_-_,

-** d
{ #de#ftu-
-' j t2
trr-
d Phobic Patient
MOH

}iGROLI'ND
Arxiery has been described as ir pervasive feelin
SIGNIFICANCtr sion, dread, and apprehenslon assoclared witr. .'{ of ,.nr
'ICAL be an undefined threat.r The Americr." oln1, *ru
{TEGIES FOR APPLICATION IN Association, in its Diagnostic and Srar;1,.*r)_thialr;i
rTICE Mental Disorders (DSM-IV), recogniz., . h,_ln1rrl rf
anxiery disorders including pruric attack. ,.,-'""u,.lur, #
havior Modification ..rgoraphobia,..specific phobia, .o.irl qtsorder,
phoiir"'
compulsive disorder, posttraurnatic *t.rriua_
stress,1.-'
dication stress disorder, lnd generalized lnxierv ai,^,r-lt'*u.ut.
conditions heve not bcen widely stujied - *'' I'hese
\IARY
Loutext, but ell of therrr can hevc inrpurnn,';,.'lL d.n,.l
ft,r dental treiltment. Patients with any nf ,1,".^ lf"lution,
\NINq 2BJECT'IVES .lisordcrs arc likely to be uncomf"ir*t t. ;" Prslchiarll.
'
treatment serting. Patierrrs with socill phob "( den,u,
:,itplatiort oJ-this cbapter, thc lcarnar rail/ bc ablc to: rflssment and being judced lr1 orhers, nn,J ,,,_,1'.hburr
:-rin the n'.1ture, clinical irnpirct, and epiderniology rrgoraphobia [elr siruations fi.om which ,t.,.,t"^']tn,t *i,h
::ntrrl irnxierv and its relatior-rsl-rip to other atrxiert, escape. Anecdotal eviderce suggesrs,r.,., iJ.r"'i'lo,..rir1,
rders. or an epinephrine irrjection carr elicit pun;,.'.]jatme,i
-lu:rte available ir-rstrurrrents used in resezrrch and strsceptible i n dividuels. Patierr r s wi th por,rr,,i*l'.'acks 1n
to me2lsure or rlssess dental arlxiery.
:-.icirl settings disorder are perticulerly sensitive ,n .nuiro,,n.,""l^'lc srress
...rriue the con-rplexiry of issues ir-rvolved in the eti- Specific phobias ro such things as 61oo6. ,""'ol noises.
iv of dentai an-xiety. tissue damage probably rrre more *ia.tv r..,lijl'llt, o,
,,.-iew and compare the pharmacological versus dentnl clinic. Other parienrs f.rr. .hokln'r''lo,n,h.
'avioral trcJtrnent of derrt:rl rrruiery. vomiting. suffocating, contamination, oi 1"jf;^guS8ing,
:ntifi, the issues in and limitations of dental arrxiery Becausc the dental literarure does nor.,tar.,r rl^5^,ontrot.
,earch and t1-ie limitations of reserrrch findings for rrnxicry disorders this discussion *n, t;^i,.a::esqecific
nical practice. generally and generically referred to ., a"l,^Y whut i,
""*, a[xi.ty.
Anxiery can pose real problems for the
si onal wi thou t fu I fi liing speci fi c diagnostic
- .n,^li lr.f.;-
.Y TERAIS psyclriltric disorder. Although this review *t,r.lo,o, any
.rssical conditioning marily adult patients, children .^n .rh;Ult ,,II).: pri-
qnitive behavior therapy anxiery and_much in the dental lirerature .aJu,l. o.r,ot
.ep sedation treatment.3 5 -""'sises
their

.rsnostic and Statistical Manual of Mental Disorders

,.posure therapy
BACKGROT.IND
frtinction
Terms encountered
[ooding il. !h. dental literature n1p r;
f'ear," "dental anxiery" "dental phobia,,, and.'"'^.d,ntal
|einforcement "odontoplrobia," and "apprehensive
felaxation therapy pn1i.ni,i-fir0tlally,
tr stematic desensitization these rerms has hee, adequately^d.fin.d or,i;rriJ:1...f
---'y 0tstin-
guished. Sometimes more specific terms
- '^' 4r\
' are used'
such
145 . a\
 146 Part777 ,Arr"rr-.nt ltrttegics to Zailor Your Patient Care Plan
"dental injection phobic." Some authors link pein and
anriety, but for many patients, denta/ anxiety is not a liar
of pain. Tl-re general term "dental anxiery" is uscd in this
chaltter to refi:r rc all o{the a6ove c'xcept when another
term is needcd to makc a specific distinction.
AIo conclusive evidence exists at this rime irbour the
prevalence of dental anxiety. Many epidemiological
studies estimate the prevalence of this condition irt
approximately 10o/o of the popularion.l,-r1 The rate varies
depending on the def-inition used and the setting in
which dental anxiery is assessed. A review of publications
fiom 1950 to 2000 found no evidence that dental an-xiery
has increased or decreased appreciably.r2
Gender differences in denta.l anxiery, although seemingly
apparent in previous studies, have been contradicted by
rnore recent research. Many studies show that females
are more likely than males to report having dental
aruiety.6'7"t'rt,lr However, one recent srudy indicates that
men are more likely to report dental arxiery.ls The possi-
bility that women reporr denta.l anxiety more freely than
men has been noted as a likely explanation for these
difTerences. Therefore, no conclusive statement can be
made about gender differences in dental anxiery.
Age differences in the prevalence of dental arxiery
have been consistently reported. In general, dentai irnxi-
ety decreases with increasing age. Age-dependent decline
in prevalence is well established in the lirerature.7,1r,1(,
Dental professionals cannot assurne that an older person
will not have dental rrnxiery.
Psychological variables are aiso important in predicting
the cleveloprnent of dentai anriery. Specifically, if an indil
vidual has one or more psychological disorders, such as
generalized an-xiery disorder, maj or depression, substance
dependence, or specific phobia, the incidence of dental
arxiery increases signifi cantly. 16
CLINICAL SIGNIFICANCE
Highly arxious patienrs exhibit greatly decreased dental
clinic attendance and use of dental services. The 2000
Surgeon General's report on Oral Health in America
estimates that 4.3o/o of the population refrains from
getting dental care because of dental anxiery.17
Avoidance- of dental care because of arxiety can
perpetuate a vicious cycle. On average, fearful patients
suffer pain for 17.3 days before consulting i dental
professional.l8 This delay in treatment can eventually lead
to additional dental complications that necessirare more
extensive treatment and possibly emergency treatment.
Sorne anxious individuals neglect their dental health to
such an extent that they are in danger of losing some of
their teeth.le High levels of anxiery and hence avoidance
of the dentist, are associated with an increased number of
decayed teeth and fewer remaining teeth.e'13 This pattern
of delay in seeking care can exacerbate the anxiery. When
treatment is avoided, more invasive treatments such as
root canals and extractions are eventually required, which
are rnore trauntatie .1nit ,rt-,.-: - . .
invasive rrearmenrs.
Dental fear is cited as a rezrson ior
in approximately 750/o of cases.l.r'l
dental patients are less likely to keep
appointments for preventive care such as
cleanings, they can cornpromise their furure - rri
status. The synergistic relationship be _:1er
:riP,
avoidance and continued pain and fear and a
: t,rrr
about the escalating expense associated with
dental care leads to even greater irregular -re
-:.a
Preventive care is relatively inexpensive -.^-e
more extensive dental procedures such as
crowns, and restorations. There are added
dentist as well.
,.:t
:, 1
Providing care to anxious patients can be s
dental professional. Anxiety-related patient
_:'t(
.:a(
issues require the dental staff to spend extra
effort beyond what is expected with most
Arxious dental patients may break scheduled
ments and actually require more time for trea
other patients.ls,2l Anxious patients also
Paln during d e n tal treatme nt co m P ared wl th
patients.22 All of these factors place ad ded
the dental professional.
Diagnosis of dental rrnxiery can be difficult
standardized diagnostic criteria exist for this
The current lack of both a specific and widel1'
definition ofdental anxiery and standardized
teria frustrates both research and treatment. A
review ofbehavioral interventions for dental feat
fied only three studies that included a formal
e n try.
23
Dental fear orP hobia often CO m Parei
psychi atn diagno SlS ofsiPe cific pho,b t?, hi ch ls
as excessive, uncontrollable fear that exceeds the
fear others may occasionally experience.l Box
the D SM IV diagnostic crl te na for specific
illustrative exam ple of diagnostic cr1 tefl a for one
disorder.
Approximately 470/o of patienrs seeking trea
dental anxiety fulfill the DSM-IV criteria for
phobia, 33o/o do not meet diagnostic criteria for
chiatric disorder, and L90/o meet criteria for
chiatric disorders.23 As many as 4Oo/o of dental
patients meet criteria for one or more psychiatric
noses other than specific phobia. App roxlrn a teh-
p^.tlents with an intraoral lnJ ectron Pho bi a also
least one othe r D SM IV psychiatr diso rder.25
common psychiatric co-morbidities are other
disorders and mood disorders. These srudies
that dental anxiety patients represent a highly
*t?"rtiL*tfrfi'efforts
have been made to a"ra"f
nostlc classifica .tro n system for SU btypes o f den td,
Recognizing the diversi ty among Pa tle ntS,
Sheehan26 propose d tha dental anxretv should be
fied as exogenous sltuatron -specific :) vefs riS
 Chrpter t2 Zhe ltarful and Aobic
&tient
' 147

. )AGNASTIC AND STATISTICAL MANUAL /I/DIAGNOSTIC CRITERIA FOB SPECIFIC PHOBIA

-\

r -iBlA
l,larked and persistent fear that is excessive or unreasonable, cued by the presence or anticipation
ofa specific
r_lect or sltuatron.

-:rposure to the phobic stimulus almost invariably.provokes an immediate anxiety response, which mal
,rm ofa situationally bound or situationally predisposed panlc attack. rake
the
- he person recognizes that the fear is excessive or unreasonable.
- he phobic situation(s) is avoided or else is endured with intense anxiety or distress.
lae avoidance, anxious anticipation, or distress in the feared situation(s) interferes significant
' :,rm'al routine, occupational'(or academic) functioning, or social activities or relationshtor,Trl*:T p*rlr:n',
v'
r-' rrrlrr ts marked
-.-rress about having the phobia.
.: individuals under age 18 years, the duration is at least 6 months.
, re anxiety, panic attacks, or phobic avoidance associated with
rLs assuLralsu wrtrr the
urE specific
sPcculc object
ooject or situr
sifuation tte
not
.:counted for by anoth.. *art"l disorder. better

J rvitlr perrr-rission fiom thc Diagnostit ani Slatistica/ Munual of Mantal Disonlo: (DSM-|tr!, ed 4, Tbxr Revision,
Psychiirtric Associ :rtion. ) Dc,

:'.e ous and generirlized). The Seatrle systerr, lear of dentel treatment, "5', indicates mo.lo*^.
"10" indicates extreme fe ar'.rt -''4rur
rrruucrate
-icr.rtifies fbur types of dentirl rrnxiery is described fta\ and
, 12-7.2; No snrdies sLlpporr the clinical value of Th..I91 widely used scale is rhe I)e.,.,r
-,gnostic schemes. ^
Scele (DAS).'r The NIodificJ b*,,,T111' Anrien,
' :re difficulties rvith diirgnosis, several instrLlments
.:iru developed for scaline the severiry of dental
0\.{?e,S] was.devetoped to address
of thc DAS.lt Borli sc,rres :lre show,, ,"iiliV
Scarl
.;,;
're Tl-rese assessment instrunre nts are r.rse d in .,,foainn*
The NIDAS differs frorn the OAS, *i,r'l'^"]1t]:.12_2.
",""'oad,tion,J
.' clinicrl rrnd reseurrch settirrgs to deterrnine tl-re itenr rnelsuring the prtierrt's anxierv
J severity of the arxiery. Perh:rps the siniplest of injection of local anesrhetic. l, ,;.;;;jj]],ns an
.,1es is the der-rtal :rrxiety question, which consists ^ir.Both
items
:rsle losical question 'Are you afrarid of goir-rg to ['J'ililf1':::n XI'o" '", il; rjit,T;
-i;1)"3t) Gatchel's f-ear scale :rsks tl-re patient to rate edd resses pote n tiar ry i ; ;:1i^:'iil,ll ".l,:T,l n.'*,,
:e'.rr on a 1O-point scale rvhere "1" ir"rdicates no embarrassmcnr, fear o[ loss of .on,-r"'rl ]l S,rit1,
helplessness, and feelings of inadeo,,r.r-r'tt,rg, of

E*r,, can be as stressful for some prri.nu'rrih.'"'ot leelings

fears associated with dentrl
Trr general, available studies show
-- "'"tc joqu5e"d
tr.rrr
the,.i;rl,,,l"o pu;n.
- :ITTLE CLASSIFICATION
TING DENTAL
SYSTEM FOR
sensitiviry and specificiry of the oor.i[fifivat;a;r.'
ANXIETY
....prrbi.. The posirive predrtrve valrre nf ,o U'.
rnents has been reported to be ,rr..*ri'il ^^-,\l,lr,ru-
-] Conditioned fear of specific painful A rather sizable fraction of tf,. ,.,;."r.1"t*o'I lo*.r,
or unpleasant stimuli (driils, 37o/o to 410lo) who achieved tr;nt-,
,.nr". Ilruxrmarely
needles, sounds, smells) or MDAS acrually had visited th.i.;;,;".'ne DAS
*'*,- tr&iurly
during the past 5 years, which s,,r*,
I1 A.ruicry about sornc somatic
patients do overcome their fear ,"d"rrir,rlr,," *,ti
reactions during treatment (allergic --""arr I

reactions, fainting, panic attacks)

attendance. re$l]a;

The Dental Fear Survey shown in Bor rr

III Patients with other complicating example of a scale "'o^"{ i, ,,
,fr., or"ri.r"r'''"---""
range
trait an-xiety or multiphobia content.3s This scale asks patients 0f
concerning 27 dental situations. ,n. .,. ,"'"t
an-xiet1,
IV Distrust of dent:rl personnel
to th ree
i n su bsca les cove ri ng parterns rf
J.;,;i ;,i:.,rp.d
""''lvoldanre
: iion'r Moorc R, Brodsgaard I, Birn H: Mar.rifest:rtions, and anticipatory arxiery feir associateJ
r and diagnostic categories of dental fear in a self-referred derrral stirnuli and procedtrres, and
,**ir.a v"1:tologicnl
. . Behlat Rel Tho'29:57,1991.) lrousal during dental treatment. "rll,,f.,;{i,
 148 ' Art III ,Assessment ftrategics to Zailor You, Patrcr'rt Care Pran

DENTAL ANXIETY SCALE (DAS) AND MODIFIED DENTAL ANXIETY SCALE (MDAS)

DENTAL ANXIEW SCALE MODIFIED DENTAL ANXIETY SCALE

1. If you had to go to the dentist romorrow, how would 1. If you went to your dentist for treatment tomorrow..
you feel about it? how would you feel?
a) I would look forward to ir as a reasonably enjoyable a) Not arxious
experience.
b) I wouldnt care one way or the other. b) Slightly anxious
c) I would be a little uneasy about it. c) Fairly anxious
d) I would be afraid that it would be unpleasant d) Very anxious
and painful.
e) I would be very frightened of what the dentist e) Extremely anxious
might do.
2. When you are waiting in the dentistt office for your 2.If you were sitting in the waiting room (waiting for
turn in the chair, how do you feel? treatment), how would you feel?
a) Relaxed a - e same as for number 1
b) A little uneasy
c) Tense
d) Anxious
e) So arxious that I sometimes break out in a sweat
or almost feel physically sick.

3. When you are in the dentist's chair waiting while he 3. If you were about to have a tooth drilled, how
gets his drill ready to begin working on your teerh, you feel?
how do you feeli a - e same as for number 1
a - e same as for number 2

4. You are in the dentist's chirir to have your teeth cleaned. 4. Ifyou were about to have your teeth scaled and
While you are waiting and the dentist is getting orrt polished, how would you feel?
the instrurler-rts rvhicl'r l-re will use to scrape your a - e same as for number 1
teeth around the gums, how do you feel?
a - e same as for nurnber 2
5. Ifyou were about to have a local anesthetic
in your gum, above an upper back tooth, how
you feel?
a - e same as for number 1

(Dental Anxiery scale reprinted with pennission liom Corah NL: Developmenr of :r denral arxiery sclile,J Dent Res 48:596,7969;lVlodif.ied
Anxiety Scale reprintcd with pcrmission from Humphries GNll, Morison T, Lir-rdsay SJE: The Nlodified Dental Alxiety Scale: Validatio' irnd
Kingdom norms, Contntun Dent lTealth 12:143,7995.)

The choice of an instrurnent to scale dental arxiety
will depend on the particular need and setting. For
screening unfamiliar patients in the clinic, the Dental
An-riety Qrestion and Gatchelt fear scale are recom-
rnended. Follow-up questions designed to properly assess
the nature and severiry of any elicited report of arxiety is
always necessary. Even if the level of anxiety is very low it
could benefit the dental professional to be aware of it.
The DAS offers the distinct advantage of being widely
used, therefore cornparative data are available from
studies conducted in various patient populations and
treatment settings. However, the MDAS is believed to be
superior to the original DAS.
In the research setting the choice of an assessrril
instrument will depend on how dental anxiery ir is--C
and operationalized. None of the available instrur::d
(including those not reviewed here) possesses all fr
qualities needed,'and more research is needed to sup.ilul
the existing ones. A scale to measure specific b,:d
phobia in the dental setting will be different frorn :r
designed to measure the overall stress of a dental nsd
A need exists for scales that can measure a broader ::rtr
of stress eliciting factors, including financial con.d
embarrassment, guilt, fear of loss of controlrand fee'-lil
of inadequacy. Research is needed to identifi, scale. ::r!
assess dental an-xiety wirhin rhe contexr of ih. pac.dii
 At',rpter 1.2 Zrc liarful and Aobic Atient 1,49

_: DENTAL FEAR SURVEY

1,' O IDAITICE OF DET"ITISTRY

12. Dental chair
-=never...5=often)
13. Smell of office
-. Have avoided calling for an appointment
14. Seeing dentist
-. Have cancelled t:r not appe ared
15. Seeing needle
;: tT PHYSIO[OGICAL BESPON$ES 16. Feeling needle
- =1one...5=great) 17. Seeing drill
i, Muscles become tense 18. Hearing drill
: Breathing increases 19. Feeling drili
,', Perspiration increases 20. Feeling as if you will gag
. Nausea 27. Having teeth cleaned
- Heart rate increases 22. Feeling pain even after anesthetic iniection
:, Mouth salivates 23. Generally, how fearful are you of dentistry
::ARFUINESS 0t STIMULI HOW FEABFUL ARE/WEBE YOUE
. =none...2=great) 24. Mother
- Making an appointment 25. Father
Approaching office 26. Brothers and sisters
Waiting room 27. Childhood friends
tctl fiorrr: Klcinknccht IL\, Klcprc l{K, Alcxandcr l,l): ()ri,{ins rrnd characteristics of feirr of dentistry,JADA 84:842-8.48,7973-,
Table 3 with
:,rn fionr the /\nrcricarr l)cntirl Associrtion.)

,1 proPer-rsir1, to experience itn-xie t1, and trlso to
.:ste nce of possible independcr-rt rrr.xiett, disorders.
: ect classical conditioning is thc theorv most ofien
:ed to explair-r the ctioloq], of dcntal aruiet\,.
'.ered r-rear the end of tl're ninctccnth centurl' by
j.ir,lor,,
clurssical cor-rditior-rir.rg is :r r1,pe of learning in
nvo stirnuli, one neutral and or-rc fear-elicitinu, irre
r.: Another theory contends that irruriety is i'iclri-
:rrrned. According to this theor-v, an-xiery is lean-red
:h witnessing an anxious resporlse in someone else
:Crve s lLS a model. For
instrrnce, a cl-ri1d n-right
'-r der.rtirl anxiety after rvitnessing e parenr display
' associated rvith an upcoming dental appointment.
.Jies using a cross-sectionrrl, correlationirl design
:ted a possible link betr,veen experience with dental
rd der-rtal arrriery The ma.jority of an-xious dental
:s can recall a traumatic dent:rl treatrnent experience,
-.idies using Questionnaire or interview methods show
-rciation befween dental an-xiety and selFreported
' of painfi.rl or otherwise traumatic dental experi-
'-3e Other studies show that the experience of a
.rtic dental treatment event cannot fuliy explain the
'-)ment of dental anxiety.ao'41 Evidence for the
us learning of anxiety alio has beer-r reported.38,3e
sectional studies cannot demonstrate that the
rr exacerbatior-r of dental an-riety follows exposure
:.ra1 carc. Only prospective, longitudinal studies, in
dental an-xiery is measured at multiple points
:, can convincingly show tl-rat the orrset of au-xiery
: experience. AJso, patients witl"i dental arrxiety
recall or report past experiences difTerently tl-ran
irssess patients wl'ro are not anxious, and prospective designs
rninimize such rcporting bias, wlrich is inherent in rerro_
spective srudies.
One prospective srudy investigated the association
befween restorative d.ental tre.atment (measured by
decayed, rnissing, and filled_teeth) at. ag-es 5 and t5
yearr,
and der-rtal an-xiety at age 18. years.a2 Study participants
who had at le..rst one restora^tion (a potentially traumatic
experience) before the age of 5 years were not more likelv
to l-rave dental anxiety at age 18 years compared witi
those with no resrorarions. dental iatients *ho hrd
on.
or more teeth restored at age 15 were nearly 5 times more
likely to have dental
.r*i.ry at age 18 compared with
those who had not had'restorative dental treatment.
This finding suggests that conditioning may not be the
primary mechanism responsible for dentai anxiety in
young children, but it may play a more important role
during adolescence. Another srudy demonstrated that
although the incidence of dental anx]ety increased by
approximately 2.10/o per year between the ages of 1g and
26 years, the incidence was greatest among parients
who had nor received any dental treatment du.l.rg th.
previous B years.a3 Of the dental patients who were
arxious at age 18 years, only 52.5o/o remained anxious at
age 26 years, and of the patients who were not anxious
at
age 1B yetrs,76.60/o became anxious by age 26 years. The
authors concluded that conditioning cannot explain the
onset of dental anxiety in the.rnajoriry of young ajults,
and
suggested that certain psychological traits J, ,.-p..u_
ments might indicate vulnerability to dental anxi"ty in
young adults. Another study produced contrasting ..srlt,
 150 ' Prnt rrr ,4.ses.,r".,t rtrategies rc Tttror yorr
when dental fear, which the authors distinguished fiom
dental anxiery was considcrcd.ra Patienrs
-ith late onser
dental fear (fear onset,after rrge 1B years but before age
26 years) dernonstrated the strongest associarion bemeJn
potential aversive conditioning experiences such as caries
and tooth loss, and dental fear. Contrary to findings for
dental anxiery rhe authors reported that personaliry iraits
were more strongly associated with early onset dental
fear, yet the authors' distinction between dental anxiery
and dental fear was not convincing.
Research into the etiology of dental anxiety is hindered
by the lack ofstandard diagnostic criteria uni by the lack
of prospective study designs. At this time, conditioning
and modeling remain viable theoretical models, bui
constitutional factors also seem to be implicated.
STRATEGIES FOR
APPLICATION IN PRACTICE
Behavior Modification
Randomized controlled triais now support the effec_
tiveness of various behavioral interventions for treating
anxiety disorders.as Some triirls are considered to havl
met criteria established to define empirically supported
treatments for anxiery disorders, including exposure
therapy, relaxation, and cognitive behavioi ther-
apy.to o' It is not surprising ihat therapies based on
these methods also i-rave beer-r applied ro the treatment
of dental anxiety. Nearly all behaviorally based treat_
ment programs described in the literature rely not on
orre specific technique, but rather on a combi,-ration of
several behavioral techniques thirt are merged into a
behavioral treatment package (Chapter ti). On an
intuitive level, this should exrend the applicability and
amplif,, the effectiveness of treatmenr, bui it also makes
it difficult to assess the individual elemenrs of the
behavioral treatments that are commonly used to treat
dental arxiery.
Exposure,therapy includes various psychotherapeutic
techniques designed to diminish conditio,red fears by
repeatedly exposing a patient, in the absence of an
adverse experience, to a stimulus associated with stress.l
Exposure therapy is theoretically based on the premise
that fears a'e acquired through classical condiiioning.
_
In the case of dental anxiery thii premise is not universall"y
supported by research. Classical conditioning is a form of
learning in which a neutral stimulus (the dintal profes-
sional or gffice) is paired with a stimulus that reflexively
elicits anxiery (pain or_social embarrassment). This pair'-
ing is known as "reinforcement." Classical conditioning
theory further contends that the learned association
between the neutral and fear-eliciting stimuli can be
unlearned if the neutral stimuius is repeatedly presented
without the fear-eliciting stimulur, pro...i k,o*,-, *,
"extinction." Exposure therapy seeks "to break the learned
association by exposing the individual to the neutral
patient care prrr^
strm ulu while preven trng the occurrence of
elicitin tfo (reinforcing) timulus. The obj ectrve of
therapy is to irnmerse the ir-rdividual ln an
which extinction cirn occur.
Exposure therapy dates back to the 920s,1,
popularized as systematic desensitization ln the
try Toseph Wolpe The first step ln this
therapy lnterventron ls for the
Patlent and
collaboratively devise a graded hierarchy of
lmages. For the patlent wl rh dental anxiery, the
the low end of the hierarchy might be thinking
calling to schedule a dental appolntment, or
gettrng dresse d for a dental appotntment. Items
high end of the hierarchy might be rmaglnlng
an rnJectlon or periodo ntal probing. N,ext, the
taught serles of muscle-tensing and relaxing
intended to generate state of
The final stage depends on the
deep muscle relaxation ate lncompa tible
assumed that if
the patlent can marntarn deep
relaxatio n while rmagrnrng the SCCNC s on the fear
chy, the extlnction of the anxlefy will occur. In
st:19e, the P^ tle nt IS asst ted to enter state
muscle rela-xation whiie the therapist verball
v
lmage from the lorv end of the fear hierarchy.
patlent begins to feel anxlous he or she glves a
the therapis t wl thdraWS the lmage and e
relaxation. o nce the patlent rematns deeply
hile lmaglnrng one rtem frorn tl're
th eraptst suggests the next higher rtem on the
Th ts process conttnLles perhaps during several
un ril the Patlen t c 21n remarn deeply relaxed
lm agrnrng th e mo t fearful scenes withi n
hierarchy. A represenrarive example of
desensitization in the treatment of dental
provided by Klepac.re
A variant of systematic desensitization is
or her anxretv passes.Next, the P atlent might be
to examlne a mtrror and explorer. Later, the patrent
be glven an rnJectron syrl nge with only the cap
and allowed to closely examlne the lnstrument.
rh dental professional might dem onstrate
rnJectlon would be glven, uslng only the cap and
gen tle Pressure to the
8lngrva. Depending
patient's specific fears, graded exposure to a rub
or the sounds of a drill igh t be considered
the process every effort 1S made to encourage
and to place the pattent 1n a nonthreatening
to facilitate extrnctlon of the fe af, An elample
detailed xn .uxao desensitization protocol can be
Conyers et al. 50

,,rding is rrnothcr fbnr of cxp()sure therrrlty tl-rat
' c-\posurc tti a rniuti rnu rn - i n te s i ty, f car-ltroduci nu
r.r
r, firr rn extcnded tirnc.l The patie r-rt is confrontccl
' .c fiarccl ob.icct or situation eitl'rcr in aiao or
- r in'rrgined sccnes at lull strcngth ratl-rcr th:rn ir-r
b .rlges. The reesoning behind floodir-rg thenpy is
- reperceive
re prttient is allowed to escape the fearful sirurttior.r,
' ',,,'ill subside and negativcly rcinlbrcc rhc conrrccrit_rrr
h :-. the eliciting stimulus and the arxiety response.
:.4 has not been widely use d in treating dental f-e ar,
,.',-.,rks well with other types of arrxiety, including
phobiirs.
' .:...rtion therlpy lbcuscs on pror-notinl{ a deep
:cl:rxatior-r rcsponse, becrruse it is scen rs incor-r-r-
.r'rtlr :rnxicty. Mrirry rnxit>us pttict)ts cxpcricrrt.c
I tension when frlced .,vitl-r der-rtal tre:rtr.nent, and
- .,n training equips thern with a coping strategy
t help rranage irruxiery. Iir-rtry inttt a state of deep
. relaxation is a learned skili, which l:rter can be
: r cope with any an-xietv-provoking situation.
- :res relztration is taugl'rt usir.rg
the srrme r.nuscle
- -relaxing exercises r.rsed ir.r systerrirtic deser-rsitizir-
r\vever, tl-re emphrrsis more often is plirced on
. rela-xation through relir-xing nrental imagery.
- :--res biofeedback is added
to provide patienrs with
l!
,tion about physiological changes thar accorrpany
lh
,''reqi irnd sonletimes trrrir-ring in deep diirphra[nratic
:.g is added. Audiotapes containing eitl-rer ir-rstruc-
F
' : progressive deep musclc reirrration cxercises or
I
. :rentirl irnages cirn be provided lbr home pracrice
r .patienrs
,. Whatever the specific rela-rarion rnethods used,
r -r '.lre encouraged to use leirrned relrrxation
skills to
f'
I ,:h stress or an-xicry.
lposed to the strict behaviorirl philosophy tl"rat
I ;bliclv observirble behaviors can be measured,
-. rne rs of cognitive bel-ravioral therapy acklowledge
I - rivate thotrghts and beliefi affect behavior.
::,,'e behavior therapy is based on a set of principles
:,cedures that assume a synergistic interaction
-:r cognitive rnental processes and behavior without
,rzing causation.l Cognitive behavioral therrrpists
'crse psycirotherapeutic techniques to alter the
: thought process and beiief sysrem. Patients are
- :o closely,self-monitor their thoughts and
acrions,
i'ith the aid of counters, checklists, or diaries.
' :11 :rssist patients to become aware of maladaptive
' ,,ns and actions and their context. Often patients
:ouraged to self-monitor what are called self-
:rrts-the statements people make to themselves
-ide their behavior. For instance, patients may not
l' .:e that they are engaging in irrational, catastrophic
I .q. When anticipating a dental appointment, they
t, .r,e the irrational idea that something catasrrophic
,)pen, for instance, that the dental professional will
::h the drill or syringe. The therapist will explain
:ntal treatment is not normally or necessarily asso-
,vith anxiery but that people can cause themselves
practitioners properly trained in their ad,rinirti^tion.ii
Chapter t2 7he fi:arful and Aobic Atient .
151
to become arxioLrs by.having negative and irrational
bcliefs about anticipatcd treatrnenr. If this perception
directly confronted, pali:n_rs m ay acknowt.ag, is
idea is irrationirl, but still feei the need to use
iil,',hi
avoidance
behavior. Such a patient might be instruced ," ,.ff.r""ii.,
the. irrational thou-ghts and be taught ways ro
their irratior-ral self*statements or recast their
a"Jr"*r.
beliefs. Th,ey are taught t9
lggnitively resrructure the
situation. The therapist rypically challenges ,h. .;i;#;
for the irrational beliefs, perhaps irf"r*uiii;
"ri.g
recorded by the patien_t during self_monitolrg.
*ofC"g"i.ir.
behavioral therapy often includes the ,r.
inrervenrion techniques. including self_distraffi
.;ili;
thought stopping or substirution and the ull of
coping
skills based on relaxarion, meditation
An example of a brief .ogniii,n. u.r,^ulo.^ropl"ll:itil;
treating dental anxiery is provided in De
Jongh ., .i.ji"'
Individual srudies report that behavio*l iit.*.ition,
are successful in more than 90yo of dental anxiety
p.;i;;;;
and that the success rate rlpically ranges b.dj;'ili;
and B0o/o.s2 A recent systemaiic reyiew r,iith meta_analysis
suggesred that such. estimares probably ,.. irn.[i.i]
The reviewers icientified . pooi of g0 relevara-r;;;,
but noted that few were of sufficient qrdiry to
ilcluded in the meta-analysis. The srudies ;.;; U.
heterogeneous that the authors were unable to
;;
pool thern
and fruitfully cornlare various rrearment approaches.
When self-reported change in dental ,nxiety'*;,
rneasureof a treatment outcome,_the majority'rf
;;
indicated that most
*aj.,
who underg"- b.h;;r;i
treatment report a reduction in theirun*ieqr. tf tir.
*.r.
objective criterion of act'al dental treatmeirt attencrance
was required as the definition of behaviorat
"."*.r,
success, however, the conclusions were 1.,, optimisti..
A need remains for well-designed, randomlr.a
trials of behavioral treatments for dental anxiety.-",rJi.i
Patients with dental anxiety may nor be willins
to n*
the cost of dental or behavioral rreatmenr.s., O.n ;":r:1
into a 10-week dental anxiety treatment ,*ay, pu,i.n,|
with dental anxiery were asked about theirciri.rq
willingness to pay for treatment. If a treatn
inctudlng .o-fin.,I der-rtat and an-xiery ..J.:il.orlt|}f;
nitrous oxide sedation, cognitive behavioral tfr.rupy,'0,
rela-xation was offered, only 24% of patients ,.id
i'h;y
be willing t9 pay the actual cosf of the rreatment.
:?."1d
they were asked the same_question at the completion
{hen
of the studyJl% said they would be willing to pay for the
treatment. This study suggests that th*e
"ir;ili.y'.f
patients who are in need of treatment Ar aentat
aniiery
are not willing to pay for it.
Medication
The American Dental Association confirms the efficacy
and safety of conscious sedation, deep sedation, and
genr-
eral anesrhesia in dentistry and. suppoirs their use
ny aJri^f
 152 ' Partrrl lssessment rtrirtegies to railur your
Pharmacological approaches to rrerrting dcntal arrxiety
l-rlve lor-rg been a comrr()n practicc. Evrrluation of tl-reir
cflicacy and ease of applicability befbre iidoption is
important. Four basic approachcs are used in dental
pructice: benzodiazepines, nitrous oxide cor-rscious sedrrtion,
intravenous (IV) conscious sedation, :rncl gener.al anesthesia.
Benzodiazepines and nitrous oxide are the more commonly
uscd approaches fbr tl're ge nerirl dentirl practitionei
whereas IV sedation and general anesthesia are reserrred
for practirioners with irdvanced degrees and oral and
maxillof-acial surgeons. Pain control needs to be distin_
guished frorn arxiety control when choosing medication.
Although rhese techniques may have stme varying
degrees of analgesic efl'ects, Iocai,/regional anesthesia ii
still used fbr pain control.
Ben-zodiazepines are commonly used because they are
cost-effbctive and easy ro use. Although multiple *.ii.r_
tions and routes of administration n.id to beionsidered,
the most cornmonly used approach is oral sedation given
as premedicarionto relieve anxiety during the plriod
lead.ing up ro and during the dental appoinime,,,t.
Midazolarn as a premedication has been cornpared with
behavioral
Tranagement techniques.s6,sT In ihis srudy,
patients in the behavior modification group were given
psychological rreatment 1 week before- the dlntal
appointment. Use of audiocassettes at home, behaviorirl
manage ment techniques such as progressive muscle
rela-xation, and a 1.5-hour offlce i,.,tei,entio,., session
teirchir-rg stress man agenl en t traini ng, rehxation traini ng,
and cognitive restructuring rve re included in the ,.".,Irr.i,
protocol. Patients in the prernedication Eroup were given
midazolam orally 30 minutes before their qppointrienr.
both groups experienced reduced leveis of anxiety
+lthoug.h
during their appointments when compared with the .o.r,rol
group, on the day after the appointment, the midazolam
group reported an increase in their fear, whereas the
behavioral management group reported both short-tenn
and more long-term reductions- in anxiety. Moreover,
when the patients were followed during , p.iiod of 1 yeai
to evaluate adherence and dental attenJance, it was found
that only-the psychologically rreated group had maintained
a reduced fear level and continued their iental treatment.
This study suggests that although short-term results of
the two techniques are equivalent, long-term results are
more highly associated with a behavi-oral approach. A
behavioral- approach to managing d.rriri anxiety
addresses the problem as opposedlo Lasking the prob'-
le.m by treating ryrrrpto*r with meclicationl However,
pharmaceutical approaches are invaluable ,,-rd h^rr.
tremendous applicability for patients in an ernergency
situation, for those who are mintally incapable of Ioop'_
erating with the dentist, or when a behavioral opprorih
can not be used.
One study, on the treatmenr of flight phobia,
compared alprazolam with behavior therapy anj found
that the use of alprazolam was in f".t .our"rt..productive
in the long term.58 Although alprazolam reduced
"..rt.iy
patiet-rt c.rre plu-,
sclf:reported irn-riety and rension on rhe first flighr. u
subscqucnt llight without rhe use of ,rlprazol,rm. ir
individuals reported increased anxiety and te:.,ii
compared witl-r the plrrcebo group. This inverse effe.-: q
obtair-red beciruse the medicaiion prevented bend
provicled by the gradual exposure t.ih.,iqrre. Succrd
exposure therapy relies or-r experiencing an_xiery bur d
the alprazolirm the patients did not expeiie.,ce {
anxiery and thus were unable to benefit f.om gra&
exposure to the feared situation. Are dental profess;rd
perpetuating the problem by r-rot treating the anxien uf
bel-ravioral techniques befbre using pharmaceur4
methods? Perhaps futu." research wfll'investigare
{
long-term eflbcts of using pharmaceutical therap! tcr{
treatmcnr of dental arxiety.
Nitrous oxide is an inhaled gas that can be used(
trained and certified dental professionals as a methrdi
conscious sedation. Conscious sedation is definec I
minirnaliy depressed level of consciousness that rrlJ
the. patient's abiliry to independenrly and continu{
m.aintain an airway:rnd respond appropriately to phr{
stimulation and verbal commands.5e A srudy eval,i,ntJ
rhc rnood-ultering cfibcrs of nitrous o*iae inf,a--uJ
found rhrrt its use "reduced dysphoria in patients {
high levels ofpreoperariue de.,tal anxiery r.rj
el.-d
mood to rhe sarne desree as that in paiients *ho "lro
anxious."('(r It rvirs concluded that nitio.rs oxid" l.,,se"*
{
cd
an effective therapv tbr reducing anxiery. Anorher s;u{
found thar nitrous oxide rvhen .o,l-,p,are8"*ith IV ,.c*{
produces a_ greater degree of an_xiery reduction d
-d
treatment.('1 Nitrous oxide, rvhen administered ,roJ
reduces arrxiery but long-term effects on anxiery p;.;r{
lre unknorvn
il
A recent prospective study compared ,ro.r{
controlled with clinician-controlled IV conscious ..*f
with propofof specifically.62 This technique invol.-es
use of an infusion pump, controiled by the pati.-m
{
deliver the needed dose (rnuch like the p"ti.,rt-.or-,rr{
{
morphine used in hospital sertings). The srudy i.r.rriitl
whether err-xiery levels carr be efGctively reducld
d.p.-.fl1
on whether the patient or the clinician .o.r,roil.. {
administration dosage of the medication being
Overdosing is a major concern with giving the"pr-.|
".1
control over sedation levels. Howeve.,"th. ,-.rrrltr'"r i
srudy concluded that patients controlling rheir
{
medication received significantly lower doses .3-p^..d qf
patients who received clinician-controlled
-.di.rJ
Wh:1 the patient could control their degree of sedr-il
the risk of excessive sedation was lower beiause the nr.r,J
was unable to push the trigger for more medi:,il
Altirough
.more patients prefeired the patient-.o.,oCl
sedation, the study failed L produc. , diff....,.. i.
level reduction between the patient-controlled g.orrp "*{dl
the clinician-controlled group. It was .orr.tid.j tl
although the acute psy.hJlogi.il response of dental
{
can be countered r',ii,rg ,.driion, the underlying pht
does not disapperrr.o2 ,[
 Aupter 12 7he ltarful and Aobic Atient 153

r.i.)thcr study cvaluatir-rg lV cor.tsciorts se datitlr-r
-.J lcss ty
'.rrr-rie rcdttctittrt ther-r bchrivitlr rlrotiiflt:rttion.
rtionally rnore prrtients trcrrtcd with IV scdrrtiorl
rrcd cler-rtirlly itttxiotts tl-r:ir-r p:lticnts tre'lted witl-r l
. ioral approrrch.('l llttturc ir-rvestigations should eval-
re interirction of combined psychological rnd phar-
. ,girrrl rtPP1r.ri11 l1g* to lnxicty ll)JIl:ll{cll)cl)t.
.t use of dcep scdatiott atld general lnestl'rcsit is
'-J to oral and rnzr-xiliofacial surgeor-rs and irdvanced
..: holding practitioners bet'ettse of tl-re addition'J tr';rir.r-
- :.rt is required to achieve certification. Thc' defi-rition
:cep sedation is ttt indr-rcecl state of depresscd con-
.:11e SS ilCCorrlpanied by p';rrtial loss oi
Pr()te Ltivc
,.es, including thc inebiliry to cor-rtinultlly nr,rintrrirl
:rvay ir-idependently, respond purposefully to verbirl
: ,'rnd, or both.5e The definition tlf generrrl lnesthesiir
. induced st2tte of ttnconsciottsncss ilcconlprrnied by
- .,1 or complete loss of protective retlexes, including
:litv to independently rr-ririntain rrn eirway and
rd purposefully to physicirl stirnulirtiou or verbrrl
,,r,lnd.5"
;onrpirrisot-t of tre irtt-t-reut grouPs rvl-ro reccivcd gene rirl
.:hesia or behaviorzrl therapy fottr-rd thirt both gror"rps
-iqnificrrntly reduced levels of arrxies'.t'* The behavioral
'-\, group had signiflctrtdv greirter reductior.rs of anxierv,
r acnraliv rc:rched the level of de ntal patients with
: to no irn-xieBr N'Ioreover, the Patients self:reported
::rrsion and ferver crrncellations :rnd broken irppoir-rt-
:s rvhen they rvere p:rrt of the bcl-rrn'ior'al n-rodific:rtiorl
- ,.,,rrrr,.1,, pl-ran'rt:rcolo{ica1 tl-re rarpies have bccn
'. n to be highli' effcctive in reducing dental rrnxictl;
:ially clurine tl-re sl-rort terrn. Tl-reir ease ol ttse irtld
:ica1 appiicatior-r in clinical Practice, have rendered
to be rvidelv used by der-ital professiot'rals. Wherr
:.';ired u,ith behirvioral m anage me nt therapy, howet'er,
:ilirceuticals tend to l-rave fewer long-term benefits
:rre associated witl-r greater relapse. Future research
:1d evaluate the lortg-terrn advantages and disadvantages
.ese ph:rrmacological treatment modalities to evalttate
: applicability in effectively reducing dental aruxicry.
trezltment, ask permission to cont2lct the therapist to dis-
cuss various treatment options. lt is likely that the thera-
pist will be abie to make specific recomrnendations to the
dentrl professional or address tl're patier-rt's dental arxiety
in thcir treatment domain.
It has been suggested that dentrrl professionals may be
somewhat reluctant to refer patients for behavioral
therapy.('s Referral letters of 115 patients who attended a
dental hospital in Scotland because of high dental arxiery
were reviewed. Of the referring dental professionals,
113 requested pharmacological an-xiety management for
their patients, and only two requested psychological
techniques. Of the patients, 290/o opted for psychological
the rapy when it was offered.
Although a substantial proportion of the population
admits to being arxious about receiving de ntal treatment,
only ir small fraction of these have strong fears that lead
to avoiding dental attendance. Researchers often focus on
the highly anxious patient who refuses dental care,
becauseclinic attendance can be used as an objective
outcome criterion. Little rlttention has been given to
questions about how to manage the n"rajoriry of patients
wiro routinely overcome their arxiety for the sake of
maintaining their oral health. A need exists for high-
quality srudies to ex:rmine strategies for making dental
treatment less traumatic for these patients. Although
crezrting a rela-xing atmosphere through verbal and non-
verbal communication, giving the p:rtient a sense of con-
trol over the situzrtion, distrirction techniques, avoidance
of threatening language, ar-rd other approirches are ofter.r
prornoted, little evidence exists to guide their use. As
shown in Figure 12-1, a. review of both psychological and
pharmacological approaches while tailoring choices for
interventions to the needs of the patient and the ski1l
level ol the dental practitioner should follow assessment
of arrxiery levels. All successful dental treatment will
depend on a cooperative reiationship between the patient
and the dental practitioner.
Dental anxiety

)LTMMARY
: .,'rrious reasons it may be necessary to refer the highly
Assessment Management
. ous patient to another health care practitioner fcrr
..,.r',.nt. A growing number of cotnmunities have
: ral anxiety specialty clinics, either within a dental
,ol or as a private clinic. If this option is r-rot available Dental Anxiety Behavior Medication
. Benzodazepines
Scale (DAS) modification
,r referral to a psycirologist familiar with treating or *
Exposure . Nitrous oxide
:ety disorders should be considered' Patients may be The tt/odified therapy .
Conscious
::iring fiom serious anxiery disorders that extend Dental Anxiety
Scale (MDAS)
'Flelaxation
.
Cognitive
sedation
. Deep sedation
. -,r',d ihe dental treatment setting and interferes rvith behavior
jr aspects of life. Referral to a psychiatrist or psychologist therapy
- t,.iher evaluation is recommended. Finally, if the
rent is receiving psychological treatment for an anxicry Figure 12-1 Assessment and management approaches
.,rder, and an arrxiety problem surfaces during dental for patients experiencing dental anxiety.
 154 ' Part llt /ssessmenr Jtrategies to zailor your patient care pran
lloy-Ilyrnc
R ,,*,rr* 24 Nlilgrom I),'l-rry K-M ct al.:
PP,
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lloutledgc.
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