Journal of Anxiety Disorders 28 (2014) 724–730

Contents lists available at ScienceDirect

Journal of Anxiety Disorders

Clinical implications of panic symptoms in dental phobia

Carrie M. Potter a , Dina G. Kinner a , Marisol Tellez b , Amid I. Ismail c ,
Richard G. Heimberg a,∗
a
Adult Anxiety Clinic, Department of Psychology, Temple University, 1701 North 13 Street, Philadelphia, PA 19122, USA
b
Department of Pediatric Dentistry and Community Oral Health Sciences, Kornberg School of Dentistry, Temple University, 3223 North Broad Street,
Philadelphia, PA 19140, USA
c
Kornberg School of Dentistry, Temple University, 3223 North Broad Street, Philadelphia, PA 19140, USA

a r t i c l e i n f o a b s t r a c t

Article history: The occurrence of panic symptoms in various anxiety disorders has been associated with more severely
Received 28 February 2014 impaired and difficult-to-treat cases, but this has not been investigated in dental phobia. We examined the
Received in revised form 21 June 2014 clinical implications of panic symptoms related to sub-clinical and clinically significant dental phobia.
Accepted 21 July 2014
The sample consisted of 61 patients at a university dental clinic who endorsed symptoms of dental
Available online 12 August 2014
phobia, 25 of whom met criteria for a formal diagnosis of dental phobia. Participants with dental phobia
endorsed more panic symptoms than did those with sub-clinical dental phobia. In the total sample, greater
Keywords:
endorsement of panic symptoms was associated with higher dental anxiety, more avoidance of dental
Dental anxiety
Dental phobia
procedures, and poorer oral health-related quality of life. Among those with dental phobia, certain panic
Specific phobia symptoms exhibited associations with specific anxiety-eliciting dental procedures. Panic symptoms may
Panic serve as indicators of clinically significant dental phobia and the need for augmented treatment.
Oral health-related quality of life © 2014 Elsevier Ltd. All rights reserved.

Dental anxiety is increasingly recognized as a major pub-
lic health concern, as it affects 10–20% of adults in the United
States (Doerr, Lang, Nyquist, & Ronis, 1998; Locker, Liddell, &
Shapiro, 1999; Milgrom, Fiset, Melnick, & Weinstein, 1988; Sohn
& Ismail, 2005) and leads to underutilization of dental care and
poor oral health (Berggren & Meynert, 1984; Hakeberg, Berggren,
Carlsson, & Grondahl, 1993; Ng & Leung, 2008; Thom, Sartory, &
Jöhren, 2000; Thomson, Stewart, Carter, & Spencer, 1996). It is
also associated with low oral health-related quality of life, such
as problems with sleep and impaired social and occupational func-
tioning (Berggren, 1993; Cohen, Fiske, & Newton, 2000; Kaufman,
Bauman, Lichtenstein, Garfunkel, & Hertz, 1991; Kent, Rubin, Getz,
& Humphris, 1996). Although the terms “dental anxiety” and “den-
tal phobia” are often confounded in the literature, the diagnosis
of dental phobia (i.e., specific phobia of dental procedures) repre-
sents a subset of dental anxiety in that it not only involves anxiety
about dental procedures but also requires interference or distress
∗ Corresponding author at: Adult Anxiety Clinic of Temple, Department of Psy-
chology, Temple University, 1701 North 13th Street, Philadelphia, PA 19122, USA.
Tel.: +1 215 204 1575; fax: +1 215 204 5539.
E-mail addresses: carrie.potter@temple.edu (C.M. Potter),
dina.kinner@temple.edu (D.G. Kinner), Marisol@dental.temple.edu (M. Tellez),
ismailai@dental.temple.edu (A.I. Ismail), heimberg@temple.edu (R.G. Heimberg).
related to the anxiety and avoidance of dental procedures (Gordon,
Heimberg, Tellez, & Ismail, 2013). As the majority of the published
studies on dental anxiety have not included a diagnostic assess-
ment, there is a dearth of available data comparing correlates of
dental anxiety and dental phobia; however, given the interfer-
ence component of dental phobia, individuals who meet criteria
for dental phobia likely experience heightened problems with qual-
ity of life and physical health. Although one of the major concerns
regarding dental phobia is avoidance of dental care, many dentally
phobic individuals who attend appointments experience signifi-
cant distress and exhibit poor compliance with dental procedures
(ter Horst & De Wit, 1993). Furthermore, patients with high dental
anxiety are more likely to be referred for sedation during den-
tal treatment, which is an expensive and potentially hazardous
technique (Boyle, Newton, & Milgrom, 2009). Developing effective
psychological interventions for dental phobia has important public
health implications, such as a potential reduction in overutilization
of emergency dental care and sedation (Kanegane, Penha, Borsatti,
& Rocha, 2003), calling for a better understanding of this condition
and informed directions for treatment.
A major change introduced in the DSM-5 is that panic attacks
can now be used as a clinical specifier across disorders to indi-
cate potentially more severe and difficult-to-treat cases (American
Psychiatric Association [APA], 2013; Batelaan et al., 2012; Craske
et al., 2010); however, there is a lack of research examining the

http://dx.doi.org/10.1016/j.janxdis.2014.07.013
0887-6185/© 2014 Elsevier Ltd. All rights reserved.
 C.M. Potter et al. / Journal of Anxiety Disorders 28 (2014) 724–730
prevalence and clinical implications of panic symptoms in dental
phobia. Although panic attacks are the defining feature of panic
disorder, they are often associated with other anxiety disorders,
particularly specific phobia (Kessler et al., 2006). Data from the
National Comorbidity Survey Replication indicate that 21.1% of
individuals who experience panic attacks, but who do not meet
criteria for panic disorder, have a specific phobia, which is the
highest rate of co-occurrence between panic attacks and an anx-
iety disorder other than panic disorder (Kessler et al., 2006). Of the
specific phobias, dental phobia may be among the most highly asso-
ciated with panic attacks. In a sample of 59 individuals with both
panic disorder with agoraphobia and specific phobia, dental phobia
was one of the two most commonly endorsed phobias, with 40.7%
of individuals meeting diagnostic criteria (Starcevic & Bogojevic,
1997). Although panic attacks appear to be associated with den-
tal phobia, more data are needed documenting the prevalence of
panic symptoms and attacks in dental phobia to clarify the degree
to which panic is a component of this disorder.
Examining the occurrence and intensity of panic symptoms
associated with dental phobia will also help inform the debate
about whether it is appropriate to categorize dental phobia as a
subtype of blood-injection-injury (BII) phobia (i.e., phobia of blood,
injury, needles, and invasive medical procedures), as it is classified
in DSM-5 (APA, 2013; van Houtem et al., 2013). One of the major
defining features of BII phobia is that, unlike other specific pho-
bias, it involves a biphasic physiological response to phobia-related
stimuli (Öst, Sterner, & Lindahl, 1984; Ritz, Meuret, & Ayala, 2010).
Whereas individuals with other types of phobia typically exhibit
increased heart rate and blood pressure when they encounter
phobia-related stimuli, individuals with BII phobia exhibit an ini-
tial increase followed by a subsequent sharp decrease in heart
rate and blood pressure, which can lead to vasovagal fainting (Öst
et al., 1984). Existing research on cardiac response in dental pho-
bia suggests that the biphasic response pattern may not apply, as
individuals with dental phobia who are exposed to phobia-related
stimuli (e.g., shown pictures of dental treatment procedures) typ-
ically exhibit an acceleration in heart rate that is not followed by
a deceleration (e.g., Leutgeb, Schafer, & Schienle, 2011). Examining
dental phobia-related panic symptoms can help further determine
whether or not dental phobia appears to involve the biphasic phys-
iological response pattern that is indicative of BII phobia, as some
panic symptoms are suggestive of this response (e.g., fainting).
Clarifying which panic symptoms are the most relevant to den-
tal phobia will help address the question of whether or not dental
phobia should be considered a subtype of BII phobia.
The presence and severity of panic symptoms among patients
with dental phobia has several important clinical implications.
First, the presence of panic in various anxiety and mood disorders
has been associated with greater disorder severity and comor-
bidity, as well as poorer treatment response (Feske et al., 2000;
Frank et al., 2000, 2002; Goodwin & Hoven, 2002; Goodwin &
Roy-Byrne, 2006; Hinton et al., 2008; Jack et al., 1999; Roy-Byrne
et al., 2000). These findings support the use of panic attacks as a
clinical specifier across most disorders, as introduced in DSM-5
(APA, 2013). Panic symptoms in dental phobia may also serve as
clinical indicators of complex cases in need of more comprehen-
sive assessment and intervention. However, no existing studies
have examined the clinical correlates of panic symptoms in den-
tal phobia, so it is unclear if panic attacks should be used as a
clinical specifier for dental phobia. Second, panic symptoms may
be differentially associated with various anxiety-eliciting dental
procedures (e.g., drilling/filling, X-rays), suggesting specific treat-
ment targets for different presentations of dental phobia. For
instance, individuals who primarily fear oral X-rays may experi-
ence panic attacks characterized by choking sensations, whereas
individuals who fear other types of dental procedures may exhibit a
725
different constellation of panic symptoms. There is some evidence
that panic symptoms are differentially associated with variations
in anxiety pathology (Rachman et al., 1987; Rapee et al., 1992),
but this has not been examined in dental phobia. Third, examining
the prevalence of panic in dental phobia can inform the impor-
tance of targeting panic symptoms in therapy for this disorder.
Most existing empirically supported therapies for dental phobia do
not directly address panic symptoms (Gordon et al., 2013); how-
ever, incorporating techniques such as interoceptive exposure, an
empirically supported treatment for panic symptoms in panic dis-
order (Craske et al., 1991), might improve the efficacy of therapy for
dental phobia. Dental phobia-related panic symptoms may serve
as an additional barrier to receiving dental care, as patients who
exhibit high physiological arousal (e.g., high blood pressure) at
the beginning of a dental appointment can be denied treatment
because they are at increased risk for experiencing cardiovascular
complications during dental procedures (Brand et al., 1995; Little,
2000). Therefore, if panic is prevalent in dental phobia, targeting
panic symptoms in therapy for dental phobia could improve pho-
bic individuals’ access to dental care. Further studies examining
the presence and implications of panic symptoms in dental phobia
are needed to clarify if panic symptoms are an important aspect of
dental phobia to address in assessment and treatment.
As a preliminary step toward evaluating the presence and
implications of panic symptoms in dental phobia, the present
investigation tested the following hypotheses among a group of
individuals with varying levels of dental phobia symptoms: (1)
individuals with clinically significant dental phobia would endorse
more panic symptoms than those with sub-clinical dental phobia,
(2) experiencing higher numbers of panic symptoms would be asso-
ciated with greater self-reported dental anxiety, greater avoidance
of dental procedures, and poorer oral health-related quality of life,
and (3) different panic symptoms would be associated with specific
anxiety-eliciting dental procedures.
1. Method
1.1. Participants
The current sample was comprised of 61 adults (59.0% female;
Mage = 40.89, SD = 12.98, range = 19–69) seeking dental care at
various clinics within Temple University’s Kornberg School of
Dentistry in north Philadelphia, PA. The racial/ethnic composi-
tion of the present sample was generally consistent with that of
north Philadelphia (United States Census Bureau, 2010): approx-
imately 50.8% of participants identified as black, 37.7% identified
as white/Caucasian, 3.3% identified as Asian or Pacific Islander,
and 8.2% identified as other. The primary inclusion criterion for
the present investigation was endorsement of symptoms of den-
tal phobia during the diagnostic interview, the Anxiety Disorders
Interview Schedule for DSM-IV (ADIS-IV; Brown et al., 1994). Of
120 individuals screened, 65 met this criterion. However, four of
these individuals were missing data on panic symptoms and were
therefore excluded from all analyses, resulting in a total sample of
61 participants.
1.2. Measures
Semi-structured diagnostic interview. The ADIS-IV (Brown
et al., 1994) is a semi-structured clinical interview for assessing
DSM-IV (APA, 1994) criteria for current anxiety, depressive,
somatoform, and substance use disorders. The ADIS-IV has demon-
strated good to excellent inter-rater reliability for the diagnosis
of all assessed disorders (’s = .56–.81; Brown et al., 2001), with
the exception of dysthymic disorder ( = .31). All diagnosticians
726 C.M. Potter et al. / Journal of Anxiety Disorders 28 (2014) 724–730
were advanced doctoral students or research assistants who were
trained to strict reliability standards established by Brown et al.
(2001).
For the present investigation, only the specific phobia module of
the ADIS-IV was administered to assess the presence and severity
of a current diagnosis of dental phobia and of dental phobia-related
panic symptoms. Details regarding the assessment and computa-
tion of each of these variables are provided below.
Dental phobia. Dental phobia was assessed using the specific
phobia module of the ADIS-IV. Interviewers have demonstrated
excellent inter-rater reliability for the principal diagnosis of spe-
cific phobia in a mixed sample of anxiety disorder patients ( = .86;
Brown et al., 2001). In the present study, participants were
only interviewed about phobia of dental procedures. Interviewers
assessed participants’ anxiety and avoidance of dental procedures,
as well as their distress and impairment due to dental phobia symp-
toms and assigned a clinician’s severity rating (CSR) for dental
phobia that ranged from 0 (none) to 8 (very severe); a CSR of 4 or
above indicates that the participant met criteria for diagnosis. In
order to improve diagnostic validity, the phobia module includes
a question that assesses whether participants are afraid of dental
procedures because they are afraid of having an unexpected panic
attack. Any participants who endorsed this item were asked further
probing questions to determine whether their dental phobia was
better accounted for by panic disorder; if so, they were not given
a diagnosis of dental phobia. A random sampling of ten interviews
was reviewed by reliability coders who were not informed about
the diagnoses derived by the original interviewer. There was 90%
( = .78) agreement with the original determination of the pres-
ence or absence of a diagnosis of dental phobia. For the one case in
which the original interviewer and reliability coder differed in their
assessment of the presence of dental phobia, they assigned CSRs
within one point of each other, one just at the diagnostic threshold
(4) and the other just below (3). Interviewer ratings of the pres-
ence of a diagnosis of dental phobia, as well as CSRs for those who
met diagnostic criteria for dental phobia, were used in the present
analyses.
Panic symptoms. Participants’ dental phobia-related panic
symptoms were also assessed using the specific phobia module
of the ADIS-IV. During the interview, participants were asked if
they usually experience the DSM-IV symptoms of a panic attack
when they encounter dental procedures and how intensely each
symptom is experienced. Interviewers explained that panic symp-
toms that occurred in anticipation of, during, or following dental
procedures qualified. Interviewers then rated each of the panic
symptoms on a scale of 0 (none) to 8 (very severe); a rating of 4
or above denotes clinical significance. The DSM-IV panic symp-
tom “fear of losing control or going crazy” is administered as two
separate items on the ADIS-IV, so a total of 14 panic symptoms
was assessed. In the present analyses we examined endorsement
of clinically significant panic symptom (CSR ≥ 4) by including total
number of clinically significant panic symptoms endorsed (possi-
ble range = 0 – 14) and endorsement of specific panic symptoms
(yes/no) in analyses.
Dental anxiety. Dental anxiety was measured using the Mod-
ified Dental Anxiety Scale (MDAS; Humphris et al., 1995), a
5-item self-report measure that assesses fear of dental procedures,
including drilling, scaling and polishing (i.e., cleaning), and local
anesthetic injections. Sample items include, “If you went to your
dentist for treatment tomorrow, how would you feel?” and “If you
were about to have your tooth drilled, how would you feel?” Items
are rated on a 5-point Likert-type scale ranging from 1 (not anxious)
to 5 (extremely anxious). The total score ranges from 5 to 25; a score
of 19 or above indicates high dental anxiety (Humphris et al., 1995;
King & Humphris, 2010). The MDAS has demonstrated good inter-
nal consistency (˛ = .89) and test–retest reliability (r = .82, interval
unspecified; Humphris et al., 1995). In the present analyses, the
MDAS total score (˛ = .89) was used to index global dental anxi-
ety, and three individual item scores were used to assess anxiety
specifically related to drilling, scaling and polishing, and injections.
Oral health-related quality of life. Oral health-related qual-
ity of life was measured using the Short-Form Oral Health Impact
Profile (OHIP-14; Slade, 1997), a 14-item self-report measure
that assesses the impact of oral conditions on individuals’ well-
being. The OHIP-14 evaluates the consequences of oral conditions
across multiple dimensions, including physical pain, psychological
discomfort, physical disability, psychological disability, social dis-
ability, and handicap. Sample items include, “Has your diet ever
been unsatisfactory because of problems with your teeth, mouth,
or dentures?” and “Have you ever been self-conscious because of
your teeth, mouth, or dentures?” Items are rated on a 5-point Likert-
type scale ranging from 0 (never) to 4 (very often). Higher OHIP-14
scores indicate greater impact of oral conditions, thus poorer oral-
health-related quality of life. The OHIP-14 has demonstrated good
reliability, construct and discriminant validity, and internal consis-
tency (Slade, 1997; Steele et al., 2004). In the present analyses, the
OHIP-14 total score (˛ = .93) was used to index global oral health-
related quality of life.
1.3. Data analytic plan
First, descriptive characteristics of participants were evaluated
with regard to dental phobia, panic symptoms, dental anxiety, and
oral health-related quality of life. Second, a series of independent
samples t-tests was conducted to compare dental anxiety, oral
health-related quality of life, and endorsement of clinically signifi-
cant panic symptoms (CSR ≥ 4) between those with sub-clinical and
clinically significant dental phobia. Third a series of bivariate corre-
lations was conducted among endorsement of clinically significant
panic symptoms, dental anxiety, avoidance of dental procedures
(as assessed by the ADIS-IV), and oral health-related quality of life.
These correlations were examined both among the total sample
and the sub-group of individuals with a diagnosis of dental phobia.
Fourth, among the clinically significant dental phobia sub-group,
a series of bivariate correlations was conducted among endorse-
ment of specific clinically significant panic symptoms and anxiety
ratings of specific dental procedures (drilling, scaling and polishing,
and injections).
2. Results
2.1. Participant characteristics
Table 1 provides descriptive characteristics of participants who
did/did not meet criteria for clinically significant dental phobia.
Among the total sample of participants (N = 61), all of whom
endorsed some degree of dental phobia symptoms, participants
received dental phobia CSRs that ranged from very mild (CSR = 1;
n = 7) to severe/very severe (CSR = 7; n = 3), with a median CSR
of mild/moderate (CSR = 3). The most common anxiety-eliciting
dental procedures participants mentioned during diagnostic inter-
views were injections (n = 24), tooth extractions (n = 11), drilling
(n = 7), and root canals (n = 3). Over half (57.4%) of the total sam-
ple endorsed at least one clinically significant panic symptom, and
almost one-fifth (16.4%) of the sample endorsed four or more clin-
ically significant panic symptoms, one of the DSM-5 criteria for
a panic attack (APA, 2013). The most commonly endorsed clini-
cally significant panic symptoms were cardiac sensations (32.8%),
nausea/stomach distress (19.7%), sweating (18.0%), and trem-
bling/shaking (13.1%). Please see Table 2 for further information
regarding frequency of endorsement of each of the DSM-5 panic
 C.M. Potter et al. / Journal of Anxiety Disorders 28 (2014) 724–730 727

Table 1
Descriptive data and comparisons between sub-clinical and clinically significant dental phobia groups.

Sub-clinical dental phobia (n = 36) Clinical dental phobia (n = 25) t p

M SD M SD

Dental phobia CSR 2.03 0.65 5.24 1.09 13.17 <.001

Clinically significant panic symptoms
Cardiac sensations 0.22 0.42 0.48 0.51 2.08 .043
Sweating 0.06 0.23 0.36 0.49 2.89 .007
Trembling/shaking 0.03 0.17 0.28 0.46 2.63 .014
Shortness of breath 0.06 0.23 0.20 0.41 1.60 .119
Choking 0.06 0.23 0.12 0.33 0.89 .375
Chest pain 0.00 0.00 0.08 0.28 1.45 .161
Nausea/abdominal distress 0.14 0.35 0.28 0.46 1.30 .201
Dizziness/faintness 0.00 – 0.16 0.37 2.14 .043
Derealization/depersonalization 0.03 0.17 0.12 0.33 1.28 .209
Paresthesias 0.00 – 0.17 0.38 2.15 .043
Chills/hot flushes 0.03 0.17 0.20 0.41 2.00 .055
Fear of losing control 0.00 0.00 0.08 0.28 1.45 .162
Fear of going crazy 0.00 0.00 0.08 0.28 1.45 .161
Fear of dying 0.00 0.00 0.12 0.33 1.81 .083
Total # clinically significant panic symptoms 0.61 0.96 2.72 2.34 4.27 <.001
MDAS total score 14.19 4.07 19.08 4.28 4.51 <.001
OHIP total score 18.42 10.17 30.52 10.99 4.42 <.001

Note. CSR = Anxiety Disorders Interview Schedule for DSM-IV Clinician Severity Rating; MDAS = Modified Dental Anxiety Scale; OHIP = Short-Form Oral Health Impact Profile.
CSR and ratings of panic symptoms are on a 0–8 scale, with higher scores representing greater severity. Significant between-group comparisons appear in bold print.

symptoms in the total sample and the clinically significant dental
phobia subgroup.
Of the total sample, 25 participants received a dental phobia
CSR of four or above, indicating that they met criteria for a diag-
nosis of dental phobia. In this group, CSRs ranged from moderate
(CSR = 4; n = 9) to severe/very severe (CSR = 7, n = 3), with a median
CSR of moderate/severe (CSR = 5). Over three-quarters (76.0%) of
participants in this group endorsed at least one clinically significant
panic symptom, and one-third (33.0%) endorsed four or more clin-
ically significant panic symptoms. The most commonly endorsed
clinically significant panic symptoms in this group were cardiac
sensations (48.0%), sweating (36.0%), trembling/shaking (28%), and
nausea/stomach distress (28%, see Table 2).
significantly worse oral health-related quality of life. Participants
with a diagnosis of dental phobia also endorsed more clinically
significant panic symptoms than did those with sub-clinical symp-
toms of dental phobia. In terms of individual clinically significant
panic symptoms, those with a diagnosis of dental phobia were
significantly more likely to endorse cardiac sensations, sweating,
trembling/shaking, dizziness/faintness, and paresthesias (numb-
ness and tingling sensations) than were those with sub-clinical
dental phobia symptoms.
2.3. Correlates of panic symptoms in the total sample and the
dental phobia subgroup

In the total sample, endorsement of a greater number of clin-

2.2. Comparisons between sub-clinical and clinically significant
dental phobia groups
Table 1 provides comparisons on the variables of interest
between the sub-clinical and clinically significant dental phobia
groups. Compared to participants with sub-clinical symptoms of
dental phobia, those who met criteria for a formal diagnosis of den-
tal phobia exhibited significantly higher levels of dental anxiety and
ically significant panic symptoms was associated with dental
anxiety (r = .49, p < .001), avoidance of dental procedures (r = .31,
p = .015), and poorer oral health-related quality of life (r = .49,
p < .001).
Among participants who met diagnostic criteria for dental pho-
bia, endorsement of a greater number of clinically significant panic
symptoms was associated with poorer oral health-related quality of
life (r = .62, p < .001) but was only modestly associated with dental

Table 2
Frequency of endorsement of dental phobia-related panic symptoms among the total sample and clinically significant dental phobia subgroup.

Total sample (N = 61) Clinical dental phobia (n = 25)

Frequency Percentage Frequency Percentage

Cardiac sensations 20 32.8 12 48.0

Sweating 11 18.0 9 36.0
Trembling/shaking 8 13.1 7 28.0
Shortness of breath 7 11.5 5 20.0
Choking 5 8.2 3 12.0
Chest pain 2 3.3 2 8.0
Nausea/abdominal distress 12 19.7 7 28.0
Dizziness/faintness 4 6.6 4 16.0
Derealization/depersonalization 4 6.6 3 12.0
Paresthesias 4 6.6 4 16.0
Chills/hot flushes 6 9.8 5 20.0
Fear of losing control 2 3.3 2 8.0
Fear of going crazy 2 3.3 2 8.0
Fear of dying 3 4.9 3 12.0

Note. Frequency = number of people who endorsed experiencing each panic symptom at a clinically significant level (clinician severity rating ≥4). Percentage = percentage of
sample who endorsed experiencing each panic symptom at a clinically significant level.
728 C.M. Potter et al. / Journal of Anxiety Disorders 28 (2014) 724–730
anxiety (r = .39, p = .057) and was not associated with avoidance of
dental procedures (r = .17, p = .405). However, higher dental anxiety
was significantly correlated with greater endorsement of clinically
significant cardiac sensations (r = .48, p = .016) and sweating (r = .52,
p = .007). In terms of associations between specific panic symptoms
and anxiety related to specific dental procedures, the panic symp-
tom of sweating was associated with anxiety related to both drilling
and injections (r’s > .41, p’s < .041), whereas the panic symptom of
cardiac sensations was specifically associated with anxiety related
to drilling (r = .45, p = .025). There were no significant associations
between clinically significant panic symptoms and anxiety related
to scaling and polishing.
3. Discussion
The present findings are generally consistent with our hypothe-
ses about the associations between panic symptoms and dental
phobia. As predicted, individuals who met criteria for a diagnosis
of dental phobia reported experiencing more clinically significant
panic symptoms related to dental procedures than did those with
sub-clinical dental phobia. Specifically, this group was more likely
to endorse the occurrence of cardiac sensations, sweating, trem-
bling/shaking, dizziness/faintness, and paresthesias. This finding
suggests that assessing for the presence and symptom composi-
tion of panic attacks may help determine whether an individual is
experiencing dental phobia at a clinical level.
It is noteworthy that the panic symptoms dizziness/faintness
and paresthesias were associated with a diagnosis of dental pho-
bia, as these symptoms have been found to be more prevalent in
individuals with panic disorder than in those with specific pho-
bia (Rapee et al., 1992). It is possible that the symptoms of dental
phobia overlap more with panic disorder than is the case for other
specific phobias or that dental phobia is more highly comorbid with
panic disorder than are other specific phobias, and this is worthy
of future research attention. The association of dizziness/faintness
with dental phobia also suggests that some individuals with dental
phobia may exhibit the biphasic physiological response to dental
procedures that often results in vasovagal fainting (Öst et al., 1984),
and this is another important direction for future research. It would
be interesting to examine the specific fears endorsed by individ-
uals with dental phobia who do/do not experience fainting when
they encounter dental procedures to see if fainting is associated
with more typical BII phobia-related fears (e.g., fear of receiving an
injection) as opposed to dental procedure-specific fears (e.g., fear
of losing teeth). Future studies comparing endorsement of panic
symptoms across different anxiety disorders are also needed to
evaluate which symptoms are more or less related to dental pho-
bia. This line of future work will help clarify how the assessment
of panic symptoms can improve the differential diagnosis of dental
phobia and other highly associated anxiety disorders, such as social
anxiety disorder (Moore et al., 2004), and whether dental phobia
appears to involve the same type of physiological arousal as other
subtypes of BII phobia (van Houtem et al., 2013).
Also consistent with our expectations, in the total sample,
experiencing more dental phobia-related panic symptoms was
associated with greater dental anxiety, avoidance of dental proce-
dures, and poorer oral health-related quality of life. However, only
the associations between panic symptoms and dental anxiety and
poor oral health-related quality of life held among the subset of par-
ticipants who met diagnostic criteria for dental phobia. It is possible
that the small size of the clinically significant dental phobia group
did not provide enough power to detect a more moderate associa-
tion between dental phobia-related panic symptoms and avoidance
of dental procedures, and future studies examining this relation-
ship among larger samples of individuals with a diagnosis of dental
phobia are needed. Restricted range of scores may also have been a
problem on some measures in the dental phobia group, although a
number of relationships were quite robust. Still, the observed asso-
ciations between panic symptoms, dental anxiety, and poor oral
health-related quality of life in the clinically significant dental pho-
bia group suggest that individuals with dental phobia who expe-
rience panic symptoms represent more severe and complex cases.
Our findings support the use of panic attacks as a clinical specifier
for dental phobia as is recommended in DSM-5 (APA, 2013).
It is noteworthy that in both the total sample and the clinically
significant dental phobia subgroup, those with panic symptoms
were more likely to experience oral health-related impairment (as
assessed by the OHIP-14), such as difficulties with speaking, eating,
or sleeping. There are a number of ways that dental phobia-related
panic symptoms may serve as a barrier to dental care and place
individuals at increased risk for experiencing problems related to
poor oral health. Our finding that panic symptoms were related
to avoidance of dental procedures in the total sample suggests
that individuals who experience dental phobia-related panic symp-
toms may be more likely to avoid dental procedures, which may
lead to greater oral health impairment. Another reason that indi-
viduals who experience dental phobia-related panic may receive
inadequate dental care is that many dental procedures cannot be
safely performed on individuals who exhibit increased physiolog-
ical arousal (Brand et al., 1995; Little, 2000). Dentists routinely
measure patients’ blood pressure before and during invasive dental
procedures, such as placement of dental implants, and stop proce-
dures if patients exhibit high blood pressure or sudden changes
in pressure (Little, 2000). Given that panic symptoms are marked
by elevated physiological arousal, patients who experience dental
phobia-related panic may be more likely to be denied dental care
and therefore at increased risk for experiencing subsequent oral
health-related impairment. Since over three-quarters of the clini-
cal dental phobia group reported experiencing at least one clinically
significant panic symptom, addressing dental phobia-related panic
may be an important component of treatment for many individuals
and may improve anxious individuals’ access to dental care. Future
work on clinical interventions for dental phobia should examine if
individuals with dental phobia who experience panic symptoms
benefit from interoceptive exposure (Craske et al., 1991) to the
physical and cognitive symptoms experienced in anticipation of
or during dental procedures, and if incorporating interoceptive
exposure into therapy reduces physiological arousal during dental
treatment and improves delivery of care.
Our hypothesis that panic symptoms would be associated with
specific anxiety-eliciting dental procedures among the clinically
significant dental phobia subgroup was partially supported. Of the
three procedures assessed by the MDAS (drilling, injections, and
scaling and polishing), cardiac sensations were associated with
anxiety related to drilling, and sweating demonstrated associations
with anxiety related to both drilling and injections. These findings
provide very preliminary evidence that dental phobia-related panic
symptoms may vary depending on the procedure in question, per-
haps because different dental procedures evoke distinct physical
sensations. For example, oral X-rays involve placing a piece of film
in the mouth and therefore may be more likely to induce feelings
of choking than receiving a filling would. It is important to further
examine associations between specific anxiety-eliciting dental pro-
cedures and panic symptoms to inform potential treatment targets
for dental phobia. It is possible that individuals with dental phobia
who experience anxiety related to different procedures may ben-
efit from different exposure exercises that address distinct panic
symptom profiles.
The current study has a number of strengths and limitations
that should be considered in interpreting the findings. Our study
included a diagnostic interview, which allowed us to examine
 C.M. Potter et al. / Journal of Anxiety Disorders 28 (2014) 724–730
associations between panic symptoms and dental anxiety among
individuals who met DSM-IV criteria for dental phobia. A limited
number of published studies on dental anxiety have included a
diagnostic assessment of dental phobia (Gordon et al., 2013), and
the present study is an addition to that literature. However, only
25 participants met criteria for dental phobia, which limited the
sample size of the clinical group. Further, as we only administered
self-report measures and the specific phobia module of the ADIS-IV,
we were unable to examine or control for psychiatric comorbidity
and our measures were limited to self-report and clinician rat-
ings. Additionally, the specific phobia module of the ADIS-IV does
not include questions regarding the timing of panic symptoms, so
we were unable to examine whether panic symptoms occurred in
anticipation of, during, or after dental procedures. Future studies
examining panic and dental anxiety in larger clinical samples that
include a comprehensive diagnostic assessment and other types
of measurement (e.g., behavioral, physiological) are necessary. Our
sample was comprised of individuals seeking dental care at a uni-
versity clinic who exhibited symptoms of dental phobia, many of
whom met criteria for clinically significant dental phobia and had
a history of avoidance of dental procedures. However, our find-
ings may not generalize to individuals who completely avoid dental
treatment, and future studies should examine correlates of dental
phobia among this group. Another limitation of the present study
is that anxiety related to specific dental procedures was assessed
using single items on the MDAS. Future studies should build off of
our preliminary findings on the associations between panic symp-
toms and specifically feared dental procedures by including more
detailed assessments that measure anxiety related to a wider range
of dental procedures.
The present findings provide preliminary evidence that most
individuals with clinically significant dental phobia experience
dental anxiety-related panic symptoms, illustrating the need for
targeting them in the treatment of dental phobia. Assessing panic
symptoms among individuals with dental phobia appears to be
clinically useful in making diagnoses and identifying more severe
cases that may necessitate augmented treatment.
Conflicts of interest
The authors of this manuscript do not have any direct or indi-
rect conflicts of interest, financial or personal relationships or
affiliations to disclose.
Acknowledgements
Portions of this paper were presented at the 2013 annual meet-
ing of the Association for Psychological Science in Washington
DC, and the presentation was supported in part by a Building
Bridges Award from the National Institute of Dental and Cranio-
facial Research to Carrie M. Potter. This research was supported
in part by a grant from the Pennsylvania Department of Health to
Marisol Tellez (grant number 100054871).
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