SEARCH

SEARCH BY CITATION

Keywords:

  • behavioral science;
  • dental anxiety;
  • interdisciplinary research

Abstract

  1. Top of page
  2. Abstract
  3. Enter the psychologists
  4. A novel approach
  5. Treatment evolution
  6. Etiological issues
  7. Current and future challenges
  8. Conclusion
  9. Acknowledgements
  10. Conflicts of interest
  11. References

This introductory article to the Symposium on Behavioral and Community Dentistry aims to describe the development of research and clinical work on dental anxiety, and includes a discussion of the historical background and the evolution since the 1970s. In view of its pioneering activities in this regard, special focus is placed on research and development at the Institute of Odontology of the University of Gothenburg, Sweden.

Clinical research on dental anxiety in Gothenburg, Sweden, began in the early 1970s. A main reason for this was the continuously increasing influx of referrals of severely anxious patients to the Institute of Odontology with requests for dental care, ranging from rather minute treatment needs through dental treatment under sedation to full dental treatment under general anesthesia. These multifaceted referrals derived, in at least half of the cases, from non-dental sources, such as occupational physicians, psychiatrists, or general medical practitioners. Even if the referral source was indeed a dentist, it was clear that those referrals were in most cases one-way only; there was no eventual going back for the patient for further dental care.

This, combined with the fact that the dental treatment offered in principle did not encompass any alleviation of the basic problem, led to a novel focus: how can these patients be better understood; and by acquiring a better mechanistic background of the ailment, how can these patients be taken care of to be able to cope with dental treatment, not only for the present but also for the future? This clinical problem clearly called for research in wider circles beyond those of traditional dental research and of a behavioral science depth hitherto seen very little of within this field. Collaboration between dentists and psychologists was thus instituted, and this has been the key to our continuous research and clinical work over the last 40 yr.

Enter the psychologists

  1. Top of page
  2. Abstract
  3. Enter the psychologists
  4. A novel approach
  5. Treatment evolution
  6. Etiological issues
  7. Current and future challenges
  8. Conclusion
  9. Acknowledgements
  10. Conflicts of interest
  11. References

The members of the Department of Psychology who were contacted and first got in touch with dentists at the Institute of Odontology – for discussions of dental fear as well as of other clinical complications – realized immediately that the problems presented by the dentists offered unique possibilities to explore psychological issues. The dentists to become involved encountered clinical difficulties where they felt that psychology might be of help. The main problem was the care of severely fearful patients. Other problems – not a focus of this Symposium – included stress-related muscular tension in temporomandibular dysfunction conditions and dentist–patient interactions.

The treatment options that the dentists had to offer a dentally fearful patient at the time were treatment under sedation or general anesthesia, or different treatments based on ‘tell-show-do’ principles in the dental operatory. However, the experience from the profession was that patients who had these treatments were usually not cured of their dental anxiety and came back some years later with renewed poor oral status. For that reason and for a few others – financial, risk, and the problems of giving optimal care to a patient under general anesthesia – there was a need for alternative treatment methods.

A novel approach

  1. Top of page
  2. Abstract
  3. Enter the psychologists
  4. A novel approach
  5. Treatment evolution
  6. Etiological issues
  7. Current and future challenges
  8. Conclusion
  9. Acknowledgements
  10. Conflicts of interest
  11. References

The question arose of whether the psychologists knew of any possible and adequate method, and one such method, Systematic Desensitization, had indeed been launched by the South African-born psychologist, Joseph Wolpe [1]. Wolpe relied upon a physiological analogy: Sherrington's concept of reciprocal inhibition between antagonistic muscles [2]. In the same vein, Wolpe postulated that a state of phobic anxiety could not exist simultaneously with relaxation. So, one possibility to reduce the anxiety reactions responsible for the avoidance of dental visits would be to outmaneuver the anxiety by inducing a relaxed state.

The treatment technique developed by Wolpe prescribed that this could be brought about by a step-by-step procedure: the patient was first taught relaxation in a neutral situation and was then instructed to maintain the relaxed state whilst imagining himself in a situation related to the phobic object. The scenes to be imagined were successively made more threatening; for example, in the case of a snake phobia, they started with imagining a snake in a place far away, through viewing a snake confined in a terrarium, to encountering direct contact with a snake. When the patient experienced tension or anxiety, he/she was immediately instructed to stop imagining the scene and regain a relaxed state. Sooner or later a scene could be imagined whilst maintaining a calm and relaxed state, and the training could be escalated to the next step. Wolpe published studies showing that a whole ‘hierarchy’ of scenes could be managed within a limited number of sessions, and that the effectiveness of the treatment was amazing [1].

The team of psychologists started to treat dentally fearful patients using an exact application of the procedure launched by Wolpe, but with scenes dealing with snakes or spiders being replaced with material from dental care such as calling for an appointment, sitting in the waiting room, being placed in the treatment chair, seeing the dentist examinations, and drilling. The psychologists were encouraged when they observed the report of a successful case study from a few years earlier [3]. That study was performed at the School of Dentistry, State University of New York at Buffalo (NY, USA), which was then one of the very few academic centers where dental fear research was performed. We got in touch with the two leading investigators: psychologist Professor Elliot Gale visited the clinic in Gothenburg repeatedly for scientific exchange, and we used, from the very start, the Dental Anxiety Scale developed by psychologist Professor Norman Corah [4], since then a standard instrument in this type of research.

Later, contacts were also established with several other important dental anxiety researchers: Professor Peter Milgrom (Seattle, WA, USA); Professors Magne Raadal and Erik Skaret (University of Bergen, Bergen, Norway); Professor Ilana Eli (University of Tel Aviv, Tel Aviv, Israel); and Dr Odont. Rod Moore (University of Aarhus, Aarhus, Denmark).

Treatment evolution

  1. Top of page
  2. Abstract
  3. Enter the psychologists
  4. A novel approach
  5. Treatment evolution
  6. Etiological issues
  7. Current and future challenges
  8. Conclusion
  9. Acknowledgements
  10. Conflicts of interest
  11. References

The initial results of the dental anxiety treatment at the clinic were quite amazing, with most of a small group of patients showing significant reduction in their fear, as assessed psychometrically and by ratings performed by the dentist attempting the first dental treatments after completed desensitization. The first international scientific report from our clinic was published by Carlsson et al. [5], in 1980, describing the treatment modality in a single group study; significant improvements in dental anxiety and treatability from pre- to post-therapy were indicated.

Already, as described in that report [5], the therapy procedure had subsequently undergone several modifications based upon experiences in the clinical work:

  1. As many patients had difficulties in imagining dental-treatment scenes, video recordings of different dental-care situations were produced at the clinic and used to facilitate exposure during treatment. This mode of virtual reality exposure is still the main exposure technique used at the clinic (Fig. 1).
  2. The treatment sessions were moved from a neutral room to a dental-treatment room, where the patient was placed in a dental chair while viewing the film scenes. In this way the ecological validity was enhanced and the exposure became more effective.
  3. Instead of reporting upcoming tension by raising a hand, the patient was given control by means of a remote device, breaking the ongoing scene.
  4. The ability to relax was trained by means of a brief version of Jacobson's progressive muscle relaxation [6]. The patient received an instructional tape for daily training at home.
  5. A biofeedback technique was added to enhance the patient's ability to relax, by providing continuous information of the tension level to the patient and the therapist during treatment.
  6. Cognitive perspectives of dental anxiety became increasingly important parts of the therapy process. This meant exploration of the patient's thoughts and beliefs concerning dental treatment and dental anxiety, and active attempts to induce less anxiety-provoking conceptions.
image

Figure 1. The modern treatment setting. The patient is viewing dental scenes whilst observing feedback information of stress-induced muscle tension. Reprinted with permission from the Swedish Dental Journal [20].

Download figure to PowerPoint

The treatment method has been subjected to several evaluations. Ulf Berggren, in his Doctoral Thesis from 1984, presented, together with one of his supervisors, Anders Linde, a randomized controlled trial with a comparison between our psychological treatment and treatment under general anesthesia [7]. The differences in terms of psychometric and clinical outcomes were greatly in favor of the psychological mode of treatment. A follow-up study, 2 yr later [8], showed a preserved effect: a significantly higher proportion of the patients in the psychological treatment group were in regular dental care in some general practice clinics, either in private or public dental service.

In two systematic reviews [9, 10], our method and similar ones with behavioral/cognitive behavioral methods have shown moderate to good evidence of being clinically valuable means of handling the clinical problems of dental anxiety. However, because of the quality of the studies reviewed, it was concluded that new and better designed clinical trials should be performed in order to achieve better evidence for the applicability and success in a long-term perspective of the different methods [10].

Etiological issues

  1. Top of page
  2. Abstract
  3. Enter the psychologists
  4. A novel approach
  5. Treatment evolution
  6. Etiological issues
  7. Current and future challenges
  8. Conclusion
  9. Acknowledgements
  10. Conflicts of interest
  11. References

There are still numerous problems deserving intensified attention in the dental anxiety area. One largely unresolved issue concerns the etiology of the condition. There seems to be a small genetic component [11], but as usual there is a wide scope remaining for environmental factors. Like many others, we have attempted to separate the unfortunate experiences of dentists and dental treatment, supposedly leading to lingering conditioned-anxiety reactions, from the more indirect roots such as the influence of fearful parents or mates. We have attempted to separate those two possible subgroups by means of systematized anamnestic information [12, 13]. One aim has been to investigate whether the two groups respond differently to various treatment varieties, one hypothesis being that individuals with a conditioned anxiety reaction maintaining their fear and avoidance would benefit from a more relaxation-oriented treatment. However, when we compared the outcomes of a relaxation-oriented treatment with a more cognitively oriented type of treatment, no marked differential effects could be observed between patients with a ‘conditional’ background to their fear and patients with a more ‘indirect’ causation [14].

One obvious possibility of why research into etiological factors is hazardous may emanate from the way we think of causality. There lies a tremendous simplification in notions of dental anxiety as depending mainly upon some remote single cause – genetic or experiential. Dental anxiety is quite a complex phenomenon, with somatic and psychological, as well as social, aspects. Moreover, etiologically, the development of this composed syndrome may run through several stages, each bringing a new complication to the condition, and each forming a changing basis for the maintenance and the continued development of the fearfulness syndrome. Figure 2 illustrates an intuitive conception of how a perpetual interaction among biological, psychological, and social factors may bring about a successively more complex and more firmly maintained state of illness.

image

Figure 2. Intuitive analysis of the development of dental anxiety. bio, biological; psych, psychological; soc, social.

Download figure to PowerPoint

However, such a conceptual model may be too complicated for research purposes [15]. It has to be broken down into simpler components in order to facilitate empirical testing. One way of doing so would be to discern specific arrays of factors involved in vicious-cycle processes. In this vein, Berggren, in his PhD thesis [16], presented a model describing the possible circular relationship among fear/anxiety, avoidance, deterioration of dental state, and feelings of shame and inferiority (‘Berggren's model’; Fig. 3) [16]. This model has recently gained additional empirical support [17]. A similar model, emphasizing the interplay among oral health, dental-health utilization, and dental fear, has been presented by Armfield et al. [18].

image

Figure 3. Berggren's model describing the ‘vicious’ circular connection maintaining and enforcing dental fear and avoidance.

Download figure to PowerPoint

Current and future challenges

  1. Top of page
  2. Abstract
  3. Enter the psychologists
  4. A novel approach
  5. Treatment evolution
  6. Etiological issues
  7. Current and future challenges
  8. Conclusion
  9. Acknowledgements
  10. Conflicts of interest
  11. References

The models reported so far are either hypothetical or based upon cross-sectional data. Because the processes being considered supposedly evolve over time, there is a need for longitudinal data in order to explore possible causal links during the development of the fear/avoidance syndrome. An attempt in that direction is presented in this issue of the European Journal of Oral Sciences [19]. One hope for the future would be that more etiological research will be based upon data collected over a sufficiently long enough period of time to enable us to approximate the complex shaping of the dental anxiety/avoidance condition. This would mean enhanced means of prevention and treatment. Theoretically, increased insight into the etiological dynamics of dental anxiety may help to form generalized models for understanding other anxiety conditions that are less directly accessible to empirical research.

It is important to point out that research of dental anxiety should pinpoint different perspectives, inasmuch as dental anxiety may be seen both from individual and public health aspects. Future research should focus not only on treatment methods but also highlight patient-centered factors, such as health-related quality of life, in relation to dental anxiety/phobia. Our current and future research at the Department of Behavioral and Community Dentistry comprises: (i) randomized controlled trials (RCTs) for evaluating better and more tailored treatments for adult patients; (ii) an RCT study for Cognitive Behavioral Therapy treatment of adolescents with dental anxiety; (iii) a longitudinal, observational study of dental anxiety and concomitant factors among children and adolescents; and (iv) observational studies evaluating the relationships among dental anxiety, sense of coherence, oral health-related quality of life, and neuropsychiatric conditions.

A sine qua non in this research has been, and still is, the collaboration between dentists and psychologists. Thus, the setting currently encompasses a dental clinic for treatment of dental anxiety/phobia as part of the Clinic of Oral Medicine, which belongs to the Public Dental Service and the Department of Behavioral and Community Dentistry (DBCD) at the Institute of Odontology (part of the Sahlgrenska Academy at the University of Gothenburg). The spectrum of DBCD has been widened to include not only clinical research of dental anxiety but also epidemiological projects.

Conclusion

  1. Top of page
  2. Abstract
  3. Enter the psychologists
  4. A novel approach
  5. Treatment evolution
  6. Etiological issues
  7. Current and future challenges
  8. Conclusion
  9. Acknowledgements
  10. Conflicts of interest
  11. References

Much remains to be explored in dental anxiety research, but still three cornerstones of outcome from treatment are of utmost importance for the patients: the main focus should be (i) the eradication of dental anxiety, (ii) maintenance of regular dental care, and (iii) the competence by the patient to change dentist and/or clinic if needed.

Acknowledgements

  1. Top of page
  2. Abstract
  3. Enter the psychologists
  4. A novel approach
  5. Treatment evolution
  6. Etiological issues
  7. Current and future challenges
  8. Conclusion
  9. Acknowledgements
  10. Conflicts of interest
  11. References

Our own research, referred to above, was supported by the NIDCR, National Institutes of Health, USA; the Swedish Medical Research Council; the Swedish Council for Working Life and Social Research; the Swedish Foundation for Health Care and Allergy Research; the University of Gothenburg; and Region Västra Götaland.

References

  1. Top of page
  2. Abstract
  3. Enter the psychologists
  4. A novel approach
  5. Treatment evolution
  6. Etiological issues
  7. Current and future challenges
  8. Conclusion
  9. Acknowledgements
  10. Conflicts of interest
  11. References