Written by the Dental Fear Central Web Team
Last updated on June 22, 2020
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 – in a nutshell
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.
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
- Shaking or trembling
- An upset stomach
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.)
Dental phobia – in (lots of) detail!
If you feel like delving deeper into the fascinating nitty-gritty of dental anxiety, fear and phobia, read on! Or you can jump straight to a section that interests you:
- The difference between dental anxiety, fear and phobia
- The “official” definition of dental phobia
- Problems with the official definition
- What causes dental fears?
- Other mental health issues and dental phobia
- How is dental phobia measured?
- How common is a fear of the dentist?
- Is dental phobia more common among women than men?
- The impact of dental phobia on everyday life
The difference between dental anxiety, fear and phobia
The terms dental anxiety, fear and phobia are often used interchangeably – not only in everyday use, but also in the literature (see footnote).1
One useful way of distinguishing between them is as follows:
- 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. Many people will avoid dental care at all costs until either a physical problem or the psychological burden of the phobia becomes overwhelming. Some people, for various reasons, may opt to still attend a dentist, but will endure the encounter with intense fear or anxiety.
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 dental phobia
The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) is the handbook used by health care professionals in much of the world as the authoritative guide to the diagnosis of mental health issues 2.
According to DSM-5, the diagnostic criteria for a specific phobia (which are relevant to dental phobia) are:
- a marked fear or anxiety about a specific object or situation
- the phobic object or situation almost always provokes an immediate fear or anxiety response
- the fear or anxiety is out of proportion to the actual danger posed by the specific object or situation and to the sociocultural context
- the phobic object or situation is either actively avoided or endured with intense fear or anxiety
- the fear, anxiety, or avoidance causes significant distress or impairment in social, occupational, or other important areas of functioning
- the disturbance is not better explained by the symptoms of another mental health condition, including fear, anxiety, and avoidance of situations associated with panic-like symptoms; objects or situations related to obsessions; reminders of traumatic events; or social situations.
- the symptoms must have lasted for at least 6 months.
Problems with the traditional definition of dental phobia
1. Dental phobia is hard to pin down
Dental phobia itself is not actually listed as a separate entity in DSM-5 (though see the footnote)3.
For coding a specific phobia, DSM-5 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!
According to Peter Milgrom, Philip Weinstein and Tracy Getz 4, most dental fears tend to fall into two general categories :
- Specific situations, instruments and procedures, for example
- the feel and/or sight of the needle
- the sound and/or feel of the drill
- Personality and behaviour of the dental personnel (impersonal, disinterested, mean, uncaring, cold, rough etc.)
- Fear of being embarrassed and belittled
- Personal vulnerability and lack of control over the dentist
They also mention two other categories of dental fears:
- generalised anxiety (dental anxiety which occurs as part of a more general pattern of feeling anxious about things), and
- fear of panic attacks (a fear that the dental situation will trigger a panic attack, with catastrophic consequences).
We could also add being an abuse survivor to this list, as there can be many parallels between sexual, physical and emotional abuse and the dental situation. And some people have an extreme fear of medical settings in general, which includes the dental setting.
In conclusion, dental phobia should really have its own DSM-5 entry, because it doesn’t fit well into the existing schema.
2. Is dental phobia really out of proportion to the actual danger? (or: on Bondi Beach)
While some people do perceive their fears as excessive or irrational, 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.
3. Phobia vs. Trauma
In a similar vein, it has been suggested 5 that dental phobia is a misnomer and in many cases could be more accurately described as a type of post-traumatic stress disorder (PTSD):
“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.”
Indeed, DSM-5 took note of this conundrum and added the disclaimer that “the disturbance is not better explained by the symptoms of another mental health condition, including… reminders of traumatic events (as in posttraumatic stress disorder)” to its list of criteria.
But things are rarely this clear-cut, are they? Usually, it’s not a case of either/or. Where previous bad dental experiences are involved, it can be almost impossible to draw the line between dental phobia and PTSD. In real life, bad dental experiences may combine with a whole host of other emotions (self-blame, guilt, embarrassment, shame) to form a muddled whole which shares as many characteristics with a specific phobia as it shares with PTSD.
4. Whose phobia is it anyway?
What’s the purpose of defining dental phobia? For the purposes of this website, it’s simply useful shorthand for an extreme fear of the dentist and/or dental procedures and/or anything dental-related. It’s your own experience that counts. If you feel a feeling of terror at the thought of someday having to visit a dentist, then that’s as good an indicator of a dental phobia as any. The same applies if you do somehow manage to regularly visit a dentist, but you endure those visits with intense fear or anxiety.
On the other side of the coin, dentists often use the concept of dental phobia as an indicator of how deep-rooted the fear is. If it’s a “true” phobia, the process of overcoming it will demand even more time and respect than tackling a more straightforward fear of the dentist. This common sense approach to defining phobia is shared by most dentists with an interest in dental anxiety management.
DSM-5 itself is not concerned with these issues – it does not include information or guidelines for the treatment of the mental health experiences it lists.
What can cause dental fear and phobia?
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 6.
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.
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.7
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 8.
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.
Another potential cause of dental anxiety is observational learning 9. 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 contribute to developing dental fears. Examples include “Horton Hears a Who” and “Nick at Night”.
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.
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).
It is often impossible to say if dental phobia and other mental health issues are directly or indirectly related (the chicken and the egg question). But when another mental health issue is present, this can make overcoming your fears more challenging, and symptoms may be more severe. Additional psychological support is invaluable and will improve the chances of overcoming all of the related challenges.
How is dental phobia measured?
Although the “official” diagnosis of a phobia is by a structured clinical interview, this doesn’t normally happen in a dental setting. Self-report tools such as the Modified Dental Anxiety Scale (MDAS) are occasionally used in dental practice to assess the level and the nature of the fear, but this is very rare.
There are a number of questionnaires which attempt to measure dental fear, which can be found here: Dental Anxiety Scales. One of the most common ones is the Modified Dental Anxiety Scale. However, if you suffer with dental phobia, you probably 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).
Disclaimer: many people in the medical field feel that the term “dental phobia” should be limited strictly to anyone who has been officially diagnosed by a mental health professional, using structured clinical interviews – but here at DFC, if you self-identify as dental phobic, that’s fine!
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 10.
In this video, dentist Niall Neeson answers the question: “Is dental phobia still common?”:
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 of 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.
There is a light at the end of the tunnel…
It is possible to overcome dental phobia and make progress that would have seemed utterly impossible previously. The path to success will be different for different people, but there are many options to help. If you do your research, find the right person and the right practice for you, then it is possible. There are many people out there who used to have a debilitating dental phobia, but they actually managed to build trust and confidence and overcome this burden. At this time, that may seem very difficult to imagine, but remember, if others can do it – you can do it too!
If you or someone close to you is affected by dental phobia, fear, or anxiety, visit our Dental Phobia Support Forum!
Dental Phobia Success Stories – feel free to add yours!
Footnotes and References
- There is no clear consensus regarding the use of the words “anxiety” and “fear” in the scientific literature (Armfield JM. How do we measure dental fear and what are we measuring anyway? Oral Health and Preventive Dentistry 2010; 8:107-15). One common distinction of anxiety vs. fear (coming from a neuropsychological perspective) is based on when the threat occurs (i.e. a temporal distinction):
Dental anxiety is an unpleasant emotional state related to an anticipated (rather than an actual) encounter with a feared stimulus or situation.
In contrast, dental fear is a response to an imminent threat in the here-and-now. On this basis, it is very often a normal, valid physiological response. For example, if someone is coming at you with something sharp, it’s a normal thing to be fearful of that and for the adrenaline to kick in.
Another commonly used definition of fear is “anxiety that is attached to a specific thing or circumstance” (Horwitz, AV (2013). Anxiety: a short history. Baltimore, Maryland: The Johns Hopkins University Press). This definition also forms the basis of the distinction favoured by Mike Gow, who lectures extensively on Dental Anxiety Management, and whose definition is used on this website.
- Diagnostic and Statistical Manual, 5th Ed., 2013
- Dental phobia does not have its own category in DSM-5. Instead, it is a sub-classification of Blood-Injection-Injury (BII) specific phobia that also includes needles and invasive medical procedures. This is highly problematic, because even though a true BII phobia may present in the dental environment, more commonly, dental phobia will present in a completely different manner to a typical BII phobia. While the conditions can overlap, the typical vast-vagal fainting response in BII phobia is, more often than not, absent in dental phobia (Ost L. Blood and injection phobia: background and cognitive, physiological, and behavioral variables. J Abnorm Psychol. 1992; 101(1):68-74).
- Milgrom, P., Weinstein, P., Getz, T. (1995). Treating Fearful Dental Patients. Seattle: University of Washington.
- Bracha HS, Vega EM. Posttraumatic dental-care anxiety (PTDA): Is “dental phobia” a misnomer? Hawaii Dent J. 2006 Sep-Oct;37(5):17-9.
- Milgrom P, Vignehsa H, Weinstein P. Adolescent dental fear and control: prevalence and theoretical implications. Behav Res There. 1992 Jul; 30(4): 367-73.
- Bernstein DA, Kleinknecht RA, Alexander LD (1979). Antecedents of dental fear. Journal of Public Health Dentistry, 39, 113-124.
- Moore R, Brodsgaard I, Rosenberg N. The contribution of embarrassment to phobic dental anxiety: a qualitative research study. BMC Psychiatry, 2004; 4:10.
- 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.
- The Health and Social Care Information Centre. Adult dental health survey 2009. London: Department of Health, 2010.