Anxiety and Phobia in Dental Settings: Theories and Their Relations

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Dental anxiety is one of the most common ordeals and challenges faced by dental practitioners around the world. Yet very little is known about the reasons for this anxiety. While many models have been put forward to identify and define reasons for anxiety and phobia production, there is still very little known about the true nature of fear, phobia, and anxiety, and especially, fear and phobia within clinical settings. The clinician in most circumstances is left to his own devices in managing a clinical case of anxiety and phobia, with mixed results each depending on the individual dentist him or herself.

Dental fear and anxiety are one of the common issues faced by practitioners in clinical settings. There are no rules or age limits in this matter, and whereas a young child may show no signs of fear or apprehension in the clinical procedures, an older patient may experience extreme anxiety to even prophylactic procedure, and vice versa. Similarly, various studies have shown that dental anxiety is not sex-specific.

Many efforts have been undertaken in order to understand the basis of dental anxiety, and theories have been postulated to clarify this dilemma. For example, it is hard to comprehend extreme dental phobia in a child who may not have had any clinical exposure to a dental setting before. Now dentists are able to understand the importance of a positive and stress-reducing environment in reducing anxiety.

The percentages of people suffering from anxiety-related issues in dental settings are relatively high, which emphasizes the need for understanding the key issues that contribute to it. Anxiety can lead to altogether avoidance in a person to undertake dental care. While external factors may lead to the creation of the anxiety pattern in a patient, the subsequent dental treatment and procedures and their experiences may either exacerbate or altogether nullify the condition. Therefore, predental and post-dental experiences and thought patterns are serious contributors to anxiety-related issues in a patient. ¹

Age, sex, and previous experiences of dental procedures, also seem to play an important role and may affect the psychological approach to dentistry. Understanding the role of age and the onset of particular anxiety may be very helpful in the management of such patients. For example, children may be exposed to a minimum of bloody procedures to help them deal with anxieties of blood. Accepting and easing adolescents in an open and friendly doctor and patient relationship can help address the social anxieties that these individuals are going through. And adults may be facing agoraphobia or claustrophobia, along with the feeling of loss of control, which can be handled with proper care.

Social factors may include the experiences of a family member or peers, and their positive or negative experiences may condition the responses of a previously unexposed patient to the dental setting. Similarly, negative feedback from a parent and fear of needles may evoke a strong phobic response in a child. It may be that some individuals may become fearful of dental procedures after adolescence, and may have had no such problem in their childhoods. These procedures are classic examples of conditioning following painful dental procedures. In all age groups, the fear needs to be handled on the psychological make as well as the mental caliber of the patient.

The current debate is the applicability of the various fear and anxiety-related theories that have been revolving in the literature for many years. The application of these theories in dental clinical setup is no doubt different when comparing to other everyday life events. Patients are more prone to show dental anxiety than generalized medical anxiety, and this is counterproductive to both parties. The patient in his fear may not resort to treatment, which eventually may lead to exacerbation of his symptoms, poor results and outcomes, and a further increase in the cognitive response of fear for the dentist and the procedures of dentistry. On the other hand, dental anxiety among the patients is among the biggest challenges for the practicing clinicians and this conserves much of their time and energies to help the patient relax.

The theoretical models of fear and anxiety in this regard are able to identify some crucial aspects of the personality and its possible role in the development of dental anxiety yet is still unhelpful given the vast variety of reactions that can be exhibited in every patient. Previously, such theories were relying on the conditioning responses and/ or the Darwinian concepts of inherent fears and reaction patterns. If such is the case, almost all the patients would respond to a fear or anxiety factor in more or less the same way. However, this is not the case. Studies that have been carried out in the research for dental anxiety all have come to one conclusion. That individual variation can lead to an entirely different response to the expected or predictable pattern thought of before. While it is wrong to claim that such predictions and theories are completely unable to address or help clinicians identify with anxiety issues, they nevertheless do show gaps in their theoretical knowledge and need more extensive researches for proper identification of human nature.

Of the many factors thought to contribute to dental anxiety, a study by Moore has shown some elements of embarrassment as contributory to dental phobia and anxiety. ²His research is based on understanding the factors other than the usually debated ones, such as pain, previous experiences, etc., and focusing on the personality of the patient and various stimuli and environmental factors that may be contributory to the present state of response in the dental environment. The key lies in identifying various psychological behaviors among patients that are left undiagnosed, such as public and social anxieties and phobias. Moore’s study was significant in identifying that fear of pain and “social powerlessness” and “lack of control in the dental settings” are the main reasons for anxiety within the dental settings. Certain factors such as the doctor’s approach to the treatment, or seemingly lack of attention given to the patient may contribute towards it, as well as embarrassment over lack of attention given by the patient about his or her oral hygiene state or consulting a dentist at the appropriate time. This Moore explained through examples, was especially seen in patients who may have a take-charge attitude towards life. In such cases, the person may not be willing to accept failure to handle his own oral hygiene, and this, in turn, can lead to the integration of embarrassment as a factor in seeking dental treatment.

The “latent inhibition” theory explains the phenomenon as a direct result of the kind of experience the patient had undergone. ³ This theory states that a positive experience in a dental environment helps the patient cope with more demanding procedures, with lesser anxiety or negative conditioning. However, a negative experience, especially in childhood can cause pain, anxiety, and negative response from the patient in even very mild procedures. The psychological makeup of the patient, such as an anxious patient may exacerbate the patient’s outlook towards the treatment. This theory, however, lacks in identifying fear in patients who may never have undergone any dental procedure or may not have been conditioned negatively about it by peers or family members. Still, such patients may exhibit intense phobia and fear of the procedure. Also, some patients in normal clinical situations and life, in general, maybe very open and relaxed with no anxieties, yet still may become intensely scared of the dental procedure. The latent inhibition theory, therefore, although used in the past, fails to clarify such patients.

The inhibition theory still has shown its efficacy in identifying dental anxiety reasons in a part of the population. Such patients may show intensely anxious or very relaxed attitudes towards the dental treatment, independent of the type of procedure carried out. Hence, the initial treatments are done on the patients, if mild and of less intensity, can evoke favorable conditioning, and may help such patients in managing and dealing with their dental anxieties.

Moore’s study is an attempt to clarify the various personality issues that are often ignored when considering dental phobias and anxieties. However, among these only neuroticism has shown some suggestive relation with dental anxiety. There are many factors that contribute to the feeling of embarrassment, and these may include bad conscience, and self-punishment attitudes, secrecy or taboo thinking, self-esteem issues, and personality changes usually accompanied by social withdrawal. Understanding this factor may be of immense help in the clarification of issues surrounding dental anxiety. Many assumptions have been made regarding personality issues in dental phobias and anxieties. Many psychologists agree that negative images of self are largely contributory to not only dental but also to surgical and dermatological treatments.

Broadly speaking, dental anxiety has been assumed to take shape due to various psychological factors. These include “personality characteristics, conditioning experiences, vicarious learning or modeling, body image perceptions, blood injury fears, various coping styles and pain reactivity”.

But the main problem is the multi-dimensional nature of dental anxiety and therefore, the complexity of the factors that contribute towards it. Classified as either Exo or endogenous, the patients are usually done so due to the nature of the stimuli they have received over the years or the type of conditioning that they experience. Exogenous patients are those who have had negative dental experiences in the past, and therefore, assume that any visit to the dentist will be a bad one. Endogenous patients, may, however, not have had any dental experience at all, but may feel apprehensive due to their natural psychological makeup.⁴

The vicious circle theory is a little different from the classic division of exogenous and endogenous patients primarily as it focuses on the addition and snowball effect of various experiences into full-fledged phobias, fears, and anxieties. However, in contrast to the Exo and endogenous people reaction development, this reaction may occur within minutes, with a rapid rate of development. The anxiety stimulus may be very insignificant, such as a prick of the injection needle by the dentist, yet the anxiety reaction elicited may lead to a person collapsing into a state of shock. The simple action can in such cases elicit a state of chain reaction, which can lead to the rapid development of acute anxiety states.

Other theories of dental and anxiety phobia include the 3-alarms theory, catastrophic cognition theory, and others. The associative and non-associative theories of anxiety are among those theories which are undergoing extensive changes of outlooks. The depth of these types of fears has now shown independent patterns to those that were used to define them. Catastrophic theory, one of the most cited and debated ones of its times, explains the phenomenon of anxiety and fear based on the different physical as well as environmental sensations, that may evoke anxiety. The body sensations become an important contributor to the fear and can lead to attacks of panic.⁵ Since this theory believes that positive feedback intensifies the reaction state, it follows that a previous procedure may cause intense reactions even a mild exposure or revision of the event. The levels of reactions may vary, and may not, in fact, be so intense to cause alarm, but this theory has in many ways explained the intensely close relationship of the mind to the body, and the way both can affect and influence each other.

Yet this theory is very much dependant on the thought process of a person, and this may be difficult to fathom and may be unreliable, as opposed to a concrete physical symptom or sign. Again this physical sign may be up for debate, for the reflex and conditioned thoughts may lead to physical and bodily responses. Yet these thoughts again are a myriad of complexities, made of both emotional and mental processes. And excluding these two basic components of the human mind hardly leaves us with any real substance to debate on.

The core theory is perhaps one of the best models of fear acquisition and anxiety models. This elaborate model details the presence of three-alarm kinds and two alarm systems. The alarms may be triggered in response to stresses, early experiences, genetic influences, etc. Whether the alarm is true or false, the application of the body’s defense mechanisms is essentially the same, and the responses are likewise not different. The two anxiety systems include innate primitive present-oriented fear system and the future–oriented defensive anxiety system.

The theoretical approach however how much developed, becomes unnecessary and even sometimes useless should a clinical situation arises. In clinical situations, the dentist may not be properly able to address and remove the patient’s anxiety due to several reasons. These may include the time constraints, the failure or the inexperience of the dentist to realize and recognize the needs of the patient, the inability to distinguish various personality types, and how they would react and respond to the different situations. The lack of information about the patient’s mental, emotional and social state, and the effect of the external environment including family, peers, and the public on the development of anxiety and fear in relation to dentistry. This is because each individual demands separate attention and understanding, which may not be easy to do so for a new practitioner. Therefore, the identification of the fear factor or its proneness to it is actually dependant on the clinician’s experience.

in conclusion, dental anxiety and phobia have been topics of discussion and theoretical frameworks for many years, yet understanding this phenomenon still remains until and unless we find out the true nature of fear and anxiety, and what governs and affects it. Proper patient care and satisfaction are highly dependant on the level of ease the patient feels with the dentist, the dental procedure, and the dental settings. A good dentist can help reduce phobias in such patients, but a bad dentist is more likely to create a permanent negative picture of the profession as well as the motivation to do something about his or her oral health. The identification of this area is therefore very important for anyone aspiring to be a good clinician.

REFERENCES

George C. Economou, 2003. Dental Anxiety and Personality: Investigating the Relationship between Dental Anxiety and Social Consciousness. Journal of Dental Education, Volume 67, No. 9.
Rod Moore, Inger BrØdsgaard and Nicole Rosenberg, 2004. The Contribution of Embarrassment to Phobic Dental Anxiety: a Qualitative Research Study.BMC Psychiatry. 2004; 4, 10.
A.J. van Wijk and J. Hoogstraten, 2005. Experience with Dental Pain and Fear of Dental Pain. Journal of Dental Research 84(10):947-950, 2005.
D. Locker, A. Liddle, L. Dempster and D. Shapiro, 1999. Age of Onset of Dental Anxiety. J Dental Res 78(3) 1999.
Walton T. Roth, Frank H. Wilhelm and Dean Pettit, 2005. Are Current Theories of Panic Falsifiable? Psychological Bulletin, Vol. 131, No. 2, 171-192.

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Anxiety and Phobia in Dental Settings: Theories and Their Relations

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