Anxious patients are everywhere, and yet it seems we know very little about how to manage them. Our research shows wildly varying prevalence percentages, and even the terminology is used interchangeably throughout the literature. It’s no wonder that we’re all aware of dental anxiety as a phenomenon but probably don’t feel too confident about managing it. Its presentations are very diverse, and not knowing what to expect can increase stress levels for the clinician as well as the patient.

While anxiety and phobias are typically defined as an irrational fear, the cause of dental anxiety can be quite rational. A previous bad dental experience is a common trigger for anxiety, particularly if this has occurred during childhood. Anxious family members also provide a hurdle, as there is generally an effort to reassure before and during appointments. Unfortunately, comments like “it doesn’t hurt for long” and “the needle will be quick” can exacerbate anxiety rather than alleviate it.

Certain groups have been identified in research as more likely to have dental anxiety, particularly older populations. Personality types, particularly Type A, can predispose to anxiety. Anxious patients I have cared for very often have a phobia of needles too. The fear of being judged and feeling ashamed of their teeth is a significant cause of dental anxiety and can lead to a defensive reaction if not carefully handled.

Anxious patients: what to look for

Some patients are frank about anxiety, even going so far as saying “I hate the dentist” as they walk in. Subtle indicators of anxiety should also be looked for where possible – be aware of patients having an increased heart rate, or who are more prone to fainting. Excessive fidgeting and holding objects in front of the torso as a barrier can be another sign of anxiety. Patients may even be visibly distressed, so it’s best to approach with empathy and reassurance where possible.

Above all, it’s good to remember that as each patient is unique, our anxious patients are also unique. Some will be open about their anxiety and others will not. Some may disclose with relief when asked; others may confirm it but not want to dwell. Finding an appropriate opportunity to ask a patient if they have dental anxiety is a good approach – but it is important not to push it.

So why does identifying anxious patients matter? If people want their pain fixed or a check-up, should it matter? Patients with dental anxiety tend to be unhappier with their teeth and have higher expectations of treatment. That means more pressure when they attend your practice to get the ‘perfect smile’. Patients with dental anxiety are also more likely to be an irregular attendee or avoid us completely, meaning inconsistency in appointments. Finally, research also suggests that dental anxiety may be a central aspect of the cycle of dental disadvantage – undermining what we want to achieve as a profession.

How to ease a patient’s anxiety

Communication is extremely important when providing care. Remember we’re not just talking to patients – our body, tone and facial expressions play an important role in conveying messages and alleviating anxiety. Seating yourself at the same level removes the feeling of towering over a patient, which can convey a power imbalance.

Consider sight, smell, sound and sensations in the dental practice and the way they could individually trigger a patient – seeing a needle and the sounds of high-speed suction and drills are a few examples. Look for ways to reduce these triggers, such as keeping LA out of sight and encouraging patients to bring in their headphones for music. Doing something as simple as asking permission before touching the patient, or devising a signal during treatment, can help gain trust and give the anxious patient a sense of control.

Conventional management techniques like progressive muscle relaxation and paced breathing are tried and true, and can be excellent tools to help establish trust. However, effective and painless anaesthesia is the fastest way (in my experience) to win over a patient. Allowing adequate time for your topical anaesthetic, then warming the local anaesthetic before slowly depositing it, will help ease the patient into treatment. By being able to tolerate what is often considered the worst part of the appointment, there is a feeling of achievement and a renewed expectation for the treatment being provided. 

Why empathy is the best approach

Ultimately, communicating with empathy has been found to be the best management technique for anxious patients. Seeing someone’s situation from their perspective and sharing their emotions, rather than avoiding the shared perspective or pitying them, is the key to building rapport and trust. Cultivating a safe environment and fostering trust between yourself and the patient, in a way that avoids judgment or criticism, will help improve a stressful situation. Validate their concerns and reassure your anxious patient that their anxiety is normal – because while it can seem irrational, it actually is quite common.

Monitor your own responses and be aware of your own feelings and how you express them. Model the behaviour you want your patient to have and be mindful that if you are short or abrupt, it may seem as though you are frustrated with the patient. By being calm and collected, the patient will pick up on it and often mirror this positive demeanour.

Collaborate on treatment options, discuss the pros and cons and avoid making decisions for the patient – consider yourselves a team working towards a common goal, rather than the dentist who knows best.

It’s important not to become overly confident and start making promises you can’t keep, such as guarantees of no pain or treatment complications. If this can’t be delivered, it will cause a huge failure of trust, which could create a further barrier for your anxious patient. It is only more stressful for yourself and the patient if you cannot deliver on your word, so be careful what you say.

Managing your own stress

Working under high stress and being hypervigilant is exhausting and can lead to burnout. Empathy, while an excellent tool for managing anxious patients, is exhausting. Repeated exposure to anxious patients can lead to a phenomenon known as vicarious trauma, described as “work getting inside of you”.

So how can we care for these patients and ourselves, with so much to consider? At a patient level, it is best to set healthy boundaries and manage expectations early. Set clear limits to your relationship, such as not seeing the patient outside normal hours. Ensure you practise with empathy. Honour their resilience and praise the achievements – but remember that you cannot save everyone and it may take a few appointments to gain trust.

Within your team, having the support of your DAs and their confidence in your abilities can provide further reassurance. Sometimes, hearing how good you are from someone else will have a bigger impact on a patient. Ensure that you have a good relationship with your staff and you are mutually respectful of each other, as anxious patients may be looking for discord and will pick up on a tense atmosphere.

Try to plan appointments at a time where you are at your best – often, the morning is a good option because it gives less time for the patient to build up their anxiety, and the clinician is less tired than they would be late in the afternoon. You are also more likely to be running on time, preventing another trigger for anxious patients – having to sit and wait for their appointment.

Taking care of you

Finally – you need to ensure you are practising self-care. Keep your social circles active and find ways to express your creativity. While online dental communities can be an excellent way to be in touch, try to limit it to supportive groups rather than those that thrive off drama. Hobbies that encompass mindfulness, like hiking and baking, can be extremely rewarding and help with stress management. Stay active and make sure you are scheduling time off in the year, so your stress doesn’t accumulate when you don’t have an opportunity to take a break. Above all, give and accept praise where it is due, to validate the effort you, your DA and your patient put in.

If you need additional support, consider talking to your GP or Dental Protection’s support and wellbeing service, which is provided by ICAS and offers telephone counselling 24/7 and face to face counselling sessions near you at your convenience. Further details are available under the “For members” tab of the Dental Protection homepage, dentalprotection.org. 

Managing anxious patients is extremely satisfying and challenging work. It requires full engagement from the practitioner and the challenges it poses can make it tempting to avoid seeing these patients altogether. Burnout and vicarious trauma are real risks if you do not look after and prioritise yourself. Remember you are not impervious to stress and when you work with anxious patients frequently, you have to put in as much effort for yourself as you do them.