+

STRESS, FEAR & ANXIETY IN

DENTAL SETTING
+

Lecture Created By
Osama Ahmadi, BDS, MSc
+ Objectives
 At the end of the topic, students should be able to:

 Define and differentiate between the stress, fear and anxiety

 Understand the manifestations of stress, fear and anxiety in dental setting

 Understand the causes of stress, fear and anxiety in dental settings

 How to recognize and diagnose stress and anxiety.

 Understand the association between stress , oral and general health

 Discuss possible behavioral interventions to reduce dental fear, anxiety

and stress-induced oral habits
© AAPHD 3
+ Definitions

Stress: It's a natural response to challenging situations, whether they're physical, emotional, or mental

Fear is an emotional response to a specific threat or danger. It's an immediate reaction to something

perceived as harmful or potentially harmful.

Anxiety unlike fear, which is a response to a known threat, anxiety is a more generalized feeling of

worry, apprehension, or unease, often without a specific or identifiable trigger

(Marya et al., 2012)

© AAPHD 4
+ Dental anxiety: ADA Definition

Dental anxiety is a term used to describe stress, anxiety, or dental fear at the

though of any number of dental settings and it’s relatively common

Dental anxiety is extreme nervousness associated with the thought of visiting the

dentist for preventive care and dental procedures. Essentially, it is a fear, stress,

or panic caused by any dental setting

(Marya et al., 2012)

© AAPHD 5
+ 6

 While stress, fear, and anxiety are all part

W h at i s
of the body's natural response
mechanisms, they differ in their triggers, ?
e r en ces
duration, and effects on the individual. diff
Understanding these differences can help
in managing and coping with each of
these experiences effectively.

© AAPHD 6
+ Differences between stress, fear and anxiety

Anxiety Fear Stress Feature

External pressure or challenge
(unspecific) stimuli (specific) stimuli Trigger
Job promotion / (-) Job loss )+(
Acute (temporary), episodic
Chronic (persistent) Acute (immediate)
(intermittent), and chronic Duration
Long term Short term
(persistent)
Rational (fear of
Affect on daily life negative effect on mental and Effects on
physical harm)
and functioning physical health (depression) individuals
Irrational (phobia)

Acute: Car accident, diagnosed

Generalized feeling of Immediate with chronic illness
worry, apprehension, response to Episodic: Presenting at work Examples
or unease something harmful Chronic: Discrimination, lack of
support

© AAPHD 7
+ How stress is manifested in dental
settings?
 Stress can manifest in various ways related to dental health:
 Physical symptoms: bruxism or teeth gridding, jaw clenching during the
examination and Temporomandibular joint disorder (TMJ)
 Physiological symptoms: Increased blood pressure, increased heart rate,
muscular tension and decreased immune response
 Psychological Effects: increased anxiety, depression, and decreased self-
esteem, stemming from concerns about dental procedures
 Behavior changes: neglecting regular brushing and flossing can lead to
increase dental caries and other oral diseases
 Oral Health Conditions: chronic stress can contribute to the development of
gum disease and oral infection

© AAPHD 8
+ How fear is manifested in dental
settings?
 Fear can manifest in different ways:

1. Increased heart rates

2. Sweating

3. Heightened awareness

© AAPHD 9
+ How anxiety is manifested in dental
settings?
People with dental anxiety may experience:

1. Physiological components: increased heart rate, dryness of mouth,

increased perspiration, an upset stomach, flushed face and increased
muscle tension.

Physiological responses of children to initial dental experience (Sipmpson et

al. 1974) Dentist changes in white coat >>> Heart rate Increased by
+10

Dentist says “I am a dentist” >>> Heart rate Increased by

+15

Dentist chair elevation >>> Heart rate Increased by +12

Lamp adjustment >>> Heart rate Increased by +10

End of examination >>> Heart rate Increased by -3

© AAPHD 10
+ How anxiety is manifested in dental
settings?
2. Cognitive components
 Felling of apprehension
 Dread expectation of failure
 Catastrophising
 Depression
 Low self-esteem

(Gale,
1972)

© AAPHD 11
+ How anxiety is manifested in dental
setting?
3. Behavioral components
 Avoidance

“… I do everything you are supposed to do except visit the dentist. I change

my toothbrush regularly, I always buy a good make of toothbrush and
toothpaste, I clean my teeth regularly, I use mouthwash and I brush not just
my teeth but my gums as well” (Diagnostic and Statistical Manual of Mental
Disorder, 2013).
 Disruptive behavior
 Increased muscle tension
 Non-verbal signs

(Gale, 1972)
© AAPHD 12
+ Causes of fear and anxiety
1. learning (Davey, 1989)

 Pain >>>> Fear Pain + Dental setting >>> Fear (Classical conditioning)

 Avoidance of dental setting >>> Fear reduction (Operant conditioning)

 Fear of needle Sensory overload: sounds, smells and sight of dental clinics and dental instruments

 Loss of control: patient lying back in dental chair

2. Observation (Kent and Croucher, 1998)

 Hearing from others about their traumatic experience

 Anxious patients are more likely to have parents/relatives who are themselves anxious about visiting the
dentist

© AAPHD 13
+ Causes of fear and anxiety
3. Generalization

 Fear of dentists may be generalizing (more common) from other setting such as
doctors / hospitals

4. Learned preparedness

 This ideas that we are evolutionarily prepared to be phobic of certain things.

‘programed’ to be fearful of animals / situations that in the past would have
reduced our chance of survival (Generalized Anxiety Disorder)

(kent and
Croucher 1998)
© AAPHD 14
 How common is dental
+ anxiety?
15

Evidence is Found……
 Rates of dental anxiety that causes avoiding the dentist range from 7.8%-
18.8%, depending on the study. (Thomson et al., 1996)
 Around 60% (some reports say up to 75%) of people
have some kind of fear about visiting the dentist. (Saatchi
et al., 2015)
 Dental fear is the 5th most common cause of anxiety. (Appukuttan, 2016)
 Most people report less anxiety after a procedure is done than the
anticipation of dental work. (Caltabiano et al., 2018)

 About 1-5% of people experience full-blown dental phobia, suffering from

irrational fear so strong that they may actively avoid the dentist even
when in extreme pain
© AAPHD 15
+ Assessment of Anxious Patients
16

 Questionnaires

1. The Dental Anxiety Scale (Corah 1968)

2. The Modified Dental Anxiety Scale (Humphris et al 1993)

3. The Modified Child Dental Anxiety Scale (Wong et al 1998)

4. Indicator of Sedation Need (IOSN)

5. Children’s Experiences of Dental Anxiety Measure (Newton et

al 2018)

© AAPHD 16
+ Assessment of Anxious Patients
(Modified Dental Anxiety Scale)

© AAPHD 17
+ Assessment of Anxious Patients 18

(Modified Dental Anxiety Scale)

 The Modified Dental Anxiety Scale. Each item scored as follows:
 Not anxious = 1
 Slightly anxious = 2
 Fairly anxious = 3
 Very anxious = 4
 Extremely anxious = 5
 Total score is a sum of all five items, range 5 to 25: Cut off is 19
or above which indicates a highly dentally anxious patient,
possibly dentally phobic

© AAPHD 18
+ Stress Management Components 19

Necessary in Dental Education

 Developmental psychology (enabling an understanding of the person’s
fears and needs at different stages of life)
 Dynamics of stress and anxiety (enabling the dentist to understand the
patient’s fear of dentistry and the dentist’s own occupational stress)
 Interpersonal communication skills or how to deal with conflict and
confrontation
 Interviewing skills and effective listening skills
 Management of difficult, uncooperative, anxious and aggressive
patients
 Stress management procedures (for example, relaxation, hypnosis,
desensitization, time management and cognitive coping skills)
(Moller and Spangenberg,
1996)
© AAPHD 19
+The Possible Interventions to 20

Overcome Fear , Anxiety and Stress in

Dental Settings
1. Cognitive-Behavioral Techniques (CBT)

2. Educational Interventions

3. Distraction Techniques

4. Behavioral Interventions

5. Psychological Support

6. Pharmacological Interventions

7. Stress-Induced Oral Habits Interventions

© AAPHD 20
+ Cognitive-Behavioral Techniques 21

(CBT)
1. Cognitive-Behavioral Therapy (CBT):

 Thought Record: Patients keep a diary of their thoughts before, during, and after
dental visits. This helps identify irrational fears and replace them with rational
thoughts.

 Cognitive Restructuring: dentist work with patients to challenge and change

negative thought patterns related to dental visits.

 2. Exposure Therapy:
 Gradual Exposure: Patients are gradually exposed to dental-related stimuli, starting
from the least fearful (e.g., looking at pictures of dental tools) to more fearful (e.g.,
sitting in a dental chair).

 Systematic Desensitization: Combining relaxation techniques with gradual exposure

to help reduce fear.

© AAPHD 21
+ Cognitive-Behavioral Techniques 22

(CBT):
3. Relaxation Techniques:

 Deep Breathing Exercises: Involves slow, deep breaths to reduce physical symptoms
of anxiety.

 Progressive Muscle Relaxation (PMR): Patients tenses and then slowly releases
different muscle groups to reduce physical tension.

 Guided Imagery: Patients visualize calming and positive images to distract and relax
them during dental procedures.

(Newton and
Asimakopoulou, 2015) 22
© AAPHD
+ Educational Interventions 23

1. Information Provision:

 Pre-visit Information: Providing detailed information about what to expect during the
dental visit to reduce uncertainty and fear.

 Procedure Explanation: Dentists explain each step of the procedure in a calm and
reassuring manner.

2. Modeling:

 Videos or Live Demonstrations: Patients watch videos or live demonstrations of other

patients undergoing dental treatments calmly. This helps them understand that the
procedures are manageable

(Newton and
Asimakopoulou, 2015)

© AAPHD 23
+ Distraction Techniques 24

1. Audio-Visual Distraction:

 Music or Audiobooks: Patients listen to their favorite music or audiobooks during

the procedure.

 Virtual Reality (VR): Using VR headsets to immerse patients in a different

environment, reducing awareness of the dental procedure.

2. Interactive Distraction:

 Stress Balls or Fidget Toys: Patients use stress balls or fidget toys to occupy their
hands and minds.

 Handheld Games: Providing patients with simple handheld video games to focus
on during the procedure.

(Buchanan and Niven, 2002;

Sulivan et al., 2000)

© AAPHD 24
+ Behavioral Interventions 25

1. Positive Reinforcement:

 Rewards System: Implementing a reward system where patients earn rewards

(stickers, small toys, or certificates) for attending appointments and exhibiting
calm behavior.

 Verbal Praise: Dentists and staff provide positive feedback and encouragement
throughout the visit.

2. Desensitization:

 Gradual Introduction: Dentists introduce dental tools and procedures slowly,

allowing patients to become accustomed to them without immediate treatment.

 Mock Visits: Conducting mock dental visits where no actual treatment is

performed, helping patients get used to the environment

(Aemfield and
Heaton, 2013)

© AAPHD 25
+ Psychological Support 26

1. Counseling:
 Individual Therapy: One-on-one sessions with a psychologist to address
specific fears and anxieties related to dental care.
 Family Therapy: Involving family members to provide support and
encouragement.

2. Support Groups:
 Group Sessions: Facilitating group sessions where individuals with similar
fears can share their experiences and coping strategies.
 Peer Support: Pairing patients with a "dental buddy" who has successfully
overcome similar fears

(Appukuttan, 2016)
© AAPHD 26
+ Pharmacological Interventions 27

1. Sedation:
 Nitrous Oxide (Laughing Gas): A mild sedative inhaled through a
mask that helps patients relax.
 Oral Sedatives: Medications like diazepam taken before the
appointment to reduce anxiety.

2. Anxiolytic Medication:
 Prescribed Medication: Anti-anxiety medications prescribed by a
doctor to be taken before dental visits.

(Malmed,
2003) 27
© AAPHD
+ Stress-Induced Oral Habits 28

Interventions
1. Habit Reversal Training:

 Awareness Training: Helping patients become aware of their habits and the triggers that lead to them.

 Competing Response Training: Teaching patients alternative behaviors to replace the harmful habits
(e.g., chewing gum instead of biting nails).

2. Stress Management Techniques:

 Mindfulness Meditation: Practicing mindfulness to increase awareness and control over stress and
anxiety.

 Physical Exercise: Incorporating regular physical activity to reduce overall stress levels.

3. Biofeedback:

 Technology-Assisted Training: Using biofeedback devices to monitor physiological responses (e.g.,

heart rate) and teach patients how to control them to reduce stress.

(Locker, 2003)

© AAPHD 28
+ Strategies to Overcome Dental 29

Fear

5. Find The
Right Dentist
4. Practice
Behavior
3. Use CBD Oil Modification
Before Dental and Relaxation
Work Techniques
2. Try A
Sensory-
1. Open Adapted
Communicatio Environment
n

© AAPHD 29
+
Strategies To Overcome
Dental Fear

10. Undergo
General
9. Try IV Anesthesia
Sedation
8. Take Dentistry
Anxiety-
7. Request Relief
Nitrous Medication
6. Try Oxide before your
Cognitive- (Laughing visit
Behavioral Gas)
Therapy

© AAPHD 30
+ The association between stress, oral
health and general health
 Immune System Function: Chronic stress can impair the immune system. when
the immune system is weakened, the body's ability to fight off bacteria and
viruses that cause oral diseases like gum disease (gingivitis and periodontitis) is
compromised

 Inflammation: stress triggers inflammation in the body, which can exacerbate

existing oral conditions such as gingivitis and periodontitis

 Bruxism: bruxism can leads to tooth wear, fractures, jaw pain, and TMJ disorder, all
of which can impact oral health and overall well-being

 Oral Health Behaviors: High levels of stress may lead to neglect of oral hygiene
practices such as regular brushing, flossing,
© AAPHD
and
31 dental check-ups
+ The association between stress, oral
health and general health
 Several studies have shown that stress has an impact on the oral health status
(Vasiliou et al., 2016).
 Individuals with higher levels of stress were found to have higher risk of
developing diseases such as periodontitis (Marcenes and Sheiham, 1992) and
have been found to have poor oral health related behaviors such as self-care
scores (Sanders and Spencer, 2005).
 Dental diseases can be caused by the indirect effects of psychosocial factors:
 Stress leads people to indulge in unhealthy eating habits leading to increased risk
of dental caries (Sisson, 2007).
 Smokers when they are stressed increase smoking times which affect their
periodontal health

© AAPHD 32
+ The association between stress,
oral health and general health
Systemic Health Impact Several systemic conditions, such as
diabetes and cardiovascular disease, have been associated with
poor oral health. Stress-induced oral health problems can
exacerbate these systemic conditions and vice versa, creating a
cycle of negative health outcomes

Psychological Impact: Poor oral health due to stress can have

psychological effects, including decreased self-esteem, social
withdrawal, and increased anxiety or depression

© AAPHD 33
+ References
 Armfield JM, Heaton LJ. Management of fear and anxiety in the dental clinic: a review.
Australian dental journal. 2013 Dec;58(4):390-407.

 Appukuttan DP. Strategies to manage patients with dental anxiety and dental phobia:
literature review. Clinical, cosmetic and investigational dentistry. 2016 Mar 10:35-50.

 Asimakopoulou K, Newton JT. The contributions of behaviour change science towards dental
public health practice: a new paradigm. Community dentistry and oral epidemiology. 2015
Feb;43(1):2-8.

 Buchanan H, Niven N. Validation of a Facial Image Scale to assess child dental anxiety.
International journal of paediatric dentistry. 2002 Jan;12(1):47-52.

 Caltabiano ML, Croker F, Page L, Sklavos A, Spiteri J, Hanrahan L, Choi R. Dental anxiety in
patients attending a student dental clinic. BMC oral health. 2018 Dec;18:1-8.

 Corah NL, Pantera RE. Controlled study of psychologic stress in a dental procedure. Journal of
Dental Research. 1968 Jan;47(1):154-7.

© AAPHD 34
+ References
 Davey GC. Dental phobias and anxieties: evidence for conditioning processes in the acquisition and modulation of a learned fear.
Behaviour Research and Therapy. 1989 Jan 1;27(1):51-8.

 Gale EN. Fears of the dental situation. Journal of Dental Research. 1972 Jul;51(4):964-6.

 Wong HM, Humphris GM, Lee GT. Preliminary validation and reliability of the modified child dental anxiety scale. Psychological
reports. 1998 Dec;83(3_suppl):1179-86.

 Humphris GM, Morrison T, Lindsay SJ. The Modified Dental Anxiety Scale: validation and United Kingdom norms. Community
dental health. 1995 Sep 1;12(3):143-50.

 Locker D. Self‐esteem and socioeconomic disparities in self‐perceived oral health. Journal of public health dentistry. 2009
Jan;69(1):1-8.

 Marcenes WS, Sheiham A. The relationship between work stress and oral health status. Social Science & Medicine. 1992 Dec
1;35(12):1511-20.

 Marya CM, Grover S, Jnaneshwar A, Pruthi N. Dental anxiety among patients visiting a dental institute in Faridabad, India. West
Indian Medical Journal. 2012 Mar 1;61(2):187.

 Möller AT, Spangenberg JJ. Stress and coping amongst South African dentists in private practice. The Journal of the Dental
Association of South Africa= Die Tydskrif van die Tandheelkundige Vereniging van Suid-Afrika. 1996 Jun 1;51(6):347-57

© AAPHD 35
+ References
 Newton T, Porritt J, Morgan A, Rodd H, Gupta E, Gilchrist F, Baker S, Creswell C, Williams
C, Marshman Z. Development and evaluation of the children's experiences of dental anxiety
measure. International Journal of Paediatric Dentistry. 2018 Mar;28(2):140-51
 Thomson WM, Stewart JF, Carter KD, Spencer AJ. Dental anxiety among
Australians. International dental journal. 1996 Aug 1;46(4):320-4.
 Saatchi M, Abtahi M, Mohammadi G, Mirdamadi M, Binandeh ES. The
prevalence of dental anxiety and fear in patients referred to Isfahan Dental
School, Iran. Dental research journal. 2015 May 1;12(3):248-53.
 Simpsom WJ. Physiologic responses of children to initial dental experience.
J. Dent. Child.. 1974;41:465-70.
 Vasiliou A, Shankardass K, Nisenbaum R, Quiñonez C. Current stress and
poor oral health. BMC Oral Health. 2016 Dec;16:1-8

© AAPHD 36