Psychological Factors in Dental Patient Care: Odontophobia

Dentistry and oral health are at the heart of the systemic health of humans. Often this branch of medicine is underestimated either due to socioeconomic reasons or due to fear. In fact, in dentistry, there is often a widespread condition of odontophobia among patients. A clinician's knowledge of this condition, and an accompanying understanding of how to successfully manage it, is surely one of the first steps to gaining a patient's trust and maintaining his or her patronage. Being able to manage a dental phobic patient in the best way is the key to successful therapy. Psychological techniques often have to work alongside dentistry in managing these patients. A future perspective concerns precisely the implementation of non-invasive practices such as hypnosis in the management of the latter.

Barriers to special care patients with mental illness receiving oral healthcare. A cross sectional study in the Holy City of Makkah, Saudi Arabia

Objectives:

To assess barriers to patients with mental illness receiving oral healthcare in Makkah city, Saudi Arabia.

Methods:

This was a 3-month cross-sectional study from the Department of Psychiatry at Al-Noor, Specialist Hospital in Makkah city, Saudi Arabia, between January 2017 and April 2017. A structured questionnaire with closed-ended questions was considered. A total of 161 psychiatric patients were recruited, made up of 81 male (50.3%) and 80 female (49.7%) participants. Simple descriptive statistics were used to define the characteristics of the study variables, through a form of counts and percentages. The chi-square test was also used to evaluate the distribution of the nominal variables.

Results:

Of the 161 psychiatric patients, 51 were aged 26-35 years old (31.7%). Most participants (n=73) had psychological development disorders (45.3%). Ninety-one (56.5%) were unemployed, and among them, 25 (15.5%) reported problems with access to oral health and dental care. Participants also suffered from dry mouth (64%) and dental anxiety (23%).

Conclusions:

This study suggested that dental anxiety is considered the major barrier to dental care, followed by the cost of dental treatments and accessibility. Most belonged to the group of psychological development disorder and reported having the most barriers to oral healthcare.

[Treatment of a patient with psychogenic non-epileptic seizures]

A 36-year old man is referred to a centre for special dental care due to problems with treatability in the general dental practice and a deteriorated oral state. His behaviour is unpredictable due to the possible development of sudden changes in the patient's consciousness which are accompanied by severe aggression. The patient suffers from a conversion disorder, a serious mental disorder which expresses itself in his case with the occurrence of psychogenic non-epileptic seizures. The patient fears that dental treatment will provoke a seizure and that he will react aggressively to his surroundings. He therefore requests that he undergoes dental treatment using general anaesthesia and patient fixation measures. This case study provides an example for the discussion of the problems and the rights of patients with severe mental disorders and the use of measures of physical restraint in dentistry.

Oral health, sense of coherence and dental anxiety among middle-aged women

AIMS

The specific aims of this investigation were to analyze the relationship between sense of coherence (SOC), dental anxiety (DA) and oral health status among middle-aged women, measured both subjectively and objectively and adjusted for socioeconomic status (SES).

MATERIALS AND METHODS

Randomly selected women, 38 (n = 206) and 50 (n = 287) years of age, were included in a cross-sectional health examination. The participants underwent a series of examination stages, including a clinical and dental radiographic examination. The women responded to questionnaires concerning SES, oral health, DA and SOC.

RESULTS

The number of teeth was significantly related to SOC, where more missing teeth revealed a lower SOC level among 50-year-olds. The variables of caries, apical periodontitis and filled surfaces were not statistically significantly associated with SOC. However, the self-reported measure of oral health was associated with SOC in both age groups. High DA was significantly related to self-perceived poor oral health regardless of age. Individuals with high DA also had fewer teeth, more filled surfaces and more approximal caries. The multivariate models showed that higher SOC levels were associated with better oral health, as estimated by objective or subjective measures, while the inverse results were seen for DA. Thus, individuals reporting high DA were more likely to have fewer teeth and poor perceived oral health, taking SES into account.

CONCLUSIONS

Sense of coherence and dental anxiety are psychological aspects with respect to health- and risk-factors of oral health.

Children's dental fear in relation to dental health and parental dental fear

OBJECTIVE

The aim was to (1) assess the proportion of children with dental fear, to (2) compare results obtained by a single fear question to those obtained by using a set of 11 fear questions, to (3) study associations between children's dental fear and their dental health, and to (4) compare children's dental fears to those of their parents.

MATERIALS AND METHODS

A cross-sectional sample of 344 8-10-year-old schoolchildren from South Estonian primary schools participated. Children's fears were measured with the modified Dental Subscale of the Children's Fear Survey Schedule (CFSS-DS). The scale includes 11 fear items amongst which five represent less invasive (noninvasive items), another five invasive aspects of dental treatment (invasive items), and one question represents general dental fear of the child. In addition, two questions were included to assess parental dental fear. The dental health of children was examined using the International Caries Detection and Assessment System (ICDAS) criteria.

RESULTS

The proportion of children with general dental fear was 6.1%. The mean score of noninvasive fears was higher among the youngest than among the oldest age group (p<0.02). Children whose dmft/DMFT-scores were >0 had higher fear scores than those whose dmft/DMFT-scores were =0 (p<0.01). A total of 16.8% and 15.7% of mothers and fathers afraid of dentistry in general. There were strong correlations between children's dental fears and maternal (p<0.01), and paternal (p<0.01) dental fear.

CONCLUSIONS

Children's fears were strongly associated with untreated caries and experience of dental treatment, and with parental fears.

Association of dental anxiety to personality traits in a general population sample of Finnish University students

OBJECTIVE

To estimate the association between personality and dental anxiety among Finnish University students.

MATERIALS AND METHODS

A total of 880 university students in Finland returned the questionnaires addressing dental anxiety by using the Modified Dental Anxiety Scale (MDAS) questionnaire. In addition, the personality of traits (neuroticism, extraversion, agreeableness, conscientiousness and openness to experience) were noted. Personality traits of students were compared with the level (high, mild or none) of dental anxiety derived from the MDAS questionnaire. The relative odds of dental anxiety associated with the level of dental anxiety were estimated by logistic regression, Chi-Square tests and one-way analysis of variance (ANOVA).

RESULTS

Median age of the respondents was 22 years. Of the respondents, 99 (11.3%) were classified as dentally anxious patients (90, 12.2% of females; 9, 6.6% of males)). Neuroticism was the only personality trait that was significantly associated with dental fear (p < 0.001). A tendency, although not significant, was seen between high dental fear and lower extraversion and agreeableness.

CONCLUSIONS

Of the five different personality traits, neuroticism was a significant risk factor for developing dental anxiety, and this should be recognized in clinical practice.

[Treatment of dental phobia and quality of life]

Phobia for dental treatment often has a considerable influence on a person's perceived quality of life. In this research project, the relationship and interactions between dental anxiety, oral health and quality of life were studied. Scores on the basis of several parameters of these factors were analyzed prior to and following dental treatment. It appeared that quality of life was associated with both dental anxiety and oral health. When improvement in quality of life was investigated, it appeared that this was only statistically correlated with a reduction in dental anxiety. These findings suggest that treatment of dental phobia patients should focus not only on making patients treatable (pharmacologically), but also on reducing anxiety.

[Cardiac response as stress marker in surgery]

Surgical area--as a precursor of negative emotions, is the threshold between the two areas of anxiety and anxiety among the general and specific stimuli. By dominant color, noise, odors and environmental factors in complex anxiety these elements define the specific treatment of dental medicine better. The emotional stress on the patient child which undergoes a surgical dento-alveolar therapy is negative and consists of the combination of three important elements, in close relationship: score of dental anxiety, the anticipation and experience of pain and phobic stimuli which is implicitly true precursor of pain.

MATERIAL AND METHOD

Our study was performed on 448 patients. Different methods of preanesthesia were made per oral, intravenous, intramuscular, according with DAS score: Midazolam, Diazepam + Algocalmin, Xanax.

RESULTS

58% of our patients declare after surgery that their satisfaction score is 100% positive after one of our method of preanesthesia.

CONCLUSIONS

The purpose of premedication should be unconditionally determined by the effect of the analgesic and anxiolytic drugs to improve cardiac response and avoid medical emergency. Doses administered must be correlated with the anxiety score DAS, road use and the probable duration of surgery.

Psychosocial and dental factors in the maintenance of severe dental fear

The aim was to study the relationship between psychosocial factors and dental status in adult subjects with severe dental fear (DF). A consecutive sample of 148 adults (mean age 36.1 yrs, range 21-69 yrs) referred for dental fear treatment was investigated using an intake questionnaire on dental attendance and history, psychometric questionnaires on dental fear, general anxiety and depression and a radiographic examination. The subjects had a mean DFMT (Decayed, Filled, Missed Teeth) score of 18.6 (SD = 5.6). A deterioration in dental status defined as the presence of root remnants was present in 57% of the subjects and was related to the negative consequences of dental fear, general anxiety and depression. Most subjects (84%) reported clinical levels of general anxiety and 46% reported clinical levels of depression. In conclusion, subjects with severe DF often suffer from psychosocial consequences and distress.This is even more marked if their dental status has deteriorated.The findings support a biopsychosocial vicious circle understanding of the maintenance of DF.

The patient with asthma: implications for dental practice

A history of asthma is reported commonly by adult dental patients and may be more prevalent in children. An acute episode of asthma in the dental office may be precipitated by extrinsic factors such as inhaled allergens, as well as intrinsic factors such as fear or anxiety. An asthma episode should be considered a medical emergency and must be treated promptly by inhalation of a bronchodilating agent. A history of asthma in the dental patient should alert the dentist to implement strategies that may prevent an acute attack and to be prepared to manage this potentially life-threatening medical emergency appropriately. The chronic use of bronchodilating inhalers and/or glucocorticoids for the management of asthma can increase the likelihood of oral candidiasis, particularly in patients who have additional risk factors such as smoking, denture use, or the use of xerostomic medications.

Vasovagal syncope in children and adolescents

Vasovagal syncope is not an uncommon event in children and adolescents; however, this fact is not widely known among the dental community. Although there is little information about the incidence of vasovagal syncope occurring among children and adolescents in the dental setting, dentists should always take care to eliminate factors that can predispose a patient to a vasovagal reaction. The dental team should be familiar with the emergency protocols for a vasovagal syncope episode. For this study, the author conducted a MEDLINE search using the key terms "vasovagal syncope", "syncope in children", "syncope treatments", and "syncope and dentistry" to define the pathophysiology, incidence, treatment options, and dental implications of vasovagal syncope. The articles included those published in English and in peer-reviewed journals, in addition to the most recent medical and dental textbooks as they related to syncope.

Endodontic treatment in young permanent teeth. Prevalence, quality and potential risk factors

National epidemiologic data on oral health in children and adolescents in Sweden are restricted to caries, such as the number of decayed and filled teeth (DFT) and decayed and filled surfaces (DFS). Information about more complicated and time-consuming procedures such as endodontic treatment is scarce. The aims were to study the prevalence, quality and potential risk factors for endodontic treatment in young permanent teeth. The material consisted of dental records and radiographs. The subjects were all 19-year-olds born in 1979 (paper I-III) and all 15-year-olds born in 1990 (paper IV) belonging to the public dental clinics in Malmo. Paper III also included a control group.

Intrusion of overerupted upper first molar using two orthodontic miniscrews. A case report

Loss of the mandibular first molar often leads to the overeruption of the opposing maxillary first molar, resulting in occlusal interference, loss of periodontal bony support, and inadequate room to restore the mandibular edentulous space. Without orthodontic molar intrusion or segmental surgical impaction, restoring the posterior occlusion often entails the need for significant reduction of maxillary molar crown height, with the potential need for costly iatrogenic root canal therapy and restoration. The literature has cited successful maxillary molar intrusion with minor prosthodontic reduction using palatal orthodontic miniscrews and buccal zygomatic miniplates. In this report, the authors present successful maxillary molar intrusion with two orthodontic miniscrews in a patient with extreme dental anxiety and significant dental erosion due to gastric reflux. Using two orthodontic miniscrews for skeletal anchorage to intrude the maxillary molar simplified the orthodontic treatment by eliminating the need for extensive surgery, headgear, and intraoral multiunit anchorage and preserved indispensable tooth enamel. The clinical results showed significant intrusion through the maxillary sinus cortical floor while maintaining periodontal health, tooth vitality, and root length.

Background factors associated with endodontic treatment due to caries in young permanent teeth

OBJECTIVE

The aim of this retrospective cohort study was to assess the association between background factors and future endodontic treatment due to caries in young permanent teeth.

MATERIAL AND METHODS

The material comprised all 19-year-olds born in 1979 in a city in Sweden who had experienced endodontic treatment due to caries in permanent teeth (n=105) and a control group with no endodontic treatment. From dental records, the following independent variables were derived from age 7 to age 19: immigrant background, caries prevalence (DMFT values) at age 10, occurrence of dental anxiety, and missed or cancelled appointments before endodontic treatment. The outcome variable was presence or absence of endodontic treatment due to caries. Bivariate analysis and a multiple logistic regression model were used to analyse the data.

RESULTS

In the bivariate analyses, all independent variables except cancelled appointments were statistically significantly associated with future endodontic treatment. Of these, immigrant background did not remain as a statistically significant factor in the multiple regression model. The highest odds ratios were 4.3 for >2 DMFT at age 10 and 4.1 for >20% missed appointments.

CONCLUSION

In the present sample, with a relatively high proportion of individuals with an immigrant background, >2 DMFT at age 10, many missed appointments and dental anxiety were all risk indicators for future endodontic treatment due to caries up to age 19.

Salivary cortisol levels and dental anxiety in children with attention deficit hyperactivity disorder

Attention deficit hyperactivity disorder (ADHD) is a common developmental disorder. The present study tested the hypotheses that children with ADHD, particularly those exhibiting severe hyperactivity and impulsivity, have a different stress reaction (measured by salivary cortisol) during a dental recall visit and are more dentally anxious than children in a control group. Eighteen children with ADHD and a control group of 71 children, all 13 yr of age, underwent a clinical dental examination and completed the Corah Dental Anxiety Scale (CDAS). Four saliva samples were gathered for analysis of cortisol: one prior to dental examination, one after, and two the following morning. The subgroup ADHD with hyperactivity/impulsivity had statistically significantly lower cortisol levels than the control group 30 min after awakening. When cortisol values were plotted on a timeline, this subgroup always had lower cortisol concentrations than children in the control group. There was a significant correlation between CDAS scores and cortisol concentrations prior to the dental examination in both the ADHD and the control group. Behavioral expressions of anxiety in children with ADHD may be different from those in other children, not only due to the characteristics of their disorder, but also because of lower stress reactivity.

Risk factors and risk indicators associated with high caries experience in Swedish 19-year-olds

OBJECTIVE

To study the risk factors and risk indicators associated with high caries experience (DMFS >or= 10) in 19-year-olds.

MATERIAL AND METHODS

The subjects (n=800) lived in seven suburbs of Stockholm and answered a structured questionnaire about their parents' education, occupation, and country of birth, as well as their dietary habits, oral hygiene habits, and attitudes to dental care. Dental caries was assessed by clinical and radiographic examination using the decayed, missing, filled teeth (DMFT), and surfaces (DMFS) indices. Dental plaque (VPI%) and gingival bleeding (GBI%) indices were recorded.

RESULTS

A total of 696 subjects (364 M, 332 F) participated in the study. The mean DMFT and DMFS were 3.9 and 5.1, respectively. In 81% of subjects, the DMFT was >or= 1 and 15% had DMFS >or= 10. In the multivariate analysis, the variables significantly associated with high caries experience were: dental fear (p<0.001, odds ratio (OR) 2.8), GBI >or= 15% (p=0.003, OR 2.1), mother born abroad (p=0.007, OR 2.0) and irregular toothbrushing at night (p=0.008, OR 1.9). When all significant variables in the multivariate analysis were present, the cumulative probability of DMFS >or= 10 was 52%.

CONCLUSIONS

Dental fear, gingival inflammation, a foreign-born mother, and irregular toothbrushing at night are variables that are strongly associated with high caries experience in 19-year olds. The study indicates that foreign-born parents, oral hygiene habits, and behavioral factors still have a strong impact on dental health in late adolescence.

Dental anxiety and behavioural problems: what is their influence on the treatment plan?

AIM

This was to investigate the influence of emotional and behavioural problems on the choice of treatment type. In addition, the actual contents of the treatment of dentally fearful children was studied in an attempt to develop dental treatment protocols for children with such problems.

METHODS

The parents of 265 children (144 girls, mean age 88.4 months, SD+/-34.2 months), referred to a centre for special dental care, were asked to complete the Child Behaviour Check List (CBCL) before their first appointment. The CBCL was used to assess behavioural problems. All selected children were dentally anxious (score >or=35 on the Children's Fear Survey Schedule Dental Subscale, CFSS-DS). After treatment, the children's records were analysed on treatment type and contents.

RESULTS

The CBCL score was related to the type of treatment. Children treated with the aid of nitrous oxide sedation scored significantly higher on the CBCL than children treated with behavioural management or under intravenous anaesthesia (IVA). In the IVA group more surfaces were treated than in the other groups. The CBCL score was not related to the treatment contents (number of surfaces filled, amount of radiographs, sealants, stainless steel crowns or pulpotomies), the time spent on the child's treatment or the number of sessions.

CONCLUSION

Dentally anxious children with behavioural problems as assessed by the CBCL have dental treatment (contents and length) comparable with that of dentally anxious children without those problems. However, anxious children with behavioural problems are more often treated with nitrous oxide sedation. Therefore, there seems to be an urgent need for access to nitrous oxide sedation for dentists working in special dentistry.

Dental anxiety in a subpopulation of African children: parents ability to predict and its relation to general anxiety and behaviour in the dental chair

AIM

This was to investigate the ability of Nigerian parents to predict their child's dental anxiety level and the relationship between the child's dental anxiety, general anxiety and behaviour in the dental chair.

METHODS

A group of 53 mothers and 35 fathers and their respective children completed schedules that measured general and dental anxiety. The child's behaviour on the dental chair was also assessed. The child's self report of dental anxiety and general anxiety was compared with that of the parents. Dental anxiety ratings by the children and parents were correlated with the behaviour assessment of the dentist. Statistical significance was determined at <0.05.

RESULTS

There was no statistically significant difference between the parent's assessment of their child's dental anxiety level and the child's self report (t=0.389; p=0.689). However, the mothers were able to rate their child's dental anxiety level better than the fathers (r=0.497 and p<0.001 for mothers, r=-0.049 and p=0.789 for fathers). Also there was a moderate correlation between the child's self reported dental anxiety and general anxiety levels (r=0.58, p<0.05) and a low correlation between the clinical behaviour ratings and the child's self reported dental anxiety level (r=0.10, p>0.05).

CONCLUSION

The Nigerian mothers could be relied upon to make objective assessment of their child's dental anxiety. General anxiety appears to play a significant role in dental anxiety development in Nigerian children who appear to behave well in the dental chair despite their reported dental anxiety levels.

Dental anxiety, dental health attitudes, and bodily symptoms as correlates of asthma symptoms in adult dental patients with asthma

PURPOSE

The purpose of this study was to examine the relationship between asthma symptoms and dental anxiety, dental health attitudes, and physical symptoms and sensations such as watery eyes, upset stomach, headaches, and nausea in a group of adult dental patients with asthma. These variables are believed to be highly related to stress levels, which can exacerbate asthma symptoms during dental treatment.

METHODS

Four self-report questionnaires and a demographic information form were completed by 60 adults with asthma in a waiting room of a private dental practice prior to receiving treatment. These instruments assessed dental anxiety, dental health attitudes, bodily symptoms, and asthma symptoms. Bivariate correlations were computed and tested for significance. They were followed by multiple regression analysis to analyze the relationship between the predictor variables-dental anxiety, dental health attitudes, and bodily symptoms, to the dependent variable-asthma symptoms.

RESULTS

Pearson product correlations between the study variables revealed a statistically significant relationship between dental anxiety and bodily symptoms (r = 0.23, p < 0.05), and asthma symptoms and bodily symptoms (r = 54, p < 0.01). The analysis of variance indicated that the overall regression model (R2 = 30) was statistically significant (F(3,56) = 7.92, p < 0.01). Bodily symptoms was the only significant variable in the model.

CONCLUSION

Dentists and dental hygienist should be attuned to adult patients who have asthma and exhibit signs of anxiety and/or other physical symptoms, or indicators of stress that can exacerbate asthma during or prior to dental treatment.

Clinical study of anesthetic management during dental treatment of 25 patients with cardiomyopathy

This retrospective study analyzed the management of 25 patients with hypertrophic cardiomyopathy (HCM), dilated cardiomyopathy (DCM), or dilated phase of hypertrophic cardiomyopathy (dHCM) treated in the outpatient clinic of the Department of Dental Anesthesiology at Hokkaido University. A total of 87 dental treatment sessions were completed. Intravenous sedation was used significantly more often for patients with HCM than those who had DCM. This seemed to be because dental anesthesiologists expected sedative drugs to suppress hyperdynamic circulatory changes caused by mental stress. Intraoperative complications occurred during 19 treatments. The incidence of circulatory complications increased when participants with DCM also reported dental fear. For participants with HCM who reported dental fear, circulatory complications occurred only when sedation was not used. It is not clear whether complications were related to cardiac function or dental treatment. Therefore, it is important to continually monitor patients with these conditions and to be prepared to handle complications that may arise during dental treatment.

'Do-it-yourself' dental treatment: a case report

The use of topical desensitizing agents and the placement of superficial restorations at cervical margins are part of a conventional treatment plan for hypersensitive teeth. This case report describes a dental-phobic patient who employed a rather peculiar 'do-it-yourself' approach to alleviate the problems of hypersensitivity, by covering her teeth with a mixture of candle wax and 'household' glue.

Treatment of patients who have type 1 diabetes mellitus: physiological misconceptions and infusion pump therapy

BACKGROUND

This article reviews the unique physiology of patients who have type 1 diabetes mellitus (insulin-dependent diabetes mellitus, or IDDM); allays some common physiological misconceptions; and updates dental practitioners on the emerging technology of insulin infusion pump therapy, now available to patients who have type 1 diabetes mellitus.

DESCRIPTION

The authors review the physiology of stress and describe the dawn phenomenon. They also describe insulin infusion pump therapy, as well as its advantages and disadvantages, to familiarize dentists with new technologies in caring for patients who have diabetes. Emergencies that may present themselves as a result of these advances in biotechnology are discussed.

CLINICAL IMPLICATIONS

Dental practitioners who treat patients who have IDDM need to have a solid foundation in the basic medical sciences and emerging biomedical technology as they each relate to diabetes. Practitioners must become familiar with infusion pump therapy, not only for cases of medical emergencies, but also to customize treatment for patients who have diabetes. Practitioners also need to remain up to date in the rapidly changing realm of caring for people who have diabetes.

Immediate placement and implant loading for expedited patient care: a patient report

This patient report concerns etiologic factors leading to a failed natural dentition, masticatory function, and poor dental esthetics in a 30-year-old woman. The surgical and restorative treatment provided for the patient was designed to address her dental phobia, location of residence, and debilitated oral condition. While the following case report details an example of the clinical success that can be achieved through advances in dental implant treatment, the most satisfying event was not necessarily the procedure itself, but the profound change that the generosity of the osseointegration community has made on the life of a needy individual. Through the active leadership of the Osseointegration Foundation Charitable Grant Program, the patient, whose complex treatment is described here, was able to take advantage of treatment that otherwise would not have been available to her. This complex treatment was enabled by the Osseointegration Foundation and other caring donors.

Treatment of dental anxiety disorders. Outcome related to DSM-IV diagnoses

In this study we evaluated treatment effects in 70 consecutively admitted patients in a specialized university clinic for treatment of dental fear. Thirty-three (47%) of the patients fulfilled the diagnostic criteria for Specific Phobia alone (Dental Phobia, DP), 24 (33%) had severe dental anxiety without fulfilling the criteria for phobia (ND), and 13 (19%) fulfilled the criteria for multiple DSM-IV diagnoses (MD). Dental anxiety was measured prior to, immediately after and at follow-up (mean = 19 months) using Corah's Dental Anxiety Scale and Dental Fear Survey. Dental attitudes were measured by Getz' Dental Beliefs Survey. Dental attendance and everyday functioning were measured by self-report. DP patients received significantly more treatment-sessions as compared to the ND group. Despite significant overall reductions in scores on all psychometric instruments from pretreatment to follow up, patients in the MD group reported significantly more severe anxiety at pre- and post-treatment and at follow-up as compared to patients in the ND group. There was no interaction between diagnostic group and assessment occasion (pre treatment, post treatment and follow up) on the self-reported anxiety. Patients reported significant improvements in self-esteem, social relations and everyday functioning, regardless of diagnostic group. Sixty-three percentage of the respondents had been to the dentist within 1 year after completed treatment. Patients treated by dentists who had received supervised training in exposure treatment had significantly more often seen the dentist at follow-up.

Case study of an anxious child with extensive caries treated in general dental practice: financial viability under the terms of the UK National Health Service

This case study describes the management of Callum, an anxious 7-year-old boy with extensive caries. Callum's dental care was carried out in a general dental practice in the North of England under the terms of the National Health Service. A preventive programme was carried out in conjunction with the restorative philosophy according to guidelines published by the Dental Practice Board in 1997.

[Effect of the parents' dental fear on the child's oral health]

There are various factors which influence the oral status, among them the dental fear. Dental anxious individuals are likely to have more missing teeth and fewer filled ones. This study examined the association between dental anxiety and oral health status in parents and indirectly in children. The authors found that there is positive correlation between dental fear and missing teeth in the older generation. These tendency can also be seen in younger ones.

Structural relationships of dental anxiety, mood, and general anxiety

The aim of this study was to explore the structural relationships between dental anxiety, mood, and general anxiety among 220 dentally anxious patients who participated in a clinical study. A structural equation modeling analysis (SEM) was applied by using the LISREL program on the hypothesized latent variables dental anxiety, mood, and general anxiety, which were measured by means of several psychometric tests. The final model showed that mood and general anxiety had positive factor loadings on dental anxiety. However, the impact of the general anxiety latent variable was not significant as compared with the mood factor. Another finding was that the residual variance for the latent variable dental anxiety was 0.68, indicating that a major portion of the variance is still unexplained by the tested variables. In conclusion, this study showed a relationship between dental anxiety, general anxiety, and mood among dentally anxious patients.

Dental anxiety in relation to mental health and personality factors. A longitudinal study of middle-aged and elderly women

Little is known about the longitudinal course of dental anxiety in relation to age, mental health and personality factors. In 1968 69 a representative sample of 778 women aged 38 to 54 yr took part in a psychiatric examination. Three hundred and ten were followed up in 1992-93. A phobia questionnaire, including assessment of dental fear, and the Eysenck Personality Inventory were distributed to the participants at both occasions. High dental fear was reported by 16.8% of the women at baseline and was associated with a higher number of other phobias, a higher level of neuroticism, more psychiatric impairment, more social disability due to phobic disorder, and a higher anxiety level. Among women who reported high dental fear in 1968 69 (n=36), 64% remitted and 36% remained fearful. Among women with low dental fear in 1968 69 (n = 274), 5% reported high dental fear in 1992-93. Chronicity was associated with higher neuroticism, lower extraversion, and more psychiatric impairment at base-line. Remission was associated with higher extraversion at baseline. Dental anxiety increased or decreased over time in concert with the number of other fears.

Factors associated with dental anxiety among older people in Britain

OBJECTIVE

This paper reports on a study of dental anxiety among adults aged 60 years living independently in Britain.

DESIGN

A national cross-sectional study carried out with the assistance of the Office for National Statistics' Omnibus Surveys in 1999.

SETTING

Data was collected by face to face interviews with older people in their homes.

MEASUREMENTS

Data on dental anxiety were collected from 973 subjects by means of face to face interviews and was measured by the Dental Anxiety Scale (DAS) (Corah, 1969). In addition, data on dental service use and oral health status (self-reported) was collected.

RESULTS

The mean DAS score was 8.4 (sd 3.5), and 13% (129) of subjects were classified as dentally anxious (DAS > or = 13). DAS scores were associated with numerous socio-demographic factors (P < 0.01), self-reported oral health status (P < 0.01) and dental service (P < 0.01) factors. A series of regression analyses revealed that dental anxiety was a significant predictor of a number of behavioural and oral health outcomes.

CONCLUSION

One in eight older people in Britain are dentally anxious and this is associated with their use of services and oral health status (self-reported).

The impact of dental anxiety on daily living

AIM

To explore the impact of dental anxiety on daily living.

METHOD

Twenty people attending a dental sedation clinic completed the Modified Dental Anxiety Scale, and were interviewed privately using a reflexive, in-depth technique. All interviews were audio-tape recorded and transcribed. The transcripts were analysed to identify the impact of dental anxiety upon the participants' daily lives. Twenty-five per cent of the qualitative data was reviewed by an independent researcher to ensure the reliability of the analysis.

RESULTS

The mean age of participants was 41 years (range 23 to 60). The mean MDAS score was 21.5 (range 14 to 25). Five main impacts of dental anxiety were identified: physiological; cognitive; behavioural; health; and social. Subsumed under these broad categories were: the fright response; a vast array of negative thoughts, feelings and fears; avoidance behaviour and behaviours related to eating, oral hygiene, and self-medication; and other manifestations of anxiety in the dental environment including muscular tension, crying and aggression were all identified. Dental anxiety was also found to disturb sleep and to have a profound affect socially, interfering with work and personal relationships.

CONCLUSION

The impact that dental anxiety can have on people's lives is wide-ranging and dynamic.

Patients with cardiac disease: considerations for the dental practitioner

The provision of dental treatment under both local anaesthesia and sedation has an excellent safety record, although medical problems may occur. The high prevalence of cardiac disease in the population, particularly ischaemic heart disease, makes it the most common medical problem encountered in dental practice. Additionally, the increasing survival of children with congenital heart disease makes them a significant proportion of those attending for dental treatment. While most dental practitioners feel confident in performing cardio-pulmonary resuscitation, treating patients with co-existent cardio-vascular disease often causes concern over potential problems during treatment. This article aims to allay many of these fears by describing the commoner cardiac conditions and how they may affect dental treatment. It outlines prophylactic and remediable measures that may be taken to enable safe delivery of dental care.

Needs for oral care among people with intellectual disability not in contact with Community Dental Services

Previous research has found an unmet need for oral care among people with intellectual disability. The key factors which have been indicated are low expectations, fear of treatment, lack of awareness among carers and problems in accessing dental services. The withdrawal of many general dental practitioners (GDPs) from the National Health Service (NHS) may have exacerbated the latter problem in the UK. The aims of the present study were: (1) to assess the extent of unmet clinical needs in a group of adults with intellectual disability living in the community who were not in contact with the Community Dental Service (CDS); and (2) to explore their perceptions of teeth and contact with dentists to identify how oral care can be improved. Interviews were completed with subjects and/or carers and a dental examination was completed. There were higher levels of untreated caries (decay), and gingival or periodontal (gum) problems among the sample than in either the general population, or in a previous survey of CDS users at day centres and residential facilities. The subjects were largely unaware of dental problems, and used the appearance and absence of pain to judge the condition of their teeth. They depended greatly on their carers for decision-making and support with regard to visiting the dentist and tooth-brushing. Carers requested training in oral care and the use of dental services, and support in dealing with clients who have problems tolerating tooth-brushing. The subjects had experienced a wide variation in the treatment provided by dentists, but had not found it difficult to access a dentist despite recent reductions in the availability of NHS dental care. They expressed a particular need for a good relationship with their dentist and for their dentist to have personal skills in relating to people with an intellectual disability. Dental screening checks and oral care training for carers should be made easily available. Care plans should include tooth-brushing and dietary issues for all clients who have their own natural teeth. There are significant training issues for dentists in developing personal skills in total communication, disability awareness and attitudes which value people with intellectual disability.

What hurts during dental hygiene treatment

PURPOSE

The purpose of this study was to examine clients' pain reports for routine clinical procedures during dental hygiene treatment, and to examine the degree to which physical and psychological variables contribute to pain.

METHODS

A convenience sample consisting of 53 (18 male, 35 female) undergraduate students enrolled at Dalhousie University participated as dental hygiene clients. Before treatment, the demographics, dental anxiety, and pain catastrophizing of students were measured. During procedures, dental status was measured. Following procedures, the amount of pain associated with procedures was recorded. Data was analyzed using an SPSS/PC statistical package.

RESULTS

Most procedures were associated with little or no pain. However, probing and scaling were associated with greater pain. Furthermore, 25 percent of the sample reported their pain was > or = 7/10 on at least one dental hygiene procedure. Dental status measures and treatment difficulty did not correlate with pain. Individuals higher in dental anxiety and pain catastrophizing reported greater pain. Multiple regression showed that all predictor variables combined to account for approximately 1/3 of the variance in pain reports.

CONCLUSION

On average, clinical dental hygiene treatment is associated with low levels of pain, but approximately 25 percent of subjects experienced at least one of the seven procedures as being moderately to severely painful. Findings illustrate the need for effective pain management that may be physiologically or psychologically based. Interventions geared toward reducing anxiety and pain catastrophizing may be useful additions to the curriculum of dental hygiene programs.

Behavioural and emotional problems in children referred to a centre for special dental care

This study was conducted among 203 children (103 boys) referred to a centre for special dental care because of a high level of dental fear. It was undertaken to explore to what extent behavioural and emotional problems co-exist in these children compared with children of a Dutch norm group. The children's parents filled out the parental version of the Child Behaviour Checklist (CBCL), before their first appointment at the centre. The behavioural and emotional problems of the children were assessed by this CBCL, and the mean scores of the children in the study were compared with the mean scores of the norm group. The mean scores on all scales, except on the subscale 'sex problems', of the children with a high level of dental fear proved to be significantly higher than the mean scores of the norm group (P< or =0.001). The results indicated that children referred to a special dental care centre not only suffer from high dental fear but also have problems in several other behavioural and emotional areas. These problems appear to be heterogeneous; they were found in several specific problem areas, both external and internal.

Treatment modalities in a dental fear clinic and the relation with general psychopathology and oral health variables

OBJECTIVE

To assess differences among highly anxious dental patients assigned to different treatment modes (i.e. behavioural management (BM), nitrous oxide sedation (NOS), intravenous sedation (IVS). Patients were compared with regard to psychological and dental variables before treatment (e.g. number of decayed teeth), and dental variables after treatment (e.g. number of fillings made).

DESIGN

Dentists experienced in the treatment of highly anxious patients allocated patients to a treatment mode based upon their clinical judgement.

SETTING

Centre for Special Dental Care, Amsterdam, The Netherlands.

SUBJECTS

211 patients from this dental fear clinic.

MEASURES

General psychopathology, as measured by the Symptom Checklist 90 (SCL-90), and dental anxiety (DAS, S-DAI, 10-point scale) were measured prior to treatment. From the panoramic radiograph the following pre-treatment dental variables were assessed: number of teeth, number of decayed teeth, number of retained roots, and number of root-filled teeth. After treatment, number of fillings, extractions, endodontically treated elements, number of visits, and treatment duration, were determined from the patients' records.

RESULTS

Of the 144 patients who received dental treatment at the clinic, 46.5% was treated using a BM approach, 27.8% with NOS, 22.9% with IVS, and 2.8% under GA. No differences among the treatment groups were found with regard to SCL-90 and dental anxiety. The results showed that patients in the IVS group had statistically significant more decayed teeth than patients in the BM group. Furthermore, more fillings were made in the IVS group than in the BM group.

CONCLUSION

Since it appeared possible to treat a large proportion of patients by BM alone, training dentists in the application of psychological methods for the treatment of anxious patients should be stimulated. In addition, future research should seek for variables that, besides oral health, are better able to discriminate between groups of highly anxious patients than measures of dental anxiety and psychopathology.

Dental caries and changes in dental anxiety in late adolescence

Little is known about changes in dental anxiety with ageing and their association with changes in oral health. This study examined the relationship between changes in dental caries experience and dental anxiety from 15 to 18 years of age among adolescent participants in the Dunedin Multidisciplinary Health and Development Study. Dental anxiety was estimated using the Corah Dental Anxiety Scale (DAS), and individuals with a DAS score of 13+ were identified as being dentally anxious. Dental examinations were performed on 649 individuals at ages 15 and 18, and a DMFS score was computed for each. Caries prevalence among those who were dentally anxious at both 15 and 18 years was significantly higher than for those who were not at either age. Regression analysis revealed that dental anxiety predicted caries incidence between ages 15 and 18 years. Dental anxiety is likely to be a significant predictor of dental caries experience, and may be a risk factor for dental caries incidence.

Blood-injury-injection phobia and dental phobia

The present study was carried out to explore the relation between BII phobia and dental phobia. An additional aim was to determine the fainting tendency of dental phobics and BII phobics during an invasive treatment procedure. Participants were 63 patients undergoing treatment in a dental fear clinic, and 173 patients undergoing dental surgery in a university hospital. They completed measures on fears of particular medical and dental stimuli, fainting history, general trait anxiety, dental anxiety, BII anxiety, BII avoidance, and a questionnaire aimed to define a phobia based on DSM-IV criteria. Immediately after treatment information was obtained on exposures to blood or injections, state anxiety, and feelings of faintness during treatment. The results did not indicate any significant relationship between measures of dental anxiety and BII anxiety or BII avoidance. However, 57% of the dental phobic patients could also be classified as BII phobic. The proportion of dental phobics who reported fainting episodes in their past was similar to that of the BII phobics (37%), but none of the participants fainted during treatment. It is concluded that, albeit the level of co-occurrence for both types of phobias is high, dental phobia should be considered as a specific phobia, independent for the BII subtype within DSM-IV. Further, the findings are inconsistent with the notion that individuals with BII phobia have a remarkably high tendency to faint in the presence of their phobic stimuli.

The Australian public's perception of mercury risk from dental restorations

The debate about mercury and dental amalgam has been one of the longest running in dentistry, and shows no signs of abating. This study aimed to investigate perceptions about mercury in dental fillings among a representative sample of the Australian public. A random sub-sample of participants in a national dental telephone interview survey completed a follow-up postal questionnaire which included four items on dental mercury. The postal survey response rate was 85.2%. Concern about mercury in dental fillings was expressed by 37.5%, while 16.2% reported having requested fillings that do not contain mercury. Avoidance of dental care because of concern about mercury in fillings was reported by 5.8%, but only 4.7% reported having had fillings replaced because they contained mercury. The data indicate that there is a substantial degree of concern about mercury and dental amalgam among the Australian public, but that the dental behavioural and treatment-pattern consequences of that concern are infrequent.

Problems complicating dental treatment with local anaesthesia or sedation: prevention and management

The provision of dental treatment under both local anaesthesia and sedation has an excellent safety record. However, problems that either complicate treatment or lead to medical emergencies can arise. This paper considers the prevention of foreseeable problems and the treatment of unforeseeable emergencies in the dental surgery.

The appropriateness of referral of medically compromised dental patients to hospital

Hospital departments of oral and maxillofacial surgery make a substantial contribution to both managing and treating medically-compromised dental patients. Contracting arrangements should take account of this. Demographic data suggest that the treatment of medically-compromised elderly dentate patients will become increasingly important in the General Dental Service (GDS). To determine the medical conditions and treatment requirements prompting referral of these patients to hospital, a prospective study was undertaken of 75 consecutive adults referred for hospital treatment specifically because of a medical condition which prevented delivery of routine dental care in the GDS. Patients (mean age: 56 years) were referred mainly from general medical (33%) and dental (62%) practitioners. Cardiovascular disease was the most frequently cited medical condition requiring referral (43%; n = 32 cases). Forty-eight patients (64%) were symptomatic on presentation and on average had attended on 2.3 occasions before definitive treatment was instituted. Fifty-two patients (70%) had no special treatment requirements other than those available in the GDS, 11 patients (15%) simply required antibiotic prophylaxis and 81% were treated by undergraduates or junior staff. These data suggest that many patients referred for dental hospital treatment because of underlying medical condition are not in fact medically-compromised and may be treated in the primary care setting.

Fatal intracerebral hemorrhage during dental treatment

Although chronic arterial hypertension is the leading cause of intracranial hemorrhage, an abrupt rise in systemic arterial pressure in normotensive people may sometimes induce a hemorrhagic stroke. Dental treatment is rarely associated with such an event. We report here on two middle-aged women, apparently healthy, who suffered from a fatal intracerebral hemorrhage following a dental treatment. On admission, high levels of arterial hypertension were found. It seems that trigeminal manipulation during dental treatment as well as increased serum levels of induced epinephrine mainly by stress and pain, and the small amounts absorbed from the site of local anesthesia might produce abrupt elevation of blood pressure, subsequent increase in cerebral blood flow and severe, even fatal intracerebral hemorrhage. The addition of catecholamines to local anesthetics should be considered. We recommend the use of benzodiazepin as a premedication drug to reduce stress during dental treatment.