Dental fear

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Dental fear
SynonymsDental anxiety, dental phobia, odontophobia
Figure 1 Vicious cycle of dental fear.jpg
Cycle of dental fear

Dental fear is a normal emotional reaction to one or more specific threatening stimuli in the dental situation.[1][2] 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.[1] 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.[1] The term ‘dental fear and anxiety’ (DFA) is often used to refer to strong negative feelings associated with dental treatment among children, adolescents and adults, whether or not the criteria for a diagnosis of dental phobia are met. Dental phobia can include fear of dental procedures, dental environment or setting, fear of dental instruments or fear of the dentist as a person.[3]

Signs and symptoms[edit]

People with dental phobia often avoid the dentist and neglect oral health, which may lead to painful dental problems and ultimately force a visit to the dentist. The emergency nature of this appointment may serve to worsen the phobia. This phenomenon may also be called the cycle of dental fear[3]


Odontophobia (dental fear) is a “unique phobia with special psychosomatic components that impact on the dental health of the odontophobic persons”. For some individuals, dental fear may be so great that normal life is impaired. In these instances, the individual experiences fear or anxiety that is out of proportion to the actual danger present in the situation. This often leads to avoidance behaviour, and clinically significant levels of distress or impaired functioning.[4]

Reasons for dental phobia may be:

· Fear of pain. Fear of pain is a very common reason for avoiding the dentist. This fear usually stems from an early dental experience that was unpleasant or painful or from dental "pain and horror" stories told by others. Thanks to the many advances in dentistry made over the years, most of today's dental procedures are considerably less painful or even pain-free.

· Fear of injections or fear the injection won't work. Many people are terrified of needles, especially when inserted into their mouth. Beyond this fear, others fear that the anesthesia hasn't yet taken effect or wasn't a large enough dose to eliminate any pain before the dental procedure begins.

· Fear of anaesthetic side effects. Some people fear the potential side effects of anaesthesia such as dizziness, feeling faint, or nausea. Others don't like the numbness or "fat lip" associated with local anaesthetics

· Feelings of helplessness and loss of control. It's common for people to feel these emotions considering the situation—sitting in a dental chair with your mouth wide open, unable to see what's going on.

· Embarrassment and loss of personal space. Many people feel uncomfortable about the physical closeness of the dentist or hygienist to their face. Others may feel self-conscious about the appearance of their teeth or possible mouth odours.[5]

  • a traumatic dental experience or other healthcare experience(s)
  • previous trauma to the head and neck
  • other traumatic experiences, including abuse
  • generalised anxiety, depression or post-traumatic stress disorder
  • the view that the mouth is a personal area and accessing the mouth is an invasion of personal space
  • trust issues.[6]
  • negative past experience.[7]
  • The whine of a dental drill or the sound of a suction tube also trigger dental fear.
  • Patients who have neglected at-home oral hygiene habits or routine preventative dentistry treatments will probably have poor oral health. These patients can benefit the most from restorative dentistry treatments to address dental complications. Unfortunately, poor oral health or a neglect of dental care is a common cause of dental phobia. When a person knows they will need extensive dental care to restore the strength of the smile, they may be afraid to schedule a dental exam. Many patients who suffer from poor oral health also fear that they will be judged or reprimanded by the dentist for letting their smile get to the state it is in.[8]

Other people[edit]

Dental fear can be transmitted through other people's experience or their perception. Although the main anxiety comes from the fear of treatment, many studies suggest that the fear of going to the dental office is influenced by their family members.[9][10][11]

Sexual abuse[edit]

Dental fear is associated with prior sexual abuse.[12]


Dental fear was 30% heritable and fear of pain was 34% heritable.[13]


Dental fear can be transmitted through social media, reading a comic dental paper, watching a movie involving gruesome dental scenes and listening to a fearful dental story from a friend or a family member. Dental fear can also arise from observation of other people attending for complex dental treatments.[14]


It is viewed as counterproductive to discuss dental fear with people because it is believed that this may exacerbate the pre-existing fear. Despite this common idea, it has been found that it is actually more beneficial in most cases to discuss dental fear with the patient. The first step in accommodating to patients with dental fear is to:

  • Identify the patient has fear. This can be done through observation (constant moving, talking loudly, sweating) or by asking the patient directly.
  • Then to create a conducive environment and open dialogue which can allow the patient to feel more comfortable in the dental setting.

Several methods have been developed to diagnose dental fear and anxiety. In addition to identifying the patients with dental fear, different categories of dental fear have been established.[3][15] These include:

  • Dental fear survey (DFS) which incapsulates 20 items in relation to various situations, feelings and reaction to dental work which is used to diagnose dental fear.
  • Modified child dental anxiety scale (MCDAS), used for children and it has 8 items with a voting system from 1-5 where 1 is not worried and 5 is very worried.
  • The index of dental anxiety and fear (IDAF-4C+), used for adults and it is separated into 8 item module and then a further 10 item module.
  • Corahs dental anxiety scale 1-4 questions and then 1-26 question. This scale has a ranking system and the second section with 26 questions has 1-4 options ranging from 'low' to 'don't know' which is used to assess dental concern. The first section with 1-4 questions has 5 Likert scale options which are worth 1-5 points with the possible amount of maximum points is 20. Then depending on the result you rate the dental anxiety. 9-12 being moderate 13-14 being high, and 15-20 being severe.
  • Spielberger State Trait Anxiety Index (STA): an instrument for measuring anxiety in adults. It differentiates between temporary condition of “state anxiety” and the more general and long-lasting quality of “trait anxiety”. It can also help differentiate between anxiety and depression[16]
  • Anxiety Sensitivity Index (ASI): a 16-item scale that focuses on apprehension about the symptoms of anxiety itself[17]
  • Seattle System: consists of four diagnostic types in which such individuals are categorised according to the main source of their dear regarding dental treatment[3]
    • Type 1: simple conditioned phobia—fear of dental procedures
    • Type 2: fear of catastrophe—anxiety about somatic reactions during dental treatment e.g. fainting, panic attack, heart attack
    • Type 3: Generalized anxiety—nervous person in general
    • Type 4: distrust of dentists—fear of the dentist


Dental fear varies across a continuum, from very mild fear to severe. Therefore, in a dental setting, it is also the case where the technique and management that works for one patient might not work for another. Some individuals may require a tailored management and treatment approach.[18]

The management of people with dental fear can be done using shorter term methods such as hypnosis and general anesthetic, or longer term methods such as cognitive behavioral therapy and the development of coping skills. Short term methods have been proven to be ineffective for long term treatment of the phobia, since many return to a pattern of treatment avoidance afterwards. Psychological approaches are more effective at maintaining regular dental care, but demand more knowledge from the dentist and motivation from the patient[3]


Cognitive behavioral therapy (CBT) appears to decrease dental fear and improve the frequency people go to the dentist.[19] Other measures that may be useful include distraction, guided imagery, relaxation techniques, and music therapy.[20][21] Behavior techniques are believed to be sufficient for the majority of people with mild anxiety.[22] The quality of the evidence to support this, however, is low.[23]


General anaesthesia for dentistry can only be carried out in a hospital setting.

The use of general anaesthesia to reduce the pain and anxiety associated with dental treatment should be discouraged and general anaesthesia should be undertaken only when absolutely necessary.[18]


Hypnosis may be useful in certain people.[20] Hypnosis may improve a person's level of cooperation and decrease gagging.[24]


Individuals who are highly anxious about undergoing dental treatment comprise approximately one in six of the population.[25] Younger people, female, and those who have experienced prior unpleasant dental experience have higher rates.

See also[edit]


  1. ^ a b c Seligman LD, Hovey JD, Chacon K, Ollendick TH (July 2017). "Dental anxiety: An understudied problem in youth". Clinical Psychology Review. 55: 25–40. doi:10.1016/j.cpr.2017.04.004. PMID 28478271.
  2. ^ Anthonappa RP, Ashley PF, Bonetti DL, Lombardo G, Riley P (2017). "Non-pharmacological interventions for managing dental anxiety in children". Cochrane Database of Systematic Reviews. doi:10.1002/14651858.CD012676.
  3. ^ a b c d e Moore R (1991), The Phenomenon of Dental Fear - Studies in Clinical Diagnosis, Measurement and Treatment, Fællestrykeriet, Aarhus University; Aarhus Denmark, doi:10.13140/rg.2.1.3647.5363/1
  4. ^ Suckling G, Thurley DC (1984). "Histological, macroscopic and microhardness observations of fluoride-induced changes in the enamel organ and enamel of sheep incisor teeth". Archives of Oral Biology. 29 (3): 165–77. doi:10.1016/0003-9969(84)90050-5. PMID 6587836.
  5. ^ Thurley D (2009). "Easing dental fear".
  6. ^ Jones J. "Conditions and treatment".
  7. ^ Bell D (2004). "Causes of dental phobia".
  8. ^ Charlton J (2012). "CXauses of dental anxiety".
  9. ^ Liu Y, Gu Z, Wang Y, Wu Q, Chen V, Xu X, Zhou X (January 2019). "Effect of audiovisual distraction on the management of dental anxiety in children: A systematic review". International Journal of Paediatric Dentistry. 29 (1): 14–21. doi:10.1111/ipd.12430. PMID 30362187.
  10. ^ Barreiros D, de Oliveira DS, de Queiroz AM, da Silva RA, de Paula-Silva FW, Küchler EC (2018-01-01). "Audiovisual distraction methods for anxiety in children during dental treatment: A systematic review and meta-analysis". Journal of Indian Society of Pedodontics and Preventive Dentistry. 36 (1): 2–8. doi:10.4103/JISPPD.JISPPD_188_16 (inactive 2019-03-06). PMID 29607831.
  11. ^ Ainscough SL, Windsor L, Tahmassebi JF (February 2019). "A review of the effect of music on dental anxiety in children". European Archives of Paediatric Dentistry. 20 (1): 23–26. doi:10.1007/s40368-018-0380-6. PMID 30374854.
  12. ^ Larijani HH, Guggisberg M (2015). "Improving Clinical Practice: What Dentists Need to Know about the Association between Dental Fear and a History of Sexual Violence Victimisation". International Journal of Dentistry. 2015: 1–12. doi:10.1155/2015/452814. PMC 4309219. PMID 25663839.
  13. ^ Randall CL, Shaffer JR, McNeil DW, Crout RJ, Weyant RJ, Marazita ML (February 2017). "Toward a genetic understanding of dental fear: evidence of heritability". Community Dentistry and Oral Epidemiology. 45 (1): 66–73. doi:10.1111/cdoe.12261. PMC 5388586. PMID 27730664.
  14. ^ Townend E, Dimigen G, Fung D (January 2000). "A clinical study of child dental anxiety". Behaviour Research and Therapy. 38 (1): 31–46. doi:10.1016/S0005-7967(98)00205-8. PMID 10645022.
  15. ^ De Jongh A, Adair P, Meijerink-Anderson M (April 2005). "Clinical management of dental anxiety: what works for whom?". International Dental Journal. 55 (2): 73–80. doi:10.1111/j.1875-595X.2005.tb00037.x. PMID 15880961.
  16. ^ "The State-Trait Anxiety Inventory (STAI)". American Psychological Association. Retrieved 2019-02-19.
  17. ^ Gilbert C (2014). "Chapter 6.4 - Psychological assessment of breathing problems". In Chaitow L, Dinah Bradley D, Gilbert C. Recognizing and Treating Breathing Disorders (2nd ed.). Elsevier. pp. 129–136. doi:10.1016/b978-0-7020-4980-4.00011-3. ISBN 9780702049804.
  18. ^ a b Appukuttan DP (2016). "Strategies to manage patients with dental anxiety and dental phobia: literature review". Clinical, Cosmetic and Investigational Dentistry. 8: 35–50. doi:10.2147/CCIDE.S63626. PMC 4790493. PMID 27022303.
  19. ^ Newton, T.; Asimakopoulou, K.; Daly, B.; Scambler, S.; Scott, S. (2012-09-21). "The management of dental anxiety: time for a sense of proportion?". British Dental Journal. 213 (6): 271–274. doi:10.1038/sj.bdj.2012.830. ISSN 1476-5373. PMID 22996472.
  20. ^ a b Armfield, J. M.; Heaton, L. J. (2013). "Management of fear and anxiety in the dental clinic: a review". Australian Dental Journal. 58 (4): 390–407. doi:10.1111/adj.12118. ISSN 1834-7819. PMID 24320894.
  21. ^ "Standards for Conscious Sedation in The provision of dental care" (PDF). p. 11.
  22. ^ Department of Health. Salaried Primary Dental Care Services: Toolkit for Commissioners. p9. London: Department of Health, 2009
  23. ^ Boman, Ulla Wide; Carlsson, Viktor; Westin, Maria; Hakeberg, Magnus (2013). "Psychological treatment of dental anxiety among adults: a systematic review". European Journal of Oral Sciences. 121 (3pt2): 225–234. doi:10.1111/eos.12032. ISSN 1600-0722. PMID 23659254.
  24. ^ Allison N (October 2015). "Hypnosis in modern dentistry: Challenging misconceptions". Faculty Dental Journal. 6 (4): 172–175. doi:10.1308/rcsfdj.2015.172.
  25. ^ Armfield JM, Heaton LJ (December 2013). "Management of fear and anxiety in the dental clinic: a review". Australian Dental Journal. 58 (4): 390–407, quiz 531. doi:10.1111/adj.12118. PMID 24320894.