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Dental fear

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Dental fear refers to the fear of dentistry and of receiving dental care. A severe form of this fear (specific phobia) is variously called dental phobia, odontophobia, dentophobia, dentist phobia, or dental anxiety. However, it has been suggested not to use the term "dental phobia" for people who do not feel their fears to be excessive or unreasonable and resemble individuals with post-traumatic stress disorder, caused by previous traumatic dental experiences.[1]

Prevalence

It is estimated that as many as 75% of US adults experience some degree of dental fear, from mild to severe.[2][3][4] Approximately 5 to 10 percent of U.S. adults are considered to experience dental phobia; that is, they are so fearful of receiving dental treatment that they avoid dental care at all costs.[5] Many dentally fearful people will only seek dental care when they have a dental emergency, such as a toothache or dental abscess. People who are very fearful of dental care often experience a “cycle of avoidance,” in which they avoid dental care due to fear until they experience a dental emergency requiring invasive treatment, which can reinforce their fear of dentistry.[6]

Women tend to report more dental fear than men,[7] and younger people tend to report being more dentally fearful than older individuals.[8] People tend to report being more fearful of more invasive procedures, such as oral surgery, than they are of less invasive treatment, such as professional dental cleanings, or prophylaxis.[9]

Causes

Direct experiences

Direct experience is the most common way people develop dental fears. Most people report that their dental fear began after a traumatic, difficult, and/or painful dental experience.[10] However, painful or traumatic dental experiences alone do not explain why people develop dental phobia. The perceived manner of the dentist is an important variable. Dentists who were considered "impersonal", "uncaring", "uninterested" or "cold" were found to result in high dental fear in students, even in the absence of painful experiences, whereas some students who had had painful experiences failed to develop dental fear if they perceived their dentist as caring and warm.[11]

Indirect experiences

  • Vicarious learning: Dental fear may develop as people hear about others' traumatic experiences or negative views of dentistry (vicarious learning).[12]
  • Stimulus Generalization: Dental fear may develop as a result of a previous traumatic experience in a non-dental context. For example, bad experiences with doctors or hospital environments may lead people to fear white coats and antiseptic smells, which is one reason why dentists nowadays often choose to wear less "threatening" apparel. People who have been sexually, physically or emotionally abused may also find the dental situation threatening.[13]
  • Helplessness and Perceived Lack of Control: If a person believes that they have no means of influencing a negative event, they will experience helplessness (see Learned helplessness). Research has shown that a perception of lack of control leads to fear. The opposite belief, that one does have control, can lead to lessened fear. For example, the belief that the dentist will stop when the patient gives a stop signal lessens fear. Helplessness and lack of control may also result from direct experiences, for example an incident where a dentist wouldn't stop even when the person was in obvious pain.

Diagnosis

Phobia of dental care is sometimes diagnosed using a fear measurement instrument like Corah’s Dental Anxiety Scale or the Modified Dental Anxiety Scale.

Treatment

Treatments for dental fear often include a combination of behavioral and pharmacological techniques. Specialized dental fear clinics use both psychologists and dentists to help people learn to manage and decrease their fear of dental treatment. The goal of these clinics is to provide individuals with the fear management skills necessary for them to receive regular dental care with a minimum of fear or anxiety. While specialized clinics exist to help individuals manage and overcome their fear of dentistry, they are rare. Many dental providers outside of such clinics use similar behavioral and cognitive strategies to help patients reduce their fear.

Many people who suffer from dental fear may be successfully treated with a combination of "look, see, do" and gentle dentistry. People fear what they don't understand and they also, logically, dislike pain. If someone has had one or more painful past experiences in a dental office then their fear is completely rational and they should be treated supportively. Non-graphic photographs taken pre-operatively, intra-operatively and post-operatively can explain the needed dentistry. Pharmacologic management may include an anxiety-reducing medication taken in a pill, intravenously and/or using Nitrous Oxide (laughing) gas. Most importantly is the need to provide an injection of anesthetic extremely gently.[14] Certain parts of the mouth are much more sensitive than other parts; therefore it is possible to provide local anesthesia (a "novocaine" shot) in the less sensitive area first and then moving the injection within the zone of just-anesthetized tissue to the more sensitive area of the mouth. This is one example of how a dentist can dramatically reduce the sensation of pain from a "shot." Another idea is to allow the novocaine time (5 – 15 minutes) to anesthetize the area before beginning dental treatment.

Behavioral techniques

Behavioral strategies used by dentists include positive reinforcement (e.g. praising the patient), the use of non-threatening language, and tell-show-do techniques.[15] The tell-show-do technique was originally developed for use in pediatric dentistry, but can also be used with nervous adult patients.[16] The technique involves verbal explanations of procedures in easy-to-understand language (tell), followed by demonstrations of the sights, sounds, smells, and tactile aspects of the procedure in a non-threatening way (show), followed by the actual procedure (do).[17]

More specialized behavioral treatments include teaching individuals relaxation techniques, such as diaphragmatic breathing and progressive muscle relaxation, as well as cognitive, or thought-based techniques, such as cognitive restructuring and guided imagery.[4] Both relaxation and cognitive strategies have been shown to significantly reduce dental fear.[18] One example of a behavioral technique is systematic desensitization, a method used in psychology to overcome phobias and other anxiety disorders.[19] This is also sometimes called graduated exposure therapy or gradual exposure. For example, for a patient who is fearful of dental injections, the therapist first teaches relaxation skills to the patient, then gradually introduces the feared object (in this case, the needle and/or syringe) to the patient, encouraging the patient to manage his/her fear using the relaxation skills previously taught. The patient progresses through the steps of receiving a dental injection while using the relaxation skills, until the patient is able to successfully receive a dental injection while experiencing little to no fear. This method has been shown to be effective in treating fear of dental injections.[20] Cognitive restructuring, if applied in a non-threatening situation, might be a useful alternative as a first step after years of avoidance of dental care and less threatening than immediate exposure to the feared stimuli.[21]

It is interesting to take into account the views of people who have been provided with behavioural treatments for dental fear. From a psychologist's perspective, techniques such as graded exposure, relaxation techniques or challenging catastrophic thinking are important. However, it has been noted that from the patient's perspective, interventions can be conceptualized quite differently.[22] He argues that high levels of anxiety or phobia should not be considered as residing simply within the individual or in the individual's perceptions of dental care, but more within the relationship with the dentist. For example, when patients who had successfully completed a cognitive-behavioural programme were asked what had helped them to tolerate treatment, they mentioned factors such as the provision of information, the time taken, being put in control by the dentist, and the dentist understanding and listening to their concerns.[23] Such findings suggest that an interpersonal model of anxiety and anxiety-reduction is useful when trying to understand and treat dental fears.

Certain aspects of the physical environment also play an important role in alleviating dental fear. For example, getting rid of the smells traditionally associated with dentistry, the dental team wearing non-clinical clothes, or playing music in the background can all help patients by removing and replacing stimuli which can trigger feelings of fear (see classical conditioning). Some anxious patients respond well to more obvious distraction techniques such as listening to music, watching movies, or even using virtual-reality headsets during treatment.[24]

Pharmacological techniques

Pharmacological techniques to manage dental fear range from mild sedation to general anesthesia, and are often used by dentists in conjunction with behavioral techniques.[25] One common anxiety-reducing medication used in dentistry is nitrous oxide (also known as “laughing gas”), which is inhaled through a mask worn on the nose and causes feelings of relaxation and dissociation. Dentists may prescribe an oral sedative, such as a benzodiazepine like temazepam (Restoril), alprazolam (Xanax), diazepam (Valium), or triazolam (Halcion). Triazolam (Halcion) is not available in the UK.[26] While these sedatives may help people feel calmer and sometimes drowsy during dental treatment, patients are still conscious and able to communicate with the dental staff. Intravenous sedation uses benzodiazepines administered directly intravenously into a patient’s arm or hand. IV sedation is often referred to as “conscious sedation” as opposed to general anesthesia (GA). In IV sedation, patients breathe on their own while their breathing and heart rate are monitored and are still responsive to a dentist's prompts. In GA, patients are more deeply sedated and unable to breathe on their own and are not responsive to verbal or physical prompts.

Self-help and peer support

Recent research has focused on the role of online communities in helping people to confront their anxiety or phobia and successfully receive dental care. The findings suggest that certain individuals do appear to benefit from their involvement in dental anxiety online support groups.[27][28]

Dental fear in children

Dental phobia or dental fear, and dental anxiety have been used interchangeably in the dental literature to describe the overwhelming discomfort that some youth and adults experience in dental situations. The prevalence of dental anxeity (fear or phobia) in children and adolescents is between 5.7% and 19%. Klingberg & Broberg [29] reviewed these studies and estimated that about 9% of children and adolescents suffer from the condition. In the literature, dental phobia is categorised as a specific phobia – like Needle phobia. It is difficult to differentiate between Dental Behaviour Management Problems(DBMP) and dental phobia. DBMP is defined as disruptive behaviour that counteracts cooperation and makes dental care difficult or impossible. About 27% of children with DBMP present dental fear and 61% of children with dental phobia have DBMP.

Cognitive behaviour therapy for children

Several studies show that psychological methods based on exposure treatment such as Cognitive Behaviour Therapy (CBT) are effective for dealing with various anxiety disorders. A meta-analysis of CBT studies for children and adolescents found CBT to be effective in the treatment of anxiety disorders such as specific phobias.[30] A number of studies have investigated the effect of cognitive and behavioural therapeutic methods in conjunction with treatment of dental anxiety in adults.[31] The fundamental basis of CBT is the exposure principle,supported by home exercises with parental assistance.

See also

References

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  11. ^ Bernstein DA, Kleinknecht RA, Alexander LD (1979). "Antecedents of dental fear". J Public Health Dent. 39 (2): 113–24. doi:10.1111/j.1752-7325.1979.tb02932.x. PMID 287803.{{cite journal}}: CS1 maint: multiple names: authors list (link)
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  13. ^ Dental Fear Central (2004). "Tips for Abuse Survivors and Their Dentists".
  14. ^ Dorfman J, The Center for Special Dentistry.
  15. ^ Behavioral Techniques for Overcoming Dental Fears
  16. ^ Dental Fear Central. The Tell-Show-Do Technique for Adult Dental Patients.
  17. ^ American Academy of Pediatric Dentistry (AAPD). Guideline on behavior guidance for the pediatric dental patient. Chicago (IL) 2006.
  18. ^ Lundgren J, Carlsson SG, Berggren U (2006). "Relaxation versus cognitive therapies for dental fear—a psychophysiological approach". Health Psychol. 25 (3): 267–73. doi:10.1037/0278-6133.25.3.267. PMID 16719597. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
  19. ^ Wolpe J (1958). Psychotherapy by reciprocal inhibition. Stanford, CA: Stanford University Press.
  20. ^ Coldwell SE, Wilhelm FH, Milgrom P; et al. (2007). "Combining alprazolam with systematic desensitization therapy for dental injection phobia". J Anxiety Disord. 21 (7): 871–87. doi:10.1016/j.janxdis.2007.01.001. PMID 17320345. {{cite journal}}: Explicit use of et al. in: |author= (help)CS1 maint: multiple names: authors list (link)
  21. ^ de Jongh A, Muris P, ter Horst G, van Zuuren F, Schoenmakers N, Makkes P (1995). "One-session cognitive treatment of dental phobia: preparing dental phobics for treatment by restructuring negative cognitions". Behav Res Ther. 33 (8): 947–54. doi:10.1016/0005-7967(95)00027-U. PMID 7487854. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
  22. ^ Kent G (1997). Davey, Graham (ed.). Phobias: a handbook of theory, research and treatment. New York: Wiley. pp. 107–27. ISBN 0-471-96983-4.
  23. ^ Smith T, Getz T, Milgrom P, Weinstein P (1987). "Evaluation of treatment at a dental fears research clinic". Special Care in Dentistry. 7 (3): 130–4. doi:10.1111/j.1754-4505.1987.tb00622.x. PMID 2954240.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  24. ^ Jerome, Lloyd (2004). "The Art and Science of Distraction".
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  26. ^ Dyer C (13 February 1999). "European court upholds UK ban on Halcion". BMJ. 318 (7181): 418. PMC 1114899. PMID 9974446.
  27. ^ Buchanan H, Coulson NS (2007). "Accessing dental anxiety online support groups: an exploratory qualitative study of motives and experiences". Patient Educ Couns. 66 (3): 263–9. doi:10.1016/j.pec.2006.12.011. PMID 17320336. {{cite journal}}: Unknown parameter |month= ignored (help)
  28. ^ Coulson NS, Buchanan H (2008). "Self-reported efficacy of an online dental anxiety support group: a pilot study". Community Dent Oral Epidemiol. 36 (1): 43–6. doi:10.1111/j.1600-0528.2007.00349.x. PMID 18205639. {{cite journal}}: Unknown parameter |month= ignored (help)
  29. ^ . Klingberg G, Broberg AG. Dental fear/anxiety and dental behaviour management problems in children and adolescents: a review of prevalence and concomitant psychological factors. Int J Paediatr Dent. 2007;17(6):391-406.
  30. ^ .Compton SN, March JS, Brent D, Albano AM, Weersing R, Curry J. Cognitive-behavioral psychotherapy for anxiety and depressive disorders in children and adolescents: an evidence-based medicine review. J Am Acad Child Adolesc Psychiatry. 2004;43(8):930-959.
  31. ^ .Kvale G, Berggren U, Milgrom P. Dental fear in adults: a meta-analysis of behavioral interventions. Community Dent Oral Epidemiol. 2004;32(4):250-264.
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