Jasdev Bhalla

Clinical Feature BDS MSc

Anxiety and Dental Management

Introduction Table 1.
Mental illnesses are characterized by
alterations in thinking, mood or be- Estimates of One-Year
Mental Illness
haviour associated with significant Prevalence2,3
distress and impaired functioning.7
Twenty percent of Canadians will per- Mood Disorders
Major (Unipolar) depression 4.1 – 4.6%
sonally experience a mental illness
Bipolar disorder 0.2 – 0.6%
during their lifetime. Mental illnesses
Dysthymia 0.8 – 3.1%
affect people of all ages, educational
and income levels, and cultures.9, 10 Schizophrenia 0.3%
Examples of specific mental ill-
nesses include: Anxiety Disorders 12.2%
• schizophrenia
• mood disorders: major depression Personality Disorders —
and bipolar disorder
• anxiety disorders Eating Disorders4 – Anorexia, Bulimia Anorexia 0.7% women
• eating disorders 0.2% men
Bulimia 1.5% women
• personality disorders
0.1% men

The most common anxiety disorders
are shown in Table 1. The chance of a
dentist seeing these in his/her practice
are much higher compared with other
disorders. Anxiety disorders can lead
to behavioural problems during pa-
tient appointments and can intensify
the emotional response of patients to
both the dentist and the dentistry, the
latter manifesting as a lower pain
threshold and difficulty in achieving
adequate local anesthesia.
An anxious patient has a higher-
than-average tendency to become
angry and uncooperative, posing a
challenge for the dentist to manage
the patient’s behaviour and to also
successfully complete the treatment.
Deaths from Suicide (1998)
(Adapted from A Report on Mental Illnesses in Canada”; Public Health Agency of Canada)10
Also, it is not unusual these days to
see young children and teens on anti-
anxiety medications.
Definition and Etiology
Anxiety is defined as “a state of ap-
prehension, uncertainty, and fear re-
12.2 per 100,000 (1998)
2% of all deaths
24% of all deaths among those
aged 15-24 years
16% of all deaths among those
aged 25-44 years
sulting from the anticipation of a re-
alistic or fantasized threatening event
or situation, often impairing physical
and psychological functioning.”8
A complex interplay of genetic, bi-
ological, personality and environ-
mental factors causes mental illnesses.

20 Ontario Dentist • October 2009

 Clinical Feature

Anxiety states can also be associated with organic diseases 6) phobias in conjunction with other psychiatric and be-
and other psychiatric disorders (for example, schizophre- havioural problems
nia) and mood and personality disorders, use of certain
drugs, hyperthyroidism and mitral valve prolapse.3,4 Management of an Anxious or a Dental Phobic
The anxiety disorders include: 4,8 Patient
• panic disorder Managing a patient with anxiety can pose serious chal-
• obsessive-compulsive disorder (OCD) lenges for the whole dental team and can actually make
• post-traumatic stress disorder (PTSD) the dentist anxious and fearful of the patient. The goal in
• social phobia (or social anxiety disorder) managing is to minimize the damaging effect of anxiety.
• specific phobias (for example, needles, heights, spiders) Fear and phobias which look unreal to a non-anxious per-
• generalized anxiety disorder son are real for the phobic patient; hence an empathetic
Each of these disorders has its own distinct features, but all approach is essential.
anxiety disorders are bound together by a common theme The dentist should know what can potentially be
of excessive, irrational fear and dread. avoided so as not to bring about a flight or a fight response.
Some anxious patients respond well to more obvious
Dental Phobia
continued page 22
The Diagnostic and Statistical Manual of Mental Disorders
(DSM-IV) describes dental phobia as a “marked and per-
sistent fear that is excessive or unreasonable.” It also as-
sumes that the person recognizes that the fear is excessive
or unreasonable. Studies done in the past indicate that 20
percent of patients with dental phobia may have a concur-
rent psychiatric disorder. The main difference between
anxiety and phobia is that anxiety is more a “fear of the
unknown” which in dentistry would relate to a patient un-
dergoing a dental procedure which has never been experi-
enced before.1,8,11
Phobia conversely is “extreme dental fear,” where the pa-
tient fearing pain or physical harm would think excessively
about the procedure, magnify the discomfort associated
such that a flight or fight response is activated and the pa-
tient avoids treatment until the burden of dental disease is
too much to bear. Even then it might take psychological
therapy, psychiatric or pharmacologic help to successfully
complete the dental treatment. Dental anxiety coupled
with a bad dental experience can lead to dental phobia.1,8,11
Common causes of dental phobias in patients include
(but are not limited to): 3,13
1) bad experiences — the most common cause. It also en-
compasses painful visits and/or humiliation by a dentist
2) history of abuse — physical or mental abuse, including
childhood sexual abuse.
3) uncaring dental personnel
4) vicarious learning — parents’ dental anxiety transferred
to their children
5) post-traumatic stress

October 2009 • Ontario Dentist 21

Clinical Feature

Table 2.

Generic Name Dose Range Onset Half life

Oral Formulations Comments
(Brand Name) mg (min) (hr)

Diphenhydramine 25-50 Syrup: 12.5mg/5ml and 25mg/5ml 15-60 2.4-9.3 Anticholinergic side effects
(Benadryl) Tablets and capsules: 25 & 50 mg

Hydroxyzine 50-100 Syrup: 10 mg/5 ml 15-60 14 Anticholinergic side effects

(Atarax) Capsules: 10,25,50 & 100 mg
Oral suspension: 25 mg/5 ml
Tablets and capsules: 25,50 and 100 mg

Promethazine 25-50 Syrup: 6.25 mg/5 ml &25 mg/5ml 15-60 7-15 Anticholinergic side effects
(Phenergan) Tablets: 12.5,25 & 100 mg

Triazolam 0.125-0.5 Tablets: 0.125 & 0.25 mg 15-30 1.5-5 Very good for short to moderate
(Halcion) length appointments(2-4 hrs)

Lorazepam 0.25-4 Oral solution: 2mg/ml 30-60 >8 Very good for longer
(Ativan) Tablets: 0.5, 1, & 2 mg appointments(3 hrs)

Diazepam 2-20 Oral solution: 5 mg/5 ml and 5 mg/ ml 20-40 >24 Best administered the evening
(Valium) Tablets: 2, 5 & 10 mg before a sedation appointment
Extended release tablets: 15 mg and can be followed on the
appointment day

distraction techniques such as listen-
ing to music, watching movies or
even using virtual-reality headsets
during treatment. But for these to be
successful it is essential that the den-
tist and the patient share an open di-
alogue regarding specific fears.
Situations which bring about the
stress response should be avoided.
Behavioural strategies which can be
used effectively by dentists include:
• positive reinforcement (for exam-
ple, praising the patient)
• the use of non-threatening lan-
guage
• tell-show-do. Although developed
primarily for the pediatric popula-
tion this can also be successfully
used for adults.3,11,13
If a patient remains apprehensive
after behavioural strategies the dentist
may use hypnosis, oral or parenteral
sedation. Nitrous oxide/oxygen is a
good safe alternative with limitations
being its technique sensitivity and the
need for specialized equipment.
Oral Medications
Benzodiazepines offer the safest and
most predictable effect for in-office
use. The most commonly used drugs
are Diazepam, Lorazepam and Triazo-
lam. If the patient is anxious about
the upcoming appointment, a long-
acting benzodiazepine such as Valium
can be given the night before to facil-
itate good sleep followed by another
Valium on the day of appointment, if
needed. For oral drugs to work well it
is a good practice to make the sur-
roundings less distracting — such as
having the patient relax in a quiet
room with subdued lighting. The pa-
tient should be encouraged to try not
to engage in intense mental or physi-
cal activity before the appointment.
The limitations of oral drugs to con-
trol anxiety include an unpredictable
response and the need for the patient
to be accompanied. Table 21,5 gives a
list of drugs which can be used to con-
trol anxiety in the dental office.
It is imperative to be very familiar
with the pharmacology of all sedative
medications being considered for use.
Drugs with a faster onset and short
half-lives are preferred because of
faster recovery and lower rate of ad-
verse effects.
The Next Level
Patients with intense anxiety, espe-
cially those who have co-existing men-
tal and behavioural disorders, may
benefit from deep sedation or general
anesthesia. A recent study done by
Chanpong et al (2005) yielded some
interesting conclusions:3,12
1) Overall, 5.5 percent of the 1,100
Canadians surveyed were very
afraid of seeing a dentist, and
about half of those had cancelled
or avoided a dental appointment
as a result, compared with only 5.2
percent of those people who re-
ported low anxiety.
2) Extrapolating these numbers to the
adult Canadian population, the
data suggest more than 400,000
people may not have visited the
dentist due to fear or anxiety; more
than 1.5 million may have can-
celled or avoided an appointment
at some time in their lives.

22 Ontario Dentist • October 2009

 Clinical Feature

3) 12.4 percent of those surveyed References

were definitely interested in seda-
tion options, with another 42.3
percent expressing interest if the
cost was not prohibitive.
Deep sedation and/or general anes-
thesia may be an excellent option for
severely anxious patients especially if
they have other co-existing psychi-
atric disorders. Its use requires admin-
istration and monitoring by highly
trained personnel.
Dr. Bhalla is an Assistant Professor in
the Department of Dental Anesthesia at
the Faculty of Dentistry, University of
Toronto. He is a Diplomate of the
American Board of Dental
Anesthesiology and the first in Canada
to be awarded specialty status in Dental
Anesthesiology. Dr. Bhalla maintains a
part-time private practice limited to
dental anesthesiology in London,
Ontario. He may be reached at jas-
dev.bhalla@dentistry.utoronto.ca
1. American Hospital Formulary Service Drug Information 2005. Bethesda, MD:
American Hospital Formulary Service Drug Information; 2005. pp. 2252–2260.\
2. Bracha HS, Vega EM, Vega CB (2006). “Posttraumatic dental-care anxiety (PTDA): Is
“dental phobia” a misnomer? “ Hawaii Dent J 37 (5): 17–9. PMID 17152624
3. Chanpong, B; Haas, DA; Locker, D. Need and demand for sedation or general anes-
thesia in dentistry: a national survey of the Canadian population. Anesth Prog.
Spring 2005;52(1):3–11
4. Dental Management of the Medically Compromised Patient;7th edition; Little and
Falace;Mosby publications
5. Oral Sedation: A Primer on Anxiolysis for the Adult Patient;Mark Donaldson,
BScPhm, RPh, PharmD,* Gino Gizzarelli, BScPhm, DDS, MSc,† and Brian Chanpong,
DDS, MSc‡
6. Milgrom P, Heaton LJ (January 2007). “Enhancing sedation treatment for the long-
term: pre-treatment behavioural exposure”. SAAD Dig 23: 29–34. PMID 17265912.
7. www.dictionary.reference.com/ browse/anxiety
8. www.anxietynetwork.com/helpadd.html
9. www.phac-aspc.gc.ca/ccdpc-cpcmc/topics/mental-eng.php#facts
10. www.publichealth.gc.ca
11. www.dentalfearcentral.org/what_is_dental_phobia.html
12. www.news.bio-medicine.org/medic
13. www.dentalfearcentral.org/overcome_fear_of_dentist. html

Visit us at www.aurumgroup.com

Progressive Restorative Options...

Exclusively from Aurum/Classic!
Create perfect smiles for your patients with:
• NaturalTemps® Milled Provisionals: A whole new concept in temporaries.
• Contessa™ Zirconia: Superior milled zirconia strength – pressed or layered
ceramic esthetics.
• Aurum’s Cristal® (Minimum Prep) Veneers: Ultra Thin – Ultra Conservative
– Ultra Beautiful.
• Easi-ACCES™ Implant Bridges: Harmonized esthetics and function.

Call TOLL FREE for Free Pick-up

Anywhere in Ontario
Toronto (416) 410-1330
1-800-268-4294
Ottawa (613) 736-1946
1-800-267-7040
LASSIC Dentistry courtesy of Dr. Nathanial Podilsky.
DENTAL LABORATORIES
LABORATORIES - CANADA Restorations fabricated by Aurum/Classic.

October 2009 • Ontario Dentist 23

Copyright of Ontario Dentist is the property of Ontario Dentist and its content may not be copied or emailed to
multiple sites or posted to a listserv without the copyright holder's express written permission. However, users
may print, download, or email articles for individual use.