Dental Anxiety and Its Consequences to Oral Health Care Attendance and Delivery

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Chapter 3
Dental Anxiety and Its Consequences to Oral Health
Care Attendance and Delivery
Irene Kida Minja and
Febronia Kokulengya Kahabuka
Additional information is available at the end of the chapter
http://dx.doi.org/10.5772/intechopen.82175
© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons
Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use,
distribution, and reproduction in any medium, provided the original work is properly cited.
Irene KidaMinja and
Febronia KokulengyaKahabuka
Additional information is available at the end of the chapter
Abstract
Dental anxiety has been reported to be a common problem aecting widespread societies,
hence a global public health concern. This chapter provides an updated information to
dental practitioners, about dental anxiety and its implication to oral health-care aendance
and service delivery. It is introduced by dening dental anxiety, providing a summary of
prevalence of the problem among children and adults; and its relationship with sociode-
mography, oral health status, and cultural issues. Causes of dental anxiety and simple
ways to diagnose it and management options of dental anxiety for dierent age groups
of populations are summarized to assist dental practitioners during patient management.
How dental anxiety inuences dental aendance and ultimately impact oral health sta-
tus of populations; and its relationship with oral health-care delivery are also discussed.
Finally, preventive measures both in community and clinical seings are provided and
recommendation for dental professionals and other stake holders is outlined.
Keywords: dental anxiety, oral health-care delivery, oral health-care aendance
1. Introduction
1.1. Denition
The terms dental anxiety, fear, and phobia, though often used mutually, dier depending on
the situation within which they occur. Nevertheless, a distinction has been made between these
terminologies. Dental fear is a reaction to a known danger, which involves a “ght-or-ight”
response when confronted with a threatening stimulus. On the other hand, dental anxiety is a
© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use,
distribution, and reproduction in any medium, provided the original work is properly cited.

reaction to an unknown danger, and dental phobia is basically the same as fear, only much stron-
ger, whereby the “ght-or-ight” response occurs when just thinking about or being reminded
of the threatening situation [1].
Dental anxiety is extremely common, and most people experience some degree of the anxiety
especially if they are about to have a certain dental procedure done which they have never expe-
rienced before. Moreover, someone with a dental phobia will avoid dental care at all costs until
either a physical problem or the psychological burden of the phobia becomes overwhelming. In
this chapter, the term dental anxiety is employed.
1.2. Prevalence of dental anxiety
Dental anxiety is reported to be a global public health concern due to its eects on individual’s
oral health and quality of life. The prevalence of the condition in children ranges from 5 to
61% [2, 3] and in adults from 1 to 52% [4–12], inclusive of participants with both moderate and
high dental anxiety.
1.3. Factors associated with dental anxiety
1.3.1. Sociodemographics
A majority of studies done reveal that females of all age groups, younger age and people who
are classied to have low level of education are at more risk of having dental anxiety [2, 11].
The main reasons cited for the observed dierences are more linked to environmental factors
rather than biological makeup among children. However, Folayan and coworkers [13] revealed
no dierences in the prevalence of dental anxiety with sociodemography in children, while
Minja et al. [11] showed no sex dierence in their study among adults.
1.3.2. Oral health status
Individuals with poor oral health status are reported to perceive dental anxiety than their
counter parts with good oral health status. Clinically, these patients are observed to have high
number of decayed and missing teeth and less restored teeth [14–16]. DeDonno [17] revealed
an association between participants’ dental anxiety and oral hygiene, whereby individuals
with dental anxiety were seen to have poor oral hygiene. Furthermore, patients who are den-
tally anxious are usually least satised with the appearance of their teeth [18].
1.3.3. Oral health-related behaviors
Population studies show that individuals with dental anxiety have diculties to aend to
a dentist [19]. Dental anxiety has also been reported to impact on individuals’ daily living
including modication of eating habits, such as avoidance of hard to chew and foods that
cause sensitivity. Further to this, individuals with dental anxiety are reported to have a high
tendency to self-medication so as to avoid visiting a dentist [20].
Anxiety Disorders - From Childhood to Adulthood36

1.3.4. Cultural issues
The role of culture and norms in modifying individual’s perception of dental fear and anxiety is
also of prime importance when explaining these phenomena. Culture has been reported to have
inuence on perceiving dental anxiety [21]. Studies have shown that dental anxiety expres-
sion signicantly varied according to ethnicity as well as religion due to the engraved dental
anxiety coping mechanisms and expression among dierent cultures [22]. Generally, it has been
reported that societies with cultures that emphasize on greater self-control, emotional restraint,
and compliance to social rule (such as some Asian and African countries) were more likely to
score higher in their fears/anxiety [23].
2. What is dental anxiety
In order to understand the dental anxiety well, it is important to explain its pathway, causes,
diagnosis, and management.
2.1. Dental anxiety pathway
Five theories are thought to beer explain the pathways of dental anxiety: Pavlovian cognitive
conditioning, informative pathway, vicarious conditioning, verbal transmission/threat, and parental
pathway [24].
Pavlovian cognitive conditioning is the most commonly utilized pathway of dental fear and anxi-
ety used by the patients, whereby past painful dental experience may negatively impact an
individuals’ future dental aendance.
Informative pathway is an indirect pathway to phobia that involves learning about fearful den-
tal events as told by other individuals.
Vicarious conditioning is another indirect pathway, whereby individuals may acquire dental
phobia by learning indirectly through observing the responses of others aending a dentist.
In Verbal transmission/threat, there is no direct observation of traumatic/fearful event, but through
hearing or reading about dangerous or threatening information about a stimulus irrespective of
an actual presence of the threating stimulus. In this pathway, dental visit is used as a disciplin-
ary measure for misbehaving.
Parental pathway refers to a situation where a fearful behavior displayed by a parent becomes
a pathway of acquiring dental anxiety by a child. A stronger relationship is observed when it
is the mother who expresses intensied fearful behavior.
2.2. Causes of dental anxiety
Dental anxiety has a wide range of causes and hence it is considered complex and multifacto-
rial [25]. The causes may be patient, provider, or environment related. The patient-related
Dental Anxiety and Its Consequences to Oral Health Care Attendance and Delivery
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causes include past dental experience, pain, inuence of family, or peer experience and per-
sonality, whereas provider-related causes include communication techniques and provider’s
bad behavior. Environmental-related causes include sounds of drills or other apprehensive
patients, unpleasant smell/clinic area, and sight of blood or local anesthetic injections [26].
2.3. Diagnosis of dental anxiety
The importance of proper diagnosis of dental anxiety cannot be underrated. Identifying
anxious patients helps a dental care provider to plan for appropriate ways and procedures
for managing the patient. Several means have been developed to identify patients who have
dental anxiety before treatment is initiated, so as to assist a dentist to provide appropriate
treatment with no negative consequences to both the patient and provider. The measures are
grouped into two: use of questionnaires and objective measures of dental anxiety.
2.3.1. Use of questionnaire
Using reliable and easy-to-administer tools for assessment of dental anxiety at the dental set-
ting is benecial for the dental team [27]. Despite the presence of a number of pretreatment
questionnaires for patient administration, very few dental health-care providers utilize them
[28]. Using self-reported questionnaire has been reported to be useful to assist in disclosing
as well as reducing dental anxiety, as it might be a way for the dental team to gently build
rapport with a patient [29]. A number of self-rated tools are available and no single instrument
can be regarded as a gold standard set of questions. Mentioned here are the most commonly
used and have shown acceptable psychometric properties for use in dierent languages world-
wide. These measures are simple, easy to use, and acceptable to both patients and dental team
[30–32]. They include a four-item Corah’s dental anxiety scale (CDAS) and a ve-item modied
dental anxiety scale (MDAS) which proved to be suitable for use among adults. The results can
be utilized in grouping patients according to the level of dental anxiety that is low, moderate,
and high. Other measures suitable for use among children are the modied child dental anxiety
scale (MCDAS) containing eight questions; and a faces version of the modied child dental
anxiety scale (MCDASf) that incorporates facial images on the response format, and this can
be used by children as young as 3 years old [27, 29]. Use of questionnaires assists in identifying
patients with dental anxiety thus allows planning for possible approaches that can be utilized
for management of patients, as suggested by Newton and coworkers [33].
2.3.2. Objective measures
Measuring patients’ vital signs can add into the identication of patients with dental anxiety
at the dental clinic seing. These measures are assessment of blood pressure, pulse rate, pulse
oximetry to assess blood oxygen levels which is aected by stress and anxiety, nger tempera-
ture, and galvanic skin response that measures skin conductance of weak electric current [29, 34].
2.4. Management of dental anxiety
When managing a patient with dental anxiety, utilization of dierent measures to counter
anxiety will depend on the patient’s history, age, and cooperation. In all instances, a dental care
Anxiety Disorders - From Childhood to Adulthood38

provider needs to portray behavior that will contribute to reducing anxiety to the patient. These
include, but not limited to, being composed and relaxed, friendly to the patient, avoiding being
judgmental or instilling pain, being supportive and encouraging to the patient, and working
eciently [26, 29]. Dierent measures are employed in managing patients with dental anxiety
as explained below according to the age group of the patient.
2.4.1. Management in children
In managing children with dental anxiety, the following is suggested:
• Allocate enough time for appointment.
• Communicate eectively.
• Utilize the four “s” principle by reducing triggers of stress. These are sight of injections,
handpieces, and blood; smell of materials such as eugenol; sound of drilling or other patients
crying; and sensation of vibrating instruments.
• Distract the patient using music, video.
• Give a sense of control over the procedure by involving the patient during treatment, like
to raise hand when feeling pain or uncomfortable.
• Reduce pain by giving enough anesthesia.
• Provision of cognitive behavioral therapy (CBT).
• Provision of relaxation therapy for older children that will assist patients to gain control
over their psychological state. The techniques can be given before and even during the
procedure. These may include Jacobsen’s progressive muscular relaxation, paced breathing
techniques.
In highly anxious patients who could not do any of the psychotherapeutics, pharmacotherapy
may be indicated such as:
• Conscious sedation technique, whereby drugs are provided to render an anxious patient
to a depressive state. The routes of application can be oral, sublingual, intramuscular, rec-
tal, and in dental seing with enough resources, intravenous administration, or inhalation
using nitrous oxide (N2O) gas.
• When the above techniques do not help, the practitioner can refer the patient to a specialist
psychologist for further management or can resort to general anesthesia if equipment and
trained personnel are available.
2.4.2. Management in adults and older adults
All the techniques used in children can be utilized when managing adults with dental anxiety.
In addition, the following techniques can be employed:
• Utilization of computer-assisted relaxation learning (CARL), which is a self-paced treatment
by patients to cope with dental anxiety (needle specic) without the presence of a therapist.
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• Individual systematic desensitization, whereby patients are gradually introduced to a fear-
ful stimulus and learn to cope with anxiety by utilizing another method such as CARL or
relaxation therapy methods.
• For patients whose anxiety is induced by a needle, computer-controlled local anesthesia
can be used; or electronic dental anesthesia, wherein anesthesia is achieved based on
“gate-control theory of pain,” with no use of a needle. This method, though, is expensive
and requires special training.
• Adults could also be referred for group therapy with specialist psychologist and behavioral
therapist.
2.4.3. Benets to patients
A patient will calm down, hence be receptive of oral health information provided for his/her
own benet. Furthermore, the patient will allow receiving the required treatment. Ultimately,
the patient will be positively motivated, on a long-term basis and thus acquire positive ai-
tudes toward dentistry.
2.4.4. Benets to practitioner
This will assist service provider to be at peace, hence facilitate accurate provision of the
required treatment. The whole scenario will, eventually, minimize occupational stress.
3. Dental anxiety and its consequences to oral health-care aendance
and delivery
Generally, dental procedures take a couple of minutes to accomplish, and therefore require a
patient to be calm and cooperative in the dental chair. Unfortunately, this is not always the case,
since some patients are apprehensive probably because most procedures are either believed or
are actually associated with some degree of pain to the patient. Furthermore, dental patients
are usually “alert” or “not ill,” thus in full perception of all that is happening. This situation
contributes to acquisition of dental anxiety.
3.1. Inuence of dental anxiety on dental aendance and oral health status
It has been observed that individuals with dental anxiety tend to fail to keep appointments,
avoid aending to a dentist for dental care or complying with prescribed treatment [35]. This
tendency cuts across all individuals regardless of their socioeconomic status or geographical
location. Dental anxiety is also associated with poor dental health conditions [36]. Research
shows that anxious patients possess poor oral health when compared to nonanxious counter-
parts in terms of decayed, missing, and lled teeth [37]. Moreover, poor oral health conditions
negatively impact individuals’ quality of life [38, 39]. Generally, dental anxious patients have
been viewed as unreliable and of poor economic risk [26].
Anxiety Disorders - From Childhood to Adulthood40

The cycle of dental anxiety (Figure 1) explains the interrelationship of the above. Whereby, an
individual with dental anxiety is usually worried and anticipates that something bad is going
to happen if she/he visits a dentist; thenceforth, tends to delay or avoid dental aendance.
This action deprives the individual from receiving dental preventive care and treatment and
thus leads to deterioration of oral health, poor oral health status, and poor dental-related
quality of life. Poor oral health, coupled with feeling of guilt, shame, inferiority, and worry
of being reprimanded by a dentist for oral neglect, further increases dental anxiety and the
cycle continues [40, 41]. Failure to provide the required treatment to counter dental anxiety,
the vicious cycle will continue. It has been suggested that eective treatment of dental anxiety
will improve dental aendance and ultimately the oral health of individuals [42].
3.2. Inuences of dental anxiety on oral health-care delivery
Good oral health-care delivery entails harmonious environment contributed to by both pro-
viders and patients as well as dental environment. When either party’s aributes are not posi-
tive toward reaching a harmonious environment, it may interfere with aaining the intended
management goals.
3.2.1. Provider perspective
Provider’s good communication skills coupled with proper use of behavior management tech-
niques as well as positive behavior toward dental patients play a signicant role in creating a
harmonious dental treatment environment. The reverse may induce dental anxiety or exacer-
bate the already anxious situation [43]. Ultimately, treatment may take longer or may have to
be rescheduled but may also be compromised. Various consequences of this situation include
loosing patients, bad provider reputation, and negative professional image, as well as negative
economic implications. Consequences aecting the patient directly include eliciting pain and
Figure 1. The vicious cycle of dental anxiety [40, 41].
Dental Anxiety and Its Consequences to Oral Health Care Attendance and Delivery
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contributing to patients’ unpleasant dental experience. Handling an anxious patient when not
prepared has been reported to add stress on the dentist and the dental team as a whole [44].
3.2.2. Patient perspective
Delaying, rescheduling, or avoiding dental visit due to dental anxiety leads to seeing a dentist
only when it is inevitable, which may end up into a need for complicated treatment [36]. The
laer might bring about more anxiety, failure to abide to instructions, or comply to preventive
care hence exaggerate oral health problems [43]. Unfortunately, causes of dental anxiety such
as personality, past dental experience, or family/peer inuence are basically out of patients’
control. Therefore, they need to be assisted to overcome the anxiety, which is a sole responsi-
bility of the dental team. The dental team should have a broad approach on patient’s needs,
not be judgmental while managing the patient, instead do all that is required to allay the
patient’s anxiety, thus facilitating provision of proper care.
3.2.3. Environmental perspective
Dental environment is generally perceived by patients to be unfriendly, oensive, and anxiety-
provoking, especially so by anxious patients. The looks of the dental chair and its accessories
may not give an appealing rst impression. Smell of the medicaments as well as invasive con-
tact in the mouth, sound of the drill, sight of blood are some of the situations that most patients
may have diculties to tolerate [45]. The dental environment condition, coupled with the
nature and duration of dental treatment procedures, may bring about or amplify patient dental
anxiety. This situation will interfere with delivery of dental care. It is, therefore, the responsibil-
ity of the dental team to make sure that the dental environment is friendly to patients with or
without dental anxiety.
3.3. Prevention of dental anxiety
Like in any other disease/condition, prevention before development of dental anxiety is impor-
tant for eective management of patients. This may entail puing in place modications to
address operators, patients, or dental clinic environment concerns. Further to this, strategies
aiming at the community may be critical.
3.3.1. Modication of operator characters
Operators/dental team character plays a big role in determining future behavior of dental
patients. Particularly, what the patient experiences at his/her rst visit to a dentist is what shapes
his/her aitudes with dental care services [46]. Positive behavior of operator and the dental team
will automatically inuence positive aitudes and minimize chances for dental anxiety. On the
contrary, a bad operator/dental team behavior may induce, as well as exaggerate, dental anxiety
in patients [43, 47]. To prevent operators/dental team from inducing dental anxiety, starting
from the moment the patient enters the dental clinic to exiting, it is advisable for the team to
have good communication skills, be sympathetic, have empathy, and be able to control temper.
To make this happen, proper training and continuing education on prevention of dental anxiety
Anxiety Disorders - From Childhood to Adulthood42

are of paramount importance. Therefore, the provider and dental team at large should strive to
intentionally acquire these characteristics, which will lead to having positive behavior toward
patients, particularly to be understanding to anxious ones.
3.3.2. Modication of patient characters
Every dental patient has his/her own preconceived ideas about dental care. Apparently, each
patient might be anxious depending on his/her personality trait, past dental experience, inuence
from family and peers, etc. Therefore, all patients aending the dental clinic should be calmed
down and be made to relax regardless of whether the patient is anxious or not, (Figure 2a and b).
This is a sole responsibility of the dental team [48].
3.3.3. Modication of dental clinic environment
Most patients consider the dental environment to be unfriendly and anxiety provoking. For
this reason, various eorts have been made by dental professionals to modify the environ-
ment so as to counter that eect (Figures 3 and 4). The eorts include avoiding white uni-
forms by using aractive colorful aire, minimizing bright lights, playing soft/relaxing music,
placement of nondental aractions in waiting rooms, making reception and waiting rooms
colorful for children, minimizing noise from dental instruments/equipment by sound proof-
ing the operating rooms, and intentionally engaging a receptionist who is charming, positive,
and having caring aitudes to patients. Other measures are utilization of aromatherapy and
sensory-adapted dental environment (SDE). Aromatherapy in dental seings is done using
essential oils, the most common ones being smell of orange and lavender. Lavender smell has
been shown to produce positive physiological and pharmacological eects which proved to
Figure 2. (a) A 7-year-old child presenting with dental anxiety trying to stop the doctor from performing oral examination.
(b) The same child while a dentist employs behavior management techniques to allay the child’s dental anxiety (pictures
by courtesy of Dr. Gustav Rwekaza).
Dental Anxiety and Its Consequences to Oral Health Care Attendance and Delivery
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be eective in reducing state anxiety [49]. Similarly, SDE, which has been utilized and proved
to be eective for management of dental anxiety, is also helpful in reducing the anxiety and
relaxing the patient [45].
3.3.4. Community prevention
At community level, prevention of dental anxiety through giving education is a responsibility
of the dental team. The education should primarily be directed to children since the onset of
dental anxiety often occurs in childhood. This implies that early intervention will help to pre-
vent the problem from extending into adulthood, but adults should also be involved. Among
measures of intervention at community level, it is to inform the community on the impact
of dental anxiety on individual’s oral health status, oral health-care aendance, and service
delivery. Another measure is to educate and discourage individuals from sharing their dental
fears and/or negative dental experiences in such a way that it may inuence others to develop
Figure 3. A patient-friendly dental clinic reception (picture by Jacob Francis, courtesy of Smiles dental clinic).
Figure 4. A child-friendly dental surgery (picture by Jacob Francis, courtesy of Smiles dental clinic).
Anxiety Disorders - From Childhood to Adulthood44

dental anxiety or negativity toward dentistry. Furthermore, it is benecial to empower the
community to prevent dental diseases, to encourage them on the importance of regular visit
to a dentist for checkup, and to strongly disapprove the use of dental visit/services as punitive
measure or to shape behavior [24, 48]. Moreover, population screening for dental anxiety will
assist in identifying those who are aected thus earmarking them for preventive intervention.
4. Conclusions
Dental anxiety is a problem aecting populations of all ages, from all geographical locations.
It aects individuals’ oral health status, interferes with dental aendance and service deliv-
ery. Dental professionals, therefore, have a major role to play in the management and preven-
tion of dental anxiety among dental patients and the community at large.
5. Recommendations
We recommend that:
1. Dental professional associations and dental teaching institutions should conduct work-
shops and continuing education and professional development (CPD) courses for the
dental fraternity on management and prevention of dental anxiety.
2. Dental professionals to educate themselves on the dierent options of management and
prevention of dental anxiety.
3. Dental professionals to educate community on dental anxiety.
Acknowledgements
Authors acknowledge funding support by Swedish International Development Agency (Sida)
through Muhimbili University of Health and Allied Sciences (MUHAS).
Conict of interest
The authors of this chapter declare no conict of interest.
Author details
Irene Kida Minja* and Febronia Kokulengya Kahabuka
*Address all correspondence to: ikminja@gmail.com
Muhimbili University of Health and Allied Sciences (MUHAS), Dar es Salaam, Tanzania
Dental Anxiety and Its Consequences to Oral Health Care Attendance and Delivery
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45

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