CBT to overcome fear of the dentist

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Cognitive behavioural therapy could help many people with a dental phobia overcome their fear of visiting the dentist and enable them to receive dental treatment without the need to be sedated, according to a new study by King’s College London.

Anxiety about visiting the dentist is common and becomes a phobia when it has a marked impact on someone’s well-being; people with dental phobias typically avoid going to the dentist and end up experiencing more dental pain, poorer oral health and a detrimental effect on their quality of life. Estimates from the most recent Adult Dental Health Survey in the UK suggest around one in ten people suffers from dental phobia.

Cognitive behavioural therapy (CBT) is a short-term therapy, typically lasting 6-10 sessions. CBT has been shown to help with a range of psychological problems, most notably for depression and anxiety-related disorders. Both cognitive and behavioural interventions have been shown to be successful in reducing dental anxiety and increasing dental attendance.

The latest study looked at the characteristics of 130 patients (99 women and 31 men) attending a psychologist-led CBT service and the outcomes of their treatment. Patients attending a clinic run by the King’s College London Dental Institute Health Psychology Service at Guy’s and St Thomas’ NHS Foundation Trust were surveyed for their levels of dental anxiety, general anxiety, depression, suicidal thoughts, alcohol use and oral health-related quality of life.

Three-quarters of those assessed scored 19 or higher on the Modified Dental Anxiety Scale (MDAS), indicating dental phobia. The remainder all scored high on one or more items of the MDAS, suggesting a specific fear of some aspect of dentistry. Fear of dental injections and the dental drill were the most common high scoring items on the MDAS. Nearly all patients (94%) reported a knock-on effect from problems with their teeth, mouth or gums on their daily living and quality of life.

A proportion of the patients surveyed were found to have other psychological conditions – 37% had high levels of general anxiety and 12% had clinically significant levels of depression. Suicidal thoughts were reported by 12% of patients and four (3%) reported a recent intent to commit suicide. Individuals were referred to support services via the care of their GP and for suicide risk, immediate action was taken based on local service guidelines.

Of all patients referred, four-fifths (79%) went on to have dental treatment without the need for sedation and 6% had their dental treatment under sedation. The average number of CBT appointments required before a patient received dental treatment without sedation was five.

Professor Tim Newton from the Dental Institute at King’s College London and lead author of the study said: “People with dental phobia are most commonly given sedation to allow them to become relaxed enough for a short period of time to have their dental treatment performed. However this does not help them to overcome their fear in the long term. The primary goal of our CBT service is to enable patients to receive dental treatment without the need for sedation, by working with each individual patient to set goals according to their priorities. Our study shows that after on average five CBT sessions, most people can go on to be treated by the dentist without the need to be sedated.

“However, there is a need for people with dental phobia to be carefully assessed by trained CBT practitioners working with dental health professionals. Some of the patients referred to us were found to be experiencing additional psychological difficulties, and needed further referral and management. CBT provides a way of reducing the need for sedation in people with a phobia, but there will still be those who need sedation because they require urgent dental treatment or they are having particularly invasive treatments. Our service should be viewed as complementing sedation services rather than as an alternative, the two together providing a comprehensive care pathway for the ultimate benefit of patients.”

Abstract
Introduction: The aim of this study was to conduct an exploration of differences in oral health behaviour and outcome between dentally phobic and non-phobic participants in the UK Adult Dental Health Survey (ADHS, 2009). The null hypotheses for this study were that there are no differences in oral health status of non-phobic and dental phobic individuals.
Methods: The ADHS survey covered the adult population in England, Wales and Northern Ireland and was commissioned by the NHS Information Centre for Health and Social Care (NHS IC). Dental anxiety was defined using the Modified Dental Anxiety (MDAS) with the cut-off point set at 19 and above as indicating dental phobia. Descriptive statistics were calculated and the chi-square test was used to compare both groups in terms of their demographics, oral health, oral health-related behaviour and attitudes, and treatment.
Results: More women (16.8% [1,023]) than men (7% [344]) reported dental phobia. Generally, people with dental phobia were in routine occupations (648 [47.7%]), single (402 [29.4%]) and with lower educational attainment (858 [80.9%]). They were irregular attendees (798 [58.5%]), had a less restored dentition, increased numbers of one or more teeth with caries (292 [39.9%]), and were more likely to have PUFA (puss, ulceration, fistulae, abscess) scores of one or more (89 [12.2%]) in comparison to the non-phobic group (314 [5.6%]). However, people with and without dental phobia had similar numbers of sound and missing teeth (34.5% of the phobic group had 20 or more sound teeth in comparison to 31.7% of the non-phobic group). There were significant differences (p <0.001) between the phobic group’s and non-phobic group’s Oral Health Impact Profile-14 (OHIP) and Oral Impacts on Daily Performance (OIDP) scores with phobic participants having generally higher scores. Additionally, the phobic group responded negatively more commonly about their most recent dental treatment in terms of dentists’ ability to listen to their concerns, explaining the reasons for their dental care while paying full attention to their needs by treating them with respect and dignity. The difference between the two groups was statistically significant (p <0.001).
Conclusions: Participants reporting dental phobia are mostly females, irregular attendees and have a greater treatment need with increased caries levels.

Kings College London material
British Dental Journal abstract


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