Dental fear

Dental fear or dental anxiety refers to the fear of dentistry and of receiving dental care. A pathological form of this fear (specific phobia) is variously called dental phobia, odontophobia, dentophobia, dentist phobia, or dental anxiety. However, it has been suggested that the term "dental phobia" is often a misnomer, as many people with this condition do not feel their fears to be excessive or unreasonable and resemble individuals with post-traumatic stress disorder, caused by previous traumatic dental experiences.

It is estimated that as many as 75% of US adults experiences some degree of dental fear, from mild to severe. 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. 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.

Women tend to report more dental fear than men, and younger people tend to report being more dentally fearful than older individuals. 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.

Cause
Many people report that their dental fear began after a traumatic, difficult, and/or painful dental experience. 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.

Dental fear may also develop as people hear about others' traumatic experiences or negative views of dentistry.

Treatments for dental fear often include a combination of behavioral and pharmacological techniques. Specialized dental fear clinics, such as those at the University of Washington in Seattle and Göteborg University in Sweden, 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. Although specialized clinics exist to help individuals manage and overcome their fear of dentistry, many dental providers outside of such clinics use similar behavioral and cognitive strategies to help patients reduce their fear.

Treatment
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. Both relaxation and cognitive strategies have been shown to significantly reduce dental fear. One example of a behavioral technique is systematic desensitization, a method used in psychology to overcome phobias and other anxiety disorders. 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. Cognitive restructuring, if applied in a non-threatening situation, might be an useful alternative as a first step after years of avoidance of dental care and less threatening than immediate exposure to the feared stimuli.

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, Gerry Kent, a clinical psychologist from the University of Sheffield UK, notes that from the patient's perspective, interventions can be conceptualized quite differently. 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. Such findings suggest that an interpersonal model of anxiety and anxiety-reduction is useful when trying to understand and treat dental fears.

Behavioural strategies used by dentists include positive reinforcement (e.g. praising the patient), the use of non-threatening language, and tell-show-do techniques. The tell-show-do technique was originally developed for use in pediatric dentistry, but can also be used with nervous adult patients. 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).

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.

Pharmacological techniques to manage dental fear range from mild sedation to general anesthesia, and are often used by dentists in conjunction with behavioral techniques. 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. 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. In GA, patients are more deeply sedated.

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.

Books

 * Botto, R. W. (2006). Chairside Techniques for Reducing Dental Fear. Malden, MA: Blackwell Publishing.
 * Chapman, H. R., & Kirby-Turner, N. C. (2005). The Treatment of Dental Fear in Children and Adolescents - A Cognitive-Behavioural Approach to the Development of Coping Skills and their Clinical Application. Hauppauge, NY: Nova Science Publishers.

Papers
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 * Abrahamsson, K. H., Berggren, U., Hallberg, L. R. M., & Carlsson, S. G. (2002). Ambivalence in coping with dental fear and avoidance: A qualitative study: Journal of Health Psychology Vol 7(6) Nov 2002, 653-664.
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 * Locker, D., Shapiro, D., & Liddell, A. (1997). Overlap between dental anxiety and blood-injury fears: Psychological characteristics and response to dental treatment: Behaviour Research and Therapy Vol 35(7) Jul 1997, 583-590.
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 * Lundgren, J., Berggren, U., & Carlsson, S. G. (2004). Psychophysiological reactions in dental phobic patients with direct vs. indirect fear acquisition: Journal of Behavior Therapy and Experimental Psychiatry Vol 35(1) Mar 2004, 3-12.
 * Lundgren, J., Carlsson, S. G., & Berggren, U. (2006). Relaxation versus cognitive therapies for dental fear--A psychophysiological approach: Health Psychology Vol 25(3) May 2006, 267-273.
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 * McGlynn, F. D., McNeil, D. W., Gallagher, S. L., & Vrana, S. (1987). Factor structure, stability, and internal consistency of the Dental Fear Survey: Behavioral Assessment Vol 9(1) Win 1987, 57-66.
 * McNeil, D. W., & Berryman, M. L. (1989). Components of dental fear in adults? : Behaviour Research and Therapy Vol 27(3) 1989, 233-236.
 * Mehrstedt, M., Tonnies, S., & Eisentraut, I. (2002). Dental Fears, Health Status and Quality of Life: Verhaltenstherapie & Verhaltensmedizin Vol 23(3) 2002, 329-340.
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 * Milgrom, P., Vignehsa, H., & Weinstein, P. (1992). Adolescent dental fear and control: Prevalence and theoretical implications: Behaviour Research and Therapy Vol 30(4) Jul 1992, 367-373.
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 * Moore, R., Brodsgaard, I., & Birn, H. (1991). Manifestations, acquisition and diagnostic categories of dental fear in a self-referred population: Behaviour Research and Therapy Vol 29(1) 1991, 51-60.
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 * Muris, P., Jongh, A. D., Merckelbach, H., Postema, S., & Vet, M. (1998). Thought suppression in phobic and non-phobic dental patients: Anxiety, Stress & Coping: An International Journal Vol 11(4) 1998, 275-287.
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 * Rowe, M. M., & Moore, T. A. (1998). Self-report measures of dental fear: Gender differences: American Journal of Health Behavior Vol 22(4) Jul-Aug 1998, 243-247.
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Books

 * McGlynn, F. D., & Vopat, T. (1994). Simple phobia. New York, NY: Plenum Press.

Papers

 * Google Scholar