1. Cognitive Behaviour Therapy
Karen Clark
CBT Nurse
Birmingham Community Healthcare Trust

2. What is CBT……. Some people call it a talking therapy
Understanding how our fears develop and what effect fear has on our reactions. These are our learnt responses our automatic thoughts
Understanding these learnt responses, help us mange our fears differently

3. What causes dental anxiety
Traumatic experiences
Single event – flashbulb memory
Vicarious learning from
friends / family /media

4. THREE SYSTEMS OF FEAR
Lange 1969
Physical
Cognitive
Behavioral 4

5. Cognitive Feeling out of control Feeling trapped Distortion of events
Catastrophic misinterpretations
Heightened fear response

6. Physical Perspiration Increased heart rate Increased respiratory rate
Shallow respiratory function
Pins and needles
Palpitations
Feeling nausea / faint

7. Behaviour Avoidance/poor attendance Co –operation reduced
Aggressive/ unfocused
Escape/ritualised behaviour

8. Case History – Alan 62 year old
Requested to be ‘knocked out’ for treatment
Bad experiences as child and adult ++
Last had treatment 15 yrs ago
Treatment ‘always painful’ even with anaesthetic
MDAS Pre 31/25 Post 6/25

9. The CBT process Formulation – history, timeline, MDAS
Collaboration – working together, empathy
Planned gradual / guided exposure
Systematic desensitisation

11. Modified Dental Anxiety Score
MDAS score above 19 = CBT intervention
1 Not anxious
2 Slightly anxious
3 Fairly anxious
4 Very anxious
5 Extremely anxious

12. How would you feel if ……. 1 – 5 scores
you were going for treatment tomorrow
you were in the waiting room, waiting for treatment
you were about to have your tooth drilled
you were to have your teeth scaled
you were about to an injection

13. Catastrophic thoughts are real !!!!

14. Grading exposure A = Situation B = Response C = Consequence
0 = Extremely relaxed
10 = Extremely anxious

15. Remember…… The patient exposes themselves to the fear
I don’t expose the patient to fear

16. Attention switching Relaxation - zone out / ‘their place’
Breathing exercises / Diaphragmatic
Personal journey / music / aromatherapy
Applied tension

17. Limitations of CBT Age Unable to commit Time just not right
Pain / infection

18. Case Study – Janet 54 year old Last attended GDP 40 yrs ago
Multiple medical interventions for Hydrocephalus as a child
(while conscious)
Anxiety – vibration / sounds / smells
MDAS Pre 22/25 Post 7/25

19. Janet’s comments
I cannot thank CBT enough. I have been scared of the Dentist for 40 years.
My CBT Nurse made me feel at ease and I was able to open my mouth for a check up, something I thought I would never be able to do.
I cannot thank you enough to rid me of these terrible fears

20. Case Study - Harriet 16 year old
Needle phobic – unable to have any vaccinations (Mum also needle phobic)
Previously attended Dental Hospital for 4 years – no treatment achieved
MDAS 21/25 Post 10/25

21. I am going to have my vaccinations soon too
Harriet's comments
I am so pleased I have been able to have two fillings done I have even had my noise pierced. Mum loves it.
I still have to have a tooth extracted but I think I will be able to do it.
I am going to have my vaccinations soon too

22. Build trust not dependence

23. Feedback - Callum
I cannot thank you enough for helping Callum overcome this trauma and I must tell you he has conquered another fear by going on climbing courses and abseiling for his GCSE, it took four attempts but he did it.
He is much more confident and looking forward to having his brace fitted.

24. CBT - 45 pts referred so far

25. Referral information 5 Male / 23 female Average age 31
Ranging from 15 – 72 yrs
Average number of CBT apt 5.56
Ranging from 4 - 9

26. Outcomes so far

27. Mandatory Psychological Supervision

28. Contact details
Karen Clark