Dental Phobics Research Articles

Commonly Used Oral Sedatives in Treating Pediatric Patients

One in seven of the population of the world is highly anxious about undergoing dental treatment and requires careful and considerate management by dental practitioners. The interaction between the dentist, dental health team and the patient can reveal the presence of anxiety, fear, and phobia. In such situations, subjective evaluation by interviews and self-reporting on fear and anxiety scales and objective assessment of blood pressure, pulse rate, pulse oximetry, finger temperature, and galvanic skin response can greatly enhance the diagnosis and enable categorization of these individuals as mildly, moderately, or highly anxious or dental phobics Formulating acceptable evidence-based therapies for children is essential, or else they can be a considerable source of stress for the dentist.

Strategies to manage patients with dental anxiety and dental phobia: literature review.

Dental anxiety and phobia result in avoidance of dental care. It is a frequently encountered problem in dental offices. Formulating acceptable evidence-based therapies for such patients is essential, or else they can be a considerable source of stress for the dentist. These patients need to be identified at the earliest opportunity and their concerns addressed. The initial interaction between the dentist and the patient can reveal the presence of anxiety, fear, and phobia. In such situations, subjective evaluation by interviews and self-reporting on fear and anxiety scales and objective assessment of blood pressure, pulse rate, pulse oximetry, finger temperature, and galvanic skin response can greatly enhance the diagnosis and enable categorization of these individuals as mildly, moderately, or highly anxious or dental phobics. Broadly, dental anxiety can be managed by psychotherapeutic interventions, pharmacological interventions, or a combination of both, depending on the level of dental anxiety, patient characteristics, and clinical situations. Psychotherapeutic interventions are either behaviorally or cognitively oriented. Pharmacologically, these patients can be managed using either sedation or general anesthesia. Behavior-modification therapies aim to change unacceptable behaviors through learning, and involve muscle relaxation and relaxation breathing, along with guided imagery and physiological monitoring using biofeedback, hypnosis, acupuncture, distraction, positive reinforcement, stop-signaling, and exposure-based treatments, such as systematic desensitization, “tell-show-do”, and modeling. Cognitive strategies aim to alter and restructure the content of negative cognitions and enhance control over the negative thoughts. Cognitive behavior therapy is a combination of behavior therapy and cognitive therapy, and is currently the most accepted and successful psychological treatment for anxiety and phobia. In certain situations, where the patient is not able to respond to and cooperate well with psychotherapeutic interventions, is not willing to undergo these types of treatment, or is considered dental-phobic, pharmacological therapies such as sedation or general anesthesia should be sought.

Functional changes in brain activity after hypnosis in patients with dental phobia

Visiting the dentist is often accompanied by apprehension or anxiety. People, who suffer from specific dental phobia (a disproportional fear of dental) procedures show psychological and physiological symptoms which make dental treatments difficult or impossible. For such purposes, hypnosis is often used in dental practice as an alternative for a number of treatments adjuvant or instead of sedation or general anaesthetics, as medication is often associated with risks and side effects. This is the first study to address the effects of a brief dental hypnosis on the fear processing structures of the brain in dental phobics using functional magnetic resonance imaging (fMRI). 12 dental phobics (DP; mean 34.9years) and 12 healthy controls (CO; mean 33.2years) were scanned with a 3T MRI whole body-scanner observing brain activity changes after a brief hypnotic invervention. An fMRI event-related design symptom provocation task applying animated audio-visual pseudorandomized strong phobic stimuli was presented in order to maximize the fearful reactions during scanning. Control videos showed the use of familiar electronic household equipment.In DP group, main effects of fear condition were found in the left amygdala and bilaterally in the anterior cingulate cortex (ACC), insula and hippocampu (R<L). During hypnosis DP showed a significantly reduced activation in all of these areas. Reduced neural activity patterns were also found in the control group. No amygdala activation was detected in healthy subjects in the two experimental conditions. Compared to DP, CO showed less bilateral activation in the insula and ACC in the awake condition. Findings show that anxiety-provoking stimuli such as undergoing dental surgery, endodontic treatments or insufficient anaesthetics, can be effectively reduced under hypnosis. The present study gives scientific evidence that hypnosis is a powerful and successful method for inhibiting the reaction of the fear circuitry structures.

Presence, Content, and Characteristics of Memories of Individuals with Dental Phobia

SummaryKnowledge about memories of distressing events underlying fears and specific phobias is limited. This study assessed (1) the presence, content, and characteristics of memories of events that initiated or exacerbated dental anxiety levels; and (2) the relationship between dental trait anxiety and some key features of these memories. This study used a semi‐structured interview and included dental phobics (n = 42), subthreshold dental phobics (n = 41), and normal controls (n = 70). Dental phobics were more likely to report a memory underlying their anxiety than the normal controls. Moreover, dental phobics' memories were reported as more vivid, disturbing, and more intensely relived than the memories of the normal controls. Greater severity of dental trait anxiety was significantly associated with greater disturbance of patients' memories. The results suggest that memories of distressing events play a significant role in the development of dental phobia and that their characteristics are associated with severity of dental trait anxiety. Copyright © 2015 John Wiley &amp; Sons, Ltd.

Functional Brain Connectivity During Fear of Pain: A Comparison Between Dental Phobics and Controls

Fear of pain is the most common reason for avoiding the dentist by patients suffering from dental phobia. Previous functional magnetic resonance imaging investigations demonstrated that already thinking about pain during the viewing of images depicting dental treatment provoked enhanced orbitofrontal cortex (OFC) activation in the clinical group. In the present study, the authors investigated whether this differential activation can be explained by differential connectivity patterns between patients and controls. They found that the control subjects displayed a stronger and more widespread connectivity compared to patients. This connectivity pattern comprised prefrontal seeds (e.g., the anterior cingulate cortex), which were coupled with limbic structures (e.g., the amygdala) and the basal ganglia (putamen, pallidum, caudate nucleus). This pattern might reflect successful emotion regulation, which was absent in the clinical group. The patients showed coupling of the OFC and the caudate nucleus, which may be the neural correlate of associating pain with dental treatment.

Diagnostic classification of specific phobia subtypes using structural MRI data: a machine-learning approach.

While neuroimaging research has advanced our knowledge about fear circuitry dysfunctions in anxiety disorders, findings based on diagnostic groups do not translate into diagnostic value for the individual patient. Machine-learning generates predictive information that can be used for single subject classification. We applied Gaussian process classifiers to a sample of patients with specific phobia as a model disorder for pathological forms of anxiety to test for classification based on structural MRI data. Gray (GM) and white matter (WM) volumetric data were analyzed in 33 snake phobics (SP; animal subtype), 26 dental phobics (DP; blood-injection-injury subtype) and 37 healthy controls (HC). Results showed good accuracy rates for GM and WM data in predicting phobia subtypes (GM: 62% phobics vs. HC, 86% DP vs. HC, 89% SP vs. HC, 89% DP vs. SP; WM: 88% phobics vs. HC, 89% DP vs. HC, 79% SP vs. HC, 79% DP vs. HC). Regarding GM, classification improved when considering the subtype compared to overall phobia status. The discriminatory brain pattern was not solely based on fear circuitry structures but included widespread cortico-subcortical networks. Results demonstrate that multivariate pattern recognition represents a promising approach for the development of neuroimaging-based diagnostic markers that could support clinical decisions. Regarding the increasing number of fMRI studies on anxiety disorders, researchers are encouraged to use functional and structural data not only for studying phenotype characteristics on a group level, but also to evaluate their incremental value for diagnostic or prognostic purposes.

Fear Processing in Dental Phobia during Crossmodal Symptom Provocation: An fMRI Study

While previous studies successfully identified the core neural substrates of the animal subtype of specific phobia, only few and inconsistent research is available for dental phobia. These findings might partly relate to the fact that, typically, visual stimuli were employed. The current study aimed to investigate the influence of stimulus modality on neural fear processing in dental phobia. Thirteen dental phobics (DP) and thirteen healthy controls (HC) attended a block-design functional magnetic resonance imaging (fMRI) symptom provocation paradigm encompassing both visual and auditory stimuli. Drill sounds and matched neutral sinus tones served as auditory stimuli and dentist scenes and matched neutral videos as visual stimuli. Group comparisons showed increased activation in the insula, anterior cingulate cortex, orbitofrontal cortex, and thalamus in DP compared to HC during auditory but not visual stimulation. On the contrary, no differential autonomic reactions were observed in DP. Present results are largely comparable to brain areas identified in animal phobia, but also point towards a potential downregulation of autonomic outflow by neural fear circuits in this disorder. Findings enlarge our knowledge about neural correlates of dental phobia and may help to understand the neural underpinnings of the clinical and physiological characteristics of the disorder.

Neural substrates of defensive reactivity in two subtypes of specific phobia

Depending on threat proximity, different defensive behaviours are mediated by a descending neural network involving forebrain (distal threat) vs midbrain areas (proximal threat). Compared to healthy subjects, it can be assumed that phobics are characterized by shortened defensive distances on a behavioural and neural level. This study aimed at characterizing defensive reactivity in two subtypes of specific phobia [snake (SP) and dental phobics (DP)]. Using functional magnetic resonance imaging (fMRI), n = 39 subjects (13 healthy controls, HC; 13 SP; 13 DP) underwent an event-related fMRI task employing an anticipation (5-10 s) and immediate perception phase (phobic pictures and matched neutral stimuli; 1250 ms) to modulate defensive distance. Although no differential brain activity in any comparisons was observed in DP, areas associated with defensive behaviours (e.g. amygdala, hippocampus, midbrain) were activated in SP. Decreasing defensive distance in SP was characterized by a shift to midbrain activity. Present findings substantiate differences between phobia types in their physiological and neural organization that can be expanded to early stages of defensive behaviours. Findings may contribute to a better understanding of the dynamic organization of defensive reactivity in different types of phobic fear.

Investigating phobic specificity with standardized low resolution brain electromagnetic tomography (sLORETA)

The current study investigated differential sources of late event-related potentials (ERPs) in two subtypes of specific phobia using sLORETA (standardized low resolution brain electromagnetic tomography). In two experiments, 14 spider-phobic patients (and controls), and 14 dentophobic patients (and controls) were confronted with disorder-relevant and affectively neutral pictures while an electroencephalogram was recorded. Mean ERP amplitudes were extracted in the time windows of 300–450ms (P300) and 450–800ms (late positive potential, LPP). Analyses revealed that both spider phobics and dental phobics showed enhanced current density in parietal regions (i.e., cuneus, precuneus) for the P300 time frame when exposed to disorder-specific contents. This result can be interpreted to reflect automatic attention allocation. Spider phobics additionally displayed greater current density in the insula and the anterior/posterior cingulate cortex in the LPP time window relative to controls. Most likely, the phylogentically based spider phobia is characterized by a deeper and more prolonged attention engagement than dental phobia. Our findings are in good accordance with existing brain imaging studies and underline that source localization is a useful alternative for identifying relevant cortical regions in subtypes of specific phobia.

A Practice-Based Comparison of Brief Cognitive Behavioural Treatment, Two Kinds of Hypnosis and General Anaesthesia in Dental Phobia

Background: A practice-based study was carried out to assess the comparative effectiveness and acceptability of standardised hypnosis, hypnosis with individualised imagery, cognitive behavioural treatment (CBT) and general anaesthesia (GA) in the treatment of dental phobia. Methods: A 4-group design was used with 4 repeated measurement occasions. Of an initial total of 137 dental phobics, 77 completed the study with sample sizes of between 14 and 29 patients in the 4 groups. Participants completed questionnaires of dental anxiety at the beginning of the trial, before and after the first dental appointment and again before the second dental appointment a week later. Results: Standardised hypnosis evidenced a significantly higher rate of premature termination of treatment than CBT. The completer analysis showed a significant reduction of dental anxiety after CBT and individualised hypnosis compared to the GA condition. The intent-to-treat analysis showed significant improvement only after CBT. Conclusions: The results suggest that CBT is the treatment of choice in dental phobia when taking both effectiveness and acceptability into account.

Late cortical positivity and cardiac responsitivity in female dental phobics when exposed to phobia-relevant pictures

ObjectivesDental phobia is currently classified as a specific phobia of the blood-injection-injury (BII) subtype. In another subtype, animal phobia, enhanced amplitudes of late event-related potentials have consistently been identified for patients during passive viewing of disorder-relevant pictures. However, this has not been shown for BII phobics, and studies with dental phobics are lacking. Findings on cardiac responses in BII phobia during exposure are heterogeneous, as some studies showed a diphasic pattern of heart rate acceleration and deceleration, whereas others observed pure acceleration. In contrast, heart rate increase has consistently been shown for dental phobics, resembling the reaction of animal phobics. Moreover, the BII subtype is characterized by elevated disgust reactivity whereas the role of habitual disgust proneness in dental phobia is unclear. MethodsWe recorded the electroencephalogram and the electrocardiogram from 18 dental phobic and 18 healthy women while they watched pictures depicting dental treatment, disgust, fear and neutral items. ResultsPhobics relative to controls showed an enhanced late positive potential (300–700ms) and heart rate acceleration towards phobic material, reflecting motivated attention and fear. Affective ratings revealed that dental phobics experienced significantly higher levels of fear than disgust during exposure to phobia-relevant material. Patients' elevated habitual disgust proneness was restricted to specific domains, such as the oral incorporation of offensive objects. ConclusionThe psychophysiology of dental phobia resembles the fear-dominated subtypes of specific phobia reported in earlier studies. Future studies should continue to investigate whether the current classification of this disorder as BII phobia needs to be reconsidered.

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Attention focusing versus distraction during exposure in dental phobia

A survey of the discrepant findings regarding the effects of attention focusing and distraction on exposure suggested that subjective measures of anxiety and avoidance respond better to the latter condition, and heart rate (HR) reaction responds to the former. To test this hypothesis, 63 dental phobics were recruited who had not visited a dentist for a mean of 6.6 (1.5–25) years. Participants received a 1-h exposure session with either attention focusing or distraction. Subjective anxiety and HR to phobia-related pictures were assessed before and after the treatment session and again after 1 week. Avoidance was recorded in terms of adherence to the dental treatment schedule in the following 6 months. Contrary to expectation, state anxiety showed a greater decrease in the attention focusing than the distraction condition after 1 week. Both treatment conditions were similarly effective with regard to HR and avoidance. HR habituated in both groups after exposure and 73% of followed-up patients adhered to the dental treatment schedule. Comparison of the present with previous results suggests that the differences between attentional conditions tend to be more pronounced during shorter exposure sessions than were employed in the present study.

Do Dental Anxiety Questionnaires Raise Anxiety in Dentally Anxious Adult Patients? A Two-Wave Panel Study

To test whether or not dentally anxious patients attending the dentist for an appointment become more anxious when completing a dental anxiety questionnaire. Patients were initially screened to include only those who were dentally anxious. A pre- and post-test was planned with the completion of the Modified Dental Anxiety Scale (MDAS) questionnaire as the intervention. Two dental access centres in the North West of England. Initially, 583 patients were screened. Of these, 182 (31%) were found to be dentally anxious and were recruited into the study. State-Trait Anxiety Inventory Scale Short Form. State anxiety did not change with the completion of the MDAS questionnaire in either designated dental phobics (MDAS >or=19) or those classified as non-phobics (MDAS <19). The MDAS can be used to assess dental anxiety without raising anxiety in patients with or without self-reported dental phobia.

Predictors of behavioral avoidance in dental phobia: The role of gender, dysfunctional cognitions and the need for control

Dental anxiety and the related avoidance of dental treatment can result in severe impairment of health. We investigated the influence on avoidance behavior of phobic severity, gender, characteristics related to generalized anxiety and depression, such as dysfunctional cognitions and sensitivity of bodily symptoms, as well as personality traits of self-efficacy and locus of control. Forty-eight dental phobics were given an initial assessment and avoidance behavior was determined by the degree of observance of three subsequent dental appointments. Principal component analysis revealed separate factors for trait and phobic anxiety as well as for avoidance and dysfunctional cognitions. Women showed a higher degree of avoidance than men. Regression analysis revealed a high desire for control over dental treatment combined with a low level of perceived control as the only significant predictor variable of avoidance. The results suggest that avoidance behavior in dental phobia could be reduced by extending patients’ control over treatment conditions.

Treating the phobic patient

Many dental phobics are afraid to discuss or admit their fears. Sharon Floyd is a counsellor at a practice specializing in dental phobia and discusses the available ways to treat these patients.

Dental anxiety in a representative sample of residents of a large German city

In a demographic survey, 300 residents of a German city were questioned to determine the prevalence of dental anxiety. The correlation between the amount of dental anxiety and the age, sex, and education of the subjects was examined and the reasons for avoiding dentist's appointments, the duration of this avoidance, and what the subjects desire from future dental treatment. The Hierarchical Anxiety Questionnaire (HAQ) was used to measure the amount of dental anxiety. The average level of anxiety was 28.8+/-10.1 according to the HAQ. Young people were more afraid than older people (p=0.007), and women were more anxious than men (p=0.004). Of the women, 72% go to the dentist regularly, but only 60% of the men do (p=0.020). A painful experience while receiving dental treatment was given by 67% as the main reason for their dental anxiety, followed by a fear of needles (35%). The people wished for the most accurate information available about the dental treatment they receive (69%), followed by a compassionate dentist (62%), and treatment that is free of pain (62%). Of the people, 11% [95% CI: (7.5%; 14.5%)] suffer from dental phobia. All dental phobics were able to state the cause of their fear and more urgently wished for help from the dentist in overcoming their anxiety than the non-phobics (p=0.030). To satisfy the needs of the phobic patients, it appears necessary to screen the phobics out of the group of all patients and then offer them adequate therapy, or refer these patients to specialised treatment centres.

Dental Anxiety Among Adults in Turkey

This aim of this study was to investigate the prevalence of dental anxiety and related factors in a Turkish population. The Turkish translation of the Dental Fear Scale (DFS) and the Modified Dental Anxiety Scale (MDAS) were administered to 115 dental patients consisting of 21 subjects who had dental phobia and of 94 patients who did not. The scales were also administered to a non-clinical general population (N=183). The Turkish version of the DFS was internally consistent and reproducible. The scale had strong correlations (r=0.80, p<0.001 ) with the MDAS. Female participants scored higher (45.2+/-18.1) on the scale than men (38.2+/-15.7). The DFS had a negative correlation (r=-0.25, p<0.001) with education level. There was a statistically significant difference between dental phobics and the remaining groups on the DFS total score. At a cut-off point 55, the sensitivity of the scale was 0.80, specificity 0.80, positive predictive value 0.48, and negative predictive value 0.95. Thirty-nine subjects (21.3%) in the general population had total scores above this cut-off point. Dental fear is common in clinical and non-clinical settings in Turkey. The good psychometric characteristics of the DFS among Turkish participants supports its cross-cultural validity.

A joint approach to treating dental phobics between community dental services and specialist psychotherapy services – a single case report

A joint approach to treating dental phobics between community dental services and specialist psychotherapy services – a single case report

Dental phobics – how does dental anxiety affect their lives?

Dental phobics – how does dental anxiety affect their lives?