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Anxiety prevention: Implementing the 4 S principle in conservative dentistry

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24 auxiliary September/October 2007
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High levels of dental anxiety is a problem that
many dental patients experience. Most
recent studies in the international literature
show that the prevalence of severe dental anxiety is
approximately one in every 7 adults, and the same
rate was documented in Australian adults in a 2006
telephone interview survey.1Most studies also show
that females in the middle adult years have the
highest prevalence, which also is true in Australia.
Known effects of dental anxiety are many (Table 1)
and impact upon the dental practice as well as upon
the individual patient. Altered patterns of care are
perhaps the most obvious impact of dental anxiety
with disease having progressed to a stage too late
for conservative measures to be effective. A
surprising statistic from 2006 is that only 25% of
visits in private general practice in Australia were
for recall or maintenance - the same percentage as
for treatment of dental caries as the presenting
problem!2This figure was not greatly different from
the Brisbane Statistical District Survey of Adult
Dental Health conducted in 1984,3in which the
author participated as a field clinical examiner.
Clearly, dental anxiety has not altered significantly
over the quarter century period.
Severe dental anxiety is a multifaceted problem
with no one common single causal factor in all
patients (Table 2), although for most patients the
stimuli for dental fear are sensory in nature. By
focussing on these stimuli, the clinician aims to
reduce the anxiety response at its sources, as
opposed to dulling the response pharmacologically
or by using distraction methods. The 4 S principle
is based on removing four of the major sensory
triggers for dental anxiety, and it is used in con-
junction with other measures to mitigate anxious
behaviours and their consequences.
The 4 S Principle is to reduce the 4 primary trig-
gers of stress when in the dental setting, namely:
Smells (e.g. eugenol and cut dentine);
Sights (e.g. needles, air turbine drills);
Sounds (drilling); and
• Sensations (high frequency vibrations - the
annoyance factor).
Anxiety prevention:
implementing the 4 S principle
in conservative dentistry
By Professor Laurence J. Walsh
“for most
patients the
stimuli for dental
fear are sensory
in nature. By
focussing on
these stimuli,
the clinician
aims to reduce
the anxiety
response at its
sources...”
Table 1. Consequences
of severe dental anxiety
Avoidance of dental treatment
Cancellation of appointments
Greater economic risk for the practice
Poor compliance with follow-up treatment
Negative expectations of treatment visits
Longer time required for dental treatment
Higher caries prevalence and severity (DMFT)
Greater need for oral rehabilitation
Poor oral health
Reduced self confidence
Feelings of shame and inferiority
Negative thoughts
Sleep disturbances
Crying and aggression
Lower satisfaction with treatment provided
Table 2. Causes of dental anxiety
Fear of pain
Fear of loss of control
Conditioning experiences, such as past trau-
matic dental experiences in childhood Influence
of dentally anxious family members or peers
Sights, sounds and sensations of the dental drill
Sights and sensations of dental local anaes-
thetic injections
Angry and aggressive dental staff
September/October 2007 auxiliary 25
A range of approaches can be used for
this, and they can be mixed and matched to
meet the particular needs of the situation.
Table 3 shows four commonly used alterna-
tive methods for dental restorative care
(Ultra-low speed cutting, atraumatic restora-
tive treatment (ART) with hand instruments,
chemo-mechanical caries removal with
Carisolv, and Erbium lasers), each of which
reduces the smells, sights, sounds and sensa-
tions experienced during restorative dental
care. This list is not meant to be exclusive, as
there are other approaches that could equally
be included, for example polymer bur cut-
ting, air abrasion (alumina powder streams),
particle streams in fluid media (e.g. Durr
Vector ultrasonic with silicon carbide parti-
cles in a fluid medium), and ultrasonic tips
coated with diamond particles.
To these methods should be coupled
effective communication with patients,
expressing sympathy and providing reas-
surance. The next higher level of
intervention is training in relaxation and
breathing techniques. In the most severe
cases, these measures can be used after
providing pharmacological support by
conscious sedation techniques including
oral, inhalation and intravenous sedation.
Relaxation techniques are safe, have no
side effects and give patients control over
their anxiety levels. Like the 4 S methods,
they work by eliminating or reducing the
problem at its cause.
Ultra-low speed cutting leverages the
reduced physical properties of infected car-
ious dentine with its broken and degraded
collagen crosslinks. A slow rotating instru-
ment (e.g. 200 rpm with a #3 or #5 round
bur) will remove this dentine but will not
cut sound dentine to any great extent. This
non-viable dentine has no viable odonto-
blast processes and can also be excavated
by hand (as in the ART method), although
care must be taken that the excavator is
used with a whisking action so that exces-
sive penetration pulpally does not occur.
Patients who are not given LA and undergo
ultralow speed cutting or ART provide
interesting feedback on the experience. In a
classic study in 1987, Ken Anusavice4
(who in the same year authored the interna-
tional guidelines on indications for placing
and replacing restorations) in Florida con-
ducted an intriguing clinical study in which
some 47 patients who were not given an
LA injection underwent restorative care.
Some 34 of these (72%) did not request
local anaesthesia for treatment, although
nearly half (47%) experienced pain. Cut-
ting or removing infected carious dentine,
however, elicited little or no painful sensa-
tions, even though the patients could in
some cases sense diffuse low frequency
vibrations. The pain which was reported
occurred once vital affected or sound den-
tine was cut. The nature of the pain (sharp,
well localized, pin-prick) belies the fact
that the tissue being cut is vital - and there-
fore amenable to healing. This begs the
question, should dentine that can heal be
cut away in the first place?
The same minimal intervention philos-
ophy underlies the chemo-mechanical
caries removal method. This targets col-
lagen in infected dentine because of its
broken crosslinks, which are susceptible
to proteolysis by sodium hypochlorite
and chloramines.5,6
Laser technology for caries removal in
anxious dental patients has been in use for
more than 20 years.7Avoidance of the under-
lying affected and healthy vital dentine is
possible because of selective photo-mechan-
ical and photo-acoustic effects that occur
because of the volume expansion of rapidly
heated water within the carious dentine.8
Typically, patients undergoing cavity prepa-
ration with erbium lasers do not need local
anaesthesia, a fact established from large
scale clinical trials, in which only 2-5% of
patients requested LA - even though many
noted slight, intermittent sensations of
cooling or vague shock-like sensations
during laser pulses. There is a short-term
analgesic effect created by the laser which
attenuates these responses in most cases.
Using one of these four alternative
methods of caries removal (or others), the
clinician can apply the 4 S principle for
restorative care in dentally anxious adult
and child patients. As can be seen from
Blood-injury fear
Dentist/Staff
Communication
techniques/skills
(condescending remarks,
bad comm’s skills)
Bad Manners
Angry Dentist/ Staff
Unsympathetic/
non-supportive staff
Negative dental
team behaviours
(unfriendly, unaccepting
or reassuring)
Place
Sounds of drills
Smell
Waiting room (lay out
and design, content)
Waiting period
Sounds of
screaming patient
Procedure
Sight of needle
Sensation of drill
Extraction
Root Canal Treatment
Scaling and root planing
Fillings and
crown preparations
Gag-inducing
procedures
Patient
Fear of pain
Vicarious learning
(fearful family members,
bad stories from
friends, movies)
Past trauma and
dental experience
(Conditioning
experiences)
Personality
characteristics:
e.g: neuroticism
Figure 1. Some possible interactions in factors relating to dental anxiety. Adapted from Reference 9.
26 auxiliary September/October 2007
Table 3, these methods vary in their
implementation but can all achieve a more
pleasant patient experience. If we con-
sider the high number of patients who
currently avoid dental care, the impact of
using these methods on those population
subgroups can be very significant - as well
as being professionally worthwhile.
References
1. JM Armfield, AJ Spencer, JF Stewart. Dental fear in
Australia: who’s afraid of the dentist? Australian
Dental Journal 2006; 51(1): 78-85.
2. Brennan DS, Spencer AJ (ARCPOH). Practice pro-
files of Australian private general dental practitioners
Australian Dental Journal 2006; 51(1):91-93, 2006.
3. Powell RN, McEniery TM. The Brisbane Statistical
Division Survey of Adult Dental Health 1984. 2. Soci-
ological aspects of the survey. ADJ 1988; 33(1):14-17.
4. Anusavice KJ, Kincheloe JE. Comparison of pain asso-
ciated with mechanical and chemomechanical removal
of caries. J. of Dental Research 1987; 66(11):1680-1683.
5. Ericson D, Zimmerman M, Raber H, Gotrick B,
Bornstein R, Thorell J. Clinical evaluation of efficacy
and safety of a new method for chemo-mechanical
removal of caries. A multi- centre study. Caries
Research 1999; 33:171-177.
6. Maragakis GM, Hahn P, Hellwig E. Chemomechanical
caries removal: a comprehensive review of the literature.
International Dental Journal 2001; 51:291-299.
7. Hibst R, Keller U. Experimental studies of the
application of the Er:YAG laser on dental hard sub-
stances: I. Measurement of the ablation rate. Lasers in
Surgery and Medicine 1989; 9:338-344.
8. Walsh LJ. The current status of laser applications in
dentistry. Australian Dental Journal 2003; 48:146-155.
9. Hmud R, Walsh LJ. Dental anxiety: causes, compli-
cations and management approaches. International
Dentistry, 2007. In press.
About the author
Professor Laurence J. Walsh is the tech-
nology editor of Australasian Dental
Practice magazine. He has worked in
clinical practice in special needs dentistry
for the past 20 years and contributed to
the development of preventive protocols
for special needs patients.
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Table 3. Comparison of four approaches from the 4S perspective
Parameter Ultra-low ART with Carisolv Erbium lasers
speed cutting hand instruments
Reduced need for injected LA Yes Yes Yes Yes
Dominant physical sensations Low freq. vibration Scraping Scraping Popping: shock waves
Likelihood of odontoblastic Moderate Low Very low to nil Very low to nil
pain during caries removal
Basis of selectivity for Lack of Lack of Lack of Increased water
infected carious dentine collagen crosslinks collagen crosslinks collagen crosslinks content
(shear strength) (shear strength) (chemical reaction) (ablation threshold)
Suppressed nociceptor firing No No Possibly, because Yes
of low pH (analgesic effect)
Annoyance factor during Low Low Low Very low
restorative treatment
Dentine ablation
Smell and vapours Dentine cutting Nil Hypochlorite vapour if suction
and chloramines inadequate;
typically nil
Cost of implementation Nil, as existing Nil, as regular Low. Gel is stored Medium to
in terms of equipment burs and low speed spoon excavators refrigerated and high for initial
handpieces are used are used mixed when needed purchase
Tactile sense Yes Yes Yes No, unless
sapphire tips used
Conservative Conservative Gel has no effect Laser will remove
Accessing the carious dentine access form access form on sound tooth structure resin and GIC,
or restorations but not amalgam
Learning curve Low Low Low Medium
Ancillary guides Patient response Patient response Loss of opacity Ablation sound, change
for caries removal in the gel change in fluorescence
Speed of dentine removal Medium Low Low Medium to high
Suitable for adhesive Ye s Ye s Ye s Ye s
materials such as GIC
Antibacterial action No No Yes (sodium Yes (photothermal
hypochlorite) ablation)
... For this reason, the "4S" rule, which is based upon the removal of four of the major primary sensory triggers-sound (drilling), sight (air turbine drill), smell, and sensation (high-frequency vibrations) is used. [1][2][3][4][5][6][7][8] The idea of substituting the drill with Erbium family lasers helps pediatric dentists in the treatment of the hard and soft tissues of the oral cavity safely and efficiently. The Er,Cr:YSGG laser (2780 nm) has proven to be an effective tool for ablating enamel and dentine. ...
... Dental anxiety can be coped with by removing four major primary sensory triggers-sound (drilling), sight (air turbine drill), smell, and sensations (high-frequency vibrations). [1][2][3][4][5][6][7][8] In the present study, pulse rate was found to be significantly higher after the cavity preparation with airotor when compared to the baseline pulse rate. However, no significant difference in pulse rate was observed before and after cavity preparation with the laser. ...
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Aim: To evaluate and compare the pain perception, anxiety level, and acceptance of Er,Cr:YSGG laser (2780 nm) with a conventional rotary method during cavity preparation in children. Materials and methods: In a randomized controlled trial, using split-mouth design thirty 6- to 12-year-old children with 60 carious molars were examined. In one quadrant, cavity was prepared conventionally by airotor while, in the other quadrant, Er,Cr:YSGG laser was used. Anxiety was assessed by measuring pulse rate using a fingertip pulse oximeter, while the pain was measured on the Wong-Baker Faces Pain Rating Scale. After the cavity preparation by both the methods, the child was asked about the preference for future treatment of a carious lesion. Results: Pulse rate was found significantly higher in the airotor group but no significant difference in pulse rate was found in the laser group when compared to the baseline pulse rate. The mean value of pain in the airotor group was slightly higher than the laser group. Fifty-seven percent of children preferred Er,Cr:YSGG laser for cavity preparation in the future. Conclusion: During cavity preparation, Er,Cr:YSGG laser comes out to be more effective and acceptable, as it is less anxiety-provoking and may cause less pain when compared with the airotor. Clinical significance: Er,Cr:YSGG laser helps the children to remain calm during the cavity preparation. How to cite this article: Alia S, Khan SA, Navit S, et al. Comparison of Pain and Anxiety Level Induced by Laser vs Rotary Cavity Preparation: An In Vivo Study. Int J Clin Pediatr Dent 2020;13(6):590-594.
... Despite the revolutions in dental technologies and materials and improved knowledge, a significant percentage of patients still suffer from dental anxiety [6]. This anxiety includes apprehension regarding dentistry and receiving dental care, which normally leads to the avoidance of dental treatment and poor oral health and may cause the deterioration of oral health-related quality of life [7][8][9]. Many investigators have reported that anxious patients have worse periodontal health, fewer filled teeth, and more decayed and missing teeth than non-anxious patients do [10][11][12]. ...
... Many researchers have concentrated on studying dental anxiety in university students [27][28][29][30][31][32][33][34][35][36][37], and the incidence of anxiety ranges from 11% to 27.5% among students at different universities globally [38][39][40]. Higher dental anxiety has been reported in non-dental students than in dental students, which might be because of inadequate dental health education, which leads to high dental anxiety among undergraduate students from non-dental colleges [27][28][29], and additional decreases in dental anxiety have been revealed among dental students during the course of their dental training [9], [41]. Therefore, for these students, it is necessary to study procedures that can assist them in overcoming such anxiety [28]. ...
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The aim was to investigate the dental anxiety and fear levels among students and its relation with their field of study and gender. This cross-sectional study included 720 (360 females and 360 males) which recruited from the collages of Dentistry and Humanities and Social Science in University of Science and Technology in Sana'a, Yemen. Corah's Dental Anxiety Scale (DAS) and Dental fear survey (DFS) was used to measure dental anxiety and fear among the study population. Spearman's correlation was used to analyze the association among the dental anxiety measurements or between DAS and DFS tests. Chi-square tests and linear regression analyses were used to determine the associations between dental anxiety or fear and contextual variables. Out of 720 students enrolled, 713 students (354 males and 359 females) completed and returned the questionnaire having response rate of 99.03%. The association between dental anxiety measurements or the DAS and DFS were statistically significant (p < 0.01). Dental students were less anxious and fear than humanities and social sciences students (p < 0.05). Females were more anxious and fear than males (p < 0.05). Dental anxiety and fear was more associated with female than other contextual variables [for fear (OR = 1.14, p = 0.001); for anxiety (OR = 1.90, p = 0.001)]. Dental anxiety was found to be related to dental fear. Male students were less anxious and fear than female students. Students from medical background faculties were less anxious and fear.
... Sensory-based methods of stress and anxiety management have been proposed to decrease DFA in dental patients. For example, the "4S principle" aims to reduce four triggers of DFA in the environment: sights (e.g., needles and drills), sounds (e.g., drilling), sensations (e.g., vibrations), and smells (e.g., clinical odors) [269,270]; however, this intervention has not yet been studied. The utilization of other sensory-based interventions during dental care has been investigated, with most reporting preliminary success. ...
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Dental fear and anxiety (DFA) is common across the lifespan and represents a barrier to proper oral health behaviors and outcomes. The aim of this study is to present a conceptual model of the relationships between DFA, general anxiety/fear, sensory over-responsivity (SOR), and/or oral health behaviors and outcomes. Two rounds of literature searches were performed using the PubMed database. Included articles examined DFA, general anxiety/fear, SOR, catastrophizing, and/or oral health behaviors and outcomes in typically developing populations across the lifespan. The relationships between the constructs were recorded and organized into a conceptual model. A total of 188 articles were included. The results provided supporting evidence for relationships between DFA and all other constructs included in the model (general anxiety/fear, SOR, poor oral health, irregular dental attendance, dental behavior management problems [DBMP], and need for treatment with pharmacological methods). Additionally, SOR was associated with general anxiety/fear and DBMP; general anxiety/fear was linked to poor oral health, irregular attendance, and DBMP. This model provides a comprehensive view of the relationships between person factors (e.g., general anxiety/fear, SOR, and DFA) and oral health behaviors and outcomes. This is valuable in order to highlight connections between constructs that may be targeted in the development of new interventions to improve oral health behaviors and outcomes as well as the experience of DFA.
... According to the concept of MID, the so-called "4S" principle as a minimally invasive approach in behavioral dentistry is developed. It is based on removing four of the major primary sensory triggers for dental anxiety when in dental settingsight (air turbine drill), sounds (drilling), sensations (high-frequency vibrations), smells [3,4]. It is used most commonly in conjunction with other alternative methods to mitigate anxious behaviors and their consequences. ...
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Dental caries is the most common chronic dental disease in the world. It is defined as a multifactorial microbial infectious disease characterized by demineralization of the inorganic and destruction of the organic substance of the tooth. Conventional treatments for caries removal are often associated with pain and fear. Minimally invasive treatment offers an attractive alternative to managing carious lesions in a more conservative and effective manner, resulting in enhanced preservation of tooth structure. The aim of this review article is to analyze the scientific literature regarding the alternative therapeutic approach to the caries lesion management. A search was performed to summarize the evidence behind the alternative methods for caries removal, including the use of air abrasion, lasers, ultrasonic devices, polymer burs, At-raumatic restorative technique, chemo-mechanical caries removal, and their advantages and disadvantages to be discussed. The findings of the literature review give grounds to undertake studies investigating the efficiency of the different methods for caries removal. Future explorations will be interesting as the profession begins adopting the alternative caries management strategies that may decrease the use of behaviour management techniques in the treatment of paediatric dental patients.
... Medical procedures cause a feeling of fear, inability, as well as anxiety 2 . It can be provoked due to multiple factors, such as previous negative or traumatic experience, sensory triggers such as sights of needles and air-turbine drills, sounds of drilling and screaming, vicarious learning from anxious people, patients' personality characteristics and their coping strategies [3][4][5][6][7][8] . ...
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A range of lasers is now available for use in dentistry. This paper summarizes key current and emerging applications for lasers in clinical practice. A major diagnostic application of low power lasers is the detection of caries, using fluorescence elicited from hydroxyapatite or from bacterial by-products. Laser fluorescence is an effective method for detecting and quantifying incipient occlusal and cervical carious lesions, and with further refinement could be used in the same manner for proximal lesions. Photoactivated dye techniques have been developed which use low power lasers to elicit a photochemical reaction. Photoactivated dye techniques can be used to disinfect root canals, periodontal pockets, cavity preparations and sites of peri-implantitis. Using similar principles, more powerful lasers can be used for photodynamic therapy in the treatment of malignancies of the oral mucosa. Laser-driven photochemical reactions can also be used for tooth whitening. In combination with fluoride, laser irradiation can improve the resistance of tooth structure to demineralization, and this application is of particular benefit for susceptible sites in high caries risk patients. Laser technology for caries removal, cavity preparation and soft tissue surgery is at a high state of refinement, having had several decades of development up to the present time. Used in conjunction with or as a replacement for traditional methods, it is expected that specific laser technologies will become an essential component of contemporary dental practice over the next decade.
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This study aimed to describe both the prevalence of dental fear in Australia and to explore the relationship between dental fear and a number of demographic, socio-economic, oral health, insurance and service usage variables. A telephone interview survey of a random sample of 7312 Australian residents, aged five years and over, from all states and territories. The prevalence of high dental fear in the entire sample was 16.1 per cent. A higher percentage of females than males reported high fear (HF). Adults aged 40-64 years old had the highest prevalence of high dental fear with those adults aged 80+ years old having the least. There were also differences between low fear (LF) and HF groups in relation to socioeconomic status (SES), with people from higher SES groups generally having less fear. People with HF were more likely to be dentate, have more missing teeth, be covered by dental insurance and have a longer time since their last visit to a dentist. This study found a high prevalence of dental fear within a contemporary Australian population with numerous differences between individuals with HF and LF in terms of socioeconomic, socio-demographic and self-reported oral health status characteristics.