Dentists' views on fearful patients:
Problems and promises
Carl-Otto Brahm1, 2, Jesper Lundgren1, 3, 4, Sven Carlsson1, 4,
Peter Nilsson2, Catharina Hägglin1
1Department
of Behavioral and Community Dentistry, Institute of Odontology, The
Sahlgrenska Academy, University of Gothenburg, 2Department of Oral and Maxillofacial
surgery, The Institute for Postgraduate Dental Education, Jönköping, 3Research Center,
Public Dental Service, Region Västra Götaland, Gothenburg, 4Department of Psychology,
University of Gothenburg, Sweden
Key words
Dental fear, dentist, attitude, experience, background factor
Running title
Dentists’ views on fearful patients
Corresponding author
Carl-Otto Brahm
Käkkirurgiska kliniken, Hus H3, Länssjukhuset Ryhov, 551 85 JÖNKÖPING
+46-36-326051
Carl-Otto.Brahm@lj.se alternativt Carl-Otto.Brahm@gu.se
1
Abstract
Care delivery to adult patients with dental fear is described focusing dentists’ attitudes,
experiences and feelings. The prevalence of moderate dental fear is approximately 20%
and these patients mainly receive treatment in public dental health care clinics.
However, this field is not very well described in the literature.
The aim of this study was to explore if differences in dentists’ attitudes, experiences and
feelings in relation to treating fearful patients reflect background factors like age,
gender, years of practice, and site of education. 889 Swedish dentists responded to a
web survey including 25 questions. Data were analyzed using quantitative (parametric)
and qualitative methods. The majority of the responding dentists stated that dental fear
is a problem in routine dental care, that treating patients with dental fear is challenging
in a positive way and that they feel like making a contribution. They also reported hard
work and poor revenues, and poor appreciation by their employers. Female dentists
reported higher estimated shares of patients with dental fear in their practices, and they
also consider themselves good at treating these patients, compared to self-ratings by
their male colleagues. Dentists trained abroad reported stress before treating fearful
patients more frequently compared to colleagues trained in Sweden. These are
important findings since an increasing number of dentists trained abroad are recruited
to work in Sweden; they may need additional education in dental fear. It is promising
that dentists’ views of treating fearful patients are mainly positive.
2
Tandläkares syn på patienter med tandvårdsrädsla: Problem eller
möjlighet
Sammanfattning
Patienter med tandvårdsrädsla är en heterogen grupp som mestadels behandlas inom
allmäntandvården. Prevalensen för måttlig tandvårdsrädsla är ca 20 %. Endast de med
grav/fobisk tandvårdsrädsla remitteras för specialiserat omhändertagande. Tidigare
forskning har i huvudsak behandlat ämnet tandvårdsrädsla utifrån patienternas
perspektiv. Betydligt mindre finns skrivet om hur tandläkare eller tandvårdspersonalen
upplever omhändertagande av tandvårdsrädda patienter. Syftet med denna artikel är att
kartlägga tandläkares attityder, erfarenheter och känslor kring behandling av dessa
patienter. En enkät skickades ut till tandläkare anslutna till Tjänstetandläkarna och av
dessa svarade 889 stycken. Majoriteten av tandläkarna tyckte att tandvårdsrädsla är ett
problem i den kliniska vardagen. Många tyckte trots det att behandling av dessa
patienter var positivt utmanande och att de bidrog till något gott. Andra sidan av myntet
var som väntat att det är tufft i negativ bemärkelse och ekonomiskt ofördelaktigt att
behandla rädda patienter, samt känslan av att klinikledningen inte uppskattade deras
arbete. Kvinnliga tandläkare rapporterade högre andel rädda patienter, och ansåg i
högre utsträckning än män att de var bra på att behandla dem. Tandläkare som utbildats
utomlands upplevde mer stress inför behandling av tandvårdsrädda patienter än
kollegor utbildade i Sverige. Detta är intressanta fynd eftersom många utlandsutbildade
tandläkare anställs i Sverige. Vi ska i en framtida studie undersöka om dessa tandläkare
har behov av vidare utbildning inom ämnesområdet. Det är lovande att tandläkares syn
på omhändertagande av patienter med tandvårdsrädsla i huvudsak är positiv, då deras
insatser kan minska utveckling av fobiska beteenden.
3
Introduction
Dental fear is recognized as one of the most common fears and phobias [1-3]. However,
dental fear is a heterogeneous diagnosis that could be described in either way, through
different intensities or different qualities. Moore expressed differences in strength
through categorization into subgroups defined by cut-offs using psychometric measures:
low, moderate, and high dental fear [4]. The low dental fear subgroup reported less fear
of specific stimuli, than did the high fear subgroup. The moderate dental fear subgroup
was not characterized by gender differences, negative dentist contacts or general
fearfulness, as much as the high dental fear subgroup. The prevalence of low dental fear
was 30%, followed by moderate fear 6%, and high dental fear 4%. The Seattle model on
the other side use different focus of fear in order to categorize dental fear patients. Here,
the first group is fear of specific painful or unpleasant stimuli (drills, needles, smells,
etc.), a fear of being unable to tolerate discomfort associated with dental treatment. The
second is distrust of the dental provider due to loss of self-esteem, feelings of
helplessness and lack of control, and suspicion or doubt are central. Generalized anxiety
is the third group where many different situations appear as difficult and stressful, as in
complicating trait anxiety or multi phobic symptoms. The last group is fear of
catastrophe, medically or emotionally, based on fear of having an uncontrollable bodily
reaction to dental treatment (panic attacks, fainting, etc.). Making subgroups of dental
fear may be regarded as an academic issue, but both categorizations have clinical
relevance. The dentist should be able to deliver care to as many of the fearful patients as
possible, leaving only the most severe cases to psychological expertise. Compared to the
great knowledge of high dental fear, little is known about mild to moderate forms of
dental fear and it’s impact upon care delivery.
Dental fear may create psychological and practical problems not only for the
4
patient but also for the dental team members. However, only a few studies have
reported dental fear from a dentist perspective [5-9]. Dental fear and missing
appointment/being late are factors causing stress [5-9]. On one hand anxious patients
are thought to be problematic, unreliable, and complaining [6, 7]. Treating fearful
patients may cause irritation, anger and frustration [6]. The treatments are often time
consuming and not profitable [6, 8, 9]. On the other hand dentists usually treat fearful
patients despite the extra time needed [8, 9]. Some dentists believe that the extra time is
an investment for the future in their dental practice [8]. Dentists are satisfied about the
quality of care and enjoy helping anxious patients [9]. These studies report on
background data including age, gender and time of practice but only three of them
analyze group differences [6-8]. None of them take cultural aspects into consideration.
The Swedish Public Dental Health Care Service is recruiting foreign dentists to
vacancies in rural areas (SOS 2001-125-26), which means a transfer from one social
culture to another. This also occurs when foreign students graduate from dental schools
at Swedish Universities, and vice versa for Swedish dental students trained abroad (SCB
UF 20 SM 1001). Thus, dentists may be trained in one cultural context but are expected
to be able to work in another. Dental anxiety is reported as a global phenomenon
according to a Pub Med/MEDLINE search in august 2010, where 3521 hits were
received. The first 100 articles were published in 2009 to 2010 originating from
Universities representing all populated continents. Although dental anxiety is a
worldwide problem, there may be different approaches to treatment as has been shown
in other fields of health care service regarding cultural background factors [10][11][12].
If such cultural differences include a neglect of dental fear as a clinical problem in its
own right, the needs of substantial number of patients will not be met.
The aim of the present study was to explore Swedish dentists’ attitudes,
5
experiences, and feelings regarding treating patients with low to moderate dental fear.
What is the importance of gender, age, and site of education? Are there differences in
dentists’ views on dental fear due to country of education? We believe that dentists in
Sweden think dental fear is a problem, that treating fearful patients is associated with
stress.
Material and methods
Sample
The sample consisted of members of the Association of Public Health Dentists in
Sweden. Out of in total 4300 members, e-mail addresses were available for 1556
members. These dentists were asked by e-mail to respond to a web-survey concerning
dental fear. Information about the study was attached to the web survey, formulated
according to general outlines given by the Ethics Committee at the University of
Gothenburg. The inclusion criterion ‘working as a dentist treating not only children’, was
not met for 253 members and another ten e-mails were sent back by auto-response due
to vacation, parental leave etc. Thus, 1293 dentists were left as ‘potential responders’,
out of whom 889 returned their surveys, resulting in a response rate of 69%. A majority
of the respondents had had their dental training in Sweden (n 809) and approximately
ten percent were trained abroad (n 80). In seven responses from the latter group,
information of specific foreign country was missing. The abroad group was further
divided into the European Union (EU) and third country. The latter is defined as a
country that is not part of the EU or affiliated to the European Employment Strategy
(EES). Countries representing the European Union in this study were Poland (n 16),
Germany (n 11), Greece (n 6), Romania (n 4), Finland (n 3), Holland, Hungary, Denmark,
Estonia, France, and Spain. Norway (n 3) was also included in the EU group due to a
6
cooperation agreement. Third countries were Iraq (n 7), Russia (n 4), Azerbaijan,
Belarus, Bosnia, Colombia, Lithuania, Mexico, Pakistan, Serbia, Syria, United States of
America, and Venezuela (table 1). One dentist each represented the countries with no
numbers mentioned. Thus, out of the 80 dentists trained abroad, 49 (61%) were trained
in the EU and 24 (30%) in third country.
The web survey
The web survey was sent by e-mail, and two reminders were delivered with one week
apart. The web survey contained 25 questions, and for the present study 12 of these
were chosen for analysis. These questions refer to background factors and the dentists’
attitudes, experiences and emotions regarding treating patients with dental fear. The
other questions in the survey will be treated in a future study that will focus on
treatment of dental fear and need of education within this field.
Background factors were gender, age, site of education (‘any of the four faculties of
dentistry in Sweden’ or ‘other country - specified’) and number of years working as a
dentist. Other background factors asked for were ‘number of hours per week working as
a dentist?’ and ‘estimated proportion of adult patients’. The last background question
addressed the responding dentists own feelings being a dental patient and has been
used in other studies [13]. The question could be answered in either of four ways
referring to discomfort/dental fear and were dichotomized as ‘Yes‘ in the sense of ‘I do
not like it and I think it is rather unpleasant’; ‘I am very frightened or I think it is very
unpleasant’; and ‘I am terrified’; ‘No’ meaning ‘I do not care at all’. In the affirmative
group the dentists report both discomfort and fear/anxiety, concepts that are not
equivalent but express negative emotions regarding dental treatment.
7
Five of the questions in the survey referred to the dentists’ attitudes, experiences
and feelings regarding treating patients with dental fear. The response alternatives to
‘Do you think dental fear is a problem in dental health care service?’ were four and
dichotomized into ‘Yes’ in the sense of ‘yes, ought to be more focused on’, ‘yes, but
nothing to do about it’, ‘yes, but other problems are more important’, and ‘No’ meaning
‘no, not particularly’. The question ‘Do you feel stress before treating a patient that you
know has dental fear?’ was answered on a scale from 1 (‘always’) to 5 (‘never’). The
question “How do you feel/think about treating an adult patient with dental fear?” was
answered from seven given options (figure 1) or/and possibility to leave own option. It
was possible to mark one to three of the given response alternatives. In one analyses the
response alternatives were categorized and analyzed as principally ‘positive’, ‘neutral’
or principally ‘negative’. In this analyses ‘poor economics’ was omitted, leaving ‘positive
challenge’, ‘exciting’, and ‘making a contribution’ defined as principally positive.
Principally negative alternatives were ‘stressful’, ‘hard’, and ‘reluctant’. “Do you find
yourself good at treating adult patients with dental fear?” could be answered: ‘Yes, very
good’, ‘Yes, pretty good’, ‘No, not particularly’, or ‘No, not at all’. The last two alternatives
were dichotomized into ’No, not particularly/no, not at all’, since only one dentist
answered ‘not at all’. The dentists were also asked to estimated the proportion of their
patients suffered suffering from dental fear?’ answered to on a scale (0 - 100%).
Statistical analyses
No data were missing, since all questions were compulsory and it was not possible to return
the web-survey without responding to all questions. Because of non-normal distributions we
preferred non-parametric statistics. Data is described by using mean, standard deviation (SD)
and range. For comparison between frequency distributions the Chi-square test was used. For
8
other group comparisons Mann-Whitney and Kruskal-Wallis tests were used when
appropriate. The pre-chosen level of significance was p<0.05.
Results
In the present study 889 dentists responded to the survey, 570 were women (64 %). In
table 1 more background data of the respondents are presented in total and in relation
to gender. Average weekly working time was 88% and the mean rate of adult patients in
the dental practices was 68%. The age group >50 was the significantly largest one (table
1). A statistically significant difference was found for age and site of education (2=57.5,
p<0.001). The majority (50%) of the dentists trained in Sweden were 50 years or older,
compared to 11% of those trained abroad (R>1.96). Among dentists trained abroad the
majority (45%, R>1.96) were in the age group 31 to 40 (2=57.5, p=0.000).
In the Swedish trained dentist group 36% compared to 50% of the abroad group
reported own discomfort or fear when seeing the dentist (2=8.7, p=0.003).
‘Do you think dental fear is a problem in dental health care service?’
712 dentists (80%) thought of dental fear as a problem in dental care. There were no
gender differences. According to age a significant difference was found. Younger dentists
compared to elder reported dental fear being a problem (24-30: 87%; 31-40: 80%; 4150: 83%; >50 years old: 76%)(2=8.89, p=0.031). Similar results were shown for ‘years
of practice”. 88% (R>1.96) of the dentists who had practiced for 2-5 years thought that
dental fear was a problem, compared to 78-79% in the two groups with longer
experience (2=10.3, p=0.016). Dentists reporting discomfort or dental fear when being
patients answered ‘yes’ (83%) to a higher extent than their non-discomfort/fearful
colleagues (78%)(2=3.1, p=0.08).
9
‘Do you feel stress before treating a patient that you know has dental fear?’
Feelings of stress before treating a patient suffering from dental fear were reported
‘always/usually’ by 9.6% of the dentists, ‘sometimes’ by 37% and ‘seldom/never’ by
54%. ‘Always/usually’ feeling stress were significant more common among dentists
trained abroad (24%, R>1.96) than Swedish trained dentists (8%) (2=27.0, p<0.001),
with no difference between the EU and Third country. Dentists with own dental
discomfort/fear reported more feelings of stress before treatment of patient suffering
from dental fear than their non-discomfort/fearful colleagues (2=6.7, p=0.036). No
significant differences were found for gender, age and years of practice.
‘Do you find yourself good at treating adult patients with dental fear?’
Out of the 889 dentists, 19% regarded themselves as ‘very good’ in treating patients
with dental fear, 73% as ‘pretty good’, and 8% ‘not particularly/no not at all good’. More
women than men reported being good treating fearful patients (2=13.8, p=0.001)
Significant differences were also found regarding feelings of stress before treating a
fearful patient. Less self-efficacy corresponded to more feelings of stress reported before
treatment (2=59.3, p<0.001). No statistically significant differences were found for age,
years of practice, own discomfort/dental fear, and site of education. 20% of dentists
trained in Sweden, 17% in Third country, and 14% in EU reported ‘very good’ treatment
skills (2=3.5, p=0.479).
‘How do you feel/think about treating an adult patient with dental fear?’
One response alternative was filled in by 16%, two by 28%, and three by 56%. In
average the dentists reported 2.4 alternatives. There were no significant differences
10
regarding background factors as gender, age, experience, and own discomfort/dental
fear, neither site of education.
The most common attitudes towards treating a fearful patient reported by dentists
were ‘making a contribution’ (79%) and a ‘positive challenge’ (55%). Men (12%) were
more reluctant than women (6%) to treat fearful patients (R>1.96) (2=11.4, p=0.001)
but no other statistically significant differences were reported in accordance to gender
and attitudes towards treating fearful patients. In table 2 the seven response
alternatives are shown in accordance to age, years of practice and site of education.
Dentists trained abroad compared to Swedish trained reported more stress and did not
feel they made a contribution when treating fearful patients (table 2). When dividing
‘abroad’ into the two subgroups, dentists trained in the EU experienced more ‘stress’
(35%) than dentists trained in third country (13%)(2=8.2, p=0.016) and ‘less feelings
of contribution’ (59% and 75% respectively)(2=13.2, p=0.001) compared to third
country. In figure 1 the response to the different alternatives are shown in accordance to
self-efficacy when treating fearful patients. 21% (R>1.96) of the men reported
principally negative attitudes, compared to 14% of their female colleagues (2=8.3,
p=0.015) table 4.
Qualitative remarks to the question
The comments to the alternative ‘other’ illustrate the dual nature of the dental fear
challenge: problems and promises. Several of the respondents express a positive
attitude to treating fearful patients: “Makes you develop as a dentist and a human
being”; “[gives] positive feedback”; “Stimulating to feel the patient’s trust”; “Rewarding”.
Others, in a more neutral tone, declare that giving care to the fearful patient is an
integrated part of their job: “[it is] my job”; “[it is] necessary”; “part of the normal
11
variation”. Many comment the taxing qualities of giving care to fearful patients: “[it is]
heavy”; “It requests focus and devotion, therefore tiring”; “taxing and time-consuming”;
“takes much energy [which] makes you tired afterwards, though in a positive manner”.
The most common type of comment has to do with economic and organizational
obstacles. One respondent declares: ”[I] would gladly have more fearful patients…but
within the public dental care system it is ONLY the economic result that counts, and this
in turn affects your salary which means that you get punished…” Another similar
remark: “Difficult question to answer, because I really believe that I make a contribution
[treating fearful patients], but it does not make your employer appreciate you, given the
present economic situation. When on emergency duty, it is stressing because you are not
given the time needed.” Some plainly declare that taking care of fearful patients is an
economic burden because the extra time needed is not allowed.
‘Estimated proportion of adult patients with dental fear?’
The estimated mean proportion of patients treated suffering from dental fear was 16.4%
(SD=15.2). Women reported significantly more patients with dental fear than men (z=3.8, p<0.001). Dentists reporting feelings of discomfort/dental fear when being patients
themselves reported having more fearful patients (z=3.3, p=0.001). Fewer patients
suffering from dental fear were reported if being older or having more years of practice
(2=22.3, p=0.000 and 2= 29.7, p=0.000 respectively). Dentist with more positive
attitudes towards treating fearful patients also reported treating these patients to a
higher extent (2=15.1, p=0.001) and the same relation was found for those with high
self-efficiency when treating these patients (2=44.8, p=0.000). Dentists who not
experience dental fear as being a problem in dental care reported treating significantly
12
fewer patients with dental fear (z=-6.6, P=0.000). No statistically significant differences
were found regarding place of training.
Discussion
The majority of all dentists responding to the web-survey believed that dental fear is a
problem in dental health care, younger colleagues with short dental practice in
particular. Dentists trained in other countries than Sweden reported more stress when
treating fearful patients. We also found that female dentists consider themselves as good
at treating patients with dental fear to a higher extent than their male colleagues. Male
dentists would rather be excused from treating patients with dental fear. Interestingly
dentists rating themselves as not being good at treating these patients also reported
more stress before the appointments.
The response rate of the web survey was acceptable, more than two thirds of the
potential responders participated. Out of the 31% who did not respond, certainly some
did not receive the e-mails due to for example not terminated e-mail accounts. However,
the exact proportion is hard to tell.
The data collection is based on a fairly representative random sample with fairly
small losses. The questions in the web survey are more thoroughly illustrated than in
previous studies in this field [7][6][5], giving a more balanced picture of dentists’
experiences, attitudes and feelings regarding treating patients with dental fear. It also
brings new knowledge to the field, since most of the literature dealing with the topic is
somewhat outdated [7][6][5]. However, this study also has weaknesses. One limitation
is lack of private practicing dentists in our study group. The reason is that the register of
these dentists could not be available to us.
13
The results regarding dentists’ attitudes to treating patients with dental fear are
promising. The majority reported positive attitudes as ‘making a contribution’ and
‘positive challenge’, but there are also negative ones like ‘hard’ and ‘poor economic
reward’. It would be beneficial to overcome this problem through action and
encouragement from the employers. We would also like to intervene in this process in
the future, trying to reduce negative attitudes.
It is interesting that younger dentists and/or dentists with only few years (two to
five) of practice, think of dental fear as a problem in dental health care service. Probably
these dentists represent the same group. After graduation it is common to practice one
year with supervision by an older colleague, and the demands of revenues are low. The
young dentist is supposed to work more independently with increasing responsibility
when the learning period is over, including treatment of fearful patients. Rating of dental
fear as a problem was higher by dentists reporting dental fear of their own, compared to
non-fearful colleagues. This may be explained by better perception of the signs of dental
fear, with a more genuine understanding of the problem.
The reason why dentists trained abroad feel more stressful when treating fearful
patients is hard to tell. What we do know is that dental fear is not a specific SwedishNordic phenomenon, but is present in all cultures worldwide. However, we can
hypothesize that some dental education sites outside Sweden and the other Nordic
countries put less resources in this field to their agenda. Education in dental fear has
improved over the last 30 years, meaning that dentists with long practice have less
knowledge from their undergraduate training. Nevertheless they should have been able
to repair this lack of knowledge later in their careers. If that is the case one could further
hypothesize that the dentists have made other priorities in their postgraduate training
14
than dental fear. Also, dentists trained in third countries reported that dental fear is a
clinical problem they are unable to handle, more frequently than did dentists trained in
Sweden and in the EU. We cannot tell whether this is an educational issue. We will
further investigate these questions in a future study.
Female dentists reported themselves as good at treating fearful patients more
frequently than male dentists. These female dentists also reported higher proportions of
patients with dental fear than their male colleagues. The question is whether women
really are better than men in treating fearful patients? Are women better in recognizing
dental fear, making diagnosis and treating the complete heterogeneous group or are
there differences in how women and men define dental fear, and/or their abilities?
Dentists’ primary task in relation to dental fear should be to prevent the
development of fearfulness, and secondary to offer care to these patients. Health care in
Sweden including dental health care is regulated by law and should be equal for all
patients. Negative attitudes and experiences among dentists concerning patients with
dental fear may affect the quality of care and lead to future problems. However, if the
results of this study are not a cohort effect but general findings, we can look to the future
with confidence.
To conclude, the majority of Swedish dentists believe that dental fear is a clinical
problem. Dentists think they make a contribution and regard treating patients with
dental fear as a positive challenge. Female dentists report they are good at treating
fearful patients, and they estimate a higher number of these patients in their practice
compared to male colleagues. Dentists trained abroad, especially in the European Union
report stress more frequently than those trained in Sweden. The future study will deal
with dentists’ need of education, and eventually we wish to make methods for
15
intervention in order to reduce stress in the dental situation for both patients and the
dental personal.
Acknowledgements
Greatly acknowledge to all participated colleagues, Textalk Ltd., Lars Sandman, and
Susanna Magnusson.
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Figures Legends
Tables
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