Helen R. Chapman BDS, MSc, LDS RCS (Eng) PGCert (CBT)
Nick Kirby-Turner BSc, Dip Clin Psychol, CPsychol
The incidence of moderate and severe dental anxiety in Europe, Asia and North America are 40% and 20% respectively, with 5% of people suffering fear levels sufficiently high to be classed as phobia (1). People who are dentally fearful tend to avoid treatment and are much more likely to attend the dentist when prompted by pain (2). Their avoidance removes opportunities for learning, as does the dental profession’s emphasis on the use of sedation or general anaesthetic with fearful patients. Patients simply do not learn that the catastrophe they fear (such as being unable to tolerate pain, losing control, or collapsing with fear) does not occur in the dental office.
Historically, the alternatives to sedation/anaesthesia have been hypnosis or behavioural treatments; role modelling and behaviour shaping in children and in vivo desensitisation in children and adults. These behavioural treatments have been successful (3). However, they rely on multiple, incremental learning experiences to provide an opportunity for cognitive reappraisal of dental treatment and the spontaneous modification of negative automatic thoughts. On some occasions, this learning does not take place and treatment stalls. Without an appreciation of the exact nature of the patient’s fears and the ability to address them directly, the clinician may be ineffective in progressing treatment (4).
At the simplest level, all patients should be given a Subjective Units of Distress Scale (SUDS). However, this is not routinely taught to dentists, at least in the UK. Patients can be taught to measure their distress and communicate with a stop signal (5) when they reach a certain level on the SUDS.
We have found that the ability to access patients’ cognitive world is essential, even though they may not initially have full meta-awareness of their automatic thoughts. Making patients aware of their automatic thoughts facilitates targeted treatment. For example, when dentists elicit a fear from patients that they (the dentist) might ‘spring’ something on them, dentists can take special care to explain procedures and routinely check if the patient needs more information. Dentists need to take care, though, to avoid helping patients merely replace automatic thoughts with positive responses that the patient doesn’t believe. Dentists may need to collaborate with a therapist or specialist training for the dental team to help some patients. Properly done, targeted cognitive restructuring can result in very rapid treatment; we have ‘cured’ some adult patients with under 2 hours of psychological treatment. It is our impression that properly focussed cognitive work reduces the patient’s dependency on the treating dentist and facilitates generalisation of the skills.
What type of automatic thoughts do patients have? In our experience, they fall into 5 basic themes: pain, fear of the unknown, fear of loss of control, lack of trust/fear of betrayal and intrusion (physical, psychological and/including threats to self-esteem) (6). Pen and paper questionnaires do not necessarily reveal some of the less common or more idiosyncratic thoughts; that is why it is important to elicit automatic thoughts directly from the patient.
So where does this leave us? Oral sedation appears to have no long-term benefits on fear levels (7). Inhalational sedation seems to provide a relatively aware and conscious experience which can lead to spontaneous reappraisal of fears in some (8). There is little evidence for spontaneous improvement in dental fear after intravenous (IV) sedation (7). There is only limited evidence for improvement in dental fear after general anaesthesia (9) and indeed, some may find anaesthesia a traumatic experience in its own right. Also, it carries a small but finite risk of mortality and morbidity. There is a role for these techniques to cover a very difficult procedure which exceeds the coping skills possessed by the patient and for urgent and extensive treatments in those who have previously avoided. Indeed, it may be the treatment protocol of choice for patients who need treatment and are not able to trust even the most caring, considerate of dentists in the most structured of circumstances. For these patients, desensitisation after becoming dentally fit allows the building of trust independent of active dental treatment.
From a public health perspective, time and money spent in a formal CBT package may well obviate the need for multiple episodes of sedation or general anaesthesia. The skills learned by the patient can be generalised to other situations, particularly medical ones. Following a successful CBT treatment, patients are likely to attend dental appointments regularly and receive preventive advice and care, thus reducing future treatment need.
It is our belief that members of the dental team can be trained to use a limited and focussed form of CBT that would be of great benefit to patients and would be cost-effective.
Helen R Chapman is a Registered Specialist in Paediatric Dentistry, works in dental practice where her treatment is limited to phobic patients, and is a freelance trainer.
Nick Kirby-Turner is a Consultant Clinical Psychologist. They have produced and delivered training packages for the dental team and have co –authored “Getting through Dental Fear with CBT – A Young Person’s Guide,” Blue Stallion Publications, Witney, 2006
1. de Jongh, A et al Negative cognitions of dental phobics: reliability and validity of the Dental Cognitions Questionnaire Behaviour Research & Therapy 1995; 33(5): 507-15
2. Hagglin, C et al Factors associated with dental anxiety and attendance in middle-aged and elderly women Community Dentistry and Oral Epidemiology 2000; 28: 451-60
3. Kvale, G et al Dental fear in adults: a meta-analysis of behavioral interventions Community Dentistry and Oral Epidemiology 2004; 32: 250-264
4. Mansell, W The Dental Cognitions Questionnaire in CBT for dental phobia in an adolescent with multiple phobias Journal of Behavior Therapy and Experimental Psychiatry 2003; 34(1): 65-71
5. Chapman, HR & Kirby-Turner, NC Visual/verbal analogue scales: examples of brief assessment methods to aid management of child and adult patients in clinical practice British Dental Journal 2002; 193(8): 447-50
6. Chapman, HR & Kirby-Turner, NC Dental fear in children–a proposed model British Dental Journal 1999; 187(8): 408-12
7. Johren, P et al Fear reduction in patients with dental phobia Br.J.Oral Maxillofac.Surg. 2000: 38(6): 612-6
8. Willumsen,T. et al One-year follow-up of patients treated for dental fear: effects of cognitive therapy, applied relaxation, and nitrous oxide sedation Acta Odontologica Scandinavica 2001; 59(6): 335-340
9. Hakeberg, M et al Long-term effects on dental care behaviour and dental health after treatments for dental fear Anaesthesia Progress 1993; 40(3): 72-