Understanding these elements of fear allows effective planning for the treatment of fearful and anxious patients.

According to the maxim that “fear dissolves in a trusting relationship,” establishing good rapport with patients is especially important. Second, preparatory explanations may deal effectively with fear of the unknown and thus give the patient a sense of control. Allowing patients to signal when they wish to pause or speak further alleviates their fear of loss of control. Finally, well-executed dental technique and clinical practices minimize unpleasantness.

Usually, dental-related fears are learned directly from a traumatic experience in a dental or medical setting. The experience may be real or perceived by the patient as a threat, but a single event may lead to a lifetime of fear when any element of the traumatic situation is reexperienced. The situation may have occurred many years before, but the intensity of the recalled fear may persist. Associated with the incident is the behavior of the doctor in the past. Thus, for defusing learned fear, the behavior of the present doctor is paramount.

Fears also may be learned indirectly as a vicarious experience from family members, friends, or even the media. Cartoons and movies often portray the pain and fear of the dental setting. How many times have dentists seen the negative reaction of patients to the term root canal, even though they may not have had one?

Past fearful experiences often occur during childhood, when perceptions are out of proportion to events, but memories and feelings persist into adulthood, with the same distortions. Feelings of helplessness, dependency, and fear of the unknown are coupled with pain and a possible uncaring attitude on the part of the dentist creates a conditioned response of fear when any element of the past event is reexperienced. Such events may not even be available to conscious awareness.

Dental fears may be seen as similar to classic Pavlovian conditioning. Such conditioning may result in generalization, in which the effects of the original episode spread to situations with similar elements. For example, the trauma of an injury or details of an emergency setting, such as sutures or injections, may be generalized to the dental setting. Many adults who had tonsillectomies under ether anesthesia may generalize the childhood experience to the dental setting, complaining of difficulty with breathing or airway maintenance, difficulty with gagging, or inability to tolerate oral injections. Modeling is vicarious learning through indirect exposure to traumatic events through parents, siblings, or any other source that affects the patient.

According to studies, patients perceive the dentist as both the controller of what the patient perceives as dangerous and as the protector from that danger. Thus, the dentist’s behavior and communications assume increased significance. The patient’s ability to tolerate stress and cope with fears depends on her or his ability to develop and maintain a high level of trust and confidence in the dentist. To achieve this goal, patients must express all the issues that they perceive as threatening, and the dentist must explain what he or she can do to address patients’ concerns and protect them from the perceived dangers. This is the purpose of the clinical interview. The result of this exchange should be increased trust and rapport and a subsequent decline in fear and anxiety.

Psychological theorists have suggested that events and situations are evaluated by using interpretations that are personality-dependent (i.e., based on individual history and experience). Emotions evolve from this history. Positive or negative coping abilities mediate the interpretative process—people who believe that they are capable of dealing with a situation experience a different emotion during the initial event than those with less coping ability. The resulting emotional experience may be influenced by vicarious learning experiences (e.g., watching others react to an event), direct learning experiences (e.g., having one’s own experience with the event), or social persuasion (e.g., expressions by others of what the event means).

A person’s belief about his or her coping ability, or self-efficacy, in dealing with an appraisal of an event for its threatening content is highly variable, based on the multiplicity of personal life experiences. Belief that one has the ability to cope with a difficult situation reduces the likelihood that an event will be appraised as threatening, and a lower level of anxiety will result. A history of failure to cope with difficult events or the perception that coping is not a personal accomplishment (e.g., reliance on external aids, drugs) often reduces self-efficacy expectations, and interpretations of the event can result in higher anxiety.

Because fears of dental treatment are learned, relearning or unlearning is possible. A comfortable experience without the associated fearful and painful elements may eliminate the conditioned fear response and replace it with an adaptive and more comfortable coping response. Through the interview process, the secret is to uncover which elements have resulted in the maladaptation and subsequent response of fear, eliminate them from the present dental experience by reinterpreting them for the adult patient, and create a more caring and protected experience. During the interview, the exchange of information and insight gained by the patient decrease levels of fear, increase rapport, and establish trust in the doctor-patient relationship. The clinician only needs to apply an expert operative technique to treat the vast majority of fearful patients.

Opening comments by the dentist to inform the patient about what to expect during a procedure—for example, pressure, noise, pain—may reduce the patient’s fear of the unknown and sense of helplessness. Control through knowing is increased with these preparatory communications.

A simple instruction that allows patients to signal by raising a hand if they wish to stop or speak returns a sense of control. Also, patients can be given the choice of whether to lie back or sit up.

Denial is a psychological term for the defense mechanism that people use to block out the experience of information with which they cannot emotionally cope. They may not be able to accept the reality or consequences of the information or experience with which they will have to cope; therefore, they distort that information or completely avoid the issue. Often, the underlying experience of the information is a threat to self-esteem or liable to provoke anxiety. These feelings are often unconsciously expressed by unreasonable requests of treatment.

For the dentist, patients who refuse to accept the reality of their dental disease, such as the hopeless condition of a tooth, may lead to a path of treatment that is doomed to fail. The subsequent disappointment of the patient may result in litigation issues.

A phobia is an irrational fear of a situation or object. The reaction to the stimulus is often greatly exaggerated in relation to the reality of the threat. The fears are beyond voluntary control, and avoidance is the primary coping mechanism. Phobias may be so intense that severe physiologic reactions interfere with daily functioning. In the dental setting, acute syncopal episodes may result.

Almost all phobias are learned. The process of dealing with true dental phobia may require a long period of individual psychotherapy and adjunctive pharmacologic sedation. However, relearning is possible, and establishing a good doctor-patient relationship is paramount.

Post-traumatic stress disorder (PTSD) is an anxiety disorder that develops subsequent to a traumatic event, such as sexual or physical abuse, serious accident, assault, war combat, or natural disaster. Symptoms include intrusive memories, avoidance behaviors, mood disorders, and high levels of physiologic arousal.

Past traumatic events, whether remembered or suppressed in the subconscious, may trigger behavioral responses that occur when similar or even vicarious events occur in the present. These events may be through direct experience, such as an accident, combat wound, or sexual abuse, or associated with observation of such events. The triggered behavior in the patient may be generalized fear and anxiety, and even extreme panic.

Patients with PTSD who come for dental treatment may feel very vulnerable and can sometimes find the experience retraumatizing. This is because the patient is often alone with the dentist, is placed in a horizontal position, is being touched by the dentist, who is hierarchically more powerful (and often male), is having objects placed in the mouth, is unable to swallow, and is anticipating or feeling pain. Many PTSD sufferers avoid going to the dentist, often cancel or reschedule appointments, have stress-related dental issues, and experience heightened distress while undergoing procedures.

Often these patients are reluctant to admit this, so it is a good idea to ask during the diagnostic interview, “Have you ever suffered from post-traumatic stress disorder?”

Similar to treating other anxious patients, dentists want to practice active listening, show compassion, and try to give the patient as much control in the situation as possible. You might offer an initial appointment just to talk, place the chair in an upright position, keep the door open, have an assistant present, check in frequently to see how the patient is doing, offer reassurance, and explain the procedures as you proceed.

Also, you can offer soothing music, blanket, or body covering (e.g., an x-ray cover). Make sure that the patient has been instructed to stop you whenever their anxiety level is getting too high. Premedication may be helpful.

If the patient is unable to tolerate being in the dental chair because her or his anxiety is uncontrollably high, you might want to refer this patient to a professional who specializes in the treatment of anxiety disorders. Counseling and antianxiety medications can be helpful in the treatment of PTSD and, in some cases, may be a prerequisite to dental work being carried out.

The gag reflex is a basic physiologic protective mechanism that occurs when the posterior oropharynx is stimulated by a foreign object; normal swallowing does not trigger the reflex. When overlying anxiety is present, especially if anxiety is related to the fear of being unable to breathe, the gag reflex may be exaggerated. A conceptual model is the analogy to being tickled. Most people can stroke themselves on the sole of the foot or under their arm without a reaction, but when the same stimulus is done by someone else, the usual results are laughter and withdrawal. Hence, if patients can eat properly, put a spoon in their mouth, or suck on their own finger, they are usually considered physiologically normal and may be taught to accept dental treatment and even dentures with appropriate behavioral therapy.

In dealing with these patients, desensitization involves the process of relearning. A review of the history to discover episodes of impaired or threatened breathing is important. Childhood general anesthesia, near-drowning, choking, or asphyxiation may have been the initiating event that created increased anxiety about being touched in the oral cavity. Patients may fear the inability to breathe, and the gag becomes part of their protective coping mechanism. Thus, reduction of anxiety is the first step; an initial strategy is to give information that allows patients to understand their own response better.