Download Clinical Psychology in Dentistry

Division of Clinical Psychology
Clinical Psychology in Dentistry
A Guide to Commissioners of Clinical Psychology
Services
Briefing Paper No. 11
This Briefing Paper was prepared on behalf of the Division of Clinical
Psychology by Dr Jenny Hainsworth ([email protected])
and Dr Heather Buchanan ([email protected]) based
on an original 1996 Briefing Paper developed by Dr Stan Lindsay. Dr
Hainsworth is a Chartered Clinical Psychologist currently based in the
Medical Psychology Department at Leicester General Hospital. Prior to
this she provided a Clinical Psychology service to dentally anxious adults
at Birmingham Dental Hospital, and continues to contribute to teaching
on the undergraduate and postgraduate dental programmes. Dr
Buchanan is a Lecturer in Health Psychology at Nottingham University.
She is a Chartered Health Psychologist whose research focuses on the
aetiology, assessment and treatment of individuals with dental anxiety.
Thanks are extended to the following clinicians and colleagues for their
helpful thoughts and comments on this Briefing Paper: Gerry Humphris,
Professor of Health Psychology, Bute Medical School, University of St
Andrews; Dr Liz Offen, Consultant Clinical Psychologist, South
Birmingham Primary Care Trust; Kevin Fairbrother, Clinical Lead and
Consultant in Restorative Dentistry at Birmingham Dental Hospital;
Deborah White, Associate Professor of Dental Public Health, University
of Birmingham; Barbara Hylton, Senior Dental Officer, Heart of
Birmingham Teaching PCT; Kenneth Wilson, Consultant in Special Care
Dentistry, Heart of Birmingham Teaching PCT.
Published by:
The Division of Clinical Psychology, The British Psychological Society,
St Andrews House, 48 Princess Road East, Leicester LEl 7DR.
Tel. 0116 2549568
© The British Psychological Society 2009
Copies of this Briefing Paper are available from the Society's office at a
cost of £3.75 to members of the Division and £5.00 to others.
May 2009
ISBN: 978-1-85433-491-6
If you have problems reading this document and
would like it in a different format, please contact us
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Tel: 0116 2254 9568; e-mail [email protected]
Contents
Executive summary
4
Introduction
5
The extent of psychological need
6
Recommended service specifications
16
Estimate of staffing levels for clinical psychology services
20
Who can commission clinical psychology services?
21
Delivering psychological treatment to dentally anxious patients
21
Joint approaches in the treatment of dentally anxious patients
22
Potential health gains
22
Standards upon which service is based
23
Governance issues
25
References
26
Appendix 1
31
Appendix 2
32
Appendix 3
34
Clinical Psychology in Dentistry
3
Executive summary
The fear or inability to accept routine dental care affects
approximately one-third of the adult population in the UK. It has
been estimated that as many as 10 per cent are phobic of dentistry
and either avoid it altogether or are very distressed if they do attend
a dentist. As a result, significant deterioration in dental health is
frequently reported.
Clinical Psychologists can provide effective psychological treatment
to help anxious patients accept routine dental care more frequently
and with less distress. This review summarises the evidence-base to
support the use of psychological interventions in dentistry and the
availability of this type of service provision.
Psychologists also have a key role in the assessment of the
psychological impact of oral disfigurement and its treatment, as well
as dental implant surgery.
Clinical psychology services can be commissioned by primary care
services, e.g. primary dental practitioners (including salaried dental
services) and general medical practitioners, and secondary services,
e.g. dental hospital settings. Alternatively, Universities and Teaching
Hospitals (Foundations, Trusts or Boards) may collaborate together
to fund an academic clinical psychologist who can provide a parttime clinical service to a Dental Hospital.
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Clinical Psychology in Dentistry
Introduction
Clinical psychology in dentistry should aim:
■
to reduce distress associated with dental treatment;
■
to promote the uptake of necessary dental care;
■
to promote oral health;
■
to assess the need for cosmetic dental care.
These aims may be achieved by direct intervention with dental
patients or by advising primary care dental practitioners, PCTs and
Foundation Trusts as well as other professionals groups concerned
with the delivery of effective dental care.
Clinical Psychology in Dentistry
5
The extent of psychological need
Fear of dentistry and associated psychological difficulties, is a
widespread problem prevalent in both children and adults. Patients
who are highly anxious about receiving dental treatment may delay
or cancel appointments, have difficulty in tolerating treatment whilst
in the dental chair and setting, and may not access care at all. As a
result, dental fear is reported as being the greatest difficulty faced by
dentists in terms of managing their patients (Enneking et al., 1992).
It has been increasingly recognised that the behavioural sciences
have an important role in dental education, practice and research.
Furthermore, the need for psychological interventions in dentistry is
now supported by recent guidelines, as is the importance of
providing the necessary psychological guidance and expertise in
terms of treatment planning and clinical decision-making (General
Dental Council, 1990; British Psychological Society, 1996).
The NICE Guidelines on Dental Recall (2004) examined the
potential of the patient and the dental team to improve or maintain
the patient’s quality of life and to reduce morbidity associated with
oral and dental disease. The recommendations take account of the
impact of dental checks on: patients’ well-being, general health and
preventive habits; caries incidence and avoiding restorations;
periodontal health and avoiding tooth loss; and avoiding pain and
anxiety. Addressing the anxiety experienced by a significant
proportion of patients in the general population could increase
attendance rates, improve patients’ dental and oral health, and
ultimately reduce the use of secondary care services and associated
costs.
The epidemiology of dental fear
Onset of dental anxiety has been linked to early conditioning during
childhood (e.g. traumatic or painful dental experiences) or through
vicarious learning experiences (e.g. attitudes of family members).
It remains unclear as to whether dental anxiety is simply a
conditioned fear or part of a more generalised anxiety or mood
disorder (Locker et al., 1999).
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Clinical Psychology in Dentistry
Figures based on surveys, such as the 1998 UK Adult Dental Health
Survey, suggest that 64 per cent of adults are ‘nervous of some kinds of
dental treatment’ and 45 per cent ‘always feel anxious about going to
the dentist’ (Kelly et al., 2000). Todd and Walker (1980) reported that
43 per cent of patients avoided going to the dentist unless they were
experiencing trouble with their teeth. Of these, 58 per cent said that
part of the reason was that they were ‘scared of the dentist’.
A recent study of dentally anxious adults in the West Midlands (Hill et
al., 2007) found that 25 per cent of respondents cancelled or deferred
dental appointments as a direct result of their anxiety. Furthermore,
16 per cent of respondents reported high levels of dental anxiety as
measured by the Modified Dental Anxiety Scale (MDAS; Humphris et
al., 1995). Fewer elderly adults admit to being highly nervous of
dentistry. However, it is probable that more avoid dentistry because of
their fear than among the young (Locker et al., 1991).
Approximately 10 per cent of anxious patients require sedation to
receive dental care (Francis & Stanley, 1990). However, specialist
psychological treatment approaches would be a more appropriate
alternative with the added benefit that patients can learn to manage
their fear and change previous patterns of behaviour.
Among children, approximately eight per cent require special care
from dentists because of their fear of treatment (Holst, 1990)
although possibly less than one per cent of children require
specialist psychological help. For those that do suffer, the effects of
dental anxiety have been shown to persist into adulthood, which can
often lead to avoidance of dental care (Skaret et al., 1998) and
subsequent deterioration of oral health (Hakeberg et al., 1993). It is,
therefore, important that dentists are able to assess dental anxiety in
child patients as early as possible in order to establish the nature and
extent of their fear. Although informal clinical observations can be
useful, some children are disruptive and/or unco-operative in the
dental setting as a result of general behavioural problems, not
because of dental anxiety. Hence, formal direct measures (i.e. selfreport questionnaires/picture scales) should be employed, of which
a number are available. These include: the Facial Image Scale
(FIS; Buchanan & Niven, 2002); Children’s Dental Fear Survey
Clinical Psychology in Dentistry
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Schedule (CDFSS; Cuthbert & Melamed, 1982); Modified Child
Dental Anxiety Scale (MCDAS; Wong et al., 1998) and The Smiley
Faces Programme (SFP; Buchanan, 2005).
Malocclusion and facial disfigurement
There continues to be conflicting evidence on the impact of
malocclusion on quality of life (Bernabe et al., 2007) and it has been
concluded that a greater understanding is required of the physical,
psychological and social consequences of malocclusion (Zhang et al.,
2006). A recent 20-year longitudinal study concluded that there was
little objective evidence to support the assumption that orthodontics
improves long-term psychological health (Kenealy et al., 2007).
Orthognathic treatment involves a combination of surgery and
orthodontic treatment to realign the jaws and the teeth, and to
improve the bite. A systematic review (Hunt et al., 2001) concluded
that orthognathic patients experience psychosocial benefits,
including improved self-confidence, body and facial image and social
adjustment, as a result of orthognathic surgery. However, there were
wide variations in the study designs and a lack of uniformity in
measuring the psychosocial constructs. This made it difficult to
quantify the extent and the duration of the psychosocial benefits.
Recent research has recommended the provision of a clinical
psychology service to orthognathic patients (British Orthodontic
Society, 2007), in view of the functional and psychological benefits
derived from orthognathic treatment. Although the benefits of
orthognathic surgery may be more difficult to demonstrate in milder
conditions such as maloccluded dentition, individual variation is
important to assess in such cases (Humphris & Ling, 2000).
Other oral health disorders
A number of other conditions seen in dental patients have
psychological components that may have a direct or indirect impact
on the condition. For example, temperomandibular joint (TMJ)
pain; bruxism; and burning mouth syndrome.
The psychological impact associated with facial disfigurement and
oral dysfunction can cause considerable distress. For example, from
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Clinical Psychology in Dentistry
facial scarring and port wine stains to a severe maxillofacial injury or
extensive resection for head and neck cancer. These patients require
practical and psychological support to adjust to their difficulties and
a multi-disciplinary team approach can play a vital role in terms of
recovery. Furthermore, any surgical intervention in the treatment of
orofacial disease involves a multi-disciplinary team approach (British
Association of Oral and Maxillofacial Surgeons, 2007).
Dental implants
In recent years there have been considerable advances in implant
surgery, and they are being used increasingly as abutments for fixed
and removable prothodontics. The psychological benefits of dental
implants in patients distressed by untolerated dentures has been
reviewed by Lindsay et al. (2000). Clinical Psychologists can carry out
psychological assessment prior to surgery which can be important
both in terms of suitability and preparation for this type of surgery as
well as post-operative care. Dysmorphophobia, and Body Dysmorphic
Disorder are relatively rare psychological conditions that may be
more prevalent in clinics specialising in the placement of dental
implants. Patients may request implants for mild aesthetic problems
which normally a health commissioning team would be reluctant to
supply. Other delusional or psychotic difficulties would be contraindicative of treatment with implants.
Consequences of dental fear
Dental anxiety can have a significant impact on patients’ lives. Firstly,
it often leads to poor dental attendance, which can have a
deleterious effect on oral health (Schuller et al., 2003). Patients who
do attend, may take longer to treat and treatment can become more
complex as oral health deteriorates (Skaret et al., 2000). Secondly,
dental anxiety and phobia can have a wide-ranging and profound
impact on individuals’ daily lives (Buchanan & Coulson, 2007; Cohen
et al., 2000). Patients report significant psychological and social
consequences of their anxiety or phobia; shame and embarrassment
are common experiences (Moore et al., 2004) with research
indicating that patients often report widespread negative social life
Clinical Psychology in Dentistry
9
effects (Locker, 2003) and a threat to self-respect and well-being
(Abrahamsson et al., 2002a, 2002b).
In addition, major inequalities exist in the dental population with
poorer dental attendance and higher rates of disease prevalent in
lower socio-economic groups (Watt & Sheiham, 1999). These factors
are often associated with dental anxiety (particularly in children).
Therefore, those patients who are most in need and excluded from
dental care settings at present should continue to be a priority in
terms of service provision.
Types of difficulties commonly seen in dental settings
Many experiences have been reported as being feared by patients in
a dental setting (Abrahamsson et al., 2002b; Lindsay & Jackson,
1993). For example:
■
Fear of specific stimuli: fear of being able to tolerate a procedure
or pain associated with dental treatment;
■
Gagging and associated fear of catastrophe, e.g. choking,
suffocation, inability to breathe;
■
General anxiety: feeling that ‘everything about dentistry is awful’;
■
Fear of losing control;
■
Fear of fainting or having an adverse reaction to the local
anaesthetic (LA);
■
Fear that anaesthetic will be ineffective;
■
Embarrassment about oral health;
■
Distrust of dental staff: feeling of helplessness; fear of humiliation
(e.g. as a result of past experiences), suspicion or doubt about
what dentist says or does;
■
Previous trauma including history of sexual and/or physical
abuse.
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Clinical Psychology in Dentistry
Moreover, Oosterink et al. (2008) have recently investigated
reactions to a wide range of stimuli in order to provide an anxietyprovoking hierarchy for use with dentally anxious individuals. Results
indicated that invasive stimuli (e.g. surgical procedures) were rated
as the most anxiety-provoking and non-invasive stimuli (e.g. the
dentist as a person) as least anxiety provoking in Dutch adults.
Phobias/fears associated with dentistry
Choking phobia
Choking phobia is characterised by fear and avoidance of objects and
situations that may lead to choking. During dental treatment patients
may be confronted with situations that give rise to extreme fear of
suffocating or being choked (e.g. taking dental impressions).
Cognitive-behavioural treatments have been of proven efficacy, as
well as anxiolytic medication with a remission rate of 58.5 per cent
(De Lucas-Taracena & Montañés-Rada, 2006). There is increasing
evidence for the effectiveness of Eye Movement Desensitisation and
Reprocessing (EMDR), a therapy which has been used to treat a
range of distressing experiences including trauma, dental phobia
and choking phobia (De Jongh & Ten Broeke, 1998; De Jongh et al.,
2002). Furthermore, EMDR (and trauma-focused CBT) have been
recommended by NICE in the treatment of PTSD (NICE Guidelines,
2005). CBT has been used successfully with patients who gag and
have an associated fear of suffocation or choking (Barsby, 1997; Bassi
et al., 2004; Hainsworth et al., 2008). Acupuncture and hypnosis have
also been used successfully with patients who gag (Noble, 2002;
Hainsworth et al., 2005).
Blood injury injection fears
The essential components of blood injury injection fears (BII)
include fear and avoidance of exposure to blood, injury, injections
and related stimuli. There has been evidence that BII fears exist in
the dental context, and overlap with dental phobia/fear. For example,
Berggren et al. (1995) found that the 37 per cent of a group of 109
anxious dental patients rated the item ‘hypodermic needles’ as highly
anxiety provoking suggesting a significant co-occurrence of dental
fear with BII fears. However, other researchers have found less
Clinical Psychology in Dentistry
11
compelling evidence, for instance, De Jongh et al. (1998) found there
were more differences than similarities between dental phobia and
BII phobia. They argue this is consistent with the literature on dental
anxiety (e.g. Stouthard & Hoogstraten, 1987; De Jongh et al., 1995),
showing that anxious dental patients mainly demonstrate fear of
specific dental stimuli or procedures other than blood, injuries or
injections. They noted that although the level of co-occurrence for
both types of phobias was high, dental phobia should be considered
as a specific phobia, independent of the BII subtype within DSM-IV
(American Psychiatric Association, 1994). Behaviour therapy in the
form of in vivo exposure (i.e. graded and prolonged exposure to
feared stimuli) is the most effective treatment for specific,
uncomplicated phobias (Aartman et al., 1999). A number of studies
have reported that exposure therapy effectively reduces fear and
disgust, as well as fainting. This treatment is usually effective within
five to 10 sessions. Applied muscle tension is a simple technique that
may reduce vasovagal reactions, often seen in people with BII fears,
by maintaining blood pressure. It has been successfully used to treat
patients with blood and injury phobias (Ost et al., 1989).
Fear of dental pain
Fear of dental pain is a state of distress related to pain specifically
(Gower, 2004), and is commonly seen within a dental setting (Van
Wijk & Hoogstraten, 2003). People who are predisposed to respond
fearfully to pain are at an increased risk of ending up in a vicious
circle of anxiety, fear of pain, and avoidance of dental treatment.
A recent study (Van Wijk & Makkes, 2008) has shown that highly
anxious dental patients indicated more pain, of longer duration,
than non-anxious patients when receiving an anesthetic injection.
Most predictive for the amount of pain felt was the pain felt during a
previous injection. They conclude that there should be awareness
that anxious dental patients with a negative experience regarding
dental injections may feel elevated levels of pain which most likely
leads to negative expectations for the future. There is some evidence
(Van Wijk & Hoogstraten, 2006) that positive information about pain
may make patients less fearful, certainly in the case of endodontic
treatment. Providing a sense of control (both through the provision
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Clinical Psychology in Dentistry
of information and behavioural strategies such as the use of a stopstart signal) can help reduce fear of dental pain as can the provision
of a high level of predictability including sensations that might be
experienced. In this respect, carrying out a rehearsal of the actual
steps in a dental procedure (similar to ‘Tell, Show, Do’ commonly
used with children) can be particularly effective and can also help to
identify any specific triggers to a patient’s dental fear. It should be
noted too, however, that there are individual differences in how
individuals cope with anxiety (e.g. some patients prefer to use
distraction) so discussion surrounding this is encouraged.
Assessment of dental anxiety: standard measures
Formal psychometric measures such as dental anxiety questionnaires
have been recommended in helping to reach an accurate assessment
of dental anxiety in patients referred for treatment. Although many
studies have been conducted into their use as outcome measures in
relation to various behavioural interventions, their application in
clinical practice in a survey of UK dental practitioners, was
surprisingly low with only 20 per cent of dentists using adult dental
anxiety assessment questionnaires (Dailey et al., 2001). However,
since 2007, the Modified Dental Anxiety Scale (MDAS; see Appendix
3) has been used as a screen for a number of GDS and CDS dentists
in Scotland, with plans to extend this coverage to the whole of
Scotland. The MDAS comprises five items based on the dental
experience (e.g. ‘If you were about to have your tooth drilled, how
would you feel?’) and is rated on a five-point scale ranging from ‘Not
anxious’ to ‘Extremely anxious’; the cut-off score is 19 (indicating a
strong likelihood of dental phobia). Previous studies have
demonstrated good internal reliability for this measure (e.g. Newton
& Edwards, 2005) and it is used widely in research (e.g. Coulson &
Buchanan, 2008). Other dental anxiety questionnaires are available,
but tend to be of greater length and so are more suitable for
research purposes (Newton & Buck, 2000). Please see Appendix 2
for more information on measures.
Clinical Psychology in Dentistry
13
Effectiveness of psychological interventions
A systematic (Cochrane) review of psychotherapy for dental anxiety
(McGoldrick et al., 2003) assessed the effectiveness of psychological
interventions in the treatment of dental anxiety. Although the results
of the 11 studies meeting inclusion criteria for this review were
inconclusive, behavioural and cognitive behavioural therapies
demonstrated a positive outcome in terms of greater attendances at
future dental appointments than the control groups. However, the
authors state that additional research with larger sample sizes and
quality randomised controlled trials are needed to provide further
support for the effectiveness of psychological interventions for dental
anxiety. There is increasing evidence for the effectiveness of EMDR
in the treatment of dental anxiety (De Jongh et al., 2002), and in
view of the NICE guidelines for the treatment of PTSD, EMDR
should certainly be considered for patients who present with prior
traumatic experiences within a dental setting.
Awareness of issues of cultural diversity in dental
treatment
Communities consist of diverse ethnic origins, with different
religions, languages and cultural values. It is, therefore, important to
recognise the many cultural beliefs relating to dental disease and
treatment, e.g. in many cultures treatment is only sought if or when
symptoms occur as opposed to a more preventative dental care
approach. Other beliefs and practices may also be affected or
challenged by certain medical/dental procedures, e.g. tooth
extraction, loss of blood, taste of the anaesthetic. Language and
communication difficulties may necessitate the need for an
interpreter, preferably who has experience in working with anxious
dental patients and who is sensitive to the types of difficulties that
might arise from a cultural perspective. There may be difficulties
associated with working practices and hours, thus making services
inaccessible to those working in certain businesses.
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Clinical Psychology in Dentistry
Children and adults with disabilities
Dental care also needs to be considered for children and adults with
disabilities and again the potential role of clinical psychologists in
this area of special care dentistry. Adults may present with
developmental disabilities (e.g. cerebral palsy, autistic spectrum
disorder, epilepsy, learning disability), as well as those acquired later
in life (e.g. arising from trauma or a chronic condition, for example,
dementia). Patients may have other physical disabilities affecting
sensory perception (hearing, sight, etc.), as well as attentional
disorders, e.g. attention deficit hyperactivity disorder (ADHD) or
mental illness (such as psychosis and substance misuse). High levels
of fear and anxiety have been described in patients with a disability
and this may reflect previous levels of dental care attendance and
past experiences (Stiefel, 2002). An integrated health care approach
is needed to address the health inequalities often faced by this group
of patients and to improve their oral health.
Clinical Psychology in Dentistry
15
Recommended service specifications
In view of the large percentage of the population who are dentally
anxious, there is a lack of appropriate psychological therapies within
dental hospitals and general dental practice settings. Clinical
Psychologists are well placed to provide effective and evidence-based
psychological interventions for dentally anxious adults and children.
Psychological care and psychological aspects of health and care, are
at the heart of current national priorities for health services (Paxton
& D’Netto, 2001). Furthermore, there is a robust evidence-base
supporting the use of exposure-based treatments and cognitive
behaviour therapy in the treatment of anxiety disorders (DoH, 2001;
NICE Guidelines, 2007).
The provision of teaching and training in the psychological
assessment and management of dental anxiety, at both
undergraduate and postgraduate level, will enable students and staff
to manage patients presenting with milder forms of dental anxiety
and fear. Indeed, De Jongh et al. (2005) argue that general dental
practitioners are able to treat adults with mild forms of dental
anxiety effectively, with more specialist interventions (e.g. Clinical
Psychologist or Psychiatrist) required for moderate to severe levels of
anxiety.
Anxious dental patients are seen across both primary care (general
dental practice; salaried dental service) and secondary care (dental
hospitals) settings. Accessibility of clinical psychology services to
anxious dental patients in the community is less likely, with
Community Mental Health Teams (CMHT) accepting referrals for
people presenting with more severe and enduring mental health
difficulties. The number of other applied psychologists (e.g.
counselling, health psychologists and other professionals providing a
service to anxious dental patients in community settings) has not
been well-documented. However, despite the obvious need for the
provision of psychological therapies in this area, the availability of
clinical psychologists is clearly lacking.
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Clinical Psychology in Dentistry
Assessment and intervention
Clinical Psychologists can provide specialist assessments and
interventions in ensuring provision of the most effective treatment
approach for dentally anxious patients. Co-morbid psychopathology
(e.g. other anxiety and depressive disorders) is often seen in patients
experiencing high levels of dental anxiety (Aartmann et al., 1999)
and other psychological difficulties can have a negative impact on
treatment outcome in patients experiencing a high level of dental
anxiety (Kleinhauz et al., 1992). The initial assessment of patients
presenting with dental anxiety is, therefore, crucial as dental anxiety
may be a manifestation of another anxiety disorder or earlier
traumatic experience.
Cognitive Behaviour Therapy (CBT) has been shown to be an
effective psychological intervention in the treatment of dental anxiety.
In vivo exposure is described as the most effective approach in the
treatment of specific phobias (Aartman et al., 1999) and in patients
without additional psychopathology (Milgrom & Weinstein, 1993).
Referral criteria
Patients who are too afraid to visit a dental setting can ask to be
referred to a Clinical Psychologist by their own GP. General dental
practitioners may also be able to advise patients who enquire about
such a service. Although treatment can be carried out by the
psychologist alone, it is important that access to a dental setting is
available, with the recommended treatment approach being carried
out in collaboration with a dentist (either in a primary or secondary
care setting). Unfortunately, due to current referral criteria, funding
constraints, and lack of service provision in dentistry, accessibility of
Clinical Psychologists in the UK with expertise in this field is limited.
Teaching/training
Clinical psychologists have an important role to play in teaching on
the undergraduate dental curriculum and in contributing to ongoing
postgraduate programmes and workshops for qualified dentists.
In addition, electives can be offered and supervised for
undergraduate students in the management of dental anxiety.
Clinical Psychology in Dentistry
17
Advisory/consultancy services
Clinical Psychologists are well placed to provide consultancy services
in the assessment and management of dental fear. For example,
through contributing to seminars for postgraduate vocational
trainees in general dental practice and salaried service dentists;
through teaching on postgraduate programmes (for example, the
MSc in General Dental Practice at Birmingham University and the
Bristol University Open Learning Diploma (BUOLD) at Bristol
University; see Hill et al., 2008, for a list of postgraduate dental
sedation programmes in the UK); also through presentations to
dental forums and conferences such as the Dental Sedation Teachers
Group. Individual dentists could also be targeted and made aware of
non-pharmacological approaches in the management of dental fear
and anxiety.
Cosmetic dental care
Patients can be referred by their orthodontist, dentist or GP to
establish whether psychological dysfunctions can be attributed to
dental malocclusion or other disfigurement. The monitoring of these
dysfunctions should continue after orthodontic or surgical
treatment.
Other resources
Several recent studies have reported preliminary data on the reasons
for, and benefits associated with, dental anxiety/phobia online
support group participation. Results have shown that dentally
anxious/phobic individuals who accessed an online support group
found the experience to be positive and beneficial, and reported that
their anxiety was lower since accessing the group (Buchanan &
Coulson, 2007; Coulson & Buchanan, 2008). Although preliminary,
these results are encouraging and indicate that such groups may
help facilitate attendance at a dental surgery. For examples of online
groups, please see Appendix 2. A new service at Guy’s Hospital in
London has been opened which provides a non-pharmacological
treatment approach for patients presenting with dental phobia.
Tim Newton, Professor of Psychology as Applied to Dentistry, leads
the CBT unit and research programme in the Department of
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Clinical Psychology in Dentistry
Sedation and Special Care Dentistry, and has further demonstrated
the effectiveness of cognitive behaviour therapy as an alternative to
sedation in the treatment of patients who are fearful of dental
treatment. Professor Newton is also developing a computer-based
programme that it is hoped will eventually be accessible for dentally
phobic patients through their primary care trust.
Clinical Psychology in Dentistry
19
Estimate of staffing levels for clinical
psychology services
A survey of 13 Dental Hospitals in the UK, indicated the need for
Clinical Psychology service provision for patients presenting with
dental phobia and other psychological difficulties (Hainsworth et al.,
2006). The dentists who responded commented on the lack of this
type of service provision as well as the belief that this should be
‘more readily available’. In view of these findings, and in addition to
the high prevalence of dental anxiety (Kelly et al., 2000) and its
impact on oral health (Schuller et al., 2003), it is recommended that
a minimum requirement should be 1.0 wte Clinical Psychologist
based at each UK dental hospital, working alongside a dental
practitioner experienced in the management of anxious dental
patients. It is likely that the training of staff in psychological
approaches to the anxious dental patient will be an important aspect
to this service especially as there are interesting changes occurring in
complimentary dental health personnel (hygienists, therapists and
nurses) who will all need assistance in the provision of their
respective services to patients. Alternative funding streams should be
considered. For example, Universities and Teaching Hospitals
(Foundations, Trusts or Boards) could collaborate together to fund
an academic Clinical Psychologist who can provide a part-time
clinical service to a Dental Hospital. It is also recommended that
clinical psychology services should be accessible for dentists working
in general dental practice or salaried services in areas that are
remote from a dental hospital. It is difficult to estimate the number
of Clinical Psychologists that might be required, but each Strategic
Health Authority or Health Board should ensure that the services of
a Clinical Psychologist for dentistry are available to their population.
At a minimum, sessions should be available within each PCT area.
Further surveys to determine the exact ratio of Clinical Psychologists
to a given population are indicated.
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Clinical Psychology in Dentistry
Who can commission clinical psychology
services?
Clinical psychology services may be purchased via contracts with
NHS commissioning bodies, e.g. PCTs who may contract strategically
across the PCT or more local practice-based commissioning teams or
consortia with responsibility for a smaller geographical area. In this
way, clinical psychology time is likely to be a component of a larger
team contract to provide comprehensive dental services possibly
linked to a hospital or other specialist service. However, there is
nothing to prevent dental practitioners acting collaboratively across
practices to employ Clinical Psychologists via local contracts. The
latter may well be negotiated on a sessional basis convenient to all
parties.
Delivering psychological interventions to
dentally anxious patients
Although it is increasingly being recognised that Clinical
Psychologists can deliver effective interventions for patients
presenting with dental phobia and other dental health difficulties,
many members of the general public, dentists and GPs continue to
be unaware of this type of service. It is, therefore, strongly
recommended that the potential role of Clinical Psychologists and
Departments who can offer this service be publicised both locally
and nationally. This could be facilitated through general dental and
medical practices, the websites and promotional material of the
British Dental Association (www.bda.org/) and the British Dental
Health Foundation (www.dentalhealth.org.uk/), the Royal College of
Surgeons and the specialist group of general dental surgeons, and
the media.
Clinical Psychology in Dentistry
21
Joint approaches in the treatment of
dental anxiety
Wilson and Davies (2001) demonstrated the effectiveness of joint
working in their study of dentally anxious adults treated by both a
community dental service and specialist psychotherapist service.
Their single case report discussed how a dentally phobic adult was
able to receive dental treatment and return to general dental care
following a brief intervention of just one hour of Cognitive
Behaviour Therapy (CBT). Wilson and Davies discuss the potential
cost-effectiveness of providing a combination of CBT and community
dentistry in the treatment of patients with severe dental phobia and
that such a ‘co-operation’ between services could provide an optimal
treatment approach for this particular type of phobia. Clinical
Psychologists are well placed to provide a comprehensive service to
this client group, working with dentists with a special interest and
training in the management of dental anxiety.
Potential health gains
For dental fear, successful intervention will ensure:
■
less distress in anticipation of dental treatment;
■
more frequent attendance for dental care;
■
reduced social and health inequalities through increased access to
dental care;
■
improved oral health and reduced morbidity associated with oral
and dental disease;
■
improved quality of life;
■
reduced use of secondary care services and associated costs.
For dental disfigurement, if psychological assessment has indicated
that the disfigurement has contributed to psychological distress in a
given patient, successful orthodontic treatment should reduce that
distress.
22
Clinical Psychology in Dentistry
Standards upon which the service is based
1.
The service should be provided by Chartered Clinical
Psychologists or Chartered Health Psychologists (with practice
certificates). Psychologists will need to be registered with the
Health Professions Council, which is due to become the
statutory regulatory body for Psychologists in 2009.
2.
The service should adhere to the professional and ethical
guidelines of the British Psychological Society.
3.
The confidentiality of clinical information should be ensured.
4.
The service should be subjected to regular audit.
5.
Clinical psychology services should be easily accessible to
patients and dentists in a timely manner.
6.
Clinical psychology services should be culturally appropriate and
be aware of issues of cultural diversity in dental treatment.
7.
Patient information leaflets should be available in different
languages and formats. Access to interpreting services should be
readily available.
8.
Clinical psychology services should be publicised to dentists,
patients and GPs.
9.
Clinical Psychologists providing the service should be well
informed about the nature of dental treatment, dental health
and dental practice
10. Treatment and advisory services should be evidence-based on
sound scientific practice, and Clinical Psychologists should be
encouraged to draw attention to evidence in professional
journals supporting the efficacy of psychological intervention in
dentistry
11. Record-keeping should give evidence, accessible to outside
agencies and compiled annually, of the effectiveness of direct
intervention.
Clinical Psychology in Dentistry
23
12. Clinical psychology services should be supported by staff to
ensure:
(a) adequate record-keeping and reporting;
(b) efficient liaison with members of the public and referring
agencies.
24
Clinical Psychology in Dentistry
Governance issues
1.
The provision of evidence-based interventions following NICE
and other clinical practice guidelines and recommendations,
e.g. cognitive behavioural therapy, Eye Movement
Desensitisation and Reprocessing.
2.
Ensure equality of access to services for members of Black and
Minority Ethnic communities.
3.
Ensure that Continuing Professional Development training
needs are met and linked with service needs.
4.
Appraising and implementing research.
5.
Risk assessment and management.
6.
Increasing user involvement.
7.
Ensuring professional regulation procedures are understood
and employed.
8.
Ensuring regular monitoring of performance against standards
through supervision and audit.
9.
The development of integrated care pathways that incorporate
joint working with dental practitioners and across different
settings (e.g. primary and secondary care).
10. Regular audit of the service, e.g. measures of the psychological
well-being of patients; records of satisfaction provided by clients;
measures of dental health; measures of dental anxiety; the time
patients for direct intervention spend on the waiting list.
Clinical Psychology in Dentistry
25
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Clinical Psychology in Dentistry
Appendix 1: Quality principles for clinical
psychology services
This statement from the Division of Clinical Psychology outlines the
responsibilities of psychologists for quality improvement of their
practice and services. It applies equally to practitioners working on
their own in independent practice and to psychologists employed in
service organisations.
1. All psychologists have a responsibility for the quality of their
practice and the services they provide. This is inherent in the
British Psychological Society’s Code of Ethics and Conduct, the legal
duty of care of professionals, and in broader ethical principles.
2. In carrying out their responsibility for quality, all psychologists will
be involved in a systematic process of examining and improving
their practice. Individual practitioners should ensure that at least
one other psychologist or professional peer is involved to ensure
objectivity.
3. All psychology services should have agreed written principles and
processes for quality improvement. These principles and processes
and their implementation need to be open to inspection by
outside parties.
4. Psychology services in organisations are usually part of a wider
network of services. Psychologists have a joint responsibility in
organisations, to be part of and contribute to, improving the
quality of the services provided by the organisation as a whole.
Clinical Psychology in Dentistry
31
Appendix 2:
Resources and further information
Assessing dental anxiety/pain
Useful reviews of self-report measures
Newton, J.T. & Buck, D.J. (2000). Anxiety and pain measures in
dentistry: A guide to their quality and application. J Am Dent Assoc,
131(10), 1449–1457.
The authors review measures of anxiety and pain used in recent dental
studies. In particular, the study identifies the reliability, validity and
usefulness of the measures.
Aartman, I.H., van Everdingen, T., Hoogstraten, J. & Schuurs, A.H.
(1998). Self-report measurements of dental anxiety in children:
A critical assessment. J Dent Child, 65(4), 252–258.
This article reviews self-report measurements frequently used to assess dental
anxiety in children. The main focus is on their reliability and validity.
Copies of measures
Most widely-used measures are available either in the original article
that the author(s) present data on the tool’s psychometric properties
(see the reference section of this briefing paper) or can be obtained
by contacting the author.
The MDAS is available in a number of different language versions
(http://medicine.st-and.ac.uk/supplemental/humphris/
dentalAnxiety.htm). For an English version please see Appendix 3.
A new set of UK norms for the MDAS with data obtained from a
national telephone poll, including percentile tables (the first time
these have been provided with a dental anxiety measure) has been
submitted to BioMed Central for publication (personal
communication by Professor Gerry Humphris December 2008).
32
Clinical Psychology in Dentistry
Useful websites for information
British Dental Health Foundation
The Foundation is the leading UK-based independent charity
working to bring about improved standards of oral health care –
both in the UK and around the world. It has a series of information
leaflets, including one on dental fear; information on how to find a
dentist and a helpline.
www.dentalhealth.org.uk/
British Dental Association site for patients
The independent dental advice site for patients by the British Dental
Association with easy to use sections for children, teenagers, adults
and seniors.
www.bdasmile.org/
Dental anxiety/phobia support groups
www.dentalfear.com/
This American site is a free resource for patients to come to get useful
information about dentistry and fear, facilitated by experts. It includes
answers to frequently asked questions, and a number of interviews (including
Clinical Psychologists).
Examples of online support groups for individuals to read and post
messages are listed below (publication of these websites does not
represent an endorsement by the authors or the Division of Clinical
Psychology).
www.dentalfearcentral.org/
www.beyondfear.org/
Clinical Psychology in Dentistry
33
Appendix 3: Modified Dental Anxiety Scale
(MDAS; Humphris et al., 1995)
Can you tell us how anxious you get, if at all, with your dental visit?
Please indicate by inserting ‘X’ in the appropriate box.
1. If you went to your Dentist for TREATMENT TOMORROW,
how would you feel?
Not
Anxious
■
Slightly
Anxious
■
Fairly
Anxious
■
Very
Anxious
■
Extremely
Anxious ■
2. If you were sitting in the WAITING ROOM (waiting for
treatment), how would you feel?
Not
Anxious
■
Slightly
Anxious
■
Fairly
Anxious
■
Very
Anxious
■
Extremely
Anxious ■
3. If you were about to have a TOOTH DRILLED, how would you
feel?
Not
Anxious
■
Slightly
Anxious
■
Fairly
Anxious
■
Very
Anxious
■
Extremely
Anxious ■
4. If you were about to have your TEETH SCALED AND
POLISHED, how would you feel?
Not
Anxious
■
Slightly
Anxious
■
Fairly
Anxious
■
Very
Anxious
■
Extremely
Anxious ■
5. If you were about to have a LOCAL ANAESTHETIC INJECTION
in your gum, above an upper back tooth, how would you feel?
Not
Anxious
34
■
Slightly
Anxious
■
Fairly
Anxious
■
Very
Anxious
■
Extremely
Anxious ■
Clinical Psychology in Dentistry
Instructions for scoring (remove this section before
copying for use with patients)
The Modified Dental Anxiety Scale. Each item scored as follows:
Not anxious
= 1
Slightly anxious
= 2
Fairly anxious
= 3
Very anxious
= 4
Extremely anxious = 5
Total score is a sum of all five items, range 5 to 25: Cut off is 19 or
above which indicates a highly dentally anxious patient, possibly
dentally phobic.
Clinical Psychology in Dentistry
35
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