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Dorsal vagal freeze: Its role in dental anxiety

Feb. 27, 2022
Dental hygienists need to recognize intense dental anxiety in our patients, but the signs are not always obvious. Jean Manz, MA, LMFT, has been treating dental anxiety for many years and helps us recognize its “hidden face.”

Jamie is always a few minutes late for appointments and is known to call at the last minute to cancel. When I greet her in the reception area, she seems startled and rises from the chair with her body communicating “resigned to have to do this.”

I make my best effort at casual conversation, commenting on her beautiful red jacket, and she mutters “thanks” in a barely audible tone. She is hard to engage. When she sits in my office, her neck and shoulders are contracted and I notice her foot bouncing around as if she’s keeping time to a quick-paced tune. She seems slightly embarrassed that she didn’t follow up on my suggestions from our last appointment and tells me she just forgot. Her face is hard to read but is unmistakably tense. She’s worried about an upcoming procedure and doesn’t think she can go through with it. She asks me to help her “get a grip.” She’s hurting and needs this dental appointment.

Your dental hygiene patients are my therapy patients. We’ve already been working together for years. Most of my patients experience anxiety, often debilitating and interfering with their ability to do the things they want and need to do in life.

The National Institute of Mental Health estimates that 31% of adults in the United States will experience an anxiety disorder sometime in their lifetime and that 19% of the population had an anxiety disorder in the past year.1 That is one in five of your patients. Perhaps it’s you. The COVID-19 pandemic has only worsened this statistic with estimates that the prevalence of anxiety has more than tripled in the United States.2

My mental health practice in Northern New Mexico attracts clients seeking help to prepare for dreaded events: flying in an airplane, taking an exam, undergoing a medical procedure, or giving a speech. For those whose “dreaded event” is the dental chair, successful preparation means being able to sit through a procedure reasonably still with relaxed facial muscles while feeling a general sense of calm.

For the one in three people who is estimated to be affected by moderate to severe dental anxiety,3 suffering often begins well before getting to your office. They experience difficulty sleeping, irritability, a racing heartbeat, feeling on edge, and being scared, sometimes for days and weeks before you see them.

Steven brought his 10-year-old daughter Elise to see me because she feared going to the dentist. She had tooth decay and needed extractions. She wouldn’t get out of the car to go in. After a few counseling sessions, she was able to manage well enough to walk in on her own, sit through the procedure without sedation, and return for follow-up appointments, looking forward to the treat her mother had promised as her reward.

Another of my patients, John, came in because he found the thought of instruments in his mouth and lying on his back in a chair excruciating. He had been sexually abused as a child; this dental treatment scenario was way too triggering. He had never shared this with his dental provider; it felt too private to bring up. Therapy helped him differentiate his trauma from the dental care experience, taught him ways to induce some calm, and trained him to focus his attention where he could feel some comfort.

What is anxiety?

Anxiety isn’t a feeling; it’s a physiological response. We’ve all felt and seen the unmistakable signs of the mobilized fear response: sweaty palms, rapid heart rate, fidgety movement, muscle tension, eyebrows expressing concern, the “deer in the headlights” look. It’s hard to mask these overt signs of anxiety.

But intense anxiety has another appearance—it can look quiet and still. This is its hidden face that is easy to miss. Some patients may look extremely calm when their anxiety is intense. Consider your compliant patient, the one who doesn’t interfere with your treatment—the “easy patient.” This person may be the one who really needs your extra emotional support.

The mobilizing fight-or-flight response is good for overwhelming escapable stress. We run away or get angry and fight, and the body returns to “rest and digest.” But what about overwhelming inescapable stress, such as financial problems, the COVID-19 pandemic, or having to sit through a procedure that scares us?

Also in this issue: 6 things I want you to know

What is dorsal vagal freeze?

If we can’t mobilize and don’t have resources to increase our sense of safety, the autonomic nervous system engages the response of “freezy business” by way of the dorsal vagus nerve.4 This is a shutting down of systems. Think of an electrical grid overwhelmed by power demands during a heat wave. Controlled “rolling blackouts” are a way to manage the demand and prevent the entire system from crashing. This is what “freezy business” is all about: nonessential systems shut down, such as higher reasoning and digestion. The senses dull, blood pressure lowers, and saliva production ceases.

This is a high-intensity stressful event in the body and an undesirable state for your patient to be in as it is paired with feelings of helplessness and being invisible; impaired ability to engage higher reasoning centers in the brain to understand information and instructions; slack muscle tone; difficulty relating socially; and restricted capacity to register information in the environment. Here are some of the tells:

How to assess a dental patient for dorsal vagal “freeze”

What you’ll see:

  • Dulled senses
  • Trouble responding to directions
  • Slackened muscle tone
  • Lack of prosody
  • Unusual physical or emotional numbness
  • Constricted pupils
  • Low blood pressure
  • Pale skin
  • Motor stillness (tonic immobility)
  • Dry mouth
  • Flat face (lack of shown emotion)
  • Soft voice
  • Shallow breathing
  • Fixed eye gaze
  • Cold hands/feet
  • Tense/droopy eyelids

Coping mechanisms

There are active steps you can take to signal body safety and improve coping. Some simple exercises can help with freeze recovery. These involve low-intensity movement, activation of cranial nerves, and signals of safety from social connection such as the relaxed, friendly face of a hygienist. Explaining and giving information isn’t very helpful; remember that higher cognitive processes are in “rolling blackout” mode. Reducing stimulation helps. Think about dimming the lights, lowering the music volume, and backing up your chair to give more personal space.

Here is an easy technique called the “half salamander” that supports recovery from freeze and comes from the book Accessing the Healing Power of the Vagus Nerve by Stanley Rosenberg.5 It can be done rather discreetly and suggested to your patient when in the dental chair. I use it myself between patients to reset my biology after an intense appointment.

  • Without turning your head, let your eyes look to the far right.
  • Continuing to face straight forward, tilt your head to the right so that your right ear moves closer to your right shoulder, without lifting the shoulder to meet it.
  • Hold your head in this position for 30 to 60 seconds.
  • Let your head come back up to neutral and shift your eyes to look forward again.

Do the same on the other side. Let your eyes look to the left, and then side-bend your head to the left. After 30 to 60 seconds, return your head to an upright position, and your eyes to a forward direction.

Whether you are a dental professional, first responder, friend, partner, teacher, or parent, it is important to be able to assess freeze, both in others and in yourself. Freeze recovery allows us to be fully effective in relationships and have presence, the capacity to have focused attention that is attuned and responsive to the nervous system state of another. This is our relational “superpower,” and one that allows us as dental providers the capacity to show up with both empathy and the power to influence for good.

Also in this issue: Make self-care a priority—or pay the cost

I encourage you to pause daily, do your own self-check, and ask yourself where your own system is hovering: fight, flight, or freeze. And what about that of your patients, kids, spouse, friends? Don’t let someone you care about be “under the radar” because they are silent, people-pleasing, or have the appearance of emotional calm. They may be “freezy” and in need of your kindness, sensitive responsiveness, and some easily learned techniques to make an experience much more comfortable and manageable.

Editor's note: This article appeared in the February 2022 print edition of RDH magazine. Dental hygienists in North America are eligible for a complimentary print subscription. Sign up here.


  1. Managing stress and anxiety. Anxiety and Depression Association of America. February 2021. https://adaa.org/understanding-anxiety/generalized-anxiety-disorder-gad/managing-stress-and-anxiety
  2. Tackling the mental health impact of the COVID-19 crisis: an integrated, whole-of society response. Organisation for Economic Cooperation and Development. May 12, 2021. https://www.oecd.org/coronavirus/policy-responses/tackling-the-mental-health-impact-of-the-covid-19-crisis-an-integrated-whole-of-society-response-0ccafa0b/
  3. Silveira ER, Cademartori MG, Schuch HS, et al. Estimated prevalence of dental fear in adults: a systematic review and meta-analysis. J Dent. 2021;108:103632. doi:10.1016/j.jdent.2021.103632
  4. Dana D. Polyvagal Exercises for Safety and Connection. W.W. Norton & Co; 2020.
  5. Rosenberg S. Accessing the Healing Power of the Vagus Nerve. North Atlantic Books; 2017.