Dental fear and avoidance: causes, symptoms, and consequences

General and specific fears in referred and self-referred adult patients with extreme dental anxiety

The levels of, and relationships between, dental fear and general fears and phobias were studied in 109 adult patients at a specialized dental fear clinic using two dental fear scales (the Dental Anxiety Scale and the Dental Fear Survey) together with the Fear Survey Schedule II (FSS-II) and some additional fear items. Referred and self-referred fearful dental patients answered mailed questionnaires in conjunction to being put on a 1 yr waiting list for treatment. Among feared objects and situations the separate item 'pain' revealed the highest mean scores for both men and women, followed by fear of suffocating, death of a loved one and sharp objects among women, and death of a loved one, suffocating and hypodermic needles among men. With few exceptions, women scored higher than men. The frequencies of extreme fears (6 and 7 on a 7-point scale) were high and 92.7% of the patients reported at least one extreme fear. Half of the subjects (49.5%) reported five fears or more. It was also shown that a number of FSS-II items correlated to dental fear indicating a relationship between general and dental fear. These results indicated that a large proportion of these dentally fearful individuals were prone to fear-associated reactions and behaviors, which has previously been shown to negatively influence the prognosis of treatment.

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.

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.

Generalization of effects of dental fear treatment in a self-referred population of odontophobics

Effects of dental fear treatment on general anxiety and mood in 60 dental phobics with high and low general anxiety were compared with "attention" effects in 75 dental phobics on a waiting list using the Dental Anxiety Scale, a State-Trait Anxiety Inventory and a modified Fear Survey Schedule. Positive effects of the treatment were apparent in reduced dental and general fearfulness as well as elevated mood on numerous measures that paralleled dentist ratings of patient behavior. Ss had less fear of going to the next dentist after the program than before, according to a visual analogue measure. Ninety-three percent of Ss started dental treatment with private dentists within 1 year.

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.

A comparison of anxiety levels associated with root canal therapy and oral surgery treatment

Questionnaires regarding experience, hearsay, and perceptions of anxiety toward eight dental treatments were distributed to a general patient population. Data revealed that among 349 respondents 35% heard that root canal therapy was the most unpleasant dental treatment, whereas 29% listed oral surgery treatment as having the worst reputation. However, 53% of those experiencing oral surgery treatment stated that an oral surgery treatment was the most unpleasant treatment whereas only 17% experiencing root canal therapy stated the same for root canal therapy. On the basis of anxiety scores, root canal therapy and oral surgery treatment were categorized in the high-anxiety category, crowns, dentures, and fillings in the moderate-anxiety category, and cleaning, sick call, and examination in the low-anxiety category. The anxiety levels of root canal therapy and oral surgery treatment were then analyzed as they related to different experience groups (combinations of root canal therapy and oral surgery and experience), hearsay experience, and most unpleasant experience with root canal therapy and oral surgery. Patients having experience with root canal therapy or oral surgery treatment had lower anxiety levels toward these respective treatments than did those who had no such experience. Patients who have heard negative stories (hearsay) of root canal therapy and oral surgery showed higher levels of anxiety toward these respective treatments than did those who have not heard such stories. But former endodontic patients who had heard negative stories about root canal therapy actually recorded lower anxiety levels toward root canal therapy than those patients with no negative hearsay experience.(ABSTRACT TRUNCATED AT 250 WORDS)

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

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.

Manifestations, acquisition and diagnostic categories of dental fear in a self-referred population

This study aimed to clarify how manifestations and acquisition relate to diagnostic categories of dental fear in a population of self-referred dental fear patients, since diagnostic criteria specifically related to dental fear have not been validated. DSM III-R diagnostic criteria for phobias were used to compare with four existing dental fear diagnostic categories, referred to as the Seattle system. Subjects were 208 persons with dental fear who were telephone interviewed, of whom a subsample of 155 responded to a mailed Dental Anxiety Scale (DAS), State-Trait Anxiety Inventory and a modified FSS-II Geer Fear Scale (GFS). Personal interviews and a Dental Beliefs Scale of perceived trust and social interaction with dentists were also used to evaluate a subsample of 80 patients selected by sex and high dental fear. Results showed that the majority of the 80 patients (66%), suffered from social embarrassment about their dental fear problem and their inability to do something about it. The largest cause of their fear (84%) was reported to be traumatic dental experiences, especially in childhood (70%). A minority of patients (16%) could not isolate traumatic experiences and had a history of general fearfulness or anxiety. Analysis of GFS data for the 155 subjects showed that fear of snakes and injuries were highest among women; heights and injections among men. Fear of blood was rarely reported. Spearman correlations between GFS individual items and DAS scores indicated functional independence between dental fear and common fears such as blood, injections and enclosures in most cases. Only in specific types of dental fear did these results support Rachman and Lopatka's contention that fears are thought to summate.(ABSTRACT TRUNCATED AT 250 WORDS)

Effectiveness of a videotaped behavioral intervention in reducing anxiety in emergency oral surgery patients

This study evaluated the effectiveness of a videotaped behavioral treatment program in reducing dental anxiety in emergency oral surgery patients. It compared a videotaped placebo program and a no-treatment control condition. Anxiety, measured for two periods during the study (an anticipatory phase just before oral surgery and a post oral surgery phase), was evaluated by means of self-report, physiological, and behavioral observation measures. Results revealed significant treatment group as well as Group X Sex interaction effects for the heart rate index of physiological arousal. Results also revealed that the treatment program was reported by subjects to be significantly more helpful than the placebo program. Overall, these results suggest that a short, videotaped behavioral intervention can have a positive effect on the oral surgery patient, and that the sex of the subject may be an important variable to be incorporated in evaluating the effectiveness of this type of treatment program.

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.

Effect of systematized "behavior shaping" on acceptance of dental treatment in children

The aim of this study was to compare the acceptance level of children treated by dentists who had participated in a training program of psychologic care and systematized "behavior shaping", with the acceptance level of children treated to a large extent by the same dentists before their training program. The material consisted of 2400 children treated by 149 dentists, to be compared with the material of 2773 children treated by 161 dentists in the "before training" study; 127 dentists took part in both studies. The training program included a video film, a manual, and a case form. Of the children treated before the dentists underwent the training program, 79% showed positive acceptance of all treatment steps encountered during dental visits, 13% reluctant acceptance, and 8% negative or no acceptance. The corresponding figures for children treated after the training program were 92, 6, and 2%. The distributions of overall positive acceptance in the two studies were compared by means of a logistic regression model. The level of overall positive acceptance was significantly increased after the dentists had participated in the training program. The improvement was most pronounced among the youngest children and children in need of restorative treatment or extraction. Of all the background variables studied, age, present need of treatment, and the before/after training variable had the greatest influence. The study shows that dentists can be trained to obtain significantly increased positive acceptance of dental treatment in children, and that the method does not require extra time in the dental chair.

Prediction of behavior management problems in children

The aim of the present investigation was to study non-dental and dental background variables with a view to estimating their influence on behavior management problems by means of a structured interview and analyzing their separate and combined predictive power. The material consisted of a case group, 101 children aged 3-16 yr, referred for management problems to clinics of specialized pedodontics, and a control group, individually matched with the cases as regards age, sex, residential area, number of tooth surfaces restored, and dentist. The children or their parents were interviewed concerning background variables. Logistic regression was used for the analyses. Three non-dental variables turned out to be statistically significant as predictors (P less than 0.05): problems on visiting a medical doctor, dental fear in the mother or father, and anxiety when meeting unfamiliar people. Management problems might be expected if one of these attributes is found. Four dental variables had significant predictive power: earlier problems on seeing a dentist, dislike of the dentist, not enough time to adjust to the dental situation, and fear of injection. However, none of these dental variables was found to have predictive power in 3-6-yr-olds, and none of them improved the predictive power of the three main non-dental variables.

Chemomechanical caries removal--a clinical evaluation

The aim of this investigation was to evaluate the efficacy and convenience of decayed dentine removal with N-monochloro-DL-2 aminobutyrate (CARIDEX) in all classes of cavities. Fifty-seven patients, each with two teeth having similarly sized carious cavities, participated in this study. One cavity in each patient was treated with the chemomechanical CARIDEX technique and the other cavity was treated with conventional mechanical drilling. The cavities were restored with either amalgam, composite or glass ionomer restorative materials. The time taken for access and caries removal was noted and the efficacy of caries removal with each technique was evaluated. The chemomechanical caries removal technique was effective in removing 90-100% of decayed dentine in 98% of the cavities treated. Multiple regression adjusted access and caries removal time to account for volume of caries removed. This adjusted time was operator dependent, and ranged from 4 to 10 minutes longer for CARIDEX than for the conventional technique. Ninety-three per cent of patients preferred the chemomechanical method of caries removal over the conventional technique (highly significant P less than 0.001). Even though the chemomechanical removal of caries is slower than the conventional technique, the efficacy of CARIDEX and its high patient acceptance provides a viable alternative method for dentinal caries removal in all classes of cavities.

Pathways to full mouth extraction

The process of not attending the dentist is a vicious cycle in which anxiety plays a crucial role. A research project concerning the disease and non-disease reasons for full mouth extraction provided an opportunity to describe the dental histories in terms of dental attendance pattern and related factors which resulted in full dentures. Three profiles of dental histories could be outlined: 1) The regular attenders (19%). Because of their age (means = 47 yr), their positive attitude towards dentistry together with their positive attitude towards full dentures, it is suggested that the possibilities of keeping the natural dentition were exhausted so that full mouth extraction was an acceptable solution. 2) The symptomatic attenders (38%). Because anxiety, which was widespread in this group, was not based on negative experiences, it is suggested that anxiety is caused by social learning. Together with their positive attitude towards full dentures, the high prevalence of full dentures in their social environment and their low socioeconomic status, the conclusion is drawn that these patients lived in a culture which supports behavior that leads to total tooth loss. 3) Once regular attenders (43%). In this group anxiety leads to a negative perception of dental visits and to a negative attitude towards dentists. As a consequence dental visits are deferred, which results in deterioration of the dentition. Experiences with dentists are distorted in a negative way, which increases dental anxiety. Facilitated by a positive attitude towards full dentures, their bad dental condition finally urges them to take full dentures at early age.

Ratings of fears associated with twelve dental situations

Ratings of fear aroused by 12 dental situations were obtained by the method of paired comparisons. The dental situations concerned one of four categories: (a) preparations for the dental visit, (b) preparations for dental treatment, (c) comments by the dentist on oral state, and (d) actual dental treatment. The situations originated from Gale's ranking questionnaire. It was hypothesized that the amount of fear elicited would increase in the order a, b, c, and d. Results indicated that subjects were capable of ranking dental situations according to the amount of anxiety they aroused. Overall ratings show reasonably good agreement with the results of Gale's study. The hypothesis concerning the rank order of the situations was partly confirmed. Two situations deviated strongly from the expected order. The categories (c) and (d) were rated highest in the hierarchy of fear arousal, but their rank order couldn't be established. This finding suggests that dental fear contains a component of physical danger as well as a component of threat to a person's self-esteem.

Cultural perceptions of pain and pain coping among patients and dentists

A combination of qualitative and quantitative methods were developed to describe pain and pain coping perceptions of 25 Chinese, 25 Anglo-Americans and 35 Scandinavians (54 patients and 21 dentists). Results revealed universal dimensions of pain such as time, intensity, location, quality, cause and curability. More culture-specific dimensions included the Chinese concept suantong, a multivariate concept of bone, muscle, joint, tooth and gingival pain. "Real" and "imagined" pains were mostly described by Western subjects, especially dentists; "imagined pain" being the conversion of fear or anxiety into perceived pain. These data indicate that the methods were sensitive to culture as a variable and indicate that ethnicity may play a stronger role in the perceptions of pain description than does professional socialization, but that professional socialization processes may have more influence on the perception of pain coping modes for this sample population.

Long-term effects of two different treatments for dental fear and avoidance

Follow-up clinical studies of treatment for dental fear and avoidance behavior are infrequent in the literature. The present investigation reports follow-up results over more than two years from 84 out of 99 patients treated for dental fear in a Swedish community-based dental fear clinic. Broad-based behavioral therapy (BT) or general anesthesia (GA), both in combination with adjusted conventional dental treatment, were used. The frequency of patients' attendance for regular dental care after two years was unchanged or even somewhat increased and was significantly higher in those who had received the BT therapy. Most patients stated that they had no problems after leaving the dental fear clinic. Among patients reporting such problems, the change of dentist was most frequently reported. The level of dental anxiety as measured by Corah's DAS was still at a low level, in spite of a slight increase over the two years since initial therapy.