Review

Med Princ Pract 2014;23:295–301 Received: June 23, 2013 DOI: 10.1159/000357223 Accepted: November 17, 2013 Published online: December 20, 2013

Why Are People Afraid of the Dentist? Observations and Explanations

a a b Laura Beaton Ruth Freeman Gerry Humphris a b Dental Health Services Research Unit, School of Dentistry, University of Dundee, Dundee , and Health Psychology, School of Medicine, University of St Andrews, St Andrews, UK

Key Words Introduction Dental anxiety · Dental phobia · Aetiology Dental anxiety, or dental fear, is estimated to affect ap- proximately 36% of the population, with a further 12% suf- Abstract fering from extreme dental fear [1] . This anxiety can have Objective: The aim of this review was to explore the peer- serious repercussions in terms of an individual’s oral reviewed literature to answer the question: ‘Why are people health, and it is considered to be a significant barrier to afraid of the dentist?’ Method: Relevant literature was identi- dental attendance [2] resulting in poor attendance. This is fied by searching the following on-line databases: PubMed, known as dental avoidance and can lead to poor oral health PsycInfo, the Cochrane Library and Google Scholar. Publica- or the necessity for specialist dental care [3] . High dental tions were extracted if they explored the causes and conse- anxiety has also been shown to influence the quality of life, quences of dental fear, dental anxiety or dental phobia. Re- with low oral health-related quality of life associated with sults: The research evidence suggests that the causes of high dental anxiety [4, 5] . Indeed, 73% of participants in a dental fear, dental anxiety or dental phobia are related to study by McGrath and Bedi [5] reported believing that exogenous factors such as direct learning from traumatic ex- their oral health affected their life quality. If dental fear af- periences, vicarious learning through significant others and fects oral health status, dental attendance and the quality the media, and endogenous factors such as inheritance and of life, then it is important for dental practitioners to un- personality traits. Each individual aetiological factor is sup- derstand the concepts and aetiology of dental fear, dental ported by the evidence provided. Conclusions: The evi- anxiety and/or dental phobia. Therefore, the aim of this dence suggests that the aetiology of dental fear, anxiety or review was to explore the peer-reviewed literature to an- phobia is complex and multifactorial. The findings show that swer the question: ‘Why are people afraid of the dentist?’ there are clear practical implications indicated by the exist- ing research in this area: a better understanding of dental fear, anxiety and phobia may prevent treatment avoidance. L i t e r a t u r e S e a r c h © 2013 S. Karger AG, Basel Relevant literature was identified by searching the fol- lowing on-line databases: PubMed, PsycInfo, the Co- chrane Library and Google Scholar. Search terms included

© 2013 S. Karger AG, Basel Prof. Ruth Freeman 1011–7571/13/0234–0295$38.00/0 Dental Health Services Research Unit 9th Floor, School of Dentistry, University of Dundee, Park Place E-Mail [email protected] Th is is an Open Access article licensed under the terms of the Dundee DD1 4HN (UK) www.karger.com/mpp Creative Commons Attribution-NonCommercial 3.0 Un- E-Mail r.e.freeman @ dundee.ac.uk ported license (CC BY-NC) (www.karger.com/OA-license), applicable to the online version of the article only. Distribu- tion permitted for non-commercial purposes only. Downloaded by: 41.128.165.40 - 3/17/2015 11:36:31 AM subject heading and key words relevant to the causes and Table 1. Comparison of the two prominent classification defini- consequences of dental fear, dental anxiety and dental tions for specific phobias phobia. Publications from this search were examined and Classification Definition of ‘specific phobia’ included if they explored specifically the causes and con- manual sequences of dental fear, dental anxiety or dental phobia. DSM-IV ‘Marked and persistent fear that is excessive or unreasonable, cued by the presence or Concepts of Dental Fear, Dental Anxiety and anticipation of a specific object or situation… Exposure to the phobic stimulus almost invariably Dental Phobia provokes an immediate anxiety response… The phobic situation is avoided or is endured with The first to adopt the term ‘dental anxiety’ was Coriat intense anxiety or distress.’ [6] , who defined it as ‘an excessive dread of anything be- ICD-10 ‘Phobic anxiety disorders (are) a group of ing done to the teeth’ with the result that ‘any dental sur- disorders in which anxiety is evoked only, or gery, no matter how minor, or even dental prophylaxis, predominantly, in certain well-defined situations may be so postponed or procrastinated that the inroads that are not currently dangerous. As a result these of disease may affect the entire dental apparatus’. Coriat situations are characteristically avoided or endured with dread. (Specific phobias are) [6] suggested that a fear of the dentist was ‘anticipatory phobias restricted to highly specific situations… anxiety’ because it stemmed from a fear of real danger and Though the triggering situation is discrete, an anticipated unknown danger. contact with it can evoke panic.’ The terms ‘dental fear’ and ‘dental anxiety’ are fre- quently used interchangeably, and the umbrella term ‘dental fear and anxiety’ (DFA) will be used in this paper. However, dental phobia is sometimes considered to be a 12]. The MDAS has an empirically devised cut-off point separate concept; Lautch [7] defined dental phobia as ‘a where scores above a certain level indicate the possibility special kind of fear, out of proportion to the demands of of dental phobia, rather than dental anxiety, as follows: the situation, which will not respond to reason, is appar- 5–9 = not dentally anxious, 10–18 = fairly dentally anx- ently beyond voluntary control and leads to avoidance of ious, and 19–25 = very dentally anxious/dentally phobic dental treatment where this is really necessary’. Freeman [13] . [2] also stressed the importance of avoidance being pres- In both the Diagnostic and Statistical Manual of Men- ent in dental phobia, stating that dental phobia cannot be tal Disorders (DSM-IV) and the International Statistical diagnosed purely from the presence of dental anxiety – Classification of Diseases and Related Health Problems the patient’s history of dental experiences must also be 10th Revision (ICD-10) [14], there is no specific defini- considered. tion for dental anxiety; instead, it is understood as a spe- With regard to ‘dental phobia’, current research sug- cific phobia ( table 1 ). One way to differentiate between gests that it is actually one end of a continuum of dental dental anxiety and dental phobia is to consider the impact anxiety [1, 8]. As Freeman [8] noted, a continuum of den- the anxiety has on normal functioning, i.e. if it interferes tal anxiety explains the differences in intensity of anxiety, with an individual’s occupation, or social activities, or if as well as the differences that exist regarding the underly- the individual is distressed by his/her anxiety then this ing causes. Evidence for this continuum comes from the individual would meet the DSM-IV criteria for a specific results of the Adult Dental Health Survey 2009 [1] . It was (dental) phobia [15] . noted that over the previous two Adult Dental Health One way of examining the relationship between func- Surveys the prevalence of dental anxiety had decreased tion and dental phobia is to study the interaction of DFA considerably (possibly due to improvements in pain re- and oral health status. In a longitudinal study following a duction [9] ) but the incidence of extreme dental fear, or large sample of adolescents in New Zealand from age 15 dental phobia, had remained constant, suggesting that for to 18 years, Kruger et al. [16] found that high dental anx- those who are classified as ‘dentally phobic’ there are iety was predictive of dental caries in adolescents; den- more complex underlying causes of their fear. The notion tally anxious patients had the highest levels of caries se- of a continuum is supported by the two dominant mea- verity among the sample. This finding was confirmed by sures of dental anxiety: the Dental Anxiety Scale (DAS) an epidemiological study of 374 male army soldiers whose [10] and the Modified Dental Anxiety Scale (MDAS) [11, dental anxiety and dental status were measured [17] .

296 Med Princ Pract 2014;23:295–301 Beaton /Freeman /Humphris DOI: 10.1159/000357223

Downloaded by: 41.128.165.40 - 3/17/2015 11:36:31 AM Dentally anxious soldiers had significantly more carious Exogenous Sources of DFA teeth than those who were less anxious. In addition, Thom The term ‘exogenous’ means that the source of an in- et al. [18] found that in a study of German participants dividual’s anxiety is external, and it is understood by cur- with a specific (dental) phobia, as measured by the DSM- rent research to be due to direct traumatic experiences or IV, a quarter of participants’ teeth were in a state of decay indirect vicarious experiences [16] . and required treatment. When compared with the gen- eral German population, those with extreme dental fear Direct Previous Traumatic Experiences had a higher prevalence of decayed teeth. The above ob- It has been reported that individuals with high levels servations of the existence of oral health disparities in of DFA often attribute their anxiety to their experience of those with extreme dental fear [16–20] not only highlight a traumatic past dental event. Locker et al. [23] referred the consequences of DFA for oral health function but also to this as ‘conditioning via aversive treatment experi- support the idea that a specific dental phobia exists [15] . ence’. In a study of phobic patients [24], 61% report- ed that their phobia stemmed from ‘conditioning experi- ences’. The Aetiology of DFA It has been suggested that when the traumatic dental episode occurs in childhood it has a lasting effect with re- Locker et al. [19] studied the age of onset of dental gard to adult DFA. As previously mentioned, Locker et al. anxiety in a survey of 1,420 adult participants, 16.4% of [19] found that half of those suffering from DFA devel- whom were assessed as being dentally anxious. Half of oped their fear or anxiety in childhood, highlighting the those who were dentally anxious reported that their den- need to understand how children acquire DFA. ten Berge tal fear started in childhood. This relationship between et al. [25] examined how children acquire dental fear, spe- dental anxiety and childhood onset reinforces the need to cifically with regard to invasive treatment experiences. understand the aetiology of dental fear in order to prevent Regression analysis showed that there was a significant the potential for oral disease in adulthood. This proposi- relationship between child DFA and the number of ex- tion is supported by ten Berge [20] , who stated the impor- tractions a child had experienced; suggesting that one of tance of targeting children at risk for DFA. Indeed, when the causes of DFA was invasive dental treatment. An in- Akbay Oba et al. [21] examined the relationship between teresting additional finding by ten Berge et al. [25] was DFA and dental caries in 275 children, they reported that that children who had experienced more check-up visits the number of decayed, missing or filled teeth increased before they experienced their first curative treatment (i.e. as dental fear increased. This further highlights the im- they had a longer history of non-invasive experiences) portance of addressing the issue of DFA in children to reported low levels of dental fear. This suggests that the prevent the negative effects on oral health. longer the child continues to have a positive experience To understand these aetiological factors, Eli et al. [22] when visiting the dentist the less likely they are to become assessed patient dental anxiety using the Dental Anxiety dentally fearful whenever they do eventually have a nega- Survey, and psychological distress profiles were deter- tive experience, referred to as latent inhibition. mined by the Symptom Check List (SCL-90). Patients An important part of the child dental experience is the were asked to complete a dentist evaluation question- interaction with dental staff, yet this is a relatively under- naire. It was shown that the best predictor of dental anx- researched topic in terms of dental anxiety. However, re- iety was the patient’s evaluation of their present dentist search in this area suggests one possible way of reducing followed by previous dental anxiety. The three SCL-90 dental anxiety, by highlighting specific behaviours that dimensions of patient interpersonal sensitivity, anxiety increase or reduce anxiety. Zhou et al. [26] collected re- and phobic anxiety correlate with present dental anxiety. search from 11 publications in a systematic review exam- Therefore, a patient’s dental anxiety was negatively cor- ining the impact of dental care professionals’ clinical be- related with a positive evaluation of their dentist. haviours on child DFA. A relationship existed between It is important, therefore, to understand each aetio- dental staff behaviour and child DFA, with punishing be- logical factor associated with DFA in terms of exogenous haviours associated with high child DFA. To reduce DFA, and endogenous sources of DFA in order to improve pa- they suggested that practitioners adopt an empathic com- tients’ oral health and quality of life and to increase den- munication style, verbal explanation and reassurance. tists’ awareness and understanding of the dentally anx- Of particular importance when discussing past child ious patient [9] . dental experiences is the role memory plays in maintain-

Dental Fear, Anxiety and Phobia Med Princ Pract 2014;23:295–301 297 DOI: 10.1159/000357223 Downloaded by: 41.128.165.40 - 3/17/2015 11:36:31 AM ing DFA. Kent [27] examined dental patients’ memory of In a systematic review and meta-analysis of 43 experi- pain by comparing patients’ remembered pain 3 months mental studies about parental and child dental fear, after treatment with their expected and experienced pain. Themessl-Huber et al. [33] confirmed that there was a sig- Kent [27] found that there was a closer association be- nificant relationship between child and parental dental tween remembered and expected pain than there was be- fear. The interplay between both the mother’s and the fa- tween remembered and experienced pain. This associa- ther’s dental fear was further examined and it was found tion was particularly strong in patients who scored high that, in a family, both the mother’s dental anxiety and the on the DAS. Kent hypothesized that dental anxiety might father’s dental anxiety are significant predictors of child be maintained because the anxious patients have inaccu- DFA [34]. Similarly, Locker et al. [19] found an associa- rate memories of the pain they experienced during treat- tion between the onset age of dental anxiety and a family ment. The view of Kent [27] was supported by Freeman history of dental anxiety, which would confirm that vi- [28] , who demonstrated that memories of unpleasant carious learning is a potential cause of DFA. Specifically, past dental experiences were greater in dentally anxious Locker et al. [19] found that 56% of participants who re- patients than in non-anxious patients, with dentally anx- ported child onset dental anxiety had a parent or sibling ious patients reporting more experiences of traumatic who also suffered anxiety about dental treatment. This dental events, thereby indicating that the cause of DFA is suggests that, as children, these participants indirectly more complex than simply a negative past dental experi- learned their anxious response to dental treatment by ob- ence. serving the behaviour of those around them. The authors Humphris and King [29] examined the impact of pre- noted that the association with a family history of dental vious distressing experiences upon dental anxiety. One anxiety only existed with child onset anxiety, which con- thousand and twenty-four students participated and firmed the findings of Öst [35] that child onset phobias completed the MDAS and an assessment of their suscep- were more likely to develop through vicarious learning tibility (Level of Exposure-Dental Experiences Question- compared to those phobias that have their onset in adult- naire; LOE-DEQ) [30] . The authors found that 11% of the hood. sample reported high dental anxiety. The local anaesthet- In a qualitative study of DFA in children and adoles- ic injection was the most feared item. With regard to past cents, Gao et al. [36] analysed videos from YouTube traumatic dental treatment, participants who reported a about dentistry. Twenty-seven videos that involved 32 distressing experience were two and a half times more children and adolescents were analysed for the ‘manifes- likely to experience high dental anxiety [29] . Humphris tations and impacts of dental fear and anxiety’ and the and King [29] stated that experience of a dental treatment ‘origins of dental fear and anxiety’. ‘Influence of parents trauma was most predictive of DFA. and peers’ emerged as an important point in DFA causa- Moreover, Humphris and King [29] showed that other tion. For children parental teasing and for adolescents distressing experiences could be displaced onto dental hearing stories from their friends about negative dental treatment resulting in DFA. They reported that sexual as- experiences were the root of the development of DFA sault victims were almost two and a half times more like- [36] . Influences from friends and family members are ly to report high dental anxiety compared to participants therefore considered to be the most relevant when con- who had not experienced sexual assault. Similarly, Leen- sidering DFA in children [33] , whereas for DFA in ado- ers et al. [31] found that women with an experience of lescents it is the impact of the peer group which is believed sexual assault reported DFA related to lying flat in the to be more important [36, 37] . dental chair, and they found that those with a history of Examining the impact of the media upon DFA, Ooster- sexual abuse had a more pronounced gagging reflex and ink et al. [38] asked 1,464 participants to complete the higher DFA [32] . These findings highlight the point that LOE-DEQ measure, which contains questions about their it is not just previous, negative dental experiences that can experiences of frightening stories told in the media about cause subsequent DFA but also other traumatic experi- dental treatment. They found no significant difference be- ences far removed from the dental surgery. tween those who had and had not been exposed to fright- ening stories in the media. In contrast, Humphris and Indirect Vicarious Experiences King [29] found that individuals with high DFA were al- Vicarious learning is defined as indirect learning from most two and a half times more likely, compared to the role models, such as family members or peers, or external rest of their sample, to have heard about or seen frighten- sources such as the media [22] . ing stories about dental treatment in the media. Therefore,

298 Med Princ Pract 2014;23:295–301 Beaton /Freeman /Humphris DOI: 10.1159/000357223

Downloaded by: 41.128.165.40 - 3/17/2015 11:36:31 AM the evidence base concerning the influence of vicarious Cognitive Ability learning and the impact of the media remains equivocal. In a study examining anxiety in a dental setting, 40 children (age 8–16 years) who did not have a previous Endogenous Sources of DFA experience of visiting the dentist had their intelligence The term ‘endogenous’ relates to the idea that indi- measured by the Wechsler Intelligence Scale of Children viduals are dentally anxious for internal reasons, such as (WISC III). Toledano et al. [43] found that children with personality traits. Locker et al. [19] has referred to inter- high intelligence quotients showed less anxiety than oth- nal aetiological factors as a ‘constitutional vulnerability to ers at their first visit to the dentist. Blomqvist et al. [44] (dental) anxiety disorders’. expanded on this research by measuring the relationship between cognitive ability (measured by the WISC III) and Heritability specifically DFA (measured by the Children’s Fear Survey Ray et al. [39] tested the hypothesis of a genetic com- Schedule Dental Subscale) in 70 children. They found a ponent of DFA. In their longitudinal study of over 2,000 significant negative correlation between DFA and verbal twins (the Swedish Twin Study of Child and Adolescent intelligence. No other significant relationships were Development), the authors measured DFA and dental found between DFA and other aspects of intelligence. fear intensity. These measures took the form of 3 dental This finding suggests that children with a high verbal in- fear questions answered by selecting yes or no, and a sin- telligence suffer from less dental anxiety. This may be un- gle question about the intensity of the dental fear. Data derstood by considering how valuable being able to ex- were collected when participants were 13–14 years old press and ventilate anxious feelings and explain coping and again 3 years later. A genetic component in dental strategies may be when entering a stressful environment fear/anxiety was found, and the heritability was shown to such as a visit to the dentist [44] . be higher in girls than in boys. No such gender difference was found for dental fear intensity. These findings not only fill a gap in the literature but they also provide an Consequences of DFA for Dental Practice interesting addition to theories of the antecedents of DFA. The relationship between DFA and avoidance has been described as a ‘vicious cycle’ [45, 46] or, as Klepac Personality Traits et al. [47] stated: the ‘possible confounding of oral health The predominant model of personality, in current psy- and fear level is one manifestation of the vicious cycle chological research, is the 5-factor model which divides ubiquitous in neglected health concerns, wherein ne- personality into 5 traits: (a) openness to experience, (b) glect leads to increased health concerns that render conscientiousness, (c) extraversion, (d) agreeableness avoidance more likely, etc.’ This hypothesis, first pro- and (e) neuroticism [40, 41] . Neuroticism and extraver- posed by Berggren [45] in 1984, suggests that DFA leads sion are the two traits that are predominantly related to to avoidance of dental care, which results in neglect of DFA [40] . Costa and McCrae [41] define these traits as dental treatment and subsequently poor oral health. follows: This is compounded by feelings of embarrassment [48] • Extraversion involves warmth, excitement seeking and shame, as well as by the likelihood that when a den- and assertiveness. tally anxious patient attends after a long period of avoid- • Neuroticism involves aspects of anxiety, self-con- ance they will need more invasive treatment [3] which sciousness, hostility and depressive symptoms. has the potential to reinforce DFA and further, future Neuroticism has been shown to have a strong associa- avoidance ( fig. 1 ). tion with a propensity to experience anxiety [42] . There- The model of Berggren [45] of the vicious cycle has fore, in a study of 880 students at 4 Finnish universities, been supported by recent studies that have sought to test participants’ dental anxiety and the above 5 personality and expand this theory [46, 50] . De Jongh et al. [46] vali- traits were measured. Halonen et al. [40] reported that dated the model of Berggren [45] by demonstrating that dental anxiety was significantly and positively correlated the deterioration of dental health status exacerbated the to neuroticism, and significantly but negatively correlat- effects of dental avoidance, resulting in poorer oral health ed to extraversion. These results suggest that individuals status, together with increased negativity associated with who are highly neurotic or introverted are more likely to receiving dental treatment. experience dental anxiety.

Dental Fear, Anxiety and Phobia Med Princ Pract 2014;23:295–301 299 DOI: 10.1159/000357223 Downloaded by: 41.128.165.40 - 3/17/2015 11:36:31 AM Conclusions and Practice Implications

Fear, anxiety Dental anxiety and dental phobia represent points on a continuum and may reflect complex psychological problems that have significant effects on the lives of the individuals that suffer from them, whether they cause Feelings of Avoidance of guilt, shame avoidance, increased dental caries or poor oral health-re- dental care and inferiority lated quality of life. Therefore, it is necessary to consider how best to treat dental anxiety and phobia to prevent poor oral health in the future. As De Jongh et al. [53] not- ed, clinical experience and data from research suggests Deterioration of dentition that general dental practitioners are capable of effectively treating patients with dental anxiety, but when a patient is phobic they should be referred to secondary level care such as psychological or pharmacological management. Fig. 1. The vicious cycle of dental anxiety of Berggren [48, 49] . There are clearly many different aetiological factors in the development of DFA, with evidence supporting theo- ries of exogenous and endogenous causes such as past experiences, role models, the media, genetics, personality, More recently, Armfield [50] considered the vicious and intelligence. An individual may have had a negative cycle by measuring DFA, the frequency of dental visits experience of visiting the dentist in the past, with evi- and treatment needs in 1,036 dentate Australians. He dence suggesting that DFA is more likely to have occurred found that 39% of people with moderate to high dental in childhood, may have known someone who had a past fear fit the cycle of ‘avoiding dental visiting because of negative experience, or may have the kind of personality fear, having treatment need and visiting for a problem’ traits that make him/her more likely than normal to be compared to only 1% of people without dental fear, there- susceptible to anxiety. A person may be afraid of the den- by supporting the vicious cycle model, with dental fear tist for one or all of these reasons, or even due to an inter- acting as a determinant of dental avoidance. action between them. Indeed, an individual who is highly Despite the evidence supporting the impact of dental neurotic may be subsequently more vulnerable to a nega- anxiety upon dental attendance, the authors [45, 46, 50] tive experience than someone who is highly extraverted. did not examine the relationship between previous fright- This was summarized succinctly by Liddell and Locker ening dental treatment experiences and the onset and [54] when they stated that: ‘It is impossible to say from maintenance of dental anxiety. Moreover, they did not this study whether the experiences were, in fact, very trau- provide an explanation for the observation that not every- matic, or whether the subjects were more sensitive to one who has an unpleasant treatment experience enters them.’ the vicious cycle of dental anxiety. This review has highlighted the complexity of the mul- Willumsen et al. [51] examined this in more detail. She tifactorial aetiology of dental fear, anxiety and phobia. posited an internal vicious cycle in which she hypothe- The implications for dental practice are associated with sized that patients perceive dental treatment as threaten- knowing the degree to which the patient’s fears prevent ing. In response, patients experience increasing muscular dental attendance, the history of the patient’s dental anx- tension and increased blood pressure and sweating, which iety and how the role of exogenous and endogenous fac- further increases their dental anxiety. These physical sen- tors impact the patient’s DFA. Revealing these important sations may be perceived as a threat to the patient’s inter- aetiological factors will allow the dentist to tailor her/his nal world, leading to feelings of panic and anxiety. This treatment to the dental anxiety needs of the patient and internal vicious cycle and misinterpretation of bodily thereby reduce patient fear and diminish workplace sensations is a modification of Clark’s cognitive model of stress. panic [52] in which panic attacks are said to be caused by a ‘catastrophic misinterpretation’ of sensations such as palpitations or dizziness as being symptoms of a more serious condition.

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Dental Fear, Anxiety and Phobia Med Princ Pract 2014;23:295–301 301 DOI: 10.1159/000357223 Downloaded by: 41.128.165.40 - 3/17/2015 11:36:31 AM