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The Roots of Dental Fears
A Peer-Reviewed Publication
Written by Kandice Swarthout-Roan, RDH, BS & Priya Singhvi, MS, LPC-I, LMFT-A
Abstract
The relationship between a dental professional and the patient
is the heart of what keeps the practice thriving and patients
returning. Most patients trust the staff members and establish
a “dental home” in which they feel cared for and safe. For some
people, a history of personal trauma, anxiety, or substance use
can paralyze them during a dental appointment. The fear of a
dental appointment or professional may be so overwhelming,
a patient may behave in an exaggerated manner in the chair or
avoid going to the dentist altogether. Awareness of potential
stressors that provoke these behaviors, including the neurobiological responses to trauma, can help dental professionals
provide optimum service with empathy and compassion.
Educational Objectives:
At the conclusion of this educational activity
participants will be able to:
1. Describe the reactions of patients who
have dental fear due to past non-dental
related trauma.
2. Explain biological and physiological
effects of trauma in the human brain.
3. Associate psychological symptoms of
trauma with dental anxiety.
4. Identify practical applications for dental
professionals to alleviate dental fear.
Author Profiles
Kandice Swarthout-Roan, RDH, BS, has practiced clinical
dental hygiene for 16 years and is part-time faculty in the
dental hygiene program at Collin College, McKinney, Texas.
Priya Singhvi, MS, LPC-I, LMFT-A, has been working in the
field of psychology and education for over 11 years. Priya
currently serves as P.A.L. sponsor, wellness educator, and
full-time counselor at a private school in Addison, Texas.
Author Disclosure
Kandice Swarthout-Roan and Priya Singhvi have no commercial ties with the sponsors or providers of the unrestricted
educational grant for this course.
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Publication date: Dec. 2013
Expiration date: Nov. 2016
Supplement to PennWell Publications
PennWelldesignatesthisactivityfor2ContinuingEducationalCredits
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“ThiscoursemeetstheDentalBoardofCalifornias’requirementsfor2unitsofcontinuingeducation.”
ThePennWellCorporationisdesignatedasanApprovedPACEProgramProviderbythe
AcademyofGeneralDentistry.Theformalcontinuingdentaleducationprogramsofthis
programproviderareacceptedbytheAGDforFellowship,Mastershipandmembership
maintenancecredit.Approvaldoesnotimplyacceptancebyastateorprovincialboardof
dentistryorAGDendorsement.Thecurrenttermofapprovalextendsfrom(11/1/2011)to
(10/31/2015) Provider ID# 320452.
This educational activity was developed by PennWell’s Dental Group with no commercial support.
This course was written for dentists, dental hygienists and assistants, from novice to skilled.
Educational Methods: This course is a self-instructional journal and web activity.
Provider Disclosure: PennWell does not have a leadership position or a commercial interest in any products or
services discussed or shared in this educational activity nor with the commercial supporter. No manufacturer or third
party has had any input into the development of course content.
Requirements for Successful Completion: To obtain 2 CE credits for this educational activity you must pay the
required fee, review the material, complete the course evaluation and obtain a score of at least 70%.
CE Planner Disclosure: Heather Hodges, CE Coordinator does not have a leadership or commercial interest with
products or services discussed in this educational activity. Heather can be reached at [email protected]
Educational Disclaimer: Completing a single continuing education course does not provide enough information to
result in the participant being an expert in the field related to the course topic. It is a combination of many educational
courses and clinical experience that allows the participant to develop skills and expertise.
Scientific Integrity Statement: Information shared in this CE course is developed from clinical research and
represents the most current information available from evidence based dentistry.
Registration: The cost of this CE course is $49.00 for 2 CE credits.
Cancellation/Refund Policy: Any participant who is not 100% satisfied with this course can request a full refund by
contacting PennWell in writing.
Educational Objectives
At the end of this self-instructional educational activity, the
participant will be able to:
1. Describe the reactions of patients who have dental fear due
to past non-dental related trauma.
2. Explain biological and physiological effects of trauma in the
human brain.
3. Associate psychological symptoms of trauma with dental
anxiety.
4. Identify practical applications for dental professionals to
alleviate dental fear.
“tooth neurosis.” He said that the fear of dental treatment is
unique because it is rooted in unknown fear and real danger.
The patient is well aware that real danger is possible, but in
most cases little or no pain is experienced.3 The combination
of the perceived and real fear can escalate the anticipatory
anxiety to a level beyond the patient’s ability to process.
Reactions to dental treatment include severe fear and
anxiety during a dental appointment. Prior experiences may
be the source of the dental fear including; adult survivors of
childhood sexual abuse (CSA), posttraumatic stress disorder
(PTSD), substance abuse, and anxiety disorders.
Abstract
Childhood Sexual Abuse
The relationship between a dental professional and the patient
is the heart of what keeps the practice thriving and patients returning. Most patients trust the staff members and establish a
“dental home” in which they feel cared for and safe. For some
people, a history of personal trauma, anxiety, or substance use
can paralyze them during a dental appointment. The fear of a
dental appointment or professional may be so overwhelming,
a patient may behave in an exaggerated manner in the chair or
avoid going to the dentist altogether. Awareness of potential
stressors that provoke these behaviors, including the neurobiological responses to trauma, can help dental professionals
provide optimum service with empathy and compassion.
Approximately 20% of all females seeking dental treatment
are survivors of CSA.15 Another study25 reported that among
women with high levels of dental fear, 34% experienced
childhood molestation, 15% reported attempted rape, and
13% reported rape or incest. Three-fourths of women with
a history of oral penetration associated with CSA had very
high levels of dental fear. Women with CSA had higher levels of dental fears than those in the normative sample.24 It is
crucial for dental professionals to increase their awareness of
this issue to ensure optimum patient care. During a typical
day at the office it is likely that a survivor of CSA will be
treated.
Childhood sexual abuse is a serious issue that, for most individuals, is based in shame and may remain undisclosed for
a lifetime. CSA can affect oral health in many ways with the
mostseriousoftheconsequencesmanifestingaspsychological
issues. The patient may have reduced self-esteem, difficulty
in interpersonal relationships, and reduced initiative. When
these factors continue unresolved, a dental appointment may
be a fearful situation. The patient feels extremely vulnerable
during an appointment, which results in a sense of helplessness.24 In order to avoid helplessness and vulnerability, the
patient may choose to circumvent dental appointments until
he or she is in severe pain or in an advanced disease state, increasing the vicious cycle.2 Others will seek dental treatment
in spite of their fear, but suffer from anxiety without always
understanding the etiology. Treating fearful dental patients
can develop into a stressful situation for the provider and patient. As clinicians become more aware of the signs and symptoms of CSA-based fear, they can modify their approach to
the patient, provide a less stressful visit, and potentially help
patients reduce their fear long term.
As a dental professional, it is important to recognize survivors of CSA to understand extreme reactions during an appointment. CSA is typically a secret for the patient. They may
not connect their dental fear to past experiences.
Problem Assessment
Dental professionals recognize that building a relationship
with patients cultivates trust, which is critical for the patient to
make informed decisions about treatment and return for future
appointments. For some patients, the bond with the hygienist, assistant, or dentist may be a matter of life or death in their
minds. When a person has suffered a severe traumatic experience, he or she may perceive little to no control when placed in
a vulnerable situation including a dental appointment. In this
vulnerable state, the patient may suddenly, sometimes without
knowing why, react with fear and anxiety in the chair. Dental
fear manifests in many ways, sometimes leaving the clinician
confused and frustrated and the patient further traumatized.
The vicious cycle of dental fear and avoidance suggests that
intense fears lead to dental avoidance, poor oral health, fewer
office visits, increased need for treatment, and greater perceived vulnerability.2 The patient gets trapped in this cycle of
fear and continues to avoid appointments or feels extremely
anxious at the mere thought of going to the dentist. The delay
in seeking treatment due to dental fear can greatly impact the
patient’s quality of life.17 The recognition of dental fear and the
potentialunderlyingcausesmayenablethedentalprofessional
to help patients reduce or stop the cycle.
In 1946, Coriat described dental fear as “an excessive
dread of anything done to the teeth.”3 He suggested that this
anticipatory anxiety was not based on the actual pain, but on
a psychological meaning deeper than the actual dental treatment. He named this anxiety, based in expectation and dread,
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Posttraumatic Stress Disorder
Posttraumatic stress disorder is characterized as an anxiety
disorder. This course will focus on PTSD as a separate entity
from the other anxiety disorders because of the need to raise
RDH | December 2013
awareness of its impact on human lives and the dental appointment.
The Diagnostic and Statistical Manual for Mental Disorders (DSM-IV-TR) defines posttraumatic stress disorder
(PTSD) as:
“the development of characteristic symptoms following
exposure to an extreme traumatic stressor involving direct
personal experience of an event that involves actual or threatened death or serious injury, or other threat to one’s physical
integrity; or witnessing an event that involves death, injury, or
a threat to the physical integrity of another person, or learning
about unexpected or violent death, serious harm, or threat of
death or injury experienced by a family member or close associate.”1
Many people believe that PTSD happens only to members of the military that have been in combat situations.
PTSD can affect anyone at any time when faced with serious
or perceived danger. The potential events leading to PTSD
other than military related events include: violent personal
assault, kidnapping, terrorist attack, torture, incarceration,
natural or manmade disasters, automobile accidents, lifethreatening illness, murder of a loved one, and peer suicide.10
Other events such as witnessing another person suffer harm
can trigger PTSD. The actual event does not cause trauma,
but rather how the event was experienced, which helps to explain why some people can overcome unthinkable situations
without PTSD symptoms, while others cannot. Posttraumatic stress disorder is different from other mental health
diagnoses due to four types of symptoms: reexperiencing,
avoidance, numbing, and arousal. PTSD breaks down the
entire system, leaving the patient in survival mode and
chronically hypervigilant.5
When a dental professional is unaware of a patient’s PTSD
diagnosis, he or she may be surprised that dental treatment can
trigger any of the referenced four symptoms. “Tooth neurosis”
can be a reaction to a specific danger that is either an internal
or external threat. A patient with PTSD may respond to a perceived threat in the dental chair due to a hypervigilant state.3
Disclosure of PTSD may not be revealed in the health
history for many reasons ranging from the patient not thinking the information is relevant to simply not realizing he or
she suffers from PTSD.
Anxiety Disorders
Eighteen percent of American adults suffer from anxiety
disorder, ensuring that dental professionals occasionally treat
patients with significant anxiety disorder that manifests in the
dental chair.
Individuals with anxiety disorders are more likely to have
higher levels of dental fear than patients without these disorders.18 Anxiety disorders include a wide range of symptoms
and specific diagnoses. The American Psychiatric Association
lists the following anxiety disorders in the DSM-IV-TR:
• Panic attack
RDH | December 2013
•
•
•
•
•
•
•
•
•
•
•
•
Agoraphobia
Panic attack without agoraphobia
Agoraphobia without history of panic attack
Specific phobia
Social phobia
Obsessive-compulsive disorder
Posttraumatic stress disorder
Acute stress disorder
Generalized anxiety disorder
Anxiety disorder due to a medical condition
Substance-induced anxiety disorder
Anxiety disorder not otherwise specified1
All of these disorders present with diverse symptoms, but
they are all rooted in irrational dread and fear. These fears can
be acquired through classical conditioning, modeling, and
stimulus generalization. Classical conditioning occurs when
a person experiences similar events that transpire within a
close time proximity, stimulating an anxious or fearful response. Modeling is when someone develops fear based on
observations of others’ phobias. Stimulus generalization is a
phenomenon that occurs when a response to one stimulus can
be provoked by a separate but similar stimulus.4 The patient
may not be able to conceptualize the onset or etiology of their
fear, but it can be very real and powerful.
Anxiety disorders may be easy to recognize during the
health history update because many patients with anxiety
disorders will be medicated.The general categories of medications include: selective serotonin reuptake inhibitors (SSRIs),
tricyclic antidepressants, monoamime oxidase inhibitors
(MAOIs), and beta blockers. Gentle, open-ended questions
may facilitate the patient’s disclosure of anxiety medications
and may assist in identifying a patient with an anxiety disorder.
At least 40 million American adults suffer from anxiety
disorders in a given year. Some anxiety disorders are acute in
nature, causing situational disturbances. Other more serious
forms of anxiety disorders may grow increasingly worse and
last a lifetime, requiring medication and counseling, and are
associated with depression and substance abuse (U.S. Department of Health and Human Services, 2009).
Participants with anxiety disorder were surveyed for
dental fear and 36.9% of the participants reported moderate to
severe dental fear.18
Substance Abuse
Substance abuse may not be widely recognized by dental professionals as a source of anxiety for the patient. When describing a patient with substance abuse, some dental professionals
may tend to think of a drug-seeking patient, which results in
mistrust and lack of compassion. Though it is important to
recognize when a patient is seeking narcotics, it is also important to be knowledgeable of how a person with substance
abuse issues can present as an anxious patient.
rdhmag.com | 55
The Diagnostic and Statistical Manual of Mental Disorders,
Fourth Edition (DSM-IV-TR) defines substance abuse as:
A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by one (or
more) of the following, occurring within a 12-month period:
1. Recurrent substance use resulting in a failure to fulfill
major role obligations at work, school, or home.
2. Recurrent substance use in situations in which it is physically hazardous.
3. Recurrent substance-related legal problems.
4. Continued substance use despite having persistent or
recurrent social or interpersonal problems cause by or
exacerbated by the effects of the substance.1
A patient can easily get caught in the vicious cycle when
struggling with substance abuse. For most, avoidance of dental appointments until severe dental issues arise is common
because the clinically significant impairment or distress (as
described in the DSM-IV-TR) overrides the need for selfcare. The patient may have significant dental neglect due to
the substance-related manifestations of behaviorandfeelings.
The patient may tend to neglect his or her personal needs
while engaging in risky and impulsive behaviors. When the
patient finally does seek dental care, he or she is in pain and
may feel highly embarrassed by the neglect and events leading
to the emergency appointment.11 Most likely, substance abusing patients will not disclose their addictive behaviors. They
will proceed with anxiety about the treatment and worry that
their addiction will be discovered by the dentist or hygienist.
Neuroscience of Dental Fear
The neurobiological response to various stressors can fluctuate from patient to patient. A dental professional’s awareness
of the brain processes that react to stimuli can enhance understanding of the patient’s and clinician’s actions.13
The impact of sexual abuse, in addition to other influences, on biological stress systems and the development of the
brain are complex and challenging to separate.6 There are social, psychological, and cognitive effects that may result after
a person has experienced sexual abuse.6 As seen in Figure 1,
a person could experience anxiety symptoms similar to those
of posttraumatic stress disorder. The secondary symptoms
may include unregulated disturbances on several biological
systems which, as time elapses, could result in malfunctioning brain development and exaggerated symptoms of fear and
anxiety during a dental appointment.
The anatomy of PTSD anxiety or overwhelming stress
is multifaceted. During the amplified traumas of child abuse
incidents, the neuroendocrine axes and several neurotransmitter systems are stimulated. Exposure to stress influences
several systems: the immune system, neurotransmitter systems, and neuroendocrine systems—which are linked to
regulate reactions to standard stimuli in addition to acute
and prolonged stressors.
56 | rdhmag.com
Figure 1. The psychobiology of sexual abuse: Dysregulation of
biological stress systems to adverse brain development.
The neurobiological effects of childhood sexual abuse
and trauma are very similar to the direct and indirect effects
experienced during a dental appointment. The neurobiological effects of PTSD are similar to the fear-based reactions to
dental anxiety, so behaviors may be amplified during a dental
appointment.
“The essential symptoms of pediatric PTSD and generalized anxiety disorder are social worries and associated
autonomic hyperarousal….Social cues may trigger PTSD
symptoms of hypervigilance.”6 Childhood sexual abuse is a
trauma associated with social situations. Therefore, cues that
may remind patients of the trauma are relational and can come
without intention (e.g., looking directly at a person, inflection
of voice, etc.).
Hypotheses for posttraumatic stress disorder in adult
populations indicate that these neurobiological stress response systems develop in abnormal ways, which can result in
permanent, damaging effects.6
The neurobiological effects of PTSD are very similar to
the direct and indirect effects experienced during a dental
appointment. If you are treating a patient with PTSD, these
biological responses may be exaggerated and could place the
patient at risk.
Compromised Immune System
Unfavorable experiences during childhood and adolescence
are strongly correlated with several acute health problems
in adulthood, including poor self-rated health and hygiene.8
Patients with poor oral hygiene that exhibit a lack of self-care
for health issues are more likely to need a dental appointment.
These patients are more likely to require additional dental
work during an appointment or have severe pain that will
force them to seek dental treatment.
The effects of sexual abuse and trauma on health and immunity merits future research in pediatric populations.
RDH | December 2013
Increased Generalized Fear and Reduced Sociability
Primate studies have shown that children reared in an unstable environment developed insecure attachment behavior
patterns,evidencedbyreducedsocialcompetenceandheightened fearful behaviors.19 Individuals who have been raised in
an unstable environment may develop into dental patients
that appear to have increased fear of the dentist in addition to
being unsociable.
Patient Presentation
The aforementioned issues should serve as a guide for knowledge and awareness so the clinician can make adjustments
to provide optimum care. The clinician should not use these
recommendations to make a diagnosis or confront the patient
about a possible concern. In fact, a practitioner may spend
years treating a patient who presents with an emotional or
mental health issue without patient disclosure.
If an individual statistically combines the number of
patients that may have experienced sexual abuse (20%), or
an anxiety disorder (18%), the magnitude of these afflictions
becomes very apparent. In any given day, a dentist or hygienist could have patients that suffer from dental related anxiety.
Knowledge and awareness are key components to making appointments a success.
Childhood Sexual Abuse
Patients who have dental fear due to a history of CSA may
experience a lack of trust, fear of loss of control, struggle with
factors relating to communication, and have difficulty receiving negative information.24 It may be challenging to remain
still or quiet during the appointment. Dental treatment may
provoke PTSD symptoms, flashbacks, and dissociation. Dissociation is “a disruption in the usually integrated functions
of consciousness, memory, identity, or perception of the environment” which becomes the patient’s way of coping during
a time of crisis.14
Patients who dissociate may present clinically in ways
that are surprising or frustrating to the clinician. Many patients have an intense fear of being in a supine position, of the
dentist or hygienist touching their lips or putting anything in
their mouths, and being in close proximity to the clinician.24
Patients may react with panic, tension in the body, crying,
reluctance to open their mouth, a sense of distrust toward
the clinician, and a need to know what is happening. To the
hygienist or dentist, this behavior may seem extreme or unnecessary during a simple procedure, but to the patient the
appointment can be perceived as a matter of life or death in
that moment. The reaction of the patient sometimes elicits
frustration and a feeling of powerlessness for the clinician as
well as the patient. Despite the clinician’s best attempt to ease
the patient, the patient may seem inconsolable. These events
may also unfold even when a fearful patient is told they need
a simple procedure.
RDH | December 2013
Hygienists have reported anecdotally being surprised
when a patient gets extremely emotional after being told they
need a single-surface composite filling. To the hygienist, this
may be an exaggerated response. To the female patient, the
fear of having a male dentist close to her with his hands in her
mouth is more than she can tolerate. Specifically, the dentist is
referenced here as male because statistics show most abusers
are male, making a male dentist more threatening to a female
patient.24 Willumsen’s research also revealed that 56.3% of
women in the study suffering from dental fear reported oral
penetration during sexual abuse. It was concluded that these
past experiences evoked severe anticipatory anxiety prior to
the dental visit and created a situation of fear of loss of control
and fear of an “intimate” situation with the dentist.
It should be noted that not all victims of CSA suffer from
dental fear. Traumatic experiences do not always result in
psychological issues for the patient. As clinicians it is important to be aware of these potential aspects of patient’s experiences. It is also crucial to remember that CSA is a secret for
most victims and if behavior is indicative of childhood sexual
abuse, the clinician handles it with respect and compassion.
Posttraumatic Stress Disorder
Patients suffering with PTSD may look very similar to those
who are survivors of CSA. Sexual trauma and PTSD may go
hand in hand because victims of CSA may have PTSD due to
the extent of the trauma.
Reexperiencing the traumatic event is also called “flashback.” The individual is haunted with vivid recurring
thoughts, memories, dreams, or nightmares. These experiences are very real to the individual. They may actually
reexperience the trauma in their minds, transporting them to
a place of intense fear and helplessness. Avoidance is the act
of purposefully avoiding thoughts, activities, or conversations
thatremindtheindividualoftheevent.Reducedresponsiveness
or numbing occurs when individuals detach themselves from
activities or interests that were formerly enjoyed. Some will
experience symptoms of dissociation or psychological separation. Arousal or increased anxiety occurs because the person
feels a sense of hyperalertness, is startled easily, has trouble
concentrating, and may develop sleep disorders. He or she
may also experience extreme levels of guilt surrounding the
event.4
Information about these symptoms may be ascertained in
the health history, but often patients do not share it or they
are not aware that something during the dental appointment
could trigger maladaptive responses.
Pain and sensitivity in the dental chair may elicit emotional
and/or physical responses such as increased heart rate, chills,
panic, or uncontrollable shaking.10 The procedures during a
dental appointment can be a trigger for patients due to pain,
lights, sounds, and smells. The loss of connection and highly
aroused state when the patient experiences one these triggers
rdhmag.com | 57
puts him or her in survival mode, creating a stressful situation for the patient and provider. It is not the dental clinician’s
responsibility to diagnose PTSD, but when symptoms are
recognized, the hygienist, assistant or dentist can make the
proper adjustments to accommodate the patient.
Anxiety Disorders
Anxietycanbedescribedasanambiguousawarenessofdanger
that increases breathing, body temperature, and muscle tension. It prepares or alerts people to adapt to a “fight or flight”
situation. For some, the anxiety becomes incapacitating and
prevents the enjoyment of everyday life events.4 Individuals
with anxiety and phobia disorders more frequently reported
intensified dental fear than those without such conditions.17
The relationship between individuals with phobias and a
tendency to attach exaggerated meaning to their experiences
may lead to the expression of inappropriate behavior during a
dental visit.9 The perceived threat is intense and he or she is in
a vulnerable position with loss of control. Similar to survivors
of CSA and PTSD, a patient with an anxiety disorder may
become extremely overwhelmed by being in the supine position. The dental experience can be fearful to someone without
an anxiety disorder due to the unknown and anticipated pain
and discomfort.
Behaviors consistent with dental fear due to an anxiety
disorder can present as a patient who is suddenly tearful, cries
or yells out when minimal dental work is being performed,
becomes aloof or angry once they are seated in the chair, has
somatic symptoms such as shaking or sweating, tenses up,
and/or has difficulty keeping his or her mouth open. The patient may even move his or her head abruptly and erratically
during a procedure, creating a dangerous situation. These
same behaviors may also be present in a survivor of CSA.
Since it is not the clinician’s responsibility to diagnose the
psychological etiology, it is important that he or she proceeds
with awareness and compassion. Only by establishing trust
can the patient start a journey toward decreasing intense dental fear.
Substance Abuse
The patient suffering from any type of substance abuse
will likely avoid dental treatment as long as possible due to
self-neglect and fear their addiction will be discovered. This
patient is likely to seek care after a dental emergency occurs.
There is a high risk of periodontitis, caries, missing teeth, and
other oral disease among persons with substance addiction.14
Also, there may be an increased risk for problems with pain
management during dental procedures as the anesthetic may
be perceived as ineffective.16
Based on the elevated incidence of disease and decreased
effectiveness of oral anesthesia, a patient actively or formally
addicted to a substance may suffer from severe anxiety about
dental treatment. The anxiety could stem not only from the
58 | rdhmag.com
perceived threat of pain during treatment, but also the anticipated embarrassment when others witness the oral condition.
With multifaceted levels of potential shame and fear due to
neglect and risky behavior, it is crucial to build a trusting relationship with this patient. It is likely that he or she will require
a great deal of empathy and compassion to return for a nonemergency visit. A patient actively or formally addicted may
show similar symptoms to someone with an anxiety disorder.
Anxiety disorders are often dual diagnosed with substance
abuse.
Coping with Dental Anxiety
The link between consequences of trauma and an experience
in the dental office may manifest in a variety of ways including
resistance to being placed in the horizontal position, fear of
having objects placed over the face, sudden outbursts of crying without apparent reason, difficulty opening wide, severe
gagging, and an involuntary turning of the head away from
the clinician as he or she approaches the mouth.13
Regrettably, dentists and hygienists can exacerbate the
dental experience due to lack of knowledge and/or comprehension of the processes that are the root of the patient’s
actions. Patients who have been victims of childhood sexual
abuse or assault may have flashbacks when in the dental chair
due to the restrictive environment of a confined office or chair.
The most harmful reaction is the frustrated dental professional who attempts to take control of the situation or inadvertently makes insensitive comments. Demeaning the patient or
dealing with the situation authoritatively may deteriorate the
patient’s state of mind and may reactivate the traumatic event.
Effects on the Dental Professional
The concept of emotional labor is defined as “the practice of
controlling one’s emotions on the job, [which] may be integral to performing the job, but may have unintended consequences for the practitioner.”20 Emotional labor becomes
particularly draining for the professionals who are invested
in the patient’s well-being. Thinking about patients after
they have left the dental office has been strongly linked with
interpersonal, psychological, and vocational stress. In addition, dental professionals carry the burden of frequently being
required to inflict discomfort in order to appropriately execute
dental treatments. Emotional labor has been correlated with
individual and organizational concerns including employee
attrition, diminished performance at work, and burnout.20
If a patient presents with symptoms that are associated
with childhood sexual abuse, trauma, anxiety, or substance
abuse, a dental professional is more likely to experience high
levels of emotional labor. It is important for dentists and
hygienists to protect themselves from these vocational and
psychological strains. Some techniques utilized to alleviate
emotional labor include deep acting and surface acting. Deep
acting is less psychologically exhausting than surface acting
RDH | December 2013
for dental professionals. Deep acting denotes altering an individual’s perception of an experience or distracting attention
and refocusing on positive cognitions to actually augment the
underlying emotions.20 For example, a dentist who is irritated
by a patient telling him or her to stop every few seconds could
understand the situation from the patient’s point of view to
reduce the feelings of irritation. In addition, operating from
a framework of empathy is less taxing on the dental professional and even builds rapport with the patient. Surface acting,
however, refers to changing only the visible representation
of a reaction to an experience without actually modifying
thoughts. For example, a dental hygienist could pretend to be
excessively amiable or completely repress feelings by smiling
through a painful procedure. Surface acting was linked to feeling numb or drained emotionally. Another aspect to keep in
mind is that the dental profession is well-respected, appreciated, and gives back to the community; this conceptualization
can buffer psychological stressors.20
Techniques to Integrate
Being a well-informed, aware dental professional is the first
step to ensure optimal care for patients. Moreover, some additional procedures may be employed that have implications
for training, educating, and coping for dental professionals
and practices.
Informing patients. The dental professional may inform all patients (regardless of whether or not they display the
symptoms of fear, anxiety, etc.) of practices that encourage
compassion and open communication in the dental appointment. If space allows, let patients know that they can bring
a family member or friend to dental appointments. Notify
patients that they can request extra time for appointments if
they anticipate anxiety. Some fearful patients will naturally
take more time so it is better to be informed in advance to accommodate busy schedules. Ask if the patient would like to
operate the suction when the space and procedure allows.This
may help the patient regain a sense of control. If symptoms of
trauma history appear to be present, inform the patient that
the dentist can offer clear explanations before and during a
procedure. Offer patients the option to bring headphones, or
play soothing music throughout the dental office. Give the
patient the option to provide a nonverbal gesture to signify
when anxiety is increased and/or to cease the procedure.
Using sedation. Sedation can be a very beneficial tool for
some patients with anxiety. Dr. Carmen Santos21 indicated
that most sexual abuse survivors would rather not be sedated.
For individuals who have experienced trauma, the utilization
of sedatives could increase feelings of helplessness and loss of
control at a time when the patient is already in a compromised
position.
For patients with a substance abuse history, the use of sedation should be carefully considered. For some patients, the
use of sedation could trigger feelings of being high or of addic-
RDH | December 2013
tion. As such, some dental patients in recovery may prefer to
abstain from using sedation, even during particularly painful
procedures.
When sedation is necessary it is mandatory for a relative
or friend to accompany the patient. Ask about any previous
experiences of using sedation and if there are any ways to
provide more comfort for the patient. In addition, communicating with empathy and compassion can relieve fear and
anxiety.
Building the relationship. Patients frequently report
that a compassionate, empathetic dental professional who
displays patience and active listening was the turning point in
reduction of dental fear.21 Empathy has been defined as the
“process by which observers attempt to project themselves
into an observed person or object.”12 Generally, in psychotherapy, the treatment outcome of the client depends more
heavily on the perceived empathy of the professional, rather
than the professional’s actual skill level, techniques, or education. The relationship between two individuals is much more
powerful than the intervention. The most beneficial action a
dental professional can take is to invest in building rapport
with a patient, regardless if he or she is exhibiting symptoms
of past abuse, trauma, or anxiety.
Effective Communication
How can dental professionals begin to build the relationship
with fearful patients and communicate empathetically and
effectively? In order to facilitate empathy, a person must be
aware of one’s own emotions and start from a place of deep
acting and understanding, rather than judgment. The question, “What are my expectations of others; my coworkers,
my boss, my patients” and in turn “How does that reflect my
expectation of self?” The heart of compassion is really acceptance.7 When people learn to accept themselves and others,
compassion and empathy naturally follow. It is important to
be mindful of how the dental professional would like to act,
regardless of how a patient is acting or reacting. In order to reduce emotional labor and cultivate a healthy, happy work environment, the dental professional must model and advocate
effective, empathetic exchanges. This kind of communication
is conveyed through understanding, listening, reflecting feeling, and asking open-ended questions.
Understanding. Before approaching a potentially fearful patient, it is important to pause and evaluate the level of
self-awareness. Greater understanding of self can be developed by asking questions including: “What am I feeling?”
or “What are the thoughts I am having? Why?” and even
more importantly when interacting with patients, “How am
I approaching this conversation?” If dental professionals are
cognizant of these emotions and thoughts prior to communication, they are empowered to think about what is truly the
desired outcome and take appropriate action.
rdhmag.com | 59
Actively listening. Certain behaviors immediately
indicate active listening to the dental patient. These include
providing focused, intermittent eye contact; nodding the head
in affirmation; maintaining soft body language; and having a
warm, engaged expression. Before, during, and after contact
with dental patients, ask questions such as, “What is the
patient feeling?” or “What are the thoughts the patient may
be having?” and “Why might the patient be acting this way?”
Helping patients to become empowered, especially those
who experience dental anxiety, requires listening to them,
thoughtfully considering what is being said, and expressing
appropriate, consistent nonverbal indicators.
Other nonverbal indicators can be expressed by sitting the
patient up, removing the mask and gloves. Extremely fearful
patients feel powerless when lying back in the chair. An attempt to be empathetic while maintaining them in a supine or
semisupine position may be ineffective.
Reflecting feelings. The ability to reflect what a fearful
patient is expressing back to him or her takes some practice,
but is a key component to communicating effectively. Mirroring a patient’s emotions helps build the relationship, acknowledges and validates his or her feelings without minimizing
the effect. It also conveys understanding and empathy, and
assists the patient in the expression of additional feelings. For
example, a patient may ask, “Are we done yet? Are we almost
finished? How long is this going to take?” Rather than simply
replying with an objective answer, consider responses such as
“You sound a bit nervous about how long this procedure may
take.” Reflecting the feeling of “nervous” can allow for patients to feel heard, rather than rushed. This will further build
the relationship with the fearful patient, hopefully resulting in
reduced fear and more frequent visits.
Reflection of feeling is the key component in helping the
patient feel understood and heard. Many times, patients feel
minimized or dismissed when they are told “it will be okay”
or “it is just a simple procedure.” If the patient has a traumatic
past that stimulates memories in the dental chair, the feeling
of being misunderstood can be amplified.
Reflecting feelings, even those with a negative connotation
such as fear, sadness, or frustration, is one of the most effective
ways to build rapport with patients. For example, when patients
show the symptoms of a traumatic past, they are more likely to
feel understood when the clinician can try to reflect an emotion.
The hygienist may say, “It seems like you are afraid today. How
can I best support you during this appointment?” This opens
the door for further communication and begins to alleviate
anxiety for both the patient and hygienist. When a patient with
dental fear is not properly attended to, he or she may feel alone
and withdraw. Reflection of feeling or joining with the patient is
the first step for healing and diminishing the fear.
Conclusion
Many factors should be considered when easing a patient’s
concerns, especially those who suffer from past traumatic ex60 | rdhmag.com
periences. When clinicians are aware of the impact that a patient’s mental health can have on the dental appointment, are
cognizant of the symptomology of trauma, and are informed
about how to proceed with empathy and compassion, the patient may be more likely to consistently attend appointments
and receive optimal dental care.
References
1. American Psychiatric Association (2005). Diagnostical and
stastical manual of mental disorders: DSM-IV-TR (4 ed.).
Washington, DC: Jaypee Brothers.
2. Armfield, J. M. (2012). What goes around comes around:
Revisiting the hypothesized vicious cycle of dental fear and
avoidance. Community Dentistry and Oral Epidemiology,
41, 279-287.
3.Capps, D., & Carlin, N. (2011). Sublimation and
symbolization: the case of dental anxiety and the symbolic
meaning of teeth. Pastoral Psychology, 60, 773-789.
4. Comer, R. J. (2010). Abnormal psychology (7 ed.). New
York, NY: Worth Publishers.
5. Curran, L. A. (2010). Trauma competency: A clinician’s
guide. Eau Claire, Wisconsin: PESI, LLC.
6. De Bellis, M. D., Spratt, E.G., & Hooper, S. R. (2011).
Neurodevelopmental biology associated with childhood
sexual abuse. Journal of Child Sexual Abuse, 20 (5), 548-587.
doi:http://dx.doi.org/ 10.1080/10538712.2011.607753.
7. Brown, B. (2010). The gifts of imperfection: Letting go of
who you think you’re supposed to be and embrace who you
are. Cente City, MN: Hazelden.
8. Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D.
F., Spitz, A. M., Edwards, V., et al. (1998). Relationship of
childhood abuse and household dysfunction to many of the
leading causes of death in adults. The Adverse Childhood
Experiences (ACE) Study. American Journal of Preventive
Medicine, 14, 245–258.
9.Forbes, M.D.L., Boyle, C. A., & Newton, T. (2011).
Acceptability of behaviour therapy for dental phobia.
Community Dentistry and Oral Epidemiology, 40, 1-7.
10.Greco, L. J., & Garcia, W. M. (2008, July). Post-traumatic
stress disorder: Treatment with confidence, competence,
and compassoin. Access, 22(6), 30-33.
11.Gunn, R. L., Finn, P. R., Endres, M. J., Gerst, K. R., &
Spinola, S. (2013). Dimensions of disinhibited personality
and their relation with alcohol use and problems. Addictive
Behaviors, 38, 2352-2360.
12.Hassenstab, J., Dziobek, I., Rogers, K., Wolf, O. T., & Convit,
A. (2007). Knowing what others know, feeling what others
feel: A controlled study of empathy in psychotherapists.
The Journal of Nervous and Mental Disease, 195(4), 277281.
13.Kamin, V. (2006). Fear, stress, and the well dental office.
Northwest Dentistry, 85(2), 10.
14.Khocht, A., Schleifer, S. J., Janal, M. N., & Keller, S. (2009).
Dental care and oral disease in alcohol-dependent persons.
RDH | December 2013
Journal of Substance Abuse Treament, 27, 214-218.
15.Leeners, B., Stiller, R., Block, E., Gorres, G., Inthurn, B.,
& Rath, W. (2007). Consequences of childhood sexual
abuse experiences on dental care [Abstract]. Journal of
Psychosomatic Research, 62, 581-588.
16.Metsch, L. R., Crandall, L., Wohler-Torres, B., Miles, C.
C., Chitwood, D. D., & McCoy, C. B. (2002). Met and
unmet need for dental services amoung active drug users in
Miami, Florida. The Journal of Behavioral Health Services
and Researach, 29(2), 176-188.
17.Newton, T., Asimakopoulou, K., Daly, B., Scambler, S., &
Scott, S. (2012). The management of dental anxiety: Time
for a sense of proportion? British Dental Journal, 213, 271274.
18.Pohjola, V., Mattila, A. K., Joukamaa, M., & Satu, L. (2011).
Anxiety and depressive disorders and dental fear among
adults in Finland. European Journal of Oral Sciences, 119,
55-60.
19.Rosenblum, L. A., & Andrews, M. W. (1994). Influences
of environmental demand on maternal behavior and infant
development. Acta Paediatrica, 397(supplement), 57–63.
20.Sanders, M., & Turcotte, C. (2010). Occupational stress in
dental hygienists. Work, 35(4), 455-465. doi:http://dx.doi.
org/ 10.3233/WOR-2010-0982
21.Santos, C. (Interviewee). Sexual Abuse in Childhood and
Dental Fear [Interview transcript]. Retrieved from Dental
Fears Web site: http://www.dentalfear.com/santos.asp.
22.Vermetten, E., & Bremner, J. D. (2002). Circuits and
systems in stress II applications to neurobiology and
treatment in posttraumatic stress disorder. Depression and
Anxiety, 16, 14–38.
23.U.S. Department of Health and Human Services (2009).
Anxiety disorders: National Institute of Mental Health.
24.Willumsen, T. (2004). The impact of childhood sexual
abuse on dental fear. Community Dentistry and Oral
Epidemiology, 32, 73-79.
Author Profiles
Kandice Swarthout-Roan, RDH, BS, has practiced clinical
dental hygiene for 16 years and is part-time faculty in the
dental hygiene program at Collin College, McKinney, Texas.
Priya Singhvi, MS, LPC-I, LMFT-A, has been working in
the field of psychology and education for over 11 years. Priya
currently serves as P.A.L. sponsor, wellness educator, and
full-time counselor at a private school in Addison, Texas.
Author Disclosure
Kandice Swarthout-Roan and Priya Singhvi have no
commercial ties with the sponsors or providers of the
unrestricted educational grant for this course.
Notes
RDH | December 2013
rdhmag.com | 61
Online Completion
Use this page to review the questions and answers. Return to www.ineedce.com and sign in. If you have not previously purchased the program select it from the “Online Courses” listing and complete the
online purchase. Once purchased the exam will be added to your Archives page where a Take Exam link will be provided. Click on the “Take Exam” link, complete all the program questions and submit your
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and/or printed anytime in the future by returning to the site, sign in and return to your Archives Page.
Questions
1. The “vicious cycle” is:
a. The progression of periodontal disease
b. Avoiding the dentist due to intense fear which leads to
an increased need for dental work
c. Bacteria formation due to poor oral hygiene
d. Over-exaggerate behaviors during a dental visit
2. After a person has experienced sexual
abuse, the outcomes may affect a person:
a.Psychologically
b.Socially
c.Cognitively
d. All of the above
3. The core of dental anxiety is rooted in:
a.
b.
c.
d.
Expectation and dread
Fear of the “drill”
Childhood memories of the dentist
Fear of an aggressive hygienist
4. When the symptomatic nervous system
(SNS) is stimulated by acute anxiety or
fear, the body responds with the following
reaction:
a.
b.
c.
d.
Rest and digest
Parasympathetic stimulation
Fight or flight
None of the above
5. What percentage of women seeking dental
care are survivors of childhood sexual
abuse?
a. 80%
b.34%
c.20%
d.8%
6. Why is it important for dental professionals
to be aware of the neurobiological effects of
childhood sexual abuse and trauma?
a. So the dental professional can accurately diagnose the
patient
b. Because the effects are similar to the effects experienced
during a dental appointment
c. So the hygienist can ask the patient directly if she or he
has experienced trauma or sexual abuse
d. All of the above
7. All of the following are symptoms of
posttraumatic stress disorder except:
a. Flashbacks
b. Avoiding situations
c.Numbing
d. Hearing voices
8. A patient who seems isolated and
unsociable during a dental appointment:
a.
b.
c.
d.
Usually requires a root canal
Can be best described as an extrovert
May have been raised in an unstable environment
Is likely experiencing psychosis
9. posttraumatic stress disorder can affect:
a.
b.
c.
d.
Combat soldiers
Someone who has witnessed a murder
Someone who has experienced a natural disaster
All of the above
10. The brain structure that regulates fear,
anxiety, and social inhibition is the:
a.Amygdala
b.Cortex
c. Corpus callosum
d. White matter
11. Tooth neurosis is:
a.
b.
c.
d.
Fear of teeth
Fear of anything being done to the teeth
Brushing and flossing excessively
Nightmares about losing teeth
62 | rdhmag.com
12. Unfortunately, dental professionals have
exacerbated the dental experience for the
fearful patient by:
a.
b.
c.
d.
Responding with frustration
Attempting to take control of the situation
Assuming they know why the patient is reacting
All of the above
13. Patients with dental fear due to CSA may
display which of the following behaviors
during a dental visit:
a.
b.
c.
d.
Crying
Amplified response after learning they need dental work
Fear of leaning back in the chair
All of the above
14. Changing perception of an experience or
redirecting attention to positive thoughts
is called:
a.
b.
c.
d.
Emotional labor
Deep acting
Surface acting
Cognitive impairment
15. The most objective way for a clinician to
detect an anxiety disorder in a patient is:
a.
b.
c.
d.
The patient lists anxiety medications on health history
The patient seems nervous
The patient states that he or she is nervous
The patient is sweating
16. In regard to dental fear, it is the clinician’s
responsibility to:
a. Diagnose the patient with a mental disorder
b. Ask the patient if he or she has an anxiety disorder
c. Be aware a of patient’s behavior and respond with
compassion and empathy
d. Refer the patient to another dentist or hygienist
17. Lack of trust, fear of loss of control, and
struggles with communication may be
factors for a patient who:
a. Has a toothache
b. Has dental fear due to childhood sexual abuse or other
trauma
c. Is new to the practice
d. Has not been to the dentist in many years
18. A patient that struggles with selfregulation of behaviors and neglects
self-care may be suffering from:
a. Anxiety disorder
b. Trauma from abuse
c. Substance abuse
d.PTSD
19. A dental practice can inform patients of
practices that encourage compassion and
tolerance, including:
a. Informing patients that appointments only have a
30-minute time slot, which should go by quickly
b. Encouraging patients to come alone so that less people
are in the room
c. Offering patients to bring music to the dental appointment
d. Letting the patient know that the dental professional
will not stop until the procedure is completed
20. The use of sedation should:
a. Always be utilized for patients with previous childhood
sexual abuse because it will put them at ease
b. Be encouraged for past substance abuse users because it
gives them a familiar high
c. Be used if any patient has previously had sedation
d. Be discussed with the patient and offered in conjunction
with support
21. For a survivor of trauma with high dental
anxiety, the most important part of a dental
appointment is:
a. Removing every piece of calculus
b. That the hygienist use impeccable advanced
instrumentation
c. Trusting the clinician and feeling safe during the
appointment
d. Receiving thorough OHI
22. Dental clinicians sometimes mistake
dental fear due to an anxiety disorder as:
a. The patient’s unwillingness to cooperate
b. Shame and embarrassment
c. Fear due to past experiences
d. PTSD
23. Anticipatory anxiety refers to:
a. Reaction to actual dental pain
b. Anger about pain experienced after a dental appointment
c. Perceived threat about the possibility of future pain or
discomfort
d. The reduction of anxiety with the use of nitrous oxide
24. In a study on dental fear, what percentage
of those surveyed reported moderate to
severe dental anxiety:
a. 25%
b. 36.9%
c. 12.2%
d. 8.5%
25. A person who suffers from substance
abuse may avoid the dentist until he or she
is in pain because:
a. Their insurance is running out
b. Guilt and shame about their addiction and condition
of teeth
c. They have a Groupon
d. They decided to improve the health and appearance of
their teeth
26. Emotional labor correlates to:
a. Interpersonal, psychological, and vocational stress
b. The need for midday naps
c. Crying in the darkroom
d. Clinicians frequently changing jobs
27. Changing only the visible representation
of a reaction to an experience without
actually modifying thoughts is:
a. Emotional labor
b. Deep acting
c. Surface acting
d. Artificial empathy
28. An effective way to empower a fearful
patient during an appointment is to:
a. Ask them to fill out paperwork before they get to your
office
b. Help them feel as if they have control over the appointment
c. Inform them that you are very busy and this will be a
short appointment
d. Refer them to a clinician that has experience working
with nervous patients
29. Patients with substance abuse history may
avoid sedation because:
a. The sedatives may trigger familiar feelings of being high
b. They may have flashbacks of previous trauma
c. They do not have anyone to drive them home
d. Dentists usually don’t recommend sedation for
substance abuse patients
30. The process by which observers attempt
to project themselves into an observed
person or object is called:
a. Perceived reality
b. Empathy
c. Emotional osmosis
d. Telepathy
RDH | December 2013
ANSWER SHEET
The Roots of Dental Fears
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Requirements for successful completion of the course and to obtain dental continuing education credits: 1) Read the entire course. 2) Complete all information
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Educational Objectives
1. Describe the reactions of patients who have dental fear due to past non-dental related trauma.
Academy of Dental Therapeutics and Stomatology,
A Division of PennWell Corp.
2. Explain biological and physiological effects of trauma in the human brain.
P.O. Box 116, Chesterland, OH 44026
or fax to: (440) 845-3447
3. Associate psychological symptoms of trauma with dental anxiety.
4. Identify practical applications for dental professionals to alleviate dental fear
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