Free article: Patient anxiety and COVID-19

Published: Tuesday, 23 June 2020

Glenys Bridges talks about some practical measures to help reduce patient anxiety when they come for dental appointments following the lockdown.


  • This article sets out the practical steps dental practices can take to ensure their patients are safe, and explains patients’ potential emotional responses during their visits.
  • Dental practices can help to mitigate patients’ anxiety by risk-assessing every step of the patients’ journey and putting safety measures in place.
  • People respond to stress in different ways. They can be fighters, fly-ers, freezers or fawners, and it helps to have a different strategy for dealing with each type.


In times of uncertainty, everyone looks for clarity, instructions, and direction, which have been in short supply since the lockdown began in March 2020. Clarity, dates and a road map are desperately sought after, but in unprecedented times ‘making it up as you go along’ is the best that even the government can offer.

In contrast, when it comes to reopening dental services, there are guidance and examples to look to. The first step is to risk-assess every step of the patient journey to put safety measures in place. The infection control measures implemented in hospitals and dental hubs at the height of the pandemic provide guidance on how to prepare the environment, train the team and offer patients the safest possible dental care environment. This article sets out those practical steps and explains patients’ potential emotional responses during their dental visits.

Practical steps

Risk assessment

Risk assessment is the first required step. This is a detailed review of all risks and the potential harm, to produce an action plan to manage the risks. This is specific to your building and procedures (see the example in the Toolkit).

Measures implemented must be communicated to patients, to show you are taking risks seriously and intend to treat them safely. This could include a poster in the waiting room, details on your website and clear signage explaining what measures you have in place and what they need to do. This will be comforting and concerning for patients. Make sure the team are confident to be respectful if they need to address issues with patients where patients do not follow the new rules.

Make it clear to patients what the practice is doing to keep them safe

Safety measures should include:

  • Contacting the practice: Let patients know that walk-ins are not permitted, and that they should make contact by phone or, if possible, the internet. Tell them that you will offer either an in-surgery appointment, online consultation, or telephone consultation.
  • On arrival at the practice: Let patients know what to do when they arrive at the practice for in-surgery appointments. If possible, ask them to wait off the premises until called in.
  • Hand hygiene: On entering the practice, patients must go straight to and use your hand sanitising point. They should sanitise their hands again on leaving the treatment room.
  • Cleaning: Let patients know that you are following strict guidelines for domestic cleaning and have installed sneeze screens to prevent cross-infection. Once they leave the practice, you will disinfect and sterilise the treatment room, making it ready for the next patient. 
  • Social distancing: Inform patients that they should observe social distancing guidance when visiting the practice. If patients have questions that they may have about any aspect of their visit they should ask a member of the dental team.

Personal protective equipment and respiratory protective equipment

The team will be wearing enhanced PPE/RPE as per national guidelines.

COVID-19 safety, signs and symptoms

Continue to use your triage process and screen patients up to 24 hours before their appointment. Let patients know that staff are screened daily to ensure their safety. When they enter the premises, a member of the team will screen patients and take their temperature. When patients enter the treatment room, they will be asked to rinse their mouth before and after treatment.

Due to all of the above, a visit to the dentist will now feel totally different for patients. Nervous patients will find this new dental environment particularly challenging, and they are likely to be more fearful, which can lead to defensive behaviour.

Patients’ emotional responses

Putting patients’ interests first is the primary ethical principle on which dental professionals base patient care. This has never been more obvious than in the arrangements and new working processes introduced following the COVID emergency. After a lengthy lockdown, on returning to work, there is a whole new, unfamiliar rule book and the consequences of getting it wrong are unthinkable. Patients and the dental team are in unfamiliar territory, and challenges are immense.

This will create emotions that patients will handle in the ways that their temperament directs. These feelings are prompted by the sense of a lack of control. Responses from the team should show recognition that the patients feel frustrated and powerless. This does not mean that they are weak or inadequate.

To help patients offer support, provide information to educate and strengthen their understanding of what the practice can do to protect them. Let them know what they must do to play their part. The aim is to help them relax into the ‘new normal’, becoming calmer and increasingly at ease.

Understanding patients’ emotions

The anxiety caused by dental visits will lead patients to behave in ways explained in the Four ‘F’s’ of fear.1

Patients’ behaviour will be promoted by the tension caused by the belief that they are in immediate danger. They will resort to one or more of the four ‘f”s’ of fear. Everyone has one or two ‘go-to’ ways of dealing with anxiety. People will pick their favourite method of dealing with anxiety over a lifetime of patterns, deciding what has worked for them in the past. Once a person is past their 20s, those patterns tend to be pretty well set as either:

  • Fighters
  • Fly-ers
  • Freezers
  • Fawners.


Fighters are defensive and angry. They will complain loudly and resist, or grudgingly accept the directions given for their protection. They are prone to outbursts of anger borne of a feeling of loss of control. Their sense of frustration will be expressed forcibly. Staff might feel threatened by this behaviour, which even under the current circumstances is unacceptable. The previous zero-tolerance measures in place for dealing with aggressive patients are relevant and necessary. In many cases, this behaviour is frequently short-lived and forgotten by the patient as soon as it subsides. The team needs to be prepared to accept an apology if one is made.


Fly-ers tend to run away from anxiety-causing situations. Fly-ers will remove themselves from the stress, and so they are likely to fail to keep their appointments. This will be a particular problem due to the current high demand for fewer appointments than have previously been available. These patients will need reassurance to increase their sense of safety and of being understood. This can be offered in a “We are looking forward to welcoming you to the practice” email. This would be well-received by all patients and will provide them with an overview of how their visit will be different from previous visits, and this reassurance will be comforting.


Freezers respond by closing down. As with the flyers, they may find it challenging to get anything done as their fear response makes thinking difficult. Even when the Freezers are given clear instructions, they cannot understand what they need to do. We need to support and guide them rather than asking them to observe the guidelines and signage around the practice. Give frequent gentle reminders about routine requirements, such as sanitising hands and social distancing.


Fawners really, really want to please. On the surface, they are cooperative. However, fawners often feel smothered under the weight of other peoples’ expectations. Worse, they often internalise them as their own. They need plenty of reassurance and confirmation that they are doing well and playing their part in being treated safely and protecting the safety of others. They need a virtual hug.

And finally, to understand the psychological dynamic of patients’ and staff’s anxiety responses, the responses of the Meerkat, the Elephant and the Monkey Brains provides powerful insight. At different stages of the dental experience, different brains will be dominant.

The Meerkat

The meerkat brain looks out for danger. The Meerkat wants to keep us safe. It will raise the alarm if any threat is perceived and trigger our chosen Fight, Flight, Freeze or Fawn responses, The Meerkat alerts us to the danger.

When the Meerkat brain is engaged, neither the elephant brain nor the monkey brain can act at all. The Meerkat takes over completely, making all the decisions and influencing all of our actions. Because of this, we need to understand that, in challenging situations, the Meerkat will take over. This is why it is essential to take time to bring the Meerkat under control before trying to problem solve.

The Elephant

The Elephant is the ‘feelings’ brain. It enables us to recall and evaluate what we have learned from past experiences. Its territory is everything we remember, and the emotions attached to those memories. Our Elephant brain never forgets! At this time of ‘New Normal’, the Elephant brain will struggle to operate as there are no historical experiences to evaluate.

The Monkey

The Monkey is our thinking brain. The monkey is intelligent and rational, able to weigh up the consequences of our actions. Based on facts, Monkey Brain helps with complex issues and to understand other people using logic and consideration of other’s needs


Ref 1 Forensic Psychologist. Paul G. Mattiuzzi, PhD P.O. Box 255841 Sacramento, CA 95865 916.538.1027, This email address is being protected from spambots. You need JavaScript enabled to view it., twitter: @paulgmattiuzzi


Use the following item in the Toolkit to put the ideas in the article into practice:

About the author

Glenys Bridges CMIPD RDN is Managing Partner of Glenys Bridges and Partners Practice Pathways and offers a range of leadership and management programmes. She is a twice-published author and contributor to Messages from Dental Masters 2. She has developed and delivers a range of practice management qualifications

Please note that this article was correct at the time of writing, but as the situation is changing rapidly with the COVID-19 pandemic, you should always check the latest government .

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