The origin of dental phobia
The term “phobia” can be translated as “fear that generates escape”: in the field of dental patient management, the concept is declined in dental phobia, a unique framework with a psychosomatic component and able to impact on oral health. The renouncing and avoiding attitude inherent in the psychological framework is also able to interfere heavily with the indirect aspects of the clinic, for example, in the planning of the treatment plan.
The present treatment, taking the most relevant data of the most articulated revision of Carter in 2014, wants to consider some aspects related to the development of phobia and dental anxiety with a look at the clinical management of the patient.
A variable picture is often the expression of a multifactorial etiology.
First of all, consider the genetic data, which is a psychological condition and can be of controversial interpretation. It can be said that phobia itself is not a hereditary condition. On the contrary, some factors capable of interacting with environmental elements would seem to be transmissible. It, therefore, seems correct to speak of genetic vulnerability.
Inheritance could also be linked to the evolutionary advantage and to the concept of preparedness, for which dental phobia would represent an ancestral protective response against aggression by non-nutritive foreign bodies.
Negative affectivity means a stable personality trait, a further condition of vulnerability, linked, in this case, with exposure to negative emotional states and capable of predisposing to different disorders of the psyche, including forms of phobia.
Let us now consider the process of onset of dental phobia and all other kind of phobia.
The classical conditioning refers to the very famous experiments conducted by Pavlov on the canine model. The subject develops a conditioned response to a previously neutral stimulus after this has been combined with an inducing stimulus of unconditional response. The sound of a handpiece or the mere presence of the dentist based on this model may induce the anxious response following, for example, a previous painful episode. This type of model is useful in interpreting adult dental anxiety and should guide the basic approach to the paediatric subject.
In operating conditioning, on the other hand, the frequency of certain behaviour changes with the expected consequences. This is a mechanism that has been well studied with reference to rewarding schemes in gambling. In the onset of phobias, the most important elements would be negative punishments (e.g., pain during the session) and negative reinforcements, i.e., the avoidance of the session as a means of alleviating anxiety.
Ultimately, authors such as Rachman and Bandura proposed the possible indirect acquisition of phobias.
The first way is represented by the vicarious experience, for which, for example, a child interprets as a threat to the dental session on the basis of the observation of the parent. One model, in which the role of the parent is perhaps even more decisive, is the verbal transmission.
Conditioning is a process by which the subject binds a negative outcome to a certain event or stimulus with experience.
Pavlov’s response to the canine model was to increase the salivary flow. The human phobic experiences are observed through clinical signs such as heart rate, breathing, sweating.
A strong direct correlation between the severity of the previous traumatic event and the resulting phobic degree was also found with a common variance of 38%.
It can, therefore, be concluded that indication of conditioning is the main pathway in the onset of dental phobia. Alongside this, however, it is necessary to consider several indirect pathways.
The informative pathway is part of Rachman’s studies and strongly interacts with the growing subject, which is directed to identify negativity in the dental environment from the narration provided by the outside with important reference to the media (television and cinema in premise).
The vicarious pathway does not need the presence of an unconditional stimulus. This type of process is typically studied in patients (apparently females more often) subject to extreme dental phobia and a strong tendency to avoid. These are the patients who most easily renounce to undergo normal check-ups.
In truth, in practice, it is difficult to separate it from the conditioning pathway. The evidence, however, supports the role in the onset of the pediatric age, which is influenced by the observation of unpleasant manifestations provided by the adult in the case of the dental environment, typically accompanied by the parent before they were, in turn, subjected to a dental session.
Remaining on the subject, it has been defined as a real parental pathway interconnected with the two previously mentioned. Already in 1991, Ollendick found, in a sample of 40 patients between 9 and 12 years of age, a positive correlation with respect to the degree of dental fear expressed by mothers. It seems that the role of the parent is synergistic with that of the growing patient.
Verbal threat pathway: even in the latter case, the presence of an unconditional stimulus is not necessary. In order to define the origin of apparently inexplicable fear, it is necessary to understand its “emotion,” which, in turn, depends on verbal cognition, physiological states, and behavioural changes. Such changes, in the growing patient, could not take place without the verbal filter of an authoritative figure. In this sense, it seems necessary to stress once again the importance of the role of the parent in favouring the positive approach of the young patient to the dental environment. Intercepting opposite behaviours, in the pre-treatment phase, therefore, seems fundamental for the clinician before even implementing behavioural protocols that, even if well codified, would arrive late in this sense.