THE PHENOMENON OF DENTAL FEAR - ON SCIENCE, TECHNOLOGY and PEOPLE ENGLISH TRANSLATION OF: Moore R. Fænomenet tandlægeskræk - om videnskab, mennesker og teknologi. Tandlaegebladet. 1993;97(2):45-50. Figures from the original article are found within the article in Danish and translated to English where relevant. Rod Moore Dental Anxiety Research and Treatment Center, Department of Community and Children's Dentistry, Aarhus School of Dentistry, Health Sciences, Aarhus University 8000 Aarhus C Denmark Email: [email protected] APPETIZER: The article is based on a Ph.D. thesis defense lecture that includes a number of clinical studies on phobic anxiety for dental treatment. In addition to the results from the articles, the text contains a philosophical reflection on scientific research as well as some thoughts and suggestions on the future of dentistry. In all scientific research, but especially in behavioral research, one can ask, "What is science's overall objective?" Lademann's lexicon (1) describes science as "a methodical research work and its findings converted into a form of exact knowledge." There could also be added that this systematic search for exact knowledge or "truth" should also facilitate and improve the human condition. For some scientists, it is hard to keep such an aim high their priorities, not because of malice or indifference, but rather, because the human thread in daily work and life get lost due to the distance resulting from the requirement of objectivity. This can remove scientists from the obvious problems that ordinary people would like to have solved. It is of course debatable whether one thinks it is appropriate to include the participation of ordinary people's desires in all kinds of scientific research, but science, research and technology should ultimately serve human purposes. EXISTENCE OF A PROBLEM A current example of scientific research where one cannot avoid the general population's needs and desires is the research of fear of dentists and dental treatment. This topic has aroused great attention among populations and the dental profession in the form of frequent mass media coverage, long waiting lists for specialist clinics and professional debate. Why this overwhelming interest, and what is this phenomenon all about? The purpose of this article is to summarize the results of a Ph.D. dissertation and with these scientific findings as a basis, to come up with some ideas and suggestions that will foster debate on the future of the world of dentistry. Historically, dental treatment and the dental profession have been considered violent, painful and taxing. It is not more than 200 years ago, it was the barber and blacksmith who were pulling teeth for a fee. Or it was traveling "jesters" who took payment for extracting teeth on stage in front of an enthusiastic audience (Fig. 1). As late as the 1940s generation, it was common in Denmark to have dentures made as a religious confirmation present for teenagers. Our professional ancestors have unfortunately had much to do with developing a popular belief that still casts a long shadow over our professional image among the population. In this way, "dental fear" is nothing new. As in so many other contexts, technological progress and human development do not always run parallel. Contemporary extraction elevators and forceps (Fig. 2) as well as public performances with tooth

extraction on stage are today replaced by today's screaming drills (Fig. 3), sharp needles and confining electronic dental chairs as symbols of the scary process. In this context, the nature of anxiety about dental treatment has changed, but it exists nonetheless, even if some dentists will deny that the phenomenon existence.

"Dental fear" can mean many things. The term covers all intensity degrees of anxiety or fear of the dentist and dental treatment, while "odontophobia" refers to the highest degree of anxiety, which often leads to total avoidance of dental visits(2). Taking this into consideration, it is perhaps not so difficult to understand that some dental practitioners deny the existence of the phenomenon since dentists rarely have contact with "odontophobics" (i.e. people with odontophobia), and if that occurs, it is most often associated with sporadic, tedious emergency treatment. It is these phobic people we have observed in our research. The literature describes a typical population of odontophobics to range from 4 to 14% of populations, depending on the nation.(3 7) It consists of more women than men with an average age of between 30 and 45 years (2.8); and most typically have avoided dental treatment on an average of 11 years (in Denmark) (2). But this does not describe the personal stories of the phenomenon. Individuals with this phobia may have a grotesque perception of dentistry and see the world of the dentist as dangerous and something to be avoided. We as dentists and staff often experience the same phenomenon as if odontophobics have an unusual and distinctive perspective of our daily routines. It takes extra time to work with such patients, and for many dentists, time is money. Patients with odontophobia seem also unstable because they appear sporadically. As a dentist, one may get the feeling that it is a waste of time to invest in such patients. The gap between the two views makes it difficult from the outset to build a good working relationship with mutual respect and understanding. Since this series of Ph.D. studies has focused on the patient's perspective, there will first be described here a few patient examples. Patient 1 was a 47 year-old director from Vejle, who had not been to the dentist in 12 years. The reason was that he as 11 years were held in the chair of a female dentist while she drilled in his teeth. His psychosocial history included divorce partly caused by bad teeth and appearance. He did not smile with his mouth, only with his eyes, a handicap in his work. He was extremely embarrassed about the problem. Treatment for his dentition would 20 years ago have been the extraction of all of his teeth, probably under general anesthesia and then complete dentures. But now the technology exists to save them and the patient wanted to and had the economy to maintain his teeth.

Patient 2 was a 26 year old inhabitant of Aarhus who had never been regularly to the dentist because of a traumatic experience as a child. He did not get a proper explanation in connection with installation of braces with orthodontics and the usual subsequent aches and pains one get in the teeth. This resulted in painful removal of the orthodontic apparatus at the hospital after consultation with his father, who also had dental phobia. Currently he had conflicts with his brother about being allowed to attend his wedding, and he found it hard to get in touch with girls because of his bad looks. He did not brush his teeth due to fear of losing further tooth pieces and fillings (Fig. 4). These examples of disastrous dental status and the subsequent social consequences could have been prevented by regular dental care, and it is this that distinguishes odontophobia from other types of phobias. One can for instance. avoid snakes and spiders, if one has a phobia about those, without consequences for one's health. From these examples it can be seen that the consequences of odontophobia comprise poorer dental status and partly in the form of psychosocial problems. Therefore in odontophobia is a "psycho-" (with the soul to do) "somatic" (with the body to do) disorder. In this context, Berggren (9) described a vicious circle of odontophobia, with many years of avoiding dental treatment that can cause decay of teeth, which can lead to feelings of guilt and embarrassment. This in turn can enhance the anxiety and avoidance because a potential. treatment are likely to be more extensive and complicated, and it becomes harder and harder to get out of the vicious circle. The scientific objective of this Ph.D. project has been to increase knowledge about the causes, symptoms, diagnostic types, the quality of measuring instruments and factors that contribute to the success of treatment of dental phobia in a series of studies on the same population (2). More than 85% of subjects in this study themselves sought help at the Research and Treatment Center (FoBCeT), mostly via newspaper articles (49%) (10). Their distribution with respect to demographic factors corresponded to the literature (3,8); However, there was an equal distribution in terms of socioeconomic status and a preponderance of lower-educated subjects(10). SYMPTOMS, ETIOLOGY and DIAGNOSTICS The most frequently cited complaint from the 208 telephone interviews with odontophobics from FoBCeTs waiting list was fear of "everything" at the dentists and associated with a feeling of powerlessness and embarrassment in treatment situations(10). Only then was drilling pain and fear of needles designated , in that order (10). Only 11% cited fear of doctors / hospital as a parallel phenomenon (10). A representative sample of 80 patients (from the 208 Ss) completed a number of questionnaires about dental anxiety, general anxiety and their attitudes about dentistry. They were also interviewed about their psychosocial background, previous experiences with dentists, social consequences of the fear and the factors they thought might affect treatment. The most frequently mentioned reason for odontophobia was bad experiences at the dentist (84%) typically in childhood (70%) (10). These were most often associated with negative behaviors of the dentist and a bad atmosphere in the clinic. Only 25% of the experiences could be directly linked to pain (10). For 63% of these cases were also found a social influence of family and/or close friends who had dental phobia (10). To clarify diagnostic categories for the 80 odontophobic patients according to the association between cause and symptoms of dental phobia, an untested system was studied (10). The so-called "Seattle system" describes the four main types of dental fear diagnostic: Type I. Fear of pain or unpleasant stimuli. Type II. Fear of catastrophic bodily reactions treatment. Type III. Patients with general anxiety or multiphobic (co-morbidity) complications. Type IV. Distrust of dental staff.

The Seattle system was compared to a breakdown in simple phobias, social phobias or generalized anxiety complications described in the Diagnostic and Statistical Manual of Mental Disorders (DSM III R) (11), of the American Psychiatric Association. Corroboration of interview data and questionnaire data formed the basis for diagnostic categorization for an exclusion process. Based on these criteria, Seattle Type I presented as a simple phobia of pain or discomfort from quite accurate fear objects (drill, needle etc.). That only 19% of patients in this study (10) belonged to this type might be surprising because one would be inclined to believe that the pain from instrumental treatment would be the most common cause of odontophobia. 7% had fear of bodily reactions such as choking, allergic reactions, fainting or panic attacks, and 28% had predisposition to odontophobia via general anxiety or multiphobic symptoms (10). In 46% of the 80 patients, a social phobic state was found aimed specifically at the dentist-patient relationship where embarrassment and distrust was the greatest obstacle to seeking the dentist (10). One can categorize the Type IV on three subgroups depending on the origin of the phobia, but for all patients of this type, social phobia maintained by a vicious cycle of odontophobia, as described by Berggren (9).

Conclusions about etiology and cause For these patients, odontophobia was more often conditioned by interactions with the dentist than the pain of instrumental procedures or general anxiety tendency (10). It was "not so much the drill, but the man (or woman) behind it" that had the greatest impact. Also, to highlight the difference between the social phobic fear of dentists and general anxiety: Patient 3 was a 36 year old Type IV patient from Randers, who did not hesitate to do parachute jumping as a hobby, but who did not dare return to dentistry for 17 years due to anxiety arising from the trauma at the hands of a tough and domineering dentist with a German accent. This girl did not suffer from other mental disorders and obviously much more courage than most of us. MEASUREMENT METHODS The methods for classification of these diagnoses were chosen based on scientific theoretical considerations (12) in evaluations. (13) Registration of dental phobia in the current studies were based on interviews, questionnaires and behavioral patterns. The assessment of questionnaire data was based on reliability, validity and usefulness of the various tests. 155 odontophobics completed questionnaire tests for dental anxiety and general anxiety tendency. After six months on the waiting list, 75 completed the same tests again, and 80, in connection with interviews and treatment at FoBCeT, also completed a questionnaire on mood and trust about dentists. All tests showed a high level of reliability, and it was found that these various tests revealed various aspects of odontophobia, and were consistent with interviews and behavioral characteristics (13). The results also showed that a high level of general phobia tendency was a very useful predictor of resistance to therapy for dental phobia. Finally, it was found that mood was the primary indicator of the patients' confidence in treatment processes. TREATMENT Of psychological therapies systematic desensitization (2.9) is the preferred method of treatment of dental phobia, according to other studies. Systematic desensitization (or SD) is a habituation treatment, wherein therapist very gradually by means of specific verbal agreements and always in combination with relaxation training, are confronted with threatening instruments and situations at a pace that the patient can cope with without adverse reactions. The following two SD methods were studied (14,15): 1) "Video training": combined relaxation, so-called biofeedback muscular tension detection and video clips of treatment sessions until the patient is ready to try them directly on themselves in clinic (Fig. 5). 2) "Rehearsal training": combined relaxation training with habituation in the form of rehearsals where the patient incrementally gets demonstrated the instrumentation process without having completed an actual treatment, for example.

topical anesthesia, injection with plastic cap on the needle and the drill by "drilling" in the air above the tooth without drilling (Fig. 6). In both video and rehearsal therapy, the patient can stop the procedure with a pre-arranged hand signal, thereby giving enough emotional time to complete the task. Finally, the patient completes the actual treatment as a challenge. An experiment was performed to compare these two methods of distribution by randomization, where 27 patients completed video training, and 33 patients "rehearsal" training. The criteria that were used in the patient selection was a high level of dental anxiety (at least 15 out of 20 possible points on the Dental Anxiety Scale); equal distribution of men and women; a certain number of patients with higher general anxiety disorder; and age between 18 and 67 years. Found significant reduction in dental anxiety for both groups compared to the 75 waiting list patients who received a lengthy telephone conversation (14). There was no significant difference in anxiety reduction between the two treatments, but video training took significantly more time (14). Patients with multiphobic general anxiety required significantly more treatment hours than the other patients (14). After training, a total of 9 patients from the two groups hesitated to implement the 3 test dental treatments, consisting of 2 standard fillings and a third challenging treatment (such as extraction). In a exit interview about the factors that helped the patients the best with their dental anxiety, they said it was

not so much the type of habituation method, but more often conversations and the trust they built up to the staff and the ability to relax, in that order (15). Another object of the experiment was to assess the general psychological effects of this treatment for dental anxiety and thereby reveal the mechanisms which contribute to the treatment effect (15). After SD treatment, there was significant reduction in the general level of anxiety and concurrent significant mood increases for all patients. A "anxiety thermometer" (14) showed that after the training, the patients had significantly reduced their negative expectations and anxiety for the "next dentist".

Conclusions from treatment experimentation It could be concluded that the positive mood increases and expectations about the confrontation with the dentist and the rest of the staff are very important elements in the treatment of dental phobia (2). The patient's own subjective assessments of treatment effect seems central to his/her recovery. Incremental mood elevations measured at each step was proof of patients' gradual confidence in their ability to successfully interact with a dentist (2). So maybe it's more correct to say that the experiment did not compare technological content of the two training methods with each other directly, so much as comparing each program's ability to inspire patient confidence in the treatment process. This says something about the balance between technology and humanistic treatment.

Preliminary follow-up results Among the patients who met the criteria for successful implementation of specialist treatment and who could be contacted after one year (i.e. 48 out of 60 patients), continued about 94% from each of the two treatment groups at a chosen private practicing dentist (2). There was a continued low level of dental anxiety with no significant difference between the two groups.

FUTURE RESEARCH A research model was presented in an review article by Moore and Birn (16) as a starting point for further research. In this model the dentist-patient relationship is conceptualized as the central "action site" with a focus on three research groups, 1) dentist's image in the community, 2) the role of the patient and 3) the dentist's role. The purpose of the conceptual model is to identify and clarify factors that influence the emergence of odontophobia. This is necessary to develop effective prevention and treatment strategies in a larger context. It is a priority in the future to make a study of the adult population to assess the prevalence and characteristics of the phenomenon odontophobia and ordinary people's perceptions of the dentist's image. The Ph.D. thesis (2) has also identified a need for further research of the patient factors such as embarrassment about dental anxiety. It also seems appropriate to assess the effect of group therapy, where the patient processes the problem in a social environment of acceptance and support from peers. The effect of different treatments for different diagnostic categories of odontophobia also has research interest. Past research has focused on the patients' perspective in the phenomenon of dental phobia. But research of the dentist's role in the interaction is also important. There has not been much research of the phenomenon in general private practice, neither the patient’s behavior nor dentists’ perceptions of these patients. Dentists' current attitudes toward applied psychology and communication skills are also not known. CONCLUSIONS & BROADER IMPLICATIONS These studies show that some people find it very difficult to follow what is going on in the dentist's chair, regardless of the technological developments that are happening in dentistry; not because of the technology itself, but because. We as dentists could be better at communicating with patients and thereby become familiar with their perceptions and expectations. Maybe we, as therapists, seen from the patients' perspective, become distracted by the new technological methods and practices, and forgot to place the patient in the center. The old reduction of human suffering odontophobia to “device failure” in the patient’s ”physical chemical machinery” must be replaced by a holistic approach (17), where also the patient's psyche be involved to promote the goals of therapy. Dentistry is a field with a very fast evolving technology. Just to mention the latest "high tech" developments: implant systems with extensive crown and bridge work, tooth attachment reconstruction using membranes in periodontal treatment, cosmetic dentistry systems, advanced computer systems for reading x-rays and computer-controlled manufacturing of porcelain inlay fillings, while the patient waits in the dentist's chair, and more. With these great technological developments and the current dental practice forms of thought, there must here be asked two important questions: 1) Will the future dentist prioritize sufficient time for human contact and thereby prevent and treat such human suffering as odontophobia? While working with feelings and expectations often takes time, will we as dentists continue to prioritize the "time is money" philosophy in all cases? Can the reward of helping a frightened patient with his anxiety only be measured in monetary terms or are other measures of professional satisfaction valued more? 2) Will dentists be able to master or control patient expectations and cooperation in relation to the new technologies? Will dentists be able to master their own stress associated with modern dental practice? Speaking of quality and service, the Danish Dental Association has discussed plans to call 1992 and 1993 a "year of quality" in dentistry because of "increasing demands from citizens and politicians about the quality of care" (18), both physical and psychological in nature. The patient is positioned in the center (Fig. 7), it is important that the dentist can promote the whole dental team's self-esteem feeling through mutual and equal respect. If the dentists prioritize time for patients and staff expectations will result in the prevention of conflicts and thus reduce stress, create a more positive work environment and enhance the quality of the work.

In an assessment of future dental care, described in the Danish Dental Journal (Tandlægebladet), no. 12 1991 (19), it was mentioned that the future of dentistry "will have a greater biological and medical knowledge that enables them to make a diagnosis based on the "whole patient ", which makes them better suited to perform complex medical needs "(s.565). Although the Future Dental Education Report (FODU Report) (20) was cited as the basis for these statements, an essential element of FODU report about the treatment of the "whole patient" was not mentioned. One of FODU report's conclusions was that the dental team's future form will also require better knowledge and skills in patient service features which include patient psychology and communication. This requires new role models for dentists, models that should and can be developed within the dental education at a higher priority related to scientific knowledge and skills (Fig. 8). The phenomenon of dental phobia is proof that we as dentists in the future much more should be in possession of knowledge and skills about people, their behavior, thoughts and feelings on an equal level with all new technological developments and modern practices so that the "whole patient" oriented treatment is prioritized as important as "high tech" treatments

Fig 7. Demand for quality (patient in the center requiring Fig 8. Model for future dental education includes more time, equality, self-worth, conflict resolution treating the whole patient with equality of biomedical, dental technical and behavioral skills REFERENCER 1. Lademann (leksikon), bind 30, vest-Å, København: Lademann Forlags A/S, 1988, s.20. 2. Moore R. The Phenomenon of Dental Fear - Studies in Clinical Diagnosis, Measurement and Treatment. Royal Dental College, Ph.D. Dissertation, Århus, Denmark, 1991. 3. Milgrom P, Fiset L, Melnick S, Weinstein P. The prevalence and practice management consequences of dental fear in a major US city. J Am Dent Assoc 1988; 116: 641-7. 4. SIFO (Swedish Institute for Opinion Research). Tandläkarbesök intervjuundersökning för tandvärnet. Stockholm: SIFO, 1962. 5. Stouthard MEA, Hoogstraten J. Prevalence of dental anxiety in the Netherlands. Community Dent Oral Epidemiol 1990; 18: 139-42. 6. Hakeberg M, Berggren U, Carlsson SG. Prevalence of dental anxiety in an adult population in a major urban area in Sweden. Community Dent Oral Epidemiol 1992; 20: 97-101. 7. Freidson E, Feldman J. The public looks at dental care. J Am Dent Assoc 1958; 57: 325-35. 8. Berggren U, Meynert G. Dental fear and avoidance - causes, symptoms and consequences. J Am Dent Assoc 1984; 109: 247-51.

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