Exposure and CBT for Dental Phobia

Written by the Dental Fear Central Web Team. Needle phobia desensitisation protocols provided by Mike Gow BDS and Gordon Laurie BDS
Last updated on January 17, 2021

Exposure therapy is a form of Cognitive Behavioural Therapy (CBT) which is especially useful for phobias. As the name suggests, it involves exposing yourself to the objects or situations that scare you.

Real Life Stories: My Story of Overcoming Dental Phobia

Alex* decided to tackle their dental phobia using desensitisation: “Over the last 10 years or so I have come to love going to the dentist. Prior to that, I was such a phobic. I couldn’t even walk past a dentist practice. My teeth were in dire straights, and I did lose all my top ones as they couldn’t be saved. If I can get around this, anyone can so let me tell you how I did it.”

Exposure therapy usually involves facing your fears in a planned and structured way with the help of a therapist. You start off with less frightening items and situations – things which cause you anxiety, but anxiety that you can tolerate. Then, you gradually work your way up to the things that scare you the most.

An example of (not so) gradual exposure: spider phobia cartoon

But you can also use some of these techniques by yourself, or engage in more informal types of exposure. We’ll give lots of practical examples on this page.

Finding a supportive and caring dentist you like and trust is the key to overcoming dental phobia and fears. Exposure therapy is one of many tools which can help, depending on your individual fears and needs.


Variations of exposure therapy

Exposure can take various forms – here are some common types:

  1. Imaginal exposure: Imagining the feared object or situation.
  2. Interoceptive exposure: This means deliberately bringing on bodily sensations that you are scared of. For example, if you have a fear of feeling numb, you might put a topical numbing gel on a small part of your gums, in the safety of your own home, to get used to the numb sensation and learn that it is not dangerous.
  3. In vivo exposure: Facing the feared object or situation in real life.
  4. Graded exposure: This usually involves making a fear hierarchy. You come up with a list of feared objects or situations, which you then rank according to how scary they are. Then, you start off with exposing yourself to the easiest item, until you are confident that you can handle this item. You only move on to the next item once you feel confident and relatively relaxed with the current one.
  5. Systematic desensitisation: Pretty much the same as graded exposure, except that it’s combined with a relaxation exercise such as belly breathing.

Working with a psychologist

Some of the examples of exposures on this page can be done without any professional help. But when it comes to actual CBT and graded exposure, you’ll usually work with a therapist. A psychologist can:

  • help come up with a plan and ideas about how to go about the exposure
  • run you through the feared situation in your imagination
  • use pictures or videos of feared things or situations, or actual objects
  • or even visit the waiting room of a dental practice with you.

Doing it right: exposure

Exposure therapy for dental phobia needs to be done right. Otherwise, you may end up pushing yourself but still end up feeling scared. If you feel that you’re not making progress, or that you’re getting worse using exposure, have a look at footnote 1.1


Exposures and Desensitisation for Dental Phobia

What follows are actual examples of exposures, including needle phobia desensitisation protocols.

1 a. Passive imaginal exposure

Try not to do anything which reinforces or worsens your fears. One piece of advice we’re hearing time and time again from our forum members is to avoid YouTube videos like the plague. Many exposures are much better done together with a supportive dentist, rather than in front of a computer or mobile device, where your imagination can run wild.

1 b. Active imaginal exposure

  • Write down the events that led to your fear or phobia
  • Record a narrative of the events onto your smartphone
  • Start a journal on our forum

Of course, there’s not much point in reliving painful memories just for the sake of it. Getting feedback from others can be vital. If you have experienced trauma, you may think that whatever happened to you was “normal” (or normal at the time). Or you may wonder if your mind is playing tricks on you and that it wasn’t really that bad. You may even blame yourself for what happened. Sometimes, we need to hear from other people that what happened to us was wrong and that history doesn’t have to repeat itself. Getting emotional support from others who have been in a similar situation can be invaluable.

2. Exposure to bodily sensations

  • To help with a fear of panic attacks, you deliberately bring on the sensations that frighten you. One example is running on the spot to make your heart speed up, and thereby learning that the sensation of a rapidly-beating heart is not dangerous. You can find lots of other examples on the PsychologyTools website.
  • To tackle fear of feeling numb, you can use an over-the-counter topical anaesthetic to simulate and practice the numbing sensation.
  • Use an electric toothbrush under the shower, with the water running over your ears, to get used to dental instrument noises.

3. Real-life exposures

Practice making the phone call

Work up towards scheduling your first appointment by calling the dental practice out-of-hours. Just listen to their answering machine and then hang up. Make sure you check the opening hours so there will be just an answering machine and not a receptionist (keep it predictable).

Going near the chair

Have a chat with the dentist in the treatment room, without actually sitting in the dental chair. If this is too difficult, see if you can have a chat outside the treatment room first. Once you’re comfortable with having a chat in the treatment room, continue the chat in the dental chair, but sitting on the side of the chair. Once you’re able to cope with this, sit on the chair itself.

Having a check-up

If you’re scared of the dentist looking at your teeth,

  • start by letting them have a look outside the chair, without a mirror
  • repeat this in a brighter place, this time allowing some touching and perhaps a mirror, but still outside the chair
  • once you’re happy there won’t be a negative reaction, you can try out “the real thing” in the chair.

Tell-show-do

If you like, let your dentist show you and demonstrate some of the tools and materials they use. You can find out more here: Tell-Show-Do – It’s not just for children!

Rehearsals

Rubber dam rehearsal: You may want to practise breathing and swallowing with the dental dam on, before any actual treatment. For more information, visit the rubber dam page.

Dental injections: See the cap-on-off rehearsal below

4 + 5. Graded exposure and systematic desensitisation

Graded exposure involves making a fear hierarchy. You come up with a list of feared objects or situations, which you then rank according to how scary they are. Then, you start off with exposing yourself to the easiest item, until you are confident that you can handle this item. You only move on to the next item once you feel confident and relatively relaxed with the current one.

Example of a fear hierarchy for dental phobia

There are several ways as how the final hierarchy could look like.

Simple ladder

It can either be a simple ladder in form of things going from lowest fear to highest fear, such as: 

(lowest fear)
1. Watching a toothpaste ad
2. Talking / writing about my situation / my fears 
3. Seeing a webpage of a dental practice
4. Walking past a dental practice
5. Listening to the answering machine of a dental practice
6. Emailing a practice 
7. Scheduling an appointment 
8. Sitting in the waiting room 
9. Having a conversation with a dentist 
11. Sitting in the chair 
12. Having the dentist looking at my teeth briefly
13. Having a full exam 
14. Having a cleaning 
15. Dental injection 
(highest fear)

Graded list of items

Or it can be a list with items that come to mind when it comes to dental visit, each point graded from 0-100 based on the severity of the fear, such as:

10 – Watching a toothpaste ad
20 – Talking/writing about my situation / my fears 
40 – Seeing a webpage of a dental practice
40 – Walking past a dental practice 
60 – Listening to the answering machine of a dental practice 60
70 – Emailing a practice
75 – Scheduling an appointment
80 – Sitting in the waiting room
90 – Having a conversation with a dentist 
90 – Sitting in the chair
95 – Having the dentist looking at my teeth briefly
95- Having a full exam 
95 – Having a cleaning
100- Dental injection 

Loose scale

It can also be a rather lose scale with very few items, such as

0 – Watching a toothpaste ad



40 – Seeing a web page of a dental practice



70 – Scheduling an appointment


80 – Having an exam


100 – Having a filling done


Whichever way you choose, a fear ladder is highly personal and depends on your individual fears and on the situation. To give an example, there will be people who are completely fine as long as there is no treatment involved. For others, sitting in the chair is already a 100. You may be terrified of injections but not of the drill, or vice versa – or both.

Also, if you do a hierarchy on different days at different times, it will look slightly different each time. While the rough order may be the same, the items may shift. And as people start working on their fears, the fear grading changes too, so while at the beginning, scheduling an appointment may feel like a 70, it might only feel like a 50 once the first steps on the ladder have been completed.

Example of a dental needle desensitisation protocol

In the case of dental injection phobia, the order of graded exposure might be something like this:

  1. Your dentist shows you the numbing gel (the least threatening stimulus).
  2. They put some numbing gel onto your gums, so you can feel what it’s like. They explain that this makes the tissue numb so that the needle can pass painlessly into it.
  3. You are shown and allowed to hold the cartridge that contains the local anaesthetic solution, which looks like water. You then get an explanation of how it works.
  4. Your dentist shows you the syringe and encourages you to hold it. Maybe you’ll also want to have a go at figuring out how to insert the cartridge.
  5. Once you’re comfortable with this, you can have a look at the needle if you think you can manage. You can see how small the tip is, and you may be shown how easily it glides into things. The cap is put back onto the needle immediately afterwards.
  6. If you feel you are ready, the next big milestone is the “cap on” practice. Here, you practice the first step again (putting on the numbing gel), and then your dentist holds the needle (with the plastic cap on!) against your mucosa. You repeat this step quite a few times until you feel fully comfortable.
  7. Once you have built up enough confidence to move on, the same thing is repeated with the cap off the needle. No injection is given.
  8. When you are happy to take the final step, you can give consent to try a gentle injection. Obviously, your dentist will reapply the numbing gel beforehand.

It may take anything from about half an hour to three appointments to get to step 8.

Fast-track systematic desensitisation for needle phobia

Systematic desensitisation is essentially the same, except that a relaxation exercise is built in. Traditionally, you would spend some time learning to relax “on demand” before exposing yourself to the situation. Here is an example of a fast-track version of systematic desensitisation for dental needle phobia:

Speedometer
  1. You may be asked to imagine you’re in a car looking at the speedo. The faster the speed, the more nervous you feel. Then you try to imagine lowering the speed and thus lowering your anxiety.
  2. Then, you and your dentist get an empty syringe with no needle on it. You move it towards your mouth, and you have to lower the “speed” as the two of you are doing it. This is repeated 5 or 6 times until you are completely relaxed.
  3. Then you “escalate”, the needle is attached but with the cap on, and the same is repeated until you’ve lowered the speed so that you feel completely relaxed.
  4. Repeat with the local anaesthetic cartridge in the syringe, but with the needle still capped.
  5. Then, the cap is taken off the needle but the needle isn’t inserted.
  6. And so on…

All this would take a dentist skilled with this technique about half an hour, although it very much depends on the individual.

For a more detailed step-by-step description of dental needle desensitisation, Greig Taylor and Caroline Campbell have published A clinical guide to needle desensitisation (PDF). Although the guide refers to child patients, one can easily adapt it for use with adult patients.


The bottom line

Exposure really works when it’s done right, and it can be very empowering to face your fears head-on. On the flip side, it means you may have to go through some discomfort and really feel the anxiety instead of hiding from it, which can be unpleasant. So it can make sense to do it for things that are really affecting us and that we will have to face often in life (such as a simple check-up), and to use some additional help like distraction or sedation for things we only have to face only once or very occasionally (such as having a tooth removed).


Further reading

  • Cognitive Behavioral Therapy for Dental Phobia and Anxiety (2013). Lars-Göran Öst (editor), Erik Skaret (Editor). John Wiley & Sons, Ltd.
  • One-session cognitive treatment of dental phobia: preparing dental phobics for treatment by restructuring negative cognitions. (1995). de Jongh A, Muris P, ter Horst G, van Zuuren F, Schoenmakers N, Makkes P. Behav Res Ther. 33(8):947-54. doi: 10.1016/0005-7967(95)00027-u

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Footnotes

*not their real name

  1. Exposure works best if it is:

    Planned

    It’s not a good idea to go “today, I’ll do some exposure” on the spur of the moment. Ideally, it is planned with the points below in mind.

    Structured and gradual

    This is about making a hierarchy. Before diving into exposure, you need to know what scares you, what absolutely terrifies you, what scares you just a little, etc. Exposure starts with things that are pretty scary, but not too scary, and figuring out where they are on your hierarchy of fears.

    Predictable

    Exposure only works if we feel in control. And whatever is not predictable, we cannot control and it can increase the fear.

    Prolonged

    It’s important to stay with the feared situation or object until the fear actually goes down. If we stop too early, the phobia won’t lessen.

    Repeated

    This is to make sure that the fear won’t come back. Exposure works best if it is repeated at regular intervals. That’s the reason why having several shorter dental appointments works better than having one long marathon session. Not repeating the exposure is also the reason why people may slip back into avoiding the dentist, even after they’ve had a good experience and thought their fear was gone.

    No distractions or safety behaviours

    Exposure works best if we don’t distract ourselves. So if you want to confront a fear of the drill head-on, then it’s best not to listen to loud music from your headphones and forcing yourself to think of something else. This is not to say that headphones or television or distraction techniques are bad; it’s just not desensitisation.

    Control

    In therapy, it is essential that the client has control over when to do the exposure, how far to go, when to stop, who to take with them and at which pace to go.[]