Take a Deep BREATH: A 6-Step Process to Management of Anxious Patients in the Dental Office

Rational or irrational, patient fears and concerns need to be properly addressed before you can begin treatment.

Today is just like any other working day, you walk into the treatment room to greet the patient but before you can continue the conversation, the patient says something like this to you:

“Don’t take this personally but I hate dentists.”

“I had a very bad experience and now I am scared of the dentist.”

“No offense but I don’t like coming here.”

“I have not seen a dentist in twenty years.”

“You are not going to hurt me, are you?”

“I went on YouTube last night to watch wisdom teeth taken out and now I can’t sleep.”

I am sure these statements are not foreign to you. If you’ve heard one or more of these statements at least one time in your career, you are probably dealing with an anxious patient. An anxious patient may or may not be on anxiolytic medications.

Therefore, it is important to pick up these cues prior to treating anxious patients. Some of these initial statements may serve to raise a flag for the providers to take some extra measures in order to make the procedures go more smoothly.

Anxiety can also manifest as fear or anger, and physical signs and symptoms. The patient’s anxiety may be masked during the initial encounter, only to be revealed later at the time of the treatment. So, you may have experienced the following scenarios:

• Mrs. Smith keeps on asking how much pain and swelling she will be experiencing and if she might die from extraction sites bleeding. You keep reassuring her, but she keeps on asking the same questions over and over again. Her husband also called asking the same questions. She had called ten times between Tuesday and Thursday. Her husband another ten. Your staff members were dreading who should be picking up the next phone call from this patient.
• Mr. McDonald told you he used to have a school dentist who was mean and took out his tooth while he was “feeling everything”. He sat there quietly but he started to tremble and sweat. You took his blood pressure and it was 180/100.
• College Junior Michael came with his mom. Michael was on the wrestling team. He’s 6 feet and 220 lbs. He acted non-chalantly about the procedure saying, “it’s not a big deal, I can handle it.” On the day of the procedure, his eyes rolled backwards and went into syncope as soon as you started venipuncture on him.
• Seventeen-year-old Megan said to you she didn’t do well with needles and passed out last year when someone did bloodwork on her. As you started to work on her, she hyperventilated, coughed, and retched. She was weeping and her heart rate was 128.
• Mr. Ramsey had a heart attack and triple bypass three months ago. He was also a heavy smoker with a history of severe COPD. His doctor did not clear him for the procedure. He told you “the only way I could have this done is to be put to sleep completely.” When you told him you couldn’t put him to sleep completely, he started getting abrasive and started to curse at you.

All these different scenarios reflect different ways anxious patients may express themselves. Most people feel somewhat nervous going to dentists or doctors. Is the person’s anxiety within normal limits? How do we determine whether it’s within normal limits or not? Many people may not be clinically diagnosed as having generalized anxiety disorder; some may be dental-phobic. Others may be already on anxiety medications but still feel anxious about the procedure.

I recommend a 6-step approach in treating the anxious patients in your dental office. Ask the patient to take a deep B-R-E-A-T-H with you.

Step 1. B for Body language/non-verbal cues

Someone who may be anxious may be touching or holding themselves in the chair, crossing their arms, sitting forward, moving back and forth, looking around, or moving away from you. You may notice the patient looking pale or possibly diaphoretic. The patient’s blood pressure and heart rate may be elevated, and hyperventilation may be present. A Fight-or-flight response is triggered making an anxious patient excessively talkative, or excessively quiet.

There are different coping mechanisms to anxiety for each and every person. As a provider, keep your voice low, speak slowly and reassure the patient that you are only talking. Ask the patient to try to take a deep breath and sit back. Continue to reassure the patient throughout the procedure as you keep track of their body language throughout the process.

Step 2. R for Review of Systems or History of Present Illness (HPI)

During your initial consultation with the patient, ask the following questions:

• What exactly bothers you about the procedure? (Sounds, vibration, not getting numb easily)
• Have you had any unusual situations or bad experiences with dental treatment in the past?
• When was your last dental visit? What was done?
• Was the procedure completed?
• How did you do with your last procedure?
• Are you currently taking any medications to help with your anxiety?
• Do you want to talk to a provider about your anxiety?

Knowing about what happened with the previous visit helps to navigate the root of the cause for the patient’s anxiety. Many times, I find that just by talking it through, I bond with my patient and develop an initial trust.

I once had a patient who was very nervous about being reclined too far back. He simply told me “I went into a panic attack when my dentist dropped the chair all the way.” So, I kept him in more or less of an upright position and he responded well to the positioning.

Step 3. E for setting Expectations

The key to a successful outcome will be to establish healthy expectations as close to the reality of what you can achieve and what you can’t. If this patient is very anxious but his or her medical conditions do not support deep sedation or general anesthesia in the office, state so. Offer alternatives with lighter anesthesia options and shorter procedures. Very anxious patients should be scheduled for shorter visits. Gag reflex may be more pronounced and exaggerated with anxiety. Avoid aspiration by sitting patients in a slightly reclined position.

Step 4. A for Anesthesia or other adjuncts to reduce anxiety

Enteral sedation and/or nitrous oxide, if not contraindicated, are good adjuncts to local anesthesia to help manage very anxious patients. I perform intravenous sedations in my office. Many patients are in fear of venipuncture. I will put the patient in the Trendelenberg position to avoid decrease of blood flow to the brain which can cause syncope or seizure activities in an anxious patient who has been NPO (nothing by mouth) for 8 hours prior to procedure.

I may decide to use 100% oxygen delivered via mask or nasal cannula, or to give nitrous/oxygen mixture to shift the patient’s focal point. Various anesthesia modalities are means to help manage anxiety but should not be relied on as the only way to manage anxiety.

In some other patients, having something to squeeze during the procedure helps. It could be as simple as a pillow or a stuffed animal. Some patients bring in their own stuffed animals from home. Some offices utilize sunglasses. I allow earphone in one ear for some patients as long as they can hear me as well. Some offices will even offer massage chair and hot towels to achieve a spa experience. All these measures will help to reduce anxiety.

Step 5. T for time

Take your time during the procedure. Schedule shorter procedures and take small breaks in between if possible. Many anxious patients also gag easily. I use a smaller biteblock and take some small breaks in between each step of the procedure.

Step 6. H for humor

Distract the patient a bit by using humor. I might ask about the patient’s occupation, field of study, or a trip that a patient just took. I might decide to throw a story in or to talk about something my patient and I have in common. For example, I saw a patient who had my same birthday and also was a fellow piano player as I noticed his cell phone cover being a piano keyboard.

This little conversation carried a long way. Use humor to relate to your patient on a personal level, in addition to telling them “you are in good hands”, can really help to make the patient feel comfortable, and trusting, with you personally.

I hope you find this 6-step process helpful. Let’s take a deep breath and get through this together!

For more insight on addressing patient concerns, read on here!