A few months ago, I was presented with a case of pre-orthodontic extraction a palatally displaced upper 5 for a male teenager who suffered from severe dental phobia.
The patient was horrified. He sat in the chair shrunken into himself, shivering uncontrollably and repeatedly asking me not to hurt him every 10 seconds. That was before I even touched him!
I had seen dental phobia before but never have I seen such a reaction. His shivering, begging and breaking voice paralyzed me that I barely anesthetized him and then called upon my supervisor to do the extraction himself.
The boy was so relieved when the tooth was extracted that he kept it for memory.
The boy was so relieved when the tooth was extracted that he kept it for memory.
Dental Phobia Among Patients
Although this is somewhat an extreme example, dental phobia is so common that we encounter it on a daily basis and most of us have probably experienced it ourselves. I have seen the most wise and bold-looking people overwhelmed with nervous anticipation as they climbed into the dental chair.
The literature distinguishes dental fear, dental anxiety and dental phobia as different identities, but for the purposes of this post, we don’t need to make that distinction.
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"Dental anxiety, or dental fear, is estimated to affect approximately 36% of the population, with a further 12% suffering from extreme dental fear." [2]
"This anxiety can have serious repercussions in terms of an individual's oral health, and it is considered to be a significant barrier to dental attendance resulting in poor attendance. This is known as dental avoidance and can lead to poor oral health or the necessity for specialist dental care." [2]
Dental anxiety has been rated the fifth most common anxiety [3]. Over time, compounded by stereotypes, bad experiences, tales of bad experiences and many other factors, the fear precipitates into a repulsion and a general dislike.
These feelings are definitely justified. You just can't blame the patients. From media portrayals of dentists and the stereotypes, to the medieval-torture-looking instruments, to the pay-a-lot-of-money-to-get-hurt business model, the layman is left with no choice but to hate dentists and dental care.
Money may not be much of an issue in many parts of the world due to high income or dental insurance policies, but it’s definitely a factor in Egypt and may be other similar economic state countries.
Moreover, the literature addressing the cost of care and it's implications, at least in my region, is definitely scarce.
Moreover, the literature addressing the cost of care and it's implications, at least in my region, is definitely scarce.
Even if a patient is educated beyond these stereotypes and misconceptions, there still remains other common causes for dental fear as shown by research like the feeling of loss of control, claustrophobia and white coat syndrome to name a few.
One important one is anticipation of the unknown, or what is referred to as “irrational fear”, where being unfamiliar with the procedures and instruments results in fearful anticipation and exaggerated expectations.
One important one is anticipation of the unknown, or what is referred to as “irrational fear”, where being unfamiliar with the procedures and instruments results in fearful anticipation and exaggerated expectations.
"People fear what they don't understand and hate what they can't conquer."
- Andrew Smith
This is the basis of one of the most popular fear management techniques called “gradual exposure”, “exposure therapy” or “systematic desensitization”.
If you're practicing, you have definitely encountered the patient who has watched videos or read upon the procedure they're supposed to get or at least talked to someone who has. This familiarization process does relieve a lot of the anxiety.
If you're practicing, you have definitely encountered the patient who has watched videos or read upon the procedure they're supposed to get or at least talked to someone who has. This familiarization process does relieve a lot of the anxiety.
May be I’ll do an article on the fear management techniques later on. For now, I think you should read upon this if you haven’t. It will greatly help your practice. I'll give you a good place to start at the conclusion of this post.
Dental Phobia Among Dentists
Now, in my experience, an interesting phenomenon that’s noticed among many dentists, at least where I am, is that they also, like the public, try to avoid going to the dentist and try to postpone it as far as they possibly can.
That was definitely counter-intuitive to me when I first started noticing it. You’d think that, as a group, we’d know better, right?
That was definitely counter-intuitive to me when I first started noticing it. You’d think that, as a group, we’d know better, right?
Apparently not.
In a 2014 study assessing the prevalence and level of dental fear among dental and medical undergraduates:
"Dental students reported higher prevalence of dental fear (96.0% versus 90.4%). However, most of the fear encountered among dental students was in the low fear category as compared to their medical counterpart (69.2 versus 51.2%)." [3]
"“Heart beats faster” and “muscle being tensed” were the top two physiological responses experienced by the respondents." [3]
"“Drill” and “anesthetic needle” were the most fear provoking objects among respondents of both faculties." [3]
I suppose we can safely say that money isn't a main issue here. I’ve seen financially capable dentists and dental students who get offered to even have their teeth done for free and would still refuse.
My own take on this is that, as “people on the inside”, we see enough dental mistakes done in real life and read enough about dental misconduct that we get a distorted picture.
We know all the things that can go wrong and the consequences of these things that our perception might be biased towards the negative.
It also doesn’t help to be a dental student where most of your circles are other dental students who are generally at the beginnings of their learning curves and are normally messy and make mistakes.
This is somewhat similar to the concept of “Medical student syndrome” which is an interesting idea that I suggest you read about if haven’t already.
Put another way, I would say that as you get more and more dental education, the fear of dentists doesn’t exactly diminish, but rather changes from the irrational fear of the layman to a more rational one where the fear, although possibly unjustified, is based on “knowing” rather than “not knowing”.
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Put another way, I would say that as you get more and more dental education, the fear of dentists doesn’t exactly diminish, but rather changes from the irrational fear of the layman to a more rational one where the fear, although possibly unjustified, is based on “knowing” rather than “not knowing”.
I feel that it is necessary to mention at this point that in no way am I saying that all dental care in Egypt is unsound or in any way unsatisfactory, nor am I saying that it’s all good. Rather, I am addressing the feelings of the two groups towards the profession.
There are definitely a lot of outstanding dentists and there are definitely a lot of aspiring dental students out there (of whom I’d like to think I’m one).
Let's save this date for future reference to see whether I'd make it.
12/09/2018
Conclusion
Dental phobia can be caused by various aspects during the visit. These range from exaggerated expectations, to the feeling of loss of control, to claustrophobia, to the different sounds, smells and sensations.
Some dentists also might avoid dental care. This is either caused by knowledge of the possible errors and negative expectations from treatment, or by similar fears to the ones exhibited by patients.
If you want a good place to start reading in depth about dental fear, dental anxiety and dental phobia, I recommend the first literature review I referenced below [1]. It is a well-structured and comprehensive read and it helped me write this blog post.
I linked the references below to their respective articles on PubMed. You can click below and go straight to the articles.
What other causes do you think are behind dental phobia?
I would love to know your views on this!
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References:
- Appukuttan DP. Strategies to manage patients with dental anxiety and dental phobia: literature review. Clinical, Cosmetic and Investigational Dentistry. 2016;8:35-50. doi:10.2147/CCIDE.S63626.
- Beaton L, Freeman R, Humphris G. Why Are People Afraid of the Dentist? Observations and Explanations. Medical Principles and Practice. 2014;23(4):295-301. doi:10.1159/000357223.
- Hakim H, Razak IA. Dental Fear among Medical and Dental Undergraduates. The Scientific World Journal. 2014;2014:747508. doi:10.1155/2014/747508.
- My Faculty’s fourth year Operative Dentistry coursebook
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