13: The Anxious or Fearful Dental Patient

CHAPTER 13

The Anxious or Fearful Dental Patient

Henrietta Logan and Cindy Marek

CHAPTER OUTLINE

Nature and Scope of the Problem

Impact on Society
Impact on the Dental Team
Impact on the Patient
Characteristics of Dental Anxiety, Fear, and Phobia

Anxiety and Pain Perception
Anxiety and Pain Memory
Gender Differences in Pain Response
Etiology
Recognition and Diagnosis of Dental Anxiety

Standardized Indices
Patient Examination, Referral, and Treatment Plan Presentation

Interviewing the Fearful Patient
Referral
Treatment Plan Presentation
Delivery of Care to the Fearful Patient

Distraction
Relaxation
Hypnosis and Guided Imagery
Altering the Treatment Approach and Sequence
Pharmacologic Intervention

Routes of Administration
Benzodiazopines
Nitrous Oxide
Intravenous Sedation
General Anesthesia
Integrating Anxiolytic Therapy Into the Delivery of Dental Care
Conclusion

Even after years of experience, many practitioners find that treating fearful/anxious dental patients is stressful. Part of the stress comes from the manner in which patients express their dental fear. The anxious patient may blurt out, “Don’t take it personally, but I hate going to the dentist.” Some fearful patients appear angry and hostile, whereas others are furtive and withdrawn both groups may be distrustful. Not only is such patient behavior unsettling to the dentist, but it may also significantly limit his or her ability to treat the patient’s dental problems. This chapter is designed to help the practitioner understand the problem of dental fear and to deal with it more effectively. This chapter familiarizes the reader with (1) the nature and scope of the problem; (2) the characteristics of fearful patients; (3) methods to evaluate, diagnose, and plan treatment for fearful patients; and (4) suggestions on how to deliver dental care to fearful individuals, including pharmacologic interventions when necessary.

NATURE AND SCOPE OF THE PROBLEM

In present times, the media often portray fear as a commonplace reaction to dental treatment. Many practitioners are offended by this portrayal, but the fact remains that fear of the dentist is a common phenomenon and is universally recognized. Little wonder that some (but not all) patients are so forthright with their own fearful dental stories.

Several studies confirm that dental anxiety and fear are common among people in the U.S. and other countries.1,2 About 50% of U.S. adults report some dental fear, with 8% to 11% being fearful enough that going to a dentist at all is problematic. In a Seattle area survey, 20% of respondents were classified as having high fear of dentistry.3 Smith and Heaton reviewed 19 articles involving more than 10,000 adults in the United States and concluded that the rate of dental anxiety and/or fear has remained stable during the past 50 years.4 Francis and Stanley drew from multiple sources and estimated the prevalence of dental phobia (an extreme form of fear) in Australian adults to be 10% to 14%.5 Surveys in Iceland, Taiwan, and Japan show at least some dental fear among 21%, 50%, and 82% of the adult respondents, respectively.68 Studies of children have shown a global variation in the prevalence estimates of dental anxiety between 3% and 43%.9 Methods used to collect dental fear data vary widely across studies, making direct comparisons of fear rates between countries problematic. Nonetheless, dental fear appears to be a problem internationally and affects the use of dental services in all countries from which data are available.

Many fears are not regarded as socially acceptable. The presence of dental fear, however, is widely accepted and carries little social stigma. This may make it easier for patients to rationalize and justify their own dental fear and hence maintain their own fearful and avoidant behavior. Given the international prevalence and universal acceptance of dental fear, it is impossible for the dentist anywhere to avoid fearful patients. Consequently, it is worth the clinician’s time and energy to learn to effectively treat fearful patients.10

Impact on Society

The large numbers of fearful dental patients and their associated behavior have an impact on the greater society.11 For the reported 14% of patients who delay having dental treatment because of their fear, the consequences can be unnecessary pain and suffering. Society then pays through lost workdays and diminished productivity of its members.12 Current estimates are that between 15% and 33% of the U.S. public experience dental-related disability days. In a study of 2600 employed people, 25% reported an episode of work loss in the past 12 months related to a dental problem.13

Impact on the Dental Team

About 14% of the public report canceling or failing to appear for dental appointments because of fear. The cost of missed or unfilled appointments becomes a financial issue for the dentist. This increased cost for dental practitioners in turn influences the cost of dental care for other patients in the practice. In addition, even when fearful patients do appear for their appointment, they often require more staff time and attention. Interactions with fearful patients may result in a reduction in job satisfaction. The patient’s fearful behavior may result in more stress and fatigue for the practitioner and less satisfaction among staff members as well. Dental fear may also result in reduced patient compliance, and therefore a diminished likelihood of treatment success for both patient and dentist.

Impact on the Patient

Dental fear has its greatest impact on the individual patient.14,15 The physical and psychological effects are significant, and the emotional toll on the millions of affected individuals is inestimable. In some families, several generations of individuals have suffered ill health, oral infection, acute and chronic dental pain, loss of oral function, and loss of self-esteem all because of dental anxiety.

Some patients are embarrassed by their fear and may seek to hide it by avoiding going to the dentist altogether. On the other hand, if patients do mount the courage to schedule an appointment, they may fail to appear or avoid scheduling certain types of appointments (e.g., root canal therapy or surgery). This avoidance puts the patient at risk for failing to understand the symptoms he or she is experiencing, overestimating or underestimating their seriousness, and making it difficult to know when to seek help. Fearful patients may also have difficulty in making well-reasoned treatment decisions about their dental care needs. Some dentists may charge a fee for missed appointments, thus further increasing the financial burden of care. Delayed or nonexistent maintenance and preventive care frequently results in the need for more complex care, often at increased cost. If the patient delays too long, he or she must bear the burden of the greater cost for emergency care (Figure 13-1). The fearful patient is at risk for poor oral health, a lowered quality of life, and a substantial financial obligation.16,17

image

Figure 13-1 Delaying dental treatment can result in increased cost to treat conditions, such as rampant caries.

CHARACTERISTICS OF DENTAL ANXIETY, FEAR, AND PHOBIA

Anxiety is both a physical and emotional response to an anticipated experience that the individual perceives as threatening in some way. In some instances, the anxiety is generalized with a poorly defined focus. In its most extreme form, anxiety may significantly limit the individual’s ability to function in everyday life. Pathologic anxiety requires psychiatric intervention and is discussed in Chapter 14. When the dentist observes symptoms of extreme generalized anxiety, patients should be referred to an appropriate health care provider.

Fear is an emotional response to a genuine threat or danger. In its extreme form, fear of any stimulus can interfere with the ability to perform daily tasks. When the fear of a particular stimulus dominates the individual’s life, it is described as a phobia, also discussed in Chapter 14. Sometimes such fears become generalized to multiple stimuli. For example, dental fear is generalized to overall fear in 20% of the phobic population. Dental phobia is a special case of dental fear characterized as a consistent and persistent fear that interferes with one’s social or role functioning and often leads to avoidance of dental treatment of almost any type. Mental health workers may make a distinction between anxiety, fear, and phobias, but for most patients, the terms are used interchangeably.

Researchers in the field have been able to identify some circumstances and events that contribute to dental anxiety in susceptible patients. Children who received restorative or surgical dental treatment as 9-year-olds are more likely to report dental anxiety as 12-year-olds than are children who received regular treatment.18 Adult patients whose fears developed during childhood and early adolescence are less trusting and more hostile toward the dentist than other patients. Among adults, anxiety is often associated with the patient’s current assessment of the dentist’s likelihood to inflict pain.19 Evidence suggests that when the patient no longer fears pain, dental fear declines. Studies also show that relatively brief dental treatment may result in the incubation of dental fear that may manifest at a later time. Longer episodes of treatment, including spending time building trust and encouraging good oral self-care behaviors, may actually lessen the likelihood of dental fear. Therefore, brief emergency treatment appointments with such patients should be avoided.20 The implications of this research for the dentist are that special care should be taken in managing the distress and pain of adolescents who are irregular careseekers and who will require invasive dental procedures. Additional time spent with the patient, establishing rapport, providing the patient with a degree of personal control over the pace of treatment delivery, and fully informing the patient may lessen the likelihood of dental fear developing at a later date.

Fearful dental patients often report they are frightened by certain dental stimuli.21 The feared object or objects may include the needle, office sounds, the drill, or even the smell of the office.22 Patients also may report distrust of dental personnel and fear of catastrophe, such as a heart attack or choking during treatment. Such patients may have generalized anxiety about other life events as well. For many patients, the underlying fear is fear of pain.23,24 In fact, even among routine patients, fear of pain can be high.25

Emotional arousal increases the likelihood that patients will process the information they hear from the dentist and staff less carefully.26 As a result, anxious patients cannot be counted on to pay close attention to the details of a message about their care. Instead the anxious patient may pay closer attention to superficial and peripheral stimuli that reinforce negative stereotypes about dental treatment. The implications of this phenomenon are that the dental team must be attentive to the verbal and nonverbal messages with a fearful patient. An abrupt or “short” command to the patient may be interpreted as an admonition. The patient may also misinterpret nonverbal messages, such as perceiving the appearance of the physical surroundings (presence of “sharp” instruments) as threatening. The patient may focus on items in the environment that reinforce the perception of being in a frightening place, including anything that appears disorganized or not sterile.

Anxiety and Pain Perception

It is commonplace for dentists to downplay the degree of pain experienced by their patients. For some patients, the use of a local anesthetic may be sufficient to make them comfortable during treatment but for others it is not. Pain is a complex experience.27 The International Association for the Study of Pain defines pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.”28 But the sensation of pain as it is experienced by a patient is more than a simple reflection of the amount of tissue damage that has occurred. Pain is always subjective and includes biological, psychological, and social dimensions. Sessle proposed that orofacial pain may be more complex than pain in other regions of the body because of the “special emotional, biologic, and psychologic meaning” it holds for the person.29 In addition, sensory nerves are heavily concentrated in the oral cavity, increasing the likelihood that all individuals are acutely aware of what is happening in their mouths.

Evidence suggests that anxiety lowers the pain threshold.30 However, there is also some evidence that anxiety and fear may have differential effects on pain reactivity. In a landmark experiment, Rhudy and Meager showed that experimentally induced anxiety led to increased pain reactivity whereas high levels of fear led to decreased pain.31 Whether the dental setting produces fear or anxiety is not clear, but within the dental care context, patients may have worried for days about a scheduled treatment, resulting in elevated levels of autonomic arousal and high levels of anxiety. This elevated arousal may produce heightened levels of plasma catecholamines, which in laboratory studies have been shown to lower the pain threshold and tolerance.32 It is not surprising then that many highly anxious patients show elevated levels of pain reactivity during dental treatment as compared with less anxious patients.33 Clinicians should therefore anticipate that anxious patients will experience more sensory and affective distress during dental treatment than less anxious patients and treat them accordingly (see the What’s the Evidence? box).34

Anxiety and Pain Memory

Anxiety appears to play a role in the level of pain that dental patients remember. Negative emotions, such as anxiety, become stronger predictors of the pain memory than the actual pain intensity. One study35 asked patients to recall their perception of pain during root canal treatment at 1 week after treatment and again 18 months later. All patients had an accurate recall of the pain level at the 1 week interval, but at 18 months, the patients with a higher level of anxiety remembered the pain as being greater than was actually recorded at the time of the time of the treatment. Experimental pain research has shown that the recall of pain intensity is reasonably accurate immediately after a painful experience and after a short delay of about 2 weeks. But after 6 months, the memory of pain delivered within a stressful context becomes exaggerated, with women recalling more pain than men.36 Moreover, exaggerated pain memories can alter brain pathways, further sensitizing the individual to painful stimulation.37 These findings illustrate the importance of anxiety management at the time of dental treatment to minimize the patient’s long-term recollection of the aversiveness of dental treatment and their anticipation of pain at future visits.

 

What’s the Evidence?

What Is the Relationship Between Anxiety and the Perception of Pain?

Melzack1 states that the perception of pain is a complex process involving emotional arousal, motivational drive, and cognition. Studies have shown that when an individual feels anxious about a perceived danger, such as pain, he or she is more aware of information regarding that danger.26 Increased awareness of information regarding the possible danger may bias cognitive functions, resulting in a distorted perception.7 Cognitive assessment of the strength of nociceptive stimuli may be imprecise in the state of anxiety.8 Studies have shown that with an increase in anxiety, pain sensitivity also increases,911 and that techniques to reduce anxiety help to reduce the amount of perceived pain.12

Although some research supports the theory that anxiety is related to pain perception, other research opposes this theory. In a review of research, Rachman and Arntz13 concluded that anxiety only influences the expectation of pain and that the level of pain experienced is independent of the level of dental fear. Conversely, procedures involving oral surgery have been shown to elicit high anxiety1417 and may be associated with a higher expectation of pain during the procedure.18 Studies have also shown a relationship between dental anxiety and pain during periodontal procedures1920 and after periodontal surgery.21

In a study of patients who were receiving dental implants, significant correlations between anxiety and pain were found preoperatively, immediately postoperatively, and at 4 weeks postoperative.22 In this study, the level of anxiety positively correlated with pain and was the best predictor of the level of pain the patient would experience. The conclusion that the pain anticipated by patients is directly related to their levels of anxiety is similar to conclusions drawn in other studies.2325

In a study of individuals who had either an extraction or root canal therapy, participants with a high level of dental anxiety also anticipated more affective, sensory, and intense pain.26 Patients with a high level of fear had a high level of pain sensitivity and reported stronger and more intensive pain. These results are similar to those of other dental studies showing more intense perception of pain by individuals who had expected more pain.2731

 

1. Melzack, R, Wall, PDThe challenge of pain. London: Penguin Books, 1988.

2. Aldrich, S, Eccleston, C, Crombez, G. Worrying about chronic pain: vigilance to threat and misdirected problem solving. Behav Res Ther. 2000; 38(5):457–470.

3. Eccleston, C, Crombez, G. Pain demands attention: a cognitive-affective model of the interruptive function of pain. Psychol Bull. 1999; 125(3):356–366.

4. Weisenberg, M. Cognitive aspects of pain and pain control. Intl J Clin Exp Hypn. 1998; 46(1):44–61.

5. von, Graffenried B, Adler, R, Abt, K, et al. The influence of anxiety and pain sensitivity on experimental pain in man. Pain. 1978; 4(3):253–263.

6. Robin, O, Vinard, H, Vernet-Maury, E, et al. Influence of sex and anxiety on pain threshold and tolerance. Funct Neurol. 1987; 2(2):173–179.

7. Mandler, GMind and body: psychology of emotion and stress. New York: Norton, 1984.

8. Cornwall, A, Donderi, DC. The effect of experimentally induced anxiety on the experience of pressure pain. Pain. 1988; 35(1):105–113.

9. Schumacher, R, Velden, M. Anxiety, pain experience, and pain report: a signal-detection study. Percept Motor Skills. 1984; 58(2):339–349.

10. Rhudy, JL, Meagher, MW. Fear and anxiety: divergent effects on human pain thresholds. Pain. 2000; 84(1):65–75.

11. Dougher, MJ, Goldstein, D, Leight, KA. Induced anxiety and pain. J Anxiety Disord. 1987; 1:259–264.

12. Sternbach RA, ed. The psychology of pain. New York: Raven Press, 1978.

13. Rachman, S, Arntz, A. The overprediction and underprediction of pain. Clin Psychol Rev. 1991; 11:339–355.

14. Wong, M, Lytle, WR. A comparison of anxiety levels associated with root canal therapy and oral surgery treatment. J Endod. 1991; 17(9):461–465.

15. Soh, G, Yu, P. Phases of dental fear for four treatment procedures among military personnel. Milit Med. 1992; 157(6):294–297.

16. Brand, HS, Gortzak, RA, Palmer-Bouva, CC, et al. Cardiovascular and neuroendocrine responses during acute stress induced by different types of dental treatment. Intl Dent J. 1995; 45(1):45–48.

17. Eli, I, Bar-Tal, Y, Fuss, Z, et al. Effect of intended treatment on anxiety and on reaction to electric pulp stimulation in dental patients. J Endod. 1997; 23(11):694–697.

18. Eli, I, Baht, R, Kozlovsky, A, et al. Effect of gender on acute pain prediction and memory in periodontal surgery. Eur J Oral Sci. 2000; 108(2):99–103.

19. Sullivan, MJ, Neish, NR. Catastrophizing, anxiety and pain during dental hygiene treatment. Community Dent Oral Epidemiol. 1998; 26(5):344–349.

20. Chung, DT, Bogle, G, Bernardini, M, et al. Pain experienced by patients during periodontal maintenance. J Periodontol. 2003; 74(9):1293–1301.

21. Croog, SH, Baume, RM, Nalbandian, J. Pre-surgery psychological characteristics, pain response, and activities impairment in female patients with repeated periodontal surgery. J Psychosom Res. 1995; 39(1):39–51.

22. Eli, I, Schwartz-Arad, D, Baht, R, et al. Effect of anxiety on the experience of pain in implant insertion. Clin Oral Implants Res. 2003; 14(1):115–118.

23. Klepac, RK, Dowling, J, Hauge, G, et al. Reports of pain after dental treatment, electrical tooth pulp stimulation, and cutaneous shock. J Am Dent Assoc. 1980; 100(5):692–695.

24. Klepac, RK, Dowling, J, Hauge, G. Characteristics of clients seeking therapy for the reduction of dental avoidance: reactions to pain. J Behav Ther Exp Psychiatr. 1982; 13(4):293–300.

25. Kent, G. Anxiety, pain and type of dental procedure. Behav Res Ther. 1984; 22(5):465–469.

26. Klages, U, Ulusoy, O, Kianifard, S, et al. Dental trait anxiety and pain sensitivity as predictors of expected and experienced pain in stressful dental procedures. Eur J Oral Sci. 2004; 112(6):477–483.

27. Watkins, CA, Logan, HL, Kirchner, HL. Anticipated and experienced pain associated with endodontic therapy. J Am Dent Assoc. 2002; 133(1):45–54.

28. Litt, MD. A model of pain and anxiety associated with acute stressors: distress in dental procedures. Behav Res Ther. 1996; 34(5-6):459–476.

29. Arntz, A, van, Eck M, Heijmans, M. Predictions of dental pain: the fear of any expected evil, is worse than the evil itself. Behav Res Ther. 1990; 28(1):29–41.

30. Wardle, J. Dental pessimism: negative cognitions in fearful dental patients. Behav Res Ther. 1984; 22(5):553–556.

31. Lindsay, SJ, Wege, P, Yates, J. Expectations of sensations, discomfort and fear in dental treatment. Behav Res Ther. 1984; 22(2):99–108.

Gender Differences in Pain Response

There is considerable interest in gender differences in both clinical and experimental pain reporting. Several reviews and meta-analyses show that men are somewhat more pain tolerant than women.38 The differences, however, are often small,39 and the findings are not always consistent.40,41 Several explanations for the reported differences have been made, including the possibility that social learning encourages women to acknowledge painful stimuli, whereas men are expected to hide pain.42,43 Gender-specific hormones have also been implicated. For women, differences in the phase of the menstrual cycle are believed to influence pain sensitivity. A meta-analysis of experimental pain showed that during the follicular phase of their menstrual cycle women show the greatest tolerance and highest pain threshold. Research suggests that certain forms of analgesia may be differentially effective in women and men, but these differences are not universal.4446 So it is not practical for the dentist to try to select an anxiolytic strategy or technique based on the gender of the patient. The best current wisdom is that there are large individual differences in the biological, psychological, and social mechanisms that underlie the human pain experience, and these individual differences are much more significant determinants of pain perception than is gender. As such, patients respond to dental pain and anxiety in unique ways, and a single approach to pain management in the dental office cannot be expected to work for all or even a majority of patients regardless of gender.

ETIOLOGY

The cause of dental fear is complex and multifactorial.47 Although dental fear may appear at any age, current data suggest that most fears begin in the preteen years. Direct conditioning and modeling play important roles in the development of fear in children who have a family history of dental fear. Such a history is predictive of early-onset dental anxiety.48 Adolescent-onset patients are more likely to exhibit high levels of generalized anxiety. These fears may lessen with maturity and after positive experiences with the dentist.49 For some patients, however, dental fear persists into adulthood. Evidence suggests that those who maintain their fear into adulthood tend to overpredict the level of pain they will experience during dental treatment. This overprediction of pain is often associated with a high level of anxiety during the treatment.50 Although the data show that this group of patients may or may not report more pain during treatment, their anxiety may make it difficult to correct their expectations.51 Thus the vicious cycle of anxiety-pain-fear persists, with little opportunity for the patient or the dentist to disrupt the cycle.

About 27% of fearful patients develop their fear as adults. Adult-onset dental fear seems to be associated with multiple severe fears and, in some cases, may be indicative of psychiatric problems. The perception of a lack of personal control during the dental appointment can contribute to dental fear.52,53 Some theorists have suggested that dental fear may be constant in spite of improved dental technology because many patients find that during dental treatment, they can exert very little personal control over what will happen to them. Patients may perceive their inability to speak and their supine position below the level of the dentist equivalent to helplessness. In a society in which some people seem to feel they are losing control of their lives, the loss of personal control during dental treatment can become symbolic of life in general. Several studies show that when this perceived lack of control is coupled with a heightened desire for control, patients are at risk for high levels of dental stress and pain.54,55 Whether this need for control is the result of negative experiences with the dentist at an early or at a more advanced age is not clear. It is clear, however, that patients who want control and believe that they will not have it expect high levels of pain and experience and remember more pain than other patients. The resulting dental treatment is likely to be stressful for both the dentist56 and patient.

In general, patients younger than 40 years of age are more fearful than those who are over 40, but no differences among socioeconomic groups or racial/ethnic groups have been demonstrated. Females are more fearful than males, but the differences between men and women are not so great that dentists should assume that male patients will not be fearful.57 Research shows that women demonstrate higher dental anxiety in association with root canal therapy than do men.58 Men may appear more stoic than women because women find it more socially acceptable to be overt about their distress. The clinical significance of this finding is that dentists may underestimate the amount of pain their male patients experience.59

There is increasing evidence that women with high levels of dental fear are more likely to have a history of sexual/physical abuse than other women. The current estimate of childhood sexual abuse in the general U.S. population is 5.8% to 34% for women and 2% to 11% for men, which is considered by many to be a conservative estimate.60,61 The sheer numbers of patients who have experienced sexual abuse suggest that dentists frequently treat sexually abused patients, and a greater understanding of the impact of abuse on dental attitudes and reactions may help both the patient and dentist to form an effective treatment partnership. For instance, a study of sexually abused European women who were categorized as to whether they had been exposed to sexual touching, intercourse, or oral penetration showed that women in the oral penetration group scored significantly higher on dental fear than women in the other two groups.62 In addition, women with a history of childhood sexual abuse and high levels of dental fear considered interpersonal factors related to the dentist as more important than did women with high levels of dental fear but without a history of childhood sexual abuse. These interpersonal factors included not believing that the dentist can be trusted and the absence of a sense of control.63

Not surprisingly, psychological distress, including the tendency to catastrophize upcoming events, was greater among women with an abuse history compared with other women.64 Unfortunately, knowing that there can be a relationship between sexual abuse and dental anxiety does not usually help the dentist in managing the anxiety. Raising the issue of physical abuse, even when done with the utmost tact and sensitivity, can be embarrassing for both parties (especially if the inference is wrong), can be psychologically traumatizing for the patient, and can irreparably harm the dentist-patient professional relationship. If there is clinical evidence of ongoing physical abuse, then the issue must be broached. Otherwise, unless the patient raises it, the dentist is usually best served not delving into the question. If, however, all other strategies for managing the anxiety have been tried and none have been met with success, and if the dentist has reason to believe that the patient’s dental anxiety has roots in underlying psychological problems that may have their origin with physical or sexual abuse, this avenue can be pursued. But if so, it must be with the guidance and counsel or via direct referral to a mental health specialist with experience and training in dealing with abuse.

RECOGNITION AND DIAGNOSIS OF DENTAL ANXIETY

Several directly observable behaviors can be used to identify the fearful patient. Often patients will volunteer information about dental fear without being asked. It is important for the dentist not to become defensive. A statement such as “Why do you feel that way?” may be interpreted as confrontational and may make it difficult to build a therapeutic relationship with the patient. Instead, comments such as “I understand that you are concerned about receiving dental care. Please tell me more about your concerns,” allows the patient to elaborate without having to justify his or her feelings.

It is usually possible to observe a patient before or during the appointment and to recognize fearfulness. Fearful patients often have enlarged pupils and sweaty or cold hands, and are extremely fidgety in the chair. They may either talk excessively or not want to talk at all. When a patient behaves in such a way, it is wise to say, “You seem uneasy, is there anything I can do to help you be more comfortable?” Ignoring the patient’s fear does not help the patient relax, and the patient may interpret the dentist’s behavior as callous. Moreover, it is easier to treat the patient if the dentist has more specific information about the patient’s concerns.

Patients may exhibit indirect indicators of their dental fear. Dental assistants and front desk personnel are often in an excellent position to observe these indirect indicators. Patients who chronically cancel appointments and reschedule may be struggling with their fear of dental treatment. Similarly, patients who fail to appear or who are chronically late may also be fearful patients. For patients exhibiting these behaviors, a question such as, “I see that you frequently have trouble getting here for your appointment. Are you nervous about receiving dental care?” allows the patient to either acknowledge the fear or to identify other barriers the dentist should know about. In either case, the information helps the dentist make better decisions about future dental care.

Standardized Indices

When any or all of the above clues are apparent, it may be advantageous to quickly administer one of several available surveys to establish the patient’s level of dental fear. Kleinknecht’s Dental Fear Survey consists of 20 items, has good psychometric properties, can be completed in less than 10 minutes in the waiting room, and can be quickly scored and interpreted.6567 Other instruments that have shown good predictive utility are the Corah Anxiety Scale6870 and the Iowa Dental Control Index54,7173 (Boxes 13-1 to 13-3).

 

BOX 13-1   Kleinknecht’s Dental Fear Survey

Dental Fear Survey (DFS)

1. Has fear of dental work ever caused you to put off making an appointment?

a. Never
b. Once or twice
c. A few times
d. Often
e. Nearly every time
2. Has fear of dental work ever caused you to cancel or not appear for an appointment?

a. Never
b. Once or twice
c. A few times
d. Often
e. Nearly every time

When Having Dental Work Done:

3. My muscles become tense.

a. Not at all
b. A little
c. Somewhat
d. Much
e. Very much
4. My breathing rate increases.

a. Not at all
b. A little
c. Somewhat
d. Much
e. Very much
5. I perspire.

a. Not at all
b. A little
c. Somewhat
d. Much
e. Very much
6. I feel nauseated and sick to my stomach.

a. Not at all
b. A little
c. Somewhat
d. Much
e. Very much
7. My heart beats faster.

a. Not at all
b. A little
c. Somewhat
d. Much
e. Very much

Following is a list of things and situations that many people mention as being somewhat anxiety or fear producing. Please rate how much fear, anxiety, or unpleasantness each of them causes you. (If it helps, try to imagine yourself in each of these situations and describe what your common reaction is.)

8. Making an appointment for dentistry.

a. Not at all
b. A little
c. Somewhat
d. Much
e. Very much
9. Approaching the dentist’s office.

a. Not at all
b. A little
c. Somewhat
d. Much
e. Very much
10. Sitting in the waiting room.

a. Not at all
b. A little
c. Somewhat
d. Much
e. Very much
11. Being seated in the dental chair.

a. Not at all
b. A little
c. Somewhat
d. Much
e. Very much
12. The smell of the dentist’s office.

a. Not at all
b. A little
c. Somewhat
d. Much
e. Very much
13. Seeing the dentist walk in.

a. Not at all
b. A little
c. Somewhat
d. Much
e. Very much
14. Seeing the anesthetic needle.

a. Not at all
b. A little
c. Somewhat
d. Much
e. Very much
15. Feeling the needle injected.

a. Not at all
b. A little
c. Somewhat
d. Much
e. Very much
16. Seeing the drill.

a. Not at all
b. A little
c. Somewhat
d. Much
e. Very much
17. Hearing the drill.

a. Not at all
b. A little
c. Somewhat
d. Much
e. Very much
18. Feeling the vibrations of the drill.

a. Not at all
b. A little
c. Somewhat
d. Much
e. Very much
19. Having your teeth cleaned.

a. Not at all
b. A little
c. Somewhat
d. Much
e. Very much
20. All things considered, how fearful are you of having dental work done?

a. Not at all
b. A little
c. Somewhat
d. Much
e. Very much

The DFS contains 20 questions, each with answers ranging from one (least) to five (most). The summed scores may range from 20 (no fear) to 100 (terrified), but the DFS is primarily designed to detect fear induced by the separate items. Schuurs and Hoogstraten found the “normal patient” in the US to have a mean score of 38. However, no directory with normative mean scores and cutoff scores for DFS and its separate questions is currently available, question 20 excepted. Alternatively a study done by Cesar, de Moraes, Milgrom, and Kleinknecht reported that scores exceeding 60 are indicative of high dental fear. The DFS contains three areas pertaining to dental fear: questions 1 and 2 assess the patient’s avoidance of dentistry because of fear. Questions 3 to 7 allow the patient to report the degree of arousal they feel while undergoing dental treatment. Questions 8 to 20 allow the patient to indicate how much fear each of several dental situations and procedures causes for them, with 20 being a summary question.

 

BOX 13-2   Corah Anxiety Scale

Questionnaire

(Please circle the answer that matches your feelings about each question.)

1. If you had to go to the dentist tomorrow, how would you feel about it?

a. I would look forward to it as a reasonably enjoyable experience.
b. I wouldn’t care one way or the other.
c. I would be little uneasy about it.
d. I would be afraid that it would be unpleasant and painful.
e. I would be very frightened of what the dentist might do.
2. When you are waiting in the dentist’s office for your turn in the chair, how do you feel?

a. Relaxed.
b. A little uneasy.
c. Tense.
d. Anxious.
e. So anxious that I sometimes break out in a sweat or almost feel physically sick.
3. When you are in the dentist’s chair waiting while he gets his drill ready to begin working on your teeth, how do you feel?

a. Relaxed.
b. A little uneasy.
c. Tense.
d. Anxious.
e. So anxious that I sometimes break out in a sweat or almost feel physically sick.
4. You are in the dentist’s chair to have y/>

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Jan 5, 2015 | Posted by in General Dentistry | Comments Off on 13: The Anxious or Fearful Dental Patient
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