Steven Daws is a Regent for the Student Professionalism & Ethics Association (SPEA). Learn more here.
In February 2017, the Journal of Dental Hygiene published results of a study that found 19% of the sampled population had moderate to high dental anxiety. Dental practitioners are well aware of the clinical challenges posed by patient anxiety. But one situation in which its influence may be overlooked is during the informed consent process. Informed consent is an essential component of the treatment sequence as well as an ethical obligation of every practicing dentist. It rests on the ability of the professional to communicate effectively with the patient and on the capacity of the patient to understand and synthesize the relevant information. The ultimate goal is to allow the patient to arrive at an autonomous decision.
A 2015 review published in the British Dental Journal suggests that the informed consent process can be impaired by disturbances in cognition and reasoning associated with anxiety. While studies have found that comprehension of treatment information is actually markedly improved in patients with dental anxiety versus those without, it has also been found that the information is frequently distorted. Patients experiencing anxiety often simply do not trust the information they are receiving, and therefore they disregard it. Generally accepted risks are more readily viewed as catastrophic, and benefits are commonly viewed as insignificant when compared to the sense of impending doom these patients may feel. Anxiety can also cause a sense of lost control. Patients may not realize they have the option of saying “no” at any point during a procedure. Overall, anxiety can greatly affect a patient’s capacity to provide consent.
To help mitigate these concerns, a number of strategies can be adopted. It might be prudent to obtain consent in the absence of any stimulus. That is to say, consent should be obtained outside of the dental operatory, away from instruments and equipment that may evoke a fearful response. Similarly, it may be advantageous not to obtain consent immediately prior to the procedure, when the patient is anxious about the procedure about to happen. This discussion could occur when presenting a treatment plan or at the appointment before the more intimidating procedures.
Good rapport and an established patient-provider relationship are doubly important in the context of dental anxiety. Improving this could facilitate the informed consent process as well. We need to remember that patients do have the right to decline treatment, regardless of the professional’s recommendation. We can’t assume all anxious patients declining treatment are behaving irrationally. However, it would also be a mistake not to recognize the potential effects of dental anxiety on the informed consent process. Listening and responding to the patient’s specific concerns may help put them at ease. Non-threatening information such as educational videos about the procedures may also help the patient understand. The best service you can provide your patients is compassionate care built on their trust that you have their best interests at heart. Given how common dental anxiety is, reducing dental-related stress and encouraging consistent follow up with patients is a good place to start.
~ Steven Daws, Pennsylvania ’18