Psychosocial Aspects of Dental Anxiety and Clinical ...

60 downloads 40 Views 9MB Size Report
Soon, pain control was commonplace in dental practice and by 1935 it was proclaimed in an ...... Bernstein et al. 92 showed that ...... researcher Richard Lazarus and colleagues generally confirm this advice. 480;481. Harmful or ...... 1976;54:81-91. 770. Segal H, Warner R. Origins of paternalism. Med Law. 1985;4:269-273.
Psychosocial Aspects of Dental Anxiety and Clinical Pain Phenomena

Doctor of Odontology dissertation by Rod Moore DDS, PhD

Faculty of Health Sciences Institute of Odontology, University of Aarhus

This dissertation, as related to the nine published articles listed below, has been approved for public defense for the Danish Doctor of Odontology (dr. odont.) degree by the Faculty of Health Sciences, University of Aarhus. The defense will take place on December 1, 2006, at exactly 2 PM in Auditorium 424, at the Institute of Anatomy, University of Aarhus. The opponents are Professor Ad de Jongh, dentist, dr. psych., Academic Center for Dentistry Amsterdam; Professor David Locker Ph.D. (sociology), Dept. of Community Dentistry, University of Toronto; and Professor, dr. odont. Peter Svensson Ph.D., University of Aarhus (Faculty representative). Published at Fællestrykkeriet, University of Aarhus, Århus, Denmark, 2006 Udgiver: Rod Moore Kirkebakken 80 8330 Beder Denmark e-mail – [email protected] ISBN 87-991417-2-8

On leadership and enlightenment: “…we have brought you into the world to be rulers of the hive, kings of yourselves and of the other citizens, and have educated you far better and more perfectly than they have been educated... Wherefore each of you, when his turn comes, must go down to the general underground abode, and get the habit of seeing in the dark. When you have acquired the habit, you will see ten thousand times better than the inhabitants of the cave, and you will know what the images are, and what they represent, because you have seen the beautiful and just and good in their truth.” From Plato’s The Republic, “Allegory of the Cave”

“Dentistry is a two-way street. Whatever benefits the patient should in turn benefit the dentist as well.” Rankin and Harris, 1985 “Tucked away in some convenient place in your mind I would suggest that you keep this slogan: “Every dentist should be a psychologist.” Psychiatrist FJ Braceland speaking before Academy of Stomatology, Philadelphia, PA, USA, 1940

Preface This Doctor of Odontology dissertation was completed during a period of time spanning nearly 17 years associated with the Royal Dental College, Århus, Denmark. Data were collected in Denmark, Sweden, USA, Peoples’ Republic of China and Taiwan Republic of China. The dissertation consists of seven chapters whose thesis was drawn from 9 published articles and where the overall structure includes five parts - introduction/ review of the literature, rationale, results and discussion. Related to the dissertation, but from previous separate work, are the following 4 published papers and Ph.D. thesis entitled: The phenomenon of dental fear - Studies in clinical diagnosis, measurement and treatment. (Royal Dental College, 1991.), which were also often cited as background references: Moore R, Brødsgaard I, Birn H. Manifestations, acquisition and diagnostic categories of dental fear in a self-referred population. Behavior Research and Therapy 1991; 29: 51-59. Moore R. Dental fear treatment - Comparison of a video training procedure and clinical rehearsals. Scandinavian Journal of Dental Research 1991; 99 (3): 229-235. Moore R, Berggren U, Carlsson SG. Reliability and clinical usefulness of psychometric measures in a self-referred population of odontophobics. Community Dent Oral Epidemiol 1991; 19: 347-351. Moore R, Brødsgaard I, Berggren U, Carlsson SG. Generalized effects of a dental fear treatment program in a self-referred population of odontophobics. Journal of Behavior Therapy & Experimental Psychiatry 1991; 22: 290-298. The following studies are continuations or supplemental to the Ph.D. thesis. They are chronologically numbered and referred to in the dissertation text by bolded Roman numerals (I-IX). I.

Moore R, Miller ML, Weinstein P, Dworkin SF, Liou H-h. Cultural perceptions of pain and pain coping among patients and dentists. Community Dentistry Oral Epidemiology, 1986; 14:327-333.

II. Moore R, Birn H, Kirkegaard E, Brødsgaard I, Scheutz F. Prevalence and characteristics of dental anxiety in Danish adults. Community Dentistry Oral Epidemiology 1993; 21: 292-296. III. Moore R, Brødsgaard I, Mao T-K, Kwan H-W, Shiau Y-Y, Knudsen, R. Fear of injections and report of negative dentist behavior among caucasian American and Taiwanese adults from dental school clinics. Community Dentistry Oral Epidemiology 1996; 24: 292-295. IV. Moore R, Brødsgaard I. Adult dental anxiety and related dentist beliefs in Danish private practices. Tandlægebladet [Danish Dental Journal ] 1997; 101; 562-567. V. Moore R, Brødsgaard I, Mao T-K, Miller ML, Dworkin SF. Perceived need for local anesthesia in tooth drilling among AngloAmericans, Chinese and Scandinavians. Anesthesia Progress 1998; 45: 22-28. VI. Moore R. Danish dentists’ career satisfaction in relation to perceived occupational stress and public image. Tandlægebladet [Danish Dental Journal ] 2000; 104: 1020-1024. VII. Moore R, Brødsgaard, I. Dentists’ perceived stress and it’s relation to perceptions about anxious patients. Community Dentistry Oral Epidemiology 2001; 29:73-80. VIII. Moore R, Brødsgaard I, Abrahamsen R. 3-year comparison of dental anxiety treatment outcomes: hypnosis, group therapy and individual desensitization. European Journal of Oral Sciences 2002; 110: 287-295. IX. Moore R, Brødsgaard, I, Rosenberg N. The contribution of embarrassment to phobic dental anxiety – a qualitative research study. BMC Psychiatry 2004; 4: 10. 1.

Acknowledgments These investigations would not have been possible without assistance and support from family, friends, colleagues and institutions, to all of whom I am sincerely grateful. Thank you all! Inger Brødsgaard MD - wife, best friend and research colleague for her personal, organizational, statistical and professional support and advice. Many long hours were spent at the expense of our personal life in writing this dissertation. Bente Kjær - my clinical assistant, co-therapist, research assistant and friend whose loyalty, in spite of inevitable research employment crises, has been a significant factor in the practical success of the Dental Phobia Research and Treatment Center. Senior Associate Professor, Docent, dr. odont., Dr.P.H., Flemming Scheutz, Dept.of Community Oral Health and Pediatric Dentistry, University of Aarhus for epidemiological, statistical and personal support/advice which arose at untimely moments for him, but nonetheless were usually expedited in a timely manner. Professor Samuel F. Dworkin (emeritus), Depts. of Oral Medicine and Psychiatry, University of Washington, for theoretical and practical support and advice on a draft of this dissertation; and a 6year association as co-author of several articles during the “Crosscultural Pain” study in Seattle, WA. Professor Marc L. Miller, Depts. of Anthropology and Marine Affairs, University of Washington, for aid in my quest to learn a cognitive anthropological perspective on pain perception research. Associate Professor Leif Glavind (retired), Dept. of Periodontology and Geriatric Dentistry, University of Aarhus for advice during the dissertation process and help with the Danish summary. His loyalty and support were greatly appreciated during times of struggle with this and Ph.D. studies. Randi Abrahmsen, dentist/hypnotist practitioner, for her engagement in the fight against dental anxiety and our cooperative research on hypnosis. Lis Jørgensen, laboratory technician, for data technical support and general advice about data. Docent Ulf Berggren, Dept. of Oral Diagnosis, Göteborg University. Ulf's work with dental fear patients for over two decades has been a continuous source of inspiration and practical knowledge. Ulf was research supervisor during Ph.D. studies and an advisor thereafter in later work. Docent Sven G. Carlsson, Dept. of Psychology, Göteborg University, for sharing his theoretical and statistical genius and offering his advice and support during and after the Ph.D. project. Professor Tim Smith, Dept. of Oral Health Sciences, University of Kentucky, for theoretical and practical support and advice both during and since his 5-month sabbatical stay at Århus in 1990. Professor Philip Weinstein, Dept. of Dental Health Services, University of Washington, for theoretical and practical support and advice during earlier research. In memoriam: Herluf Birn was formerly Associate Professor at the Dept. of Community Oral Health and Pediatric Dentistry, University of Aarhus, as well as at the Prince Philip Hospital, Hong Kong University. Herluf helped with theoretical wisdom and practical know-how that made the Dental Phobia Research and Treatment Center become a reality during its initial establishment and growing pains 1985-86. Herluf was not only a valuable colleague, but also a dear friend, who could also entertain as “Hans Christian Andersen” as he did at my wedding party in 1987. Herluf was a brilliant, yet underestimated man. I was deeply affected by news of his death in 1997. Jens Kølsen Petersen was formerly Associate Professor at the Dept. of Oral and Maxillofacial Surgery, University of Aarhus. Jens was helpful with advice on the Ph.D. dissertation as well as an inspiration to me personally in our professional contacts and especially our coursework together on pain and anxiety. Jens passed away so suddenly in May, 2004 that I was not able to benefit from his examination of a draft of this Doctor of Odontology dissertation. Jens always had time. His loss is felt. These doctoral studies were financially supported by the Danish Ministry of Education (Division of Postgraduate Studies), Danish National Health Insurance Fund, Danish Research Academy, The Danish Dental Association, Colgate Palmolive A/S, Denmark and National Institute for Craniofacial and Dental Research, Bethesda, Md.

2.

List of common abbreviations in the dissertation ADP = Avoidant Personality Disorder DAS = Dental Anxiety Scale DBS = Dental Beliefs Survey DFS = Dental Fear Survey DSM-IV = Diagnostic and Statistical Manual of Mental Disorders, 4th ed, American Psychiatric Assoc FSS-II = Fear Survey Schedule, second edition FoBCeT = Forsknings- og BehandlingsCenter for Tandlægeskræk (Danish for “Dental Phobia Research and Treatment Center” in Århus, Denmark) GAD = General Anxiety Disorder; GSP = Generalized Social Phobia GFS = an 18-item version of the larger FSS-II (Geer Fear Scale) GT = Group therapy; HT = Hypnotherapy ICD = International Classification of Diseases & Related Health Problems, World Health Orgnzation MACL = Mood Adjective Checklist NHS = National Health Service (Great Britain) PIDAS = Psychosocial Impact of Dental Anxiety Scale PRC = People’s Republic of China PP = private practices ROC = Republic of China in Taiwan QSR"N4" = Qualtitative Software Research program, N4 version RM = Rod Moore, author/interviewer SCID = Structured Clinical Interview for DSM SD = Systematic desensitization; SES = Socioeconomic status SLT = Social Learning Theory SSP = Specific Social Phobia STAI = State-Trait Anxiety Inventory STAI-T = ditto (Trait anxiety subscale only) VAS = Visual Analogue Scale

Figure and Table locations Figure 1 - Medieval traveling dentist extracting teeth Figure 2 - Airotor high speed dental drill - 1957 Figure 3 - Cartoon portrayal of dentist Figure 4 - The Ethnomedicogenesis Thesis Figure 5 - Neuromatrix in the brain – Melzack Figure 6 - Hendrix’s model of stress in dentistry Figure 7 - Vicious circle of dental anxiety (Berggren) Figure 8 - Seattle system - matching diagnosis to treatment Figure 9 - “A feeling like everyone is looking” Figure 10 - Clinical features of social anxiety disorder Figure 11 - Ethnic pain/remedy beliefs of dentists and patients Figure 12 - Ethnomedicogenesis: dentists and patients Figure 13 - Psychosocial model of dental anxiety Figure 14 - Dentist stress: expectations and outcomes Figure 15 - Vicious circle of dentist-patient dissatisfaction Table 1 - Common and severe fears in Denmark Table 2 - Dental anxiety characteristics by intensity Table 3 - Perceived stressors among Danish dentists Table 4 - Examples of common beliefs/myths Table 5 - Behaviors in active patient participation 3.

- page 8 - page 10 - page 11 - page 16 - page 18 - page 21 - page 31 - page 35 - page 40 - page 41 - page 46 - page 53 - page 58 - page 76 - page 82 - page 25 - page 27 - page 68 - page 84 - page 89

Table of contents Page number: Preface + List of published articles contributing to this dissertation 1 Acknowledgments 2 Abbreviations list and coding; Figure and Table Locations 3 English résumé; Abstract of the nine dissertation articles 5-7 Chapter 1. Introduction 8-14 An historical perspective on psychosocial aspects of dentistry, fear and pain. 8 Modern society and the image of the dentist 9 Relevance and aims of the dissertation 12-13 Chapter 2. Researching dental anxiety and pain 14-23 Psychosocial theoretical models relevant to the dissertation 14 Need for research on multiple dimensions with multiple methods 21 Qualitative methods - understanding and explaining psychosocial phenomena 22 Quantitative methods - verifying and testing relationships between variables 22 Methods and valid, reliable or generalizable data 23 Chapter 3. Dental anxiety. What is it? What is it not? How many have it? 24-43 Defining dental anxiety - terminology and limitations 24 Prevalence of dental anxiety 25 Characteristics of extreme and phobic dental anxiety 26 Manifestations, symptoms: documenting a public health problem 29 Etiological factors in odontophobia 31 Diagnostic categories of dental anxiety 34 A dental clinical screening model – the Seattle system 34 A psychiatric diagnostic model – the DSM for mental disorders 36 Psychiatric assessment of patients with odontophobia 38 Socially conditioned anxiety - “fear of dentist behavior” vs. “fear of scrutiny” 40 Chapter 4. Clinical pain, psychosocial perspectives and relation to anxiety 43-57 Defining pain 43 Emotional meanings of pain - social frameworks for individual pain experience 44 Individual pain experience, psychological trauma; Suffering.. but torture? 47; 54 Chapter 5. Patients’ and dentists’ ways of being, anxiety and pain 58-92 The patient role - passivity in the dental chair 58 Empowerment of patients 62 The dentist role - part of the problem and part of the solution 64 Occupational stress among dentists 67 Consequences of stress 69 Dentist perceptions of anxious or “troublesome” patients; “labeling” effects 72 Coping with stress 77 Dentists’ image, patient and dentist satisfaction, professional socialization 79 Meaning of anxiety and pain to dentist-patient relations and communication; Summary 84;87 Models of dentist-patient relations and optimal communication 88 Trust, caring, communication and “partnership building” 90 Chapter 6. Psychosocial aspects of anxiety and pain management 93-108 Clinical management of dental anxiety and pain expectations 93 Regarding “fitting treatment strategy to anxiety type” 97 Longitudinal results of specialist clinic treatment 98 Working with patient expectations 99 Reducing pain and suffering – the less tangible methods 102 Nonverbal and other supportive communication forms 104 Redefining “chairside manner” 107 Dentists and primary care in management of odontophobia 107 Chapter 7. Conclusions and suggestions for the future 109-113 Dansk Sammenfatning (Danish summary) 114-125 References 126-172

4.

English résumé Psychosocial Aspects of Dental Anxiety and Clinical Pain Phenomena The background for the doctoral dissertation in the first chapter describes the historical development of dentistry, where certain social and psychological conditions (expectations and beliefs) have prevailed in relation to pain and anxiety as well as how these have affected the public image of the dentist. The dissertation has seven chapters that build on literature research and 9 original published research articles. Since the dissertation has a decidedly cross-disciplinary orientation, Chapter Two describes theoretical considerations in researching psychosocial aspects of pain and anxiety within the context of dentist-patient relating. These theoretical perspectives require a plethora of research methods in efforts to capture valid and reliable results. The third chapter describes different aspects of dental anxiety, including definitions that correlate with anxiety intensity as well as the phenomenon’s prevalence, characteristics, etiology, consequences, and differential diagnostics, including how beliefs and expectations affect clinical presence of anxiety. A theoretical review of the relationship of pain to dental anxiety is described in the fourth chapter. Discussions include the accepted definition of pain, the emotional meaning of pain, aspects of beliefs/expectations as frameworks for pain perception and reactions as well as the symbolic meaning pain has related to emotional suffering in dental treatment situations. The fifth chapter describes patients’ and dentists’ roles and how the relationship influences or is influenced by expectations and beliefs surrounding pain and anxiety. Relative role passivity of patients as well as the dentist’s work environment demands and resultant job stress, are described. The literature clearly indicates that patients’ and dentists’ respective role satisfaction are dependent on the meaning of anxiety and pain in social context and their ability to communicate successfully. Dentists’ perceptions of their public image are also associated with career satisfaction. Dentists learn many of their social values and attitudes during their education and early practice years. Given evidence of the profession’s generally dominant and non-altruistic values, considerations should be given to advocating changes in dental educational priorities with more weight on successful communication techniques, stress management as well as career development planning. This would not only be for patients’ sake, but also the dentists’. Regarding management of anxiety and pain in dental treatment, the dissertation’s sixth chapter reviews both formal therapeutic methods as well as less obvious interpersonal factors presented by anxiety therapists that are necessary to help patients reduce suffering. Treatment regimens for odontophobia such as trained relaxation combined with gradual stepwise desensitization of dental procedures, hypnosis, and group therapy showed similar results with significant and enduring changes in: 1) dental behavior (regular dental care attendance), 2) more positive beliefs about dentists and 3) anxiety reduction over a 3 yr period. But these results from the Dental Phobia Research and Treatment Center overall were better than for a cohort of similar patients who had managed on their own to seek treatment again with private dentists after long-term avoidance due to anxiety. It has also been shown in studies of personnel at specialist dental anxiety clinics, that they also exhibit other more “hidden” interpersonal factors such as empathy, active listening, touch, and other nonverbal behaviors. Working with patient expectations is also emphasized. These necessary ingredients for successful treatment are not currently systematically taught during dental education, but should become a focus for future research and education. In the seventh and final chapter, it is concluded that anxiety and pain problems reveal dental professional political issues such as stress in relation to practice style as well as specific communication problems encountered in the dentist-patient relationship. It was suggested that these could be positively influenced by a more patient-centered practice style, where the patient is encouraged to become more involved in treatment. Less dominant, more altruistic dentists then will be able to contribute positively to improved satisfaction of both patients and themselves. Research of dentist characteristics, both positive and negative, requires careful consideration in the future. 5.

Thematic abstract of the nine dissertation articles Psychosocial aspects of dental anxiety and clinical pain phenomena The dissertation aimed to clarify the influence of psychological and social variables among patients and dentists that persistently contribute to perceptions of anxiety and/or clinical pain, and thus point to optimal treatment or prevention. Qualitative methods helped identify and describe specific role variables. Quantitative methods aided testing of variables in epidemiological and experimental studies. In the first study (I), in order to find out how beliefs and expectations contribute to pain and remedy perceptions, Mandarin Chinese, Danish, Swedish and Anglo-American subjects were interviewed and tested to classify common pains. Most types were universal, but some differed meaningfully by ethnicity, e.g. Chinese “suan“ (sourish) tooth drilling sensations or “imaginary pains” among Western patients or dentists. Lay-dentist differences were only evident for remedy descriptions. In study II extreme dental anxiety or phobia was found in 4.2% of 565 adult Danes; moderate anxiety in 6% and some or little anxiety in another 29.5%. Characteristics of extreme anxiety differed from moderate anxiety and were best explained by bad experiences with dentists, not necessarily pain related. Interviews of 30 long-term treatment avoiders validated that embarrassment, shame or guilt amplified anxiety and, for many, created a more devastating reaction to treatment situations (IX) than actual fear of dental procedures or pain. Negative expectations of dentists and dentistry were found to affect diagnostic typing of extreme or phobic dental anxiety. This recurring theme of influences of social expectations and beliefs on perceptions of anxiety and pain was further explored in two cross-cultural studies (III, V). In a study of 951 dental school patients (III), Mandarin Taiwanese reported much less use of local anesthetic for routine treatment and less overall fear of injections than did Caucasian Americans. All highly anxious dental patients had similar high fears of injections. High anxiety Taiwanese reported using anesthetic much less than did high anxiety Americans, inspite of similar fears about dental drilling. Only Americans associated negative dentist remarks with high anxiety. Avoidance of appointment making was the most typical sign of high dental anxiety, regardless of ethnicity or cause. Interviews on a sample of 525 mandarin Chinese, Danish, Swedish and Anglo-American dentists and patients also showed meaningful variations about use/non-use of local anesthetic for routine fillings (V). Only about half of Scandinavians required anesthetic for proximal fillings compared with 5% of Taiwanese and 95% of Anglo-American patients (V) and confirmed earlier results (I, III). Use of anesthetic was predominantly decided by patients in Western practices and by dentists in Taiwan, where “not pain; only suan “ was the rationale for no anesthetic with drilling. Most patients not using anesthetic said drilling was bearable, while Danes also cited extra out-of-pocket fees for “pain-free treatment”. Thus, use of local anesthetic was dependent on ethnic beliefs or expectations of dentists or patients. Qualitative data were collected in 26 Danish private practices on experiences and beliefs that dentists had about anxious patients (IV). Dentist interviews revealed that anxious patients created 6.

practical problems and that anxiety problems were 1) dentist caused, 2) patient caused or 3) troubles in the dentist-patient relationship regardless of fault (IV). In a questionnaire study of 216 Danish dentists, nearly 60% perceived dentistry as more stressful than other professions, citing time pressures, causing pain and anxious patients as the main stressors. These “high stress” dentists reported being less likely to spot dental anxiety among their patients and some tended to label all dental anxiety patients as generally psychologically compromised (VII), contrary to the literature. Dentists who perceived a poor public image (31%) had less career satisfaction and tended to perceive high occupational stress (VI). Finally, in a quasi-experimental 3-year study, anxious patients treated at the FoBCeT specialist clinic with various psychological strategies maintained regular dental care habits and reduced anxiety better than a longitudinal control reference cohort of similar anxious patients in private practices (VIII). Conclusions: Psychosocially formed role expectations and beliefs of dentists and patients influence dental anxiety, pain perceptions and outcomes of treatment. High quality in dentist communications and behaviors is important, especially to help odontophobic patients cope with anxiety and pain and inhibit a vicious circle of phobic dental anxiety and treatment avoidance. Dentists who perceive less stress in their practices have fewer adverse perceptions about anxious patients, think of themselves as having more positive public images and tend to have greater career satisfaction. This lead to formulation of an hypothesis: If dentists adopt specific psychological strategies to combat anxiety and pain in patient-centered approaches, they not only could prevent/treat patient suffering from anxiety and pain more successfully, but also likely improve their own career satisfaction and public image. Key words: anxiety, fear, phobia, dental care, dentist-patient relationship, behavioral psychology, psychiatry.

7.

Chapter 1. Introduction An historical perspective on psychosocial aspects of fear and pain in dentistry Inspite of tremendous technical advancements in the profession of dentistry such as modern, effective local anesthesia products since 1905,362;718 the air turbine drill from 1957 362;718 and more recently laser and osseointegrated implant technology, pain and fear in dental treatment among the worlds’ populations is an enduring and puzzling phenomenon.718 The history of the dental profession is replete with developments of both technical, psychological and social considerations in treatment of dental and oral diseases, many of which pertain to the relief or infliction of pain.362 In the time of pre-Hippocratic Greek civilization, toothache was often treated by priests who would advise a semi-hypnotized patient as to the course of treatment, mainly through ritual healing, not physical treatment.362;718 The fate of the Greek gods was thus called upon in such a task, so that any treatment failure could not be attributed to the practitioner, but rather to the sins or evil ways of patients themselves. Some centuries later, Hippocrates, the father of modern medicine, used deductive logic to treat observable maladies. In his book, “On Affections” he described for the first time in medical history, “In cases of toothache, if the tooth is decayed and loose, it must be extracted.” 718 A century later, the Greek philosopher Aristotle wrote that it was no longer necessary to only extract “loose teeth” if there was toothache and with his invention of dental forceps, the first concept of “dental doctors” was described. The Roman Empire brought with it the Aristotelian ethic in Fig. 1. Medieval “tooth drawer” (courtesy Abrams: treatment of human diseases. Orators began to “Dentistry- an Illustrated History” by Ring (1985) laud the medical professionals who did dental services as “the keepers of the gold bound to the teeth of the dead”, as part of the economic concerns of the Roman Empire.718 In the Middle Ages, no health treatment was more satirized or even ridiculed than dental treatment. It was not more than two hundred years ago that the dentist was a traveling showman, a “tooth drawer” (Fig. 1), who pulled teeth on stage for local towns and villages, of course, expecting to get paid for services.362;528;718 Patients were expected to be reluctant and vulnerable objects of these theatrical exhibitionists, who had to pay for the humiliating privilege of relief from toothache pain. Alternatively, the rural blacksmith or urban physician would extract teeth, if necessary, in more mundane surroundings and with less fanfare so as not to detract from their chief business interest. The lay traditions of wandering dental practitioners reached a pinnacle in the 17th and 18th centuries. Even though e.g. the French parliament in 1699 set an example for the Western world by requiring dental practitioners, among others, to be examined by a committee of surgeons before being permitted to practice in Paris, traveling dentists pervaded even well into the 19th century, especially in rural areas.718 Barbers then initiated a tradition of dental surgery, including an apprentice period for young practitioners. Eventually schools of barbering and dentistry would evolve and apprentices shared both tasks. It was only with the advent of responsible physicians who had come to specialize in dentistry that

8.

creditable colleges of dental surgery were founded in the mid-1800s. The first school of dental surgery was founded in Baltimore, Maryland in 1840.362;718

Modern society and the image of the dentist In modern society, polls have consistently shown that dentists are highly respected professionals and that most patients are satisfied with their own dentist.198;452;706;803 So how much has the profession's earlier mercantile image as roving tooth drawers described above changed over time? It would be fair to say that such extreme folklore is not commonplace in modern society. However, given the historical background above, spectacles of pain of treatment and fear still seem imprinted in the social image of dentistry and are engrained within the collective conscience of the population at large to some degree or another, especially as portrayed in the mass media, as we shall see below.93;339;528;672;760 Most dental historians insist that these images have remained largely unchanged, since it is only in the last four decades that tooth extraction has become a less appropriate treatment for most dental ailments and only as a "last resort".93;97;528 It appears then that the public's relations to the dentist may be governed by implicit beliefs about social roles that affect the way one is expected to act as a dental patient and the ways one is expected to be treated by a dentist.190 This popular “culture of dentistry” as first described by sociologist Peter Davis,190 describes routines in which a patient-dentist encounter is filled with impressions of “the white coat, the passive patient, a lack of verbal communication and an overwhelming impression of orderliness, restraint and formality which all seem to be superfluous, if not directly counter, to the technical requirements of the task at hand.” Peter Davis cited the works of Nadel500 who described highly visible aspects of dentist-patient interactions such as patient passivity, orderliness, restraint, formality, lack of communication as unnecessary, yet persistent. Furthermore, both patient and practitioner regard them as normal aspects of relating, as described in Chapter 5. Davis interpreted this as serving to enhance the scientific and professional authority of the provider, both in direct contact with patients and more broadly, in the wider society.”190 Nettleton643 described a sociological and historical perspective of the changes in the context and circumstance for the dentist-patient relationship. She pointed out that at the beginning of the twentieth century, the dental profession saw pain in treatment as solely a physical response to procedures that involved an intervention on the human body – a physiological and biomedical fact that was required in order to fix a biomedical problem. This problem was often endogenous pain, such as toothache, in which, of course, some dental treatment pain was acceptable, considering the significant pain relief obtained. But in other more preventive procedures such as tooth cleanings and fillings, dentist-inflicted pain was comparably less acceptable. With the advent of nitrous oxide (Wells, Colton) and ether (Clarke, Morton) sedation starting in the 1840s, it was widely known at the end of the 19th century that painless treatment was possible, at least for tooth extractions and surgeries. But, use of anesthesia in general dental practice was not widespread in the 19th century. Only after the First World War did dentistry begun to discover a “new patient”,643;730 due to the increasing use of local anesthetics. The discovery of procaine (Novocaine) in 1905 and the cylinder ampule in 1917, made dental anesthesia more accessible to all general practitioners.362 Soon, pain control was commonplace in dental practice and by 1935 it was proclaimed in an article in the British Dental Journal: “…the old idea of the manipulation in the mouth almost regardless of the feelings of the patient has gone, and rightly so, forever. We are at the dawn of a new era of sympathetic dentistry.”730 It was believed that once pain was eradicated, so too would fear fall in order, since the reason people feared dentistry was that they associated it with pain.118 This meant that the profession perceived that patients were less willing to bear pain inflicted by dental treatment, 9.

were more frightened of being hurt, and were developing a “dental conscience”.730 Best also noted in 1935 that pain was “one of our greatest problems, the mastery of which contributes profoundly to professional success.”96 The mind of the patient had come to the attention of the dentist and not just their teeth.730 A new conceptualization of pain and fear (of inflicted pain) involved not only creation of a subjective, feeling patient but also required a sensitive and caring dentist.643 By the 1950s, although pain was still thought of as a part of the patient’s body, the “psychophysiological connection”, in which the individual’s state of mind could affect pain perception, had gained wide acceptance. Certainly, the advent of the airotor drill in 1957 (Fig 2.) reduced the amount of unpleasantness associated with tooth drilling that had existed with conventional dental drills.362 But then after the 1950s and with the advent of epidemiological and socio-anthropological scientific awareness, pain and fear transcended individual psychophysiology. Social factors were also seen to influence pain perception.642 Dentists, through trying to eliminate inflicted experiences of pain or fear, had perhaps paradoxically perpetuated their existence.643 Because of the increased use of anesthetic, patients began to expect more in relation to the dentist – pain-free dental care. Fig. 2. Airotor drill - 1957 Descriptions of a fuzzy border between physical sensation of pain and psychosocial influences on pain perception began to appear in the literature.643 A new social perspective on pain of treatment emerged. When patients became disappointed with dental treatments that continued to be associated with dental pain, they also became increasingly fearful, prompting resistance to both dental authority and to non-emergency dental care. Patients avoided treatment or entered into regular care begrudgingly.643 Inflicting pain, then, came to be confirmed as the main problem for the dentists, since it was perceived to stand in the way of successful treatment of disease, while also affecting their professional image negatively. The use of anesthetic techniques was often not sufficient, because the emotional and physiological responses to pain were equipotent. So what became essential was the way in which dentists administered these procedures. The dental practitioner came to wonder with local anesthesia failure, whether it was the physiological vs. psychological or social components that needed most attention. The usual response was a “shot-gun approach”, but primarily anatomical or physiological anesthetic solutions emerged as the main domain for solving the pain problem and reinforced a narrow biomedical model of pain. Pain experienced by the dental patient required more than just knowledge and facts about physical complaints about the teeth. Pain, it came to be clear, could be experienced without apparent physical cause643 in parallel with the changes in which patients were becoming increasingly more skeptical about the authority of the dentist. This new social conceptualization of pain and fear in the 1960s and 1970s not only created patient needs for a new, more sensitive and caring dentist in order to manage anxiety and pain but also brought dentists to either respond by changing their behavior or by sedating patients.643 Aware of this dilemma, Epstein230 argued “Overwhelming the patient with sedatives or hypnotic drugs which destroy the capacity to resist, is not pain control, nor is administering additional narcotizing drugs to control movement so that dental procedures can be performed… (To ensure) the effectiveness of drugs used in pain control, one cannot discount the importance of the manner by which the drugs are administered.” Dentists, again, had to become aware of the fact that they were “...treating humans and not just teeth”,230 because patients’ acceptance of possibly painful treatment appeared to depend more on the rapport the dentist established with them than on any measure of technical proficiency.230 Thus, Nettleton surmised that the concept of pain was caught in a polemic in the 1960s and 1970s, between patients’ resistance to dentistry on the one 10.

hand and on the other conscious sedation of patients as a type of dentist resistance to role change. This polemic confirmed that the concept of pain from clinical procedures had moved into a social paradigm. The idea that anxiety prevented many people from visiting their dentist resulted in extensive attempts by the profession to understand the nature and cause of fear and anxiety. It was argued that “the legend still lingers of the dentist as someone who hurts”.156 Conway162 noted in 1976 that only 50% of the British adult population regularly attended the dentist inspite of modern, effective physiological and psychological pain control methods available. He described a need for the profession to destroy the legends or myths tied to the dentist image and claimed, “If we wish to move into the twenty-first century with a better public relationship than currently, one as of a ‘butcher or torturer’, then we have to show that we do not still treat patients as in the dark ages. Perhaps then we shall see our ‘other fifty per cent’”.162 To dental health care consumers, images of the dentist and of what a dental visit means in a purely social context has often been made laughable. The most persistent signs of the public’s fear of dentists are the “counter-phobic” jokes about them, which has been seen as a form of defensive humor.657 One can hear in modern work settings, as colleagues leave work on their way to the dentist, parting remarks such as "Hope you survive and that we see Fig. 3. Cartoon portrayal of dentist you at work tomorrow!" or "I don't envy you." Such comments are not so far removed from victims of “tooth drawing” on stage. The irony is that many dentists live this injustice inspite of all the tremendous technical and patient comfort improvements that have occurred in the dental profession for patients’ benefit. Yet a majority of extremely anxious or phobic dental patients79;598;611 have a history of contact with family or close friends with dental fears who had influenced their own fear. Comments about dentists or dentistry in the workplace among workers, discussions of dentists among students in classrooms and reports in newspapers about tragedies in the dental chair whether reporting all the facts or not, often combine to make dentists and dentistry the butt of jokes.93;528 Countless cartoon drawings of the ridiculousness and vulnerability of being a patient in the “clutches” of the dentist, also attest to a strange role image of the dentist and what dentistry has meant to the public.93;528;600 Pre-modern depictions of dentists and dentistry by writers, painters and cartoonists over a span of a thousand years indicate two recurrent themes: pain and humoristic caricatures.362;718;760 There has been an overwhelming development of mass media in modern times,241;760;822 and spectacular images of dentistry and dental victims are broadcast en mass. (See Fig. 3.) Take for example perhaps the best-known film about a dentist, the images of the ex-Nazi dentist (actor Sir Lawrence Olivier) who tortures actor Dustin Hoffman by drilling into the pulp of his front teeth in the film "Marathon Man".760 There is also the sadistic dentist caricature of Orin Scovilla DDS by actor Steve Martin in the film “Little Shop of Horrors”93;760 in which after terrorizing children in the waiting room, he morbidly twists a half-numbed tooth from the head of a terrified man who had literally been hanging from the ceiling just before. Prior to this incident, Scovilla himself had prepared himself for the event by getting a few whiffs of nitrous oxide laughing gas. One study 760 looked at 16 movies (including the two mentioned above) and 6 American television series from 1932 to 1992 for depictions of dentists. With few exceptions, motion pictures and television have displayed a view of dentistry and dentists as figures of humor and derision or as brutal sadists. The images are consistent with those presented throughout history: fear and humor, where humor is seen as a comic relief and society laughs at and ridicules its fears, in the same way that individuals do, by exaggeration and mockery. 11.

Even though these images may be unfair, given all the great accomplishments of the dental profession in reducing disease, pain and suffering, all of these sources of images can nonetheless guide and shape the beliefs and expectations of many dentists and patients. They facilitate perceptions in terms of role stereotypes in a great comedy, discounting positive personal experiences between dentists and patients that occur on a daily basis. In the dental literature, perceived public image and practice stress of dentists, in many surveys, has often focused on the importance of avoiding inflicting pain and anxiety.201;452;650;690;797 However, in the 1980s one profoundly positive phenomenon and another unspeakably negative one again altered the public image of dentists804 beyond pain and anxiety. The positive change was the decade’s “self-health care and fitness” boom, which created a seemingly insatiable appetite for health information. Dentistry faired well here, as prevention had always been the favorite ideal of the profession, inspite of the apparent conflicts with dentistry’s economic dependence on restoring teeth. The negative one was the impact of AIDS and its enormous stigma, which seemed to culminate in the actions of a single dentist in Florida, USA242;804 in the late 1980s. Not only did this show that sensitive public health issues also affect the dental profession, but also that each and every dentist can affect the public’s opinion of the profession. An American Dental Association attempt to bolster dentists’ image in the USA in 1986, the “Smile America” campaign, had virtually no effects.93 Dental professional organizations have become aware that it is important to know what the common perception of the dentist is, before endeavoring on such image campaigns. In the 1990s the focus of media attention on the dental profession continued to be shifted away from pain and anxiety even more, when issues of amalgam vs. composite and drill disinfection came to the forefront. There were even some529 who speculated that the image of the dentist has slowly been changing at the end of the 20th century toward the positive, mainly due to the emphasis within the profession on prevention and cosmetic dentistry and that, inspite of AIDS, infection control or amalgam controversies, most media attention on dentists was positive.804 These and other authors198;692 call for dentists to focus on improving dentist-patient relating as the best way to build positive images about the profession. This would require dentists to relinquish a traditional dominating role in the relationship146 and to improve communication skills with patients into the 21st century.198;465;467;692;758

Relevance of the dissertation for dentists and patients about anxiety and pain In considering this background description of dentists, patients, anxiety and pain the relevance of this dissertation can be summed up by three conditions related to these phenomena. First, the occurrence of anxiety and pain has been indelibly associated with the dentist role and dental treatments and is engrained as a part of the image of dentists and dentistry. Second, inspite of technological improvements, there is considerable evidence indicating that dental patients still experience much anxiety and inflicted-pain and there is a strong psychosocial component in these phenomena. Third, dentists consciously or unconsciously are still often missing opportunities in practice to use management strategies that, if applied, would decrease anxiety, pain and unnecessary suffering of their patients. Improvements would also aid in the development of better relations with patients, which indirectly would promote greater career satisfaction and a more positive professional social image. As was established in the Ph.D. thesis,598 the interaction of multiple social and psychological factors contributes to the phenomena of anxiety and pain in clinical settings. The study of dentists’ and patients’ perceptions of these phenomena within a larger social context is pursuant to the overall aims of 12.

this dissertation. Also pursuant to these conditions, renewed interest in psychological clinical strategies must be considered in forming new dentist role expectations and patient beliefs in the future.

Aims of the doctoral dissertation Overall aims This dissertation, which is a continuation of the Ph.D. studies on dental anxiety cited above, describes research of broader psychosocial aspects including beliefs and expectations about anxiety and pain phenomena as seen from the perspectives of patients’ perceptions and of dentists’ perceptions, as well as specific outcomes of these perceptions. The ultimate goal with knowledge gained from this research is to identify strategies to improve the conditions for optimal treatment and prevention of dental anxiety and clinical pain and thus to improve role satisfaction of both patients and dentists. Specific aims (studies I – IX) Toward these overall aims, specific aims of the single studies are presented in detail in the individual papers, and are summarized here. •

to determine if and/or how much expectations and beliefs contribute to pain and pain remedy perceptions by finding out if descriptions of human pain perceptions and pain remedies vary by ethnicity and professional socialization.



to determine valid and reliable epidemiological estimates of the prevalence and characteristics of dental anxiety in Danish adults 16 years of age or older.



to determine if expectations about dental anxiety differ across cultures, specifically looking at anesthetic injections and reports of negative dentist behaviors related to anxious avoidance among caucasian American and mandarin Chinese adult patients.



to describe Danish general dentists’ experiences with dental anxiety and their beliefs about the phenomena, as well as examining qualitative characteristics of clinical populations of anxious adult dental patients in Danish private practices compared with a specialist clinic.



to describe the influence of beliefs and expectations on perceived need for use of local anesthetics in tooth drilling among AngloAmericans, mandarin Chinese, Swedes and Danes by studying reasons that dentists say their patients do not use anesthetic for proximal fillings, if they don’t. Dentist responses are compared with patient responses for validation.



to describe the relationship between career satisfaction, perceived public image and perceived stress in a representative epidemiological sampling of Danish general dentists.



to describe in an epidemiological sample of Danish general dentists, reports of kinds of stressors and amount of work stress that they perceive in comparison with unspecified “other professionals” as well as how stress perceptions relate to 1) sensitivity in detecting dental anxiety and 2) beliefs about anxious patients.



to compare three-year outcome results of specialist treated anxious patients with a comparable group of patients treated in unspecified private dental practices using measures of regular dental care attendance behavior, dental anxiety and beliefs about dentists. 13.



to describe social aspects of patients’ clinical expectations related to contributions of embarrassment, shame and guilt in the differential diagnosis of extreme or phobic dental anxiety using case study analyses of records, interviews and simple clinical rating scales.

Before addressing substantive issues about dental anxiety and pain phenomena, it is important to discuss the relevant theoretical and methodological considerations from dental behavioral science research regarding such phenomena, as background for the doctoral articles and dissertation.

Chapter 2. Researching dental anxiety and pain There are several ways to research dental anxiety and pain. The description of social phenomena in the dental clinic or the study of hypotheses aimed to explore and understand specific clinical issues or treatment of pain and anxiety are all linked to theoretical considerations. There are also methodological approaches that fit these theoretical considerations and the specific research questions to be studied. Qualitative methods are used to identify, describe, classify and explain specific dentist and patient variables, while quantitative methods are used to check for associations between explanatory variables in epidemiological and experimental or quasi-experimental studies. Careful consideration of these theoretical and methodological choices can contribute to a fuller understanding of the phenomena involved while also furthering the development of theory. Theoretical models most often used to explore dental anxiety and pain, including the nine dissertation articles, will be described. Then more detail about methods used to support them will follow.

Psychosocial theoretical models relevant to present anxiety and pain research The Biopsychosocial Model of Health, Disease and Illness Clearly, it is essential for understanding and tackling the clinical anxiety and pain problems facing dentists and patients that researchers and clinicians have a broader outlook than merely physical or biomedical aspects of these phenomena, which is the focus of this dissertation. However, it is not the intention of this dissertation to negate the relationship that biological aspects, especially neurobiological aspects, have to psychological and behavioral aspects of anxiety and pain. A biopsychosocial model of disease and illness, as originally described by Engel,226;227 acknowledges the interplay between physical, psychological and social factors and views them as extensions of one another. The biopsychosocial paradigm views as incomplete and scientifically indefensible a biomedical model’s underlying notion that disease and illness arise exclusively from biologic (i.e., physical) causes, independent of the person’s emotions, thoughts and behaviors and independent of the social or physical environment.208;226;227 As Dworkin208 describes it : “It is not only cancer or tooth decay or bleeding gums that cause somatic changes. Thinking is a somatic process: when the mind changes, the brain changes. Emotions and feeling states are somatic states as well.” So, the biopsychosocial model is a scientific proposition, not a political one, which helps us integrate our own views about illness, disease and wellness208 while providing a philosophical model that can logically drive a research program through such health problem areas as dental anxiety and clinical pain. They also provide an omnipotent foundation for teaching health practitioners how to help their patients to change their understanding of health and wellness factors. It is within the assumptions of this paradigm that the following theoretical models or methods were employed in the research programs of this dissertation. 14.

Social Learning Theory (SLT) Social learning theory, has been expanded to include a broader social perspective called social cognitive theory. Since most of the literature uses social learning theory specific to anxiety and behavioral change, this term is used throughout the dissertation. The earliest SLT pioneers were Miller & Dollard from 1941586 who studied imitation as a learning process. According to Rotter,741;742 SLT emphasizes that the majority of human behaviors are learned in social situations and that these are mediated through needs that individuals have for acknowledgment and reinforcement from other persons. Although physiological factors may be antecedent or concurrent with some unlearned reinforcements,470 social learning theory dispenses with the assumption that all unlearned reinforcements are the result of physiological drive reductions.576;742 According to Rotter,742 physiological indicators alone are often valuable in indicating what individuals cannot do, but may not be as useful in appraising what they will do. SLT is interested in predicting which behaviors a person will do, since it proposes that behavior is determined not only by the importance of goals or rewards, but also by the person’s anticipation or expectancy that these goals will be met.54-56;742 Thus, SLT is useful in exploring the learned factors that are predictive of treatment outcomes, e.g. reduction of avoidance of dental treatment due to fear. Bandura’s social psychological research was grounded in cognitive and behavioral psychology and especially in the works of Rotter. According to Bandura,51;54-57;742 the individual learns through experiencing, but all learning does not occur from direct experience. One can also learn vicariously from others’ experiences. Via guidance or by observing or hearing about others’ experiences in being able to perform desired learning tasks, one attains greater self-confidence. The central concept in Bandura’s addendum to social learning theory is the concept of self-efficacy,51;53 which means selfconfidence in performing a specific behavioral task (so-called specific self-confidence). Specific selfconfidence increases primarily by either performing the desired task directly, experiencing it vicariously, such as with films or videos or by personal persuasion. Specific self-confidence is inhibited by stressful experiences, e.g. anxiety or other emotional arousal51;52;59;61;499 Based on these concepts, a learning program is based on stepwise tasks that would promote specific self-confidence. The subjects’ attitude to the task after each step could indicate if they are ready to move on to the next more difficult or demanding step in a predetermined hierarchy. Bandura51;53;58;60 asserts that perceived self-efficacy is the expectation of gaining personal control e.g. over phobic behaviors, which can predict treatment outcome with a high degree of accuracy. Other health theories such as the Health Belief Model734 and the Theory of Reasoned Action12 unite with SLT on the concept of self-efficacy, since 1) a person’s perceived vulnerability or susceptibility to an illness or anxiety/pain phenomenon, 2) the perception of the seriousness of it and 3) the person’s expectations and beliefs about overcoming it inspite of the perceived threat, decide the health behavior outcome.683;734 Kent & Gibbons424 and Kirsch,431;433 citing Rotter741;742 emphasized that Bandura’s self-efficacy construct includes not only expected behaviors but also expected anxiety cognitions (e.g. catastrophic thinking) which are also highly correlated with outcome. They also posited that these expectancy paradigms can be influenced by other factors external to the person tested, such as perceived task difficulty. Since personalities of dentists (threateningnonthreatening) and cognitive difficulty of dental tasks vary, the dental fear situation supports Kirsch’s (and Rotter’s) corollary. Thus, in the dental situation, it would be important to examine negative patient expectations about dentist-patient interactions, since they can be more predictive of dental fear treatment outcome than expectations of pain, as documented by Kent421 and Kent & Warren426 and Moore.598;599

15.

Behavioral change models As mentioned above a hierarchy of tasks can be devised as a practical learning model for planned interventions toward positive long-lasting change in behaviors or beliefs of patients, e.g. suffering from extreme dental anxiety. These behavior change models incorporate SLT and use cognitive-behavioral methods as developed and promoted by Prochaska693 and Meichenbaum & Turk.564 They focus on the intra-psychic (cognitive) factors such as thoughts and mental pictures around a given behavior, usually including a goal of improved self-efficacy. Stepwise tasks with increasing difficulty are employed with the goal of elimination (extinction) of undesirable behaviors or thoughts. One consequence of the hierarchical progression of cognitive aspects in behavioral interventions is progressive patient engagement in the treatment/therapy, in order for them to attain the long-range goal (regularly going to a dentist). In a typical therapy session at the beginning of the change program, the therapist would actively guide the patient through what Prochaska called the stages of change model.693 As sessions continue, patient/clients gradually learn skills and thoughts that enable them to monitor, evaluate and regulate their own behavior (internalization).562 Long-term, enduring behavioral change requires that clients exhibit these self-monitoring skills and aided by a set of intermediate goals (e.g. being able to hear the sound of drill without tensing up, being able to have a drill running in the mouth) can most effectively promote an overall behavioral change goal (e.g. regular dental care with reduced anxiety). The patient’s newly learned behaviors would be monitored over a period of at least several months. Internalization cannot always be achieved and relapse is often a hair-fine balance between selfmonitoring and outside influences on expected behaviors,850 e.g. anxious patient who in maintenance phase suddenly experiences relapse after other unexpected social pressures, such as a divorce or a death in the family. Expectancy Theory, the Ethnomedicogenesis Thesis and Explanatory Models Expectancy theory as formulated by personality psychologists,707;710-712 suggests that expectations are learned at the same time other learning events occur, e.g. that a person who (+) Beliefs and becomes anxious due to a previous Faith Expectations Healing experience of dental drilling also can Paradoxical expect to become anxious about drilling Placebo Placebo Effects in subsequent attempts, given similar Medical Outcome Effects (+ ) ( -) conditions. Studies have shown that Pathology Health Nocebo Paradoxical both expectations of anxiety707;712 and Nocebo Effects Effects painful treatment40;435 can create a kind Voodoo of self-fulfilling prophecy 574 that makes Death ( -) it more likely for these events to be Fig. 4. The Ethnomedicogenesis Thesis: Relationship experienced. In the anxiety expectancy between beliefs/expectations and health outcomes model, “fear of fear” makes people overly sensitive to anxiety and thus 707;710;848 reinforces or exaggerates its negative affects. In a broader ethnographic concept similar to psychological expectancy theory, medical anthropologists Hahn and colleagues314-317 and others587 have developed an ethnomedicogenesis thesis, which posits that beliefs and expectations of patients and healthcare workers influence or draw on positive or negative outcomes of treatments. Shapiro784 called it “iatroplacebogenesis”. Extremes would be, e.g. faith healing on the most positive side, and tribal Voodoo 16.

“death wish“ rituals in Haiti on the negative side.316;317(Fig. 4) These responses to non-specific treatment effects have shown rates that vary between 7%-60% in different settings.587 There is some evidence to indicate that production of endogenous endorphins is linked to positive placebo responses.15;128;486;820 In researching such phenomena, it is important to consider both the perspective of providers and of patients and the social context from which they derive their expectations - their explanatory models, as psychiatrist-anthropologist Arthur Kleinman called them.441;442 Explanatory models can also be used to explore possible iatrogenic or healing effects of dentist and patient interactions. This theory is graphically portrayed in Fig. 4 as “positive” (hopeful) and “negative” (fearful) beliefs and expectations on the vertical axis, pathological and therapeutic outcomes on the horizontal, and a “property-space” of relations between expectations and outcomes which also can be “side-effects” or paradoxical relationships. For example, it is unlikely in a western society that a belief like “tooth extraction doesn’t hurt” would be normative and thus does not require anesthetic. Yet there are individuals who, against dentist advice (V), or due to allergy,355 prefer sensations of tooth extraction to the use of local anesthetic. Likewise, lack of patient faith in anesthetics may diminish their potency, and faith or skepticism about “pharmacologically inert” materials or practices (e.g. praying) may shift the results in positive directions by mere expectation. Thus, for any disease or treatment, one should consider at the same time the accompanying psychological process. There is a psychology of expectation, of hope, fear and all variants in between in patient-care provider relating.128;316;317;814;820 Capturing nuances of these psychosocial phenomena often require qualitative research methodologies. Proponents of the ethnomedicogenesis thesis often research their topics using so-called “Grounded Theory”.299;829 Grounded theory in qualitative research Grounded theory is often thought of as a qualitative methodology as much as it is a theory of psychosocial research based on symbolic interactionism.106 It advocates that subjects be asked to introspect as to meanings, motives, characteristic behaviors and thinking (cognitive) process prior to behaviors (antecedents) or related to actual behavioral outcomes. As the researcher ponders these introspections, the subject is asked to verify categorizations and explanations about the phenomena studied. The approach described combines theoretical perspectives of Glaser & Strauss,299 Strauss & Corbin,829 and Charmaz.148 Grounded theory has been widely used in health care research147;278;331;342;546 and in studies of doctor-patient459;641 and dentist-patient relationships.456;458 First, data collection usually occurs with some of the first subjects through open-ended interviews or observations relevant to the topic. Then as more and more knowledge emerges, new questions are asked, in order to reflect on previous findings and how these are influenced and adapted to the emerging concepts or categories. This method is called “constant comparison”.299;829 Qualitative analysis requires an initial coding and labeling of substantive (nominal) data and organization into categories (open coding). Categories depend on the similarities and differences in meaning among them. Some categories are closely related and may build toward higher level categories of abstraction (selective coding299). These higher-level categories, e.g. “dentists’ ability to provide reassurance”, include subcategories such as “healing” and “touching”, as an example taken from a Swedish study of dentist-patient interactions.456;458 The process of investigating the relationship among categories is called “axial coding” and although there are theoretical controversies about levels of coding, it is generally agreed that the most important guideline or coding is relevance to specific research goals.393;411 Relationships between categories are investigated and a phenomenonspecific theoretical model is designed, continuously refined and developed depending on the new concepts emerging from continued input of the new research subjects. The final step is labeling a core 17.

category829 which is the central concept that permeates all the higher-order categories and has the highest level of abstraction. An example would be “exhibiting understanding for others’ concerns”. In the method of constant comparison,829 the researcher is forced to compare emerging categories both to the raw data and to the highest level of abstraction, which provides built-in validation and decreases the possibility of researcher imposed categories that don’t “make sense” to the participants. Gate Control Theory of Pain and other current pain concepts The "Gate Control Theory" is the currently accepted theory for integrating physiologic and psychologic mechanisms of pain and thus, is helpful in explaining the relationship between pain and fear. The Gate Control Theory as originally (1965) proposed by Melzack & Wall,570 and later expanded by Melzack & Casey,569 supports the combined interactions of sensory, emotional and cognitive components of pain. It postulates that control is exerted from higher brain centers by a kind of sorting of impulses received via the substantia gelatinosa (SG) of the dorsal horn of the spinal cord from peripheral nerve impulses. Depending on brain states or perceptions, descending impulses are involved in either activating or inhibiting firing of impulses from transmitter cells (T) that can activate muscles, internal organs and other action (pain reaction) systems. Therefore, via these neuroanatomical "gate mechanisms", so-called Fig. 5. Melzack’s Neuromatrix in the Brain568 - Factors involved in a neuromatrix comprising sensory, affective and cognitive aspects of perception that produce homeostatic and behavioral responses; a “bodyself” perspective in which psychosocial aspects combine with brain physiology. (courtesy of Melzack568)

"cognitive down-flow" from the brain induces psychological and social influence on pain perceptions and reactions.570 More recently, Melzack567;568 has proposed a theoretical “neuromatrix” that tries to explain the actual functioning of the brain in these neurobiological processes and our responses to pain or stress (Fig. 5). The theory proposes that pain is a multidimensional experience produced by a characteristic "neurosignature" or patterns of nerve impulses generated by a widely distributed neural network in each individual’s brain, in which patterns of the "body-self neuromatrix" or personal feelings of integrity or identity, are projected into a perceptual and response pattern reality, not unlike a virtual reality computer system. The neurosignature for pain experience is determined by the synaptic architecture of the neuromatrix, as modulated by sensory or physical inputs (“S” in Fig. 5) and by cognitive (“C”) or affective (“A”) events, such as occur in psychological stress. Even though these neurosignature patterns are usually triggered by site specific sensory inputs,844 they may also be generated independent of them, that is, by C or A elements of the signature. The 18.

example of the latter used by Melzack is phantom leg pain after amputation.567;568 As described in Melzack’s concept of “cognitive down-flow”, these influences originate from earlier experiences with pain, individual emotional factors (e.g. fear or anxiety), degree of attention focused on the painful stimuli, social relationships and ethnoculturally derived expectations. The brain, as for all other organs of the body, makes homeostatic adjustments to pain or stress, thus affecting perceptual, behavioral and/or physiological responses or outputs (the right side of Fig. 5) . The gate-control concept originally focused on defining pathways at the spinal or brainstem level, while clearly implying higher brain center involvement. Melzack’s neuromatrix theory expands and attempts to explain this connection. One aspect of these neurosignature response patterns is production of “endogenous opiates” (Fig. 5). Today, there is a growing literature regarding the body's production of natural opioid neurochemicals in the spinal cord and brain, called endorphins, enkephalins and dynorphins.202;360;851;852 Although at the time of the Gate Control Theory paper (1965) these were unknown, Melzack & Wall570 predicted that “a better understanding of the pharmacology and physiology of the substantia gelatinosa may lead to new ways of controlling pain”. Current findings confirm the presence of more global interactions involving neuronal and hormonal effects on stress and pain.140;202 There is some evidence that they are also active in placebo responses.15;128;486;820 Recent findings support an important contribution of endogenous opiates in the mediation, modulation, and regulation of endocrine, autonomic nervous system, and behavioral responses.202 A distinctive feature of this anti-pain/anti-stress regulatory system is it’s multidimensionality and interactivity851 such as the analgesic action of opioid peptides at specific mu-opioid receptors not only on sensation, but also in blunting the distressing, emotional or affective component of pain.202;941 Recent research has also found differing mu-receptor responses in men and women942 which could partially explain higher pain ratings reported by women. In general, the perception of pain may be facilitated when these neurochemical receptors are blocked or otherwise inhibited, e.g. in states of passivity, exhaustion, too much stress or work, focusing on pain or negative beliefs, depression, anxiety, muscle tension, and pessimism and may be facilitated by e.g. relaxation, rest, massage, warmth, acupuncture, balanced work levels, exercise, happiness, satisfaction and optimism.128;202;566;570;853;854 This area of neurochemical and psychological research has relevance towards improving treatment and prevention of pain and anxiety and should gain in importance in the future. The concept of stress, models of stress and a specific model of stress in dentistry Stress in the dental clinic has been extensively reviewed and researched in the dental literature.153;163;269;270;422;589;650;717 There are general theoretical models of stress, that are physiologically oriented773;774 and then those mostly related to occupation and coping.250;350;792;857 What constitutes stress is complex and controversial, particularly since both the definition and concept have been debated in the psychological literature.778 Some sociologists speculate that stress is often misused as a causal factor in diseases, for lack of better explanations, and has achieved status as a popular (and unexplainable) folk illness.348;361;638 The research of endocrinologist Hans Selye has had a major influence on the concept of stress. He described the “General Adaptation Syndrome” physiological model of stress773;779;782 in which there is an “alarm phase”, “reaction phase” and an “adaptation phase”. He borrowed the English word “stress” from physics to describe the body’s response to everything from viruses and cold temperatures to emotions such as fear and anger; thus, Selye’s definition: “ the body’s nonspecific response to any demand placed on it, whether that demand is pleasant or not.”781;782 Subdivisions of the stress concept have developed such as "eustress (good stress) ", "distress 19.

(negative stress)", "systemic stress", and "local stress". Confusion between stress as both an agent and a result can only be avoided by making verbal distinctions between "stress" and "stressor" or “stress factor”. Concepts in this dissertation are referred to in the following ways: Stressors – those events or entities that have the potential to cause a stress response. Stress cognitions or perceptions – the individual’s perception of stressors. Stress responses or reactions – the responses of an individual to stressors and stress perceptions. Selye’s numerous experiments on animals and humans described stress mechanisms in detail, explaining the body’s adaptation to stress and clarifying the interaction between mental and physical processes.775-777 Depending upon conditioning factors, the possibility exists for selective influence of reactivity of certain organs, where the same stressor can elicit different manifestations in different individuals.778 The way an individual perceives a stressor is usually much more important than the stressor itself in terms of a reaction pattern.404;521;857 Thus, the cognitive aspects of stress are the filters through which the stressor passes in the development of a reaction or pattern of reactions. The predictability of stressful events reduces impact of a wide range of stressors. Endogenous enkephalins appear to play an important role in this process.202 A stress reaction can mobilize physical “fight or flight” responses that can save one from real threat. But problems arise when the alarm system is constantly alerted by non-lifethreatening or even illusory threats in chronic stress states.778 In a continuation of Selye’s recognition of short-term protective functions vs. long-term damaging effects of stress, several research and review articles by McEwen and colleagues 548-550 point to a plasticity of physiologic systems in the stress response including constant dendritic remodeling of areas of the brain, particularly the hippocampus area of the limbic system,550 that are sensitive to changes in glucocorticoid and catecholamine levels. McEwen describes an “allostasis” in which the body’s response to stress attempts to maintain a balance, and which can vary according to levels of demand during certain stressful periods. When there is chronic stress, the mechanisms for allostasis can become taxed and through “wear and tear” create an “allostatic load” which may lead to irreversible damage, contributing to symptoms such as decreased memory, cardiovascular disease and premature aging.520;551-553 Continual elevation of blood pressure, increased heart rate, cessation of gut activity and tensing of muscles can lead to diseases like ulcers, strokes, heart attacks or premature death.404;521;748 Out of a research need to take psychosocial factors and work type into account, various models of stress have been developed114;404;793;857 that extend to encompass complex psychological, social and cultural observations. The “demand-control” model of stress developed by Karasek and co-workers404;521;857 theorized that the combination of contributions of low job decision control (e.g. factory workers) and high psychological job demands cause the physical signs of stress. Karasek found a relationship between feelings of having control at work with types of job task demands and risks for such psychosomatic illnesses, particularly coronary heart disease. Risk categories were: Relaxed (low risk for disease) e.g. librarians, priests; Passive (moderate disease risk): patrol guards, night watchmen; Active (periodic stress, good coping possibilities due to high control, varying risk): academicians, physicians, dentists; and High strain (chronic stress, low control, high disease risk): assembly line workers, seamstresses, long-haul truck drivers. More recently, Siegrist and colleagues114;792;793 have also studied psychosocial and physiological aspects of combinations of low job rewards and high work effort that promote deleterious stress effects, a so-called “effort-reward imbalance at work” model, which has further developed understanding of psychosocial aspects of how stress reaction tendencies and stressors can lead to negative work relationship patterns resulting in undesirable health consequences, social conflicts or crises. Therefore stress management and 20.

individual coping are important concepts for the prevention of effects from stressors and negative stress perceptions. With these models in mind, a model of stress in the dental work environment would need to examine predisposing factors for stress (stressors) as well as specific effects of possible stressors on diverse behavioral and cognitive outcomes such as increased prevalence of alcohol/substance abuse, ulcers, coronary heart disease, even premature death,44;507;589;702;748 as well as relationship problems with family, staff, or patients.507 The model most often used to explore research aims about psychosocial aspects of stress in the dental environment has been Hendrix’s model of stress in dentistry.350 The model relates precursors of stress and stressor observations with health, perceptual and behavioral outcomes of dentists. Locker507 and Atkinson et al.589 referred to it as the most relevant research model for studying job stress in dentistry. It is based on “perceived stress” (psychological stress)350 and identifies with elements of both demand-control and effort-reward imbalance models of stress and outcomes.349;351-353

Stress Antecedents:

Stress

Stress response or consequence

Personal characteristics * * * *

Dentist’s age Dentist’s gender Dentist’s practice experience Personality type e.g. “A”

*Dentists’ Health: Mental & Physical

Perceived stress External factors * Perceived public image * High overhead costs/debt * Perceived public image

*Perceptions of Patients *Career Satisfaction

Job-related factors * * * * *

Time pressures Number of patients Solo/Group type practice Number of chairs Urban/rural location

*Dentist behaviors and ability to help patients

Figure 6. Hendrix’s model of stress in dentistry350 and consequences of dentists’ perceived stress. In using perceived stress Hendrix350 wrote, “The rationale for choosing this definition is that stress is a perceptual phenomenon; for example, any given stressor may have a different effect on different individuals, as all of us perceive the world differently. … It appears reasonable therefore to define stress in terms of an individual’s cognitive interpretation (appraisal) of internal or external events judged (consciously or unconsciously) to be threatening, harmful or challenging.” It posits that job-related factors and external factors, which are moderated by personal characteristics of the worker, contribute to perceived stress and have psychological, behavioral and physical consequences (Fig. 6).

Need for research on multiple dimensions with multiple methods Anxiety and pain have clinical aspects that are physiological, psychological and social. Multidimensional phenomena require multiple methodological strategies in order to achieve valid and reliable results.601 Qualitative methods - understanding and explaining psychosocial phenomena; identifying variables In order to research psychosocial phenomena, one must gain some understanding of them as the basis for explaining the existence of certain relationships and their power of association. This requires 21.

discovery and confirmation of nominal data and categories by characteristics. This is an important task that is often described as a precursor to experimental or epidemiological studies. Corah’s Dental Anxiety Scale (DAS),167;171 is a highly reliable dental anxiety measure that has been in use for over 30 years. When measuring dental anxiety DAS looks only at four items 1) making appointments, 2) sitting in the waiting room, 3) tooth drilling and 4) tooth cleaning. They do not cover all variables that would explain any particular patient’s irrational anxiety response or avoidance of a dental visit. Those four items present sufficient range of experiences that they provide a reliable estimate of relative intensity of trait dental anxiety. But in order to discover what actually triggers a specific anxious persons’ irrational thinking and behavior, more must be known about the circumstances for that person’s anxiety. Qualitative methods are used to discover and explain sequences and circumstances of such relationships. Associations of behaviors to cognitions are best studied using qualitative observations within in a clinical setting,819 but cognitive features and relations between variables are best researched using qualitative interviews.601;818 Qualitative interviews are usually unstructured or semi-structured and can provide information that identify specific psychological or social contextual factors that are meaningful and emotionally significant to perceptions of pain or anxiety, e.g. specific issues of ethnic or family beliefs or expectations. When interview “informants” tell about their pain or fear, it not only provides nominal “facts”, but also indicates strengths of associations between variables. Quantitative methods – verifying and testing relationships between variables Epidemiological and experimental methods are usually thought of as quantitative methods. However, one definition of epidemiology47;655 is “the study of determinants of the occurrence of health-related events or conditions”. This definition of epidemiology emphasizes two aspects, the strictly scientific aspect, which is to increase knowledge by searching for the truth, and the public health aspect, which primarily considers the utility of the knowledge for the purpose of preventing health problems.47;310 Some scientists might morally object to the entry of informed opinions and value judgments into public health epidemiology, but such elements in public health decision-making are necessary, according to the arguments above. Thus, scientific knowledge is only one of many aspects of public health described by Greenland310 as “a form of social activism”, which includes “..irrational elements pertaining to society, individual beliefs and value judgments”.47;310 So in effect, all types of data, (e.g. survey, experimental or qualitative) can have public health epidemiological purpose, if they reveal associations or causal inferences that seek the truth with the goal of promoting physical or mental health. Quantitative epidemiological survey research process, using tests of association, odds ratios and regression modeling, hopes to obtain valid and reliable findings using the logic of probability statistics and/or confidence interval estimations. The goal of this process is to isolate factors relevant to an outcome and observe possible effects of variation in those factors.47 But problems of representativity are not logically solvable in any neat way, as discussed in the next section.135 This makes any particular research only as good as the sampling design and the variables chosen. This is also true in the study of therapeutic outcomes for experimental treatment of anxiety. It is also important to consider effects of interactions with factors such as gender, age and socioeconomic differences, since the literature has indicated that these variables may affect anxiety or pain perceptions.598;601;609 Experimental designs must also take into account the conditions under which subjects were subjected, trying to make them equal across outcome groups or across time, among other things. If samples cannot be randomized, then the study must be described as pre-experimental or quasi-experimental.135 Recent emphasis on 22.

randomized controlled trials and “evidence-based medicine” seek to improve external validity of experimental results and is a laudable trend in medical and dental intervention research. However, some in the scientific community maintain that evidence-based medicine cannot provide all the answers required for modern scientific medical practice and research.243;398;691;704;828 One criticism of evidencedbased drug designs might be that controlling for operator placebo effects are not optional in real clinical situations and it is debatable if the clinical efficacy of giving a medicine for an ailment could be devoid of these effects. Doctors or dentists when giving drug therapies can contribute to the outcome by what they say, how they behave and the expectations they place on patient response.48;442;587 Is it a clinically relevant piece of research if these “confounders” are removed? Perhaps it is more useful to study and describe these “placebo effects” and other operator/therapist variables as separate research topics themselves.128;146 This is especially true for cognitive-behavioral experimental interventions in anxiety studies, since study designs require a comprehensive awareness on the part of the medical or dental researcher that often may transcend their specific field of knowledge.

Methods and validity, reliability or generalizability Qualitative results are designed to provide insight into research phenomena. Insight and validity constitute scientific reflection. As social science philosopher and researcher Polkinghorne685 described it, “The final criterion for the validity of the research is the clarity of insight of the phenomenon’s essence, for the insight is self-validating. If the insight is communicated well, then others will also recognize the description as a statement of the essence of the phenomenon for themselves.” At some stage in the development of an understanding of patients, when interviewing them as to what transpires in anxious or painful situations, there is often an inherent truth in meaning that still transcends what can be usefully measured using tests based on psychometrics and statistics. Patients value appreciation of this personalized, culturally embedded biographical data much more than doctors and dentists are aware of.505 In addition to insight, there is also a need to know if there is any broader consensus or generalizability to a particular phenomenon or belief within its social context or if the data could be an isolated individual’s pain or anxiety beliefs. Representativity is inevitably linked to sampling in some manner.613;727;899 But whether answers to research questions about anxiety or pain phenomena are found using numerical representativity or if they are built on strength of agreement among subjects about qualitative descriptions of specific clinical situations and their emotional significance,613;727;898in the end, qualitative and quantitative research must be closely related in seeking scientific truth. It is perhaps helpful to think of them, in terms of prediction (predictive validity) or functional usefulness. Thus, combining qualitative and quantitative methods in a research program may improve concurrent validity and reliability.601;613 The concept of concurrent validity is somewhere between internal reliability (consistency within a data set or in interviewed persons’ descriptions) and external validity (replicability of results) and is a natural way for a researcher to co-validate results, assuming phenomena are observed from several perspectives. It is much like the ancient mariner sailing unknown oceans who triangulated a path388;601 armed only with a simple measuring device and a knowledge of the stars, moon and sun. Of course, when researching pain and anxiety phenomena in psychosocial contexts, one must choose the research approach that is most appropriate to the aims of a study and the sampling methods best suited to accomplishing those aims.

23.

Chapter 3. Dental anxiety - What is it? What is it not? How many have it? Defining dental anxiety - terminology and limitations Dental fear or dental anxiety? Fear of dentists and dentistry can mean many things to many people and can include a range of intensities and types. By far the most common terms used in the literature are “dental fear” and “dental anxiety”. “Fear” usually refers to an emotion toward an object or situation in the present tense that is “here and now”, while “anxiety” is more diffuse, anticipatory and oriented toward future events (worrying).576;585;608 These terms are often used synonymously in the literature, since they are phenomena that are hard to separate in a dental clinical situation, mainly because the physiological responses are the same – muscle tension, sweating, increased heart action, stomach symptoms etc. In this doctoral dissertation, although “dental anxiety” is used more often, “dental fear” or “dental anxiety” will be used as interchangeable general terms for being afraid of dentists and dentistry at all levels of intensity. In the dental fear and anxiety literature and psychological literature in general, a distinction is made between what is called “trait anxiety” and “state anxiety”.815;816;895 State anxiety refers to the complex emotional reactions that fluctuate over time as a function of stressors experienced by the individual, i.e. patients become afraid in particular situations during some conditions, but not in others. An example would be a dental patient who has no problem coming to the dentist and having work done, as long as he receives an anesthetic injection, but who would become afraid if suddenly there was no anesthetic. Trait anxiety refers to a personality characteristic that is relatively stable within an individual over time. If a patient were so afraid of injections that even the thought of the possibility of an injection caused great dental anxiety, which could also include worrying about having to deal with drilling after the injection as well, then it would be thought of as a trait anxiety. If dental anxiety is so intense as to cause avoidance of dental treatment for long periods of time, it would also be a trait anxiety. However, trait anxiety is more often associated with a general anxiety complex of worrisome, often unfounded, irrational cognitions that lead to anxious behavior608;611 and thought sensitizing709;711 patterns. Reiss and colleagues708;709;712 and Taylor et al.849 distinguish a concept of anxiety sensitivity from trait anxiety by noting that, whereas trait anxiety predicts future anxiety generally, anxiety sensitivity predicts future fear specific to anxiety sensations based on beliefs that these sensations have harmful consequences. Anxiety sensitivity is also relevant to dental anxiety, since the fear of being anxious is often a part of the psychological profile of persons with odontophobia. What is a phobia? Patient reactions to dental treatment settings can range from slight nervousness to outright panic and avoidance of the setting. Intense anxiety with pronounced irrational avoidance behavior is called phobic anxiety. The definition of a phobia according to the American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders Fourth Edition (DSM-IV)16;17 is “a persistent fear in which an object or situation is avoided or endured with intense anxiety, significantly interfering with normal routines or relationships and which is recognized by the person as unreasonable.”16;17 In adolescents, there must be duration of this anxiety for at least 6 months. A more comprehensive description of criteria and systems for establishing a psychiatric diagnosis is presented below.16;17 24.

There is no documented Greek derived name for phobias about dentistry in the psychiatric literature,476 but this severe avoidant degree of anxiety has been called “dental phobia”,282;325;387;477 “dentistry phobia”326 and “odontophobia”112;276;325;598;605 in the dental literature, the latter derived from Greek “phobos” to fear/flee and “odontos”2 having to do with teeth.598;605 Perhaps a correct Greek derivation for fear of dentists would also be the word “odontiatrophobia” from “iatros” meaning doctor,2 hence “tooth doctor (dentist) fear”. (Curiously, the Danish word commonly used for dental anxiety is tandlægeskræk, which literally means “dentist fear”.) The correct English would be “dentist phobia”. Since the word odontiatrophobia is unwieldy and specifically intended, and all dental fears are not limited to just the dentist’s person, “odontophobia“ or otherwise more commonly called dental phobia (meaning dental treatment phobia) is used in this dissertation as a more general label for a disorder in which persons have an extreme anxiety and/or phobic reaction to dentists or dentistry. The word is used in the same sense as odontology, which is the “science of things having to do with the teeth”. Persons with odontophobia will often be referred to in this dissertation as dental phobics or odontophobics, for ease of description. If psychiatric criteria for phobia, according to DSM16 or ICD,923 are not fulfilled and yet a highly irrational state of anxiety is present before or during dental treatment, this may also specifically be referred to in this dissertation as “extreme dental anxiety”, but otherwise as odontophobia.

Prevalence of dental anxiety Compared with other fears, some American epidemiological studies have shown that only fear of heights,247 snakes, storms and flying9 were more frequent than fear of dentists. Although later studies have shown decreases over time186;264;412 fear of dentists, when specified, has been greater than common fears such as fear of injury, death and claustrophobia.9;247 In Table 1 below, statistical ranking for Table 1. Prevalence of selected fears among of residents (N = 565*) of Århus, Denmark, 1992-3 (II) * N for some fears may not total 565 due to missing data. Level of Fear (in frequencies) Type of Fear: % population A Little: with any level”common fear”: Heights 44.9% 93 Dentists/Dentistry 36.1% 138 Death 35.8% 90 77 Injections 25.8% Closed-in spaces 22.5% 74 Flying 21.1% 44 Blood 18.6% 54 Thunder storms 17.9% 60 50 Doctors/Hospitals 17% 29 Traveling alone 9%

Some: 74 33 83 32 28 32 33 23 24 11

Very Much: + Terrified:  % with “severe fear”: 60 25 15% 13 9 4% 24 3 5% 24 11 6% 16 10 4.6% 20 10 6% 12 5 3.2% 17 1 3.2% 17 4 3.7% 6 2 1.7%

common fears (all levels of fear) in the Danish population include dentists/dentistry as the second most frequently feared after heights (II). In other similar studies,9;247 prevalence of severe fears by rank, (combined “very much afraid” and “terrified” were 1) heights, 2) injections, 3) flying, 4) death, 5) claustrophobia, 6) dentists, 7) doctors/ hospitals, 8) blood, 9) storms and 10) traveling alone. A common “fear of physicians” was only reported in 1/1000 of an American population.9 Some people have specific fears of medical procedures, such as fear of operations or fear of injections. Moore, 25.

Brødsgaard and Birn611 found in the Ph.D. clinical study of 208 odontophobic patients that only 11% were afraid of physicians and/or hospitals. This was comparable to 8% who were at least “somewhat afraid” in the Danish adult population (II), but was lower than in Danes reporting high dental anxiety, where ca. 25% also feared physicians and/or hospitals at this level (II). Thus, there appears to be something special about the dentist role and dentistry that is especially anxiety provoking. Odontophobia differs from snake or height phobias,598;611 since the latter often can be successfully avoided without serious consequences. Avoiding dental treatment can have profound effects on oral health. Until the late 1980s and early 1990s, there were inconsistent reports in epidemiological studies of the prevalence of dental anxiety and its relationship to avoidance of dental treatment. Prevalence of dental phobia (here defined as total avoidance of treatment) in adult populations of 16 yr or older in various countries was estimated to be from 5%271 to 7%286;581 in the US, from 4% to 10%825 in the Netherlands, 4%326 to 14%794 in Sweden and 9%482 in Finland. The Danish Adult Dental Health Investigation430 from 1985 showed that up to 15% of the Danish adult population did not go regularly to the dentist with the reasons that they were either afraid of the dentist or painful treatment. A Gallup study in 1983 reported that 10%766 of Danish adults totally avoided the dentist because of anxiety. Combined with such estimates of odontophobic total avoiders, other persons with a high degree of dental fear delayed dental visits, exhibited poor cooperation or didn’t show up for scheduled appointments in up to 50% of cases as reported by one US study.581 It was apparent beginning in the 1990s that exact estimates of odontophobia in populations was necessary605 in order to 1) mobilize a public health education and prevention effort, 2) re-emphasize behavioral science coursework for dentists, specifically addressing the problem, and 3) to determine what kinds of resources were necessary to tackle the problem. The use of the same clinical measures in epidemiological studies also made studies more comparable. In this dissertation, the epidemiological study (II) on prevalence, characteristics and consequences of dental anxiety in Denmark (1993) used telephone interview techniques to survey a representative sample of 645 Danish adults (16 yr or older). Participation rate was 87.6% (n=565) on a randomly selected sample where demographics, fear of specific procedures, experiences with negative dentist behavior, general fear tendency, treatment utilization and perceived oral conditions were explored by level of dental anxiety using the 4-item Dental Anxiety Scale (DAS).167;171 DAS scores range from 4 (no anxiety) to 20 (extreme anxiety), where 12 (II) or 13 509;514 has been used as standard of reference for epidemiological studies. Prevalence results indicated that 4.2% of the Danish adult population were odontophobic treatment avoiders, while another 6% were moderately anxious sporadic attenders and 29.5% were “a little” or “somewhat” afraid, but often attended dental care. The most recent estimates of dental anxiety in a major US population indicate that high dental anxiety (DAS > 13) in 1998 was 10%200 and in 2005 was 12.3% of dentate adults808 respectively. This is an indication that the prevalence of high dental anxiety reported in western civilizations has been relatively stable over the past 10-20 years.

Characteristics of extreme or phobic dental anxiety Characteristics of odontophobia for dentate subjects were analyzed in logistic regression analyses using odds ratios and confidence intervals. Odds ratios are the statistical likelihood that an event occurs that is greater or less than 1 (no effect). Results indicated highest associations with odontophobia as fear of drilling, negative dentist contacts and general fear tendency (Table 2), as well as avoidance of treatment (OR = 16.8) and increased oral symptoms (OR = 4.4) compared with low or no fear subjects (II). 26.

Moderate dental anxiety was also related to drilling (Table 2), but with fewer tendencies to avoid treatment than odontophobics (OR = 6.8) compared with low or no fear subjects (II). Differences in characteristics of those reporting moderate vs. extreme/phobic dental anxiety as shown in Table 2, illustrate the importance of the quality of dentist-patient interactions, which are also central to patient perceptions of pain and unpleasantness (e.g. dental drilling), according to other studies.91;92;513;611 Dentist-patient relations’ effects on pain and suffering will be described in Chapter 4. Table 2. Logistic regression analysis: relative strengths of characteristics by DAS fear intensity for Danish adult dentate subjects compared with “low or no anxiety” subjects (n = 487). Relative association of factors Relative association of factors for moderate dental anxiety: for extreme/phobic anxiety: OR: 95%CI: P: OR: 95%CI: P: Fear of drilling 22.3 6.4-77.5 .000 38.7 8.4-178.6 .000 Fear of tooth cleaning 9.5 1.8-51.1 .008 7.3 1.5-36.8 .016 Fear of injections 0.98 .2-4.2 .981 1.0 0.2-4.8 .991 Negative dentist 0.45 .02-13.2 .641 9.3 1.4-60.7 .020 General fear prone 0.96 .2-5.0 .959 3.4 0.8-14.4 .097 Gender (women) 0.94 .3-2.9 .919 4.2 0.7-24.7 .112 Low education 3.2 1.0-10.8 .058 2.5 0.6-10.4 .210 High income 0.06 .01-0.6 .013 1.8 0.4-9.4 .485 Age 2.1 0.6-7.1 .237 0.52 0.1-2.2 .381 Hosmer-Lemeshow statistics: Coding of dichotomous variables:

(C) = 2.59, P=0.958, 8 df.

(C) = 6.2, P=0.625, 8 df.

Fear of drilling, prophylaxis, injections: 0=little/none 1=very much/some; Negative dentist: 0=no 1=yes; General fear: 0=no 1=yes; Gender: 0=men 1=women; Education: 0=>7yr 1=40 yr 1=15 cutoff for differentiating moderate and extreme dental anxiety has also been 27.

confirmed in clinical observations, since both Swedish80;89 and Danish (VIII)604 dental anxiety specialty clinics consistently report mean DAS scores of around 17-18 over a 20 year period. Also, for the first time in a dental anxiety epidemiological study, consistency of scores in “same subject” analyses indicated that extreme anxiety was measured the same way on 78-95% of the subjects depending on the test match-ups (II). Other studies followed509;514 in which standards of epidemiological measurement of dental anxiety intensity were further developed and compare favorably with the Danish data. In addition, the study of the relationship of dental anxiety intensity to prevalence and identification of symptoms/characteristics, as compared with other US, Dutch and Nordic population studies of odontophobia, is useful in examining associations with age, gender, education, socioeconomic status, geographical location and dentulous-/edentulousness. Central findings are summarized below. Age: The average age of odontophobics has been reported from 3091 to 45482 in larger clinical studies. Dental anxiety has been shown to decrease significantly with age, especially after 50 yr in US, Norwegian and Dutch populations.581;644;825 However, a 1998 US study200 and the Danish epidemiological study (1993) for adults over 16 yr old showed no such dental anxiety association with age (II).598;599 But, in a more recent investigation (2001) of Danes aged 20-34 yr old that focused on predisposing, enabling and need factors effecting dental care attendance, Scheutz & Heidmann755 found that 29% of irregular dental care users had DAS scores between 12 and 20 compared with 16.3% of the whole sample (n=464). This was higher than for Danish adults over 16 yr (II) from the 1993 prevalence study. Scheutz & Heidemann called for a special effort to aid these anxious young individuals.755 Similar results were found in young Norwegians, especially for women.798;799 Gender: Distribution by gender indicates that women report high dental fear at least twice as often as men, according to many studies.200;285;320;581;644;762 Danish results (II) indicated that women were over four times as likely to have extreme dental anxiety as men. In general, other population studies117;133;186 have also shown that women report other phobias more often than do men. Socioeconomic status (SES)/Education: There is some confusion in the literature about the relationship between SES, education and dental anxiety. Three Swedish epidemiological studies over three decades have indicated that odontophobics are more often found among lower social classes and levels of education.320;326;478 However, one American population study581 and a Dutch825 study found no significant differences in the distribution of high dental fear by SES or levels of education. Present Danish epidemiological results (II) found adults with highest income to have significantly less DAS anxiety (P = 0.01), than the rest. Danish adults with lower levels of education showed significantly more anxiety (P = 0.03) than other subjects. A more recent US population study200 also found a relationship between dental anxiety and lower income or educational status. Inspite of a lack of consensus about SES and dental anxiety, it seems likely that educated persons have fewer economic barriers and perhaps more social responsibility that could provide greater motivation for them to deal with any dental anxiety.79;91;598 Dentate/non-dentate: Edentulous subjects showed neither more nor less anxiety about dental treatment than dentate persons in a Dutch population.827 However, Dutch edentulous persons differed considerably from dentate persons in distribution of dental anxiety.827 In general, denture wearers have been found to be nearly equally divided between those who are dentally anxious and those who are free from any dental anxiety when compared with dentate subjects, i.e. a bimodal distribution.326;827 Since edentulous persons seek dental care irregularly, they provide confounding for anxiety-avoidance studies and are often excluded in analyses.(II)200;808 The Danish epidemiological study of 1992-93 (II), with prevalence statistics that are similar to recent US population studies,200;808 also documented consequences of dental anxiety as a public health 28.

problem in Denmark. They are specifically compared with the dental literature below. More specific information about health consequences of odontophobia can facilitate planned changes in health care policy, as has been the case in neighboring Sweden, where odontophobia research has resulted in systematic support for treatment of documented dental anxiety.617;843

Manifestations and symptoms of anxiety - documenting a public health problem Odontophobia constitutes a public health problem not to be taken lightly, since long-term avoidance of dental treatment due to severe anxiety impacts on dental health and mental health for around 10% of Danish adult citizens. Many of them have avoided regular or any dental care often up to 15-20 years, even up to 40 years in some cases.605;611 Dental Health Many studies have shown that dental decay157;200;318;322;611;759 and periodontal disease200;318;322;326 are significantly greater for groups of high dental fear subjects than for groups with low dental fear in several countries. Complaints of dental problems, such as toothache, difficulty chewing and bleeding gums were also significantly greater with high dental fear in US,200;581 Danish (II)611 and Swedish318;321;322 studies. According to Danish epidemiological results (II), dentate adults with extreme dental anxiety were over four times more likely to report toothache within the last year, were nearly four times less satisfied with the appearance of their teeth and were more than 12 times more likely to perceive a need for dental treatment (not just teeth cleaning) than adults with lower fear levels in the same study. In a 1998 study of a major US city population,200 similar associations were found between high dental anxiety and self-rated oral health, oral health symptoms and dissatisfaction with dental appearance. These perceptions were also validated in clinical examinations of subjects.200 Dental health consequences of years of treatment avoidance for the 80 extremely anxious patients in the Danish clinical Ph.D. study598;611 was evident in high DMFT (Decayed, Missing and Filled Tooth surfaces) mean of 19.1 teeth out of 28 compared with the Danish adult normative mean of 17.7 (N = 2112).430 Mean number of decayed teeth of 9.1 per person was significantly greater than the Danish normative mean of 1.35 (N = 2112).430 Findings were strikingly similar to a subsequent Swedish322 and US studies200 which also pointed out that anxious patients presented with poor periodontal indices. Reports of actual destruction of the dentition in highly anxious subjects has varied considerably from patient to patient in clinical studies.157;322;611 In some studies, there were no significant DMFT correlations with DAS dental anxiety157;611 nor other psychometric scores.611 One explanation given was that there is a high degree of variation in DMFT in adult populations in general,157;322;611 depending on dental health values of the populations. But, hygiene habits among odontophobics are also known to vary considerably.326;611 While some odontophobics indicate that they fear brushing away fillings or tooth fragments, others are diligent in preventing further caries or periodontal disease in lieu of treatment.611 Mental Health There is a psychosomatic component to odontophobia, since a psychological problem becomes entwined with somatic problems described above, which in turn, creates other psychological problems as a consequence.85 Dental anxiety or phobia is a handicapping or disabling type of anxiety6 because these conditions impact on broader aspects of the person’s life. Normal functions that are interrupted by the mental disorder include lack of sleep, difficulty eating and work loss due to painful symptoms 29.

(II).85;87;581;611 Even when motivated to seek treatment, just calling on the telephone for a dental appointment has cost some odontophobics days of worry with symptoms such as vomiting, diarrhea or sleeplessness.580;611;764 There is evidence that general mental health and quality of life can be affected by phobic dental anxiety.85 Since many years of neglect may have affected the dental health and facial appearance of many odontophobics,91;326;769 many hide their teeth and mouth in their daily social routine (IX). Loss of significant others, including spouses have also been reported by odontophobics, which they have attributed to their dental neglect.598;611 Although rare, suicide attempts have also been reported among odontophobics as a direct result of self-disdain, primarily focused on poor dental appearance.611;769 Other evidence for compromised general mental health and quality of life of odontophobics can be reasonably inferred from many who successfully complete dental anxiety therapy, whose co-morbid psychological problems (usually general fearfulness and depressed mood) before starting therapy have shown significant improvement after therapy.87;610 It is often difficult to differentiate consequences or symptoms of phobic dental anxiety from causation. A good example is guilt, shame or embarrassment that occurs with odontophobia. Many odontophobic persons who have avoided dentists for many years due to anxiety, experience that they can no longer separate their anxiety from their embarrassment or shame as the cause for avoiding the dentist (IX). A case history illustrates this. Case history: 60 year old school teacher (“60 F”) who had avoided the dentist for 22 years due to dental anxiety had a very bad conscience about it. She meets us with a pale face and sweating brow. As she describes it, she has become the victim of embarrassment and shame that maintains her deep anxiety for going to the dentist for what she perceives are the worst teeth in the world, even though in our eyes, she has all of her front teeth intact. She is ashamed to show one side of her face to her students in classes for fear that they might discover her bad teeth. She openly admits that she has held herself in a vicious circle of fear and shame for over 20 years with a deep-seated feeling that she cannot stand the thought of a dentist scrutinizing her oral condition and the dreadful news that awaits her about her neglected teeth. During an exit interview, she tells of her feelings about her anxiety as she experienced it at the end of 9 months of weekly therapy and just before she would be starting up with a new dentist. RM = author; 60 F = patient RM: “I remember the first time that you sat there. It was good that you had your partner with you. It was very obvious that embarrassment was a large part of the problem… if not all of it.” 60 F: “It has been a question that I am left with. It is of course that I was so embarrassed that had over-shadowed so much of why I was afraid. But I also had an unbelievable amount of trouble just getting going to the dentist. I had been frightened as hell about it. It can also be that the embarrassment in the final analysis has been that which has been most difficult. You even referred to that after we had gotten (me) over the embarrassment.. and then comes the actual dental work. I hope that I haven’t ruined your statistics about pain, but if I say so, it has been the embarrassment that has occupied my mind the most.” RM: “A vicious circle? Is that your perception of it?” 60 F: “I believe so, now that we have talked so much and seen it in so many ways. Maybe in the final analysis it had been the most difficult just to make an appointment. I’ve talked about that many times.. that (for years) I had made an appointment with a dentist and even stood outside the clinic door. But then I went home again. I don’t know if it has been mostly embarrassment or being afraid of getting started. That I am not sure of. …Now I believe that after all the terrible things I had put myself through, it shouldn’t be any problem when I first have made a new dentist’s acquaintance.” RM: “Does that mean that all that (we have done to develop) your mental resources, with the shots and this and that (that you have learned here).. You can tackle those now?”

30.

60 F: “I believe so.” RM: “So what is it now that you fear most?” 60 F: “Now? That he is going to be looking at my teeth!”

Fig. 7. Vicious circle of dental anxiety - Berggren80 Fear, anxiety

The vicious circle described above is typical for psychiatric somatoform disorders, in that it reflects psychosomatic and psychosocial Feelings of guilt, shame components in dynamic interaction. As with the Avoidance of and inferiority 60 F case example described above, dental care odontophobics tend to overestimate the damage they feel they have caused their teeth through Deterioration neglect, since they are often extremely focused of dentition on the problem, embarrassed and feel guilty (IX).611 Thus, anxiety and avoidance of dental treatment often results in a perception of tooth destruction real or imagined that can profoundly affect a persons self-image and personal integrity, which in turn maintains this vicious circle of dental anxiety and treatment avoidance, and eventual dental destruction. This vicious circle was first described by Berggren80;91(See Fig. 7). Given these special psychosomatic and psychosocial phenomena and frequent occurrence of a vicious circle of fear, origins of odontophobia can often be difficult to tease out. Nevertheless, much is already known, as indicated in the following review of etiological factors associated with dental anxiety.

Etiological factors in odontophobia 1) Fear of negative, traumatic and/or painful experiences Patients with dental anxiety often complain about sensitivity to sounds598 and smells598;720 in the dental clinic. These are known conditioned responses to previous negative experiences at the dentist611;720 and often are symbolic of emotionally meaningful traumatic and/or painful experiences. There is usually at least one negative experience with the dentist for about 85% of extremely anxious subjects as reported in Denmark (II),611 Sweden91;320 and the US.581 These experiences occur mostly in childhood91;510;611;663 and are often painful, but can be other than pain as chief complaint.91;92;513;611 Bernstein et al.92 showed that most bad experiences originated from dentists’ behavior. Other studies concur.477;523;581;611 Although odontophobic patients attribute their anxiety most often to these negative experiences, the nature of the experience as both clinical procedures and social events require further discussion. Pain, trauma and anxiety as related to suffering are described more thoroughly in Chapter 4. 2) Feelings of lack of control, powerlessness and embarrassment Lack of control over personal emotional reactions421;424 and over the social situation in the dental chair168;170;192;281;611 is another factor in dental fear as was illustrated in the case history above. Feelings of powerlessness can be the result of the patient lying too far back in the chair,189;598 for example, or from dental personnel too busy to explain procedures172;283;584;588;611 before they happen or to give patients needed rest pauses.170;172;585;611 Patients have been shown to perceive less pain if they feel they have some influence and control in a treatment situation.584 Seeman & Molin769 also claimed that the amount of

31.

powerlessness perceived in the dental chair directly contributed to high dental anxiety, although presence of other psychiatric problems also contributed to these subjects’ dental phobia. In the Danish Ph.D.598 clinical studies, Moore, Brødsgaard & Birn611 found that feelings of powerlessness and embarrassment with the whole process of treatment were identified as the most frequent chief complaints, followed by fear of drilling, pain and “the needle” for the 208 odontophobics telephone interviewed. Of a clinical sample of 80 patients, 66% of odontophobic patients in the study611 suffered embarrassment about their dental fear problem and/or a feeling of inability to do anything about it. This embarrassment was manifest at the dentist in all cases and was also apparent in other social circumstances. It had affected established close relationships dramatically in six cases, due to the poor condition and appearance of the dentition. One woman reported attempting suicide after a separation, four men had lost spouses and a fifth man had been denied appearance at a brother’s wedding.611 Forty-four percent described symptoms of not being able to smile fully and 21% reported covering their teeth with either hand, lip or tongue during social interactions.611 Building on these Ph.D. findings, results of a more recent Danish study (IX) with interviews and observations of 30 odontophobics indicated strong correlations between number of years of treatment avoidance, intense embarrassment and severe mouth hiding behaviors (IX). This study is described in more detail in “Diagnostic categories” below. Berggren85 also found the majority of phobic patients at a Swedish specialist clinic85 to be socially inhibited. Especially long-term treatment avoiders reported widespread negative effects on social life, loneliness and social isolation. They suffered from more severe and obvious dental deterioration, and lacked social skills. Berggren85 compared odontophobics with other groups with chronic diseases and concluded that odontophobics were more frequently affected in situations involving relations with family, friends or work colleagues. 3) Social learning processes as etiological factors for dental anxiety There may be several levels at which we learn to react to dentists and treatment. In societal interactions, dentists are often cast in a negative light by relatives, friends, or work colleagues611 or even by the mass media.93;190 These processes of vicarious experience and information transmission772 create special negative expectations of the dentist's role91;439;889 through labeling effects439;732;753 and possible self-fulfilling prophecies574;807;904 that could predispose to dental anxiety.523 Shoben & Borland790 and a subsequent reevaluation of their study255 indicated for the first time that dental anxiety could be directly transmitted between parent and child. Shaw786 revealed that parents of fearful children were more frequently dentally anxious than parents in a control group. Shoben & Borland790 also found that the most frequently named origin of dental anxiety was vicarious learning, followed by traumatic experience. However, later studies91;611;670 have only implicated vicarious learning as a predisposing factor to dental fear. Thus, the literature prior to 1991 seemed inconclusive about whether it was a direct or indirect contributing factor in the formation and maintenance of dental fear. In 1991, Moore, Brødsgaard & Birn611 reported that 63% of their clinical sample of odontophobic patients had a history of family/close friends with dental fears, indicating possibilities for vicarious learning. However, when asked directly only two patients named vicarious experiences as the primary cause of their dental fear and avoidance. Thus, Moore et al.611 concluded that the influence of vicarious learning was rarely a direct cause of dental anxiety. Later, Swedish researchers also linked parental dental fear as predisposing to children’s fears in larger population studies.24;447

32.

The etiological study (III) of this dissertation aimed to explore broader levels of social learning about dentists and norms of dental treatment, namely those connected within specific sociocultural expectations and beliefs and how they impact on normative behavior or reactions related to anxiety and pain perceptions. In a cross-cultural clinical epidemiological study on dental anxiety and related pain perceptions (III) among adults attending dental school clinics (N =951), mandarin–speaking Chinese from Taipei, Taiwan (n=595) reported less use of dental anesthetics for routine dental treatment and were less afraid of injections than caucasian Americans from Iowa City, Iowa (n=395). Taiwanese and Americans with high dental anxiety (DAS > 12) had similar occurrences of high fear of injections. But inspite of similar fears about dental drilling, high anxiety Taiwanese reported using local anesthesia less frequently for routine treatments than did high anxiety Americans. Only Americans reported negative dentist behaviors as significantly related to dental anxiety. Avoidance of appointment-making was high for all subjects afraid of injections and for Americans reporting negative dentist behaviors. Avoidance was highest in subjects with high dental anxiety regardless of ethnicity. Thus, in study III, it was established that predominant characteristics or etiologies of dental anxiety could differ by ethnocultural background and dental health care system. These appear to be related to specific beliefs and/or expectations of patients within those systems, which are explored in other studies described in Chapter 4. Within the normative patterns of these implicit, yet powerful psychosocial influences, each patient also brings along his/her own specific set of experiences and expectations417 that have uniquely influenced their perceptions of dentists and/or dental procedures. For anxious individuals, these most often are negative beliefs and expectations. 4) Other psychological problems complicating dental anxiety An American epidemiological study of adults found that 22% of persons with moderate to severe dental fear also had two or more serious phobias,247 that complicated their dental anxiety. In the epidemiological study of Danish adults (II), subjects with extreme dental anxiety (DAS >15) were up to six times more likely to have high general fearfulness and to have had psychological treatment within the past 5 years. That translates to 25-40% having two or more other serious fears, dependent on whether DAS scores were > 12 or > 15 (II). Concomitant fear of physicians or hospitals among this group was 20-30%, again dependent on DAS anxiety level (II). The Danish Ph.D. clinical study by Moore, Brødsgaard & Birn611 indicated that up to 35% of odontophobic patients had other symptoms of psychological distress than just dental anxiety. A large Swedish specialist clinic study also indicated that nearly 49% of 160 adult dental anxiety patients had had psychiatric/psychological treatment at some time or other and patients were mostly referred by physicians or psychiatrists.91 As Schuurs et al.763 speculated, it might be a “question of whether dental anxiety in these persons is a consequence of the (person’s) other personality traits.” More recently, twin studies have suggested a genetic vulnerability to phobias for some,412 but this may be less relevant for specific phobias than for social anxiety and agoraphobias.413;414 Inspite of the literature indicating that odontophobia is co-morbid with other psychological problems in a minority of cases, “fear of dentists” are often consigned to the same category as specific blood or injection (BI) fears in psychological or psychiatric epidemiology.186;412;413 However, several studies using convenience samples191;437;440;689 have found these fears to be partially independent. One large Canadian population study515 showed that overall, only16% of dentally anxious subjects were BI fearful while 31.6% of those with high levels of BI fears were dentally anxious. From the dentist’s perspective, encounters with patients exhibiting symptoms of other types of mental disorders make treatment more difficult and may affect the average dentist's perception of dental anxiety. This could lead to generalized perceptions of anxious patients that might deny types of dental anxiety not necessarily 33.

associated with general psychological problems (II,VII). Several studies (VII)5;90;497;512;516;597;608;611 have encouraged the dental profession to differentiate between cognitive and conditioned anxieties, since odontophobics with general psychological complexes are reported to be resistant to therapeutic improvement.920 Studying diagnostic differences are important since they are helpful in predicting outcomes of intervention strategies.787 The following section covers chief complaints and other symptoms, manifestations, or possible causes that aid differential diagnosis of dental anxiety.

Diagnostic categories of dental anxiety Two diagnostic models of dental anxiety have evolved that shed light on differentiation of useful clinical categories. It is useful to distinguish between dental clinical models and psychiatric models because social and psychological aspects of dentist and patient variables have been shown to contribute to extreme dental anxiety. Just how much or how little they contribute to a diagnosis can have meaning for heuristics in dental fear research as well as choice and outcome of treatment strategies. The dental clinical model is more tailored for use by dental practitioners who wish to study and screen their patients’ anxiety. It is based on exploring a combination of chief complaints, symptoms and etiologies and adapting treatment to a specific dental anxiety diagnostic category for optimal dental clinic utility. The psychiatric model takes into account all of the patient’s chief complaints or symptoms. Using specific criteria, as formulated by the American Psychiatric Association16;17 or the World Health Organization,923 a psychiatric diagnosis can be deduced which includes a consideration of the degree of dysfunction caused by the mental disorder compared to other mental disorders. This assessment is helpful in mobilizing social and health care services relative to a patient’s level of dysfunction. The establishment of both types of diagnostic categories confirms that differentiation by diagnostic type is the main aim of a clinical evaluation process because this directs the logic of a treatment strategy. There is a paucity of literature as to goals and valid criteria for differentiating phobias by type, similar to the DSM-IV process. Sheehan & Sheehan (1983)787 described three test criteria for distinguishing categories of phobic disorders: 1) distinct uniqueness, 2) internal consistency and 3) distinct response to treatment type. In regard to this third criterion, the therapeutic utility of diagnostic categories in dental settings is of primary importance to dentists as shown in the following model. A dental clinical diagnostic model – “The Seattle System” Milgrom et al.584;585 (Dental Fears Research Clinic) proposed four diagnostic types categorized or screened according to main symptoms of dental anxiety called the “Seattle system” in this dissertation: Type I. Conditioned fear of pain or specific unpleasant stimuli (drills, needles, sounds, smells, etc.). Type II. Distrust of dental personnel; fear of belittlement (loss of self-esteem) and loss of control. Type III. Patients with complicating trait anxiety, multiple phobias or other psychological disorders. Type IV. Anxiety about catastrophic somatic reactions during treatment (allergic reactions, fainting, panic attacks, heart attacks, death). (Note: In previously published reports, Moore et al.598;605;611and Locker et al.511 used an older Seattle notation system in which labeling of types II and IV were reversed. In personal communication with Milgrom et al.,585 present descriptions fit how Seattle system authors prefer labels. This is a minor problem in that category descriptions themselves remain the same.)

The Danish Ph.D. studies598;599 validated the Seattle system and indicated that of the 80 Danish odontophobic patients, who were representative of a total of 208 patients at the clinic, 19% were 34.

primarily afraid of pain or unpleasant procedural experiences as chief complaint (Type I), notably dental drilling, injections or other instruments, significantly more than the rest of the sample combined (P = .044). These patients also had high numbers (67%) of vicarious learning sources (e.g., family, friends). The existence of multiple phobias, general anxiety complexes or agoraphobia complicated the picture of dental fear for 35% of the Danish patients, representing other distinct and internally consistent categories: Type III (28%) (multiple phobias or generalized anxiety) and Type IV (7%)(fear of catastrophic bodily reactions). Many subjects had fear of closed spaces or of injections, but in most cases these appeared functionally independent of the dental anxiety, offering no causal or predictive relationships.611 Less than half of these never had had any particular traumatic dental experience. Types III and IV are described as more resistant to successful dental anxiety treatment.584;598 Thirty-seven (46%) expressed distrust of the dentist in the dental situation (Type II). Differentiation of categories were also aided by the use of the Dental Beliefs Survey (DBS)584;585;816 in which high DBS scores reflected negative, distrusting beliefs about dentists and inability to confront the consequences of long term dental avoidance.611 This evidence supported Berggren's contention that embarrassment, shame or guilt is the catalyst for maintenance of the vicious circle of dental anxiety.80;91 It also indicated that it could possibly be a special problem of its own for many odontophobics, since many described resulting personality changes. Other patients also expressed embarrassment or distrust of the dentist to some degree, but these were secondary to chief complaints of pain, specific instrumental procedures and/or general anxiety or multiple fear characteristics. It appeared from the data611 that the way the dental anxiety was acquired was crucial to a differential diagnosis of Type II subtypes. Type II.1 (12%) was adult distrust originally fostered by pain conditioning in childhood and always with some kind of vicarious reinforcement, with low scores on trait anxiety and “other fears”.611 Persons with Type II.2 (15%) expressed no specific anxiety for pain or fear of instruments, nor were generally anxious, and the stimulus was genuine, unique and clearly the dentist role, according to their interview results and DBS scores.611 Some with Type II.2 exhibited psychiatric criteria for social anxiety disorder. Type II.3 was distrust reinforced by trait anxiety or general fearfulness (19%).611 Reinforcing critical relationships in differential diagnoses, Roy-Byrne, Milgrom et al.747 later validated the Seattle Fig. system on a clinical Fig. 88 sample of 73 extremely anxious Desensitization: Desensitization: Cognitive Cognitive therapy: therapy: patients in Seattle. ((Relaxation ((Cognitive Relaxation ++ exposure exposure)) Cognitive restructuring restructuring)) Fear of specific u u Type Type II -- painful painfulstimuli stimuli u u Type Type II. II.33 -- trait trait anxiety anxiety distrust distrust stimuli Type I was found in 29% of u u Type Type II II.1.1 –– distrust distrust (pain) (pain)u u Type Type III III––general generalanxiety/ anxiety/ fears fears cases, distrust on u u Type Type II. II.22 ––distrust distrust u Type IV – fear of panic, fainting 28%, generalized /social /socialanxiety anxietyu Type IV – fear of panic, fainting fear/anxiety on 29% Best done by: and fear of Dentist Psychotherapist catastrophic physical reactions was found on 14%. Distributions of the categories between Seattle and Århus would have been similar if Type II.1 Danish patients had been classified Type I, as would be the case when thinking of a phobia as a specific phobia according to psychiatric diagnostic criteria. Guidelines for selection of treatment strategy

Main Main treatment treatment re. re. Seattle Seattle screening screening

35.

according to the Seattle diagnostic system584;585indicate that treatment would be the same, that is primarily desensitization strategies, for Types I, II.1 and II.2 (see Fig. 8). The Danish sample (N= 208) indicated that powerless feelings were what they feared most – the dominant chief complaint.611 The most frequent chief complaint of patients in the Seattle study747 was pain (34%). Unpleasant stimuli such as drilling, noise (12%) and needles (6%), feelings of a lack of control (19%) and embarrassment (15%)747 had different distributions compared to Århus data.611 These differences may be attributable to differences in American and Danish cultural attitudes about what is embarrassing, what hurts, thoughts about injections or differences in clinical practice or attitudes towards dentists (I, III, V). Locker et al.511 provided the only population-based study to assess the validity of the Seattle system for diagnosing dentally anxious individuals. Subjects were 1420 randomly selected adults aged 18 years and over who responded to questionnaires which used measures of dental anxiety and standardized measures of general anxiety and fearfulness. Overall, 16.8% of the sample had dental anxiety (DAS > 12) and distribution across the four Seattle types was: fear of pain or unpleasantness 49.6%; distrust of dentists 9.9%; generalized anxiety 19.4% and fear of bodily catastrophe 7.8%. The remaining 13.3% could not be categorized, which Locker interpreted as borderline cases, mostly related to fear of pain. Scores on measures of anxiety and fearfulness indicated that the diagnostic system was valid and identified sub-groups of dentally anxious persons which were internally consistent. Locker et al.511 also observed differences in distribution of diagnoses according to age. Younger subjects were more likely categorized as Type I, while older subjects were more likely categorized as Type III. It was concluded that dental anxiety is a complex fear with a number of components, requiring varying therapy. The three Seattle screening system validation studies, one from Seattle, USA,581 one from Ontario, Canada511 and one from Århus, Denmark,611 all concluded the system was helpful in placing patients and designing therapeutic strategies, but all had different distributions by type. This is to be expected because 1) dental anxiety intensity cutoffs were different in the studies, 2) two were clinical studies and 3) norms for categorizing anxiety and fearfulness may vary from country to country.235;236 However, the advantages of using the Seattle system were pointed out, including triage of cases by categories so that logical treatment choice and monitoring of outcomes by category was possible. Figure 8 provides guidelines for dental anxiety treatment strategies and main caregiver responsibility using the diagnostic and treatment matching strategy originally described by Milgrom et al.584;585 A psychiatric model – Diagnostic and Statistical Manual of Mental Disorders (DSM) The goals, usefulness and comprehensiveness of a psychiatric model of odontophobia differ from those of the dental model described above. Unlike the non-criteria based classifications described above, a psychiatric diagnosis has a more comprehensive purpose and takes more into account the degree of dysfunction caused by the mental disorder compared to other mental disorders that occur in a society. This approach aids in prioritizing and mobilizing a healthcare and social system response. The following section is a background and historical developmental perspective of psychiatric evaluation of odontophobia leading up to a description of the need for doctoral dissertation study IX. In the 1970’s phobic dental anxiety was evaluated without using any special systematic psychiatric criteria. Seeman & Molin769 (1976) were the first investigators to try to document categories of extreme dental anxiety using psychiatric descriptions. They classified them as manifestations of I. problems with body image (shame), II. other neurotic disturbances, III. Borderline schizophrenia or schizoid process, IV. no overt psychiatric disorder and V. experiences of confinement or helplessness in 36.

the dental chair and negative relationships with the dentist.588 No standardized psychometric instruments were used and all analyses were based on one-hour interviews with 19 Swedish odontophobic subjects. A psychiatric evaluation ascertained that 10 subjects had suffered with depression and 7 had undergone psychiatric treatment at some time in their lives, while 3 were regarded as borderline schizophrenics. Authors clearly stated that the categories were only meant as a research starting point and emphasized that the main association was that subjects with poor body image also suffered from fear of confinement and helplessness. The most disturbing experience for these patients was feeling the “need to protect themselves from bodily exposure to another person, in particular an assaulting person.”769 Another Swedish study by Bjercke et al. in 197798 interviewed and assessed 22 patients referred for specialist treatment for dental phobia. A high proportion of patients (12 out of 22) had had previous psychiatric treatment and 14 provided subjective data about a discordant childhood. Twelve had feelings of inferiority based on their inability to go to a dentist and therefore avoided other people in general. The study indicated that dental phobia was a complex psychiatric syndrome and was puzzling in that it was more intensely experienced by patients than expected. It also demonstrated the need for complete diagnostic information in planning therapeutic interventions. Since 1952 the American Psychiatric Association has continuously been developing diagnostic guidelines for mental disorders that can aid in differential diagnosis, the most recent being from 1994, the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV).16;17 The DSM-IV was developed in a limited cooperation with the development of the International Classification of Diseases and Related Health Problems (ICD-10) published by the World Health Organization.923 The DSM-IV was built on a multiaxial system, that is, assessment based on several axes, each of which refers to a different domain of information that may help clinicians plan treatment and predict outcome. These are: Axis I: Clinical Disorders (e.g. anxiety, mood, somatoform, eating, sleeping, or sexual disorders); Axis II: Personality Disorders (e.g. Paranoid, Schizoid, Avoidant or Dependent) and Mental Retardation; Axis III: General Medical Conditions affecting mental disorders (e.g. organic nervous or circulatory); Axis IV: Psychosocial and Environmental Problems affecting mental disorders (e.g. abuse, illiteracy); and Axis V: Global Assessment of Functioning (GAF), using a GAF Scale as a single measure to track clinical progress of individuals in global terms (from “superior = 100” to “danger to self or others = 1”). Criteria from the DSM-IV relevant to odontophobia as Axis I clinical disorders are briefly described below as background for article IX. In the DSM manual,16;17 the criterion for a “principal diagnosis” in an outpatient setting is that it must be the primary reason for seeking treatment as related to a chief complaint and need for treatment16;17(pg.3). Even if presenting with complicating symptoms from another potentially serious category in the DSM hierarchy which requires additional treatment, it is can be surmised from DSM logic that categories of dental anxiety can comprise principal diagnoses608 for patients seeking treatment at a dental anxiety specialty outpatient clinic. For example, specific phobia related to dentistry could be complicated by periods of mood swings. Unless the patient was under psychiatric care for the mood swings at the time of seeking anxiety treatment, the principal diagnosis would be a specific phobia. However, the mood swings are important information that affect therapeutic choice. The DSM-IV16;17 designates anxiety disorders, including phobias, as Axis I clinical disorders, that is, anxiety not attributable to personality disorders or mental retardation (Axis II). Phobic persons regardless of type must recognize their fear to be excessive or unreasonable. The anxiety disorders hierarchy is described as: Panic Disorder with Agoraphobia - fear and avoidance of being in places or situations, e.g. outside the home alone (bus, train, car or crowd) from which escape or help might be 37.

embarrassing or complicated in the event of a panic attack (or if Agoraphobia Without Panic, some other embarrassing symptom). If not panic or agoraphobia, then: Social Phobia is persistent fear and avoidance of embarrassment or humiliation in social situations that interferes with normal routines or relationships. If not social phobia, then: Specific Phobia is a persistent fear in which an object or situation (e.g. dental drill or elevators) is avoided or endured with intense anxiety and interferes with normal routines. If none of these, then Generalized Anxiety Disorder (or GAD) is excessive anxiety and worry, occurring more days than not (> 6 mo), about events or activities which the person finds difficult to control and with at least 3 of the following 6 symptoms: 1) restlessness, (2) easy fatigue, (3) difficulty in concentrating or mind going blank, (4) irritability, (5) muscle tension or (6) sleep disturbance. Existence of multiple phobias is often also associated with generalized anxiety symptoms. Posttraumatic Stress Disorder is when a person experiences or witnesses event(s) of actual or threatened death or loss of physical integrity which is relived for months afterwards by either recurrent, intrusive memories, dreams, or feelings that the incident is reoccurring by associations or exposure to something similar. Dental patients could also exhibit Axis I Mood Disorders or Somatoform Disorders among others, as described by DSM, often accompanied by anxiety and vice versa. Relevant principal diagnoses of Mood Disorders include: Major Depressive Disorder with at least 2 weeks' duration, or Dysthymic Disorder with chronic (> 2 yr) duration of depressed mood more days than not, or Cyclothymic Disorder characterized by chronic mood swings, with symptoms of preoccupation with death or suicide, insomnia, fatigue, excessive weight loss, social withdrawal, guilt, expressed pessimism, or excessive crying. Or in a minority of mood disorders there are manic types with elevated, expansive or irritable mood of at least 1-week duration with marked social impairment or hospitalization. Bipolar Disorders are periodic combinations of mania and depression. DSM-IV Somatoform Disorders are recurrent and multiple chronic somatic complaints, where no physical disorder can be found with medical examination. Major diagnostic subtypes of DSM-IV Somatoform Disorders include: Somatization Disorder (psychogenic polysymptomatic complaints of pain, GI and neurological symptoms), Undifferentiated Somatoform Disorder (unexplained physical complaints for 6 mos. or more), Conversion Disorder (suspected psychological cause of sensory or motor deficits), Pain Disorder (psychological precursors to onset, severity, exacerbation or maintenance of pain), Hypochrondriasis (fear of having or ideating serious disease), Body Dysmorphic Disorder (unreasonable body image problems) and Somatoform Disorder Not Otherwise Specified. Psychiatric assessment of patients with phobic dental anxiety using DSM criteria Danish interview and psychometric data were re-analyzed by Moore et al.611 for differential diagnosis of dental anxiety from a psychiatric perspective in a second study608 and three main types were found: specific phobias (pain, drilling, injections etc.), social anxiety or phobia, and general psychological complications, such as multiple phobias and agoraphobia with or without general anxiety symptoms. The latter were also differentiated by higher GFS (Geer Fear Scale - a short form of FSS-II) general fear scores and State Trait Anxiety Inventory-Trait subscale (STAI-T) compared to others.608 Symptoms of GAD, although not always fulfilling all DSM-IV criteria, were present in 30 of the 80 patients, who also had higher STAI-T and GFS scores and lower MACL (Mood Adjective Checklist) scores than nonGAD patients.608 None of the patients presented with mood or somatoform disorders that fulfilled all DSM criteria, when such data was available, but data gathered was insufficient for validation. Roy-Byrne, Milgrom et al.747 after extensive psychiatric evaluations of 73 subjects with extreme dental anxiety, concluded that about 60% of dental phobias were simple or specific phobias according 38.

to DSM (III-R) criteria. They pointed out that the other 40% presented co-morbidity with other types of Axis I disorders, mainly anxiety (20%) and mood disorders (16%) and 35% had more than one Axis II personality disorder. Only one patient reported an unstable childhood. Roy-Byrne et al.747 concluded that concurrent Axis I diagnoses other than simple phobias were more useful in identifying a subgroup of more distressed and dysfunctional subjects with dental phobia and that identification of these specific Axis I disorders could allow for treatment plans that took those disorders into account. Roy-Byrne et al.747 continued, “The chief dental complaint related to subjects’ dental phobia suggested disparate concerns on the part of these phobic subjects, with a focus on 1) fear of pain or injury, 2) interpersonal discomfort with dentists (loss of control/embarrassment), and 3) fear of a panic reaction, or phobias related to different dental stimuli. Although these three broad categories might be relevant for mode of acquisition of dental fear, the overall levels of disability, distress and psychiatric history associated with them were not different.” If findings of co-morbidity are taken into account as an additional category, these chief dental complaints correspond to broad categories described by Moore and colleagues.608;611 Only the relative frequency distributions between categories appear to differ in the two clinical populations. Roy-Byrne et al. did not study effects of diagnostic differences on treatment outcome.747 Another study by Kvale et al.464 used Structured Clinical Interview for DSM-IV Axis I (SCIDI)817 and psychometric tests to render psychiatric diagnoses for a similar clinical sample at a dental anxiety specialist treatment center in Norway. They found that nearly half of 70 patients fulfilled DSMIV criteria for Specific Phobia, while about one-third did not fulfill criteria for any DSM-IV diagnosis. The remaining 19% fulfilled criteria for multiple DSM-IV diagnoses. Patients with specific phobia required significantly more treatment sessions than those with no psychiatric diagnosis. Patients with multiple DSM-IV diagnoses reported significantly more severe anxiety at all treatment steps, including one-year follow-up, compared to patients with no diagnosis. The results confirmed previous findings regarding difficulty in successfully treating patients with multiple phobia or trait anxiety complexes in two similar dental anxiety specialist centers.90;597;603 But more importantly, this was the first prospective study to reveal differences in treatment outcome specifically by psychiatric diagnoses. The studies described above leave questions regarding the role of social conditioning in the formation of odontophobia. For example, social anxiety was seen as a preexisting co-morbid or multiphobic condition in Kvale et al.817 and Roy-Byrne et al.747 studies. It was seen as a relevant clinical possibility and principal diagnosis related specifically to dentist-patient social situations in studies by Moore and colleagues.608;611 Dental anxiety patients who are interviewed solely with some versions of the SCID are questioned for social phobia with formulations that do not pertain directly to dental treatment situations or presentation of dental appearance, e.g. ”Is there anything that you were ever afraid to do or felt uncomfortable doing in front of other people, like speaking, eating, writing, using a public toilet?” etc. It does not cover a specific fear and avoidance of negative scrutiny by a dental professional when the person has to exhibit embarrassing results of years of dental neglect due to treatment avoidance. In questioning for fear of blushing, fear of being watched while eating or writing and fear of public performance or toilets etc. in SCID interviews, the focus is to collect data about existence of multiple symptoms, which is most often associated with a more severe and generalized type of social phobia, that can border on Axis II Avoidant Personality Disorder (ADP). However, more specific types of social anxiety disorders or phobias have been described in the psychological literature.532;703;868;869;938 Turner et al.,868;869 Rapee and Heimberg703 and Weinshenker et al.891 differentiated ”specific” or “circumscribed” social phobia (SSP) from a more “generalized” social phobia (GSP), which is explicitly emphasized in the DSM-IV. GSP is more often accompanied by other Axis I or II co-morbidity (depression, substance abuse, personality disorders etc.) and greater dysfunction, is more familial or genetic, has earlier 39.

childhood onset and requires longer treatment duration than does SSP.363;396 Specific social phobias are also more often related to specific traumatic experiences or social conditioning and have panic-like symptoms more similar to specific phobia than does GSP or ADP.363;396 SSP especially appears to respond well to short-term cognitive-behavioral Fig. 9. A feeling like everyone is looking therapy.328;345;396;740 Consensus is that GSP and SSP are classified together in the DSM-IV, since the major common denominator for both of these subtypes is fear of negative social evaluation.50;396;703 Gabbard280 and Zerbe938 added that shame, grief and unresolved loss, but especially shame, is considered an important underlying dynamic in many cases of social anxiety disorder. Zerbe938 wrote “Patients with social anxiety disorder who struggle with underlying shame are terrified that others will come to know who they really are and they will be found sorely lacking.” Weinshenker et al.891 also concluded the word “specific” for social phobia has not been addressed adequately for a variety of situations in which it may occur and that classic situations that are named in SCID and DSM limit response categories for other possible circumscribed situations, where there is fear of negative social scrutiny. Dentist-patient interactions appear to be one of these (Fig. 9). Socially conditioned odontophobia: fear of dentist behaviors vs. fear of negative social evaluation Understanding the role that social conditioning plays, it’s nature and magnitude in the formation of phobic dental anxiety, is an important research goal. It is very pertinent to the profession of dentistry, since the consequences of dentists’ behaviors on patient anxiety has been shown to be predictive, if not causal in most cases of odontophobia.79;598 However, nuances of anxiety reactions of these patients in response to dentist behavior have scarcely been explored. As illustrated in the case study of 60 F above, embarrassment is reported to be a part of phobic dental anxiety phenomena. But it is unclear whether the intense embarrassment reported by many odontophobics is a consequence and symptom of another primary cause of a dental phobia such as pain or fear of threat or whether embarrassment and feelings of inferiority can also be the primary odontophobic problem for some persons. In dissertation study IX, the theoretical discussions above regarding social anxiety and fear of scrutiny were explored using qualitative methods. The aim was to describe details of social aspects of anxiety in dental situations, especially focusing on embarrassment phenomena, since they are named, yet rarely described in the literature as a factor in extreme dental anxiety or phobia. But there can even be confusion about terminology since the words embarrassment, shame and guilt are used interchangeably in daily conversations. Embarrassment and shame are associated with personal response to public scrutiny about moral conventions or loss of self-esteem, while guilt (“bad” or “guilty conscience”) is thought of as self-scrutiny with a breach of personal standards.220 When it is referred to as a specific emotion, embarrassment is described as more fleeting in duration and has less serious consequences220 than shame. However, embarrassment is also used as a more general term,356 like emotional reaction (shame or guilt) to unintended and/or unwanted social predicaments or transgressions.356 In this dissertation, embarrassment is used as the latter, unless otherwise specified.

40.

Subjects were consecutive Dental Phobia Research and Treatment Center (FoBCeT) specialist clinic patients, 16 men, 14 women, 20-65 yr, who avoided treatment mean 12.7 yr due to anxiety (IX). Electronic patient records and Fig 10. Consensus: Clinical features of social anxiety disorder50 transcribed initial assessment and Anxiety in social interactions or performance situations exit interviews were analyzed using Unique perceptions of negative evaluation by others qualitative software (QSR"N4"). Blushing, palpitations, sweating, tachycardia trembling in these situations The interview process was similar to Onset in childhood or adolescence stepwise SCID "diagnosis by Impairment usually leads to avoidance of these social and elimination” logic, but it was also performance situations based on guidelines of a consensus report about social anxiety disorder 49;50 or phobia (See Fig. 10.) Qualitative findings about social aspects of dental anxiety and embarrassment phenomena were co-validated in tests of association with embarrassment intensity ratings, years of treatment avoidance, and mouth-hiding behavioral ratings. Findings from these interview data and clinical observations indicated that chief complaints and reasons for treatment seeking were 1) fear of pain (30%), 2) powerlessness related to dental social situations (47%), some specific to embarrassment and 3) difficulty with dental situations due to co-morbid psychosocial dysfunction from sexual abuse, general anxiety, gagging, fainting or panic attacks (23%). Embarrassment was a complaint in all but three cases. But intense embarrassment was manifested in nearly one third of cases in both clinical and non-clinical situations due to poor dental status or perceived neglect, with accompanying descriptions resembling criteria for social anxiety disorder (IX). These nine cases were qualitatively different from other cases with chief complaints of social powerlessness associated with conditioned distrust of dentists and negative behaviors. Secrecy, taboo thinking, and mouth hiding were associated with intense embarrassment. The majority of embarrassed Ss to some degree inhibited smiling/laughing by hiding with lips, hands or changed head position. Especially after many years of avoidance, embarrassment phenomena had led to feelings of selfpunishment, poor self-image/esteem and in some cases personality changes in the previously described vicious circle of anxiety and avoidance. Thus, embarrass-ment intensity ratings were positively correlated with years of avoidance and degree of mouth-hiding behaviors. Although some of these symptoms likely co-varied with mood, as was found in the Ph.D. studies598 on similar samples, no complaints of depression were reported. Furthermore, recent research found that social anxiety symptoms account for significant variance in disability above and beyond that accounted for by depressive symptoms when depression is present.327 The overall relationship of mood to social anxiety disorder related to odontophobia will be explored in future research. It was concluded from study IX that complexities of dental anxiety related to embarrassment or fear of social evaluation deserve clinical attention, since in many cases, it was a clinically meaningful part of a complicated picture of suffering for these dental phobic patients that amplified their anxiety and treatment avoidance patterns. Embarrassment varied by perceived intensity and complaint characteristics. Some cases exhibited manifestations similar to DSM psychiatric criteria for social anxiety disorder as chief complaint, while most manifested embarrassment as a side effect. Thus the existence of what appears to be a ”specific social anxiety disorder” related to the dental treatment situation as well as a specifically dentist behavior conditioned dental phobia was documented in study IX. It was also important to note that many subjects exhibited learned distrust of dentist behaviors, rather than fear of scrutiny of their teeth and negative social evaluation as the primary clinical problem. Liddell & Gosse494 noted this distinction between conditioned social distrust at the dentist vs. fears of negative dentist evaluation and criticism in a sample of graduate students with dental fear. They referred to earlier Danish 41.

studies by Moore & Brødsgaard608;611 who perhaps used DSM criteria too liberally in assessments of social phobia. These studies did, however, indicate that some degree of social anxiety complexity was present for many odontophobic individuals, making social functioning difficult in treatment and/or other social situations. Present qualitative results (IX) on similar Danish samples now allow contrast regarding conditioned distrust vs. dysfunctional embarrassment distinction that was not distinguished in earlier Danish studies. Conditioned distrust of dentist behavior appears to relate to DSM criteria of specific situational phobia, which are persistent fear in which an object or situation is avoided or endured with intense anxiety and significantly interferes with normal routines or relationships. This distinction is relevant to choice of therapeutic strategy since specific phobias require primarily desensitization schedules for fear reduction, while social anxiety related dental anxiety would require more cognitive psychotherapy with reframing of social interaction contexts, which would then be followed by desensitization of clinical procedures, such as injections or drilling. Further research will also be required to determine actual estimates of distribution frequency in odontophobic populations. Results of the 1977 Swedish psychiatric study described earlier98 indicated that dental phobia was puzzling since it was more intensely experienced by patients than one would expect of other phobic patients. Regarding intensity with which patients can experience dental anxiety, the strategy for therapeutic management of odontophobic patients has changed substantially at the FoBCeT Dental Phobia Research and Treatment Center over the course of its 19-year existence. Much as Sheehan & Sheehan787 have described that outcomes of treatment can reveal accuracy of diagnoses in retrospect, results over time at the Center have shown that improved efficacy of cognitive behavioral therapy often was linked to a two phase course of treatment, dependent on diagnosis of intensity of embarrassment, shame or guilt presented by the client. The first treatment phase was cognitive restructuring of social interactions with clients, where embarrassment, shame or guilt was the primary focus. Desensitizations were confined to the therapist-dentist as “object” (interpersonal distances and stepwise mouth exam sequence), if necessary. This “turned down the phobic amplifier” so to speak, making it easier for clients to focus on the second phase, which was desensitization to dental instruments and procedures. This clinical account illustrates how initial diagnosis of psychiatric/ psychological status – embarrassment in this case – aids in client-centered treatment strategies. Thus, awareness about embarrassment complexes is important to optimal therapeutic outcomes for dental anxiety and reveals the need for further research of such clinical phenomena. If we assume that accurate diagnoses of dysfunctional dental anxiety will optimize the possibilities of the health care system to treat and prevent it, then we should ask how either or both of the dental anxiety models described above can be beneficial towards that end. Perhaps it is best to see each subject as an individual case (IX)608;611 that varies in terms of the amount of social dysfunction caused by the mental disorder. The dental clinical model perhaps provides the best possible clinical understanding of the problem for dentists, making it easier to devise appropriate treatment in cooperation with a psychologist or psychiatrist. However, in terms of the psychiatric epidemiology of this prevalent health and social problem and the need to understand the plight of these patients, these disorders have socially dysfunctional consequences that are perhaps not immediately apparent to dentists or others. In order for social and health care systems to facilitate solutions to this problem, qualified mental health professionals armed with the most up-to-date information should also evaluate these patients and render a diagnosis. This could provide the patient with a legitimizing opportunity to seek optimal social, psychological and dental health care that has eluded them in all their years of treatment avoidance due to phobic anxiety. These patients namely meet resistance often times within social and health care systems, since they have 42.

a problem that is wrongly perceived as “self-inflicted”. Fee schedules for working with anxious dental patients should be reconsidered, since the current system of fee-for-service tends to stress dentists’ clinical economies, given the extra time required for treatment. In summary, there is evidence that dentist-patient relationship variables have considerable impact on differential screening or diagnostic categories. Both models of assessing severe dental anxiety presented are useful in different ways, in supporting screening, diagnosis, treatment planning and prevention of extreme dental anxiety or phobia. The dental clinical model is best suited for bringing the focus and involvement of dental practitioners to bear on the problem, which often relates to dentist behaviors and thinking, as described in Chapter 5. The dental model also provides a common language that is less precise, but somewhat conceptually related to the psychiatric model. The criterion-based psychiatric model is more rigorous and necessary for the purpose of comparison with other psychiatric disorders in a society so that the amount of resultant social dysfunction or disability can be assessed and appropriate treatment and social or public health care policies can be invoked.

Chapter 4. Clinical pain, psychosocial perspectives and relation to anxiety As can be seen by the ways in which dental anxiety has been categorized, clinical pain is not the usual chief complaint of extremely anxious or phobic dental patients. Although fear of pain associated with different aspects of treatment is important to many dental phobics, it is important to know the contexts within which both pain and anxiety are encountered and thereby possibly provide meaning to one another. The following terminology and contexts are relevant to describing pain in relation to anxiety.

Defining pain Pain has been defined by the International Association for the Study of Pain (IASP) as: "An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage. Note: Pain is always subjective. Each individual learns the application of the word through experiences related to injury in early life. Biologists recognize that those stimuli which cause pain are liable to damage tissue. Accordingly, pain is that experience which we associate with actual or potential tissue damage. It is unquestionably a sensation in a part or parts of the body, but it is also always unpleasant and therefore also an emotional experience. …There is no way to distinguish their experience from that due to tissue damage if we take the subjective report. If they regard their experience as pain caused by tissue damage, it should be accepted as pain. This definition avoids tying pain to the stimulus. Activity induced in the nociceptor and nociceptive pathways by a noxious stimulus is not pain, which is always a psychological state, even though we may well appreciate that pain most often has proximate physical cause.."370 Thus, pain is a psychosocial contextual phenomenon, not just a physical sensation. This means that there are perhaps also social ways to define pain. Or perhaps a better word to use here is “describe” pains, since defining implies limitation. Either way, the meaning of pain in social context is a topic that underlies the entire thesis of this dissertation. It is true that individuals in the course of their daily lives happen to experience painful sensations and learn conditioned responses to them – pain reactions. But these experiences are not devoid of social influences in the form of beliefs and learned expectations that a person has grown up with in the context of family and ethnic background that create an emotional meaning for the pain. That is, pain reactions must be seen in the social context within which they occur in order to fully understand them.

43.

Emotional meanings of pain - social frameworks for individual pain experience Certain emotional states may make pain more tolerable or even extinguished in certain situations, while other situations make it worse. The influence of affect and meaning on the amount of pain reported has long been noted as weighing heavily on the perception of pain.69;70;210;211 In everyday experiences we may note that a child running with joy or excitement does not notice a badly scuffed knee, yet will cry out with pain during a skin scratch test in the doctor's office. Sometimes children seek to have more control over parents, siblings or other peers, by exaggerating or facilitating pains. Having a headache at an appropriate time can become a maneuver to avoid an unpleasant social situation. To gain advantages in football or soccer, where a penalty or free kick could determine the outcome of a heated game, players can also facilitate pain reactions. On the other hand, a football player may also not realize he had an injury during a close game, until after the game. These types of phenomena were first documented by army physician Dr. Henry Beecher69 whose observations of wounded soldiers after the battle at Anzio Beach in World War II indicated that pain expressions, reactions to injury and use of pain medications were less than those of noncombatant surgical patients with similar injuries. The soldiers knew that they would be removed from battle and thus would survive, changing the meaning of their pain. Beecher69 proposed to define pain not only as a sensory experience in response to injury, but also as an emotional experience where meaning is given to pain according to its social context.69;70 Of course there are also emotional and social aspects of pain in dentistry. Pain or fear of pain is a phenomenon that must be dealt with in almost every phase of dentistry. Dental personnel may notice that some patients react in pain to drilling when the drilling has only been confined to superficial enamel surfaces of the teeth, that is, little possibility for physiological dental pain. The personnel should register these events not just as troublesome or unrealistic, but rather as messages about a patient’s psychosocial background. The message might be that the patient feels a need to communicate, perhaps only to ask for more anesthetic or just to talk about the procedure and allay nervousness or fear that may be changing their pain threshold. The pain is real to patients and they need to have some influence over it. In acute pain situations, regardless of whether fear of pain is actually based directly on painful past experiences or only on the expectation of pain, pharmacological agents can usually be successfully employed to control both physiological pain sensations and unpleasant psychological perceptions. But the fear of pain must be worked with for lasting change using psychological or social means. The important distinction here is that anxiety or fear of pain may be persistent even after drug effects wear off after treatment in an acute or emergency episode. In other words, in the long run it is better to help the patient to change underlying thoughts and beliefs that drive fear of pain or anxiety with the purpose of forming new health care attitudes and behavioral habits that maximize oral health and psychological coping. If pain is expected, then it is reasonable to assume that this expectation has been learned, regardless of whether or not the pain is actually experienced. Expectations and beliefs are similar to suggestions in many ways,316;317;814 as briefly touched on in Chapter 2. According to Melzack & Wall, authors of the "Gate Control Theory",570 expectations and beliefs about pain are learned in larger culturally defined social contexts (e.g. familial, ethnic), while others are shaped by individual experience (e.g. trauma, emotional factors, degree of attention). From the discussion above about emotional meaning and social ways to define pains, it seems that the smallest "unit" of pain analysis is “personal experiences within a framework of normative beliefs and social expectations about any particular pain phenomenon”. With the coming of the Gate Control Theory570 pain as a purely physical sensation could no longer serve as the only pain research construct. 44.

Several researchers took Beecher’s findings a step further in search of pain context differences and how this might influence medical treatment. In 1952, Zborowski937 reported that among a hospital sample of Italians, Jews, Irish and Old Americans that the Irish were deniers and Americans belittlers of pain; but the Italians were non-optimistic expressers of pain, while the Jews were optimistic expressers. He concluded that behavioral response patterns to pains have different functions in various cultures and that pain coping modes adhere to these contexts. Until 1986, most other empirical cross-cultural studies had largely confirmed Zborowski's68;449;502 pain reaction findings on Irish, Italians, and AngloAmericans. One exception was a quasi-experimental study of dental pain and anxiety among African American, Caucasian American and Puerto Rican ethnic groups. Weisenberg, et al.896 were first to explore possible contextual differences in dental anxiety and pain. They used an eight item questionnaire developed by Zola940 to measure attitudes toward pain by denial of pain or willingness to deal with pain. However, the Zola questionnaire had been developed for Italian, Irish and AngloAmerican samples and appeared not to have fully captured culturally significant pain beliefs of AfroAmericans and Puerto Ricans. This distinction is important since cultures have been shown to differ in typical linguistic reports and classifications of pain,237;238 and these may have emotional significance or meaning in treatment contexts.196 Since it seemed plausible that cultural responses to pain, including description, self/care remedy, and local medical or dental practice modes, were linked to such perceptual sorting by emotional significance, the first study in this dissertation (I) and related studies595;615 specifically aimed to verify and describe the existence of ethnocultural contexts of pain, while testing a methodology for doing so. The ultimate goal of such cross-cultural research was to evaluate the power of expectations and beliefs in relation to social norms of pain perceptions, pain reactions and remedy preferences, and how these can affect clinical practice. Common pains and remedies for them were described within different ethnocultural groups of first generation or immigrant mandarin Chinese, Danish, Swedish and AngloAmerican subjects from the greater Seattle area (54 patients and 31 dentists) in order to compare semantic categories of these pain/remedy perceptions (I). All of the patient groups were demographically matched as closely as possible. Equal numbers of male and female patient subjects were chosen and matched by education, age and socio-economic status. In interviews, each was asked to answer the following questions in their native language: "What kinds of pain are there?”, "What kinds of pain can one feel in the face and mouth?", "What kinds of pains can one feel at the dentist?" and "What kinds of ways are there to get rid of or ease these pains?". Based on patient responses, psychometric instruments of kinds of pains, pain descriptors and pain coping remedies were developed and tested. Nearly all groups said they categorized the kinds of pains according to location, intensity, time, quality, curability and cause dimensions. In addition to these, Western subjects named a mental/physical dimension differentiating emotional or “imagined” pain from physical or “real” pain (I).374 Especially in interviews with dentists, this distinction was made clear and was often discussed as a negative perception about patient thinking. This raises the question of who determines when there is pain or not in clinical situations – patients or dentists? This complicated question was explored in study V, described further below. The mind/body dichotomy of real vs. imagined pains was barely mentioned among Chinese subjects (I). On the other hand, only Chinese subjects classified pains according to a suan or “sourish” dimension not previously described in the Western medical literature (I). “Suantong” or sourish pain appeared to be most similar to quality and cause categories in Western concepts of pain, and varied according to body location, amount of area involved and by depth. Tooth drilling suantong, for example, was described as dull, less intense, short-lasting pain that had a sourish, metallic characteristic. This was in contrast to Westerners who described dental pain to be sharp and intense and where 45.

AngloAmericans specifically used “excruciating“, an English word indicating great suffering as in death by crucifixion.615 Interview results showed that the frequencies with which certain pain concepts such as suantong and mental/physical pains were reported, clearly indicated qualitative differences among groups. Danish “jagende” (like intense shooting) and “murrende” (like nagging aching) were also considered to be ethnospecific terms with special sociolinguistic meanings. What may comfort patients was also often seen as culturally determined. Differences between patient and dentist Fig. 11. Multidimensional scaling representations of ethnic and dentist-patient pain and remedy belief s (Dentists: 1=American, 3=Chinese, 6= Scand.; Patients: 2=American, 4=Chinese, 5+7=Scand.)

perceptions of kinds of pain and descriptors were not as great as differences in pain coping remedies. In general, subjects categorized coping remedies as internally applied chemical agents, externally applied agents, changes of bodily function, psychosocial and healing-other dimensions, active pain tolerance, passive pain tolerance, ingestion of food or drink, and non-traditional medicine. Westerners named internally applied chemical agents most frequently, while Chinese patients most often named external agents such as salves and balms. Using multidimensional scaling of each subject’s pain data profile, relationships of clusters of subject data points (Fig. 11) indicated that descriptions of pains were most influenced by ethnocultural groupings while all dentist groups had similar cognitive patterns concerning pain remedies and contrasted with lay perceptions. Dentist perceptions did not differ from patient perceptions of pain description in any of these data. For example, Chinese dentists indicated closer ethnic affiliation with Chinese patients by perceptions of pain description than any other patient or dentist group. Ethnicity, therefore, appeared to have the major influence on pain description, whereas professional socialization had more influence on pain coping preferences in this population sample. These findings were followed up with a series of studies, the US National Institutes of Health funded “Pain in Context” studies, that explored how sociocultural contexts provide a framework for individual pain and anxiety perceptions and reactions. In one study (V), both dentists (n=129) and patients (n=396) were interviewed about the variance in use of local anesthetics for routine dental fillings among Mandarin Chinese, Danes, Swedes and AngloAmericans. Over half of Scandinavian patients (n=125) did not require local anesthetic for similar routine fillings (proximal), while 5% of mandarin Chinese speaking Taiwanese patients (n=159) and 95% of AngloAmerican patients (n=112) required anesthetic (V).612 Use of anesthetic was decided mainly by dentists in Taiwan and by patients 46.

in Western practices, but was readily available in all health care systems. Thus, perceptions of intensity and type of pain were dramatically different in the ethnic groups and indicated that psychosocial factors weigh heavily in perceived need for the use of local anesthetic. Most Western subjects who did not use anesthetic felt tooth drilling “did not hurt so much”. But Danes had a special reason for not using local anesthesia. In spite of broad National Dental Health Insurance coverage in Denmark, patients are required to pay for "pain free" fillings. Danish national insurance does, however, officially only cover use of local anesthetic as included in the cost of extractions.845 Non-use of anesthetic in Denmark was also reported by some dentists to be a “barometer of trust” in the dentist-patient relationship, directly linking trust of dentists with altered pain thresholds. This had its ultimate test in two reported cases where patients had extractions without use of local anesthetic (V). Unless it was suantong, or sourish pain, most Chinese dentists described tooth drilling as only "sourish", whereas dentists usually described injections to patients as outright "painful" (tong). There were few attempts by Chinese dentists to cognitively diminish the sensation of injections as Western dentists did when describing it only as a "pinch" or quick, short-lasting "discomfort". Thus, mandarin Chinese patients were frequently inhibited to use local anesthetic due to “fear of pain worse than drilling”, even though it was readily available. It was concluded that social expectations of pains, fear of painful treatment and perceived remedies for pains varied from culture to culture and that these differences manifested themselves in beliefs and expectations of patient and dentist roles. These two studies emphasize that powerful social beliefs and expectations help individuals to surmise the meaning or emotional significance of pains. These beliefs appear somewhat automatic and subconscious and are like a set of fundamental “building blocks” with which individuals can build their own personal expectations. They influence expectations in dental treatment just as in other potentially anxiety- or pain-provoking situations. The social interactions that patients have with dentists and experiences of pain or emotional reaction can also dramatically affect an individual’s perception of pain. Normative beliefs or expectations about anxiety or pain with dental treatment can undergo changes during a person’s psychosocial development and as a result of personal experiences over the years, i.e., the belief building blocks are still there, but actual painful or anxiety provoking experiences have modified or reinforced some of them. The powerful variables of expectations and beliefs indicate that there are factors in researching clinical phenomena of pain and anxiety that perhaps many psychology and dental researchers take for granted, but to which they should pay more attention. In the next section, research of psychological aspects of individual pain experiences or expectations is described and how these relate to trauma and anxiety. These are then described in relation to the concept of suffering.

Individual pain experience, anxiety, trauma and suffering Expectations vs. experiences: anxiety, fear and pain beliefs As stated above, if pain is expected, then it is reasonable to assume that this expectation has been learned. Regardless of whether or not the pain is actually experienced, there are contextual norms for how a pain is experienced, dependent on ethnic or social influences. However, individual experiences within this social framework of expectations make pain perceptions and reactions more specific. So what is the relationship of expected pain with actual painful or other traumatic dental experiences and how does this relate to dental anxiety? There is a body of research literature in psychology and behavioral dentistry that has focused on this topic. 47.

In the mid and late 1980s, Kent and colleagues416-419;421;423;424;426 researched expected and experienced pain as it specifically related to dental anxiety using convenience samples. First, on 76 general practice patients, Kent416 found that highly anxious patients (DAS mean 12.0) expected more pain than they experienced when they received drilling or extraction type procedures compared to lowanxiety patients (DAS mean 5.2). The discrepancy was smaller when they received a dental check-up. Then, Kent417 also found on 146 NHS hospital dental patients that highly anxious patients and irregular dental care attenders focused on negative events more than did patients with low anxiety. Irregular attenders were more anxious than regular attenders, because, as they explained, they believed they would require more extensive treatment. This was evidence that thought processes (cognitions) could explain why high anxiety was maintained despite repeated pain-free experiences. Other cognitions were explored in subsequent studies. In a study of 57 general practice patients, Kent418 showed that anxious patients reconstructed their memories of discomfort-free experiences over time so that they became consistent with their (negative) pain expectations.418 In another study of 166 general practice patients, Kent419 found that after “surprisingly” good experiences, anxious patients were unsure that under similar or better conditions, a similar outcome would occur. A large discrepancy between expected and experienced pain was associated with a change in dental anxiety only when patients were convinced that the discrepancy was not mere chance.419 Kent & Gibbons424 and Kent421 also explored the possibility that Bandura's concept of self-efficacy53;55 and control over anxious cognitions could explain the discrepancy between expected and experienced pain in relation to dental anxiety. On a sample of 205 university students, those with low dental anxiety (DAS < 6) claimed to experience fewer negative thoughts and claimed to have more control over such thoughts than those with moderate (DAS 8-10) or high anxiety (DAS > 12).424 Kent & Gibbons424 concluded that the experience of dental anxiety was more closely allied to feelings of control or loss of control over negative thought content424 than to actual pain experience. Kent repeated the self-efficacy study on 145 NHS hospital clinic patients421and reached a similar conclusion. This supported earlier results by Kent & Warren,426 who suggested that a patient’s ability to convert unrealized pain expectations to decreasing dental anxiety might also be dependent on a dentist’s ability to help patients see the pain expectation-pain experience discrepancy. Kent further surmised that if dentists could avoid cold, disinterested or businesslike mannerisms426 and tried to bolster patients’ beliefs in their ability to stay calm, optimistic and in control,421 that this might result in quicker extinction of dental trait anxiety. Kent’s contemporary researchers confirmed these findings.698;889 Rankin & Harris698;699 confirmed that bad or good experiences with dentists and dentists’ behaviors were crucial to patient coping and decreased anxiety. On a sample of 258 dental patients from 20 dental offices (88 men; 169 women)698 they looked at dental experiences in relation to dental anxiety (DAS) scores. Personal experiences, “bad” and “good”, were related to DAS means as follows: good experiences before and after a bad experience = 7.2; good and bad at the same time = 8.4; bad experience followed by good = 9.1; only bad experiences = 10.3; good experience followed by bad = 11.5; bad experiences before and after a good = 12.3. Those with good-bad, bad-good-bad or only bad experiences combined (mean DAS 11.4) had higher anxiety (P < 0.001) than those with bad followed by good or good before and after bad (mean DAS 8.0). Rankin & Harris698 concluded: "Perhaps the most positive contributions that dentists and dental auxiliaries can make to reducing dental anxiety in their patients are to provide patients with positive experiences and to train them in the use of effective coping skills." In 2000, Rankin & Harris’ results were supported in a representative study of Canadians (N = 2609) by Liddell & Locker495 who found that remitted anxious dental avoiders (n = 652) with time and positive experiences could start regular attendance habits. They referred to Foa & Kozak’s248 theory of emotional reprocessing of fear through exposure to positive counteracting experiences over time. 48.

Starting in the late 1980s, Arntz and colleagues25;28;29;35-37;380;382;697 among others, also explored expectations and predictions of pain and anxiety. Their findings in general support the notion that among anxious persons there are often discrepancies between expectations and actual experiences of pain. One study40 was on dental anxiety and pain in 40 general practice patients, aged 17-71 yrs, who twice underwent extensive dental treatment within a mean of 10.4 days. Measures included the DAS and Visual Analogue Scales (VAS) of pain and fear to rate expectations and experiences. Anxious patients had inaccurate expectations about pains and overestimated pain and fear experiences. Five months after the treatment sessions, memory and new predictions of pain were influenced more by original pain predictions than by actual pain experienced, much as Kent had found.418;423 The results suggested that old cognitive patterns (beliefs) were ultimately reinstated if disconfirmation of pain expectations by good experiences were few and far between. Anxious subjects did not experience more pain than less fearful subjects according to VAS measures. Dworkin et al.(1986)213 confirmed that this was possible by experimentally controlling psychological preparation of anxious clinical subjects enough to neutralize and even reverse the analgesic efficacy of nitrous oxide sedation without increasing their anxiety. Detailed investigation of the process of changes after disconfirmation have shown that anxiety experienced during treatment is a factor that plays a part in maintaining the problem of inaccurate expectations and fear of treatment. Also acting in these clinical situations were probably mood recall mediators71;218;418;423 according to other research, i.e., negative hedonic tone was more easily remembered. In later studies, Janssen, Arntz and others28-30;380;382 found that increased attentional focus on pain or discomfort, not anxiety, had the main effect on pain ratings, among anxious subjects. This has implications for distraction as an effective therapy against pain expectations382 in some anxious patients, as will be described later. Arntz and colleagues’ later work focused mainly on theoretical aspects of fear or pain and so-called “match-mismatch” models of fear or pain prediction vs. actual experience31;32;35;697 on non-dental patient samples.28;36;37;39 Certainty of prediction32 was another important factor in stable changes in fear of pain, which Arntz and colleagues linked to the concepts of perceived dangerousness,26;27;33 unpredictable pain intensity,38 and ability to escape to safety.38;39 Thus, Arntz found that personal beliefs about anxiety and pain affect dysfunctional overprediction of pain or anxiety.25 These support Kent’s and Rankin & Harris’ earlier conclusions about dental patient samples, including Kent’s documentation that control of negative thoughts and self-efficacy for anxious patients were more important in determining the predicted pain than were actual pain experiences. The concept that manipulation of patient expectations or emotions can manifest differences in pain response has also been confirmed in experimental situations by Jones, Zachariae and colleagues,394;395;931 as well as by Dworkin et al.209-211;213 Apropos discussions of expected pain, anxiety and focus of attention is the concept of pain "catastrophizing". Catastrophizing is described by Sullivan et al.841 as an exaggerated negative "mental set" brought to bear before or during painful experiences where social factors and social goals may play a role in the development and maintenance of negative expectancy processes (vigilance) that are intermediary to pain experience and increased emotional distress.841 With the caveat that many of Sullivan et al.’s results were derived from student samples, trait anxiety was shown to correlate with catastrophizing, but not with fear of pain nor pain experienced.842 Intermediary vigilance has also been confirmed in other pain and expectation studies.29;378;380 In a study of students undergoing tooth cleaning procedures, “catastrophizers”, as they were called, reported significantly more pain and emotional distress than “non-catastrophizers” and they benefited more from disclosure of their physical and emotional experience in diaries.836 Their levels of catastrophizing and dental anxiety post-treatment remained essentially unchanged.836 Similarly, Chaves & Brown149 had reported in a 1987 study that 49.

catastrophizing patients did not cope as well with injections or extraction than non-catastrophizers. Sullivan et al.837-842 use the term “catastrophizers” regardless of whether pain is acute or chronic, experimental or patholog-ical, endogenous or inflicted and thus provides no overall guidance for discussions of what is a normal or expected level of anticipation of pain and what is not in these different contexts. So perhaps discussions of differences in normative expressions of suffering are the issue left out by Sullivan and colleagues. There is no doubt that identification of catastrophizing, especially related to chronic pain syndromes as intended by Keefe and colleagues,408;733 in certain cases may be helpful in providing therapeutic solutions toward productive coping strategies. However, the social relativism in pain expression, described in the works of Zborowski937 and others,68;69;209-211;213 are lost to rather simplistic clinical labels in some of this research, especially in relation to acute pain, anxiety or fear of pain in dental treatment.836-840;842 This could unintentionally and inadvertently promote adversarial thinking among some general practice clinicians, that is, unnecessary focus on the patient’s “fault” in pain reactions, instead of encouraging mature clinician management of a patient’s suffering and nonproductive thinking. This would especially be detrimental in relating to many patients with odontophobia, given their often irrational, yet, in some ways justifiable, conditioned responses to dental treatment, as a result of dentist-induced psychological trauma. When are such reactions “exaggerated”? Sullivan et al.835 did, however, look at communicative dimensions of pain catastrophizing and social cueing effects on pain behavior and coping. They found on a homogeneous student sample that when observers were present, persons exhibiting high catastrophizing showed a propensity to engage in coping strategies that galvanized their pain, and were less likely to engage in strategies that might minimize pain.835 Thus, this research appears to be useful as an aid in devising and directing positive strategies for patient coping, especially in chronic pain conditions. Summary: Psychological research studies about anxiety, pain expectation and actual pain experience were based on convenience samples of university students, non-dental phobia patients and anxious dental patients in private practice. Only a few studies have employed experimental controls in examining the relationship of pain and expectations in anxious clinical patients. Subjects did not chronically avoid dental treatment situations and therefore most likely did not have phobia per definition or diagnosis. Perhaps as a result of the sampling, it was assumed that dental anxiety was unidimensional, that is, primarily associated with fear of injury/pain. Given these caveats, results showed that overprediction of pain and exaggerated focus of attention on pain due to anxiety, resulted in relapsing beliefs about feared situations based on memories of previous pain expectations or related moods and not on actual pain experiences. There were discussions and suggestions that dentists or therapists could aid improvement of patients’ self-efficacy, and then over time, with consistently good or painless experiences, dental anxiety would decrease with stable duration. Pain of dental treatment in relation to dental anxiety and psychological trauma The psychiatric epidemiology literature often categorizes “fear of dentists” as a unidimensional fear of mutilation or injury, as mentioned earlier. It is often combined for study with fear of blood or injections.133;186;264;412 Studies by some psychologists, notably McNeil, McGlynn and associates392;554;559 have posited that dental anxiety is primarily due to fear of pain. But in a recent (2001) study of orofacial pain patients, McNeil et al.559 acknowledged that we do not know enough about what fear of pain means in relation to other factors associated with dental anxiety. Given the sampling for these psychological studies (college students and low-moderate anxiety dental clinic patients), their deductions may not extrapolate to dental phobia, where long-term anxious dental treatment avoiders provide more 50.

complicated clinical manifestations, according to the literature described in Chapter 3. In using these samples that exhibit “anxiety = fear of pain”, it is assumed that the directionality is “pain leads to anxiety”. However, there is also evidence that many people who expect to experience pain do not report anxiety.427 So another explanation for the relationship could be that “anxiety leads to pain” or that the relationship is circular,427 possibly involving necessarily these “other factors”, as have been reported in other similar convenience sample studies on the topic. In an interview study of 487 students, Kleinknecht et al.(1973)439 reported that personal qualities of dentists were extremely influential in the development of adverse reactions to dentistry. Bernstein et al.(1979)92 also showed on 93 high fear university students that of bad dental experiences in childhood, half were attributed to negative dentist behaviors and 81% of these had not mentioned pain. As described above, Kent & Warren’s data426 also suggested to them that dentist behaviors in helping a patient feel in control could be more crucial to dental anxiety than actual pain experienced. Thus, most dental anxiety research on “components of dental fear” has taken exception to a unidimensional portrayal of dental anxiety, especially in relation to odontophobia.399;511;515;608;611 Population-based research on dental anxiety and studies of dental phobic populations are important for helping us understand the relationship of pain with odontophobia. Of course, clinical trials may, however, be the only way to confirm or validate such epidemiological discoveries,211;213 Even so, it is important to identify factors that may influence pain and anxiety and that can contribute to theory. Although pain during dental treatment has been identified as playing a major role in the development of dental anxiety and is a major concern of patients when seeking dental care, there have been very few representative population studies of the prevalence of pain in dental treatment and the factors associated with patients' perceptions of pain, also in relation to degree of dental anxiety. In a unique study, Maggirias & Locker523 used data from a longitudinal populationbased investigation to assess the proportion of dental attenders who reported pain during dental treatment and psychological characteristics which predisposed to or coincided with the experience of pain. Of 1422 Canadian subjects who completed questionnaires at baseline and five-year followup, nearly all had visited a dentist over the observation period. Two-fifths reported having pain during treatment and one-fifth had pain that was moderate to severe in intensity. Reports of pain were associated with the types of treatment received as well as several baseline sociodemographic and psychological factors. Using logistic regression analysis, Maggirias & Locker523 predicted the probability of pain. They found that number of types of invasive treatments received had the strongest effect. Pain was also more likely to be reported by those with previous painful experiences as well as those who were anxious about dental treatment, expected treatment to be painful and felt that they had little control over treatment. Those who said they were unwilling to accept or tolerate pain less likely reported pain. Younger subjects and those with higher levels of education were more likely to report pain than older subjects and those with less education. Maggirias & Locker523 concluded that pain is as much a cognitive and emotional construct as a physiological experience, pointing out implications for dentist behavior. In an earlier study, Locker et al.513 also found on another large Canadian sample (N = 3055) that 75% reported direct negative experiences at the dentist; 71% were primarily typed as painful experiences, 23% were frightening experiences and 9% were embarrassing experiences. Locker et al. results indicated that frightening experiences and painful experiences in combinations with each of the others were the strongest predictors of anxiety. Those with painful and frightening experiences had almost ten times (OR= 9.7) the risk of being anxious dental patients (DAS > 13), while those with painful and embarrassing experiences had seven times the risk (OR=7.3). The odds ratios for all three experiences increased risk to OR = 22.4. This emphasized that frightening experiences with dentists and 51.

embarrassment had substantial influence over anxious patients’ perceptions of negative dental experiences that were reported as painful. Five years later (2000) on the same population, Liddell & Locker495 studied the group of remitted anxious dental avoiders (n = 652) mentioned above and found that the majority had experienced painful treatment, but fewer of them reported frightening or embarrassing experiences than did the anxious cohort (n = 235) who had continued dental treatment avoidance. These differences were attributed to anxious avoiders who only visited dentists when experiencing pain or were otherwise in a crisis about avoidance, conditions that would likely increase, not decrease, their fears. Liddell & Locker495 also concluded in examination of differences of the two groups, that discrete categorization of highly anxious individuals (e.g. fear of pain) is less productive in understanding the phenomenon of trait dental anxiety than is adoption of a multidimensional view, which is more characteristic of its nature. Vassend875 showed in large epidemiological samples (N = 3670) that 60% of Norwegian adults reported having had a painful dental experience and 5-6% experienced treatment to be very painful in general. Vassend emphasized that the relationship between pain and anxiety is reciprocal, and that dental anxiety in general is significantly related to pain reports (r = 0.32-0.48). Curiously however, Norwegian teenagers had significantly higher dental anxiety levels than other adults, but there were no significant differences in dental pain or discomfort ratings between the groups. Vassend offered no explanation for this, since the focus of the study was to explore why “pain-free dentistry” was still not prevalent inspite of modern dental anesthetic availability. The Danish epidemiological study (II)606;614 indicated that most odontophobics had high fear of the dental drill (Table 1), which one would assume was fear of pain or discomfort, much as with moderate anxiety. However, there were significant and meaningful differences in relative importance of negative dentist behaviors as cause attributed by odontophobic patients (OR = 9.3) compared with moderately anxious patients (OR = 0.5), when these two groups each were compared with low/non-anxious patients. Clinical studies on patients with odontophobia are also important in this discussion, since the character of dental anxiety for extremely anxious chronic avoiders of treatment have been shown to differ from those in student samples611 or general dental practices (IV). Berggren & Meynert91 found that onset of odontophobia in childhood was significantly associated with dentist behavior, whereas onset in adulthood was caused by painful experiences. A chief complaint of painful dental procedures was only 28% for anxious patients, while 48% cited poor management by dentists as the main reason for their anxiety. This has been explained as differences in adult and child perceptions in which adults possess the ability to differentiate between dentists’ intentions and the painful events that occurred.83 Norwegian studies464;909 confirm that bad experiences with dentists has had grave consequences for patients with odontophobia at two specialist centers. The Danish Ph.D. study598;599 also showed that there was usually at least one traumatic experience with the dentist for about 85% of odontophobic cases, especially in childhood up to age 12 yr. (70%)91;611 These experiences occurred with and without pain complaints. Furthermore, of the 80 Danish odontophobic patients, who were representative of a total of 208 patients at the clinic, only about 19% were actual Seattle Type I cases i.e., fear of pain.611 while many more (47%) were Type II patients with conditioned distrust or feelings of powerlessness or embarrassment. Only ca. 12% of the latter indicated that the initial cause of the anxiety many years ago in childhood was painful treatment. In interviews, the 80 subjects described traumatic experiences in 25% of cases as painful, while 30% complained of “being held down in the dental chair” and 40% attributed their distress to “hard-handed” dentists. Hard-handedness described negative dentist behaviors ranging from “not gentle” to “slapping”, “hitting”, “poking” or even the “sticking of body parts other than teeth with a dental probe”.611 52.

From the above review, it is apparent that much more than just fear of pain is associated with high dental anxiety. The contribution of dentist’s behaviors requires scrutiny, among other factors. Two satisfaction studies496;831 about patient perceptions of dentists' positive and negative attributes have pointed out that patients who had higher levels of dental anxiety were more likely to describe negative dentist attributes than respondents who reported lower anxiety. Women, younger subjects and the dentally anxious consistently chose “unsympathetic” and “indifferent” as the two top negative characteristics of their dentists.496 Other clinical evidence257;281;826 suggests that negative dentist behaviors such as “Dentist laughs as he looks in your mouth.” or “Dentist tells you that you have bad teeth.”, in the social context of dental treatment are among the most intense anxiety stimuli. Beliefs and (+) Expectations

Medical Outcome

Paradoxical Placebo Effects

Placebo Effects

Dentist helps frightened patient after work hours; listening,touching caring

(-) Pathology

( +) Paradoxical Nocebo Effects

Nocebo Effects Dentist intentionally forces treatment or ”punishes” patient.

Health

(-)

Fig. 12. Ethnomedicogenesis in dentist-patient relating. Patient expectations and dentist role outcomes

Biro & Hewson97 even found that dislike for dentists is a more intense deterrent for regular dental care than fear, although fear of treatment is more frequent. Thus, iatrogenesis, or induced or unexpected responses in the patient as a result of doctor or dentist’s treatment, can either directly or indirectly contribute to a mental disorder in patients and can perhaps affect the diagnosis of that disorder. Seen in it’s social setting, the possibility of iatrogenic effects in dental treatment situations, according to the ethnomedicogenesis thesis314;317(Fig. 12 above), makes it likely that professional distancing or uncaring attitudes of some dentists would magnify unpleasant or painful effects experienced by patients. There is even an hypothesis stating that experiencing the same pain stimulus at the hands of a kind dentist, may not create the same pain reaction in the same person as with a cold, uncaring dentist.213;311;410;585;699 As psychiatrist Braceland said speaking to dentists at a congress in 1940,118 “People will forget painful instances – they grow dim in time - but careless or clumsy dental work is never forgotten.”

53.

Suffering, yes… but torture? The Ph.D. studies598;599 and study IX indicated that one of the most striking characteristics for patients with odontophobia was feelings of powerlessness. This was associated with the dental situation in general and often more specifically to negative dentist behaviors or embarrassment. Catalyzed by some degree of embarrassment over what they perceived to be their poor dental status or dental care neglect, a vicious circle of dental anxiety had maintained avoidance of dental treatment. Therefore, according to the ethnomedicogenesis thesis, one might hypothesize that perhaps those suffering from odontophobia may have fewer verified chief complaints about physical pain or unpleasantness from instrumental manipulation compared with those with moderate dental anxiety or less. There was some evidence for this in study II (Table 4) as described in Chapter 3. The meaning of pain for odontophobics is often associated with psychological trauma or suffering within the context of the dentist-patient relationship that goes beyond, but can include, physical pain. This suffering includes patients’ perceptions of dentists as often distant, pain inflicting and less caring and is laden with feelings of powerlessness and victimization.8;79;598 A case study from the FoBCeT clinic illustrates that an initial chief complaint of fear of painful treatment, was actually mostly a fear of dentists’ behaviors. Case history : 39 yo factory worker (“39 M”) avoided treatment for over 15 yr due to phobic dental anxiety. As a 7 year old he had been treated without local anesthesia and held down in a dental chair by a public dental service dentist and her assistants. The memories of trauma had lasted all of his adult years. 39 M: “The dentist said, ”We are only going to look.” I’ll tell you, she looked at it along with two others and all I remember (afterwards) was that elastic cord that went around and around on that dental drill.” RM: “So she didn’t just look?” 39 M: “I remember Ms T. (dentist) as she looked and said, ‘There are a couple of cavities and I think that we should fill them.’ I protested right away. A dental assistant put her hands over my legs, so I couldn’t kick. (39 M demonstrates). Then another assistant was on my left side and held my hands. Ms T. had her free hand here (points to throat).” RM: “On the throat?!” 39 M: “Yeah and then my teeth got fixed. After just a few minutes I was so paralyzed with fear that I couldn’t move anymore. When my father came back, I told him that I would never forgive him that he had left (the clinic while I was being treated). He answered, ‘Oh, it couldn’t have been that bad.’”

At age 24, 39 M visited a woman dentist in private practice who underestimated his anxiety, and inspite of insisting that she would, did not take it seriously. She reinforced his distrust for dentists. 39 M: “She meant well when she said ‘Come on in the chair and let’s get it over with, because it isn’t as bad as you think it is’. But I cried.. and got laughing gas and got stuck in two or three places. She filled three cavities and didn’t tell me during the procedure she had placed a clamp around a tooth and that it had fallen apart. She just did it. Even with all that laughing gas and anesthetic, it didn’t seem to help. I was really upset. An assistant got sick at the sight of a grown man sobbing like a baby. I just simply couldn’t take it. When I got out of the chair it was like tearing a band-aid from it ’cause I had sweated so much. So afterwards she said, ‘Oh my God, is it so bad?’ I said, ‘That’s what I tried to tell you. Now you have seen me three times – the first, the only and the last.’ Since then, I have never even been close to a dental chair.”

39 M’s chief complaint at initial assessment interview, was enormous pain during dental treatment. On closer examination, many defense mechanisms were observed. For example, as an excuse for avoiding dentists: “I won’t be making any payments for any dentists’ new Porsche!” His initial complaint about pain appeared to be more symbolic of relational problems with dentists throughout his life. Especially for odontophobics, it is perhaps easier to say that a dentist “hurt” them, meaning 54.

physically, then to try, especially as a child, to get someone to believe that they were assaulted by a dentist and staff and suffered the effects of interpersonal trauma. Not relieving pain brushes dangerously close to the act of willingfully inflicting it.618 So it is often beliefs about dentists as unscrupulous pain-inflicting experts who manipulate injection syringes and dental drills, that creates the aversion to treatment. These beliefs reflect the vulnerability that odontophobics often express as an unequal balance of power in the relationship. Therefore, these induced traumatic experiences can at least be described as unnecessary suffering in social situations. In some cases, it borders on torture*, according to U.N.871 and dictionary1 definitions, since patients and especially children, were often directly and intentionally subjected to unpleasant or painful experiences, against their will. (*Compiled definition of torture used here is “the intentional infliction of severe pain or suffering, whether physical or mental, as a means of punishment, coercion or discrimination by persons with public authority or their agents.”) It has also been shown in studies of political torture survivors that the trauma they have endured at the hands of torturers affects physical, psychological and oral/dental aspects of their personalities.107;386 This usually leaves the survivor extremely sensitive to dental treatment settings, including the attitudes of the dentist.107;386 Even if traumatic treatments at the dentist may not qualify as torture by definition, the specter of iatrogenesis of severe pain and suffering at the hands of a dentist, especially in the innocence and vulnerability of childhood, becomes a real, yet irrationally experienced threat for the sufferer. The following excerpt from the case history of “39M” illustrates this: 39M: “My own evaluation is that I was ‘had’ by Ms. T., in a way. If she had been a decent person and could have understood what it was, then I think that I wouldn’t be sitting here (dental anxiety clinic). I suffered a horrible breakdown in spirit (knowing) that other people could treat me that way. They just did with me what they wanted. So it still lies there in me. No one will ever do that again. I’ll make those decisions myself.” RM: “One could almost compare it to being a victim of torture in your case. Can that be?!” 39 M: “I dare to state that I would rather be beaten under the soles of my feet with a rod then I would sit in a dental chair, yes!”

Suffering is not only distinct from physical pain sensation, but it also represents another level of individual response.401 A person’s perception of and reaction to pain outwardly appears due to some neurological or physical cause that is mediated by other individual experiences or cultural factors.(I,V)612;937 However, suffering on the other hand, is not grounded in the same cause or stimuli, but derives from the individual’s evaluation of the significance of the meaning of a traumatic or painful experience. This has even been discussed in a recent review of research on cerebral cortical mappings of pain.865 Suffering is a meaning given to pain.141;144;401 Actual pain, anticipation of pain not yet experienced or identification with the pain and other experiences may all contain meanings that lead to individual suffering. However, unlike physical pain, suffering is not a phenomenon that can be reduced beyond meaning to the whole person.141;144;401 This distinction is acknowledged in every day language. For example, I may complain that my head or my arm hurts, but only I can suffer or not suffer from it. Suffering is a response that depends on personal beliefs and expectations. Often suffering is related to events outside the self with the environment in a manner that appears evident or understandable to an outside observer, however, this need not always be so.401 As individuals are unique, so are the meanings they create.141 As Cassell143 proposed, “Suffering is ultimately a personal matter.” Suffering cannot be treated unless it is recognized and diagnosed. Suffering involves some symptom or process that threatens the patient because of fear, the meaning of the symptom, and concerns about the future. A theoretical definition is that “suffering is experienced when some crucial aspect of one’s own self, 55.

feelings or existence is threatened.”143;401 The meaningfulness of such a threat is to the integrity of one’s own experience of personal identity. Changes in personal identity may also result from loss of function or changes in body image that is perceived as threatening. Personal identity can be threatened not only by actual events, but also by the imaginary. The emotional meanings and the fear are so personal and individual, that even if two patients have the same symptoms, their suffering would be different. Atkinson43 describes that the use of the term sufferer in relation to patients has become increasingly common. The words "patient" and "client" originate from the Latin roots "to suffer" and "to lean on" respectively. Atkinson43 examined the varied meanings implicit in the word sufferer from the Judaeo-Christian perspective. Biblical themes of suffering as human nature, as punishment, as a test, as atonement and as liberation and deliverance were included. Atkinson43 describes that the trend more recently has been to come away from suffering as a victim, since in an empowered learning experience the sufferer can still be proud to be a survivor, which allows them to claim some meaning out of their suffering. Another point regarding suffering is that pain that might otherwise be easily endured can induce suffering, since the individual can be lead to imagine that it will increase or continue. Anticipation of pain will induce suffering to the extent that one imagines that the pain “still-tocome” may threaten personal integrity or identity. As seen above in the case study of “39 M”, the symbolic meaning of conditioned responses to sounds or sensations of dental drilling initially presented by FoBCeT odontophobic patients in anticipation of pain, are often later found to be an underlying fear of threatening dentist behaviors (See also case “39 L” in Chapter 5). It is in this regard that some anxious patients whose chief complaint of pain from dental treatment may often have a combined problem of difficult anatomical circumstance for successful anesthesia and not being able to focus on relaxation due to perceived imminent threat. They tend to feel pain easily, and say so, in a way that makes pain a first line of defense against unpredictable dentist behaviors that are actually more threatening than the pain itself. Perhaps even more illustrative of this psychosomatic conversion are three cases in FoBCeT therapy where odontophobic patients were so convinced that they would feel pain from tooth drilling that merely the sound of the high speed airotor drill caused them to feel pain in their teeth; just from psychological conditioning. One 37 year old woman described a burning pain sensation in a particular tooth (lower right first molar), another 46 year old woman felt pain in all upper teeth and the third woman (41 yr) experienced sharp stabbing pains in the upper left second molar. Similar pain conversion has also been reported for odontophobics in two separate reports of male patients258;410 where both were attributed to high suggestibility traits and spontaneous trance-like pain experiences, one of which was in response to dentist characteristics.410 These cases could possibly have been examples of “somatization” as described earlier in the DSM-IV psychiatric model. Since these three FoBCeT patients could also produce the pain just by thinking about tooth drilling, this was useful in their therapy. After learning a relaxation technique, they would sit in the therapy office away from the clinic and learn to exercise control by 1) imagining hearing the drill, 2) producing the pain and then 3) stopping the pain again with other thoughts and relaxation. Once this was accomplished, further desensitization with actual drill sounds could continue, with the patient aware that they now had control over the perception of pain. This process has also been described by Arntz et al.34 in experiments on normal subjects who could eliminate pains without physical anesthesia by psychological extinction of their “imagined pains”. These findings also support Melzack’s contention of “neurosignature patterns” 56.

described in Chapter 2, which although are most often triggered by sensory inputs, may also be generated independently of them in the brain, similar to phantom pains.567;568 The techniques and methods that dentists and physicians normally use are aimed at the body (especially teeth) rather than the person, i.e. the pain, not the suffering. In the above three cases, unwary practicing dentists might unknowingly fall into a trap of finding that the patients were very difficult, if not impossible, to anesthetize. In order to gain effective pain control they would probably seek more effective physical means of anesthesia, such as giving higher doses of local anesthesia or consider using general anesthesia. The signs of suffering are therefore often missed, even in severely painful reactions and even when it should be fairly obvious to dentists or physicians.143 A degree of awareness must be maintained in the presence of persistent disease or pain, and patients must be directly questioned about it’s emotional significance. In this way, the dentist or physician shows recognition and respect for the suffering symbolized as pain and a dialogue can lead to resolution or even amelioration of the psychosomatic reaction.143;487 The information on which the assessment of suffering is based is subjective and may pose difficulties for dentists or physicians, who tend to value objective findings more highly and see a conflict between the two kinds of information. Knowing patients as individuals well enough to understand the origin of their suffering and ultimately its best treatment, requires methods of empathic attentiveness and non-discursive thinking. The relief of suffering depends on the doctor or dentist knowing or acquiring these skills141-143 which could be learned through professional training. Clinical strategies to reduce suffering are described in Chapter 6. As stated earlier, the majority of odontophobic patients treated at FoBCeT expressed complaints of powerlessness, embarrassment and feeling of inability to achieve personal contact with dentists. There appears then to exist a kind of cultural gap between patient and dentist perspectives and needs. In the next chapter a description of this gap and its relation to anxiety and pain are discussed.

57.

Chapter 5. Patients’ and dentists’ ways of being, anxiety and pain In order to clearly understand or research the social contextual gaps that may occur between patients and dentists, an explanatory or conceptual model is necessary. According to the aims of this dissertation, a description of the roles of the actors and factors converging on the dentist-patient relationship is crucial for construction of such a theoretical model and each follows in the various sections of this chapter. In the discussion above, there are three interacting social components involved in phenomena of dental anxiety and clinical pain: 1) the patient role 2) the dentist role and 3) the societal image of the dentist, as illustrated in Figure 13 below and how these influence the dentist-patient relationship.

THE COMMUNITY Dental health care policy

Structure of dental health care system

Dental professional organization

Dentist

Societal Image of the Dentist Radio/TV entertainment, films, literature, news

Beliefs/value norms about pain, anxiety, price and dentist role

Fellow Family and workers’ Ca.1/3 have close friends’ beliefs complicating beliefs psychology

Patient Financial Role Beliefs, expectations Beliefs, expectations Role pressures, Dentist – Patient Relationship practice style Personal finances Socialization, Too busy/stressed, Beliefs/fear and priorities education Contributing factors: dominating, of authority; 1. Traumatic experiences (85% of non-listening passivity all odontophobics; 70% as child) 2. Patient feels lack of control over: a. Own emotional reactions b. The social situation Leads to feelings of powerlessness

Figure 13. A dynamic interaction model of psychosocial elements influencing development of extreme or phobic dental anxiety by Moore (1989, slightly modified).

The patient role - passivity in the dental chair When we look broadly at the roles of patients and dentists, there is a general framework or pattern to the relationship, as captured in highly detailed observational studies by Coleman & Burton158 in English dental clinics. Patients seek dental treatment due to dental problems or a need to prevent them. Although they usually initiate contacts in the relationship, dentists manage activities thereafter. Even though the patient is the cause and focus of the activity in the dental clinic,158 the dentist is the expert that has the skills and training to accomplish the necessary technical tasks.158 The patient willingly cooperates, recognizing a need for the dentist’s skills. The dentist is responsible for a successful treatment outcome158 and takes pride in his craftsmanship.177;324;650 Thus, the dentist is given the central role in dental treatment by default. The dentist’s central role as technical expert is reinforced by his role as “host” as well,158 since the clinic is the dentist’s home ground. As host, the dentist initiates and manages all activities and is expected to make the patient as comfortable as possible.158 Patients want their faith in the dentist to be 58.

confirmed and the success of the treatment (patient satisfaction) also depends upon this confirmation of faith. Therefore, the patient cooperates and prepares to be led through all the activities that the treatment entails.158 The dentist’s familiarity with the clinic and the treatment procedures are inherent in the role of expert and host, which means that he manipulates the patients’ behavior through verbal and nonverbal cues. To ensure the patient’s continuing cooperation, the dentist may reduce overt signs of dominant management and avoid authoritarian language by rephrasing instructions as requests and suggestions, modifying criticisms with adjectives such as “quite”, “pretty”, “fairly”158, “a little bit” (V) etc. or softening instructions by prefixing the imperative verb with “just”(bare or lige in Danish) , when sometimes ignoring patient behaviors and distracting his attention,158 e.g. “Please open just a bit wider.” Thus, the dentist’s control of clinical activities is enhanced by his adeptness at manipulating the patient’s attention and accurately predicting the sequence of activities and how the patient will feel .115;158 In this scenario, then, the patient assumes a passive or acquiescent role and becomes a ready accomplice to the dentist’s control over activities in the clinic. The patient may relinquish some emotional security in the hope that the technically demanding procedures that require the full concentration of the dentist will be accomplished efficiently and with high quality.103;158 An acquiescent patient role strengthens the dentist’s dominant position and his expertise has an even greater sense of social importance or status.158 The social distance established between the dentist and patient does not necessarily encourage the development of familiarity and can increase an impersonal nature to the transaction, inspite of physical proximity.158 The patient sensing that his behavior is under professional scrutiny, may also present a “censored image” of himself, suppressing behaviors that he thinks may be seen as uncooperative, since sometimes the dentist is “not to be disturbed” while concentrating on dental tasks.158 The dentist, knowing that the patient’s respect is a contributing factor to successful treatment, attempts to reduce this professional distance only when the patient’s cooperation is required, e.g. politely asking to open the mouth, after noting that the patient is tiring. These basic descriptions of an average dental visit may sound cold and clinical to many dentists who try their best to befriend and chitchat with their patients at the beginning and end of a séance. However, they cover basically what is happening in the role-play between the two main actors on the dental treatment “stage”. Even though in other normal non-dental clinical situations, feelings of lack of control among clients and patients can inhibit improved or positive clinical outcomes,124;648;724 consistent patterns of expected patient acquiescence and vulnerability appear to be specific to dental care and are seldom found to the same degree in other clinical situations, with the possible exception of gynecological examinations.357;475;571;900 Here it is perhaps useful to employ some psychodynamic concepts in describing subjective experiences regarding the oral cavity, teeth and dentist-patient relating 102-105;265;266;268 and add further color to the utilitarian social role descriptions above. It is a fact that a child’s oral activities play a significant part in the first and early experiences in life. In addition to the means for food intake, the lips, tongue and mouth are the means through which a child learns to express himself and investigates a variety of objects in the world about him. According to psychodynamic theory,102;103;105;265;266 little of these learned emotional experiences is lost to the individual in later developmental stages. So it follows that in adult life, the oral cavity and teeth are both utilitarian, e.g. eating and communicating, as well as symbolic for expressions of intimacy, e.g. kissing and sexuality. Thus, however directly or indirectly, early experience influences later response. The adult individual can interpret reality according to emotions he or she experiences,265;266 as described above with actual vs. expected pain. As described above, patients become dependent upon their dentists as authority figures who care for their teeth, which implies a certain degree of passivity. But seen from a psychodynamic perspective, dentists also intrude on 59.

the oral cavity as a symbol of intimacy or at least corporal integrity; even at times causing physical pain or unpleasantness.102;265;266 Using either social learning theory or psychodynamic thinking, it follows that traumatic childhood dental experiences can lead to fear and anxiety, which can also continue on into the adult years.265 One way of thinking of these relational transactions is that patients can make connections and transfer previous negative associations to current dentist-patient relations.104;105;265 This so-called “transference” carries attributes from emotional situations from the past forward to the present one, which affects a current behavior pattern (e.g. fright, avoidance).266 These reactions may cause feelings or reactions within the dentist or dental team (“countertransference”) and requires special understanding or soul-searching in order for them to better help the patient feel secure and change these dysfunctional behaviors.104;105;266 It is possible to manipulate these interpersonal effects toward positive outcomes, especially addressing dysfunctional patient passivity in relation to the dentist. At a less dramatic level of manipulation, a psychodynamic perspective suggests, for example, that presence of a child’s parent in the operatory during childhood dental experiences may be an important security step for a person’s future adjustment to dental treatment.268 However, other examples of the power of these psychodynamic concepts are the successful use of hypnosis62;100;150;436;469;812 against pain and anxiety and short-term interpersonal psychotherapy against depression,195;446 where results often equal or surpass those in use of medication. The effects that positive suggestions from dentists or therapists have on patient expectations are an important ingredient in therapeutic success with anxiety and pain phenomena in the dental clinic and will be further discussed in Chapter 6. Regardless of which psychological perspective one chooses for observation these dentist and patient patient variables, anxious dental patients often describe crushing feelings of lack of control over emotions and worrisome thoughts about the dental situation.91;194;417;426;611 Of 80 dental phobic patients studied by Moore et al.611 26% disclosed that they had been too passive in relating to the dentist and it had influenced their own fear. An important question here is, are odontophobic patients too passive or are the dentists too dominating, business-like or at least in a hurry and stressed? And if both, then how much do each contribute to the problem? A case history illustrates how a patient with severe dental anxiety can feel about dentists and themselves in this vulnerable, passive and complicated role. Case history : A 39 year old male (“39 L”) had avoided dental treatment for about 12 years due to anxiety. He complained of pain from dental treatment and that he was difficult to anesthetize, but also at the same time complained of losing control over what happens to him in the dental chair, with a strong unpleasant feeling of being “locked in”; that “dentists can continue working no matter what” was an overwhelming thought for him. He had never experienced himself so irrational before in his life. Twelve years ago “39 L” had several wisdom teeth extracted in one appointment. Inspite of incomplete anesthesia, the dentist continued after a very difficult first extraction, where the tooth broke into pieces, leading to a nearly nightmarish experience lasting for hours.“39 L” never protested, stating that the male private dentist should have stopped after the first tooth, but that the dentist went on to the other 2 extractions, probably for economic motives. Codes: RM = author; 39 L = patient RM: “So you say that it is the pain and not the dentist you are afraid of?” 39 L: “Not the dentist.” RM: “On the other hand, one needs to trust people who say that it won’t hurt, right?” 39 L: “Well, not that it should hurt, but I just knew that the anesthetic hadn’t started working yet. That is what was going through my mind when I sat in the chair. After 2 shots and laughing gas and that he says that I got 3 times as much as a normal patient, one feels good and dead. But as soon as he touched the tooth, it hurt and I woke up and couldn’t relax.”

60.

RM: “So how did it go wrong? Tell me.” 39 L: “It was like a picture out of a comic book, where he sat half-way up on my lap. He kind of held me down with his arm and of course he did what he could to get me numb, or at least I think he did. And I knew that I had to get those teeth out and I knew that he might have to drill and saw – cause pain. And that is what you focus on while it is happening.” RM: “Did you tell him that it hurt?” 39 L: “They couldn’t help but notice, when they saw me tensing up. They knew I could feel it. He was just interested in getting those teeth out. ‘Well,’ he says, ‘I’ll have to saw them out.’ And I knew there were still patients in the waiting room. I just wanted to get it over with as soon as possible. But at the same time, it hurt like hell! So of those two evils, I chose to remain seated.” RM: “It seems important that you can see that that situation represents a turning point in terms of you developing this phobic anxiety.” 39 L: “Yeah, it made such an impression on me that I haven’t gone regularly to the dentist since.” RM: “Afterwards, did you regret that you went along with the dentist about it or that you didn’t stop him?” 39 L: “No, because I’m maybe a little old fashioned and have faith that dentists and doctors, they know what they are doing. And they know better than I do and I have a tendency to trust them 100%. They have a long education.” RM: “But now do you have a feeling that that this incident was not carried out in good faith?” 39 L: “No, he just did his job. I know that this may sound crazy, but the faster he was done with me, the faster he could get the next patient in. It was just plain business. That’s how I experienced it. Money rules in society. It’s the same for dentists.” RM: “But knowing that you had pain, do you think the dentist maybe should have stopped?” 39 L: “Yeah, he should have waited and found out if there was another way that he could have anesthetized me. But of course, one uses extra time doing that. And they don’t do it for free. He has his rent to pay.” RM: “But how would you have liked to have been treated?” 39 L: “I would have preferred that he had stopped when he saw that it hurt so much with the first one. And that I should also sit there for two more??! I wouldn’t wish that on my worst enemy!”

This case study illustrates that interactions with dentists can be difficult for fearful patients, causing low self-confidence and feelings of distrust and yet at the same time, a bad conscience about being so troublesome, especially since they often have avoided treatment for longer periods of time. To summarize the arguments above, patients have a primary dependence on the technical skills of the dentist, which requires that they trust the dentist and acquiesce to or cooperate with the dentist’s working conditions. If the patient encounters difficulties in feeling secure with this more active, often dominant dentist role, it requires the dentist to demonstrate responsive managerial skills and in many cases, nurturing or reassuring behavior. Often without any conscious effort on the part of dentists, technical and procedural demands reduce the prospect for friendly contact and increase the social distance between them and patients.158 This allows dentists to fully concentrate on their craft and business, especially given the time restraints of dental treatment. Fortunately, many dentists do make conscious efforts to make themselves emotionally accessible and take time to reassure or advise patients who need it. But there are also many who do not instill the trust of their patients (VII).465 The average patient can cope with this very special social relationship without much problem, not questioning the dentist’s dominant role and can exhibit behaviors that facilitate the treatment. In patients with phobic dental anxiety, however, this scenario of dentist dominance and patient passivity can seem more exaggerated and extreme in their perceptions. Since feelings of patients are their own, the dentist cannot control them directly and is often forced to acknowledge patients’ emotional needs in some manner in order to provide an effective, high quality technical service. The alternative might be to refuse to treat them (VII). 61.

So, what do patients think are optimal dentist behaviors that make it easier for them to accept their more or less passive role in dental treatment, especially when they are anxious? Like other helping professions that involve the technical and humane, patients have preferences about dentists and their ways of being. In studies of satisfaction with dental care 409;496;556;699;745;831dental patients in general reported that they valued professional competence first and interpersonal skills second, depending on anxiety level and age.496 Studies of Danish odontophobic patients,80;597 indicated that interpersonal skills of dentists were the priority over technical competence. Before therapy, these patients598;599 reported that they couldn't ask dentists to stop for a pause, felt rushed, that dentists didn't take their worries seriously, that dentists gave no clear explanations and felt that dentists were not willing to listen to them. Thus, anxiety combined with an inherent passive patient role can change patient preferences in communication style. Street831 found in a sample of 572 US patients from 17 dentists’ practices that dentists' communication styles and patient satisfaction with the dentist were highly correlated. Patients preferred the dentist to be more involved in communication and less dominant, although this was less important for more highly educated patients. Rankin & Harris699 also showed that patients are sensitive to dentists' behaviors on a sample of 258 US patients. The patients also asserted that responsibility for setting the tone of the relationship rests primarily with the dentist and that it is important for dentists to be aware of patient needs and preferences so that they can act in ways that will make patients’ experiences more comfortable. Other studies have shown that among the most common complaints of fearful patients is that dentists don't respect their pain thresholds91;611 and that patients are most satisfied with dentists who exhibit the ability to relieve fear and pain.172;323;698 As described above, research about patient fear and pain indicates the importance of patient self-efficacy beliefs40;421;424;426;585 i.e. having more control is also important in decreasing pain perceptions. Other ways of allowing patients to feel less passive, more in control and less helpless are through the use of hand signals for rest breaks and strict adherence to patient-dentist contracts about how long the procedures will take, the order of the work by difficulty and numbers and durations of pauses.168;170;173;174;176;598;652 Therefore, anxious patients may often need help in becoming empowered with a belief in their own ability to relate with the dentist and to feel as if they can negotiate or become more actively involved in decision-making or in the conduct of treatments. Empowerment of patients Given evidence in the literature that dentists often fill a dominant role in the dentist-patient relationship,146;158;341;657 then it would be advantageous to bring some feelings of control and influence back to the patient. This includes both in patient to dentist contacts one-on-one, as well as in the broader sense of their social roles and patient activation. Immediately, this could appear to be threatening to the dental profession, since it politicizes or polarizes dentists and patients. Certainly it is absurd to think that patients in large numbers would become so radical that they would start treating their own teeth. But even at this extreme, in rare instances it has been observed that odontophobic clients who eventually submit to therapy at dental anxiety specialist clinics after years of treatment avoidance, have attempted to treat themselves, be it self-extractions or esthetic dentistry with wax or paper fillings.79;81;598;611 On an individual level, the concept of empowerment of passive patients can be conducted within a therapeutic process that teaches them social skills for improved self-confidence.159;607;750 Assertiveness training uses techniques to improve passive patients’ ability to respond appropriately to more active or dominant others in order to facilitate an optimal and mutually respectful relationship and thus a better outcome.108;159;607;637;834 Assertiveness training is further described in detail in Chapter 6 as treatment and 62.

prevention of anxiety and pain. Patients who take a more active role are better at monitoring their own health and know more about dental treatment. This saves the dentist chair time. When patients want to take more responsibility for their own dental health, the dentist is relieved of a burdening responsibility and subsequent occupational stress. If perceived occupational stress can be reduced, study results indicate that there is some hope that dentists could become more satisfied with their occupation.95;649;650 If dentists would want to learn new communication skills that would facilitate effective mutual cooperation in the dental chair, they would be rewarded as a group by the individual patient taking more responsibility for oral health care – i.e. better patients.212 Thus, even though it may not be immediately apparent from the dental professional’s perspective that it is advantageous that patients become more active in the dental chair, in the long run it will create another less stressing, more satisfying practice style and may even help prevent malpractice claims.125;518;791;882 It is important that dentists not only see it as advantageous and nonthreatening, but also that they can fairly easily learn the social skills necessary for this patientcentered approach.95;517 The type of empowerment described above is mostly related to an interpersonal or “micro” level where patients seek treatment based on their own premises. This assumes that dentists want to help their patients become actively involved in treatment. What if dentists find patient activation threatening and resist patient-centered approaches? Empowerment at the “macro” level is a social/political process endorsing and enforcing patient-centered medicine as a moral and ethical human right. It espouses that professional dominance must give way to patient rights and informed consent as the primary force in health care systems. What do we know from the health care literature about this type of empowerment? Empowerment as a concept originated in Paolo Freires theory about critical recognition of the underprivileged.273;885-887 239;240;863 The empowerment school works toward problem identification rather than problem solving. It also stands for improving communication skills, assertive behavior and for mobilization of broad social support. The ultimate goal of empowerment is improved social competence and control, whereby the individual or group to be empowered obtains greater influence on the determinants for health care. 273;886 885 887 296 295 The primary goal is to strengthen the individual’s or group’s belief in their own resources and competence as a means of health promotion. In this way, knowledge and skills must be shared with the patient primarily in order to achieve informed consent and optimal health care that encourages long-lasting patient effort and active involvement, including prevention. Empowerment was originally a radical, liberating political movement, but has also enjoyed continuous development in the sociology of medical treatment.239;240;543 Fahrenfort239;240 suggested that health care systems within current contexts are too medicocentric and authoritarian to allow for patient education that would lead to true liberation and empowerment of the individual in deciding their own course of disease prevention and treatment. There is a fundamental dilemma in both wanting to liberate and strengthen the individual and then have the patient comply with specific medical regimens or advice. Fahrenfort’s239;240 argument is that one can teach the individual self-regulation, i.e. that the patient can become their own treatment specialist, but that this will require transfer of medical ideology and thereby be just a continuation of the “compliance model”, which is theoretically contradictory to the empowerment of patients/clients. Skelton801 800 concurs and points out that the empowerment concept is often used by health care professionals in a rhetorical sense, where they are able to protect their own interests and ideologies instead of the concept as it was originally meant, that is, for them to share power and influence with patients. One way around any polarizing debate on this topic is to think of empowerment as the ability of the parties (here, dentists and patients) to self-regulate their expectations of each other on the basis of increasing each “partners’’” specific self-confidence.246 18;23;491;678 This is an understanding that lies 63.

further from the concept’s political connotation, but may be necessary for dentists to understand the usefulness of adopting new attitudes. Anderson18;19 further developed this theme and concluded that it is probably less difficult to attain empowerment among individuals with mental, physical and social resources, who are able to take responsibility for the process. But it is perhaps difficult to think that empowerment strategies will work for persons who lack resources necessary for coping with health problems, such as is the case for many anxious dental treatment avoiders. It seems possible that existing power imbalances in dentist-patient relating in most dental practices, contributes to increased marginalization of odontophobic individuals within the health care system. It is important to reiterate that there is documentation showing that the majority of dental treatment phobias are associated with traumatic experiences due to unfortunate or negative dentist behavior, especially in childhood.79;598 Too often, this important association is not emphasized. Odontophobics, due to their patterns of treatment avoidance, appear to be captains of their own dental demise and are blamed for the phenomenon, since most normal adult health values require compliance to regular dental check-ups and treatment. Many Danish hospitals with dental treatment units refuse to treat phobic treatment avoiders with general anesthesia on grounds that treatment cannot be given patients with “social reasons” for dental conditions. Since Carl Rogers' work724;725 in the 1950s and 1960s, educators, researchers, and clinicians have generally agreed that effective helping relationships are characterized by the core conditions of empathy, positive regard, and congruence with client, student or patient thinking. Northouse648 differentiates empowerment from “referent power”, which is defined as the ability of an individual to influence another because the other identifies with or is attracted to the individual in some way. This applies also between dentists and patients. Empowerment is more a process that enables individuals themselves to take control of the factors surrounding their circumstances, regardless of influences in “favoritism”. Both concepts benefit the patient, but in terms of helpfulness, are particular to the situation and personality of individual clients or patients and their therapists. In summary, empowerment as a viable strategy related to improving the conditions for treatment of anxious patients at the “micro” level must have as its main objective that health care workers see sharing power with clients as one of their goals and that a patient-centered perspective becomes the basis for their activities and methods.124;648;724;725 New structural relations between clinicians and patients can make a balance of power in clinical activities possible. At a “macro” or societal level, there is a moral or ethical imperative to provide health care for all and to avail resources to that end.124;648;724;823 These concepts are crucial for odontophobic patients who have avoided treatment for many years due to anxiety, often associated with iatrogenic factors. Assimilating them back into the dental health care system requires special considerations, not only by individual dentists, but also by the profession and the society as a whole, since these are humanitarian issues. This may require some type of social activism. Dentists and the society at large have a social responsibility to create health care environments that are humane.207

The dentist role - part of the problem and part of the solution The majority of patients are satisfied with their dentists.188;452;496 Dentists have not only a critical role in the prevention and management of dental disease and pain, as described above, it turns out that some also contribute to the formation of dental phobias in some patients.79;598 Bad dental experiences in childhood, including negative dentist behavior, are the most frequently described causes of odontophobia.79;585;598 New knowledge about fear and pain perceptions can help practicing dentists prevent odontophobia. In studying the dentist’s role in this problem, it is useful to observe the context of conditions in clinical 64.

practice as well as the personality traits and value structures that exist among dentists as described in the literature. Literature about the role of the dentist and the context of interactions with patients reveals some very special patterns among dentists that perhaps make this role unique among health care workers. Coleman & Burton158 pointed out that there is considerable difference between dental and medical consultations in that the latter are treatment sessions only in exceptional cases. The functions of the physician in a typical consultation are to investigate, to prescribe treatment, to review progress and to give information and advice. A visit to the dentist, on the other hand, has all of these functions in addition to the crucial function of actual administration of physical dental treatment. As described above, patients usually initiate consultations with dentists, but must more or less acquiesce to the dentist’s expertise, technical focus and familiarity with the clinic. A dentist’s control over the situation can be quite dominating. But are dentists really being dominant in their clinical interactions with patients? In his classic book on the psychology of social interactions, Argyle21 describes dominance as “partly a matter of who speaks most, partly of the degrees of deference with which the two role actors treat each other, of whose ideas are to be taken most seriously, of who shall for the purposes of the encounter be regarded as the most important person.” From the descriptions above, it is apparent that the patient traditionally exhibits deference. There is also evidence that the dentist does most of the talking,158 especially while the patient is preoccupied with opening the mouth. The most frequent lines of communication emanate from the dentist, either asking the patient to cooperate or to the dental assistant at chairside.158 The dentist clearly orchestrates verbal activities and in general is at the center of all clinical activities.158 In extreme cases, one could even argue that the ownership of the patient’s teeth comes into question, at least during the duration of clinical activities, especially when some patients hold paternalistic attitudes770 toward their dentist. Motivation for self-care between examinations may become “not wanting to disappoint the dentist at the next check-up”, rather than genuine patient concern and motivation for oral health. Therefore, there is strong evidence that the dentist often assumes a dominant role in relation to patients,158;831 which is not always satisfying.831 Literature about dentist personality profiles and value structures also support this. In a major literature review from 2001 about studies of personality styles and social values of US dentists and dental students,146 Chambers pointed out general trends among dentists in personal preferences: 1) highly structured and judgmental of others in order to avoid ambiguity and determine personal usefulness, 2) concrete, task-oriented as opposed to theoretical and 3) seeking situations where their accomplishments are appreciated while usually practicing leadership in local (clinical) not larger social settings. Chambers summarized these findings146 in an hypothesis that dentists seek situations where they can exercise power or control and establish paternalistic relationships when helping others, without having to affiliate or be equal with them.146 To check this hypothesis, Chambers sought evidence in the degree of dentist career satisfaction as well as what dentists find satisfying and dissatisfying. Several studies290;450;507;639;791;914;926 including a Danish study (VI), have shown that between 20 percent and 50 percent of dentists are so dissatisfied that they would not choose to be dentists again, “knowing what they do now”. Yet the number leaving the profession voluntarily is less than the number of career changers in the general population by a factor of about 1 to 15.146 Chambers therefore interpreted these high dissatisfaction figures as a “need to complain” or “grumbling”, much as people do about paying taxes. Consistently, reasons for dissatisfaction have to do with issues or situations where the dentist can often lose direct control, i.e. with patients, staff, practice, especially those leading to lack-of-time stress. Issues more under direct control of the dentist were most satisfying, i.e. technical delivery of care and one-time practice decisions where the dentist 65.

had a sense of accomplishment acknowledged by others. Chambers146 concluded that personality and value structures of dentists and the expression of these through professional norms of expected percep-tions and behaviors may serve to confuse our understanding of dentists. Furthermore, the current dental educational system tends to protect this status quo of dentist values and control needs.146 Earlier research supports this, calling for clarification of professional values in dental education.346;471;519;788 Values changes in dental students and dentists were investigated in studies of University of Minnesota students and graduates.471;519 Findings over a ten-year period of time showed significant values changes associated with professional satisfaction. After 5 years of practice, the most satisfied dentists considered dentistry to be more interesting, more artistic and more of a science than did their not-as-satisfied colleagues.471 Findings also showed that values of dentists over the ten years from 1967 to 1977 changed from less ego-involved task focus to more social oriented values.519 Results were similar to a 40-year longitudinal study of professionals872 from 1937, in which Vaillant concluded that the most satisfied professional person is the one who has made a successful personal developmental transition from late adolescence to adulthood and is generally more active, productive and mature. He saw a high level of maturity as necessary for good psychological health. Mature professionals exhibited more altruism, benevolence and social leadership. Values of the most satisfied dentists in the Minnesota study had professional and personal developmental traits that included leadership qualities, social activation (church, civic group activities) and benevolence, with less emphasis on receiving support from others and being looked-up-to and admired.471;519 The most satisfied dentists also seemed to be more optimistic and less threatened by change and the possibility of greater outside control over their lives.471 This supports Chambers’ conclusions in 2001.146 Finally, regarding dentists’ professional values and specific aspects of control in the dentistpatient relationship, sociolinguists Coleman & Burton158 concluded from their studies that the inequality which they discovered in the matter of control in the dentist–patient interaction was due partly to the differences in status and knowledge between dentists and patients and partly to the dentists’ urgent need to get his work completed in a very short time. Even though they found dominance of the dentist in both verbal and nonverbal activities, they did not interpret the dentists’ control merely as a manifestation of the way in which society generally interprets dominance as “negative, dehumanizing and restrictive”.158 On the other hand, they did not perceive dentist-patient communication in these general practice settings to be a delicately adjusted mechanism that had no faults. In light of their unique study observations, Coleman & Burton158 concluded that through his tight control of the dental visit, the dentist succeeds in providing a highly demanding technical treatment in a short period of time for his patient, i.e. that a certain amount of dentist dominance is necessary in order to facilitate complex and demanding work conditions. On the other hand, for the dentists’ sake, a better understanding of the process of personal and professional maturity and clarification of values must become a more important part of becoming a dentist in the future, since this could foster greater satisfaction. Satisfied dentists could also benefit certain patient groups who feel oppressed by the highly-ordered, dentist-dominated practice model. Health care professionals without a mature perspective on the human condition could see anxious patients as distracting, stress provoking, and troublesome in a busy practice, as is discussed in the next section.

66.

Occupational stress among dentists Dentists report a high degree of occupational stress163;178;199;324;589;650 as discussed in Chapter 2. In one of the first larger studies of occupational stress in dentistry, O’Shea and colleagues650 found in a sample of nearly 1000 American dentists that 75% identified dentistry as “more stressful than other occupations”. However, most believed that other dentists were under more stress than themselves. The stressors particularly noted included falling behind schedule, striving for technical perfection, causing pain or anxiety in patients, cancelled or late appointments, and lack of cooperation from patients.650 These common dentist stressors were also found in other studies in the US199 as well as in other countries.163;178;324;575;589;883;913 O’Shea et al. suggested more research on stressors that daily occur in office, waiting room and operatory environments. Micheelis575 conducted a survey of 274 German dentists regarding work stress and psychosocial work conditions and found that the dentists’ work environment was marked by the necessity to inflict pain or unpleasantness on patients. Dealing with constant demands of compassion, understanding and emotional control led many of the dentists to a feeling of exhaustion. Similarly, another survey of 473 German dentists’ stress levels883 indicated that 80% suffered from some degree of stress reaction and did significantly more so than comparison groups of physicians and business executives. Perceptions of stress were most evident in patient contact situations, especially when inflicting pain or unpleasantness. Results were similar to an earlier Swiss study45;343;344of 1759 dentists and their perceived stress and reactions. Möller589 studied stress and coping among 311 South African dentists and found that about 40% perceived extremely high stress levels. Stressors they most often experienced were financial, time and scheduling pressures, followed closely by patients' unfavorable perceptions of dentists, being perceived as inflictors of pain, working with children, treating nervous patients, concerns about the future and worrying about an oversupply of dentists.589 Next to financial or scheduling issues, problems in dealing with patients were the second most frequent group of stressors. In in-depth interviews with 25 US practicing dentists, aged 26-60 yrs, Hilliard-Lysen & Riemer359 found that the occupational stress the dentists encountered were mainly due to 1) economic problems; 2) status dilemmas (felt that the rest of the medical community and the larger society viewed them as “2nd-class doctors”.); and 3) the involvement of pain in dental work, that hampered development of any strong dentist-patient relationships. They concluded that the collective result for many dentists is frustration and stress from their work world, which could result in marital and family problems, substance abuse, and at times, major depression or suicide. Danish dentist perceptions of stressors were similar to other international studies described above according to two separate studies(VII).95 Nearly 60% of Danish dentists surveyed perceived that dentistry was more stressful than other professions (VII). In Table 3 below, the most intense and most frequently occurring stressors described by Danish dentists are ranked, showing a clear tendency toward work schedule related problems and inflicting pain or fear as the top sources of occupational stress (VII). As in most of the healing professions, dentists report valuing their relationships with patients among their satisfactions with practice.560 However, they also report that patients who demand more attention ("troublesome patients") create some of the most stressing situations in their professional lives (VII),163;650;864 similar to the other international studies cited. Studies on dentists’ stress reactions during invasive procedures have also shown that dentists experience specific psychological and physiological affects. Studies have shown that dentists have specific reactions to providing anesthetic injections,201;591;714;797;883 dental treatment in all phases (injections, drilling and

67.

extractions)122;123;214;883 and dental extractions on anxious vs. non-anxious patients111 i.e. infliction of pain or anxiety. Table 3. Perceived stressful situations – Danish dentists’ evaluations (N=216) by intensity and frequency (Moore & Brødsgaard, 2001, (VII)) Perceived stressful situations: Running behind schedule/emergencies Causing pain/unpleasantness Too heavy work load Late patients Anxious patients Inadequate assistance Talkative/uncooperative patients Broken or canceled appointments Technical demands for perfection Patients not opting for ideal treatment Regulations and governmental control

Intensity Rank

%

Frequency Rank

%

1 2 3 4 5 6 7 8 9 10 11

74.5 41.2 29.7 26.8 26.4 23.7 22.3 17.6 15.3 10.2 4.7

1 3 2 4 8 9 7 6 5 11 10

69.4 32.0 37.0 28.7 22.7 12.0 23.1 24.0 24.1 7.9 9.3

Render714 surveyed 181 American military dentists’ perceptions about inflicting or anesthetizing patients’ operative pains and found most experienced a classic “stress response”, both immediate and continuous, after this type of dental stressor. Render also confirmed that the way an individual perceives a stressor is more important than the stressor itself. Similarly, 18.8% of 711 surveyed California private dentists201;797 reported that the administration of injections caused them enough distress to have at least at some time reconsidered dentistry as a career.797 There were no differences by type of injection. Two-thirds of the respondents also described anxious patients as the main source of dentists’ distress, followed by treatment of children.201 Authors concluded that anxious or child patients contributed significantly to overall perceived professional stress and are troublesome for many, but not all, dentists. Another study592 also identified the administration of the inferior alveolar nerve injection as a significant source of stress for 26 military dentists during 78 observations of heart rate changes. Half of the dentists perceived patient anxiety or fear in at least one patient (18 anxious patients in all). The same 13 dentists had notably higher mean heart rates for each of the measured periods, regardless if patient stress was observable or not, than did the dentists who did not perceive stress (anxiety/fear) in any of their patients. This demonstrated that although all dentists experienced stress in administering inferior alveolar block injections, heart rate elevation occurred faster in those dentists who perceived stress in some patients. These results were comparable with a hierarchy of dental stressors in a survey study of 30 American military dentists.690 There is also specific evidence that stress reactions in dentists during dental treatment parallel those of their patients.111;122 Brand122 observed that changes in mean heart rate and systolic and diastolic blood pressure were induced by both anticipation and actual dental treatment and that dentist changes reflected patient distress, especially before administration of a local anesthetic, during subgingival debridement and during extractions. Individual changes in patient heart rate and blood pressure were affected by age, gender, hypertension, previous dental experience and the experience of pain. The study emphasized the need for adequate anesthesia, not only for the patient, but also for the 68.

dentist’s sake. Similarly, Borea et al.111 made 72 observations on heart rates and blood pressures of 6 dentists treating 12 patients of which half were anxious and half were non-anxious. Half also had difficult and half had less difficult extractions. Results suggested that 1) dental extractions represented a particularly stressful task for dentists; 2) during operations, patient anxiety had more negative effects on cardiovascular reactions of dentists than did extraction difficulty; and 3) dentists’ cardiovascular responses to stress were significantly dependent on an “intrinsic stress reaction” rating of each individual dentist. Direct evidence for stress from treatment of anxious or distressed patients could also be compounded by the stress of “running behind schedule” (VII).592 Herein lies the potential (to many dentists, this may mean “threat”) that extra time demands for special behavioral management of even one anxious patient might change office dynamics for any given clinical work day, depending on the amount of time scheduled, the case load for the day and the procedure to be performed. In relation to such time or economic pressures, more time may be required for treatment of anxious patients than many of the dentists from the Danish study were willing to spend, mainly due to “fee-for-service” economics of most private clinics (VII). Therefore, since anxious patients exhibit unpredictable behaviors and require time consuming management, they do not fit the description of “good patients”177;649 (being on time, paying bills promptly, accepting the dentist's treatment plan) and may contribute more uncertainty and stress than dentists are willing to admit. Without question, the literature shows that the social aspects of dental practice are quite demanding for the dentist and that patients who do not fit into the normal time plan of the dentist perhaps contribute most to occupational stress. Consequences of dentist occupational stress Dentist satisfaction and occupational stress have usually been researched as independent phenomena associated with dentists’ physical or mental health as described earlier in Chapter 2 in the Hendrix model of stress in dentistry.350 The traditional consequences of dentist occupational stress are briefly covered here first, in order to indicate the personal consequences and emotional significance that occupational stress can have for dentists. This includes a discussion of emotional “burnout”, alcohol abuse and suicide among dentists. Consequences of occupational stress in dentists in relation to quality of care of patients are largely unstudied. The limited literature on this topic, particularly in anxiety provoking or pain reaction situations, is covered at the end of the section, including study VII from the doctoral dissertation. 1) Effects of stress on dentists’ physical health There are adverse health consequences reported for dentists related to occupational stress,95;132;199;366;575;866;883 which can also simultaneously effect job satisfaction. Results from a study132 of 393 British dentists’ reasons for premature retirement due to illness (1981 to 1992) indicated most frequent causes to be musculoskeletal disorders (29.5%), then cardiovascular disease (21.1%), and neurotic symptoms (16.5%). 82.7% of cases examined were in the > 50 years age group. Burk et al132 concluded that musculoskeletal disorders and stress-related illnesses were the two most important groups which influenced premature retirement. In 2002, Berthelsen et al.94;95 also showed a significant relationship between occupational stress and dentists’ health on a sample of 222 Danish dentists. The dentists perceived considerable stress due to changes in their role and relationships with patients, as well as other practice management demands. They reported significantly more musculoskeletal symptoms from neck, shoulder and low back than did the general Danish population, while the level of psychological distress was only slightly higher and 69.

their self-rated global health was better than other Danish adults. A study of public health dentists in Sweden found similar results.72 2) Effects of stress on personal and occupational performance: ”burnout” phenomena Consequences from high occupational stress that are more directly related to occupational performance are so-called burnout phenomena. Dentist stress in a busy dental practice is affected by contacts with patients and staff. If the stress is felt as negative and extreme, with little or no feelings of control over the situation, this continual contact with staff and patients can lead to burnout.244;540 Professional burnout, a long-term consequence of occupational stress, is considered to be a factor that explains a substantial proportion of incapacity for work.484 It was added to the mental health lexicon in the 1970s.538;682 It has been detected in a wide variety of professionals including physicians, nurses, social workers, dentists, care providers in oncology, AIDS-patient care personnel, emergency service staff members, mental health workers, and speech and language pathologists, among others.484 In a 1996 study cited earlier,883 473 German dentists were compared with 1,570 physicians and 357 business executives and found to have significantly more perceived stress. Stress reactions were also compared and dentists reported erratic work performance, worries, feelings of weakness, and pathological muscle tension complaints signific-antly more than physicians and business executives. These are classic burnout symptoms, since burnout literature lists three main components: emotional exhaustion (weariness triggered by repetitive emotional demands of patient/client exposure), depersonalization (distancing response exhibited toward patients), and diminished personal achievement (lack of feelings of professional accomplish-ment).244;539;540 A study of 600 American health care workers244 indicated that burnout resulted in lowered production, increased absenteeism, increased health care costs, and increased personnel turnover. The physical and behavioral changes associated with burnout, in many cases, lead to drug abuse.366 Depression may also be a consequence of prolonged experience of burnout.366 Employees who had worked for many years in patient care settings were particularly vulnerable to burnout,682 particularly patient care in mental health settings.682 Only one case study report267 had specifically investigated issues of dentist stress or burnout on patient care,366 before article VII, described below under “Dentist stress and perceptions of anxious patients”. In a review of burnout in dentists, Humphris366 confirmed that dentists are prone to burnout in large part due to possibilities for losing control over patient treatment situations.366 Prevention was deemed possible if dentists recognized the burnout process and took measures366 such as better communication with staff, recognition of individual worth, job time redesign, flexible work hours, full orientation to job requirements, and greater use of free-time activities.366 Although burnout among dentists has been described in many professional articles, it has only occasionally been the subject of empirical study.366 Most recently, occupational factors related to levels of burnout among over 700 Dutch dentists was investigated in two larger studies302;303 showing high burnout levels especially related to emotional exhaustion and stagnant career development. They recommended attention to career planning among dentists, much as Chambers146 and the University of Minnesota471;519 dentist values studies suggested. In one of the earliest studies of dentist burnout, Murtomaa et al.640 surveyed 232 Finnish dentists and found that almost half were exhausted at the end of each day. One third of dentists experienced some apathy about what happened for their patients. Similar results were found on three different English dentist samples185;367;660 totaling over 700 subjects where burnout was measured by Maslach Burnout Inventory (MBI)539 subscales: emotional exhaustion, depersonalization and personal 70.

accomplishment. Dentists were more likely to report high levels of emotional exhaustion and low levels of personal accomplishment if they worked in solo practices, with a high number of days per week spent in practice and low job satisfaction. Berthelsen94;95 reported only moderate burnout overall in 220 Danish dentists, citing “high burnout” in only 18% of women and 19% of men. However, of men who had high burnout, 47% were in solo practice and 19% were in group practice settings. Middle-aged men and men with longer work weeks had higher burnout risk.94 A study695 of 121 British mental health professionals about perceived sources of stress and satisfaction at work found similar results in that stress from "clients" was associated with the "depersonalization" component of burnout (apathy). Emotional exhaustion and poor mental health were associated with less career satisfaction. Other reports of burnout in nursing were similar.244;376;855 3) Alcohol/substance abuse among dentists Symptoms of psychological burnout and/or depression are sometimes related to misuse or abuse of alcohol or other mind-altering substances among health professionals.152;415;434;702;771;915 A 2001 US literature review indicated that the most common early sign of suicidal ideation in dentists and physicians is alcohol and/or substance abuse.14 Those dentists who report more effective strategies for coping with stress experience fewer health problems.300;589 (“Stress coping” is covered in a section below.) Alcohol use among dentists appears to be more common than substance use, according to US studies.340;702 A 2003 study by Winwood et al.915 of 312 Australian dentists in which levels of stress, personality and alcohol consumption were measured showed that high levels of stress/burnout and related alcohol abuse were between two and four times higher than the normative South Australian population, particularly among male and rural dentists. However they concluded that compared with work stress/burnout, existing personality factors were much stronger predictors of hazardous alcohol consumption.915 In the most recent (2004) study, Kenna et al.415 investigated alcohol use, misuse and abuse in a sample of 479 US dentists, nurses, pharmacists and physicians. It reported on patterns of alcohol use, monthly drinking, heavy episodic drinking, alcohol-related dysfunction and social or professional influences. Kenna et al.415 concluded that when compared to the general population, healthcare professionals appear to drink less, but also reported that dentists used significantly more alcohol in almost all categories than other groups of healthcare professionals. However, use of alcohol was thought to have a slightly greater impact on social dysfunction of nurses than for dentists. Kenna et al.415 were not able to determine in this study whether the nature of the association between dentistry and alcohol use was best characterized by selection (professional career choice and image) or other socialization variables, such as job stress, after becoming a dentist.There were no published findings (MedLine) about alcohol use/abuse among Scandinavian dentists. Thus, the few literature sources available indicate an association between dentistry and alcohol, but seems inconclusive regarding maladaptive use of alcohol related to occupational stress in dentists. 4) Suicide among dentists At the extreme of burnout and/or depression is suicidal behavior. There have been varying reports over the last 30 years, but dentists have been generally recognized as an occupational group with a high incidence of suicide.359;658;659;821 Möller589 reported that 15% of the 311 South African dentists he studied had had serious suicidal ideations at some time. However, in a 2001 review of US literature on stress and suicide in health professionals, Alexander14 asserted that the media repeatedly portrays 71.

dentists and other health professionals as being at high risk of committing suicide, without reliable data to verify the risk, nor any relationship between stress and suicide. Alexander14 concluded that largescale studies, and not results of regional studies with varying quality and conclusions, are needed before drawing general conclusions about occupational stress-related suicides among dentists. However, Alexander did call for educational reforms to aid dentists in managing the stress of dental practice.14 In a 1996 study, Stack,821 whom Alexander cited, pointed out that past work658;659 had focused on bi-variate dentist-suicide relationships and that risk of suicide among dentists due to occupat-ional stress could be confounded by e.g. gender or divorce, which are known co-variates of dentist status related to suicide.589;700;701 Stack821 reassessed dentistry's co-variates using the 1990 National Mortality Detail File (U.S. Public Health Service) that included 21 states and found by comparing dentist suicides with a controlled mortality risk group and multivariate analysis, that dentists had a significantly higher risk of suicide (564% more than normal). He suggested that occupational stress might be a meaningful source of dentists’ high suicidality. Although no published reports of dentist suicide in Denmark were available, a study from census data in neighboring Sweden22 indicated that dentist suicide rates from 1961-1970 showed no differences from the general Swedish population, but that male dentists were nearly two times more likely than other academic Swedish males to commit suicide. The number of Swedish dentist suicides over this time period was very low (n = 20) out of ca. 4700-5000 dentists. Thus, there are no published data reporting high Scandinavian dentist mortality due to suicide and no relation to occupational stress has been studied. However, a US Institute of Medicine42 summary report from 2003 lists US dentists as having OR = 5.4 greater risk of suicide compared with OR = 2.3 greater risk for physicians than reference populations. This report made recommendations similar to those of Forrest256 who confirmed a self-destructive pattern among dentists more than for other occupational groups. Certain dentists with risk characteristics may need to achieve a desirable balance of stressors with career satisfaction through re-evaluation of life style, health habits, and personal goals.256 Dentist stress and perceptions of anxious or “troublesome” patients; "labeling” effects There have been relatively few investigations studying possible associations between dentists’ perceived stress levels and how they perceive “troublesome” or anxious patients and their treatment as a consequence.267;366 In studying possible associations, one issue is whether dentists even notice patient anxiety. Some studies have indicated that dentists have sometimes had difficulty spotting anxiety,65;172;890 but the studies did not try to examine why. Lack of sensitivity would be detrimental for anxious patients, since they require extra time and special strategies for successful treatment.172;649 Dentists who feel highly stressed could potentially be less sensitive or responsive to anxious patient needs for special attention or could result in decreased quality of treatment or errors.223;582;893;894 Another issue could be if dentist stress might play some role in whether dentists can accurately differentiate dental anxiety from general anxiety and if they provide appropriate management. Only a minority of patients who are anxious about dental treatment have been reported to exhibit complicating general anxiety traits84;511;585;611 as inferential cause. Dentists who would incorrectly assume general psychological traits as the main cause of dental anxiety could be prone to adverse labeling of anxious patients who are not suffering from such general disorders. Such dentist beliefs could lead to e.g. avoidance of treating anxious patients or provision of overtreatment with general anesthesia or sedation, where most would require only a little extra time, personal attention and patience.172;324

72.

The medical literature suggests that patient attributes can affect physician perceptions and behavior as counter-transference phenomena.203;219;364;647 Labeling theory proposes that constructs of normal social perceptions from within a specific context, e.g. mental institutions, medical clinics, dental clinics etc., color the health care professional’s perceptions of any particular patient, often leading to false or biased assumptions and stereotyping outside the patient’s own context.732;752;753 These assumptions can lead to or facilitate positive or negative outcomes for patients (VII).732;753 Wills908 described the “good patient” for professional helpers in terms of 1) likeability where good patients are described as agreeable, likeable, warm and attractive; 2) manageability i.e. obedient, conforming and willing to fill the role of patient with little risk of threat to professional authority; and 3) treatability in which the good patient exhibits a less complicated level of pathology and demonstrates high motivation for treatment. Others have also suggested that these categories apply to dentist traits.205;206;383;384;649;858 Since the dominant actor in the dentist-patient relationship is the dentist, it is important to understand how the dentist perceives patient attributes, which are often based on first impressions, and how these affect dentist communication and behavior as well as treatment outcomes. Based on earlier qualitative descriptions of dentist perceptions,649 Rouse & Hamilton744 had 618 dentists rate their patients with a questionnaire. The results indicated that they did indeed judge patients on likeability, manageability and treatability or prognosis, much as Wills described. They also determined that dentists exhibited preferential treatment of their patients based on patient selectivity.384;744 More recently, Thierer et al.858 studied relationships between six dentists' communication behavior and their perception of 47 patients’ attributes (Wills’ model of Likeability, Manageability, and Treatability908) as well as style of communication (non-controlling, controlling or neutral). They observed dental hospital residents’ verbal and nonverbal communication behaviors with patients in videotaped séances. Based on questionnaire data about his/her perception of each patient, they found that verbal and nonverbal communication leads by dentists were significantly correlated with their perceptions of patient attributes in each case, including the amount of recognized interruptions that the dentist allowed. Interestingly, dentists tended to view talkative patients negatively, but used more time orienting to them, while spending less time and used more controlling communications on patients they viewed favorably. These dentists altered their communication behavior based on patient attributes in order to feel comfortable or appreciated by their patients, inspite of their need for control. This supports Chambers’ description of “grumbling” dissatisfaction of dentists.146 Baric et al.63 and Handelman et al.330 examined nonverbal and verbal behaviors of dentists during videotaped interactions with geriatric patients. Baric et al.63 found that there were high correlations between “patient-centered” nonverbal behaviors such as amount of time the dentist was looking at or oriented to the patient and if he liked the patient, found the patient manageable and if the patient could be treated reasonably efficiently. Handelmann et al.330 specifically studied verbal communication using the same videotapes and found dentists’ communication leads to be of three kinds: controlling, non-controlling and neutral. Results indicated a high proportion of closed-ended questions and no statistically significant differences in communication by gender. Dunstone conducted interviews205;206 about Australian dentists' perceptions of their patients using Wills’ categories.908 Although concerns of dentists were markedly similar to those of other helping professionals,908 the rank order of value priorities were perhaps specific to the dentist’s work environment. The 17 Australian dentists’ preferences (aged 29-60 yr.) were patient likeability (specifically naming giving vs. taking, passivity, gregariousness), manageability (specifically naming trust, cooperativeness, interpersonal sensitivity) and treatability, in that order. Dunstone also 73.

analyzed four perceptual processes that occur in everyday clinical situations that often lead to unfavorable perceptions of patients and work against motivation to help them. Evidence of three of these four processes was found in the constructs described by the dentists: 1) attraction to similarity with patient interests, 2) tendency to attribute other’s behaviors to personality, while attributing one’s own behavior to situational factors, and 3) psychological reactance to the patient's resistance to dentists’ control of the situation. These were also similar to what Chambers described for US dentists.146 Ironically, the fourth process, tendency to focus on negative aspects of patients' behavior, was not found. These dentists tended to sample more positive aspects of patients' behavior. In view of studies on dentists’ perceptions of patients, it is probable that such labeling of patients can lead to unfavorable or even harmful outcomes for “troublesome patients”.384 As an example, in one case study a patient’s dental anxiety reportedly led to an initial misdiagnosis of an endodontic pathology.223 Since fear, anxiety and anticipation of pain are prepotent emotional and cognitive mediators of pain behavior, pain reactions used in evaluating tooth vitality could obfuscate a diagnosis, especially if the dentist was not aware of his own stress reactions to patient anxiety. Moore & Brødsgaard (VII) observed that Danish dentists’ perceptions of anxious patients can often lead them to label anxious patients and associate them with perceptions of stressfulness in practice. Dentists who tend to label their patients as generally psychologically compromised, when their anxiety is specific to dental treatment, might adversely effect the quality of dental care, as reported in other studies of influences of dentist perceptions on quality of care.583;893;894 Dentists often only get quick, frustrating glimpses of odontophobics in emergency situations,297;530;611 and often only to experience that the patient disappears afterwards, inspite of promises to pursue regular care.297;530;611 Such patients can often be stereotyped with pejorative terms such as "crazy" or "nuts" because of the demands they make, complaints they express and lack of motivation they show (VII).611 Even though anxious dental patients in reality may not all exhibit other psychological complications, each one brings along a set of bad experiences and negative expectations417 that have uniquely influenced their perceptions of dentists and/or dental procedures often creating dramatic phobic reactions. These learned reactions to dental stimuli often appear extreme and could be confusing to dentists untrained in differentiating a specific dental anxiety reaction from a general anxiety reaction. However, as shown in earlier studies,247;611 only about 20 to 35% of odontophobics have multiple fears or other psychological conditions that could complicate treatment of dental anxiety, whereas in the majority of cases, specific dental anxiety or phobias can be treated with simple relaxation and desensitization techniques. Dentists' experiences with and beliefs about anxious patients are important in order to understand 1) how to improve education of dentists about treating anxious patients and 2) to reduce possible adverse effects of dental anxiety on dentists' occupational stress and satisfaction. Increased dentist awareness is important to the success of any systematic attempt to treat and prevent dysfunctional dental anxiety in a population.598;605 However, there is limited literature on effects these patient behaviors have on dentist beliefs and the ways dentists approach such situations. Also, even though British,163;165 American,650 Canadian,116 South African,589 Australian,503 Italian111 and Swedish324 studies about dentist occupational stress pointed out that anxious patients or painful treatments contribute to adverse stress reactions, no previous studies have reported on dental anxiety patient characteristics in private practice settings compared with anxious patients seen in specialist clinics. Neither had private dentist beliefs and behaviors related to a particular patient anxiety level been described in any studies. Therefore, kinds of problems and amount of patient dental anxiety experienced by Danish private 74.

dentists as well as dentists' beliefs about dental anxiety phenomena were explored in a qualitative study (IV) as well as a larger quantitative study (VII). The first aim of the qualitative study (IV) was to compare anxious patients' thoughts and behaviors in Danish private practices with those of the specialist clinic using standard anxiety and behavioral measures. This attempt at calibration was based solely on judgments of the dentists as to which patients they would consecutively select as “anxious” based on their own experience. The design was seen as advantageous since the dental anxiety specialist clinic (acronym "FoBCeT") and patient samples had previously been described in the literature for comparison. The second aim was to assess the beliefs and experiences of private dentists involved in treatment of these patients in order to estimate influences of dental anxiety on routine dental practice and needs for professional education on the subject. Characteristics of 53 anxious patients were surveyed from 26 randomly selected private practices (PP) in Århus, Denmark and were compared with those of 80 FoBCeT patients (IV). STAI general trait anxiety was greater than the mean value for adult Danes in 40% of PP cases compared with 46% of FoBCeT cases, while GFS (Geer Fear Scale for “general fearfulness”) total scores were greater than the mean for 57% of PP patients and 55% for the FoBCeT sample. Thus, general anxiety and fear levels of private patients did not vary significantly from FoBCeT patients. Dental anxiety (DAS)167 means scores of PP patients (15.7) before treatment were significantly lower than patients treated at the specialist clinic (mean = 18.1). Inspite of this, dropouts (58.5%) in private practices were much greater than for FoBCeT patients (10%) during the same time period. Broken appointments among private dental patients were also greater per scheduled appointment (85/357 = 25%) than for FoBCeT patients (99/917 = 11%). Of a subsample of 20 telephone-interviewed dentists (16 men, 4 women aged 35-66 yr.), frequencies of anxious patients in their practices were estimated to be between 0.3% and 9% (mean = 1.9%). Of these dentists, 75% had experienced broken appointments as the most characteristic behavior. While 35% judged dental anxiety to be due to the patients' own personality, 40% blamed previous dentists and 10% neutrally pointed to a relationship problem between dentists and patients. So dentists saw the anxiety problem as either 1) dentist caused, 2) patient caused or 3) troubles in the dentist-patient relationship regardless of fault (IV). The dentists expressed confidence about treating anxious patients, but also a need for more education about management skills. Using knowledge from the qualitative study about Danish dentist experiences and beliefs about anxiety, as well as other literature about perceived occupational stress and dental anxiety treatment practices, a study of dentists was designed to examine consequences of stress in dental practices as it affects perceptions about anxious patients. Using the Stress in Dentistry Model,350 an epidemiologically representative sample of 216 Danish actively practicing private dentists (VII) completed a mailed questionnaire about their perceptions about dental anxiety and its management. As reported in the preceding section, nearly 60% perceived dentistry as more stressful than other professions. Dentist perceptions of most intense stressors are seen in Table 3. Odds ratio analyses were undertaken for associations of perceived stress or other dentist variables with perceptual outcomes about anxious patients. Results showed that for those dentists who perceived their occupation to be more stressful than other professions, there was a significantly increased likelihood that they would not be able to recognize dental anxiety among their patients. Ability to detect signs of dental anxiety was reported less often by older (>52 years) dentists (OR = 3.1) who perceived high job stress (OR = 3.2). For the whole sample of 216 dentists, perceived causes of dental anxiety (1st, 2nd or 3rd choices tallied and then ranked) were 1) fear of pain, 2) trauma in dental treatment, 3) general psychological problems, 4) shame about dental status and 5) economic excuses. Some dentists tended to label anxious patients as generally psychologically compromised (VII), which is contrary to current dental literature on characteristics of dental anxiety. 75.

These dentists usually had solo practices (OR = 2.4), older practices (>18 years) (OR = 2.6) and reported high perceived stress (OR = 2.2). Adjusted odds ratios for these two dentist perception outcomes generally improved strength of associations and confidence intervals. There were no meaningful differences by practice location (urban or rural) or perceived public image (poor or OK). Figure 14. Study VII: Adaptation of “stress in dentistry” model to associations between Danish dentists’ (N = 216) perceived stress and other variables about dentist perceptions of anxious patients

Stress Antecedents :

Stress

Stress response or consequence

Personal characteristics * Dentist’s age * Dentist’s gender * Dentist’s practice experience

External factors Perceived * Perceived public image

Spotting signs of dental anxiety

stress Tendency to attribute cause to general psychological problems

Job-related factors * * * *

Number of patients Solo/Group type practice Number of chairs Urban/rural location

Use of pharmacological methods for anxiety control

There was no association between perceived high stress and dentist use of pharmacological agents as initially expected. Nearly all dentists talked with anxious patients as their main treatment strategy. It was concluded that psychosocial aspects of dental practice meaningful and often adverse associations with dentist perceptions about anxious patients. Some dentists appeared to require more knowledge about dental anxiety and managing their own stress. One stressor not measured directly in study VII was economic pressures, which is often related to time pressures and have been shown to influence dental career satisfaction. “Time-is-money” as a stressor was perhaps only partly reflected in “running behind schedule” in Table 3, which was the most intense and frequent stressor for Danish dentists in this study. Given trends to expand services by adding auxiliaries in the modern practice of dentistry at the end of the 20th century, economic pressures for dentists became reinforced,94;95 but these were offset by a relatively high volume of patients and adequate amounts of work per patient. This may offer a reason for reluctance of dentists to spend more time with "troublesome patients" during the mid-late 20th century given “fee-for-service“ pay structures. However, up through the late 1980s and 1990s, new patients became more scarce, since dental health in the Western world had improved.593;594 This made the high volume practice less and less feasible.593;594 The practice of dentistry has also required more and more new technology as it has developed. Thus, overhead costs for dental practitioners has been increasing, while amount of potential work per patient has decreased.593;594 Competitive market pressures now push dentists toward more patient-centered practices94;292;451;823 in order to attract new patients, since patients are now better informed about dental health and less reticent asking questions. This has created conflicts about choice of practice style among dentists, since there is traditionally a strain between economic pressures and humane treatment.187

76.

Given evidence that dental practice is very stressful due to patient-staff stressors and the rapid changes in practice management demands described above, it is important to know how dentists deal with occupational stress. Therefore, more specific discussions of literature about stress coping follows. Coping with stress Stress coping strategies among dentists like coping strategies among others can be active or passive in nature.249-251;300;365;366;657;702 In other words, there are less effective ways and more effective ways that dentists have tried to cope with occupational stress. In a US national study of 238 dentists, Rankin & Harris702 found that most used alcohol and/or drugs in moderation, mostly at night (66%), while fewer than 15% reported daytime drinking. Both sexes used alcohol more frequently than other drugs. Godwin and coworkers300 questioned young US dental graduates (N=133) about how they coped with excessive stress or worry in private practice. The main stressor was patient management (anxious patients; difficulty with pain control)300 and they found that 47% of the dentists used sports to “de-stress”, while 44% simply avoided the stressful activities (taking more time off, vacations etc.), 9% developed family activities as primary coping, 8% used religious activities and 8% “used” alcohol or drugs. They concluded that most of these young dentists dealt with stress by passive means and distractions or diversions instead of directly tackling the underlying causes of the stress reactions.300;480;589;657;774 Möller,589 who studied stress and coping among South African dentists, found that although dentists reported low drug use, there were substantial numbers of reported problems in marital and other personal relationships and a severe lack of social involvement or outside interests. Möller589 and others153;300;480;657;774 suggest therefore replacing passive coping habits such as drug and alcohol abuse, sexual promiscuity and other distraction/problem avoidance strategies with active coping such as tackling the problems, exercise, hobbies and family involvement.199;527;619;701 Dr. Hans Selye’s formula for coping 782 is to moderate the amount of stress so that the optimal level for each individual is maintained – that is: “.. the right kind of stress for the right length of time and at the level that is best..” in order to satisfy motivations yet to also avoid burn-out. 782 Selye specified the formula as: 782 1) seeking one’s own optimal stress level ; 2) choosing specific goals and 3) acquiring a sense of “altruistic egoism”, i.e., making oneself necessary to others. Merely identifying the source and nature of the stressors that are harmful, can also have therapeutic value. Although these bits of Selye wisdom were not based on results of any studies, psychologist and stress coping researcher Richard Lazarus and colleagues generally confirm this advice.480;481 Harmful or protracted stress levels do their damage even when a person does not feel frustrated or anxious.774;779;782 If an especially stressful event can be anticipated, it is possible to mentally rehearse a solution in advance. For example, if a dentist writes notes to himself or a special journal entry regarding specific strategies for anxious patients, such techniques can help the dentist prepare himself emotionally, while also showing patients that they care enough to take special considerations.774;782 With adequate priorities for timeframes, satisfied practitioners have been shown to value knowing their patients’ emotional and treatment needs.146;519;743;831 As suggested by Selye,774;782 Lazarus479-481 and others,256 dentists need to be aware of their reaction patterns and promote work attitudes and coping mechanisms that are productive. One study assessed perceptions relevant to the stress and well-being of 86 physicians, 40 dentists, and 94 nurses working in the same naval medical hospital474;855 by having the workers 1) predict the frequency, timing and duration of stressful events in the work environment 2) understand how and why 77.

stressful events happen, and 3) control the outcomes desired by effectively influencing the events, things or patients, so as to decrease stress reactions to the work environment. Prediction, understanding, and control were all found to have direct relationships with perceived stress, but only control had a relationship with job satisfaction. Similarly, descriptions of dentist stress management coursework often consider three approaches: stressor elimination, cognitive restructuring and stress effect reduction, or any combination of the three.714 Stressor elimination requires making choices with the aim to decrease the amount of exposure to those events, situations, or occurrences that can lead to a stress reaction.714 Decreasing stressor exposure by scheduling fewer hours in patient contact is effective for many dentists, according to Danish94;95 and Swedish72 studies. But for some dentists, decreasing exposure could also mean not treating anxious patients or children. For others it could mean referring wisdom tooth extractions or prosthetic cases. For a few it has even meant abandoning the practice of dentistry all together.715 This time and exposure management is often difficult or only a periodic need. Changing the way one perceives the event, so-called cognitive restructuring,224 may also produce long-term reductions in negative stress reaction experienced by dentists. O’Shea et al.177 pointed to redefinition of problem patient behaviors. As an example of dentist beliefs about patients, one dentist wrote in the survey: “It is interesting behavior. Doesn’t bother me because of the educational possibilities with that patient. It makes the day great and non-monotonous. The way patients react reflects how the dentist and staff treat them. It can be a beautiful experience if handled nicely.” With such beliefs and values, there are, by self-definition, fewer uncooperative patients. On the other hand, unrealistic expectations and inflexible beliefs result in internal conversations like: “I need for everyone to think highly of me.”, “To be a good dentist I must be a perfect dentist.” or “I should be able to completely eliminate every patient’s pain.” This kind of thinking compounds the amount of stress associated with an already stressful event. Considering these thoughts as goals rather than demands leads to a much more rational internal conversation: “It would be nice if everyone thought highly of me.” or “I would like to be able to eliminate every patient’s pain.” 714 Finally, dentists who are less perfectionistic and self-doubting are shown to have fewer psychiatric problems.354 Reducing damaging effects of stress is also a beneficial alternative when elimination or redefining a problem are difficult. This requires learning to recognize when a stress reaction is taking place and doing something to return the body or mind states to a baseline level such as through exercise, relaxation techniques, self-hypnosis, recreational activities and meaningful social activities.714 The importance of adopting benevolent attitudes is supported by the finding that satisfied dentists are more benevolent and that dentists who like being dentists also like helping people in trouble or need.749;765 Many researchers suggest that dentists should take specific steps toward expanding their social networks as a way to cope with high occupational stress.153;544;702 Such strategies require self-reflection and support networks of dentists and staff, which requires initiatives to form such networks in most cases. Dentists in group practices have also reported much less distress and greater ability to cope with the stressors they face than do solo practitioners.204 In the study of 222 Danish private dentists, Berthelsen’s results94;95 also showed significant relationships between occupational stress, dentists’ health and social isolation effects of solo practice and concluded that the social support of multi-dentist practices, combined with time-limited exposures to patient treatment situations was beneficial to dentists’ health, regardless of gender. A study of public health dentists in Sweden concluded much the same.72 Dentists in group practice settings appear to have built-in social support networks. Incorporating patients as a part of the dentist’s social network is also a strategy. An era of erosion of public respect in recent times429;558 has lead voices in the medical125;142;473;558 and dental professions429;558;692 to call for a return to improved contact with patients in 78.

doctor/dentist-patient relating in order to improve public image.429;558 A Swedish study showed that dental anxiety specialists have developed natural styles that call on patients and therapist-dentists to share their daily lives and to proceed in treatment based on an understanding of mutual support and trust.456 With the aid of creative stress management and an eye toward personal growth, longevity and quality of life,544 dentists would more naturally and easily be able to cope with the stressors of their occupation. Practice pressures and consequences of occupational stress, have made leaders of the dental profession more aware of dentistry’s public image and the need for dentists to set career goals and attain job satisfaction, all of which point to needs for change in dental education. This interrelated set of topics is covered in the following section.

Dentists’ image, patient and dentist satisfaction and professional socialization In general, population studies report that patients favorably describe their dentists.188;452;496 Even in light of the tremendous service the dental profession has rendered conquering dental disease and painful oral conditions throughout time, as described in Chapter 1, the image of the dentist often historically suffers from widespread popular perceptions that dental treatment is anxiety provoking, unpleasant and often painful. This infers that the dentist inflicts pain and suffering during treatment. Also discussed above were dentists’ needs for control in the dental clinical environment and that resultant dominating behaviors may not be optimal for some patient groups who have special needs, such as odontophobic persons.79;598 Dentist dominance was shown to be correlated with patient dissatisfaction.831 Thus, patient satisfaction with dentists is often dependent on what the patient would expect as ideal dentist behavior, which is reviewed in subsection 1 below. Inflicting pain on patients and the inability to obtain adequate pain control was a direct source of occupational stress (VII)201;591;602;690;797 and dissatisfaction (VI)166;651;797 for many dentists. As if this were not enough, other studies infer that dentists who have dissatisfied patients are also prone to find them stressful, since such patients do not acknowledge or respect dentists’ important contributions to oral health and alleviating endogenous pain 174;175;177 In subsection 2 below, discussions of the relationship between satisfaction and dentist image expectations culminate in arguments for existence of a potential vicious circle between patients and dentists who do not recognize or respect one another’s needs and which bear all the symptoms of a poor relationship. The literatures on patient satisfaction and dentist career satisfaction are also discussed in relation to how they may contribute to this vicious circle of dissatisfaction, occupational stress and poor communication. Finally, dentist stress and career satisfaction issues are discussed in relation to the socialization of dentists in subsection 3. 1) Patient satisfaction and the “ideal dentist vs. the actual dentist” A professional role image carries with it a powerful set of expectations based on a professional ideal. Although patient satisfaction studies have been favorable to the profession,188;452;496 some also reveal something about the image of the dentist that dentist’s often don’t find out directly from their patients, since clinical conversations with patients to evaluate treatment are rare.158 It has become clear that highly informed patients expect to receive health care that satisfies their expressed or often even their unexpressed expectations.831 Since there is compelling evidence that patients’ expectations and beliefs about dentists173;175;831;939 and physicians126;127;161;680;802;935 are highly associated with patient satisfaction/dissatisfaction and regular/irregular health care attendance, this has led to a new motivating force in the provision of health care described earlier - the patient-centered approach.292;517 79.

Gaps in our understanding about the dentist’s image are explored below by studying what patients expect of dentists, what kind of treatment they actually receive and how these are related to concepts of ideal dentist behaviors. Studies of patient and dentist perceptions about ideal dentist role behaviors and how these correlate with actual behaviors have been an important contribution to discovering patterns in what dentists do “right” and what they do “wrong” in the dentist-patient relationship.452;465-467;556;705;873;874 This research perspective was already seen in the early 1960s with the work of McKeithen556 and Kreisberg & Treiman.452 The research aim of these studies was to discover clues in dentist-patient relating, that would improve quality of care and regular dental attendance. In 1964, McKeithen556 compared characterizations of ideal dentists with patient reports about actual dentists by Kreisberg & Treiman.452 Kreisberg & Treiman452 had found patients valuing technical competence of the dentist as more important than the dentist’s personality. However, pain and fear affected patient images of dentists. A mean of 18% of the random patient sample of 1,843 stated that they felt their dentists were not concerned enough about infliction of pain. Patients’ biggest complaint was that dentists are too interested in making money, but almost no one doubted the honesty of their own dentist and most subjects seemed satisfied. On the other hand, McKeithen556 found that a dentist’s personality was just as important as technical competence on a sample of 400 US government employees who were interviewed about best or worst characteristics of dentists (not their actual dentist). To a third of the sample, the ideal dentist was one who was pleasant or sociable, or who possessed a good sense of humor. Upper income groups were less concerned with pain in describing the ideal dentist than were lower income groups. In comparing these data with those of actual dentist data of Kreisberg & Treiman,452 McKeithen556 interpreted that patients needed for the dentist to make the dental experience as pleasant as possible. In general, ideal descriptions focused on factors of dentist’s mannerisms in interactions with patients rather than upon their ability to relieve pain as in actual dentist descriptions.452 One other interpretation was that dentist mannerisms could also affect pain perceptions of patients. A study of 513 Dutch adult patients in 1980,873;874 analyzed ideal expectations about dentistry and dentist behavior and found that patients did not perceive dentists as caring, helping people, but rather as distant and primarily motivated by money. People of low socio-economic status (SES) regarded a reassuring manner as more important than the dentists’ technical skills. Persons with higher SES felt technical skills were more important. Of the irregularly attending patients, 35% gave reasons such as “bad experiences with dentists” and “afraid of going”. Thus, resistance to regular care was influenced by emotional factors and perhaps lack of reassuring behaviors from dentists, as in other studies.260;751 These Dutch researchers concluded that in order to increase regular dental attendance in more patients, dentists need to offer a more personal, caring relationship874 and should learn more about communication in dental school. Lahti et al.465 studied 33 dentists and 271 of their patients from public and private sectors in different parts of Finland to learn about desirable behaviors of the ideal dentist and found that the expectations of both dentists and patients in technical procedures were usually met. In general, patients did not disrupt procedures and dentists were able to concentrate on treatment. The discrepancies most often found between ideal and actual behavior concerned communication skills. Patients preferred the dentist to talk with them more during the course of treatment, especially when they needed encouragement or reassurance. The dentists were not sure whether their patients were interested or motivated about the treatment. These Finnish researchers465-467 80.

concluded that there was a clear gap in communication between dentists and patients, which can lead to frustration for both. They suggested more emphasis on communication skills in the training of dentists. In 1997 a Swedish group458 also found in a sample of 64 dentists that ideal skills of a “good dentist” were in three categories: 1) interpersonal skills; 2) clinical skills; and 3) others, such as selfconfidence, stress tolerance, and managerial or administrative skills. These experienced practitioners rated, in order, contact with patients, communication skills and empathy as the top three. The Swedish researchers concluded that these receive inadequate priority in the dental curriculum.458 2) Dentists’ career satisfaction and their perceived role image Apparent gaps between dentists’ self-images and patient images of them can create potential conflicts for both patients and dentists. Since dentists confront these potential conflicts nearly daily, one could surmise that the issue could be crucial to dentists’ career satisfaction. A recent study of 216 Danish dentists found that what dentists perceived to be their public image had a meaningful association with dentist job dissatisfaction (VI). 216 randomly selected private practitioners in and around Århus completed a mailed questionnaire. Of these, only 19% were dissatisfied so much that they would not recommend dentistry as a career to young people, while almost 60% perceived dentistry as more stressful than other professions and 31% felt that dentists’ public image was less than good or poor. Odds ratio analyses indicated that perceived career dissatisfaction was most prevalent and around three times more probable in dentists aged >45 years (OR = 3.1) or who had practiced more than 18 years (OR = 2.7) and who perceived a poor dentist role image (OR = 3.0). Although career dissatisfaction was over two times more probable with high perceived-stress (OR = 2.1), the contribution of perceived high stress approached, but did not attain statistical significance. Adjusted odds ratios provided slight improvement only regarding age. There were no meaningful or significant relationships by gender, practice type, location or size. Considering these statistics and that nearly all the Danish dentists in the study believed that patients evaluated them more by style or behavior than their technical competence (VII), it was concluded that perceived public image of dentists had a significant and meaningful association with dentist job dissatisfaction. Dentists’ perceived stress also contributed to this dissatisfaction (VI). In a related study, a majority of the dentists questioned wanted the Danish Dental Association to help change their public image (VI). However, US experiences indicate that good patient contacts, not image media campaigns like those of the American Dental Association in the 1980s, may still have the greatest impact on the public’s image of dentists.291;692;804 One author wrote, “People will see us as we see ourselves.”692 i.e. ways that dentists visualize themselves with their patients, as listeners, as technical experts and as leaders, leads the way to positive image changes in their patients. The 19% of Danish dentists who were dissatisfied with their career choice were comparable to 18% in a Swedish study 324 and 33% in a British study.166 As in those studies, dentist dissatisfaction was related to age, stress and patient relation variables. These same British166 and Swedish324 studies as well as an American study,650 affirmed that dentists perceived stress most when patients did not "appreciate" them, especially patients who criticize or show outright hostility toward them. Related to devaluation of dentists and their activities, dentist's images as "inflictors of pain" were also ranked highly as a stressor in the perceived stress study of these same Danish dentists (VII) as well as in a British study163 and an American study.650 Frazier et al. in looking at provider expectations vs. 81.

consumer perceptions, both at the dentist-patient relationship level260 and the mass media level261 also wrote that American dentists need to have a sense that patients and public at large value their role. Therefore a positive dynamic can flourish when cooperation between dentist and patient is optimal. But when it is not, poor relationships can promote a vicious circle for some dental professionals who find themselves “trapped” in a dental practice as shown in the conceptual model in Fig. 15. Besides findings reported in studies VI and VII, a Pearson’s correlation anaIysis of data for the 216 Danish dentists indicated that perceived stress was correlated with career dissatisfaction (P = 0.005) and negative dentist image perceptions (P =0.04). Negative image and career dissatisfaction were also correlated (P = 0.004). Thus, when highly stressed, the dentist may enter a negative spiral and perceive troublesome, anxious or Figure 15. Vicious circle of perceived stress, career dissatisfaction, poor dissatisfied patients as communication and “troublesome patients” among some dentists. job stressors since these patients are often late or miss appointments and Perceived are most often stress unappreciative of his Dissatisfied, work. High job stress ”troublesome” contributes to apathy Poor role patients and poor image communication Apathy and poor (burnout) as well as to communication lower levels of selfCareer worth (image). High stress and poor role dissatisfaction image also contribute to Moore, 2006 career dissatisfaction. Career dissatisfaction can also contribute to a lack of concern for the patient’s perspective /apathy and poor communication. Inevitable negative encounters with dissatisfied or troublesome patients again lead these dissatisfied dentists to perceived stress and the vicious circle is completed. The irony and major concern in this vicious circle is that patients who perhaps need the special consideration of dentists most, such as odontophobics, are also the ones most likely to meet the apathy and poor communication of dissatisfied, overstressed dentists. Future studies will attempt to further verify this conceptual model. The model is derived from the ethnomedicogenesis theory (see Figs. 4 and 12) regarding negative medical outcomes from negative beliefs and expectations. Dentists who perhaps do not enjoy practicing dentistry as much as others provide reinforcement in this negative vicious circle. The antithesis would be that dentists who cope well with stressors of dental practice and who enjoy spending time with people also enjoy the pressures of running a practice and the challenges they face as a professional. Chambers,146 asserted that career satisfaction can be partially predicted from an understanding of dentists' personality and values. Unfavorable time management factors such as uncooperative patients or incompetent staff, and perceived intrusions by government and insurance companies are career “dissatisfiers”. Dentists who are prepared to change their practice routines and who are willing to flex on dominating core values have better success coping with these dissatisfiers.146 Dentists may not be aware of numerous possibilities for attaining career satisfaction. 82.

In the “Minnesota studies” of Lange471 and Loupe,519 profiles of the most satisfied dentists were contented, non-threatened, positive persons, who were active in the profession and community, who had confidence in management skills, and were positive about the direction of dentistry.471 These dentists knew what they wanted and had values that were likely to help them attain their goals. Many of the behaviors shown by highly satisfied dentists read like a prescription for avoiding professional burnout. By counseling dentists to become more active professionally and socially, by improving practice management and communication skills, and by developing a positive attitude toward change in the dental profession, it should be possible to help dissatisfied dentists to gain more positive feelings about themselves and their profession. Although changes toward these positive value structures of currently dissatisfied dentists may be difficult, Lange et al.471 felt it was possible to encourage “benevolent leader” types to enter the profession with new admission selection values. Dentists need to learn to reflect on what it is that they want to get from life and practicing dentistry.146;153;154;405;481;527;765;780 Dissatisfied dentists should not be seen as “culprits” in some dire plot to dominate, but rather as persons who react to a stressful work setting and may not yet be fully aware of the potential they have to improve conditions of treatment, both for patient satisfaction as well as their own career satisfaction. Images as purveyors of pain and fear must give way to mature friendliness and cheerfulness that patients find attractive372;692;804 since today’s patients expect more service and on their terms than in earlier decades.292;823;853 This presents a real challenge to the values structures of dentists and also to the educational institutions that should promote those values. 3) Professional socialization In the discussion above about ideal vs. actual dentists, it was shown that a professional role image carries with it a powerful set of expectations based on a professional ideal. The process of becoming a dentist through professional education charts the course for the ways that dentists behave. Professional socialization337;346;788 is a kind of cultural process whereby standards for what exists, what goals are to be valued and how one should behave are learned by identifying with a group of individuals within an occupation.337 This often includes admission selection procedures such as by social class or familial profession, types of initiation rituals and buildup of networks that facilitate uniqueness of the profession.262;263 Values and normative expectations learned in dental school are usually not learned in formal studies, but rather are informally transmitted from dental academician to eager young dental student346;522;788;796;881 These values have not been shown to be very altruistic and humane346;788 in some studies. There is evidence that stressful or even morbid personality traits 504;544;765;768 such as excessive perfectionism,256;354;556;768;912 productivity vs. time constraints,881 as well as domineering values262;346;788;796 can also be passed on to dental students from dental educators or shaped and modeled by the inherent structure of the dental education.346;768;788 These issues have not been fully acknowledged nor solutions addressed in dental education.146;346;788;927 Many dental school administrators and dental health politicians have become aware of the problem, but changes occur slowly.146;256 Some studies point to the Westernized concept of monochronic time as a major contributing factor to effects of stress348;361;638;687in which life is dominated by schedules. Others in dentistry directly cite time constraints as job stressors.164;165;199;650 Time is valuable and not to be wasted; a force and yet a commodity.348;361;638 Observation of advertisements about dental practice indicate that it is not uncommon to discern “time = money” concepts.528;716;760 The equation of “time lost” is the same as “money lost” and is a very strong dental practitioner motivator726;830 that links to the various stress models described earlier.164;165;199;650 The roots of such thinking point to the product-time model employed in dental education768 and thus are part of the professional socialization process. The product-time model is also operationalized in fee-for-service payment schedules later in dental practice. This stands in contrast to an hourly fee as used in many private mental health care settings. An hourly fee for some dental patients, 83.

especially odontophobic patients, would be more supportive of patient and practitioner needs than present fee-for-service schedules (VII,VIII). Of necessity, professional dental education has had to focus on new and exciting technical advances that the profession has continuously undergone in the last four decades,262;346;788 which may contribute to the product-time and perfectionistic values in dentistry. Human aspects of treatment require more time and reflection207 and have often been assumed to be unlearnable, since they may appear subject to personality differences of dental students or dentists.146;262;471;518;796 But this has begun to change with teaching of behavioral sciences starting in the 1980s.373;420;428;572 Alexander’s14 survey of dental schools showed that dental students received varying amounts of education on stress management. Stress management, communication skills and behavioral techniques can be learned by interested dental professionals373;428;522;572 and it is important that dental school faculties recognize this as a first step in acknowledging the problem of values education in the dental school environment.207 As argued above, it has become financially and emotionally imperative for many dentists to reconsider their previous modes of practice and to enter in good faith with patients to take steps towards improving both patient satisfaction and their own occupational satisfaction. Changes in dentist-patient communication could benefit treatment and prevention of anxiety and pain, as argued in the next section.

Meaning of anxiety and pain to dentist-patient relations and communication As described in several ways above, what dentists and patients believe about each other, especially regarding dental anxiety and pain phenomena, is important to their satisfaction with dental treatment situations. According to the theoretical model at the beginning of this chapter, the phenomenon of Table 4. List of examples of common inappropriate beliefs or expectations that patients and dentists can have about dental treatment or each other. (Many are possible hypotheses for future research.) Patients

Dentists

“Injections in the front of the mouth hurt more than in the back of the mouth.”

“Palatinal injections of local anesthetic hurt more than others.”

“My teeth are difficult to numb.”

“Patients only think they have pain.”

“Root canal treatment is always painful.”

“Anxious patients are just exaggerating and have psychological problems in general.”

“The best way to cope with dental fear is get in and out of the treatment as quickly as possible.”

“It takes too much time to work with nervous or anxious patients.”

“Some people faint without any apparent reason.” “Only a psychologist can cure anxious patients.” “I know that I’m tense, but I just can’t relax for fear that it will hurt.” “Training in slow, controlled breathing doesn’t work.” “Dentists are more interested in money than in my well- “Time is money.” being and feelings.” “Patients must have optimal dental treatment and don't “Dentists overtreat patients and thus can’t be trusted.” understand how necessary it is.” “Tooth cleanings are the worst! They hurt!”

“Tooth cleanings are not painful, just uncomfortable.”

“It has to hurt during dental drilling.”

“Some patients only say it hurts when they are really only anxious.”

dental anxiety and differences between patient and dentist perceptions of pain may be facilitated by misunderstandings and incorrect beliefs generated by both roles and that can lead to decreased quality 84.

of care605 (see Table 4 above for hypothetical examples). Unconfirmed beliefs or expectations about each other and procedures can lead to assumptions that do not fit the actual situation had the partners communicated properly toward some mutual understanding and expectations. This can increase the probability of negative expectations and anxiety or pain for patients (VIII)4;7;585;611 as well as countertransference reactions in dentists, that lead to stress and eventual dissatisfaction (VI).113;166;926 The setting for interactions between the two roles occurs in the dental chair during the busy daily routine of a dental practice. Patients visit dentists and enter their world only perhaps 2-5 hours a year, while the dental workplace consumes personnel with daily rituals that can lead to presumptions based on their own work needs, e.g. horizontal chair position, staying on time and tight scheduling. The ability of the medical or dental professional to be supportive and relate well with a patient who is fearful or has negative pain expectations appears to be directly dependent upon the ability of the clinician to see the clinical reality from the patient’s perspective,217;454;456;457;506;745 e.g. communication to find out that an anxious patient feels more comfortable sitting less horizontally in the dental chair or needs a rest pause or more anesthetic. Unfortunately, health care providers are often ill equipped in their biomedical training to respond appropriately to the expectations of patients and their needs for information, reassurance, and effective treatment66;134;472;488;684;736;745 and this leads to subsequent negative beliefs and expectations or even fear or anxiety in patients.585 Since specific beliefs about the dentist and dental treatment are reported to be related to both dental anxiety,7;389;604 pain experienced,460 and expected or feared pain40 (Chapter 4), it is surprising that the emotional meaning of these beliefs have only been researched in a limited manner to date. Many studies that use measures of dental anxiety on anxious patients also include the Dental Beliefs Survey (DBS) which in various factor analyses455;461;463;585;604 has been shown to measure patient beliefs about social interaction distress with dentists,455 trust of dentists, control in relation to dentists, belittlement by dentists, communication with dentists and, in a revised version, dentist ethics.463 Johansson et al.389 found that dentists’ belittlement of their patients had the most clearly defined correlation with dental anxiety. Kulich et al.455 found communication and social interaction distress factors to dominate overall DBS scores of Swedish odontophobics. On a sample of 474 German patients,460 DBS scores were also shown to vary significantly with absence or presence of dental pain. Clinical usefulness studies of odontophobics have indicated that DBS change scores are highly correlated with dental anxiety after successful treatment,389;460;461;604 indicating that patients’ beliefs and expectations about dentists are crucial to long-term success.4;7;585 Aartman et al.3 in Holland and Kvale et al.464 in Norway also found that although a significant anxiety reduction was achieved after specialist dental fear treatment, up to 37% of odontophobic patients had not visited a dentist at followup one year later. This was explained in the Norwegian study464 as inconsistent changes in dental beliefs (DBS). Abrahamsson et al.4;7 discovered that even after only a first meeting with a dentist, many Swedish odontophobics had reassessed their negative beliefs about dentists enough that it was predictive of successful specialist treatment outcomes. Moore et al. (VIII) showed that specialist treated Danish odontophobics were significantly more often regular treatment attenders after 3 years than were patients in a comparable private practice control cohort. The group of Danish anxious avoiders who had remitted on their own to regular dental treatment with private dentists had significantly reduced their dental anxiety, but not their negative beliefs (DBS) about dentists at 3-yr follow-up. Specialist treated patients, on the other hand, showed significantly reduced anxiety and negative beliefs and both were significantly lower than the private practice controls (VIII). One can conclude that DBS is useful in explaining some of the variance in behavioral outcomes of dental

85.

anxiety therapy. It explains the meaning of patients’ anxiety about dentists, i.e. insight into the contribution of negative beliefs to odontophobic patients’ suffering. Other than the DBS, which specially looks at beliefs about dentists and relating to them, there is currently only one other instrument that could be used to study the overall relationship of patients’ dental beliefs to anxiety or pain. Locker508 recently (2003) developed what can be called the “Psychosocial Impact of Dental Anxiety Scale”(PIDAS) in order to capture emotional meanings stemming from dental anxiety and any related general fearfulness. Originally piloted in 1996 by Kent et al.425 as the Social Attributes of Dental Anxiety Scale, the PIDAS explores factors that could impact negatively on anxious dental patients, both pointing to consequences of the anxiety and their specific expectation antecedents. The scale was designed for evaluation of non-dental outcomes and correlated well with DAS scores508 and FSS-II “other fears” 289 on a sample of over 1200 Canadian subjects. Locker specifically added four items to Kent’s425 two dimensional scale in order to capture feelings of inferiority and embarrassment and could identify three dimensions: 1) personal psychological outcomes, 2) negative effects on social relationships and 3) avoidance or social inhibition. The most commonly reported items were “feeling foolish about being afraid of dental treatment” (51.8%), “worrying about the dental status/appearance “ (45.9%), “feeling upset when going by a dental office” (37.3%) and “hiding fears about dentistry from others” (34.8%). Locker concluded that the instrument aided in establishing that high dental anxiety has pervasive non-clinical psychosocial consequences, which were more exaggerated in subjects who also had high levels of general fearfulness.508 Research of beliefs contributing to dental anxiety has been mainly confined to patient beliefs in the DBS and PIDAS questionnaires. Only a couple of anxiety research programs, other than the present dissertation program, have studied both beliefs of phobic patients as well as dentists in the same program.4;454 All of these have, at least in part, employed qualitative interview techniques and/or grounded theory analyses as a major strategy.4;454 In qualitative interviews with Swedish odontophobics, Abrahamsson et al8 found that their experiences with dentists fell into three categories of emotional meaning: existential threat, vulnerability and unsupportive dentists. Existential threat was identified and described as the central or “core” meaning of their experiences in dental care.8 This consisted of two sub-categories: threat of violation and threat of loss of autonomy and independence.8 Thus, Abrahamsson et al showed that the onset of dental fear in odontophobia was commonly related to individual vulnerability and to traumatic dental experiences, where perceived negative dentist behavior played a significant role.8 This confirms discussions above regarding suffering, in which threat to personal integrity imposed by negative dentist behaviors constitutes an important interpersonal transgression that perhaps dentists or dental staff may underestimate,141;144;401 much as Locker also found in the psychosocial impact study.508 Kulich et al.454 studied what general dentists458 thought were ideal traits as well as the specific traits of anxiety specialist dentists456 and their patient-centered approaches457 to interpersonal skills and communication values454 in the dentist patient relationship. The findings were compared with a factor analysis of DBS responses of 362 dental phobic patients. Main findings were that dental phobic patients exhibit social interaction distress in dental treatment455 and that dentists with positive personal beliefs about people and patient contacts can best help them to deal with their anxiety.456;457 This supported findings of the Minnesota dentist values studies471;519 as well as Kent et al.421;424 and Rankin & Harris698;699 regarding good experiences and dentist maturity. Regarding the concept of decreasing patient suffering in the dentist-patient relationship, elicitation of information about the patient's pain sensation and response is very important, as described at the end of Chapter 4. The patient's perception of pain must not be taken lightly, or based on false assumptions, since the pain can have symbolic meaning and not just be a somatic sensation. In the cross-cultural study of 86.

pain perceptions (V), there were revealing discrepancies among Chinese and Scandinavian dentists about use of local anesthetic for their own personal dental care compared with what they advised their patients. Chinese dentists in 90% of cases stated that they would have dental anesthetic for dental drilling of proximal fillings as did 93% of Scandinavian dentists (V). One could ask if this is an indication of a double standard or is it just a professional–lay difference in preferences? Or could there be other explanations, such as dentists’ aversions to giving injections? At any rate it points out the necessity for dentists to evaluate their own decision-making and communication processes, since attending to the meaning of a patient’s pain is often highly related to satisfying therapeutic outcomes.174;175;523 Although there have been no direct studies of discrepancies dentists may have with patients about pain control, there is some evidence that dentists or dental students perceive patients’ pain responses more easily than they do anxiety or other emotional distress.65 This is important since anxiety and other emotions, are mediators of pain behavior and can facilitate or exaggerate pain reactions. It is important that patients do not perceive the dentist as adversarial or judgmental about pain reactions, as this has been shown to increase the likelihood for continued reactions in similar treatments.217 Communication skills training would enhance a doctor’s or dentist’s ability to understand their patients’ feelings of discomfort. Summary – Emotional significance of anxiety and pain phenomena in dental clinical contexts Patient and dentist beliefs and expectations were shown to affect emotional aspects of pain and anxiety in dental practice in a mutually reinforcing manner. To summarize the findings and to reformulate the statement of problems in relation to the theme of this dissertation, the perspectives of dentists and patients are each presented. Thereafter, considerations about various solutions to these problems will be discussed related to models of communication and concepts of trust and caring. These discussions then continue into Chapter 6 as considerations of management strategies. From the patient’s perspective: Technical competence of the dentist is important to a patient, but depending on anxiety level, education level or age, it is not an essential emotional issue in the relationship with a dentist. Trustworthiness and sensitivity of the dentist are the most essential emotional issues to patients. The amount of dentist dominance perceived is directly related to the amount of patient satisfaction and these affect patient pain and fear reactions. As they signal harm or potential harm to physical or mental integrity of patients, pain and fear reactions can often be seen as crude forms of communication about suffering or expected suffering specific to emotional significance of the clinical situation. In other words, the “messages” odontophobic patients direct toward dentists and dental activities are often unconscious or subconscious attempts to counteract threatening negative outcomes in dentist-dominated relationships. Odontophobic patients need to understand that they can attain power in the relationship through use of more effective communication and social skills. They also need to “re-learn” beliefs so that they can believe and expect that the dentist is there to support them emotionally and to re-establish that patients, not dentists, are the raison de étre of dental clinical activities. Finally, if anxious patients can show the dental staff that they appreciate their efforts, the staff will more likely respect them and become engaged in allaying patient worries or concerns. This requires a certain level of social or communication skills and self-confidence. Depending on age or educational level, patients may or may not have these skills and therefore may require counseling. From the dentist’s perspective: The most intense and frequent stressors in the clinic are time pressures and patient factors, which likely overlap more than most dentists realize. Anxious patients and infliction of pain are extremely stressful, if not the most stressful elements in everyday practice and probably are more so than most dentists are willing to admit. Stress reactions are cumulative, and dentists 87.

may often be unaware or only subliminally aware of them, according to Selye and other stress researchers. Occupational stress, possibly coupled with personal or marital stress and a reluctance to reexamine the need for lifestyle and practice style changes such as benevolence, altruism, pursuit of interests and social activities outside the clinic, can lead to negative consequences for dentists, including burnout and career dissatisfaction. This dissatisfaction may become recycled to “troublesome” patients who then find the dentist less communicative, less caring and more dominating. Professional educational institutions need to help dentists become more aware that there are choices of lifestyle and values that lead to more mature decisions about dental practice and in relation to their lives as a whole, in order to ensure psychological well-being. Emotionally mature dentists are less stressed, happier with practicing dentistry and thus more naturally involved with patients, which leads to less fear and fewer pain reactions for those patients. As Rankin & Harris699 put it, “Dentistry is a two-way street. Whatever benefits the patient should in turn benefit the dentist as well.” Since better dentist-patient communication has repeatedly been the recommendation of several studies above and since these have particular relevance to pain and anxiety in the dentist-patient relationship, studies of styles of communication, as well as ways to improve communication are presented in the next section. As it is rare, there is a need for more research specific to communication in dentistry. Models of dentist-patient relations: optimal communication in relation to anxiety and pain There are two compelling reasons behind examining models of doctor- or dentist-patient relating by typology: 1) to discuss and foster what would be the most ethical or moral medical or dental relationship type372 and 2) to establish how the roles can maximize communication and thereby facilitate patient compliance, satisfaction and/or high quality of care.197;429;506;824;894 In dentistry, it is nearly taken for granted that quality of care refers to technical treatment,579;583;894but as Kerr429 argued, ”The patient or the public can only perceive quality of care. That perception is based on factors other than the technical, biological and research aspects.” Or as Pawlicki676 perhaps overstated it, “People don’t care how much you know, they only know how much you care.” Ley and Spelman489 and Ley488 proposed that most misunderstandings arising in doctor-patient communications are: 1) patients are not familiar with the professional technical language; 2) many patients find consultations anxiety provoking, causing lapses of memory about discussions and 3) when information is given the patient, too much is presented too quickly, resulting in selective recall. Other studies160;684 found that practitioner communication styles were 1) paternalistic, where information was withheld intentionally from patients to keep them from worrying, 2) bureaucratic-task oriented, characterized by efficient questioning and limited sensitivity to the patient or 3) person-oriented where empathy and awareness of patient feelings were central to the consultation. The two first styles, depending on the situation, often offer inadequate communication and are doctor or dentist dominated.346;506;557;788 Many studies or reviews of models of doctor-patient relationship refer to the works of Szasz & Hollender,846 who described three types by communication style: 1) The activity - passivity model is one in which the doctor assumes complete responsibility for the patient's treatment – a dominant father-figure approach where patients have a passive role. Often, dental patients assume dentists will tell them what they need to know and don’t seek advice.500;506 This can be reassuring, especially for older patients, but unsatisfactory for others, depending on expectations.

88.

2) The guidance - cooperation model is one in which the doctor or dentist informs or instructs the patient on what needs to be done and the patient cooperates by following advice or submitting to treatment. This model describes most modern dental clinical relationships – a kind of utilitarian model. 3) In the mutual participation model the doctor or dentist helps the patient to self-help through a series of contractual agreements that will, for example, lead to successful dental anxiety reduction in anxious patients or patients who are otherwise expecting painful treatment. Which of the models is evident in any particular situation and which is preferred will vary according to the patient’s condition and nature of the treatment offered.506 At the expense of oversimplifying these models for clarity, however, the activity-passivity model is a like a parent-small child relationship where the parent is dominant, yet perhaps caring. The guidance-cooperation model is like a parent-older child relationship, where the child is respected if it says "no", but “no” is not expected. The mutual participation model is similar to an adult-to-adult relationship, where mutual respect and trust form the basis of interactions and where communication is open and expression is encouraged. These analogies are similar to those in psychodynamic transactional communication analysis.279;332 Positive expectations of both the patient and the dentist for any of these relationship models is likely to have powerful therapeutic effects, likened to placebo effects in relation to the prescribing and taking of drugs.587;784 As Balint proclaimed in a now classic book ,48 “The doctor is the drug.” in good relationships. Regardless of type, failure to develop a satisfactory relationship with a patient means that optimal therapeutic benefit is not obtained.48;587 There is, however, growing evidence that patients who more actively participate in clinical encounters are more satisfied with their health care, receive more patient-centered care (e.g. information, support) and are more committed to treatment than are more passive patients.738;831;834;861 Street & Millay834 defined patient participation as the extent to which patients can significantly influence the content and structure of the interaction as well as the health care provider’s beliefs and behaviors. Besides obvious nonverbal acts of cooperating with dentists in the dental chair, active participation would also mean that patients would actively seek pauses as needed, ask and receive information from the dentist about procedures, express concern, give opinions, make suggestions and state preferences739;831;834 without a feeling of inconveniencing dentists. (See Table 5.) Table 5. An analysis of communicative behaviors in active patient participation834

Verbal Behavior

Definition

Example

Asking questions

Expressions seeking information and/ or clarification

“Why must I have periodontal surgery?”

Expressions of concern

Expressions in which the patient expresses worry, anxiety, fear, anger, frustration and other forms of negative affect or emotions.

“I’m pretty scared about getting that surgery. It sounds so serious.”

Assertive responses

Expressions in which the patient states his or her rights, beliefs, interests, and desires as in offering an opinion, stating preferences, making suggestions or recommendations, disagreeing or interrupting

“Go ahead and do it. I’d rather be safe than sorry later.” OR “No, it will have to wait until after the anxiety therapy.”

89.

Sondell & Söderfeldt809 reviewed the literature on relevant models and concluded that a theory of communication was lacking for special dental clinical contexts. They suggested a new model, which is similar to a model described for the nurse-patient relationship called “comforting interactions”620;633 where what is done and what is said during dentist-patient encounters accounts for both patient and dentist needs, i.e. “We are here to help each other ‘take care of business’.” Study results831 about dentist communicative engagement vs. dominance cited earlier indicated that patients expected a certain level of emotional engagement through conversations with dentists in order for them to fully trust and cooperate. Trust in interpersonal relating in health care settings is the basis for all communication that promotes health care goals. Respect and trust in the relationship can optimize placebo effects of dentist-patient relating described above and can decrease patient pain perceptions and suffering. A discussion of the research on concepts of trusting and caring below will hopefully lead to more research on these topics that are vital in dentist-patient relating. Trust, caring, communication and “partnership building”- relation to anxiety and pain The guiding assumptions of all therapeutic techniques are that trust and caring define the professional-patient relationship. Trust and caring are concepts used both in everyday language and in the scientific realm. To enter an intimate relationship or even a professional relationship with certain intimacy requirements, individuals must have reciprocal feelings of trust and emotional closeness as well as be able to openly communicate thoughts and feelings with each other.862 Inspite of common knowledge that trust is essential in health care relations with patients, an exploration of scientific conceptualizations of trust within the disciplines of medicine, dentistry, psychology, sociology and nursing,298;368;369;371;390;856;902 has only evolved in recent years. In criterion-based concept analyses, Hupcey & Morse,368;369 identified universal components of trust common to each discipline.368;369 Using qualitative methods, they found that the core value for patients who maintained trust in care providers was having their expectations met.368 Patients monitored behaviors to evaluate congruency between their expectations of care and actual behaviors of providers when criteria for expectations were “met”, “exceeded”, or “unmet”. Trust was shown to be dynamic (i.e., powerful and adaptive) and permitted caregivers multiple chances to meet patient expectations, depending on the importance or intensity of values behind those expectations. For example, that patients would “feel better soon” and “not die” compared to if a necessary service was provided in a timely manner (e.g. pain medications, toilet visits etc.) Given these patient data368 and a meta-analytic review of the literature,369 Hupcey & Morse found that attributes of trust were: 1) dependency on another individual or group to have a need met, 2) choice or willingness to take some risk, 3) an expectation that the trusted individual would behave in a certain way, 4) limited focus to the area or behavior related to the need and 5) testing of the trustworthiness of the individual or group. They proposed a provisional interdisciplinary scientific definition of trust as:369 “Trust emerges from the identification of a need that cannot be met without the assistance of another and some assessment of the risk involved in relying on the other to meet this need. It is a willing dependency on another’s actions, limited to the area of need and is subject to overt and covert testing. The outcome of trust is an evaluation of the congruence between expectations of the trusted person and (outcomes or) actions.” This definition is relevant to dentist-patient relating. Research into how to improve trust in the relationship should be a future priority.

90.

Caring is a concept that has also been researched.625;626;636;737;767 The concept of caring in nursing625;636 is seen as: caring as a human state, caring as a moral imperative or ideal, caring as an affect, caring as an interpersonal relationship, and caring as a therapeutic intervention. Willing involvement with the patient is affected by whether the caregivers’ focus is on the sufferer or on themselves (altruism vs. egoism) and whether the caregiver is responding personally and genuinely or with “auto-pilot” learned responses. A continuum of caring/non-caring was identified: 626 1) engaged responses are patient-focused where caregivers offer connected, closer relationships with patients; 2) pseudo-engaged responses are when caregivers are patient-focused but present with automatic, reflexive professional responses; 3) anti-engaged responses are when caregivers are self-focused, protecting self against patient’s suffering with automatic, reflexive professional responses similar to parenting; and 4) non-engaged responses are when caregivers are described as “detached”. This provides additional meaning and support for findings of Kulich et al.454;456;457 regarding patient-centered dentists as optimal anxiety therapists. Other researchers and philosophers have speculated about the power of trust and caring in healer–patient relating48;587;784 and directly or indirectly confirm Hahn & Kleinman’s317 ethnomedicogenesis model of health care expectation and outcome as described in Chapter 2. If a caregiver prepares patients thoroughly and helps them to define a positive outcome, then the profess-ional health care worker has optimally supplemented the effects of medication or procedures to be undertaken. This requires finesse in communication. Roter & Hall738 and others743;831-833 advocate that good clinical communication should: 1) serve the patient’s need to tell the story of his or her illness and the doctors need to hear it; 2) reflect the special expertise and insight that the patient has into his or her physical state and well-being; 3) reflect and respect the relationship between a patient’s mental state and his or her physical experience of illness or pain; 4) maximize the usefulness of the doctor’s expertise; 5) acknowledge and attend to emotional content; 6) openly reflect the principle of reciprocity, in which the fulfillment of expectations is negotiated; and 7) help participants overcome stereotyped roles and expectations so that both participants gain a sense of power and freedom to change within the encounter. These guiding principles promote the significance of “talking” as a term used to label the process of communicating, which has as much or more to do with listening as talking. (See Chapter 6.) Partnership building in the health care communication literature refers to communicative acts within a trusting relationship in which the doctor or dentist encourages patients to discuss opinions, express feelings, help them understand contexts and participate in decision-making.738;834 Partnership building also occurs when the clinician explicitly agrees with, accepts or affirms patients’ opinions, beliefs, requests, or acts which all serve to empower the patient. Supportive talk includes statements of reassurance, support, empathy and other verbal displays of interpersonal sensitivity.656;738;834 These verbal behaviors facilitate patient participation because they encourage and legitimize expressions of patients’ views, needs and concerns. Thus, if asked by a dentist, a patient is more likely to state his or her preferences for treatment, since the dentist has provided an opportunity to discuss these issues and thus may feel obligated to share his or her views in light of the dentist’s request. Interactions at the very beginning of medical or dental visits have been shown to significantly influence the rest of the interactional pattern of the séance.531 As named earlier, the three forms of speech that indicate active patient participation are 1) asking questions, 2) expressing concerns and 3) assertive responses. (See Table 5.) These types of responses are important because of their potential to influence the course of the interaction, elicit services from providers (e.g. information, patient-centered care) and contribute to quality of treatment outcomes. Asking questions is a 91.

straightforward task. An expression of concern may occur both vocally by a change in tone of voice or verbally by such words as concern, worry, afraid, frustrated, nervous or mad. A patient is being assertive when stating an opinion about health, expressing preferences for treatment, making suggestions or recommendations, introducing new topics for discussion, or disagreeing with the clinician. Although these three behaviors are more difficult to achieve in the dental clinic after dental operations have commenced, conversations and verbal contracts prior to dental operations set the emotional tone for procedures and require thoughtful consideration. Doctors who use fewer controlling and directive behaviors and who promote these patient-centered responses, are perceived by patients as more interpersonally sensitive and more actively engaged in partnership building.834 Significantly more interpersonal time spent by doctors in the clinic is devoted to giving information and asking patients rather than to partnership building and supportive talk.738 But these patientcentered acts are remembered and valued by patients even though relatively rare, since they acknowledge patient needs.834 Patients pay attention when dentists show caring.738;834 A fully informed patient receives the best dental care while also sharing the responsibility of risks vs. benefits with the dentist.770 Another type of supportive talk in partnership building occurs in emergency or crisis situations. A unique set of linguistic and intonation patterns characterize a “Comfort Talk Register”.694 In nursing, comfort talk registers are characterized by statements that: 1) help patients to 'hold on'; 2) relay information about the patient's condition (‘You’re alright’.); 3) inform about unexpected procedures; and 4) communicate a sense of compassion and caring to the patient. This reassurance concept is similar to the “Iatrogenic Interview”541 or “Iatrosedative Process”275 which Friedman popularized in the 1980s274 and early 1990s275;541 for use with anxious or fearful patients in which a doctor’s behavior induces calm in patients by use of a broad spectrum of reassuring verbal and nonverbal communications, while activating patient feelings of control in the dental situation. Reassurance as a general supportive process reduces anxiety or other suffering.48;216;810;811 Certain dental and medical patient groups require more reassurance than others,467;874;876;877 so dentists must recognize this and plan their clinical time accordingly,657;876;877 i.e. prioritize reassurance and quality care. Use of significant others (close family or friends) is a good strategy in many situations.229;810;811 Reassuring statements from a companion like “Don’t worry about it.” or “It’s not so bad.” have been shown to prompt anxiety reduction by helping individuals re-evaluate situations cognitively, and reinterpret them as less fear evoking.810;811 Already, by just talking with patients and listening to them, the potential of emotional contact and support can start a therapeutic and/or preventative process for anxiety and pain in dentistry. The next chapter presents descriptions and research findings of standard therapeutic practice for anxiety and pain problems. This is followed by further discussion of more intangible therapeutic ingredients that are either necessary or would be beneficial in reducing suffering and pain associated with dental treatment.

92.

Chapter 6. Psychosocial aspects of anxiety and pain management Clinical management of dental anxiety and pain in dentistry Recent reviews of the literature on treatment of odontophobia indicate a multitude of specific psychological techniques that have been used, some with greater success than others.86;462 Phobic dental anxiety is sometimes treated in general anesthesia with hopes of a quick solution, but this has proven to be ineffective in improving dental attendance or reducing anxiety, as shown in Swedish longitudinal studies.78;82 Some practitioners have also routinely used premedication with benzodiazepines or nitrous oxide in helping fearful patients through treatment,679 but these also have shown no long-term effects on anxiety or especially regular attendance behavior.3;319;321;859;910;911 Other more psychological approaches include exposure therapy or flooding, where some anxious patients learn through participation to endure the fear through massive exposures to routine dental treatments in rapid succession.46;287;534;598 Since this can backfire on some patients, a gradual and predictable systematic desensitization (SD) or counter-conditioning is often preferred.485;919 SD is combined with progressive muscle relaxation375;485 and/or paced breathing155;490 and sometimes by cognitive restructuring techniques224 which capitalize on patient self-efficacy.53;60 There are variations in principles of the techniques described above, depending on the patient’s needs or preferences. Fading is the systematic use of a series of positive and negative images (pictures) to decrease the strength of tension related to a feared object or situation.661 Biofeedback training is learned tension control in stressful situations through muscle tension monitoring devices.136;138;225;597 Biofeedback is especially useful in trying to automate behavioral changes for some anxiety types e.g. linked with videotapes of stressful or fear situations138;225 and there is a natural self-attribution to successful outcomes.225 Stress inoculation training is an individualized package of cognitive –behavioral interventions and relaxation methods that encourage positive thinking and coping toward behavioral changes.86;563 Hypnosis can also help the patient to restructure negative thinking to more positive expectations toward treatment and induce relaxation.254;329;603 Finally, modeling good patient behaviors for dental fear patients can be as effective as desensitization.785;925 It is often employed to aid in behavior change of anxious or uncooperative children using videos of children displaying positive expected behaviors.307;448;565 Behavioral and cognitive therapeutic techniques used at the Dental Phobia Research and Treatment Center in Århus will be the focus of the following discussions. Trained relaxation: According to the Gate Control Theory of pain, the more the body can maintain a homeostatic status, mentally and physically, the less pain an individual should perceive.380;566 It is also difficult to worry while in a relaxed state.919 Thus, techniques that help combine mind and body, such as progressive muscle relaxation techniques90;138;375 are important in reduction of acute pain and anxiety perceptions. Much of the effects of relaxation besides the actual physiological effects, have to do with patient beliefs in the therapeutic process of relaxation.334;335 Recent studies even attribute successful behavioral outcomes to learned relaxation, more than previously conceived.86;90;379 When patients are trained to monitor a state of relaxation while sitting in the dental chair, they are both focusing on a positive physiological state while perhaps also distracting themselves from unpleasant thoughts or worries by concentrating on obtaining a relaxation response.585 This assumes that a regular relaxation program is chosen and that this training occurs in a non-threatening clinical environment. Deep breathing252 and paced breathing 155;761 exercises have also been shown to be effective techniques for relaxation have often also been shown to be effective and possibly a better fit in private dental practices. Both of these breathing 93.

techniques require patients to actively monitor their breathing patterns during treatment, thereby shifting the focus away from negative thoughts and toward internal harmony. Systematic desensitization (SD): SD first became well-known when Wolpe918;919 described a type of psychotherapy by reciprocal inhibition, which means learning a relaxation response, instead of tension, when confronted with anxiety provoking stimuli or thoughts. SD incorporates trained relaxation and is a safe, stepwise method for reducing fear in many types of anxiety or phobias including dental anxiety. Basic steps in SD are 1) interview and review patient’s history with the disorder and decide if SD is appropriate, 2) reduce or eliminate other conflicts or anxiety provoking situations at the time of treatment as much as possible, 3) learning of progressive relaxation, 4) a hierarchy of anxiety-producing stimuli is developed by therapist and patient from least provoking to most provoking, and 5) stepwise progression through the hierarchy and visualizing or experiencing play-acted stimuli while maintaining a relaxed state.86;379 At the FoBCeT Dental Phobia Research and Treatment Center clinic in Århus, video SD training was a modification of Carlson et. al.'s method136;138 of successively exposing patients to eight 30 sec videotaped dental situations, e.g. making appointment, sitting in waiting room or chair, mouth exam, anesthetic injection, tooth drilling and tooth extraction. Scenes could be interrupted with hand signals for relaxation pauses and instructions. Patients used biofeedback monitoring to test their change and the therapist was constantly present for instructions/conversations or to halt the video on request. Clinical rehearsal SD was simulated exposure to threatening dental situations or instruments in gradual, approximating steps, directly performed in the dental chair, e.g. mock injections with plastic needle cap on, drilling teeth without a bur. These were combined with relaxation/tension awareness training, hand-signaled pauses and breathing control. Wolpe919 himself and later others379;662 recognized that SD was not a panacea for all anxiety treatment, pointing out that many variables influence the treatment course and outcome of desensitization during relaxation. Jameson & Vernon379 summarized the caveats for SD as: 1) Relaxation is a significant aspect of desensitization and the optimal degree of relaxation necessary is unknown. 2) Hypnotic trance states and suggestibility play a nebulous role, influencing speed of progress. 3) The ability to evoke anxiety to imagined stimuli is essential to in vitro desensitization. 4) Interview-induced emotional responses, although demonstrated to have a significant affect upon desensitization, are not essential. 5) Interpretation, confrontation and insight are not significant aspects of psychotherapy by reciprocal inhibition. 6) Patients with a history of specific conditioned stimulus acquisition and minimal free-floating anxiety, benefit most from desensitization. 7) The positive influence of the reciprocal inhibition theory on patients’ motivation, attitude and expectancy may be related to primary suggestibility. Wilkins903;904 advocated that the only necessary ingredient in desensitization is instructed imagination or positive visualizations, which are most dependent on the ability of the therapist to manipulate patient expectations. In this regard, there is some evidence that there may be more time efficient ways to eliminate phobic reactions than by hierarchical development of desensitization schedules,664 e.g. using one-session cognitive instructions, exposure can reduce anxiety for claustrophobia,666 fear of flying,667 fear of spiders,665;668 blood phobia347 and needle injection phobia.669 One-session cognitive therapy has also been shown to be more successful for dental phobia when compared with control groups (information and waiting list) 193 or benzodiazepine treatment.859 Hypnotherapy: First known as mesmerism, hypnotic trance states have been employed since the time of Mesmer in the early 1800s to aid patient treatment.305;813 Milton Erickson’s hypnosis technique 336 is the standard for hypnotic induction therapies813 and is reported to incorporate theoretical concepts of self-efficacy, spontaneous compliance, and cognitive restructuring (see below).671 The most popular use of hypnosis is for treatment of anxiety and phobia555;673 including dental 94.

phobias254;293;673;722 as well as pain control.179 Patients learn to restructure negative thoughts e.g. the sound of the drill, as a way to reimprint a signal to help deepen a trance state. Hypnosis can also be seen as another form of relaxation100;673 and desensitization145;533;673 that also can be learned and practiced as self-hypnosis.130;377;536;928 Besides relaxing thoughts, instructions can be used to draw up imagery of dental anxiety e.g. as a wall and that it is up to the patient to find out how to get to the other side. Such dissociation techniques have been created using trance states to help patients deal with particularly stressful situations and previous traumatic experiences.259;432 Dissociations are psychological processes in which mental activities break away from the usual context of stream of consciousness and function as separate conscious entities, i.e. recircuiting normal associations.181;259;432;545 These dissociations are susceptible to suggestion so that a therapist can readdress previous negative associations, such as phobic reactions to drilling, and reimprint them to give more positive associations. Age regression of this reimprinting of special episodes in a person’s life can also be employed. Hypnotizability, or patients’ ability to enter trance, has been shown to influence ease of treatment and other treatment outcomes such as time in treatment, effectivity and reduced possibility of relapse.336;673 Given the need to predict treatment outcome and therapist dependency issues, it is recommended that interested odontophobic patients should be checked with a hypnotizability test, such as the Harvard Group Scale of Hypnotic Susceptibility, Form A,293;336;933;936 to determine if hypnosis is a suitable treatment choice. The Stanford Hypnotic Clinical Scale616 quickly measures hypnotizability on a scale of 5 (high) to 0 (none) and takes around 20 minutes to perform. It is highly correlated with the longer Harvard scale.616 Side effects from hypnosis are possible, such as exacerbations of borderline psychiatric problems. Dental practitioners are advised to seek consultation with psychological professionals before commencing hypnotherapy.301;336 Psychotherapy and cognitive behavioral therapy: Having established rapport with an anxious patient, the job of the psychotherapist or dentist is to have the patient help them to understand their anxiety, including symptoms, timing, environmental factors, psychological background and social factors that may have influenced the anxiety reactions. Once these have been established it becomes necessary to institute a strategy that not only aids in reducing symptoms, but also provides the patient with insight into their reactions. This requires reflection by both therapist and patient. If irrational thought patterns intrude into the patient’s conscience when presented with provoking stimuli, some type of psychotherapy becomes necessary to address the emotional distress these thoughts provoke. Cognitive restructuring224 in psychotherapy refers to helping the patient reframe their thinking from negative or pessimistic thoughts that are unproductive to more positive and optimistic thoughts that can facilitate a desired outcome. Talking with patients about their emotional reactions to a stressful stimuli has been shown to give lower levels of autonomic arousal with subsequent repeated stimulations than just a distraction condition.573 Thus, it is better to acknowledge patients’ fears and anxieties, while also helping restructure their emotional reaction toward more positive outcomeoriented thinking. Some therapists report that patients keeping a diary through the treatment period385;400;402 is an aid to psychotherapy and cognitive-behavioral methods of reducing anxiety. Patient reflections in daily journal form can bring fear-related thoughts into focus and facilitate treatment. This technique is encouraged at the FoBCeT clinic. The techniques described above are all meant to build up the patient's psychic coping resources. Often it is also important to build up the patient's social skills so that he/she can deal with dental personnel in a diplomatic, yet self-determined way.99;653 Assertiveness training: Due to passivity characteristics in many patients, they often need to train social skills to identify and/or express their needs in a manner41;637 that exudes selfconfidence.653 Assertiveness training requires about 10-20 hours of evaluated training 95.

typically.99;108;109;607;637 and usually includes assessment of current skill levels, definition of assertiveness, recognizing nonverbal components of assertive, non-assertive and aggressive responses, learning to handle criticism, learning to turn down requests, expressing concerns, disagreeing or challenging others and deciding when to assert oneself.108-110;637 Videotaping is not necessary but is very effective in assertiveness training. Assertiveness training on an individual level is the basis of patient empowerment in dental clinical situations. Group Therapy: Moore, Brødsgaard and Birn611 raised the issue of social embarrassment as a major origin of reinforcement of the vicious circle of dental fear. They postulated that social acceptance mechanisms in the form of group therapy could be an efficient and effective way to incorporate assertiveness training, psychotherapeutic discussions and video desensitization of dental procedures.603;607 Before these FoBCeT results were published,603;607 only two known group therapy studies on dental fear had been conducted.137;646 One pilot study137 showed excellent results on a small Swedish sample. While checking various parameters of successful group therapy outcomes, Ning et al.646 found that 5 of 15 odontophobics dropped out before completion of therapy, but that the remainder reported significantly reduced anxiety and made appointments with dentists. In a follow-up study varying from 1-4 yr after this group therapy, 70% were paying regular visits to dentists.493 FoBCeT group therapy comprised 5 groups of 6 patients, equal numbers of men and women for about seven 2-hour sessions led by the therapist/dentist, a dental assistant and a former patient of the Center. Sessions included information about phobic dental anxiety, social assertiveness training, relaxation training with 12 min audiotapes as above and video desensitization in groups using the same videotape sequences described above, with the use of hand signals for relaxation pauses. The final session was demonstration of injection and drilling procedures in the clinic. Interaction and support among participants was actively encouraged in all sessions. At 3-yr follow-up, described in further detail below, there were no discernible differences found between group therapy and individual desensitization or hypnosis interventions (VIII) using measures of regular dental health care habits and anxiety reduction. This appears to be an economical approach to dental anxiety interventions,603;607 even with suggested combinations of group therapy and individual therapy for perhaps more effective results. Pharmacological (anxiolytic) considerations: Actual methods used by practicing dentists to deal with anxiety of dental patients had rarely been explored in previous studies172 and thus was also an aim in study VII. Results showed that Danish dentists did not prefer pharmacological ways of reducing anxiety over talking with patients as their primary strategy (VII). Another recent Danish study confirmed this.735 As discussed earlier in the Chapter 1 introduction, the increased use of sedation in dental practices became popular from the 1960s through the 1980s and allowed practitioners to exert more control over emotional aspects of patient treatment in the dental clinical environment.230 The data in study VII indicated that Danish dentists preferred patient contact methods over premedication of anxious patients in the late 1990s. Similar to general anesthesia and premedication78;82;319;321 use of nitrous oxide as an anxiolytic agent has failed to provide long-term improvement in dental anxiety or dental care attendance compared with cognitive-behavioral management in treatment of odontophobics.3 Norwegian odontophobics treated with relaxation and behavioral management also faired better on attendance behaviors than did a nitrous oxide treated group at 1-yr and 5-yr followups.910;911 Therefore, as a primary management strategy, it is perhaps more rewarding and effective for odontophobic patients in the long run to learn with professional help to use their own psychological resources in tackling their phobic anxiety than to become dependent on pharmacological remedies. However, there is no doubt that pharmacological remedies are very effective and useful in acute pain and anxiety situations, when e.g. emergency treatment must be afforded. Psychological strategies are 96.

based on efforts to improve patient self-efficacy and promote long-term attribution of successful treatment to patients’ own efforts, while pharmacological solutions may inhibit such self-attributions. Since 1990, the FoBCeT specialist clinical philosophy has been only to use sedatives598 as supportive to patients in often strenuous therapeutic learning processes, e.g. sedation the night before a dental appointment to enable some anxious patients with sleep problems to meet up fresh and rested.596 Likewise, use of general anesthesia should only be used in acute or emergency pain situations. Otherwise it can be used as an adjunct to support a dental anxiety reduction program. For example, in situations where a dental treatment plan is complicated by a large number of restorative and surgical procedures, it may be best for the patient to have the majority of the dental work done under general anesthesia, since the initial arduous dental work might jeopardize the long range goals of anxiety management. Support for the primary strategy of cognitive-behavioral anxiety management and selfefficacy is emphasized before any pharmacological treatment is initiated. Pain control - local anesthetics: Pain control is often crucial to the success of a dental anxiety treatment outcome. Patients who do not complete treatment because of anesthetic failure not only lose confidence in a dentist-therapist, they can also come to question the ability of modern dentistry to provide pain control.406 Furthermore, dental anxiety and anesthetic failure have been shown to have a reciprocal association.406 Thus, pain control also warrants status as a psychosocial aspect of management. Successful pain control in routine dental treatment is affected by patient beliefs about possible pain stimuli,28;37;40 the ability of patients to maintain a relaxation response584;598;892 and the ability of dentists to provide adequate anesthesia.406;584;892 Since the former is under the control of the patient and the later is under control of the dentist, it behooves dentists to help pain sensitive patients to learn techniques in the dental chair that decrease sensitivity, negative expectations and distract them from focusing on possible painful procedures.28;37;40 The literature on failures to anesthetize patients has shown 1) that mandibular block anesthesia is the most frequently reported failure,921 where up to one in five injections fail in the first attempt;406;729;9211.5% after subsequent attempts;729;921 2) mandibular molars may experience incomplete anesthesia with inferior alveolar nerve block due to accessory innervations of the mylohyoid nerve,277;921 the long buccal nerve728 or the lingual nerve729and 3) crossover innervations from one inferior alveolar or mental nerve to the other at the midline.728;729 Maxillary infiltration anesthesia is largely successful with the first attempt depending on the dosage and use of active vasoconstriction.406 Thus, it is judicious to start dental treatment of odontophobics on maxillary teeth.79;598 Periodontal ligament injections have shown rates of failure from 7 to 82%,406;901 depending on procedures. PDL injections are notably used in situations where mandibular anesthesia has been difficult to obtain,526;888 but there is doubt as to its endodontic utility.901 It is suggested in most reviews101;721;729 that for greater success, mandibular anesthesia should be thought of as anesthetizing a plexus of nerves between major nerves with multiple possibilities for tooth innervations. Regarding “fitting treatment to anxiety type” strategy As described earlier, screening or diagnostic models of dental anxiety were constructed to enable a tailored fit to treatment strategies. The concept is based on fitting the therapy to the person’s profile and type of anxiety in order to make the intervention effective, efficient and prevent possible relapses. Sheehan & Sheehan787 advocated that evaluations of therapeutic outcomes in phobia interventions would test the diagnosis in a reciprocal manner and thus provide knowledge about diagnostics. This would also promote “best fit” research, i.e. the study of patterns of outcomes to symptomatology and diagnoses. As discussed earlier, there are proponents in anxiety research that have hypothesized that 97.

cognitive or endogenous anxiety problems require primarily cognitive therapy, while conditioned or learned problems require primarily more relaxation-desensitization training662;920 as shown in Figure 8. Despite early studies that showed this to generally be true,253;577;578;662 there are still doubts as to whether these patterns are consistent enough to make generalizations90;333;387;670 and perhaps have more to do with e.g. patients’ levels of motivation90 or cognitive or emotional preferences.88;90;333 On a sample of 112 odontophobics, Berggren et al.90 (2000) found that although cognitive therapy outcomes seemed to be less influenced by motivation level (willingness to engage in treatment) and thereby achieved good results (fewer dropouts), a relaxation-SD group reduced anxiety and negative beliefs significantly better. Author’s felt the latter was due to a quick, positive counteraction of negative fear responses.90 Overall, motivation was the best predictor of outcome regardless of diagnostic type (cognitive vs. conditioned problems). Low motivation failures were greatest in number and occurred early in therapy while failures due to high general fear were usually seen in patients who completed the therapy without significant anxiety reduction. Some hypotheses regarding the ambiguous nature of these results will be discussed below, but perhaps a cautious conclusion would be that although it sounds good in theory, in practice, there are factors in optimal therapeutic process that have not been adequately explained in the experimental anxiety therapy literature.90;333;387;670 Longitudinal results of FoBCeT specialist clinic treatment strategies Patient treatment outcomes in hypnotherapy (HT), group therapy (GT), and individual desensitization (SD) therapy on extremely anxious adults (N = 174) at the FoBCeT specialist clinic, aged 19-65 yr, were initially studied to see how these interventions would vary in effectivity and behavioral change maintenance compared with a static waiting list reference control group.603 The waiting list subjects had discussed the possibility of therapy with the dentist-therapist and were given hope that their anxiety would be reduced. Effects were measured using scales of dental anxiety (DFS), dental beliefs (DBS), and fear of a “next dentist” (after specialist treatment) as well as behavioral measures such as treatment dropout and hours of therapy required. All experimental groups were demographically comparable. Patients were treated using principles of behavioral change in each of the interventions and outcomes were monitored: 1) after initial therapy and before the first test dental treatment, 2) after completion of three test dental treatments; two fairly routine fillings and one more challenging treatment such as endodontics or extraction and 3) follow-up at the private dentist chosen by the client one year after therapy and test treatments. Exit interviews were conducted and using patients own words, factors that had helped were determined.598;603 Experimental groups showed reduced anxiety and improved dental beliefs compared with 51 waiting list patients. The 25 HT patients did not differ significantly in numbers of dropouts during training compared with the 30 GT patients or 68 SD patients. For patients completing treatment, HT (n= 22) reduced dental anxiety to the same degree as GT (n=24) and SD (n=60). HT and SD patients required more therapist hours per patient than did GT. Total dropouts (dropouts during therapy plus those not attending a new dentist one year after specialist treatment) were significantly greater in HT (13/25) than for SD rehearsals (5/34) or SD video (8/32), but not GT (15/30). Hypnotizability was found to vary from patient to patient, with a direct relationship to time saved. But hypnotizability had an inverse relationship to STAI general anxiety level for those who went on to new dentists after one year. Differences in experimental group attendance with new dentists after one year were seen as problems where patients attributed their success to personal characteristics of the therapist. This therapist dependency especially inhibited HT patients. 98.

In a 3-year follow-up of these same experimental FoBCeT subjects (VIII), a quasi-experimental design was used to compare outcome results with anxious patients in an active control reference cohort of 65 patients (Dental Anxiety Scale > 15). This cohort of patients had similar demographic (age 19-65) and psychological (GFS, STAI-T) profiles as the quasi-experimental groups. They were originally patients who had dropped out from the FoBCeT waiting list. They were observed over a mean period of 6 years. They had gone back to private practices after a longer period of dental care avoidance, during or overlapping with the same time periods as experimental groups. At 3-yr follow-up, 54.5% of HT patients, 69.6% of GT patients and 65.5% of SD patients were maintaining regular dental care habits compared with 46.1% of the “6 yr” reference group, who reported going regularly to the dentist again, and 38.9% of a control subgroup with 3-yr observations. Overall, women were better regular attenders than men at 3 yr. Specialist-treated regular attenders were significantly less anxious (DAS) and had more positive beliefs (DBS) than regular attenders from reference control groups. All experimental groups exhibited significant improvement compared to baseline, but there were no significant differences between groups after 3 yr. These results compared favorably to those of a recent meta-analytic study 462 that examined behavioral interventions for dental anxiety and dental phobia. It was concluded, as shown by the control group, that many patients could on their own successfully start and maintain regular dental treatment habits with dentists inspite of years of avoidance associated with phobic or extreme anxiety. However, it also appeared that these patients had less success in reducing dental anxiety and improving beliefs about dentists long-term than did patients who were treated in the specialty clinic with prescribed psychological strategies. Better recovery from negative beliefs about dentists among FoBCeT patients compared to private practice control patients in these longitudinal quasi-experimental results attests to the power that such beliefs about dentists has on success or failure in behavioral outcomes of odontophobia therapy. One likely interpretation of results could be that even though these behavioral outcomes were not apparent for some experimental groups at 1 yr follow-up, a latent set of self-efficacious therapeutic beliefs learned by FoBCeT clients, such as in principles of relaxation and thought control, and these came to bear in the 3 yr follow-up. At 3 years, patients’ attribution of success to the specialist clinic staff may have become extinguished with the passage of time in favor of internalized beliefs or values toward regular dental care. If this is true, it is important information for specialist therapists and dentists. In order to aid patient recovery from negative beliefs over the long-term, specific strategies may be needed. When confronted with an anxious patient with negative beliefs about dentists, it is nonproductive for dentists to take these beliefs personally or shrug their shoulders and say “It isn’t my fault!” What is needed is dialog with patients about the development of these negative beliefs and how these beliefs hinder regular dental care habits. Direct confrontation such as “Do you want to change these beliefs? What can I do to help you do that?” are beneficial for long-term success. This requires mature attitudes and altruistic helping values in dental professionals. It also requires some interpersonal skills to work with patients’ beliefs and expectations. Working with patient expectations The main finding of the longitudinal follow-up intervention study (VIII) was that specialist care was more effective on both behavioral and anxiety or dental beliefs measures when compared with private dentist care of anxious patients. According to three-year results between experimental group outcomes among FoBCeT specialist center patients all contributed to significantly improved outcomes. However, there were no meaningful differences in anxiety reduction and behavior changes between hypnosis, 99.

group therapy and individual desensitization groups, inspite of differences in attendance at one-year follow-up. Several interpretations are possible. One is that there were no real or meaningful differences in the effects of the interventions on dental anxiety, assuming that all conditions were equal and controlled. Another possibility could be that there may have been factors common to the interventions across all groups that decreased sensitivity of the methods to detect differences in intervention effects. One example might be differential application of reassuring and thought restructuring conversations with patients, depending on individual patients’ need for reassurance or cognitive restructuring. There could also be other similar “therapeutic environment” interpretations. In a similar specialist center in Sweden, Berggren has also described difficulties in experimental intervention studies on dental anxiety due to inescapable human elements in the required therapeutic environment and lack of “laboratory conditions” in clinical studies.86;90 This view is also shared by some in the clinical psychology literature.903-905 It may also be that longitudinal studies provide more valid assessments of experimental intervention effects79;598 for some reasons described above. Considering that the same therapists were involved in the quasi-experimental intervention studies at FoBCeT, another common denominator in treatment of these patients was strong expectations of positive outcome regardless of method, probably due to the patient’s faith in the therapeutic process and/or the therapist.379;433;590;686;707;904 In a well-designed experimental dental anxiety treatment study, Getka & Glass294 reported on outcomes of automated video behavior therapy, cognitive-behavioral therapy, a static reference waiting list control group and a positive dentist belief strategy using “active listening” by selected dentists, also 1 yr after therapy. Using multiple psychometric measures, they found that both semi-automated behavior therapy and cognitive-behavioral therapy were equally effective treatments in terms of dental anxiety reduction, reduced incidence of negative thoughts, reduced expectations and experiences of pain and increased patient self-efficacy. Getka & Glass also unexpectedly found marked changes in the “positive dentist experience” group that were equivalent with these two therapy forms.294 They noted that the interpersonal skills of the dentists had a significant effect on patient’s 1) confidence in their ability to cope (self-efficacy), 2) decreased negative beliefs and 3) decreased experiences of pain.294 Getka & Glass294 called for controlled studies of dentists’ thoughts, feelings, behavior and physiological reactions while treating anxious patients and the effect of these variables on the patient’s experience of dental treatment. Earlier in this chapter a therapeutic concept of “cognitive restructuring” was described where a therapist or dentist tries to help the anxious patient to see other perspectives and develop new positive, yet realistic expectations, while providing reassurance. After therapy for dental anxiety, changes in patient behavior such as regular visits to the dentist without cancellations were usually the result of improved patient skills in coping, social interaction and relaxation as well as reduced anxiety and improved beliefs about dentists (VIII).597;603;607;610 While learning to deal with the dental environment, the patient also learns to expect that they can cope with regular dental treatment and dentists. 598 However, anxiety reduction is not the same as improving beliefs in dentists or even necessarily eliminating treatment avoidance due to dental anxiety. In other words, changes in anxiety states do not always correlate with successful changes in beliefs and behaviors. Dental anxiety itself is not pathological, but beliefs that lead to avoidance of needed dental treatment perhaps is.696 Anxiety is something the dental anxiety patient needs to accept, and alter with time, in order to improve and maintain positive beliefs about dental health care behaviors. A willingness to change expectations about a feared situation (dentistry and dentists) along with a process of stepwise positive accomplishments toward a larger goal (regular dental care) are necessary ingredients in the odontophobic person’s struggle to master the consequences of dental anxiety.248;431;495;698 100.

But what are expectations in operational terms as they exist in the dentist-patient relationship and how do they differ from beliefs? I suggest that beliefs are precursors to expectations. That is, beliefs “guide” or are the perceptual frameworks for our expectations. I suggest that expectations are like “packages of motivation” that contain positive or negative energy and are exhibited and merchandised by patients and dentists to each other in their interactions. Expectations are most often induced in the dental clinic through behavioral (nonverbal) cues, e.g. kindness or consideration vs. consternation; altruism vs. egoism. Historically, before the tremendous advent of technologically based biomedicine, the roles of healers in most ethnocultural groups recognized the importance of beliefs and expect-ations within the healing encounter. “Medicine men” created complex rituals and ceremonies designed to elicit or foster positive expectations in participation from both the healer, the patient and often times the community as a whole.442-445 This holistic approach to health care has been a fundamental component in the spiritual healing rituals of virtually all traditional native cultures,443-445;916 similar to Balint’s description of “The doctor is the drug.”48 With the coming of scientific research on neuropeptides and new cross-disciplinary branches such as “psychoneuroimmunology”, 929;930;932;934 there is new meaning to Balint’s edict. An understanding of the importance of the healing process and healer roles by skilled dentists or therapists is required in order to facilitate and positively reinforce patient expectations.725 Philosopher/psychologist Wilkins904 wrote: “In spite of the popular belief that psychotherapy outcome is strongly influenced by the expectancies a client holds about the benefits he may receive from therapy… a closer inspection of the studies conducted suggests that therapeutic improvements may be more appropriately attributed to the influence of the therapist rather than to clients' initial expectancies of improvement.”

Similarly, in an intervention study of 112 odontophobic patients (2000) Berggren et al.,90 interpreted positive outcomes describing them in the following passage: “.. the interaction between therapist and patient may have a prominent function in guiding the patient, not only by specific advice about relaxation or by re-orientation of faulty cognitions, but in addition, and perhaps more importantly, by attracting the patient’s attention to and reinforcing positive change. This should lead to the development of positive, selfreinforcing circles of successively increased feelings of competence for patients in handling the dental situation.”

Giving patients hope and cognitive skills that improve their self-confidence, while also helping them to learn to appraise the dental environment and dentists less negatively, could be enough to improve their belief in their ability to accomplish the task (self-efficacy). This is not to say that it was enough to eliminate anxiety completely, but perhaps enough to allay unnecessary suffering. Thus, the healing or iatrogenic qualities of dentist behaviors are important to patient coping or enduring of extreme or phobic dental anxiety or clinical pain (I, III,V).456;595 The 3 yr results reported above are evidence for the importance of organizing a systematic effort to treat odontophobia. The methods described above are the most frequently reported therapies for dental anxiety reduction. But as can be seen in the discussion about working with patients’ expectations, dentists and dental anxiety therapists are also required to supplement these methods with other, less tangible interpersonal ways of managing pain, anxiety and suffering in the dental health care environment. These are seldom reported, researched or even discussed in the dental literature, but require increased focus and research.

101.

Reducing pain and suffering – “the less tangible methods” According to the ethnomedicogenesis theory, dentists can be part of the “medicine” for the management of dental anxiety and pain of their patients, or they can also be like the “poison” at the root of the problem. Within each of the therapeutic strategies described above are other less tangible care provider variables that are more difficult to measure and have received some mention,86;90;456;909;910 but very little research attention in the dental or psychological literature.456;457 These elements usually address the concept of reducing pain and suffering.456;457 Often in experimental situations these less tangible factors are thought of as confounders, nonspecific treatment or demand affects and unwanted “placebo effects”.245;407;492;867;903 However, if one takes a more existentialist or phenomenological approach to the art and science of clinical treatment, these elements may actually be inseparable parts of a drug or specific procedure’s efficacy.232;407;909 Even those who have wanted scientific method to more actively exclude such expectancies or demand effects, admit that they do not detract from the clinical efficacy of a technique such as systematic desensitization, since there are “a number of ingredients (e.g. scientific rationale, graded hierarchy, proprioceptive feedback from muscle relaxation) that make it especially effective in establishing and maintaining therapeutic expectancies”(Lick and Bootzin, 1975492). Lick and Bootzin492 hypothesized that these effects were probably 1) reinforcement for behavioral improvement (by self and others) which motivates one to test the therapy in real life situations and 2) cognitive changes may occur which immediately reduce fear reactions e.g. self-efficating thoughts. Wilkins903 argued that the effectiveness of the desensitization process may not be due to the mutual antagonism between muscle relaxation and anxiety (reciprocal inhibition) as advocated by Wolpe, but rather to social variables in the patient-therapist relationship such as positive expectations, information feedback, training in the control of attention or focus, and vicarious learning of contingencies through instructed suggestion.903-905 Thus, separating the social variables upon which success of experimental procedures are dependent can be problematic or irrelevant to anxiety interventions outcomes. Cartwright & Cartwright139 urged therapy researchers to stop worrying about “placebo effects” as confounders and to start investigating actual functional relations between different kinds of beliefs and improvement of therapeutic outcome. Given the paucity of studies about dentists as therapists,456;458 research on the subject-subject nature of dentist-patient relating and identification of powerful social variables that influence therapeutic success in treating anxiety and pain will be important in the future. Regarding optimal anxiety treatment in private dental practice, dentists have described talking with patients as the most important strategy they have in combating anxiety (VII) and that they choose more active-passive or cooperative-guidance dentist-patient relationship models described above.172;173 Talking - Talking with patients can be many things. Rouse93;743 found that clear, understandable explanations can act as vital aids to patients in coping with dental situations that the patient might otherwise find distressing or unpleasant. Once a patient recognizes the difference between high speed and conventional speed drills or mandibular and maxillary anesthesia, for example, they are better prepared emotionally to receive treatment.600 They come to feel more “in control”652 because the element of the unknown, and thus negative surprise, is removed. This is especially effective when the necessary emotional steps and desensitizing sequences are contracted directly with the patient before each clinical session.652 O’Shea et al 652 found that to help reduce anxiety, patients wanted to increase and improve dentists’ communication skills such as initial explanation, in-process explanation, warning about possible pain and helping the patient think positively. Corah et al.173 also found dentists that “encourage questions” from patients as helpful in stressful or anxious situations. Rankin & Harris699 102.

added “explaining how the patient should act” and also that patients dislike when the dentist started treatment without any explanation or claimed that the procedure would be painless when it actually hurt, i.e. most patients do not like unpleasant surprises.698;699 Thus, short positive explanations of procedures with repetitions help to form patient expectations and eliminate misunderstandings. In talking, dentists can also consciously or unconsciously be using distraction as a kind of natural cure for dental anxiety.169;172;380;453;652;735;783;878 A recent survey of 107 Danish private dentists showed that they most frequently (72%) used distraction as a strategy.735 Several scientific studies have shown that attention or focus had more influence on overprediction of pain than did anxiety.28-30;380 It has also been shown that distraction can attenuate fear of pain in low-moderately anxious patients, bolster patients’ endorphinergic responses and thus positively affect outcome of a treatment.28-30;380;382 However, distraction does not work as well if anxiety is too high272;378;783 and studies have shown that phobic patients may not induce endorphinergic analgesia as readily as less anxious subjects.29;380;381 Janssen et al.382 showed that when it is possible to distract attention, this could have larger effects on pain than reducing sympathetic activation due to anxiety. However, when anxiety or fear of pain is too high to distract attention from the painful stimulus, reducing anxiety and sympathetic activation may become relative more effective.382 Studies of devices such as video-glasses74-76;272 have reported high patient satisfaction and pain-reducing ability. However, with rare exceptions,76;783 they are not controlled trials, so the therapeutic gain of these and similar video-distraction devices783 compared with e.g. nitrous oxide sedation76 is relatively untested. Similarly, music11;754 is reported to be a sufficient distractor. Distraction is seen as similar to medication in that it helps in the immediate situation, but provides no carry-over benefits for subsequent dental visits.169 Besides information-giving behaviors, patient contract control mechanisms and distraction, studies by Corah et al.173;174;176 and O’Shea et al652 showed that patients want the dentist to "have a calm manner", being reassuring, empathetic, friendly, communicative and to take patient complaints seriously, especially about relief of fear and pain. Although sparse, there is also a specific dental literature on the art and science of these conversational techniques. Drawing on clinical experiences as dentists, several authors have explored therapeutic communication techniques. As early as 1951 Ewen234 encouraged use of "Active Listening" which consists of 1) permitting the patient to unload emotionally; 2) finding out the patient’s purpose in seeking help; 3) noting how much the patient leaves out, e.g. exactly what the patient expects of the new dentist and 4) exploring patients’ recent dental history to judge current feelings about dentistry and dentists. Active listening requires that both patient and dentist make follow-up questioning in order be certain of mutual understanding.383;384 The dentist paraphrases what he heard the patient has just said when responding to patient statements or questions. This lets the patient know that the dentist has heard what was said. The patient then has the opportunity to clarify in his own words. Active listening builds rapport and increases patient’s self-esteem. Patients know they are heard and feel that what they have to say is important.383;384 This two-way communication is the basis for stepwise contractual agreements between dentist or therapist and anxious patient. provides instant patient security and a more active patient role. In nursing, the concept of suffering has been researched extensively, as has concepts of enduring, hope, and comforting as its main antidotes.623;628;634 Dentists and physicians can learn much from the nursing profession about reducing suffering and pain. Most of the concepts below originate from theoretical arguments and specific research studies conducted by the nursing profession. “Enduring” - Morse and colleagues630;634 explored concepts of suffering and enduring. Three types of enduring were identified: enduring to survive (which occurs during physiological jeopardy), enduring to live (which occurs with untenable psychological stressors), and enduring to 103.

die (which occurs with inevitable degenerative and terminal disease). Where suffering is seen as threats to self-integrity, as described earlier, enduring is an attempt at gaining control over the overwhelming feelings of suffering; a coping mechanism using mostly denial and avoidance of feelings in order to buy time and find courage to face suffering in gradual stages.621;623;630;631;634 Individuals move through developmental stages in accepting and dealing with strong emotions. Through this process, individuals gain new insight and reformulate their self-integrity. Comforting patients in appropriate ways gives hope and enables them to endure or actively cope more successfully.632;634;635 “Hope”: Advanced concept analysis using qualitative methods has also enabled researchers to describe essential components of hope:632 1) a realistic initial assessment of a predicament or threat, 2) envisioning alternatives or setting new goals, 3) bracing for negative outcomes, 4) a realistic assessment of personal or external resources, 5) solicitation of mutually supportive relationships, 6) continuous evaluation to reinforce selected goals, and 7) a determination to endure. The various manifestations include hoping for a chance, incremental hope, hoping against hope, and provisional hope. Knowing more about patient processes with anxiety, shame and pain problems and the ability of the dentist or therapist to facilitate hope on their part, seems important to patient self-efficacy. “Comforting” – Given that therapists or dentists are proficient at talking with patients, there are other ways in which they can comfort patients and aid coping with pain, anxiety and suffering, e.g. specific “comfort talk registers”. Comforting as a concept620;622;623;628;629;694 relies on that patients associate it with relief, even temporary relief, from any attention-demanding discomfort,620;622;628;629;860 as opposed to reaching a state of peace and serenity. Illness and injury can dominate patients’ attention and disrupt their accustomed orientation to the world. Relief from discomfort often entails strengthening patients’ abilities to relate their minds to their bodies.622;628;629;860;861 Attaining comfort through alleviating discomfort requires communication with patients that focus on recognizing their own needs in a particular discomforting situation. In discomforting situations if dentists “ask” rather than “tell” patients about their discomfort, the possibility for improving patient comfort increases, according to this literature. In the dental literature, two references860;861 indirectly describe comforting by dentists as the use of continuous information during treatment to reduce patient discomfort. The concept of comforting is substantially conveyed in nonverbal support modes.622;628;629;860;861 Nonverbal and other supportive communication forms Nonverbal communication and other supportive communication described below include touching, silence, empathy, humor, and active listening. They are important ways to comfort and help patients ease their suffering383;561;677;858 and can be used to define comforting behaviors in the dentist-patient relationship. These concepts become essential when dealing with anxiety or pain problems, where the patients’ perceptions are to be comforted, guided or manipulated. In dentistry, suffering often occurs from psychological trauma, acute pain and sometimes, chronic pain. Patients who have an anxious or phobic relationship to dentistry can readily gain hope of learning to cope with treatment and can quickly reduce suffering and enduring modes via therapeutic techniques described above and specialist therapist characteristics described by Kulich et al.,454;456;457 many of which are based on nonverbal communication. Considering how important concepts of nonverbal communication and

104.

support are in dentistry, there is a paucity of specific research and attention in the dental literature to nonverbal communication and use of touching, silence or humor. Nonverbal communication describes all forms of communication not controlled by speech. Besides paralinguistic cues, such as nonverbal utterances e.g. "M-m-m", "Uh-hum", "Huh" etc., nonverbal behaviors incorporate the following:674 1) interpersonal distance, 2) gaze direction, 3) touch, 4) body lean, 5) body orientation, 6) facial expressions, 7) posture and postural adjustments, 8) gestures, 9) hand movements, 10) foot or leg movements, 11) grooming behaviors, 12) self- and object manipulations (scratching, adjusting clothes, fiddling with rings, keys or other objects), 13) pupillary dilation-constriction, 14) pauses in movement, 15) interruptions, 16) speech duration/silence. Mehrabian561 found that the total impact of a message could be broken down to 7% verbal (words only), 38% vocal or paralinguistic aspects (tone of voice, silence, inflections, other sounds) and 55% nonverbal. Pease677 believes that practitioner intuition is often grounded in an ability to correctly interpret nonverbal communication and paralanguage of patients. Indeed, when one listens and pays attention, the right response occurs naturally, according to Kacperek.400 As a nurse who had lost her voice, Kacperek found that developing listening and non-verbal communication skills appeared to increase her ability to utilize the intangible qualities of presence, intuition and empathy. Seeing herself as a case study in health care communication, she found that by being in tune with her own nonverbal behavior, it became easier to react to patients’ nonverbal cues.400 There is also other evidence that caring is perhaps most often conveyed by nonverbal behavior.498;626;636;767 Touching: Touching is a means of conveying warmth, security and competence, but most importantly, caring.498;626;636;767 The literature about therapeutic and healing touching has been explosive since the late 1970s and early 1980s, where the author found over 30,000 references in a recent computer search of these two topics. McCoy547 studied the use of nurses’ touch in the emergency room and found, as in other nursing studies746;884;922that those patients touched by the nurse perceived a sense of caring, whereas those patients not touched viewed the nurse as only wanting to expedite them. Touch is also a powerful aid in persuasion312 and has anti-stress or healing effects.723;847;906;922 Compared to nursing and medical literature, there are relatively few dental references on supportive touching 63;67;221;306;456;756;858 and only four were empirical studies.64;306;456;858 Two videotaped studies showed virtually no supportive touching by 16 dentists over 60 encounters.63;858 One randomized control trial showed that dentists’ supportive touching significantly reduced nervous fidgeting in 7 to10 year old patients.306 Supportive touching by dental anxiety specialists in Sweden were part of the profile of a therapeutic process.456 Estabrooks & Morse231 proposed a theory of touching consisting of touching process and the acquisition of a “touching style” based on nursing studies. Their conclusions are relevant to dentistry, since the degree of intimacy with which dental practitioners must touch patients is similar. They identified elements of touch that go beyond physical paradigms of physical contact. Values that people internalize from their own family patterns influence later expectations and touching style relevant to clinical situations as both patients and practitioners. Estabrooks & Morse231 described the touching process as entering, where the health practitioner gains permission to enter the patient’s personal space and connecting when the practitioner allows feelings of caring about the patient’s well-being. Entering can be difficult. Health care providers are often inhibited to touch their patients for fear of perceived sexual advances.143;183;215;713;907 There are also same-sex, opposite-sex considerations.183;184;215;233 Touching initiatives are driven by the wills of practitioners and are therefore dependent on levels of practitioner caring. This could be a fertile area for research, since behaviors taken for granted in everyday clinical practice may vary considerably from dentist to dentist.231 The only literature on touching or other 105.

nonverbal communication in dental education was one study that reported that students preferred learning by observation of faculty or more experienced students rather than by trial and error.756 Silence: Silence in social situations is an important aspect of human interaction that is highly underestimated. Silence is often associated with interpersonal discomfort and is therefore quickly filled with words in social interactions.537 Porritt688 explains that inspite of an inherent, yet quickly passing discomfort with silence, the patient in health care settings will usually signal nonverbally when he/she wants verbal interaction, e.g. by making eye contact. Silent pauses that are coupled with a relaxed approach, give patients time and space in which to think during meaningful clinical or therapeutic conversations.121;284;400;468;537 Some experimental studies also indicate that silence facilitates the “relaxation response” and desensitization therapies.719;754 Therapists have noted a lack of training in the use of silence.309;358 While parameters of silence such as timing and duration are easily recognized, qualitative experiential aspects are much more difficult to identify and describe, since emotions are experiential and complex. Silence is useful for identifying and working with emotions, since it is necessary to recognize what is underlying each silent period in communications.284;468;537 One study358 of 81 therapists’ attitudes about using silence in therapy indicated that they used silence primarily to facilitate reflection, encourage responsibility, facilitate expression of feelings, not interrupt session flow, and convey empathy. During silence, therapists observed the client, thought about the therapy, and conveyed interest nonverbally. In general, therapists indicated that they would use silence with clients who were actively problem solving, but they would not use silence with very disturbed clients. They had learned about using silence mostly through trial and error. Empathy: Research suggests that “feeling as the other person feels” plays a vital role in clinical relationships.175;313;743;745 Empathy consists of moral, emotive, cognitive and behavioral components. 624;627 Non-verbal doctor behaviors such as leaning forward, talking without crossed-arms, positive head nodding, eye contact313;743 and smiling175;313;743 are all highly correlated with perceptions of empathy and thus are conducive to reducing patient anxiety or increasing patient perceptions of safety and understanding.175 Not surprisingly, such responses have also been shown to facilitate communication with patients. Pattison675 found that counselor-client touch, seen as empathy, tended to increase the client’s depth of self-exploration during sessions. Aguilera10 found patients’ desire to approach and talk to a nurse was correlated with nurse-patient touching. To verbally convey empathy one must first acknow-ledge the patient’s emotional state or condition with an “I” statement,383;384 “I notice that you are a little anxious today..” and then continue with a suggestion, “Please let me know what would help you to feel more comfortable.” Of course the dentist’s nonverbal behavior must also support what is being said in framing openness and disclosures. Acknowledging stronger emotions such as fear or anger has shown to be most effective in neutralizing them.112;383;384 A dentist’s choice of words, tone of delivery and nonjudgmental behaviors are a concert of messages conveying understanding and reassurance.383;384 Humor: Humor is an integral part of everyday life and therefore also a component of the care and treatment of patients.73;222;308;501 Humor usually has verbal and nonverbal components and has been shown to affect vital brain centers including speech,391;525 memory,77;757 as well as control of vital functions,338;924 and the immune system.182;403 In the face of illness, humor may even have healing qualities.182;535;789 Deliberate use of humor signals permission for others to laugh and to relax and has been described as a desensitizing intervention for tension and anxiety both in case histories879 and in random clinical trials.880 Humor has also been shown to be an adjunct to pain control483;524;542;897 and other medical treatment.524;535;789 Humor also improves job satisfaction and motivation.131;228;397;731 There are several references on use of humor in dentistry222;228;645;681;731 but only one known scientific 106.

study.645 Nevo645 reported on behaviors of 10 dentists (8 men; 2 women) and their characteristics regarding use of humor in child dental practice and found both common and individually fitted types of humor cues for their patients. Desensitization using humor879;880 has three common elements:645 It helps 1) by changing emotions (fear to joy), 2) by changing perceptions, or assumptions (as in role playing) or 3) when time is short and other relaxation training is not feasible. Thus it has social, emotional, cognitive, informative and motivational functions in dentist-patient relating.645 Future research implications in dental health care appear to be advantageous for both patients and dentists. Redefining “chairside manner” Given the literature on active listening and nonverbal communication, there is great potential for research in understanding and improving “chairside manner”. Behavioral science coursework in dental education usually includes active listening,288;304 but much more can be accomplished according to several authors.14;207;212;384 Jepsen384 reported that certain things dentists do are “harmful” and others are “helpful”. Empathetic, warm, genuine and respectful questioning is always helpful in dental health care situations. For example, when a patient would say, “I hate going to the dentist.”, there are different ways to respond; some more helpful than others. Instead of providing a presumptive question that can be answered with “yes” or “no”, the dentist can invite the patient to be more explicit with an open-ended question like “Can you tell me about past experiences or other reasons that would lead you to say that you hate being here?”; i.e. answering with questions is often more positively confrontative, focused and therapeutically efficient.384 Using an evaluation rating scale developed by Wolf et al.,917 Jepsen384 also described 5 levels in helping relationships from “destructive” to “extremely helpful” where it is actually possible to rate dentist statements as to the degree of active listening and involvement in the patient’s perspective. Wolf et al.917 found that about 90% of professional health care providers studied were functioning at harmful or destructive levels.917 More research on dentist behavior is needed.

Dentists and primary care in management of odontophobia It is not insignificant to consider who should organize and manage treatment of odontophobia. As psychiatrist Braceland118 said in speaking to dentists in 1940, “Tucked away in some convenient place in your mind I would suggest that you keep this slogan: “Every dentist should be a psychologist.” If we of the dental profession take Braceland’s comments to heart, the future dentist must become much more knowledgeable and involved in treating psychological disorders associated with dentistry. With this, I also argue below that it should be dentists with public health, psychology or behavioral science specialties who should lead in managing the problem. However, as Berggren86 advocates, cooperative relationships with qualified mental health professionals are also required. There are also necessary prerequisites for a responsible role of dental professionals in organizing efforts to combat odontophobia. The profession should take responsibility for previous mistakes in lack of priorities on teaching of behavioral sciences,207 including values education and patient management and must address both in educational reforms. The first argument for dentists as best to organize primary care for odontophobics is that dentists have unique knowledge of nuances of instrumentation and dental procedures e.g. the differences between high speed and low speed drill sensations, the expected effects of maxillary and mandibular anesthesia and descriptions of anatomy and physiological processes. Such knowledge is essential for stepwise desensitization therapies for anxious patients. In diagnoses where the primary strategy requires cognitive psychotherapy for restructuring of non-productive thinking, it would often be necessary for 107.

dentists to cooperate with a psychotherapist.86 A qualified psychotherapist would also be needed for rendering a psychiatric diagnosis in cases where such a diagnosis would be beneficial to a phobic patient’s rehabilitation after many years of avoidance. A second argument for dentists as primary care-takers in treatment of odontophobia is dentists’ practice style. In a recent meta-analysis, Smith & Heaton805 compared self-reported levels of dental anxiety during the past 50 years in US studies and determined that inspite of an increase in general anxiety within the United States during the past 50 years,870 dental anxiety seems to have remained stable throughout the same period. Smith & Heaton805 interpreted this stable trend in dental anxiety levels to increasing awareness about treatment and prevention of dental anxiety and the structure of the dental health care system itself. Coursework in dental behavioral sciences have made dentists more aware of needs of their patients regarding anxiety and pain over the last twenty years. In the United States, the outpatient setting of dental practice is the cottage industry model rather than larger corporate models such as found in most medical clinics and hospitals. Smith & Heaton805 suggest that these small traditional settings allow for social connectedness because of the continuity of staff, which is not evident in many other areas of modern medical health care. Patients can also more freely choose or change a dentist and dental setting based on personal, practical or emotional needs. A third argument is one of motivation, since it is in the best interests of the dental profession to adequately deal with anxiety and pain problems. From the history of dentistry and discussions of dentist career satisfaction earlier in this dissertation, it appears that it is just as important and beneficial for dentists to be able to resolve issues of dental anxiety and pain as it is for patients who have been avoiding dental care for years due to their anxiety. However, this also points to a need for health care policy decisions by government that support both patients and dentists, as well as coordination of the required cooperation with psychologists, psychiatrists and academic dental anxiety specialists.86 One potential scenario that would promote more positive images of dentists in the public’s eye would be a systematic training of a special corps of dentists who would treat dental anxiety patients. Of course, it would be necessary to place specific demands for documentation of dentists’ competence to treat the problem. Coursework approved by the Board of Health Administration (Sundhedsstyrelsen) that would certify dentists and cooperating psychotherapists as qualified health care providers for anxious dental patients would be a step in the right direction. It would then also be appropriate for the Board to recommend to the National Health Insurance Board that there be financial coverage for therapy related to a diagnosed psychiatric dysfunction. An hourly fee schedule for some dental patients would be more supportive of patient and practitioner needs than present fee-for-service schedules. Reintroducing patients into the established dental health care system would be the goal of such a combined systematic effort. Since they would be general practitioners, this core of dentists trained and specializing in therapeutic relationships with patients would also create a competitive force that would motivate other dentists to participate in coursework and provide services preventing anxiety and pain. Groups of dentists with a common interest in treating dental anxiety have already been established in Norway,617 Sweden and Northern Denmark.20 These and other organizational societies would also create incentives for further study of dental anxiety. Emphasis on patient-centered practice and dentist networking would tend to improve the psychosocial quality of dental care and public image of dentists in general. The hope is that this would also decrease the stress of practice for a majority of dentists, while improving dentist career satisfaction. Mutually supportive relationships with patients and improved economic incentives to treat anxious patients could become two potential keys to improved dentist career satisfaction. 108.

Chapter 7. Conclusions and suggestions for the future Status of dentist-patient relations, anxiety, and pain in Denmark In conclusion, the dynamics of the dentist-patient relationship as a social phenomenon has often led the two parties to misunderstand each other resulting in unnecessary pain and anxiety on the patient’s part and unnecessary poor self-image and career dissatisfaction on the dentists’ side; unnecessary because both parties fall victim to vicious circles which may feed on each other in many cases. Dentists often have not recognized that times have changed and that patients have new needs, including less tangible, yet emotionally prominent needs for compassion and security. Patients have struggled with self-assertiveness and rising from passivity without fear of rejection or reprisal in relating to dentists. Especially in Denmark the Jantelov13;654 is a palpable phenomenon and it may have general adverse affects on critical belief in authority (IX). The image of dentists is colored by past images, when technology was underdeveloped and less related to professional practice than to showmanship based on patient suffering. This role image has been colored over time by fearful or painful stimuli, inspite of time and generational changes and the fact that dentistry, perhaps more than any other health profession, has accomplished majors goals toward elimination of disease, also having decidedly used prevention as a flagship. There has been and still is a need for leadership in the dental profession that consistently promotes systematic treatment and prevention efforts that will impact on the causes and symptoms of anxiety and pain phenomena related to clinical treatment. The research in this dissertation has focused on each of three targets as described in Figure 13 - patients, dentists and public images of the dentist. Each has required specific study that lead to suggestions for change. The nine doctoral articles focused mostly on dentist and patient roles and perceptions related to clinical anxiety and pain. The need to come out into the community and make the social environment (dentists and the public) acceptable for these patients is also an important factor to be considered in an overall strategy. The so-called patient-centered model 292;823 of dentistry has created a new power-base in the dentist-patient relationship and has come to effect dental health care policy. In order for dentists to embrace the patient-centered model of health care they must be brought to understand the ultimate benefits of changing practice style, managing practice stress and enjoying professional development and the practice of dentistry to a greater degree than perhaps currently exists for many dentists.

Toward a biopsychosocial model of future dental professional roles The profession of dentistry has made great accomplishments during the 20th century toward eliminating caries and periodontal disease. In Denmark, making a complete set of dentures for a patient has become relatively rare when compared to only 20 years ago. If this rate of developmental trends continues throughout the 21st century and the focus of the profession becomes less and less biomedical craftsmanship, then the roles of dentists and dental educators will of necessity have to change to meet new health care needs.129 Brown129 points out that 80% of people in the USA see a dentist within 3 to 4 years. These figures are at least as good in Scandinavia. Thus, visiting a dentist could become a general health care opportunity or “wellness-promotion”, if the profession chooses to promote itself in that manner. In providing patient-centered services, dentists create a psychosocial environment that values patient contact. This would also enable the dentist to expand his or her role to provide other medical or mental health supportive services.208 Screening and advice /referrals related to cancer, high blood pressure, diabetes, physical, emotional or substance abuse or recognition of depression, suicidal tendencies, anxiety 109.

or panic disorder or other mental or psychosomatic problems, could fall within the education and area of expertise of dental professionals.208 In 2001, Dworkin208 described this expanded dental clinician role as the “biobehavioral clinician” and outlined new tasks for the future. No other health profession has been more engaged with health problem prevention than dentistry. It is part of our (dentists’) basic way of thinking, perhaps in response to prevention of pain and anxiety throughout our professional history since these two phenomena are great motivators for human action. With an emphasis on prevention,129 dentistry has made significant accomplishments in reducing oral diseases that have plagued mankind through the ages. The 21st century could possibly see dentists also become disease prevention specialists for other more general health problems.208 As pointed out in the dissertation, active and genuine engagement of dentists in their patients’ well-being would naturally lead them to expand their role beyond dental “biotechnician”, e.g. learning more about medical disease processes and mental health, in order to conduct informative consultations with patients, also for a fee. This would require screening skills, not necessarily diagnostic skills.208 Dental education would need to anticipate these changes and be in the forefront in developing new roles.151;207 If dentists can become better in tackling psychosocial aspects of dental anxiety and clinical pain problems, then they can also become motivated as prevention specialists with expanded roles given the proper education and guidance during their professionalization. Thus, understanding gained from practicing biopsychosocial principles in tackling anxiety and pain could hopefully, among other activities, lead the profession into a new exciting era of development. However, there are currently social barriers to this relationship. It requires the profession to become more aware of current biomedical thinking and a new understanding of the meshing of social and psychological influences on biological processes and vice versa. Most dentists are doing a great job in this regard, as witnessed by high rates of patient satisfaction. However, traditional public views of the dental profession as both pain-healers and pain-inflictors over the ages have provided a schizoid-like conflict in the development of a positive professional image. For those dentists who do not practice values that ensure good emotional contacts with patients, pain of treatment and anxiety must be respected as both part of an emotional human right of expression and also as a symbol of suffering, before it will fade from the public mind’s eye as a dinosaur image of dentistry-past. To rise beyond these social barriers, dentists and patients must see new horizons of possibility. They must understand that what they expect of themselves and each other is only a matter of being forthright, open and showing their humanity.207 With this in mind, suggestions below are meant as a blueprint for concrete steps to be taken to reduce psychosocial barriers and decrease suffering from pain and anxiety related to dentistry. They support both patients and dentists in their respective needs.

Suggestions and future directions From the treatise in the first six chapters of this dissertation, it is apparent that the phenomena describe the need for broad social and psychological changes in 1) public health care policy 2) education of dental professionals and therapists, and 3) education of the public. Currently, there is no public policy in Denmark regarding diagnosis, treatment and prevention of extreme or phobic dental anxiety. If there is to be a systematic development for improved diagnosis, treatment and prevention of dysfunctional dental anxiety, then some kind of public policy will be required. Governing agencies and academicians will have to work closely with the National Board of Health to provide policy recommendations that fit the situation as it exists in Denmark. Based on the literature review and findings in this doctoral dissertation, the following points are recommended. 1) National Health Insurance coverage for therapy: In 1999 Sweden843 changed their policies and Norway is currently considering changes in regard to national health insurance coverage of 110.

patients who have suffered from dysfunctional dental anxiety. Patients also contribute with a nominal payment (e.g. 100 kroner or about 15 Euro or US$ per visit.) It is suggested that a similar supplemental economic coverage be provided for diagnosed phobia or extreme anxiety in Denmark. An hourly fee is suggested, in order to reduce focus on actual physical dental services, since the primary problem is anxiety, which requires a process-oriented, not a producttime approach. As described earlier, in relation to time or economic pressures of fee-for-service payment schedules, more time is required for anxious patients. 2)

Competency based provider services: National insurance coverage of treatment for anxious dental patients should be based on competent care provider credentials. Successful completion of e.g. National Health Board and/or Danish Dental Association certified post-graduate coursework should be mandatory for provider number qualification of existing dental practices.

3)

Cost free pain-free treatment: Currently the fee schedule for “pain-free treatment” negotiated by the Danish Dental Association has patients pay ca. 150 kroner out-of-pocket, except for tooth extractions. The National Health Insurance does not cover it. Full coverage of “pain-free treatment” in Danish dental clinics should receive serious consideration. The values of the Danish dental profession should confirm that dental patients have the right to treatment free from pain and suffering, as do dental professions in other modern Western societies. There should be no economic resistance or other hindrance for the patient to obtain pain free treatment. Any other values appear to be unethical and do not enhance the image of the profession. Thus, based on the findings of research results presented in this dissertation, it is suggested that in periodical revision of fee schedules as negotiated with national county authorities (Amtsrådsforening), the dental association should not have to account for “pain-free treatment” on the fee schedule and assume that it should be included in the cost of treatment or be free of charge. This ethically responsible view of treatment is equally the responsibility of Amtsrådsforening politicians as well as the dental association.

4)

Involvement of medical and mental health professionals: Practicing physicians and social case workers in Danish communities would have to be informed about the dysfunctional consequences of phobic dental anxiety for some patients and must become more aware of developments in a new system for tackling the problem. Using psychiatric diagnostic criteria of either DSM or ICD, the diagnosis of phobic dental anxiety would require involvement of qualified psychologists and psychiatrists. It is suggested that a national task force of specialist dentists, psychiatrists and/or psychologists be set to the task of organizing practicalities with regard to psychiatric diagnostic procedures as the prerequisite to special insurance coverage of treatment of extremely anxious or phobic dental patients.

Regarding competent knowledge and clinical therapy for anxiety and pain, the doctoral research program focused on perspectives of dentists and patients in relation to each other. Evidence of societal perceptions of dentist-patient relating were revealed through studies I, III, IV, V, VI, VII and VIII in this dissertation, looking at patients’ and dentists’ roles respectively. The aim was to illuminate the aspects of dentist-patient relating albeit from each perspective, pointing out role pitfalls that may be occurring within the socialization process and development of the dental professional. Dentists’ positions on the major beliefs and/or cognitive-behavioral events surrounding pain and anxiety of their patients have been described and documented. Dentists do affect patient perceptions of pain and they do contribute in their choice of actions and beliefs as possible sources of patient anxiety or pain perceptions. Since the dentist-patient relationship is so crucial to these role manifestations, the following suggestions for dental professional educational policy changes would strengthen the positive aspects of the relationship and thus aid in general in reducing patient pain and anxiety. Some 111.

of the topics are already currently being taught in dental schools.304;373;428;806 However, they are listed and described below, since they are also important topics for continuing education coursework of practicing dentists. Specific educational suggestions: 1) Separate examination in psychological aspects of clinical dental practice should be required in the Danish dental school curriculum, including diagnosis and treatment of dental anxiety and psychological aspects of pain control. This examination would either become a greater part of the required 5% social dentistry (samfundsodontologi) requirement for the Danish dental curriculum or be added in addition to this distribution, depending on an assessment of the entire curriculum. The psychological demands of dental practice must become more highly valued and receive greater attention and than currently exists, considering the consequences of psychosocial factors described in this dissertation for both patients and dentists. This curriculum should also serve as a solid foundation for special post-graduate coursework in principles of diagnosis and treatment of dental anxiety and psychology of pain that would be required for dentists to receive a special national health insurance provider number. Such coursework should not be limited to just dentists, but also be offered to psychiatrists and clinical psychologists who also have developed a special interest in this area. Specific coursework topics below also are mentioned as relevant to continuing education. 2) Communication skills: Dentists should also be required to systematically pursue some kind of training in principles of precise communication and the “art” of asking questions or active listening. Patients should be thought of as crucial informants and their expectations should be placed in the center of dentist actions. Dentists need to ask far more questions that require patient input before mutual expectations are clearly identified and actual treatment is commenced. This has been shown to be beneficial for both patient satisfaction with treatment, quality of care and perhaps indirectly to dentist career satisfaction. 3) Relaxation techniques: Dentists should learn “hands-on” about the various specific relaxation techniques commonly regarded by the profession of psychology to be effective in decreasing distress, both their own and their patients’ stress. Techniques should be provided to patients who require or wish to use them after a thorough initial conversation with the dental professional about that possibility. 4) Stress management: Dentists should become more knowledgeable as to limitations regarding excessive perfectionism and their own time-product stress motives. Dentist education about stress and its management should become high priority starting with formal dental school training. Stress management techniques should first be learned by dental educational staff (in-faculty training) in order to provide role models for dental students, who would also receive formal training. Coursework should be motivated by stress-burnout-suicide statistics in the dental profession and that there is evidence that occupational career satisfaction of dentists is highly related to how they learn or do not learn to cope with stress, both in professional and personal life. 5) Career development and planning: Dentists may need to be reminded that career satisfaction is a combination of professional and personal values that cannot always be measured in terms of parameters of time or financial rewards. Other values such as friendship, benevolence and interest in patients’ personal development need to be strengthened. Such values are best instilled in the education and socialization of dentists, if they are openly debated in professional organizations and educational circles as important outcome in defining the concept of “professionalism”. Other medical or technical aspects 112.

of professional development should naturally come into discussions based on these values clarifications. The forum could be small-group seminars for both preclinical and clinical dental students.119;120;180 6) Certifying and non-certifying continuing educational coursework in differential diagnosis of dental anxiety, psychiatric diagnostic criteria and whether criteria are fulfilled or not fulfilled, would be helpful in providing tailor-made treatment strategies, both for psychotherapists and certified dental therapists or motivated private practitioners who also work with anxious patients. Involvement of qualified psychiatrists and psychologists would be required. 7) Formation of a special Danish dental society for studies of dental anxiety and pain phenomena. This society would be open to dentists and non-dentist professionals as well as interested or informed laypersons. Practical facilities for preparation for coursework, special guest lecturers and study circles would facilitate and promotes such an organization. Future research Patients: Future research should focus on how anxiety resistant or pain tolerant patients have coped with unfortunate or traumatic dental treatment episodes and how these coping responses compare with e.g. odontophobic patient coping. The cross-cultural pain and anxiety literature indicates that patient coping varies from ethnic group to ethnic group and that these are due to the social context and network of expectations that have developed (I, III, V). A fertile area for research is linking behavioral research variables, such as specific expectations or beliefs, with neuroimmunological and neuropharmacological biomedical research in order to understand mechanisms that optimize positive patient responses as well as to prevent unproductive responses. Perhaps the emotional significance of pain and anxiety within these psychosocial contexts are specific keys to release of neural peptides or hormones that modulate pain and anxiety. Recent stress and placebo studies make this association seem possible. Dentists: We need to know more about specific dentist behaviors that contribute to unnecessary pain or anxiety, in cases where there has been trauma as a probable cause. Research should also more specifically explore what successful practitioners do when providing pain-free and anxiety preventive treatment. Naturalistic studies of practitioners and their behaviors could provide important information for understanding the dynamics of the dentist side of the dentist patientrelationship. More research about the power of expectations, self-fulfilling prophecies, vicious circles and misleading myths about dentistry, pain and anxiety would reveal important aspects to problems on both sides of the dentist-patient relationship. With more knowledge about dentist and patient perceptions as a guide, the potential for decreasing pain, anxiety and suffering in patients and poor self-image or career dissatisfaction in dentists should move dentistry and behavioral research into a new, exciting direction in the 21st century.

113.

Dansk Sammenfatning (Danish summary) Kapitel 1. Historisk baggrund for angst og smerte i tandlægens virke Det er mindre end 200 år siden, at det var smeden og barbereren, der mod betaling trak tænder ud bag hestestalden eller i frisørlokalet. Behandlingen lindrede tandpinen, men virkede ofte voldelig og smertegivende i sig selv. Andre gange var det omrejsende gøglere, der trak tænder ud på skrækslagne ”patienter” på scenen foran et veloplagt publikum. Tandlægeskræk er således ikke noget nyt. Vore faglige forgængere har derfor givetvis haft stor betydning for udviklingen af tandlægefagets tvetydige image af både smertelindrende samarittere samt at de volder smerte og angst under behandling. Lidelser fra tandpine og andre tand- og tandkødssygdomme forekommer sjældent i dag takket være betydelige teknologiske fremskridt og udvikling indenfor odontologisk videnskab. Men på trods af udvikling af teknik der giver mere kontrol over smerte og ubehag ved behandling, som lattergas (1884), effektiv lokal bedøvelse (1905) og airotor boremaskine (1957), forbindes tandlæger stadig ofte med smerte og ubehag. Dette kan skyldes at den teknologiske og den menneskelige udvikling ikke altid følges ad. Sideløbende med fremskridtene er patienternes forventninger til komfort ved tandbehandling steget til et niveau, der ikke altid har kunnet opfyldes. Selvom de fleste patienter giver rosende udtryk for tilfredshed med deres egen tandlæge, er der stadig problemer med angst og smerte på tandklinikker. Fortidens ekstraktionskroge, tænger og de offentlige forestillinger med tandudtrækning er i dag erstattet med angstfremkaldende ”hylende” boremaskiner, spidse kanyler og ”bevægelsesindskrænkende” elektroniske tandlægestole i mange patienters opfattelse. Smerte ved tandbehandling og angst for tandbehandling eksisterer således fortsat, men har ændret karakter, og påvirker stadig folks opfattelse af tandlægen. Tandlæger har efterhånden måttet acceptere, at angst for tandbehandling er vanskelig at udrydde, selvom man har gjort flere forsøg herpå, fx i 1930erne med ”psykologi af angst og smerte”-bevægelsen og i 1970-80erne med indførelse af ”halvnarkosebehandling”. Gennem tiden har de sociale og psykologiske aspekter ved tandbehandling således til stadighed bidraget til både anstrengelser og alvorlige konsekvenser for såvel patienter som tandlæger i mange tilfælde. Overordnet formål Afhandlingen udgøres af en afhandlingsoversigt og ni publicerede artikler (markeret I-IX ). Formålet med afhandlingen er at øge vores viden om psykologiske og sociale aspekter af angst og smertefænomener fra såvel patienternes som tandlægernes perspektiv. Det ultimative formål med denne viden er at give mulighed for optimal håndtering af angst og smerte og dermed mere tilfredse patienter og tandlæger. Afhandlingens relevans Angst og smerte ved tandbehandling har ikke kun haft konsekvenser for patienterne, men har også bidraget til arbejdsstress på tandklinikkerne og til en række andre konsekvenser for tandlægerne. Det er derfor vigtigt, at tandlæger får indblik i, hvad der bidrager til patienternes opfattelser, og at begge parter fokuserer på, hvad der kan gøres for at mindske opståen af disse fænomener og deres uønskede konsekvenser. Afhandlingens resultater forventes at kunne sætte skub i denne erkendelsesproces og at kunne give indsigt i håndtering af problemerne, ikke kun i forholdet mellem tandlæge og patient, men også på et fagpolitisk niveau. Den tilvejebragte viden vil desuden kunne gøre læger, psykologer og socialrådgivere mere opmærksom på fobisk tandlægeangst og dens psykiske og fysiske konsekvenser blandt deres patienter og klienter og derved kunne hjælpe dem til relevant behandling.

114.

Oversigt over afhandlingens opbygning Efter gennemgangen af baggrund, formål og rationale for afhandlingen i første kapitel, beskrives i næste kapitel, hvordan forskning af psykosociale aspekter af angst og smerte kræver tværfaglige teoretiske overvejelser og brug af forskellige forskningsmetoder. I tredje kapitel fremlægges forskellige aspekter af fænomenet tandlægeskræk inklusive definitioner, udbredelse, årsager til og differentiering af typer. Fjerde kapitel dækker teoretiske overvejelser om smerte og dens forhold til angst, samt den symbolske betydning smerte kan have for suffering (sjælelig lidelse) i tandbehandlingssituationer. Femte kapitel beskriver patienternes og tandlægernes respektive roller, og hvordan deres indbyrdes forhold påvirker og bliver påvirket af angst og smerte, med særlig fokus på tandlægens image og begge parters rolletilfredshed. Faglige holdninger og grundværdier via socialisering af tandlægerollen diskuteres i denne sammenhæng. Med henblik på håndtering af angst og smerte gennemgås i sjette kapitel en række formelle behandlingsmetoder såvel som medmenneskelige faktorer, der er forudsætninger for at kunne mindske odontofobiske patienters suffering. Endelig præsenteres resultater fra en treårs followupundersøgelse blandt patienter behandlet ved Forskningsog BehandlingsCenter for Tandlægeskræk (FoBCeT). I sidste kapitel fremhæves det, at angst og smerteproblemer ikke kun handler om specifikke kommunikationsproblemer mellem tandlæger og patienter men også om sundhedspolitik og fagpolitik, og der fremlægges en række forslag til afhjælpning af disse problemstillinger.

Kapitel 2. Kort beskrivelse af de teoretiske og metodologiske overvejelser Det er nødvendigt at anvende flere teoretiske indgangsvinkler for at kunne give et nuanceret helhedsbillede af tandlægeskræk og smertefænomener. For at beskrive angst og smerte og for at kunne opstille testbare hypoteser har man i forskningssammenhænge gennem de sidste 40 år anvendt teoretiske forklaringsmodeller som Social Learning Theory, Expectancy Theory og/eller Ethnomedicogenesis Thesis, Gate Control Theory of Pain og en række stress modeller. Tre typer metoder, der adskiller sig: kvalitativt deskriptivt, kvantitativt epidemiologisk og eksperimentelt/quasi-eksperimentelt, har været anvendt i afhandlingen. Hver metode har sit fokus, der afhænger af forskningsspørgsmål og hypoteser. De kvalitative metoder kan belyse fænomener og nuancer som fx subjektive årsager til angst, smerte eller stress og beskrive symptomer, kronologi af begivenheder og forsøg på at løse problemerne. Den kvalitative indfaldsvinkel kan også bidrage til at opstille kvantitativt testbare hypoteser. Kvantitative epidemiologiske metoder har været anvendt til at beskrive forekomsten af angst og smerte og til at angive mål på associationen mellem disse og en række andre faktorer. De eksperimentelle eller quasi-eksperimentelle metoder er blevet anvendt til at vurdere effekt af bestemte behandlinger eller interventioner.

Kapitel 3. Hvad er tandlægeskræk? Hvad er det ikke? Hvor mange har det? Definitioner Der er en vis forvirring om brugen af forskellige "skræk" ord som frygt, angst og fobi. Følgende definitioner anvendes i denne afhandling, hvor rækkefølgen er anført efter stigende intensitetsgrad. FRYGT er en følelsesmæssig reaktion på en ”her og nu” trussel med en "her og nu" respons: muskelspændinger, øget hjerterytme, sved, hurtig vejrtrækning og ”ondt i maven”. Der er typisk reel fare til stede, og reaktionen er en forberedelse til flugt. Dette er en normal respons, især hos børn. ANGST er en følelsesmæssig reaktion på forventningen om en truende oplevelse, dvs. ”forhåndsangst” med samme fysiske reaktioner som ved frygt, men hvor faren kan være reel, overdreven eller slet ikke eksisterende. Kognitivt kendetegnes angst af generalisering og katastrofetænkning i modsætning til frygt. 115.

FOBI er en meget intens og irrationel angstreaktion rettet mod en truende oplevelse, oftest karakteriseret ved langvarig undgåelse af det, der udløser angsten. Den psykiatriske beskrivelse af fobi omfatter en række kriterier, som skal være opfyldt for at kunne stille diagnosen. Angsten kan ofte have karakter af panik, og erkendes af den pågældende som en urimelig reaktion i forhold til den reelle fare. Den påvirker personens arbejdsliv, sociale relationer eller andre funktioner. Personer, der lider af ekstrem angst eller fobi ifm. tandbehandling lider af “odontofobi” og benævnes i denne afhandling ”odontofobikere”. Udbredelse af tandlægeskræk En telefonundersøgelse (studie II) af 565 voksne over 16 år i Århus kommune viste, at 4,2% gav udtryk for eller havde ekstrem eller fobisk angst og totalt undgik tandlægebesøg. Angsten blev målt på Dental Anxiety Scale (DAS), og ekstrem/fobisk angst blev defineret som scores mere end eller lig med 15 ud af max. 20 point, hvilket skal ses i relation til en gennemsnitsværdi på 7,5 blandt voksne danskere. Seks procent var moderat angste dvs. havde en DAS-score på 14-12, hvilket gav sig udtryk i tilfældige udeblivelser og afbud til aftalte tandlægebesøg. I alt beskrev næsten 40% en eller anden grad af angst for tandbehandling. Karakteristika af tandlægeskræk ift. angstintensitetsniveau I samme undersøgelse blev karakteristika dels for odontofobikere (DAS >15) og dels for personer med moderat angst (DAS 12-14) sammenlignet med personer med lav angst (DAS 12) andre alvorlige fobier: Tilsvarende danske tal (II) var 25-40 %, afhængig af DAS angst niveau (DAS >12 eller 15). Blandt danskere med odontofobi havde 20-30 % også angst for læger eller hospitaler (II). I denne afhandling har den ætiologiske forskning primært fokuseret på yderligere afdækning af social indlæring af angst og smerteopfattelser. For at se hvordan angst for tandlæger kan blive påvirket af forskellige sociale rammer, gennemførtes en tværkulturel undersøgelse af en række faktorer, der bidrager til tandlægeangst (III). I et klinisk epidemiologisk studie af 951 voksne fra klinikker på tandlægeskoler i Iowa City, Iowa, USA og Taipei, Taiwan, fandt man, at anvendelsen af lokalbedøvelse ved rutinemæssige behandlinger samt angst for injektioner var langt større blandt amerikanere end blandt taiwanesere. Men taiwanesere og amerikanere med høj angst for tandbehandling (DAS > 12) havde i samme grad angst for injektioner. På trods af samme niveau af angst for boring, rapporterede ”høj angst” taiwanesere, at de brugte langt mindre lokalbedøvelse ved rutinetandbehandlinger end ”høj angst” amerikanere. Nedladende tandlægebemærkninger var næsten udelukkende et amerikansk fænomen og var signifikant relateret til deres angst. Undgåelse af behandling var mest prævalent for alle med høj angst for injektioner samt for amerikanere, der havde oplevet negativ tandlægeadfærd. Undersøgelsen viste, at karakteristika og årsagssammenhænge for angst for tandbehandling er forskellige for forskellige kulturelle grupper, dels afhængig af sundhedssystem, og dels afhængig af forventninger og holdninger til behandling blandt såvel tandlæger som patienter indenfor de respektive systemer. Diagnostik Allerede i den danske odontofobi Ph.D. afhandling (Moore, 1991) om angst for tandbehandling blev det påpeget, at der i tidens løb er udviklet to modeller til betragtning af angst forbundet med tandbehandling en odontologisk model og en psykiatrisk model. Det der er vigtigt for en tandlæge ved behandling af en patient med fobisk angst for tandbehandling, er ikke nødvendigvis det, der er vigtigt for en psykiater. Men begge perspektiver er vigtige. Den odontologiske screeningsmetode, “Seattle-systemet” bruges hovedsageligt til at finde et differentieret behandlingstilbud, som passer til ”diagnosen”, og skelner mellem følgende fire typer af odontofobi: Type I. Specifik angst for smerte eller ubehag (19% ifølge Ph.D. studiet); Type II. Mistillid til tandplejepersonalet (46%); Type III. Patienter med høj trait angst, andre fobier og/eller andre generelle psykiske problemer (28%); og Type IV. Angst for katastrofale reaktioner (besvimelse el. anfald) under behandling (7%). Den psykiatriske model, baserede på DSM-IV, har et bredere formål end den odontologiske og vha. meget pålidelige udspecificerede kriterier fører til en psykiatrisk diagnose, der kan give mulighed for en bred samfundsmæssig erkendelse af patientens dysfunktion. Diagnosen kan bruges til, gennem valg af behandlingsstrategi såvel som socialrådgivning og økonomisk støtte, at hjælpe patienten til at mobilisere de ressourcer, der er nødvendige for, at han igen kan fungere optimalt i sociale og sundhedsmæssige sammenhænge. Fælles for begge systemer gælder at der ved kategorisering af odontofobi skelnes mellem tre hovedmanifestationer: 1) angst for specifikke trusler - instrumenter/procedurer, 2) mere socialt betinget angst og 3) odontofobi påvirket af andre mere generelle psykiske problemer. I de relevante undersøgelser (Ph.D.,II,IX) viste fordelingerne af fund sig at være sammenlignelige med disse kategorier Afhandlingens diagnostiske undersøgelse (IX) handlede om de mere socialt betingede angstformer og beskrives nedenfor. Socialt betinget angst: Forskel mellem angst for tandlægens truende adfærd vs. angst for tandlægens negative evaluering Der foreligger kun ganske få beskrivelser af sociale aspekter ved odontofobi diagnoser, skønt mange odontofobikere giver udtryk for en socialt betinget magtesløshed i forbindelse med deres angst. I sin Ph.D117.

afhandling kunne Moore ikke adskille, om disse patienter følte sig truet af tandlægens adfærd, eller om de følte sig ualmindeligt flove over forsømmelsen af tænderne pga. deres angst for tandbehandling. Eftersom denne kvalitative forskel har betydning for videreudvikling af diagnostik og tilpasset behandling, blev 30 odontofobiske patienter interviewet om baggrunden for deres angst i det kronologisk seneste studie (IX). Hovedklager og begrundelser for opsøgning af behandling ved FoBCeT på Tandlægeskolen i Århus, var fordelt således: 30% havde primært angst for smerte ved tandbehandlingsprocedurerne; 47% oplevede magtesløshed i relation til tandlæge situationer (nogle udspecificerede flovhed/skam); og 23% nævnte anden psykosocial dysfunktion relateret til seksuelt misbrug i barndommen, kvælningsfornemmelser, generel angst, synkope eller panikanfald. Alle patienterne undtagen tre, klagede over flovhed i en eller anden grad, hvor de typisk beskrev flovhed/skam som en sekundær faktor eller bivirkning af deres angst for tandbehandling. Intens flovhed var tilstede i både kliniske og ikke-kliniske situationer og hang sammen med dårlig tandstatus eller selvbebrejdelser og dårlig samvittighed begrundet i forsømmelse af tænderne. Ni af patienterne angav som hovedklage angst for negativ omtale i deres sociale netværk (fx ”Jeg er bange for hvad de synes om mig og mine tænder”). Disse ni patienter adskilte sig kvalitativt fra de andre som påpegede ”en truende tandlæge” som hovedklage, eksempelvis ”Jeg er bange for de ting han pludselig kan trække frem”. Alle ni intenst flove patienter havde hæmninger omkring at smile eller grine og udviste en eller anden form for ”gemmeadfærd”, hvor de skjulte deres tænder med læber, hænder eller ved ændret hovedstilling. Flovheden førte til selvbebrejdelser, dårligt selvimage og i nogle tilfælde selvrapporterede personlighedsforandringer, ligesom flovhedens intensitet var stærkt relateret til antallet af år uden tandbehandling og graden af gemmeadfærd. Konklusionen af dette studie blev, at flovhed i forbindelse med odontofobi har forskellige intensitetsgrader og karakteristika. I enkelte tilfælde opfyldte patienterne de psykiatriske kriterier for social angst tilstand, mens flovheden hos de fleste (18 ud af 27 der nævnte flovhed) var en generende bivirkning til andre mere centrale manifestationer. Det blev bekræftet, at flovhed er en katalysator for den onde cirkel af odontofobi (Fig. 7), også i tilfælde hvor flovhed ikke er hovedklagen, hvilket har betydning for differentieret behandling.

Kapitel 4. Klinisk smerte og dens forhold til angst Smerte og angst er tit forbundet med hinanden ved angst for tandbehandling. Men som beskrevet i kapitel 3 er der forskel i rapportering af smertens indblanding på forskellige angstintensitetsniveauer. Derfor er det vigtigt at sætte sig ind i, hvad det betyder at lide af smerte i forhold til angsten. Definitioner og grænseområder Den officielle definition af smerte ifølge International Association for the Study of Pain (IASP) er: “en ubehagelig sensorisk og emotionel oplevelse og erfaring, der er knyttet til aktuel eller potentiel vævsskade, og som beskrives med terminologi som ved skader”. “… Smerte er altid subjektiv. Ethvert individ lærer brugen af ordet ved oplevelser relateret til skader eller muligheden for skader i en tidlig alder. …det er altid ubehageligt og dermed også en følelsesmæssig oplevelse.” IASP definitionen giver muligheder for andre, mere socialt betingede aspekter af smerteopfattelsen. Dagligdags eksempler hvor smerte har et socialt budskab kan fx være smerte på det rigtige tidspunkt i en fodboldkamp, hvor frispark kan give mulighed for sejr. Eller fx i tandlæge-patient forholdet, hvor en patient reagerer med tydelig smerte blot ved boring i emaljen. Man får indtryk af, at reaktionen er udløst af angst eller manglende tillid til situationen. Dvs. der er forskel på selve den fysiske smertestimulus og på smertereaktionen. Smertereaktioner er lærte fænomener og er afhængig af den følelsesmæssige betydning af smerten.

118.

Emotionel betydning af smerte - psykosociale rammer for individuelle oplevelser Der er en række klassiske studier omkring betydning af smerte i sociale sammenhængeog især af smertens emotionelle betydning. Den amerikanske læge Henry Beecher viste, at smertereaktionerne hos sårede amerikanske soldater i anden verdenskrig var langt mindre end forventet i forhold til sår størrelse, fordi det betød, at de skulle hjem og væk fra krigens rædsler. Et sammenligneligt udsnit bestående af civile med mindre sår havde større klager over smerter og havde et signifikant større behov for smertestillende. Tyve år senere lagde Melzack og Wall fundamentet til den moderne tænkning om smertefysiologi, smerteopfattelse og smertereaktioner med ”port kontrol teorien”, som hævder, at smerte er koblet til ”kognitive” (tankemæssige) og følelsesmæssige faktorer der er afgørende for, om en person vil registrere stimuli som smertefulde. Forbindelsen mellem smerte og angst kan være præget af personens tidligere erfaringer, følelsesmæssige faktorer, og grad af opmærksomhed på det frygtede objekt eller situation. Dvs. der er sociale forhold og normer for, hvad man kan forvente af en evt. smerteprovokerende behandling. I afhandlingens kronologisk første studie (I) beskrev patienter og tandlæger fra forskellige etniske grupper, i alt 35 skandinavere (danskere og svenskere), 25 anglo-amerikanere og 25 mandarin-talende kinesere, universelle dimensioner af smerte som tid, intensitet, lokalisering, kvalitet, årsag og kurabilitet (I). Herudover blev der afdækket kultur-specifikke dimensioner som det unikke kinesiske begreb, ”suan” eller ”suantong”, et multivariant begreb for knogle, muskel, led, tand og gingivale sensationer eller smerter. Suan beskrives som en blanding af flere vestlige begreber: intensitet, ”metal-kontakt-lignende” ved tænder og ”syrlig” kvalitet ved muskler (ligner det danske ”det syrer i benene”). ”Indbildte” smerter blev beskrevet af vesterlændinge og især af tandlæger som en konvertering af frygt eller angst til en smerteopfattelse, hvor man ”bilder sig ind”, at ting gør ondt. Fænomenet blev ikke nævnt af kineserne. De anvendte antropologiske forskningsmetoder viste sig følsomme overfor kulturelle forskelle. Bevis for en psykosocial påvirkning af smerteopfattelser og reaktioner er, at etnicitet spillede en stærkere rolle end professional socialisering, hvad angik beskrivelser af smertetyper, men ikke med hensyn til smerteremedier. Dette studie, foretaget blandt immigranter i USA, blev forstudiet til et større forskningsprojekt med næsten 700 forsøgspersoner i 5 lande, hvor der blev undersøgt yderligere detaljer om psykosociale aspekter af smerte. Ved studie V blev 129 angloamerikanske, mandarintalende kinesiske, og skandinaviske tandlæger interviewet om deres patienters: 1) relative hyppighed i brug af eller ikke-brug af lokalbedøvelse ved standard proksimale fyldninger, 2) begrundelser for brug/ikke-brug af bedøvelse, og 3) fordeling af begrundelser for ikke at bruge lokalbedøvelse. De amerikanske tandlæger fortalte, at ca. 1% af deres voksne patienter ikke brugte lokalbedøvelse sammenlignet med 90% hos kinesiske og 37,5% hos skandinaviske tandlæger. I 396 patientinterviews fortalte kun 6% af amerikanerne, at de ikke brugte bedøvelse sammenlignet med 90% af kineserne og 54% af skandinaverne. Begrundelserne blandt anglo-amerikanere og skandinaver var stort set ens: følelsen af boring var udholdelig, undgåelse af ubehag efter bedøvelsen og angst for indsprøjtninger, i nævnte rækkefølge. Det næsthyppigste svar blandt danskere var dog, at ”man skal betale ekstra penge for det”. I de vestlige lande forventedes det, at patienten bestemte, hvornår de vil have bedøvelse, hvorimod de kinesiske tandlæger typisk bestemte, om der skulle bruges lokalbedøvelse. Hvis kinesiske patienter kun oplevede ”suan”-sensationen, var bedøvelse ikke nødvendig i modsætning til ”tong” (rigtig ondt). Det var afslørende, at kinesiske tandlæger ofte beskrev indsprøjtninger som ”tong”, hvilket var en af de mulige grunde til, at de undgik at give bedøvelse. Ligesom studie I, viste studie V, at der var signifikant etnisk indflydelse på smerteopfattelse ved tandboring. Anvendelse af lokal bedøvelse viste sig afhængig af forventningerne mellem tandlæger og patienter i de forskellige sundhedssystemer, på trods af samme adgang til moderne lokal anæstesi.

119.

Individuelle smerteoplevelser, forventninger og angst Indenfor disse psykosociale grundrammer har ethvert individ oplevelser gennem livet ,der lærer én, hvordan man kan reagere overfor et smertefremkaldende stimulus. Der er megen litteratur både generel og mere specifik om den indflydelse angst og forventninger til smerte har i forhold til den aktuelle oplevelse af smerte. Studier af Kent og kollegaer, Rankin og Harris samt Arntz og kolleger viser bl.a., at det ikke er selve oplevelsen af smerte, der er noget galt med, men snarere at hukommelsen for selve den reelle smerteoplevelse blandt de angste svigter. Når man er angst og møder op med negative forventninger om at opleve smerte, er det fordi man langt bedre husker ”følelserne” bag de negative forventninger og ikke selve oplevelsen. Dvs. man fokuserer på de negative forventninger og ”beliefs” (betyder her ”vedvarende forestillinger eller holdninger”), også selvom oplevelsen ikke er så slem som forventet. En selektiv og følelsespræget hukommelse træder i kraft. Litteraturen peger på, at det er angstens intensitet,der styrer graden af fokus på disse negative forventninger. Man kan ikke distrahere sig fra smertefokusering, når man er for bange. Dette mønster kan dog ændre sig, men det kan tage lang tid. En terapeutisk tilgang og gentagne beskeder gennem år fra en tillidsvækkende tandlæge om, at man har klaret sig flot, kan få de gamle negative forventninger og beliefs til at fortabe sig og helt forsvinde, således at man kan begynde at tro på sine evner til at klare sig. Men dette kræver både tid og følsomme tandlæger. Smerte, traume, lidelse – jo..; men tortur? Nordamerikanske og svenske undersøgelser har vist, at smerte var den mindst hyppige hovedklage blandt odontofobikere, og at traumatiske oplevelser oftest havde relation til negativ tandlægeadfærd og/eller patienternes egen flovhed. Den danske epidemiologiske undersøgelse (II) uddybede dette og påviste betydningsfulde forskelle i den relative styrke af oplevelser af negativ tandlægeadfærd blandt ekstrem/fobisk angste personer sammenlignet med moderat angste personer. Dette bekræfter Ph.D. undersøgelsen der fandt, at kun 19% primært havde angst for smerte. Angsten var forbundet med traumatiske oplevelser for 84%, hvor kun 25% af disse traumatiske oplevelser var forbundet med smerte, mens 30% var et resultat af “at blive holdt fast i stolen”, og 40% var forårsaget af tandlæger med “hårde hænder”, dvs. alt fra “ikke blid” til “prikke til én med en sonde”, ”lussinger”, eller ”slag”. Disse kvalitative beskrivelser af traumatiske oplevelser, hvor patienterne, typisk som børn, hensynsløst var blevet påført ubehag og smerter eller endog simpelthen var ofre for ondskab, giver en klar fornemmelse af egentlige overgreb i et omfang, der i flere tilfælde kunne ligne tortur. (Tortur her defineret som overlagt påførsel af intens smerte, fysisk eller psykisk lidelse begået af personer med offentlig myndighed enten som straf, for at påtvinge andre ens vilje eller for at diskriminere.) Hvor vidt definitionen har været opfyldt vides ikke. Det er sikkert yderst sjældent. Men der har været tale om grænseoverskridelser, som har medført langvarig lidelse med både fysiske og primært psykiske konsekvenser, såkaldt ”suffering”. Det er noget, der er svært at tale om, og når man endelig er tvunget til det, er det mere acceptabelt at sige, at behandlingen ”gjorde ondt” i stedet for at sige, at tandlægen voldte dem smerte og lidelse. Odontofobi er således en lidelse med omfattende sociale og psykiske konsekvenser, som samfundsmæssigt stadig underkender i forhold til andre psykiske lidelser med samme grad af dysfunktion. Det er på tide at gøre op med den udbredte fejlagtige opfattelse af, at odontofobi er selvforskyldt.

Kapitel 5. Patienters og tandlægers roller relateret til angst og smerte Fra ovennævnte beskrivelse af suffering og smerte, kan man se, at disse er påvirket af forholdet mellem patienter og tandlæger, hvilket uddybes i nedenstående ”forklaringsmodeller”(se Fig. 13).

120.

Patienternes rolle og passivitet En helt almindelig tandbehandlingssituation er karakteriseret ved, at patienten læner sig tilbage i tandlægestolen, og ved at tandlægen er bøjet ind over patienten. Tandlægen er meget centralt stillet i forhold til patienten i den sociale situation, fordi han indenfor meget kort tid skal undersøge og behandle i et meget lille arbejdsområde, og helst smertefrit. Det er her nødvendigt, at patienten har tillid til og afgiver indflydelse til tandlægen, for at denne kan udføre det teknisk krævende arbejde og de ofte presserende ydelser. Mange patienter har ikke problemer med denne mere eller mindre passive rolle, men en del har tydelige følelsesmæssige problemer som regel pga. tidligere erfaringer, som beskrevet ovenfor. Derfor er det vigtigt at øge de odontofobiske patienters selvtillid og styring af den sociale situation, såkaldt empowerment, for at der kan komme en fordelagtig magtbalance i tandlæge-patient forholdet. Empowerment kan foregå på to niveauer: 1) det konkrete behandler-patient forhold (”mikro”-niveauet) og 2) de samfundsmæssige eller fagpolitiske forhold omkring patienters vilkår i forbindelse med behandlingstilbud (”makro”-niveauet). Tandlægernes rolle, arbejdsstress og ”besværlige” patienter I litteraturen er der skrevet meget om, hvad der skal til for at give patienterne gode behandlingsoplevelser: høj teknisk kvalitet, omsorg og tryghed, mere indflydelse, smertefrihed og rimelige økonomiske aspekter. Vi har kendskab til noget, men ved ikke nok om de faktorer og værdier (udover ”tid = penge”), der motiverer tandlægerne, og hvad der sker i det daglige kliniske arbejdsmiljø set fra tandlægens perspektiv. Adskillige undersøgelser har påvist, at privatpraktiserende tandlæger rapporterer om høj grad af ”occupational stress” og har stor risiko for udbrændthed (følelsesmæssig udmattelse, distancering til patienter og mindreværdsfornemmelse), samt at tandlæger med ekstrem stresssymptomer ofte har et misbrug af alkohol eller stoffer og/eller udvikler depression/selvmordstanker. De største kilder til stress i praksis er ifølge litteraturen: 1) tidspres, 2) at volde patienter smerter og 3) at behandle angste patienter. Hvordan tandlæger oplever angste patienter i privatpraksis, foreligger der imidlertid ikke megen litteratur om. Dette gav anledning til en kvalitativ undersøgelse (IV) af karakteristika og konsekvenser af tandlægeskræk i privat praksis for at kunne beskrive tandlægeskræk fra tandlægernes synsvinkel. I 42 tilfældigt udvalgte private praksis i Århus blev der behandlet 53 tandlægeskrækpatienter. Disse patienters DAS scores før behandling var signifikant lavere end scores hos en referencegruppe af patienter behandlet ved specialklinikken FoBCeT. Trods dette var dropouts i privat praksis (33/53) signifikant flere end fra FoBCeT (8/80) i samme periode. Telefoninterviews med 20 af de 42 tandlæger (alder 35-66 år; 16 mænd, 4 kvinder) viste, at hyppigheden af angste patienter i deres praksis varierede fra 0,3% til 9% (gennemsnit 1,9%). 75% havde oplevet udeblivelser og afbud, som det mest karakteristiske for disse patienter. 35% af tandlægerne vurderede, at årsagen til angstproblemet primært var patienternes egen indstilling, hvorimod 40% gav tidligere tandlæger og deres dårlige behandling skylden. Andre 10% kom med udsagn som, at der blot var gået noget galt i tandlæge-patient-forholdet. Kun én ud af de 20 tandlæger mente, at uddannelsen om angst og patientkommunikation var tilstrækkelig. Konklusionen blev, at angste patienter er et væsentligt problem, der påvirker tandlægens hverdag, og at de kan være problematiske at behandle. På baggrund af disse resultater, gennemførtes en epidemiologisk undersøgelse af 216 danske tandlæger mht. deres opfattelser af arbejdsstress og angste patienter (VII). Den viste, at 60% opfattede tandlægefaget som mere stressende end andre professioner, og at de mest intense stressfaktorer var: 1) at komme bagefter pga. en nødbehandling, 2) at volde patienter smerte eller ubehag, 3) for meget arbejde, 4) forsinkede patienter og 5) angste patienter. Dette svarede til lignende udenlandske fund. Odds ratio sandsynlighedsberegninger viste, at ældre tandlæger (>44 år) med en opfattelse af høj arbejdsstress i de daglige kliniske kontakter havde sværest ved at gennemskue, om patienter var angste (OR = 3,2). Tandlægernes opfattelser af årsagen til angst blandt patienter var i rangorden: 1) angst for smerte, 2) tidligere traumatisk 121.

tandbehandling/mistillid, 3) generelle psykiske problemer, 4) skam/flovhed og 5) et dække over andre økonomiske prioriteter. Tandlæger, der mente, at angst for tandbehandling primært var et resultat af generelle psykiske problemer, var mere end to gange så sandsynligt fra solopraksis, fra ældre praksis (> 18 år) og havde en høj stressopfattelse. Det kunne konkluderes, at tandlægers stresssituation kan påvirke deres opfattelser af angste patienter. Næsten alle tandlæger mente, at patienter oftere evaluerer tandlæger udfra deres adfærd på klinikken end udfra deres tekniske færdigheder. Flertallet anså samtale med angste patienter som den primære strategi i behandling af angst. Tandlægernes image ift. professionel socialisering, patienternes og tandlægernes tilfredshed Tandlægen har lige siden sin uddannelse lært og vænnet sig til at være den ledende og ofte dominerende kraft, ikke kun i forhold til patienten, men også i forhold til hele klinikken. Det er en rolle, tandlægen har lært via sin professionelle socialisering, dvs. den proces, hvori værdier og rolleadfærd indlæres af mennesker, der har fælles identitet igennem deres uddannelse og senere beskæftigelse. Man lærer også, at man har behov for kontrol over tidsmæssige bedrifter og at når man kommer ud i praksis, er ”tid lig penge”. Det passer imidlertid ofte dårligt sammen med nogle patienters forventninger, værdier og behov. Selvom høj teknisk kvalitet er vigtig, er det påvist i adskillige undersøgelser, at mange patienter har mere brug for en behandling med omsorg og tryghed, hvor der er gode muligheder for kommunikation og indflydelse, relativ smertefri behandling og overkommelige priser. Undersøgelser viser , at de fleste patienter er tilfredse med deres tandlæge, samt at de fleste tandlæger er tilfredse med deres valg af karriere. Men for tandlæger der ikke er tilfredse, er det vigtigt at undersøge hvorfor, eftersom det kan påvirke opfattelser og adfærd på klinikken. Det har vist sig vigtigt for tandlæger, at de ikke bare ”ekspederer” patienter, men i stedet at de fordyber sig i kontakten med den enkelte patient, hvilket kan fremme deres professionelle trivsel. Forholdet mellem danske tandlægers opfattelse af tilfredshed med valg af professionel karriere og opfattelse af arbejdsstress og image i befolkningen blev ligeledes undersøgt hos de samme 216 tandlæger (VI). Af disse var 19% utilfredse nok til ikke at ville anbefale en karriere som tandlæge til yngre mennesker. 31% mente, at tandlæger har et mindre godt eller dårligt image blandt befolkningen. Sandsynlighedsberegninger viste, at utilfredshed med valg af job var mere end tre gange så hyppigt blandt tandlæger ældre end 44 år end blandt de yngre tandlæger. Blandt de “utilfredse” var det mere sandsynligt, at de opfattede tandlægefaget som mere stressende end andre professionelle fag (OR = 2.1; P = 0,09), og at de opfattede deres image blandt befolkningen som negativt (OR = 3.0). Der var ingen signifikante associationer med køn, praksistype, praksis placering eller praksis størrelse. På baggrund af disse fund kan det konkluderes, at privatpraktiserende tandlægers opfattelse af deres image i befolkningen og oplevelse af stress i praksis påvirker graden af jobtilfredshed. Et flertal af tandlægerne så gerne Tandlægeforeningen gøre noget for at ændre på tandlægestandens image og noget for, at de kan lære mere om styring af arbejdsvilkår og opnåelse af faglig tilfredshed. Det er vigtigt at tandlæger er opmærksomme på forhold, der måtte påvirke deres trivsel som praktiserende tandlæge. Betydningen af angst og smerte for tandlæge-patientforholdet og optimal kommunikation De to gruppers forventninger til tandbehandlingssituationen kan ofte føre til værdikonflikter, som yderligere forstærkes af samfundets beliefs og forventninger til tandlægerollen. Ifølge litteraturen er tandlægeadfærd i høj grad præget af teknisk fokus, minimal social kontakt samt stærke forventninger om økonomisk belønning og anerkendelse af tandlægens indsats, netop fordi der kan være angst og smerte. Disse forhold tolkes ofte negativt af nogle patienter og kan let medføre et dårligt image. Det er også vist, at patienternes tilfredshed er afhængig af, i hvilken grad de føler, de kan kontakte tandlægen, og hvor god tandlægen er til at hjælpe dem med at klare deres angst og smerteproblemer. Konflikt kan opstå omkring opfattelse af smerte og forventninger, hvor tandlægen måske ikke tror på patientens egen vurdering af smerten. Især her er 122.

kvaliteten i tandlæge-patient forholdet og kommunikationen afgørende for begge parters tilfredshed. ”Den gensidige deltagelsesmodel” er den bedst egnede til behandling af angste patienter i odontologisk praksis, hvor der er behov for en gensidig kommunikation for at undgå potentielle angst- eller smertereaktioner. I denne model informerer lægen/tandlægen patienten om sygdom og behandlingsmuligheder og undersøger samtidig patientens holdninger, fordomme og ønsker med henblik på, at der kan indgås aftaler baseret på den seneste viden og patientens subjektive behov. Denne stil fører til den såkaldte ”patient-centrerede ” behandling, hvor ”empowerment” af patienterne er fuldkommen i modsætning til andre kommunikationsmodeller, hvor patienten kun er tilladt en mere passiv rolle. Denne model er også god for tandlægernes jobtilfredshed på længere sigt, eftersom man oftere har patienten ”med sig”og derved får et lettere samarbejde og færre angst og smertereaktioner. For at kunne sætte patienterne i stand til at have indflydelse på deres behandling i et tæt samarbejde, skal tandlæger forstå og opmuntre patienterne til større engagement i oral sundhed og bevidsthed om konsekvenser af deres beslutninger og handlinger. Forandring til denne form for gensidig dialog kræver både etisk, økonomisk og sundhedspolitisk støtte til ikke kun de odontofobiske patienter men også til de tandlæger, der behandler dem.

Kapitel 6. Håndtering af angst og smerte i tandplejen Dette kapitel giver en gennemgang af de mere formelle behandlingsmetoder såvel som de medmenneskelige terapeutiske faktorer, der er nødvendige forudsætninger for at mindske patienternes suffering. Den foretrukne behandlingsform er for mange odontofobikere og tandlæger helbedøvelse, der kan virke som en “hurtig løsning”. Men det har vist sig at være en meget dyr og i sidste ende ineffektiv løsning. Svenske longitudinelle undersøgelser har således vist, at patienter behandlet med helbedøvelse har flere udeblivelser og afbud end psykoterapeutisk behandlede patienter. På FoBCeT klinikken har der været anvendt forskellige former for systematisk desensibilisering (SD) samt hypnose, hvorfor de skal beskrives yderligere her. SD er trinvis tilvænning til procedurer koblet sammen med en eller anden form for afspænding, for at patienten gradvist kan tackle angsten. 1) Video SD træning - Patienterne blev udsat for 8 successive 30 sekunders videoklip af gradvist mere truende tandbehandlingssituationer, med mulighed for at afbryde med håndsignaler, når de havde brug for pause eller instruktion. Vha. biofeedback registrering af muskelspænding/afspænding blev patienten klar til gradvis at prøve tandbehandling på klinikken. 2) Rehearsal SD træning - Patienterne blev udsat for simulerede behandlingssituationer eller tandlægeinstrumenter gennem trinvis tilvænning kombineret med bevidstgørelse om spændingstilstand, pauser ved håndsignaler og åndedrætskontrol, f.eks. indsprøjtninger med plastikhætte på og boremaskine uden bor med muligheder for pauser eller instruktion. 3) Gruppeterapi (GT) - Grupper på 3 mænd og 3 kvinder deltog i syv 2-timers seancer ledet af en terapeut/tandlæge, en klinikassistent og en tidligere behandlet patient ved FoBCeT. Patienterne diskuterede tidligere oplevelser og nye forventninger, fik instruktion om fobiske reaktioner og social assertionstræning samt trænede afspænding. Patienterne gennemgik video SD i gruppen (samme videoklip som ovenfor) med håndsignalerede pauser. I den sidste seance var der demonstration af procedurer som indsprøjtning (med hætten på) og boremaskine (uden bor) på klinikken. 4) Hypnoterapi (HT) - Mekanismen i hypnose kendes ikke fuldt ud men handler blandt andet om omkodning af forventninger og afspændingsprocesser. Ved at lave negative tanker som fx. lyden af boremaskinen om til et signal til fordybelse i trance samt at tegne et mentalt billede af tandlægeangst som en mur, som man skal forbi, hjælper terapeuten patienten over forhindringer. I specielt stressede situationer blev der brugt ”spaltninger” til patientens foretrukne sted (f.eks. på stranden). I tilfælde hvor der havde været traume, blev der anvendt regression (tilbageføring i alder) og omkodning gennem suggestioner. 123.

Longitudinelle undersøgelsesresultater af angstbehandling på FoBCeT (VIII) Motiveret af manglende litteratur om langtidseffekter af behandling for tandlægeangst blev effekten af behandling af FoBCeT angstpatienter i en 3-års undersøgelse (VIII) sammenlignet med resultater fra en privat praksis kontrolgruppe. Behandlingsgrupperne (n=106) var alders- og kønsmæssigt sammenlignelige med kontrol kohorten på 65 angstpatienter (DAS > 15), som blev fulgt over gennemsnitligt 6 år. Efter 3 år kunne 55% af HT patienter, 70% af GT patienter og 66% af SD patienter klare regelmæssig tandbehandling (dvs. ikke sporadiske besøg). Dette var signifikant bedre end de 46% af hele kontrolgruppen og 39% af en kontrol subgruppe med præcist 3-års observation. Overalt var kvinder bedre til regelmæssige tandlægebesøg end mænd efter 3 år. FoBCeT-behandlede regelmæssige patienter efter 3 år var signifikant mindre angst og havde mere positive beliefs om tandlæger end de regelmæssige patienter fra kontrolgrupperne i privat praksis. Imidlertid var der ikke signifikant forskelle i adfærd, angst eller opfattelser af tandlæger mellem de FoBCeT behandlede HT, GT and SD grupper efter 3 år. Undersøgelsen viste, at FoBCeT patienter klarede sig signifikant bedre med hensyn til både vedligeholdelse af regelmæssig tandplejeadfærd og reduktion af angst end odontofobikere behandlet af alment praktiserende tandlæger. Det blev konkluderet, at mange odontofobiske patienter ved egne kræfter og med succes kunne starte op igen og vedligeholde regelmæssig tandpleje på trods af mange års undgåelse. Men disse patienter havde mindre succes over tid med angstreduktion og tiltro til tandlæger end specialistbehandlede patienter. Det er derfor fordelagtigt at behandle odontofobi med dokumenterede psykologiske principper og uddannet personale. Reduktion af smerte og lidelse - de ”skjulte” menneskelige faktorer i behandlingssucces Selvom ovennævnte undersøgelse viste bedre resultater blandt FoBCeT patienter i forhold til privatpraksis, var der ingen signifikante forskelle mellem de forskellige specialisttiltag. De var alle lige effektive. Én fortolkning af dette kunne være, at der kan være andre terapeutiske faktorer, der har optimeret behandlingen uafhængig af hvilken strategi der blev anvendt. Fra et eksperimentelt videnskabeligt perspektiv kan disse betragtes som ”støj” i resultaterne, men i praksis er de nødvendige for terapeutisk succes. I litteraturen er beskrevet ”skjulte” behandlingsfaktorer som berøring, empati, aktiv lytning, og adskillige andre nonverbale metoder blandt personale, der behandler odontofobi på angstspecialistklinikker. Medmenneskelig betragtning af patienter hjælper, fx at man er villig til at arbejde med patientens ”enduring” (psykisk udholdenhed overfor lidelser), at man kan indgyde håb, og at man udviser trøstende adfærd fx berøring for at hjælpe patienten til at falde til ro. Tavshed på det rigtige tidspunkt i en samtale signalerer til patienten, at man er villig til at lytte. Med empati (indfølingsevne) viser behandleren patienten, at han ”forstår”, og ved aktiv lytning checkes forståelsen af kommunikationen ved at gentage, hvad der er blevet sagt. Man er mere spørgende end talende med patienterne og får derved afklaret patientens behov og forventninger. Man skal også som en god terapeut eller tandlæge kunne gøre brug af humor i visse situationer. Der er et stort behov for yderligere specifik forskning af disse psykosociale behandlingsfaktorer. Tandlægen og håndtering af odontofobi Andre faggrupper (psykologer, psykiatere, socialrådgivere) bør involveres i et tværfagligt samarbejde, men her præsenteres tre argumenter for, hvorfor tandlæger bør være hovedansvarlige i organisering og håndtering af behandling af odontofobi: 1) Det er tandlægerne, der kender de angstprovokerende tandlægelige procedurer, og de kan bedst forklare fx et desensibiliseringsforløb med boremaskine eller bedøvelseseffekt i forhold til anatomien.

124.

2) Tandklinikker er typisk små enheder. Derfor har patienter bedre mulighed for at lære personalet at kende og for at vælge tandlægen ud fra egne personlige og følelsesmæssige behov. Dette er i modsætning til medicinske institutioner fx hospitaler. Hvis forholdet ikke fungerer, kan man skifte tandlæge relativt let. 3) Tandlægeprofessionen har en naturlig motivation for at formindske angst og smerte forbundet med behandling, eftersom de påvirker arbejdsstress og image, faktorer der igen påvirker tilfredshed. Dokumentation fra artiklerne VI, VII og VIII giver et klart billede af, at der skal ske noget i uddannelsestilbuddet for tandlæger. Det blev også slået fast, at timeløn er at foretrække i behandlingen af odontofobikere i stedet for det eksisterende stykprissystem. Derfor kunne et forslag være en specialefteruddannelse af interesserede tandlæger og psykoterapeuter via et certificeret kompetencegivende kursus under Sundhedsstyrelsen og de akademiske institutioner. Dette vil åbne mulighed for at tilknytte det danske offentlige sygesikringssystem til denne type behandling.

Kapitel 7. Konklusion Tandlæge-patientforholdet som et socialt fænomen har ofte ført til konflikter og misforståelser mellem de to parter, hvilket har medført unødig smerte og angst for mange patienter samt unødvendig stressende arbejdsforhold, dårlig selvopfattelse og faglig utilfredshed blandt mange tandlæger. Der er behov for en sundhedspolitik, der støtter op om både patienter og tandlæger. Patient-centreret tandlægepraksis er kommet for at blive og giver håb om, at tandlæger og patienter indbyrdes kan finde ud af, hvad en optimal behandling består af til begge parters fordel. Forslag til danske forhold og fremtidig udvikling En samfundsstrategi mod angst og smertefænomener i tandbehandling bør fokusere på tre områder: 1) aktivering (empowerment) af patienter, 2) uddannelse og efteruddannelse af tandlæger og terapeuter og 3) sundhedsoplysning til befolkningen om disse fænomener og remedier for dem. Derfor kan der peges på: 1) dækning af behandling/terapi ved Sygesikring eller kommunale støtte efter en model fra Sverige, 2) behandlingsydelser ved specialuddannet personale, 3) afgiftsfri smertefri behandling ved al tandbehandling og 4) tværfagligt samarbejde med læger og psykologer. Mht. uddannelse/efteruddannelse bør der være: 1) separat eksamen af psykologiske aspekter indenfor tandlægepraksis for tandlægestuderende; 2) kursus i kommunikationsfærdigheder; 3) kursus i afspændingsteknikker; 4) kursus om ”stress management”; 5) kursus om professionel udvikling og planlægning for tandlægestuderende og tandlæger, 6) certificeret odontofobi kursus for tandlæger og terapeuter og 7) etablering af en dansk forening for studie af angst- og smertefænomener.

Fremtidig forskning I fremtidens angst- og smerteforskning skal der være mere fokus på behandlerrollen. Vi har behov for at forstå, hvad det er, tandlæger gør, der medfører, at det går galt, såvel som når det går godt i forhold til angste patienter. Kvalitative undersøgelser i praksis er vigtige for bedre at kunne afdække hvilke tandlægevariable, der påvirker forholdet både positivt og negativt. På patientsiden er det vigtigt at studere de tilfælde, hvor traumatiske oplevelser hos tandlægen ikke eller kun i mindre grad resulterer i angst og fobi. Der er også behov for mere forskning af, hvordan behandlere kan skabe positive forventninger hos patienter, der kan hjælpe dem igennem en svær følelsesmæssig oplevelse. Ved at sætte mere fokus på de positive aspekter i tandlægearbejdet er målet, at tandlægerne efterhånden kan se et behov for mere omfattende viden om og undervisning i psykologi på klinikken. Dette vil på længere sigt kunne give nye perspektiver på tandlægernes psykosociale arbejdsmiljø, påvirke deres forhold til patienter og klinikpersonale i positiv retning samt forbedre deres livskvalitet, for dem der kunne være utilfredse med tandlægejobbet. 125.

Reference List 1.

Webster's New World Dictionary of the American Language, College Edition. Cleveland/New York: World Publishing Co.; 1964.

2.

Oxford Dictionary of Modern Greek. Oxford: Clarendon Press; 1987:135-136.

3. Aartman IH, de Jongh A, Makkes PC, Hoogstraten J. Dental anxiety reduction and dental attendance after treatment in a dental fear clinic: A follow-up study. Community Dent Oral Epidemiol. 2000;28:435-442. 4. Abrahamsson KH. Dental Fear and Oral Health Behavior - Studies on Psychological and Psychosocial Factors. Göteborg, Sweden: Faculty of Odontology, Göteborg University; 2003. 5. Abrahamsson KH, Berggren U, Carlsson SG. Psychosocial aspects of dental and general fears in dental phobic patients. Acta Odontol Scand. 2001;58:37-43. 6. Abrahamsson KH, Berggren U, Hakeberg M, Carlsson SG. Phobic avoidance and regular dental care in fearful dental patients: a comparative study. Acta Odontol Scand. 2001;59:273-9. 7. Abrahamsson KH, Berggren U, Hakeberg M, Carlsson SG. The importance of dental beliefs for the outcome of dental-fear treatment. Eur J Oral Sci. 2003;111:99-105. 8. Abrahamsson KH, Berggren U, Hallberg L, Carlsson SG. Dental phobic patients' view of dental anxiety and experiences in dental care: A qualitative study. Scand J Caring Sci. 2002;16:188-196. 9. Agras S, Sylvester D, Oliveau D. The epidemiology of common fears and phobia. Compr Psychiatry. 1969;10:151-156. 10. Aguilera DC. Relationship between physical contact and verbal interaction between nurses and patients. J Psychiatr Nurs Ment Health Serv. 1967;5:5-21. 11. Aitken JC, Wilson S, Coury D, Moursi AM. The effect of music distraction on pain, anxiety and behavior in pediatric dental patients. Pediatr Dent. 2002;24:114-118. 12. Ajzen I. Nature and operation of attitudes. Annu Rev Psychol. 2001;52:27-58. 13. Aldersey-Williams H. Great Dane. New Statesman. 1999;June 21:40. 14. Alexander RE. Stress-related suicide by dentists and other health care workers. Fact or folklore? J Am Dent Assoc. 2001;132:786-794. 15. Amanzio M, Benedetti F. Neuropharmacological dissection of placebo analgesia: Expectationactivated opioid systems versus conditioning-activated specific subsystems. J Neurosci. 1999;19:484-494. 16. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, DSM-IV. Washington, D. C.: American Psychiatric Association; 1994. 17. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). Arlington, VA: American Psychiatric Publishing; 2000. 18. Anderson RM. Patient empowerment and the traditional medical model. A case of irreconcilable differences? Diabetes Care. 1995;18:412-415. 19. Anderson RM, Funnell MM, Butler PM, Arnold MS, Fitzgerald JT, Feste CC. Patient empowerment. Results of a randomized controlled trial. Diabetes Care. 1995;18:943-949.

126.

20. Ando T. [Re. dental anxiety - look it up on text TV] Ved tandlægeskræk - slå op på tekst-tv. Tandlægebladet. 1997;101:678. 21. Argyle M. The Psychology of Interpersonal Behavior. 5 ed. London: Penguin; 1994. 22. Arnetz BB, Horte LG, Hedberg A, Malker H. Suicide among Swedish dentists. A ten-year followup study. Scand J Soc Med. 1987;15:243-246. 23. Arnold MS, Butler PM, Anderson RM, Funnell MM, Feste C. Guidelines for facilitating a patient empowerment program. Diabetes Educ. 1995;21:308-312. 24. Arnrup K, Berggren U, Broberg AG, Lundin SA, Hakeberg M. Attitudes to dental care among parents of uncooperative vs. cooperative child dental patients. Eur J Oral Sci. 2002;110:75-82. 25. Arntz A. Stimulus estimation and the overprediction of fear: a reply to Taylor. Behav Res Ther. 1995;33:817-818. 26. Arntz A. Why do people tend to overpredict pain? On the asymmetries between underpredictions and overpredictions of pain. Behav Res Ther. 1996;34:545-554. 27. Arntz A, Claassens L. The meaning of pain influences its experienced intensity. Pain. 2004;109:2025. 28. Arntz A, de Jong P. Anxiety, attention and pain. J Psychosom Res. 1993;37:423-431. 29. Arntz A, Dreessen L, de Jong P. The influence of anxiety on pain: Attentional and attributional mediators. Pain. 1994;56:307-314. 30. Arntz A, Dreessen L, Merckelbach H. Attention, not anxiety, influences pain. Behav Res Ther. 1991;29:41-50. 31. Arntz A, Hildebrand M, van den Hout M. Overprediction of anxiety, and disconfirmatory processes, in anxiety disorders. Behav Res Ther. 1994;32:709-722. 32. Arntz A, Lousberg R. The effects of underestimated pain and their relationship to habituation. Behav Res Ther. 1990;28:15-28. 33. Arntz A, Rauner M, van den HM. "If I feel anxious, there must be danger": Ex-consequentia reasoning in inferring danger in anxiety disorders. Behav Res Ther. 1995;33:917-925. 34. Arntz A, Spit S, Merckelbach H. Cued UCS rehearsal and the impact of painful conditioned stimuli: UCS rehearsal increases SCRS but reduces experienced pain. Behav Res Ther. 1997;35:591-605. 35. Arntz A, van den Hout MA. Generalizability of the match/mismatch model of fear. Behav Res Ther. 1988;26:207-223. 36. Arntz A, van den Hout MA, Lousberg R, Schouten E. Is the match/mismatch model based on a statistical artefact? Behav Res Ther. 1990;28:249-253. 37. Arntz A, van den Hout MA, van den BG, Meijboom A. The effects of incorrect pain expectations on acquired fear and pain responses. Behav Res Ther. 1991;29:547-560. 38. Arntz A, Van Eck M, de Jong P. Avoidance of pain of unpredictable intensity. Behav Res Ther. 1991;29:197-201. 39. Arntz A, Van Eck M, de Jong P, van den Hout MA. The relationship between underpredicted pain and escape. Behav Res Ther. 1990;28:87-90.

127.

40. Arntz A, Van Eck M, Heijmans M. Predictions of dental pain: The fear of any expected evil, is worse than the evil itself. Behav Res Ther. 1990;28:29-41. 41. Arrindell WA, Sanderman R, Van der Molen H, Van der Ende J, Mersch PP. The structure of assertiveness: a confirmatory approach. Behav Res Ther. 1988;26:337-339. 42. Atkinson J. Reducing Suicide. Unique Opportunities The Physician's Resource. 2003;May/Jun:10. 43. Atkinson JM. The patient as sufferer. Br J Med Psychol. 1993;66 ( Pt 2):113-120. 44. Atkinson JM, Millar K, Kay EJ, Blinkhorn AS. Stress in dental practice. Dent Update. 1991;18:6064. 45. Augustiny KF. [Occupational stress and the forms of dealing with it - A study of Swiss dentists] Beruflicher Stess und seine Bewältigungsformen - eine Untersuchung an Scheiwzer Zahnärzten. SSO Schweiz Monatsschr Zahnheilkd. 1983;93 Spec No:786-803. 46. Ayer WA, Corah NL. Behavioural factors influencing dental treatment. In: Cohen LK, Bryant PS, eds. Social Sciences and Dentistry: A critical biography. London: Quintessence/Fédération Dentaire Internationale; 1984:267-322. 47. Bælum V. The epidemiology of destructive periodontal disease: Causes, paradigms, problems, and empirical evidence [Doctoral dissertation]. Århus, Denmark: Royal Dental College, University of Aarhus; 1998. 48. Balint M. The doctor, his patient and the illness. 2 ed. London: Pitman Medical Publishing; 1964. 49. Ballenger JC. Recognizing the patient with social anxiety disorder. Int Clin Psychopharmacol. 2000;15:S1-S5. 50. Ballenger JC, Davidson JR, Lecrubier Y, Nutt DJ, Bobes J, Beidel DC, Ono Y, Westenberg HG. Consensus statement on social anxiety disorder from the International Consensus Group on Depression and Anxiety. J Clin Psychiatry. 1998;59:54-60. 51. Bandura A. Self-efficacy: toward a unifying theory of behavior change. Psychol Rev. 1977;84:191-215. 52. Bandura A. Self-efficacy determinants of anticipatory fears and calamaties. J Pers Soc Psychol. 1983;45:464-9. 53. Bandura A. Self-efficacy. Social Foundations of Thought and Action - A Social Cognitive Theory. Englewood Cliffs, NJ: Prentice-Hall; 1986:390-453. 54. Bandura A. Social foundations of thought and action - A social cognitive theory. Englewood Cliffs, NJ: Prentice-Hall; 1986. 55. Bandura A. Self-Efficacy: The Exercise of Control. New York: Freeman; 1997. 56. Bandura A. Social cognitive theory: an agentic perspective. Annu Rev Psychol. 2001;52:1-26. 57. Bandura A. Social learning theory . Englewood Cliffs, N. J.: Prentice-Hall; 2002. 58. Bandura A, Adams NE, Hardy AB, Howells GN. Tests of the generality of self-efficacy theory. Cognitive Ther Res. 1980;4:39-66. 59. Bandura A, Reese A, Adams NE. Microanalysis of action and fear arousal as a function of differential level of perceived self-efficacy. J Pers Soc Psychol. 1982;43:5-21. 60. Bandura A, Schunk DH. Cultivating competence, self-efficacy, and intrinsic interest through proximal self-motivation. J Pers Soc Psychol. 1981;41:586-598.

128.

61. Bandura A, Taylor CB, Williams SL, Mefford IN, Barchas JD. Catecholamine secretion as a function of perceived coping self.efficacy. J Cons Clin Psychol. 1985;53:406-14. 62. Barber J, Mayer D. Evaluation of the efficacy and neural mechanism of a hypnotic analgesia procedure in experimental and clinical dental pain. Pain. 1977;4:41-48. 63. Baric JM, Espeland MA, Stege PM, Saunders RH, Handelman SL. A study of nonverbal behaviors of dentists with healthy older patients using closed-circuit television. Gerodontics. 1985;1:170175. 64. Barlow DH. The dimensions of anxiety disorders. In: Tuma AH, Maser J, eds. Anxiety and the anxiety disorders. Hillsdale, New Jersey: Lawrence Erlbaum; 1985. 65. Baron RS, Logan HL, Kao CF. Some variables affecting dentists' assessment of patients' distress. Health Psychol. 1990;9:143-53. 66. Barry CA, Stevenson FA, Britten N, Barber N, Bradley CP. Giving voice to the lifeworld. More humane, more effective medical care? A qualitative study of doctor-patient communication in general practice. Soc Sci Med. 2001;53:487-505. 67. Baseheart JR. Nonverbal communication in the dentist-patient relationship. J Prosthet Dent. 1975;34:4-10. 68. Bates MS. Ethnicity and pain: a biocultural model. Soc Sci Med. 1987;24:47-50. 69. Beecher HK. Relationship of significance of wound to pain experienced. JAMA. 1956;161:16091613. 70. Beecher HK. The measurement of pain. Pharmacol Rev. 1959;9:59-209. 71. Beese A, Morley S. Memory for acute pain experience is specifically inaccurate but generally reliable. Pain. 1993;53:183-189. 72. Bejerot E. [Psychosocial working conditions in the Swedish public dental health care system] Psykosociala arbetsmiljön i folktandvården. Tandläkartidningen. 1989;81:730-735. 73. Bennett HJ. Humor in medicine. South Med J. 2003;96:1257-1261. 74. Bentsen B, Svensson P, Wenzel A. The hypoalgesic effect of 3-D video glasses on cold pressor pain: Reproducibility and importance of information. Anesth Prog. 2000;47:67-71. 75. Bentsen B, Svensson P, Wenzel A. Evaluation of effect of 3D video glasses on perceived pain and unpleasantness induced by restorative dental treatment. Eur J Pain. 2001;5:373-378. 76. Bentsen B, Wenzel A, Svensson P. Comparison of the effect of video glasses and nitrous oxide analgesia on the perceived intensity of pain and unpleasantness evoked by dental scaling. Eur J Pain. 2003;7:49-53. 77. Berg EM, Lippman LG. Does humor in radio advertising affect recognition of novel product brand names? J Gen Psychol. 2001;128:194-205. 78. Berggren U. Dental fear and avoidance - A comparison of two modes of treatment. J Dent Res. 1984;63:1223-1227.

79-80. Berggren U. Dental fear and avoidance - A study of etiology, consequences and treatment (Doctor of Odontology Dissertation). Göteborg, Sweden: University of Göteborg; 1984. 81. Berggren U. A Swedish community based program for treatment of dental fear and avoidance [Unpublished papers]. Göteborg, Sweden: University of Göteborg, Institute of Odontology; 1985.

129.

82. Berggren U. Long-term effects of two different treatments for dental fear and avoidance. J Dent Res. 1986;65:874-876. 83. Berggren U. [Dental anxiety - background and manifestations] Tandvårdsrädsla - bakgrund och manifestation. Tandläkartidningen. 1986;78:933-939. 84. Berggren U. General and specific fears in referred and self-referred adult patients with extreme dental anxiety. Behav Res Ther. 1992;30:395-401. 85. Berggren U. Psychosocial effects associated with dental fear in adult dental patients with avoidance behaviours. Psychol Health. 1993;8:185-196. 86. Berggren U. Long-term management of the fearful adult patient using behavior modification and other modalities. J Dent Educ. 2001;65:1357-1368. 87. Berggren U, Carlsson SG. Qualitative and quantitative effects of treatment for dental fear and avoidance. Anesth Prog. 1986;33:9-13. 88. Berggren U, Carlsson SG, Hagglin C, Hakeberg M, Samsonowitz V. Assessment of patients with direct conditioned and indirect cognitive reported origin of dental fear. Eur J Oral Sci. 1997;105:213-220. 89. Berggren U, Carlsson SG, Hakeberg M, Hägglin C, Samsonowitz V. Assessment of patients with phobic dental anxiety. Acta Odontol Scand. 1997;55:217-222. 90. Berggren U, Hakeberg M, Carlsson SG. Relaxation vs. cognitively oriented therapies for dental fear. J Dent Res. 2000;79:1645-1651. 91. Berggren U, Meynert G. Dental fear and avoidance - causes, symptoms and consequences. J Am Dent Assoc. 1984;109:247-251. 92. Bernstein DA, Kleinknecht RA, Alexander LD. Antecedents of dental fear. J Public Health Dent. 1979;39:113-124. 93. Berry JH, McCann D. Dentistry's public image: does it need a boost? J Am Dent Assoc. 1989;118:687-692. 94. Berthelsen H. [Stress, health and social support in the workplace in view of changes in demands made of dentists - A cross-sectional survey of Danish general dentist practitioners] Stress, helbred og kollegiale støtte i en tid med nye udfordringer til tandlæger (Masters in Public Health Thesis). Copenhagen: University of Copenhagen; 2002. 95. Berthelsen H, Petersen PE. [Stress at the workplace in view of changing demands to dentists] Stress i en tid med nye udfordringer til tandlægers faglighed. Tandlægebladet. 2003;107:830-839. 96. Best ES. The psychology of pain control. J Am Dent Assoc. 1935;22:256-267. 97. Biro PA, Hewson ND. A survey of patients' attitudes to their dentist. Australian Dent J. 1976;21:388-393. 98. Bjercke O, Blomberg S, Linde A. [Psychiatric evaluation of patients with pronounced fear of dental treatment] Psykiatrisk bedömning av patienter med tandvårdskräck. Läkertidningen. 1977;74:1390-1392. 99. Blanchard EB, Turner J, Eschette N, Coury VM. Assertiveness training for dental students. J Dent Educ. 1977;41:206-208. 100. Blankfield RP. Suggestion, relaxation, and hypnosis as adjuncts in the care of surgery patients: a review of the literature. Am J Clin Hypn. 1991;33:172-186.

130.

101. Blanton PL, Jeske AH. The key to profound local anesthesia: Neuroanatomy. J Am Dent Assoc. 2003;134:753-760. 102. Blum LH. Psychological aspects and the dentist-patient relationship: I. N Y J Dent. 1969;39:8-11. 103. Blum LH. Psychological aspects and the dentist-patient relationship: II. N Y J Dent. 1969;39:51-55. 104. Blum LH. Doctor-patient relationship in psychological perspective of transference countertransference. I. N Y J Dent. 1970;40:125-129. 105. Blum LH. Doctor-patient relationship in psychological perspective of transference countertransference. II. N Y J Dent. 1970;40:166-171. 106. Blumer H. Symbolic Interactionism. Englewood Cliffs, New Jersey: Prentice-Hall; 1969. 107. Bøjholm S, Jørring L, Bakke M. [Torture survivors - general and odontological aspects] Torturoverlevere - generelle og odontologiske aspekter. Tandlægebladet. 1995;99:910-912. 108. Bond M. Assertiveness training. Number 1. Understanding assertiveness. Nurs Times. 1988;84:61-4. 109. Bond M. Assertiveness training. Number 3. Assertive rights and body language. Nurs Times. 1988;84:67-70. 110. Bond M. Assertiveness training. Number 6. Saying no assertively. Nurs Times. 1988;84:63-66. 111. Borea G, Montebugnoli L, Braiato A. The effects of patient anxiety on the cardiovascular stress of dentists. Quintessence Int. 1989;20:853-857. 112. Borland LR. Odontophobia - inordinate fear of dental tratment. Dent Clin North Am. 1962;6:683695. 113. Born DO. Career satisfaction of older male dentists. Gerodontics. 1985;1:75-80. 114. Bosma H, Peter R, Siegrist J, Marmot M. Two alternative job stress models and the risk of coronary heart disease. Am J Public Health. 1998;88:68-74. 115. Bouma J, Schaub RM, van d, Westert G. Dentists' and patients' opinions of the dental condition at moment of full clearance. Community Dent Oral Epidemiol. 1987;15:79-84. 116. Bourassa M, Baylard JF. Stress situations in dental practice. J Can Dent Assoc. 1994;60:65-71. 117. Bourdon KH, Boyd JH, Rae DS, Burns BJ, Thompson JW, Locke BZ. Gender differences in phobias: Results of the ECA Community Survey. J Anxiety Disord. 1988;2:227-241. 118. Braceland FJ. Psychologic and psychiatric aspects of pain control. In: Appleton JLT, ed. Control of pain in dental practice : A symposium conducted by the Academy of Stomatology. Philadelphia: Lippincott; 1940:56-80. 119. Branch WT, Jr. Small-group teaching emphasizing reflection can positively influence medical students' values. Acad Med. 2001;76:1171-1172. 120. Branch WT, Jr., Kern D, Haidet P, Weissmann P, Gracey CF, Mitchell G, Inui T. Teaching the human dimensions of care in clinical settings. JAMA. 2001;286:1067-1074. 121. Branch WT, Malik TK. Using 'Windows of Opportunities' in brief interviews to understand patients' concerns. JAMA. 1993;269:1667-1668. 122. Brand HS. Cardiovascular responses in patients and dentists during dental treatment. Int Dent J. 1999;49:60-66.

131.

123. Brand HS, Abraham-Inpijn L. Cardiovascular responses induced by dental treatment. Eur J Oral Sci. 1996;104:245-252. 124. Brenders DA. Perceived control and the interpersonal dimension of health care. Health Commun. 1989;1:117-135. 125. Brødsgaard I, Moore R. Medical malpractice phenomena: signals for changes in medical and health care values. In: Jensen UJ, Mooney G, eds. Changing Values in Medical and Health Care Decision Making. Chichester: Wiley; 1990:149-163. 126. Brody DS, Miller SM, Lerman CE, Smith DG, Caputo GC. Patient perception of involvement in medical care: relationship to illness attitudes and outcomes. J Gen Intern Med. 1989;4:506-511. 127. Brody DS, Miller SM, Lerman CE, Smith DG, Lazaro CG, Blum MJ. The relationship between patients' satisfaction with their physicians and perceptions about interventions they desired and received. Med Care. 1989;27:1027-1035. 128. Brody H. The placebo response. Recent research and implications for family medicine. J Fam Pract. 2000;49:649-654. 129. Brown LJ. Dental work force strategies during a period of change and uncertainty. J Dent Educ. 2001;65:1404-1416. 130. Buchser E, Burnand B, Sprunger AL, Clemence A, Lepage C, Martin Y, Chedel D, Guex P, Sloutskis D, Rumley R. Hypnosis and self-hypnosis, administered and taught by nurses, for the reduction of chronic pain: a controlled clinical trial. Schweiz Med Wochenschr Suppl. 1994;62:77-81. 131. Burchiel RN, King CA. Incorporating fun into the business of serious work: the use of humor in group process. Semin Perioper Nurs. 1999;8:60-70. 132. Burke FJ, Main JR, Freeman R. The practice of dentistry: an assessment of reasons for premature retirement. Br Dent J. 1997;182:250-254. 133. Burns LE. The epidemiology of fears and phobias in general practice. J Int Med Res. 1980;8 Suppl 3:1-7. 134. Buyck D, Lang F. Teaching medical communication skills: a call for greater uniformity. Fam Med. 2002;34:337-343. 135. Campbell DT, Stanley JC. Experimental and Quasi-Experimental Designs for Research. 2 ed. Boston: Houghton Mifflin; 1966. 136. Carlsson SG. Biofeedback in the treatment of tension: Applications in dentistry [Doctoral Dissertation]. Göteborg, Sweden: University of Göteborg; 1977. 137. Carlsson SG, Linde A, Andersson U-B. [Group therapy as treatment for serious dental anxiety] Gruppterapi som behandlingsform mot grav tandvårdsrädsla. 1 ed. Göteborg, Sweden: Göteborgs Universitet; 1978:1-11. 138. Carlsson SG, Linde A, Öhman A. Reduction of tension in fearful dental patients. J Am Dent Assoc. 1980;101:638-641. 139. Cartwright DS, Cartwright RD. Faith and improvement in psychotherapy. J Coun Psychol. 1958;5:174-177. 140. Casey KL, Svensson P, Morrow TJ, Raz J, Jone C, Minoshima S. Selective opiate modulation of nociceptive processing in the human brain. J Neurophysiol. 2000;84:525-533. 141. Cassell EJ. The nature of suffering and the goals of medicine. N Engl J Med. 1982;306:639-645.

132.

142. Cassell EJ. The changing concept of the ideal physician. Daedalus. 1986;115:185-208. 143. Cassell EJ. Diagnosing suffering: a perspective. Ann Intern Med. 1999;131:531-534. 144. Cassell EJ. The Nature of Suffering and the Goals of Medicine. 2nd ed. New York: Oxford University Press; 2004. 145. Cautela JR. Desensitization factors in the hypnotic treatment of phobias. J Psychol. 1966;64:277-88. 146. Chambers DW. The role of dentists in dentistry. J Dent Educ. 2001;65:1430-1440. 147. Charmaz K. 'Discovering' chronic illness: using grounded theory. Soc Sci Med. 1990;30:1161-72. 148. Charmaz K. Grounded Theory - Objectivist and Constructivist Method. In: Denzin NK, Lincoln YS, eds. Handbook of Qualitative Research. 2nd ed. Newbury Park, California: Sage; 2000:509-36. 149. Chaves JF, Brown JM. Spontaneous cognitive strategies for the control of clinical pain and stress. J Behav Med. 1987;10:263-276. 150. Chaves JF, Dworkin SF. Hypnotic control of pain: historical perspectives and future prospects. Int J Clin Exp Hypn. 1997;45:356-376. 151. Chaves JF, Lantz MS. Educating the next generation of dentists. J Indiana Dent Assoc. 2001;80:10-15. 152. Chiodo GT, Tolle SW. Chemically dependent doctors. Gen Dent. 1997;45:532-4, 536, 538. 153. Christen AG. Stress and Distress in Dental Practice. In: Goldman HS, Hartman KS, Messite J, eds. Occupational hazards in dentistry. Chicago: Year Book Medical Publishers; 1984:151-170. 154. Christen AG, Nevin RS, Christen JA. Active coping strategies. From self-help to psychological counseling. Dent Clin North Am. 1986;30:S67-S78. 155. Clark M, Hirschman R. Effects of paced respiration on affective responses during dental stress. J Dent Res. 1980;59:1533. 156. Clements FW. Some problems in the communication of professional knowledge to the public. Dent Mag Oral Topics. 1962;79:89-90. 157. Cohen ME. Dental anxiety and DMFS status: association within a US naval population versus differences between groups. Community Dental Oral Epidemiology. 1985;13:75-78. 158. Coleman H, Burton J. Aspects of control in the dentist-patient relationship. Int J Soc Lang. 1985;51:75-104. 159. Collins J, Collins M. Social Skills Training and the Professional Helper. Chichester: John Wiley & Sons; 1992. 160. Comarroff J. Communicating information about non-fatal illness: the strategies of a group of general practitioners. Sociol Rev. 1976;24:269-290. 161. Comstock LM, Hooper EM, Goodwin JM, Goodwin JS. Physician behaviors that correlate with patient satisfaction. J Med Educ. 1982;57:105-112. 162. Conway R. The other fifty per cent. Oral Health. 1976;66:7. 163. Cooper CL, Mallinger M, Kahn R. Identifying sources of occupational stress among dentists. J Occup Psychol. 1978;51:227-234.

133.

164. Cooper CL, Mallinger M, Kahn RL. Dentistry: What causes it to be a stressful occupation? Int Rev Appl Psychol. 1980;29:307-319. 165. Cooper CL, Watts J, Baglioni AJ, Kelly M. Occupational stress amongst general practice dentists. J Occup Psychol. 1988;61:163-174. 166. Cooper CL, Watts J, Kelly M. Job satisfaction, mental health, and job stressors among general dental practitioners in the UK. Br Dent J. 1987;162:77-81. 167. Corah NL. Development of a dental anxiety scale. J Dent Res. 1969;48:596. 168. Corah NL. Effect of perceived control on stress in pedodontic patients. J Dent Res. 1973;52:1261-64. 169. Corah NL. Reduction of patient stress and the patient-dentist relationship. N Y State Dent J. 1984;50:478-479. 170. Corah NL, Bissell GD, Illing SJ. Effect of perceived control on stress reduction in adult dental patients. J Dent Res. 1978;57:74-76. 171. Corah NL, Gale EN, Illing SJ. Assessment of a dental anxiety scale. J Am Dent Assoc. 1978;97:816-819. 172. Corah NL, O'Shea RM, Ayer WA. Dentists' management of patients' fear and anxiety. J Am Dent Assoc. 1985;110:734-736. 173. Corah NL, O'Shea RM, Bissell GD. The dentist-patient relationship: Perceptions by patients of dentist behavior in relation to satisfaction and anxiety. J Am Dent Assoc. 1985;111:443-446. 174. Corah NL, O'Shea RM, Bissell GD. The dentist-patient relationship: Mutual perceptions and behaviors. J Am Dent Assoc. 1986;113:253-255. 175-176. Corah NL, O'Shea RM, Bissell GD, Thines TJ, Mendola P. The dentist-patient relationship: Perceived dentist behaviors that reduce patient anxiety and increase satisfaction. J Am Dent Assoc. 1988;116:73-76. 177. Corah NL, O'Shea RM, Skeels DK. Dentists' perceptions of problem behaviors in patients. J Am Dent Assoc. 1982;104:829-833. 178. Coster EA, Carstens IL, Harris AM. Patterns of stress among dentists. J Dent Assoc S Afr. 1987;42:389-394. 179. Cotanch PH, Harrison M, Roberts J. Hypnosis as an intervention for pain control. Nurs Clin North Am. 1987;22:699-704. 180. Coulehan J, Williams PC. Vanquishing virtue: the impact of medical education. Acad Med. 2001;76:598-605. 181. Counts RM. The concept of dissociation. J Am Acad Psychoanal. 1990;18:460-479. 182. Cousins N. Anatomy of an illness (as perceived by the patient). N Engl J Med. 1976;295:14581463. 183. Crawford CB. Effects of sex and sex roles on avoidance of same- and opposite-sex touch. Percept Mot Skills. 1994;79:107-112. 184. Crawford CB. Effects of sex and sex roles on same-sex touch. Percept Mot Skills. 1994;78:391-4. 185. Croucher R, Osborne D, Marcenes W, Sheiham A. Burnout and issues of the work environment reported by general dental practitioners in the United Kingdom. Community Dent Health. 1998;15:40-43.

134.

186. Curtis GC, Magee WJ, Eaton WW, Wittchen HU, Kessler RC. Specific fears and phobias. Epidemiology and classification. Br J Psychiatry. 1998;173:212-217. 187. Dansk Tandlægeforening. DTF'S etiske regler og kollegiale vedtægt. 2000:1-7. 188. Davies AR, Ware JE, Jr. Measuring patient satisfaction with dental care. Soc Sci Med [A]. 1981;15:751-760. 189. Davies MH, Eccles JD. Attitudes of dental patients to conservation treatment in different chair positions. J Dent. 1978;6:294-298. 190. Davis P. The social context of dentistry. London: Croom Helm; 1980. 191. de Jongh A., Bongaarts G, Vermeule I, Visser K, De V, Makkes P. Blood-injury-injection phobia and dental phobia. Behav Res Ther. 1998;36:971-982. 192. de Jongh A., Muris P, ter HG, Duyx MP. Acquisition and maintenance of dental anxiety: the role of conditioning experiences and cognitive factors. Behav Res Ther. 1995;33:205-210. 193. de Jongh A, Muris P, ter Horst G., van Zuuren F., Schoenmakers N, Makkes P, Weiner AA, Weinstein P. One-session cognitive treatment of dental phobia: preparing dental phobics for treatment by restructuring negative cognitions. Behav Res Ther. 1995;33:947-954. 194. de Jongh A, Muris P, ter Horst G, van Zuuren FJ, De Wit CA. Cognitive correlates of dental anxiety. J Dent Res. 1994;73:561-566. 195. de Mello MF, de Jesus MJ, Bacaltchuk J, Verdeli H, Neugebauer R. A systematic review of research findings on the efficacy of interpersonal therapy for depressive disorders. Eur Arch Psychiatry Clin Neurosci. 2005;255:75-82. 196. Diller A. Cross-cultural pain semantics. Pain. 1980;9:9-26. 197. DiMatteo MR. A social-psychological analysis of physician-patient rapport: toward a science of the art of medicine. J Social Issues. 1979;35:12-33. 198. DiMatteo MR, McBride CA, Shugars DA, O'Neil EH. Public attitudes toward dentists: a U.S. household survey. J Am Dent Assoc. 1995;126:1563-1570. 199. DiMatteo MR, Shugars DA, Hays RD. Occupational stress, life stress and mental health among dentists. Journal of Occupational & Organizational Psychology. 1993;66:153-162. 200. Doerr PA, Lang WP, Nyquist LV, Ronis DL. Factors associated with dental anxiety. J Am Dent Assoc. 1998;129:1111-1119. 201. Dower JS, Jr., Simon JF, Peltier B, Chambers D. Patients who make a dentist most anxious about giving injections. J Calif Dent Assoc. 1995;23:35-40. 202. Drolet G, Dumont EC, Gosselin I, Kinkead R, Laforest S, Trottier JF. Role of endogenous opioid system in the regulation of the stress response. Prog Neuropsychopharmacol Biol Psychiatry. 2001;25:729-741. 203. Drucker E. Hidden values and health care. Med Care. 1974;12:266-273. 204. Dunlap JE, Stewart JD. Survey suggests less stress in group offices. Dent Econ. 1982;72:46-56. 205. Dunstone S. Interpersonal processes in dentistry. Part I. Aust Dent J. 1990;35:152-158. 206. Dunstone S. Interpersonal processes in dentistry. Part II. Aust Dent J. 1990;35:282-289.

135.

207. Dworkin SF. Behavioral sciences in dental education: Broad purposes and educational objectives. J Dent Educ. 1974;38:204-210. 208. Dworkin SF. The dentist as biobehavioral clinician. J Dent Educ. 2001;65:1417-1429. 209. Dworkin SF, Chen AC, LeResche L, Clark DW. Cognitive reversal of expected nitrous oxide analgesia for acute pain. Anesth Analg. 1983;62:1073-1077. 210. Dworkin SF, Chen AC, Schubert MM, Clark DW. Cognitive modification of pain: Information in combination with N2O. Pain. 1984;19:339-351. 211. Dworkin SF, Chen ACN. Pain in clinical and laboratory contexts. J Dent Res. 1982;61:772-774. 212. Dworkin SF, Ference TP, Giddon DB. Behavioral science and dental practice. St. Louis: C.V. Mosby Company; 1978. 213. Dworkin SF, Schubert M, Chen AC, Clark DW. Psychological preparation influences nitrous oxide analgesia: replication of laboratory findings in a clinical setting. Oral Surg Oral Med Oral Pathol. 1986;61:108-112. 214. Eccles JD. Skin conductance changes in dentists and patient during conservation treatment. Dent Pract Dent Rec. 1970;21:43-48. 215. Edwards SC. An anthropological interpretation of nurses' and patients' perceptions of the use of space and touch. J Adv Nurs. 1998;28:809-817. 216. Egbert LD, Battit GE, Welch CE, Bartlett MK. Reduction of post-operative pain by encouragement and instruction of patient. N Engl J Med. 1964;270:825-827. 217. Eggly S, Tzelepis A. Relational control in difficult physician-patient encounters: negotiating treatment for pain. J Health Commun. 2001;6:323-333. 218. Eich E, Reeves JL, Jaeger B, Graff-Radford SB. Memory for pain: relation between past and present pain intensity. Pain. 1985;23:375-380. 219. Eisenberg JM. Sociologic influences on decision-making by clinicians. Ann Intern Med. 1979;90:957-964. 220. Eisenberg N. Emotion, regulation, and moral development. Annu Rev Psychol. 2000;51:665-697. 221. Elfenbaum A. A dentist can see with his fingers. Dent Dig. 1969;75:459-463. 222. Elfenbaum A. Humor in the dental clinic. Dent Dig. 1971;77:159-161. 223. Eli I. Dental anxiety: a cause for possible misdiagnosis of tooth vitality. Int Endod J. 1993;26:251253. 224. Ellis A, Dryden W. The Practice of Rational-Emotive Therapy (RET). New York: Springer; 1987. 225. Elmore AM. Biofeedback therapy in the treatment of dental anxiety and dental phobia. Dent Clin North Am. 1988;32:735-744. 226. Engel GL. The need for a new medical model: a challenge for biomedicine. Science. 1977;196:129-136. 227. Engel GL. From biomedical to biopsychosocial. Being scientific in the human domain. Psychosomatics. 1997;38:521-528. 228. Engelhardt D. Letting out a laugh; the value of workplace humor. Dent Teamwork. 1993;6:22-23.

136.

229. Epley SW. Reduction of the behavioral effects of aversive stimulation by the presence of companions. Psychol Bull. 1974;81:271-283. 230. Epstein S. Teaching psychology to dental students . J Dent Educ. 1964;28:203-206. 231. Estabrooks CA, Morse JM. Toward a theory of touch: the touching process and acquiring a touching style. J Adv Nurs. 1992;17:448-456. 232. Evans FJ. The domain of hypnosis: a multifactorial model. Am J Clin Hypn. 2000;43:1-16. 233. Evans JA. Cautious caregivers: gender stereotypes and the sexualization of men nurses' touch. J Adv Nurs. 2002;40:441-448. 234. Ewen SJ. The dental interview: A guided psychological process. N Y J Dent. 1951;21:392-397. 235. Fabrega H. Diagnosis interminable: Toward a culturally sensitive DSM-IV. J Nerv Ment Dis. 1992;180:5-7. 236. Fabrega H. The role of culture in a theory of psychiatric illness. Special Issue: The cultural construction of diagnostic categories: The case of American psychiatry. Social Science & Medicine. 1992;35:91-103. 237. Fabrega H, Tyma S. Culture, language and the shaping of illness: An illustration based on pain. Journal of Psychosomatic Research. 1976;20:323-337. 238. Fabrega H, Tyma S. Language and cultural influences in the description of pain. British Journal of Medical Psychology. 1976;49:349-371. 239. Fahrenfort M. Patient emancipation by health education: an impossible goal? Patient Educ Couns. 1987;10:25-37. 240. Fahrenfort M. Freire revisited: old truths in new disguise. A reaction to Skelton's 'Patient education for the millennium'. Patient Educ Couns. 1997;31:159-162. 241. Farster V. Negative publicity and public perception. CDS Rev. 2000;93:22. 242. FDI-News. AIDS dentist murder theory considered. 180 ed. Ferney-Voltaire, France: Federation Dentaire International; 1991:3. 243. Federspil G, Vettor R. [Evidence-based medicine: a critical analysis of the concept of evidence in medicine]. Ital Heart J. 2001;2:614-623. 244. Felton JS. Burnout as a clinical entity - its importance in health care workers. Occup Med (Lond). 1998;48:237-250. 245. Fernandez E, Turk DC. Demand characteristics underlying differential ratings of sensory versus affective components of pain. J Behav Med. 1994;17:375-390. 246. Feste C, Anderson RM. Empowerment: from philosophy to practice. Patient Educ Couns. 1995;26:139-144. 247. Fiset L, Milgrom P, Weinstein P, Melnick S. Common fears and their relationship to dental fear and utilization of the dentists. Anesth Prog. 1989;36:258-264. 248. Foa EB, Kozak MJ. Emotional processing of fear: Exposure to corrective information. Psychol Bull. 1986;99:20-35. 249. Folkman S, Lazarus RS. Coping as a mediator of emotion. J Pers Soc Psychol. 1988;54:466-475.

137.

250. Folkman S, Lazarus RS, Dunkel S, DeLongis A, Gruen RJ. Dynamics of a stressful encounter: Cognitive appraisal, coping, and encounter outcomes. J Pers Soc Psychol. 1986;50:992-1003. 251. Folkman S, Lazarus RS, Gruen RJ, DeLongis A. Appraisal, coping, health status, and psychological symptoms. J Pers Soc Psychol. 1986;50:571-579. 252. Forbes EJ, Pekala RJ. Psychophysiological effects of several stress management techniques. Psychol Rep. 1993;72:19-27. 253. Foreman PA. Behavioral considerations in patient management. Anesth Prog. 1979;26:161-165. 254. Forgione AG. Hypnosis in the treatment of dental fear and phobia. Dent Clin North Am. 1988;32:745-761. 255. Forgione AG, Clark RE. Comments on an empiricial study of the causes of dental fears. J Dent Res. 1974;53:496. 256. Forrest WR. Stresses and self-destructive behaviors of dentists. Dent Clin North Am. 1978;22:361371. 257. Forsberg A. [Dental fear] Tandvårdsskräck. Tandläkartidningen. 1966;59:147-59. 258. Frankel FH. Trance capacity and the genesis of phobic behavior. Arch Gen Psychiatry. 1974;31:261-263. 259. Frankel FH. Hypnotizability and dissociation. Am J Psychiatry. 1990;147:823-829. 260. Frazier PJ, Jenny J, Bagramian RA, Robinson E, Proshek JM. Provider expectations and consumer perceptions of the importance and value of dental care. Am J Public Health. 1977;67:37-43. 261. Frazier PJ, Jenny J, Ostman R, Frenick C. Quality of information in mass media: a barrier to the dental health education of the public. J Public Health Dent. 1974;34:244-257. 262. Fredericks MA, Mundy P. Dental students: behaviorally observed aspects of professionalization. J Am Coll Dent. 1968;35:275-281. 263. Fredericks MA, Mundy P. Relations between social class, stress-anxiety responses, academic achievement, and professional attitudes of dental students. J Dent Educ. 1969;33:377-384. 264. Fredrikson M, Annas P, Fischer H, Wik G. Gender and age differences in the prevalence of specific fears and phobias. Beh Res Ther. 1996;34:33-39. 265. Freeman R. A psychodynamic theory for dental phobia. Br Dent J. 1998;184:170-172. 266. Freeman R. A psychodynamic understanding of the dentist-patient interaction. Br Dent J. 1999;186:503-6. 267. Freeman R. Barriers to accessing dental care: dental health professional factors. Br Dent J. 1999;187:197-200. 268. Freeman R. The case for mother in the surgery. Br Dent J. 1999;186:610-613. 269. Freeman R, Main JR, Burke FJ. Occupational stress and dentistry: theory and practice. Part I. Recognition. Br Dent J. 1995;178:214-217. 270. Freeman R, Main JR, Burke FJ. Occupational stress and dentistry: theory and practice. Part II. Assessment and control. Br Dent J. 1995;178:218-222. 271. Freidson E, Feldman J. The public looks at dental care. J Am Dent Assoc. 1958;57:323-335.

138.

272. Frere CL, Crout R, Yorty J, McNeil DW. Effects of audiovisual distraction during dental prophylaxis. J Am Dent Assoc. 2001;132:1031-1038. 273. Freudenberg N, Eng E, Flay B, Parcel G, Rogers T, Wallerstein N. Strengthening individual and community capacity to prevent disease and promote health: in search of relevant theories and principles. Health Educ Q. 1995;22:290-306. 274. Friedman N. Psychosedation Part 2: Iatrosedation. In: McCarthy FM, ed. Emergencies in Dental Practice. Philadephia: Saunders; 1979:236-265. 275. Friedman N. Fear reduction with the iatrosedative process. J Calif Dent Assoc. 1993;21:41-44. 276. Friis H, Hutchings B. [The psychology of phobias in relation to dental anxiety] Fobiens psykologi i relation til odontofobi. Tandlægebladet. 1990;94:42-46. 277. Frommer J, Mele FA, Monroe CW. The possible role of the mylohyoid nerve in mandibular posterior tooth sensation. J Am Dent Assoc. 1972;85:113-117. 278. Fuat A, Hungin AP, Murphy JJ. Barriers to accurate diagnosis and effective management of heart failure in primary care: qualitative study. BMJ. 2003;326:196. 279. Furlong FW. The new psychotherapies: the courage to be. Can Psychiatr Assoc J. 1977;22:207-14. 280. Gabbard GO. Psychodynamics of panic disorder and social phobia. Bull Menninger Clin. 1992;56:A3-13. 281. Gale EN. Fears of the dental situation. J Dent Res. 1972;51:964-966. 282. Gale EN, Ayer WA. Treatment of dental phobias. J Am Dent Assoc. 1969;78:1304-7. 283. Gale EN, Carlsson SG, Erisson A, Jontell M. Effects of dentist's behavior on patients' attitudes. J Am Dent Assoc. 1984;109:444-446. 284. Gans JS, Counselman EF. Silence in group psychotherapy: A powerful communication. Int J Group Psychother. 2000;50:71-86. 285. Gatchel RJ, Ingersoll BB, Bowman L, Robertson MG, Walker C. The prevalence of dental fear and avoidance: A recent survey study. J Am Dent Assoc. 1983;107:609-610. 286. Gatchel RJ, Ingersoll BB, Bowman L, Robertson MG, Walker C. The prevalence of dental fear and avoidance:a recent survey study. J Am Dent Assoc. 1983;107:609-10. 287. Gauthier J, Savard F, Halle JP, Dufour L. Flooding and coping skills training in the management of dental fear. Scand J Behav Ther. 1985;14:3-15. 288. Geboy MJ. Communication and behavior management in dentistry. Toronto: B.C. Decker; 1984. 289. Geer JH. The development of a scale to measure fear. Behav Res Ther. 1965;3:45-53. 290. Gerbert B, Bernzweig J, Bleecker T, Bader J, Miyasaki C. How dentists see themselves, their profession, the public. J Am Dent Assoc. 1992;123:72-78. 291. Gerbert B, Bleecker T, Saub E. Dentists and the patients who love them: professional and patient views of dentistry. J Am Dent Assoc. 1994;125:264-272. 292. Gerbert B, Love CV, Caspers NM. The provider-patient relationship in academic health centers: the movement toward patient-centered care. J Dent Educ. 1996;60:961-966. 293. Gerschman JA. Hypnotizability and dental phobic disorders. Anesth Prog. 1989;36:131-137.

139.

294. Getka EJ, Glass CR. Behavioral and cognitive-behavioral approaches to the reduction of dental anxiety. Behav Ther. 1992;23:433-448. 295. Gibson CH. A concept analysis of empowerment. J Adv Nurs. 1991;16:354-361. 296. Gibson CH. The process of empowerment in mothers of chronically ill children. J Adv Nurs. 1995;21:1201-1210. 297. Gibson GB, Blasberg B, Hill SJ. A prospective survey of hospital ambulatory dental emergencies. Part 1: Patient and emergency characteristics. Spec Care Dentist. 1993;Mar-Apr. 13:61-65. 298. Gilbert T. Towards a politics of trust. J Adv Nurs. 1998;27:1010-1016. 299. Glaser B, Strauss AL. The Discovery of Grounded Theory. Chicago: Aldine; 1967. 300. Godwin WC, Starks DD, Green TG, Koran A. Identification of sources of stress in practice by recent dental graduates. J Dent Educ. 1981;45:220-221. 301. Gordon JE. Conclusions. In: Gordon JE, ed. Handbook of Clinical and Experimental Hypnosis. 1st ed. New York: Macmillan; 1967:613-641. 302. Gorter RC, Albrecht G, Hoogstraten J, Eijkman MA. Work place characteristics, work stress and burnout among Dutch dentists. Eur J Oral Sci. 1998;106:999-1005. 303. Gorter RC, Albrecht G, Hoogstraten J, Eijkman MA. Professional burnout among Dutch dentists. Community Dent Oral Epidemiol. 1999;27:109-116. 304. Gorter RC, Eijkman MA. Communication skills training courses in dental education. Eur J Dent Educ. 1997;1:143-147. 305. Gravitz MA. Early American mesmeric societies: a historical study. Am J Clin Hypn. 1994;37:41-8. 306. Greenbaum PE, Lumley MA, Turner C, Melamed BG. Dentist's reassuring touch: effects on children's behavior. Pediatr Dent. 1993;15:20-24. 307. Greenbaum PE, Melamed BG. Pretreatment modeling: a technique for reducing children's fear in the dental operatory. Dent Clin North Am. 1988;32:693-703. 308. Greenberg M. Therapeutic play: developing humor in the nurse-patient relationship. J N Y State Nurses Assoc. 2003;34:25-31. 309. Greene M. On the silence of the therapist and object loss. Int J Psychoanal Psychother. 1983;9:183200. 310. Greenland S. Probability versus Popper: An elaboration of the insufficiency of current Popperian approaches for epidemiologic analysis. In: Rothman KJ, ed. Causal Inference. Chestnut Hill, MA: Epidemiological Resources; 1988. 311. Gryll SL, Katahn M. Situational factors contributing to the placebos effect. Psychopharmacology (Berl). 1978;57:253-261. 312. Guéguen N. Touch, awareness of touch, and compliance with a request. Percept Mot Skills. 2002;95:355-360. 313. Haase RF, Tepper DT. Nonverbal components of empathic communication. J Coun Psychol. 1972;19:417-424. 314. Hahn RA, Kleinman A. Biomedical practice and anthropological theory: Frameworks and directions. Ann Rev Anthropol. 1983;12:305-333.

140.

315. Hahn RA. A sociocultural model of illness and healing. Placebo: Clinical Phenomena and New Insights. New York: Guilford Press; 1983. 316. Hahn RA. The nocebo phenomenon: Concept, evidence, and implications for public health. Prev Med. 1997;26:607-611. 317. Hahn RA, Kleinman A. Belief as pathogen, belief as medicine:"Voodoo death" and the "placebo phenomenon" in anthropological perspective. Med Anthro Quarterly. 1983;14:16-19. 318. Hakeberg M. Dental anxiety and health [Doctor of Odontology dissertation]. Göteborg, Sweden: University of Göteborg; 1992. 319. Hakeberg M, Berggren U, Carlsson SG. A 10-year follow-up of patients treated for dental fear. Scand J Dent Res. 1990;98:53-59. 320. Hakeberg M, Berggren U, Carlsson SG. Prevalence of dental anxiety in a adult population in a major urban area in Sweden. Community Dent Oral Epidemiol. 1992;20:97-101. 321. Hakeberg M, Berggren U, Carlsson SG, Grondahl HG. Long-term effects on dental care behavior and dental health after treatments for dental fear. Anesth Prog. 1993;40:72-77. 322. Hakeberg M, Berggren U, Gröndahl HG. A radiographic study of dental health in adult patients with dental anxiety. Community Dent Oral Epidemiol. 1993;21:27-30. 323. Hakeberg M, Heidari E, Norinder M, Berggren U. A Swedish version of the Dental Visit Satisfaction Scale. Acta Odontol Scand. 2000;58:19-24. 324. Hakeberg M, Klingberg G, Noren JG, Berggren U. Swedish dentists' perceptions of their patients. Acta Odontol Scand. 1992;50:245-252. 325. Hall N, Edmonson HD. The aetiology and psychology of dental fear. Br Dent J. 1983;154:247-52. 326. Hällström T, Halling A. Prevalence of dentistry phobia and its relation to missing teeth, alveolar bone loss and dental care habits in an urban community sample. Acta Psychiatr Scand. 1984;70:438-446. 327. Hambrick JP, Turk CL, Heimberg RG, Schneier FR, Liebowitz MR. Psychometric properties of disability measures among patients with social anxiety disorder. J Anxiety Disord. 2004;18:825-39. 328. Hambrick JP, Weeks JW, Harb GC, Heimberg RG. Cognitive-behavioral therapy for social anxiety disorder: supporting evidence and future directions. CNS Spectr. 2003;8:373-381. 329. Hammarstrand G, Berggren U, Hakeberg M. Psychophysiological therapy vs. hypnotherapy in the treatment of patients with dental phobia. Eur J Oral Sci. 1995;103:399-404. 330. Handelman SL, Stege PM, Baric JM, Espeland MA, Saunders RH. Dentists' verbal communication leads during an interview with geriatric patients. Spec Care Dent. 1986;6:253-257. 331. Happ MB, Kagan SH. Methodological considerations for grounded theory research in critical care settings. Nurs Res. 2001;50:188-192. 332. Harris TA. I'm OK - You're OK. 1 ed. New York: Penguin; 1974. 333. Harrison JA, Berggren U, Carlsson SG. Treatment of dental fear: systematic desensitization or coping? Behav Psychother. 1989;17:125-133. 334. Harrison JA, Carlsson SG. Methodological issues in process and outcome studies: psychophysiology, systematic desensitization, and dental fear. Scand J Behav Ther. 1984;13:97-116.

141.

335. Harrison JA, Carlsson SG, Berggren U. Research in clinical process and outcome methodology: Psychophysiology, systematic desensitization and dental fear. J Behav Ther Exp Psychiatr. 1985;16:201-209. 336. Hartland J. Medical and Dental Hypnosis and It's Clinical Applications. In: Waxman D, ed. Hartland's Medical and Dental Hypnosis. 3rd ed. London: Baillière, Tindall & Cassell; 1989. 337. Harwood A. Introduction. In: Harwood A, ed. Ethnicity in Medical Care. Cambridge, MA: Harvard University Press; 1981:1-36. 338. Hassed C. How humour keeps you well. Aust Fam Physician. 2001;30:25-28. 339. Hasset J. Why dentists are a pain in the mind. Psychol Today. 1978;Jan:60-65. 340. Hedge HR. Recovering addicted dentists: a preliminary survey. Iowa Dent J. 1982;68:41-42. 341. Heering SH, Toennies S. Stress and tension control 3: Stress management. In: McGuigan F.J. SWE, ed. Stress of dentists caused by anxious patients. New York, NY, USA: Plenum Press; 1989:119-126. 342. Heifner C. The male experience of depression. Perspect Psychiatr Care. 1997;33:10-18. 343. Heim E. Job stressors and coping in health professions. Psychother Psychosom. 1991;55:90-99. 344. Heim E, Augustiny KF. [How dentists deal with occupational stress] Umgang der zahnärtzte mit berufsstress. Schweiz Monatsschr Zahnmed. 1988;98:1057-1066. 345. Heimberg RG. Cognitive-behavioral therapy for social anxiety disorder: current status and future directions. Biol Psychiatry. 2002;51:101-108. 346. Helfrich M, Quarentelli EL. The Professionalization of Dental Students: Intent and Reality. New Haven: United Printing Services Inc.; 1974. 347. Hellström K, Fellenius J, Öst LG. One versus five sessions of applied tension in the treatment of blood phobia. Behaviour Research and Therapy. 1996;34:101-112. 348. Helman CG. Heart disease and the cultural construction of time: the type A behaviour pattern as a Western culture-bound syndrome. Soc Sci Med. 1987;25:969-979. 349. Hendrix WH. Factors predictive of stress, organizational effectiveness, and coronary heart disease potential. Aviat Space Environ Med. 1985;56:654-659. 350. Hendrix WH. Dental stress model and assessment questionnaire. Dent Clin North Am. 1986;30:S110. 351. Hendrix WH. Job and personal factors related to job stress and risk of developing coronary artery disease. Psychol Rep. 1989;65:1136-1138. 352. Hendrix WH, Hughes RL. Relationship of trait, Type A behavior, and physical fitness variables to cardiovascular reactivity and coronary heart disease risk potential. Am J Health Promot. 1997;11:264-271. 353. Hendrix WH, Ovalle NK, Troxler RG. Behavioral and physiological consequences of stress and its antecedent factors. J Appl Psychol. 1985;70:188-201. 354. Henning K, Ey S, Shaw D. Perfectionism, the imposter phenomenon and psychological adjustment in medical, dental, nursing and pharmacy students. Med Educ. 1998;32:456-464. 355. Herod EL. Psychophysical pain control during tooth extraction. Gen Dent. 1995;43:267-269.

142.

356. Higuchi M, Fukada H. A comparison of four causal factors of embarrassment in public and private situations. J Psychol. 2002;136:399-406. 357. Hilden M, Sidenius K, Langhoff-Roos J, Wijma B, Schei B. Women's experiences of the gynecologic examination: factors associated with discomfort. Acta Obstet Gynecol Scand. 2003;82:1030-1036. 358. Hill CE, Thompson BJ, Ladany N. Therapist use of silence in therapy: a survey. J Clin Psychol. 2003;59:513-524. 359. Hilliard-Lysen J, Riemer JW. Occupational stress and suicide among dentists. Deviant Behavior. 1988;9:333-346. 360. Hirst M. The changing nature of pain control. Clinical aspects of endorphins and enkephalins. J Can Dent Assoc. 1985;7:493-498. 361. Hocking B. An anthropological view of stress diseases. Community Health Stud. 1982;6:14-18. 362. Hoffman-Axthelm W. History of Dentistry. Chicago: Quintessence; 1981. 363. Hook JN, Valentiner DP. Are specific and generalized social phobias qualitatively distinct? Clin Psychol Sci Pract. 2002;9:379-395. 364. Hooper EM, Comstock LM, Goodwin JM, Goodwin JS. Patient characteristics that influence physician behavior. Med Care. 1982;20:630-638. 365. Huffine CL, Folkman S, Lazarus RS. Psychoactive drugs, alcohol, and stress and coping processes in older adults. Am J Drug Alcohol Abuse. 1989;15:101-113. 366. Humphris G. A review of burnout in dentists. Dent Update. 1998;25:392-396. 367. Humphris G, Lilley J, Kaney S, Broomfield D. Burnout and stress-related factors among junior staff of three dental hospital specialties. Br Dent J. 1997;183:15-21. 368. Hupcey JE, Penrod J, Morse JM. Establishing and maintaining trust during acute care hospitalizations. Sch Inq Nurs Pract. 2000;14:227-242. 369. Hupcey JE, Penrod J, Morse JM, Mitcham C. An exploration and advancement of the concept of trust. J Adv Nurs. 2001;36:282-293. 370. IASP Subcommittee on Taxonomy, Merskey Hc. Pain terms: A list with definitions and notes on usage. Pain. 1979;6:249-252. 371. Illingworth P. Trust: the scarcest of medical resources. J Med Philos. 2002;27:31-46. 372. Illingworth PM. The friendship model of physician/patient relationship and patient autonomy. Bioethics. 1988;2:23-36. 373. Jackson E, Katz JO. Implementation of interpersonal skill training in dental schools. J Dent Educ. 1983;47:66-71. 374. Jackson JE. "After a While No One Believes You": Real and Unreal Pain. In: Good M-JD, Brodwin PE, Good BJ, Kleinman A, eds. Pain as human experience : an anthropological perspective. Berkeley: University of California; 1992:138-168. 375. Jacobsen E. Progressive relaxation. Chicago: University of Chicago Press; 1929. 376. Jain VK, Lall R, McLaughlin DG, Johnson WB. Effects of locus of control, occupational stress, and psychological distress on job satisfaction among nurses. Psychol Rep. 1996;78:1256-1258.

143.

377. James FR, Large RG, Beale IL. Self-hypnosis in chronic pain. A multiple baseline study of five highly hypnotisable subjects. Clin J Pain. 1989;Jun. 5:161-168. 378. James JE, Hardardottir D. Influence of attention focus and trait anxiety on tolerance of acute pain. Br J Health Psychol. 2002;7:149-162. 379. Jameson JS, Vernon P. Variables affecting Wolpean systematic desensitization. Can Psychiatr Assoc J. 1970;15:41-48. 380. Janssen SA, Arntz A. Anxiety and pain: Attentional and endorphinergic influences. Pain. 1996;66:145-150. 381. Janssen SA, Arntz A. No evidence for opioid-mediated analgesia induced by phobic fear. Behav Res Ther. 1997;35:823-830. 382. Janssen SA, Arntz A, Bouts S. Anxiety and pain: Epinephrine-induced hyperalgesia and attentional influences. Pain. 1998;76:309-316. 383. Jepsen CH. Precision communication in dentistry. J Dent Pract Adm. 1987;4:115-119. 384. Jepsen CH. Are you harmful or helpful? J Calif Dent Assoc. 1989;17:19-25. 385. Jepsen CH. Journal writing as an adjunct for neutralizing dental fear. J Calif Dent Assoc. 1993;21:46-50. 386. Jerlang B, Orloff J, Jerlang P. [Torture survivors - psychological and dental aspects] Torturoverlevere - psykologiske og odontologiske apsekter. Tandlægebladet. 1995;99:906-909. 387. Jerremalm A, Jansson L, Öst LG. Individual response patterns and the effects of different behavioral methods in the treatment of dental phobia. Behav Res Ther. 1986;24:587-596. 388. Jick TD. Mixing Qualitative and Quantitative Methods: Triangulation in Action. In: Van Maanen J, ed. Qualitative Methodology. Newbury Park, CA: Sage; 1983. 389. Johansson P, Berggren U, Hakeberg M, Hirsch JM. Measures of dental beliefs and attitudes: their relationships with measures of fear. Community Dent Health. 1993;10:31-39. 390. Johns JL. A concept analysis of trust. J Adv Nurs. 1996;24:76-83. 391. Johnson AM. Language ability and sex affect humor appreciation. Percept Mot Skills. 1992;75:571-581. 392. Johnson B, Mayberry WE, McGlynn FD. Exploratory factor analysis of a sixty-item questionnaire concerned with fear of dental treatment. J Behav Ther Exp Psychiatr. 1990;21:199-203. 393. Johnson M, Long T, White A. Arguments for 'British Pluralism' in qualitative health research. J Adv Nurs. 2001;33:243-249. 394. Jones A, Zachariae R. Investigation of the interactive effects of gender and psychological factors on pain response. Br J Health Psychol. 2004;9:405-418. 395. Jones A, Zachariae R, Arendt-Nielsen L. Dispositional anxiety and the experience of pain: genderspecific effects. Eur J Pain. 2003;7:387-395. 396. Jørgensen L. [Social Phobia. Two Disorders - One Treatment Programme] Socialfobi - To Lidelser - Ét Behandlingsprogram Psychology Thesis. Aarhus, Denmark: Psychology Institute, University of Aarhus; 2004. 397. Judge TA, Bono JE, Locke EA. Personality and job satisfaction: the mediating role of job characteristics. J Appl Psychol. 2000;85:237-249.

144.

398. Julian DG. What is right and what is wrong about evidence-based medicine? J Cardiovasc Electrophysiol. 2003;14:S2-S5. 399. Kaakko T, Coldwell SE, Getz T, Milgrom P, Roy-Byrne PP, Ramsay DS. Psychiatric diagnoses among self-referred dental injection phobics. J Anxiety Disord. 2000;14:299-312. 400. Kacperek L. Non-verbal communication: the importance of listening. Br J Nurs. 1997;6:275-279. 401. Kahn DL, Steeves RH. The experience of suffering: conceptual clarification and theoretical definition. J Adv Nurs. 1986;11:623-631. 402. Kaiser RB. The way of the journal. Psychol Today. 1981;64-76. 403. Kamei T, Kumano H, Masumura S. Changes of immunoregulatory cells associated with psychological stress and humor. Percept Mot Skills. 1997;84:1296-1298. 404. Karasek RA, Theorell TG, Schwartz J, Pieper C, Alfredsson L. Job, psychological factors and coronary heart disease. Swedish prospective findings and US prevalence findings using a new occupational inference method. Adv Cardiol. 1982;29:62-67. 405. Katz CA. Are you a hardy dentist? The relationship between personality and stress. J Dent Pract Adm. 1987;4:100-107. 406. Kaufman E, Weinstein P, Milgrom P. Difficulties in achieving local anesthesia. Journal American Dental Association. 1984;108:205-208. 407. Kazdin AE, Wilcoxon LA. Systematic desensitization and nonspecific treatment effects: A methodological evaluation. Psychol Bull. 1976;83:729-758. 408. Keefe FJ, Crisson J, Urban BJ, Williams DA. Analyzing chronic low back pain: the relative contribution of pain coping strategies. Pain. 1990;Mar. 40:293-301. 409. Kelly MA, Lange B, Dunning DG, Underhill TE. Reasons patients stay with a dentist. J Dent Pract Adm. 1990;7:9-15. 410. Kelly SF. Hypnotizability and the inadvertent experience of pain: A brief communication. Int J Clin Exp Hypn. 1980;28:189-191. 411. Kendall J. Axial coding and the grounded theory controversy. West J Nurs Res. 1999;21:743-757. 412. Kendler KS, Myers J, Prescott CA. The etiology of phobias: An evaluation of the stress-diathesis model. Arch Gen Psychiatry. 2002;59:242-248. 413. Kendler KS, Myers J, Prescott CA, Neale MC. The genetic epidemiology of irrational fears and phobias in men. Arch Gen Psychiatry. 2001;58:257-265. 414. Kendler KS, Neale MC, Kessler RC, Heath AC, Eaves LJ. The genetic epidemiology of phobias in women. The interrelationship of agoraphobia, social phobia, situational phobia, and simple phobia. Arch Gen Psychiatry. 1992;49:273-281. 415. Kenna GA, Wood MD. Alcohol use by healthcare professionals. Drug Alcohol Depend. 2004;75:107-116. 416. Kent G. Anxiety, pain and type of dental procedure. Behav Res Ther. 1984;22:465-469. 417. Kent G. Cognitive processes in dental anxiety. Br J Clin Psychol. 1985;24:259-264. 418. Kent G. Memory of dental pain. Pain. 1985;21:187-194. 419. Kent G. The typicality of therapeutic 'surprises'. Behav Res Ther. 1986;24:625-628.

145.

420. Kent G. Behavioural sciences teaching in UK dental schools. Med Educ. 1987;21:105-108. 421. Kent G. Self-efficacious control over reported physiological, cognitive and behavioral symptoms of dental anxiety. Behav Res Ther. 1987;25:341-347. 422. Kent G. Stress amongst dentists. In: Payne R, Firth-Cozens J, eds. Stress in Health Professionals. Wiley series on studies in occupational stress. New York, NY: Wiley & Sons; 1987:127-149. 423. Kent G. Thinking about anxiety. Br Dent J. 1990;8:133-135. 424. Kent G, Gibbons R. Self-efficacy and the control of anxious cognitions. J Behav Ther Exp Psychiatr. 1987;18:33-40. 425. Kent G, Rubin G, Getz T, Humphris G. Development of a scale to measure the social and psychological effects of severe dental anxiety: Social Attributes of the Dental Anxiety Scale. Community Dent Oral Epidemiol. 1996;24:394-397. 426. Kent G, Warren P. A study of factors associated with changes in dental anxiety. J Dent Res. 1985;64:1316-1318. 427. Kent GG, Blinkhorn AS. The Psychology of Dental Care. Second ed. Oxford: Wright / Butterworth-Heinemann; 1991. 428. Kent GG, Croucher R. Priorities of undergraduate dental education: What do students think? Med Educ. 1992;26:372-377. 429. Kerr IL. Quality assurance and the dentist-patient relationship. Dent Clin North Am. 1985;29:581-8.

430. Kirkegaard E, Borgnakke WS, Grønbæk L. [Investigation of Danish adult dental habits and dental health status (dissertation)] Tandsygdomme, behandlingsbehov og tandplejevaner hos et repræsentativt udsnit af den voksne befolkning (Voksenundersøgelsen). Århus and Copenhagen: Royal Dental Colleges; 1985. 431. Kirsch I. Self-efficacy and expectancy: Old wine with new labels. J Pers Soc Psychol. 1985;49:824-830. 432. Kirsch I, Lynn SJ. Dissociation theories of hypnosis. Psychol Bull. 1998;123:100-115. 433. Kirsch I, Tennen H, Wickles C, Saccone AJ, Cody S. The role of expectancy in fear reduction. Behav Ther. 1983;14:520-533. 434. Kittelson L. Secrets and lies: alcohol and drug addiction in dentistry. J Calif Dent Assoc. 1998;26:744-750. 435. Klages U, Ulusoy Ö, Kianifard S, Wehrbein H. Dental trait anxiety and pain sensitivity as predictors of expected and experienced pain in stressful dental procedures. Eur J Oral Sci. 2004;112:477-483. 436. Kleinhauz M, Eli I. When pharmacologic anesthesia is precluded: the value of hypnosis as a sole anesthetic agent in dentistry. Spec Care Dentist. 1993;13:15-18. 437. Kleinknecht RA. Specificity and psychosocial correlates of blood/injury fear and fainting. Behav Res Ther. 1988;26:303-309. 438. Kleinknecht RA, Bernstein DA. The assessment of dental fear. Behav Res Ther. 1978;9:626-634. 439. Kleinknecht RA, Klepac RK, Alexander LD. Origins and characteristics of fear of dentistry. J Am Dent Assoc. 1973;86:842-848.

146.

440. Kleinknecht RA, Lenz J. Blood/injury fear, fainting and avoidance of medically-related situations: a family correspondance study. Behav Res Ther. 1989;27:537-547. 441. Kleinman A. The use of "explanatory models" as a conceptual frame for comparative cross-cultural research on illness experiences and the basic tasks of clinical care amongst Chinese and other populations. In: Kleinman A, et al , ed. 1976;645-658. 442. Kleinman A. Patients and Healers in the Context of Culture - An Exploration of the Borderland Between Anthropology, Medicine, and Psychiatry. Berkeley: University of California Press; 1980. 443. Kleinman A. On illness meanings and clinical interpretation: Not 'rational man', but a rational approach to man the sufferer/man the healer. Cult Med Psychiatry. 1981;5:373-377. 444. Kleinman A. The Illness Narratives: Suffering, Healing and the Human condition. New York: Basic Books, Inc.; 1988. 445. Kleinman A, Kleinman J. Suffering and its professional transformation: Toward an ethnography of interpersonal experience. Cult Med Psychiatry. 1991;15:275-301. 446. Klerman GL, Weissmann MM. Interpersonal psychotherapy (IPT) and drugs in the treatment of depression. Pharmacopsychiatry. 1987;20:3-7. 447. Klingberg G, Berggren U, Carlsson SG, Noren JG. Child dental fear: cause-related factors and clinical effects. Eur J Oral Sci. 1995;103:405-412. 448. Klingman A, Melamed BG, Cuthbert MI, Hermecz DA. Effects of participant modeling on information acquistion and skill utilization. J Cons Clin Psychol. 1984;52:414-422. 449. Koopman C, Eisenthal S, Stoeckle JD. Ethnicity in the reported pain, emotional distress and requests of medical outpatients. Soc Sci Med. 1984;18:487-490. 450. Koslowsky M, Bailit H, Valluzzo P. Satisfaction of the patient and the provider; evaluation by questionnaire. J Public Health Dent. 1974;34:188-194. 451. Kress G, Shulman JD. Consumer satisfaction with dental care: where have we been, where are we going? J Am Coll Dent. 1997;64:9-15. 452. Kriesberg L, Treiman BR. Dentists and the practice of dentistry as viewed by the public. J Am Dent Assoc. 1962;64:58-73. 453. Kulas JF, Conger JC, Smolin JM. The effects of emotion on memory: An investigation of attentional bias. Journal of Anxiety Disorders. 2003;17:103-113. 454. Kulich KR. Interpersonal Skills in the Dentist-Patient Relationship - The Art of Dentistry (Doctor of Odontology Dissertation). Department of Psychology, Göteborg University; 2000. 455. Kulich KR, Berggren U, Hakeberg M, Gustafsson JE. Factor structure of the Dental Beliefs Survey in a dental phobic population. Eur J Oral Sci. 2001;109:235-240. 456. Kulich KR, Berggren U, Hallberg LR. Model of the dentist-patient consultation in a clinic specializing in the treatment of dental phobic patients: a qualitative study. Acta Odontol Scand. 2000;58:63-71. 457. Kulich KR, Berggren U, Hallberg LR. A qualitative analysis of patient-centered dentistry in consultations with dental phobic patients. J Health Commun. 2003;8:171-187. 458. Kulich KR, Ryden O, Bengtsson H. A descriptive study of how dentists view their profession and the doctor-patient relationship. Acta Odontol Scand. 1998;56:206-209.

147.

459. Kumar S, Little P, Britten N. Why do general practitioners prescribe antibiotics for sore throat? Grounded theory interview study. BMJ. 2003;326:138. 460. Kunzelmann KH, Dünninger P. Dental fear and pain: Effect on patient's perception of the dentist. Community Dent Oral Epidemiol. 1990;18:264-266. 461. Kvale G, Berg E, Nilsen CM, Raadal M, Nielsen GH, Johnsen TB, Wormnes B. Validation of the Dental Fear Scale and the Dental Belief Survey in a Norwegian sample. Community Dent Oral Epidemiol. 1997;25:160-164. 462. Kvale G, Berggren U, Milgrom P. Dental fear in adults: A meta-analysis of behavioral interventions. Community Dent Oral Epidemiol. 2004;32:250-264. 463. Kvale G, Milgrom P, Getz T, Weinstein P, Johnsen TB. Beliefs about professional ethics, dentistpatient communication, control and trust among fearful dental patients: the factor structure of the revised Dental Beliefs Survey. Acta Odontol Scand. 2004;62:21-29. 464. Kvale G, Raadal M, Vika M, Johnsen BH, Skaret E, Vatnelid H, Oiama I. Treatment of dental anxiety disorders. Outcome related to DSM-IV diagnoses. Eur J Oral Sci. 2002;110:69-74. 465. Lahti S, Tuutti H, Hausen H, Kaariainen R. Comparison of ideal and actual behavior of patients and dentists during dental treatment. Community Dent Oral Epidemiol. 1995;23:374-378. 466. Lahti S, Tuutti H, Hausen H, Kaarlanen R. Patients' expectations of an ideal dentist and their views concerning the dentist they visited: do the views conform to the expectations and what determines how well they conform? Community Dent Oral Epidemiol. 1996;24:240-244. 467. Lahti S, Verkasalo M, Hausen H, Tuutti H. Ideal role behaviours as seen by dentists and patients themselves and by their role partners: do they differ? Community Dent Oral Epidemiol. 1996;24:245-248. 468. Lane RC, Koetting MG, Bishop J. Silence as communication in psychodynamic psychotherapy. Clin Psychol Rev. 2002;22:1091-1104. 469. Lang EV, Benotsch EG, Fick LJ, Lutgendorf S, Berbaum ML, Berbaum KS, Logan H, Spiegel D. Adjunctive non-pharmacological analgesia for invasive medical procedures: a randomised trial. Lancet. 2000;355:1486-1490. 470. Lang PJ. The Cognitive Psychophysiology of Emotion: Fear and anxiety. In: Tuma AH, Maser J, eds. Anxiety and the anxiety disorders. Hillsdale, New Jersey: Lawrence Erlbaum Associates Publisher; 1985:331-370. 471. Lange AL, Loupe MJ, Meskin LH. Professional satisfaction in dentistry. J Am Dent Assoc. 1982;104:619-624. 472. Lantzman E. The need for teaching emotional behavior in dentistry. Refuat Hapeh Vehashinayim. 1978;27:29-30-35-36. 473. Larkin GV. Medical dominance in Britain: image and historical reality. Milbank Q. 1988;66 Suppl 2:117-132. 474. LaRocco JM, Tetrick LE, Meder D. Differences in perceptions of work environment conditions, job attitudes, and health beliefs among military physicians, dentists, and nurses. Military Psychology. 1989;1:135-151. 475. Larsen M, Oldeide CC, Malterud K. Not so bad after all..., Women's experiences of pelvic examinations. Fam Pract. 1997;14:148-152. 476. Laughlin HP. The neuroses. Washington D.C.: Butterworth; 1967.

148.

477. Lautch H. Dental phobia. Br J Psychol. 1971;119:151-158. 478. Lavstedt S. [The needs for dental health care in a normal (Swedish) population. Rebus Investigation II] Behovet av tandhälsovård hos en normalpopulation. Rebusundersökningen II. Tandläkartidningen. 1978;70:971-991. 479. Lazarus RS. Some principles of psychological stress and their relation to dentistry. J Dent Res. 1966;45:1620-1626. 480. Lazarus RS. Coping strategies. In: McHugh S, Vallis TM, eds. Illness behavior: A multidisciplinary model. New York: Plenum Press; 1986. 481. Lazarus RS, Folkman S. Stress, appraisal and coping. New York: Springer; 1984. 482. Lehtinen R. A dental health survey in a Finnish urban population. Proc Finn Dent Soc. 1975;71 supp I:39-41. 483. Leise CM. The correlation between humor and the chronic pain of arthritis. J Holist Nurs. 1993;11:82-95. 484. Leiter MP, Maslach C. Six areas of worklife: a model of the organizational context of burnout. J Health Hum Serv Adm. 1999;21:472-489. 485. Levin RB, Gross AM. The role of relaxation in systematic desensitization. Behav Res Ther. 1985;23:187-196. 486. Levine JD, Gordon NC, Smith R, Fields HL. Analgesic responses to morphine and placebo in individuals with postoperative pain. Pain. 1981;10:379-389. 487. Lewis G. The place of pain in human experience. J Med Ethics. 1978;4:122-125. 488. Ley P. Communicating with Patients - Improving Communication, Satisfaction and Compliance. London: Croom Helm; 1988. 489. Ley P, Spelman M. Communicating with the patient. London: Staples Press; 1970. 490. Ley R. The modification of breathing behavior. Pavlovian and operant control in emotion and cognition. Behav Modif. 1999;23:441-479. 491. Libassi MF, Maluccio AN. Competence-centered social work: Prevention in action. J Primary Prevention. 1986;6:168-180. 492. Lick J, Bootzin R. Expectancy factors in the treatment of fear: Methodological and theoretical issues. Psychol Bull. 1975;82:917-931. 493. Liddell A, Di Fazio L, Blackwood J, Ackerman C. Long-term follow-up of treated dental phobics. Behav Res Ther. 1994;32:605-610. 494. Liddell A, Gosse V. Characteristics of early unpleasant dental experiences. J Behav Ther Exp Psychiatry. 1998;29:227-237. 495. Liddell A, Locker D. Changes in levels of dental anxiety as a function of dental experience. Behav Modif. 2000;24:57-68. 496. Liddell A, May B. Patients' perception of dentists' positive and negative attributes. Soc Sci Med. 1984;19:839-842. 497. Lieb R, Wittchen HU, Hofler M, Fuetsch M, Stein MB, Merikangas KR. Parental psychopathology, parenting styles, and the risk of social phobia in offspring: a prospectivelongitudinal community study. Arch Gen Psychiatry. 2000;57:859-866.

149.

498. Lindholm L, Eriksson K. To understand and alleviate suffering in a caring culture. J Adv Nurs. 1993;18:1354-1361. 499. Lindsay SJE, Humphris G, Barnby GJ. Expectations and preferences for routine dentistry in anxious adult patients. Br Dent J. 1987;163:120-124. 500. Linn EL. Role behaviors in two dental clinics: A trial of Nadel's criteria. Human Org. 1967;26:141148. 501. Linn LS, DiMatteo MR. Humor and other communication preferences in physician-patient encounters. Med Care. 1983;21:1223-1231. 502. Lipton JA, Marbach JJ. Ethnicity and the pain experience. Soc Sci Med. 1984;19:1279-1298. 503. Litchfield NB. Stress-related problems of dentists. Special Issue: Biofeedback and diagnostic techniques. Int J Psychosomatics. 1989;36:41-44. 504. Lloyd C, Musser LA. Psychiatric symptoms in dental students. J Nerv Ment Dis. 1989;177:61-69. 505. Locker D. Symptoms and Illness. London: Tavistock; 1979. 506. Locker D. Dentist-patient communication. An Introduction to Behavioural Science in Dentistry. London: Tavistock/Routledge; 1989:117-131. 507. Locker D. Stress in dental practice. An Introduction to Behavioural Science & Dentistry. London: Tavistock/Routledge; 1989:177-192. 508. Locker D. Psychosocial consequences of dental fear and anxiety. Community Dent Oral Epidemiol. 2003;31:144-151. 509. Locker D, Liddell A. Stability of Dental Anxiety Scale scores: A longitudinal study of older adults. Community Dent Oral Epidemiol. 1995;23:259-261. 510. Locker D, Liddell A, Dempster L, Shapiro D. Age of onset of dental anxiety. J Dent Res. 1999;78:790-796. 511. Locker D, Liddell A, Shapiro D. Diagnostic categories of dental anxiety: a population-based study. Behav Res Ther. 1999;37:25-37. 512. Locker D, Poulton R, Thomson WM. Psychological disorders and dental anxiety in a young adult population. Community Dent Oral Epidemiol. 2001;29:456-463. 513. Locker D, Shapiro D, Liddell A. Negative dental experiences and their relationship to dental anxiety. Community Dent Health. 1996;13:86-92. 514. Locker D, Shapiro D, Liddell A. Who is dentally anxious? Concordance between measures of dental anxiety. Community Dent Oral Epidemiol. 1996;24:346-350. 515. Locker D, Shapiro D, Liddell A. Overlap between dental anxiety and blood-injury fears: psychological characteristics and response to dental treatment. Beh Res Ther. 1997;35:583-590. 516. Locker D, Thomson WM, Poulton R. Psychological disorder, conditioning experiences, and the onset of dental anxiety in early adulthood. J Dent Res. 2001;80:1588-1592. 517. Logan HL. The patient and the shifting health-care paradigm. J Am Coll Dent. 1997;64:16-18. 518. Logan HL, Muller PJ, Berst MR, Yeaney DW. Contributors to dentists' job satisfaction and quality of life. J Am Coll Dent. 1997;64:39-43.

150.

519. Loupe MJ, Meskin LH, Mast TA. Changes in the values of dental students and dentists over a tenyear period. J Dent Educ. 1979;43:170-175. 520. Luine V, Villegas M, Martinez C, McEwen BS. Repeated stress causes reversible impairments of spatial memory performance. Brain Res. 1994;639:167-170. 521. MacDonald LA, Karasek RA, Punnett L, Scharf T. Covariation between workplace physical and psychosocial stressors: Evidence and implications for occupational health research and prevention. Ergonomics. 2001;44:696-718. 522. Mackenzie RS, Heins PJ, Holbrook W, Low SB, Kramer M. An analysis of behavioral contingencies in clinical teaching. J Dent Educ. 1979;43:578-584. 523. Maggirias J, Locker D. Psychological factors and perceptions of pain associated with dental treatment. Community Dent Oral Epidemiol. 2002;30:151-159. 524. Mahony DL, Burroughs WJ, Hieatt AC. The effects of laughter on discomfort thresholds: does expectation become reality? J Gen Psychol. 2001;128:217-226. 525. Mahony DL, Mann VA. Using children's humor to clarify the relationship between linguistic awareness and early reading ability. Cognition. 1992;45:163-186. 526. Malamed SF. The periodontal ligament (PDL) injection: an alternative to inferior alveolar nerve block. Oral Surg Oral Med Oral Pathol. 1982;53:117-121. 527. Mallinger MA, Brousseau KR, Cooper CL. Stress and success in dentistry. Some personality characteristics of successful dentists. J Occup Med. 1978;20:549-553. 528. Mandel ID. Changing dental images - from stone tablets to comic strips. J Am Dent Assoc. 1989;118:695-699. 529. Mandel ID. The image of dentistry in contemporary culture. J Am Dent Assoc. 1998;129:607-613. 530. Manji I. Managing emergency patients. J Can Dent Assoc. 1995;61:662-663. 531. Manning P, Ray GB. Setting the agenda: an analysis of negotiation strategies in clinical talk. Health Commun. 2002;14:451-473. 532. Mannuzza S, Schneier FR, Chapman TF, Liebowitz MR, Klein DF, Fyer AJ. Generalized social phobia. Reliability and validity. Arch Gen Psychiatry. 1995;52:230-237. 533. Marks IM, Gelder MG, Edwards G. Hypnosis and desensitization for phobias: a controlled prospective trial. Br J Psychiatry. 1968;114:1263-1274. 534. Marshall WL, Gauthier J, Gordon A. The current status of flooding therapy. Prog Behav Mod. 1979;7:205-75. 535. Martin RA. Humor, laughter, and physical health: methodological issues and research findings. Psychol Bull. 2001;127:504-519. 536. Martinez T, Capafons A, Weber V, Cardena E. Rapid self-hypnosis: a new self-hypnosis method and its comparison with the Hypnotic Induction Profile (HIP). Am J Clin Hypn. 2001;44:3-11. 537. Martyres G. On silence: A language for emotional experience. Aust N Z J Psychiatry. 1995;29:118-123. 538. Maslach C. Burned-out. Can J Psychiatr Nurs. 1979;20:5-9. 539. Maslach C, Jackson SE, Leiter MP. Maslach Burnout Inventory Manual. 3rd ed. Palo Alto, CA: Consulting Psychology Press; 1986.

151.

540. Maslach C, Schaufeli WB, Leiter MP. Job burnout. Annu Rev Psychol. 2001;52:397-422. 541. Mass R. The iatrogenic interview in the effective management of the fearful dental patient. Compendium. 1995;16:152-162. 542. Matz A, Brown ST. Humor and pain management. A review of current literature. J Holist Nurs. 1998;16:68-75. 543. Maunsbach M. ["One thing is theory - Another is practice.." Aspects of compliance and noncompliance among Type-2 diabetics]"En ting er teori - Noget andet er praksis..." Aspekter af compliance og noncompliance blandt type-2 diabetikere [Ph.D. Dissertation]. Århus, Denmark: Det Sundhedsvidenskabelige Fakultet, Aarhus Universitet; 1999. 544. Mazey KA. Stress in the dental office. J Calif Dent Assoc. 1994;22:13-19. 545. McConkey KM, Bryant RA, Bibb BC, Kihlstrom JF. Trance logic in hypnosis and imagination. J Abnorm Psychol. 1991;100:464-472. 546. McCord EC, Brandenburg C. Beliefs and attitudes of persons with diabetes. Fam Med. 1995;27:267-271. 547. McCoy P. Further proof that touch speaks louder than words. RN. 1977;40:43-46. 548. McEwen BS. Protective and damaging effects of stress mediators. N Engl J Med. 1998;338:171-9. 549. McEwen BS. The neurobiology of stress: From serendipity to clinical relevance. Brain Res. 2000;886:172-189. 550. McEwen BS. Plasticity of the hippocampus: adaptation to chronic stress and allostatic load. Ann N Y Acad Sci. 2001;933:265-277. 551. McEwen BS. Sex, stress and the hippocampus: Allostasis, allostatic load and the aging process. Neurobiol Aging. 2002;23:921-939. 552. McEwen BS, Magarinos AM. Stress and hippocampal plasticity: Implications for the pathophysiology of affective disorders. Hum Psychopharmacol. 2001;16:S7-S19. 553. McEwen BS, Stellar E. Stress and the individual. Mechanisms leading to disease. Arch Intern Med. 1993;153:2093-2101. 554. McGlynn FD, McNeil DW, Gallagher SL, Vrana S. Factor structure stability, and internal consistency of the Dental Fear Survey. Behav Assess. 1987;9:57-66. 555. McGuinness TP. Hypnosis in the treatment of phobias: a review of the literature. Am J Clin Hypn. 1984;26:261-272. 556. McKeithen EJ. The patient's image of the dentist. J Am Coll Dent. 1964;2:87-107. 557. McKinlay JB. The business of good doctoring or doctoring as good business: reflections on Freidson's view of the medical game. Int J Health Serv. 1977;7:459-488. 558. McKinlay JB, Marceau LD. The end of the golden age of doctoring. Int J Health Serv. 2002;32:379-416. 559. McNeil DW, Au AR, Zvolensky MJ, McKee DR, Klineberg IJ, Ho CC. Fear of pain in orofacial pain patients. Pain. 2001;89:245-252. 560. Mechanic D. Public perceptions of medicine. N Engl J Med. 1985;312:181-183. 561. Mehrabian A. Silent Messages. Belmont: Wadsworth; 1971.

152.

562. Meichenbaum D. Teaching thinking : a cognitive-behavioral approach. Austin, Tex.: Society for Learning Disabilities and Remedial Education; 1982. 563. Meichenbaum D, Turk DC. The cognitive-behavioral management of anxiety, anger and pain. In: Davidson PO, ed. The Behavioral Management of Anxiety, Depression and Pain. New York: Brunner/Maxel; 1976. 564. Meichenbaum D, Turk DC. Cognitive-behavior modification: an integrative approach. New York: Plenum Press; 1977. 565. Melamed BG, Hawes R, Heiby E, Glick J. Use of filmed modeling to reduce uncooperative behavior of children during dental treatment. J Dent Res. 1975;54:797-801. 566. Melzack R. Neurophysiological Foundations of Pain. In: Sternbach RA, ed. Neurophysiology of Pain. New York: Raven Press; 1986:1-24. 567. Melzack R. From the gate to the neuromatrix. Pain. 1999;Suppl 6:S121-S126. 568. Melzack R. Pain and the neuromatrix in the brain. J Dent Educ. 2001;65:1378-1382. 569. Melzack R, Casey KL. Sensory, motivational and control determinants of pain: A new conceptual model. In: Kenshalo D, ed. The Skin Senses. Springfield, IL: Charles C. Thomas; 1968:423-439. 570. Melzack R, Wall PD. Pain mechanisms: A new theory. Science. 1965;150:971-979. 571. Menage J. Women's perception of obstetric and gynecological examinations. BMJ. 1993;306:1127-1128. 572. Mendola P, O'Shea RM, Gogan C, Thines TJ, Corah N, L. Training general practice residents in patient behavioral management. J Dent Educ. 1989;53:727-730. 573. Mendolia M, Kleck RE. Effects of talking about a stressful event on arousal: does what we talk about make a difference? J Pers Soc Psychol. 1993;64:283-292. 574. Merton RK. The self-fulfilling prophecy. Antioch Review. 1948;8:193-210. 575. Micheelis W. [Measurable Dentist Occupational Hazards] Merkmale zahnärtlicher Arbeitsanspruchung - Ergebnisse einer Fragebogenstudie. Köln: Deutscher Zahnärzte Verlag; 1984. 576. Michels R, Frances A, Shear MK. Psychodynamic models of anxiety. In: Tuma AH, Maser J, eds. Anxiety and the Anxiety Disorders. Hillsdale, New Jersey: Lawrence Erlbaum; 1985. 577. Michelson L. Treatment consonance and response profiles in agoraphobia: the role of individual differences in cognitive, behavioral and physiological treatments. Behav Res Ther. 1986;24:263-75. 578. Michelson L, Mavissakalian M, Marchione K. Cognitive, behavioral, and psychophysiological treatments and agoraphobia: a comparative outcome investigation. Behav Ther. 1988;19:97-120. 579. Milgrom P. Quality control of end results: identifying avoidable adverse events in dentistry. J Am Dent Assoc. 1975;90:1282-1290. 580. Milgrom P. Behavioral methods and research issues in the management of the adult dental patient. Anesth Prog. 1986;33:5-9. 581. Milgrom P, Fiset L, Melnick S, Weinstein P. The prevalence and practice management consequences of dental fear in a major US city. J Am Dent Assoc. 1988;116:641-647. 582. Milgrom P, Ratener P, Conrad D, Weinstein P. Determinants of the quality of restorative dental care. Med Care. 1980;18:400-415.

153.

583. Milgrom P, Ratener P, Weinstein P. Evidence of the validity of a model of determinants of quality of restorative dental care. Community Dent Oral Epidemiol. 1983;11:33-39. 584. Milgrom P, Weinstein P, Kleinknecht R, Getz T. Treating Fearful Dental Patients - A Patient Management Handbook. First ed. Reston, VA: Reston Publishing; 1985. 585. Milgrom P, Weinstein P, Kleinknecht R, Getz T. Treating Fearful Dental Patients - A Patient Management Handbook. Second ed. Seattle, WA: University of Washington Press; 1995. 586. Miller NE, Dollard J. Social Learning and Imitation. First ed. New Haven, CT: Yale University Press; 1941. 587. Moerman DE. General medical effectiveness and human biology: Placebo effects in the treatment of ulcer disease. Med Anthro Quarterly. 1983;14:3-15. 588. Molin C, Seeman K. Disproportionate dental anxiety: Clinical and nosological considerations. Acta Odontol Scand. 1970;28:197-212. 589. Möller AT, Spangenberg JJ. Stress and coping amongst South African dentists in private practice. J Dent Assoc S Afr. 1996;51:347-357. 590. Montgomery GH, Kirsch I. Classical conditioning and the placebo effect. Pain. 1997;72:107-113. 591-592. Moore CA, Liggett WR. The inferior alveolar block: Effect on the dentist's heart rate. Gen Dent. 1983;31:386-388. 593. Moore R. Dentist unemployment--a Scandinavian reality. J Am Dent Assoc. 1985;110:92-96. 594. Moore R. Dentist unemployment. A Scandinavian reality and workforce issues in the United States. J Can Dent Assoc. 1986;52:45-51. 595. Moore R. Ethnographic assessment of pain coping responses. Psychosom Med. 1990;52:171-181. 596. Moore R. [Clinically relevant treatment of dental fear] Tandlægeskræk - klinisk relevante behandlingsformer. Tandlægebladet. 1990;94:58-60. 597. Moore R. Dental fear treatment: a comparison of a video training procedure and clinical rehearsals. Scand J Dent Res. 1991;99:229-235. 598-599. Moore R. The Phenomenon of Dental Fear - Studies in Clinical Diagnosis, Measurement and Treatment (Ph.D. Dissertation). Århus, Denmark: University of Aarhus; 1991. 600. Moore R. [The phenomenon of dental fear - on science, people and technology] Fænomenet tandlægeskræk - om videnskab, mennesker og teknologi. Tandlægebladet. 1993;97:45-50. 601. Moore R. Combining qualitative and quantitative research approaches in understanding pain. J Dent Educ. 1996;60:709-715. 602. Moore R. Danish dentists' career satisfaction in relation to perceived occupational stress and public image. Tandlægebladet. 2000;104:1020-1024. 603. Moore R, Abrahamsen R, Brødsgaard I. Hypnosis compared with group therapy and individual desensitization for dental anxiety. Eur J Oral Sci. 1996;612-618. 604. Moore R, Berggren U, Carlsson SG. Reliability and clinical usefulness of psychometric measures in a self-referred population of odontophobics. Community Dent Oral Epidemiol. 1991;19:347-351. 605. Moore R, Birn H. [The phenomenon of dental fear - Background, need and research strategy for a systematic treatment and prevention effort] Fænomenet "Tandlægeskræk"- Baggrund og behov for en samfundsodontologisk indsats. Tandlægebladet. 1990;94:34-41.

154.

606. Moore R, Birn H, Brødsgaard I, Kirkegaard E, Scheutz F. [Prevalence and perceptions of dental anxiety among Danish adults] Udbredelse og opfattelser af angst for tandbehandling blandt voksne danskere . Tandlægebladet. 1993;97:51-54. 607. Moore R, Brødsgaard I. Group therapy compared with individual desensitization for dental anxiety. Community Dent Oral Epidemiol. 1994;22:258-262. 608. Moore R, Brødsgaard I. Differential diagnosis of odontophobic patients using the DSM-IV. Eur J Oral Sci. 1995;103:121-126. 609. Moore R, Brødsgaard I. Crosscultural pain investigations. In: Crombie IK, Croft PR, Linton SJ, LeResche L, Von Korff M, eds. Epidemiology of Pain. Seattle: IASP Press; 1999:53-80. 610. Moore R, Brødsgaard I, Berggren U, Carlsson SG. Generalization of effects of dental fear treatment in a self-referred population of odontophobics. J Behav Ther Exp Psychiatr. 1991;22:243-253. 611. Moore R, Brødsgaard I, Birn H. Manifestations, acquisition and diagnostic categories of dental fear in a self-referred population. Behav Res Ther. 1991;29:51-60. 612. Moore R, Brødsgaard I, Mao T-K, Miller ML, Dworkin SF. Acute pain and use of local anesthesia: Tooth drilling and childbirth labor pain beliefs among AngloAmericans, mandarin Chinese and Scandinavians. Anesth Prog. 1998;45:27-37. 613. Moore R, Brødsgaard I, Miller ML, Mao T-K, Dworkin SF. Consensus analysis: Reliability, validity and informant accuracy in use of American and mandarin Chinese pain descriptors. Ann Behav Med. 1997;19:295-300. 614. Moore R, Brødsgaard I, Scheutz F, Birn H. [Fear of dental treatment. Prevalence and characteristics among adult Danes] Angst for tandbehandling. Prevalens og karakteristika blandt voksne danskere. Ugeskr Læger. 1995;157:1845-1848. 615. Moore RA, Dworkin SF. Ethnographic methodologic assessment of pain perceptions by verbal description. Pain. 1988;34:195-204. 616. Morgan AH, Hilgard JR. The Stanford Hypnotic Clinical Scale for adults. Am J Clin Hypn. 1978;21:134-147. 617. Mörk C, Pöyry M, Nissen C, Sangnes G. [New knowledge about dental anxiety influences dental health care in the Nordic countries] Ny viten om tannlægeskrekk påvirker tannhelsetjenesten i de nordiske land. Tandlægebladet. 2003;107:6-7. 618. Morris DB. The culture of pain. Berkeley: University of California Press; 1991. 619. Morse DR. Variety, exercise, meditation can relieve practice stress. Dent Stud. 1977;56:26-29. 620. Morse JM. Comfort: The refocusing of nursing care. Clin Nurs Res. 1992;1:91-106. 621. Morse JM. Responding to threats to integrity of self. ANS Adv Nurs Sci. 1997;19:21-36. 622. Morse JM. On comfort and comforting. Am J Nurs. 2000;100:34-37. 623. Morse JM. Toward a praxis theory of suffering. ANS Adv Nurs Sci. 2001;24:47-59. 624. Morse JM, Anderson G, Bottorff JL, Yonge O, Brien B, Solberg SM, McIlveen KH. Exploring empathy: a conceptual fit for nursing practice? Image J Nurs Sch. 1992;24:273-280. 625. Morse JM, Bottorff J, Neander W, Solberg S. Comparative analysis of conceptualizations and theories of caring. Image J Nurs Sch. 1991;23:119-126.

155.

626. Morse JM, Bottorff JL, Anderson G, O'Brien B, Solbjerg S. Beyond empathy: Expanding expressions of caring. J Adv Nurs. 1992;17:809-821. 627. Morse JM, Bottorff JL, Anderson G, O'Brien B, Solbjerg S. Beyond empathy: expanding expressions of caring. J Adv Nurs. 1992;17:809-821. 628. Morse JM, Bottorff JL, Hutchinson S. The phenomenology of comfort. J Adv Nurs. 1994;20:189-95. 629. Morse JM, Bottorff JL, Hutchinson S. The paradox of comfort. Nurs Res. 1995;44:14-19. 630. Morse JM, Carter B. The essence of enduring and expressions of suffering: the reformulation of self. Sch Inq Nurs Pract. 1996;10:43-60. 631. Morse JM, Carter BJ. Strategies of enduring and the suffering of loss: modes of comfort used by a resilient survivor. Holist Nurs Pract. 1995;9:38-52. 632. Morse JM, Doberneck B. Delineating the concept of hope. Image J Nurs Sch. 1995;27:277-285. 633. Morse JM, Havens GA, Wilson S. The comforting interaction: developing a model of nurse-patient relationship. Sch Inq Nurs Pract. 1997;11:321-343. 634. Morse JM, Penrod J. Linking concepts of enduring, uncertainty, suffering, and hope. Image J Nurs Sch. 1999;31:145-150. 635. Morse JM, Proctor A. Maintaining patient endurance. The comfort work of trauma nurses. Clin Nurs Res. 1998;7:250-274. 636. Morse JM, Solberg SM, Neander WL, Bottorff JL, Johnson JL. Concepts of caring and caring as a concept. ANS Adv Nurs Sci. 1990;13:1-14. 637. Morton J. Assertion training: one approach to interpersonal skill training in dentistry. J Dent Educ. 1983;47:102-104. 638. Mulhall A. Cultural discourse and the myth of stress in nursing and medicine. Int J Nurs Stud. 1996;33:455-468. 639. Murray BP. Professional role satisfactions of dentists: some cross-cultural comparisons. J Am Coll Dent. 1980;47:214-229. 640. Murtomaa H, Haavio-Mannila E, Kandolin I. Burnout and its causes in Finnish dentists. Community Dent Oral Epidemiol. 1990;18:208-212. 641. Nair K, Dolovich L, Cassels A, McCormack J, Levine M, Gray J, Mann K, Burns S. What patients want to know about their medications. Focus group study of patient and clinician perspectives. Can Fam Physician. 2002;48:104-110. 642. Nettleton S. Power and pain: The location of pain and fear in dentistry and the creation of a dental subject. Soc Sci Med. 1989;29:1183-1190. 643. Nettleton S. Power and pain: the location of pain and fear in dentistry and the creation of a dental subject. Soc Sci Med. 1989;29:1183-1190. 644. Neverlien PO. Normative data for Corah's Dental Anxiety Scale (DAS) for the Norwegian adult population. Community Dent Oral Epidemiol. 1990;18:162. 645. Nevo O, Shapira J. Use of humor in managing clinical anxiety. ASDC J Dent Child. 1986;53:97-100. 646. Ning L, Liddell A. The effect of concordance in the treatment of clients with dental anxiety. Behav Res Ther. 1991;29:315-322.

156.

647. Nordholm LA. Beautiful patients are good patients: evidence for the physical attractiveness stereotype in first impressions of patients. Soc Sci Med. 1980;14A:81-83. 648. Northouse PG. Effective helping relationships: the role of power and control. Health Educ Behav. 1997;24:703-706. 649. O'Shea RM, Corah NL, Ayer WA. Dentists' perceptions of the 'good' adult patient: An exploratory study. J Am Dent Assoc. 1983;106:813-816. 650. O'Shea RM, Corah NL, Ayer WA. Sources of dentists' stress. J Am Dent Assoc. 1984;109:48-51. 651. O'Shea RM, Corah NL, Ayer WA. Why patients change dentists: practitioners' views. J Am Dent Assoc. 1986;112:851-854. 652. O'Shea RM, Corah NL, Thines TJ. Dental patients' advice on how to reduce anxiety. General Dentistry. 1986;34:44-47. 653. Oestrich I. Træning i sociale færdigheder. København: Munksgaard; 1986. 654. Olofsson J. About the Nordeners: Subject 2.6 The essence of Nordishness, 2.6.1 What is Janteloven? The Jante Law. Web-reference, http://www.lysator.liu.se/nordic/scn/faq26.html 1998. 655. Olsen J, Trichopoulos D. Principles of Epidemiology. In: Olsen J, Trichopoulos D, eds. Teaching Epidemiology: What you should know and what you could do. Oxford: Oxford University Press; 1992. 656. Ong LM, de H, Hoos AM, Lammes FB. Doctor-patient communication: a review of the literature. Soc Sci Med. 1995;40:903-918. 657. Opton EM, Jr. Psychological stress and coping processes in the practice of dentistry. Int Dent J. 1969;19:415-429. 658. Orner G. The quality of life of the dentist. Int Dent J. 1978;28:320-326. 659. Orner G, Mumma RD. Mortality Study of Dentists: Final Report - Prepared for the U.S. Department of Health, Education, and Welfare. Washington, D.C.: U.S. Department of Health, Education, and Welfare; 1976. 660. Osborne D, Croucher R. Levels of burnout in general dental practitioners in the south-east of England. Br Dent J. 1994;177:372-377. 661. Öst LG. Fading - A new technique in the treatment of phobias. Behav Res Ther. 1978;16:213-216. 662. Öst LG. Ways of acquiring phobias and outcome of behavioral treatments. Behav Res Ther. 1985;23:683-689. 663. Öst LG. Age of onset in different phobias. J Abn Psychol. 1987;96:223-229. 664. Öst LG. One-session treatment for specific phobias. Behav Res Ther. 1989;27:1-7. 665. Öst LG. One-session group treatment of spider phobia. Behav Res Ther. 1996;34:707-715. 666. Öst LG, Alm T, Brandberg M, Breitholtz E. One vs five sessions of exposure and five sessions of cognitive therapy in the treatment of claustrophobia. Behav Res Ther. 2001;39:167-183. 667. Öst LG, Brandberg M, Alm T. One versus five sessions of exposure in the treatment of flying phobia. Behav Res Ther. 1997;35:987-996. 668. Öst LG, Ferebee I, Furmark T. One-session group therapy of spider phobia: direct versus indirect treatments. Behav Res Ther. 1997;35:721-732.

157.

669. Öst LG, Hellström K, Kåver A. One versus five sessions of exposure in the treatment of injection phobia. Behav Ther. 1992;23:263-282. 670. Öst LG, Hugdahl K. Acquisition of blood and dental phobia and anxiety response patterns in clinical patients. Behav Res Ther. 1985;23:27-34. 671. Otani A. Characteristics of change in Ericksonian hypnotherapy: a cognitive-psychological perspective. Am J Clin Hypn. 1990;33:29-39. 672. Owen D. The secret lives of dentists. Harper's Magazine. 1982;264:42-52. 673. Patel B, Potter C, Mellor AC. The use of hypnosis in dentistry: a review. Dent Update. 2000;27:198-202. 674. Patterson ML. Nonverbal Behavior - A Functional Perspective. New York: Springer-Verlag; 1983. 675. Pattison JE. Effects of touch on self-exploration and the therapeutic relationship. J Consult Clin Psychol. 1973;40:170-175. 676. Pawlicki RE. Psychological/behavioral techniques in managing pain and anxiety in the dental patient. Anesth Prog. 1991;38:120-127. 677. Pease A. Body Language. London: Sheldon Press; 1985. 678. Persson L-O. Mood as a function of expectation and experience of success and failure in a test situations. Göteborg Psychol Rep. 1988;18:1-37. 679. Petersen JK. [Pharmacological treatment of dental fear] Farmakologisk behandling af odontofobi. Tandlaegebladet. 1990;94:61-63. 680. Phillips D. Medical professional dominance and client dissatisfaction. A study of doctor-patient interaction and reported dissatisfaction with medical care among female patients at four hospitals in Trinidad and Tobago. Soc Sci Med. 1996;42:1419-1425. 681. Pickens JE. Office humor keeps patients coming back. Dent Econ. 1989;79:67-68. 682. Pines A, Maslach C. Characteristics of staff burnout in mental health settings. Hosp Community Psychiatry. 1978;29:233-237. 683. Piper SM, Brown PA. Psychology as a theoretical foundation for health education in nursing: empowerment or social control? Nurse Educ Today. 1998;18:637-641. 684. Plaja AO, Cohen LM, Samora J. Communication between physicians and patients in outpatient clinics: social and cultural factors. Milbank Mem Fund Q. 1968;46:161-214. 685. Polkinghorne D. Methodology for the Human Sciences. Albany: State University of New York Press; 1983. 686. Pollack S. Pain control by suggestion. J Oral Med. 1966;21:89-95. 687. Pollock K. On the nature of social stress: production of a modern mythology. Soc Sci Med. 1988;26:381-392. 688. Porritt L. Interaction Strategies: An Introduction for Health Professionals. 2 ed. London: Churchhill Livingstone; 1994. 689. Poulton R, Thomson WM, Brown RH, Silva PA. Dental fear with and without blood-injection fear: Implications for dental health and clinical practice. Behav Res Ther. 1998;36:591-597.

158.

690. Powers WJ, Brusch WA, Klugman PJ, Mize SA. Stress in dentistry: a survey of military dentists. Dent Surv. 1980;56:64-68. 691. Poynard T, Munteanu M, Ratziu V, Benhamou Y, Di M, Taieb J, Opolon P. Truth survival in clinical research: an evidence-based requiem? Ann Intern Med. 2002;136:888-895. 692. Pride J. Dealing with dentistry's image dilemma. J Am Dent Assoc. 1991;122:91-92. 693. Prochaska JO, Norcross JC, DiClemente CC. Changing for the GOOD - The revolutionary program that explains the six stages of change and teaches you how to free yourself from bad habits. New York: William Morrow & Co.; 1994. 694. Proctor A, Morse JM, Khonsari ES. Sounds of comfort in the trauma center: how nurses talk to patients in pain. Soc Sci Med. 1996;42:1669-1680. 695. Prosser D, Johnson S, Kuipers E, Szmukler G, Bebbington P, Thornicroft G. Perceived sources of work stress and satisfaction among hospital and community mental health staff, and their relation to mental health, burnout and job satisfaction. J Psychosom Res. 1997;43:51-59. 696. Rachman S. The treatment of anxiety disorders: A critique of the implications for psychopathology. In: Tuma AH, Maser J, eds. Anxiety and the anxiety disorders. Hillsdale, New Jersey: Lawence Erlbaum; 1985. 697. Rachman S, Arntz A. The overprediction and underprediction of pain. Clin Psychol Rev. 1991;11:339-355. 698. Rankin JA, Harris MB. Dental anxiety: the patient's point of view. J Am Dent Assoc. 1984;109:4347. 699. Rankin JA, Harris MB. Patients' preferences for dentists' behaviors. J Am Dent Assoc. 1985;110:323-327. 700. Rankin JA, Harris MB. Male and female dentists talk about stress and coping. Dent Econ. 1989;79:59-64. 701. Rankin JA, Harris MB. Comparison of stress and coping in male and female dentists. J Dent Pract Adm. 1990;7:166-172. 702. Rankin JA, Harris MB. Stress and health problems in dentists. J Dent Pract Adm. 1990;7:2-8. 703. Rapee RM, Heimberg RG. A cognitive-behavioral model of anxiety in social phobia. Behav Res Ther. 1997;35:741-756. 704. Raspe H, Stange EF. [Evidence-based medicine: context and relevance]. Z Gastroenterol. 1999;37:525-533. 705. Redford M, Gift HC. Dentist-patient interactions in treatment decision-making: a qualitative study. J Dent Educ. 1997;61:16-21. 706. Reifel NM, Rana H, Marcus M. Consumer satisfaction. Adv Dent Res. 1997;11:281-290. 707. Reiss S. Pavlovian conditioning and human fear: An expectancy model. Behav Ther. 1980;11:380-96. 708. Reiss S. Expectancy theory of fear, anxiety, and panic. Clin Psychol Rev. 1991;11:141-153. 709. Reiss S. Trait anxiety: It's not what you think it is. J Anxiety Disord. 1997;11:201-214. 710. Reiss S, McNally RJ. The Expectancy Model of Fear. In: Reiss S, Bootzin R, eds. Theoretical Issues in Behavior Therapy. New York: Academic Press; 1985:107-121.

159.

711. Reiss S, Peterson RA, Gursky DM. Anxiety sensitivity, injury sensitivity, and individual differences in fearfulness. Behav Res Ther. 1988;26:341-345. 712. Reiss S, Peterson RA, Gursky DM, McNally RJ. Anxiety sensitivity, anxiety frequency and prediction of fearfulness. Behav Res Ther. 1986;24:1-8. 713. Remland MS, Jones TS, Brinkman H. Interpersonal distance, body orientation, and touch: effects of culture, gender, and age. J Soc Psychol. 1995;135:281-297. 714. Render J. Providers' reaction to dental patients' pain. Mil Med. 1985;150:160-164. 715. Rice CD, Hayden WJ, Glaros AG, Thein DJ. Career changers: dentists who choose to leave private practice. J Am Coll Dent. 1997;64:20-26. 716. Richardson ME. As others see us. Br Dent J. 2000;189:290-294. 717. Ring ME. Oddments in dental history: stress, to the dentist, from practicing dentistry is nothing new! Bull Hist Dent. 1979;27:104-106. 718. Ring ME. Dentistry - An Illustrated History. New York: Abrams; 1985. 719. Robb SL. Music assisted progressive muscle relaxation, progressive muscle relaxation, music listening, and silence: a comparison of relaxation techniques. J Music Ther. 2000;37:2-21. 720. Robin O, Alaoui I, Dittmar A, Vernet M. Basic emotions evoked by eugenol odor differ according to the dental experience. A neurovegetative analysis. Chem Senses. 1999;24:327-335. 721. Roda RS, Blanton PL. The anatomy of local anesthesia. Quintessence Int. 1994;25:27-38. 722. Rodolfa ER, Kraft W, Reilley RR. Etiology and treatment of dental anxiety and phobia. Am J Clin Hypn. 1990;33:22-28. 723. Roger J, Darfour D, Dham A, Hickman O, Shaubach L, Shepard K. Physiotherapists' use of touch in inpatient settings. Physiother Res Int. 2002;7:170-186. 724. Rogers CR. Client-Centered Therapy: Its Current Practice, Implications and Theory. Cambridge, MA: Riverside; 1951. 725. Rogers CR. On Becoming a Person - A Therapist's View of Psychotherapy. 4 ed. London: Constable; 1972. 726. Romberg E, Cohen L. Dentists' outlook toward their profession. J Dent Pract Adm. 1990;7:39-43. 727. Romney AK, Weller SC, Batchelder WH. Culture as consensus: a theory of cultural and informant accuracy. Am Anthropologist. 1986;88:313-338. 728. Rood JP. The analgesia and innervation of mandibular teeth. Br Dent J. 1976;140:237-239. 729. Rood JP. Some anatomical and physiological causes of failure to achieve mandibular analgesi. British Journal of Oral Surgery. 1977;15:75-82. 730. Roper-Hall HT. Sedatives in dentistry. Br Dent J. 1935;59:177-186. 731. Rosenberg L. A qualitative investigation of the use of humor by emergency personnel as a strategy for coping with stress. J Emerg Nurs. 1991;17:197-202. 732. Rosenhan DL. On being sane in insane places. Science. 1973;179:250-258. 733. Rosenstiel AK, Keefe FJ. The use of coping strategies in chronic low back pain patients: relationship to patient characteristics and current adjustment. Pain. 1983;17:33-44.

160.

734. Rosenstock IM, Strecher VJ, Becker MH. Social learning theory and the Health Belief Model. Health Educ Q. 1988;15:175-183. 735. Rosted P, Bundgaard M. [How is odontophobia treated in dental practice, and with which results?] Hvorledes behandler vi odontofobi i tandlægepraksis, og hvilke resultater opnår vi? Tandlægebladet. 2004;108:816-820. 736. Roter DL, Hall JA. Physician's interviewing styles and medical information obtained from patients. J Gen Intern Med. 1987;2:325-329. 737. Roter DL, Hall JA. Health education theory: an application to the process of patient-provider communication. Health Educ Res. 1991;6:185-193. 738. Roter DL, Hall JA. Doctors Talking with Patients / Patients Talking with Doctors - Improving Communication in Medical Visits. Westport, CT: Auburn House; 1993. 739. Roter DL, Hall JA, Katz NR. Relations between physicians' behaviors and analogue patients' satisfaction, recall, and impressions. Med Care. 1987;25:437-451. 740. Roth DA, Heimberg RG. Cognitive-behavioral models of social anxiety disorder. Psychiatr Clin North Am. 2001;24:753-771. 741. Rotter JB. Social learning and clinical psychology. New York: Prentice-Hall; 1954. 742. Rotter JB. The development and applications of social learning theory: selected papers. New York: Praeger; 1982. 743. Rouse RA. A paradigm of intervention: Emotional communication in dentistry. Health Commun. 1989;1:239-252. 744. Rouse RA, Hamilton MA. Dentists evaluate their patients: an empirical investigation of preferences. J Behav Med. 1991;14:637-648. 745. Rouse RA, Hamilton MA. Dentists' technical competance, communication, and personality as predictors of dental patient anxiety. J Behav Med. 1994;13:307-19. 746. Routasalo P. Physical touch in nursing studies: a literature review. J Adv Nurs. 1999;30:843-850. 747. Roy-Byrne PP, Milgrom P, Tay K-M, Weinstein P, Katon W. Psychopathology and psychiatric diagnosis in subjects with dental phobia. J Anxiety Disord. 1994;8:19-31. 748. Russek HI. Emotional stress and coronary heart disease in American physicians, dentists and lawyers. Am J Med Sci. 1962;242:716-726. 749. Rutter H, Herzberg J, Paice E. Stress in doctors and dentists who teach. Med Educ. 2002;36:543-49. 750. Sadock BJ. Group psychotherapy, combined individual and group psychotherapy, and psychodrama. In: Kaplan H, Sadock B, eds. Comprehensive Textbook of Psychiatry. Baltimore: Williams & Wilkins; 1989:1517-1535. 751. Scarrott DM. Attitudes to dentists. Br Dent J. 1969;127:583-590. 752. Scheff TJ. Towards a sociological model of consensus. Am Sociol Rev. 1967;32:32-46. 753. Scheff TJ. The labelling theory of mental illness. Am Sociol Rev. 1974;39:444-452. 754. Scheufele PM. Effects of progressive relaxation and classical music on measurements of attention, relaxation, and stress responses. J Behav Med. 2000;23:207-228.

161.

755. Scheutz F, Heidmann J. Determinants of utilization of dental services among 20- to 34- year-old Danes. Acta Odontol Scand. 2001;59:201-211. 756. Schifter CC, Bogert M, Boston D. Acquisition of a touching style. J Dent Educ. 1999;63:400-406. 757. Schmidt SR. Effects of humor on sentence memory. J Exp Psychol Learn Mem Cogn. 1994;20:953-967. 758. Schouten BC, Eijkman MA, Hoogstraten J. Dentists' and patients' communicative behaviour and their satisfaction with the dental encounter. Community Dent Health. 2003;20:11-15. 759. Schuller AA, Willumsen T, Holst D. Are there differences in oral health and oral health behavior between individuals with high and low dental fear? Community Dent Oral Epidemiol. 2003;31:116-121. 760. Schuman NJ, Owens BM, Johnson WW, Moore DS. Dentistry as portrayed in motion pictures and television. Compendium. 1993;14:102, 104-102, 106. 761. Schutt NL, Bernstein DA. Relaxation skills for the patient, dentist, and auxiliaries. Dent Clin North Am. 1986;30:S93-105. 762. Schuurs AH, Duivenvoorden HJ, Thoden vVSK, Verhage F, Eijkman MA, Makkes PC. Sociodemographic correlates of dental anxiety. Community Dent Oral Epidemiol. 1985;13:212-15. 763. Schuurs AHB, Duivenvorden HJ, Makkes PC, van Velzen SK, Verhage F. Personality traits of patients suffering extreme dental anxiety. Community Dent Oral Epidemiol. 1988;16:38-41. 764. Schuurs AHB, Duivenvorden HJ, van Velzen SK, Verhage F. Dental anxiety, the parental family and regularity of dental attendance. Community Dent Oral Epidemiol. 1984;12:89-95. 765. Schwartz RH, Shenoy S. Personality factors related to career satisfaction among general practitioners. J Dent Educ. 1994;58:225-228. 766. Schwarz E, Pedersen KM. [The Danish adult populations dental behavior] Den voksne danske befolknings tandplejeadfærd. Tandlægebladet. 1983;82:49-58. 767. Scott RA, Aiken LH, Mechanic D, Moravcsik J. Organizational aspects of caring. Milbank Q. 1995;73:77-95. 768. Sebor RJ. Stress: inherent to dentists or taught to dental students? Dent Stud. 1984;63:14-20. 769. Seeman K, Molin C. Psychopathology, feelings of confinement and helplessness in the dental chair, and relationship to the dentist in patients with disproportionate dental anxiety (DDA). Acta Psychiatr Scand. 1976;54:81-91. 770. Segal H, Warner R. Origins of paternalism. Med Law. 1985;4:269-273. 771. Seidberg BH, Sullivan TH. Dentists' use, misuse, abuse or dependence on mood-altering substances. N Y State Dent J. 2004;70:30-33. 772. Seligman M. On the generality of the laws of learning. Psychol Rev. 1970;77:406-418. 773. Selye H. The stress of life. New York: McGraw-Hill; 1956. 774. Selye H. Stress and dentistry. Annu Meet Am Inst Oral Biol. 1968;25:131-140. 775. Selye H. Adaptive steroids: retrospect and prospect. Perspect Biol Med. 1970;13:343-363. 776. Selye H. The evolution of the stress concept. Stress and cardiovascular disease. Am J Cardiol. 1970;26:289-299.

162.

777. Selye H. Hormones and resistance. J Pharm Sci. 1971;60:1-28. 778. Selye H. Confusion and controversy in the stress field. J Human Stress. 1975;1:37-44. 779. Selye H. Stress and distress. Compr Ther. 1975;1:9-13. 780. Selye H. A code for coping with stress. AORN J. 1977;25:35-42. 781-782. Selye H, Cherry L. On the real benefits of eustress. Psychol Today. 1978;11:60-72. 783. Seyrek SK, Corah NL, Pace LF. Comparison of three distraction techniques in reducing stress in dental patients. J Am Dent Assoc. 1984;108:327-329. 784. Shapiro AP, Morris LA. The placebo effect in medical and psychological therapies. In: Garfield SL, Bergin AE, eds. Handbook of Psychotherapy and Behavior Change: An Empirical Analysis. New York: John Wiley & Sons; 1978:269-410. 785. Shaw DW, Thoreson CE. Effects of modeling and desensitization in reducing dentist phobia. J Coun Psychol. 1974;21:415-420. 786. Shaw O. Dental anxiety in children. Br Dent J. 1975;139:134-139. 787. Sheehan DV, Sheehan KH. The classification of phobic disorders. Int J Psychiatr Med. 1983;12:243-266. 788. Sherlock BJ, Morris RT. Becoming a dentist. Springfield, IL: Charles C. Thomas; 1972. 789. Sherman KM. Healing with humor. Semin Perioper Nurs. 1998;7:128-137. 790. Shoben EJ, Borland L. An empirical study of the etiology of dental fears. J Clin Psychol. 1954;10:171-174. 791. Shugars DA, DiMatteo MR, Hays RD, Cretin S, Johnson JD. Professional satisfaction among California general dentists. J Dent Educ. 1990;54:661-669. 792. Siegrist J. Adverse health effects of high-effort/low-reward conditions. J Occup Health Psychol. 1996;1:27-41. 793. Siegrist J, Klein D, Voigt KH. Linking sociological with physiological data: The model of effortreward imbalance at work. Acta Physiol Scand Suppl. 1997;640:112-116. 794. SIFO. Tandläkarebesök intervjuundersökning för tandvärnet. Stockholm: Swedish Institute for Opinion Research; 1962. 795. SIFO. [Dental attendance interview investigation for dentistry] Tandläkarebesök intervjuundersökning för tandvärnet. Stockholm: Swedish Institute for Opinion Research; 1962. 796. Silberman SL. Standardization of value profiles of dental students and dental faculty. J Dent Res. 1976;55:939-950. 797. Simon JF, Peltier B, Chambers D, Dower J. Dentists troubled by the administration of anesthetic injections: Long-term stresses and effects. Quintessence Int. 1994;25:641-646. 798. Skaret E, Raadal M, Berg E, Kvale G. Dental anxiety among 18-yr-olds in Norway. Prevalence and related factors. Eur J Oral Sci. 1998;106:835-843. 799. Skaret E, Raadal M, Kvale G, Berg E. Gender-based differences in factors related to non-utilization of dental care in young Norwegians. A longitudinal study. Eur J Oral Sci. 2003;111:377-382.

163.

800. Skelton AM. Patient education for the millennium: beyond control and emancipation? Patient Educ Couns. 1997;31:151-158. 801. Skelton R. Nursing and empowerment: concepts and strategies. J Adv Nurs. 1994;19:415-423. 802. Skipper J. Communication and the hospitalized patient. In: Skipper J, Leonard R, eds. Social Interaction and Patient Care. London: Pitman Medical; 1965:61-82. 803. Skogedal O, Heloe LA. Public opinions on dentists in Norway. Community Dent Oral Epidemiol. 1979;7:65-68. 804. Smith C. Molding our image: the media and dentistry. CDS Rev. 1994;87:12-19. 805. Smith TA, Heaton LJ. Fear of dental care: are we making any progress? J Am Dent Assoc. 2003;134:1101-1108. 806. Smudski JW. Perspectives on dental education. Anesth Prog. 1986;60-61. 807. Snyder M, Tanke ED, Berscheid E. Social perception and interpersonal behavior: on the selffulfilling nature of social stereotypes. J Pers Soc Psychol. 1977;35(9):656-66. 808. Sohn W, Ismail AI. Regular dental visits and dental anxiety in an adult dentate population. J Am Dent Assoc. 2005;136:58-66. 809. Sondell K, Soderfeldt B. Dentist-patient communication: a review of relevant models. Acta Odontol Scand. 1997;55:116-126. 810. Spector PE, Sistrunk F. Does the presence of others reduce anxiety? J Soc Psychol. 1978;105:301-02. 811. Spector PE, Sistrunk F. Reassurance: a mechanism by which the presence of others reduces anxiety. J Soc Psychol. 1979;47:119-126. 812. Spiegel D, Albert LH. Naloxone fails to reverse hypnotic alleviation of chronic pain. Psychopharmacology (Berl). 1983;81:140-143. 813. Spiegel H. Hypnosis: Myth and reality. Psychiatr Ann. 1981;11:336-342. 814. Spiegel H. Nocebo: The power of suggestibility. Prev Med. 1997;26:616-621. 815. Spielberger CD, Gorsuch RL, Lushene RE. STAI manual for the state-trait anxiety inventory. Palo Alta, CA: Consulting Psychologists Press; 1970. 816. Spielberger CD, Vagg PR, Barker LR, Donham GW, Westberry LG. The factor structure of the State-Trait Anxiety Imventory. In: Spielberger CD, Sarason I, eds. Stress and Anxiety. 7 ed. Washington DC: Hemisphere Publishing; 1980:95-109. 817. Spitzer RL, Williams JB, Gibbon M, First MB. The Structured Clinical Interview for DSM-III-R (SCID). I: History, rationale, and description. Arch Gen Psychiatry. 1992;49:624-629. 818. Spradley JP. The Ethnographic Interview. New York: Holt, Rinehart and Winston; 1979. 819. Spradley JP. Participant observation. New York: Holt, Rinehart and Winston; 1980. 820. Staats P, Hekmat H, Staats A. Suggestion/placebo effects on pain: Negative as well as positive. J Pain Symptom Manage. 1998;15:235-243. 821. Stack S. Suicide risk among dentists: a multivariate analysis. Deviant Behav. 1996;17:107-118. 822. Steiber S, Thome D. Brand, image, reputation. Healthc Strateg. 1998;2:8-10.

164.

823. Stewart M, Brown JB, Weston WW, McWhinney IR, McWilliam CL, Freeman TR. PatientCentered Medicine: Transforming the Clinical Method. Thousand Oaks, CA: Sage; 1995. 824. Stoeckle JD. Adult patient-dentist relationship. Dent Clin North Am. 1988;32:763-769. 825. Stouthard ME, Hoogstraten J. Prevalence of dental anxiety in the Netherlands. Community Dent Oral Epidemiol. 1990;18:139-142. 826. Stouthard MEA, Hoogstraten J. Ratings of fears associated with twelve dental situations. J Dent Res. 1987;66:1175-1178. 827. Stouthard MEA, Hoogstraten J. Dental anxiety: a comparison of dentate and edentulous subjects. Community Dent Oral Epidemiol. 1990;18:267-268. 828. Straus SE, McAlister FA. Evidence-based medicine: a commentary on common criticisms. CMAJ. 2000;163:837-841. 829. Strauss A, Corbin J. Basics of qualitative research. Grounded theory procedures and techniques. 1990. 830. Strawn CE. Time management practices for the dentist. Dent Clin North Am. 1986;30:S107-S116. 831. Street RL, Jr. Patients' satisfaction with dentists' communicative style. Health Commun. 1989;1:137-154. 832. Street RL, Jr. Information-giving in medical consultations: the influence of patients' communicative styles and personal characteristics. Soc Sci Med. 1991;32:541-548. 833. Street RL. Communicative styles and adaptations in physician-parent consultations. Soc Sci Med. 1992;34:1155-1163. 834. Street RL, Jr., Millay B. Analyzing patient participation in medical encounters. Health Commun. 2001;13:61-73. 835. Sullivan MJ, Adams H, Sullivan ME. Communicative dimensions of pain catastrophizing: Social cueing effects on pain behaviour and coping. Pain. 2004;107:220-226. 836. Sullivan MJ, Neish N. The effects of disclosure on pain during dental hygiene treatment: the moderating role of catastrophizing. Pain. 1999;79:155-163. 837. Sullivan MJ, Neish N. Catastrophic thinking and the experience of pain during dental procedures. J Indiana Dent Assoc. 2000;79:16-19. 838. Sullivan MJ, Neish NR. Psychological predictors of pain during dental hygiene treatment. Probe. 1997;31:123-126, 135. 839. Sullivan MJ, Neish NR. Catastrophizing, anxiety and pain during dental hygiene treatment. Community Dent Oral Epidemiol. 1998;26:344-349. 840. Sullivan MJ, Neish NR. A psychological intervention for reducing pain during dental hygiene treatment. Probe. 1999;33:23-30. 841. Sullivan MJ, Thorn B, Haythornthwaite JA, Keefe F, Martin M, Bradley LA, Lefebvre JC. Theoretical perspectives on the relation between catastrophizing and pain. Clin J Pain. 2001;17:52-64. 842. Sullivan MJ, Thorn B, Rodgers W, Ward LC. Path model of psychological antecedents to pain experience: experimental and clinical findings. Clin J Pain. 2004;20:164-173. 843. Sundberg H. [Report of the task force to determine which dental care will be deemed "special illness" treatment] Rapport från arbetsgrupp med uppgift att beskriva vilken tandvård som skall

165.

anses vara et led i en sjukdomsbehandling. 02-5061/98 ed. Stockholm: Hälso- och Sjukvårdsavdelningen, Almänna enheten, Medicinalrådet; 1998:1-10. 844. Svensson P, Minoshima S, Beydoun A, Morrow TJ, Casey KL. Cerebral processing of acute skin and muscle pain in humans. J Neurophysiol. 1997;78:450-460. 845. Sygesikringens Forhandlingsudvalg, Dansk Tandlægeforening. [Agreement on Fees for National Dental Services] Tandlægeoverenskomst - Landsoverenskomst om tandlægehjælp mellem Sygesikringens Forhandlingsudvalg (SFU), og Dansk Tandlægeforening. 55.30.1 ed. Copenhagen: Ministry of the Interior; 2004:1-69. 846. Szasz TS, Hollender MHA. A contribution to the philosophy of medicine: The basic models of the doctor-patient relationship. Arch Intern Med. 1956;97:585-592. 847. Taylor B, Lo R. The effects of Healing Touch on the coping ability, self esteem and general health of undergraduate nursing students. Complement Ther Nurs Midwifery. 2001;7:34-42. 848. Taylor S. Anxiety sensitivity: Theoretical perspectives and recent findings. Behav Res Ther. 1995;33:243-258. 849. Taylor S, Cox BJ. Anxiety sensitivity: Multiple dimensions and hierarchic structure. Behav Res Ther. 1998;36:37-51. 850. Taylor SE. Health Psychology. 3 ed. New York: McGraw-Hill Inc.; 1995. 851. Terenius L. Endogenous pain control. In: Andersson S, Arnér S, eds. Acute pain. Lund, Sweden: Benzon Pharma AB; 1991:25-33. 852. Terenius L. From opiate pharmacology to opioid peptide physiology. Ups J Med Sci. 2000;105:1-15. 853. Terman GW, Liebeskind JC. Relation of stress-induced analgesia to stimulation-produced analgesia. Ann N Y Acad Sci. 1986;467:300-308. 854. Terman GW, Shavit Y, Lewis JW, Cannon JT, Liebeskind JC. Intrinsic mechanisms of pain inhibition: activation by stress. Science. 1984;226:1270-1277. 855. Tetrick LE, LaRocco JM. Understanding, prediction, and control as moderators of the relationships between perceived stress, satisfaction, and psychological well-being. J Appl Psychol. 1987;72:538-543. 856. Teuscher GW. Elements of a trusting relationship. ASDC J Dent Child. 1998;65:232. 857. Theorell T, Karasek RA. Current issues relating to psychosocial job strain and cardiovascular disease research. J Occup Health Psychol. 1996;1:9-26. 858. Thierer TE, Handelman SL, Black PM. Effects of perceived patient attributes on dentist communication behavior. Spec Care Dentist. 2001;21:21-26. 859. Thom A, Sartory G, Johren P. Comparison between one-session psychological treatment and benzodiazepine in dental phobia. J Consult Clin Psychol. 2000;68:378-387. 860. Thrash WJ, Marr JN, Boone SE. Continuous self-monitoring of discomfort in the dental chair and feedback to the dentist. J Behav Assess. 1982;4:273-284. 861. Thrash WJ, Marr JN, Box TG. Effects of continuous patient information in the dental environment. J Dent Res. 1982;61:1063-1065. 862. Timmerman GM. A concept analysis of intimacy. Issues Ment Health Nurs. 1991;12:19-30.

166.

863. Tones K, Tilford S. Health Education. Effectiveness, efficiency and equity. 2 ed. London: Chapman & Hall; 1994. 864. Train GJ. The dentist's emotional reaction to the troublesome patient. Psychosomatics. 1969;10:176-180. 865. Treede RD, Kenshalo DR, Gracely RH, Jones AK. The cortical representation of pain. Pain. 1999;79:105-111. 866. Turley M, Kinirons M, Freeman R. Occupational stress factors in hospital dentists. Br Dent J. 1993;175:285-288. 867. Turner JA, Deyo RA, Loeser JD, Von Korff M, Fordyce WE. The importance of placebo effects in pain treatment and research . JAMA. 1994;271:1609-1614. 868. Turner SM, Beidel DC, Larkin KT. Situational determinants of social anxiety in clinic and nonclinic samples: physiological and cognitive correlates. J Consult Clin Psychol. 1986;54:523-527. 869. Turner SM, Beidel DC, Townsley RM. Social phobia: a comparison of specific and generalized subtypes and avoidant personality disorder. J Abnorm Psychol. 1992;101:326-331. 870. Twenge JM. The age of anxiety? Birth cohort change in anxiety and neuroticism, 1952-1993. J Pers Soc Psychol. 2000;79:1007-1021. 871. United Nations General Assembly. U.N. Convention against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment, 1984. (General Assembly Resolution 39/46, 10 December, 1984) ed. New York: United Nations; 1987. 872. Vaillant GE. Adaptation to life. Boston: Little; 1977. 873. Van Groenestijn, Maas-de Waal CJ, Mileman PA, Swallow JN. The ideal dentist. Soc Sci Med. 1980;14A:533-540. 874. Van Groenestijn MAJ, Maas-de Waal CJ, Mileman PA, Swallow JN. The image of the dentist. Soc Sci Med. 1980;14A:541-546. 875. Vassend O. Anxiety, pain and discomfort associated with dental treatment. Behav Res Ther. 1993;31:659-666. 876. Venham LL. The effect of mother's presence of child's response to dental treatment. ASDC J Dent Child. 1979;46:219-225. 877. Venham LL, Bengston D, Cipes M. Parent's presence and the child's response to dental stress. ASDC J Dent Child. 1978;45:213-217. 878. Venham LL, Goldstein M, Gaulin-Kremer E, Peteros K, Cohan J, Fairbanks J. Effectiveness of a distraction technique in managing young dental patients. Pediatr Dent. 1981;3:7-11. 879. Ventis WL. A case history: The use of laughter as an alternative response in systematic desensitization. Behav Ther. 1973;4:120-122. 880. Ventis WL, Higbee G, Murdock SA. Using humor in systematic desensitization to reduce fear. J Gen Psychol. 2001;128:241-253. 881. Vinton JC. A four-year longitudinal study of the impact on learning structure on dental student lifestyle values. J Dent Educ. 1978;42:251-256. 882. Virshup BB, Oppenberg AA, Coleman MM. Strategic risk management: reducing malpractice claims through more effective patient-doctor communication. Am J Med Qual. 1999;14:153-159.

167.

883. von Quast C. [Stress in Dentists - Results from a Psychological Survery] Streß bei Zahnärzten Ergebnisse aus einer testpsychologischen Felduntersuchung. Köln: Deutscher Ärzte-Verlag; 1996. 884. Vortherms RC. Clinically improving communication through touch. J Gerontol Nurs. 1991;17:6-10. 885. Wallerstein N. Powerlessness, empowerment, and health: implications for health promotion programs. Am J Health Promot. 1992;6:197-205. 886. Wallerstein N. Empowerment to reduce health disparities. Scand J Public Health. 2002;Suppl 59:72-77. 887. Wallerstein N, Bernstein E. Empowerment education: Freire's ideas adapted to health education. Health Educ Q. 1988;15:379-394. 888. Walton RE, Abbott BJ. Periodontal ligament injection: a clinical evaluation. J Am Dent Assoc. 1981;103:571-575. 889. Wardle J. Dental pessimism: Negative cognitions in fearful dental patients. Behav Res Ther. 1984;22:553-556. 890. Weiner AA, Weinstein P. Dentists' knowledge, attitudes, and assessment practices in relation to fearful dental patients: a pilot study. Gen Dent. 1995;43:164-168. 891. Weinshenker NJ, Goldenberg I, Rogers MP, Goisman RM, Warshaw MG, Fierman EJ, Vasile RG, Keller MB. Profile of a large sample of patients with social phobia: comparison between generalized and specific social phobia. Depress Anxiety. 1997;4:209-216. 892. Weinstein P, Milgrom P, Kaufman E, Fiset L, Ramsay D. Patient perceptions of failure to achieve optimal local anesthesia. Gen Dent. 1985;33:218-220. 893. Weinstein P, Milgrom P, Ratener P, Morrison K. Patient dental values and their relationship to oral health status, dentist perceptions and quality of care. Community Dent Oral Epidemiol. 1979;7:121-127. 894. Weinstein P, Milgrom P, Ratener P, Read W, Morrison K. Dentists' perceptions of their patients in relation to quality of care. J Public Health Dent. 1978;38:10-21. 895. Weisenberg M, Kreindler M, Schachat R. Relationship of the Dental Anxiety Scale to the StateTrait Anxiety Inventory. J Dent Res. 1974;53:946. 896. Weisenberg M, Kreindler M, Schachat R, Werboff J. Pain, anxiety and attitudes in black, white and Puerto Rican patients. Psychosom Med. 1975;37:123-135. 897. Weisenberg M, Tepper I, Schwarzwald J. Humor as a cognitive technique for increasing pain tolerance. Pain. 1995;63:207-212. 898. Weller SC. Shared knowledge, intracultural variation, and knowledge aggregation. Am Behav Sci. 1987;31:178-193. 899. Weller SC, Romney AK. Systematic data collection. Newbury Park, CA: Sage; 1988. 900. Wendt E, Fridlund B, Lidell E. Trust and confirmation in a gynecologic examination situation: a critical incident technique analysis. Acta Obstet Gynecol Scand. 2004;83:1208-1215. 901. White JJ, Reader A, Beck M, Meyers WJ. The periodontal ligament injection: a comparison of the efficacy in human maxillary and mandibular teeth. J Endodontics. 1988;14:508-514. 902. Wieselquist J, Rusbult CE, Foster CA, Agnew CR. Commitment, pro-relationship behavior, and trust in close relationships. J Pers Soc Psychol. 1999;77:942-966.

168.

903. Wilkins W. Desensitization: social and cognitive factors underlying the effectiveness of Wolpe's procedure. Psychol Bull. 1971;76:311-317. 904. Wilkins W. Client's expectancy of therapeutic gain: Evidence for the active role of the therapist. Psychiatry. 1973;36:184-190. 905. Wilkins W. Expectancy of therapeutic gain: An empirical and conceptual critique. J Cons Clin Psychol. 1973;40:69-77. 906. Wilkinson DS, Knox PL, Chatman JE, Johnson TL, Barbour N, Myles Y, Reel A. The clinical effectiveness of healing touch. J Altern Complement Med. 2002;8:33-47. 907. Willis FN, Rawdon VA. Gender and national differences in attitudes toward same-gender touch. Percept Mot Skills. 1994;78:1027-1034. 908. Wills TA. Perceptions of clients by professional helpers. Psychol Bull. 1978;85:968-1000. 909. Willumsen T. Treatment of Dental Phobia: Short-time and Long-time Effects of Nitrous Oxide Sedation, Cognitive Therapy and Applied Relaxation (Thesis). Oslo: University of Oslo; 1999. 910. Willumsen T, Vassend O. Effects of cognitive therapy, applied relaxation and nitrous oxide sedation. A five-year follow-up study of patients treated for dental fear. Acta Odontol Scand. 2003;61:93-99. 911. Willumsen T, Vassend O, Hoffart A. One-year follow-up of patients treated for dental fear: Effects of cognitive therapy, applied relaxation, and nitrous oxide sedation. Acta Odontol Scand. 2001;59:335-340. 912. Wilson B. Stress in dentistry: national survey. Dent Manage. 1984;24:14-19. 913. Wilson RF, Coward PY, Capewell J, Laidler TL, Rigby AC, Shaw TJ. Perceived sources of occupational stress in general dental practitioners. Br Dent J. 1998;184:499-502. 914. Wingrove F, Porter P, Bisby G, May C. Perceptions on occupational satisfaction among Iowa dentists. Iowa Dent J. 1994;80:23-24. 915. Winwood PC, Winefield AH, Lushington K. The role of occupational stress in the maladaptive use of alcohol by dentists: a study of South Australian general dental practitioners. Aust Dent J. 2003;48:102-109. 916. Wirth DP. The significance of belief and expectancy within the spiritual healing encounter. Soc Sci Med. 1995;41:249-260. 917. Wolf S, Wolf C, Spielberg G. The Wolf Counseling Skills Evaluation Handbook. Omaha, NE: National Publication; 1980. 918. Wolpe J. Reciprocal inhibition as the main basis of psychotherapeutic effects. AMA Arch Neurol Psychiatry. 1954;72:205-226. 919. Wolpe J. Psychotherapy by reciprocal inhibition. Stanford: Stanford University Press; 1958. 920. Wolpe J. The dichotomy between classical conditioned and cognitively learned anxiety. J Behav Ther Exp Psychiatr. 1981;12:35-42. 921. Wong MKS, Jacobsen PL. Reasons for local anesthesia failures. Journal American Dental Association. 1992;12:69-73. 922. Woods DL, Dimond M. The effect of therapeutic touch on agitated behavior and cortisol in persons with Alzheimer's disease. Biol Res Nurs. 2002;4:104-114.

169.

923. World Health Organization. International Classification of Diseases - ICD-10. Geneva: WHO;1994. 924. Worthen R, Connell WE. Social interest and humor. Int J Soc Psychiatry. 1969;15:179-188. 925. Wroblewski PF, Jacob T, Rehm LP. The contribution of relaxation to symbolic modeling in the modification of dental fears. Behav Res Ther. 1977;15:113-115. 926. Yablon P, Rosner JF. The career satisfaction of dentists. In relation to their age and income. J Am Coll Dent. 1982;49:45-52. 927. Yamamoto S. A new trend in the study of low back pain in workplaces. Ind Health. 1997;35:173-185. 928. Zach GA. Hypnosis, Part II: theories and structure. Compend Contin Educ Dent. 1990;11:360-366. 929. Zachariae B. [The Thinking Body - Essays on Biology, Psychology and Health] Den tænkende krop: essays om biologi, psykologi og sundhed. 1ed. Copenhagen: Munksgaard-Rosinante; 2000. 930. Zachariae R. Mind and immunity: Psychological modulation of immunological and inflammatory parameters. Copenhagen: Munksgaard-Rosinante; 1996. 931. Zachariae R, Bjerring P, Arendt Nielsen L, Nielsen T, Gotliebsen K. The effect of hypnotically induced emotional states on brain potentials evoked by painful argon laser stimulation. Clin J Pain. 1991;7:130-138. 932. Zachariae R, Hansen JB, Andersen M, Jinquan T, Petersen KS, Simonsen C, Zachariae C, Thestrup Pedersen K. Changes in cellular immune function after immune specific guided imagery and relaxation in high and low hypnotizable healthy subjects. Psychother Psychosom. 1994;61:74-92. 933. Zachariae R, Jorgensen MM, Christensen S. Hypnotizability and absorption in a Danish sample: testing the influence of context. Int J Clin Exp Hypn. 2000;48:306-314. 934. Zachariae R, Kristensen JS, Hokland P, Ellegaard J, Metze E, Hokland M. Effect of psychological intervention in the form of relaxation and guided imagery on cellular immune function in normal healthy subjects. An overview. Psychother Psychosom. 1990;54:32-39. 935. Zachariae R, Pedersen CG, Jensen AB, Ehrnrooth E, Rossen PB, von der MH. Association of perceived physician communication style with patient satisfaction, distress, cancer-related selfefficacy, and perceived control over the disease. Br J Cancer. 2003;88:658-665. 936. Zachariae R, Sommerlund B, Molay F. Danish norms for the Harvard group scale of hypnotic susceptibility, form A. Int J Clin Exp Hypn. 1996;44:140-152. 937. Zborowski M. People in Pain. San Francisco: Jossey-Bass; 1969. 938. Zerbe KJ. Uncharted waters: psychodynamic considerations in the diagnosis and treatment of social phobia. Bull Menninger Clin. 1994;58:A3-20. 939. Zimmerman RS. The dental appointment and patient behavior. Differences in patient and practitioner preferences, patient satisfaction, and adherence. Med Care. 1988;26:403-414. 940. Zola IK. Culture and symptoms: An analysis of patients presenting complaints. Am Sociol Rev. 1966;31:615-630. 941. Zubieta JK, Smith YR, Bueller JA, Xu Y, Kilbourn MR, Jewett DM, Meyer CR, Koeppe RA, Stohler CS. Regional mu opioid receptor regulation of sensory and affective dimensions of pain. Science. 2001;293:311-315. 942. Zubieta JK, Smith YR, Bueller JA, Xu Y, Kilbourn MR, Jewett DM, Meyer CR, Koeppe RA, Stohler CS. mu-opioid receptor-mediated antinociceptive responses differ in men and women. J Neurosci. 2002;22:5100-5107.

170.

Article I

Article II

Article III

Article IV

Adult dental anxiety and related dentist beliefs in Danish private practices Rod Moore and Inger Brødsgaard -----------------------------------------------------------The aim of this qualitative study was to understand the kinds of problems that persons with dental anxiety present to private dentists in Denmark as well as dentists’ beliefs about dental anxiety phenomena. Characteristics of 53 anxious patients were surveyed from 42 randomly selected private practices (PP) in Århus, Denmark. Dental anxiety (DAS) scores of PP patients before treatment were significantly lower than patients treated at the specialist clinic (acronym »FoBCeT«). In spite of this, dropouts in PP were much greater than for FoBCeT patients during the same period. Of 20 dentists interviewed in a subsample, 75% had experienced broken appointments as the most characteristic behavior, while 35% judged dental anxiety to be due to the patients’ own personality, 40% blamed previous dentists and 10% pointed to a relationship problem between dentists and patients. The dentists expressed confidence about treating anxious patients, but also a need for more education about management skills. A future epidemiological study of dentist beliefs will be based on these findings.

562

A

lmost all of the literature about adult dental anxiety has focused on the perceptions and experiences of patients or persons who have dental anxiety in specialist clinics or epidemiological studies (1-6). No studies have previously presented data about dental anxiety in private practice. None have provided case-control studies to reveal behaviours compared with a standardized specialist treatment protocol. Such a case-control study has an advantage in that specialist clinics and the patient samples frequenting them have been previously described in the literature. Furthermore, only a few studies have investigated what dentists experience when confronted with anxious patients (7-14) and these were on British, American or Swedish samples. Dentists’ experiences with anxious patients is important information, since it is confirmed in a large American study (15) that the quality of the dentist-patient relationship directly effects the physical quality of dental treatment. It also seems intuitively important to understand any possible effects of dental anxiety on dentists’ occupational stress and professional satisfaction. The first aim of the present qualitative study was to compare anxious patients’ thoughts and behaviours in Danish private practice settings with those of a specialist clinic using standard anxiety and behavioural measures. The second aim was to assess beliefs and experiences of private dentists involved in treatment of these patients in order to estimate influences of dental anxiety on routine dental practice and needs for professional education on the subject. The understanding gained from these qualitative results are expected to provide heuristics for item selection in a larger epidemiological survey of dentist beliefs.

Material and methods Sample and questionnaire protocol Forty-five private practicing (PP) dentists were selected using random number selections (16) based on a complete list of names of Danish Dental Association dentists practicing in the Århus area. Århus is considered to be a good mix of rural and urban populations that are very much like Denmark as a whole (17). For a period of over 18 months, the dentists were asked to have new patients who showed signs of dental anxiety to fill out the following questionnaires in their waiting rooms before the first appointment and again after treatment was completed. Dental Anxiety Scale (DAS) (18) is a four item scale with questions about how one would feel about 1) going to a dentist tomorrow, and waiting 2) in the waiting room, 3) for drilling or 4) for tooth cleaning each on a scale of 4 (so anxious and afraid that I’d almost feel sick) to 1 (relaxed). DAS scores range from 20 (extreme anxiety) to 4 (none). State-Trait T A N D L Æ G E B L A D E T 19 9 7 ⋅ 101 ⋅ N R . 11

Table 1. Summary statistics for anxious patient sample characteristics (N = 133). Age (yr) Gender Mean SD Range Women Men Specialist clinic (n = 80) Private practices (n = 53)

37.0 31.9

10.3 7.8

19-65 18-50

Anxiety Inventory (STAI) (19) measures general trait anxiety tendencies on 20 items with scores ranging from 80 (extremely anxious) to 20 (no anxiety). STAI-T items are rated on a scale of 4 (almost always) to 1 (almost never) and include whether subjects 1) feel pleasant, 2) get tired fast, 3) feel like crying, 4) wish they were happy like others, 5) miss a lot from not deciding things, 6) feel rested, 7) feel calm, 8) let problems pile up so they can’t keep up, 9) worry too much about small things, 10) are happy, 11) take things too heavily, 12) lack of self-confidence, 13) feel secure, 14) avoid facing problems, 15) feel depressed, 16) feel content, 17) are irritated by speculating too much, 18) take disappointments poorly, 19) feel mentally well-balanced and 20) get tense thinking of problems here and now. A modified Geer Fear Scale (GFS) (20, 21) measured existence of other phobias and fears with 18 items rated on a scale of 7 (terrified) to 1 (not afraid at all): 1) sharp objects, 2) worms, 3) rats and mice, 4) injection needles, 5) spiders, 6) blood, 7) heights, 8) enclosed rooms, 9) thunderstorms, 10) snakes, 11) cemeteries, 12) dark places, 13) strange dogs, 14) stinging insects, 15) auto accidents, 16) social situations, 17) open spaces and 18) other people. GFS scores range from 126 (extremely phobic) to 18 (no fears). These tests have proven reliability and clinical usefulness for these parameters of dental anxiety (22). Normative means of DAS = 9.0, STAI-T = 38.6 and GFS = 37.4 (21). Evaluation of resultant patient behaviours and associated beliefs in private practice settings were accomplished by having the dentists and staff fill out a standardized »Patient information form« (PIF), where treatment starting date, total number of appointments, number of broken appointments, treatment end date and dentist comments were recorded (including reasons for drop-out). Results were compared with results from the specialist clinic at the Forsknings- og BehandlingsCenter for Tandlægeskræk FoBCeT (Dental Phobia Research and Treatment Center) in approximately the same time period, as a general indicator of effectiveness of management and treatment. Interviews Of the 42 Århus dentists who participated, 20 were randomly T A N D L Æ G E B L A D E T 19 9 7 ⋅ 101 ⋅ N R . 11

40 31

40 22

Anxiety test CDAS (dental) STAI-T (general) GFS (general) Mean SD Mean SD Mean SD 18.1 15.7

1.4 3.2

39.8 37.4

12.4 10.0

44.5 40.5

14.2 12.0

selected to be interviewed by telephone to evaluate their experiences and beliefs about the phenomenon of dental anxiety. Age, gender, number of years in practice, percentage of dental patients who have anxiety, beliefs about the primary cause of dental anxiety, beliefs about most typical characteristics of anxious patients, reports of the usual strategies pursued in treatment of the patients and assessment of educational needs required to tackle the problem were polled (12 questions). Results Three of the 45 dentists could not participate due to death, retirement, or having moved to a distant location. Of the 53 dental anxiety patients (Table 1) who filled out questionnaires and were treated on a first time basis by 26 of the 42 dentists, only 22 completed treatment. Reasons the 16 dentists gave for not contributing patient data during the observation period were: »saw no new anxious patients« (n=10), »the patients asked would not participate« (n=2), »kept forgetting to ask the patients« (n=2) and »no comment« (n=2). During approximately the same time period, of the 80 patients (Table 1) 72 (90%) completed treatment at the specialist clinic and 63 of these 72 (88%) had continued treatment with private dentists by one year follow-up. Twelve of 22 patients who successfully completed treatment had been treated by five of thirteen dentists whose patients responded after treatment, indicating a high degree of variance in patient acceptance of individual dentists. Broken appointments among PP dental patients were also greater per scheduled appointment (85/357 (25%) with mean of 6.7 appointments per patient) than for FoBCeT patients (99/917 (11%) with mean of 11.5 appointments per patient). DAS pre-treatment scores of the 53 private practice patients (Table 1; median = 16) were significantly different (P1000 Solo practice No. chairs ≥2 Location = City

24/127 13/59 40/191+ 23/127

0.9 1.4 6.4 0.9

0.5-1.8 0.6-2.3 0.8-48.4 0.4-1.7

Public image (low)

21/67**

3.0

1.5-5.9

2.1

1.0-4.4

Perceived stress (high) 30/129++ Chi-square significance: No asterisk = not significant * P ≤0.5 ** P ≤0.1 + Fisher’s Exact Test P = 0.054 ++ Uncorrected x2 = 3.81, P = 0.051 Corrected x2 = 3.14, P = 0.076

Results Sample characteristics Response rate was 83% (228/275). Of these, three were specialists, three were employed in the children’s public health service, five returned the survey but refused to answer on principle and one was retired from practice, for a useable response rate of 79% (216/275). See Table 1 for sample characteristics. Detailed analysis of non-responders was not possible since the local dental association (»5. Kreds«), who co-ordinated the mailings, required anonymous coding. However, given gender and age distributions of all practitioners in Århus, there appeared to be no meaningful differences with the sample. It should be pointed out that age differences by gender exist where mean age for men was 47.5 years (SD = 9.4) and mean age for women was 41.3 years (SD = 8.3) (t = 4.9; P < .001). Male dentists (x ¯ = 21.3 yr., SD = 9.7) also had significantly 1022

more practice experience than did females (x ¯ = 14.2 yr., SD = 8.5) (P < .001). Danish dentists’ perceptions of career satisfaction Most of these Danish dentists seemed satisfied with their career choices and there were no statistically significant differences in career satisfaction by gender, practice location, number of patients, type of practice or number of chairs. Only 15.3% unconditionally and 66% conditionally would recommend dentistry as a career, to young aspirants, while 15.3% would probably not and 3.7% would definitely not. Career dissatisfaction as reflected in the later two choices was most prevalent in dentists aged ≥45 yr. (OR = 3.1, CI = 1.5-6.6, x2 = 8.2, P = .004) or with more than 18 years in practice (OR = 2.7, CI = 1.3-5.5, x2 = 6.6, P = .01) as well as among dentists who perceived low public image (OR = 3.0, CI = 1.5-5.9, x2 = 8.5, P = .004) and high stress (OR = 2.1, CI = 1.0-4.4, P = .08) (significant only with uncorrected x2 test). Associations with career dissatisfaction improved in strength with logistic analysis for dentists aged ≥45 yr. (ORL = 3.5, CI = 1.6-7.6, P = .002), but not for perceived high stress (ORL = 2.0, CI = .9-4.6, P = .09) nor low public image (ORL = 3.0, CI = 1.4-6.2, P = .004) when controlling for multiple chair practices. Perceived stress of dentists Of the dentists surveyed, 59.7% perceived dentistry as more stressful than other professions with associations to job satisfaction as stated above. Another 37% perceived stress as »the same« and 3.3% as »less stressing«. Dentists’ perceived stress was not statistically associated with perceptions of negative public image for any age group. Danish dentists’ perceptions of their public image A perception that dentists’ professional image was less than good (27.8%) or poor (3.2%) in the mass media or public at large was reported by 31%. Overall, perceptions of less than good or poor role image were associated with career dissatisfaction as stated above. Related to dentists’ image perceptions and their patients, most dentists either fully (24.1%) or partly (67.1%) agreed that patients evaluate dentists based on style or behaviours more than by technical skills. Dentists varied in wanting the dental association to intervene in campaigning for a better public image: nearly 12% were negative, 25% did not know, 63% were positive. Discussion The present investigation aimed to describe dentist or practice characteristics and dentists’ perceptions of job satisfacTA N D L Æ G E B L A D E T 2 0 0 0 ⋅ 10 4 ⋅ N R . 16

tion, professional stress and public image for a sample of typical private dentists in Denmark. Results indicated that 19% of these Danish dentists were dissatisfied with their career choice, which was comparable to 18% in a Swedish study (3) and 33% in a British study (1). As in those studies, dentists’ dissatisfaction was related to age, stress and patient relation variables. However, it is important here to point out that career satisfaction is a combination of many things, some of which were only indirectly measured in the present study. Born (5) concluded that older male dentists that he had studied experienced a greater sense of personal identity with their practices than did younger male dentists and that they would be dissatisfied with the practice of dentistry if they had tended to entangle their home and professional lives, had experienced a »mid-life crisis« or had felt »trapped« in the profession. Such circumstances can contribute to career »burnout« phenomena (13,14). Present study did not directly measure personal crises or other lifestage events that could have contributed to professional dissatisfaction. However, studies in Finland (13) and Great Britain (14) indicated that dentists who tend to burnout, most often come to dislike the daily clinical and economic challenges of practice. Thus, indicators of personal and professional dissatisfaction inevitably overlap and reflect one another. Another career satisfaction issue is income. At least one study has shown that dentists in general, and especially young dentists, tend to equate satisfaction with income more than do older dentists (6). It appears from the literature (5,6) that as dentists grow older they tend to become more naturally satisfied, since they may have usually found their »niche« economically and socially. Present results of Danish dentists showed the opposite – an association between increasing age and increased dissatisfaction. Although we did not directly measure income of the dentists in this study at the request of local dental association officials, one possible explanation might be that dissatisfaction may be the result of high economic pressures and time/product stress factors perceived by Danish private dentists (15). A possible hypothesis that economic and time pressures may be greater for dentists in Denmark than in other countries could not be tested here. American (11), British (1) and Swedish (3) studies have affirmed that dentists perceive the most stress when patients do not »appreciate« them, especially criticising or showing outright hostility toward them. Related to devaluing the dentist and the dentists’ activities, dentists’ images as »inflictors of pain« were also ranked highly as a stressor in the recent study of these same Danish dentists (15) as well as a British study (1) and an American study (11). T A N D L Æ G E B L A D E T 2 0 0 0 ⋅ 10 4 ⋅ N R . 16

Still other studies have indicated that inflicting pain on patients and the inability to obtain adequate pain control was a direct source of occupational stress and dissatisfaction for many dentists (16,17), with a surprising number of dentists who have considered changing occupation as a direct result (17). In other studies, such clinical stressors were followed closely in magnitude by management issues such as maintaining a practice and a schedule when patients were late, skipped appointments or did not pay their bills (3,11). The image of the dentist, then, is also meaningfully influenced by the phenomenon of anxious patients and can indirectly contribute to dentists’ job dissatisfaction, since they exhibit unpredictable behaviours and require more time and management (15). Given the economic and time pressures of private practices, treatment of anxious patients might best be facilitated by a financial system other than present fee-for-service dental fees, for example, an hourly rate similar to psychotherapists. The main focus of the present study was to explore and describe the relationship of career satisfaction with dentist perceptions of their stressfulness and their public image. Although the majority responded positively, many Danish colleagues expressed career dissatisfaction, perceptions of undue stress and negative public image. We found that perceptions of negative public image were meaningfully different among dentists who were dissatisfied with their careers compared to dentists who expressed satisfaction enough to recommend the profession to young aspirants. We also found that nearly all the dentists believed that patients evaluated them more by their personal style or behaviour rather than by their technical competence. Thus, it appears that there is a need for many dentists to learn psychological strategies for successful patient management that could improve conditions for treatment and prevention of dental anxiety, of pain and possibly relieve potential stress and job dissatisfaction. Talking with patients, taking extra time and allowing brief rest pauses during anxious moments and after pain or discomfort are all approaches with long histories to improve treatment of anxiety or pain (18,19). Furthermore, coursework in stress and practice management, optimum staff communication and learning about normal career developmental stages might help many dissatisfied dentists (20). As a professional social issue, these Danish dentists wanted the dental association to take actions to improve their collective image. Such actions and improved dentist-patient interactions would hopefully aid dentists in achieving increased job satisfaction and prevent professional burnout.

FAGLIGE ARTIKLER

1023

Dentists’ job satisfaction

Funded by Colgate-Palmolive A/S of Denmark. Author wish to thank Bente Kjær and Lis Jørgensen for data collection and preparation.

Dansk resumé Danske tandlægers faglige tilfredshed relateret til deres opfattelse af eget arbejdsstress og image i befolkningen Forholdet mellem danske tandlægers opfattelse af tilfredshed med deres valg af professionel karriere og deres opfattelse af arbejdsstress og deres image i befolkningen blev undersøgt. Et postomdelt spørgeskema blev udfyldt og returneret af 216 privatpraktiserende tandlæger i en randomiseret stikprøve fra Århus og omegn. Af disse var kun 19% utilfredse og ville ikke anbefale en karriere i tandpleje til yngre mennesker. Tres procent opfattede tandlægefaget som mere stressende end andre professioner, og 31% mente at tandlæger har et mindre godt eller dårligt image i befolkningen. Odds ratio (OR) sandsynlighedsberegninger viste at opfattelsen af utilfredshed med jobvalg var tre gange hyppigere blandt tandlæger i alderen 45 år eller over (OR = 3,1) end blandt de yngre tandlæger. Dette svarer også til at have været i praksis i mere end 18 år (OR = 2,7). Blandt de »utilfredse« var det mere sandsynligt at de opfattede tandlægefaget som mere stressende end andre professionelle fag (OR = 2,1; ikke signifikant), og at deres image blandt befolkningen var negativt (OR = 3,0). Justerede odds ratios øgede styrken af disse associationer kun for alder. Der var ingen signifikante associationer med køn, praksistype, placering eller størrelse. Næsten alle de deltagende tandlæger opfattede at patienter evaluerer tandlæger mere ud fra deres adfærd på klinikken end ud fra deres kliniske kompetence. På baggrund af disse fund kan det konkluderes at privatpraktiserende tandlægers opfattelse af deres image i befolkningen havde et betydningsfuldt forhold til professionel utilfredshed og at praksisstress også bidrog. Et flertal af tandlægerne så gerne Tandlægeforeningen gøre noget for at ændre på deres image. Nogle af tandlægekollegerne syntes at have behov for at lære mere om styring af deres egne arbejdsvilkår og om processen omkring opnåelsen af faglig tilfredshed. References 1. Cooper CL, Watts J, Kelly M. Job satisfaction, mental health and job stressors among general dental practitioners in the UK. Br Dent J 1987; 24: 77-81. 2. Humphris GM, Peacock L. Occupational stress and job satisfaction in the community dental service of north Wales: a pilot study. Community Dent Health 1992; 10: 73-82. 3. Hakeberg M, Klingberg G, Noren J, Berggren U. Swedish dentists’ perceptions of their patients. Acta Odontol Scand 1992; 50: 24552.

1024

4. DiMatteo MR, Shugars DA, Hays RD. Occupational stress, life stress and mental health among dentists. J Occup Organ Psychol 1993; 66: 153-62. 5. Born DO. Career satisfaction of older male dentists. Gerodontics 1985; 1: 75-80. 6. Yablon P, Rosner JF. The career satisfaction of dentists in relation to their age and income. J Am Coll Dent 1982; 49: 45-52. 7. Eccles J, Powell M. The health of dentists: A survey in South Wales. Br Dent J 1967; 123: 379-87. 8. Shugars DA, DiMatteo MR, Hays RD, Cretin S, Johnson JD. Professional satisfaction among California general dentists. J Dent Educ 1990; 54: 661-9. 9. Gerbert B, Bernzweig J, Bleecker T, Bader J, Miyasaki C. How dentists see themselves, their profession, the public. J Am Dent Assoc 1992; 123: 72-8. 10. Moore R, Birn H, Kirkegaard E, Brødsgaard I, Scheutz F. Prevalence and characteristics of dental anxiety in Danish adults. Community Dent Oral Epidemiol 1993; 21: 292-6. 11. O’Shea RM, Corah NL, Ayer WA. Sources of dentists’ stress. J Am Dent Assoc 1984; 109: 48-51. 12. Shugars DA, Hays RD, DiMatteo MR, Cretin S. Development of an instrument to measure job satisfaction among dentists. Med Care 1991; 29: 728-44. 13. Murtomaa H, Haavio-Mannila E, Kandolin I. Burnout and its causes in Finnish dentists. Community Dent Oral Epidemiol 1990; 18: 208-12. 14. Osborne D, Croucher R. Levels of burnout in general dental practitioners in the southeast of England. Br Dent J 1994; 177: 372-7. 15. Moore R, Brødsgaard I. Dentists’ perceived stress and its relation to perceptions about anxious patients. Community Dent Oral Epidemiol 2000; (in press). 16. Dower JS Jr, Simon JF, Peltier B, Chambers D. Patients who make a dentist most anxious about giving injections. J Calif Dent Assoc 1995; 23: 35-40. 17. Simon JF, Peltier B, Chambers D, Dower J. Dentists troubled by the administration of anesthetic injections: long-term stresses and effects. Quintessence Int 1994; 25: 641-6. 18. Weiner AA, Weinstein P. Dentists’ knowledge, attitudes, and assessment practices in relation to fearful dental patients: A pilot study. Gen Dent 1995; 43: 164-8. 19. Corah NL, O’Shea RM, Ayer WA. Dentists’ management of patients’ fear and anxiety. J Am Dent Assoc 1985; 110: 734-6. 20. Möller AT, Spangenberg JJ. Stress and coping amongst South African dentists in private practice. J Dent Assoc S Afr 1996; 51: 347-57.

Author Rod Moore, DDS, PhD Department of Community Dentistry and Public Health, Dental Phobia Research and Treatment Center (FoBCeT), Royal Dental College, Aarhus University, Aarhus, Denmark

TA N D L Æ G E B L A D E T 2 0 0 0 ⋅ 10 4 ⋅ N R . 16

Article VII

Copyright C Munksgaard 2001

Community Dent Oral Epidemiol 2001; 29: 73–80 Printed in Denmark . All rights reserved

ISSN 0301-5661

Dentists’ perceived stress and its relation to perceptions about anxious patients

Rod Moore and Inger Brødsgaard Department of Oral Epidemiology and Public Health, Dental Phobia Research and Treatment Center, Royal Dental College, University of Aarhus, Aarhus, Denmark

Moore R, Brødsgaard I: Dentists’ perceived stress and its relation to perceptions about anxious patients. Community Dent Oral Epidemiol 2001; 29: 73–80. C Munksgaard, 2001 Abstract – Dentists’ perceptions about the stressfulness of dental practice, their perceptions about dental anxiety and its management were surveyed in a descriptive study. A mailed questionnaire was completed by 216 randomly selected Danish private dentists. Of these, nearly 60% perceived dentistry as more stressful than other professions. Dentist perceptions of the most intense stressors were (ranked): 1) running behind schedule, 2) causing pain, 3) heavy work load, 4) late patients and 5) anxious patients. Bivariate odds ratio (OR) analyses were undertaken to check for associations of perceived stress and other dentist variables with perceptual outcomes about anxious patients. Signs of dental anxiety were reported to be less often spotted by older (Ø52 yr) dentists (ORΩ3.1) who perceived their job stress to be greater than that of other professionals (ORΩ3.2). Perceived causes of dental anxiety (1st, 2nd or 3rd choices tallied and then ranked) were 1) fear of pain, 2) trauma in dental treatment, 3) general psychological problems, 4) shame about dental status and 5) economic excuses. Dentists who reported that dental anxiety was primarily the result of general psychological problems in patients, usually had solo (ORΩ2.4) practices older than 18 years (ORΩ2.6) and reported high perceived stress (ORΩ2.2). Adjusted odds ratios for these two dentist perception outcomes about anxious patients generally improved strength of associations and confidence intervals. There were no meaningful differences by practice location or perceived public image. Also, there was no significant association between the use of pharmacological strategies for anxiety and the perceived stress of dentists. Nearly all dentists talked with anxious patients as their main treatment strategy. It was concluded that psychosocial aspects of dental practice have meaningful and often adverse associations with dentist perceptions about anxious patients. Some dentists appeared to require more knowledge about dental anxiety and managing their own stress.

Most investigations of psychosocial environments in dental practice have described perceived stress or stressors among dentists (1–5) and variables that may be effected by or associated with stress, such as career satisfaction (1, 4, 6) or role image (7). Two studies also related stress to dentist health problems (5, 6) and three studied stress in relation to marital or other social or psychological outcomes (4–6). Only one study has investigated interactive effects of dentist behaviors on normative patient beliefs (8). This study notably did not address den-

Key words: anxiety; dental care; dentistpatient relations; epidemiology; occupational stress Rod Moore, Department of Oral Epidemiology and Public Health, Dental Phobia Research and Treatment Center (FoBCeT), Royal Dental College, DK-8000 Aarhus C, Denmark Fax: π45 86 196029 e-mail: rmoore/odont.au.dk Submitted 1 March 2000; Accepted 15 June 2000

tist stress or patient anxiety or pain. There have, however, been studies that looked at dentists’ or dental students’ assessments of problematic patient behaviors including anxiety (1, 9–12) and typical management strategies for anxious patients (9–11). But there have been no investigations studying possible associations between dentists’ perceived stress levels and how they perceive anxious patients and their treatment. In studying possible associations between dentist stress and perceptions of anxious patients, one is-

73

Moore & Brødsgaard

sue is whether dentists even notice patient anxiety. Some studies have indicated that dentists have sometimes had difficulty spotting anxiety (9–11), but the studies did not try to examine why. Lack of sensitivity would be detrimental for anxious patients, since they require extra time and special strategies for successful treatment (11, 13, 14). Dentists who feel highly stressed could potentially be less sensitive or responsive to anxious patients’ need for special attention. Another issue could be if dentist stress might play some role in whether dentists can accurately differentiate dental anxiety from general anxiety and if they provide appropriate management. Only a minority of patients who are anxious about dental treatment have been reported to exhibit complicating general anxiety traits (13–17) as primary cause. Dentists who would incorrectly assume general psychological traits as the main cause of dental anxiety, could be prone to adverse labeling of anxious patients who are not suffering from such general symptoms. Such dentist beliefs could lead to e.g. avoidance of treatment or provision of overtreatment with general anesthesia or sedation, where most would require only extra time, personal attention and patience (1, 11, 13, 14). Thus, the present investigation had two primary aims: 1) to study stress that Danish private dentists perceive, identifying major practice stressors including patient anxiety and 2) to study the relationship of perceived stress on dentists’ perceptions of anxious patients and their management. This second aim was designed to emphasize exploration of dentists’ self-reported sensitivity in spotting anxiety, their attribution of cause, especially related to

Fig. 1. Conceptual model adapted from Hendrix’s Stress in Dentistry Model, 1986 (18) regarding possible associations between dentist’s perceived stress and other variables with dentist perceptions of anxious patients.

74

any potential adverse labeling of patients, and dentist use of behavioral or pharmacological aids in fighting anxiety. The model (Fig. 1) that was used to explore aims of dentists’ perceived stress and its relation to their perceptions of patient anxiety was adapted from Hendrix’s model (18) of stress in dentistry in which job-related factors, external factors and personal characteristics contribute to work stress, which in turn has psychological and behavioral consequences. Other related aims were to study dentist beliefs about communication skills and economics that would improve anxiety treatment.

Material and methods Sampling protocol Subjects were 275 private dentists drawn randomly from the Danish Dental Association list of all private dentists (nΩ425) within the boundaries of Aarhus, Denmark. Considering demographics and a unique mix of urban and rural areas within its limits, Aarhus is considered quite similar to Denmark as a whole (16, 19). In Denmark, private dentists almost exclusively treat adults. Dentists in the Public Dental Health Services treat almost exclusively children. Since present aims pertained to adult dental anxiety, no public dentists were surveyed.

Survey instrument and protocol The mailed questionnaire survey of dental practice, stress and dental anxiety consisted of 20 items. Some items were derived from results of a qualitative study of 42 randomly selected Aarhus dentists regarding beliefs about anxious patients (14). Other items about dentist perceptions of stress in practice, patient problem behaviors, public image and anxiety management were taken from other surveys of dentists (1, 3, 4, 7, 11) for comparisons. Besides standard demographic items about dentists, such as gender, age and years of practice, four items covered type of dental practice: location, solo or group practice, number of dental chairs, total number of patients (see Table 1) and number of anxious patients. Three items referred directly to dentist perceptions of stress in practice. The main independent variable was translated from an item covalidated in a survey of 977 US dentists by O’Shea, Corah & Ayer (3): ‘‘Compared with other professions, do you think that being a dentist is more, less or about the same amount of stress?’’ (1Ω‘‘more’’, 2Ω‘‘less’’,

Dentists, stress and perceptions about anxious patients Table 1. Sample characteristics* (nΩ216 dentists) Personal characteristics Gender Men nΩ

Age (years old) (nΩ212) Women

133 83 (61.6%) (38.4%) (x¯Ω47.5 yr; (x¯Ω41.3 yr; SDΩ9.4) SDΩ8.3) (tΩ4.9; P⬍0.001)

22–37 51 (24.1%)

38–44

45–51

Years in practice (nΩ214) 52–75

51 54 56 (24.1%) (25.4%) (26.4%) (x¯Ω45.1 yr; SDΩ9.4)

1–10 55 (25.7%)

11–18

19–25

26–46

53 56 50 (24.8%) (26.1%) (23.4%) (x¯Ω18.5 yr; SDΩ9.9)

Practice characteristics Size (Number of patients) (nΩ210) 0–799 nΩ

800–999 1000–1273 1274–3300

44 39 75 52 (21%) (18.6%) (35.7%) (24.7%) (x¯Ω1058 patients; SDΩ529)

Type Practice (nΩ215)

No. of Chairs

Location

Group

Solo

One

Ø2

County

Town

City

156 (72.6%)

59 (27.4%)

25 (11.6%)

191 (88.4%)

52 (24.1%)

37 (17.1%)

127 (58.8%)

* Some frequencies are lower, as marked, due to missing data for that item.

Table 2. Perceived stressful situations in practice – dentists’ evaluations (nΩ216) by intensity and frequency of either 1st, 2nd or 3rd rank choices Perceived stressful situations Running behind schedule/emergencies Causing pain/unpleasantness Too heavy work load Late patients Anxious patients Inadequate assistance Talkative/uncooperative patients Broken or canceled appointments Technical demands for perfection Patients not opting for ideal treatment Regulations and governmental control

3Ω‘‘same’’). Two other items were used to describe and clarify stress perceptions for comparison with the literature (1, 3, 4, 6). Dentists responded to a list of 11 commonly named stressors in practice, ranking them by both intensity and frequency of occurrence from 1 (most stress) to 11 (least) (Table 2). All 1st, 2nd, or 3rd choices were tallied and entered as combined scores in the cells for overall ranking. These ‘‘top three’’ intermediate variables were used here and in ‘‘cause of anxiety’’ to gauge the strongest perceptions that dentists had, in order to improve confidence in measuring dentists’ knowledge or beliefs compared with the literature. Dentists’ perceived role image among the public as a possible source of perceived stress was an item translated from a survey of over 2081 US dentists

Intensity Rank

%

Frequency Rank

%

1 2 3 4 5 6 7 8 9 10 11

74.5 41.2 29.7 26.8 26.4 23.7 22.3 17.6 15.3 10.2 4.7

1 3 2 4 8 9 7 6 5 11 10

69.4 32.0 37.0 28.7 22.7 12.0 23.1 24.0 24.1 7.9 9.3

(7). This was an ‘‘external stress factor’’ from the conceptual model.: ‘‘The mass media’s and public’s image of dentists is (1Ω‘‘very good’’, 2Ω‘‘good’’, 3Ω‘‘less than good’’ and 4Ω‘‘poor’’). Another item was used to aid in describing and clarifying image: ‘‘Patients evaluate a dentist more by personal style or behavior than by perceived technical competence.’’ (1Ω‘‘strongly disagree’’ to 4 Ω‘‘strongly agree’’). Five items assessed dentists’ experiences and beliefs about dental anxiety and its treatment. Two of these were the main dependent variables of interest. The first dependent variable was dentists’ selfreported sensitivity in spotting anxiety. It was translated from an item covalidated in a survey of 746 US dentists by Corah, O’Shea & Ayer (11): ‘‘I

75

Moore & Brødsgaard

can tell if a patient is anxious.’’ (1Ω‘‘always’’, 2Ω ‘‘usually’’, 3Ω‘‘sometimes’’, 4Ω‘‘not so often’’ and 5Ω‘‘never’’). Another variable studied how these dentists attributed cause of dental anxiety: ‘‘What are the main reasons that people are anxious about dentistry?’’ a) ‘‘general psychological problems’’, b) ‘‘distrust of dentists due to harsh treatment‘’’ c) ‘‘afraid of pain’’, d) ‘‘a cover for economic priorities’’ and e) ‘‘shame over their dental status’’. These were ranked from 1Ω‘‘most likely’’ to 5Ω ‘‘least likely’’ where dentists were asked to skip items not considered relevant. Dentists’ perceptions about anxious patients were also described with: 1) ‘‘Which of the following behaviors are characteristic for anxious patients?’’ (Table 3). 2) ‘‘Your opinion or experience in treating anxious patients is (check one) a) ‘‘.. not enough time (economics), b) ‘‘I treat them despite the extra time ...’’, c) ‘‘.. have an older practice; no new patients.’’, d) ‘‘The time is an investment in reputation and new patients.’’ and e) ‘‘I can build a practice on anxious patients.’’ 3) ‘‘Which procedures do you use for treatment of anxiety?’’ (Table 4). The variable ‘‘use of pharmacological solutions’’ was a dichotomous

Table 3. Anxious behaviors – Dentists’ (nΩ216) responses to ‘‘Which behaviors are characteristic for anxious patients?’’ Behavior Late cancellations Time consuming Skipping appointments Show only for emergencies Drop out often times Bad payers Often ungrateful

Rank

Frequency

%

1 2 3 4 5 6 7

192 162 156 155 124 34 15

88.9 75.0 72.2 71.8 57.4 15.7 6.9

Table 4. Preferred anxiety treatments – Dentists’ (nΩ216) responses: ‘‘Which do you usually use for treatment of anxious patients?’’ Treatment strategy Conversations/build up trust Assure good local anesthesia Gradual habituation to procedures Nitrous oxide Oral premedication Controlled breathing Relaxation training Refer to psychotherapist Hypnosis Refer for general anesthesia ‘‘I don’t treat them’’

76

Rank

Frequency

%

1 2

211 206

97.7 95.4

3 4 5 6 7 9 9 9 11

130 69 64 52 13 3 3 3 1

60.2 31.9 29.6 24.1 6.0 1.4 1.4 1.4 0.5

variable in which any dentist using nitrous oxide, conscious or general sedation was entered as a case vs. the controls, those dentists who reported only using behavioral strategies (Table 5). Finally, two items assessed dentists’ educational or political/economic needs related to treatment of anxious patients (1Ω‘‘strongly disagree’’ to 4Ω ‘‘strongly agree‘‘): 1) ‘‘Therapeutic conversations with seriously anxious patients should be covered by the National Health Insurance.’’ 2) ‘‘Do you think communication skills with such patients can be learned in coursework?’’.

Data analysis Besides description of response frequencies and ranking as in aim 1, associations between selected variables were assessed using bivariate odds ratios (OR), c2 , Fisher’s Exact or t-tests. For aim 2, associations between each dependent variable relative to independent variables were calculated according to the conceptual model in Figure 1 (20). In order to avoid loss of information, representation of continuous variables such as age, years of practice and numbers of patients as dichotomies were thoroughly investigated using continuous or quartile versions (Table 1) before determining cut-offs for the values chosen in Table 5. The cut-off points listed were the result of either a meaningful, natural occurring dichotomous pattern in the data or the need to improve statistical power due to small subsample size where cells could be combined and the cut-offs were meaningful. Use of logistic regression adjusted odds ratios (ORL) was limited to checking effects on strength of associations among key variables 2 or 3 at a time, since some cell sizes prohibited adequate power. Exploration of associations between variables was not limited exclusively to theorized directions of relationships in the conceptual model, although this was the main thrust of aim 2. Other relationships related to dentist perceptions of anxious patients, dentist stress and dentists’ self-reported behavior provided details about these constructs and potential solutions to problems facing dentists. The level of 0.05 was used to determine statistical significance of associations by means of two-sided P-values and 95% confidence intervals (CI).

Results Response rate was 83% (228/275). Of these, 3 were specialists, 3 were employed in the children’s public health service, 5 returned the survey but refused to answer on principle and one was retired from

Dentists, stress and perceptions about anxious patients Table 5. Bivariate analysis results re. model in Fig. 1: reactions and consequences associated with perceived dentist stress and possible antecedents (nΩ214) Cause .1: General psychological problems

Not spotting anxiety n

OR

95%CI

Dentists’ personal characteristics Age Ø52 yr Men Ø18 yr practice

8/56* 12/132 11/106

3.1 2.0 2.4

Practice factors No. patients ⬎1000 Solo practice No. chairs Ø2 LocationΩCity

9/127 6/59 15/189 8/126

External factor Public image (low)

4/67

Perceived stress (high)



13/127

Chi-square significance: * PÆ0.05; No asteriskΩnot significant. ** PÆ0.01.



n

Use of pharmacological remedies

OR

95%CI

n

OR

95%CI

1.1–8.7 0.6–6.3 0.8–7.1

8/56 2.0 15/133 2.0 14/106* 2.6

0.8–5.3 0.7–5.7 1.0–7.1

33/56 74/133 58/106

1.6 1.7 1.4

0.9–2.9 1.0–3.0 0.8–2.4

0.8 1.6 2.1 0.7

0.3–2.3 0.6–4.7 0.3–16.4 0.2–1.9

9/127 9/59 17/191 12/127

1.9 2.4 0.7 1.1

0.7–5.5 0.9–6.1 0.2–2.6 0.4–2.7

74/127** 32/59 96/191 66/127

2.1 1.2 0.9 1.2

1.8–3.7 0.7–2.2 0.4–2.1 0.7–2.0

0.8

0.2–2.3

8/67

1.5

0.6–4.0

29/67

0.7

0.4–1.2

3.2

0.9–11.6

15/129

2.2

0.8–6.2

66/129

1.1

0.6–1.9

Fisher’s Exact test PΩ0.052.

practice, for a usable response rate of 79% (216/ 275) (see Table 1). Detailed analysis of non-responders was not possible since the local dental association, who coordinated the mailings, required anonymous coding. However, given the gender and age distributions of all practitioners in Aarhus, there appeared to be no meaningful differences with the sample.

Perceived stress and image Of the dentists surveyed, 59.7% perceived dentistry as more stressful than other professions, 37% perceived stress as ‘‘the same’’ and 3.3% as ‘‘less stressing‘‘. The most intense stressors in practice were ranked similarly to the most frequently occurring stressors in practice, but there were some differences, notably for anxious patients (Table 2). The dentists who perceived their image to be less than good (27.8%) or poor (3.2%) in the mass media or public at large, were nearly 2 times more likely to report comparatively high professional stress (ORΩ1.8, CIΩ.9–3.2; PΩ0.07). Most dentists (91.2%) agreed that patients evaluate dentists on style or behaviors more than by technical skills.

Sensitivity of dentists in spotting dental anxiety and related items Most dentists (91.7%) perceived that they were ‘‘usually’’ (83.7%) or ‘‘always’’ (8%) able to recognize dental anxiety. For dentists who reported less aptitude for spotting anxiety, the model (Table 5)

showed a high association with perceived stress and age over 51 years. Logistic regression analysis of these relationships (nΩ212) indicated increased strength of association for age Ø52 years. (ORLΩ 3.8; CIΩ1.3–11.0; PΩ0.01) and perceived high stress (ORLΩ4.1; CIΩ1.1–15.3; PΩ0.05) when controlling for numbers of chairs. Also, in a related bivariate analysis, dentists reporting inability to spot anxiety were nearly three times as likely (10/83 vs. 6/131) (ORΩ2.9, CIΩ1.0–8.2; PΩ0.08) to attribute cause to general problems as 1st, 2nd, or 3rd choices.

Perceptions about anxious patients and causes of dental anxiety Sampled dentists reported that about 14% of their patients were anxious. The dentists perceived anxious patients as unreliable and a poor economic risk (Table 3). According to 1st, 2nd or 3rd rankings, the most frequent cause of dental anxiety stated by dentists (nΩ216) was fear of pain (97.5%), followed by traumatic treatment (90.9%), general psychological problems (38.5%), embarrassment about the status of their teeth (32.3%) and patients making excuses for other economic priorities (14.9%). Only general psychological problems showed a significant relationship with the perceived stress variable (ORΩ1.9, CIΩ1.1–3.3; c2Ω3.91, P⬍0.05). Looking only at first rankings attributed to dental anxiety (nΩ216), 9.3% attributed it to general psychological problems, 50.9% to previous treatment trauma, 44.4% to fear of

77

Moore & Brødsgaard

pain, 1.9% to a pretense for economic priorities and 0.9% to embarrassment. There were no significant relationships with perceived stress among these first choice cause variables, but general psychological problems indicated the highest association (ORΩ2.2; CIΩ0.8–6.2; PΩ0.14) compared with all others (OR⬍1.0) for each cause. In the model (Table 5), solo practitioners (ORΩ2.4) with practices over 18 yr (ORΩ2.6) and with high stress perceptions (ORΩ2.2) were identified as most likely to associate this cause as first choice. Logistic analysis indicated increased association and significance for solo practice (ORLΩ2.7; CIΩ1.0–7.3; PΩ 0.05) and perceived high stress (ORLΩ3.2; CIΩ1.0– 10.5; PΩ0.05), when controlling for years of practice and numbers of patients (nΩ209).

Management and treatment of anxiety Regarding the dentists’ attitudes about treating anxious patients, 3.7% felt they lacked the time or economics it takes to treat them, 89.4% treated them despite the extra time, 3.2% reported older practices accepting no new patients and 66% stated that the extra time is an investment in a good local reputation and more new patients. Finally, 16.2% felt that one can build up a whole practice on a good reputation with anxious patients. Talking with patients was the most frequently applied strategy, followed by assuring painless treatment (Table 4). Use of at least one pharmacological remedy was practiced by over half (nΩ109/216) of the dentists and it was neither significantly nor highly related to perceived stress (Table 5) nor reported inability to spot anxiety (OR⬍1.0). It was however, associated with tendency to attribute cause to general problems (ORΩ1.9; CIΩ0.7–5.1; PΩ0.17), dentists over 45 years of age (ORΩ1.8; CIΩ1.1–3.1; PΩ 0.03), and males (ORΩ1.7; CIΩ1.0–3.0; PΩ0.054) with larger practices (⬎1000) (ORΩ2.1; CIΩ1.8–3.7; PΩ0.01 [Table 5]).

National Insurance coverage and coursework in communication Most dentists (84.2%) were at least partly of the opinion that the cost of therapeutic conversations with anxious dental patients should be covered by the Danish National Health Insurance. Most (85.5%) believed at least in part that one can learn required communication skills with such patients through coursework. The 14.5% who did not think these skills could be learned were most likely to have had over 18 years of practice (ORΩ4.2, CIΩ 1.8–10.4, c2Ω10.2; PΩ0.001).

78

Discussion Most of the literature about adult dental anxiety has focused on the perceptions and experiences of persons with dental anxiety and consequences for their oral health (16, 17, 21–23). These studies point to a history of traumatic and/or painful dental experience as the most frequent cause of dental anxiety (13, 15–18, 21–23). Since dentists are implicated in traumatic and/or painful treatments and since technical quality of dental health care has been shown to be dependent on the psychosocial climate of dentist-patient relating (1, 24), it seemed compelling to investigate dentists’ occupational stress in relation to their perceptions about anxious patients. Present results indicated possible clinical consequences of dentists’ perceived stress. Since most job stressors have been related to pressures for the dental team to produce a certain amount of dental work within a certain period of time, anything perceived to slow down production is likely to be perceived as stressing, since fee-forservice schedules have been normative. Dentists in Swedish (1), American (3), and South African (6) studies were similar to these Danish dentists who ranked anxious patients as creating less stress than did running behind schedule or causing patients pain. However, it seemed that in relation to time or economic pressures, more time may indeed be required for anxious patients than many of the present dentists were willing to spend. The potential that even one anxious patient might change office dynamics for any given clinical work day would be a threat to fee-for-service economics. Therefore, since anxious patients exhibit unpredictable behaviors and require time consuming management, they do not fit the description of ‘‘good patients’’ (12) (being on time, paying bills promptly, accepting the dentist’s treatment plan) and may contribute more uncertainty and stress than dentists are willing to admit. In this context, present Danish dentists expressed a need for insurance coverage that would encourage them to treat anxious patients. Regardless of nationality or whether coverage is private or national, perhaps an hourly rate for these patients would be more supportive of patient and practitioner needs than present feefor-service schedules. The majority of these Danish dentists perceived that they could ‘‘usually’’ spot dental anxiety. Only 16 dentists reported not being able to spot dental anxiety and results should be viewed with caution, since cell sizes were sometimes small. However,

Dentists, stress and perceptions about anxious patients

any potential self-report bias would favor dentists reporting that they were able to spot anxiety, since this is a more desirable behavior to report to dental anxiety researchers. Thus, present results perhaps only provide a conservative estimate of dentists’ abilities to spot anxiety and are likely to be robust. Since a number of dentists felt they could not spot anxiety, present results supported the conclusions of an experimental study by Baron, Logan & Kao (10). They suggested that some dentists need to learn to recognize emotional distress and that all dentists should encourage patient expression about distress, in order to emphasize its significance. More research of factors influencing dentist perceptions of distressed patients is needed. Present results for this representative sample of private dentists in Denmark also confirm qualitative study results about dental anxiety in 42 Danish private practices (14). Assuming the 42 practitioners in Aarhus are similar to the 216 presently surveyed, what they subjectively judged as ‘‘anxious patients’’ could be measured by a mean reported intensity of anxiety as DAS 15.7 (SDΩ3.2) out of 20, which is considered to be high. General anxiety tests indicated that most of the 53 patients studied in those 42 practices did not manifest general anxiety, similar to the literature (13, 15–17), where ca. 20–35% of highly anxious dental patients also had complicating general anxiety symptoms. Since over 9% of present dentists perceived anxious dental patients to suffer primarily from general psychological problems, these typically older, ‘‘high stress’’ solo practitioners, may tend to stigmatize this patient group and perhaps consciously or unconsciously avoid them. Danish dentists were similar to international colleagues in their strategies for treating the anxiety of their patients. The primary treatment strategy was talking with anxious patients (98%), similar to studies in America (9, 11) where up to 87% also named it as the main strategy. Talking, taking extra time and allowing brief rest pauses during anxious moments or discomfort all have successful histories (11, 25). Not unlike Swedish colleagues (1), Danish dentists expressed confidence in treating patients with dental anxiety, yet frustration about unpredictable behaviors of anxious treatment avoiders. Most asserted that dental anxiety required special skills that they believed could be learned through continuing education. The literature also supports this (9, 25–27), as well as that other related psychological strategies such as practice stress management and optimal staff com-

munication can also be learned at continuing education courses (6, 27). Given the levels of present dentists’ perceived occupational stress, it was concluded that psychosocial aspects of dental practice have meaningful and often adverse associations with dentist perceptions about anxious patients. Some of these Danish dentists appeared to require more knowledge about dental anxiety and managing their own stress.

Acknowledgments Funded by Colgate-Palmolive A/S of Denmark. Authors wish to thank Bente Kjær and Lis Jørgensen for data collection and preparation.

References 1. Hakeberg M, Klingberg G, Noren J, Berggren U. Swedish dentists’ perceptions of their patients. Acta Odontol Scand 1992;50:245–52. 2. Humphris GM, Cooper CL. New stressors for GDP’s in the past ten years: a qualitative study. Br Dent J 1998; 185:404–6. 3. O’Shea RM, Corah NL, Ayer WA. Sources of dentists’ stress. J Am Dent Assoc 1984;109:48–51. 4. Cooper CL, Watts J, Kelly M. Job satisfaction, mental health and job stressors among general dental practitioners in the UK. Br Dent J 1987;24:77–81. 5. DiMatteo MR, Shugars DA, Hays RD. Occupational stress, life stress and mental health among dentists. J Occup Org Psychol 1993;66:153–62. 6. Möller AT, Spangenberg JJ. Stress and coping amongst South African dentists in private practice. J Dent Assoc South Africa 1996;51:347–57. 7. Gerbert B, Bernzweig J, Bleecker T, Bader J, Miyasaki C. How dentists see themselves, their profession, the public. J Am Dent Assoc 1992;123:72–8. 8. Gale EN, Carlsson SG, Eriksson A, Jontell M. Effects of dentists’ behavior on patients’ attitudes. J Am Dent Assoc 1984;109:444–6. 9. Weiner AA, Weinstein P. Dentists’ knowledge, attitudes, and assessment practices in relation to fearful dental patients: a pilot study. Gen Dent 1995;43:164–8. 10. Baron RS, Logan H, Kao CF. Some variables affecting dentists’ assessment of patients’ distress. Health Psychol 1990;9:143–53. 11. Corah NL, O’Shea RM, Ayer WA. Dentists’ management of patients’ fear and anxiety. J Am Dent Assoc 1985;110:734–6. 12. Corah NL, O’Shea RM, Ayer WA. Dentists’ perceptions of the ‘‘good’’ adult patient: an exploratory study. J Am Dent Assoc 1983;106:813–6. 13. Moore R, Brødsgaard I. Differential diagnosis of odontophobic patients using the DSM-IV. Eur J Oral Sci 1995; 103:121–6. 14. Moore R, Brødsgaard I. Adult dental anxiety and related dentist beliefs in Danish private practices. Dan Dent J [Tandlægebladet] 1997;101:562–7. 15. Locker D, Liddell A, Shapiro D. Diagnostic categories of

79

Moore & Brødsgaard

16.

17.

18.

19. 20.

21.

80

dental anxiety: a population-based study. Behav Res Ther 1998:37:725–37. Moore R, Birn H, Kirkegaard E, Brødsgaard I, Scheutz F. Prevalence and characteristics of dental anxiety in Danish adults. Community Dent Oral Epidemiol 1993;21: 292–6. Moore R. The phenomenon of dental fear – studies in clinical diagnosis, measurement and treatment (Ph.D. Thesis) Århus, Denmark: Royal Dental College; 1991. Hendrix WH. Dental stress model and assessment questionnaire. Dent Clin North Am 1986;30(Supplement):S1– 10. Statistisk Årbog for Århus 1995 [Århus Statistical Year Book 1995], Århus, Denmark: Universitetsforlaget; 1995. Victora CG, Huttly SR, Fuchs SC, Olinto MTA. The role of conceptual frameworks in epidemiological analysis: a hierarchical approach. Int J Epidemiol 1997;26:224–7. Locker D, Shapiro D, Liddell A. Negative dental experiences and their relationship to dental anxiety. Community Dent Health 1996;13:86–92.

22. Hakeberg M. Dental anxiety and health – A prevalence study and assessment of treatment outcomes (Dissertation). Go¨teborg, Sweden: University of Göteborg; 1992. 23. Milgrom P, Fiset L, Melnick S, Weinstein P. The prevalence and practice management consequences of dental fear in a major US city. J Am Dent Assoc 1988;116:641–7. 24. Weinstein P, Milgrom P, Ratener P, Read W, Morrison K. Dentists’ perceptions of their patients: relation to quality of care. J Public Health Dent 1978;38:10–21. 25. Corah NL, O’Shea RM, Bissell G. The dentist-patient relationship: perceptions by patients of dentist behavior in relation to satisfaction and anxiety. J Am Dent Assoc 1985;111:443–6. 26. Mendola P, O’Shea RM, Gogan C, Thines TJ, Corah NL. Training general practice residents in patient behavioral management. J Dent Educ 1989;53:727–30. 27. Atkinson JM, Millar K, Kay EJ, Blinkhorn AS. Stress in dental practice. Dent Update 1991;18:60–4.

Article VIII

Copyright  Eur J Oral Sci 2002

Eur J Oral Sci 2002; 110: 287–295 Printed in UK. All rights reserved

European Journal of Oral Sciences ISSN 0909-8836

A 3-year comparison of dental anxiety treatment outcomes: hypnosis, group therapy and individual desensitization vs. no specialist treatment

Rod Moore1, Inger Brødsgaard1,2, Randi Abrahamsen1 1

Department of Oral Epidemiology and Pediatric Dentistry, Dental Phobia Research and Treatment Center, Royal Dental College, Aarhus University, Aarhus, Denmark; 2 Department of Psychiatry, Aarhus Municipal Hospital, Aarhus University, Aarhus, Denmark

Moore R, Brødsgaard I, Abrahamsen R. A 3-year comparison of dental anxiety treatment outcomes: hypnosis, group therapy and individual desensitization vs. no specialist treatment. Eur J Oral Sci 2002; 110: 287–295.  Eur J Oral Sci, 2002 Outcomes of hypnotherapy (HT), group therapy (GT) and individual systematic desensitization (SD) on extreme dental anxiety in adults aged 19–65 yr were compared by regular attendance behaviors, changes in dental anxiety and changes in beliefs about dentists and treatment after 3 yr. Treatment groups were comparable with a static reference control group of 65 anxious patients (Dental Anxiety Scale ‡ 15) who were followed for a mean of nearly 6 yr. After 3 yr, 54.5% of HT patients, 69.6% of GT patients and 65.5% of SD patients were maintaining regular dental care habits. This was better than the 46.1% of the reference group, who reported going regularly to the dentist again within the cohort follow-up period, and 38.9% of a control subgroup with observation for 3 yr. Women were better regular attenders than men at 3 yr. Specialist-treated regular attenders were significantly less anxious and had more positive beliefs than regular attenders from reference groups. There were few differences between HT, GT and SD after 3 yr. It was concluded that many patients can, on their own, successfully start and maintain regular dental treatment habits with dentists despite years of avoidance associated with phobic or extreme anxiety. However, it also appears that these patients had less success in reducing dental anxiety and improving beliefs about dentists long-term than did patients who were treated at the specialist clinic with psychological strategies.

Of methods reported to aid odontophobic patients in their fight to conquer their extreme anxiety for dentists and dentistry, the results of any particular kind of treatment strategy are not often compared with other treatment methods, especially in longitudinal follow-up studies with a control cohort (1–6). Also, to our knowledge, there is no literature about numbers of odontophobic persons who have avoided treatment for years and then successfully start up treatment with only the benefit of supportive encouragement, or how often they continue to avoid treatment without the aid of a clinical intervention. Such a cohort of persons can provide a realistic baseline as controls for comparison with longitudinal results of experimental or quasi-experimental anxiety interventions used in specialist treatment. The use of psychological strategies such as individual systematic desensitization (SD) (1–4), group therapy (GT) (5, 6), and hypnosis (HT) (4, 5) have been reported to provide favorable results in reducing dental anxiety but vary in longterm changes of dental care attendance behavior, as the authors earlier showed in a 1-yr follow-up study (5). The present longitudinal study aimed to compare behavioral attendance results where the main criterion for success was regular dental care among patients 3 yr

Rod Moore DDS, PhD, Dental Phobia Research and Treatment Center, Royal Dental College, DK)8000 Aarhus C, Denmark Telefax: +45–86136550 E-mail: [email protected] Key words: anxiety; dental care; psychotherapy, hypnosis. Accepted for publication May 2002

after treatment for extreme/phobic dental anxiety with HT, GT or one of two types of individual SD (video training and direct clinical rehearsals). Anxiety and dental belief test scores of regularly attending patients were also compared. These intervention results were expected to be superior when compared with the same measures for a cohort of similarly anxious patients that received no specialist treatment but were followed over a period averaging nearly 6 yr. Other aims were to test for gender, educational or income differences for behavioral outcome, since these variables have been shown to be associated with variance in dental attendance (7).

Material and methods The subjects were 206 persons with extreme dental anxiety that had received treatment or were on the waiting list at the Dental Phobia Research and Treatment Center. As a result of a mass media campaign about the nature of phobic dental anxiety and treatment avoidance, 85% were self-referred (8). Other referrals were from physicians or dentists, who were requested to have patients call directly to the Center on a self-referral basis in order to provide more personal at-

288

Moore et al.

tention and a description of the Center’s system of operation. All subjects were telephone interviewed about the problem in the same manner and were counseled and encouraged to believe that their dental anxiety was treatable. They also completed psychometric written tests shortly after interviews and returned them by mail. In the original treatment groups, patients also completed the same test battery in the days prior to the first scheduled appointment (T1) and returned them by mail. Inclusion criteria were: (a) Dental Anxiety Scale (DAS) score of 15 or more (extreme dental anxiety); (b) a need for dental treatment; (c) comparable numbers of men and women; and (d) aged 18–65 yr. A group of 25 patients (10 men, 15 women) were consecutively assigned for HT (Table 1) for comparison with 68 randomly assigned SD therapy patients (34 men, 34 women) and 30 patients (15 men, 15 women) consecutively assigned for GT. Test score measures were DAS (9), Dental Fear Survey (DFS) (10), Dental Beliefs Survey (DBS) (11), State–Trait Anxiety Inventory (STAI) (12), and a modified FSS-II Geer Fear Scale (GFS) (13). The DAS is a four-item scale, whereas the 20-item DFS measures anxiety on three dimensions, behavioral, physiologic and cognitive. The DBS scores evaluated patient beliefs and security in relating with dentists, the GFS measured existence of other phobias and fears (such as sharp objects, injections, snakes, thunder, etc.), while the 20 items in the STAI, hereafter called STAI-T, were used to measure general trait anxiety. Both DFS and DBS were chosen as the main change indicators, since they were found to be the most reliable indicators of dental anxiety and trust changes after treatment (8). The DAS, GFS and STAI-T were used for sample comparability and inclusion criteria. Normative means of DAS ¼ 9.0, DFS ¼ 39.1, GFS ¼ 37.4, STAI-T ¼ 38.6 and DBS ¼ 30.3 (14-items) (8). The following therapeutic intervention protocols were conducted directly or directly supervised by the principal author during the entire intervention period. Systematic desensitization for individuals At appointment two, Jacobson’s progressive muscle relaxation (14,15) was trained in the dental chair, using a 12-min cassette tape and one of two kinds of SD training began. Video SD training was a modification of the method of Carlsson et al. (16), successively exposing patients to eight

30-s videotaped dental situations where scenes were interrupted with hand signals for relaxation pauses and instructions. The therapist was constantly present for conversations and to halt the video on request. Clinical rehearsal SD was direct, but simulated exposure to threatening dental situations or dental instruments in gradual, approximating steps, combined with tension awareness training, hand signaled-pauses and breath control. Group therapy At a second appointment, five groups of three men and three women each met for seven 2-h GT sessions led by the therapist/dentist, a dental assistant and a former patient of the Center. Sessions included information about phobic dental anxiety, social assertiveness training, relaxation training with 12 min audio-tapes as above and video desensitization in groups using the same videotape sequences described above, with a mix of voluntary and assigned use of hand signals for relaxation pauses. The final session was demonstration of injection and drilling procedures in the clinic. Interaction and support among participants was actively encouraged in all sessions. Hypnotherapy At the second appointment, HT patients experienced hypnosis in the dental chair and in subsequent appointments were gradually introduced to situations and instruments similar to clinical rehearsals described above. An Erickson hypnosis technique (17) was employed in which HT patients learned to restructure negative thoughts (e.g. the sound of the drill was reimprinted into a signal to help deepen trance state). Hypnosis was described to patients as a relaxation technique that could also be practiced at home using a 12 min cassette tape. In addition to relaxing thoughts, instructions also drew imagery of dental anxiety as a wall, and it was up to the patient to find out how to get to the other side. Dissociations were created in particularly stressful situations and in cases of previous traumatic experiences in treatment, age regression and reimprinting of the episode were employed. On the other side of the home practice tape was a 5-min self-induction for practice and use at future dental visits in private practices.

Table 1 Summary statistics for initial sample characteristics (n ¼ 206)* Age (Years)

Desensitization: (n ¼ 68) Video SD  (n ¼ 32) Rehearsal SD (n ¼ 34) Group therapy (n ¼ 30) Hypnotherapy (n ¼ 25) Reference control group (n ¼ 83) 3 yr subgroup (n ¼ 18)

Years avoiding dentist

Mean

SD

Range

Mean

37.0 33.3 40.6 36.7 39.3 35.6 32.7

10.3 7.9 11.1 8.2 7.9 8.8 8.5

19–65 19–50 19–65 22–60 24–58 19–60 19–47

10.0 9.3 11.0 9.0 8.9 6.5 3.6

SD 7.1 5.8 8.1 6.7 7.3 5.7 3.0

CDAS

GFS

STAI-T

Range

Mean

SD

Mean

SD

Mean

SD

1–33 1–21 1–33 0–28 1–26 0–30 0–10

18.1 18.0 18.0 17.5 18.2 17.9 17.7

1.4 1.6 1.2 1.5 2.0 1.9 1.9

43.4 43.4 43.9 45.6 39.2 42.9 47.0

13.4 14.8 12.0 15.0 13.6 15.1 17.8

39.3 39.0 39.8 39.2 37.0 41.3 41.4

12.1 11.6 13.0 12.5 9.8 13.4 11.9

*CDAS=Dental Anxiety Scale; DFS=Dental Fear Survey; STAI-T=State–Trait Anxiety Inventory; GFS=a modified FSS-II Geer Fear Scale.  SD=is systematic desensitization in this column.

Three-year anxiety treatment outcomes vs control Quasi-experimental measurement protocol and sample attrition The second psychometric test battery was given upon completion of video, rehearsal, group, or hypnosis training (T2). Training was considered complete when patients chose to go on after experiencing all situations described in each protocol, while maintaining a relaxed state. After training, two routine dental restorative test treatments were performed on each patient, as well as a third choice of another highly feared procedure, all of which occurred under hypnosis for HT. The final test battery was completed after the three test dental treatments (T3). Test dental treatments were similar for all intervention groups as described in 1-yr follow-up studies (5). A letter of introduction specific to each patient’s needs was formulated with the patient’s help and sent to a private dentist chosen from a list of interested dentists. All patients were encouraged to follow through with their choice of dentist and informed of follow-up plans. In the quasi-experimental groups, there were in all 17 dropouts during the first appointments of the therapy sessions. These were not included in the statistical comparisons of behavioral treatments because they had requested not to be contacted for follow-up. For comparisons, this training dropout category also had no equivalent with the reference control. Two men had dropped out after appointment one and thus had not even been assigned. The other 15 dropped out after assignment in therapy groups. This left 27 out of 32 video SD subjects, 33 out of 34 rehearsal SD subjects, 22 out of 25 HT subjects and 24 out of 30 GT subjects (Table 2) that completed therapy and test treatments (NS). After 3 yr, only six treatment intervention patients could not be recontacted (6/106); one from GT, four from rehearsal SD (2 were deceased) and one from video SD. (See sample attrition and flow diagram in Fig. 1 for quasi- experimental group comparisons as well as attendance comparisons in Fig. 2.) Of the 23 subjects from the intervention groups who could not or did not wish to participate in the follow-up study, seven were women and 16 were men, with mean age 33.6 yr (SD ¼ 9.4), which was less than the participating quasi-experimental cohort (mean 38.3 year; SD ¼ 9.2, t ¼ )2.2, P ¼ 0.03). Education, income levels, number of years avoidance and scores on DAS (mean 17.8), STAI-T (mean 40.2) and GFS (mean 38.5) were similar to the rest of the intervention cohort. Overall dropout rate 3 yr after successfully completed therapy was 36% (36/100) of those who were living, could be contacted and would participate. Static reference control group measurement protocol and attrition Out of 83 possible recontacts, a group of 65 (81.3%) consisting of 25 men and 40 women on the Center’s waiting list who were never treated, served as longitudinal reference control cohort for comparison. This group of patients may not be a Ônatural historyÕ comparison group, given that they received telephone counseling and were encouraged that their fear was treatable. However, their results were expected to be competitive with experimental subjects who received specialist care. The reasons that this group of waiting list patients were never treated by the specialist at the time they were called were that either they had sought dental treatment on their own before they were called in for specialist treatment (n ¼ 30), or felt they could

289

not afford the fees when called in for treatment (n ¼ 25), or refused treatment when called in owing to anxiety or other personal circumstances (n ¼ 10). It should be pointed out that the Center was state financed between 1990 and 1996, while after 1996, patients were required to pay standard hourly psychological counseling fees. Of the 18 subjects from the waiting list group that could not or did not wish to participate in the follow-up study, 10 were women and eight were men, with mean age 36.5 yr (SD ¼ 8.7), which was comparable with the participating control cohort. Observation duration (mean 7.7 year), educational, income levels, avoidance and scores on DAS (mean 17.6), STAI-T (mean 44.0) and GFS (mean 41.1) were also similar to the rest of the control cohort. Three of these subjects had died during the observation period compared with two from active intervention groups. The control cohort completed the test batteries at initial registration (T1) and again after a period varying from 2 to 10 yr (T4) (mean 5.9, SD ¼ 2.5). A control subgroup with observation duration of nearly 3 yr (mean 2.8; SD ¼ 0.5) was also used in analyses for maximum comparability with intervention groups. Control subjects completed the same battery as did intervention subjects initially, but control subjects were only asked to complete DAS, DFS, DBS and answer questions about visits to dentists in the present longitudinal follow-up (T4). Behavioral measures Three behavioral measures were tabulated at quasiexperimental or reference control follow-up: (a) patients that never went on to the dentist during the observation period; (b) patients that only went sporadically for emergency or pain treatment; and (c) patients that reported they regularly attended dental treatment at 3 yr or control follow-up (Fig. 2). Regular attendance was thought to indicate complete behavioral adjustment with intentions to deal with anxiety, while sporadic attendance was thought to indicate a more haphazard and incomplete behavioral adjustment. Thus, subjects were dichotomized in psychometric test analyses by regular attendance or lack thereof, since regular attenders had tested their own fears and negative beliefs about dentists by attending the dentist. Change of status in dental care attendance possibilities was examined by counting the numbers of experimental and control subjects that had reported being sporadic or regular attenders at a dentist within 2 yr prior to the initial telephone contact with the center. This was compared with subject report at follow-up. In addition to behavioral outcome and gender, dichotomized variables were also used for education level (high ¼ university or high school; low ¼ grade school/lower) and income (high ‡ $US 22 500/yr; low < $US 22 500/yr) as outcome predictors. Statistical methods A v2 (Yates’ correction) and bivariate odds ratios (OR) were used within and between groups in calculations of frequencies of behavioral outcomes for analysis of association. Therapeutic gains were also calculated as the difference in cure rate obtained by using any particular treatment over any other treatment or control group. Student’s t-tests and multiple regression analyses were also used to compare within- and between-group longitudinal change scores of DFS and DBS. Assumptions for data normality and use of

Table 2

*Not applicable.  Observed mean ¼ 5.9 yr.

DBS (15–75 points) Pretest Post therapy Post dental Tx All at follow-up (n at follow-up) Regular attenders (n at follow-up)

DFS (20–100 points) Pretest Post therapy Post dental Tx All at follow-up (n at follow-up) Regular attenders (n at follow-up):

Test

T4

T1 T2 T3 T4

T4

T1 T2 T3 T4

Time

46.6 20.0 16.8 23.9 (n ¼ 24) 21.8 (n ¼ 19)

76.0 39.5 30.1 41.1 (n ¼ 24) 38.3 (n ¼ 19)

Mean

9.7

13.6 9.4 3.8 9.9

16.1

12.8 12.8 7.2 16.5

SD

Video (n ¼ 27)

49.6 18.8 18.0 24.4 (n ¼ 27) 19.5 (n ¼ 17)

73.0 37.8 33.3 45.9 (n ¼ 27) 42.0 (n ¼ 17)

6.7

9.9 3.9 3.9 9.9

13.6

13.3 10.5 8.1 16.0

SD

Rehearsals (n ¼ 33) Mean

46.6 18.7 16.2 21.0 (n ¼ 19) 19.0 (n ¼ 16)

78.4 36.5 27.0 36.0 (n ¼ 19) 31.6 (n ¼ 16)

Mean

5.3

11.5 6.5 2.2 9.4

8.3

10.3 10.3 6.4 16.1

SD

Group Tx (n ¼ 24)

48.3 20.0 16.3 21.2 (n ¼ 14) 21.3 (n ¼ 12)

81.5 38.1 29.7 34.4 (n ¼ 14) 33.8 (n ¼ 12)

Mean

10.1

13.5 9.3 2.8 9.3

19.6

12.5 14.9 9.0 12.6

SD

Hypnosis (n ¼ 22)

Systematic desensitization (original n)

47.3 * * 36.0  (n ¼ 65) 24.7  (n ¼ 30)

80.2 * * 66.7  (n ¼ 65) 52.5  (n ¼ 30)

Mean

13.8

14.7 * * 18.4

19.6

11.7 * * 21.0

SD

Control  (n ¼ 65)

43.9 * * 37.4 (n ¼ 18) 26.9 (n ¼ 7)

78.9 * * 74.2 (n ¼ 18) 66.3 (n ¼ 7)

Mean

16.7

15.2 * * 18.1

16.7

14.3 * * 17.9

SD

Control 3 yr (n ¼ 18)

Summary statistics for Dental Fear Survey (DFS) dental anxiety and Dental Beliefs Survey (DBS) dental beliefs/trust scale scores for intervention and reference control groups in chronological order (n ¼ 171, See attrition flow diagram Fig. 1)

290 Moore et al.

Three-year anxiety treatment outcomes vs control

291

Initial population ca. 1987-1997 N = 206 Quasi-experimental cohort n = 123 Static reference control group n = 83

2 dropouts before experimental assignment

n = 121 15 droputs during training

18 non-participants (3 died, 15 not willing)

n =106 2 died, 4 no contact @ 3 yr,

Reference control cohort n = 65

n = 19

x- = 5.9 yr. observation

Rehearsal SD n = 29 regular attenders @ 3 yr:

n = 17

Whole reference control group regular attenders Static reference n = 30 3 yr subgroup cohort

n = 18

x- = 2.8 yr. observation

n = 100

Video SD n =26 regular attenders @ 3 yr:

Control 3 yr subgroup regular attenders

n=7

Group Tx n = 23 regular attenders @ 3 yr:

n = 16 Compare outcomes

Hypnosis Tx n = 22 regular attenders @ 3 yr:

n = 12

Flow diagram for quasi-experimental group comparisons Fig. 1. Longitudinal study attrition and selection flow diagram ending with samples of regular dental care attenders for comparisons between intervention cohorts and static reference control cohorts. (SD ¼ systematic desensitization).

Results Sample characteristics

Characteristics of HT, GT, and SD samples showed no meaningful differences when compared by age, initial dental fear, general fear or anxiety and years of treatment avoidance in the original samples (Table 1). Characteristics for the 25 men and 40 women of the reference control group showed no significant or meaningful differences from therapeutic intervention groups, despite differences in initial years of treatment avoidance at T1 (Table 1). In intervention groups, 37% had high educational level compared with 48.4% of controls; 46.2% had high income compared with 43.8% of reference controls (all non-significant, NS). Fig. 2. Dental care attendance behaviors exhibited by intervention and reference control cohorts. (Tx ¼ therapy).

Behavioral outcomes at 3-yr follow-up

parametric analyses, and specifically linear regression analysis, were fulfillled, since Q–Q plots indicated normality and Bartlett’s test indicated homogeneity of variances in psychometric test change scores. A level of P ¼ 0.05 was used to determine statistical significance by means of two-sided P-values and 95% confidence intervals (CI) where appropriate. SPSS 8.0 was used for calculations. All quasi-experimental and waiting list subjects were fully informed as to the nature of the research according to the Helsinki Declaration of 1975 and to local scientific ethics committee standards. Subjects volunteered to participate and consented in writing.

Patients avoiding private dental treatment at 3 yr after specialist treatment were often not willing to complete psychometric tests at follow-up and essentially dropped out of the research program, except to divulge in telephone conversations that they had not gone on to the dentist in the 3-yr period. After 3 yr (Fig. 1), 54.5% of HT patients (12/22) continued regular treatment with a private dentist compared with 69.6% of GT (16/23), 73.1% (19/26) of video-trained patients and 58.6% (17/ 29) of chair rehearsal trained patients for no significant differences (see Fig. 1). Only tallies from video-trained subjects (19/26) were significantly better than for subjects in the whole reference control group (30/65) (v2 ¼ 4.39, P ¼ 0.03) and for the 3-yr subgroup (7/18) (v2 ¼ 3.82,

292

Moore et al.

P ¼ 0.05). Therapeutic gains were 26.9% (CI ¼ 6.0– 47.8%) and 34.2% (CI ¼ 5.9–62.4%), respectively. The scores of GT patients approached significant improvement over whole control group (v2 ¼ 2.85, P ¼ 0.09) and 3-yr subgroup (v2 ¼ 3.03, P ¼ 0.08), where gains were 23.4% (CI ¼ 1.0–45.8%) and 30.7% (CI ¼ 1.3–60.0%), respectively. Regular attendance after 3 yr more often occurred among combined intervention groups (64/100) than for the whole control group (30/65) (v2 ¼ 4.42, P ¼ 0.04) and for 3 yr subgroup (7/18) (v2 ¼ 3.03, P ¼ 0.08) for therapeutic gains of 17.9% (CI ¼ 2.5–33.2%) and 25.1% (CI ¼ 0.7–49.5%), respectively. Change of status analysis showed that 13 out of 65 control subjects was proportionately higher than eight out of 106 experimental patients as sporadic or regular attenders before being treated at the specialist clinic (v2 ¼ 4.7, P ¼ 0.03, OR ¼ 3.1, CI ¼ 1.2–7.8). This was compared with follow-up in which 16 out of 65 controls were non-attenders vs 25 out of 100 intervention subjects. This indicated no significant advantage in change of status for control or intervention groups. Other longitudinal observations of attendance behaviors indicated that regardless of active intervention or reference control condition, women (65/97) were more likely (OR ¼ 2.7; CI ¼ 1.4–5.2; v2 ¼ 8.71, P ¼ 0.003) to be regular attenders than men (29/68). This held for women in combined treatment groups (43/57) (OR ¼ 3.2; CI ¼ 1.4–7.5; v2 ¼ 6.42, P ¼ 0.01) and the whole control group (22/40) (OR ¼ 2.6; CI ¼ 0.9–7.4; v2 ¼ 2.41, P ¼ 0.12). Overall, both treatment and control subjects with university or high school education (47/67) were more likely to attend dental care regularly than those with grade school education (44/94) (OR ¼ 2.7; CI ¼ 1.4–5.2; v2 ¼ 7.74, P ¼ 0.006). The same applied to family incomes equivalent to $US 22 500/yr or more (48/73) (OR ¼ 2.1; CI ¼ 1.1–3.9; v2 ¼ 4.27, P ¼ 0.04) compared with less than this figure (43/89). Longitudinal changes in dental anxiety and trust

Within-group changes – Of subjects within each active treatment intervention group who had gone on for regular care at 3-yr follow-up, there were significant (P < 0.001) and meaningful reductions in dental anxiety (DFS) and increased trust/positive beliefs (DBS) (P < 0.001) (Tables 2 and 3 and Fig. 3) from T1. This was also true for the whole reference control group (Table 3), but only reduction in DFS dental anxiety was significant for the 3-yr control subgroup (t ¼ )3.1, df ¼ 69, P ¼ 0.02). (DBS was t ¼ )2.2, df ¼ 69, P ¼ 0.07) (Tables 3 and 4). Between intervention and reference control groups – Compared with the whole reference control group, regular attenders (n ¼ 30), combined active intervention group regular attenders (n ¼ 64) fared better in change scores for DFS (t ¼ )3.3, df ¼ 92, P ¼ 0.001) and DBS (t ¼ )2.1, df ¼ 92, P ¼ 0.04). The same was true compared with 3-yr reference control subgroup (DFS t ¼ ) 4.2, df ¼ 69, P < 0.001; DBS t ¼ )3.0, df ¼ 69, P ¼ 0.004). (See also Table 4.)

Fig. 3. Box plots of mean group differences and 95% confidence interval (CI) for Dental Fear Survey (DFS) and Dental Beliefs Survey (DBS) change scores from baseline to exit for 3-yr intervention cohorts (n ¼ 64) compared with 3-yr reference control subgroup (n ¼ 7). (SD ¼ systematic desensitization; Hypno Tx ¼ hypnotherapy; Group Tx ¼ group therapy).

Between each intervention – In the regression analyses of between-group comparisons for intervention patients completing treatment and continuing after 3 yr, significantly larger DFS change scores were noted for each of the other interventions (n ¼ 47) vs direct rehearsal SD group (n ¼ 17). Regression model statistics were t ‡ 2.3, P £ 0.03 and R2 ¼ 0.21; adjusted R2 ¼ 0.16, F ¼ 3.9, df ¼ 63, and P ¼ 0.007. Differences in DBS between groups at 3 yr were not significant and regression models were inconclusive. There were no interactions by gender for anxiety scores or dental beliefs between quasi-experimental or with control groups in any of the regression analyses.

Discussion All of the therapeutic interventions were effective in dental anxiety reduction and improved trust at the end of

293

Three-year anxiety treatment outcomes vs control Table 3

Change score descriptives for Dental Fear Survey (DFS) dental anxiety and Dental Beliefs Survey (DBS) dental beliefs of regular dental care attenders at 3 yr follow-up (see box plots in Fig. 3) 95% CI Tests

n

Mean

SD

SE

Lower

Upper

Minimum

Maximum

DFS (20–100 points) Video systematic desensitization Direct rehearsal systematic desensitization Group therapy Hypnotherapy Whole control (3-yr subgroup).

19 17 16 12 30 7

40.3 29.2 42.5 50.2 27.3 13.1

16.7 13.2 10.2 19.5 18.7 11.2

3.8 3.2 2.5 5.6 3.4 4.2

32.2 22.4 37.1 37.8 20.3 2.8

48.3 36.1 47.9 62.6 34.3 23.5

6 9 23 19 )2 0

69 57 65 77 68 33

Total

94

35.8

18.0

1.9

32.1

39.5

)2

77

DBS (15–75 points) Video systematic desensitization Direct rehearsal systematic desensitization Group therapy Hypnotherapy Whole control (3-yr subgroup)

19 17 16 12 30 7

23.6 27.5 24.7 28.9 19.0 10.1

15.9 11.4 9.4 16.0 18.1 12.4

3.6 2.8 2.3 4.6 3.3 4.7

15.9 21.6 19.7 18.8 12.2 )1.4

31.2 33.3 29.7 39.1 25.7 21.6

0 4 8 7 )37 )10

52 44 47 53 47 23

Total

94

23.7

15.2

1.6

20.6

26.8

)37

53

Table 4 Multiple regression change score model results for Dental Fears (DFS) and Dental Beliefs (DBS) for intervention group regular attenders after 3 year (n ¼ 64) vs. reference control subgroup after 3 year (n ¼ 7). (In all, 71 gender controlled observations) n

Coefficient

SE

DFS anxiety change model – intervention groups vs reference control group* DFS for: Video systematic desensitization 19 27.5 6.5 Direct systematic desensitization 17 15.8 6.6 Group therapy 16 30.1 6.7 Hypnotherapy 12 36.8 7.0 Gender )4.9 3.8 Constant 19.4 7.4 DBS dentist beliefs change model – intervention groups vs reference control group  DBS for: Video systematic desensitization 19 13.4 5.9 Direct systematic desensitization 17 17.4 6.0 Group therapy 16 14.4 6.1 Hypnotherapy 12 18.8 6.4 Gender 0.74 3.4 Constant 9.2 6.7

t

4.3 2.4 4.5 5.3 –1.3 2.6

2.3 2.9 2.4 3.0 0.22 1.4

P

95% CI

0.000 0.019 0.000 0.000 0.199 0.010

14.6 2.7 16.8 22.9 )12.4 4.7

40.5 28.9 43.4 50.8 2.6 34.1

0.027 0.005 0.021 0.004 0.830 0.177

1.5 5.3 2.3 6.8 )6.1 )4.2

25.2 29.4 26.6 31.5 7.6 22.6

*R2 ¼ 0.37; adjusted R2 ¼ 0.32; F ¼ 7.6, df ¼ 70, P ¼ 0.0000.  R2 ¼ 0.14; adjusted R2 ¼ 0.07; F ¼ 2.1, df ¼ 70, P ¼ 0.08.

the specialist training period (T2) and after test dental treatments (T3) on a population of odontophobics with known and previously described characteristics (5, 7). Hypnosis had the greatest attrition, where nearly 50% of the original subjects had dropped out or not regularly attended private dentists during the 3-yr follow-up period, but this was not significantly greater attrition than for other methods. Only video SD patients had a significantly greater percentage of regular attenders at followup than did the controls, even though GT was close. Overall, intervention subjects were significantly better regular dental care attenders after 3 yr than were reference controls. Since sustained dental care behavior is the

ultimate goal of dental anxiety treatment (1–7, 18), these differences in rates indicate that fundamental and positive changes have occurred for present therapy patients over the 3-yr period and that these were significantly better than controls. These results were robust even though they favored the whole control group, which was observed for a longer period and thus had greater opportunity to establish regular care habits than did intervention groups. All specialist intervention 3-yr regular attenders were also significantly less anxious and had more positive beliefs about dentists than regular attenders from the whole control group. Regression model results confirmed that regular attenders receiving

294

Moore et al.

specialist treatment had reduced their dental anxiety more effectively at 3-yr follow-up than had 3-yr subgroup control regular attenders (Fig. 3 and Table 4). However, although there were also significant differences between specialist intervention dental belief changes and reference control belief changes for 3-yr regular attenders, the best regression model for these results could explain only 7% of the variance. This may suggest that since these subjects changed their beliefs, with or without specialist help, that this was a key variable that directly affected their dental care behavior. Although dental beliefs had changed among regular dental care attenders, anxiety reduction appears to require special expertise. Perhaps this makes the possibility of care avoidance relapse more likely in clinical populations similar in nature to these reference controls if anxiety is not properly handled. This suggests potentially important information about the relationship between behavior, beliefs and anxiety, since dental beliefs in the control subjects appear to coincide with attendance behavior better than anxiety reduction. Although the aim of the present study was not to check attendance/non-attendance vs beliefs/anxiety, this relationship should be explored in future research, since dental beliefs have been shown to be associated with dental anxiety among anxious patients (7, 8). The present results may suggest some directionality in these relationships, at least for these reference control subjects and their self-reported clinical conditions. Untreated anxious dental patients in general populations are also an important risk group for future research. It could be concluded from the present data that many anxious patients can successfully start and maintain regular dental treatment on their own, despite years of treatment avoidance owing to poor dental beliefs and related phobic or extreme anxiety. However, it also appears that dentists treating the anxious dental patients in reference control groups had less success in reducing dental anxiety while improving trust and beliefs about dentists and dentistry to some degree than did patients treated at the specialist center. The Ôbalance of powerÕ within the dentist–patient relationship requires that busy, often stressed dental practitioners (19) note and address the anxiety or pain perceptions of patients or that patients become more assertive about their needs. Dentists must provide patients with a sense of trust that they will take the time to explain procedures, provide reassurance, obtain adequate anesthesia from the patient’s perspective, and encourage patient participation in their own treatment. Thus, in general, it must be concluded that the process of trust in dentist–patient relations should be promoted as a primary therapeutic goal that enables patients to improve beliefs about dentists and dentistry while also confronting and controlling their anxiety and avoidance of dental care. The present results also indicated that in order to achieve long-term regular dental care attendance after specialist treatment, it is also important for specialists to provide adequate counseling that would benefit regular dental-care habits. Patients should be helped to learn to attribute their success mainly to their own efforts and not the therapist’s, so that they may

successfully continue regular dental health care in private practices of their choice after initial therapy (5). In general, restructuring of counterproductive thoughts through psychological counseling (cognitive therapy) is essential to help many odontophobic patients, especially those that present with high general trait anxiety or fears (7, 20). Thus, the present results concur with two older Swedish studies (21, 22) as well as a recent Swedish study (20) and a Danish study (23). These indicate that in order to predict and improve treatment outcome, the relationship between outcome and differential diagnosis by dental anxiety type requires a broad spectrum of approaches specifically suited to each patient’s situation. The relationships between outcomes, differential diagnosis and fitting therapy to patient are important and require further clinical research, especially research that uses longitudinal designs. Acknowledgments – This study was supported by The Danish National Health Insurance Fund (#H11/93, # H11/214–92; #11/1–90 and #11/138–87), New National Dental Association, and Colgate Palmolive Co., Denmark. Authors thank Lis Jørgensen for data preparation and Flemming Scheutz for analytic help.

References 1. Berggren U. Long-term effects of two different treatments for dental fear and avoidance. J Dent Res 1986; 65: 874–876. 2. Hakeberg M, Berggren U, Carlsson SG. A 10-year followup of patients treated for dental fear. Scand J Dent Res 1990; 98: 53–59. 3. Aartman IHA, De Jongh A, Makkes PC, Hoogstraten J. Dental anxiety reduction and dental attendance after treatment in a dental fear clinic: a follow-up study. Community Dent Oral Epidemiol 2000; 28: 435–442. 4. Hammarstrand G, Berggren U, Hakeberg M. Psychophysiological therapy vs hypnotherapy in the treatment of patients with dental phobia. Eur J Oral Sci 1995; 103: 399–404. 5. Moore R, Abrahamsen R, Brødsgaard I. Hypnotherapy compared with group therapy and individual desensitization for dental anxiety. Eur J Oral Sci 1996; 104: 612–618. 6. Moore R, Brødsgaard I. Group therapy compared with individual desensitization for dental anxiety. Community Dent Oral Epidemiol 1994; 22: 258–262. 7. Moore R. The phenomenon of dental fear. Studies in clinical diagnosis, measurement and treatment. PhD Thesis. A˚rhus: Royal Dental College, 1991. 8. Moore R, Berggren U, Carlsson SG. Reliability and clinical usefulness of psychometric measures in a self-referred population of odontophobics. Community Dent Oral Epidemiol 1991; 19: 347–351. 9. Corah NL. Development of a dental anxiety scale. J Dent Res 1969; 48: 596. 10. Kleinknecht RA, Bernstein DA. The assessment of dental fear. Behav Ther 1978; 9: 626–634. 11. Milgrom P, Weinstein P, Kleinknecht R, Getz T. Treating fearful dental patients: a clinical handbook. Reston: Reston, 1985. 12. Spielberger CD, Gorsuch RL, Lushene RE. STAI manual for the state-trait anxiety inventory. Palo Alto: Consulting Psychologists Press, 1970. 13. Berggren U, Carlsson SG. Psychometric measures of dental fear. Community Dent Oral Epidemiol 1984; 12: 319–324. 14. Jacobson E. Progressive relaxation. Chicago: University of Chicago Press 1929.

Three-year anxiety treatment outcomes vs control 15. Levin RB, Gross AM. The role of relaxation in systematic desensitization. Behav Res Ther 1985; 23: 187–196. ¨ hman A. Reduction of tension in 16. Carlsson SG, Linde A, O fearful dental patients. J Am Dent Assoc 1980; 101: 638–641. 17. Waxman D, ed. Hartland’s medical and dental hypnosis. London: Baillie`re Tindall, 1989. 18. Dailey Y-M, Crawford AN, Humphris G, Lennon MA. Factors affecting dental attendance following treatment for dental anxiety in primary dental care. Prim Dent Care 2001; 8: 51–56. 19. Moore R, Brødsgaard I. Dentists’ perceived stress and its relation to perceptions about anxious patients. Community Dent Oral Epidemiol 2001; 29: 73–80.

295

20. Berggren U, Hakeberg M, Carlsson SG. Relaxation vs. cognitively oriented therapies for dental fear. J Dent Res 2000; 79: 1645–1651. ¨ st LG. Ways of acquiring phobias and the outcome 21. O of behavioral treatments. Behav Res Ther 1985; 23: 683– 689. 22. Harrison JA, Berggren U, Carlsson SG. Treatment of dental fear: systematic desensitization or coping? Behav Psychother 1989; 17: 125–133. 23. Moore R, Brødsgaard I. Differential diagnosis of odontophobic patients using the DSM-IV. Eur J Oral Sci 1995; 103: 121–126.

Article IX

BMC Psychiatry

BioMed Central

Open Access

Research article

The contribution of embarrassment to phobic dental anxiety: a qualitative research study Rod Moore*1, Inger Brødsgaard2 and Nicole Rosenberg3 Address: 1Dental Phobia Research and Treatment Center, Department of Community Oral Health and Pediatric Dentistry, Royal Dental College, University of Aarhus, Aarhus, Denmark, 2Department of Psychiatry, Psychiatric Hospital, University of Aarhus, Aarhus, Denmark and 3Clinic for Anxiety and Personality Disorders, Department of Psychiatry, Psychiatric Hospital, University of Aarhus, Aarhus, Denmark Email: Rod Moore* - [email protected]; Inger Brødsgaard - [email protected]; Nicole Rosenberg - [email protected] * Corresponding author

Published: 19 April 2004 BMC Psychiatry 2004, 4:10

Received: 17 December 2003 Accepted: 19 April 2004

This article is available from: http://www.biomedcentral.com/1471-244X/4/10 © 2004 Moore et al; licensee BioMed Central Ltd. This is an Open Access article: verbatim copying and redistribution of this article are permitted in all media for any purpose, provided this notice is preserved along with the article's original URL.

Abstract Background: Embarrassment is emphasized, yet scantily described as a factor in extreme dental anxiety or phobia. Present study aimed to describe details of social aspects of anxiety in dental situations, especially focusing on embarrassment phenomena. Methods: Subjects (Ss) were consecutive specialist clinic patients, 16 men, 14 women, 20–65 yr, who avoided treatment mean 12.7 yr due to anxiety. Electronic patient records and transcribed initial assessment and exit interviews were analyzed using QSR"N4" software to aid in exploring contexts related to social aspects of dental anxiety and embarrassment phenomena. Qualitative findings were co-validated with tests of association between embarrassment intensity ratings, years of treatment avoidance, and mouth-hiding behavioral ratings. Results: Embarrassment was a complaint in all but three cases. Chief complaints in the sample: 30% had fear of pain; 47% cited powerlessness in relation to dental social situations, some specific to embarrassment and 23% named co-morbid psychosocial dysfunction due to effects of sexual abuse, general anxiety, gagging, fainting or panic attacks. Intense embarrassment was manifested in both clinical and non-clinical situations due to poor dental status or perceived neglect, often (n = 9) with fear of negative social evaluation as chief complaint. These nine cases were qualitatively different from other cases with chief complaints of social powerlessness associated with conditioned distrust of dentists and their negative behaviors. The majority of embarrassed Ss to some degree inhibited smiling/laughing by hiding with lips, hands or changed head position. Secrecy, taboo-thinking, and mouth-hiding were associated with intense embarrassment. Especially after many years of avoidance, embarrassment phenomena lead to feelings of self-punishment, poor selfimage/esteem and in some cases personality changes in a vicious circle of anxiety and avoidance. Embarrassment intensity ratings were positively correlated with years of avoidance and degree of mouth-hiding behaviors. Conclusions: Embarrassment is a complex dental anxiety manifestation with qualitative differences by complaint characteristics and perceived intensity. Some cases exhibited manifestations similar to psychiatric criteria for social anxiety disorder as chief complaint, while most manifested embarrassment as a side effect.

Page 1 of 11 (page number not for citation purposes)

BMC Psychiatry 2004, 4

http://www.biomedcentral.com/1471-244X/4/10

Table 1: Clinical features distinguishing social anxiety disorders from other anxiety disorders (adapted from Ballenger et al. [17, 18]

Fear, anxiety

Feelings of guilt, shame and inferiority

Avoidance of dental care

Deterioration of dentition Figure circle Vicious 1 of dental anxiety as described by Berggren [11] Vicious circle of dental anxiety as described by Berggren [11]

Background Most studies of the symptomatology of dental treatment anxiety have focused on the contributions of pain or unpleasant experiences [1-6], traumatic experiences [3-5] and co-morbidity with other anxiety and mood complexes [2,7-9]. Although some have also reported feelings of lack of control, powerlessness and embarrassment in dental treatment situations as contributing factors [4,710], actual mechanisms and other details of these psychosocial factors have not been thoroughly described. Earlier Scandinavian studies [7,8,11,12] indicated existence of a vicious circle of dental anxiety, in which embarrassment, shame or guilt have a central role in facilitating both anxiety and treatment avoidance, but they gave few details as to the exact role of embarrassment in this vicious circle (see Fig. 1). Since symptomatology and clinical significance are important in differential diagnosis of anxiety disorders, it seems that the influences of embarrassment, shame or guilt on dental anxiety have been relatively neglected in the literature. Inspite of the fact that the dentist-patient clinical situation is a social situation and that several studies have also pointed to negative dentist behavior as highly anxiety provoking [4,7,8,11,1316], descriptions of possibilities for the existence of social anxiety, defined as intense fear of negative evaluation [17,18] or humiliation [19] in social situations, have been few for patients suffering with dental anxiety [7,8,13]. Recent medical literature [18,20-22] has drawn attention to primary care occurrences of social anxiety disorder or phobia. They suggest that perhaps practitioners and counselors are focused on other problems than social anxiety

* Anxiety precipitated by social interactions or performance situations * Unique cognitions of negative evaluation by others * Blushing, palpitations, sweating, tachycardia, trembling are characteristic * Onset in childhood or adolescence * Impairment usually leads to avoidance of named social and performance situations

or judge that feelings of embarrassment, shame or guilt are only secondary to more concrete problems, such as specific phobias or presence of other co-morbid anxiety or mood disorders. Thus, social anxiety and phobia are described as substantially under-diagnosed in both clinical and non-clinical samples [19-21]. Some [19,22] have questioned the adequacy of present methods in differentiating the existence of social anxiety disorder as principal diagnosis in both clinical and non-clinical populations. This is currently accomplished using a standard interview schedule of the Diagnostic and Statistical Manual [23], the Standard Clinical Inventory of Disorders – Patient version (SCID-P)[24]. Examples used in the SCID-P interview for social anxiety are fear of negative social evaluation with speaking, eating or writing. This would result in anxious dental patients rarely being diagnosed with social anxiety disorder or phobia, when fear of negative scrutiny in clinical social contexts might otherwise be a chief complaint and possible principal diagnosis. There has been a call for more case study research on the topic of social anxiety criteria in medical and other social contexts in order to discover new situations in which this nominal data category may arise, also as principal diagnosis [19,22]. An International Consensus Group on Depression and Anxiety proposed guidelines for distinguishing social anxiety disorder from other anxiety disorders [17] as shown in Table 1. There can be confusion about the terms themselves, since in the course of daily conversation they are often used interchangeably. The main differences are that embarrassment and shame are associated with personal response to public scrutiny about moral conventions or loss of selfesteem, while guilt ("bad" or "guilty conscience") is thought of as self-scrutiny with breach of personal standards [25]. When it is referred to as a specific emotion, embarrassment is described as more fleeting in duration and has less serious consequences [25] than shame. However, embarrassment is also used as a more general term [4,7,16,26]: an emotional reaction (shame or guilt) to unintended and/or unwanted social predicaments or transgressions [26]. In the present study, we use the term embarrassment as this general term, unless otherwise specified.

Page 2 of 11 (page number not for citation purposes)

BMC Psychiatry 2004, 4

http://www.biomedcentral.com/1471-244X/4/10

Table 2: Sample summary statistics (N = 30)

Age (yr)

Years avoiding dentist

CDAS

GFS

STAI-T

DBS

Mean

SD

Range

Mean

SD

Range

Mean

SD

Mean

SD

Mean

SD

Mean

SD

45.1

9.9

20–65

12.7

9.1

0.5–37.5

17.8 9.0

2.1

37.6 39.1

15.5

39.3 38.6

12.1

44.2 30.1

13.1

Normative scores* * Standard mean scores of psychometric tests on normal populations

The aim of the present study was to describe details of social aspects of anxiety in dental situations, especially focusing on embarrassment phenomena and their contribution to manifestations of extreme or phobic dental anxiety.

Methods Subjects were 30 consecutive Danish adult patients from the Dental Phobia Research and Treatment Center (16 men, 14 women), aged 20–65 yr, who had avoided dental treatment for a mean of 12.7 years due to anxiety. 63% were self-referred as a result of mass media attention and/ or friends or family urging, while 37% were professional referrals (physicians 20%; dentists 17%). Previously published research inclusion criteria included: 1) extreme or phobic dental anxiety (Dental Anxiety Scale score = 15 (max. 20), 2) a need for dental treatment, and 3) ages ca. 18 to 65 yr. Patients at the specialist center filled out psychometric questionnaires previously described in the literature [27] which included Corah's Dental Anxiety Scale (DAS)[28], Dental Beliefs Survey (DBS) [29] covering aspects of patient perceptions about relations with dentists, State-Trait Anxiety Inventory-Trait subscale (STAIT)[30] covering general anxious anticipation, and a modified FSS-II Geer Fear Scale (GFS)[31] covering existence and intensities of other fears. Table 2 has sample statistics and normative scores for DAS, GFS, STAI-T [27] and DBS [32]. Subjects were asked the following questions in audiotaped initial fear assessment interviews: 1) "When was your last dental visit? How did it go? 2) "What is the worst thing for you about dental visits?" 3) "Try to tell in your own words about your fear of dental treatment. Where do you think it started?" 4) "Have there been any special experiences related to this? " (If so: How old were you?) 5) "Do your friends or family know about your dental anxiety? (If so: How do they react to it?) 6) "Do you feel that the condition of your teeth influences your relations to family and friends in any way?" 7) "Is there anything in your background that makes it so that you would be so afraid (besides any bad dental experiences)?" 8) "Are there other things that you are as afraid of?" (Specify: Doc-

tors? Hospitals?) 9) "How do you experience yourself under stressful conditions?" In an exit interview after treatment completion, patients were asked: 1) "What helped you most to get over your dental anxiety?", 2) "What helped you next most?" and 3) "Are there other things besides resolution of your dental anxiety that you have learned here?". Such questions intended to provide a retrospective validation of initial chief complaint or indicate changes in diagnostic type as well as assess efficacy of treatment strategy for the type [33]. In all interviews, unstructured follow-up questions were also employed to encourage descriptive detail e.g., "Could you tell me more about 'such and such'?" or confirmations of meanings e.g., "So you mean that you are embarrassed about your teeth?" Although analysis of qualitative descriptions was the main research method, embarrassment intensity and degree of mouth-hiding behaviors were also scaled to check for associations with each other and with years of treatment avoidance for conceptual validation and explanatory purposes. An embarrassment intensity rating scale was devised in which Ss were rated by the first and second authors from 0 = "no embarrassment" to 1 = "little", 2 = "some", 3 = "much" and 4 = "very much embarrassment or principal problem" based on clinical records and transcript material. (Kappa statistic for the two raters concurred at 0.79, P < .001.) Patient transcription reports about symptoms of not being able to smile or laugh fully and mouth-hiding during social interactions were coded: 0 = "none", 1 = "unspecified inhibitions or hiding – low degree", 2 = "hiding with lip or tongue only" and 3 = "combined hiding with lip or tongue and hiding with hand or head behaviors". All subjects participated after written and verbal informed consent, in accordance with local ethics committee standards and the Helsinki declaration.

Page 3 of 11 (page number not for citation purposes)

BMC Psychiatry 2004, 4

Analysis Patients' electronic clinical records and all audio-taped interviews were transcribed verbatim and saved in "text only" raw files after appropriate measures to assure anonymity of clients and their previous dentists. These text files of patient records and interviews were then imported into Qualitative Solutions Research "N4" software [34] in order to aid exploration of categories or contexts related to social aspects of dental anxiety as well as embarrassment phenomena. The program basically aids in "cut and paste" procedures in examining evidence to support categorical analyses. Spearman's rho (rs) correlations, odds ratios (OR) with 95% confidence intervals (CI) and Chisquare tests were used for analysis of associations between quantifiable variables. Statistical significance of tests were set at P = 0.05, but this was only used to indicate meaningful relationships between variables, not as a claim to statistical inference to representativity, since this is unknown.

Results Sample characteristics Three Ss did not complete therapy; two dropped out after three appointments and one was satisfied with two consultations. The 30 Ss were demographically and psychometrically (Table 2) similar to those previously described for present specialist clinic [27]. They received cognitivebehavioral therapy and limited dental treatments for a mean of 15.3 appointments (SD = 6.1).

Twelve Ss of the 30 had mentioned general anesthesia in initial interviewing, where 8 thought of it initially as a possible "quick fix" solution to their problems. Three had tried it as children and had negative experiences and therefore didn't think of it as a solution. One client had never tried it, but when a physician offered to refer him, he was too afraid. For 66.7% of Ss, self-reported age of onset was 12 yr. or less. Mean age of onset was 15.1 yr. (SD = 9.7; range = 5.5–43 yr.). Although not usually chief complaints, incidence of embarrassment was substantial in this sampling. When asked about the condition of their teeth or effects on social relationships, all but three of the Ss expressed some degree of embarrassment about their dental fear problem or its consequences. Chief complaints Chief complaint at initial consultation for 9 Ss was pain, while 14 Ss cited "the whole process", referring to social aspects of the dental care situation and specifically named powerlessness or lack of control in the dental environment as the main problem. Seven Ss described co-morbid psychosocial dysfunction mostly related to general anxiety as a reason for seeking specialist treatment for dental

http://www.biomedcentral.com/1471-244X/4/10

anxiety, but none complained of depression at the time of interviews. Seven Ss had had previous psychiatric care. Nine patients described a generally discordant childhood, including 3 cases of sexual abuse. Moods disorders or depression was never a chief complaint among these subjects. Thus, 47% of Ss expressed a sense of powerlessness about the whole dental situation as chief complaint, implying in relation to dentists or other personnel. Although several other Ss described feelings of a lack of control in the situation, it was secondary to other chief complaints or specific problems such as fear of anesthesia failure, panic attacks, choking or due to generally anxious feelings perceived as uncontrollable. Thus, the term "social powerlessness" was used in the following chief complaint analysis, since patients most often used the Danish terms for "powerless" or "powerlessness" to designate feelings of lack of control in relation to the dentist or staff. A qualitative analysis about chief complaints of feelings of social powerlessness was first undertaken in order to differentiate embarrassment from other possible types of social powerlessness. Then, analyses of both clinical and nonclinical manifestations specific to categories and characteristics of the phenomenology of embarrassment followed. English translations of all Danish transcript passages were checked among the three bilingual authors. Social powerlessness as chief complaint associated with anxiety in dental care situations In the present study, patient perceptions and descriptions about powerlessness in social interactions with the dentist were of two categories: 1) Social powerlessness associated with conditioned distrust of dentists' behaviors e.g. "I am afraid of how the dentist will do what he has to do and that I can't stop him." This could also include secondary embarrassment, since subjects' own behaviors or cognitions can seem out of control, e.g. "My reactions get so out of control sometimes that it's embarrassing." and 2) Social powerlessness primarily associated with embarrassment about anxiety, dental care neglect and treatment avoidance or appearance e.g. "I am afraid of what the dentist or others are thinking about me and how bad my teeth are or how long it has been since I had treatment." This did not preclude complaints of conditioned distrust of dentists in some cases, but these were secondary to the chief complaint or reason for seeking therapy. Case studies below illustrate the two types of social powerlessness. Social powerlessness as conditioned distrust of dentist behavior Descriptions of humiliating or physically traumatic events in an uneven power struggle with dentists filled this category of negative dentist behaviors as illustrated in the following case study.

Page 4 of 11 (page number not for citation purposes)

BMC Psychiatry 2004, 4

Case #21 35 yr old day care mother (35 F) had last been to the dentist 7 years ago for emergency care. As a 10 yr old girl, she was forced against her will to have an operation to reposition an impacted canine tooth. The mother had accompanied her to the clinic and had originally given permission for the operation. But she protested at the last minute when she saw how frightened her daughter became. She was asked to leave the operatory and the operation was performed behind closed doors. 35 F: "And I remember that I screamed like a wild animal.. that I didn't want them to do it. So they just closed the door into the clinic, then in come a couple more assistants and I was held down here (shows on her arms and legs). Then they told me that I had a choice. Either I would lie still and they could get it over with quickly or I would be held down and it would take a long time. It was my choice. And that's how it was." (She cries.) In this case, the resultant reaction was a dreadful anxiety about being entrapped and "forced" into treatment situations, akin to claustrophobia. Her presenting symptoms of crying whenever in the dental chair provoked embarrassment secondarily. The patient described her struggle to gain control over the irrational feelings of a perceived threat from not knowing what dentists might do.

http://www.biomedcentral.com/1471-244X/4/10

Case #3 A 36 yr old career business-woman (36 F) had avoided dental treatment 13 years and was embarrassed to admit it to her family and co-workers. Whereas 10 years ago her dental anxiety had been coupled to negative cognitions of dental procedures, it had now turned into something else. She tried to keep it a secret from family and co-workers, but had great difficulty, considering the toothache pains she experienced periodically. Since she could not face the problem without professional help, oral neglect led to a bad conscience and conflicts about her own image as mother and career woman since at home and work she was known as a "take charge" kind of person by her own description. RM (first author): "What is the worst thing, when you think about going to the dentist?" 36 F: "Today it would perhaps have something to do with being embarrassed about the condition of my teeth. But 10 years ago they were not as bad as they are today. And I don't know if it is the (feelings of) powerlessness that made it so... but I simply couldn't foresee these consequences. I can't really explain it." RM: " So it has come to that the embarrassment is actually the biggest barrier?"

35 F: "...normally I can say to myself, 'Just try it. It only takes 10 minutes... like going to the doctor and getting a gynecological checkup. Try to relax and breathe all the way down to your big toe and in about 2 minutes it will all be over.' What irritates me most (about at the dentist) is that you can't have control at all over what is happening. A wire just short circuits up in my head. It's horrible, really terrible."

36 F: " Yes. If you don't take care of your teeth, you get pain. And the pain, it really gets bad sometimes, where I need pain killers for it. Then I've often thought when I've had toothache, 'If I had (only) been to the dentist. It couldn't hurt more than this!' But from there to take the steps (dental visit), ... they are miles apart. "

RM: "You are just afraid that---?"

36 F: Yes... yes!

35 F: "Just suddenly he would pull out something or other (instrument).. "

This exemplifies the plight of many patients with phobic dental anxiety who have thoughts and feelings that the problem is bigger than themselves or their physical pain, and as in this case, was specifically related to embarrassment about getting started after a longer period of treatment avoidance.

Social powerlessness primarily associated with embarrassment Feelings of powerlessness related to the embarrassment of revealing years of dental neglect to dentist and staff had developed as the main reason for dental treatment avoidance for this category, even though there may have been other reasons at the beginning of the avoidance history. Symptoms of embarrassment were also manifested outside clinical settings, indicating that complexities of shame and guilty conscience about avoiding treatment were not the only manifestations of this type of social powerlessness. Embarrassment was the main reason for seeking therapy, where other usually highly motivating factors such as pain, were not. These complexities are illustrated in the following case.

RM: "So the anxiety is worse than the pain, in a way?"

Embarrassment phenomena and characteristics The embarrassment category identified above as chief complaint (n = 9) manifested for Ss both at the dentist office when showing their mouths to dental personnel and having to admit to long periods of neglect and anxiety, as well as in general embarrassment or shame about dental neglect with inhibited smiling or dysfunctions in other social situations. Sixty-three percent of the sample described and were observed with symptoms of not being able to smile or laugh fully or had learned to cover their

Page 5 of 11 (page number not for citation purposes)

BMC Psychiatry 2004, 4

teeth with a hand, lip or tongue during social interactions. Blushing was also commonplace, especially at oral examinations. Other embarrassment phenomena, whether in clinical or non-clinical settings, were bad conscience/selfpunishment, secrecy/taboo-thinking, poor self-image/esteem and in some cases, social withdrawal and personality changes. Six patients expressed feelings of inferiority based on their dentist avoidance and/or shame about their facial appearance and tended to avoid other people. Bad conscience / self-punishment Social circumstances for embarrassment were often linked to bad conscience about years of neglect where avoiding dental care was often seen as a sign of personal failure or inadequacy leading to self-punishment and associated poor self-image/esteem. The following case study exemplifies this:

Case #18 50 yr male (50 M) computer programmer was embarrassed about having avoided dental treatment for 26 yr and he described embarrassment characteristics as a personal failure in that regard: 50 M: " I feel as if I may have been punishing myself. I feel awful with the fact that I have not been able for that period of time to go regularly to the dentist. I think it is really bad of me. It is like a personal failure in some way that I wasn't able to take care of it." RM: "So you see yourself as a rational human being and that was irrational?" 50 M: "Exactly. It is that that is my problem, because in my daily life I am used to thinking rationally and I can even criticize other people if they react so irrationally... since I do it also myself ... I don't know if I can say it is a double standard, but it is something like it. It gives cause for selfpunishment. ..It's just too bad that I couldn't deal with it." He went on to describe that his social inhibitions had lead him to a generally poor self-image. Two subjects also indicated they felt embarrassed at the dentist because they might be "troublesome patients" for dentists. Neither subject experienced a high degree of embarrassment intensity. Secrecy / taboo-thinking Many patients had developed secrecy rituals that had to do with social taboos in talking about the topic of going to the dentist or the condition of their oral health. Taboothinking with rituals of secrecy both at work (11/30) and with family members (6/30) was observed and was associated with descriptions of bad conscience or poor selfesteem in patients (n = 11) who had been avoiding

http://www.biomedcentral.com/1471-244X/4/10

treatment for more than the mean number of years (12.7 yr) of treatment avoidance. This subgroup had mean 18.2 yr of avoidance. Some of these patients expressed fear that their teeth or mouths were being observed and were negatively evaluated by others. The following case study illustrates these relationships. Case #8 51 yr old passenger ferry captain (51 M) who had avoided treatment for 23 years and who had carefully guarded his secret until recent events at his workplace: 51 M: "Clearly I haven't felt good about that I haven't done anything with my teeth for so many years. I just don't talk about it with anyone. That's the way it is." RM: "Taboo?" 51 M: "Yes, because generally I am a very reasonable person and I don't want anyone to discover that I have a hard time with something." RM: "But when someone talks about dentists?" 51 M: "I don't talk much about it." RM: "In your social circle?" 51 M: "Yes, I keep my mouth shut. I hadn't even said anything to my wife about it. She has actually first now learned about it yesterday that I was coming here (therapy)." RM: "So it's a secret?" 51 M: "It's a secret." (nodding confirmation). RM: "And it is a secret that you want to get rid of?" 51 M: "Yes, of course I would like to get to the point where I can say like anyone else, 'Now I have also been to the dentist and everything is OK." He continued to explain after treatment completion: 51 M: "(Now) I can talk freely about going to the dentist It had been taboo before. It affected me in relation to others... that I have had to hide something. I had always feared that someone (would say) 'When have you been to the dentist?' Therefore, if people started talking about the dentist, I changed the topic... because then I wouldn't get that question. And I would have been terribly embarrassed if I had to say 'It has been darn many years ago.' It has been like a symptom every single time I have opened my mouth, that one could see those two front teeth. So I thought, 'You must get them fixed!' I can tell you that it

Page 6 of 11 (page number not for citation purposes)

BMC Psychiatry 2004, 4

really is a load off my mind to be able to talk about going to the dentist.". Poor self-image or self-esteem As a symptom of embarrassment, poor self-image/esteem was cognitively manifested in two ways. Self-esteem problems were related to 1) job or professional image in which avoiding dental care and having bad teeth was not fitting to social status, which again returns to secrecy and taboo as in the example above or 2) how their children would see them or if a child would "catch" dental anxiety from them. The case of the ferry captain above is an example of self-esteem problems related mostly to career image. Here is an example of how phobic patients could worry about affecting their children:

Case #12 41 yr old quality control expert (41 M) who had avoided dental care for 12 years had never gotten over bad experiences that he had had with a dentist in his childhood. The many years of avoidance and neglect of painful dental conditions had set his beliefs about dentists and created a bad conscience that had affected his self-image and self-esteem. He stated in this regard: "I hope that that (going to the dentist and having selfrespect) can happen in the not too distant future, because it hurts like hell, especially since I have two small children to whom I try to explain about how important it is take care of their teeth. It wouldn't be very credible, and children can quickly sense such things about a person." With analysis of these cases, self-image/self-esteem seemed to become an important driving concept for embarrassment/shame, i.e. the belief that "neglecting yourself" leads to poor self-esteem as related to societal norms and values. In other words, poor self-esteem was the result of a chronic condition of many years of neglect, secrecy, and feelings of shame and bad conscience. In many cases, the chronicity of the problem lead to social withdrawal and personality changes. Social withdrawal and personality changes Nine of the 30 Ss mentioned that they underwent changes in their personality as a result of long periods of time with dental neglect, bad conscience, poor self-image or selfesteem and social withdrawal. The following case report revealed that chronic dysfunctional embarrassment, and specifically fear of negative social evaluation associated with anxiety and avoidance, can lead to personality change.

Case #22 33 yr old factory worker (33 M) had experienced painfully traumatic root canal treatments on his two upper canine teeth as a 12 yr old child. His last emergency dental visit had been 7 years ago. He admitted to

http://www.biomedcentral.com/1471-244X/4/10

embarrassment and despair about the appearance of his teeth. It had affected his personality and eventually contributed to a divorce with his wife. 33 M: "... I don't know if you have noticed, but I don't smile so that you can see my teeth. My wife has nice teeth and is very happy and smiles a lot. She misses getting a smile from me once in a while. When we met about 14 years ago, I smiled a lot. I liked to tell jokes and make fun with people and laugh. But it has become less and less, where now I go more alone with myself." RM: "Why do you think it is that you don't smile?" 33 M: "It's because my teeth are ugly and because I am missing teeth." RM: "Are you saying that you are embarrassed about your teeth?" 33 M: "Yeah, I am a lot." RM: "Do you think that you have undergone a change in your personality because of your embarrassment?" 33 M: "Yeah, it has been coming on as of about 6 to 8 years ago.... Actually, I am positive and happy, but I don't smile by showing my teeth... If someone tells a joke that I would laugh at, I really have to fight back doing it (laughing). So in that way, there are many times where I really don't listen carefully when someone tells a joke, since I can't allow myself to break out in a good laugh. I just can't allow myself. ... It is a sad state of affairs when you have to be embarrassed about your smile and to admit that you are afraid to go to the dentist. So I talked with my physician about sending a referral to your clinic." Patients often first realized that they had undergone negative personality changes only after they had completed or nearly completed therapy. In contrast to how they had been before, they could sense an improved self-image and /or self-confidence they had acquired during therapy. The following case illustrates important reflections at exit interviews. Case #24 44 yr old female day care mother (44 F) originally saw herself as a person with a "deep-dark secret" in which others could not "pass through" and she made all attempts to avoid contacts with new people, also hiding her teeth with both lips, hands and head gestures. She had suffered from a self-admitted inferiority complex about her mouth for over 20 years. Now she reflects upon the changes that had occurred for her at the conclusion of therapy.

Page 7 of 11 (page number not for citation purposes)

BMC Psychiatry 2004, 4

http://www.biomedcentral.com/1471-244X/4/10

Figure 2oral destruction due to phobic avoidance of dental treatment in a 26 yr old Danish man Extreme Extreme oral destruction due to phobic avoidance of dental treatment in a 26 yr old Danish man

44 F: "Yesterday when I sat and was talking with someone, I noticed she kept looking at my mouth. Then my hand went up (in front of my face) and I thought, 'OK, hello, I can still fall back into the old pattern!' This was a very, very good girlfriend. One who knows that I have been coming here (for therapy). I removed my hand again... Since we had removed what I thought everyone else was looking at (tarter buildup on front teeth), about which I was so embarrassed... I didn't have anything to be embarrassed about anymore. I told someone else a few days ago that I was having therapy here and had done so for 1 1/2 years because of my dental anxiety. I noticed that I was completely relaxed as I told it. A change had definitely occurred. I was a completely different person and I noticed the difference from before. It took a long time before I dared to tell anyone that I was in therapy for this, because it was embarrassing." RM: "So in some way, has there occurred a personality change?" 44 F: "You bet. Yeah, I notice that I feel more free, because I don't have to think about covering my mouth. I do still

have it a little bit yet. But you can't just snap your fingers and say it's gone! And I still wonder if I have bad breath." Co-validation of embarrassment intensity, phobic avoidance and mouth-hiding behaviors Embarrassment intensity increased with years of dental care avoidance (rs = 0.44; P = 0.02). Ss were nearly twice (OR = 1.9; CI = 1.3–2.8) as likely to have highly intense embarrassment (scores 3 or 4) after 4 years of treatment avoidance (?2 = 4.3; P = 0.04), compared to lower embarrassment levels (scores 0–2). Embarrassment intensity also correlated with the mouth-hiding behavior scale (rs = 0.53; P = 0.003). The mouth-hiding scale was rs = 0.32; P = 0.09 with years of avoidance. With greater numbers of years avoiding dental treatment, the following phenomena were noted in descriptions among embarrassed subjects (multiple possible) 1) guilty conscience as attributed to the act of neglecting dental care (n = 19), 2) actual dental damage from neglect that was visible (n = 22) (e.g. Fig. 2) or 3) unrealistic, exaggerated perceptions of tooth damage that were not as visible as patients perceived and thus were incongruent with actual dental status (n = 10). The latter appeared most often in cases where there were

Page 8 of 11 (page number not for citation purposes)

BMC Psychiatry 2004, 4

perceptions of negative social evaluation, guilty conscience and/or poor self-image/esteem.

Discussion The number of Ss in the present study was designed to be the minimum, manageable number necessary to capture a comprehensive range of embarrassment phenomena and characteristics. Although some caution must be advised in the interpretation of results, sampling is similar to previously described larger samples at the same clinic. The self-referral nature of the dental anxiety specialist clinic probably excluded patients with symptoms of mood disorders, depression, or agoraphobia in this clinical sample. Clearly, some odontophobic patients have a perception of the dental environment as threatening beyond just the threat of physically painful treatment. Present results showed that chief complaints of social powerlessness in dental situations either resulted from conditioned distrust of dentist behaviors or embarrassment with decreases in self-esteem often leading to fear of negative social scrutiny. These latter complaints often appear to fulfill DSM psychiatric criteria for social anxiety disorder for this circumscribed area. This fear of negative social evaluation and associated poor self-esteem is comparable in many ways to other circumscribed specific social anxiety disorders, such as fear of scrutiny while speaking, eating, or writing and perhaps is just as socially and personally debilitating. Indeed perhaps what is being described here is the process of suffering [35,36]. Researchers of suffering process Kahn & Steeves [36] have described it as, "Changes in personal identity may result from loss of function or changes in body image that are perceived as threats to self.". Feelings related to neglect of dental health care and poor appearance of the teeth were often associated with identity problems for many of the present cases. Perhaps to the routined private practitioner of dentistry, the oral cavity is a technical work place divided up into quadrants, where each tooth has its number and anatomical coordinates. But even a casual comment with a raised eyebrow as to "how long it has been since the last appointment" becomes a feared catastrophe for many phobic patients. Some might even quit a dental practice inspite of critical need for treatment of painful oral symptoms. Berggren [11] first described the "vicious circle of dental anxiety" among a population of Swedish odontophobic patients in whom feelings of guilt, shame and inferiority catalyzed maintenance of fear and further avoidance (Fig. 1). Present results confirm this vicious circle and describe the embarrassment factor as an amplifier for anxiety, increasing the intensity of the phobic reaction, especially with more and more years of treatment avoidance.

http://www.biomedcentral.com/1471-244X/4/10

Although they did not refer directly to embarrassment or shame, Gale [15] and Stouthard and Hoogstraten [16] reported that negative dentist behaviors such as "Dentist laughs as he looks in your mouth." or "Dentist tells you that you have bad teeth.", in the social context of dental treatment are among the most intense anxiety stimuli. Their findings indicated that there may be a dimension of humiliation in the anxiety. In college students with high dental anxiety Bernstein et al [14] found that half cited negative dentist behaviors as the origin; 81 percent did not mention pain. In results from Danish [7,8] and Swedish [37] dental anxiety studies of clinical samples similar to the present sample, there were similar findings of complicated psychiatric symptomatology specific to the dentist-patient situation. In a 1977 Swedish qualitative study, Bjercke et al [37] assessed 22 patients referred for specialist treatment of dental phobia. After extensive interviewing, they were classified according to "standard psychiatric nomenclature". Over half of the patients had a record of previous psychiatric problems or a discordant childhood. Twelve of the patients described feelings of inferiority based on their dental anxiety and avoided other people. They concluded that dental phobia was usually a more complex psychiatric syndrome that was puzzling, since it was more intensely experienced by patients than one would expect of other phobias. It also demonstrated the necessity to gain complete diagnostic information before planning interventions. Regarding intensity with which patients can experience dental anxiety, much as Sheehan and Sheehan [33] described that outcomes of treatment can reveal accuracy of diagnoses in retrospect, results over 17-years at the Dental Phobia Research and Treatment Center has shown that in many cases improved efficacy of cognitive behavioral therapy often was linked to a two phase course of treatment. Dependent on the intensity of embarrassment, shame or guilt presented by the client, the first phase was cognitive restructuring of social interactions with clients, where embarrassment, shame or guilt has been the primary focus. Desensitizations were first confined to the therapist-dentist as "object" (interpersonal distances and stepwise mouth exam sequence), if necessary. This "turned down the amplifier" so to speak, making it easier for the client to focus on the second, more instrumental phase of desensitization to dental instruments and procedures, often with surprising ease. This illustrates how awareness of embarrassment complexes is important to therapy for dental anxiety and as well as a need for further research. Feelings of social powerlessness and embarrassment in dental situations were also the most important factors

Page 9 of 11 (page number not for citation purposes)

BMC Psychiatry 2004, 4

associated with phobic avoidance in nearly half of 80 patients in earlier Danish studies by Moore et al[7,8]. Although results indicated that the most frequent category was social phobia when comparing another diagnostic system with DSM terminology, the assessment was overestimated according to current social anxiety disorder criteria [17,18]. Many of these subjects probably exhibited learned distrust of dentist behaviors, which was confused with symptoms of social phobia. Liddell and Gosse [13] referred to the Danish studies described above and noted the distinction between conditioned social distrust at the dentist versus fears of negative dentist evaluation in a sample of graduate students with dental anxiety. Present results also confirm a clinical distinction between distrust of dentists versus embarrassment, shame or guilt as chief complaint and primary problem. This embarrassment was associated with 1) the act of self-neglect, 2) actual, visible tooth damage from neglect or 3) exaggerated perceptions of tooth damage associated with guilty conscience. In phobic distrust of dentist behaviors, embarrassment also presented as a secondary reaction. Conditioned anxious distrust of dentists by DSM criteria would be a specific phobia, which is persistent fear in which an object or situation is avoided or endured with intense anxiety and significantly interferes with normal routines or relationships. Choice of therapeutic strategy for specific phobias requires primarily desensitization for fear reduction, while social anxiety related dental anxiety would primarily require cognitive reframing of social interaction contexts combined with interpersonal desensitization [38]. Thus, it is important that clinicians become attentive to the degree of embarrassment related to dental anxiety, where different intensity levels require different choices or sequences of therapeutic strategy. There may be differences between Danish patients and other ethno-cultural groups of patients experiencing dental anxiety[39,40]. Moore et al[39,40] have indicated that distribution of type of dental anxiety and perceptions of painful procedures varies among different ethno-cultural groups. For example, the "Law of Jante" is perhaps a special phenomenon unique to Scandinavian populations that could facilitate embarrassment and fear of negative social evaluation [41,42] in general. Thus, hypothetically there could be a higher incidence of embarrassment and/or social anxiety disorder in Denmark or other Scandinavian countries than in other countries [43]. Given that DSM-IV psychiatric criteria have been coordinated with European standard criteria (ICD10) [23], one would not expect international variation in diagnostic categories, but rather differences in their percentages of distribution from country to country.

http://www.biomedcentral.com/1471-244X/4/10

Since they have broad implications for therapeutic outcome and relapse, there is a need to operationalize the meanings of specific "social situations" for diagnostic accuracy, since no standardized instrument can be used in all contexts for comparisons [17,18,22]. In dental clinical contexts, a start would be to ask clients, 1) "Are you uncomfortable or embarrassed about your mouth?" and 2) "Do you find it hard to interact with people in general (or 3) dentists or staff) due to your dental situation?". These are similar to recommendations made by the International Consensus Group on Depression and Anxiety on future studies of social anxiety disorder [17]. A recently described scale measuring psychosocial effects of dental anxiety also appears to hold promise [10].

Conclusions The complexities of phobic dental anxiety that baffled Swedish researchers in the late 1970s are perhaps only now beginning to be understood. Embarrassment is a complex dental anxiety manifestation showing clinical differences by complaint characteristics and perceived intensity. Some of present cases exhibited manifestations similar to psychiatric criteria for social anxiety disorder, while most manifested embarrassment as a side effect. Sensitivity and understanding about the psychosocial nature of the dental health care environment should be an aim in the education of dentists in the 21st century, in order to prevent and treat suffering from extreme or phobic dental anxiety and related dysfunctional phenomena.

Competing interests None declared.

Authors' contributions RM conceived and carried out the study, entered qualitative data, led the analysis and drafted the manuscripts. IB entered qualitative data and aided in transcription, data analysis and manuscript revision. NR aided in analysis and manuscript revision. All authors read and approved the final manuscript.

Acknowledgements Authors wish to thank Bente Kjær for transcription of interviews as well the Danish Dental Association for financial support (FUT Fund).

References 1. 2. 3. 4.

Johnson B, Mayberry WE, McGlynn FD: Exploratory factor analysis of a sixty-item questionaire concerned with fear of dental treatment. J Behav Ther Exp Psychiatr 1990, 21:199-203. Kvale G, Raadal M, Vika M, Johnsen BH, Skaret E, Vatnelid H, Oiama I: Treatment of dental anxiety disorders. Outcome related to DSM-IV diagnoses. Eur J Oral Sci 2002, 110:69-74. de Jongh A, Aartman I, N. Brand: Trauma-related phenomena in anxious dental patients. Community Dent Oral Epidemiol 2003, 31:52-58. Locker D, Shapiro D, Liddell A: Negative dental experiences and their relationship to dental anxiety. Community Dent Health 1996, 13:86-92.

Page 10 of 11 (page number not for citation purposes)

BMC Psychiatry 2004, 4

5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17.

18. 19. 20. 21. 22.

23. 24.

25. 26. 27.

28. 29. 30. 31.

Vassend O: Anxiety, pain and discomfort associated with dental treatment. Behav Res Ther 1993, 31:659-666. Kaakko T, Coldwell SE, Getz T, Milgrom P, Roy-Byrne PP, Ramsay DS: Psychiatric diagnoses among self-referred dental injection phobics. J Anxiety Disord 2000, 14:299-312. Moore R, Brødsgaard I, Birn H: Manifestations, acquisition and diagnostic categories of dental fear in a self-referred population. Behav Res Ther 1991, 29:51-60. Moore R, Brødsgaard I: Differential diagnosis of odontophobic patients using the DSM-IV. Eur J Oral Sci 1995, 103:121-126. Roy-Byrne PP, Milgrom P, Tay K-M, Weinstein P, Katon W: Psychopathology and psychiatric diagnosis in subjects with dental phobia. J Anxiety Disord 1994, 8:19-31. Locker D: Psychosocial consequences of dental fear and anxiety. Community Dent Oral Epidemiol 2003, 31:144-151. Berggren U, Meynert G: Dental fear and avoidance - causes, symptoms and consequences. J Am Dent Assoc 1984, 109:247-251. Berggren U, Carlsson SG, Gustafsson JE, Hakeberg M: Factor analysis and reduction of a Fear Survey Schedule among dental phobic patients. Eur J Oral Sci 1995, 103:331-338. Liddell A, Gosse V: Characteristics of early unpleasant dental experiences. J Behav Ther Exp Psychiatry 1998, 29:227-237. Bernstein DA, Kleinknecht RA, Alexander LD: Antecedents of dental fear. J Public Health Dent 1979, 39:113-124. Gale EN: Fears of the dental situation. J Dent Res 1972, 51:964-966. Stouthard MEA, Hoogstraten J: Ratings of fears associated with twelve dental situations. J Dent Res 1987, 66:1175-1178. Ballenger JC, Davidson JR, Lecrubier Y, Nutt DJ, Bobes J, Beidel DC, Ono Y, Westenberg HG: Consensus statement on social anxiety disorder from the International Consensus Group on Depression and Anxiety. J Clin Psychiatry 1998, 59:54-60. Ballenger JC: Recognizing the patient with social anxiety disorder. Int Clin Psychopharmacol 2000, 15:S1-S5. Zerbe KJ: Uncharted waters: psychodynamic considerations in the diagnosis and treatment of social phobia. Bull Menninger Clin 1994, 58:A3-20. Bruce TJ, Saeed SA: Social anxiety disorder: a common, underrecognized mental disorder. Am Fam Physician 1999, 60:2311-2320, 2322. Katzelnick DJ, Greist JH: Social anxiety disorder: an unrecognized problem in primary care. J Clin Psychiatry 2001, 62 Suppl 1:11-15. Weinshenker NJ, Goldenberg I, Rogers MP, Goisman RM, Warshaw MG, Fierman EJ, Vasile RG, Keller MB: Profile of a large sample of patients with social phobia: comparison between generalized and specific social phobia. Depress Anxiety 1997, 4:209-216. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, DSM-IV Washington, D. C., American Psychiatric Association; 1994. Spitzer RL, Williams JBW, Gibbon M, First MB: Structured Clinical Interview for DSM-III-R - Patient Version (SCID-P, 5/1/89) New York, Biometrics Research Department, New York State Psychiatric Institute; 1989. Eisenberg N: Emotion, regulation, and moral development. Annu Rev Psychol 2000, 51:665-697. Higuchi M, Fukada H: A comparison of four causal factors of embarrassment in public and private situations. J Psychol 2002, 136:399-406. Moore R, Berggren U, Carlsson SG: Reliability and clinical usefulness of psychometric measures in a self-referred population of odontophobics. Community Dent Oral Epidemiol 1991, 19:347-351. Corah NL: Development of a dental anxiety scale. J Dent Res 1969, 48:596. Milgrom P, Weinstein P, Kleinknecht R, Getz T: Treating Fearful Dental Patients - A Patient Management Handbook Second edition. Seattle, WA, University of Washington Press; 1995. Spielberger CD, Gorsuch RL, Lushene RE: STAI manual for the statetrait anxiety inventory Palo Alta, CA, Consulting Psychologists Press; 1970. Hakeberg M, Gustafsson JE, Berggren U, Carlsson SG: Multivariate analysis of fears in dental phobic patients according to a reduced FSS-II scale. Eur J Oral Sci 1995, 103:339-344.

http://www.biomedcentral.com/1471-244X/4/10

32. 33. 34. 35. 36. 37.

38. 39.

40.

41. 42. 43.

Johansson P, Berggren U, Hakeberg M, Hirsch JM: Measures of dental beliefs and attitudes: their relationships with measures of fear. Community Dent Health 1993, 10:31-39. Sheehan DV, Sheehan KH: The classification of phobic disorders. Int J Psychiatr Med 1983, 12:243-266. Richards T, Richards L: Q.S.R. (Qualitative Solutions and Research) Manual, NUD*IST (Nonnumerical Unstructured Data * Indexing, Searching and Theory building) London, Sage; 1995. Cassell EJ: Diagnosing suffering: a perspective. Ann Intern Med 1999, 131:531-534. Kahn DL, Steeves RH: The experience of suffering: conceptual clarification and theoretical definition. J Adv Nurs 1986, 11:623-631. Bjercke O, Blomberg S, Linde A: [Psychiatric evaluation of patients with pronounced fear of dental treatment] Psykiatrisk bedömning av patienter med tandvårdskräck. Läkertidningen 1977, 74:1390-1392. Wolpe J: The dichotomy between classical conditioned and cognitively learned anxiety. J Behav Ther Exp Psychiatr 1981, 12:35-42. Moore R, Brødsgaard I, Mao TK, Kwan HW, Shiau YY, Knudsen R: Fear of injections and report of negative dentist behavior among Caucasian American and Taiwanese adults from dental school clinics. Community Dent Oral Epidemiol 1996, 24:292-295. Moore R, Brødsgaard I, Mao T-K, Miller ML, Dworkin SF: Perceived need for local anesthesia in tooth drilling among AngloAmericans, mandarin Chinese and Scandinavians. Anesth Prog 1998, 45:22-28. Gustavsson B: The human values of Swedish management. J Human Values 1995, 1:153-172. Olofsson J: About the Nordeners: Subject 2.6 The essence of Nordishness, 2.6.1 What is Janteloven? The Jante Law. http:// www lysator liu se/nordic/scn/faq26 html 1998. Kirmayer Laurence J.: Cultural variations in the response to psychiatric disorders and emotional distress. Soc Sci Med 1989, 29:327-339.

Pre-publication history The pre-publication history for this paper can be accessed here: http://www.biomedcentral.com/1471-244X/4/10/pre pub

Publish with Bio Med Central and every scientist can read your work free of charge "BioMed Central will be the most significant development for disseminating the results of biomedical researc h in our lifetime." Sir Paul Nurse, Cancer Research UK

Your research papers will be: available free of charge to the entire biomedical community peer reviewed and published immediately upon acceptance cited in PubMed and archived on PubMed Central yours — you keep the copyright

BioMedcentral

Submit your manuscript here: http://www.biomedcentral.com/info/publishing_adv.asp

Page 11 of 11 (page number not for citation purposes)