Skills, Knowledge, and Implementation of Techniques for Behavioral Guidance in Adults with a Fear of Dentistry.

BACKGROUND: Dental fear and anxiety (DFA) is considered the main reason of dental negligence which can lead to detrimental oral health as well as overall health including psychological well-being and quality of life in an individual. AIMS: The present trial was aimed to assess the skill and knowledge of dentists in managing DFA in adult subjects, to evaluate the available strategies used in treating such subjects, and to find the need for further education.
MATERIALS AND METHODS: The present study was an original survey and questionnaire trial, which was distributed to the 82 dentists. The collected data were subjected to statistical evaluation and the results were formulated.
RESULTS: Educating and motivating subjects was found to be effective by 62.19% (n = 51) of dentists followed by successive approximation, and muscle relaxation was considered highly ineffective by one responder (1.21%). Music and reduced waiting time in the clinic appeared to be the most effective strategy as responded by 56.09% (n = 46) of dentists. Attempting treatment in various visits than a single seems to be a highly ineffective technique by 4 dentists (4.87%).
CONCLUSION: Within its limitation, the study showed that the application of various behavior modification techniques can be effective in alleviating DFA in adult patients. Copyright:

INTRODUCTION

Various techniques of behavior guidance including empathy, communication, listening, and/or flexibility are applied regularly in pediatric dentistry to provide effective dental care by alleviating the dental fear and anxiety (DFA) from the children seeking dental treatment. These also help in maintaining the trust and develop a positive attitude toward dentistry and oral health care.[1]

Such techniques should also be applied in adult subjects with few modifications if required as DFA is also prevalent in the adult population seeking dental care. DFA is also considered the main reason for dental negligence which can lead to detrimental oral health as well as overall health including psychological well-being and quality of life in an individual. DFA results from anxiety and the ill experiences faced or heard. Delayed dental treatment owing to FDA also puts an additional financial burden on adult subjects.[2]

DFA are not only limited to the subjects with previous negative experience but also instill fear in subjects with no previous experience. Unlike pediatric subjects, adults do not express their anxiety and fear freely in the dental office and make no expressions and signs of fear masking actual responses. This makes it difficult for dental practitioners to motivate and counsel such adult subjects.[3]

Hence, it should be a regular practice for dental practitioners to reinforce behavior modification techniques and coping skills to all the subjects seeking dental care. These techniques should aim at providing positive reinforcements to avoid fear and anxiety in adults seeking dental treatment. Behavior modification techniques utilize the psychology principles, leading to effective treatment by dentists and great acceptance by subjects.[4]

Although these techniques proved to be effective in both adults and children, dentistry focus solely on pediatric subjects for behavior modification. Recently, modification in adults is largely pharmacological, which has associated risks and is accepted less than nonpharmacologic means by controlling subjects and interfering with their coping. These techniques in adults should be based on trust, thus benefitting both patient and dental care provider.[5]

The present trial was aimed to assess the skill and knowledge of dentists in managing DFA in adult subjects, to evaluate the available strategies used in treating such subjects, and to find the need for further education.

MATERIALS AND METHODS

The present nonexperimental cross-sectional trial was aimed to assess the skill and knowledge of dentists in managing DFA in adult subjects, to evaluate the available strategies used in treating such subjects, and to find the need for further education. The present study utilized the random sampling method.

The study included the dentists with a valid degree of BDS or higher and was registered with the Dental Council of India. The dentists having practiced for 1 year or more were only included. The dentists treating majorly adult subjects were enrolled to participate in the study. The pediatric dentists and the dentists relying on the pharmacological management of the fear and anxiety were excluded from the study. The population of the included dentists was heterogeneous as all the dentists were seeing a different number of patients. The final study population consisted of 82 dentists.

The study was based on a survey and questionnaire, which were adopted from the international model of Dentists skills with fearful patients: Education and treatment.[6] As the present study was an original survey and questionnaire trial, ethical forum clearance was taken. The survey was distributed to the dentists with the definition of behavior modification on the top of the survey form, with a purpose of not to educate the dentists but to provide clarity. The 82 dentists included belonged to the specialties of general dentistry, orthodontists, periodontics, endodontics, oral pathology, oral radiology, public health dentists, and prosthodontics. Pediatric dentists, students, interns, and retired dentists were excluded. The dentists who did not give consent and refused to participate were also not included.

The collected data were subjected to statistical evaluation and the results were formulated.

RESULTS

The present nonexperimental cross-sectional trial was aimed to assess the skill and knowledge of dentists in managing DFA in adult subjects, to evaluate the available strategies used in treating such subjects, and to find the need for further education. The survey questionnaires were available to the dentists for 2 weeks and excluded were those who did not respond within 2 weeks. The study sample had 82 subjects, which were 23 females and 59 males with 79.26% (n = 65) having the practice of 10 years or more, 14.63% (n = 12) had the practice of 6–10 years, and 7.31% (n = 6) with the dental practice of 2–4 years. 40.24% (n = 33) of the participating dentists were BDS dentists and 59.75% (n = 49) were MDS practitioners.

The present study also assessed the awareness of the participating dentist toward the various existing techniques for behavior modification in the subjects with DFA. The results are described in Table 1. Maximum subjects were aware of education/motivation technique with 93.9% (n = 77) dentists aware of it followed by signaling known to 90.24% (n = 74) dentists, and minimum awareness was regarding muscle relaxationtechnique with 40.24% (n = 33) subjects were aware of it. The respective awareness for behavior shaping, distraction, successive approximation, and diaphragm breathing was seen in 80.48% (n = 66), 85.36% (n = 70), 73.17% (n = 60), and 65.85% (n = 54) of dentists.

Table 1

Awareness of participant dentists towards various behavior modification techniques

Technique	Aware (n=82), % (n)	Not aware (n=82), % (n)
Education/motivation	93.9 (77)	6.09 (5)
Signaling	90.24 (74)	9.75 (8)
Behavior shaping	80.48 (66)	18.29 (15)
Distraction	85.36 (70)	13.41 (11)
Muscle relaxation	40.24 (33)	59.75 (49)
Successive approximation	73.17 (60)	26.82 (22)
Breathing/relaxation	65.85 (54)	34.14 (28)

The study also assessed if any of the techniques were appropriate to use in the dental office to reduce DFA in subjects visiting the dental office. Furthermore, the study evaluated the effectiveness of various strategies employed by dentists in-office to reduce the fear in dental patients. The results are summarized in Table 2. Maximum dentists responded that educating and motivating subjects is a highly effective method of reducing DFA as responded by 62.19% (n = 51) of dentists and the successive approximation, and muscle relaxation was considered highly ineffective by 1.21% (n=1) responder. Muscle relaxation was considered ineffective by 12.19% of dentists (n = 10). Furthermore, among evaluated in-office techniques, music and reduced waiting time in the clinic were found most effective strategy as responded by 56.09% (n = 46) dentists. Attempting treatment in various visits than a single visit seems to be a highly ineffective technique by 4 dentists (4.87%) as shown in Table 2.

Table 2

Effectiveness of different techniques and in-office strategies in reducing dental fear and anxiety perceived by study participants

	Highly effective, % (n)	Effective, % (n)	Ineffective, % (n)	Highly ineffective, % (n)
Technique
Education/motivation	62.19 (51)	35.36 (29)	2.43 (2)	0
Signaling	58.53 (48)	39.02 (32)	2.43 (2)	0
Behavior shaping	50 (41)	45.12 (37)	4.87 (4)	0
Distraction	51.21 (42)	46.34 (38)	2.43 (2)	0
Muscle relaxation	34.14 (28)	52.43 (43)	12.19 (10)	1.21 (1)
Successive approximation	43 (35)	51.21 (42)	4.87 (4)	1.21 (1)
Breathing/relaxation	43.90 (36)	47.56 (39)	8.53 (7)	0
In-office strategy
Music	56.09 (46)	40.24 (33)	3.65 (3)	0
Local anesthesia	46.34 (38)	41.46 (34)	10.97 (9)	1.21 (1)
Less waiting time	56.09 (46)	39.02 (32)	3.65 (3)	1.21 (1)
Education	53.65 (44)	4.87 (4)	40.24 (33)	1.21 (1)
Multiple visits	36.58 (30)	43.90 (36)	14.63 (12)	4.87 (4)
Relaxation	40.24 (33)	53.65 (44)	6.09 (5)	0

The study also assessed, if the participant dentists were interested and thought that the proper learning of these techniques can be effective in implementing them in routine practice and also their thinking regarding the suitable health-care professional to provide such training was evaluated [Table 3]. 36.58% (n = 30) of dentists recommend taking training in educating the patients to implement it effectively in the routine practice. Least desirable technique by dentists was diaphragm breathing, as responded by 28.04% (n = 23) dentists, and was also considered highly ineffective by 4 dentists (4.87%). Furthermore, a high percentage of dentists recommended training by the qualified dentist by 74.39% (n = 61) of subjects and only 52.43% (n = 43) preferred training by motivational speakers. 47.56% (n = 39) of dentists found motivational speakers not suitable for training.

Table 3

Behavior modification by participants towards technique and trainer

Technique	Highly effective, % (n)	Effective, % (n)	Ineffective, % (n)	Highly ineffective, % (n)
Education/motivation	36.58 (30)	50 (41)	10.97 (9)	2.43 (2)
Signaling	34.14 (28)	51.21 (42)	10.97 (9)	3.65 (3)
Behavior shaping	31.70 (26)	52.43 (43)	13.41 (11)	2.43 (2)
Distraction	31.70 (26)	52.43 (43)	14.63 (12)	1.21 (1)
Muscle relaxation	29.26 (24)	14.63 (12)	53.65 (44)	2.43 (2)
Successive approximation	30.48 (25)	53.65 (44)	14.63 (12)	1.21 (1)
Breathing/relaxation	28.04 (23)	52.43 (43)	14.63 (12)	4.87 (4)
Preferred trainer	Suitable, % (n)		Not suitable, % (n)
Dentist	74.39 (61)		25.60 (21)
Motivational speaker	52.43 (43)		47.56 (39)
Psychologist	71.95 (59)		28.04 (23)

DISCUSSION

The present nonexperimental cross-sectional trial was aimed to assess the skill and knowledge of dentists in managing DFA in adult subjects, to evaluate the available strategies used in treating such subjects, and to find the need for further education. Maximum subjects were aware of education/motivation technique with 93.9% (n = 77) dentists aware about it followed by signaling known to 90.24% (n = 74) dentists and minimum awareness was seen regarding muscle relaxation technique with 40.24% (n = 33) were aware of it. The respective awareness for behavior shaping, distraction, successive approximation, and diaphragm breathing was seen in 80.48% (n = 66), 85.36% (n = 70), 73.17% (n = 60), and 65.85% (n = 54) of dentists. Similar results were reported by Farhat-McHayleh et al.,[7] and Sharath et al.,[8] in 2009 where similar responses were seen.

Maximum subjects were aware of education/motivation technique with 93.9% (n = 77) dentists aware of it followed by signaling known to 90.24% (n = 74) dentists, and minimum awareness was regarding muscle relaxation technique with 40.24% (n = 33) subjects were aware of it. Muscle relaxation was considered ineffective by 12.19% of dentists (n = 10). Also, among in-office techniques; music and reduced waiting time in the clinic were appeared to be the most effective strategy as responded by 56.09% (n = 46) dentists. Attempting treatment in various visits than a single visit seems to be a highly ineffective technique by 4 dentists (4.87%). These were consistent with the findings of Newton and Buck[9] in 2000 and Ogle and Hertz[10] in 2012 where these techniques were effective in reducing anxiety and fear in dental subjects.

36.58% (n = 30) of dentists recommend taking training in educating the patients to implement it effectively in the routine practice. Least desirable technique by dentists was diaphragm breathing, as responded by 28.04% (n = 23) dentists, and was also considered highly ineffective by 4 dentists (4.87%). 47.56% (n = 39) of dentists found motivational speakers not suitable for training. Hill et al.,[11] in 2008 and Ogletree BT and Oren[12] in 2001 have findings similar to the present study, where the authors suggested training and modification techniques showing similar results.

CONCLUSION

Within its limitation, the study showed that the application of various behavior modification techniques can be effective in alleviating DFA in adult patients. These should be implemented in all adult subjects. However, training should be provided in dental schools regarding the same. The study had few limitations including smaller participant size and all the dentists resided in the same geographical area. Hence, more such studies are required to reach a definitive conclusion.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.