Fears of the dental situation

Stress and Hypothalamic-Pituitary-Adrenal Axis: Effect on Prognosis of Dental Treatment

Stress is a process that activates neuronal, metabolic, and neuroendocrine mechanisms. The individual's response may be determined by variables such as genetic factors, environmental conditions, sex, and age, among others. These responses are critical for survival, and the involvement of the hypothalamic-pituitary-adrenal axis is necessary for adaptation, which through counter-regulatory mechanisms seeks to restore homeostasis. Dentists are aware that there are variations in people's response to treatment, and there are many patients in whom dental treatment generates an important source of stress, which in many cases leads to treatment avoidance behavior.

What is the gold standard of the dental anxiety scale?

It is important to understand patients' anxiety and fear about dental treatment. A patient's anxiety can be quantified through a self-report questionnaire, and many related scales have been developed. In this review, I tried to find out which scale is most suitable for the patient's dental anxiety and fear evaluation by examining the contents of previously developed scales and comparing the strengths and weaknesses of each scale.

Variation in Hemodynamic Characteristics during Periodontal Crown-Lengthening Surgical Procedure: An Uncontrolled Cohort Study

(1) Background: The purpose of this prospective study was to determine the changes in primary hemodynamic parameters and oxygen saturation in systemically healthy patients during the surgical procedure involving crown lengthening. (2) Methods: A total of 44 patients who required a crown-lengthening procedure in a single tooth in the maxillary arch were included in this study. Heart rate (HR), blood pressure (BP) and oxygen saturation (SpO₂) were measured in all the subjects at three different intervals: before injecting the anesthetic (T1), after the anesthetic injection (T2) and after the procedure (T3). Descriptive statistics were computed, and observations were recorded as mean and standard deviation (SD). Analysis of variance (ANOVA) was used to compare the mean observation within parameters at different time intervals. (3) Results: All primary hemodynamic parameters were increased in the T2 phase over T1 and decreased in the T3 phase over T2. However, SpO₂ decreased in both the T2 and T3 phases compared to the initial T1 phase. No significant differences were observed among the primary hemodynamic variables. However, SpO₂ showed a significant difference (p = 0.013) among the T1, T2 and T3 phases. (4) Conclusions: Further study with larger sample size is required in order to analyze the accurate hemodynamic alterations.

Trusting the Dentist—Expecting a Leap of Faith vs. a Well-Defined Strategy for Anxious Patients

This article aimed to set into perspective the unique aspects of trust within the dentist–patient relationship by exploring the literature as well as historical aspects of dentistry in the association between trust/distrust and patient anxiety. In order to characterise this uniqueness, the assumptions for trusting in dentistry are compared and contrasted with other professions using a conceptual analysis. The professions of medicine, sociology, psychology, nursing and dentistry were check listed according to the tenets of a concept analytical approach reported by Hupcey et al., in 2001. Recommendations for patient/person-centred care, as opposed to dentist-centred care, that would improve trust are specified according to the literature. These include empowering patients, practicing active listening, empathy and relationship building that might benefit dental patients in relation to the perceived risks of anxiety or induced pain. It was concluded that global distrust of dominating dentists must give way to person-centred professional strategies so that dentists and patients can tackle their dental anxiety-trust challenges, both in the public’s image of the dental profession and in clinical relationships. Future directions would be to explore incentives for dentists to change to patient/person-centred care.

Dental Anxiety and Higher Sensory Processing Sensitivity in a Sample of German Soldiers with Inflammatory Periodontal Disease

(1) Background: Dental anxiety with disease value usually leads to avoidance of dental treatment. For the initial diagnosis of the level of anxiety, questionnaires such as the Hierarchical Anxiety Questionnaire (HAQ) are suitable. The construct of sensory processing sensitivity (SPS) describes a general trait in which people with a higher degree of SPS perceive information more strongly and process it more thoroughly. (2) Methods: This cross-sectional study evaluated the relationship between dental anxiety and higher levels of SPS in 116 soldiers referred with different stages of periodontitis for mandatory dental fitness before military deployment. (3) Results: The proportion of patients with periodontitis in stage III + IV was 39% and in stage I + II was 27%. The mean cumulative values of the questionnaires were 20.9 ± 10.6 for HAQ and 27.7 ± 16.0 for SPS. Eleven moderately anxious patients had a SPS value of 37.4 ± 13.5 and 10 highly anxious patients had a value of 36.3 ± 14.1. Patients diagnosed with stage III + IV periodontitis showed significantly higher values on the SPS subscale Low Sensory Threshold (LST), which describes overstimulation by external sensory stimuli, compared to patients with stage I + II periodontitis. Dental anxiety showed moderately significant correlations with the SPS subscale Ease of Excitation (EOE), which measures emotional reactivity to physiological stimuli. (4) Conclusions: Due to the frequency of dental anxiety and higher sensitivity in patients with severe periodontitis, it is useful to record said frequency.

Determination of Onset of Action and Efficacy of Topical Lignocaine Anesthesia in Children: An In Vivo Study

Anxiety is one of the major issues in the dental treatment in children and needle is the most anxiety provoking armamentarium. For this reason, pediatric dentists are on a constant search to find more comfortable means for administering anesthesia. Topical anesthesia has proven to be a boon in this attempt. Literature shows that quite often there is little pain relief from topical anesthesia and one reason for failure may be that there is no consensus regarding the most appropriate time duration for topical anesthesia to anesthetize intraoral tissue prior to injection. Therefore, the aim and objectives of the study are as follows: (1) To determine duration for onset of action of lignocaine gel and lignocaine spray used as a topical anesthesia during local anesthetic infiltration in palatal area in pediatric patients. (2) To compare the efficacy of lignocaine spray and lignocaine gel in the same patient with bilateral injection. The study group consists of children in the age group of 6–12 years of both genders. Only those children who require palatal bilateral infiltration for their treatment, included in the study. A total of 120 children divided equally into 3 sub-groups depending on the amount of time gap between topical anesthetic application and local infiltration. (1) Group I–30 seconds (2) group II–1 minute (3) group III–3 minutes. Pain responses compared based on subject self-report using visual analogue scale to record subjective symptoms and sem (sound eye motor) scales to record objective symptoms. Results subjected to statistical analysis.

Short Version Dental Anxiety Inventory Score May Predict the Response in the Insular Cortex to Stimuli Mimicking Dental Treatment

Background: Dental anxiety is a common reason for avoiding dental visits and is associated with poor dental status. The short version of Dental Anxiety Inventory (SDAxI) is an easy-to-use, multi-faceted questionnaire for assessing the level of trait dental anxiety. However, there was no neurophysiological data indicating if its score associates with the state anxiety when an individual is under real/mock dental environment. We hypothesized that there exists such an association. Materials and Methods: Twenty systemic healthy adults with dental attendance experience and self-claimed free of dental phobia were recruited in this cross-sectional study, with their dental anxiety level assessed by SDAxI. Functional magnetic resonance imaging recorded their brain signals in response to audiovisual footages resembling dental scaler or turbine in action. After the brain imaging, they gave fear ratings to the footages in visual analog scale (VAS). Results: Participants' SDAxI scores positively correlated with their responses in the insular cortex (r² = 0.388-0.445, P < 0.005). Their SDAxI scores also positively correlated with their fear ratings of the footages (r ² = 0.415-0.555, P < 0.005). Discussion: Our findings indicated a possible neurobiological relevance of SDAxI, and reinforced its neurobiological validity in assessing dental anxiety level of dental attenders.

Hemodynamic variations and anxiety during the surgical extraction of impacted lower third molars

Background

The surgical removal of an impacted third molar can cause patient anxiety. Such anxiety and the use of vasoconstrictor drugs and local anesthetics in turn can induce hemodynamic variations during the operation. A study is made of the variations in hemodynamic parameters (systolic and diastolic blood pressure and heart rate) and their correlation to patient gender and anxiety during surgical removal of an impacted lower third molar.

Material and Methods

A prospective study was carried out in the Oral Surgery Unit of a university clinic, with the inclusion of 125 patients (mean age 24.9 years). Anesthesia was administered in the form of 4% articaine and adrenalin 1:200,000 for surgical removal of the impacted lower third molars.

Results

Women experienced greater anxiety than men. Systolic blood pressure showed few changes - the maximum and minimum values being recorded at the time of incision and upon suturing, respectively. Diastolic blood pressure in turn showed maximum and minimum values before the start of surgery and during extraction, respectively, while heart rate proved maximum during incision and minimum upon suturing. The differences in systolic and diastolic blood pressure, and heart rate, between men and women, and between patients with and without anxiety, failed to reach statistical significance.

Conclusions

The fact that these were young patients could contribute to explain the absence of significant hemodynamic changes in our study. Key words:Anxiety, third molars, extraction, surgery.

Psychological Intrusion - An Overlooked Aspect of Dental Fear

Dental fear/anxiety is a widely recognised problem affecting a large proportion of the population. It can result in avoidance and/or difficulty accepting dental care. We believe that psychological intrusion may play a role in the aetiology and maintenance of dental fear for at least some individuals. In this narrative review we will take a developmental perspective in order to understand its impact across the lifespan. We will consider the nature of 'self,' parenting styles, the details of intrusive parenting or parental psychological control, and briefly touch upon child temperament and parental anxiety. Finally, we draw together the supporting (largely unrecognised) evidence available in the dental literature. We illustrate the paper with clinical examples and discuss possibly effective ways of addressing the problem. We conclude that psychological intrusion appears to play an important role in dental fear, for at least some individuals, and we call for detailed research into the extent and exact nature of the problem. A simple means of identifying individuals who are vulnerable to psychological intrusion would be useful for dentists.

The relationship between subjective oral health and dental fear in Korean adolescents

Background

This study is aimed to evaluate the level of fear and to reduce the overall fear, thereby enabling patients to receive treatment via timely visits.

Methods

In a survey conducted by 460 South Korean middle school students, we used 453 data that faithfully responded to the survey. Multiple regression analysis was conducted to investigate the factors influencing subjective oral health and dental fear. The significance level used for statistical significance was α = 0.05.

Results

The level of fear was higher for upper grade, female students. The factors affecting dental fear were higher for gingival bleeding and dental pain. Regarding factors for dental fear affecting subjective oral health, lower fear of puncture needle and tooth removal tool resulted in higher subjective oral health.

Conclusion

The study found that adolescents had higher fear of dental care when they had gingival bleeding and tooth pain. Gingival bleeding is a symptom of early gingival disease and dental pain is likely due to advanced dental caries. These results suggested that it is necessary to have a program to reduce dental fear and anxiety as well as a program to prevent dental diseases through regular periodic screening and education.

Pre-treatment anxiety in a dental hygiene recall population: a cross-sectional pilot study

Background

Increased levels of anxiety may affect a patient’s receptiveness to treatment, health care information and behaviour modification.

This study was undertaken to assess pre-treatment anxiety in a dental hygiene recall population maintaining a schedule of regular preventive care appointments.

Methods

The sample population consisted of 46 consecutive adult recall patients waiting for their regularly scheduled dental hygiene appointment. Pre-treatment state (current) anxiety was assessed using the State-Trait-Anxiety Inventory (STAI), State form; dental anxiety with the Hierarchical Anxiety Questionnaire (HAQ); subjective stress using a visual analogue scale (VAS); and mood/alertness/calmness using the Multidimensional Mood Questionnaire (MDMQ).

Results

Two distinct groups, based on state anxiety scores, were formed; one displaying increased levels of pre-treatment anxiety (n = 14), the other low anxiety (n = 32). The HA group was characterized by significantly higher dental anxiety and subjective stress levels prior to treatment; as well as worse mood, lower alertness, and less calmness in the dental office setting. There was no correlation between anxiety level and years in dental hygiene recall.

Conclusions

A high level of pre-treatment anxiety was present in about one third of the sample population. The prevalence of this anxiety demonstrates the need for both early recognition and patient management strategies (psychological and pain management) to positively influence their treatment experience.

Electronic supplementary material

The online version of this article (doi:10.1186/s12903-016-0198-8) contains supplementary material, which is available to authorized users.

Dental fear & anxiety and dental pain in children and adolescents; a systemic review

BACKGROUND

There are few previous studies investigating the relationship of dental fear and anxiety (DFA) with dental pain among children and adolescents. To address this issue, we examined the literature published between November 1873 and May 2015 to evaluate the prevalence of DFA and dental pain among children and adolescents, and their relationships with age and sex.

METHODS

We performed a broad search of the PubMed database using 3 combinations of the search terms dental fear, anxiety, and dental pain and prevalence. A large proportion of the identified articles could not be used for the review due to inadequate end points or measures, or because of poor study design. Thirty-two papers of acceptable quality were identified and reviewed.

RESULTS

We found that the prevalence of DFA was estimated to be 10%, with a decrease in prevalence with age. It was more frequently seen in girls, and was related to dental pain.

CONCLUSIONS

We concluded that dental fear, anxiety, and pain are common, and several psychological factors are associated with their development. In order to better understand these relationships, further clinical evaluations and studies are required.

Dental fear and its possible relationship with periodontal status in Chinese adults: a preliminary study

BACKGROUND

The aim of the present study was to describe the characteristics of dental fear of Chinese adult patients with periodontal disease and provide information for clinical assessment.

METHODS

A total of 1203 dental patients completed questionnaires that included Corach's Dental Anxiety Scales (DAS), Dental Fear Survey (DFS) and the short-form Dental Anxiety Inventory (S-DAI). Among all the patients, 366 cases were self-reported periodontal disease. The general characteristics were described, such as socio-demographics, dental attendances and oral health behaviors. The statistical analysis was performed by t-test, Mann-Whitney U test and linear regression respectively to evaluate correlations between dental fear and general characteristics according to the three scales.

RESULTS

The prevalence of dental fear was 74% among 1203 patients, 23.4% of total with high dental fear, while 27.3% in the patients with periodontal disease. The average score of DAS and DFS for patients with periodontal disease was significantly higher than those without periodontal disease. The regression analysis indicated that gender, age, periodontal status, dental attendances and oral health behaviors were correlated with dental fear. Among 366 patients with periodontal disease, gender, dental attendances and oral health behaviors had correlation with dental fear. The analysis of DFS scale exhibited that 'drilling with handpiece' and 'injecting the anesthetic' were the most important factors to contribute to dental fear.

CONCLUSIONS

There was high prevalence of dental fear in Chinese adult patients, particularly in patients with periodontal disease, and high level of dental fear may lead to poor periodontal status.

Dental fear among medical and dental undergraduates

OBJECTIVE

To assess the prevalence and level of dental fear among health related undergraduates and to identify factors causing such fear using Kleinknecht's Dental Fear Survey (DFS) questionnaire.

METHODS

Kleinknecht's DFS questionnaire was used to assess dental fear and anxiety among the entire enrollment of the medical and dental undergraduates' of the University of Malaya.

RESULTS

Overall response rate was 82.2%. Dental students reported higher prevalence of dental fear (96.0% versus 90.4%). However, most of the fear encountered among dental students was in the low fear category as compared to their medical counterpart (69.2 versus 51.2%). Significantly more medical students cancelled dental appointment due to fear compared to dental students (P = 0.004). "Heart beats faster" and "muscle being tensed" were the top two physiological responses experienced by the respondents. "Drill" and "anesthetic needle" were the most fear provoking objects among respondents of both faculties.

CONCLUSION

Dental fear and anxiety are a common problem encountered among medical and dental undergraduates who represent future health care professionals. Also, high level of dental fear and anxiety leads to the avoidance of the dental services.

The role of memory on the dentally anxious patient's response to dental treatment

The aetiology of dental anxiety is multifactorial. Psychologically traumatising events associated with dental treatment have been shown to be of particular importance. The present investigation examines the role of memory in relation to these traumatic episodes and investigates their influence on the patient's response to dental treatment.

The study has shown that patients with dental anxiety have had more experience of “traumatic dental events” (p<0.001), relate the cause of their dental anxiety to specific dental procedures and report more fear of dental treatment than controls. The memories of such traumatic dental events are important indicators of anxiety in the clinical setting, with dentally anxious patients having significantly higher scores for dental anxiety (p<0.001) compared with controls. Furthermore, the memories of these events have a special relevance to the patient's subjective experience of dental anxiety in the here and now. The past event sensitises the susceptible patient and maintains and intensifies the anxiety through a feed-back mechanism, resulting in a vicious circle of anticipatory dental fear.

Management of fear and anxiety in the dental clinic: a review

People who are highly anxious about undergoing dental treatment comprise approximately one in seven of the population and require careful and considerate management by dental practitioners. This paper presents a review of a number of non-pharmacological (behavioural and cognitive) techniques that can be used in the dental clinic or surgery in order to assist anxious individuals obtain needed dental care. Practical advice for managing anxious patients is provided and the evidence base for the various approaches is examined and summarized. The importance of firstly identifying dental fear and then understanding its aetiology, nature and associated components is stressed. Anxiety management techniques range from good communication and establishing rapport to the use of systematic desensitization and hypnosis. Some techniques require specialist training but many others could usefully be adopted for all dental patients, regardless of their known level of dental anxiety. It is concluded that successfully managing dentally fearful individuals is achievable for clinicians but requires a greater level of understanding, good communication and a phased treatment approach. There is an acceptable evidence base for several non-pharmacological anxiety management practices to help augment dental practitioners providing care to anxious or fearful children and adults.

Current sedation practice among general dental practitioners and dental specialists in Jordan: an example of a developing country

Purpose

The study reported here aimed to identify current sedation practice among general dental practitioners (GDPs) and specialist dental practitioners (SDPs) in Jordan in 2010.

Methods

Questionnaires were sent by email to 1683 GDPs and SDPs who were working in Jordan at the time of the study. The contact details of these dental practitioners were obtained from a Jordan Dental Association list. Details on personal status, use of, and training in, conscious sedation techniques were sought by the questionnaires.

Results

A total of 1003 (60%) questionnaires were returned, with 748 (86.9%) GDPs and 113 (13.1%) SDPs responding. Only ten (1.3%) GDPs and 63 (55.8%) SDPs provided information on the different types of treatments related to their specialties undertaken under some form of sedation performed by specialist and/or assistant anesthetists. Approximately 0.075% of the Jordanian population received some form of sedation during the year 2010, with approximately 0.054% having been treated by oral and maxillofacial surgeons. The main reason for the majority of GDPs (55.0%) and many SDPs (40%) not to perform sedation was lack of training in this field. While some SDPs (26.0%) indicated they did not use sedation because of the inadequacy of sedative facilities.

Conclusion

Within the limitations of the present study, it can be concluded that the provision of conscious sedation services in general and specialist dental practices in Jordan is inconsistent and inadequate. This stresses the great need to train practitioners and dental assistants in Jordan to enable them to safely and effectively perform all forms of sedation.

Clinical anesthetic effectiveness of intraoral mucoadhesive tablets of amitriptyline in healthy volunteers

PURPOSE

Topical anesthetics are widely used in dentistry. One of their indications is to diminish the pain of the injection of anesthetics. Amitriptyline is a tricyclic antidepressant that provides local anesthetic effects by blocking the sodium channels. The present study was performed in an attempt to assess the anesthetic efficacy of an intraoral mucoadhesive tablet of amitriptyline.

MATERIALS AND METHODS

The present study was performed as a randomized, double-blind, placebo-controlled, clinical trial of 25 healthy female volunteers. The mucoadhesive tablet was randomly placed for 15 minutes on the buccal mucogingival tissue adjacent to the root of the upper lateral incisor, and a placebo was placed on the other side. A 27-gauge needle was inserted to touch the alveolar periosteum of the designated site. The pain intensity associated with the stimulation was evaluated every 5 minutes after removing the mucoadhesive tablet using a visual analog pain scale and pain rating scoring methods.

RESULTS

The difference between the amitriptyline and placebo groups was statistically significant 20, 25, 30, 35, and 40 minutes after placing the mucoadhesive tablet. Its mean onset and duration of action was 25 and 20 minutes, respectively (P<.05).

CONCLUSIONS

To our knowledge, the present study represents an initial step toward achieving an efficient and safe anesthetic method. The intraoral mucoadhesive amitriptyline tablet proved to be a promising anesthetic device for manipulating pain in dental procedures. However, it should also be mentioned that to achieve high efficiency, it will be necessary to optimize the release profile.

Auditory symptom provocation in dental phobia: a near-infrared spectroscopy study

The act of drilling a tooth belongs to the most feared situations of patients suffering from dental phobia. We presented 25 female patients and 24 nonphobic women with the sound of a dental drill, pleasant and neutral sounds. Brain activation was recorded via near infrared spectroscopy in fronto-parietal and premotor areas. The groups differed in supplementary motor area (SMA) recruitment. Relative to controls, the phobics displayed increased oxy hemoglobin while presented with the phobia-relevant sound, but showed comparable activation in the other conditions. As the SMA is engaged in the preparation of motor actions, the increased response in patients might mirror the priming of flight behavior during exposure. We found no indication of an emotional modulation of parietal and dorsomedial prefrontal cortex activation.

Dental anxiety and pain related to dental hygienist treatment

OBJECTIVE

To evaluate different groups of patients' self-reported assessments of dental anxiety and pain related to various routine dental hygienist treatment procedures, and to investigate the relationship between anxiety concerning dental and dental hygienist treatment.

MATERIAL AND METHODS

A consecutive sample of 393 patients participated in the study (59.7% F, age range 20 to 85 years, mean 47.6 years). Periodontology (PC), oral medicine (OM), student and general practice (GP) clinics were included. Each patient was asked to answer a questionnaire which included different demographic information, self-reported levels of dental anxiety, and experience of pain in relation to different dental hygienist treatments.

RESULTS

Higher dental anxiety was found in relation to gender (women), dentist treatment, and PC and OM patients. Experiences of high or extreme pain were reported by between 7.1% and 9.7% of participants for all dental hygienist procedures except polishing (0.8%). There were significant correlations between dental hygienist fear levels and reported extreme pain experiences among all five treatment procedures. Patients treated at the PC clinic scored significantly higher on pain compared with patients at the other clinics, with the exception of the OM clinic.

CONCLUSIONS

Patients reported higher dental anxiety levels for dentist treatment as compared with dental hygienist treatment. Moreover, dental anxiety was significantly associated with perceived pain related to different dental hygienist treatment procedures.

What are people afraid of during dental treatment? Anxiety-provoking capacity of 67 stimuli characteristic of the dental setting

Relatively little is known about the anxiety-provoking capacity of the various objects and situations characteristic of the dental setting. The aims of the current study were to establish a hierarchy of anxiety-provoking capacities of a large set of dental stimuli and to determine the differences in relation to gender, age, ethnicity, and level of dental trait anxiety. An additional aim was to derive an estimate of the number of stimuli to be presented to anxious patients in order to obtain full coverage of their dental fears. A questionnaire describing 67 potentially anxiety-provoking stimuli was constructed and presented to 960 adults. The results indicated that invasive stimuli (e.g. surgical procedures) were rated as the most anxiety provoking and that non-invasive stimuli (e.g. the dentist as a person) were the least anxiety provoking. The fear-evoking capacity of the dental stimuli varied with gender, age, ethnicity, and level of dental trait anxiety, whereas the rank order of these stimuli appeared to be independent of these factors. Furthermore, it appeared that the top 25 most anxiety-provoking objects and situations found in the current study contained only eight (28%) stimuli, which had been taken into account in previous research. The present findings support the need for assessment procedures using a broad spectrum of potentially anxiety-provoking stimuli.

Portuguese version of Corah's Dental Anxiety Scale: transcultural adaptation and reliability analysis

This study explores the psychometric properties of the Portuguese version of Corah's Dental Anxiety Scale (DAS), an instrument designed to assess the manifestations of dental anxiety. The DAS has been translated into several languages, but no adaptation and reliability analysis of the Portuguese version of the scale has yet been carried out. A total of 747 Brazilian undergraduate students participated in this study. The instrument proved to have good internal consistency and test-retest reliability. Furthermore, we observed that women are more anxious during dental treatment routines compared to men. Our findings suggest that the Portuguese version of DAS is a reliable instrument for assessing adults' dental anxiety traits, and can be used for both clinical and research purposes.

Current state of sedation/analgesia care in dentistry

PURPOSE OF REVIEW

Dentistry treatment is one of the most anxiety-inducing events in people's lives. The development of pain and anxiety-control techniques has always been very closely aligned to the development of dentistry. The purpose of this review is to summarize the recent literature in this field.

RECENT FINDINGS

The literature in the last 12 months falls into four main categories: dental anxiety and its influence on patient care, dental sedation for children, sedation with benzodiazepines for dentistry, and intravenous propofol sedation for dentistry.

SUMMARY

Considerable progress is being made with a number of innovative techniques. Oral midazolam for children and patient-controlled propofol show very promising results. More research is needed before propofol can be recommended for use without anaesthetic staff. The recently published systematic review of sedation in children outlines gaps in the literature and contains recommendations for future work.

Dental anxiety--an epidemiological study on its clinical correlation and effects on oral health

Pronounced dental anxiety could lead to avoidance strategies to evade dental visits. The aim of the present epidemiological study was to investigate the prevalence and related oral disease patterns of dental anxiety in young adult male soldiers. Therefore, the intensity and frequency of dental anxiety are presented and the correlation with oral clinical findings are evaluated. Three hundred seventy-four soldiers who underwent a compulsory dental check-up were randomly assigned to this study. Psychological parameters were collected based on a protocol integrating the Dental Anxiety Scale (DAS) and the Gatchell Fear Scale (GaFS). Patient-based measures included D3,4MF-scores for dental status and the Community Periodontal Index of Treatment Need (CPITN) for periodontal status. Thirty-two individuals (8.6%) showed DAS-scores of 13 or 14 (anxious), while 4.6% had a DAS-score > or = 15 (highly anxious/phobic). Highest DAS-values were measured among patients' aged 19-29 (n = 262). DMFS-values of anxious and less anxious patients showed only minor differences. However, anxious patients had significantly more carious lesions (P < 0.001). CPITN periodontal values showed no significant differences between both groups. 89.2% of less anxious individuals and 79.6% of anxious patients went for regular dental check-ups. Thus, every tenth patient was considered to have high dental anxiety. Anxiety results in avoidance behaviour, which can only be discovered upon compulsory examinations and which is associated with higher caries morbidity and need for oral rehabilitation. As anxiety has a direct influence on oral health, it should be detected and accounted for in a treatment concept integrating dental and cognitive-behavioural therapeutic approaches.

Dental Anxiety Before Removal of a Third Molar and Association With General Trait Anxiety

PURPOSE

The aim of the present study was to evaluate dental anxiety in patients consulting for third molar removal, and to assess possible relationships with general trait anxiety.

MATERIALS AND METHODS

Dental anxiety was measured using Corah's Anxiety Scale (DAS), the Dental Fear Survey (DFS), and the state anxiety scale of the State-Trait Anxiety Inventory (STAI). Trait anxiety was measured with the trait anxiety scale of the STAI.

RESULTS

Trait anxiety showed significant positive correlations with both DAS score and DFS score. The 3 measures of dental anxiety all showed significant positive correlations with each other. The difference between men and women was only statistically significant in the case of trait anxiety.

CONCLUSION

These results suggest that trait anxiety may be a useful predictor of a patient's predisposition to dental anxiety.

Dental anxiety in a representative sample of residents of a large German city

In a demographic survey, 300 residents of a German city were questioned to determine the prevalence of dental anxiety. The correlation between the amount of dental anxiety and the age, sex, and education of the subjects was examined and the reasons for avoiding dentist's appointments, the duration of this avoidance, and what the subjects desire from future dental treatment. The Hierarchical Anxiety Questionnaire (HAQ) was used to measure the amount of dental anxiety. The average level of anxiety was 28.8+/-10.1 according to the HAQ. Young people were more afraid than older people (p=0.007), and women were more anxious than men (p=0.004). Of the women, 72% go to the dentist regularly, but only 60% of the men do (p=0.020). A painful experience while receiving dental treatment was given by 67% as the main reason for their dental anxiety, followed by a fear of needles (35%). The people wished for the most accurate information available about the dental treatment they receive (69%), followed by a compassionate dentist (62%), and treatment that is free of pain (62%). Of the people, 11% [95% CI: (7.5%; 14.5%)] suffer from dental phobia. All dental phobics were able to state the cause of their fear and more urgently wished for help from the dentist in overcoming their anxiety than the non-phobics (p=0.030). To satisfy the needs of the phobic patients, it appears necessary to screen the phobics out of the group of all patients and then offer them adequate therapy, or refer these patients to specialised treatment centres.

Validation of a Chinese version of the Dental Anxiety Inventory

OBJECTIVES

To translate the English version of Dental Anxiety Inventory (DAxI) and its short-form (SDAxI) and to validate their use in Hong Kong Chinese.

METHODS

The DAxI and SDAxI were translated into Chinese. A total of 500 adults (18-64 years) were interviewed, the Chinese DAxI, Symptom Checklist 90 (SCL-90), Depression Anxiety Stress Scales (DASS) and State-Trait Anxiety Inventory (STAI) were completed. Based on their initial DAxI scores, 135 interviewees were invited to attend a dental examination 1 month later. Then, the subjects completed the DAxI again, together with Beck Anxiety Inventory (BAI) which measured the state anxiety level of the participants. Two months after the initial interview, all 500 subjects were asked to complete the DAxI again. Another 300 adults were recruited and interviewed for the SDAxI validation.

RESULTS

Cronbach's alpha of the Chinese DAxI and SDAxI were 0.77 and 0.80 and the test-retest correlation coefficients were 0.90 and 0.84, respectively. High correlation between BAI and DAxI scores and its stability over time supported construct validity of the Chinese DAxI. Small positive correlations between the DAxI and other subscales of the SCL-90, DASS and STAI supported discriminant validity of the instrument. The SDAxI demonstrated comparable validity and reliability with DAxI.

CONCLUSION

The translated Chinese DAxI demonstrated good validity and reliability. It is available for use in dental anxiety research in adult Chinese. In situations where a short-form is desirable, the Chinese SDAxI is a simple, valid, reliable and interpretable scale for measuring dental anxiety in both research and dental practice.

[Pregnant women's perceptions of the Family Health Program concerning barriers to dental care in Pernambuco, Brazil]

This study focused on barriers to dental care for pregnant women registered with the Health Family Program in Cabo de Santo Agostinho, Pernambuco, Brazil. A qualitative approach using three focal groups was adopted. Each focal group included four to nine pregnant women. The information was analyzed by means of content analysis. The main individual barriers were folk beliefs that discouraged dental care during pregnancy, lack of perceived need, and fear of pain. In addition, the women reported difficulties in leaving home in the early hours of the morning to meet a dental appointment, highlighting an aspect of barriers to dental care which has not been identified in other studies. The article concludes by emphasizing the importance of health education for pregnant women, humanization of dental care, and continuing education for health professionals.

The contribution of embarrassment to phobic dental anxiety: a qualitative research study

BACKGROUND

Embarrassment is emphasized, yet scantily described as a factor in extreme dental anxiety or phobia. Present study aimed to describe details of social aspects of anxiety in dental situations, especially focusing on embarrassment phenomena.

METHODS

Subjects (Ss) were consecutive specialist clinic patients, 16 men, 14 women, 20-65 yr, who avoided treatment mean 12.7 yr due to anxiety. Electronic patient records and transcribed initial assessment and exit interviews were analyzed using QSR"N4" software to aid in exploring contexts related to social aspects of dental anxiety and embarrassment phenomena. Qualitative findings were co-validated with tests of association between embarrassment intensity ratings, years of treatment avoidance, and mouth-hiding behavioral ratings.

RESULTS

Embarrassment was a complaint in all but three cases. Chief complaints in the sample: 30% had fear of pain; 47% cited powerlessness in relation to dental social situations, some specific to embarrassment and 23% named co-morbid psychosocial dysfunction due to effects of sexual abuse, general anxiety, gagging, fainting or panic attacks. Intense embarrassment was manifested in both clinical and non-clinical situations due to poor dental status or perceived neglect, often (n = 9) with fear of negative social evaluation as chief complaint. These nine cases were qualitatively different from other cases with chief complaints of social powerlessness associated with conditioned distrust of dentists and their negative behaviors. The majority of embarrassed Ss to some degree inhibited smiling/laughing by hiding with lips, hands or changed head position. Secrecy, taboo-thinking, and mouth-hiding were associated with intense embarrassment. Especially after many years of avoidance, embarrassment phenomena lead to feelings of self-punishment, poor self-image/esteem and in some cases personality changes in a vicious circle of anxiety and avoidance. Embarrassment intensity ratings were positively correlated with years of avoidance and degree of mouth-hiding behaviors.

CONCLUSIONS

Embarrassment is a complex dental anxiety manifestation with qualitative differences by complaint characteristics and perceived intensity. Some cases exhibited manifestations similar to psychiatric criteria for social anxiety disorder as chief complaint, while most manifested embarrassment as a side effect.

Beliefs about professional ethics, dentist-patient communication, control and trust among fearful dental patients: the factor structure of the revised Dental Beliefs Survey

The revised version of the Dental Beliefs Survey (DBS-R), intended to measure three dimensions of the patient dentist relationship as perceived by the patient, namely Ethics, Communication and Control, was tested in a confirmatory factor analysis. Five different models for the internal structure of the questionnaire were tested. The final model, a 5-factor solution, basically including the 3 assumed dimensions as well as the re-introduced dimension Trust covered in the first version of the DBS plus a global factor including all items, yielded an acceptable fit. This model also omits 4 items from DBS-R, i.e. items 3, 11, 18, and 28. The reduced DBS-R is recommended for clinical use when assessing the patient's perception of the relationship to the dentist, including both trust and ethical behavior.

Conscious sedation for dentistry: risk management and patient selection

There are many safe and effective medications available to the dental practitioner for producing conscious sedation. Given the many sedatives available, all possessing slightly different clinical characteristics and various degrees of risk, careful consideration needs to be given to the objectives of the sedation when deciding which pharmacologic agents to use. Before making plans to sedate dental patients, however, one needs to make sure that several "layers" of risk management are in place to ensure the sedation procedure is as safe as possible. Included in this risk management plan is a complete understanding of the regulations that define conscious sedation and the training that is required to deliver this state of depressed consciousness. Careful attention also needs to be given to selecting appropriate dental patients for sedation. A thorough understanding of the patient's physical and psychologic status is necessary when making decisions about sedation. Because most dental disease is not life threatening, dental treatment needs tend to be primarily elective in nature. Considering the training requirements for delivering inhalational or enteral conscious sedation with a single agent, it is prudent to limit this type of sedation to the patient population that is healthy (e.g., ASA I and II) and psychologically stable as a way of minimizing risk. The amount of additional risk one encounters when sedating more medically compromised patients (ASA III and greater) should suggest that deferring elective dental treatments until the health status improves is prudent. In situations in which an improvement in the patient's health status is not likely, referral to someone with more experience sedating medically compromised patients is strongly recommended. Equally important to the conscious sedation risk management plan is an assurance that the patient understands what is meant by conscious sedation and that their treatment expectations are realistic. Finally, even though conscious sedation is safe when all precautions are followed, being prepared to manage unexpected sedation-related emergencies is necessary. The principles of risk management covered in this article are applicable to other articles in this issue, in which N2O/O2 inhalational sedation and enteral sedation in adults and children are discussed. The remaining article in this section that reviews the prevention of medical emergencies and the pharmacologic agents necessary to treat emergency events that are likely to occur in dental settings further enhances the level of preparedness necessary when administering conscious sedation to adults and children.

The way forward for dental sedation and primary care?

OBJECTIVES

Firstly to determine the current provision of sedation in primary dental care in an area of Scotland without local secondary care support and secondly, to investigate dental practitioners' desire for formal postgraduate training in sedation techniques.

DESIGN

A prospective postal questionnaire-based study.

SETTING

Grampian Primary Care NHS Trust, UK, 2001.

SUBJECTS

Questionnaires were sent to all NHS dental practitioners and community dental service clinicians (N = 194] employed through Grampian Primary Care NHS Trust, Scotland during March - April 2001. The questionnaires sought details about personal status and the use and perceived need for conscious sedation techniques in practice in addition to the stated desire for postgraduate training in sedation techniques.

RESULTS

One hundred and thirty-six questionnaires were returned (70%). Forty-nine per cent of respondents reported current sedation use, with intravenous sedation the favoured technique (82%), followed by oral sedation (33%) and inhalation sedation (19%). Seventy-four per cent of participants considered that there was a need for sedation in their own practice and 68% were interested in further postgraduate training in sedation techniques.

CONCLUSION

Nearly three-quarters of practitioners who responded felt that there was a need for sedation in their own practice, although less than half were able to offer sedation to their patients. Nearly 70% of practitioners felt there was a need for postgraduate training in sedation techniques.

A computer-controlled anesthetic delivery system in a periodontal practice: patient satisfaction and acceptance

BACKGROUND

Many dental patients are fearful about receiving intraoral injections of local anesthetic. In fact, many patients cite injections as their primary reason for avoiding dental treatment. In late 1997, however, a computerized local anesthetic delivery system was introduced to address the problems of pain and anxiety associated with these injections. The author initiated a year-long assessment study in which patients evaluated and rated injections administered with the computerized device as compared with previously administered standard injections.

METHODS

One hundred and fifty randomly selected patients received local anesthesia delivered via the computer-controlled anesthetic delivery system. All patients had at some time received standard injections during treatment at the practice. Different types of injections were administered to all quadrants, enabling the researcher to qualify results according to injection type and location. Patient responses were recorded and evaluated to assess the levels of anxiety and pain associated with the computer-driven system.

RESULTS

Overall, 71.4% of patients reported the experience to be superlative, positive, or somewhat positive. Results indicated that the system was highly preferred to traditional injection techniques, regardless of the arch and quadrant receiving the injection. Several factors may have contributed to this preference, including increased patient comfort, the nonthreatening appearance of the instrument, and the lack of residual facial numbness commonly associated with oral anesthetic injections.

CLINICAL SIGNIFICANCE

By removing the discomfort associated with the dental injection, which is a common source of patient anxiety, use of the computer-controlled anesthetic delivery system may encourage patient acceptance of recommended periodontal treatment modalities.

Clinical evaluation and comparison of 2 topical anesthetics for pain caused by needle sticks and scaling and root planing

BACKGROUND

Pain generated by needle sticks (Ns) for the delivery of local anesthetic and/or scaling and root planing (SRP) instrumentation is commonly addressed by the use of topical anesthetics, such as a benzocaine-gel preparation (BGP). Pain suppression following such use has been highly variable. Development of medicine-containing patches and adhesives for intraoral use have led to a new approach for topical anesthesia in the form of a transoral lidocaine delivery system (LDS). The purpose of this double-blind study was to evaluate the efficacy of the LDS and also to compare LDS with BGP for pain suppression to Ns and SRP.

METHODS

One group of 20 subjects randomly received in both maxillary and mandibular molar-bicuspid areas LDS or BGP on one side and non-anesthetic control on the other side. A second group of 20 subjects compared the effectiveness of LDS directly with BGP in molar-bicuspid areas of both arches. Random order determined the selection for each anesthetic tested between the arches and bilateral. Pain perception was separately scored to a pain-inducing Ns simulation without anesthetic injection at each area and subsequently also to SRP using both a verbal pain scale (VPS) and a visual analog scale (VAS).

RESULTS

VPS and VAS results analyzed by Bonferroni-adjusted Wilcoxon matched-pairs signed-rank tests found pain suppression scores significantly (P < 0.005) reduced for Ns by LDS to controls and to BGP. Comparing LDS directly with BGP, LDS was significantly (P < 0.05) more effective in reducing pain to Ns in both arches, to SRP in the maxillary arch, and equally effective as BGP in the mandibular arch.

CONCLUSIONS

LDS is more effective than BGP for topical pain suppression to Ns and SRP in both arches.

A clinical evaluation of an Erbium:YAG laser for dental cavity preparation

OBJECTIVE

A randomised controlled trial to determine the acceptability to dentists and patients of cavity preparation with an Erbium:YAG laser as compared with conventional handpieces.

METHODS

Fifteen dentists (9 GDPs, 1 community dentist and 5 hospital dentists) treated 77 patients (age range 3.5-68 years old) who had two matched cavities, in a split mouth, randomised trial. One cavity was prepared conventionally, the other with the laser, with dentist and patient preference determined by questionnaire.

RESULTS

In the majority of cases, where dentists expressed a preference, it was for conventional cavity preparation, and this was significant (P < 0.001). In more than half of the laser appointments, dentists had to use conventional handpieces to complete the cavity. Principle difficulties reported with the laser were access (25 cases) and slow speed of cutting (11 cases). Patients aged > or = 10 years who expressed a preference, preferred laser treatment, and this was significant (P < 0.001). Patients aged < 10 years, assessed using a simplified pictorial questionnaire, did not show a significant preference for either technique.

CONCLUSIONS

Dentists preferred conventional handpieces for cavity preparation while patients aged > or = 10 years old preferred laser treatment. Patients < 10 years old did not express a preference.

Diagnostic categories of dental anxiety: a population-based study

This study aimed to use a population-based sample to assess the psychological validity of the Seattle system for diagnosing dentally anxious individuals. This system consists of four diagnostic types in which such individuals are categorized according to the main source of their fear regarding dental treatment. Subjects were 1420 randomly selected adults aged 18 years and over who took part in a two-stage mail survey. The questionnaires contained measures of dental anxiety and standardized measures of general anxiety and fearfulness. Allocation to the Seattle categories was based on responses to four diagnostic items. Overall, 16.4% of the sample were dentally anxious. Their distribution across the four Seattle types was as follows: type I (simple conditioned phobia)--49.6%; type II (fear of catastrophe)--7.8%; type III (generalized anxiety)--19.4% and type IV (distrust of dentists)--9.9%. The remaining 13.3% could not be categorized. Judging by their scores on measures of dental anxiety, these subjects were borderline cases. Scores on the measures of anxiety and fearfulness indicated that the diagnostic system was valid and identified sub-groups of the dentally anxious population which were internally consistent. However, all subjects indicated extreme fear of dental treatment and were broadly similar in terms of their cognitive and behavioral responses to dental care. Of particular interest was the distribution of diagnoses according to age. Younger subjects were more likely to be categorized as type I, while older subjects were more likely to be categorized as type III. Overall, the results indicate that dental anxiety is a complex fear with a number of components.

Liaison psychiatry and psychology in dentistry

Dentists are trained to provide treatment for patients with straightforward problems that respond to routine therapy and do not recur. However, patients may present to dentists and complain solely of physical symptoms such as toothache, headache, and facial pain: only after much inappropriate treatment these symptoms are revealed to be due to emotional disturbance. The dentist may spend hours investigating such patients, in some of whom dental pathology may be present, but the symptoms and ensuing disability cannot be satisfactorily explained as a result. There are other patients who are preoccupied by physical symptoms or by their appearance. In others, anxiety may manifest itself as a phobia, or a dysmorphic concern about certain aspects of their appearance. This article reviews the role of liaison psychiatry and psychology in dentistry.

Assessment of patients with phobic dental anxiety

This study investigated a screening procedure for psychologic distress in adult patients with dental phobia before treatment of dental fear. The screening procedure was performed among 191 individuals in consecutive steps and included a medical/dental history, psychologic interviewing, and testing. Data collected during this process were analyzed and compared with SCL-90(R) data. The screening process was successful in selecting individuals without major psychologic distress problems. Among the excluded patients 91% had general symptoms scores on the SCL-90(R) exceeding a normative population mean, and 95% of included patients had a mean lower than an average for psychiatric outpatients. There were statistically significant differences between included and excluded patients on all subdimensions of the SCL-90. Thus, excluded patients had higher levels of psychologic distress, poorer psychosocial background, and more psychosomatic symptoms. This was accompanied by higher levels of negative attitudes toward dentists and their performance of dentistry, whereas no significant differences were found among the dental fear measures used.

Four dimensions of fear of dental injections

In 1995, students and staff at the University of Washington were surveyed regarding avoidance of dental care and fear of dental injections. More than 25 percent of adults surveyed expressed at least one clinically significant fear of injections. Almost one in 20 respondents indicated avoiding, cancelling or not appearing for dental appointments because of fear of dental injections. Fear of dental injections consists of four dimensions. General fear of dental injections including pain of injection and of bodily injury from injection are the two most common dimensions of dental injection fear. Many people also express fears of acquired disease. Fear related to local anesthetic (such as side effects, inadequate anesthesia) is less frequent. Some respondents have fears that must be categorized using more than one of these dimensions. Understanding the nature of a patient's fear of injection may suggest strategies to address his or her concerns.

Assessing dental anxiety, dental care use and oral status in older adults

This study examined associations between dental anxiety and dental care use and oral health status in dentate older adults. Analysis of data from the Piedmont 65+ Dental Study revealed that aspects of dental care use and oral health status were independently associated with high dental anxiety. These results suggest that measures to control dental anxiety may help to improve dental care use and oral health status in older adults.

Periodontal implications: anxiety

1. Monitoring significantly improves patient outcomes. 2. Observing and communicating with the patient is the most important means of monitoring the patient's status during sedation. 3. Monitoring of ventilations along with the assessment of oxygen saturation via a pulse oximeter is significant in preventing hypoxemia. 4. The use of supplemental oxygen is recommended. 5. Monitoring of blood pressure and pulse is highly recommended for assessing hemodynamic status. 6. Use of electrocardiograms is recommended for the patients with cardiovascular disorders.

Analgesic efficacy and safety of an intraoral lidocaine patch

The effectiveness of intraoral II-docaine patches was tested by asking participants to rate the pain experienced after insertions of a 25-gauge needle. Needlesticks were performed at baseline and at various time points after patch placement. Each needlestick included contact with the periosteum. Lidocaine patches achieved significantly better analgesia than the placebo within 2.5 to five minutes after placement. Drug-related side effects were minimal and venous blood levels of lidocaine were low, averaging 10 to 14 times less than those achieved with a typical injection of lidocaine plus epinephrine. The authors conclude that the lidocaine patches used in this study are effective and safe in reducing needle insertion pain in adults.

Assessing abuse and neglect and dental fear in women

Little is known about how specific life stressors, such as sexual, physical and emotional abuse and neglect, might be factors in the establishment or maintenance of dental fears or might affect routine dental treatment. The authors collected data from 462 female members of a large urban health maintenance organization about their dental fear and histories of childhood and adult traumas. According to these data, a history of trauma appears to be significantly associated with elevated dental fear, although multiple factors play a major role in the establishment and maintenance of these phobias.