Easing Anxiety with Therapy Dogs

The use of animal-assisted interventions in health-care settings is an evidence-based practice.^1–12 There are two types of animal-assisted interventions used in health-care settings: animal-assisted therapy (AAT) and animal-assisted activities (AAA). AAT is a goal-oriented, therapeutic intervention that involves animals, with the goal of enhancing overall health and well-being of patients, and is facilitated by health, education, or service professionals with formal training in the field.¹ Conversely, AAA are not usually goal-oriented, but instead provide informal interactions for educational and/or motivational purposes.¹ AAT typically requires the facilitator to have an active license or degree, whereas AAA does not require formal licensure, but rather introductory training and preparation.¹ Although research has examined the use of various animals, dogs have consistently been shown to be more effective in animal-assisted interventions when compared with other animals (eg, horses, aquatic animals).¹³

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:

1. Allergies should be considered. Finding a breed that is hypoallergenic is most suitable for health-care settings.^34,40
2. 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
3. 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
4. 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
5. 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
6. 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
7. 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

CONCLUSION

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.

REFERENCES

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From Dimensions of Dental Hygiene. March 2019;17(3):31–34.