Oral Care repOrt

Dental Fear
Dental fear is one of the most fy the patient’s fear and thus reinforce and
In This Issue
important reasons that individuals do not perpetuate the vicious cycle.4
seek dental care. Sometimes called “den- Dental Fear 1
tal anxiety” or “dental phobia,” the con- Dental fear typically develops in
dition typically develops in childhood or childhood or adolescence.
adolescence.1,2 Periodontal Page 3
This model has found empirical sup-
Development of Dental Fear port in a recent study of 1,036 Australians,
The development of this condition of whom 18.8% reported moderate to high Hygiene Page 4
is a complex, multi-factorial process, which dental fear.4 Among them, 38.5% admit-
may involve the experiences of the child ted to: (1) avoiding dental visits because
with dental disease or its treatment, neg- of fear or dislike; (2) having a current treat- Clinical Practice 6
ative family experiences, and socio-eco- ment need; and (3) usually visiting a den-
nomic or environmental factors.3 The tist for a problem rather than a check-up.4
reported prevalence of dental fear in chil- In contrast, this response pattern was seen Healthcare Trends 8
dren ranges widely, from 6.5 to 43%, in only 7.5% of people who reported a lit-
reflecting differences in populations and tle dental fear and in 0.9% of those who
methodological approaches.3 A recent reported no dental fear.4 Dental fear was
study of 1,129 five-year-old children resid- strongly associated with perceived treat-
ing in the urban area of Pelotas, Brazil, ment need and visiting dentists only when
found that 16.8% of the children had den- a problem arises (p < 0.001).4
tal fear, as reported by their mothers.3 Educational
Independent variables associated with the Assessment of Children’s Dental
presence of dental fear in these children Fear in Clinical Practice Objectives
were low family income at the child’s birth, Because dental fear develops early
dental caries (≥ 2 decayed, missing, or After reading this issue of the
in life, it is important for clinicians to rec-
filled surfaces [DMFS]), dental pain, and ognize this problem in their young Colgate Oral Care Report and
having never visited a dentist.3 Children patients in order to develop appropriate correctly answering the questions
who suffered from caries were more like- approaches and to prevent consolidation in the Continuing Education Quiz,
ly to have dental fear, regardless of their of negative emotions and attitudes.5 you will
socioeconomic status at birth or their Ideally, a questionnaire assessing dental
mother’s characteristics, such as her years 1. understand the importance of
fear in children in clinical practice should
of schooling or her own dental fear.3 This breaking the “Vicious Cycle of
be easy to administer (e.g., brief, so it can
finding suggests that prevention of den- Dental Fear” in children and
be completed in the waiting room), while
tal caries in children may help reduce the covering a variety of specific dental pro- adults;
risk of development of dental fear early cedures and situations.5 A questionnaire 2. discover the most recent
in life. for children should have a suitable for- evidence supporting the notion
mat, ideally allowing its use in children that smoking cessation can result
The “Vicious Cycle of Dental of various ages.5 Importantly, the tool in substantial improvements in
Fear” should contain items that provide a valid oral health;
Caries may contribute to dental fear measure of dental fear.5
by playing an important role in the “Vicious Many questionnaires have been used 3. be aware of new treatment
Cycle of Dental Fear.” According to this to assess dental anxiety in children; each protocols that have been
model, individuals afraid of dental treat- has benefits and potential drawbacks. A proposed and tested in studies to
ments typically avoid or delay dental vis- recent systematic review examined nine relieve the symptoms of oral
its, which may, over time, contribute to instruments that have been used to assess lichen planus; and
the development of severe dental disease dental anxiety by self-report in children.
4. learn the importance of prudent
(e.g., dental caries).4 Severe dental disease The table on page 2 provides details that
use of antibiotics in pediatric
requires invasive and sometimes painful dental care.
interventions, which may further intensi- Volume 24, Number 2, 2014

Providing Continuing Education as a Service to Dentistry Worldwide

2 Oral Care repOrt

distinguish one instrument from the other.5 In addition to knowing whether the the instruments listed in the table, only
The review recommends four of the instru- patient is afraid and what specifically trig- two, the Dental Fear Survey and the Dental
ments for use in clinical practice based gers his or her fear, to be able to effective- Anxiety Inventory-short version, cover mul-
on factors such as validity, ease of admin- ly treat dental anxiety, it is important to tiple aspects of dental anxiety, such as
istration, and suitability for children. These understand which factors are involved in unhelpful behaviors and physical reac-
include the Modified Child Dental Anxiety sustaining the fearful emotions.5 Five char- tions.5 While these instruments allow a
Scale, the Smiley Faces Programmes, the acteristics have been identified that inter- more comprehensive assessment of the
Dental Fear Survey, and the Facial Image act to maintain and enhance anxiety: patient’s anxiety, they may be more suit-
Scale.5 The latter, while very easy to use, unhelpful thoughts; negative feelings; ed for use in older children (e.g., age ≥ 8
provides only a snapshot of the child’s cur- behaviors (e.g., cancelling an appoint- years) or adults.5
rent feelings, whether or not these are relat- ment); physical symptoms (e.g., muscle
ed to the dental visit.5 tenseness); and specific situations.5 Among Consequences of Dental Fear
Dental fear carries important con-
sequences for patients, dental care
providers, and dental care services.5
Treatment of patients with dental fear can
be challenging and time-demanding.
Sometimes these patients are referred to
special dental care services, which con-
tributes to increased treatment costs.5
Consequences for patients include gen-
erally more decayed (DT) and missing
teeth (MT), as confirmed in large popu-
lation-based studies.6
The association between dental fear
and number of filled teeth (FT) is more
complex. The National Survey of Adult
Oral Health, which examined 5,364
Australians between 2004 and 2006, report-
ed a U-shaped association, with people
who reported being moderately afraid of
going to the dentist having the greatest
mean number of FT, while those who were
not or a little afraid, as well as those very
or extremely afraid had fewer FT.6 People
with high levels of dental fear may delay
dental treatment until tooth extraction
becomes unavoidable (i.e., MT).6 This
could explain why people with high lev-
els of dental fear may have fewer FT but
more MT than those with moderate fear.6

Dental fear has detrimental

consequences for patients,
dental care providers, and
dental care services.

Overall, in the Australian survey, after

controlling for demographic and socio-
economic variables as well as plaque index,
people who reported being “extremely
afraid” of dental visits had 186.3% more
Continued on p. 5
 Oral Care repOrt 3

PERIODONTAL PAGE
compared with non-smokers was 1.74 95% CI: 1.12–2.50; p = 0.011).3 There was
Smoking Cessation (95% confidence interval [CI]: 1.21–2.50; a trend for smoking cessation to be asso-
p = 0.003).3 Conversely, the odds of hav- ciated with fewer teeth lost (OR: 1.35 ex-
and Periodontal ing periodontitis was not significantly dif- smokers versus non-smokers; 95% CI:
ferent between those who had quit smok- 0.94–1.94; no significant difference). The
Health ing for longer than 11 years and those who number of teeth lost was lower in those
never smoked (OR: 1.27; 95% CI: with prolonged duration of smoking ces-
T he negative effect of smoking on 0.90–1.78); the OR further decreased as sation; those who quit smoking for 11 years
periodontal health has been studied exten- the duration of smoking cessation or less had on average 3.9 fewer teeth than
sively, leading to the suggestion that smok- increased (see graph below). those who had quit for 31 years or more
ing cessation would result in substantial When radiographic bone loss was (graph).3 Consistently, two longitudinal
improvements in oral health. The evidence assessed in a Swedish cohort (two prospec- studies showed that the risk of tooth loss
supporting this hypothesis has been tive studies reviewed by Fiorini, et.al.1), ex- decreased with increasing time since smok-
reviewed recently;1,2 the main findings are smokers compared well to non-smokers ing cessation,4,5 and was equivalent to that
presented here. in terms of progression of periodontal of non-smokers after 13 years of smoking
breakdown and had less bone loss than cessation.4 Lastly, a small study suggested
Improvement of Periodontal smokers (decrease of 27% over 10-year that the rate of early implant loss was high-
Status follow-up). er among smokers versus quitters.2
There is no data on the effect of Finally, in a birth cohort of 26-year-
smoking cessation on the risk of subse- old subjects from New Zealand (prospec- Smoking Cessation and the
quent development of periodontitis;1 how- tive study; reviewed by Fiorini, et.al.1), the Subgingival Microflora
ever, a number of studies provide strong progression of clinical attachment loss was Smoking was shown to negatively
evidence on the benefits of stopping smok- estimated to be three-fold higher among affect subgingival microbial composition,
ing cigarettes on periodontal status.1,2 smokers versus ex-smokers (six-year rate: favoring the proliferation of putative peri-
In a cohort study of 1,088 Japanese 28.4% versus 10.1%; p < 0.001).1 odontal pathogens at the expense of non-
men aged between 40 and 75 years, smok- pathogenic bacteria.6 Following 12
ing was strongly associated with periodontal Prevention of Tooth Loss months of recolonization, smoking ces-
disease (defined as at least one site with a In the Japanese cohort study, smok- sation reestablished a healthy flora, as
pocket depth of at least 6 mm). The odds ing was associated with a fewer number reported in a study of subgingival plaque
ratio (OR) of smokers with periodontitis of teeth (OR: 1.67 versus non-smokers; Continued on p. 5
4 Oral Care repOrt

HYGIENE PAGE
Oral Hygiene and small studies from Italy, Spain, and Brazil
address such an alternative, using the ration-
tistically significantly lower after the treat-
ment protocol (see Figure 2, red bars).
ale that improving gingival health will alle-
Gingival Lichen viate those symptoms when gingival involve- Spanish Study Assessing
ment is present.
Planus Combination Therapy
Another single-arm clinical study of
Italian Clinical Trial 40 patients with OLP was conducted to eval-
O ral lichen planus (OLP) is an
Evaluating Combination uate the efficacy of a treatment protocol,
immune-mediated disorder that common- including motivational patient education
ly affects the buccal and lingual mucosa, as Therapy consisting of good oral hygiene and brush-
well as the gingiva.1 It may appear as whitish In a single-blind clinical trial of 30 ing instructions to minimize plaque.3 This
lacy patches, reddish swollen tissues, or as patients with OLP, the combination of oral motivation protocol was incorporated into
ulcerations (see Figure 1). Lesions may be hygiene instruction, gingival scaling, and a treatment regimen that also included scal-
painful, and cause burning or other dis- mouthwashes to control plaque, in con- ing, tooth polishing, and topical corticos-
comfort. OLP is a chronic oral condition junction with topical corticosteroid thera- teroids. After four and eight weeks, there
that has alternating periods of remission and py, was assessed as a treatment regimen.2 was a statistically significant reduction of
symptom intensification. It can manifest as The objective was to determine if there was gingival scores and improvement of the peri-
odontal condition (see Figure 2, blue bars).
Figure 1. Lichen planus affecting: the palatal gingiva (left); buccal gingiva (center); buccal mucosa (right).
These results suggest that the inclusion of
an active prevention program to a treatment
course of topical corticosteroids may be a
more effective strategy to control OLP.

Brazilian Study Surveying the

Specific Impact of Plaque
Control
Another short-term study of 20 patients
early as puberty, but is mostly diagnosed after reduced dental plaque and gingival bleed- with gingival OLP was performed to deter-
the age of 30 years, and more frequently in ing as measured by the plaque index (PI) mine the singular effect of periodontal treat-
women than in men.2 An estimated 10% of and bleeding on probing (BOP), respec- ment.1 All patients received supragingival
patients with OLP have involvement of the tively. The PI scores and the number and scaling, oral hygiene instruction, and week-
gingiva, which is a form of desquamative gin- percentage of BOP-positive sites were sta- Continued on p. 7
givitis. Desquamative gingivitis is a descrip-
tive term, and is characterized by sloughing
of gingival epithelium that can progress to
painful, erosive gingival lesions.2 Symptoms
of OLP are exacerbated by plaque accumu-
lation, often due to the inability to maintain
adequate oral hygiene practices due to pain
and bleeding. This can also lead to the onset
of other oral diseases, including dental caries.2

Treatment Regimens for OLP

The general aim of any given treat-
ment regimen for OLP is to provide relief
from the symptoms.1 The most extensively
used treatment for patients with OLP is top-
ical corticosteroids. However, the lack of
sustained adherence of the drug at the affect-
ed sites reduces treatment efficacy.2,3 As a
result, other treatment protocols that include
plaque control have been proposed and test-
ed in studies with patients with OLP.1-3 Three
 Oral Care repOrt 5

Continued from p. 2 mental impacts on their health-related Caries Res 2014;48(4):263-70.

DT, 39.6% more MT, and 14.7% more quality of life.7-9 4. Armfield JM. What goes around comes
DMFT than people “not at all afraid.”6 around: revisiting the hypothesized vicious
However, the relationship between den- Summary cycle of dental fear and avoidance. Community
tal fear and DMFT was significant in Dental fear remains an important Dent Oral Epidemiol 2013;41(3):279-87.
younger adults only, i.e., those between problem today, affecting all age groups 5. Porritt J, Buchanan H, Hall M, Gilchrist F,
the ages of 18 and 44 years, while no sig- (however, starting early in life), and its recog- Marshman Z. Assessing children’s dental
nificant association was found in those nition and effective treatment can con- anxiety: a systematic review of current meas-
aged 45 and older, possibly because older tribute to reducing the need for invasive ures. Community Dent Oral Epidemiol
people with dental fear had markedly fewer and often costly interventions, ease the bur- 2013;41(2):130-42.
FT than those without fear.6 Interestingly, den on dental services, and improve 6. Armfield JM, Slade GD, Spencer AJ. Dental
in contrast to measures of current and patients’ oral health and quality of life. O C fear and adult oral health in Australia.
treated caries (i.e., DMFT), dental fear was Community Dent Oral Epidemiol 2009;37(3):
not associated with periodontitis or gin- References 220-30.
givitis, painless inflammatory conditions 1. Locker D, Liddell A, Dempster L, Shapiro 7. McGrath C, Bedi R. The association
that arise from plaque accumulation.6 D. Age of onset of dental anxiety. J Dent Res between dental anxiety and oral health-
Similar levels of gum disease across den- 1999;78(3):790-6. related quality of life in Britain. Community
tal fear levels may indicate similar oral 2. Locker D, Thomson WM, Poulton R. Onset Dent Oral Epidemiol 2004;32(1):67-72.
hygiene or preventive practices, while the of and patterns of change in dental anxi- 8. Mehrstedt M, John MT, Tonnies S,
differences in DMFT appear to primarily ety in adolescence and early adulthood: a Micheelis W. Oral health-related quality
result from delayed caries treatment birth cohort study. Community Dent Health of life in patients with dental anxiety.
among people with dental fear.6 2001;18(2):99-104. Community Dent Oral Epidemiol
In addition to the clinical conse- 3. Torriani DD, Ferro RL, Bonow ML, Santos 2007;35(5):357-63.
quences of delayed treatment, dental fear IS, Matijasevich A, Barros AJ, et al. Dental 9. Mehrstedt M, Tonnies S, Eisentraut I. Dental
can affect patients’ social and psychologi- caries is associated with dental fear in child- fears, health status, and quality of life. Anesth
cal well-being, with well-documented detri- hood: findings from a birth cohort study. Prog 2004;51(3):90-4.

Continued from p. 3 to consider smoking status as an inform- 2. Warnakulasuriya S, Dietrich T, Bornstein

analysis among 22 subjects.6 These results ative parameter in periodontitis risk assess- MM, Casals PE, Preshaw PM, Walter C, et
suggest that while smoking-associated ment, and incorporate smoking cessation al. Oral health risks of tobacco use and
changes in microbial composition may counseling and/or other smoking cessa- effects of cessation. Int Dent J 2010;60(1):
be a contributing factor to periodontal tion strategies into periodontal therapy 7-30.
disease etiology and progression, the ben- and prevention programs. Preliminary 3. Yanagisawa T, Ueno M, Shinada K, Ohara
eficial effect of smoking cessation on peri- data on the effectiveness of counseling S, Wright FA, Kawaguchi Y. Relationship of
odontal health may be mediated at least comes from a single-arm longitudinal clin- smoking and smoking cessation with oral
partly by the normalization of subgingi- ical study where smoking cessation coun- health status in Japanese men. J Periodontal
val flora. Studies are needed to test this seling was provided to smokers with chron- Res 2010;45(2):277-83.
hypothesis. ic periodontitis; cessation rate reached 4. Krall EA, Dietrich T, Nunn ME, Garcia RI.
20% after 12 months.7 Although the com- Risk of tooth loss after cigarette smoking
Incorporating smoking cessation bined effect of non-surgical periodontal cessation. Prev Chronic Dis 2006;3(4):A115
counseling into periodontal treatment and smoking cessation has not 5. Dietrich T, Maserejian NN, Joshipura KJ,
therapy and prevention been researched extensively, this study Krall EA, Garcia RI. Tobacco use and inci-
showed at least a modest added benefit dence of tooth loss among US male health
programs is essential. of smoking cessation on the response to professionals. J Dent Res 2007;86(4):373-7.
periodontal treatment.7 Future research 6. Delima SL, McBride RK, Preshaw PM,
Role of Dental Healthcare on this question is warranted. O C Heasman PA, Kumar PS. Response of sub-
gingival bacteria to smoking cessation. J Clin
Professionals References
Microbiol 2010;48(7):2344-9.
In conclusion, there is a consider- 1. Fiorini T, Musskopf ML, Oppermann RV,
7. Preshaw PM, Heasman L, Stacey F, Steen
able body of evidence showing improve- Susin C. Is there a positive effect of smok-
N, McCracken GI, Heasman PA. The effect
ment of periodontal health benefits fol- ing cessation on periodontal health? A sys-
of quitting smoking on chronic periodon-
lowing smoking cessation. Therefore, den- tematic review. J Periodontol 2014;85(1):
titis. J Clin Periodontol 2005;32(8):869-79.
tal practitioners are strongly encouraged 83-91.
6 Oral Care repOrt

CLINICAL PRACTICE
ticular through avoidance of unnecessary ios were in-office cases and two were week-
Appropriate Use of use (e.g., for viral infections), selection of end cases. Adherence to professional guide-
appropriate antibiotics and dosing sched- lines set by the AAPD and ADA was assessed.
Antibiotics in ules, consideration of narrow-spectrum Among 154 dentists who completed the sur-
agents where appropriate, and awareness vey, adherence rates ranged from 10% to 42%
Pediatric Dentistry of potential side effects and drug interac- across the three in-office clinical case scenar-
tions3,4 (see Tables 1 and 2). ios. Adherence to professional prescribing
W idespread use of antibiotics has guidelines was 14% and 17% for the two week-
resulted in increasing prevalence of antibi- end scenarios surveyed. Dental practitioners
otic-resistant microorganisms, represent-
Systemic antibiotic therapy who had obtained postgraduate qualifications
ing a growing health problem that con- during the first year of life was were significantly more likely to adhere to pro-
tributes to the morbidity and mortality of associated with an increased risk fessional guidelines across the surveyed sce-
infectious diseases around the world.1 A fur- of early childhood caries during narios (p < 0.05).6
ther important consideration is that antibi- Similarly, Sivaraman and colleagues5
otic use carries a risk of toxicity or allergy,
ensuing years. surveyed pediatric dentists to evaluate
which in some cases can be severe.2 Taking antibiotic prescribing practices, familiari-
these facts into account, and recognizing Low Level of Adherence to ty with the concept of antibiotic resistance,
that one might not benefit from a therapy and knowledge of antibiotic stewardship
which itself has significant adverse effects
Professional Guidelines in programs implemented by hospitals to pro-
to the individual and the environment, it Antibiotic Prescribing Practices mote adherence to published guidelines.
is clear that care must be taken in its use. Two recent studies suggest that adher- The survey was e-mailed to 4,636 pediatric
In the United States, the American ence to professional guidelines for antibiotic dentists; 984 surveys were returned and
Dental Association (ADA) and the use among US dental practitioners is low, with included in the analysis. The antibiotic
American Academy of Pediatric Dentistry a tendency toward overtreatment.5,6 Cherry most often prescribed by dentists was
(AAPD) have developed guidelines for and colleagues6 surveyed 280 general and pedi- amoxicillin (n = 764; 78%), followed by
the use of antibiotics in the treatment of atric dentists in North Carolina to determine penicillin (n = 201; 20%). Based on a com-
oral infections.3,4 The guidelines empha- antibiotic prescribing decisions in response parison with AAPD guidelines, the over-
size the judicious use of antibiotics, in par- to different clinical scenarios. Three scenar- all survey responses suggested overpre-
scribing of antibiotics for the following
conditions: irreversible pulpitis, with (32%)
and without vital pulp (42%); localized
dentoalveolar abscess, with (68%) and
without draining fistula (39%); mitral valve
prolapse, with regurgitation (43%), intru-
sion (15%), extrusion (13%); and rheuma-
toid arthritis (12%). Only 15% of dentists
reported awareness of antibiotic steward-
ship initiatives, although 98% acknowl-
edged that antibiotic resistance is a grow-
ing concern.5

Evidence for an Association of

Antibiotic Use with Early
Childhood Caries
Use of systemic antibiotics is also known
to impact the composition of the oral
microflora.7,8 A study based on Medicaid
insurance data filed in Michigan between
2001 and 2004 investigated whether antibi-
otic use in general among children was asso-
ciated with later caries development.9 The
study reported that systemic antibiotic ther-
Continued on p. 7
 Oral Care repOrt 7

apy during the first year of life (period of 3. American Dental Association. Antibiotic Continued from p. 4
primary teeth development) was associat- use in dental care. On American Dental ly professional plaque removal. The study
ed with an increased risk of early childhood Association website [updated 2013 May; outcomes consisted of periodontal indices
caries during the ensuing years. Oral antibi- cited 2014 Mar 28]. Available from: for plaque control, and clinical and pain
otic prescriptions were filled for 67% of chil- https://www.ada.org/sections/professional scores for lesions assessed at baseline and
dren during their first year of age, 55% of Resources/pdfs/May2013Antibiotics3.pdf. at the end of study. There was a statistically
children between 13 to 18 months, and 47% 4. American Academy of Pediatric Dentistry. significant improvement in all evaluated
at 19 to 40 months of age. The most com- Guideline on use of antibiotic therapy for periodontal indices. There was also improve-
monly used antibiotics were penicillins (84% pediatric dental patients. On Clinical ment in the clinical measures and pain
of the total sample) and macrolides (34%).9 Guidelines website [updated 2009; symptoms (see Figure 2, green bars). The
Available from: www.aapd.org/media/ study concluded that stand-alone plaque
Conclusion Policies_Guidelines/G_AntibioticTherapy. control is beneficial in both reducing the
The above studies suggest that inap- pdf? pain associated with gingival OLP, and
propriate use of antibiotics is common in 5. Sivaraman SS, Hassan M, Pearson JM. A improving the periodontal status.
the treatment of pediatric dental patients. national survey of pediatric dentists on
Conservative use of prescription antibiotics antibiotic use in children. Pediatr Dent A treatment regimen consisting
is essential to mitigate undesired conse- 2013;35(7):546-9.
6. Cherry WR, Lee JY, Shugars DA, White RP,
of plaque control, in addition
quences of antibiotic overuse. Another issue
brought to light by recent evidence is that Jr., Vann WF, Jr. Antibiotic use for treating to patient education and
systemic antibiotic therapy during the first dental infections in children: a survey of topical medication, is effective
year of life may increase the likelihood of dentists’ prescribing practices. J Am Dent in alleviating the pain and
caries development in early childhood. Assoc 2012;143(1):31-8.
7. Staves E, Tinanoff N. Decline in salivary S.
clinical manifestations of OLP.
Further, since the potential harmful effects
of antibiotic use are not immediately per- mutans levels in children who have received
ceptible, proper utilization is not always short-term antibiotic therapy. Pediatr Dent Conclusion
seen as important. Dental practitioners are 1991;13(3):176-8. Despite differences in periodontal
advised to use antibacterial drugs in a pru- 8. Handelman SL, Mills JR, Hawes RR. Caries indices used, all three studies demonstrate
dent manner. O C incidence in subjects receiving long term that a reduction in plaque formation and
antibiotic therapy. J Oral Ther Pharmacol gingival bleeding is achievable in patients
References 1966;2(5): 338-45. with gingival manifestations of OLP. These
1. Davies J. Origins and evolution of antibiot- 9. Alaki SM, Burt BA, Garetz SL. The associa- results indicate that the inclusion of peri-
ic resistance. Microbiologia 1996;12(1):9-16. tion between antibiotics usage in early child- odontal therapy, especially plaque con-
2. Pallasch TJ. Antibiotic resistance. Dent Clin hood and early childhood caries. Pediatr trol, is essential for improving the clini-
North Am 2003;47(4):623-39. Dent 2009;31(1):31-7. cal condition and painful symptoms of
OLP lesions. O C
References
1. Salgado DS, Jeremias F, Capela MV,
Onofre MA, Massucato EM, Orrico SR.
Plaque control improves the painful symp-
toms of oral lichen planus gingival lesions.
A short-term study. J Oral Pathol Med
2013;42(10):728-32.
2. Guiglia R, Di LC, Pizzo G, Picone L, Lo
ML, Gallo PD, et al. A combined treat-
ment regimen for desquamative gingivi-
tis in patients with oral lichen planus. J
Oral Pathol Med 2007;36(2):110-6.
3. Lopez-Jornet P, Camacho-Alonso F.
Application of a motivation-behavioral
skills protocol in gingival lichen planus:
a short-term study. J Periodontol
2010;81(10):1449-54.
8 Oral Care repOrt

HEALTHCARE TRENDS
Fear of the Dentist:
Another Access to Care Concern
O ne of the most important challenges faced by the dental profession is the provi-
sion of universal oral healthcare. Lack of access to dental services is due to a variety of fac-
tors. On the provider side, these include a lack of availability of oral healthcare clinicians,
as well as unequal geographic distribution of providers. For patients, barriers include a
lack of resources to pay for dental services (or the availability of private or public insur-
ance), absence of health literacy that if present would instill the need for regular dental
care, and, as examined in the lead article of this issue of the Oral Care Report, a fear of
dental care.
The prevalence of dental fear is not well-defined, and for adults has been reported
Editor-in-Chief to be between 5% and 25%, with the true percentage likely in the 10%–15% range. An
even greater range has been reported for children. Fear of dental treatment is a vicious
Ira B. Lamster, DDS, MMSc cycle. If dental problems are present, anxiety occurs. Avoidance behavior results in pro-
Professor of Health Policy & Management,
gression of the problem, and the result is an even greater need for care. This further
Mailman School of Public Health
Dean Emeritus,
compounds the problem.
Columbia University College of Dental Medicine Dental anxiety is complex, and has been associated with specific personality traits,
exposure to unfavorable images in the media, as well as the experiences of family mem-
bers (i.e., parent to a child). Certain individuals may be more prone to dental anxiety; for
International Editorial Board example, people with autism spectrum disorder. These feelings often originate in child-
P. Mark Bartold, BDS, BScDent (Hons), PhD, hood, and while pediatric dentists have more training in caring for patients with dental
DDSc, FRACDS (Perio); Australia fear than do general dentists, these patients can be challenging for all oral healthcare
providers.
John J. Clarkson, BDS, PhD; Ireland Dental anxiety should be part of the assessment when a patient is seen for an initial
Kevin Roach, BSc, DDS, FACD; Canada evaluation. Reduction of anxiety can actually begin in the waiting area, and front desk
personnel can assist in this regard by creating a welcoming environment. An excellent
Prof. Cassiano K. Rösing; Brazil review of approaches to manage dental fear is available.1 Many of the suggested tech-
Mariano Sanz, DDS, MD; Spain niques are not pharmacological, and can be used by oral healthcare providers. These
range from simple, clear communication to systematic desensitization and hypnosis.
Ann Spolarich, RDH, PhD; USA Preventive dentistry is an important part of the general approach to oral healthcare
for patients with dental anxiety. Proper self-care will promote oral health, regular main-
Xing Wang, MD, PhD; China
tenance visits will desensitize the dental office visit, and a healthy mouth will promote
Rebecca S. Wilder, RDH, MS; USA self-assurance and social interaction. While non-pharmacological techniques are pre-
ferred, pre-operative anxiolytic medications, as well as the use of conscious sedation dur-
David T.W. Wong, DMD, DMSc; USA ing treatment, are important options. General anesthesia is one approach, but is expen-
sive and does not address the primary cause. At times referral to other health profession-
© 2014 Colgate-Palmolive Company.
als, including a psychiatrist or psychologist should be considered. It has been suggested
All rights reserved.
that dental fear can be considered a public health problem,2 with a need to focus on risk
The Oral Care Report
factors for dental anxiety. The concentration should be on children, with the intent of
(ISSN 1520-0167) is supported by preventing dental anxiety in adulthood.
the Colgate-Palmolive Company While the traditional access to care issue focuses on availability of oral healthcare
for oral care professionals. Medical providers, consideration must be given to those individuals who do not seek services
writing by LASER Analytica, Montréal, QC because of fear of dental care. The dental profession seeks to provide services to all indi-
(Canada). viduals, and providers should be familiar with strategies to address the needs of patients
with dental anxiety. O C
Published by Professional Audience
Communications, Inc., Yardley, PA (USA). References
1. Armfield JM, Heaton LJ. Management of fear and anxiety in the dental clinic: a review.
E-mail comments and queries to the
Aust Dent J 2013;58:390.
Editor, Oral Care Report...
ColgateOralCareReport@gmail.com 2. Crego A, Carrillo-Diaz M, Armfield JM, Romero M. From public mental health to commu-
nity oral health: the impact of dental anxiety and fear on dental status. Front Public Health
2014;2:16.