Introduction

This article explores fear as a potential contagion and how, over time, constant exposure to patient fear and anxiety may impact the dental practitioner’s stress level. Additional stress factors and their effects are also discussed. Dental phobia is defined in conjunction with an explanation of the neuroscience of fear, and how olfactory, auditory, and visual stimulation in the dental office may trigger an amygdala response in patients. In conclusion, the sensory impact of the dental office will be discussed, and how, by creating a soothing environment, patient anxiety and fear may be ameliorated.

Fear Itself

It is well known that when someone coughs or sneezes, visually perceptible germ particles are emitted. While there are methods to remove harmful particles from almost any surface, the presence of fear is not so easily nullified. How can we protect ourselves against this known stressor and its potential long-term impact?

While dentists’ focus may be on the patient’s oral health, in particular the mouth, the “whole” patient must be kept in mind. An individual’s history is essential in the dynamic of care. However, critical details may only be evident through certain behaviors or responses.

The mouth impacts the body’s biology, physiology, and psychology, and its health depends on both patient and dentist. Yet despite many advances in dental technology and pain control, it is reported that 50-80% of the U.S. adult population has some level of dental treatment anxiety, with women reporting much higher than men; more than 20% do not seek regular dental care; and an estimated 9-15% of all Americans avoid much-needed care due to anxiety and fear surrounding the dental experience. This adds up to approximately 30-40 million people so afraid of dental treatment they avoid it altogether. Although a fairly large percentage of dental fear patients see the dentist regularly, there is a high incidence of missed or cancelled appointments. Other patients with dental fear use dental services only in emergencies.

The best dental or medical care works with the body’s natural defenses, but these can be seriously challenged when a patient presents with a toothache or more serious secondary infection. Treating symptoms and easing pain are only the beginning of a treatment plan. What directs it is not only an understanding of the causal agents and a strategy to effectively manage these issues, but of the connection between the patient and dental team.

Wear and Care

A daily caseload ranging from patients in intense pain to routine care with underlying fear/anxiety can cause wear and tear on the psyche of dentists and the entire office team. Over time, symptoms of this stress become more noticeable.

“Erosion of one’s well being is not immediately recognized, and eventually, without intervention, the symptoms can slowly increase in severity, impacting behavior and activities both in the office and at home,” explains Gretchen Stein, Ph.D., president and CEO of The Sand Creek Group, who in collaboration with the Minnesota Dental Association and Dentists Concerned for Dentists provides the Minnesota Dentist Wellness Program, which is available to all Minnesota dentists and their families. “Often it is only when the more severe and corrosive effects of anxiety and depression are felt that dentists reach out for more skillful ways to cope and manage,” says Dr. Stein.

According to the American Dental Association’s 2003 Dentist Well Being Survey (published January 2005), 37.6-44.8% of dentists surveyed agreed or strongly agreed that they would have difficulty seeking professional help — i.e., counseling or psychotherapy — because they believe they should be able to solve their own problems. Of that group, 68.6% reported they have a moderate level of stress at work, and these levels were approximately the same for male and female dentists and for younger versus older dentists.

“Of further interest in this survey," notes Ms. Linda Keating, Manager, Dentist Health and Wellness at the ADA, “is that dentists with severe stress levels at home reported they were more likely to have severe stress at work, and 42.6% of dentists who had severe stress at home also had severe stress at work. Of dentists who reported they had light stress at home, only 9.2% had severe stress at work ... Leaving the office in a depleted state after managing not only patients with both behavioral and dental care challenges but problems with staff and potential financial concerns as well, often the dentist does not have much strength or patience left to cope with the stress, whatever the source, that awaits at home. The personal situations compound the existing conditions at work, with the reverse being true as well.”

What It Means to be Afraid

Despite the fact that fear of dental treatment is widely acknowledged by the general public, surprisingly little research has been carried out into its origins, treatment,
and prevention, according to Dr. Peter Milgrom, professor at the University of Washington/Seattle and one of the founders of the UW Dental Fears Research Clinic (DFRC), a world-renowned clinic established to serve anxious, phobic, and mentally ill patients. DFRC is served by clinical psychologists, anesthesiologists, and dentists working together to conduct research in this area and provide training and patient care.

For many patients, just stepping into a dental office sets off a cascade of emotions. Milgrom et al explain, “The development of fear responses to potentially threatening situations is normal, natural, and adaptive; however, it is important to realize that what determines a person’s reaction is not an outsider’s view or judgment of the actual or potential threat. It is a result of the individual’s personal perception of the situation, based upon his or her experiences and interpretation of the present situation.”

Milgrom et al believe it is important to clarify what is meant by fear in the context of dental care, and to further differentiate fear from the related terms anxiety and phobia.

As defined by Milgrom and his colleagues, they are:

Fear. An individual’s emotional response to a perceived threat or danger. This response is composed of three related components:

(1) An unpleasant cognitive state, such as feeling something terrible is going to happen.

(2) Physiologic changes, primarily involving activation of the sympathetic branch of the autonomic nervous system. Intense fear reactions will typically include tachycardia, perspiration, respiration changes such as hyperventilation, muscle tension, gastrointestinal upset, and other physiologic signs of emotional arousal.

(3) Overt behavioral movements such as jitteriness, shaking, pacing, and attempts to escape or avoid the perceived threat.

Anxiety. Milgrom et al differentiate anxiety from fear, observing that anxiety denotes responses to situations in which the source of threat is ill-defined, ambiguous, or not immediately present. A person reacting emotionally in anticipation of a future event such as a dental appointment is said to experience “anticipatory anxiety”. The major difference is the immediacy of the threat or stimulus.

Phobia is a form of intense fear, and exposure to phobic stimulus almost invariably provokes an immediate anxiety response. Avoidance is of such degree that it causes significant distress or interferes with one’s social or role functioning.

Characteristic Behaviors

In treating fearful dental patients, another area of relevance in Milgrom’s work is the understanding of approach/avoidance behavior and its impact on accessing dental care. Understanding this element may enhance the practitioner’s ability to more effectively manage patientswho exhibit this challenging behavior pattern.

“An approach behavior conflict exists when a person has two competing tendencies with respect to a single situation. The individual may want to attain a goal but at the same time avoid it. Dental patients’ motives to ‘approach’ a dentist are the need for care and desire to have attractive, healthy teeth. At the same time they avoid following through with the appointment. These competing tendencies leave the person in perpetual conflict. There are several factors that may, over time, lower the avoidance gradient. Unfortunately, it may take a severe toothache to succeed at overcoming the tendency to avoid keeping an appointment.” (Milgrom et al) Milgrom describes an interesting sub-category of phobic patients as “goers but haters”. They make appointments on a relatively regular basis but experience intense fear and may begin to worry days in advance. Once in the office, their fear causes them so much discomfort they are unable to hide it. Such patients often stop the dentist, and frequently need to be told to “open wider”, “relax”, and so forth. They may even directly state how much they “hate dentistry”, whereupon the dentist may feel the patient is reacting adversely to the treatment or, in a more personal way, to the dentist or his assistant. These patients require more time to treat, and if not scheduled for, can affect the office for the rest of the day.

Within this category is another type: the "total avoiders", whose fear level is so intense they put off appointments for years at a time. If the fear is not treated, they are unlikely to become regular dental patients, and it is typically only with an extenuating circumstance that an appointment is made. Because of the time between appointments, these patients may require extensive treatment. The intensity of their fear has the potential to add to the stress level of the dentist. According to Milgrom et al, this behavior often deters the individual’s daily activities and functioning, and qualifies as a phobia. Milgrom notes these patients often self-medicate, may use alcohol or other pain-killing drugs, and may be under their influence when presenting for care. Challenging to care for, these patients can exacerbate any stressful condition already present for the dentist, even if this condition is seemingly under control.

The Dental Office Environment

While understanding fear/anxiety/phobia provide insight into managing patient care, of equal relevance in the Milgrom et al research are studies on the aspects of dentistry that frighten most people.

Study results were divided into specific situations, instruments, and procedures which are feared, and characteristics of dental personnel patients find disturbing. These characteristics, while not comfortable to acknowledge, may serve as tools for self-analysis and enhance a practice’s mission by changing behaviors and subsequent responses to patients.

Patients cite two instruments as producing the most fear and dread: the needle and the drill. The next most fear-provoking aspect of going to the dentist was the sound of the drill, followed by its “feel” or vibration. It is not just those patients who were termed highly fearful or phobic who found the needle and drill frightening. Both children and adults expressed fear of choking and of having the dentist in close proximity.

The dentist’s personal and professional behavior is also an important factor influencing a patient’s view of dentistry. Milgrom’s subjects included patients who focused on the personal attributes of the dentist such as “he is impersonal”, “nasty”, “disinterested”, “nervous”, “mean”, “uncaring”, “cold”. Patients who expressed views from a more professional perspective stated, “he is incompetent”, “rough”, “he yells at me”, “would not stop drilling when I told him it hurt”, “told me it wouldn’t hurt when it really would”, “would strap my arms and legs down”.

Auxiliary personnel and assistants are seen by most patients as soothing, caring, and non-threatening. Office staff assist in creating an atmosphere in the office, and often set the tone for the patient’s experience. There are, however, a significant number of patients who expressed fear of being embarrassed or belittled by dental personnel. While integrating this message into an office’s SOP, dentists and staff need also be aware that these feelings can be a critical clue to a portion of the patient population who are often misunderstood or handled ineffectively: patients with a history of childhood sexual abuse. 

Childhood Sexual Abuse Patients

Studies reveal that sexual abuse (believed to be underreported) is quite prevalent, with one in four females and one in seven males reporting a history. Dr. Jack Bynes, president of Dentalfear.com, a service for dental practitioners and phobic dental patients, states, “The dental and medical community, in general, need to start adopting new techniques to deal with these patients or the health of millions of Americans will deteriorate dramatically.” “There are,” he continued “several signs of childhood sexual abuse that dental patients exhibit. Dental treatment is often avoided without a clear understanding of why, and even if the patient is aware, he or she may not disclose this information. Although it is not at all appropriate to raise the possibility or existence of this childhood trauma with a patient unless there is an established long-term relationship and a high degree of trust and respect, it is important for the dentist to be aware of, and sensitive to, the possibility of a history of sexual trauma.”

Common effects of sexual abuse in specific relationship to the dental experience may include resistance to being placed in the horizontal position, fear of having objects placed over the face, sudden outbursts of crying without apparent reason, difficulty opening wide, severe gagging, and an involuntary turning of the head away from the dentist as he approaches the mouth.

“Unfortunately for both patient and dentist, dentists have unintentionally made the situation worse by not understanding the mechanisms underlying the patient’s behavior. Patients who have been sexually abused during childhood will sometimes have flashbacks in a confining situation such as being in the dental chair,” explains Bynes.

The situation can be exacerbated with abuse survivors. Bynes states, “The worst thing for a patient is the frustrated dentist who tries to deal with the situation authoritatively, with statements such as ‘You can’t possibly feel that’.”

Attempting to take control of the situation or belittling the patient may worsen the patient’s state of mind and create the potential for reactivation of the trauma.

Brain Function

How traumatic memories are formed, stored, and retrieved is the focus of study of emotion, memory, and the brain at the LeDoux Laboratory at the Center for Neural Science at New York University. A fundamental assumption of Dr. LeDoux’s work is that the brain has multiple memory systems, each devoted to a different memory function. For traumatic memory, two systems are important: explicit (conscious) memory, and implicit (unconscious) memory mediated by the amygdala and its neural connections. They are “memory” in the sense that they cause the body to respond in a specific way as a result of past experience.

The amygdala is a pair of almond-shaped structures in the brain whose main function is to regulate negative emotional responses like fear and anxiety. It is an emotional filter that assesses every situation for potential trouble, assigns emotional meaning to events in our lives, then stores emotional memories that influence our reactions. It also plays a role that is central to traditional mind/body medicine: it sets off the alarm that gives rise to the “fight or flight” response.

Although the response to the different sources of stress, as well as to olfactory, visual, and auditory cues, may vary widely in patients, awareness that there is a mechanism in the brain that receives and responds to these various stimuli can assist in developing a deeper understanding not only of patient behaviors but of the dentist’s own behavior and responses as well.

It’s All of Us

How contagious is fear, and what in the environment can help ameloriate anticipatory anxiety, fear, and phobias? Dr. LeDoux suggests that the psychology of contagious emotional responses is more relevant than neuroscience in this case, explaining that animal psychology supports this. In the laboratory, rats can detect stress signals in other rats in two forms: vocalization (a scared rat emits ultrasonic sounds that predators cannot hear to warn other rats), and chemical signals that cause stress in other rats.

If you put a rat in a chamber where another rat had been recently stressed, the second rat also expresses stress.

While the dental operatory is not a laboratory cage and patients and staff are not equated with animal models, the communal effects of stress are palpable and should be taken into consideration when planning and implementing a “well” dental office.

Acknowledgments

The author thanks the following for their contributions: Jack Bynes, D.M.D., Dentalfear.com; Linda Keating, M.S., RN, Manager, Dentist Health and Wellness, American Dental Association, Chicago, IL; Mary Jo Kreitzer, Ph.D., RN, Center for Spirituality and Healing, University of Minnesota; Dr. Joseph LeDoux, Center for Neural Science, New York University; Peter Milgrom, D.D.S., University of Washington Dental Fears Research Clinic; Gretchen Stein, Ph.D., The Sand Creek Group Ltd.;David Resch, D.D.S., Saint Paul;William E. Stein, D.D.S., Aitkin, Minnesota.

 
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About the Author. Vara Kamin is a former public health nurse and graduate of Massachusetts General Hospital School of Nursing, an author and artist. Her writing has appeared in national magazines, and for the past several years, her original works of art have been placed in a variety of private and public settings throughout the U.S. and are being replicated for hospital and healing centers throughout the country and placed in diagnostic and radiology suites, labor and delivery, pediatric ICUs, and other high stress areas. She is now working with Patterson Office Supplies, offering a selection of her images to the dental community throughout the U.S. and Canada.

Vara Kamin serves on the National Board of Directors for the National Society for Arts in Healthcare.