Development of the Gagging Problem Assessment: a pilot study

Summary  An accepted management strategy for gagging problems appears not to exist. A reliable and valid instrument is needed to develop an evidence based treatment for this clinical problem. The aim of this pilot study was to evaluate the reliability and validity of a newly developed measurement tool for dental gagging: the Gagging Problem Assessment (GPA). An experimental group ( n  =   13) comprising individuals with gagging problems, and a control group ( n  =   12) that had received dental care without gagging, completed a questionnaire focused on general health aspects and dental anxiety and the patient part of the GPA. The dentist part consisted of tests with increasing intrusiveness. This part was completed by two dentists. Statistical analyses concerned inter-rater reliability (Cohen's κ ) , reliability of the questionnaire (Cronbach's α , Pearson correlation coefficient) and the statistical difference between the GPA and two dental anxiety questionnaires (Mann–Whitney U- test, α  = 0·05). Within the limits of this study, the findings suggested that dental gagging warranted the development of a diagnostic and evaluative instrument. Gagging appeared to be a specific problem that cannot be interpreted as some form of dental anxiety. The GPA proved to be a reliable questionnaire to assess the presence of gagging problems, with a satisfying inter-rater reliability ( κ  = 0·64; s.d. = 0·16). Significant differences were noted between the experimental group and the control group. This pilot study will be followed by a confirmation study with a larger sample size, evaluated according to recently formulated quality criteria for measurement properties of health status questionnaires.     

Self‐reported gagging in dentistry: prevalence,psycho‐social correlates and oral health

Although gagging has a profound effect on the delivery of dental care, it is a relatively under‐investigated phenomenon. This study aimed to derive a prevalence estimate of gagging during dental treatment based on patient‐reported information, to determine some socio‐demographic and psychological correlates and to assess the relationship of gagging with self‐reported oral health and avoidance of dental care. Data were collected with a survey among Dutch twin families (n = 11 771). Estimated overall prevalence of gagging during dental treatment was 8·2% (95% CI 7·7–8·7). Patients' self‐report of gagging was found to be significantly associated with female sex, a lower level of education and higher levels of dental trait anxiety, gagging‐related fears (e.g. fear of objects in the mouth), anxious depression and neuroticism. Gagging also appeared to be significantly associated with untreated cavities, gingival bleeding and wearing full dentures, but not with avoidance of dental care. It can be concluded that individuals who report to gag during dental treatment are moderately dentally anxious, fear‐specific situations that can trigger a gagging response and, albeit visiting the dentist equally frequently, report to have a poorer oral health compared to those who do not gag.     

Relationship between gagging severity and its management in dentistry

The purpose of this study was to investigate how grading according to our new gagging reflex index correlated with patient background and subsequent management. After obtaining institutional approval and informed consent, 110 patients with a gagging problem were enrolled. The patients completed the State–Trait Anxiety Inventory (STAI), the Dental Anxiety Scale (DAS), and a health questionnaire at initial consultation. On the second visit, an intra‐oral examination was carried out and the severity of gag reflex determined according to our new, 5‐level Classification of Gagging Problem (CGP) index: normal gagging but not desensitised (G1 = score 1); mild gagging (G2 = score 2); moderate gagging (G3 = score 3); severe gagging (G4 = score 4); and very severe gagging (G5 = score 5). No difference was found in grade based on age or STAI or DAS scores. The CGP score in male patients was significantly higher than that in female. The management classification method and degree of desensitisation were investigated retrospectively in each patient at 3 months and 1 year after initial consultation. The higher the CGP grade, the more often intravenous sedation or general anaesthesia was required due to difficultly in desensitisation. The present results suggest that determining whether it is possible to examine the molar area without inducing the gag reflex offers the key to deciding the treatment strategy.     

Self-reported efficacy of an online dental anxiety support group: a pilot study

Abstract – Objectives: This study aimed to explore the self‐reported effectiveness of an existing online dental anxiety support group in terms of perceived level of anxiety since accessing the group. Methods: An online questionnaire was completed by 91 individuals who accessed the Dental Fear Central, an online support group bulletin board, during an 8‐week period in 2005. Participants reported background demographic information, their own self‐reported evaluation of the efficacy of the support group, as well as completing the Modified Dental Anxiety Scale (MDAS). Results: In total, 60% of the sample considered that the support group had ‘somewhat’ or ‘greatly lessened’ their anxiety. Overall MDAS scores were significantly lower in the ‘greatly lessened’ group. Conclusions: The results of this nonrandomised pilot study suggest some individuals retrospectively considered that, since accessing the online group, they experienced a reduction in dental anxiety. Future research should employ a randomised controlled design in order to determine the contribution of the online group to self‐reported changes in dental anxiety over time.     

Progressive muscle relaxation therapy to relieve dental anxiety: a randomized controlled trial

Dental anxiety causes patients to refuse or delay treatment, which may exacerbate oral diseases. The aim of the current randomized controlled trial was to determine whether progressive muscle relaxation therapy could relieve dental anxiety. The trial included 68 periodontal patients with dental anxiety scores of ≥13 who were randomly assigned to either an intervention group or a control group (n = 34 per group). The intervention group was administered progressive muscle relaxation therapy for 20 min and oral health education for 15 min before periodontal treatment once per week for 4 wk. The control group was provided with oral health education only, for the same duration. Changes in dental anxiety, depression symptoms, blood pressure, heart rate, and salivary cortisol were evaluated 4 wk and 3 months after the intervention. The intervention group exhibited statistically significantly greater reductions in dental anxiety scores than did the control group at the 4‐wk (?3.82 vs. ?0.89) and 3‐month (?4.22 vs. ?0.28) assessments. They also exhibited significantly greater reductions in depression symptoms, systolic and diastolic blood pressure, pulse rate, and salivary cortisol levels at both time‐points. Progressive muscle relaxation therapy relieves tension and anxiety in dental patients.     

Dental beliefs: factor structure of the revised dental beliefs survey in a group of regular dental patients

The aim of this study was to investigate the factor structure of the revised dental beliefs survey (DBS‐R) in a group of regular dental patients. The study group consisted of 278 patients (mean age 54 yr), 61% of whom were women. The DBS‐R item mean value was 1.6. Principal component analysis (PCA) and confirmatory factor analysis (CFA) were performed. The initial PCA among the 28 DBS‐R items showed four factors with eigenvalues of > 1 explaining 67% of the total variance. Five different CFA models were tested. The final model revealed a four‐factor solution with one second‐order factor (i.e. a hierarchical CFA). Thus, the latent second‐order variable, ‘dental beliefs’, explains the variance from all DBS‐R items through the four first‐order factors labeled ‘ethics’, ‘belittlement’, ‘communication and empathy’, and ‘control and anxiety’. The results suggest a somewhat different factor structure of DBS‐R than previously reported for dental‐fear patients. Hence, the underlying factor structure of the DBS‐R may differ between different patient groups. The results point towards the use of the original 28‐item DBS‐R and interpreting the scale as measuring an overall construct of ‘dental beliefs’ and thus patients’ attitudes and feelings related to dentists and dentistry.     

Gagging and its associations with dental care–related fear,fear of pain and beliefs about treatment

BackgroundGagging is a behavioral response that interferes with oral health care and may be related to dental care–related fear. Little is known, however, about the epidemiology of gagging during dental treatment.MethodsTo explore this phenomenon, the authors recruited participants from the waiting area of an oral diagnosis clinic. Participants completed a gagging behavior questionnaire, the Dental Fear Survey, the Fear of Pain Questionnaire—9, the Revised Dental Beliefs Survey and a demographics questionnaire.ResultsAlmost one-half of the 478 participants reported gagging on at least one occasion during dental visits, and 7.5 percent of participants reported almost always or always gagging. With higher frequency of problems with gagging, patients were more likely to have greater levels of dental care–related fear, fear of pain and more negative beliefs about dental professionals and dental treatment. Furthermore, participants who gagged more readily had greater dental care–related fear than did participants who had less of a propensity to gag.ConclusionsGagging in the dental office is a prevalent problem, and dental care–related fear and fear of pain are associated with more frequent gagging.Practical ImplicationsGiven the prevalence of patients reporting problems with gagging, it may be helpful for providers to assess patients' propensity for gagging, which can be a barrier to treatment. By targeting dental care–related fear, fear of pain and negative beliefs about dental care in patients who often gag when receiving dental care, clinicians may be able to help reduce gagging in frequency or intensity, potentially making treatment more comfortable for patients and easier for dental care providers.     

Perceptions of the dental profession: a comparative analysis through scale development

Dentistry is a science‐based profession that has a close interaction with people and society. However, despite this close interaction, perceptions of the dental profession by both patients and dental professionals have received little research attention. The purpose of this study was to compare the perceptions of dentists, dental students, and patients toward the dental profession through the development and testing of the Dental Profession Perceptions Scale (DPPS). The DPPS contains a total of 17 items measured on a 5‐point Likert response scale. The DPPS showed excellent internal reliability (Cronbach's α = 0.92) and test–retest reliability (r = 0.93). Explanatory and confirmatory factor analyses of the DPPS showed that dentists’, dental students’, and patients’ perceptions of the dental profession could be grouped according to ‘status’, ‘human’, and ‘scientific’ factors. There were no statistically significant differences between participants’ DPPS total or sub‐scale scores according to dental group, gender, or income. The DPPS developed can be used in future studies as a psychometrically sound measuring tool. Further studies should examine the factors that may affect the perceptions of the dental profession in different societies and cultures.     

Assessing short and long‐term educational impact of visits to hospice via a combination of qualitative methods

While qualitative methods have gained considerable recognition in medical education research, employing multiple qualitative data sources in assessing long‐term educational impact is rare. Utilising in‐depth data analysis method to six cross‐sectional cohorts (2004–2009) of students’ reflection papers (n = 213), this article demonstrates how students experienced subtle but important shifts in their attitudes (including personal, professional and spiritual domains) after making field visits to a hospice centre as part of the Special Needs Dentistry module. For retrospective assessment of learning retention, a pilot focus group was conducted with three junior faculty members who participated in the field visits to a hospice during their own undergraduate training. A subsequent focus group was conducted with graduates of the 2008 (n = 8) cohort using a refined discussion guide arising from the analysis of pilot group results. Graduates were unanimous in stating that the visits had sown ‘seeds’ in their minds and hearts, seeds which started to grow after they completed dental school and began to practice. This is demonstrative of the long‐term positive educational impact of the pedagogical design that entailed a special site visit coupled with post‐visit debrief and written reflection.     

Oral health‐related quality of life,measured using the five‐item version of the Oral Health Impact Profile,in relation to socio‐economic status: a population survey in Sweden

Oral health‐related quality of life (OHRQoL) is an important patient‐reported outcome measure in dental research. This study was conducted to analyse the association between OHRQoL, as measured using the five‐item version of the Oral Health Impact Profile (OHIP‐5), and different socio‐economic indices. A national survey of randomly selected adult individuals in Sweden (n = 3,500) was performed using telephone interviews. The questions asked for the purpose of this study were defined by the items of the OHIP‐5, just as questions were asked regarding socio‐economic variables, including education, income, and economic resources. Poor OHRQoL, as identified by an OHIP‐5 score of 3 or higher on at least two of the five items, was statistically significantly associated in multivariate analysis with low income (OR = 1.84) and having no economic resources (OR = 2.19). The statistical models were adjusted for age, gender, ethnicity, marital status, dental‐care utilization, dental anxiety, and smoking. The OHIP‐5 may be used in larger epidemiological surveys because it demonstrates the ability to discriminate for a range of important areas of measurement in dental public health, including social determinants.     

Dental fear affects adolescent perception of interaction with dental staff

The main purpose of this study was to explore whether subjective perception of interaction with dental staff is associated with dental fear in a population‐based sample of 18‐yr‐old adolescents (n = 773). The interaction was measured using the Patient Dental Staff Interaction Questionnaire (PDSIQ), validated with exploratory and confirmatory factor analyses, which yielded the factors of ‘kind atmosphere and mutual communication’, ‘roughness’, ‘insecurity’, ‘trust and safety’, and ‘shame and guilt’. Dental fear was measured using the Modified Dental Anxiety Scale (MDAS). Gender and sense of coherence (SOC) were included as potential confounding variables. Adolescents with high dental fear more often perceived their interaction with dental staff negatively and more often felt insecure than others. This difference persisted after adjustment for gender and SOC. In conclusion, adolescents with high dental fear may perceive their interaction with dental staff more positively if the staff succeed in creating a positive, trusting, approving, and supportive atmosphere with kindness, calmness, and patience. The communication and interaction skills of dental staff may play a particularly important role when encountering highly fearful dental patients.     

Are maternal mental disorders associated with children's oral health? A systematic review

Maternal mental problems may lead to a negative effect on children's oral health (COH). The aim of this study was to systematically review the literature to answer the question: Are maternal mental disorders (MMD) associated with COH from zero to 12 years old? Electronic searches were performed in five databases with no language restriction. Cohort, case‐control, and cross‐sectional studies were included. A total of 1183 references were identified, and seven studies were included. In relation to MMD studies investigated: Common Mental Disorders (n = 2), Major Depressive Disorder (MDD) (n = 2), symptoms of depression (SD) (n = 3), Alcohol‐related diagnosis (n = 1), and symptoms of anxiety (n = 2). As outcome, the studies investigated dental caries (n = 5), gingivitis and periodontal diseases (n = 1), sleep bruxism (SB) (n = 1), and malocclusion (n = 1). Positive association was found between MDD and OH (SB and dental caries). There was no MMD associated with malocclusion. Alcohol‐related diagnosis showed a positive association with gingivitis and periodontal diseases and no association with dental caries; anxiety had a positive association with dental caries and no association with SB. The heterogeneity of the data precluded precise conclusions to be drawn, but MMD may have influence on COH.     

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.     

Association of temperament with dental anxiety and behaviour of the preschool child during the initial dental visit

The aim of this study was to investigate whether there is an association between temperament characteristics of preschool children, dental anxiety, and their dental behaviour. A total of 100 children, aged 3–5 yr, who were attending their initial dental visit accompanied by a parent, were included in this cross‐sectional study. Dental anxiety of children was measured using the Facial Image Scale. The behaviour of children during the initial oral examination and oral prophylaxis was assessed using Frankl's behaviour rating scale. Temperament was assessed using Emotionality, Activity, Shyness Temperament Survey for Children (parental ratings). Statistically significant weak linear positive correlations were seen between the following: the percentage duration of definitely negative behaviour and shyness scores (r_s = 0.28); anxiety level and emotionality scores (r_s = 0.28); and anxiety level and shyness scores (r_s = 0.26). Multinomial logistic regression analysis revealed that children with higher anxiety had higher odds of showing definitely negative behaviour, which decreased with increasing age of the child. Emotionality and shyness temperaments may be weakly associated with dental anxiety, and shyness may be weakly associated with the dental behaviour of the preschool child. Definitely negative dental behaviour is associated with dental anxiety and age of the child.     

A multi‐country comparison of reasons for dental non‐attendance

The purpose of this study was to describe differences across countries with respect to the reasons for dental non‐attendance by Europeans currently 50 yr of age and older. The analyses were based on retrospective life‐history data from the Survey of Health, Ageing, and Retirement in Europe and included information on various reasons why respondents from 13 European countries had never had regular dental visits in their lifetime. A series of logistic regression models was estimated to identify reasons for dental non‐attendance across different welfare‐state regimes. The highest proportion of respondents without any regular dental attendance throughout their lifetime was found for the Southern welfare‐state regime, followed by the Eastern, the Bismarckian, and the Scandinavian welfare‐state regimes. Factors such as patients’ perception that regular dental treatment is ‘not necessary’ or ‘not usual’ appear to be the predominant reason for non‐attendance in all welfare‐state regimes. The health system‐level factor ‘no place to receive this type of care close to home’ and the perception of regular dental treatment as ‘not necessary’ were more often referred to within the Southern, Eastern, and Bismarckian welfare‐state regimes than in Scandinavia. This could be relevant information for health‐care decision makers in order to prioritize interventions towards increasing rates of regular dental attendance.     

Do traumatic events have more impact on the development of dental anxiety than negative,non‐traumatic events?

The importance of exposure to traumatic events for the development of dental anxiety has not been investigated. The aim of the present study was to test the hypotheses that individuals who reported having been exposed to a traumatic event [that is, fulfilling Criterion A of the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM‐5), for post‐traumatic stress disorder (PTSD)] as the cause of their dental anxiety would report significantly higher levels of dental anxiety, typical trauma‐related (PTSD) symptoms, and greater disturbance of memories involving these events than those who reported being exposed to non‐traumatic events. Patients of a specialized dental fear clinic (n = 90) were divided into those who reported a traumatic event that initiated their dental trait anxiety and those who did not. The two groups did not differ in their severity of dental anxiety and number of PTSD symptoms, but the memories of those who had been exposed to traumatic events were significantly more vivid than the memories of those in the reference group. Length of time since the event took place did not play a role. Hence, traumatic events are remembered more vividly, but do not seem to initiate more severe forms of dental anxiety than other events.     

Reliability and validity of the Turkish version of the shorter form of the gagging problem assessment questionnaire

Summary  The aim of this study was to evaluate the reliability and validity of the Turkish version of the shorter form of the gagging problem assessment questionnaire. Forty-three patients with gagging problems and 89 patients who showed no signs of gagging during dental examination were included in the study. The patients completed the patient portion of the gagging problem assessment questionnaire, as well as the modified dental anxiety scale, dental fear scale and Spielberger trait anxiety scale for comparison. Two experienced dentists subsequently completed the dentist portion of the gagging problem assessment questionnaire by performing clinical examinations with a dental mirror. The results indicate that patients with gagging problems had significantly higher mean scores than the control group ( P  <   0·001). The internal consistency of the questionnaire was found to be adequate, and good intra- and inter-observer reliability was present. Patients with a gagging reflex had significantly higher anxiety scores, indicating the validity of the questionnaire. The Turkish translation of the shorter form of the gagging problem assessment questionnaire was found to be reliable and valid for distinguishing among patients with and without a gagging reflex.