Anxiety and Depression in the Dental Office

The mouth is an integral part not only of a physical body, but also of a body image, in other words, of a body presented at a psychic level. Due to the primary experiences that the mouth allows in human development, feelings intimately linked to the identity of the self are represented in it. From being the first organ of contact with the outside world where a new being obtains the first experience of the self that will remain indelibly in the structure of the future personality, since the oral phase, described by Freud, is through which a child, by sucking on objects, recognizes the external world, any disturbance in this phase is related to emotional alterations in adulthood. The mouth is also the psychological seat of the first physiological needs and emotional gratifications, with it we get a taste for the world around us, it is the one that provides the first sensations of security, pleasure, satisfaction and success, leading all this oral activity to the first perceptions of oneself. The most important thing is to understand the strong psychosocial significance that the mouth has for human beings. In some way, we are fully represented in it and our intimacy is revealed. The mouth plays an important role in the feeling of unity and in the construction of the self. Therefore, it is understandable that it generates anxiety when exposing this intimate area of ​​the body to another person such as the dentist, who in many cases is a stranger, whose intervention, both objectively and subjectively, implies some form of aggression. It is not only the physical damage, it is the threat to psychological integrity, to the perception of oneself.

The relationship is strengthened by considering the patient as an independent person who has certain knowledge and decision-making capabilities to improve and maintain oral health. If combined with techniques that help reduce the patient’s anxiety when attending a dental consultation, it will help the patient develop self-care behaviors to improve and maintain oral health in optimal conditions.

Dental anxiety intervenes in the management of the patient in the consultation and in the subsequent adherence and success of the treatment. Authors point out that a person with dental phobia can suffer up to 17 days of pain before consulting a dentist, which is why anxiety is a powerful predictor of deterioration of oral health, high risk of cavities, appointment cancellations and more frequent abandonment of treatments. (1, 2, 3, 4)

Definition of dental anxiety: anxiety, fear and phobia are different.

Anxiety: psychological state characterized by feelings of tension, pressure, nervousness and worry, experienced by an individual at a particular moment in which he or she remembers or presents an expectation that generates uncertainty in situations that are anticipated as threatening (1).

Dental anxiety: multisystemic response to a belief of danger or threat from the environment, being an individual, subjective experience that generates a high impact on daily life, being a great barrier to seeking dental care. There are 3 increased response components: cognitive-emotional (interference in concentration, attentional hypervigilance and inability to remember certain events), physiological (high degree of activation of the autonomic nervous system leading to shortness of breath, sweating and palpitations) and motor (poorly adjusted and poorly adaptive behaviors, ranging from avoidance to escape from the appointment). It can occur in advance, just by thinking about the encounter that generates fear, there is no clear determined danger, but rather a subjective perception of it (1, 4). Anxiety is similar to another psychological symptom: stress, where in this there is a stressor that is affecting the subject.

Anxiety can vary in intensity and duration, and according to (Carballo, 1997) it is classified in dental care as:

• Mild or low: Calm prevails (organic homeostasis). There is slight difficulty in carrying out the dental examination, diagnosis or treatment.
• Moderate: There are signs and symptoms of psychological-functional deterioration that are intense enough to make the dental examination, diagnosis or treatment difficult, which forces a change in the dentist’s routine. It is usually accompanied by uncertainty, apprehension and nervousness.
• Severe or high: It is characterized by fear and intense fear, which may be accompanied by panic. Various signs and symptoms of functional psychological deterioration are detected that prevent the dental examination, diagnosis and treatment from being carried out at the scheduled appointment, forcing a change in the day of the appointment, or the refusal by the patient, the dentist or both to follow the treatment. (1)

Anxiety is closely related to fear and phobia, with intensity being the distinction between them. (2)

Fear: it is not a multidimensional concept. It can be understood as an imminent feeling of harm, evil, problem or an emotional response, it can reach extreme levels such as terror or panic.

Phobia: significant degree of avoidance of the stimulus that produces fear, interfering in the normal routine of the person, occupational or academic functioning and social activities and relationships (4), between 8 and 15% of the population has a phobia of the office and also of receiving care (1)

Dental phobia: severe type of anxiety, fear and dental fear characterized by a marked and persistent concern in relation to situations/objects, dental situations or the dentist himself (2, 4).

There are studies that have shown that there is a correlation between phobia, anxiety and depression.

Depression involves the disturbance of the content of thought and the way it is processed. The content of thought of a depressed person is characterized by a considerable increase in self-contempt, pessimism, fear-laden thoughts regarding oneself, the world and the future – Beck’s Cognitive Triad. There is a particular type of knowledge specific to depression, known as automatic negative thoughts. These are characterized by spontaneous thoughts or images that constitute an important type of knowledge in times of emotional distress. (2)

Anxiety disorders alone are the most frequent psychological pathology, with a lifetime prevalence rate of 19.5% for women and 8% for men, while Asian countries have the highest levels worldwide (between 30 and 48%) (2) 34% in preschoolers, where parents also have a high incidence of dental anxiety of 41% (4).

The results obtained, with respect to the incidence of phobia of the dentist, are the following: 65% of the people have a slight fear of the dentist, 15.83% have a moderate fear, and 19.17% have a phobia of the dentist.

75% of the dental patients surveyed have ups and downs considered normal, 11.67% have a mild disturbance of the mood, 5.83% have intermittent depression, and another 5.83% have moderate depression. Only 0.83% have severe depression.

We reached two important conclusions: that, as the phobia of the dentist increases, the prevalence of depressive symptoms could increase, and that women are generally more anxious than men, and they show anxiety in different circumstances or situations that they have to face, not only in front of the dentist.

Visiting the dentist is the 5th most feared situation by people (1, 2).
Currently, there are instruments to measure the anxiety experienced by a patient in the dental consultation, such as:

The Corah Anxiety Scale (DAS), a questionnaire created by Norman Corah
Another instrument is the MDAS or modified Humpris dental anxiety scale
In children, the most commonly used system is the Facial Image Scale (FSI) for children from 3 to 18 years of age.

Anxiety can cause various physiological changes in patients such as: increased heart rate, elevated blood pressure, faster and deeper breathing, with muscle stiffness. Signs and symptoms can be observed that manifest as a feeling of nervousness and irritability, tachycardia, muscle spasms, mydriasis (dilation of the pupils), nausea with possible vomiting, peripheral vasoconstriction and central vasodilation, piloerection of body hair and hair, increased activity of sweat glands, bronchodilation, alteration of the intestine and stimulation of fecal deposition, while the bladder induces the urge to urinate.

It can cause exacerbation of pre-existing medical problems such as angina, asthma, seizures, hypertension and diabetes mellitus, or induce other stress-related problems such as hyperventilation syndrome or vasodepressor syncope. (1)

The concern of dental sciences to improve the oral health of the population is not questionable, so the search for a solution to the anxiety that occurs in the office becomes vitally important and thus be able to provide comprehensive management to the patient, because its presence can trigger important conflicts when performing a procedure when inappropriate conduct or behavior appears, so prior knowledge could minimize possible adverse consequences. Interventions that have shown effectiveness in reducing the problem.

Sharif recommends following a logical order of management such as promoting communication between the dentist and the patient: Psychoeducation: through the delivery of information regarding which dental procedures will be performed, unfounded concerns are cleared up, which reduces the loss of control. The importance of a good relationship with the patient and generating trust in the office and its environment is highlighted, where the patient is aware of the interest that the dentist has in reducing the anxiety-provoking burden that care generates (1,4). A verbal or written meaning is added, a relationship that symbolically represents the first experiences with authority, whether with the father or some caregiver who presents the role, so the patient sees the dentist as a figure invested with authority, on the one hand he sees him as the person with the possibility of healing him and on the other hand as a threatening person. That is why the interpersonal relationship between dentist and patient is important, since it is the latter who presents a infantile regression, so it is here where the dentist must provide an environment of security and trust, making the patient see that oral health care is an effort of two people, not of one person over the other, therefore the dentist must be flexible in modifications in the treatment plan, where an equal status between dentist and patient is sought, which helps to reduce disruption in treatment, a treatment alliance must be sought, where a common objective is aligned, eliminating anxiety because it is a barrier to such an alliance. (3)

Bare and Duntes identified the strategies recommended by patients, which were found to help 89% of them relax with background music: instrumental sounds that do not have vocalization, intended to modulate the emotional-social-cognitive response of the patient, in which the activation levels in the subject can be significantly reduced (1,4) and 75% stated that the presence of books and magazines decreased dental anxiety.

• Jacobson’s progressive muscle relaxation techniques: both psychic and muscular relaxation, facilitating recovery and balance, towards a state of tranquility. The patient is ordered to gradually tense and relax the different muscle groups of the body, in combination with slow breathing, lasting 10 to 15 minutes. (1,4)
• Distraction technique: focusing attention outside of dental procedures, with music being a form of distraction.
• Cognitive restructuring – Perception of control: where the patient is given the possibility of stopping the dental procedure when he/she deems it convenient, observing a 40% of effectiveness, much higher than that of relaxation. Where the patient’s thought patterns are modified through a process of rational confrontation of irrational beliefs (1,4). Sessions can be organized with the patient prior to the consultation where his/her avoidance or rejection thoughts are fully explored.
• Sedation, acupuncture, hypnosis.
  On the other hand, in children the techniques that have proven to be effective are voice control, breathing management, show-tell-do, perception of control and distraction: such as singing, watching a video, playing a game and having games in the waiting room.
  Recommendations for the dentist are presented such as:

• The profile of the dentist, in which he must have a positive relationship with the anxious patient, based on cooperation and trust, developing psychological qualities such as empathy, understanding, tolerance and receptivity, where his main role is to calm and appease the patient, therefore the tone of voice, attitude, gestures, posture must be directed to that end.
• Predictability in dental procedures, explaining to the patient what is going to be done and strictly complying with what is explained, such as the duration of the procedure, the waiting time, the time of the appointments, starting from simple or conservative treatments to the most complex ones.
• Internalization and universalization: explaining to the patient that he is not the only patient with fears and worries, that he is not the only one who presents these signs and symptoms in the consultation
• Verbalizing the effects of dental treatment: he must acknowledge to the patient the suffering or discomfort inherent to the dental procedure and assure him that this will be avoided or reduced as much as possible. If the patient exhibits inappropriate behavior, avoid aggressive or violent responses or behaviors.
• Use of anesthesia or sedation technique: anxiolytics or general anesthesia
• Characteristics of the dental office: calm and peaceful environment, induce patient relaxation, with color, music and smell playing an important role, which should be pleasant to reduce anxiety levels.
• Constant training or coaching by the dentist: on basic knowledge in clinical psychology, with emphasis on methodologies or techniques aimed at controlling or reducing anxiety.
• Interdisciplinary treatment with the clinical psychologist: care should be suspended in the event of a strong anxiety crisis.
• Include a psychological section in the clinical history: where the patient can recognize, express and categorize their level of anxiety in response to dental care.
  Conduct studies on anxiety in the dental field, establish a proposal for a psychological intervention program for patients who suffer from anxiety episodes associated with dental care. (1)

Psychology and dentistry have multiple interests in common, as a behavioral science which takes on vital importance in the consultation because the behavior of individuals can affect dental treatment (1, 3). It is important to know what dental anxiety is for its subsequent management in the dental consultation, addressing the patient in a comprehensive manner, this includes knowing the psychosocial variables of people and not just limiting it to the oral area (4).

Good psychological management of the patient causes both a better quality and prognosis of the treatment, as well as a better quality of life for the dentist. (3)

A series of variables intervene in the dentist-patient interaction, which determine that this relationship symbolically represents the encounter between two people, where there is no higher power between one person and the other, because the treatment plan is not successful if the patient does not adhere to the recommendations and instructions easily, and this is how anxiety or depression phenomena can be generated in the treatment by not observing changes or improvement in their oral status, being of vital importance that the patient becomes aware of their responsibility in the care of their oral health. Therefore, the form that this relationship takes has implications not only in individual care, but also repercussions at the level of public health. (3)

My recommendation is to find a dentist who generates trust and credibility, in whom you feel safe to start your treatment, as we have seen, this is what the success of the treatment and the reduction of anxiety produced in the office is about. At Dra Stefany Lince, we create a pleasant, calm space where we listen to your requests, we clearly explain each step we take in the treatment to empower you with your oral health and put it 100% in your hands, giving you tools and recommendations that are easy to follow.
We invite you to experience a new pain-free dentistry. Schedule your appointment with us.

1. Amaíz Flores AJ, Universidad Central de Venezuela (U.C.V) V, Flores MÁ, Universidad Central de Venezuela (U.C.V.) V. Abordaje de la ansiedad del paciente adulto en la consulta odontológica: propuesta interdisciplinaria. Odontología Vital. 2016(24):21-8.
2. Krahn N, García A, Gómez L, Astié F. Fobia al tratamiento odontológico y su relación con ansiedad y depresión. Fundamentos en Humanidades. 2011;12(23):213-22.
3. Rojas Alcayaga G, Chile Ud, Misrachi Launert C, Chile Ud. La interacción paciente-dentista, a partir del significado psicológico de la boca. Av Odontoestomatol. 2004;20(5):239-45.
4. Ríos Erazo M., Herrera Ronda A., Rojas Alcayaga G.. Ansiedad dental: evaluación y tratamiento. Av Odontoestomatol . 2014. (30): 39-43.