By: Dr. Richard Heimberg

As some of you may know, I have been collaborating with Dr. Marisol Tellez of the Temple University Kornberg School of Dentistry (TUKSoD) for the last few years in an effort to develop and evaluate a brief internet-based intervention for dental anxiety. Dental anxiety is a significant public health concern associated with increased risk of oral health problems, as well as problems related to sleeping, social and occupational functioning, and other health problems. Approximately 10-20% of individuals in the US report significant dental anxiety and many cancel preventative dental care, delay treatment for painful dental conditions, or avoid dental treatment altogether. They are more likely to be referred for sedation or utilize emergency dental services, which leads to increased individual and public dental healthcare costs.

Cognitive behavioral therapy (CBT) has demonstrated good efficacy for the treatment of dental anxiety, but it has not made its presence felt in dental clinics in any meaningful way, as there is little penetration into the world of dentistry (e.g., other than me, there is only one psychologist in TUKSoD!). Dentists are well aware of the problems that anxious patients may experience, but most know little of non-medical interventions, and, as noted, there are few people in the dental environment to make a meaningful dent in the problem. Clearly, dental clinics around the world are not going to hire large numbers of psychologists or other mental health professionals to administer CBT! So how do we solve this problem?

One possible solution is technology, and internet-based CBT (iCBT) has been successfully utilized for most of the anxiety disorders, and several randomized trials and meta-analyses suggest that iCBT is as efficacious as face-to-face CBT, at least when it is facilitated by a therapist or coach, which can be done with a fraction of the resources necessary for face-to-face CBT. We have developed a 1-hour single-session iCBT for dental anxiety, based on a combination of psychoeducation, motivational techniques, cognitive coping skills, and exposure to videos of feared dental procedures (e.g., injections, extractions, root canals, having a cavity filled) and demonstrated that it is superior to a waitlist control for reducing dental anxiety and substantially reducing the percentage of patients who meet criteria for a diagnosis of specific phobia.

A problem, however, is that the iCBT facilitators in that study were well trained "CBTers." Thus, the intervention as evaluated to date is probably not sustainable. It would be unlikely to be taken up by or integrated into dental clinics. For that to have a chance to happen, it must be put in the hands of dental professionals, and they must be able to facilitate the patient's intervention experience as well as experienced CBT personnel. To see if this can be done successfully is one of the primary missions of our current research, funded by the National Institute of Dental and Craniofacial Research, and pilot work from our previous grant suggests cautious optimism.

In the study currently gearing up, we will randomize anxious patients from one of the TUKSoD clinics to (1) iCBT administered by CBT-experienced facilitators, (2) iCBT administered by CBT-inexperienced facilitators, i.e., dental assistants who have completed a 3-hour training course in CBT essentials, or (3) a control condition (watching a neutral video rather than receiving iCBT). All patients will also attend an appointment for dental care immediately afterwards and their dental provider will be made aware of their score on a measure of dental anxiety. We will examine anxiety reduction immediately after these activities, 1 month later, and 3 months later. We will also compare their attendance at dental care appointments in the 12-month periods before and after intervention.

It is worth stating that this form of iCBT is rather minimalist, designed to move the needle a little bit to ease the patient into the dental chair rather than to eradicate their anxiety altogether. From a public health perspective, a small movement by a large number of people really can make a difference. In the future, we hope to expand the effort to include interventions for children and adolescents, to persons whose primary language is other than English, and to individuals who have not already made their first foray into dental care because their anxiety has gotten in the way.