Dental anxiety: what solutions are available for anxious patients?

Fear of the dentist, or dental anxiety, is one of the most common forms of specific anxiety. According to studies, 27 per cent of Romanians have a severe fear of dental treatment, whilst an even higher percentage experience a moderate level of anxiety. Two in ten suffer from such severe anxiety that they specifically request conscious sedation in order to undergo the necessary treatment.

Bianca Radu, a psychologist at the DENT ESTET and DENT ESTET 4 KIDS clinics, explains to us, in this article, what causes dental anxiety, what happens in the brain and nervous system when we visit the dentist, and what solutions are available at DENT ESTET clinics for anxious patients. 

Our bodies are designed to protect us, and our nervous system is constantly, unconsciously, assessing whether our surroundings are safe or might pose a threat. When it perceives a potential danger, it automatically activates the body’s defence mechanisms.

In the dentist’s surgery, there are numerous stimuli that the brain may interpret as signs of threat:  

• an invasion of personal space;
• the sound of the drill;
• specific odours;
• bright light;
• being reclined in the chair;
• the feeling of having little control over the situation;
• memories of unpleasant past experiences.  

“From this perspective, fear of the dentist is not a choice, but a biological protective reaction. Neuroscientist Stephen Porges developed the polyvagal theory, a model that seeks to provide a useful framework for understanding how the nervous system responds to perceptions of safety or danger. According to this model, our nervous system is constantly seeking an answer to a simple question: ‘Am I safe?’. If the answer is ‘yes’, we can communicate, cooperate, learn and tolerate discomfort more easily. If the answer is “no”, the body activates automatic defence mechanisms: fight, flight or – in situations perceived as overwhelming – freeze and withdrawal.” – Bianca Radu

Fear of the dentist can manifest itself differently from one patient to another. Some people become anxious at the mere thought of going to the dentist’s surgery and put off or avoid appointments altogether.

Once we are actually in the surgery, the brain may interpret certain stimuli as dangerous, and the body automatically triggers a stress response. The heart rate increases, breathing becomes shallow, muscles tense up, and attention focuses on potential threats. These reactions occur before the person is able to analyse the situation rationally.

Another form of manifestation can be a ‘freeze’. The patient ‘freezes’ and is no longer able to communicate how they feel or what is troubling them.

“In the case of children, freezing can sometimes be mistaken for acceptance of treatment. A child may appear cooperative at the first session, although, in reality, they are overwhelmed by fear. At the next visit, when they already know what is coming, they may refuse treatment or become uncooperative. These reactions do not indicate a lack of courage, but represent the way in which the nervous system tries to protect the person from a perceived danger.” – Bianca Radu

When a patient is anxious, they are most likely to adopt one of two behaviours:  

• They avoid booking an appointment;
• They will cancel the appointment or fail to attend.

The result is a vicious circle: the longer the visit to the dentist is postponed, the more severe the oral problems can become, and the prospect of complex treatment can heighten anxiety.  

What problems can worsen or become acute if we put off a visit to the dentist:

• early-stage tooth decay can spread and cause acute pain or infection (dental abscess);
• gum problems can worsen without treatment, gradually affecting the tissues that support the teeth (periodontal disease);
• orthodontic problems, such as crowded teeth or an incorrect bite, can become more pronounced and affect chewing, oral hygiene and the correct distribution of pressure on the teeth;
• missing teeth that are not replaced lead, over time, to gum recession and the need for more complex procedures, such as bone grafts or All-on-4 dental implant treatments, to replace teeth across an entire dental arch;

“Paradoxically, regular check-ups are less stressful than seeing a dentist only when an emergency arises. Identifying dental problems at an early stage usually allows for simpler and more tolerable treatments.” – Bianca Radu 

Fear of the dentist can be reduced through an approach tailored to each patient’s level of anxiety, experiences and needs. An initial assessment, open communication, pain management and a step-by-step treatment plan can all help to create a more predictable and more tolerable experience.

The initial consultation

For anxious patients, the first visit can be devoted to discussion, assessment and familiarisation with the dental environment, without the pressure of starting treatment immediately.  

For adults – the modern dental surgery, a safe space

For anxious adults, the familiarisation consultation provides the necessary time to discuss fears and previous experiences. When the team creates a predictable, empathetic and collaborative environment, and the patient feels seen, listened to and involved in decision-making, treatment becomes easier to tolerate.  

Positive experiences can gradually change the association between a visit to the dentist and danger, helping to reduce anxiety.

For children – getting to know the dentist before dental problems arise

In the case of children, it is recommended that they become familiar with the paediatric dentist as soon as their first teeth appear, before any pain sets in.  

Usually, the first visit is an introductory one, aimed at:

• getting to know the dentist
• exploring the surgery  
• getting used to the specific instruments and sounds.

The dentist will explain, in terms the child can understand, what is going to happen, show them the instruments and allow them to take their time to adjust. 

Step-by-step communication with the dentist

Research in psychology and medicine consistently shows that the relationship between the patient and the healthcare professional influences anxiety levels and even the perception of pain.

Stress levels decrease when the patient feels that:

• they are being listened to;
• they receive clear explanations;
• they have some control over the procedure.

In other words, a sense of security does not come solely from modern technology or the absence of pain; the quality of the human relationship carries great weight, all the more so when dealing with anxious patients.

Sometimes, a few seemingly small gestures can make an enormous difference:  

“For the nervous system, all these are signs that the person is not alone and that the situation is under control, thereby increasing the patient’s trust in the medical team. This enhances the level of doctor–patient cooperation, and everyone is left with a positive experience following the interaction, even if the treatment itself may sometimes be less than pleasant. It is the experience that leaves a lasting impression on the mind and body.” – Bianca Radu

Local anaesthesia

Local anaesthesia is used in numerous dental treatments to temporarily numb the area being treated and to prevent pain during the procedure. The patient remains conscious and can communicate with the medical team at all times.

Before treatment begins, the dentist will explain to the patient that, although the area is anaesthetised, they may feel some pressure, discomfort or vibration, but these sensations are different from pain.  

It is important for the patient to inform the dentist of any unpleasant sensations experienced during the procedure, so that treatment can continue comfortably.

Dental sedation

Conscious sedation may be recommended for patients with severe anxiety or a fear of the dentist, to help them undergo treatment in a state of calm and with greater comfort. This can be particularly useful for complex procedures, longer appointments, or when fear prevents the necessary treatment from being carried out.

The need for sedation is determined on a case-by-case basis, only after assessing the patient’s general state of health, medical history and level of anxiety. The dentist will choose the appropriate method and explain to the patient how the procedure works and what instructions must be followed.

Sedation is not necessary for all anxious patients. In many situations, a preliminary consultation, step-by-step communication, agreeing on a signal to pause, and carrying out the treatment at the patient’s own pace can help to reduce fear.

Staged treatments

For anxious patients, the treatment plan can be divided into shorter sessions, tailored to the individual’s comfort level. In the first stage, priority is given to emergencies and issues requiring rapid intervention, whilst other procedures are scheduled gradually.

This approach gives the patient the time needed to get to know the dentist, the team and the practice environment. Each positive experience can help to build confidence and reduce anxiety ahead of subsequent appointments. 

Preparation for the consultation begins before the patient arrives at the surgery. Another important step is to mention these concerns as early as when booking the appointment.

To begin with, the patient may opt for a consultation dedicated to discussion and assessment, without immediately booking a complex course of treatment. During this session, they can speak openly about previous experiences, prepare a list of questions that are on their mind, and ask for clear explanations about the recommended procedures, the sensations they might experience, and the options available for pain management.

Managing dental anxiety in adults

It is recommended that the appointment be scheduled at a time of day when the patient is more rested and less pressed by other responsibilities. Before the consultation, it is advisable to avoid alarming stories, negative experiences recounted by others, or information that might intensify their fear.

Once at the clinic, the patient can practise abdominal breathing for a few minutes, with a slow, prolonged exhalation. This technique can help reduce tension and regulate the stress response.

Before treatment begins, the patient is encouraged to ask any questions they may have and to agree on a signal with the medical team that they can use to request a break. The fact that they can temporarily halt the procedure gives them a greater sense of control and can strengthen their trust in the doctor.

Hypnosis does not mean losing control

Another strategy can be self-hypnosis, whereby the patient focuses their attention on a place where they would feel calm and safe.  

“Patients can imagine they are anywhere other than the dentist’s surgery. They can visualise that place in as much detail as possible, using all their senses. If they allow themselves to immerse themselves in that place with all their senses, they will be able to enjoy a positive experience with significantly reduced discomfort. However, these techniques do not completely eliminate fear, but they can reduce the level of nervous system arousal and increase the sense of safety and control.” – Bianca Radu

Managing dental anxiety in children

In the case of children, preventing anxiety begins with early familiarisation with the dentist. According to the recommendations of the American Academy of Paediatric Dentistry, a child’s first visit to a paediatric dentist should take place at the age of 1 year or, at the latest, 6 months after the first tooth appears.

Before the visit, it is recommended that parents avoid alarming stories and expressions that might suggest pain. The appointment can be explained to the child in a calm and simple manner, without making any absolute promises, leaving it to the dentist to explain, in terms the child can understand, what is going to happen.

At DENT ESTET 4 KIDS clinics, there are psychologists who offer solutions for treating anxious children. During these sessions, children are helped to overcome their fears and gradually become familiar with the environment and the medical team.  

“It is important for the dentist and the parent to respect the child’s pace and not to mistake their resistance for cooperation. Repeated experiences in which the child feels listened to and safe can gradually build a positive relationship with the dentist.” – Bianca Radu 

It is important for people with severe anxiety or a fear of the dentist to consult a psychologist who works in collaboration with the medical teams. This collaboration can bring significant benefits and reduce the time and discomfort associated with treatment.

The psychotherapist helps patients understand the mechanisms of fear, identify catastrophic thoughts and learn effective strategies for emotional regulation and gradual, controlled exposure to their fears.

Allergies to certain medicines, bleeding or excessive salivation, pain and severe anxiety can be easily managed through relaxation techniques and clinical hypnosis carried out by a hypnotherapist specialising in medical hypnosis.  

In conclusion, the strategies we can use to manage feelings of fear or anxiety do not completely eliminate fear, but they can reduce the level of arousal in the nervous system and increase the sense of safety and control.  

“Fear of the dentist is a natural reaction of the nervous system, which is trying to protect us. It should not be seen as a weakness, nor as an insurmountable obstacle. Once we understand this, we can transform the experience in the dentist’s surgery into one where safety, trust and cooperation become just as important as the treatment itself.” – Bianca Radu 

1. Armfield JM, Heaton LJ. – Management of fear and anxiety in the dental clinic: a review. Australian Dental Journal, 2013
2. Gordon D, Heimberg RG, Tellez M, Ismail AI. – A critical review of approaches to the treatment of dental anxiety in adults, Journal of Anxiety Disorders, 2013
3. Porges SW – The Polyvagal Theory: Neurophysiological Foundations of Emotions, Attachment, Communication, and Self-Regulation. W.W. Norton, 2011.
4. Porges SW – The Pocket Guide to the Polyvagal Theory. W.W. Norton, 2017.
5. Patel B., Potter C., Mellor A.C. – The use of hypnosis in dentistry: a review. Dental Update, 2000
6. Wolf TG, Schläppi S, Benz CI, Campus G. – Efficacy of Hypnosis on Dental Anxiety and Phobia: A Systematic Review and Meta-Analysis. Brain Sciences, 2022
7. Dilmahomed H., Jovani-Sancho M. – Hypnoanalgesia in Dentistry: A Literature Review. American Journal of Clinical Hypnosis, 2019