As so much of dental fear and phobia stems from a history of trauma or overwhelm, and Somatic Experiencing is the modality that is most helpful for the treatment of physiological shock trauma – I encourage you to explore this modality.
That being said – the relationship between stress and phobia is complex – and it is even POSSIBLE that less than ideal oral care which produces oral inflammation can CAUSE systemic physiological inflammation and emotional stress. Yes – a vicious circle!
I will write more about this in the Oral Self Care heading above!
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Organization of this Chapter
Basics
The Origin of Dental Fears
The Fear Response
Behavioral Responses
Personal History of Trauma
Nature of Dental Treatment
A NOTE to Dental Professionals
Professional Help
Bottom Line for Stress and Anxiety
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Dental Fear and Phobia: Basics
In this section will be discussed WHY people don’t like to go to the dentist!
The reason is not as obvious as it may seem.
I have included this subject in the Section on Data Collection because it is important that the dentist be cognizant of any aspect of the patient’s wellbeing that can affect the ability to provide care. But – a dentist cannot collect ANY information about a patient he/she never sees!
Some people never GO to the dentist, and they may have a perfectly good reason! Other people go to the dentist, but put it off as long as they can, often cancelling appointments at the last minute – they also might have a good reason. Other people see the dentist, but anticipate the visit with great fear and anxiety – and THEY might have a good reason.
Each of these situations is unhealthy. Not going to the dentist leads to uncontrolled and destructive oral conditions. Having a lot of anxiety and fear is also not healthy.
What can we do about this? It all depends on two things – first; the willingness of the person to address the problem, and second; the willingness of the person to share personal information about their life that may demonstrate the root CAUSE of their fear and avoidance.
The information in this section is based on what little there is in the literature about dental phobia – but there is enough to get a good start on the issue. Nothing regarding this problem was presented to me in dental school, and maybe still isn’t. My interest in this stems from my studies and training in the relationship between a person’s behavior and their history of trauma.
One book on the subject that addresses the subject in terms of Cognitive Behavioral Therapy is “Cognitive Behavioral therapy for Dental Phobia and Anxiety”, Ost and Skaret, (eds.), Wiley-Blackwell, 2013.
We will first take a look at a more organized presentation of the field, and at the end, what might be done to help people with dental phobia.
The Origin of Dental Fears
There are four likely causes of dental fear:
First: Personal factors.
Mostly this is the response to previous history. This response could be traumatic if there were factors present that resulted in nervous system overwhelm. History of trauma, history of lack of control and choice, vulnerability and inescapability all contributing. History of trauma to the teeth is especially potent, but not necessary.
Second: Dental Treatment Factors.
Position of body, obstruction in mouth, invocation of survival response, invasive nature of procedure, having to keep the mouth open for extended periods, remembered experience of pain in dental treatment, the need for more control than experiencing, and conflicting personalities with the dentist are all contributing factors in this area.
Third: External Factors
Parental communication of fear – or from peers. Socioeconomic and immigrant status contributes – although I think this has more to do with likelihood of previous trauma.
Fourth: Sensory Sensitivity
Some people are extremely sensitive to light, touch and sound. In the dental office we have each of these in excess of normal conditions. There is a condition called SPD, Sensory Processing Disorder, which is not universally recognized, but the fact is that some people are unusually, and even pathological hypersensitive to sensory stimuli.
The Fear Response
The four triggers listed above can all combine in a variety of ways, with varying weights, to generate significant fear in a prospective dental patient. Now, the RESPONSE to those fears is what concerns us next.
A person can be afraid and not react to it (OVERTLY), or they can react violently. If there is a significant reaction, it may be due to a chain of responses. This is called an OVERCOUPLED RESPONSE. And this chain of reactions will mostly occur instantaneously at the subconscious level. Loosening this chain, teasing it apart, so parts of it can be viewed consciously, is the goal of certain therapies.
I’ll illustrate a chain reaction that extends through five different modes of experience, listing each parenthetically.
- There is the perception of a threat, visualizing the dental chair, for example (Image);
- Followed by a physiologic reaction by initiation of muscular tension and autonomic nervous system activation, increasing heart rate, breathing rate and production of sweat (Sensation);
- There is a misinterpretation of these sensations as signs or cues of danger or threat (Meaning or thought);
- This is followed by emotional reactions of dread, panic and fear even terror (Affect or emotion);
- And this results in our running out of the dental office (behavior).
But, as I said above – a person can also react INTERNALLY to stimuli, without an overt behavior response. The patient may wince or twinge in pain but when this is ignored by the dentist, the patient may just pull inside their shell and let their nervous system fire itself into a frenzy without even being aware. If no calming action is taken at that point, it may be that they are hyperesponsive to every stimulus for a couple weeks after the visit. They may experience intense pain in parts of their mouth as a reaction to their fear and have no idea what happened to cause this, but that it probably happened at the dental office. No wonder they don’t want to go back!
Behavioral Responses
The fifth mode of experience is our BEHAVIOR, as it is driven by the chain reaction illustrated above. Behaviors that are driven by strong emotions tend to fall into three categories, FIGHT or FLIGHT or FREEZE – what many of us learned in school as autonomic nervous system responses.
In this case flight may be simply withdrawal from dental treatment. And fight may be an aggressive defense response in the dental chair. And freeze may be an immobility response – in response to helplessness as the dental therapy reminds us of a past assault, like an animal that has been attacked and cornered!
We could also respond by deflection of attack – excuses not to get treatment, forming a poor relationship with the dental office personnel because of skipped appointments, or not seeking treatment with resultant shame response due to poor dental appearance.
Another behavioral response to this fear may show up as TMJ problems or excessive wear to the opposing teeth.
The Freeze response may be problematic – because it does not allow the patient to process the impact of the dental “assault”. This helplessness may be survived in the moment, but it resurfaces helplessness and overwhelm of the nervous system experienced in the past, and this can manifest in many ways for some days or weeks to come. When a person NEEDS to respond to danger and is prevented from doing so, given no CHOICE about how to respond, and they “shut down” – this is a form of trauma which will not in many instances just quietly go away. It will manifest in behaviors outside the dental office, beyond the moment.
Dentists need to be MUCH more aware of the likelihood that a patient will respond to their “ministrations” poorly in the moment, or as a consequence of the visit. But, while dentists often don’t take the time to be AWARE of their patient, in a healthy dental office, the assistants can play a role in noticing what the dentist does not, and passing these impressions to the dentist.
Personal History of Trauma
Trauma may be considered in two categories, developmental and shock trauma – and we may be dealing with either or both in dental phobia situations. In the case of any history involving loss of control or choice, the body’s nervous system will have a response now, even though the originating event happened long ago. If you had an experience where you were vulnerable and had the experience of an INESCAPABLE assault, the nervous system will likely still respond.
There is no difference between this and wartime traumas that produce a reaction that is widely known as Post Traumatic Stress Disorder – PTSD. PTSD can become part of your nervous system response to a variety of different assaults, from sexual assault to being hit by a car. Even a particularly poor experience being raised in a abusive household will result in overcoupled reactions to a variety of stimulii, not the least will be dental therapy.
The Nature of Dental Treatment
In dental therapy we are of necessity needing to INVADE one of your most private areas. Most people hesitate or avoid even looking into their OWN mouth, because of what they might be afraid they will see! What we don’t know won’t hurt us, right? And don’t get the idea I am self-righteous about this, it is the same for ME!
When you are undergoing dental treatment of any type, you are exposed and vulnerable at a private and personal level. Your fears may be on display, and your behaviors may follow suit. There is nothing you can do about this chain reaction until you learn more about it.
It is not the dentist’s job to help you with awareness of WHY you react the way you do – it is his/her job to as much as possible help you to become more comfortable and settled. This may be challenging in an office that is interested only in efficiency and productivity – the dentist or assistant or hygienist does not have much time to help you become settled. But this settling CAN be accomplished by a dental professional that has some understanding of physiological stress reactions, and can read the signs in you.
If the dental professional is familiar with you, they should schedule extra time to help you anticipate every moment of the visit, and help desensitize you in whatever way may be possible, to the anticipated experience. But, beyond these comforting measures, the dental professional is limited in their scope to help the anxious or phobic patient.
It is perhaps surprising that the dentist does have a procedure that can be of significant help to the phobic or hypereactive patient. It is a procedure that the dentist does NOT like to perform, because most never got good at it. It is the placement of a rubber dam – which is a small sheet of rubber that separates the patient from the dentist. It has holes through which the teeth pass so the dentist can work on them – but your mouth, tongue, cheeks, lips and saliva are on the other side where you can keep “an eye” on them. I, personally, love wearing a rubber dam.
In dental school all students are required to place a rubber dam, but hate it because most don’t have the dexterity to do it easily on their own. In a practice a well trained assistant will help the dentist place a dam quickly and easily – but dentists mostly react to their dental experience of being forced to do something they are not good at – and stop as soon as they leave school, just like a kid who leaves home immediately stops eating brussel sprouts.
A mechanical benefit of the rubber dam is that the patient doesn’t have to swallow so much, which is always hard to do with the dentist keeping your mouth open. I often have my students swallow during a lecture while keeping their mouth open so they will see what it is like!
Dentists don’t realize the benefit to the patient of proper rubber dam isolation, in terms of both physical and psychological comfort, and they don’t even realize that it could make their work faster and make them more money! It’s all a childish reaction on their part, but there is no reason the patient should have to suffer for their ignorance!
All that being said – it is possible that the only tool the professional has that can help a patient get the treatment you need is sedation. But, the patient still has to show up at the office! And, the patient would be well advised to first consider their choice of dentists with their awareness in mind, and potentially to seek further support elsewhere – see below.
A Note to Dental Professionals
Dental students are not trained to recognize patients that may not conform to “expectations”. This means that practicing dentists are not likely to take into account that patients differ in their reaction to what we do!
There are two chapters on this site that you should explore: “The Skills of Dentistry“, and “Training of Dental Professionals“. BUT – neither goes into what the dentists needs to bring to the patient in terms of empathy and more of an emotional/physiological understanding at the nervous system level. Dentists CAN learn about these things and treat their patients better!
The other day I was examining the jaw movements of a consultation patient. As careful as I was, the manipulation of the jaw joint (condyle) and the sensing of this joint movement while the patient moved the jaw in various directions, caused an extreme nervous system reaction. The patient’s muscles around the upper neck and the base of the skull tightened up like rocks, and were very reactive to sudden movements for a couple of weeks.
Some patients have biting reflexes – and I know someone like this. ANYTHING that stimulates jaw movement is likely to exacerbate this spasmodic reaction of the jaw closing muscles.
These are nervous system reactions to what we, as dentists, do. Without a rare amount of sensitivity toward our patients, and without knowing their history, especially traumatic history, we will not serve these patients well – even “simply” during evaluation appointments.
I do not hesitate to admit that I am as guilty of these oversights as the next dentist. I was trained in the typical fashion and worked for many years considering patients more as “mouths” and “teeth” than nervous systems. The closest I came to treating a patient in a more appropriate way was one of my patients who was completely blind. But, I did not take as much away from that experience as I could have, for all patients should be treated like that – and I did not!
Now, most of you dentists and dental students will say “I’ve certainly never had a patient with such profound sensitivity” – but you would likely be wrong. Just because you don’t notice, and are not aware – it does not mean a thing does not exist! If you ever have had a patient that comes in for an initial visit and never returns for some unknown reason – this could be the one!
Now – what dentists and dental students are likely to pay this much attention to the nervous system needs of their patients? In the Chapter on Pedodontics I talk about what dentists are GOOD at working with children. What makes them good?
Mostly a good pedodontist is extremely empathetic and naturally sees things from the point-of-view of the child. This skill would not be amiss when working with adults!
The one difference between kids and adults is that kids will let you know their reactions far more than will adults. A highly traumatized child may well not and it takes a really experienced and insightful dentist to work with them constructively – but most are quite communicative. Adults, on the other hand, tend to keep things in more often than not. Obviously this does not apply to the adult patient that has done a lot of personal work and states clearly what they are experiencing. But – most adults just “stuff” the negative aspects to the experience – even if it is traumatic and elicits an energetic response that lasts for weeks. That is why you may never see them again.
The next section is entitled “professional help” – and it refers to the help that patients can find that might make the dental visit more tolerable. On the other hand, the dentist should get some therapeutic help – to get their own personal work done, to deal with their own issues, or at least to get some awareness of what human beings go through as a consequence of various overwhelming experiences in their life.
The enhanced awareness of the dental professional toward HOW people may react to dental therapy, and why, and what can be done about it, is critical. And, the more the dentist works with their OWN reactions, past and present, the more predisposed they become to offering truly positive experiences to their patients.
Dental Fear and Phobia: Professional Help
There are therapists to whom the dentist can refer you that are trained in the resolution of stress and even past traumatic events. This help may be found within the psychoanalytical or psychotherapeutic world, but there are other modalities that are more focused on trauma-related nervous system reactions – the most accepted among these is Somatic Experiencing.
More on this subject can also be found at duggandentalsolutions.com when this site gets launched later this year.
Bottom Line for Dental Fear and Phobia
In this section on data collection – for the dentist to have some awareness of the personal factors which give rise to fear around a dental visit is important. For him/her to know something about your history and your behaviors and actions in response to past history, will be very valuable to them. For example, why propose a comprehensive treatment plan for a patient that does not have the nervous system capacity to manage this treatment?
If you can manage your response to the prospect of dental treatment well enough to make your appointments, and the dentist knows how difficult this is for you, then the scheduled visits can be designed to involve the least amount of discomfort to you, for your particular response system. There can be more time scheduled for each visit, and more attention/distraction from the staff so that you will find more comfort in the dental office and dental chair and be less likely to get into fight/flight/freeze mode.
A dental professional must wear many hats as they go about their day’s work, and one must be of a more psychological nature for the nervous, scared, or phobic patients that can actually make it to the office. There must be a sympathetic or even empathetic feel to the care you receive, to have any chance that your nervous system will not react as if an old trauma were happening again.