Milieu in Dental School and Practice

Strategies for Combating Dental Anxiety

Lyndsay C. Bare, B.A.; Lauren Dundes, M.H.S., Sc.D.
Abstract: Dental anxiety and subsequent avoidance of dental care and deterioration of oral health pose a significant problem for
the dental profession. In an attempt to elucidate preferences of anxious dental patients, we gathered survey data from 121 persons
at a small, private liberal arts college in the mid-Atlantic region of the United States. Half of the respondents experienced dental
anxiety, and most of these (66 percent) attributed anxiety to fear of anticipated pain. The majority of anxious patients preferred a
dentist to be friendly (93 percent), talkative (82 percent), and to have an office with adorned walls (89 percent) and a slightly
cool temperature (63 percent). Patients who identified themselves as anxious also indicated that music in the background (89
percent) and magazines and books in the dental office (75 percent) were helpful. Anxious patients were more likely than non-
anxious patients to prefer a male dentist (77 percent versus 52 percent). This finding was especially marked among anxious male
respondents, 93 percent of whom preferred a male dentist compared to 73 percent of anxious female respondents. These survey
data may assist dental professionals in understanding and combating patients’ dental anxiety, in order to increase the frequency of
dental visits and to prompt a corresponding restoration or maintenance of oral health.
Ms. Bare is a class of 2008 student, University of Maryland Baltimore College of Dental Surgery; Dr. Dundes is Associate
Professor of Sociology, McDaniel College. Direct correspondence and requests for reprints to Dr. Lauren Dundes, Department of
Sociology, McDaniel College, 2 College Hill, Westminster, MD 21157-4390; 410-857-2534 phone; 410-386-4671 fax;
ldundes@mcdaniel.edu.
Key words: dental anxiety, patient preferences, gender, dentist traits, pain management
Submitted for publication 5/26/04; accepted 8/16/04

D
espite formidable challenges arising from
patients’ dental anxiety, we have only lim-
ited knowledge about what causes and
abates this significant problem facing the dental pro-
fession. Helping patients overcome such apprehen-
sions can reduce the incidence of delayed or missed
dental visits and the negative repercussions from
avoidance of needed care. In addition, allaying den-
tal anxiety may facilitate the work of dental hygien-
ists and dentists who themselves may find working
with anxious patients to be taxing. Even the imple-
mentation of a single strategy that calms a small pro-
portion of tense patients could yield benefits for pa-
tient and practitioner alike. While dentists employ a
number of different techniques to accomplish this
goal (such as providing background music or read-
ing material in their offices), many unanswered ques-
tions remain about patient preferences, including
personality and appearance of the practitioner as well
as attributes of the dental office, particularly those
of patients most overwrought about their visit. This
article provides data about causes of patient anxiety
as well as attributes of clinicians and the office envi-
ronment that patients prefer. Clarification of these
preferences could contribute to strategies applied to
alleviate fears surrounding dentistry, which in turn
could increase the frequency of dental visits and en-
courage a corresponding restoration of oral health in
anxious patients.
Reported Causes of Patient
Anxiety and Pain
Past research reveals a number of factors asso-
ciated with patients’ reporting of dental pain and
anxiety: 1) if they have had previous painful experi-
ences;1-3 2) if they believe that painful treatment is
inevitable;1-2 3) if they feel that they lack control over
the situation, including the inability to stop a proce-
dure they find unpleasant;1,4-5 4) if they do not un-
derstand the procedures that the dentist performs or
harbor a general fear of the unknown;1,4 5) if they
have experienced exposure to frightening portrayals
of dentists in the media or conveyed by acquaintan-
ces’ recounting of unpleasant experiences;4 6) if they
have experienced detached treatment by a dentist and/
or a sense of depersonalization;1,4 and 7) if they have
fears of experiencing ridicule because of how they
react to situations arising during their visit.4

1172 Journal of Dental Education ■ Volume 68, Number 11

 According to Quteish Taani,6 reasons for in-
frequent dental visits include a perceived lack of time
(36 percent), a belief that treatment is not needed
(34 percent), fear of dentists (13 percent), and cost
(17 percent). In particular, apprehensions can be sig-
nificantly exacerbated by fears of injections and
drills, especially among females and those who do
not regularly (at least yearly) visit the dentist.6 Oth-
ers have found that women are more likely to ex-
hibit dental anxiety, which was most often attributed
to a negative dental experience.7-8 Although the lit-
erature includes suggestions for combating dental
anxiety (for example, establishing trust, appropriate
attire, making pharmacological support available),9-
10
the bulk of the research on this topic documents
such anxiety rather than addresses how to ease it.
Methods
From February to April 2004, a sample of 121
male (27 percent) and female (73 percent) under-
graduate students and faculty at a small, private, lib-
eral arts college in the mid-Atlantic area responded
to a one-page anonymous survey gauging the extent
of their dental anxiety and preferences within a den-
tal office. The survey, which was developed by the
primary author, was approved by the college’s Insti-
tutional Review Board and granted a waiver of in-
formed consent. It was pilot-tested for clarity on two
students and two faculty members.
Undergraduate respondents completed the sur-
vey during a number of sociology and biology
classes: Introductory Sociology, Medical Sociology,
Vertebrate Diversity, Advanced Molecular Genetics,
and Epidemiology. The students in the sociology
classes were approached as a class, and the students
in the biology classes were approached individually.
Faculty respondents received the survey in their cam-
pus mailboxes and returned completed surveys
through the campus mailing system. Our college
community respondents comprising this convenience
sample were selected due to their familiarity with
and willingness to complete surveys.
The survey, which consisted of twenty-five
questions in yes/no, fill-in-the-blank, and multiple
choice formats, began with a brief description of
dental anxiety (avoidance and fear of dentists and
dental procedures) and the study’s purpose, which
was to identify what factors intensify and/or allevi-
ate that anxiety. The survey included a question,
November 2004 ■ Journal of Dental Education
designed by the primary author, in which respondents
rated their perception of their dental anxiety. The
question specifically asked the respondent to what
extent he or she experienced anxiety when visiting
the dentist. The respondent was given four choices
to circle: no anxiety, mild anxiety, moderate anxiety,
and severe anxiety. For the purposes of our study,
we later simplified these choices to either not expe-
riencing anxiety or experiencing some degree of anxi-
ety.
The survey also included questions in which
respondents rated attributions for their anxiety (such
as anticipated pain, feeling out of control, unpleas-
ant stories heard from others, and a negative experi-
ence such as gagging). In addition, they were asked
to elucidate their preferences for the dentist: friendly
or aloof, younger or older than age forty-five, hav-
ing perfect or average teeth, female or male, wear-
ing scrubs or dressed formally with a white lab coat
(for protective, rather than aesthetic, reasons), talk-
ative or silent, and maintaining a patient-doctor re-
lationship that is either strictly professional or one
in which the dentist is perceived as an acquaintance.
Additional questions asked the respondent to indi-
cate what might enhance their comfort in the office
setting: adornment on walls, preferred temperature,
magazines and books, music in the background, tele-
visions with headphones, imagining themselves in a
calm place (guided imagery), taking an unspecified
relaxation drug, taking nitrous oxide (laughing gas),
or undergoing hypnosis. These questions were de-
termined by our curiosity rather than previous stud-
ies. The student response rate was 100 percent (N=79)
and the faculty response rate was 76 percent (fifty-
five surveys sent; forty-two returned). Percentages
were analyzed using Chi square.
Results
The majority of the sample was college stu-
dents (65 percent) and female (73 percent) (see Table
1 for total sample demographics). Half (50 percent)
of the anxious respondents stated that they experi-
ence some dental anxiety, ranging from mild to se-
vere. Two-thirds of these respondents (66 percent)
attributed their dental anxiety to anticipated pain, 25
percent to a negative experience, 23 percent to an-
ticipated choking or gagging, 18 percent to feeling
out of control, and 13 percent to unpleasant stories
heard from others (see Table 2).
1173
 regardless of anxiety level, preferred the dental of-
Table 1. Characteristics of sample fice to be slightly cool (61 percent) (see Table 3).
Sample Demographics Percent (Number) Although subjects without dental anxiety preferred
Student proportion 65% (79)
a younger dentist (52 percent) and to have a rela-
Faculty proportion 35% (42) tionship with the dentist as an acquaintance (55 per-
Males 27% (33) cent), these differences were not significant. The most
Females 73% (88) striking difference between subjects who were and
Proportion of males who are anxious 45% (15) were not anxious related to dentist gender: 77 per-
Proportion of females who are anxious 50% (44) cent of anxious respondents preferred a male dentist
No anxiety 50% (60) compared to 52 percent of respondents without anxi-
Some anxiety (mild to severe) 50% (61)
ety (p=0.00). This difference was even more marked
when taking into account the gender of the respon-
dents: 93 percent of anxious males preferred a male
Table 2. Prevalence of manifestations of anxiety dentist compared to 73 percent of anxious females
Cause of Anxiety Proportion of Respondents Who (see Table 4).
Experience Cause of Anxiety* Respondents had clear preferences about de-
Percent (Number)
sired attributes of the office setting. Most (89 per-
Anticipated pain 66% (40) cent) prefer the walls to be decorated, although the
Negative experience 25% (15) few who prefer white, unadorned walls were more
Choking and/or gagging 23% (14)
likely to be anxious respondents (12 percent versus
Feel out of control 18% (11)
Unpleasant stories from others 13% (8)
3 percent of non-anxious respondents). Regardless
of anxiety level, most subjects found magazines,
*Some respondents reported that they experienced more books, or music to be helpful (75 percent-89 per-
than one cause of anxiety.
cent) (see Table 5). A greater proportion of anxious
subjects found television with headphones helpful
(48 percent compared to 27 percent of patients with-
The majority of respondents self-reported to out anxiety: p=0.01). Anxious subjects were also
be anxious preferred a dentist to be friendly (93 per- more likely to see guided imagery as useful (41 per-
cent), talkative (82 percent), male (77 percent), to cent compared to 12 percent of subjects without anxi-
wear formal clothing, i.e., a white lab coat (59 per- ety: p=0.00) as was the case with taking a relaxation
cent) versus scrubs, to be older than age forty-five drug (33 percent compared to 8 percent of respon-
(57 percent), and to have a strictly professional rela- dents without anxiety: p=0.00) and nitrous oxide (7
tionship as opposed to the dentist being an acquain- percent compared to 0 percent of subjects without
tance (56 percent). In addition, most respondents, dental anxiety: p=0.06). Significant differences were

Table 3. Patient preferences for dentist and office characteristics*

Dentist and Office Traits Total Respondents Anxious Respondents Not Anxious Respondents
Percent (Number) Percent (Number) Percent (Number)
Friendly/aloof 96% (116) 4% (5) 93% (57) 7% (4) 98% (59) 2% (1)
Young/old (>45 yrs) 42% (51) 49% (59) 33% (20) 57% (35) 52% (31) 40% (24)
Perfect teeth/average teeth 44% (53) 46% (56) 42% (26) 49% (30) 45% (27) 43% (26)
Female/male 17% (20) 65% (78) 8% (5) 77% (47) 25% (15) 52% (31)
Wear scrubs/dress formally with white lab coat 27% (33) 61% (74) 33% (20) 59% (36) 22% (13) 63% (38)
Talkative/silent 86% (104) 12% (14) 82% (50) 16% (10) 90% (54) 7% (4)
As an acquaintance/solely dentist 49% (59) 48% (58) 43% (26) 56% (34) 55% (33) 40% (24)
Office with white, unadorned walls/posters
and pictures on walls 7% (9) 90% (109) 12% (7) 89% (54) 3% (2) 92% (55)
Preferred temperature of dental office:
slightly warm/slightly cool 39% (44) 61% (70) 37% (22) 63% (37) 40% (22) 60% (33)

*Because of respondents with no preference for a trait, some variable totals are less than 100%.

1174 Journal of Dental Education ■ Volume 68, Number 11

found in subject responses to drills: 38 percent of Dentists should also consider patient prefer-
anxious respondents found drills to be both irritat- ences that exist independent of anxiety experienced:
ing and frightening as compared to only 12 percent dentist friendliness, formal dress consisting of a white
of subjects without dental anxiety (p=0.00) (see Table lab coat, and an office with walls adorned with post-
6). No significant differences by age or dental expe- ers and pictures, supplied with ample books, maga-
rience of the respondents were found. zines, and background music. It has been reported
that classical music such as J.S. Bach’s “Aria” cre-
ates a relaxing environment and subsequently stimu-
Discussion lates physiologic relaxation.12 We also suggest gentle
music such as classical or soft-rock that could help
Half of our respondents reported some level of the patient relax. In addition, we believe that having
dental anxiety, from mild to severe. Anxious patients in the office a large variety of magazines and books
attributed their nervousness to, in descending order, that appeal to all types of patients is indispensable.
anticipated pain, a negative experience, anticipated Most respondents prefer a slightly cool office, so we
choking and/or gagging, feeling out of control, and suggest maintaining a cooler temperature. In addi-
unpleasant stories heard from others. If the patient is tion, because 38 percent of anxious patients found
anxious because he or she thinks the procedure is drills to be both irritating and frightening (compared
going to be painful, the pa-
tient can be reassured that
everything is being done to Table 4. Respondent anxiety and gender and gender preference of dentist
make the procedure as
Prefers Male Prefers Female No
pain-free as possible. If the Dentist Dentist Preference
patient is anxious due to a
Non-anxious males 41% (7) 35% (6) 24% (4)
negative experience or un-
Anxious males 93% (14) 0 7% (1)
pleasant stories, the dental Non-anxious females 56% (24) 21% (9) 23% (10)
professional could discuss Anxious females 73% (32) 9% (4) 18% (8)
these experiences with the ALL non-anxious 52% (31) 25% (15) 23% (14)
patient. Patients fearful of ALL anxious 77% (46) 8% (4) 15% (9)
choking and gagging can
be offered means to mini-
mize this reaction (e.g., Table 5. Preferences for strategies to enhance dental visit
table salt on the tongue, ni- Strategies Perceived as Helpful Total Anxious Not Anxious
trous oxide inhalation11), Respondents Respondents Respondents
Percent (Number) Percent (Number) Percent (Number)
and those who feel out of
control can be reassured Music in background 88% (106) 89% (54) 87% (52)
that the procedure can be Magazines and books 75% (91) 75% (46) 75% (45)
stopped at any time. In Televisions (with headphones) 37% (45) 48% (29) 27% (16)
comparison to subjects Imagining oneself in a calm place
(guided imagery) 26% (31) 40% (24) 12% (7)
who did not report anxiety,
Having taken a relaxation drug 21% (25) 33% (20) 8% (5)
subjects with anxiety were Nitrous oxide (laughing gas) 18% (22) 18% (11) 18% (11)
more likely to find the fol- Hypnosis 3% (4) 7% (4) 0% (0)
lowing to be helpful: tele-
visions with headphones
(p=0.01), guided imagery Table 6. Reactions to the sound of drills
(p=0.00), taking a relax-
Perception of the Total Anxious Not Anxious
ation drug (p=0.00), and ni- Sound of Drills Respondents Respondents Respondents
trous oxide (p=0.06). Percent (Number) Percent (Number) Percent (Number)
While these options are not Irritating 46% (55) 38% (23) 53% (32)
typically available in den- Frightening 14% (17) 23% (14) 5% (3)
tal offices, making them Both 25% (30) 38% (23) 12% (7)
available could help to as- Neither 16% (19) 2% (1) 30% (18)
suage anxiety.

November 2004 ■ Journal of Dental Education 1175

 to only 12 percent of patients without dental anxi-
ety: p=0.00), we recommend muting the sound pro-
duced by these instruments (for example, by closing
the door to a patient’s room and the door to the wait-
ing room).
The principal cause of anxiety among the sub-
jects participating in this study was their fear of ex-
periencing pain. Given that the anxious subjects re-
ported that they preferred friendly, formally dressed
males who are older than age forty-five, it is pos-
sible that they perceived such dentists as more expe-
rienced and thus better able to handle this dimension
of dental care. In addition, since historically male
dentists have been the norm, patients might have a
preference for what is familiar. Yet this reasoning
does not explain why anxious subjects, particularly
anxious males, were so much more likely to prefer a
male dentist (77 percent and 93 percent respectively).
Unfortunately, our small sample size and conve-
nience sampling limit our confidence in these results,
which clearly require replication. Nevertheless, this
finding merits further investigation given literature
that indicates that, stereotypically, male dentists may
be perceived by male patients to be more proactive
problem-solvers13-15 and that women physicians may
be less likely to give pain relief, especially to male
patients,16-17 some of whom may feel culturally obli-
gated to remain stoic.18-24 As women constitute an
increasing number of dentists,25-27 they must be cog-
nizant of psychosocial factors that affect how patients
may react to them.
Although some of our other findings are easier
to interpret (for example, that 96 percent of respon-
dents prefer a friendly dentist), future research should
delve into patients’ criteria for this attribute, the de-
gree to which such qualities are desired, and how
such preferences vary by demographic characteris-
tics. For example, while a related finding revealed
that 86 percent of subjects prefer a talkative dentist,
we did not determine the importance of the topics of
conversation nor the timing of such interaction (such
as in-between versus during procedures) which could
vary by level of anxiety. Most importantly, our find-
ing that the majority of our respondents did indeed
have preferences about dentists and office charac-
teristics underscores the need for dentists’ awareness
of the impact of such factors that are unrelated to
their expertise and skill.
1176
Conclusion
Although our findings are based on a small,
non-random sample, respondents expressed a clear
preference for dentists who are amiable and dress
formally. While we found only minor variation in
preferences between patients with and without den-
tal anxiety, dental professionals need to be conscious
of these differences. In particular, given the prefer-
ence for male dentists, female dentists perhaps should
reassure patients, especially male patients, that pa-
tients’ feeling at ease is a priority and that patients
should openly communicate their comfort level to
facilitate appropriate action such as pain relief.
Awareness of the causes of dental anxiety and small
steps towards alleviating this angst could have a sub-
stantial impact on an anxious dental patient. Addi-
tional investigation of these issues is needed to fur-
ther our understanding of how to decrease dental
anxiety, which in turn could help increase the regu-
larity of dental visits and prompt a corresponding
maintenance or restitution of oral health.
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