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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.

Figure 1 Vicious cycle of dental fear

Prevalence and impact of dental fear

High dental fear affects approximately 1 in 6 Australian adults, and this prevalence is similar to that of many Western countries around the world[4]. Younger patients, female, and patients with previous unpleasant dental experience were associated with increased MDAS score [5].
People with high dental fear are much more likely to delay or avoid dental visiting, and some constantly fail to show for appointments. For those who attend may require more time, and may prove difficult to treat. Finally, because of their avoidant behaviours, people with high dental fear often have poorer dental health. If patients are not managed appropriately, it is possible to establish what has been referred to as a vicious cycle of dental fear, illustrated in figure 1. It is estimated that approximately 40% of people with high dental fear fit in the vicious cycle of dental fear[6].


Causes

The causes of dental fear are mainly categorised into two sections;[7] [8] the external and the internal factors.

External Factors

  • Direct experience: Dental fear can be due to negative or difficult past experiences, such as, noise of dental drill, fear of loss of control by the operator and any other medical procedure in the past.
  • Indirect modeling experience: Dental fear can be developed by observation of an anxious dental patient, friend or family member.
  • Information transmission: Dental fear can be transmitted through social media, reading a comic dental paper, watching a vicarious dental movie and listening to a fearful dental story from a friend or a family member.

Internal Factors

Some people are inherently or genetically fearful and, thus, are more vulnerable to being traumatised by a dental experience. However, age and gender can also influence dental fear.

  • Genetics: Evidence shows that there is a strong relationship between parents and child fear as well as some evidence suggests that fear has robust genetic relationship. It is worth mentioning that psychological factors may result in developing dental fear.
  • Age: Generally, young children aged 4-12 have the greatest number of fears and anxieties.
  • Gender: Evidence suggests that girls and women have higher degree of dental fear, especially, about drilling and local anesthesia than boys and men. This could be partly due to societal mentality that it is okay for girls and women to express fear but not for boys and men.

Assessing dental fear

It is important to first identify that the patient is fearful of the dental treatment to work successfully.
Observing behaviour and physiology: Observing the patient’s behaviour in a waiting room can provide an early indication of dental fear, for example sweating, fidgeting, breathing rapidly, rapid head motions, changing sitting positions often, and observing pace walking. However, this should not be used as a method of diagnosis dental fear. [9]
Asking the patient: Some patients may raise the issue of their dental fear. [10]
Use a self-report dental anxiety scale:

  • The Dental Fear Survey (DFS)
  • The Modified Child Dental Anxiety Scale (MCDAS)
  • The Index of Dental Anxiety and Fear (IDAF-4C+)
  • Corah’s Dental Anxiety Scale, Revised (DAS-R)

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. [11]

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. [12][13]
  • 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. [14]

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). [15]
  • 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. [16]
  • 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. [17][18]
  • 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. [19]
  • 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. [20]
  • 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. [21][22]
  • 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. [23]
  • 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. [24]
  • 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.” [25]

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. [26]
  • 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. [27]
  • Deep breathing: Practice deep breathing anywhere. [28]

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 [Internet]. 2017 Jun [cited 2018 Apr 21]; (6). Available from: http://cochranelibrary-wiley.com/doi/10.1002/14651858.CD012676/full
  2. ^ Anthonappa RP, Ashley PF, Bonetti DL, Lombardo G, Riley P. Non‐pharmacological interventions for managing dental anxiety in children. The Cochrane Library [Internet]. 2017 Jun [cited 2018 Apr 21]; (6). Available from: http://cochranelibrary-wiley.com/doi/10.1002/14651858.CD012676/full
  3. ^ Anthonappa RP, Ashley PF, Bonetti DL, Lombardo G, Riley P. Non‐pharmacological interventions for managing dental anxiety in children. The Cochrane Library [Internet]. 2017 Jun [cited 2018 Apr 21]; (6). Available from: http://cochranelibrary-wiley.com/doi/10.1002/14651858.CD012676/full
  4. ^ Armfield JM, Heaton LJ. 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
  5. ^ Fayad MI, Elbieh A, Baig MN, Alruwaili SA. Prevalence of Dental Anxiety among Dental Patients in Saudi Arabia. J Int Soc Prec Community Dent [Internet]. 2017 Mar [cited 2018 Apr 21];7(2):100-104. Available from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5390573/ DOI: 10.4103/jispcd.JISPCD_19_17
  6. ^ Armfield JM, Heaton LJ. 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
  7. ^ Annie GM, Jenny P, editors. Background and Prevalence of Dental Fear and Anxiety. Preston: Springer International Publishing AG; 2017. 252 p. (Caroline C, editor. Dental Fear and Anxiety in Pediatric Patients).
  8. ^ Chapman H. R, Kirby-Turner N. C. Dental Fear in Children – a proposed model. British Dental Journal. 1999 Oct 23;187(8):408-12.
  9. ^ 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
  10. ^ 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
  11. ^ 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
  12. ^ Armfield JM, Heaton LJ. 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
  13. ^ 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
  14. ^ 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
  15. ^ 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
  16. ^ Armfield JM, Heaton LJ. 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
  17. ^ 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
  18. ^ 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
  19. ^ 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
  20. ^ 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
  21. ^ 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
  22. ^ Armfield JM, Heaton LJ. 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
  23. ^ Armfield JM, Heaton LJ. 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
  24. ^ 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
  25. ^ Armfield JM, Heaton LJ. 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. ^ 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
  27. ^ 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
  28. ^ 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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