Oral health and oral treatment needs in patients fulfilling the DSM-IV criteria for dental phobia: Possible influence on the outcome of cognitive behavioral therapy

Interdisciplinary CBT treatment for patients with odontophobia and dental anxiety related to psychological trauma experiences: a case series

BACKGROUND

While cognitive-behavioural therapy (CBT) is a well-established treatment for odontophobia, research is sparse regarding its effect on patients with dental anxiety related to psychological trauma experiences. This study aimed to evaluate changes in symptoms and acceptability of interdisciplinary Torture, Abuse, and Dental Anxiety (TADA) team treatment for patients with odontophobia or dental anxiety. We also wanted to describe the sample's oral health status. The TADA teams offer targeted anxiety treatment and adapted dental treatment using a CBT approach.

METHODS

The study used a naturalistic, case series design and included 20 consecutively referred outpatients at a public TADA dental clinic. Pre- and post-treatment assessments included questionnaires related to the degree of dental anxiety, post-traumatic stress, generalized anxiety, and depression. Patients underwent a panoramic X-ray before treatment. Before dental restoration, patients underwent an oral health examination to determine the mucosal and plaque score (MPS) and the total number of decayed, missing, and filled teeth (DMFT). Patients were referred to dentist teams for further dental treatment and rehabilitation (phase 2) after completing CBT in the TADA team (Phase 1). Results from the dental treatment in phase 2 is not included in this study.

RESULTS

All patients completed the CBT treatment. There were significant improvements in symptoms of dental anxiety, post-traumatic stress, and depression and moderate changes in symptoms of generalized anxiety. Dental statuses were heterogeneous in terms of the severity and accumulated dental treatment needs. The TADA population represented the lower socioeconomic range; 15% of patients had higher education levels, and half received social security benefits. All patients were referred to and started adapted dental treatment (phase 2).

CONCLUSIONS

TADA treatment approach appears acceptable and potentially beneficial for patients with odontophobia and dental anxiety related to psychological trauma experiences. The findings suggest that further research, including larger controlled studies, is warranted to validate these preliminary outcomes.

TRIAL REGISTRATION

The study was approved by the regional ethical committee in Norway (REK-Midt: 488462) and by the Data Protection Board at Møre and Romsdal County Authority.

Relationship between dental anxiety levels and oral health among dental patients in Turkey: a cross-sectional study

BACKGROUND

This study aimed to determine the relationship between dental anxiety and oral health in adult patients who applied to the Department of Restorative Dentistry at the Faculty of Dentistry at Suleyman Demirel University.

METHODS

The study included 500 subjects. The dental anxiety levels of the patients were determined using a modified dental anxiety scale (MDAS). Information on sociodemographic details, oral hygiene and nutritional habits were recorded. Intraoral examinations of the subjects were performed. Caries prevalence of individuals was determined using the decayed, missing or filled teeth (DMFT) and decayed, missing, or filled surfaces (DMFS) indices. Gingival health was evaluated using the gingival index (GI). Statistical analyses were performed using the Mann-Whitney U, Kruskal-Wallis and Chi-square tests and Spearman correlation analysis.

RESULTS

The ages of the 276 female and 224 male participants ranged from 18-84 years. The median MDAS value was 9.00. The median DMFT and DMFS values were 10.00 and 23.00, respectively. The median MDAS values ​​of women were higher than those of men. Individuals who postponed their appointment had a higher MDAS median value than those who did not (Mann-Whitney U test, p < 0.05). No statistically significant correlation was found between dental anxiety level (MDAS) and GI, DMFT and DMFS index scores (Spearman correlation analysis, p > 0.05).

CONCLUSION

The MDAS values of individuals who did not remember the reason for their dental visit were higher than those who visited the dentist for routine control. Based on the findings of this study, further research on the relationship between dental anxiety and oral health is necessary to determine the factors that pose a risk for dental anxiety and to ensure the regular benefits of dental services.

Oral health in prison: an integrative review

PURPOSE

Prisoners' oral health is an often overseen, yet important aspect of the general health of prisoners. To develop effective measures to improve the situation, it is important to get an overview of existing research. The purpose of this study is to examine and analyse existing research on oral health of prisoners and provide a thorough understanding of prisoners' oral health and related factors.

DESIGN/METHODOLOGY/APPROACH

Due to relatively few scientific papers on prisoners' oral health, an integrative review was chosen. Integrative reviews allow for the inclusion of diverse methodologies. A literature search was conducted, followed by an assessment of the quality of the studies by using the Mixed Methods Appraisal Tool. Thematic analysis was used to analyse the studies.

FINDINGS

The few studies addressing European prisoners' oral health in the last 21 years differ in design and methodology. The results from this review indicate that prisoners' oral health is a complex phenomenon and should be understood from both individual and organisational perspectives. More research is needed to bridge the gap in the literature on prisoners' oral health.

ORIGINALITY/VALUE

To the best of the authors' knowledge, this is the first literature review on European prisoners' oral health.

Seeing the person before the teeth: A realist evaluation of a dental anxiety service in Norway

Patients with a trauma history, whether sexual abuse or torture, or dental phobia, tend to avoid dental services due to severe dental anxiety. Subsequently, they experience poor oral health, lower quality of life, and poorer general health. In Norway, a specific service (torture, abuse, and dental anxiety [TADA]) targets these patients' dental anxiety through cognitive behavioural therapy (CBT) prior to dental restoration. By exploring patients' experiences with TADA services using a realist evaluation approach, this paper aims to increase our understanding of how this type of service addresses patients' dental anxiety in terms of its mechanisms and contextual factors. Interviews with TADA patients (n = 15) were analysed through a template analysis driven by context-mechanism-outcome heuristics. The analysis revealed that patients value a dental practitioner who provides a calm and holistic approach, positive judgements and predictability elements that lean towards a person-centred care approach. Provided this, patients felt understood and cared for, their shame was reduced, self-esteem emerged, and control was gained, which led to alleviation of dental anxiety. Therefore, our findings suggest that combining CBT with a person-centred care approach helps alleviate patients' dental anxiety. This provides insights into how dental services could be executed for these patients.

Dental anxiety and potentially traumatic events: a cross-sectional study based on the Tromsø Study-Tromsø 7

OBJECTIVE

The objectives of the study were to describe the prevalence of dental anxiety and the possible associations between dental anxiety and potentially traumatic events in an adult population.

METHOD

The study is based on cross-sectional questionnaire data from the 7th wave of the Tromsø Study, a study of the adult general population in the municipality of Tromsø carried out in 2015-2016. The Modified Dental Anxiety Scale was used to measure dental anxiety across potentially traumatic events, oral health, dental attendance (avoidance) and current mental health symptoms (Hopkins Symptom Checklist). Individuals with high and low dental anxiety scores were compared to investigate differences in the distribution of potentially traumatic events, current mental health symptoms, avoidance, sex and oral health, and hierarchical multivariable regression was used to study the influence of traumatic events on dental anxiety.

RESULTS

High dental anxiety was reported by 2.9% of the sample and was most prevalent among females and in the youngest age groups. Individuals with high dental anxiety reported more current mental health symptoms, and they were more likely to report poorer oral health and more irregular dental visits compared to individuals with no or lower dental anxiety scores. Concerning traumatic events, the reporting of painful or frightening dental treatment showed the biggest difference between those with high dental anxiety and low dental anxiety scores (a moderate effect). The hierarchical regression model indicated that reporting sexual abuse, traumatic medical treatment in hospital and childhood neglect significantly predicted dental anxiety in the step they were entered in, but only sexual abuse remained a significant individual contributor after controlling for current mental health symptoms.

CONCLUSIONS

The prevalence of high dental anxiety was lower than expected (2.9%), but dentally anxious individuals expressed a high burden of mental health symptoms, poor oral health and the avoidance of dental care. The regression analysis indicated that experiences with sexual abuse could affect dental anxiety levels in the absence of generalised symptoms of anxiety and depression.

More than just a dental practitioner: A realist evaluation of a dental anxiety service in Norway

Patients with dental phobia or a history of trauma tend to avoid dental services, which may, over time, lead to poor oral health. In Norway, a specific service targets these patients by providing exposure therapy to treat their fear of attendance and subsequently enable oral restoration. Dental practitioners deliver the exposure therapy, which requires a role change that deviates from their traditional practice. This paper explores how - and under what circumstances - dental practitioners manage this new role of alleviating dental anxiety for patients with a history of trauma or dental phobia. Using a realist evaluation approach, this paper develops theory describing which contexts promote mechanisms that allow practitioners to alleviate dental anxiety for patients with trauma or dental phobia. A multi-method approach, comprising service documents (n = 13) and stakeholder interviews (n = 12), was applied. The data were then analysed through a content analysis and context-mechanism-outcome heuristic tool. Our findings reveal that dental practitioners must adopt roles that enable trust, a safe space, and gradual desensitisation of the patient to their fear triggers. Adopting these roles requires time and resources to develop practitioners' skills - enabling them to adopt an appropriate communication style and exposure pace for each patient.

Outcome of Chair-Side Dental Fear Treatment: Long-Term Follow-Up in Public Health Setting

Aim

Purpose of this practice and data-based study was to evaluate the outcome of dental fear treatment of patients referred to the Clinic for Fearful Dental Patients (CFDP) in the primary oral health care, City of Oulu, Finland, during period 2000–2005.

Methods

A psychological approach including behavioral interventions and cognitive behavioral therapy (BT/CBT) was used for all participants combined with conscious sedation or dental general anesthesia (DGA), if needed. The outcome was considered successful if later dental visits were carried out without any notifications in the patient records of behavioral problems or sedation. Data collection was made in 2006; the average length of the observation period from the last visit in the CFPD to data collection was 2 y 3 m (SD 1 y 5 m). All information was available for 163 patients (mean age 8.9 y at referral). Study population was dominated by males (58.0%). Cause for referrals was mostly dental fear (81.0%) or lack of cooperation.

Results

The success rate was 69.6% among females and 68.1% among males. Success seemed to be (p=0.053) higher for those treated in ≤12 years compared with the older ones. The participants, without need for dental general anesthesia (DGA) in the CFDP, had significantly a higher success rate (81.4%) compared with those who did (54.8%, p < 0.001). Use of conscious oral sedation (p=0.300) or N₂O (p=0.585) was not associated with the future success.

Conclusions

A chair-side approach seems successful in a primary health care setting for treating dental fear, especially in early childhood. Use of sedation seems not to improve the success rate.

Attitudes and lifestyle factors in relation to oral health and dental care in Sweden: a cross-sectional study

OBJECTIVE

The aim of the present study was to investigate attitudes to and perceptions of dental treatment and costs, self-assessed personal oral health status and dental self-care in an adult Swedish population, with special reference to potential associations between these factors and periodontal status.

MATERIAL AND METHODS

The study population comprised 1577 subjects who had undergone radiographic dental examination. The subjects were grouped by severity of periodontitis, based on extent of bone loss, as none, mild/moderate or severe. Subjects answered a questionnaire about socioeconomic factors, oral care habits and attitudes to dental treatment. Other questions covered medical history, smoking and other life style factors. Associations were tested using the Chi-squared test and a logistic regression model.

RESULTS

Compared to subjects with no periodontitis, those with mild/moderate or severe periodontitis were less likely to afford (p < .001), more often refrained from treatment due to costs (p < .001) and in the past year had experienced dental problems for which they had not sought treatment (p < .001). They also reported more anxiety in relation to dental appointments (p = .001). Regarding caries prevention, the severe periodontitis group used least fluoride products (p = .002).

CONCLUSIONS

Swedish adults regard their oral health as important, those with periodontitis have a more negative perception of their oral health and are less prone to seek help. These discouraging findings suggest the need for targeted measures, which focus on improving the care of this group of patients.

Prevalence of dental anxiety and associations with oral health, psychological distress, avoidance and anticipated pain in adolescence: a cross-sectional study based on the Tromsø study, Fit Futures

OBJECTIVE

To describe the prevalence of dental anxiety (DA) among adolescents in Tromsø and Balsfjord region in northern Norway and present a multivariate logistic regression model to predict high dental anxiety scores (DASs) among these adolescents.

MATERIALS AND METHODS

We used self-report questionnaires and clinical dental examination data from adolescents registered in upper secondary school (15-18 years of age) in this region (n = 986). Logistic regression was used to estimate odds ratios and their 95% confidence intervals (CI) when using Corah's DAS as a dichotomous dependent variable.

RESULTS

Twelve percent of the respondents reported a DAS score ≥13, indicating high DA. The strongest predictors for reporting high DA were anticipated pain at the dentist, 'external control belief', avoidance, low social motivation on oral health behaviour and sex. In this population, dental caries (DMFS), symptoms of psychological distress (HSCL-10) and self-motivation concerning oral health behaviour did not differ significantly between those reporting high DA (DAS ≥13) and those that reported low DA (DAS ≤12).

CONCLUSIONS

Severe DA in adolescence is a dental public health challenge and this study shows that DA is a hindrance to seeking dental treatment irrespective of dental status. Dental anxiety should have a higher focus on preventive oral health strategies and have a higher priority in public dentistry to avoid this problem to escalate into adulthood.

Changes in dental anxiety among 15- to 21-year-olds. A 2-year longitudinal analysis based on the Tromsø study: Fit futures

OBJECTIVE

Identify predictive variables related to the development and continuation of high dental anxiety among young people over 2 years and assess differences between youth experiencing increased, decreased or unchanged dental anxiety scores over time.

METHODS

An observational panel study of 15- to 21-year-old people in Tromsø and Balsfjord region followed students from their first to their last year of upper secondary school (2010/11-2012/13). Logistic regression was used to estimate odds ratios and their 95% confidence intervals (CI) of possible predictive variables assessed at baseline when using dental anxiety score from the second wave as a dichotomous dependent variable. Variables measured at baseline: Sex, Dental Caries Experiences (DMFS index), Dental Anxiety (Corah's Dental Anxiety Scale/DAS), Psychological Distress (Hopkins Symptom Checklist/HSCL-10), Avoidance of dental treatment, Pain Estimation at the dentist and motivational questions related to tooth brushing and caries (Self and Social Motivation). Wilcoxon signed-rank tests and Kruskal-Wallis tests were used to test whether changes in DAS score between waves were associated with changes in Pain Estimation between waves and HSCL-10 scores at baseline.

RESULTS

Hopkins Symptom Checklist, DMFS and DAS scores at baseline predicted high dental anxiety scores after 2 years. Sex, motivation related to oral hygiene and avoidance due to fear at baseline did not contribute significantly to our model. DMFS and HSCL-10 were higher among young people who reported a substantial change in DAS score (2.0 > Interquartile range/IQR), irrespective of the direction of change. Pain Estimation changed consistently with a change in DAS score.

CONCLUSION

Mental health symptoms, pre-existing dental anxiety and dental health status are important contributors to the development of dental anxiety in youth. Estimations of pain at the dentist are central when it comes to changes in dental anxiety over time in this study.

Dental pain and oral health-related quality of life in individuals with severe dental anxiety

OBJECTIVES

To analyze the prevalence and level of dental pain among adult individuals with severe dental anxiety (DA), and the association between dental pain and oral health-related quality of life (OHRQoL).

METHODS

The study was based on 170 adult individuals with DA referred to a specialized DA clinic. All patients answered a questionnaire including questions on DA (DAS, DFS), OHRQoL (OIDP) and dental pain. An adapted clinical examination and a panoramic radiograph revealed the present oral status.

RESULTS

The prevalence of dental pain was high (77.6%) and among those reporting pain the intensity was high (49.0-61.0 on a VAS). One or more problems during the last 6 months with the mouth or teeth affecting the individual's daily activities were reported in 85.3% of the participants. Individuals who reported dental pain had lower OHRQoL compared with those who did not report dental pain (p < .001). Dental pain and number of decayed teeth were associated with the probability of poor OHRQoL (OR = 8.2, p < .001, OR = 3.8, p = .008).

CONCLUSION

This study revealed a high prevalence and a high level of dental pain among adult individuals with severe DA. Having dental pain was associated with poor OHRQoL.

Anxiety Related to Nonsurgical Root Canal Treatment: A Systematic Review

INTRODUCTION

Anxiety is an emotion characterized by feelings of tension, worried thoughts, and physical changes. Dental anxiety has been associated with pain, fear, care avoidance, and more invasive treatments including nonsurgical root canal treatment (NSRCT). The very words root canal are deeply embedded in societal consciousness. Better understanding of dental anxiety may prevent treatment avoidance. The purpose of this study was to conduct a systematic review of NSRCT-associated anxiety.

METHODS

Inclusion/exclusion criteria defined MEDLINE, Cochrane Library, psychINFO, manual, and citation searches. Title lists and abstracts were read to determine utility; data were extracted, summarized, and compiled into an evidence table, and meta-analyses were performed.

RESULTS

Defined searching produced 835 titles; 36 articles were included, mostly representing modern populations from countries with very high human development indices. Major sources of heterogeneity included differing study aims, outcome measures, clinical settings, locations, operators, sample selection, and sample size. Meta-analysis of 18 articles including 1989 subjects gave a pretreatment anxiety rating of 39 (standard deviation, 9) on a normalized 100-point scale. Meta-analysis of 4 articles including 232 subjects gave a post-treatment anxiety rating of 27 (standard deviation, 5) on a normalized 100-point scale, representing a 30% reduction. A L'Abbe plot of 5 studies also showed that anxiety decreased after NSRCT. Limited data indicated that gender, age, and prior NSRCT experience influenced NSRCT-associated anxiety. NSRCT-associated anxiety was ranked high among dental treatments, often close to oral surgery.

CONCLUSIONS

NSRCT-associated anxiety was generally moderate. Anxiety decreased after NSRCT. Limited evidence suggested that anxiety is influenced by patient and treatment factors.

Oral health and dental anxiety in a German practice-based sample

OBJECTIVE

Does dental anxiety have an effect on dental and periodontal health?

METHODS

Survey data was collected from n = 200 adults (53 % females, average age 49 years) in a cross-sectional study. Dental anxiety was measured with the modified dental anxiety scale (MDAS, score 1-5, the greater the score, the greater the anxiety). Clinical parameters including probing depth (PD), clinical attachment level (CAL), plaque index (SLI), and bleeding on probing (BoP) as well as the DMFT index were recorded and statistically analyzed.

RESULTS

Rating of dental anxiety was higher in women than in men (65 vs 35 %). Subjects with higher MDAS values visited the dentist less frequently (p = 0.001) and had more decay (DT 6.7 ± 4.2 vs 1.7 ± 2.4; p < 0.001) but fewer filled teeth than subjects with lower ratings of dental anxiety (FT 7.1 ± 4.5 vs 9.8 ± 5.7; p = 0.042). There were no differences in PD or CAL between subjects with or without dental anxiety, while patients with higher MDAS value showed significantly more BoP (50 ± 19 vs 34 ± 20 %; p = 0.002) than patients with low MDAS scores (no or low dental anxiety).

CONCLUSIONS

Patients with higher ratings of dental anxiety had significantly more caries experience and gingivitis. Therefore, dental anxiety is associated with negative effect on dental and periodontal health.

CLINICAL RELEVANCE

Identifying patients with high dental anxiety and helping to manage this anxiety has important implications to improve oral health in adults. The MDAS appears to be an easy and efficient tool that can be used to identify patients with dental anxiety in dental practices.

Associations between dental anxiety, sense of coherence, oral health-related quality of life and health behavior--a national Swedish cross-sectional survey

Background

Dental anxiety (DA) is a common condition associated with avoidance of dental care and subsequent health-related and psychosocial outcomes, in what has been described as the vicious circle of DA. Also, recent studies have found an association between the psychosocial concept of sense of coherence (SOC) and DA. More studies are needed to verify the relationship between DA and SOC, especially using population-based samples. There is also a need for studies including factors related to the vicious circle of DA, such as oral health-related quality of life (OHRQoL), in order to further establish the correlates of DA in the general population. Therefore, the aim of this study was to investigate the relationship between DA and SOC, OHRQoL and health-related behaviour in the general Swedish population.

Methods

The survey included a randomly selected sample of the adult Swedish population (N = 3500, age 19 – 96 years.). Data was collected by means of telephone interviews. Dental anxiety was measured with a single question. The SOC measure consisted of three questions conceptualising the dimensions of the SOC: comprehensibility, manageability and meaningfulness. The data collection also included the five-item version of the Oral Health Impact Profile (OHIP-5), as a measure of OHRQoL, as well as questions on oral health-related behaviour and socioeconomic status. Statistical analyses were made with descriptive statistics and inference testing using Chi-square, t – test and logistic regression.

Results

High DA was associated with low OHRQoL, irregular dental care and smoking. There was a statistically significant relationship between the SOC and DA in the bivariate, but not in the multivariate, analyses. Dental anxiety was not associated with oral health-related behaviour or socioeconomic status.

Conclusions

This cross-sectional national survey gives support to the significant associations between high dental anxiety, avoidance of dental care and health-related outcomes, which may further reinforce the model of a vicious circle of dental anxiety. The results further indicate a weak relationship between dental anxiety and sense of coherence.

Orofacial esthetics and dental anxiety: associations with oral and psychological health

OBJECTIVE

Severe dental anxiety (DA) is associated with both oral health and psychosocial consequences in what has been described as a vicious circle of DA. The aim of this study was to investigate self-rated orofacial esthetics in patients with DA and its relationship to psychological and oral health.

MATERIALS AND METHODS

A consecutive sample of 152 adult patients who were referred or self-referred to a specialized dental anxiety clinic filled out the Orofacial Esthetic Scale (OES) as well as measurements on DA, self-rated oral health and general anxiety and depression. Clinical measures of dental status were also obtained.

RESULTS

Compared with the general population, patients with DA had lower ratings of satisfaction on all aspects of their orofacial esthetics, which included the teeth, gingiva, mouth and face, as well as a global orofacial assessment. Furthermore, the perception of the orofacial appearance was related both to dental status and self-rated oral health, as well as to general anxiety and depression. The level of dissatisfaction with the orofacial appearance was similar for both genders, but women reported more regular dental care and better dental status.

CONCLUSIONS

The results of this study clearly show less satisfaction with dental and facial appearance in patients with DA, and that the self-rating of orofacial esthetics is related to both oral and psychological health. The OES can be used to assess orofacial esthetics in patients with DA.

Explanation and causal reasoning: A contribution to the interpretation of competing explanatory claims

The aim of this study is to attain a better understanding of the relationship between competing or complementary scientific explanatory claims. First, six different ways of approaching explanatory claims are briefly described and found, in part, to be unsatisfactory. It is argued that they should be supplemented by an analysis of underlying and sometimes partly unacknowledged causal presuppositions. This approach could be termed a causal analytical investigation, and in order to demonstrate its potential, it is applied to a concrete example: research into dental anxiety. The analysis shows that seemingly competing or complementary explanatory claims here neither compete with nor complement each other; instead, the analysis demonstrates that they explain different things. We then broaden the picture by discussing the relationship between aetiology and treatment. Finally we argue in favour of the general applicability of the approach and its relevance to science in general and to science-based practice.

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.

Psychological treatment of dental anxiety among adults: a systematic review

The aim was to investigate the efficacy of behavioural interventions as treatment of dental anxiety/phobia in adults, by conducting a systematic review of randomized controlled trials (RCTs). The inclusion criteria were defined according to the Patients, Interventions, Controls, Outcome (PICO) methodology. The study samples had documented dental anxiety, measured using validated scales [the Dental Anxiety Scale (DAS) or the Dental Fear Survey (DFS)], or fulfilled the psychiatric criteria for dental phobia. Behavioural interventions included were based on cognitive behavioural therapy (CBT)/behavioural therapy (BT), and control conditions were defined as information, sedation, general anaesthesia, and placebo/no treatment. The outcome variables were level of dental anxiety, acceptance of conventional dental treatment, dental treatability ratings, quality of life and oral health-related quality of life, and complications. This systematic review identified 10 RCT publications. Cognitive behavioural therapy/behavioural therapy resulted in a significant reduction in dental anxiety, as measured using the DAS (mean difference = -2.7), but the results were based on low quality of evidence. There was also some support that CBT/BT improves the patients' acceptance of dental treatment more than general anaesthesia does (low quality of evidence). Thus, there is evidence that behavioural interventions can help adults with dental anxiety/phobia; however, it is clear that more well-designed studies on the subject are needed.

A test of Berggren's model of dental fear and anxiety

Berggren's (1984) model of dental fear and anxiety predicts that dentally anxious individuals postpone treatment, leading to a deteriorating dental state and subsequently to fear of negative evaluations in relation to their oral condition. The present study aimed to test one of the core assumptions of this model, namely that deterioration of dental health status would mediate the effects of avoidance of dental care on self-reported fear of negative evaluation. Participants were 73 patients (mean age 38.5 yr) meeting the diagnostic and statistical manual of mental disorders - 4th edn - Text Revision (DSM-IV-TR) criteria of dental phobia. Variables in the theoretical model were operationalized with multiple measures. A series of Sobel tests indicated that mediation was present for the relationship between years of avoidance and fear of negative self-evaluation when dental health status was based on the assessment of dentists or patients' opinion of their own dental state, but not when dental health status was operationalized as decayed, missing or filled surfaces (DMFS). Although the findings are supportive of Berggren's model, other causal pathways that contribute to the perpetuation of anxiety and fear still need to be tested. The results suggest that individuals with high levels of dental anxiety would particularly benefit from interventions specifically designed to break their avoidance pattern.

Oral health and its influence on cognitive behavioral therapy in patients fulfilling the Diagnostic and Statistical Manual of Mental Disorders-IV criteria for intra-oral injection phobia

OBJECTIVE

To describe self-perceived and clinically assessed oral health and oral treatment needs among intra-oral injection-phobic patients (Diagnostic and Statistical Manual of Mental Disorders-IV) and to explore whether these factors have an impact on the outcome of cognitive behavioral therapy (CBT).

MATERIAL AND METHODS

Fifty-five patients (43 women, mean age 32.5 years, range 18-62 years) were treated with short-duration CBT. Dental anxiety (Dental Anxiety Scale and Dental Fear Survey) and self-perceived oral health were assessed by means of questionnaires. Three dentists assessed oral health by means of clinical examination and radiographs. Treatment outcome was measured by ability to receive an intra-oral injection by a general dentist within a 1-year follow-up (FU) period or ability to complete a behavioral avoidance test (BAT) at FU, and changes in dental anxiety and positive and negative thoughts from pretreatment to FU.

RESULTS

Forty percent of patients ranged their oral health as "good" or "very good". Mean decayed teeth (DT) was 2.2 (range 0-15). The total number of teeth in need of treatment, periodontal treatment, endodontic treatment and extractions ranged from 0 to 15, 0 to 19, 0 to 4 and 0 to 5, respectively. Self-rated oral health correlated significantly with clinical oral health. The outcome of CBT in terms of being able to receive a dental injection during FU was not influenced by oral health status. However, correlation analyses indicated that patients with the poorest oral health had the greatest increase in positive thoughts and the greatest decrease in negative thoughts from pretreatment to FU.

CONCLUSIONS

The oral health of intra-oral injection-phobic patients varies substantially, but is comparable to that of the normal population. Coping with a dental injection after CBT is not influenced by oral health and treatment needs.

Dental avoidance behaviour in parent and child as risk indicators for caries in 5-year-old children

AIM

The aim of this study was to explore associations between avoidance behaviour and dental anxiety in both parents and children and caries experience in 5-year-old children. It was hypothesised that parents' dental avoidance behaviour and dental anxiety were related to dental caries in 5-year-old children.

DESIGN

Data were collected from dental records and by clinical and radiographic examination of 523 children. The parents completed a questionnaire regarding education, national background, dental anxiety, dental attendance, and behaviour management problems. Bivariate and multivariate logistic regression was conducted.

RESULTS

Children having one or more missed dental appointments (OR = 4.7), child behaviour management problems (OR = 3.3), child dental anxiety (OR = 3.1), and parents avoiding dental care (OR = 2.1) were bivariately associated with caries experience at the age of 5 years. In multivariate logistic regression, having one or more missed dental appointments (OR = 4.0) and child behaviour management problems (OR = 2.4) were indicators for dental caries in 5-year-old children, when controlling for parents education and national origin.

CONCLUSION

Parents that avoid bringing their child to scheduled dental appointments and previous experiences of behaviour management problems for the child indicated risk for dental caries in 5-year-old children.