Fear of the dentist is one of the most common fears across Europe and North America. Recent research in the British Dental Journal suggesting that over 50% of the UK population claim to experience dental fear when visiting the dentist, while the British Society of Dental Hygiene and Therapy suggest a further 36% are moderately anxious and approximately 12% are dentally phobic.
This is despite huge advances in dental care over the past 100 years. Pain relief is now routinely used and very effective, there have been improvements in the way diseased teeth are treated. Other developments include: minimally invasive (non-drill based) treatments to remove decay and save teeth; improvements in materials used to restore teeth; and in training for dentists on the importance of communication and person-centred care. And yet dental fear remains widespread.
Why?
The media certainly enjoy running horror stories about dentistry. In 2016 the Guardian ran a piece on the Dutch dentist Jacobus Van Nierop who was sentenced to 8 years in prison in France for “mutilating the mouths of more than 100 patients” when he “pulled out healthy teeth, broke patients’ jaws, and caused abscesses and blood poisoning”. In May 2019 the BBC ran a story under the headline “HIV fear over ‘dirty’ dental equipment” about a dental hygienist who used dirty equipment to treat 563 patients who were offered blood tests over fear that they may have been exposed to HIV or Hepatitis. These stories are horrific, but the reality is that these events are extremely rare. We have come a long way from the historical images of tooth drawers and barber-surgeons yanking teeth out in public with huge pliers and no pain relief. The problem now, I would argue, is more insidious and less visceral.
The Wikipedia page on dental fear defines it as “a normal emotional reaction to one or more specific threatening stimuli in the dental situation”. Herein lies the problem. Dental fear has become normalised. Despite all the material changes in dentistry, there is still a socially constructed expectation that visiting a dentist is scary and painful. You can buy books for children about why visiting the dentist isn’t scary, CBeebies series ‘Something Special’, ‘Charlie and Lola’ and ‘My First’ all have programmes on going to the dentist with the aim of making it less scary. While all of this is positive, underlying it is the assumption that dentists are people we should fear.
Research by Borreani et al (2009) on access to and use of dental services by older people suggests that for many people dental fear develops from experiences in childhood, particularly around school dental visits in the post-war period. This is echoed in other studies. Psychologists have also suggested that fear is learned through vicarious conditioning as, particularly younger relatives, learn to be anxious by hearing from others about traumatic experiences. In 1998 Kent and Crouch wrote that anxious patients are more likely to have parents or relatives who are anxious than non-anxious patients.
These are not the only ways that a culture of fear develops, however. It only takes a brief search for portrayals of dentists in the popular media to see this in action. The blurb from a recent children’s book reads as follows:
“Darkness had come to the town. Strange things were happening in the dead of night. Children would put a tooth under their pillow for the tooth fairy, but in the morning they would wake up to find… a dead slug; a live spider; hundreds of earwigs creeping and crawling beneath their pillow.
Evil was at work. But who or what was behind it…?”
And the answer?
The book is funny and hugely popular with younger children but it also perpetuates the scary dentist image. And it is not alone in this. While the dentist in Finding Nemo is fairly friendly, the clinic itself becomes a scene of terror for Nemo as he encounters the brace wearing, fish-killing, niece of the dentist while trapped in the clinic fish tank. From Marathon Man’s Dr Schnell, taking pleasure in inflicting pain in the classic horror film to Steve Martin’s portrayal of Scrivello as the laughing gas addicted sadistic dentist in Little Shop of Horrors, to Julia Harris and her inability to avoid harassing people in Horrible Bosses, it is nearly impossible to find positive popular representations of dentists. This has been recognised by researchers who suggest the need to promote positive images of dentists and dentistry to enhance trust of patients and so increase satisfaction, reduce fear and improve oral health.
What this suggests, as I have argued in a recent paper, is that dental fear is socially produced and reproduced through family networks and social representations of dentistry within literature, film and the media. Contextualising dental fear in this way allows us to see how the fear has become separated from the experiences of dentistry itself. It is easy to see how the prospect of having teeth pulled out, with no pain relief, in public, while being held down in a chair, would be terrifying. This no longer happens, however, and the objects of fear have changed with the changes in treatment. A study by Tickle at Manchester University found that “pain is actually quite rare in dental surgeries”. Dental fear has become associated with the very technologies that have reduced the pain, needles, the dental drill and the sight, smell and sounds of the clinical space itself. This is exacerbated by the plethora of negative images, stories and associations we are surrounded by and pass on to those around us.
Dental fear, whilst very real, is largely socially constructed. To reduce the fear (and improve oral health) we need to deconstruct it and challenge popular images and narratives of dentistry and the dentist.
