high risk of caries.
The variable most closely associated with
the high risk of caries was being an evening type person,
with the risk for an evening person nearly 4 times higher
than the risk for a morning person.
Discussion.—Circadian rhythm, caries risk, tooth-
brushing frequency, and breakfast habits were correlated
in these adolescents. Morning and neutral type people
were more likely to be at low risk for caries; evening people
were more likely to be at high risk.
Clinical Significance.—The effect of circadian
rhythms on young people’s oral health can be sig-
nificant. Dentists should include questions about
being tired in the morning or alert at night in
forms to be completed by their adolescent pa-
tients. Those who are evening types may be
Dental Fear/Anxiety
Managing anxious or fearful patients
Background.—Dental anxiety, fear, and phobia
contribute significantly to an avoidance of dental care.
Dental anxiety is an emotional state that occurs before
the encounter with the dentist and can be directed at
threatening stimuli or at an unidentified cause. Dental
fear is a reaction to a known or perceived threat or danger
and leads to a fight-or-flight response. Dental phobia, also
termed odontophobia, is a persistent, unrealistic, intense
fear that leads to complete avoidance of dental care. This
overwhelming fear causes hypertension, terror, trepida-
tion, and unease and is an identified phobic disorder. Phys-
ical, cognitive, emotional, and behavioral responses are
evoked by each of these states. As a result, the individual re-
acts with avoidance of dental care, leading to poor dental
health until an emergency situation develops, when com-
plex, highly traumatic treatments may be needed, further
reinforcing the fear and perpetuating the cycle. Dental prac-
titioners should quickly identify dentally anxious or fearful
individuals and alleviate these feelings while positively
motivating them with the goal of achieving long-term re-
sults. The causes of dental anxiety, identification of anxious
or phobic individuals, and management of these individuals
in the dental office were explored.
Causes.—Multiple factors play a role in the develop-
ment of dental anxiety and fear. These include having a pre-
vious traumatic experience, especially during childhood;
seeing family members or peers who are anxious; having
226 Dental Abstracts
encouraged to not let breakfast or oral hygiene
habits slip because of morning tiredness. In addi-
tion, oral health education programs for adoles-
cents should include information about
circadian rhythms so that all youth are made
aware of the effect these natural fluctuations can
have on their oral health.
€ €nsson B: Do adolescents who are night
Lundgren A-M, Ohrn K, Jo
owls have a higher risk of dental caries? – a case-control study.
Int J Dent Hygiene 14:220-225, 2016
€nsson, The Public Dental Health Service
Reprints available from B Jo
Competence Ctr of Northern Norway, PO Box 2406, N-9271 Tromsø,
Norway; fax: þ47 77690114; e-mail: bjo@du.se
personality characteristics such as being self-conscious or
neurotic; not understanding; seeing frightening portrayals
of dentists in the media; having poor coping skills; experi-
encing altered body image perceptions; and feeling vulner-
able when considering lying back in a dental chair. Sensory
triggers can also contribute to fear. These include the sight
of needles, the sounds of drilling, the smell of eugenol, or
the sensation of drilling vibrations.
Fears that give rise to dental anxiety include a fear of
pain, of blood, of betrayal, of being ridiculed, of the un-
known, of depersonalization in the eyes of the dentist, of
exposure to radiation or mercury poisoning, of choking
or gagging, or of lack of control over the situation. Anxious
persons can be classified using the Seattle system as influ-
enced by specific dental stimuli, by distrust of dental
personnel, by a generalized sense of fear of dentistry, or
by fear of catastrophe.
Identification.—Dentists can often identify dentally
anxious or phobic individuals through their first interactions
with them. However, it is also possible to identify these indi-
viduals using questionnaires or objective measures.
Dentists can try to identify which dental situations cause
a patient fear and anxiety through a calm, uninterrupted
conversation. The dentist should ask a few open-ended
questions to guide the discussion and identify why the
patient came for treatment, what he or she has experienced
previously in a dental setting, what causes him or her anxi-
ety or fear, and what expectations the patient has for the
visit. If the dentist identifies the dental anxiety as part of a
broader psychological disorder, the patient can be referred
for psychological help. Often the dentist and psychologist/
psychiatrist can work together to alleviate the patient’s
anxiety.
Dentists should not rely solely on clinical judgment.
Self-reporting questionnaires can also help to identify pa-
tients with anxiety or fear related to the dental setting.
These include multi-item scales such as Corah’s Dental Anx-
iety Scale (CDAS), Modified Dental Anxiety Scale (MDAS),
Spielberger State-Trait Anxiety Inventory, Dental Fear Sur-
vey (DFS), Dental Anxiety Inventory, and fear scales.
Single-item dental anxiety-and fear questionnaires can
also be used. The tools most often used are the CDAS,
MDAS, and DFS. Using these questionnaires, patients can
be identified has having mild anxiety, moderate anxiety, or
extreme anxiety or phobia.
Among the objective measures used to identify anxious
patients, the galvanic skin response may be the most accu-
rate. Other objective measures include blood pressure,
pulse rate, pulse oximetry, and finger temperature.
Management.—Once the patient has been properly
evaluated and the source and level of their anxiety or
fear identified, an appropriate treatment plan can be
formulated. The broad categories of interventions are
psychotherapeutic methods, pharmacologic interven-
tions, or a combination of psychotherapy and pharmaco-
logic agents. Both psychological and pharmacologic
interventions can be effective in reducing anxiety and
phobia.
Among the psychotherapeutic interventions are
behavioral or cognitive approaches, along with the use
of cognitive behavior therapy (CBT), which has proved
highly successful for extremely anxious and phobic per-
sons (Table 2). However, behavioral and cognitive thera-
pies require multiple sessions to achieve a response,
although the response tends to be maintained once it
has developed.
Pharmacologic aids provide either sedation or general
anesthesia and usually are effective only on a short-term ba-
sis. These agents should be used only when the patient
cannot respond and cooperate well with psychotherapeutic
interventions, is unwilling to undergo a psychotherapeutic
treatment approach, or is considered dental phobic. This
can include patients with special needs. Before resorting
to pharmacologic measures the dentist should weigh the
risks in relation to behavioral versus pharmacologic ap-
proaches; the evidence when selecting agents to use; the
Table 2.—Psychotherapeutic Interventions
Communication skills, rapport, and trust building: iatrosedative
technique
Behavior-management techniques
Relaxation techniques: deep breathing, muscle relaxation
Jacobsen’s progressive muscular relaxation
Brief relaxation or functional relaxation therapy
Autogenic relaxation
Ost’s applied relaxation technique
Deep relaxation or diaphragmatic breathing
Relaxation response
Guided imagery
Biofeedback
Hypnotherapy
Acupuncture
Distraction
Enhancing control
‘‘Tell-show-do’’, signaling
Systematic desensitization or exposure therapy
Positive reinforcement
Cognitive therapy
Cognitive behavioral therapy (CBT)
(Courtesy of Appukuttan DP: Strategies to manage patients with dental
anxiety and dental phobia: Literature review. Clin Cosmetic Invest Dent
8:35-50, 2016.)
extent of the patient’s dental needs as well as the severity
of the anxiety or fear; the patient’s cognitive and emotional
needs, along with his or her personality; the practitioner’s
skill, training, and experience; if proper equipment is avail-
able along with appropriate monitoring devices; and the
cost involved.
A sedation needs tool has been developed to help clini-
cians determine the need for conscious sedation, which is
defined as the use of a drug or drug combination to depress
the central nervous system and reduce the patient’s aware-
ness of his or her surroundings. Sedation can be conscious,
deep, or general, but it does not control pain or replace the
use of local anesthetics.
When the patient is under general anesthesia, he or she
cannot be aroused, even by painful stimuli. Ventilatory func-
tion can be impaired, and help may be required to maintain
a patent airway, maintain ventilation, or support neuromus-
cular or cardiovascular function. General anesthesia is used
for patients who are phobic, have severe learning diffi-
culties, have severe anxiety, suffer from severe psychiatric
disorders, have physical disabilities or movement disorders,
or have significant comorbid conditions. Sedation is gener-
ally not considered safe for these patients, and periopera-
tive monitoring is required.
Environmental Measures.—While psychotherapeutic
and pharmacologic measures are highly useful, the dentist
can also address issues related to the dental office envi-
ronment and communication approaches. Often the
Volume 62  Issue 4  2017 227
patient becomes anxious just entering the dental environ-
ment. Therefore receptionists, dental nurses, and dental
hygienists should help to create a soothing atmosphere.
This includes providing positive, caring interactions and
using a concerned but calm tone when obtaining informa-
tion. The addition of soft music, the avoidance of bright
lights, providing a slightly cooler room temperature, and
having posters and pictures on the walls as well as maga-
zines and books in the waiting area can contribute to a
calm atmosphere. Sounds of instruments should be
muted in the waiting area, and the patient should not
have to wait long. Pleasant ambient odors can be used
to mask clinical smells and provide a calming effect.
Aromatherapy has been useful in managing moderate
but not severe anxiety. The scent of lavender has been
shown to reduce salivary cortisol and chromogranin
levels, lower serum cortisol levels, increase blood flow,
and decrease galvanic skin conductance and systolic
blood pressure. A sensory-adapted dental environment
(SDE) may also prove useful and is especially helpful
with children and those with developmental disabilities.
The dentist should also establish two-way communica-
tion with the patient, conversing personally before the
clinical portion of the visit. He or she should maintain a
calm, composed, and nonjudgmental demeanor, listening
closely to what the patient has to say. Patients should be
encouraged to ask questions about all aspects of the visit.
The dentist should continue to (1) ask the patient if he or
she is experiencing any discomfort, (2) provide moral sup-
port, and (3) reassure the patient during the procedure.
These approaches will help to cement a rapport with
the patient that can increase the patient’s confidence in
the dentist. It can be important to normalize the patient’s
anxious feelings and avoid negative phrasing. Nonverbal
communication should be in line with what is being
said. Patients respond well to touch to convey comfort
and provide control. Dentists should seek to maintain
eye contact with the patient when possible and continu-
ally observe the patient’s responses throughout the pro-
cedure. The dentist should avoid rapid movements,
provide empathy, and try to make the patient feel
welcome. These patients need to feel the dentist is their
friend, someone who is sensitive to their needs and sym-
pathetic to their struggles.
Emergency Room Follow-up
Dental clinic use after nonemergency hospital visits
Background.—Both emergency and nonemergency
dental care is being sought increasingly at hospital
228 Dental Abstracts
Technologic Aids.—In addition to making the envi-
ronment comforting and providing support therapy as
indicated, the dentist can make use of various technolo-
gies that have the ability to reduce anxiety. These
include computer-controlled local anesthetic delivery,
electronic dental anesthesia, and computer-assisted
relaxation learning. During restorative treatments,
patients can be managed by eliminating the primary sen-
sory triggers for dental anxiety (sight, sounds, sensa-
tions, and smells). Among the newer methods for
reducing pain or discomfort associated with dentistry
are atraumatic restorative treatment, air abrasion using
alumina powder streams, ultrasonic tips coated with dia-
mond particles, chemomechanical caries removal, and
lasers for cavity preparation.
Clinical Significance.—Quality of life is
impaired by dental anxiety or fear, so the
dentist should take seriously any patient who
comes for treatment with these conditions.
Overcoming fear and anxiety related to the
dental experience will allow the patient to
obtain and maintain good oral health. Therapy
should be tailored to the specific patient and
based on the results of a proper evaluation,
the dentist’s expertise and experience, the de-
gree of anxiety and fear, the patient’s mental
capability and age, the degree of cooperation
that can be achieved, and the clinical situation.
Good communication is essential in allaying
fear and allowing the patient to relax and expe-
rience reduced stress. Success in treatment will
require a trusting dentist-patient relationship.
Appukuttan DP: Strategies to manage patients with dental anxiety
and dental phobia: Literature review. Clin Cosmetic Invest Dent
8:35-50, 2016
Reprints available from DP Appukuttan, Dept of Periodontics,
Sri Ramakrishna Mission Dental College and Hosp, Bharathi Salai,
Ramapuram, Chennai, Tamil Nadu 600 089, India; e-mail:
devapriyamds@gmail.com
emergency departments (EDs). A disproportionate num-
ber of these visits are from low-income families who often