Fear of routine dental treatment in adults: Its nature and management

Abstract

The fear of dental treatment in adults can be characterised in several ways, loosely related, such as anticipating being afraid, avoiding dental check-ups and seeking treatment only under general anaesthesia. Defined thus, at least a quarter of adults are highly afraid of dentistry. The feared experiences are many, including most frequently, pain. Several studies have shown that anxious patients experience less pain during treatment than they expect. It remains to be confirmed that these are typical experiences because other studies show that local anaesthesia can fail to protect patients from sudden pain in 13% of treatments on average. Expectations of pain are highly resistant to change, the result probably of several influences including distortion in recall of pain-free treatment, intermittent experience of sudden severe pain, expecting pain in order to reduce its impact, and uncertainty about treatment. It has yet to be shown that experience free of discomfort can reduce these expectations. However, relaxation instructions and information about pain management and stop signals can reduce pre-treatment fear. To prevent the onset and the maintenance of anxiety: the prevention of pain is essential; controlled behavioural studies of the treatment of pain and other experiences such as panics are needed. Finally, the need for new instruments to assess all aspects of fear of dentistry is described.     

Predictions of dental pain: the fear of any expected evil, is worse than the evil itself

In a study of 40 subjects, who twice underwent extensive dental treatment, the relationships between expectations and experiences of pain and of anxiety were investigated. Inaccurate expectations were adjusted in the same way as observed in the laboratory. Especially anxious subjects expected more pain and anxiety than they experienced, and they appeared to need more experiences before their predictions became accurate. In the course of time, the expectations (and memories) of anxious subjects returned to their original more inaccurate level of prediction. The results suggest that the old schema is ultimately reinstated if disconfirmations are few and far between. Anxious subjects did not experience more pain, but they did experience more anxiety than fearless subjects. Detailed investigation of processes of change after disconfirmation showed that anxiety experienced during treatment is a factor that plays a part in maintaining the problem of inaccurate expectations and fear of treatment. Theoretical and clinical implications of these findings are discussed.     

The effect of pre-treatment enquiries on child dental patient's post-treatment ratings of pain and anxiety

Abstract

The aim of this study was to attempt to replicate a study in adults: to determine whether pre-treatment enquiries about anxiety and pain in children, attending the dentist, influenced their subsequent reports of pain and anxiety immediately after treatment. One hundred and ninety five children aged from seven to 16, attending four Community Dental Clinics, were allocated at random to five groups. Before treatment the first group was asked questions about their dental anxiety, expectations and memories of pain. The second group was asked about dental anxiety and expectations of pain. The third group was asked only about dental anxiety; the fourth was asked only about pain. The fifth, the control group, was asked about none of these topics. All the children were asked after treatment to rate 1) their anxiety about dentistry and 2) their experience of pain in the treatment just completed. The children experienced less pain than they had expected. There were no differences between the groups in disruptiveness or in the amount of pain experienced. However, the children who were asked about both pain and dental anxiety (groups one and two) reported significantly less dental anxiety than the control group. These results are consistent with the conclusion that pre-treatment enquiries about both anxiety and pain have no effect on disruptiveness or the experience of pain but do reduce anxiety about dentistry.     

Dental phobias and anxieties: evidence for conditioning processes in the acquisition and modulation of a learned fear

The present study investigated some of the factors which differentiate individuals with dental anxieties and phobias from those without such fears. In particular, two questions were addressed: (i) What differentiates subjects who have never been anxious about dental treatment from subjects who at some time have been anxious? and (ii) What factors lead to subjects changing their attitudes either from anxious to relaxed or from relaxed to anxious? The results suggest that the factors which influence the acquisition and modulation of dental anxieties are consistent with the associative and representational processes portrayed in contemporary models of human conditioning. Subjects who reported never having had anxieties about dental treatment were less likely to have had a painful dental treatment than subjects who did report an anxiety. Subjects who did report a painful dental experience but did not acquire anxiety reported a history of dental treatment favourable to the operation of latent inhibition. Subjects who reported that they were good at enduring pain were more likely to report a longer interval between their very first dental treatment and their first painful dental treatment. Under some conditions in which latent inhibition should have precluded the acquisition of a dental fear, an anxiety appeared to be acquired because a very painful experience had attenuated the latent inhibition process. Subjects whose dental anxiety did not remit reported significantly more painful and traumatic dental experiences than subjects whose anxiety did remit.     

Sensations, cognitions and the perception of cues associated with expected and unexpected panic attacks

Panic attacks may be perceived by patients as either cued or uncued (spontaneous) and either expected or unexpected. The purpose of the present study was to examine the prevalence and characteristics of these types of panic. Twenty-six panic disorder patients with mild avoidance and 18 with moderate or severe avoidance were instructed to complete a questionnaire during or immediately following each of three consecutive naturally occurring panic attacks they experienced. They were asked to rate the extent to which they expected the panic attack to occur, whether they felt it was associated with an external panic "cue" (e.g. a shopping mall), whether they would expect to panic again in similar circumstances, their mood, present level of life stress, and fear and severity of their body sensations and disturbing cognitions. Results indicated that from a sample of 92 questionnaires, each representing a separate panic, nearly 70% of panic attacks were rated as cued-expected and only one panic was rated as uncued-expected. The other two categories each comprised about 15% of all panic attacks. There were few reported differences in body sensations and cognitions reported as a function of type of panic and no differences with regard to extent of agoraphobic avoidance. Expected panic was associated with a higher expectation of future panic in similar circumstances.     

Manifestations, acquisition and diagnostic categories of dental fear in a self-referred population

This study aimed to clarify how manifestations and acquisition relate to diagnostic categories of dental fear in a population of self-referred dental fear patients, since diagnostic criteria specifically related to dental fear have not been validated. DSM III-R diagnostic criteria for phobias were used to compare with four existing dental fear diagnostic categories, referred to as the Seattle system. Subjects were 208 persons with dental fear who were telephone interviewed, of whom a subsample of 155 responded to a mailed Dental Anxiety Scale (DAS), State-Trait Anxiety Inventory and a modified FSS-II Geer Fear Scale (GFS). Personal interviews and a Dental Beliefs Scale of perceived trust and social interaction with dentists were also used to evaluate a subsample of 80 patients selected by sex and high dental fear. Results showed that the majority of the 80 patients (66%), suffered from social embarrassment about their dental fear problem and their inability to do something about it. The largest cause of their fear (84%) was reported to be traumatic dental experiences, especially in childhood (70%). A minority of patients (16%) could not isolate traumatic experiences and had a history of general fearfulness or anxiety. Analysis of GFS data for the 155 subjects showed that fear of snakes and injuries were highest among women; heights and injections among men. Fear of blood was rarely reported. Spearman correlations between GFS individual items and DAS scores indicated functional independence between dental fear and common fears such as blood, injections and enclosures in most cases. Only in specific types of dental fear did these results support Rachman and Lopatka's contention that fears are thought to summate.(ABSTRACT TRUNCATED AT 250 WORDS)     

Increased interoceptive awareness in fear of flying: sensitivity to suffocation signals

In flight phobia, particular environmental factors can facilitate a fear response. The current study aimed to explore the relationship between respiratory sensations and fear of flying: individuals with fear of flying may be more sensitive to suffocation signals and could experience more bodily sensations as a consequence of an added resistive respiratory load. The sample included 19 subjects with fear of flying and 19 controls. Each subject wore a mask to which a respiratory load could be added. First, an interference paradigm was used: respiratory loads were presented during a tone detection task. Next, subjects were asked to detect the loads. After each task, subjects reported their somatic sensations. All subjects showed interference of the respiratory loads. However, subjects with fear of flying were more accurate in detecting the loads, thereby indicating higher interoceptive awareness. Moreover, their superior accuracy was related to increased bodily sensations: a higher interoceptive awareness resulted in increased symptom reporting. It follows that treatment interventions for fear of flying should be supplemented with interventions that target internal stimuli.     

Normal body scheme and absent phantom limb experience in amputees while dreaming

While dreaming amputees often experience a normal body image and the phantom limb may not be present. However, dreaming experiences in amputees have mainly been collected by questionnaires. We analysed the dream reports of amputated patients with phantom limb collected after awakening from REM sleep during overnight videopolysomnography (VPSG). Six amputated patients underwent overnight VPSG study. Patients were awakened during REM sleep and asked to report their dreams. Three patients were able to deliver an account of a dream. In all dreaming recalls, patients reported that the amputated limbs were intact and completely functional and they no longer experienced phantom limb sensations. Phantom limb experiences, that during wake result from a conflict between a pre-existing body scheme and the sensory information on the missing limb, were suppressed during sleep in our patients in favour of the image of an intact body accessed during dream.     

A clinical study of child dental anxiety

Dental fear in children was studied using Rachman's theory of fear acquisition. Sixty children from two age groups (7-10 years, 11-14 years) participated in the project. The children were new patients attending a paediatric consultation clinic for specialised dental treatment. Thirty-one were diagnosed as being clinically anxious regarding dentistry and 29 were found to be nonanxious. Information regarding children's past experiences and present level of anxiety was obtained from the examining dentist, the children and their parents. Mothers were also interviewed and observed to ascertain their own anxieties and behaviour. The results showed that of Rachman's three pathways to fear, conditioning appeared largely responsible for the children's development of dental fear. Children's fear was more strongly associated with subjective experience of pain and trauma than with objective dental pathology. Indirect learning processes were found to be of only minor importance in this study.     

Determinants of early- vs late-onset dental fear in a longitudinal-epidemiological study.

A longitudinal investigation of risk factors for early- and late-onset dental fear was conducted. Early-onset dental fear was related to conditioning experiences (indexed via caries level and tooth loss), service use patterns, stress reactive personality and specific beliefs about health professionals. Late-onset dental fear was related to aversive conditioning experiences, irregular service use and an external locus of control. In contrast to recent findings for dental anxiety, personality factors were not strongly related to the onset of dental fear in young adulthood. The key role played by conditioning events in the development of both early- and late-onset dental fear was confirmed. Conditioning events appear to play a different role in the development of dental fear vs dental anxiety. This may reflect important, but largely ignored differences between these two closely-related constructs. Interventions for early-onset dental fear should aim to modify both the dental fear and the personality vulnerabilities that may contribute to the development of dental fear early in the life-course.     

An exploratory investigation of the origin and maintenance of phobias

Phobies were asked to relate past events which they believed caused or contributed to their fear, and to describe cognitive events experienced while imagining phobic interactions. Approximately half the subjects were able to recall relevant learning experiences, with direct experiences far more common than vicarious experiences or learning based on verbal instruction. Almost all of the subjects reported self-verbalizations while imagining the phobic situation, in every case phobic relevant. However, in a minority of instances were the verbalizations ‘catastrophic’ in nature. In only about half the cases did the phobies report that, in vivo, thoughts preceeded fear in the phobic situation (in contrast to a comparison group of less fearful subjects for which thoughts did preceed fear to a significant degree). Results are discussed in terms of possible limitations of a cognitive interpretation of phobic behavior.     

Anxiety, pain and type of dental procedure

The anxiety, pain expected and pain experienced of patients arriving for their scheduled dental appointments were measured. The amount of pain expected and experienced was found to be related to the type of dental procedure. Highly anxious patients expected more pain than they experienced when they received drilling/extraction type procedures but the discrepancy was small when they were due to receive a check-up. Low-anxiety patients, by contrast, accurately predicted the amount of pain they would experience, whatever the procedure. The results may explain why anxiety about dentistry is slow to extinguish.     

Children's event knowledge of cancer treatment

The purpose of the present study was to systematically describe the schematic organization of children's knowledge of the routine procedures they experience when being treated for cancer (leukemia) in outpatient pediatric oncology clinics. The effects of several independent variables, including age, time in treatment, prognastic condition, and gender, were tested on children's cognitive organization and recall of their experiences in oncology clinics relative to their experiences of other common recurrent events in their lives. In general, findings indicated that children between the ages 4 and 17 demonstrated well-organized knowledge about the events they experience in oncology clinics, particularly the administration of chemotherapy.     

疼痛恐惧的形成、泛化与消退

疼痛恐惧源于把疼痛等同于伤害的灾难化信念及对疼痛的负性解释, 它在慢性疼痛和能力丧失的发生和发展过程中起着重要作用。疼痛恐惧可以通过联合学习和观察学习等方式获得, 并且在具有相似特征的刺激中存在泛化现象。通过教育干预和等级暴露疗法等可以成功消退疼痛恐惧, 在消退过程中要控制安全信息等因素的不良影响。在疼痛恐惧的获得与消退中, 主要有杏仁核, 脑岛和前扣带皮层等脑区参与。未来的研究可以集中在深入探讨疼痛恐惧形成中的泛化及消退后的恢复、再巩固等现象, 加强其临床上的应用, 并综合心理、生物和认知神经科学, 研究疼痛恐惧的获得、泛化与消退的深层机制。     

The typicality of therapeutic ‘surprises’

One reason why exposure to a feared stimulus does not result in a reduction in anxiety involves patients' cognitions as to the typicality of the encounter. This possibility was tested by relating the discrepancy between the discomfort dental patients expect to feel and their actual experience to their views of the typicality of the appointment and any change in dental anxiety reported 3 months later. As predicted, a large discrepancy between expected and experienced pain was associated with a change in anxiety only when the patients were confident that the discrepancy was a typical one. Implications for the design of therapeutic programmes are discussed.     

Incorporating Principles from Acceptance and Commitment Therapy into Cognitive-Behavioral Therapy for Insomnia: A Case Example

Although traditional cognitive behavioral treatments for insomnia have demonstrated efficacy for many individuals with primary and comorbid insomnia, not all individuals benefit from treatment and some experience a subsequent relapse of insomnia. Furthermore, many individuals experience difficulty in implementing the sleep restriction and stimulus control strategies, especially over the long-term. The current article describes ways in which principles from a newer type of behavior therapy, Acceptance and Commitment Therapy (ACT), can be integrated with traditional behavioral treatment strategies for insomnia. A major goal of ACT is to increase willingness to experience unpleasant thoughts, feelings, and physical sensations, and to promote engagement in personally-valued behaviors while non-judgmentally observing these unpleasant experiences. ACT has the potential to enhance the behavioral treatment of insomnia by fostering willingness to experience short-term discomfort (e.g., fatigue) that occurs while implementing sleep restriction and stimulus control strategies. A case example is presented to illustrate how these principles from ACT can be integrated with behavioral techniques in the treatment of insomnia.     

The influence of an interpolated experience upon recognition

It was demonstrated in a previous experiment that an experience interpolated between an original experience and its recall may bring about changes in the points of emphasis in the recall of the original experience. Moreover, details of the interpolated experience may be recalled as if they had formed part of the original experience. These results were taken to mean that two experiences of a related kind may become merged in memory into something akin to Bartlett's notion of an organized mass of past experiences. In the experiment here reported, the original experience was the hearing of a story, and the interpolated experience the seeing of a picture which illustrated part of the story. When in a recognition test subjects were asked to select from three alternatives (including the original) the one version which was “most like the original story,” a proportion of them preferred to the original story a version which differed from the original by including a number of details from the picture. Asked about details, all the subjects tended to place details from the picture in the story, even if they had not been mentioned there. The results of the two experiments are thought to show that irreversible changes are brought about in the memory of an experience by subsequent experiences of a related kind.     

General and specific fears in referred and self-referred adult patients with extreme dental anxiety.

The levels of, and relationships between, dental fear and general fears and phobias were studied in 109 adult patients at a specialized dental fear clinic using two dental fear scales (the Dental Anxiety Scale and the Dental Fear Survey) together with the Fear Survey Schedule II (FSS-II) and some additional fear items. Referred and self-referred fearful dental patients answered mailed questionnaires in conjunction to being put on a 1 yr waiting list for treatment. Among feared objects and situations the separate item 'pain' revealed the highest mean scores for both men and women, followed by fear of suffocating, death of a loved one and sharp objects among women, and death of a loved one, suffocating and hypodermic needles among men. With few exceptions, women scored higher than men. The frequencies of extreme fears (6 and 7 on a 7-point scale) were high and 92.7% of the patients reported at least one extreme fear. Half of the subjects (49.5%) reported five fears or more. It was also shown that a number of FSS-II items correlated to dental fear indicating a relationship between general and dental fear. These results indicated that a large proportion of these dentally fearful individuals were prone to fear-associated reactions and behaviors, which has previously been shown to negatively influence the prognosis of treatment.