Cold and uncomfortable metal recliner chairs, the screeching hums of drills, and blinding white lights are the stuff of nightmares for many people. Unfortunately, dental fear is far too common. Various studies have shown that around 15% of the adult population report experiencing dental anxiety, with the statistic being even higher among children. One review estimates that almost one in four children experience dental fear.
Dental anxiety is associated with a “lower frequency of dental visits and a higher prevalence of dental caries,” leading to worsened oral health. In fact, in the 2000 U.S. Surgeon General’s report on oral health, “4.3 percent of patients reported fear as their reason for not using dental health services.” This can be detrimental to a patients oral health, leading to a vicious feedback loop as anxious individuals avoid check-ups, only to require more invasive, daunting treatments after years of neglect. To improve oral health worldwide, it’s clear we need to better understand the aggravators of dental anxiety and implement effective treatments and interventions to combat this issue.
1. Dentistry in the Media
One commonly proposed explanation for dental anxiety is patients’ negative expectations “due to information obtained from mass media sources.” For the past century, dentists have been portrayed in different lights within film, television, and other forms of visual media. Typically, dentists assume the roles of scary, corrupt individuals with nefarious intentions. For example, the 1976 thriller Marathon Man showcases a Nazi dentist extracting teeth to inflict torture. Furthermore, in the 1996 comedy film The Dentist, a dentist discovered that his wife cheated on him and thus expressed his rage by abusing and murdering patients in his practice. In the children’s movie Finding Nemo, a frightening dentist abducted the clownfish Nemo into his fish tank. Since these movies that feature dentists range from a variety of genres, they influence audiences with a wide variety of interests from different age groups. All of these portrayals convey a common trend: patients surrender control of themselves when visiting the dentist. Analyzing the evolution of dentistry-containing films over the past century shows that the portrayal of dentists has simply not changed. Dentists are still portrayed in the movies in a comedic role or as “incompetent, sadistic, immoral, disturbed, or corrupt,” which makes it crucial to understand and employ sustainable interventions toward dental anxiety.
2. Pharmacological Treatments
Although dental anxiety remains prevalent, oral health professionals can effectively manage this condition. The administration of drugs and medicines, also known as pharmacological treatment, is a common method for treating dental anxiety. Usually, pharmacological treatments serve as a last resort for patients due to the side effects associated with the various medicines. Before a patient undergoes pharmacological treatment for their condition, one must consider the severity of the patient’s anxiety, alongside the risks involved.
Pharmacological control of dental anxiety can be administered through sedation. Ideal sedative agents would help reduce anxiety, while still ensuring that the patient is conscious and able to complete their dental treatment. Nitrous oxide sedation, also known as laughing gas, is the most commonly used and safest conscious sedative. A randomized controlled study tested how nitrous oxide would affect dental anxiety during the treatment of dental pulp, the inside of the tooth. Among a population of those with self-reported dental anxiety, a control group received only local anesthesia, while the experimental group received local anesthesia and 30%–50% nitrous oxide sedation. These patients reported a feeling of euphoria and warmth when inhaling the nitrous oxide gas. Following the treatment, the patients reported lower levels of both anxiety and pain, thereby demonstrating the effectiveness of sedation.
While nitrous oxide is the most common sedative agent for dental anxiety, an alternative option is midazolam, which is typically administered orally or intravenously. One study found that administering oral midazolam results in decreased separation anxiety before dental procedures. Yet, this study did not specify whether the participants possessed specifically dental anxiety or simply anxiety about operative procedures. Rather than using solely oral midazolam, most pharmacological treatments instead use a combination of nitrous oxide and oral midazolam. A study found that combining midazolam and nitrous oxide decreased movement and crying following a dental restorative procedure, compared to midazolam alone. This finding suggests that combining both sedatives may synergistically provide extra comfort to pediatric dental patients.
Though pharmacological treatments present a probable approach to combatting dental anxiety, their limitations cannot be ignored. Pharmacological treatments have been shown to only be effective in the short term. They serve as temporary solutions, only providing relief for a specific procedure, yet not reducing dental fear and anxiety for future treatments. Furthermore, administering excess amounts of a sedative may lead to unconsciousness or respiratory failure, so this form of treatment requires much more training and stricter guidelines. Lastly, pharmacological therapies require proper infrastructure and equipment, so this treatment is usually reserved for more severe operative oral procedures.
3. Hypnosis Therapy
To avoid the limitations of pharmacological treatments, dentists often turn to behavioral modification therapies to treat dental anxiety, such as hypnosis. During hypnosis, an individual attempts to modify a subject’s feelings by coaxing them through images and ideas. Hypnosis acts on the unconscious mind, changing how a person automatically reacts to a certain stimulus. In this case, hypnosis intends to induce automatic relaxation in response to dental procedures.
The specific method of hypnosis differs across studies, but the results are typically positive. One study included a hypnosis intervention that consisted of a “3-minute progressive muscle relaxation induction followed by a 5-minute deepening procedure.” These patients were instructed to visualize a “safe and special garden” and a fountain with water that “would make their mouth numb and relaxed.” The individuals exposed to this treatment exhibited decreased heart rate and more positive attitudes during dental anesthetic infiltration. Another study compared two different types of hypnosis: a standardized relaxation hypnosis CD and an individualized visual hypnosis that focused on activities the patient found pleasant. The individualized hypnosis resulted in significantly lower self-reported scores of dental anxiety compared to the standardized method, suggesting the potential for personalized treatment within dental anxiety interventions.
Hypnosis not only successfully reduces dental anxiety, but it is relatively inexpensive and has a low risk of side effects. However, dentists require specialized training if they hope to perform the hypnosis themselves. Furthermore, not all individuals react positively to hypnosis, so it may not be a reliable or safe technique for those with mental health issues and personality disorders..
4. Cognitive Behavior Therapy
While hypnosis operates at the unconscious level, other treatments act at the conscious state. These treatments are known as cognitive behavior therapy (CBT). The purpose of CBT is for patients to identify their thoughts, alter these thoughts, and practice behaviors to prevent harmful thoughts from reoccurring. When conducted in a clinical setting, CBT usually consists of some variation of homework exercises, psychoeducation, and exposure.
In one such study, patients with dental anxiety watched short films that showcased a child going through several dental procedures. Furthermore, children had access to materials, like cotton balls, probes, and topical anesthetics, for them to practice with at home. The results of this study showed that after one year, 91% of the CBT group no longer met the diagnostic criteria for dental anxiety. This finding indicates that visual and hands-on experience before dental procedures provides a sustainable level of comfort and reassurance.
As technology has grown more advanced, web-based CBT has become increasingly popular. This subset of CBT involves patients taking online courses in preparation for their dental procedures. In one such study, children with dental anxiety engaged in an online course consisting of 12 modules of guiding text, 18 worksheets, and 10 informational documents regarding mindfulness and pain management training. The participants re-evaluated their dental anxiety a year later, and results showed that this treatment improved their ability “to cope with dental procedures [and] reduced their negative feelings and thoughts about dentistry.”This finding highlights that web-based CBT has comparable positive effects to the traditional in-person model.
Compared to hypnosis, CBT has more long-term successful effects. In fact, a study found that CBT proved more successful at reducing dental anxiety than both standardized and individualized hypnotherapy. Although CBT requires time and effort to produce informational materials, the web-based alternative deems this process more cost-efficient and feasible. As of now, CBT—and specifically web-based CBT—is the most effective and accessible intervention for dental anxiety.
5. Virtual Reality Therapy
As technology continues to evolve, tech-based alternatives to CBT are becoming popular interventions for dental anxiety. One such example, virtual reality (VR), employs wearable devices and sensors to craft an immersive, simulated environment for users. With VR, individuals can visit the Eiffel Tower, swim with dolphins, and enter the world of Harry Potter all at their fingertips. Recently, dentists have introduced VR technology into their clinics, allowing both children and adults to wear VR headsets during procedures
So far, the outcomes of VR technology in dentistry have been exceedingly favorable. In one study, children ages 4-6 wore VR eyeglasses when receiving fluoride treatment. Following the treatment, these patients reported lower levels of fear and anxiety regarding visiting the dentist, suggesting that VR provides a productive distraction mechanism. These patients also reported feeling less pain throughout the procedure, highlighting that the audio, visual, and kinesthetic sensations of VR alter the way patients interpret incoming pain signals. A study conducted on adults reported similar findings, such as lower heart rates and blood pressure after wearing a VR nature distraction system during their dental treatments. Furthermore, a study conducted on children with mild intellectual disabilities also demonstrated positive effects. After these individuals listened to relaxing music and watched age-appropriate videos exhibiting the underwater world, they reported a decrease in pulse and an increase in oxygen saturation levels, which led to more stable breathing. These results suggest that VR not only has positive effects on self-reported measures of dental anxiety but also tangible, objective physiological measures on people of all ages and abilities.
Compared to CBT and hypnotherapy, virtual reality requires significantly less effort from the provider. Rather than spending time coaching or working with patients, dentists simply provide a video headset. Furthermore, VR therapy is simple to use, safer than pharmacological therapies, and can be easily used in both children and adults simply by changing the size of the headset. However, since VR therapy is relatively new to dental settings, there has not been much research on the long-term effects of this intervention.
6. Conclusion
Although dental anxiety will likely never go away permanently, oral health professionals must choose the most effective, safe, and cost-efficient treatment for this issue. Pharmacology presents a successful, medically-based intervention, yet it displays the most risk factors of all the treatments discussed and is only beneficial in the short term. Hypnosis and CBT both have safe, long-term psychological treatments for dental anxiety, yet they require significant time and effort to execute. Thus, web-based CBT and virtual reality are arguably the current best interventions for the disorder. Web-based CBT offers a more cost-effective alternative to traditional CBT, while still preserving the long-term positive effects of CBT on dental anxiety. VR is the most time-efficient and feasible intervention, but its long-term have not been studied as closely. As VR is further studied, refined, and regularly used, it may very well become the most prominent intervention for dental anxiety.
