Introduction

Dental journals have long contained articles relating to the stress experienced by dentists1,2,3,4 and recently there has been a focus on the stress experienced by dental students.5,6,7 But, what about the patients?

This paper aims to consider ways in which the use of trained counsellors as part of the dental team could enhance the experience for the patient, allow better treatment by the team and distinguish between the patient who is genuinely nervous and one who has a dental phobia which may be a symptom of a deeper psychological disturbance.

The unpleasantness of dentistry seems to be generally accepted8 and may date back to the barber surgeons of the seventeenth and eighteenth centuries when teeth were extracted without anaesthesia and the rich had teeth implanted into their empty sockets from the poor.9 Indeed this was one of the fates experienced in Victor Hugo's original version of 'Les Miserables';10 as well as selling her hair and her virtue, the heroine also sold her teeth. When teeth were extracted without anaesthetic a drum was banged to drown the patient's screams.11 Until the middle of the twentieth century it was common, in the North of England, for young women to have their teeth extracted and dentures fitted before marriage;12 this pattern is still reflected in the varying levels of edentulousness in different parts of the UK.13,14 Since for generations dentistry has had unpleasant connotations perhaps it is not surprising that the stigma remains and still many people fear a visit to the dentist.

It could be argued that this perception is because dentistry is so painful. But, the anaesthetic use of nitrous oxide was developed in 1844 by Horace Wells a dental surgeon of Hartford, Connecticut, USA, to alleviate pain experienced during removal of a third molar15 and, with the development of local anaesthesia, pain experience should be minimal if not non-existent. Yet still many people dread a visit to the dentist even if, as in the less caries prone younger generation, they have not experienced dental treatment.

The psychological importance of the oral cavity relates back to embryological development; the oral tissues develop by week 7 in utero and often the foetus can be seen on ultrasound sucking his/her thumb.16 After birth, suckling and maternal bonding are recognised as important by psychologists.17 The mouth assumes importance in relationships through the range of facial expressions exhibited by the muscles of facial expression, mouth and lips — smiling, anger, shyness etc.18 Non-verbal activity provides up to 65% of the information in human communication,19 much through facial expression. In the most intimate relationships, kissing and use of the oral cavity play a crucial role. Since dentistry is performed in a highly sensual area of the body perhaps it is not surprising that patients feel vulnerable during treatment and may suffer from dental anxiety — fear of the treatment per se — or from dental phobias where the problem may relate to deeper psychological problems.

Childhood experiences are important. If parents do not provide a good diet or encourage tooth-cleansing, the first experience of dentistry may be of extractions under general anaesthesia (GA). Where parents are apprehensive, this may cause the child, sensing the parents' stress, to become frightened in turn. The use of phrases like: 'I'm not going to hurt you' or, 'the dentist isn't going to hurt you' do not reassure but implant the idea of pain in addition to fear. Once an individual has had a negative experience, the likelihood of their readily seeking dental treatment in the future is slim. A nervous child is unable to differentiate between pain caused by the illness and that caused by a doctor or dentist while performing a clinical task; some of this pain may be real and some psychological due to fear.20 If first experiences can occur in an informal and relaxed setting the individual is more likely to accept future dental treatment and possibly might enjoy it.

In the school and teen years children are dependent on their parents and may not receive regular check-ups if the parents are afraid. It is therefore important that nursing mothers are educated so that children have the best 'dental' start in life. As pre-adolescent children start to become independent, the problems of overseeing their oral hygiene — encouraging good tooth-brushing habits and a responsible attitude to sugar-consumption — may cause stresses to affect the relationship between parent and child.

Good dental care is important to the individual for two reasons: pain and self-perception. Dental pain is particularly unpleasant since the area has such a rich nerve supply and also, because it is situated close to the brain, the pain is particularly offensive. The self-perception aspect is especially pertinent in today's society where appearance is so important. In earlier times many peoples' teeth were decayed and ugly; it is suggested that the enigmatic smile of the Mona Lisa is as it is, because she could not display her decayed teeth. As adolescents mature interest in their appearance may make them focus on their teeth.

Middle-aged women may report that during pregnancy their teeth started to decay. Possibly during pregnancy women neglect tooth cleansing and are unaware of dental problems until they have time to themselves when the children are older — or until tooth-ache drives them to act. They may start to question whether their appearance has declined and attend for treatment hoping their looks can be restored.

Elderly people often attend the surgery after years of neglect and non-attendance when their terminal dentition is becoming painful and eating difficult.21 For generations people have accepted they will lose the majority of their teeth as they age. Indeed, in 'As you like it', Shakespeare22 describing the last stage in his 'strange eventful history' of the seven ages of man, recognised the symbolism of tooth loss:

........Last scene of all, That ends this strange eventful history, Is second childishness, and mere oblivion 'Sans teeth, sans eyes, sans taste, sans everything'

The dentist–patient relationship

The dentist–patient relationship is unique in the medical area. The general dental practitioner (GDP) both diagnoses the problem and undertakes the treatment, which differs from general medicine where the practitioner sees the patient and may prescribe drugs or tests, but usually refers the patient on for specialist or hospital treatment.

Clearly, dentists deal with people who have a wide range of past experiences affecting their willingness or ability to accept treatment. On first meeting a patient the dentist has to investigate the patient's history focussing on pain or a specific problem;23 the dentist considered by the patient to be merely a 'technician', may react as one, performing requested procedures. Sadly, this may lead to over-treatment as the dentist, realising the patient expects treatment, removes a filling or eases a denture when in fact the problem may be caused by localised trauma which would heal itself in a few days. A patient with an underlying psychological problem may present with clinical symptoms (Clinical Case Study 1); a clinician not trained or able to recognise life problems may treat the presenting problem mechanistically with the consequence that the condition fails to improve or becomes chronic.24 This produces further distress for the patient, further consultations and prescriptions and also additional cost for the healthcare provider.

Case Study 1

It is important that when patients display visible psychological distress, they are approached with caution and given the opportunity to explore whether the underlying problem is dental anxiety or a dental phobia, symptomatic of a psychological disturbance.25 When dealing with a nervous patient, much of the appointment should be used to calm them, explaining the processes involved and, giving them time, allowing them to present their oral symptoms and concerns about themselves. A good chair-side manner and excellent team approach makes the appointment less frightening for these individuals.23 Moulton17 suggests 'good therapy starts with good history-taking' establishing the basis for good communication and confidence building. Where patients are obviously distressed it provides the opportunity for the dentist to attempt to determine whether the distress is due to dental anxiety or other more deep-seated psychological causes;26 the pain may be a somatic representation of a psychical pain'.27

There are cases where it is apparent that other aspects of the patient's life affect their need for, or ability to, accept treatment (Clinical Case Study 2). The agenda may differ from the apparently presenting one; the dentist should try to be aware of the existence of both overt and covert agendas27 as, without this understanding, treatment will be compromised. The patient may divulge sensitive and affecting material (Clinical Case Study 3). Often people are lonely and unhappy and to be presented with a caring, listening person willing to give them time, enables them to share problems they are unable to discuss elsewhere.

Case Study 2
Case Study 3

Three different emotionally related mechanisms can produce pain: emotional tension, anxiety and hysteria.28 Patients with psychological or emotional problems may 'take it out on their teeth', grinding excessively, especially at night.29,30,31 Not only may this wear the teeth down, it may also affect the muscles of mastication and the temporo-mandibular joint (TMJ) (Clinical Case Study 1).

Certain areas of dentistry have long been recognised as suitable for help by psychotherapy or hypnosis; particularly treatment of retching patients,32,33 and dental phobics where patients may exhibit unexplained physical symptoms or focus excessively on their dental problems (dysmorphophobia)29 indicative of a psychological distubance.34,35 If these patients are given time, with careful explanation of each stage of treatment, allowing it to take place on their terms rather than following the dentist's agenda, many of them can successfully be treated by a dentist using the core counselling skills described by Rogers – empathy, congruence and unconditional positive regard — (attentive listening, an ability to understand the other person's viewpoint as if from their own perspective and an ability to summarise the feelings of the other person so they can emotionally engage with their viewpoint)36 (Clinical Case Study 4).

Case Study 4

There are however other areas where psychotherapy or professional counselling rather than simply the use of counselling skills would be effective. Cancer patients suffer great stress during and after treatment. In some areas of cancer therapy, for example mastectomy, psychological support is generally available for patients. Major maxillo-facial reconstruction and cancer operations on the head and neck, face and in the mouth, are particularly stressful as a person's sense of themselves is totally identified with their facial appearance. Changes to this area have ramifications extending beyond the immediate physical facts,17 yet counselling is not routinely available. Clinical results following operations to the head and neck, relating to appearance or scarring may be upsetting to a patient and prostheses to replace an eye or nose often fall short of convincing. It could be argued that these patients are 'lucky' to be alive but what about the quality of life? (Clinical Case Study 5).

Case Study 5

If a psychologist or counsellor were always included in surgical teams, patients and their families would be able to approach the operation supported, with greater understanding and less fear. When the dentist–patient relationship is successful, patients develop faith in their clinician trusting them to work in the very sensitive area, constantly invading their personal space. Obviously a surgeon cannot always be sure of surgical outcomes but often patients are afraid to ask or are so overcome by emotion or fear, they cannot think of the right questions. In his book 'Cowards get cancer too.....' John Diamond38 charted the progress of his own disease demonstrating the need for support to ease misery and suffering.

Success or failure rates of operations may have been mentioned by the surgeon: John Diamond had been warned he might not be able to swallow but the reality of saliva dribbling constantly from his lower lip made his plight much worse. He did not seem to resent the lack of 'proper' information and had a supportive family but for many patients, the loneliness of their suffering is severe.

'And as so many of my correspondents were keen to remind me, however sympathetically, hardly any of my squeezing and sluicing or the symptoms which occasioned them had anything to do with cancer. They were the products of the cure for cancer ('cure' being the word which all too often they put in quotation marks so as to show how hollow they thought the concept to be). This was iatrogenic illness: illness caused by doctors.

They were right. Iatrogenic illness was just what it was. And there were times when I had to remind myself that it was the iatrogenic illness which was saving my life.' 38

Many doctors' GP surgeries now employ counsellors for those who are anxious or depressed, for nervous patients with mild psychiatric conditions and also for a wide range of people not suffering from a specific complaint, but not coping satisfactorily with their lives. It would seem from the above case scenarios that there would be a place for referral of such patients by dental surgeons as well as by doctors.

The dentist and counselling skills versus Counselling

Counselling skills

It was not until 1997 that a General Dental Council directive specifically included behavioural sciences in the undergraduate curriculum.39 Thus most dentists practising today have had little direct teaching about counselling skills but will, if lucky, have 'picked them up' from their teachers. There can be no doubt that good dentists use the core concepts of counselling with their patients,36 either during history taking, or while explaining treatment options or practicalities and will be able to recognise psychosomatic symptoms and react accordingly. General dental practitioners describe their main reason for leaving the health service to work in private practice as wanting to be able to spend more time with their patients,40 indicating a wish to enjoy a closer working relationship with patients. It could be argued that patients will respond with their feet and, where a dentist does not show sufficient empathy, congruence and unconditional positive regard, they will not return or recommend the dentist to other prospective patients.

However, it is very important that, in the close relationship with the patient, the dentist is aware of the dangers involved in allowing them to open up and discuss long-term unresolved problems. McLeod41 cautions:

'where untrained people attempt to undertake counselling the clients may become confused, or damaged when people attempting to help them get enmeshed in role conflicts through attempting to counsel as well as be their teacher'.

Should the patient disclose material indicating the need for further exploration by a counsellor or other medical personnel, the dentist should refer the patient on. Otherwise the patient may have to deal with emotional issues they are not ready or able to deal with at that time. In order to be able to facilitate this referral effectively, it would be wise for a dentist to have a liaison with a suitable counsellor willing to accept referrals. The counsellor, who could be considered part of the dental team, could also educate them to ensure boundaries are understood and respected.

Counselling

Counselling involves strict boundaries of task, role, time and confidentiality with counsellors having supervision to ensure clarity, awareness of issues and judiciousness of response (for example transference and counter-transference) affecting their own ability to attune effectively to a client or manage a particular case.42 The counsellor's skill lies in knowing when to respond with emotional engagement, when to focus on understanding and perspective and when to join in a collaborative relationship.43 They are also trained to recognise severe psychological disturbance or psychotic states and refer the patient on where appropriate.

Appropriate type of counselling

If a counsellor were attached to a dental practice as part of the team s/he could have two roles to:

  • Advise and educate the team on 'best practice'. The team members could be made aware of the roles they take up in relationships with patients.

  • Help patients who could benefit from counselling — a direct referral pathway.

A counsellor in this role would need to be flexible. An integrated approach allowing both of the above roles to be adopted might include:

  • Education of the team on the use of counselling skills

  • Person-centred counselling

  • The Egan model

  • Psychodynamic counselling

  • Cognitive behavioural therapy

Education on the use of counselling skills

As a member of the dental team, the counsellor could ensure that all members used adequate counselling skills. Rogers' three core elements (empathy, congruence and unconditional positive regard)36 and the need for awareness of boundaries and onward referral would be stressed. If a dentist is aware of a good onward referral pathway, s/he is more likely to use it.

Person-centred counselling

Clinical Case 3 demonstrates the dentist using a person-centred approach using counselling skills rather than counselling. The client responded to the closeness and empathy provided so as to divulge delicate material and was encouraged to seek help elsewhere. If the dentist were not aware, the client could be harmed as cautioned by McLeod.41 But, if a counsellor were available in the practice, direct referral would be able to help the patient resolve their problem.

The Egan Model

This method provides a structure for counselling to follow.44 Aspects of dental treatment can be related to the Egan framework (Fig. 1). Using this approach, the counsellor can help the 'patient' to concentrate on areas of life presenting barriers to getting treatment undertaken (Clinical Case 4), or, the framework may be used to provide the required focus, allowing the patient to complete treatment where otherwise they might fail (Clinical Case 2).

Figure 1
figure 1

Using the Egan model to facilitate dental treatment

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Psychodynamic

Patients — particularly those who are nervous or phobic (Clinical Case 4) — may impose distorted past events or relationships onto the dentist in the form of transference.45 This usually involves regression (the psychological state as the patient moves from control to less well controlled); the dentist may be viewed as 'the caring parent' or 'the powerful and potentially harmful adult' — relating this back to unpleasant past experiences — abuse etc.46 If the dentist is unaware of this possibility he/she may act inappropriately. The counsellor attached to a dental team could educate the staff using Matan's Triangle to demonstrate the dynamics of this relationship (Fig. 2).

Figure 2
figure 2

Matan's Triangle demonstrates how the patient may transfer past events onto the dental experience

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If the dentist understands the role of transference in this psychodynamic relationship, s/he will be able to adapt to the patient's needs, reformulating the way they relate to the patient allowing them to return from the childlike to the adult state and also be aware that they, as dentists, may themselves be using transference, subconsciously reacting to the patient. Where dentist and patient are unable to work together, the counsellor could help by exploring barriers to the formation of a satisfactory treatment alliance.47

Cognitive behavioural therapy (CBT)

Using the view of human experience involving the four interactive elements of cognition, emotion, behaviour and physiology, CBT helps clients break out of negative chains reactions (Fig. 3).48 By analysing behaviour and attitudes etc., the patient can be helped to change core beliefs and thereby achieve symptom reduction and behavioural change.

Figure 3
figure 3

The relationship of the elements involved in negative chain reactions (after Scott and Dryden 1998).43

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The role of this approach to the treatment of a patient has been described in Clinical Case 1. It is useful for neurotic or depressed individuals49 and also for patients who retch. Susan Wright (1980)32 compared 53 retchers with a group of controls and found no evidence that retchers were neurotic. She concluded that since retching is multifactorial in origin, low levels of neuroticism contribute to the condition. These patients could be helped using counselling to determine whether problems in their past make them react in this way and, by analysing their behaviour, help them to overcome their phobia. Hoad-Reddick50 used a relaxation technique developed by the National Childbirth Trust,51 14 patients out of a group of 19 were helped to wear dentures by making them reconsider their problem and then, through breathing instruction, break the retching habit by increasing their confidence. This type of treatment could involve the use of a person-centred approach by a counsellor to elicit the cause and a CBT approach to increase the patient's awareness and effect change.

Discussion

The case has been made for the inclusion of a counsellor in the dental team. In general medicine, patients with somatic symptom presentations are common but are seriously under-diagnosed.30 The same applies to some aspects of dentistry partly because dental education has, until recently, been based in science and biology (body focussed) and has neglected psychology, sociology or spirituality. The clinician today needs to focus on both mind and body. Patients tend to view dentists as providing symptom relief but in some areas, for example, long-term headaches or atypical facial pain, if the patient could become aware — through counselling — of the opportunity for personal growth, the problem might be contained. Broom27 suggests that such conditions might respond to psychodynamic work using the GOOD/BAD splitting where the 'patient' has a poor cohesive sense of self.

A new clinical panorama would recognise that the main visible manifestation of a disease is a physical dimension but would focus on non-physical, psychological, social and spiritual elements of the disease process. Patients who would benefit from this approach include those:

  • Who are frightened or phobic

  • Diagnosed as requiring long and complex treatment

  • With cancerous or pre-cancerous conditions, (Clinical Case 5)

  • Exhibiting behavioural habits affecting their teeth, muscles or joints

  • Suffering from psychological problems eg depression preventing them from accepting treatment or whose condition is not yet being treated.

The difficulty of attempting to get this approach accepted in the profession is due to the lack of evidence as there has been little research into the role counselling can play in the care of patients.52 Increasingly in medicine there is a requirement for practice to be evidence based.53 CBT is the area of counselling most suited to formal research with the possibility of controlled randomised trials versus placebos. There urgently needs to be research focussed on evidence-based practice in the use of counselling related to dentistry so that the approach described above is generally accepted.

Conclusion

This paper has attempted to describe ways in which counselling is relevant to dentistry. There are two strands. Firstly it is suggested that dentists should have a wider understanding of the dentist–patient relationship and an active awareness of the role counselling could play in their practices to allow provision of true holistic care. By having a better understanding of the dynamics of their relationships with patients and colleagues, practitioners would become more insightful and reflective and would be able to respond more effectively to patients' needs. This in turn would reduce stress on the dentist and make the working environment more fulfilling.

Secondly it has been demonstrated that a counsellor could benefit the whole dental team by advising and taking an active role in patient care and management. If such a counsellor had an understanding of integrated practice, they could proceed from Rogers Core Skills, through Egan, to psychodynamic or CBT as appropriate. In addition to seeing clients/patients on referral, the counsellor could help the team members to view patients as a whole and understand that:

'There are some things which cannot be learned and one of these is the meaning of a patients' illness. This must be discovered by the patient and the clinician working collaboratively'.27

If dentistry wishes to be viewed as a 'true profession' and a 'vocational training', it must look to wider horizons which will benefit patients as a whole — we must learn to listen to our patients.

'All of us have unseen capacities for development. Mutual respect means valuing unknown potentialities of the other as a separate, unique person'.54

It seems certain that the practitioners who focused their practice in this way would have greater fulfilment in their work and thus would provide maximum benefit to their patients. If appropriate evidence-based research were conducted, the importance of this approach would be recognised.