Journal of Anxiety Disorders 27 (2013) 365–378

Contents lists available at SciVerse ScienceDirect

Journal of Anxiety Disorders

Review

A critical review of approaches to the treatment of dental anxiety in

adults
Dina Gordon a , Richard G. Heimberg a,∗ , Marisol Tellez b , Amid I. Ismail c
a
Adult Anxiety Clinic, Department of Psychology, Temple University, 1701 North 13 Street, Philadelphia, PA 19122, USA
b
Department of Pediatric Dentistry and Community Oral Health Sciences, Kornberg School of Dentistry, Temple University, 3223 North Broad Street,
Philadelphia, PA 19140, USA
c
Kornberg School of Dentistry, Temple University, 3223 North Broad Street, Philadelphia, PA 19140, USA

a r t i c l e i n f o a b s t r a c t

Article history: Dental anxiety and specific phobia of dental procedures are prevalent conditions that can result in sub-
Received 22 September 2012 stantial distress and oral health impairment. This paper critically reviews 22 randomized treatment trials
Accepted 4 April 2013 aimed at reducing dental anxiety and avoidance in adults, published in peer-reviewed journals between
1974 and 2012. The following treatment techniques are reviewed: various forms of cognitive-behavioral
Keywords: therapy (CBT), relaxation training, benzodiazepine premedication, music distraction, hypnotherapy,
Dental anxiety
acupuncture, nitrous oxide sedation, and the use of lavender oil scent. CBT delivered in a variety of
Dental phobia
formats, including one-session treatment, has the most evidence for its efficacy. Cognitive techniques,
Cognitive-behavioral therapy
Exposure therapy
relaxation, and techniques to increase patients’ sense of control over dental care are also efficacious
Relaxation training but perform best when combined with repeated, graduated exposure. Other interventions require fur-
ther study in randomized trials before conclusions about their efficacy are warranted. Limitations of the
extant outcome research and implications for future treatment and research are discussed.
© 2013 Elsevier Ltd. All rights reserved.

Contents

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 366
2. Literature search method . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 366
3. Measures of dental anxiety and related constructs used in treatment studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 370
3.1. Self-report assessments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 370
3.2. Interview assessments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 370
3.3. Behavioral assessments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 370
4. Treatment outcome trials . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 371
4.1. CBT interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 371
4.1.1. CBT at varying intervals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 371
4.1.2. CBT compared with relaxation training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 371
4.1.3. CBT in varying amounts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 372
4.1.4. Variations of exposure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 372
4.1.5. CBT versus benzodiazepine premedication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 373
4.2. Non-CBT interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 374
5. Meta-analysis of cognitive-behavioral interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 374
6. Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 375
6.1. Summary of findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 375
6.2. Methodological limitations in reviewed studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 375
6.3. Directions for future research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 376
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 376

∗ Corresponding author. Tel.: +1 215 204 1575.

E-mail addresses: dina.gordon@temple.edu (D. Gordon), heimberg@temple.edu (R.G. Heimberg), Marisol@dental.temple.edu (M. Tellez), ismailai@dental.temple.edu
(A.I. Ismail).

0887-6185/$ – see front matter © 2013 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.janxdis.2013.04.002
366 D. Gordon et al. / Journal of Anxiety Disorders 27 (2013) 365–378
1. Introduction
Dental anxiety, or the fear of dental procedures, is a relatively
common problem affecting 10–20% of the adult population in
the United States (Doerr, Lang, Nyquist, & Ronis, 1998; Locker,
Liddell, & Shapiro, 1999; Milgrom, Fiset, Melnick, & Weinstein,
1988; Sohn & Ismail, 2005), with estimates ranging from 4% to 30%
in other countries around the world (Humphris, Dyer, & Robinson,
2009; Humphris & King, 2011; Schwarz & Birn, 1995; Vassend,
1993). Despite improvements in modern dentistry, dental anxiety
scores have remained stable since the mid-1900s (Smith & Heaton,
2003). Dental anxiety is associated with postponement or avoid-
ance of dental treatment and, hence, poorer oral health and oral
health-related quality of life (Berggren & Meynert, 1984; Hakeberg,
Berggren, Carlsson, & Grøndahl, 1993; Ng & Leung, 2008; Thomson,
Stewart, Carter, & Spencer, 1996). For example, in one study, den-
tally anxious individuals had eight to nine decaying teeth compared
with only one or two in the general population (Thom, Sartory, &
Jöhren, 2000).
Dental patients with elevated dental anxiety also experience
negative thoughts and feelings, sleep disturbance, increased use of
medication, a greater tendency toward somatization, and impaired
social and occupational functioning relative to patients without
dental anxiety (Berggren, 1993; Cohen, Fiske, & Newton, 2000;
Kaufman, Bauman, Lichtenstein, Garfunkel, & Hertz, 1991; Kent,
Rubin, Getz, & Humphris, 1996). Moreover, these individuals report
elevated scores on a broad range of psychological difficulties as
measured by the Symptom Checklist 90-Revised (Aartman, de
Jongh, & van der Meulen, 1997). Dental anxiety has important
public health implications; however, the literature generally fails
to examine specific constructs which may moderate the anxiety
response to dental procedures and settings.
The study of dental anxiety and its treatment has been compli-
cated by the imprecise use of the terms fear and anxiety, resulting
in conflicting findings in regard to its prevalence, consequences,
and treatment outcomes. Although the distinction between these
constructs is well-documented (Craske, 1999; McNaughton & Corr,
2008; Sylvers, Lilienfeld, & LaPrairie, 2011), it is largely disregarded
in the dental literature. Fear is a primitive, basic emotion tied to the
fight or flight response, activated in response to an imminent and
specific threat; anxiety is a conditioned response characterized by
anticipation of or worry about a potential future threat. The term
phobia has also been used with varying degrees of accuracy, obscur-
ing the object of investigation or target of treatment. In contrast
to dental anxiety, the diagnosis of specific phobia of dental proce-
dures, as described in the Diagnostic and Statistical Manual of Mental
Disorders – 4th edition (DSM-IV; American Psychiatric Association,
1994), can be distinguished by the significant degree to which the
fear or avoidance of dental procedures (i.e., the feared stimulus)
interferes with an individual’s daily routine, occupational or social
functioning, or whether the presence of the fear itself is associated
with significant distress. Several studies reviewed here use the term
phobia without having conducted a formal diagnostic assessment.
The overarching etiological explanations of dental anxiety have
broadly highlighted conditioned responses to aversive dental
experiences, predisposing temperamental or personality charac-
teristics, and heightened pain sensitivity or fear of dental pain
(Locker, Liddell, Dempster, & Shapiro, 1999; Locker, Liddell, &
Shapiro, 1999). Such etiological factors may also contribute to the
maintenance of anxiety; personality traits are enduring, and con-
ditioned responses do not extinguish in the absence of repeated
exposure to the feared stimulus (i.e., regular attendance at den-
tist appointments). The acquisition of dental anxiety has been
most consistently tied to aversive conditioning experiences (Davey,
1989; Locker, Liddell, Dempster, et al., 1999; Thomson, Locker &
Poulton, 2000; Weiner & Sheehan, 1990). Furthermore, Weiner and
Sheehan (1990) noted that, along with direct or indirect condi-
tioning experiences, an underlying vulnerability to anxiety may
increase the likelihood of developing dental anxiety. With regard
to personality variables, high dental fear was associated with neu-
roticism in a longitudinal study of women in Sweden (Hägglin
et al., 2001). A twin study conducted in Norway expanded on these
findings by showing that dental anxiety and neuroticism share
considerable overlap of genetic, but not environmental, variance
(Vassend, Røysamb, & Nielsen, 2011). Furthermore, trait anxiety
and anxiety sensitivity are both associated with dental anxiety
(Locker, Liddell, & Shapiro, 1999).
Poulton, Waldie, Thomson, and Locker (2001) found, in a lon-
gitudinal study examining early- and late-onset dental anxiety,
that conditioning experiences, indexed by number of dental caries
and tooth extractions, are a major risk factor for dental anxiety.
Additionally, the likelihood of developing late-onset dental anx-
iety increased substantially if one or more teeth had been lost
due to caries and if more caries were present during adolescence.
Poulton et al. (2001) also found that late-onset dental anxiety was
more likely among individuals who were symptomatic, rather than
preventive, users of dental health services. Moreover, an external
locus of control over one’s health (i.e., the belief that health out-
comes depend on chance and/or a medical professional rather than
oneself) was associated with a significantly greater likelihood of
acquisition of dental anxiety.
Dental anxiety appears to be characterized by a maladaptive
cycle, in which dental anxiety leads to delay or avoidance of den-
tal treatment, which causes dental problems that are related to
more invasive or even emergency treatment, which, in turn, leads
to the maintenance or exacerbation of dental anxiety (Armfield,
Stewart, & Spencer, 2007). The cycle has also been described
as involving guilt, shame, and feelings of inferiority, which may
amplify dental anxiety and avoidance (Berggren & Meynert, 1984;
Moore, Brødsgaard, & Rosenberg, 2004). Patients with dental anx-
iety are considered a population of public health importance
because of the extensive dental health consequences caused by this
cycle. Although cognitive behavioral therapy (CBT) has consistently
proven efficacious in managing dental anxiety and specific phobia
of dental procedures, rates of dental treatment avoidance have seen
only a slight reduction, anxiety treatment is underutilized, and the
prevalence of dental anxiety remains high (Choy, Fyer, & Lipsitz,
2007; Kvale, Berggren, & Milgrom, 2004).
This review will unpack and draw conclusions from the liter-
ature on the treatment of dental anxiety and specific phobia of
dental procedures in adults. A discussion of the limitations of the
extant dental anxiety treatment research and a proposal for future
directions for research and treatment will be presented.
2. Literature search method
A search of EBSCOhost, Medline, PsycINFO, and Google Scholar
databases was conducted using the following search terms and
their combinations: dental, dentist, fear, anxiety, phobia, odon-
tophobia, treatment, therapy, intervention, and management. The
titles and abstracts generated by the search engines, along with
relevant articles cited in reference lists, were screened according
to the following inclusion criteria: (1) published in the English
language, (2) published in a peer-reviewed journal, (3) adult
sample age 18 and over, (4) patients were randomized to treat-
ment conditions, and (5) patients with primary dental anxiety
and/or specific phobia of dental procedures as diagnosed accord-
ing to DSM-IV criteria. Publication dates, sample sizes, and number
and rigor of compared treatments were not restricted. Unpub-
lished manuscripts and theses, book chapters, and case studies
were excluded. Twenty-two studies that met criteria for inclusion,
Table 1
Reviewed treatment outcome studies for dental anxiety and phobia.
Authors; location Active Control Target of Duration of Outcome Findings Original Follow-up Follow-up Length Setting/clinic Comments, limitations
treatment condition(s) treatment treatment measure(s) sample size sample size interval avoidance
condition(s) Pre-tx
Agdal et al. (2008); Exposure by WL DSM-IV 1 3-hr session or DAS, DFS, Better dental health 40 31 1-Year Range = 3–30 Specialized Follow-up on CBT
Norway trained dentist: dental 5 1-hr sessions presence of correlated w/low years dental fear conditions from
1 session vs. 5 phobia positive/ anxiety and positive clinic Haukebø et al. (2008)
session negative cognitions
cognitions
Armitage and Reidy Imaginal Imaginal Dental 2 min of imaginal STAI Process > outcome in 75 n/a n/a N.R. Dental No dental anxiety
(2012); England exposure to exposure to anxiety exposure reducing state anxiety practice specific measure;
dental process outcome of pre and post dentist inclusion criteria
dental care appt unclear
Berggren et al. (2000); CR vs. relax n/a Dental Up to 8 sessions DAS, DFS, CR > relax for anxiety 112 n/a n/a N.R. Specialized Low scores on a 0–100
Sweden anxiety of unspecified dentist rating tx adherence; dental fear measure of
length of pt anxiety relax > CR anxiety clinic willingness to engage

D. Gordon et al. / Journal of Anxiety Disorders 27 (2013) 365–378

on 1–6 scale reduction in anxiety treatment
predicted attrition
Dailey et al. (2002); UK Dentist Dentist not Dental n/a STAI-6 Significantly less state 119 n/a n/a N.R. Primary Only measured dental
informed of pts informed of anxiety anxiety reduction in dental care anxiety prior to dental
MDAS score pts anxiety control group from pre care; enrolled if MDAS
prior to dental level to post-dental tx 19+ or a 5 on any 1
tx MDAS item
de Jongh, Muris, Ter 1 session of: CR WL Dental 1 1-hr session DAS, DCQ CR > Info = WL; 52 20 (only 1-Month and Range = 1–27 Specialized WL not re-assessed at
Horst, et al. (1995); by dentist/ anxiety CR = Info at 1-year active tx pts 1-year years dental fear follow-up
Netherlands psychologist vs. follow-up were clinic
psychoed by assessed)
hygienist
Gatchel (1980); USA Group No anxiety tx Dental 6 1.5-hr sessions DAS, Desensitization > 19 19 1-Month N.R. N.R.
desensitization anxiety over 3 weeks attendance, Psychoed/Discussion
(relax, imagery) bx in dentist & Control in anxiety
vs. Group chair reduction; Psy-
edu + discussion choed/Discussion > Control
group (txs in avoidance reduction
delivered by
trained
dentists)
Getka and Glass CBT vs. BT vs. WL Dental 6 weekly 1-hr DAS, CBT = BT > WL, PDE 41 35 1-Year M = 30 months N.R.
(1992); USA positive dental anxiety sessions for CBT, attendance
experiences BT
(PDE)
Hammarstrand et al. Hypnotherapy General Dental 8 sessions DAS, dentist BT > hypnotherapy 33 n/a n/a Median = 9.5 Specialized Randomized only to tx
(1995); Sweden vs. BT (relax, anesthesia anxiety rating year dental fear groups, not to control;
biofdbk, clinic BT led to increase in
exposure) mood
Haukebø et al. (2008); Exposure by WL DSM-IV 1 3-hr session or DAS, BAT, 5 session > 1 40 35 1-Year Range = 3–30 Specialized
Norway trained dentist: dental 5 1-hr sessions DFS, DBS session > WL; 1 years dental fear
1 session vs. 5 phobia session = 5 sessions at clinic
session 1-year-FU
Jerremalm et al. Group CR vs. n/a Dental 9 1.5-hr weekly DAS, DFS, CR = relax, regardless 37 27 9–12 months Range = 2–20 N.R. Randomization to tx
(1986); Sweden group relax anxiety sessions BAT, HR of pt reactivity type year condition only within
(cognitive or pt types
physiological)
Karst et al. (2007); Auricular PBO Dental 30 min STAI, 0–10 Auricular acupunc- 67 n/a n/a N.R. N.R. Did not use specific
Germany acupuncture vs. acupuncture; anxiety visual ture = midazolam > pbo dental anxiety
intranasal no anxiety tx anxiety scale acupuncture, control measure, did not
midazolam measure avoidance
(benzo)

367
 368
Table 1 (Continued)
Authors; location Active Control Target of Duration of Outcome Findings Original Follow-up Follow-up Length Setting/clinic Comments, limitations
treatment condition(s) treatment treatment measure(s) sample size sample size interval avoidance
condition(s) Pre-tx
Kritsidima et al. Lavender oil No scent Dental Varied; MDAS, Dental anxiety did not 340 n/a n/a N.R. Private Pre-tx data not
(2010); UK scent anxiety depending on STAI-State differ between dental reported; sample
amount of time conditions; state practice ranged from low to
spent in waiting anxiety lower in high dentally anxious
room lavender scent
condition
Lahmann et al. (2008); Dentist- No anxiety tx Dental Relax = 10 min; STAI-S Relax > Music > Control 87 n/a n/a N.R. N.R. Did not use specific
Germany administered anxiety music during dental anxiety
brief relax vs. dental tx measure, did not

D. Gordon et al. / Journal of Anxiety Disorders 27 (2013) 365–378

music measure avoidance
distraction
Liddell et al. (1994); Group CBT n/a Dental 4 sessions DAS, 70% across both 26 23 1–4-Year N.R. N.R. Follow-up on some pts
Canada massed vs. anxiety (massed = 2/wk; attendance conditions continued from Ning and Liddell
group CBT spaced = 1/wk), to regularly attend (1991) and additional
spaced; groups hw monitoring dentist; irregular pts
of 3–6 pts attendance = less
decrease in anxiety
Mathews and Rezin Hi-arousal/ Relax Dental 4 1-hr sessions Sum of Low arousal > high 63 63 2-Month Range = 1–25 N.R. Self-report scales
(1977); UK coping vs. anxiety 10-point arousal for anxiety years unpublished; no
Hi-arousal/no- scale choices reduction; high standardized “coping”
coping vs. for various arousal > low arousal technique
Lo-arousal/ dental for avoidance
coping vs. situations, reduction; low arousal
Lo-arousal/no- attendance interacted with no
coping (arousal coping to reduce
induced by avoidance
imaginal
exposure)
Moore et al. (1991a,b); Video exposure WL attention Dental M = 7.5 hr DAS, DFS, Both txs reduced 143 48 (only 1-Year Range = 0–33 Specialized Randomized only to tx
Denmark w/relax & (told that anxiety DBS dental anxiety and active tx pts years dental fear groups, not to control;
biofeedback anxiety is elevated mood; 93% were clinic only attendance
(systematic treatable) returned to dental assessed) measured at follow-up
desensitiza- care in 1 year
tion) vs. Direct
exposure
(systematic
desensitiza-
tion)
Moses and Education vs. WL Dental 1.5-hr education; DAS, SIT & 24 n/a n/a At least 1 year N.R. Tx components not
Hollandsworth Coping + anxiety 2.5-hr cop- attendance coping + application > described in detail;
(1985); USA application ing +application education & WL at stratified by
training vs. training; 3.5-hr reducing avoidance; demographic variables
Coping + full SIT education did not prior to randomization
application contribute to SIT
training +
education (full
SIT)
 Ng et al. (2004); Hong Level of n/a Oral surgery 1 info session 0–100 dental 2 groups including 192 n/a n/a N.R. General
Kong pre-operative anxiety anxiety recovery information dental
information: SUDS; led to decreased practices
basic info only Depression anxiety in both high
vs. basic info and Anxiety and low trait anxiety
w/details of Stress Scale pts
operative (used only for
procedures vs. trait anxiety
basic info subgrouping)
w/details of
expected
recovery vs.
basic info
w/details of
both operative

D. Gordon et al. / Journal of Anxiety Disorders 27 (2013) 365–378

procedures and
recovery
Ning and Liddell Group CBT n/a Dental 4 sessions DAS, Massed = spaced 18 12 6-Month N.R. N.R.
(1991); Canada massed vs. anxiety (massed = 2/wk; attendance
group CBT spaced = 1/wk),
spaced; groups hw monitoring
of 3–6 pts
Shaw and Thoresen Modeling WL; Dental 1-hr sessions Attendance, Modeling & Desensiti- 36 N.R. 3-Month M = 3.7 years Counselor Self-report scales
(1974); USA (relax, imaginal psychoed anxiety weekly, 0–10 scale zation > control training unpublished and
exposure, see PBO maximum 10 anxiety scale conditions in anxiety facility developed by authors
video of model) sessions (average and avoidance for this study; Pt
vs. 7 hr total per tx) reduction ability to pay for
desensitization dental tx is part of
inclusion criteria
Thom et al. (2000); Benzo vs CBT No anxiety tx DSM-IV CBT: 1.5-hr DAS, DFS, CBT > Benzo = Control 50 N.R. 1 week, N.R. Dental clinic Randomization
Germany (dental care dental session + 1 week DCQ, HR, 2-month sequential/restricted
by sensitive phobia hw blood
dentist) pressure
Vika et al. (2009); CBT by trained n/a DSM-IV 1 or 5 sessions, DAS, BAT, 89% received 55 45 1-Year Range = 0–40 Specialized
Norway dentist: 1 intra-oral length of session attendance, injections during years (injection dental fear
session vs. 5 injection N.R. Injection 1-year follow-up; 1 avoided) clinic
sessions phobia Phobia Scale- session = 5 session
Anxiety except lower DAS for
5-session at follow-up
Willumsen et al. CBT vs. applied WL for 1 Dental 10 weekly DAS, DFS, CBT = Relax = N2 O > WL 65 n/a 5-Year N.R. N.R. WL was 4 weeks,
(2001); Norway relax vs. N2 O month prior anxiety sessions of DBS wheras tx was 10
sedation to tx individual weeks; Pts paid fee for
therapy; N2 O tx that was refunded if
during dental all sessions were
procedure attended
Willumsen and CBT vs. applied WL for 1 Dental 10 weekly DAS, All respondents had 62 (just tx 43 5-Year N.R. N.R. Follow-up to
Vassend (2003); relax vs. N2 O month prior anxiety sessions of attendance attended dentist since completers) Willumsent et al.
Norway sedation to tx individual anxiety tx, Mean DAS (2001)
therapy; N2 O score = 10.4
during dental
procedure
Note: BAT, Behavioral Approach Test; BT, behavior therapy; Benzo, benzodiazepine; CBT, cognitive behavioral therapy; CR, cognitive restructuring; DAS, Dental Anxiety Scale; DBS, Dental Beliefs Survey; DCQ, Dental Cognitions
Questionnaire; DFS, Dental Fear Survey; HR, heart rate; hr, hour; Hw, homework; MDAS, Modified Dental Anxiety Scale; N2O, nitrous oxide; N.R., not reported; n/a, not applicable; PBO, placebo; Psychoed, psychoeducation; Pt,
patient; relax, relaxation; SIT, Stress Inoculation Training; STAI, State-Trait Anxiety Inventory; Tx, treatment; WL, wait list.

369
370 D. Gordon et al. / Journal of Anxiety Disorders 27 (2013) 365–378
published between 1974 and 2012, were selected for review (see
Table 1). If follow-up studies were published separately, they are
included in the present report but considered as part of the original
study.
3. Measures of dental anxiety and related constructs used
in treatment studies
Attempts to assess prevalence, correlates, and consequences of
dental anxiety have been limited by the use of different, and often
unvalidated, measures of dental anxiety/phobia. The importance of
this statement is highlighted by a study comparing three self-report
instruments for the assessment of dental anxiety differing in degree
of validational support. Despite statistically significant associations
between scores on pairs of measures, agreement among them was
only fair ( ranged from .37 to .56; Locker, Shapiro, & Liddell, 1996).
The use of different measures to assess the construct of dental anx-
iety may pose problems for the reliability of its operationalization
and contribute to inconsistent findings across studies. This com-
plicates the assessment of treatment outcome and the drawing of
conclusions based on the outcome literature. In this section, we
review the most commonly used assessment instruments for dental
anxiety and phobia.
3.1. Self-report assessments
Although the use of self-report measures varies across treat-
ment studies, both in regard to which measures and how many
of them are used, the most common measure of dental anxiety
in treatment research is the four-item Dental Anxiety Scale (DAS;
Corah, 1969). Higher scores indicate greater anxiety and a score
of 15 or higher is often used as the cutoff for high dental anxiety.
Internal consistency of the DAS has ranged from .62 to .91 in var-
ious samples (Schuurs & Hoogstraten, 1993). The validity of the
measure is poor as demonstrated a low correlation with dentists’
ratings of patients’ anxiety (r = .40, Corah, 1969); however, this low
correlation may be equally attributable to dentists’ lack of insight
into their patients’ anxiety.
To improve upon the validity of the DAS, the Modified Dental
Anxiety Scale (MDAS; Humphris, Morrison, & Lindsay, 1995) was
developed and is gaining popularity. The MDAS is a five-item mea-
sure assessing anticipatory anxiety associated with an upcoming
dental appointment, fear of dental cleaning and drilling, and fear of
local anesthetic injection. The last item (regarding injection) was
added to the MDAS when amending the original DAS. The total
score ranges from 5 to 25, with higher scores indicating elevated
anxiety and a score of 19 serving as the cut-off for high anxiety
based on receiver operating characteristic analyses from two stud-
ies (Humphris et al., 1995; King & Humphris, 2010). The MDAS
has demonstrated good internal consistency (˛ = .89; Humphris,
Freeman, Campbell, Tuutti, & D’Souza, 2000) and test–retest reli-
ability (r = .82, interval unspecified; Humphris et al., 1995). The
scale was significantly correlated with avoidance of dental proce-
dures in an internationally diverse sample (Humphris et al., 2000).
In assessing change in dental anxiety, some studies have used
the Dental Fear Survey (Kleinknecht, Klepac, & Alexander, 1973),
a 20-item measure assessing fear of specific dental procedures
(e.g., drilling), avoidance, and physiological arousal (e.g., palpita-
tions, sweating) related to dental treatment. Summed scores vary
from 20 (no fear) to 100 (terrified), with higher scores indicating
greater anxiety. The Dental Fear Survey yielded test–retest reliabil-
ity of r = .73 (interval not reported), internal consistency of ˛ = .93,
and split-half reliability of r = .96 (Kleinknecht et al., 1973; Schuurs
& Hoogstraten, 1993). Survey scores were significantly correlated
with trait anxiety, pain intensity, and avoidance of dental proce-
dures (Kleinknecht & Bernstein, 1978).
Additionally, the Dental Beliefs Survey (Milgrom, Weinstein,
Kleinknecht, & Getz, 1985) is a 15-item measure used to assess
patients’ attitudes toward and perceptions of the dentist’s behav-
ior, the process of dental care delivery, and how these interactions,
along with communication between patient and dentist, affect
one’s dental anxiety. On the basis of exploratory and confirmatory
factor analyses, it was determined that the Dental Beliefs Survey
comprises one general dimension (Kulich, Berggren, Hakeberg, &
Gustafsson, 2001). This scale has demonstrated good reliability and
validity across several samples and is significantly correlated with
measures of dental anxiety (Kvale et al., 1997; Moore, Berggren, &
Carlsson, 1991).
Lastly, the Dental Cognitions Questionnaire (de Jongh, Muris,
Schoenmakers, & Ter Horst, 1995) is a 38-item measure assessing
the frequency and believability of patients’ negative cognitions
related to dental treatment, in regard to both dentistry in general
(e.g., “Dentists don’t care. . .”) and to the patients themselves (e.g., “I
can’t stand pain”). Patients are instructed to indicate the frequency
with which these negative cognitions occur and the degree to which
they believe these cognitions on scales from 0% to 100%. The fre-
quency and believability subscales of the questionnaire had good
internal consistency (˛ = .89 and .95, respectively) and were signif-
icantly correlated with each other (r = .58) and with measures of
dental and trait anxiety. With regard to discriminant validity, indi-
viduals with dental anxiety reported a significantly higher number
of negative cognitions and gave significantly higher believability
ratings than non-anxious controls (de Jongh, Muris, Schoenmakers,
& Ter Horst, 1995).
Self-report of dental anxiety has also been obtained during
behavioral assessments (see below) by asking patients to report
Subjective Units of Distress Scale (SUDS; Wolpe, 1969, 1973) rat-
ings before, during, and after exposure to dental situations, based
on hierarchical steps, ranging from entering the waiting room to
having a tooth extracted. SUDS ratings are provided on a numeric
scale of subjective anxiety (e.g., 0–10, 0–100), ranging from no anx-
iety to the greatest level of anxiety that the individual has ever
experienced or can imagine experiencing.
3.2. Interview assessments
Two interviews have been utilized in dental anxiety treat-
ment studies to identify patients with specific phobia of dental
procedures. The specific phobia module of the Anxiety Disor-
ders Interview Schedule for DSM-IV (ADIS-IV; Brown, Di Nardo, &
Barlow, 1994), a semi-structured interview designed to establish
reliable diagnoses of the DSM-IV anxiety, mood, and somatoform
disorders, is used to assess specific phobia of dental procedures.
Clinicians assign a dimensional clinical severity rating (CSR), ran-
ging from 0 = none to 8 = very severely disturbing/disabling, with
scores of 4 or greater indicative of the severity of distress and
impairment that would meet criteria for diagnosis. The Structured
Clinical Interview for DSM-IV Axis I Disorders (SCID-I; First, Spitzer,
Gibbon, & Williams, 1996) is another common semi-structured
interview used to assess for Axis I psychiatric disorders, including
specific phobia.
3.3. Behavioral assessments
Various behavioral measures have also been used to assess
change in dental anxiety and avoidance. Avoidance of dental treat-
ment is often measured by tracking attendance at scheduled dental
appointments. Avoidance behavior is also measured by recording
patients’ progress on a behavioral approach test (BAT; Haukebø
et al., 2008), which consists of a series of behavioral tasks increasing
in difficulty. The BAT incorporates SUDS ratings to measure level of
anxiety during exposure and may sometimes include measurement
 D. Gordon et al. / Journal of Anxiety Disorders 27 (2013) 365–378
of physiological responses such as heart rate variability or galvanic
skin response as the patient works up a standardized hierarchy of
dental anxiety provoking situations. The BAT is occasionally used in
dental anxiety studies to evaluate the extent of patients’ avoidance
for inclusion in treatment; patients able to reach the most anxiety-
provoking item on the hierarchy may be excluded from treatment.
Additionally, some studies (e.g., Shaw & Thoresen, 1974) leave the
length of anxiety treatment open-ended and use patients’ ability
to complete all steps on a BAT with little discomfort to signify the
conclusion of treatment.
Some studies use combinations of self-report, interview, and
behavioral measures. Multimethod measurement is typically best
because each type of measurement alone contains flaws and,
whereas BATs provide objective, observable assessments of anxi-
ety and avoidance during exposure to dental situations, self-report
measures allow participants to report their subjective experience
of anxiety. Most commonly, treatment response in the dental anxi-
ety literature is measured by a statistically significant difference in
outcome scores between treatment conditions from pre- to post-
treatment. Little attention has been devoted to criteria for clinical
significance of change as is common in other areas of psychother-
apy research (Jacobson & Truax, 1991).
4. Treatment outcome trials
The studies reviewed here evaluate and compare the following
treatment techniques: various forms of CBT, relaxation training,
benzodiazepine premedication, music distraction, hypnotherapy,
acupuncture, nitrous oxide (N2 O) sedation, and the use of laven-
der oil scent. CBT interventions are reviewed, followed by non-CBT
treatments.
4.1. CBT interventions
Getka and Glass (1992) compared CBT and behavior therapy (BT)
to a wait list control and a positive dental experience condition
in which dentists were particularly gentle with anxious patients.
Forty-one patients with a minimum DAS score of 13 were random-
ized to one of the four conditions. CBT and BT were administered
in 6 weekly 1-h individual sessions by psychology graduate stu-
dents. CBT was comprised of psychoeducation, repeated video and
in vivo exposure, cognitive restructuring, and relaxation training.
BT involved the same components, except for cognitive restruc-
turing, and was administered almost exclusively via audio- and
videotape. CBT and BT were significantly more efficacious at reduc-
ing dental anxiety and negative cognitions than the wait list and
positive dental experience conditions. At 1-year follow-up, patients
in the two active treatments reported significantly less dental anxi-
ety than wait list controls and had avoided dental care significantly
less often than patients in the wait list and positive experience
conditions. One possible conclusion from these findings is that the
cognitive change may arise from behavioral intervention without
a formal cognitive component, as there was no difference between
CBT and BT in any comparison. However, the small sample of
patients in this study (approximately 10 patients per condition)
does not allow a good test of this hypothesis, as it was insuffi-
ciently powered to detect the modest effect size that one might
expect between two active treatment conditions.
An older study by Moses and Hollandsworth (1985) examined
the relative efficacy of the psychoeducation component of stress
inoculation training (SIT; Meichenbaum & Turk, 1976) by ran-
domizing 24 patients who had avoided dental care for at least 1
year and reported high dental anxiety (DAS) to various combina-
tions of SIT components, delivered by a psychology intern. SIT is
a form of CBT involving psychoeducation, the acquisition of cop-
ing skills to manage fear and anxiety, and application training, i.e.,
371
exposure to feared stimuli while utilizing coping skills. Moses and
Hollandsworth (1985) randomized patients to either (a) psychoe-
ducation alone, (b) coping skills plus application, (c) the entire SIT
package composed of education, coping skills, and application, or
(d) a wait list control. There were no differences among conditions
in dental anxiety reduction. Significantly more patients from the
three active treatments scheduled dentist appointments than those
on the wait list, but significantly more patients from the coping
plus application and full SIT package conditions attended the den-
tist appointments than those receiving psychoeducation alone or
the wait list. Because psychoeducation did not fare better than wait
list on either dental anxiety or avoidance reduction, it may not be
a necessary treatment component. However, given the very small
sample size and the lack of detailed description of the coping and
application (i.e., exposure) components, it is difficult to speculate
about the reasons for these outcomes.
4.1.1. CBT at varying intervals
A trial of immediate and long-term outcomes of group CBT (Ning
& Liddell, 1991) randomized patients to either massed (two ses-
sions per week for 2 weeks) or spaced (one session per week for
4 weeks) CBT. Treatment consisted of relaxation training, cogni-
tive restructuring, imaginal graduated exposure, and homework
monitoring, administered by clinical psychologists to 18 patients
with a minimum DAS score of 15. All treatment completers in both
groups attended dentist appointments post-treatment, and DAS
scores significantly decreased for both groups with no between-
group differences. This study demonstrates that group CBT can be
effective in reducing dental anxiety at various inter-session inter-
vals. A follow-up to this study assessing anxiety and attendance
of treatment completers 1–4 years after completing anxiety treat-
ment found that 70% of patients reached for follow-up attended
dental care regularly (i.e., at least once per year), suggesting that
group CBT delivered in massed or spaced sessions can have long-
lasting anxiety reduction effects (Liddell, Di Fazio, Blackwood, &
Ackerman, 1994). Regular and irregular dental treatment attenders
did not differ significantly on demographic factors, although those
with irregular attendance (i.e., greater avoidance) demonstrated
significantly less anxiety reduction at post-treatment.
4.1.2. CBT compared with relaxation training
The comparative efficacy of CBT and relaxation training was
examined in 112 patients with a minimum DAS score of 13
(Berggren, Hakeberg, & Carlsson, 2000). One clinical psycholo-
gist delivered both treatments, which included video exposure
to eight hierarchically arranged dental scenes. Progressive mus-
cle relaxation training was paired with electromyography (EMG)
biofeedback during video exposure until patients could watch all
scenes and handle dental instruments in a fully relaxed state. The
CBT condition involved psychoeducation and cognitive restructu-
ring during video exposure. More patients in the CBT condition
(74%) completed anxiety treatment than patients in the relaxation
condition (59%), although this difference was not significant. Both
conditions led to significant reductions in dental anxiety, but relax-
ation was associated with significantly greater anxiety reduction
than CBT. However, the substantial, albeit non-significant, differ-
ence in completion rates may bias the anxiety reduction findings
which are based only on the findings for treatment completers.
A unique study in the dental anxiety literature examined the
use of different types of group behavioral treatment methods for
patients differing in anxiety response patterns (Jerremalm, Jansson,
& Öst, 1986). Individuals with self-reported dental anxiety (unspec-
ified cut-off on the DAS and Dental Fear Survey), referred to
anxiety treatment by their dentists, were divided into two groups
depending on whether they reacted more cognitively or physio-
logically to dental procedures, measured by an examination of their
372 D. Gordon et al. / Journal of Anxiety Disorders 27 (2013) 365–378
cognitions and heart rate during a BAT. Within each group, patients
were randomized to either cognitive restructuring (cognitively
focused method) or applied relaxation (physiologically focused
method), provided by graduate student therapists. Applied relax-
ation involved psychoeducation and progressive muscle relaxation
exercises practiced during exposure to graduated video and in vivo
dental situations. Both treatment groups attended the dentist with
other supportive patients and received an unspecified reward
afterward. No significant differences between conditions were
found; both treatments significantly reduced anxiety for both
types of patients on self-report measures and somatic arousal
for patients classified as physiological reactors. Performance on
the BAT improved for both groups. Upon follow-up 9–12 months
later, the majority of patients attended dental appointments with
dentist-rated anxiety significantly reduced from pre-treatment
to follow-up. Overall, matching behavioral treatment type to a
patient’s idiographic anxiety response pattern did not appear to
enhance efficacy.
A study comparing CBT, applied relaxation, and N2 O seda-
tion randomized 65 patients with a minimum DAS score of 15
to one of the three treatment conditions (Willumsen, Vassend, &
Hoffart, 2001). All three treatments were provided by a dentist
and included 10 weekly sessions of individual therapy, except for
sedation which involved N2 O administration during the dental pro-
cedure. CBT involved cognitive restructuring and in vivo exposure.
Applied relaxation was practiced in the dental chair during sessions
and at home. Patients in all three conditions showed significant
reduction in dental anxiety measures (DAS, Dental Fears Survey,
and Dental Beliefs Survey) following treatment, and no between-
group differences were found. At 5-year follow-up, Willumsen and
Vassend (2003) found that all of the patients who responded had
attended a dentist appointment during the follow-up period, with
no between-group effects. This study indicates that several ses-
sions of CBT, relaxation, and the use of N2 O sedation administered
by dentists trained in these techniques are comparably efficacious
in reducing dental anxiety and avoidance and that these effects are
maintained over time.
4.1.3. CBT in varying amounts
A randomized controlled trial (RCT) compared one session to
five sessions of exposure in treating specific phobia of the dentist
(Haukebø et al., 2008). Forty patients with DSM-IV dental phobia
as diagnosed using the SCID-I who had avoided dental care for
at least 3 years were randomized to one 3-h exposure session,
five 1-h exposure sessions, or a wait list control. Active treat-
ments were delivered by a CBT-trained dentist. Both treatments
were equally effective at reducing avoidance behavior (BAT) and
changing negative cognitions during feared dental situations and
produced significantly more improvement than the control condi-
tion. Patients in the five-session condition had significantly lower
scores on self-report measures of dental anxiety (DAS, Dental Fears
Survey, and Dental Beliefs Survey) than those in the one-session
condition. Improvements in the active treatments were considered
clinically significant according to Jacobson and Truax’s (1991) defi-
nition: there was a combination of statistically significant reduction
in anxiety from pre- to post-treatment and a post-treatment anx-
iety score falling within the range of the normal population. At
post-treatment, 20 (55%) individuals in the one-session condition
and 19 (95%) in the five-session condition achieved clinically sig-
nificant improvement.
At 1-year follow-up, patients in the two treatments no longer
differed significantly on level of dental anxiety. Nineteen (75%)
individuals in the one-session treatment and 16 (87%) in the
five-session treatment achieved clinically significant improvement,
suggesting that the patients who received the one-session treat-
ment continued to improve. Seventy-seven percent of patients
across active conditions sought dental care in the follow-up year,
with no significant differences between groups (Haukebø et al.,
2008). With regard to the relationship between oral health and
dental anxiety among the anxiety treatment completers, includ-
ing individuals in the control condition who received one of the
active treatments following the waiting period, the number of teeth
needing treatment (e.g., restorative, periodontal, and extractions)
was correlated with positive thoughts related to dental care and
with anxiety, such that patients with the best dental health and the
least dental care needs experienced increased positive cognitions
and the largest decrease in dental anxiety (Agdal, Raadal, Skaret, &
Kvale, 2008).
The idea that dental anxiety could be significantly reduced in
just one session was not new, as several years prior, one session of
cognitive restructuring (CR) was found to be more effective than
information about oral health and dental treatment and a con-
trol condition (de Jongh, Muris, Ter Horst, et al., 1995). Fifty-two
patients with high dental anxiety (minimum DAS score of 15) were
randomized to a 1-h session of CR by a psychologist and dentist,
dental information provided by a dental hygienist, or a wait list
control, 1 week prior to dental care. CR was significantly more
effective at reducing anxiety and negative cognitions (Dental Cogni-
tions Questionnaire) than the information and control conditions.
Patients in the CR condition continued to fare better than those
in the information condition (controls were not re-assessed) at 1-
month follow-up, but at a 1-year follow-up patients in the active
treatments no longer differed in dental anxiety. This lack of long-
term effects of CR may be due to the very brief nature of the single
session of treatment and to the absence of a repeated, graduated
exposure component.
In a trial of patients with intra-oral injection phobia, different
quantities of CBT for dental anxiety were compared by the same
research group who investigated similar treatments for specific
phobia of dental procedures (Vika, Skaret, Raadal, Öst, & Kvale,
2009). Patients diagnosed using the ADIS-IV were randomized to
either one session or five sessions of CBT delivered by dentists
trained in CBT. The treatment consisted of cognitive restructuring
combined with graduated, repeated in vivo exposure to injection
stimuli. Both groups experienced significant improvement in anx-
iety as measured by the DAS, SUDS, and attendance measures
at post-treatment and 1-year follow-up. The five-session group
reported significantly less dental anxiety (DAS) than the one-
session group at follow-up, which was the only between-group
difference. Eighty-nine percent of patients received intra-oral
injections by a dentist during the follow-up period. CBT seems to
have a positive effect on both dental anxiety and intra-oral injection
phobia. It is notable that dentists trained in CBT successfully deliv-
ered the anxiety treatment in this study and the study by Haukebø
et al. (2008).
4.1.4. Variations of exposure
The first RCT examining CBT for dental anxiety and avoidance
was conducted by Shaw and Thoresen (1974). They randomized 36
patients who avoided the dentist for at least 1 year to one of four
conditions: (a) modeling plus imaginal exposure, (b) desensitiza-
tion, (c) placebo control, and (d) wait list control. Modeling plus
imaginal exposure involved relaxation training, video exposure
to models undergoing dental procedures, and imaginal exposure
to oneself undergoing dental procedures. Desensitization involved
the same components as modeling, except that audio instead of
video exposure was presented and there was no imaginal expo-
sure. The placebo control group received 10 sessions of 30-min
audiotapes of relaxation training, psychoeducation, and discussion
of anxiety and treatment principles with a counselor. Patients in
all conditions with the exception of wait list engaged in treat-
ment for 6–8 h in 1-h weekly sessions. Outcome assessments
 D. Gordon et al. / Journal of Anxiety Disorders 27 (2013) 365–378
included tracking attendance to dental appointments following
anxiety treatment, 0–10 SUDS ratings of anxiety regarding the
dentist and dental procedures, and a number of unpublished,
author-developed self-report measures. The modeling plus ima-
ginal exposure and desensitization conditions were significantly
more efficacious at reducing anxiety and avoidance at 3-month
follow-up than either of the control groups. In the modeling plus
imaginal exposure condition, 78% of patients visited a dentist dur-
ing the follow-up period, compared to 44% in the desensitization
group, but this difference was not significant. Although this study
is limited by a small sample size (n = 9 per group), it provided early
evidence for the efficacy of video and imaginal exposure in the
reduction of dental anxiety.
Mathews and Rezin (1977) examined the use of imaginal expo-
sure in the treatment of dental anxiety by randomizing 63 anxious
patients to four weekly 1-h sessions of audio-presented treatment.
The treatment conditions included combinations of imaginal expo-
sure to high or low arousal situations in the presence or absence
of coping rehearsal. Coping techniques were varied, including
methods such as distraction and relaxation. The control condition
presented progressive muscle relaxation audiotapes. Dental anxi-
ety was measured by an unpublished questionnaire assessing the
total level of anxiety across various dental procedures on a 10-point
scale. Exposure to high arousal situations led to significantly greater
anxiety reduction than exposure to low arousal situations, whereas
the opposite pattern emerged for avoidance reduction. Although
coping did not significantly influence anxiety, it interacted with
arousal level to affect avoidance, in that exposure to low arousal
situations without coping led to significantly less avoidance. These
results may be interpreted in several ways: the authors suggest
that using imaginal exposure with anxiety-evoking material of low
to moderate intensity may be most effective. An alternative is that
graduated exposure, which begins at low levels of anxiety arousal,
is best; however, the low arousal condition in this study began and
remained at low intensity which may have limited its own effects
even if it was more efficacious than beginning at a high level of
arousal. These conclusions are limited by the study’s implementa-
tion of an un-standardized coping technique for conditions which
included coping and by the possibility that people differ in their
definitions and experiences of which scenarios evoke high or low
arousal.
Most recently, Armitage and Reidy (2012) examined the efficacy
of imaginal exposure in 75 patients whose level of anxiety upon
entering the study was unreported. Patients were randomized to
either “process simulation” or a control condition, “outcome simu-
lation.” Process simulation involved a 2-min imaginal exposure to
the process of dental procedures in which participants were asked
to vividly imagine preparing to see the dentist. Outcome simula-
tion asked participants to vividly imagine for 2 min the outcome
of dental care or seeing oneself after meeting with the dentist.
Dental anxiety was not measured, but state anxiety was assessed
using a modified form of the State-Trait Anxiety Inventory (STAI-
6; Marteau & Bekker, 1992). Differences in anxiety prior to the
intervention were not reported. Patients in the process condition
reported significantly less state anxiety prior to and after the den-
tist appointment than controls, as well as significantly lower state
anxiety after the appointment than prior to the appointment. It is
likely that the dentist appointment itself served as exposure, which
may have contributed to the further decrease in anxiety. This study
supports the numerous findings that exposure, even brief or ima-
ginal, leads to short-term anxiety reduction, but it is limited by the
lack of a dental anxiety specific measure and unreported inclusion
criteria.
Another study examined various forms of exposure in the treat-
ment of dental anxiety among 143 adults with a minimum score of
15 on the DAS who were randomized to video or in vivo exposure
373
(Moore, Brødsgaard, Berggren, & Carlsson, 1991). An attention
placebo control, comprised of patients on the dental clinic’s wait
list, involved telling patients that dental anxiety was treatable.
Active treatments involved progressive muscle relaxation training
in the dental chair followed by either “video training” or “clin-
ical rehearsals” for an average of 7.5 h. Video training involved
graduated video exposure in combination with relaxation and
biofeedback until all scenes could be watched in a relaxed state.
Clinical rehearsals involved in vivo exposure combined with relax-
ation (the presence or absence of biofeedback in this condition
was not reported). Both types of exposure significantly reduced
patient dental anxiety compared to the control condition (DAS,
Dental Fears Survey, and Dental Beliefs Survey), and 93% of patients
who completed exposure returned to dental care within 1 year of
completing the study. This study indicates that repeated, graduated
exposure delivered in either video or in vivo formats is efficacious
in reducing anxiety and leads to lasting improvement.
In a trial examining group therapy, Gatchel (1980) randomized
19 patients with high dental anxiety (DAS) to one of three group
conditions led by dentists: desensitization (n = 8), psychoeducation
and discussion (n = 5), and no treatment control (n = 6). Desensiti-
zation involved psychoeducation, progressive muscle relaxation,
repeated imaginal exposure to a hierarchy of dental situations,
in vivo exposure to dental instruments, and training in interac-
ting with dental providers meant to increase a sense of control
over procedures on the part of the patient. The other treatment
involved psychoeducation and discussion about previous dental
experiences and information about dental procedures and how to
interact with dental providers. Dental anxiety was reduced signif-
icantly more from pre- to post-treatment in the desensitization
condition than in the psychoeducation/discussion and control con-
ditions, which did not differ. At 1-month follow-up, attendance at
dental appointments was highest in the psychoeducation condi-
tion (100%), followed by the desensitization (87.5%) and control
(33.3%) conditions, with a significant difference in avoidance found
only between psychoeducation and the control condition. Although
this study is limited by a very small sample size, it seems that
desensitization can reduce dental anxiety in the short-term when
administered in a group format.
One study examined the relative efficacy of exposure and
hypnotherapy using patients treated by general anesthesia as
the control group (Hammarstrand, Berggren, & Hakeberg, 1995).
Twenty-two women were randomized to exposure or hypnother-
apy. The exposure condition (referred to by the authors as
psychophysiological therapy) involved video exposure to den-
tal scenes combined with progressive muscle relaxation and
biofeedback. Hypnotherapy, delivered by a psychologist, involved
progressive muscle relaxation, visual imagery of hierarchical dental
scenes and procedures similar to those in the exposure condition,
and suggestions that the patient was not fearful of dental proce-
dures. The active treatment conditions had a high degree of overlap,
differing in their use of video versus imaginal exposure, and sug-
gestion versus biofeedback. The non-randomized control condition
was comprised of women consecutively selected from the wait
list who underwent general anesthesia. The video exposure group
exhibited significant reductions in dental anxiety (DAS), whereas
the hypnotherapy group did not. Further, the hypnotherapy group
had a higher drop-out rate. Control patients experienced a signifi-
cant reduction in dental anxiety but reported higher dental anxiety
post-treatment than either of the active treatment groups.
4.1.5. CBT versus benzodiazepine premedication
Thom, Sartoty, and Johren (2000) compared the efficacy of CBT,
premedication with the benzodiazepine midazolam, and a con-
trol condition in reducing DSM-IV dental phobia and avoidance
in 50 patients undergoing oral surgery (e.g., tooth extraction).
374 D. Gordon et al. / Journal of Anxiety Disorders 27 (2013) 365–378
Patients were allocated to conditions sequentially and via restricted
randomization (preferentially placed in the groups with fewer
patients). Outcome measures included the DAS, Dental Fear Sur-
vey, and Dental Cognitions Questionnaire, along with heart rate and
blood pressure measurements. Groups did not differ on outcome
variables prior to anxiety treatment. CBT consisted of one 1.5-h
session including psychoeducation, cognitive restructuring, ima-
ginal exposure, progressive muscle relaxation, and homework, 1
week prior to oral surgery. Treatment adherence was not measured.
Benzodiazepine was administered 30 min before dental treatment.
Individuals in the control condition were told that they would
be operated on by a surgeon with experience in treating dentally
anxious patients who would treat them particularly carefully. The
active treatment conditions reduced dental anxiety during surgery
more than the control condition. Heart rate did not differ between
conditions, except for a lower heart rate in the benzodiazepine
group immediately prior to surgery. One day, 1 week and 2 months
after surgery, individuals in the CBT condition were significantly
less anxious than individuals the benzodiazepine and control con-
ditions, whose anxiety returned to pre-treatment levels. Further,
those treated with CBT were significantly less likely to avoid future
dental appointments compared with patients receiving the benzo-
diazepine or no treatment.
4.2. Non-CBT interventions
Several RCTs examined treatments other than CBT in the reduc-
tion of dental anxiety. One study examined the effect of informing
the dental care provider of the patient’s dental anxiety level prior
to dental treatment on patients’ state anxiety (Dailey, Humphris,
& Lennon, 2002). Patients with a minimum total score of 19, or a
five on any one item, on the MDAS were randomized to a group
in which their dentist saw their MDAS score prior to the dental
procedure or to a control group in which the dentist was unaware
of the patient’s dental anxiety score. Patients whose dentists saw
their dental anxiety score exhibited significantly greater reduction
on the STAI-6 from pre- to post-dental treatment than the control
group. These results may be due to change in dentist behavior (e.g.,
greater sensitivity toward patients’ anxiety) or patient beliefs and
expectations about the dental situation (i.e., increase in positive
cognitions regarding dentist’s sensitivity to their anxiety); further
study may clarify whether either of these variables was responsible
for the outcome. Additionally, it would be prudent to re-administer
the MDAS following dental care to assess change in dental anxiety,
not just state anxiety.
Lahmann and colleagues (2008) compared brief relaxation,
music distraction, and no treatment control conditions. Relaxation
was practiced for 10 min prior to dental care, administered by a
dentist trained in leading relaxation exercises. Music distraction
involved listening to music of the patient’s choice during dental
care. Anxiety was measured by the state subscale of the full STAI
(Spielberger, Gorsuch, Lushene, Vagg, & Jacobs, 1983). Both relax-
ation and music distraction significantly reduced anxiety, with the
relaxation group producing significantly greater anxiety reduction
than music distraction. Like Dailey et al. (2002), this study is limited
by its omission of a dental anxiety specific measure, unclear den-
tal anxiety related inclusion criteria, lack of measurement of dental
treatment avoidance, and absence of follow-up data.
Karst et al. (2007) conducted a trial examining auricu-
lar acupuncture, intranasal premedication with midazolam, and
placebo acupuncture. Sixty-seven patients were randomly assigned
to one of these treatments or to a no treatment control group.
Auricular acupuncture involved using three points in the exter-
nal ear (i.e., relaxation, tranquilizer, and master cerebral points) on
the non-dominant side with needles puncturing the skin. Placebo
acupuncture used finger and liver points without puncturing the
skin. The midazolam group received an average of 4 mg of the
drug administered via spray bottle into each nostril. All patients
underwent tooth extractions under local anesthetic, as is typical for
this type of dental procedure. Auricular acupuncture and intranasal
midazolam were equally efficacious in reducing state anxiety and
more efficacious than the placebo acupuncture and no treatment
control conditions, as measured by the STAI. As with Dailey et al.’s
(2002) and Lahmann et al.’s (2008) trials, this study did not use
a dental anxiety specific measure, nor did it assess dental treat-
ment avoidance. Future studies should also report follow-up results
to examine these treatments’ ability to maintain dental anxiety
reduction over time.
In an examination of a less common form of treatment for den-
tal anxiety, lavender oil scent was compared to a no scent control
(Kritsidima, Newton, & Asimakopoulou, 2010). Participants either
waited for dental treatment in a lavender scented waiting area
or in a non-scented waiting area. Patients’ scores on dental anx-
iety (MDAS) ranged from 5 to 25, which spans the entire range
of anxiety, including very low scores. Post-treatment dental anxi-
ety did not differ between conditions, but a significant difference
was found in state anxiety (STAI-6), with those in the lavender
scent group reporting lower anxiety than controls. These results
may be explained by the measurement differences in the two self-
report scales; state anxiety assesses an immediate response to the
dental situation, whereas the dental anxiety scale assesses both
immediate and anticipatory anxiety, related specifically to dental
situations. Additionally, although lavender scent may be useful in
reducing state anxiety or enhancing relaxation, it does not target
cognitions around dental fear. Further research using only a high-
anxious sample and collection of pre-post data is also warranted.
Another research group examined whether differing amounts
of pre-operative information provided to 192 high- and low-trait
anxiety oral surgery patients undergoing operations under local
anesthesia affected oral surgery anxiety (Ng, Chau, & Leung, 2004).
Patients were randomized to one of four treatment conditions that
included one pre-operative informational session in which individ-
uals were provided (1) basic information only, (2) basic information
plus details of the operative procedure, (3) basic information with
details of expected recovery from surgery, and (4) basic information
with details of both operative procedures and expected recovery.
No formal control condition was included. The four intervention
groups did not differ on trait anxiety prior to surgery. SUDS rat-
ings served as the primary outcome variable and were obtained
immediately before, five times during, and ten minutes after the
oral surgery. Avoidance was not assessed. SUDS were significantly
lower for the low-trait anxiety patients, but the rate at which
SUDS decreased throughout surgery did not differ between high-
and low-trait groups or between the intervention conditions. The
two conditions providing detailed information regarding expected
recovery from surgery led to a significant decrease in anxiety in
patients regardless of trait anxiety classification. Provision of infor-
mation on the operative procedure only led to significant anxiety
reduction in the low-trait anxiety patients.
5. Meta-analysis of cognitive-behavioral interventions
Cognitive-behavioral interventions have garnered strong sup-
port in the treatment of dental anxiety. A meta-analysis of 38
studies (including book chapters and unpublished data or theses)
focusing on cognitive-behavioral interventions provides support
for their efficacy in reducing dental anxiety among adults (Kvale
et al., 2004). Interventions such as systematic desensitization,
relaxation, biofeedback, education, and hypnosis were included
under the umbrella of CBT and were compared to non-CBT treat-
ments such as general anesthesia, intravenous (IV) or N2 O sedation,
 D. Gordon et al. / Journal of Anxiety Disorders 27 (2013) 365–378
premedication, and various types of control conditions. Outcome
measures were self-reported anxiety and dental attendance, when
reported.
The effect sizes reported for dental anxiety were calculated
by subtracting the post-treatment control group mean from the
treated group mean and dividing by the pooled standard deviation
of the groups. Effect sizes for single-group pre-post designs were
calculated by dividing the pre-post-treatment mean difference by
the pooled standard deviations. The overall effect size for dental
anxiety reduction following CBT, for controlled and uncontrolled
studies combined, was 1.78 (95% CI: 1.67, 1.89) and indicated pos-
itive outcomes in the 33 studies that included data allowing for
effect size estimates. Effect sizes were weighted by sample size to
account for treatment groups with small samples.
Attendance was treated as a dichotomous variable and effect
sizes, weighted by sample size, were calculated based on the pro-
portion of subjects per group with a dental visit following anxiety
treatment. Chi-square tests were reported for studies with single-
group pre-post designs. An effect size of zero indicated that half
of the group had a dental visit following anxiety treatment and a
negative effect size indicated that less than half attended a dental
visit. The overall effect size, weighted by sample size, for atten-
dance to dental care following CBT in the 30 studies that measured
attendance was 1.40 (95% CI: 1.27, 1.58), falling to .76 (95% CI: 0.61,
0.92) when taking attrition into account (what this means is not
clearly defined by the authors). Attendance varied between 33%
and 100% within 6 months post-treatment (M = 79.5%). For a follow-
up period of 6 months to 4 years, the overall effect size for dental
visits, for controlled and uncontrolled studies combined, was 1.17
(95% CI: 1.27, 1.58) with 48–100% of participants attending a den-
tist appointment post-treatment, and a mean of 77% attending at
least once when accounting for attrition.
Like the heterogeneity among the studies reviewed in this
paper, Kvale et al.’s (2004) meta-analysis found much variation in
sampling procedures, population characteristics, design, reported
attrition, outcome measures, and effect sizes among the studies
analyzed. On the basis of the meta-analysis, the authors concluded
that reductions in dental anxiety following cognitive-behavioral
interventions represent medium to large effect sizes (based on
overall measurements including combined controlled and uncon-
trolled trials), with improvement maintained over time (Kvale et al.,
2004). However, the conclusions of this meta-analysis should be
interpreted with much caution. All effect sizes for dental anxi-
ety and dental attendance were reported for combined controlled
(i.e., between groups) and uncontrolled (i.e., within groups) trials.
Controlled and uncontrolled effect sizes were considered identi-
cal for the sake of analyses, precluding determination of how much
change resulted from active treatments and control conditions. Fur-
ther, effect sizes for dental attendance were essentially proportions
rather than established effect size measures. Given these limita-
tions, and the passage of nearly a decade since this meta-analysis
was published, it is recommended that a meta-analysis be con-
ducted with properly calculated and clearly defined effect sizes,
specifically for controlled trials.
6. Discussion
6.1. Summary of findings
In light of the limitations to be discussed, the majority of stud-
ies reviewed here, consistent with the meta-analysis (Kvale et al.,
2004), show that CBT techniques, delivered in a variety of formats
(e.g., exposure with relaxation, cognitive restructuring, cognitive
and behavioral approaches combined), modalities (e.g., individual,
group), intervals (e.g., massed, spaced), and quantities (e.g., one
375
session, five sessions), are efficacious at reducing dental anxiety
and avoidance among adult patients in the short term and upon
follow-up. Cognitive-behavioral interventions can be successfully
delivered by practitioners of various training levels, from spe-
cially trained dentists to cognitive-behaviorally oriented clinical
psychologists. Additionally, it is a promising finding that one-
session CBT interventions can lead to substantial improvement.
Results summarized in this review emphasize the importance of
repeated, graduated exposure, whether or not it is paired with
relaxation, biofeedback, or a cognitive component. Cognitive tech-
niques, relaxation, and the provision of detailed information about
dental procedures meant to increase patients’ sense of control over
dental care also appear to lead to a reduction in dental anxiety
and avoidance; however, they perform best when combined with
exposure.
Other interventions for dental anxiety require further study in
randomized trials. One study found hypnotherapy to be compara-
ble to exposure treatment; however, the hypnotherapy condition
included elements of desensitization and cognitive restructuring,
thereby leaving conclusions about the relative efficacy of hyp-
notherapy unclear. Only one randomized trial compared CBT to
benzodiazepine pretreatment, with CBT faring better in reduc-
ing anxiety and avoidance (Thom, Sartory, & Jöhren, 2000). Other
studies found no significant differences between the efficacy of
benzodiazepine premedication and acupuncture, or between CBT
and N2 O sedation, but these comparisons have been examined in
only one randomized study each and therefore should be further
researched before conclusions are drawn. A less common form of
treatment for dental anxiety, eye movement desensitization and
reprocessing, has been explored in one case series (de Jongh, van
den Oord, & ten Broeke, 2002) and shows promise, but more rig-
orous study is needed before making any conclusions about its
efficacy. Less traditional interventions such as lavender scent and
music distraction lack sufficient evidence for their efficacy in reduc-
ing dental anxiety and require further investigation, as well.
6.2. Methodological limitations in reviewed studies
Although clear patterns of results regarding which treatments
fare best in reducing dental anxiety and avoidance emerged, many
of the studies reviewed contained important methodological flaws
which undermine the validity of their outcomes. In most studies,
patients were referred by their current dentists or recruited from
dental clinic wait lists to participate in anxiety treatment studies,
which excludes those individuals too fearful and avoidant to initi-
ate dental care, thereby reducing the actual range of anxiety and
avoidance levels demonstrated by study samples and limiting the
range of generalization of study findings. Many studies also suf-
fered from very small sample sizes, limiting the power necessary to
detect potentially meaningful differences among active treatments.
Different studies used varying criteria for measuring dental anx-
iety and applied different inclusion criteria regarding the level of
dental anxiety required for study admission. Although numerous
trials assessed patients using common dental anxiety measures
(e.g., DAS, MDAS) and their established cutoffs for “high anxi-
ety,” other studies used unsubstantiated cutoffs, included patients
who reported low dental anxiety, used more general state anxiety
assessments (e.g., STAI-6) to the exclusion of measures of dental
anxiety, or administered unpublished scales developed for use in
just that trial. Additionally, although some studies assessed patients
using a combination of self-report scales, behavioral evaluations of
attendance, SUDS ratings, and physiological measures (e.g., heart
rate monitoring), the majority of studies neglected to use multi-
method measurement.
Three studies assessed DSM-IV specific phobia of dental proce-
dures (and in another case, intra-oral injection phobia); however,
376 D. Gordon et al. / Journal of Anxiety Disorders 27 (2013) 365–378
the majority of studies did not conduct diagnostic assessments. The
systematic assessment of dental phobia in addition to self-reported
dental anxiety and avoidance is important because specific pho-
bia is more debilitating and more difficult to treat (Uguz et al.,
2005). Several studies also failed to report group differences in
pre-treatment dental anxiety and did not specify whether such dif-
ferences were controlled in statistical analyses, which may have
confounded treatment outcome (e.g., Armitage & Reidy, 2012;
Kritsidima et al., 2010). Another confounding factor often present
in the studies reviewed involved charging patients fees or deposits
(sometimes returned upon study completion) for anxiety treat-
ment and/or dental care (e.g., Shaw & Thoresen, 1974; Willumsen
et al., 2001); it is possible that the presence or absence of a fee
affected dental treatment avoidance outcomes for certain individ-
uals, especially those in lower SES groups. Low SES may also serve
as a barrier to treatment and prevent such individuals from enter-
ing these studies. Moreover, the majority of studies failed to assess
and control for comorbid anxiety disorders, which may further con-
found outcome.
Just as there is a lack of standardization across studies for mea-
suring the magnitude of dental anxiety upon entering treatment,
there is no common definition of treatment success. The majority
of studies reviewed here consider treatment to be successful when
there is a statistically significant reduction in dental anxiety and
avoidance. Others (e.g., Haukebø et al., 2008) tested for clinical sig-
nificance, defined by Jacobson and Truax (1991) as a combination
of statistically significant change from pre- to post-treatment and
a post-treatment value falling within the range of the normal pop-
ulation or outside the range of the patient population (i.e., M ± 2
SD) in the direction of less pathology. Other trials reported success
as the reduction of dental anxiety scores to the primary measure’s
cutoff for “low anxiety.” Dental anxiety differs from other specific
phobias and subclinical fears in that even those individuals without
high dental anxiety often report some amount of discomfort dur-
ing dental procedures (Kleinknecht & Bernstein, 1978). Therefore,
improvement in dental anxiety may be more modest than what is
found for other anxiety disorders.
In evaluating treatment outcome, just over half of the stud-
ies assessed patients at follow-up intervals, varying from 1 month
to 5 years, most commonly re-assessing avoidance of dental care
and sometimes re-administering self-report measures. The stud-
ies lacking follow-up data, and those with short intervals from
post-treatment to follow-up, are not able to properly assess how
the treatments being tested perform in terms of maintenance of
treatment gains. Two studies only followed those in active treat-
ment conditions and did not reassess participants from the wait
list control at follow-up; therefore, time and exposure to dental
appointments were not properly controlled. However, because of
the ethical issues that arise when considering long-term follow-ups
of patients in control conditions, such a design becomes problem-
atic.
In the extant dental anxiety outcome literature, there is little
use of intent-to-treat samples, which would allow for assessment
of the overall efficacy of a treatment from a public health per-
spective. Not all studies reported drop-out rates and treatment
adherence, and the majority based their statistical analyses only
on the subsample of treatment completers; however, the overall
effectiveness of a treatment encompasses treatment adherence.
Similarly, more sophisticated statistical techniques such as hier-
archical linear modeling have rarely been used; such techniques
would allow for better management of missing data and exam-
ination of nesting issues related to anxiety treatment provider
effects, dentist effects, and dentist by treatment interactions. More-
over, the reviewed trials did not assess provider adherence to
treatment protocol (and in some cases, there was no specific
protocol).
6.3. Directions for future research
Beyond the need for future studies to improve upon the method-
ological weaknesses enumerated above, there are several ways
in which dental anxiety treatment research may be expanded.
The use of mindfulness as a coping technique has been shown to
be efficacious in the treatment of spider phobia (Hooper, Davies,
Davies, & McHugh, 2001) and other anxiety disorders (Hofmann,
Sawyer, Witt, & Oh, 2010), so it will be important to examine
mindfulness among individuals with dental anxiety and possibly
incorporate elements of mindfulness training into current treat-
ments. Additionally, d-cycloserine (DCS), a partial NMDA receptor
agonist used to facilitate and expedite the reduction of fear and
avoidance through enhancement of extinction learning, has been
found to enhance exposure for several different anxiety disorders
(Otto, Basden, Leyro, McHugh, & Hofmann, 2007). There is promise
for DCS to facilitate extinction learning in dental anxiety and spe-
cific phobia, but its use has not yet been examined among dentally
anxious patients (Heaton, McNeil, & Milgrom, 2010).
Studies described in this review that tested brief CBT (de Jongh,
Muris, Ter Horst, et al., 1995; Haukebø et al., 2008; Thom et al.,
2000) found support for the brief intervention. Self-administered
treatments have also shown promise (Getka & Glass, 1992). Further
studies replicating and expanding these results may help make CBT
more accessible and better utilized. It is recommended that a CBT
protocol be developed that could be self-administered with the use
of a computer at home, via the internet, or in the dentist’s waiting
area in one brief session. This type of treatment would be eas-
ily disseminated, accessible, cost efficient, and potentially reach a
greater number of patients who might otherwise avoid dental treat-
ment. On a related note, in a large number of the reviewed studies,
specially-trained dentists delivered the anxiety treatments; there-
fore, it may be prudent for schools of dentistry to incorporate CBT
training into their curricula, given the high prevalence of dental
anxiety and the difficulty anxious patients pose to dental providers.
An uncontrolled trial without random assignment that evalu-
ated the efficacy of CBT, IV sedation, and N2 O sedation (Aartman,
de Jongh, Makkes, & Hoogstraten 2000) found that a greater num-
ber of treatment sessions in a shorter period of time and increased
frequency of dental appointments (i.e., exposure) predicted anxi-
ety scores after anxiety treatment was completed. Very little work
has been done with regard to the evaluation of treatment outcome
moderators, and this is a fruitful area of research.
A discussion of dental anxiety treatments for youth was beyond
the scope of this review, but prevention can play an important role
in reduction of dental anxiety and avoidance, along with the health
consequences that accompany them. Given the strong support for
the role of direct and vicarious conditioning in the etiology of dental
anxiety, it is important to prospectively examine whether a reduc-
tion in dental anxiety and avoidance in adults leads to a reduction
in anxiety and avoidance behavior in their children.
References
Aartman, I. H. A., de Jongh, A., Makkes, P. C., & Hoogstraten, J. (2000). Dental anx-
iety reduction and dental attendance after treatment in a dental fear clinic:
a follow-up study. Community Dentistry and Oral Epidemiology, 28, 435–442.
http://dx.doi.org/10.1034/j.1600-0528.2000.028006435.x
Aartman, I. H., de Jongh, A., & van der Meulen, M. J. (1997). Psychological char-
acteristics of patients applying for treatment in a dental fear clinic. European
Journal of Oral Sciences, 105, 384–388. Retrieved from. http://onlinelibrary.
wiley.com.libproxy.temple.edu/journal/10.1111/(ISSN)1600-0722/issues?
activeYear=1997
Agdal, M. L., Raadal, M., Skaret, E., & Kvale, G. (2008). Oral health and oral treat-
ment needs in patients fulfilling the DSM-IV criteria for dental phobia: possible
influence on the outcome of cognitive behavioral therapy. Acta Odontologica
Scandinavica, 66, 1–6. http://dx.doi.org/10.1080/00016350701793714
American Psychiatric Association. (1994). Diagnostic and statistical manual of mental
disorders (4th ed., pp. ). Washington, DC: Author.
 D. Gordon et al. / Journal of Anxiety Disorders 27 (2013) 365–378
Armfield, J. S., Stewart, J. F., & Spencer, A. J. (2007). The vicious cycle of dental fear:
exploring the interplay between oral health, service utilization and dental fear.
BMC Oral Health, 7, 1. http://dx.doi.org/10.1186/1472-6831-7-1
Armitage, C. J., & Reidy, J. G. (2012). Evidence that process simulations reduce
anxiety in patients receiving dental treatment: randomized exploratory
trial. Anxiety, Stress & Coping: An International Journal, 25, 155–165.
http://dx.doi.org/10.1080/10615806.2011.604727
Berggren, U. (1993). Psychosocial effects associated with dental fear in adult den-
tal patients with avoidance behaviours. Psychology and Health, 8, 185–196.
http://dx.doi.org/10.1080/08870449308403178
Berggren, U., Hakeberg, M., & Carlsson, S. G. (2000). Relaxation vs. cognitively
oriented therapies for dental fear. Journal of Dental Research, 79, 1645–1651.
http://dx.doi.org/10.1177/00220345000790090201
Berggren, U., & Meynert, G. (1984). Dental fear and avoidance: causes, symptoms,
and consequences. Journal of the American Dental Association, 109, 247–251.
Retrieved from. http://jada.ada.org/content/109/2/247.short
Brown, T. A., Di Nardo, P. A., & Barlow, D. H. (1994). Anxiety Disorders Interview
Schedule for DSM-IV. New York: Oxford University Press.
Choy, Y., Fyer, A. J., & Lipsitz, J. D. (2007). Treatment of specific phobia in adults. Clini-
cal Psychology Review, 27, 266–286. http://dx.doi.org/10.1016/j.cpr.2006.10.002
Cohen, S., Fiske, J., & Newton, J. (2000). Behavioral dentistry: the impact
of dental anxiety on daily living. British Dental Journal, 189, 385–390.
http://dx.doi.org/10.1038/sj.bdj.4800777
Corah, N. L. (1969). Development of a dental anxiety scale. Journal of Dental Research,
48, 596. http://dx.doi.org/10.1177/00220345690480041801
Craske, M. G. (1999). Anxiety disorders: psychological approaches to theory and treat-
ment. Boulder. CO: Westview Press.
Dailey, Y.-M., Humphris, G. M., & Lennon, M. A. (2002). Reducing patients’ state anx-
iety in general dental practice: a randomized controlled trial. Journal of Dental
Research, 81, 319–322. http://dx.doi.org/10.1177/154405910208100506
Davey, G. C. L. (1989). Dental phobias and anxieties: evidence for conditioning pro-
cesses in the acquisition and modulation of a learned fear. Behaviour Research
and Therapy, 27, 51–58. http://dx.doi.org/10.1016/0005-7967(89)90119-8
de Jongh, A., Muris, P., Schoenmakers, N., & Ter Horst, G. (1995). Nega-
tive cognitions of dental phobics: reliability and validity of the Dental
Cognitions Questionnaire. Behaviour Research and Therapy, 5, 507–515.
http://dx.doi.org/10.1016/0005-7967(94)00081-T
de Jongh, A., Muris, P., Ter Horst, G., Van Zuuren, F., Schoenmakers, N., & Makkes,
P. (1995). One-session cognitive treatment of dental phobia: preparing dental
phobics for treatment by restructuring negative cognitions. Behaviour Research
and Therapy, 33, 947–954. http://dx.doi.org/10.1016/0005-7967(95)00027-U
de Jongh, A., van den Oord, H. J. M., & ten Broeke, E. (2002). Efficacy of eye move-
ment desensitization and reprocessing in the treatment of specific phobias:
four single-case studies on dental phobia. Journal of Clinical Psychology, 58,
1489–1503. http://dx.doi.org/10.1002/jclp.10100
Doerr, P. A., Lang, W. P., Nyquist, L. V., & Ronis, D. L. (1998). Factors associated
with dental anxiety. Journal of the American Dental Association, 129, 1111–1119.
Retrieved from. http://www.adajournal.com/content/129/8/1111.short
First, M. B., Spitzer, R. L., Gibbon, M., & Williams, J. (1996). Structured clinical interview
for DSM-IV axis I disorders – patient edition (SCID-I/P, Version 2.0). New York, NY:
Biometrics Research Department, New York State Psychiatric Institute.
Gatchel, R. J. (1980). Effectiveness of two procedures for reducing dental fear: group-
administered desensitization and group education and discussion. Journal of the
American Dental Association, 101, 634–637.
Getka, E. J., & Glass, C. R. (1992). Behavioral and cognitive-behavioral
approaches to the reduction of dental anxiety. Behavior Therapy, 23, 433–448.
http://dx.doi.org/10.1016/S0005-7894(05)80168-6
Hägglin, C., Hakeberg, M., Hallstrom, T., Berggren, U., Larsson, L., Waern, M., et al.
(2001). Dental anxiety in relation to mental health and personality factors: a
longitudinal study of middle-aged and elderly women. European Journal of Oral
Sciences, 109, 27–33. http://dx.doi.org/10.1034/j.1600-0722.2001.00946.x
Hakeberg, M., Berggren, U., Carlsson, S. G., & Grøndahl, H.-G. (1993). Long-
term effects on dental care behavior and dental health after treat-
ments for dental fear. Anesthesia Progress, 40, 72–77. Retrieved from.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2148740/?tool=pubmed
Hammarstrand, G., Berggren, U., & Hakeberg, M. (1995). Psychophys-
iological therapy vs. hypnotherapy in the treatment of patients
with dental phobia. European Journal of Oral Sciences, 103, 399–404.
http://dx.doi.org/10.1111/j.1600-0722.1995.tb01864.x
Haukebø, K., Skaret, E., Öst, L.-G., Raadal, M., Berg, E., Sundberg, H., et al. (2008).
One- vs. five-session treatment of dental phobia: a randomized controlled
study. Journal of Behavior Therapy and Experimental Psychiatry, 39, 381–390.
http://dx.doi.org/10.1016/j.jbtep.2007.09.006
Heaton, L. J., McNeil, D. W., & Milgrom, P. (2010). Propranolol and d-cycloserine as
adjunctive medications in reducing dental fear in sedation practice. Society for
the Advancement of Anaesthesia in Dentistry Digest, 26, 27–35. Retrieved from.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2893885/
Hofmann, S. G., Sawyer, A. T., Witt, A. A., & Oh, D. (2010). The effect of mindfulness-
based therapy on anxiety and depression: a meta-analytic review. Journal of Con-
sulting and Clinical Psychology, 78, 169–183. http://dx.doi.org/10.1037/a0018555
Hooper, N., Davies, N., Davies, L., & McHugh, L. (2001). Comparing thought suppres-
sion and mindfulness as coping techniques for spider fear. Consciousness and
Cognition, 20, 1824–1830. http://dx.doi.org/10.1016/j.concog.2011.05.013
Humphris, G., Dyer, T., & Robinson, P. (2009). The Modified Dental Anxiety Scale: UK
general public population norms in 2008 with further psychometrics and effects
of age. BMC Oral Health, 9, 20–28. http://dx.doi.org/10.1186/1472-6831-9-20
377
Humphris, G. M., Freeman, R., Campbell, J., Tuutti, H., & D’Souza, V.
(2000). Further evidence for the reliability and validity of the Mod-
ified Dental Anxiety Scale. International Dental Journal, 50, 367–370.
http://dx.doi.org/10.1111/j.1875-595X.2000.tb00570.x
Humphris, G., & King, K. (2011). The prevalence of dental anxiety across pre-
vious distressing experiences. Journal of Anxiety Disorders, 25, 232–236.
http://dx.doi.org/10.1016/j.janxdis.2010.09.007
Humphris, G. M., Morrison, T., & Lindsay, S. J. (1995). The Modified Dental Anxi-
ety Scale: validation and United Kingdom norms. Community Dental Health, 12,
143–150. Retrieved from. http://www.cdhjournal.org/journals/
Jacobson, N. S., & Truax, P. (1991). Clinical significance: a statistical approach to
defining meaningful change in psychotherapy research. Journal of Consulting and
Clinical Psychology, 59, 12–19. http://dx.doi.org/10.1037/0022-006X.59.1.12
Jerremalm, A., Jansson, L., & Öst, L.-G. (1986). Individual response pat-
terns and the effects of different behavioral methods in the treat-
ment of dental phobia. Behaviour Research and Therapy, 24, 587–596.
http://dx.doi.org/10.1016/0005-7967(86)90040-9
Karst, M., Winterhalter, M., Münte, S., Francki, B., Hondronikos, A., Eckardt,
A., et al. (2007). Auricular acupuncture for dental anxiety: a ran-
domized controlled trial. Anesthesia and Analgesia, 104, 295–300.
http://dx.doi.org/10.1213/01.ane.0000242531.12722.fd
Kaufman, E., Bauman, A., Lichtenstein, T., Garfunkel, A., & Hertz, D. G. (1991).
Comparison between the psychopathological profile of dental anxiety patients
and an average dental population. International Journal of Psychosomatics, 38,
52–57.
Kent, G., Rubin, G., Getz, T., & Humphris, G. (1996). Development of a scale to measure
the social and psychological effects of severe dental anxiety: social attributes
of the Dental Anxiety Scale. Community Dentistry and Oral Epidemiology, 24,
394–397. http://dx.doi.org/10.1111/j.1600-0528.1996.tb00886.x
King, K., & Humphris, G. M. (2010). Evidence to confirm the cut-off for screening den-
tal phobia using the Modified Dental Anxiety Scale. Social Science and Dentistry,
1. Retrieved from. http://www.st-andrews.ac.uk/dentalanxiety/
Kleinknecht, R. A., & Bernstein, D. A. (1978). The assessment of dental fear. Behavior
Therapy, 9, 626–634. http://dx.doi.org/10.1016/S0005-7894(78)80138-5
Kleinknecht, R. A., Klepac, R. K., & Alexander, L. D. (1973). Origins and characteris-
tics of fear of dentistry. Journal of the American Dental Association, 86, 842–848.
Retrieved from. http://jada.ada.org/content/86/4/842.short
Kritsidima, M., Newton, T., & Asimakopoulou, K. (2010). The effects of
lavender scent on dental patient anxiety levels: a cluster randomized-
controlled trial. Community Dentistry and Oral Epidemiology, 38, 83–87.
http://dx.doi.org/10.1111/j.1600-0528.2009.00511.x
Kulich, K. R., Berggren, U., Hakeberg, M., & Gustafsson, J.-E. (2001). Factor structure of
the Dental Beliefs Survey in a dental phobic population. European Journal of Oral
Sciences, 109, 235–240. http://dx.doi.org/10.1034/j.1600-0722.2001.00118.x
Kvale, G., Berg, E., Nilsen, C. M., Raadal, M., Nielsen, G. H., Johnsen, T. B., et al.
(1997). Validation of the Dental Fear Scale and the Dental Beliefs Survey in a
Norwegian sample. Community Dentistry and Oral Epidemiology, 25, 160–164.
http://dx.doi.org/10.1111/j.1600-0528.1997.tb00915.x
Kvale, G., Berggren, U., & Milgrom, P. (2004). Dental fear in adults: a meta-analysis
of behavioral interventions. Community Dentistry and Oral Epidemiology, 32,
250–264. http://dx.doi.org/10.1111/j.1600-0528.2004.00146.x
Lahmann, C., Schoen, R., Henningsen, P., Ronel, J., Muehlbacher, M., Loew,
T., et al. (2008). Brief relaxation versus music distraction in the treat-
ment of dental anxiety: a randomized controlled clinical trial. Jour-
nal of the American Dental Association, 139, 317–324. Retrieved from.
http://jada.ada.org.libproxy.temple.edu/content/139/3/317.full.pdf+html
Liddell, A., Di Fazio, L., Blackwood, J., & Ackerman, C. (1994). Long-term follow-
up of treated dental phobics. Behaviour Research and Therapy, 32, 605–610.
http://dx.doi.org/10.1016/0005-7967(94)90014-0
Locker, D., Liddell, A., Dempster, L., & Shapiro, D. (1999). Age of
onset of dental anxiety. Journal of Dental Research, 78, 790–796.
http://dx.doi.org/10.1177/00220345990780031201
Locker, D., Liddell, A., & Shapiro, D. (1999). Diagnostic categories of dental anx-
iety: a population-based study. Behaviour Research and Therapy, 37, 25–37.
http://dx.doi.org/10.1016/S0005-7967(98)00105-3
Locker, D., Shapiro, D., & Liddell, A. (1996). Who is dentally anxious? Concordance
between measures of dental anxiety. Community Dentistry and Oral Epidemiology,
24, 346–350. http://dx.doi.org/10.1111/j.1600-0528.1996.tb00874.x
Marteau, T. M., & Bekker, H. (1992). The development of a six item
short-form of the state scale of the Spielberger State-Trait Anxiety
Inventory (STAI). British Journal of Clinical Psychology, 31, 301–306.
http://dx.doi.org/10.1111/j.2044-8260.1992.tb00997.x
Mathews, A., & Rezin, V. (1977). Treatment of dental fears by imaginal flooding and
rehearsal of coping behaviour. Behaviour Research and Therapy, 15, 321–328.
http://dx.doi.org/10.1016/0005-7967(77)90063-8
McNaughton, N., & Corr, P. J. (2008). The neuropsychology of fear and anxiety: a
foundation for reinforcement sensitivity theory. In: P. J. Corr (Ed.), The reinforce-
ment sensitivity theory of personality (pp. 44–94). Cambridge, UK: Cambridge
University Press.
Meichenbaum, D., & Turk, D. (1976). The cognitive-behavioral management of anx-
iety, anger, and pain. In: P. O. Davidson (Ed.), The behavioral management of
anxiety, depression, and pain. New York: Brunner/Mazel.
Milgrom, P., Fiset, L., Melnick, S., & Weinstein, P. (1988). The prevalence and
practice management consequences of dental fear in a major US city.
Journal of the American Dental Association, 116, 641–647. Retrieved from.
http://adajournal.com/content/116/6/641.short
378 D. Gordon et al. / Journal of Anxiety Disorders 27 (2013) 365–378
Milgrom, P., Weinstein, P., Kleinknecht, R. A., & Getz, T. (1985). Treating fearful dental
patients: a clinical handbook. Reston, VA: Reston Publishing Company.
Moore, R., Berggren, U., & Carlsson, S. G. (1991). Reliability and clini-
cal usefulness of psychometric measures in a self-referred population of
odontophobics. Community Dentistry and Oral Epidemiology, 19, 347–351.
http://dx.doi.org/10.1111/j.1600-0528.1991.tb00185.x
Moore, R., Brødsgaard, I., Berggren, U., & Carlsson, S. G. (1991). Generalization
of effects of dental fear treatment in a self-referred population of odonto-
phobics. Journal of Behavior Therapy and Experimental Psychiatry, 22, 243–253.
http://dx.doi.org/10.1016/0005-7916(91)90040-C
Moore, R., Brødsgaard, I., & Rosenberg, N. (2004). The contribution of embarrass-
ment to phobic dental anxiety: a qualitative research study. BMC Psychiatry, 4
http://dx.doi.org/10.1186/1471-244X-4-10
Moses, A. N., & Hollandsworth, J. G. (1985). Relative effectiveness of education alone
versus stress inoculation training in the treatment of dental phobia. Behavior
Therapy, 16, 531–537. http://dx.doi.org/10.1016/S0005-7894(85)80031-9
Ng, S. K. S., Chau, A. W. L., & Leung, W. K. (2004). The effect of
pre-operative information in relieving anxiety in oral surgery
patients. Community Dentistry and Oral Epidemiology, 32, 227–235.
http://dx.doi.org/10.1111/j.1600-0528.2004.00161.x
Ng, S. K. S., & Leung, W. K. (2008). A community study on the relation-
ship of dental anxiety with oral health status and oral health-related
quality of life. Community Dentistry and Oral Epidemiology, 36, 347–356.
http://dx.doi.org/10.1111/j.1600-0528.2007.00412.x
Ning, L., & Liddell, A. (1991). The effect of concordance in the treatment of
clients with dental anxiety. Behaviour Research and Therapy, 29, 315–322.
http://dx.doi.org/10.1016/0005-7967(91)90066-C
Otto, M. W., Basden, S. L., Leyro, T. M., McHugh, R. K., & Hofmann, S. G. (2007). Clin-
ical perspectives on the combination of d-cycloserine and cognitive-behavioral
therapy for the treatment of anxiety disorders. CNS Spectrums, 12, 51–56, 59–61.
Poulton, R., Waldie, K. E., Thomson, W. M., & Locker, D. (2001).
Determinants of early- vs. late-onset dental fear in a longitudinal-
epidemiological study. Behaviour Research and Therapy, 39, 777–785.
http://dx.doi.org/10.1016/S0005-7967(00)00060-7
Schwarz, E., & Birn, H. (1995). Dental anxiety in Danish and Chinese adults:
a cross-cultural perspective. Social Science and Medicine, 41, 123–130.
http://dx.doi.org/10.1016/0277-9536(94)00288-5
Schuurs, A. H. B., & Hoogstraten, J. (1993). Appraisal of dental anxiety and fear ques-
tionnaires: a review. Community Dentistry and Oral Epidemiology, 21, 329–339.
http://dx.doi.org/10.1111/j.1600-0528.1993.tb01095.x
Shaw, D. W., & Thoresen, C. E. (1974). Effects of modeling and desensitization
in reducing dentist phobia. Journal of Counseling Psychology, 21, 415–420.
http://dx.doi.org/10.1037/h0037102
Smith, T., & Heaton, L. (2003). Fear of dental care: are we making progress?
Journal of the American Dental Association, 134, 1101–1108. Retrieved from.
http://jada.ada.org/content/134/8/1101.full.pdf+html
Sohn, W., & Ismail, A. (2005). Regular dental visits and dental anxiety in an adult den-
tate population. Journal of the American Dental Association, 136, 58–66. Retrieved
from. http://jada.ada.org/content/136/1/58.full.pdf
Spielberger, C. D., Gorsuch, R. L., Lushene, R., Vagg, P. R., & Jacobs, G. A. (1983). Man-
ual for the State-Trait Anxiety Inventory: STAI (Form Y). Palo Alto, CA: Consulting
Psychologists Press.
Sylvers, P., Lilienfeld, S. O., & LaPrairie, J. L. (2011). Differences between trait fear and
trait anxiety: implications for psychopathology. Clinical Psychology Review, 31,
122–137. http://dx.doi.org/10.1016/j.cpr.2010.08.004
Thom, A., Sartory, G., & Jöhren, P. (2000). Comparison between one-session psycho-
logical treatment and benzodiazepine in dental phobia. Journal of Consulting and
Clinical Psychology, 68, 378–387. http://dx.doi.org/10.1037/0022-006X.68.3.378
Thomson, W. M., Locker, D., & Poulton, R. (2000). Incidence of dental anxi-
ety in young adults in relation to dental treatment experience. Community
Dentistry and Oral Epidemiology, 28, 289–294. http://dx.doi.org/10.1034/
j.1600-0528.2000.280407.x
Thomson, W. M., Stewart, J. F., Carter, K. D., & Spencer, A. J. (1996). Dental anxiety
among Australians. International Dental Journal, 46, 320–324. Retrieved from.
http://onlinelibrary.wiley.com/journal/10.1002/(ISSN)1875-595X/issues
Uguz, S., Seydaoglu, G., Dogan, C., Inanc, B. Y., Yurdagul, E., & Diler, R. S.
(2005). Short-term antidepressant treatment of comorbid dental anxiety in
patients with panic disorder. Acta Odontologica Scandinavica, 63, 266–271.
http://dx.doi.org/10.1080/00016350510020007
Vassend, O. (1993). Anxiety, pain and discomfort associated with
dental treatment. Behaviour Research and Therapy, 31, 659–666.
http://dx.doi.org/10.1016/0005-7967(93)90119-F
Vassend, O., Røysamb, E., & Nielsen, C. S. (2011). Dental anxiety in relation to neuroti-
cism and pain sensitivity: a twin study. Journal of Anxiety Disorders, 25, 302–308.
http://dx.doi.org/10.1016/j.janxdis.2010.09.015
Vika, M., Skaret, E., Raadal, M., Öst, L.-G., & Kvale, G. (2009). One- vs. five-
session treatment of intra-oral injection phobia: a randomized clinical
study. European Journal of Oral Sciences, 117, 279–285. http://dx.doi.org/
10.1111/j.1600-0722.2009.00628.x
Weiner, A., & Sheehan, D. (1990). Etiology of dental anxiety: psychological trauma
or CNS chemical imbalance? General Dentistry, 22, 39–43.
Willumsen, T., & Vassend, O. (2003). Effects of cognitive therapy, applied
relaxation and nitrous oxide sedation: a five-year follow-up study of
patients treated for dental fear. Acta Odontologica Scandinavica, 61, 93–99.
http://dx.doi.org/10.1080/00016350310001442
Willumsen, T., Vassend, O., & Hoffart, A. (2001). A comparison of cognitive
therapy, applied relaxation, and nitrous oxide sedation in the treatment
of dental fear. Acta Odontologica Scandinavica, 59, 290–296. Retrieved from.
http://www.sv.uio.no/psi/english/people/aca/ovassend/index.html
Wolpe, J. (1969). The practice of behavior therapy (1st ed., pp. ). New York: Pergamon.
Wolpe, J. (1973). The practice of behavior therapy (2nd ed., pp. ). New York:
Pergamon.