Dental pessimism: negative cognitions in fearful dental patients

Common risk factors for postoperative pain following the extraction of wisdom teeth

The extraction of third molars is a common task carried out at dental/surgery clinics. Postoperative pain is one of the two most common complications of this surgery, along with dry socket. Knowledge of the frequent risk factors of this complication is useful in determining high-risk patients, planning treatment, and preparing the patients mentally. Since the risk factors for postoperative pain have never been summarized before while the risk factors for dry socket have been highly debated, this report summarizes the literature regarding the common predictors of postextraction pain. Except for surgical difficulty and the surgeon's experience, the influences of other risk factors (age, gender and oral contraceptive use) were rather inconclusive. The case of a female gender or oral contraceptive effect might mainly be associated with estrogen levels (when it comes to dry socket), which can differ considerably from case to case. Improvement in and unification of statistical and diagnostic methods seem necessary. In addition, each risk factor was actually a combination of various independent variables, which should instead be targeted in more comprehensive studies.

From public mental health to community oral health: the impact of dental anxiety and fear on dental status

Dental fear is a widely experienced problem. Through a “vicious cycle dynamic,” fear of dental treatment, lower use of dental services, and oral health diseases reinforce each other. Research on the antecedents of dental anxiety could help to break this cycle, providing useful knowledge to design effective community programs aimed at preventing dental fear and its oral health-related consequences. In this regard, frameworks that analyze the interplay between cognitive and psychosocial determinants of fear, such as the Cognitive Vulnerability Model, are promising. The onset of dental fear often occurs in childhood, so focusing on the child population could greatly contribute to understanding dental fear mechanisms and prevent this problem extending into adulthood. Not only can public mental health contribute to population health, but also community dentistry programs can help to prevent dental fear. Regular dental visits seem to act in a prophylactic way, with dental professionals playing an important role in the regulation of the patients’ anxiety-related responses. Both public mental health and community dentistry could therefore benefit from a multidisciplinary approach to dental fear and oral health.

The moderating role of dental expectancies on the relationship between cognitive vulnerability and dental fear in children and adolescents

OBJECTIVE

Recently, cognitive approaches have been successfully applied to the understanding of child dental anxiety. Our study aimed to analyze the interplay between cognitive variables and their associations with dental fear. In particular, we proposed that the observed relationship between dental treatment-related cognitive vulnerability (i.e., uncontrollability, unpredictability, dangerousness, and disgustingness appraisals) and dental fear is moderated by the expectancies of the probability and aversiveness of negative events during dental treatments.

METHODS

A questionnaire survey was conducted with data obtained from 179 participants (8-18 years, 55.9% female) who attended 12 randomly selected educational establishments in Madrid (Spain).

RESULTS

Dental fear was associated with an irregular pattern of dental visits. As expected, cognitive vulnerability was strongly linked to dental anxiety. For those children who expected a lower likelihood of negative dental events or appraised them in a less aversive way, the relationship between cognitive vulnerability and fear was attenuated.

CONCLUSIONS

As dental fear and oral health are connected, the prevention and reduction of dental fear among children and adolescents might be a worthwhile target for public health interventions. Our study sheds some light on how this could be achieved, that is, by modifying the children's vulnerability appraisals as well as their fearful dental expectancies.

Treatment experience, frequency of dental visits, and children's dental fear: a cognitive approach

Cognitive elements play a key role in dental anxiety. Nevertheless, relatively little is known about how dental treatments and frequency of visits to the dentist are related to dental fear and its cognitive antecedents. This study aimed to explore the relationships between dental visits, past treatment experiences, expectations on the aversiveness/probability of negative dental events, and dental fear in children. The participants were 147 children (60% female; mean age = 12.0 yr) who completed a questionnaire comprising measures of dental treatment-related experience (attendance, fillings, and extractions), perceived aversiveness and probability of dental events, and dental anxiety. Bivariate correlations and multiple linear regression analyses were used to analyze the data. A higher frequency of dental visits was associated with less dental fear and a decreased belief in the probability of negative events occurring during treatment. The type of treatments received was not directly linked to dental fear. However, having received fillings was significantly associated with the perceived probability of negative dental events, whereas extractions were positively associated with these expectations but negatively associated with the perceived aversiveness of possible dental events. Regular dental visits, as well as dental treatments, can influence, in different ways, cognitive elements associated with dental anxiety in children.

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.

Comparison between one-session psychological treatment and benzodiazepine in dental phobia

To compare the effects of a single session of psychological treatment and acute administration of benzodiazepine, 50 dental phobic patients were allocated either to psychological treatment, benzodiazepine, or no treatment for anxiety. Psychological treatment consisted of stress management training and imaginal exposure to phobic stimuli with homework assignments. Benzodiazepine was administered 30 min before dental treatment. Both treatment conditions led to less anxiety during dental surgery than did the control condition. Phobic patients in the benzodiazepine condition showed a relapse after dental treatment, whereas those in the psychological treatment condition showed further improvement until the follow-up 2 months later. Of the latter group, 70% continued dental treatment; only 20% and 10% returned in the benzodiazepine and control conditions, respectively.

A model of pain and anxiety associated with acute stressors: distress in dental procedures

Many acute stressful experiences are not inherently very harmful, yet are associated with great pain and anxiety. The characteristics and experiences that the person brings to the situation are more important than any objective characteristics of the experience itself in determining how aversive the experience will be. Dental procedures are excellent examples of this type of stressor. Drawing primarily on the literature related to dental procedures, the present article discusses the nature of pain and anxiety in the face of an acute stressor, and presents the dispositional and situational factors that contribute to the perception of an acute stressor as aversive. A model is presented illustrating how the various factors interact. It is argued that, in addition to being descriptive, the model is also prescriptive of measures that may be taken to ameliorate the distress of persons subjected to acute stressors like dental procedures.

Dutch students' dental anxiety and occurrence of thoughts related to treatment

The present study was intended to explore the relationship between individuals' level of dental anxiety and thoughts (both self-statements and mental images) related to dental treatment. Subjects were 210 psychology students (75 males, 135 females). The results showed that 98% of the subjects reported one or more negative or catastrophic thoughts. A significant positive relationship was found between reported severity of anxiety (S-DAI scores) and frequency of thoughts. The results indicate that dental anxiety is associated with the tendency to experience negative or threatening thoughts concerning treatment.

Acquisition and maintenance of dental anxiety: the role of conditioning experiences and cognitive factors

This study presents a contribution to the understanding of the mechanisms that are involved in the development and maintenance of dental anxiety. Subjects were 224 undergraduate psychology students who completed questionnaires regarding dental anxiety, painful and traumatic experiences, negative cognitions, dental beliefs, and how their attitude to dental treatment had changed during their life. The results showed that both the extent to which earlier dental treatments were perceived as painful and the extent to which these incidents were reported as traumatic were significantly related to dental anxiety. Evidence was also found to support the latent inhibition hypothesis, which predicts that patients less easily acquire dental anxiety in case they received a number of relatively painless treatments prior to conditioning. Both findings confirmed those earlier obtained by Davey in a conceptually similar design (Behaviour Research and Therapy, 27, 51-58, 1989). In addition, frequency of negative cognitions about dental treatment and dental anxiety appeared to be positively related (r = 0.74; P < 0.001). Significant differences were found between highly anxious Ss and Ss showing low levels of anxiety on a variety of expectations and beliefs related to undergoing dental treatment. The results are discussed in terms of a cognitive-behavioural perspective of dental anxiety.

The overprediction of fear: a review

There is converging evidence that many people overestimate how frightened they will be when faced by a fear-provoking situation (Arntz & van den Hout, 1988, Behaviour Research and Therapy, 26, 207-223; Rachman & Bichard, 1988, Clinical Psychology Review, 8, 303-313; Rachman, 1990, Fear and courage (2nd edn). New York: W. H. Freeman). This overprediction of fear is commonly seen in people who are troubled by excessive fear (e.g. claustrophobics, panic patients), but is not confined to them. Anecdotal, clinical, and research evidence suggests that the tendency to overestimate the subjective impact of an aversive event is a common psychological phenomenon. This review will present examples of overpredictions, put forward some explanations of why people might overpredict, consider the function that overpredicting might serve, and the possible consequences of overpredicting. The process by which overpredictions are reduced is also considered and an attempt will be made to relate this strong tendency to overpredict fear to other types of psychological overestimation.

The 'match/mismatch' model of fear: empirical status and clinical implications

This paper reviews empirical evidence for the 'match/mismatch' model of fear and defines what is currently known about the prediction of fear. It also outlines several gaps in the literature on this topic and problems with the methodology used to study this phenomenon. Some of these gaps are filled by studies on the prediction of pain and where relevant these are discussed. Important areas for future research are identified, the clinical implications of the model are outlined and specific suggestions for treatment are made.

Proximity and anticipation of a negative outcome in phobias

Thirty-five patients being treated for one of three anxiety disorders were asked to rate the likelihood of a negative outcome prior to entering a feared situation, while in the situation and after leaving the situation. Ratings made in anticipation were consistently higher than ratings made either in the situation or after leaving it. In contrast, normal Ss, about to undertake tourist rides perceived as being mildly dangerous, rated the likelihood of negative outcome as highest when actually in the situation.

What do anxious patients think? An exploratory investigation of anxious dental patients' thoughts

According to BECK's cognitive model of emotional disorders (1976) anxiety is associated with negative and threatening thoughts concerning the likelihood of personal danger. In the present study the content of thoughts of 32 anxious dental patients was investigated. Patients' mean score for the Dental Anxiety Scale was 17.1 (SD = 2.0). The average time period patients had not visited a dentist was 9.1 yr (SD = 8.7). Using semi-structured interviews 132 thoughts were explored. The mean number of thoughts reported per patient was 4.1 (SD = 1.6). Almost all patients reported thoughts in some way related to their fear. All patients except one reported self-verbalizations of a negative or catastrophizing nature. Nine different categories of the content of the thoughts were identified. Nine percent of the thoughts consisted of visual images. The largest category (23%) consisted of catastrophic thoughts about the patient's own functioning during dental treatment, e.g., thoughts about losing control, panicking and dying. Fifty-nine percent of the patients reported thoughts of this type. The findings provide support for BECK's cognitive model of emotional disorders.

Anxiety about dental hygienist treatment

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; STOUTHARD, DE JONGH & HOOGSTRATEN, 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.

Predictions of dental pain: the fear of any expected evil, is worse than the evil itself

In a study of 40 subjects, who twice underwent extensive dental treatment, the relationships between expectations and experiences of pain and of anxiety were investigated. Inaccurate expectations were adjusted in the same way as observed in the laboratory. Especially anxious subjects expected more pain and anxiety than they experienced, and they appeared to need more experiences before their predictions became accurate. In the course of time, the expectations (and memories) of anxious subjects returned to their original more inaccurate level of prediction. The results suggest that the old schema is ultimately reinstated if disconfirmations are few and far between. Anxious subjects did not experience more pain, but they did experience more anxiety than fearless subjects. Detailed investigation of processes of change after disconfirmation showed that anxiety experienced during treatment is a factor that plays a part in maintaining the problem of inaccurate expectations and fear of treatment. Theoretical and clinical implications of these findings are discussed.

A study of factors associated with changes in dental anxiety

Patients were given the Dental Anxiety Scale (DAS) to complete and asked to indicate the degree of pain they expected to feel on that day's visit to a dentist. After the appointment, they indicated the degree of pain actually experienced. Three months later, the patients were contacted by mail and asked about the amount of pain they remembered having experienced and to complete the DAS again. There was considerable stability in DAS scores over the two administrations, but some of the change in scores was associated with the discrepancy between the degree of pain the patients expected and the degree of pain they actually experienced.