Iatrosedation

[Anonymous]

Fear of dentistry is a worldwide health problem of considerable significance.
In the United States it is estimated that twenty million people avoid the
dentist because of fear. For these people, fear is a more destructive lesion
than caries or periodontal disease since it is the major obstacle to their
seeking dental health care.
Avoidance of the dentist frequently results in extensive pathology.
Consequently, such patients are driven to the dentist by some crisis-like
situation; either pain, swelling, acute infection or the last-ditch need to have a
badly destroyed dentition repaired. However, the dentist cannot “get to” the
teeth until the barrier of fear is removed in some way. Attempting to ignore
the wall of fear usually leads to great frustration and stress for the dentist and
a higher fear level for the patient.
A recent survey of dentists indicates that 57% of those responding
considered the “difficult patient” to be the most stressful single factor in their
practices. It is clear that for both the doctor and the patient, fear must be
viewed as a significant syndrome requiring treatment. In a sense, each time
the dentist is faced with a fearful patient, he is dealing with an emergency;
not a dental emergency, but the emergency of fear. For the dentist, facing
the fearful patient may create considerable stress, a sense of inadequacy
and frustration unless he is equipped to deal with the problem expertly.
The dentist has a variety of ways to help the fearful patient. The use of drugs
is the traditional modality. The techniques of inhalation, intravenous,
intramuscular and oral sedation have been taught for years in dental schools
and, postdoctorally, through continuing education channels. The techniques
are well structured, the goals quite clear and the dentists using these
modalities are confident of their effectiveness. However, it must be
recognized that pharmacosedation does not reduce or eliminate fear; it
temporarily circumvents it. Its value lays primarily in making dental treatment
approachable for the patient by diminishing awareness and producing a
temporary state of tranquility.
Treatment of the fear syndrome requires a different technique, one with
which the fear is eliminated or significantly reduced by means of a relearning
process. The relearning process is the result of interactions initiated by the
doctor designed for this purpose.
Traditionally, sedation has been equated with the use of drugs to induce
calmness. Although in a vague way it is conceded that the behavior of the
doctor is helpful in calming the anxious patient, it is considered a haphazard,
intuitive effort. The concept of fear treatment to be developed in the following
pages is based on a system of simple behavioral techniques designed to
accomplish the goal with maximum efficiency and minimum use of time. This
system is iatrosedation.

        

[sushantpatel_doc]

How to Overcome Dental Phobia
Through a Non-Pharmaceutical Method:
"Iatrosedation"

Without use of drugs, a tried-and-true method developed and used at the Herman Ostrow School of Dentistry of USC since the late 1960’s can predictably help patients overcome high anxiety or phobia associated with dental treatment. This non-pharmaceutical method is called “iatrosedation.” It is defined as “an interpersonal-cognitive (doctor-patient) process by which patient suffering from dental phobia/high anxiety are calmed by the behaviors, attitudes, communicative and “painless” skills of the doctor. In other words, this method calls for the doctor to use his/her verbal and “painless” skills in a particular way to help the patient dissolve dental phobia or anxieties. “Iatro-“refers to the doctor and “sedation” means, in this instance, to mean “calm.” Doctor calming the patient, without the use of drugs, is therefore called “iatrosedation.”
What then is dental phobia and why is it necessary for this condition to be treated in such a special way? A phobia is an intense fear of certain situations, activities, things, animals, or people. The main symptom of this disorder is the excessive and unreasonable desire to avoid the feared subject. Dental phobia may be described as excessive and unreasonable fear of dental treatment.
In contrast to other phobias, dental patients suffering from dental phobia generally cannot avoid repeated exposure to the threatening stimuli, but yet be expected to do so. Continued avoidance leads to significant consequences, such as dental emergencies. For the truly phobic individual it is common for a vicious cycle to develop in which fear leads to avoidance of dentists, results in neglected dental care, increased awareness of unmet needs, and likely feelings of shame and inadequacy.
It is estimated that 5-10 % of adults in the U.S. suffer from this condition. This means over 10 million people suffer from this debilitating condition. More often than not highly anxious patients are treated with pharmaceuticals, such as oral sedatives, nitrous oxide, IV sedation and general anesthesia. However, often after extensive dental treatment, these patients do not return for maintenance care and their dental conditions continue to deteriorate over time. This may be because the root of the problem is not addressed, i.e., resolution of the phobia.
Doctors trained in the “iatrosedative” approach recognize that fear of dental treatment generally arises from past dental/medical procedures which gave rise to a “conditioned response” that manifests as unreasonable fear of dental treatment. The role of the doctor consists of helping the patient recognize how the fear developed and that through positive experiences this “learned” fear response can be “un-learned.” Through an empathetic process the doctor ferrets out what specific conditions trigger the fear. With the specific fears identified the doctor maps out a plan of treatment that would reassure the patient that each specific fear is addressed and the patient can expect to have a comfortable, secure treatment experience. For instance, if the patient is afraid that “novacaine” would not completely numb up the tooth, the doctor can use new anesthetics that are more potent than those in the years past, give the area plenty of time to numb up, and encourage the patient to raise a hand whenever something bothers the patient. Through this kind of “iatrosedative” process trust is developed between the doctor and patient, and thereby the fears are dissolved.

        

[Drsumitra]

Dental fear refers to the fear of dentistry and of receiving dental care. A severe form of this fear (specific phobia) is variously called dental phobia, odontophobia, dentophobia, dentist phobia, or dental anxiety. However, it has been suggested that the term "dental phobia" is often a misnomer, as many people with this condition do not feel their fears to be excessive or unreasonable and resemble individuals with post-traumatic stress disorder, caused by previous traumatic dental experiences.
Incidence

It is estimated that as many as 75% of US adults experience some degree of dental fear, from mild to severe.] Approximately 5 to 10 percent of U.S. adults are considered to experience dental phobia; that is, they are so fearful of receiving dental treatment that they avoid dental care at all costs.Many dentally fearful people will only seek dental care when they have a dental emergency, such as a toothache or dental abscess. People who are very fearful of dental care often experience a “cycle of avoidance,” in which they avoid dental care due to fear until they experience a dental emergency requiring invasive treatment, which can reinforce their fear of dentistry.

Women tend to report more dental fear than men,and younger people tend to report being more dentally fearful than older individuals. People tend to report being more fearful of more invasive procedures, such as oral surgery, than they are of less invasive treatment, such as professional dental cleanings, or prophylaxis.
Causes
Direct experiences

Direct experience is the most common way people develop dental fears. Most people report that their dental fear began after a traumatic, difficult, and/or painful dental experience.However, painful or traumatic dental experiences alone do not explain why people develop dental phobia. The perceived manner of the dentist is an important variable. Dentists who were considered "impersonal", "uncaring", "uninterested" or "cold" were found to result in high dental fear in students, even in the absence of painful experiences, whereas some students who had had painful experiences failed to develop dental fear if they perceived their dentist as caring and warm.
Indirect experiences

* Vicarious learning: Dental fear may develop as people hear about others’ traumatic experiences or negative views of dentistry (vicarious learning)

* Mass media: The negative portrayal of dentistry in mass media and cartoons may also contribute to the development of dental fear.

* Stimulus Generalization: Dental fear may develop as a result of a previous traumatic experience in a non-dental context. For example, bad experiences with doctors or hospital environments may lead people to fear white coats and antiseptic smells, which is one reason why dentists nowadays often choose to wear less "threatening" apparel. People who have been sexually, physically or emotionally abused may also find the dental situation threatening.The dental situation may be especially difficult for people who have experienced forced sexual intercourse which included oral penetration.

* Helplessness and Perceived Lack of Control: If a person believes that they have no means of influencing a negative event, they will experience helplessness (see Learned helplessness). Research has shown that a perception of lack of control leads to fear. The opposite belief, that one does have control, can lead to lessened fear. For example, the belief that the dentist will stop when the patient gives a stop signal lessens fear. Helplessness and lack of control may also result from direct experiences, for example an incident where a dentist wouldn’t stop even when the person was in obvious pain.

Diagnosis

Phobia of dental care is sometimes diagnosed using a fear measurement instrument like Corah’s Dental Anxiety Scale or the Modified Dental Anxiety Scale.

        

[Drsumitra]

Treatment

Treatments for dental fear often include a combination of behavioral and pharmacological techniques. Specialized dental fear clinics, such as those at the University of Washington in Seattle and Göteborg University in Sweden, use both psychologists and dentists to help people learn to manage and decrease their fear of dental treatment. The goal of these clinics is to provide individuals with the fear management skills necessary for them to receive regular dental care with a minimum of fear or anxiety. While specialized clinics exist to help individuals manage and overcome their fear of dentistry, they are rare. Many dental providers outside of such clinics use similar behavioral and cognitive strategies to help patients reduce their fear.

Dental fear is very common; people should seek out a dentist who makes them feel comfortable so they can benefit from proper dentistry.
Behavioral techniques

Behavioral strategies used by dentists include positive reinforcement (e.g. praising the patient), the use of non-threatening language, and tell-show-do techniques.The tell-show-do technique was originally developed for use in pediatric dentistry, but can also be used with nervous adult patients.The technique involves verbal explanations of procedures in easy-to-understand language (tell), followed by demonstrations of the sights, sounds, smells, and tactile aspects of the procedure in a non-threatening way (show), followed by the actual procedure (do).

More specialized behavioral treatments include teaching individuals relaxation techniques, such as diaphragmatic breathing and progressive muscle relaxation, as well as cognitive, or thought-based techniques, such as cognitive restructuring and guided imagery.Both relaxation and cognitive strategies have been shown to significantly reduce dental fear.One example of a behavioral technique is systematic desensitization, a method used in psychology to overcome phobias and other anxiety disorders] This is also sometimes called graduated exposure therapy or gradual exposure. For example, for a patient who is fearful of dental injections, the therapist first teaches relaxation skills to the patient, then gradually introduces the feared object (in this case, the needle and/or syringe) to the patient, encouraging the patient to manage his/her fear using the relaxation skills previously taught. The patient progresses through the steps of receiving a dental injection while using the relaxation skills, until the patient is able to successfully receive a dental injection while experiencing little to no fear. This method has been shown to be effective in treating fear of dental injections. Cognitive restructuring , if applied in a non-threatening situation, might be a useful alternative as a first step after years of avoidance of dental care and less threatening than immediate exposure to the feared stimuli.

It is interesting to take into account the views of people who have been provided with behavioural treatments for dental fear. From a psychologist’s perspective, techniques such as graded exposure, relaxation techniques or challenging catastrophic thinking are important. However, Gerry Kent, a clinical psychologist from the University of Sheffield UK, notes that from the patient’s perspective, interventions can be conceptualized quite differently. He argues that high levels of anxiety or phobia should not be considered as residing simply within the individual or in the individual’s perceptions of dental care, but more within the relationship with the dentist. For example, when patients who had successfully completed a cognitive-behavioural programme were asked what had helped them to tolerate treatment, they mentioned factors such as the provision of information, the time taken, being put in control by the dentist, and the dentist understanding and listening to their concerns Such findings suggest that an interpersonal model of anxiety and anxiety-reduction is useful when trying to understand and treat dental fears.

Certain aspects of the physical environment also play an important role in alleviating dental fear. For example, getting rid of the smells traditionally associated with dentistry, the dental team wearing non-clinical clothes, or playing music in the background can all help patients by removing and replacing stimuli which can trigger feelings of fear (see classical conditioning). Some anxious patients respond well to more obvious distraction techniques such as listening to music, watching movies, or even using virtual-reality headsets during treatment.
Pharmacological techniques

Pharmacological techniques to manage dental fear range from mild sedation to general anesthesia, and are often used by dentists in conjunction with behavioral techniques. One common anxiety-reducing medication used in dentistry is nitrous oxide (also known as “laughing gas”), which is inhaled through a mask worn on the nose and causes feelings of relaxation and dissociation. Dentists may prescribe an oral sedative, such as a benzodiazepine like temazepam (Restoril), alprazolam (Xanax), diazepam (Valium), or triazolam (Halcion). Triazolam (Halcion) is not available in the UK. While these sedatives may help people feel calmer and sometimes drowsy during dental treatment, patients are still conscious and able to communicate with the dental staff. Intravenous sedation uses benzodiazepines administered directly intravenously into a patient’s arm or hand. IV sedation is often referred to as “conscious sedation” as opposed to general anesthesia (GA). In IV sedation, patients breathe on their own while their breathing and heart rate are monitored and are still responsive to a dentist’s prompts. In GA, patients are more deeply sedated and unable to breathe on their own and are not responsive to verbal or physical prompts.
Self-help and peer support

Recent research has focused on the role of online communities in helping people to confront their anxiety or phobia and successfully receive dental care. The findings suggest that certain individuals do appear to benefit from their involvement in dental anxiety online support groups.

        

[Anonymous]

Although this modality is not preferred by many dentists or patients but remains a choice for mentally retarded and uncoperative andlong term procedures

        

[Author]

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