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

Deva Priya Appukuttan, Deva Priya Appukuttan

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; conscious sedation; general anesthesia; pharmacological intervention; psychotherapeutic intervention.

Figures

Figure 1
Figure 1
Vicious cycle of dental fear. Note: Reproduced from Armfield JM, Stewart JF, Spencer AJ. The vicious cycle of dental fear: exploring the interplay between oral health, service utilization and dental fear. BMC Oral Health. 2007;7:1 (http://creativecommons.org/licenses/by/2.0/).

References

    1. Pohjola V, Lahti S, Vehkalahti MM, Tolvanen M, Hausen H. Association between dental fear and dental attendance among adults in Finland. Acta Odontol Scand. 2007;65(4):224–230.
    1. Gatchell RJ, Ingersoll BD, Bowman L, Robertson MC, Walker C. The prevalence of dental fear and avoidance: a recent survey study. J Am Dent Assoc. 1983;107(4):609–610.
    1. Agras S, Sylvester D, Oliveau D. The epidemiology of common fears and phobia. Compr Psychiatry. 1969;10(2):151–156.
    1. Berggren U, Hakeberg M, Carlsson SG. No differences could be demonstrated between relaxation therapy and cognitive therapy for dental fear. J Evid Based Dent Pract. 2001;1(2):117–118.
    1. Weisenberg M, Aviram O, Wolf Y, Raphaeli N. Relevant and irrelevant anxiety in the reaction to pain. Pain. 1984;20(4):371–383.
    1. Al Absi M, Rokke PD. Can anxiety help us tolerate pain? Pain. 1991;46(1):43–51.
    1. Moore R, Brødsgaard I. Dentists’ perceived stress and its relation to perceptions about anxious patients. Community Dent Oral Epidemiol. 2001;29(1):73–80.
    1. Brahm CO, Lundgren J, Carlsson SG, Nilsson P, Corbeil J, Hägglin C. Dentists’ views on fearful patients. Problems and promises. Swed Dent J. 2012;36(2):79–89.
    1. Eli I. Dental anxiety: a cause for possible misdiagnosis of tooth vitality. Int Endod J. 1993;26(4):251–253.
    1. van Wijk AJ, Hoogstraten J. The Fear of Dental Pain questionnaire: construction and validity. Eur J Oral Sci. 2003;111(1):12–18.
    1. Armfield JM, Spencer AJ, Stewart JF. Dental fear in Australia: who’s afraid of the dentist? Aust Dent J. 2006;51(1):78–85.
    1. Eitner S, Wichmann M, Paulsen A, Holst S. Dental anxiety – an epidemiological study on its clinical correlation and effects on oral health. J Oral Rehabil. 2006;33(8):588–593.
    1. Armfield JM, Slade GD, Spencer AJ. Dental fear and adult oral health in Australia. Community Dent Oral Epidemiol. 2009;37(3):220–230.
    1. Armfield JM, Stewart JF, Spencer AJ. The vicious cycle of dental fear: exploring the interplay between oral health, service utilization and dental fear. BMC Oral Health. 2007;7:1.
    1. Cohen SM, Fiske J, Newton JT. The impact of dental anxiety on daily living. Br Dent J. 2000;189(7):385–390.
    1. Locker D, Shapiro D, Liddell A. Overlap between dental anxiety and blood-injury fears: psychological characteristics and response to dental treatment. Behav Res Ther. 1997;35(7):583–590.
    1. Seeman K, Molin C. Psychopathology, feelings of confinement and helplessness in the dental chair, and the relationship to the dentist in patients with disproportionate dental anxiety (DDA) Acta Psychiatry Scand. 1976;54(2):81–91.
    1. Benjamin C, Schuurs AH, Kooreman T, Hoogstraten J. Self-reported and physiologically measured dental anxiety, coping styles and personality traits. Anxiety Stress Coping. 1996;9(2):151–162.
    1. Ost LG, Hugdahl K. Acquisition of blood and dental phobia and anxiety response in clinical patients. Behav Res Ther. 1985;23(1):27–34.
    1. Oosterink FM, de Jongh A, Aartman IH. What are people afraid of during dental treatment? Anxiety-provoking capacity of 67 stimuli characteristic of the dental setting. Eur J Oral Sci. 2008;116(1):44–51.
    1. Walsh LJ. Anxiety prevention: implementing the 4 S principle in conservative dentistry. Auxiliary. 2007;17(5):24–26.
    1. Hmud R, Walsh LJ. Dental anxiety: causes, complications and management approaches. J Minim Interv Dent. 2009;2(1):67–78.
    1. Milgrom P, Weinstein P, Getz T. Treating Fearful Dental Patients: A Patient Management Handbook. Seattle: Reston Prentice Hall; 1995.
    1. Armfield JM, Heaton LJ. Management of fear and anxiety in the dental clinic: a review. Aust Dent J. 2013;58(4):390–407.
    1. Corah NL. Development of a dental anxiety scale. J Dent Res. 1969;48(4):596.
    1. Humphris GM, Morrison T, Lindsay SJ. The Modified Dental Anxiety Scale: validation and United Kingdom norms. Community Dent Health. 1995;12(3):143–150.
    1. Spielberger CD. Assessment of state and trait anxiety: conceptual and methodological issues. South Psychol. 1985;2(4):6–16.
    1. Kleinknecht RA, Klepac RK, Alexander LD. Origins and characteristics of fear of dentistry. J Am Dent Assoc. 1973;86(4):842–848.
    1. Stouthard ME, Mellenbergh GJ, Hoogstraten J. Assessment of dental anxiety: a facet approach. Anxiety Stress Coping. 1993;6(2):89–105.
    1. Gatchel RJ. The prevalence of dental fear and avoidance: expanded adult and recent adolescent surveys. J Am Dent Assoc. 1989;118(5):591–593.
    1. Moore R, Birn H, Kirkegaard E, Brødsgaard I, Scheutz F. Prevalence and characteristics of dental anxiety in Danish adults. Community Dent Oral Epidemiol. 1993;21(5):292–296.
    1. Neverlien PO. Dental anxiety, optimism-pessimism, and dental experience from childhood to adolescence. Community Dent Oral Epidemiol. 1994;22(4):263–268.
    1. Viinikangas A, Lahti S, Yuan S, Pietilä I, Freeman R, Humphris G. Evaluating a single dental anxiety question in Finnish adults. Acta Odontol Scand. 2007;65(4):236–240.
    1. Armfield JM. A comparison of three continuous scales used to determine the prevalence of clinically significant dental fear. Community Dent Oral Epidemiol. 2011;39(6):554–563.
    1. Luyk NH, Beck FM, Weaver JM. A visual analogue scale in the assessment of dental anxiety. Anesth Prog. 1988;35(3):121–123.
    1. Armfield JM. How do we measure dental fear and what are we measuring anyway? Oral Health Prev Dent. 2010;8(2):107–115.
    1. Humphris G, Hull P. Do dental anxiety questionnaires raise anxiety in dentally anxious adult patients? A two-wave panel study. Prim Dent Care. 2007;14(1):7–11.
    1. McGlynn FD, Harkavy J. Factor analysis of the dental fear survey with cross-validation. J Am Dent Assoc. 1984;108(1):59–61.
    1. Dailey YM, Humphris GM, Lennon MA. The use of dental anxiety questionnaires: a survey of a group of UK dental practitioners. Br Dent J. 2001;190(8):450–453.
    1. Lahti S, Tuutti H, Hausen H, Kääriäinen R. Comparison of ideal and actual behavior of patients and dentist during dental treatment. Community Dent Oral Epidemiol. 1995;23(6):374–378.
    1. Caprara HJ, Eleazer PD, Barfield RD, Chavers S. Objective measurement of patient’s dental anxiety by galvanic skin reaction. J Endod. 2003;29(8):493–496.
    1. Bare LC, Dundes L. Strategies for combating dental anxiety. J Dent Educ. 2004;68(11):1172–1177.
    1. Lehrner J, Eckersberger C, Walla P, Potsch G, Deecke L. Ambient odor of orange in a dental office reduces anxiety and improves mood in female patients. Physiol Behav. 2000;71(1):83–86.
    1. Lehrner J, Marwinski G, Lehr S, Johren P, Deecke L. Ambient odors of orange and lavender reduce anxiety and improve mood in a dental office. Physiol Behav. 2005;86(1):92–95.
    1. McCaffrey R, Thomas DJ, Kinelman AO. The effects of lavender and rosemary essential oils on test-taking anxiety among graduate nursing students. Holist Nurs Pract. 2009;23(2):88–93.
    1. Chen YJ, Shih Y, Chang TM, Wang MF, Lan SS, Cheng FC. In: Spink AJ, Ballintijn MR, Bogers ND, et al., editors. Inhalation of neroli essential oil and its anxiolytic effects in animals; Proceedings of Measuring Behavior 2008: 6th International Conference on Methods and Techniques in Behavioral Research; Wageningen, the Netherlands: Noldus Information Technology; 2008. pp. 256–257.
    1. Muzzarelli L, Force M, Sebold M. Aromatherapy and reducing preprocedural anxiety: a controlled prospective study. Gastroenterol Nurs. 2006;29(6):466–471.
    1. Kritsidima M, Newton T, Asimakopoulou K. The effects of lavender scent on dental patient anxiety levels: a cluster randomised-controlled trial. Community Dent Oral Epidemiol. 2010;38(1):83–87.
    1. Toda M, Morimoto K. Effect of lavender aroma on salivary endocrinological stress markers. Arch Oral Biol. 2010;53(10):964–968.
    1. Shapiro M, Melmed RN, Sgan-Cohen HD, Eli I, Parush S. Behavioural and physiological effect of dental environment sensory adaptation on children’s dental anxiety. Eur J Oral Sci. 2007;115(6):479–483.
    1. Cermak SA, Stein Duker LI, Williams ME, et al. Feasibility of a sensory-adapted dental environment for children with autism. Am J Occup Ther. 2015;69(3):1–10.
    1. Shapiro M, Melmed RN, Sgan-Cohen HD, Parush S. Effect of sensory adaptation on anxiety of children with developmental disabilities: a new approach. Pediatr Dent. 2009;31(3):222–228.
    1. Marci CD, Ham J, Moran E, Orr SP. Physiologic correlates of perceived therapist empathy and social-emotional process during psychotherapy. J Nerv Ment Dis. 2007;195(2):103–111.
    1. Friedman N. Iatrosedation: the treatment of fear in the dental patient. J Dent Educ. 1983;47(2):91–95.
    1. Friedman N, Wood GJ. An evaluation of the iatrosedative process for treating dental fear. Compend Contin Educ Dent. 1998;19(4):434–436. 438, 440–442.
    1. Botto RW. Chairside techniques for reducing dental fear. In: Mostofsky DI, Forgione AG, Giddon DB, editors. Behavioral Dentistry. Oxford: Blackwell; 2006. pp. 115–125.
    1. Corah NL. Dental anxiety: assessment, reduction and increasing patient satisfaction. Dent Clin North Am. 1988;32(4):779–790.
    1. Jacobson E. Progressive Relaxation. Chicago: University of Chicago Press; 1938.
    1. Loew TH, Tritt K, Siegfried W, Bohmann H, Martus P, Hahn EG. Efficacy of “functional relaxation” in comparison to terbutaline and a “placebo relaxation” method in patients with acute asthma: a randomized, prospective, placebo-controlled, crossover experimental investigation. Psychother Psychosom. 2001;70(3):151–157.
    1. Lahmann C, Nickel M, Schuster T, et al. Functional relaxation and guided imagery as complementary therapy in asthma: a randomized controlled clinical trial. Psychother Psychosom. 2009;78(4):233–239.
    1. Pikoff H. A critical review of autogenic training in America. Clin Psychol Rev. 1984;4(6):619–639.
    1. Ost LG. Applied relaxation: description of a coping technique and review of controlled studies. Behav Res Ther. 1987;25(5):397–409.
    1. Biggs QM, Kelly KS, Toney JD. The effects of deep diaphragmatic breathing and focused attention on dental anxiety in a private practice setting. J Dent Hyg. 2002;77(2):105–113.
    1. Benson H. Timeless Healing: The Power and Biology of Belief. New York: Scribner; 1996.
    1. Benson H, Beary JF, Carol MP. The relaxation response. Psychiatry. 1974;37(1):37–46.
    1. Tusek D, Church JM, Fazio VW. Guided imagery as a coping strategy for perioperative patients. AORN J. 1997;66(4):644–649.
    1. Hofmann SG, Sawyer AT, Witt AA, Oh D. The effect of mindfulness-based therapy on anxiety and depression: a meta-analytic review. J Consult Clin Psychol. 2010;78(2):169–183.
    1. Gonzales EA, Ledesma RJ, McAllister DJ, Perry SM, Dyer CA, Maye JP. Effects of guided imagery on postoperative outcomes in patients undergoing same-day surgical procedures: a randomized, single-blind study. AANA J. 2010;78(3):181–188.
    1. Hirschman R. Physiological feedback and stress reduction; Poster presented at: Annual Meeting of Society of Behavioral Medicine; November 1980; New York.
    1. Milgrom P, Weinstein P, Heaton LJ. Treating Fearful Dental Patient: A Patient Management Handbook. 3rd ed. Seattle: University of Washington; 2009.
    1. Agnihotri H, Paul M, Sandhu JS. Biofeedback approach in the treatment of generalized. Iran J Psychiatry. 2007;2(3):90–95.
    1. Morarend QA, Spector ML, Dawson DV, Clark SH, Holmes DC. The use of a respiratory rate biofeedback device to reduce dental anxiety: an exploratory investigation. Appl Psychophysiol Biofeedback. 2011;36(2):63–70.
    1. Facco E, Zanette G, Casiglia E. The role of hypnotherapy in dentistry. SAAD Dig. 2014;30:3–6.
    1. Montgomery GH, DuHamel KN, Redd WH. A meta-analysis of hypnotically induced analgesia: how effective is hypnosis? Int J Clin Exp Hypn. 2000;48(2):138–153.
    1. Flammer E, Bongartz W. On the efficacy of hypnosis: a meta-analytic study. Contemp Hypn. 2003;20(4):179–197.
    1. Glaesmer H, Geupel H, Haak R. A controlled trial on the effect of hypnosis on dental anxiety in tooth removal patients. Patient Educ Couns. 2015;98(9):1112–1115.
    1. Ernst E, Pittler MH. The effectiveness of acupuncture in treating acute dental pain: a systemic review. Br Dent J. 1998;184(9):443–472.
    1. Rosted P. The use of acupuncture in dentistry: a review of the scientific validity of published papers. Oral Dis. 1998;4(2):100–104.
    1. Karst M, Winterhalter M, Münte S, et al. Auricular acupuncture for dental anxiety: a randomised controlled trial. Anesth Analg. 2007;104(2):295–300.
    1. Ma R, Xu SJ, Wen XY, et al. Acupuncture for generalized anxiety disorder: a systematic review. J Psychol Psychother. 2014;4(5):1000155.
    1. Pilkington K, Kirkwood G, Rampes H, Cummings M, Richardson J. Acupuncture for anxiety and anxiety disorders – a systematic literature review. Acupunct Med. 2007;25(1–2):1–10.
    1. Au DW, Tsang HW, Ling PP, Leung CH, Ip PK, Cheung WM. Effects of acupressure on anxiety: a systematic review and meta-analysis. Acupunct Med. 2015;33(5):353–359.
    1. American Academy of Pediatric Dentistry Special issue: Proceedings of the conference on behavior management for the pediatric dental patient. Pediatr Dent. 2004;26(2):110–183.
    1. Ram D, Shapira J, Holan G, Magora F, Cohen S, Davidovich E. Audiovisual video eyeglass distraction during dental treatment in children. Quintessence Int. 2010;41(8):673–679.
    1. White JM. State of the science of music interventions: critical care and perioperative practice. Crit Care Nurs Clin North Am. 2000;12(2):219–225.
    1. Moola S, Pearson A, Hagger C. Effectiveness of music interventions on dental anxiety in paediatric and adult patients: a systematic review. JBI Database System Rev Implement Rep. 2011;9(18):588–630.
    1. Allen KD, Stanley RT, McPherson K. Evaluation of behavior management technology dissemination in pediatric dentistry. Pediatr Dent. 1990;12(2):79–82.
    1. Farhat-McHayleh N, Harfouche A, Souaid P. Techniques for managing behaviour in pediatric dentistry: comparative study of live modelling and tell-show-do based on children’s heart rates during treatment. J Can Dent Assoc. 2009;75(4):283.
    1. Wolpe J. Reciprocal inhibition as the main basis of psychotherapeutic effects. AMA Arch Neurol Psychiatry. 1954;72(2):205–226.
    1. Carter AE, Carter G, Boschen M, AlShwaimi E, George R. Pathways of fear and anxiety in dentistry: a review. World J Clin Cases. 2014;2(11):642–653.
    1. Roberts JF, Curzon ME, Koch G, Martens LC. Review: behaviour management techniques in paediatric dentistry. Eur Arch Paediatr Dent. 2010;11(4):166–174.
    1. Dumitrache MA, Neacsu V, Sfeatcu IR. Efficiency of cognitive technique in reducing dental anxiety. Procedia Soc Behav Sci. 2014;149:302–306.
    1. Bray A, Chhun A, Donkersgoed R, Hoover S, Levitan S. An evidence-based report investigating the most effective method to reduce dental anxiety. 2009. [Accessed November 28, 2015]. Available from: .
    1. Heaton LJ. Behavioral interventions may reduce dental anxiety and increase acceptance of dental treatment in dentally fearful adults. J Evid Based Dent Pract. 2013;13(4):160–162.
    1. Getka EJ, Glass CR. Behavioral and cognitive-behavioral approaches to the reduction of dental anxiety. Behav Ther. 1992;23(3):433–448.
    1. Bowman U, Carlsson V, Westin M, Hakeberg M. Psychological treatment of dental anxiety among adults: a systematic review. Wide. Eur J Oral Sci. 2013;121(3 Pt 2):225–234.
    1. Berggren U, Hakeberg M, Carlsson SG. Relaxation vs. cognitively oriented therapies for dental fear. J Dent Res. 2000;79(9):1645–1651.
    1. Heaton LJ, Leroux BG, Ruff PA, Coldwell SE. Computerized dental injection fear treatment: a randomized clinical trial. J Dent Res. 2013;92(7 Suppl):S37–S42.
    1. Fukayama H, Yoshikawa F, Kohase H, Umino M, Suzuki N. Efficacy of anterior and middle superior alveolar (AMSA) anesthesia using a new injection system: the Wand. Quintess Int. 2003;34(7):537–541.
    1. Zhao X, Liu H, Qin M. Application of computer-controlled local anesthetic delivery system in children. Hua Xi Kou Qiang Yi Xue Za Zhi. 2011;29(4):389–392. Chinese.
    1. Yap AU, Henry CW. Electronic and local anesthesia: a clinical comparison for operative procedures. Quintessence Int. 1996;27(5):549–553.
    1. Dhindsa A, Pandit IK, Srivastava N, Gugnani N. Comparative evaluation of the effectiveness of electronic dental anesthesia with 2% lignocaine in various minor pediatric dental procedures: a clinical study. Contemp Clin Dent. 2011;2(1):27–30.
    1. Jacobs R, van Steenberghe D. The effect of electronic dental analgesia during sonic scaling. J Clin Periodontol. 1994;21(10):728–730.
    1. Coldwell SE, Getz T, Milgrom P, Prall CW, Spadafora A, Ramsay DS. CARL: a LabVIEW 3 computer program for conducting exposure therapy for the treatment of dental injection fear. Behav Res Ther. 1998;36(4):429–441.
    1. Patel MX, Baker D, Nosarti C. Injection phobia: a systematic review of psychological treatments. Behav Cogn Psychother. 2005;33(3):343–349.
    1. Reddy RS, Kotha R, Pavani K, Subbarayudu G, Rajesh N, Sruthi R. Dental anxiety – neglect of dental care. International Journal of Health. 2015;3(1):20–23.
    1. Folayan MO, Faponle A, Lamikanra A. Seminars on controversial issues. A review of the pharmacological approach to the management of dental anxiety in children. Int J Paediatr Dent. 2002;12(5):347–354.
    1. Newton T, Asimakopoulou K, Daly B, Scambler S, Scott S. The management of dental anxiety: time for a sense of proportion? Br Dent J. 2012;213(6):271–274.
    1. Coulthard P. The indicator of sedation need (IOSN) Dent Update. 2013;40(6):466–468. 470–471.
    1. Intercollegiate Advisory Committee for Sedation in Dentistry . Standards for Conscious Sedation in the Provision of Dental Care. London: RCS Publications; 2015. [Accessed November 29, 2015]. Available from: .
    1. British Dental Association . Conscious Sedation. London: BDA; 2011. [Accessed November 29, 2015]. Available from: .
    1. O’Halloran M. The use of anaesthetic agents to provide anxiolysis and sedation in dentistry and oral surgery. Australas Med J. 2013;6(12):713–718.
    1. Levering NJ, Welie JV. Current status of nitrous oxide as a behavior management practice routine in pediatric dentistry. J Dent Child (Chic) 2011;78(1):24–30.
    1. Berggren U. Long-term management of the fearful adult patient using behavior modification and other modalities. J Dent Educ. 2001;65(12):1357–1368.
    1. Willumsen T, Vassend O. Effects of cognitive therapy, applied relaxation and nitrous oxide sedation: a five-year follow-up study of patients treated for dental fear. Acta Odontol Scand. 2003;61(2):93–99.
    1. Thom A, Sartory G, Jöhren P, Deecke L. Comparison between one-session psychological treatment and benzodiazepine in dental phobia. J Consult Clin Psychol. 2000;68(3):378–387.
    1. Jaafer NA, Izadi M, Daly B, Newton JT. The social validation of pharmacological approaches to the management of dental anxiety in adults: impact of treatment urgency, method of intervention and treatment outcome. Soc Behav Pers. 2007;35(3):375–386.
    1. Kvale G, Berggren U, Milgrom P. Dental fear in adults: a meta-analysis of behavioral interventions. Community Dent Oral Epidemiol. 2004;32(4):250–264.
    1. Forbes MD, Boyle CA, Newton T. Acceptability of behaviour therapy for dental phobia. Community Dent Oral Epidemiol. 2012;40(1):1–7.
    1. Newton JT, Naidu R, Sturmey P. The acceptability of the use of sedation in the management of dental anxiety in children: views of dental students. Eur J Dent Educ. 2003;7(2):72–76.
    1. Jacobson’s progressive relaxation technique (leaflet 2926/VER2) Guy’s and St Thomas’ NHS Foundation Trust. Date published: January 2016; Review date: January 2019. Available from .

Source: PubMed

스폰서 및 공동 작업자

건강 상태

약물 개입

3
구독하다