Motivation and emotion/Book/2020/Dental fear

Overview
Dental fear (dentophobia) is experienced by about 36% of the US population with 12% suffer from extreme dental fear (Beaton, Freeman & Humphris, 2013). The anxiety of avoiding the dentist can cause serious impact on an individual's oral health, which can then impact the individual's quality of life (Beaton, Freeman & Humphris, 2013). This anxiety can be triggered by needles, drills or the dental setting in general, in combination with a traumatic experience from an early age (Department of Health, Victoria, 2020). Treatments, such as therapy, are ways that can help with individuals that have trouble getting over their fears of the dentist and to help them be able to take care of their oral health so that they can live the quality of life they want.

Models used to help explain dental fear anxiety measurement, and therapeutic techniques used in the treatment include:


 * Theory of learning
 * Cognitive theories
 * Social Model - The Model of Anxiety (Sobol-Kwapińska et al., 2018)

Focus questions:
 * What causes dental fear?
 * What are the consequences of avoiding the dentist?
 * How can dental fear be managed?

Underlying Features of Dental Phobia


Dental fear is a generic fear of dentists and dental work. People who suffer from dentophobia have difficulties visiting the dentist without suffering from anxiety attacks or other types of symptoms. These attacks can be brought on by generic smells, sights and/or sounds of the dental surgery, or even being at a clinic can trigger a response. In most cases though, dental fear can be revolved around something more defining to individuals, such as fear of the dentist, needles, pain, numbness, choking, anaesthetic, dental drill (see Figure 1), being embarrassed by the state of their teeth, and the diagnosis (if the dentist has found something more concerning than they originally thought) (What is Dental Phobia, 2018).

Dental Anxiety and Phobia (Dentophobia):
Anxiety is a mental health disorder that causes worry, fear and anxiousness which can interfere with an individual's daily activities. Dental anxiety is a form of anxiety where an individual feels anxious or worried about entering a dentist room and having someone prod around their mouth with sharp, uncomfortable tools (Department of Health, Victoria, 2020)

There are several types of dental anxiety models that are conditioned to be aversive in dental experiences. These models assume that the experiences are negative and often painful dental experiences, which is a factor in the development of dental anxiety. Rachaman (1997) presented a three pathways model relating to dental fear, such as people acquire pain before dental appointments, because they have either experienced an unpleasant experience themselves, witnessed someone else experience an unpleasant experience themselves, or heard of an incident of an unpleasant dental appointment (Sobol-Kwapińska et al., 2018).

The Cognitive Vulnerability Model is primarily based on a cognitive evaluation of the situation, where a person's perspective of a dental experience is crucial in the development of fear (Sobol-Kwapińska et al., 2018).

The Model of Anxiety is an example of a social model, where it is a vicious circle. It presents correlations between dental anxiety, avoidance of dental care, deterioration of dentition and feelings of guilt, shame and inferiority (Sobol-Kwapińska et al., 2018).

The Theory of Learning refers to a learning process, however, different from the techniques discussed above in the sense that indirect learning is involved. Indirect learning refers to learning from others, for example from parents or peers. Research has shown that children can profit and learn from seeing other children, friends or parents undergoing treatment, without fear reactions or scary things happening (Berge, 2008).

Why people avoid the dentist
The origins of dental fear can be sourced through childhood as children and adolescents try to avoid making an appointment with the dentist more and more as they grow up. Rachman (1990) proposed that although fears are often acquired directly; they may also be acquired through two other pathways, vicarious experiences or threatening information (Milgrom et al., 1995). Both direct conditioning and parent modelling factors were significant independent predictors of fear level even when controlling for gender, age and other sociodemographic and attitudinal factors. There were three groupings of concerns when the study have found through the dental fear survey: highly invasive procedures, such as injections and drilling; fear of potential victimisation, including fear of strangers, choking and hospitals; and fear of less invasive procedures, such as opening the mouth and being examined by the dentist (Milgrom et al., 1995).
 * 1) Dental anxiety is most commonly caused by feelings of helplessness, embarrassment, or negative past experiences. Phobias of situations where you feel like you have no control are very common, such as a fear of aeroplanes. People who don’t feel comfortable with their dentist can often feel this way.
 * 2) Finding time to make an appointment can be extremely difficult for some people. However, this can be destructive to your oral health as urgently needed care can often be neglected. Tooth decay and gum disease certainly won’t treat itself.
 * 3) Although pain may have been a deterring issue in the past, modern dental techniques ensure any amount of pain is thoroughly reduced.
 * 4) Most patients are well aware of their own dental issues and don’t want to visit the dentist to be lectured about how they should have taken better care of their teeth.
 * 5) For some people, regular dental treatment is considered an unnecessary cost. For this reason, treatment is only considered when a problem arises. This attitude can prove to be more costly than receiving regular check-ups and cleans. Preventive dental care is far more affordable than having to undergo intensive restorative work. (5 Reasons Why People Avoid Seeing the Dentist, 2017)

Case study: Severe dental phobia in an adolescent boy
A 12-year-old boy was referred to the Children's Department by his general dental practitioner with a history of lack of co-operation and failed compliance with general anaesthetic administration and oral sedation. The boy reported that 2 years previously he had had a traumatic experience during the administration of local anaesthesia and since then his anxiety had grown and generalised to most aspects of the dental environment. The patient required prevention, conservation and root canal therapy. (Levitt et al., 2000)

This case study demonstrates the model of anxiety and cognitive theory throughout the first stage of his treatment as he experienced anticipatory anxiety, with difficulty sleeping before appointments and he felt overwhelmed by his dental problems (Levitt et al., 2000). He also had a fear of catastrophe, which manifested as a fear of a panic attack which he believes that he would be unable to breathe, as well as a fear of specific stimuli, where he fears about the needle and also the drill when being treated by a dentist (Levitt et al., 2000).

Consequences of Dentist Avoidance


There are many reasons why someone may risk avoiding the dentist but that can lead to quite a few consequences that can affect the health and wellbeing of an individual. The consequences of avoiding the dentist room are mostly the damage it can have on the oral health of an individual such as:


 * 1) Tooth decay (see Figure 2): it can destroy your tooth enamel, the outer layer of your teeth. When the sticky bacteria called plaque is left to form on your teeth, it produces an acid that eats away at the protective enamel. This can lead to cavities which require a filling. When left undetected, cavities can continue to deepen as the decay progresses. This leads to the need for more complicated restorations such as root canals. If left too long, it can even lead to tooth loss (Dawson Dental, 2019).
 * 2) Gum diseases can lead to stages where bone and tissues surrounding the teeth start to deteriorate
 * 3) Stained, yellow teeth: Lifestyle habits can increase staining such as smoking or drinking red wine or tea and coffee. Without regular dental care at checkups, your teeth will begin to yellow and severe yellowing can turn into a deeper, very unsightly brown colour — common for smokers. This will require intense and costly whitening, or in some cases even more advanced cosmetic treatments such as veneers (Dawson Dental, 2019)
 * 4) Can lead to root canal treatment if a cavity needing a filling is left untreated
 * 5) Higher dental cost: Visiting the dentist just once or twice a year usually incurs a relatively small fee. But if you look at the cost of more involved dental and cosmetic treatments to restore and repair teeth, not to mention specialised periodontal treatments for gum disease, you are looking at fees ranging in the thousands. Regular preventative dental care prevents you from incurring these more serious issues and higher fees in the future to repair the damage that resulted from this neglect (Dawson Dental, 2019)
 * 6) Advanced periodontal disease: It begins as gingivitis with swelling gums, redness and bleeding due to harmful bacteria. Gingivitis is easily spotted at regular dental checkups. However, when left to progress, your teeth will become loose, your breath will become extremely unpleasant and you will often have a bad taste in your mouth (Dawson Dental, 2019).
 * 7) Tooth loss (see Figure 3): When left unchecked, decay and gum disease can lead to advanced destruction and in the most severe cases, complete tooth loss. This means the removal of all of your teeth. This is a painful process which requires costly solutions such as dentures or dental implants (Dawson Dental, 2019)
 * 8) Poor diet: With the loss of teeth, or even challenges presented by painful teeth, your gums and jaws have to work harder to eat and swallow. They may become irritated due to the extra wear and tear and you might be more inclined to reach for softer, less healthy foods to avoid this. Many health consequences can be affected by this such as:
 * 9) * Weight issues
 * 10) * High blood pressure
 * 11) * High cholesterol
 * 12) * Heart disease and stroke
 * 13) * Type-2 diabetes
 * 14) * Some cancers
 * 15) * Depression
 * 16) * Eating disorders (Dawson Dental, 2019)

The longer it is left untreated, the more expensive it'll be for an individual's teeth to be treated (Baker, 2017)

Management of Dental Fears
When it comes to the management of dental anxiety with individuals, there are many ways to help overcome those fears, depending on the level of anxiety they experience with dentistry. These are:


 * Cognitive behavioural therapy: has been shown to be effective in patients completing the treatment process and overcoming their fears (Berggren et al., 2000). It changes and reconstructive negative thoughts and increases control over such thoughts (Sobol-Kwapińska et al., 2018).
 * Adults with low anxiety levels can be suggested to enhance their sense of control such as the stop signal during the procedure, the cognitive distraction where the individual is encouraged to think about something other than the dental procedure, and also environmental change, such as changing the smell in the reception/waiting room with lavender as an immediate sense of relaxation (Newton et al., 2012)
 * Adults with high anxiety levels are more likely to undergo cognitive behavioural therapy to create a new understanding that the feared stimuli are unlikely to be dangerous and in turn, all the safety behaviours they exhibit through their anxiety aren't required anymore (Newton et al., 2012)
 * Relaxation-oriented therapy: although not as effective as cognitive behavioural therapy, it has resulted in a significant reduction of anxiety for dental fear, as well as general anxiety (Berggren et al., 2000)
 * Sleep Dentistry: allowing the dentist to put an individual under anaesthesia so that they are able to be asleep while the dentist does the work required on their teeth (Willumsen et al., 2009)
 * Pharmacological treatments: medications that can help manage dental fear, which can range from mild sedation to general anaesthetic, and are often used by dentists in conjunction with behavioural techniques. One common anxiety-reducing medication used is nitrous oxide (also known as laughing gas or happy gas), which is inhaled through a mask worn on the nose and causes feelings of relaxation and dissociation (Dental Fear, 2019)
 * Pharmacological approaches can be seen as less acceptable for the management of dental fear with individuals with extreme dental fear, so psychological techniques is more beneficial for them (Newton et al., 2012)

Case Study: Management
The case of the 12-year-old boy has demonstrated the use of physical strategies including muscle relaxation and relaxation breathing, practice strategies including graded exposure and cognitive strategies, combined with individual control methods and inhalation sedation to complete the dental treatment plan successfully (Levitt et al., 2000). This case exhibit how each individual experiences dental fear differently and how each case moving forward needs to be strategised to suit just that individual.

The models of Cognitive learning and social model of anxiety demonstrates how the management of each individual is based on the level of dental fear they exhibit and how to perform the right treatment for each individual so that they are able to confidently go to their dentist appointment without the high levels of anxiety they display.

Conclusion
To conclude with, Dental fear is one of the common fear in people, starting from a young age and has a huge emotional effect on an individual growing up as they avoid seeing the dentist which in turn will affect their oral health. It is caused by common anxiety of the unknown, the tools that dentists use as well as the pain from them, and also the embarrassment of the state of their teeth. The consequences of avoiding the dentist can cause tremendous health problems to their teeth and mouth as the more a person avoids the dentist to fix the pain or problems in their teeth, the more expensive it'll cost them to get it done in the end. Ways that an individual can manage their fears and anxiety are through cognitive and behavioural therapy and/or pharmacological treatments. So to avoid having all your teeth fall out, its best to try and keep on top of going to the dentist for 6-month checkups to ensure that the fear of the dentist can decrease, as well as knowing that your teeth are able to stay in place and you're not risking yourself to potential teeth decaying or gum disease.