The “Third Ear” and the Interview

The above interview is a reconstruction of a relatively uncomplicated exchange. It seems simple, merely a matter of “common sense”. However it is technically highly structured, proceeding in an arrow-like projection straight to the target.

More complicated histories require additional skills. The ability to be effective will depend upon how well one “hears” what is being said. One may listen but may not “hear”. “Hearing” relates to the picking up of obscure cues; words and phrases that contain the clue to the fear being expressed, cues less obvious than “pain”, “drill” and “needle”. Hence they may go “unheard”. Success will depend on the doctor’s knowledge of these cues and the development of his “third ear” which permits him to “hear” the subtle and less obvious statements of fear.

What follows is an example of an interview in which some obscure cues are put forth by the patient. She is not aware of their meaning, yet without knowing the significance of these cues, the patient is compelled to give them. The interview was performed by a relatively inexperienced third year dental student as part of a course on iatrosedation. He did quite well up to a point, but his “third ear” was not developed sufficiently to enable him to pick up the more obscure cues.

Student: “Are you having any difficulties?”

Patient: “Yes, I have a tooth that has been aching and I need to have it fixed… but I can’t take novocaine… and the whole idea makes me nervous.”

Student: “Is there some reason why you cannot have a local anesthetic?”

Patient: “My doctor said I am allergic to all of the ‘caine’ family and therefore I must have a general anesthetic to get my work done.”

Student: “How did your doctor come to the conclusion that you are allergic? What happened?”

Patient: “Well, I had to have a tooth pulled that was in my palate, an eye tooth. The dentist gave me several shots and then left while it took effect. All of a sudden I couldn’t breathe. It felt like something terribly heavy on me. My heart started palpitating, pounding and I was choking and having a terrible problem. The dentist came back, was upset and said that I had to have an EKG immediately… he wouldn’t work on me… so I went to see the doctor he called. There was nothing wrong with my heart… he said I can’t take local anesthetics.”

Student: “Have you had dental work since then? What did you do?”

Patient: “I had all my work done without a local… even the rebuilding of a tooth with spikes in it… I so dread it… it’s worse than having a baby which I also had without a local.”

Student: “How did you feel when you did get injections?”

Patient: “There’s a little tenseness… but not bad. The needle doesn’t bother me… but I’m kind of scared… I think most people are anxious, don’t you? It has nothing to do with the dentist as a person… I don’t know… there’s just something about it… it’s a sort of a frightening experience… you don’t know if you’re going to choke or something. It’s more a matter of being able to control the situation.”

This interview had been videotaped as part of the course on iatrosedation. A teacher reviewed the tape with the student and pointed out that the patient had repeated a cue three times to which he had not responded. She had said, “…I couldn’t breathe… I was choking…. you don’t know if you’re going to choke or something…” and then added, “It’s more a loss of being able to control the situation.”

Generally speaking, when a patient reacts to a dental situation with a sensation of not being able to breathe, or feeling like he/she is choking, the cue suggests some previous experience that was a threat to breathing. The student was advised to resume the interview with the patient, stating that during the review of the tape it was noticed that she mentioned having had difficulty with breathing and choking. He was to ask the patient if she had ever had an experience that was a threat to her breathing. Her response was, “Yes, now that I think of it, when I was a young girl I almost drowned.” So indeed, she had suffered the harrowing experience of suffocation and the assumption can be made that any sensation which suggests interference with the airway may trigger the feeling of panic that accompanies suffocation. The suffocating experience was generalized to the dental scene.

The probable sequence of events was reconstructed in order to offer the patient an interpretation of the origin and cause of her fear. Working with such an interpretation is helpful to the patient in diminishing the fear and permits the doctor to plan for the clinical phase of the iatrosedative process. The evidence was pieced together in the following manner. The dentist had given several injections to produce palatal anesthesia. This undoubtedly extended to the soft palate producing a numbness and a feeling of largeness that so many patients report with a posterior palatal injection. This feeling of intrusion on the airway triggered off a feeling of panic, resulting in the acute anxiety the dentist faced on his return to the operating room.

The student was advised to have the patient tested for tolerance to one of the local anesthetics. Results of the testing indicated that she was not allergic. Armed with this information and the reconstruction of the past events, he proceeded to explain and interpret what he thought was the origin of her anxiety, suggesting that she could unlearn the feeling involved and learn a new way to respond to the situation. He suggested that by starting with treatment where no palatal anesthesia was involved she would undoubtedly tolerate it very well. This is indeed what happened. The treatment phase started with the use of infiltration injections for anesthesia. The patient tolerated this very well and the relearning process expanded as treatment continued, to the point where palatal injections did not set off a high anxiety response.