by Mary Therese Keating-Biltucci, RDH, MA
Most of us are familiar with the findings of the U.S. Surgeon General's report on oral health that came out in 2000 and found extensive oral diseases and disorders in vulnerable populations.1 But 10 years later it is important to ask if we have made any progress toward the dissolution of this problem. Therefore, causes of anxiety in vulnerable populations might be a viable focus for research. If some cultures are suspicious, fearful, or anxious toward dentistry, then avoiding any dentistry might be the accepted behavior within that culture.
Researchers in 1997 looked at dental health attitudes of black and white adults in Florida. Results of the study showed that of the 873 respondents, 45% reported going to the dentist only when they had a problem, and 10% of the respondents themselves reported removing a permanent tooth. This study concluded that dental care is heavily influenced by race and poverty.2 We might think this is a horrific depiction of our poorest citizens. But consider this – a self extraction may be what some people are more comfortable undergoing to avoid a terrifying experience with a stranger using a needle, pliers, and chisel (or what some patients assume we use) to stop the pain. Self-extractions may be a completely foreign concept to some of us, but in some cultures it could be a familiar and viable solution to a common inconvenient problem.
Dental anxiety and fear has been a constant dynamic of the dental patient since the beginnings of humankind. With the use of anesthesia, it might be assumed that fear of dental procedures would be a thing of the past, but dentists still report that 15% of patients fail to feel the benefit of the anesthetic. Anesthesia failure could be ascribed to anatomical differences, but other factors may play the largest role when dental patient fear is examined.3
Studies conducted over the last four decades report that dental anxiety affects 29.2% of the adult population and 43% of children. Many experts suspect that this number is low, especially when researchers look at specific demographics.4 This article will look at the possible social and cultural etiologies behind the fear and anxiety, and how these may impact the dental experience.
Definition of anxiety and fear
Fear is the distressing emotion aroused by danger or pain, whether real or imagined. When a fear becomes irrational and uncontrollable, it becomes a phobia. It is worthy to note that fears are often fueled by our imagination, and so every fear will have a degree of irrationality to it.5 Specific fears are a result of learning, and this is referred to as fear conditioning. Scientists such as Joseph B. Watson discovered that fear conditioning was acquired when people personally experienced a traumatic event, and when they saw someone else experience a traumatic event knowing that the same event was to be experienced by them.6
However, fears are not just learned, but is a part of being human. Fears and phobias that relate to our environment are actually protective in nature. Early humans who were quick to sense fear were more likely to survive and be reproductive in the theory of natural selection.7
Anxiety is a psychophysiological sign that the stress response has been triggered. Stress is yet another component of the dental experience, and while researchers do not always agree on its definition, it seems to represent an internal response due to stimuli such as a life event (the dental experience). The stress response has many dimensions since each person defines the stress factor.8
What is common is that stress is perceived as a threat that makes a demand on the person or demands adaptation. However, the threat may not be a tangible concept because it includes anticipation of a future event, an evaluation of an event based on a person's beliefs, intensity of the stimulus, and the time of the event. Some degree of stress is essential for living and is actually protective, but efforts should be made to minimize the stress felt by dental patients.9
Origins of dental fear and anxiety
The origins of fear and anxiety, especially in the dental environment, have a complex and multifactorial psychological and physiological etiology. Most dental providers are versed in treating pain with pharmacological tools, but few receive pedagogical instruction on the treatment of the underlying fears of patients. The most superficial and obvious reasons for our dental fears are that we anticipate some kind of suffering. But this does not provide all of the answers since researchers also found that many people who expect to feel pain do not experience anxiety.
Researchers have found that a number of factors contribute to the etiology of dental fears. Four global causes of fear include conditioning, an innate predisposition, physiological differences, and fear due to direct stimulation or nonassociative perspective.10 This review of the literature examines socialization of emotional expressions as a possible etiology of fear and anxiety.
Negative experiences in childhood or direct conditioning are the most common causes of dental fear. An event of dental pain or an unpleasant attitude of the care provider establishes the initial stimulus that triggers patterns of fear and anxiety. Conditioning or the socialization of emotional expressions can be categorized by both negative and positive effects that can be a learned response.
Our relatives are also powerful motivators and predictors of our dental anxieties. Johnson and Baldwin (1968) provided strong evidence that mothers who had high levels of anxiety were more likely to have children who reacted negatively to a dental situation.11 This was further validated because it was a first dental visit for these children, so past experience was not an influential factor.12 Regardless of the origins, fears and anxieties are modeled after the patient's friends and relatives that transmit their expectations to observers.13
Fear is also a learned response from observing family, peers, society, and role models.14 Indirect learning of fear seems to be more difficult to measure. Studies showed no correlation between perceived dental anxiety and family members, or positive correlations between dental anxiety and the frequency of visits by the mother. The evidence is largely anecdotal or indirect because it is unethical in most instances to research the scope of fear without acquisition of fearful behaviors.15
Researcher Amy Halberstadt agrees with family influence on emotional expression. Halberstadt found that the family influences communication skills, but she found scarce research that proved these ties to emotions. She concluded that it is not only what we feel, but also how we show it that is influenced by family dynamics.16 Author Peter Milgrom and coworkers questioned familial control on oral health. They proposed that during our lifetime, a framework exists that defines a variety of forces that influence our health behaviors.17
We are influenced by culture, gender, and social demands when we learn how to express our emotions. Display rules are body language or facial expressions, but author Matsumoto (1990) believes that our emotions can be influenced early on by display rules even without invoking an emotional response. For example, he believes display rules such as facial expressions in cultural group dynamics define the emotional displays that are passed down to indivudals from generation to generation. Display rules are understood based on the form of expression and the motivation for their use.18
Author Susan Denham's research also suggests a rich area for study on the differences in children's understanding of emotion.19 Facial expressions of caregivers may be a good area to research the origins of dental fears, especially in specific demographics. Irene Hilton feels that modifications to the dental care delivery system may not be enough to tackle fears if cultural norms and behaviors of parents and children are not addressed. A focus on parents' and children's negative associations with dental experiences is needed, as are dental providers with empathy for patients' past experiences.20
There may also be more subtle reasons why specific ethnicities, race, and socioeconomic groups fear the dental environment. Researchers who looked at unmet health care needs found that the determinants of missed or delayed care were multifactorial. Among their findings were a general lack of empowerment by patients to address needs, language differences, and cultural beliefs and practices.21 Researcher L. Ebony Boulware found that trust in physicians, health insurance plans, and hospitals differed by race. Boulware feels diverse health care systems could reflect cultural experiences and influence institutional and interpersonal trust. Interpersonal trust is based on personal experiences, but institutional trust is more likely to be based on general impressions or social cues.22
In the article titled "Is trust a predictor of having a dental home?" Michelle Graham found a lack of trust to be a factor in people who don't seek out regular dental care.23 In fact, Graham is among many authors who found that mistrust of medicine and research in minority groups might be due to experiences that date back to slavery and historical events such as the Tuskegee Syphilis Study (unethical recruitment and denying necessary treatment to research subjects).24, 25, 26
Culture strongly influences how patients view the health care environment, and trust affects every aspect of the doctor/patient interaction. Graham concludes that efforts to reduce disparities must include programs that increase patients' confidence by demonstrating that their best interest is a top priority of the health care system.27
Dental anxiety has been extensively studied in the U.S. since 1960. However, authors Smith and Heaton found no significant trend that showed an increase or decrease in reported anxieties. Overall they found that even though general anxiety has risen in the U.S. for the past 50 years, dental anxiety remains stable.28 In our multicultural society, population shifts stress how the importance of cultural influences may affect health disparities.
More health care dollars will continue to be spent on emergency dental care instead of prevention if we cannot address the needs of all cultures by recognizing the cultural effects of fear, and mother-child patterns of coping with stress.
Mary Therese Keating-Biltucci, RDH, MA, is currently with the University of Rochester Eastman Institute for Oral Health as a health project coordinator in clinical dental research. She is also an adjunct instructor in the dental hygiene health science department at Monroe Community College. Contact her at (585) 273-3107 or [email protected].
- U.S. Department of Health and Human Services. Oral Health in America: A Report of the Surgeon General.
- Rockville, MD: U.S. Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health, 2000.
- Gilbert GH, Duncan P, Heft MW, Coward RT. Dental Health Attitudes among Dentate Black and White Adults. Medical Care, 35, (3); Mar., 1997, pp. 255-271.
- l Locker MJ. Psychological factors and perceptions of pain associated with dental treatment. Community Dent Oral Epidemiology 2002: 30: p. 151-159.
- Armfield JM. Cognitive vulnerability: A model of the etiology of fear. Clinical Psychology Review. 2006; 26 p. 746-768.
- Eli I. Oral Psychophysiology; Stress, Pain, and Behavior in Dental Care. 1992. CRC Press Inc. Boca Raton, Florida p. 61-62.
- Watson JB, Rayner R. Conditioned Emotional Reactions. 1920. Journal of Experimental Psychology, 3(1); pp 1-4.
- Eli I. Oral Psychophysiology; Stress, Pain, and Behavior in Dental Care. p.67.
- Robinson L. Stress and Anxiety. Nurs Clin North Am. 1990 Dec;25 (4):pp. 935-943.
- Eli I. Oral Psychophysiology; Stress, Pain, and Behavior in Dental Care. p.61-62.
- Kent GG, Blinkhorn AS. The Psychology of Dental Care. p.66.
- Johnson R, Baldwin DC. Relationship of Maternal Anxiety to the Behavior of Young Children Undergoing Dental Extraction. Journal of Dental Research. 1968; 47; p.801-805.
- Kent GG, Blinkhorn AS. The Psychology of Dental Care. p.70.
- Kent GG, Blinkhorn AS. The Psychology of Dental Care. p.72.
- Eli I. Oral Psychophysiology; Stress, Pain, and Behavior in Dental Care. p. 68.
- Rachman S. The Conditioning Theory of Fear Acquisition: A Critical Examination. Behav. Res. & Therapy. 1977, 15; pp 375-387.
- Halberstadt AG. Family Socialization of Emotional Expression and Nonverbal Communication Styles and Skills. Journal of Personality and Social Psychology. 1986,51;(4) pp. 827-836.
- Milgrom P, Vignehsa H, Weinstein P. Adolescent Dental Fear and Control: Prevalence and Theoretical Implications. 1992. Behav. Res. Ther.; 30(4); pp. 367-373.
- Matsumoto D. Cultural Similarities and Differences in Display Rules. 1990, Motivation and Emotion, 14 (3); pp. 195-213.
- Denham SA, Zoller D, Couchoud EA. Socialization of Preschoolers Emotion Understanding. 1994. Developmental Psychology. 30; (6); pp. 928-936.
- Hilton IV, Stephen S, Barker JC, Weintraub JA. Cultural Factors and Children's Oral Health Care: A Qualitative Study of Carers of Young Children. 2007. Community Dent Oral Epidemiol. 35: pp. 429-438.
- Shi L, Stevens GD. Vulnerability and Unmet Health Care Needs. 2004. J Gen Intern Med, 20: p. 153.
- Boulware LE, Cooper LA, Ratner LE, et al. Race and Trust in the Health Care System. 2003. Public Health Reports. 118, p 362.
- Graham MA, Logan HL, Tomar SL. Is trust a predictor of having a dental home? 2004. J Am Dent Assoc; 135; pp.1550-1558.
- Graham MA, Logan HL, Tomar SL. Is trust a predictor of having a dental home? p.1551.
- Corbie-Smith G, Thomas SB, St. George DM. Distrust, Race and Research. 2002, Arch Intern Med, 162 (21) pp. 2458-2463.
- Boulware LE, et al. p.359.
- Graham MA, Logan HL, Tomar SL. Is trust a predictor of having a dental home? p.1557.
- Smith TA, Heaton LJ. Fear of dental care: are we making any progress? 2003, J Am Dent Assoc. 134(8):pp. 1101-1108.
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