Patient Management - The Dentist-Patient Relationship
Posted by John Doe at Dental Assistant on January 1, 1970.
Categories: Dental Secrets
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32. How is stress related to pain and anxiety? What are the major parameters of the stress response?
When a person is stimulated by pain or anxiety, the result is a series of physiologic responses dominated by the aut000mic nervous system, skeletal muscles, and endocrine system. These physiologic responses define stress. In what is termed adaptive responses, the sympathetic responses dominate (increases in pulse rate, blood pressure, respiratory rate, peripheral vasoconstriction, skeletal muscle tone, and blood sugar; decreases in sweating, gut motility, and salivation). In an acute maladaptive response the parasympathetic responses dominate, and a syncopal episode may result (decreases in pulse rate, blood pressure, respiratory rate, muscle tone; increases in salivation, sweating, gut motility, and peripheral vasodilation, with overall confusion and agitation). In chronic maladaptive situations, psychosomatic disorders may evolve. The accompanying figure illustrates the relationships of fear, pain, and stress. It is important to control anxiety and stress during dental treatment. The medically compromised patient necessitates appropriate control to avoid potentially life-threatening situations.
33. What is the relationship between pain and anxiety?
Many studies have shown the close relationship between pain and anxiety. The greater the person's anxiety, the more likely it is that he or she will interpret the response to a stimulus as painful. In addition, the pain threshold is lowered with increasing anxiety. People who are debilitated, fatigued, or depressed respond to threats with a higher degree of undifferentiated anxiety and thus are more reactive to pain.
34. List four guidelines for the proper management of pain, anxiety, and stress.
- Make a careful assessment of the patient's anxiety and stress levels by a thoughtful inter view. Uncontrolled anxiety and stress may lead to maladaptive situations that become life-threatening in medically compromised patients. Prevention is the most important strategy.
- From all information gathered, medical and personal, determine the correct methods for control of pain and anxiety. This assessment is critical to appropriate management. Monitoring the patient's responses to the chosen method is essential.
- Use medications as adjuncts for positive reinforcement, not as methods of control. Drugs circumvent fear; they do not resolve conflicts. The need for good rapport and communication is always essential.
- Adapt control techniques to fit the patient's needs. The use of a single modality for all patients may lead to failure; for example, the use of nitrous oxide sedation to moderate severe emotional problems.
35. Construct a model for the therapeutic interview of a self-identified fearful patient.
- Recognize a patient's anxiety by acknowledgment of what the patient says or observation of the patient's demeanor. Recognition, which is both verbal and nonverbal, may be as simple as saying, "Are you nervous about being here?" This recognition indicates the dentist's concern, acceptance, supportiveness, and intent to help.
- Facilitate patients' cues as they tell their story. Help them to go from generalizations to specifics, especially to past origins, if possible. Listen for generalizations, distortions, and deletions of information or misinterpretations of events as the patient talks.
- Allow patients to speak freely. Their anxiety decreases as they tell their story, describing the nature of their fear and the attitude of previous doctors. Trust and rapport between doctor and patient also increase as the patient is allowed to speak to someone who cares and listens.
- Give feedback to the patient. Interpretations of the information helps patients to learn new strategies for coping with their feelings and to adopt new behaviors by confronting past fears. Thus a new set of feelings and behaviors may replace maladaptive coping mechanisms.
- Finally the dentist makes a commitment to protect the patient - a commitment that the patient may have perceived as absent in past dental experiences. Strategies include allowing the patient to stop a procedure by raising a hand or simply assuring a patient that you are ready to listen at any time.
36. Discuss behavioral methods that may help patients to cope with dental fears and related anxiety.
- The first step for the dentist is to become knowledgeable of the patient and his or her presenting needs. Interviewing skills cannot be overemphasized. A trusting relationship is essential. As the clinical interview proceeds, fears are usually reduced to coping levels.
- Because a patient cannot be anxious and relaxed at the same moment, teaching methods of relaxation may be helpful. Systematic relaxation allows the patient to cope with the dental situation. Guided visualizations may be helpful to achieve relaxation. Paced breathing also may be an aid to keeping patients relaxed. Guiding the rate of inspiration and expiration allows a hyperventilating patient to resume normal breathing, thus decreasing the anxiety level. A sample relaxation script is included below.
Relaxation Script
The following example should be read in a slow, rhythmic, and paced manner while carefully observing the patient's responses. Backing up and repeating parts are beneficial if you find that the patient is not responding at any time. Feel free to change and incorporate your own stylistic suggestions.
Allow yourself to become comfortable. . . and as you listen to the sound of my voice, I shall guide you along a pathway of deepening relaxation. Often we start Out at some high level of excitement, and as we slide, down lower, we can become aware of our descent and enjoy the ride. Let us begin with some attention to your breathing...taking some regular, slow...easy...breaths. Let the air flow in...and out... air in... air out... until you become very aware of each inspiration... and... expiration [ Very good. Now as you feel your chest rise with each intake and fall with each outflow,
notice how different you now feel from a few moments ago, as you comfortably resettle yourself in the chair, adjusting your arms and legs just enough to make you feel more comfortable.
Now with regularly paced, slow, and easy breathing, I would like to ask that you become aware of your arms and hands as they rest [ where you see them, e.g., "on your lap"] Move them slightly. [ Next become aware of your legs and feel the chair's support under them. . . they may also move slightly. We shall begin our total body relaxation in just this way .. . becoming aware of a part and then allowing it to become at ease.. . resting, floating, lying peacefully. Start at your eyelids, and, if they are not already closed, allow them to become free and rest them downward. . . your eyes may gaze and float upward. Now focusing on your forehead . . . letting the subtle folds become smoother and smoother with each breath. Now let this peacefulness of eyelids and forehead start a gentle warm flow of relaxing energy down over your cheeks and face, around and under your chin, and slowly down your neck. You may find that you have to swallow . . . allow this to happen, naturally. Now continue this flow as a stream ambling over your shoulders and upper chest and over and across to each arm [ and when you feel this warmth in your fingertips you may feel them move ever so slightly. [ for any movement] Very good.
Next allow the same continuous flow to start down to your lower body and over you waist and hips reaching each leg. You may notice that they are heavy, or light, and that they move ever so slightly as you feel the chair supporting them with each breath and each swallow that you take. You are resting easily, breathing comfortably and effortlessly. You may become aware of just how much at ease you are now, in such a short time, from a moment ago, when you entered the room. Very good, be at ease.
- Hypnosis, a useful tool with myriad benefits, induces an altered state of awareness with heightened suggestibility for changes in behavior and physiologic responses. It is easily taught, and the benefits can be highly beneficial in the dental setting.
- Informing patients of what they may experience during procedures addresses the specific fears of the unknown and loss of control. Sensory information - that is, what physical sensations may be expected - as well as procedural information is appropriate. Knowledge enhances a patient's coping skills.
- Modeling, or observing a peer undergo successful dental treatment, may be beneficial. Videotapes are available for a variety of dental scenarios.
- Methods of distraction may also improve coping responses. Audio or video programs have been reported to be useful for some patients.
37. What are common avoidance behaviors associated with anxious patients?
Commonly, putting off making appointments followed by cancellations and failing to appear are routine events for anxious patients. Indeed, the avoidance of care can be of such magnitude that personal suffering is endured from tooth ailments with emergency consequences. Mutilated dentition often results.
38. Whom do dentists often consider their most "difficult" patient?
Surveys repeatedly show that dentists often view the anxious patient as their most difficult challenge. Almost 80% of dentists report that they themselves become anxious with an anxious patient. The ability to assess carefully a patient's emotional needs helps the clinician to improve his or her ability to deal effectively with anxious patients. Furthermore, because anxious patients require more chair time for procedures, are more reactive to stimuli, and associate more sensations with pain, effective anxiety management yields more effective practice management.
39. What are the major practical considerations in scheduling identified anxious dental patients?
Autonomic arousal increases in proportion to the length of time before a stressful event. A patient left to anticipate the event with negative self-statements and perhaps frightening images for a whole day or at length in the waiting area is less likely to have an easy experience. Thus, it is considered prudent to schedule patients earlier in the day and keep the waiting period after the patient's arrival to a minimum. In addition, the dentist's energy is usually optimal earlier in the day to deal with more demanding situations.
40. What behaviors on the dentist's part do patients specify as reducing their anxiety?
- Explain procedures before starting.
- Give specific information during procedures.
- Instruct the patient to be calm.
- Verbally support the patient: give reassurance.
- Help the patient to redefine the experience to minimize threat.
- Give the patient some control over procedures and pain.
- Attempt to teach the patient to cope with distress.
- Provide distraction and tension relief.
- Attempt to build trust in the dentist.
- Show personal warmth to the patient.
41. What perceived behaviors on the dentist's part are associated with patient satisfaction?
- Assured me that he would prevent pain
- Was friendly
- Worked quickly, but did not rush
- Had a calm manner
- Gave me moral support
- Reassured me that he would alleviate pain
- Asked if I was concerned or nervous
- Made sure that I was numb before starting to work
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