Received: 25 January 2022 Revised: 28 May 2022 Accepted: 30 May 2022

DOI: 10.1111/scd.12749

REVIEW

Dentophobia and dental treatment: An umbrella review of

the published literature

Sarmad Aburas1 Florian Pfaffeneder-Mantai1,2 Alina Hofmann1

Oliver Meller1 Benedikt Schneider1 Dritan Turhani1

1 Centerfor Oral and Maxillofacial

Surgery, Department of Dentistry, Faculty
of Medicine and Dentistry, Danube
Private University, Krems/Donau, Austria
2 Division for Chemistry and Physics of
Materials, Department of Medicine,
Faculty of Medicine and Dentistry,
Danube Private University,
Krems/Donau, Austria
Correspondence
Dritan Turhani, Center for Oral and
Maxillofacial Surgery, Steiner Landstraße
124, Danube Private University (DPU),
Steiner Landstraße 124, A-3500
Krems-Stein, Austria.
Email: Dritan.Turhani@DP-Uni.ac.at
[Correction added on June 29, 2022, after
first online publication: The article’s title
was updated in this version.]
Abstract
Aims: Dentophobia is a well-know kind of phobia and psychological problem in
dentistry. Although patients might suffer from severe oral pain and have serious
health complications, dentophobia is still posing a threat to oral healthcare and
remains an unresolved worldwide phenomenon. According to estimates, up to
80% of the general population are affected by this condition. Dentophobia is an
unpleasant problem with serious consequences not only for patients but also for
dentists and the public health system in general. This umbrella review provides
a comprehensive overview of the various aspects of dentophoia as addressed in
the published literature, and the current level of knowledge concerning their
treatment.
Methods and results: Based on 35 reviews of the published literature, address-
ing various aspects of dentophobia and published between 2008 and 2021,
this umbrella review was written. The search was based on the PubMed and
PsycINFO databases. The extraction was structured by open coding and each
aspect of the subject analyzed according to Ritchie and Lewis.
Conclusion: We conclude that the evidence concerning the efficacy of the
various interventions is still rather weak and there is an obvious need for fur-
ther research, because of the yet and unresolved challenges and the lack of
standardised guidelines to deal with patients with dentophobia.

KEYWORDS
dental anxiety, dental fear, dentophobia, odontophobia, review

1 INTRODUCTION ing to estimates in the USA, 80% of the population

The phenomena referred to jointly as dentophobia have
been investigated since the 1960’s, and have received
more attention recently with increase in research
activities and publications on this subject. Accord-
Sarmad Aburas and Florian Pfaffeneder-Mantai contributed equally to
this paper.
is affected by dentophobia. Its negative consequences
concern patients, dentists and the public health
system in general.1 Moreover, it is worth mention-
ing that most literature came from English speaking
countries.
This umbrella review of the published reviews is a
reconstruction of the current level of knowledge about

© 2022 Special Care Dentistry Association and Wiley Periodicals LLC.

Spec Care Dentist. 2023;43:163–173. wileyonlinelibrary.com/journal/scd 163


164
FIGURE 1 The selection process of the reviews in the Prisma Flow Chart
dentophobia. The aims were two-fold: (1) to make dentists
more aware of this phenomenon and stimulate updated
research on the subject, (2) to draw attention to the var-
ious types of measures, especially behavioral therapy for
dentophobia, and encourage research on the subject and
give more details on the measures.
We tried to find answers to the following ques-
tions: What is the definition of dentophobia? How
is it measured? How frequently does it occur? What
are its causes? What measures and techniques can be
used to counteract dentophobia and how successful are
these?
2 MATERIALS AND METHODS
Several systematic searches of the published literature
were conducted in PubMed and PsycINFO in Decem-
ber 2021. The search terms used were “dental fear”,
“dental phobia”, and “dental anxiety”; these terms were
checked individually and in combination. The search was
confined to the following inclusion and exclusion cri-
teria: (1) publications in the English, in peer-reviewed
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ABURAS et al.
journals, (2) reviews, (3) the time period from Jan-
uary 2008 to December 2021, (4) search terms in the
titles and the keywords, and (5) papers focused on
dentophobia.
Of the 158 reviews found, we ruled out duplicates
and arrived at 153 reviews, of which 107 reviews were
excluded because it was not focused on dentophobia.
Of 46 reviews which were obtained and subjected to a
full-text analysis, a further eleven were excluded for the
following reasons: (foreign languages, general in terms
of content, ambiguous descriptions and analytical pro-
cedures, or derived from a non-peer-reviewed journal)
(cf. Figure 1).
The remaining 35 reviews (see Table 1) were first
structured by the open coding method. Individual units
were assigned codes, which were intended to facilitate
subsequent analysis and categorization. The analysis of
topics was based on the recommendations of Ritchie and
Lewis.2 The advantage of this method is that the cate-
gories can be clearly traced back to predefined research
questions. Atlas-TI (Version 8.1.30.0) was used for all qual-
itative analyses. The 35 analyzed reviews are listed in
Table 1.
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ABURAS et al. 165

TA B L E 1 The 35 analyzed reviews

Number Article
1 Armfield JM, Heaton LJ. Management of fear and anxiety in the dental clinic: a review. Aust Dent J.
2013;58:390–407. https://doi.org/10.1111/adj.12118.
2 Appukuttan DP. Strategies to manage patients with dental anxiety and dental phobia: literature review. Clin
Cosmet Investig Dent. 2016;8:35–50. https://doi.org/10.2147/CCIDE.S63626.
3 Alharbi A, Freeman R, Humphris G. Dental anxiety, child-oral health related quality of life and self-esteem in
children and adolescents: a systematic review and meta-analysis. Community Dent Health. 2021;38:119.
https://doi.org/10.1922/CDH_00295Alharbi08.
4 Barreiros D, De Oliveira DSB, De Queiroz AM, Da Silva RAB, De Paula-Silva FWG, Küchler EC. Audiovisual
distraction methods for anxiety in children during dental treatment: a systematic review and meta-analysis.
J Indian Soc Pedod Prev Dent. 2018;36. https://doi.org/10.4103/JISPPD.JISPPD_188_16.
5 Cai H, Xi P, Zhong L, Chen J, Liang X. Efficacy of aromatherapy on dental anxiety: a systematic review of
randomised and quasi-randomised controlled trials. Oral Dis. 2021;27:829–847.
https://doi.org/10.1111/odi.13346
6 Carter, Ava Elizabeth, Carter G, Boschen M, Alshw aimi E. Pathways of fear and anxiety in dentistry: a review.
World J Clin Cases. 2014;2:642. https://doi.org/10.12998/wjcc.v2.i11.642.
7 Cianetti S, Lombardo G, Lupatelli E, et al. Dental fear/anxiety among children and adolescents. a systematic
review. Eur J Paediatr Dent. 2017;18:121–130. https://doi.org/10.23804/ejpd.2017.18.02.07.
8 Cianetti S, Abraha I, Pagano S, Lupatelli E, Lombardo G. Sonic and ultrasonic oscillating devices for the
management of pain and dental fear in children or adolescents that require caries removal: a systematic
review. BMJ Open. 2018;8:e20840. https://doi.org/10.1136/bmjopen-2017-020840.
9 Cunningham A, McPolin O, Fallis R, Coyle C, Best P, McKenna G. A systematic review of the use of virtual
reality or dental smartphone applications as interventions for management of paediatric dental anxiety. BMC
Oral Health. 2021;21:244. https://doi.org/10.1186/s12903-021-01602-3.
10 Elmore JL, Bruhn AM, Bobzien JL. Interventions for the reduction of dental anxiety and corresponding
behvioral deficits in children with autism spectrum disorder. J Dent Hyg JDH. 2016;90:111–20.
11 Moola S, Pearson A, Hagger C. Effectiveness of music interventions on dental anxiety in paediatric and adult
patients: a systematic review. JBI Database Syst Rev Implement Reports. 2011;9:588–630.
https://doi.org/10.11124/01938924-201109180-00001.
12 Murad M, Ingle N, Assery M. Evaluating factors associated with fear and anxiety to dental treatment—A
systematic review. J Fam Med Prim Care. 2020;9:4530. https://doi.org/10.4103/jfmpc.jfmpc_607_20.
13 De Stefano R, Bruno A, Muscatello MR, Cedro C, Cervino G, Fiorillo L. Fear and anxiety managing methods
during dental treatments: a systematic review of recent data.2020;6. Minerva Stomatol. 2019;68.
https://doi.org/10.23736/S0026-4970.19.04288-2.
14 Gazal G, Fareed WM, Zafar MS, Al-Samadani KH. Pain and anxiety management for pediatric dental
procedures using various combinations of sedative drugs: a review. Saudi Pharm J. 2016;24:379–85.
https://doi.org/10.1016/j.jsps.2014.04.004.
15 Goettems ML, Zborowski EJ, Costa F dos S, Costa VPP, Torriani DD. Nonpharmacologic Intervention on the
Prevention of Pain and Anxiety During Pediatric Dental Care: a Systematic Review. Acad Pediatr.
2017;17:110–9. https://doi.org/10.1016/j.acap.2016.08.012.
16 Gordon D, Heimberg RG, Tellez M, Ismail AI. A critical review of approaches to the treatment of dental anxiety
in adults. J Anxiety Disord. 2013;27:365–78. https://doi.org/10.1016/j.janxdis.2013.04.002.
17 Gujjar KR, van Wijk A, Kumar R, de Jongh A. Are technology-based interventions effective in reducing dental
anxiety in children and adults? A Systematic Review. J Evid Based Dent Pract. 2019;19:140–155.
https://doi.org/10.1016/j.jebdp.2019.01.009.
18 Klinberg G. Dental anxiety and behaviour management problems in paediatric dentistry – a review of
background factors and diagnostics. Eur Arch Paediatr Dent. 2008;9 Suppl 1:11–5.
https://doi.org/10.1007/BF03262650.
19 Leal SC, Abreu DMDM, Frencken JE. Dental anxiety and pain related to ART. J Appl Oral Sci. 2009;17:84–8.
https://doi.org/10.1590/s1678-77572009000700015 [pii].
20 Liu Y, Gu Z, Wang Y, et al. Effect of audiovisual distraction on the management of dental anxiety in children: a
systematic review. Int J Paediatr Dent. 2019;29:14–21. https://doi.org/10.1111/ipd.12430.
(Continues)
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166 ABURAS et al.

TA B L E 1 (Continued)

Number Article
21 Lin C-S, Wu S-Y, Yi C-A. Association between anxiety and pain in dental treatment: a systematic review and
meta-analysis. J Dent Res. 2017;96:153–162. https://doi.org/10.1177/0022034516678168.
22 Lee DW, Kim JG, Yang YM. The influence of parenting style on child behavior and dental anxiety. Pediatr Dent.
2018;40:327–333.
23 López-Valverde N, Fernández JM, López-Valverde A, et al. Use of virtual reality for the management of anxiety
and pain in dental treatments: systematic review and meta-analysis. J Clin Med. 2020;9:1025.
https://doi.org/10.3390/jcm9041025.
24 Grisolia BM, dos Santos APP, Dhyppolito IM, Buchanan H, Hill K, Oliveira BH. Prevalence of dental anxiety in
children and adolescents globally: a systematic review with meta-analyses. Int J Paediatr Dent.
2021;31:168–183. https://doi.org/10.1111/ipd.12712.
25 Passos De Luca M, Massignan C, Bolan M, et al. Does the presence of parents in the dental operatory room
influence children’s behaviour, anxiety and fear during their dental treatment? A systematic review. Int J
Paediatr Dent. 2021;31:318–336. https://doi.org/10.1111/ipd.12762.
26 Prado IM, Carcavalli L, Abreu LG, Serra-Negra JM, Paiva SM, Martins CC. Use of distraction techniques for the
management of anxiety and fear in paediatric dental practice: a systematic review of randomized controlled
trials. Int J Paediatr Dent. 2019;29:650–668. https://doi.org/10.1111/ipd.12499.
27 Seligman LD, Hovey JD, Chacon K, Ollendick TH. Dental anxiety: an understudied problem in youth. Clin
Psychol Rev. 2017;55:25–40. https://doi.org/10.1016/j.cpr.2017.04.004.
28 de Oliveira TN, dos Santos IBF, Souza GLN, et al. Sense of coherence and dental fear/dental anxiety: a
systematic review and meta-analysis. Spec Care Dent. 2021,42:257–265. https://doi.org/10.1111/scd.12663.
29 Silveira ER, Cademartori MG, Schuch HS, Armfield JA, Demarco FF. Estimated prevalence of dental fear in
adults: a systematic review and meta-analysis. J Dent. 2021;108:103632.
https://doi.org/10.1016/j.jdent.2021.103632.
30 Shim Y-S, Kim A-H, Jeon E-Y, An S-Y. Dental fear & anxiety and dental pain in children and adolescents; a
systemic review. J Dent Anesth Pain Med J Dent Anesth Pain Med. 2015;15:53–61.
https://doi.org/10.17245/jdapm.2015.15.2.53.
31 Simon AK, Bhumika T V, Nair NS. Does atraumatic restorative treatment reduce dental anxiety in children? A
systematic review and meta-analysis. Eur J Dent. 2015;9:304–9. https://doi.org/10.4103/1305-7456.156841.
32 Themessl-Huber M, Freeman R, Humphris G, MacGillivray S, Terzi N. Empirical evidence of the relationship
between parental and child dental fear: a structured review and meta-analysis. Int J Paediatr Dent.
2010;20:83–101. https://doi.org/10.1111/j.1365-263X.2009.00998.x.
33 Wide Boman U, Carlsson V, Westin M, Hakeberg M. Psychological treatment of dental anxiety among adults: a
systematic review. Eur J Oral Sci. 2013;121:225–34. https://doi.org/10.1111/eos.12032.
34 Zhang C, Qin D, Shen L, Ji P, Wang J. Does audiovisual distraction reduce dental anxiety in children under local
anesthesia? A systematic review and meta-analysis. Oral Dis. 2019;25:416–424.
https://doi.org/10.1111/odi.12849.
35 Zhou Y, Cameron E, Forbes G, Humphris G. Systematic review of the effect of dental staff behaviour on child
dental patient anxiety and behaviour. Patient Educ Couns. 2011;85:4–13.
https://doi.org/10.1016/j.pec.2010.08.002.

3 RESULTS AND DISCUSSION
3.1 Definitions of dentophobia
The term dentophobia refers to phenomena such as
dental anxiety, dental fear, and dental phobia.3 Since the
distinctions are rather ambiguous and inhomogeneous,
these terms are frequently used as synonyms in the
published literature.4,5 However, unequivocal terms are
needed to differentiate common and occasional anxiety
reactions from unspecific, non-stimulus-related anxiety
disorders and phobias. The authors of published stud-
ies usually do no more than differentiate between the
subjective severity of the phenomenon and the degree
of cognitive impairment (loss of self-control, dizziness,
unconsciousness).4 A more clear demarcation appears to
exist for dentophobia because it can rely upon a general
definition of phobia as such.3 The severity of the psy-
chosocial burden and the presence of disorder-specific
symptoms, such as avoidance behavior seem to play a
role. However, we do not know with certainty whether
dentophobia is an independent syndrome or a special

ABURAS et al.
form of phobia (such as fear of injury due to blood spatter,
disgust, etc.).4,6,7
3.2 Measuring instruments
Various methods are used to measure dentophobia: (1)
self-reporting by means of validated questionnaires; (2)
interviewer’s assessment by means of validated assessment
tools; (3) behavioral assessment by direct observation; and
(4) psychological assessment with validated instruments.
The instruments used for screening usually differ from
those used in the dentist’s office. In the latter setting the
dentist wishes to obtain an immediate diagnostic impres-
sion of the patient. The visual analog scale proved to be
a valid and useful instrument for this purpose. As the con-
cepts of dentophobia are not entirely clear, the instruments
used for this purpose are understandably a frequent subject
of criticism.1,8 The most common instruments are listed in
Table 2.
3.3 Prevalence of dentophobia
The prevalence of dentophobia ranges from 3% to 56% in
the general population, depending on the study, the instru-
ment used, and the country. On average about 20% of all
adults in European countries are affected by the condition.
This figure appears to be a very reasonable benchmark for
a moderate to high degree of dentophobia; the percentage
may well be markedly higher for a low level of dentopho-
bia. At least a low level of anxiety is assumed for about 80%
of the population in the USA; about 20% are believed to
categorically avoid visits to the dentists and the prescribed
oral hygiene sessions.1 The prevalence of dentophobia is
reported to vary between 1% and 11%; the latter value
applies to Germany.3 A mean of 5%–7% appears to be real-
istic here as well.3 With regard to children, the prevalence
varies between 3% and 43%. Moreover, dentophobia has
higher prevalence in preschool and schoolchildren than
in adolescents.9 Severe dentophobia is quite uniformly
reported to range between 1% and 5%.1
Dentophobia tends to decrease with age among chil-
dren and adolescents.3 It then reduces rapidly at an adult
age, somewhat earlier in men than in women.1,3,10 Further-
more, dentophobia was found to be related to a person’s
ethnic origin and socio-economic status.11
Dentophobia is viewed as a public health problem not
only because of its potentially and surprisingly high preva-
lence and the fact that its management calls for painkillers
and psychotropic drugs; it is also a problem because it leads
to avoidance behavior and poor dental health as a result.
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167
Public health policies are required to fulfil a number of
preventive tasks in this setting.1
3.4 Causes of dentophobia
Numerous factors have been discussed as causes of a
patient’s fear of dental treatment. These have been system-
atized as follows by3 :
1. Conditioning or traumatization is considered a direct
and most common step in the emergence of dento-
phobia. It is based on negative personal experiences
acquired on visits to the dentist, involving painful inter-
ventions or those generally perceived as unpleasant or
traumatic. From this empirical and well substantiated
point of view, dentophobia is primarily regarded as a
phenomenon created by dentistry itself.12
2. Mere accounts of the consequences of poor dental
health and painful, laborious interventions at the den-
tist’s office may trigger dentophobia especially among
children, even without the persons or children ever hav-
ing had any unpleasant experiences. The media as well
as booklets about dental health distributed in kinder-
gartens and schools tend to create unforeseen problems
in this regard.
3. Witnessing painful dental treatment experienced by
parents and siblings or even other persons could be an
indirect cause of dentophobia.13
4. The threat of a visit to the dentist as a penalty for a
child’s misbehavior may serve as an indirect cause of
dentophobia.
5. Finally, dentophobia may be passed on from a parent
to a child. Learning from role models and imitative
learning are concepts that would explain how anxiety
is duplicated by a child.
Apart from individual idiosyncrasies of a person –
such as sensitivity to disgust, pain, congenital or acquired
anxiety, evident psychological diseases – the loss of control
is regarded as a major psychological factor in the emer-
gence of dentophobia. Loss of control is interpreted either
as an actual anxiety-inducing factor 4,11,14 or as a factor
aggravating the rising anxiety of a person,1 and is an inher-
ent aspect of any dental intervention. Therefore, measures
that enhance the patient’s control of the situation are of
prime importance.
Conditioning has been addressed as the main cause
of dentophobia in many reviews, which refer to a
vicious circle. Fear of dental treatment leads to avoid-
ance behavior which concerns the visit to the dentist
as well as daily oral hygiene. This results in impaired
dental health which then necessitates more intensive
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168 ABURAS et al.

TA B L E 2 List of the most common measurement instruments

Self-reporting by means of
validated questionnaires
DAS-Dental Anxiety scale
Modified Dental Anxiety Scale
(MDAS)
The Dental Subscale of the
Children’s Fear Survey
Schedule
Anxiety Disorders Interview
Schedule for DSM-IV (ADIS-IV)
The Dental Fear Survey (DFS)
Fear Questionnaire (FQ)
Wong-Baker FACES pain rating
scale
Adolescents’ Fear of Dental
Treatment Cognitive Inventory
(AFDTCI)
Smiley Faces Program (SFP)
Armfield’s Index of Dental
Anxiety and Fear (IDAF)
Behavioral assessment by direct
observation
Venham Rating Scales
Behavior Profile Rating Scale
(BPRS)
Visual Analogue Scale (VAS)
Corah, NL, Gale, E. N., Illig SJ. Assessment of a dental anxiety scale. J Am Dent Assoc.
1978;97:816–9.
Humphris, GM, Morrison, T, Lindsay SJE. The modified dental anxiety scale: validation
and united kingdom norms. Community Dent Health. 1995;12:143–50.
Klingberg G. Reliability and validity of the Swedish version of the Dental Subscale of the
Children’s Fear Survey Schedule, CFSS-DS. Acta Odontol Scand. 1994;52:255–6.
Brown TA, Di Nardo PA, Lehman CL, Campbell LA. Reliability of DSM-IV anxiety and
mood disorders: implications for the classification of emotional disorders. J Abnorm
Psychol. 2001;110:49–58. https://doi.org/10.1037//0021-843X.110.1.49.
Kleinknecht RA, Klepac RK, Alexander LD. Origins and characteristics of fear of
dentistry. J Am Dent Assoc. 1973;86:842–8.
https://doi.org/10.14219/jada.archive.1973.0165.
Marks IM, Mathews AM. Brief standard self-rating for phobic patients. Behav Res Ther.
1979;17:263–267.
Wong DL, Baker CM. Pain in children: comparison of assessment scales. Pediatr Nurs.
1988;14:9–17.
Gauthier JG, Morin BA, Dufour L, Ricard S. [Concomitant and discriminatory validity of
the Adolescents’ Fear of Dental Treatment Cognitive Inventory]. J Can Dent Assoc.
1991;57:733–6.
Buchanan H, Niven N. Validation of a Facial Image Scale to assess child dental anxiety.
Int J Paediatr Dent. 2002;12:47–52. https://doi.org/10.1046/j.09607439.2001.00317.x.
Armfield JM. Development and psychometric evaluation of the index of dental anxiety
and fear (IDAF-4C+). Psychol Assess. 2010;22:279–87. https://doi.org/10.1037/a0018678.
Venham L, Bengston D, Cipes M. Children’s responses to sequential dental visits. J Dent
Res. 1977;56.
Melamed BG, Hawes RR, Heiby E, Glick J. Use of filmed modeling to reduce
uncooperative behavior of children during dental treatment. J Dent Res.
1975;54:797–801. https://doi.org/10.1177/00220345750540041701.
Appukuttan D, Vinayagavel M, Tadepalli A. Utility and validity of a single-item visual
analog scale for measuring dental anxiety in clinical practice. J Oral Sci. 2014;56:151–6.

and potentially more painful dental treatment; the lat-
ter appears to justify and aggravate a patient’s fear of the
dentist.6,14
The published literature is inconsistent with regard to
the role played by parents.15 Several studies report an
association between dentophobia in parents and that in
children.15 However, the causality behind the association
remains unclear. The small number of studies that have
measured this phenomesnon in a comparable manner by
validated scales (DAS, DFS) report diverse conclusions.8 In
one study comparing the impact of learning by role models
with the impact of the child’s own traumatic experiences,
the authors conclude that the latter phenomenon is much
more significant.7
3.5 Emotional and behavioral
symptoms of dentophobia
The most important consequence of dentophobia, which
is also one of its clear symptoms is avoidance behavior:
anxious patients tend to avoid visits to the dentist or do
not keep their appointments. Furthermore, many of them
either do not perform their personal oral hygiene, or do so
in a rudimentary fashion. Sooner or later this leads to poor
dental health 6 or – since the teeth influence the entire
organism – worsen the person’s general health (such as
leading to endocarditis).8
At the dentist’s office dentophobia is initially expressed
as negative feelings and physiological stress reactions or

ABURAS et al.
even dizziness and fits of unconsciousness. It is also fre-
quently associated with uncooperative behavior on the
part of the patient, which makes it difficult for the den-
tist to provide appropriate quality-assured treatment.6
The spectrum of these manifestations is large and may
extend from the patient’s anxious refusal to open his/her
mouth to fits of rage and aggression. This, in turn, causes
stress for the dentist and his staff as well as inappropri-
ate or inadequate reactions that worsen the conflicting
situation.1,3,6,8,16
3.6 Interventions for dealing with
dentophobia
3.6.1 Dental and pharmacological
interventions
One anxiety-reducing effect of dental techniques is
derived from the fact that the intervention does not
require local anesthesia and dispenses with an injec-
tion; injections give rise to anxiety in many patients.
These methods include dental sandblasting, atraumatic
restorative treatment,6,17 ultrasonic devices,18 and work-
ing with infrared laser.18 One means of providing local
anesthesia without an injection is electronic anesthesia.
However, the effects of this approach are unreliable and
unpredictable.6,14
The commonly used tools of pharmacological (local)
anesthesia tend to numb the patient’s perception of pain,
which also has the effect of reducing anxiety. Anxious
patients frequently need additional medication to reduce
their anxiety and thus ensure smooth and standard
treatment. Psychotropic drugs, however, call for extreme
caution especially in children and adolescents as well
as specific patient groups (such as those with addictive
diseases or lung diseases) and elderly persons19 . This
is due to the addiction potential of benzodiazepines
as well as its side effects such as respiratory depres-
sion or muscle relaxation that need to be taken into
account.
3.6.2 Psychotherapeutic interventions
These primarily consist of behavioral therapy: cognitive
restructuring, modeling, biofeedback and relaxation
techniques, graded exposure, massed exposure, and
systematic desensitization by means of pictures, video
films or virtual reality, as well as psychoeducation by
way of training the patient.3,6,14,20,21 All interventions
of psychotherapy have a preventive character. In fact,
some of them are mainly preventive in nature because
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169
they cannot be used directly in the acute setting.6 The
published literature mentions various models for the
application of psychotherapeutic interventions. Some are
administered by the dentist trained in psychotherapy,
which (such as relaxation techniques) are especially use-
ful for acute interventions. Others are administered by a
professional psychotherapist working at the medical office
or the dental clinic, who then provides treatment of longer
duration.3,6,11,14
3.6.3 Communication-based interventions
A basic factor in dealing with dentophobia is the den-
tist’s communication behavior. This includes simple
forms of communication such as the creation of a
relationship of trust, showing empathy, addressing the
patient’s questions and anxieties, as well as well-founded
information about diagnosis and treatment, which go
a long way in reducing anxiety.6 In general, all forms
of communication that enhance the patient’s coopera-
tion are favorable: encouragement, clear instructions,
or positive acknowledgment of the patient’s behavior.
When dealing with children it would be advisable to
include the parents in the communication process. In
the case of very anxious patients, it would be advisable to
involve an accompanying person who could provide social
support.6
On the contrary, non-communication-based interven-
tions, which are no longer contemporary methods, are
raising one’s voice, verbal rebukes, or coercive physical
measures such as holding the child still, placing one’s
hand on the mouth’s child, or fixing the child to a spe-
cial chair.8 Studies have shown that these measures have
a traumatic effect on a large majority of children and do,
in fact, cause dentophobia in the first place or aggravate
it. Some children react to such measures with anger and
resentment.6,16 For obvious reasons, such measures are
clearly unacceptable and inadvisable.
Measures of distraction and diversion are given substan-
tial attention in the published literature. Especially in the
case of children these include counting tasks or encourag-
ing them to undertake imaginary journeys.10,22,23 Recently,
significant attention has been given to various forms of
auditory and visual distraction. The simplest forms provide
special background music24 , even with headphones. More
laborious procedures utilize the options of virtual reality
glasses and 2D or 3D video films.6,20
Forms of communication that call for a specific type of
training on the part of the dentist or his/her staff have also
been discussed and tested. These include the traditional
tell-show-do method or its extension, the explain-ask-do
method, which informs the patient about the anticipated

170
course of treatment, the instruments used for it, and their
mode of function.6 The fact that dentophobia can also
be triggered by the loss of control associated with the
treatment has given rise to communication systems that
provide the patient a means of influencing the treatment
while it is in progress. The simplest of these systems
is agreed-upon hand signals to indicate interruptions,
acoustic signals, or blinking one’s eyes.6
3.6.4 Complementary interventions
In addition to these three types of intervention we have
complementary measures which are primarily used as
a supplement or addition. These include hypnosis11 ,
aromatherapy (such as the aroma of lavender oil), the use
of acupuncture or homeopathy.14,25–27
3.7 Efficacy of the interventions
With regard to the efficacy of the various types of inter-
vention, the following may be concluded: (1) No single
method is the best and would deserve to be given pref-
erence over others in all cases; (2) A mixture of various
interventions oriented to the patient’s needs appears to be
the best available approach.11,22
3.7.1 Effects of medical and
pharmacological interventions
In accordance with general expectations, anxiety-reducing
effects have been reported for technical medical inter-
ventions as well as pharmacological methods of sedation.
Depending on the severity of anxiety, a combination of
these is recommended.11,22 However, this approach is
subject to two points of criticism: (1) pharmacological
interventions are less readily accepted by patients than
non-pharmacological ones, (2) these measures do not per-
mit anxious patients to cope with their anxiety problems in
a structured manner and develop appropriate behavioral
strategies.14
3.7.2 Effects of psychotherapeutic
interventions
Psychotherapeutic interventions proved to be basically
effective for the treatment of dentophobia. Nevertheless,
systematic reviews and meta-analyses express cautious
conclusions. This is because of the diversity of methods
used in the studies, including combinations of meth-
ods, as well as the heterogeneity of the measurement
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ABURAS et al.
procedures used; these factors limit the comparability of
the studies.10,14,26 Therefore, psychotherapeutic interven-
tions are primarily recommended for long-term treatment,
in the acute setting, and for patients with moderate anxiety
problems. A combination of these with psychotropic drugs
are recommended for patients with severe or most severe
symptoms of anxiety. Combinations of these are also
advised because they enhance the acceptance of dental
interventions.26
Children constitute a special category because anxious
and defensive behavior in potentially fear-inducing sit-
uations associated with an impending loss of control is
normal in children to the age of 11 or 12 years.4 Since
the stages of development vary markedly in children, and
because they react differently due to specific personality
traits, it is impossible to provide a standardized one-size-
fits-all recommendation for children.10 A small number of
studies addressing the effects of psychotherapeutic inter-
ventions for fear of injections in children have reported
significantly positive results.10 Given the problems associ-
ated with the use of psychotropic drugs in children, many
reviews strongly advocate non-pharmacological options
for the reduction of anxiety in children.6
Relaxation through breathing exercises, monitoring the
patient’s heartbeat, and progressive muscle relaxation have
been proven clearly effective in terms of reducing anxiety
and negative emotions.3,14,25 Under specific circumstances,
these procedures may be used in the acute setting as well.
Interestingly, these techniques have a favorable effect on
the patient as well as the dentist, and consequently have a
beneficial effect on the doctor-patient relationship. While
breathing exercises and monitoring a patient’s heartbeat
work better on experienced or practiced patients, progres-
sive muscle relaxation can be used effectively by a dentist
trained in the procedure.6
Positive results have also been reported for the method
of cognitive restructuring (CR). The same is true for long-
term cognitive behavioral therapy in the group setting.25
So-called one-session interventions were developed to
counteract the difficulty of using these interventions in
the acute setting. One-session interventions are forms of
CR that require only one session. These strategies were
developed and tested, and some of them were found to
be effective. One-session CR proved superior to purely
communication-based interventions. The results support
the use of the method in the acute setting as well14,25
Compared to five or more CR sessions, this form proved
to be much more effective and the effects persisted for a
longer period of time.25
One comparison showed that progressive muscle
relaxation (pME) and CR are both effective in reducing
dentophobia, but much larger effect sizes were noted
for pME. Contrary to the proposed hypothesis, the

ABURAS et al.
combination of the two methods failed to enhance the
overall effect significantly.25
Systematic desensitization (SD) by various techniques
(pictorial or video-based confrontation) may also exert a
positive effect in terms of reducing dentophobia.3,6,10,14,22,25
However, the efficacy of this method has been proven with
a high degree of evidence only for those persons who com-
pleted a full program. In these persons the effects were still
measurable at the 10-year follow-up.3
Graded and massed exposure (gE, mE) – which are
defined as confrontation with the anxiety-inducing stim-
ulus slowly and with gradually increasing intensity over
several sessions, or a single massive confrontation – were
reported to achieve positive effects independent of the
severity of anxiety at baseline.3,14,25 Besides, techniques
of exposure can be easily combined with cognitive tech-
niques to enhance their effects. No appreciable effects
have been reported for the various forms of modeling.
3.7.3 Effects of communication-based
interventions
The positive effect of communication that basically
expresses empathy and understanding towards the patient
has been extensively demonstrated in the published liter-
ature – not only with regard to the work of a dentist. The
dentist’s empathy towards the patient determines whether
the latter experiences anxiety or trust; in fact, it is even
more important than the dentist’s technical competence.6
With regard to informing the patient comprehensively,
anxiety-reducing effects have been reported for sensory
information that describes the anticipated feelings and
pain, as well as prognostic information that describes the
patient’s condition after the intervention and later.6,16,25
We have only anecdotal information and little qualitative
evidence of the anxiety-reducing effect of the tell-show-
do method, which is very popular among many dentists
in many countries.6 The same is true for appointments
between the doctor and the patient, which give the patient
an opportunity to influence the treatment.6 High-quality
research on both subjects is rather meager. However, the
fact that such opportunities of control could reduce anx-
iety has been proven by the highly significant results of
tests with a computer-based system which lets the patient
“speak”; it permits the patient to communicate his/her
pain, that he/she wishes to have more anesthesia, interrupt
the procedure, etc.6
The effects of distraction in general, especially in chil-
dren, are well established. Robust evidence has been
reported for the anxiety-reducing effects of auditory
and audiovisual media such as music, television or
games.6,10,28–32 However, this is not true of all forms
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171
of distraction; no effects were proven for virtual reality
glasses.6
3.7.4 Effects of complementary
interventions
Hypnosis appears to reduce anxiety, but only in persons
who are responsive to it. In non-responsive patients it may
have the opposite effect.6,11 Acupuncture proved to be an
effective intervention for dentophobia and the perception
of pain, both in the acute setting as well as in long-term
treatment. At least acute pain was reported to be alleviated
by acupressure.14 In one RCT, aromatherapy with laven-
der oil reduced anxiety to a certain extent compared to
a control group.25 In general, these non-pharmacological
and non-psychotherapy-based techniques could be useful
and deserve to be included in the spectrum of treatment
options for dentophobia.
4 SUMMARY AND CONCLUSION
Despite the fact that many questions concerning defi-
nitions and measuring instruments for the description
of dentophobia remain unanswered at the present time,
the estimated prevalence derived from the existing data
indicate that at least 20% of persons experience moder-
ate dentophobia. It was also reported that people with
stronger sense of coherence (SOC) have lower levels
of dentophobia.33 This makes dentophobia, a common
problem in children and adolescents worldwide,34 a
highly relevant problem for patients affected by the
condition as well as dentists and the public health
system in general.35,36 Children play a major role in
pathway to develop dental phobia. Since many of the
pathways to develop dentophobia start in this age
phase.3
No ideal solutions have been developed yet for cop-
ing with the problem. However, the dentist has several
options to address dentophobia, both preventively as well
as in the process of treatment, in the acute setting and in
long-term therapy. In view of the fact that negative expe-
riences and traumatization during dental treatment are
considered to be the most common cause of dentophobia,
the dentist should be addressed as the target for potential
interventions.
In summary, the following may be stated about coping
with dentophobia:
We have robust evidence of the fact that mild forms
of dentophobia can be avoided or reduced by the
dentist himself through competent communication strate-
gies. This is especially true in regard of basic empathy,

172
communication that evokes trust, and passing on sensory
as well as prognostic information.
We have equally robust evidence of the fact that, in
clinical routine at the dentist’s office, common forms of
distraction are liable to reduce anxiety, especially among
children. Furthermore, the suitably trained dentist can
reduce anxiety by methods of biofeedback. In appropri-
ate cases, hypnosis and other methods of complementary
medicine may also be useful.
Dental as well as pharmacological interventions were
shown to reduce dentophobia in the acute setting,
although the latter type of intervention should be used
with the utmost caution.
We also have evidence of the fact that the spectrum of
interventions based on behavioral therapy in general may
help persons to cope with their dentophobia, in the acute
setting as well as the mid or long term. Techniques of
biofeedback are very suitable in the acute setting; this is
especially true of pME, CR and SD are also effective, but
only after several sessions or after the patient has com-
pleted an entire program. The same is true of gE. The
existing body of data on mE is currently insufficient.
Other interventions have not yet been substantiated by
adequate evidence, primarily because of the paucity of
research on the respective subject. This is true of the poten-
tial effects of the tell-show-do method and its extensions,
as well as methods of agreement concerning cooperation
between the doctor and the patient, which are currently in
the process of development. The latter methods are focused
on creating a co-productive relationship which enables the
patient to control and direct the course of treatment. There
is an urgent need for research on the subject. Such research
should address not only the efficacy of these interventions
but also, in the course of phase-4 studies, address the
question as to what conditions will be needed to achieve
the foreseeable effects of the interventions. Implementa-
tion studies of this type would have to take various legal,
organizational and social conditions of dental action into
account.
However, in general the given evidence appears ade-
quate to express suitable guidelines for coping with den-
tophobia. These should be substantiated by facilities of
education and advanced training in the form of courses to
acquire the skills stipulated by the guidelines.
CONFLICT OF INTEREST
All authors certify that they have no affiliations with or
involvement in any organization or entity with any finan-
cial interest or non-financial interest in the subject matter
or materials discussed in this manuscript.
E T H I C S S TAT E M E N T
Not applicable.
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ABURAS et al.
ORCID
Dritan Turhani https://orcid.org/0000-0002-7311-3191
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How to cite this article: Aburas S,
Pfaffeneder-Mantai F, Hofmann A, Meller O,
Schneider B, Turhani D. Dentophobia and dental
treatment: An umbrella review of the published
literature. Spec Care Dentist. 2023;43:163–173.
https://doi.org/10.1111/scd.12749