[Online survey on dental anxiety results]. / Online enquête over behandelangst: de resultaten.

In the months leading up to this special on 'dental anxiety', an online survey was conducted on various aspects of the treatment of anxious patients. This survey was completed by 128 people, of whom approximately one third were men and two thirds were women. The results show that more than half of the respondents feel they haven't learned enough about treating anxious patients during the training. Yet more than two thirds of the respondents also indicated they did not refer anxious patients to a Centre for Special Dentistry. The reasons for this are not clear.

[Diagnosis and treatment of dental anxiety]. / Diagnostiek en behandeling van angst voor de tandheelkundige behandeling.

Fear of dental treatment is a common phenomenon. Every oral health care provider will have to treat a patient with this fear one day. Adequate diagnostics are essential for a correct assessment of the level of fear and how an anxious patient can best be helped. In cases of mild fear, lowering the state anxiety by teaching the patient coping skills, will suffice. In cases of extreme fear, reducing disposition anxiety (the core of the anxiety disorder) comes first, since this will not only reduce fear during the treatment, but will also halt avoidance behavior, which in the end will have a positive effect on the oral health care of the patient.

[Dental anxiety and alexithymia; research on anxiety acquisition]. / Behandelangst en alexithymie, onderzoek naar angstleerprocessen.

People with alexithymia have difficulty identifying and describing feelings, have little imagination and mental processes largely orientated towards facts and less towards inner experience. It occurs in about 1 in 10 people and therefore in the dental office, too. A positive association has been found between alexithymia and the development of dental anxiety. With the help of an anxiety-conditioning experiment, the acquisition and the extinction of anxiety can be studied. To gain more knowledge about these processes of acquisition in people with alexithymia, such an experiment was conducted among 32 people with severe dental anxiety, 13 of whom with (possible) alexithymia. Relatively little anxiety conditioning occurred during the experiment. This may be explained by the aversive stimulus and the context in which the experiment was conducted. However, it emerged that for people with alexithymia, a physical outcome measure may be a better indicator of anxiety than a subjective score on a visual analogue scale.

[A study to determine possible success variables in the treatment of gag reflex patients]. / Onderzoek naar mogelijke succesvariabelen bij de behandeling van kokhalspatiënten.

A disproportionately sensitive gag reflex can hamper adequate dental treatment. Because an evidence-based treatment for this condition is lacking at this moment, a study of patients and success variables for the treatment was carried out. The study was based on the clinical records of and interviews with 40 people who had been treated in a Centre for Special Dental Care (CBT) because of extreme gag problems two years earlier. It was found that the gag complaints of half of the respondents had disappeared or become manageable, while those of the other half had not changed. It did not matter which intervention had been adopted. In order to determine how patients can best be treated and which patients can best be treated, research among larger patient samples is needed.

[DSQ-13-youth: measuring instrument for patient satisfaction with dental attendance among adolescents, young adults and parents of young children]. / DSQ-13-jeugd: meetinstrument voor patiënt­tevredenheid van adolescenten, jongvolwassenen en ouders over tandartsbezoek.

The Dental Satisfaction Questionnaire (DSQ) is a questionnaire consisting of 31 items assessing patient satisfaction with dental attendance. By means of factor analysis (principal component analysis), the number of items of the DSQ was reduced to 13, which together constitute the DSQ-13-youth. The first objective was to investigate the psychometric properties of the DSQ-13-youth; the second was to compare the satisfaction scores on the various dimensions between and within subgroups (23-year-olds, 17-year-olds and parents of 5-year-olds). The DSQ-13-youth has 4 domains measuring patient satisfaction with dental attendance. The internal consistency of those domains was high; the correlation between the domains low to moderate and the factor structure was highly congruent in the various subgroups. The differences in satisfaction scores between and within subgroups were small. The DSQ-13-youth is a reliable instrument to assess patient satisfaction with dental attendance among adolescents, young adults and the parents of young children in urban areas.

[Disease burden of extreme treatment anxiety; quality of life for patients with and without extreme dental treatment anxiety]. / Ziektelast en kwaliteit van leven bij patiënten met en zonder extreme angst voor tandheelkundige behandelingen.

In this study, a comparison was made between disease-specific (oral health-related) quality of life (OHQoL), measured with the OHIP-14 questionnaire, and generic (general health-related) quality of life (GHQoL), measured with the EQ5D-5L questionnaire, in patients with and without extreme dental treatment anxiety. A total of 76 patients who could not be treated due to extreme dental treatment anxiety were referred to a centre for special dentistry. These patients were matched, according to age, gender and socioeconomic status, with participants in an epidemiological study on oral health (n = 1125). Wilcoxon signed-rank tests were used on both groups to compare GHQoL and OHQoL. The total OHIP score was higher (representing a lower quality of life) in the patient group than in the control group. Anxiety patients scored higher on all 7 domains of the OHIP-14. With respect to general quality of life, patients with extreme treatment anxiety were found to report lower utility scores than the matched control group. With these results, a total disease burden of 74,000 disability-adjusted life years (DALYs) was calculated for extreme treatment anxiety in the Netherlands. The findings of this study reveal that having extreme dental treatment anxiety results in a significant disease burden in the Netherlands.

[Caries in deprived areas 2. Youngsters]. / Cariës in Krachtwijken 2. Jongeren.

In the Netherlands, no epidemiologic data on the oral health of cultural groups of children and adolescents living in deprived areas are available. The aim of the present study was to obtain an impression of the amount of caries experience among poorly educated groups of youngsters in deprived areas, in comparison with a reference group of poorly educated youngsters from the cities of Alphen aan den Rijn, Gouda, 's-Hertogenbosch and Breda. 725 Poorly educated respondents participated in a clinical and sociological study. The reference group had the lowest caries experience and the youngsters living in deprived areas with a non-Dutch cultural affiliation had the largest amount of caries experience. The latter group had more untreated caries and in 20-year-olds, a relatively large number of teeth had been extracted. Despite the low numbers, the difference in average DMFS scores among 14- and 20-year-olds were statistically significant. In the Netherlands a cultural dichotomy in oral health appears to exist, independent of level of education, in which youngsters with a non-Dutch cultural background are at a disadvantage.

[Caries in deprived areas 1. Adults]. / Cariës in Krachtwijken 1. Volwassenen.

In the Netherlands, little epidemiologic data is available on the oral health of the various cultural groups comprising the adult population living in deprived areas. The aim of an investigation carried out in 2013 was to obtain an impression of the extent of caries experience among less well-educated adults in deprived areas by comparison with a reference group of adults from the city of 's-Hertogenbosch. A total of 1,597 less well-educated respondents participated in this research. The reference population had the largest amount of caries experience, mostly due to a relatively large number of filled surfaces. The relatively low caries experience found in the respondents in the deprived areas with a non-Dutch cultural affiliation was due to lower numbers of filled surfaces. The differences in average filled-surface scores were statistically significant in all age categories, except the youngest. The strategy of 'extension for prevention' in caries treatment in the permanent dentition represents a possible explanation for the fact that less well-educated adults in 's-Hertogenbosch had significantly more filled surfaces than those with a non-Dutch cultural affiliation.

[A PhD completed 8. Are extreme dental treatment anxiety, fainting or gagging separate or overlapping phenomena?] / Hora est 8. Zijn extreme angst, flauwvallen of kokhalzen losstaande of overlappende fenomenen?

Extreme dental treatment anxiety, fainting or gagging in the dentist's chair can seriously hinder a patient's dental treatment. While a series of widely diverse studies on extreme dental treatment anxiety have been carried out, less is known about gagging and fainting. The most important questions in this dissertation research were whether dental treatment anxiety ('stimuli') can be identified and whether dental treatment anxiety and fainting or gagging are separate or overlapping phenomena. Fear of dental treatment can be divided into several subtypes: fear of invasive treatments, loss of control and aversive physical sensations. The current level of dental anxiety is closely related to various characteristics of memories underlying this fear. A combination of fainting in the dental setting and extreme fear of the dental treatment affects only a small part of the respondents (17.8%). The same applies to gagging and extreme fear of dental treatment (16.4%). Based on these findings, the conclusion can be drawn that severe forms of dental treatment anxiety, fainting or gagging in the dental setting are largely unrelated phenomena.

The burden of disease of dental anxiety: generic and disease-specific quality of life in patients with and without extreme levels of dental anxiety.

The aim of this study was to compare disease-specific (oral health-related) quality of life (OHRQoL), assessed using the Oral Health Impact Profile-14 (OHIP-14), and generic (health-related) quality of life (HRQoL), assessed using the EuroQol5D (EQ-5D-5L), in patients with severe dental anxiety (who were visiting a centre for special care dentistry) with a control group from the general population. Seventy-six patients with severe dental anxiety [Dental Anxiety Scale (DAS) score ≥ 13] were matched, according to age, gender, and socio-economic status, to a control group of 76 participants in a larger epidemiological study on oral health in the Netherlands (n = 1,125). The Wilcoxon signed-rank test was used to compare levels of HRQoL and OHRQoL in both groups. The total OHIP score (indicating lower OHRQoL) was higher for the patient group (10th percentile = 30.5; 90th percentile = 46.0) than for the control group (10th percentile = 1.0; 90th percentile = 14.5). The patient group showed higher scores on all seven OHIP domains. Lower utility scores were found in patients with severe dental anxiety (HRQOL: 10th percentile = 0.7; 90th percentile = 0.9) relative to the control group (HRQOL: 10th percentile = 0.9; 90th percentile = 1.0). A disease burden of 74,000 disability-adjusted life years (DALYs) was calculated for the Netherlands. The findings of this study show differences between patients visiting a dental fear clinic and matched controls from the general population for both OHRQoL and HRQoL, indicating that having severe dental anxiety generates a significant burden of disease.

Self-reported gagging in dentistry: prevalence, psycho-social correlates and oral health.

Although gagging has a profound effect on the delivery of dental care, it is a relatively under-investigated phenomenon. This study aimed to derive a prevalence estimate of gagging during dental treatment based on patient-reported information, to determine some socio-demographic and psychological correlates and to assess the relationship of gagging with self-reported oral health and avoidance of dental care. Data were collected with a survey among Dutch twin families (n = 11 771). Estimated overall prevalence of gagging during dental treatment was 8·2% (95% CI 7·7-8·7). Patients' self-report of gagging was found to be significantly associated with female sex, a lower level of education and higher levels of dental trait anxiety, gagging-related fears (e.g. fear of objects in the mouth), anxious depression and neuroticism. Gagging also appeared to be significantly associated with untreated cavities, gingival bleeding and wearing full dentures, but not with avoidance of dental care. It can be concluded that individuals who report to gag during dental treatment are moderately dentally anxious, fear-specific situations that can trigger a gagging response and, albeit visiting the dentist equally frequently, report to have a poorer oral health compared to those who do not gag.

[Treatment of a patient with psychogenic non-epileptic seizures]. / Behandeling van een patiënt met psychogene pseudo-epileptische aanvallen.

A 36-year old man is referred to a centre for special dental care due to problems with treatability in the general dental practice and a deteriorated oral state. His behaviour is unpredictable due to the possible development of sudden changes in the patient's consciousness which are accompanied by severe aggression. The patient suffers from a conversion disorder, a serious mental disorder which expresses itself in his case with the occurrence of psychogenic non-epileptic seizures. The patient fears that dental treatment will provoke a seizure and that he will react aggressively to his surroundings. He therefore requests that he undergoes dental treatment using general anaesthesia and patient fixation measures. This case study provides an example for the discussion of the problems and the rights of patients with severe mental disorders and the use of measures of physical restraint in dentistry.

Is dental phobia a blood-injection-injury phobia?

BACKGROUND: Dental phobia is part of the Blood-Injection-Injury (B-I-I) phobia subtype of specific phobia within DSM-IV-TR. To investigate the conceptual validity of this classification, the purpose of the present study was to determine the co-occurrence of dental phobia, typical dental (and B-I-I related) fears, vasovagal fainting, and avoidance of dental care. METHOD: Data were collected by an online survey in Dutch twin families (n = 11,213). RESULTS: Individuals with a positive screen of dental phobia (0.4% of the sample) rated typical B-I-I-related stimuli as relatively little anxiety provoking (e.g. of all 28 fears the stimulus "the sight of blood" was ranked lowest). Presence of dental phobia was significantly associated with a history of dizziness or fainting during dental treatment (OR = 3.4; 95% CI: 1.5-8.1), but of the dental phobic individuals only 13.0% reported a history of dizziness or fainting during dental treatment. Presence of dental phobia (OR = 5.0; 95% CI: 2.8-8.8) was found to be associated with avoidance of dental care, but a history of dizziness or fainting during dental treatment was not (OR = 1.0; 95% CI: 0.8-1.2). CONCLUSIONS: The present findings converge to the conclusion that dental phobia should be considered a specific phobia subtype independent of the B-I-I cluster within the DSM classification system.

A review and meta-analysis of the heritability of specific phobia subtypes and corresponding fears.

Evidence from twin studies suggests that genetic factors contribute to the risk of developing a fear or a phobia. The aim of the present study was to review the current literature regarding twin studies describing the genetic basis of specific phobias and their corresponding fears. The analysis included five twin studies on fears and ten twin studies on specific phobias. Heritability estimates of fear subtypes and specific phobia subtypes both varied widely, even within the subtypes. A meta-analysis performed on the twin study results indicated that fears and specific phobias are moderately heritable. The highest mean heritability (±SEM) among fear subtypes was found for animal fear (45%±0.004), and among specific phobias for the blood-injury-injection phobia (33%±0.06). For most phenotypes, variance could be explained solely by additive genetic and unique environmental effects. Given the dearth of independent data on the heritability of specific phobias and fears, additional research is needed.

[Post-academic specialties 9. Dental care of disabled children living at home]. / Beroepsdifferentiatie in de tandheelkunde 9. Problemen in de mondzorg voor kinderen met een ernstige verstandelijke beperking.

The aim of this study was to identify possible problem areas regarding preventive selfcare and dental care for severely mentally retarded children living at home. The sample test comprised parents (n = 126) and dentists (n = 40) of children between the ages of 4 and 12 from 7 randomly selected daycare centres in The Netherlands, who were asked to fill out a questionnaire. Of the children 32% were found to receive no dental care at all, while among the children from ethnic minority groups this number exceeded 50%. Of the parents two-thirds indicated that they had encountered problems with daily dental care and 70% reported that their child's oral hygiene was in need of improvement. Of the dentists 25% were dissatisfied with the dental care they provide, and 75% felt that dental care for mentally retarded children needs improving. The results suggest that there is room for improvement in the support of parents of mentally disabled children in maintaining an adequate level of oral hygiene, and that adequate training of dental professionals in serving the needs of people with severe disabilities is wanted.