Animal-assisted therapy in the dental practice

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Keywords: animal-assisted therapy benefits dental practice dog limitations minireview

University Medical Centre Rostock | Department of Operative Dentistry and Periodontology: Prof. Dr. Hermann Lang, Janna Schnelle

Translation from German: Yasmin Schmidt-Park

Citation: Lang H, Schnelle J: Animal-assisted therapy in the dental practice. Dtsch Zahnärztl Z Int 2021; 3: 192–194

DOI.org/10.3238/dzz-int.2021.0022

Introduction

Fear of the dentist is a problem that affects many patients and often stands in the way of dental care in the context of preventive, as well as curative treatment. The fear can be acquired through direct conditioning or through the narrated experience of other people in the context of indirect conditioning [3, 14]. To be able to carry out treatment despite dental anxiety, pharmacological techniques are often used to calm or immobilize the patient by means of nitrous oxide, sedation or intubation anesthesia. All these techniques have side effects. An alternative method is the use of “animal-assisted” therapy, which is known as AAT (animal-assisted therapy) in Anglo-American countries [3, 14, 16].

Man’s interest in animals stems from the fact that primitive human survival depended in part on animals in the environment. These served as indicators of a safe environment, but also of threats. This is the basis of Edward O. Wilson’s biophilia hypothesis (1984). When animals are observed in a peaceful state, it can signal safety, security, and a sense of well-being [6, 10, 16]. Dogs, in particular, are suitable therapy animals because they have developed human-like social skills through domestication that enable them to be sensitive to human posture, attentional states, and emotions [2, 8, 12].

Dogs are increasingly being used as part of animal-assisted therapy in German dental practices. In the following, an overview of the currently available literature on this therapy approach will be given and possible problems will be mentioned.

Statement

A review of the literature shows that most articles on animal-assisted therapy in the context of dentistry have been published in American journals. These are mainly clinical studies, meta-analyses and case reports. The number of studies addressing the benefits of animal-assisted intervention in dentistry is currently small. Increasingly, there is literature on the use of therapy dogs in areas outside dentistry, for example, rehabilitation, geriatrics, and psychiatry.

Methodology for determining the benefits of animal-assisted intervention

Numerical subjective rating scales such as the Corah Dental Anxiety Scale (CDAS) or similar are often used to determine the usefulness of a therapy dog for dental treatment [3, 5–7, 16, 18]. Other criteria include measurement of the patient’s pulse and blood pressure [3, 5, 6, 18] as well as oxytocin (happiness or bonding hormone) and cortisol (stress hormone) levels, which reflect the (reduced) fear response [2, 20].

Results of dental studies

According to a 2019 clinical study by Cruz-Fierro, Vanegas-Farfano et al., a therapy dog turns out to be useful in a dental (preventive) treatment of patients with dental anxiety. Thanks to the animal-assisted treatment, there was a decrease in blood pressure and pulse rate, as well as a better evaluation of the treatment using CDAS. Thus, the treatment was somewhat less painful and anxiety-provoking [3].

In 2018, Gupta and Yadav published a study on the acceptance of the use of a therapy animal in the dental office among parents. 41 of 61 parents agreed with the use of a therapy animal [8]. In a study by Vincent, Easton et al. (2020), 90 % of parents reported approving of treatment of their child in the presence of a therapy dog [19].

A study by Nammalwar and Rangeeth (2018) compared the anxiety levels of children with dental anxiety in a private pediatric dental facility in Chennai. A dog-assisted intervention was conducted in the waiting area as well as in the treatment area. The results showed that a 15-minute exposure in the waiting area already reduced the anxiety level [16].

A study by Fox (2019) also exclusively involved patients with dental anxiety. They were divided into two groups. One group had a 10-minute intervention with a therapy dog during dental treatment, and the second group served as a control group. The result was that the use of a therapy dog led to a reduction in physical and psychological anxiety [5]. In a study with a similar design, Thakkar, Naik et al. (2020) used independent t-tests to show that the anxiety reduction from having a dog present during therapy was highly significant (p < 0.001) [18].

Vincent, Heima et al. 2020 studied children between the ages of 8 and 12 with a known dental anxiety. They were subjected to treatment in the presence of a therapy dog. Saliva was measured for oxytocin and cortisol, which reflect the fear response. In most of the samples, there was an increase in oxytocin as a result of the therapy dog intervention. However, this was not statistically significant. Cortisol levels tended to decrease [20].

General medical studies

In general medicine, a dog-assisted intervention is used in the hospital in psychiatry, geriatrics, pediatrics and psychosomatics [6, 12, 13]. Dog-assisted therapy has a statistically small to moderate (but not significant) effect on psychiatric disorders (e.g., schizophrenia) and cognitive disorders (e.g., Alzheimer’s disease) and on various medical interventions in palliative care [12]. Animal-assisted intervention can result in significant pain relief. Objective reports of reduced pain and pain-related symptom relief (especially in physical rehabilitation and in patients with chronic pain) are supported by studies. These measured decreased catecholamine and increased endor­phin levels in people who received visits from therapy dogs [13, 15].

Further results show that a 20-minute session with a therapy dog can be an effective intervention to improve well-being and mood, as well as reduce anxiety. This is shown in an exploratory study of students at Heriot-Watt University [7].

Limitations for the use of a therapy dog

As described earlier, animal-assisted dental treatment can be useful for patients with anxiety as well as for children with lack of compliance.

Contraindications include immunosuppression (due to increased susceptibility to infection), allergy to animal hairs, and pregnancy. Animal-assisted intervention is also not indicated for persons with an aversion or phobia towards animals. An existing acute infection, colonization with MRE, open wounds and a lack of compliance with hand hygiene also speak against the use of a therapy dog [4, 9, 11].

Hygiene problems

In Germany, it is not forbidden from a hygiene point of view to use a therapy dog in the dentist’s office; in principle, the domestic authority applies [1].

According to Gussgard, Weese et al. (2019), risks to human health and safety during therapy dog intervention are present but low. Compliance with hygiene rules is crucial. The sources of danger can be divided into 4 categories: 1. the dog as a source of both zoonotic and human pathogens, 2. a contact with allergens in case of an existing animal hair allergy, 3. an undesirable animal behavior, 4. a reduced space due to the dog and an increased risk of falling (over the dog) [9].

According to the recommendation of the DGKH, the consent of all parties involved must be obtained before introducing a therapy dog. In addition, liability for damage caused by the dog must be clarified.

Conditions should be established and confirmed by the practice owner. The rooms entered by the therapy dog and the furniture in them must be wipe-disinfectable and a basin for washing hands must be easily accessible from the therapy room [4]. Furthermore, a notification to the health and veterinary office is required. The therapy dog must be labeled as such and must not be fed raw meat [11]. The dog’s state of health must be checked regularly, and it requires a certificate of suitability as a therapy dog [4,9]. This is not yet awarded in Germany according to uniform criteria [17].

The personnel must be instructed on how to handle the animal and on the hygiene regulations. The hygiene plan must be written down. Attention must be paid to adequate hand hygiene and the prevention of scratch marks on the patient’s skin and furniture [4, 9].

Conclusion

Animal-assisted therapy is increasing­ly used in medical practices. Before its introduction, some important hygienic precautions are to be taken. Furthermore, indication or, if neces­sary, contraindications for the respec­tive patient have to be checked. The advantages lie in the reduction of anxiety, which has been proven in many studies, and which leads to effects such as a reduction in blood pressure, pulse reduction, an increase in oxytocin and a reduction in cortisol. Regarding the subjective sensa­tion of the patients, this is expressed in a better evaluation by means of a numerical evaluation scale. However, there is still no standardized measurement methodology, which lim­its the significance and comparability of studies.

Overall, the use of a therapy dog as part of an anti-anxiety therapy during dental treatment is an feasible and cost-efficient approach to alleviating dental anxiety and has the poten­tial to improve the therapy of anxiety patients and patients with poor compliance if studies improve in the future [14].

Conflict of interest

The authors declare that there is no conflict of interest as defined by the guidelines of the International Committee of Medical Journal Editors.

References

  1. Auschra R: Therapiehund in der Praxis. DFZ 2018; 62: 60–62
  2. Buttner AP: Neurobiological underpinnings of dogs’ human-like social competence: How interactions between stress response systems and oxytocin mediate dogs’ social skills. Neurosci Biobehav Rev 2016; 71: 198–214
  3. Cruz-Fierro N, Vanegas-Farfano M, González-Ramírez MT: Dog-assisted therapy and dental anxiety: A Pilot Study. Animals 2019; 9: 512
  4. Deutsche Gesellschaft für Krankenhaushygiene: Empfehlung zum hygienegerechten Umgang mit Therapiehunden in Krankenhäusern und ver­gleichbaren Einrichtungen. Mitteilung des Vorstandes der DGKH. Hyg Med 2017; 42: 197–198
  5. Fox PJ: The effects of therapy dog intervention on distress in adult patients undergoing dental procedures: A pilot study. Master’s Thesis, Bethesda, Maryland 2019
  6. Gelhart E: Tiergestützte Therapie. Ein kritischer Review. Magisterarbeit, Linz, Österreich 2011
  7. Grajfoner D, Harte E, Potter LM, McGuigan N: The effect of dog-assisted intervention on student well-being, mood, and anxiety. Int J Environ Res Public Health 2017; 14: 483
  8. Gupta N, Yadav T: Parents’ acceptance and their children’s choice of pet for animal-assisted therapy (A.A.T.) in 3- to 12-year-old children in the dental operatory – A questionnaire-based pilot study. Int J Pediatr Dent 2018; 28: 373–379
  9. Gussgard AM, Weese JS, Hensten A, Jokstad A: Dog-assisted therapy in the dental clinic: Part A – Hazards and assessment of potential risks to the health and safety of humans. Clin Exp Dent Res 2019; 5: 692–700
  10. Joye J, De Block A: “Nature and I are Two”: A critical examination of the biophilia hypothesis. Environmental Val­ues 2011; 20: 189–215
  11. Landesamt für Gesundheit und Soziales: Hygienische Anforderungen bei Tierbesuchen und tiergestützter Therapie in Gesundheitseinrichtungen von M-V. Abteilung Gesundheit, Dezernat für Krankenhaushygiene und Allgemeine Hygiene. Stand: 08.11.2017
  12. 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
  13. Mandrá PP, Da Moretti TCF, Avezum LA, Kuroishi RCS: Animal assisted therapy: systematic review of literature. Terapia assistida por animais: revisão sistemática da literatura. Codas 2019; 31
  14. Manley L: On the use of pets to manage dental anxiety. Dent Hypotheses 2016; 7: 117–119
  15. Marcus DA: The science behind animal-assisted therapy. Curr Pain Headache Rep 2013; 17
  16. Nammalwar RB, Rangeeth P: A bite out of anxiety: Evaluation of animal-assisted activity on anxiety in children attending a pediatric dental outpatient unit. J Indian Soc Pedod Prev Dent 2018; 36: 181–184
  17. Röger-Lakenbrink I: Das Therapiehunde-Team: Ein praktischer Wegweiser. Kynos Verlag, Nerdlen/ Daun 2006
  18. Thakkar TK, Naik SN, Dixit UB: Assessment of dental anxiety in children between 5 and 10 years of age in the presence of a therapy dog: a randomized controlled clinical study. Eur Arch Paediatr Dent 2021; 22: 459–467
  19. Vincent A, Easton S, Sterman J, Farkas K, Heima M: Acceptability and demand of therapy dog support among oral health care providers and caregivers of pediatric patients. Int J Pediatr Dent 2020; 42: 16–21
  20. Vincent A, Heima M, Farkas KJ: Therapy dog support in pediatric dentistry: a social welfare intervention for reducing anticipatory anxiety and situational fear in children. Child Adolesc Soc Work J 2020; 37: 615–629

Prof. Dr. Hermann Lang

University Medical Centre Rostock

Department of Operative Dentistry and Periodontology

Strempelstr. 13, 18057 Rostock

Hermann.Lang@med.uni-rostock.de

Photo: Hermann Lang

Janna Schnelle

Dentist

University Medical Centre Rostock

Department of Operative Dentistry and Periodontology

Strempelstr. 13, 18057 Rostock

Janna.Schnelle@med.uni-rostock.de

Photo: Janna Schnelle


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