Dentally anxious and phobic individuals are an underserved special needs population because of their avoidance of treatment. Dentists and their auxiliary staff, with an understanding of the etiologies leading to this potentially serious health obstacle, can enhance the patient’s overall quality of life. Techniques are available for dentists to evaluate and treat this critical phenomenon. Through proper information, education, and staff sensitivity, these individuals can be rehabilitated and enjoy improved oral and systemic health.
Modern dentistry has made much progress in providing a patient-friendly environment. Still, despite revolutionary new dental techniques, anxiety toward dentistry has stayed relatively constant over the past 50 years. It is said to be ranked fourth among common fears and ninth among intense fears. Severe dental anxiety leading to avoidance is a common occurrence in the United States, where avoidance rates range between 6%–20% of the population. These individuals avoid dental treatment at all costs. Patients who struggle with this debilitating phobia have special needs and, therefore, require special care once they present for dental treatment. Among dental patients who regularly seek care, as many as 50% report some anxiety toward their dental experiences. These individuals can be classified as “casual avoiders” because they frequently postpone necessary dental treatment. In both cases referenced above, the resulting neglect usually leads to dental breakdown. Fearful dental avoiders tend to receive less oral health care, or a lower quality of care, than the general population and may have oral problems that can affect systemic health. Dentists with knowledge and interest in this serious problem can do well to rehabilitate these suffering individuals, whose quality of life is compromised by this troubling phenomenon. For the past 8–10 years, the Commission for Dental Accreditation of the American Dental Association has developed a competency component in the Standard for Dental Education to better address the behavioral aspects of special needs dental care and management issues. The social, psychologic, and physical functional problems of dental phobia have extended this phenomenon to a comprehensive quality of life concern. When oral health is compromised, overall health and quality of life may be diminished. A study by James found that lack of insurance, finances, or gainful employment had nothing to do with avoidance of dental treatment—it was solely due to fear. A discussion of the subject of dental avoidance due to fear requires a definition of common terms used to describe this issue. Fear is an individual’s response to a real threat or danger. The operative word in this definition is “real.” Fear is objective, because it is directly linked to something specific, a known danger, and causes a physiologic response. For example, an individual who is going to attempt to ski downhill for the first time following some brief lessons is facing a real threat. One could be seriously injured during this activity. Anxiety is synonymous with fear except that the threat is ill-defined. It is subjective, anticipatory, and often associated with the unknown or ambiguous. Chambers notes that the manifestation of a certain degree of anxiety by the patient toward the dental experience is not only an expected response but also a desirable one. The argument is offered that all situations in life are best approached and executed by the individual when he possesses a measure of anxiety that is optimal for the particular situation. It is important to distinguish between anxiety and phobia. In the example of downhill skiing, an experienced skier who feels uneasy about the activity only on a particular day illustrates anxiety. One often cannot pinpoint the reason for this underlying feeling of uneasiness. A phobia is an overwhelming, irrational feeling of fear which causes one to avoid the threatening stimulus at all costs. Exposure to the feared object provokes an immediate anxiety response that may produce panic-like symptoms. In the case of a skier, an individual cannot even imagine participating in the activity without feeling symptoms of severe anxiety and discomfort. Much of the research in the area of dental phobia shows that “fear” consists of feelings and thoughts that are often expressed through avoidance behavior, and dental fear is learned primarily through aversive experiences.
Etiology
Fearful dental avoidance stems from either direct or indirect experiences. Direct experiences are those which one experiences personally. A painful dental experience, either past or current, or the belief that painful treatment is inevitable, can initiate the pattern of avoidance. Indirect experiences are those that are vicariously adopted from others (ie, family members, peers, media, etc.). Children are impressionable and often adopt parental fears. Body language and subtle comments can be transferred in such a way that they create a subconscious fear in an “innocent bystander.” This phenomenon is not uncommon in adults as well.
Negative interactions with dental staff members can provoke and embarrass a sensitive dental patient into many years of dental treatment avoidance. Many patients who present to the dental office after long periods of avoidance report a feeling of belittlement, which in some way validates their absence. Today’s dental staff is cognizant of this serious problem. Staff members are chosen with care and carefully trained to deal with the special needs of the phobic patient. The goal is to ensure that everyone who makes contact with the patient—from the receptionist who takes the initial phone call to the hygienist and dentist, who perform many potentially painful procedures—is adept at welcoming these patients and helping them to relax.
Some dental phobic individuals suffer from a host of psychologic and emotional disorders in addition to their dental phobia. There are many forms of anxiety, and the four major classes of anxiety are: generalized anxiety disorder, obsessive compulsive disorder, phobic anxiety disorder, and panic disorder, which can lead to anxiety crisis or panic syndrome. A panic attack can be a serious and upsetting occurrence during a dental visit, in which one or more of the following physical symptoms may be exhibited: palpitations, sweating, trembling, shortness of breath, feeling like choking, chest pain, nausea, dizziness, derealization, fear of dying, paresthesias, or chills. A comprehensive medical and dental history can elicit the patient’s mental health status and possibly prevent this untoward reaction. Consultation with a mental health professional would be in order in these extreme cases.
Most people like to have a sense of control over their circumstances. In the area of dental treatment, phobic individuals report “an intense lack of control,” which exacerbates anxiety and produces a panic-like response. Often patients do not understand the procedure being performed and harbor a general fear of the unknown. Feelings of helplessness may be induced by something as simple as reclining the dental chair. In addition, instrument presentation or manipulation, and the customary hand-piece water spray often cause feelings of choking.
A more comprehensive discussion of the treatment techniques that can be useful in patient management to prevent the previously mentioned etiologic factors are described later in this article.
Evaluation of dental fear
The evaluation of a dental phobic individual is crucial to the overall management and treatment outcome. Dental phobic adults often manifest their anxiety at its worst in the waiting room, where clinicians are less likely to observe it. Fidgeting, pacing, sitting on the edge of the chair, repetitious limb movement, or startled reactions to noise may be manifested by the anxious patient while waiting for the appointment. A characteristic presentation often includes body language in the form of generalized muscle tension, as noted by clenched hands, causing “white knuckle syndrome.” Tension in the facial muscles often causes an eye fixation depicting their fear as a “deer-in-headlights.”
Dental phobic individuals tend to cancel or break appointments frequently. In observing this behavior the clinician can ascertain whether these missed appointments are related to the patients’ anxiety. One strategy that may be helpful to both patient and practitioner is to work out an agreement with the patient in which the appointment is kept, even if the patient does not want to participate in the planned treatment procedure. In this way, the clinician has the opportunity to further counsel the patient, and the patient has a better sense of control. An added benefit is that the negative reinforcement which would have occurred had the patient not attended the scheduled appointment is thereby averted.
An inquiring dental phobic individual’s first contact with the dental office is usually via telephone. It is most important that this patient is greeted by a caring and empathic staff member. This phone call sets the tone for the entire dental experience and should be representative of the office philosophy in regard to the treatment of dental anxiety.
The first face-to-face interview should be an friendly “get-acquainted” meeting with staff members, including dental auxiliaries and clinicians. This may be best accomplished in a location of the office with no dental equipment. In some cases the sights and sounds may trigger memories that increase anxiety. In this interview the patient is encouraged to verbalize in their own words their perception of the origin of their dental fear. This may produce a catharsis, which itself is therapeutic. To enhance the interview process the dentist could ask questions that would elicit more valuable information. Questions such as, “What could a dentist do to make you more comfortable during your procedure?” and “What might a dentist do that would make you more uncomfortable?.”
The interview process is often thought to be the foundation of the therapeutic relationship between a health professional and the patient. Whereas communication skills are key to a good relationship, a friendly, smiling face and a reassuring tone are probably more important than getting the dialog correct. Dental phobic individuals are assessing at all times that their dental needs will be met by a sensitive clinician. Effective listening, effective feedback, and clarification also help the professional develop good communication with the patient. Patients who feel that they can communicate with their dentist are more likely to show an improvement in their symptoms, and will return to the same dentist for continued treatment. This rapport establishes a mutual working relationship, whereby the patient builds confidence that their needs are being satisfied, and the clinician enjoys the positive outcomes of the treatment relationship. Non-verbal communication such as touch, proximity, posture and orientation, body movements and gestures, facial expression, gaze and eye contact, and general appearance is an equally essential component to the interview. Dentists are unique practitioners because they have to touch a sensitive part of the body, the oral cavity. The issue of proximity may be threatening to the patient due to the encroachment on their “personal space.” It is important for the dentist to face the patient and observe their expressions and reactions during verbal exchange. Rapid movements increase anxiety and should be avoided. The dentist should attempt to offer positive facial expressions which yield optimistic impressions in the patient. Eye contact is essential in conveying respect for the patient. The professional demeanor of the clinician and his or her office staff are substantial elements in establishing overall confidence.
Assessments of dental anxiety have been conducted in various populations around the world. Dental anxiety represents a specific situational and anticipatory state that can be identified and categorized using validated, specially designed questionnaires. The objective assessment of dental anxiety could be made by the Dental Anxiety Scale ( Fig. 1 ), developed by Norman Corah, and the Dental Fear Survey (DFS) ( Fig. 2 ), developed by Ronald Kleinknecht. Newton and Buck set out to provide an overview of measures of anxiety and pain in dental research over a 10-year period. The authors collected and reviewed the following information: the length of the scale; response format used; data on the reliability of the scale; data on the validity of the scale; and availability of alternate forms of the scale. According to their findings, and consistent with its reputation, the Corah Dental Anxiety Scale is known to maintain high internal consistency and test–retest reliability. Its use as a measurement tool for dental anxiety is well established and evidenced by over 35 articles in which the scale has been used or cited since 1988. The Kleinknecht Dental Fear Survey, measures three dimensions: avoidance of dental treatment, somatic symptoms of anxiety, and anxiety caused by the dental stimuli. They are scored on a 5-point Likert scale ranging from “never” to “nearly every time.” Newton & Buck find this scale to be reliable and stable across different groups of respondents. This measurement tool is considered in the field of anxiety research to be the most sensitive and reliable measure for dental anxiety because of the internal consistency of the scale, test–retest reliability and validity of the questionnaire.
In terms of the patients beliefs and perceptions related to dental anxiety, the Dental Beliefs Survey (DBS) ( Fig. 3 ) addresses the subjective perceptions of the patient regarding the behavior of the dentist, and the process of how the care is delivered. The purpose of the DBS is to identify to what degree the patient perceives the behavior of dental staff members as contributing to the problem. Therefore, the vital information obtained from this survey can alert the staff to the relative special needs of that patient and enhance the treatment experience.
Ascertaining the specific foci of threatening dental situations is useful, particularly in developing a hierarchy where the patient can rank on a sliding scale his/her responses toward those experiences. The Mount Sinai Dental Fear Inventory (Mount Sinai Medical Center, 1978) ( Fig. 4 ), allows patients to rate themselves on a scale from 0–100, where 0 is so relaxed they might fall asleep, and 100 is the point when fear is at its greatest. The inventory includes many common threatening situations and sensations. It also allows individuals to add their own category if not already included. In reviewing this inventory the dental clinician can develop a treatment plan beginning with the least threatening situation and progressing at a comfortable pace to completion of the treatment.
Evaluation of dental fear
The evaluation of a dental phobic individual is crucial to the overall management and treatment outcome. Dental phobic adults often manifest their anxiety at its worst in the waiting room, where clinicians are less likely to observe it. Fidgeting, pacing, sitting on the edge of the chair, repetitious limb movement, or startled reactions to noise may be manifested by the anxious patient while waiting for the appointment. A characteristic presentation often includes body language in the form of generalized muscle tension, as noted by clenched hands, causing “white knuckle syndrome.” Tension in the facial muscles often causes an eye fixation depicting their fear as a “deer-in-headlights.”
Dental phobic individuals tend to cancel or break appointments frequently. In observing this behavior the clinician can ascertain whether these missed appointments are related to the patients’ anxiety. One strategy that may be helpful to both patient and practitioner is to work out an agreement with the patient in which the appointment is kept, even if the patient does not want to participate in the planned treatment procedure. In this way, the clinician has the opportunity to further counsel the patient, and the patient has a better sense of control. An added benefit is that the negative reinforcement which would have occurred had the patient not attended the scheduled appointment is thereby averted.
An inquiring dental phobic individual’s first contact with the dental office is usually via telephone. It is most important that this patient is greeted by a caring and empathic staff member. This phone call sets the tone for the entire dental experience and should be representative of the office philosophy in regard to the treatment of dental anxiety.
The first face-to-face interview should be an friendly “get-acquainted” meeting with staff members, including dental auxiliaries and clinicians. This may be best accomplished in a location of the office with no dental equipment. In some cases the sights and sounds may trigger memories that increase anxiety. In this interview the patient is encouraged to verbalize in their own words their perception of the origin of their dental fear. This may produce a catharsis, which itself is therapeutic. To enhance the interview process the dentist could ask questions that would elicit more valuable information. Questions such as, “What could a dentist do to make you more comfortable during your procedure?” and “What might a dentist do that would make you more uncomfortable?.”
The interview process is often thought to be the foundation of the therapeutic relationship between a health professional and the patient. Whereas communication skills are key to a good relationship, a friendly, smiling face and a reassuring tone are probably more important than getting the dialog correct. Dental phobic individuals are assessing at all times that their dental needs will be met by a sensitive clinician. Effective listening, effective feedback, and clarification also help the professional develop good communication with the patient. Patients who feel that they can communicate with their dentist are more likely to show an improvement in their symptoms, and will return to the same dentist for continued treatment. This rapport establishes a mutual working relationship, whereby the patient builds confidence that their needs are being satisfied, and the clinician enjoys the positive outcomes of the treatment relationship. Non-verbal communication such as touch, proximity, posture and orientation, body movements and gestures, facial expression, gaze and eye contact, and general appearance is an equally essential component to the interview. Dentists are unique practitioners because they have to touch a sensitive part of the body, the oral cavity. The issue of proximity may be threatening to the patient due to the encroachment on their “personal space.” It is important for the dentist to face the patient and observe their expressions and reactions during verbal exchange. Rapid movements increase anxiety and should be avoided. The dentist should attempt to offer positive facial expressions which yield optimistic impressions in the patient. Eye contact is essential in conveying respect for the patient. The professional demeanor of the clinician and his or her office staff are substantial elements in establishing overall confidence.
Assessments of dental anxiety have been conducted in various populations around the world. Dental anxiety represents a specific situational and anticipatory state that can be identified and categorized using validated, specially designed questionnaires. The objective assessment of dental anxiety could be made by the Dental Anxiety Scale ( Fig. 1 ), developed by Norman Corah, and the Dental Fear Survey (DFS) ( Fig. 2 ), developed by Ronald Kleinknecht. Newton and Buck set out to provide an overview of measures of anxiety and pain in dental research over a 10-year period. The authors collected and reviewed the following information: the length of the scale; response format used; data on the reliability of the scale; data on the validity of the scale; and availability of alternate forms of the scale. According to their findings, and consistent with its reputation, the Corah Dental Anxiety Scale is known to maintain high internal consistency and test–retest reliability. Its use as a measurement tool for dental anxiety is well established and evidenced by over 35 articles in which the scale has been used or cited since 1988. The Kleinknecht Dental Fear Survey, measures three dimensions: avoidance of dental treatment, somatic symptoms of anxiety, and anxiety caused by the dental stimuli. They are scored on a 5-point Likert scale ranging from “never” to “nearly every time.” Newton & Buck find this scale to be reliable and stable across different groups of respondents. This measurement tool is considered in the field of anxiety research to be the most sensitive and reliable measure for dental anxiety because of the internal consistency of the scale, test–retest reliability and validity of the questionnaire.
