What is dental phobia?

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!

Dental phobia, an extreme fear of the dentist, is an umbrella term which can involve many different fears, or one specific fear. Dental phobia causes a lot of distress, and can impact on other aspects of your life.

You may spend an awful lot of time thinking about your teeth or dentists or dental situations, or else spend a lot of time trying NOT to think about teeth or dentists or dental situations. Which is pretty hard in today’s society, which is saturated with ugly reminders such as toothpaste commercials.

Rather be dead than be faced with a dentist? – You might be suffering with dental phobia!

When you encounter things that remind you of the threatening situation, you may experience anxiety symptoms such as:

  • A fast heartbeat / palpitations
  • Dizziness or feeling faint
  • Nausea
  • Sweating
  • Shaking or trembling
  • An upset stomach
  • Breathlessness

This is called the Fight-or-Flight response, and full-blown panic attacks are not uncommon. (There’s also the Freeze response, which allows you to dissociate from the here and now when an enemy is deemed by your brain to be too powerful to fight or outrun. The Freeze reaction may be particularly common in trauma survivors.)

The difference between anxiety, fear and phobia

The words ‘anxiety’, ‘fear’, and ‘phobia’ are often used interchangeably (even on this website!). However, there is a subtle difference 1.

  • Dental anxiety is a reaction to a potential danger. Most people experience some degree of dental anxiety, especially if they’re about to have something done which they’ve never experienced before. Often, it’s a fear of the unknown – the “uncertainty factor”.
  • Dental fear tends to be far more specific. If somebody has a fear, they’re usually able to pinpoint what they have a fear of, for example a fear of injections or gagging or being humiliated. Generally, a fear will be linked with some degree of physical or psychological harm – a fear of pain is common. If you have a lot of different dental fears, pinpointing them can become a little overwhelming because there are so many of them, but you should be able to identify them with some prompting.
  • Dental phobia is even more intense. The terror you feel is so strong that you avoid the dentist altogether. Avoidance is a key characteristic of dental phobia. Many people will avoid dental care at all costs until either a physical problem or the psychological burden of the phobia becomes overwhelming.

On the face of it, this conceptualisation might suggests a mild-moderate-severe progression. But in reality, dental anxiety (a reaction to a potential danger) can be just as debilitating as a full-blown phobia. Sometimes, dental anxiety can be more difficult to tackle than dental phobia. For example, if you’re not sure what exactly is causing your anxiety, it can make it harder to come up with solutions.

The “official” definition of a phobia

According to DSM-5, phobias are defined as unreasonable, excessive fears 2 that lead to avoidance of the feared situation, object or activity. The symptoms must have lasted for at least 6 months. The phobia causes significant distress, and being exposed to (or even just thinking about) the feared stimulus usually results in the symptoms of anxiety listed above.

Problems with the traditional definition of dental phobia

1. “Dental phobia” can be hard to pin down:

Dental phobia itself is not actually listed as a separate entity in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), the handbook used by health care professionals in much of the world as the authoritative guide to the diagnosis of mental health issues.

Perhaps this is because dental phobia is simply too messy to pin down. For coding a specific phobia, DSM-5 only lists 5 stimuli:

  • Animal (e.g. spiders, insects, dogs)
  • Natural environment (e.g. heights, storms, water)
  • Blood-injection-injury (e.g. needles, injections, blood, invasive medical procedures, injury)
  • Situational (e.g airplanes, elevators, enclosed places) and
  • Other (e.g. situations that may lead to choking or vomiting)

From this list, dental phobia may involve a “blood-injection-injury” stimulus (such as needles or surgery or injury), a “situational” stimulus (the dental surgery or waiting room), or “other” (e.g. situations that may lead to choking or vomiting). Interestingly, there is no option for a “person” phobic stimulus in DSM-5, only an “animal”, so a phobia of the dentist (as a person) can’t be easily coded.

In many ways, dental phobia is very different from other specific phobias.

  • Firstly, the fear is often directly linked to another person (usually the dentist) and their behaviour.
  • Secondly, many common dental fears are realistic: many of the things people are afraid of, for example being lectured or told off, not getting numb, mutilation in the form of unnecessary treatment, to name but a few, really can happen (especially with the wrong dentist) – which brings us to the second major problem with defining dental phobia below.
  • There is another peculiarity about dental phobia: the large number and variety of fears which people may experience. There are over 20 common fears discussed on this website alone, and this list is by no means exhaustive!

2. Is dental phobia really an irrational and excessive fear? (or: on Bondi Beach)

While some people do perceive their fears as irrational and excessive, others don’t. Mike Gow, a dentist from Glasgow (and founder of the International Society for Dental Anxiety Management), has come up with the following analogy:

If you were standing on Bondi Beach and you look out into the water and you see a dark shape moving around in the water, do you have a shark phobia if you never want to go into the water? Is that a shark phobia? No. Because you’re on Bondi Beach and it’s a suspicious dark shape that could be a shark. If you’re at your local swimming pool and you see a dark shape in the water and you decide not to get in, that’s a phobia. That’s excessive.

Now somebody who has only had difficult and bad experiences at the dentist, their only reality has been on Bondi Beach. And actually, their phobic response is legitimate. If their recollection of what happened during in this horrible appointment is true, then wanting to stay away from that situation for me is entirely rational, that is not a phobic response. Now the difference, and the crucial part, is making sure that when they go to a dentist they see a dentist who is as safe as the swimming pool. So it’s the environment that becomes important rather than the phobia. The phobia has protected them from all dentists when actually it’s just the dentists that are not nice to them that they need to avoid.

How common is dental phobia?

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. In the UK’s Adult Dental Health Survey (2009), 12% of adults had extreme dental anxiety, while over a third (36%) had moderate dental anxiety 3.

In this video, dentist Niall Neeson answers the question: “Is dental phobia still common?”:

What can cause dental fear and phobia?

Bad experiences:

Most (though by no means all) dental fears and phobias are caused by previous bad experiences with dentists or dental treatment. 85% of people with dental fears report having had negative, traumatic or painful experiences.

One large study from Singapore found that individuals who reported having experienced painful dental treatments and perceived a lack of control were 13.7 times more likely to report higher dental fear, and 15.9 times more likely to report being less willing to return to dental treatment 4.

Feelings of powerlessness:

Many people with extreme dental anxiety or phobia feel powerless in dental social situations. You may have felt in the past that you had to obey the dentist, or you may have had a dentist who would not stop even though you were in distress.

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 can also contribute to developing dental phobia.

Uncaring dentist:

It is often thought 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 or controlling that has a huge psychological impact. Pain caused by a dentist who is perceived as caring is far less likely to result in psychological trauma.5

Embarrassment:

Especially after years of avoidance, you may feel shame and intense embarrassment in social situations and try and hide your mouth. The thought of a dentist seeing your teeth may be impossible to even contemplate 6.

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, although this appears to be of relatively minor importance compared to direct experience 7. 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:

It has been suggested 8 that dental phobia is a misnomer and in many cases could be more accurately described as a type of post-traumatic stress disorder (PTSD). Most people who have developed dental phobia as a result of past bad experiences don’t feel that their fear is “excessive and unreasonable”. PTSD would be a much more accurate description than calling this a “phobia” (and, by implication, irrational):

“We propose that the term “Posttraumatic Dental-care Anxiety (PTDA) is more accurate since it specifies that the mode of acquisition is typically not innate (as with blood phobia), but rather acquired, most frequently through direct conditioning akin to PTSD.”

Other mental health issues and dental phobia

Dental phobia and anxiety can co-occur with other mental health issues, especially

  • Generalised Anxiety Disorder and Health Anxiety (the things you worry about intensely may include or focus on dental stuff),
  • panic disorder/agoraphobia (the fear of what will happen if you panic while visiting the dentist and/or the fear of having to leave your safe space),
  • depression (lack of motivation resulting in lack of self-care, including caring for your dental health, which will exacerbate avoidance because of fear of lectures or dental treatment; embarrassment over the state of your teeth which makes it even harder to feel good about yourself or to socialise), and
  • emetophobia (fear that you may gag or choke on something and throw up, or fear of drugs used in dentistry causing nausea and vomiting).

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!

When you’re in the depth of a dental phobia, this cute teddy may strike you as pretty frightening (a dentist in teddy’s clothing) – yet another reminder of your worst nightmare…

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).

Is dental phobia more common among women than men?

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 perhaps women are simply more likely to admit to their fears.

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 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.”

“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 things more difficult, because you may find it much harder to be open about your fears, and you may be inclined 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.

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 and people from all walks of life being anxious or phobic – it is not at all unusual.

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 effects on your life. Not only can your dental health suffer, but dental phobia may lead to anxiety and depression. Laughing out loud may be 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. Some people 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 or someone close to you is affected by the issues raised on this page, feel free to join our Dental Phobia Support Forum!

References

  1. Armfield JM. How do we measure dental fear and what are we measuring anyway? Oral Health and Preventive Dentistry 2010; 8:107-15.
  2. Diagnostic and Statistical Manual, 5th Ed., 2013
  3. The Health and Social Care Information Centre. Adult dental health survey 2009. London: Department of Health, 2010.
  4. Milgrom P, Vignehsa H, Weinstein P. Adolescent dental fear and control: prevalence and theoretical implications. Behav Res There. 1992 Jul; 30(4): 367-73.
  5. Bernstein DA, Kleinknecht RA, Alexander LD (1979). Antecedents of dental fear. Journal of Public Health Dentistry, 39, 113-124.
  6. Moore R, Brodsgaard I, Rosenberg N. The contribution of embarrassment to phobic dental anxiety: a qualitative research study. BMC Psychiatry, 2004; 4:10.
  7. Townend E, Dimigen G, Fung D. A clinical study of child dental anxiety. Behaviour Research and Therapy, Vol. 38, Issue 1, January 2000, pp 31-46.
  8. Bracha HS, Vega EM. Posttraumatic dental-care anxiety (PTDA): Is “dental phobia” a misnomer? Hawaii Dent J. 2006 Sep-Oct;37(5):17-9.