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Manifestations, acquisition and diagnostic categories of dental fear in a self-referred population

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Manifestations, acquisition and diagnostic categories of dental fear in a self-referred population
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  Behav.Res.Ther. Vol. 29, No.I,pp. U 1991 PrintedinGreatBritain.Allrightsreserved 0005-79679153.00 + 0.00 Copyright © 1991 PergamonPresspic MANIFESTATIONS,ACQUISITIONANDDIAGNOSTICCATEGORIESOFDENTALFEARINASELF-REFERREDPOPULATION ROD MooRE,I* INGERBR0DSGAARD 2 and HERLUFBIRN 1 'RoyalDentalCollege,DepartmentofChildDentalHealthandCommunityDentistry,DentalPhobiaResearchandTreatmentCenterandlOdderHospital,8000AarhusC,Denmark  Received12July1990) Sununary- Thisstudyaimedtocl arif yhowmanifestationsandacquisitionrelatetodiagnosticcategoriesofdentalfearinapopulationofself-referreddentalfearpatients,sincediagnosticcriteriaspecificallyrelatedtodentalfearhavenotbeenvalidated.DSM III·R diagnosticcriteriaforphobiaswereusedtocomparewithfourexistingdentalfeardiagnosticcategories,referredtoastheSeattlesystem.Subjectswere208personswithdentalfearwhoweretelephoneinterviewed,ofwhomasubsampleof155respondedtoamailedDentalAnxietyScale(DAS),State-TraitAnxietyInventoryandamodifiedFSS·IIGeerFearSeale(GFS).PersonalinterviewsandaDentalBeliefsScaleofperceivedtrustandsocialinteractionwithdentistswerealsousedtoevaluateasubsampleof80patientsselectedbysexandhighdentalfear.Resultsshowedthatthemajorityofthe80patients(66%),sufferedfromsocialembarrassmentabouttheirdentalfearproblemandtheirinabilitytodosomethingaboutit.Thelargestcauseoftheirfear(84%)wasreportedtobetraumaticdentalexperiences,especiallyinchildhood(70%).Aminorityofpatients(16%)couldnotisolatetraumaticexperiencesandhadahistoryofgeneralfearfulnessoranxiety.AnalysisofGFSdataforthe155subjectsshowedthatfear of snakesandinjurieswerehighestamongwomen;heightsandinjectionsamongmen.Fearofbloodwasrarelyreported.SpearmancorrelationsbetweenGFSindividualitemsandDASscoresindicatedfunctionalindependencebetweendentalfearandcommonfearssuchasblood,injectionsandenclosuresinmostcases.OnlyinspecifictypesofdentalfeardidtheseresultssupportRachmanandLopatka'scontentionthatfearsarethoughttosummate.TheSeattlesystemwasmodifiedtoinclude3newsocialphobicsubgroups.ThreetestcriteriadevelopedbySheehanandSheehanwereusedtoevaluatethevalidityofSeattlecategories.ThesuggestedrevisionswerepresentedinDSM-III-Rterminologyforclarity. INTRODUCTION Fearofthedentistisafamiliarphenomenonthatisexperiencedtovaryingdegrees.Themostseriousdegree of dentalfearisodontophobia.Odontophobicshavebeenreportedtoavoidthedentistformanyyearsandnumberasmanyas 5-15 ofnationalpopulationsinvariousstudies(Freidson   Feldman, 1958; Kirkegaard,Borgnakke   Grenbaek ,1985; Milgrom,Fiset,Melnick   Weinstein, 1988). Inadditiontothesetotalavoiders,otherpersonswithhighdegreesofdentalfeardelayeddentalvisits,exhibitedpoorcooperationorbrokedentalappointmentsinupto 50 ofcases(Milgrom etal., 1988). Allofthesebehaviorshaveadverseeffectsontheoralhealth of individuals(Berggren   Meynert, 1984; Milgrom etal.,1988). Therearevariousmanifestationsandcauses of dentalfearthatappeartoimpactondiagnosis.Moreaccuratediagnosiswouldbehelpfulinplanningtreatmentstrategies.Dentalfearhasbeenattributedtotraumaticexperienceespeciallyinchildhood(Bernstein,Kleinknecht   Alexander, 1979; Berggren etal., 1984; Milgrom etaI., 1988), fearfulattitudeslearnedfromparentsandothers(Shoben   Borland, 1954; Berggren   Meynert, 1984) afeelingofalackofcontrolinthedentalsituation(Kent, 1987) and/orafunctionaldependencewithotherphobiasorgeneralanxietycomplexes(McNeil   Berryman, 1989). Somebelieveodontophobiatobeasimplephobiafunctionallydependentonothersimplephobiaswhileotherscontendthatthereareaspectsofsocialphobiainvolved(McNeilandBerryman, 1989; Gale, 1972; Stouthard   Hoogstraten, 1987). McNeilandBerryman (1989) usedstandardmeasures of simpleandsocialphobiasrecentlyonasample of studentstotrytorevealpredictorsofdentalfearandindicatedfunctionaldependencewithfearsofpain,closedspacesandmutilation,butnotsocialphobias.  Towhomallcorrespondenceshouldbeaddressed.51  52 ROD MOORE etal. DiagnosticcriteriaforsimplephobiaaccordingtotheDiagnosticandStatisticalManualofMentalDisorders(DSM-III-R)(1987)are:apersistentfearinwhichanobjectorsituation.isavoidedorenduredwithintenseanxiety;significantlyinterferingwithnormalroutinesorrelationshipsandrecognizedbythepersonasunreasonable(pp.244-245).Criteriaforsocialphobiasare:apersistentfearinoneormoresituationsinwhichaperson'sfearofsocialembarrassmentorhumiliationisavoidedorenduredwithintenseanxiety;significantlyinterferingwithnormalroutinesorrelationshipsandrecognizedbythepersonasunreasonable(p.243).ButDSM-IIIdiagnosticcriteriahavenotbeenusedtodiagnoseodontophobiatotheauthors'knowledge.Onlyonediagnosticsystemfordentalfearsisdocumented(Milgrom,Weinstein,Kleinknecht   Getz,1985),buttherewereno data presentedtosupporttheseclinicalobservations.Milgrom etal. (1985)proposedfourmajordiagnostictypes,herereferredtoastheSeattlesystem:(I)conditionedfearofspecificpainfulorunpleasantstimuli(drills,needles,sounds,smells,etc.),(II)anxietyaboutsomaticreactionsduringtreatment(allergicreactions,fainting,panicattacks,death);(III)patientswithothercomplicatingtraitanxietyormultiphobicsymptoms,and(IV)distrustofdentalpersonnel.ThesediagnosticcategoriesappeartorelatetoDSM-III-Rcriteriaaswellastomanifestationsandcausalattributesmentionedabove,butthishypothesishasyettobetestedpriortothepresentstudy.Moststudies of manifestationsandcausesofdentalfearhaveemployedsamplesofeithercollegestudentsorroutinedentalpatientswithsomenotableexceptions(BerggrenandMeynert,1984;Smith,Getz,Milgrom   Weinstein,1987).Althoughinmostcasesthesestudieshavebeenusefultocontrastfearfuland'normal'patientcognitionsandbehavior,empiricalstudiesofwholepopulations of dentalfearpatientshavebeenrareandnone of thesehaveaddressedtheproblemofdiagnostictypes.Theaim of thepresentstudywastoexplorethemanifestationsandacquisitionofdentalfearandtoclarifydiagnosticcategoriesforapopulation of self-referreddentalfearpatients. METHOD TheSswere208personswithdentalfearwhowereeitheronawaitinglistorbeingtreatedattheDentalPhobiaResearchandTreatmentCenterandconsistedof128womenand80men,aged18-69yr (meant 36.2)whohaveavoideddentaltreatmentforameanof7.8yr(Table1).OftheseSs,86%wereself-referredastheresultofanationwidemassmediainformationcampaignaboutdentalfearandpossibilitiesfortreatment(Table2).All Ss weretelephoneinterviewedaboutage,years of avoidance,whattheyfearedmostaboutdentistry,wheretheyhadheardabouttheprojectandtheexistence of fearsofdoctors/hospitalsoranyothermajorfearsthandentistry.First Table 1. Samplecharacteristicsfortotalsample  n = 208)andsubsamplesbymethodAgeYravoiding n MethodsSexMeanRangeSDMeanSDRange208Phoneonlyinterview128f 80m 36.2(18-69)10.97.76.9 (0-40) ISS Phonedonly,96 r 59m 36.1(19-69)10.68.16.8(0-33)DAS,STAI,GFSDemographics80Allabove + interview,40f 40m 36.9(19-65)10.09.76.8(0.33)exam,DBSTable2. Wheredidyouhearaboutthedentalfearclinic? No.Ss % NewspapersRadio TV DentistDoctorsFriends.familyInstitutions10216241633710208 Self- referred = 17949 8 12 8 I 175100%86%  Categoriesofdentalfear   complaintswereexploredwithfollow-upquestions that differentiatedchiefcomplaints.Participantswerethenmailedaquestionnaire about otherpersonaldemographicinformationincludingmaritalstatus,taxablefamilyincome,educationallevelaswellasthefollowingpsychometrictests:CorahDentalAnxietyScale(DAS)(Corah,1969),State-TraitAnxietyInventory(STAI)(Speilberger,Gorsuch&Lushene,1970),andamodifiedFSS-IIGeer Fear Scale(GFS)(Geer,1965;Berggren&Carlsson,1984).The4itemDASisareliablemeasure of dentalfeartraits(Corah,1969,1986)from20points(extreme)to4(none).ThetwoSTAItestsmeasuredpersonalitytraitanxiety(80-20points) and specificstateanxietyatthedentist(80-20points),whilethe GFS measured18otherfears(126-18points).Sincethe GFS scaleranfrom1(nofear)to7(terrified)foreachitem,allfearsscoring6or7werealsotalliedseparatelyasweightedresponses and wereused,inadditiontothe GFS totalscores,inanalysis of generalfearfulness. Of theoriginal208telephoneinterviewed Ss, atotalof155(96women and 59men)respondedtothequestionnaires.Theremaining53Sswhowerenottestedhad,accordingtothetelephoneinterview,similarage,dentalavoidancepatterns and chiefcomplaintsasthe155testedSs.DASscoresforthe155testedSsweretestedagainstademographicallycomparablegroup of 148(84womenand64men)routinedentalpatientsrepresentativeoftheDanishadultpopulationsampledfromthesameinstitutionandnearlythesametimeperiod(Lund,Stylsvig,Ladefoged   Mikkelsen,1987).Noothertestscoreswereavailableforthisreferencegroup.OthernonnativetestscoresusedforcomparisonwereSTAI-state(dentalsetting)(Scheutz,1986),S'I'Al-trait(Spielberger etal., 1970) andGFS (Berggren&Carlsson,1984). Of the155testedSs,40men and 40women(called  pat ients'throughoutthispaper)aged19-65wereselectedforin-depthinterviewsfromascreeningusingtheDAS,theSTAI-traitandtheGFS.DASscores of 15ormore and equalnumbersofmenandwomenwerefirstusedascriteriaforinclusion.Then, GFS and STAI-traitscoreswerealsochecked and foundtohaveapproximatelythesamedistributionastheoriginalgroup of 155respondents(Table3).Inspiteofdifferencesingenderratio,yearsofavoidance(Table1) andDAS duetoselection,therestofthecharacteristicsforthis80patientsubsample,includingSTAIand GFS scores,showednosignificantdifferences (Mann-Whitney testat P = 0.05)fromtheother56womenand19menwhowerenotinterviewed.Thisensuredarepresentativesubsamplewithveryhighdentalfear and thepossibilitythroughinterviewsandteststoexplorerelationshipsbetweengeneralfearandhighdentalfearforbothgenders.Anotherscale,the15itemGetzDentalBeliefScale(DBS)(Milgram et al., 1985)wasalsousedtoevaluatethese80patients'perceivedtrustandsocialinteractionwiththedentistsonscoresfrom15(hightrust)to75(lowtrust).Semi-structuredinterviewswereconducted about these80patients'social,psychological and pharmacological data aswellaspreviousexperienceswithdentists,effectsofdentalphobiaontheirlives and thoughts about whatinteractionshindersuccessfultreatment.Afterthisinterviewandpriortotreatmentfortheirdentalfears,these80patientsreceiveddentalX-rayandoralclinicalexaminations.Decayed,MissingandFilledTeeth (DMFT) scoresweretalliedandcomparedwithDanishadultnormativedata(Kirkegaard et al., 1985)asanindicationoftheinfluenceoffearondentaldiseaseincidence.The data wereanalyzedwithSpearmancorrelations(rJandWilcoxon,Mann-Whitney. Kru skal-Wallis,Chi-square and FisherExactpr obab ilitytestswithinandbetweengroupsat P = 0.05. Table3.Summaryofpsychometrictestscoresfor n = 155andpatientsubsample  n = 80)InterviewedTotalgroupgroup Normat ivetest  n , 155)  n = 80)scoresTestMedianMeanSOMedianMean SD MedianMeanOAS1 80 17.52.218.218.11.48.59.0STAI-state71.069.84.971.070.66.840.041.7STAI-trait38.440.912.536.839.812.438.6 GFS 43.945.715.944.0 44.5 14.237.4OBS • 49.547.512.6 °Not availableorapplicable.  54 ROD MOORE etal. RESULTS Approximatelytwiceasmanywomenreferredthemselvesfordentalanxietytreatmentasmen  N = 208).Womenadmittedhavingsignificantlymorefearsofotherkindsthandidmen  P < 0.001)byGFSscores  n = ISS),buttherewerenosignificantdifferencesindentalfear(DAS)bygender.Sswithgrammerornoschoolingweremorefrequent  n = 99;64%)amongtheISSdentalphobicsthanhighschool  n = 22;14%)oruniversity/technicalcollegegraduates  n = 34;22%).SincomewasevenlydistributedamongDanishstandardsoflowandhighincome.Otherresultsaredescribedherebytypeofdataanalyzed. InterviewsManifestations. Themostfrequentchiefcomplaints  N = 208)were'thewholeprocess/afeelingofpowerlessness'  n = 122),drilling(includingthesoundofit)  n = 106),'pain'intreatment  n = 62)and'theneedle'  n = 45).Multipleresponseswereallowed.Only23ofthesepersonswerealsoafraidofphysiciansand/orhospitals.ChiefcomplaintswereofapproximatelythesameratioforthesubsamplesofISSSsand80patientsasfortheoriginal208Ss. Not allSshadbeenavoidingthedentistformanyyears,sobyanoperationaldefinitionofavoidance,2yrormorewastabulatedseparately.Only16%ofthe208Sshadavoided <2 yrwhile10%hadavoidedfor2yr.Thesetwogroupswereofspecialinterest,sincetheyreportedsimilarcognitiveandautonomicsymptomsaslongtermavoiders.Ofthe80patientsubsample,only16hadrequiredgeneralpsychotherapeutictreatment,9hadhadyoga,LaMazclassesorotherformsofrelaxationtraining,while37useddrugs,notablyanxiolyticdrugsandpainkillers,tocontrolpainorfearassociatedwithdentaltreatment.Threeadmittedgeneralalcoholabuse.Daysofanticipatoryanxietybeforeappointmentswerenotuncommonwiththefollowingautonomicsymptoms(multipleresponses):disturbedsleep  n = 45),diarrhoea/stomachache  n = 40),restlessness  n = 15),excessivesweating  n = 10)nausea/vomitting  n = 9)andtachycardia(5).The80patientsindicatedthatthingstowhichdentistsshouldnotsubjectpatientstowere(multipleresponses):condescendingremarks/rejection  n = 24),powerlessness/dominantdentist  n = 23),betoobusy  n = 19),notstopwhenthepatientfeltpain  n = 14),nottalkatall  n = 13)ornotexplainthings  n = 12)tothepatientanduseofdentallanguage  n = 5).Fifty-three(66%)ofthese80sufferedsocialembarrassmentabouttheirdentalfearproblemand/orinabilitytodosomethingaboutit.Thisembarrassmentwasmanifestatthedentistinallcasesandwasalsoapparentinothersocialcircumstances.   hadaffectedestablishedcloserelationshipsdramaticallyin6cases,duetothepoorconditionandappearanceofteeth;onewomanreportedattemptingsuicideafteraseparation,4menhadlostspousesandafifthmanhadbeendeniedappearanceatabrother'swedding.44%describedsymptomsofnotbeingabletosmilefullyand21%learnedtocovertheirteethwitheitherahand,liportongueduringsocialinteractions. Acquisition. Thelargestcausefordentalfearreportedbythe80patientswastraumaticdentalexperiences(84%; n = 67),especiallyinchildhood(70%; n = 56).TheagesatonsetofdentalfeararegiveninTable4.Ofthesetraumaticexperiences  n = 67),only25%hadbeenassociatedwithpain,30%weretheresultofbeinghelddownduringtreatmentandanother40%wereattributedto'hardhanded'dentists.Aminorityofpatients(16%; n = 13)couldnotisolatetraumaticdentalexperiencesandhadahistoryofgeneralfearfulnessoranxiety.Ofthe80patients,26%admittedbeingtoopassiveinthedentalchairand63%hadahistoryoffamily/closefriendswithdentalfears,indicatingpossibilitiesforvicariouslearning.Onlytwopatientsnamedvicariousexperiences Table4.Ageatonsetofdentalfear  n = 80)(13.8%)(16.2%) = 13 n = 11AttributedtotraumaticdentalexperiencesChildhood « 6yr) n = 56(70.0%)Q-4yr n=5 5-7yr n = 168-11yr n = 2512-16yr n = 10 Adult-17 yrormoreNotraumaticexperiences:(alwaysafterage16)  Categoriesofdentalfear Table5.Correlationsbetweenpsychometrictestscores 55 DASSTAI-stateSTAI-traitGFS *p < 0.001.DASSTAI-state0.50*STAI-trait n = 155 0.10 0.21*DDS n = 80GFS(vssame80)0.27*0.190.29·0.47*0.32* om 0.17 astheprimarycauseoftheirdentalfearandavoidance.Outoftheninepatientswhohadavoideddentists :::;2 yr,fivehadnoespeciallytraumaticdentalexperiences. Psychometrictesting DASscoresforthe155testedSs(median = 18)weresignificantlyhigher  P < 0.(001)thanthereferencegroupof148patients(DASmedian = 8.5)(Table3).These155SsalsoshowedSTAI-statedentalscoresto be wellovernormalclinicalmeansscores,whileonly77(nearly50%)hadSTAI-traitscoresabovenormalmeans.Ninety-nineSs(64%)hadhigherGFSmeansthanpreviouslyreportednormalmeanGFSscores.LowcorrelationsbetweenSTAIstateandtraitscoresofthe155Ssreflectextremefearspecifictodentalsettings(Table5).DASscoresforSsavoidingdentalvisitsfor < 2yr(median = 17; n = 34)werefoundto be significantlylower  P = 0.04)thanfortherestofthegroupof155(median = 18; n = 121 ; butGFSorSTAI-traitscoreswerenotsignificantlydifferent.Ofthe155testedSs,50hadtwoormoreGFSscoresof7and70hadtwoormoreGFSscoresof6or7.Womenshowedhighestfrequencies.Frequencyofpersonswith6-7pointfearsareshowninTable6.Fearofsnakesandinjurieswerehighestamongwomen;fear of heightsandinjectionsamongmen.Fearofbloodwasrarelyreported  n = 10).TheonlysignificantSpearmancorrelationsthatwere セ 0.20between GFS individualitemsandDAStotalscoreswere:  N = 155)snakes r s = 0.22  P = 0.(06),injuryr s = 0.26  P < 0.001)andbloodr s = 0.20  P = 0.01);for n = 80subsample r s = 0.22  P = 0.048)forclosedspaces,r s = 0.30  P = 0.007)forinjections,and r s = 0.32  P = 0.002)forsnakes.DBSscoresofthe80patientsindicatedthatmanydentalfearpatientsfeltthatthoughtsofhearing'badnews'abouttheirteethkeptthemavoiding,thattheycouldn'tstopthedentistforrestbreaks,feltrushedandthatdentistsdidn'ttaketheirworriesseriouslyandwassimilartointerviewdata.(Table7).TheDBSCronbach if. reliabilitycoefficient  n = 80)was0.86 Table6.RankordersforGFSitemsscoring6or7withfrequencyresponseof25ormoreforwholegroups  n = 155)andbysexFear n = 155Rank n = 96Rank n = 59RankSnakesInjuriesInjectionsHeightsClosedspaces n =44 n = 38 n = 36 n = 34 n = 31 I n = 37 2 n = 313 n = 27 4 n = 245 II = 25I n = 73.52 n = 73.53 n = 92 5 n = 10 I 4 n = 65 Table7.SummarystatisticsforDentalBeliefsSurvey(DBS)  n = 80)DDSscoresrangefromI(disagree)to5(agree)ItemNo.MeanSORank(15)Thoughtofhearingbadnewskeepsmeavoiding4.341.32I(13)DonotfeelIcanstopforrest3.9l1.352(2)Feelrushed3.591.283.5(9)Dentistsdonottakemyworriesseriously3.591.413.5(3)Givenoclearexplanations3.451.475(4)Dentistsdonotreallylisten3.431.426(6)Makemefeelguilty3.341.487(5)DowhathewantstodonomailerwhatIsay3.311.418(I)Dentistsdonotlikerequestsasked3.291.339(12)Ifithurts,donotthinkdentistswillstop3,161.6210(14)Donotfeelcomfortableaskingquestions3.011.66II(7)NotsureIcanbelievewhatdentistsays2.831.5212 (II) Worrydentistsaretechnicallycompetent2.201.4813(10)Dentistsputmedown2.281.3914(8)Saythingstotryandfoolme1.761.1615
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