JOURNAL OF DENTISTRY AND DENTAL MEDICINE (ISSN:2517-7389)

Dental anxiety is an unpleasant emotion which may be experienced across the lifespan Anxiety is better defined as an unpleasant subjective bodily state which acts as an alerting reaction and/or coping mechanism to some certain impending event that may arise it is somehow a specific term that described a wide range of altered psychological status of patients visiting dental clinics or hospital. Anxiety is not always negative or psychopathologic in the sense of hindering a person’s function, but often is normal and necessary to help prepare for a crisis situation. Anxiety is a popular term describing the feeling of nervousness or worries about something, and can be characterized by agitation and a diffuse sense of dread. Yet dental anxiety compromises the treatment outcomes, helps to make some sort of occupational stress among dental staff, and usually is causes a barrier between the dental staff and the patient. The ongoing progression in the development of the field of managing anxiety and the introduction of new systems and/or materials the whole dental procedures have changed in a better way where, the inhibition and reduction of pain during dental procedure has benefited patients, dentists and the dental hygienist which had a major reflect on pain control in every single clinic. Dentists have used numerous techniques to improve patient comfort during treatment and reduce any state of anxiety that any patient might reveal, these include: employing distraction techniques, calming dialogue and conversations and positive reinforcement to manage anxious patients who otherwise would use the “white-knuckle” technique. Administering oral medications (with or without nitrous oxide) to anxious dental patients is popular; oral benzodiazepines are a commonly prescribed, low-cost, low-risk treatment adjunct for the reduction of dental anxiety but from my opinion can be avoided in most of the cases if a proper approach to the patient has been established.

Dentally anxious and patients [1-5] are one such population whom the dentist might attempt to target in his or her practice, this report describes a case study of a 13 year old girl, we will here in this article try to concentrate on the proper management and how to approach anxiety state [Figure 1] by discussing a case focus on the following point:-

I. The recognition of anxiety.

II. The background of the certain problem.

III. Any issues (items) that may help in predisposing the problem.

IV. The protocol and the appropriate ways and technique that will help the dentist to be able to deal with such cases.

V. The end results and impacts on the dentist and patient after following the proper steps in management. 

This 14 -year-old female student patient attended the office with her mother during the summer holiday, seeking consultation and treatment, she was presented concerned about the decay in her lower teeth, she had a level of pre-surgical anxiety which was of serious consent to the patient and her mother. The clinical examination revealed slight gingival inflammation, signs of caries on the lower right first molar and the upper right second molar which was confirmed by diagnostic radiograph, a previously filling on the upper right first molar, apart from that Inspection of the other sides of the oral cavity was found normal. The patient’s general oral hygiene was good Carrying on with the medical history revealed to be to be insignificant as the patient during that time was not taking any medication and was not on regular medication before and had no known allergies.

The case history stated that the patient was the second born of her parents, At the time, she was a high school student who was planning to do her GCSE during the next year, her parents were working both in the education sector and she has an older brother and a younger sister , according to the patient’s mother the School records of this patient indicated that the patient earned grades in a very high -average range, and was enjoying the school , the patient also reported that she likes to work in the medical field and that she liked attending social and sport school activities. The patient also had the belief that her mouth was in poor health because she could see decay and dark spots on her teeth. The patient was fit and attending the gym regularly and had special concern about healthy food and as she mentioned was aware of the problems linked to sugary (sweet food) and drinks. Digging deep into the origin of the problem the patient confirmed that somehow she has been terrified for many years of receiving oral injections from dentists. She attributed this to having been brusquely treated by a dentist when she was a child. And she described her experience as being “so painful “and” a terrible experience. She could also remember that she felt in such a pain and was terrified from the needle that she did not want to carry out her treatment at that occasion and she was anxious that she might have to go through the same again and did not want to have a needle in her mouth.

V.1. How was the anxiety manifest?

It is important first to remember that learning knows no particular time or age limit, as people are never born fear of dentists. Dental anxiety and fear are an avoidance of fearful situation and the worry that it might take place , pain, trauma and unpleasant or discomfort or any negative interpersonal interactions between the clinician and the patient is well defines as the most common direct source of experience that will result in anxiety and fear the patient at started exhibited slight signs of hands trembling and trying to keep hands out of sight, together with somehow continuous body movement which is are listed among the behavior signs also, continuous questions Which might also indicate a signal of anxiety or concern, in time with getting more comfortable and showing signs of trust, the Movement eventually vanished (Figure 2).

V.1. How might it have arisen?

In general, when the patient is fully cooperative, any dental procedure can be performed properly Dental appointments can produce anxiety severe enough to that might induce phobia in time [6]. The fear of the susceptibility of having an anxiety attack while away from familiar surroundings restricts activities and other usual environment; this has the power to result in infrequent dental visits [7]. In most of the cases Parents obviously have a profound influence on the way their children perceive themselves and the world. And any roots of fear inside them [8]. The parental attitude toward body values is easily assumed by the children in this case here with the mother highly health motivation and the daughter’s eager to have (clean teeth) and her self-awareness of oral hygiene, we can exclude any family background factor that might have participated in predisposing the anxiety, out of the different elements that have mentioned regarding different stimuli, the stimuli that gave rise to the problem here is the anxiety of receiving an injection with the painful past experience Other involved stimuli might include : the smell, and the environment of the dental clinic (Figure 3).

We should remember first that there are in this case no factors that might interfere with the solving of the problem such as (shame, fear, financial status, lack of social support) and this is an encouraging start [9,10]. According to the management of dental anxiety approach strategy, we have first to

Assess the level of anxiety and if there is any urgent treatment needed 

In this case first we must state (Figure 4)

A. There was no need for any urgent treatment (as by diagnosis and approach the main problem was caries not reaching the pulp yet, just in the dentin)

B. By evaluating the patient’s level of anxiety the patient showed , it can be categorized as a low level as it can be observed through behavior and physical action as she showed no decreased level of social adjustment, also the patient did not reveal any signs of uncooperative behavior, as she was so keen for the treatment, and did not show clinical signs of crying, talking in such nervous scared way, all that can exclude our patient from being in the high dental anxiety level [11].

Other signs which disappeared shortly after the patient settled in the chair (such as a hand moving) together with the patient confidence also the patient not using any words such as (disaster, depressed) with no facial symptoms of agony can exclude the patient from the moderate level yet this was confirmed by using the Modified Child Dental Anxiety Scale [12]. With the exception of the fourth question where she scored a two the rest of the questions where 1 which mean that it is a case of low level of anxiety even more a concern related to the needle. Also the medical history and straight questions is another way to assess the level of anxiety in the patient (Figure 5).

Based on the diagnosis, we should start the treatment plan

a) Rapport building: this was achieved by breaking the ice mechanism using soft topics for initial small talks ( i.e. where did you travel), also using listening techniques, listening carefully to what the patient says, trying to introduce some elements of humor in the conversation , maintaining eye contact Feck, et al. [13] Smyth [14].
b) voice control: using loud voices with deep tone can help with such ages
c) Distraction techniques used included audio tape distraction
d) Modeling and desensitizing via website assistance was of great help here
e) Memory reconstruction the verbal component was partially used here together with the provision of the concrete example phase
f) Environmental change: this was of a big deal of help in this case, making the environment more attractive did help the patient gain good confidence

Another strategy was explaining to the patient that dental treatment does not always mean a needle, and a needle if used is a source of treatment not a source of pain [15,16].

Impact and outcomes for the patient, you and anybody else who was involved

At the end of the session both parties the dental team and the patient and her mother were satisfied about the outcome, the treatment included no injection insertion and no adjunctive sedation therapy or IV sedation programme as there was no need for it and instead a pulp capping therapy was applied [17]. Relaxation therapy with biofeedback was combined with cognitive-behavioral therapy by allowing the patient to calmly explore and discuss material that was highly charged emotionally together with breaking the barrier and good understanding from the patient did lower the level of anxiety and concern to being positive towards any dental treatment [18,19]. At the second session which was 6 weeks later the patient exhibited a high level of confidence and even was ready for any sort of treatment that might involve needle insertion (although such needle was not required). Since then the patient has been regularly attended to the clinic on her routine checkup appointments , her oral hygiene and dental health (although she used to look after) but improved to a high level The outcome was mentally, physically relaxing for all, and the impact was positive on the patient whom in time had a total change and there were no anxiety or concern issues even when she attends the clinics (no longer exhibited any signs of anxiety such as moving hands, asking question) indeed can describe her as being more friendly, open and talkative [19].

a. We need to identify, diagnose and recognize anxiety.
b. Each certain case may determine the use of a special technology.
c. This assessment process is always the main step in such cases and could be achieved by two ways could.
d. The first method is to fill out some sort of anxiety scale.
e. Another alternative method is to review the patient medical by direct questions and filling a medical history forms that all new patients fill out, a number of relevant open-ended questions such as “What concerns you have about treatment [20,21].
f. Based on the proper assessment we can then evaluate the level of anxiety.
g. In case f children anxiety , parents attitude and behavior is to be considered seriously
h. Before starting the management, we should always analyze any factor that might interrupt the proper management
i. Remember the protocol for each level of anxiety bearing in mind the patient’s own psychology
j. Although the protocol of management in the baasic guideline for managing patients there might be always a new strategy the dentist might find useful to add 

It is essential always to follow up the prognosis and outcome of each individual case this will be useful in estimating the success of the treatment and if any alternative method can be use which might result in a better outcome.

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