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.     

Evaluation of the ability of dental clinicians to rate dental anxiety

The aim of this study was to evaluate the ability of dental clinicians to rate dental anxiety. A total of 104 clinicians from 24 public dental clinics in the Region of Östergötland, Sweden, examined 1,128 adult patients undergoing their regular dental examination. The patients rated their dental anxiety using the Modified Dental Anxiety Scale and a Visual Analogue Scale. After the examination, the clinicians rated the patients’ levels of dental anxiety on a Visual Analogue Scale. The correlation (r_s) between the clinicians’ and patients’ ratings of dental anxiety was 0.45. Among highly dentally anxious patients, there was no correlation between clinicians’ and patients’ ratings. Dental clinicians rated dental anxiety lower than their patients did, especially if the patients were highly anxious. The ability of clinicians to rate dental anxiety was better when the clinician was older and the patient was older. There was an inverse association between clinicians’ confidence and their ability to rate a patient's dental anxiety. In conclusion, clinicians are unsuccessful in identifying a dentally anxious patient without the concurrent use of patient self‐assessment tools. A Visual Analogue Scale is a suitable screening tool in general practice for detection of dental anxiety.     

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 anxiety and quality of life: the effect of dental treatment

Abstract – Objective: The aim of the present study was to determine the association between dental anxiety and quality of life (QoL) and to test the hypothesis that treatment of highly anxious patients would significantly enhance QoL. Material and methods: Subjects were 35 highly anxious dental patients of a Dutch dental fear clinic who were assessed on dental trait anxiety (DAS and S‐DAI) and QoL (oral health‐related QoL with the use of OHIP‐14, dental anxiety‐related QoL with the SADAS, and general aspects of QoL using Global Assessment of Functioning, while five different aspects of life satisfaction were quantified on a VAS‐scale) both prior to and after treatment (an average of six sessions of 45–60 minutes each). Also, both objective (DMFT and dentists’ judgement) and subjective (patients’ judgement) indices of oral health status were recorded. Results: Higher dental anxiety was significantly associated with lower OH‐QoL as indexed by the OHIP‐14 (r = 0.51–0.56, P < 0.01). Treatment was associated with marked improvement on oral health status, reduction of dental anxiety, and improvements regarding a variety of aspects of QoL (all Ps < 0.001). Reduction of dental anxiety, rather than improved oral health, was found to predict enhanced OH‐QoL. Conclusion: The results underline the importance of applying effective treatment methods for dentally anxious patients, not only with the purpose to alleviate their dental anxiety and to improve their oral health, but also because it contributes to an enhancement of their QoL.     

Effect of a special dental program upon extreme dental anxiety

Abstract Dental anxiety of 60 extremely anxious dental patients enrolled in a special program, was measured multioperationally before and immediately after treatment, and 6 months later. The mean anxiety level was substantially lowered during the course of treatment, indicating a favourable effect of the program. After Amsterdam, The Netherlands 6 months dental anxiety was still at the lower level.     

Prevalence of dental anxiety in the Netherlands

The main purpose of this study was to investigate the prevalence of dental anxiety in the Netherlands by means of both a nationwide representative sample and a valid measurement instrument. The secondary aim was to discriminate between patients with high and low levels of dental anxiety on the basis of socioeconomic and oral health variables. Results showed that about 40% of the Dutch population experience a considerable degree of anxiety about dental treatment, and more than half of them can be considered as highly anxious. Dental anxiety is related to sex, age, and oral health status. Individual most prone to experience dental anxiety are women between 26 and 35 yr of age who do not visit a dentist regularly, live in one of the big cities, have a moderate or high educational level, are Public Health Insurance (Ziekenfonds) patients with a minimum income, judge their oral health as bad, and do not attach much importance to the preservation of their teeth.     

Memory of pain and anxiety associated with tooth extraction

Concerns regarding pain constitute a large component of dental anxiety, and patients with high dental anxiety are likely to have exaggerated memory and prediction of dental pain. It remains to be investigated, however, if memory of anxiety is exaggerated in a manner similar to that of pain, and if anxiety and pain assimilate in memory over time. A sample of 79 patients presenting for emergency extraction rated their anxiety and pain before, during, and two weeks after the procedure. Measures of trait dental anxiety and fear of pain also were collected. All patients exaggerated their recall of procedure pain, but only those high in trait dental anxiety exaggerated their recall of anxiety. Highly anxious patients reported more pain prior to the procedure and expected more pain; ratings of anxiety and pain for all participants assimilated over time.     

Attitudes of some young female bank employees to dentistry

Structured interviews were undertaken with one hundred 18-30-year-old females, seeking their views on dental care. Almost all regarded their own past experience as affecting their general level of dental anxiety. Over half were anxious about visiting the dentist and almost all of these were anxious before entering the surgery. The Anxious emphasized the negative features in dental care and the practice environment whereas the Non-anxious concentrated on positive features, particularly their relationship with the dentist. Many spontaneously commented that their attitudes had been improved by changing dentists, although some still remained anxious. 'Worst visits' had frequently occurred early in their lives. Appearance was of prime importance; function was ignored. Interviewees believed that visiting the dentist would be eased by lower costs, more convenient hours, better surroundings in the practice and improved techniques to make dentistry more comfortable.     

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.     

Interviewing self-reported highly anxious patients during periodontal treatment

BACKGROUND: Little information exists on highly anxious patients referred for periodontal therapy. METHODS: All patients referred for periodontal therapy between November 1, 2002 and April 1, 2004 were included in this study. Patients who perceived themselves as extremely anxious were interviewed further, and their anxiety levels were observed during the various stages of periodontal therapy. RESULTS: Twenty-one (19 females and two males, average age, 49.76 years) of 176 patients (12.1%) reported extreme anticipatory anxiety. The main reasons for their anxiety were fear of pain and previous bad experience(s). CONCLUSIONS: Average anxiety levels decreased with the progress of the periodontal therapy. However, individual responses varied greatly and were unpredictable.     

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.     

Experience with dental pain and fear of dental pain

Anxious people tend to overestimate the intensity of aversive events such as fear and pain. When an aversive event has been experienced personally, prediction is based on experience and is possibly less subject to bias due to anxiety. Therefore, it was hypothesized that subjects will overestimate fear of specific dental pains relative to subjects who experienced the pain or procedure personally. Samples of highly anxious dental patients (n=48), patients waiting for periodontal treatment (n=56), and psychology freshmen (n=262) completed a measure of dental anxiety and the Fear of Dental Pain (FDP) questionnaire. All FDP items were extended with the question whether the subject ever experienced the pain personally (yes or no). Less fear was reported when the pain had been experienced personally, with the exception of the sample of highly anxious dental patients. The results suggest that fear of dental pain is a highly important covariate in dental pain research.     

Trajectories of dental anxiety in a birth cohort

Abstract – Objective: To examine predictors of dental anxiety trajectories in a longitudinal study of New Zealanders. Methods:  Prospective study of a complete birth cohort born in 1972/73 in Dunedin, New Zealand, with dental anxiety scale (DAS) scores and dental utilization determined at ages 15, 18, 26 and 32 years. Personality traits were assessed at a superfactor and (more fine‐grained) subscale level via the Multidimensional Personality Questionnaire at age 18 years. Group‐based trajectory analysis was used to identify dental anxiety trajectories. Results:  DAS scores from at least three assessments were available for 828 participants. Six dental anxiety trajectories were observed: stable nonanxious low (39.6%); stable nonanxious medium (37.9%); recovery (1.6%); adult‐onset anxious (7.7%); stable anxious (7.2%) and adolescent‐onset anxious (5.9%). Multivariate analysis showed that males and those with higher DMFS at age 15 years were more likely to be in the stable nonanxious low trajectory group. Membership of the stable nonanxious medium group was predicted by the dental caries experience at age 15 years. Participants who had lost one or more teeth between ages 26 and 32 years had almost twice the relative risk for membership of the adult‐onset anxious group. Personality traits predicted group membership. Specifically, high scorers (via median split) on the ‘stress reaction’ subscale had over twice the risk of being in the stable anxious group; low scorers on the traditionalism subscale were more likely to be members of the recovery trajectory group; and high scorers on the ‘social closeness’ subscale had half the risk of being in the stable anxious group. Dental caries experience at age 5 years was also a predictor for the stable anxious group. Membership of the late‐adolescent‐onset anxious group was predicted by higher dental caries experience by age 15 years, but none of the other predictors was significant. Conclusion:  Six discrete trajectories of dental anxiety have been observed. Some trajectories (totalling more than 90% of the cohort) had clear associations with external influences, but others were more strongly associated with characteristics such as personality traits. A mix of both influences was observed with only the stable anxious dental anxiety trajectory.     

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.     

Strategies for combating dental anxiety

Dental anxiety and subsequent avoidance of dental care and deterioration of oral health pose a significant problem for the dental profession. In an attempt to elucidate preferences of anxious dental patients, we gathered survey data from 121 persons at a small, private liberal arts college in the mid-Atlantic region of the United States. Half of the respondents experienced dental anxiety, and most of these (66 percent) attributed anxiety to fear of anticipated pain. The majority of anxious patients preferred a dentist to be friendly (93 percent), talkative (82 percent), and to have an office with adorned walls (89 percent) and a slightly cool temperature (63 percent). Patients who identified themselves as anxious also indicated that music in the background (89 percent) and magazines and books in the dental office (75 percent) were helpful. Anxious patients were more likely than non-anxious patients to prefer a male dentist (77 percent versus 52 percent). This finding was especially marked among anxious male respondents, 93 percent of whom preferred a male dentist compared to 73 percent of anxious female respondents. These survey data may assist dental professionals in understanding and combating patients' dental anxiety, in order to increase the frequency of dental visits and to prompt a corresponding restoration or maintenance of oral health.     

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.     

Childhood fear and anxiety states in relation to dental treatment

Five years experience by the authors in organizing a dental psychology clinic has impressed on them that many excessively fearful child patients have a history of untoward dental and medical experiences which might have been prevented. A background to an understanding of fear and anxiety in children is presented, and two cases are described to illustrate straight-forward behavior modification techniques which can be used to help the fearful or excessively anxious child cope with dental treatment.     

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.