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

项目摘要/摘要 牙齿恐惧症影响着5300多万美国成年人。根据美国卫生局局长的说法，这会导致 “不必要的痛苦和折磨，对个人的福祉造成毁灭性的并发症，经济和 显著降低生活质量并给美国社会带来负担的社会成本。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ANE- 感觉障碍，(A)对减少随后的焦虑或回避毫无作用，(B)导致持续的牙科探查- (C)使恐惧--避免--牙病--的循环永久化。或者，认知-行为 针对牙科恐惧症的治疗(CBT)已经开发出来，经过了数十次高质量的试验，并发现 要有效率。然而，CBT几乎只在世界范围内的几个专科诊所提供，因为- 与大学合作，将CBT整合到牙科工作流程中还没有可传播的模式 练习。为了填补这一空白，我们创建了一种阶梯式护理方法来治疗牙科恐惧，这种方法可以 在美国各地的私人牙科诊所实施，并具有卓越的可扩展性。分步护理- 伏尔群从最不密集的选项开始，只有在必要时才会进展到更密集的选项。 低端是一种自我管理的干预：(A)一种可以在等待时私下使用的智能手机“应用程序” 由不限数量的病人组成的房间与(B)纸和铅笔相结合的“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)引起最大焦虑的因素，(3)病人将用来提醒牙医的停止信号，(4)事情 牙科团队可以做的是最大限度地提高患者的舒适度，以及(5)自我产生的焦虑管理计划。 如果患者在牙科手术后没有处于“低恐惧区”，他们可能会得到1小时(如果还在 中等区域)或2小时(如果仍处于严重区域)在牙医办公室进行牙科恐惧CBT，由 合作的精神健康提供者。在这项研究的第一阶段，我们将对该方法进行初步测试 两个大学牙科中心的患者(N？35,700人)。在第二阶段，我们将在私人牙科进行测试。 诊所(来自菲拉德尔大都市地区10,000名执业牙医的100名志愿者- 从纽约牙科学校毕业的菲亚和纽约[以及他们之间的走廊] 大学或宾夕法尼亚大学)。目的是研究影响患者和牙医健康的因素。 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 取决于患者的恐惧程度，并测试我们认为CBT起作用的方式(即帮助 患者不再相信他们对结果的担忧)才是真正的有效成分。最后，我们 将为牙医和心理健康提供者编写宣传材料，介绍如何有效地治疗 牙科恐惧症与阶梯式护理方法。

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.”