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Definition of Dental Anxiety and Fear Research Paper


Dental anxiety is the type of anxiety experienced by the patients who are soon to visit a dentist for an appointment or treatment (Bracha, Vega & Vega 2006; Saatchi et al. 2015). Oral health procedures are perceived as frightening (Appukuttan et al. 2013; Saatchi et al. 2015). Due to the negative expectations, the patients with high levels of dental anxiety may behave in an aggravated manner and disrupt the professional’s work (Frydendal Hoem & Marlén Elde 2012). That way, dental anxiety is a significant issue for both the dentists and their patients. The prevalence of dental anxiety was evaluated in many studies conducted throughout the world. This review presents the definition, risk factors of dental anxiety, its epidemiology, four groups of patients, impact, techniques of addressing dental anxiety, its effects, and assessment methods.

Definition

To provide an appropriate definition of dental anxiety, it is important to define fear at first. Fear is characterized as an individual’s reaction to a dangerous event or a threatening environment (Naudi 2009). In this regard, dental anxiety can be described as an individual’s perception of versatile dental procedures and visits to the dentist overall as threatening and dangerous (Naudi 2009). Settineri et al. (2013) argued that dental anxiety should be classified as a part of the family of mood disorders instead of that of anxiety disorders. That way, studying the facts that contribute to the prevalence of anxiety in dental patients, the researchers should study the psychopathological profiles of anxious individuals (Settineri et al. 2013).

This conclusion implies the need for cross-disciplinary links between dentistry and psychiatry. In fact, from the psychological perspective, dental phobia, as a term, maybe a misnomer; Bracha, Vega, and Vega (2006) propose a new name for it – Posttraumatic Dental Care Anxiety- a term that reflects the nature and the most common cause of the phenomenon. According to this study, the prevalence of dental anxiety is likely to be 14 times higher in the patients who had experienced painful dental treatments who also become 16 times less compliant with dental care and just as unwilling to return to the dentist’s office for another procedure.

Due to the feeling of anxiety and fear, the patients may demonstrate inadequate behaviors during their dental treatments (Madfa et al. 2015). Also, many patients tend to avoid visiting a dentist for their regular checkups and dental procedures when they experience dental health problems (Gaffar, Alagl & Al-Ansari 2014).

Epidemiology

Dental anxiety is a phenomenon that was registered all around the world. Many studies have been done to evaluate the prevalence of dental anxiety. Fear of dentists is one of the most common phobias registered by the psychologists (Yip 2012). Moreover, the overall prevalence of dental anxiety may vary from one group of patients to another and also is diverse in different countries. (Naudi 2009). Depending on the types of subjects and their characteristics, the researcher all around the globe reported rates of dental anxiety that hesitate from very low to very high (Naudi 2009). In other words, it is possible to conclude that geography is an insignificant factor when it comes to the prevalence of dental anxiety (Naudi 2009).

For instance, Frydendal Hoem and Marlén Elde (2012) reported that prevalence of dental phobia and anxiety among adult patients is usually estimated somewhere between 4 and 20%, in rare cases, it is found to be even higher – 40%. Besides, the authors reported that about 16% of the phobic patients develop their fears in adult life being between 18 and 26 years old. Busuttil Naudi (2009) reported that the prevalence of dental anxiety in Scotland is slightly higher than 7%; that in the United States of America is varied between 6 and 10%. Overall, the researcher in Scotland mentions that dental anxiety prevalence is very different throughout the globe and the variations usually fit into the wide range of 3 to 43%.

Attaullah (2011) assessed a sample of 385 university students in Islamabad to identify the levels of dental anxiety; the findings showed that 21% of the sample had it and just as many had dental fear. The author evaluated this prevalence as high and recommended that another study is done assessing the stimuli that contribute to the occurrence of dental fear and anxiety for a purpose to understand the phenomena and possibly, begin addressing them to alleviate the patients as well as the dentists.

In Romania, Rãducanu et al. (2009) investigated the prevalence of dental anxiety among children and adolescents and pointed out that 21.6% of the sample were recognized as anxious. The children who had the highest levels of anxiety and anxious behaviors were usually younger than 6 years; also, female children were more likely to be anxious than male children. Hamissi et al. (2012) assessed a sample of 780 randomly selected teenagers studying in high schools of Iran and found that the prevalence of anxiety in the group was about 30%, of which 29% had high levels of it and 21% also had levels of fear. Another Iranian study evaluated a sample of 473 participants and showed the prevalence of dental anxiety of about 59%; out of this sample the members with higher levels of anxiety were women; also, the individuals without previous traumatic and painful oral treatment experiences were less likely to experience anxiety (Saatchi et al. 2015).

Hawamdeh and Awad (2013) estimated the prevalence of dental anxiety in a sample of 413 university students and found it to be 36% (mid-level of severity); the researchers’ goal was to find the correlations of anxiety with demographics of the sample. The authors found that dental anxiety was not in correlation with the gender of the respondents and the frequency of their visits to a dentist; the following predictors of dental anxiety were identified: the anticipation of painful sensations and the lack of control over the situation (Hawamdeh & Awad 2013; Viswanath, Kumar & Prabhu 2015). Yip (2012) reported the dental anxiety prevalence rates to be as high as 8 to 12% in the adult population of the United States. Also, the author stated that many female patients suffering from dental anxiety avoided pregnancy for a purpose to stay away from visits to a dentist’s office.

Also, assessing the prevalence of dental anxiety and pain among the children of five years of age Moura-Leite et al. (2008) found that 25% of the sample demonstrated anxious reactions to the visits to a dentist according to the reports of the parents. Dental pain was found to be tightly connected to anxiety. Alaki et al. (2011) researched Jeddah assessing the prevalence of dental anxiety in adolescents and teenagers studying in schools and found that of 518 children, 34% showed high levels of dental anxiety. Moreover, the researchers observed that dental anxiety in the children was in a positive correlation with that of their caregivers.

Shim et al. (2015) offer a systematic review to assess the prevalence of dental anxiety in adolescents and children; the percentage of anxious patients, according to the findings, is 10%. The literature included in the review covered 142 years. The authors report that prevalence tended to become less significant depending on the age of the children (the older the children – the less anxiety); also, they found that girls were more anxious than boys, and the dental pain was a serious contributing factor to the level of anxiety or its presence. Nakai et al. (2006) concluded that anxiety levels were in correlation with the children’s gender (girls were more likely to experience it) and some of the aspects of dental treatments such as invasive procedures, injections, and meeting strangers. Also, the researchers noticed that the dental fear that first appears in childhood tends to become less evident as the people age (Hmud & Walsh 2009).

Alvares Duarte Bonini Campos et al. (2013) assessed a sample of 592 participants and reported that the percentage of individuals suffering from dental anxiety was 15%. The same study also mentioned that the British researchers detected 11% prevalence of dental anxiety in their research, and the Canadian study showed the prevalence of this phenomenon as high as 31% (Alvares Duarte Bonini Campos et al. 2013). Some other studies conducted in Brazil reported the dental anxiety prevalence equal to 17, 18, and 32.5% (Alvares Duarte Bonini Campos et al. 2013). Also, the anxiety prevalence was higher in female samples than in male ones, which allows one to conclude that females are more likely to be affected by this phenomenon (Al-Afaleg 2011; Al-Khalifa 2015).

Also, some researchers pointed out that rural dwellers tend to experience a higher level of dental fear and anxiety than the residents of the urban centers (Malvania & Ajithkrishnan 2011).

Risk Factors

Along with the epidemiology of dental anxiety, many researchers focused on the major risk factors contributing to its development and severity. In particular, the scholars identify a multitude of different impacts, however, many of them tend to repeat from one patient to another (Appukuttan et al. 2013; Bhola & Malhotra 2014). To be more precise, one of the most commonly found risk factors is the frequency of visits to the dentist; the individuals who attend a dental professional more often tend to have a lower prevalence of dental anxiety (Gaffar, Alagl & Al-Ansari 2014).

Moreover, another risk factor is the presence of a chronic dental condition and the need for multiple and frequent treatments during which the patients feel pain and discomfort (Gaffar, Alagl & Al-Ansari 2014). Also, one more significant driver of dental anxiety is the quality of an individual’s dental hygiene – this risk factor includes such behaviors as replacing toothbrushes, visiting the dentist for checkups, using mouthwash, brushing the teeth every day (Bhola & Malhotra 2014). Practically, the researchers found that individuals whose dental hygiene is poor tend to have a higher level of dental anxiety (Bhola & Malhotra 2014).

Moreover, Tellez et al. (2014) found a strong correlation between the painful experience during the last visit to the dentist and the following dental anxiety when facing the need to have another dental appointment. Swarthout-Roan and Singhvi (2013) and the University of Adelaide (2016) connected the prevalence of dental anxiety in female patients with the traumatic experiences of the past such as rape and molestation. Practically, the invasive oral procedures carried out by the dentists and the patients’ lack of control over the situation were named as the primary sources of distress and fear.

The prevalence of dental anxiety in children was explored in Brazil by Oliveira and Colares (2009) who connected it to the dental pain that occurs due to caries; they also related it to such causes as dental fear of the parents and previous painful experiences of visiting a dentist; another factor driving dental anxiety was the age of a child that was related to the fear of meeting strangers. Moreover, Kanegane et al. (2006) attempted to relate dental anxiety to the education and income level of their sample and found connections; however, they concluded that about 50% of their sample carried the fears as the results of previous dental treatments. Akeel and Abduljabbar (2006) named the level of education as a risk factor for dental anxiety. Serra-Negra et al. (2011) found that having experienced a dental treatment recently or expecting it shortly increases the levels of anxiety.

In Australia, the researchers found that about one out of six adult dental patients is affected by various levels of fear and anxiety related to the dental treatment; the prevalence of the same phenomena is lower in children – one in ten child-patients experience them (The University of Adelaide 2016). About 5% of Australian patients suffer from high and severe levels of dental anxiety. These are the levels that are capable of producing adverse effects on the patients’ quality of life. Moreover, just like American researchers, scholars from Australia found connections between dental anxiety in women and the traumatic experiences from the past related to sexual abuse (The University of Adelaide 2016).

Finally, another risk factor is knowledge of dental procedures. In particular, the students studying to become dentists tend to have a lower prevalence of dental anxiety than the people whose knowledge of dental treatments is more superficial (Sghaireen et al. 2013).

Vulnerable Groups

Frydendal Hoem and Marlén Elde (2012) described the Seattle System that distinguishes between four groups of dental patients based on the causes of their dental anxiety. The first group is ‘Anxiety of Specific Stimuli’, it involves the patients whose fear is triggered by the specific visual or audial factors such as needles, the sound of the drill, the idea of having a tooth removed, and sitting in the dental chair, to name a few (Appukuttan et al. 2013). The second category is ‘Distrust of Dental Personnel’, it includes the patients who are anxious due to the need to interact with an unknown individual (the dentist) and have no control over the situation (Frydendal Hoem & Marlén Elde 2012).

In particular, such patients are anxious about their dentists being rough while providing treatment or concerning only about their money but not about the needs and comfort of the patients (Frydendal Hoem & Marlén Elde 2012). The third group is ‘Generalized Anxiety’, it concerns the patients who have anxiety in general; they are likely to be highly unsettled by a visit to the dentist (Frydendal Hoem & Marlén Elde 2012). Finally, the fourth group is ‘Anxiety of Catastrophe’, it involves the patients who tend to feel paranoid about the potential adverse outcomes of the dental procedures such as numbness not going away after the treatment is over, or an unexpected allergy to a certain medication used on them (Frydendal Hoem & Marlén Elde 2012).

Impact on Patients Direct & Indirect

First of all, due to the avoidance of dental treatments and regular checkups, anxious individuals are likely to develop dental issues and have deteriorating dental health (Gaffar, Alagl & Al-Ansari 2014). Consequently, it is possible to assume that the poor dental health would affect the quality of life of the individuals adding stress from dental pain, communication issues due to halitosis, employment issues, and unsatisfying personal image (if one’s teeth are visibly affected by a condition) (Frydendal Hoem & Marlén Elde 2012). Also, The Swedish authors Wide Bouman et al. (2013) pointed out that dental anxiety is a rather serious problem for the patients and it may produce and very significant adverse impact on the life of an affected individual. The Swedish researchers stated that this issue is in strong connection with the other types of anxiety and mentioned that it can lead to the reduction of a person’s quality of life and cause social isolation (Wide Bouman et al. 2013).

Effects on the Dental Professional

From the perspective of a dentist, anxious patients are very difficult to work with because they tend to disrupt the work of a dental professional or even prevent them from performing their duties well (Madfa et al. 2015). Also, a patient who is unsettled and restless tends to endanger themselves due to startling, moving, and using their hands to interfere with the dentist’s work (Madfa et al. 2015). Moreover, as pointed out in the research conducted by Madfa et al. (2015) in Yemen, dental anxiety experienced by the patients can cause the deterioration of the relationship between the client and his or her dentist and even result in misdiagnosing due to the patient’s unsettled behavior during the dental examination or treatment procedures.

Management of Anxious people

To be able to deliver high-quality and safe dental care, a dental practitioner is to know how to manage anxious patients. There exist methods that could help a dental practitioner achieve a calm and harmonious environment while delivering dental care (Frydendal Hoem & Marlén Elde 2012). Adult patients are easier to manage than children (Frydendal Hoem & Marlén Elde 2012). Adults can be reasoned with and are more perceptive of motivation and soothing communication (Frydendal Hoem & Marlén Elde 2012; Gao et al. 2013).

Management of dental anxiety is critical because it produces important benefits for both the patient and the dentist; due to the elimination or minimization of dental anxiety and its effects, the patients can receive a safer treatment of higher quality, and the dental professionals can work faster and more successfully; besides, both parties find themselves in a calmer and stress-free environment (Madfa et al. 2015). DeNitto (2009) identified that the invasive dental procedures such as root canal procedures and dental surgeries are usually surrounded by fears and anxiety of the highest levels due to the patients’ negative perception of these types of treatments. The researcher connected them with the invasive nature of the procedures that is related to fearful expectations of pain and proposed audiovisual distractions as reconditioning factors to reduce anxiety.

Techniques for Helping People with Dental Anxiety

The Nigerian researchers Koleoso, Osinowo, and Akhigbe (2013) argue that the pharmaceutical treatment of dental anxiety may have dangerous consequences and offer relaxation therapy and cranial electrotherapy stimulation as ways to address the problem. The researchers state that dental anxiety is a serious factor that usually contributes to the deterioration of dental health (Woodmansey 2010). One of the major techniques for work with anxious individuals is the one known as iatrosedative (Frydendal Hoem & Marlén Elde 2012).

This technique is based on the calming and confident conduct of the dental practitioner that ensures a patient’s trust and calms him or her down (Frydendal Hoem & Marlén Elde 2012). Some other techniques include rehearsal, where the dentist demonstrates their actions to the patient before carrying them out, and behavioral control, where the dentist and the patient work out a system of signals that would provide the latter with more control of the situation (Frydendal Hoem & Marlén Elde 2012). Also, for the patients who experience distrust of the dental professional, there are two helpful techniques – informational control (the patient learns about the treatment and develops a better idea of what would be happening during it) and building a trustful relationship with the dentist – this approach may take some time and work after several visits (Frydendal Hoem & Marlén Elde 2012).

Moreover, for the patients whose dental anxiety is caused by their general anxiety, the techniques for the latter are the most helpful; they include distraction, relaxation, cognitive restructuring, guided imagery, and thought to stop. (Frydendal Hoem & Marlén Elde 2012). Finally, for the patients suffering from what is known as the anxiety of catastrophe, the approaches, and helpful techniques are based on the establishment of a trusting relationship with the dentist and developing the feelings of calmness and confidence that can be achieved with the help of the iatrosedative technique (Frydendal Hoem & Marlén Elde 2012).

Assessing Dental Anxiety

The patients’ levels of dental anxiety and fear can be assessed by dental professionals and researchers for different purposes. There is a variety of scales and questionnaires helping to carry out a survey that would allow the evaluation of the severity of dental anxiety experienced by the patients. For instance, some of the most commonly applied questionnaires are titled the Dental Anxiety Scale (DAS) and the Modified Dental Anxiety Scale (DAS) (Madfa et al. 2015; Minja, Jovin & Mandari 2016). One more assessment is known as the Dental Fear Survey (DFS); finally, another well-known assessment tool is the Dental Belief Survey (DBS) (Frydendal Hoem & Marlén Elde 2012). Due to the variety of tools, each practitioner may choose the ones that are particularly suitable for the objectives of their assessment in particular. Al-Namankany, de Souza, and Ashley (2012) concluded that none of the existing scales is suitable as a golden standard for measuring anxiety in all types of child-patients.

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