July 15, 2019
NIH, Bethesda, Md.
People range from being completely comfortable to extremely fearful when it comes to visiting the dentist. Being afraid enough to avoid the dentist results in more tooth decay and an increased likelihood of poor oral health.
To explore the problem, NIDCR convened “Addressing Fear and Anxiety: Steps Toward Accelerating Progress and Building a Cumulative Science.” The workshop, which was held in July in Bethesda, Md., drew US and Canadian researchers from the fields of dentistry, psychology, and psychiatry. Their charge was to examine how fear and anxiety are currently managed in dental settings, consider what can be learned from other fields, and discuss interventions being developed to help dental patients manage their fear. They also addressed practical challenges to integrating fear-reducing interventions with dental care.
The expert input will be used by program officers in NIDCR’s Behavioral and Social Sciences Research Program to set directions for future research. The branch’s interests include behaviors that affect oral health and the study of interventions used in dental practices.
The expert panel agreed that preventing anxiety and fear is a priority. Fear—relative to dentistry—is understudied. An estimated 10% to 20% of US adults have some trepidation about going to the dentist. Despite improvements in technology and materials used in dentistry, these levels have stayed constant since the 1960s.
The participants noted that there are tools to alleviate anxiety for the “haters, but goers,” who show up to the dental office despite intense aversion. But dentists can’t help the people who never sit in a dental chair. There was a consensus that advancing oral health on a broad scale will require a wider public conversation about dental care. Such discussions should aim to counter negative—and sometimes cartoonish—depictions of dental visits.
The workshop attendees believe that preventing fear should start early, perhaps before a child’s first visit to the dentist. It is important to detect and manage distress early to prevent a child from developing persistent fearful associations with dental visits.
Although researchers know less than they would like about how children develop anxiety, they do know that children pick up on the anxiety of their parents and other caregivers. Studies show that the way caregivers talked with children about medical and dental procedures shaped children’s memories of how painful and distressing those procedures were. Also, specific (“labeled”) praise associated with desired behaviors—for instance, “You did a great job sitting still during your cleaning”—is more helpful to children than simply saying, “You did a good job.”
The extent of a child’s fear and anxiety predicts how cooperative they will be in the dentist’s chair. Creating positive experiences builds positive associations for patients. One workshop participant, a dental researcher who works with children with special needs, described how his practice draws on Snoezelen, a Dutch approach to designing a space that feels comfortable, safe, and fun. His practice’s space includes a trampoline for jumping off nervous energy and tailored sensory environments, where lights, sounds, textures, and experiences are designed specifically for a patient’s needs. Children are allowed multiple visits to acclimate to the dentist’s office and to use the tools that help them manage their anxieties. This approach makes it possible to treat children who otherwise might not get dental care. (People with special needs have worse dental health and more untreated caries than the general population.) Adults with special needs also have done well in this setting. By limiting distress, dentists also may be able to do fewer hospital-based surgeries with full anesthesia for conditions that would normally be treated in a dental office.
The participants from mental health fields described effective, proven anxiety and fear treatments that could be integrated into the dental setting. The psychologists noted the success of cognitive behavioral therapy in helping people face situations that scare them and reduce the fear-inducing qualities of those experiences over time. Virtual-reality exposure therapy, a variation on traditional cognitive-behavioral exposure therapy, was highlighted. Virtual-reality exposure therapy has been used to successfully treat people who may be afraid of heights or flying and to help combat veterans diagnosed with post-traumatic stress disorder. The treatment exposes patients to virtual simulations of fear-invoking situations (such as standing on a high balcony), and, with a therapist’s guidance, patients learn how to overcome those feelings.
In addition to behavioral methods, there is also a place for pharmacological interventions to manage anxiety in the short term, the researchers said. Behavioral approaches seem to provide the advantage of long-lasting results, and they give patients coping skills that are transferable to other medical settings. Workshop participants viewed both treatment methods as potentially valid, alone or in combination, depending on the clinical need and available resources. A concern was raised about access to behavioral treatments in under-served clinics and community settings, highlighting the need to consider the ramifications for equity in any line of dental fear intervention research.
Because patients may use words such as fear, anxiety, and nervousness interchangeably, most of the researchers agreed that academic endeavors to establish semantic distinctions were not as helpful as identifying specifically what people dreaded. To treat the fear, dentists need to know what triggers the feelings. Could it be injections, dental instruments, specific procedures, fear of gagging or choking, the sound or smell of drilling, concern about one’s oral health status, or shame about lack of compliance with previous hygiene instructions?
Workshop participants emphasized the need for the right intervention for the right person at the right time, a goal that is hampered by the lack of universal standards for dentists to assess patients’ anxiety. A potential solution is to include such assessments on patient intake forms.
The workshop participants discussed the importance of dentists’ acknowledging the cultural background of their patients. In some communities, for example, stoicism may be a value, so patients may downplay any concerns they have. People in communities that have been under-served may be reluctant to go to a dentist.
Various studies are being conducted to learn whether devices such as smart phones and iPads could be used to reliably deliver interventions either at home or in the dentist’s office prior to treatment. One such approach is to determine effectiveness of videos that expose patients to dental instruments and procedures, so they know what to expect. Early results are promising, and some participants found the actual procedures easier to endure than the videos they viewed. One dental school takes a completely different approach to managing fear. A trained service dog sits in the dental chair with pediatric patients during their treatments. The dog’s presence calms the young patients.
Integrating effective anxiety treatments into dental practices poses some logistical hurdles. Questions were raised about work flow and care roles. Should the patients’ fears be addressed before they get to the dentist’s office? Who in the office—the hygienist, dentist, or someone else—should administer interventions? How could technology best be used to deliver efficacious behavioral therapies?
Training was an important consideration for the group. Some suggested that dental students receive enhanced training related to patient communication skills or mental health, and they proposed including these topics in dental school curricula. Given that dental students already have heavy coursework and clinical requirements, the experts also said it will be important to address the feasibility and sustainability of additional training.