Behavior Management on Adult Patient The most common problem in dental clinic with Adult patient is anxiety Fear and anxiety toward the dentist and dental treatment are both significant characteristics that contribute to avoidance of dental care. Anxiety associated with the thought of visiting the dentist for preventive care and over dental procedures is referred to as dental anxiety. Dental anxiety and phobia result in avoidance of dental care. It is a frequently encountered problem in dental offices. Formulating acceptable evidence-based therapies for such patients is essential, or else they can be a considerable source of stress for the dentist. These patients need to be identified at the earliest opportunity and their concerns addressed. Fear is a reaction to a known or perceived threat or danger. It leads to a fight-or-flight situation. Dental fear is a reaction to threatening stimuli in dental situations. The initial interaction between the dentist and the patient can reveal the presence of anxiety, fear, and phobia. In such situations, subjective evaluation by interviews and self-reporting on fear and anxiety scales and objective assessment of blood pressure, pulse rate, pulse oximetry, finger temperature, and galvanic skin response can greatly enhance the diagnosis and enable categorization of these individuals as mildly, moderately, or highly anxious or dental phobics. Broadly, dental anxiety can be managed by: 1- Psychotherapeutic interventions. 2- Pharmacological interventions. 3- Combination of both, depending on the level of dental anxiety.

1. Behavior Management on
Adult Patient
ACHIEVED BY: Dr.Maen Dawodi

2. • The most common problem in dental clinic with Adult patient is
anxiety
• Fear and anxiety toward the dentist and dental treatment are both
significant characteristics that contribute to avoidance of dental care.

3. • Anxiety associated with the thought of visiting the dentist for
preventive care and over dental procedures is referred to as dental
anxiety.

4. • Dental anxiety and phobia result in avoidance of dental care. It is a
frequently encountered problem in dental offices. Formulating
acceptable evidence-based therapies for such patients is essential, or
else they can be a considerable source of stress for the dentist. These
patients need to be identified at the earliest opportunity and their
concerns addressed.

5. • Fear is a reaction to a known or perceived threat or danger. It leads to
a fight-or-flight situation.
• Dental fear is a reaction to threatening stimuli in dental situations.

6. • The initial interaction between the dentist and the patient can reveal
the presence of anxiety, fear, and phobia.
• In such situations, subjective evaluation by interviews and self-
reporting on fear and anxiety scales and objective assessment of
blood pressure, pulse rate, pulse oximetry, finger temperature, and
galvanic skin response can greatly enhance the diagnosis and enable
categorization of these individuals as mildly, moderately, or highly
anxious or dental phobics.

7. • Broadly, dental anxiety can be managed by:
1- Psychotherapeutic interventions.
2- Pharmacological interventions.
3- Combination of both, depending on the level of dental anxiety.

8. • Pharmacologically, these patients can be managed using either
sedation or general anesthesia.

9. • Etiology of dental anxiety
1-previous negative.
2- traumatic experience.
3- vicarious learning from anxious family members.
4- individual personality characteristics such as neuroticism and
self- consciousness .
5- lack of understanding.
6- exposure to frightening portrayals of dentists in the media.
7- the coping style of the person.
8-perception of body image.
9- the vulnerable position of lying back in a dental chair.
10 -others can also be provoked by sensory triggers such as sights of needles and
air-turbine drills, sounds of drilling and screaming, the smell of eugenol and cut
dentine, and also sensations of high-frequency vibrations in the dental setting.

10. • Psychophysiological responses
1- Muscle tightness.
2- Hands unsteady.
3- Restlessness.
4- Clearing the throat.
5- Sweating of the palms of hands, forehead, upper lip (the palm of the hand
can be assessed during handshake).
6- Pulsation in the carotid and temporal arteries.
7- Depth and speed of respiration, Stiff posture.
8- Holding things tightly.
9- Strong startle response.
10- Frequent urination.

11. •Behavioral and emotional responses
1- Hyperactivity.
2- Walking or talking faster.
3- In a hurry.
4- Irritation with delays.
5- Panicky.
6- Blushing.
7- Getting tongue-tangled.
8- Avoiding people.
9- Nervous habits.
10- Poor memory.
11- Confusion, stumbling over words.
12- Sitting on the edge of the chair, leaning forward.
13- Rapidly thumbing through magazines.
14- Pacing.
15-Inattentiveness.
16- Excessive worrying.
17 Outburst of emotions.

12. Management of dental anxiety
1-The dental office environment.
2-Communication skills, rapport, and trust building.
3-Psychotherapeutic management
1-Behavior-management techniques 2- Relaxation techniques 3-Jacobsen’s
progressive muscular relaxation.
4-Guided imagery.
5-Biofeedback.
6-Hypnotherapy.
7-Acupuncture.
8-Distraction.

13. 9-Enhancing control.
10- Positive reinforcement .
11-Cognitive therapy.
12-Technological advancements in local anesthetic administration-Computer-
controlled local anesthetic delivery -Electronic dental anesthesia- Computer-
assisted relaxation learning.
13-Technological advancements that help alleviate anxiety in restorative dentistry.
14-Pharmacological management.
15-Conscious sedation.
16-Inhalation sedation.
17-Psychological intervention versus pharmacological intervention.

14. • The dental office environment
Dental office ambience can play a significant role in initiating dental
fear and anxiety. Receptionists, dental nurses, and dental hygienists are
crucial personnel in creating an apt atmosphere in the dental office.
They should be positive and caring, and elicit information from the
patients in a unhurried concerned tone to make the patients
comfortable.

15. • Communication skills, rapport, and trust building
dentist should first introduce themselves and personally converse with
the patient in their office, and listen carefully in a calm, composed, and
nonjudgmental way. Proper information should be acquired from the
patient regarding their dental problems and concerns, taking time to
inquire and listen about their fears Furthermore, patients should be
encouraged to ask questions about the treatment, and should be kept
completely informed about what is to be done before starting the
procedure and also during the procedure.

16. Relaxation techniques
A relaxation response is the opposite of a stress response, and when
practiced regularly it not only lowers stress and anxiety levels but also
enables an individual to cope with the symptoms of anxiety. This can be
achieved by both deep breathing and muscle relaxation.

17. Biofeedback
Biofeedback is also referred to as applied psychophysiological feedback,
and is a mind–body technique. Biofeedback therapies use instruments
to measure, amplify, and feed back physiological information to the
patient being monitored. The information assists the patient in gaining
self-regulation of the physiological process being monitored.
Monitoring oneself and then utilizing the information to practice and
achieve self-regulation are the main goals of biofeedback.

18. • Enhancing control
Loss of control over the treatment procedure is a significant cause for
anxiety, and hence providing control is very essential. Telling the
patient what to expect, and what measures are taken to ensure their
safety, will help make the treatment as comfortable as possible. Control
can be provided by giving information and through behavioral control.
Informational control can be achieved by the “tell-show-do” and
modeling techniques.

19. • Computer-controlled local anesthetic delivery
This system represents a significant change in the manner in which a
local anesthetic injection is administered, thereby alleviating anxiety in
patients who fear injections or are needle-phobic. It is essentially a
computer-controlled dental injection. The flow rate of the local
anesthetic is controlled by a computer.

20. • Electronic dental anesthesia
This technique is used to produce dental anesthesia by using the
principle of transcutaneous electric nerve stimulation. By means of
electrodes, electric flow from the stimulation unit is converted into an
ionic current flow in the living tissue and anesthesia is produced,
offering pain control without needles, based on the gate-control theory
of pain. Electrodes can be placed either extraorally or intraorally.

21. • Pharmacological management
Pharmacological control of pain and anxiety can be achieved by the use
of sedation and general anesthesia, and should be sought only in
situations where the patient is not able to respond and cooperate well
with psychotherapeutic interventions, is not willing to undergo this
type of treatment, or is considered dental-phobic. Patients with special
needs (mental retardation, autism, mental illness, traumatic brain
injury) and clinical situations can also necessitate pharmacological
management.

22. • Inhalation sedation
This is a commonly used technique for dental sedation. A mixture of
nitrous oxide (N2O) and oxygen is used. Nitrous oxide has an anxiolytic
and sedative effect, and also promotes muscular relaxation and
analgesia. It is nonirritant for the respiratory tract, with minimal
alveolar concentration and low solubility in tissues. It acts with a quick
onset and rapid recovery, the entire procedure lasting only a few
minutes.

23. • Reference
• Clin Cosmet Investig Dent. 2016; 8: 35–50.

24. literature review In Clinical management of the
adult patient with dental anxiety

25. • Dental anxiety is a prevalent issue which every dental practitioner will
face. As dental anxiety involves personal consequences for the
affected patients - as well as hampering the clinical performance of
the dental profession – this matter should be taken seriously and
dealt with accordingly. The treatment of dental anxiety thus should
be within the competence of the general practitioner.

26. • Aims: To systematically review the literature concerning treatment of
adult fearful and anxious patients, in order to find strategies to
empower both patient and dentist in the clinical situation. Our
hypothesis is that there are measures a general dentist can take to
ease the dental treatment of fearful patients. Our goal is to present
the general dentist approaches regarding identification and care of
these patients.

27. • Material and methods: Systematic search of the literature was
performed via Pubmed and using Google search engine. We used
search terms such as: “dental anxiety”, “fearful dental patients”,
“etiology of dental fear” and “adult fearful patients.” The primary
selection of articles, books and doctoral theses was based on their
title abstract, and time of publication. The inclusion criteria were
Scandinavian and English publications presenting knowledge about
etiology, prevalence and clinical management of dental anxiety in
adults. We also performed interviews with anxious patients at the
TkNN (Tannhelsetjenestens kompetansesenter for Nord-Norge).

28. • Conclusions: Identifying anxious dental patients can be achieved by
the use of a semi-structured interview and/or through psychometric
questionnaires, such as Dental Anxiety Scale (DAS), Dental Belief
Survey (DBS) and Dental Fear Survey (DFS). There are both general
and specific approaches to treating dental anxiety, as well as
pharmacological aids. The method of choice should be adapted to the
patient’s prerequisites and individual needs. Even though much can
be accomplished by the general dentist, some patients may have very
complex and comprehensive problems and need care from a
specialist.

29. • Reference
Clinical management of the adult patient with dental anxiety
Anna Frydendal Hoem, Kathrine Tvermyr og Kine Marlén Elde 2012

30. Thank you