Eur J Oral Sci 2003; 111: 99–105 Copyright
Eur J Oral Sci 2003

Printed in UK. All rights reserved European Journal of

Oral Sciences
ISSN 0909-8836

Kajsa Henning Abrahamsson1,

The importance of dental beliefs for the Ulf Berggren1, Magnus Hakeberg1,
Sven G. Carlsson2
outcome of dental-fear treatment 1
Department of Endodontology and Oral
Diagnosis, Faculty of Odontology, Gteborg
University, Sweden; 2Department of
Psychology, Gteborg University, Sweden
Abrahamsson KH, Berggren U, Hakeberg M, Carlsson SG. The importance of dental
beliefs for the outcome of dental-fear treatment. Eur J Oral Sci 2003; 111: 99–105.

Eur J Oral Sci, 2003

This study investigated the importance of dental beliefs and the predictive value of the
Dental Belief Survey (DBS) in dental-fear treatment. The sample comprised 117 adult
patients seeking treatment at a dental-fear clinic. Pretreatment data were collected
during a screening procedure, including two visits to the dentist. Outcome measure-
ments were completed after treatment. The dentist rated successful/unsuccessful
treatment outcome. Patients unsuccessful in treatment (n ¼ 48) reported more initial
negative dental beliefs, while patients successful in treatment (n ¼ 69) showed a larger Kajsa Henning Abrahamsson, Department of
decrease in negative beliefs between the first and second visit to the dentist. However, Endodontology and Oral Diagnosis, Faculty of
Odontology, Gteborg University, Box 450,
these differences were small. There was a significant difference between the groups at
SE)405 30 Gteborg, Sweden
visit two. Thus, patients unsuccessful in treatment reported more negative beliefs
about how dentists communicate. Regression analyses showed that improved dental Telefax: +46–31–7733125
beliefs during the first two visits to the dentist predicted dental-fear reduction, while E-mail: Kajsa.Henning.Abrahamsson
@odontologi.gu.se
longer avoidance time, female gender, low engagement in treatment, and depressed
mood increased the risk of unsuccessful treatment outcome. Our results suggest that Key words: dental beliefs; dental anxiety;
the DBS provides valuable information, and that patients’ subjective perceptions communication; psychological distress;
about how dentists communicate are important for treatment outcome. However, outcome
initial dental beliefs were not found to predict clinical treatment outcome. Accepted for publication November 2002

The expression of dental fear interacts with several gen-
eral psychological and social factors. Many investigations
have focused on different situational and technical pro-
cedures that anxious dental patients fear (i.e. pain, the
drill, vibrations, and the anesthetic needle). However, the
dental care situation also includes the social interaction
between the patient and the dentist (1). It has been found
that the majority of traumatic dental care experiences,
which gave rise to dental fear, could not be directly linked
to pain but rather to the dentist’s behavior and attitude
and the atmosphere at the clinic (2). Thus, other investi-
gations have focused on the patient–dentist relationship
and its assumed influence on treatment, most often
reflecting the view of either the patient or the dentist (3).
In order to assess how patients perceived dentist behavior
and delivery of care, Getz and coworkers developed a
Dental Belief Survey (DBS) (4). The instrument identifies
to what degree the patient perceives the behavior of the
dentist as contributing to, or constituting the reason for
the patient’s fear. The DBS has frequently been used and
has been shown to correlate significantly with dental fear
(5–8). However, the change in dental anxiety during
dental-fear treatment is not necessarily paralleled with a
corresponding change in dental beliefs (9).
Although different (behavioral) treatment methods
have been shown to be efficient in reducing dental fear,
some patients do not respond satisfactorily to treatment.
Several studies have shown that general psychological
distress may have a negative impact on treatment
outcome (9–13). An association between general psy-
chological distress and negative dental beliefs has been
suggested. Thus, Moore et al. (2) found that negative
dental beliefs among a subgroup of fearful dental
patients were associated with negative social experiences
in dentistry and with significantly higher levels of general
fearfulness. In a study by Berggren et al. (14) it was
found that general psychological distress assessed by the
Symptom CheckList (SCL-90-R) (15) accompanied
higher levels of negative dental beliefs. This relationship
was especially evident with regard to the depression and
hostility dimensions. Further, individual differences in
determining the strength of the anxiety response have
been proposed. It has been argued that patients high in
neuroticism may be more sensitive and consequently
require an even more considerate approach from the
dentist (16). Thus, general psychological distress may
influence patients’ perceptions and attitudes about den-
tists and about how dental care is delivered.
In order to further explore predictors of treatment
outcome, we found it valuable to investigate the
importance and predictive value of dental beliefs. Dental
beliefs may influence the development, manifestation and
treatment of dental fear. Moreover, a relationship
between negative dental beliefs and general psychological
distress has been suggested. It can therefore be hypo-
thesized that dental beliefs predict treatment outcome for
dental fear. Thus, the aim of the present study was to
investigate if initial dental beliefs, and changes in beliefs

100 Abrahamsson et al.
after meeting with the dentist, predict treatment outcome
among adult dental-fear patients. Our specific hypotheses
were that a larger decrease in DBS between the first and
the second visit to the dentist would predict (a) successful
treatment, and (b) greater reduction in dental fear.
Material and methods
Subjects and procedure
The subjects of the present investigation consisted of 117
adult patients consecutively selected among patients apply-
ing for treatment at a specialized dental-fear clinic at
the Faculty of Odontology, Göteborg University, Sweden.
A screening procedure ensured the selection of high dental-
fear patients (Corah’s (17) dental anxiety score ‡ 13) with
an estimated need of at least two restorations. Patients with
psychiatric diagnoses and/or present psychiatric treatment,
as well as major psychosocial problems were excluded (14).
All participants received information about the study and
an informed consent was required. The Ethics Committee of
Göteborg University approved the study.
Pre-treatment data was collected during the screening
process, which included interviews and examinations by
dentists and a clinical psychologist (14). The patients met
the dentist twice for interview and for examination and
therapy planning. Between these two visits to the dentist, the
patients saw the psychologist once for further screening and
questionnaires, and an X-ray examination was conducted at
the Radiology Department. Thus, 117 patients followed all
steps described above and met the criteria for inclusion in
this study.
The scheduled treatment protocol comprised behavioral
treatment with the psychologist, with a maximum of
eight treatment sessions, followed by three standardized
dental treatments. The dental treatments comprised scaling
during the first visit, and local anesthesia and restorations
during the second and third visits. One psychologist and
three dentists, all men, performed treatment.
Outcome measurements were completed after dental-fear
treatment and the dentist rated patients’ behavior, cooper-
ation and treatment ability on a 1–6-point scale (1 ¼ totally
relaxed, 6 ¼ patient refuses treatment) (18,19). A dentist
rating score of 3 (fair relaxation, treatment can be performed
with minor adjustment to patient reactions) or less indicated
a clinically successful treatment outcome (12). Sixty-nine
patients with a dentist rating of £ 3 were regarded as clin-
ically Ôsuccessful in treatmentÕ and were referred to general
practitioners in the city of Göteborg. Forty-eight patients
were regarded as Ôunsuccessful in treatmentÕ and were offered
further treatment at the specialist clinic. Among those a
limited number of subjects (n ¼ 14) completed the scheduled
dental treatments unsuccessfully (with a dentist rating of
> 3). However, the Ôunsuccessful groupÕ also comprised
patients that, for several stated reasons (fear, lack of finan-
ces, lack of time or not interested), were unable to go through
with dental-fear treatment at the time of the study (n ¼ 28)
or never showed up for treatment (n ¼ 6). ÔDrop-outsÕ were
most frequent early in treatment during the behavioral
therapy with the psychologist (12).
Assessments
Questionnaires investigated background data, including
dental anxiety, dental beliefs, general fear and anxiety,
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depressed mood, and motivation and willingness to engage
in treatment.
The variables investigated were gender, age, education level
and dental attendance pattern/last regular dental visit. Edu-
cation level was scored as follows: (a) 9 yr compulsory school
or less, (b) upper secondary school and (c) higher education.
Oral health effects were indicated according to the DMFT
index (Decayed, Missing and Filled Teeth). Clinical exami-
nations (commonly only visual inspection without probing
was possible) and radiographs were used. The criteria for
decay were manifest caries level 3–5, according to
Gröndahl et al. (20).
Dental anxiety was measured by two well-established
scales, the Dental Anxiety Scale (DAS) (17,21) and the
Dental Fear Survey (DFS) (22,23). The four-item DAS
assesses dental anxiety traits from 4 (no fear) to 20 (extreme
fear). The DFS consists of 20 items, scored from 1 (low
intensity) to 5 (high intensity), giving a range of total scores
from 20 to 100. The DFS assesses different dimensions of
dental fear (24,25).
Dental beliefs were assessed by Getz’s 15-item DBS (4),
exploring patients confidence in the interaction with the
dentist on a scale with sum of scores from 15 (highly pos-
itive) to 75 (highly negative). The validity and reliability of
DBS has been tested and confirmed in several studies (5–8).
For dental fear, patients’ pretreatment average item scores
of 3.3 and 3.2 have been presented (7,8). Four separate
dimensions of DBS (communication, trust, belittlement and
lack of control) have been suggested in order to capture the
specific clinical concerns of the patient (4). However, factor
analysis of DBS has indicated a three-factor solution,
including dimensions of communication, trust, and fear of
negative information (26).
General anxiety was assessed by the State–Trait Anxiety
Inventory (STAI) (27) and general fear was measured by the
Geer Fear Scale (GFS), which is a shortened and modified
version of the original Fear Survey Schedule-II (28,29).
The STAI scale measures both short-term fluctuation
(STAI-State) and levels of anxiety more stable over time
(STAI-Trait). Scores for both STAI subscales can vary from
a minimum of 20 to a maximum of 80 (27). The GFS scale
investigated number and levels of fears other than dental
fear in 32 items, scored from 1 (no fear) to 7 (totally terri-
fied). The GFS sum-score was used as an indicator of gen-
eral fearfulness (30).
Depression was measured with the Beck Depression
Inventory (BDI) (31). The BDI contains 21 items scored
0–3, forming a 0–63-point scale indicating level of depres-
sion. The BDI has become one of the most widely used
instruments for measurement of depression. The following
guidelines have been presented by the Center of Cognitive
Therapy (32): < 10 no to mild depression; 10–18 mild to
moderate depression; 19–29 moderate to severe depression;
30–63 severe depression.
In addition, before treatment, patients rated how likely
they thought it was that their fear could be cured on a scale
from 0 (not at all possible) to 10 (absolutely sure). Further,
patients made a 0–100% assessment of their motivation and
willingness to engage in treatment in relation to the fol-
lowing question ÔHow willing are you to engage in treatment
for your dental fear considering your life situation (family,
work, leisure activities and so on)?Õ.
Statistical analyses
The data was analysed with descriptive statistics, v2 analysis,
t-test and Mann–Whitney test for independent groups, as
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Importance of dental beliefs in treatment for dental fear 101

well as with bivariate and multiple regression analyses. 0.048), and pretreatment values of dental fear (DAS,
Spearman rank-order correlation coefficients were calculated q ¼ 0.32, P ¼ 0.000; DFS, q ¼ 0.41, P ¼ 0.000), STAI-S
for DBS and gender, age, last regular dental visit, DAS, DFS, (q ¼ 0.19, P ¼ 0.038), GFS (q ¼ 0.24, P ¼ 0.010) and
STAI-S-T, GFS, BDI, and motivation to engage and believe BDI (q ¼ 0.23, P ¼ 0.014).
in dental-fear treatment. Cronbach’s a reliability coefficients Table 2 shows data for dental fear (DAS and DFS)
were calculated to test the internal consistency of DBS.
Data analysis was processed by the SPSS statistical
and dental beliefs (DBS) from pretreatment assessment
package (33) and a P-value of 0.05 was considered the level at the first visit to the dentist, and for the DBS also
of statistical significance. assessment values at the second visit to the dentist
(comprising treatment planning). Both groups showed
comparably high initial dental-fear values (DAS and
Results DFS). Patients unsuccessful in treatment showed higher
DBS values, indicating more negative dental beliefs. At
Background data and oral status the second visit to the dentist, both groups showed a
The 117 patients (85 women) had a mean age of 33.3 yr decrease in negative dental beliefs, with a somewhat
and a mean avoidance time from regular dental care of larger decrease among patients successful in treatment.
9.7 yr. Forty-four (37.6%) patients had 9-yr compulsory However, there was no statistically significant difference
school or less, 46 (39.3%) upper secondary school edu- between the groups with regard to initial DBS or to
cation, and 27 (23.1%) had higher education. The decreased DBS values.
patients were grouped with regard to those clinically
successful (n ¼ 69) and unsuccessful (n ¼ 48) in treat-
ment for dental fear. Background data given in Table 1 Table 1
showed that men were significantly more successful in Description of the groups of patients investigated: clinically suc-
treatment than women (v2 ¼ 4.67, P ¼ 0.031). Patients cessful and unsuccessful in dental-fear treatment, with regard to
successful and unsuccessful in treatment reported an background data and oral status (DMFT)
average time since last regular dental treatment of 9.2 yr
Successful Unsuccessful
(7.8) and 10.6 yr (1.8), respectively. Twenty-three (n ¼ 69) (n ¼ 48)
patients reported that they had never managed regular
dental care. To include these patients in further analyses, Men 24 8
the avoidance variables were dichotomized according *
to the median value into £ 8 yr and > 8 yr since last Women 45 40
Education–
regular dental treatment. The 23 patients that reported
(a) 28 16
that they had never managed regular dental care were (b) 24 22
included in the > 8 yr group and did not differ in any (c) 17 10
significant way with regard to age or investigation group Last regular visit (yr)
distribution, compared with the others. There was no £8 35 16
statistically significant difference between the groups >8 34 32
with regard to education level, age, time since last regular Mean SD Mean SD
Age (yr) 34.2 10.1 32.1 8.3
dental visit, or oral status. DMFT 18.1 5.7 19.1 6.4
Decayed 6.5 4.5 7.3 5.5
Missing 1.9 3.2 2.4 3.4
Dental anxiety and dental beliefs
Filled 10.6 5.7 9.3 4.7
Correlation analysis (Spearman’s q) showed that pre-
The v2 and t-test were used for significance testing *(v2 ¼ 4.67,
treatment values of DBS-sum scores were significantly P ¼ 0.031).
correlated with gender, with women showing higher –Education level was scored (a) 9 yr compulsory school or less,
values (q ¼ 0.29, P ¼ 0.001), age (q ¼ )0.18, P ¼ (b) upper secondary school, (c) higher education.

Table 2
Pretreatment assessments of dental fear at visit one, and dental beliefs at the first and second visit to the dentist

Successful (n ¼ 69) Unsuccessful (n ¼ 48)

Mean SD Mean SD

Dental Anxiety Scale (DAS) 17.2 2.3 17.3 2.0

Dental Fear Survey (DFS) 77.4 11.7 80.3 10.5
Anticipatory anxiety 35.3 5.9 36.3 5.7
Physiological reactions 18.1 3.6 19.2 2.9
Situational anxiety 20.2 4.3 21.4 3.2
Dental Beliefs Survey (DBS)
Visit 1 36.5 13.4 40.1 14.9
Visit 2 33.8 12.7 38.0 13.1
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102 Abrahamsson et al.

Table 3
Pretreatment assessments of Dental Beliefs Survey (DBS) at the first visit to the dentist, separate item mean scores and standard
deviations, among patients clinically successful and unsuccessful in dental fear treatment

Successful (n ¼ 69) Unsuccessful (n ¼ 48)

Mean SD Rank Mean SD Rank

1. Dentists do not like patients’ requests 2.5 1.2 7 2.7 1.3 8

2. Dentists seem to be in a hurry, so I feel rushed 2.7 1.3 4 3.0 1.3 3
3. Dentists do not provide clear explanations 2.5 1.3 7 2.7 1.4 8
4. Dentists do not really listen 2.6 1.4 5 3.0 1.4 3
5. Dentists do what they want no matter what I say 2.5 1.4 7 2.7 1.4 8
6. Dentists make me feel guilty about how I care for my teeth 2.5 1.5 7 2.8 1.5 6
7. I am not sure I can believe what the dentist says 1.5 0.9 14 1.8 1.0 14
8. Dentists say things to try and fool me 1.5 0.9 14 1.7 0.9 15
9. Dentists do not take my worries seriously 3.3 1.4 2 3.3 1.4 1
10. Dentists put me down 1.7 1.2 13* 2.3 1.4 13
11. I worry if dentists are technically competent 2.1 1.3 12* 2.7 1.3 8
12. If it hurts I do not think the dentist will stop 2.6 1.4 5 2.8 1.6 6
13. I do not feel I can stop for a rest during treatment 3.4 1.5 1 3.3 1.6 1
14. I do not feel comfortable about asking questions 2.4 1.4 11 2.5 1.4 12
15. The thought of hearing bad news could be enough to finish a treatment 2.8 1.5 3 2.9 1.4 5

*t-Tests were used for significance testing. Item 10, t ¼ )2.24, P ¼ 0.027; item 11, t ¼ )2.16, P ¼ 0.033.

Table 3 shows that the rank orders of DBS items
followed the same pattern in both groups, even though
patients unsuccessful in treatment showed somewhat
higher values for all items, except item 9, ÔDentists do
not take my worries seriouslyÕ, and item 13, ÔI do not
feel I can stop for a rest during treatmentÕ. The highest
ranked DBS items were item 9 and 13. There was a
significant difference between the groups for the lower-
ranked item 10, ÔDentists put me downÕ (t ¼ )2.24,
P ¼ 0.027), and item 11, ÔI worry if dentists are tech-
nically competentÕ (t ¼ )2.61, P ¼ 0.033), with higher
values among patients unsuccessful in treatment. Item 7
ÔI am not sure I can believe what the dentist saysÕ and
item 8 ÔDentists say things to try and fool meÕ which
were both related to trust, were the lowest-ranked items
in both groups. There were no statistically significant
differences between the groups with regard to DBS
dimensions or factors suggested by Milgrom et al. (4)
and Kulich et al. (26) at the first visit to the dentist.
However, there was a significant difference between the
groups at visit two with regard to the original dimen-
sion (4) and the factor (26) ÔcommunicationÕ. Thus,
patients clinically successful and unsuccessful in treat-
ment showed DBS communication item mean values
and standard deviations (SD) according to Milgrom
and Kulich of 2.4 (0.9) and 2.8 (1.0) (t ¼ )2.10,
P ¼ 0.038); and 2.3 (0.9) and 2.8 (0.9) (t ¼ )2.70,
P ¼ 0.008), respectively.
The a reliabilities among the belief survey scores were
generally high, with a Cronbach’s a coefficient of 0.93.
General fear, anxiety and depression
Both groups showed mean levels in pretreatment data
with regard to general fear (GFS) and anxiety (STAI-T)
in accordance with earlier reports for dental phobic
patients. The state anxiety (STAI-S) group mean levels
were somewhat lower than those reported elsewhere
(Table 4). Even though the patients unsuccessful in
treatment showed higher values with regard to GFS and
STAI-T these differences were limited and statistically
non-significant. The BDI values indicated no depression
to mild depression in both groups. However, there was a
significant difference (t ¼ )2.94, P ¼ 0.004) between the
groups with regard to BDI, with higher values among
patients unsuccessful in treatment (Table 4).
Motivation and beliefs in treatment
Both groups reported a generally high motivation and
belief in treatment for dental fear. Even so, patients
successful in treatment showed a significantly greater
willingness to engage in dental-fear treatment
(Z ¼ )3.34, P ¼ 0.001) (Table 4).
Regression analyses
Logistic regression analyses were performed in order to
explore predictors of successful and unsuccessful treat-
ment outcome. For statistical reasons, initial bivariate
analyses preceded the multiple regression in order to
avoid the inclusion of too many variables. Thus, the
following independent variables were used in the
regression analyses: gender, age, education, last regular
dental visit, DAS, DBS, GFS, BDI, and willingness to
engage. Before entering the logistic equation, the varia-
bles age and willingness to engage in treatment were
transformed into categorical variables. Thus, age was
trichotomized as (a) 20–28 yr (40%), (b) 29–39 yr
(33.5%), and (c) ‡ 40 yr (26.5%), while willingness to
engage were dichotomized according to mean value in (a)
0–80%, and (b) > 80%. Dental beliefs were included,
and indicated by the changes in DBS between visits one
and two, to estimate the importance of the initial meeting
with the dentist for treatment outcome. The final model
(Table 5) shows that last regular visit (P ¼ 0.013;
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Importance of dental beliefs in treatment for dental fear 103

Table 4
Pretreatment assessments of general fear, anxiety, depression, and willingness to engage and believe in dental fear treatment, among
patients clinically successful and unsuccessful in treatment for dental fear*

Successful (n ¼ 69) Unsuccessful (n ¼ 48)

Mean SD Mean SD

GFS 77.7 23.7 84.8 22.9

STAI-S 40.0 10.3 39.6 12.6
STAI-T 36.8 10.1 40.1 11.6
BDI 5.2 5.2 8.9 7.4–
Willingness to engage 85.7 21.7 75.0 21.6
Belief in fear remedy 8.1 1.8 7.6 2.5

*GFS, Geer Fear Scale; STAI-S, State–Trait Anxiety Inventory–State; STAI-T, State–Trait Anxiety Inventory–Trait; BDI, Beck
Depression Inventory.
–t-Test; t ¼ )2.93, P ¼ 0.004.
Mann–Whitney; z ¼ )3.34; P ¼ 0.001.

Table 5
The final model of the logistic regression (forward stepwise) predicting successful (0) vs. unsuccessful (1) treatment outcome*

Variable B SE Wald df P OR CI

Last regular visit 1.16 0.47 6.20 1 0.013 3.2 1.28–8.00

Willingness to engage 1.46 0.46 10.32 1 0.001 4.3 1.77–10.56
Gender 1.09 0.53 4.24 1 0.039 3.0 1.05–8.33
BDI 0.07 0.04 3.67 1 0.055 1.1 0.99–1.15

*OR, odds ratio; CI, 95% confidence interval. Nagelkerke R2 ¼ 0.27; Hosmer & Lemeshow goodness of fit v2 ¼ 3.21, df ¼ 8,
P ¼ 0.92. PAC-sensitivity (mean predictive values among classes) overall ¼ 69.2%.

Table 6
The final model of the linear regression (forward stepwise) predicting decrease in dental fear (Dental Anxiety Scale, DAS) from the first
assessment to outcome measurement after dental fear treatment

Variable B SE b t P

Constant 8.30 0.52 15.88 0.000

Beck Depression Inventory (BDI) )0.15 0.06 )0.28 )2.58 0.012
Dental Beliefs Survey (DBS) (DBS visit1 ) DBS visit 2) 9.83 0.05 0.22 2.00 0.049

n ¼ 82; R2 ¼ 0.11; adjusted R2 ¼ 0.085; F2,79 ¼ 4.7.

odds ratio (OR) ¼ 3.2), willingness to engage (P ¼
0.001; OR ¼ 4.3) and gender (P ¼ 0.039; OR ¼ 3.0)
significantly predicted dental-fear treatment outcome,
but also that there was an increased (but non-significant)
risk for unsuccessful treatment with higher pretreatment
values of BDI (P ¼ 0.055; OR ¼ 1.1). Thus, longer
avoidance time from regular dental care, low engagement
in treatment, female gender, and depressed mood
increased the risk for clinically unsuccessful treatment
outcome. The model showed an overall good fit
according to the measure of Nagelkerke (R2 ¼ 0.27) and
Hosmer & Lemeshow statistic (v2 ¼ 3.2; P ¼ 0.92).
Finally, to predict decrease in dental fear (DAS) from
the first assessment to outcome measurement after den-
tal-fear treatment, a linear regression analysis was per-
formed. The predictor variables were, with exception of
DAS, the same as those used in the logistic regression
analysis. The final model of the forward stepwise pro-
cedure (Table 6) showed that BDI (t ¼ )2.58,
P ¼ 0.012) and a decrease in DBS scores between visits 1
and 2 (t ¼ 2.00, P ¼ 0.049) significantly predicted
dental-fear reduction. Thus, a depressed mood seemed to
counteract dental-fear remedy, while improved dental
beliefs (DBS) after meeting with the dentist predicted
greater dental-fear reduction. However, the level of
explained variance in this model was low.
Discussion
The present study was part of a longitudinal treatment
study of dental-fear patients seeking treatment at a spe-
cialized dental-fear clinic in Göteborg, Sweden (14). The
specific aim was to investigate if initial dental beliefs, and
changes in beliefs after meeting with the dentist, predict
treatment outcome among adult dental-fear patients.
Different behavioral treatment regimens have been
shown to be efficient in reducing dental anxiety (3,34).

104 Abrahamsson et al.
However, a review of the literature found that
approximately 25–30% of patients do not benefit or
cannot follow through with dental (fear) treatment (34).
In our study, 41% of patients were regarded as
unsuccessful in treatment. This higher figure may be
explained by the study design, where all patients that
followed screening and agreed to participate in the
treatment study were included. It may also be due to
methodological differences between studies, i.e. how
success and failure were estimated. In this study, the
dentist that rated patient’s behavior, cooperation, and
treatment ability judged a clinically successful treatment
outcome (18,19).
Although all patients successful in treatment were
referred to general dental practitioners, this study did not
consider whether patients continued to receive regular
dental treatment after leaving our clinic. Moreover,
nothing is known about what happened subsequently to
those patients that decided not to go through with den-
tal-fear treatment at the time of the study. Aartman
et al. (10) and Kvale et al. (9) investigated dental anxi-
ety reduction and dental attendance after treatment in a
dental-fear clinic and found that although a reduction in
dental anxiety level took place, 37–38% of the patients
had not visited a general dental practitioner at follow-up
1 yr later. This reflects the complexity of dental fear and
dental visiting habits, and the importance of also asses-
sing dental-fear treatment outcome in a long-term
perspective.
One expression of general psychological and emo-
tional distress may be a more negative attitude to den-
tists and to how dental care is delivered (2,14,16). Thus,
as suggested by Moore et al. (2), for some patients
distrust of dental personnel may be reinforced by trait
anxiety and general fearfulness, depending on what the
person had heard or experienced and the focus of their
speculations. A statistically significant relationship
(although with low correlations) between pretreatment
assessments of DBS, GFS and BDI was confirmed in the
present study.
Both groups showed initially high values of negative
dental beliefs. Even so, patients unsuccessful in treatment
reported more initial negative dental beliefs and patients
successful in treatment showed a larger decrease in neg-
ative beliefs between the first two visits to the dentist.
However, these differences were small and statistically
non-significant. Item analyses showed that the initial
rank orders in DBS items followed the same pattern in
both groups. Nevertheless, patients unsuccessful in
treatment reported to a significantly higher extent that
they Ôworry if the dentist is technically competentÕ and
had feelings of inferiority and social embarrassment in
relation to dentists (Ôdentists put me downÕ). Moore
et al. (2) argued that social embarrassment could be seen
as a major catalyst for maintenance of dental fear, and
that it seems necessary to emphasize the role of the
dentist in treating these patients. Thus, the early meeting
between the dentist and the dental (fear) patient is crucial
for this specific relationship and for treatment outcome.
Kulich et al. (35) explored the dentist–patient interac-
tion in consultations with patients visiting a dental-fear
16000722, 2003, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1034/j.1600-0722.2003.00016.x by University Of Debrecen, Wiley Online Library on [12/10/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
clinic and found that the dentist’s professional and in-
terpersonal skill, as well as the patient’s verbal and non-
verbal cues and emotions were important aspects of the
dentist–patient encounter. In the present study, assess-
ments of DBS at the second visit to the dentist showed
significantly more negative beliefs about how the dentist
communicates among patients unsuccessful in treatment.
Our results indicated that the first meeting with the
dentist, and patients’ subjective perceptions about how
dentists communicate are important factors in dental-
fear treatment. Thus, even though recent research (26)
has proposed the use of DBS as an overall measure of
dental beliefs, this study has indicated that at least the
DBS communication factor can provide valuable infor-
mation for the treatment of dental fear and for predic-
tion of treatment outcome. However, for psychometric
properties, the underlying factor structure of DBS has to
be further established (26).
Regression analyses showed that improved dental
beliefs (between the first and the second visit to the
dentist) predicted dental-fear reduction, but also that
there were several important factors to consider that may
impact on dental-fear treatment and treatment outcome.
Thus, even though patients reported a generally high
motivation for treatment, our analyses confirmed that
willingness to engage seemed to be crucial for a suc-
cessful treatment outcome. In a previous study it was
shown that a low engagement usually manifested early in
treatment, and drop-outs during the psychologist’s
intervention were common (12). Further, although
assessment of BDI indicated no to mild depression,
depressed mood increased the risk for unsuccessful
treatment outcome. It has been argued that with pro-
longed phobic dental avoidance, social conflicts (i.e. guilt,
embarrassment, and inferiority) reinforce anxiety and
result in further avoidance and social withdrawal, with
subsequent consequences for health and well-being
(2,36). The importance of such psychosocial processes in
the maintenance and treatment of dental fear needs
further attention.
The effect of gender on treatment outcome was inter-
esting and, to our knowledge, has not been described
previously. It is well known that women report more
dental fear, as well as more general emotional distress,
than men. This was also found in our analyses (data
not presented). Looking at other areas, Weinstock (37)
reported on gender differences in the presentation and
management of social anxiety disorders. Although most
studies indicate that more women suffer from social
anxiety disorders, men are more likely to seek treatment.
This was discussed in relation to gender roles and social
expectations, and this may also have implications for
dental-fear patients. Another factor to consider may be
the effect of patient gender and therapist gender with
regard to treatment outcome. In the present study all
therapists were men. However, even though contradict-
ory results are reported, much of the evidence suggests
that the association between patient/therapist gender and
treatment outcome is weak (38).
In conclusion, dental beliefs are one among several
interacting factors in the treatment of dental fear. Thus,

Importance of dental beliefs in treatment for dental fear
initial DBS values were not found to predict clinical
treatment outcome. However, our results suggest that
the assessment of dental beliefs provides valuable infor-
mation for the treatment of dental fear, and that the
early meetings with the dentist, as well as patients’ sub-
jective perceptions about how dentists communicate are
important for treatment outcome.
Acknowledgements – This study received support from the
National Institute of Dental Research, NIH, USA (grant DE
08296), the Swedish Medical Research Council (grants 11335,
11259, and 13449), and the Swedish Foundation for Health,
Care, Science and Allergic Research (V96,206, V2000,073, and
V2000,099).
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