Eur J Oral Sci 2000; 108: 268±274 Printed in UK. All rights reserved
Characteristics of adult dentally fearful individuals. A cross-cultural study
Ulf Berggren1, Calvin J. Pierce2, Ilana Eli3 1
Department of Oral diagnosis, Faculty of Odontology, GoÈteborg University, GoÈteborg, Sweden, 2Department of Behavioral Sciences, School of Dental Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA, 3 Department of Occlusion and Behavioral Sciences, School of Dental Medicine, Tel Aviv University, Tel Aviv, Israel
Berggren U, Pierce CJ, Eli I. Characteristics of adult dentally fearful individuals. A cross-cultural study. Eur J Oral Sci 2000; 108: 268±274. # Eur J Oral Sci, 2000 This cross-cultural study investigated adult dental fear patients in three countries. A joint intake interview questionnaire and a dental anxiety scale explored the level, background and concomitant factors of dental anxiety among patients at the Universities of Tel Aviv (Israel), GoÈteborg (Sweden), and Pittsburgh (USA). It was shown that patients at all three sites were quite similar with regard to age, sex, level of dental anxiety (DAS) and avoidance time. Negative emotions were common, with more negative everyday life eects among Swedish patients. Regardless of country, most patients stated that they had always been fearful, but environmental etiologic factors were frequently reported. Swedish patients more often reported both direct and indirect learning patterns than Israeli patients. Patients' motivation for treatment was high, while the belief in getting fear reduction was clearly lower. The most common reason for Israeli patients to seek treatment was a personal decision to try to cope with the situation, while for Swedish patients it was pain. Israeli and US patients preferred more `active' modes of treatment such as behavioral management therapies, while Swedish patients equally preferred active and more `passive' treatment approaches such as general anesthesia. Preference for dentist attributes were similar among groups and underlined the strong emphasis that fearful individuals place upon dentists' behaviors and their performance of dentistry.
Since the 1960s there have been an increasing number of research reports on dental anxiety and dental phobia. During this period, a number of multidisciplinary programs and clinics have been established to investigate dental fear with regard to its theoretical aspects as well as its practical consequences (1±7). These developments re¯ect a welldocumented need to improve dental services to groups of underprivileged individuals (8±12), while bolstering the eort to disseminate new knowledge to the profession. There have been, however, several shortcomings with regard to the interpretation of the reported research, mainly due to the wide variety of methodologies used, the variation in studied groups, and the problems encountered in making cross-cultural evaluations. Indeed, already the NIDR workshop on Integrating behavioral and pharmacological techniques in the treatment of dental fear (held in Bethesda, MD, USA, 1985) identi®ed several required
Professor Ulf Berggren, Dept of Oral Medicine, GoÈteborg University, Box 450, SE 405 30 GoÈteborg, Sweden Telefax: z46±31±7733347 E-mail:
[email protected] Key words: cross-cultural; dental anxiety; dentist attributes; etiology; treatment preference Accepted for publication April 2000
improvements for research eorts with regard to theoretical as well as clinical aspects (13, 14). The workshop emphasized the need for multicenter and cross-laboratory research, with common measures and protocols. The importance of the NIDR statement was further underlined in a review of behavioral research in dentistry during the period 1987±1992 by TER HORST & DE WIT (15). The authors pointed to the continuing dif®culties in comparing the results of dierent studies in this ®eld. The major diculties originated in the heterogeneity of methodology when attempting to identify pro®les of dentally anxious patients, including factors such as demographic variables, dental health and visiting patterns, and dental experience and personality characteristics. TER HORST & DE WIT concluded that with regard to most of these factors, little research progress had been made during the reviewed years (15).
A cross-cultural study of dentally fearful individuals From the perspective of these reviews, it is important to favor eorts that create agreements on cross-validations of measurement instruments and that focus on joint methodology in investigating the background and the concomitant factors of dental anxiety. Thus, the aim of this explorative study was to analyze characteristics of dental patients seeking special care for severe dental anxiety at specialized dental phobia clinics in Tel Aviv (Israel), GoÈteborg (Sweden), and Pittsburgh (USA), by using a specially constructed intake interview protocol at all three sites. Due to unforeseen changes in research interests and faculty changes at the School of Dental Medicine in Pittsburgh, data collection was interrupted after the admission of only 17 patients. Because of the small size of the Pittsburgh sample, results from this group are only reported when major dierences from the Tel Aviv or GoÈteborg data occur.
Material and methods The data collection took place during a period of about 8 months in 1995±1996, simultaneously at three specialized dental phobia research and treatment clinics at the following locations: 1. The Clinic for Oral Psychophysiology, School of Dental Medicine, Tel Aviv University, Tel Aviv, Israel (TA), which specializes in providing behavioral and dental care for dental patients suffering from various dentally related behavioral dysfunctions; 2. The Dental Fears Research and Treatment Clinic, Department of Oral Medicine, GoÈteborg University, GoÈteborg, Sweden (G), which provides treatments for dental phobic adults using a full scale program of behavioral and pharmacological techniques; and 3. The Dental Fears Evaluation and Treatment Center at the University of Pittsburgh School of Dental Medicine, Pittsburgh, PA, USA (P). This clinic serves the dentally anxious patient in the tri-state area of Western Pennsylvania. Instruments
At each of the three clinics, an intake interview questionnaire and a dental anxiety rating scale were distributed to the patients who applied for treatment due to severe dental anxiety. These instruments were administered as part of the routine intake procedures, and were, after consent, answered in the waiting room before meeting the treatment team. Measurement variables included a dental fears intake interview questionnaire (IIQ), the Corah Dental Anxiety Scale (DAS) (16), and
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additional local rating scales at each site (the latter not being reported here). Dental fears IIQ
The three authors collaboratively designed the questionnaire in order to sample the various demographic, etiologic and emotional aspects of the patients' dental anxiety. In addition to date, identi®cation, age and sex, the questionnaire contained questions concerning the patient's present and previous experience of dental care, perceived origin and reason for dental fear reactions, eects of dental fear on everyday life, and treatment motivation and preferences. The questions were of three formats: 1) open assessment questions (e.g. ``How many years ago was your last regular visit to the dentist?''); 2) selection ± one possible alternative (e.g. ``How was your last dental visit?'' with alternative answers from ``very successful'' to ``worst ever''); or 3) selection of several alternatives (e.g. ``Which were the most important reasons to seek treatment now? Check the alternatives below that ®t you.'') in a list of options. This item format used Likert scales from 0 ± ``not at all'' to 6 ± ``very much/important/fearful'', to assess the patients' reactions and opinions. The interview was initially constructed in English. After translation into Hebrew and Swedish versions, pilot tests at each clinic were performed. Following patient input, minor changes and some reduction of the number of questions, a ®nal selection of items were back-translated by experienced bi-lingual researchers in Tel Aviv and GoÈteborg, and the used ®nal version was agreed upon. (The interview questionnaire is available from the senior author in its three language versions). Dental anxiety scale (DAS). The DAS was used in its English original version (16) and in previously used and well-evaluated translations into Hebrew and Swedish (17±20), which have been shown to correspond well between the three countries. An individual may score a minimum of 4 (no anxiety) through to a maximum of 20 (extreme anxiety). The scale is simple to complete, reliable and valid, and it has been suggested that scores of 13 or above indicate individuals who are anxious about dental treatment (21). Data analysis
All data were analyzed using the SPSS statistical package (version 8.0). Simple descriptive statistics were used together with the Chi-square test and
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Student's t-test to estimate signi®cant dierences. A P50.05 was considered as statistically sign®cant. Results During the investigation period, 54 TA, 130 G patients and 17 P patients took part in the study. As mentioned previously, the Pittsburgh data collection was interrupted and results from this group are only reported when major dierences from the Tel Aviv or GoÈteborg data occur. The distribution of gender and age were similar in both the TA and G samples (Table 1). The two study groups were almost similar as far as general demographic characteristics are concerned. Women predominated by 2:1 in both TA and G groups, and most of the patients were younger than 40 yr. Only a few individuals (6% and 12% among TA and G patients, respectively) reported regular dental contacts, and about a third of each group reported no dental visits during at least the last 5 yr. The average DAS scores were 15.5 and 16.0 among the TA and G samples, respectively, and 16.7 in P patients with no signi®cant dierences between the groups (Table 1). Most patients (48% of the TA and 70% of the G samples, respectively) reported that they experienced various negative eects on their daily life due to their dental fear (Table 2). This was more pronounced among G patients, who reported signi®cantly higher levels of negative eects as compared Table 1 Sex, age and present dental anxiety status among the investigated groups Tel Aviv n Number of responders Sex Women Men Regularity of dental visits Regular check-ups Going occasionally Never going Last dental visit 52 yr 2±4 yr 5±10 yr 410 yr Age (yr) DAS
%
54
GoÈteborg n
%
130
37 17
68.5 31.5
85 45
65.4 34.6
3 24 25
5.8 46.2 48.1
15 58 56
11.6 45.0 43.4
18 11 9 3 M 33.0 15.5
43.9 26.8 22.0 7.3 (SD) (15.2) (4.0)
48 30 31 15 M 34.7 16.0
38.7 24.2 25.0 12.1 (SD) (10.7) (3.1)
to TA patients, especially with regard to being with family or friends and to having intimate relationships. Among the P patients, however, the negative impact on work situation was rated higher than among TA and G patients (a mean of 2.0 compared to 1.2 and 1.6, respectively). The patients' evaluation of the emotional impact of their dental fear was similar in the TA and G samples. A vast majority (98% in both samples) had some or strong feelings of anger, shame and depressed mood related to their dental fear. Both TA and G patients indicated a very strong repressive emotional state by rating `trying not to think about dental fear' at the highest level of their negative feelings (Table 2). This was also the case for P patients (data not shown). The contribution from etiologic factors to present dental fear was generally assessed at a higher level among G patients as compared to TA patients (Table 3). This concerned the total average of the negative experiences (direct learning and vicarious learning factors) as well as most of the separate factors. Most patients claimed that fear had always existed (91% of the TA and 92% of the G samples, respectively, means of 4.2 and 4.4, respectively). The situation was similar also to P patients (mean of 4.5). These ratings were only exceeded in etiological importance by G patients' ratings of impact from painful dental experiences. Table 4 shows the assessment of motivation for treatment among the investigated groups. The single most common reason for TA patients to apply for treatment was that they had ``decided to try to cope with the problem'' (63%), while patients in GoÈteborg claimed that their contact with the specialist clinic primarily was made ``due to pain'' (61%). These frequencies both constituted statistically signi®cant dierences between the two samples (w2~3.93; P50.05 and w2~4.74; P50.01, respectively). It Table 2 Negative eects and feelings from dental fear. Assessments were made on a Likert scale from 0 (not at all) to 6 (very much) Tel Aviv
GoÈteborg
M
SD
M
SD
P
Negative eects Being with the family Having intimate relationships Being with friends Go to work
0.9 0.9 0.4 1.2
1.7 1.8 1.0 1.9
2.2 1.8 1.5 1.6
2.3 2.3 2.1 2.1
0.001 0.05 0.001 NS
Negative feelings I'm angry about it I'm ashamed of it I'm depressed about it I try not to think about it
3.2 2.9 3.5 4.2
2.3 2.4 2.3 1.9
3.3 3.1 3.2 4.1
2.3 2.3 2.4 2.0
NS NS NS NS
A cross-cultural study of dentally fearful individuals was also a signi®cantly higher proportion among G patients that stated that ``others persuaded me to go'' (34% as compared to 17%; w2~3.49; P50.05). Among the P patients it was commonly stated that ``decided to try to cope with it'' was the most important incentive to coming for treatment (59%), followed by `esthetic reasons' (35%), `pain' (24%) and `others' persuasion' (12%). Both TA and G patients gave high scores concerning the importance of getting treatment for both dental fear and for dental problems, indicating a high motivation for treatment (Table 4). In general, the beliefs in achieving fear reduction at the specialized clinic was signi®cantly higher Table 3 Reported etiologic background of dental fear. Assessments were made on a Likert scale from 0 (not at all) to 6 (very much) Tel Aviv
GoÈteborg
M
SD
M
SD
P
Negative experience Mean dentist Painful treatment Hospital/physicians Total average
1.9 3.2 1.2 2.3
2.4 2.4 2.2 1.9
3.3 4.7 2.2 3.4
2.5 1.7 2.6 1.5
0.01 0.001 NS 0.001
Vicarious learning Mother Father Friends Total average
1.4 0.7 1.2 1.2
1.9 1.3 1.6 1.5
2.5 1.9 2.1 2.5
2.2 2.2 2.1 1.9
0.01 0.01 0.05 0.001
``Others made me fearful'' ``Feel a lack of control'' ``Always been fearful''
0.7 3.8 4.2
1.5 2.3 2.0
0.9 3.5 4.4
1.7 3.6 2.0
NS NS NS
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among Tel Aviv patients (TA 3.9 compared to G 3.2; t~2.51; P50.05). Patients' preferences of dentist attributes revealed mostly similar results among the TA and G groups (Table 5). On the highest level of preference (means 5.6 and 5.8, respectively), both groups rated that the dentist should be ``supportive and patient'' and equally important that the dentist ``tries to avoid pain'' (5.6 and 5.7, respectively). The only factor which was signi®cantly dierent between groups was that the dentist should ``work fast and eciently'' (t~2.14; P50.05). Regarding treatment modality, Tel Aviv patients preferred behavioral management therapies and relaxation training, while GoÈteborg patients equally clearly preferred i.v.-sedation and general anesthesia (Table 5). The rating of these modes of treatment also constituted the variables that were signi®cantly dierent between the groups. Thus, behavioral management therapy was rated ®rst by TA patients but much lower by G patients (TA 5.4 and G 2.9; t~7.22; P50.001). Similarly, TA patients preferred signi®cantly more to be treated by relaxation training than their counterparts (TA 4.2 and G 3.0; t~3.23; P50.01). G patients, on the other hand preferred more treatment by i.v. sedation or general anesthesia (TA~2.8 versus G~4.5; t~4.17; P50.001). Comparable ratings for Pittsburgh patients showed less varying results with the highest preference scores for relaxation training (4.1) and lowest for i.v./general anesthesia (2.7). Discussion This study investigated patients applying for treatment at clinics specialized in therapy for severe
Table 4 Assessment of motivation for treatment among the investigated groups
``Why did you decide to seek treatment now?'' (multiple answers possible) ``Decided to try to cope with it'' ``For esthetic reasons'' ``Due to pain'' ``Others persuaded me to go'' ``How important is it to you to _?'' (Likert scale from 0 ± not at all to 6 ± extremely important) Treat dental anxiety Treat dental problems ``What are your chances to get fear reduction?'' (Likert scale from 0 ± none to 6 ± very good)
Tel Aviv
GoÈteborg
%
%
P
63.0 18.5 35.2 16.7
46.9 23.8 60.8 33.8
0.05 NS 0.01 0.05
M
(SD)
M
(SD)
P
5.4 4.5
1.5 1.8
5.1 5.3
1.5 1.4
NS NS
3.9
1.8
3.2
1.9
0.05
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Berggren et al. Table 5
Patients preferences of dentist professional attributes and mode of treatment. Assessments were made on a Likert scale from 0 (not at all) to 6 (very much) Tel Aviv
GoÈteborg
M
SD
M
SD
P
Dentist attributes Supportive and patient Explains treatment Tries to avoid pain Works fast and ecient
5.6 4.7 5.6 4.1
0.8 2.1 1.0 2.3
5.8 4.8 5.7 3.4
0.6 1.7 0.8 2.0
NS NS NS 0.05
Mode of treatment Behavioral management/ Guided exposure Relaxation training Hypnosis/``mental training'' Premedication/nitrous oxide i.v./general anesthesia
5.4 4.2 2.9 2.5 2.8
1.4 2.1 2.8 2.4 2.8
2.9 3.0 2.6 2.9 4.5
2.2 2.3 2.3 2.4 2.1
0.001 0.01 NS NS 0.001
dental fear and avoidance in a cross-cultural context. It tried to address some of the research problems previously identi®ed in reviews of the research literature in the area of behavioral dentistry (22, 23). There is a general agreement as to the predominance of dental fear and anxiety across world cultures. Numerous epidemiological studies, performed since the 1960s, have evaluated the prevalence of dental fear and anxiety over the world as ranging between 5±15% of the adult population (15, 23±29). The emotional status of these individuals has an extreme adverse eect on their oral health (8, 9, 11, 30). It is thus clear that we are facing a huge population of patients who pose a major community health problem and need special attention and treatment. In the present study, an attempt was made to de®ne the characteristics of the adult, dentally fearful individual, in a cross-cultural study carried out simultaneously in Sweden, Israel, and the USA. The purpose of the study was to learn, for dierent populations, the possible etiologic factors, which led patients to develop severe dental fear, the eect of this condition on their lives, their motivation for treatment, and their preferred mode(s) of treatment. However, the closing of the dental fear clinic at the School of Dental Medicine, University of Pittsburgh, unfortunately limited our data, so only cursory comparisons could be made between the Pittsburgh and the GoÈteborg and Tel Aviv groups. In general, it was shown that the dentally fearful patients in Israel, Sweden and the USA are quite similar as far as age, sex, level of dental anxiety (DAS), and time which elapsed since their last dental visit is concerned. The similarities in the demographic characteristics of sex, age, average
avoidance time, and level of dental fear are in agreement with a number of previous studies (3, 8, 15, 31±33). This is not surprising, since most studies have been performed in settings very similar to the present clinics. It is worth underlining that these clinical samples are not necessarily representative of all dentally fearful patients, especially those whose avoidance of dental care is complete. In addition, this study (like most others) captured the dentally fearful patients at a time when (for some reason) they attempted treatment for their fear and/or their dental health problems. Thus, the results relate to the special care setting, and generalizations should be made with caution. Secondly, the study elucidated the psychosocial eects that severe dental fear may have in terms of frequent experience of negative eects in life and, especially, with regard to relating to other people. The most common emotional reaction was repression ± trying not to think about the fear ± a behavioral strategy that was not necessarily successful. In addition, emotions of anger, shame and depression were common and rated important. All three groups reported that the condition of high dental fear had consequences in high incidence of negative emotions (anger, shame, depression, repression), but in comparison to Israeli patients, the Swedish patients indicated more strongly the negative eect of the condition on their everyday lives. These factors both create and aggravate cognition and thoughts about dental fear and one's ability to cope with the situation. It can also contribute to the maintenance of the fear condition (22, 34±36). It has previously been shown that dental fear and avoidance can lead both to severe dental problems, which in turn augment and reinforce the avoidance, and to negative emotional and psychosocial symptoms. These factors have been discussed in vicious cycle models, which include a time perspective and the mutual reinforcement among factors through negative cognitions (1, 37). The assessment of origins of dental fear revealed strong similarities in self-reported etiology among all three samples. The high frequency and rating of ``Always been fearful'' may point to an overrepresentation of individuals for whom personality factors and early development of emotional reaction patterns play an important role. The importance of factors like negative emotional aectivity, shyness, and feelings of low control have been shown to be concomitant to or predict the development of dental fear in children (38±41). However, these factors have not overruled the strong in¯uence from direct and indirect learning factors. In this adult population assessment, retrospective distortion may have occurred, and it is reasonable to believe that this especially relates to
A cross-cultural study of dentally fearful individuals the early and more non-speci®c in¯uence from others (indirect learning). In addition, most patients had more or less frequent and recent episodes of speci®c negative and painful experiences, which resulted in assessments of strong in¯uence from this factor. It is not clear why the assessments were generally on a higher level among the Swedish patients. One might speculate that there are genuine cultural dierences that make it less easy for a Swede to admit to having an emotional problem and to seek health care, which include this aspect. Such reasoning is supported by the strong preference for pharmacological treatments given by the Swedish patients. It may also be that the more than two generation long perspective of mandatory public dental services in Sweden have created stronger feelings of shamefulness about dental fear and a need to ®nd excuses for fear and avoidance. The groups diered regarding motivation and beliefs concerning treatment. Both Israeli and American patients tended more to make operative decisions concerning their fear and treatment preferences than Swedish patients. The most common reason for both Israeli and American patients to seek treatment was due to a personal decision to try to cope with the situation, while among Swedish patients it was pain. Although patients at all three clinics rated fear of treatment equally high, Swedes were more often `forced' to go to treatment by pain or by others. Treatment preferences revealed that both Israeli and American patients clearly preferred the more `active' modes of treatment, such as behavioral management and relaxation training therapies, while Swedish patients stated an equally strong preference for more `passive' treatment approaches, such as i.v. sedation and general anesthesia. This may be due to the cultural dierences, which aect the conceptualization of dentistry between the three communities. One may speculate that an Israeli `prone for action' nature may be the incentive which pushes patients to seek professional help before pain becomes unavoidable. Thus, the feeling of free will and personal choice may have been lower in Swedish patients. This was further underlined by a lower belief in treatment success among Swedish as compared to Israeli patients. It is also possible that the active decision ``to cope with the problem'', rather than following its eects (pain), increases patients' self-ecacy of success. Despite the dierences in motivation and beliefs concerning treatment, the patients' preferences for dentist attributes were very similar among groups. These results are in agreement with a number of previous studies, both among dental phobic and ordinary dental patients (8, 15, 42±45). Our results underline the strong emphasis that
273
fearful individuals put on dentists' behavior and their performance of dental treatment. Clearly, empathic behavior and pain-free treatment are most important, while giving information and control is rated second. Apparently, while patients' preferences for treatment modalities may be dierent, the dentist attribute preferences are very much alike across cultures. This study has elucidated some similarities but also dierences between treatment settings for dental fearful patients in dierent countries. The study suggests that when evaluating patients for treatment of dental fear, consideration of cultural dierences may be measurably important. The focus in this report was based upon patient background data and treatment motivation factors. In this cooperative multicenter study, no enlarged psychometric instrumentation was used, but we believe that the results of this attempt warrant studies to further elaborate the similarities and dierences found. Several aspects of this study should, in our opinion, be investigated in more depth and should include the analyses of the reliability and validity of psychometric instruments. Further, the investigation of the importance of the dierences found should be evaluated from a treatment prediction perspective. Acknowledgements ± The authors would like to thank the clinical sta, students and patients of the dental fear clinics at the Universities of Tel Aviv, GoÈteborg and Pittsburgh for taking part in the present study. We especially thank Jesper Lundgren for his able assistance with statistical calculations. Dr. Pierce is currently in private practice in North Kingstown, RI, USA.
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