J Dent Educ. 68(11): 1172-1177 2004
© 2004 American Dental Education Association
Milieu in Dental School and Practice |
Strategies for Combating Dental Anxiety
Lyndsay C. Bare, B.A.;
Lauren Dundes, M.H.S., Sc.D.
Ms. Bare is a class of 2008 student, University of Maryland Baltimore College of Dental Surgery; Dr. Dundes is Associate Professor of Sociology, McDaniel College. Direct correspondence and requests for reprints to Dr. Lauren Dundes, Department of Sociology, McDaniel College, 2 College Hill, Westminster, MD 21157-4390; 410-857-2534 phone; 410-386-4671 fax; ldundes{at}mcdaniel.edu.
Key words: dental anxiety, patient preferences, gender, dentist traits, pain management
Submitted for publication 05/26/04;
accepted 08/16/04
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Abstract
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Dental anxiety and subsequent avoidance of dental care and deterioration of oral health pose a significant problem for the dental profession. In an attempt to elucidate preferences of anxious dental patients, we gathered survey data from 121 persons at a small, private liberal arts college in the mid-Atlantic region of the United States. Half of the respondents experienced dental anxiety, and most of these (66 percent) attributed anxiety to fear of anticipated pain. The majority of anxious patients preferred a dentist to be friendly (93 percent), talkative (82 percent), and to have an office with adorned walls (89 percent) and a slightly cool temperature (63 percent). Patients who identified themselves as anxious also indicated that music in the background (89 percent) and magazines and books in the dental office (75 percent) were helpful. Anxious patients were more likely than non-anxious patients to prefer a male dentist (77 percent versus 52 percent). This finding was especially marked among anxious male respondents, 93 percent of whom preferred a male dentist compared to 73 percent of anxious female respondents. These survey data may assist dental professionals in understanding and combating patients’ dental anxiety, in order to increase the frequency of dental visits and to prompt a corresponding restoration or maintenance of oral health.
Despite formidable challenges arising from patients’ dental anxiety, we have only limited knowledge about what causes and abates this significant problem facing the dental profession. Helping patients overcome such apprehensions can reduce the incidence of delayed or missed dental visits and the negative repercussions from avoidance of needed care. In addition, allaying dental anxiety may facilitate the work of dental hygienists and dentists who themselves may find working with anxious patients to be taxing. Even the implementation of a single strategy that calms a small proportion of tense patients could yield benefits for patient and practitioner alike. While dentists employ a number of different techniques to accomplish this goal (such as providing background music or reading material in their offices), many unanswered questions remain about patient preferences, including personality and appearance of the practitioner as well as attributes of the dental office, particularly those of patients most overwrought about their visit. This article provides data about causes of patient anxiety as well as attributes of clinicians and the office environment that patients prefer. Clarification of these preferences could contribute to strategies applied to alleviate fears surrounding dentistry, which in turn could increase the frequency of dental visits and encourage a corresponding restoration of oral health in anxious patients.
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Reported Causes of Patient Anxiety and Pain
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Past research reveals a number of factors associated with patients’ reporting of dental pain and anxiety: 1) if they have had previous painful experiences;1–3 2) if they believe that painful treatment is inevitable;1–2 3) if they feel that they lack control over the situation, including the inability to stop a procedure they find unpleasant;1,4–5 4) if they do not understand the procedures that the dentist performs or harbor a general fear of the unknown;1,4 5) if they have experienced exposure to frightening portrayals of dentists in the media or conveyed by acquaintances’ recounting of unpleasant experiences;4 6) if they have experienced detached treatment by a dentist and/or a sense of depersonalization;1,4 and 7) if they have fears of experiencing ridicule because of how they react to situations arising during their visit.4
According to Quteish Taani,6 reasons for infrequent dental visits include a perceived lack of time (36 percent), a belief that treatment is not needed (34 percent), fear of dentists (13 percent), and cost (17 percent). In particular, apprehensions can be significantly exacerbated by fears of injections and drills, especially among females and those who do not regularly (at least yearly) visit the dentist.6 Others have found that women are more likely to exhibit dental anxiety, which was most often attributed to a negative dental experience.7–8 Although the literature includes suggestions for combating dental anxiety (for example, establishing trust, appropriate attire, making pharmacological support available),9–10 the bulk of the research on this topic documents such anxiety rather than addresses how to ease it.
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Methods
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From February to April 2004, a sample of 121 male (27 percent) and female (73 percent) undergraduate students and faculty at a small, private, liberal arts college in the mid-Atlantic area responded to a one-page anonymous survey gauging the extent of their dental anxiety and preferences within a dental office. The survey, which was developed by the primary author, was approved by the college’s Institutional Review Board and granted a waiver of informed consent. It was pilot-tested for clarity on two students and two faculty members.
Undergraduate respondents completed the survey during a number of sociology and biology classes: Introductory Sociology, Medical Sociology, Vertebrate Diversity, Advanced Molecular Genetics, and Epidemiology. The students in the sociology classes were approached as a class, and the students in the biology classes were approached individually. Faculty respondents received the survey in their campus mailboxes and returned completed surveys through the campus mailing system. Our college community respondents comprising this convenience sample were selected due to their familiarity with and willingness to complete surveys.
The survey, which consisted of twenty-five questions in yes/no, fill-in-the-blank, and multiple choice formats, began with a brief description of dental anxiety (avoidance and fear of dentists and dental procedures) and the study’s purpose, which was to identify what factors intensify and/or alleviate that anxiety. The survey included a question, designed by the primary author, in which respondents rated their perception of their dental anxiety. The question specifically asked the respondent to what extent he or she experienced anxiety when visiting the dentist. The respondent was given four choices to circle: no anxiety, mild anxiety, moderate anxiety, and severe anxiety. For the purposes of our study, we later simplified these choices to either not experiencing anxiety or experiencing some degree of anxiety.
The survey also included questions in which respondents rated attributions for their anxiety (such as anticipated pain, feeling out of control, unpleasant stories heard from others, and a negative experience such as gagging). In addition, they were asked to elucidate their preferences for the dentist: friendly or aloof, younger or older than age forty-five, having perfect or average teeth, female or male, wearing scrubs or dressed formally with a white lab coat (for protective, rather than aesthetic, reasons), talkative or silent, and maintaining a patient-doctor relationship that is either strictly professional or one in which the dentist is perceived as an acquaintance. Additional questions asked the respondent to indicate what might enhance their comfort in the office setting: adornment on walls, preferred temperature, magazines and books, music in the background, televisions with headphones, imagining themselves in a calm place (guided imagery), taking an unspecified relaxation drug, taking nitrous oxide (laughing gas), or undergoing hypnosis. These questions were determined by our curiosity rather than previous studies. The student response rate was 100 percent (N=79) and the faculty response rate was 76 percent (fifty-five surveys sent; forty-two returned). Percentages were analyzed using Chi square.
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Results
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The majority of the sample was college students (65 percent) and female (73 percent) (see Table 1
for total sample demographics). Half (50 percent) of the anxious respondents stated that they experience some dental anxiety, ranging from mild to severe. Two-thirds of these respondents (66 percent) attributed their dental anxiety to anticipated pain, 25 percent to a negative experience, 23 percent to anticipated choking or gagging, 18 percent to feeling out of control, and 13 percent to unpleasant stories heard from others (see Table 2).
The majority of respondents self-reported to be anxious preferred a dentist to be friendly (93 percent), talkative (82 percent), male (77 percent), to wear formal clothing, i.e., a white lab coat (59 percent) versus scrubs, to be older than age forty-five (57 percent), and to have a strictly professional relationship as opposed to the dentist being an acquaintance (56 percent). In addition, most respondents, regardless of anxiety level, preferred the dental office to be slightly cool (61 percent) (see Table 3). Although subjects without dental anxiety preferred a younger dentist (52 percent) and to have a relationship with the dentist as an acquaintance (55 percent), these differences were not significant. The most striking difference between subjects who were and were not anxious related to dentist gender: 77 percent of anxious respondents preferred a male dentist compared to 52 percent of respondents without anxiety (p=0.00). This difference was even more marked when taking into account the gender of the respondents: 93 percent of anxious males preferred a male dentist compared to 73 percent of anxious females (see Table 4).
Respondents had clear preferences about desired attributes of the office setting. Most (89 percent) prefer the walls to be decorated, although the few who prefer white, unadorned walls were more likely to be anxious respondents (12 percent versus 3 percent of non-anxious respondents). Regardless of anxiety level, most subjects found magazines, books, or music to be helpful (75 percent–89 percent) (see Table 5). A greater proportion of anxious subjects found television with headphones helpful (48 percent compared to 27 percent of patients without anxiety: p=0.01). Anxious subjects were also more likely to see guided imagery as useful (41 percent compared to 12 percent of subjects without anxiety: p=0.00) as was the case with taking a relaxation drug (33 percent compared to 8 percent of respondents without anxiety: p=0.00) and nitrous oxide (7 percent compared to 0 percent of subjects without dental anxiety: p=0.06). Significant differences were found in subject responses to drills: 38 percent of anxious respondents found drills to be both irritating and frightening as compared to only 12 percent of subjects without dental anxiety (p=0.00) (see Table 6). No significant differences by age or dental experience of the respondents were found.
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Discussion
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Half of our respondents reported some level of dental anxiety, from mild to severe. Anxious patients attributed their nervousness to, in descending order, anticipated pain, a negative experience, anticipated choking and/or gagging, feeling out of control, and unpleasant stories heard from others. If the patient is anxious because he or she thinks the procedure is going to be painful, the patient can be reassured that everything is being done to make the procedure as pain-free as possible. If the patient is anxious due to a negative experience or unpleasant stories, the dental professional could discuss these experiences with the patient. Patients fearful of choking and gagging can be offered means to minimize this reaction (e.g., table salt on the tongue, nitrous oxide inhalation11), and those who feel out of control can be reassured that the procedure can be stopped at any time. In comparison to subjects who did not report anxiety, subjects with anxiety were more likely to find the following to be helpful: televisions with headphones (p=0.01), guided imagery (p=0.00), taking a relaxation drug (p=0.00), and nitrous oxide (p=0.06). While these options are not typically available in dental offices, making them available could help to assuage anxiety.
Dentists should also consider patient preferences that exist independent of anxiety experienced: dentist friendliness, formal dress consisting of a white lab coat, and an office with walls adorned with posters and pictures, supplied with ample books, magazines, and background music. It has been reported that classical music such as J.S. Bach’s "Aria" creates a relaxing environment and subsequently stimulates physiologic relaxation.12 We also suggest gentle music such as classical or soft-rock that could help the patient relax. In addition, we believe that having in the office a large variety of magazines and books that appeal to all types of patients is indispensable. Most respondents prefer a slightly cool office, so we suggest maintaining a cooler temperature. In addition, because 38 percent of anxious patients found drills to be both irritating and frightening (compared to only 12 percent of patients without dental anxiety: p=0.00), we recommend muting the sound produced by these instruments (for example, by closing the door to a patient’s room and the door to the waiting room).
The principal cause of anxiety among the subjects participating in this study was their fear of experiencing pain. Given that the anxious subjects reported that they preferred friendly, formally dressed males who are older than age forty-five, it is possible that they perceived such dentists as more experienced and thus better able to handle this dimension of dental care. In addition, since historically male dentists have been the norm, patients might have a preference for what is familiar. Yet this reasoning does not explain why anxious subjects, particularly anxious males, were so much more likely to prefer a male dentist (77 percent and 93 percent respectively). Unfortunately, our small sample size and convenience sampling limit our confidence in these results, which clearly require replication. Nevertheless, this finding merits further investigation given literature that indicates that, stereotypically, male dentists may be perceived by male patients to be more proactive problem-solvers13–15 and that women physicians may be less likely to give pain relief, especially to male patients,16–17 some of whom may feel culturally obligated to remain stoic.18–24 As women constitute an increasing number of dentists,25–27 they must be cognizant of psychosocial factors that affect how patients may react to them.
Although some of our other findings are easier to interpret (for example, that 96 percent of respondents prefer a friendly dentist), future research should delve into patients’ criteria for this attribute, the degree to which such qualities are desired, and how such preferences vary by demographic characteristics. For example, while a related finding revealed that 86 percent of subjects prefer a talkative dentist, we did not determine the importance of the topics of conversation nor the timing of such interaction (such as in-between versus during procedures) which could vary by level of anxiety. Most importantly, our finding that the majority of our respondents did indeed have preferences about dentists and office characteristics underscores the need for dentists’ awareness of the impact of such factors that are unrelated to their expertise and skill.
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Conclusion
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Although our findings are based on a small, non-random sample, respondents expressed a clear preference for dentists who are amiable and dress formally. While we found only minor variation in preferences between patients with and without dental anxiety, dental professionals need to be conscious of these differences. In particular, given the preference for male dentists, female dentists perhaps should reassure patients, especially male patients, that patients’ feeling at ease is a priority and that patients should openly communicate their comfort level to facilitate appropriate action such as pain relief. Awareness of the causes of dental anxiety and small steps towards alleviating this angst could have a substantial impact on an anxious dental patient. Additional investigation of these issues is needed to further our understanding of how to decrease dental anxiety, which in turn could help increase the regularity of dental visits and prompt a corresponding maintenance or restitution of oral health.
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Abstract
Reported causes of patient...
