Jamie is always a few minutes late for appointments and has been known to call at the last minute to cancel. When I greet her in the reception area, she seems surprised and rises from the chair with her body communicating “resigned to having to do this”.
I do my best to have a casual conversation, commenting on her beautiful red jacket, and she mumbles “thank you” in a barely audible tone. She is difficult to engage. When she sits in my office, her neck and shoulders are tight and I notice her foot bouncing as if she is marking time with a quick tune. She seems a bit embarrassed that she didn’t follow my suggestions from our last date and tells me she just forgot. His face is hard to read, but it is unmistakably tense. She is worried about an upcoming procedure and does not think she can carry it out. She asks me to help her “pull herself together”. She is in pain and needs that dentist appointment.
Your dental hygiene patients are my therapy patients. We have already been working together for years. Most of my patients suffer from anxiety, which is often debilitating and interferes with their ability to do the things they want and need to do in life.
The National Institute of Mental Health estimates that 31% of adults in the United States will experience an anxiety disorder in their lifetime and that 19% of the population has experienced an anxiety disorder in the past year.1 That’s one in five patients. Maybe it’s you. The COVID-19 pandemic has only worsened this statistic with estimates that the prevalence of anxiety has more than tripled in the United States.2
My mental health practice in northern New Mexico attracts clients seeking help preparing for dreaded events: flying on a plane, taking an exam, undergoing a medical procedure, or giving a speech. For those whose “dreaded event” is the dental chair, successful preparation means being able to sit during a procedure reasonably still with relaxed facial muscles while experiencing an overall sense of calm.
For one in three people estimated to be affected by moderate to severe dental anxiety,3 suffering often begins long before it arrives at your desk. They experience difficulty sleeping, irritability, rapid heartbeats, feel nervous and frightened, sometimes for days and weeks before seeing them.
Steven brought his 10 year old daughter, Elise, to see me because she was afraid to go to the dentist. She had tooth decay and needed extractions. She didn’t want to get out of the car to get into it. After a few counseling sessions, she was able to manage well enough to enter on her own, sit through the procedure without sedation, and return for follow-up appointments, looking forward to the treat her mother had promised her as a reward.
Another patient of mine, John, came because he found the idea of instruments in his mouth and lying on his back in a chair awful. He had been sexually abused as a child; this dental treatment scenario was way too triggering. He had never shared this with his dental provider; it was too private to talk about it. The therapy helped him differentiate his trauma from the dental experience, taught him ways to induce calm, and trained him to focus his attention where he could feel comfort.
What is anxiety?
Anxiety is not a feeling; it is a physiological response. We have all felt and seen the unmistakable signs of the mobilized fear response: sweaty palms, rapid heartbeat, restless movements, muscle tension, eyebrows expressing concern, the “deer in the headlights” look. It’s hard to hide these obvious signs of anxiety.
But intense anxiety has another appearance: it can seem calm and still. It is its hidden side that is easy to miss. Some patients may seem extremely calm when their anxiety is intense. Consider your patient docile, the one who does not interfere with your treatment, the “easy patient”. This person may be the one who really needs your extra emotional support.
The energizing fight-or-flight response is good for overwhelming stress that can be escaped. We run away or we get angry and fight, and the body goes back to “rest and digest”. But what about unavoidable and overwhelming stress, such as financial problems, the COVID-19 pandemic, or having to undergo a procedure that scares us?
Also in this issue: 6 things I want you to know
What is Dorsal Vagal Gel?
If we can’t mobilize ourselves and don’t have the resources to increase our sense of security, the autonomic nervous system engages the “freezing business” response through the dorsal vagus nerve.4 This is a systems shutdown. Think of a power grid overwhelmed with power demands during a heat wave. Controlled “blackouts” are a way to manage demand and prevent the entire system from failing. That’s what it’s all about: non-essential closed systems, such as higher reasoning and digestion. The senses dull, blood pressure drops and saliva production ceases.
This is a high intensity stressful event in the body and an undesirable state for your patient, as it is accompanied by a feeling of helplessness and invisibility; impaired ability to engage higher reasoning centers in the brain to understand information and instructions; relaxed muscle tone; difficulty establishing social relationships; and the restricted ability to record information in the environment. Here are some of the tells:
How to Assess a Dental Patient for Dorsal Vagal “Freeze”
What you will see:
- Dulled senses
- Difficulty responding to instructions
- Relaxed muscle tone
- Lack of prosody
- Unusual physical or emotional numbness
- Pupils constricted
- Low blood pressure
- Pale skin
- Motor immobility (tonic immobility)
- Dry mouth
- Flat face (lack of emotion shown)
- Soft voice
- Shallow breathing
- Stare
- Cold hands/feet
- Tense/droopy eyelids
Coping mechanisms
There are active steps you can take to signal body safety and improve adaptation. A few simple exercises can help recovery after a freeze. These involve low-intensity movements, cranial nerve activation, and safety cues from social connections such as the relaxed, friendly face of a hygienist. Explaining and giving information is not very helpful; remember that higher cognitive processes are in “progressive blackout” mode. Reducing stimulation helps. Consider dimming the lights, lowering the volume of music, and moving your chair back to give more personal space.
Here is a simple technique called the “Half Salamander” that helps recovery after a freeze and comes from the book Accessing the Healing Power of the Vagus Nerve by Stanley Rosenberg.5 It can be done quite discreetly and suggested to your patient in the dental chair. I use it myself between patients to reset my biology after an intense date.
- Without turning your head, let your eyes gaze to the far right.
- Continuing to face straight ahead, tilt your head to the right so that your right ear comes closer to your right shoulder, without raising your shoulder to meet it.
- Hold your head in this position for 30 to 60 seconds.
- Let your head return to neutral and move your eyes to look forward again.
Do the same on the other side. Let your eyes look to the left, then tilt your head to the left. After 30 to 60 seconds, return your head to an upright position and your eyes forward.
Whether you are a dental professional, first responder, friend, partner, teacher or parent, it is important to be able to evaluate the gel, both in others and in yourself. Freeze recovery allows us to be fully effective in relationships and to have a presence, the ability to have focused attention that is attuned and sensitive to the state of the other’s nervous system. It is our relational “superpower” and the one that allows us, as dental providers, to present ourselves with both empathy and the power to influence for good.
Also in this issue: Make self-care a priority or pay the price
I encourage you to pause every day, do your own self-checking, and ask yourself where your own system is: fight, flight, or block. And what about that of your patients, children, spouse, friends? Don’t let someone you care about go “under the radar” because they’re quiet, people-pleasing, or appear to be emotionally calm. They can be “frozen” and need your kindness, sensitive responsiveness, and a few easy-to-learn techniques to make for a much more comfortable and manageable experience.
Editor’s note: This article originally appeared in the February 2022 print edition of HDR magazine. Dental hygienists in North America are eligible for a free print subscription. Register here.
The references
- Management of stress and anxiety. American Anxiety and Depression Association. February 2021. https://adaa.org/understanding-anxiety/generalized-anxiety-disorder-gad/managing-stress-and-anxiety
- Coping with the impact of the COVID-19 crisis on mental health: an integrated whole-of-society response. Organisation for Economic Co-operation and Development. May 12, 2021. https://www.oecd.org/coronavirus/policy-responses/tackling-the-mental-health-impact-of-the-covid-19-crisis-an-integrated-whole-of-society – response-0ccafa0b/
- Silveira ER, Cademartori MG, Schuch HS, et al. Estimated prevalence of dental fear in adults: a systematic review and meta-analysis. J Tooth. 2021;108:103632. doi:10.1016/j.jdent.2021.103632
- Dana D. Polyvagal exercises for safety and connection. WW Norton & Co; 2020.
- Rosenberg S. Accessing the healing power of the vagus nerve. North Atlantic Books; 2017.
