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Dental fear

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The terms dental fear, dental anxiety and dental phobia are quite often used inter-changeably. Dental fear is a normal emotional reaction to one or more specific threatening stimuli in the dental situation.[1] However, dental anxiety is indicative of a state of apprehension that something dreadful is going to happen in relation to dental treatment, and it is usually coupled with a sense of losing control.[2] Similarly, dental phobia denotes a severe type of dental anxiety, and is characterised by marked and persistent anxiety in relation to either clearly discernible situations or objects (e.g. drilling, local anaesthetic injections) or to the dental setting in general.[3]

The term ‘dental fear and anxiety’ (DFA) is often used to refer to strong negative feelings associated with dental treatment among children, adolescents and even adults, whether or not the criteria for a diagnosis of dental phobia are met.


Prevalence

Although it is not easy for many dental practitioners to identify the number of current and potential patients that have high dental fear, the characteristics can be seen in intervals between visits and chronic appointment cancellations. It is estimated that as many as 75% of US adults experience some degree of dental fear, from mild to severe[4] [5] [6]. 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 [7]. Many dentally fearful people will only seek dental care when they have a dental emergency, such as a toothache or dental abscess [8]. 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 [9].

A study published in the European Journal of Oral Sciences concluded that out of a survey of 1,959 Dutch adults between the ages of 18 and 93, the prevalence of dental fear was 24.3%, coming fourth to fears associated with snakes, height and physical injuries. With regards to phobia, dental phobia was the most commonly reported phobia at 3.7% followed by height phobia and spider phobia.[10] The demographic of dental fear and anxiety (DFA) is more commonly displayed in females than males, with the prevalence decreasing with age. Fear of dental treatment is thought to be more associated with females due to the fear of intrusive re-experiencing.[11]

Women tend to report more dental fear than men [12], and younger people tend to report being more dentally fearful than older individuals [13]. 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.[14]

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.[15] 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" may develop high dental fear in patients, even in the absence of painful experiences, whereas some patients who had had painful experiences failed to develop dental fear if they perceived their dentist as caring and warm.[16]

Indirect experiences

Vicarious learning
Dental fear may develop as people hear about others' traumatic experiences or negative views of dentistry (vicarious learning).[17]
Mass media
The negative portrayal of dentistry in mass media and cartoons may also contribute to the development of dental fear. [citation needed] The negative portrayal may come from such films as the 1932 comedy film The Dentist, the unrelated horror film The Dentist, its sequel, the 1933 cartoon The Merry Old Soul, and Marathon Man (the antagonist, Dr. Christian Szell, is a Nazi war criminal who tortures with dental equipment).
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.[18]
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.[19]

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. [citation needed]

Treatment/Management

Dental fear varies across a continuum, from very mild fear to severe. Therefore, in dental setting, it is also the case where the technique and management that works for one patient might not work for another. Some patients may require a tailored management and treatment approach. Numerous dental fear management strategies and techniques are put forward to avoid what has been referred to as a vicious cycle of dental fear, illustrated in figure 1.1. [20]

Non-pharmacological interventions

Communication skills, rapport and trust building

  • Verbal communication: It is important for dental practitioners to have a positive behaviour, attitude and communicative stance. Dental practitioners should establish a direct approach by communicating with the patient in a friendly, calm and non-judgmental manner, using appropriate vocabulary and avoiding negative phases. Essential elements of good verbal communication include effective listening and two-way interaction, genuinely acknowledging patient’s concerns rather than dismissing, demonstrating empathy, effective listening and accurate reflection on what the patient says, and using appropriate voice and tone. [21][22]
  • Non-verbal communication: positive eye-contact, friendly facial expressions and positive gestures are essential to achieve an empathetic relationship between the patient and dental practitioner. [23]

By doing so, communication skills create a bond of understanding, trust and confidence between the dental practitioner and the patient.

Behavior modification technique

  • Tell-show-do: This technique involves an explanation of what is about to happen, what type of instruments will be used, reasons for using those instruments (‘tell’ phase), followed by demonstration of the procedure (‘show’ phase), and the then carrying out the procedure (‘do’ phase). [24]
  • Signaling: This is to allow the patient to communicate with dental professional during any stage of the treatment by means of previously-established signals with specific meanings. A signal can be as simple as a raised hand to notify the dental practitioner for break or unpleasant feelings. This increases the patient’s sense of control over the treatment and improves relationship of trust. [25]
  • Positive reinforcement: This technique aims to reward any positive efforts made by the patient and thus strengthens recurrence of those behaviours. Encouraging phrases (using positive voice modulation), such as “thank you for helping me by sitting still in the chair and keeping your mouth wide open”, or physical manifestation, such as a smile or thumbs up, encourages the patient to collaborate during the treatment. [26][27]
  • Relaxation breathing therapy: Slow, deep and steady breathing for 2-4 minutes provides more oxygen to the body, thus reducing the patient’s heart rate. Breathing relaxation is easy to perform, and can be adopted in the dental chair immediately before proceeding the treatment or at home. [28]
  • Progressive muscle relaxation: Ask patient to focus on specific voluntary muscles and, in sequence, tense for 5-7 seconds and then relax for 20 seconds. As this sequence progresses, other aspects of the relaxation response also naturally occur. [29]
  • Distraction: There is evidence that diverting the patient’s attention from what may be perceived as an unpleasant procedure to specific alternative visual or auditory stimuli in the dental clinic has shown to be effective. Several options are available for clinician, ranging from giving the patient short breaks during a stressful procedure, background music, television sets, and computer games. [30][31]
  • Modelling: The patient’s behaviour can be altered through modelling. Modelling can be presented for viewing on televisions, computers or live by making the patient observe the behaviour of their siblings or family members or another patient in similar situation. This conditions the patient to exhibit positive behaviour. [32]
  • Guided imagery/Hypnosis: This technique uses a direct, deliberate daydream to create a focused state of relaxation. For example, the patient, seated in the dental chair, is taught to develop a mental image or asked to use their imagination skills to develop a pleasant, tranquil experience. This continuously guides the patient’s attention to achieve relaxation. [33]
  • Systemic desensitization: It is strongly recommended that the treatment should be planned in phases (systemic desensitization) with techniques that are the least fear-evoking, painful and traumatic.
- Initial phase: Get the patient used to the clinical environment and encourage them to discuss their status of dental fear. Patient may not be ready to undergo any diagnostic procedures at this stage.
- Early phase: Teach the patient relaxation techniques. The most commonly used relaxation techniques are, deep breathing and muscle relaxation.
- Final phase: Gradually expose the patient to the treatment that is from the least to the most anxiety-provoking (from simple procedures to more extensive dental work).

Cognitive behavior therapy Dental fear often lead patient to cause unrealistic expectations about dental treatment, especially in children. Cognitive therapy aims to alter and restructure negative beliefs to reduce dental fear by enhancing the control of negative thoughts. “The process involves identifying the misinterpretations and catastrophic thoughts often associated with dental fear, challenging the patient’s evidence for them, and then replacing them with more realistic thoughts.” [34]

Pharmacological interventions

  • Benzodiazepines
  • Nitrous oxide
  • General anesthesia: though it is discouraged due to possible but rare risk of death and high cost since it requires the involvement of specialist facilities.

For the patient – Coping skills for facing dental fear

Some common strategies for the patient to help get through the appointment:

  • Speak up: Talk to the clinician about the coping skills that have worked for you in the past; Do not be afraid to ask questions; Agree on a signal you can give. [35]
  • Distract yourself: Bring headphones and some music or an audio book to listen to; Occupy your hands by squeezing some soft toys or play with fidget toy; Ask your clinician for other options that may help in distracting yourself. [36]
  • Deep breathing: Practice deep breathing anywhere. [37]

See also

References

  1. ^ Anthonappa RP, Ashley PF, Bonetti DL, Lombardo G, Riley P. Non‐pharmacological interventions for managing dental anxiety in children. The Cochrane Library. 2017.
  2. ^ Anthonappa RP, Ashley PF, Bonetti DL, Lombardo G, Riley P. Non‐pharmacological interventions for managing dental anxiety in children. The Cochrane Library. 2017.
  3. ^ Anthonappa RP, Ashley PF, Bonetti DL, Lombardo G, Riley P. Non‐pharmacological interventions for managing dental anxiety in children. The Cochrane Library. 2017.
  4. ^ ^ Kleinknecht RA, Thorndike RM, McGlynn FD, Harkavy J (January 1984). "Factor analysis of the dental fear survey with cross-validation". J Am Dent Assoc. 108 (1): 59–61. PMID 6582116
  5. ^ Getka EJ, Glass CR (Summer 1992). "Behavioral and cognitive-behavioral approaches to the reduction of dental anxiety". Behavior Therapy. 23 (3): 433–48. doi:10.1016/S0005-7894(05)80168-6.
  6. ^ ^ Jump up to: a b Milgrom P, Weinstein P, Getz T (1995). Treating Fearful Dental Patients: A Patient Management Handbook (2nd ed.). Seattle, Wash.: University of Washington, Continuing Dental Education. doi:10.1111/j.1600-0528.1996.tb00893.x. ISBN 1-880291-01-0.
  7. ^ Gatchel RJ, Ingersoll BD, Bowman L, Robertson MC, Walker C (October 1983). "The prevalence of dental fear and avoidance: a recent survey study". J Am Dent Assoc. 107 (4): 609–10. PMID 6579095.
  8. ^ "Fear Of The Dentist – Causes and Cures for Dental Anxiety - Oradyne". 11 July 2016.
  9. ^ Armfield JM, Stewart JF, Spencer AJ (2007). "The vicious cycle of dental fear: exploring the interplay between oral health, service utilization and dental fear". BMC Oral Health. 7: 1. doi:10.1186/1472-6831-7-1. PMC 1784087 . PMID 17222356.
  10. ^ Oosterink F, De Jongh A, Hoogstraten J. Prevalence of dental fear and phobia relative to other fear and phobia subtypes. European journal of oral sciences. 2009 Apr 1;117(2):135-43.
  11. ^ Klingberg G, Broberg AG. Dental fear/anxiety and dental behaviour management problems in children and adolescents: a review of prevalence and concomitant psychological factors. International Journal of Paediatric Dentistry. 2007 Nov 1;17(6):391-406.
  12. ^ Armfield JM, Spencer AJ, Stewart JF (March 2006). "Dental fear in Australia: who's afraid of the dentist?". Aust Dent J. 51 (1): 78–85. doi:10.1111/j.1834-7819.2006.tb00405.x. PMID 16669482.
  13. ^ Erten H, Akarslan ZZ, Bodrumlu E (April 2006). "Dental fear and anxiety levels of patients attending a dental clinic". Quintessence Int. 37 (4): 304–10. PMID 16594362.
  14. ^ Stabholz A, Peretz B (April 1999). "Dental anxiety among patients prior to different dental treatments". Int Dent J. 49 (2): 90–4. doi:10.1111/j.1875-595x.1999.tb00514.x. PMID 10858738.
  15. ^ Locker D, Shapiro D, Liddell A (June 1996). "Negative dental experiences and their relationship to dental anxiety". Community Dent Health. 13 (2): 86–92. PMID 8763138.
  16. ^ 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.
  17. ^ Hilton IV, Stephen S, Barker JC, Weintraub JA (December 2007). "Cultural factors and children's oral health care: a qualitative study of carers of young children". Community Dent Oral Epidemiol. 35 (6): 429–38. doi:10.1111/j.1600-0528.2006.00356.x. PMID 18039284.
  18. ^ Dental Fear Central (2004). "Tips for Abuse Survivors and Their Dentists".
  19. ^ "What is Dental Phobia and Dental Anxiety - Colgate® Oral Care".
  20. ^ Appukuttan P. Strategies to manage patients with dental anxiety and dental phobia: literature review. Clin Cosmet Investig Dent [Internet]. 2016 [cited 2018 Apr 21];2016(8):35-50. Available from https://www.ncbi.nlm.nih.gov/pubmed/27022303 DOI: 10.2147/CCIDE.S63626
  21. ^ JM Armfield, LJ Heaton. Management of fear and anxiety in the dental clinic: a review. Aust Dent J [Internet]. 2013 [cited 2018 Apr 21];58(4):390-407. Available from https://www.ncbi.nlm.nih.gov/pubmed/24320894 DOI: 10.1111/adj.12118
  22. ^ Anthonappa RP, Ashley PF, Bonetti DL, Lombardo G, Riley P. Non-pharmacological interventions for managing dental anxiety in children (Protocol). Cochrane Database of Systematic Reviews [Internet]. 2017 [cited 2018 Apr 21]; (6). Available from: http://www.cochrane.org/CD012676/ORAL_non-pharmacological-interventions-managing-dental-anxiety-children
  23. ^ Anthonappa RP, Ashley PF, Bonetti DL, Lombardo G, Riley P. Non-pharmacological interventions for managing dental anxiety in children (Protocol). Cochrane Database of Systematic Reviews [Internet]. 2017 [cited 2018 Apr 21]; (6). Available from: http://www.cochrane.org/CD012676/ORAL_non-pharmacological-interventions-managing-dental-anxiety-children
  24. ^ The University of Adelaide. Dental fear and anxiety: Information for Dental Practitioners. Australian Research Centre for Population Oral Health. Adelaide: The University of Adelaide; 2016
  25. ^ JM Armfield, LJ Heaton. Management of fear and anxiety in the dental clinic: a review. Aust Dent J [Internet]. 2013 [cited 2018 Apr 21];58(4):390-407. Available from https://www.ncbi.nlm.nih.gov/pubmed/24320894 DOI: 10.1111/adj.12118
  26. ^ Appukuttan P. Strategies to manage patients with dental anxiety and dental phobia: literature review. Clin Cosmet Investig Dent [Internet]. 2016 [cited 2018 Apr 21];2016(8):35-50. Available from https://www.ncbi.nlm.nih.gov/pubmed/27022303 DOI: 10.2147/CCIDE.S63626
  27. ^ Anthonappa RP, Ashley PF, Bonetti DL, Lombardo G, Riley P. Non-pharmacological interventions for managing dental anxiety in children (Protocol). Cochrane Database of Systematic Reviews [Internet]. 2017 [cited 2018 Apr 21]; (6). Available from: http://www.cochrane.org/CD012676/ORAL_non-pharmacological-interventions-managing-dental-anxiety-children
  28. ^ The University of Adelaide. Dental fear and anxiety: Information for Dental Practitioners. Australian Research Centre for Population Oral Health. Adelaide: The University of Adelaide; 2016
  29. ^ Anthonappa RP, Ashley PF, Bonetti DL, Lombardo G, Riley P. Non-pharmacological interventions for managing dental anxiety in children (Protocol). Cochrane Database of Systematic Reviews [Internet]. 2017 [cited 2018 Apr 21]; (6). Available from: http://www.cochrane.org/CD012676/ORAL_non-pharmacological-interventions-managing-dental-anxiety-children
  30. ^ Appukuttan P. Strategies to manage patients with dental anxiety and dental phobia: literature review. Clin Cosmet Investig Dent [Internet]. 2016 [cited 2018 Apr 21];2016(8):35-50. Available from https://www.ncbi.nlm.nih.gov/pubmed/27022303 DOI: 10.2147/CCIDE.S63626
  31. ^ JM Armfield, LJ Heaton. Management of fear and anxiety in the dental clinic: a review. Aust Dent J [Internet]. 2013 [cited 2018 Apr 21];58(4):390-407. Available from https://www.ncbi.nlm.nih.gov/pubmed/24320894 DOI: 10.1111/adj.12118
  32. ^ JM Armfield, LJ Heaton. Management of fear and anxiety in the dental clinic: a review. Aust Dent J [Internet]. 2013 [cited 2018 Apr 21];58(4):390-407. Available from https://www.ncbi.nlm.nih.gov/pubmed/24320894 DOI: 10.1111/adj.12118
  33. ^ Appukuttan P. Strategies to manage patients with dental anxiety and dental phobia: literature review. Clin Cosmet Investig Dent [Internet]. 2016 [cited 2018 Apr 21];2016(8):35-50. Available from https://www.ncbi.nlm.nih.gov/pubmed/27022303 DOI: 10.2147/CCIDE.S63626
  34. ^ JM Armfield, LJ Heaton. Management of fear and anxiety in the dental clinic: a review. Aust Dent J [Internet]. 2013 [cited 2018 Apr 21];58(4):390-407. Available from https://www.ncbi.nlm.nih.gov/pubmed/24320894 DOI: 10.1111/adj.12118
  35. ^ Cianetti S, Paglia L, Gatto R, Montedori A, Lupatelli E. Evidence of pharmacological and nonpharmacological interventions for the management of dental fear in paediatric dentistry: a systematic review protocol. BMJ [Internet]. 2017 [cited 2018 Apr 21];7(8):1-6. Available from http://bmjopen.bmj.com/content/7/8/e016043 DOI: 10.1136/bmjopen-2017-016043
  36. ^ Cianetti S, Paglia L, Gatto R, Montedori A, Lupatelli E. Evidence of pharmacological and nonpharmacological interventions for the management of dental fear in paediatric dentistry: a systematic review protocol. BMJ [Internet]. 2017 [cited 2018 Apr 21];7(8):1-6. Available from http://bmjopen.bmj.com/content/7/8/e016043 DOI: 10.1136/bmjopen-2017-016043
  37. ^ Cianetti S, Paglia L, Gatto R, Montedori A, Lupatelli E. Evidence of pharmacological and nonpharmacological interventions for the management of dental fear in paediatric dentistry: a systematic review protocol. BMJ [Internet]. 2017 [cited 2018 Apr 21];7(8):1-6. Available from http://bmjopen.bmj.com/content/7/8/e016043 DOI: 10.1136/bmjopen-2017-016043
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