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Far Beyond Anxiety
It is not an exaggeration to argue that dental anxiety is the most important psychological factor dental staff will meet in practice. Dental anxiety is that feeling of apprehension experienced by an individual when confronted with matters that are dentally related. It is commonly described as having psychological, conceptional and behavioural aspects. Hence, patients who describe themselves as dentally anxious may complain of raised heart rate (physio-logical), imagining painful consequences of dental treatment (conceptional) and preferring to delay making a dental appointment (behavioural).
The extensity of dental anxiety has been studied over the past 50 years. Levels of self-reported dental anxiety appear to be remarkably stable when comparing representative samples from a single culture (in this article, samples picked from USA) over a time span of 34 years (1967-2001) and using identical measures (Corah’s Dental Anxiety Scale). This may appear to be disappointing, especially when attempts are being made to make dental treatment more comfortable. Repeated surveys in other countries however, suggest that dental anxiety prevalence has fallen due to procedures that have assisted in reducing anxiety. These include use of preventive treatments, lasers, new dental materials for fixing restorations, and use of written and computer-assisted information systems. The falling levels if dental anxiety may be something of a success story for the dental profession, considering there has been a definite rise of general anxiety levels in the population over the past 50 years.
A Common Problem
From this optimistic standpoint, it is still disappointing that approximately 30% of the adult population continue to feel nervous about visiting the dentist. In a large Dutch representative sample it was found that 36% respondents afraid of visiting the dentist. Hence nervousness may not seem too important until it is realized that about one in five respondents delay making a dental appointment because of their anxiety. Dental anxiety promotes avoidance. So universal is the ‘condition’ of dental anxiety that the experienced practitioner with large numbers of patients, many of whom will be dentally anxious, is able to manage the vast majority of patients with quick and simple procedures that are learnt from observing or copying other colleagues, training, courses and general clinical experience. Some patients present, however, with either unusual features that may not respond quickly to the dental practitoner’s standard procedure or with such intensity that at first sight the anxiety cannot be challenged to reduce it. This group is sometimes classified, rather punishing, as ‘difficult’ could be interpreted to mean that the patient has a choice over whether to volunteer his/her feelings. S/he might have voluntarily made a decision to receive special attention and extra time from the dental team. Evidence would appear to indicate the reverse. Most dentally anxious patients are acutely embarrassed to admit to their difficulty and would gladly prefer, if at all possible, to hide their feelings and attempt to cope without any special arrangements and procedures. The more intense the quality and quantity of anxiety felt by the patient, the greater the sense of shame and need to avoid any exposure to the dentist or dentally related stimuli. Therefore a distinction needs to be made between those patients who attend despite of their intense fear (dentally anxious) and those who avoid dental treatment (dentally phobic). Individuals who avoid dental care at all costs are best described as dentally phobic, which is distinct and separate from dental anxiety. While dentally anxious patients can link their fear to specific frightening dental experiences, the same is not the case for those who are dentally phobic. Dentally phobic patients tend to displace or impose frightening experiences from outside the dental surgery onto dental treatment. The resulting anxiety is unbearable, and they avoid the situation that evokes such a magnitude of fear. Therefore dental phobia is a condition with discrete features, which can be a symptom of a psychological disorder and as such may require referral for secondary-level care.
So Develops The Dental Anxiety
A direct traumatic dental experience, such as painful injection or exposure to insensitive dental staff
An indirect traumatic dental experience, such as hearing negative stories about dental procedures in the family, school playground or article in magazines, books and the media
A direct traumatic medical experience, such as lumbar puncture or tonsillectomy conducted at an early age.
These various traumatic experiences are interpreted by the individual under several conditions that have a bearing on the strength and stability of dental anxiety, including:
The vulnerability of the individual concerned. Patients with multiple mental health problems or a generally anxious disposition may be more prone to developing dental anxiety.
The timing of the experience. Patients who encounter a dental (or perhaps medically-related) traumatic experience at an early age (under five years of age) are more likely to exhibit dental anxiety.