Dental Health Research Paper

1. The Term ‘Dental Health’

Dental health can be defined and measured both objectively and subjectively. Objectively, dentists often use the decayed, missing, and filled teeth (DMFT) index as an indicator of dental health, but this may be more appropriately seen as a measure of dental history rather than health. Subjective assessments given by patients may not correspond to professionally developed objective measures. For example, Heyink et al. (1986) found only weak associations between dentists’ and patients’ appraisals of dentures. For dentists, clinical indicators such as fit, stability, and bite force were important, but for patients, denture quality depended on how well they functioned in practical everyday terms. It is useful to recall the World Health Organization’s (1980) distinction between impairment (the objective pathology such as tooth loss), disability (limitation on activities such as not being able to eat certain foods as a result of tooth loss) and handicap (inability to perform social roles, such as being reluctant to accept invitations to dinner because of the potential social embarrassment of not being able to eat the food that might be served). Although it is possible to define dental health in any of these ways, it is useful to consider impairment primarily as an objective measure of health, while disability and handicap are more subjective in nature. Seen in terms of disability and handicap, dental disease is widespread. Cushing et al. (1986) found that 26 percent of adults had experienced dental pain, 20 percent had difficulty in eating and 15 percent had associated problems of communication within the previous year.

Psychologists and sociologists have been keen to understand the causes of dental ill health, partly with a view towards reducing disease and partly with a view towards using the dental setting to test and develop theories of health behavior. Two areas which have received considerable attention are (a) the development and alleviation of dental anxiety and (b) the exploration of why some individuals engage in regular preventive dental care whereas others place less emphasis on this aspect of their physical well being.

2. Dental Anxiety

Research in this area has addressed three questions. First, there is the issue of the nature of dental anxiety. Like other forms of anxiety, it has behavioral, somatic, and cognitive components. Second, there is the issue of etiology of dental anxiety. Despite the development of modern anesthetics, it is widespread: depending on how it is measured, 3–5 percent of the general population can be said to have a debilitating level of dental anxiety. Third, there is the issue of treatment. Several treatment approaches show consistently good results.

2.1 Components Of Dental Anxiety

Historically, the behavioral aspects of dental anxiety have received the most attention. This is probably due to the consistent finding that anxiety is a powerful barrier to the receipt of professional care. For example, Curson and Coplans (1970) interviewed patients in an emergency clinic and 38 percent reported that they did not make regular visits to a dentist because they were too afraid to do so. Of these, only 12 percent made and kept further appointments for a course of treatment at the clinic. The extent of behavioral difficulties has been measured through both observational and self-report methods. Melamed et al. (1975) used an observational schedule which contained a series of behavioral indices of anxiety in children (crying, refusal to open the mouth, verbal complaints), rating these activities at 3 min intervals during the appointment. Kent et al. (1996) designed a self-report scale to measure the extent to which dental phobics avoided and were troubled by dental stimuli. Physiological measures of anxiety are less easily taken, but they too show a consistent relationship with self-reported anxiety. Patients are more likely to show increased heart rate at certain points of an appointment, especially at the beginning of treatment. Perhaps the most commonly used self-report measure of anxiety is Corah et al.’s (1978) dental anxiety scale, which asks people to indicate how relaxed or tense they are in the dental setting.

An interest in the cognitive aspects of dental anxiety has developed in the late 1990s. As in other forms of anxiety, anxious patients are more likely to engage in catastrophic thinking. They are more likely to ruminate on the worst possible outcomes of an appointment, of an ‘Any moment now the dentist will get the nerve and then it will really hurt’ kind. For many anxious patients, it is not a question of if they will experience pain, but when. De Jongh et al. (1995) have developed the dental cognitions questionnaire, which contain such items as ‘They will find something terribly wrong with me’ and ‘They might drill too deep.’

2.2 The Etiology Of Dental Anxiety

The research strongly supports the notion that, especially for children, dental anxiety is a classically conditioned response to dentistry (ter Horst and de Wit 1993). Given that modern anesthetics are thought by dentists to be very effective in alleviating discomfort during dental treatment, and given that the need for invasive treatment has declined for many people owing to the introduction of fluoride in the water supply of many areas, it is surprising to find that levels of dental anxiety have not declined to the expected extent in the latter part of the twentieth century. There seems to be several reasons for this. First, it appears that many more patients experience discomfort during treatment than is often assumed. Depending on how it is measured, up to 77 percent of patients report that they feel some pain during their visits to the dentist. Second, it has been argued that the notion of ‘preparedness’ is particularly relevant here. Just as humans might be innately prepared to become anxious about small animals such as spiders and rats because they posed a realistic threat in our evolutionary past, so too might sitting in the dental chair, with an adult placing sharp instruments in our mouths be one in which anxiety is quick to develop. It might take only the slightest degree of discomfort for anxiety to occur. Although classical conditioning is generally seen as the prime mechanism for the onset of dental anxiety, other learning modalities may also contribute. There is evidence that dental anxiety can be modeled by hearing about someone else’s discomfort (Corkey and Free- man 1994). Finally, the role of biological factors merits attention. Dentally anxious individuals score higher on personality questionnaires measuring emotional lability or neuroticism, and children who have a ‘difficult child’ type of temperament are more likely to be dentally anxious. Such research suggests that dental anxiety might be more likely to develop in individuals who have other psychological difficulties (Aartman et al. 1997).

One of the most important methodological issues in this area concerns the retrospective nature of almost all studies. Although it is likely that negative experiences contribute to onset, it is also likely that current levels of anxiety affect interpretations of dental experiences. Owing perhaps to hypersensitivity, an anxious patient might interpret sensations felt in the dental chair as painful, whereas a nonanxious patient may interpret such sensations differently. Certainly, highly anxious patients expect to experience more pain than patients with low anxiety, even if their actual experiences do not differ. Memory processes may also play a role. Kent (1985) asked patients after their appointment to indicate the amount of pain they felt. Three months later, they were asked to indicate the level of pain they remembered having experienced. Whereas those with low anxiety gave reports that corresponded closely to their immediate postappointment ratings, those with high anxiety recalled much higher levels of discomfort. In fact, their reports corresponded most closely to their preappointment expectations. Such studies indicate that retrospective studies are open to severe criticism.

2.3 Treating Dental Anxiety

Interventions designed to assist people to deal with their dental anxiety are similar to those designed to help people with other types of anxiety. There is the fundamental importance of graded exposure to the dental setting in combination with the provision of coping strategies. Before discussing these interventions, however, it is helpful to outline some of the research pertaining to the prevention of dental anxiety.

2.3.1 Prevention. Two factors stand out as critical in reducing the likelihood that dental anxiety will develop, particularly in children. The first concerns the alleviation of pain, in that a reduction in the need for invasive treatments is likely to reduce anxiety. One study that has not been performed is a comparison of the levels of dental anxiety between areas that do and do not have fluoridated water supplies. The second factor concerns the nature of the relationship between the patient and the dentist. A number of studies have indicated that warm and nurturant dentists can help patients to overcome their dental anxiety when it has been acquired but also that they can reduce the probability that anxiety will develop, even after a painful experience (Bernstein et al. 1979).

2.3.2 Interventions. As noted above, most interventions for the alleviation of dental anxiety rely on traditional methods of graded exposure to the feared stimulus. There is much consistency between individuals concerning the most feared aspects of dental care (usually extractions followed by drilling and injections) and fear hierarchies can usually be constructed without difficulty. There is considerable evidence that systematic desensitization, relaxation, hypnosis, and modeling can all have positive effects (Kent and Croucher 1998). As in other areas of psychological intervention, 60 percent of patients report substantial improvement in their difficulties, regardless of the type of approach used. This may be because all types of intervention serve to enhance patients’ sense of control over the situation. In this context, the use of stop signals—where the patient is invited to indicate a wish to take a break from treatment—can be a simple yet effective method for increasing a sense of control over the dentist’s behavior. Pharmacological treatments—especially using nitrous oxide—can not only be effective for the alleviation of anxiety in the short term but may also have longer-term beneficial effects. The alleviation of uncertainty and the provision of information are particularly relevant to dental anxiety. Because it is closely associated with the presence of catastrophic thinking, realistic information can not only dispel some irrational fears about the nature of professional care, but can also provide patients with knowledge about when invasive treatment might cause discomfort. An interesting theoretical and practical issue here concerns the amount of information provided. There are indications that patients who have a blunting coping style show greater distress when given detailed information, whereas those with a monitoring coping style are most likely to receive benefit (Auerbach et al. 1976).

3. Maintenance Of Oral Health

The maintenance of oral health is largely a function of behavior. Although fluoridated water supplies have led to a substantial reduction of dental caries in some areas, most dental ill health could be prevented if people took the appropriate actions. These actions are mainly of two types: a reduction in the frequency of eating sugar to reduce caries, and an increase in the use of brushing, dental floss, and regular dental visits to reduce the amount of plaque (which leads to gingivitis and tooth loss through the destruction of supporting tissue).

3.1 Educational Approach

The notion that education could improve dental health is based on the findings concerning the generally low levels of relevant knowledge in the general population. Many people are unaware that the occurrence of caries is most closely associated with the frequency of eating sugar, rather than the absolute amount. Similarly, many people do not realize the importance of reducing plaque for the maintenance of healthy gums. Theories of health behavior (Connor and Norman 1996) predict that patients’ levels of knowledge will have an effect on what they do to maintain good health. According to these models, people will begin to make changes to their behavior—or at least move from one stage of preventive care to another—only when they appreciate the importance of regular dental care and have a correct interpretation of symptoms.

Horowitz et al. (1976) provide a good example of an experiment on intensive dental education. One group of children was given 10 sessions of 30 min on plaque removal, being taught in small groups by a dental hygienist. They were informed about plaque, how to identify it with disclosing agents, and how to remove it. Plaque removal was practiced under supervision every day for the next 6 months. The comparison group of children were not given any of this extra information or practice. At the baseline, the two groups were similar on both measures. At the 8 month assessment, there was a significant decline in gingivitis scores in the education group compared with the comparison group, but at 12 months there was no difference. There was no long-term effect, and there were never any differences between the two groups in caries levels or amount of plaque. On the basis of such typical results, it seems that educational programs have little or no long-term effects, but it should be noted that most training has been given in school and there has been little attempt to integrate what children have learned in the school environment with what they do at home. Another possible reason for the lack of an effect is that the education approach is only part of the answer to changing behavior. Educational approaches may make some difference by increasing knowledge, but they may not provide sufficient motivation to put this new-found information into practice. In order to accomplish this, a motivational or behavioral approach may also be needed.

3.2 Motivational Approaches

In terms of the stages of change model, people will move from the contemplative and preparation stages to the action and maintenance stages only when they can see some kind of clear benefit in doing so. Furthermore, the benefit needs to be apparent in the short term rather than some years in the future. From the viewpoint of behavioral analysis, it is crucial to identify actual and potential reinforcers in the person’s environment. One of the important difficulties facing those who wish to change patients’ behavior is that there are many positive reinforcements maintaining undesired behavior (e.g., the sweetness of foods) and few negative ones which might lead to desired changes (e.g., caries might develop months or years in the future).

This issue is particularly relevant for children who will have difficulty in seeing the relevance of regular brushing in the present to ensure that they will not lose their teeth through gingivitis decades in the future. Thus, behavioral programs to encourage preventive dental behavior have focused on the use of immediate reinforcements to increase the likelihood that people will monitor their sugar uptake, brush daily, and floss regularly. There are several evaluations of such programs, most showing positive results (Kent and Croucher 1998). Monetary reinforcers have been used for both children and their parents, but often stars on a calendar can be similarly effective.

Bibliography:

1. Aartman I W, De Jongh A, van der Muelen M J 1997 Psychological characteristics of patients applying for treatment in a dental fear clinic. European Journal of Oral Sciences 105: 384–8
2. Auerbach S M, Kendall P C, Cuttler F et al. 1976 Anxiety, locus of control, type of preparatory information and adjustment to dental surgery. Journal of Consulting and Clinical Psychology 44: 809–18
3. Bernstein D A, Kleinknecht R R, Alexander L D 1979 Antecedents of dental fear. Journal of Public Health Dentistry 39: 113–24
4. Connor M, Norman P (eds.) 1996 Predicting Health Behavior. Open University Press, Milton Keynes, UK
5. Corah N L, Gale E N, Illig S J 1978 Assessment of a dental anxiety scale. Journal of the American Dental Association 97: 816–9
6. Corkey B, Freeman R 1994 Predictors of dental anxiety in six year-old children: findings from a pilot study. Journal of Dentistry for Children 61: 267–71
7. Curson I, Coplans M-P 1970 The need for sedation in conservative dentistry. British Dental Journal 128: 19–22
8. Cushing A M, Sheiham A, Maizels J 1986 Developing socio-dental indicators—the social impact of dental disease. Community Dental Health 3: 3–17
9. De Jongh A, Muris P, Schoenmakers N, ter Horst G 1995 Negative cognitions of dental phobics: reliability and validity of the dental cognitions questionnaire. Behaviour Research and Therapy 33: 507–15
10. Heyink J, Heezen J, Schaub R 1986 Dentist and patient appraisals of complete dentures in a Dutch elderly population. Community Dentistry and Oral Epidemiology 14: 323–6
11. Horowitz A M, Suomi J D, Peterson J K et al. 1976 Effects of supervised daily dental plaque removal by children. Journal of Public Health Dentistry 36: 193–200
12. Kent G 1985 Memory of dental pain. Pain 21: 187–94
13. Kent G, Croucher R 1998 Achieving Oral Health, 3rd edn. Wright, Oxford, UK
14. Kent G, Rubin G, Getz T, Humphris G 1996 The development of a scale to measure the social and psychological effects of severe dental anxiety. Community Dentistry and Oral Epidemiology 24: 394–7
15. Melamed B G, Weinstein D, Katin-Borland M, Hawes R 1975
16. Reduction of fear-related dental management problems with use of filmed modeling. Journal of the American Dental Association 90: 822–6
17. ter Horst G, de Wit C 1993 Review of behavioral research in dentistry 1987–1992: dental anxiety, dentist–patient relationship, compliance and dental attendance. International Dental Journal 43: 265–78
18. World Health Organization 1980 Health Promotion. A Discussion Document on the Concept and Principles. World Health Organization, Copenhagen, Denmark