1. Stress Reduction Protocol
in Dentistry
Dr Neil Pande
BDS MFGDP(UK) MFDS RCS(Eng)
General Dental Practitioner
Kathmandu, Nepal
www.smilenepal.com

2. Stress
a physical, chemical, or emotional factor that
causes bodily or mental tension and may be a
factor in disease causation
factors that tend to alter an existent equilibrium
Cause of 3/4 Medical Emergencies in Dentistry

3. Stages of Stress Response
Hans Selye
Stage 1: One of the Five senses sends stimuli to
the brain
Stage 2: Brain analyzes it as a ‘Threat’ or ‘No
Threat’
Stage 3: Body aroused until threat is over
Stage 4: Body returns to homeostasis (calm) once
threat is gone.

4. Anxiety:Stress
Release of epinephrine, nor-epinephrine
Heart Rate
Blood Flow
Respiration
Vasodilatation in the periphery (arms and legs)
Serum Glucose Level

5. Signs of Acute Anxiety
Cold, sweaty palms or forehead
Flushing of face
Altered facial expression such as bulging
eyebrows
Dry mouth or increase in salivation
Bruxism or clenching of teeth
Increased need to urinate
Unnaturally stiff posture

6. Acute Anxiety
Inability to sit still
Trembling or tremors
Fiddling with items in his or her hands
“White-knuckle” syndrome
Tapping feet or fingers
Crying out or moaning
Hyperventilation, syncope, nausea, or vomiting
Increased respiration, blood pressure, and heart
rate

7. Stress Reduction in
Dentistry
Pre-Treatment Peri-Treatment Post-Treatment
Medical History Iatrosedation
Written Instructions
ASA PS Relaxation Tech
Anxiety Reduction Music, Aroma,
Analgesics
MDAS Massage
Proper Rest / Diet
Transportation Hypnosis
Follow-up Telephone
Medication Acupuncture
Short Morning Local Anaesthetic
Referral, if needed
Appointment followed by Topical

8. First Consultation
Get to know the patient
Try to befriend him/her
Thorough Medical History
Written
Verbal (Re-enforced)
Discuss likes and dislikes, acknowledge feelings
Empathy
Understand him/her well - it’s a long term affair...

9. Medical History
Written, signed and verbal
Categorization as per ASA PS Score
ASA I A normal healthy patient
ASA II A patient with mild systemic disease
ASA III A patient with severe systemic disease
ASA IV A patient with severe systemic disease
that is a constant threat to life
Check vitals

10. Communication
Let them talk
Be a good listener
Show interest in their conversation
At an eye level
Away from the equipment

11. Examination
Do a thorough check-up including; examination of
Extra-oral: TMJ, Lymph Nodes, abnormalities (A
gentle palpation of the area ensuring that you
care.)
Intra-oral: Soft Tissues
Occlusion
Periodontal Tissues
Teeth

12. Diagnosis and Treatment Plan
Try to find the cause of the problem and discuss with
patient rather than just trying to pick up that handpiece...
Make a preventive programme for the patient
Make a comprehensive treatment plan in phases
Emergency
Stabilization
Maintenance
Definitive

13. Modified Dental Anxiety Scale
MDAS
Helps us to recognize the level of anxiety in
patients
Plan treatment accordingly

14. Anxious Patient
Short Morning Appointment followed by a good
morning breakfast
Pre-medication with Lorazepam 1mg (check
interaction with other drugs) night before sleep
followed by 90 minutes prior to procedure
No driving
Need to be accompanied by friend/relative/
escort
Extremely short or no waiting time in the waiting
area

15. During the treatment
Duration, only as much as patient can tolerate
Making sure patient feels he/she is in command
Better to have a short and simple procedure first
to gain patient’s confidence
Pain free
Topical Gel
Local Anaesthetics with 30G needle, slow, warm
Iatrosedation

16. Iatrosedation
Vocal
Music Relaxation Techniques
Aroma Deep Breathing
Massage Guided Imagery
Hypnosis Progressive Relaxation
Acupuncture

17. Vocal Sedation
“I will be careful.”
“You may feel a slight sting.”
“I will make the area numb so that it is comfortable
for both, you and me.”
“I will apply this strawberry surface anesthetic first
and you will hardly feel anything.”
“I am slowly putting some solution inside so that
you will not feel a thing.”

18. Vocal Sedation
Avoid “needle”, “hurt”, “sharp”
Talk to them as you go through the procedure.
It will make them feel more relaxed and compliant.

19. Post Treatment
Clear verbal and written instructions
Pain control medications
Phone number of the treating doctor (to call in
case of emergency)
Protocol for referral if needed

20. Friend for life...
Relationship between a patient and a dentist is the
one that is made for life.
Helping people in making their quality of life,
better...
You treat patients well, and they will treat you well.
Respect is a 2 way street. You get what you give...

21. MDAS Scale
CAN YOU TELL US HOW ANXIOUS YOU GET, IF
AT ALL,
WITH YOUR DENTAL VISIT?
PLEASE INDICATE BY INSERTING ‘X’ IN THE
APPROPRIATE BOX

22. 1. If you went to your Dentist for TREATMENT
TOMORROW, how would you feel?
Not Slightly Fairly Very Extremely
Anxious Anxious Anxious Anxious Anxious
! ! ! ! !
2. If you were sitting in the WAITING ROOM (waiting for
treatment), how would you feel?
Not Slightly Fairly Very Extremely
Anxious Anxious Anxious Anxious Anxious
! ! ! ! !

23. 3. If you were about to have a TOOTH DRILLED, how would you
feel?
Not Slightly Fairly Very Extremely
Anxious ☐ Anxious ☐ Anxious ☐ Anxious ☐ Anxious ☐
4. If you were about to have your TEETH SCALED AND
POLISHED, how would you feel?
Not Slightly Fairly Very Extremely
Anxious ☐ Anxious ☐ Anxious ☐ Anxious ☐ Anxious ☐
5. If you were about to have a LOCAL ANAESTHETIC
INJECTION in your gum, above an upper back tooth, how
would you feel?
Not Slightly Fairly Very Extremely
Anxious ☐ Anxious ☐ Anxious ☐ Anxious ☐ Anxious ☐

24. Instructions for scoring
The Modified Dental Anxiety Scale. Each item scored as
follows:
Not anxious = 1
Slightly anxious = 2
Fairly anxious = 3
Very anxious = 4
Extremely anxious = 5
Total score is a sum of all five items, range 5 to 25: Cut
off is 19 or above which indicates a highly dentally
anxious patient, possibly dentally phobic.