A Stepped-Care Approach to Treating Dental Fear: A Sequential, Multiple Assignment, Randomized Trial For Cognitive-Behavioral Treatment via Mobile App and Evidence-Based Collaborative Care

项目总结/摘要 牙科恐惧症影响着超过5300万美国成年人。根据美国卫生局局长的说法， “不必要的痛苦和折磨，对个人的福祉造成毁灭性的并发症， 社会成本大大降低了生活质量，给美国社会带来了负担。”标准治疗- 富有同情心，但最终适得其反-包括抗焦虑药物或更实质性的anes- 感觉，（a）不能减少随后的焦虑或回避，（B）导致持续的牙齿修复B- lems，以及（c）使恐惧->回避->牙齿问题的循环持续下去。或者，认知-行为 牙科恐惧症的治疗（CBT）已经开发出来，经过数十次高质量的试验，发现 要有效。然而，CBT几乎只在全球少数专科诊所提供，因为- 与大学有联系，并且没有将CBT整合到牙科工作流程中的可传播模型 实践为了填补这一空白，我们已经创建了一个分步护理的方法来治疗牙科恐惧，可以 在美国各地的私人诊所牙科诊所实施，并且具有显著的可扩展性。在- 从最不密集的选项开始，只有在必要时才逐步增加密集的选项。 低端是自我管理的干预：（a）一个智能手机“应用程序”，可以在等待时私下使用 （B）一个纸和笔的“赛前计划”，其中， 患者记录-在牙科服务之前与牙科工作人员一起审查-（1）治疗前的恐惧水平， (2)产生最大焦虑的因素，（3）患者将用于提醒牙医的停止信号，（4） 牙科团队可以做的，以最大限度地提高这个病人的舒适度，和（5）自我产生的焦虑管理计划。 如果患者在牙科手术后不在“低恐惧”区，他们可能会接受1小时（如果仍然在 中度区）或2小时（如果仍在严重区）的牙科恐惧CBT在他们的牙医办公室进行， 心理健康合作提供者在本研究的第一阶段，我们将用恐惧测试这种方法。 患者（N> 35，700）在两个大学牙科中心。在第二阶段，我们会在私家牙科诊所测试资讯科技 实践（n = 100名志愿者，来自Philadel大都市地区的10，000名执业牙医， 纽约和纽约[以及它们之间的走廊]，他们从牙科学校毕业，要么来自纽约， 宾夕法尼亚大学（University of Pennsylvania）目的是研究影响患者和牙科医生的因素， 愿意尝试阶梯式护理，测试方法的有效性，测试CBT干预措施的剂量， 等待患者的恐惧水平，并测试我们认为CBT的工作方式（即，通过帮助 患者否认他们对恐惧结果的信念）是真正的活性成分。最后我们 我将为牙医和心理健康提供者开发关于“如何有效治疗 “一个人的牙科恐惧症，一个人的牙科恐惧症”

PROJECT SUMMARY/ABSTRACT Dental fear affects over 53 million American adults. According to the U.S. Surgeon General, it leads to “needless pain and suffering, causing devastating complications to an individual's wellbeing, with financial and social costs that significantly diminish quality of life and burden American society.” Standard treatment — compassionate but ultimately counterproductive — includes anti-anxiety medication or more substantial anes- thesia, which (a) does nothing to reduce subsequent anxiety or avoidance, (b) leads to continued dental prob- lems, and (c) perpetuates the cycle of fear—>avoidance—>dental problems. Alternatively, cognitive-behavioral treatments (CBT) for dental fear have been developed, subjected to dozens of high-quality trials, and found to be efficacious. However, CBT has, almost exclusively, been offered only in a few specialty clinics worldwide as- sociated with universities and there is no disseminable model for integrating CBT into the workflow of dental practices. To fill this gap, we have created a stepped-care approach to dental fear treatment that can be implemented in private practice dental offices throughout the U.S. and is eminently scalable. Stepped-care in- volves starting with the least intensive option and progressing to more intensive options only when necessary. At the low end is a self-administered intervention: (a) a smartphone “app” that can be used privately in waiting rooms by an unlimited number of patients combined with (b) a paper-and-pencil “Pre-Game Plan” in which the patient records — to be reviewed with the dental staff prior to dental services — (1) pre-treatment fear levels, (2) the factor generating the most anxiety, (3) a stop-signal the patient will use to alert the dentist,(4) things the dental team can do to maximize this patient's comfort, and (5) a self-generated anxiety management plan. If patients are not in the “low fear” zone following their dental procedures, they may receive 1-hour (if still in moderate zone) or 2-hours (if still in severe zone) of dental fear CBT in their dentists' offices conducted by a collaborating mental health provider. In the first phase of this study, we will pilot test the approach with fearful patients (N»35,700) at two University dental centers. In the second phase, we will test the it in private dental practices (n = 100 volunteers from a pool of 10,000 practicing dentists in the metropolitan areas of Philadel- phia and New York [and the corridor between them] who graduated from dental school from either New York University or the University of Pennsylvania). The aims are to study factors influencing patients' and dentists' willingness to try stepped-care, to test the efficacy of the approach, to test the dosing of CBT interventions de- pending on patients' fear levels, and to test whether the way in which we believe CBT works (i.e., by helping patients disconfirm their beliefs regarding feared outcomes) is truly the active ingredient. Finally, we will develop dissemination materials for dentists and mental health providers on “How to Effectively Treat Dental Fear with a Stepped-Care Approach.”