Journal of Behavior Therapy

and Experimental Psychiatry 34 (2003) 65–71

The dental cognitions questionnaire in

CBT for dental phobia in an adolescent
with multiple phobias
Warren Mansella,*, Kathleen Morrisb
a
Department of Psychology, Institute of Psychiatry, De Crespigny Park, London SE5 8AF, UK
b
Phoenix Children’s Resource Centre, Bromley, BR2 9JG, UK

Abstract

A case of an adolescent boy with multiple phobias who was treated successfully for his
dental phobia is described to illustrate the clinical utility of the Dental Cognitions
Questionnaire (DCQ) in aiding effective cognitive-behavior therapy. The client showed drops
in dental anxiety that coincided with the use of the DCQ in cognitive restructuring, and there
was a close correlation between dental cognitions and degree of dental anxiety over the time-
course of therapy and follow up.
r 2003 Elsevier Science Ltd. All rights reserved.

Keywords: Anxiety disorders; Children; Cognitive-behavior therapy; Exposure; Comorbidity

1. Introduction

Dental phobia is a significant clinical problem because of its great impact on

physical health and quality of life, and its high prevalence, at around 5%, which
peaks during early adolescence (Kent, 1997). It has been suggested by many authors
that multiple fears maintain dental phobia (e.g. Kent, 1997; de Jongh, Muris,
Schoenmakers, & ter Horst, 1995b; Chapman & Kirby-Turner, 1999). A
comprehensive series of research studies have culminated in the characterization of
dental fears using the Dental Cognitions Questionnaire (DCQ; de Jongh et al.,
1995b). Patients’ scores on this scale have been shown to account for 70% of the
variance in state anxiety while in the chair awaiting dental treatment.

*Corresponding author.
E-mail address: w.mansell@iop.kcl.ac.uk (W. Mansell).

0005-7916/03/$ - see front matter r 2003 Elsevier Science Ltd. All rights reserved.
doi:10.1016/S0005-7916(03)00020-X
66 W. Mansell, K. Morris / J. Behav. Ther. & Exp. Psychiat. 34 (2003) 65–71

The most effective treatment for phobias to date is graded exposure to the fear-
.
provoking stimulus (Ost, 1996). Nevertheless, an important debate concerns the
extent to which the mediation of change during therapy may involve cognitive
processes (Mansell, 2000), and emerging evidence suggests that cognitive factors are
indeed important in facilitating change (De Jongh et al., 1995a; Kamphuis & Telch,
2000). Indeed close inspection of some treatment protocols suggests that ‘graded
exposure’ may actually use cognitive methods. For example, Ost, . Svensson,
.
Hellstrom, and Lindwall (2001) suggest that in graded exposure, ‘‘the guiding
principle of treatment is the cognitive-behavioral analysis of the child’s catastrophic
cognition concerning what will happen when encountering the feared object or
situation’’ (p. 817).
The following case study describes the assessment and treatment of an adolescent
with incapacitating dental phobia. The aim of the study was to explore the
effectiveness of CBT for dental phobia, in particular using the DCQ as a focus of
cognitive intervention. The role of cognitive factors in change was assessed in two
ways. First, changes in belief ratings across and during sessions were recorded to test
whether the use of the DCQ was associated with a drop in dental anxiety, relative to
periods where exposure-based techniques were used. Second, the relationship
between changes in dental anxiety and DCQ was assessed by investigating the degree
to which they correlated with one another across time.

2. Description of the case

John was 14 years old and lived with his mother and younger sister. He was
referred by the Dental Officer at the local special needs medical center following his
refusal to receive either local anesthetic or gaseous sedation prior to dental
treatment. He had been extremely anxious and highly resistant to any treatment
involving injection or possible loss of consciousness. John’s dental phobia prevented
him from getting five fillings, one of which was giving him pain. He also had a
phobia of injections that had prevented him from receiving important vaccinations.
He had a longstanding vomit phobia which led him to drastically limit his food and
drink because of the belief that they would make him sick. He avoided taking lifts,
also because of his anxiety.
John developed his vomit phobia at around six years of age following a period
when his father left home after a ‘breakdown’ with PTSD and depression, and John
was sick at home in front of his mother and friends of the family. During the next
year, John had an accident in which he damaged his front teeth, requiring prolonged
emergency dental treatment on the top floor of a specialist hospital. John’s lift
phobia emerged soon after this occasion. The treatment itself involved an injection
into the gum at the base of each front tooth. After the operation, John’s mother told
him that he had received injections and that the dentist was surprised that John
wasn’t sick considering the amount of blood that he had swallowed. In the following
year, when John was seven, he received a rubella injection. He had tried to refuse
treatment but the nurse used physical constraint to force him to receive the injection,
 W. Mansell, K. Morris / J. Behav. Ther. & Exp. Psychiat. 34 (2003) 65–71 67

and she insisted to John that the injection did not hurt. The next year marked the
onset of a brief period of school phobia, after he witnessed another boy having an
epileptic fit next to him in assembly. The school phobia was addressed by behavior
therapy. John went to dental treatment over the next 6 years but he refused
treatment when he required several injections for his fillings.

3. Treatment plan

The treatment plan was broadly cognitive-behavioral, and incorporated elements

from a number of published treatment studies (de Jongh et al., 1995b; Kent, 1997;
Chapman & Kirby-Turner, 1999). It was formulated that John had a range of
specific fears that led to the experience of anxiety, in anticipation of, and during the
dental procedure. In response to these feelings, he would fear a complete loss of
control, which would lead him to tense up which in turn maintained his feelings of
anxiety. Alternatively, he would terminate the procedure and avoid it, thereby
maintaining his fears, which would be left unchallenged.
The elements of treatment were as follows: imaginal and in vivo exposure that was
under the client’s control; timeline construction of the onset and progression of the
dental phobia and other fears; psychoeducation on the anxiety response; information
about the dental procedure; identification and restructuring of cognitions using the
DCQ; and brief relaxation techniques.

4. Assessment measures

The following standardized questionnaires were used: MDAS (Humphris,

Morrison, & Lindsay, 1995); DCQ (de Jongh et al., 1995a,b); Beck Anxiety
Inventory (BAI; Beck, Epstein, Brown, & Steer, 1988); Birleson Depression Scale
(BDS; Birleson, 1981). Furthermore, the MDAS and the degree of belief in five
‘critical’ cognitions (those chosen by the client and therapist to be monitored because
of their relevance for recovery) were assessed at several points during session seven:
prior to a brief cognitive intervention (7.1); after the cognitive intervention (7.2); and
after the first exposure to dental treatment (7.3).

5. Results

5.1. Dental cognitions

The DCQ was used at the start of session six to identify the client’s key fears. The
statements that were endorsed with a belief rating of over 80% were: ‘‘Everything
goes wrong’’, ‘‘Something will surely go wrong’’, ‘‘I can’t stand this treatment for
long’’, ‘‘This treatment will hurt’’, ‘‘The nerve will be touched’’, ‘‘I am helpless’’, ‘‘I
have no control over what happens’’, ‘‘I can’t escape, I’m locked in’’, ‘‘The sound of
68 W. Mansell, K. Morris / J. Behav. Ther. & Exp. Psychiat. 34 (2003) 65–71

the drill frightens me’’, ‘‘I will panic during treatment’’, ‘‘I become sick’’ and ‘‘The
dentist will lose control over the drill’’.
Each of the key dental cognitions was addressed during session six using cognitive
techniques. For example, the therapist asked him what made him believe that he
would panic during the treatment. He explained that he experienced bodily
sensations, such as shaking and feeling hot that he found frightening and meant
that he was losing control. The therapist explained that these feelings were due to
anxiety and the formulation (described earlier) was shared with the client so that he
could see how his beliefs about his physical reactions could lead to a vicious cycle.
He was also reminded of his experience during exposure therapy that the feelings of
anxiety would gradually drop with time. The belief that the dentist will lose control
of the drill was addressed by prompting the client to remember a particular event he
had witnessed on an earlier session; the dentist had carved the client’s name on a
pencil with the drill, indicating how precisely she could control it. The client was
asked how he might have more control over what happened during the treatment.
He suggested that one way would be for him to signal to the dentist by squeezing her
free hand if he wanted to stop the procedure. This procedure was instigated. The
belief that he would be locked in was addressed by simply explaining to the client
that the door would not be locked behind him at any point.

5.2. Effectiveness of treatment

The effectiveness of the treatment was assessed by change on the MDAS, and by
the extent to which the client could tolerate each of the items on the fear hierarchy.
The client started therapy with the maximum possible score on the MDAS (25),
ended therapy with a score in the normal range (10) that was maintained at 1-, 6- and
18-month follow-up (see Table 1). He moved in a graded manner through the

Table 1
Changes in measures of psychopathology from pre-treatment to follow-up

Pre Post 1-month 6-month 18-month Clinical Non-clinical

follow-up follow-up follow-up mean mean

Modified Dental 25 10 10 5 9 2272.9 1075.4

Anxiety Scale
Dental Cognitions 14 2 2 0 0 2376.7 1077.0
Questionnaire—
Frequency
Dental Cognitions 46 5 4 3 2 50716 19712
Questionnaire—
Believability
Beck Anxiety 18 12 18 0 2 16713 7.378.4
Inventory
Birleson 5 1 0 1 1 21 6.371.3
Depression Scale
 W. Mansell, K. Morris / J. Behav. Ther. & Exp. Psychiat. 34 (2003) 65–71 69

following items on the fear hierarchy: imagining a stationary syringe; imagining a

moving syringe; picture of syringes; syringe on table; syringe in hand; syringe in
therapist’s hand near mouth; dental equipment; dental sounds; video of arm being
injected; dental surgery; syringe with cap on in mouth; drills and other equipment;
syringe in mouth with cap off; injection, drilling and filling; observe another patient
having injection and treatment; observe mother having injection and treatment;
further injections, drilling and filling. After the end of the psychological therapy, the
client completed all his required dental treatment.

5.3. The role of cognitive change

The scores on the DCQ before and after treatment are shown in Table 1. The
dental cognitions dropped dramatically in frequency of endorsement and degree of
belief rating after treatment. Inspection of the scores on the DCQ during the
treatment itself indicated that most of the change had occurred by session eight.
Fig. 1 illustrates this pattern of change for the five ‘critical’ cognitions. The figure

Fig. 1. The change in dental cognitions with exposure and cognitive treatment.
70 W. Mansell, K. Morris / J. Behav. Ther. & Exp. Psychiat. 34 (2003) 65–71

shows that the cognitive techniques used during session six and seven accounted for
the largest drop in the degree of belief in the critical cognitions. The relationship
between dental anxiety and dental cognitions was assessed by exploring the
correlation between the MDAS and the DCQ mean belief ratings. The Pearson
correlation coefficient was rð10Þ ¼ 0:91; po0:001: The correlation remained
significant even when using session number as a covariate in the analysis, rð7Þ ¼
0:69; po0:05: This indicates that the correlation between these measures was not
merely a function of both of them dropping with time.

6. Discussion

This study documents the successful cognitive-behavioral treatment of dental

phobia in an adolescent with multiple phobias. The DCQ proved to be extremely
useful in accessing, discussing and gently challenging and coping with the multiple
fears that are present in dental phobia. It is very likely that the therapist would not
have known in advance about several of the key dental cognitions without the use of
the DCQ. Therefore, the fears may have been addressed before they led to significant
interference in the dental treatment. The observed drops in dental anxiety after
cognitive restructuring with the aid of the DCQ are strongly indicative of cognitive
mediation. Furthermore, the extremely high correlation between the DCQ and
dental anxiety supports their close relationship. However, further more controlled
research would be necessary to fully test the cognitive mediation hypothesis.
Although the DCQ was not designed with adolescents in mind, it proved highly
appropriate in this case. We would recommend that other therapists, and
psychologically trained dentists, could use this questionnaire in cases that appear
to be resistant to other methods of intervention. The approach of graded exposure
also proved to be important. For this individual, imaginal exposure was commenced
before using in vivo stimuli because of the intense fear generated by real stimuli. It is
clearly desirable to be flexible to the client’s level of anxiety, maintain the client’s
own control over their treatment, and modify the hierarchy accordingly. It remains
to be tested whether the kind of interventions described here could be provided in a
single session, a method that recent studies have shown to be highly effective in
specific phobias in children and adolescents (Ost . et al., 2001) and dental phobia in
.
adults (de Jongh et al., 1995a; Thom, Sartory, & Johren, 2000). In summary, this
case study suggests that the DCQ can be helpful and effective in cognitive-behavior
therapy for dental phobia.

Acknowledgements

We would like to thank Sara Hutchinson for her support in the process of
therapy, and Stan Lindsay for his help with providing materials for treatment and
assessment.
 W. Mansell, K. Morris / J. Behav. Ther. & Exp. Psychiat. 34 (2003) 65–71 71

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