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.     

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.     

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在儿童牙科,如何引导惠儿配合牙科治疗一直是儿童牙医面临的一大挑战,疼痛和焦虑的控制是非常重要的环节.本文主要讨论儿童牙科不同治疗阶段疼痛和焦虑的控制方法.     

Referrals to a secondary care dental clinic for anxious adult patients: implications for treatment.

OBJECTIVES: This study aimed to determine the methods suggested by general dental practitioners for management of patients with dental anxiety whom they refer to a dental hospital setting, the treatment modalities eventually used with such patients and the relationship between patients previous sedation experience and the current referral. METHODS: Consecutive referral letters (n = 125) for management of patients with dental anxiety over a 16 month period were analysed for content, including reason for referral and suggested treatment modalities. Patient records were also examined for previous sedation experience. RESULTS: From 115 referrals eligible for analysis, the dentists requested management of anxiety using pharmacological methods in 113 referrals with only two referrals mentioning psychologically-based treatments. In secondary care, 29% of the adult referrals opted for dental treatment using psychological techniques alone. CONCLUSIONS: In spite of the efficacy of psychological treatments for dental anxiety, primary and secondary care dentists appear not to be suggesting or promoting their use for patients with dental anxiety. Further research into the availablility of, and barriers to accessing the full range of services for those with dental anxiety, including patient perspectives, needs to be undertaken.     

儿童牙科焦虑:与父母牙科焦虑的关系和有效的儿童应对策略

目的:研究较大年龄儿童和他们的父母的牙科焦虑,评价对儿童牙科治疗疼痛有效的儿童应对策略。方法:102名儿童和他们的父母作为研究对象,用Corah牙科焦虑问卷、牙科应对问卷研究儿童和父母的牙科焦虑,应对策略。结果:父母的牙科焦虑与儿童的焦虑有关(r=0.998,P=0.002),母亲的焦虑会影响儿童(β=0.991,P=0.000,R²=0.892),父亲亦影响儿童(β=0.943,P=0.000,R²=0.888)。儿童更常用内部策略应对口腔治疗中的疼痛,最有效的应对策略是外部策略。结论:父母的焦虑与较大年龄儿童焦虑有关,研究结果有助于制定干预措施,预防和减轻儿童牙科焦虑。     

Dental anxiety associated with orthodontic care: Prevalence and contributing factors

Dental anxiety specifically associated with orthodontic treatment has not been well studied. This is in part because of the use of general dental anxiety scales to assess orthodontic dental anxiety, and the assumption that dental anxiety may not exist in orthodontic patients because of the lack of evoking stimuli (i.e., drills, needles) typically associated with orthodontic treatment. The research objective is to assess the prevalence of and factors contributing to general and orthodontic dental anxiety. Data was collected using a questionnaire asking about general dental anxiety, anxiety associated with orthodontic treatment (orthodontic dental anxiety), and contributing factors. Participating patients (n = 675) were 64.3% female, mean (SD) age 17.6 (6.9) years; with 24.9% being future orthodontic patients and 75.1% current patients (p < 0.05). 18.7% reported orthodontic dental anxiety, with 11.0% reporting both general dental and orthodontic dental anxiety and 7.7% reporting only orthodontic dental anxiety. Future orthodontic patients reported higher levels of orthodontic dental anxiety (35.1%) than current patients (13.2%; p < 0.05). This difference was not associated with practice location. Factors contributing to patients’ anxiety were their relationship with the orthodontist, perceptions of orthodontic treatment and treatment factors. Results confirm orthodontic dental anxiety exists and is reported more so in future than current patients. Patient concerns contributing toorthodontic dental anxiety should be addressed in order to reduce patients’ anxiety related to orthodontic care.     

The effect of psychological management on dental anxiety in children

The aim of this study was to determine the effect of using of psychological management techniques on the level of anxiety in Nigerian children during dental management. The Short Form of the Dental Anxiety Survey Schedule was administered to 81 children who were attending a suburban dental clinic for the first time. This schedule was re-administered again two weeks later when they came for a follow up visit. The age of the patients was recorded. The types as well as number of psychological techniques employed during treatment were also noted. The overall mean dental anxiety level of the children decrease from an average of 15.23 +/- 5.03 before treatment to 13.40 + 4.13 after treatment (p < 0.001). However, the mean dental anxiety score in children in whom no psychological technique was employed during treatment increased after treatment. On the other hand, there was also a statistically significant decrease in the mean dental anxiety level of children treated using either a single psychological technique or combined psychological techniques after treatment. Better results were obtained when combined psychological techniques where used than when only a single technique was used. It was concluded that psychological techniques used in the management of dental anxiety in children are highly effective in decreasing dental anxiety levels. Better results are obtained when a number of techniques are combined effectively.     

Effect of information on dental anxiety and behaviour ratings in children.

AIM: To establish the effect of information received about dental care on the anxiety level of the child prior to receiving any form of dental treatment and on their behaviour during dental treatment. METHODS: Eighty-four healthy child patients at their first dental visit, between the ages of 8 and 13 years attending a paediatric dental clinic in Nigeria participated in the study. Information on their dental anxiety level was collected using the Dental Subscale of the Child Fear Survey Schedule. The children were asked to identify their source and type of dental information received. The information given was later categorised into positive or negative for analysis purposes. The children's behaviour during dental treatment was assessed using Venham's clinical ratings of anxiety and cooperative behaviour. The mean dental anxiety scores, as well as the mean Venham behavioural ratings, of those that had received information on dental treatment were compared with those that had never received any information. RESULTS: Previously received information did not appear to have any significant impact on the measures of the dental anxiety level of these children neither was there a statistically significant association between information received and behaviour of the child in the dental chair. CONCLUSION: Past information may play only a minor role in affecting dental anxiety levels and behaviour of the child during dental treatment.     

Music interventions for dental anxiety

Anxiety is a significant issue in the dental care of adults and children. Dental anxiety often leads to avoidance of dental care which may result in significant deterioration of oral and dental health. Non‐pharmacological anxiety management interventions such as music listening are increasingly used in dental care. Although efficacy for music's anxiolytic effects has been established for pre‐operative anxiety, findings regarding the use of music listening for dental anxiety are inconclusive, especially for children. The use of music for passive distraction may not be adequate for children and highly anxious adults. Instead, interventions offered by a trained music therapist may be needed to optimize music's anxiolytic impact. Music therapy interventions are individualized to the patient's presenting needs and geared at enhancing patients’ active engagement in the management of their anxiety. Interventions may include (i) active refocusing of attention, (ii) music‐guided deep breathing, (iii) music‐assisted relaxation, and (iv) music‐guided imagery. In addition, music therapists can teach patients music‐based anxiety management skills prior to dental treatments, offer them the opportunity to express emotions related to the upcoming procedure, and help them gain a sense of control and safety. Clinical guidelines for the use of music listening by dental practitioners are offered.     

The use of dental anxiety questionnaires: a survey of a group of UK dental practitioners

AIM: To determine the frequency of use of dental anxiety assessment questionnaires and factors associated with their use in a group of UK dental practitioners. METHOD: A postal questionnaire to all 328 dentists whose names appear in the British Society for Behavioural Sciences in Dentistry Directory. Information collected for each practitioner included gender, year of qualification, type of practice in which anxious dental patients were treated, treatment used to manage anxious dental patients, type and frequency of use of dental anxiety assessment indices. RESULTS: Questionnaires were returned from 275 (84%) practitioners. 269 were analyzed. Only 54 practitioners (20%) used adult dental anxiety assessment questionnaires and only 46 (17%) used child dental anxiety assessment questionnaires. Male practitioners were more likely to report questionnaire use in comparison with females (P< 0.05), when treating dentally anxious adults (26% v 14%). In addition, practitioners providing intravenous sedation were more likely to use an adult dental anxiety questionnaire (P < 0.04) than those who did not use intravenous sedation (29% v 15%). The type of treatment provided had a significant association with the use of child dental anxiety. Those providing general anaesthesia (P = 0.03) and hypnosis (P = 0.01) for dentally anxious children were more inclined to use a questionnaire. CONCLUSION: The use of pre-treatment dental anxiety assessment questionnaires was low in this group of dentists. Male practitioners and those providing intravenous sedation, general anaesthesia or hypnosis seem more likely to use dental anxiety assessment questionnaires.     

Dental fear in children and adolescents: a comparison of forms of anxiety management practised by general and paediatric dentists

International Journal of Paediatric Dentistry 2011; 22: 60–67 Background. About 11% of children and adolescents suffer from dental fear. These young people run an increasing risk of undergoing more invasive treatments. Aim. We researched the management of dental anxiety in young patients by general and paediatric dentists as well as by trained and untrained dentists. Design. Eight hundred dentists in Germany were interviewed via e‐mail regarding their experience, treatment techniques, information material and complications during the treatment of fearful children. We also examined how difficult dentists judge the treatment of anxious children and how often they participate in continuing education courses. Results. Paediatric dentists applied a greater spectrum of management techniques than general dentists. They used more often psychotherapeutic interventions and anxiety assessment questionnaires. Dentists who frequently attend in continuing education courses judged the treatment to be less difficult and also used psychotherapeutic interventions more often. Conclusions. German paediatric dentists and dentists who take continuing education courses utilise a broader range of techniques to manage dental anxiety. They may be eminently suited to treat children with severe forms of anxiety. Therefore, dentists who treat young patients should participate in education programmes so as to reduce both the anxiety of their patients and their own anxiety.     

Management of fear and anxiety in the dental clinic: a review

People who are highly anxious about undergoing dental treatment comprise approximately one in seven of the population and require careful and considerate management by dental practitioners. This paper presents a review of a number of non‐pharmacological (behavioural and cognitive) techniques that can be used in the dental clinic or surgery in order to assist anxious individuals obtain needed dental care. Practical advice for managing anxious patients is provided and the evidence base for the various approaches is examined and summarized. The importance of firstly identifying dental fear and then understanding its aetiology, nature and associated components is stressed. Anxiety management techniques range from good communication and establishing rapport to the use of systematic desensitization and hypnosis. Some techniques require specialist training but many others could usefully be adopted for all dental patients, regardless of their known level of dental anxiety. It is concluded that successfully managing dentally fearful individuals is achievable for clinicians but requires a greater level of understanding, good communication and a phased treatment approach. There is an acceptable evidence base for several non‐pharmacological anxiety management practices to help augment dental practitioners providing care to anxious or fearful children and adults.     

Prediction of success and failure of behavior modification as treatment for dental anxiety

Behavior modification techniques are effective in the treatment of extreme dental anxiety, but their success is by no means absolute. In the present article, the Corah Dental Anxiety Scale (DAS), the self-report symptom inventory SCL-90R and a questionnaire accessing subjects' daydreaming styles (the Short Imaginal Process Inventory) were used to develop possible predictive measures for success and failure of behavior modification as a treatment for dental fear. The patients' level of distractibility and mind wandering, initial dental anxiety and somatization significantly predicted the success of therapy. The odds ratio indicated that the risk of therapy failure increased about 11 times with an increase of one scale of the Poor Attention Control Scale, about three times with an increase of one level of the mean DAS score, and 0.17 times with an increase of one level of somatization. The predictive value of the chosen scales was 80%. Thus, the use of these scales as part of an initial admittance process for patients who suffer from dental anxiety can enhance our ability to better recognize patients who are prone to fail behavior therapy as treatment for their problem, and enable their referral for other possible modes of treatment.     

Personality traits of patients suffering extreme dental anxiety

In order to investigate the relationship between dental anxiety and some personality traits, a group of 103 patients suffering extreme dental anxiety and therefore enrolled in a special treatment program were compared with controls sampled at random. The mean scores of the controls on dental anxiety measurements and on questionnaires dealing with personality traits were transformed into 50 with standard deviation equal to 10 to make them mutually comparable, and these subsequently were used as reference points, from which the likewise transformed mean scores of the anxiety group have to differ substantially if both groups stem from different populations. The mean scores were tested for difference with ANOVA. It appears that the anxious patients are more neurotic, i.e. more unstable, than the controls. Moreover, the patients feel themselves more uncertain with regard to having control, are less decisive, have a lower self-esteem, are less inclined to act and are, in general, anxious persons. These findings may have implications for selecting the most appropriate approach for amelioration of their anxiety or support of their coping capacity.     

Dental anxiety in a representative sample of residents of a large German city

In a demographic survey, 300 residents of a German city were questioned to determine the prevalence of dental anxiety. The correlation between the amount of dental anxiety and the age, sex, and education of the subjects was examined and the reasons for avoiding dentist’s appointments, the duration of this avoidance, and what the subjects desire from future dental treatment. The Hierarchical Anxiety Questionnaire (HAQ) was used to measure the amount of dental anxiety. The average level of anxiety was 28.8±10.1 according to the HAQ. Young people were more afraid than older people (p=0.007), and women were more anxious than men (p=0.004). Of the women, 72% go to the dentist regularly, but only 60% of the men do (p=0.020). A painful experience while receiving dental treatment was given by 67% as the main reason for their dental anxiety, followed by a fear of needles (35%). The people wished for the most accurate information available about the dental treatment they receive (69%), followed by a compassionate dentist (62%), and treatment that is free of pain (62%). Of the people, 11% [95% CI: (7.5%; 14.5%)] suffer from dental phobia. All dental phobics were able to state the cause of their fear and more urgently wished for help from the dentist in overcoming their anxiety than the non-phobics (p=0.030). To satisfy the needs of the phobic patients, it appears necessary to screen the phobics out of the group of all patients and then offer them adequate therapy, or refer these patients to specialised treatment centres.     

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.     

Assessing anxiety in pre-school dental patients with a doll placement test

The prospect of dental treatment causes many young patients to be anxious and/or afraid. Because it is helpful to know in advance how much anxiety a child is experiencing, we have devised a test in which the child places dolls in a miniature dental office. We used this model to study 48 children, aged three to five years, who visited our paediatric dental office. We prepared a doll-house-sized model of a dental office with a dental chair, a dentist, and dental hygienist. We asked children to place two dolls, one a self-doll and the other a parent/guardian-doll at a location of their choosing in the model clinic. The positions children chose to place the dolls helped us to gauge the anxiety they were experiencing as they anticipated dental treatment. The majority of children we tested were not anxious, and they placed the self-doll in the dental chair. In contrast, we observed that many children who did not place the self-doll on the dental chair were uncooperative during subsequent dental treatment. Thus, our doll-placement test is a valuable predictor of the anxiety of children who will receive dental treatment. Although how children placed the parent/guardian-doll also provided useful information, we gained the most valuable information from whether or not the child put the self-doll on the dental chair.     

Preventive oral health related behaviour of dentally anxious schoolchildren aged 13-14 years in Lothian, Scotland.

The aim of this study was to determine the self-reported preventive oral health related behaviours of dentally anxious schoolchildren. 1103 children participated in the study, mean age 14 years (SD 0.35 years), and the prevalence of high dental anxiety was 7.1 per cent (95 per cent confidence interval = 5.6 per cent, 8.6 per cent). Children with high self reported dental anxiety were more likely to defer, cancel and or not attend dental appointments. In addition, for this group the last dental visit was more likely to be as a result of pain and less likely to have been for a dental examination only. Overall dentally anxious children did not help themselves by keeping their teeth clean. Fluorides were infrequently used by all the children, and only 12 per cent of all who participated in the study used fluoride supplements regularly. In this context it is not surprising that no differences in present or past use of fluoride supplements could be determined between high and low/moderate dental anxiety groups. The high dental anxiety group spend significantly more (median = 50p) on sweets per day and drank more cans of fizzy drinks (median = 2) compared with the low/moderate anxiety groups. These effects were significant after taking into account social class and gender differences. It was clear from the study that even when social class and gender are taken into account the children with high dental anxiety were not helped by their relatively poor attitudes towards preventing disease in their own mouths.     

Incidence of dental anxiety in young adults in relation to dental treatment experience

OBJECTIVES: To document the incidence of dental anxiety among individuals aged 18 years at baseline and 26 years at follow-up, and to determine if dental treatment experience continues to play a significant etiological role with respect to the onset of dental anxiety in young adults. METHODS: Dental anxiety scale (DAS; Corah, 1969) scores at ages 15, 18 and 26 were obtained for Study members in the Dunedin Multidisciplinary Health and Development Study. Dental examinations were conducted, and sociodemographic and dental service-use data were collected using a self-report questionnaire. Using a case definition of a DAS score of 13 or more, age 18-26 incident cases were identified and their dental treatment experience and service-use characteristics compared with the remainder. RESULTS: DAS scores at 18 and 26 were available for 792 (80.8%) of the 980 26-year-old Study members. An increase in dental anxiety prevalence was observed over the eight-year period, with an annualized incidence of 2.1%. Fewer incident cases had visited a dentist in the previous eight years, and there were no differences between incident cases and others in their eight-year DFS, FS or tooth-loss increments. A subgroup of "recurrent" cases was identified who were dentally anxious at 15 and 26 but not at 18, and their eight-year incidence of tooth loss due to caries was substantially higher than non-cases. CONCLUSIONS: Aversive conditioning experiences appear to be unrelated to the adult onset of dental anxiety, and it may be that particular temperamental or psychological traits are associated with the condition.