Definition of dental anxiety and causes of/reasons for dental anxiety
How is dental anxiety measured?
Dental anxiety is difficult to measure, especially considering that self-reporting techniques are not always accurate. Some methods used to measure dental anxiety have not been specifically designed for children, yet are being used to measure dental anxiety in children. Measuring dental anxiety over the course of a period of subsequent visits if often overlooked. An effort to address this is the Bayesian estimator, a neuropsychology technique, which has been used to consider the progress that a patient experiences over the course of multiple dental visits. Other aspects, such as whether a patient had a behavioral pattern of cancelling appointments or failing to show up, should also be considered yet are often neglected. Due to the complexity of the issue, there are many important factors that need to be considered when looking at treatments for dental anxiety.
How is dental anxiety treated?
Brief relaxation versus music distraction in the treatment of dental anxiety
As Claas Lahmann explains, “Effective treatment options include an explanation of the treatment procedure, pharmacological strategies involving the use of benzodiazepines and antidepressants, biofeedback, hypnosis and behavioral interventions” (Lahmann, 2). He continues: “Thus, the question arises whether interventions aimed at patients’ psychophysiological arousal, such as relaxation techniques, result in effects that are different from those achieved with approaches that involve more passive distraction from the anxiety-provoking stimuli” (Lahmann 3). Music is often used as this passive distraction. The study looked at whether brief relaxation techniques were more effective at relieving dental anxiety than music distraction. During this study, which focused on patients who were over18 years old, participants were divided into three groups: brief relaxation, music distraction, and a control group. All patients were treated for a single-visit restoration for dental caries. All participants completed a State-Trait Anxiety Inventory (STAI) and a Hierarchical Anxiety Questionnaire (HAQ). The brief relaxation technique focused on functional relaxation, which encourages self-awareness of the body and selecting individual body parts to relax.
The music distraction group listened to music during the dental procedure. As stated by Lahmann: “It is based on a widely held perception that in a dental setting, music can reduce pain and anxiety, which are linked closely and lead to a mutual amplification” (4). The patients were given a list of various musical genres to choose from, listened to the music through headphones, and were allowed to set the volume at the level that they preferred. The STAI was used to compare anxiety levels before and after treatment. The HAQ was only administered once because it was “developed to measure dental anxiety as a consistent characteristic” and was, thereby, only needed at the beginning of the study to identify the typical dental anxiety level of the patient (Lahmann 4).
This particular study concluded that all three techniques used were effective at decreasing dental anxiety, with the brief relaxation group experiencing the largest decrease in anxiety from before treatment to after treatment. Music distraction was, however, significantly more effective than the control, which did not provide any intervention. The higher efficacy of brief relaxation was predicted to be from the patient feeling as if he/she was able to “control his or her own perception of stress, thereby achieving reduced pain sensitivity” (Lahmann 6). The control group most likely experienced the least amount of anxiety reduction because anxiety does not rapidly decline on its own. This study excluded patients with a dental phobia and did not consider the dentist’s oral communication, which very well may have played a role in the patient experience.
The effect of music distraction on pain, anxiety and behavior in pediatric dental patients
In another study focused specifically on pediatric patients, from 4 to 6 years old, involved restorative dentistry with local anesthesia over a two-visit period. As Jennifer Creem Aitken, DMD, MS states: “Patients provided with music before or during the injection of a preoperative medication or immunization exhibited less pain and anxiety-related behavior than a no-music control group” and hoped to study this finding in dental patients (114). The parent/guardian of each pediatric patient was asked to fill out a questionnaire to gauge the feelings of the patient towards visiting the dentist. For example, one question asked about how his/her child would feel if he/she had to go to the dentist tomorrow; answers ranged from the child looking forward to the experience to being frightened. The sample of patients was divided into three groups: upbeat music distraction, relaxing music distraction, and a control group that did not listen to music.
The first visit was used as a baseline, during which the patients did not listen to music. The Venham picture test was used to measure anxiety, as self-reported by patients. Heart rate was recorded in 5-minute intervals and the patient was recorded on video in order to study his/her behavior. The Venham picture test was repeated at the end of the visit and a visual analogue scale was also used to determine post-treatment levels of anxiety and pain, respectively. During the second visit, one group listened to upbeat music through headphones, another group listened to relaxing music through headphones, and a third group did not listen to music but still wore headphones. The same techniques for measuring anxiety and pain were used during the second visit. In addition to the steps taken at the end of the first visit, patients were also asked about whether they enjoyed listening to music during their visit and whether they would like to listen to music at their next visit. Behaviors, such as crying, moving, and resisting, were recorded on a computer based on the video recordings using the North Carolina Behavior Rating Scale.
Among the three groups, there was consistently an increase in heart rate during the injection of anesthesia and heart rate subsequently decreased during treatment, yet did not reach the baseline level. In the groups that listened to music, 93% stated that they enjoyed listening to music during their visit; 87% from the upbeat music group stated that they would like to listen to music at their next visit, while 93% from the relaxing group said that they would like to listen to music at their next visit. While these results may seem promising, there was actually no difference in anxiety or pain levels for any of the groups. Both psychological and physiological measures were taken as measurements for this study. There also may have been a flaw in the self reporting methods of the visual analogue scale: “Since it was administered after the treatment, the child may not have been able to transfer feelings of pain during the appointment to the time when the test was administered” (Aitken 117). In addition, the volume was set at a volume that allowed the patient to hear the music, yet also allowed the patient to hear the dentist’s instructions and all other sounds in the room, such as the sound of the high-speed hand piece. These sounds potentially impacted the anxiety level of the patients, despite the background music. As Aitken points out: “It is possible that solid headphones, a higher volume and a microphone for communication by the operator may have allowed more complete immersion into the music and therefore, more distraction from the dental procedure” (118). Despite the lack of data from this particular study to support the idea that music distraction decreases pain and anxiety for pediatric dental patients, there is promise in the fact that most patients responded positively to the music and hoped to listen to it during their next visit.
Best Practice: Evidence-based information sheets for health professionals offers three recommendations for the use of music when seeking to decrease dental anxiety: offer pre-recorded music through headphones during the visit, allow patients to choice the musical genre or give patients the option of bring their own music, and music is preferable over pharmacological treatments.
Other studies regarding techniques to decrease dental anxiety have been performed such as the use of audiovisual therapy to decrease anxiety in endodontic patients.