"Ooh, It Was All So Awful".

This narrative illustrates how patient post-operative pain experiences can be influenced by worry, catastrophizing, previous learning experiences, and expectations about what will happen and how they will cope. It also demonstrates that a sympathetic dentist can help shape these expectations to the benefit of patients.

The evaluation of a continuing professional development package for primary care dentists designed to reduce stress, build resilience and improve clinical decision-making.

Introduction Stress and burnout are widely accepted as a problem for primary care dental practitioners. Previous programmes to address this issue have met with some success. Burnout is associated with poor coping skills and emotion regulation, and increased rates of clinical errors. Anxiety is associated with poor decision-making and is thought to be associated with poor clinical decision-making. Attempts to improve decision-making use increasing meta-awareness and review of thinking processes. Bibliotherapy is an effective method of delivering cognitive behavioural therapy as self-help or guided self-help (with some therapist input) formats.Objective To evaluate the efficacy of a specially designed CPD package which was designed to improve coping skills, build resilience and reduce the impact of anxiety on dentists' clinical decision-making.Design A multi-centred quasi-experiment.Setting Lincolnshire and Nottinghamshire (England) 2014.Materials and methods Thirty-five volunteer primary care dentists used two versions (self-help [SH] and guided self-help [GSH], which included a 3 hour workshop) of a specially written cognitive behavioural therapy bibliotherapy programme designed to improve well-being and decision-making.Main Outcome Measures The main outcome measures were dentists' burnout, depression, anxiety, stress and decision-making style. Data were also collected on use and evaluation of the programme.Results At 6 weeks there was a clinically and statistically significant reduction in depression, anxiety and stress levels, a statistically significant reduction in burnout (emotional exhaustion) and hypervigilant decision-making, and an increase in personal achievement. The improvements in depression, stress, emotional exhaustion and hypervigilant decision-making were maintained at 6 months. Dentists were overwhelmingly positive in their evaluation of the project and used most of its contents.Conclusion With the caveat of small numbers and the lack of a no-treatment control, this project demonstrated that a self-help package can be highly acceptable to dentists and, in the short-to-medium term, improve dentists' well-being and decision-making with implications for patient safety.

A study to explore if dentists' anxiety affects their clinical decision-making.

Aims To develop a measure of dentists' anxiety in clinical situations; to establish if dentists' anxiety in clinical situations affected their self-reported clinical decision-making; to establish if occupational stress, as demonstrated by burnout, is associated with anxiety in clinical situations and clinical decision-making; and to explore the relationship between decision-making style and the clinical decisions which are influenced by anxiety.Design Cross-sectional study.Setting Primary Dental Care.Subjects and methods A questionnaire battery [Maslach Burnout Inventory, measuring burnout; Melbourne Decision Making Questionnaire, measuring decision-making style; Dealing with Uncertainty Questionnaire (DUQ), measuring coping with diagnostic uncertainty; and a newly designed Dentists' Anxieties in Clinical Situations Scale, measuring dentists' anxiety (DACSS-R) and change of treatment (DACSS-C)] was distributed to dentists practicing in Nottinghamshire and Lincolnshire. Demographic data were collected and dentists gave examples of anxiety-provoking situations and their responses to them.Main outcome measure Respondents' self-reported anxiety in various clinical situations on a 11-point Likert Scale (DACSS-R) and self-reported changes in clinical procedures (Yes/No; DACSS-C). The DACSS was validated using multiple t-tests and a principal component analysis. Differences in DACSS-R ratings and burnout, decision-making and dealing with uncertainty were explored using Pearson correlations and multiple regression analysis. Qualitative data was subject to a thematic analysis.Results The DACSS-R revealed a four-factor structure and had high internal reliability (Cronbach's α = 0.94). Those with higher DACSS-R scores of anxiety were more likely to report changes in clinical procedures (DACSS-C scores). DACSS-R scores were associated with decision-making self-esteem and style as measured by the MDMQ and all burnout subscales, though not with scores on the DUQ scale.Conclusion Dentists' anxiety in clinical situations does affect the way that dentists work clinically, as assessed using the newly designed and validated DACSS. This anxiety is associated with measures of burnout and decision-making style with implications for training packages for dentists.

Role Reversal.

This narrative illustrates how easy it is to be thoughtless when treating patients, resulting in the patient feeling dehumanized and belittled. This has the potential to trigger dental fear in vulnerable individuals.

A study to explore specific stressors and coping strategies in primary dental care practice.

Background and aims It is widely acknowledged that dentists experience occupational stress. This qualitative study aimed to explore previously identified specific stressors in more detail in order to inform the development of a future stress management programme.Method Two focus groups of dentists (N: 7 &6) were conducted to explore, in more detail, nine specific stressors and concepts; being out of one's comfort zone, zoning out from the patient, celebrating the positive aspects of work, thinking aloud, the effect of hurting patients, the impact of perfectionism, responsibility for patient's self-care, the emotional impact of difficult situations as a foundation dentist. Participants were also asked for their views on the structure and contents of the proposed stress management package. Verbatim transcripts were subjected to thematic analysis.Results and discussion Dentists described the impact of these stressors and their current coping methods; thematic analysis revealed nine themes which covered the above concepts and a further overall theme of need for control. The findings are elaborated in connection to their relevant stress, coping and emotion psychological theory. Their implications for personal well-being and clinical outcomes are discussed.Conclusion Dentists' stressful and coping experiences are complex and it is essential that any stress management programme reflects this and that the skills are easily accessible and sustainable within the context of a busy dental practice.

A Ghost from the Past.

This narrative illustrates how childhood trauma can influence the ability to cope with dental fear and treatment. It also demonstrates that a sympathetic dentist with the appropriate training can help these patients to overcome their dental fear and give them the skills to deal with other problems.

Understanding emotionally relevant situations in primary dental practice. 3. Emerging narratives.

BACKGROUND AND AIMS: Dentists experience considerable occupational stress. Stressful clinical situations can provoke high levels of negative emotions, and situations which are associated with positive emotions tend to be overlooked by practitioners. Reflection regarding difficult situations is encouraged to facilitate learning. Cognitive behavioural therapy (CBT) formulations may be applied to situations appraised both positively and negatively. Analysis and interpretation of the dentist's coping behaviour and the consequent outcomes facilitate learning and reflection upon individual interactions with patients. METHOD: Twenty primary care dental practitioners in the greater Lincoln area participated in a semi-structured interview which explored their stressful and positive clinical experiences. Some of the episodes were analysed to create CBT formulations. RESULTS AND DISCUSSION: CBT formulations are presented and the learning points highlighted by this structured presentation are discussed. In particular, it is suggested that this structured reconstruction of events, which highlights dentists' emotions, responses and the transactional effects of coping responses, might well facilitate objective reflective learning either individually or as part of peer to peer support. It should facilitate dentists' emotional processing of events and may thus contribute to stress reduction. CONCLUSION: CBT formulations of positive and negative dental scenarios may be constructed. It is proposed that this is a useful technique to foster reflection and learning in clinical situations and should lead to improved communication skills and shared decision-making, resulting in fewer complaints and thereby reduced stress. It should also improve dentists' emotional processing.

Understanding emotionally relevant situations in primary dental practice. 2. Reported effects of emotionally charged situations.

BACKGROUND AND AIMS: Dentistry is widely reported to be a stressful profession. There is a limited body of research relating to the coping strategies used by dentists whilst in clinical situations. This study aims to use qualitative methods to explore the full extent of the coping strategies associated with stressful events in primary dental practice. METHOD: Semi-structured interviews were conducted with 20 dentists within a 50 mile radius of Lincoln. A thematic analysis was conducted on verbatim transcriptions thereby identifying six themes and 35 codes. RESULTS: Participants described both problem-focussed and emotion-focussed strategies. The strategies used had a variety of outcomes in the context of use. Most dentists denied that their emotions affected their decision-making, but then proceeded to describe how they were influential. DISCUSSION AND CONCLUSION: Dentists use a wide variety of coping strategies some of which are maladaptive. Training in the development and recognition of appropriate coping decisions would be appropriate as they would, potentially, improve practitioner decision-making and well-being.

Understanding emotionally relevant situations in primary care dental practice: 1. Clinical situations and emotional responses.

BACKGROUND AND AIMS: The stressful nature of dental practice is well established. Much less information is available on the coping strategies used by dentists and the emotions which underlie the stressful experience. Previous research has been almost exclusively questionnaire-based, limiting the range of emotions explored. This study used qualitative methods to explore the full extent of emotions and coping strategies associated with stressful events in primary dental practice. METHOD: Semi-structured interviews were conducted with 20 dentists in Lincoln and the surrounding area. Verbatim transcriptions were analysed using thematic analysis. RESULTS: Participants reported a wide variety of stressful situations, consistent with the existing literature, which were associated with a diverse range of negative emotional responses including anxiety, anger and sadness. Dentists tended to have more difficulty identifying positive events and emotions. The designation of a situation as stressful or otherwise was dependent on the dentist's personal interpretation of the event. Data relating to the effects of stressors and the coping strategies used by dentists will be presented in subsequent papers. CONCLUSION: The situations which dentists find difficult are accompanied by a diverse set of emotions, rather than omnipresent 'stress.' This has implications for stress management programmes for those in dental practice.

Teaching of the assessment of head and brain injury in UK dental schools--The Headway Survey.

Under the auspices of Headway--the brain injury association, the charity supplies information on head/brain injury and runs a telephone advice line: (0115 924 0800). Questionnaires regarding the undergraduate teaching related to head/brain injuries were sent to, and returned by, all 12 UK dental schools. The replies suggest that undergraduate teaching of this subject is patchy and inadequately prepares dentists to recognise and cope with patients who may have had head, and consequently brain, injuries. It is recommended that dental schools review their teaching of this subject and ensure that it is consistent with the current guidelines issued by the National Institute of Clinical Excellence (NICE) on the recognition of head injury and that the findings are brought to the attention of the General Dental Council in the context of the GDC's "The first five years" report.

Bicycle helmets--does the dental profession have a role in promoting their use?

OBJECTIVES: To review the available literature regarding the: epidemiology of bicycle related head injuries; consequences of head injuries; rates of cycle helmet use; impact of educational campaigns and legislation on usage rates; effectiveness of cycle helmets in protecting against head and facial injuries; arguments against the compulsory use of bicycle helmets. DATA SOURCES: A computerised Medline search was conducted using the keywords: head injury, facial injury, bicycle helmets, accidents. DATA SELECTION: All available information was considered. DATA SYNTHESIS: Data was collated manually. CONCLUSIONS: The wearing of bicycle helmets contributes significantly to the prevention of head injuries (HI) and traumatic brain injury (TBI), particularly in children and adolescents. There is evidence to support the role of cycle helmets in the prevention of injuries to the middle third of the face and some dental injuries. There is a case for the implementation of legislation accompanied by educational campaigns to increase significantly the use of cycle helmets. The dental profession could: play an active role in promoting cycle helmet use; support calls for the compulsory wearing of cycling helmets, particularly for children; press for modification of helmet design and standards to increase protection of the face.

Visual/verbal analogue scales: examples of brief assessment methods to aid management of child and adult patients in clinical practice.

The flexible use of a visual/verbal analogue scale--the thermometer--is described as a means of monitoring patients' levels of cognitive fear, trust, pain and self-esteem during treatment visits. Variations for use with very young children and those with physical and learning disabilities are also described.

Dental fear in children--a proposed model.

Over the past eleven years, we have worked together to treat children who are dentally phobic. This has enabled us to develop an understanding of how children come to be dentally fearful. We have constructed a model of child dental fear which helps us in our work. It is important to acknowledge that fear is a normal phenomenon when any of us are exposed to threat. Helping dentally fearful children appraise or evaluate threat, face their fear and build upon their strengths is the task facing dentists and, occasionally, psychologists. The consequences for children of not doing so are extreme difficulty with accepting and ultimately total avoidance of treatment. Both of these can persist into adulthood. First, we propose to discuss the normality of fear in children, placing dental fear within a developmental context. We will then outline a model for assessing and treating dental fear which identifies five discrete but interrelated factors. Each of the factors and its treatment is illustrated with examples.

The composition of milk xanthine oxidase.

The composition of milk xanthine oxidase has been reinvestigated. When the enzyme is prepared by methods that include a selective denaturation step in the presence of sodium salicylate the product is obtained very conveniently and in high yield, and is homogeneous in the ultracentrifuge and in recycling gel filtration. It has specific activity higher than previously reported preparations of the enzyme and its composition approximates closely to 2mol of FAD, 2g-atoms of Mo and 8g-atoms of Fe/mol of protein (molecular weight about 275000). In contrast, when purely conventional preparative methods are used the product is also homogeneous by the above criteria but has a lower specific activity and is generally comparable to the crystallized enzyme described previously. Such samples also contain 2mol of FAD/mol of protein but they have lower contents of Mo (e.g. 1.2g-atom/mol). Amino acid compositions for the two types of preparation are indistinguishable. These results confirm the previous conclusion that conventional methods give mixtures of xanthine oxidase with an inactive modification of the enzyme now termed ;de-molybdo-xanthine oxidase', and show that salicylate can selectively denature the latter. The origin of de-molybdo-xanthine oxidase was investigated. FAD/Mo ratios show that it is present not only in enzyme purified by conventional methods but also in ;milk microsomes' (Bailie & Morton, 1958) and in enzyme samples prepared without proteolytic digestion. We conclude that it is secreted by cows together with the active enzyme and we discuss its occurrence in the preparations of other workers. Studies on the milks of individual cows show that nutritional rather than genetic factors determine the relative amounts of xanthine oxidase and de-molybdo-xanthine oxidase. A second inactive modification of the enzyme, now termed ;inactivated xanthine oxidase', causes variability in activity relative to E(450) or to Mo content and formation of it decreases these ratios during storage of enzyme samples including samples free from demolybdo-xanthine oxidase. We conclude that even the best purified xanthine oxidase samples described here and by other workers are contaminated by significant amounts of the inactivated form. This may complicate the interpretation of changes in the enzyme taking place during the slow phase of reduction by substrates. Attempts to remove iron from the enzyme by published methods were not successful.