Dental phobia and fear of the dentist

The Problem:

“I’m absolutely terrified of the the drill – even just thinking about that sound sends shivers down my spine! “

Some people have had painful experiences with the dental “drill” because they weren’t properly numbed (or perhaps not numbed at all). Not surprisingly, if this has happened you are likely to feel terrified of the “drill” (or “handpiece” in layman’s speak). Thinking of the sound alone is likely to produce intense anxiety.

There should be no pain once the tooth is properly numb – only vibration and light pressure.

Other people just don’t like the sound of the handpiece, or the very idea of it.

There are many ways of dealing with this fear, and you should choose the tip(s) which you feel will work best for you. Some are based on distraction, others are based on exposure (of course, you can use a mixture of both).

Distraction
Blending out the sounds:

•Bringing an mp3 or CD player and playing your favourite music is a tip frequently mentioned on our forum. Some people recommend turning up the volume really high and choosing fast tunes without lengthy gaps in between the tracks, to blend out any sounds.
•Others prefer more soothing music, relaxation tracks, or tracks with nature sounds such as waves or tropical thunderstorms.
•It is helpful to have the “Pause” button handy in case you want to communicate with your dentist.
•Choose earphones that don’t pop out easily.
•Some dentists provide CD or mp3 players, but most don’t. The reason is hygiene regulations (they would have to be cleaned in between patients). But all dentists will let you bring your own mp3 or CD player.

Getting comfortable:

•Some people much prefer to keep their eyes closed during treatment.
•You can bring a blanket to make you feel more comfortable and secure. Some people also like holding their favourite soft toy.
•Make a conscious effort to relax – it is impossible to be anxious and relaxed at the same time. Have a stop signal agreed with your dentist in case you need to take a break, or in case you need more numbing. There are various relaxation techniques, such as concentrating on your breathing, deliberately relaxing the muscles which you find tense up when you’re anxious (for example, your shoulder muscles), and self-hypnosis.
•Do not hesitate to ask for anaesthetic top-up if you don’t feel completely numb! Many people think that they can only have what they are originally given, but it’s easy to give a top-up.
•If you are worried about not being numb, ask your dentist to check that you are numb (for example, with the explorer) before using the handpiece.
•Stress balls are malleable balls which can be squeezed with one or both hands to reduce stress and tension. They are available from places like toy shops, drug stores, and sports shops.

Watching TV or DVDs:
A few dentists provide entertainment systems such as TV screens (sometimes with a selection of DVDs – you can also bring your own) or even virtual-reality goggles.

Exposure
Getting familiar with the equipment:
It can be helpful to be able to look at, touch and hear the handpiece before it is used. Our expectations about the size and noise of the handpiece are often exaggerated, and getting familiar with the handpiece can help put things into perspective.

Ask your dentist if they can show you the handpiece and ask if you can touch it. If this sounds too scary, you can ask for a prophy handpiece (used for cleanings) with a rubber prophy cup (see photo) first. Ask your dentist to show you the instrument like they would show it to a child patient. A lot of dentists are familiar with techniques to make children feel more confident and comfortable about treatment.

Seeing what is happening:
Sometimes it helps to see what is happening. Our imagination can often run wild. Actually seeing what is happening, with the help of a mirror, can put things into perspective.

Preparing for the sounds and sights:

•Some people find it useful to desensitize themselves to the sounds they may encounter. For example, using an electric toothbrush can help. You can play around with the way sound is amplified by brushing your teeth while having a shower, and letting the water run over your ears. This may be very anxiety-provoking at first, so only try it if you think you can handle it.
•Depending on the nature and extent of your phobia, you may find it helpful to watch a video where someone is having a filling. You can watch this repeatedly and observe if your anxiety levels drop over time. Please do not watch this if you feel it might increase your fears. Although the following video might not be the best (I’ve been told that the handpiece sounds louder than it does in reality), it is quite sensitively done. Click here for the video which shows a young woman with learning difficulties going to the dentist. Remember, there is a stop button if you decide you don’t feel up to it!

Other Factors
Dental Equipment:
•Although handpieces have generally become a lot quieter (you may be pleasantly surprised if you haven’t been to a dentist for a long time), some handpieces are even more quiet than others. If the sound level is a major concern to you, some dentists use electric handpieces rather than air-driven ones. Electric handpieces are the quietest type.
•While some dentists advertise air abrasion (a sort of mini-sandblaster) as an alternative to the handpiece, the reality is that air abrasion cannot be used in all situations. For example, it isn’t good when larger fillings are needed.
•Laser dentistry is still very rare due to the very high cost of the equipment. Again, lasers are not suitable for all situations.

Behavioral dentistry is an interdisciplinary science. The objective of the science is to develop in a dental practitioner an understanding of the interpersonal social force that influences a patient’s behavior. The foundation of practicing dentistry on children is the ability to guide them through their dental experiences. This ability is a prerequisite to provide their immediate dental needs. The concept of treating the patient and not just the tooth should be the operative with all patients, but is essential with a child patient.

One major aspect of child management in the dental chair is managing dental anxiety, a worldwide problem and universal barrier to oral health care. The dentist treating a child patient almost always assesses one aspect of behavior – cooperativeness. Cooperative behavior is the key to render treatment. According to Wright (1975), children can be generally classified in one of the three ways: cooperative, lacking cooperative ability or potentially cooperative. There are many behavior-rating scales available to assess and evaluate the behavior of a child on each dental visit. The child’s behavior on every dental visit depends on variables like age, parental behavior, parental anxiety, past medical / dental history, the awareness of their dental problem, type of dental procedure, the behavior management, and the procedural techniques followed by the dentist. [1]

According to Folayan and Idehen, behavior management strategies range from informal and common sense techniques to formal relaxation techniques. [2] Formal relaxations vary from pre-appointment preparations to modeling procedures during the dental visit. Tell-show-do (TSD) introduced by Addelston in 1959, remains the corner stone of behavior management techniques followed by dentists. Machen and Johnson showed that the time spent per child has diminished when compared with the period before the approach was introduced. [3] Distraction, physical contact in the form of patting and stroking also tend to be effective in reducing anxiety that may accompany dental care. [4] A technique found to be effective in preventing dental anxiety developing in a child, who has a potential to do so, is the use of positive reinforcement. Here, the child is praised and given gifts when he shows acts of cooperation. The desensitization technique is effective for children who have developed dental anxiety. It entails gradual exposure of the child to dental treatments for short periods of time starting from noninvasive procedures. Pinkham JR has shown that it is a time consuming technique, but very rewarding as the child eventually becomes comfortable with the dental procedures. [5] These established psychological strategies have been found to be more effective because the strategies enhance trust, feelings of control, and the development of coping skills in both the child and professionals. This retrospective study was planned with the following aims and objectives:

1.To assess the behavior pattern of children during their dental visits
2.To evaluate the behavior management techniques used in managing the children during their dental visits
3.Age-wise and sex-wise comparisons of data collected

Materials and Methods

Case records of 247 children (144 boys and 103 girls) who had had a minimum of three visits to the Department of Pedodontics, Meenakshi Ammal Dental College, Chennai, India, were used to carry out this retrospective study. All the children were examined and treated by the same pediatric dentist. Wright’s modification of Frankl’s behavior rating scale was used to assess the behavior of all the children in each of their visits to the dental office. Behavior was recorded in their case records in every visit by the same examiner. Case records were categorized into four groups based on the ages of the children [Table 1]: Group I (45) included 22 boys and 23 girls in the age range of 3-6 years; Group II (115) 66 boys and 49 girls, between 6 and 9 years of age; Group III (72) included 48 boys and 24 girls in the age range of 9-12 years; and Group IV (15) eight boys and seven girls, above 12 years of age. Behavior management techniques used by the dentist in managing the children during the three visits were also evaluated. They were categorized as Tell-show-do (TSD), Voice control (VC), Hand over mouth exercise (HOME), and others (presence of mother, reinforcements, retraining, modeling). The type of behavior management technique used on each visit was noted in the case records. Any improvement or deterioration of behavior during the same visit was also recorded. Comparison of the proportion of behavior and behavior management techniques between different age groups during the three visits, and comparison of the proportion of behavior and behavior management techniques between the males and females of each group during the three visits were done. The proportions were compared by either the Chi-Square test, Chi-Square test with Yates continuity correction or Fisher’s exact test (two-tailed), appropriately. In the present study, p < 0.05 was considered as the level of significance.

Results and Discussion

On the first dental visit, 10 children exhibited Frankl 1 (Wright’s –) behavior. Twenty-three children showed Frankl 2 (Wright’s -) behavior. Frankl 3 (Wright’s +) was exhibited by 161 children. Fifty-three children showed Frankl 4 (Wright’s ++) behavior [Figure 1]. Statistically significant differences in Frankl 1 (–) and Frankl 2 (-) categories, between different age groups, were seen (p-value 0.003 and 0.02, respectively). No statistically significant differences between the male and female groups were seen in any of the age groups.

On the second dental visit, five children exhibited Frankl 1 (–) behavior. Eighteen children showed Frankl 2 (-) behavior. Frankl 3 (+) behavior was exhibited by 159 children. Sixty-five children showed Frankl 4 (++) behavior. Statistically a significant difference in the Frankl 1 (–) category between the different age groups was seen (p-value 0.004). No statistically significant difference between the male and female groups was seen in any of the age groups.

On the third dental visit, four children exhibited Frankl 1 (–) behavior. Eleven children showed Frankl 2 (-) behavior. Frankl 3 (+) behavior was exhibited by 160 children. Seventy-two children showed Frankl 4 (++) behavior. Statistically significant differences in the Frankl 1 (–) and Frankl 4 (++) categories, between the different age groups, were seen (p-value 0.02). No statistically significant difference between the male and female groups was seen in any of the age groups.

The overall assessment of behavioral pattern during the three dental visits did not show any statistically significant difference. However, there had been a definite improvement in the behavior of children on their subsequent visits as shown in [Figure 2]. Frankl 3 (+) was the most common behavior observed in the children, in this study. Almost 65% of the total children population showed Frankl 3 behavior on all the three dental visits.

On the first dental visit, Tell-show-do was used in all the 247 children. Voice control, Hand over mouth exercise and other techniques were used on 20, 1, and 14 children, respectively [Figure 3]. Statistically significant differences in using voice control and other techniques category between age groups were seen (p-value 0.03 and 0.001, respectively). No statistically significant difference between the male and female groups was seen in any of the age groups.

On the second dental visit, Tell-show-do was used in all the 247 children. Voice control, Hand over mouth exercise and other techniques were used on 16, 0, and 11 children, respectively. Statistically significant differences in using other techniques between age groups were seen (p value 0.049). No statistically significant difference between the male and female groups was seen in any of the age groups.

On the third dental visit, Tell-show-do was again used in all the 247 children examined. Voice control, Hand over mouth exercise, and other techniques were used on 14, 1, and 9 children, respectively. Statistically significant differences in using voice control between age groups were seen (p-value 0.03). No statistically significant difference between the male and female groups was seen in any of the age groups.

Overall assessment of behavior management techniques during the three dental visits did not show statistically significant differences. However, [Figure 4] clearly proves that there is a gradual reduction in the use of more aversive techniques like Voice control and Hand over mouth exercise on the subsequent visits. Tell-show-do was observed to be the most common behavior management technique used, and this technique was used routinely in all the children visiting the department.

In this study children showed improvement in their behavior on subsequent visits. Howitt and Stricker, Venham and Quatrocelli, and Venham and Cipes, have shown that the behavior of children improves in subsequent dental visits, [6],[7],[8] and their results are in accordance with this study. Koenigsberg and Johnson have shown that behavior cannot be predicted from the preceding appointment. [9] Venham L has shown that the younger group of children became more apprehensive on their subsequent visits. [10] However, both the studies quoted above have considered the effect of treatment procedures on the behavior of children. Folayan and Ufomata have shown that there is no association between age and gender with behavior of the child, [11] which is again in accordance with the present study.

Allen and Stanley demonstrated that traditional behavior management techniques like Tell-show-do, restraints, Hand over mouth exercise, and sedation were better than the newer ones like modeling and contingency management. [12] Carr and Wilson showed that the Southeastern US dentists used less aversive techniques and there was a marked reduction in the use of the Hand over mouth exercise. [13] Peretz and Ram showed that the Israel dentists used Tell-show-do and material reinforcement more than any other behavior management strategies. [14] Adair et al , emphasized that the AAPD members used communicative skills more often, with the exception of the Hand over mouth exercise. [15] All the above-mentioned reports have been in favor of the results of this study and they emphasize the significance of Tell-show-do in the field of behavioral pediatric dentistry.

Summary and Conclusions

The findings and the results of this study can be summarized as follows

1.Better behavioral response was seen on subsequent visits
2.Frankl 3 (+) was the most common behavioral pattern seen
3.Tell-show-do was the most common management technique used
4.Reduction in the use of more aversive techniques on subsequent visits
5.There was no significant difference between boys and girls in their behavior pattern and the management techniques used

Behavior assessment helps us to plan appointments and provide quality oral health care to children. Proper use of management techniques improves behavior on subsequent visits, making things easy for the child patient and the pediatric dentist. Assessment and evaluation helps us to reinforce our beliefs in our own techniques.