Latest / Becker’s Healthcare Podcast / Understanding and Treating Dental Fear with Kelly Daly, PhD

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Understanding and Treating Dental Fear with Kelly Daly, PhD · Becker’s Healthcare Podcast

• 0:02
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  - Hello. This is Arianna Podolatin with the Becker's
• 0:59
  - Dental and Diasa Ruby podcast. I'm thrilled to
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  - be joined today with doctor Kelly Daley, a
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  - clinical psychologist psychologist, excuse me, an expert on
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  - dental fear. Doctor Daley, thank you so much
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  - for being here today. It's a pleasure to
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  - have you with us. Thank you for having
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  - me.
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  - Yeah. To start us off, can you introduce
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  - yourself for our listeners and tell us a
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  - little bit about your background as well?
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  - Sure. I am a clinical psychologist by training
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  - and a research scientist at NYU,
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  - and much of my work is focused on
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  - what we call implementation science, which really means
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  - finding ways to better disseminate and get systems
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  - and individuals
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  - to adopt
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  - psychological
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  - treatments, practices,
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  - protocols that have an evidence base. So things
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  - that have been shown to be effective through
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  - rigorous research,
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  - and dental peer treatment is actually one of
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  - those approaches.
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  - Okay. Thank you for that.
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  - So how does dental anxiety typically present itself
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  - in the operatory? Can you tell us a
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  - little bit about that?
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  - Sure. So that's a really interesting question because
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  - there are a variety of ways that dental
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  - anxiety can show up.
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  - A misconception we've seen across the literature and
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  - actually among a lot of dentists we've worked
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  - with
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  - is this idea that anxiety is really overt,
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  - that it's always visible, and sometimes that's true.
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  - Sometimes you'll see patients who are sweaty or
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  - clammy or maybe their legs shake or their
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  - voices are quivering,
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  - but for a lot of people, anxiety is
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  - really internalized.
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  - So you might have a patient who looks
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  - completely, you know, fine,
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  - cool as a cucumber on the outside,
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  - and internally, they're having these catastrophic thoughts and
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  - freaking out.
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  - So that's not an uncommon presentation.
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  - And sometimes patients who are extremely anxious are
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  - actually perceived as kinda rude or aloof
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  - because they're so in their own heads working
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  - through kind of all of these awful thoughts
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  - about what's gonna go wrong
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  - that they they have trouble being present and
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  - kind of socially appropriate.
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  - So there's a huge spectrum here in terms
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  - of what anxiety looks like and and no
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  - one answer.
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  - Yeah. That's super interesting that you talk about
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  - the spectrum as you mentioned and how different
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  - it can look, in each patient.
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  - What are some of the challenges that come
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  - with dental anxiety both on the patient side
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  - as well as the provider side?
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  - Sure. So on the patient side,
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  - you know, as I said, dental anxiety really
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  - spans this huge spectrum. So for some people,
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  - they drag the dentist so much and become
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  - so convinced that their visit is gonna be
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  - extensive and painful
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  - that they avoid going, and they'll even avoid
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  - going for years.
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  - And then with no preventative
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  - or prophylactic or routine cleanings or treatment,
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  - their oral health starts to suffer.
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  - So inevitably
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  - for these people, it takes a real emergency
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  - for them to get to the dentist, and
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  - then they go to the dentist and it
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  - is expensive and it is painful because they've
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  - missed out on all that treatment they should
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  - have had over the years,
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  - and they kind of have their worst fears
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  - fulfilled. So it becomes the self fulfilling prophecy
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  - for a big group of people.
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  - Afterward, they think to themselves, yep. The dentist
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  - is always super painful.
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  - I do always need extensive work done. It
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  - really is that bad. I was right, and
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  - they kind of go back to avoiding.
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  - So it's called the vicious cycle of dental
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  - fear, and it's actually been validated across a
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  - lot of research. So there's there's a huge
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  - contingent of people who fall in that bucket.
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  - Other fearful people don't avoid the dentist, but
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  - they'll spend days and even weeks up until
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  - an appointment kind of ruminating about it, freaking
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  - out in their head, you know, breaking into
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  - sweats.
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  - They're extremely uncomfortable and anxious while there
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  - and it makes the entire appointment miserable.
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  - They tend to have these negative
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  - anxiety driven cognitive lenses that lead them to
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  - focus on
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  - the worst parts of an appointment and even
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  - overlook
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  - innocuous or positive elements of them.
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  - And then when things don't go wrong, instead
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  - of learning from the experience,
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  - people who are prone toward dental anxiety
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  - often interpret that as a fluke or them
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  - having having gotten lucky that something bad didn't
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  - go wrong.
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  - So sometimes we see catastrophic fears,
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  - that people just can't shake. So, you know,
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  - an example would be the dentist is gonna
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  - hit a nerve and paralyze me, and sometimes
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  - people have more realistic fears about what could
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  - happen, but they're convinced that they they just
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  - can't tolerate it.
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  - You know, this is gonna be an extremely
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  - uncomfortable procedure,
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  - and maybe it will be. That's not unrealistic,
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  - but it's this idea of I can't possibly
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  - get through it.
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  - So with dental care,
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  - we see a reduction in prophylactic regular care,
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  - more problems over time, poor long term health
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  - and systemic health,
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  - and a lot of needless pain and suffering.
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  - I've worked with a variety of cases of
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  - people with, you know, kind of across the
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  - spectrum here and people with really severe dental
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  - fear to the point that
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  - it's led to job loss.
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  - You know, I worked with somebody who had
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  - a really bad abscess.
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  - It was starting to smell,
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  - to the point where he couldn't be in
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  - his office and had to quit his job.
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  - His personal relationships were suffering.
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  - So it can be an incredibly,
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  - incredibly debilitating
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  - condition and kind of have these cascading effects,
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  - general fear is to ask, which patients actually
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  - respond really well to.
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  - On top of that, you're working against that
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  - patient's kind of cognitive filter where they're looking
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  - out for bad things and convincing themselves that
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  - everything's gonna go wrong, and sometimes you're working
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  - against prior really bad experiences at the dentist.
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  - So as a provider, it's really on you
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  - to show them that things can be different,
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  - that you do care about this person and
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  - their oral health,
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  - and to slow down and kinda listen to
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  - that person and their fears. So showing them
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  - that this really is a partnership and and
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  - you're there to figure out how to provide
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  - care with with them.
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  - So many great points there. Thank you so
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  - much for giving us those details. And, speaking
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  - of, some of the research that you mentioned,
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  - I know New York University recently conducted a
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  - study on dental anxiety.
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  - Can you give us a brief summary of
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  - the study that was conducted there? How was
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  - it done and what were some of the
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  - results?
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  - Absolutely.
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  - So to back up briefly,
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  - dental fear is really treatable and that's something
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  - we've known for a long time. So even
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  - with these cases of pretty severe fear or
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  - phobia,
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  - we can sometimes see complete abatement in as
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  - little as three hours, and we can almost
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  - always get significant improvement and relief
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  - per patient, meaning less severe anxiety, less avoidance,
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  - more engagement in oral health.
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  - The issue is that a lot of these
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  - evidence based treatments, which are cognitive behavioral and
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  - exposure based,
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  - were developed in specialty clinics and traditionally require
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  - a dental chair, a trained mental health professional,
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  - and a dentist or a dentist who's duly
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  - trained as a mental health practitioner.
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  - So mental health professionals don't get trained in
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  - these approaches.
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  - They need to be conducted in dental operatories
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  - and taking up chairs, which is a huge
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  - challenge because, you know, that's treatment time and
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  - that's money for a practice.
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  - So our research group was thinking about ways
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  - that we could bring some of these traditional
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  - evidence based treatments
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  - to the many, many fearful people who really
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  - need them.
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  - Now given that there's so much variability in
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  - symptoms and severity in dental care,
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  - we know that not everyone needs a full
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  - three or four hours and increasingly,
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  - we've been seeing kind of the power of
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  - mental health apps that translate evidence based treatments
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  - for people.
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  - So we developed an app as our first
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  - set of treatment, and it has lots of
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  - cognitive behavioral strategies and some exposures built in
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  - that fearful patients can work through, and it's
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  - presented in a really accessible way as changing
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  - what you think, feel, and do at the
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  - dentist.
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  - So fearful patients in our trial did that
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  - as a first step of treatment,
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  - and if they decreased enough in fear after
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  - doing that, we said, okay. Go to the
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  - dentist, you know, see how you do now
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  - with some of these new coping strategies.
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  - If they were still fearful after completing the
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  - app, which we tended to see in our
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  - most phobic patients,
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  - we offered them an individualized
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  - one on one session with a psychologist
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  - or a licensed clinical social worker on our
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  - team who has this specific training in dental
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  - care.
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  - And they we spent an hour together and
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  - really tailored that session to their individual fears
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  - and needs and worked through them.
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  - We were originally doing this in partnership with
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  - some dentists and doing these visits in person
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  - in dental operatories, you know, trying to take
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  - up an hour instead of three or four
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  - hours of chair time.
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  - But, actually, as COVID happened, there was a
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  - lot of interest in us pivoting to telehealth,
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  - which we eventually figured out. So these one
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  - hour visits became virtual, but really immersive opportunities
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  - using a lot of kind of visual effects,
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  - you know, sounds,
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  - really trying to get that person exposed to
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  - some of those
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  - sensations
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  - and, stimuli that you would encounter at the
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  - dental office.
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  - And
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  - so we did, you know, some of these
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  - visits in person, some of them over telehealth,
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  - and we didn't see a difference actually in
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  - how effective that was. And overall through this
• 10:19
  - study, almost half of our sample wasn't didn't
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  - have any dental anxiety
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  - at all following treatment, and we saw,
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  - some significant reduction in fear for virtually everyone.
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  - In addition, when patients reported back after going
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  - to the dentist,
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  - the majority of them said that
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  - or eighty five percent of them, yeah, reported
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  - that the appointment had gone way better than
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  - they had worried about and sixty percent reported
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  - that the fear they experienced was less intense
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  - intense than they thought it would be. So,
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  - basically, our goal here is to help people
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  - see that either their dental fear is unrealistic
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  - or learn that they can tolerate going and
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  - get through it and it's not as bad
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  - as they think. So the pilot was pretty
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  - promising to us in terms of our ability
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  - to do that and get these treatment principles
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  - that had been pretty cloistered in specific locations
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  - out there to people.
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  - Great. And can you tell me a little
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  - bit about how NYU plans to continue the
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  - research long term and what does the next
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  - phase of research look like?
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  - Yeah. So currently, we're running a nationwide RCT
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  - that provides free remote treatment to fearful patients,
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  - based on this model.
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  - So, basically, we're taking this pilot. It's all
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  - virtual now. No in person component.
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  - That two step treatment, you know, some people
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  - get
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  - the apps, some people get the app plus
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  - the individualized one on one tele telehealth appointment,
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  - and we're doing this, you know, nationwide
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  - for the next few years to try to
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  - get a really big study to show us,
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  - you know, can this work at scale? Can
• 11:50
  - this be something that is really helpful?
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  - Because it's an RCT, not everybody does receive
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  - the treatment, but people are compensated
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  - for completing some questionnaires about their fear every
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  - four to six months, and at the end
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  - of the study everybody is offered the treatment
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  - anyway.
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  - Great.
• 12:08
  - And I'm super interested to hear your thoughts
• 12:09
  - on this next question. What does the dental
• 12:11
  - industry still get wrong about managing anxious patients?
• 12:16
  - Yep. You know what? I should have plugged
• 12:17
  - the website for the study. Sorry. For anybody
• 12:20
  - who wants to,
• 12:22
  - anybody who wants to refer to us, you
• 12:24
  - know, any dentist or staff who wanna refer
• 12:26
  - to us or, you know, learn more or
• 12:29
  - contact our team can go to www.dentalfearless.com.
• 12:34
  - Great.
• 12:35
  - And what does the industry still get wrong
• 12:36
  - about managing anxious patients?
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  - So this idea that if you can't see
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  - anxiety, it doesn't exist,
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  - and also this kinda not my patients bias,
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  - which we see, and, you know, all health
• 12:49
  - care providers, psychologists have this too. There have
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  - been lots of studies where, you know, it's
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  - ninety five percent of people rate themselves above
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  - average in terms of the care they provide.
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  - Right?
• 12:59
  - So the not my patients bias is kind
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  - of dental practitioners saying, yeah, I know this
• 13:04
  - is a thing. I know it's common. I
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  - know it's, you know, about one in four
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  - or one in five people, but not at
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  - my practice.
• 13:10
  - You know? I I my care is kind
• 13:12
  - of so good and comprehensive that we don't
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  - see it at all.
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  - And that's something we're all vulnerable to as
• 13:18
  - health care practitioners, but kind of being aware
• 13:20
  - of that bias and learning to look out
• 13:24
  - for,
• 13:25
  - kind of different ways that anxiety
• 13:28
  - manifests in patients and what that experience can
• 13:30
  - be like.
• 13:32
  - Okay. Yeah. That's really interesting. Do you think
• 13:34
  - it's almost better to assume that every patient
• 13:36
  - has anxiety than to assume that none do?
• 13:40
  - I would say yes.
• 13:42
  - That's it's actually interesting because
• 13:45
  - something that, you know, we really recommend is
• 13:47
  - just ask. Right?
• 13:49
  - Screening patients saying, hey. Do you have any
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  - fear?
• 13:53
  - There's this misconception and, you know, we see
• 13:56
  - this kind of across health. Right? There was
• 13:58
  - a long time, a lot of fear mongering
• 14:01
  - about assessing suicide in adolescents. Right? This idea
• 14:04
  - that, oh my god, if I ask, I'm
• 14:06
  - gonna give them the idea.
• 14:08
  - And there's the same thing we've seen among
• 14:10
  - dentists where they say, well, if I bring
• 14:11
  - up anxiety, then they're gonna feel anxious, and
• 14:14
  - there's so much research that has debunked that.
• 14:17
  - When you say, hey. I just wanted to
• 14:19
  - know, do you have any do you experience
• 14:21
  - any fear or anxiety? What you're doing is
• 14:23
  - really validating that person. You're not putting it
• 14:25
  - in their head. If they're gonna have anxiety,
• 14:26
  - they're gonna have anxiety. But by acknowledging it,
• 14:29
  - you kind of normalize it and give that
• 14:31
  - person space to say, oh, okay. It's okay.
• 14:33
  - You know, this this is not just me.
• 14:35
  - There's a lot of guilt actually that people
• 14:38
  - carry around, especially adults saying,
• 14:40
  - you know, I'm in my forties. What's wrong
• 14:42
  - with me? How am I afraid of the
• 14:44
  - dentist? Like, I'm I feel ridiculous.
• 14:47
  - So,
• 14:48
  - in addition to feeling kind of really
• 14:50
  - apprehensive about the whole appointment,
• 14:52
  - people carry around a lot of shame too
• 14:54
  - and just just asking, just making it part
• 14:57
  - of your normal practice to check-in with patients
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  - and ask
• 15:01
  - can be so empowering to those patients who
• 15:04
  - are fearful,
• 15:05
  - and that alone
• 15:06
  - can can start to make them more comfortable.
• 15:09
  - Super helpful. In terms of, additional advice,
• 15:13
  - what would
• 15:14
  - you advise practices,
• 15:16
  - that want to improve in this area maybe
• 15:19
  - immediately, but don't know initially, like, where to
• 15:21
  - start?
• 15:23
  - Yeah. So I think some empathy and perspective
• 15:25
  - taking can go a long way. When dentists
• 15:27
  - use your entire life,
• 15:29
  - people being afraid can almost feel kind of
• 15:31
  - silly. Right? Because it's like, no, I do
• 15:33
  - this all day long. I know what I'm
• 15:34
  - doing.
• 15:35
  - But there is something almost everyone dreads or
• 15:38
  - is afraid of. One of the dentists I
• 15:40
  - really adore who I work with always gets
• 15:43
  - slightly anxious and lightheaded when she has to
• 15:45
  - have blood drawn, for example, and she discloses
• 15:47
  - this to her patients as a way to
• 15:49
  - normalize their fear
• 15:51
  - and really uses it as a way to
• 15:53
  - put herself in their heads and think about,
• 15:55
  - okay, when I go for that blood draw
• 15:57
  - and I know that I feel kind of
• 15:58
  - boozy and I feel kind of light headed
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  - and I am, you know, thinking those those
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  - not so good thoughts,
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  - What makes me comfortable if a phlebotomist or
• 16:07
  - or a nurse does that or says that?
• 16:09
  - So just really kind of thinking about your
• 16:11
  - own fears or or your own,
• 16:15
  - situations that evoke anxiety in you and thinking
• 16:17
  - about what you need, I think can be
• 16:19
  - so helpful in terms of your empathy and
• 16:21
  - the way you communicate.
• 16:23
  - In addition, you know, as I mentioned before,
• 16:26
  - just asking patients, being comfortable talking about it.
• 16:29
  - We know that asking and talking about it
• 16:31
  - doesn't cause it, but it does validate the
• 16:34
  - people
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  - who, you know, who feel it and starts
• 16:37
  - to normalize it. And when you start to
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  - have those conversations,
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  - then you can talk with patients about what
• 16:43
  - might make them more comfortable or what are
• 16:45
  - those things that, you know, they're super afraid
• 16:47
  - are gonna happen to try to dispel some
• 16:49
  - of those fears.
• 16:51
  - Alright. Well, that is all I have for
• 16:52
  - you today, doctor Daly. Thank you so much
• 16:54
  - for joining us today. It was a pleasure
• 16:55
  - speaking with you and looking forward to connecting
• 16:57
  - with you again in the future. Yeah. Thank
• 16:59
  - you so much for having me.