Management of

dental phobia
LIBRARY DISCUSSION

Fathima Arshad, Gayathri Menon, Heino Tony, Henna Khadeeja

Introduction

Fear and anxiety toward the dentist and dental treatment are both significant

characteristics that contribute to avoidance of dental care. Anxiety associated

with the thought of visiting the dentist for preventive care and over dental

procedures is referred to as dental anxiety. It has been cited as the fifth-most

common cause of anxiety by Agras et al.

Anxiety, fear, and phobias are strongly related, in that the three concepts may

lead to one another. Anxiety involves apprehension and arousal regarding a

future situation. Fear usually occurs as a result of exposure to situations that are

either real or imagined. Reactions to these situations are often considered

normal. It is common for children to be afraid of things such as darkness, animals,

and dentists. A phobia is a form of fear that cannot be controlled voluntarily.

Phobias create feelings that are out of proportion to the actual situation. Using

reasoning to overcome phobias becomes difficult, if not impossible. As a result,

individuals usually resort to avoidance of the situation that has become feared

(King, Hamilton, & Ollendick, 1988).

“Anxiety is an emotional state that precedes the actual encounter with the

threatening stimuli, which sometimes is not even identifiable.”

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It is normally experienced in day-to-day life, such as during exams, while making

crucial decisions, in the workplace, and in several other circumstances.

Fear is a reaction to a known or perceived threat or danger. It leads to a fight-or-

flight situation. Dental fear is a reaction to threatening stimuli in dental situations.

Phobia is persistent, unrealistic, and intense fear of a specific stimulus, leading to

complete avoidance of the perceived danger. Overwhelming and irrational fear of

dentistry associated with devastating feelings of hypertension, terror, trepidation,

and unease is termed “odontophobia”, and has been diagnosed under specific

phobias according to the Diagnostic and Statistical Manual of Mental

Disorders (DSM)-IV and the International Statistical Classification of Diseases and

Related Health Problems (ICD).

Both dental anxiety and fear evoke physical, cognitive, emotional, and behavioral

responses in an individual. This is a frequently encountered problem in dental

offices. Anxiety is often closely linked to painful stimulus and increased pain

perception, and thus these patients experience more pain that lasts longer;

moreover, they also exaggerate their memory of pain.

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Treating such anxious patients is stressful for the dentist, due to reduced

cooperation, requiring more treatment time and resources, ultimately resulting in

an unpleasant experience for both the patient and the dentist. Eli suggested that

a strained dentist–patient relationship dominated by severe anxiety resulted in

misdiagnosis during vitality testing for endodontic therapy.

Fearful and anxious individuals feel that something dreadful is going to happen

during dental treatment, and hence do not visit the dentist. Such behavior

ultimately results in bad oral health, with more missing teeth, decayed teeth, and

poor periodontal status. They present to the dental office only when in acute

emergency situations often requiring complicated and traumatic treatment

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procedures, which in turn further exacerbates and reinforces their fear, leading to

complete avoidance in the future. Consequently, a vicious cycle of dental fear sets

in if these patients are not managed appropriately

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Cohen et al reported that dental anxiety affects an individual’s life in multiple

ways.

The physiological impacts included signs and symptoms of the fright response and

feelings of exhaustion after a dental appointment, while the cognitive impacts

included an array of negative thoughts, beliefs, and fears.

The behavioral impacts included not only avoidance but also other behaviors

related to eating, oral hygiene, self-medication, crying, and aggression.

A significant impact on general health due to sleep disturbance was also reported,

which influenced both established and new personal relationships. Furthermore,

social interactions and performance at work were affected, due to feelings of low

self-esteem and self-confidence.

Owing to such widespread significant impacts, it is of utmost importance not only

to efficiently identify dentally anxious individuals but also to treat them

appropriately when they arrive at the dental office. The practitioner should aim at

alleviating the anxiety and fear in such a way that these patients are positively

motivated on a long-term basis for future dental visits.

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This concise review gives an overview of the etiology of dental anxiety, and

strategies to identify and manage anxious or phobic individuals in the dental

office, with brief literature evidence

Dental phobia

Phobic disorders are experienced by 77 out of 1,000 people in the general

population. A person is said to have a phobic disorder when he or she attempts to

avoid an object, situation, or activity. The object, situation, or activity is avoided

because of the enduring, irrational fear that accompanies the situation .

Before a phobia can be defined, it is important to distinguish between the ideas of

anxiety and fear. Anxiety, fear, and phobias are strongly related, in that the three

concepts may lead to one another. Anxiety involves apprehension and arousal

regarding a future situation. Fear usually occurs as a result of exposure to

situations that are either real or imagined. Reactions to these situations are often

considered normal. It is common for children to be afraid of things such as

darkness, animals, and dentists. A phobia is a form of fear that cannot be

controlled voluntarily. Phobias create feelings that are out of proportion to the

actual situation.

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Using reasoning to overcome phobias becomes difficult, if not impossible. As a

result, individuals usually resort to avoidance of the situation that has become

feared .

An Understanding described three groups of phobias: specific, formerly called

simple, social, and agoraphobia. The main focus found that direct conditioning

was believed to be the origin of the fear in the majority of the individuals they

asked.

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Etiology of dental anxiety

Dental anxiety can arise due to multiple factors, such as previous negative or

traumatic experience, especially in childhood (conditioning experiences), vicarious

learning from anxious family members or peers, individual personality

characteristics such as neuroticism and self-consciousness, lack of understanding,

exposure to frightening portrayals of dentists in the media, the coping style of the

person, perception of body image, and the vulnerable position of lying back in a

dental chair.

Anxiety can also be provoked by sensory triggers such as sights of needles and air-

turbine drills, sounds of drilling and screaming, the smell of eugenol and cut

dentine, and sensations of high-frequency vibrations in the dental setting.

Some common fears giving rise to dental anxiety are fear of pain, blood-injury

fears, lack of trust or fear of betrayal, fear of being ridiculed, fear of the unknown,

fear of detached treatment by a dentist or a sense of depersonalization, fear of

mercury poisoning, fear of radiation exposure, fear of choking and/or gagging, a

sense of helplessness on the dental chair, and lack of control during dental

treatment.

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Milgrom et al identified four different groups of anxious patients based on their

origin or source of fear (the “Seattle system”, developed at the University of

Washington). They were

1) anxious of specific dental stimuli,

2) distrust of the dental personnel

3) generalized dental anxiety,

4) anxious of catastrophe.

Based on questionnaires, patients can be categorized as mildly anxious,

moderately anxious, and extremely anxious or dental-phobic. Evidence on the use

of such questionnaires in routine clinical practice is very scarce. The practitioner

should not rely exclusively on clinical judgment in assessing anxious patients, as

studies indicate that there is disagreement between patient self-reported anxiety

status and clinician rating of dental anxiety; moreover, patients report masking

their anxiety, and hence evaluation with brief anxiety questionnaires is beneficial

and recommended, as it not only discloses the degree of anxiety but also appears

to reduce it, thereby facilitating better management.

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Subjective assessment of anxious patients can also be done based on their

psychophysiological, behavioral, and emotional responses

Identifying dentally anxious or phobic patients

The initial interaction of the dentist with the patient can fairly reveal the presence

of anxiety and fear, and in such situations, subjective and objective evaluations

can greatly enhance the diagnosis for successful management.

Semistructured interview and subjective assessment using questionnaires

Semistructured interview

The dentist must have a calm, uninterrupted conversation with the patient and

try to identify which of the dental situations gives rise to fear and anxiety. Asking

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a few open-ended questions can help to guide the conversation in the right

direction. The dentist needs to identify the reason for the current visit, the kind of

experience the patient has had during previous dental treatment, the main fears

and worries, and the expectations. Sometimes, the interview may reveal that the

dental anxiety is part of a wider psychological disorder. In those cases, it is

important that the patient be referred to experts in the field of psychology, such

as a psychologist or psychiatrist. They can make the correct psychological

diagnosis, and decide what kind of further treatment the patient needs. In some

cases, the psychologist and the dentist need to work together, with the former

deciding the treatment plan concerning anxiety.

Anxiety questionnaires

Multiple- and single-item self-reporting questionnaires are available for assessing

anxious and phobic patients. A few such popularly used multi-item scales are

Corah’s Dental Anxiety Scale (CDAS), Modified Dental Anxiety Scale (MDAS),

Spielberger State–Trait Anxiety Inventory, Kleinknecht et al’s Dental Fear Survey

(DFS), Stouthard et al’s Dental Anxiety Inventory, and Gatchel’s 10-point fear

scale. Single-item questionnaires are a Seattle survey item, the Dental Anxiety

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Question, a Finnish single dental anxiety question, a single-item dental anxiety-

and-fear question, and the visual analog scale.

However, none of these existing instruments has been regarded as a gold

standard, as they have their own limitations. The CDAS, MDAS, and DFS are the

most commonly used questionnaires, and have been shown to be reliable and

valid in multiple languages.

The CDAS is a widely used instrument; it is brief and has good psychometric

properties. The scale consists of four questions about different dental situations.

Each question is scored from 1 (not anxious) to 5 (extremely anxious), so the

range of possible scores is 4–20. The cutoff point of more than 15 indicates high

anxiety level or possibly phobic.

The major limitation of this scale is that it does not include a question on anxiety

regarding local anesthetic injection, and also there is no uniformity in the choices

for the questions in the scale, making it difficult to compare the responses.

The MDAS is a brief, well-validated five-item questionnaire with 5-point Likert

scale responses to each question, ranging from “not anxious” to “extremely

anxious”.

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The responses are scored from 1 to 5. The score for the scale ranges from a

minimum of 5 to a maximum of 25. The higher the score, the higher the dental

fear, and a cutoff point for high dental fear has been suggested at a score of 19,

based on clinical relevance. Humphris and Hull reported that the administration

of this questionnaire did not increase anxiety.

The DFS consists of 20 items concerning avoidance behavior, physiological fear

reactions, and different fear objects concerning dental appointments and

treatment. This questionnaire also has five response options, giving summed

scores from a minimum of 20 to a maximum of 100. A cutoff point for high dental

fear has been suggested at ≥60. The scale has three dimensions: avoidance of

dental treatment, somatic symptoms of anxiety, and anxiety caused by dental

stimuli.

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Subjective assessment of anxious patients based on their psychophysiological,

behavioral, and emotional responses

Psychophysiological responses- Behavioral and emotional

responses

Muscle tightness Hyperactivity

Hands unsteady Walking or talking faster
Restlessness In a hurry
Clearing the throat Irritation with delays
Sweating of the palms of hands, forehead, Panicky
upper lip (the palm of the hand can be Blushing
assessed during handshake) Getting tongue-tangled
Pulsation in the carotid and temporal Avoiding people
arteries Nervous habits
Depth and speed of respiration, Stiff Poor memory
posture Confusion, stumbling over words
Holding things tightly Sitting on the edge of the chair,
Strong startle response leaning forward
Frequent urination Rapidly thumbing through
magazines
Pacing
Inattentiveness
Excessive worrying
Outburst of emotions

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Objective measures

Objective measures involve assessment of blood pressure, pulse rate, pulse

oximetry, finger temperature, and galvanic skin response. An extremely accurate

objective method used in various studies to measure dental anxiety is galvanic

skin response. It takes advantage of the electrical changes induced by minute

amounts of fluid from epidermal sweat glands released secondary to anxiety.

Sweat on the skin provides a low-resistance pathway for electric current, which is

then recorded. The use of galvanic skin response has been validated as an

accurate method in measuring dental anxiety

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Management of dental anxiety

The etiology for dental anxiety is multifactorial, and hence there is no

monotherapy for management. Proper evaluation of the patient and identifying

their source and level of anxiety can enable the dentist in deciding a proper

treatment plan. Anxiety can be triggered by even the most innocuous situations,

such as the encounter with the receptionist while scheduling their appointments

or clinic ambience, and thus it is essential that every aspect of the dental practice

be appropriate.

Broadly, dental anxiety can be managed by psycho-therapeutic interventions,

pharmacological interventions, or a combination of both, depending on the

dentist’s expertise and experience, degree of dental anxiety, patient

characteristics, and clinical situations. Psychotherapeutic interventions are either

behaviorally or cognitively oriented, and recently, the use of cognitive behavior

therapy (CBT) has been shown to be highly successful in the management of

extremely anxious and phobic individuals. Based on specific indications, these

patients can be managed pharmacologically using either sedation or general

anesthesia

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Psychotherapeutic interventions

 Communication skills, rapport, and trust building: iatrosedative technique

 Behavior-management techniques

 Relaxation techniques: deep breathing, muscle relaxation

 Jacobsen’s progressive muscular relaxation

 Brief relaxation or functional relaxation therapy

 Autogenic relaxation

 Ost’s applied relaxation technique

 Deep relaxation or diaphragmatic breathing

 Relaxation response

 Guided imagery

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 Biofeedback

 Hypnotherapy

 Acupuncture

 Distraction

 Enhancing control

 “Tell-show-do”, signaling

 Systematic desensitization or exposure therapy

 Positive reinforcement

 Cognitive therapy

 Cognitive behavioral therapy (CBT)

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The dental office environment

Dental office ambience can play a significant role in initiating dental fear and

anxiety. Receptionists, dental nurses, and dental hygienists are crucial personnel

in creating an apt atmosphere in the dental office. They should be positive and

caring, and elicit information from the patients in a unhurried concerned tone to

make the patients comfortable.

The office atmosphere can be made calm and unthreatening by the playing of soft

music and avoidance of bright lights. A slightly cooler dental office was preferred

by individuals in a study by Bare and Dundes. The walls can be adorned with

posters and pictures, the waiting area supplied with ample books and magazines.

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The sounds produced from the instruments in the treatment room should be

muted by closing the door. Importantly, anxious patients should not be made to

wait too long, so that they have less time to absorb negative experiences;

additionally longer waiting times give them time to recall the threatening stimuli.

Introducing pleasant ambient odors to the dental environment can also help to

reduce anxiety by masking the smell of eugenol and by the potential anxiolytic

effects of the odors themselves. Smell can trigger an array of emotions, and can

condition a patient negatively toward dental treatment. Aromatherapy is an

alternative treatment approach, wherein essential oils of aromatic plants are used

to produce positive physiological or pharmacological effects through the sense of

smell. Inhalation of pleasant scents such as essential oils has an anxiolytic effect

and improves mood. Studies have shown it to be more efficient in managing

moderate rather than severe anxiety. In healthy individuals, inhalation of

lavender has been shown to significantly reduce the levels of salivary cortisol,

salivary chromogranin, and serum cortisol, increase blood flow, and decrease

galvanic skin conductance and systolic blood pressure.

A sensory-adapted dental environment (SDE) might also be effective in reducing

anxiety and inducing relaxation. The Snoezelen environment concept aims at

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stimulating the primary senses of sight, touch, feel, and smell, along with patient-

centered therapy. Shapiro et al adapted a “Snoezelen” dental environment for

pediatric patients comprised of dimmed lighting, soothing music, and a special

Velcro butterfly vest that hugs the child, providing a calming, deep-pressure

sensation. Typical children and those with developmental disabilities have been

shown to benefit by this SDE, as behavioral and psychophysiological measures of

relaxation improved significantly in the SDE compared with a conventional dental

environment.

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Communication skills, rapport, and trust building
A good patient–dentist relationship is crucial for the management of anxiety.

Communication strategies are very important. There should always be two-way

communication. The dentist should first introduce themselves and personally

converse with the patient in their office, and listen carefully in a calm, composed,

and nonjudgmental way. Proper information should be acquired from the patient

regarding their dental problems and concerns, taking time to inquire and listen

about their fears (iatro sedative technique). Furthermore, patients should be

encouraged to ask questions about the treatment, and should be kept completely

informed about what is to be done before starting the procedure and also during

the procedure. Keep inquiring if the patients are having any discomfort, give

moral support, and reassure during the procedure. The patients should be

convinced that their words are taken seriously and with utmost concern. Dentists

should give all the necessary complete information regarding description of the

problem, treatment options, and preventive procedures. This meeting should

build good rapport and increase the patient’s confidence in the dentist. Patients

appreciate clear, honest, and straightforward answers; also avoid false

reassurances, as these can break trust. Normalizing anxious feelings and avoiding

negative phrasing can be beneficial. Nonverbal communications are an essential

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skill. Touch can be used to comfort and control the patients. The dentist should

face the patient, make eye contact, and observe them; this is a positive gesture.

Avoid rapid movements, empathize with the patients, and make them feel

welcome, and use understandable words when talking about the treatment.

Usually, a friendly, sensitive, and sympathetic approach will be well appreciated

by patients.

Psychotherapeutic management

Behavior-management techniques

Behavior modification is based on the principles of learning, both in terms of

classical conditioning or operant conditioning and of social learning. It aims to

change undesirable behavior in certain situations through learning. The strategies

involve relaxation along with guided imagery and adjuvant use of physiological

monitoring using biofeedback, hypnosis, acupuncture, distraction, positive

reinforcement, stop-signaling, and exposure-based treatments, such as

systematic desensitization, “tell-show-do”, and modeling.

Relaxation techniques

A relaxation response is the opposite of a stress response, and when practiced

regularly it not only lowers stress and anxiety levels but also enables an individual
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to cope with the symptoms of anxiety. This can be achieved by both deep

breathing and muscle relaxation. Once a person is physically relaxed, it is

impossible to be psychologically upset at the same time. Anxiety-provoking

stimuli give rise to physical tension, which in turn increases the person’s

perception of anxiety.

Multiple relaxation techniques have been proposed, such as Ost’s applied

relaxation technique, Jacobsen’s progressive muscular relaxation, functional

relaxation, the rapid-relaxation technique, autogenic relaxation, and relaxation

response. Dentists need to familiarize themselves with these techniques, and if

required undergo special training before they can implement them in practice.

Once the patient is identified as anxious, these techniques can be taught even

before they sit on the dental chair.

Jacobsen’s progressive muscular relaxation

The most common technique taught to the patient is Jacobsen’s progressive

muscular relaxation. This involves tensing specific muscle groups for 5–7 seconds,

followed by 20 seconds of relaxation. The method can be demonstrated chairside,

and should be practiced and rehearsed by the patient at home. Four major

muscle groups are commonly tensed and relaxed. These are: 1) feet, calves,

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thighs, and buttocks; 2) hands, forearms, and biceps; 3) chest, stomach, and lower

back; and 4) head, face, throat, and shoulders. Allow 15–20 minutes to practice

the relaxation technique.

Step-by-step instructions are given as follows-

• Gently breathe in – hold – and let go.

• Gently pull your toes up toward your knees – just a little – hold briefly – and let go. Recognize the
difference.

• Press your heels into the floor – hold – and let go.

• Pull your knees together – hold briefly – now let them drift apart a little. Be aware of the new position.

• Squeeze your buttocks together – hold – now let go.

• Gently pull in your tummy muscles toward your spine – hold briefly – now let go. Feel the difference.

• Shoulders – gently pull them up toward your ears, just enough to recognize the tension – hold briefly –
now let go. Recognize the new position.

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• Gently press your elbows and upper arms to the sides of your body – hold for a moment – now let go.

• Hands – gently clench – hold – and let go.

• Push your head forward slightly – hold briefly – now let your head go back to a balanced position. Feel
the difference.

• Grit your teeth together – hold briefly – now let your jaw sag slightly. Feel the difference.

• Lips – press together – now let go until hardly touching. Purse your lips – now let go and feel the
difference.

• Press your tongue briefly to the roof of your mouth – hold – and let it drop loosely. Feel the new
position. Eyes – screw them up a little – hold – and let go.

• Forehead – frown a little – hold – now let go.

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Brief relaxation or functional relaxation therapy

Functional relaxation is used for the treatment of a variety of psychosomatic

disorders through positive stimulation of the autonomic nervous system. Patients

perform minute movements of small joints during relaxed expiration while

focusing on perceived changes in bodily feelings triggered by the movements

Brief or functional relaxation therapy instructions

Instructions

Let your lower jaw fall loosely and move it easily from right to left for 3–5seconds.

Move the joints of your head and neck smoothly so that your head nods slightly

from one shoulder to the other for 3–5 seconds. Let gravity do the work. Do you

notice a change in awareness of your neck?

For 3–5 seconds, move your relaxed shoulders in a circular motion in their joints

in such a manner that another person would barely see your movements. Let

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gravity work for you.

Pay attention to your awareness of your body. Do you notice any variation?

Beginning with your backbone, move like a snake, loosely from side to side and

from back to front for 3–5 seconds. Imagine that your chest is suspended from

many flexible small joints. Let your ribs fall with gravity.

Feel the flexibility of your chest. Notice the sensation inside your chest.

Keep in touch with your body and be aware of your bodily experiences.

Notice your flexibility.

You do not need to worry about doing something wrong.

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Autogenic relaxation

Autogenic relaxation can be useful in teaching patients to reduce muscle tension

and control their breathing. It is defined as a psychophysiological self-control

technique that aims at physical and mental relaxation. The technique uses

autosuggestions by which patients learn to alter certain psychophysiological

functions. Autogenic exercises should be practiced in a quiet room with reduced

lighting, so as to exclude the possibility of disturbance, all restricted clothing

should be loosened or removed, and the body should be relaxed with the eyes

closed, before the mental exercises are begun. It involves mental repetition of

brief verbal phrases, emphasizing feelings of 1) general peace, 2) heaviness in the

limbs, 3) peripheral warmth, 4) respiratory regularity, 5) cardiac regularity, 6)

abdominal warmth, and 7) coolness of the forehead. The technique requires daily

training for several weeks.

Ost’s applied relaxation technique

In this technique, patients keep a detailed record of their anxious feelings,

especially physical sensations, so that they become more aware of them. The

steps followed are given as follows-

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In this technique, the patients keep a detailed record of their anxious feelings,

especially physical sensations, so that they become aware of them. Then they

learn to practice the following steps:

1. Tension-release progressive relaxation: the patient is asked to tense a group of

muscles for approximately 20 seconds and then release the tension.

2. Release-only relaxation: the patient is asked to only relax a group of muscles.

3. Cue-controlled relaxation: in this step, the patient is asked to link release-only

relaxation to breathing. As they breathe in, they are told to think “in”, and as they

breathe out to think “relax” and release tension at the same time, and to practice

this daily and achieve a relaxed state in 2–3 minutes.

4. Differential relaxation-practice relaxation in different situations.

5. Rapid relaxation-practice relaxation in a more natural surrounding and attempt

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to quicken the pace of the relaxation process.

6. In the final step the patient is made to practice relaxation under the stress of

clinic situation.

Deep relaxation or diaphragmatic breathing

The most important and fundamental way of helping patients to relax physically is

to teach them proper breathing techniques. Diaphragmatic breathing is a relaxed

form of breathing. Use of the diaphragm for breathing reduces tension in the

chest and provides more oxygen for the body per breath. The technique can be

done as follows:

1. sit up straight; head should be upright not hanging forward or tilted back

2. rest one hand on your chest and the other hand on your abdomen

3. next, blow out all the air in your lungs until you feel empty

4. then begin to breathe in; inhaling must be done evenly: count your

breathing until you feel exactly full, to help you get a measured, even

breath
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 5. exhale evenly: count the breath out of your body, without any sudden

release

6. exhale longer than you inhale.

It is recommended to use relaxation breathing and muscle relaxation

simultaneously. The patient is supposed to tense a specific set of muscles during

inhaling, and then to relax them during exhaling. Guided imagery and biofeedback

can also be combined with relaxation techniques.

Relaxation response

Herbert Benson at Harvard Medical School demonstrated that meditation is

another efficient technique that allows greater control over the peripheral

nervous system and central nervous system (CNS). It is based on transcendental

meditation. He hypothesized that relaxation is hypothalamically mediated, and is

a counterbalancing mechanism to the stress response. There are four elements

necessary to elicit the relaxation response: relaxed musculature, a quiet

environment, passive disregard of everyday thought, and the focus of attention

on a repetitive mental stimulus, such as a word, a sound, a phrase, or even

repetitive breathing. Regular elicitation of the relaxation response appears to

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diminish the effects of the stress response, and is also effective in the treatment

of many health problems.

Guided imagery

Guided imagery has been defined as a directed, deliberate daydream that uses all

the senses to create a focused state of relaxation and a sense of physical and

emotional well-being. It is a mind–body exercise, wherein patients are taught to

develop a mental image of a pleasant, tranquil experience that consciously guides

their attention to achieve relaxation, thereby reducing anxiety. There are

generally three stages to guided imagery: relaxation, visualization, and positive

suggestion. Imagery can be a pleasant place such as a beach, mountains, lake, or a

safe place, and should be engaging and customized to each patient. Patients can

be allowed to choose their own mental image or they can be guided by using

scripts by the dentist. They are instructed to create a scenario full of specific,

concrete details, along with sound, smell, and colors of the scene. This technique

produces wonderful, soothing relaxation throughout the body. It can be used

along with relaxation techniques and CBT. Studies have shown the effectiveness

of guided imagery in the treatment of distress, mood, and anxiety symptoms

associated with chronic pain, social anxiety disorder, attention

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deficit/hyperactivity disorder, and cancer pain. It is relatively easy to learn, teach,

and use in practice. It can be performed by an adequately trained dentist or with

the use of audio recordings, and can be performed daily or as needed by the

patient.

Biofeedback

Biofeedback is also referred to as applied psychophysiological feedback, and is a

mind–body technique. Biofeedback therapies use instruments to measure,

amplify, and feed back physiological information to the patient being monitored.

The information assists the patient in gaining self-regulation of the physiological

process being monitored. Monitoring oneself and then utilizing the information to

practice and achieve self-regulation are the main goals of biofeedback. Milgrom

et al showed that it is efficient in clinical settings. Reduction of muscle-tension

levels through electromyographic biofeedback and operant conditioning of brain-

wave activity through electroencephalographic biofeedback are commonly used

for reducing anxiety. Recently, the use of respiratory rate-biofeedback device has

been shown to reduce preoperative general anxiety levels. Implementing this

technology into practice would require not only special instruments but also a

trained dentist.

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Hypnotherapy

Clinical hypnosis (from the Greek hypnos [sleep]), although criticized and

misunderstood, has been successfully used in medicine and dentistry. The term

“hypnosis” denotes an interaction between one person – the “hypnotist” – and

another person or people – the “subjects”. In this interaction, the hypnotist

attempts to influence the subjects’ perceptions, feelings, thinking, and behavior

by asking them to concentrate on ideas and images that may evoke the intended

effects. The verbal communications that the hypnotist uses to achieve these

effects are termed “suggestions”. Suggestions differ from everyday kinds of

instructions in that they imply that a “successful” response is experienced by the

subject as having a quality of involuntariness or effortlessness. They can be used

to induce relaxation, as an adjunct to inhalation sedation, to alleviate pain,

anxiety, and stress, in reducing problems with excessive gag reflex, and may also

be a part of CBT. The techniques have pre- and postsuggestion components. The

presuggestion component involves attentional focusing through the use of

imagery, distraction, or relaxation, and is similar to other relaxation techniques.

Subjects focus on relaxation, and passively disregard intrusive thoughts. The

postsuggestion component involves the continued use of the new behavior

following the termination of hypnosis. Individuals widely vary in their hypnotic

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susceptibility and suggestibility, although the reasons for these differences are

incompletely understood. It is inexpensive, and has a very low risk of side effects.

The technique needs to be avoided in those with mental health problems,

personality disorders, and neurodegenerative disorders. Dentists require special

training before they can practice hypnotherapy.

In a meta-analytic review, it was shown that 75% of subjects experienced pain

reduction following hypnosis. Studies have also shown effectiveness in anxiety

reduction, allowing people to handle stressful dental treatments. More studies

are required to validate the practicality and effectiveness of hypnosis on a routine

basis in dental clinical settings.

Acupuncture

Acupuncture is a technique, wherein the disease is treated by inserting needles at

various points on the body, known as acupuncture points. It has been reported

that acupuncture is effective in treating dental problems such as anxiety,

temporomandibular dysfunction syndrome, pain, and Sjögren’s syndrome. It is a

simple, inexpensive treatment modality that requires special training before it can

be incorporated into practice. Reports on the use of auricular acupuncture for

treating chronic and acute anxiety have shown promising results. A randomized

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controlled trial comparing auricular acupuncture with intranasal midazolam for

managing dental anxiety suggested that both treatment methods were similarly

effective. Though inconclusive, systematic reviews have suggested acupuncture as

a promising therapy for the management of anxiety disorders in a dental setting.

In a recent systematic review and meta-analysis on the effect of acupressure on

anxiety, Au et al concluded that it was effective in providing immediate relief of

pretreatment anxiety among adults and had a medium effect size. However,

conflicting results were found for improvements on physiological indicators.

Distraction

Distraction is a useful technique of diverting the patient’s attention from what

may be perceived as an unpleasant procedure. This enables decreased perception

of unpleasantness and averting negative or avoidance behavior. Giving the

patient a short break during a stressful procedure can be an effective use of

distraction prior to considering more advanced behavior-guidance techniques.

Several technological options are available for both visual and auditory

distraction, such as background music, television sets, computer games, and 2-D

and 3-D video glasses for watching movies.

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Suitable music has been shown to influence human brain waves, leading to deep

relaxation and alleviating pain and anxiety. Music distraction is a noninvasive

technique in which the patient listens to pleasant music during a stressful

procedure. The effect is believed to be a combination of relaxation and distraction

that in turn reduces the activity of the neuroendocrine and sympathetic nervous

systems. It has been successful in both pediatric and adult dental patients. Music

therapy can be either active or passive. The former involves a music therapist

with interactive communication, while the latter involves passive listening to

prerecorded music.

Enhancing control

Loss of control over the treatment procedure is a significant cause for anxiety,

and hence providing control is very essential. Telling the patient what to expect,

and what measures are taken to ensure their safety, will help make the treatment

as comfortable as possible. Control can be provided by giving information and

through behavioral control. Informational control can be achieved by the “tell-

show-do” and modeling techniques.

Tell-show-do is a behavior-shaping technique that reduces uncertainty and

increases predictability in the clinical setting. This technique can be used for both

39
child and adult patients. It involves verbal explanations of procedures in phrases

appropriate to the developmental level of the patient (tell); demonstrations for

the patient of the visual, auditory, olfactory, and tactile aspects of the procedure

in a carefully defined, unthreatening setting (show); and then, without deviating

from the explanation and demonstration, completion of the procedure (do). The

tell-show-do technique is used with communication skills (verbal and nonverbal)

and positive reinforcement.

Individuals learn much about their environment from observing the consequences

of other people’s behavior. Modeling is a technique used to alleviate anxiety. This

can be achieved through observation of a dental procedure, either by viewing a

videotaped model who is demonstrating appropriate cooperative behavior in the

dental setting or through observation of an actual successful dental procedure.

This could reduce anxiety due to “fear of the unknown”, and demonstrates to the

anxious patient what is considered appropriate behavior in the dental setting and

what can be expected in the upcoming treatment session. When setting up a

program, the following details should be taken care of: the model should be close

to the age of the patient, the model should be shown entering and leaving the

surgery to prove treatment has no lasting effect, and the dentist should be shown

to be a caring person who praises the patient.

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Behavioral control involves giving the patient a chance to feel that they are in

control of the treatment procedure. It involves signaling to the dentist or dental

hygienist to stop the procedure; this increases the patients’ sense of control and

trust in the dentist. A signal can be as simple as a raised hand to notify the dental

practitioner that the patient would like to stop the procedure. Specific signals can

be decided before the treatment commences. The dentist should stop the

procedure as agreed earlier; failure to do so will breach the trust relationship.

Patients can also be given mirrors to watch the procedure, so as to feel they are in

control.

Systematic desensitization or exposure therapy

Wolpe’s technique, known as systematic desensitization, is based on relaxation

and played a very prominent role in the evolution of behavior therapy during the

1960s and 1970s. The treatment procedure is carried out in multiple sessions. The

use of systematic desensitization involves three sets of activities. Encourage the

patients to discuss their status of fear and anxiety, in order to construct a

hierarchy of feared dental situations, from the least to the most anxiety-

provoking. Teach the patient relaxation techniques. The most commonly used

techniques are breathing and muscle relaxation. The final step is to gradually

41
expose the patient to these situations in the hierarchy, from the least to the most

anxiety-promoting.

When it is difficult to expose the patient directly to the dental setting, it may be

appropriate to instruct the patients to practice imaginary systematic

desensitization, wherein the patients are encouraged to imagine that they are

entering the dental clinic, able to sit in the dental chair, and eventually able to

receive dental treatment. Flooding or implosion therapy is an intensive form of in

vivo exposure therapy for treating phobias. The patient is confronted with the

feared stimuli for repeated and prolonged duration until they experience a

reduction in their anxiety level. The use of this technique requires more caution,

due to adverse effects and limited evidence in the literature.

Positive reinforcement

Positive reinforcement is an effective technique to reward desired behaviors and

thus strengthens the recurrence of those behaviors. Reinforcers include positive

voice modulation, facial expression, verbal praise, and appropriate physical

demonstrations of affection by all members of the dental team. These should be

individualized, frequently provided, and varied over time.

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Cognitive therapy

The thoughts and emotions of a person are not separate; rather, they overlap

each other and behavior depends on their thoughts. Thoughts and expectations

trigger different feelings and physiological reactions. Anxious patients most often

have inappropriate expectations and beliefs about dental treatment. The

modification of such negative cognitions is a means of reducing anxiety. Cognitive

treatment strategies aim to alter and restructure the content of negative

cognitions and enhance control over the negative thoughts. The patient’s focus is

directed away from his or her worries about the feared situation by using

different cognitive techniques, such as encouragement, altering expectations,

distraction, guided imagery, focusing attention, and thought stopping.

CBT is a combination of behavior therapy and cognitive therapy. It is today the

most accepted psychological treatment for anxiety related to particular situations

and specific phobias. It involves learning to change negatively distorted thoughts

(cognitions) and actions (behaviors). Basically, new skills are learned to manage

anxiety symptoms over multiple sessions with the therapist. It is structured,

problem-focused, goal-oriented, teaches proven strategies and skills, and lastly

emphasizes the importance of a good, collaborative therapeutic relationship

43
between the therapist and the patient. CBT treatment generally contains

psychoeducation, graded exposure, cognitive restructuring, behavioral

experiments, and relaxation, as well as self-assertiveness training. Self-

assertiveness training aims to improve fearful patients’ communication skills

concerning personal opinions, feelings, and needs during dental treatment. Case

reports, systematic reviews, and meta-analyses indicate that CBT is effective in

reducing dental anxiety and phobia. Dentists need special training to integrate

this therapy in practice.

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Technological advancements in local anesthetic administration that help alleviate

anxiety

Computer-controlled local anesthetic delivery

This system represents a significant change in the manner in which a local

anesthetic injection is administered, thereby alleviating anxiety in patients who

fear injections or are needle-phobic. It is essentially a computer-controlled dental

injection. The flow rate of the local anesthetic is controlled by a computer. A

plastic handpiece is less threatening in appearance than the traditional syringe.

Injecting local anesthetic solution slowly reduces tissue distension and leads to a

more comfortable injection with less postoperative pain. The greater control over

the syringe and the fixed flow rate of the drug are responsible for a significantly

improved injection experience, as demonstrated in many clinical studies

conducted with computer-controlled local anesthetic delivery devices in

dentistry. A growing number of clinical trials in medicine have also demonstrated

measurable benefits of this technology.

Electronic dental anesthesia

This technique is used to produce dental anesthesia by using the principle of

transcutaneous electric nerve stimulation. By means of electrodes, electric flow

45
from the stimulation unit is converted into an ionic current flow in the living

tissue and anesthesia is produced, offering pain control without needles, based

on the gate-control theory of pain. Electrodes can be placed either extraorally or

intraorally. The intraoral electrodes are cotton-roll electrodes, clamp electrodes,

and adhesive electrodes. Adhesive electrodes are the most widely used. These

electrodes are thin and flexible, and so can easily adapt to the oral mucosa. The

technique is noninvasive, safe, and generally well accepted by the patient.

Advantages of electronic dental anesthesia are as follows: there is no need for a

needle, no need for injection of drugs, limited soft-tissue anesthesia, the residual

analgesic effect remains for several hours, it is suitable for the needle-phobic, and

there is no residual anesthetic effect at the end of the procedure. Disadvantages

are the high cost of the unit are as follows: it is not suitable for all patients and all

treatments, efficacy is not as predictable as with other methods of anesthesia, it

requires training, and there is a learning curve, whereby initially the success rate

may be low but then it increases with experience. Some studies have proposed

electronic dental anesthesia to be effective and efficacious in pain control, but

there are contradictions with questionable efficacy.

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Computer-assisted relaxation learning

Computer-assisted relaxation learning is a program developed to reduce fear of

dental injections. It is a computer-based application utilizing principles of CBT.

Individuals view a series of videos in which a fearful patient is taught coping skills

and then taken through the gradual steps of a dental injection. A randomized

controlled trial by Heaton et al suggested that computer-assisted relaxation

learning led to significant changes in self-reported fear of dental injections in the

study participants. A systematic review by Patel et al indicated that the overall

quality of evidence for psychological treatment for injection fear or phobia is

poor, and outcome measures need consensus and further development.

Jet injections and vibrotactile devices are other modern gadgets available for local

anesthetic administration. Whether these devices are efficient in alleviating

anxiety and phobia needs more exploration with randomized controlled clinical

trials.

Technological advancements that help alleviate anxiety in restorative dentistry

Anxious patients who must undergo restorative procedures are often managed

using the “4 S” rule or the so-called 4 S principle. This is based on eliminating four

of the primary sensory triggers for dental anxiety when in the dental setting: sight

47
(air-turbine drill, needles), sounds (drilling), sensations (high-frequency vibrations

[the annoyance factor]), and smells. Newer methods, such as atraumatic

restorative treatment, air abrasion using alumina powder streams, ultrasonic tips

coated with diamond particles, chemomechanical caries removal targeting

collagen in infected dentine, which are susceptible to proteolysis by sodium

hypochlorite and chloramines, and lasers for cavity preparation, may reduce

painful or uncomfortable aspects of dentistry, thereby reducing anxiety and fear

of pain during treatment.

Pharmacological management

Indications

Pharmacological control of pain and anxiety can be achieved by the use of

sedation and general anesthesia, and should be sought only in situations where

the patient is not able to respond and cooperate well with psychotherapeutic

interventions, is not willing to undergo this type of treatment, or is considered

dental-phobic. Patients with special needs (mental retardation, autism, mental

illness, traumatic brain injury) and clinical situations can also necessitate

pharmacological management.

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There are a few factors to be considered prior to pharmacological management:

1. risks involved with pharmacological management when compared to

behavioral therapies

2. appropriate evidence-based selection of drugs for pharmacological

management

3. extent of the patient’s dental needs and severity of anxiety

4. patient’s cognitive and emotional needs and personality

5. practitioner skill, training, and experience

6. proper equipment and monitoring

7. cost of the procedure.

Indicator of sedation needs tool

This is an adjunct tool developed to support clinicians in deciding about need for

conscious sedation. It has three indicators: anxiety, medical and behavioral, and

treatment complexity. Scores for each of these indicators range from 1 to 4. Final

scores sum to 3–12. A score of 3 or 4 indicates minimal need for sedation, 5 or 6

moderate need, 7–9 high need, and 10–12 suggests very high need or even use of

general anesthesia.
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Sedation is defined as the use of a drug or combination of drugs to depress the

CNS, thus reducing patient awareness of their surroundings. Depending on the

degree of CNS suppression, the sedation may be conscious, deep, or general.

Sedation does not control pain, and consequently does not eliminate the need for

the use of local anesthetics. According to the American Society of

Anesthesiologists (ASA), patients should fulfill the demands of being classified as

category ASA I (mentally and physically healthy) or ASA II (only mild systemic

disease, which does not result in any functional limitation), in order to be

considered a candidate for sedation. Sedation is a continuum that proceeds from

minimal to deep in a dose–response manner. This continuum can be divided into

levels with characteristics that have been used to design several subjective

sedation scales .

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American Society of Anesthesiologists (ASA) physical status classification

ASA I – normal healthy patient

ASA II – patient with mild systemic disease

ASA III – patient with severe systemic disease

ASA IV – patient with severe systemic disease that is a constant threat to life

ASA V – moribund patient who is not expected to survive without the operation

ASA VI – patient declared brain-dead whose organs are being removed for donor

purposes

E – emergency operation of any variety (used to modify one of the

aforementioned classifications, ie, ASA III–E)

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 Continuum of depth of sedation: definition of general anesthesia and levels of
sedation/analgesia

Minimal Moderate Deep General

sedation sedation/analgesia sedation/analgesia anesthesia
(anxiolysis) (conscious
sedation)

Responsiveness Normal Purposeful Purposeful Not arousable,

response response to verbal response following even with painful
to verbal or tactile repeated or painful stimulus
stimulation stimulation stimulation

Airway Unaffected No intervention Intervention may Intervention often

required be required required

Spontaneous Unaffected Adequate May be inadequate Frequently

ventilation inadequate

Cardiovascular Unaffected Usually maintained Usually maintained May be impaired

function

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Minimal sedation/anxiolysis is a drug-induced state during which patients

respond normally to verbal commands. Although cognitive function and physical

coordination may be impaired, airway reflexes and ventilator and cardiovascular

functions are unaffected. This level is achieved with either oral sedatives alone or

in combination with nitrous oxide and oxygen. This is used for managing patients

with mild-to-moderate anxiety.

Moderate/conscious sedation is a drug-induced depression of consciousness

during which patients respond purposefully to verbal commands, either alone or

accompanied by light tactile stimulation. No interventions are required to

maintain a patent airway, and spontaneous ventilation is adequate.

Cardiovascular function is usually maintained. This is used for managing patients

with moderate-to-severe anxiety.

Deep sedation is a drug-induced depression of consciousness during which

patients cannot be easily aroused but respond purposefully following repeated or

painful stimulation. Ability to maintain ventilatory function independently may be

impaired. Patients may require assistance in maintaining a patent airway, and

spontaneous ventilation may be inadequate. Cardiovascular function is usually

maintained.

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General anesthesia is a drug-induced loss of consciousness during which patients

are not arousable, even by painful stimulation. The ability to maintain ventilatory

function independently is often impaired. Patients often require assistance in

maintaining a patent airway, and positive pressure ventilation may be required

because of depressed spontaneous ventilation or drug-induced depression of

neuromuscular function. Cardiovascular function may be impaired.

Dental-phobic patients and those with severe learning difficulties, severe anxiety

and phobias, severe psychiatric disorders, physical disability and movement

disorders, and significant comorbidity, such as those with congenital disorders, in

whom sedation may not be safe and perioperative monitoring is required, are

candidates for general anesthesia in special care dentistry.

Conscious sedation

This is a technique in which the use of a drug or drugs produces a state of

depression of the CNS, enabling treatment to be carried out, but during which

verbal contact with the patient is maintained throughout the period of sedation.

The drugs and techniques used to provide conscious sedation for dental

treatment should carry a margin of safety wide enough to render loss of

consciousness unlikely. Based on the routes of administration, conscious sedation

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techniques are inhalational, intravenous (IV), oral, sublingual, intranasal,

intramuscular, or rectal.

A thorough medical, dental, and social history must be taken and recorded to

ensure that the conscious sedation technique chosen is the most appropriate to

enable successful treatment outcomes for each individual, taking into account

such factors as the patient’s age, state of health, social circumstances, and any

special needs they may have. Sedation should not be used habitually when there

is no specific indication.

The dentist and the dental team should be adequately trained and be familiar

with appropriate regulations according to the country of practice. Each country

has its own guidelines and advice on special training for dentists.

Inhalation sedation

This is a commonly used technique for dental sedation. A mixture of nitrous oxide

(N2O) and oxygen is used. Nitrous oxide has an anxiolytic and sedative effect, and

also promotes muscular relaxation and analgesia. It is nonirritant for the

respiratory tract, with minimal alveolar concentration and low solubility in tissues.

It acts with a quick onset and rapid recovery, the entire procedure lasting only a

few minutes. As a rule, 70% of patients will need 30%–40% nitrous oxide to

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achieve sedation. In most purpose-built equipment, there is an inbuilt safety

feature that does not allow more than 70% nitrous oxide to be delivered to the

patient. Most of the disadvantages of nitrous oxide relate to equipment and the

logistics of safe delivery, such as operative space, cost of the equipment and

supplies, and cost to the patient.

Oral sedation is an enteral technique of administration in which the drug is

absorbed through the gastrointestinal tract. It is often used for the management

of mild-to-moderate anxiety, and in some cases to assist the patient to have a

restful night prior to the appointment. It may also be used or as an adjunct to

other methods of sedation for the severely anxious. The goal is to produce a

lightly sedated, relaxed, more cooperative patient that is easier to manage.

Benzodiazepines are commonly used. The benzodiazepines have antianxiety,

sedative–hypnotic, anticonvulsant, and skeletal muscle-relaxant properties. They

exert their sedative effects by a generalized depression of the CNS. Commonly

used drugs in this class are diazepam, midazolam, and triazolam.

IV sedation entails the administration of sedative agents directly into the vascular

compartment. The use of IV sedation in a dental office requires additional

advanced training. The main advantages of the IV route are rapid onset of action

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and ability to titrate to effect and control the duration of sedation. Other

advantages include higher levels of efficacy than oral or inhalation sedation and IV

access for emergency drugs or reversal agents if needed. The most common

parenteral sedation technique involves the use of a benzodiazepine (eg, diazepam

or midazolam) alone or in combination with an opioid (eg, fentanyl or Demerol).

Berggren identified four specific situations where CBT can be combined with

pharmacological treatment:

1. When the patient has an immediate need for dental treatment because of

acute dental pain. It is difficult to motivate the patient to work with their

anxiety in painful conditions. Nitrous oxide sedation, or oral/IV sedation

with benzodiazepines is typically the first choice, and sometimes general

anesthesia may be needed.

2. When the patient has need of multiple and complex treatment with

increased risk for acute dental pain. These patients are so preoccupied by

their need for dental treatment that they cannot deal with their underlying

fear or anxiety. They can be managed under general anesthesia, later

followed by psychological anxiety-reducing therapies.

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3. When the patient is referred to the clinic specifically for general anesthesia

treatment, and categorically demands it. These patients may be motivated

for anxiety treatment afterward.

4. When it may be strategic for highly motivated patients to start exposure

therapy aided by mild sedation.

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Psychological intervention versus pharmacological intervention

Psychological and pharmacological interventions are both equally effective in

reducing dental anxiety and phobia. Response to behavioral and cognitive therapy

is not immediate, and multiple sessions are usually needed to maintain an initial

treatment response; however, studies have shown that dropout rates were low

and reduction in anxiety or phobia was maintained over longer time periods, with

more patients reporting back for future treatment. Pharmacological approaches

are seen as less acceptable by patients when compared to psychological

techniques, and have been shown to be effective on only a short-term basis.

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Conclusion

Dental anxiety and phobia can have adverse impacts on a person’s quality of life,

and hence it is imperative to identify and alleviate these significant obstacles to

pave the way for better oral health and overall well-being of the individual. It is

the duty and responsibility of the dentist to provide excellent dental care to these

patients with special needs as well. Management of these patients should be an

integral part of clinical practice, as a substantial proportion of the population

suffers from anxiety and fear. Therapy should be customized to each individual

following proper evaluation, and should be based on the dentist’s experience,

expertise, degree of anxiety, patient intellect, age, cooperation, and clinical

situation. The dentist should communicate with the patient and identify their

source of fear and anxiety, with adjuvant use of self-reporting anxiety and fear

scales to enable categorization as mild, moderate, or extreme anxiety or dental-

phobic. Manifold psychological therapies are employed to mollify emotional,

cognitive, behavioral, and physiological dimensions of dental anxiety and fear.

These therapies are efficient on a long-term basis with positive effects on the

patients, enabling them to seek dental care in future, which should be the

primary focus of the dental team. Mildly and moderately anxious patients can be

frequently managed using psychological interventions, and occasionally anxiolytic

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drugs or conscious sedation may be necessary. Extremely anxious or phobic

patients most frequently require combined management approaches. Due to the

high risk involved in pharmacological interventions, it is mandatory that the

dentist and dental team follow proper guidelines and be adequately trained and

sufficiently equipped with proper infrastructure before pharmacological

interventions can be incorporated. All successful treatment will rest on dentist–

patient cooperation, and thus a relaxed patient will obviously result in a less

stressful atmosphere for the dental team and better treatment outcomes.

61