- Bunt
"Changes and transformation in our lives can resonate in the symbolic forms of music; in this way, music acts as a 'transformer of shared meaning."

Holding Pain Part 2

“Holding Pain” - Navigating the Scope of Practice Through Mindfulness and Music interventions

Part II – Mindful Best Practices in Dentistry in the Present & Implications for Developing a Mindful Dentistry Practice

Best Practices - How is this being practiced in the field of dentistry today?

Dalhousie University Elective and Perspective - John G Lovas and Professor Nancy Neish out of Dalhousie University recently have embarked upon offering an 8 week mindfulness elective for dentistry and dental hygiene students focusing on the provision of mindfulness theory, practice, qi gong breathing, discussion and journaling (self-reflective). In developing this elective, Lovas and Neish noted the need to improve participant professionalism relative to specific humanistic elements that mindfulness promotes (awareness and acceptance of self & others, empathy, sense of calm and confident patient management, congruence (action and value alignment), self-care/quality of life. In examining some of the ways in which mindfulness has and is being used (cancer patients, anti-aging relative to quality of life and promoting longevity), they discerned the overlap between essential professional qualities and cultivation of them via mindfulness. Namely the inherent qualities around fostering self-awareness, acceptance and wisdom. Bottom line, this program identified that fostering deep and meaningful connection and reflection as a habit of mind and being, facilitated self-improvement, awareness of beliefs and transformation. Relative to the field of dental practice, the emphasis of the Dalhousie elective was matters around self-care (change management & coping with uncertainty), stress management (self and patient) and improved relations (staff patients). Other related research spawning from this elective and its pilot, include the development of a values scale for dentists (as a potential screening tool for applicants into dentistry programs to assess for fit), assessing for mindfulness to improve professionalism and quality of life and looking at long term measure to employing mindfulness to foster empath, professional attitudes and values.

In a recent publication by John and David Lovas, Mindfulness and Professionalism in Dentistry, both explored overlap of construct between prosocial ends and letting go of selfish short term rewards while promoting long term common good. In this article, deep reflection was given to “being” in a state of professionalism and understanding how to best teach and support this way of being positively and genuinely. They noted that there was a need to narrow the gap between intellectual ethics and living these principles in daily life. Their paper reviewed how professional development and mindset in medicine and nursing demonstrated the lack of research in the field of dentistry relative to the use of mindfulness while at the same time noting the overlap between medicine/nursing and dental practice relative to core professional competencies. Lovas et. al identified key needs in the field of dentistry in this article name addressing the issue of attentiveness in learning and practice as well as relative to optimizing the learning potential of students and professional in terms of their development in the long term. A pervasive issue across all human development, regardless of profession is that mindlessness is a cognitive issue occurring without intention, awareness and is intrusive throughout the day impacting task performance. In their reflection, what they reported on was millennial propensities – generalized ADD, multi-taskers, preferences for technology invasive interactive learning, all of which present

challenges for traditional modes of learning, feedback & coaching. In today’s day and age task saturation, whether it be from a learning or work performance perspective, make it difficult to manage so many competing demands and to set right priorities. Thus, inattentiveness impacts both patient care and self-care as practitioners, resulting in resistance and conflicts disruptive to patients and staff alike.

University of Kentucky College of Dentistry – 2014 pilot where by 75% of students using mindfulness reported increases in focus, attention and reduced stress. Other significant outcomes include improvements in study skills, emotional regulation, and reductions in negative physiological stress response and anxiety. Specific to this training initiative was the use of Koru mindfulness training targeted to college students in oral health and emerging adults. This method included the use of mind/body skills like abdominal breathing and guided imagery, insight meditation (to reduce stress and increase personal motivation to practice). As students contributing factors to managing stress and anxiety in this type of program included information overload, while learning and perfecting hand skills for oral surgery and procedures. In the process of developing this student support, needs around relaxation, addressing test anxiety, sleep problems, mental chatter/brain fog and creating a balanced lifestyle were identified. Students engaged, affirmed that to achieve benefits, 100% buy in was necessary.

Mindfulness in Dental Education – Raymond et al (Canadian Medical Association website), examined teaching mindfulness meditation to 32 engaged preclinical and clinical Harvard medical and dental students. The focus of the research was on developing self-reflection, reflective listening, journaling, negotiating effective relations, seeking support, team building and leadership. The format was workshop and dyad based. The outcomes supported personal growth and professional development. Raymond also taught mindfulness and rapid relaxation to graduate dentists, doctors and psychologist in professional development courses, with the goal to create states of calm, awareness and presence as well as to foster the capacity to guide anxious and fearful patients. The gains from this type of training fed into both patient management and self-care.

Universities using mindfulness based training:

· University of Massachusetts Medical School (since 1985) – 1st and 2nd year med students

· Monash University Med School (Australia) – offered meditation to med students for > 15 years

· Jefferson Med College – provide a 10 week MBSR program focusing on reduction of mood disturbance scores (as a stress management strategy) and with nursing students (reducing anxiety, psychological distress and depression while increasing empathy. Findings from this program include 71% of students were more mindful in daily living, 60% could handle stress better, 98% would recommend to future med students

Beacon Cove Dental Practice (Port Melbourne) – This dental practice offers a case in point relative to application in the real world. This mindful dentistry practice employs elements like yogic breathing, meditation for mindfulness, Alexander technique for positive jaw

posture/alignment and visualization to support patient needs in their clinic. With the primary objectives being to focus on calming the mind, decreasing stress, monitoring patient stress levels, creating and sustaining strong human connections, a safe healing space all of which nurtures a state of calm for both patients and practitioners alike. Their practice emphasizes understanding the whole person and determining the root cause of what is impacting their lifestyle and dental health. Their philosophy around practicing dentistry with heart paired with assessing dental health for disease prevention (heart disease, stress and inflammation in the body) all contribute to this holistic and mindful approach to wellbeing.

Benefits to Integration of Mindfulness coaching & Music Assisted Mindfulness in Dental Practice for Practitioners:

In working with clients relative to supporting needs in the moment as they present in mindfulness coaching, various types of inductions are employed and adapted to suit and match where the client is relative to the type of visualizer they are relative to imagery and music. Some clients respond best to a breath induction while other’s may be more responsive to light, tension/release, progressive relaxation like the Jacobson technique or even a stretch induction. These approaches could be implemented within the context of the dental practice as they are easy to facilitate and coach a client about to undergo dental procedures with the potential to trigger stress and anxiety responses. When stress response is reduced by altering the state of the mind/body, the client’s capacity to tolerate pain is increased and receptivity to the pain management interventions elevated, with potential to reduce the amount of pain medication necessary to manage pain, anxiety and the stress response in the body. Thus, supporting mindfulness practices while in the waiting room and while in the dental treatment room as an adaptive practice is something that could be considered and created to supportive and safe spaces for wellness. This state paired with integration of therapeutic music which is prescribed based on patient needs in the moment offers a safe, supportive container for dental procedures to occur in that the music masks disturbing sounds, has the potential to transport the patient to more positive associations & memories, while can alter mood states and entrain to brain states and bodily rhythms and further reducing stress levels via supportive pacing and rhythmic states inherent to the body’s physiology.

To illustrate in the International Journal of Music and Performing Arts December 2015, Vol. 3 Music therapy In Dental Medicine by Dr. Gabriela Lorgulescu examined the following aspects of employing music therapy for the following benefits to both patient and staff alike:

· Anxiolytic / relaxing effect

· Distraction (often partial) of the patient`s attention from dental procedures which creates discomfort

· Direct antalgic effect (carried out especially by endorphins)

She noted that the therapeutic value of the music assisted interventions in dental practice, are due the following factors:

· The effectiveness of this method is, in most of the studies, favorable, in variations, ranging from a simple euphoric effect in isolation or placebos to equal to related to psychotherapeutic methods although there is association with music assisted mindfulness and other relaxation therapies (e.g. cognitive - behavioral therapy).

· The most visible effects of music assisted interventions in dental medicine are visible on the most anxious and on the female patients (without the existence of distinctions in age until senescence, when dental anxiety level decreases - in fact, dental practices seem to be less painful).

· The type of music used must be prescribed in accordance with two criteria:

1. The atmosphere of the musical pieces must be clear, meditative, relaxing, fact that is compatible with a slower tempo

2. The style of the music can be classic or the favorite music, noting that, in the case of classical music, there is the advantage of using some prior registration, applied without demarches involved, in the case of favorite music, by selecting a type of pre-recorded music.

At the same time, there is support with Iwanaga`s opinion, who claims that the effects of music interventions depend largely by the stimulant or sedative type of music than the style of it, including the case of favorite music.

Essentially, the algo-anxiolytic music intervention, used in the dental office, contributes, as has been demonstrated by a study performed by Olszewska, (to reduce the anxiety, a better cooperation of the patient with the doctor, and at a greater effectiveness of treatment.

So Why Mindfulness?

Mindfulness teaches a self-activated response to stress (by choice), which manifest in two manners – formal (intentional meditation – mindful walk, yoga, body scans etc.) and informal (bringing more active intention to the tasks of daily living – while brushes one’s teeth). Mindful physicians, according to Zoppi and Epstein demonstrate:

· Increased capacity to be in relationship with patients

· Ability to create healing relationships via effective communications

· Greater emotional and mental awareness

· Enhanced presence, attentiveness and curiosity to patient needs

· Improvements in abilities to deal clearly and appropriately with people and life events

· Capacity to cultivate professional virtues from within versus imposed from without

· Pro-social orientation central to the role of healing relationships in the ethics of both medicine and dentistry (value clarification process)

8 Attitudes Fostering a Mind full mindset:

1. Beginner’s Mind – presenting a fresh new outlook filled with curiosity

2. Nonjudgement – taking on the perspective of the impartial observer of thoughts, feelings & senses

3. Acknowledgement – developing the capacity to validate and acknowledge the present

4. Non-striving – not trying to get anywhere than where we are

5. Equanimity – being in a state of balance and wisdom; becoming change with insight & compassion

6. Letting be – letting things be as they are in the present

7. Self-reliance – both the truths and untruths of one’s experiences are held

8. Self-compassion – self-love

What does the research show relative to the findings in mindfulness and health care education today?

· Increased mental processing

· Stress and anxiety reduction

· Improvements to concentration and focus

· Cognitive and metacognitive optimization

· Increased self-awareness and emotional regulation

· Fosters greater creativity, self-compassion and empathy

Mindfulness research notes benefits not only reductions in stress response, anxiety, depression and rumination but relative to increases in emotional control, wellbeing and immune system functioning.

What is a process for nurturing mindfulness:

1. Concentration meditation – sitting still and in a balanced upright position, focused attention on a state/object (i.e. breath), letting go of mental chatter, be patient, non-judgemental and redirection of attention to breath and being in the moment (develops with practice over time)

2. Mindful meditation – is a state to promote open awareness to thoughts, feelings, and senses with no judgement. This state typically practices alert, non-self-centred, appropriate and pro-social ways of being and responding

Integration into daily practice (professionalism, patient and self-care):

Conscious Dental Procedure Mindsets to Nurture:

· Not to judge my actions, but to learn from them (Be gentle with thyself)

· Healing comes from acknowledgement/validation

· Increase capacity to embrace and be present with all types of pain and be in the moment versus avoidance

· Acceptance of change as inevitable and necessary

· Development of self-trust and self-belief

Benefits to Profession and Evolution of the State of Practice:

· Prevention of clinical practice errors

· Keeps the pathways of knowledge and receptivity to knowledge open (learning mindset)

· Ownership of both faults and strengths

· Self-care and assertion of needs (self- compassion)

· Self-awareness aids effective client care & promotes sustainable professional standards, preventing ethical drift

· Aids in the improvement of overall clinical teaching and learning in the field

Self-awareness training and coaching is recommended to transform and build leadership capacity by:

· Increase capacity to decision making

· Foster patient-centered care

· Improve communication skills

· Facilitate cultural competency

· Professional development and team building

· Promote personal growth and self-care

· Engendering a sense of belonging

· Creates a safe, caring, accepting, trustworthy and respected community of learners

· Builds emotional congruence

· Develops a genuine, active listening characteristic of empathy

Self-care & Self-Compassion: the act of caring for others and oneself are interdependent; health care professional wellbeing positively impact work-related effectiveness and mindfulness practice can be means to end relative to support two key aspects to professional ethics – the aspiration to a good life and the obligation to do the right thing. Mindfulness promotes congruence by supporting the notion that doctors practice what they preach and being coherent relative to beliefs in action which fosters a greater sense of both adaptability and sense making. Dental directed relaxation techniques when taught and practiced by the dental team demonstrates embodiment and support for the approach.

In the field of health care, the benefits to patients include a reduction in suffering and improvements in general health and wellbeing, particularly those with chronic pain and stress related disorders. Mindfulness can be tailored to the full range of clinical issues and integrated not only with patients, but with medical and nursing students as well as practicing clinicians.

Bringing a Mindful Approach into a Dental Practice:

1. Engage dental staff with 4 to 8 week training focusing on body scans

2. Addressing mental obstacles and resistance associated with goal orientated approaches versus mindfulness which is about non-striving and developing an aware and accepting mindset

3. Coping with patient resistance and rejection to procedures (in these moments, supporting the development of focusing on self-talk and attending to physical sensations)

4. Offering opportunities to address issue of being in the moment and responsive to patients relative to building and sustaining positive patient/dental relations

5. Employ mindfulness practices to create space/time to become aware of one’s own internal processes relative to being responsive with clarity versus reactivity

6. Enlist the help of a teacher/coach/weekly drop in group to develop a mindfulness practice with staff and patients

Additional Tools for Integration into Daily Practice for Staff & Patients:

Mindfulness/Meditative Practices & Interventions:

· Inductions (breath, tension/release, stretch, light/ball of light, directed/non-directed guided imagery, Jacobson’s progressive muscle relax technique, autogenic relaxation)

· Linking images sourced from patients during initial consults

· Sitting/walking meditations

· Breath work (diaphragmic breathing)

· Hypnotherapy

· Biofeedback

· Acupuncture

· Art of distraction and enhancing control (via music, tv shows etc.)

· Positive reinforcement & cognitive therapy

· Mindfulness in day to day activities

· Practicing the art of loving kindness & compassion

· Yoga

· Accessing a Mindfulness coach employing music assisted mindfulness/psychotherapy

Ways to Incorporate Mindfulness into a Busy Practice:

· Eat mindfully, free of all distractions savouring one’s lunch

· Breathe mindfully before and with each patient, releasing each patient and resetting one’s intention with each new one to foster presence

· Making mindful use of cancellation and no show time by reflecting on one’s thoughts, reactions, and behaviors to these situations; being conscious of habits of mind and exploring potential reframes and other mindful ways to respond that would support self-care and compassion

· Record and journal reactions to anxious/fearful patients by noting one’s thoughts, self and patient judgement, monitoring body reactions and analyzing for triggers/patterns

· Actively listen to patients/staff by listening without agenda/gaols with 1 or 2 people per day and notice the impacts on relationship.

Ultimately dentistry is a behavior science that involves human beings providing care to human beings. So how do we intentionally develop human beings, human relationships, compassion, empathy and professional behaviors. Mindfulness and music changes the relationship humans have with stress, it increases stillness, awareness translating into transformation and change management, individually and systemically. Could music and mindfulness play a role in this process across the spectrum of health care and education?

Bonnie Kowaliuk is a registered social worker, accredited music therapist, mindfulness coach, transformational leadership consultant and founder of Senses Mindfulness Coaching. She employs music assisted mindfulness, positive psychology, brain-based approaches to support education and leadership develop with individuals and healthy & education organizations to create meaning, balance and peace in all aspects of their lives. Visit Bonnie’s website at www.sensesmindfulness.com or contact her at 403-519-1959 or info@sensesmindfulness.com to discover how music, mindfulness and brain-based approaches to learning and development could support you in your practice.

References:

1. Lovas, J.G., Lovas, D.A., & Lovas P.M. (2008). “Mindfulness and Professionalism in Dentistry.” Journal of Dental Education. 72(9), 998-1009. http://www.jdentaled.org/content/72/9/998.long

2. Lovas, J.G & Neish, N. “Mindfulness in Dentistry.” Dalhousie University, Faculty of Dentistry, Programs, Special Offerings. Retrieved from https://www.dal.ca/faculty/dentistry/programs/special-offerings/mindfuln...

3. Boyce, J. (2014). “How Can Dentists Find Peace – Bringing Mindfulness into the Dental Practice.” Ontario Dentist, Health and Wellness, 44-46. http://getinflow.ca/sites/default/files/uploads/OD_Nov14_FINAL_Health+We...

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5. Gawel, R. (2015). “Mindful Techniques Reduce Dental Stress.” Dentistry Today, Industry News. http://www.dentistrytoday.com/news/industrynews/item/625-mindful-techniq...

6. Stein, J.M. (2017). “Mindfulness: Bringing the Science of Mindful Living into Dental Hygiene.” Dentistry IQ, Hygiene Dept. http://www.dentistryiq.com/articles/2017/04/mindfulness-bringing-the-sci...

7. Holexa, D., Lovas, J., Neish, N., Belzer, M., & Gold, E. (2011). “Mindfulness: Enhancing the Clinical, Professional, and Personal Outcomes of Dental and Dental Hygiene Students - Mindfulness at U of Dalhousie PPT.” ADEA Workshop, 2011 Annual Session. www.adea.org/2011annualsession/resources/Documents/holexapptfdw.pdf

8. Iorgulescu, G.(2015). “Music Therapy in Dental Medicine.” International Journal of Music and Performing Arts. 3(2), 19-24. http://ijmpa.com/journals/ijmpa/Vol_3_No_2_December_2015/3.pdf

9. Safer, A. (2017). “Navigating anxiety and stress through mindfulness: Cultivating mindfulness and awareness in a community-based setting,” Positive Psychology Conference Series, Workshop Notes. http://positivepsychology.conferenceseries.com/abstract/2017/navigating-...

10. Appukuttan, D.P. (2016). “Strategies to Manage Patients with Dental Anxiety and Dental Phobia: Literature Review.” Journal of Clinical, Cosmetic and Investigational Dentistry. 8, 35-50. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4790493/

11. White, A. (2017). “Mindful Dentistry to Calm and Reduce Patient Stress Spearheaded in Australia by Beacon Cove Dental.” Prweb, News Centre. http://www.prweb.com/releases/mindful/dentistry/prweb12068620.htm

12. Beach, S.R. “Mindful Dentistry.” http://leftbrainbuddha.com/mindful-dentistry/

13. Barbosa, P., Raymond, G., Ziotnick, C., Wilk, J., Toomey III R., Mitchell III J. “Mindfulness-based Stress Reduction Training is Associated with Greater Empathy and Reduced Anxiety for Graduate Health Care Students.”(2013). Education for Health Journal. 26(1), 9-14. http://www.educationforhealth.net/article.asp?issn=1357-6283;year=2013;v...

14. “Mindfulness and Pain – a View from the Dentist’s Chair.” Brilliant Living. https://www.brilliantlivinghq.com/mindfulness-and-pain/

15. Basson, R.A. (2013). “Management and Prevention of Burnout in the Dental Practioner.” Dentistry: An Open Access Journal. 3 (2) 1-4. https://www.omicsonline.org/management-and-prevention-of-burnout-in-the-...

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