Disseminable Evidence-Based Treatment for the Dental Office: Virtual Exposure Tools for Dental Fear - neVR Fear the Dentist

项目摘要/摘要 每年有超过2000万患有中度恐惧的成年人和超过1400万患有严重恐惧的成年人访问 牙医。因为恐惧预示着未来口腔健康状况不佳，患有牙科恐惧症的患者会经历最糟糕的情况 恐惧：疼痛，外科手术，以及需要更频繁地看牙。回避是一种自然而强化的反应，具有讽刺意味的是，它保证了令人恐惧的事件重演。打破这一循环是首要的 这项提案的目标。标准的治疗--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麻醉，它们(A)对减少随后的焦虑或 回避，(B)导致持续的牙科问题，以及(C)使恐惧-回避-牙科的循环永久化 有问题。或者，针对牙科恐惧症的认知行为疗法(CBT)已经被开发出来， 经过数十次高质量的试验，结果证明是有效的。然而，CBT几乎是独家提供的 仅在世界范围内与大学相关的少数几个专科诊所；没有可传播的模式将CBT整合到牙科实践的工作流程中。为了填补这一空白，这份快速跟踪STTR提案描述了 计划开发和测试一种适销对路的产品，该产品可以为 目前在美国现有的执业生态系统内的牙科办公室。Nevr Fear the DentistTM是一套可商业化的自行管理的电子健康工具套件，用于治疗牙科恐惧，可在私人诊所实施 牙科诊所遍布全美，具有极强的可扩展性。Nevr Fear DentistTM包括三个主要部分 循证干预。First是一款自我管理的电子健康应用程序，用于CBT/心理教育 治疗-通过移动平板电脑提供-可以在候诊室私下使用。第二种是引发沟通的干预，病人记录一份“赛前计划”--与牙科医生一起审阅 牙科服务前的员工--包括(1)治疗前的恐惧程度，(2)产生最多焦虑的因素，(3)患者将用来提醒牙医的停止信号，(4)牙科团队可以做的事情，以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。治疗组的所有患者将接受前两次EBI，作为对片剂的单一干预。第三个(对于严重范围内的患者)是 1小时虚拟现实曝光治疗(VRET)。VRET将允许我们提供CBT，它可以在牙科的正常操作中自我管理，并将允许每一家牙科诊所成为牙科恐惧专科 诊所。这种方法对于改变临床实践是必要的，因为近20万美国牙医只会 采用一种自下而上的方法，以适应21世纪牙科的繁忙和业务 练习。研究部分将使用动力充足的随机对照试验来测试以下两方面的有效性： Nevr Fear the DentistTM，并使用NIH的实验医学方法来建立行为改变模型， (B)抑制性学习是否是影响变化的机制。

PROJECT SUMMARY/ABSTRACT Each year over 20 million adults with moderate fear and over 14 million adults with severe fear visit the dentist. Because fear portends poor future oral health, patients with dental fear come to experience their worst fears: pain, surgical procedures, and the need for more frequent dental visits. Avoidance is the natural and reinforced response, ironically guaranteeing a repetition of the feared events. Breaking this cycle is the primary target of this proposal. Standard treatment — compassionate but ultimately counterproductive — includes anti-anxiety medication or more substantial anesthesia, which (a) does nothing to reduce subsequent anxiety or avoidance, (b) leads to continued dental problems, 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 associated with universities; there is no disseminable model for integrating CBT into the workflow of dental practices. To fill this gap, this Fast-Track STTR proposal describes plans for development and testing of a marketable product that can bring effective dental fear treatment to dental offices within the currently existing U.S. practice ecosystem. neVR Fear the DentistTM is a commercializable suite of self-administered eHealth tools to treat dental fear that can be implemented in private practice dental offices throughout the U.S. and is eminently scalable. neVR Fear the DentistTM comprises three major evidence-based interventions. First is a self-administered eHealth app for CBT/psychoeducation with exposure therapy — delivered via a mobile tablet — that can be used privately in waiting rooms. Second is a communication-eliciting intervention, in which the patient records a “Pre-Game Plan” — to be reviewed with the dental staff before dental services — comprising (1) pre-treatment fear levels, (2) the factor generating the most anxiety, (3) a stop-signal the patient will use to alert dentist, (4) things the dental team can do to maximize this patient's comfort, and (5) a self-generated anxiety management plan. All patients in the treatment group will receive the first two EBIs as a single intervention on the tablet. Third (for patients who are in the severe range) is a 1-hr virtual reality exposure treatment (VRET). VRET will allow us to provide CBT that can be self-administered within the normal operations of dentistry and will allow every dental practice to be a dental fear specialty clinic. Such an approach is necessary to shift clinical practice, as the nearly 200,000 U.S. dentists will only adopt an approach designed, from the bottom up, to fit both the busy-ness and business of 21st-century dental practices. The research component will use an adequately powered RCT to test both (a) the effectiveness of neVR Fear the DentistTM and, using the NIH's Experimental Medicine Approach to Behavioral Change model, (b) whether inhibitory learning is the mechanism through which it affects change.