Dental anxiety reduction and dental attendance after treatment in a dental fear clinic: a follow-up study

OBJECTIVES: The aim of the present study was to assess treatment outcome in terms of dental anxiety reduction at a post-treatment assessment and dental anxiety reduction and dental attendance one year later. Furthermore, it was determined to what extent psychopathological characteristics were related to treatment outcome. METHODS: Questionnaires were sent to 280 patients treated with one of three treatment modes (i.e., behavioral management (BM), nitrous oxide sedation (NOS), and intravenous sedation (IVS)) at a dental fear clinic in The Netherlands. Dental anxiety before (T1) and after (T2) treatment was assessed using the Dental Anxiety Scale (DAS) and the Short version of the Dental Anxiety Inventory (S-DAI); the Symptom Checklist 90 (SCL-90) was used to assess general psychopathology. Dental anxiety was assessed again a year later and patients were questioned about their dental attendance pattern (T3). RESULTS: ANOVA showed that the DAS and S-DAI scores at T2 and T3 were statistically significant lower than the initial scores. In addition, IVS patients showed less anxiety reduction than BM patients at both T2 and T3. Of the 145 patients whose last visit to the clinic was at least one year ago, 62% had visited a GDP at T3. A regression analysis revealed that, beside treatment mode, somatization, number of visits to clinic for dental treatment, and number of months between first and last visit to the clinic predicted dental anxiety at follow-up. CONCLUSIONS: It is concluded that, although a reduction in dental anxiety level was present, a relatively large proportion of patients did not improve, in terms of both dental anxiety and dental attendance.     

Predicting anxiety during dental treatment using patients'self-reports: less is more

BACKGROUND: Self-reported dental fear measures seldom are used in clinical practice to assess patients' fears. This study examined how well dental fear measures predicted anxious behaviors displayed during dental treatment. METHODS: One hundred eight adult patients (54 percent female) in a periodontology clinic completed several paper-and-pencil demographic, dental fear and general anxiety measures before treatment. Dental practitioners, blinded to their patients' responses, rated their patients' anxiety during treatment on a series of 100-millimeter visual analog scales. RESULTS: Higher Dental Fear Survey scores, younger age, more invasive treatment type and previous avoidance of dental care because of a bad experience all were predictive of greater observed anxiety. Neither self-reported nor observed anxiety was affected by previous experience with a particular practitioner or treatment. CONCLUSIONS: Dentists may assess patients' anxiety quickly and accurately with the Dental Fear Survey or a similar measure, as well as by asking patients about their current dental attendance and previous dental experiences.     

Dental anxiety and regularity of dental attendance in younger adults

Dental anxiety constitutes a major problem for patients and dental care providers alike. The aim of this study was to examine the relationship between dental anxiety and regularity of dental attendance among young adults. A random sample of 15 course directors (1:50) was asked to participate in the study. Of these, only 10 course-directors agreed to handout the 500 questionnaires. All undergraduate students who participated in this study were asked to complete a questionnaire modified from Dental Fear Survey (DFS) questionnaire and 368 (73.6%) filled forms were returned for statistical analysis. The results showed that only 20.9% were regular dental attendee while the majority (79.1%) were irregular attendee. The reasons given for irregular attendance were 'lack of time' (36%), 'treatment not needed' (34.1%), 'fear from dentist' (13.3%) and 'cost' (16.6%). The sight and sensation of the injection and sight, sound, and sensation of the drill were the most common fear-eliciting stimuli. Increased heart rate was the commonest reported physiological response. Females had higher mean ratings, therefore tended to be more anxious than males. Dental anxiety represented by the mean responses to the items, was found to be higher in irregular dental attendee than regular attendee. In conclusion, this suggests that dental anxiety may affect the seeking of dental care, therefore to be taken into account when training dental care providers.     

Differentiating anxiety-panic disorders from psychologic dental anxiety

It has always been believed that fear and anxiety of dental treatment was a simple continuum of experience that occurs in mild, moderate, or severe form. Past and present studies that attempt to both trace etiology and measure it reflect this view. The numerous studies that are concerned with methods of management are based on this accepted philosophy regarding the etiology of dental fear and anxiety. To a large extent, this may be true. However, there are some notable exceptions, and it is these cases that present the greatest management problem. Omitting the symptoms of fear and anxiety related to physical illness, drug withdrawal, or major mental illness, they present anxiety as a unidimensional learned problem usually conditioned by externally negative forces or experiences. They postulate that the fear and anxiety seen is due to a variety of factors. The interpretation of the definitions of fear, anxiety, and phobias by many in the profession that are presented in this issue also reflect the view that fear, anxiety, and phobias are learned or conditioned responses. This single-minded view has determined much of our understanding and subsequent management of this problem in dentistry.     

Management of the petrified dental patient

Fear and anxiety are common responses to anticipated or actual dental treatment. This may range from slight feelings of unease during routine procedures, such as an injection or cavity preparation, to feelings of extreme anxiety long before treatment is happening. There is general agreement that anxiety constitutes a major problem for the dentist, and a barrier to optimal care for the patient, as one of the most significant consequences is avoidance of dental treatment. Common triggers include local anaesthetic injection and the dental drill. This paper uses the term anxiety to encompass both fear and anxiety and reviews current strategies for managing anxious people in the dental setting, with a focus on non-invasive operative techniques. CLINICAL RELEVANCE: Being able to recognize fear and anxiety in dental patients is an important part of overall patient management. Knowledge of various behaviour management techniques, and the use of less-invasive operative techniques, enable the clinician to treat a large proportion of anxious people and help them to cope with dental treatment in the primary care setting. Those who remain anxious and unable to cope in the dental setting may require pharmacological techniques, such as conscious sedation, to enable them to receive dental treatment. These techniques are not always readily available, require appropriate training, are more time consuming and costly. In extreme cases, general anaesthesia may be a last resort option.     

A dental support group for anxious patients

OBJECTIVE: To evaluate, qualitatively, a support group for dentally anxious patients reluctant to visit the dentist and obtain dental care. DESIGN: Semi-structured interviews by group discussion, face-to-face or telephone. SETTING: Community: primary health care centre. SUBJECTS: 14 (50%) of the members of the support group. INTERVENTIONS: 13 interviewees were also monitored during a course of treatment following support group attendance. MAIN OUTCOME MEASURES: Views of interviewees concerning dental attendance and dental care before, during and after attendance at the support group. RESULTS: Attendance at the group was a major factor in dispelling fears and negative beliefs about dental care. The 13 interviewees whose progress was monitored through a subsequent course of treatment had a mean age of 43 years and had last attended for dental care 9 years previously. Treatment lasted for a mean of 5.4 visits with few failed appointments. They showed a significant (P < 0.01) reduction in Corah dental anxiety scale score. CONCLUSIONS: Attendance at the support group generated empathy between members and confidence to seek treatment. It increased trust in the dental team but tended to lead to dependence on the dentist group leader. Wider availability of such groups could help to reduce dental anxiety in non-attending adults and encourage treatment uptake.     

An evaluation of the PALS after treatment modelling intervention to reduce dental anxiety in child dental patients

Aim.  The aim of this study was to assess the effectiveness of the passivity to activity through live symbolic (PALS) after treatment modelling intervention to reduce child dental anxiety.
Methods.  A convenience sample of consecutive 5- to 10-year-old dental patients were randomly assigned to intervention or control groups. Self-reported child dental anxiety was assessed at the start of each visit. At the end of each visit, children in the intervention group were introduced to a glove puppet, which acted as the PALS model. The intervention group children re-enacted the treatment they had just received on the puppet's teeth. At the end of each visit, the control children received motivational rewards only. The change in dental anxiety scores was examined by t -tests and analysis of covariance.
Results.  The final analysis included 27 intervention children and 26 control children. For the intervention group, there were no statistically significant changes in dental anxiety over a course of treatment, between first and second preventive visits, between first and second invasive treatment visits, or between first attendance and subsequent recall attendance. For the control group, a statistically significant decrease in dental anxiety was observed between the first and second invasive dental treatment visits.
Conclusion.  The PALS after treatment modelling intervention was ineffective in reducing child dental anxiety.     

Anxiety about dental hygienist treatment

Abstract – Although dental anxiety is a well investigated phenomenon in dental health care, remarkably little is known about anxiety reactions related to treatment carried out by the dental hygienist. In the present study anxiety reactions were measured among 101 patients attending the dental hygienist. General level of anxiety was assessed through the PAQ (Photo Anxiety Questionnaire; S touthard , D e J ongh & H oogstraten , 1991), whereas an additional questionnaire was used to obtain information about specific stimuli and situations that might provoke anxiety in the dental hygienist situation. The results indicated that during dental hygienist treatment only 15% of the patients experienced no feelings of anxiety. Another 15% of the patients reported that a visit to the dental hygienist was more distressing than dental treatment. The level of anxiety appeared to be strongly related to a number of stimuli and situations, with actual pain (78%) and expected pain (67%) major anxiety provoking factors. The relation between pain and anxiety was highly significant, with highly anxious patients having more fear for pain than their low anxious counterparts. Also feelings and sounds of instruments, patient's helplessness and perceived lack of control over what happens were identified as important contributors to anxiety for the dental hygienist treatment. The results of this study suggests that treatment by the dental hygienist is a distressing event for many patients.     

Attitudes to conscious sedation in patients attending an emergency dental clinic.

INTRODUCTION: Anxiety and fear in relation to dentistry are long-standing problems and the incidence of dental fear does not appear to be decreasing. It can result in poor dental health and wastage of clinical time. Conscious sedation is one method of allaying anxiety in dental patients and enables such patients to accept dental treatment. AIMS, MATERIALS AND METHODS: A questionnaire survey was undertaken among patients attending an emergency dental clinic. Its aims were to assess the levels of dental anxiety in these subjects, the impact on their attendance for dental treatment, and their knowledge of and desire to have conscious sedation, should it be available. RESULTS: The results indicated that in the 72 patients who responded, levels of anxiety regarding dental treatment were high, with 49 (68%) claiming some nervousness or worse. Thirty-one (43%) cited fear/nervousness as a reason for delaying making a dental appointment. Twenty-seven (38%) were not aware of the existence of conscious sedation for dental treatment, of whom half reported that they were in the highly anxious group. Forty (56%) respondents said they would like to have sedation if it were available. Twenty-five (35%) claimed to have received sedation for dental treatment in the past. CONCLUSION: It was concluded that the availability of dental sedation was currently not matching the needs and demands of several patients who took part in the survey. Increased availability of dental sedation could remove a barrier to dental care for many highly anxious dental patients.     

A 3-year comparison of dental anxiety treatment outcomes: hypnosis,group therapy and individual desensitization vs. no specialist treatment

Outcomes of hypnotherapy (HT), group therapy (GT) and individual systematic desensitization (SD) on extreme dental anxiety in adults aged 19-65 yr were compared by regular attendance behaviors, changes in dental anxiety and changes in beliefs about dentists and treatment after 3 yr. Treatment groups were comparable with a static reference control group of 65 anxious patients (Dental Anxiety Scale > or = 15) who were followed for a mean of nearly 6 yr. After 3 yr, 54.5% of HT patients, 69.6% of GT patients and 65.5% of SD patients were maintaining regular dental care habits. This was better than the 46.1% of the reference group, who reported going regularly to the dentist again within the cohort follow-up period, and 38.9% of a control subgroup with observation for 3 yr. Women were better regular attenders than men at 3 yr. Specialist-treated regular attenders were significantly less anxious and had more positive beliefs than regular attenders from reference groups. There were few differences between HT, GT and SD after 3 yr. It was concluded that many patients can, on their own, successfully start and maintain regular dental treatment habits with dentists despite years of avoidance associated with phobic or extreme anxiety. However, it also appears that these patients had less success in reducing dental anxiety and improving beliefs about dentists long-term than did patients who were treated at the specialist clinic with psychological strategies.     

Treatment of dental anxiety disorders. Outcome related to DSM-IV diagnoses

In this study we evaluated treatment effects in 70 consecutively admitted patients in a specialized university clinic for treatment of dental fear. Thirty-three (47%) of the patients fulfilled the diagnostic criteria for Specific Phobia alone (Dental Phobia, DP), 24 (33%) had severe dental anxiety without fulfilling the criteria for phobia (ND), and 13 (19%) fulfilled the criteria for multiple DSM-IV diagnoses (MD). Dental anxiety was measured prior to, immediately after and at follow-up (mean = 19 months) using Corah's Dental Anxiety Scale and Dental Fear Survey. Dental attitudes were measured by Getz' Dental Beliefs Survey. Dental attendance and everyday functioning were measured by self-report. DP patients received significantly more treatment-sessions as compared to the ND group. Despite significant overall reductions in scores on all psychometric instruments from pretreatment to follow up, patients in the MD group reported significantly more severe anxiety at pre- and post-treatment and at follow-up as compared to patients in the ND group. There was no interaction between diagnostic group and assessment occasion (pre treatment, post treatment and follow up) on the self-reported anxiety. Patients reported significant improvements in self-esteem, social relations and everyday functioning, regardless of diagnostic group. Sixty-three percentage of the respondents had been to the dentist within 1 year after completed treatment. Patients treated by dentists who had received supervised training in exposure treatment had significantly more often seen the dentist at follow-up.     

Factors affecting the amount of long-term restorative dental treatment provided to 100 patients by 20 dentists in 3 Adelaide private practices

Apart from the effects of the frequency of patient attendance for dental examination, and of a change of dentist, little is known of those factors which may influence the amount of treatment provided in dental practice. The present study investigated during 1992 the effects of seven factors on the amount of treatment provided for 100 adult patients treated by 20 male dentists over many years in three selected Adelaide private practices. The amounts of particular types of restorative treatments provided were significantly related to patient age, gender and frequency of attendance, and to practice location, change of dentist and number of changes of dentist, and to the experience or time since graduation of the dentist. These factors were of special significance for the number of crowns provided, most of which were placed in older patients by more experienced dentists. But, there was no evidence of increased numbers of direct placement restorations being received by patients who attended more frequently or who changed their dentists.     

Treatment for dental anxiety. Evaluation of treatment of patients with anxiety

This article presents the results of a study among 332 extremely anxious persons who applied for treatment at SBT, a Dutch special dental care clinic, between July 1990 and December 1991. It was found that 85% of these persons actually started treatment. Two and a half years later it appeared that 39% of them still received regular treatment, whereas 34% had completed treatment. Twelve percent stopped visiting before treatment was completed. Furthermore, results showed that dental anxiety was reduced after treatment. However, 36% of the patients still avoided appointments with a dentist. It is concluded that for most of the dentally anxious patients specialized care and oral health are no guarantee for regular dental attendance in the long term.     

Dental care for aging populations in Denmark, Sweden, Norway, United kingdom, and Germany

This article reviews access to and financing of dental care for aging populations in selected nations in Europe. Old age per se does not seem to be a major factor in determining the use of dental services. Dentition status, on the other hand, is a major determinant of dental attendance. In addition to perceived need, a variety of social and behavioral factors as well as general health factors have been identified as determinants of dental service use. Frail and functionally dependent elderly have special difficulties in accessing dental care; private dental practitioners are hesitant to provide dental care to these patients. One reason may be that the fee for treating these patients is too low, considering high dental office expenses. Another reason may be problems related to management of medically compromised patients. This raises an important question: does inadequate training in geriatric dentistry discourage dentists from seeking opportunities to treat geriatric patients? Overall, the availability of dental services, the organization of the dental health care delivery system, and price subsidy for dental treatment are important factors influencing access to dental care among older people in Europe as well as in the United States.     

Patients treated by dental students in outreach: the first year of a pilot project

This paper describes the patients treated by 4th year undergraduate students during the first year of a pilot outreach course to teach Restorative Dentistry in community clinics in 2001-02. Data were collected from 908 summaries of patient treatment completed by the students, and from 139 patient questionnaires. Some 75% of patients were aged between 16 and 64, 58% were female, and 16% had dental phobia or anxiety. Most lived locally to the clinic and 41% made their initial contact as an emergency or drop-in. Some 37% made only a single visit (including children treated as emergencies) but 22% made six or more visits. Did not attend (DNA) was a problem and 18% of patients DNA to complete their treatment. Students undertook the full range of restorative procedures, with the emphasis on direct restorations, preventive treatment and advice, scaling, extractions and emergency treatment. Patients' main reasons for attending the clinic were lay recommendation, the need for treatment, convenience, free treatment, or the lack of access to a dentist. Some 30% said they did not have or did not know of an alternative source of dental care, and half had not seen a dentist for at least 2 years. The study demonstrates that despite difficulties related to attendance, a suitable patient base can be established offering students the opportunity to provide comprehensive care for adults in a primary care setting.     

Dental caries, age and anxiety: factors influencing sedation choice for children attending for emergency dental care

OBJECTIVES: The aim of the study was to examine how physical (dental caries) and psychosocial (age, dental anxiety and dental health behaviour) factors, associated with child and parent, influenced dentists' sedation choice when a child presents in pain. METHODS: 600 parents whose children were aged between 5 and 11 years took part: 200 attended for routine dental care (RDC); the remaining 400 attended as emergency patients and were offered either dental general anaesthesia (DGA) or relative analgesia (RA). The subjects were approached and invited to take part. The researcher was blind as to the child's pattern of dental attendance and the type of sedation offered. All parents and children completed self-reported ratings of dental anxiety. The children's teeth were examined to determine past and present dental caries experience. RESULTS: The results showed that children who were offered DGA had greater experience of dentinal caries, were younger and dentally anxious. The children offered RA were older, had a higher frequency of brushing their teeth with fluoride toothpaste and were also dentally anxious. Discriminant analysis showed that 2 canonical functions provided clear categorisation of the three treatment groups. Function 1 was a physical (dental caries) factor, which was related to the child's experience of dentinal caries. Function 2 was a psychosocial factor, which was related to the child's age, dental anxiety and frequency of tooth brushing. A greater proportion of the variance in the treatment offered was explained by Function 1, suggesting that the most important factor in the decision to offer DGA was dentinal caries. Function 2 was of lesser importance. CONCLUSIONS: The findings have implications for the type of sedation offered to children presenting for emergency care. These children may not otherwise receive treatment and the need to provide less anxiety provoking forms of sedation must be promoted. By doing so, parents who have only brought their children when in pain may take advantage of RDC and the treatments offered to prevent and control dental caries and anxiety in their children.     

Orthodontic treatment for disabled children--a survey of patient and appliance management

The objective of this article was to investigate the management problems encountered during the orthodontic treatment of children with disability, and took the form of a retrospective analysis. The investigation took place at the Center for the Treatment of Cranio-facial Disorders, Department of Orthodontics, Hebrew University Hadassah School of Dental Medicine, Jerusalem, Israel, between years 1989 and 1997. The subjects were the 37 children with mental and/or physical disability whose orthodontic treatment was either completed or nearly completed, whose parents were given a questionnaire. Thirty-five patients responded with a mean age of 13 years (range 7-21 years), representing 94.6 per cent of the sample. Most of the patients (94.3 per cent) were able to conclude the orthodontic treatment and 91.4 per cent of the parents reported that the added responsibilities were either negligible or bearable. In 63 per cent of the children, compliance increased during the treatment as anxiety decreased. The problems encountered with fixed appliances were generally more severe than with removable appliances. The two major obstacles were attendance at frequent and regular intervals (37.1 per cent) and maintaining an appropriate level of oral hygiene (37.1 per cent). Children with a disability are able and willing to undergo orthodontic treatment. Recommendations intended to facilitate management are presented.     

Long-term effects of two different treatments for dental fear and avoidance

Follow-up clinical studies of treatment for dental fear and avoidance behavior are infrequent in the literature. The present investigation reports follow-up results over more than two years from 84 out of 99 patients treated for dental fear in a Swedish community-based dental fear clinic. Broad-based behavioral therapy (BT) or general anesthesia (GA), both in combination with adjusted conventional dental treatment, were used. The frequency of patients' attendance for regular dental care after two years was unchanged or even somewhat increased and was significantly higher in those who had received the BT therapy. Most patients stated that they had no problems after leaving the dental fear clinic. Among patients reporting such problems, the change of dentist was most frequently reported. The level of dental anxiety as measured by Corah's DAS was still at a low level, in spite of a slight increase over the two years since initial therapy.