FEAR

ANXIETY
PHOBIA
V.Tejaswika
PG 1st year
 CONTENTS
• INTRODUCTION

• EMOTION

• FEAR

• ANXITEY

• FEAR AND ANXIETY SCALES

• PHOBIA

• REFERENCES
4
 EMOTION
DEFINITION
DEFINITION

An effective state of consciousness in which joy, sorrow, fear, hatred or the likes
are expressed.

A strong feeling state, arising subjectively and directed toward a specific object,
with physiological,somatic and behavior components.
(Dorland’s medical dictionary for health consumers)
5
Characteristics of commonly seen emotion in a child

Distress or Cry

Anger

Fear

Anxiety

Phobia

6
Behavioural pedodontics:- It is a
study of science which helps to
understand development of fear,
anxiety and anger as it applies to
child in the dental situations
7
▸ Behavior: Is an observable act,
which can be described in
similar ways by more than one
person.
▸ ”It is defined as any change
observed in the functioning of
the organism.”
 Dorland Medical FEAR….
Dictonary

•
• The
The unpleasant
unpleasant emotional
emotional state
state consisting
consisting of
of psychological
psychological and
and psycho-physiological
psycho-physiological responses
responses to
to
a
a real external
real external threat or danger including agitation, alertness, tension and mobilization of the
threat or danger including agitation, alertness, tension and mobilization of the
alarmed
alarmed reaction.
reaction.

Delbridge

A
A PAINFUL
PAINFUL FEELING
FEELING OF
OF IMENDING
IMENDING DANGER,
DANGER, EVIL,
EVIL, TROUBLE,
TROUBLE, ETC.
ETC.

Rubin

REACTION TO A KNOWN DANGER

8
Fear related emotional pattern

• Shyness…..

• Characterized by shrinking from

contact with who are stranger and
unfamiliar

• It is always stimulated by people

never by objects, animals or
situations.

9
• In baby usual response in shyness is crying, turning
the head.

• If able to walk- run away and hide

• Older children- by blushing, by stuttering, by

nervous mannerisms- a pulling at the ears or clothing,
shifting from one foot to the other, and bending the
head to one side

10
 Embarrassment:
Fear reaction stimulated by uncertainty about how people
will judge one and one’s behaviour.

State of self conscious distress.

Not present in a child less than 5 or 6 years old

11
 Different types of fears corresponding to age
0-2 yrs

Loss
Loss of
of support
support
Strange
Strange objects
objects

Loud STRANGER
STRANGER
Loud noises
noises

12
2-4 yrs

Being alone

Darkness

13
 Development of fear
At birth
Preschooler: (2-4)
Early schooler(4-7 yrs):
Late schooler(8-11 yrs) :
primary response-startle reflex , newborn is
unaware of the stimulus
- With age he starts becoming aware of
fear, can fight or flight
-
Fear of animals or being left alone or abandoned
- More apprehensive about failures, learns to
fear his prestige
Fear of the dark, staying alone, shows fear of
supernatural powers like ghosts and witches,
imaginary objects and situations fear of war,
spies, beggars etc
Fear of bodily injury
- Fear of failure, not being liked,
competition, fear of punishment
- fear of crowds and heights
- fear of separation from parents
14
4-7 yrs
Environment at
threat
Imaginary creatures
Animals

15
TYPE OF
FEAR

16
 Innate fear
▸ Without stimuli or previous experience

▸ It is thus also dependent on the vulnerability of the

individual

17
 Objective Fear :
• Produced by direct physical stimulation of the sense organs
and are generally not of parental origin.

• Objective fears are responses to stimuli that are felt, seen,

heard, smelled or tasted, and are of a disagreeable or
unpleasant nature.

18
SOUND OF DRILL FEAR EVOKING DENTAL SITUATION

Anesthetic
Anesthetic administration
administration locally
locally by
by
injection
injection
Extraction
Extraction

19
* The Fear of Needles: A Systematic Review and Meta‐Analysis journal of advanced nursing
* Jennifer Mclenon Mary A.M. Rogers
* First published: 14 August 2018 
Aims
* To evaluate the prevalence of needle fear and summarize the characteristics of individuals who exhibit this fear.
* Systematic review and meta‐analysis.
* Review Methods
* Prevalence of needle fear was calculated and restricted maximum likelihood random effects models were used for meta‐
analysis and meta‐regression.
Results
* The search yielded 119 original research articles which are included in this review, of which 35 contained sufficient
information for meta‐analysis. The majority of children exhibited needle fear, while prevalence estimates for needle fear
ranged from 20‐50% in adolescents and 20‐30% in young adults. In general, needle fear decreased with increasing age. Both
needle fear and needle phobia were more prevalent in females than males. Avoidance of influenza vaccination because of
needle fear occurred in 16% of adult patients, 27% of hospital employees, 18% of workers at long ‐term care facilities and 8%
of healthcare workers at hospitals. Needle fear was common when undergoing venipuncture, blood donation and in those with
chronic conditions requiring injection.
Conclusions
* Fear of needles is common in patients requiring preventive care and in those undergoing treatment. Greater
attention should be directed to interventions which alleviate fear in high risk groups.
 Subjective fear:
I heard that dental
Is that so I never had one treatment
gives a lot of pain

Subjective fears are those based on feelings and attitudes that have been suggested to the child
by others about him without child’s having had the experience personally.

Shoben and borland reported that fear of dentistry in adult was based more on what they heared
about dentistry from their parents than on anything else

The influence of parents is one of most important in child attitude towards dentistry.

21
 Suggestive fear : Acquired by imitation by observation of other

Imitative
Imitative fears:
fears: transmitted
transmitted while
while displayed
displayed by
by other
other (parent)
(parent) and
and acquired
acquired by
by the
the child
child without
without being
being
aware of it.
aware of it.

Displayed
Displayed emotion
emotion in
in parent’s
parent’s face
face creates
creates more
more impression
impression than
than verbal
verbal suggestions.
suggestions.

•
• Even
Even aa tight
tight clenching
clenching of
of the
the child’s
child’s hand
hand in
in dental
dental office
office while
while undergoing
undergoing dental
dental treatment
treatment creates
creates
fear in child’s mind about dental treatment
fear in child’s mind about dental treatment

Imaginative fear: As the child’s imaginative capability

develop, they become more intense with age and mental
development with certain age.

22
 * Factors causing dental fear

1. Fear of pain or its anticipation

2. Fear of betrayal or A lack of trust
3. Fear of loss of control
4. Fear of the unknown
5. Fear of intrusion

23
 Fear of pain or its anticipation:
▸ The link between actual or misinterpreted pain, or the anticipation of pain and
dental fear is well established.

▸ We frequently see children who report that they were experiencing pain, but the
dentist ignored them and carried on.

Fear of betrayal
Trust may also be learned either direct from the behavior of the parents, or peers.

Fear of unknown
In anyone’s eyes, a visit to the dentist may be classified as a potentially threatening condition.
Helpful comment from the mother such as, it will not hurt; even before an examination,
aregoing to raise thepossibility in the child’s mind of being hurt .

24
 SYMPTOMS
SYMPTOMS OF
OF INTENSE
INTENSE FEAR
FEAR
Unpleasant feeling of terror • Pounding of the heart

• Tense muscle

• Liability to startle

• Dryness of throat and mouth

• Sinking feeling

• Nausea feeling

• Anger

• Weakness

• Sense of unreality
25
 CHRONIC FEAR LEADS TO….
Tiredness
Difficulty in sleeping and bad dream

•
• Restlessness
Restlessness
•
• Loss of
Loss of apatite
apatite
• Aggression
• Aggression
•
• Avoidance of tension
Avoidance of tension producing
producing situation
situation
26
PHYSIOLOGICAL
PHYSIOLOGICAL SIGN
SIGN OF
OF FEAR
FEAR

27
Described at three levels
RESPONSE TO FEAR

Intelectual
Intelectual level:
level:

Where
Where the
the child
child is
is readily
readily to
to accept
accept the
the situation
situation and
and face
face the
the difficulties
difficulties to
to
achieved result and benefits ( usually seen at adolescent age)
achieved result and benefits ( usually seen at adolescent age)

Emotional
Emotional level:
level:

Usually
Usually the
the child
child shows
shows the
the fight
fight or
or flight
flight response,
response, which
which acts
acts as
as an
an instantaneous
instantaneous
response. (seen in school age)
response. (seen in school age)

Hedonic level

Usually reflected as self-centeredness, thereby accepting what is comfortable and rejecting

what is not without too much concern for the outcome or nature of the treatment
28
 Value of fear
▸ Fear lowers the threshold of pain so that every pain produced
during the dental treatment becomes magnified.

▸ Fear has safety value when given proper direction and control.

▸ Since fear producing stimuli can cause actual harm to the child,
fear is protective mechanism for self protection.

29
▸ The nature of fear can be utilizes to keep the child away from
dangerous situation of either social or physical nature.

▸ If child does not fear punishment or parental disfavor, his

behavior may make him a threat to society.

30
 The
The child
child should
should be
be taught
taught that
that dental
dental office
office is
is not
not a
a place
place to
to fear.
fear.

On the other hand, if the child has become attached to the dentist, fear of loss of his
approval may have some value in motivating the child for dental treatment

31
 MEASURING CHILD DENTAL FEAR

Measuring child dental fear involves several difficulties regarding technique as well as
interpretations of results.

Four main types of measures have been used:

1. Rating of child behavior during dental visits,

2. Psychometric scales,

3. Physiological measures,

4. Projective techniques
32
COMMONLY USE FEAR SCALE

33
 CHILDREN’S FEAR SURVEY SCHEDULE

The Children’s Fear Survey Schedule, or CFSS, is designed to assess a range of general fears in
children.

• Given by Scherer and Nakamura (1968)

• It consists of 80 items on a 5-points likert scale.

Newton JT, Buck DJ. Anxiety and pain measures in dentistry: a guide to their quality and application.
The Journal of the American Dental Association. 2000 Oct 31;131(10):1449-57

34
• A dental subscale (CFSS-DS) has been developed by cuthbert
and melamed that consists of 15 items rated on a five-point
scale, ranging from 1 (not afraid) to 5 (very afraid).

35
36
Scale scores are calculated by summing item scores; the total score can
range from 15 to 75.

• Scores above 38 indicate significant dental fear.

• The CFSS-DS has been found to discriminate between children who do and
do not display dental fear and behavioral problems during dental treatment.

37
 Venham Picture Scale

• Age group 4-11 years.

• This scale consists of a series of eight paired drawings of a child

Venham LL, Gaulin -Kremer E. A self-report measure of situational anxiety for

young children. Pediatr Dent. 1979 Jun;1(2):91-6

38
39
The children were asked to point at the figure they felt most like at that moment.

All cards were shown in their numbered order.

If the child pointed at the ‘anxious’ figure a score of one was recorded, if the child
pointed at the ‘nonanxious’ figure a score of zero was recorded.

The number of times the ‘anxious’ figure was chosen was totalled to give a final
score (minimum score, zero; maximum score, eight).

40
 KLEINKNECHT’S DENTAL FEAR SURVEY.

• Age group above 12 year

• Second most commonly use

• Originally developed as 27 item scale (Kleinknecht ’ et al 1978) and subsequently reduced to 20

items.

Kleinknecht RA, Thorndike RM, McGlynn FD, Harkavy J. Factor 69 analysis of the dental fear
survey with cross-validation. Journal of the American Dental Association (1939). 1984
Jan;108(1):59.

41
• Kleinknecht’s Dental Fear Survey asks respondents to rate their anxieties about 20 specific
situations—
such as
making an appointment or hearing the dental drill—
on a five-point Likert scale ranging from “none” to “great.”

• These factors are reliable and stable across different groups of respondents.
.

Kleinknecht RA, Thorndike RM, McGlynn FD, Harkavy J. Factor 69 analysis of the dental fear
survey with cross-validation. Journal of the American Dental Association (1939). 1984
Jan;108(1):59.

42
43
 FEAR ASSESSMENT PICTURE SCALE(FAPS )
 6-8 years age

 The FAPS was designed by taking a part of Klingberg’s children dental fear picture
test (CDFP) pointing picture.

 what do you feel when a dentist checks your oral cavity with instruments?

Tiwari N, Tiwari S, Thakur R, Agrawal N, Shashikiran ND, Singla S. Evaluation of

treatment related fear using a newly developed fear scale for children:“Fear
assessment picture scale” and its association with physiological response.
Contemporary clinical dentistry. 2015 Jul;6(3):327.

44
 WHAT DO YOU FEEL WHEN A
DENTIST CHECKS YOUR ORAL
CAVITY WITH INSTRUMENTS

45
 ANXIETY

• Theterm anxiety entered the field of psychology as a translation of the German

word “Angst”, which was used by Freud in 1936

• Anxiety is a normal part of childhood, and every child goes through phases.

• A phase is temporary and usually harmless.

• But children who suffer from an anxiety disorder experience

fear, nervousness, and shyness, and they start to avoid places
and activities.

46
Is an emotion similar to fear but arising without any objective source of danger.

• Is a reaction to unknown dangerand learned process being in response to one’s

environment.

• As an anxiety depends on the ability to imagine, it develops later than fear

47
 Types of anxiety

Trait anxiety.

• It is life-long pattern of anxiety as a temperament feature.

• It is a preset level of anxiety experienced by an individual who has tendency to be more

anxious; to react less appropriately to anxiety provoking stimuli.

• These children are generally jittery, skittish, and hypersensitive to stimuli.

48
 STATE ANXIETY

• These are acute situational-bound episode of anxiety that do not persist

beyond the provoking situation.

• It is a fear, nervousness, discomfort, and the arousal of the autonomic

nervous system induced temporarily by situations perceived as dangerous

• Examples: A child feels anxious when confronted by a large, strange

animal. A person feels anxious to get on an airplane for the first time .

49
Free floating anxiety:

• It is condition of persistently anxious mood in which the cause of emotion is

unknown and many other thoughts or event trigger the anxiety.

Situational anxiety:

• It is only seen in specific situations or objects.

General anxiety:

• Where the individual experiences a chronic pervasive feeling of anxiousness,

whatever may be the external circumstances.
50
Causes of Anxiety
Uncertainty

Previous Learning

Biological Difference

51
Dental anxiety and its implications for paediatric dentists

• With regard to paediatric dentistry, it is important to keep in mind that

anxious patients manifest their anxiety in different ways.

• Some can respond with disruptive or interruptive behavior.

• Others can respond by sweating and an increased heart rate, whereas other
patients do not show any external sign of anxiety.

52
• Dental anxiety, and the avoidance of situations that involve dental treatment
and care, have frequently been considered to be the source of serious oral
health problems in children and adults.

• High levels of anxiety prevent a patient from cooperating fully with their
dentist, which can result in lost time for the practitioner and unnecessary
difficulties when carrying out the treatment, and, most importantly, can limit
the effectiveness of the dental treatment and prevent the early detection of
pathological processes

53
 Methods of assessing dental anxiety
• Objective
• Subjective

54
Types OF ANXIETY MEASURING SCALE

 Venham picture test

 Venham anxiety & behavior rating scale
 Facial image scale
 Visual analogue scale
 Children’ fear survey schedule –dental subscale (CFSS-DS)
 Corah’s dental anxiety scale (DAS)
 Modified Corah’s dental anxiety scale (DAS)
 Clinical anxiety rating scale
 Revised children’s manifest anxiety scale(RCMAS)

55
 Corah’s Dental Anxiety Scale

• The most widely used for measurement of dental anxiety

• Developed by Norman Corah and Panterra (1969)

• DAS, is a four-item measure.

• Respondents are asked about four dentally related situations and are asked
to indicate which of four responses (of increasing severity) is closest to
their likely response to that situation.

Corah
Corah NL.
NL. Development
Development of
of a
a dental
dental anxiety
anxiety scale.
scale. Journal
Journal of
of dental
dental research.
research. 1969
1969 Jul
Jul
1;48(4):596
1;48(4):596
56
57
Scoring the Dental Anxiety Scale, Revised (DAS-R)

a = 1, b = 2, c = 3, d = 4, e = 5
Total possible = 20

Anxiety rating:

• 9 - 12 = moderate anxiety but have specific stressors that should be discussed and
Managed

• 13 - 14 = high anxiety

• 15 - 20 = severe anxiety (or phobia).

May be manageable with the Dental Concerns Assessment but might require the help of a
mental health therapist.

58
 Venham
Venham Anxiety
Anxiety and
and Behavior
Behavior Rating
Rating Scales
Scales

• These two scales assess the anxiety and uncooperative behavior of children in the
dental setting.

• Both scales consist of five behaviorally defined categories ranging from 0 to 5, with
higher scores indicating greater levels of anxiety or lack of cooperation.

• This is one of the most reliable indicators of observed anxiety and has been
used predominantly in anxiety assessment protocol.

Venham
Venham L,L, Gaulin-Kremer
Gaulin-Kremer E,
E, Munster
Munster E,
E, Bengston-Audia
Bengston-Audia D,
D, Cohan
Cohan J.
J. Interval
Interval rating
rating scales
scales for
for
children’s dental anxiety and uncooperative behavior. Paediatr Dent 1980; 2:195-202.
children’s dental anxiety and uncooperative behavior. Paediatr Dent 1980; 2:195-202.

59
ANXIETY THERMOMETER

This is the image of thermometer where the respondent

selects a point on the thermometer to rate anxiety,
where

1= no anxiety, and

10= extreme anxiety

60
FACIAL ANXIETY SCALE

61
 * RMS-pictorial scale-(2015)

Shetty RM, Khandelwal M, Rath S. RMS Pictorial Scale (RMS-PS): An

Raghavendra, Madhuri,
innovative scale for the assessment of child's dental anxiety. Journal of
Sujata (RMS) Pictorial Scale
Indian Society of Pedodontics and Preventive Dentistry. 2015 Jan
1;33(1):48.
 * CHOTA BHEEM– CHUTKI SCALE

Sadana G, Grover R, Mehra M, Gupta S, Kaur J, Sadana S. A novel Chotta Bheem–Chutki

scale for dental anxiety determination in children. J Int Soc Prevent Communit Dent
2016;6:200-5.
* FEAR VS ANXIETY
Behavioural treatment in
fearful child
▸ Communication Behavioural treatment for
▸ Euphemisms anxious child
▸ Distraction - visual and auditory ▸ Desensitization
distraction, ▸ Modelling
▸ background music, television ▸ Tell show do
sets, computer games, and 2-D
and 3-D video glasses for
watching movies.

▸ Parent in operatory
 BEHAVIORAL
BEHAVIORAL TREATMENT
TREATMENT OF
OF FEARFUL
FEARFUL CHILDREN
CHILDREN
Communication

EUPHEMISMS
EUPHEMISMS
Distraction
Guided imagery

• The guidance cooperation model

• Time-structuring
• Behavior modification
• Parent in operatory

66
J Indian Soc Pedod Prev Dent. 2018 Apr-Jun;36(2):167-172.
Assessment of the effect of parental presence in dental operatory on the behavior of children aged
4-7 years.
Ahuja S1, Gandhi K1, Malhotra R1, Kapoor R1, Maywad S1, Datta G1.
AIMS AND OBJECTIVES:
The objective is to evaluate the influence of parental presence or absence in the operating room on child's
behavior during dental procedure on children of 4 years and above.
MATERIALS AND METHODS:
The study was carried out on 30 children of 4-7 years of age group, 16 (4-6 years) preschoolers, and 14
(6-7 years) early schoolers. Two consecutive restorative procedures were carried out. On a first visit,
parents were present and on a second visit, separation of parents was done. Behavior rating was done by
commonly used Frankel's Behavior Rating Scale.
RESULTS:
Chi-square test was performed for the statistical analysis. There was no significant difference found in the
child's behavior by the presence or absence of parents in the perception of dental treatment in the dental
operatory. In contrast to that there was a significant increase in cooperative behavior of some children due
to other factors influencing the behavior of the child with a Chi-square value = 35.296, P < 0.001.
CONCLUSION:
Parents can be excluded from the dental operatory to eliminate many behavior-related problems during
the course of treatment.
J Clin Pediatr Dent. 2017;41(6):399-423.
Barriers and Drawbacks of the Assessment of Dental Fear, Dental Anxiety and Dental Phobia in Children: A
Critical Literature Review.
Asl AN, Shokravi M, Jamali Z, Shirazi S.
OBJECTIVE:
Dental anxiety, fear and phobia have different etiology, response patterns, time courses, and intensities that
justify a clear distinction between these constructs. Differentiation of dental anxiety, fear or phobia in
practice is a critical prerequisite for developing and implementing effective treatment for children. The aim of
this study was to investigate whether current researches in the pediatric dentistry appropriately discriminate
the central construct of dental anxiety, fear and phobia. We also highlighted the specific methodological issues
in the assessment of these issues in pediatric dentistry.
STUDY DESIGN:
A systematic search was conducted in Pubmed/medline and Scopus for articles which assessed dental anxiety,
fear or phobia in children.
RESULTS:
104 research papers were included in the review that had made a distinction between dental anxiety, fear and
phobia and had not used them interchangeably. Only five studies used different clinical measures or cut-offs to
discriminate between dental anxiety, fear and phobia.
CONCLUSION:
The dental literature appears unable to capture and also measure the multi-sided construct of dental anxiety,
fear and phobia and, therefore, there was a tendency to use them interchangeably.
 PHOBIA

* It is an irrational fear resulting in the conscious avoidance of a specific feared object,

activity or situation.

* PHOBIA
It may be defined as a persistent, excessive, unreasonable fear of a specific object,

activity or situation that results in a compelling desire to avoid the dreaded object.
Types of phobia

* Shelhan (1982) divided anxiety and phobia into two major groups:
1. exogenous (non-endogenous)
2. Endogenous

Non-endogenous: This is a psychologically affected group which involves situation

related anticipatory anxiety symptoms such as:

* Moist palms

* Fluttery stomach

* Fine hand tremors

* Shaky inside

* Rapid heartbeat
* Endogenous
This anxiety is present without any prior warning or the presence of any detectable stress
situation. The cause is “to be produced from within". This type of anxiety Phobia in Childhood
has a more severe cluster of symptoms such as:

* Light headedness or dizziness

* Difficulty in breathing
* Parasthesia
* Hyper-ventilation
* Chest pain
* Losing control
* Simple phobia – fear of single object

Acrophobia- Height; Zoophobia- Animals; Pyrophobia- Fire; Anthrophobia- People;

Odontophobia - Dentist; Claustrophobia-Closed space

* Situational phobia – fear of open or crowded places

* Social phobia – fear of appearance, public speaking

 PHOBIA IN CHILDHOOD

* 2-4years-fear of animals-Zoophobia
* 4-6years-darkness-Nyclophobia
* 11-12years-school- Didaskaleinophobia
* 12years-dental phobia-Odontophobia
* Adolescence-fear of blushing and fear of being looked at.
 summary
▸ Basic and complex emotions
▸ Attachment
▸ Compliance through parenting styles
▸ Children are unique and do not exist in isolation

76
 REFERENCES

Pediatric Dentistry-Nikhil marwah

Clinical pedodontics : Sidney Finn

Pediatric dentistry principles and practice M.S Muthu shviakumar

 
Newton JT, Buck DJ. Anxiety and pain measures in dentistry: a guide to their quality and application. The
Journal of the American Dental Association. 2000 Oct 31;131(10):1449-57

The Fear of Needles: A Systematic Review and Meta‐Analysis journal of advanced nursing Jennifer
Mclenon Mary A.M. Rogers 14 August 2018
 
Shetty RM, Khandelwal M, Rath S. RMS Pictorial Scale (RMS-PS): An innovative scale for the assessment
of child's dental anxiety. Journal of Indian Society of Pedodontics and Preventive Dentistry. 2015 Jan
1;33(1):48.
77
.

Sadana G, Grover R, Mehra M, Gupta S, Kaur J, Sadana S. A novel Chotta Bheem–Chutki scale for
dental anxiety determination in children. J Int Soc Prevent Communit Dent 2016;6:200-5.

Barriers and Drawbacks of the Assessment of Dental Fear, Dental Anxiety and Dental Phobia in
Children: A Critical Literature Review. J Clin Pediatr Dent. 2017;41(6):399-423.

Assessment of the effect of parental presence in dental operatory on the behavior of children aged 4-7
years. J Indian Soc Pedod Prev Dent.2018 Apr-Jun;36(2):167-172.