Reducing dental anxiety

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Associate Professor Jason Armfield
Associate Professor Jason Armfield

It was by accident that Associate Professor Jason Armfield fell into the world of dental research, but it’s very lucky for the dental profession that he did. The 43-year-old has spent almost 20 years researching anxieties, and for the past 15 years that work has specifically targeted the dental field. Few researchers have experienced the success or the respect, in terms of research results, awards, scholarships and fellowships, that Armfield has enjoyed. 

He’s now well on the way to achieving his lofty goal of changing the way Australian society feels about dentistry. “My entire research program and the way I’m working involves a series of steps I have envisioned,” he says. “It is built around the fact that I want to make a difference. I want to be able to reduce the level of dental anxiety in society.

The question is, how do you get to that? What do you do? It’s a big ask.” It certainly is a big ask, especially for somebody that never intended to enter the dental field in the first place. Armfield grew up in rural New South Wales, moving around quite often as his father’s job with the NSW Dairy Corporation demanded. After leaving school midway through year 12 he took a few years off then enrolled at Flinders University, studying psychology as a mature-age student. Armfield’s overriding interest has always been the causes of fear and when he launched into a PhD in psychology in 1996, it was this that he was studying.

But in 1999 when he took a job as a research assistant in the School of Dentistry within the University of Adelaide, he shifted his work’s focus from general fears to dental anxiety. “My PhD in psychology was a general theory around the etiology of all fears,” he says. “Coming to the School of Dentistry I wanted to apply that same theory to dental anxiety, which fits in perfectly in the same way a fear of spiders is a prototypical fear. So in the end I wasn’t awarded a PhD in psychology because I never finished it. I had done four studies during that project then completed another four or five looking at dental fear specifically. So the final PhD, undertaken in dentistry, was in two sections, one as a general background of fear, the other focusing on the fear of going to the dentist.”

And so a promising academic slipped in to the field of dentistry via a job he took to supplement his meagre student income. Since then he has cemented his place as a thought leader and a change maker, but actually he’s only part of the way towards finishing what has become a lifelong plan.

The research

As soon as Armfield completed his PhD he was awarded an overseas postgraduate training fellowship. This saw him spending two years at the University of Washington’s renowned Dental Fears Research Clinic followed by another two years of funding back at the University of Adelaide. Another fellowship, once again from the National Health & Medical Research Council, immediately followed the first, allowing him to further pursue his research agenda. Fellowships are set up to fund researchers at the very top of their game and who are conducting work that could make a significant difference.

The second fellowship carries Armfield through to 2017. “I’ve got at least eight different research projects that are at different stages. They’re all on dental anxiety relating to children and adults,” the father of two says. “A few years ago I developed a dental fear scale to measure dental anxiety amongst adults. This was quite successful and since then I’ve been involved in helping translate it into a number of different languages. “This year I’ve been funded to develop a scale specifically for children. I’m also trying to pick up large grants for a longitudinal study taking children from when they’re four or five and following them over time. It will look at the development of dental anxiety and relate it back to experiences and treatments. “Along the way I have worked with dentists and patients and I have put in an application to look at dentistry students and find out what they’re learning in terms of identifying, treating and managing dental anxiety.”

Now an associate professor at the Australian Research Centre for Population Oral Health within the School of Dentistry at the University of Adelaide, Armfield has developed a research plan that looks far into the future of his career. It begins with the development of an understanding of why people suffer dental anxieties. The second section of the research, which he’s working on now, looks at possible intervention points that are available for introducing change. “From what I have identified so far, one of these points might be around what dental students are actually learning—about their education,” Armfield says. “Do they feel empathy? Do they know how to effectively identify and manage a patient’s anxiety? “Next I’m looking at what dentists know, learn and experience on the job. What are they doing and how are they treating patients? Finally, I’ll look at how patients are perceiving what the dentists are doing. So my work will cover the education system, the dentists and the patients themselves. “After looking at all of those areas and finding the gaps, finding areas where things could be done better, the aim is to hopefully earn funding to conduct more research that will specifically look at interventions to make changes,” explains Armfield. “We’ll test whether those interventions can provide some sort of benefit, then roll out those research findings, translating them into actual changes in the system to bring about an overall reduction in the levels of dental anxiety in the Australian community.”

Practical implications

Understanding fear as related to dentistry is important on a number of levels, Armfield says. “It’s a mental health concern with over 15 per cent of the population suffering high dental anxiety, making it one of the most common anxieties. It’s also a dental concern as people with dental anxiety tend to avoid visiting the dentist, meaning their oral health problems become more serious over time. For instance, those with dental anxieties have twice the levels of tooth decay than those that have no such anxiety. Then the fear causes a public health concern as public money is often required to treat people with serious oral health issues,” he says. “From a personal point of view for dentists, people with dental anxiety can be more difficult and stressful to treat. When they come in they can be quite tense and very reactive. Some might present in a way that might be a little confrontational or sarcastic. They essentially release their anxiety however they can.” So what can dentists do about the issue? How can it be better managed? Start by offering your patients a chance to admit to their fears, but in an environment in which they will not feel judged, Armfield says. This could take the form of a questionnaire to be filled out in the waiting room, or as part of the registration of a new patient. Don’t rely on verbal confirmation of anxieties—a verbal discussion should only take place after the anxiety has been identified. “For people who are anxious, being able to provide information about how they feel is an indicator to them that this clinic takes their concerns seriously.

It tells them that the staff are interested and caring enough to ask about it,” Armfield says. “The questionnaire also provides information to the dentist that they can use as a way of broaching the conversation. “You can’t manage a fearful patient unless they’re properly identified in the first instance. People don’t always admit to anxiety, especially men. But as part of a questionnaire they’re more likely to admit to it without feeling as if they’re being judged.” Finally, don’t make the mistake of assuming that all dental fear is about pain, Armfield says. “People can be afraid of going to the dentist for a host of different reasons,” he explains. “They might have had a painful experience, but that’s not sufficient to end up with anxiety.

A lot of people have painful experiences at the dentist and most don’t end up with a long-term anxiety issues. Some people who have never had a painful experience at the dentist hate going there. “For some, the lack of control is a big issue. People like to have a sense of control over their lives. If you go to the dentist you get laid down and someone is literally in your mouth doing stuff. You can’t see what’s going on. You don’t know what’s happening. You feel a lack of predictability. You don’t know when it is going to hurt or even whether it is going to hurt,” continues Armfield. “Some have problems going to dentists because they have been sexually abused. There are big issues there. Others are very shy or have issues with germs or have social phobias. There is a range of reasons why people might have problems going to the dentist. It’s very complicated. But we need to understand it before we can do something about it.”

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