The following vignette is illustrative:

Mrs. K is a 28-year-old married woman. She is happily married and has a son aged 8. She attended the dentist because she had an impacted wisdom tooth that was partially erupted and had been repeatedly infected and was now causing great pain. She described herself as ‘phobic of the needle’ and could not bear the thought of any type of injection. She spoke freely and divulged that although she enjoyed hospital programmes she could not look when a patient would be given an injection as it felt as if she was having it herself. Although not concerned about the pain of an injection she was always worried that the needle would break. Mrs. K talked about her son’s illness and how she had become distressed when she saw him ‘having the needle’. She feared that the needle would break in his body.

In the example of Mrs. K a false connection had been made between her son’s injection and her ‘needle fears’. The element in common was the injection and there had been a shift of emphasis from her son’s injection to her own injection and her own injection fears were a substitute for the fears about her son’s injection.

Within the context of false connections, displacement, substitution and concentration of affect, the differences between patients who are dentally anxious compared with those who experience phobic reactions may now be considered. The dentally anxious patient makes connections between two dental treatment experiences. The anxiety is associated with the past, disagreeable treatment experience and is displaced and substituted by present day anticipated dental care. The concentration of the anxiety is bearable and the patient attends for dental care. Dental phobia is different. The phobic patient has to contend with a more profound intensity of anxiety. In this heightened state of arousal he can only repeat rather than remember the true reason for his dental fear. Nevertheless the dentist can help such patients as Mrs. K by encouraging them to speak freely thereby helping them to identify the false connection. Mrs. K readily accepted the link between her son’s illness and her own ‘needle fears’ and consequently was able to have IV sedation for the local anaesthetic extraction of her impacted tooth.

Occasionally adults and adolescents present for whom there appears to be no experience of a frightening dental experience and it is hard to discover where there might be a false connection with regard to linking something that happened outside with something that happened inside the dental surgery. These individuals experience such an intensity of anxiety that they refuse dental treatment despite being in considerable pain. It seems that for this group of patients their dental phobia is a symptom of a wider psychological problem associated with a disturbance in the individual’s emotional development. The following clinical vignettes from the case histories of two adolescents girls (one of these is male!) are illustrative:

Case 1: John is 14 years old. He has over the years developed a ‘needle phobia’. At the time of his referral despite experiencing considerable pain refused to have his painful tooth extracted either with conscious sedation or dental general anaesthesia. Close questioning of John’s mother revealed John’s food fads and avoidances and a considerable separation anxiety. John found it impossible to be on his own; he would not let his mother out of his sight and insisted that he slept in the same bed as mother. This suggested that all was not well with Johne.

Case 2: Jane is 16 years old. She also refused to have dental treatment and at the time of referral was in pain. Jane was fearful of the injection and the drill. She had never had an intra-oral injection nor had her teeth drilled. Jane’s mother was most concerned about her daughter. Although being continent for about 3 years, from the age of 5 Jane had suffered from enuresis. She still wet the bed at night and continued to be wet during the day. Despite urological investigations nothing physical could be found to explain Jane’s enuresis. As with John it seemed that there had been a disturbance in her psychological development.

It may be proposed that the emotional development of the two adolescents in the above vignettes had not proceeded smoothly. They both experienced dental phobia but this seemed to be a symptom of a wider psychological disturbance rather than an entity in its own right. While it is possible to identify these patients it is necessary to refer them for secondary level psychological care. The questions of how to deal with their dental treatment need remains.

There is yet another 2 groups of patients who may present with extreme dental anxiety - they are those with learning disability. For these first set of patients it may be a situation that the patient is unable to understand what is happening and so feels distressed and anxious. To provide a treatment which can be used simply and easily may vanquish the need for referral for secondary level specialist dental treatment. In the second set, there are a group of patients who have severe illnesses. They are anxious about any potential treat to their well-being.

Case 3: A good example of this is Charlotte, a 12 year old who attended at UKSmiles dental practice in Wokingham, Berkshire. Charlotte has a platelet count of 12. By all reasonable expectations, she has been very lucky to survive as long as she has. Charlotte knows that any penetrating injury, and that includes dental needles, can cause severe and uncontrolled bleeding into the injury site. Paste dental care resulted in such an injury, that require hospital treatment o reduce. And that was just for a simple single surface filling in an upper tooth. Imagine the scenario of an inferior dental block for traditional dental treatment to a lower molar tooth. The result could have been life threatening. Yet with a very simple and short treatment with ozone, she has had the areas of decay reversed, and long lasting fillings placed. She and her mother do not have the anxiety they once shared about dental care.

Clinical experiences such as those above suggest that dental anxiety must be considered as a presenting symptom and the underlying causation differs as reflected by the intensity of affect. For patients presenting with dental anxiety who have had a frightening dental experience it is the connection from past to present in dental treatment terms that consolidates the fear. For patients with phobic reactions it is the false connection and displacement from traumatic episodes outside to inside the surgery that forms the nexus of the dental phobia. A third category of dentally anxious patients exists in which details of their history suggest that their dental phobia is a symptom of a disturbance in their psychological development. Finally there are those with learning disability for whom it a lack of understanding of what is happening that gives rise to their fears of dental treatment. In each of the above categories the need for dentists to be able to identify and use appropriate treatment techniques to forge the treatment alliance is the key to provide care for this patient group.

Dental anxiety and dental phobia: methods of psychological assessment

The need to identify patients who are dentally anxious as opposed to those who are dentally phobic allows the dentist to envisage an appropriate treatment plan. It has been proposed that a continuum of dental anxiety-phobia exists which will dictate the form and type of dental treatment that may be offered to the patient. For patients who present with varying intensities of dental anxiety the use of an alternative treatment modality that would be quick, painless and abnegate the need for injections and/or the drill would provide means of acceptable and appropriate treatment of carious lesions.

There is, however, an additional requirement that is a reliable and valid means of assessing dental anxiety. Various questionnaires have been devised for the general practitioner and these include the Dental Anxiety Scale (Corah 1969), the Modified Dental Anxiety Scale (Humphris et al 1995) for adult patients and the Child Fear Survey Schedule (Belfast version: Carson and Freeman 2000) and the Modified Child Dental Anxiety Scale (Wong et al 1998) for children. These scales are simple and easy to use and provide the practitioner with a means of confirming his diagnosis and developing a treatment alliance with them.

The Dental Anxiety Scale (DAS):

The DAS was developed by Corah (1969) to assess adult dental anxiety. It is a four item inventory. The questions ask about the intensity of dental anxiety when waiting for, first the day of the appointment, secondly in the waiting room, thirdly for drilling and finally for scaling. Examples of questions to assess anxiety when visiting the dentist to-morrow and waiting in the waiting room for treatment are:

[1] If you had to go to the dentist to-morrow, how would you feel ?

1	Would look forward to it as a reasonably enjoyable experience	Y/N
2	Wouldn’t care on way or the other	Y/N
3	Would be uneasy about it	Y/N
4	Would be afraid	Y/N
5	Would be very frightened	Y/N

[2] While you are waiting in the waiting room for your turn in the dentist’s chair, how do you feel?

1	Relaxed	Y/N
2	Uneasy	Y/N
3	Tense	Y/N
4	Anxious	Y/N
5	So anxious, I feel sick and break out in a sweat	Y/N

Each question has 5 possible responses from feeling relaxed (scoring 1) to feeling anxious (scoring 5). This gives a possible range of scores from 4 to 20 with the score of 8.89 representing the population average score. Scores between 17 and 20 correspond to dental phobia.

The MDAS was developed in 1995 by Humphris et al(Humphris et al, 1995. This is a modification of Corah’s scale and includes a question about local anaesthesia. The questions assess the intensity of dental anxiety when waiting for, first the day of the appointment, secondly in the waiting room, thirdly for drilling and for scaling and finally for local anaesthesia. Examples of questions to assess dental anxiety when waiting for a dental appointment and treatment are:

[1] If you went to your dentist for TREATMENT TOMORROW, how would you feel ?

1	Not anxious/b>	Y/N
2	Slightly anxious	Y/N
3	Fairly anxious	Y/N
4	Very anxious	Y/N
5	Extremely anxious	Y/N

[2] If you were sitting in the WAITING ROOM (waiting for treatment), how would you feel?

1	Not anxious	Y/N
2	Slightly anxious	Y/N
3	Fairly anxious	Y/N
4	Very anxious	Y/N
5	Extremely anxious	Y/N

The scoring system is the same as for the DAS with total scores ranging from 5 to 25. Scores above 19 indicate dental phobia with 10.97 being the population average, for people attending general dental practitioners.

Child Fear Survey Schedule (Belfast version)

The children’s dental anxiety may be assessed using the Children’s Fear Survey Schedule (CFSS) which they were asked to complete. The CFSS was adapted and validated by Carson and Freeman (2000) to assess child dental anxiety. The child was asked to rate how anxious they felt with regard to 10 dental items on a 5 point scale; a score of 1 corresponding to ‘no fear’ and 5 corresponding to ‘very afraid’. This gives a range of scores between 10 and 50.

The Modified Child Dental Anxiety Scale

The MCDAS was developed by Wong et al in 1998 to assess children’s dental anxiety when having dental general anaesthesia (DGA) or relative analgesia (RA). The questionnaire consisted of 8 items. A score of 1 relaxed/not worried to 5 very worried. It has been modified to include faces (Figure 1). The scores range from 8 to 40.

Figure 1: The Modified Child Dental Anxiety Scale

1	going to the dentist	1	2	3	4	5
2	having your teeth looked at	1	2	3	4	5
3	having your teeth scraped & polished	1	2	3	4	5
4	having an injection in the gum	1	2	3	4	5
5	having a filling	1	2	3	4	5
6	having a tooth out	1	2	3	4	5
7	being put to sleep for treatment	1	2	3	4	5
8	having a mixture of gas and air to make you feel comfortable but not asleep	1	2	3	4	5

Assessment of Dental Anxiety Inventory

The child has to identify which of the pairs of drawings explains how they feel about dental treatment (Figure2). There are 8 pairs of drawings and the possible range of scores are from 0 to 8 (Venham 1979).

Combining the patient’s history and scores from the psychological questionnaires to assess dental anxiety the dentist is now in a position to identify the patient with dental anxiety, phobic reactions and for whom their dental phobia is merely a symptom of a greater psychological disturbance. Working in this way the dentist is forging the treatment alliance in preparation for the next stage of care that is negotiating the treatment plan.

Figure 2: Assessment of dental anxiety inventory

Dental anxiety and dental phobia: what treatment modalities are possible?

The use of conventional dental treatment modalities such as the local anaesthetic injection, the fast and slow handpieces have been related to patients’ fears of dental treatment. Writing in the 1970s, for instance, Kleinknecht et al (1973) stated that the most anxiety provoking items of dental treatment cited by patients were the drill and the injection. Later research agreed with these earlier findings demonstrated that the drill, the injection and pain were the most commonly reported fears of dental treatment (Freeman 1991). Furthermore it was fear and use of the local anaesthetic injection that was predictive of patient dental anxiety status (Moore et al 1996).

Examining the links between reported fears and dental anxiety status Freeman (1991) suggested that memory acted to distort the original frightening dental treatment experience. The difficulty with the distortion was that the dentally anxious patient would perceive each new dental treatment experience as potentially harmful. In this heightened state of anxiety patients would be more likely to recall, re-experience and learn more about events which corresponded to their mood. Essentially a vicious circle of anxiety would be developed and with it the incubation and maintenance of the patient’s dental anxiety.

This work suggested that if patients were given a ‘corrective dental experience’ within a framework of behavioral management it would be possible to cut the vicious circle of dental fear and assist patients to contain their dental fears and accept treatment. However the need to use alternative treatment modalities that abnegated the need for the injection or the drill and would allow the patient to accept the treatment offered and provided by the dentist remained until recently an unresolved problem.

With the advent of Ozone as an alternative to conventional restorative techniques, such as local anaesthesia, drilling and filling, it seemed that Ozone would be a useful treatment modality for the management of dental anxious patients requiring conservative treatment. Ozone is currently being used in a variety of clinical settings. Ozone treatment for dental decay has been shown to reverse carious process in just a single application. Dental ozone devices deliver ozone for 30 - 60 seconds via a delivery tip onto the tooth area requiring treatment. In terms of its non-invasive mode of application and the short treatment time, it seems ideal in terms of a treatment modality for the dentally anxious patient.

Recent research on 377 patients (Domingo et al 2002) who required conservative treatment for two carious lesions assessed patients’ attitudes, satisfaction and dental anxiety status with regard to conventional conservative treatment and treatment with Ozone. The patients were asked to complete a questionnaire prior to and after treatment with Ozone and conventional restorative treatment for their carious lesions respectively. The questionnaire assessed their satisfaction with treatment, their dental anxiety before and after treatment and contrasted dental anxiety status with regard to conventional dental treatment and Ozone. The Modified Dental Anxiety Scale (Humphris et al 1995) was used to assess dental anxiety.

The findings from this preliminary work are positive and encouraging. Nearly all of the patients stated that they were happy and satisfied with the Ozone treatment. The reduced time in the dental chair was perceived as a highly desirable characteristic of the new treatment. All of the patients stated that Ozone was their preferred treatment option - irrespective of the financial costs. In terms of their dental anxiety status patients were less anxious before and after Ozone treatment compared with conventional treatments for their carious lesions.

It is known that large proportions of patients (Kelly et al 2000) attending for dental treatment show varying degrees of apprehension, worries and anxieties that may result in avoidance of dental treatment. As the majority of people perceive the injection and the drill to be the most fearful aspects of dental treatment it would seem that non-invasive methods of treating the carious lesion must have a role to play in the clinical management of the dentally anxious patient. Ozone treatment, which requires no local anaesthesia, drilling or filling and is completed from 10 seconds, is an ideal solution for those patients who are dentally anxious. The reduction of dental fear experienced by those receiving Ozone compared with conventional methods of caries management suggested that Ozone provided a new treatment modality for dental anxiety management.

Conclusions

It is not only patients who present with dental anxiety provide the busy general dental practitioner with management difficulties. Knowing that time and patience are at the centre of the objective and empathetic treatment of this patient group the dentist also appreciates that it may be impossible to spend the necessary time help the patient accept dental treatment.
The patients close relatives may need more re-assurance than the patient them self. In a general dental practice setting, the GDP may have the anxiety of mothers and fathers to cope with, quite apart from the young child. GDP’s spend as much time calming the patients’ relatives in this case, as they do in the provision of effective dental care for the patient. In this scenario, ozone has had a major impact in the group of dental practices who have adopted the ozone technologies early. As the treatment is fast, painless, does not involve the placement of anaesthesia and any form of drilling, the anxiety of the relatives is reduced. The guilt that this group of cares has is reduced too, a point often over looked by researchers, and GDP’s.
Professor Edward Lynch and Dr Julian Holmes both have young daughters of similar age. Both had large carious lesion found not by their fathers, but by their child’s orthodontists. Both expressed guilt at this lack of care, despite regular and routine screening sessions. With the ozone technologies, both children avoided the need for traditional drilling and filling. Their dental care was simple, and predictable. The end result was complete remineralisation of the lesions on x-ray, and the guilt factor for both parents was reduced by the knowledge that their children’s teeth were saved by a modern technology. Both children now are happy adolescents, who still have no traditional cavities or restorative care, and have no dental anxiety associated with modern dental care.

It remains to be seen if this technology has the potential to encourage a group of dental patients who will take up a "could-not-care-less" attitude, in the knowledge that modern technology may be able to reverse the effects of decay!

The practitioner must identify patients who can accept surgery-based treatment and those for whom it would be impossible. Engaging the patient and discovering the cause of their dental anxiety together with the use of questionnaires to assess the affect allows the dentist to quickly identify those who can and cannot accept dental treatment. Some patients will remain with the practice while others will be referred for secondary and specialist care.

For patients with carious lesions who are fearful of the injection and the drill this poses yet another management difficulty and the next stage is to decide how the dentally anxious patient’s conservative treatment will be conducted. With the advent of Ozone it seems that a reasonable alternative to conventional restorative treatment may exist fro those who are dentally anxious. The reduced treatment time of 10 seconds compared with 30 minutes together with the use of snugly-fitting cup over the tooth Ozone would seem to have all the characteristics to reduce dental anxiety and allow the fearful patient to accept the treatment the dentist is providing. In addition it may have a part to play in the care of the dentally anxious child as children perceived the prophylaxis polishing cup as the least fearful aspect of dental treatment. Ozone is a new treatment modality which seems to have the potential to provide treatment of the carious lesions which is acceptable for the dentally anxious adult and child patient.

References