Seeing the person before the teeth: A realist evaluation of a dental anxiety service in Norway

A call for trauma-informed dental care for individuals with intellectual disabilities

People with intellectual disabilities are at increased risk of dental anxiety and poor oral health. In addition, people with intellectual disabilities are at increased risk of potentially traumatic experiences, such as violence and sexual abuse, and appear to be more vulnerable to developing trauma-related disorders following such experiences. While psychological trauma is associated with poor oral health and dental anxiety in the general population, the potential link between dental anxiety, poor oral health and psychological trauma is yet to be explored in people with intellectual disabilities. In this conceptual paper, we provide an overview of recent findings concerning the relationships between oral health and intellectual disabilities, psychological trauma and intellectual disabilities, as well as between psychological trauma and oral health, and discuss the relevance of these findings related to dental care for people with intellectual disabilities. We conclude that psychological trauma is likely to contribute to dental anxiety and poor oral health also in people with intellectual disabilities. Implications include an urgent need for research exploring how trauma affects oral health and experiences of dental care for people with intellectual disabilities, as well as the importance of individualized and trauma-informed dental care for these individuals.

Differences in anxiety, depression, and oral health-related quality of life among dental anxiety patients with and without reported abuse experience

This study aimed to explore the differences in anxiety, depression, and oral health-related quality of life between people with dental anxiety who reported abuse experience (n = 60) and people with dental anxiety who did not report abuse experience (n = 97). Both groups attended a dental service focused on the treatment of dental anxiety intended for people with a history of physiological or psychological trauma, or odontophobia. The participants responded to a questionnaire that included the Hospital Anxiety and Depression Scale (HADS), Oral Impacts on Daily Performance (OIDP), and the Index of Dental Anxiety and Fear (IDAF-4C+ ). The differences between groups were tested for statistical significance using Welch's T-tests, and linear regression was used to adjust for gender. The participants with reported abuse experience expressed greater psychological symptoms of anxiety and poorer oral health-related quality of life. The participants with reported abuse experience also expressed a higher fear of losing control, as well as feeling shame and disgust. This study shows that individuals with dental anxiety and a history of abuse may face more complex challenges than those with dental anxiety and no history of abuse.

Exploring dental students' attitudes toward patient-centered management of dental fear

PURPOSE/OBJECTIVES

A patient-centered care (PCC) paradigm undergirds modern dental education. PCC is particularly relevant in the management of patient dental fear. The aims of this study were three-fold: (a) to examine the preliminary psychometric properties of an author-designed survey administered to explore dental fear knowledge and perceptions, (b) to assess how 4th-year dental students regard dental fear, (c) and to investigate the relationship between students' knowledge and perceptions of dental fear and their clinical behavior.

METHODS

In 2022, 4th-year dental students (N = 453) participated in a cross-sectional study. Participants completed a 16-item survey that assessed (a) knowledge and perceptions about dental fear, (b) common biases in patient fear assessment, and (c) patient management behaviors when fear is encountered. Exploratory factor analysis, descriptive statistics, and logistic regressions were run to address the study's aims.

RESULTS

Exploratory factor analysis revealed three factors, with the two strongest factors pertaining to beliefs about the importance of dental fear (α = 0.87) and self-efficacy in managing fear (α = 0.74). Participants indicated that it is important to assess for dental fear and rated their self-efficacy in ability managing it as high. Ratings on both factors slightly increased the odds of engaging in routine patient screening for dental fear. Students also displayed assessment biases commonly seen among practicing dentists.

CONCLUSION(S)

Results indicate educational gaps within the current behavioral-science training for dental students. Changes to improve advanced dental students' appreciation of their patients' dental fear are warranted.

The complexity of dental anxiety and its association with oral health-related quality of life: An exploratory study

This study aimed to explore the factors associated with oral health-related quality of life (OHRQoL) in a sample with high dental anxiety. Data were obtained from 107 patients attending a therapeutic treatment program for people who have experienced abuse and for those with dental phobia in Norway. Patients completed questionnaires, including the Index of Dental Anxiety and Fear, the Anxiety subscale of the Hospital Anxiety and Depression Scale, and the Oral Impacts on Daily Performance scale, measuring OHRQoL prior to treatment. The various measurement instruments were evaluated psychometrically, and the variables associated with OHRQoL were explored using hierarchical multiple regression. Symptoms of dental anxiety and general anxiety were high, while OHRQoL was poor. Dental anxiety, higher age, higher number of years since the last dental treatment, and higher general anxiety were discernibly associated with lower OHRQoL. The strongest association was found between general anxiety and OHRQoL. In conclusion, several factors were associated with OHRQoL in a sample with high dental anxiety, suggesting a complex picture of dental anxiety. When treating patients with high dental anxiety, dental practitioners should be aware that there may be factors complicating the therapeutic setting, such as general anxiety.

Exploring the contexts, mechanisms and outcomes of a torture, abuse and dental anxiety service in Norway: a realist evaluation

Background

Torture, abuse and dental anxiety (TADA) are often precursors to developing a pathological relationship with dental care due to elevated anxiety. Consequently, patients who suffer from one or more of these tend to avoid dental services. This could leave them with severe tooth decay, which could affect their general and psychosocial health. Norwegian dental services have implemented the TADA service to specifically alleviate dental anxiety and restore oral health for the TADA patient group. However, the service has not been evaluated, and there is a need to understand how and why this service works, for whom, under what circumstances. Therefore, this study aimed to develop theories on how the service’s structure alleviates dental anxiety and restores these patients’ oral health. Although developed in a Norwegian context, these theories may be applicable to other national and international contexts.

Methods

This realist evaluation comprised multiple sequential methods of service and policy documents (n = 13), followed by interviews with service developers (n = 12).

Results

The analysis suggests that, by subsidising the TADA service, the Norwegian state has removed financial barriers for patients. This has improved their access to the service and, hence, their service uptake. National guidelines on service delivery are perceived as open to interpretation, and can hereby meet the needs of a heterogeneous patient group. The services have become tailored according to the available regional resources and heterogeneous needs of the patient population. A perceived lack of explicit national leadership and cooperative practices has resulted in regional service teams becoming self-reliant and insular. While this has led to cohesion within each regional service, it is not conducive to interservice collaborations. Lastly, the complexity of migration processes and poor dissemination practices is presumed to be the cause of the lack of recruitment of torture survivors to the service.

Conclusions

Policy documents and service developers described the TADA service as a hybrid bottom-up/top-down service that allows teams to practise discretion and tailor their approach to meet individual needs. Being free of charge has improved access to the service by vulnerable groups, but the service still struggles to reach torture survivors.