Patients with odontophobia

DSM-IV criteria for Specific Phobiodontophobia (as described in APA, 1994):

1. Marked and persistent anxiety that is irrational and unreasonable, triggered by the presence of oranticipation of specific objects or situations.
2. Exposure to the phobic stimulus almost always elicits an immediate anxiety response that can manifest as a situational or situation-predisposed panic attack.
3. Persons aware that the anxiety is excessive and unreasonable.
4. The phobic situation (s) are avoided or endured only with intense anxiety or discomfort.
5. The avoidance behavior, anticipation anxiety, or discomfort in the feared situation (s) significantly affect the person's normal routines, social activities, work functioning, or relationships with others, or there is marked discomfort from having the phobia.
6. In people over 18 years of age, its duration should be at least 1 year.
7. The anxiety, panic attacks or phobic avoidance behaviors associated with the specific object or situations are not better explained by another mental disorder.

Specifications of inclusion in odontophobia

Persons are included if it results in functional impairment as described in Criterion E above. This means that the patient's anxiety about dental treatment affects the daily functioning and implies that the anxiety is also triggered outside of dental treatment situations.

Examples

Social difficulties

The patient experiences strong shame for their teeth and often avoids smiling/showing off their teeth in fear of negative social evaluation. Some people will avoid intimate relationships because of the shame associated with teeth. Present self-awareness in terms of what prevents spontaneous behavior is often present.

Pain

The patient is more likely to go with teeth/gum pain rather than seek dental treatment. The use of painkillers, alcohol, anxiolytics, etc. to alleviate symptoms rather than treat the cause is not uncommon. The intake of food and drinks often entails pain.

Evasion

Dental treatment is mainly avoided, or sought out only in case of acute need for treatment and is then endured with strong anxiety activation. It is not uncommon for patients to avoid eating foods that they fear could cause damage to their teeth, e.g. foods with high chewing resistance. Significant avoidance of teeth-related triggers such as talking about teeth and dental procedures is also common. Avoidance of smells, sounds, advertisements, TV/radio programs that a suspect may address teeth and dental procedures may be present.

Difficulties in relating to one's own teeth e.g. looking at one's own teeth, avoiding brushing, etc. due to shame are also seen. Some avoid accompanying children or other relatives to dental treatment for fear of anxiety response. Severe anticipatory anxiety prior to dental treatment is common and may affect a patient's sleep, causing nausea/vomiting/diarrhoea and general elevated physiological stress activation in the weeks/days prior to treatment, thus affecting the patient's overall level of functioning.

Patients subjected to torture

The TOO offer is directed at persons who have been subjected to gross torture as described by the United Nations, including deliberate acts of inflicting severe physical or mental pain on a person in order to obtain information, threaten or punish the person or a third person. For it to be considered torture, the act must be committed by, or with the permission of, a public service person or another acting in the commission of office. Pain stemming from lawful punitive responses is not considered torture in the Torture Convention. This includes torture directly against teeth and/or against structures in the neck and head region.

Persons who are torture survivors who are included in TOO may have the following forms of injury history and type of injuries:

1. Injuries to the mouth and to teeth resulting from the direct application of pain and injuries, i.e. direct dental torture.
2. Injuries resulting from forced ingestion of harmful fluids (such as urine and others), poor and inadequate nutrition over time, serious deficiencies in hygiene conditions that make regular dental care impossible, back binding or other forms of physical restriction that make dental care impossible.
3. Injuries that can be linked to fear (or phobias) of going to the dentist due to experiences of torture, in particular dental torture carried out, for example, in dental chairs and with equipment resembling dental utensils.
4. Injuries resulting from more general psychological conditions after torture, post-traumatic stress disorder (PTSD), depression, apathy, agitation, which can lead to a general attitude in which dental care and other personal care become a low priority.

Patients exposed to sexual assault and/or domestic violence

The costs associated with oral rehabilitation are covered by government grants for the project. The subsidy regulation lays down guidelines on the use of tariffs; “When purchasing services by private persons, it is assumed that the prices for the individual treatment are not higher than the prices at the county council's own operation”. Trøndelag County Municipality's public tariffs therefore form the basis for the oral rehabilitation. TKMIDT's tariffs, as a county municipal enterprise, form the basis for the use of tariffs in case of need of treatment with a specialist in the rehabilitation phase.

Regular national calibration meetings are conducted to ensure an equal level of treatment for TOO patients nationally.

When starting in a dental team, some time will be spent on relationship building, reviewing the coping plan, examining, preparing a treatment plan and reviewing it with the patient, as well as preparing cost estimates. For this, up to 4 hours can be used using Trøndelag County Municipality's tariff 905. For private dental teams, it is requested to create a tariff called 905 under various text in Opus. This facilitates the understanding of transmitted cost estimates and invoices.

A written application for rehabilitation is requested prior to commencement of treatment if the treatment includes;

• Any kind of fixed prosthetics
• Any type of advanced removable prosthetics (combination works = fixed and removable prosthetics in combination)
• Endodontic treatment distal to tooth number 5 (on pillars with good prognosis)

Pain and infection treatment can be started without application.

The Health Directorate's supervisor “Good clinical practice” is based on the planning, and the plan should be evaluated according to 9 issues mentioned below. The Nemd, consisting of a dentist with expertise in implant prosthetics, a dentist with experience from a multidisciplinary treatment team, a periodontist and a TOO coordinator (dental health secretary) as an administrative resource, assesses the treatment plan on the basis of the following issues:

1. Is the treatment according to Good Clinical Standards?
2. Have alternative treatment proposals been made?
3. What assessments were the basis for the therapist/patient to choose the appropriate treatment proposal?
4. Has it been considered how long the treatment should take?
5. Has the therapist made any reservations in the treatment plan?
6. Does the cost estimate match the current rates?
7. Is the patient considered fit to carry out the treatment?
8. Is it considered that the patient has the necessary capacity and will for self-care/hygiene to attend to the treatment?
9. Is it considered that the patient is capable of follow-up treatment as well as future maintenance?

The application must contain sufficient information to give the applicant a good basis for assessment, including x-rays, written assessment of health/compliance and other relevant information such as clinical photographs. Implants are not the primary treatment chosen under TOO auspices. In special cases, implants may still be considered, for example, single-tooth implants in the front of the upper jaw in which neighboring teeth are intact. It is a prerequisite that the patient can carry out the insertion of implants, as well as the prepping and cementing of crowns, and bridging in the awake state to ensure that the patient is able to attend to the treatment solution in the future.

For patients with particularly high treatment needs or challenging anxiety problems, it may be difficult to provide a complete cost estimate when initiating oral rehabilitation. In these cases, dental teams may submit for approval a cost estimate of an initial phase (e.g., for pain relief and infection elimination), and then the final treatment plan/cost estimate.

Who can refer?

Dentists, doctors, psychologists, other health professionals, etc. who come into contact with patients who have been subjected to torture, abuse or who may have odontophobia can refer tothe competence center or to a local “Multidisciplinary Treatment Team TOO”.

What information should the citation contain?

• Patient's personal data, including social security number.
• Brief information about the patient's difficulties in the dental treatment situation, and preferably whether the patient has been subjected to violence, sexual abuse or torture if this information is known.
• Information about whether the patient has rights within the publicDental Health Service.
• Brief information about tooth status.

What happens after the referral is received?

All referrals are reviewed weekly. The patient is sent information that they have been referred and placed on a waiting list. The multidisciplinary treatment team TOO does not have treatment responsibility for the patients during the waiting period and any urgent treatment needs that should arise until the patient is included in the TOO offer.

After a conversation with a psychologist followed by a diagnostic interview/screening, it will be revealed whether the patient meets the criteria to be included in the offer.

Those who meet the criteria will first be offered anxiety treatment. Multidisciplinary therapist team TOO primarily offers anxiety treatment (cognitive behavioral therapy) for dental treatment anxiety (+-10hours). Any dental treatment is carried out only in the phase of the anxiety treatment as well as in the case of pain and infection. Once the patient is able to carry out basic dental treatment the patient is transferred to Dentist Team TOO for further dental treatment and follow-up. Both the anxiety treatment and dental treatments per dd. free for the patient as long as the patient is covered by the offer cf. the guidelines of the Directorate of Health, this means that the treatment is free of charge until:

1. The dentition has been rehabilitated according to the supervisor IS-1589 Good clinical practice in dental care

Within ordinary dental care, dental treatment is not free, but some treatments are entitled to social security reimbursement. The co-payment depends on the amount of the refund and the dentist's price.

Dentistry under general anesthesia

Some patients have such a high need for treatment that it may be appropriate to consider the appropriateness of dental treatment under general anesthesia before anxiety treatment. Assessment and referral to dentistry under general anesthesia is done by multidisciplinary team. It is a prerequisite for referral to dental treatment under general anesthesia under the auspices of TOO that the patient is motivated for anxiety treatment in the aftermath of the dental treatment.

Patients who apply to the project solely for dental treatment under general anesthesia, and are not interested in trying psychological approach to treat their dental treatment anxiety, will be rejected from the project. The dental treatment performed under general anesthesia is limited to pain and infection remediation where extirpation and temporary fillings are preferred.

It is important that the patient understands that only part of the dental treatment needs will be treated under anesthesia, and that some of the treatment will be temporary solutions. Minor treatment needs may remain in order to be used in the phase of exposure therapy.