Dental fear, odontophobia, or dentophobia, is a normal emotional reaction to one or more specific threatening stimuli in the dental situation. However, dental anxiety is indicative of a state of apprehension that something dreadful is going to happen in relation to dental treatment, and it is usually coupled with a sense of losing control. Similarly, dental phobia denotes a severe type of dental anxiety, and is characterized by marked and persistent anxiety in relation to either clearly discernible situations or objects (e.g. drilling, local anesthetic injections) or to the dental setting in general. The term 'dental fear and anxiety' (DFA) is often used to refer to strong negative feelings associated with dental treatment among children, adolescents and adults, whether or not the criteria for a diagnosis of dental phobia are met. Dental phobia can include fear of dental procedures, dental environment or setting, fear of dental instruments or fear of the dentist as a person. People with dental phobia often avoid the dentist and neglect oral health, which may lead to painful dental problems and ultimately force a visit to the dentist. The emergency nature of this appointment may serve to worsen the phobia. This phenomenon may also be called the cycle of dental fear. Dental anxiety typically starts in childhood. There is the potential for this to place strains on relationships and negatively impact on employment.
Dental fear, anxiety, and phobia seem to be interchangeably used, however, there is a fundamental difference between each.
Dental anxiety is fear of the unknown. It's the worry that people commonly experience because they are about to do something that they have never done, possibly going to dental clinic for the first time or getting a new procedure.
Dental fear is a response to past negative experiences that triggers apprehension.
Dental phobia is a severe, irrational fear of dental situations leading to complete avoidance of dental care, often impacting daily functioning and health.
Signs and symptoms As with all types of fear and phobias, dental fear can manifest as single or combination of emotional, physiological, cognitive and behavioural symptoms.
Dental Phobia can be classified into 3 broad classes:
Mild odontophobia: the most common also referred to as dental anxiety Moderate odontophobia: can be classified as dental fear Severe dental phobia: The most severe one which is most difficult to manage.
Emotional response
Feeling of fear Feeling of anxiety Apprehension Panic
Physiological response
Increased heart rate Breathlessness Sweating Nausea Shaking
Cognitive response
"I don't like the feeling of this..." "I am choking to death" "I am having a heart attack" "I am going to die" "Feeling of swollen face" "I am not able to breathe"
Behavioural response
Agitation High vigilance
Cause
Research suggests that there is a complex set of factors that lead to the development and maintenance of significant dental anxiety or dental phobia, which can be grouped as genetic, behavioral and cognitive factors. In comparison to other phobias, literature on odontophobia is relatively limited.
In order to better address the patients with dental fear, it is very important to understand the causes and factors associated with them.
Traumatic Experiences: Previous negative or painful dental experiences are primary contributors. Learned Behavior: Observing others' fearful reactions, particularly during childhood, can reinforce dental fear. Fear of Pain: A common underlying factor, often exacerbated by misconceptions about modern dental procedures. Biological Responses: Increased cortisol levels and heightened autonomic nervous system activity have been observed in anxious dental patients.
Several theories have been proposed; however, a 2014 review describes five pathways which relate specifically to development dental fear and anxiety: Cognitive Conditioning, Vicarious, Verbal Threat, Informative, and Parental. However, there may be a variety of background factors common to all general fear and anxiety conditions that may be at play and affect these more specific pathways.
Research utilising process drama with children aged 7-10 has identified four overarching concepts; fear of the unknown, unpleasant sensory experience, society’s portrayal of dentists and learnt negative associations with going to the dentist.
Conditioning
Conditioning is defined as the process by which a person learns through personal experience that an event or stimulus will result in a detrimental outcome, e.g. "if I visit the dentist, it is going to be sore." As, expected dental fear is associated with previous traumatic experiences, especially their first one. It is believed to be the most commonly used pathway for patients to develop dental fear and anxiety.
Informative
This indirect pathway relates to fear acquisition through gaining information and becoming bias to the dental environment from dental phobic elders, negative connotations advertised by media (e.g. television, movies), and friends with personal negative experiences.
Vicarious
The vicarious pathway suggests that fear is acquired through imagination of the feelings, experience or actions of another person. Whether this pathway occurs on its own or in combination with others is still unknown. It has been suggested that dental fear in the very young is passed through this pathway through observation of expressions of fear by elders/parents at the dentist.
Verbal threat
This pathway can be seen as similar to the informative pathway, however it is more reliant on the emotion of fear elicited by "word of mouth" and is heavily modulated by the messenger. In essence the verbal threat pathway is the fear induced when an authority figure threatens an individual with a painful experience. In the case of dental fear, the painful and/or negative experiences linked to dental visits. Although at a glance, the verbal threat and informative pathway are similar, in odontophobia the two pathways differ in that the verbal threat pathway occurs when a "visit to the dentist" is literally used as a form of punishment for bad behaviour. This does not occur in the informative pathway.
Parental modelling
There is a significant relationship between child and parental dental fear, especially that of the mothers. it has been suggested that this relationship is strongest in children 8 years or younger. However, the parental modelling pathway may overlap with the informative or vicarious pathways are all linked in some way.
Diagnosis Several methods have been developed to diagnose dental fear and anxiety. In addition to identifying the patients with dental fear, different categories of dental fear have been established. These include:
Dental fear survey (DFS) which incapsulates 20 items in relation to various situations, feelings and reaction to dental work which is used to diagnose dental fear. Modified child dental anxiety scale (MCDAS), used for children and it has 8 items with a voting system from 1–5 where 1 is not worried and 5 is very worried. The index of dental anxiety and fear (IDAF-4C+), used for adults and it is separated into 8 item module and then a further 10 item module. Dental Anxiety Scale designed by Norman Corah et al: This test is considered best in terms of reliability and consistency. The scale consist of 1–4 questions and then 1–26 question. This scale has a ranking system and the second section with 26 questions has 1–4 options ranging from 'low' to 'don't know' which is used to assess dental concern. The first section with 1–4 questions has 5 Likert scale options which are worth 1–5 points with the possible number of maximum points is 20. Then depending on the result you rate the dental anxiety. 9–12 being moderate 13–14 being high, and 15–20 being severe. Spielberger State Trait Anxiety Index (STA): an instrument for measuring anxiety in adults. It differentiates between temporary condition of "state anxiety" and the more general and long-lasting quality of "trait anxiety". It can also help differentiate between anxiety and depression Anxiety Sensitivity Index (ASI): a 16-item scale that focuses on apprehension about the symptoms of anxiety itself Seattle System: consists of four diagnostic types in which such individuals are categorised according to the main source of their fear regarding dental treatment Type 1: simple conditioned phobia—fear of dental procedures Type 2: fear of catastrophe—anxiety about somatic reactions during dental treatment, e.g. fainting, panic attack, heart attack Type 3: Generalized anxiety—nervous person in general Type 4: distrust of dentists—fear of the dentist
General health impacts caused by Dental phobia The presence of dental phobia can have major impacts on overall health, wellbeing, and quality of one's life, in addition to directly impacting their dental health.
Gum and periodontal diseases have been linked to heart problems. Broken teeth lead to chewing issues which can cause digestive disorders and malnutrition. Missing teeth affect speech and self-esteem. Not getting routine dental cleaning can lead to bad breath.
Management Dental fear varies across a continuum, from very mild fear to severe. Therefore, in a dental setting, it is also the case where the technique and management that works for one patient might not work for another. Some individuals may require a tailored management and treatment approach.
The management of people with dental fear can be done using shorter term methods such as hypnosis and general anesthetic, or longer term methods such as cognitive behavioral therapy and the development of coping skills. Short term methods have been proven to be ineffective for long-term treatment of the phobia, since many return to a pattern of treatment avoidance afterwards. Psychological approaches are more effective at maintaining regular dental care, but demand more knowledge from the dentist and motivation from the patient
Similarly, distraction techniques can also be utilized to divert the patient's attention to allow them to avoid supposed negativity and be more comfortable. This can be achieved through television or movies, or a physical distraction such as focusing on another body part such as wiggling the toes or fingers.
More recent research indicates that the use of conscious sedation combined appropriate communication techniques may relieve the anxiety in the long-term.
Psychocognitive Modelling
Modelling is a form of psycho-behavioural therapy used to alleviate dental fear. Commonly used in paediatric dentistry, it involves the showing of a procedure under a simulated environment. It allows the patient to observe the behaviour of a friend, family member, or other patient when put in a similar situation, therefore, accommodating for the learning of new coping mechanisms. Modelling can be presented live using a parent or actor as well as virtually through pre-recorded films.
Tell-show-do Tell-show-do is a common non-pharmacological practice used to manage behaviour such as dental fear, especially in paediatric dentistry. The purpose of this intervention is to promote a positive attitude towards dentistry and to build a relationship with the patient to improve compliance. The patient is gradually introduced to the treatment. Firstly, the dentist "tells" the patient what the dental procedure will be using words. In 'show' phase, the patient is familiarized with dental treatment using demonstrations. Lastly, in 'do' phase, the dentist proceeds with the treatment following the same procedure and demonstrations illustrated to the patient.
Behavioral techniques