Drilling Down on Dental Fears

March 31, 2016 at 8:23 AM

By Rebecca A. Clay
American Psychological Association
March 2016, Vol 47, No. 3
Print version: page 60

By the time one patient came to psychologist Lisa J. Heaton, PhD, it had been more than 15 years since she had last seen a dentist.

"She would walk into the operatory and be so upset she would start to cry and say, ‘I can't do this,'" remembers Heaton, a clinical assistant professor of oral health sciences who collaborates with dentists at a special clinic at the University of Washington's School of Dentistry. "For the first two appointments we saw her, she wouldn't even sit in the dental chair."

To help the woman overcome her fears, Heaton launched her on a program of gradual, desensitizing exposure to the dental experience and taught her effective coping strategies. Thanks to those interventions, the woman now visits her dentist regularly, despite some lingering nervousness. Instead of replaying scenes from her childhood dentist's office, she practices deep breathing, listens to music on her iPod and raises her hand whenever she wants the dentist or hygienist to give her a break.

"She has all kinds of coping strategies lined up," says Heaton. "We've tried to replace her negative experiences with positive ones."

Heaton is one of several psychologists working alongside dentists to improve patients' oral health. Like her, many focus on helping patients overcome dental anxiety and phobia via cognitive-behavioral therapy and other techniques. Others are exploring the causes of and cures for oral health problems, such as temporomandibular joint disorder. Psychologists are also playing important roles in training future dentists and hygienists, bringing psychological and behavioral science to bear on such topics as communicating effectively with patients, managing pain and encouraging smoking cessation.

"Dentistry was never on my radar," says psychologist Dolores Cannella, PhD, associate dean for education at New York's Stony Brook School of Dental Medicine. "But there's so much psychologists can do in dentistry. Dentistry is about interacting; it's about human behavior."


Overcoming anxiety

Anxiety is one of the most common problems psychologists see in the dental arena, says Daniel W. McNeil, PhD, a professor of psychology and clinical professor of dental practice and rural health at West Virginia University.

In a chapter in the 2014 book "Behavioral Dentistry," he and doctoral candidate Cameron L. Randall note that almost half of American adults have at least moderate levels of dentistry-related fear, with 5 percent to 10 percent reporting that they avoid dental care as a result.

It's not only bad childhood experiences that spur dental fear, says McNeil.

"It's actually less common that dental trauma alone contributes to dental fear and phobia," he says. Instead, going to the dentist often evokes other fears, such as being trapped, getting an injection, seeing blood or having your personal space invaded. Anxious family members can pass on the idea that dentistry is scary, a message underscored by popular media depictions of dental visits as unpleasant or painful. "I heard an ad on the radio once that said refinancing your mortgage shouldn't be as painful as a root canal," says McNeil.

There may even be a genetic basis to dental fear, says McNeil. McNeil is supervising research at the National Institute of Dental and Craniofacial Research-funded Center for Oral Health Research in Appalachia, focusing on a gene variant that may contribute to heightened pain sensitivity and thus dental anxiety.

The consequences of dental fear don't just include bad breath, cavities and periodontal disease. "The research clearly shows that having decayed or missing teeth has a strong negative impact on self-esteem," says McNeil. "It also has an impact on employability." And because periodontal disease is associated with cardiovascular disease, diabetes, stroke and premature birth, he adds, the fear of going to the dentist can ultimately even be life-threatening.

Fortunately, say McNeil and others, psychologists can treat that fear.

At the clinic where Heaton works, for example, the process begins with an assessment of patients' specific concerns. She then uses gradual exposure to desensitize patients to whatever they fear. If it's injections, Heaton teaches her patients progressive muscle relaxation, diaphragmatic breathing and other coping skills. A dentist then rehearses the steps of an injection with the patient, beginning by simply inserting a capped needle into the patient's mouth and — as anxiety decreases — working up to an actual injection.

Heaton also encourages patients to replace negative thoughts with positive ones.

"Very often people are thinking, ‘This is terrible; it's never going to end; I can't stand this,'" says Heaton. "We work on developing alternative statements they can tell themselves, such as, ‘I'm going to be happy with myself when this is done' or ‘I'm doing something good for my health.'"

This cognitive-behavioral approach is safer than sedating patients with nitrous oxide or benzodiazepines, adds Heaton. Plus, medication can take hours to wear off, which can interfere with patients getting home and resuming their normal activities again.

"If we say, ‘We'll give you pills and you'll be fine,' patients tend to ascribe their success to the medication," she says. "Over time, they may become more and more reliant on medication and say, ‘I can't get my teeth cleaned unless you knock me out or can't do x, y, z unless I have three Xanax on board.'"

Patients can also use these self-calming strategies in other arenas, such as fear of flying, she adds.

Even if patients do need a pharmacological adjunct, says Heaton, the medications are more effective when patients are relaxed. "If people are holding their breath or breathing quickly, for example, nitrous oxide doesn't have as much of an effect," she says.

Plus, cognitive-behavioral interventions work, says psychology professor Richard Heimberg, PhD, of Temple University, whose adult anxiety clinic has increasingly focused on dental anxiety in recent years.

In a paper published this year in the Journal of Anxiety Disorders, Heimberg and colleagues reviewed 22 randomized trials of interventions to reduce adults' dental anxiety and avoidance, including various forms of cognitive-behavioral therapy, relaxation techniques, medication, acupuncture, hypnosis, musical distraction and even lavender oil. They found that cognitive-behavioral therapy — even if it was just a single session — was the most effective option. They also found that relaxation, cognitive approaches and interventions to give patients a sense of control also worked well, but worked best with graduated exposure.

If your goal is simply to make it through the procedure, taking a tranquilizer is OK, says Heimberg. But, he says, if the goal is to empower patients so that routine dental care can become just that, "the medical approach doesn't have as much going for it."

Of course, says Heimberg, few dental offices have psychologists on staff. That's why he and colleagues have developed a cognitive-behavioral dental anxiety intervention that can be delivered electronically, freeing up psychologists to focus on the most severe cases.

The intervention features videos of various dental procedures, such as cleaning, getting a filling and undergoing a root canal.

"We're basically giving patients information, sharing with them what things are for, why the dentist is doing things and why it's necessary to do x rather than y," says Heimberg. "But the main components are exposure and cognitive restructuring."

For each procedure, there are three videos. Users first watch a dentist perform the procedure, with animated depictions of what's going on inside the mouth. The next video offers close-ups of the patient's face but with the dentist talking as a cognitive-behavioral therapist would and helping the patient translate what Heimberg calls "Oh, my God!" thoughts into more positive thoughts. The final video lets users experience the procedure as if they're sitting in the dental chair themselves. "In the voiceover, the patient from the previous video is talking to the patient sitting in front of the computer and helping that patient develop coping thoughts about the procedure," says Heimberg.

In a randomized, controlled trial of 151 adult patients described in a clinical research supplement to the Journal of Dental Research in 2015, Heimberg and colleagues found that the hourlong intervention significantly reduced dental anxiety, fear, avoidance and severity of dental phobia among patients with high dental anxiety. (The control group was assigned to a waiting list.) The effects were lasting, too: A month later, fewer patients with full-fledged dental phobia still met the criteria for phobia. The researchers now have a grant from the National Institute of Dental and Craniofacial Research to conduct a trial of an online version.


Stopping jaw pain

Psychologists are also helping dentists and their patients address chronic pain, most commonly temporomandibular joint disorders, which are characterized by pain in the jaw and the muscles surrounding it and in some cases difficulty moving the jaw. According to the National Institute of Dental and Craniofacial Research, more than 10 million Americans — more often women than men — may have temporomandibular joint and muscle disorders.

In the past, dentists have attempted to treat the disorder by replacing a joint or changing the way the teeth fit together. That approach has been "woefully unsuccessful," says psychologist Roger B. Fillingim, PhD, a professor at the University of Florida's College of Dentistry. Now, he says, there's a growing understanding that complex interactions among physical, psychological, environmental and other factors contribute to jaw pain.

To identify those factors, Fillingim and other researchers launched the Orofacial Pain: Prospective Evaluation and Risk Assessment study in 2006. Still ongoing, the study collected information about ethnically and racially diverse people without temporomandibular joint disorder recruited at the four study sites, then waited to see who would develop the problem.

In a 2013 paper in the Journal of Pain, Fillingim and colleagues examined psychological variables among more than 2,700 participants, about 200 of whom had developed temporomandibular joint disorder. While current and past stress and negative affect were correlated with the disorder, the most important predictor turned out to be somatic symptoms — dizziness, stomach upset, headaches and the like.

That doesn't mean patients are converting psychological pain into physical symptoms, a stance Fillingim describes as unhelpful and pejorative. Instead, he says, people who report high levels of physical symptoms may just be more attuned to what's going on in their bodies than most people.

"Many of us are just tuned differently in our central nervous system," says Fillingim, who also directs the university's Pain Research and Intervention Center of Excellence. "If your central nervous system is particularly expert at detecting physical symptoms, at one time in the history of our species, that was incredibly adaptive and kept us from harm; it's not so adaptive anymore."

While psychological factors may not be at the root of temporomandibular joint disorder, psychological interventions could help, says Fillingim. Cognitive-behavioral therapy, cognitive reframing and affective regulation could change the way the central nervous system responds to stimuli, he says. Now he and his fellow researchers are trying to put their findings on risk factors to use in developing prevention and treatment strategies and identifying the patients at greatest risk.


Training dentists

Psychologists also have an important role to play in training dentists, says Dolores Cannella. Many dental schools now have at least one psychologist on staff, says Cannella. "It is the norm," she says.

Cannella, for example, has helped transform the Stony Brook School of Dental Medicine's curriculum to incorporate more behavioral science.

The National Board Dental Examination includes questions on behavioral science, Cannella points out. And accreditation standards for dental schools also require dental students to learn behavioral science as well as communication, ethics and professionalism.

When the Stony Brook School of Dental Medicine recruited Cannella in 2007, the only training students received in behavioral science was a 14-hour class in their second year. That wasn't nearly enough, she says.

Cannella ended up revamping the curriculum to add behavioral science. Spanning four years, the new comprehensive curriculum integrates basic, clinical and behavioral science; uses a team-based approach; and blends didactic training with application in the clinic.

Now students get training in behavioral science and work in the clinic in their first year — unlike students at many dental schools, who only get into clinical settings in their third or fourth years. The emphasis at this stage is on how to adapt their communication style to a broad range of patients. Communicating with pediatric and geriatric patients, for example, involves issues about autonomy and independence, "but at different ends of the spectrum, with children having increasing levels of decision-making and autonomy and the elderly possibly having decreased capacity and decision-making ability," says Cannella. In subsequent years, the students tackle more complex issues, such as managing dental anxiety, recognizing interpersonal violence and encouraging better oral hygiene, healthier nutrition and smoking cessation.

The new curriculum also emphasizes interprofessionalism. When students are learning how to interview patients, for example, Cannella works alongside clinical staff to ensure that the students receive both clinical and behavioral science feedback on their videotaped interviews with actors paid to perform the role of patients. "Dentists tend to focus on the technical aspects of dentistry, such as whether the student accurately diagnosed the problem and made the correct recommendations," she says. "I tend to focus more on body language, word choice and tone and the feelings created by the interaction."

In January, the school launched a new center established to bring the dental, nurse practitioner and social work fields together to provide health promotion and disease prevention services to older adults with multiple chronic illnesses while advancing interprofessional education. Funded with a grant from the Health Resources and Services Administration, the program will teach students not just the clinical material but how to work as a team.

Other dental school psychologists focus on ensuring that students make it through what can be the grueling process of dental education.

"My first priority is to help first-year students survive," says psychologist Bruce Peltier, PhD, who also teaches behavioral science and ethics at the Arthur A. Dugoni School of Dentistry at the University of the Pacific in San Francisco.

"Dental education has a long history of being harsh, paternalistic and hierarchical," says Peltier. Although the University of the Pacific's dental school made a conscious decision about 35 years ago to be more student-friendly, he says, the experience can still be tough on students.

Plus, says Peltier, the very nature of dentistry can be trying. "Few of your patients really want to be there, and many of them tell you when they walk in, ‘I hate dentists,'" he says. "The negativity wears on dentists."

The school initially hired Peltier in the late 1980s to help train faculty in counseling and advising skills, then asked him to see students struggling with stress and learning problems. His one-day-a-week gig soon turned into a full-time position. In addition to his work with first-year students and his teaching duties, Peltier now offers psychological services to other students, teaches listening skills and hypnosis and runs a weekly meditation workshop.

"It has been a great fit," says Peltier. "I think they could really use five of me. Every dental school could use about five psychologists, because there's just so much we can do that's of great benefit to dental education."


Further reading

  • American Dental Education Association. The association includes a behavioral science section dedicated to developing, integrating and transmitting social, behavioral and biomedical science related to oral health. Visithttp://www.adea.org/.
  • Dental Fear Central. Available at http://www.dentalfearcentral.org/, this site offers information about common fears and what can help, plus a forum, tips for dentists and more.
  • Mostofsky, D. I., & Fortune, F. (2014). Behavioral dentistry, (2nd ed.). Hoboken, NJ: Wiley-Blackwell.