1. 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

2. 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

3. 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

4. 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

5. 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

6. 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)

7. 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

8. 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

9. 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.

10. 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

11. 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

12. 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

13. 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 )
25% of final score reflects psychological symptomatology, 60% to fear of specific stimuli, 10% to avoidance, 5% general fear

14. 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

15. 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.

16. 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

17. 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