Easing Anxiety with Therapy Dogs
While animal-assisted interventions may reduce distress for anxious patients, dental professionals need to adhere to appropriate guidelines to ensure their proper introduction into dental practice.
This course was published in the March 2019 issue and expires March 2022. The authors have no commercial conflicts of interest to disclose. This 2 credit hour self-study activity is electronically mediated.
After reading this course, the participant should be able to:
- Define the purpose of animal-assisted interventions in health-care settings.
- Discuss the prevalence and symptoms of dental anxiety.
- Discuss the use of animal-assisted therapy in the dental setting.
- Identify the guidelines and recommendations for safely incorporating therapy animals into a dental practice.
ANIMAL-ASSISTED INTERVENTIONS IN HEALTH-CARE SETTINGS
Dog-assisted therapy (DAT) is an effective practice primarily in aging populations, pediatric care, and pain reduction.3–5 Research in nursing-home populations has examined the impact of DAT on depression, mood, agitation associated with dementia, and overall quality of life.3–5 For example, Lutwack-Bloom et al3 identified a significant, positive change in mood over 6 months among participants who received DAT in long-term care facilities. Additionally, DAT has been found to enhance mood, psychosocial function, and to delay the progression of disease among residents with dementia.4,5 Individuals with behavioral problems associated with severe dementia showed stabilization of agitation and depression over 4 weeks after DAT interventions, whereas those who received traditional treatment experienced an increase in agitation and depression overtime.4
DAT is also an effective intervention among children with mood, anxiety, and eating disorders.6–9 Stefanini et al6 demonstrated that children with acute mental disorders had positive changes in behavior, motivation, competence, and overall functioning, and decreases in internalizing problems with the implementation of DAT. Additionally, DAT is used in nonclinical pediatric populations to reduce distress associated with medical procedures. For example, the presence of a dog during blood collection reduced cortisol levels in children, indicating a reduction in distress.9 Cortisol is released in the body in response to increased stress associated with anxiety. Although differences in cortisol levels can vary depending on time of day and other lifestyle factors, a decrease in cortisol levels associated with DAT provides initial evidence that the therapy can be beneficial for anxious patients in health-care settings.9
DAT is also indicated for pain reduction in general health-care settings. For example, patients who received total joint arthroplasty procedures and engaged in three consecutive sessions of DAT, beginning 1 day after the procedure, reported decreases in pain perception.10 In all three sessions, participants reported a decrease in pain level.10 In an acute pediatric care unit, a significant reduction in pain level, up to four times greater, was reported among children receiving DAT compared with the control group who did not receive DAT.11 Additionally, the reduction in pain was noted 15 minutes after introducing the dog to the child.11 Of particular note are DAT’s promising results as a nonpharmacological intervention for pain reduction in children with profound intellectual disabilities.12 This population is not only at increased risk for pain from daily care activities and medical procedures, but is also more likely to present with dental anxiety.12,14,15
DENTAL ANXIETY SYMPTOMS, RATES, AND PERVASIVENESS
The identification of positive changes in mood and pain reduction associated with DAT demonstrates the potential benefit of incorporating the practice into dentistry. The introduction of AAT and AAA may reduce dental anxiety-related distress and promote positive oral health-seeking behaviors. If a patient perceives a threat in the dental operatory, which causes an emotional and/or physical response, it is likely he or she has dental anxiety.16,17 For most patients, the threat does not have to be present; the mere perception of a threat can provoke an anxious response.17 Many facets of a dental appointment can be perceived as threatening, such as anesthetic injections, uncomfortable and lengthy procedures, high cost, pain, and tooth loss. Dental anxiety may present in a variety of ways, from a mild reaction (eg, gripping the chair, increased heart rate) to severe where the symptomatology can be debilitating (eg, panic attacks, jumping during injections causing injury).16,17
In the United States, although rates vary by methodology and may be underreported, researchers estimate up to 80% of people experience some form of dental anxiety.16–20 Of those with dental anxiety, approximately 20% do not receive routine dental care, such as oral prophylaxis, and between 9% and 15% avoid the dentist at all costs.19 Research demonstrates patients with higher dental anxiety have more frequent missed appointments, which may lead to the need for more extensive and expensive care.21–23 Dental avoidance can lead to incomplete care or detrimental oral health complications that require difficult procedures. This becomes a cycle of avoidance, incomplete treatment, and pervasive procedures, which results in more pain and increased dental anxiety.22 Many of these patients end up in the emergency department for dental pain and infection, which likely results in additional health-care costs.24 Perceptions of pain also alter a patient’s rate of dental anxiety; if a patient believes that scaling or the administration of local anesthesia will be painful, he or she typically reports higher levels of anxiety for the overall dental appointment.19,25 Dental anxiety is higher among certain groups, such as women, children, and those with previous negative dental experiences.20,25–27
ANIMAL-ASSISTED INTERVENTION IN DENTISTRY
Very little has been documented on animal-assisted interventions in dental settings to assist with dentally anxious patients. In 2000, pilot testing failed to identify statistically significant differences in behavioral stress in pediatric dental patients with the introduction of a companion animal.7 However, children who were stressed about the appointment, as indicated by verbal expression of distress upon arrival to the pediatric facility, experienced a reduction in physiological arousal during the appointment. The reduction in physiological arousal was particularly apparent when children were waiting for the dentist to arrive.7 There were several limitations to this study, such as the inability to control for the type of dental procedure, children being able to hear other pediatric patients in the facility, and the time spent waiting for procedures to occur. Despite a lack of significant findings regarding behavioral stress and a wide array of limitations, this study demonstrated the feasibility of animal-assisted interventions in a dental setting, positive perceptions of pediatric patients and caregivers in regard to animal-assisted interventions for dental procedures, and a reduction in physiological arousal due to a dental procedure.7
Although the use of an animal-assisted intervention among adults in a dental setting has yet to be examined, empirical results from other health-care settings indicate animal-assisted interventions could be integrated into dental settings and may benefit anxious patients. Reductions in pain related to decreased catecholamines and increased endorphins in patients with animal-assisted interventions have been demonstrated in health-care settings.28–30 Studies have also identified an increase in oxytocin in conjunction with the use of animal-assisted interventions, which is associated with lower levels of stress and increased pain thresholds.29,31–33 In summary, the present research indicates possible positive objective and subjective benefits for the use of animal-assisted interventions—particularly DAT—among patients in dental settings.28
GUIDELINES AND RECOMMENDATION
Although initial evidence suggests animal-assisted interventions can be an effective method of reducing pain and anxiety, it has not been examined enough in dental settings. Dental professionals thinking about implementing animal-assisted interventions should consider creating guidelines before moving ahead with AAT. Many guidelines have been developed for health-care settings with the increasing popularity of AAT in nursing homes and hospitals.34-41 Dental professionals can adapt these to the dental setting:
- Allergies should be considered. Finding a breed that is hypoallergenic is most suitable for health-care settings.34,40
- Fear of animals, such as dogs, should also be considered. Though many patients would be excited to have a therapy animal present, some may be fearful and may find the presence of a dog problematic. The practice should maintain a place for the dog to remain away from patients when this occurs. Conversely, the practice could also hire a therapy animal to be present only on certain days if there are not many patients with dental anxiety in the practice.34,40,41
- Animal-assisted interventions should be restricted to suitable animal species, such as dogs. Species identified for higher risk of human infection and/or injury should be avoided. The temperament of the animal should also be considered before implementation.41
- Keeping the office disinfected and equipment sterile can also be a concern for a dental practice. The US Centers for Disease Control and Prevention has not identified any evidence to suggest that animals pose more risk for transmitting infection than people; however, it can still be a concern of patients and employees. The office should consider the type of treatment, protocols, and policies when considering the use of animal-assisted interventions in order to maintain a hygienic and safe environment for all. This should include hand hygiene policies and health screening of animals to include vaccinations.35,41
- Informed consent is crucial in any health-care setting. Offices must secure documentation that patients consented to being treated in the presence of a therapy animal.41
- Using professionally trained animals should also be considered before implementation. Several organizations train dogs for AAT. These organizations—such as Alliance of Therapy Dogs, Bright and Beautiful Therapy Dogs, Love on a Leash, and Therapy Dogs Inc—choose breeds ideal for reducing anxiety.40 In addition, animal handlers should have proper training and certifications for animal-assisted interventions in a health-care setting.41
- Offices should use evidence-based research for implementing animal-assisted interventions in practice. Although there is testimonial on successful incorporation of therapy dogs into dental settings, minimal clinical research in dentistry exists. However, research of animal-assisted interventions, specifically DAT, in other health-care settings can inform the practice and lead to success of therapy dogs in dentistry.34-41 Please reference Guidelines for Animal-Assisted Interventions in Health Care Facilities for more detailed information on proper guidelines and procedures for introducing animal-assisted interventions into dental practice.41
Animal-assisted interventions, particularly DAT, have been documented in health-care settings as having positive effects on patients. Research supports the use in aging populations, pediatric patients, and in pain reduction.3–5 Patients with dental anxiety typically expect to experience pain during dental appointments, resulting in increased fear and anxiety.16,17 A large portion of the US population experiences dental anxiety, which has been linked to a range of symptoms that negatively impact dental appointments.16–20 Ultimately, dental anxiety can lead to missed appointments and avoidance of dental care, resulting in adverse health outcomes for the patient.21–23 The introduction of animal-assisted interventions may reduce distress for anxious patients and subsequently reduce the negative consequences of dental anxiety. Guidelines for proper introduction of animals into health-care settings should be followed before implementing animal-assisted therapy in dental practice.
- Jegatheesan B, Beetz A, Ormerod E, et al. The IAHAIO definitions for animal assisted intervention and guidelines for wellness of animals involved. Available at: http:/ / iahaio.org/ wp/ wp-content/ uploads/ 2017/ 05/ iahaio-white-paper-final-nov-24-2014.pdf. Accessed February 15, 2018.
- Lundqvist M, Carlsson P, Sjödahl R, Theodorsson E, Levin L.Å. Patient benefit of dog-assisted interventions in health care: a systematic review. BMC Complement Altern Med. 2017;17:358.
- Lutwack-Bloom P, Wijewickrama R, Smith B. Effects of pets versus people visits with nursing home residents. J Gerontol Soc Work. 2005;44:137–159.
- Majić T, Rapp MA, Gutzmann H, Heinz A, Lang UE. Animal-assisted therapy and agitation and depression in nursing home residents with dementia: a matched case-control trial. Am J Geriatr Psychiatr. 2013;21:1052–1059.
- Travers C, Perkins J, Rand J, Bartlett H, Morton J. An evaluation of dog-assisted therapy for residents of aged care facilities with dementia. Anthrozoös. 2013;26:213–225.
- Stefanini MC, Martino A, Bacci B, Tani F. The effect of animal-assisted therapy on emotional and behavioral symptoms in children and adolescents hospitalized for acute mental disorders. Eur J Integr Med. 2016;8:81–88.
- Havener L, Gentes L, Thaler B, Megel ME, et al. The effects of a companion animal on distress in children undergoing dental procedures. Issues Compr Pediatr Nurs. 2001;24:137–152.
- Johnson RA, Meadows RL, Haubner JS, Sevedge K. Animal-assisted activity among patients with cancer: effects on mood, fatigue, self-perceived health, and sense of coherence. Oncol Nurs Forum. 2008;35:225–232.
- Vagnoli L, Caprilli S, Vernucci C, Zagni S, Mugnai F, Messeri A. Can presence of a dog reduce pain and distress in children during venipuncture? Pain Manag Nurs. 2015;16:89–95.
- Harper CM, Dong Y, Thornhill TS, et al. Can therapy dogs improve pain and satisfaction after total joint arthroplasty? A randomized controlled trial. Clin Orthop Relat Res. 2015;473:372–379.
- Braun C, Stangler T, Narveson J, Pettingell S. Animal-assisted therapy as a pain relief intervention for children. Complement Ther Clin Pract. 2009;15:105–109.
- Lima M, Silva K, Amaral I, Magalhães A, de Sousa L. Can you help when it hurts? Dogs as potential pain relief stimuli for children with profound intellectual and multiple disabilities. Pain Med. 2014;15:1983–1986.
- Nimer J, Lundahl B. Animal-assisted therapy: a meta-analysis. Anthrozoös. 2007;20(3):PP0-00.
- Gordon SM, Dionne RA, Snyder J. Dental fear and anxiety as a barrier to accessing oral health care among patients with special health care needs. Spec Care Dentist. 1998;18:88–92.
- Howell R, Brimble M. Dental health management for children with special healthcare needs. Nurs Child Young People. 2013;25:19–22.
- Kamin V. Fear, stress, and the well dental office. Northwest Dent. 2006;85:10–18.
- White A, Giblin L, Boyd L. The prevalence of dental anxiety in dental practice settings. J Dent Hyg. 2017; 91:30–34.
- Humphris G, Crawford JR, Hill K, Gilbert A, Freeman R. UK population norms for the Modified Dental Anxiety Scale with percentile calculator: adult dental health survey 2009 results. BMC Oral Health. 2013;13:29.
- Humphris G, King K. The prevalence of dental anxiety across previous distressing experiences. J Anxiety Disord. 2011;25:232–236.
- Humphris GM, Dyer TA, Robinson PG. The modified dental anxiety scale: UK general public population norms in 2008 with further psychometrics and effects of age. BMC Oral Health. 2009;9:20.
- Lin KC. Behavior-associated self-report items in patient charts as predictors of dental appointment avoidance. J Dent Educ. 2009;73:218–224.
- Armfield JM. What goes around comes around: revisiting the hypothesized vicious cycle of dental fear and avoidance. Community Dent Oral Epidemiol. 2013;41:279–287.
- Sohn W, Ismail AI. Regular dental visits and dental anxiety in an adult dentate population. J Am Dent Assoc. 2005;136:58–66.
- Otto M. Teeth: The Story of Beauty, Inequality, and the Struggle For Oral Health in America. New York The New Press; 2017.
- Sanikop S, Agrawal P, Patil S. Relationship between dental anxiety and pain perception during scaling. J Oral Sci. 2011;53:341–348.
- Malvania EA, Ajithkrishnan, CG. Prevalence and socio-demographic correlates of dental anxiety among a group of adult patients attending a dental institution in Vadodara city,Gujarat, India. Indian J Dent Res. 2011;22:179–180.
- Nicolas E, Collado V, Faulks D, Bullier B, Hennequin M. A national cross-sectional survey of dental anxiety in the French adult population. BMC Oral Health. 2007;7:12.
- Marcus DA. The science behind animal-assisted therapy. Curr Pain Headache Rep. 2013;17:322.
- Odendaal JS, Meintjes RA. Neurophysiological correlates of affiliative behaviour between humans and dogs. Vet J. 2003;165:296–301.
- Barker SB, Knisely JS, McCain NL, Best AM. Measuring stress and immune response in healthcare professionals following interaction with a therapy dog: a pilot study. Psychol Rep. 2005;96:713–29.
- Beetz A, Uvnäs-Moberg K, Julius H, Kotrschal K. Psychosocial and psychophysiological effects of human-animal interactions: the possible role of oxytocin. Front Psychol. 2012;3:234.
- Miller SC, Kennedy C, Devoe D, et al. An examination of changes in oxytocin levels in men and women before and after interaction with a bonded dog. Anthrozoös. 2009;22:31–42.
- Handlin L, Hydbring-Sandberg E, Nilsson A, et al. Short-term interaction between dogs and their owners—effects on oxytocin, cortisol, insulin and heart rate—an exploratory study. Anthrozoös. 2011;24:301–316.
- Solana K. Pediatric dentist shares dental therapy dog success story. Available at: ada.org/ en/ publications/ ada-news/ 2015-archive/ may/ pediatric-dentist-shares-dental-therapy-dog-success-story. Accessed on February 15, 2019.
- Raymond-Allbritten J. Pet therapy in the dental office: would animals dispel dental phobias? Available at: colgateprofessional.com/ hygienists/ articles/ pet-therapy-in-the-dental-office-would-animals-dispel-dental-pho. Accessed on February 15, 2019.
- McCullough A, Ruehrdanz A, Jenkins M. The use of dogs in hospital settings. Available at: https:/ / habricentral.org/ resources/ 54871/ download/ hc_ brief_ dogsinhospitals20160115Access.pdf. Accessed February 15, 2019.
- Coakley AB, Mahoney EK. Creating a therapeutic and healing environment with a pet therapy program. Complement Ther Clin Pract. 2009;15:141–146.
- Glenk LM. Current Perspectives on therapy dog welfare in animal-assisted interventions. animals. Animals (Basel). 2017;7:E7.
- Krawczyk M. Caring for patients with service dogs: information for healthcare providers. Online J Issues Nurs. 2017;22:7.
- American Kennel Club. Therapy dog program. Available at: akc.org/ sports/ title-recognition-program/ therapy-dog-program/ . Accessed on February 15, 2019.
- Lefebvre SL, Golab GC, Christensen E, et al. Guidelines for animal-assisted interventions in health care facilities. Am J Infect Control. 2008;36:78–85.
From Dimensions of Dental Hygiene. March 2019;17(3):31–34.