Treatment modalities in a dental fear clinic and the relation with general psychopathology and oral health variables.

OBJECTIVE: To assess differences among highly anxious dental patients assigned to different treatment modes (i.e. behavioural management (BM), nitrous oxide sedation (NOS), intravenous sedation (IVS). Patients were compared with regard to psychological and dental variables before treatment (e.g. number of decayed teeth), and dental variables after treatment (e.g. number of fillings made). DESIGN: Dentists experienced in the treatment of highly anxious patients allocated patients to a treatment mode based upon their clinical judgement. SETTING: Centre for Special Dental Care, Amsterdam, The Netherlands. SUBJECTS: 211 patients from this dental fear clinic. MEASURES: General psychopathology, as measured by the Symptom Checklist 90 (SCL-90), and dental anxiety (DAS, S-DAI, 10-point scale) were measured prior to treatment. From the panoramic radiograph the following pre-treatment dental variables were assessed: number of teeth, number of decayed teeth, number of retained roots, and number of root-filled teeth. After treatment, number of fillings, extractions, endodontically treated elements, number of visits, and treatment duration, were determined from the patients' records. RESULTS: Of the 144 patients who received dental treatment at the clinic, 46.5% was treated using a BM approach, 27.8% with NOS, 22.9% with IVS, and 2.8% under GA. No differences among the treatment groups were found with regard to SCL-90 and dental anxiety. The results showed that patients in the IVS group had statistically significant more decayed teeth than patients in the BM group. Furthermore, more fillings were made in the IVS group than in the BM group. CONCLUSION: Since it appeared possible to treat a large proportion of patients by BM alone, training dentists in the application of psychological methods for the treatment of anxious patients should be stimulated. In addition, future research should seek for variables that, besides oral health, are better able to discriminate between groups of highly anxious patients than measures of dental anxiety and psychopathology.     

Reliability and validity of the short version of the Dental Anxiety Inventory

The present study focused on a newly developed questionnaire to assess dental anxiety. The short version of the Dental Anxiety Inventory (S-DAI) contains nine items of the Dental Anxiety Inventory (DAI), which was designed to take into account three situations that may evoke dental anxiety, four time elements in which dental anxiety may be provoked, and three reactions. The aim was to assess the validity and reliability of the S-DAI in a sample of highly anxious dental patients applying for treatment at a dental fear clinic in the Netherlands. Three hundred and twenty-one patientslled out several questionnaires assessing dental anxiety (S-DAI, DAS, and a 10-point Likert-scale) and psychological complaints. Total mean score on the S-DAI for women (mean=40.5, s =5.7) was some-what higher than for men (mean=38.8, s =6.9) ( t (306)=2.35; P =0.019). Cronbach's α for the present sample was 0.88. Correlations with other measures of dental anxiety were 0.73 with the DAS ( P < 0.001) and 0.69 ( P < 0.001) with the 10-point scale. The results indicated that the S-DAI has good reliability and construct validity. It was concluded that the S-DAI is easy to administer in general dental practices and dental fear clinics and has satisfactory psychometric qualities.     

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.     

Reliability and validity of the Dutch version of the Social Attributes of Dental Anxiety Scale

The aim of the present study was to assess the reliability and (factorial) validity of the Dutch version of the Social Attributes of Dental Anxiety Scale (SADAS). A factor analysis using the English version of the SADAS revealed two separate scales. The first eight items involved unwanted psychological upsets when patients encounter dental care directly; the four remaining items were about social inhibitions or restrictions due to the perceived state of oral health. Psychometric properties of the Dutch version were assessed using a sample of 170 highly anxious dental patients of a dental fear clinic in Amsterdam, The Netherlands. The Dental Anxiety Scale (DAS) and the Short version of the Dental Anxiety Inventory (S-DAI) were used as measures of dental anxiety. Factor analysis revealed that four factors explained 72.8% of the variance, and two forcedly extracted factors explained 53.4% of the variance. Correlations indicated that the SADAS does measure a different concept than dental anxiety. In addition, t-tests indicated that the SADAS was able to discriminate between a group of non-anxious individuals and the present group of patients. In conclusion, the SADAS is a promising new questionnaire with moderate factorial, but with more than sufficient reliability, as well as construct and discriminant validity.     

Dental anxiety among patients prior to different dental treatments

The purpose of the present study was to evaluate dental anxiety among patients anticipating various dental treatments. One hundred and eighty patients who were scheduled for specific dental treatments at the School of Dental Medicine, the Hebrew University--Hadassah, Jerusalem, Israel participated in the study. Patients were anticipating one of the following dental procedures: scaling, filling, root canal therapy, preparation for crown, periodontal surgery or extraction. For each of the six dental treatments, 30 patients were selected at random. Dental Anxiety Scale (DAS) questionnaires were completed by the patients while waiting for their treatments. The results indicated that extraction caused the highest score, followed by scaling (though not significantly). Patients in the 35 to 49 year age group showed the highest total DAS scores. Women demonstrated higher total DAS scores than men. The relative influence of gender, type of treatment and age on the anxiety scores is demonstrated by using logistic regression, which revealed gender to have the strongest impact on the DAS scores, followed by the type of treatment and age.     

Dental anxiety among patients undergoing various dental treatments in a Nigerian teaching hospital

The aim of the present study is to evaluate the levels of dental anxiety among patients undergoing various dental treatments and to compare the anxiety levels with those of similar studies conducted with subjects from different socio-cultural backgrounds. Dental anxiety was evaluated by the administration of a questionnaire based on the Corah's Dental Anxiety Scale (DAS). Student t-test and analysis of variance (ANOVA) with Bonferoni correction was employed to compare the mean DAS scores. Females recorded higher total DAS scores than males (7.49 +/- 2.96 and 7.16 +/- 3.44, respectively). Patients in the 24-34 year age group showed the highest total DAS scores (8.25 +/- 3.20) followed by the <24 year age group. The total DAS scores for age groups 35-39 and >50 years differ significantly from those of age groups <24 and 24-34 years. The highest DAS score was recorded for root canal therapy (9.30 +/- 2.84) followed by extraction. The level of dental anxiety among this study population is lower than those reported elsewhere. The observed avoidance of dental treatment among Nigerians, despite the seemingly low mean DAS scores, may be related to dental anxiety. The authors are, however, of the opinion poor dental awareness may be a contributory factor.     

Dental anxiety in adolescents with a history of childhood dental sedation

The purpose of this study was to determine whether adolescents with a history of childhood dental treatment using sedation had a higher level of self-reported dental anxiety than adolescents without such a history. A group of 287 adolescents were identified who had received dental treatment using an identical sedation regime during childhood (mean age 5.05 +/- 0.16 years). A cover letter and a modified Dental Anxiety Scale (DAS) were mailed to the parents of all subjects. Sixty-one subjects (n = 61, 21 males, 40 females, mean age = 14.79 +/- 0.16 years) (+/- SE) completed and returned the form. Age matched control subjects (n = 38, 18 females, 20 males, mean age = 14.36 +/- 0.06 years) who had no history of sedation or general anesthesia for dental or medical procedures also completed the DAS. Using the Mann-Whitney U test, the DAS score for test subjects (13.49 +/- 0.76) was found to be significantly higher (p < 0.05) than the DAS score for control subjects (10.84 +/- 0.69).     

Dental anxiety, optimism–pessimism, and dental experience from childhood to adolescence

Abstract 94 adolescents, 58% of the original study group, participated in a 5-yr follow-up questionnaire study to assess the predictive power of self-reported dental anxiety, optimism–pessimism dimension, and previous dental experience on dental anxiety level over the 5-yr period. The mean values on Corah's Dental Anxiety Scale (DAS) and Dental Anxiety Question (DAQ) had increased for the girls and remained stable for the boys. The predictive power of DAS and DAQ on anxiety levels as measured by these same scales 5 yr later was weak to moderate, although statistically significant. The optimism–pessimism dimension and dental treatment experiences did not have any effect on dental anxiety changes from childhood to adolescence. DAS had an independent, weak, but statistically significant negative effect on optimistic disposition over the period. The internal reliability of DAS was high and highly similar results using DAS and DAQ were found. Except for significantly more dental experience in the drop-out group (n= 69) than in the current study group in the first study, there were no satistically significant differences in mean scores between the groups with respect to self-reported and clinical dental anxiety, and optimism. Methodological complications are discussed.     

A 10-year follow-up of patients treated for dental fear

Abstract – Different types of treatment have been used in trying to reduce dental anxiety in adult patients with severe fear and avoidance behavior. However, there is an obvious shortage in long-term treatment follow-up. The present investigation reports results over a period of 10 yr of 14 patients treated for dental fear in a specialized dental fear treatment and research clinic. The aims of this project were to evaluate patients' regularity in dental behavior between 1977 and 1987, changes in and present level of dental fear and other long-standing positive/negative effects of the respective initial treatments. The 14 dental phobic patients were assigned to two treatment groups, one receiving Systematic Desensitization and one Premedication with valium before dental treatment. Pre- and posttreatment status as well as the 10-yr follow-up were evaluated by psychometric (Corah's Dental Anxiety Scale and a Mood Adjective Checklist) and physiological (Skin Conductance Response) measurements. A majority of patients (100% SD, 63% P) reported regular dental care during the period 1977–87. Positive side-effects were reported by seven patients. A significant reduction of dental fear (DAS) was found with a better effect for the SD-group. This was paralleled by a rise in mood (MACL). The SCR figures were non-significant. In conclusion, the results revealed long-standing effects with regard to a high degree of regular dental care and reduction of dental fear. In addition, positive side-effects were reported.     

Self-assessed dental status, oral behavior, DMF, and dental anxiety

The purpose of this study was to evaluate the relation between self-assessed dental status, oral behavior, dental anxiety, and DMF scores. The study was conducted among young army personnel (eighteen to twenty-one years old) who arrived at a single military dental clinic for dental screening. A questionnaire was used to collect the data anonymously. The questionnaire included self-assessment of dental status and behavior, as well as the Dental Anxiety Scale (DAS). Dental caries status was evaluated using the World Health Organization (WHO) caries diagnostic criteria for decayed, missing, and filled teeth (DMFT). A total of 393 young adults were examined (98.3 percent response rate). Approximately one-third brushed their teeth once a day or not at all. Of the participants, 10.7 percent assessed their dental status as "Poor" and 46.3 percent as "Fair." Furthermore, 25.5 percent assessed their dental treatment needs as high. The average DAS score was 7.14. The average DMF score was 6.2. There was a correlation between self-reported tooth status, participants' assessment of their dental treatment needs, and DMF score (p<0.0001). Anxious participants assessed their dental treatment needs as higher (p=0.05). The dental practitioner could ask patients to assess their dental status prior to treatment or appointment. These findings will help the practitioner to accomplish more effective time and patient management.     

Attendance pattern of anxiety-treated dental patients: a pilot study

Ex-patients of a dental fear clinic were found to have significantly reduced, yet still high, dental anxiety scores in comparison with the pre-intervention scores. In spite of the intervention about one quarter of the ex-patients did not visit a dentist regularly. A positive relationship was found between dental anxiety, measured with Corah's DAS, and "dislike of drilling". A short duration of (self-reported) psychophysiologic anxiety reactions appeared to be associated with the intention to ask for treatment, e.g. if a cavity were present. However, regular dental attendance was not correlated with dental anxiety scores.     

Development of a questionnaire measuring treatment concerns in regular dental patients

Abstract – Objectives: The aim of this study was to develop an instrument measuring core concerns about dental treatment guided by Reiss’ expectancy theory of fear. This would include the content domains of injury, somatic reaction and interpersonal concerns, to study the underlying factorial structure, and to determine the test quality of the resulting subscales. Methods: A total of 555 regular dental patients answered the item pool. Subsamples filled in the Dental Anxiety Scale (DAS) (n = 346) and the Anxiety‐Present Scale of the state‐form of the State‐Trait Anxiety Inventory (STAI‐S) (n = 187). A second sample (n = 89) was used to determine test‐retest reliability and bias for social desirability [Self Disclosure Scale of the Freiburg Personality Inventory (FPI)]. Results: Exploratory and confirmatory factor analyses identified a stable three‐dimensional structure underlying the items convergent to the content domains of interpersonal, injury and somatic reaction concerns. Internal consistencies of the resulting subscales were between α = 0.84 and α = 0.87, test‐retest reliabilities were from r_tt = 0.72–0.78. No evidence for a social desirability response bias was found. All subscales discriminated between patients with low and high dental trait anxiety at a level of P < 0.00001. Dental treatment concerns predicted 36% of variations in actual anxiety during treatment. Conclusions: The results suggest that the proposed instrument, namely the Dental Treatment Concerns Inventory, shows good test qualities according to construct, discriminant and predictive validity, and may be a promising tool for research and clinical applications.     

Anxiety and cortisol excretion correlate prior to dental treatment

The aim of this study was to investigate the possible relationship between dental anxiety and cortisol excretion prior to dental treatment. Trait and state dental anxiety of male subjects were determined using the Dental Anxiety Scale (DAS) and a visual analogue scale (VAS), respectively. Urine and stimulated parotid saliva were collected immediately before dental treatment sessions. Cortisol levels were determined by radioimmunoassay. The self-reported trait dental anxiety (= DAS score) showed a significant relation to the urinary cortisol excretion. The salivary cortisol concentration did not correlate with either VAS or DAS score. The data suggest that dental anxiety has a long-term effect on cortisol metabolism of patients. Therefore, measurement of the cortisol concentration in urine, which reflects a longer term response to stress, seems a promising parameter in the investigation of dental anxiety.     

Efficacy of a trauma‐focused treatment approach for dental phobia: a randomized clinical trial

It has been hypothesized that treatment specifically focused on resolving memories of negative dental events might be efficacious for the alleviation of anxiety in patients with dental phobia. Thirty‐one medication‐free patients who met the Diagnostic and Statistical Manual of Mental Disorders (DSM‐IV‐TR) criteria of dental phobia were randomly assigned to either Eye Movement Desensitization and Reprocessing (EMDR) or a waitlist control condition. Dental anxiety was assessed using the Dental Anxiety Questionnaire (DAS), the Dental Fear Survey (DFS), a behavior test, and dental attendance at 1‐yr of follow up. Eye Movement Desensitization and Reprocessing was associated with significant reductions of dental anxiety and avoidance behavior as well as in symptoms of post‐traumatic stress disorder (PTSD). The effect sizes for the primary outcome measures were d = 2.52 (DAS) and d = 1.87 (DFS). These effects were still significant 3 months (d = 3.28 and d = 2.28, respectively) and 12 months (d = 3.75 and d = 1.79, respectively) after treatment. After 1 yr, 83.3% of the patients were in regular dental treatment (d = 3.20). The findings suggest that therapy aimed at processing memories of past dental events can be helpful for patients with dental phobia.     

Children with baby bottle tooth decay treated under general anesthesia or sedation: behavior in a follow-up visit

The purpose of the present study was to compare the behaviors of a group of children, who were treated for baby bottle tooth decay (BBTD) under general anesthesia (GA) or under sedation in a dental school environment in a routine follow-up examination, and to assess the dental anxiety levels of the parents. Sixty-five children, who were treated for BBTD in the Pediatric Dentistry clinic of the Hebrew University-Hadassah School of Dental Medicine between 1995-1997 under GA (34 children) or sedation (31 children). The parents of these children agreed to attend our clinic for recall examination 13 months post treatment following a telephone conversation. Frankl's behavioral scale and the sitting pattern were recorded for each child. In the sedation group, Frankl's scores of the present visits were then compared to the scores recorded at the initial examination visit that were obtained from the dental records. The accompanying parents were asked to note the number of visits to the dentist in the past two years, and to complete Corah's dental anxiety scale (DAS). No difference was observed between the children in both groups. Most of the children in the GA and in the sedation groups sat alone on the dental chair, without the assistance of the parents. Parents of the sedation group showed higher scores than the GA group in the total DAS (9.35 and 8.90 respectively), however these differences were not statistically significant. It is concluded that children treated for BBTD under GA or under sedation at a very young age behave similarly in a follow-up examination nearly 13 months postoperatively.     

阻生智齿拔除患者牙科焦虑症与特质焦虑症的相关性研究

目的：评估阻生智齿拔除患者牙科焦虑症与特质焦虑的关系，为拔除阻生智齿前进行心理治疗和心理护理提供指导。方法：采用Corah’s的牙科焦虑量表（DAS），凯氏牙科畏惧调查量表（DFS），状态一特质焦虑问卷（STAI）。特质焦虑由STAI的特质焦虑问卷（TAI）量度。对60个患者进行横断面调查，然后对各量表的分值进行相关性分析。结果：特质焦虑与DAS，DFS的分值有显著相关性。3种调查方法相互之间有显著相关性。在特质焦虑调查中，性别差异唯一有统计学意义。结论：阻生智齿拔除患者牙科焦虑症与特质焦虑相关，拔牙前进行心理治疗和心理护理是必要的。     

Assessment of dental fear. A comparison of two psychometric instruments.

To analyze further dental fear and its presentation in dental patients, two psychometric instruments were distributed among 50 patients attending a dental emergency clinic (EMC) and 44 patients applying for treatment at a specialized dental fear clinic (FEC). The Dental Fear Survey (DFS) was compared with the Corah Dental Anxiety Scale (DAS). After separating the EMC patients into high- and low-fear individuals in accordance with DAS scores, analysis showed that DFS values also clearly distinguished between these groups and between the FEC group and EMC groups. The dental fear levels were in correspondence with previous results, and the correlation between the DAS and the DFS was high (r = 0.92). In contrast to the DFS avoidance and arousal dimensions, the difference between the mean item scores on the dental situation dimension was not significantly different between high-fear EMC and FEC individuals. This indicated that the evaluation and appraisal of the dental situation among high-fear EMC and FEC patients may have been corresponding, whereas the behavioral and physiologic effects were different. Thus, in spite of this similar appraisal of the dental situation, FEC patients were interpreted as showing a more phobic behavior, and this was better captured in the DFS than in the DAS.     

Dental caries and changes in dental anxiety in late adolescence

Little is known about changes in dental anxiety with ageing and their association with changes in oral health. This study examined the relationship between changes in dental caries experience and dental anxiety from 15 to 18 years of age among adolescent participants in the Dunedin Multidisciplinary Health and Development Study. Dental anxiety was estimated using the Corah Dental Anxiety Scale (DAS), and individuals with a DAS score of 13 + were identied as being dentally anxious. Dental examinations were performed on 649 individuals at ages 15 and 18, and a DMFS score was computed for each. Caries prevalence among those who were dentally anxious at both 15 and 18 years was signicantly higher than for those who were not at either age. Regression analysis revealed that dental anxiety predicted caries incidence between ages 15 and 18 years. Dental anxiety is likely to be a signicant predictor of dental caries experience, and may be a risk factor for dental caries incidence.     

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.