Long-term follow-up of treated dental phobics

Large Group Exposure Treatment: A Feasibility Study of Exposure Combined with Diaphragmatic Breathing in Highly Dental Fearful Individuals

A large-group one session treatment (LG-OST) combining exposure and diaphragmatic breathing as a bodily coping element was carried out to investigate its feasibility and effectiveness in a sample of 43 highly dental fearful individuals treated simultaneously. We assessed subjective dental fear, dysfunctional dental-related beliefs, and perceived control pre- and post-intervention and at four-month follow-up. Participants additionally performed a behavioural approach test (BAT) pre- and post-intervention. During the applied exposure exercises, four participants (9.3%) discontinued the program all reporting too high levels of distress. Regarding subjective dental fear and dysfunctional dental related beliefs post treatment effects, LG-OST showed medium to large effect sizes, ranging from Cohen's d = 0.51 to d = 0.84 in the Intention-to-Treat analysis. Subjective dental fear improved clinically significantly in about one fourth (25.6%) of therapy completers. All post-treatment effects remained stable over time. Concerning the behavioral fear dimension, we observed a strong ceiling effect. Already at pre-assessment, participants accomplished more than six out of seven BAT-steps. Thus, behavioral approach did not increase significantly following treatment. Overall, the LG-OST protocol proved feasible and efficient. Compared to other one-session individual and multi-session group treatments the observed LG-OST effects were smaller. However, if LG-OST could match the efficacy of highly intensive short treatments delivered in an individual setting in the future, for example, by applying a wider array of exposure exercises, it could be a very useful treatment option as an intermediate step within a stepped care approach.

A critical review of approaches to the treatment of dental anxiety in adults

Dental anxiety and specific phobia of dental procedures are prevalent conditions that can result in substantial distress and oral health impairment. This paper critically reviews 22 randomized treatment trials aimed at reducing dental anxiety and avoidance in adults, published in peer-reviewed journals between 1974 and 2012. The following treatment techniques are reviewed: various forms of cognitive-behavioral therapy (CBT), relaxation training, benzodiazepine premedication, music distraction, hypnotherapy, acupuncture, nitrous oxide sedation, and the use of lavender oil scent. CBT delivered in a variety of formats, including one-session treatment, has the most evidence for its efficacy. Cognitive techniques, relaxation, and techniques to increase patients' sense of control over dental care are also efficacious but perform best when combined with repeated, graduated exposure. Other interventions require further study in randomized trials before conclusions about their efficacy are warranted. Limitations of the extant outcome research and implications for future treatment and research are discussed.

O desafio da convivência: assessoria de diversidade e apoio aos cotistas (2004-2008)

Em 2003, a Universidade de Brasília adotou uma política de ações afirmativas para pessoas negras, o Sistema de Cotas para Negros. Em 2004, foi criada a Assessoria de Diversidade e Apoio aos Cotistas - ADAC. Ante à demanda do movimento social por uma sala de apoio aos estudantes, desenvolveu-se o Centro de Convivência Negra - CCN, espaço aberto a toda a comunidade acadêmica. O presente artigo apresenta a experiência da ADAC até 2008 e analisa os desafios da convivência entre estudantes cotistas e o espaço acadêmico a partir de pesquisa qualitativa sobre percepções, sentimentos e expectativas acerca do CCN, na forma de questionários com uma pergunta de evocação ao CCN, aplicados a 35 estudantes universitários oriundos do Sistema de Cotas para Negros frequentadores do CCN. Os dados de evocação foram analisados utilizando-se o software Evoc. Os resultados indicam que o CCN, no período analisado, era reconhecido por seus usuários como um espaço de acolhimento ante a uma organização acadêmica heterogênea, marcada por preconceitos. São discutidas as limitações e as possibilidades de intervenção a partir do uso do CCN, e uma agenda propositiva para a ADAC, com foco na gestão da diversidade.

Clinical management of dental anxiety: what works for whom?

This paper aims to provide an overview of the current knowledge regarding the management of adult dentally anxious patients. Furthermore, an attempt is made to formulate a number of preliminary clinical guidelines, based on the available literature. The findings are discussed in the light of the following four problem areas or types of patients, those with: 1) a mild form of fear or anxiety, 2) a phobia of specific dental procedures or situations, 3) interfering psychiatric symptoms and/or 4) a high treatment need. The literature suggests that particularly the implementation of a high level of predictability during treatment, the training of patients in the use of coping skills, and the application of in vivo exposure to anxiety provoking stimuli are the most appropriate options for the management of anxious dental patients and the reduction of their anxiety level.

Willingness to pay for dental fear treatment. Is supplying dental fear treatment socially beneficial?

The aim of this paper is to discuss the social desirability of supplying dental fear treatment in addition to dental treatment using the results from a treatment programme for patients with severe dental fear. The programme consisted of three different dental fear treatments: Cognitive therapy, applied relaxation and nitrous oxide sedation, in addition to dental treatment. To evaluate the effects of uncertainty on the patients' benefits from the programme, we elicited their willingness to pay, both before and after receiving treatment, since we expected patients to be uncertain about the outcome of the dental fear treatment. We found that the social desirability of the treatment was very sensitive to uncertainty. While only 24% of the patients were willing to pay the actual cost of the treatment before attending, 71% were willing to pay afterwards. This implies that many patients who would benefit from the treatment ex post are not willing to pay the cost of the treatment ex ante, and will thus not receive any treatment unless it is subsidized.

Dental fear in adults: a meta-analysis of behavioral interventions

OBJECTIVES

The aim of this meta-analytic and systematic quantitative approach is to examine the effects of behavioral interventions for dental anxiety and dental phobia.

METHODS

Eighty studies were identified where dental fear treatment with behavioral methods was evaluated. Thirty-eight of 80 met entry criteria and were included in a meta-analysis.

RESULTS

The calculated effect sizes (ESs) for self-reported anxiety after intervention indicate positive changes in 36 of the 38 studies and no changes in two. The overall ES = 1.8 (95% CI: 1.6, 1.8). The percent of subjects with post-treatment dental visits in the first 6 months post-treatment varied between 50 and 100%. The overall ES for attendance at dental visits, weighted by sample size, is 1.4 (95% CI: 1.3, 1.6). The homogeneity analysis indicates that the studies cannot be adequately described in one ES. The reported percentage of subjects with a dental visit between 6 months and 4 years post-treatment varied from 48 to 100%. The overall weighted ES for visiting the dentist, adjusted for drop-outs in the studies, is 1.2 (95% CI: 0.99, 1.4).

CONCLUSIONS

Despite extensive heterogeneity, changes in self-reported anxiety represent medium to large ESs. Patients signing up for a behavioral intervention for dental fear can be expected to report a significant reduction in their fear, and this effect generally seems to be lasting. Mean long-term attendance ( >4 years after treatment) is 77%.

Prediction of success and failure of behavior modification as treatment for dental anxiety

Behavior modification techniques are effective in the treatment of extreme dental anxiety, but their success is by no means absolute. In the present article, the Corah Dental Anxiety Scale (DAS), the self-report symptom inventory SCL-90R and a questionnaire accessing subjects' daydreaming styles (the Short Imaginal Process Inventory) were used to develop possible predictive measures for success and failure of behavior modification as a treatment for dental fear. The patients' level of distractibility and mind wandering, initial dental anxiety and somatization significantly predicted the success of therapy. The odds ratio indicated that the risk of therapy failure increased about 11 times with an increase of one scale of the Poor Attention Control Scale, about three times with an increase of one level of the mean DAS score, and 0.17 times with an increase of one level of somatization. The predictive value of the chosen scales was 80%. Thus, the use of these scales as part of an initial admittance process for patients who suffer from dental anxiety can enhance our ability to better recognize patients who are prone to fail behavior therapy as treatment for their problem, and enable their referral for other possible modes of treatment.

Effects of cognitive therapy, applied relaxation and nitrous oxide sedation. A five-year follow-up study of patients treated for dental fear

Five years after completing a controlled, randomized treatment trial comparing the effect of nitrous oxide sedation (NO), cognitive therapy (CT), and applied relaxation (AR), all 62 patients who had participated were invited to a follow-up questionnaire study. Forty-three responded. All participants had been to the dentist during the follow-up period. Mean scores (s) on Corah's Dental Anxiety Scale (CDAS) and Symptom Checklist 90 Revised (SCL-90-R, a measure of general psychological distress) were 10.4 (4.1) and 0.35 (0.34), respectively. There were no between-group effects. Significant changes across the assessment phases (at enrollment, after treatment, and 5 years after) were found for both dental fear and general distress (CDAS: F = 137.8, P < 0.01; SCL-90-R: F = 12.5, P < 0.01). However, no significant changes between measures obtained after treatment and at follow-up emerged. Seven participants (3 from the NO group, 2 from the CT group, and 2 from the AR group) had CDAS scores above 14, indicating a recurrent or continual dental fear problem. The majority (81%) assessed the dental fear treatment received 5 years previously to have been useful for them. In conclusion, the favorable effects on dental fear and general psychological distress continued at 5-year follow-up for all treatment groups.

Treatment of dental anxiety disorders. Outcome related to DSM-IV diagnoses

In this study we evaluated treatment effects in 70 consecutively admitted patients in a specialized university clinic for treatment of dental fear. Thirty-three (47%) of the patients fulfilled the diagnostic criteria for Specific Phobia alone (Dental Phobia, DP), 24 (33%) had severe dental anxiety without fulfilling the criteria for phobia (ND), and 13 (19%) fulfilled the criteria for multiple DSM-IV diagnoses (MD). Dental anxiety was measured prior to, immediately after and at follow-up (mean = 19 months) using Corah's Dental Anxiety Scale and Dental Fear Survey. Dental attitudes were measured by Getz' Dental Beliefs Survey. Dental attendance and everyday functioning were measured by self-report. DP patients received significantly more treatment-sessions as compared to the ND group. Despite significant overall reductions in scores on all psychometric instruments from pretreatment to follow up, patients in the MD group reported significantly more severe anxiety at pre- and post-treatment and at follow-up as compared to patients in the ND group. There was no interaction between diagnostic group and assessment occasion (pre treatment, post treatment and follow up) on the self-reported anxiety. Patients reported significant improvements in self-esteem, social relations and everyday functioning, regardless of diagnostic group. Sixty-three percentage of the respondents had been to the dentist within 1 year after completed treatment. Patients treated by dentists who had received supervised training in exposure treatment had significantly more often seen the dentist at follow-up.

One-year follow-up of patients treated for dental fear: effects of cognitive therapy, applied relaxation, and nitrous oxide sedation

The effects of dental fear treatments were assessed in a 1-year follow-up study. Sixty-two patients had finished a controlled study in which they were randomly allocated to nitrous oxide sedation (NO), cognitive therapy (CT), or applied relaxation (AR). During the trial highly significant reductions in dental fear and general distress were observed. One year later a majority (95%) of the participants had attended dental treatment in general practice. On the whole, continued favorable effects with regard to dental fear and general distress were observed. Patients in the applied relaxation group evidenced the largest reductions on the dental fear measures. All patients judged the dental fear treatment to have been beneficial, and 80% judged the treatment given in the year after the dental fear treatment successful. All three treatment groups scored in the normative range for general distress both at the end of treatment and at follow-up.

A joint approach to treating dental phobics between community dental services and specialist psychotherapy services – a single case report

A 41-year-old male patient presented at the local dental hospital requesting treatment under IV sedation, a treatment that he had had for the past 25 years. The patient was referred to the specialist psychotherapy services for cognitive behavioural therapy (CBT), and received a 1 hour course of therapy. He was then introduced to dental services, and at this visit had a check-up, OPG, and treatment planning discussion. At a subsequent visit he had local anaesthetic, three fillings, and a scale and polish. The patient is now able to return to general dental practice, after only a brief therapeutic intervention, and subsequent dental treatment. The present and future cost saving to the NHS is substantial compared with the treatment method initially sought by the patient.

Factors affecting dental attendance following treatment for dental anxiety in primary dental care

AIM

To explore factors affecting patients' dental attendance behaviour following referral from a dental anxiety clinic to a general dental practitioner.

DESIGN

A four-year follow up of patients who completed a course of treatment for dental anxiety by conducting semi-structured interviews, face-to-face or by telephone, with confirmation of dental attendance from the dental records.

SUBJECTS

Forty-one patients who had completed a course of treatment for dental anxiety, in a specially designed community clinic. Mean time since last dental visit before treatment was 7.8 years (range 0.5-29).

RESULTS

Twenty-three patients were successfully followed up and 11 (47%) were receiving regular asymptomatic dental care. The dental anxiety scores of those who subsequently became asymptomatic attenders were significantly lower at follow-up than the patients who became symptomatic attenders (P = 0.01). Effective dentist-patient communication was a common theme of the interviews.

CONCLUSIONS

At four-year follow-up, dental anxiety was substantially lower in those who subsequently became asymptomatic attenders than those who became symptomatic attenders. A positive dentist-patient relationship had developed with the asymptomatic attenders.

Comparison between one-session psychological treatment and benzodiazepine in dental phobia

To compare the effects of a single session of psychological treatment and acute administration of benzodiazepine, 50 dental phobic patients were allocated either to psychological treatment, benzodiazepine, or no treatment for anxiety. Psychological treatment consisted of stress management training and imaginal exposure to phobic stimuli with homework assignments. Benzodiazepine was administered 30 min before dental treatment. Both treatment conditions led to less anxiety during dental surgery than did the control condition. Phobic patients in the benzodiazepine condition showed a relapse after dental treatment, whereas those in the psychological treatment condition showed further improvement until the follow-up 2 months later. Of the latter group, 70% continued dental treatment; only 20% and 10% returned in the benzodiazepine and control conditions, respectively.

Development of a scale to measure the social and psychological effects of severe dental anxiety: social attributes of the Dental Anxiety Scale

This paper describes the development of a scale designed to measure the extent to which severe dental anxiety or phobia affects patients' social wellbeing outside of the dental setting. Items initially selected on the basis of clinical experience were administered to two groups: 78 patients seeking help for severe anxiety and 88 patients attending the general clinic of a dental hospital. Items on the scale discriminated between these two groups and also between patients who were reluctant to attend even when experiencing symptoms and those who attend more regularly. Although the scale correlated moderately well with Corah's Dental Anxiety Scale, factor analysis indicated that its items assess the effects of severe anxiety on the two domains of psychological reactions and social inhibition as they occur as indirect effects of dental care. The scale could be included in assessments designed to measure the social and psychological effects of severe dental anxiety.