Treatment of Dental Fear: Systematic Desensitization or Coping?

Relaxation versus cognitive therapies for dental fear--a psychophysiological approach

By separating 127 adult dental-phobic patients according to fear etiology and psychophysiologic response style, the authors investigated the outcome of 2 dental fear treatments. Before and after either relaxation or cognitively oriented treatment, subjects were exposed to neutral and fear-relevant video sequences while the subjects' forehead muscle tension, heart rate, and skin conductance were recorded. Pre- to postintervention differences in self-reported dental fear, general fear, and trait anxiety were analyzed together with psychophysiological data. Both treatments resulted in a significant reduction of dental fear. Despite significant interaction effects of Treatment Modality x Psychophysiological Response Style, it could not be concluded that patients with different fear etiologies or response styles benefit differentially from the 2 treatments given.

Cognitive vulnerability: a model of the etiology of fear

This paper attempts to fill the partial theoretical vacuum surrounding the understanding of fear acquisition. A review of recent and contemporary theories of the etiology of fear is presented, serving as a justification for further theorizing and allowing for greater understanding of those aspects of fear that remain to be adequately explained. A new model of the etiology of specific fears is subsequently put forward and the various aspects and implications of this model are discussed. How an individual perceives a stimulus is proposed as being critical in determining fear in relation to the stimulus. In particular, perceptions of the stimulus as uncontrollable, unpredictable, dangerous and disgusting create a schema of vulnerability. The Cognitive Vulnerability Model integrates much of the extensive body of research on fears and specific phobias into a unifying theory of the etiology of fear. The model offers parsimonious explanations for the various characteristics of specific fears and phobias.

Clinical management of dental anxiety: what works for whom?

This paper aims to provide an overview of the current knowledge regarding the management of adult dentally anxious patients. Furthermore, an attempt is made to formulate a number of preliminary clinical guidelines, based on the available literature. The findings are discussed in the light of the following four problem areas or types of patients, those with: 1) a mild form of fear or anxiety, 2) a phobia of specific dental procedures or situations, 3) interfering psychiatric symptoms and/or 4) a high treatment need. The literature suggests that particularly the implementation of a high level of predictability during treatment, the training of patients in the use of coping skills, and the application of in vivo exposure to anxiety provoking stimuli are the most appropriate options for the management of anxious dental patients and the reduction of their anxiety level.

Dental fear in adults: a meta-analysis of behavioral interventions

OBJECTIVES

The aim of this meta-analytic and systematic quantitative approach is to examine the effects of behavioral interventions for dental anxiety and dental phobia.

METHODS

Eighty studies were identified where dental fear treatment with behavioral methods was evaluated. Thirty-eight of 80 met entry criteria and were included in a meta-analysis.

RESULTS

The calculated effect sizes (ESs) for self-reported anxiety after intervention indicate positive changes in 36 of the 38 studies and no changes in two. The overall ES = 1.8 (95% CI: 1.6, 1.8). The percent of subjects with post-treatment dental visits in the first 6 months post-treatment varied between 50 and 100%. The overall ES for attendance at dental visits, weighted by sample size, is 1.4 (95% CI: 1.3, 1.6). The homogeneity analysis indicates that the studies cannot be adequately described in one ES. The reported percentage of subjects with a dental visit between 6 months and 4 years post-treatment varied from 48 to 100%. The overall weighted ES for visiting the dentist, adjusted for drop-outs in the studies, is 1.2 (95% CI: 0.99, 1.4).

CONCLUSIONS

Despite extensive heterogeneity, changes in self-reported anxiety represent medium to large ESs. Patients signing up for a behavioral intervention for dental fear can be expected to report a significant reduction in their fear, and this effect generally seems to be lasting. Mean long-term attendance ( >4 years after treatment) is 77%.

A 3-year comparison of dental anxiety treatment outcomes: hypnosis, group therapy and individual desensitization vs. no specialist treatment

Outcomes of hypnotherapy (HT), group therapy (GT) and individual systematic desensitization (SD) on extreme dental anxiety in adults aged 19-65 yr were compared by regular attendance behaviors, changes in dental anxiety and changes in beliefs about dentists and treatment after 3 yr. Treatment groups were comparable with a static reference control group of 65 anxious patients (Dental Anxiety Scale > or = 15) who were followed for a mean of nearly 6 yr. After 3 yr, 54.5% of HT patients, 69.6% of GT patients and 65.5% of SD patients were maintaining regular dental care habits. This was better than the 46.1% of the reference group, who reported going regularly to the dentist again within the cohort follow-up period, and 38.9% of a control subgroup with observation for 3 yr. Women were better regular attenders than men at 3 yr. Specialist-treated regular attenders were significantly less anxious and had more positive beliefs than regular attenders from reference groups. There were few differences between HT, GT and SD after 3 yr. It was concluded that many patients can, on their own, successfully start and maintain regular dental treatment habits with dentists despite years of avoidance associated with phobic or extreme anxiety. However, it also appears that these patients had less success in reducing dental anxiety and improving beliefs about dentists long-term than did patients who were treated at the specialist clinic with psychological strategies.

Relaxation vs. cognitively oriented therapies for dental fear

Cognitive therapy has been reported for the treatment of dental phobia, but comparisons with other behavioral treatments are scarce. This study investigated the outcome of two modes of treatment for phobic dental fear. Relaxation and cognitively oriented therapy were compared in a sample of 112 adult fearful dental patients. The patient made questionnaire assessments of background and outcome variables, and the specialist dentist rated successful/non-successful outcome. It was shown that a higher number of patients who received cognitively oriented therapy completed the treatment program, while anxiety was more reduced among patients who received relaxation-oriented therapy. Dropout during the initial phobia therapy with a psychologist was related to lower motivation (willingness to engage in treatment), while failures during dental treatment after the completion of therapy were related to higher levels of general fear and anxiety. A multiple logistic regression model explaining 67% of the variance revealed that the risk of failure was only slightly increased by general fears, while patients with low (below median) motivation ran a 3.6-times-higher risk of dropping out. In conclusion, it was shown that the two treatment methods were both effective in reducing dental phobic reactions. However, while cognitively oriented therapy resulted in a higher number of patients completing therapy, relaxation-oriented treatment generally resulted in a more significant reduction in dental fear as well as in general anxiety and fear. Motivation was found to be a significant predictor of successful treatment outcome.

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.

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.

Psychophysiological therapy vs. hypnotherapy in the treatment of patients with dental phobia

The aim of this study was to compare two different modes of behaviorally-oriented therapies for dental fear. The subjects were chosen consecutively from the waiting-list of a Dental Fears Research and Treatment Clinic. In addition, a control group was selected from patients treated under general anesthesia to compare levels of dental and general fear with the experimental groups. Twenty-two women, with a mean age of 31.8 yr, were included and randomly assigned to two groups. The median time of avoidance of dental care was 9.5 yr. One group received hypnotherapy (HT) and one group a behavioral treatment based on psychophysiological principles (PP). Both therapies included eight sessions followed by standardized conventional dental test treatments. Pre- and posttreatment measures were dental fear, general fear, mood, and patient behavior. Nine patients were not able to conclude the treatment sessions (6 HT and 3 PP); these patients did not differ significantly from the remaining patients before treatment. The PP group reported a statistically significant decrease in dental fear as well as a rise in mood during dental situations, as opposed to the HT group. General fear levels decreased but not significantly. Eleven patients completed conventional dental treatment according to a dentist's behavioral rating scale, indicating that they were relaxed, and no problems occurred during the treatments. These patients were referred to general practitioners within the community dental service. In conclusion, this small size study showed that a majority of the patients, who accomplished the behavioral therapy and the dental test treatments, became less fearful of dental care and were able to manage conventional dental care, including changing dentist.

Long-term follow-up of treated dental phobics

Behavioural treatment programmes have been shown repeatedly to be effective in alleviating dental anxiety but few studies have provided long-term follow-ups. In this study, dentally anxious Ss who had completed a 4-session behavioural group programme were followed up for periods between 1 and 4 years after successful completion of treatment. It was hypothesized that dental visit satisfaction would be associated with regular dental attendance. 88% of Ss contacted agreed to cooperate; of these, 70% were still maintaining regular check-ups. There were no differences between regular and irregular attenders in terms of age, gender, education, marital status, degree of pre-treatment avoidance or time elapsed since completion of the programme. However, Ss who did not see their dentists regularly were more likely to have shown higher levels of anxiety immediately after completing the programme, less concordance between the subjective and overt behavioural aspects of anxiety and to have experienced more invasive than non-invasive procedures than the others. It was argued that dentally anxious individuals are not a homogeneous group and that a better understanding of their individual differences would lead to the development of more efficacious treatment procedures.