# data[].attributes.body
This would be helpful in answering the question as it describes why preventing dental anxiety is important.

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This is a scholarly source because it is written by research professionals for dental professionals using complex language and features a list of references.

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Dental anxiety can contribute to poor oral health and should be prevented to improve quality of life. Prevention measures begin at the source, the dentist and office. Various techniques can be implemented to ensure positive experiences at the dentist.

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This would be helpful in answering the research question because there are numerous in-depth strategies for easing dental anxiety as a dentist.

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This is a scholarly source because it is written by a scholar in the field for professionals in the field with specialized vocabulary and a list of references at the end.

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This article discusses how dentists and other dental professionals can help their patients manage dental anxiety and why it is important. Dental anxiety can greatly impact a person's quality of life and therefore it is important to address and treat it. "Management of dental anxiety should be an integral part of clinical practice" and treatment should be tailored to the individual. There are a number of techniques that have been proven to work and should be regularly implemented.

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This would be helpful in answering the research question because it gives direct advice to dentists about how to ease dental anxiety.

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This is a trade source because it is written by someone in the field for other professionals in the field.

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This article discusses 7 ways to help your patients with dental anxiety as a healthcare provider; "provide ways to assess dental fear", "offer pre-treatment sessions whenever possible", "create good distractions", "develop trust through good communication", "assert professionalism", "create a professional atmosphere", and "wear the right uniforms"

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This would be helpful in answering the research question because it describes that dental anxiety is exogenous and endogenous.

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This is a scholarly source because it is a researcher from the field describing their research findings and results.

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This study looked at why people might have dental anxiety or what may have caused it. They found that dental anxiety is "exogenous factors such as direct learning from traumatic experiences, vicarious learning through significant others and the media, and endogenous factors such as inheritance and personality traits."

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This source would be helpful because it describes the correlation between various variables and dental anxiety.

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This is a scholarly source because it is a researcher describing the results of research.

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This study looked at the correlation between the PPE that dental providers were wearing and anxiety in children. It found that:
- There is no association between the type of face mask used and dental anxiety
- There is "association between gender and previous dental visits"
- There is "no association between age and dental anxiety"

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This source would be somewhat helpful because it states that there is no correlation between dental anxiety and the type of dental office, so it is determined that this is not a cause of dental anxiety.

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This is a scholarly source because it was written by a researcher with original research findings.

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This study was on the impact of different kinds of dental offices on the prevalence of dental anxiety, if a certain specialty maybe causes more anxiety. Research found that "the type of dental office has no effect on dental anxiety" and the journal further discusses the prevalence of dental anxiety and which populations are more likely to have it.

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This is a helpful source because it does a good job answering the question by providing strategies to treat dental anxiety.

# data[].attributes.body
This is a trade source because it is written by a professional in the dental industry for other dental professionals.

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This article suggests a number of ways to improve symptoms of dental anxiety from a provider standpoint.
- "Practice mindfulness": Do some breathing exercises
- "Take a break to move": Stop the treatment and get up and stretch or walk around
- "Create a calm environment": Play some relaxing music or display calming images
- "Build connections": Make sure patients are comfortable around you and other staff
- "Meet fear with kindness": Approach anxious patients kindly to ease anxiety

# data[].attributes.body
This is a helpful source because it shares coping techniques for those who suffer from dental anxiety.

# data[].attributes.body
This is a trade source because it is written by someone in the field and published to a trade site (American Dental Association) and is directed towards dental professionals.

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Describes strategies for dealing with dental anxiety; speak up, which includes explaining to your dentist that you struggle with this phobia, distract yourself, which includes occupying yourself with other things such as music or fidget toys, and mindfulness techniques such as breath counting.

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This source is helpful because it explains the different types of dental anxieties and treatment options to go with.

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This is a popular source because it is written on a blog by an author who is not a dentist or in the dental field. Additionally, there are advertisements that do not relate to the field.

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- There are different types of dentophobia; the dentist, pain, numbness, sounds and smells, and needles
- Health complications can be a result of dentophobia
- Different therapies can be helpful, such as cognitive-behavioral therapy, medications, or hypnosis

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Why Are People Afraid of the Dentist? Observations and Explanations, L. Beaton, R. Freeman, G. Humphris, Scholarly

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Why Are People Afraid of the Dentist? Observations and Explanations, L. Beaton, R. Freeman, G. Humphris, Scholarly

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Abstract

Objective

The aim of this review was to explore the peer-reviewed literature to answer the question: 'Why are people afraid of the dentist?'

Method

Relevant literature was identified by searching the following on-line databases: PubMed, PsycInfo, the Cochrane Library and Google Scholar. Publications were extracted if they explored the causes and consequences of dental fear, dental anxiety or dental phobia.

Results

The research evidence suggests that the causes of dental fear, dental anxiety or dental phobia are related to exogenous factors such as direct learning from traumatic experiences, vicarious learning through significant others and the media, and endogenous factors such as inheritance and personality traits. Each individual aetiological factor is supported by the evidence provided.

Conclusions

The evidence suggests that the aetiology of dental fear, anxiety or phobia is complex and multifactorial. The findings show that there are clear practical implications indicated by the existing research in this area: a better understanding of dental fear, anxiety and phobia may prevent treatment avoidance.

Key Words: Dental anxiety, Dental phobia, Aetiology

Introduction

Dental anxiety, or dental fear, is estimated to affect approximately 36% of the population, with a further 12% suffering from extreme dental fear [ 1]. This anxiety can have serious repercussions in terms of an individual's oral health, and it is considered to be a significant barrier to dental attendance [ 2] resulting in poor attendance. This is known as dental avoidance and can lead to poor oral health or the necessity for specialist dental care [ 3]. High dental anxiety has also been shown to influence the quality of life, with low oral health-related quality of life associated with high dental anxiety [ 4, 5]. Indeed, 73% of participants in a study by McGrath and Bedi [ 5] reported believing that their oral health affected their life quality. If dental fear affects oral health status, dental attendance and the quality of life, then it is important for dental practitioners to understand the concepts and aetiology of dental fear, dental anxiety and/or dental phobia. Therefore, the aim of this review was to explore the peer-reviewed literature to answer the question: 'Why are people afraid of the dentist?'

Literature Search

Relevant literature was identified by searching the following on-line databases: PubMed, PsycInfo, the Cochrane Library and Google Scholar. Search terms included subject heading and key words relevant to the causes and consequences of dental fear, dental anxiety and dental phobia. Publications from this search were examined and included if they explored specifically the causes and consequences of dental fear, dental anxiety or dental phobia.

Concepts of Dental Fear, Dental Anxiety and Dental Phobia

The first to adopt the term 'dental anxiety' was Coriat [ 6], who defined it as 'an excessive dread of anything being done to the teeth' with the result that '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'. Coriat [ 6] suggested that a fear of the dentist was 'anticipatory anxiety' because it stemmed from a fear of real danger and an anticipated unknown danger.

The terms 'dental fear' and 'dental anxiety' are frequently used interchangeably, and the umbrella term 'dental fear and anxiety' (DFA) will be used in this paper. However, dental phobia is sometimes considered to be a separate concept; Lautch [ 7] 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'. Freeman [ 2] also stressed the importance of avoidance being present in dental phobia, stating that dental phobia cannot be diagnosed purely from the presence of dental anxiety - the patient's history of dental experiences must also be considered.

With regard to 'dental phobia', current research suggests that it is actually one end of a continuum of dental anxiety [ 1, 8]. As Freeman [ 8] noted, a continuum of dental anxiety explains the differences in intensity of anxiety, as well as the differences that exist regarding the underlying causes. Evidence for this continuum comes from the results of the Adult Dental Health Survey 2009 [ 1]. It was noted that over the previous two Adult Dental Health Surveys the prevalence of dental anxiety had decreased considerably (possibly due to improvements in pain reduction [ 9]) but the incidence of extreme dental fear, or dental phobia, had remained constant, suggesting that for those who are classified as 'dentally phobic' there are more complex underlying causes of their fear. The notion of a continuum is supported by the two dominant measures of dental anxiety: the Dental Anxiety Scale (DAS) [ 10] and the Modified Dental Anxiety Scale (MDAS) [ 11, 12]. The MDAS has an empirically devised cut-off point where scores above a certain level indicate the possibility of dental phobia, rather than dental anxiety, as follows: 5-9 = not dentally anxious, 10-18 = fairly dentally anxious, and 19-25 = very dentally anxious/dentally phobic [ 13].

In both the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) and the International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD-10) [ 14], there is no specific definition for dental anxiety; instead, it is understood as a specific phobia (table ). One way to differentiate between dental anxiety and dental phobia is to consider the impact the anxiety has on normal functioning, i.e. if it interferes with an individual's occupation, or social activities, or if the individual is distressed by his/her anxiety then this individual would meet the DSM-IV criteria for a specific (dental) phobia [ 15].

Table 1

Classification manual

Definition of 'specific phobia'

DSM-IV

'Marked and persistent fear that is excessive or unreasonable, cued by the presence or anticipation of a specific object or situation ... Exposure to the phobic stimulus almost invariably provokes an immediate anxiety response ... The phobic situation is avoided or is endured with intense anxiety or distress.'

ICD-10

'Phobic anxiety disorders (are) a group of disorders in which anxiety is evoked only, or predominantly, in certain well-defined situations that are not currently dangerous. As a result these situations are characteristically avoided or endured with dread. (Specific phobias are) phobias restricted to highly specific situations. Though the triggering situation is discrete, contact with it can evoke panic.'

One way of examining the relationship between function and dental phobia is to study the interaction of DFA and oral health status. In a longitudinal study following a large sample of adolescents in New Zealand from age 15 to 18 years, Kruger et al. [ 16] found that high dental anxiety was predictive of dental caries in adolescents; dentally anxious patients had the highest levels of caries severity among the sample. This finding was confirmed by an epidemiological study of 374 male army soldiers whose dental anxiety and dental status were measured [ 17]. Dentally anxious soldiers had significantly more carious teeth than those who were less anxious. In addition, Thom et al. [ 18] found that in a study of German participants with a specific (dental) phobia, as measured by the DSM-IV, a quarter of participants' teeth were in a state of decay and required treatment. When compared with the general German population, those with extreme dental fear had a higher prevalence of decayed teeth. The above observations of the existence of oral health disparities in those with extreme dental fear [ 16, 17, 18, 19, 20] not only highlight the consequences of DFA for oral health function but also support the idea that a specific dental phobia exists [ 15].

The Aetiology of DFA

Locker et al. [ 19] studied the age of onset of dental anxiety in a survey of 1,420 adult participants, 16.4% of whom were assessed as being dentally anxious. Half of those who were dentally anxious reported that their dental fear started in childhood. This relationship between dental anxiety and childhood onset reinforces the need to understand the aetiology of dental fear in order to prevent the potential for oral disease in adulthood. This proposition is supported by ten Berge [ 20], who stated the importance of targeting children at risk for DFA. Indeed, when Akbay Oba et al. [ 21] examined the relationship between DFA and dental caries in 275 children, they reported that the number of decayed, missing or filled teeth increased as dental fear increased. This further highlights the importance of addressing the issue of DFA in children to prevent the negative effects on oral health.

To understand these aetiological factors, Eli et al. [ 22] assessed patient dental anxiety using the Dental Anxiety Survey, and psychological distress profiles were determined by the Symptom Check List (SCL-90). Patients were asked to complete a dentist evaluation questionnaire. It was shown that the best predictor of dental anxiety was the patient's evaluation of their present dentist followed by previous dental anxiety. The three SCL-90 dimensions of patient interpersonal sensitivity, anxiety and phobic anxiety correlate with present dental anxiety. Therefore, a patient's dental anxiety was negatively correlated with a positive evaluation of their dentist.

It is important, therefore, to understand each aetiological factor associated with DFA in terms of exogenous and endogenous sources of DFA in order to improve patients' oral health and quality of life and to increase dentists' awareness and understanding of the dentally anxious patient [ 9].

Exogenous Sources of DFA

The term 'exogenous' means that the source of an individual's anxiety is external, and it is understood by current research to be due to direct traumatic experiences or indirect vicarious experiences [ 16].

Direct Previous Traumatic Experiences

It has been reported that individuals with high levels of DFA often attribute their anxiety to their experience of a traumatic past dental event. Locker et al. [ 23] referred to this as 'conditioning via aversive treatment experience'. In a study of phobic patients [ 24], 61% reported that their phobia stemmed from 'conditioning experiences'.

It has been suggested that when the traumatic dental episode occurs in childhood it has a lasting effect with regard to adult DFA. As previously mentioned, Locker et al. [ 19] found that half of those suffering from DFA developed their fear or anxiety in childhood, highlighting the need to understand how children acquire DFA. ten Berge et al. [ 25] examined how children acquire dental fear, specifically with regard to invasive treatment experiences. Regression analysis showed that there was a significant relationship between child DFA and the number of extractions a child had experienced; suggesting that one of the causes of DFA was invasive dental treatment. An interesting additional finding by ten Berge et al. [ 25] was that children who had experienced more check-up visits before they experienced their first curative treatment (i.e. they had a longer history of non-invasive experiences) reported low levels of dental fear. This suggests that the longer the child continues to have a positive experience when visiting the dentist the less likely they are to become dentally fearful whenever they do eventually have a negative experience, referred to as latent inhibition.

An important part of the child dental experience is the interaction with dental staff, yet this is a relatively underresearched topic in terms of dental anxiety. However, research in this area suggests one possible way of reducing dental anxiety, by highlighting specific behaviours that increase or reduce anxiety. Zhou et al. [ 26] collected research from 11 publications in a systematic review examining the impact of dental care professionals' clinical behaviours on child DFA. A relationship existed between dental staff behaviour and child DFA, with punishing behaviours associated with high child DFA. To reduce DFA, they suggested that practitioners adopt an empathic communication style, verbal explanation and reassurance.

Of particular importance when discussing past child dental experiences is the role memory plays in maintaining DFA. Kent [ 27] examined dental patients' memory of pain by comparing patients' remembered pain 3 months after treatment with their expected and experienced pain. Kent [ 27] found that there was a closer association between remembered and expected pain than there was between remembered and experienced pain. This association was particularly strong in patients who scored high on the DAS. Kent hypothesized that dental anxiety might be maintained because the anxious patients have inaccurate memories of the pain they experienced during treatment. The view of Kent [ 27] was supported by Freeman [ 28], who demonstrated that memories of unpleasant past dental experiences were greater in dentally anxious patients than in non-anxious patients, with dentally anxious patients reporting more experiences of traumatic dental events, thereby indicating that the cause of DFA is more complex than simply a negative past dental experience.

Humphris and King [ 29] examined the impact of previous distressing experiences upon dental anxiety. One thousand and twenty-four students participated and completed the MDAS and an assessment of their susceptibility (Level of Exposure-Dental Experiences Questionnaire; LOE-DEQ) [ 30]. The authors found that 11% of the sample reported high dental anxiety. The local anaesthetic injection was the most feared item. With regard to past traumatic dental treatment, participants who reported a distressing experience were two and a half times more likely to experience high dental anxiety [ 29]. Humphris and King [ 29] stated that experience of a dental treatment trauma was most predictive of DFA.

Moreover, Humphris and King [ 29] showed that other distressing experiences could be displaced onto dental treatment resulting in DFA. They reported that sexual assault victims were almost two and a half times more likely to report high dental anxiety compared to participants who had not experienced sexual assault. Similarly, Leeners et al. [ 31] found that women with an experience of sexual assault reported DFA related to lying flat in the dental chair, and they found that those with a history of sexual abuse had a more pronounced gagging reflex and higher DFA [ 32]. These findings highlight the point that it is not just previous, negative dental experiences that can cause subsequent DFA but also other traumatic experiences far removed from the dental surgery.

Indirect Vicarious Experiences

Vicarious learning is defined as indirect learning from role models, such as family members or peers, or external sources such as the media [ 22].

In a systematic review and meta-analysis of 43 experimental studies about parental and child dental fear, Themessl-Huber et al. [ 33] confirmed that there was a significant relationship between child and parental dental fear. The interplay between both the mother's and the father's dental fear was further examined and it was found that, in a family, both the mother's dental anxiety and the father's dental anxiety are significant predictors of child DFA [ 34]. Similarly, Locker et al. [ 19] found an association between the onset age of dental anxiety and a family history of dental anxiety, which would confirm that vicarious learning is a potential cause of DFA. Specifically, Locker et al. [ 19] found that 56% of participants who reported child onset dental anxiety had a parent or sibling who also suffered anxiety about dental treatment. This suggests that, as children, these participants indirectly learned their anxious response to dental treatment by observing the behaviour of those around them. The authors noted that the association with a family history of dental anxiety only existed with child onset anxiety, which confirmed the findings of Öst [ 35] that child onset phobias were more likely to develop through vicarious learning compared to those phobias that have their onset in adulthood.

In a qualitative study of DFA in children and adolescents, Gao et al. [ 36] analysed videos from YouTube about dentistry. Twenty-seven videos that involved 32 children and adolescents were analysed for the 'manifestations and impacts of dental fear and anxiety' and the 'origins of dental fear and anxiety'. 'Influence of parents and peers' emerged as an important point in DFA causation. For children parental teasing and for adolescents hearing stories from their friends about negative dental experiences were the root of the development of DFA [ 36]. Influences from friends and family members are therefore considered to be the most relevant when considering DFA in children [ 33], whereas for DFA in adolescents it is the impact of the peer group which is believed to be more important [ 36, 37].

Examining the impact of the media upon DFA, Oosterink et al. [ 38] asked 1,464 participants to complete the LOE-DEQ measure, which contains questions about their experiences of frightening stories told in the media about dental treatment. They found no significant difference between those who had and had not been exposed to frightening stories in the media. In contrast, Humphris and King [ 29] found that individuals with high DFA were almost two and a half times more likely, compared to the rest of their sample, to have heard about or seen frightening stories about dental treatment in the media. Therefore, the evidence base concerning the influence of vicarious learning and the impact of the media remains equivocal.

Endogenous Sources of DFA

The term 'endogenous' relates to the idea that individuals are dentally anxious for internal reasons, such as personality traits. Locker et al. [ 19] has referred to internal aetiological factors as a 'constitutional vulnerability to (dental) anxiety disorders'.

Heritability

Ray et al. [ 39] tested the hypothesis of a genetic component of DFA. In their longitudinal study of over 2,000 twins (the Swedish Twin Study of Child and Adolescent Development), the authors measured DFA and dental fear intensity. These measures took the form of 3 dental fear questions answered by selecting yes or no, and a single question about the intensity of the dental fear. Data were collected when participants were 13-14 years old and again 3 years later. A genetic component in dental fear/anxiety was found, and the heritability was shown to be higher in girls than in boys. No such gender difference was found for dental fear intensity. These findings not only fill a gap in the literature but they also provide an interesting addition to theories of the antecedents of DFA.

Personality Traits

The predominant model of personality, in current psychological research, is the 5-factor model which divides personality into 5 traits: (a) openness to experience, (b) conscientiousness, (c) extraversion, (d) agreeableness and (e) neuroticism [ 40, 41]. Neuroticism and extraversion are the two traits that are predominantly related to DFA [ 40]. Costa and McCrae [ 41] define these traits as follows:

Extraversion involves warmth, excitement seeking and assertiveness.

Neuroticism involves aspects of anxiety, self-consciousness, hostility and depressive symptoms.

Neuroticism has been shown to have a strong association with a propensity to experience anxiety [ 42]. Therefore, in a study of 880 students at 4 Finnish universities, participants' dental anxiety and the above 5 personality traits were measured. Halonen et al. [ 40] reported that dental anxiety was significantly and positively correlated to neuroticism, and significantly but negatively correlated to extraversion. These results suggest that individuals who are highly neurotic or introverted are more likely to experience dental anxiety.

Cognitive Ability

In a study examining anxiety in a dental setting, 40 children (age 8-16 years) who did not have a previous experience of visiting the dentist had their intelligence measured by the Wechsler Intelligence Scale of Children (WISC III). Toledano et al. [ 43] found that children with high intelligence quotients showed less anxiety than others at their first visit to the dentist. Blomqvist et al. [ 44] expanded on this research by measuring the relationship between cognitive ability (measured by the WISC III) and specifically DFA (measured by the Children's Fear Survey Schedule Dental Subscale) in 70 children. They found a significant negative correlation between DFA and verbal intelligence. No other significant relationships were found between DFA and other aspects of intelligence. This finding suggests that children with a high verbal intelligence suffer from less dental anxiety. This may be understood by considering how valuable being able to express and ventilate anxious feelings and explain coping strategies may be when entering a stressful environment such as a visit to the dentist [ 44].

Consequences of DFA for Dental Practice

The relationship between DFA and avoidance has been described as a 'vicious cycle' [ 45, 46] or, as Klepac et al. [ 47] stated: the 'possible confounding of oral health and fear level is one manifestation of the vicious cycle ubiquitous in neglected health concerns, wherein neglect leads to increased health concerns that render avoidance more likely, etc.' This hypothesis, first proposed by Berggren [ 45] in 1984, suggests that DFA leads to avoidance of dental care, which results in neglect of dental treatment and subsequently poor oral health. This is compounded by feelings of embarrassment [ 48] and shame, as well as by the likelihood that when a dentally anxious patient attends after a long period of avoidance they will need more invasive treatment [ 3] which has the potential to reinforce DFA and further, future avoidance (fig. ).

The model of Berggren [ 45] of the vicious cycle has been supported by recent studies that have sought to test and expand this theory [ 46, 50]. De Jongh et al. [ 46] validated the model of Berggren [ 45] by demonstrating that the deterioration of dental health status exacerbated the effects of dental avoidance, resulting in poorer oral health status, together with increased negativity associated with receiving dental treatment.

More recently, Armfield [ 50] considered the vicious cycle by measuring DFA, the frequency of dental visits and treatment needs in 1,036 dentate Australians. He found that 39% of people with moderate to high dental fear fit the cycle of 'avoiding dental visiting because of fear, having treatment need and visiting for a problem' compared to only 1% of people without dental fear, thereby supporting the vicious cycle model, with dental fear acting as a determinant of dental avoidance.

Despite the evidence supporting the impact of dental anxiety upon dental attendance, the authors [ 45, 46, 50] did not examine the relationship between previous frightening dental treatment experiences and the onset and maintenance of dental anxiety. Moreover, they did not provide an explanation for the observation that not everyone who has an unpleasant treatment experience enters the vicious cycle of dental anxiety.

Willumsen et al. [ 51] examined this in more detail. She posited an internal vicious cycle in which she hypothesized that patients perceive dental treatment as threatening. In response, patients experience increasing muscular tension and increased blood pressure and sweating, which further increases their dental anxiety. These physical sensations may be perceived as a threat to the patient's internal world, leading to feelings of panic and anxiety. This internal vicious cycle and misinterpretation of bodily sensations is a modification of Clark's cognitive model of panic [ 52] in which panic attacks are said to be caused by a 'catastrophic misinterpretation' of sensations such as palpitations or dizziness as being symptoms of a more serious condition.

Conclusions and Practice Implications

Dental anxiety and dental phobia represent points on a continuum and may reflect complex psychological problems that have significant effects on the lives of the individuals that suffer from them, whether they cause avoidance, increased dental caries or poor oral health-related quality of life. Therefore, it is necessary to consider how best to treat dental anxiety and phobia to prevent poor oral health in the future. As De Jongh et al. [ 53] noted, clinical experience and data from research suggests that general dental practitioners are capable of effectively treating patients with dental anxiety, but when a patient is phobic they should be referred to secondary level care such as psychological or pharmacological management.

There are clearly many different aetiological factors in the development of DFA, with evidence supporting theories of exogenous and endogenous causes such as past experiences, role models, the media, genetics, personality, and intelligence. An individual may have had a negative experience of visiting the dentist in the past, with evidence suggesting that DFA is more likely to have occurred in childhood, may have known someone who had a past negative experience, or may have the kind of personality traits that make him/her more likely than normal to be susceptible to anxiety. A person may be afraid of the dentist for one or all of these reasons, or even due to an interaction between them. Indeed, an individual who is highly neurotic may be subsequently more vulnerable to a negative experience than someone who is highly extraverted. This was summarized succinctly by Liddell and Locker [ 54] when they stated that: 'It is impossible to say from this study whether the experiences were, in fact, very traumatic, or whether the subjects were more sensitive to them.'

This review has highlighted the complexity of the multifactorial aetiology of dental fear, anxiety and phobia. The implications for dental practice are associated with knowing the degree to which the patient's fears prevent dental attendance, the history of the patient's dental anxiety and how the role of exogenous and endogenous factors impact the patient's DFA. Revealing these important aetiological factors will allow the dentist to tailor her/his treatment to the dental anxiety needs of the patient and thereby reduce patient fear and diminish workplace stress.

References

8. Freeman R. Points of care: question 1. J Can Dent Assoc. 2005;71:341-342.

20. ten Berge M. Dental Fear in Children: Prevalence, Etiology and Risk factors. Amsterdam: Universiteit van Amsterdam; 2001. pp. 69-80.

28. Freeman R. The role of memory on the dentally anxious patient's response to dental treatment. Ir J Psychol Med. 1991;8:110-115.

41. Costa PT, Jr, McCrae RR. NEO PI-R Professional Manual. Odessa: Psychological Assessment Resources; 1992.

42. Matthews G, Deary IJ, Whiteman MC. Personality Traits. ed 2. Cambridge: Cambridge University Press; 2003. pp. 344-350.

45. Berggren U. Dental fear and avoidance: a study of etiology, consequences and treatment. Göteborg: Göteborg University; 1984.

51. Willumsen T, Haukebø K, Raadal M. Aetiology of dental phobia. In: ÖM L, Skaret E, editors. Cognitive Behavioural Therapy for Dental Phobia and Anxiety. Chicester: Wiley-Blackwell; 2013. pp. 45-59.

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Why Are People Afraid of the Dentist? Observations and Explanations

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The aim of this review was to explore the peer-reviewed literature to answer the question: 'Why are people afraid of the dentist?' Relevant literature was identified by searching the following on-line databases: PubMed, PsycInfo, the Cochrane Library and Google Scholar. Publications were extracted if they explored the causes and consequences of dental fear, dental anxiety or dental phobia.

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Helping Your Patients Overcome Dental Anxiety, Trade

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Helping Your Patients Overcome Dental Anxiety, Trade

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Helping Your Patients Overcome Dental Anxiety

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Dental anxiety has been putting a lot of Americans’ oral health at risk. Here’s how you can help your patients overcome their fear of the dentist.

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5 Tips to Reduce Anxiety and Stress in Dentists Patients During Their Visit, Trade

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5 Tips to Reduce Anxiety and Stress in Dentists Patients During Their Visit, Trade

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The past few years have been more stressful than most.

More than 70% of dentists surveyed by the ADA Health Policy Institute in 2021 saw an increase of patients experiencing teeth grinding and clenching, conditions often associated with stress. Meanwhile, the 2021 Dentist Well-Being Survey Report found dentists are reporting higher level of stress at work.

Take the stress out of your patient's next visit with five quick tips to support your patient's dental and emotional health. These strategies can help your patient and the whole dental team feel more at ease.

1. Practice mindfulness
Mindfulness might sound intimidating, but it can be as simple as taking a few deep breaths. Here's a basic breathing exercise you can practice and teach your patients.

Mark Abramson, D.D.S., founder and facilitator of Mindfulness-Meditation Based Stress Reduction programs at Stanford Health Care and Stanford University School of Medicine defines mindfulness as "non-judgmental, moment to moment awareness" and reminds us that we are already mindful in so many areas of our lives. Bringing this mindfulness to our practice and patients can help ease stress and fear.

Take a moment to watch this series created specifically for you, your dental teams and your patients.

2. Take a break to move
Moving can help get us out of our heads and back into our bodies. Dental professionals should make sure they're moving and stretching throughout the day. Bethany Valachi, D.P.T., walks you through the ergonomic impact of dentistry during a pandemic and offers ways to get back on track for your overall health.

Patients should also be encouraged to take a break and stretch if that would help their anxiety. Talk to your patients at the beginning of their appointment and agree on a time interval to take a break or a way they can signal you that they need to pause.

3. Create a calm environment
Create a peaceful environment for you and your patients as much as you can. It's helpful to play relaxing music and set your TV to display calming images. Offer patients something to do with their hands, like a stress ball or fidget spinner they can use during their appointment and take home with them.

4. Build connections
Above all, build connections with your patients. Developing trust over time can improve patient communication, make it easier for them to tell you what they need and help you anticipate their needs to have a great appointment. Jessica Nguyen, D.D.S., explains that connecting to her patients on a personal level helps her gain their trust.

Taking the time to listen is key, especially if patients have experienced a traumatic dental surgery. Dr. Nashid Ahmed believes that by hearing their stories, we can help change that familiar old phrase, "I hate the dentist!"

5. Meet fear with kindness
Dr. Abramson reminds us that when patients come in with fear, the stage is set for a negative experience. Instead of reacting negatively to fear, he recommends meeting it with kindness. Learning to identify and manage fear in ourselves can help us share calm with our patients. Dr. Abramson discusses his own experience with trauma and mindfulness in this short video.

For more information on how to reduce stress, listen to Ben Bernstein, Ph.D., a performance psychologist specializing in stress reduction and performance enhancement for dentists. And remember that it can be easy to rush from one thing to the next, but truly connecting with ourselves and with our patients takes time and practice.

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5 tips to reduce anxiety and stress in dentists patients during their visit

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The past few years have been more stressful than most. More than 70% of dentists surveyed by the ADA Health Policy Institute in 2021 saw an increase of patients experiencing teeth grinding and clenching, conditions often associated with stress. Meanwhile, the 2021 Dentist Well-Being Survey Report found dentists are reporting higher level of stress at work.

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The Prevalence of Dental Anxiety in Dental Practice Settings, A. M. White, L. Giblin, L. D. Boyd, Scholarly

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The Prevalence of Dental Anxiety in Dental Practice Settings, A. M. White, L. Giblin, L. D. Boyd, Scholarly

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Abstract

Purpose: The purpose of this study was to assess the prevalence of dental anxiety and missed dental appointments due to dental anxiety among patients within three types of private dental offices.

Methods: This descriptive, cross-sectional study utilized the Modified Dental Anxiety Scale (MDAS). The MDAS consists of five questions to assess dental anxiety. Demographics and an open-ended question about missed dental appointments due to dental anxiety were included. Linear and logistic regression models were used to analyze anxiety scores as related to gender and age. Participants' responses to the open-ended question were compiled according to themes.

Results: Three hundred and eight (n=308) dental patients participated in the study. Using the MDAS cut-off scores of 15 and 19, the prevalence estimates of moderate to high and high dental anxiety within the total study population was 19% and 6.82% respectively. Females had an MDAS score 2.12 times higher than males (p<0.05). For every one unit increase in age, the MDAS score was 0.08 units lower (p<0.05). Out of the 308 participants, 26 (8.4%) responded to missing a dental appointment due to dental anxiety. Five common themes were coded as the source of dental anxiety: fear of dental experience, previous negative dental experience, cost of treatment, gag reflex, and fear of bad news.

Conclusions: Moderate to high dental anxiety was present in 19% of the population sampled. Awareness of patients' dental anxiety level and the utilization of anxiety reducing measures during treatment may encourage routine care.

Introduction

Dental anxiety is characterized by a physical and/or emotional response to a perceived threat. This threat does not always have to be physically present, as the mere idea of an uncomfortable situation can provoke feelings of uneasiness and apprehension. In the dental office setting, this perceived threat could be a painful injection or procedure, the discomfort of keeping one's mouth open for an extended period of time, or a lengthy and costly treatment plan. It is important to differentiate dental anxiety from fear and a phobia: fear is an emotional and/or physical response to what is perceived as a more distinct and immediate threat; phobia is associated with overwhelming feelings of fear that can cause a severe hindrance to daily activities. A study of 1,959 individuals comparing the prevalence of fears and phobias, such as snakes and physical injuries, identified dental fear present among 24.3% of the participants, fear of snakes was 34.8%, and fear of physical injuries was 27.2%.

According to researchers, anywhere 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.1 A patients's perceptions may influence their level of anxiety. For example, if a patient expects pain during a scaling procedure, they are more likely to report highter anxiety levels. Additionally, there is an association between frequent gagging and higher anxiety levels. Research has also shown possible correlations between dental anxiety, missed appointments, avoidance of care, and a greater need for more extensive treatment. Avoidance of care refers to a refusal to seek care or to follow recommended treatment plans and can often result in a greater need for treatment.

Dental Anxiety

In terms of high dental anxiety, research has shown the prevalence to range anywhere from 10 to 20% in adult populations. Humphris et al. examined the prevalence of dental anxiety among a representative sample (n=11,382) of adults aged 16 years and older from the general population in England, Wales, and Northern Ireland using the Modified Dental Anxiety Scale (MDAS). They reported the prevalence of high dental anxiety in 11.6% of their study population. Two other studies from India and France suggest 46% of patients had some degree of dental anxiety; with 6 to 16% being moderately anxious, 17.33% being highly anxious, and 7 to 12.67% being extremely anxious. The overall prevalence reported was between 11.6 to 12.67%.

Results from the aforementioned studies indicated that women tend to have greater anxiety than men, anxiety decreases with age, and those with higher anxiety receive less regular dental care. Also, those with previous negative dental experiences were more anxious than those with no history of previous negative experiences. Limitations include cross-sectional study designs, self-reported bias, and lack of generalizability; but apart from these limitations, a valid, reliable scale was used to assess dental anxiety.

Use of Dental Anxiety Assessments

Since research has shown a possible correlation between dental anxiety and avoidance of care, assessing anxiety prior to treatment would increase awareness for dental staff so that anxiety-reducing measures could be incorporated into patient care. Using the Level of Exposure Dental Experiences Questionnaire (LOE-DEQ) and the MDAS, Humphris and King determined that "extreme helplessness" during treatment was the most influential experience affecting anxiety levels and recommended the use of these questionnaires so the dental team can plan appropriate treatment patients with identified dental anxiety. It would seem appropriate to administer an anxiety assessment such as the MDAS to determine whether patients are suffering from dental anxiety, as research has shown it to be a valid, reliable scale. Any concern that using these assessments may increase patients' anxiety prior to treatment is unfounded, as current research shows otherwise.

A United Kingdom (UK) study by Dailey et al. revealed a lack of use of anxiety assessments among a relatively large sample of dentists. Of the 269 questionnaires included in the final analysis, the most frequently used assessment for adults was the MDAS; only 54 dentists (20%) used adult dental anxiety assessments, and only 31% of the 54 dentists used them often or always, while 69% used them sometimes or rarely. Studies in other countries have also supported the use of the MDAS in terms of reliability and validity. Even with its ease of use, it seems that dentists may not be regularly employing such a survey to assess anxiety among their patients.

The purpose of this study was to determine the prevalence of dental anxiety among a convenience sample of patients within three types of dental offices: general, endodontic, and periodontal; to identify possible correlations between dental anxiety, age, gender, and missed appointments; and to reveal, in their own words, what patients feel is the source of their dental anxiety.

Methods and Materials

This cross-sectional study, approved by the Massachusetts College of Pharmacy and Health Sciences (MCPHS) University Institutional Review Board (IRB), assessed the level of dental anxiety and missed dental appointments due to anxiety among a convenience sample of patients in three different types of dental offices: a general dental office that offers sedation dentistry, an endodontic office, and a periodontal office, all located in Framingham, Massachusetts. Inclusion criteria included anyone over 18 years of age. Exclusion criteria included: those under age 18, those who were unable to read and write English, those who failed to provide consent, and those who failed to fully answer the questionnaires.

Informed consent was obtained and the ability to refuse to participate at any point during the study was provided along with the dental anxiety questionnaire. The questionnaire included demographic questions regarding the type of dental office age, gender, and level of dental anxiety. Figure 1 shows the MDAS, which was used to assess dental anxiety. Participants were asked to respond to the questions based on their level of agreement. Possible responses include: not anxious, slightly anxious, fairly anxious, very anxious, and extremely anxious. Using a Likert scale, not anxious is equal to a score of 1, slightly anxious is equal to a score of 2 and so on. The sum of all five questions can range from 5 to 25, with 5 being not anxious and 25 being extremely anxious. Any score of 19 or higher indicates a highly anxious patient. Similar research using this survey determined any score of 11 or higher indicative of moderate to high dental anxiety. One open-ended question was included to ask if patients had ever missed a dental appointment due to their anxiety and, if so, what they believed was the source of their dental anxiety.

Data collected from the survey was downloaded into Microsoft Excel and imported into STATA® statistical software version 11.2 for analysis. As per the survey responses, demographics including age, gender, and dental office type were enumerated using frequency percentiles and summary statistics. Differences in age and gender across dental office type were assessed via ANOVA and Fisher's Exact Test. Modified Dental Anxiety Scale (MDAS) scores were tabulated for each survey. MDAS scores were assessed as both a linear continuous outcome and a binary outcome (MDAS score ≥19). Using the binary outcome (MDAS score ≥19) as an indicator of dental anxiety, dental anxiety prevalence across dental office types was enumerated with exact Binomial 95% Confidence Intervals. The prevalence of moderate to high dental anxiety (MDAS score >15) was determined as a percentage of the entire study population.

Univariate and multivariate linear and logistic regression models were used to assess associations between age and gender on MDAS scores (both continuous and binary). Qualitative analysis was used to analyze answers from the one open-ended question on missed appointments and dental anxiety. Themes were identified among all participants' answers and coded accordingly.

Results

There were a total of 308 participants; 200 from the general dental office, 99 from the endodontic office, and 9 from the periodontal office. Table I shows the demographic characteristics of the study population; 59% of participants were females; the mean age of the study population was approximately 52 years (SD 14.7 years) with an age range between 18 and 90 years. Mean MDAS score for the total study population was 10.19; with 10.06 from the general dental office, 10.59 from the endodontic office, and 9.22 from the periodontal office. Using the cut-off score of ≥19, the prevalence estimate of high dental anxiety within the total study population was 6.82% (Exact Binomial 95% CI: 4.27%-10.23%); 5% within the general dental office (Exact Binomial 95% CI: 2.42%-9.00%), 3.16% within the endodontic office (Exact Binomial 95% CI: 5.68%-19.01%), and 0% within the periodontal office (Exact Binomial 95% CI: 0.00%-33.63%). Using the cut-off score of >15, the percentage of participants with moderate to high dental anxiety was 19%.

Table II shows univariate and multivariate logistic regression models using the MDAS score as a binary variable based on the cut-off score of ≥19. As per the MDAS score ≥19 cutoff, the odds of dental anxiety is 3.19 (95% CI 1.05, 9.71) times greater for females than males. The univariate association between binary MDAS score and age was not found to be statistically significant. A multivariate logistic regression model includ-ing both gender and age showed little change in the estimated odds ratios for gender and age respectively, with additional controlfor office type showing little change with identical inference (odds ratio for gender 3.28; 95% CI 1.06, 10.01).

Table III shows univariate and multivariate linear regression models for the MDAS scores when used as a continuous variable. Females had a mean MDAS score 2.12 points higher than males (95% CI 1.09, 3.15), with mean MDAS score 0.08 points lower for each one-year increase in age (95% CI −0.12, −0.05). A multivariate linear regression model including both age and gender showed little change in the estimated regression coefficients. Additionally controlling for office type showed little difference in the estimated regression coefficients for age and gender on mean MDAS score, leading to identical inference.

As per the qualitative analysis, 26 participants (8.4%) responded to missing a dental appointment due to dental anxiety; 17 from the general dental office, 8 from the endodontic office, and 1 from the periodontal office. Five common themes were coded as being the source of dental anxiety: fear of dental experience (8), previous negative dental experience (13), cost of treatment (2), gag reflex (1), and fear of bad news (2).

Discussion

The results of this study indicate there was no statistically significant difference in the prevalence of high dental anxiety among different types of dental offices. This suggests the type of dental procedure being performed may not be a significant factor in terms of dental anxiety. The prevalence estimate of 6.82% for high dental anxiety among the study population is lower than expected when compared to other studies, which indicate a prevalence of 10-20%. However, the percentage of the study population with moderate to high dental anxiety (19%), suggests that a substantial portion of the patient population suffers from some degree of anxiety and would benefit from anxiety-reducing measures during treatment.

Similar to other research findings, this study found a statistically significant difference in dental anxiety between males and females, with females reporting higher levels of dental anxiety. This study also found that high dental anxiety decreases with increased age, which was similar to other findings. For participants who reported missing an appointment due to dental anxiety, a common theme among a majority of the participants was having had a previous negative dental experience as the source for their dental anxiety, similar to other research findings.

There are several limitations to this study. The overall response rate of 308 is low; the response rate of 9 for the periodontal office is too low to draw any significant conclusions for this type of office specifically and also makes it difficult to compare data between the three offices. The mean age of the patients was 52 years, suggesting that young adults and elderly populations may not have been adequately represented in this sample. Participants were not asked if it was their first visit to the office and those who were new patients may have been more likely to feel anxious compared to those who had been receiving care at a familiar office for a period of time. All three offices were located in one community, making it difficult to generalize results to other populations. Another limitation is the cross-sectional design of the study, which does not allow for causality to be shown. Also, studies such as this one, using self-reported data, are likely to introduce bias into the study results, as participants may not answer questions honestly or may misunderstand what a question is asking.

Suggestions for future research include longitudinal studies to examine possible correlations between gender, age, socioeconomic status and dental anxiety. It is important to survey those who do not regularly seek care at dental offices, as research suggests that those with high dental anxiety may avoid regular care altogether. For this reason, it would be beneficial to reach out to a larger segment of the population; not limited to those who are actually arriving for treatment at a dental office. Further research should also be conducted to examine possible correlations between dental anxiety and missed appointments, as well as whether the use of dental anxiety assessments in dental offices improves patient outcomes. A qualitative research design could provide a deeper understanding of sources of dental anxiety as well as anxiety-reducing measures that patients feel would lover their dental anxiety.

Conclusion

Although it may be helpful to assess the prevalence of dental anxiety among a more representative sample of the population as in previous studies, dental offices may directly benefit from assessing the prevalence of anxiety among their patient population. Dental hygienists are in a unique position to assess patient comfort and to educate patients on dental anxiety and coping mechanisms. Anxiety assessments such as the MDAS are arguably an easy, reliable way to assess dental anxiety so that care can be more patient-centered and effective. Being aware of patients' anxiety may contribute to the dental professionals' establishment of a trusting rapport and thus encourage routine care in an effort to help patients maintain optimal oral health.

Footnotes

Angela M. White, RDH, MS, is a graduate of the Master of Science program at the Forsyth School of Dental Hygiene, MCPHS University, Boston, Massachusetts. Lori Giblin, RDH, MS, is an Assistant Professor and Linda J. Boyd, RDH, RD, EdD, is a Professor and Dean at the Forsyth School of Dental Hygiene, MCPHS University, Boston, Massachusetts.

This manuscript supports the NDRHA priority area, Client level: Oral health care (new therapies and prevention modalities).

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The Prevalence of Dental Anxiety in Dental Practice Settings

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Purpose: The purpose of this study was to assess the prevalence of dental anxiety and missed dental appointments due to dental anxiety among patients within three types of private dental offices. Methods: This descriptive, cross-sectional study utilized the Modified Dental Anxiety Scale (MDAS). The MDAS consists of five questions to assess dental anxiety.

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Are You Afraid of Going to the Dentist?, Lisa Fritscher, Popular

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Are You Afraid of Going to the Dentist?, Lisa Fritscher, Popular

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Dentophobia, or fear of dentists, is a common phobia among people of all ages. It is sometimes related to iatrophobia, or fear of doctors, as well as trypanophobia, or fear of needles. Dentophobia may be mild or severe, and can eventually lead to devastating consequences.

Types of Dentophobia

Dentophobia can be divided into numerous elements. Most people with this phobia fear more than one element, while those with severe dentophobia may fear all or most elements simultaneously.

The dentist - Like doctors, IRS auditors and others in commonly feared professions, "The Dentist" is often cast as cold and unfeeling at best, or sadistic at worst. If you have had a negative personal experience with a particular dentist, you may be more prone to this phobia.

Pain - Until relatively recently, completely painless dentistry was difficult or impossible. Even today, some procedures may involve a slight amount of pain. Many people are extremely sensitive to mouth pain and fear that the pain may be excruciating.

Numbness or Gagging - Some people, particularly those who have experienced choking or difficulty breathing, are afraid of having their mouths numbed. You might worry that you will be unable to breathe or swallow.

Sounds and Smells - Many people, particularly those who have had previous bad experiences with dentists, are afraid of the sounds and smells of a dentist's office, particularly the sound of the drill.

Needles - If you have a needle phobia, you might be extremely afraid of the injections that dentists use to numb the mouth.

Complications of Dentophobia

Whether due to genetics or simple luck, dental health varies dramatically from person to person. Some people are able to last for years between dentist visits with little or no impact on their teeth or gums. Others are prone to decay and gum disease, no matter how frequently they brush and floss. If you are not one of the lucky few, dentophobia can have real consequences in your life.

Tooth decay tends to worsen over time. Small cavities that once could have been easily filled can lead to broken and rotten teeth, requiring expensive and invasive root canal therapy and reconstructive work. This knowledge can, in turn, make you even less likely to seek treatment, creating a vicious cycle.

In the modern world, we are expected to have clean, healthy, shiny teeth. If yours become broken and rotted due to decay and neglect, you might experience a social stigma. It may become more difficult to get certain jobs. Dating might be impacted and even your friends may start to talk. This can lead to isolation, depression, social anxiety and even agoraphobia.

In some cases, dental problems can cause infection. Failure to treat the infection could cause it to spread, causing medical illness. Infected tissues also hurt, so pain is not an uncommon effect of dentophobia.

Coping With Dentophobia

If your dentophobia is severe and paralyzing, it is best to consult with a trained mental health professional before beginning dental treatment. Cognitive-behavioral therapy, medications, and hypnosis can help you get your fear under control.

Once your phobia is at a manageable level, you will be able to visit the dentist. However, it is important to choose the right dentist. Today's dentistry is much different than what you may remember. Nonetheless, not all dentists use the same tricks and techniques to assist patients with phobias.

It is always acceptable to schedule an initial consultation without a full exam and workup. When you call for the appointment, explain that you suffer from dentophobia and are not ready to book a full exam. This initial appointment will allow you to develop a rapport with the dentist and get used to his manner and demeanor.

As you progress to further appointments, remember that you are always in control. Work out a signal with your dentist that you can use when you need a break, and a different signal to let the dentist know that you need more anesthetic. Even such matters as how far back the chair is tilted and the order of work performed can be discussed in advance.

Many people like to bring a portable music player or even DVD system to their appointments (remember your earphones!). Some dentists offer these devices or even virtual reality systems. These items can distract you and help you relax.

Dentophobia is a common and treatable phobia. Untreated, however, it can lead to a range of physical difficulties. See a mental health professional first to bring your phobia under control, and then search for a dentist that makes you feel comfortable. Finding a dentist that you fully trust is worth the effort.

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Article Sources

American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th Ed.). Washington, DC: Author.

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Dentophobia, or fear of dentists, is a common phobia among people of all ages. It is sometimes related to iatrophobia, or fear of doctors, as well as trypanophobia, or fear of needles. Dentophobia may be mild or severe, and can eventually lead to devastating consequences. Dentophobia can be divided into numerous elements.

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Strategies to manage patients with dental anxiety and dental phobia: literature review, Deva Priya Appukuttan, Trade

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Strategies to manage patients with dental anxiety and dental phobia: literature review, Deva Priya Appukuttan, Trade

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Abstract

Dental anxiety and phobia result in avoidance of dental care. It is a frequently encountered problem in dental offices. Formulating acceptable evidence-based therapies for such patients is essential, or else they can be a considerable source of stress for the dentist. These patients need to be identified at the earliest opportunity and their concerns addressed. The initial interaction between the dentist and the patient can reveal the presence of anxiety, fear, and phobia. In such situations, subjective evaluation by interviews and self-reporting on fear and anxiety scales and objective assessment of blood pressure, pulse rate, pulse oximetry, finger temperature, and galvanic skin response can greatly enhance the diagnosis and enable categorization of these individuals as mildly, moderately, or highly anxious or dental phobics. Broadly, dental anxiety can be managed by psychotherapeutic interventions, pharmacological interventions, or a combination of both, depending on the level of dental anxiety, patient characteristics, and clinical situations. Psychotherapeutic interventions are either behaviorally or cognitively oriented. Pharmacologically, these patients can be managed using either sedation or general anesthesia. Behavior-modification therapies aim to change unacceptable behaviors through learning, and involve muscle relaxation and relaxation breathing, along with guided imagery and physiological monitoring using biofeedback, hypnosis, acupuncture, distraction, positive reinforcement, stop-signaling, and exposure-based treatments, such as systematic desensitization, "tell-show-do", and modeling. Cognitive strategies aim to alter and restructure the content of negative cognitions and enhance control over the negative thoughts. Cognitive behavior therapy is a combination of behavior therapy and cognitive therapy, and is currently the most accepted and successful psychological treatment for anxiety and phobia. In certain situations, where the patient is not able to respond to and cooperate well with psychotherapeutic interventions, is not willing to undergo these types of treatment, or is considered dental-phobic, pharmacological therapies such as sedation or general anesthesia should be sought.

Keywords: behavioral therapy, cognitive therapy, general anesthesia, psychotherapeutic intervention, pharmacological intervention, conscious sedation

Introduction

Fear and anxiety toward the dentist and dental treatment are both significant characteristics that contribute to avoidance of dental care. 1, 2 Anxiety associated with the thought of visiting the dentist for preventive care and over dental procedures is referred to as dental anxiety. It has been cited as the fifth-most common cause of anxiety by Agras et al. 3 Anxiety is an emotional state that precedes the actual encounter with the threatening stimuli, which sometimes is not even identifiable. It is normally experienced in day-to-day life, such as during exams, while making crucial decisions, in the workplace, and in several other circumstances.

Fear is a reaction to a known or perceived threat or danger. It leads to a fight-or-flight situation. Dental fear is a reaction to threatening stimuli in dental situations. Phobia is persistent, unrealistic, and intense fear of a specific stimulus, leading to complete avoidance of the perceived danger. Overwhelming and irrational fear of dentistry associated with devastating feelings of hypertension, terror, trepidation, and unease is termed "odontophobia", and has been diagnosed under specific phobias according to the Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV and the International Statistical Classification of Diseases and Related Health Problems (ICD)-10. 4

Both dental anxiety and fear evoke physical, cognitive, emotional, and behavioral responses in an individual. This is a frequently encountered problem in dental offices. Anxiety is often closely linked to painful stimulus and increased pain perception, and thus these patients experience more pain that lasts longer; moreover, they also exaggerate their memory of pain. 5, 6 Treating such anxious patients is stressful for the dentist, due to reduced cooperation, requiring more treatment time and resources, ultimately resulting in an unpleasant experience for both the patient and the dentist. 7, 8 Eli suggested that a strained dentist-patient relationship dominated by severe anxiety resulted in misdiagnosis during vitality testing for endodontic therapy. 9

Fearful and anxious individuals feel that something dreadful is going to happen during dental treatment, and hence do not visit the dentist. Such behavior ultimately results in bad oral health, with more missing teeth, decayed teeth, and poor periodontal status. 10 They present to the dental office only when in acute emergency situations often requiring complicated and traumatic treatment procedures, which in turn further exacerbates and reinforces their fear, leading to complete avoidance in the future. Consequently, a vicious cycle of dental fear sets in if these patients are not managed appropriately (). 11- 14

Cohen et al reported that dental anxiety affects an individual's life in multiple ways. The physiological impacts included signs and symptoms of the fright response and feelings of exhaustion after a dental appointment, while the cognitive impacts included an array of negative thoughts, beliefs, and fears. The behavioral impacts included not only avoidance but also other behaviors related to eating, oral hygiene, self-medication, crying, and aggression. A significant impact on general health due to sleep disturbance was also reported, which influenced both established and new personal relationships. Furthermore, social interactions and performance at work were affected, due to feelings of low self-esteem and self-confidence. 15

Owing to such widespread significant impacts, it is of utmost importance not only to efficiently identify dentally anxious individuals but also to treat them appropriately when they arrive at the dental office. The practitioner should aim at alleviating the anxiety and fear in such a way that these patients are positively motivated on a long-term basis for future dental visits. This concise review gives an overview of the etiology of dental anxiety, and strategies to identify and manage anxious or phobic individuals in the dental office, with brief literature evidence.

Etiology of dental anxiety

Dental anxiety can arise due to multiple factors, such as previous negative or traumatic experience, especially in childhood (conditioning experiences), vicarious learning from anxious family members or peers, individual personality characteristics such as neuroticism and self-consciousness, lack of understanding, exposure to frightening portrayals of dentists in the media, the coping style of the person, perception of body image, and the vulnerable position of lying back in a dental chair. 16- 19 Anxiety can also be provoked by sensory triggers such as sights of needles and air-turbine drills, sounds of drilling and screaming, the smell of eugenol and cut dentine, and also sensations of high-frequency vibrations in the dental setting. 20- 22

Some common fears giving rise to dental anxiety are fear of pain, 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 on the dental chair, and lack of control during dental treatment. Milgrom et al identified four different groups of anxious patients based on their origin or source of fear (the "Seattle system", developed at the University of Washington). They were 1) anxious of specific dental stimuli, 2) distrust of the dental personnel, 3) generalized dental anxiety, and 4) anxious of catastrophe. 23, 24

Identifying dentally anxious or phobic patients

The initial interaction of the dentist with the patient can fairly reveal the presence of anxiety and fear, and in such situations, subjective and objective evaluations can greatly enhance the diagnosis for successful management.

Semistructured interview and subjective assessment using questionnaires

Semistructured interview

The dentist must have a calm, uninterrupted conversation with the patient and try to identify which of the dental situations gives rise to fear and anxiety. Asking a few open-ended questions can help to guide the conversation in the right direction. The dentist needs to identify the reason for the current visit, the kind of experience the patient has had during previous dental treatment, the main fears and worries, and the expectations. Sometimes, the interview may reveal that the dental anxiety is part of a wider psychological disorder. In those cases, it is important that the patient be referred to experts in the field of psychology, such as a psychologist or psychiatrist. They can make the correct psychological diagnosis, and decide what kind of further treatment the patient needs. In some cases, the psychologist and the dentist need to work together, with the former deciding the treatment plan concerning anxiety.

Anxiety questionnaires

Multiple- and single-item self-reporting questionnaires are available for assessing anxious and phobic patients. A few such popularly used multi-item scales are Corah's Dental Anxiety Scale (CDAS), 25 Modified Dental Anxiety Scale (MDAS), 26 Spielberger State-Trait Anxiety Inventory, 27 Kleinknecht et al's Dental Fear Survey (DFS), 28 Stouthard et al's Dental Anxiety Inventory, 29 and Gatchel's 10-point fear scale. 30 Single-item questionnaires are a Seattle survey item, 31 the Dental Anxiety Question, 32 a Finnish single dental anxiety question, 33 a single-item dental anxiety-and-fear question, 34 and the visual analog scale. 35 However, none of these existing instruments has been regarded as a gold standard, as they have their own limitations. The CDAS, MDAS, and DFS are the most commonly used questionnaires, and have been shown to be reliable and valid in multiple languages. 34, 36

The CDAS is a widely used instrument; it is brief and has good psychometric properties. The scale consists of four questions about different dental situations. Each question is scored from 1 (not anxious) to 5 (extremely anxious), so the range of possible scores is 4-20. The cutoff point of more than 15 indicates high anxiety level or possibly phobic. The major limitation of this scale is that it does not include a question on anxiety regarding local anesthetic injection, and also there is no uniformity in the choices for the questions in the scale, making it difficult to compare the responses. 25

The MDAS is a brief, well-validated five-item questionnaire with 5-point Likert scale responses to each question, ranging from "not anxious" to "extremely anxious". The responses are scored from 1 to 5. The score for the scale ranges from a minimum of 5 to a maximum of 25. The higher the score, the higher the dental fear, and a cutoff point for high dental fear has been suggested at a score of 19, based on clinical relevance. 26 Humphris and Hull reported that the administration of this questionnaire did not increase anxiety. 37

The DFS consists of 20 items concerning avoidance behavior, physiological fear reactions, and different fear objects concerning dental appointments and treatment. This questionnaire also has five response options, giving summed scores from a minimum of 20 to a maximum of 100. A cutoff point for high dental fear has been suggested at ≥60. The scale has three dimensions: avoidance of dental treatment, somatic symptoms of anxiety, and anxiety caused by dental stimuli. 28, 38

Based on these questionnaires, patients can be categorized as mildly anxious, moderately anxious, and extremely anxious or dental-phobic. Literature evidence on the use of such questionnaires in routine clinical practice is very scarce. Dailey et al reported that only 20% of dentists used these questionnaires in their practice in the UK. 39 The practitioner should not rely exclusively on clinical judgment in assessing anxious patients, as studies indicate that there is disagreement between patient self-reported anxiety status and clinician rating of dental anxiety; moreover, patients report masking their anxiety, and hence evaluation with brief anxiety questionnaires is beneficial and recommended, as it not only discloses the degree of anxiety but also appears to reduce it, thereby facilitating better management. 40 Subjective assessment of anxious patients can also be done based on their psychophysiological, behavioral, and emotional responses ().

Objective measures

Objective measures involve assessment of blood pressure, pulse rate, pulse oximetry, finger temperature, and galvanic skin response. An extremely accurate objective method used in various studies to measure dental anxiety is galvanic skin response. It takes advantage of the electrical changes induced by minute amounts of fluid from epidermal sweat glands released secondary to anxiety. Sweat on the skin provides a low-resistance pathway for electric current, which is then recorded. The use of galvanic skin response has been validated as an accurate method in measuring dental anxiety. 41

Management of dental anxiety

The etiology for dental anxiety is multifactorial, and hence there is no monotherapy for management. Proper evaluation of the patient and identifying their source and level of anxiety can enable the dentist in deciding a proper treatment plan. Anxiety can be triggered by even the most innocuous situations, such as the encounter with the receptionist while scheduling their appointments or clinic ambience, and thus it is essential that every aspect of the dental practice be appropriate.

Broadly, dental anxiety can be managed by psycho-therapeutic interventions, pharmacological interventions, or a combination of both, depending on the dentist's expertise and experience, degree of dental anxiety, patient characteristics, and clinical situations. 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 (). Based on specific indications, these patients can be managed pharmacologically using either sedation or general anesthesia.

Table 2

Communication skills, rapport, and trust building: iatrosedative technique

Behavior-management techniques

Relaxation techniques: deep breathing, muscle relaxation

Jacobsen's progressive muscular relaxation

Brief relaxation or functional relaxation therapy

Autogenic relaxation

Ost's applied relaxation technique

Deep relaxation or diaphragmatic breathing

Relaxation response

Guided imagery

Biofeedback

Hypnotherapy

Acupuncture

Distraction

Enhancing control

"Tell-show-do", signaling

Systematic desensitization or exposure therapy

Positive reinforcement

Cognitive therapy

Cognitive behavioral therapy (CBT)

The dental office environment

Dental office ambience can play a significant role in initiating dental fear and anxiety. Receptionists, dental nurses, and dental hygienists are crucial personnel in creating an apt atmosphere in the dental office. They should be positive and caring, and elicit information from the patients in a unhurried concerned tone to make the patients comfortable. The office atmosphere can be made calm and unthreatening by the playing of soft music and avoidance of bright lights. A slightly cooler dental office was preferred by individuals in a study by Bare and Dundes. The walls can be adorned with posters and pictures, the waiting area supplied with ample books and magazines. 42 The sounds produced from the instruments in the treatment room should be muted by closing the door. Importantly, anxious patients should not be made to wait too long, so that they have less time to absorb negative experiences; additionally longer waiting times give them time to recall the threatening stimuli. 43, 44

Introducing pleasant ambient odors to the dental environment can also help to reduce anxiety by masking the smell of eugenol and by the potential anxiolytic effects of the odors themselves. Smell can trigger an array of emotions, and can condition a patient negatively toward dental treatment. Aromatherapy is an alternative treatment approach, wherein essential oils of aromatic plants are used to produce positive physiological or pharmacological effects through the sense of smell. Inhalation of pleasant scents such as essential oils has an anxiolytic effect and improves mood. Studies have shown it to be more efficient in managing moderate rather than severe anxiety. 45- 47 In healthy individuals, inhalation of lavender has been shown to significantly reduce the levels of salivary cortisol, salivary chromogranin, and serum cortisol, increase blood flow, and decrease galvanic skin conductance and systolic blood pressure. 48, 49

A sensory-adapted dental environment (SDE) might also be effective in reducing anxiety and inducing relaxation. 50 The Snoezelen environment concept aims at stimulating the primary senses of sight, touch, feel, and smell, along with patient-centered therapy. Shapiro et al adapted a "Snoezelen" dental environment for pediatric patients comprised of dimmed lighting, soothing music, and a special Velcro butterfly vest that hugs the child, providing a calming, deep-pressure sensation. Typical children and those with developmental disabilities have been shown to benefit by this SDE, as behavioral and psychophysiological measures of relaxation improved significantly in the SDE compared with a conventional dental environment. 51, 52

Communication skills, rapport, and trust building

A good patient-dentist relationship is crucial for the management of anxiety. Communication strategies are very important. There should always be two-way communication. The dentist should first introduce themselves and personally converse with the patient in their office, and listen carefully in a calm, composed, and nonjudgmental way. 53 Proper information should be acquired from the patient regarding their dental problems and concerns, taking time to inquire and listen about their fears (iatrosedative technique). 54, 55 Furthermore, patients should be encouraged to ask questions about the treatment, and should be kept completely informed about what is to be done before starting the procedure and also during the procedure. Keep inquiring if the patients are having any discomfort, give moral support, and reassure during the procedure. The patients should be convinced that their words are taken seriously and with utmost concern. 56 Dentists should give all the necessary complete information regarding description of the problem, treatment options, and preventive procedures. This meeting should build good rapport and increase the patient's confidence in the dentist. Patients appreciate clear, honest, and straightforward answers; also avoid false reassurances, as these can break trust. Normalizing anxious feelings and avoiding negative phrasing can be beneficial. Nonverbal communications are an essential skill. Touch can be used to comfort and control the patients. The dentist should face the patient, make eye contact, and observe them; this is a positive gesture. Avoid rapid movements, empathize with the patients, and make them feel welcome, and use understandable words when talking about the treatment. Usually, a friendly, sensitive, and sympathetic approach will be well appreciated by patients. 57

Psychotherapeutic management

Behavior-management techniques

Behavior modification is based on the principles of learning, both in terms of classical conditioning or operant conditioning and of social learning. It aims to change undesirable behavior in certain situations through learning. The strategies involve relaxation along with guided imagery and adjuvant use of physiological monitoring using biofeedback, hypnosis, acupuncture, distraction, positive reinforcement, stop-signaling, and exposure-based treatments, such as systematic desensitization, "tell-show-do", and modeling.

Relaxation techniques

A relaxation response is the opposite of a stress response, and when practiced regularly it not only lowers stress and anxiety levels but also enables an individual to cope with the symptoms of anxiety. This can be achieved by both deep breathing and muscle relaxation. Once a person is physically relaxed, it is impossible to be psychologically upset at the same time. Anxiety-provoking stimuli give rise to physical tension, which in turn increases the person's perception of anxiety.

Multiple relaxation techniques have been proposed, such as Ost's applied relaxation technique, Jacobsen's progressive muscular relaxation, functional relaxation, the rapid-relaxation technique, autogenic relaxation, and relaxation response. Dentists need to familiarize themselves with these techniques, and if required undergo special training before they can implement them in practice. Once the patient is identified as anxious, these techniques can be taught even before they sit on the dental chair.

Guided imagery

Guided imagery has been defined as a directed, deliberate daydream that uses all the senses to create a focused state of relaxation and a sense of physical and emotional well-being. It is a mind-body exercise, wherein patients are taught to develop a mental image of a pleasant, tranquil experience that consciously guides their attention to achieve relaxation, thereby reducing anxiety. There are generally three stages to guided imagery: relaxation, visualization, and positive suggestion. 67 Imagery can be a pleasant place such as a beach, mountains, lake, or a safe place, and should be engaging and customized to each patient. Patients can be allowed to choose their own mental image or they can be guided by using scripts by the dentist. They are instructed to create a scenario full of specific, concrete details, along with sound, smell, and colors of the scene. This technique produces wonderful, soothing relaxation throughout the body. It can be used along with relaxation techniques and CBT. Studies have shown the effectiveness of guided imagery in the treatment of distress, mood, and anxiety symptoms associated with chronic pain, social anxiety disorder, attention deficit/hyperactivity disorder, and cancer pain. 68, 69 It is relatively easy to learn, teach, and use in practice. It can be performed by an adequately trained dentist or with the use of audio recordings, and can be performed daily or as needed by the patient.

Biofeedback

Biofeedback is also referred to as applied psychophysiological feedback, and is a mind-body technique. Biofeedback therapies use instruments to measure, amplify, and feed back physiological information to the patient being monitored. The information assists the patient in gaining self-regulation of the physiological process being monitored. Monitoring oneself and then utilizing the information to practice and achieve self-regulation are the main goals of biofeedback. Milgrom et al showed that it is efficient in clinical settings. 70, 71 Reduction of muscle-tension levels through electromyographic biofeedback and operant conditioning of brain-wave activity through electroencephalographic biofeedback are commonly used for reducing anxiety. Recently, the use of respiratory rate-biofeedback device has been shown to reduce preoperative general anxiety levels. 72, 73 Implementing this technology into practice would require not only special instruments but also a trained dentist.

Hypnotherapy

Clinical hypnosis (from the Greek hypnos [sleep]), although criticized and misunderstood, has been successfully used in medicine and dentistry. The term "hypnosis" denotes an interaction between one person - the "hypnotist" - and another person or people - the "subjects". In this interaction, the hypnotist attempts to influence the subjects' perceptions, feelings, thinking, and behavior by asking them to concentrate on ideas and images that may evoke the intended effects. The verbal communications that the hypnotist uses to achieve these effects are termed "suggestions". Suggestions differ from everyday kinds of instructions in that they imply that a "successful" response is experienced by the subject as having a quality of involuntariness or effortlessness. 74 They can be used to induce relaxation, as an adjunct to inhalation sedation, to alleviate pain, anxiety, and stress, in reducing problems with excessive gag reflex, and may also be a part of CBT. The techniques have pre- and postsuggestion components. The presuggestion component involves attentional focusing through the use of imagery, distraction, or relaxation, and is similar to other relaxation techniques. Subjects focus on relaxation, and passively disregard intrusive thoughts. The postsuggestion component involves the continued use of the new behavior following the termination of hypnosis. Individuals widely vary in their hypnotic susceptibility and suggestibility, although the reasons for these differences are incompletely understood. It is inexpensive, and has a very low risk of side effects. The technique needs to be avoided in those with mental health problems, personality disorders, and neurodegenerative disorders. Dentists require special training before they can practice hypnotherapy.

In a meta-analytic review, it was shown that 75% of subjects experienced pain reduction following hypnosis. Studies have also shown effectiveness in anxiety reduction, allowing people to handle stressful dental treatments. 75, 76 More studies are required to validate the practicality and effectiveness of hypnosis on a routine basis in dental clinical settings.

Acupuncture

Acupuncture is a technique, 89 wherein the disease is treated by inserting needles at various points on the body, known as acupuncture points. It has been reported that acupuncture is effective in treating dental problems such as anxiety, temporomandibular dysfunction syndrome, pain, and Sjögren's syndrome. It is a simple, inexpensive treatment modality that requires special training before it can be incorporated into practice. Reports on the use of auricular acupuncture for treating chronic and acute anxiety have shown promising results. 77, 78 A randomized controlled trial comparing auricular acupuncture with intranasal midazolam for managing dental anxiety suggested that both treatment methods were similarly effective. 79 Though inconclusive, systematic reviews have suggested acupuncture as a promising therapy for the management of anxiety disorders in a dental setting. 80, 81 In a recent systematic review and meta-analysis on the effect of acupressure on anxiety, Au et al concluded that it was effective in providing immediate relief of pretreatment anxiety among adults and had a medium effect size. However, conflicting results were found for improvements on physiological indicators. 82

Distraction

Distraction is a useful technique of diverting the patient's attention from what may be perceived as an unpleasant procedure. This enables decreased perception of unpleasantness and averting negative or avoidance behavior. Giving the patient a short break during a stressful procedure can be an effective use of distraction prior to considering more advanced behavior-guidance techniques. 83 Several technological options are available for both visual and auditory distraction, such as background music, television sets, computer games, and 2-D and 3-D video glasses for watching movies. 83, 84

Suitable music has been shown to influence human brain waves, leading to deep relaxation and alleviating pain and anxiety. Music distraction is a noninvasive technique in which the patient listens to pleasant music during a stressful procedure. The effect is believed to be a combination of relaxation and distraction that in turn reduces the activity of the neuroendocrine and sympathetic nervous systems. It has been successful in both pediatric and adult dental patients. 85, 86 Music therapy can be either active or passive. The former involves a music therapist with interactive communication, while the latter involves passive listening to prerecorded music.

Enhancing control

Loss of control over the treatment procedure is a significant cause for anxiety, and hence providing control is very essential. Telling the patient what to expect, and what measures are taken to ensure their safety, will help make the treatment as comfortable as possible. Control can be provided by giving information and through behavioral control. Informational control can be achieved by the "tell-show-do" and modeling techniques.

Tell-show-do is a behavior-shaping technique that reduces uncertainty and increases predictability in the clinical setting. 83 This technique can be used for both child and adult patients. It involves verbal explanations of procedures in phrases appropriate to the developmental level of the patient (tell); demonstrations for the patient of the visual, auditory, olfactory, and tactile aspects of the procedure in a carefully defined, unthreatening setting (show); and then, without deviating from the explanation and demonstration, completion of the procedure (do). The tell-show-do technique is used with communication skills (verbal and nonverbal) and positive reinforcement. 87

Individuals learn much about their environment from observing the consequences of other people's behavior. Modeling is a technique used to alleviate anxiety. This can be achieved through observation of a dental procedure, either by viewing a videotaped model who is demonstrating appropriate cooperative behavior in the dental setting or through observation of an actual successful dental procedure. This could reduce anxiety due to "fear of the unknown", and demonstrates to the anxious patient what is considered appropriate behavior in the dental setting and what can be expected in the upcoming treatment session. When setting up a program, the following details should be taken care of: the model should be close to the age of the patient, the model should be shown entering and leaving the surgery to prove treatment has no lasting effect, and the dentist should be shown to be a caring person who praises the patient. 88

Behavioral control involves giving the patient a chance to feel that they are in control of the treatment procedure. It involves signaling to the dentist or dental hygienist to stop the procedure; this increases the patients' sense of control and trust in the dentist. A signal can be as simple as a raised hand to notify the dental practitioner that the patient would like to stop the procedure. Specific signals can be decided before the treatment commences. The dentist should stop the procedure as agreed earlier; failure to do so will breach the trust relationship. Patients can also be given mirrors to watch the procedure, so as to feel they are in control. 24

Systematic desensitization or exposure therapy

Wolpe's technique, 89 known as systematic desensitization, is based on relaxation and played a very prominent role in the evolution of behavior therapy during the 1960s and 1970s. The treatment procedure is carried out in multiple sessions. The use of systematic desensitization involves three sets of activities. Encourage the patients to discuss their status of fear and anxiety, in order to construct a hierarchy of feared dental situations, from the least to the most anxiety-provoking. Teach the patient relaxation techniques. The most commonly used techniques are breathing and muscle relaxation. The final step is to gradually expose the patient to these situations in the hierarchy, from the least to the most anxiety-promoting. 24, 88, 89

When it is difficult to expose the patient directly to the dental setting, it may be appropriate to instruct the patients to practice imaginary systematic desensitization, wherein the patients are encouraged to imagine that they are entering the dental clinic, able to sit in the dental chair, and eventually able to receive dental treatment. Flooding or implosion therapy is an intensive form of in vivo exposure therapy for treating phobias. The patient is confronted with the feared stimuli for repeated and prolonged duration until they experience a reduction in their anxiety level. The use of this technique requires more caution, due to adverse effects and limited evidence in the literature. 90

Positive reinforcement

Positive reinforcement is an effective technique to reward desired behaviors and thus strengthens the recurrence of those behaviors. Reinforcers include positive voice modulation, facial expression, verbal praise, and appropriate physical demonstrations of affection by all members of the dental team. These should be individualized, frequently provided, and varied over time. 91

Cognitive therapy

The thoughts and emotions of a person are not separate; rather, they overlap each other and behavior depends on their thoughts. Thoughts and expectations trigger different feelings and physiological reactions. Anxious patients most often have inappropriate expectations and beliefs about dental treatment. The modification of such negative cognitions is a means of reducing anxiety. Cognitive treatment strategies aim to alter and restructure the content of negative cognitions and enhance control over the negative thoughts. The patient's focus is directed away from his or her worries about the feared situation by using different cognitive techniques, such as encouragement, altering expectations, distraction, guided imagery, focusing attention, and thought stopping. 92, 93

CBT is a combination of behavior therapy and cognitive therapy. It is today the most accepted psychological treatment for anxiety related to particular situations and specific phobias. It involves learning to change negatively distorted thoughts (cognitions) and actions (behaviors). Basically, new skills are learned to manage anxiety symptoms over multiple sessions with the therapist. It is structured, problem-focused, goal-oriented, teaches proven strategies and skills, and lastly emphasizes the importance of a good, collaborative therapeutic relationship between the therapist and the patient. 94, 95 CBT treatment generally contains psychoeducation, graded exposure, cognitive restructuring, behavioral experiments, and relaxation, as well as self-assertiveness training. Self-assertiveness training aims to improve fearful patients' communication skills concerning personal opinions, feelings, and needs during dental treatment. Case reports, systematic reviews, and meta-analyses indicate that CBT is effective in reducing dental anxiety and phobia. Dentists need special training to integrate this therapy in practice. 96, 97

Technological advancements in local anesthetic administration that help alleviate anxiety

Computer-controlled local anesthetic delivery

This system represents a significant change in the manner in which a local anesthetic injection is administered, thereby alleviating anxiety in patients who fear injections or are needle-phobic. It is essentially a computer-controlled dental injection. The flow rate of the local anesthetic is controlled by a computer. A plastic handpiece is less threatening in appearance than the traditional syringe. Injecting local anesthetic solution slowly reduces tissue distension and leads to a more comfortable injection with less postoperative pain. The greater control over the syringe and the fixed flow rate of the drug are responsible for a significantly improved injection experience, as demonstrated in many clinical studies conducted with computer-controlled local anesthetic delivery devices in dentistry. 98- 100 A growing number of clinical trials in medicine have also demonstrated measurable benefits of this technology. 98- 100

Electronic dental anesthesia

This technique is used to produce dental anesthesia by using the principle of transcutaneous electric nerve stimulation. By means of electrodes, electric flow from the stimulation unit is converted into an ionic current flow in the living tissue and anesthesia is produced, offering pain control without needles, based on the gate-control theory of pain. Electrodes can be placed either extraorally or intraorally. The intraoral electrodes are cotton-roll electrodes, clamp electrodes, and adhesive electrodes. Adhesive electrodes are the most widely used. These electrodes are thin and flexible, and so can easily adapt to the oral mucosa. The technique is noninvasive, safe, and generally well accepted by the patient. Advantages of electronic dental anesthesia are as follows: there is no need for a needle, no need for injection of drugs, limited soft-tissue anesthesia, the residual analgesic effect remains for several hours, it is suitable for the needle-phobic, and there is no residual anesthetic effect at the end of the procedure. Disadvantages are the high cost of the unit are as follows: it is not suitable for all patients and all treatments, efficacy is not as predictable as with other methods of anesthesia, it requires training, and there is a learning curve, whereby initially the success rate may be low but then it increases with experience. Some studies have proposed electronic dental anesthesia to be effective and efficacious in pain control, but there are contradictions with questionable efficacy. 101- 103

Computer-assisted relaxation learning

Computer-assisted relaxation learning is a program developed to reduce fear of dental injections. It is a computer-based application utilizing principles of CBT. Individuals view a series of videos in which a fearful patient is taught coping skills and then taken through the gradual steps of a dental injection. A randomized controlled trial by Heaton et al 104 suggested that computer-assisted relaxation learning led to significant changes in self-reported fear of dental injections in the study participants. 98 A systematic review by Patel et al indicated that the overall quality of evidence for psychological treatment for injection fear or phobia is poor, and outcome measures need consensus and further development. 105

Jet injections and vibrotactile devices are other modern gadgets available for local anesthetic administration. Whether these devices are efficient in alleviating anxiety and phobia needs more exploration with randomized controlled clinical trials.

Technological advancements that help alleviate anxiety in restorative dentistry

Anxious patients who must undergo restorative procedures are often managed using the "4 S" rule or the so-called 4 S principle. This is based on eliminating four of the primary sensory triggers for dental anxiety when in the dental setting: sight (air-turbine drill, needles), sounds (drilling), sensations (high-frequency vibrations [the annoyance factor]), and smells. 21, 106 Newer methods, such as atraumatic restorative treatment, air abrasion using alumina powder streams, ultrasonic tips coated with diamond particles, chemomechanical caries removal targeting collagen in infected dentine, which are susceptible to proteolysis by sodium hypochlorite and chloramines, and lasers for cavity preparation, may reduce painful or uncomfortable aspects of dentistry, thereby reducing anxiety and fear of pain during treatment.

Pharmacological management

Indications

Pharmacological control of pain and anxiety can be achieved by the use of sedation and general anesthesia, and should be sought only in situations where the patient is not able to respond and cooperate well with psychotherapeutic interventions, is not willing to undergo this type of treatment, or is considered dental-phobic. Patients with special needs (mental retardation, autism, mental illness, traumatic brain injury) and clinical situations can also necessitate pharmacological management. 107, 108

There are a few factors to be considered prior to pharmacological management:

1. risks involved with pharmacological management when compared to behavioral therapies

2. appropriate evidence-based selection of drugs for pharmacological management

3. extent of the patient's dental needs and severity of anxiety

4. patient's cognitive and emotional needs and personality

5. practitioner skill, training, and experience

6. proper equipment and monitoring

7. cost of the procedure.

Indicator of sedation needs tool

This is an adjunct tool developed to support clinicians in deciding about need for conscious sedation. It has three indicators: anxiety, medical and behavioral, and treatment complexity. Scores for each of these indicators range from 1 to 4. Final scores sum to 3-12. A score of 3 or 4 indicates minimal need for sedation, 5 or 6 moderate need, 7-9 high need, and 10-12 suggests very high need or even use of general anesthesia. 109

Sedation is defined as the use of a drug or combination of drugs to depress the CNS, thus reducing patient awareness of their surroundings. Depending on the degree of CNS suppression, the sedation may be conscious, deep, or general. Sedation does not control pain, and consequently does not eliminate the need for the use of local anesthetics. According to the American Society of Anesthesiologists (ASA; ), patients should fulfill the demands of being classified as category ASA I (mentally and physically healthy) or ASA II (only mild systemic disease, which does not result in any functional limitation), in order to be considered a candidate for sedation. Sedation is a continuum that proceeds from minimal to deep in a dose-response manner. This continuum can be divided into levels with characteristics that have been used to design several subjective sedation scales ().

Table 6

ASA I - normal healthy patient

ASA II - patient with mild systemic disease

ASA III - patient with severe systemic disease

ASA IV - patient with severe systemic disease that is a constant threat to life

ASA V - moribund patient who is not expected to survive without the operation

ASA VI - patient declared brain-dead whose organs are being removed for donor purposes

E - emergency operation of any variety (used to modify one of the aforementioned classifications, ie, ASA III-E)

Table 7

Minimal sedation
(anxiolysis)

Moderate sedation/analgesia
(conscious sedation)

Deep sedation/analgesia

General anesthesia

Minimal sedation/anxiolysis is a drug-induced state during which patients respond normally to verbal commands. Although cognitive function and physical coordination may be impaired, airway reflexes and ventilator and cardiovascular functions are unaffected. This level is achieved with either oral sedatives alone or in combination with nitrous oxide and oxygen. This is used for managing patients with mild-to-moderate anxiety.

Moderate/conscious sedation is a drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained. This is used for managing patients with moderate-to-severe anxiety.

Deep sedation is a drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully following repeated or painful stimulation. Ability to maintain ventilatory function independently may be impaired. Patients may require assistance in maintaining a patent airway, and spontaneous ventilation may be inadequate. Cardiovascular function is usually maintained. 110, 111

General anesthesia is a drug-induced loss of consciousness during which patients are not arousable, even by painful stimulation. The ability to maintain ventilatory function independently is often impaired. Patients often require assistance in maintaining a patent airway, and positive pressure ventilation may be required because of depressed spontaneous ventilation or drug-induced depression of neuromuscular function. Cardiovascular function may be impaired.

Dental-phobic patients and those with severe learning difficulties, severe anxiety and phobias, severe psychiatric disorders, physical disability and movement disorders, and significant comorbidity, such as those with congenital disorders, in whom sedation may not be safe and perioperative monitoring is required, are candidates for general anesthesia in special care dentistry.

Conscious sedation

This is a technique in which the use of a drug or drugs produces a state of depression of the CNS, enabling treatment to be carried out, but during which verbal contact with the patient is maintained throughout the period of sedation. The drugs and techniques used to provide conscious sedation for dental treatment should carry a margin of safety wide enough to render loss of consciousness unlikely. Based on the routes of administration, conscious sedation techniques are inhalational, intravenous (IV), oral, sublingual, intranasal, intramuscular, or rectal. A thorough medical, dental, and social history must be taken and recorded to ensure that the conscious sedation technique chosen is the most appropriate to enable successful treatment outcomes for each individual, taking into account such factors as the patient's age, state of health, social circumstances, and any special needs they may have. Sedation should not be used habitually when there is no specific indication. 112, 113

The dentist and the dental team should be adequately trained and be familiar with appropriate regulations according to the country of practice. Each country has its own guidelines and advice on special training for dentists.

Inhalation sedation

This is a commonly used technique for dental sedation. A mixture of nitrous oxide (N ₂ O) and oxygen is used. Nitrous oxide has an anxiolytic and sedative effect, and also promotes muscular relaxation and analgesia. It is nonirritant for the respiratory tract, with minimal alveolar concentration and low solubility in tissues. It acts with a quick onset and rapid recovery, the entire procedure lasting only a few minutes. As a rule, 70% of patients will need 30%-40% nitrous oxide to achieve sedation. In most purpose-built equipment, there is an inbuilt safety feature that does not allow more than 70% nitrous oxide to be delivered to the patient. Most of the disadvantages of nitrous oxide relate to equipment and the logistics of safe delivery, such as operative space, cost of the equipment and supplies, and cost to the patient.

Oral sedation is an enteral technique of administration in which the drug is absorbed through the gastrointestinal tract. It is often used for the management of mild-to-moderate anxiety, and in some cases to assist the patient to have a restful night prior to the appointment. It may also be used or as an adjunct to other methods of sedation for the severely anxious. The goal is to produce a lightly sedated, relaxed, more cooperative patient that is easier to manage. Benzodiazepines are commonly used. The benzodiazepines have antianxiety, sedative-hypnotic, anticonvulsant, and skeletal muscle-relaxant properties. They exert their sedative effects by a generalized depression of the CNS. Commonly used drugs in this class are diazepam, midazolam, and triazolam.

IV sedation entails the administration of sedative agents directly into the vascular compartment. The use of IV sedation in a dental office requires additional advanced training. The main advantages of the IV route are rapid onset of action and ability to titrate to effect and control the duration of sedation. Other advantages include higher levels of efficacy than oral or inhalation sedation and IV access for emergency drugs or reversal agents if needed. The most common parenteral sedation technique involves the use of a benzodiazepine (eg, diazepam or midazolam) alone or in combination with an opioid (eg, fentanyl or Demerol).

Berggren identified four specific situations where CBT can be combined with pharmacological treatment: 114

1. When the patient has an immediate need for dental treatment because of acute dental pain. It is difficult to motivate the patient to work with their anxiety in painful conditions. Nitrous oxide sedation, or oral/IV sedation with benzodiazepines is typically the first choice, and sometimes general anesthesia may be needed.

2. When the patient has need of multiple and complex treatment with increased risk for acute dental pain. These patients are so preoccupied by their need for dental treatment that they cannot deal with their underlying fear or anxiety. They can be managed under general anesthe-sia, later followed by psychological anxiety-reducing therapies.

3. When the patient is referred to the clinic specifically for general anesthesia treatment, and categorically demands it. These patients may be motivated for anxiety treatment afterward.

4. When it may be strategic for highly motivated patients to start exposure therapy aided by mild sedation.

Psychological intervention versus pharmacological intervention

Psychological and pharmacological interventions are both equally effective in reducing dental anxiety and phobia. Response to behavioral and cognitive therapy is not immediate, and multiple sessions are usually needed to maintain an initial treatment response; however, studies have shown that dropout rates were low and reduction in anxiety or phobia was maintained over longer time periods, with more patients reporting back for future treatment. 114- 117 Pharmacological approaches are seen as less acceptable by patients when compared to psychological techniques, and have been shown to be effective on only a short-term basis. 118- 120

Conclusion

Dental anxiety and phobia can have adverse impacts on a person's quality of life, and hence it is imperative to identify and alleviate these significant obstacles to pave the way for better oral health and overall well-being of the individual. It is the duty and responsibility of the dentist to provide excellent dental care to these patients with special needs as well. Management of these patients should be an integral part of clinical practice, as a substantial proportion of the population suffers from anxiety and fear. Therapy should be customized to each individual following proper evaluation, and should be based on the dentist's experience, expertise, degree of anxiety, patient intellect, age, cooperation, and clinical situation. The dentist should communicate with the patient and identify their source of fear and anxiety, with adjuvant use of self-reporting anxiety and fear scales to enable categorization as mild, moderate, or extreme anxiety or dental-phobic. Manifold psychological therapies are employed to mollify emotional, cognitive, behavioral, and physiological dimensions of dental anxiety and fear. These therapies are efficient on a long-term basis with positive effects on the patients, enabling them to seek dental care in future, which should be the primary focus of the dental team. Mildly and moderately anxious patients can be frequently managed using psychological interventions, and occasionally anxiolytic drugs or conscious sedation may be necessary. Extremely anxious or phobic patients most frequently require combined management approaches. Due to the high risk involved in pharmacological interventions, it is mandatory that the dentist and dental team follow proper guidelines and be adequately trained and sufficiently equipped with proper infrastructure before pharmacological interventions can be incorporated. All successful treatment will rest on dentist-patient cooperation, and thus a relaxed patient will obviously result in a less stressful atmosphere for the dental team and better treatment outcomes.

Footnotes
Disclosure
The author reports no conflicts of interest in this work.

References

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Strategies to manage patients with dental anxiety and dental phobia: literature review

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Dental anxiety and phobia result in avoidance of dental care. It is a frequently encountered problem in dental offices. Formulating acceptable evidence-based therapies for such patients is essential, or else they can be a considerable source of stress for the dentist. These patients need to be identified at the earliest opportunity and their concerns addressed.

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If you ever get nervous just thinking about going to the dentist, you're not alone. Perhaps you're scared the visit might hurt or you haven't been in a while and not sure what the dentist will find.

Whatever your reason, the right dental team will make sure your dental and your emotional health are taken care of. The more you delay - or just don't go - to the dentist, the higher your risk of developing dental problems that will make gearing up for future dental visits more difficult. In fact, seeing your dentist regularly can actually make the entire process - from making an appointment to sailing through it - much easier on many levels.
Use these strategies at your next appointment to help ease your anxiety and strengthen your smile.

1. Speak up

Anyone with anxiety knows sharing your feelings makes a world of difference. If you're tense or anxious, do yourself a favor and get your concerns off your chest. Your dentist and dental team are better able to treat you if they know your needs.

Tell your dentist about your anxiety. When you book your appointment, tell the receptionist you're nervous about dental visits. Remind the dentist and dental staff about your anxiety when you arrive. Share any bad experiences you may have had in the past, and ask for suggestions on coping strategies.

Don't be afraid to ask questions. Sometimes knowing what is going to happen alleviates any fears of the unknown.

Agree on a signal. Let your dentist know by raising your hand if you need to take a break during an exam.

If you experience pain even with a local anesthetic, tell your dentist. Some patients get embarrassed about their pain tolerance or don't want to interrupt a dentist during a procedure. Talk with your dentist about pain before it starts so your dentist knows how to communicate with you and make it more comfortable.

2. Distract yourself

Taking your mind off the exam may seem impossible when you're nervous, but there are some things that that can help distract your thoughts.

Wear headphones. If the sound of the drill bothers you, bring headphones so you can listen to your favorite music or audiobook. Some dental offices even have televisions or show DVDs.

Occupy your hands by squeezing a stress ball or playing with a small handheld object, like a fidget spinner.

Imagine your happy place and visualize yourself at a relaxing beach or garden.

3. Use mindfulness techniques

Relaxation starts in the mind. Try deep breathing exercises to help relax tension in your muscles.

Count your breaths. Inhale slowly and then exhale for the same number of counts. Do this five times while you're waiting for your appointment, or during breaks while you're sitting in the dental chair.

Do a body scan. Concentrate on relaxing your muscles, one body part at a time. Start with your head and work your way down to your toes. For example, you can focus on releasing tension starting in your forehead, then your cheeks, your neck and down the rest of your body.

More About Going to the Dentist:

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If you ever get nervous just thinking about going to the dentist, you're not alone. Perhaps you're scared the visit might hurt or you haven't been in a while and not sure what the dentist will find. Whatever your reason, the right dental team will make sure your dental and your emotional health are taken care of.

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What sensitivities matter in dental anxiety? Investigating sensitivity to anxiety, pain, and disgust, S. M. Witcraft, M. E. Wickenhauser, D. J. Maack, L. J. Dixon, Scholarly

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What sensitivities matter in dental anxiety? Investigating sensitivity to anxiety, pain, and disgust, S. M. Witcraft, M. E. Wickenhauser, D. J. Maack, L. J. Dixon, Scholarly

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Influence of different personal protective equipment on children's anxiety in dental office: a randomized controlled trial, Maha Moussa Azab, Scholarly

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Influence of different personal protective equipment on children's anxiety in dental office: a randomized controlled trial, Maha Moussa Azab, Scholarly

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What are treatment options for patients with dental anxiety?

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What are treatment options for patients with dental anxiety?

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How can dental professionals ease dental anxiety in a clinical setting?

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How can dental professionals ease dental anxiety in a clinical setting?