The Roots of Dental Fears - RDH Magazine - Dental ...

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The Roots of Dental Fears

A Peer-Reviewed Publication
Written by Kandice Swarthout-Roan, RDH, BS & Priya Singhvi, MS, LPC-I, LMFT-A

Abstract Educational Objectives: Author Profiles
The relationship between a dental professional and the patient At the conclusion of this educational activity Kandice Swarthout-Roan, RDH, BS, has practiced clinical
is the heart of what keeps the practice thriving and patients participants will be able to: dental hygiene for 16 years and is part-time faculty in the
returning. Most patients trust the staff members and establish 1. Describe the reactions of patients who dental hygiene program at Collin College, McKinney, Texas.
a“dental home”in which they feel cared for and safe. For some
people, a history of personal trauma, anxiety, or substance use have dental fear due to past non-dental Priya Singhvi, MS, LPC-I, LMFT-A, has been working in the
can paralyze them during a dental appointment. The fear of a related trauma. field of psychology and education for over 11 years. Priya
dental appointment or professional may be so overwhelming, 2. Explain biological and physiological currently serves as P.A.L. sponsor, wellness educator, and
a patient may behave in an exaggerated manner in the chair or effects of trauma in the human brain. full-time counselor at a private school in Addison, Texas.
avoid going to the dentist altogether. Awareness of potential 3. Associate psychological symptoms of Author Disclosure
stressors that provoke these behaviors, including the neuro- trauma with dental anxiety. Kandice Swarthout-Roan and Priya Singhvi have no com-
biological responses to trauma, can help dental professionals 4. Identify practical applications for dental mercial ties with the sponsors or providers of the unrestricted
provide optimum service with empathy and compassion. professionals to alleviate dental fear. educational grant for this course.

Go Green, Go Online to take your course This educational activity was developed by PennWell’s Dental Group with no commercial support.
This course was written for dentists, dental hygienists and assistants, from novice to skilled.
Publication date: Dec. 2013 Supplement to PennWell Publications Educational Methods: This course is a self-instructional journal and web activity.
Expiration date: Nov. 2016 Provider Disclosure: PennWell does not have a leadership position or a commercial interest in any products or
services discussed or shared in this educational activity nor with the commercial supporter. No manufacturer or third
PennWelldesignatesthisactivityfor2ContinuingEducationalCredits party has had any input into the development of course content.
DentalBoardofCalifornia:Provider4527,courseregistrationnumberCA#02-4527-13098 Requirements for Successful Completion: To obtain 2 CE credits for this educational activity you must pay the
“ThiscoursemeetstheDentalBoardofCalifornias’requirementsfor2unitsofcontinuingeducation”. required fee, review the material, complete the course evaluation and obtain a score of at least 70%.
ThePennWellCorporationisdesignatedasanApprovedPACEProgramProviderbythe CE Planner Disclosure: Heather Hodges, CE Coordinator does not have a leadership or commercial interest with
AcademyofGeneralDentistry.Theformalcontinuingdentaleducationprogramsofthis products or services discussed in this educational activity. Heather can be reached at [email protected]
programproviderareacceptedbytheAGDforFellowship,Mastershipandmembership Educational Disclaimer: Completing a single continuing education course does not provide enough information to
maintenancecredit.Approvaldoesnotimplyacceptancebyastateorprovincialboardof result in the participant being an expert in the field related to the course topic. It is a combination of many educational
dentistryorAGDendorsementT. hecurrenttermofapprovalextendsfrom(11/1/2011)to courses and clinical experience that allows the participant to develop skills and expertise.
(10/31/2015) Provider ID# 320452. Scientific Integrity Statement: Information shared in this CE course is developed from clinical research and
represents the most current information available from evidence based dentistry.
Registration: The cost of this CE course is $49.00 for 2 CE credits.
Cancellation/Refund Policy: Any participant who is not 100% satisfied with this course can request a full refund by
contacting PennWell in writing.

Educational Objectives “tooth neurosis.” He said that the fear of dental treatment is
At the end of this self-instructional educational activity, the unique because it is rooted in unknown fear and real danger.
participant will be able to: The patient is well aware that real danger is possible, but in
1. Describe the reactions of patients who have dental fear due most cases little or no pain is experienced.3 The combination
of the perceived and real fear can escalate the anticipatory
to past non-dental related trauma. anxiety to a level beyond the patient’s ability to process.
2. Explain biological and physiological effects of trauma in the
Reactions to dental treatment include severe fear and
human brain. anxiety during a dental appointment. Prior experiences may
3. Associate psychological symptoms of trauma with dental be the source of the dental fear including; adult survivors of
childhood sexual abuse (CSA), posttraumatic stress disorder
anxiety. (PTSD), substance abuse, and anxiety disorders.
4. Identify practical applications for dental professionals to

alleviate dental fear.

Abstract Childhood Sexual Abuse
Therelationshipbetweenadentalprofessionalandthepatient Approximately 20% of all females seeking dental treatment
is the heart of what keeps the practice thriving and patients re- are survivors of CSA.15 Another study25 reported that among
turning. Most patients trust the staff members and establish a women with high levels of dental fear, 34% experienced
“dental home”in which they feel cared for and safe. For some childhood molestation, 15% reported attempted rape, and
people, a history of personal trauma, anxiety, or substance use 13% reported rape or incest. Three-fourths of women with
can paralyze them during a dental appointment. The fear of a a history of oral penetration associated with CSA had very
dental appointment or professional may be so overwhelming, high levels of dental fear. Women with CSA had higher lev-
a patient may behave in an exaggerated manner in the chair or els of dental fears than those in the normative sample.24 It is
avoid going to the dentist altogether. Awareness of potential crucial for dental professionals to increase their awareness of
stressors that provoke these behaviors, including the neuro- this issue to ensure optimum patient care. During a typical
biological responses to trauma, can help dental professionals day at the office it is likely that a survivor of CSA will be
provide optimum service with empathy and compassion. treated.

Problem Assessment Childhood sexual abuse is a serious issue that, for most in-
Dental professionals recognize that building a relationship dividuals, is based in shame and may remain undisclosed for
with patients cultivates trust, which is critical for the patient to a lifetime. CSA can affect oral health in many ways with the
makeinformeddecisionsabouttreatmentandreturnforfuture mostseriousoftheconsequencesmanifestingaspsychological
appointments. For some patients, the bond with the hygien- issues. The patient may have reduced self-esteem, difficulty
ist, assistant, or dentist may be a matter of life or death in their in interpersonal relationships, and reduced initiative. When
minds. When a person has suffered a severe traumatic experi- these factors continue unresolved, a dental appointment may
ence, he or she may perceive little to no control when placed in be a fearful situation. The patient feels extremely vulnerable
a vulnerable situation including a dental appointment. In this during an appointment, which results in a sense of helpless-
vulnerablestate,thepatientmaysuddenly,sometimeswithout ness.24 In order to avoid helplessness and vulnerability, the
knowing why, react with fear and anxiety in the chair. Dental patient may choose to circumvent dental appointments until
fear manifests in many ways, sometimes leaving the clinician he or she is in severe pain or in an advanced disease state, in-
confused and frustrated and the patient further traumatized. creasing the vicious cycle.2 Others will seek dental treatment
The vicious cycle of dental fear and avoidance suggests that in spite of their fear, but suffer from anxiety without always
intense fears lead to dental avoidance, poor oral health, fewer understanding the etiology. Treating fearful dental patients
office visits, increased need for treatment, and greater per- can develop into a stressful situation for the provider and pa-
ceived vulnerability.2 The patient gets trapped in this cycle of tient. As clinicians become more aware of the signs and symp-
fear and continues to avoid appointments or feels extremely toms of CSA-based fear, they can modify their approach to
anxious at the mere thought of going to the dentist.The delay the patient, provide a less stressful visit, and potentially help
in seeking treatment due to dental fear can greatly impact the patients reduce their fear long term.
patient’s quality of life.17The recognition of dental fear and the
potentialunderlyingcausesmayenablethedentalprofessional As a dental professional, it is important to recognize sur-
to help patients reduce or stop the cycle. vivors of CSA to understand extreme reactions during an ap-
pointment. CSA is typically a secret for the patient. They may
In 1946, Coriat described dental fear as “an excessive not connect their dental fear to past experiences.
dread of anything done to the teeth.”3 He suggested that this
anticipatory anxiety was not based on the actual pain, but on Posttraumatic Stress Disorder
a psychological meaning deeper than the actual dental treat- Posttraumatic stress disorder is characterized as an anxiety
ment. He named this anxiety, based in expectation and dread, disorder. This course will focus on PTSD as a separate entity
from the other anxiety disorders because of the need to raise

54 | rdhmag.com RDH | December 2013

awareness of its impact on human lives and the dental ap- • Agoraphobia
pointment. • Panic attack without agoraphobia
• Agoraphobia without history of panic attack
The Diagnostic and Statistical Manual for Mental Dis- • Specific phobia
orders (DSM-IV-TR) defines posttraumatic stress disorder • Social phobia
(PTSD) as: • Obsessive-compulsive disorder
• Posttraumatic stress disorder
“the development of characteristic symptoms following • Acute stress disorder
exposure to an extreme traumatic stressor involving direct • Generalized anxiety disorder
personal experience of an event that involves actual or threat- • Anxiety disorder due to a medical condition
ened death or serious injury, or other threat to one’s physical • Substance-induced anxiety disorder
integrity; or witnessing an event that involves death, injury, or • Anxiety disorder not otherwise specified1
a threat to the physical integrity of another person, or learning
about unexpected or violent death, serious harm, or threat of All of these disorders present with diverse symptoms, but
death or injury experienced by a family member or close as- they are all rooted in irrational dread and fear. These fears can
sociate.”1 be acquired through classical conditioning, modeling, and
stimulus generalization. Classical conditioning occurs when
Many people believe that PTSD happens only to mem- a person experiences similar events that transpire within a
bers of the military that have been in combat situations. close time proximity, stimulating an anxious or fearful re-
PTSD can affect anyone at any time when faced with serious sponse. Modeling is when someone develops fear based on
or perceived danger. The potential events leading to PTSD observations of others’ phobias. Stimulus generalization is a
other than military related events include: violent personal phenomenonthatoccurswhenaresponsetoonestimuluscan
assault, kidnapping, terrorist attack, torture, incarceration, be provoked by a separate but similar stimulus.4 The patient
natural or manmade disasters, automobile accidents, life- may not be able to conceptualize the onset or etiology of their
threatening illness, murder of a loved one, and peer suicide.10 fear, but it can be very real and powerful.
Other events such as witnessing another person suffer harm
can trigger PTSD. The actual event does not cause trauma, Anxiety disorders may be easy to recognize during the
but rather how the event was experienced, which helps to ex- health history update because many patients with anxiety
plain why some people can overcome unthinkable situations disorderswillbemedicated.Thegeneralcategoriesofmedica-
without PTSD symptoms, while others cannot. Posttrau- tions include: selective serotonin reuptake inhibitors (SSRIs),
matic stress disorder is different from other mental health tricyclic antidepressants, monoamime oxidase inhibitors
diagnoses due to four types of symptoms: reexperiencing, (MAOIs), and beta blockers. Gentle, open-ended questions
avoidance, numbing, and arousal. PTSD breaks down the may facilitate the patient’s disclosure of anxiety medications
entire system, leaving the patient in survival mode and and may assist in identifying a patient with an anxiety disor-
chronically hypervigilant.5 der.

When a dental professional is unaware of a patient’s PTSD At least 40 million American adults suffer from anxiety
diagnosis,heorshemaybesurprisedthatdentaltreatmentcan disorders in a given year. Some anxiety disorders are acute in
trigger any of the referenced four symptoms.“Tooth neurosis” nature, causing situational disturbances. Other more serious
can be a reaction to a specific danger that is either an internal forms of anxiety disorders may grow increasingly worse and
or external threat. A patient with PTSD may respond to a per- last a lifetime, requiring medication and counseling, and are
ceived threat in the dental chair due to a hypervigilant state.3 associated with depression and substance abuse (U.S. Depart-
ment of Health and Human Services, 2009).
Disclosure of PTSD may not be revealed in the health
history for many reasons ranging from the patient not think- Participants with anxiety disorder were surveyed for
ing the information is relevant to simply not realizing he or dentalfearand36.9%oftheparticipantsreportedmoderateto
she suffers from PTSD. severe dental fear.18

Anxiety Disorders Substance Abuse
Eighteen percent of American adults suffer from anxiety Substance abuse may not be widely recognized by dental pro-
disorder, ensuring that dental professionals occasionally treat fessionals as a source of anxiety for the patient.When describ-
patients with significant anxiety disorder that manifests in the ing a patient with substance abuse, some dental professionals
dental chair. may tend to think of a drug-seeking patient, which results in
mistrust and lack of compassion. Though it is important to
Individuals with anxiety disorders are more likely to have recognize when a patient is seeking narcotics, it is also im-
higher levels of dental fear than patients without these disor- portant to be knowledgeable of how a person with substance
ders.18 Anxiety disorders include a wide range of symptoms abuse issues can present as an anxious patient.
and specific diagnoses. The American Psychiatric Association
lists the following anxiety disorders in the DSM-IV-TR:
• Panic attack

RDH | December 2013 rdhmag.com | 55

The Diagnostic and Statistical Manual of Mental Disorders, Figure 1. The psychobiology of sexual abuse: Dysregulation of
Fourth Edition (DSM-IV-TR) defines substance abuse as: biological stress systems to adverse brain development.

A maladaptive pattern of substance use leading to clinical- The neurobiological effects of childhood sexual abuse
ly significant impairment or distress, as manifested by one (or and trauma are very similar to the direct and indirect effects
more) of the following, occurring within a 12-month period: experienced during a dental appointment.The neurobiologi-
1. Recurrent substance use resulting in a failure to fulfill cal effects of PTSD are similar to the fear-based reactions to
dental anxiety, so behaviors may be amplified during a dental
major role obligations at work, school, or home. appointment.
2. Recurrent substance use in situations in which it is physi-
“The essential symptoms of pediatric PTSD and gen-
cally hazardous. eralized anxiety disorder are social worries and associated
3. Recurrent substance-related legal problems. autonomic hyperarousal….Social cues may trigger PTSD
4. Continued substance use despite having persistent or symptoms of hypervigilance.”6 Childhood sexual abuse is a
trauma associated with social situations. Therefore, cues that
recurrent social or interpersonal problems cause by or mayremindpatientsofthetraumaarerelationalandcancome
exacerbated by the effects of the substance.1 without intention (e.g., looking directly at a person, inflection
A patient can easily get caught in the vicious cycle when of voice, etc.).
struggling with substance abuse. For most, avoidance of den-
tal appointments until severe dental issues arise is common Hypotheses for posttraumatic stress disorder in adult
because the clinically significant impairment or distress (as populations indicate that these neurobiological stress re-
described in the DSM-IV-TR) overrides the need for self- sponse systems develop in abnormal ways, which can result in
care. The patient may have significant dental neglect due to permanent, damaging effects.6
thesubstance-relatedmanifestationsofbehaviorandfeelings.
The patient may tend to neglect his or her personal needs The neurobiological effects of PTSD are very similar to
while engaging in risky and impulsive behaviors. When the the direct and indirect effects experienced during a dental
patient finally does seek dental care, he or she is in pain and appointment. If you are treating a patient with PTSD, these
mayfeelhighlyembarrassedbytheneglectandeventsleading biological responses may be exaggerated and could place the
to the emergency appointment.11 Most likely, substance abus- patient at risk.
ing patients will not disclose their addictive behaviors. They
will proceed with anxiety about the treatment and worry that Compromised Immune System
their addiction will be discovered by the dentist or hygienist. Unfavorable experiences during childhood and adolescence
are strongly correlated with several acute health problems
Neuroscience of Dental Fear in adulthood, including poor self-rated health and hygiene.8
The neurobiological response to various stressors can fluctu- Patients with poor oral hygiene that exhibit a lack of self-care
ate from patient to patient. A dental professional’s awareness for health issues are more likely to need a dental appointment.
of the brain processes that react to stimuli can enhance under- These patients are more likely to require additional dental
standing of the patient’s and clinician’s actions.13 work during an appointment or have severe pain that will
force them to seek dental treatment.
The impact of sexual abuse, in addition to other influ-
ences,onbiologicalstresssystemsandthedevelopmentofthe The effects of sexual abuse and trauma on health and im-
brain are complex and challenging to separate.6 There are so- munity merits future research in pediatric populations.
cial, psychological, and cognitive effects that may result after
a person has experienced sexual abuse.6 As seen in Figure 1,
a person could experience anxiety symptoms similar to those
of posttraumatic stress disorder. The secondary symptoms
may include unregulated disturbances on several biological
systems which, as time elapses, could result in malfunction-
ingbraindevelopmentandexaggeratedsymptomsoffearand
anxiety during a dental appointment.

The anatomy of PTSD anxiety or overwhelming stress
is multifaceted. During the amplified traumas of child abuse
incidents, the neuroendocrine axes and several neurotrans-
mitter systems are stimulated. Exposure to stress influences
several systems: the immune system, neurotransmitter sys-
tems, and neuroendocrine systems—which are linked to
regulate reactions to standard stimuli in addition to acute
and prolonged stressors.

56 | rdhmag.com RDH | December 2013

Increased Generalized Fear and Reduced Sociability Hygienists have reported anecdotally being surprised
Primate studies have shown that children reared in an un- when a patient gets extremely emotional after being told they
stable environment developed insecure attachment behavior need a single-surface composite filling. To the hygienist, this
patterns,evidencedbyreducedsocialcompetenceandheight- may be an exaggerated response. To the female patient, the
ened fearful behaviors.19 Individuals who have been raised in fear of having a male dentist close to her with his hands in her
an unstable environment may develop into dental patients mouth is more than she can tolerate. Specifically, the dentist is
that appear to have increased fear of the dentist in addition to referenced here as male because statistics show most abusers
being unsociable. are male, making a male dentist more threatening to a female
patient.24 Willumsen’s research also revealed that 56.3% of
Patient Presentation women in the study suffering from dental fear reported oral
The aforementioned issues should serve as a guide for knowl- penetration during sexual abuse. It was concluded that these
edge and awareness so the clinician can make adjustments past experiences evoked severe anticipatory anxiety prior to
to provide optimum care. The clinician should not use these the dental visit and created a situation of fear of loss of control
recommendations to make a diagnosis or confront the patient and fear of an “intimate” situation with the dentist.
about a possible concern. In fact, a practitioner may spend
years treating a patient who presents with an emotional or It should be noted that not all victims of CSA suffer from
mental health issue without patient disclosure. dental fear. Traumatic experiences do not always result in
psychological issues for the patient. As clinicians it is impor-
If an individual statistically combines the number of tant to be aware of these potential aspects of patient’s experi-
patients that may have experienced sexual abuse (20%), or ences. It is also crucial to remember that CSA is a secret for
an anxiety disorder (18%), the magnitude of these afflictions most victims and if behavior is indicative of childhood sexual
becomes very apparent. In any given day, a dentist or hygien- abuse, the clinician handles it with respect and compassion.
ist could have patients that suffer from dental related anxiety.
Knowledge and awareness are key components to making ap- Posttraumatic Stress Disorder
pointments a success. Patients suffering with PTSD may look very similar to those
who are survivors of CSA. Sexual trauma and PTSD may go
Childhood Sexual Abuse hand in hand because victims of CSA may have PTSD due to
Patients who have dental fear due to a history of CSA may the extent of the trauma.
experience a lack of trust, fear of loss of control, struggle with
factors relating to communication, and have difficulty receiv- Reexperiencing the traumatic event is also called “flash-
ing negative information.24 It may be challenging to remain back.” The individual is haunted with vivid recurring
still or quiet during the appointment. Dental treatment may thoughts, memories, dreams, or nightmares. These experi-
provoke PTSD symptoms, flashbacks, and dissociation. Dis- ences are very real to the individual. They may actually
sociation is “a disruption in the usually integrated functions reexperience the trauma in their minds, transporting them to
of consciousness, memory, identity, or perception of the envi- a place of intense fear and helplessness. Avoidance is the act
ronment”which becomes the patient’s way of coping during of purposefully avoiding thoughts, activities, or conversations
a time of crisis.14 thatremindtheindividualoftheevent.Reducedresponsiveness
or numbing occurs when individuals detach themselves from
Patients who dissociate may present clinically in ways activities or interests that were formerly enjoyed. Some will
that are surprising or frustrating to the clinician. Many pa- experiencesymptomsofdissociationorpsychologicalsepara-
tients have an intense fear of being in a supine position, of the tion. Arousal or increased anxiety occurs because the person
dentist or hygienist touching their lips or putting anything in feels a sense of hyperalertness, is startled easily, has trouble
their mouths, and being in close proximity to the clinician.24 concentrating, and may develop sleep disorders. He or she
Patients may react with panic, tension in the body, crying, may also experience extreme levels of guilt surrounding the
reluctance to open their mouth, a sense of distrust toward event.4
the clinician, and a need to know what is happening. To the
hygienist or dentist, this behavior may seem extreme or un- Information about these symptoms may be ascertained in
necessary during a simple procedure, but to the patient the the health history, but often patients do not share it or they
appointment can be perceived as a matter of life or death in are not aware that something during the dental appointment
that moment. The reaction of the patient sometimes elicits could trigger maladaptive responses.
frustration and a feeling of powerlessness for the clinician as
well as the patient. Despite the clinician’s best attempt to ease Painand sensitivity inthe dentalchair may elicitemotional
the patient, the patient may seem inconsolable.These events and/or physical responses such as increased heart rate, chills,
may also unfold even when a fearful patient is told they need panic, or uncontrollable shaking.10 The procedures during a
a simple procedure. dental appointment can be a trigger for patients due to pain,
lights, sounds, and smells. The loss of connection and highly
arousedstatewhenthepatientexperiencesonethesetriggers

RDH | December 2013 rdhmag.com | 57

puts him or her in survival mode, creating a stressful situa- perceived threat of pain during treatment, but also the antici-
tion for the patient and provider. It is not the dental clinician’s patedembarrassmentwhenotherswitnesstheoralcondition.
responsibility to diagnose PTSD, but when symptoms are With multifaceted levels of potential shame and fear due to
recognized, the hygienist, assistant or dentist can make the neglect and risky behavior, it is crucial to build a trusting rela-
proper adjustments to accommodate the patient. tionship with this patient. It is likely that he or she will require
a great deal of empathy and compassion to return for a non-
Anxiety Disorders emergency visit. A patient actively or formally addicted may
Anxietycanbedescribedasanambiguousawarenessofdanger show similar symptoms to someone with an anxiety disorder.
that increases breathing, body temperature, and muscle ten- Anxiety disorders are often dual diagnosed with substance
sion. It prepares or alerts people to adapt to a“fight or flight” abuse.
situation. For some, the anxiety becomes incapacitating and
prevents the enjoyment of everyday life events.4 Individuals Coping with Dental Anxiety
with anxiety and phobia disorders more frequently reported The link between consequences of trauma and an experience
intensified dental fear than those without such conditions.17 in the dental office may manifest in a variety of ways including
resistance to being placed in the horizontal position, fear of
The relationship between individuals with phobias and a having objects placed over the face, sudden outbursts of cry-
tendency to attach exaggerated meaning to their experiences ing without apparent reason, difficulty opening wide, severe
mayleadtotheexpressionofinappropriatebehaviorduring a gagging, and an involuntary turning of the head away from
dental visit.9 The perceived threat is intense and he or she is in the clinician as he or she approaches the mouth.13
a vulnerable position with loss of control. Similar to survivors
of CSA and PTSD, a patient with an anxiety disorder may Regrettably, dentists and hygienists can exacerbate the
become extremely overwhelmed by being in the supine posi- dental experience due to lack of knowledge and/or com-
tion. The dental experience can be fearful to someone without prehension of the processes that are the root of the patient’s
an anxiety disorder due to the unknown and anticipated pain actions. Patients who have been victims of childhood sexual
and discomfort. abuse or assault may have flashbacks when in the dental chair
due to the restrictive environment of a confined office or chair.
Behaviors consistent with dental fear due to an anxiety The most harmful reaction is the frustrated dental profes-
disorder can present as a patient who is suddenly tearful, cries sional who attempts to take control of the situation or inadver-
or yells out when minimal dental work is being performed, tentlymakesinsensitivecomments.Demeaningthepatientor
becomes aloof or angry once they are seated in the chair, has dealing with the situation authoritatively may deteriorate the
somatic symptoms such as shaking or sweating, tenses up, patient’s state of mind and may reactivate the traumatic event.
and/or has difficulty keeping his or her mouth open. The pa-
tient may even move his or her head abruptly and erratically Effects on the Dental Professional
during a procedure, creating a dangerous situation. These The concept of emotional labor is defined as “the practice of
same behaviors may also be present in a survivor of CSA. controlling one’s emotions on the job, [which] may be inte-
gral to performing the job, but may have unintended conse-
Since it is not the clinician’s responsibility to diagnose the quences for the practitioner.”20 Emotional labor becomes
psychological etiology, it is important that he or she proceeds particularly draining for the professionals who are invested
with awareness and compassion. Only by establishing trust in the patient’s well-being. Thinking about patients after
can the patient start a journey toward decreasing intense den- they have left the dental office has been strongly linked with
tal fear. interpersonal, psychological, and vocational stress. In addi-
tion, dental professionals carry the burden of frequently being
Substance Abuse required to inflict discomfort in order to appropriately execute
The patient suffering from any type of substance abuse dental treatments. Emotional labor has been correlated with
will likely avoid dental treatment as long as possible due to individual and organizational concerns including employee
self-neglect and fear their addiction will be discovered. This attrition, diminished performance at work, and burnout.20
patient is likely to seek care after a dental emergency occurs.
There is a high risk of periodontitis, caries, missing teeth, and If a patient presents with symptoms that are associated
other oraldiseaseamongpersonswith substanceaddiction.14 with childhood sexual abuse, trauma, anxiety, or substance
Also, there may be an increased risk for problems with pain abuse, a dental professional is more likely to experience high
management during dental procedures as the anesthetic may levels of emotional labor. It is important for dentists and
be perceived as ineffective.16 hygienists to protect themselves from these vocational and
psychological strains. Some techniques utilized to alleviate
Based on the elevated incidence of disease and decreased emotional labor include deep acting and surface acting. Deep
effectiveness of oral anesthesia, a patient actively or formally acting is less psychologically exhausting than surface acting
addicted to a substance may suffer from severe anxiety about
dental treatment. The anxiety could stem not only from the

58 | rdhmag.com RDH | December 2013

for dental professionals. Deep acting denotes altering an in- tion. As such, some dental patients in recovery may prefer to
dividual’s perception of an experience or distracting attention abstain from using sedation, even during particularly painful
and refocusing on positive cognitions to actually augment the procedures.
underlying emotions.20 For example, a dentist who is irritated
by a patient telling him or her to stop every few seconds could When sedation is necessary it is mandatory for a relative
understand the situation from the patient’s point of view to or friend to accompany the patient. Ask about any previous
reduce the feelings of irritation. In addition, operating from experiences of using sedation and if there are any ways to
a framework of empathy is less taxing on the dental profes- provide more comfort for the patient. In addition, commu-
sionalandevenbuildsrapportwiththepatient.Surfaceacting, nicating with empathy and compassion can relieve fear and
however, refers to changing only the visible representation anxiety.
of a reaction to an experience without actually modifying
thoughts. For example, a dental hygienist could pretend to be Building the relationship. Patients frequently report
excessively amiable or completely repress feelings by smiling that a compassionate, empathetic dental professional who
through a painful procedure. Surface acting was linked to feel- displays patience and active listening was the turning point in
ing numb or drained emotionally. Another aspect to keep in reduction of dental fear.21 Empathy has been defined as the
mind is that the dental profession is well-respected, appreci- “process by which observers attempt to project themselves
ated, and gives back to the community; this conceptualization into an observed person or object.”12 Generally, in psycho-
can buffer psychological stressors.20 therapy, the treatment outcome of the client depends more
heavily on the perceived empathy of the professional, rather
Techniques to Integrate than the professional’s actual skill level, techniques, or educa-
Being a well-informed, aware dental professional is the first tion. The relationship between two individuals is much more
step to ensure optimal care for patients. Moreover, some ad- powerful than the intervention. The most beneficial action a
ditional procedures may be employed that have implications dental professional can take is to invest in building rapport
for training, educating, and coping for dental professionals with a patient, regardless if he or she is exhibiting symptoms
and practices. of past abuse, trauma, or anxiety.

Informing patients. The dental professional may in- Effective Communication
form all patients (regardless of whether or not they display the How can dental professionals begin to build the relationship
symptoms of fear, anxiety, etc.) of practices that encourage with fearful patients and communicate empathetically and
compassion and open communication in the dental appoint- effectively? In order to facilitate empathy, a person must be
ment. If space allows, let patients know that they can bring aware of one’s own emotions and start from a place of deep
a family member or friend to dental appointments. Notify acting and understanding, rather than judgment. The ques-
patients that they can request extra time for appointments if tion, “What are my expectations of others; my coworkers,
they anticipate anxiety. Some fearful patients will naturally my boss, my patients” and in turn “How does that reflect my
take more time so it is better to be informed in advance to ac- expectation of self?”The heart of compassion is really accep-
commodate busy schedules. Ask if the patient would like to tance.7 When people learn to accept themselves and others,
operatethesuctionwhenthespaceandprocedureallows.This compassion and empathy naturally follow. It is important to
may help the patient regain a sense of control. If symptoms of be mindful of how the dental professional would like to act,
trauma history appear to be present, inform the patient that regardless of how a patient is acting or reacting. In order to re-
the dentist can offer clear explanations before and during a duce emotional labor and cultivate a healthy, happy work en-
procedure. Offer patients the option to bring headphones, or vironment, the dental professional must model and advocate
play soothing music throughout the dental office. Give the effective, empathetic exchanges.This kind of communication
patient the option to provide a nonverbal gesture to signify is conveyed through understanding, listening, reflecting feel-
when anxiety is increased and/or to cease the procedure. ing, and asking open-ended questions.

Using sedation. Sedation can be a very beneficial tool for Understanding. Before approaching a potentially fear-
some patients with anxiety. Dr. Carmen Santos21 indicated ful patient, it is important to pause and evaluate the level of
that most sexual abuse survivors would rather not be sedated. self-awareness. Greater understanding of self can be devel-
For individuals who have experienced trauma, the utilization oped by asking questions including: “What am I feeling?”
ofsedativescouldincreasefeelingsofhelplessnessandloss of or “What are the thoughts I am having? Why?” and even
control at a time when the patient is already in a compromised more importantly when interacting with patients, “How am
position. I approaching this conversation?” If dental professionals are
cognizant of these emotions and thoughts prior to communi-
For patients with a substance abuse history, the use of se- cation, they are empowered to think about what is truly the
dation should be carefully considered. For some patients, the desired outcome and take appropriate action.
use of sedation could trigger feelings of being high or of addic-

RDH | December 2013 rdhmag.com | 59

Actively listening. Certain behaviors immediately periences. When clinicians are aware of the impact that a pa-
indicate active listening to the dental patient. These include tient’s mental health can have on the dental appointment, are
providingfocused,intermittenteyecontact;noddingthehead cognizant of the symptomology of trauma, and are informed
in affirmation; maintaining soft body language; and having a about how to proceed with empathy and compassion, the pa-
warm, engaged expression. Before, during, and after contact tient may be more likely to consistently attend appointments
with dental patients, ask questions such as, “What is the and receive optimal dental care.
patient feeling?” or “What are the thoughts the patient may
be having?” and “Why might the patient be acting this way?” References
Helping patients to become empowered, especially those
who experience dental anxiety, requires listening to them, 1. American Psychiatric Association (2005). Diagnostical and
thoughtfully considering what is being said, and expressing stastical manual of mental disorders: DSM-IV-TR (4 ed.).
appropriate, consistent nonverbal indicators. Washington, DC: Jaypee Brothers.

Other nonverbal indicators can be expressed by sitting the 2. Armfield, J. M. (2012). What goes around comes around:
patient up, removing the mask and gloves. Extremely fearful Revisiting the hypothesized vicious cycle of dental fear and
patients feel powerless when lying back in the chair. An at- avoidance. Community Dentistry and Oral Epidemiology,
tempt to be empathetic while maintaining them in a supine or 41, 279-287.
semisupine position may be ineffective.
3. Capps, D., & Carlin, N. (2011). Sublimation and
Reflecting feelings. The ability to reflect what a fearful symbolization: the case of dental anxiety and the symbolic
patient is expressing back to him or her takes some practice, meaning of teeth. Pastoral Psychology, 60, 773-789.
but is a key component to communicating effectively. Mirror-
ing a patient’s emotions helps build the relationship, acknowl- 4. Comer, R. J. (2010). Abnormal psychology (7 ed.). New
edges and validates his or her feelings without minimizing York, NY: Worth Publishers.
the effect. It also conveys understanding and empathy, and
assists the patient in the expression of additional feelings. For 5. Curran, L. A. (2010). Trauma competency: A clinician’s
example, a patient may ask,“Are we done yet? Are we almost guide. Eau Claire, Wisconsin: PESI, LLC.
finished? How long is this going to take?”Rather than simply
replying with an objective answer, consider responses such as 6. De Bellis, M. D., Spratt, E.G., & Hooper, S. R. (2011).
“You sound a bit nervous about how long this procedure may Neurodevelopmental biology associated with childhood
take.” Reflecting the feeling of “nervous” can allow for pa- sexualabuse. JournalofChildSexualAbuse,20(5),548-587.
tients to feel heard, rather than rushed. This will further build doi:http://dx.doi.org/ 10.1080/10538712.2011.607753.
the relationship with the fearful patient, hopefully resulting in
reduced fear and more frequent visits. 7. Brown, B. (2010). The gifts of imperfection: Letting go of
who you think you’re supposed to be and embrace who you
Reflection of feeling is the key component in helping the are. Cente City, MN: Hazelden.
patient feel understood and heard. Many times, patients feel
minimized or dismissed when they are told “it will be okay” 8. Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D.
or“it is just a simple procedure.”If the patient has a traumatic F., Spitz, A. M., Edwards, V., et al. (1998). Relationship of
past that stimulates memories in the dental chair, the feeling childhoodabuseandhouseholddysfunctiontomanyofthe
of being misunderstood can be amplified. leading causes of death in adults. The Adverse Childhood
Experiences (ACE) Study. American Journal of Preventive
Reflecting feelings, even those with a negative connotation Medicine, 14, 245–258.
such as fear, sadness, or frustration, is one of the most effective
waystobuildrapportwithpatients.Forexample,whenpatients 9. Forbes, M.D.L., Boyle, C. A., & Newton, T. (2011).
show the symptoms of a traumatic past, they are more likely to Acceptability of behaviour therapy for dental phobia.
feelunderstoodwhenthecliniciancantrytoreflectanemotion. Community Dentistry and Oral Epidemiology, 40, 1-7.
The hygienist may say,“It seems like you are afraid today. How
can I best support you during this appointment?”This opens 10. Greco, L. J., & Garcia, W. M. (2008, July). Post-traumatic
the door for further communication and begins to alleviate stress disorder: Treatment with confidence, competence,
anxiety for both the patient and hygienist.When a patient with and compassoin. Access, 22(6), 30-33.
dental fear is not properly attended to, he or she may feel alone
and withdraw. Reflection of feeling or joining with the patient is 11. Gunn, R. L., Finn, P. R., Endres, M. J., Gerst, K. R., &
the first step for healing and diminishing the fear. Spinola, S. (2013). Dimensions of disinhibited personality
and their relation with alcohol use and problems. Addictive
Conclusion Behaviors, 38, 2352-2360.
Many factors should be considered when easing a patient’s
concerns, especially those who suffer from past traumatic ex- 12. Hassenstab, J., Dziobek, I., Rogers, K., Wolf, O. T., & Convit,
A. (2007). Knowing what others know, feeling what others
feel: A controlled study of empathy in psychotherapists.
The Journal of Nervous and Mental Disease, 195(4), 277-
281.

13. Kamin, V. (2006). Fear, stress, and the well dental office.
Northwest Dentistry, 85(2), 10.

14. Khocht, A., Schleifer, S. J., Janal, M. N., & Keller, S. (2009).
Dental care and oral disease in alcohol-dependent persons.

60 | rdhmag.com RDH | December 2013

Journal of Substance Abuse Treament, 27, 214-218. Fears Web site: http://www.dentalfear.com/santos.asp.
15. Leeners, B., Stiller, R., Block, E., Gorres, G., Inthurn, B., 22. Vermetten, E., & Bremner, J. D. (2002). Circuits and

& Rath, W. (2007). Consequences of childhood sexual systems in stress II applications to neurobiology and
abuse experiences on dental care [Abstract]. Journal of treatmentinposttraumaticstressdisorder.Depressionand
Psychosomatic Research, 62, 581-588. Anxiety, 16, 14–38.
16. Metsch, L. R., Crandall, L., Wohler-Torres, B., Miles, C. 23. U.S. Department of Health and Human Services (2009).
C., Chitwood, D. D., & McCoy, C. B. (2002). Met and Anxiety disorders: National Institute of Mental Health.
unmetneedfordentalservicesamoungactivedrugusersin 24. Willumsen, T. (2004). The impact of childhood sexual
Miami, Florida. The Journal of Behavioral Health Services abuse on dental fear. Community Dentistry and Oral
and Researach, 29(2), 176-188. Epidemiology, 32, 73-79.
17. Newton, T., Asimakopoulou, K., Daly, B., Scambler, S., &
Scott, S. (2012). The management of dental anxiety: Time Author Profiles
for a sense of proportion? British Dental Journal, 213, 271- Kandice Swarthout-Roan, RDH, BS, has practiced clinical
274. dental hygiene for 16 years and is part-time faculty in the
18. Pohjola, V., Mattila, A. K., Joukamaa, M., & Satu, L. (2011). dental hygiene program at Collin College, McKinney, Texas.
Anxiety and depressive disorders and dental fear among
adults in Finland. European Journal of Oral Sciences, 119, Priya Singhvi, MS, LPC-I, LMFT-A, has been working in
55-60. the field of psychology and education for over 11 years. Priya
19. Rosenblum, L. A., & Andrews, M. W. (1994). Influences currently serves as P.A.L. sponsor, wellness educator, and
of environmental demand on maternal behavior and infant full-time counselor at a private school in Addison, Texas.
development. Acta Paediatrica, 397(supplement), 57–63.
20. Sanders, M., & Turcotte, C. (2010). Occupational stress in Author Disclosure
dental hygienists. Work, 35(4), 455-465. doi:http://dx.doi. Kandice Swarthout-Roan and Priya Singhvi have no
org/ 10.3233/WOR-2010-0982 commercial ties with the sponsors or providers of the
21. Santos, C. (Interviewee). Sexual Abuse in Childhood and unrestricted educational grant for this course.
Dental Fear [Interview transcript]. Retrieved from Dental

Notes

RDH | December 2013 rdhmag.com | 61

Online Completion

Use this page to review the questions and answers. Return to www.ineedce.com and sign in. If you have not previously purchased the program select it from the “Online Courses” listing and complete the
online purchase. Once purchased the exam will be added to your Archives page where a Take Exam link will be provided. Click on the “Take Exam” link, complete all the program questions and submit your
answers. An immediate grade report will be provided and upon receiving a passing grade your “Verification Form” will be provided immediately for viewing and/or printing. Verification Forms can be viewed
and/or printed anytime in the future by returning to the site, sign in and return to your Archives Page.

Questions

1. The “vicious cycle” is: 12. Unfortunately, dental professionals have a. Removing every piece of calculus
a. The progression of periodontal disease exacerbated the dental experience for the b. That the hygienist use impeccable advanced
b. Avoiding the dentist due to intense fear which leads to fearful patient by:
an increased need for dental work a. Responding with frustration instrumentation
c. Bacteria formation due to poor oral hygiene b. Attempting to take control of the situation c. Trusting the clinician and feeling safe during the
d. Over-exaggerate behaviors during a dental visit c. Assuming they know why the patient is reacting
d. All of the above appointment
2. After a person has experienced sexual d. Receiving thorough OHI
abuse, the outcomes may affect a person: 13. Patients with dental fear due to CSA may 22. Dental clinicians sometimes mistake
a. Psychologically display which of the following behaviors dental fear due to an anxiety disorder as:
b. Socially during a dental visit: a. The patient’s unwillingness to cooperate
c. Cognitively a. Crying b. Shame and embarrassment
d. All of the above b. Amplifiedresponseafterlearningtheyneeddentalwork c. Fear due to past experiences
c. Fear of leaning back in the chair d. PTSD
3. The core of dental anxiety is rooted in: d. All of the above 23. Anticipatory anxiety refers to:
a. Expectation and dread a. Reaction to actual dental pain
b. Fear of the“drill” 14. Changing perception of an experience or b. Anger about pain experienced after a dental appointment
c. Childhood memories of the dentist redirecting attention to positive thoughts c. Perceived threat about the possibility of future pain or
d. Fear of an aggressive hygienist is called:
a. Emotional labor discomfort
4. When the symptomatic nervous system b. Deep acting d. The reduction of anxiety with the use of nitrous oxide
(SNS) is stimulated by acute anxiety or c. Surface acting 24. In a study on dental fear, what percentage
fear, the body responds with the following d. Cognitive impairment of those surveyed reported moderate to
reaction: severe dental anxiety:
a. Rest and digest 15. The most objective way for a clinician to a. 25%
b. Parasympathetic stimulation detect an anxiety disorder in a patient is: b. 36.9%
c. Fight or flight a. The patient lists anxiety medications on health history c. 12.2%
d. None of the above b. The patient seems nervous d. 8.5%
c. The patient states that he or she is nervous 25. A person who suffers from substance
5. What percentage of women seeking dental d. The patient is sweating abuse may avoid the dentist until he or she
care are survivors of childhood sexual is in pain because:
abuse? 16. In regard to dental fear, it is the clinician’s a. Their insurance is running out
a. 80% responsibility to: b. Guilt and shame about their addiction and condition
b. 34% a. Diagnose the patient with a mental disorder
c. 20% b. Ask the patient if he or she has an anxiety disorder of teeth
d. 8% c. Be aware a of patient’s behavior and respond with c. They have a Groupon
compassion and empathy d. They decided to improve the health and appearance of
6. Why is it important for dental professionals d. Refer the patient to another dentist or hygienist
to be aware of the neurobiological effects of their teeth
childhood sexual abuse and trauma? 17. Lack of trust, fear of loss of control, and 26. Emotional labor correlates to:
a. So the dental professional can accurately diagnose the struggles with communication may be
patient factors for a patient who: a. Interpersonal, psychological, and vocational stress
b. Becausetheeffectsaresimilartotheeffectsexperienced a. Has a toothache b. The need for midday naps
during a dental appointment b. Has dental fear due to childhood sexual abuse or other c. Crying in the darkroom
c. So the hygienist can ask the patient directly if she or he trauma d. Clinicians frequently changing jobs
has experienced trauma or sexual abuse c. Is new to the practice 27. Changing only the visible representation
d. All of the above d. Has not been to the dentist in many years of a reaction to an experience without
actually modifying thoughts is:
7. All of the following are symptoms of 18. A patient that struggles with self- a. Emotional labor
posttraumatic stress disorder except: regulation of behaviors and neglects b. Deep acting
a. Flashbacks self-care may be suffering from: c. Surface acting
b. Avoiding situations a. Anxiety disorder d. Artificial empathy
c. Numbing b. Trauma from abuse 28. An effective way to empower a fearful
d. Hearing voices c. Substance abuse patient during an appointment is to:
d. PTSD a. Ask them to fill out paperwork before they get to your
8. A patient who seems isolated and
unsociable during a dental appointment: 19. A dental practice can inform patients of office
a. Usually requires a root canal practices that encourage compassion and b. Help them feel as if they have control over the appoint-
b. Can be best described as an extrovert tolerance, including:
c. May have been raised in an unstable environment a. Informing patients that appointments only have a ment
d. Is likely experiencing psychosis 30-minute time slot, which should go by quickly c. Inform them that you are very busy and this will be a
b. Encouraging patients to come alone so that less people
9. posttraumatic stress disorder can affect: are in the room short appointment
a. Combat soldiers c. Offering patients to bring music to the dental appoint- d. Refer them to a clinician that has experience working
b. Someone who has witnessed a murder ment
c. Someone who has experienced a natural disaster d. Letting the patient know that the dental professional with nervous patients
d. All of the above will not stop until the procedure is completed 29. Patients with substance abuse history may

10. The brain structure that regulates fear, 20. The use of sedation should: avoid sedation because:
anxiety, and social inhibition is the: a. Always be utilized for patients with previous childhood a. The sedatives may trigger familiar feelings of being high
a. Amygdala sexual abuse because it will put them at ease b. They may have flashbacks of previous trauma
b. Cortex b. Beencouragedforpastsubstanceabuseusersbecauseit c. They do not have anyone to drive them home
c. Corpus callosum gives them a familiar high d. Dentists usually don’t recommend sedation for
d. White matter c. Be used if any patient has previously had sedation
d. Be discussed with the patient and offered in conjunction substance abuse patients
11. Tooth neurosis is: with support 30. The process by which observers attempt
a. Fear of teeth
b. Fear of anything being done to the teeth 21. For a survivor of trauma with high dental to project themselves into an observed
c. Brushing and flossing excessively anxiety, the most important part of a dental person or object is called:
d. Nightmares about losing teeth appointment is: a. Perceived reality
b. Empathy
c. Emotional osmosis
d. Telepathy

62 | rdhmag.com RDH | December 2013

ANSWER SHEET

The Roots of Dental Fears

Name: Title: Specialty:

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Telephone: Home ( ) Office ( )

Lic. Renewal Date: AGD Member ID:

Requirements for successful completion of the course and to obtain dental continuing education credits: 1) Read the entire course. 2) Complete all information
above. 3) Complete answer sheets in either pen or pencil. 4) Mark only one answer for each question. 5) A score of 70% on this test will earn you 2 CE credits. 6)
Complete the Course Evaluation below. 7) Make check payable to PennWell Corp. For Questions Call 216.398.7822

Educational Objectives If not taking online, mail completed answer sheet to

1. Describe the reactions of patients who have dental fear due to past non-dental related trauma. Academy of Dental Therapeutics and Stomatology,
2. Explain biological and physiological effects of trauma in the human brain.
3. Associate psychological symptoms of trauma with dental anxiety. A Division of PennWell Corp.
4. Identify practical applications for dental professionals to alleviate dental fear
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FEAR1213RDH