December 1, 2007
by Oral Health
Dental fear and anxiety are major contributors to the reluctance of people in North America and across the world to obtain dental services. The cost in human terms as a result of this fear and anxiety is staggering: pain, swelling, lack of function, lack of esthetics, missed time from work (and its attendant cost to business), lack of proper nutrition, medical complications arising from dental problems to name just a few issues. While dental fear and anxiety are two of the foremost challenges clinicians face in treating patients, strategies for managing fearful patients are not widely agreed upon or considered standard, certainly not scientifically proven. Understanding the root causes of dental fear with a view toward providing management strategies short of sedation and general anesthesia has proven elusive. In other words, there are no universally agreed upon and taught standards that the author is aware of for management of dental fear and anxiety short of pharmacological means. This study was undertaken to statistically compare the perceptions of doctors and patients with regard to very specific factors that might cause dental fear and anxiety.
A study done by the U.S. surgeon general in 2000 discussing oral health in America stated that, “primary prevention of many oral, dental and craniofacial diseases and conditions is possible with the appropriate use of professional services.”1 While factually true, the fact that the service could aid people is not a motivating factor to overcome anxieties to have routine dental service. Even with significant new dental technology, anxiety towards dentistry has stayed relatively consistent over the past fifty years.2
Daily et al (2002) looked to test the hypothesis, “that informing dentists about patients’ dental anxiety prior to commencement of treatment reduces patients’ state anxiety.” This study showed that informing dentists about a patient’s anxiety helped to decrease the patient’s anxiety level during treatment.3
Gale (1971) suggested that the main fear of the dental office is based on society’s beliefs about the dentist, rather than a painful experience in a dental office.4 More recently, Weiner and Sheehan (1990) discussed dental anxiety as being classified into two groups: exogenous and endogenous.5 Locker, et al (1999) further examined these classifications and found that child onset dental anxiety was more likely to be exogenous while adult onset dental anxiety patents were more likely to be endogenous. Within the exogenous group, dental anxiety is due to a traumatic dental experience. The endogenous group’s dental anxiety is thought to have originated from other anxiety disorders. People in this group will tend to have a general state of anxiety in similar situations.6
A 1997 study by Milgrom, et al identified multiple aspects of dental injections that make patients fearful, i.e. most dental fear is based on direct dental experience.7
REDUCING FEAR AND ANXIETY
A study conducted by Berggren and Linde (1984) concluded that relief from dental fear could be accomplished using different methods for different individuals, including behavioral therapy from a psychologist (BT) and treatment under general anesthesia.8
Berggren et al. (2000) found that dental fear and anxiety were more reduced among patients who received relaxation-oriented therapy and concluded that dental phobia is a “multidimensional condition” that does not have a “single behavioral and emotional component.”9
Materials and Methods:
One thousand surveys were mailed to patients of Dr. Richard Mounce and random general dentists in Portland, Oregon, USA. Two hundred and fifteen patient surveys were returned. One hundred and one dentist surveys were returned.
While the survey had numerous questions whose answers could be statistically evaluated, the singular purpose of this study was to measure the difference in patient and dentist perceptions with regard to the various factors which might cause patients not to seek regular care, specifically question #4 for the patients and question #10 for the dentists. Subsequent statistical evaluation of remaining data is being examined and is planned for future reporting.
Of the 215 patient responses, there were a total of 154 females, 56 males, and 5 no responses with regard to gender. The average age of these individuals was 57 years. Of the 101 dentist responses, there were a total of 21 females, 78 males, and two no responses. The average age of the dentists was 53 years and on average, they had 24 years of practice experience. Ninety-six dentists answered question #10 and 187 patients answered question #4.
A linear regression analysis was run on the survey results to the measured comparison of the patient answers to question #4 and the dentist’s answers to #10 (Table 1).
A portion of the patient population was drawn from a set of previous endodontic patients which may have affected the results. The effect of this variable is unknown.
The results would indicate that dentists are not cold and indifferent to their patient’s anxieties and fears. They, in fact, are much more “in tune” with the feelings and needs of their patients than might be imagined given the level of statistical significance to their interpretation of their patient’s level of fears and anxiety. Their responses are overwhelmingly sensitive to their patient’s needs and anxieties, in that for every category save one (the use of the rubber dam) the dentists believed that the patient’s anxieties were of greater significance than that perceived by the patients. Simply put, the patients attached less significance to the various stimuli and factors that might provoke anxiety than their dentists.
It could be asked, if this is true, why does the amount of dental fear and anxiety not diminish exponentially over time? While a definitive answer is elusive, it is clear that patients still have clear and real fears associated with various aspects of treatment, especially those aspects measured by this study. It is clear they do not like injections, etc. and as such these sources of stress (along with the other factors mentioned) keep them from obtaining dental services on a routine basis.
It is also a matter of conjecture as to what practical effect the dentist’s interpretation of the patient’s source of stress have in general on their clinical treatment, interactions with patients and satisfaction with their profession. That the dentists perceive that each of the stress sources affect the patients more than the patients perceive (to a statistically significant degree in all categories but one) is a clear sign that the dentists do not fully have a tangible and dependable yardstick or means to measure their patient’s true feelings, beliefs and needs. In essence, there is very clearly a difference in the perception of events and experience each party has from opposite sides of the dental chair.
Future research might be undertaken to study specific means to offer dentists the tools to fully appreciate the patient’s feelings and needs.
Jesse Hollander is a graduate of Macalester College in Minnesota, BA biology. He is applying to dental school in the fall of 2008. He can be reached at firstname.lastname@example.org.
The author would like to thank Dr. Richard Mounce for his editorial review and Lars T. Johnson and Dr. Daniel T. Kaplan for their statistical analysis and consultation.
Oral Health welcomes this original article.
Click here for the Survey for Patients
Click here for the Survey for Dentists
1.Oral Health in America: a report of the surgeon general. 2000. U.S. Department of Health and Human
Services. Rockville, Md. U.S. Department of Health and Human Services, National Institute of Dental and Craniofacial Research.
2.Smith, T. A., L. J. Heaton. 2003. Fear of dental care: Are we making any progress? Journal of American Dental Association 134:1101-1108.
3.Dailey, Y.-M., G.M. Humpris, and M.A. Lennon. 2002. Reducing Patients’ State Anxiety in General Dental Practice: A Randomized Controlled Trial. Journal of Dental Research 81:319-322.
4.Gale, E. N. 1971. Fear of Dental Situations. Journal of Dental Research 51:964-966.
5.Weiner A. A., D. J. Sheehan. 1990. Etiology of dental anxiety: psychological trauma or CNS chemical imbalance? General Dentistry. 22:39-43.
6.Locker, D., A. Liddell, L. Dempster and D. Shapiro. 1999. Age of Onset of Dental Anxiety. Journal of Dental Research 78:790-796.
7.Milgrom, P., S. E. Coldwell, T. Getz, P. Weinstein and D. S. Ramsay. 1997. Four Dimensions of Fear of Dental Injections. Journal of American Dental Association 128:756-762.
8.Berggren, U. and A. Linde. 1984. Dental Fear and Avoidance: A comparison of Two Modes of Treatment. Journal of Dental Research 61:1223-1227.
9.Berggren, U., M. Hakeberg and S.G. Carlsson. 2000. Relaxation vs. Cognitively Oriented Therapies for Dental Fear. Journal of Dental Research 79:1645-1651.
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