Dental fear: comparisons between younger and older adults.

Abstract: This study explored differences between 107 adults (ages 26-79) and 134 young adults (ages 18-23) on fear of dental treatment. Subjects completed scales measuring general dental anxiety (DAS-R) and negative perception of dental stimuli (DFAS). A relationship between negative perceptions and anxiety levels was found in both samples (adult r=.67, p<.001; young adult r=.74, p<.001). However, dental fear scores were significantly higher [t(239)=5.28, p<.001] in the young adult group (M=12.71, SD=5.71) than the adult group (M=9.31, SD=3.98). If health educators, psychologists and dental health providers are to manage this epidemic, identification and treatment of dental fear in young adults is necessary.

**********

Anxiety related to fear of dental treatment is often a significant barrier to proper dental health. This anxiety, or dental fear, often originates early in life through childhood experiences with dental treatment, and may lead to the lifelong fear of dentistry. Dental fear is disconcerting for both the patient and the entire dental team. It is especially problematic for hygienists, because they are frequently the first members of the dental team to treat the patient.

Patients who suffer from dental fear require a third more office time than those who experience either no fear or mild fear (King, 1991). Fearful individuals often avoid care despite extensive dental needs, and will tolerate pain for on average of 17.3 days before seeking treatment (King). These individual often self-medicate and avoid the inevitable dental visit as long as possible, increasing the likelihood of further complications.

Dental fear has reached an epidemic level affecting almost 50 million people in the United States. Of this number, twenty-five million often refuse treatment because of frightening childhood experiences. Dental fear has been ranked fifth among the most common fears (DeJongh, Morris, Schoemakers, & Ter Horst, 1995). Many fearful individuals never even consider going to the dentist while others schedule dental appointments and then break them. Consequently, there exists a large population of fearful individuals who do not seek treatment and are compromising their dental health (Kent & Blinkhorn, 1991). Dental fear can prevent an otherwise intelligent, reasonable person from optimizing and maintaining his or her oral health. While most people feel slightly anxious when visiting the dentist, those who suffer from dental fear often fail to go for routine care. Small, preventable problems later grow to require major intervention. Patients who are very fearful of routine dental treatment have poorer oral health than those who are less anxious, The extremely fearful patient will tolerate pain, inflammation, and even an abscessed tooth before talking steps to visit a dentist.

Dental fear perpetuates a vicious cycle (Ronis, Hansen, & Anton, 1995). The fear and anxiety result in avoidance, which furthers the deterioration of the teeth, leaving the person with feelings of guilt, shame, and inferiority (Moore, Brodsgaaurd & Birn, 1991). This fear is reinforced when avoidance behaviors result in the need for emergency care, which enhances the negative self perceptions, thereby reinforcing avoidance behavior. Dental fear leads to a self-perpetuating cycle, whereby fear leads to avoidance, avoidance leads to emergency treatment, and emergency treatment reinforces the fear (Gradbury-Amyot, Overman, Carter-Hanson, & Mayberry, 1995). There are also serious consequences for the provider, such as low utilization of services, failed appointments, increased emergency situations, and greater difficulty in rendering treatment (Gadbury-Amyot, 1996).

Previous studies addressing dental fear, anxiety, and phobia have reported that the primary reason people avoid dental treatment is fear of pain. The sensation of the anesthetic injection, the sight of the syringe, and the sight, sound, and sensation of the drill were most frequently identified as painful and producing fear (Ingersoll, 1982). Approximately 50% of patients who described themselves as fearful reported that the reason for their fear is the pain involved with treatment procedures. Of note, pain from dental treatment is generally rated milder than pain from other types of medical treatment. Most individuals rate dental pain somewhere between no pain and somewhat painful (Ingersoll). However, it should be noted that memories of pain are reconstructed and heightened over time, and match the existing level of dental fear for most fearful patients.

Dental fear has many causes (Berggren, 1992; Liddell, DiFazio, Blackwood, & Ackerman, 1994). The main categories include direct negative experiences reported by family, friends, or the media; general anxiety disorders, and individual personality characteristics (Bernstein, Kleinknecht, & Alexander, 1989; Moore et al., 1991). The literature also notes several sociodemographic correlates of dental anxiety. Specifically, women reported having dental anxiety more frequently than men, while men more commonly experienced severe dental fear and phobia (Berggren; Doebling & Rowe, 2000; Doerr, Lang, Nyguist, & Ronis, 1998; Locker, Shapior, & Liddell, 1996; Rowe & Moore, 1998; Schuurs, Duivenvooreen, Van Velzen, Verhage, Eijkman, & Makkes, 1985). There is conflicting evidence in the literature concerning the effect of educational level on dental anxiety; however, recent studies report that those with more education are less fearful (Doerr et al.).

A number of models have been used to explain the origins of dental anxiety. The classical conditioning model applies when a history of painful oral health care treatment or an unpleasant oral health care experience results in expectations of painful future treatment (Davey, 1989; Vassend, 1993). Negative attitudes regarding oral health care within families can predispose a patient to expect negative experiences. The influence of cognitive functioning on behavior has also been studied and found to evoke dental fear. Studies involving general anxiety indicate that such people tend to engage in negative or catastrophizing thinking (De Jongh & Ter Horst, 1993; De Jongh, et al., 1995). It is interesting to note that dentally anxious patients have about three times as many negative thoughts as low anxiety patients. Perception may also be a factor in the development and maintenance of dental fear. Specifically, perceptions that dental procedures are painful may account for the high prevalence of dental anxiety (Litt, 1996). Unpleasant experiences can leave lasting impressions, as demonstrated by the fact that highly fearful patients often attribute their dental fear to a single negative childhood event (Berstein et al., 1979; Liddell, et al., 1994). Finally, certain specific stimuli in the dental setting have been found to cause dental fear. Patients are most uncomfortable in dental situations that include having a cavity drilled and filled, having a tooth pulled, having teeth probed, and receiving an injection (Liddell, et al). Consequently, these procedures may activate threat-related cognitive schema, resulting in negative appraisal of the situation and subsequent dental fear.

Technological advances promote better care in that dental procedures are now performed with greater skill and accuracy and less trauma, in a shorter span of time. Despite technical advances, many patients still harbor negative perceptions of prior oral health care experiences and experience the same level of fear and anxiety (Katchum, 1995). Clearly, dental fear can be a difficult aspect of dental health management. Oral health care professionals often receive little, if any, education in the management of the anxious dental patient, even though this aspect of oral health care dearly contributes to positive dental experiences (Perez, Kaplan & Stabboltz, 1997).

If dental fear is to be treated, further study of perceptions that influence this fear is needed to improve treatment methods. In an attempt to further define the etiology of dental anxiety, this study examined how negative perceptions of commonly occurring dental stimuli factor into the dental fear equation. This research included stimuli that have been the focus of many studies along with common stimuli that have not been well researched. Since routine dentistry involves many stimuli, it makes sense to try to single out which items carry the most negative perceptions. The focus of this research study is on commonly encountered stimuli during routine dental visits such as personal protective equipment, hand and power-driven instruments, dental radiographs, needles, air and water spray, and suction. A better understanding of specific factors that evoke anxiety during dental treatment may result in implementation practice strategies and delivery methods that reduce anxiety ultimately leading to improved dental health.

Commonly, a patient who has had a bad prior experience during childhood will be quite apprehensive to visit the dentist again, whether or not the experience was the dentist's fault. Even a single episode of aversive conditioning may cause an individual to completely avoid the dental environment and dental stimuli. The patient learns to avoid the dentist after even one visit if it was a bad experience. Because dental fear is often a disorder that develops during childhood, it is important to determine whether or not dental fear remains as individuals move from childhood into adulthood. Therefore, the purpose of this study is to determine whether dental fear is higher in younger adults than older adults.

METHOD

SAMPLE

This study explored differences between 107 adults and 134 young adults on measures of dental anxiety (DAS-R) and perceptions of dental stimuli (DFAS). Participants in the adult sample were recruited from two sites, a large suburban private dental practice specializing in periodontics and a large urban dental school clinic. These sites were selected to gather a more diverse and widely representative group of participants who reflect the overall dental population. One hundred participants from each of the two sites were contacted through mail regarding participation. A total of 107 patients agreed to participate in the study (response rate of 53.5%). Participants in the young adult sample were undergraduate students from a medium-size suburban university. These individuals were recruited through the social sciences human participants pool and 134 students agreed to serve as participants. This sample was recruited from the university setting because, consistent with most dental practices, neither the private practice nor the dental school clinic rosters contained a significant portion of college-age patients.

MEASURES AND PROCEDURE

Participants in both groups read and completed an Informed Consent Form describing the study and their rights as human research participants. Next, they completed a demographic survey and two widely used dental fear measures, a general dental anxiety scale (DAS-R) and a negative perception of specific dental stimuli scale (DFAS). A total of 107 participants in the adult sample and 134 participants in the young adult sample completed the questionnaire packet described below.

The Dental Anxiety Scale (DAS-R) was used to measure the level of dental anxiety. The DAS-R is an updated version of the original Corah Dental Anxiety Scale (Corah, Gale, & Illig, 1997). The updated version, introduced in 1994, removed gender-specific terminology of the provider and recognized the role of dental hygienists as providers (Ronis, 1994). Research has demonstrated that the two scales are equally reliable with a Cronbach's alpha of .85 for the DAS and .84 for the DAS-R (r=+.98 between the two versions). The DAS-R presents four items assessing the patient's subjective reactions about dental visits. These include going to the dentist, waiting for dental treatment, and anticipation of drilling and scaling. Responses to the questions are numbered from one (low anxiety) to five (high anxiety). Responses are totaled to produce a total dental anxiety score. DAS-R scores range from 4 to 20, with scores of 13 or 14 indicating an anxious patient and scores of 15 or greater indicating a highly anxious patient.

The Dental Fear Assessment Scale (DFAS) was used to measure negative perceptions about the dental visit due to specific dental stimuli. The scale uses a Likert format and assesses six different factors in dental fear including infection control procedures, sight and sound of the instruments, the dental staff's attitudes, methods to reduce fear, and experiences of others. The DFAS has demonstrated strong reliability in both internal consistency (coefficient alpha, r=.83) and test-retest reliability (r=.90), and criterion-related validity has been established through correlations between the scale and regularity of dental visits (r=.51, p<.05; Rowe & Moore, 1997). The instructions requested that participlans circle the response that most closely matched their feeling about each statement. Response options ranged from strongly agree to strongly disagree. Each item was then scored from 1 to 5 (strongest disagreement to strongest agreement). Final scores ranged from 10 to 50, with higher scores representing higher dental fear. In addition to the DAS-R and DFAS, a short demographic survey was included that asked each participant to indicate his or her age, gender, and number of yearly visits to the dentist.

The practice owner and the dental school administrators granted researchers permission to solicit participants for this study. All participants in the adult population were mailed the informed consent letter, the two scales, the demographic questions, and a postage-paid return envelope. Those who consented to participate in the study were asked to read and answer both surveys by circling the appropriate responses, and to return the surveys promptly in a postage-paid envelope provided for convenience and confidentiality. One hundred questionnaire packets were mailed to patients of the private practice and 100 questionnaire packets were mailed to patients of the dental school. One hundred seven individuals returned the completed questionnaires for an overall response rate of 53.5%. Young adult participants received their Informed Consent Form, instructions, and questionnaire packet in-person. Participants gathered in a large classroom setting during a free period of the school day to complete the packets. After completing the questionnaires, they were instructed to place the completed questionnaires into an envelope, seal it, and place it on a desk by the door of the classroom to ensure confidentiality and anonymity. Data collected were coded and analyzed using Statistical Package for Social Sciences (SPSS 11).

RESULTS

The adult sample consisted of 64 females (60%) and 43 males (40%). The mean age for the adult group was 54.16 years (SD=14.16 years, range=26-79 years). Their mean number of dental appointments within a year was 3.31 (SD=2.01 visits, range=l-17 visits). The mean age during which fearful participants had experienced their first bad dental experience was 14.79 years (SD=3.14). In the young adult sample, 85 participants were women (63%) and 49 were male (37%). The mean age of the sample was 19.78 years (SD=1.16; range=18-23 years). The young adults averaged 2.22 dental appointments in a year (SD=1.92, range=1-11 visits). The mean age during which fearful participants had experienced their first bad dental experience was 14.11 years (SD=4.80).

Responses to the Negative Perception measure were explored using frequencies of responses to each choice on the Likert scale items. Each response of strongly agree or agree was considered a negative perception of that particular item. In the adult sample getting an injection ranked as the most highly feared stimuli with 68.1% of the participants rating it negatively. The second most feared item was having dental radiographs taken (61.4%), followed by the use of scalers and curettes (56%), seeing the needle (54.1%), seeing the scalers and curettes (49.4%), the use of power driven instruments (48.5%), the sound of power driven instruments (45.7%), the use of air or water spray (36.4%), and the use of suction (19.5%). Personal protective equipment worn by dental personnel produced the least negative response (7.5%). In the young adult sample, the sound of the power driven instruments was most feared (72.7%), followed by the use of the power driven instruments (70.9%), the sight of the needle (69.9%), seeing the scalers and curettes (64.7%), the use of scalers and curettes (61%), having dental radiographs taken (58.5%), the use of suction (38.4%), and the use of air or water spray (37.7%). Only 1.3% of the young adults reported fear caused by the personal protective equipment worn by dental personnel.

An overall Negative Perception score was calculated by adding the scores of responses for each item. The mean Negative Perception score for the adult sample was 30.48 (SD=7.41) while the score for the young adult sample was 36.99 (SD=9.70). Respondents with scores of 38 and above were at least one standard deviation above the mean indicating severe dental fear. These respondents represented 15% of the participants in the adult sample and 23% of the young adult sample. A Pearson's r value for the Negative Perception and the DAS-R scores revealed a significant relationship between negative perceptions of dental stimuli and overall dental anxiety levels in the adult sample (r=.67, p<.001) as well as in the young adult sample (r=.74, p<.001). Finally, a t-test was performed to determine differences between the adult and young adult samples in overall dental fear scores. Results demonstrated that dental fear scores were significantly higher [t(239)=5.28, p<.001] in the young adult group (M=12.71, SD=5.71) than in the adult group (M=9.31, SD=3.98).

DISCUSSION

The results of this study reveal a significant relationship between negative perceptions of dental stimuli and dental anxiety. Some of the findings have implications for the practice of dentistry. First, it is important to identify anxious dental patients; dental providers must be sensitive to these patients' fears. Providing a positive experience will help to lower negative perceptions regarding dentistry. If particular stimuli produce anxiety, then methods to limit exposure or a very skillful presentation is necessary. Anesthesia, analgesia, or distraction can help to alleviate some or all of the pain for pain-inducing stimuli. Encouraging coping strategies and providing detailed information about what to expect may help those with more general fears that carry over to the dental office. Finally, another idea to consider is that very few aspects of the delivery of dentistry have changed over the years. Innovative ways to perform dental procedures that alleviate pain would definitely help a large number of individuals with dental anxiety. General strategies to decrease anxiety around dental treatment include keeping windows slightly open, to reduce the medicinal smell of the office; a friendly, compassionate dental team; and continuously asking the patient if he or she is in pain or experiencing discomfort.

The most significant finding of the study is that younger adults are more fearful of dental treatment than older adults. As young adults become responsible for their own health care, this fear may initiate a process of avoiding visits to dental providers for even routine dental check-ups, cleaning, and maintenance. This pattern of avoidance can lead to lifelong dental problems that could potentially result in cardiac and renal problems. Dental fear must be screened, diagnosed, and treated to promote a lifetime of positive dental health. The earlier the screening occurs the sooner the individual can get help to overcome dental fear rather than avoiding treatment.

In conclusion, dental anxiety remains a barrier to treatment for many individuals. Early detection followed by the implementation of treatment methods that reduce anxiety is the key to improving oral health in the general population. If health educators, psychologists, and dental health providers are to manage this epidemic, identification and treatment of dental fear in young adults is imperative.

REFERENCES

Berggren, U. (1992). General and specific fears in referred and self-referred adult patients with extreme dental anxiety. Behaviour Research Therapy, 30, 395-401.

Berstein, D. A, Kleinknecht, R. A, & Alexander, L. D. (1989). Antecedents of dental fear. Journal of Public Health Dentistry, 39, 113-124.

Corah, N., Gale, E. N, & Illig, S.J. (1997). Assessment of a dental anxiety scale. Journal of the American Dental Association, 97, 816-819.

Davey, G. C. L (1989). Dental phobias and anxiety: Evidence for conditioning processes in the acquisition and modulation of a learned fear. Behaviour Research Therapy 27(5), 51-58.

Doebling, S., & Rowe, M.M. (2000). Negative perceptions of dental stimuli and their effects on dental fear. Journal of Dental Hygiene. 74(2), 110-116.

De Jongh, A., Muris, P., Schoenmakers, N., & Ter Horst, G. (1995). Negative cognitions of dental phobics: Reliability and validity of the dental cognitions questionnaire. Behaviour Research Therapy, 33, 507-515.

De Jongh, A., & Ter Horst, G. (1993). What do patients think? An exploratory investigation of anxious dental patients' thoughts. Community Dental Oral Epidemiology, 21, 221-223.

Doerr P. A., Lang, W. P., Nyquist, L. V, & Ronis, D. L. (1998). Factors associated with dental anxiety. Journal of the American Dental Association, 129, 1111-1119.

Gadbury-Amyot, C.C. (1995). Assessing and managing patients with dental fears. Comprehensive Dentistry, 2(2), 3-10.

Gadbury-Amyot, C. C., Overman, P. R., Carter-Hanson, C., & Mayberry, W. (1996). An investigation of dental hygiene treatment fear. Journal of Dental Hygiene, 70, 115-121.

Ingersoll, B. D. (1982). Behavioral aspects in dentistry. New York: Appleton-Century-Crofts. Kent, C. G. & Blinkhorn, A. S. (1991). The psychology of dental care (2nd ed.) Jordan Hill, Oxford: Butterworth-Heineman, Ltd.

Katchum, C. (1995). Freedom from fear. Registered Dental Hygiene, 15(3), 14-19. King, L.J. (1991). Treating the anxious patient. Access, 5(8), 14-18.

Liddell, A., Di Fazio, L., Blackwood, J., & Ackerman, C. (1994). Long-term follow-up of treated dental phobics. Behaviour Research Therapy, 32, 605-610.

Litt, M. D. (1996). A model of pain and anxiety associated with acute stressors: Distress in dental procedures. Behaviour Research Therapy, 34, 459-476.

Locker, D., Shapiro, D., & Liddell, A. (1996). Negative dental experiences and their relationship to dental anxiety. Community Dental Health, 13, 86-92.

Moore, R., Brodsgaaurd, I., & Birn, H. (1991). Manifestations, acquisition and diagnostic categories of dental fear in a self-referred population. Behaviour Research Therapy, 29, 51-60.

Perez, B., Kaplan, R., & Stabholtz, A. (1997). The influence of a patient-management course to dental hygiene students on the dental anxiety of their patients. Journal of Dental Education, 61(4), 368-373.

Ronis, D. L. (1994). Updating a measure of dental anxiety: Reliability, validity, and norms. Journal of Dental Hygiene, 68, 228-233.

Ronis, D. L., Hansen, C. H., & Antonakos, C.L. (1995). Equivalence of the original and revised dental anxiety scales. Journal of Dental Hygiene, 69, 270-272.

Rowe, M. M., & Moore, T. A. (1998). Self-report measures of dental fear: A gender study. American Journal of Health Behavior, 22(4), 243-247.

Rowe, M. M., & Moore, T. A. (1997). Psychometric properties of a dental fear scale. American Journal of Health Behavior, 21(3), 187-192.

Schuurs, A. H. B., Duivenvooreen, H. J., Van Velzen, S. K., Verhage, E, Eijkman M. A. J., & Makkes, E C. (1985). Sociodemographic correlates of dental anxiety. Community Dental Oral Epidemiology, 13, 212-215.

Vassend, O. (1993). Anxiety, pain and discomfort associated with dental treatment. Behaviour Research and Therapy, 31, 659-666.

CHES AREAS

Responsibility I - Assessing Individual and Community Needs for Health Education

Competency B: Distinguish between behaviors that foster and those that hinder well-being

Sub-competencies 2: Identify behaviors that tend to promote or compromise health.

Sub-competencies 3. Recognize the role of learning and affective experiences in shaping patterns of health behavior.

Competency C: Infer needs for health education on the basis of obtained data

M. Michelle Rowe, PhD is a Professor in the Department of Health Services and Director of Interdisciplinary Health Services at Saint Joseph's University. Address all correspondence to M. Michelle Rowe, PhD, Saint Joseph's University, 5600 City Avenue, Philadelphia, PA 19131; PHONE: [phone]; FAX: [phone]; E-MAIL: [e-mail].