Exploring avoidance of dental care due to dental fear and economic burden -A cross-sectional study in a national sample of younger adults in Norway.

AIM: To assess the prevalence of dental avoidance due to dental fear and economic burden and its distribution by utilization of dental care and socio-behavioural characteristics. METHOD: A sample of 9052 Norwegian adults aged 25-35 years was invited to participate, and 2551 completed electronic questionnaires regarding lifetime prevalence of dental avoidance due to fear and last year prevalence of dental avoidance due to economic burden. RESULTS: Cancelled- and avoided ordering appointments due to fear amounted to 14.7% and 30.5%, respectively. Avoidance of dental visits due to cost was 37.7%. Frequency of cancelled appointments due to fear was 30% and 16.6% among participants attending dental care several times annually and seldom, respectively. Multiple logistic regression revealed that avoiding dental visits due to cost was less likely among participants with higher household income (OR 0.4, 95% CI 0.3-0.5) and more likely among participants with dental care need (OR 1.8, 95% CI 1.2-2.7). Cancelled and avoided appointments due to fear was most likely among those with need for dental care and lower education. Early unpleasant experience with dental care remained a covariate of avoidance behaviour due to fear. CONCLUSION: 14.7%, 30.5%, and 37.7% confirmed cancelled appointments due to fear, avoided ordering appointments due to fear, and avoided visiting the dentist due to cost. Avoiding dental care due to fear and economic burden was more and less common among participants with respectively, frequent and seldom use of dental care. Dental avoidance behaviours were highest among socially disadvantaged groups, indicating a hole in the welfare state model that needs political consideration.

Restraint in paediatric dentistry: a qualitative study to explore perspectives among public, non-specialist dentists in Norway.

OBJECTIVE: The aim of this study was to explore the perspectives of non-specialist dentists on the use of restraint in paediatric dentistry in the Public Dental Service in Norway. MATERIALS AND METHOD: Two focus group interviews involving four and five dentists, respectively, were conducted in one of the most populated counties in Norway in September 2019. The thematic analysis by Braun and Clarke informed the qualitative analysis. RESULTS: According to the dentists, physical restraint in paediatric dentistry is usually used when dental treatment is absolutely necessary. The qualitative analysis revealed the following three main themes: (1) some dentists justify the use of restraint in paediatric dentistry; (2) physical restraint is often legitimised by the fact that the child is sedated; (3) the use of restraint evokes difficult ethical evaluations. Additionally, the dentists had an overarching perspective of acting in the child's best interest, but they sometimes struggled to find a justifiable path in situations involving restraint. CONCLUSIONS: Dentists seem to consider the use of restraint combined with sedation as legitimate for absolute necessary dental treatment. Furthermore, the use of restraint involves difficult ethical evaluations.

Treatment of intra-oral injection phobia: a randomized delayed intervention controlled trial among Norwegian 10- to 16-year-olds.

OBJECTIVE: To evaluate the effect of five sessions of cognitive behavioural therapy (CBT) for 10- to 16-year-olds with intra-oral injection phobia. MATERIAL AND METHODS: This was a randomized delayed intervention controlled trial in 67 patients, fulfilling the DSM-5 criteria for specific phobia. All patients received the same CBT performed by dentists specially trained in CBT. The patients were randomly assigned to either an immediate treatment group (ITG) (34 patients) or a waitlist-control group (WCG) (33 patients). The WCG was put on a waitlist for 5 weeks. After treatment, all patients were combined for post-treatment analyses. Assessments including the psychometric self-report scales Intra-oral injection fear scale (IOIF-s), Children's Fear Survey Schedule-Dental Subscale (CFSS-DS), Injection Phobia Scale for children (IS-c) and Mutilation Questionnaire for children (MQ-c) and a behavioural avoidance test (BAT) followed by a questionnaire on cognitions during the BAT, occurred pre-, post-treatment/waitlist and at a 1-year follow-up. RESULTS: CBT had a significant effect compared to no treatment (WCG). After treatment, the scores on the psychometric self-report scales were significantly reduced and higher levels in the BAT were achieved. The results were maintained at 1-year follow-up. Of the 67 patients, 70.1% received intra-oral injections during CBT treatment, whereas 69.4% of those completing the CBT, in need for further dental treatment, managed to receive the necessary intra-oral injections at their regular dentist. CONCLUSIONS: The 10- to 16-year-olds diagnosed with intra-oral injection phobia benefitted positively on CBT performed by specially trained dentists.

Reliability, validity and cutoff score of the Intra-Oral Injection Fear scale.

BACKGROUND: A proper assessment tool is needed to gain more knowledge about fear of intraoral injections in children. AIM: The aims of this study were to evaluate the reliability and validity of the novel Intra-Oral Injection Fear scale (IOIF-s) and to establish a cutoff score for a high level of such fear. METHODS: Data were obtained from two samples of 10- to 16-year-olds in Hordaland, Norway. Sample I, 1460 pupils attending elementary and high schools, provided questionnaire-based data. The survey instruments used were IOIF-s, Children's Fear Survey Schedule-Dental Subscale (CFSS-DS), Mutilation Questionnaire for Children (MQ-c) and Injection phobia Scale for Children (IS-c). Sample II was 67 patients, diagnosed with intraoral injection phobia at the Center for Odontophobia, Oral Health Center of Expertise in Western Norway-Hordaland, who provided IOIF-s data. RESULTS: Cronbach's alpha was 0.95. The IOIF-s discriminated between subjects with and without intraoral injection phobia and was associated with the other survey instruments of similar construct. Principal component analysis revealed a two-component solution, characterized as 'Contact Fear' and 'Distal Fear'. Receiver-operating characteristic (ROC) curve indicated that a cutoff score of 38 was appropriate. CONCLUSION: The IOIF-s showed satisfying psychometric properties in terms of reliability and validity.

Quality-of-life before and after cognitive behavioral therapy (CBT) in patients with intra-oral injection phobia.

OBJECTIVE: To evaluate quality-of-life (QoL), before and after cognitive behavioral therapy (CBT) in patients diagnosed with intra-oral injection phobia according to DSM-IV and to compare with the general population. This study also aimed to evaluate if QoL was associated with self-reported injection anxiety, dental anxiety, time since last dental treatment and oral health. MATERIALS AND METHODS: Subjects were 55 patients (mean age 35.5 ± 12.2, 78.2% women) who participated in a treatment study in which 89% managed an intra-oral injection at 1 year follow-up. The patients completed a set of questionnaires including Quality of Life Inventory (QOLI), Injection Phobia Scale-Anxiety, Dental Anxiety Scale and a single-item question assessing self-perceived oral health. Objective measures of oral health and treatment needs were based on clinical examination. QOLI-scores from a non-clinical sample were used for comparison. RESULTS: Before treatment the general and health specific QoL were lower among intra-oral injection phobics than in the non-clinical sample. At 1 year follow-up the QoL in general had improved significantly and was similar to that of the non-clinical sample. Poor self-reported oral health and long-term avoidance of dental treatment were associated with lower general and health-specific QoL. Self-reported injection anxiety and dental anxiety were not associated with QoL. CONCLUSIONS: Patients with intra-oral injection phobia report lower QoL compared with a general population. Phobia treatment seems to increase QoL to normative levels. Self-perceived poor oral health is associated with reduced QoL in these patients.

Oral health and its influence on cognitive behavioral therapy in patients fulfilling the Diagnostic and Statistical Manual of Mental Disorders-IV criteria for intra-oral injection phobia.

OBJECTIVE: To describe self-perceived and clinically assessed oral health and oral treatment needs among intra-oral injection-phobic patients (Diagnostic and Statistical Manual of Mental Disorders-IV) and to explore whether these factors have an impact on the outcome of cognitive behavioral therapy (CBT). MATERIAL AND METHODS: Fifty-five patients (43 women, mean age 32.5 years, range 18-62 years) were treated with short-duration CBT. Dental anxiety (Dental Anxiety Scale and Dental Fear Survey) and self-perceived oral health were assessed by means of questionnaires. Three dentists assessed oral health by means of clinical examination and radiographs. Treatment outcome was measured by ability to receive an intra-oral injection by a general dentist within a 1-year follow-up (FU) period or ability to complete a behavioral avoidance test (BAT) at FU, and changes in dental anxiety and positive and negative thoughts from pretreatment to FU. RESULTS: Forty percent of patients ranged their oral health as "good" or "very good". Mean decayed teeth (DT) was 2.2 (range 0-15). The total number of teeth in need of treatment, periodontal treatment, endodontic treatment and extractions ranged from 0 to 15, 0 to 19, 0 to 4 and 0 to 5, respectively. Self-rated oral health correlated significantly with clinical oral health. The outcome of CBT in terms of being able to receive a dental injection during FU was not influenced by oral health status. However, correlation analyses indicated that patients with the poorest oral health had the greatest increase in positive thoughts and the greatest decrease in negative thoughts from pretreatment to FU. CONCLUSIONS: The oral health of intra-oral injection-phobic patients varies substantially, but is comparable to that of the normal population. Coping with a dental injection after CBT is not influenced by oral health and treatment needs.

Oral health and oral treatment needs in patients fulfilling the DSM-IV criteria for dental phobia: Possible influence on the outcome of cognitive behavioral therapy.

OBJECTIVE: To describe oral health and oral treatment needs in a group of dental phobic patients (DSM-IV) and to explore possible relationships between these factors and changes in self-reported dental anxiety before and after phobia treatment. MATERIAL AND METHODS: Forty patients (25 women) fulfilling the DSM-IV criteria for specific phobia were included in the study. Mean age of the group was 34.9 years (range 19-60) and mean dental avoidance was 11.2 years (range 3-30 years). They were treated with cognitive behavioral therapy (CBT) during either one session (3 h) or five sessions (1 h each). Oral health was evaluated by orthopantomogram and clinical examination. The outcome of the CBT was measured by the change in dental anxiety scores (DAS, DFS) and in positive and negative thoughts during a standardized dental behavior test from pretreatment to 1-year follow-up. RESULTS: Mean (SD) DMFT was 16.5 (5.8), range 3-26; DT was 6.6 (4.2). Mean number of teeth with dental treatment need (restorative, periodontal, extractions, etc.) was 9.6 (6.9), range 1-28. There were statistically significant correlations between number of decayed teeth and decrease in negative thoughts (r=-0.39, p=0.048) and maximum anxiety (r=-0.65, p=0.001). The total number of teeth with treatment need correlated with an increase in positive thoughts (r=0.60, p=0.001) and decrease in maximum anxiety (r=0.50, p=0.015). CONCLUSIONS: There are large variations in oral health and treatment needs among patients fulfilling the DSM-IV criteria for dental phobia. Patients with the best dental health and lowest treatment needs experience the largest increase in positive cognitions during exposure to dental treatment at 1-year follow-up.