Center for the Future of the Health Professions Oct. 2024 digest
Posted: October 24, 2024
The Center for the Future of the Health Professions is excited to present another monthly op-ed column for 2024, offering insightful perspectives on issues shaping the future of health professions. Established to provide policymakers at all levels and healthcare stakeholders with accurate and comprehensive data, our center aims to support effective planning for a sustainable future in healthcare.
This month, our column shines a spotlight on animal-assisted therapy (AAT), which represents a promising approach to managing dental anxiety, a significant barrier to oral healthcare affecting approximately 20% of Americans. While AAT has a rich history dating back to 1792 and has demonstrated numerous benefits in various healthcare settings, including cardiovascular, psychological, and cognitive improvements, its application in dentistry remains relatively unexplored.
Our guest author, Mai-Ly Duong, DMD, MPH, ’12, is an associate professor and associate director of special care dentistry at A.T. Still University-Arizona School of Dentistry and Oral Health (ATSU-ASDOH). Dr. Duong earned an Advanced Education in General Dentistry certificate from NYU Langone Medical Center in 2013. This program evolved her clinical skills to include computer-aided design and computer-aided manufacturing, sedation dentistry, and advanced periodontal/oral surgery. In 2016, she earned a master’s degree in education with a dental emphasis from the University of the Pacific. Her many accomplishments and contributions to the dental profession have earned her recognition as a master of the Academy of General Dentistry, a fellowship in the Special Care Dentistry Association, a fellowship in the American College of Dentists, a fellowship in the International College of Dentists, and a fellowship in the Pierre Fauchard Academy. On a personal note, Dr. Duong loves to sing. Her personal goals are to become fluent in Spanish and American Sign Language.
We look forward to your feedback and comments as we continue to explore the dynamic landscape of healthcare professions. Please direct any comments or feedback on this month’s digest to cfhp@atsu.edu.
Randy Danielsen, PhD, DHL(h), PA-C Emeritus, DFAAPA
Professor and Director
The Center for the Future of the Health Professions
A.T. Still University
Animal-assisted therapy in the dental setting
Introduction
Animal-assisted therapy (AAT) can be used in conjunction with, or in place of, sedation to reduce and manage anxiety during dental treatment. AAT is grounded on scientific evidence that the human-animal bond is mutually beneficial and is influenced by behaviors directly leading to positive health and well-being for both.25 Because of this, AAT involves goal-centered interventions in which the animal meets, and is integral to, the treatment and healthcare process.
Although AAT is modern-day terminology and a growing field of study in psychology research, the use of animals for health benefits can date back to the beginning of mankind between cave dwellers and wolves.21 However, it was not until 1792 that the first case of animal therapy was documented in England when William Tuke found farm animals, such as rabbits and chickens, lessened the use of drugs and restraints.22 By the 19th century, animals were used as companions in European mental health institutions to increase comfort in an already seemingly prison-like environment. 23, 24
In 1919, the use of companion animals was first documented in the United States. Most notably canines were used in the psychiatric wings of hospitals.24 In the 1940s, animals were used to help U.S. veterans recuperate and reduce any PTSD symptoms. By the end of the 20th century, the use of animals in the healthcare setting had become prevalent, and the following terms were coined: animal-assisted therapy, animal-assisted interventions, and pet therapy.
Goals of AAT
Approximately 20% of Americans report a moderate to high level of anxiety about obtaining dental treatment. The most common reasons for avoiding dental treatment include fear of dental experience and previous negative dental experience.1, 19 Avoiding or delaying necessary dental treatment can lead to highly detrimental oral health consequences and inevitably reduces oral health-related quality of life.1
With stress and anxiety comes the activation of an individual’s autonomic nervous system; this system prepares the body for the sympathetic fight-or-flight response.3 Self-induced regulation is necessary as it serves as a coping mechanism for the body under certain situations.4 However, continued sympathetic activation can contribute to coronary heart disease, reproductive dysfunction, and immunosuppressive disorders.4 Orally, chronic stress and autonomic activation can lead to decreased salivary flow rate, xerostomia, and increased levels of plaque formation, all of which contribute to risk for oral disease.5
AAT programs are designed to improve an individual’s physical, social, and emotional health and cognitive functioning.12 AAT has shown cardiovascular, psychological, and cognitive benefits. Specifically, the use of AAT helps decrease anxiety, stress, and depression levels, decreases heart rate and blood pressure, improves self-esteem and mood, and lowers IgA levels.13 These changes have been seen with long- and short-term exposure to AAT. Consequently, nursing homes, hospitals, retirement communities, and many other institutions are implementing AAT.14 While AAT’s benefits are well documented in medical care facilities, AAT studies are virtually nonexistent in dental settings.
AAT in dentistry
In 2000, the American Academy of Pediatric Dentistry recommended distraction techniques to alleviate patient fear and anxiety related to dental treatment.15 Along with the other aforementioned benefits, Katcher & Friedmann (1980) reported that AAT can work as such distraction: petting an animal creates “a passive meditative focus on a non-threatening stimulus [that] can relax a person by lowering the body’s state of arousal.”16 In addition to tactile stimulation, AAT can provide deep pressure therapy (DPT) to anxious patients. DPT involves a dog using its weight and sometimes warmth to mitigate a psychiatric symptom, often either as a calming strategy or to minimize disengagement from the world. Similar to a weighted blanket for people with autism, DPT can relax and re-engage a person enduring an otherwise disabling symptom.17
One previous study attempted to show the benefits of AAT in a dental setting; however, their methods resulted in conflicting and inconclusive evidence of benefit.18 Many anecdotal experiences and case studies have shared the benefits of canine-assisted therapy in the dental setting. More properly designed studies need to be implemented to explore AAT’s effectiveness in a dental setting.
AAT’s benefits
- Cardiovascular benefits
The American Heart Association and the American Stroke Association report that an estimated 83.6 million Americans have been diagnosed with some cardiovascular disease (CVD). Further, CVD has been shown to increase premature deaths and nursing home admissions. Friedman and Thomas found that of the individuals who have experienced a myocardial infarction, those who owned pets had a higher statistically significant one-year survival rate than those who did not own pets.26 The American Heart Association has assessed the existing evidence and concluded that pet ownership positively influences the presence and reduction of CVD. It is currently examining the causal relationship that may be present.27 Other reputable institutions, such as the Mayo Clinic, have incorporated, and are also currently examining, the effects of AAT on CVD. - Psychological benefits
As previously alluded to, the positive benefits of AAT were first documented in psychology. It is also important to note that more than half of psychiatrists and psychologists indicate that they have prescribed companion animals (or pets) for their patients.28 AAT has been shown to improve social and communication skills, reduce anxiety, improve mood, and facilitate empathic skills.29 Some evidence has demonstrated that petting an animal reduces feelings of loneliness, depression, and insecurity.30 This provides strong support for the use of AAT in the dental arena when so many individuals face anxiety. - Cognitive benefits
AAT can catalyze communication, especially during psychotherapy sessions, because the presence of an animal makes the experience less threatening and more inviting. As previously stated, holding or petting an animal can provide physical comfort and a sense of security and safety.23 Because of this, the use of AAT in dental treatment is further supported. Furthermore, physiological signs such as blood pressure and respiratory rate are also decreased or normalized when an individual is comforted and secure.26
Types of AAT
Animals involved with AAT include dogs, cats, horses, dolphins, birds, rabbits, and fish. Dogs are the most common animals used for AAT. Often, canine-assisted therapy, feline-assisted therapy, or other smaller animals are used in healthcare facilities where the human or patient is receiving treatment. For example, a canine and his/her handler will visit a chronically ill patient in the hospital or long-term care facility.
Canine-assisted therapy is the most common type of AAT provided in the healthcare setting. They can be found in both short-term and long-term as well as group and individual settings. Feline-assisted therapy is often found in long-term facilities where they are seen more like pets due to their independent nature. They provide long-term facilities, a sense of continuity, and a homey feeling to the residents.
However, other types of therapy, such as equine-assisted therapy and dolphin-assisted therapy, require the human or patient to travel to the animals’ establishments. Having patients participate in grooming, feeding, and riding the horse has shown significant improvements in health and healing. Further, having patients interact, feed, and swim with dolphins has also shown increased response to physical therapy and psychological treatment.
Challenges of utilizing AAT
Sanitation
Infection control is a primary concern in all healthcare facilities. Therefore, when incorporating AAT as a strategy to improve patient well-being, it is essential to ensure the animal and handler follow all the guidelines set forth by the CDC to properly and safely reduce the risk for infection during AAT activities. These guidelines include, but are not limited to, the following:
- Establish and enforce proper hand-washing protocols.31
- Identify and treat any illness or wound that the AAT animal experiences in a timely manner.31
- Ensure that the AAT animal receives routine and regular veterinary visits, including up-to-date with all recommended vaccinations.31
- Regularly bathe and groom the AAT animal within 24 hours of interacting with patients.31
- Provide adequate time for the AAT animal to exercise and relieve themselves prior to interacting with patients.31
- Provide a healthy diet for the AAT animal.31
- Maintain an up-to-date record that shows the completion of an animal-assisted certification program.31
Animal welfare
Just as humans are prone to burnout, animals can also experience burnout or fatigue if overworked. Therefore, the Delta Society has created standards and in-depth guidelines to protect animals involved with AAT.32 These should be thoroughly reviewed and implemented into any AAT program.
To reiterate the CDC guidelines, the animal must be well cared for from a general health standpoint. The animal must also have time to enjoy being a pet. They must be trained to understand when it is time to work with patients and when it is time for them to play. When they are ill, proper action should be taken to restore their physical and mental health.
Selection process
Animals involved with AAT must be properly trained to prevent bad outcomes due to miscommunication. They should have mastered basic obedience skills and behave in a predictable manner. They must also enjoy being around people and being touched or held. Because dogs have been domesticated and can learn how to respond appropriately to voice commands, they are the most common type of AAT animal.
On the contrary, the patient receiving the AAT should be considered. Their preferences may indicate which type of animal will yield successful outcomes. The patient’s allergies to certain types of animals should be identified and avoided. Any animal with which the patient reports a poor history should also be avoided.
Conclusion
Because AAT has been highly successful in the medical arena, it is not surprising that it is slowly being incorporated into dentistry. As more and more institutions incorporate the use of AAT as a means to reduce anxiety, it can be argued that the use of AAT can be used in the following ways:
- To desensitize patients to a new dental office.
- To alleviate anxiety during consultations in the dental office.
- To reduce anxiety about invasive dental treatment.
- To help reduce anxiety during the induction of deep or general sedation.
- To help transition a patient from a deeper to a more conscious sedative state of mind.
There is a rich body of evidence showing the powerful effect the human-animal bond can have on health and well-being. Therefore, AAT programs have the potential to be a significant part of patient-centered treatment. It is important healthcare providers recognize, explore, and develop this strategy because it can have life-changing effects on the patients they care for.
References
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