This course was published in the January 2020 issue and expires January 2023. 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.
- Describe the use of a therapy dog in the dental setting.
- Identify guidelines and recommendations for safely incorporating a therapy dog into dental practice.
The use of animal-assisted interventions in health care settings is an evidence-based practice.1–12 Two types of animal-assisted interventions are used in health care settings: animal-assisted therapy (AAT) and animal-assisted activities (AAA). The former is a goal-oriented, therapeutic intervention that involves animals — typically, a therapy dog — 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, AAAs are not usually goal-oriented, but instead provide informal interactions for educational and/or motivational purposes.1 Offering AAT typically requires the facilitator to have a 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 (including horses), the therapy dog has consistently been shown to be most effective in animal-assisted interventions.13
SUITABLE PATIENT GROUPS
The use of dogs is primarily effective in aging populations, pediatric care and pain reduction.3–5 Research in nursing-home populations has examined the impact of a therapy dog 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 among participants who received AAT in long-term care facilities. Additionally, this approach 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 after therapy dog interventions, whereas those who received traditional treatment experienced an increase in agitation and depression over time.4
Therapy dog interventions are also effective in children with mood, anxiety and/or eating disorders.6–9 Stefanini et al6 demonstrated that children with acute mental disorders experienced positive changes in behavior, motivation, competence and overall functioning, and decreases in internalizing problems with the introduction of a therapy dog. Additionally, dogs can be used in nonclinical pediatric populations to reduce stress associated with medical procedures. For example, the presence of a dog during blood collection reduced cortisol levels in children, indicating a reduction in stress.9 Cortisol is released in the body in response to stress associated with anxiety. Although cortisol levels can vary depending on time of day or lifestyle factors, a decrease in cortisol levels associated with assistance dogs provides initial evidence AAT can be beneficial for anxious patients in health care settings.9
This approach 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 with a therapy dog — beginning one day after the procedure — reported decreases in pain perception.10 In all three sessions, participants reported a decrease in pain levels.10 In an acute pediatric care unit, a significant reduction in pain levels (up to four times greater) was reported among children receiving AAT, compared with the control group.11
Additionally, the reduction in pain was noted 15 minutes after introducing the dog to the child.11 Of particular note are AAT’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 use of a therapy dog demonstrates the potential benefit of incorporating the practice into dentistry. The introduction of AAT and AAA may reduce dental anxiety-related stress and promote positive oral health-seeking behaviors. If a patient perceives a threat in the dental operatory that 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 (e.g., gripping the chair and/or an increased heart rate) to severe, during which the symptomatology can be debilitating (e.g., panic attacks or jumping during injections).16,17
Although rates vary by methodology and may be underreported, researchers estimate that up to 80% of Americans experience some form of dental anxiety.16–20 Of these patients, 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 scaling or the administration of local anesthesia will be painful, he or she typically reports higher levels of anxiety for the overall 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 help 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 take place. 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 the 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 the 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 a therapy dog could be integrated into dental practice 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 these interventions, which is associated with lower levels of stress and increased pain thresholds.29,31–33 In summary, the present research indicates possible objective and subjective benefits with animal-assisted interventions — particularly use of a therapy dog — among patients in dental settings.28
GUIDELINES AND RECOMMENDATIONS
Although initial evidence suggests animal-assisted interventions can be effective in reducing pain and anxiety, this approach has not been examined enough in the dental setting. Oral health professionals thinking about implementing this type of intervention should consider creating guidelines before moving ahead with AAT. Many guidelines have been developed for health care settings, mainly due to the increasing popularity of AAT in nursing homes and hospitals.34-41 Dental teams can adapt these into their practice.
1. Allergies should be considered. Finding a dog 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 therapy dog problematic. The practice should maintain a place for the dog to remain away from patients when this occurs. Conversely, the practice could also not schedule the dog on days when 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 into practice.41
4. Keeping the office disinfected and equipment sterile can also be a concern for dental teams. While the U.S. Centers for Disease Control and Prevention has not found any evidence to suggest animals pose more risk for transmitting infection than people, this can still be a concern of patients and staff. The office should consider the type of treatment, as well as protocols and policies, when considering the use of animal-assisted interventions in order to maintain a hygienic and safe environment. 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 consent to being treated in the presence of a therapy dog.41
6. Using professionally trained animals should also be considered before implementation. Several organizations train dogs for AAT. These groups — such as the 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 AAT into practice. Although there is testimonial on the successful incorporation of a therapy dog in dental practice, minimal clinical research exists for dental settings. However, research of animal-assisted interventions, specifically dog therapy, in other health care settings can inform the practice and lead to success introduction.34–41 Please reference the 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 use of a therapy dog, have been documented in health care settings as having positive effects on patients. Research supports this therapeutic approach in aging populations, pediatric patients and for pain reduction.3–5 Patients with dental anxiety typically expect to experience pain during appointments, which further increases fear and anxiety.16,17 A large portion of the U.S. population experiences dental anxiety, which has been linked to a range of symptoms that negatively impact dental care.16–20 Ultimately, dental anxiety can lead to missed appointments and avoidance of professional care, resulting in adverse health outcomes.21–23 The introduction of animal-assisted interventions may reduce stress 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 November 22, 2019.
- 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.
- Maji´c 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: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;96:713–729.
- 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 November 22, 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 November 22, 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 November 22, 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 (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 November 22, 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 Decisions in Dentistry. January 2020;6(1):40–43.