Treatment of dental phobias

Influence of root canal instrumentation and obturation techniques on intra-operative pain during endodontic therapy

OBJECTIVE

To analyse the influence of root canal instrumentation and obturation techniques on intra-operative pain experienced by patients during endodontic therapy.

METHOD AND MATERIALS

A descriptive cross-sectional study was carried out in Ponferrada and Sevilla, Spain, including 80 patients (46 men and 34 women), with ages ranged from 10 to 74 years, randomly recruited. Patient gender and age, affected tooth, pulpal diagnosis, periapical status, previous NSAID or antibiotic (AB) treatment, and root canal instrumentation and obturation techniques were recorded. After root canal treatment (RCT), patients completed a 10-cm visual analogue scale (VAS) that ranked the level of pain. Results were analysed statistically using the Chi-square and ANOVA tests and logistic regression analysis.

RESULTS

The mean pain level during root canal treatment was 2.9±3.0 (median=2) in a VAS between 0 and 10. Forty percent of patients experienced no pain. Gender, age, arch, previous NSAIDs or AB treatment and anaesthetic type did not influence significantly the pain level (p>0.05). Pain during root canal treatment was significantly greater in molar teeth (OR=10.1; 95% C.I.=1.6-63.5; p=0.013). Root canal instrumentation and obturation techniques did not affect significantly patients' pain during root canal treatment (p>0.05).

CONCLUSION

Patients feel more pain when RCT is carried out on molar teeth. The root canal instrumentation and obturation techniques do not affect significantly the patients' pain during RCT.

Treatment of Dental Fear: Systematic Desensitization or Coping?

Thirty-two extremely anxious dental patients were given a modified form of systematic desensitization. In order to evaluate the importance of cognitive factors, a procedure of cognitive coping was added to the therapy program for half of the patients. Results show that treatment outcome was significantly better for the group without the addition of coping elements. It is suggested that the adverse effect observed may reflect an interference by the cognitively-oriented therapeutic activities with an otherwise effective therapeutic process.

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 comparison of pain levels during pulpectomy, extractions, and restorative procedures

Most previous studies on pain in endodontics have focused on pain that occurs after root canal therapy. Very few studies have compared pain during the root canal procedure with pain occurring during other dental procedures. In the present study, 250 patients were queried following dental procedures regarding their pain levels prior to treatment and their pain levels during the treatment procedure. Of the total number of patients, 150 had a pulpectomy, 50 patients had a single extraction, and 50 patients had a single restoration. These patients reported significantly more pain during extractions than during root canal therapy. Ninety-two percent of patients undergoing root canal therapy reported that pain during the procedure was less than or much less than anticipated. Eighty-three percent of the patients undergoing root canal therapy experienced less pain during the treatment procedure than they experienced prior to the treatment.

CARL: a LabVIEW 3 computer program for conducting exposure therapy for the treatment of dental injection fear

This paper describes CARL (Computer Assisted Relaxation Learning), a computerized, exposure-based therapy program for the treatment of dental injection fear. The CARL program operates primarily in two different modes; in vitro, which presents a video-taped exposure hierarchy, and in vivo, which presents scripts for a dentist or hygienist to use while working with a subject. Two additional modes are used to train subjects to use the program and to administer behavioral assessment tests. The program contains five different modules, which function to register a subject, train subjects to use physical and cognitive relaxation techniques, deliver an exposure hierarchy, question subjects about the helpfulness of each of the therapy components, and test for memory effects of anxiolytic medication. Nine subjects have completed the CARL therapy program and 1-yr follow-up as participants in a placebo-controlled clinical trial examining the effects of alprazolam on exposure therapy for dental injection phobia. All nine subjects were able to receive two dental injections, and all reduced their general fear of dental injections. Initial results therefore indicate that the CARL program successfully reduces dental injection fear.

Magnetic resonance imaging of children without sedation: preparation with simulation

OBJECTIVE

It was hypothesized that a scanner simulator that replicates the magnetic resonance imaging (MRI) environment could be used to prepare pediatric subjects for successful completion of a diagnostic-quality MRI examination without pharmacological sedation.

METHOD

Sixteen healthy children, 6 to 17 years of age, were matched for age and sex with 16 psychotropic medication-naive children with obsessive-compulsive disorder. Distress was measured throughout simulation and scanning procedures using heart rate and a self-report distress scale. Ten healthy children, 6 to 17 years of age, also underwent the same actual MRI scanning procedure but did not undergo the simulation scanning procedure.

RESULTS

Significant decreases in heart rate and self-reported distress level were observed in all subjects during the simulator session that were maintained to the end of the actual scanner experience. All subjects successfully completed MRI examinations without chemical restraint. Subjects who were not trained in the simulator had higher heart rates and self-reported distress levels in the actual scanner than did simulation-trained subjects.

CONCLUSIONS

Simulation without pharmacological sedation successfully prepared pediatric subjects in this pilot study for high-quality MRI studies. Subject preparation may be an alternative procedure to sedation for routine MRI examination in healthy and anxious children 6 years of age and older.

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.

Some problems of dental treatment. Part 2. Treatment avoidance: some differences between regular and irregular patients

Analysis of questionnaire data obtained from 54 irregular patients and 56 regular patients attending the Dental Department of the Lower Hutt Hospital and private practices in Lower Hutt and Wellington, New Zealand indicates that irregular patients are more anxious about dental treatment, value natural teeth less and find dental treatment more unpleasant than do regular patients. These and other survey findings on dental service utilization and dental anxiety suggest that the dental profession has a good deal of control over the way the public utilizes dental services. Most international surveys have found that less than 60 per cent of the population visits the dentist regularly, so there appears to be the potential for a substantial increase in regular use of dental services by the public. But, it is also likely that the longer an individual is remiss in regular dental care and the more teeth are lost, the more difficult conversion to regular visits will be.

Effectiveness of a videotaped behavioral intervention for dental anxiety: the role of gender and the need for information

The authors evaluated the effectiveness of a videotaped behavioral treatment program in reducing dental anxiety. They compared patients who witnessed the intervention videotape with patients who saw a placebo program and with a no-treatment control group. The subjects were 66 patients who visited a dentistry clinic for prophylaxis and general dental treatment. Groups were balanced for gender and level of preference for information as measured by the Krantz Health Opinion Survey--Information subscale. Self-report, physiological, and observed behavioral measures were assessed at specified times. Results demonstrated significant Group X Gender interaction effects during the different assessment periods, with men responding best to the treatment videotape, whereas women responded best to the placebo videotape. The level of information preference was found to a be a significant contributing factor at certain assessment periods. Overall, these results suggest that preparatory videotaped interventions are particularly effective in decreasing dental anxiety when patient characteristics are matched with characteristics of the intervention.

Some problems of dental treatment. Part 1. Patient anxiety: some correlates and sex differences

An analysis of questionnaire data obtained from 110 adult patients attending the Dental Department of the Lower Hutt Hospital and four private dental practices in Lower Hutt and Wellington, New Zealand indicates that patient treatment anxiety is more severe in women than men and that it is correlated with patients' descriptions of dental treatment. Altogether, survey findings indicate that treatment anxiety has adverse effects and that, with few exceptions, it results directly or indirectly from unpleasant experiences during dental treatment. Two of the most common of such experiences are evidently pain arising from the stimulation of sensitive tissue and oral injections. The eradication of treatment anxiety is therefore heavily dependent on the unobtrusive induction of profound analgesia prior to painful procedures.

Clinical correlates of dental anxiety among older adults

Most studies of the relationship between dental anxiety and oral health status have used subjective rather than clinical indicators of oral health. In this paper we examine differences between older adults who are and are not dentally anxious using a broad range of clinical measures. The data show that dentally anxious individuals were more likely to be edentulous, and among the dentate, had more missing and fewer filled teeth. As a result, dentally anxious dentate subjects were more likely to need prosthodontic treatment. They were also more likely to need immediate treatment for the relief of pain and infection and periodontal care. There was evidence to suggest differences in patterns of dental treatment between those who were and were not dentally anxious and some evidence consistent with the hypothesis that aging influences the relationship between dental anxiety and oral health status.

Illness behaviour and anxiety in dental patients

The Authors evaluate the influence of illness behaviour (measured by IBQ) on patients' delay in seeking dental treatment for caries or periodontal pathology, and the relationship with anxiety (measured by STAI) and with social--demographic and clinical data. One hundred patients were studied. Delay in coming for a dental visit is influenced by family habit, level of education and fear experienced. The 'late' patients present significantly higher scores for denial on the IBQ. More serious pathology is in relation with greater denial. Anxiety is positively correlated with the IBQ scales dysphoria, hypochondria, disease conviction, irritability and inversely with denial.

Etiology and treatment of dental anxiety and phobia

Dental anxiety and phobia afflict millions of people. Dental patients who are anxious anticipate pain and feel vulnerable and out of control. Hypnotherapy to alleviate dental anxiety and phobias has received clinical and empirical support. Our purpose in this paper is to provide a body of objective data from American Society of Clinical Hypnosis members regarding incidence rates and the relative importance of various etiological and conceptual issues in the development and maintenance of dental anxiety and treatment interventions. From these data, we constructed a model of etiology, maintenance, and treatment of dental anxiety.

Pre-school children with uncooperative behavior in the dental situation. Some characteristics and background factors

One hundred and eighty-six generally healthy pre-school children referred to a pedodontic clinic because of uncooperativeness in the dental situation were surveyed with regard to some characteristics and background factors considered of importance as possible origins of the uncooperative behavior. Information was gained from interviews with the referring dentists and the parents, from a developmental test of the child, and from dental records. In spite of a high prevalence of caries, dental treatment before referral was characterized by few restorative measures. The results also showed that the children constituted a heterogeneous group with regard to the variables studied. Further, the referring dentists represented various resources in terms of self-reported knowledge and time for treating this category of children. The data provide a basis for comparisons with a reference group, to be presented in a subsequent study.

Compliance. A review of the literature with possible applications to periodontics

This paper begins with a review of the literature on compliance. The medical literature suggests that patients with chronic illnesses tend to comply poorly, especially if the disease is not perceived by the patient as particularly threatening. The dental literature covers two principal areas: compliance with oral hygiene regimens and utilization of dental care by the public. These works show that most patients surveyed do not clean their teeth as they have been instructed, and most do not receive routine dental care. The reasons for this noncompliance are highly variable but include lack of pertinent information, fear, economics, and the patient's perception of lack of compassion on the part of the dental therapist. In periodontics the majority of studies have focused on the effectiveness of patient oral hygiene along with its modification and on maintenance therapy. Other work in the periodontal literature is discussed in light of the widespread noncompliance shown by our patients. A number of studies have been undertaken on how best to improve compliance. In general, it has been found that patients comply better when they are informed and positively reinforced, and when barriers to treatment are reduced. Suggestions are made for improving compliance in the periodontal office and for tailoring therapy to predicted compliance levels.

Direct ratings of acceptance of dental treatment in Swedish children

The aim of the present study was to bring forward data of acceptance of dental treatment for 3-16-yr-old children in a population with good dental health and annual dental care, and to evaluate the influence on acceptance of age, sex, residential area, and previous experience and present need of dental treatment. The material consisted of 2773 children. Direct ratings of behavior were made at each of 10 different treatment steps passed during dental appointments. The majority of children needed no more than one dental visit and 79% showed positive acceptance at all steps of treatment passed during dental visits. Eight percent of all children sometimes reacted in such a way that treatment could not be carried out without restraint or undue delay. Dental fear was diagnosed in 3% of all children.

Research in clinical process and outcome methodology: psychophysiology, systematic desensitization and dental fear

Eleven dental phobics were treated with a modified systematic desensitization procedure which included EMG biofeedback and videotaped scene presentations. During treatment, multiple psychophysiological recordings as well as subjective and psychometric assessments of mood were made. Intraindividual correlations between process variables were, to a large extent, idiosyncratic. Variance in treatment outcome could be accounted for by change-over treatment sessions of psychometrically assessed mood (R2 = .76) alone or in combination with change-over treatment sessions of minimum heart rate (R2 = .84). The process variable correlation patterns indicate a need for much more multivariate methodological research.

Usefulness of two psychometric scales in Swedish patients with severe dental fear

Dental fears and other fears were assessed in 67 patients with dental fear with the Corah Dental Anxiety Scale (CDAS), the Geer Fear Scale (GFS), and a behavioral dentist's rating scale (DR). Patients were selected because of extreme initial dental fear (n = 20), favorable response to treatment for dental fear (n = 23). CDAS change paralleled behavioral change (DR), supporting the usefulness of CDAS in assessing dental fear. GFS scores did not change in either group but were higher among patients who did not respond to treatment for dental fear; these findings are discussed in terms of treatment outcome prediction and treatment specificity.

Dental anxiety and DMFS status: association within a US naval population versus differences between groups

Measurement of dental treatment anxiety and oral health, in a sample of naval recruits, confirmed the generally held expectation that a high anxiety group would have significantly greater numbers of diseased surfaces (DS) than a low anxiety group. However, it was also shown that dental anxiety was not a predictor of DS within the ungrouped sample. In evaluating the public health impact of dental treatment anxiety on oral health, attention must be paid to the context of data collection and analysis. Evidence bearing on group differences does not necessarily describe the situation within a population.

Demand effects for desensitization and two placebos in a dental fear context

Forty-five subjects sampled two sessions of a prototype desensitization treatment, two sessions of the Modified Avoidance Response Placebo or two sessions of Pseudotherapy. Each subject simulated the effects on dental fear of the experimental regimen to which he was exposed. Each subject also rated the credibility of the sampled regimen. Both the simulation data and the credibility ratings showed the Modified Avoidance Response Placebo to be the preferred control for "nonspecifics" in dental-fear desensitization experiments.

Communication patterns in pedodontics

This investigation examined communication patterns between 16 randomly selected senior dental students and their child patients. Interactions were videotaped during a regular treatment appointment and analyzed according to four Practitioner Communication categories and four Child Cooperation categories. Communication categories included Directive Guidance Behavior, Permissive Behavior, Coercive Behavior, and Other Behavior. Child behavior categories included Cooperation, Resistance, Noncooperation, and Other. The probability that a given category of child's behavior would follow a given category of practitioner's behavior was calculated. Results indicated a .85 probability that Directive Guidance would be followed by Cooperation; a .67 probability that Permissiveness would lead to Noncooperation; and a .97 likelihood that Coerciveness would lead to either Noncooperation or Resistance. Practitioners' confidence was also considered; less confident operators account for 95% of the Coercive behaviors, 86% of Permissive behaviors and 87% of Uncooperative behaviors.