Are you Afraid of the Dentist?

By: Munir Gomaa, D.M.D.

What’s not to fear?

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Author: Munir Gomaa

Four years of dental school, a license to practice dentistry in hand…and the thought of going to the dentist still gives me the chills..
I get it. Dentists are mysterious creatures who reveal only 50% of their face at a time, poke you with sharp instruments and drill through your teeth like it’s butter. When taken out of context, they actually make for a perfect villain.

It thus comes as no surprise that 5-8% of Americans are so consumed by fear of the dentist that they avoid going altogether, only to experience an abundance of oral health problems that work to fuel this fear. Around 1 in 5 Americans possess a degree of dental anxiety that prevents them from seeking out dental care unless it becomes absolutely necessary, generally due to intolerable pain or lack of proper functioning. And by the time they do seek care, it’s often too late to save the teeth in question.

Dental fear and anxiety has been, and continues to be, a widespread problem among all populations. It has inevitably contributed to a “vicious cycle dynamic”, in which fear of dental treatment, lessened use of dental services, and consequent oral diseases continuously reinforce one another.

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Munir Gomaa Figure 1

A collection of variables are commonly responsible for establishing a lasting fear of the dentist. Some of these variables are discussed in this article. According to several studies, the onset of dental fear and anxiety usually occurs in childhood. Oftentimes the reason is directly related to traumatic dental experiences in the past. Sometimes this fear is deeply rooted in entirely non-dental experiences, such as childhood sexual abuse (rather disturbing findings implicating this relationship can be found here), post-traumatic stress disorder, general anxiety disorders, or even substance abuse. However, just as often, personal trauma has little or nothing to do with it.

A rather frustrating fact of life demonstrated by several studies is that parents can easily transmit their fears and anxiety to their children. Children actually learn from their parents to become fearful of spiders, social situations, or the dreaded dentist, and the mechanism of this transmission is subtle yet powerful. One study demonstrated that parents’ degree of vulnerability to certain general, non-dental related perceptions, namely uncontrollability, unpredictability, and dangerousness, reliably predicted their child’s level of dental fear. Another study found evidence that there is a genetic component to dental fear in addition to environmental influences. This study demonstrates that fear of pain is a genetically heritable trait, and that this fear is significantly associated with dental fear.

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With the presented knowledge in hand, I’m prescribing a less intuitive approach to battling dental phobia. Since vulnerable perceptions of adults can be so easily and unintentionally inherited, both socially and biologically, by their children, it’s important for dentists to focus on alleviating fear and anxiety present in their adult patients. When treating the fearful adult patient, most dentists assume that fear is so fortified that it’s useless to try and address it. Instead, they focus on temporary solutions, such as distraction techniques or compromising the treatment plan, to allow for resolution of immediate dental needs. The fear lingers and is nurtured until the next visit.

It’s also important for dentists to inform their adult patients of this very apparent risk, as they can play a large role in preventing transmission by concealing their fears or reservations from their children, or even their younger siblings or relatives, as they work on eliminating or minimizing these qualities in themselves. It’s crucial to take cautious advantage of the openness and moldability of a child’s brain by encouraging a positive attitude towards the dentist and oral hygiene, preventing a plethora of dental problems down the road.

By Munir Gomaa

Insightful read for dental practitioners–keep your patients happy

Posted by Munir Gomaa

I ran across this article and thought it’d be useful for new dental practitioners out there. Included are creative methods, some more obvious than others, that might help give dentists an edge in building healthy, lasting relationships with their patients.

My personal favorite is perhaps the most obvious one–likely why it’s the first to be listed–and that is remembering who they are! Not just their names, but their stories–to the extent which they’ve felt comfortable sharing with you during past appointments, of course. Remembering their interests, fears, and families among other qualities will help build positive, comfortable and trusting relationships, ultimately helping you deliver the best quality care you can while maintaining a warm, friendly environment.  Seems rather intuitive, but it can surely become a difficult task when you’re seeing over a thousand patients! Documenting highlights of your conversations with patients along with your post-op note is always a good idea.

Click here for another recent post on “Stress in the Dental Profession and…Horses” by Munir Gomaa

Stress in the dental profession and…horses

By: Munir Gomaa

It’s certainly no secret, especially to dentists and their families, that the dental profession is an inevitably stressful career. The multifaceted role that a dentist plays–as a clinician, an entrepreneur, a manager, a lab technician (perhaps dental students like me assume this role more than actual dentists), a therapist, and in several ways, an artist–establishes a natural tendency towards perfectionism. After all, financial success for the dental business owner does depend on the dentist’s ability to succeed in all of these facets. Proper fulfillment of these roles demands paying continuous and precise attention to detail during diagnosis and treatment, satisfying patient’s and staff’s evolving needs, and, perhaps most importantly, nurturing the dentist’s own mental health.

Juggling all of these responsibilities in a productive and time-efficient manner takes an incredible toll on the mental health of dentists. It’s no surprise that dentists rank #2, after medical doctors, in careers with the highest suicide rates.

An interesting article I ran across uses empirical data to prescribe a most natural kind of medication to alleviate stress–for dentists, physicians and, quite frankly, anyone with a stressful career or lifestyle–called horses.

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Yup.

Apparently, this mysterious creature’s heart emits an electromagnetic field five times larger than the human heart (which translates to a field extending 40-50 feet from the horse’s body!) According to research, a horse’s electromagnetic field directly influences the nearby human’s own heart rhythm by increasing its coherence–and a heart with increased coherence is directly associated with tranquility, happiness and well-being.

In fact, the physiological and psychological benefits of being around horses don’t stop there; research shows decreased heart rate and blood pressure, reduced feelings of stress, anxiety and anger, increased levels of endorphins, heightened feelings of empowerment, patience and self-efficacy, and the list goes on. Several of these effects work together to alleviate depression, which recent research has associated with a higher risk of cardiovascular disease.

Dr. Bethany Piziks, a dentist and certified life-coach, incorporates this surprisingly effective method in coaching her clients. She uses a method called “Equine Gestalt Coaching Method (EGCM)”, in which two life coaches, a horse and a human, work to help dentists alleviate stress, depression and work through longstanding personal-dilemmas to promote self-development. The outcomes achieved by her client’s are pretty incredible. Highly recommend this article to any and all stressed individuals!

Sources: Stress in the dental profession and why a horse could save your life”Top 11 professions with highest suicide ratesDepression and Cardiovascular Problems

By Munir Gomaa

Combating the Oral Epidemic in Children with Special Needs-By Munir Gomaa

My recent post discussed the preventable nature of the very real oral health epidemic targeting special needs patients. But let’s be honest, who amongst us in our hectic lives has time to address the oral health of the mentally challenged? Fair enough, layman, you’re off the hook. Go live your lives, take care of your own teeth, and be helpful to the underserved in other ways. But, dentists? More importantly, dental schools? Your voices and your actions can make a real difference for the 54.4 million special-needs patients in the US. I won’t speak for every dentist or every dental school in the nation; I can only reference the patterns I’ve noticed from research over the last forty-some years.

In 1979, a study involving over 500 dental students showed that students are willing to treat handicapped patients if they feel capable of doing so. Moreso, as instruction in disability management increased, students had significantly increased levels of perceived confidence in treating these patients. Ok, no brainer—give students more experience with treating special-needs patients, and they’re more likely to do so throughout their career. In 1993, in a survey of US and Canadian dental schools, the average amount of lecture hours about the management of disabled patients was less than 13 hours and the average clinical instruction was 17.5 hours. Considering how time-consuming appointments are at dental schools (in my program, for instance, 3 hours are allotted per appointment), this isn’t very impressive. 32 schools included less than 10 hours of instruction on this topic in their curriculum. 6 years later, a follow-up survey showed that these numbers worsened: over half of dental schools reported less than 5 hours of lecture-based instruction and over 70% of schools reported that between 0-5% of each student’s clinical instruction was dedicated to treatment of special needs patients. In 2004, over half of fourth-year dental students from 5 dental schools reported having no experience in treating the mentally challenged population.

Although I won’t mention every study out there, several studies replicate these findings and additionally show that students attending most US dental schools feel that they aren’t gaining enough clinical experience with special-needs patients to feel comfortable treating them in practice.

It’s apparent that most dental students lack the experience and confidence to treat special-needs patients, but what about general dentists? A study consisting of over 200 general dentists from the Michigan Dental Association showed that most general dentists felt that their undergraduate education had not prepared them well to treat patients with special needs. This study also showed that the more these dentists believed their undergraduate education prepared them well to work with this population, the more likely they were to treat them in practice. The conclusion here, of course, is that most general dentists won’t treat these patients because they lack confidence in doing so.

In another study, dentists and dental staff agreed in a survey that mentally-ill patients have significantly more anxiety related to dental treatment than the general population, and that this anxiety acts as a barrier to them receiving, and for dentists providing, treatment. However, this same study showed that there was no significant difference in the frequency of sedation in these patients versus other patients. Sedation is a common technique used by dentists to treat patients who are too fearful, anxious, or non-compliant to receive dental care. It is often the only means by which they can receive any dental treatment throughout their lives. If mentally challenged patients aren’t being sedated more frequently than the general population, most are likely not receiving the dental treatment they need altogether.

The root of the problem likely lies within the Commission of Dental Accreditations’ “Accreditation Standards for Dental Education Programs.” These are a set of standards that every dental school in the US must incorporate into their curriculum. Pertaining to special-needs patients, section 2-24 states “Graduates must be competent in assessing the treatment needs of patients with special needs.” Basically, this ensures that graduates simply know how to diagnose, but not necessarily treat, this population. The section continues, “An appropriate patient pool should be available to provide experiences that may include patients whose medical, physical, psychological, or social situations make it necessary to consider a wide range of assessment and care options.” The ambiguity in the phrase ‘appropriate patient pool’ allows dental schools to decide just how many special-needs patients they feel are enough to mandate their students to see.

Perhaps the most liberating part of the section is the last sentence, “Clinical instruction and experience with the patients with special needs should include instruction in proper communication techniques and assessing the treatment needs compatible with the special need.” Nowhere in this paragraph does the Commission mandate students to go beyond learning to communicate with and diagnose special-needs patients.

I write all this to raise awareness on this issue, which has always been a problem and will continue to be one unless the Commission of Dental Accreditations raises the bar for the way dental schools must instruct its’ students to treat special-needs patients. In my opinion, section 2-24 should be revised to obligate students to gain the clinical competency necessary to diagnose and treat special-needs patients, just as any other patients. It’s quite the irony that a population whose treatment needs have always been greater than the general population’s aren’t given half us much attention. It’s my sincere hope that this change is soon realized, and in the meantime, that dental schools take their own initiatives in revising their curricula to instill the confidence their students need to treat special-needs patients upon graduating.

The Oral Epidemic in Children with Special Needs-By Munir Gomaa

By: Munir Gomaa

A few weeks ago, several of my dental school classmates and I were privileged with the opportunity to volunteer at a local resource center that provides community-based, educational services to students with severe developmental disabilities. The majority of these students, ranging from 3 to 21 years of age, have profound mental retardation that significantly impairs their ability to perform simple daily tasks, such as eating and drinking, communicating, and, of course, brushing and flossing. My colleagues and I spent the morning performing oral-health screenings on these children, making referrals to our school’s clinic for emergent care when necessary. Our time with each patient was brief. Screenings were performed in a small classroom–many were in wheelchairs as we performed one-minute examinations whenever possible, often only catching a glimpse or two of the oral cavity.

To nobody’s surprise, the oral-health of most of these students was amongst the poorest we’ve seen in children since we began treating patients a year ago. A plethora of dental problems were noted, ranging from neglected oral hygiene and severe tooth wear to rampant tooth decay and non-restorable teeth. Many of these children will require dentures as young adults, suffering from the reduced chewing efficiency by at least 50% that is typically associated with these prostheses. That’s not to mention the enormous difficulty even mentally healthy patients undergo for the first few months of wearing dentures, which include relearning to eat and speak, just as one with a prosthetic leg must relearn to walk. Envisioning the countless oral-health problems these children must overcome in addition to the physical and mental impairments they already experience daily is heartbreaking.

And yet, dental diseases such as caries and periodontal disease are among the most preventable chronic diseases one can be inflicted with through proper oral hygiene, a healthy diet, and regular visits to the dentist. If we had the similarly cheap and effective knowledge and resources for treating diabetes or cancer, there’s almost no doubt that the incidence of these diseases would decline substantially. This isn’t to imply that dental diseases are comparable in magnitude to these life-threatening diseases, however most people are simply unaware of the systemic impact, both physiological and psychological, that one’s dental health has been shown to have. Most people don’t know that periodontal disease has been shown to have significant associations with cardiovascular disease (including stroke and coronary heart disease), diabetes mellitus, bacterial pneumonia, low birth-weight babies and pre-term births. They haven’t a clue that the cavities in their mouths have been significantly linked with hepatitis, hypertension, asthma, stroke, liver disease and diabetes. If they did, dental caries surely would not remain the most prevalent chronic disease in both adults and children. Periodontal disease wouldn’t be affecting nearly 50% of all adults and 70% of adults 65 and up. 1 in 4 adults over the age of 60 wouldn’t have lost all of their natural teeth.

Despite these alarming statistics, recent times has shown a large decline in dental disease, due to factors such as water fluoridation and oral health promotion. However, research has reliably shown that those who suffer from severe mental illness have not shared in these improvements. This population has suffered and will always continue to suffer from a greatly increased risk of oral disease due to a number of factors, such as xerostomia (dry-mouth) commonly associated with psychotropic medications, tobacco and drug usage (over a third of those with any behavioral disorder in the US smoke cigarettes), significant fear and anxiety associated with the dentist, lack of oral-hygiene knowledge and habits, poor living conditions that negatively impact their diet, etc. The list really does go on and on, and every additional factor places this particular population at a much larger risk than the general population. Mentally-challenged or not, the more oral-health problems one has, the more fear and anxiety of the dentist typically overpowers them, and the less willing they are to make a trip to the dentist, let alone allow a dentist to treat them. And yet, this topic remains largely unspoken as the vicious cycle continues.

What initiatives are being taking to target the oral epidemic that exists in special needs patients? Why isn’t it working? And most importantly, what can be done to make a real difference for this at-risk population? Research over the past few decades begins to shed light on these questions, and the answers can be rather frustrating. I’ll share all this along with my ideas shortly.