Dental fear treatment: comparison of a video training procedure and clinical rehearsals

Abstract – Two types of fear desensitization, video training, and clinical rehearsals, were evaluated using psychometric tests, behavioral measures, and interviews for a group of 68 dental fear patients with high and low general trait anxiety. After treatment, a visual analogue scale (VAS) also tested the degree of perceived anxiety before going off to an unknown dentist. Results indicated no significant differences in dental fear reduction effects of the two types of desensitization. However, both treatments showed significant and meaningful effects when compared with a group of 75 dental fear patients on a waiting list who were also tested once at the beginning of the waiting period and again after 6 months. Only high general anxiety subjects resisted desensitization and failed standardized dental treatment tests. Exit interviews revealed that both groups named securing/accepting personnel, conversations about their fears and relaxation, in that order, as the most important factors in their dental fear reduction. Psychometric trust scores confirmed this. VAS scores showed a significant increase in fear level about the next dentist, also indicating trust as a major factor in reducing dental fear. Suggestions are made about which patient conditions can affect the choice of either of these training methods.     

Reliability and clinical usefulness of psychometric measures in a self-referred population of odontophobics

Questionnaire responses of 155 self-referred subjects with extreme dental fear were used to evaluate the reliability and clinical usefulness of some psychometric tests used in diagnosis and treatment. The Corah Dental Anxiety Scale (DAS), State-Trait Anxiety Inventory (STAI), and a general Geer Fear Scale (GFS) were filled out by all subjects, while 80 patients with highest dental fear scores were also tested before and after dental fear treatment with the following scales; a Getz Dental Belief Survey (DBS), Dental Fear Survey (DFS), and a Mood Adjective Checklist (MACL). Cronbach's alpha measured internal consistency reliability. SPSS data analyses calculated item-remainder and test-retest correlations. Clinical usefulness of scales was judged by Spearman correlations of initial scores and test score changes after dental fear treatment. All total test scores showed high internal consistency and test-retest reliability. DFS was judged the preferred clinical measure of threatening perceptions of pain or unpleasantness specific to dental procedures. DBS and STAI-State measured confidence in relating with the dentist and situational fear associated with that relationship. GFS, STAI-Trait, and MACL discriminated levels of general fearfulness, anxiety and mood fluctuations that can impact on dental fear.     

Background data about the high dental fear scores of Hungarian 8-15-year-old primary school children

Free associations (coupling) of 139 Hungarian primary school children about their teeth was collected. Dental fear (DAS, DFS) and general anxiety scores were measured. Typical dental events (i.e.: loss of deciduous teeth, simple and traumatising dental treatments, tooth fractures) were coupled by the participants in 41.0% of the cases. Functions and importance of the teeth and oral hygiene were described in 20.1% of the cases. Simple, grotesque, or magical stories and tales about teeth were found in 8.6% of the cases. No answer was given in 30.2% of the cases. Highest dental fear and general anxiety scores were found in the group coupled traumatising dental treatment. Traumatising loss of deciduous teeth was caused by the dentist or by the father of the child, and was associated with higher dental fear and general anxiety comparing to simple loss of deciduous teeth. Higher dental fear and general anxiety scores were found in the group coupled functions and importance of the teeth comparing to the group coupled simple, grotesque, or magical stories and tales, or the group giving no answer.     

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.     

Anxiety disorders in the dental practice. Part 2. Treatment of patients with anxiety

The purpose of the present paper is to provide the dentist with a number of treatment steps that may reduce anxiety and may enhance trust, feelings of control and application of coping skills. A distinction should be made between patients with specific fear for one or more aspects of dental treatment and patients with non-specific, general anxiety. Practical implications for dental treatment of both groups are given. Dentists should be familiar with the signs and symptoms of the various anxiety disorders, in order to be able to properly refer or treat the patient.     

Reducing patients' state anxiety in general dental practice: a randomized controlled trial

Anxiety assessment by questionnaire provides information for the dentist and may also confer a psychological benefit on patients. This study tested the hypothesis that informing dentists about patients' dental anxiety prior to commencement of treatment reduces patients' state anxiety. A randomized controlled trial was conducted involving eight General Dental Practitioners in North Wales. Participants included patients attending their first session of dental treatment, and accumulating a score of 19 or above, or scoring 5 on any one question, of the Modified Dental Anxiety Scale (MDAS). Patients (n = 119) completed Spielberger's state anxiety inventory (STAI-S) pre- and post-treatment and were randomly allocated to intervention (dentist informed of MDAS score) and control (dentist not informed) groups. Intervention patients showed greater reduction in mean change STAI-S scores (F[1,119] = 8.74, P < 0.0001). Providing the dentist with information of the high level of a patient's dental anxiety prior to treatment, and involving the patient in this, reduced the patient's state anxiety.     

Dental anxiety among young Israeli male adults as related to treatment received during childhood

OBJECTIVES: To evaluate dental fear and anxiety among young male adults treated during childhood either by a certified pediatric dentist or a general dental practitioner. METHODS: A structured questionnaire that included information regarding issues related to dental fear and anxiety (Intake Interview Questionnaire and the Dental Anxiety Scale) was completed by 497 young male army recruits (18 years old). RESULTS: During childhood, 59 (11.9%) of the participants were treated on a regular basis by a certified pediatric dentist and 344 (69.2%) by a general dental practitioner. Sporadic care (not regular care) by general dental practitioners was given to 94 participants (18.9%). Average level of dental anxiety among participants treated by certified pediatric dentists was 7.9 compared to 8.2 (general dentists) and 8.7 (sporadic care by general dentists). There were no significant differences between the groups. However, significant differences were found in the prevalence of high dental anxiety between participants treated by a regular dentist in childhood and those treated sporadically (15.4% vs. 23.4%, respectively). Negative emotions were common. Environmental etiologic factors were infrequently reported. CONCLUSIONS: The general level of dental anxiety among young Israeli males was normal. No relation was found between level of dental anxiety and the professional education of the treating dentist in childhood. Regular dental care in childhood has more effect on preventing the development of high dental anxiety than the professional education of the early caregiver.     

Hypnosis compared with group therapy and individual desensitization for dental anxiety

Effects of hypnotherapy (HT) and self–hypnosis training on extreme dental anxiety in adults aged 19–65 years were compared with group therapy (GT) and individual desensitization (SD) using scales of dental anxiety, dental beliefs, and fear of a next dentist (after specialist treatment). All experimental groups were demographically comparable and showed reduced anxiety and improved dental beliefs compared with 51 control patients. The 25 HT patients did not differ significantly in numbers of dropouts during training compared with the 30 GT patients or 68 SD patients. For patients completing treatment. HT ( n =22) reduced dental anxiety to the same degree as GT ( n =24) and SD ( n =60). HT and SD patients required more therapist hours per patient than did GT, but total dropouts at 1 yr after specialist treatment were significantly greater in HT (13/25) than for SD rehearsals (5/34) or SD video (8/32). but not GT (15/30). Hypnotizability was found to vary from patient to patient, with a direct relationship to time saved. But hypnotizability had an inverse relationship to STAI general anxiety level for those who went on to dentists after 1 year. Transference effects were noted for most HT dropout patients as an aversive response to continued dental treatment with other dentists than the specialist.     

Towards a better understanding of dental anxiety and fear: cognitions vs. experiences

Armfield JM. Towards a better understanding of dental anxiety and fear: cognitions vs. experiences. Eur J Oral Sci 2010; 118: 259–264. © 2010 The Author. Journal compilation © 2010 Eur J Oral Sci Traumatic dental experiences are associated with dental anxiety and fear. However, many people with no dental fear have had negative dental experiences, and some people with considerable fear fail to recall any traumatic incidents. This study aimed to determine whether dental fear was better explained by experiences or by cognitive perceptions of going to the dentist as being uncontrollable, unpredictable, dangerous, and disgusting. A random sample of 1,084 Australian adults (response rate = 71.7%) completed a mailed questionnaire with measures of dental fear, perceptions of going to the dentist, and dental experiences. Perceptions of uncontrollability, unpredictability, dangerousness, and disgustingness had strong bivariate associations with scores on the Index of Dental Anxiety and Fear (IDAF‐4C). Vulnerability‐related perceptions accounted for 46.3% of the variance in IDAF‐4C scores beyond that accounted for by demographic variables and five possible dental experiences comprising intense pain, considerable discomfort, gagging, fainting, and having a personal problem with the dentist. In contrast, dental experiences accounted for < 1% of the variance in IDAF‐4C scores beyond that accounted for by the four cognitive perceptions. Perceptions of uncontrollability, unpredictability, dangerousness, and disgustingness were superior predictors of dental fear compared with negative dental experiences.     

The prevalence of dental anxiety in a group of 13- and 14-year-old Scottish children

The aim of this study was to determine the prevalence of dental anxiety reported by a group of 13- and 14-year-old children, and to explore the relationships between dental anxiety and general fear, social class, gender, size of family, length of time since the last dental appointment, and the number of people known by the child to be afraid of visiting the dentist. A group of 1103 children from eight schools took part in the study, which was completed in 1989. The children (mean age 14.0 years, SD 0.35) completed a structured questionnaire containing the Corah Dental Anxiety Scale (CDAS) and the Geer Fear Scale (GFS). The prevalence of high dental anxiety (CDAS greater than = 15) was 7.1%. High dental anxiety was associated with gender (girls having higher levels of anxiety than boys) and with social class as defined by father's occupation (lower social class groups having higher dental anxiety). Injection was the dental procedure most highly correlated with CDAS in children with a high dental anxiety, closely followed by 'drilling' and 'tooth scaling'. A high level of general fear (GFS) was associated with a high level of dental anxiety. Despite this, 64% of those with high dental anxiety had a low general fear. Two factors were useful predictors of high dental anxiety: the length of time since the last visit to the dentist and the number of people known by the child to be afraid of going to the dentist.     

A dental support group for anxious patients

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

Australian population norms for the Index of Dental Anxiety and Fear (IDAF-4C)

Background: The Index of Dental Anxiety and Fear (IDAF‐4C) is a theoretically derived test developed to allow clinicians and researchers to measure a person’s level of dental fear. Population norms have not previously been made available for the IDAF‐4C. The aim of this study was to provide Australian norms for the IDAF‐4C using percentile ranks and to examine associations between scores and individual‐level characteristics, dental avoidance and fear of pain. Methods: A stratified random sample of 1511 Australian adults yielded complete questionnaire data for 1063 individuals (70.4%). Percentile ranks were calculated for IDAF‐4C full scale scores stratified by age and gender. Results: IDAF‐4C mean scores varied significantly by age, gender, income, and speaking a language other than English at home. Tables to convert raw scores to percentiles showed that full scale scores varied by age and gender. Scores on the IDAF‐4C had strong and significant associations with avoidance of the dentist due to fear, average dental visiting frequency and anxiety about pain when going to the dentist. Conclusions: Population norms allow clinicians or researchers to compare results for an individual or subgroup to the Australian population. It is recommended that a dental fear scale be used to screen all dental patients for dental fear to enable a more tailored and effective dental treatment experience.     

Fear of injections and report of negative dentist behavior among Caucasian American and Taiwanese adults from dental school clinics

Abstract Fear of injections and reports of negative dentist behavior and associations with dental anxiety and avoidance of treatment were explored among 951 adults from denial school clinics in Iowa City, Iowa and Taipei. Taiwan. Use and fear of anesthetic injections and negative dentist behavior were assessed by written questionnaire to test associations with demographics, overall dental anxiety (Dental Anxiety Scale or “DAS”) and utilization behaviors. Frequency and logistic regression analyses showed that use of dental anesthetics for routine treatment was much greater overall among Caucasian Americans than Taiwanese, as was fear of injections. Taiwanese and Americans with high dental anxiety (DAS 12) had similar high fear of injections, but inspite of similar fears about dental drilling, high anxiety Taiwanese reported using much less local anesthesia for routine treatments than did high anxiety Americans. Report of condescending remarks to patients (“put downs”) by dentists was mainly an American phenomenon associated with high dental anxiety. Avoidance of appointment making was high for persons afraid of injections and for Americans reporting negative dentist behavior. Avoidance was highest in subjects with high dental anxiety. That predominant characteristics or etiologies of dental anxiety can differ by cultural differences in dental health care systems, dentist beliefs and/or expectations of patients within those systems was discussed in relation to the literature.     

Group therapy compared with individual desensitization for dental anxiety

Abstract Effects of group therapy (GT) on extreme dental anxiety were compared with individual treatment (IT). Results by scales of dental anxiety, beliefs or trust in dentists, and fear of the next dentist after specialist treatment showed reduced dental anxiety and improved dental beliefs compared with a static control group of 45 patients. The 30 GT patients showed no significant difference in dropouts during training compared with the 68 IT patients, but for patients who completed treatment. GT (n=24) had greater dental anxiety reduction than IT subjects (n=60). GT patients required fewer therapist hours therapist hours per patients than did either of the two IT methods, but time saved in GT did not reach significance over clinical rehearsal IT. Results at 1-yr follow-up after specialist treatment indicated that dropouts were significantly greater in group therapy. Rehearsal IT performed best for sustained dental care behavior. Group dynamics are discussed and suggestions made for effective and efficient group therapy as well as decision making about choice of treatment.     

Prevalence of dental anxiety and fear in children in Singapore

505 primary school children in Singapore aged 10-14 were surveyed regarding fear of the dentist. Sixty-eight children were classified as having high fear, giving a sex and race adjusted population prevalence rate of 177 fearful children per 1000 population. Females were 2.64 times more fearful than males. There were no significant racial differences in the prevalence rate. Children with high state anxiety are almost three times as likely to report dental fear as those with low state anxiety. Children with trait anxiety scores above the population mean were just as likely as those reporting below the mean to be fearful. Access to dental care is an important intervening variable in dental fear.     

Dental anxiety among young adolescent patients in Israel

Aim. To evaluate adolescents’ dental anxiety using self‐reported questionnaires previously given to adults. Sample and method. One hundred and four patients (42 boys, 62 girls) aged 12–18 years who attended their paediatric dentist completed a questionnaire in the waiting room. The survey consisted of three sections: sociodemographic information for the children, a dental anxiety scale (DAS), and a dental fear survey (DFS). Results. The scores of the girls were higher than the boys in every DAS item as well as in the total score. Girls showed higher DFS scores than boys in most items. The most anxiety‐provoking stimuli were feeling and seeing the needle. In the most anxiety provoking stimuli, among the boys who reported higher DFS scores (categories 3, 4, 5), the DAS scores were higher than the scores of the girls. As the stimulus became less anxiety‐provoking, such as sitting in the dental chair, the DAS scores of the girls in these categories were higher than boys. Significantly more girls’ responses were in categories 3, 4 and 5 in the items dealing with the needle and the drill, while no significant difference was observed among the boys and girls regarding sitting in the dental chair. Conclusions. It is concluded that individual personality traits may be the final factor to indicate those who will eventually develop higher dental anxiety, and those who will not. The difference could be also in the conditioning process and learned responses (male and female education) that these individuals have experienced in life.     

Anxiety and depressive disorders and dental fear among adults in Finland

Pohjola V, Mattila AK, Joukamaa M, Lahti S. Anxiety and depressive disorders and dental fear among adults in Finland.
Eur J Oral Sci 2011; 119: 55–60. © 2011 Eur J Oral Sci We studied the association between dental fear and anxiety or depressive disorders, as well as the comorbidity of dental fear with anxiety and depressive disorders, controlling for socio‐demographic characteristics, dental attendance, and dental health. Nationally representative data on Finnish adults, ≥ 30 yr of age (n = 5,953), were gathered through interviews and clinical examination. Dental fear was measured using the question: ‘How afraid are you of visiting a dentist?’ Anxiety and/or depressive disorders were assessed using a standardized structured psychiatric interview according to criteria presented in the Diagnostic and Statistical Manual of Mental Disorders (4th edition) (DSM‐IV).Those with depressive disorders, generalized anxiety disorder or social phobia more commonly reported high dental fear than did those without these disorders. When age, gender, education, dental attendance, and the number of decayed, missing, and restored teeth were considered, those with generalized anxiety disorder were more likely to have high dental fear than were participants with neither anxiety nor depressive disorders. The comorbidity of depressive and anxiety disorders also remained statistically significantly associated with dental fear; those with both depressive and anxiety disorders were more likely to have high dental fear than were those without these disorders. Our findings support the suggestion that some individuals may have a personality that is vulnerable to dental fear.     

Dentist Empathic Accuracy Is Associated With Patient-Reported Reassurance

ObjectivesThe aim of this work was to determine dentists’ ability to accurately estimate patients’ anxiety level during dental treatment (ie, “empathic accuracy”) and to determine the strength of the association between empathic accuracy and patient-reported reassurance.MethodsA cross-sectional study was conducted amongst 177 adult patients who underwent different invasive dental procedures (ie, extractions or procedures requiring injections and drilling) performed by 10 different dentists from 3 dental offices in the Netherlands. Patients reported their anxiety level during treatment and the extent to which they felt reassured by the dentist using a visual analogue scale (VAS). Simultaneously, the dentists estimated patients’ anxiety level. Empathic accuracy was calculated as an absolute difference between patient-reported anxiety (100-point VAS) and dentist estimation of anxiety (100-point VAS).ResultsAgreement between dentists’ assessment of patients' anxiety and patient-reported anxiety proved good, intraclass correlation coefficient (177) = 0.63; 95% confidence interval [CI], 0.53-0.71. A small to medium-sized positive correlation, r (177) = 0.15; 95% CI, 0.00-0.29, was found between dentists’ empathic accuracy and patient-reported reassurance. A negative correlation was found between empathic accuracy and patients’ anxiety scores, r (177) = ?0.23; 95% CI, ?0.38 to ?0.09.ConclusionsGiven that greater empathic accuracy was associated with higher patient-reported reassurance during treatment, training young dental professionals in empathic accuracy might help patients feel reassured. Importantly, our results also suggest that with elevated levels of patient anxiety it is increasingly challenging for dentists to recognise this emotion, and thus support the patient in anoptimal manner.     

Dental fear and anxiety as a barrier to accessing oral health care among patients with special health care needs

Persons with special health care needs due to physical and cognitive impairment can be at increased risk for dental disease which can be attributed to, as well as exacerbate, existing medical conditions. This study assessed the nature of perceived barriers to obtaining oral health care among a special-needs population and the influence of these factors (in particular, fear and anxiety) on utilization of dental services. A total of 27.9% of the sample reported fear/anxiety about dental visits, with approximately half of those reporting to be very nervous or "terrified". There was an inverse relationship between the frequency of dental visits and the proportion of respondents reporting themselves as very nervous or terrified, and between the perception of oral health status and the level of dental fear/anxiety (P < 0.001). A large difference was reported between patient preference for pharmacologic modalities for anxiety control and those received at dental visits, with 40% of the youngest age group indicating that they would go to the dentist more frequently if sedation or general anesthesia were offered. The levels of self-reported fear/anxiety and the high proportion of respondents indicating an unmet need for adjunctive anesthesia services suggest that fear/anxiety acts as a barrier to dental care among this special-needs group which could be ameliorated with greater use of these services.