Anxiety, Fear & Phobia Definitions: Anxiety: Anticipation of future threat associated with muscle tension, caution or avoidant behavior Fear: the emotional response to a real or perceived threat or danger, leads to activation of the “ fight OR flight response” Phobia: persistent, unrealistic & intense fear of a specific stimulus..leads to avoidance

Criteria of specific phobia: Marked & persistent fear of a specific object or situation (Excessive or unreasonable) Immediate anxiety response Recognition Avoidance Interferes with normal day functioning

Prevalence True incidence is difficult to measure Dental anxiety ranked fifth among common feared situations Prevalence reduces with age Higher prevalence in Females Relationships with Demographic variables: Socio-economic status :Income ;Level of Education

The Adult Dental Health Survey (2009) Half adult population has a moderate – severe dental anxiety Higher levels among younger adults 36% of adults were classified as having moderate dental anxiety Higher incident in Females 17% Vs 8% Higher incident related to injections & drilling 28-30% A slightly higher incident in lower socio-economic groups

Signs (How to identify) Psychological: Sweating, pulsation, depth and speed respiration, dizziness, nausea, tremor, palpitations, pallor, fainting Behavioral: more movement; fidgeting; sitting position; rapid thumbing; pacing; frequent visits to bathroom; frequent cancellations or rescheduling

Causes & Explanation A Multi-dimensional complex phenomenon; Affecting factors include: Personality characteristics Fear of pain Past traumatic dental experiences Family & peers (modeling) Blood- injury fears Dentists’ procedures (4 Ss: Sights; Sounds; Sensations & Smells) Psychological factors (sham; guilt; embarrassment; Close physical proximity; fear of being judged; Mistrust of personnel; helplessness; catastrophe)

Why do anxiety, fear & phobia persist? needle phobia Specific phobias: drilling, extraction, pain, the dentist, the white coat, the dental chair, gagging, mercury in amalgam Cognitions: Ideas, thoughts &beliefs about objects Low pain threshold Expectations & Uncertainty Why do anxiety, fear & phobia persist? The Circle Uncomfortable feeling-Avoidance- Rewarding (eliminating the unpleasant feeling)- more likely for avoidance to reoccur again

Consequences & Complications Anxiety associated with poor oral health Anxiety evoke feelings of exhaustion after dental treatment Cognitive impacts (negative thoughts, crying, aggression, sleep disturbances, eating disorders) Impacts social interaction Additional coasts Reduces satisfaction with treatment

Cognitive; emotional; behavioral & Psychological Assessment Dental anxiety shares characteristics with many clinical disorders Dental anxiety include several dimensions: Cognitive; emotional; behavioral & Psychological Problems with Existing measures relate: weak conceptual and theoretical structure & best methods to measure indicators Dental scales used for: determine population prevalence; measure risk factors & symptoms; Examine changes of treatments over time; Aid in screening & providing more tailored treatment options.

The Dental Anxiety Scale (DAS) Corah & Pantera (1968) Most widely used for adults 4 questions relate to scenarios varying in temporal and distal proximity from dental experience The first 2 questions measure anxiety and the other two measure anticipated fear of a specific stimulus The first item is bidirectional scale while the other three items use a unidirectional scale Problem: the response categories are not mutually

Modified Dental Anxiety Scale (MDAS) Different from DAS in: A fifth item related to the receipt of local anesthetic added. A standard response format developed(not anxious; slightly anxious; fair anxious; very anxious ; extremely anxious) Still some theoretical shortcomings shared with DAS: Multi-component nature of dental anxiety is not measured Theoretical definition of main concept not provided

Kleinknecht’s Dental Fear Scale The second most common measure of dental anxiety And Fear (DFS) Originally composes of 27 items (1973), subsequently reduced to 20 items (1884) It was not developed to produce a single fear score, but rather to provide information on a variety of specific stimuli that might elicit fear or avoidance response. The original 27 items include: 2 items on avoidance, 6 items related to felt psychological arousal, 14 items assessing fear of specific stimuli, a single item concerning overall fear & 4 items on the reaction to dentistry among family and friends

The 20 items scale: 2 items on avoidance, a single item on overall fear, reduced items of psychological arousal from 6-5, specific dental items from 14-12, eliminated items of dental reaction of friends & family. (summing the 20 items into a single score ranging 20-100) 25% of final score reflects psychological symptomatology, 60% to fear of specific stimuli, 10% to avoidance, 5% general fear

Stouthard Dental Anxiety Inventory (Daxi) Stouthard 1980s A questionnaire for anxiety based on explicit theoretical considerations / designed to measure situational-specific anxiety A 36 item scale based on three content facets: time; situation & reaction perceived as being relevant to dental fear The situation facet reflects three different elements of dental experience (Introductory aspects, interaction with dentist, actual dental treatment) The reaction facet: elements of anxiety or fear experience Shortcoming: too long to be practical… Solution: DAI-S (9 items) in the 9 items: the cognitive component of the reaction facet was not included, half of items relate to the emotional reaction

Child Fear Survey Schedule-Dental Subscales (CFSS-DS) Cuthberst & Melamed (1982) The most widely used measure of dental fear for children 15 items A Reliable & valid measure Its theoretical underpinnings have not been explored Components represent specific moments of treatment rather than fear specific stimuli Cognitive, psychological, behavioral & emotional aspects of dental fear not measured.

Individual differences in techniques used Management Individual differences in techniques used (Age; patient's cooperation; dental history & Severity) The use of several techniques rather than one ensures like hood of success Management Methods include: Conscious Sedation (Inhalation; intravenous OR Oral) General Anesthetics Psychological techniques (Distraction; Desensitization; hypnosis) Communication; Rapport and Trust

Behavioral methods (rewarding; conditioning and counter- conditioning; modeling) Relaxation (enhance trust; give control over psychological status) Cognitive Behavioral Therapy (CBT) Clinical skills (pain management; local anesthetic) Technological methods to reduce annoyance Neuro-linguistic programming Acupuncture Homeopathy Environmental changes Dentist’s behavior