Dental Psychology In-course assignment 2011

A)
B)
C)
Complain of pain and distress
How psychology is relevant to his dental practice
Dear Dr Drillete
Psychology is very relevant in all your patients, and should influence the way you
deal with them and how the practice is set up.
A. Report by the General Dental Council (1990)
B. Thorndikes Law of Effect (1898) 1) What happens as a result of a behaviour
will influence the rate of occurrence of that behaviour.
2) If the consequences are positive, the behaviour is likely to be repeated, if the
consequences are aversive, it is less likely to be repeated.

>Negative reinforcement is a term described by B. F. Skinner in his theory of operant conditioning.

Negative reinforcement strengthens behaviour because it stops or removes an unpleasant
experience
Aversive stimuli tend to involve some type of discomfort, either physical or psychological.
Behaviors are negatively reinforced when they allow you to escape from aversive stimuli that are
already present or allow you to completely avoid the aversive stimuli before they happen.
However, it is most effective when reinforcers are presented immediately following a behavior.
When a long period of time elapses between the behavior and the reinforcer, the response is likely
to be weaker.

Child patients positive reinforcing, giving them a reward (sticker and lollipop)
and vocal praise for dealing with treatment without disruption
Using a fresh fragrance so patients avoid the clinical smell
Negative punishment would be not giving them the lollipop
Be firmer, use louder voice, Hand over mouth positive punishment
>Positive reinforcement intervention Kegels et al (1978)
Children given a talk on dental hygiene and after 20 weeks group who received a
reward for compliance with programme recorded 50% compliance compared with
30% and 20% for Information and discussion used as a follow-up instead.
C. The effect of fear arousal Janis & Fesbach (1953)
Fear arousal inversely related to compliance following lectures on dental health
to high school students.

D. apply Albert Bandura's social learning theory to reduce dental anxiety in children, in a preventative nature.

Essentially, the social learning theory believes an individual, or in this case a

child, can learn from watching
another persons experience of a situation
E. Self-efficacy reduces anticipatory fear and heightens expectation of eventual success.

Levy and Domoto found dentists consider the fearful disruptive child to be
amongthe most problematic in their clinical work.
2
F. Avoid use of traditional HOM, firmer voice, restraining techniques
Children are left with little knowledge of how to positively address their dental
associated
fears; thus, they revert to destructive ways of coping such as refusal and
tantrums during dental treatment.
7. Melamed BG, Hawes RR, Heiby E, et al. Use of filmed modeling to reduce
uncooperative behavior
of children during dental treatment. J Dent Res. 1975 Jul-Aug;54(4):797-801.
8. Melamed BG, Weinstein D, Katin-Borland M, et al. Reduction of fear-related
dental management
problems with use of filmed modeling. J Am Dent Assoc. 1975 Apr;90(4):822-6.

>The problems associated with dental anxiety are not limited to the dentally
anxious child.
The dentist involved with treatment ofdentally anxious children also endures
difficulty.
Along with the frustration that would understandably occur with a resistant,
disruptive child, a
dentist may also suffer from anxiety. Melamedand Williamson reported many
dentists admit
they themselves become anxious when workingwith anxious patients.
4
The combination of frustration and anxiety felt by the dentist could possibly be
projected unconsciously back onto the
child, making the dentist visit even more unpleasant for the child and creating a
never-ending
cycle of anxiety between dentist and child
If a fear can be learned, it can also be unlearned. Rachman developed a model
to describe how fear is learned. Rachmansmodel consists of three main
pathways of learning fear: conditioning, information pathways, and
modeling/vicarious learning.
12

12. Rachman SJ. Fear and courage. New York : W.H. Freeman and Company;
1990.

Ollendick and King, taking into account guidelines developedby the American
Psychological Associations Division 12 known as the Chambless criteria for
empirically supported treatments, found live and filmed modeling to be probably
efficacious in the treatment of phobia
> Successful personal experiences raise a persons expectation of future success
G. Increasing predictability Egbert (1964) Prepared group reported less pain,
used less analgesic medication and their post-operative stay in hospital was an
average of 2.7 days shorter.
Behavioral Profile Rating
Scale (BPRS), an observation measure,
Visual analogue scale
0-10 Numeric pain intensity scale

The child would be able

to vicariously observe the model demonstrate
positive coping skills such as deep breathing,
relaxation,

H. Effect of context on pain Dworkin & Chen 1982. Participants given an electric
shock to their incisors experienced significantly lower pain thresholds and pain
tolerances in a clinical setting than laboratory setting.
Does attention affect pain? Arntz et al 1991 Distraction, defined as the process of
diverting attention away from sensations produced by noxious stimuli, has
generally been found to increase tolerance of acute pain
Audio-Analgesia Gardener & Licklinder (1959) 88% of patients undergoing cavity
preparations were able to cope without anaesthesia given the choice of white
noise or music.
Comparison of distraction techniques Seyrek et al 1984 Game > video > audio
Make the ceiling of dental clinic interesting to look at. Can even have a mounted
television above the reclining dental chair to direct the patients attention away
from the impending invasive treatment.
Presenting unconditioned stimulus with the conditioned stimulus to patient

Making patient face their phobias, distracting the patient from their phobia.
Scenic wallpaper for setting evidence that patients feel more pain in a clinical
setting
Role of EXPECTANCY in pain perception
I. Dealing with child patients politely telling parents to leave the room will lead
to child being more cooperative according to Frank et al (1995) and Marzo et al
(2003)
and an overall less stressful experience for the child, parent and practitioner.

J. Preparing children for treatment .Invasive procedures for children under 7

giving them information shortly before a procedure
For teenagers and adults benefit from giving them information 4-7 days before
BALDWIN & BARNES (1966)
The way the information is presented. Limit use of technical jargon understand it
coherently by the general public
Giving important information near the middle of the appointment
The way the information is presented. Emotional give them an insight into how
it will feel, rather than just a description of the procedure.
Johnson & Leventhal (1974) Before an ischemic pain task subjects given either
sensory, proecural or no information. Sensory information had the most
significant effect on reducing stress.
Procedural information works by allowing patients to match ongoing events with
their expectations in a non-emotional manner eg..
Sensory information works by mapping a non-threatening interpretation on to
these expectations eg.
> How much information is enough Auerbach (1983) 40 patients undergoing
dental extraction surgery were either given general or detailed information.
Patients with a greater desire for information experienced less distress when
detailed information was given, likewise patients with little desire for information
were better off without the details.
Buchanan & Niven 1999 survey showed that
Monitoring and blunting have been identified as two key psychological coping
styles for dealing with health threats [1,2]. When individuals are faced with an
aversive event they either seek out information about the threat (monitoring), or
cognitively distract from threat-relevant information (blunting). Those with a
monitoring style tend to do better when given more information, and those with
a blunting style do better with less information; this is often referred to as the
congruency hypothesis

Richard Lazarus Primary appraisal is the perception of how threatening a

situation is to the individual.
Secondary appraisal is the perception of what coping responses are
available

K. Weinstein et al (2003) as demonstrated Conditioning children for injections

showing a video of child cooperating positively with treatment.
Important that model is from the same age demographic so they can empathise
with giving a testimonial of how they felt the treatment went for them.
L. Modelling step by step, introducing the instrument to the child, because they
can be easily startled by the unfamiliar sights and sounds of the hand drill etc.
For people with a very sensitive mouth gag reflex. Slowly introducing them to the
feeling of the instrument near the anterior third of tongue, and gradually working
back. Tell-show-do approach.

Meeting the patient in the reception room instead of the nurse, so they feel less
intimated, and create a first impression that you, as the dentist are friendly and
caring towards them, rather than a stiff uptight doctor thats too arrogant to get
up off their lofty chair to greet them.
Getting to know the patient, their background, so they dont feel like youre
treating them like just another mouth. Specifically, it may be important to learn
more about the parent as they greatly influence their childs habits and attitudes.
If parent fears the dentist, then it will be highly likely that their child suffers
similar apprehension when faced with dental treatment as evidenced by Marzo et
al (2003). So, as the dentist, you can effectively anticipate patient behaviour
M. Holt & McHugh 1997 questionnaires have shown that these are seen to be the
highest rated characteristics in the eyes of the patient 1. Dentist care and
attention 2. Pain control by dentist 3. Dentist putting you at ease

N. Coping most dentists cope by changing the environment. But better to

appease their emotions.
O. Giving patients control a feedback response loop that reassures the patient
that the practitioner will stop if any discomfort is felt. This leads to the patient
having a psychologically heightened tolerance to pain as shown by Thrash et al
(1982)
Patients undergoing dental treatment signal discomfort with buttons connected
to green, yellow and red lights

P. Giving patients the choice mutual participation in decision making eg. Lefer
et al 1962 Dentures Evidence shows that choice group required fewer
adjustments and less likely to complain or reject denture.
= If treatment involves lifestyle and diet changes then patient prefers to be
involved in the decision.
Q. Responding to fearful children. Weinstein et al (1982)Coercive , Coaxing, set
specific rules, asked about feelings, explanation
Conscious sedation and clinical hypnosis. Relaxing the patient. Making them
visualise a setting in stark contrast to the bland sterile clinical operating room.
Neuro-linguistic programming to put nervous patients at ease.
NLP is a branch of Psychology and self-development that gives insight into the best ways
to positively influence others and give them the tools and skills to achieve the results
they want. His training in NLP has allowed him to master the skill and art of effective
communication with people and has enabled him to influence people in such a way as to
empower them to achieve higher levels of excellence and achievement in life.
Dealing with nervous patients ask them to fill out a questionnaire of their past dental
experiences and their specific fears about being in the dental chair. Ask them to bring it
to the first appointment. Post the patient the comprehensive history form well in advance
so that they have plenty of time to cover every detail. At the time of the consultation
listen carefully to the patients complaints and give them plenty of time to explain
themselves. In this way, the history-taking, diagnosis and treatment planning becomes
more of a dialogue with mutual participation between patient and practitioner making
the patient feel like they have some control in the decision-making process.
Observe the patient while they are talking with regard to their body language, facial
expression and behaviour. Their personality energetic, depressed etc Their breathing.
Anticipate their desire for information

Less pain and distress increase satisfaction increase attendance (Kent 1984)

http://www.simplypsychology.org/operant-conditioning.html
http://www.enjoyabledentistry.com/proof.htm
2. Levy RL, Domoto PK. Current techniques for behavior management: a survey. Pediatr
Dent. 1979 Sep;1(3):160-4.
1. Bandura A. Social Learning Theory. Englewood Cliffs: Prentice-Hall; 1977
Influence of attention focus and trait anxiety on tolerance of acute pain Jack E. James
and Drifa Hardardottir. British Journal of Health Psychology (2002), 7, 149162

Flunitrazepam Versus Placebo Premedication for Anxiety Control in General Dental

Practice
Per Lkken and Per R. Rust
Self-report treatment techniques used by dentists to treat dentally anxious children: a
preliminary investigation H. BUCHANAN & N. NIVEN International Journal of Paediatric
Dentistry 2003; 13: 912