Eur J Oral Sci 2013; 121: 225–234 Ó 2013 Eur J Oral Sci

DOI: 10.1111/eos.12032 European Journal of

Printed in Singapore. All rights reserved
Oral Sciences

Review
Ulla Wide Boman1,2, Viktor
Psychological treatment of dental Carlsson1,2, Maria Westin3, Magnus
Hakeberg1,2
anxiety among adults: a systematic 1
Department of Behavioral and Community
Dentistry, Institute of Odontology, The

review Sahlgrenska Academy, University of

Gothenburg, Go €teborg, Sweden; 2Public
Dental Service, Region Va €stra Go
€taland,
Clinic of Oral Medicine, Go€teborg, Sweden;
3
Public Dental Service, Region Va €stra
Go €
€taland, Clinic of Oral Medicine, SU Ostra
Wide Boman U, Carlsson V, Westin M, Hakeberg M. Psychological treatment of
Hospital, Go€teborg, Sweden
dental anxiety among adults: a systematic review.
Eur J Oral Sci 2013; 121: 225–234. © 2013 Eur J Oral Sci
The aim was to investigate the efficacy of behavioural interventions as treatment of
dental anxiety/phobia in adults, by conducting a systematic review of randomized
controlled trials (RCTs). The inclusion criteria were defined according to the
Patients, Interventions, Controls, Outcome (PICO) methodology. The study samples
had documented dental anxiety, measured using validated scales [the Dental Anxiety
Scale (DAS) or the Dental Fear Survey (DFS)], or fulfilled the psychiatric criteria
for dental phobia. Behavioural interventions included were based on cognitive
behavioural therapy (CBT)/behavioural therapy (BT), and control conditions were
defined as information, sedation, general anaesthesia, and placebo/no treatment. Ulla Wide Boman, Department of Behavioral
The outcome variables were level of dental anxiety, acceptance of conventional den- and Community Dentistry, Institute of
Odontology, The Sahlgrenska Academy,
tal treatment, dental treatability ratings, quality of life and oral health-related qual-
University of Gothenburg, PO Box 450,
ity of life, and complications. This systematic review identified 10 RCT SE-405 30 Go €teborg, Sweden
publications. Cognitive behavioural therapy/behavioural therapy resulted in a signif-
icant reduction in dental anxiety, as measured using the DAS (mean differ- E-mail: ulla.wide-boman@odontologi.gu.se
ence = 2.7), but the results were based on low quality of evidence. There was also
some support that CBT/BT improves the patients’ acceptance of dental treatment Key words: adult; behaviour therapy; cognitive
more than general anaesthesia does (low quality of evidence). Thus, there is evi- behaviour therapy; dental anxiety; systematic
dence that behavioural interventions can help adults with dental anxiety/phobia; review
however, it is clear that more well-designed studies on the subject are needed. Accepted for publication January 2013

The prevalence of dental anxiety is around 20% in dif-
ferent population-based studies (1–7). Severe dental
anxiety, including dental phobia and avoidance of den-
tal care, has been reported to be approximately 5% in
the general population (8, 9). Dental anxiety is similar
to specific phobias because of the pronounced avoid-
ance tendencies and because it interferes in several ways
with the afflicted person’s life (10, 11). Furthermore,
the condition often presents serious problems to the
providers of dental care (12). Studies in population and
clinical samples show that severe dental anxiety is
related to poor dental health (13–19). Psychological
and social problems may also be present in individuals
with long-standing dental anxiety. Negative conse-
quences in social relationships have been reported, and
such negative consequences may include embarrassment
about poor oral health and reduced self-confidence, as
well as increased frequency of sick-leave/absence from
work and less involvement in social contexts (20–23).
BERGGREN (24) has presented a biopsychosocial vicious-
circle model to describe how severe dental anxiety,
together with its psychosocial concomitants, shapes and
maintains severe dental anxiety over time.
The terms dental anxiety and dental phobia are often
used interchangeably to denote individuals with severe
dental anxiety and a behaviour pattern of avoidance of
dental care. Severe dental anxiety is commonly defined
by the use of cut-off points on validated self-report
scales, while a phobia is defined according to criteria in
psychiatric manuals (25).
Adult patients with severe dental anxiety may be
referred to Special Care Dentistry Clinics/Clinics of
Oral Medicine. These clinics usually provide adapted
dental care, including different types of sedation (gen-
eral anaesthesia, and nitrous oxide-, intravenous, and
peroral sedation), and, to a varying degree, behavioural
interventions for treating dental anxiety. These methods
can be combined to customize individual treatment
strategies. Treatment of dental anxiety has the aim to
decrease dental anxiety and facilitate conventional den-
tal care in the short- and long-term perspective.
Behavioural interventions applied in the dental setting
are often based on principles from learning, social
learning, and cognitive theory (26). Behavioural ther-
apy (BT)/cognitive behavioural therapy (CBT) is the
most accepted form of psychological treatment for

226 Wide Boman et al.
anxiety related to particular situations and objects (27,
28). Both behavioural interventions (such as exposure,
systematic desensitization, and relaxation) and cognitive
interventions (such as cognitive restructuring) fall under
the general term of CBT, and, in clinical practice, they
are often combined (27, 28).
In general, there is a need, within the health-care sys-
tem (both in medical care and in dental care) to evalu-
ate different types of treatment for diseases and
conditions. The obvious reason is that the best treat-
ments should be used routinely with regard to effective-
ness, cost, and patient-related outcomes. Moreover, it
is equally important to reduce, or even terminate, the
use of ineffective treatment methods. The current stan-
dard when evaluating health-care techniques is system-
atic reviews applying strict protocols according to the
Cochrane standard, for example, to scrutinize scientific
papers that report on specific treatments and methods
(29–31). Studies conducted using a randomized con-
trolled trial (RCT) design are considered to provide the
most reliable evidence when investigating the efficacy of
different interventions (32).
In a previous systematic review of behavioural inter-
ventions for dental anxiety in adults, published in 2004,
the authors concluded that, despite extensive heteroge-
neity, the changes in dental anxiety represented medium
to large effect sizes, and the effects were generally lasting
(26). This review was based on a literature search in two
databases, PubMed and PSYCHLIT, of papers published
from 1966 to 2001 (26). The review included different
study designs, and no systematic evaluation of study
quality was made. To the best of our knowledge, there
are no recent systematic reviews/meta-analyses of the
efficacy and/or effectiveness of behavioural interventions
as a treatment mode for dental anxiety/phobia in adults.
The aim of the present study was to investigate the
efficacy of behavioural interventions as treatment of
dental anxiety/phobia in adults. This was carried out by
conducting a systematic review applying a strict meth-
odology and using the Health Technology Assessment
(HTA)/Cochrane/the Grading of Recommendations
Assessment, Development and Evaluation (GRADE)
model (30, 31, 33), based on RCTs and with strict crite-
ria to validate patient selection as well as the internal
and external validity of the trials.
In this paper, we focussed on BT and CBT as broad
descriptors of the type of behavioural interventions of
interest to evaluate treatment of dental anxiety. To nar-
row the research question it was decided to evaluate
whether behavioural interventions based on CBT/BT
are effective for the treatment of dental phobia or den-
tal anxiety, compared with information on dental care,
sedation, experience of dental treatment under general
anaesthesia, or placebo/no treatment.
Material and methods
This project comprises a systematic review and a meta-
analysis.
16000722, 2013, 3pt2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/eos.12032 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
Inclusion criteria
The inclusion criteria were defined according to the
Patients, Interventions, Controls, Outcome (PICO) meth-
odology (31). The inclusion criteria were as follows: docu-
mented severe dental anxiety of the study population, as
measured using validated psychometric scales or fulfilling
the criteria for dental phobia according to psychiatric man-
uals [Diagnostic and Statistical Manual of Mental Disor-
ders, 4th edition (DSM-IV) (34) or the International
Classification of Diseases, Tenth Revision (ICD-10) (35)];
intervention being based on CBT or BT, including expo-
sure therapy, systematic desensitization, or relaxation ther-
apy; the presence of a control condition, specified as
information, sedation, general anaesthesia, or placebo/no
treatment; the following specified outcome variables: level
of dental anxiety (measured using validated scales), accep-
tance of conventional dental treatment (without sedation),
dental treatability ratings, quality of life and oral health-
related quality of life, and complications; and RCT and
systematic review as the study design.
The validated self-report scales measuring dental anxi-
ety that were used in the studies were the Dental Anxiety
Scale (DAS) (36) and the Dental Fear Survey (DFS)
(37). The DAS consists of four items describing imagi-
nary dental situations including ‘appointment tomorrow’
and different treatment situations. In this scale, responses
are scored from 1 (no anxiety) to 5 (extreme anxiety),
giving total scores of 4–20. Dental Anxiety Scale scores
of 8–9 have been reported in the general population, and
DAS scores of 13 or above have been reported among
dental anxiety patients (38–40). The DFS consists of 20
items covering anticipatory anxiety, physiological reac-
tions, and situational anxiety. In this scale, responses are
scored from 1 (no anxiety) to 5 (high intensity of anxi-
ety), giving a total score of 20–100. The subscales antici-
patory anxiety, physiological reactions, and situational
anxiety have been confirmed by factor analysis (41).
Average DFS scores range from 35 to 45 in the general
population and are above 60 in patients with extreme
dental anxiety (40).
Literature search and selection
An electronic literature search was performed of the data-
bases PubMed, The Cochrane Library, Embase, CINAHL,
and PsycINFO, and of a number of HTA databases, from
January 1970 to August 2011. English, Danish, Norwe-
gian, or Swedish publications were accepted. The main
MeSH terms used were ‘Dental Anxiety’, ‘Behaviour Ther-
apy’, ‘Cognitive Therapy’, ‘Desensitisation, Psychological’,
and ‘Relaxation Therapy’. The MeSH terms and the full
search strategies in are given in Table S1. Reference lists
of relevant articles were scrutinized for additional refer-
ences. After removal of duplicates, a total of 990 articles
was identified, of which 848 abstracts were excluded. After
evaluating the remaining 142 articles, another 86 articles
were excluded. Fifty-six articles were sent to the work
group for assessment. Ten of these articles were included
in the present analysis. (See Supporting Information for
excluded references no. 54–98.) Two librarians at the
regional HTA centre in Region V€ astra G€
otaland, Sweden,
conducted the literature searches and excluded the
abstracts in consultation with the authors. A flow chart of
the literature search and the selection procedure is pre-
sented in Fig. S1.

Rating of quality of individual studies
The articles included in the report were critically appraised
according to their scientific quality, using a checklist for
RCTs from the Swedish Council on Technology Assess-
ment in Health Care (33), which is in accordance with the
principles used at other HTA centres globally and follows
the CONSORT checklist (32). The criteria covered exter-
nal and internal validity and study precision (33), formu-
lated in 35 questions covering study population (eligibility,
and exclusion before randomization); allocation to inter-
vention (randomization method and implementation);
result of randomization (if groups were comparable on rel-
evant variables); blinding (of patients, providers of treat-
ment, and evaluators); dropouts (number, and reasons for
dropout); compliance with treatment; measures of primary
and secondary effects and complications (prespecified, ade-
quately reported); results and precision (adequately
reported, power analysis); and conflicts of interest. Each
question was answered on a four-grade scale (acceptable,
unclear, non-acceptable, and non-applicable), and an over-
all quality rating was then assigned to each study, as high,
moderate or low quality, following the Swedish Council
on Technology Assessment in Health Care checklist (33).
Rating of evidence across studies
The quality of the evidence obtained for each outcome
measure specified for this literature review was rated
according to GRADE (30, 31), taking into account the
summarized quality of all studies providing results for the
outcome. The quality of the evidence for each outcome
was assessed at four levels (31): high grade ( ) was
defined as a high level of confidence in the evidence reflect-
ing the true effect, meaning that further research is very
unlikely to change our confidence regarding the effect esti-
mate. Moderate quality ( ) was defined as moder-
ate confidence in the evidence reflecting the true effect,
and that further research could change our confidence in
the effect estimate and may change the estimate. Low
grade ( ) was defined as low confidence in the evi-
dence reflecting the true effect, with further research being
likely to change the confidence in the effect estimate and
also likely to change the estimate. Insufficient grade
( ) means that evidence is either unavailable or
does not permit estimation of an effect. The collective judg-
ment of the strength of the evidence was based on the
following criteria (31, 33): study limitations; consistency;
directness, precision; publication bias; magnitude of effect;
and other important factors, such as dose–response gradient.
Each included article and the evidence for each specified
outcome was assessed individually by at least three review-
ers, and overall assessments were then agreed upon by all
authors. Disagreements were solved by consensus.
Statistical analysis
Weighted mean differences were used for continuous out-
comes. Statistical heterogeneity between trials was deter-
mined using the chi-square test and the I2 statistic
(P > 0.1, I2 < 25) (42). A funnel plot was used to examine
publication bias. Statistical analyses were performed using
Review Manager (REVMAN) [Computer program]. Version
5.1. Copenhagen: The Nordic Cochrane Centre, The
Cochrane Collaboration, 2011.)
16000722, 2013, 3pt2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/eos.12032 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
A systematic review of dental anxiety therapy 227
Results
The systematic literature review identified 10 RCT pub-
lications, comprising seven different trials (43–52), that
fulfilled the inclusion criteria. Five of the publications
originated from two different RCTs. BERGGREN & LIN-
DE (43) and BERGGREN (44) compared BT with dental
care under general anaesthesia. The BT was given by a
psychologist, with each patient receiving an average of
six sessions. WILLUMSEN et al. (50,51) and WILLUMSEN
& VASSEND (52) compared three different treatments in
10 sessions performed at weekly intervals: CBT, applied
relaxation, and nitrous oxide sedation. A CBT-trained
dentist gave the treatment. DE JONGH et al. (45) evalu-
ated a one-session cognitive treatment method, infor-
mation, and a waiting-list condition. The treatment was
given by a dentist/psychologist. GATCHEL (46) tested a
30-min videotaped dental anxiety-reduction programme
with behavioural techniques vs. a placebo condition.
GETKA & GLASS (47) compared BT and CBT with posi-
tive dental experience and with a waiting-list condition.
The treatments comprised six sessions given by a grad-
uate psychology student. HAUKEBØ et al. (48) tested
one- and five-session exposure treatments vs. a waiting-
list condition. A dentist with special CBT training pro-
vided the treatment. MOSES & HOLLANDSWORTH (49)
tested stress inoculation, coping skills, education alone,
and a waiting-list condition. The treatment was pro-
vided by a psychologist in one session lasting 2.5–3.5 h.
All 10 publications evaluated treatment effects on
dental anxiety, using the DAS (43–52) (Table 1). Four
of the publications also evaluated the treatment effect
on dental anxiety using the DFS (48, 50–52) (Table 2).
Four studies were of moderate quality (43, 44, 50, 51)
and six of low quality (45–49, 52).
Effect on dental anxiety post-treatment
Meta-analyses of the post-treatment effect on dental
anxiety measured using the DAS were performed for
the five studies providing enough data (43, 45, 48–50),
and showed a statistically significant decreased level of
dental anxiety with a mean DAS score of 2.7
(P < 0.0001) (Table 3). When the studies were subdi-
vided according to type of control, decreased DAS
scores were seen, with a mean of 2.0 for CBT/BT com-
pared with anaesthesia/sedation (two RCTs, n = 161)
(P = 0.0006), and a mean of 3.3 DAS scores for CBT/
BT compared with no treatment (three RCTs, n = 86)
(P = 0.001) (Table 3). The two studies not included in
the meta-analysis also showed lower dental anxiety lev-
els for intervention compared with controls (46, 47).
Two studies also reported a post-treatment effect on
dental anxiety as measured using the DFS scale (48,
50). One of the studies demonstrated a statistically sig-
nificant reduction in dental anxiety (48). No meta-anal-
ysis could be performed for outcomes measured using
the DFS scale, as a result of inconsistencies of the
reported data (different subscales and/or different ver-
sions of the scale were used).
 Table 1
228

Description of studies (randomized controlled trials) reporting on the outcome variable Dental Anxiety Scale

Number Withdrawals Study groups*

of and
Authors Year Country patients dropouts Intervention Control Comments* Quality

BERGGREN & 1984 Sweden 99 – BT 8.3  3.2 GA 10.8  2.5 Before treatment: Moderate
LINDE (43) 50/49 P < 0.001 BT 16.6  3.1
GA 16.7  2.4
Wide Boman et al.

BERGGREN (44) 1986 Sweden 99 15 BT 9.1  4.2 GA 12.2  4.2 2-yr follow-up of BERGGREN & Moderate
84 6/9 P < 0.05 LINDE (43)
44/40
MOSES & 1985 USA 24 1 replaced SI 15.6  1.7 Waiting list 17.5  1.8 Before treatment: Low
HOLLANDSWORTH 6/6/6/6 CS 16.3  2.3 P < 0.09 SI 16.7  1.1, CS 17.7  1.7, E 17.3  1.7,
(49) E 15.6  1.7 Waiting list 17.5  1.3
GATCHEL (46) 1986 USA 20 ? Video programme: Placebo 16.0 The 20 high-DA patients included in Low
BT 13.5 6-month follow-up 15.8 the analysis
6-month follow- SD not available
up 13.3
GETKA & GLASS 1992 USA 41 ? BT 9.6 Waiting list 13.5 Before treatment: Low
(47) CBT 9.6 PDE 14.9 BT 15.4, CBT 14.9,
P < 0.0001 Waiting list 14.9, PDE 15.8
SD not available
DE JONGH et al. 1995 the 29 9 Cognitive intervention: Information 17.8  1.9 Before treatment: Low
(45) Nether- 15/14 8 CT 14.7  2.8 P < 0.05 CT 17.5  1.5
lands 29 1-yr follow-up 1-yr follow-up 11.4  3.2 Information 17.8  2.2
11.6  3.2) 1-month follow-up
No post-test for waiting-list condition
WILLUMSEN et al. 2001 Norway 65 AR = 2 CT 9.3  2.9 (n = 21) NO 10.0  3.1 (n = 21) Before treatment: Moderate
(50) 21/20/21 NO = 1 AR 8.1  1.9 (n = 20) P > 0.05 CT 17.0  3.0, AR 17.8  2.4, NO 17.0  3.1
WILLUMSEN et al. 2001 Norway 62 CT = 3 CT 9.7  3.5 (n = 18) NO 9.9  3.7 (n = 19) 1-yr follow-up of WILLUMSEN et al. (50) Moderate
(51) AR = 1 AR 7.8  3.2 (n = 19) P > 0.05
NO = 2
WILLUMSEN & 2003 Norway 62 CT = 9 CT 10.9  4.3 (n = 12) NO 10.6  3.9 (n = 14) 5-yr follow-up of WILLUMSEN et al. (50) Low
VASSEND (52) AR = 5 AR 9.9  4.4 (n = 15) P > 0.05
NO = 7
HAUKEBØ et al. 2008 Norway 40 1 1 (n = 10) or 5 (n = 9) Waiting list (n = 20) Before treatment: Low
(48) 10/10/20 9 sessions of exposure 16.6  2.8 Exposure therapy 17.2  2.2
40 therapy 11.5  3.0 P < 0.01 1 session 16.6  2.0
(n = 19) 5 sessions 16.6  2.8
1-yr follow-up (n = 31) Waiting list 17.0  2.8
1 session 10.4  3.4 Waiting-list group randomized
5 sessions 10.1  3.2 to 1 or 5 sessions after 5 wk

The Dental Anxiety Scale includes four items, each rated 1–5, with a higher rating denoting more dental anxiety.*The results are presented as mean sum scores or as mean sum
scores  SD. The mean sum score value ranged from 4 to 20, and the cut-off for dental anxiety was >12. Quality may vary according to outcome.
AR, applied relaxation; BT, behavioural therapy; CBT, cognitive behavioural therapy; CS, coping skills; CT, cognitive therapy; DA, dental anxiety; E, education; GA, general
anaesthesia; NO, nitrous oxide sedation; PDE, positive dental experience; SI, stress inoculation.

16000722, 2013, 3pt2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/eos.12032 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
 Table 2
Description of studies (randomized controlled trials) reporting on the outcome variable Dental Fear Survey

With- Study groups*

Number drawals
of and
Authors Year Country patients dropouts Intervention Control Comments* Quality

WILLUMSEN 2001 Norway 65 3 CT (n = 21) NO (n = 21) Before treatment: Moderate

et al. (50) 21/20/21 Arousal 2.6  1.0 Arousal 2.9  0.9 CT
Situation 2.1  0.7 Situation 2.7  0.9 Arousal 3.6  0.9
AR (n = 20) NS (between groups) Situation 4.0  0.6
Arousal 2.5  1.1 AR
Situation 2.4  1.0 Arousal 3.7  0.7
Situation 4.0  0.6
NO
Arousal 3.7  0.8
Situation 4.2  0.5
Two DFS subscales (mean item score)
WILLUMSEN 2001 Norway 62 6 CT (n = 18) NO (n = 19) 1-yr follow-up, WILLUMSEN et al. (50) Moderate
et al. (51) DFS 2.5  0.81 DFS 2.7  1.01 DFS mean item score plus three subscales
Behaviour 3.2  1.61 Behaviour 3.3  1.21
Arousal 2.5  1.02 Arousal 2.6  1.02
Situation 2.5  0.81 Situation 2.6  1.01
AR (n = 19) P < 0.05
DFS 2.0  0.71
Behaviour 2.2  1.41
Arousal 2.2  0.92
Situation 1.8  0.81
WILLUMSEN &. 2003 Norway 62 19 (non- CT (n = 12) NO (n = 14) 5 yr follow-up, WILLUMSEN et al. (50) Low
VASSEND (52) responders) DFS 2.8  0.7 DFS 2.7  0.8 DFS mean item score
2 dropouts AR (n = 15) NS (between groups)
DFS 2.3  0.9
HAUKEBØ 2008 Norway 40 1 1 (n = 10) or 5 (n = 9) Waiting list (n = 20) Before treatment: Low
et al. (48) 10/10/20 sessions of exposure 75.7  8.8 Exposure therapy 78.6  7.7
therapy 58.4  14.1 P < 0.01 (between Waiting list 75.6  8.9
(n = 19) groups) DFS mean sum score
Items 1 and 2 omitted in post-treatment
assessments

The Dental Fear Survey (DFS) includes 20 items, each rated 1–5, with a higher rating denoting more dental anxiety. *The results are presented as mean sum scores  SD (range,
20–100), and the cut-off level for dental anxiety was a DFS score of >60. The DFS was also divided into three subscales (Behaviour, Arousal, and Situation, each scoring on a
scale from 1 to 5), and the results of each subscale are presented as mean item scores SD. Quality may vary according to outcome.
AR, applied relaxation; CT, cognitive therapy; NO, nitrous oxide sedation; NS, no significant difference.
1
A systematic review of dental anxiety therapy

AR is statistically significant different from NO and CT.

2
No significant difference between groups.
229

16000722, 2013, 3pt2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/eos.12032 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
 16000722, 2013, 3pt2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/eos.12032 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
230 Wide Boman et al.

Table 3
Behavioural therapy vs. controls: Dental Anxiety Scale (DAS) outcome after treatment
Experimental Control Mean Difference Mean Difference
Study or Subgroup Mean SD Total Mean SD Total Weight IV Random 95% CI IV Random 95% CI

Behavioural therapy vs. anesthesia/sedation

BERGGREN & LINDE (43) 8.3 3.2 50 10.8 2.5 49 24.4% -2.50 -3.63, -1.37
WILLUMSEN et al. (50) 8.7 2.5 41 10.0 3.1 21 20.6% -1.30 -2.83, 0.23
Subtotal (95% CI) 91 70 45.0% -2.02 -3.17, -0.86
Heterogeneity: t² = 0.25; c² = 1.53, d.f. = 1 (P = 0.22); I² = 35%
Test for overall effect: Z = 3.42 (P = 0.0006)

Behavioural therapy vs. no treatment

DE JONGH et al. (45) 14.7 2.8 15 17.8 1.9 14 18.8% -3.10 -4.83, -1.37
GATCHEL (46) 13.5 0 10 16.0 0 10 Not estimable
GETKA & GLASS (47) 9.6 0 10 13.5 0 10 Not estimable
HAUKEBØ et al. (48) 11.5 3.0 19 16.6 2.8 20 18.1% -5.10 -6.92, -3.28
MOSES & HOLLANDSWORTH (49) 15.9 2.0 12 17.5 1.8 6 18.1% -1.60 -3.42, 0.22
Subtotal (95% CI) 46 40 55.0% -3.26 -5.22, -1.31
Heterogeneity: t² = 2.15; c² = 7.15, d.f. = 2 (P = 0.03); I ² = 72%
Test for overall effect: Z = 3.27 (P = 0.001)

Total (95% CI) 137 110 100.0% -2.67 -3.87, -1.48

Heterogeneity: t² = 1.19; c² = 11.50, d.f. = 4 (P = 0.02); I² = 65% -4 -2 0 2 4
Test for overall effect: Z = 4.38 (P < 0.0001)
Favours experimental/Favours control
Test for subgroup differences: c² = 1.16, d.f. = 1 (P = 0.28), I² = 14.0%
d.f., degrees of freedom; IV, inverse variance.

Effect on dental anxiety at follow up
Six studies, from five trials, reported follow-up results
on dental anxiety, measured using the DAS (44–47, 51,
52) (Table 1). Two studies were included in a meta-
analysis (Table 4). These studies compared CBT/BT
with anaesthesia/sedation (44, 51) (n = 79), and showed
a decreased level of dental anxiety with a mean DAS
score of 2.2 (P = 0.001) (Table 4).
The paper of WILLUMSEN & VASSEND (52) was not
included in the meta-analysis as the trial was already
represented by the publication reporting follow-up data
after 1 yr. This publication (52) found no difference in
dental anxiety between intervention and control groups
at the 5-yr follow-up. The remaining studies did not
provide enough data to be included in the meta-analy-
sis. However, DE JONG et al. (45) reported no difference
in dental anxiety between interventions and controls
after 1 yr, whilst GETKA & GLASS (47) and GATCHEL
(46) reported decreased dental anxiety in the interven-
tion groups compared with the control groups after
1 yr and 6 months, respectively.
Follow-up data using the DFS as a measure of den-
tal anxiety found no differences between groups at fol-
low up after 1 and 5 yr (51, 52).
Acceptance of conventional dental treatment
measured using dental ‘treatability’ rating
Two studies reported the effect of CBT/BT on the
acceptance of dental care, measured under controlled
conditions and including a rating of patient behaviour
(43, 48) (Table 5). One study of moderate quality
reported a statistically significant positive effect of BT
on the acceptance of conventional dental treatment,
compared with general anaesthesia, with 80% success-
ful dental sessions in the BT group and 53% in the
general anaesthesia group (P = 0.009) (43). The other
study also reported a high proportion of success in the
intervention group, but did not provide any control
data for comparison (48). There was insufficient data to
perform a meta-analysis.
Effects on quality of life/oral health-related
quality of life and complications
These outcomes were not measured in the publications
included.
Rating of quality of evidence according to GRADE
Table 6 presents a summary of the findings according
to outcome, including grading of quality. There is some
support for CBT/BT giving a clinically significant
reduction in dental anxiety, as measured using the
DAS; however, this conclusion is based on evidence of
low quality (GRADE ). There is insufficient
support for an effect of CBT/BT on dental anxiety, as
measured using the DFS and based on evidence of very
low quality (GRADE ). There is some support
that behavioural therapy improves patients’ acceptance
of conventional dental treatment more than does gen-
eral anaesthesia, based on evidence of low quality
(GRADE ).
Discussion
The main finding of this systematic review and meta-
analysis was that CBT/BT interventions may be effec-
tive in the treatment of dental anxiety/phobia. Treat-
ments result in lower dental anxiety and in increased
acceptance of dental treatment. However, the quality of
evidence was low or very low, according to a strict
evaluation scheme following the GRADE system in
 16000722, 2013, 3pt2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/eos.12032 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
A systematic review of dental anxiety therapy 231

Table 4
Behavioural therapy vs. anaesthesia/sedation: Dental Anxiety Scale (DAS) long term (1–2 yr) outcome
Experimental Control Mean Difference Mean Difference
Study or Subgroup Mean SD Total Mean SD Total Weight IV Random 95% CI IV Fixed 95% CI

BERGGREN (44) 9.1 4.2 42 12.2 4.2 42 55.2% -3.10 -4.90, -1.30
WILLUMSEN et al. (51) 8.7 3.4 37 9.9 3.7 19 44.8% -1.20 -3.19, 0.79
Total (95% CI) 79 61 100.0% -2.25 -3.58, -0.91
Heterogeneity: c² = 1.93, d.f. = 1 (P = 0.17); I² = 48% -4 -2 0 2 4
Favours experimental/Favours control
Test for overall effect: Z = 3.30 (P = 0.0010)
d.f., degrees of freedom; IV, inverse variance.

Table 5
Description of studies (randomized controlled trials) reporting on the outcome variable acceptance of dental treatment: dental treat-
ability rating

With- Results
Comments Quality
Number drawals
of and
Authors Year Country patients dropouts Intervention Control

BERGGREN 1984 Sweden 99 Behavioural therapy General Two sessions of Moderate

& LINDE 50/49 Successful 80% (n = 40) anaesthesia dental treatment,
(43) Successful rating of success
53% (n = 26) or failure made
P = 0.009 (chi- by dentist using
square test dentist rating
calculated from scale
data)
HAUKEBØ 2008 Norway 40 1 1 (n = 9) or 5 (n = 10) No control Behavioural test, Low
et al. (48) 10/10/20 sessions of exposure according to 14 steps, from
therapy. 92.3% success PICO entering room
(completed all 14 steps of to filling cavity;
a behavioural test post- success rated by
treatment) dentist

Quality may vary according to outcome.

PICO, Patients, Interventions, Controls, Outcome.

evidence-based medicine, which is used by most inter-
national Health Technology Assessment centres. The
obvious reasons for these results are found in the scien-
tific study designs of each publication included in the
systematic review. Even though only RCTs were
included, critical procedure violations, according to the
accepted evaluation principles for such study designs,
were found. Frequent problems with the studies were
no blinding procedure, small sample sizes, and no
information about the randomization procedure. Viola-
tion of such important features of an RCT results in
low, or possibly moderate, study quality.
As far as we know, no previous systematic review,
applying strict criteria according to the GRADE sys-
tem, has been performed regarding the effect of
behavioural treatments in dental anxiety/phobia. As
many as 10 publications were found after the standard-
ized exclusion procedure. Several of the included arti-
cles originated from the same study, typically reporting
pre- to post-treatment effects and possibly follow-up
data in a separate publication. All the included studies
reported acceptable homogeneous patient groups with
respect to high levels of dental anxiety, which is essen-
tial to be able to compare the outcome and efficacy of
the different interventions. Moreover, and this is an
important point when comparing the studies, the inter-
ventions differed somewhat with regard to specific
behavioural treatment protocols, even if the core of the
treatments was judged by the authors to belong to the
behavioural/cognitive behavioural family of procedures,
as far as could be deemed from the publication text. In
addition, the control groups were exposed to different
treatments/conditions, implicating the heterogeneity
and thus decreasing the interpretability of the results.
However, such weaknesses in systematic reviews are
usually present when studies performed over a long
time period, and from different health-care cultures and
countries, are compared.
The occurrence of complications was not measured in
the included publications, for any of the treatments or
methodologies studied. As with all exposure-based
behavioural treatments there is a risk of an increased
anxiety level, as the treatment is anxiety-provoking ini-
tially. However, conventional treatment of dental-anxi-
ety patients under general anaesthesia and/or sedation is
associated with certain medical risks – the mortality rate
is estimated at 1:100,000 of cases of general anaesthesia
(53). By including other types of study designs, such as
 232

Table 6
Summary of findings according to outcome, including grading of quality of evidence
Wide Boman et al.

Quality of
Outcome variable/ Relative effect evidence
number of studies Study limitations Consistency Directedness Precision Publication bias (95% CI) Absolute effect GRADE

DAS Serious limitations Some inconsistency Some uncertainty No imprecision Unlikely 3.9 to 1.5 Mean difference Low
CBT vs. all controls Unclear randomization Statistical Advertisement 2.7 less anxiety
(n = 5) No blinding heterogeneity recruitment in
few studies
DAS Serious limitations No inconsistency No uncertainty No imprecision Unlikely 3.2 to 0.9 Mean difference Low
CBT vs. anaesthesia/ Unclear randomization 2.0 less anxiety
sedation (n = 2) No blinding
DAS long-term Serious limitations Some inconsistency Some uncertainty No imprecision Unlikely 3.6 to 0.9 Mean difference Low
CBT vs. anaesthesia/ Unclear randomization Statistical Advertisement 2.3 less anxiety
sedation (n = 2) No blinding heterogeneity recruitment in
few studies
DFS Serious limitations Some inconsistency Some uncertainty Serious imprecision Unlikely NA NA Very low
CBT vs. anaesthesia/ Unclear randomization All patients
sedation, or waiting No blinding receive ‘good
list (n = 4) care’ and
compassion
Acceptance of dental Serious limitations No inconsistency No uncertainty No imprecision Likely BT leads, BT: 80% Low
treatment Unclear randomization approximately acceptance vs.
BT vs. general No blinding 1.5 times more general
anaesthesia (n = 1) often, to acceptance anaesthesia:
of conventional 50% acceptance
treatment

All included studies had a randomized controlled trial (RCT) design.

BT, behavioural therapy; CBT, cognitive behavioural therapy; DAS, Dental Anxiety Scale; DFS, Dental Fear Survey; GRADE, the Grading of Recommendations Assessment,
Development and Evaluation; NA, not applicable.

16000722, 2013, 3pt2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/eos.12032 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

observational and case–control studies, reports of com-
plications may have been elucidated and reported.
The treatments evaluated in this study target individ-
uals with severe dental anxiety/phobia, and it seems
reasonable that this group should be given priority. But
it may also be important to alleviate dental anxiety
among those who are anxious, but still receive dental
care on a regular basis without severe anxiety reactions.
The gain would be to minimize a shift towards more
negative dental-care behaviour, including avoidance of
dental care.
There is a lack of well-designed studies, both RCTs
and observational studies, as the present systematic
review has identified significant knowledge gaps. There
is a need for evaluations with clinically relevant out-
come measures (acceptance of dental treatment, quality
of life, oral-health-related quality of life, and dental sta-
tus) as well as complications from treatments and long-
term follow-up. Knowledge about the referral processes
and care proceedings for patients with dental anxiety
would also be valuable.
To conclude, this systematic review shows that
behavioural interventions for the treatment of dental
anxiety/phobia among adults decrease dental anxiety
and increase the acceptance of dental care. This result
indicates that behavioural interventions should be pro-
vided to adult patients with dental anxiety/phobia. How-
ever, the quality of the evidence was low or very low;
thus, more well-designed studies, including a broader
range of outcome measures, should be performed.
Acknowledgements – The authors would like to thank Maud Eri-
ksson, Ann Liljegren, Petteri Sj€ ogren, and Annika Strandell for
their contributions to this work.
Conflicts of interest – The authors declare no conflicts of interest.
References
1. HAKEBERG M. Dental anxiety and health. A prevalence study
and assessment of treatment outcomes. Thesis, Göteborg,
Sweden: University of Gothenburg, 1992.
€
2. HAGGLIN C. Dental anxiety in a Swedish city population of
women: a cross-sectional and longitudinal study of prevalence,
dental care utilisation and oral and mental health factors.
Thesis, Göteborg, Sweden: University of Gothenburg, 2000.
3. SKARET E, RAADAL M, BERG E, KVALE G. Dental anxiety
among 18-yr-olds in Norway. Prevalence and related factors.
Eur J Oral Sci 1998; 106: 835–843.
4. NEVERLIEN PO. Normative data for Corah’s Dental Anxiety
Scale (DAS) for the Norwegian adult population. Community
Dent Oral Epidemiol 1990; 18: 162.
5. MOORE R, BIRN H, KIRKEGAARD E, BRODSGAARD I, SCHEUTZ
F. Prevalence and characteristics of dental anxiety in Danish
adults. Community Dent Oral Epidemiol 1993; 21: 292–296.
6. MILGROM P, FISET L, MELNICK S, WEINSTEIN P. The preva-
lence and practice management consequences of dental fear in
a major US city. J Am Dent Assoc 1988; 116: 641–647.
7. OOSTERINK FM, DE JONGH A, HOOGSTRATEN J. Prevalence of
dental fear and phobia relative to other fear and phobia sub-
types. Eur J Oral Sci 2009; 117: 135–143.
8. HAKEBERG M, BERGGREN U, CARLSSON SG. Prevalence of
dental anxiety in an adult population in a major urban
area in Sweden. Community Dent Oral Epidemiol 1992; 20: 97
–101.
16000722, 2013, 3pt2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/eos.12032 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
A systematic review of dental anxiety therapy 233
9. VASSEND O. Anxiety, pain and discomfort associated with
dental treatment. Behav Res Ther 1993; 31: 659–666.
10. BERGGREN U. General and specific fears in referred and self-
referred adult patients with extreme dental anxiety. Behav Res
Ther 1992; 30: 395–401.
11. ABRAHAMSSON KH, BERGGREN U, CARLSSON SG. Psychosocial
aspects of dental and general fears in dental phobic patients.
Acta Odontol Scand 2000; 58: 37–43.
12. HAKEBERG M, KLINGBERG G, NOREN JG, BERGGREN U. Swed-
ish dentists’ perceptions of their patients. Acta Odontol Scand
1992b; 50: 245–252.
13. ARMFIELD JM, SLADE GD, SPENCER AJ. Dental fear and adult
oral health in Australia. Community Dent Oral Epidemiol
2009; 37: 220–230.
14. BERGGREN U, MEYNERT G. Dental fear and avoidance: causes,
symptoms, and consequences. J Am Dent Assoc 1984; 109:
247–251.
15. HAKEBERG M, BERGGREN U, GRÖNDAHL HG. A radiographic
study of dental health in adult patients with dental anxiety.
Community Dent Oral Epidemiol 1993; 21: 27–30.
16. WIDE BOMAN U, LUNDGREN J, BERGGREN U, CARLSSON SG.
Psychosocial and dental factors in the maintenance of severe
dental fear. Swed Dent J 2010; 34: 121–127.
17. AGDAL ML, RAADAL M, SKARET E, KVALE G. Oral health
and oral treatment needs in patients fulfilling the DSM-IV
criteria for dental phobia: possible influence on the outcome
of cognitive behavioral therapy. Acta Odontol Scand 2008; 66:
1–6.
€
18. HALLSTR € T, HALLING A. Prevalence of dentistry phobia
OM
and its relation to missing teeth, alveolar bone loss and dental
care habits in an urban community sample. Acta Psychiatr
Scand 1984; 70: 438–446.
19. NG SK, LEUNG WK. A community study on the relationship
of dental anxiety with oral health status and oral health-
related quality of life. Community Dent Oral Epidemiol 2008;
36: 347–356.
20. HAKEBERG M, BERGGREN U. Changes in sick leave among
Swedish dental patients after treatment for dental fear. Com-
munity Dent Health 1993; 10: 23–29.
21. ARMFIELD JM, STEWART JF, SPENCER AJ. The vicious cycle of
dental fear: exploring the interplay between oral health, ser-
vice utilization and dental fear. BMC Oral Health 2007; 7: 1.
22. MOORE R, BRODSGAARD I, ROSENBERG N. The contribution of
embarrassment to phobic dental anxiety: a qualitative
research study. BMC Psychiatry 2004; 4: 10.
23. LOCKER D. Psychosocial consequences of dental fear and anx-
iety. Community Dent Oral Epidemiol 2003; 31: 144–151.
24. BERGGREN U. Dental fear and avoidance. A study of etiology,
consequences and treatment. Thesis, Göteborg, Sweden: Uni-
versity of Göteborg, 1984.
25. AMERICAN PSYCHIATRIC ASSOCIATION. Diagnostic and statistical
manual of mental disorders, 4th edn, text revision. Washington
DC: American Psychiatric Association, 2000; 443–450.
26. KVALE G, BERGGREN U, MILGROM P. Dental fear in adults: a
meta-analysis of behavioral interventions. Community Dent
Oral Epidemiol 2004; 32: 250–264.
27. ROTH A, FONAGY P. What works for whom? A critical review
of psychotherapy research. 2nd edn. New York: Guilford,
2005; 150–197.
28. O’DONOHUE W, FISHER JE, HAYES SC. Cognitive behavior
therapy: applying empirically supported techniques in your
practice. New Jersey: Wiley, 2003; 1–505.
29. KAVANAGH BP. The GRADE system for rating clinical guide-
lines. PLoS Med 2009; 6: e1000094.
30. ATKINS D, BEST D, BRISS PA, ECCLES M, FALCK-YTTER Y,
FLOTTORP S, GUYATT GH, HARBOUR RT, HAUGH MC, HENRY
D, HILL S, JAESCHKE R, LENG G, LIBERATI A, MAGRINI N,
MASON J, MIDDLETON P, MRUKOWICZ J, O’CONNELL D,
OXMAN AD, PHILLIPS B, SCHUNEMANN HJ, EDEJER TT, VARO-
NEN H, VIST GE, WILLIAMS JW Jr, ZAZA S. Grading quality
of evidence and strength of recommendations. BMJ 2004;
328: 1490.
31. AGENCY FOR HEALTHCARE RESEARCH AND QUALITY (US).
Methods guide for effectiveness and comparative effectiveness

234 Wide Boman et al.
reviews [internet]. Rockville, MD, USA: 2008. Available
from: http://www.ncbi.nlm.nih.gov/books/NBK47095/.
32. MOHER D, HOPEWELL S, SCHULZ KF, MONTORI V, GOTZSCHE
PC, DEVEREAUX PJ, ELBOURNE D, EGGER M, ALTMAN DG.
CONSORT 2010 explanation and elaboration: updated guide-
lines for reporting parallel group randomised trials. BMJ
2010; 340: c869.
33. SBU. Checklist from SBU regarding randomized clinical trials
[Granskningsmall för randomiserad kontrollerad prövning]
[Internet]. Göteborg, Sweden: Region Västra Götaland. Ava-
liable from: http://www.sahlgrenska.se/upload/SU/HTA-cen-
trum [accessed 1 February 2012].
34. AMERICAN PSYCHIATRIC ASSOCIATION. Diagnostic and statistical
manual of mental disorders text revision. 4th edn. Washington
DC: American Psychiatric Association, 2000; 445pp.
35. WORLD HEALTH ORGANISATION. ICD-10 Classifications of
mental and behavioural disorder: clinical descriptions and diag-
nostic guidelines. Geneva: World Health Organisation, 1992;
114pp.
36. CORAH N. Development of a dental anxiety scale. J Dent Res
1969; 48: 596.
37. KLEINKNECHT RA, KLEPAC RK, ALEXANDER LD. Origins and
characteristics of fear of dentistry. J Am Dent Assoc 1973; 86:
842–848.
38. BERGGREN U, CARLSSON SG. Usefulness of two psychometric
scales in Swedish patients with severe dental fear. Community
Dent Oral Epidemiol 1985; 13: 70–74.
39. CORAH N, GALE E, ILLIG S. Assessment of a dental anxiety
scale. J Am Dent Assoc 1978; 97: 816–819.
40. SCHUURS AH, HOOGSTRATEN J. Appraisal of dental anxiety
and fear questionnaires: a review. Community Dent Oral Epi-
demiol 1993; 21: 329–339.
41. MCGLYNN FD, MCNEIL DW, GALLAGHER SL, VRANA S. Fac-
tor structure, stability, and internal consistency of the Dental
Fear Survey. Behav Assess 1987; 9: 57–66.
42. WENNERHOLM UB, HAGBERG H, BRORSSON B, BERGH C.
Induction of labor versus expectant management for post-
date pregnancy: is there sufficient evidence for a change in
clinical practice? Acta Obstet Gynecol Scand 2009; 88: 6–17.
43. BERGGREN U, LINDE A. Dental fear and avoidance: a compar-
ison of two modes of treatment. J Dent Res 1984; 63: 1223–
1227.
44. BERGGREN U. Long-term effects of two different treatments
for dental fear and avoidance. J Dent Res 1986; 65: 874–876.
16000722, 2013, 3pt2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/eos.12032 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
45. DE JONGH A, MURIS P, TER HORST G, VAN ZUUREN F, SCHOEN-
MAKERS N, MAKKES P. One-session cognitive treatment of
dental phobia: preparing dental phobics for treatment by
restructuring negative cognitions. Behav Res Ther 1995; 33:
947–954.
46. GATCHEL RJ. Impact of a videotaped dental fear-reduction
program on people who avoid dental treatment. J Am Dent
Assoc 1986; 112: 218–221.
47. GETKA EJ, GLASS CR. Behavioral and Cognitive-Behavioral
Approaches to the reduction of dental anxiety. Behav Ther
1992; 23: 433–448.
48. HAUKEBØ K, SKARET E, O € ST LG, RAADAL M, BERG E, SUND-
BERG H, KVALE G. One- vs. five-session treatment of dental
phobia: a randomized controlled study. J Behav Ther Exp
Psychiatry 2008; 39: 381–390.
49. MOSES AN, HOLLANDSWORTH JS. Relative effectiveness of edu-
cation alone versus stress inoculation training in the treat-
ment of dental phobia. Behav Ther 1985; 16: 531–537.
50. WILLUMSEN T, VASSEND O, HOFFART A. A comparison of cog-
nitive therapy, applied relaxation, and nitrous oxide sedation
in the treatment of dental fear. Acta Odontol Scand 2001; 59:
290–296.
51. WILLUMSEN T, VASSEND O, HOFFART A. One-year follow-up
of patients treated for dental fear: effects of cognitive therapy,
applied relaxation, and nitrous oxide sedation. Acta Odontol
Scand 2001; 59: 335–340.
52. WILLUMSEN T, VASSEND O. Effects of cognitive therapy,
applied relaxation and nitrous oxide sedation. A five-year fol-
low-up study of patients treated for dental fear. Acta Odontol
Scand 2003; 61: 93–99.
53. MESSIEHA Z. Risks of general anesthesia for the special needs
dental patient. Spec Care Dentist 2009; 29: 21–25.
Supporting Information
Additional Supporting Information may be found in the online
version of this article:
Fig. S1. Flow chart of selection process.
Table S1. MeSH terms and search strategies.
Excluded references. Articles not having met the inclusion criteria.