Reduction of Tension in Fearful Dental Patients

A R T IC L E S

Reduction of tension in fearful dental patients Sven G. Carlsson, PhD A nders Linde, DDS A lf Ohman, DDS

A method based on the principles of desensitization, biofeedback, and control by patients is described; ten patients who had severe dental fe a r were given therapy before conventional treatment was begun.

D

"ental treatment is a pleasure for only a few persons. The dental operatory is one scene of stress for modern man. The degree of stress may be toler­ able, but for some persons it may be co n sid era b le and even a risk —for example, the patient with a serious heart co n d itio n . A lso, su bstan tial stress, although tolerated by patients, may be a strain on dentists and affect their well-being and, sometimes, the quality of treatment. For patients who can tolerate stress, these aspects are noxious enough and common; how­ ever, for extremely anxious patients, the co n seq u en ces becom e serious when reluctance reaches such a point th a t d e n t a l v i s i t s a re e n t i r e l y avoided.1,2 Unfortunately, the result­ ing caries tend to decrease rather than increase the odds for the initiation of dental care. Dental fear that prevents treatment is not uncom m on as m ight be ex­ pected. In one study,3 5% of an exten­ s iv e and r e p r e s e n ta tiv e sa m p le avoided all kinds of dental treatment because of fear, and other surveys ar­ rive at similar figures. There is little conclusive evidence about the causes of dental fear. Fear of dentistry has been correlated with per­ sonality characteristics such as intro­ version or high trait anxiety. But, how such factors causally relate to fear of dentistry remains unclear. Shoben and Borland4 have presented evidence for the importance of attitudes of the pa­ tient’s family and Lautch5 identifies 638 ■ JADA, Vol. 101, October 1980

two features of dental phobia. He found dental trauma to be the most important causal factor and observed, like Shoben and Borland, unfavorable e x p e rie n c e s and a ttitu d e s in the families of the fearful patients. Berns­ tein and co-workers,6 in an analysis of essay descriptions of dental experi­ ences, observed a higher incidence of pain experiences among responders with fear of dentistry. Attem pts to treat dental phobias have varied. When a fearful patient does keep the dental appointment, it is sometimes possible to provide treat­ ment if the dentist can establish strong p o sitive co n ta ct w ith the patient. Some dentists give tranquilizers preoperatively; dentists also use hypno­ tics or nitrous oxide sedation.7,8 Corah and others9 have evaluated behavioral methods of patient stress reduction during amalgam restorations. Relaxa­ tion induction by means of a recorded instruction and a distraction condition that involved the patient in playing a video P ing-P ong gam e w ere both found effective in reducing stress. These methods, like several others, for exam p le, a u d io a n a lg e sia ,10'11 aim primarily at a temporary relief of stress to facilitate treatment at that appoint­ ment. The long-term effects of these procedures are doubtful; fearful pa­ tients can be as fearful sifter treatment under general anesthesia as before treatment, and they continue to avoid further dental treatm ent.12 Recently, successful attempts have

been made to treat dental fear by means of behaviorally oriented ther­ apy methods. Systematic desensitiza­ tion as a treatment of dental phobia has been described by Gale and Ayer13 and B jerck e and P la n te'n .12 Sh aw and Thoresen14 found a combination of de­ sensitization and modeling to be effec­ tive. M iller and others15 have demon­ strated reduced anxiety and muscle tension in dental patients trained with EMG biofeedback or progressive re­ laxation. T h is article w ill describe treatment of dental phobia by means of a newly developed methodology that in clu d es both d esen sitizatio n and biofeedback.

REDUCING (DENTAL FEAR

A R T IC L E S

Patients The ten selected patients had been re­ ferred to a special unit at the dental school for treatment with use of gen­ eral anesthesia. These patients were referred for general anesthesia because of inordinate fear of dental treatment. Background data on the patients are given in the Table. Eight patients were female, two were male; their ages ranged from 21 to 39 years (mean 29.4); they had refrained from dental treat­ ment for an average of 7.6 years. Pa­ tients were selected for behavioral treatment as an alternative to treat­ ment under anesthesia if: at an initial dental examination, they were judged impossible to treat conventionally, de­ spite “psychological handling” by the dentist; X rays and clinical examina­ tion indicated it was possible to save a considerable number of teeth, affect­ ing positively the patient’s attitudes towards dental care; and it was judged possible to motivate the patient for be­ havioral treatment instead of using general anesthesia. The patients selected were the first ten to be trained in the manner de­ scribed here.

Equipment As a series of dental scenes are shown to patients, we use a televisióncassette recorder and monitor (Sony U-matic V0-1810; Sony Color monitor CVM-1810E). Eight scenes are rec­ orded and show the usual progression for a dental appointment: —A dental nurse is seen talking on the telephone, scheduling an ap­ pointment for that afternoon. —The patient arrives at the clinic and is asked to sit down in the waiting room. —The patient is asked to enter an operatory and is seen sitting down in the chair. —The dentist enters the operatory and talks to the patient about the rea­ son for treatment. —The dentist examines the patient with use of a mirror and explorer. —A local anesthetic is injected. —The dentist is shown drilling at high speed. —The dentist is using a low-speed drill. Each scene lasts approximately 30 seconds. Between scenes, two minutes of relaxation instructions are given. A remote control enables the patient

Patient is watching dental scene while relaxed. Meter to her left indicates tension (muscle tension re­ corded from frontal area). When aroused by scene, she activates remote control to her right to stop scene. Scene is automatically repeated after short relaxation instruction.

to stop and start the tape at preselected points (GYYR-CPL-1000 Random ac­ cess locator) and has a search function that can be activated so the scene can be easily found and stopped. The con­ trol then rewinds the tape to the preset starting point of the relaxation instruc­ tion that precedes the scene and the tape automatically repeats from there. The Illustration shows a patient using the equipment. We use an EMG feedback device that measures and displays muscle tension for biofeedback training (Myometer). Connected to the patient’s forehead by means of surface electrodes, it gives continuous information on tension level and tension variation in that muscle area.

Method of treatment Initially, the patient is interviewed about all previous contacts with den­ tists. (The interview and the sub­ sequent training are done by a psy­ chologist). In addition, early experi­ ences associated with syringes and other medical treatments are explored. Other complications, both physical and psychological, are explored. The method of treatment is then described to the patient and the need for coopera­ tion throughout treatment is em­ phasized. The progressive relaxation tech­ nique derived from Jacobson16 is ex­ plained to the patient and begins dur­ ing the first or second visit. Any possi­

ble difficulties in relaxation are dis­ cussed. The patient is given a cassette tape recording of the relaxation in­ structions and the optimal hour for home practice is determined. Often, it is judged convenient to train at bed­ time. The significance of relaxation training is emphasized, not only in re­ lation to the dental anxiety, but also in relation to tension in general and to other psychosomatic symptoms. After some relaxation training, biofeedback training begins. Biofeed­ back training is intended to increase the patient’s ability to relax when watching scenes of dental treatment. Also, increased tension in response to the scenes can be monitored. For biofeedback training, the patient is placed in a dental chair. Muscle ten­ sion from the frontal region is recorded and fed back to the patient by means of the EMG feedback unit; it is possible to use audio frequency, a visual display, or both, which is determined accord­ ing to the patient’s preferences. Most patients prefer visual feedback. As biofeedback training proceeds, the pa­ tient is repeatedly encouraged to de­ velop a personal method for daily “brief relaxation.” The patient is re­ quested to test the method while con­ nected to the apparatus and to use it in situations when tension may be high. As soon as the patient manages to relax satisfactorily, that is, to keep frontal muscle tension relatively sta­ ble, approximately 5 to 7 ¡jN , desen­ sitization is started. The tape is ad-

Carlsson-Linde-Ohman : REDUCTION OF TENSION IN PATIENTS ■ 639

A RTIC LES

vanced until the patient or the tension recording feedback device indicates a slight reaction. The patient is then in­ structed to use the remote control to stop the tape. (The feedback device is, of course, connected all the time). It is explained to the patient that gradual decreases in reactivity may be dis­ closed as decreased reactions, in­ creased reaction latencies, or both. The patient is now left to train alone for 15to 30-minute periods. The training continues until all scenes can be watched without increases in tension. When all stimuli can be watched without distress, the initiation of den­ tal treatment is discussed with the pa­ tient. Instruments are demonstrated and procedures are explained. During the first appointment, patients are al­ lowed to use a tension feedback de­ vice, if they wish. This first appoint­ ment includes injection of a local anes­

thetic and the preparation and place­ ment of a regular amalgam restoration. The Corah Dental Anxiety Scale17 was administered at the first therapy session and after the first experience of dental treatment. In addition, after the first dental appointment, the patient’s behavior is rated by the dentist accord­ ing to the five-point scale: —The patient is totally relaxed. No reactions of fear are apparent even dur­ ing crucial sequences of the treatment. Treatment can be done without any hindrance. —The patient is well relaxed and not anxious. Mild reactions of fear can be observed but they are not apparent to a degree that affects treatment by the dentist. —The patient’s relaxation is fair. It is necessary to adapt treatment some­ what to the patient’s reactions; how­ ever, there are no serious problems

Table ■ Data on patients, treatment, outcome, and Corah Dental Anxiety Scale (CDAS) Patients 1

Age (yrs)

29

3*

4

27 31

21

2

5

6

39 30

7

8

30 31

9

10

31

25

Gender

F

M

F

F

F

M

F

F

F

F

Years since last treatment

9

11

1

6

1

5

14 15

7

7

Age at first trauma

6

7

6

16

5

15

5

7

+

+

+

+

+

+

+

History of dental fear in family Specific phobic element in treatment

+ +

+

History of psychiatric counseling

+

+

+

+

+

+

Other phobias

+

CDAS before therapy

18 14

No. of therapy sessions

7

5

Initial tension level (EMG, /xV)

10

Lowest tension level during therapy

18

15 14

13

19

20

19

9

11

4

8

4

5

10

19

7

10

10

20

12

8

10

12

10

6

4

4

4

7

4

4

5

5

4

Reactivity during therapy (1-5)

2-3

1

1

1

2

2

2

2

1

2

CDAS after treatment

10

6

12

6

6

5

7

10

6

•Data were not collected for patient 3 as she denied being afraid. However, she did not deny extensive psychosomatic problems before treatment. She had repeatedly fainted in response to use of the syringe.

640 ■ JADA, Vol. 101, October 1980

during treatment. —The patient is not relaxed; reac­ tions of fear are pronounced and treatment is clearly affected. —The patient is not relaxed; reac­ tions make treatment impossible for the risk of severe trauma to be avoided.

Results Data regarding patients, treatment, and outcome are presented in the Table. A range of four to 1 1 hourly ses­ sions were needed before dental treatment could be initiated; the mean was 7.2. Six of the patients were known to have had previous psychiat­ ric counseling, other phobia(s), or both. Half of the patients were aware, or became aware during treatment, of some specific phobic element in den­ tal treatment. Six of these patients were aware, or became aware during therapy, of a clearcut traumatic expe­ rience at 5 to 7 years of age. A dental operatory had been the scene for only two of these traumas; the others were related to injections of tetanus vaccine after accidents (three cases) and smallpox vaccination (one case) in a setting involving emotional arousal. Of course, retrospective data such as these may be of doubtful validity. It is evident from the data in the Table that all patients learned to relax. In addition, after therapy, dental treatment was possible with only minor problems for all patients. For the objective measure of anxiety, the Corah Dental Anxiety Scale (CDAS), all patients had a significant reduction (at least six points) in reactivity in rela­ tion to dental treatment. Before ther­ apy, the average CDAS score was 16.7; after dental treatment, the average score was 7.6. In view of the excellent metric qualities of this scale ,18 this seems to be a substantial effect.

Discussion With the use of the methodology de­ scribed, it is obviously possible to eliminate, in a relatively short time, inordinate fear of dental treatment. The therapeutic effect seems to de­ pend on the combination of several elements. An important element is biofeedback; patients learn to identify tension and find ways to control it. Through the whole training process, the biofeedback informs patients about their progress in dealing with a prob­ lem area. This maintains motivation

A R T IC L E S

T r e a tm e n t p re v e n tin g d e n ta l fe a r is n o t a s u n co m m o n a s m ig h t be e x p e c te d . In an A m e r ic a n stu d y , 5 % o f a n e x te n s iv e a n d re p re s e n ta tiv e s a m p le a v o id e d all k in d s of d e n ta l tr e a tm e n t d u e to f e a r, a n d o th e r s u rv e y s ten d to a r r iv e a t s im ila r fig u res. T h e re is little c o n c lu s iv e e v id e n c e a b o u t th e c a u s e s o f d e n ta l fe a r.

and helps patients to develop feelings of competence in an area in which they previously were failing. In the desen­ sitization phases of therapy, patients not only observe their tension but use it for decisions about the training pro­ gress. Our impression is that, in this way, a satisfactory cognitive reorienta­ tion results that is beneficial for pa­ tients’ future relationships with den­ tistry. Also important is the close geo­ graphical and logical connection be­ tween training and the actual applica­ tion of training (training occurs in an operatory at the dental school). Corah and Pantera19 and Corah and Salmonson20 have shown that video-taped dental scenes can arouse anxiety and that the anxiety-provoking property of the stimulation is enhanced when den­ tal treatment is imminent. Probably, the obvious links between our training and dental treatment and the relatively advanced technology used contribute to the perceived plausibility of the therapy. According to Lautch,5 the two main causal factors in dental fear are family attitudes and early trauma. In our limited sample, both ideas were supported. Although we are aware that patient recall may be of doubtful verac­ ity, it is noteworthy that eight of the ten patients were able to tell stories about specific situations, most often including syringes. Three of these traumatic experiences with syringes were not related to dental treatment; probably the anxiety, initially linked to one of the ingredients of dental treatm ent by generalization, had spread to all the others. During train­ ing, the reverse process could be ob­

served; the initial phobia remained when fear for the rest of the dental treatment was gone. In these instances, the training was, of course, concen­ trated on the specific object of fear. An early trauma as a cause of dental fear does not, of course, eliminate the possibility that other factors may be important. A child may be more or less vulnerable, because of situational or constitutional factors. In our sample, psychological problems other than dental fear are frequent.

Conclusions Practical and economical consid­ erations determine the extent to which the described therapy can become a routine part of the dental care for fear­ ful patients. General anesthesia, and probably other methods as well, are ef­ fective in making a patient temporarily available for dental treatment. We think, however, that the psychother­ apeutic intervention described here is advantageous when there is the ambi­ tion to change, in a broader sense, the patient’s competence to deal success­ fully with dental phobia.

Drs. Carlsson, Linde, and Ohman are with the unit of psychobiology, department of psychology, University of Goteberg, Sw edish Council for So­ cial Scien ce Research, Fack, S-400 20, Goteborg, Sw eden. Address requests for reprints to Dr. Carlsson. 1. Borland, L.R. Odontophobia— inordinate fe a r o f d e n ta l tre a tm e n t. D en t C lin N orth A m :683-695, 1962. 2. M olin, C., and Seeman, K. Disproportionate dental anxiety. Clinical and nosological consid­

erations. Acta Odontol Scand 28:194-212, 1970. 3. Friedson, E., and Feldm an, J.J. T he public looks at dental care. JADA 57:325, 1958. 4. Shoben.E .J., Jr., and Borland, L.R. An em pir­ ical study of the etiology of dental fears. J Clin Psychol 10:171, 1954. 5. Lautch, H. Dental phobia. B r J P sychol 119:51, 1971. 6. Bernstein, D.A., and others. Antecedents of dental fear. J P u b lic Health Dent 39 :1 1 3 -1 2 4 , 1979. 7. McCord, H. T he “im age” of the hypnodontist. J Am SocPsychosom Dent Med 9:38 -4 1 ,1 9 6 2 . 8. Secter, I.J. Applied psychology in dentistry. Am J Clin Hypn 8:122, 1965. 9. Corah, N.L., and others. T he use of relaxa­ tion and d istraction to reduce psy ch ological s t r e s s d u r in g d e n t a l p r o c e d u r e s . JA D A 98(3):390-394, 1979. 10. Gardner, W .J., and Licklider, J.C. Auditory analgesia in dental operations. JADA 59:11441149, 1959. 1 1 . S im p s o n , W .J. A u d io -a n a lg e s ia in periodontics. J Dent Child 29:9-10, 1962. 12. Bjercke, O., and Planten, S. En explorativ s t u d i e o v e r d ia g n o s o c h b e h a n d l i n g av tan d v ard srad sla. R apport fran P sykolo gisk a institutionen, Gotesborgs universitet, 1974. 13. Gale, E.N., and Ayer, W.A. Treatm ent of dental phobias. JADA 78:1304-1307, 1969. 14. Shaw, D.W., and Thoresen, C.E. Effects of m odelling and desensitization in reducing den­ tist phobia. J Counsel Psychol 21(5):415, 1974. 15. M iller, M.P., and others. Comparison of electrom yographic feedback and progressive re­ laxation training in treating circum scribed an xi­ ety stress re a ctio n s. J C on su lt C lin P sy ch o l 46:1291-1298, 1978. 1 6 . Ja c o b so n , E. P ro g re s s iv e re la x a tio n . Chicago, University of Chicago Press, 1938. 17. Corah, N.L. Development of a dental anxi­ ety scale. J Dent Res 48:596, 1969. 18. Corah, N.L.; Gale, E.N.; and Illig, S. As­ se ss m e n t of a d e n tal a n x ie ty sc a le . JA D A 97(5):816-819, 1978. 19. Corah, N.L., and Pantera, R.E. Controlled study of psychologic stress in a dental procedure. J Dent Res 47:154-157, 1968. 2 0 . C o ra h , N .L ., a n d S a l m o n s o n , R .J . Psychologic response to a simulated dental pro­ cedure as a function of proxim ity to an actual den­ tal appointment. J Dent Res 49:438-441, 1970.

Carlsson-Linde-Ôhman : REDUCTION OF TENSION IN PATIENTS ■ 641