May 11, 2022
Dental fear and anxiety can pose significant barriers to receiving dental treatment and affect people across socioeconomic and demographic groups.
“Estimates of dental anxiety range widely from about 30–80% in the US and worldwide,” said Lisa Heaton, PhD, science writer for Analytics and Evaluation at CareQuest Institute for Oral Health. “Different studies define and measure dental anxiety differently and measure it within different populations. For example, estimates of dental anxiety are likely to be lower in a survey in an undergraduate classroom setting than from a survey from patients in an emergency dental clinic waiting room.”
Wherever it’s measured, dental fear and anxiety can be challenging for patients to cope with and for providers to treat. It can create a “cycle of avoidance,” leading to missed care, deteriorating oral health, and costly procedures that impact the overall oral health system.
Cameron Randall, PhD, assistant professor at the Department of Oral Health Sciences at the University of Washington School of Dentistry, and Dennis Nutter, DDS, DABPD, FACD, diplomate from the American Board of Pediatric Dentistry, joined Heaton in a CareQuest Institute webinar on the topic on May 5. The trio shared their expertise on dental fear and anxiety across the life span and discussed how childhood experiences can influence oral and overall health in adulthood.
“The first conceptual issue that I think is critical for understanding and managing a patient’s anxiety is that the causes and the impact of dental fear and anxiety are highly individualized,” Randall explained.
Heaton began by exploring public perceptions of dental fear and anxiety, including some results from the CareQuest Institute’s State of Oral Health Equity survey. Randall, a clinical psychologist, explored the science behind the negative feelings many individuals have about receiving dental care. And Nutter, who has practiced pediatric dentistry for more than 30 years, discussed potential solutions for preventing or addressing dental fear and anxiety.
“We have kids who are orchids, and we have kids who are dandelions,” Nutter said. “We need to provide all of our child patients with the environment in which they can thrive. And, really, the way to do that with kids with high levels of fear is to not do procedures that you can defer until the child ages to procedural tolerance or until the baby tooth falls out.”
Webinar participants shared several thoughtful questions on the topic before and during the program. We’ve compiled a list of the questions and answers below — and tapped our expert panelists to address a few additional ones.
1. Is it appropriate to use nondental terms to lower children’s dental fears — for example, telling a child you are putting a star on their tooth instead of a filling?
We need to communicate with the child on the level at which they process their environment. You need to adjust your terminology to what the child can understand. For example, a slow-speed dental handpiece becomes “Mr. Bumpy.” We are trying to change the way they think about an apparatus or parts of a procedure so that they don’t fear it. We have to be careful about that because we can’t trick children into painful experiences, but we need to communicate with kids at their level.
2. What’s the connection between dental anxiety/fear and depression?
There is a recent systematic review on the association between higher levels of dental fear and anxiety and other psychiatric comorbidities. In the case of depression specifically, there have not been any studies that have tried to tease apart cause and effect, which comes first, or how they are related. But what we know, from the health psychology literature more broadly, is that sometimes a mood disorder like depression can lead people to become less engaged with hygiene activities, including oral hygiene. That can lead people to have more negative experiences when they finally do visit the dentist, or it can result in more symptom-driven, treatment-seeking behavior.
3. Do you have any tips for reducing sensory stimuli like the sound of the drill?
Sensory distress that comes with any part of the procedure may be there because the patient had pain associated with it in the past, a common cause of dental fear and anxiety. So, if they are having distress with the sound of a drill, they’re likely having it because it’s invoking fear. Deconditioning is necessary to curb this fear, which is done by making sure that they don’t have pain associated with the sounds and other aspects of dental treatment — and that takes time.
We also want to seize opportunities to prevent dental fear in the first place. One strategy is to distract the patient from the dental stimuli, for instance, to help minimize the “scariness” of the sounds of the drill in the future. People have a finite amount of attention to give to things, so if we can divert attention away from the dental stimuli through distraction, that is an excellent approach. The real trick to doing this most effectively is to use the most immersive, distracting stimuli, like virtual reality, television, or music.
4. How can we address anxiety that prevents patients from initially scheduling an appointment or before a patient has their first appointment?
A major source of dental fear and anxiety for people looking for a new dentist is the unknown. Will this new dentist understand my fear? Will they be able to treat me and make me comfortable? A dentist’s practice website is a great place to share information with potential new patients about how the dentist helps fearful, anxious, and phobic patients feel more comfortable before, during, and after treatment. If possible, testimonials from current patients who have overcome (or at least learned to manage) their fear and anxiety with the help of the dentist can go a long way to helping new potential patients decide to make that first call.
When working at the Dental Fears Research Clinic at the University of Washington, we sometimes had patients who were seeking a new dentist due to relocating to a new state, for example. I would always suggest that they schedule a “meet and greet” session with a new dentist to discuss their concerns, what has been helpful for them in managing their fears before, and how the new dentist can help them. Over the last two years, we’ve all become much more familiar with videoconferencing (e.g., Zoom), and it’s easy to have a short video call with a new patient so they can get to know you and vice versa. This will help alleviate at least some of the fear of the unknown before the new patient arrives in your office for the first time.
5. What tools would you recommend for assessing dental anxiety? Are there one or two you would highlight?
There are several validated self-report questionnaires that can be used to measure the severity of a patient’s dental anxiety. The Dental Fear Survey and the Index of Dental Anxiety and Fear are two good choices; they each have a strong evidence base and have been used widely in clinical and research settings. Their length — they are 20 and 24 questions long, respectively — is both a potential limitation and strength. On the one hand, a longer questionnaire takes more time to complete, and time with patients can sometimes feel scarce. On the other hand, a longer questionnaire can give providers a much more comprehensive and nuanced understanding of a patient’s individual anxiety experience and presentation, which is critical for tailored, effective management. Some clinicians (and researchers) balance these pros and cons by using the Modified Dental Anxiety Scale, which is another good choice given its strong evidence base and wide use, its length (only 5 questions!), its availability in almost 30 languages, and the accompanying support website, which can be a helpful resource for clinicians. Any of these tools can be used with adolescents and adults. For children, the Children’s Fear Survey Schedule — Dental Subscale (completed via parental report for younger children) or the Modified Child Dental Anxiety Scale (for children 8 years and older) are good evidence-based choices.
An efficient approach to dental fear assessment involves screening all patients with a brief measure and following up with longer measures for patients with elevated screening scores so a comprehensive conceptualization and tailored management plan can be developed. It is recommended that a question about dental fear and anxiety be included on all new patient intake forms or as part of the health history taking. The last question of the Dental Fear Survey, which asks about fears generally, has been validated as a single-item assessment tool and makes a great screener. Providers also can simply ask whether a patient ever experiences anxiety or apprehension about dental treatment — so long as they routinely and systematically do it for all patients and follow up with a more detailed assessment should a patient endorse fear and anxiety.
6. Can the more widespread use of silver diamine fluoride as first-line treatment for dental caries (instead of drill/fill) help reduce dental fear?
Silver diamine fluoride is a good first-line treatment for dental caries and it does help reduce dental fear, as well as associated pain experience. It does this by delaying exposure to fear and pain-evoking stimuli associated with procedures. Silver diamine fluoride can often be used to delay caries progression until the child ages to procedural tolerance — that milestone is age 7. At that age, they can assess threat better and they have better voluntary control of attention.
7. Is it researched “best practice” to cover instruments in the operatory so they are out of patients’ sight?
There haven’t been any “best practice” studies that have looked at differences in patients’ fear and anxiety based on whether the instruments are covered or not when a patient enters the operatory. During the program, we discussed that fear and anxiety are highly individualized, so some patients likely take comfort in not being able to see the instruments as they walk in, while others may find it stressful, as though the dentist is trying to hide something. As part of the initial meeting, dentists or assistants can ask patients which they prefer. While most patients haven’t given it a second thought and won’t have a strong preference, patients who prefer to see the tray of instruments at the start will appreciate being asked. The dentist or staff can then make a note in the patient’s record to uncover the tray at that patient’s future appointments. That kind of attention to detail will go a long way in making your patients much more comfortable in your practice.
Editor’s Note: View a full recording of the webinar in the CareQuest Institute webinar library.