Steele J, O'Sullivan ILondon: The Stationery Office; 2011
Dinjian MD The psychic factor in dental practice. Dent Surg. 1921; 17:471-475
Freeman RE Dental anxiety: a multifactorial aetiology. Br Dent J. 1985; 159:406-408
Humphris G, Dyer T, Robinson P The modified dental anxiety scale: UK general public population norms in 2008 with further psychometrics and effects of age. BMC Oral Health. 2009; 9
Nuttall NM, Bradnock G, White D, Morris J, Nunn J Dental attendance in 1998 and implications for the future. Br Dent J. 2001; 190:177-182
Kelly M, Steele J, Nuttall NLondon: The Stationery Office; 2000
Todd JE, Lader DLondon: HMSO; 1991
Tsakos G, Hill K, Chadwick B, Anderson T: HSCIC; 2015
Pohjola V, Lahti S, Vehkalahti MM, Tolvanen M, Hausen H Association between dental fear and dental attendance among adults in Finland. Acta Odontol Scand. 2007; 65:224-230
Cohen SM, Fiske J, Newton JT The impact of dental anxiety on daily living. Br Dent. 2000; 189:385-390
Cahill L, McGaugh JL Mechanisms of emotional arousal and lasting declarative memory. Trends Neurosci. 1998; 21:294-299
Berge TM, Veerkamp JSJ, Hoogstraten J The etiology of childhood dental fear: the role of dental and conditioning experiences. J Anxiety Disord. 2002; 16:321-329
De-Jongh A, Muris P, Hors GT, Duyx M Acquisition and maintenance of dental anxiety: the role of aversive experiences and cognitive factors. Behav Res Ther. 1995; 33:205-210
Berggren U, Meynert G Dental fear and avoidance: causes, symptoms, and consequences. J Am Dent Assoc. 1984; 109:247-251
Hofmann SG Cognitive processes during fear acquisition and extinction in animals and humans: implications for exposure therapy of anxiety disorders. Clin Psychol Rev. 2008; 28:199-210
Ost LG, Hugdhal K Acquisition of blood and dental phobia and anxiety response patterns in clinical patients. Behav Res Ther. 1985; 23:27-34
Freeman R A psychodynamic theory for dental phobia. Br Dent J. 1998; 184:170-172
Bayer TL, Coverdale JH, Chiang E, Bangs M The role of prior pain experience and expectancy in psychologically and physically induced pain. Pain. 1998; 74:327-331
Zajonc RB Feeling and thinking: preferences need no inferences. Am Psychol. 1980; 35:151-175
Law A, Logan H, Baron RS Desire for control, felt control, and stress inoculation training during dental treatment. J Pers Soc Psychol. 1994; 67:926-936
De Jongh AD, Muris P, Ter Horst G, Van Zuuren F, Schienmakers N, Makkes P One-session cognitive treatment of dental phobia: preparing dental phobics for treatment by restructuring negative cognitions. Behav Res Ther. 1995; 33:947-954
Holmes RD, Girdler NM A study to assess the validity of clinical judgement in determining paediatric dental anxiety and related outcomes of management. Int J Paediatr Dent. 2005; 15:169-176
Freeman R, Clarke HM, Humphris GM Conversion tables for the Corah and Modified Dental Anxiety Scales. Community Dent Hlth. 2007; 24:49-54
Humphris GM, Freeman R, Campbell J, Tuutti H, D'Souza V Further evidence for the reliability and validity of the Modified Dental Anxiety Scale. Int Dent J. 2000; 50:367-370
Humphris GM, Dwyer TA, Robinson PG The modified dental anxiety scale: UK general public population norms in 2008 with further psychometrics and effects of age. BMC Oral Health. 2009; 9
Stouthard ME Prevalence of dental anxiety in the Netherlands. Comm Dent Oral Epid. 1990; 18:139-142
Leong KJ, Roberts GJ, Ashley PF Perioperative local anaesthetic in young paediatric patients undergoing extractions under outpatient ‘short-case’ general anaesthesia. A double-blind randomised controlled trial. Br Dent J. 2007; 203
Mellor A Management of the anxious patient: what treatments are available. Dent Update. 2007; 34:108-114
Chadwick BL Assessing the anxious patient. Dent Update. 2002; 29:448-454
Coulthard P, Bridgman CM, Gough L, Longman L, Pretty IA, Jenner T Estimating the need for dental sedation. 1. The Indicator of Sedation Need (IOSN) – a novel assessment tool. Br Dent J. 2011; 211
Gregersen TS Nonverbal cues: clues to the detection of foreign language anxiety. Foreign Lang Ann. 2005; 38:401-409
London: BMJ Group; 2011
Modigliani A Embarrassment, facework, and eye contact: testing a theory of embarrassment. J Pers Soc Psychol. 1971; 17:15-24
Davey GCLChichester: Wiley; 1987
McCartan D, Bell R, Green JF, Campbell C, Trimble K, Pickering A, King DJ The differential effects of chlorpromazine and haloperidol on latent inhibition in healthy volunteers. J Psychopharmacol. 2001; 15:96-104
Gabbard GOWashington, DC: American Psychiatric Publishing; 2004
Leichsenring F Are psychodynamic and psychoanalytic therapies effective?: a review of empirical data. Int J Psychoanal. 2005; 86:841-868
Racker HMadison, CT, USA: International Universities Press; 2001
Dental anxiety: understanding is the key to effective management Farooq Ahmed Imran A Quddus Mohammad O Sharif Khaleel Ahmed Dental Update 2024 43:9, 707-709.
Authors
FarooqAhmed
BDS(Hons), MFDS RCSEdin, MSc, MOrth RCSEng
Post CCST Orthodontics, Barts and the London Dental Hospital, (farooq.ahmed@postgrad.manchester.ac.uk)
Dental anxiety (DA) is a common problem; the latest Adult Dental Health Survey (UK) reported nearly half of the adult population experienced anxiety when visiting the dentist. Given individual differences in the experience of dental anxiety, it is important for the dentist to understand its development, detection and management. This article aims to provide an overview of the main psychological theories to explain the development of dental anxiety (behavioural, psychoanalytical and cognitive), as well as an overview of anxiety detection and management techniques from a psychological perspective.
CPD/Clinical Relevance: Dental anxiety is a common barrier to oral healthcare, with nearly half of the UK population affected. By understanding its causes, effective management can reduce anxiety, and therefore barriers to achieving high standards of oral health can be overcome.
Article
Dental Anxiety (DA) affects nearly half of the adult population in the UK,1 and has been defined as distress or uneasiness of mind caused by fear of danger or misfortune: importantly this is different from phobia which is irrational fear that leads to compelling desire to avoid the situation.
Historically, anxiety associated with dentistry has been related to the expectation of pain.2 However, despite advances in pain control, DA management techniques and the advent of ‘preventive dentistry’ (that should now form the core of modern day treatment plans), DA is still a significant barrier to dental care for an unchanged proportion of the population.3,4,5,6,7 Moderate to severe dental anxiety affects 75% of 12-year-olds and 49% of adults.1,8 Individuals who are dentally anxious innately avoid dental care; 41% of irregular attendees attribute their attendance patterns to DA.6 Consequently, clinicians experience on average two weeks of failed attendance per year due to failed appointments.9
The effects of DA extend to an individual's general wellbeing; one report has shown that it causes sleep disturbance, negative thoughts and feelings of low self-esteem and confidence.10
Understanding how DA develops can inform its management and help decrease the likelihood of cancellations, missed appointments and irregular attendance.11,12
The purpose of this article is to provide the reader with an overview of common DA theories, detection of DA, and management through psychological methods. Common and straightforward examples are presented, relevant to GDPs.
Development of dental anxiety
The development of dental anxiety pertains to three prominent theories:
Behavioural;
Psychoanalytical; and
Cognitive anxiety.
Behavioural anxiety
This theory is based on learning; it proposes that anxiety is a learned response to certain situations. There are two principal processes attributed to the development of behavioural anxiety: direct conditioning and vicarious learning.
Direct conditioning
An unscheduled traumatic event occurs when an individual's immediate environment becomes unpleasant. Connections are made between things that are not harmful and those that have caused the pain.12 Therefore, in future, the anxiety elicited by the traumatic event can be triggered by any sensory stimulus (eg sight, smell, etc) associated with the unscheduled traumatic event.
An example of this is a patient attending a routine dental appointment, which develops into a painful restoration (unscheduled traumatic event). Next time the patient attends for a routine dental appointment it may lead to a heightened level of anxiety at merely sitting in the dental chair (conditioned stimuli). This is known as direct conditioning.13
Direct conditioning is an important factor in the development of DA. Research shows that well over half (68%) of patients with dental anxiety acquire it through conditioning (Figure 1)14
Figure 1. Diagrammatic development of direct conditioning.
Vicarious learning
This process describes how feelings of anxiety are acquired through observation, identification or indirect suggestion by family members, peers and role models.15 A common dental example is school children teasing each other and telling frightening stories regarding the dental setting and the instruments used by the dentist. This can lead to the build-up of anxiety about visiting the dentist which will surface at the thought of this activity without necessarily any direct experience. Twelve percent of patients with dental anxiety have been shown to trace the anxiety back to vicarious learning.16
Psychoanalytical
Freud, from his clinical observation, suggested that early childhood experiences determine adult behaviour. Therefore, feelings associated with childhood experiences were transferred to other situations when the two situations had elements in common. This resulted in a misunderstanding known as ‘false connections’, in which feelings associated with the original situation were displaced onto another.17
A patient may stay away from the dental setting for many years due to bad experiences in childhood. Examples include waking up with blood in the mouth after a general anaesthetic, or receiving restorative treatment with insufficient local anaesthesia. These unpleasant experiences often transfer onto other situations such as seeing blood or having dental instruments in or near the mouth.
Cognitive
This theory proposes that anxiety develops when an individual's thought processes about future events are negative or when the potential negative consequences of the events are overestimated.18 In addition, this theory accounts for anxiety that arises when individuals do not know what to anticipate, ie fear of the unknown.19
Individuals expecting pain from dental encounters are generally more likely to be anxious. This can lead to a greater intensity of pain experienced in the dental setting20,21 and consequently individuals may avoid future dental treatment, a behaviour which propagates negativity and reinforces the original idea of pain association.20,22 For example, a patient who had not attended a dentist for over 20 years, because ‘everything goes wrong’;23 the principal evidence for this was based on a friend's experience of a ‘bad injection’.
Detection of dental anxiety
In a large number of cases, clinical impression alone will alert the clinician to the presence of anxiety. Physical signs of anxiety are clear and are listed in Figure 2.24,25,26 Subjective assessment of anxiety by the clinician relies on the refined communication skills of the dentist. This method of determining anxiety levels has been shown to be equally successful to the use of formalized questionnaires, when the clinician has an understanding of the psychological causes of anxiety.27
Figure 2. Physical signs of anxiety.24,25,26
Detecting anxiety in adults
For adults, the Modified Dental Anxiety Scale (MDAS)27 is a brief five item questionnaire which can be used pre-assessment to identify patient anxiety levels (Figure 3).28 The reliability and validity of the MDAS has been proven, with most patients finding it quick and easy to complete.29,30 MDAS also acts to alert the dentist to the presence and extent of anxiety, and therefore allows treatment to be managed appropriately.9,31
Figure 3. The Modified Dental Anxiety Scale (1995).26
Detecting anxiety in children
In children, picture tests such as the Venham Picture test28 can be used, where children can indicate their level of anxiety by picking out or pointing to a picture that illustrates their perceived emotion32 (Figure 4). The images commonly used are faces with a value of 1–8, with 8 representing higher dental fear. The Venham Picture Test has been shown to be a reliable and valid measure of DA in children aged 8–12 years.32
Figure 4. Venham Picture Test, anxiety questionnaire for children, reliable from the age of eight.28
Management of dental anxiety
Dental anxiety management techniques have been well reported33,34 and can be divided into two main categories:
Pharmacological; and
Non–pharmacological.
These techniques aim to instil a positive attitude to dentistry.35 Success at resolving anxiety in patients can be improved by clinicians having an understanding of the theory behind each individual's anxiety, as this will govern the decision of the most appropriate management technique.36
The following section on management will not be exploring the traditional management techniques associated with DA (eg tell show do, sedation, etc.) but will aim to explain as an overview from a basic psychological perspective the management of the previously discussed anxiety theories.
Behavioural anxiety
To alleviate this common form of anxiety two main principles exist:
Latent inhibition is defined as: ‘a measure of reduced learning about a stimulus to which there has been prior exposure (of negative consequences) without any consequence’.38 In this management technique the ‘conditioned stimulus’ is experienced several times without the ‘unscheduled traumatic event’, in order that the association of the paired events is weakened, lessening the feelings of anxiety. For example, after a painful experience in the dental chair, sitting in the dental chair several times without having any painful stimulus could weaken the association of the dental setting with anxiety (Figure 5).
Figure 5. Management of Latent inhibition.
Result evaluation
Result evaluation refers to the process of literally evaluating the ‘result’ of the event (‘conditioned stimulus’ and an ‘unscheduled traumatic event’) and where the patient decides whether the result is a favourable outcome, outweighing the anxiety experienced. If so, the feeling of anxiety is changed by the knowledge that such an experience results in a greater good. For example, a patient requiring extensive dental treatment to obtain a stable dentition may overcome the associated anxiety in order to have a healthy dentition, ie the greater good (Figure 6).
The aim is to provide patients with successful coping strategies in times of stress through the insight of the subconscious conflicts maintaining their problems.39 This method involves establishing a good rapport with patients and utilizing various strategies to carry out the treatment.40 Strategies include analysing the current issue and: exploring childhood memories, analysing defensive characteristics, facilitating the patient in transferring the subconscious negative notions from themselves to the clinician (known as transference).41 In the example of having anxiety of dental instruments in or near the mouth, exploration of the childhood memory of insufficient local anaesthetic, and its displacement to all dental instruments in close proximity to the patient, will give patients awareness of their subconscious conflict. By showing empathy, and discussing the hallmark features of effective local anaesthesia alongside patients' ability to have other implements near/in their mouths (for example, a toothbrush/fork), without anxiety, can help customize individual coping strategies.
Cognitive
Cognitive strategies involve reappraisal and restructuring of negative thought processes by exploring and challenging the value in the patient's life. Coping promotes patients to seek statements from people they trust which in turn helps patients cope with DA.
In the example given previously, concerning a patient who concluded ‘everything goes wrong’, the patient was challenged on the over-generalization, which was based on an injection around an inflamed site. It was explained to the patient that this would cause pain due to the heightened pressure in the vessels, and that this was necessary to remove the tooth. In addition, the patient was asked if he thought it was reasonable, on the basis of this event, to draw the conclusion that ‘everything goes wrong’. After some time in thought, the patient realized that it was an irrational conclusion and that such a negative way of thinking would not be of help. Immediately after the session he had reduced his rating of the statement.
Conclusion
Dental professionals should have a working understanding of the development of DA in order to cater for patients' needs effectively. The use of an empathetic approach catering for the specific cause of anxiety and employing an appropriate management technique is more likely to result in treatment completion.
This article has highlighted the continual problem of DA experienced in a significant proportion of patients.5 Behavioural sciences were only incorporated into the dental UK undergraduate programmes in 1997.42 This would suggest that the majority of practitioners have no formal training of psychological aspects of DA development, detection and management. We have therefore provided an overview of the main theories attributed to the development of DA, techniques to detect and quantify anxiety, as well as an overview of the changes in thought processes required to help reduce the experiences of DA. We hope that the dental examples provided will allow the GDP to relate theory to practice.
