Different Treatment Approaches in Different Cultures and Health-Care Systems
At this point in the book, the discussion of cognitive behavioural therapy (CBT) for the treatment of dental phobia has focused primarily on its use in Western countries such as Norway, Sweden, the Netherlands, the United Kingdom and the United States. Indeed, much of the research in this therapeutic modality for dental phobia has come from a Western perspective. However, to conclude that dental phobia and, in turn, its treatment are unique to Western culture is to ignore a significant barrier to adequate oral health care across the world. This chapter will review some of the literature on dental phobia in non-Western countries and then discuss cultural considerations in applying CBT to dental phobia within these countries. A brief review of providing such therapy in different health-care systems will be made, followed by a discussion of alternatives to CBT that may be used to treat dental phobia.
Dental Fear and Phobia in Non-Western Countries
Asia and India
Dental fear in China, which has been assessed through Chinese versions of the Modified Dental Anxiety Scale (MDAS; Yuan et al. 2008) or the Dental Anxiety Inventory (Ng, Stouthard and Leung 2005), has both similarities and differences to patterns of dental fear in Western countries. In a comparison of samples of adults in China and Denmark, dental anxiety scores were significantly higher in the Chinese and the proportion of Chinese adults reporting moderate to phobic dental anxiety (30 per cent) was twice that of the Danes (15 per cent; Schwarz and Birn 1995). Among dentate adults in Hong Kong, high levels of dental fear were associated with poor oral health quality of life (Ng and Leung 2008), consistent with numerous other studies in Western countries linking dental fear with poor oral health quality of life (for example, Gisler et al. 2012).
Studies of dental fear in India have found differences by class in the impact of fear on dental treatment seeking (Garcha, Shetiya and Kakodkar 2010). Adults in lower classes were more likely to avoid dental care due to fear of consequences of dental treatment (e.g., loss of vision after tooth extraction, loosening of teeth after scaling) than those in higher classes. Using Indian translations of the MDAS and Modified Dental Beliefs Survey, Acharya (2008) found higher levels of dental fear in younger adults, those with lower levels of education and those with unpleasant dental experiences, similar to other studies in more Western countries.
Berggren, Pierce and Eli (2000) compared motivation for seeking treatment for dental phobia among fearful adults in Sweden, the USA and Israel. Compared to Sweden and the USA, fearful individuals in Israel were more interested in pursuing active forms of treatment, such as CBT and were more motivated to pursue such treatment in order to manage their fear, rather than seeking only pain relief. Meanwhile, in Saudi Arabia, a study of dental fear both in patients seeking dental and non-dental health care, those seeking non-dental care reported more dental fear yet fewer chronic dental problems than those seeking dental care (Al-Khodair et al. 1996).
Agbor and Naidoo (2011) interviewed traditional healers and their patients in Cameroon regarding their collaboration with and treatment seeking from oral health providers, respectively. They found that only 6 per cent of patients needing dental care are referred to an oral health specialist by traditional healers. Further, only 6.5 per cent of the patients sought treatment at a dental clinic, whether through referral or treatment seeking on their own. Fear and suspicion of dental clinics were identified as reasons for not seeking care in dental clinics, along with the higher cost compared to treatment by a traditional healer. A study by Udoye, Oginni and Oginni (2005) in Nigeria found higher levels of dental fear in individuals undergoing endodontic therapy, followed by extractions. The overall level of fear measured by Corah’s Dental Anxiety Scale, however, was lower in this sample (means between 7 and 9 on the 20-point scale), despite high levels of dental avoidance in Nigeria.
In a study in Brazil by De Oliveira and colleagues (2006), mothers were asked about their children’s resistance to receiving dental treatment. Along with the children’s temperaments and the parents’ abilities to ensure their children’s cooperation with treatment, many mothers acknowledged their own distrust of dental care and unwillingness to accept dental treatment themselves. Further, a qualitative study by Nations and Nuto (2002) found a significant amount of distrust in dental professionals, who are seen as dismissive of trusted traditional healers. Further, key informants reported, ‘Poor parents are not only barred from clinics but are blamed for children’s rotten teeth’ (p. 229).
Dental phobia and distrust of dentists, therefore, is certainly not limited to Western countries. While CBT is the most commonly used therapeutic approach for dental phobia in Western cultures, the same may not necessarily be true in other countries. As stated by Patel and Sumathipala (2006), ‘A key problem in translating this evidence [of the effectiveness of CBT] cross-culturally is the assumption that the underlying cognitions are essentially similar in Western and non-Western cultures and that the concepts underpinning CBT will be valid in different cultural settings’ (p. 57). This assumption must be taken into consideration prior to engaging dentally phobic patients from non-Western cultures in CBT.
Considerations for CBT in Non-Western Cultures
Patel and Sumathipala (2006) argue that CBT may be successfully adapted for use in developing countries ‘by simplifying the content so that it can be applied in primary care by non-specialist health practitioners; using culturally appropriate analogies; and delivering the intervention over fewer and shorter sessions’ (p. 54). In some countries, mental health services are significantly limited and are used primarily for the most severe forms of mental illness. For example, Schulz, Huber and Resick (2006) noted that in the former Yugoslavia, mental health services were primarily reserved for individuals with schizophrenia. Upon arriving in the USA, Bosnian refugees were reluctant to seek therapy for psychological distress because, in their words, ‘only crazy people saw a psychiatrist back home!’ (Schulz et al. 2006, p. 312).
Individuals from cultures where CBT and other therapeutic interventions are reserved only for the severely mentally ill are likely to feel very reluctant to seek ‘therapy’ for dental phobia, for to do so would be to label themselves as profoundly mentally ill. Instead, dentists and dental staff working with such individuals – or any individuals hesitant to engage in what they perceive as traditional therapy – may approach the topic as teaching the phobic patient ways in which to make the dental procedure more tolerable. Rather than introducing CBT or a similar intervention as ‘therapy’, the provider may ease the patient into using adaptive physical coping skills (e.g. deep breathing, muscle relaxation) to initially reduce autonomic arousal prior to beginning to address faulty cognitions.
Lin (2002) notes that CBT can be well suited for use with Chinese patients, as these individuals tend to value shorter term, more directive therapy approaches to indirect, insight-oriented approaches. CBT therapists engaging with Chinese patients are advised to take a very active role in suggesting problem-solving and coping skills. However, the Chinese culture focuses more on external sources of control than internal control and thus encouraging a Chinese patient to increase his or her own internal sense of control may be met with resistance. Further, management of dental phobia often includes encouraging patients to actively communicate their fear or discomfort through a hand signal during treatment. Asking a patient to stop a dental procedure due to pain or fear is likely to be seen by the patient as an affront or insult to the dentist and may result in the patient ‘losing face’ to the dentist and staff. Dentists or therapists working with Chinese patients are advised to watch patients’ body language for signs of discomfort or anxiety, then stop the procedure (presumably for a dental-related reason) and ‘check in’ with the patient in a non-confrontational way. As the Chinese culture is more collectivistic in nature than Western cultures, engaging the family and other support systems will be important in treating these individuals (Lin 2002).
While research on the use of CBT in anxiety disorders within Indian culture is limited, Garcha et al. (2010) identified barriers to receiving professional dental care in India. Similar to the collectivistic Chinese culture, a significant proportion of respondents (18 per cent in the highest social class, 22 per cent in the lowest) reported that they would not attend a dental appointment alone, but would wait for treatment until friends, family, or neighbours could accompany them. Many respondents indicated that they would seek dental treatment only when the pain becomes unbearable (48–66 per cent) and the majority of respondents reported that they would not like to go to a dentist who does not have specialized qualifications (82–98 per cent). Therefore, when working with dentally phobic patients from India, it is recommended that providers include family and others from the support network in treatment and to reinforce the providers’ training in both dental and anxiety management skills. As some patients may come into treatment with the assumption that dental care is meant only for treatment of pain, discussion of preventive treatment may be needed. However, this same study (Garcha et al. 2010) found that a significant proportion of respondents across social classes did not want to have scaling and polishing done for fear it would loosen their teeth (14–48 per cent). Therefore, focusing on early treatment of pain (e.g. just when the tooth starts to ache a bit, rather than become unbearable) may be the best way to engage individuals who hold these beliefs in treatment initially.
Similar to the use of CBT in Indian culture, research on the use of CBT and other therapeutic modalities with Muslim patients is limited. Hodge and Nadir (2008), however, note that cognitive therapy tends to be more consistent with the values and norms of the Muslim culture than are other therapeutic modalities, such as psychodynamic therapy. The authors point out that, while not all Muslims follow the religious teachings of Islam, being aware of the Islamic traditions is critical when working with Muslim patients. Similar to the previous discussion of Chinese and Indian collectivist cultures, Hodge and Nadir note that many Muslims place higher importance on the community than on the individual. Therefore, cognitive restructuring approaches that include ‘I’ statements are not likely to resonate with Muslim patients. Research has shown that CBT that incorporates Islamic teachings brings about more rapid symptom improvement in the treatment of Muslim patients with anxiety disorders (Azhar, Varma and Dharap 1994). Understanding the nature of the Muslim patient’s Islamic faith, if applicable, is critical to engaging in appropriate and effective CBT.
Providing CBT in Different Health-Care Systems
Dentists in most countries, pursuing a surgical specialty of medicine, have traditionally seen dental maladies as acute rather than chronic. In the past this was largely true but in developed countries today the problems are more chronic and impact only a subset of the population. Such individuals benefit from regular periodic care and long-term management. Within this group of special patients are those who are phobic or are afraid of the dentist in addition to having other significant mental health problems.
Pharmacological management, in which patient’s normal responses are obtunded, works well for acute care. However, in the sedated condition, fearful patients learn only to have acute care with pharmacological means and are less likely to enter into a care programme with a longer term horizon than patients who are treated with the behavioural approaches advocated in this book (Berggren and Linde 1984). In what might be termed a transition period within the field, many phobic and mentally ill patients prize pharmacological treatment – the knock-me-out approach – because they and often their dentists are not aware of the alternatives.
In a study in the UK, a third of patients referred to a specialty service for sedation chose behavioural treatment when given the opportunity (Boyle et al. 2010). Nevertheless, this acute care model persists and on the surface it appears to involve less money and time than a behavioural approach. In a review of outpatient-based sedation, Yagiela (2001) exemplifies this kind of logic. He writes, ‘Although behavioural strategies are clearly more cost-effective for the patient receiving routine dental care, in-office sedation is usually the least expensive alternative for patients requiring pharmacologic management’ (p. 1348). By necessity, successful behavioural therapies do require upfront expenditures of time and money. In an interesting experiment with Norwegian fearful patients, Halvorsen and Willumsen (2004) found that the uncertainty of the outcome with behavioural treatments led most to not be willing to pay for behavioural therapy. Indeed the benefits of sedation are seductive from this point of view.
For dental patients with significant pathology, a combination of approaches – as Yagiela is suggesting – may be cost effective and perhaps patients may be more willing to pay for them. One can argue that there are some dental treatments that are so unpleasant or time consuming that no patient should experience them awake. At the same time, failure to teach such patients the skills they need to cope with routine maintenance care results in the perpetuation of the acute care model that we know is wasteful and, more often than not, unsuccessful.
Because most care centres have not offered combined or coordinated treatment the acute model has predominated. Thus these chronically ill patients do not return for regular care and their problems multiply resulting in greater expense and difficulty in management. Meanwhile, they suffer significant decrements in oral health quality of life. In many cases, dentists are not trained or permitted legally to use sedation in dental practice or may not use itinerant anaesthesia providers to provide sedation in private offices with the exception of surgical specialists. Hospital care is often limited to oral surgery with little opportunity for comprehensive care approaches.
The Scandinavian countries with extensive governmental programmes for dental care for special populations and children provide or pay for treatments that reduce fears. Criteria include a DSM-IV diagnosis of phobia or post-traumatic stress disorder (PTSD), a long period of avoidance and high need for treatment. Evaluations by dentists and psychologists are required. Similarly, residents in the UK may qualify for both psychological treatments and/or sedation based on referral from general practitioners or the community dental service. However, in all these countries the actual availability of services varies because of lack of trained personnel in some areas. The Finnish insurance system includes some subsidy for patients needing sedation but not behavioural treatments. Some behavioural treatments have been available on a limited basis from the public health system.
The Netherlands government has an insurance system for subsidized fear treatment in centres for special care dentistry when treatment in general practice is not possible. The preferred approach is cognitive behavioural treatment although sedation can also be available. The government programme does not cover general anaesthesia provided by private clinics. Nevertheless, these options are generally not available in other parts of the world.
In most other developed countries – the USA, Canada, Australia, Israel, for example – dental care is paid for mostly out-of-pocket with some private insurance coverage for adults and children and public insurance for poor children. In these countries, the primary focus of care for fearful patients is sedation or general anaesthesia. Generally, behavioural psychology and psychiatric services are provided by separate systems with little connection to the dental care delivery system.
As CBT may not always be feasible within different cultures and/or health-care systems, it is useful to consider other therapeutic options with which dentally phobic patients may be treated. The following section will describe intravenous (IV) sedation, use of d-cycloserine to enhance therapeutic learning, computerized therapy approaches and approaches that focus on memory, relaxation and learning.
Alternatives to Face-to-Face CBT for Dental Phobia