_______________________________________________________ Treating the Apprehensive Dental Patient
A person with mild dental fear can develop a phobia about dental treatment as time progresses, particularly if an adverse event occurs. A phobia is diagnosed when the fear or anxiety is out of proportion to the actual danger posed by the object or situation [49]. Most dental clinicians lack formal training in psychology and should refer patients to a psychologist or psychiatrist if their level of apprehension becomes an obstacle to obtaining dental treatment. SCREENING The dental profession relies on precise measurements as an important parameter in assessing clinical situations (e.g., the depth of periodontal pockets) to determine the appropriate course of treatment. For example, a crown with an open margin of as little as 0.1 mm will allow bacterial ingress in between the crown margin and the prepared tooth, with the subsequent development of recurrent caries and a consequent clinical failure. Such precision requires patient cooperation in addition to clinician skill, and apprehensive patients may be unable to comply to the level necessary to ensure optimal dental care. Dental professionals should understand that patients’ dental apprehensions are real and subjective; they cannot be measured objectively. However, there are questionnaires to help assess dental anxiety and fear. The Corah Dental Anxiety Scale uses a series of four questions with answers ranging from “A,” for the lowest level or absent anxiety, through “E,” for the most severe anxiety reactions. The lowest cumulative point total (4) corresponds to a relaxed patient, while the highest cumu- lative point total (20) identifies a patient with severe dental apprehension [52]. The Mount Sinai Dental Fear inventory consists of 14 situa- tions common to the dental setting, with the option of listing one additional dental situation. Each item is assigned a value of 0 to 100, whereby 0 signifies complete relaxation and 100 indicates fear to the extent that the patient may faint, become ill, or be unable to continue with dental treatment [28]. The higher the cumulative point value, the higher the level of dental apprehension experienced by the patient. The answers patients provide to these questionnaires are subjective, but they provide the dental clinician with an initial baseline by which the level of apprehension can be assessed. ORIGINS OF DENTAL APPREHENSION There are several theories about the underlying origins of dental fear, anxiety, and phobia. Given the variable level and extent of dental apprehension among patients, there is not one universal theory of etiology that can apply to all cases. This section will highlight the most commonly cited sources, but it is not an exhaustive list, and the apprehension may originate from multiple sources and be affected by the patient’s unique emotional, psychological, physiologic, and spiritual history and makeup.
Studies indicate that the majority of patients with dental phobia have onset in childhood or adolescence, with an average age at onset of 12 years [40; 45]. Intense anxiety or unexpected panic responses in the presence of specific objects or situations can mark phobia onset but are not the sole causal route. Disgust, either alone or combined with fear, may trigger the onset and maintenance of blood-injection-injury phobias. Onset can even occur indirectly by observing others reacting fearfully. Some stimuli are more likely to induce phobias than others through evolutionary threat relevance. Hyperactivity in certain parts of the brain (the amygdala, anterior cingulate cortex, and insula) is believed to be the underlying pathophysiology of specific phobia. In order for a true phobia to be diagnosed the fear or anxiety must be per- sistent (longer than six months) and markedly stronger than the actual threat of the object or situation [49]. However, even subclinical phobia can interfere with the delivery of dental care and the maintenance of optimal oral hygiene. The origin of dental apprehension can be generally categorized into two distinct groups: exogenous and endogenous. Patients with exogenous dental fear and/or anxiety have experienced a traumatic dental event (either personally or vicariously). Examples of personally traumatizing dental events include dif- ficult and lengthy surgical procedures, an inability to achieve an appropriate level of local anesthesia during a dental procedure, and severe pain following a dental procedure. However, not all patients who experience these or similar events during dental treatment will become fearful, anxious, or phobic toward future dental treatment. Endogenous dental fear or anxiety has no known triggering experience and instead develops as a result of an individual’s unique predisposition or vulnerability to anxiety [6]. These categories are not mutually exclusive, and many patients display characteristics of each. It is important to remember that patients with a psychiatric or psychological disorder (other than specific dental phobia) may not have fear, anxiety, or phobia and may undergo dental treatment without incident. The fear of pain is one of the most common sources of dental apprehension and is usually associated with previous experi- ences of dental treatment-related pain [7]. The avoidance of pain is a basic survival instinct and can trigger the “fight-or- flight” response that provides a protective mechanism for humans [8]. A traumatic dental experience can stimulate this basic, yet essential response and cause the patient to approach future dental appointments with fear, anxiety, or even phobia. Dental pain may also cause a loss of trust. If a dental clinician promises a procedure will be pain-free and this is untrue, the patient may believe any procedure can result in pain. Beyond the fear of pain, there are many other situations that can cause varying levels of dental apprehension. The fear of a loss of control or helplessness is another potential source of dental apprehension [9]. Most dental procedures are performed
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