Overcoming fear for better oral health
Johnson & Johnson is delighted to bring you this article, with the aim of supporting the ongoing CPD needs of dental healthcare professionals in improving and maintaining the oral health of their patients.
This article is equivalent to one hour of Enhanced CPD. To provide feedback on this article, please contact firstname.lastname@example.org
Aims and objectives
The aim of this article is to explore how fear of attending dental appointments can adversely affect oral health, and offer practical ways for clinicians to help their anxious patients.
On completing this CPD session, the reader will:
- • Understand the prevalence of dental anxiety within the UK
- • Understand the impact dental anxiety can have on patients’ oral health
- • Understand the potential role of the Modified Dental Anxiety Scale in dental practice
- • Understand the significance of focusing on prevention when communicating with anxious patients.
Overcoming fear for better oral health
This article explores how fear of attending dental appointments can adversely affect oral health, and offer practical ways for clinicians to help their anxious patients.
Coriat was the first to adopt the term ‘dental anxiety’, defining it as ‘an excessive dread of anything being done to the teeth.’1 Meanwhile, in terms of its prevalence, according to the Adult Dental Health Survey of 2009, 12% of adults who had ever attended an appointment with a dentist achieved a Modified Dental Anxiety Scale* (MDAS) score of 19 or more, which is suggestive of ‘extreme dental anxiety’.2 A further 36% scored between 10 and 18 on the MDAS, indicating moderate dental anxiety.2
The Survey also suggests that the two elements of dental care to elicit the greatest level of anxiety were having a tooth drilled and receiving a local anaesthetic injection.2 Also rated relatively highly as anxiety-inducing were: sitting in the waiting room; the anticipation of seeing the dentist tomorrow; and having a scale and polish.2
Overall, extreme dental anxiety has been estimated to be experienced by more than 10% of dentate adults in England, Wales and Northern Ireland, and is seemingly a more significant issue for women than men.2
These appear to be fairly stark statistics, and are indicative of a need to do more to help patients overcome their fear in order to achieve and then maintain a good level of oral health. What then, is the reality of dentally-related anxiety for both the dental professional and affected patient, and how might practical help be offered?
The vicious cycle
As the Adult Dental Health Survey (2009) tells us: ‘The relationship between levels of dental anxiety and self-assessed dental health is complex. Poorer dental health may stem from neglect arising from the avoidance of dental care due to anxiety about visiting the dentist or it may be that some individuals expect that they need considerable dental treatment and are therefore extremely dentally anxious.’2
This kind of thinking led, in part, to dental anxiety being coined a ‘vicious cycle’ by Berggren in 1984.1 Defining this concept in practical terms, Beaton and colleagues (2014) wrote that dentally-related anxiety: ‘[…] leads to avoidance of dental care, which results in neglect of dental treatment and subsequently poor oral health. This is compounded by feelings of embarrassment and shame, as well as by the likelihood that when a dentally anxious patient attends after a long period of avoidance they will need more invasive treatment which has the potential to reinforce DFA [dental fear and anxiety] and further, future avoidance.’1
To place this concept of anxious patients having poorer oral health in context, Gordon and colleagues (2013) highlighted that one study showed such patients to have 8 or 9 decaying teeth compared to 1 or 2 in the general population.3Heidari and colleagues (2015) added to this body of evidence, indicating that phobic participants in their study were more likely to have one or more decayed teeth compared to non-phobic subjects (39.9% as opposed to 26.5%).4
Furthermore, the Adult Dental Health Survey reported that there was, ‘[…] a marked difference in the prevalence of PUFA [presence of open pulp, ulceration, fistula and abscesses in the mouth] according to the frequency of tooth brushing, high levels of dental anxiety, poor general and dental health.’2
Offering practical help
Humphris and colleagues (2016) suggest that: ‘Assessment of dental anxiety should be a prerequisite for any visit to the dentist and can be routinely performed. There are a variety of self-report questionnaires that are simple and easy to complete. The simplest of measures that have been developed is the Modified Dental Anxiety Scale (MDAS).’5
They continue: ‘The scale is easily employed in the practice setting as it takes no longer than 2-3 minutes to complete with simple instructions (supplied say by the dental nurse or receptionist). There are normative values for people in the UK. The total score can be compared with results obtained from the last Adult Dental Survey of England, Wales and Northern Ireland. […] There is no evidence that completing the MDAS significantly raises dental anxiety. The cut-off point that has been demonstrated to indicate where respondents would prefer additional assistance when attending the dentist for their own dental fitness is 19. That is patients who score 19 or above are likely to be extremely dentally anxious. Patients who are dentally phobic will nearly always be in this elevated sample.’5
The authors further noted that research indicates that patients are more able to cope in a dental setting if the dentist acknowledges past problems and is willing to discuss the patient’s anxiety in relation to the reason for the visit to the practice.5
They also perceived that: ‘Distress was raised when [the] dentist apparently withdrew the subject in their interactions with patients. The patient regarded this behaviour as an indication that the dentist had forgotten their potential difficulty to manage treatment.’5
Oral health-related behaviour
When it comes to home care, Heidari and colleagues (2015) wrote: ‘Individuals identified as having a phobia of dental treatment were more likely to report cleaning their teeth less frequently than the ideal twice a day, less likely to report using interdental cleaning methods and to use an electric toothbrush, attend the dentist less frequently and more often only attend when in perceived trouble. The differences between the two groups in all the previous mentioned parameters were statistically significant (p <0.001). However, phobic patients were more likely to report using a mouthwash (452 [59.3%]).’4
In relation to this last point, the authors added: ‘[…] the use of mouthwash […] was higher in the phobic group – suggesting they are more likely to use ‘preventive’ techniques that were perceived to be less invasive.’4
This may be good news for dental healthcare professionals looking to improve their anxious patients’ oral health home care regimen, assuming this concept can be capitalised upon. Dental clinicians already know, of course, that brushing and interdental cleaning are fundamental to oral hygiene.6
However, although ‘[…] it theoretically is possible to maintain a level of oral hygiene […] using mechanical methods alone, data indicate that the vast majority of people are unable to accomplish this on an ongoing basis.6
Barnett (2006) suggested that this gap in preventive care provides: ‘[…] a clear rationale for incorporating effective antimicrobial measures, such as use of an antimicrobial mouthrinse, into daily oral hygiene regimens.’6
Adding to this view, in 2015, Chapple and colleagues reported on the consensus views of Working Group 2 of the 11th European Workshop in Periodontology.7 They concluded that, ‘…where improvements in plaque control are required, adjunctive use of antiplaque chemical agents may be considered. In this scenario, mouth rinses may offer greater efficacy but require an additional action to the mechanical oral hygiene regime.’7
It would seem therefore that there is a case to be made for the use of an effective antimicrobial mouthrinse as an adjunct to mechanical cleaning in some patients. What’s more, if communication about the three steps of brushing, interdental cleaning and rinsing focuses on the idea that they are non-invasive, preventive methods, anxious patients may well be motivated to take up a more effective regimen of mechanical cleaning followed by an appropriate mouthwash formulation,4 when appropriate.
Referring back to the Adult Dental Health Survey (2009): ‘It has been suggested that a continuum of dental anxiety exists ranging from those who feel relaxed during dental treatment, to those who are dentally anxious but cope, through to those who are dentally phobic and avoid care. Dental anxiety is therefore a potential barrier to seeking dental care and its association with oral health is of central importance.’2
With greater dental fear leading to a delay in treatment – or, indeed, complete avoidance – resulting in deteriorating oral health requiring more invasive treatment that, in turn, compounds patients’ anxiety,8 it seems imperative that dental healthcare professionals face this challenge head on, perhaps using the MDAS in the first instance as a helpful tool in the pursuit of offering patients peace of mind.5
*MDAS – the modified dental anxiety scale is: ‘A self-reported psychometric anxiety questionnaire used to objectively evaluate the level of a patient’s anxiety. It is a 5 item questionnaire with a maximum score of 25. A score of 19 or above indicates a highly dentally anxious patient and possibly a dental phobic’.9
Beaton L et al. Why are people afraid of the dentist? Observations and explanations. Med Princ Pract 2014; 23: 295-301
Adult Dental Health Survey 2009. The Health and Social Care Information Centre 2011
Gordon D et al. A critical review of approaches to the treatment of dental anxiety in adults. Journal of Anxiety Disorders (2013); 27: 365-378
Heidari E et al. Oral health status of non-phobic and dentally phobic individuals; a secondary analysis of the 2009 Adult Dental Health Survey. BDJ 2015; 219(9): 1-8
Humphris G et al. Adult dental anxiety: Recent assessment approaches and psychological management in a dental practice setting. https://research-repository.st-andrews.ac.uk/handle/10023/8821. Accessed 27 July 2017
Barnett ML. The rationale for the daily use of an antimicrobial mouthrinse. JADA 2006; 137: 16S-21S
Chapple ILC et al. Primary prevention of periodontitis: managing gingivitis. J Clin Periodontol 2015; 42 (Suppl. 16): S71-S76
Armfield JM. What goes around comes around: revisiting the hypothesized vicious cycle of Armfield JM. What goes around comes around: revisiting the hypothesized vicious cycle of dental fear and avoidance. Community Dent Oral Epidemiol 2013; 41: 279–287
Ireland R. Oxford Dictionary of Dentistry. Oxford University Press 2010; 223