Dental Anxiety & Nervous Patients

A fear of needles is extremely common. It is estimated that it affects at least 10-20% of adults. Rest assured that technology and increased awareness has meant that injections are becoming less unpleasant. Dental needles in Australia are extremely thin thanks to improved metal science. Here are some tips to help:

1. Keep the injection out of sight
2. Use of topical numbing gel on the area for 5 minutes before the injection - this numbs the skin and reduces the prick
3. Distraction during the injection - gate control theory of pain states the brain can only process so many things at once, so if you focus on wiggling your toes, breathing in and out through your nose, feel the tickle/vibration from the machine and listen to your dentist's voice, your brain has a lot less ability to concentrate on the sting.
4. Breath out when we tell you to - your body is most relaxed on the exhale.
5. Warming the syringe and injection so that it does not feel as cold and stingy
6. Vibration technology to reduce pain signals processed by the brain
7. Painless injection technique - reduces trauma to the tissues
8. Needle phobia - use medication before the injection (happy gas, valium)

The mouth is one of the most sensitive areas of the body, so many people are worried about feeling pain during treatment.

Top tips:

1. Take pain medication 30 minutes before appointment - 2 paracetamol (common brand name panadol) and 2 ibuprofen (common brand name nurofen) so you have reduced pain both during and after the appointment
2. If you have had difficulty being numbed in the past, let us know. We might use more anaesthetic or anaesthetics that last longer.
3. We will confirm you are numb before we start any treatment.
4. Understand you will still feel vibration and pressure - we do not numb these nerves. We only numb the nerves that cause pain. This is normal, and good, as it means you can still function and swallow.
5. Get treatment before the infection spreads - once you have a toothache or abscess, it is much harder to achieve full anesthesia as infection/inflammation counteracts our numbing
6. Know that you are in control and if we cannot get you completely numb, you always have the option to stop treatment.

Bring in your own earphones and try and drown it out with music!

The mouth is the second most private part of our bodies, and one we normally only show to our partner or our dentist. Dentists are very much in our personal space! It could stem from a lack of trust of the dentist. It could also stem from issues completely unrelated to dentistry - some people are just very uncomfortable laying down completely.

Things that can help

1. Remember your rights as a patient. It is your mouth and your body, and you are in charge of the appointment. We are here to provide you with our knowledge and skills, but it is entirely up to you to decide what you want us to do for you. People with dental anxiety may subconsciously be thinking 'I am at the mercy of this person, treatment is going to be done TO me, and I can't do anything about it'. To treat, you need to give us your consent, and you can also withdraw consent at any time. It is about mutual respect. We are dentists also have the right to refuse to do something we aren't comfortable with.
   At Marius Street Family Dental, we are more interested in long-term health than achieving short term fixes. We appreciate that the journey to good oral health means trust and working together with the patient as a team. We only want to do treatment if you're on board with the plan. Communication all through the appointment!
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2. Use your 'stop' signal (raise the left hand) and have breaks through the appointment
3. Be involved in your treatment plan, ask lots of questions. Change things you don't like!
4. Communication throughout the treatment! Tell your dentist how much you want to know. Many patients like us to explain what we are doing and what they should be feeling as we go through the appointment. Some patients even like to hold the hand mirror and watch the treatment (especially kids, they want to know everything!). Fear of the unknown is a big contributor.
5. The dentist will regularly check in on you, give us a thumbs up if you are going well and want to just continue - if there is no thumbs up, we will pause and give you a break.
6. If you have difficulty laying back, then we will adjust the chair slowly and let you get accustomed to each position until you are happy to keep going.
   
   As a dentist, I can say that it is MUCH harder for me to do a good job if I don't lean you back at least to a 30 degree incline as I have to put myself in weird positions, I can't see the top teeth properly, etc...but if I have the choice between not treating and treating with the patient sitting more upright, then I will treat more upright.

Not being able to swallow when you want when there is lots of water, instruments and saliva in your mouth - understandable that you're worried about choking.

Choking fears can be especially heightened in people who suffer from tongue restriction or breathing-related problems such as asthma, sleep apnoea or lung disease.

What can be done to help?

1. If its primarily the water from the handpieces that bothers you the most, use of a rubber dam to catch all of this water will help.
2. Raise your left hand whenever you feel like there is too much water, and we will remove all instruments so you can swallow
3. The dentist will give you frequent breaks through the procedure so you can swallow and have a breather.
4. Ask the dentist if you can sit slightly up, or tilt your head to one side for the treatment, so the water flows to one side and is easier to suction away.
5. Request we use both the high speed and slow speed suction - the high speed catches the majority of water from the handpiece, whereas the slow speed sits at the back of the mouth and suctions up any missed liquid.
6. Practice swallowing with your mouth open. This tip comes from Mike Gow, BDS: “I teach my patients to practice swallowing with their mouths open in the run up to the next appointment. Try this yourself at home. Once you have done this for a few days, you can progress to holding a small amount of water in your mouth (and keeping it there), while allowing the swallowing reflex to take place. Obviously the trick is not to swallow any of the water – just to allow the natural reflex within the throat to take place, keeping the water in the mouth. (I hope that makes sense!) It is a very effective and useful thing to learn to do.”

Do we have to use water?

Unfortunately, yes. We use so much water to cool the instruments, but also to wash away debris as we work to keep a clean environment. Having heated instruments can damage the teeth and gums so this is why there is a limit to how much we can reduce the water spray. Sometimes we can turn the water down a bit and go slower. Alternatively, we can sometimes use hand instruments instead of machines.

Try to figure out what brings on this fear.

1. Rubber dam placement can make people who primarily breathe through their mouth feel uncomfortable as it requires you to breathe through your nose. If this is the case we can cut a breathing hole for you away from where we are working.
2. Lots of instruments/fingers etc in your mouth - this one if hard to avoid. Distraction technique is best. Close your eyes and listen to music, and focus on breathing in and out slowly. If you are worried that we will drop something, request that we use rubber dam for all treatment where possible.
3. Being numb can make you feel like you can't breathe or swallow properly, or that your throat is closing. This is most common in people with asthma, breathing/swallowing problems, or people who have had trauma related to suffocation in the past (for example, a near-drowning or severe allergic reaction). It is important to stay calm and always keep in mind that dental anaesthetic only numbs the pain nerves, not the ones that we use to function and protect the airway. So you can still swallow and move as you normally would, but you may not be able to feel the swallow well.
4. Let the dentist know - we will try and avoid a block injection (one that numbs half the jaw) if we can. Unless you need an extraction, we could reduce the numbing of the tongue's nerve.
5. We can use a short-acting anaesthetic to reduce the amount of time that you are numb
6. Sit up for a few minutes after getting the injection and just practice breathing and swallowing, so you are reassured that you still can. Try drinking water.

First, be proud of yourself for seeking help.

Second, we are professionals whose sole job is to help people with dental disease. Trust us when we say we have seen, treated and achieved good outcomes for mouths in a much worse condition. We are not here to judge or lecture you.
We try to educate in an objective manner where we stick to facts and avoid emotional language.
Some patients want us to tell them what they're doing wrong, whereas some patients just want us to fix the problem and not say anything. Let us know which one you are.

Dr Vera says this about people who are embarrassed about their teeth:

"In my personal experience as a dentist, patients' with dental anxiety are usually picturing the absolute worst. It is 100% of the time worse in their head than it is in reality. I really want to see people who are embarrassed of their smile, because it shows that they care, and I know that it's at the worst state their teeth will ever be in, because it'll only be uphill from there as we stabilise and treat disease. It's actually the relaxed patients that think its normal and expected to extract tooth after tooth that scares me the most because they genuinely don't care when they lose teeth, and get frustrated if I suggest we spend money to try and preserve teeth.

I don't care what state your teeth are in, as long as you're willing to work with me together to get things better. I think patients must think we are thinking negative, judgemental thoughts, when in reality our brains are going at full speed trying to answer the questions of 'what needs to be done to get this tooth healthy', 'what challenges might I encounter during treatment', 'what's the pattern of disease, can I figure out what's contributing to this current condition'. I'm thinking about what your teeth COULD look like and how to get there."

Bad Reaction to Local Anaesthetic‍

Complications with anaesthetic is rare and almost always temporary, but they do happen.

The majority of the time this is a reaction to the small amount of adrenaline in the local anaesthetic. On the rare occasion, this adrenaline goes into the bloodstream and will cause rapid beating of the heart - similar to a panic attack. This can be quite unpleasant for a few minutes as your heart races and your breathing can become shallow. Just focus on breathing and the fact that it will pass in a few minutes. It was just unlucky that the needle stopped at a blood vessel. We have techniques to minimise this but sometimes it happens. Don't let it turn you off - just because it happened once doesn't mean it will happen again, it was just bad luck for that one injection. But we do have non-adrenaline containing injections if you are scared of this - they do wear off much faster though, so you will need more.

Sometimes you will feel a little zap, like a little electric buzz which lasts half a second. This is fairly normal and nothing to worry about. It is a minor nerve getting activated and sending a strong short message. Nothing has gone wrong.

Very rarely, people's bodies react to the preservatives. If this occurs, note the type of anaesthetic used and make sure the dentist uses a different one.

Injection Site Being Sore

This could be from the entry point getting infected or from the muscles spasming after the injection was given. Do salty mouthrinses on the day of your appointment, and use a warm moist heat pack straight after the appointment to relax the muscles if you are prone to muscle tension/spasm. Also take regular breaks through the appointment.

Bruising around the injection site - there is always a small bruise, and will look like a little purple dot that heals very quickly.

Very rarely, people bruise extensively or have visible bruising on the face/neck. If this has happened to you, it was because the needle damaged a blood vessel on its way in. It was unlucky, and I can't say it will never happen again as there are thousands of little blood vessels in our mouth, but I can only reassure you we will use good injection technique and that the bad experience is most likely not going to repeat itself.

​Fear of Being Numb

A numb sensation is negative for many people, it is a survival response as many poisons numb the mouth. Also we 'go numb' when our body is going into panic. People who have had panic attacks might associate the feeling with the start of a panic attack.

Most people do not enjoy the numb feeling as they feel like they can't breathe/swallow/use their mouth properly, or they are constantly worried that they are going to drool or look strange.

If this is the case:

1. We can use a short acting local anaesthetic.
2. Try and reduce how much we numb you - numb just that tooth if possible, over blocking half the jaw. Use half of an injection rather than the full injection.Many patients elect to get shallow fillings and simple treatment without any numbing.
3. Reassure that you your motor nerves aren't affected - you can in fact breathe and swallow properly, but you can't feel it so it will feel strange. Desensitising yourself to the feeling - if you have a strong negative response to feeling numb, it might help for us to give you some numbing gel which you can use small amounts of to just numb the gum at home in a safe environment, so that you can get used to the feeling. If you do, do something to celebrate - be proud of being numb - and build up a positive association to the feeling rather than a negative one.

Desensitising yourself to the feeling - if you have a strong negative response to feeling numb, it might help for us to give you some numbing gel which you can use small amounts of to just numb the gum at home in a safe environment, so that you can get used to the feeling. If you do, do something to celebrate - be proud of being numb - and build up a positive association to the feeling rather than a negative one.

As mentioned before, the mouth is a very sensitive part of the body and very private and intimate. Dentistry is very much in people's personal space and can feel extremely invasive. Patients are laying back in a very vulnerable position. For dentistry to work, it requires an astounding amount of trust. It can be extremely difficult for people if this trust has been broken before.

Any number of dental fears can arise. Just to give a few examples, many abuse survivors struggle with loss of control, laying down for treatment, having objects put in the mouth, severe gagging and fear of having the mouth or nose covered. Some even have difficulty brushing their teeth.

Only you can judge the level of help you need to become comfortable with dentistry. Many do not make the connection between abuse and dental fear. Sometimes, even just being aware of this can help.

‍What can the dentist offer?

We would suggest that your first appointment be about becoming comfortable with your dentist. It is so important to only start dental treatment when you have found a dentist that makes you feel comfortable and is empathetic.

Ask for a 'verbal consultation only' where we do not do anything in the mouth, just sit and talk. Here we can establish what your dental concerns and wants are, what makes you comfortable or uncomfortable, how we might help with those things, and what the next step is. If we understand what your fear is, we can work with you. The last thing we want is for us to pick up that you're nervous but not know why, and assume that it is because you're scared of the needle.

• If you do choose to share with us your past, you can ask us not to record it in your notes and have it only as a confidential, private conversation that you don't want in your clinical notes. ‍
• Be in full control of your dental treatment. Have a plan for each appointment and make sure you are across it. Rehearse the 'stop' hand signal as well as the 'im doing well, continue' hand signal with your dentist so that you are always comfortable. Get the dentist to explain what they are doing as they go so you don't have any surprises. ‍
• Start simple and take your time: choose the most simple thing on the treatment plan and start with that, then as you build up trust and confidence, you can work on more complex dentistry.‍
• Don't force or pressure yourself into treatment, or beat yourself up if you struggled with an appointment. This will not help. Be proud of yourself for trying, forgive yourself for being scared, and try again when you are ready.

​Good Resources

Dental Fear Central

SBS New Article‍

As a profession, we have evolved so much. We now appreciate that to be a good dentist, our clinical skills are only one part of what we need. We need to be able to understand our patients, hear their needs and earn their trust rather than demand it. Assisting patients with dental fear is taught at many universities as part of the compulsory course.

The whole profession of medicine relies on trust. Although people are much more educated and have much more access to information now, it is impossible for patients to truly understand everything and to be able to make decisions without guidance from the dentist. We have to trust the dentist's judgment and ability . It is a big responsibility.

I am going to be honest here, I never lie to my patients. All medicine, whether we like it or not, is a business. Private practice dentistry more so than your GP, because we don't get our rent and fees subsidised like they do. I am saying this because there is a growing fear of dentists overtreating patients for financial gain. I personally believe this increased after the government made it legal for non-dentists to own dental practices, and we saw the surge of 'corporate dentistry' as well as health funds trying to control their costs by opening up their own clinics.

Unfortunately overtreatment (unnecessary treatment) does sometimes occur (I would like to think never in our practice!), however I believe that a great majority of 'overtreatment' is due to poor communication by the dentist rather than out of greed or lack of ethics -  When the treatment plan was based on what they think is best, not what the patient actually wanted. At the end of the day, whoever is treating you is a registered doctor and our duty is to your health and well-being (in Australia anyway - can't vouch for dental tourism). You can rest assured that all Australian dentists are heavily regulated and are legally obligated to do right by you, with serious consequences if they don't. Australia has amongst the strictest infection control, regulation and highest quality of dentistry in the world!

Tips

1. Figure out what it is that you don't 100% trust and voice this.
2. Go to someone you feel comfortable with - when the practice is owned and run by the principal dentist like Marius Street Family Dental is, you at least have peace of mind that they're local and have a vested interest in you being happy with treatment.
3. Be involved with your treatment plan - we take a lot of photos so that you can see what we see, and understand better what we are referring to. Ask questions! If you don't quite understand why we have put something on the plan, ask us. If something is not sitting right with you, voice it so that it can be resolved. It is your treatment plan.
4. Get second opinions.
   We have a rule - if you do something, then do it well. If you can't do it well, don't do it. One thing that we pride ourselves on is having a team approach to care - we have many dentists with each one having different special interests. We will tell you who is the best person for you is if there is a part of your treatment that would be better performed by someone with a special interest in that area. We encourage each other to call in the dentist with a special interest in the area to share their knowledge and judgement on cases - so you get a second opinion for free.

If there is something in the plan that you are unsure of and would like a separate opinion, talk to our receptionist and we will book you in with another clinician who will do their own examination and tests separately and provide a full consultation as to their judgement and your treatment options, at no charge. It is important to us that you are happy with your treatment plan.

FAQ: I went to two dentists and they suggested completely different things. Is one of them overtreating?

A bigger, more expensive plan does not mean overtreatment. A lot of the time, more comprehensive treatment could be because the dentist is more experienced and can offer such a plan. The more you know, the more you see. For example, many dentists do not do orthodontics, increase height of worn down teeth, treat jaw dysfunction, assess muscles, place implants etc, so of course it would not be part of their plan. The key thing is that you know why each suggested their plan - did it make sense to you? At the end of the day, go with treatment that feels right for you.

We hear many horror stories from 'dentists back in the day'. Please, give us another chance!

Dentistry is NOT THE SAME as it was 20 years ago, or even 5 years ago! Every month we have new technologies that allow us to be less invasive and more gentle.

Each dentist is different. If one dentist was disagreeable or condescending, it does not mean the next one will be. Try and associate that memory with the specific person or appointment and not dentistry as a whole. For example, "that particular appointment/dentist was unpleasant", not "dentistry/dentists are awful". Mental association is very powerful and it can be devastating when it is working against you. When you do give dentistry another chance, please be aware of any associations you have so that you can reduce its effect. For instance, if someone had a past experience with a dentist that was rude, it is very easy to treat your next dentist as if they are going to be rude to you, and then this prevents effective communication because we are now on the defensive.

Forgiveness is important in leaving a bad experience in the past. Believe that the dentist in the past did not have the technology, techniques and training that we do today, that their intentions were still good and that they were only trying to help you in the only way they knew how. We are human and don't always get everything right. Forgive them and try again.

Let us know exactly what you liked and didn't like about your dental experiences in the past and we will do our best to make you comfortable and avoid reminding you of any unpleasant appointments. If you never create new experiences, you will only ever have those bad ones to remember. The longer you avoid dentistry, the harder it is to come in.

• Let us know what has triggered your gag reflex in the past.
• Sit up in the chair and lean forward slightly.
• Breathe through your nose with slow, deep breathes. Count as you breathe in and out - 3 seconds on the inhale, 5 seconds on the exhale. This reduces your gag.
• Make sure your nose is clear - if you get a stuffy nose or if you are a mouth breather, use nasonex beforehand, or snore relief throat spray.
• Salt on the tongue works well or a salt water rinse.
• Use of rubber dam for fillings.
• Distraction technique - give your brain something else to focus on. The more you think about not gagging, the more you will gag. Listen to music, lift one leg in the air, rub one hand etc.
• Have short appointments.
• For severe gag reflexes, we can numb the tongue or spray numbing onto the back of the throat.
• Happy gas is also good for a severe gag reflex as it relaxes your muscles.