The Prevalence of Dental Anxiety
The high-pitched whirling sound of the drill… that unique medicinal smell… the pain from that one time (or many times) before… Dental anxiety. If that first sentence made you uncomfortable, you’re not alone. Research touts that nearly half of the population has dental anxiety. Hill et al., (2009) found that approximately 36% suffer from dental anxiety, with an additional 12% experiencing extreme dental fear.[1] Previously, in 2006, Kamin et al., reported that between 50 and 80% of adults in the United States have some degree of dental anxiety, ranging from mild to severe. More than 20% of dentally anxious patients do not see a dentist regularly, and anywhere from 9 to 15% of anxious patients avoid care altogether.[2] Resulting in dental avoidance, serious repercussions in one’s oral health[3] and subsequent psychological and physical health can occur. 73% of respondents in a 2004 study by McGrath and Bedi noted that their oral health directly affected their quality of life.[4]
Coriat first defined dental anxiety in 1946 as, “an excessive dread of anything being done to the teeth” with “any dental surgery, no matter how minor, or even dental prophylaxis, may be so postponed or procrastinated that the inroads of disease may affect the entire dental apparatus”. Further, Coriat noted that this fear fell under the category of “anticipatory anxiety” as it stems from a fear of real danger and an anticipated unknown danger.[5,6] While the terms “dental fear” and “dental anxiety” have been used interchangeably, “dental phobia” is a more extreme manifestation. Lautch (1971) defined dental phobia as, “A special kind of fear, out of proportion to the demands of the situation, which will not respond to reason, is apparently beyond voluntary control and leads to avoidance of dental treatment where this is really necessary”.[7,8] A 2014 study by Randall et al., compared the prevalence of fears and phobias of nearly 2,000 individuals. Among the top fear mentions included: fear of snakes (34.8%); fear of physical injuries (27.2%); and dental fear (24.3%).[9]
Manifestations of Dental Anxiety & Phobia
Dental anxiety manifests in both physical and psychological responses. Physiological impacts commonly include signs and symptoms of the fright response (e.g., feelings of exhaustion following a dental appointment). Cognitive impacts tend to include a combination of negative thoughts, beliefs, and fears.[10]
Milgrom et al., (1995) identified four different groups of anxious patients, based on their origin, or source, of fear:[11]
1) anxious of specific dental stimuli
2) distrust of the dental personnel
3) generalized dental anxiety
4) anxious of catastrophe.
Common fears associated with dental anxiety include:[12]
fear of pain
fear of blood-injury fears
lack of trust or fear of betrayal
fear of being ridiculed
fear of the unknown
fear of detached treatment by a dentist or a sense of depersonalization
fear of mercury poisoning
fear of radiation exposure
fear of choking and/or gagging
a sense of helplessness in the dental chair
a lack of control during dental treatment.
Those with dental phobia avoid going to the dentist and tend to only go when extreme pain forces them to.
Common signs of dental phobia include:[13]
Trouble sleeping the night before a dental appointment.
Nervous feelings that worsen in the dentist’s waiting room.
Being unable to enter the dentist’s office.
Crying and/or being physically ill at the thought of visiting a dentist.
Source: SeattleAnxiety (Instagram)
DEVELOPMENT OF DENTAL FEAR
Dental anxiety may develop during any point in one’s life and due to a multitude of reasons.
Research highlights commonality between childhood experiences as an indicator of dental anxiety or phobia. Locker et al. (1998) studied the age of onset of dental anxiety in a survey of 1,420 adult participants: 16.4% were assessed as being dentally anxious; half of whom reported that their dental fear started in childhood.[14]
A 2002 regression analysis noted a significant relationship between child dental anxiety and the number of extractions a child had experienced, suggesting that one of the causes of dental anxiety is invasive dental treatment. Conversely, ten Berge et al. found that children who had experienced more non-invasive check-up visits before their first curative treatment reported low levels of dental fear.[15] Beaton et al., (2014) suggest that the longer a child continues to have positive experiences when visiting the dentist, the less likely they are to become dentally fearful if/when they do eventually have a negative experience (i.e., latent inhibition).[16] Similarly, Oosterink et al., (2009) found that anticipation and expectations matter; if a patient expects pain during a scaling procedure, they are more likely to report higher anxiety levels.[17]
The role of memory is of particular importance regarding one’s dental experiences. Kent (1985) studied dental patients’ memory of pain by comparing: patients’ remembered pain 3 months after treatment with a)their expected pain and b) their experienced pain. Results indicated a closer association between remembered and expected pain than there was between remembered and experienced pain. Kent hypothesized that inaccurate memories of pain experienced during treatment may be leading to the continuation of dental anxiety in some patients.[18]
In 2011, Humphris and King examined the impact of previous distressing experiences of 1,024 that completed the Modified Dental Anxiety Scale (MDAS) and an assessment of their susceptibility (Level of Exposure-Dental Experiences Questionnaire; LOE-DEQ). Humphris and King found that 11% of the sample reported high dental anxiety. Respondents noted they most-feared local anesthetic injections and those who reported a previous distressing experience were 2.5 times more likely to experience high dental anxiety.[19,20]
Previous assault experiences also impact one’s likelihood of developing dental anxiety. Humphris and King’s study found sexual assault victims were almost two and a half times more-likely to report high dental anxiety. Similarly, Leeners et al. found that women who had been previously sexual assaulted reported anxiety related to lying flat in the dental chair, as well as a more pronounced gagging reflex.[21,22]
Dental anxiety can also develop vicariously; this occurs when one indirectly learns behavior and thought-patterns from role models (e.g., family members or peers) or from external sources (e.g., the media).[23] Themessl-Huber et al. (2010) conducted a systematic review and meta-analysis of 43 experimental studies about parental and child dental fear. They confirmed a significant relationship between child and parental dental fear, with parental dental anxiety significantly predicting a child’s subsequent dental anxiety.[24,25] Similarly, Locker et al. found that 56% of participants who reported an onset of dental anxiety during childhood had a parent or sibling who also suffered anxiety about dental treatment.[26] Additionally, Öst (1987) reported that child-onset phobias are more likely to develop through vicarious learning compared to phobias developing in adulthood.[27]
Those with dental anxiety may fall into a vicious cycle regarding their oral health care. This hypothesis, first proposed by Berggren in 1984, suggests that:[28]
dental anxiety leads to avoidance of dental care
avoidance results in neglect of dental treatment
neglected dental treatment leads to subsequent poor oral health
as one’s oral health declines, a person becomes more anxious and fearful of the expected pain they will encounter to fix said issues
the increased anxiety/fear leads to greater avoidance of dental care.
The vicious cycle becomes compounded by feelings of embarrassment and shame at the delay in addressing oral health issues.[29] Unfortunately, as the cycle continues, dental issues typically worsen and create more extensive issues.[30-32]
In 2013, Armfield’s study supported the notion of this vicious cycle. Examining the dental anxiety and frequency of dental visits and treatment needs in 1,036 dentate Australians, he found that 39% of people with moderate to high dental fear avoid the dentist due to said fear.[33]
Overcoming Dental Anxiety
Research has found several ways that dentally-anxious patients can achieve lower levels of anxiety.
Depending on the dentist’s expertise and experience, degree of dental anxiety, patient characteristics, and clinical situations, dental anxiety can generally be managed by:[34]
a combination of both.
Psychotherapeutic interventions are either behaviorally or cognitively oriented, and recently, the use of cognitive behavior therapy (CBT) has been shown to be highly successful in the management of extremely anxious and phobic individuals. Pharmacologically, patients can receive oral or inhaled sedation, or general anesthesia.
The following specific interventions/modifications may be helpful in reducing one’s anxiety in dental office settings:
Rapport & Trust Building – A positive patient–dentist relationship is of utmost importance in lessen one’s dental anxiety. Two-way communication is essential and dental staff should listen carefully in a calm, composed, and nonjudgmental way.[35] Dentists should fully describe any dental issues, possible treatment options, and preventive procedures. Further, patients should be encouraged to ask questions about what will occur/the treatment plan and should be kept informed both before starting a procedure as well as during the procedure.[36] By maintaining openness and honesty, rapport will grow as well as increasing the patient’s confidence in their dentist.[37]
Maintaining Control – As afore-mentioned, knowing what will happen (and when) during a dental procedure is essential to reducing one’s anxiety. Giving the patient a chance to feel that they are in control of the treatment procedure is of utmost importance; this can happen by both choosing what treatment they want to happen as well as by increasing interactions with their dentist. Such interactions can come in the form of signaling to the dentist or dental hygienist to stop the procedure if the patient is under duress or in pain; pre-determined signals (e.g., raising one’s hand or pressing a button the office provides) increases a patients’ sense of control and trust in their dentist. Once a patient initiates a signal, the dentist or hygienist should immediately stop the procedure, as failure to do so will breach the trust relationship and once-again increase the patient’s anxiety levels.[38]
Dental Office Ambience – The ambience of the dental office can play a significant role in initiating or reducing dental fear and anxiety. Every staff member is crucial in creating a pleasant and calming atmosphere in the dental office. To foster patients being comfortable, staff should be positive and caring, and speak in unhurried, concerned tones. Soft music and warm lighting is also helpful in creating a calming atmosphere. Distractions such as artwork and reading material are also helpful in reducing patients’ anxiety levels.[39] Further, the more distanced a patient is from treatment rooms also helps: patients can be asked to wait in their car or outside of the building until the time they can be seen by medical staff.
Research has found aromatherapy to be efficient in managing moderate anxiety.[40-42] Aromatherapy is another effective approach to improving dental office ambiance, wherein essential oils of aromatic plants are used to produce positive effects through the sense of smell. Introducing pleasant ambient odors (e.g., lavender) to the dental environment can also help to reduce anxiety by masking the medicinal, anxiety-inducing smells present in a dental office.
Hydration without Caffeine – Maintaining adequate hydration is essential to feeling one’s best mentally and physically. However, dentally-anxious patients should avoid caffeine the day of dental office visits/procedures as caffeine can worsen one’s dental anxiety by increasing overall anxious feelings and agitation.[43]
Guided Imagery - Anxiety-provoking stimuli (e.g., the sound of the dental drill or medicinal smell of the office) lead to physical tension, which increases one’s perception of anxiety. Deep breathing and muscle relaxation techniques can lessen these physical responses. Guided imagery is a type of “deliberate daydream” utilizing all of one’s senses to create a focused state of relaxation and a sense of physical and emotional well-being. In this mind–body exercise, people develop a mental image of a pleasant, tranquil experience.[44] The mental image can be somewhere imagined or based on pleasant and calming memories. During guided imagery, a person should create a scenario full of specific, concrete details, along with sound, smell, and colors of the scene[45] so that they feel fully submersed in their daydream. Research has found guided imagery to be affective in the treatment of distress, mood, and anxiety symptoms associated with chronic pain, social anxiety disorder, attention deficit/hyperactivity disorder (ADHD), and cancer pain.[46,47]
Listening to Music - Music has been shown to influence human brain waves, leading to deep relaxation that alleviates pain and anxiety. The utilization of listening to music incorporates a combination of relaxation and distraction that reduces the activity of the neuroendocrine and sympathetic nervous systems. This method has been found to be successful in both pediatric and adult dental patients.[48,49]
PEDIATRIC DENTAL ANXIETY
It is normal for children to be fearful of the unknown, or of being away from their caregivers and they might express their fears by crying or having a temper tantrum. To help a child’s dental visit go more smoothly and with less agitation, the Cleveland Clinic offers the following suggestions:[50]
Tell your child about the visit and answer their questions with simple, to-the-point answers. If they have more complex or detailed questions, let the dentist answer them. Pediatric dentists and hygienists are trained to describe things to children in easy-to-understand and non-threatening language.
Don’t tell your child about any unpleasant dental experiences you’ve had. If you act anxious, your child might pick up on that and feel anxious too.
Stress to your child how important it is to maintain healthy teeth and gums. Make sure they understand that the dentist will help them with this.
Get your child an age-appropriate book, which depicts characters going to the dentist for the first time.
Do not promise a reward for going to the dentist.
Let your child’s dentist know that the child is especially fearful so they will be able to address your child’s anxieties and ease their fears.
A sensory-adapted dental environment (SDE) might also be effective in reducing anxiety and inducing relaxation. In 2007, Shapiro et al., found that utilizing a “Snoezelen” dental environment for pediatric patients was especially helpful for dentally-anxious children.[51] Comprised of dimmed lighting, soothing music, and a special Velcro butterfly vest that hugs the child, a calming, deep-pressure sensation develops. Both behavioral and psychophysiological measures of relaxation have been found to improve significantly in the SDE compared with a conventional dental environment.[52,53]
If you would like to try incorporating cognitive-behavioral therapy (CBT) techniques into reducing your dental anxiety, you may reach out to a licensed mental healthcare provider specializing in that treatment modality.
Contributed by: Jennifer (Ghahari) Smith, Ph.D.
Editor: Jennifer (Ghahari) Smith, Ph.D.
References
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7 Ibid.
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34 Appukuttan (2016)
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37 Appukuttan (2016)
38 Ibid.
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45 Ibid.
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50 Cleveland Clinic
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52 Cermak SA, Stein Duker LI, Williams ME, et al. Feasibility of a sensory-adapted dental environment for children with autism. Am J Occup Ther. 2015;69(3):1–10.
53 Shapiro M, Melmed RN, Sgan-Cohen HD, Parush S. (2009)