Dental Fear and Phobia
Does the sound of the dentist's drill make you cringe? Does the sight of the needle make you scared and nervous? If so, you're not alone. It has been estimated that more than half of all the people in the United States will never see a dentist for regular care. Fear of the dentist, or in more severe cases, dental phobia, is the main reason that many people avoid the dentist. And the problem with staying away from the dentist is that small problems soon require major dental treatments!
Where did these fears originate?
First of all, let's acknowledge that many people who are afraid of the dentist have a legitimate reason for their fear. Maybe they recall a traumatic experience when the dentist either caused them pain during treatment or embarrassed them by making light of their fears. These memories tend to be especially acute if the traumatic incident occurred during childhood. Vivid memories of the incident recur whenever the fearful person needs to go to a dentist. I have treated patients in their 70s and 80s who still fear dental treatment due to bad experiences they had as children. Modern dentists are well aware of the impact a negative dental experience can have on children, and fortunately, many of them have had training in child psychology. Using that background, they strive to make the early experiences with dentistry positive ones for children.
The past experience that causes the most fear among patients is the memory of a dentist causing them pain during treatment and then humiliating them when they complained. These patients can remember the dentist saying things like, "This isn't hurting you," or "Stop being a baby." These denigrating remarks compound the painful experience at the dental office. Even though the pain from the treatment fades quickly, the insensitive comments made by the dentist continue to live on in the minds of the recipients of those unsympathetic comments.
There are also large numbers of people who are "afraid of the dentist" or of certain dental procedures but have never actually had a bad experience at the dentist's office. These are people who have heard from others that dentistry is painful -- and they believe it! This type of learned fear is called vicarious learning and is quite common.
Unfortunately, there is good reason for people to accept this premise on face value because it is sometimes reinforced by family and friends and also in the media. This is very similar to how we feel when we see a plane crash on the TV news. The vivid pictures and tragic personal stories stir our emotions. But, have you ever stopped to think that you rarely hear about the more than 20,000 safe take-offs and landings every day, or the incredible safety record of the airline industry? Likewise, few people share their successful dental experiences. Instead, research has shown that people are far more likely to share and embellish a negative dental experience. I know from years of treating patients the power of vicarious learning. Many times I have to suggest that a patient with a dental infection get a root canal to save a tooth. Right away, the fearful patient will say something like, "No way, put me to sleep and I'll have it pulled. I won't go through a root canal." When this happens, I ask them if they've ever had a root canal before, and if it was a bad experience. In most cases, the answer is no. I then ask them why they think it will be painful. They usually respond that they heard somewhere or from someone (a friend of a friend) that a root canal is painful.
In addition, I sometimes hear fearful parents in my waiting room unknowingly establish with their children negative stereotypes regarding dental treatment. They might say things like, "Tell the dentist if he is hurting you," or "If you don't stop misbehaving, it will be your turn to go to the dentist next time," and other things that are likely to instill a fear of dentistry.
Dentists and dental treatment are sometimes portrayed in a negative light in the media and in commercials we see on TV. We have all heard stories in the news about AIDS and dirty dental drills and water. Unfortunately, these stories are sometimes one-sided and can misrepresent the facts; this results in unnecessarily frightening people about the safety of dental treatment.
Likewise, commercials often use the fear of dental treatment, especially root canals (the replacement of the tooth's pulp with an inert material) as the punishment in their contrived scenarios. People who fear the dentist will tend to hone in on negative stories regarding dentistry to help reinforce how they feel. I agree wholeheartedly with Burt Decker, author of "You've Got to be Heard to Be Believed," when he says, "People make decisions based on emotion, and then justify them with facts." So, as you can see, fear can be a learned phenomenon. Fortunately, because fear can be learned, it can be unlearned as well.
What are these fears about and how do you address them with your parents?
The first step in overcoming any fear, including fear of the dentist, is to define the fear. Fear of the dentist involves everything from mild anxiety before or during a scheduled dental visit to high levels of stress and emotional discomfort, manifesting itself as nervousness, sweaty palms or tears. When the anxiety becomes so intense that the person will do anything to avoid going to the dentist, the fear becomes a phobia.
Before you worry that your dental fears are approaching phobic levels, remember that fear or apprehension about dental treatment is a very common reaction. In fact, of the thousands of patients I've treated, the vast majority expressed at least some fear or anxiety before dental treatment. Even I, as a dentist, experience some anxiety before I am about to be treated by another dentist! Fear of the dentist is nothing to be ashamed of, and the good news is that fears and phobias about dental treatment can be overcome in most cases.
People fear the dentist for a variety of reasons. I have found that the three most common fears are associated with:
The potential for pain during dental treatment
Fear of being scolded about the condition of their mouth
Fear of loss of control during dental treatment
How can I overcome my fear of pain?
The first step in overcoming fear of the dentist or dental treatment involves gathering accurate information to help you judge the veracity, or truth, of those fears. Knowledge can be a powerful weapon against fear. In fact, many people fear death because it is "the great unknown." A comforting component of many religions is the promise of heaven and other rewards in the afterlife. Although I cannot promise you that your dental experiences will be "heavenly," I can promise that it won't fall at the other end of the spectrum! Learning about how dentists deal with people's fears is a good starting point in alleviating a fear of the dentist, himself.
Most people have at least some fear of pain or injury in life -- and that's a good thing. It prevents us from touching a hot stove (more than once) or driving a car into oncoming traffic. Fear is a protective and instinctive emotion that helps keep us safe. It should come as no surprise that when we are confronted with a situation or environment that we believe to be painful, we try to avoid it. Some people who avoid regular dental care do so because they believe that all dental treatment is painful.
So what is the truth about dentistry and pain? I won't tell you that dental treatment is never painful - on rare occasions, it is. But I will tell you that most of the time, dental treatment is either completely painless, or only slightly uncomfortable. And be reassured by the fact that most dentists are acutely aware of the impact of pain on their patients. Many dentists pride themselves on being "painless practitioners." A dentist who causes a patient pain will sometimes lose that person as a patient, and there is a good chance that the person will tell many others about the bad experience they had at Dr. So-and-So's office. Causing people pain during treatment is no way to build a dental practice and most dentists know that!
How do dentists reduce or eliminate pain during dental treatment?
Dentists have many ways of reducing discomfort during dental treatment. The first step dentists take is to evaluate the treatment required to decide if anesthesia, given as an injection, is needed. There are many dental procedures that can be done comfortably without anesthesia, using modern dental technology. For example, shallow cavities on the side or biting surface of the teeth can be treated with a dental laser or an air abrasion unit, a new device that emits a gentle spray of an air and powder mix that smooths away tooth decay. These devices can silently and painlessly treat cavities a high percentage of the time without anesthesia. If anesthesia is needed, strong topical anesthetic gels or patches are used to greatly reduce the discomfort associated with injections. Dentists also use very thin needles and inject the solution slowly to further reduce discomfort.
The most important way a dentist reduces or eliminates discomfort during dental treatment is to make sure that the patient's mouth is as numb as possible during treatment. The approach I initially take is to begin treating the tooth very slowly. I will ask the patient, "Are you feeling this?" If the answer is "yes," I either give them more anesthesia or wait a few minutes and test again. It takes some people's mouths a little longer to become numb. I recommend that you always signal your dentist to stop if you are having pain. If the dentist doesn't listen, you need to find a new one!
What if I still feel pain after the anesthesia is given?
In some instances, you may still feel varying degrees of pain even after everything feels numb. There are a few reasons for this, including inaccurate placement of the anesthesia, not enough time allowed for the anesthetic to work; or severe infection in the area interfering with the potency of the anesthesia. The dentist can remedy these situations by redirecting the anesthesia (or giving more), waiting longer before beginning treatment; postponing the treatment; and prescribing an antibiotic to reduce the infection.
Another important issue is that different people have different thresholds for pain. I have had patients who have expressed genuine discomfort from a routine dental exam, and others who easily tolerated root canal or dental surgery without anesthesia (though I don't advise it).
Over the years, I have discovered an interesting irony when treating fearful patients. The vast majority of these patients have a very high-pain tolerance. When you think about it, it sort of makes sense. Fearful patients often avoid dental care and endure years of discomfort from their teeth. It seems likely that if they had a poor tolerance for pain, they would visit their dentist the moment a tooth became sensitive. Because of this, once a fearful patient develops trust with their dentist, the fear quickly evaporates. The fearful patient soon learns that dental treatment is not nearly as uncomfortable as the pain they go through every day with infected teeth.
When I have patients who tell me they are afraid of the pain, I make them a promise. I say that I will not perform the procedure (whether tooth extraction or root canal) if they are feeling pain -- plain and simple. On rare occasions, I will even reschedule the patient for a different day if the treatment cannot be comfortably completed.
What can be done about pain after treatment?
Some dental procedures can cause discomfort after the anesthesia has worn off. Fearful patients are often concerned that they will be in pain following a dental procedure. These procedures include dental extractions (pulling teeth) and other minor dental surgery, root canal therapy, periodontal (gum) surgery and multiple dental fillings. Dentists are just as concerned with managing pain after treatment as they are during it. One of the first things dentists do is to make sure that they perform the procedure as gently as possible. A dentist with a forceful technique can put excessive pressure on the teeth and gums, which can cause greater discomfort later on. Dentists can also use anesthesia that lasts longer (bupivacaine) or give pain medication like ibuprophen (Advil® or Motrin®) prior to some procedures, because these measures have been shown to reduce pain after treatment.
Dentists are also licensed to prescribe potent narcotic drugs that are highly effective in reducing or eliminating any discomfort after dental treatment. The final step the dentist can take is to call the patient at home after a potentially painful treatment. This is something that I have done for years. I like to see how my patient is doing, if the medication is working, or if the patient has any questions about the treatment. Some dentists do this, and I suspect more will in the future. Aside from being the right thing to do, research has shown that people's perception of pain is less when the dentist calls them at home to find out how they are doing.
Most dentists realize that pain is a very subjective thing. What this means is that a person's emotions have a large impact on their perception of pain. For example, if a patient gets the feeling that the dentist is insensitive or lacks compassion, there is a good possibility that other concrete measures the dentist uses to reduce pain will be less than successful. On the other hand, a dentist who makes a worthy effort to reduce all discomfort associated with dental treatment, and empathizes with his or her patients, will have much better results.
What if I'm afraid my dentist will scold or embarrass me?
Some patients fear being chastised by the dentist for neglecting their mouths. They might nervously comment that "I know I should have come earlier" or "Is this the worst mouth you ever saw?", expecting the dentist to reprimand them like a disapproving father or a drill sergeant. It is no wonder that people with these preconceived notions fear going to the dentist. This fear seems to have originated years ago when some dentists thought they could "help" their patients by lecturing or insulting them.
Most dentists today realize that this is a poor approach that ultimately backfires by either driving people away or building up a barrier of resentment. I look at it this way: The patient is coming to me for help. He or she has likely had bad dental experiences in the past, has been out of work; has lost his or her insurance; hasn't been educated about modern dental treatment; or is not particularly concerned about the comfort or appearance of their teeth.
Whatever the reason, the important thing is that the person is coming in for dental care now.
What should the dentist-patient relationship be like?
Ideally, the role of the dentist is to understand what the patient's expectations are, improve their dental health and then to educate them in how to avoid dental problems in the future. To achieve these goals, communication between the dentist and patient is of the utmost importance.
People who seek dental care often come from vastly different educational, cultural and socioeconomic backgrounds. I have found that most dental patients fall into three main camps. Some are not interested in saving their teeth, and just want to have a tooth removed every now and then when they are in pain; others are highly motivated to preserve all of their teeth and want to keep them in the best condition possible; still other patients have never been educated about what modern dentistry can achieve but can become (with education) motivated to improve the comfort and appearance of their teeth.
The bottom line is that most dentists do not browbeat their patients about the condition of their teeth. That may have been common years ago, but is not nearly as prevalent today. If you are worried about how a dentist will react to the condition of your mouth, try to remember that a dentist has seen everything from black and broken teeth to no teeth at all. Your teeth won't shock the dentist. If it does, or if your dentist insults you, find a new dentist. There are plenty of dentists out there who do care about helping their patients.
What if I'm afraid of losing control during treatment?
Some people who fear dental treatment are those who are used to being in control at home, work and in personal and professional relationships. In today's lingo, these people are sometimes referred to as "control freaks." Despite this negative label, these controlling people are often highly intelligent and very successful. For instance, you may have heard the statement that "doctors make the worst patients," but other professionals, including lawyers, teachers, engineers and high level business executives could just as easily be put into this category. Although that statement is a generalization, it is accurate to say that some of these high-powered people can be difficult patients because they are accustomed to controlling their environment.
When people who are used to being in a position of power are put into a situation where they must relinquish that power to their dentist, anxiety, confrontation and avoidance are the most common reactions. The first step in overcoming this fear is to tell the dentist that you want to know what he or she is doing and why. Ask your dentist to explain X-rays, show you your mouth with an intra-oral camera, give you handouts or in-office presentations, or any other information to help you have a more active role in your dental care. When you know what the dentist is doing and why, you will have a greater sense of control during the procedure.
It is also important to ask the dentist how you should signal if you are having pain or any other uncomfortable sensation. Many dentists tell the patient to raise their hand if they are having pain, and the dentist will stop. I have had patients tell me that they had a dentist continue working on them even after they repeatedly raised their hands. This is not a dentist that you want treating you. It's a good idea to test your dentist -- even if you're not having pain -- to see if he or she will indeed stop. The dentist who follows through with that promise is what we call a "keeper."
One technique I like to use is to let the patient have some input as to what procedure they want done first. Many times, there is no urgent need to have cavities on the left side of the mouth treated before those on the right side, or one tooth crown (cap) done before another. I believe that it is perfectly appropriate for you to ask your dentist if you can have a particular procedure done first or last. If there is no urgent need, the dentist may comply with your wishes. Allowing you to help "call the shots" can be an effective way to reduce tension if a loss of control is your main source of anxiety. (Please note that some dental procedures must be done before others for your benefit. Your dentist should give you a good, jargon-free explanation to help you understand why).
Whether you fear pain, being scolded or losing control, take heart with the knowledge that these fears can be overcome. The first step is to make an appointment with a dentist who has a reputation for being both skilled and compassionate. This appointment should be for consultation only, not treatment. Discuss your fears with the dentist. You should know in only a few moments if this dentist has what it takes to help you overcome your dental fears. Meanwhile, try some of these exercises designed to help relieve your dental fears.
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