The Etiology of Dental Phobia

This summary is based on information found in Cognitive Behaviour Therapy for Dental Phobia and Anxiety (Wiley Publishing, 2013)

Psychological and Interpersonal Aspects of Dental Treatment

• Taking different aspects of dental treatment into consideration, there is reason to believe that dental treatment triggers instinctive survival mechanisms.
• The threatening body position and potential obstruction of free air space during treatment may be perceived as threats by patients.
• Another essential feature of dental treatment is the intimacy of the oral area which may trigger a feeling of unpleasantness or stress and a defence reaction.

Pain

• Dental tissues are highly innervated with pain receptors and almost any dental treatment is likely to cause pain in some patients.
• Despite recent developments in local anaesthesia and dental equipment and the trend for less extensive removal of tooth substance, most people experience dental treatment as unpleasant.
• The correlation between remembered experiences of pain and dental anxiety is well documented.

Control

• Dental treatment involves some degree of stress in all patients. Experiments have demonstrated that when test subjects feel that they have control over a stressful setting, the responses to stress are reduced.

Regression

• Some dental fear patients describe a desire to scream, to cry, or to run out of the office. Regression is a state where the person reacts in an immature way, often linked to the stage where a traumatic event happened (Gill 1972).

Personality

Considering different aspects of dental treatment, basic trust between patient and dentist seems to be essential.

Incompatible personalities between dentist and patient may contribute to the increasing feeling of stress in both dentist and patient.

Elements of the Fear Reaction

The cognitive element

• Includes expectations of specific impending harm: when fear is triggered, people will automatically exaggerate the actual danger, but subsequent cognitive assessment will usually produce the correct and suitable reaction to the danger in a specific situation.
• Through selective attention, our expectations, interests and concerns will affect the perception of the fearful event (Rosenhan and Seligman 1989).

Physiological elements

• Fear reactions lead to many internal and external bodily changes: within seconds, our body’s resources are mobilized involuntarily (Rosenhan and Seligman 1989).
• Fear and stress cause an increase in muscular tension and activate the autonomic nervous system.

Emotional elements

• Feelings of fear such as feelings of dread, terror, panic or just a creeping sensation or tight stomach.

Behavioural elements

• Withdrawal: called an escape response, try to avoid the threatening situation.
• Aggressive defences: a patient with this reaction would be a ‘goer but hater’ which means that both the avoidance tendency and the stress activation are high.
• Immobility: Attentive immobility or freezing: the person stops, localizes the danger and prepares to deal with it. In order to cope with dental treatment, they
  freeze their reactions and mobilize all their energy, in an effort to get the treatment over with.
• Deflection of attacks: diverting the attack away from the source. Comparable reactions make persons with dental anxiety assert that dental treatment is too expensive, that the dental clinic is too far from home and so on.

Aetiological Theories of Dental Fear and Anxiety

Behavioural/learning approaches

• Contemporary associative accounts include previous learning histories which serve as vulnerability factors, temperamental vulnerabilities and contextual factors during and following traumatic learning events (Mineka and Zinbarg 2006).

Preparedness

• Implies genetic transmission and that what we fear and how we fear is innate (Barlow 2002).

Genetic and conditioning framework

• The treatment situation contains three possible prepared factors: sharp object causing pain, constraint and lack of control over aversive stimuli (pain) (e.g. Bracha, 2004, 2005, 2006).
• The dental treatment situation especially, becomes vulnerable to classical conditioning as pain is a true alarm.

The Multi-factorial Aetiology of Dental Phobia

The development of dental anxiety may be presented in a model, highlighting the interaction between three factors: personal factors, external/social factors and dental factors.

Personal factors

• Dental fear and anxiety often has its origin in childhood; many children, and especially small children, show fear and behaviour management problems during dental treatment.
• As the children grow older and become more mature, most of them are able to better understand the situation, be motivated for treatment and able to comply with dental procedures.
• Temperament is a personal emotional quality that is moderately stable over time. Dimensions of temperament that have been associated with dental fear and/or behaviour management problems in children are ‘shyness’, ‘negative emotionality’, ‘activity’ and ‘impulsivity’ (Stenebrand et al. 2012).
• Uncooperative behaviour and dental fear/anxiety have also been related to neuropsychiatric disorders in children and adolescents, e.g. attention deficit hyperactivity disorder (ADHD), autism, Asperger syndrome, Tourette’s syndrome and other mental disorders (Klingberg and Broberg 2007).
• Survivors of torture (Singh et al. 2008) and sexual abuse (Humphris and King 2011; Willumsen 2004) have also been shown particularly vulnerable to the development of dental anxiety.

External/social factors

• Parental dental anxiety affects fear and anxiety in children.
• Dental anxiety problems have been reported more frequently in groups with lower socioeconomic status and among immigrants (Gustafsson et al. 2007) who are more vulnerable to fearful dental stimuli as additional to other daily problems.

Dental factors

• There is strong evidence that previous painful dental procedures are the most important aetiological factor for dental anxiety disorders (Berggren and Meynert 1984; Milgrom, Mancl et al. 1995; Locker et al. 1996).

From Dental Fear to Dental Phobia – Three Vicious Circles

1. The internal vicious circle of dental fear: internal reactions as perceived during exposure to possible danger.
2. The vicious circle of interpersonal relations: consequences of postponing appointments and of not attending sessions: people with dental fear often cancel or postpone appointments.
3. The general vicious circle of dental phobia: a patient with dental fear starts to avoid dental treatment, this leads to a deterioration of the dentition. Bad teeth create negative feelings (shame, guilt and embarrassment). These feelings are in turn likely to reinforce avoidance behaviour.

List of References (PDF)