Long-Term Management of the Fearful Adult

Patient Using Behavior Modification and

Other Modalities
Ulf Berggren, D.D.S., Dr. Odont.
Abstract: This paper reviews reports on the treatment of fearful adult dental patients with special emphasis on behavioral and
cognitive methods and long-term followup. A number of such treatment methods are available that can be used by dentists for the
alleviation of fear and anxiety in their patients. At an “intuitive” level, many dentists probably use these methods frequently as a
comprehensive part of everyday praxis. Considering the high number of fearful individuals visiting dentists regularly, a better
knowledge of such methods would improve dental care for the majority of these patients. It would also help prevent aggravation
of fears among individuals at risk. However, despite the success of treatment methods performed by specially trained dentists, it
seems reasonable that there should be limits to what can be expected of a dentist in terms of psychological, diagnostic, and
therapeutic competence. Dental phobia may constitute a complex psychological and odontological problem with far-reaching
consequences for a relatively large proportion of fearful individuals. It therefore seems likely that optimal care of such patients
can best be achieved by cross-disciplinary efforts involving both dentists and psychologists.
Dr. Berggren is Professor of Behavioral Dentistry, Department of Oral Medicine, Institution of Odontology, Göteborg University.
Direct correspondence and requests for reprints reprints to him at the Department of Oral Medicine, Institution of Odontology,
Göteborg University, Box 450, SE-405 30 Göteborg, Sweden; +46-31-7733125 phone; +46-31-7733347 fax;
ulf.berggren@odontologi.gu.se.
Key words: literature review, dental anxiety, dentist-patient relations, adult, treatment outcome, long-term, behavior therapy,
cognitive therapy, pharmacological therapy

D
ental fear, in keeping with other specific pho-
bias, involves intense fear of a specific ob-
ject or situation. However, dental fear is in
many respects atypical. In contrast to many other
phobias, sufferers subject themselves to regular and
repeated exposure to threatening stimuli, or may be
expected to do so. In addition, compared to most other
specific phobias, avoiding the feared situation in
many cases leads to significant negative conse-
quences. For the truly phobic individual, it is com-
mon for a vicious cycle to develop in which fear leads
to avoidance of dentists, resulting in neglected den-
tal care, increased awareness of these unmet needs,
and feelings of shame. These factors give rise to nega-
tive social effects and hence to increased anxiety.1
Another important factor is that the dentist and aux-
iliaries are also affected by patients’ anxiety: the per-
formance of dental care may be hampered, giving
rise to occupational stress. When considering the im-
portance of treating dental fear, all of these aspects
should be taken into account.
However, it should be emphasized that a re-
view of the research literature does not provide a
complete picture. Although up to 40 percent of the
adult population admit to being fearful of dental treat-
ment, only 3 percent to 5 percent can be said to be
truly phobic or to have a debilitating high level of
fear.2-7 A limitation that should be borne in mind in
light of this is that almost all clinical studies have
been performed with selected samples of individu-
als seeking special care because of dental fear and
avoidance. Our knowledge about the larger group of
fearful individuals with regular dental care is lim-
ited. Thus, it is assumed (but not established) that
there is a difference in degree and quality, but still a
significant similarity between problems experienced
by fearful individuals with regular and irregular den-
tal care.
Scope of the Problem
From a patient’s point of view, the obvious ef-
fect of high dental fear is the inability to undergo
ordinary dental treatment. However, as mentioned
above, fairly large proportions of fearful individuals
seek dental treatment on a regular basis, but with an
increased incidence of canceled appointments.3,7 At
the dentist’s office, fearful patients report experiences
of pain7-9 and ineffective local anesthesia.10 Com-
monly, fear of specific treatments (drilling, extrac-
tions, and root-canal treatments) or instruments (sy-
ringe, explorer), and a feeling of lack of control or

December 2001 ■ Journal of Dental Education 1357

 distrust and fear of belittlement vis-à-vis dental per-
sonnel11,12 are reported.
The effect of dental fear on oral health has been
reported in several studies.13-15 These effects are
marked in phobic groups,13,16 but have also been es-
tablished in Vassend’s large-scale epidemiological
study in Norway.7 Hakeberg13 compared dental pho-
bic individuals with a matched control group of or-
dinary dental patients and found that the number of
missing teeth was four compared with one; decayed
tooth surfaces, twenty compared with eight; filled
surfaces, eight compared with thirteen; and
periradicular lesions, four compared with one. In
addition, proximal bone loss was significantly greater
among phobic individuals.
In 1996, Kent17 drew attention to individual
cognition as well as social consequences in fearful
patients compared with a group of emergency pa-
tients. Previously, Berggren16,18 reported that phobic
patients listed an array of negative side effects in
everyday life situations, including increased use of
medication and increased sick-leave periods at work.
Almost 50 percent of these phobic patients reported
having problems with family relationships, meeting
friends, eating out, and going on vacation.
From the dental profession’s perspective, pa-
tients’ dental anxiety has a negative effect on the per-
formance of dental care and gives rise to occupa-
tional stress. In a study among Swedish dentists3 the
most commonly mentioned stress-provoking patient
behaviors were “non-compliance with oral hygiene
instructions,” “missed and canceled appointments,”
and “patients showing fear.” Although “patients
showing fear” was ranked considerably lower (six-
teenth) with regard to the level of stress it produces,
the highest stress levels were reported in conjunc-
tion with patient behaviors that all may be related to
extreme fear reactions (“not appreciating your work,”
“interrupting treatment,” and, again, “missed or can-
celed appointments”). Thus, it seems that these den-
tists distinguished between dental fears, which are
common among patients complying with regular
dentistry, and noncomplying fearful patients who
have dental care on a non-regular basis or not at all.
What Determines the Choice
of Therapy
Patients come to their dentist to have dental
treatment and should obviously be provided with
1358
sound dental care. Dental status, time, cost, and pa-
tients’ preferences all are taken into account when a
specific therapy is planned. An evaluation of the
patient’s personality and psychological resources is
included, albeit seldom in a structured way. How-
ever, this process is by no means “objective,” but is
influenced by the dentist’s skills, interests, and pref-
erences, and his or her awareness and knowledge
about each of the above-mentioned factors.
In addition, regulations may govern the choice
of particular treatment methods. For example, I.V.
sedation and general anesthesia are not available for
use by dentists in their clinics, but in Scandinavia
and some other parts of Europe they must be admin-
istered by an anesthesiologist in a hospital setting.
Nitrous oxide sedation can be used in Sweden and
Norway only by dentists who have completed post-
graduate education. In the Netherlands, it is consid-
ered unethical to use general anesthesia and deep
sedation without first trying to treat patients with
behavioral methods.19 There may also be restrictions
on psychological treatment modalities. Formal hyp-
nosis, for example, cannot be used by dentists in
Norway.
Thus, within the limits of regulations and ethi-
cal rules, a dentist should try to find strategies to
explore each case and make decisions together with
the patient in the patient’s best interest. For a fearful
patient, after history taking and evaluation of infor-
mation, one important question to put to oneself and
the patient is “What is the primary problem?” The
patient often has his or her focus on treating cavities,
but frequently the primary problem is fear. These
matters should be discussed and clarified before
embarking on treatment. Regardless of the therapy
chosen, an agreement with the patient about the pri-
mary objective of treatment makes it easier to keep
the focus on just that. This is important since pa-
tients tend to be eager to have quick dental results,
which often may be counterproductive in terms of
emotional and behavioral change.
My experience is that it is most helpful to lis-
ten carefully to the patient and to take as one’s start-
ing point his or her own assessment of the situation.
The goal is always to strengthen the patient’s feel-
ings of self-efficacy. In my dental phobia clinic, the
goal is to enable the patient to leave the special fear-
clinic as soon as possible and to receive regular, con-
ventional dental care with a general practitioner. We
look upon our treatment and staff as tools for the
patient to use to enhance and build up his or her own
competence. Coping strategies should be internal-
Journal of Dental Education ■ Volume 65, No. 12
ized so that the patient should need neither premedi-
cation nor a specially trained “therapeutic” dentist
in the future. Among our long-term avoiders, we too
often meet patients who have already received such
care and who have had various dental needs met with-
out tackling the dental fear. From time to time they
relapse into fear and avoidance, and some of them
eventually come to our clinic.
Even though our basic approach relies on cog-
nitive-behavioral techniques, we sometimes combine
them with pharmacological treatments. However, we
always try to end our therapy with conventional den-
tal treatments without any adjuvant methods before
referring patients to general practitioners. As I pre-
viously mentioned, we see neither method as a sepa-
rate treatment technique, but rather as an aid to pro-
mote a psychological outcome. In fact, it is hard for
me to believe that any medicine given to reduce anxi-
ety acts on its own. My view is rather that medica-
tion sometimes is necessary to make it possible for a
patient to gain new and positive experiences. If medi-
cation leads to a lasting coping ability and anxiety
reduction, it is a beneficial approach. If the patient
continues to need medication, we have not been suc-
cessful.
However, we have found it useful to combine
cognitive-behavioral therapies with pharmacological
treatments in four situations:
a) When the patient has an immediate need for den-
tal treatment because of acute dental pain. Pain-
ful conditions make it close to impossible to
motivate the patient to work with his or her fear.
In these cases we initially choose nitrous oxide
sedation or oral or I.V. sedation with diazepam
or midazolam, although we sometimes use gen-
eral anesthesia.
b) When the patient has an accumulated massive
need for treatment with several risks for acute
dental pain. This is a situation that, for both prac-
tical and humane reasons, is often best solved
by general anesthesia. Often these patients are
so preoccupied by their need for dental treatment
that they cannot deal with their underlying fear
reactions.
c) When the patient was referred to our clinic spe-
cifically for general anesthesia treatment and
categorically demands it. It may be impossible
to change the patient’s opinion about this, but it
is often possible to motivate the patient for fear
treatment afterwards.
d) When it may be strategic for highly motivated
patients to start exposure therapy aided by mild
sedation.
December 2001 ■ Journal of Dental Education
Evidence-Based Treatment
Methods
Many research studies have shown the posi-
tive effects of a variety of psychological treatment
approaches for dental fear. However, only a limited
number of reports have included evaluations of
followups. An even smaller number have included
followup studies of general dentistry outside the spe-
cialized university or fear clinic. From a clinical point
of view, however, the results of studies with a “real-
life” followup are of special interest. Although most
studies are performed by psychologists and dentists
together, special attention should be drawn to some
recent studies that evaluated behavioral treatments
performed by dentists alone.19,20
I have mentioned that fear treatment usually
involves a combination of several different tech-
niques. However, for this paper I have chosen to dis-
cuss eclectic approaches, behaviorally oriented ap-
proaches, and cognitively oriented approaches
separately. I have also treated clinical comparative
and long-term (at least one year) followup studies
separately.
Eclectic Approaches
A fundamental prerequisite for most reported
treatments for dental fear is a good patient-dentist
relationship. Although this fact is clinically well es-
tablished, it is seldom specified as a clinical compo-
nent and is rarely considered in the analysis of treat-
ment success or failure. Interpersonal processes are
far from well explored in dentistry and are mainly
seen as cognitive processes. Other aspects were elabo-
rated on in a recent doctoral thesis by Willumsen in
Oslo, Norway,20 in which it was emphasized that be-
havioral aspects of dentists’ communication with
patients are just as important as cognitive ones. An-
other doctoral thesis, which used qualitative in-depth
interviews with dentists experienced in working with
phobic dental patients, pictured the core category of
these dentists’ view of successful interaction as “re-
latedness, based on affective resonance and concor-
dant roles.” An ability to adjust to the patient’s needs
by shifting between a professional and a personal
role vis-à-vis the patient was seen as particularly im-
portant.21
Friedman and colleagues22,23 described what
they labeled an “iatrosedative technique” as a sys-
1359
 tematic approach aimed at “making the patient calm
by the dentist’s behavior, attitude, and communica-
tive stance.” During both interview and treatment,
the dentist communicates his or her attentiveness,
concern, acceptance, supportiveness, and involve-
ment to the patient. These factors are conveyed to
the patients by responding both verbally and
nonverbally to patients’ openly expressed (and tacit)
worries and needs. Friedman et al.23 reported that
fearful patients, who received an iatrosedative inter-
view, experienced a significantly greater reduction
in dental anxiety than individuals who had a stan-
dard interview. However, after two clinical encoun-
ters using iatrosedative procedures, the dental anxi-
ety in both groups was equally reduced.
The strategies that dentists use to achieve these
effects include a) efforts to avoid pain, b) giving the
patient full control, and c) keeping the patient in-
formed of what the dentist is doing and what sensa-
tions the patient may experience. These separate com-
ponents have all been shown to be beneficial in
separate studies. Wardle24 tested them among aver-
age patients at a general practice in London and re-
ported that “sensation information” leads to signifi-
cantly less anxiety than “normal treatment.” The
patients’ pain ratings followed that of the anxiety rat-
ings, but in this case both “sensation information”
and “increased control” resulted in significantly lower
ratings than “normal treatment.” Despite being per-
formed with average and non-anxious patients, this
study lends support to the benefits of these proce-
dures in the clinical setting. There are reasons to be-
lieve that the effects might have been larger if more
anxious subjects had been included.
Behaviorally Oriented Approaches
Behavior modification tries to modify symp-
toms in patients’ behavior that interfere with their
adaptive functioning.25 Behavior modification is
based on principles of learning, both in terms of clas-
sical conditioning26,27 or operant conditioning28 and
of social learning.29 It should be emphasized that
cognitive processes have a significant influence on
behavior.29-31 In clinical practice, the treatment of
dental fear often includes concurrent components to
modify both behavior and cognitions.32 Melamed33
pointed out that in studies of a behavior modifica-
tion such as systematic desensitization, what was
described was seldom pure systematic desensitiza-
tion, but rather a variety or mixture of different tech-
1360
niques. However, for the reader’s convenience, this
and the following sections will distinguish between
these aspects. Hence, treatments based on gradual
exposure and systematic desensitization will be de-
scribed briefly first.
Systematic desensitization (SD) first came to
widespread attention when Wolpe26 presented his
theory of reciprocal inhibition. SD uses relaxation
(in Wolpe’s case, deep muscle relaxation) to coun-
teract and weaken the connection between the anxi-
ety-provoking stimulus and its response (arousal, ten-
sion, and fear) during gradual exposure. Thus, SD
involves: a) constructing an individual anxiety “scale”
for the patient to use to report anxiety at each stage
of treatment, which encourages better communica-
tion between patient and therapist and makes it pos-
sible to register changes in tension and anxiety; b)
constructing a hierarchy of situations progressively
more threatening and anxiety-provoking; c) training
the patient in a relaxation technique as an antagonist
to anxiety and tension; and d) gradually exposing
the patient during relaxation to the hierarchy start-
ing with the least threatening situations and progress-
ing to successively more taxing situations. These four
steps constitute a basic model of SD. However, they
have sometimes been modified in the dental setting.
For example, sometimes the hierarchy has been vi-
sualized,34,35 and sometimes video presentations32,36
or “clinical rehearsals”11,36,37 have been used. The lat-
ter technique, in-vivo desensitization, is based on the
same principles of working through a hierarchy of
situations and maximizing patient control, but may
or may not be combined with relaxation or sedatives.38
Relaxation can be achieved in a number of ways;
this has also been established in reports of dental
anxiety treatments.20,39-42 Moreover, biofeedback pro-
cedures have sometimes been used to facilitate the
change of physiological autonomic responses.32,43
These studies have demonstrated a substantial
reduction in self-reported dental anxiety, and there
also have been indications that treatment has a posi-
tive influence on general states of fear, anxiety, and
mood.32,36,43,44 The rate of successful outcomes (pa-
tients continuing dental care) has been reported at
more than 90 percent in a clinical sample of dental
phobic patients,45, 46 but generally there is a reported
success rate of from 70 percent to 80 percent. Thus,
across many studies approximately every fourth to
fifth patient does not benefit from the treatment or
cannot follow through with treatment. A poorer out-
come of behavioral therapies has been shown to be
Journal of Dental Education ■ Volume 65, No. 12
unrelated to the level of specific dental fear,47 but
predicted by general psychological distress or psy-
chopathology47,48 and by low levels of motivation.49
The strength of studies in this area is that they have
repeatedly shown positive side effects, and that long-
term followups of performed treatments have been
documented (see below).
A number of studies have been performed to
compare the benefits of different behavioral treat-
ment methods. Some early studies evaluated the im-
portance of using relaxation in conjunction with ex-
posure. Thus, Corah et al.39 showed that for ordinary
patients relaxation resulted in a significantly greater
reduction of anxiety than distraction or a control con-
tingency. McAmmond et al.40 reported that deep pro-
gressive muscle relaxation and hypnotic relaxation
had an equally large physiological effect. It has also
been shown that patients who were treated with sym-
bolic modeling combined with deep muscle relax-
ation reduced their avoidance behavior.42
Although it has been argued that hypnosis can
be viewed as more of a cognitive approach than a
behavioral one, most reports tend to present it as a
behavioral modality. The similarities with behavioral
techniques lie in the use of exposure to visualized or
in-vivo hierarchies under hypnosis or suggestive re-
laxation. The clinical benefits of hypnotherapies for
dental fear have been documented repeatedly, but
very few controlled studies have been performed.50
Hammarstrand et al.35 conducted a study of twenty-
two women with long-standing avoidance behaviors
(average 9.5 years). This study compared hypno-
therapy (suggestions of progressive relaxation while
imagining dental scenes and procedures in hierar-
chical order) with SD in combination with EMG bio-
feedback. After therapy, significantly more patients
who received SD treatment were able to carry out
conventional dental treatment, compared with pa-
tients who received hypnotherapy (73 percent as com-
pared with 45 percent). Subjective dental fear and
mood improvements were seen in both groups, but
these changes reached significant levels only among
SD patients.35 Similar results were reported in a study
by Moore et al.,51 who compared the effects of hyp-
notherapy, including training in self-hypnosis, with
SD administered in groups or individually. No sig-
nificant differences were detected between the groups
with regard to outcome in the number of patients
completing therapy or reduction in dental anxiety.
However, significantly fewer patients continued den-
tistry with a private dentist after therapy at the spe-
December 2001 ■ Journal of Dental Education
cialist clinic among the hypnotherapy and SD group
therapy patients compared with individually treated
SD patients (48 percent and 50 percent as compared
with 80 percent). Therapist dependence was indicated
by 60 percent of the hypnotherapy dropout individu-
als, who said they were not able to practice self-hyp-
nosis with another dentist, but needed the induction
of hypnotic trance by the dentist-hypnotist partici-
pating in the treatment experiment.51
The results of the comparison between group
therapy and individual SD treatment was reported
by Moore et al.52 in an attempt to find more a cost-
effective approach. The results were disappointing
for phobic avoiders, but it was argued that group treat-
ment may be useful in selected cases and that a com-
bination of group and individual therapy may pro-
vide patients with the advantages of both modalities.
In 1990, Ning and Liddell53 used group therapy based
on relaxation training and cognitive restructuring in
conjunction with imaginal exposure to produce ha-
bituation to the dental situation among high-fear in-
dividuals. A third of the subjects dropped out during
group therapy, but the remaining group reported a
significant drop in dental anxiety and made appoint-
ments with a dentist. Later, Liddell et al.54 carried
out a followup of fearful dental subjects who had
been successfully treated with the same group therapy
program. The followup period varied between one
and four years after group therapy for dental fear. It
was found that 70 percent of these individuals were
paying regular visits to a dentist.
In a clinical study, Moore46 compared desensi-
tization by clinical rehearsal with video training for
phobic avoiders. He showed that both methods were
able to bring down subjective dental anxiety to the
level of ordinary dental patients and to produce a
significant improvement in dental beliefs. This was
accomplished more efficiently using clinical rehears-
als as indicated by a higher proportion of successful
cases (91 percent vs. 78 percent), and a significantly
shorter time spent on preparing the patient for con-
ventional dental treatments. The methods were
equally successful in creating positive side effects in
terms of reducing general fears and anxiety and hav-
ing a beneficial effect on mood.
Cognitively Oriented Approaches
As mentioned previously, the influence of cog-
nitions on human behavior has been emphasized by
a number of researchers.29-31,55 Attention or aware-
1361
 ness, mediation (cognitive coding), individual re-
sponse repertoires, and motivational or incentive
components are important processes that influence
behavior.29,31 Ellis30 claimed that a person’s thoughts
and emotions are not separate processes, but rather
overlap each other. Thus, fearful dental patients most
often have inappropriate expectations and beliefs
about dental treatment and their ability to cope with
the situation. According to Ellis, the modification of
such negative cognitions is a means of reducing anxi-
ety. Thus, the goals for cognitive treatment strategies
and cognitive aspects of behavioral therapies are two-
fold: they aim to alter and restructure the content of
negative cognitions, and they aim to enhance control
over these thoughts.
Patients make interpretations of their emotional
(and bodily) states based on the perception of “cues”
in a situation. According to pre-existing schemata55
arising from direct and indirect experience in simi-
lar situations, a subject appraises how dangerous a
situation is and how able he or she is to cope with it.
Cognitive restructuring aims at altering the content
of the patient’s internal dialogue by changing under-
lying beliefs. Providing information that helps pa-
tients to restructure their image of the dental situa-
tion and to reattribute the use of particular
instruments and the experience of pain or unpleas-
antness can bring about such restructuring. Prefer-
ably, such explanatory information should be given
beforehand and as a running commentary on the pro-
cedures and the possible associated sensations.24
There are probably two beneficial effects from this
procedure, the first relating to the content of the in-
formation (reattribution) and the second giving the
patient control. When this is done repeatedly in the
treatment situation and is combined with components
such as relaxation or distraction, it resembles the
“cafeteria-style” approach used in Stress Inoculation
Training (SIT), which has on occasion been used with
phobic dental patients.56
The SIT has several similarities with a treat-
ment approach reported on by Berggren and
Carlsson.32 They made a post hoc analysis of this
broadbased therapy for phobic dental patients with
long-standing avoidance behavior. The method com-
bines a partly automated video desensitization pro-
cedure with EMG biofeedback and cognitive
reattribution. After therapy with a psychologist (six
or seven one-hour sessions), the patients had two
dental “test-treatments” to allow them to use their
new competence in a real-life situation. In this par-
1362
ticular qualitative study, this treatment package was
successful in twenty-one out of twenty-four cases.
Patients were able to complete regular dental care
and often extensive oral rehabilitation followed by a
one-year recall with general dentists.
Observations during the treatment seemed not
to favor any simple hypothesis of how therapy
worked. Cognitive, emotional, and physiological el-
ements seemed to be important to a different degree
for different subjects. While some patients obviously
seemed able to benefit from relaxation training, oth-
ers changed their attitude to dental treatment with-
out a concomitant change in physiological response.
This was achieved by watching the dental video
scenes and discussing them with the psychologist.
However, such patients said that the most important
factors in this cognitive process were the two “in vivo”
dental treatments. The concepts of appraisal and cop-
ing, according to Lazarus,57 may be of additional help
in understanding the change from avoidance, inca-
pability, and hopelessness to the patients’ report of
feelings of increased competence and coping skills.
It was not possible to judge the relative importance
of these factors, and the authors suggest that future
research should aim at finding predictors of the use-
fulness of different treatment strategies for different
patients.
An attempt to evaluate the influences of cogni-
tive therapy on a behaviorally oriented therapy was
made by Harrison et al.58 They found, contrary to
their clinical experience, that separating the cogni-
tive components from behavioral components so that
their individual significance could be identified led
to a more or less negative influence from the cogni-
tive therapy components. Because of this contradic-
tion, a new study was conducted of 112 dental pho-
bic patients.49 Two treatment modalities were tested,
both using the same video-based hierarchy of dental
scenes. One involved a behavioral (physiologic stress-
related) approach aiming to improve relaxation, and
the other a cognitive aiming at the modification of
maladaptive thinking. It was shown that both treat-
ment modalities were effective in reducing dental
anxiety, but the number of successful cases was
greater in the cognitive treatment group. However,
relaxation-oriented therapy generally resulted in a
more significant reduction in dental fear as well as
in general anxiety. It was also found that motivation
for treatment was the one factor that predicted suc-
cessful treatment outcome.
Journal of Dental Education ■ Volume 65, No. 12
 Based on the work by Beck,55 de Jongh and
colleagues created a short-term one-session cogni-
tive treatment of dental phobia.59 It was used to pre-
pare fearful dental patients one week before a dental
examination by trying to restructure their negative
cognitions. The therapy was introduced by explain-
ing how negative or catastrophic thoughts interact
with anxiety. Examples were given of how different
ways of interpreting a situation give rise to completely
different reactions. The cognitive intervention fo-
cused on the modification of negative cognitions.
Evidence for the negative cognitions was challenged,
and alternative ways of looking at the situation were
discussed. When cognitions seemed to be based on
false assumptions, the patient was provided with cor-
rective information. In addition, the patients were
given an audiotape of their cognitive therapy session,
which could be listened to at home during the fol-
lowing week. It was shown that, compared with ses-
sions when dental treatment information only was
provided, the frequency of negative cognitions and
the believability of these cognitions dropped mark-
edly. A one-month follow-up revealed continued
improvement in the cognitive therapy group, espe-
cially with regard to believability of cognitions. These
changes were paralleled by a decrease in dental anxi-
ety in both groups, which was also shown to con-
tinue over a one-year followup period.59
Clinical Comparative and Long-
Term Followup Studies
As previously mentioned, several studies have
compared therapies or separate treatment elements.
However, a number of limitations are apparent in
many studies in that they have often been conducted
under experimental “laboratory” conditions, used
selected special-clinic samples, or lack a long-term
followup. Virtually no study fulfills all these require-
ments, but some studies that included a comparison
and followup of clinical treatments should be reported
on.
In Sweden, Berggren45,60,61 during a three-year
period compared the effects of a “psychophysiologi-
cal” dental fear treatment with treatment under gen-
eral anesthesia. These therapies were conducted to
prepare phobic patients for in-vivo exposure, which
constituted a second phase of treatment and tested
the patients’ ability to go through with ordinary den-
tal treatment. Patients were randomly assigned to the
two treatment modalities. The behavioral therapy
December 2001 ■ Journal of Dental Education
(BT) was performed by a psychologist and consisted
of video-based desensitization in combination with
relaxation and an EMG biofeedback training, but
included no dental treatment. Dental treatment un-
der general anesthesia (GA) was performed during
one session and included the performance of all nec-
essary extractions, root treatments, and major fill-
ings, which dramatically reduced these patients’ need
for dental care. The following exposure treatment
phase included two standardized dental treatments
using local anesthesia.
In a first evaluation after pretreatment and the
two exposures, it was shown that the BT group was
significantly better in several respects.45 There were
more successful cases (92 percent vs. 69 percent),
fewer cancellations during exposure sessions (10
percent vs. 35 percent), and a lower level of dental
anxiety. The successfully treated patients then left
the fear clinic and were scheduled for treatment with
general practitioners. A followup was performed us-
ing a questionnaire, which the new dentists filled in
after the patients had completed dental treatments. It
was shown that although some patients dropped out,
significantly more BT patients remained in dental
care and were scheduled for recall (78 percent vs. 53
percent of the original samples). There were no dif-
ferences in dentist ratings of patient behavior between
the two groups.
These patients were further evaluated after two
years, when they were recalled for their second ex-
amination/treatment with their general dentist.60
Again, significantly more BT patients kept up regu-
lar dental care (82 percent vs. 57 percent of the origi-
nal sample; increased numbers resulted because some
patients, who broke off previously, took the initia-
tive to make new appointments). In addition, dental
anxiety measurements remained significantly better
in the BT group, although a non-significant increase
in scores had taken place in both groups. In an addi-
tional qualitative analysis,61 a major difference in
treatment capability during completion of dental care
two years earlier was traced. While BT patients had
received an average of seven fillings, two extractions,
two crowns or abutments, and one root canal filling
during ten appointments, the corresponding figures
for GA patients who also needed ten appointments
were three fillings and mostly removable prosthet-
ics. Thus, the BT patients had completed much more
fear-provoking treatment than the GA group. A sig-
nificant improvement in self-reported mood was re-
ported, while concomitant factors such as general
1363
 tension problems (headache, stomach problems), use
of tranquilizing medication, abuse of alcohol, and
time spent on sick leave were significantly reduced.
Both groups reported these significant general im-
provements, but BT patients reported significantly
larger improvements in tension problems.
Hakeberg and Berggren62 were able to validate
the reported positive change in sick leave in a
subsample from the two groups. They matched con-
trols by using official register data from the National
Health Insurance Board. Their study showed that the
number of sick-leave days was significantly reduced
after the period of dental fear treatment among treated
patients. The effect was confirmed by a significant
posttreatment difference between treated patients and
those who dropped out of the program. Compared to
the matched control group, a significant pretreatment
difference and a nonsignificant posttreatment differ-
ence were shown. It was concluded that, for patients
suffering from severe dental fear and phobic avoid-
ance as in this group, the benefits of a successful
phobia treatment have effects that reach far beyond
its specific goals.
Hakeberg also conducted two long-term
followup investigations of patients treated at our
clinic in small-group studies comparing behavioral
and pharmacological treatments. In the first study,
fourteen patients (out of twenty-four) who had re-
ceived either systematic desensitization (SD) or oral
premedication (P) with diazepam were followed up
after ten years.63 This study had had a major dropout
of patients from both groups, but after ten years all
SD patients had regular dental care compared to five
out of eight P-patients. Significant improvements in
psychometric measures of dental anxiety and mood
were reported after ten years in both groups. These
assessments were (nonsignificantly) in favor of the
SD group, especially with regard to the change in
mood.
Using a similar treatment study design,
Hakeberg64 was able to locate twenty-nine out of
thirty-two eligible patients and conducted a second
ten-year followup of previously treated patients. They
had been treated with SD (twelve patients) or P (eight
patients) therapy, and were compared with patients
treated under general anesthesia (G; nine patients).
Among these patients, eleven (92 percent) SD pa-
tients, five (63 percent) P patients, but only three
(33 percent) G patients attended regular dental care.
As can be expected, the dental anxiety scores of SD
and P patients, but not G patients, were significantly
1364
reduced at followup. This study also investigated oral
health variables and showed that SD and P patients
had lost an average of one tooth during ten years,
while G patients had lost seven teeth (presumably
most of them during the general anesthesia treat-
ment). While there was a significant difference in
the number of decayed tooth surfaces at the ten-year
followup between the combined groups of regular
and irregular attenders (two compared with five sur-
faces), none of these differences was evident for the
separate treatment groups. However, all groups had
far fewer decayed surfaces than ten years before (three
as opposed to eleven surfaces).
Only a few studies have attempted to investi-
gate the outcome of different treatment modalities
in a routine clinic. Kroeger and Smith65 reported the
three-year outcome of a “behavioral fear control pro-
gram” used in the general dentist’s office. This pro-
gram consisted of a two-session condensed behav-
ioral therapy that combined relaxation training, a
video modeling tape, desensitization during session
one with home practice, and a repetition at session
two. The second session used the same combination
of therapy components, but focused more specifi-
cally on the dental situations that happened to be a
particular obstacle for the patient by means of guided
imagery relaxation training performed by the dental
assistant. Although the fear status of the eighty-six
treated patients was unclear from this report, it
showed that among those who were followed up (54
percent), most patients were able to continue con-
ventional dental treatment. More than 90 percent said
that it was helpful in reducing their fear and in help-
ing them trust the dentist and the staff. However, 30
percent of the patients claimed that it was likely that
they would have continued dental treatment anyway.
The outcome of treatment for different patients
at our dental fear clinic at the University of Göteborg,
Sweden, has been followed up continuously. A ten-
year investigation between 1975 and 1985 was re-
ported in Swedish.66 The clinic accepts self-referred
patients (20 percent), but mainly treats patients who
have been referred either by dentists (30 percent) or
medical professionals (50 percent), mainly working
in psychiatry and social medicine. Thus, different
expressions of psychosocial strain were common in
addition to dental fear. Among this clientele of more
than 1,500 patients, it was reported that 17 percent
never showed up after a period on the waiting list, 16
percent broke off their therapy program, 55 percent
completed treatments, and 12 percent were able to
Journal of Dental Education ■ Volume 65, No. 12
leave the clinic after only a consultation. These indi-
viduals and those who completed therapy were taken
over by general dentists, who completed the plan for
full oral rehabilitation. The patients were investigated
according to treatment performed. A separate group
of 110 individuals categorically demanded to have
general anesthesia and nothing else. Only sixty-one
(55 percent) of these returned for a checkup after
general anesthesia and were possible to refer to gen-
eral dentist, and thirty-six (33 percent) completed
the treatments needed after general anesthesia.
Another subsample consisted of 685 individu-
als living in the city of Göteborg who did not have
any dentist of their own. These patients had been
treated according to three different models, namely
a) exposure therapy with a dentist by clinical rehears-
als in combination with enhanced control and simple
relaxation instructions, b) video-based systematic
desensitization in combination with relaxation train-
ing and biofeedback performed by a psychologist
according to Berggren and Carlsson,32 and c) initial
general anesthesia dentistry to reduce the amount of
dental treatment needed in general dentistry. The lat-
ter group of patients also received clinical rehearsals
with a dentist, including dental treatment adapted to
the patients’ needs. The average number of therapy
sessions was seven rehearsals with the dentist, seven
sessions of desensitization plus two dental treatments
to confirm the new ability, and three condensed re-
hearsals, including adapted dental treatments after
general anesthesia. It was shown that the success rate
(completed general dentistry) was more than 70 per-
cent for exposure therapy and general anesthesia plus
rehearsals, while 83 percent of the treatments with
the psychologist were successful. These differences
were not statistically significant, and it should be
remembered that this was not a randomized study.
Treatments were selected according to patients’ pref-
erences and the dentists’ evaluation of clinical use-
fulness.
A similar line of research was followed recently
in a Dutch doctoral thesis by Aartman19 that reported
the followup of patients treated in a Dutch dental
fear clinic. Dentists who were familiar with the use
of behavioral treatment modalities performed all
treatments. It was reported that patients were not ran-
domly assigned to the treatment modes, but after as-
sessment “allocated to the most appropriate form of
treatment.” When, in the evaluation, combinations
of behavioral and pharmacological treatments were
used, patients were grouped according to the treat-
December 2001 ■ Journal of Dental Education
ment modality that used the highest level of sedation
(intravenous sedation with propofol [IVS] vs. nitrous
oxide sedation [NOS] vs. behavioral management
[BM]). It was indicated that some patients saw a psy-
chologist for additional counseling, but no specifi-
cation was made as to which group(s) these patients
belonged.
In one study, the immediate outcome of dental
fear treatment for 144 patients was explored.67 The
average avoidance time was about seven years, and
women predominated. The mean age was thirty-four
years, and it was shown that patients treated with
IVS were younger than NOS and BM patients. The
treatment groups did not differ with regard to pre-
treatment psychological assessments. With regard to
oral status, the only significant difference detected
was a lower number of decayed tooth surfaces among
BM patients as compared with IVS patients (three
as opposed to nearly five surfaces). Significantly
fewer but longer restorative dental sessions were
shown among IVS patients. The number of filled
teeth was significantly higher among IVS as com-
pared with BM and NOS patients (seven vs. four and
five), while the number of extracted and endodonti-
cally treated teeth did not differ.
In a second study, Aartman and colleagues68
had extended the group and were able to conduct a
further followup with 192 patients. Assessments were
made once before and twice after treatment, the lat-
ter being made at least two years after treatment. A
discrete but statistically significant reduction in den-
tal fear was reported. This reduction was mainly de-
tected among the BM group. However, even in this
more successful group only 40 percent and 52 per-
cent, at the first and second follow-up, respectively,
reduced their dental anxiety to a level under what
has been proposed as a cut-off score for dental anxi-
ety. The corresponding frequencies for NOS (28 per-
cent and 39 percent) and IVS patients (15 percent
and 12 percent) indicated a nonsignificant effect for
these groups. However, 62 percent (>70 percent
among BM and >50 percent among NOS and IVS
patients) of all patients had visited a dentist outside
the fear clinic, but no statistically significant differ-
ences were found with regard to treatment group.
Aartman concludes in her thesis that behavioral treat-
ments are beneficial and can successfully be per-
formed by dentists in a regular clinic. She suggests
that such training should be offered to dentists and
included in the curricula of dental schools.
1365
 Further support for this notion was provided
by a recent doctoral thesis from the University of
Oslo, Norway.20 Although in most of the reviewed
clinical studies, behavioral therapies were performed
by clinical psychologists, Willumsen, in a compre-
hensive and well-controlled study, evaluated a be-
havioral and a cognitive therapy performed by a spe-
cially trained dentist. The dentist had received short
(two weeks) training in cognitive therapy followed
by supervised treatment of five pilot cases. This
therapy was based on the principles from Beck et
al.55 and Clark69 and had similarities with the one
reported by de Jongh.59 However, the method adopted
by Willumsen specifically emphasized a “Socratic
dialogue and behavioral experiments” and homework
assignments. This treatment modality was compared
with treatment under nitrous oxide sedation or ap-
plied relaxation70 performed by the same dentist.
Although all treatments were effective, posttreatment
assessments showed that the two psychologically
oriented therapies were superior to nitrous oxide se-
dation in mastering dental situations, in reduction of
self-assessed dental anxiety, and in patients’ evalua-
tion of the benefits of treatment. No differences be-
tween cognitive and relaxation therapies were noted
except for a significantly longer time used to pre-
pare patients for treatment in the cognitive therapy
group.
This study also included a one-year followup
of patients after referral to private dentists.
Willumsen20 followed up fifty-eight out of the sixty-
four patients treated in her study. The patients had
then been taken care of by general dentists after fear
therapies with Willumsen, and were investigated by
means of questionnaires filled in by the patient and
his or her private dentist. More than 90 percent of
the patients who received cognitive or relaxation treat-
ments were still attending, while 80 percent of the
nitrous oxide patients attended. However, 45 percent
of the N2O-group continued to use sedation in gen-
eral dentistry, compared to less than 10 percent of
the patients treated with behavioral methods. All
groups were without significant differences able to
master the treatment situation and carry out conven-
tional dental treatments. The cognitively and relax-
ation oriented therapies were significantly more ef-
ficient in reducing dental anxiety, and, as also found
by Berggren et al.,49 this was consistently more pro-
nounced among relaxation group patients.20
1366
Conclusion
There are a number of behavioral and cogni-
tive treatment methods that can be used by dentists
for the alleviation of fear and anxiety in the dental
office. At an “intuitive” level, many dentists prob-
ably use them very frequently as a comprehensive
part of the everyday praxis. Considering the high
number of fearful individuals visiting dentists regu-
larly, a better knowledge about such methods would
improve the dental care for the majority of these pa-
tients. It would also help prevent aggravation of fears
among individuals at risk. Thus, there are needs and
benefits that speak for an improved education in be-
havioral dentistry. However, despite the success of
treatment methods performed by specially trained
dentists reported on by Aartman19 and Willumsen,20
it seems reasonable that there should be limits to what
can be expected of a dentist in terms of psychologi-
cal diagnostic and therapeutic competence. Dental
phobia may constitute a complex psychological and
odontological problem with far-reaching conse-
quences for a relatively large proportion of fearful
individuals. It therefore seems likely that optimal care
of such patients can best be achieved by cross-disci-
plinary efforts involving both dentists and psycholo-
gists.
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