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Br Dent J 2017;222: 595–604; http://dx.doi.org/10.1038/sj.bdj.2017.361

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About one in four people are scared to visit the dentist. Bad childhood experiences, the noise of the drill, giving up control and frightening depictions of dentists in films are just some of the things that can cause people to be anxious. However, when this anxiety has a significant impact on a person's wellbeing, then it becomes a phobia. A new study from a team based at King's College London has confirmed that dental phobia certainly has a significant impact on the sufferer's quality of life and wellbeing. The team found that dental phobics are more likely to have active caries or missing teeth. It's what common sense would lead us to assume but this paper confirms this using real evidence from the 2009 Adult Dental Health Survey.

The team examined the data collected in the 2009 survey, carried out in England, Wales and Northern Ireland, to explore the oral health and oral health-related quality of life of people with dental phobia compared to those without. Their findings also showed that women were more likely to suffer from dental phobia then men. The data comprised 10,900 participants, of whom a total of 1,367 were identified as suffering from dental phobia. Of these 344 were male and 1,023 were female.

The team argue that many people with dental phobia might avoid seeing a dentist on a regular basis to address oral conditions that are preventable and chronic in nature. Also, once a visit has been made, the phobic patient might also prefer a short-term solution, such extraction of a tooth, instead of a long-term care plan.

The study also explored how dental phobia can affect a person's quality of life, impacting on their physiological, psychological, social and emotional wellbeing. For people with dental phobia there were higher levels of impact on their wellbeing, even when levels of dental disease were controlled.

The findings also have implications for preventive services for those with dental phobia. By providing patients with a detailed at home oral healthcare plan, dentists could help reduce acute conditions with preventive care.

The team at the Dental Institute are now developing a preventive programme for those with dental phobia, focusing on what can be done to help them avoid acute conditions.

Author Q&A with Ellie Heidari Kings College London Dental Institute

By Ruth Doherty

What was the key learning in this study? People with dental phobia are more likely to have active caries along with one or more missing teeth. Caries is both chronic in nature and preventable. Therefore, preventive regimes may have a place in the management of people with dental phobia to ameliorate their disease experience while they continue to avoid dental treatment. People with dental phobia also report poorer quality of life. Our research has shown that poor oral health can have a major impact on an individual's physiological, psychological, social and emotional wellbeing. People with dental phobia experience higher levels of such impact, even when levels of dental disease are controlled.

Did any of the findings surprise you?

The finding of no clear relationship between phobia and pulp exposure, ulceration, fistulae and abscess (PUFA) presence or periodontal disease was surprising. One might have assumed that people with dental phobia might present with long-standing disease as they would normally avoid dental treatment, the consequences of which would present as PUFA. However, fortunately, this does not appear to be the case.

What else would you like to interrogate the 2009 Adult Dental Health Survey for?

It would be interesting to ascertain levels of oral health in those dental phobic patients who had received care under dental sedation at their last completed course of dental treatment, since we hypothesise that sedation allows people with dental phobia to achieve a state of good oral health, but that treatment under sedation may focus less on the restoration of the teeth or the prevention of disease, and more on definitive treatments such as extraction. In addition, we would expect those receiving treatment under sedation to report a more positive experience than those phobics who did not receive sedation.

Expert view Heather Buchanan Lecturer in Health Psychology, Faculty of Medicine & Health Sciences University of Nottingham

Heidari and colleagues present an important addition to the work published so far on the latest England/Wales/NI Adult Dental Health Survey.1 The authors provide us with an understanding of the ADHS's findings in relation to dental phobia. For the first time the ADHS included a validated questionnaire to assess dental anxiety and phobia (the Modified Dental Anxiety Scale2). Findings showed that despite great advances in dentistry, dental phobia remains a significant problem with 12% of the adults having a score that indicates the likelihood of a phobia.2 There is a real need, therefore, to know more about those who have dental phobia (in comparison to non-phobics) in terms of the social and demographic correlates of oral health and oral health-related quality of life (OH-QoL). Examining this is in a large-scale survey which includes both self-report and clinical data, provides a unique opportunity to shed light on the relationship between these variables.

Their findings demonstrate the complex nature of dental phobia. Individuals with dental phobia have an increased likelihood of teeth with active caries and missing teeth. As the authors highlight, this may be due to dental phobics avoiding regular dental care, and if they do attend both the patient and the dentist may make treatment choices (such as tooth extraction) which do not necessitate the need to re-attend for multiple appointments. In addition, self-reported OH-QoL is poorer when the individual has dental phobia. Thus there are clear psychosocial and oral health implications of dental phobia. However, it should be noted that there was also an intriguing finding that we might not have expected – there was no relationship between dental phobia and PUFA scores and periodontal disease indices. It may be, as the authors and a previous study3 suggest, phobics pay increased attention to oral hygiene to try to avoid the need for dental visits. Further research may seek to explore this further. What is clear from this paper, is that the prevention and treatment of dental phobia still needs to be high on our agenda – both for research and practice.