Download II. Dentists` skills with fearful patients: Education and

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Research plan
The fearful patient in routine dental care
Carl-Otto Brahm
Senior Consultant
Department of Behavioural and Community Dentistry
Institute of Odontology at Sahlgrenska Academy, Göteborg University
Main supervisor:
Catharina
Hägglin
LDS, Senior Consultant, Ph.D.
Co-supervisors:
Sven Carlsson
Psychologist, Professor
Emeritus
Jesper Lundgren
Psychologist, Ph.D., Senior
Teacher
Peter Nilsson
LDS, Specialist in Oral and
Maxillofacial Surgery, Senior
Consultant, Associate Professor
Collaborative partner: Erik Skaret
2
LDS, Professor
3
Abstract
Dental fear is a common problem to the dental practitioner. Phobic dental fear requires
specialist treatment, and successful methods have been developed to normalize phobic dental
patients’ dental health behaviour. However, about 20 % of adult patients in regular dental care
suffer from a significant dental fear without being phobic, which may lead to considerable
clinical stress, both for the patient and for the dentist. This problem area has been only
sparsely investigated. The aims of this thesis project are to reduce stress reactions experienced
by patients and dental professionals during dental treatment and to decrease the risk that the
dental fear turns into phobic fear resulting in avoidant behaviour. The studies are based on
questionnaires responded to by dental professionals and adult patients, and implementation of
a structured treatment model regarding dental fear. This project is important in order to map
care delivery to adult patients with non-phobic dental fear, and to develop treatment strategies
that are simple and applicable in general dental practice.
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Background
Dental fear is a phenomenon that dental behavioural science research has paid attention to
during the last 50 years. The fear reaction itself is a response that takes place after being
exposed to a real or imagined threat (Öhman 2000). This process is congenital and is
important for survival. From this point of view the history of dental fear must be as old as the
practice of dentistry and dental fear is still common despite technical and dental educational
improvements. In western world the prevalence of dental fear shows only small variations.
Mild to moderate dental fear is usually reported in 35 to 45 % of the adult population and
severe dental fear in 4-5 % (Milgrom 1988, Locker 1991, Hakeberg 1992, Moore 1993,
Vassend 1993, Thomson 1996).
The onset of dental fear usually takes place in childhood (Berggren 1984, Öst 1987) and
the incidence is reported to peak in the late teen-ages and early adulthood (Locker 1999,
Thomson 2000) followed by a decline with age (Lidell 1993, Hägglin 2000). Women are
reporting dental fear more frequently than men (Milgrom 1988, Hakeberg 1992, Moore 1993,
Skaret 1998). The results are contradictory regarding correlation between socio-economic
factors and dental fear (Locker 1991, Hakeberg 1992, Vassend 1993, Skaret 1998, Hägglin
2000).
The concepts dental fear, dental anxiety, and dental phobia are sometimes used
synonymously. However a distinction is usually made. The fear reaction is a normal response
to a specific stimulus or situation that declines when the stimulus is removed. Anxiety is
similar to fear, but an anticipated negative emotional reaction to a hypothetical threat is
central (Öhman 2000). Dental phobia in adults can be regarded as a specific phobia in
accordance with the DSM-IV (American Psychiatric Association 1994) classification defined
as fear of a specific stimulus or situation. The fear is well defined, persistent and irrational.
An immediate anxiety response appears in the presence of the phobic stimulus. The fear
response is excessive, unreasonable and irrational. The reactions of the phobic stimulus are
avoidance, or endurance with intense fear and anxiety. Phobic fear interferes with interaction
with other people i.e. social activities or relationships, occupational functioning, and normal
routines.
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The traditionally recognized etiological pathways to dental fear are through classical
conditioning/direct and cognitive learning/indirect processes (Wolpe 1981). Conditioning
occurs through experiences of traumatic situations i.e. negative dentist behaviour or pain
(Berggren 1984, Milgrom 1988, Moore 1991, Klingberg 1996). Cognitive learning is
described as the individual’s negative thoughts of dentistry due to indirect or vicarious
learning i.e. through negative information about dentistry or due to observations of other
people in dental fearful situations (Berggren 1984, Moore 1991, Milgrom 1995, Berggren
1997). Usually these two pathways coexist during the onset of dental fear. Maintenance of
dental fear and concomitant psychosocial effects has been described in a vicious cycle model
(Berggren 1984). Once dental fear has been established this can lead to avoidance of dental
care that may result in a deteriorated oral status and feelings of shame and inferiority.
According to current knowledge, people with dental fear are a heterogeneous group and
the etiological factors are multiple. In addition to classical conditioning and cognitive
learning, personality factors, behaviour and temperament have been shown to play an
important role. In children the association between temperamental factors and dental fear has
been investigated, and it was found that fearful children showed significantly more shyness or
negative emotionality than non-fearful children (Klingberg and Broberg 1998, Arnrup 2003).
In a majority of adult patients with high dental fear, other extreme fears have been reported
(Berggren 1992, Frazer 1988, Schuurs 1988, Hägglin 2001). Similar results were observed in
a study of young adults with high dental fear, high levels of agoraphobia, social phobia and
simple phobia, suggesting a predisposition to develop anxiety disorders (Locker 2001).
Providing dental health care to patients with high to severe dental fear is a clinical
problem. They usually need extra or specialized attention in order to cope with the dental
treatment, and there is often a need to refer them to a psychologist, psychiatrist or a
specialized dental clinic (De Jong 2005). Behavioural interventions like systematic
desensitization have been shown to be superior to general anaesthesia regarding completing
training program, completing oral rehabilitation in community dental clinics, frequency of
cancellation, and fear reduction (Kvale 2004).
In contrast to the extensive literature on severe dental fear, the knowledge of treatment
modalities for patients with a mild to moderate form of dental fear is sparse. General dental
practitioners have been reported to be competent in treating adult patients with mild dental
anxiety without any complex psychiatric conditions (De Jong 2005). Establishing trust,
providing the patient with realistic information and control, and applying a high level of
predictability are means that help the moderately anxious patient through the dental treatment.
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Also teaching the patient coping strategies can be helpful. Other examples are distraction, and
relaxation. In order to reduce psychological stress during highly stressful dental treatment, i.e.
endodontic treatment and tooth extraction, the use of conscious sedation and hypnosis has
been shown to be effective.
Some studies have described the dentist-patient interactions, patient anxiety reduction
and satisfaction, including assessment of dentists’ and patients’ behaviours (Corah 1982,
O’Shea 1983, Corah 1988, Corah 1989, Rouse 1990, Rouse 1991, Lathi 1992, Lathi 1995,
Lathi 1996). However, general dental practitioners’ experiences, attitudes and feelings
treating patients with mild to moderate forms of dental fear are still largely unexplored. There
are only a few studies investigating this matter (Corah 1982, Corah 1984, O’Shea 1984, Corah
1985, Hakeberg 1992, Arthur 1995, Weiner 1995, Moore 2001, Hill 2008). Some dentists
experience stress when treating anxious patients (Hakeberg 1992). The most frequently
reported behaviour problems among the patients provoking stress-reactions by the dentists are
negative patient statements, such as ‘not appreciating your work’, ‘physically interrupting
treatment’, ‘missing/being late’, ‘criticising you as a dentist’, and ‘not cooperative in the
chair’.
Aims
Care delivery in adults with dental fear has been described in dental behavioural science
literature. Many studies show patient-perspectives of dental anxiety but reports of dentistperspectives are rare. The general aim of the present study is to reduce stress reactions
experienced by patients and dental professionals during dental treatment. Another aim is to
decrease the risk that the dental fear turns into phobic fear resulting in avoidant behaviour.
The specific aims are to:

1//Investigate dental caregivers attitudes, feelings and experiences regarding dental
fear (study I).

2//Investigate dental caregivers strategies when treating adult patients with dental fear
(study II).

3//Investigate impacts of undergraduate training on dental care delivery in fearful
patients, and dentists’ postgraduate training, and further educational needs
concerning treating patients with dental fear (study II).

4//Implementation and evaluation of a structured treatment model in patients with
dental fear: dental team perspectives (study III).
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
5//Implementation and evaluation of a structured treatment model in patients with
dental fear: a patient perspective (study IV).
Studies
I.
Dentists’ views on fearful patients: Problems and promises.
II.
Dentists’ skills with fearful patients: Education and treatment.
III.
The Jonkoping Fear Coping Model: dental team perspectives.
IV.
The Jonkoping Fear Coping Model: patient perspectives.
Material and methods
Studies I and II
From the headquarters of the Association of Public Health Dentists in Sweden 1915 email addresses were received. In total 4300 dentists are registered in the association, but email addresses were only available for less than 50 % (n = 1915). These dental practitioners
were asked by e-mail to respond to a web-survey concerning dental fear. A web office ran the
logistics, and two reminders were delivered with one week apart. The web survey contained
25 items, of which 20 were responded to in a 5-grade horizontal Likert scale. The response
alternatives were ‘always’, ‘usually’, ‘sometimes’, ‘rarely’ or ‘never’. For some questions it
was possible to leave open comments. In the end the responders could leave open comments.
The responders were asked about background factors like age, gender, and year of graduation
from dental school, time of employment at the current dental office. The responders were also
asked about dental training, care delivery to patients with dental anxiety, pre-treatment
information seeking, further education in dental behavioural science, pre-treatment
preparations, and treatment of patients with dental anxiety. The inclusion criterion used was
‘working as a general dental practitioner treating adult patients’.
Final sample of studies I and II
The web survey was distributed to the 1915 members of the Association of Public Health
Dentists. 359 questionnaires were returned due to inaccurate e-mail addresses, giving 1556
responders (81 %). Another 10 e-mails were sent back by auto-response due to vacation,
parental leave etc. Also 253 of the responders did not fulfil the inclusion criterion. Altogether
1293 general dental practitioners were left as ‘potential responders’. 889 surveys were
returned, and the response rate was finally 69%.
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The daa for the studies I and II have been collected as a student project at our
department.
Studies III and IV
Interventional study
In Figure I the research design of the dental fear treatment model is shown. Ten Public Dental
Service Clinics in the County of Jönköping will take part in period I (n=70), five in period II
(n=40). Every dentists and dental hygienists (dental professionals) in each period will register
50 patients. The patients take part only once and will be chosen consecutively during the
study, irrespectively of the reason of the appointment. Thus, there are different dental patients
in the two periods. The dental professionals being excluded from period II will act as controls
to those being educated in the structured treatment model (n=40). The dental professionals
taking part in period II will also act as their own controls, compared to period I. The effect of
the intervention will be analyzed regarding perceived stress-reactions among dental
professionals before and after the implementation of the structured treatment model. Also, the
effect of the intervention will be analyzed regarding the dental patients satisfaction with the
care giving.
The structured treatment model will provide the dental professionals with guidelines in
order to give care and treat patients with dental fear. The model is based on Milgroms four
dental fear categories; ‘fear of specific stimuli’, ‘distrust of dental personal’, ‘generalized
anxiety’, and ‘fear of catastrophe’. The model deals with general considerations for each
category, leading to specific treatment considerations. A logarithm based on a survey will
help the dental professionals in order to screen the adult patients. The logarithm will be
developed in collaboration with Professor Erik Skaret, University of Oslo. Professor Skaret is
the creator of a computerized programme developed in order to promote health behaviour
‘Ditt Valg’ (dittvalg.com), that will form the basis for our logarithm. Adult patients with
dental fear will be offered help according to the structured treatment model.
The evaluation of the intervention is based on surveys to dental professionals and dental
patients. All surveys will be coded. A pilot study will precede the interventional study. The
pilot study will be conducted at the Clinic of Maxillofacial Surgery, Institution of Odontology
Jönköping. All dental teams will participate in the data collection. In period II the team that
includes the main author will be excluded.
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Prior to period I the dental professionals (DP) respond to ‘DP-survey 1’ (appendix I).
The patients (P) that come to the clinic consecutively respond to ‘P-survey 1’ (appendix II)
before and ‘P-survey 2’ (appendix III) after the appointment. After each appointment the
dentists, dental assistants, or dental hygienists judge the patients’ behaviour and how dental
treatment passed, ‘dentist rating’ (appendix IV). After period I has been completed the dental
professionals fill in the ‘DP-survey 2’ (appendix V).
Prior to period II the dental professionals included will be trained in the structured
treatment model. The model will then be used consecutively on patients attending to the
clinic. The patients respond to the same surveys as in period I (appendices II and III). The
‘dentist rating’ (appendix IV) is filled in after the appointment. After period II has been
completed the dental professionals respond to the ‘DP-survey 3’ (appendix VI).
Instruments
Global question (included in P-survey 1, appendix II)
Are you afraid of going to the dentist? The response alternatives were ‘No’, ‘A little’, ‘Yes,
quite’, and ‘Yes, very’ (Neverlien 1990).
IDAF-4C+(included in P-survey 1, appendix II)
The Index of Dental Anxiety and Fear (IDAF-4C+) contains 3 modules that measure DAF,
dental phobia, and feared dental stimuli. The 8-item DAF module (IDAF-4C) assesses
emotional, behavioral, physiological, and cognitive components of the anxiety and fear
response (Armfield 2010).
The Winnberg survey (included in P-survey 2, appendix III)
This survey contains 9 items assessing patient satisfaction with the dentist; dentist’s skills and
behaviour (Gale 1984).
The Dentist Rating Scale (included in dentist rating, appendix IV)
Dental professionals use The Dentist rating scale assessing patient behaviour and treatment
functioning during dental treatment, scored 1 (complete relaxation and excellent functioning)
to 6 (refusal of treatment) (Carlsson 1980, Carlsson 1986). In this research project the Dentist
Rating Scale is renamed to the Caregivers rating Scale.
Self-constructed questions
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The four questions origin from the student project/web survey and are included in order to
make comparisons, reliability and validity testing possible (included in DP-survey 1, appendix
I; DP-survey 2, appendix V; DP-survey 3, appendix VI).
Data analyses
Since mainly ordinal scales will be used and the distributions are non-normal, we prefer nonparametric inferential statistics. However, responses to continuous scales were reported by
using mean values and standard deviations (SD). For correlations the Spearman´s Rank Order
Correlation will be used. The Chi-square test, bivariate logistic regression adjusting for years
of practice, and multivariate regressions will be used for analyses of relationships. All
dependent background variables will be dichotomized before being entered in the analyses.
The pre-chosen level of significance will be p<0.05 in all analyses.
Significance
Phobic dental patients are well investigated and documented in the literature. However mild
to moderate dental fear are not as thoroughly explored and this is also true when it comes
dental caregivers and the relation to their dental fear patients. Thus, this project concerns not
only patients with dental fear but also dental caregivers. The psychosocial effects of
implementing a structured treatment model treating these patients may be increased wellbeing
and quality of life. It may also lead to positive effects among the dental professionals treating
patients with dental fear, such as increased levels of control and security. In the end it may
reduce occupational stress. The objective with developing a simple treatment model for
systematically practice is to reduce the risk that moderately fearful patients develop phobic
anxiety and avoid dental care leading to a deteriorated oral status. Thus, in a human as well as
national economic perspective the effects of implementing this treatment model may be
significant. This project is important in order to map care delivery to patients with non-phobic
dental fear, and to develop treatment strategies that are simple and applicable in general dental
practice.
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PERIOD I
ORDINARY TREATMENT
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PERIOD II
EDUCATION
INTERVENTION/
TREATMENT MODEL
Dental professionals (n=70)
Questionnaire, pre-study
Dental professionals (n=40)
Patients (n=3500)
Questionnaires, pre-treatment
Patients (n=2000)
Questionnaires, pre-treatment
ORDINARY TREATMENT
IMPLEMENTATION OF
TREATMENT MODEL
Dental professionals
Caregiver rating, posttreatment
Questionnaire, post study
Dental professionals
Caregiver rating, posttreatment
Questionnaire, post-study
Patients
Questionnaires, post-treatment
Patients
Questionnaires, post-treatment
RESULTS
PERIOD I
CONCLUSION
RESULTS
PERIOD II
Figure 1. Research design of the dental fear treatment model. Identical questionnaires, patients and
dental professionals respectively, are used repeatedly prior to and after dental treatment.