Managing Dental Fear

Author:  Howard M. Steinberg, DMD, MDS
Filed under:  Sedation Dentistry, Patient Care   Tags:  , ,

Dental fear is a common issue affecting millions of people worldwide. In the United States, an estimated 9% to 15% of the population avoids seeking dental care due to fear. Dental fear is a problem for both the patient and the dental provider. Extremely fearful people will avoid a much needed dental visit as long as possible, increasing the likelihood of complications. Many fearful patients are unaware of improvements in dental technology, techniques and other tools available to manage dental fear.

What is Dental Fear?

Dental fear can be defined as a state of anxiety elicited by the provision of dental care. There are different degrees of dental fear. Some people have more trouble going to a dentist than others. Fearful patients may experience apprehension, dread or a sense of impending disaster in connection with dental care. Previous studies have shown the primary reason people avoid dental treatment is fear of pain. The sensation of the anesthetic injection, the sight of a syringe, or the sight, sound and sensation of a drill were frequently identified as producing fear. Other factors contributing to dental fear include traumatic experiences with previous dental treatment, fear of being scolded for oral health neglect, and fear of the cost of dental treatment.

Consequences of Dental Fear

Dental fear can prevent a person from optimizing and maintaining his or her oral health. While many people feel slightly anxious when visiting the dentist, those with dental fear often fail to go for routine care. Avoiding regular dental checkups and routine cleanings can lead to tooth decay and other oral health problems. Those who are fearful of dental treatment have a greater prevalence of tooth decay, periodontal disease and missing teeth. Dental fear is characterized by a self-perpetuating cycle, whereby fear leads to avoidance, avoidance leads to crisis, and crisis reinforces the fear. Dental fear has several negative consequences for providers as well. These include low utilization of dental services, missed appointments, emergency situations and difficulty in rendering treatment.

Management of Dental Fear

A number of dental practitioners lack the tools or skills needed to manage dental fear. Not all patients will openly admit to being afraid. It is important to recognize behaviors associated with dental fear, measure the degree of anxiety, and intervene appropriately. Patients with low levels of dental fear may require only low level interventions involving communication or the use of technology to reduce the degree of uncertainty involved in dental treatment. Those patients with moderate levels of fear may require more intensive pharmacological interventions such as nitrous oxide or oral sedatives. For those patients with extreme fear, intravenous sedation has proven highly effective.

Pain-Free Anesthetic Technology

Just the thought of a syringe makes a lot of people afraid. Some dental patients get more nervous than others at the mere sight of a needle. Discomfort from an anesthetic injection is mostly due to the feeling of pressure created by the flow of anesthetic into the tissues. A computerized anesthetic delivery system such as The Wand™ can effectively manage the anxiety resulting from the sight and sensation of conventional anesthetic syringes. This technology administers local anesthetic at a consistent volume and rate, regardless of tissue density or resistance. Several studies have demonstrated that computer-controlled delivery of local anesthetic significantly reduces a patient’s perception of pain.

Sedation Techniques for Dental Fear

Sedation refers to the use of medications to reduce or eliminate dental fear. Sedation allows the fearful patient to experience reduced anxiety and no pain during dental procedures. The use of various sedative drugs creates a state of relaxation. Depending on the type of sedation, the patient may not remember much about the procedure. Before considering sedation, the level of fear in the patient should be carefully evaluated. A sedation treatment plan should be devised based on the needs and goals of the patient. Only then can the appropriate type and level of sedation be determined.

Nitrous Oxide

Nitrous Oxide is a sweet tasting gas administered through an inhaler placed over the patient’s nose. It is also known as “laughing gas.” The patient simply breathes in the gas and quickly experiences a state of relaxation. Nitrous oxide is administered to patients requiring relatively short dental procedures and to those experiencing mild to moderate anxiety. The patient remains awake but without any pain or anxiety. Recovery time for patients receiving nitrous oxide is very brief. The effects subside within minutes.

Oral Sedation

Oral Sedation involves the use of oral medications in the form of a pill or tablet to relieve mild to moderate dental fear. The most commonly prescribed oral sedative medications are Halcion, Ativan and Valium. These drugs produce a high level of drowsiness but not a complete sleep. Oral Sedation is generally administered one hour prior to treatment. The patient remains awake and alert throughout treatment but without the fear he or she might otherwise experience.

Intravenous Sedation

Intravenous (IV) Sedation involves the use of medications administered intravenously to produce a totally painless and anxiety-free dental experience. Intravenous sedation can be used for patients with extreme dental fear and for those requiring long dental procedures. The most commonly used drugs for intravenous sedation are Versed and synthetic opiate analgesics such as Fentanyl or Demerol. During IV Sedation, the patient is hooked up to a blood pressure monitor, heart rate monitor and pulse oximeter. Though highly effective for managing dental fear, most practitioners are not qualified to administer IV Sedation. Special training and certification is required by most state dental agencies. IV Sedation produces 3 distinct levels of sedation: Conscious Sedation, Deep Sedation and General Anesthesia.

  • Conscious Sedation — Conscious Sedation is used for patients with severe anxiety and for those undergoing complex procedures. The patient is very relaxed but not fully asleep. The patient is aware and can respond to questions. Depending on the medications used, the patient will often not remember much of the dental procedure.
  • Deep Sedation — Deep Sedation is indicated for dental patients undergoing surgical dental procedures and for the fearful dental patient who says, “I want to be totally knocked out.” During deep sedation, the patient won’t feel any pain and won’t respond to questions.
  • General Anesthesia — General Anesthesia is used for patients undergoing extensive surgical dental procedures such as face and jaw reconstruction and TMJ surgery. This is this the highest level of IV Sedation, where the patient is completely unconscious and not easily aroused.

For all levels of Intravenous Sedation, the dental practitioner must have the proper training, experience, drugs and equipment to identify and manage complications that might occur. Deep Sedation and General Anesthesia should only be performed by a properly trained practitioner, a medical anesthesiologist, dental anesthesiologist or an oral surgeon.


Many people with dental fear avoid regularly visiting a dentist. As a result, they tend to develop serious oral health problems. Dental fear often leads to crisis situations that are problematic for both the patient and the dental provider. It is important for providers to be involved in treating fearful dental patients with compassion, understanding and care. With specific management tools, technologies and techniques, patients can be helped to overcome their fears, especially the fear of dentistry.

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