Characterizing Causal Mechanisms to Prevent Dental Fear and Anxiety

January 2020

Behavioral and Social Science Research Branch
Division of Extramural Research

Goal

The purpose of this initiative is to support mechanistic research to explain the etiology of dental fear and anxiety and to develop or refine interventions to prevent dental fear and anxiety based on causal mechanisms.

Background

Prior research suggests that individuals who report heightened dental fear or anxiety are more likely to delay or avoid dental care, have poorer oral hygiene and oral health, and require more time, behavioral management, and extensive treatment when they do present for treatment.¹ While estimates vary by measurement used, studies suggest that approximately 10-20% of individuals across the lifespan have clinically-significant dental fear.^2,3 As with many other health conditions, vulnerable or underserved populations tend to bear the largest burden of dental fear and its associated oral health disparities, including those from rural communities, those with limited English fluency, immigrants, and those from marginalized racial/ethnic communities.⁴ Further, estimates of dental fear and anxiety in the general population have been strikingly stable going back at least as far as the late 1960s, suggesting a clear need for innovation in this space.⁵

Ongoing research aims to improve treatment regimens available to individuals with dental fear or anxiety. Currently available pharmacological approaches including anxiolytics and sedatives/anesthetics may help patients manage intense or urgent experiences of fear or anxiety. However, the costs or medical contraindications associated with pharmacological interventions may be substantial if not prohibitive, and these approaches may alleviate aversive experiences of anxiety but do not resolve the underlying processes that perpetuate avoidance of dental care. To treat dental fear and anxiety over the long term, researchers and clinicians are working to adapt cognitive behavioral therapies — the current standard of care for specific phobias and anxiety disorders – to meet the unique needs and experiences of individuals with dental fear.² Though this scientific enterprise will require further time and resources to reach the goal of highly effective and widely accessible treatments for dental fear and anxiety, the general objectives of intervention refinement and challenges of dissemination and implementation are relatively clear. Still, even with widespread implementation of effective treatments, the most persistently avoidant patients may still miss out on the care they need. As such, it will be critical not only to develop clever plans for delivering evidence-based treatments for dental anxiety, but also to prevent dental anxiety before it becomes entrenched in peoples’ lives.

Compared with extant research on anxiety treatment, scientific understanding of the etiology of dental fear and anxiety — critical insight necessary to inform the development and implementation of prevention strategies — remains somewhat limited. Relatively few empirical studies have examined the factors that spark dental fear and anxiety or the processes by which they become entrenched. Effective interventions to prevent dental fear and anxiety across the lifespan could have tremendous benefits for the oral health of the U.S. and beyond, but much foundational work remains to be done. For instance, one lingering question in the field concerns the primacy of painful or upsetting experiences in initiating cycles of dental fear and anxiety. On this topic, some researchers suggest that aversive experiences are both necessary and sufficient to generate dental fear and anxiety,⁶ whereas others attribute importance to characteristics of the individual, such as the way they remember or degree to which they fear painful experiences,⁷ and others still acknowledge a diversity of sources for dental fear and anxiety, including processes entirely outside the dental clinic, such as cultural norms or beliefs about dental procedures or beliefs and expectations that are transmitted from parents to children.⁸ These and other questions about the etiology and prevention of dental fear and anxiety are ripe for scientific inquiry that incorporates relevant insights from the broader field of affective science and embraces rigorous methodological and analytical techniques. 

Gaps and Opportunities

The behavioral and social science community has demonstrated relatively organic momentum toward improving and expanding treatments for dental fear and anxiety, much of it funded by NIDCR in the form of investigator-initiated research. The proposed initiative would capitalize on recent advances and capacity to stimulate research in the adjacent but relatively nascent domains of etiology and prevention.

This initiative would align with recent activities by NIDCR Program Staff, including a workshop on dental fear and anxiety developed by the Behavioral and Social Sciences Research Branch and held in July 2019. In considering the current state of the science, one of the strongest recommendations of the broad group of scientists and practitioners in attendance was the immense need for evidence-based approaches to prevent dental fear and anxiety. This initiative would also complement other NIDCR initiatives (e.g., PAR-20-058, “Improving oral health and reducing disparities in adolescents”), and in some cases may encourage the application of implementation science principles from NIDCR’s 2018 FOA (RFA-DE-18-001) to the prevention of dental fear and anxiety.

More broadly, this initiative would align with priority areas and goals that emerged from the NIDCR 2030 visioning initiative, especially the integration of oral health and overall health, advancing precision oral health, and overcoming health disparities.

Scientific Areas of Interest

The proposed initiative encompasses behavioral and social science research — both basic and applied — relevant to the etiology or prevention of dental fear and anxiety. Specific topics may include:

• Processes by which aversive experiences and personality traits interact to generate or perpetuate dental fear and anxiety
• Precise strategies by which dental care providers may respond to patients during and after upsetting or painful experiences to prevent the development of recurring fear or anxiety
• Mechanism(s) by which social influence from various sources (e.g., parents, peers, society) may generate dental fear or anxiety independent of aversive experiences
• Strategies for creating positive experiences in dental settings may motivate approach (return) behaviors and preempt fixation on subsequent negative experiences that might otherwise motivate avoidance
• Attitude inoculation or other approaches to preventing the uptake and influence of expectations that dental procedures are painful or something to be feared
• Processes unique to special groups or populations, including pediatric populations, racial/ethnic minority groups, etc.

References

1. Armfield, J. M., & Heaton, L. J. (2013). Management of fear and anxiety in the dental clinic: A review. Australian Dental Journal, 58(4), 390-407.
2. Gordon, D., Heimberg, R. G., Tellez, M., & Ismail, A. I. (2013). A critical review of approaches to the treatment of dental anxiety in adults. Journal of anxiety disorders, 27(4), 365-378.
3. Hare, J., Bruj-Milasan, G., Newton, T. (2019). An overview of dental anxiety and the non-pharmacological management of dental anxiety. Primary Dental Journal, 7(4), 36-39.
4. Patrick, D. L., Shuk Yin Lee, R., Nucci, M., Grembowski, D., Zane Jolles, C., & Milgrom, P. (2006). Reducing oral health disparities: A focus on social and cultural determinants. BMC Oral Health, 6(S4), 1-17.
5. Smith, T. A., & Heaton, L. J. (2003). Fear of dental care: Are we making any progress? The Journal of the American Dental Association, 134(8), 1101-1108.
6. Oliveira, M. A., Vale, M. P., Bendo, C. B., Paiva, S. M., & Serra‐Negra, J. M. (2017). Influence of negative dental experiences in childhood on the development of dental fear in adulthood: a case–control study. Journal of oral rehabilitation, 44(6), 434-441.
7. Randall, C. L., McNeil, D. W., Shaffer, J. R., Crout, R. J., Weyant, R. J., & Marazita, M. L. (2016). Fear of pain mediates the association between MC1R genotype and dental fear. Journal of Dental Research, 95(10), 1132-1137.
8. Dahlander, A., Soares, F., Grindefjord, M., & Dahllöf, G. (2019). Factors Associated with Dental Fear and Anxiety in Children Aged 7 to 9 Years. Dentistry Journal, 7(3), 68.