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CDHO Advisory: Anxiety Disorders

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CDHO ADVISORY

SCOPE

RECOMMENDATIONS

BENEFITS/HARMS OF IMPLEMENTING THE RECOMMENDATIONS

CONTRAINDICATIONS

COLLEGE OF DENTAL HYGIENISTS OF ONTARIO ADVISORY

ADVISORY TITLE

Use of the dental hygiene interventions of scaling of teeth and root planing including curetting surrounding tissue, orthodontic and restorative practices, and other invasive interventions for persons1 with anxiety disorders.

ADVISORY STATUS

Cite as College of Dental Hygienists of Ontario, CDHO Advisory Anxiety Disorders, 2021-09-16

INTERVENTIONS AND PRACTICES CONSIDERED

Scaling of teeth and root planing including curetting surrounding tissue, orthodontic and restorative practices, and other invasive interventions (“the Procedures”).

SCOPE

DISEASE/CONDITION(S)/PROCEDURE(S)

Anxiety disorders

INTENDED USERS

Advanced practice nurses
Dental assistants
Dental hygienists
Dentists
Denturists
Dieticians
Health professional students
Nurses
Patients/clients
Pharmacists
Physicians
Public health departments
Regulatory bodies

ADVISORY OBJECTIVE(S)

To guide dental hygienists at the point of care relative to the use of the Procedures for persons who have anxiety disorders, chiefly as follows.

  1. Understanding the medical condition.
  2. Sourcing medications information.
  3. Taking the medical and medications history.
  4. Identifying and contacting the most appropriate healthcare provider(s) for medical advice.
  5. Understanding and taking appropriate precautions prior to and during the Procedures proposed.
  6. Deciding when and when not to proceed with the Procedures proposed.
  7. Dealing with adverse events arising during the Procedures.
  8. Keeping records.
  9. Advising the patient/client.

TARGET POPULATION

Child (2 to 12 years)
Adolescent (13 to 18 years)
Adult (19 to 44 years)
Middle Age (45 to 64 years)
Aged (65 to 79 years)
Aged 80 and over
Male
Female
Parents, guardians, and family caregivers of children, young persons and adults with anxiety disorders.

MAJOR OUTCOMES CONSIDERED

For persons who have anxiety disorders: to maximize health benefits and minimize adverse effects by promoting the performance of the Procedures at the right time with the appropriate precautions, and by discouraging the performance of the Procedures at the wrong time or in the absence of appropriate precautions.

RECOMMENDATIONS

UNDERSTANDING THE MEDICAL CONDITION

Terminology used in this Advisory

Nomenclature varies among clinical centres. The following reflects common though not necessarily universal usages.

Resources consulted

  1. Anxiety disorder 
    1. is a term used to distinguish anxiety as an illness from the worries or fears that are normal responses to things such as workplace pressures, public speaking, highly demanding schedules, writing an exam, or job interviews; uncomfortable though these responses are, they differ from anxiety disorders
    2. refers to any of various mental health disorders that
      1. are characterized by intense, prolonged feelings of fear, fright and distress for no seemingly well-founded reason
      2. vary to some degree in their symptoms, though all the symptoms group around prolonged feelings of fear, fright and distress for no seemingly well-founded reason
      3. interfere with relationships with family, friends and colleagues 
      4. often 
        1. occur together
        2. are comorbid with
          1. depression (CDHO Advisory)
          2. eating disorders (CDHO Advisory)
          3. substance abuse (CDHO Advisory)
          4. various physical conditions
  2. Anxiety disorders2 in children and/or adults chiefly include
    1. agoraphobia, which is
      1. anxiety about being in places or situations in which
        1. escape might be difficult 
        2. help might not be available in the event of a panic attack or panic-like symptoms
      2. experienced to some degree by most persons with panic disorder 
    2. generalized anxiety disorder, which is characterized by the syndrome of chronic anxiety, constant worry and tension that
      1. results in
        1. repeated, exaggerated episodes of worry about routine life events and activities
        2. is without seemingly well-founded reason
        3. is out of proportion to the likelihood of materialization of the matters focused on
        4. multiple worries and fears
        5. extreme pessimism, involving unreasonable anticipation of the worst of outcomes
      2. persists because it
        1. causes extreme worry on most days
        2. endures for six months or more
        3. seems unceasing
      3. impairs the quality of life because it 
        1. is debilitating
        2. undermines work, education, social relationships and quality of life
        3. creates psychosocial challenges such as 
          1. difficulty concentrating 
          2. feelings of restlessness or tension
          3. insomnia
          4. irritability
          5. proneness to fatigue
        4. may be accompanied by physical symptoms such as
          1. fatigue
          2. headache
          3. muscle tension
          4. nausea and diarrhea
          5. sweating
          6. trembling and fatigue
      4. adversely affects children and teens because it may be manifested as
        1. perfectionism 
        2. excessive need to seek approval from others
    3. panic disorder, attacks of panic which  
      1. occur without warning
      2. are accompanied by sudden, unexpected and repeated episodes of intense fear or terror
      3. may cause the person to avoid specific situations for fear of provoking panic
      4. are variously accompanied by symptoms such as 
        1. abdominal distress
        2. agoraphobia
        3. chest pain
        4. dizziness
        5. fear of dying
        6. feelings of unreality
        7. palpitations
        8. shortness of breath
    4. social anxiety disorder characterized by
      1. paralyzing, irrational, anxiety-related self-consciousness about social situations that in everyday social situations may be
        1. overwhelming and excessive 
        2. socially paralyzing
      2. intense fear of being observed as doing something wrong in the presence of other people
      3. avoidance of objects or situations that invoke the specific phobia, which impairs the ability to lead a normal life
      4. greater likelihood of developing in teenagers than in young children
        1. with symptoms such as 
          1. blushing
          2. impaired assertiveness
          3. low self-esteem
          4. muscle tension
          5. shortness of breath
          6. shyness and self-consciousness
          7. sweating
          8. tachycardia
          9. undue sensitivity to criticism
        2. in situations that may provoke avoidance behaviour, such as
          1. going to school
          2. fear about having to speak in class
          3. taking part in social or recreational activities
    5. specific phobias which,
      1. manifests as overwhelming, unreasonable and uncontrollable fears of particular situations
        1. to which exposure or expectation of exposure causes extreme anxiety and panic
        2. which are frightening to the person even though he or she recognizes that the fears are illogical
        3. which provoke anxiety sufficiently intense to interfere with a normal life
      2. include
        1. fear of dental examinations and procedures
        2. fear of flying
        3. fear of height
        4. fear of 
          1. animals
          2. blood
          3. needles
          4. open spaces
          5. confined spaces
    6. anxiety disorders in children, which 
      1. include selective mutism, where a child does not speak in particular situations but does speak in others, a condition  
        1. in which fear of speaking arises only in situations that make the child feel anxious
        2. which is outgrown by some children but not others
        3. which without treatment, may persist throughout schooling. 
      2. include separation anxiety, which usually occurs or is diagnosed only in children under the age of 18, and
        1. is characterized by excessive worry in the child about separation from the parent or major attachment figure, possibly causing the child to fear that the
          1. parent or other will be harmed
          2. child himself or herself will be kidnapped or lost
        2. usually occurs or is diagnosed only in children under the age of 18
        3. may manifest as homesickness, which may  
          1. be severe enough to result in distress and functional impairment associated with an actual or anticipated separation from home, parents and pets
          2. cause sufficient distress to persistently discourage visits away from home.
      3. may result in
        1. bouts of nausea or vomiting
        2. episodes of stomachache
        3. inability to fall asleep without an adult close by
        4. nightmares
        5. refusal to go to school
        6. various school or social problems.
  3. Syndrome, group of signs and symptoms that 
    1. occur together
    2. characterize one or more specific disorders.

Overview of anxiety disorders

Resources consulted

Anxiety disorders, generally

  1. Occurrence, causes and risk factors
    1. anxiety disorders are illnesses that
      1. in occurrence and manifestations
        1. are the most common of all mental health challenges
        2. are prevalent among and are experienced by people of 
          1. all ages
          2. all social, economic, cultural, and ethnic backgrounds
        3. are poorly understood
        4. are identifiable and treatable 
        5. are characterized by intense, prolonged feelings of fright and distress for no apparent reason
        6. affect 10–12 percent of Canadians
        7. are somewhat more prevalent among women than among men
        8. affect children as well as teenagers and adults
        9. in children 
          1. affect 5–10 percent of children severely enough to
            1. require treatment 
            2. interfere with school and social activities usual for the age and stage of development 
          2. may persist throughout life if anxiety disorders that begin in childhood are not adequately treated 
          3. chiefly include
            1. homesickness 
            2. selective mutism 
            3. separation anxiety 
      2. have causes
        1. which are incompletely understood, but which are believed to originate in some mix of 
          1. biological factors that 
            1. are believed to result from a combination of genetic, environmental, psychological, and developmental factors
            2. reflect multiple, complex factors likely rooted in the genetics and the behaviour of the parent or parents in that
              1. children and adolescents are particularly prone to anxiety disorders if they have a parent affected by depression or anxiety
              2. the beliefs and behaviours of the parent(s) contribute to and sustain the depression and anxiety experienced by the child
            3. may affect the parts of the brain involved in the production of fear and anxiety
          2. personal circumstances, such as stress
      3. create social risks that 
        1. lead to stigmatization and discrimination, which may inhibit individuals from getting help
        2. commonly interfere with relationships with family, friends and colleagues
      4. commonly co-exist with comorbid conditions, complications and associated conditions
        1. with one or more anxiety disorders
        2. with other mental disorders 
        3. with physical illnesses. 
  2. Signs and symptoms
    1. vary according to the type of anxiety disorder but generally affect
      1. behaviour
      2. emotions 
      3. physical health
      4. thoughts
    2. cause significant distress
    3. chiefly involve 
      1. a free-floating character sometimes described as a dark cloud capable of settling on anything that is in the person’s mind, surroundings or life
      2. virtually constant
        1. fear
        2. tension
        3. worry
      3. difficulty concentrating
      4. fatigue
      5. irritability
      6. sleep problems, including
        1. difficulty falling or staying asleep
        2. sleep that is often restless and unsatisfying
    4. include physical signs and symptoms, such as
      1. muscle tension resulting in shakiness and headaches
      2. gastrointestinal problems, such as 
        1. nausea
        2. diarrhea.
  3. Medical investigation
    1. contends with challenges to diagnosis, such as
      1. categorization of anxiety disorders as mental weakness or instability, leading to social stigmatization that discourages persons from
        1. seeking help
        2. disclosing their full medical history 
      2. unnecessary delay in arriving at the correct diagnosis, which may not be performed  promptly enough to assure accurate diagnosis and appropriate treatment, leading to prolongation of troubling symptoms
    2. involves physical examination and mental health tests aimed at excluding other conditions and behaviours also associated with the signs and symptoms of anxiety disorder
    3. is indicated if the person 
      1. is constantly worried and anxious 
      2. is experiencing interference with daily activities.
  4. Treatment
    1. is promising though anxiety disorders can be persistent and difficult to treat
    2. seeks to achieve functioning for everyday life
    3. chiefly comprises singly or in combination 
      1. medications
      2. cognitive-behavioural therapy, which 
        1. may target particular types of symptoms
        2. aims at the person’s
          1. gaining understanding and control of distorted views of
            1. life events
            2. life stressors
            3. other people’s behaviour
          2. recognizing and replacing panic-causing thoughts
          3. combating sensations of helplessness
          4. managing stress
          5. relaxing when symptoms arise
          6. avoiding thoughts that minor worries will evolve into major problems
        3. may involve controlled exposure to feared objects or situations
      3. advice to 
        1. avoid 
          1. caffeine
          2. substances of abuse
        2. embrace
          1. exercise
          2. rest
          3. a nutritious diet.
  5. Prevention
    1. is limited in scope because anxiety disorders as illnesses cannot be prevented, although various of the effects, attacks and manifestations of anxiety disorders can be reduced, managed, or minimized by
      1. lifestyle changes on the part of the person, including
        1. avoidance of caffeine, smoking and unhealthy eating
        2. avoidance of potentially dangerous ways of coping with anxiety, including reliance on 
          1. alcohol
          2. overuse of medications
          3. substances of abuse
        3. exercise, adequate rest and good nutrition.
      2. cognitive-behavioural therapy to assist in control of symptoms of anxiety or panic by tutoring the person to
        1. respond defensively to situations that create anxiety
        2. overcome negative thinking
        3. adapt physical and psychosocial behaviour to
          1. identify situations that create anxiety
          2. take actions likely to reduce perceived threats
        4. share feelings with trusted friends or relatives
        5. use relaxation techniques 
        6. avoid unnecessary stress by identifying and eliminating as many nonessential activities as possible from the daily routine
    2. involves encouraging the person to seek advice and care from appropriate healthcare providers.
  6. Prognosis
    1. is improved by appropriate treatment
    2. depends on the type and severity of the anxiety disorder.
  7. Social considerations
    1. involve reliable, trustworthy information resources for persons and their family caregivers
    2. include support groups 
      1. which are helpful to
        1. the person
        2. family and family caregivers, who are considerably burdened by anxiety disorder in a family member
      2. which include
        1. In Canada
        2. In the US

Multimedia and images

Comorbidity, complications and associated conditions

Comorbid conditions are those which co-exist with anxiety disorders but which are not believed to be caused by it. Complications and associated conditions are those that may have some link with it. Distinguishing among comorbid conditions, complications and associated conditions may be difficult in clinical practice.

Resources consulted

Comorbid conditions, complications and associated conditions for anxiety disorders include the following.

  1. Anxiety disorders comorbid with each other, a clinical picture that occurs commonly.
  2. Various psychosocial and mental health conditions, such as 
    1. depression (CDHO Advisory)
    2. substance abuse, often associated with self-medication to combat troublesome symptoms (CDHO Advisory)
    3. depression and substance abuse 
    4. eating disorders (CDHO Advisory)
    5. obsessive compulsive disorder. 
  3. Various physical conditions, such as
    1. asthma (CDHO Advisory)
    2. cardiovascular conditions and symptoms such as angina (CDHO Advisory)
    3. irritable bowel syndrome (CDHO Advisory)
    4. migraine
    5. multiple sclerosis (CDHO Advisory)
    6. conditions with prominent anxiety symptoms, which may exacerbate or be exacerbated by the symptoms of the anxiety disorder, such as 
      1. hyperthyroidism (CDHO Advisory)
      2. hypothyroidism (CDHO Advisory)
      3. polycythaemia (CDHO Advisory)
      4. lupus (CDHO Advisory)
      5. chronic lung disease.
  4. Symptoms in children possibly associated with physical conditions, such as 
    1. abdominal migraine
    2. functional abdominal pain
    3. functional abdominal pain syndrome
    4. functional dyspepsia
    5. irritable bowel syndrome (CDHO Advisory).

Oral health considerations

Resources consulted

  1. Distinguishing between anxiety disorders and dental anxiety is important in oral healthcare because
    1. high levels of dental anxiety may signal one or more anxiety disorders, which may call for medical investigation
    2. anxiety disorders may sustain dental anxiety
    3. dental-injection fear may be a specific phobia
    4. among persons
      1. who avoid oral healthcare to the point of developing oral disease, an important factor may be substance abuse and anxiety disorders that contribute to it
      2. who seek oral healthcare despite high levels of dental anxiety, associated factors may be
        1. previous conditioning resulting from a traumatic dental experience
        2. specific phobias unrelated to oral healthcare
      3. with dental anxiety who complain of embarrassment the
        1. manifestations of one or more of the anxiety disorders may on enquiry emerge as the chief complaint
        2. embarrassment may be a side-effect
  2. Oral healthcare management requires recognition of the implications of anxiety disorders because these may
    1. complicate use of the Procedures because of reluctance to report receiving psychiatric treatment arising from experience of or fear of stigmatization 
    2. require that, prior to embarking upon oral healthcare for a patient/client receiving care for anxiety disorder, the dental hygienist should consult with the primary-care physician about the current 
      1. psychological status as it relates actually or potentially to the Procedures
      2. medications pertaining to the anxiety disorder.

MEDICATIONS SUMMARY

Sourcing medications information

  1. Adverse effect database
  2. Specialized organizations
  3. Medications considerations
    All medications have potential side effects whether taken alone or in combination with other prescription medications, or as over-the-counter (OTC) or herbal medications.
  4. Information on herbals and supplements 
  5. Complementary and alternative medicine

Types of medications

Medications

  1. Antidepressants
    1. are effective for anxiety disorders though developed to treat depression 
    2. require from 4 to 6 weeks before symptoms start to lessen
    3. include
      1. selective serotonin reuptake inhibitors (SSRIs), such as
      2. serotonin-norepinephrine reuptake inhibitors (SNRIs), such as
      3. tricyclics, such as
      4. monoamine oxidase inhibitors, such as 
        1. isocarboxazid  (Marplan®)
        2. phenelzine  (Nardil®)
        3. tranylcypromine  (Parnate®)
      5. other antidepressantS
  2. Anxiolytics, anti-anxiety medications, include
    1. benzodiazepines, which 
      1. effectively combat anxiety
      2. require increasing doses to maintain effectiveness
      3. may create dependency
      4. are used for short periods, especially with a history of substance or alcohol abuse
      5. include
    2. azapirones, newer anxiolytics, such as buspirone  (BuSpar®)
  3. Beta-blockers, used to prevent the physical symptoms associated with some anxiety disorders, include

Side effects of medication

See the links above to the specific medications. 

THE MEDICAL AND MEDICATIONS HISTORY

The dental hygienist in taking the medical  and medications history-taking should 

  1. seek to overcome reluctance on the part of the patient/client to disclose a history of anxiety disorder, by 
    1. expressing supportive, nonjudgmental attitudes
    2. assuring the patient/client that such information
      1. is necessary for the provision of safe oral health, especially relative to
        1. contraindications
        2. obtaining advice from the appropriate primary care provider(s)
      2. will be kept confidential 
  2. focus on screening the patient/client prior to treatment decision relative to
    1. key symptoms
    2. medications considerations
    3. contraindications
    4. complications
    5. comorbidities
    6. associated conditions
  3. explore the need for advice from the primary or specialized care provider(s)
  4. inquire about
    1. pointers in the history of significance to anxiety disorders, especially  
      1. symptoms indicative of
        1. panic attack
        2. dental anxiety
      2. signals that the patient/client may be inhibited from disclosing a history  indicative anxiety disorder
    2. medications considerations, including over-the-counter medications, herbals, supplements and inappropriate use of prescription medications and substances of abuse
    3. the patient/client’s understanding and acceptance of the need for oral healthcare
    4. problems with infections generally and specifically associated with dental/dental hygiene care
    5. the patient/client’s current state of health
    6. how the patient/client’s current symptoms relate to
      1. oral health
      2. health generally
      3. recent changes in the patient/client’s condition. 

IDENTIFYING AND CONTACTING THE MOST APPROPRIATE HEALTHCARE PROVIDER(S) FOR ADVICE

Identifying and contacting the most appropriate healthcare provider(s) from whom to obtain medical or other advice pertinent to a particular patient/client

The dental hygienist should

  1. record the name of the physician/primary care provider most closely associated with the patient/client’s healthcare, and the telephone number
  2. obtain from the patient/client or parent/guardian written, informed consent to contact the identified physician/primary healthcare provider
  3. use a consent/medical consultation form, and be prepared to securely send the form to the provider 
  4. include on the form a standardized statement of the Procedures proposed, with a request for advice on proceeding or not at the particular time, and any precautions to be observed.

UNDERSTANDING AND TAKING APPROPRIATE PRECAUTIONS

Infection Control

Dental hygienists are required to keep their practices current with infection control policies and procedures, especially in relation to

  1. the CDHO’s Infection Prevention and Control Guidelines (2022)
  2. relevant occupational health and safety legislative requirements
  3. relevant public health legislative requirements
  4. best practices or other protocols specific to the medical condition of the patient/client.

DECIDING WHEN AND WHEN NOT TO INITIATE THE PROCEDURES PROPOSED

The dental hygienist 

  1. should not implement the Procedures without prior consultation with the appropriate primary or specialist care provider(s) if the patient/client 
    1. displays signs/symptoms of anxiety or an anxiety disorder that pose a risk to himself/herself or the dental hygienist during Procedures (e.g., markedly elevated heart rate with comorbid heart disease, inability to sit still, etc.)
    2. has a history of panic attack that has previously occurred in the dental/dental hygiene setting
    3. has a history of severe leukopenia (i.e., reduced white blood cell count, and hence immunosuppression) is suspected with tricyclic antidepressant (TCA) or monoamine oxidase inhibitor3 (MAOI) medication use.  [This would be a rare situation in the dental hygiene office setting.]
  2. may postpone the Procedures pending medical advice if the patient/client 
    1. appears to be experiencing a panic attack  or other signs/symptoms of anxiety or an anxiety disorder that may pose risk during, or cause inability to perform, Procedures (in which case medical intervention may first be needed)
    2. is experiencing severe signs/symptoms of anxiety (in which case attainment of better anxiety control may be indicated to alleviate the patient/client’s before attempting elective dental hygiene treatment)
    3. is experiencing symptoms suggestive of complications of anxiety disorders or its treatment (this includes the patient/client appearing drowsy and/or confused, which may be side effects of benzodiazepine use)
    4. has medical clearance pending regarding possible immunosuppression associated with TCA or MAOI use
    5. has not complied with pre-medication as directed by the prescribing physician 
    6. has recently changed significant medications, under medical advice or otherwise
    7. recently experienced changes in his/her medical condition such as medication or other side effects of treatment
    8. is unable to provide the dental hygienist with sufficient information about his/her
      1. medications
      2. medical history
    9. at the dental hygiene visit exhibits symptoms or signs of 
      1. exacerbation of an existing anxiety disorder
      2. comorbidity, complication or an associated condition of anxiety disorders
    10. not recently or ever sought and received medical advice relative to oral healthcare procedures
    11. is deeply concerned about any aspect of his or her medical condition.

DEALING WITH ANY ADVERSE EVENTS ARISING DURING THE PROCEDURES

Dental hygienists are required to initiate emergency protocols as required by the College of Dental Hygienists of Ontario’s Standards of Practice, and as appropriate for the condition of the patient/client.

First-aid provisions and responses as required for current certification in first aid.

RECORD KEEPING

Subject to Ontario Regulation 9/08 Part III.1, Records, in particular S 12.1 (1) and (2) for a patient/client with a history of anxiety disorders, the dental hygienist should specifically record

  1. a summary of the medical and medications history
  2. any advice received from the physician/primary care provider relative to the patient/client’s condition
  3. the decision made by the dental hygienist, with reasons
  4. compliance with the precautions required
  5. all Procedure(s) used
  6. any advice given to the patient/client.

ADVISING THE PATIENT/CLIENT

The dental hygienists should 

  1. urge the patient/client to alert any healthcare professional who proposes any intervention or test 
    1. that he or she has a history of an anxiety disorder
    2. to the medications he or she is taking
  2. employ communication methods that allow the patient/client to feel a sense of control over the Procedures
  3. should discuss, as appropriate 
    1. the importance of the patient/client’s
      1. self-checking the mouth regularly for new signs or symptoms
      2. reporting to the appropriate healthcare provider any changes in the mouth
    2. the need for regular oral health examinations and preventive oral healthcare 
    3. mouth ulcers and other conditions of the mouth relating to anxiety disorders, comorbidities, medications, tobacco use or diet
    4. hypersensitivity of teeth, and gingival and tooth abrasion related to compulsions and repetitive behaviours 
    5. oral self-care including information about 
      1. choice of toothpaste
      2. tooth-brushing techniques and related devices
      3. dental flossing
      4. mouth rinses
      5. management of a dry mouth 
    6. the importance of an appropriate diet in the maintenance of oral health
    7. for persons severely affected by an anxiety disorder
      1. regimens for oral hygiene as a component of supportive care 
      2. the role of the family caregiver, with emphasis on maintaining an infection-free environment through hand-washing and, if appropriate, wearing gloves
      3. scheduling and duration of appointments to minimize stress and fatigue 
    8. comfort level while reclining, and stress and anxiety related to the Procedures
    9. medication side effects such as dry mouth, and recommend treatment
    10. pain management.

BENEFITS/HARMS OF IMPLEMENTING THE RECOMMENDATIONS

POTENTIAL BENEFITS

  1. Promoting health through oral hygiene for persons who have anxiety disorders.
  2. Reducing the adverse effects, such as panic attacks, by
    1. generally increasing the comfort level of persons in the course of dental hygiene interventions 
    2. using appropriate techniques of communication
    3. providing advice on scheduling and duration of appointments.
  3. Reducing the risk that oral health needs are unmet.

POTENTIAL HARMS

  1. Causing an exacerbation of an anxiety disorder.
  2. Performing the Procedures at an inappropriate time, such as 
    1. during a panic attack
    2. when the patient/client’s anxiety disorder is inadequately controlled
    3. in the presence of complications for which prior medical advice is required
  3. Disturbing the normal dietary and medications routine of a person with an anxiety disorder.
  4. Inappropriate management of pain or medication.

CONTRAINDICATIONS

CONTRAINDICATIONS IN REGULATIONS

Identified in the Dental Hygiene Act, 1991 – O. Reg. 218/94 Part III

ORIGINALLY DEVELOPED

2009-10-27

DATE OF LAST REVIEW

2011-08-01; 2018-03-21; 2021-09-16

ADVISORY DEVELOPER(S)

College of Dental Hygienists of Ontario, regulatory body
Greyhead Associates, medical information service specialists

SOURCE(S) OF FUNDING

College of Dental Hygienists of Ontario

ADVISORY COMITTEE

College of Dental Hygienists of Ontario, Practice Advisors

COMPOSITION OF GROUP THAT AUTHORED THE ADVISORY

Dr Gordon Atherley
O StJ , MB ChB, DIH, MD, MFCM (Royal College of Physicians, UK), FFOM (Royal College of Physicians, UK), FACOM (American College of Occupational Medicine), LLD (hc), FRSA

Dr Kevin Glasgow
MD, MHSc, DTM&H, CHE, CCFP, DABPM, LFACHE, FCFP, FACPM, FRCPC

Lisa Taylor
RDH, BA, MEd, MCOD

Giulia Galloro
RDH, BSc(DH)

Carolle Lepage
RDH, BEd

ACKNOWLEDGEMENTS

The College of Dental Hygienists of Ontario gratefully acknowledges the Template of Guideline Attributes, on which this advisory is modelled, of The National Guideline Clearinghouse™ (NGC), sponsored by the Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services.

Denise Lalande
Final layout and proofreading

© 2009, 2011, 2018, 2021 College of Dental Hygienists of Ontario

FOOTNOTES

1 Persons includes young persons and children
2 Several mental illnesses are no longer classified as anxiety disorders although anxiety is a major part of the conditions.  These illnesses include obsessive compulsive disorder (OCD, in which unwanted thoughts, images, or urges [i.e., obsessions] cause anxiety resulting in repeated actions intended to reduce that anxiety [i.e., compulsions]), as well as post-traumatic stress disorder (PTSD, which involves reliving a traumatic event – such as an accident, natural disaster, or abuse – through flashbacks or nightmares, in addition to avoiding reminders of the traumatic event; lifetime prevalence is 5% to 10%).
3 MAOIs are generally not first-line choices for medical management of anxiety disorders due to their side effect and drug interaction profiles.  However, they are used in the management of panic disorder and some other anxiety disorders when first-line antidepressants are ineffective.