Stress Reduction Protocol in Dentistry

Dr Neil PandeBDS MFGDP(UK) MFDS RCS(Eng)General Dental PractitionerKathmandu, Nepalwww.smilenepal.com

Stressa 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 3/4 Medical Emergencies in Dentistry

Stages of Stress ResponseHans Selye

Stage 1: One of the Five senses sends stimuli to the brain

Stage 2: Brain analyzes it as a ‘Threat’ or ‘No Threat’

Stage 3: Body aroused until threat is over

Stage 4: Body returns to homeostasis (calm) once threat is gone.

Anxiety:StressRelease of epinephrine, nor-epinephrine

⬆ Heart Rate

⬆ Blood Flow

⬆ Respiration

Vasodilatation in the periphery (arms and legs)

⬆ Serum Glucose Level

Signs of Acute AnxietyCold, sweaty palms or forehead

Flushing of face

Altered facial expression such as bulging eyebrows

Dry mouth or increase in salivation

Bruxism or clenching of teeth

Increased need to urinate

Unnaturally stiff posture

Acute AnxietyInability to sit still

Trembling or tremors

Fiddling with items in his or 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

Stress Reduction in Dentistry

Pre-Treatment Peri-Treatment Post-TreatmentMedical History

ASA PSAnxiety Reduction

MDAS

IatrosedationRelaxation TechMusic, Aroma,

Massage

Written Instructions

Analgesics

Proper Rest / DietTransportation

MedicationShort Morning Appointment

HypnosisAcupuncture

Local Anaesthetic followed by Topical

Follow-up Telephone

Referral, if needed

First ConsultationGet to know the patient

Try to befriend him/her

Thorough Medical History

Written

Verbal (Re-enforced)

Discuss likes and dislikes, acknowledge feelings

Empathy

Understand him/her well - it’s a long term affair...

Medical HistoryWritten, signed and verbal

Categorization as per ASA PS Score

ASA I A normal healthy patient

ASA II A patient with mild systemic disease

ASA III A patient with severe systemic disease

ASA IV A patient with severe systemic disease that is a constant threat to life

Check vitals

Communication

Let them talk

Be a good listener

Show interest in their conversation

At an eye level

Away from the equipment

ExaminationDo a thorough check-up including; examination of

Extra-oral: TMJ, Lymph Nodes, abnormalities (A gentle palpation of the area ensuring that you care.)

Intra-oral: Soft Tissues

Occlusion

Periodontal Tissues

Teeth

Diagnosis and Treatment PlanTry 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

Modified Dental Anxiety Scale MDAS

Helps us to recognize the level of anxiety in patients

Plan treatment accordingly

Anxious PatientShort 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/escort

Extremely short or no waiting time in the waiting area

During the treatmentDuration, only as much as patient can tolerate

Making sure patient feels he/she is in command

Better to have a short and simple procedure first to gain patient’s confidence

Pain free

Topical Gel

Local Anaesthetics with 30G needle, slow, warm

Iatrosedation

IatrosedationVocal

Music

Aroma

Massage

Hypnosis

Acupuncture

Relaxation Techniques

Deep Breathing

Guided Imagery

Progressive Relaxation

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 you will hardly feel anything.”

“I am slowly putting some solution inside so that you will not feel a thing.”

Vocal Sedation

Avoid “needle”, “hurt”, “sharp”

Talk to them as you go through the procedure.

It will make them feel more relaxed and compliant.

Post Treatment

Clear verbal and written instructions

Pain control medications

Phone number of the treating doctor (to call in case of emergency)

Protocol for referral if needed

Friend for life...

Relationship between a patient and a dentist is the one that is made for life.

Helping people in making their quality of life, better...

You treat patients well, and they will treat you well.

Respect is a 2 way street. You get what you give...

MDAS Scale

CAN YOU TELL US HOW ANXIOUS YOU GET, IF AT ALL,

WITH YOUR DENTAL VISIT?

PLEASE INDICATE BY INSERTING ‘X’ IN THE APPROPRIATE BOX

1. If you went to your Dentist for TREATMENT TOMORROW, how would you feel?

Not Anxious

Slightly Anxious

Fairly Anxious

Very Anxious

Extremely Anxious

Not Anxious

Slightly Anxious

Fairly Anxious

Very Anxious

Extremely Anxious

2. If you were sitting in the WAITING ROOM (waiting for treatment), how would you feel?

3. If you were about to have a TOOTH DRILLED, how would you feel?

4. If you were about to have your TEETH SCALED AND POLISHED, how would you feel?

5. If you were about to have a LOCAL ANAESTHETIC INJECTION in your gum, above an upper back tooth, how

would you feel?

Not Anxious ☐

Slightly Anxious ☐

Fairly Anxious ☐

Very Anxious ☐

Extremely Anxious ☐

Not Anxious ☐

Slightly Anxious ☐

Fairly Anxious ☐

Very Anxious ☐

Extremely Anxious ☐

Not Anxious ☐

Slightly Anxious ☐

Fairly Anxious ☐

Very Anxious ☐

Extremely Anxious ☐

Instructions for scoringThe Modified Dental Anxiety Scale. Each item scored as follows:

Not anxious = 1

Slightly anxious = 2

Fairly anxious = 3

Very anxious = 4

Extremely anxious = 5

Total score is a sum of all five items, range 5 to 25: Cut off is 19 or above which indicates a highly dentally anxious patient, possibly dentally phobic.