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The vicious cycle of dental fear: exploring the interplay between oral health, service utilization and dental fear
Jason M Armfield, Judy F Stewart, A John Spencer
Australian Research Centre for Population Oral Health, Dental School, Faculty of Health Sciences, The University of Adelaide, South Australia 5005, Australia
Background
Based on the hypothesis that a vicious cycle of dental fear exists, whereby the consequences of fear tend to maintain that fear, the relationship between dental fear, self-reported oral health status and the use of dental services was explored.

Methods
The study used a telephone interview survey with interviews predominantly conducted in 2002. A random sample of 6,112 Australian residents aged 16 years and over was selected from 13 strata across all States and Territories. Data were weighted across strata and by age and sex to obtain unbiased population estimates.

Results
People with higher dental fear visited the dentist less often and indicated a longer expected time before visiting a dentist in the future. Higher dental fear was associated with greater perceived need for dental treatment, increased social impact of oral ill-health and worse self-rated oral health. Visiting patterns associated with higher dental fear were more likely to be symptom driven with dental visits more likely to be for a problem or for the relief of pain. All the relationships assumed by a vicious cycle of dental fear were significant. In all, 29.2% of people who were very afraid of going to the dentist had delayed dental visiting, poor oral health and symptom-driven treatment seeking compared to 11.6% of people with no dental fear.

Conclusion
Results are consistent with a hypothesised vicious cycle of dental fear whereby people with high dental fear are more likely to delay treatment, leading to more extensive dental problems and symptomatic visiting patterns which feed back into the maintenance or exacerbation of existing dental fear.


Background
Despite reductions in pain associated with dental visits and an increased awareness by dentists of the importance of building trusting relationships, dental fear remains a major issue for dental clinicians and their patients. Dental fear has long-term implications because it is both reasonably stable and difficult to assuage. The significance of dental fear as an issue in dentistry is magnified by the high prevalence of dental fear reported in many countries. Child dental fear has been reported to be as high as 43 per cent in some countries while estimates of the prevalence of high dental fear among Australian adults are about 16 per cent. Both the high prevalence of dental fear and the ramifications in terms of disease experience and treatment make it important that we better understand the mechanisms by which dental fear is maintained and possibly exacerbated.

A number of studies have found an association between dental fear and both visiting patterns and disease experience. For example, Schuller et al. found that individuals with high fear visited the dentist less often and had more decayed and more missing teeth. Similarly, Thomson et al. found associations between dental fear and less frequent dental visiting, increased visiting for a problem and increased social and functional impairment. Similar findings have been reported in other research. The idea of a vicious cycle of dental fear has been promulgated by several studies. Some researchers posit a role for psychological variables such as embarrassment, with dental fear and anxiety leading to avoidance, a deterioration in dental health, and feelings of shame and embarrassment culminating in reinforced avoidance. In contrast, Bouma et al. propose that anxiety plays a crucial role in avoidance behaviour by causing a deterioration in oral health and an increase in the perceived likelihood of pain and restorative treatments resulting in further negative dental visiting experiences. Similarly, Thomson et al. have argued that dental fear may be a component in a cycle of dental disadvantage, with dentally anxious individuals avoiding dental care and thereby worsening their problems and increasing the likelihood that subsequent dental visits will be for emergency reasons. These conceptualisations share the common feature that the dental fear is believed to feed back into itself as a result of a number of repercussions of the fear (Figure 1).


Model of the vicious cycle of dental fear

While it may be argued that being forced to seek help as a result of an acute dental problem, most likely due to toothache, provides an opportunity for an individual to confront their feared situation and therefore reduce their fear, given the likelihood of painful and invasive treatment associated with the visit it is likely that any positive benefit from exposure would be mitigated by the aversive treatment experiences.

References to the concept of a vicious cycle of fear are replete within the psychological literature, however no systematic effort has yet been made to apply this idea in an analytical fashion to dental fear. For the most part, the idea of a 'vicious cycle' has been used post hoc to explain the relationship between dental fear and dental visiting behaviours without any substantive effort to explore the chain of relationships presupposed by the concept. The aim of this study was, therefore, not only to explore, within a contemporary Australian population, the relationship between dental fear and dental visiting patterns, prevalence of dental problems and symptom-driven treatment but to examine the hypothesised sequence of the 'vicious cycle' of fear, whereby dental fear, delayed dental visiting, increased dental problems and symptom-driven treatment form a linked chain feeding back into the fear experience.

Results
A total of 24,938 unique telephone numbers were called in the NDTIS. A large proportion of the unlisted numbers were either out of service (n = 6,596), or out of scope predominantly due to being a business number (n = 3,923). Of the remaining 14,419 households deemed as in scope 3,141 resulted in non-contact after the six call attempts while participation was refused in a further 3,966 households. As a result of the random digit substitution, a total of 21.3% of participants were from an unlisted household. Overall, 7,312 participants providing completed interviews with a final participation rate of 64.8%. After excluding children aged 15 years old and younger, a final NDTIS study population of 6,112 people aged 16 years and over was obtained. The average age of this sample was 44.2 years (SD = 18.1, range = 1698 years of age).

Table 1

Comparison of NDTIS 2002 sample characteristics with population statistics derived for Australia from the 2001 national census

NDTIS 2002 (%)

Australia 2001 (%)

Age*

 

 

     

1624 years

13.1

13.0

     

2544 years

32.2

31.9

     

4564 years

24.8

24.7

     

65+ years

13.4

13.6

Male

49.1

49.2

Household income < $20,000 per year**

20.3

21.2

Employed***

58.8

56.6

Speaks English at home

87.6

84.0

Born in Australian

76.0

76.8

* Percentages based on total population aged 5 years +
** Australia 2001 figure refers to household income < $400 per week which translates to < $20,800 per year
*** Australia 2001 figure refers to persons aged 15 years and over

presents a comparison of the sample characteristics with those of the Australian population as derived from the Australian census in 2001. There was good similarity between population characteristics and those of the sample.
In response to the single-item DAQ, 67.7% of participants responded 'Not at all', 15.1% responded 'A little', 5.2% said 'Yes, quite', and 11.9% stated 'Yes, very'. A number of socio-demographic differences were observed between dental fear groups (Table 2).

Table 2

Socio-demographic and dental characteristics by dental fear

 

Not afraid

A little afraid

Quite afraid

Very afraid

 

n

%

n

%

n

%

n

%

Dentate status***

 

 

 

 

 

 

 

 

     

Dentate

3,482

90.3

826

96.2

295

99.0

648

95.3

     

Edentulous

375

9.7

33

3.8

3

1.0

32

4.7

Sex***

 

 

 

 

 

 

 

 

     

Male

2,024

52.4

332

38.6

124

41.6

218

32.1

     

Female

1,837

47.6

529

61.4

174

58.4

462

67.9

Age***

 

 

 

 

 

 

 

 

     

1624 years

633

16.4

160

18.6

45

15.2

61

9.0

     

2539 years

1,117

28.9

269

31.2

90

30.3

191

28.1

     

4064 years

1,417

36.7

341

39.6

135

45.5

349

51.3

     

65+ years

695

18.0

92

10.7

27

9.1

79

11.6

Country of birth

 

 

 

 

 

 

 

 

     

Australia

2,958

76.6

647

75.1

231

77.5

514

75.6

     

Other

903

23.4

214

24.9

67

22.5

165

24.3

Language spoken at home

 

 

 

 

 

 

 

 

     

LOTE

461

11.9

121

14.1

33

11.1

75

11.0

     

English

3,401

88.1

740

85.9

265

88.9

604

89.0

Employment*

 

 

 

 

 

 

 

 

     

Full-time

1,577

42.9

365

44.4

135

47.4

261

39.0

     

Part-time

673

18.3

148

18.0

64

22.5

145

21.6

     

Not employed

1,422

38.7

309

37.6

86

30.2

264

39.3

Annual household income**

 

 

 

 

 

 

 

 

     

Less than $20,000

824

24.3

151

19.8

52

20.2

141

23.5

     

$20,001 $50,000

1,111

32.8

236

30.9

97

37.7

239

39.8

     

$50,001 $80,000

783

23.1

210

27.5

62

24.1

123

20.5

     

Greater than $80,000

672

19.8

166

21.8

46

17.9

97

16.2

Residential remoteness

 

 

 

 

 

 

 

 

     

Highly accessible

2,586

67.2

590

68.7

204

69.2

455

67.5

     

Accessible

799

20.8

179

20.8

66

22.4

151

22.4

     

Moderately accessible

401

10.4

83

9.7

22

7.5

55

8.2

     

Remote

50

1.3

5

0.6

3

1.0

8

1.2

     

Very remote

10

0.3

2

0.2

0

0.0

5

0.7

* χ2 < 0.05, ** χ2 < 0.01, *** χ2 < 0.001
Note: Dentate refers to at least one natural tooth present in the mouth

Higher dental fear was associated with being dentate, female, having part-time employment or being unemployed, and having an annual household income of between $20,000 and $50,000 per year. Dental fear was also associated with age, increasing across age groups up to 4664-year-olds but then decreasing among those aged 65+ years old. The association between fear and country of birth and speaking a language other than English at home was not statistically significant. Similarly, residential remoteness as measured by the Accessibility/Remoteness Index of Australia (ARIA) and based on road distance to service centers was not significantly related to dental fear. Dental fear was associated with having had a longer time since the last dental visit and a greater average time between visits. While 56.5% of people with no dental fear last visited the dentist in the previous 12 months, 46.2% of people who were very afraid of visiting the dentist reported last visiting within the previous year. Looking at average visiting frequency, 44.1% of people who rated themselves as very afraid visited the dentist less than once every two years on average compared to approximately 30% of individuals with no dental fear. In terms of future visiting patterns a similar trend was observed, with 76.9% of people who were very afraid expecting to make a dental visit in the next year, compared to 66.7% of people with no dental fear. In relation to when people expected to make their next dental visit, perhaps the most striking difference was that 27.6% of people who were very afraid of the dentist expected to make their next visit only when they experienced pain or a problem, compared to less than 17% of people with less dental fear. Almost 17% of the no dental fear group had an existing appointment to see a dentist compared to only 11.4% of the very afraid group. People who were very afraid of visiting the dentist had significantly more teeth missing than did people with less extreme dental fear (Table 4).

Table 4

Mean number of teeth missing due to dental caries by dental fear

 

Maxillary arch

Mandibular arch

Afraid of the dentist

Mean

SD

Mean

SD

Not at all

2.73a

4.02

2.11a

2.78

A little

2.60b

3.68

1.94b

2.39

Yes, quite

3.01

4.15

1.89c

2.39

Yes, very

3.61a,b

4.66

2.61a,b,c

2.78

 

F = 9.76, p < 0.001

F = 9.01, p < 0.001

Note: Superscripts indicates significant Scheffe post-hoc differences, p < 0.05.

Confining analyses to the maxillary arch, people with the most dental fear had significantly more missing teeth than people with either no dental fear or a little dental fear. Similarly, those people who were very afraid of going to the dentist had significantly more missing teeth in the mandibular arch than those people who were not afraid, were a little afraid or were quite afraid of going to the dentist. Higher self-rated dental fear was associated with significantly greater perceived need for fillings, tooth extraction, a scale and clean, a check-up, gum treatment, a dental crown or bridge and other treatment (Figure 2).

Perceived treatment needs by dental fear

There was a linear relationship between dental fear and perceived need for a filling, an extraction and gum treatment. The distribution of responses to questions assessing the social impact of problems with the teeth, mouth or dentures of people with different levels of dental fear are shown in Figure 3.

Psychosocial impacts of problems with teeth, mouth, or dentures during the previous 12 months by dental fear

Dental fear was associated with a higher prevalence of toothache (χ2 = 64.35, p = 0.001), more discomfort with the appearance of teeth, mouth or dentures (χ2 = 184.16, p < 0.001), more frequent food avoidance due to dental problems (χ2 = 108.11, p < 0.001), finding life less satisfying because of dental problems (χ2 = 127.12, p < 0.001) and more trouble sleeping as a result of dental problems (χ2 = 78.15, p < 0.001). Not only did people with very high dental fear report these impacts more often than did people with lower fear, but the ratings were more extreme with more people with very high fear stating that these social impacts occurred 'very often' than did people with less or no dental fear. Participants made a global assessment of their oral health in response to the question "How would you rate your own dental health?" Just over 45% of people with no dental fear rated their dental health as being excellent or very good compared to 30.9% of people who were very afraid of going to the dentist (Figure 4). 


Self-rating of dental health by dental fear

Conversely, people with the most dental fear were more likely to rate their dental health as average, poor or very poor (36.4%) in contrast to people who were not afraid, a little afraid or quite afraid (17.7%, 22.2% and 28.3% respectively). The association between dental fear and self-rated oral health was statistically significant, χ2 = 178.95, p < 0.001.

Some 61.3% of people who were very afraid of going to the dentist reported that the reason for their most recent visit in the last 12 months was for a problem, compared to 47.2% of people with no fear, 53.5% of people with a little fear and 59.4% of people who were quite afraid of going to the dentist (χ2 = 31.09, p < 0.001). In addition, 67.3% of people with very high dental fear reported that their usual reason for a dental visit was for a problem compared with only 44.9% of people with no dental fear, 47.1% with a little fear and 45.8% who were quite afraid (χ2 = 121.03, p < 0.001). Of those people who usually visited the dentist for a problem 72.3% of people who were very afraid of going to the dentist stated that the problem was usually for the relief of pain, compared to 54.7% of people with no dental fear, 67.2% with a little fear and 61.7% who were quite afraid (χ2 = 57.72, p < 0.001).

Given that dental fear showed a relationship with delayed visiting patterns, poorer dental health and symptom-driven treatment, justification was provided for examining the cyclical process that is proposed as characterising the maintenance of dental fear. Specifically, we examined the relationship between fear and delayed visiting, the relationship between delayed visiting and dental problems, the relationship between dental problems and symptom-driven treatment, and finally the relationship between symptom-driven treatment and fear. Complete information on delayed visiting, dental problems, and usual reason for visiting was available for the 3,615 non afraid, 826 a little afraid, 271 quite afraid and 612 very afraid individuals.

People with high dental fear were significantly more likely to have a delayed visiting pattern, with a significantly higher percentage last visiting a dentist at intervals of greater than 2 years (43.9%) in comparison to people who were not, a little or quite afraid (29.1%, 26.5% and 27.7% respectively), χ2 = 62.65, p < 0.001. In turn, those people with a longer time since their last dental visit had significantly more dental problems. People who last visited the dentist more than two years previously were significantly (Chi-square tests, p < 0.001) more likely to perceive themselves as needing a filling (39.4%), an extraction (18.6%) or gum treatment (12.6%) in contrast to people who had last visited within 2 years (23.7%, 7.3%, and 7.9% respectively). Of those people who perceived themselves as in need of dental treatment, determined here by anybody who responded that they needed either a filling, an extraction or gum treatment, 61.1% usually visited the dentist for an emergency treatment in comparison to 36.8% of people without a perceived need for a filling, extraction or gum treatment, χ2 = 330.58, p < 0.001. Finally, a significantly greater percentage of people who usually visit the dentist for an emergency were very afraid of going to the dentist (16.3%), compared to people who normally visit for a check-up (7.3%), χ2 = 106.02, p < 0.001. A graphical presentation of the concept of a vicious cycle for the four fear groups is shown in Figure 5.


Following the path of the vicious cycle by categories of dental fear

The figure shows the number and percentage of people in each fear group, after each component of the vicious cycle, who still fit the profile at that given point in the cycle. Overall, 179 people or 29.2% of those who were very afraid of going to the dentist fitted the profile of having delayed dental visiting, dental problems, and symptom-driven treatment seeking. This can be contrasted to the 11.6% of the group with no dental fear who exhibited the same characteristics.

Because dental fear was shown to vary by individual characteristics (see Table 2),

Table 2

Socio-demographic and dental characteristics by dental fear

 

Not afraid

A little afraid

Quite afraid

Very afraid

 

n

%

n

%

n

%

n

%

Dentate status***

 

 

 

 

 

 

 

 

     

Dentate

3,482

90.3

826

96.2

295

99.0

648

95.3

     

Edentulous

375

9.7

33

3.8

3

1.0

32

4.7

Sex***

 

 

 

 

 

 

 

 

     

Male

2,024

52.4

332

38.6

124

41.6

218

32.1

     

Female

1,837

47.6

529

61.4

174

58.4

462

67.9

Age***

 

 

 

 

 

 

 

 

     

1624 years

633

16.4

160

18.6

45

15.2

61

9.0

     

2539 years

1,117

28.9

269

31.2

90

30.3

191

28.1

     

4064 years

1,417

36.7

341

39.6

135

45.5

349

51.3

     

65+ years

695

18.0

92

10.7

27

9.1

79

11.6

Country of birth

 

 

 

 

 

 

 

 

     

Australia

2,958

76.6

647

75.1

231

77.5

514

75.6

     

Other

903

23.4

214

24.9

67

22.5

165

24.3

Language spoken at home

 

 

 

 

 

 

 

 

     

LOTE

461

11.9

121

14.1

33

11.1

75

11.0

     

English

3,401

88.1

740

85.9

265

88.9

604

89.0

Employment*

 

 

 

 

 

 

 

 

     

Full-time

1,577

42.9

365

44.4

135

47.4

261

39.0

     

Part-time

673

18.3

148

18.0

64

22.5

145

21.6

     

Not employed

1,422

38.7

309

37.6

86

30.2

264

39.3

Annual household income**

 

 

 

 

 

 

 

 

     

Less than $20,000

824

24.3

151

19.8

52

20.2

141

23.5

     

$20,001 $50,000

1,111

32.8

236

30.9

97

37.7

239

39.8

     

$50,001 $80,000

783

23.1

210

27.5

62

24.1

123

20.5

     

Greater than $80,000

672

19.8

166

21.8

46

17.9

97

16.2

Residential remoteness

 

 

 

 

 

 

 

 

     

Highly accessible

2,586

67.2

590

68.7

204

69.2

455

67.5

     

Accessible

799

20.8

179

20.8

66

22.4

151

22.4

     

Moderately accessible

401

10.4

83

9.7

22

7.5

55

8.2

     

Remote

50

1.3

5

0.6

3

1.0

8

1.2

     

Very remote

10

0.3

2

0.2

0

0.0

5

0.7

* χ2 < 0.05, ** χ2 < 0.01, *** χ2 < 0.001
Note: Dentate refers to at least one natural tooth present in the mouth

a multivariate logistic regression was carried out to see if the difference between dental fear groups in fitting a vicious cycle profile was accounted for merely by differences in socio-demographic and dentate status variables between groups with differing levels of dental fear. The odds ratio of very fearful individuals having delayed dental visiting, dental problems, and symptom-driven treatment seeking was 3.33 (95% confidence interval 2.674.15) that for people without dental fear (Table 5).

Table 5

Logistic regression model of characteristics associated with a vicious cycle profile (having delayed dental visiting, dental problems and symptom-driven treatment)

 

Odds ratio

Confidence interval

P-value

Fear of going to the dentist

 

 

 

     

Not afraid (Ref.)

1

 

 

     

A little afraid

1.24

0.971.59

0.087

     

Quite afraid

1.40

0.962.04

0.079

     

Very afraid

3.33

2.674.15

<0.001

Sex

 

 

 

     

Female (Ref.)

1

 

 

     

Male

1.96

1.632.36

<0.001

Age

 

 

 

     

1624 (Ref.)

1

 

 

     

2539

1.28

0.951.73

0.100

     

4064

0.99

0.741.32

0.918

     

65+

1.10

0.751.61

0.642

Dentate status

 

 

 

     

Edentulous (Ref.)

1

 

 

     

Dentate

1.71

1.252.35

0.001

Employment

 

 

 

     

Student/retired (Ref.)

1

 

 

     

Unemployed

1.49

1.092.03

0.013

     

Part-time

1.48

1.052.07

0.023

     

Full-time

1.62

1.182.22

0.003

Annual household income

 

 

 

     

Less than $20,000 (Ref.)

1

 

 

     

$20,001 $50,000

0.64

0.500.82

<0.001

     

$50,001 $80,000

0.48

0.360.64

<0.001

     

Greater than $80,000

0.32

0.230.45

<0.001

This effect for dental fear was statistically significant even though sex, dentate status, employment status and annual household income exhibited significant associations with fitting a profile consistent with being part of a vicious cycle. The odds ratios for people who were a little afraid or quite afraid of going to the dentist (ORs = 1.24 and 1.40 respectively) were in the expected direction but not statistically significant.

Conclusion
This study found a relatively high prevalence of 11.9 percent of people with very high dental fear in a large, representative, national sample of the Australian population. Extrapolated to the population, this equates to about two and a half million Australians suffering very high dental fear and reconfirms the scope of the problem facing dentists and policy makers in improving the generally poor oral health of, and symptom-oriented treatment received by, these people. Individuals with dental fear represent a particularly difficult population to treat and present special challenges to dental staff in terms of the management of care. While efforts are being made to reduce the incidence of dental fear among younger Australians who may be visiting the dentist for the first time, a concerted effort is also required to break what appears to be a vicious cycle of dental fear and provide assistance to those individuals with established fear-avoidance patterns.

2007 Armfield et al; licensee BioMed Central Ltd.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (
http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

published: 21 January 2008

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