The House of Hygiene · Case No. 03

Dental Anxiety
Quick Reference

For RDHs managing anxious patients: assessment, communication techniques, SSRI oral health effects, and documentation.

HOH-03
Self-Study
Modified Dental Anxiety Scale (MDAS)

5-Question Scoring Guide

Ask before treatment begins. Each question scored 1 (not anxious) to 5 (extremely anxious). Max score: 25.

ScoreCategoryApproach
5–9Minimal anxietyStandard care
10–18Moderate anxietyEnhanced communication; stop signal
19+High / severePre-med consult; sedation referral possible
5 Questions: (1) Tomorrow appointment, (2) Waiting room, (3) Drill sound, (4) Scaling, (5) General anesthesia injection — each rated 1–5.
SSRIs & Oral Health — CBRP Framework

What to Assess in Every SSRI Patient

LetterEffectDetail
CCaries risk ↑ (via xerostomia)Document as HIGH; upgrade fluoride
BBruxism / attritionWear facets; consider nightguard referral
RRecall shortened3–4 months for confirmed xerostomia
PPlatelets affected (↑ bleeding)Expect/document increased bleeding
Xerostomia note: SSRI users report dry mouth at roughly twice the rate of non-users, with about a 32% reduction in salivary flow. Reduced flow raises caries and mucositis risk. Counsel on hydration, xylitol, and prescription fluoride (5,000 ppm) as appropriate.

"I notice you're on sertraline — a lot of patients on these medications notice their mouth feels dryer than usual. Has that been an issue for you?"

Communication Techniques
Tell-Show-Do
  • Tell: Explain what you're about to do in plain language, before touching
  • Show: Demonstrate on a fingernail, mirror, or the patient's hand
  • Do: Proceed slowly, narrating as you work
Evidence: TSD reduces procedural anxiety and improves cooperation in anxious adults — particularly effective when combined with a stop signal.
Stop Signal Protocol
  1. 1Establish the signal before you recline the chair
  2. 2Make it simple: raise a hand, or two taps on the armrest
  3. 3Confirm: "If anything becomes too much, just do that and I stop immediately — no questions asked."
  4. 4Honor it every time, without hesitation or comment
6-Step De-Escalation
  1. 1Stop immediately — put instruments down
  2. 2Sit the patient upright — never address distress in the supine position
  3. 3Make eye contact; match their level
  4. 4Name the emotion: "It looks like that was really uncomfortable."
  5. 5Offer choice: continue, pause, or reschedule
  6. 6Document response and next-visit plan
Differentiating Pain vs. Anxiety

Reading the Clinical Signals

SignAnxietyPain
OnsetBefore procedure beginsDuring instrumentation
Body tensionWhole body, pre-procedureLocalized flinch/guarding
BreathingShallow, rapid, may hold breathSharp intake, gasp
ExpressionWide eyes, scanning roomGrimace, eye squeeze
ResponseImproved with communicationImproved with anesthesia
SSRI bleeding: SSRIs inhibit platelet aggregation. Expect increased BOP and prolonged post-scaling bleeding. Document, communicate — not a contraindication to treatment.
Treatment Planning & Documentation

Anxious Patient Considerations

"Given what we found today, I'd like to see you back in 3 months rather than 6 — the combination of the dryness and the jaw wear means I want to keep a closer eye on things."

Documentation Language
What to Chart After an Anxious Visit
  • MDAS score recorded pre-treatment
  • Non-verbal anxiety indicators observed (e.g., "patient gripping armrests, elevated HR noted")
  • Stop signal established and honored if used
  • Communication techniques employed (TSD, narration)
  • Any pause in treatment and reason
  • Patient response and emotional state at close
  • Next-visit accommodations planned
Sample Chart Entry

"Patient presented with MDAS score of __ indicating [mild/moderate/high] dental anxiety. Non-verbal signs noted: [list]. Stop signal established pre-treatment (hand raise). Tell-Show-Do technique used throughout. [Pause/Stop noted at X — patient repositioned, offered choice to continue or reschedule — chose to continue/reschedule.] SSRI-related xerostomia discussed; 5,000 ppm fluoride paste recommended. Recall in 3 months. Occlusal guard referral discussed."

— Template: modify to match actual visit
The House of Hygiene · CE for RDHs Case No. 03 · The Anxious Patient · Self-Study thehouseofhygiene.org