Management of The Dentally Anxious Patient: The Dentist's Perspective
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Management of the Dentally Anxious Patient: The Dentist's Perspective
Article in Oral health & preventive dentistry · January 2019
DOI: 10.3290/j.ohpd.a41985
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Management of the Dentally Anxious Patient:
The Dentist’s Perspective
Nir Uziela / Joseph Meyersonb / Ephraim Winocurc / Omri Nabriskid / Ilana Elie
Purpose: To evaluate dental anxiety from the dentist’s perspective.
Materials and Methods: A cross-sectional study was performed on a convenience sample. Data were gathered
using questionnaires that included general information and specific questions concerning dentally anxious patients.
Results: Three hundred ten practicing dentists completed the survey. Participants estimated that 27% of their adoles-
cent/adult patients and 35% of their child patients suffer from dental anxiety. Dentists reported devoting about a
quarter of their weekly work hours to treating such patients. The most common anxiety management techniques used
for adults and children alike were nitrous oxide and/or behavioural techniques (such as distraction, reinforcement,
gradual exposure, and relaxation). Dentists generally agreed that it is their responsibility to help dentally anxious pa-
tients. Eighty-one percent expressed interest in taking part in dental anxiety management courses. The consensus
was that treating dentally anxious patients involves long treatment times, insufficient payment, and frequent appoint-
ment cancellations.
Conclusions: According to practicing dentists, over one-quarter of their patients suffer from dental anxiety. Most den-
tists perceive themselves as responsible for treating these patients and are willing to receive appropriate training.
Incorporating behavioural and pharmacological management techniques in the undergraduate dental curriculum and
expanding postgraduate training programmes in this field are important issues that can improve the well-being of both
dentally anxious patients and their dentists.
Key words: dental anxiety, dentist-patient relations, behavioural, management, public health
Oral Health Prev Dent 2019; 17: 35–41. Submitted for publication: 23.07.17; accepted for publication: 15.08.17
doi: 10.3290/j.ohpd.a41985
D ental anxiety is one of the most common anxieties and
is a known barrier to dental health.2,12,26 Studies show
that dental anxiety is not limited to Western societies. It
also exists in Latino and Eastern cultures.7,29 The reported
prevalence of dental anxiety varies among countries and
cultures. In China, dental anxiety ranging from moderate to
phobic affects 30% of the population.29 In European coun-
a Lecturer, Department of Oral Rehabilitation, School of Dental Medicine, Tel tries, the USA, Australia and Israel, the prevalence of den-
Aviv University, Tel Aviv, Israel. Conception and design of study, analysis and in- tal anxiety ranges from 15% to 18%.4,11,17,19,29,30 These
terpretation of data, contributed substantially to the hypothesis and discussion.
differences may originate in cultural differences but also
b Clinical Psychologist and Teaching Fellow, Department of Oral Rehabilitation,
School of Dental Medicine, Tel Aviv University, Tel Aviv, Israel. Conception and
may stem from differences in report measures. In most
design of study, interpretation of data, contributed substantially to the hypoth- studies, this estimation is based on patient reports.4,7,12,
esis and discussion. 17,23,29 Several studies have evaluated patient dental anxi-
c Senior Lecturer, Department of Oral Rehabilitation, School of Dental Medi- ety as reported by the treating dentists.6,13,24,31 As dental
cine, Tel Aviv University, Tel Aviv, Israel. Analysis and interpretation of data,
contributed to the discussion. anxiety is heterogeneous, the definition of patients’ anxiety
d Dentist in Private Practice, Tel Aviv, Israel. Acquisition, analysis and interpreta-
levels may vary among practitioners.23
tion of data, performed study in partial fulfillment of a DMD degree, contrib- Dentists consider anxious patients to be problematic
uted to manuscript discussion. and unreliable and to have a tendency to complain.13,34
e Professor of Behavioural Sciences, Department of Oral Rehabilitation, School Such patients often become irritable, angry and frustrated
of Dental Medicine, Tel Aviv University, Tel Aviv, Israel. Analysis and interpre-
tation of data, contributed substantially to the discussion, critical revision of during treatment, and dental professionals find treating
the manuscript. them time consuming and unprofitable.15,24,34 Thus, it is
not only anxious patients who have reported stress reac-
Correspondence: Nir Uziel, Tel Aviv University, School of Dental Medicine,
Ramat Aviv, Tel Aviv 6997801, Israel. Tel: +972-52-6166-555; tions to dental treatment; their treating dentists have also
Email: niruziel@gmail.com reported stress.1,13,15,24,34
Vol 17, No 1, 2019 35
Uziel et al
Table 1 Management techniques for the treatment of dentally anxious patients
Female; use with Male; use with Average use with Female; Male; Average
adolescents/ adolescents/ adolescents/ use with use with use with
Management technique adults adults adults children children children
Basic strategies (TSD, TLC),
distraction (TV, music), positive 3.32* ± 1.01 2.79* ± 1.36 2.96 ± 1.28 3.00 ± 1.50 2.54 ± 1.68 2.73 ± 1.62
reinforcement
Psychological and behavioral
techniques (gradual exposure, 2.54** ± 1.55 2.14** ± 1.44 2.27 ± 1.48 1.82 ± 1.79 1.62 ± 1.56 1.70 ± 1.64
guided imagery, relaxation)
Nitrous oxide 1.97* ± 1.53 1.39* ± 1.50 1.56 ± 1.53 2.06 ± 1.81 1.67 ± 1.66 1.82 ± 1.72
Hypnosis 0.74 ± 1.39 0.58 ± 1.22 0.62 ± 1.26 0.31 ± 0.91 0.32 ± 0.56 0.32 ± 0.88
Minimal sedation (anxiolytics /
0.88 ± 1.27 0.81 ± 1.18 0.83 ± 1.20 0.15* ± 0.61 0.55* ± 0.97 0.39 ± 0.87
oral sedatives)
Moderate (conscious) or deep
0.81 ± 1.40 0.74 ± 1.30 0.76 ± 1.33 0.28 ± 0.85 0.55 ± 1.06 0.44 ± 0.99
sedation in a private clinic
General anaesthesia in private
0.15 ± 0.64 0.25 ± 0.73 0.21 ± 0.70 0.17 ± 0.67 0.26 ± 0.73 0.22 ± 0.71
practice
Moderate (conscious) or deep
0.33 ± 0.94 0.36 ± 0.93 0.35 ± 0.93 0.74 ± 1.23 0.69 ± 1.18 0.71 ± 1.20
sedation in a hospital
General anaesthesia in a hospital 0.34** ± 0.87 0.59** ± 1.08 0.50 ± 1.02 0.74 ± 1.21 0.86 ± 1.34 0.81 ± 1.29
Referral to another dentist 0.85 ± 1.05 0.81 ± 1.04 0.83 ± 1.04 1.07 ± 0.74 0.92 ± 1.21 0.99 ± 0.66
Response to the question: ‘How often do you use the following techniques?’ Possible responses: 0 = never, 1 = very little, 2 = a little, 3 = often, 4 = very
often. TSD: Tell-Show-Do; TLC: Tenderness-Love-Care. Significant differences are indicated in bold; * p < 0.01; **p < 0.05.
The average dentist receives only basic psychological improve their self-efficacy in the face of anxious and unco-
and/or behavioural training related to treating anxious pa- operative patients.4
tients.1,15 Moreover, only limited information is available In a study conducted in the USA, about half of the den-
regarding management procedures that dentists actually tists recognised the aetiology and triggers that give rise to
use when treating such patients.9,24,25 These procedures dental anxiety and have used methods to reduce dental
range from psychological techniques such as distraction, anxiety among their patients.34 Dentists’ attitudes toward
positive reinforcement, gradual exposure, relaxation and reducing their patients’ anxieties have not been widely stud-
guided imagery to pharmacological techniques, including ied. Nevertheless, it seems that dentists are aware of the
nitrous oxide conscious sedation, tranquilisers, sedation need to acquire more education in this field. In a 2008
and general anaesthesia.5,8,9,22,25,28 A somewhat less study by Hill et al,15 44% of the dental practitioners in the
common (though no less effective) approach is hypnosis, United Kingdom indicated they would be interested in fur-
although dentists study and utilise this mode to a lesser ther training in psychological methods.
degree.34 Hypnosis is used to induce relaxation, reduce The aim of the present study was to evaluate the issue
stress and anxiety, treat severe dental phobia and enhance of dental anxiety from the dentist’s perspective, including
the effectiveness of local anaesthetics when used as an the problems dentists face in treating anxious patients,
adjunct.18,20,21,28 Nevertheless, hypnosis is often consid- their readiness to treat such patients and their level of fa-
ered to be time consuming.15 miliarity, training, and openness towards the use of various
Dentists who received basic training in dental anxiety management techniques.
are better able to cope with their anxious patients, and
they treat more such patients than do dentists without
such training.31 Considering the high number of fearful MATERIALS AND METHODS
individuals in need of dental care, better education of den-
tists through the appropriate application of behavioural, Tel Aviv University’s Committee for Approval of Experiments
psychological and pharmacological treatment should im- in Human Subjects approved this cross-sectional study
prove dental care for a large number of patients. Not only under the Helsinki Accord. All participants signed an in-
can such training prevent exacerbation of fears among in- formed consent form or approved their participation elec-
dividuals at risk, it can also reduce dentists’ stress and tronically via internet.
36 Oral Health & Preventive Dentistry
Uziel et al
Fig 1 Level of agreement regarding
dentists’ attitudes toward dental anxiety. 4
Responses to the question: ‘To what degree
do you agree with the following statements?’
1: strongly disagree; 2: disagree; 3: agree; 3.5
4: strongly agree.
2.5
1.5
1
Dentists enjoy Dentists become Dentists usually don’t Dentists are
helping dentally stressed when treating have enought time committed to helping
anxious patients uncooperative patients for dentally anxious dentally anxious
patients patients
The survey conducted in the present study was based on Statistical Analysis
the study by Hill et al.15 The questionnaire was translated The Department of Statistics at Tel-Aviv University con-
into Hebrew, back translated into English and adapted for ducted the statistical analyses. SPSS version 19.0 soft-
Israel by the team at the Clinic of Oral Psychophysiology at ware (SPSS; Chicago, IL, USA) was used for all statistical
the School of Dental Medicine, Tel Aviv University which analyses, with the significance level set at p < 0.05. Two-
specialises in treating dentally anxious patients. sample t-tests were used for comparisons of continuous
The questionnaire contained mainly closed-ended ques- parameters. Distribution of categorical variables was com-
tions. The questions cover general information, such as pared by applying the chi-squared test. Relationships
gender, year of qualification and distribution of professional between continuous measurements were evaluated with
working time between private and public settings. The ques- Pearson’s correlation coefficient.
tionnaire included specific questions regarding the number
of dentally anxious patients who were treated, the amount
of time dedicated to treating these patients, the type of RESULTS
professional training dentists received in managing anxious
patients and the frequency with which they use these tech- Of the 800 practicing dentists approached for the study,
niques. Further questions examine what type of anxiety-treat- the response rate was 54% (n = 428). Among the respon-
ment training the dentist would like to receive in the future.17 dents, 118 were excluded from the study because they did
The questionnaire was initially administered to 18 den- not complete the questionnaires adequately, so that the
tists who were not included in the final study. Following the final survey sample was 310.
initial experiment, some minor modifications were made to The male:female ratio was 2:1 (212 men and 98
the original questionnaire. These included addition of the women). On average, dentists had practical experience of
possibility of patient referral and basic management strate- 14.5 ± 11.6 years and worked 36.4 ± 12.7 hours per week.
gies, such as Tell-Show-Do (TSD), Tenderness-Love-Care Men worked statistically significantly more hours per week
(TLC), distraction (television, music) and positive reinforce- than women (38.5 ± 12.4 vs 31.8 ± 12.2; p < 0.01). More
ment as part of the treatment options (see Table 1). Partici- male than female dentists reported working in private prac-
pants answered the questionnaire in reference to children tices (87.5% vs 78.1%; p < 0.01), while women worked
up to the age of 10 and then answered the same questions more frequently in public settings (50% women vs 33.2%
for adolescent and adult patients (aged 11 or above). men; p < 0.01).
The questionnaires were distributed personally and a link Of the treated patients, 80.3% were adolescents and
to an online version of the questionnaire was sent via Face- adults and 19.7% were children under the age of 11. Fe-
book and e-mail. The inclusion criterion was being a practic- male dentists treated more children than did male dentists
ing dentist in Israel. (29.6% vs 15.2%; p <0.01).
Vol 17, No 1, 2019 37
Uziel et al
Fig 2 Dentists’ attitudes regarding
4 problems in treating dentally anxious
patients. Responses to the question ‘Which
3.5 of the following problems do you encounter
when treating anxious patients?’ 1: very
rarely; 2: rarely; 3: often; 4: very often.
3
2.5
1.5
1
Lack of financial Problematic Canellation of Lack of financial Longer than
reward (private interaction appointments reward (public expected
setting) setting) treatment
duration
Fig 3 Graduate education in management
Percent of positive responders techniques for dentally anxious patients.
General anaesthesia, deep and moderate
sedation and hypnosis were not included
because they are not part of the dental
undergraduate curriculum in Israel.
TSD = Tell-Show-Do;
TLC = Tenderness-Love-Care.
r
ns
LC
he
en
er
tio
ur
id
ea
T
ox
ag
Ot
os
em
da
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m
im
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us
se
rc
TS
us
le
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ro
ed
al
rio
in
ua
Ni
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im
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va
Gu
ad
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Gr
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–
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Di
According to participating dentists’ evaluation, 27% of Consensus among participants was also relatively high
their adolescent/adult patients and 35% of their child pa- (irrespective of gender and/or years of professional experi-
tients were dentally anxious. Participants devoted about ence) regarding the problems in treating patients with dental
25% of their weekly time to treating patients with dental anxiety. The highest consensus was for extended treatment
anxiety, in which female dentists devoted more time to time, followed by insufficient payment and appointment can-
treating anxious patients than did their male colleagues cellation (scores 3.0–3.1 ± 0.87–0.95 on a scale of 1–4)
(35.0% vs 20.4%; p < 0.01). (Fig 2). A negative correlation was found between dentists’
There was a high consensus among participants (irre- professional experience and problems they experienced
spective of gender and/or years of professional experi- while treating anxious patients. Dentists with more experi-
ence) that they have the responsibility to help dentally anx- ence (more years in practice) experienced fewer problems
ious patients (score of 3.4 ± 0.74 on a scale of 1–4). while treating such patients (r = -0.2; p < 0.01).
There was also general agreement among participating Table 1 shows the use of different techniques for man-
dentists that they rarely have enough time to spend with aging dentally anxious patients. Men and women differed in
anxious patients and that they feel stressed when treating the techniques they used with adult/adolescent patients.
uncooperative patients (scores 3 ± 0.80 and 2.8 ± 0.84 Female dentists reported using basic strategies, psycho-
respectively, on a scale of 1–4). No agreement was found logical and behavioural management techniques, and
concerning the statement whether dentists enjoy helping nitrous oxide conscious sedation more often than male den-
dentally anxious patients (score of 2.3 ± 0.92 on a scale tists, who reported more frequent use of general anaesthe-
of 1–4)(Fig 1). sia (p < 0.05 for all of the above comparisons).
38 Oral Health & Preventive Dentistry
Uziel et al
Table 2 Reasons for not qualifying in various management techniques
Inadequate Already
Technique Lack of time No demand fee Not efficient Not Interested qualified N
Nitrous oxide 8.6% 14.3% 6.1% 1.6% 16.4% 61.9% 244
Behavioural and psychological
17.9% 13.0% 7.6% 1.3% 21.1% 48.9% 223
techniques
Hypnosis 32.1% 22.2% 12.3% 2.4% 38.9% 7.5% 252
*General Anaesthesia 26.2% 17.3% 5.2% 0.4% 39.1% 17.3% 248
Responses to the question: ‘What are the reasons for not qualifying in the following techniques?’ (more than one answer is possible). *General anaesthesia
and deep/moderate sedation are taught today in the same course.
Participating dentists (81.5%) reported receiving basic ity to do so. However, despite feeling responsible for treat-
undergraduate education in treating dentally anxious pa- ing dentally anxious patients, they also claim that they
tients, mainly in using the TSD approach (Fig 3). Sixty-five rarely have enough time to spend with such patients and
percent reported taking some post-graduate courses on that they feel stressed when treating uncooperative pa-
dental anxiety management, with courses on nitrous oxide tients. These findings are similar to those reported by
being taken by 55% of participants. Twenty percent took Hill.15 While encouraging, this finding also points to the
courses on deep/moderate sedation, 17.5% in general an- main obstacles in treating dentally anxious patients. Their
aesthesia and 17.2% in hypnosis (basic strategies and psy- treatment is often time consuming, accompanied by rela-
chological and behavioural techniques were not included tively low financial compensation (insufficient payment) and
because there are no post-graduate courses for dentists on appointment cancellations. In spite of the changes occur-
these subjects in Israel.) ring over the last decades, for the most part, dentistry is
The more experienced dentists (> 10 years of practice) still considered a rather technical profession and dentists
reported receiving less education on dental anxiety manage- are usually paid per ‘product,’ such as restorations or root
ment than their younger colleagues (26% vs 10%; p < 0.01). canal fillings. Many clinics do not charge a direct fee for
On the other hand, the more experienced dentists reported time devoted to procedures such as TSD, gradual exposure
taking more continuing education courses (45% vs 27%; and relaxation.
p < 0.05). The use of pharmacological and non-pharmacological
Most of the dentists expressed interest in studying clini- techniques with moderately anxious patients reported here
cal management techniques for dealing with dental anxiety resembles what has been described in the literature.15 Hyp-
and showed a preference for one- or two-day module courses nosis is in less demand than other techniques, even though
(38%). Twenty percent showed no interest in post-graduate its utility is largely acknowledged when used properly.33
courses whatsoever. Respondents (60%–70%) stated that The study also shows that, compared to male dentists,
they do not use hypnosis and general anaesthesia because female dentists devote more time to treating dentally anx-
they do not consider themselves sufficiently qualified. ious patients. While treating adolescents and adults, fe-
Table 2 summarises the reasons participants are not quali- male dentists use techniques such as TLC, TSD, behav-
fied for the different techniques. Around 40% expressed no ioural management and nitrous oxide more often than
interest in studying general anaesthesia or hypnosis. men do, while men prefer to use general anaesthesia
(mostly in children). These findings resemble those found
in other studies.6 For example, Brahm et al6 showed that
DISCUSSION a greater proportion of women reported that they allowed
extra time when treating dentally anxious patients and
The issue of dental anxiety is gaining increasing interest in that they used anxiety-reducing techniques more fre-
scientific circles. Investigations center mostly on the pa- quently.6 These gender differences may originate in psy-
tient perspective.4,7,12,17,23,29 The percentages of dentally chosociological differences.14 While the sociological and
anxious patients around the world are notable.10,16,32 psychological aspects of these findings are beyond the
Another perspective on dental anxiety is that of the treat- scope of this paper, they raise an interesting point to be
ing dentists.3 Although most undergraduate dental curricula targeted in future investigations.
refer to treatment of dental anxious patients to some ex- The dentists in this study reported that over a quarter of
tent, in many cases, the time devoted to this topic is insuf- their adolescent/adult patients and over a third of their
ficient and unsatisfactory. The optimistic findings from this child patients manifest dental anxiety and that they devote
study indicate that most dentists feel committed to treating around a quarter of their professional time to treating them.
dentally anxious patients and feel that it is their responsibil- This is higher than the generally estimated prevalence of
Vol 17, No 1, 2019 39
Uziel et al
dental anxiety reported in the literature (around 16% in CONCLUSION
Western societies).4,11,17,19,29,30 The difficulties in dealing
with tense patients may lead dentists to classify even mod- According to dentists, about one quarter of their adult pa-
erately tense patients as anxious ones, pointing to a sub- tients are dentally anxious. These dentists perceive them-
stantial difference between patients and dentists in evaluat- selves as responsible for treating anxious patients and are
ing dental anxiety. Interestingly, dentists perceive their generally willing to receive appropriate training. Incorporat-
patients to be more anxious than do the patients them- ing behavioural, psychological and pharmacological man-
selves. It would be interesting to explore this issue with agement techniques in the dental curriculum and expanding
dentist-patient pairs in future studies. postgraduate training programmes in this field are impor-
The participants in the present study were relatively tant issues that can significantly increase the number of
young dentists (average of 14.5 years in practice), so it can patients able to receive treatment in the community. This
be assumed that their views and attitudes reflect relatively can affect the well-being of numerous dental patients, as
modern dental curricula. The dentists exhibited a low to well as that of their dentists.
moderate demand for post-graduate courses in techniques
such as general anaesthesia, sedation, and hypnosis, but
a relatively high demand for courses on nitrous oxide. This
is probably because the skill of nitrous oxide sedation can
be acquired through a relatively short course and because ACKNOWLEDGMENT
the equipment needed is simple and relatively inexpensive.
Furthermore, the public is familiar with this treatment, and The authors thank Dr. Kirsty Hill for allowing us to use the question-
naire.
dentists can easily assign a price to it. In contrast, it takes
more time to acquire and apply psychological and behav-
ioural techniques; these treatments are also lengthier and
more difficult to price, especially in a practical setting such
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