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Sexual correlates of gagging and dental anxiety

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Both oro-related behavioural and sexual dysfunctions are non-life-threatening conditions which can have an impact on individual well-being. Possible common features include intra-body penetration, giving control to another person, and experiencing encounters that can sometimes be subjectively experienced as aggressive and/or abusive. The present study examined possible sexual correlates of dental anxiety and gagging. A total of 448 individuals, who applied for sex therapy at the Sexual Medicine Center, Sheba Medical Center, Tel-Hashomer, Israel, completed the following sexual and dental functioning questionnaires: International Index of Erectile Function (men only), Female Sexual Function Index and difficulties with sexual penetration (women only), dental anxiety, gagging reflex and dentist preference (entire population). Higher gagging reflex was associated with problems in sexual penetration and history of sexual abuse in women (especially one that included vaginal penetration). It was also associated with dental anxiety and higher preference for dentist of the same gender for both genders. The study shows that gagging reflex can bear sexual connotations, especially in women.
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Community Dental Health (2012) 29, 243–247 © BASCD 2012
Received 9 March 2011; Accepted 17 September 2011 doi:10.1922/CDH_2808Uziel05
Sexual correlates of gagging and dental anxiety
N. Uziel1, G. Bronner2, E. Elran2 and I. Eli1
1The Maurice and Gabriela Goldschleger, School of Dental Medicine, Tel-Aviv University, Tel-Aviv, Israel; 2Sexual Medicine Center, De-
partment of Urology, Sheba Medical Center, Tel-Hashomer, Israel
Objective: Both oro-related behavioural and sexual dysfunctions are non-life-threatening conditions which can have an impact on individual
well-being. Possible common features include intra-body penetration, giving control to another person, and experiencing encounters that
can sometimes be subjectively experienced as aggressive and/or abusive. The present study examined possible sexual correlates of dental
anxiety and gagging. Basic research design: A total of 448 individuals, who applied for sex therapy at the Sexual Medicine Center,
Sheba Medical Center, Tel-Hashomer, Israel, completed the following sexual and dental functioning questionnaires: International Index of
Erectile Function (men only), Female Sexual Function Index and difculties with sexual penetration (women only), dental anxiety, gag-
ging reex and dentist preference (entire population). Results: Higher gagging reex was associated with problems in sexual penetration
and history of sexual abuse in women (especially one that included vaginal penetration). It was also associated with dental anxiety and
higher preference for dentist of the same gender for both genders. Conclusions: The study shows that gagging reex can bear sexual
connotations, especially in women.
Key words: gagging, dental anxiety, sexual dysfunctions, psychological, sexual offenses, sexual abuse
Introduction
The oral cavity and its associated functions share many
psycho-social similarities with sexuality and sexual
functioning. The oral cavity is the rst zone of pleasure
and satisfaction to the newborn, not only as a supplier
of nutrition, but also as an erogenous zone that provides
sexual pleasure. Even in individuals who have successfully
passed to the genital stage of development, some sexual
activity remains xed with the oral cavity (Freud, 1999).
The face and mouth play an important role also in
sexual attraction, essential for the survival of the species.
The mouth is a source of gratication and reinforcement
of sexual behaviours, a pleasure that encourages the rep-
etition of sexual acts. Moreover, oral sex has become a
normative part of sexual activities contributing to sexual
arousal and orgasm in both genders (Shindel et al., 2008).
A possible connection between dental fear and sexual
trauma has been suggested. The studies refer mainly to
sexual abuse and neglect. A prevalence of high dental
anxiety was found in women reporting past experiences of
sexual assault (Humphris and King, 2011). When women
who had high and low dental fears were compared with
respect to trauma history, high levels of dental fear were
associated with a higher prevalence of several forms of
child maltreatment and adult sexual and physical assault
(Walker et al., 1996). Among sexually abused women,
most subjects reported experiencing problems related to
dental treatment (Willumsen, 2001). Women with dental
fear who reported a history of child sexual abuse, scored
higher on the Dental Beliefs Scale than women with
dental fear with no history of sexual abuse in childhood
(Willumsen, 2004). Subjects with self-reported histories
of childhood sexual abuse report that some aspects of
Correspondence to: Dr Nir Uziel, School of Dental Medicine, Tel Aviv University, Tel Aviv, Israel. Email: niruzi@post.tau.ac.il
dental treatment (certain body positions, need for a sense
of control, fear of judgement) can be particularly difcult
(Stalker et al., 2005). Many patients with dental anxiety
report co-morbid psychosocial dysfunction due to effects
of sexual abuse, general anxiety, gagging, fainting or
panic attacks (Moore et al., 2004).
While dental anxiety is a prevalent and commonly
studied oro-related behavioural dysfunction (a dysfunction
related to the oral cavity and its functions) (Berggren and
Carlsson, 1985; Eli, 1992; Eli et al., 1997), excessive
gagging reex is another common obstacle to dental care
(Bassi et al, 2004). The co-morbidity between excessive
gagging and dental anxiety (Moore et al., 2004) may
result from gagging serving as an indirect expression of
anxiety. Presenting a “somatic” symptom, such as gag-
ging, may serve as an indirect way to avoid the threat
involved with dental treatment (Eli, 1992).
Unfortunately, the literature lacks accepted tools to
assess gagging. A Gagging Severity Index has been
proposed (Rosted et al., 2006), which is a descriptive
measure that may be useful in clinical settings but is less
appropriate for research because it is based mainly on
clinical parameters. More recently, a Gagging Problem
Assessment tool (GPA) was presented (van Linden van
den Heuvell et al., 2008). However, the GPA has been
tested on 25 individuals only and its substantial length
makes its use in research problematic. Although the
authors suggest a shorter version of the GPA for further
research, no data have been published on it, as yet.
The prevalence of both sexual dysfunctions and oro-
related behavioural dysfunctions is substantial (Eli, 1992;
Laumann et al., 1999). Neither pose immediate health
dangers, but they do have major inuences on a person’s
quality of life (Laumann et al., 1999; Mehrstedt et al.,
244
2007; Rosen et al., 1999; Shifren et al., 2008). To date,
there is no comprehensive research regarding possible
associations between oro-related behavioural dysfunc-
tions and sexual dysfunctions. The purpose of this study
was to examine the possible sexual correlates of dental
anxiety and excessive gagging reex in men and women.
Materials and Methods
This cross sectional study was conducted at the Sexual
Medicine Center, Sheba Medical Center, Tel-Hashomer,
Israel and approved by the Committee for Approval of
Experiments in Human Subjects under the Helsinki Ac-
cord at the Sheba Medical Center. All subjects signed
an informed consent form. Some 693 applicants for sex
therapy during the years 2005 to 2007 were requested
to complete questionnaires referring to sexual and dental
functioning and then had a structured interview with a
professional sex therapist (GB) leading to decisions re-
garding sexual diagnosis and treatment. Sexual diagnoses
were nalized according to Basson et al. (2000) and
Hatzimouratidis and Hatzichristou (2007).
The Dental Anxiety Scale (DAS), developed by Corah
(1969) as a specic measure of dental anxiety, has been
used extensively in research conducted on anxious dental
patients (e.g. Berggren and Carlsson, 1985; Eli, 1992; Eli
et al., 1997). Subjects’ DAS scores were categorised as
high dental anxiety or no/moderate dental fear using a
cut-off point of 13 as recommended in previous studies
(Corah et al., 1978). Regarding excessive gagging reex
however, there is no widely accepted scale or signicant
body of research. The tool proposed in this study, Gagging
Assessment Scale (GAS), was developed by two of the
present authors (NU and IE). It was tested for content
validity by gathering a group of subject matter experts
(SMEs) together to review test items. The group were 6
dentists who worked at the Tel Aviv University School of
Dental Medicine’s Clinic of Oral Psychophysiology with
clinical and academic experience in working with patients
unable to undergo routine dental treatment, mostly due
to dental anxiety and/or excessive gag reex. Each SME
proposed questions for the questionnaire and following
discussion 6 initial questions were agreed and presented
to a panel of 20 patients under treatment in the clinic.
Their feedback informed agreeing the nal 4-question
version of the GAS questionnaire: How do you feel when:
1, you brush your back teeth? 2, you are waiting in the
dental waiting room and thinking of the upcoming dental
treatment? 3, you are sitting in the dental chair and the
dentist is checking your teeth with his mirror and other
instruments? 4, the dentist is treating your back teeth?
Scores for each answer are: 1, I experience no nausea
whatsoever; 2, I feel slightly nauseous; 3, I am afraid I
will vomit; 4, I can’t do it because immediately I feel
nauseous and feel like vomiting; 5, I experience actual
spasms in my throat, sometimes even vomiting. As with
the DAS, the total score ranges from 4-20.
As the SMEs were unanimous in their conviction that a
close relation exists between dental anxiety and excessive
gagging reex, a construct validity evaluation was made
by calculating correlations between the GAS question-
naire and accepted parameters measuring dental anxiety
(DAS). Furthermore, the SMEs observed that patients
suffering from gagging tend to avoid dental treatment.
Therefore, in addition to DAS, an additional question was
presented to subjects: “How has your dental treatment
worked in recent years?” with possible answers being:
(a) I have routine dental care, (b) I go to the dentist only
occasionally when I need to; and (c) Not in treatment
at all. A low (nevertheless highly signicant) correlation
was found between GAS and DAS (r=0.282, p<0.0001)
as well as between GAS and the above mentioned ques-
tion (r=0.113, p<0.05). The correlation between the GAS
and DAS was also conrmed among a population of 402
random Israeli adults, in another study performed with
the assistance of the developers of the GAS scale (r=
0.604, p<0.001; Winocur et al. 2011).
A specic question regarding dentist preference was
presented to all subjects as follows: “What kind of dentist
do you prefer? Male, Female, Does not matter.”
Questionnaires also assessed sexual functioning. A
validated questionnaire, the Female Sexual Function Index
(FSFI, 6 domains, 19 items, women only) was used to
assess six domains of female sexual function (desire,
arousal, lubrication, orgasm, satisfaction and pain). The
six domains were summed to calculate a total FSFI
score (Rosen et al., 2000). Secondly, regarding sexual
penetration, a series of questions addressed the following
3 domains: difculties in penetration (PEN), pain during
penetration (Pain), and sexual abuse domain (SAD). In
PEN, difculties in vaginal penetration (VP) were as-
sessed by a 5-item yes/no scale, asking each woman to
report if she ever experienced problems in inserting a
tampon, participating in a gynaecological examination,
inserting self-nger, experiencing insertion of spouse’s
nger and/or participating in penile-vaginal intercourse.
Difculty with at least one of the PEN stimuli classied
subjects as PEN positive. For Pain, woman evaluated the
pain experienced during each 5 VP items on a 0-100mm
visual analogue scale (VAS). For SAD, each woman
reported if she had ever experienced an unpleasant/
abusive sexual encounter (yes/no scale) and if positive,
if the experience included VP.
For men the International Index of Erectile Function
(IIEF), a 15-item validated instrument was used to assess
5 domains of male sexuality: desire, erectile function,
intercourse satisfaction, orgasmic function and overall
satisfaction (Rosen et al., 1999).
Cronbach α was used to assess internal consistency.
Two-sample t-tests were used to compare between two
groups regarding continuous parameters. One-way
Analysis of Variance (ANOVA) was used when 3 groups
were compared. Distribution of categorical variables was
compared between groups by applying the Chi-square
test. Relationships between continuous measures were
evaluated by Pearson Correlation Coefcients. For mul-
tivariate analysis linear regression was used. SAS v9.1.3
was used for all statistical analyses with a signicance
level of p<0.05.
Results
Response rate was 64.6%. The nal study population
consisted of 236 women (mean age 31.5, sd 9.7y) and
212 men (mean age 36.0, sd 12.3y). The psychometric
properties of the scales in the present study (Cronbach
245
α) were as follows: DAS=0.89; GAS=0.67; FSFI (total
score)=0.94; IIEF (total score)=0.88. There were signi-
cant differences between women and men in the GAS and
DAS scores (4.88 sd 1.52 vs. 4.52 sd 1.16, p<0.01; and
9.66 sd 3.19 vs. 7.96 sd 3.02, p<0.0001, respectively),
with women indicating greater anxiety on both scales.
Classied by dental anxiety 69 were anxious (DAS
≥13) and 374, non-anxious. Anxious participants scored
signicantly higher on GAS than the non-anxious group
(5.60 sd 2.00; vs. 4.56 sd 1.16; respectively; p<0.0005).
There was a positive correlation between the DAS and
GAS scores (r=0.282, p<0.0001).
Most participants (86% of women and 88% of men)
showed no preference for the gender of their dentist.
Participants who preferred a dentist of their own gender
scored higher on GAS than those who showed no such
preference (p=0.05; Table 1). Signicant differences in
GAS were observed between PEN positive (114, 50.9%
of women) and PEN negative women (5.25 sd 1.85 vs.
4.57 sd 1.07, respectively, p<0.005). A correlation was
observed between GAS and the number of PEN positive
stimuli (r=0.237, p<0.001; Figure 1), i.e. the more dif-
culties in vaginal penetration among women, the higher
the tendency for gagging. No such differences with regard
to DAS could be detected. Pain levels ranged from 1.17
to 3.70 (for PEN negative stimuli). There were no cor-
relations between Pain and DAS or GAS.
Unpleasant/abusive sexual experience was reported by
93 women (SAD positive, 39.7%). SAD positive women
scored higher on GAS (5.28 sd 1.92) than women who
did not report such an experience (SAD negative, 4.61
sd 1.11; p<0.01). No such differences with regard to
DAS were detected. Unpleasant/abusive sexual experi-
ence which included vaginal penetration was reported
by 38 women. The GAS scores from this specic group
were higher than those of SAD positives without vaginal
penetration and of SAD negative women (5.79 sd 2.40
vs. 4.98 sd 1.40 and 4.61 sd 1.11, respectively, p<0.001).
Namely, the tendency of women to gag was found to
be lowest when no abuse has been experienced, higher
among women who had experienced some sexual abuse
and highest among women who experienced sexual abuse
which included vaginal penetration. No such differences
with regard to DAS were detected.
Table 2 presents the relationship between SAD group
and preference for a dentist of a particular gender. While
11% of the SAD positive women preferred a woman
dentist, the percentage among the SAD negative women
was only 2% (p<0.05).
Finally, a multivariate analysis of the data was cal-
culated (linear regression) with the dependant variable
being GAS and independent variables being: the six
domains of FSFI, PEN positive, SAD positive, and SAD
positive including vaginal penetration. The two variables
best predicting GAS were SAD which included vaginal
penetration (Parameter Estimate, PE=0.22, p<0.005) and
the PEN stimuli (PE=0.17, p<0.005)
Although detailed descriptions and analyses of the
sexual diagnoses (FSFI and IIEF scales) were beyond
the scope of the present paper and will be presented
elsewhere, the mean scores of these scales are presented
here for the readers’ general information: FSFI total
score=17.96 sd 7.76 (women only); IIEF total score=46.5
sd 15.83 (men only). No correlations were found between
sexual diagnoses, FSFI, IIEF scales, or either of the DAS
or GAS scores.
Figure 1. Mean GAS scores in women with regard to number
of PEN stimuli a
a PEN refers to inability to experience vaginal penetration
as described in the text
Table 2. Percentage dentist preference of women who
reported sexual abuse (SAD) compared to women who did
not report such experience
SAD group (%)
Negative
n=141
Positive
n=91
Male dentist preferred 8.5 7.7
Female dentist preferred 2.1 11.0
Does not matter 89.4 81.3
Table 1. Mean GAS scores according to gender and dentist preference
Male respondents Female respondents
GAS (n) sd GAS (n) sd
Male dentist preferred 5.40 (20) 2.24 5.00 (20) 0.16
Female dentist preferred 4.40 (5) 0.52 5.92 (12) 2.64
Does not matter 4.48 (183) 0.92 4.80 (192) 1.40
246
Discussion
The aim of this study was to examine possible sexual
correlates of gagging and dental anxiety. The GAS used
in the present study was developed according to the
principles of content and construct validity and shows an
acceptable internal consistency The positive association
between DAS and GAS indicates that excessive gagging
reex can be an indirect manifestation of dental anxiety
as previously proposed (Eli, 1992; Moore et al., 2004;
Ramsay et al, 1987). Additional studies are needed to
further explore the GAS (and possibly also the GPA)
questionnaires in various populations to prove its valid-
ity and reliability.
The results also agree with ndings that women show
higher dental anxiety levels than men (Eli, 1992; Milgrom
et al., 1988). Concomitantly, in the present study, women
had higher GAS scores than men. One explanation is
that women experience more oro-related behavioural
dysfunctions. However, another possibility may be that
men are more reluctant to report fear in questionnaires
(Pierce and Kirkpatrick, 1992), which may be one of the
reasons men report lower DAS and GAS scores.
Unlike GAS, in the present study no direct associa-
tion was found between dental anxiety (measured by
DAS) and sexual abuse as measured by SAD. This is
in contrast to Humphris and King (2011), Walker et al.
(1996) and Willumsen, (2001) but in accordance with
Oosterink et al. (2009) who found that pathological dental
anxiety was not associated with sexual assault and other
reports of traumatic experiences outside the dental setting.
The differences in ndings may result from the differ-
ent questionnaires used, and differences in the studied
populations. In one of those studies, Willumsen (2004)
found different parameters, like touching the back of
the mouth, to be highly associated with dental fear and
sexual abuse. This further supports our assumption that
gagging (which has been found to correlate well with
dental anxiety) may serve as an indirect manifestation of
dental anxiety, especially among victims of sexual assault.
In this study, participants suffered from sexual dys-
functions and not necessarily from oro-related behavioural
dysfunctions. Therefore, the general level of their dental
anxiety was not particularly high: about 15% suffered
from high dental anxiety similar in prevalence to the
general population (ter Horst and de Wit, 1993; Milgrom
et al., 1988)
Gagging reex was associated with a higher prefer-
ence for a dentist of the same gender, problems in sexual
penetration in women, and a history of sexual abuse in
women, especially one that included vaginal penetration.
Furthermore, the two variables best predicting GAS
were problems in sexual penetration in women and experi-
ence of sexual abuse which included vaginal penetration.
Apparently, among this population it is not the mere fact
of suffering from a sexual dysfunction, but rather the
experience of problems with sexual penetration and/or
history of abuse (with vaginal penetration) which serve
as predisposing factors for excessive gagging.
Taken together these data suggest that the symptom
of excessive gagging during dental treatment may have
more complex meanings than merely being an indirect
somatic manifestation of dental anxiety. The fact that
gagging was not associated with pain during the sexual
penetration stimuli (in women) suggests that gagging
may represent a woman’s reluctant response to the idea
of intra-body penetration. Unfortunately, the present study
did not investigate men’s difculties in experiencing
sexual penetration. Future research in this direction may
teach us more about these issues.
In spite of the temptation to declare that gagging has
immediate connections to sexual functioning, such a state-
ment needs further investigation. Physiological gagging
reex is generally elicited by immediate noxious stimuli
applied to the oropharynx. Nevertheless, gagging is also
associated with cognitive aspects which may cause “neu-
tral” stimuli to be recognized as noxious, threatening or
unpleasant by the patient, evoking the associated response
(Eli, 1992). The present study showed that some of these
stimuli may have sexual connotations in their origins.
Sexual abuse survivors show more personal distress
concerning their sexuality and less sexual satisfaction
(Rellini and Meston, 2007). It is therefore not surprising
that among the women seeking sexual therapy in the
present study, about 40% reported experiencing some
sort of sexual abuse in their past. Among this specic
group, a higher percentage of women preferred a female
dentist than those who did not report such experience.
This was also true for women who experienced difculties
with gynecological examination and/or penile penetration
during intercourse. These ndings further emphasize the
possible sexual connotations of the dental situation.
Although the study did not show signicant asso-
ciations between any of the FSFI or IIEF scales and
GAS or DAS, it raises several questions which should
be examined in more detail in the future. Possibly, the
FSFI and IIEF tools, which were built to achieve spe-
cic diagnoses in the eld of sexual functioning, are
inadequate when dealing with patients who suffer from
dental anxiety or excessive gagging reex. The questions
regarding problems in penetration and sexual abuse in
women did yield positive associations with GAS possibly
due to the more direct approach involved.
Patients with sexual dysfunctions do not necessarily
suffer from high dental anxiety or gagging. Unfortunately,
when a patient arrives for treatment with high dental
anxiety and/or excessive gagging reex, it is almost
impossible to inquire about sexual functioning. Such an
attempt would be considered intrusive and inappropriate.
At this stage, further study is recommended to address
these intriguing issues and to reach conclusions regarding
the psycho-dynamics of the presented ndings.
Acknowledgment
The authors would like to thank Mrs. E. Shabtai for
statistical analysis .
247
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Journal of Oral Rehabilitation 38, 3-11.
... Victims of sexual abuse experience dental care as more anxiety-provoking and upsetting than other patients (12)(13)(14)(15)(16). Findings include: perceived discomfort associated with instruments in the mouth; increased gagging reflex; difficulty remaining silent and relaxed; aversion to being touched; and exaggerated feelings of lack of control (12)(13)(14)(15)(16). ...
... Victims of sexual abuse experience dental care as more anxiety-provoking and upsetting than other patients (12)(13)(14)(15)(16). Findings include: perceived discomfort associated with instruments in the mouth; increased gagging reflex; difficulty remaining silent and relaxed; aversion to being touched; and exaggerated feelings of lack of control (12)(13)(14)(15)(16). ...
... The method and analysis illuminate the complexity of the participants' experiences, aiming at a broader depth and understanding than would be disclosed by solely statistical analysis (25). This meant not only affirming findings from previous studies of the possible impact of a history of sexual abuse on dental care (12)(13)(14)(15)(16)(17)(18)(19)(20)27), but also showing in what way this experience has implications, and that memory is not limited to that which can be verbalized. However, the interviewees' narratives are filtered through interpretative and experiential lenses developed over time and as a consequence of psychological treatment. ...
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The aim was to explicate persistent psychological and bodily memories of sexual abuse and how they are expressed during dental appointments. The participants comprised 13 sexually abused individuals (11 women), who recalled and expressed these experiences during a dental appointment. They were encouraged to describe, in detail, aspects of the appointment which triggered memories of the sexual abuse. The interviews were recorded, transcribed verbatim, and analyzed using Qualitative Content Analysis. The identified overall theme illustrating the latent content was ‘An echo of sexual abuse transformed into (dys) functional reactions’. The first category covering the manifest content was ‘The inner invisible struggle’, with two subcategories: (i) mental inscriptions of the abuse experience; and (ii) consequences of the dental encounter. The second category was ‘The discoverable manifestations’, with two subcategories: (i) enigmatic communication; and (ii) expressions of bodily memories. The dental appointment arouses similar psychological stressful reactions as the episodes of abuse; both implicit and explicit expressions are recognizable. Dental staff can contribute to disclosure by improved understanding of the strain a dental appointment can cause in patients who have been subjected to sexual abuse and familiarity with the associated bodily expressions.
... A history of sexual abuse in childhood may lead to multiple complications, which range from immediate psychological consequences to chronic effects that can affect adjustment throughout development into adulthood [43][44][45]. Mental health consequences in adulthood include post-traumatic stress disorder, substance abuse disorders (drugs or alcohol), personality disorders [46]-and dental anxiety [47][48][49]-as abuse survivors find dental attendance very stressful [50]. Additionally, the association between sexual abuse and use of psychoactive substances (alcohol and cigarettes) may reflect the use of maladaptive coping strategies. ...
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Introduction Sexual and oral health are important areas of focus for adolescent wellbeing. We assessed for the prevalence of sexual abuse among adolescents, oral health factors associated with this history, and investigated whether sexual abuse was a risk indicator for dental anxiety, caries experience and poor oral hygiene. Methods This was a cross-sectional study conducted between December 2018 and January 2019 among adolescents 10–19 years old in Ile-Ife, Nigeria. Survey data collected included respondents’ age, sex, and socioeconomic status, oral health risk factors (dental anxiety, frequency of tooth brushing intake of refined carbohydrates in-between-meals, flossing, dental visits, smoking, alcohol intake, use of psychoactive substances), caries experience, oral hygiene status, history of sexual abuse, and sexual risk behaviors (age of sexual debut, history of transactional sex, last sexual act with or without condom, multiple sex partners). Regression models were constructed to determine the association between outcome variables (dental anxiety, presence of caries experience and poor oral hygiene) and explanatory variables (oral health risk factors and history of sexual abuse). Results The prevalence of sexual abuse in our cohort was 5.9%: 4.3% among males and 7.9% among females. A history of sexual abuse was associated with alcohol consumption ( p = 0.009), cigarette smoking ( p = 0.001), and a history of transactional sex ( p = 0.01). High/severe dental anxiety was significantly associated with increased odds of a history of sexual abuse (AOR = 1.81; 95% CI 1.10, 2.98), but not with caries experience (AOR = 0.66; 95% CI 0.15, 2.97) nor poor oral hygiene (AOR = 1.68; 95% CI 0.95, 2.96). Dental anxiety was associated with increased odds of alcohol intake (AOR = 1.74; 95% CI 1.19, 2.56), twice daily tooth brushing (AOR = 1.48; 95% CI 1.01, 2.17) and daily consumption of refined carbohydrates in-between-meals (AOR = 2.01; 95% CI 1.60, 2.54). Caries experience was associated with increased odds of using psychoactive substances (AOR = 4.83; 95% CI 1.49, 15.62) and having low socioeconomic status (AOR = 0.40; 95% CI 0.18, 0.92). Poor oral hygiene was associated with increased odds of having middle socioeconomic status (AOR = 1.43; 95% CI 1.05, 1.93) and daily consumption of refined carbohydrates in-between-meals (AOR = 1.38; 95% CI 1.08, 1.78). Conclusion Adolescents who are highly dentally anxious need to be screened for a history of sexual abuse to facilitate access to professional care and support.
... The dentist and the CSA survivor must always discuss individual triggers (exploring individual triggers) and agree upon how treatment procedures can be best carried out. The results also supported that dental anxiety is a common problem for CSA survivors (2,4,21). Thus, treatment of dental anxiety needs to be addressed in CSA survivors, with this study showing that while frameworks for anxiety management (22) and standard treatments for dental anxiety (23,24) and sedation may be used, even this anxiety treatment ought to be based on individual needs. ...
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This qualitative study aimed to obtain a deeper understanding of what makes adult dentistry possible for child sexual abuse survivors. Sixteen adult informants were recruited from four Centres against Sexual Abuse and interviewed. Qualitative analysis of the transcribed interviews was conducted consecutively until thematic saturation was reached at 16 informants. A conceptual framework was generated, and informants’ experiences of what makes dental treatment achievable were summed as the dentist working in a trauma‐sensitive way, captured by the core category: Being considerate every step of the way. The underlying categories are: (i) offering a good start; (ii) being competent; (iii) being aware of the influence of staff behaviour; (iv) building a safe relationship; (v) arranging a secure treatment situation; and (vi) exploring individual triggers. The findings revealed that dental staff should have adequate competence to build secure relationships and explore individual triggers in dental treatment situations when treating child sexual abuse survivors. Dentists should have a trauma‐sensitive approach to all patients. When treating child sexual abuse survivors, dentists should demonstrate utmost consideration every step of the way, building long‐term solid relationships, and discussing and testing coping strategies individually adapted to the specific needs of the child sexual abuse survivors, in a safe environment.
... Few studies have shown a positive association between DA and GAG [7,[16][17][18]. Both DA and GAG can be the result of operant, classical and other conditioning [19,20]. ...
... Gagging individuals reported higher levels of dental trait anxiety than non-gagging individuals. This is consistent with several other studies (1,2,22,23). In addition, patients' self-report of gagging was more strongly associated with severity of a number of specific gagging-related fears (e.g. ...
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Although gagging has a profound effect on the delivery of dental care, it is a relatively under-investigated phenomenon. This study aimed to derive a prevalence estimate of gagging during dental treatment based on patient-reported information, to determine some socio-demographic and psychological correlates and to assess the relationship of gagging with self-reported oral health and avoidance of dental care. Data were collected with a survey among Dutch twin families (n = 11 771). Estimated overall prevalence of gagging during dental treatment was 8·2% (95% CI 7·7-8·7). Patients' self-report of gagging was found to be significantly associated with female sex, a lower level of education and higher levels of dental trait anxiety, gagging-related fears (e.g. fear of objects in the mouth), anxious depression and neuroticism. Gagging also appeared to be significantly associated with untreated cavities, gingival bleeding and wearing full dentures, but not with avoidance of dental care. It can be concluded that individuals who report to gag during dental treatment are moderately dentally anxious, fear-specific situations that can trigger a gagging response and, albeit visiting the dentist equally frequently, report to have a poorer oral health compared to those who do not gag. © 2015 John Wiley & Sons Ltd.
... Gagging individuals reported higher levels of dental trait anxiety than non-gagging individuals. This is consistent with several other studies (1,2,22,23). In addition, patients' self-report of gagging was more strongly associated with severity of a number of specific gagging-related fears (e.g. ...
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Knowledge about memories of distressing events underlying fears and specific phobias is limited. This study assessed (1) the presence, content, and characteristics of memories of events that initiated or exacerbated dental anxiety levels; and (2) the relationship between dental trait anxiety and some key features of these memories. This study used a semi-structured interview and included dental phobics (n = 42), subthreshold dental phobics (n = 41), and normal controls (n = 70). Dental phobics were more likely to report a memory underlying their anxiety than the normal controls. Moreover, dental phobics' memories were reported as more vivid, disturbing, and more intensely relived than the memories of the normal controls. Greater severity of dental trait anxiety was significantly associated with greater disturbance of patients' memories. The results suggest that memories of distressing events play a significant role in the development of dental phobia and that their characteristics are associated with severity of dental trait anxiety.
... They reported that sexual assault victims were almost two and a half times more likely to report high dental anxiety compared to participants who had not experienced sexual assault. Similarly, Leeners et al. [31] found that women with an experience of sexual assault reported DFA related to lying flat in the dental chair, and they found that those with a history of sexual abuse had a more pronounced gagging reflex and higher DFA [32] . These findings highlight the point that it is not just previous, negative dental experiences that can cause subsequent DFA but also other traumatic experiences far removed from the dental surgery. ...
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Objective: The aim of this review was to explore the peer-reviewed literature to answer the question: 'Why are people afraid of the dentist?' Method: Relevant literature was identified by searching the following on-line databases: PubMed, PsycInfo, the Cochrane Library and Google Scholar. Publications were extracted if they explored the causes and consequences of dental fear, dental anxiety or dental phobia. Results: The research evidence suggests that the causes of dental fear, dental anxiety or dental phobia are related to exogenous factors such as direct learning from traumatic experiences, vicarious learning through significant others and the media, and endogenous factors such as inheritance and personality traits. Each individual aetiological factor is supported by the evidence provided. Conclusions: The evidence suggests that the aetiology of dental fear, anxiety or phobia is complex and multifactorial. The findings show that there are clear practical implications indicated by the existing research in this area: a better understanding of dental fear, anxiety and phobia may prevent treatment avoidance.
Pain prevention and management is one of the primary goals of dental care. Postoperative dental pain (PDP) following caries removal and performance of a restorative dental treatment is a common clinical phenomenon, often causing significant discomfort to dental patients. In the present study, a psychophysical non-invasive method, qualitative sensory testing (QualST), was used in an attempt to foretell PDP following dental restorative procedures. Forty-two dental patients underwent an intra-oral cold QualST four times: immediately prior to a restorative dental procedure and at a follow-up meeting 1–3 weeks later, on the treated and on the contralateral oral sides. The QualST measures included subjects’ evaluation of the magnitude of pain and cold sensations experienced (on visual analogue scales) and the duration of the cold sensation (in seconds). Additional measures included age, gender, level of dental anxiety, jaw treated, and type of dental restoration performed (Class I or Class V). Subjects’ PDP was assessed through the phone using numeric rating scales 24, 48, and 72 h postoperatively. The highest level of PDP experienced by subjects occurred 24 h postoperatively (ANOVA with repeated measures). Of the study variables, the QualST pain sensation (B = 0.645, p < 0.001), duration of the cold sensation (B = 0.042, p < 0.05), and an interaction between gender and dental anxiety (B = 0.136, p < 0.05) emerged as possible predictors of the highest PDP experienced by subjects (stepwise regression). The results suggest that subjects’ reaction to an intra-oral cold stimulation of the oral mucosa can serve as a potential tool to foretell postoperative dental pain following restorative dental procedures.
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To assess the influence of gag reflex severity, assessed according to the short form of the patient part of Gagging Problem Assessment Questionnaire (GPA-pa SF), on the dental attendance, dental anxiety, self-reported temporomandibular disorder (TMD) symptoms and presence of prosthetic restorations among patients requiring prosthodontic treatment in Turkey. A total of 505 patients (305 women; mean age: 46·35 years, SD: 28·2 years) undergoing dental examination were administered a questionnaire containing questions regarding their age, gender, education level, dental attendance, TMD symptoms (limitation in jaw opening, muscle pain, pain/sounds in the temporomandibular jaw), the Turkish version of the Modified Dental Anxiety Scale (MDAS) and the GPA-pa SF. Subsequently, any prosthetic restoration was recorded by a dentist. Descriptive statistics, one-way analysis of variance (anova) and the chi-square test were used for statistical analysis. Differences were found between GPA-pa SF scores 0, 1 and 2 for education level (P = 0·001), MDAS scores (P = 0·003), self-reported TMD (P = 0·000) and prosthesis wear (P = 0·000), but not for attendance patterns (P = 0·826). Patients with gag reflex had lower education levels, higher levels of dental anxiety, more self-reported TMD symptoms and fewer fixed or removable prosthetic restorations than patients without gag reflex. Gag reflex has impacts on dental anxiety, self-reported TMD and prosthetic restorations, but not on dental attendance patterns, according to the results of the GPA-pa SF.
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Introduction: The literature shows a discrepancy in the association between child sexual abuse (CSA) and adult sexual function. One of the proposed explanations for this discrepancy is the different ways in which CSA is assessed. While some studies explicitly ask potential participants whether they are sexual abuse survivors, others ask whether participants experienced specific unwanted sexual behaviors. Aim: This study investigated the differences between women who self-identified as CSA survivors, women who experienced similar unwanted sexual experiences but did not identify as CSA survivors (NSA), and women with no history of sexual abuse (control). CSA was defined as unwanted touching or penetration of the genitals before the age of 16. Methods: A sample of 699 college students anonymously completed a battery of questionnaires on sexuality and sexual abuse history. Main outcome measures: Sexual function was measured with the Female Sexual Function Index (FSFI), and sexual satisfaction was measured with the Sexual Satisfaction Scale-Women. History of CSA was measured with a modified version of Carlin and Ward's childhood abuse items. Results: Differences emerged between women who experienced sexual abuse before age 16 and women who never experienced sexual abuse (control) on the personal distress subscale of the Sexual Satisfaction Scale. The CSA group (N = 89) reported greater sexual distress compared to the NSA (N = 98) group, and the NSA group reported more distress than the control group (N = 512). No significant group differences were observed in the FSFI. Characteristics of the abuse that predicted whether women identified as CSA survivors included vaginal penetration, fear at the time of the abuse, familial relationship with the perpetrator, and chronic frequency of the abuse. These abuse characteristics were associated with sexual satisfaction but not with sexual function. Conclusions: Differences in levels of sexual satisfaction between women with and without a history of CSA were associated with the type of CSA definition adopted. It remains unexplained why the CSA group showed more personal distress about their sexuality but not more sexual dysfunction.
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The purpose of the present study was to assess which types of experiences are most closely associated with pathological forms of dental anxiety. Data came from a sample of dental patients (n=1462). Pathological dental anxiety was operationalized in two ways: (1) a score of > or =36 on the Short form of the Dental Anxiety Inventory (S-DAI; high dental anxiety, HDA), or (2) fulfilling the screening criteria of specific phobia (DSM-IV-TR; dental phobia, DP). A wide variety of dental experiences appeared to be significantly related with both HDA and DP, while general traumatic experiences were not. No differences were found between women and men. Retrospective accounts of dental experiences involving helplessness were most strongly associated with having HDA [OR=8.2] and positive screens of DP [OR=16.2]. The results suggest that disruptive emotional and interoceptive reactions during dental treatment (particularly helplessness) have the greatest potential risk of precipitating pathological forms of dental anxiety.
Article
To compare the prevalence of high dental anxiety across a variety of past distressing experiences with a previously reported Dutch sample. University students from the UK (N=1024) completed an online survey containing; the Modified Dental Anxiety Scale, and the Level of Exposure-Dental Experiences Questionnaire (LOE-DEQ). Adjusted odds ratios (OR) were calculated to assess the association of self-reported distressing experiences and dental anxiety. The percentage of respondents with high dental anxiety (HDA) (total MDAS score≥19) was 11.2%. Significant prevalence of HDA across several distressing experiences was shown in both UK and Dutch samples notably: extreme helplessness during dental treatment, lack of understanding of the dentist and extreme embarrassment during dental treatment. There were little or no effects of non-dental trauma, with the exception of sexual abuse in the UK sample. Trauma from various past experiences may be implicated in an increased risk of high dental anxiety.
Article
To examine possible associations between self-reported bruxism, stress, desirability of control, dental anxiety and gagging. Five questionnaires were distributed among a general adult population (402 respondents): the Perceived Stress Scale (PSS), Desirability of Control Scale (DC), Dental Anxiety Scale (DAS), Gagging Assessment Scale (GAS), and Bruxism Assessment Questionnaire. A high positive correlation between DAS and GAS (R = 0·604, P < 0·001) was found. PSS was negatively correlated with DC (R = -0·292, P < 0·001), and was positively correlated with GAS (R = 0·217, P < 0·001) and DAS (R = 0·214, P < 0·001). Respondents who reported bruxing while awake or asleep showed higher levels of GAS, DAS and PSS than those who did not. There were no differences between the bruxers and the non-bruxers (sleep and aware) with regard to the DC scores. The best predictors of awake bruxism were sleep bruxism (OR = 4·98, CI 95% 2·54-9·74) and GAS (OR = 1·10, CI 95% 1·04-1·17). The best predictors of sleep bruxism were awake bruxism (OR = 5·0, CI 95% 2·56-9·78) and GAS (OR = 1·19; CI 95% 1·11-1·27). Self-reported sleep bruxism significantly increases the odds for awake bruxism and vice versa. Tendency for gagging during dental care slightly increases the odds of both types of self-reported bruxism, but desirability of control is not associated with these phenomena.
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To estimate the prevalence of self-reported sexual problems (any, desire, arousal, and orgasm), the prevalence of problems accompanied by personal distress, and to describe related correlates. The 31,581 female respondents aged 18 years and older were from 50,002 households sampled from a national research panel representative of U.S. women. Correlates of each distressing sexual problem were evaluated using multiple logistic regression techniques. The age-adjusted point prevalence of any sexual problem was 43.1% and 22.2% for sexually related personal distress (defined as a score of at least 15 on Female Sexual Distress Scale). Any distressing sexual problem (defined as reporting both a sexual problem and sexually related personal distress, Female Sexual Distress Scale score of at least 15) occurred in 12.0% of respondents and was more common in women aged 45-64 years (14.8%) than in younger (10.8%) or older (8.9%) women. Correlates of distressing sexual problems included poor self-assessed health, low education level, depression, anxiety, thyroid conditions, and urinary incontinence. The prevalence of distressing sexual problems peaked in middle-aged women and was considerably lower than the prevalence of sexual problems. This underlines the importance of assessing the prevalence of sexually related personal distress in accurately estimating the prevalence of sexual problems that may require clinical intervention. III.
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A number of different sets of data concerning the Corah Dental Anxiety Scale were evaluated. The data indicate that the scale is a reliable, valid, and useful measure of dental anxiety. It can be successfully used in the dental office or in research projects.
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The likelihood that males equivocate in their ratings of common fears was evaluated. A fear survey was given to 30 female and 26 male college students in a classroom setting. A second fear survey which contained duplicate items from the first was administered to the same students in a laboratory setting prior to watching videotaped scenes of fish, rats, mice and a shorter roller coaster ride. Before the second survey was given, the students received instructions which implied that their truthfulness could be independently evaluated through changes in their heart rate while they watched the videotape. Changes in the averaged fear ratings for the three high-fear items shown in the videotaped scenes were compared between males and females across the two survey conditions. Males' ratings of rats, mice, and roller coasters increased markedly from the first survey to the second, while fear ratings by females did not change. These results are consistent with the idea that the expression of fear by men is affected by conformation to the traditional male gender role.
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The causes of problematic gagging are discussed and a behavioral method for its treatment is recommended. Four case studies illustrating the application of this approach are presented.