anxiety: what works for whom?

This paper aims to provide an overview of the current knowledge regarding the management of adult dentally anxious patients. Furthermore, an attempt is made to formulate a number of preliminary clinical guidelines, based on the available literature. The findings are discussed in the light of the following four problem areas or types of patients, those with: 1) a mild form of fear or anxiety, 2) a phobia of specific dental procedures or situations, 3) interfering psychiatric symptoms and/or 4) a high treatment need. The literature suggests that particularly the implementation of a high level of predictability during treatment, the training of patients in the use of coping skills, and the application of in vivo exposure to anxiety provoking stimuli are the most appropriate options for the management of anxious dental patients and the reduction of their anxiety level.

Dental fear in adults: a meta-analysis of behavioral interventions

OBJECTIVES

The aim of this meta-analytic and systematic quantitative approach is to examine the effects of behavioral interventions for dental anxiety and dental phobia.

METHODS

Eighty studies were identified where dental fear treatment with behavioral methods was evaluated. Thirty-eight of 80 met entry criteria and were included in a meta-analysis.

RESULTS

The calculated effect sizes (ESs) for self-reported anxiety after intervention indicate positive changes in 36 of the 38 studies and no changes in two. The overall ES = 1.8 (95% CI: 1.6, 1.8). The percent of subjects with post-treatment dental visits in the first 6 months post-treatment varied between 50 and 100%. The overall ES for attendance at dental visits, weighted by sample size, is 1.4 (95% CI: 1.3, 1.6). The homogeneity analysis indicates that the studies cannot be adequately described in one ES. The reported percentage of subjects with a dental visit between 6 months and 4 years post-treatment varied from 48 to 100%. The overall weighted ES for visiting the dentist, adjusted for drop-outs in the studies, is 1.2 (95% CI: 0.99, 1.4).

CONCLUSIONS

Despite extensive heterogeneity, changes in self-reported anxiety represent medium to large ESs. Patients signing up for a behavioral intervention for dental fear can be expected to report a significant reduction in their fear, and this effect generally seems to be lasting. Mean long-term attendance ( >4 years after treatment) is 77%.

Effects of cognitive therapy, applied relaxation and nitrous oxide sedation. A five-year follow-up study of patients treated for dental fear

Five years after completing a controlled, randomized treatment trial comparing the effect of nitrous oxide sedation (NO), cognitive therapy (CT), and applied relaxation (AR), all 62 patients who had participated were invited to a follow-up questionnaire study. Forty-three responded. All participants had been to the dentist during the follow-up period. Mean scores (s) on Corah's Dental Anxiety Scale (CDAS) and Symptom Checklist 90 Revised (SCL-90-R, a measure of general psychological distress) were 10.4 (4.1) and 0.35 (0.34), respectively. There were no between-group effects. Significant changes across the assessment phases (at enrollment, after treatment, and 5 years after) were found for both dental fear and general distress (CDAS: F = 137.8, P < 0.01; SCL-90-R: F = 12.5, P < 0.01). However, no significant changes between measures obtained after treatment and at follow-up emerged. Seven participants (3 from the NO group, 2 from the CT group, and 2 from the AR group) had CDAS scores above 14, indicating a recurrent or continual dental fear problem. The majority (81%) assessed the dental fear treatment received 5 years previously to have been useful for them. In conclusion, the favorable effects on dental fear and general psychological distress continued at 5-year follow-up for all treatment groups.

Pain in orthodontics. A review and discussion of the literature

This literature review focuses on previous studies of pain and pain perception in dentistry with special emphasis on orthodontic treatment. The prevalence of pain and background factors such as age, gender and culture/society, in addition to pain physiology and the influence of concomitant emotional and cognitive factors, is examined. Pain during orthodontic tooth movement is reported from the point of view of its physiology and character and different assessment methods. These aspects are described both generally and specifically in relation to the type of orthodontic forces and to the experience of discomfort other than pain. Since the orthodontic treatment may cause some degree of suffering for the patients, it is important for orthodontists to handle this situation in the best possible way. Some ideas about the possibilities of avoiding, reducing or alleviating pain in orthodontics are discussed.

The attentional control of pain: methodological and theoretical concerns

Although it is now well accepted that attention-based cognitive coping strategies are effective in altering pain perception and have potentially useful analgesic qualities, there exists contradiction and equivocation as to the role of various factors in the production of that analgesia. Cioffi (1991) has suggested that the response to this equivocation has been a 'collective ennui' on the part of researchers. This article seeks to explore methodological and theoretical reasons for this reigning equivocation and offers some suggestions for moving beyond it. In particular, critical attention is focussed upon four possible sources of variance in experimental pain procedures: the choice of the pain induction procedure, the instructions given, the measures taken and the content of the taught strategy.

Chronic pain and distraction: an experimental investigation into the role of sustained and shifting attention in the processing of chronic persistent pain

Although there is anecdotal evidence for the psychoanalgesic properties of distraction, research evidence is equivocal. Drawing on the clinical and experimental studies of attention-based coping strategies for pain control, and the theoretically driven 'cognitive' models of the human attention system, two experiments are reported. Experiment One demonstrates that chronic pain patients suffering high intensity pain show significantly impaired performance on an attentionally demanding task when compared to low pain patients and normal controls. Experiment Two tests the hypothesis that the low intensity pain patients in Experiment One are coping with the dual demand of processing the pain and processing the task by switching quickly between these attentional demands. The results of both experiments are discussed in terms of the evidence for the analgesic properties attention based coping strategies with clinical pain populations and re-addresses the literature on coping with pain in terms of cognitive theories of attention.

The role of psychology in the teaching of medical ethics: the example of informed consent

Over the past two decades, psychology has become well established in the medical curriculum. This paper argues that it has much to say about ethical issues, particularly informed consent. Because psychology addresses such areas as providing information, ensuring understanding of this information, identifying situations in which coercion occurs and assessing competence, its inclusion in the curriculum is justified on ethical as well as scientific grounds. This has several implications, including the allocation of resources, collaboration with health and clinical psychologists and the timing of the teaching.

Patient empowerment--a strategy for pain management in endodontics

In order to promote rapid resolution of symptoms associated with root canal treatment, a multifaceted program was implemented. One-visit endodontics was performed universally, antibiotics were prescribed when infection was detected within the root canal, and nonsteroidal anti-inflammatory drugs were widely used at the time of treatment. The centerpiece of the program was the integration of various behavioral strategies designed to strengthen the patient's inherent coping capacity. The combination of clinical, pharmacological, and psychological approaches was collectively called patient empowerment. Five hundred forty patients were asked to contact the office the day after treatment. Four hundred twenty (78%) called and 390 (93%) reported a reduction in symptoms. Twenty of the 30 (7%) who were not relieved within the first 24 h reported significant improvement 1 day later. No patients experienced a flare-up or a worsening of symptoms.

Managing anxiety and pain during dental treatment

Behavioral techniques can teach patients how to cope with anxiety and tension while undergoing dental procedures. Practitioners need to know which technique best fits each patient. This report reviews the repertoire of procedures.

Avoidance of pain of unpredictable intensity

Unpredictability of the intensity of an aversive event might be an important factor in producing negative effects of the event, especially if the UCS becomes stronger than could have been expected. The present experiment tested the hypothesis that unpredictability of intensity of a painful stimulus contributes to avoidance behaviour. The experiment was concealed in a shock working-up procedure, which was done to assess the pain level subjects were willing to tolerate in a subsequent experiment. The experimental subjects, who received an unannounced sudden increase of the pain stimulus during the working-up procedure, tolerated less pain on a subjective as well as on an objective level (avoidance of high levels of pain) than the control subjects, who received the stimuli in a predictable pattern. The results support the hypothesis that unpredictability of intensity of an aversive event contributes to avoidance behaviour.

Predictions of dental pain: the fear of any expected evil, is worse than the evil itself

In a study of 40 subjects, who twice underwent extensive dental treatment, the relationships between expectations and experiences of pain and of anxiety were investigated. Inaccurate expectations were adjusted in the same way as observed in the laboratory. Especially anxious subjects expected more pain and anxiety than they experienced, and they appeared to need more experiences before their predictions became accurate. In the course of time, the expectations (and memories) of anxious subjects returned to their original more inaccurate level of prediction. The results suggest that the old schema is ultimately reinstated if disconfirmations are few and far between. Anxious subjects did not experience more pain, but they did experience more anxiety than fearless subjects. Detailed investigation of processes of change after disconfirmation showed that anxiety experienced during treatment is a factor that plays a part in maintaining the problem of inaccurate expectations and fear of treatment. Theoretical and clinical implications of these findings are discussed.

The effects of underestimated pain and their relationship to habituation

The intensity of a painful stimulus was experimentally manipulated in order to induce underpredictions of pain. The experiment aimed at (1) replicating previous findings on the effects of underpredicted pain and (2) investigating the relationship between underpredicted pain and habituation. Most previous findings were replicated: underpredictions of pain were followed by raised expectations of pain and increased fear of pain. In addition, the underprediction had long-term effects on fear of pain, uncertainty about predictions, and expected aversiveness of the painful stimulus. In contrast to previous findings and to Rachman's match/mismatch model, it was found that underpredicted pain can have dishabituating effects. It is theorized that inaccurately predicted pain can cause dishabituation, depending on the extent of the underprediction and on the subjective certainty of the prediction. Theoretical and clinical implications are discussed.

Power and pain: the location of pain and fear in dentistry and the creation of a dental subject

It has been argued that the meaning of pain in childbirth and in general medicine has changed and that this change was part of a cognitive transformation that occurred in medicine during the post World War II period. This paper uses Foucault's notion of the gaze and his unique conception of power to explore the extent to which the understanding of pain, and the associated concept of fear, in dentistry, reflects those understandings found in medicine and obstetrics. Within the discourse of dentistry the conception of pain is both object and effect of the profession's techniques of observation and analysis. Analyses of pain and fear occurred on two levels: the micro-level of the individual and the macro-level of the population. The examples of the case history and the epidemiological survey are used to demonstrate these two levels of power/knowledge. The first technique contributed to the constitution of the psychological space, the second technique confirmed the social space. Within these spatialisations new conceptualisations of pain were realised and a subjective dental subject was manufactured. The findings of this paper add weight to the thesis that the functioning of power/knowledge transcends professional and disciplinary boundaries and is a process which is far more subtle and fundamental than one of political manoeuverings by interested groups or individuals or the accumulation of an increasingly sophisticated knowledge.