Editor’s Note: In Part One of our series on adverse childhood experiences (ACE), Incisor explored how trauma experienced in childhood can have far-reaching effects on long-term physical and mental health, including oral health and dental care utilization.
Part two introduces specific strategies dentists can utilize, including sedation dentistry, to prevent adverse childhood experiences (ACE) in the dental office, as well as mitigate pre-existing anxieties.
The effects of adverse childhood experiences (ACE) on oral health include inadequate care for children, tooth damage, as well as the development of anxiety-based avoidance carried into adulthood. With this in mind, how can dental professionals prevent pediatric treatment itself from becoming an ACE? Further, how can sedation dentists integrate an applied understanding of the psychology of trauma to help create a positive, assuring experience that addresses previously experienced ACE in both children and adults?
However, fear of dentistry (odontophobia)—the fifth most common cause of anxiety (Agras et al.)—may not be etiologically linked to past negative dental experiences in all cases.
For example, 6.8 million adults, or 3.1% of the U.S. population, experience generalized anxiety disorder (DSM-5 300.02 [F41. 1]) in any given year. Characterized by persistent and excessive worry beyond what seems warranted about actual events, GAD causes a sufferer to struggle with an expectation of the worst, even when there is no apparent reason for concern—that is, no discernable trigger.
“Although the exact cause of GAD is unknown, there is evidence that biological factors, family background, and life experiences, particularly stressful ones, play a role,” according to the Anxiety and Depression Association of America.
Anxiety, dread, and avoidance can lead to the degradation of minor dental issues into acute conditions requiring advanced, more traumatic treatments that reinforce anxieties.
Dr. Deva Priya Appukuttan wrote in “Strategies to manage patients with dental anxiety and dental phobia,” a literature review in Clinical, Cosmetic and Investigational Dentistry:
Appukuttan cites the “Seattle system,” developed at the University of Washington (Milgrom et al), which groups anxious patients into four categories, based on source of fear:
- Anxious of specific stimuli
- Distrust of the dental personnel
- Generalized dental anxiety
- Anxious of catastrophe
“The etiology for dental anxiety is multifactorial, and hence there is no monotherapy for management,” wrote Dr. Appukuttan. “Anxiety can be triggered by even the most innocuous situations, such as the encounter with the receptionist while scheduling their appointments or clinic ambiance, and thus it is essential that every aspect of the dental practice be appropriate.”
Of course, dentists are trained to treat and repair teeth, but ensuring a safe, anxiety-free experience in the chair—the emotional and psychological side of treatment—requires specialized training, supplemented by continuing education to keep current.
The good news is that sedation dentistry offers a viable, highly effective way to address odontophobia and break the anxiety cycle, in concert with other strategies.
Dr. Appukuttan states emphatically that, “these patients can be managed pharmacologically using either sedation or general anesthesia.”
Other recommendations for anxiety management that Dr. Appkuttan’s report highlights include cognitive-behavioral therapy (CBT), communication skills, rapport, and building trust, along with a “sensory adapted dental environment”:
Experienced sedation dentists combine sedation treatments with other strategies proven in their clinical setting to be effective additions to their anti-anxiety toolbox. Part 3 of this series will reveal real-life methods used by practicing sedation dentists, including both tried-and-true tips and promising new technologies.
Agras S, Sylvester D, Oliveau D. “The epidemiology of common fears and phobia.” Compr Psychiatry. 1969;10(2):151–156.
Anxiety and Depression Association of America. Understanding GAD and the Symptoms. https://adaa.org/understanding-anxiety/generalized-anxiety-disorder-gad
Appukuttan, Deva Priya. “Strategies to manage patients with dental anxiety and dental phobia: literature review.” Clinical, cosmetic and investigational dentistry vol. 8 35-50. 10 Mar. 2016, doi:10.2147/CCIDE.S63626
Milgrom P, Weinstein P, Getz T. Treating Fearful Dental Patients: A Patient Management Handbook. Seattle: Reston Prentice Hall; 1995.
Nelson, Travis M, and Zheng Xu. “Pediatric dental sedation: challenges and opportunities.” Clinical, cosmetic and investigational dentistry vol. 7 97-106. 26 Aug. 2015, doi:10.2147/CCIDE.S64250
Shapiro M, Melmed RN, Sgan-Cohen HD, Eli I, Parush S. “Behavioural and physiological effect of dental environment sensory adaptation on children’s dental anxiety.” Eur J Oral Sci. 2007;115(6):479–483.