Dental Anxiety’s Past and Its Lucrative Future

Dental horrors abound in literature, artwork, and dental museum exhibits. Throughout most of the world’s history, dentistry, like childbirth, has been associated with intense pain. Yet in our modern era of preventive maintenance, restoration, and local anesthesia, the prevalence of dental anxiety remains persistently high. This widespread dental angst has created a ripe market for profitable sedation dentistry.

As the authors of a 2011 study point out, “consternation in dentistry” has been classified as dental fear, dental anxiety, and dental phobia. They propose that dental fear is the result of “a real, immediate, present and specific stimulus, such as needles or drilling,” whereas dental anxiety is characterized by a threat “ambiguous, unclear, and not immediately present.”

Other researchers have suggested that “dental phobia” is a misnomer, and that most dental anxiety is closer to a form of post-traumatic stress disorder, recommending that it be conceptualized as “Posttraumatic Dental-Care Anxiety” (PTDA) and classified as part of the PTSD spectrum. Bracha et al., (2006) state: “In our experience, most individuals with dental “phobia” do not recognize their symptoms as ‘excessive or unreasonable,’ and in that sense resemble individuals with PTSD. Our review of the dental-care literature suggests that true (innate) dental phobias (akin to unreasonable fear at the sight of blood or a syringe) probably account for a smaller percentage of cases, and that the vast majority of dental-care anxiety cases stem from aversive dental experiences.”

Tools commonly employed by researchers to identify dental anxiety include the Modified Dental Anxiety Scale and Corah’s Dental Anxiety Scale. Patients are asked questions such as “When you are waiting in the dentist’s office for your turn in the chair, how do you feel?” or “While you are waiting and the dentist is getting out the instruments which he or she will use to scrape your teeth around the gums, how do you feel?”

Dental anxiety is not merely the fear of pain. Nineteenth century literature paints a picture of what modern researchers delving into dental anxiety have categorized as a feeling of  “existential threat.” During the same year that Carl Koller first used cocaine as a local anesthetic for dental procedures, and about twenty years prior to German chemist Alfred Einhorn’s creation of what became widely known as Novocaine, French author Joris-Karl Huysmans described in his famous novel A Rebours an intrusive and anxiety-provoking memory of a molar extraction at the hands of “a mechanic who called himself a dentist of the people and who lived down near the quays.” Gatonax, The People’s Dentist, operated on the third floor, accessible from a “darkened stairway” stained with “large gobbets of blood-red spittle.”

Huysmans’ protagonist, Des Esseintes, recounts the procedure:”A cracking sound was heard, the molar was breaking as it came out; then it seemed to him that his head was being torn off, that his skull was being shattered; he lost all self control, had shouted at the top of his voice, furiously trying to defend himself against the man, who threw himself afresh on him, as if he wanted to force his arm into the very depths off Des Esseintes’ bowels, then he suddenly took a step back, and, lifting up the body that was still attached to the jaw, had brutally let it fall back down on is backside into the chair as, standing upright and filling the window frame, he panted, brandishing a blue tooth dripping with blood at the end of his forceps.”

This passage illustrates some of the qualitative aspects of dental anxiety found by Swedish researchers, such as feelings of powerlessness or the belief that the dentist has all the power, the presence of underlying neuroticism or general anxiety, and the dentist’s perceived lack of empathy. Perceived negative behavior by a dentist is common among sufferers of dental anxiety. One of the Swedish researchers’ subjects described a dentist from childhood who reeked of booze and had shaky hands. Studies have indicated that patients with anxiety often transfer negative sentiments about one dentist to all dentists they encounter subsequently.

Fear of suffocation as the mouth is filled with water, cotton, and dental instruments is another component of dental anxiety. Edgar Allan Poe’s short story, Berenice, published in 1835, invokes this fear as Berenice is buried prematurely and her thirty-two teeth, the object of her monomaniac cousin’s obsession, forcibly ripped out.

A survey of 1,882 individuals in the U.S. found an adult prevalence rate of “high dental fear” between 11.2 and 12.3 percent. Another 17.5 to 18.2 percent of respondents indicated moderate dental fear, and 15.5 percent avoided dental care out of dread. Outside of the U.S., a 2009 study in the Netherlands found that “the prevalence of dental fear was 24.3%, which is lower than for fear of snakes (34.8%), heights (30.8%), and physical injuries (27.2%). Among phobias, dental phobia was the most common (3.7%), followed by height phobia (3.1%) and spider phobia (2.7%). Scandinavian epidemiological studies found that 7 to 10 percent of population was highly anxious with regard to receiving dental care. Most research points to a higher prevalence rate among women compared to men. As to whether age and income are associated with dental anxiety, studies have shown mixed results, with some not finding any correlation with age, and others showing a curve where anxiety peaks in young adulthood and diminishes somewhat with age.

All this dental angst has fueled sedation dentistry’s growth and entrance into the mainstream. A survey of 1,101 Canadians found that the proportion of the population preferring sedation or general anesthesia was “7.2% for cleaning, 18% for fillings or crowns, 54.7% for endodontics, 68.2% for periodontal surgery, and 46.5% for extraction,” and that a greater proportion of respondents expressed an interest in sedation for dentistry than the proportion who had been sedated before. The researchers concluded that there was significant need and untapped demand.

Incidentally, The People’s Dentist charged 2 Francs for the extraction Huysmans so vividly described. Sedation dentistry is generally not covered by insurance, and prices can range from $50 for nitrous oxide to more than $1,000 for IV sedation. Fear is lucrative. The prospect of sedation has the ability to attract new dental patients to the market for general and cosmetic procedures- the patients who have avoided the dental market altogether as a result of their anxiety.

An analysis in Dental Economics showed that the highest profit in terms of dollars can be generated by IV sedation, but in terms of profit percentages, oral sedation such as Valium is the most lucrative. Also recognized was the collections advantage inherent in sedation dentistry: patients who plan to be sedated by oral or IV methods on the day of their procedure are usually required to pay up front.

Dental anxiety is a prolific problem affecting many people around the world, despite modern advances which have made dentistry dramatically more comfortable than it was historically. The avoidance of dental care due to dental anxiety can lead to deteriorating oral and general health, but also represents pent-up demand for sedation services and therefore incremental revenue for the 40 percent of U.S. dentists who are now offering some form of sedation dentistry.


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Image via Zoya Kriminskaya / Shutterstock.

Lindsay Myers, MBA, MPH

Lindsay E. Myers, MBA, MPH, is a national healthcare consultant. Ms. Myers has served as Chief Financial Officer, Director, and Consultant to hospitals, physician practices, hospices, social services agencies, and public health clinics. She lives in Sarasota, Florida.
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