Ambling along an innocent-looking road, you pass a sign for a dental surgery. Immediately, your heart starts racing, you break out in a cold sweat, and you feel shaky and nauseous. Argggh, not yet another reminder of the dreaded D-word – better cross that road and face the other way!! Is that you? You may be one of the many people who suffer with dental phobia!
A “phobia” is traditionally defined as “an irrational severe fear that leads to avoidance of the feared situation, object or activity” (even though the Greek word “phobia” simply means fear…). Exposure to the feared stimulus provokes an immediate anxiety response, which may take the form of a panic attack. The phobia causes a lot of distress, and impacts on other aspects your life, not just your oral health. Dental phobics will spend an awful lot of time thinking about their teeth or dentists or dental situations, or else spend a lot of time trying NOT to think of teeth or dentists or dental situations. Which is pretty hard in today’s society, which is saturated with ugly reminders such as toothpaste commercials.
The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) describes dental phobia as a “marked and persistent fear that is excessive or unreasonable”. It also assumes that the person recognizes that the fear is excessive or unreasonable. Conclusion? The DSM-IV criteria were obviously not decided upon by a representative group of dental phobics (read on to see why). Having said that, there is a new revised version coming out soon, so maybe the definition will have changed. You might be interested to learn that DSM-IV’s predecessor, DSM-III, defined homosexuality as a mental disorder … I’d hazard a guess that many if not most dental phobics would object to being labeled as having a mental disorder.
This is not to say that dental phobia cannot co-occur with mental health conditions – of course it can. Dental phobia appears to be more common in people who suffer from another mental health problem, notably Generalized Anxiety Disorder, panic disorder/agoraphobia, depression, and emetophobia. Research suggests that about 20% of dental phobics have a concurrent mental health problem. Then again, 25% of all British adults experience at least one diagnosable mental health problem in any one year …
The main problem with defining “dental phobia” is that there isn’t just ONE type of dental phobia, but many types – some rational, and some which seem more “irrational”.
Bracha and others (2006, HI Dental Journal) have suggested that the term dental phobia is typically a misnomer, for much the same reasons I’m outlining here (you can find the abstract of their article at the bottom of this page).
Whether the fear is “unreasonable”, “excessive”, or “irrational” is debatable… certainly not if you end up in the hands of the wrong dentist! Which, incidentally, is one of the reasons why people end up as dental phobics in the first place…
The difference between anxiety, fear and phobia
A distinction has been made between dental anxiety, dental fear, and dental phobia.
- DENTAL ANXIETY is a reaction to an UNKNOWN danger. Anxiety is extremely common, and most people experience some degree of dental anxiety especially if they’re about to have something done which they’ve never experienced before. Basically, it’s a fear of the unknown.
- DENTAL FEAR is a reaction to a known danger (“I know what the dentist is going to do, been there, done that – I’m scared!!”), which involves a fight-or-flight response when confronted with the threatening stimulus.
- DENTAL PHOBIA is basically the same as fear, only much stronger (“I know what happens when I go to the dentist – there’s no way I’m going back if I can help it. I’m so terrified I feel sick”). The fight-or-flight response occurs when just thinking about or being reminded of the threatening situation. Someone with a dental phobia will avoid dental care at all costs until either a physical problem or the psychological burden of the phobia becomes overwhelming.
There are other classification schemes; for example, Weiner and Sheehan (1990) distinguish two types of dental anxiety: exogenous (from the outside) and endogenous (from the inside). Exogenous dental anxiety is defined as anxiety due to traumatic dental experiences. Endogenous dental anxiety is thought to have originated from other anxiety disorders.
Similarly, the University of Washington Categories of Dental Fear distinguishes between 4 categories of dental fear:
- Fear of Specific Stimuli
- Distrust of Dental Personnel
- Generalized Anxiety
- Fear of Catastrophy (fear of a medical emergency)
The first two of these would usually have been caused by previous bad experiences (“exogenous”), whereas generalised anxiety and fear of catastrophy could be classed as endogenous. These distinctions aren’t always helpful, though. For example, someone may have experienced a real medical emergency in the past during dental treatment (exceedingly rare, but not impossible, e. g. in the case of a genuine severe allergic reaction). In this case, the fear of catastrophe would be due to a previous bad experience. Also, when someone is asked what they fear about the dentist and their answer is “everything”, dentists may assume that this is a sign of generalised anxiety, even though the person may not be particularly anxious in everyday life.
Of course, people may fall into more than one category. Exogenous dental anxiety may be perceived as being more “irrational” than fears caused by bad dental experiences. But in my experience, once we know a person’s history and the causes of their anxiety, there is usually a very rational explanation behind it (although where childhood trauma is concerned, people may not remember the events that led up to their anxiety).
It is always safest to assume that “irrational” fears are not irrational at all, but caused by very real events.
How is dental phobia measured?
There are various instruments for researchers which attempt to measure the degree of the fear, such as Corah’s Dental Anxiety Scale (DAS) and a shorter version, the Modified Dental Anxiety Scale (MDAS). Click here for a PDF download. However, if you suffer with dental phobia, you won’t find it too hard to beat the high score, never mind being scared enough to qualify!
Alternatively, ask yourself the following question: “Am I terrified of dentists and avoid them at all costs?” If the answer is yes, this is a good indicator of dental phobia! Even seemingly innocuous reminders of anything dental-related may produce a panic-attack if you suffer with dental phobia, such as people talking about dentists or teeth, toothpaste commercials, or “dental words” (such as words starting with de-, or words like accidental).
Problems with defining dental phobia
One problem with defining dental phobia is that “dental anxiety” (a reaction to an unknown danger) may feel just as frightening as a “phobia” to a person, and they may well be defined (or define themselves) as phobic. From what little research there is available, this may be more common in people who are generally anxious. Also, some people who’ve never had a bad experience with a dentist or a dental procedure can develop dental fear or phobia – this is usually the result of vicarious learning (that is, hearing or reading scare-stories from other people including parents, or media portrayal).
I like to think that “dental phobia” is simply useful short-hand for “terror at the thought of dentists and/or dentistry and/or anything dental-related”. Some people feel that their fear is justified and rational, while others feel they’re being silly for getting so upset over something which “everyone else” seems to have no problem with. “Dental Phobia” is really an umbrella term which covers a wide range of different fears, as you’ll see on the Common Fears pages. It would also appear that there are some fairly distinct subtypes of dental phobia, such as needle phobia or terror at the thought of gagging and being sick.
What are the most common causes of dental phobia?
- Bad experiences: Dental phobia is most often caused by bad, or in some cases horrific experiences at a dentist’s (studies suggest that this is true for about 80 -85% of dental phobias, but there are difficulties with obtaining representative samples). This not only includes painful dental visits, but also psychological behaviours such as being humiliated by a dentist.
- A history of abuse: Dental phobia is also common in people who have been sexually abused. A history of bullying or having been physically or emotionally abused by a person in authority may also contribute to developing dental phobia, especially in combination with bad experiences with dentists.
- Uncaring dentist: It is often thought, even among dental professionals, that it is the fear of pain that keeps people from seeing a dentist. But even where pain is the person’s major concern, it is not pain per se that is necessarily the problem. Otherwise, dental phobics would not avoid the dentist even when in pain from toothache. Rather, it is pain inflicted by a dentist who is perceived as cold and controlling that has a huge psychological impact. Pain caused by a dentist who is perceived as caring is much less likely to result in psychological trauma (Weiner et al, 1999).
- Humiliation: Other causes of dental phobia include insensitive, humiliating remarks by a dentist or hygienist. In fact, insensitive remarks and the intense feelings of humiliation they provoke are one of the main factors which can cause or contribute to a dental phobia. Human beings are social animals, and negative social evaluation will upset most people, apart from the most thick-skinned individuals. If you’re the sensitive type, negative evaluation can be shattering.
- Vicarious learning: Another cause of dental anxiety is observational learning. This appears to be of only minor importance, judging by our forum and by the available research (e.g. Townend, Dimigen and Diane, 1999). If a parent or other caregiver is afraid of dentists, children may pick up on this and learn to be afraid as well, even in the absence of bad experiences. Hearing other people’s horror stories about visits to the psychodentist can have a similar effect. Also, the depiction of “the dentist” in the media (especially children’s films/cartoons and comedies, and of course horror movies) can cause people to develop dental fears. Examples include “Horton Hears a Who” and “Nick at Night”.
- Preparedness: People may be inherently “prepared” to learn certain phobias, such as needle phobia. For millions of years people who quickly learned to avoid snakes, heights, and lightning (and sharp objects, such as needles, which would not have been sterilized in those days, apart from giving you a nasty sting!) probably had a good chance to survive and to transmit their genes. So it may not take a particularly painful encounter with a needle to develop a phobia.
- Post-Traumatic Stress: Research suggests that people who’ve had horrific dental experiences (unsurprisingly) suffer from symptoms typically reported by people with post-traumatic stress disorder (PTSD). This is characterized by intrusive thoughts of the bad experience and nightmares about dentists or dental situations.
This was summed up by Stefan Bracha and his colleagues (2006) in an article in the Hawaii Dental Journal:
“In this article, we suggest that the term “dental phobia”, as commonly applied to the experience of dental fear and anxiety, is typically a misnomer. The problem with using the term “phobia” in a dental-care context is as follows: by definition, phobias involve a fear that is “excessive or unreasonable”, which the individual recognizes as such, and in which the anxiety, panic attacks and phobic avoidance are not better accounted for by another disorder, including posttraumatic stress disorder (PTSD). In our experience, most individuals who experience dental anxiety or fear do not view their symptoms as “excessive or unreasonable” and in that sense, resemble individuals with PTSD. Further, our review of the dental-care literature suggests that true (innate) dental phobias (akin to unreasonable fear at the sight of blood or a syringe) probably account for a smaller percentage of cases, and that a larger subset of dental-care anxiety (DA) cases stem from dental experiences that are, at a minimum, aversive and/or painful, and at times highly traumatizing. Research has documented that individuals who reported having experienced painful dental treatments and perceived a lack of control in the dental situation were approximately 14 times more likely to also report higher dental fear, and approximately 16 times more likely to report being less willing to return to the dental treatment. Based on the current available research, we propose that this psychological condition should be conceptualized as Posttraumatic Dental-care Anxiety (PTDA), and should be classified as part of the Posttraumatic Stress Disorder (PTSD) spectrum in the forthcoming Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-V).”
Who is affected by dental phobia?
Anyone can be affected by dental phobia! It doesn’t matter if you are young or old, a man or a woman, a janitor or a nuclear scientist, rich or poor.
You may have come across news stories which imply that dental phobia is more common among women. For example, the 2009 Adult Dental Health Survey in the U.K. reported that women are twice as likely as men to experience extreme dental anxiety. But… all this means is that women are more likely to admit to their fears!
In reality, it is likely that there is no significant difference between men and women when it comes to dental anxiety. There are loads of men who avoid dentists but generally speaking, they find it much harder to admit to it (even in a survey – and it should be pointed out that the survey mentioned above involved visiting people in their homes, so it wasn’t exactly anonymous). Also, women who work in more “macho” professions such as the police force or the military often find it harder to articulate their fears. Here are some comments from our forum:
“I’m a 37 year old VERY heavily tattooed construction worker and I’d like to think I can handle everything, except my teeth.”
“Help… I really feel like a wimp as a guy. I know I shouldn’t be this way, but I can’t help it. :’(”
“I know it is not by chance that so many active duty, reserve soldiers or veterans have major issues around going to the dentist. Not that it’s announced out loud (I know I would be mortified) that you’re afraid of something so little as a dental appointment if you’ve been shot at or actually shot.”
“I’m a grown man and a full time firefighter. I can run into a burning building without blinking an eye but the thought of sitting in a dentist chair scares the hell out of me… even typing this puts a knot in my stomach.”
Being a male can make it more difficult for you to overcome your fears, because even if you did manage to see a dentist, you might find it much harder to be open about your fears, and you may try to “tough it out”. But this strategy rarely, if ever, works. A lot of men also mention their fear of a young, pretty dental assistant seeing them frightened and seeing their teeth, and this can be as big a deterrent as seeing the actual dentist for some.
The good news is that once you do manage to seek help and open up about your fears, you may find a huge weight lifted off your shoulders. Dentists (and their assistants) are well used to guys being anxious or phobic – it is not at all unusual. A study done on our dental phobia support forum concluded that:
Our findings did not suggest any discernible differences [between males and females] in either the reasons given for accessing this online group nor its advantages in terms of coping with the challenges of dental anxiety. (Buchanan & Coulson, 2007)
Here is what one of the men on our forum said:
“I too thought the only way I could have dental work done again was if I had a GA, I had a mouthful of holes and broken teeth too…
In the past, I did everything I thought I needed to, to please the dentist, being brave and putting up with anything… When I thought about that, I realised that was the wrong thing to do. I’m at the dentist because I want my teeth to be healthy, it’s for me and I have a say in it.
I now have a totally different outlook on the dentists, I’m still very nervous, but my dentist is willing to work with me, and goes at the speed that I can cope with.
My dentist talks to me and I feel so in control, it’s a totally different experience from what I had before.
You can find a dentist like this too, but you must be honest with them, don’t try and hide the fear you feel.”
The impact of dental phobia on daily life
Dental phobia can have wide-ranging consequences on a person’s life. Not only does their dental health suffer, but dental phobia may lead to anxiety and depression. Laughing out loud is out of the question – too hard to hide one’s teeth… Depending on how obvious the damage is, you may avoid meeting people, even close friends, due to embarrassment over your teeth, or avoid jobs which involve contact with the public. Loss of self-esteem over not being able to do something as “simple” as going to a dentist and intense feelings of guilt over not having looked after one’s teeth properly are also very common. Dental phobia sufferers may also avoid doctors for fear that they might want to have a look at their tongue or throat and suggest that a visit to a dentist might not go amiss.
If you suffer with dental phobia, you’ll be inclined to think that nobody else feels the way you do – after all, who else would rather be dead or prefer a global nuclear disaster in which everyone dies to meeting up with a dentist?
Actually, quite a lot of people ! While there are no reliable statistics (after all, few dental phobics will freely admit to never visiting a dentist… that’s if they hang around to complete the questionnaire!), the most conservative estimates reckon that 5% of people in Western countries avoid dentists altogether due to fear. And many more are anxious about dentistry.
However, most people actually don’t mind going to the dentist. There is a reason for this – nowadays, dentistry can be pain-free and there are many personable, kind and compassionate dental professionals around. Many if not most people who’ve suffered with dental fears and phobias reckon that having found the right dentist for them has made all the difference. This is especially true when fears were caused by previous bad experiences.