Anxiety in Dental Patients

Opening

There are different reasons to why people experience anxiety, one reason is going to the dentist. According to The University of York (2018), an estimated 30 percent of the adult population from around the world that experience dental anxiety. People who experience anxiety have different undesirable symptoms that are produced just at the thought of going to the dentist. Some of the symptoms that people experience with dental anxiety are nausea, difficulty breathing, and dizziness (The University of York, 2018). Some work themselves up to the point where they need to seek medical help. That is something that can possibly be reduced if not avoided at all. There are different reasons to why people may experience dental anxiety. Some that the University of York describes are fear of pain, needles or anesthetic side effects as well as embarrassment, and the feeling of not having control.

Anxiety not only has different undesirable effects on the patients but also on the dental team. When the patients present to a dental office and have sever anxiety the dental team is not able to give them highly effective and quality care. People seek all sorts of options to reduce anxiety. Many options that are available to them are pricey, and not many are able to pay for the options that are available. It would be amazing if there can be an option that is least expensive yet a highly effective.

There already are different interventions like intravenous general sedation, oral medication but for the general population that usually comes out costing a lot of money, especially since generally that kind of service does not get covered by insurance or if it does it will not be covered at a good rate. There has to be way of reducing anxiety that does not include taking any kind of oral medicine. Something that will be highly effective to where the patients feel comfortable enough with coming to the dentist and getting treatment. One option that was found is auricular acupuncture. Even though an old method but shown to be clinically effective.

Background

Acupuncture has been around for a long time. According to Vaiyda (2013) traditional Chinese acupuncture has a history of over 3000 years. Acupuncture is a routine treatment that has been used in China, Japan, Korea, and Taiwan. Since the late 1970's acupuncture started gaining popularity in the United States. Many are not familiar with what acupuncture means. Vaidya (2013) has a very good definition written out: puncture with a needle. Other than just for dental, acupuncture is also used for many different medical conditions. The goal of acupuncture is to stimulate trigger points in the body that are responsible for different things. Acupuncture consists of using fine sterile needles. These needles are gently inserted through the skin and then gently stimulated. When gently stimulating the needles, it stimulates the nervous system. The needles stimulate the nervous system, to produce a number of effects, modifying the way pain signals are felt, and releasing natural painkillers endorphin and serotonin in the nervous system (Vaidya, et al pg3, 2013). Acupuncture is relatively safe and non- toxic if done properly by a licensed professional.

Acupuncture has been proven to have great effective benefits for medical, and acupuncture also has been found to be as beneficial for dental. It has been studied of how acupuncture has great benefits for other dental conditions that are hard to treat. Other than just dental anxiety, some the other conditions that acupuncture is used for in dental are dental pain, gag reflex, temporomandibular disorder, chronic muscle pain, paresthesia, xerostomia aka dry mouth.

Statement Problem

Looking through different studies it has been found that dental anxiety becomes a vicious cycle that is hard to get out of. In Australia, researchers decided to conduct a survey through telephone interviews to see what the severity of dental anxiety is, and what is the root cause for dental anxiety throughout their population (Armfield 2007). Armfield (2007) found that dental anxiety not only affects the overall health of a human being but it also affects the social life of people. Starting with being scared of the dentist, going to avoidance of the dentist which results in having poor oral health which then results in health issues and patients' low self- esteem and no confidence. For most people their esthetic looks mean everything and when not having a good smile people will avoid stepping out of the house if not necessary. Armfield (2007) found through a number of different studies that patients that have avoided going to the dentist due to severe dental anxiety have a greater need in receiving dental treatment. Through all of the interviews, it has been found that a lot of people will avoid the dentist for a very long time and will only go for emergencies. Because of not being consistent with dental care these patients start to lose a lot of teeth and also have lots of decayed teeth that don't have good prognoses which then requires a lot of very extensive work that is not always most pleasant.

Literature Review

Dental anxiety is something that is dealt with on a daily basis. Dental anxiety makes it difficult for both the patient and the dental team when it comes to completing dental treatment in an efficient manner. Up to 30 percent of adults from all over the world are affected and seek different options for sedation or anything that would help reduce anxiety (University of York 2018). There are many reasons to why people experience dental anxiety some of which have already been stated earlier. According to University of York (2018) there have been some studies done on how acupuncture helps with dental anxiety and that it may be a viable solution or option for ones that suffer with sever dental anxiety. Many countries like England, China, Spain, Portugal, and Germany have conducted trials to see if acupuncture works and if so, how effective it is (University of York). When University of York (2018) looked through reviews, they did find that there was a relevant reduction in anxiety when patient received acupuncture compared to not receiving any.

Acupuncture is traditional Chinese Medicine that has been practiced for over 2000 years (Wong, L.B. et al 2012). Wong et al (2012) found a lot of other dental, and facial conditions that have been treated with acupuncture and had significant results. One of things that causes anxiety within patients is gagging. People with severe gag reflexes tend to struggle from dental anxiety. With acupuncture for the gag reflex and anxiety there has been some significant difference compared with the patients that don't receive acupuncture (Wong, L.B. et al). One of the reasons why it's important to find an alternative option to relax patients that have dental anxiety is, because over the years it's been noticed that there are patients that have had adverse reactions to medicines like benzodiazepines and midazolam. Benzodiazepines and midazolam are oral or intranasal medicines that help relax patients. Once the patients that have had adverse reactions to these medicines it becomes no longer a good sedative option for them. Since the patients that have had adverse reactions don't know of any other options to help overcome dental anxiety, they just start avoiding going to the dentist which then leads to so many oral problems, That in the long run affect the overall health of rest of the body.

Wang, S et al (2001) found that another reason to why patients have dental anxiety is the fear of post- operative pain. Wang, S. et al (2001) found that ear acupuncture reduced daily situational anxiety so with that they decided to conduct a study to see what results they would get with post- operative pain. This trial that was done was randomized, blinded, and controlled. There were 91 selected patients that did not receive any sedative premedication, and this protocol was approved by the Yale University (Wang, S. et al, 2001). All of the patients were randomly placed in to three different groups:1- Traditional Chinese Medicine group, 2- Relaxation group, 3- Control group. The first group received ear acupuncture according to the Traditional Chinese Medicine theory that kidney is related to fear, heart is related to anxiety, and the shenmen point with tranquilize the mind (Wang, S. et al 2001). The second group also received ear acupuncture by using relaxation, tranquilizer, and master cerebral points, which are documented to produce relaxation, general sedation, and anxiety diminishment (Wang, S. et al, Pg 1178, 2001). The third group which is the last group received ear acupuncture. They received acupuncture needles in three different points that have no documented effect on the reduction of anxiety. The acupuncture was performed by the author who is also a licensed acupuncturist. Prior to receiving and kind of treatment all of the patients had to complete a questionnaire. They also had to complete a baseline State- Trait Anxiety Inventory aka STAI. The baseline that is taken prior to treatment describes what makes the patient anxious, what happens when they become anxious, and what level of anxiety they are experiencing. The higher the score the higher the anxiety of the patient. The STAI baseline helps the experimenters determine on how effective ear acupuncture was to the patient. At the end of this particular trail showed that the levels of anxiety were significantly lower compared to the control group.

Naik (2014) also found that auricular acupuncture had a great potential in the dental field. According to Naik (2014), the ability of acupuncture in dentistry has been proven to manage many different chronic facial pain disorders. In trying to find an alternative treatment for anxious patients Naik(2014) found that acupuncture is a lot more effective compared to sham and placebo acupuncture. One great benefit that was also noticed during the study is how long it takes anesthetic to soak in and become fully active in a patient if the patient has received acupuncture treatment prior to dental treatment (Naik, P.N et al 2014). The study was made up of two groups. The two groups consisted of one receiving acupuncture right before they went in for dental treatment. All of the patients received the same kind of anesthetic and in the same area. The injection site that was focused on is the inferior alveolar nerve block. Naik (2014) found that the usual time for the injection was two minutes but with the intervention of acupuncture it went down to 62 seconds. The second group did not receive any acupuncture and did not have any difference in the amount of time it took to administer anesthetic (Naik, P.N et al 2014).

Allan (2018) found quite a few online databases that had randomized controlled trials from all over the world. Some of the countries that the databases were collected from are: China, Portugal, Spain, and Germany. Allan (2018) also found that acupuncture can be used for many different purposes in the dental field. The main question that was posed for this systemic review was What evidence is there for the effectiveness of acupuncture in reducing anxiety in dental patients? (Allan, F.K et al 2018).

To conduct research from all of the collected systemic reviews they did some carful sifting through all of the reviews to find the most highly effective ones and that have the least bias. From the 129 trials that were collected, only six studies were used. Out of the six, only two trials were rated as moderate to high or high quality and the other four had lower quality results, which resulted in not being really used in the study. Both of the trials used auricular acupuncture. With all of the six studies that were researched, there was a total number of eight hundred participants involved. After reviewing all of the results, they found that the two studies that were used provided limited yet very useful and good quality evidence on the effectiveness of auricular acupuncture. The meta-analysis compared acupuncture to no treatment and found that acupuncture has a clinically significant reduction in anxiety when comparing scores. The scores were recorded using STAI (State Trait Anxiety Inventory). By using STAI they were able to make a baseline for every individual patient prior to treatment. They compared the baseline scores and the scores that were recorded post treatment. Acupuncture was found to be significantly effective during this study.

The only concern that there was is that there needs to be some more definitive randomized controlled trials done (Allan, F.K et al 2018). Since there has not really been much research done on the effectiveness of acupuncture as a possible treatment for dental anxious patients, all of the authors that have done literature reviews and systemic meta analyses that have been done and written up are all based on each other's research. Karst (2007) has one of the most significant findings that many authors turn to. Due to that lack of research acupuncture cannot be implemented as one of the treatment options for dental anxious patients.

Experimental Design

More patients presenting with dental anxiety there needs to be more research done on how effective is acupuncture and is it even worth implementing it into the dental practice. With the population of Portland that is continually growing it should not be to difficult to conduct a larger randomized controlled study. Some of the things that need to be focused on is the effectiveness, cost, and how accessible will it be to patients. The study will be made up of three groups. All of the three groups will have to fill out the questionnaire that will have questions about what the dental anxiety is from, and many more questions to be able to set a baseline of what the severity of their anxiety is. This will be a blind experiment to eliminate any kind of bias. The dental team providing treatment will also not know who is part of the control, acupuncture and placebo group, so they don't end up accidentally telling the patient. The dental team will be recording the results without knowing who was part of the control group, acupuncture, or placebo groups. The first group will be the acupuncture group. This group will receive acupuncture prior to dental treatment, this group will know that they are part of a study but they will not know which of the three groups they belong to. The second group will be placebo. The placebo group will receive acupuncture in the spots that is not believed to help with anxiety. This group will also not know what group they belong in other than just knowing that they will be a part of a study to see how effective acupuncture is and is it going to beneficial to implement it into dental practice. The third group will be the control group. This group will not have any acupuncture treatment done so that the other groups can compare what the results are with placebo and acupuncture. For the trial there needs to be an equal number of males and females for all of the groups and they all need to be within the same age range.

Taking all of these measures, we will eliminate any kind of bias that may occur during the treatment. All of these steps are necessary to be able to get a more accurate result. At the end if the study all of the baselines and results of all the patients will be gathered to evaluate. All of that information that is gathered through the experiment will be placed into a table so that when others will be looking at the results, they understand what they are looking at. After the study is done, the results from previous studies and from this one will need to be compared to see what the differences are and what are the similarities.

Justification of Design

Looking at the percentage of people that suffer with dental anxiety, which according to Allan (2018) is somewhere around 30% of people from all over the world. That is a pretty large number of people that need help with reducing dental anxiety. So, can acupuncture a be a good alternative treatment for patients with dental anxiety? With the very limited but high-quality information that there is on acupuncture it is definitely worth doing more trails. In this trail I will attempt to cover the bases that have not yet been covered in previous trials. With this design all chances for bias will be eliminated because all the three groups of patients that will participating will not know what group they fall into, also the dental team will not know what group their patient belongs to. By conducting this experiment, we will be able to have more clarity on how acupuncture helps with dental anxiety. This trial needs to be done to receive more definitive findings on the effects of acupuncture for the population that experiences dental anxiety.

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