Motivation and emotion/Book/2021/Dental fear

Dental fear:
What causes dental fear, what are the consequences, and how can it be managed?

Multimedia presentation (3 min)

Overview

Dental fear is a common fear globally, across demographics and cultures. The dental experience incorporates psychological processes, in addition to avoidance of dental treatment, which can increase problems with oral hygiene (Carrillo-Diaz et al., 2012). The fear has a prevalence of between 10 and 25% in the adult population (Oliveria et al., 2017). Dental procedures require an individual to have their mouth open and teeth examined closely by a dentist with a range of instruments. The instruments used for treatment are commonly the trigger to the fear. The sound and the pressure on the teeth produce pain and discomfort. This can later turn into considerable stress for future treatment and a fear is developed. When examining the motivation and emotional effects of dental fear it is important to view it from a range of perspectives and frameworks. What is also discussed is other factors such as the comorbidity of other psychological disorders that present with dental fear, and how to manage it by the individual and others.

Focus questions: What is dental fear? What are the consequences of dental fear? How to manage this fear?

What is dental fear?

Figure 1: Amygdala within the brain

Dental fear also known as odontophobia is a fearful reaction and emotional state of worry to perceiving a negative outcome from a dentist performing dental care procedures (Scandurra et al., 2021). There are many perspectives to understand how this fear is viewed. Firstly, the physiological components on how the fear is initiated, biological and genetic vulnerability, cognitive processes and conditioning behaviours.

The physiological mechanisms of fear are an emotional response in the amygdala, which is located in the medial temporal lobe. It is the neural system that is responsible for emotional processes from fearful and threatening stimuli (Salzma, 2019). Figure 1 demonstrates where the amygdala can be found in the brain. When dental tools are presented to the mouth the body can perceive this as a dangerous threat. This elicits arousal and the amygdala then communicates to the sympathetic nervous system to activate our flight and fight, immobility and freeze responses to the situation to avoid the danger (Carter, et al., 2014). Our bodies can perceive us as being highly vulnerable to being injured when dental work is being performed.

The biological perspective is seen in genetic vulnerability. There is a strong prediction of inherited genetic vulnerability factors that predispose individuals to anxiety or certain phobias like dental fear. This is not inherited directly, it is other factors that interact with other components that influence the development of the phobia. It is important to note that fear is not related to the actual development of phobic symptoms (Carter, et al., 2014).

Cognitively, individuals can experience a set of ideas about the probability and severity of their dental visit. Negative thoughts can be ‘If I go to the dentist I will experience excruciating pain’ this may be due to seeing or hearing from another person that pain is induced Template:Awkard at the dentist. Individuals also can hold beliefs about their ability of being able to cope in a situation where the outcome is aversive (Carter, et al., 2014). Negative emotions can be tied to these thoughts, and to avoid these negative emotions being experienced it is best to avoid visiting the dentist.

The behavioural perspective of fear development can be seen in two different ways of reinforcement. Ivan Pavlov's classical conditioning is when a neutral stimulus is conditioned by an outcome. For example, in the dental environment if an individual experiences a painful procedure during their visit to the dentist, the conditioned response being elicited can go on to form as a fear. B. F. Skinner's operant conditioning is another perspective where the behaviour is reinforced by a punishment or reward. The behaviour is modified through the consequences that follow the behaviour. Rachman (1977) also described conditioning as a learning process through pathways, a direct and indirect pathway which we will focus on surrounding dental fear. For phobias to develop, commonly a positive punishment such as pain is experienced to your teeth and will reinforce you to avoid the pain again, and to avoid that level of pain it is safer to avoid the dentist altogether. (Carter, et al., 2014) This negative experience decreases an individual's motivation for future dental visits. The consequence of avoiding the dentist can make the problem worse.

Quiz 1 Does the amygdala respond to threat and produce fear-related emotions? True False

Dental fear in research

Figure 2: Vicious cycle of dental fear

Vicious cycle model

A concept known as a vicious cycle (Berggren, 1984) which starts with avoidance behaviour, creates a feedback loop that reinforces the stimuli as fearful, and conditions the response in the future to avoid the stimulus. The stimulus in this instance is dental problems (Armfield, 2012). A visual representation of the cycle is demonstrated in Figure 2. Armfield and colleagues revealed that 38% of Australians above 14 years of age experience moderate to high dental fear in contrast to 0.9% who do not experience dental fear.

Siveira and colleagues have adapted this model into a longitudinal oral health study of 535 participants, mostly subsamples of the cohort aged from 1 to 31 years in a population in Pelotas, Brazil. They investigated the relationship between dental attendance and oral health conditions, over the life course, and dental fear in adults through the vicious cycle of dental fear.

Across 11 follow up appointments over the years, results of participants who did not visit the dentist in the previous tests were likely to report dental fear. There was more dental pain reported when poor oral health was presented. Female and non-white participants were more prevalent in developing dental fear. This longitudinal study helped to identify individuals that are prone to having higher dental fear by age 31, as they presented more dental decay at age 15. Limitations to this study are the detection of dental fear and using a single question to determine the fear, this does not take into account the severity of dental fears in participants. The strengths from this study have demonstrated that dental fear is seen in countries that have a lower income, the majority of previous studies in the area of dental fear have been conducted in high-income countries. (Silvira et al, 2020)

Cognitive vulnerability model

The cognitive vulnerability model used in research by Armfield explains dental fear, how the model represents a framework that explains various characteristics of fears and phobias (Armfield, 2006). It suggests that dental treatment-related situations activate a negative schema in the individual. This schema then subsequently processes vulnerable information that activates cognitive, behavioural and emotional fear responses when exposed to or anticipating the presence of dental stimuli. Crego and colleagues apply this model to analyse the cognitive and family influences on children’s dental fear (Crego, et al., 2013).

Firstly, to understand why the model is being applied is due to dental fear commonly developing in childhood. This can be due to a child's social environment and the influence from others such as family members. For example, a mother's negative experience at the dentist can transfer to the expectations of a negative outcome for the child. This is a conditioning experience learned by the indirect learning pathway to be afraid of a dental stimulus. The study was conducted in educational institutions across Madrid, Spain. With parental consent, they recruited children and adolescents. Participants, their parents and siblings filled out a questionnaire about dental fear. There were 185 children, 88 fathers, and 97 mothers who participated in the study. From the results of the questionnaire, the analysis suggests that cognitive vulnerability is associated with a child developing dental fear. This strengthens previous research of the cognitive vulnerability model in dental fear. It makes it clear that the cognitive variables and vulnerability related perceptions explain much of the variance in dental fear than non-cognitive elements to developing the fear. Notably, a limitation to this research is where a parent may dictate the child’s answers and not accurately reflect the child’s true answer (Crego, et al., 2013). From this research, it strengthens the research that there is an indirect influence from others that can create a belief that the outcome from dental work will be negative, and fear is a response that will be more likely to develop when the belief is confirmed if there is a negative outcome.

Protection motivation theory

Protection motivation theory (PMT) is a decision making model that includes the health belief model and self efficacy theory. This model has four components that motivate healthcare behaviour.

1. The perception of severity of harm to health;
2. The perceived vulnerability to complications;
3. Belief in self-efficacy of one's ability to implement change; and
4. The belief in response to self-efficacy and change behaviours to influence outcomes.

This model has been used previously in other areas to alter health behaviours to address smoking and diabetes. The response to change beliefs and self-efficacy are two components that assist in changing behaviour. Applying this model to caregivers is an opportunity to educate and influence regular dental checkups for children. Dental cavities in children is a preventable condition that can prevent major dental work in the future that can elicit dental fear. (Kimhasawa et al, 2021)

Figure 3: Protection motivation theory

Kimhasawa and colleagues explore this model and look at the relationship between education programs and the effects of the PMT on oral health outcomes. Two outcomes were measured. The care incidence and incremental rates of two groups and the change in the four protection motivations. Children in Thailand were recruited for the analysis (N = 81). Across sub-district hospitals, interventions were conducted in a quasi-experimental setting, where participants' parents were required to fill out a questionnaire that included demographic and socioeconomics and protection motivation theory factors. For example ‘The yellow plaque on my child’s teeth may put them at risk of tooth decay’. As well as a questionnaire where other self effect promotions were done in the session by using a role model to demonstrate and educate teeth brushing and the negative consequences of high concentrate sugar drinks on teeth. Over multiple sessions, every four months, the results from the interventions revealed that promoting self-efficacy through the PMT improved behavioural and dental health outcomes. Providing education through a PMT framework assists in increasing sufficient teeth brushing to prevent cavities and increase self-efficacy (Kimhasawa et al, 2021).

Quiz 2 In the cognitive vulnerability model, what does the dental treatment-related situation activate? Feelings Emotions Schema

Why it's important to go to the dentist

Figure 4: Boy confidently smiling

Going to the dentist is important to avoid dental complications such as cavities, decay, structure issues and losing teeth. These complications can promote insecurities in the individual. To avoid insecurities and discomfort, it is important to visit the dentist and avoid the vicious cycle of avoiding the dentist. Individuals with high dental fears commonly have more dental complications such as decay and missing teeth on average than people who do not experience dental fear (Armfield et al, 2009).

What reduces our motivation to visit the dentist

The best way to understand this is by how we are motivated to avoid the dentist. Firstly it is a natural motivation to move away from any source that can cause pain to the body (Stephan et al, 2016). The problem with this motivation is that it doesn't benefit us or fix issues where there may already be a site of pain. The most common signs when we motivate ourselves to avoid the dentist can be avoidance in making an appointment, creating excuses to not visit the dentist and being unable to afford treatment (Armfield et al, 2012).

Other psychological disorder and dental fear

Other disorders can also be present with dental fear, they can also contribute to avoiding the dentist or be the underlying cause to the development of the fear. It is important to be aware if a combination of disorders are present. They may prevent you from receiving treatment or cause heightened emotions within the experience that can contribute to dental fear developing (Vigu and Stanciu, 2019). These include:

• Anxiety and Depression
• PTSD
• Other phobias
• Eating disorders

The consequences of avoiding the dentist

Deteriorating oral hygiene

Avoiding dentists can lead to higher rates of tooth loss, tooth decay and cavities. Visiting the dentist can identify complications to diets and habits that may be causing deterioration to your oral hygiene, such as smoking and poor diet. Dentists can identify signs of deterioration that may be cancerous or disease-related. These conditions and implications can affect the quality of life in a variety of ways (Vigu and Stanciu, 2019). Such as the loss of teeth can cause strain on gum while eating food and can affect our confidence and appearance.

The emotional distress

As your oral health deteriorates and your teeth may be noticeably damaged you may avoid the dentist and start to feel embarrassed. Another context that you may also feel embarrassed is in a social setting. There is a strong relationship between physical appearances and social interaction, smiling is a key component to expressing a quality of life and self-esteem, and is important for interpersonal relationships. This can lead to altering your facial expression by not smiling and avoiding your teeth showing. This also affects the emotional and functional aspects. Emotions of embarrassment, shame and discomfort are elicited and can cause social withdrawal or mental health deterioration (Magno et al, 2019).

Reinforcing the fear

As the motivation to avoid the dentist is strengthened, the fear is reinforced when dental fear is present. This conditioning will increase deterioration in oral hygiene. When the fear is being reinforced to avoid the dentist, emotional distress and deterioration in oral hygiene and quality of life affect our everyday life. The effects on everyday living can lead to developing or enhancing other disorders such as anxiety and depression (Vigu and Stanciu, 2019).

Quiz 3 Can the quality of life be affected if you have poor oral hygiene? Yes No

How to manage dental fear

Figure 5: Therapeutic session with professional and client

Managing the fear can be addressed in multiple ways. It is important to seek out assistance if needed to help manage the fear. There are many ways to help reduce the fearful experience through therapies and self-regulating techniques, as well as what others can do to prevent provoking the fear.

Individual management of the fear

As dental fear commonly develops in childhood, it can lead to avoiding treatment and uncooperative behaviour during treatment. To prevent the fear it is important to encourage regular check-ups to avoid having major dental problems that will result in painful dental experiences. It is important to motivate children to have regular visits and engage in exposure to the dentists, and encourage the individuals that the treatment will be beneficial (Carrillo-Diaz et al., 2012). Throughout literature, it is widely supported to encourage children to have exposure to the dentist, as it can prevent the development of dental fear later in life.

For adults, it is important to continue regular checkups and to recognise within themselves if fear is causing distress and to consider options that can assist in managing or overcoming the fear. There is a range of methods to cope, common in the literature therapy is the most effective to address a fear. This has been shown to assist in managing the fear or distressing sensations from dentists (Appukuttan, 2016).

Types of therapy

• Cognitive behavioural therapy helps to modify behaviour techniques and reconstruct cognitive beliefs through goal setting techniques. It is important to learn relaxation skills in the fearful dental environment and desensitise the fear of the environment. Cognitively it is important to challenge the thoughts and beliefs, recognise the physiological responses that trigger the fear and cognitively restructure that the dentist is not dangerous and it does not have to be avoided (Newton et al, 2012),
• Exposure therapy can be applied to desensitise an individual to the feared stimulus. Firstly, the individual is to talk about the fear, then construct a hierarchy of feared stimuli (dental situations) from the most fearful to the least fearful. Secondly, use relaxation techniques such as breathing exercises and muscle relaxing. The last component is to begin exposure to the fear stimulus, and gradually work up the hierarchy from the least to the most fearful situation. For example, imagine being in the dentist to start with, then standing out the front of the dental surgery, sitting in the waiting room, watching or listening to the dentist work before having treatment (Appukuttan, 2016).
• Dialectical behaviour therapy assists in emotional regulation and increases coping skills. It can help individuals recognise and manage their emotions. Components to the treatment are mindfulness practices to accept and change, distress tolerance to accept circumstances, emotional regulation to identity and challenging emotions, and lastly, interpersonal effectiveness is known as self-respect and validation. This therapy is helpful to use when there is a combination of disorders to help assist in periods of heightened emotions (Lenz et al, 2016).

How you and others can assist in managing the fear

Figure 6: Rapport building with dentist and client

Dentists

When treating individuals with dental fear it is important to build a relationship with the patient and dentist. The motivational interviewing method is suggested to help build on communication skills and treatments. This is done by having open-ended questions, reflective listening, affirmations to understand any underlying issues and emotional distress that are elicited by dental work (Brahm et al., 2018).

Family and friends

• An indirect pathway of learning can assist in establishing a fear, it is important to avoid sharing or projecting your own fear onto others (Carter, et al., 2014).
• Being a model to young children and reinforce the dentist is to help with maintaining good oral hygiene (Carter, et al., 2014)
• Be supportive and offer assistance in seeking out support to manage the fear.
• Encourage the use of relaxation techniques in triggering situations (Appukuttan, 2016).

Quiz 4 What would be helpful to adjust to fearful situations? Relaxation techniques Screaming Running away

Conclusion

Major dental work can be a scary procedure and it is important to avoid major dental work by visiting the dentist regularly for check-up and cleans. It is also important to go on a regular basis to avoid the experience being scary and developing into dental fear. Recognising that it is commonly developed in childhood and to be aware of the learning pathways a child can learn to develop a fear through. For instance, a vicious cycle can be formed by avoiding the dentist and complications can develop into more complications and undesirable outcomes. Losing a tooth can affect you in ways that can lead to isolation and avoidance of social situations. This can cause a lot of emotional distress and reduce overall motivation to enjoy social interactions with others. It is important to seek out help and support from services, your dentists and others to make the fear manageable and less distressing.

See also

• Dental fear (Book chapter, 2020)
• Dentistry (Wikipedia)
• Fear as a motivator (Book chapter, 2014)
• Jonah complex (Book chapter, 2021)
• Phobia (Book chapter, 2019)

References

Appukuttan, P. D.(2016). Strategies to manage patients with dental anxiety and dental phobia: literature review. Clinical, Cosmetic and Investigational Dentistry. 8, 35-50.https://doi.org/10.2147/CCIDE.S63626

Armfield, M. J. (2012). What goes around comes around: revisiting the hypothesized vicious cycle of dental fear and avoidance. Community Dentistry and Oral Epidemiology. 41(3), 279-287. https://doi.org/10.1111/cdoe.12005.

Armfield, M. J., Crego. A., Schuch, S. H. & Luzzi, L. (2017).The role of cognitions in short-term temporal changes in dental fear among Australian adults. Journal of Public Health Dentistry. 78(1), 32-40.https://doi-org.ezproxy.canberra.edu.au/10.1111/jphd.12232.

Brahm, C., Lundgren, J., Carlsson, S. G., Nilsson, P. & Hägglin C. (2018). Development and evaluation of the Jönköping Dental Fear Coping Model: a health professional perspective. Acta Odontologica Scandinavica. 76(5), 320-330. https://doi.org/10.1080/00016357.2018.1453082

Bernson, M. J., Hallberg, R.-M. L., Eflström, L. M. & Hakeberg, M. (2011). ‘Making dental care possible – a mutual affair’. A grounded theory relating to adult patients with dental fear and regular dental treatment. European Journal of Oral Science.119(5)373-380.https://doi-org.ezproxy.canberra.edu.au/10.1111/j.1600-0722.2011.00845.x

Carrillo-Diaz, M., Crego, A., Armfield, M. J. & Romero-Maroto, M. (2012). Treatment experience, frequency of dental visits, and children’s dental fear: a cognitive approach. European Journal of Oral Science. 120 (1), 75-81.https://doi-org.ezproxy.canberra.edu.au/10.1111/j.1600-0722.2011.00921.x.

Carter, A. E., Carter, G., Boschen, M., Al Shwaimi, E & George, R. (2014). Pathways of fear and anxiety in dentistry: A review. World Journals of Clinical Cases. 2(11),642-653. https://doi.org/10.12998/wjcc.v2.i11.642

Geuter, S., Cunningham, J. T. & Wager, T. D.(2016). Disentangling opposing effects of motivational states on pain perception. PAIN Reports. 1(3),574: https://doi.org/10.1097/PR9.0000000000000574.

Lenz, A. S., Del Conte, G., Hollenbaugh, K. M., & Callendar, K. (2016). Emotional Regulation and Interpersonal Effectiveness as Mechanisms of Change for Treatment Outcomes Within a DBT Program for Adolescents. Counseling Outcome Research and Evaluation. 7(2), 73–85. https://doi.org/10.1177/2150137816642439

Magno, B, M., de Paiva Cabral Tristão, K. S., Lucas Alves Jural, A. L., Olga Aguiar Sales Lima, S., Raildo da Silva Coqueiro, R., Lucianne Cople Maia, L. & Melo Pithon, M. (2019). Does dental trauma influence the social judgment and motivation to seek dental treatment by children and adolescents? Development, validation, and application of an instrument for the evaluation of traumatic dental injuries and their consequences. International journal of Paediatric Dentistry. 29(4), 474-488. https://doi-org.ezproxy.canberra.edu.au/10.1111/ipd.12479

Oliveria, M. A., Vale, P. M., Bemdo, B. C., Paiva, M. S. & Serra-Negra, M. J.(2017).Influence of negative dental experiences in childhood on the development of dental fear in adulthood: a case–control study. Journal of Oral Rehabilitation. 44(6), 434-441.https://doi-org.ezproxy.canberra.edu.au/10.1111/joor.12513

Salzman, C. D. (2019). Amygdala. Encyclopedia Britannica. https://www.britannica.com/science/amygdala

Silveira, E. R.m, Cademartori, M. G., Schuch, H. S., Armfield, J. A & Demarco, F. F. (2021)Estimated prevalence of dental fear in adults: A systematic review and meta-analysis. Journal of Dentistry. 108, 103632. https://doi.org/10.1016/j.jdent.2021.103632

Vigu, A and Stanciu, D. (2019).When the fear of dentist is relevant for more than one’s oral health. A structural equation model of dental fear, self-esteem, oral-health-related well-being, and general well-being. Patient Preference and Adherence. 13, 1229-1240. https://doi.org/10.2147/PPA.S209068.

External link

• Bupa, how to manage dental fear (YouTube)
• Dental anxiety and phobia (Better health, Victorian Government)
• I avoided the dentist until it was too late( YouTube)
• Tooth or consequences: Even during a pandemic, avoiding the dentist can be bad for your oral health (The Conversation, 2021)
• Why are we afraid to go to the dentist? (Wire feed)