Behavior of Dental Phobic Residents of
Large and Small Communities

Benjamin PERETZ1
Joseph KATZ2
Aryeh ELDAD3

1The Hebrew University Hadassah Faculty of Dental Medicine, and The Israel Defense Force, Jerusalem, Israel
2Medical Corps, Israel Defense Force, Department of Oral Medicine, The Hebrew University Hadassah Faculty of Dental Medicine, Jerusalem, Israel
3Medical Corps, Israel Defense Force, and Department of Plastic Surgery, Hadassah Medical Center, Jerusalem, Israel

Braz Dent J (1999) 10(1): 1-60 ISSN 0103-6440

| Introduction | Material and Methods | Results | Discussion | References |

The purpose of the present study was to characterize differences among dental phobic patients in past dental experience between residents of standard metropolitan areas (SMSA), and non-SMSA. Over a period of 1 year, the records of 41 dental phobic patients were evaluated. These patients were attending a special Israeli Defense Force clinic designed to treat dental phobics. The mean time since the last routine visit in both groups was 12.42 ± 6.54 years and the mean age at which the patients had had their last routine dental treatment was 14.56 ± 4.62 years. Over a two-year period prior to the present visit, the main reason for SMSA patients to seek any dental care was dental pain (P = 0.015). All other variables that compared the dental behavior of SMSA patients with non-SMSA patients showed no difference. The findings suggest that the availability of dentists in the SMSA did not increase the seeking of dental care. The fact that SMSA residents were more likely to seek care because of pain suggests that residents of non-SMSA areas were more likely to tolerate pain without seeking care. These findings underscore the need for proper behavioral and pain management during childhood.

Key Words: dental phobia, large communities (SMSA), small communities (non-SMSA), dental experience.


    Provocation of anxiety by dental treatment is a universal phenomenon (Gatchel et al., 1983; Domoto et al., 1988). In its severe form, anxiety may have an impact on the dentist/patient relationship and contribute to misdiagnosis (Eli, 1993). Patients who had experienced dental anxiety during dental visits reported that the worst experiences had occurred early in their lives (Green and Green, 1989; Friis-Hasche, 1990). The occurrence of a severe form of anxiety as the result of a dental visit that is irrational and out of proportion to the actual threat is defined as a dental phobia (Kent, 1984). The Diagnostic and Statistical Manual (DSM) of the American Psychiatric Association (1994) defines phobia as a persistent and irrational fear of a specific object, activity or situation that results in a compelling desire to avoid the dread object, activity or situation (a phobic stimulus). The fear is recognized by the individual as excessive or unreasonable in proportion to the actual danger, accompanied by uncontrolled statements or actions.
    A typical behavior pattern of dental phobics is to delay making dental appointments as well as to cancel or to fail to appear (Peretz et al., 1998). A study conducted in Sweden found that dental phobics delayed dental treatment up to 16 years and reported extraordinary deterioration of dental health (Berggren and Meynert, 1984). In a previous study on phobic patients, the mean DMF (D = decay; M = missing tooth; F = filling) was found to be high (10.7 ± 5). The mean D component of DMF was 4.8 ± 3.4. Most patients required four sessions or more. No correlation emerged between DMF and age, nor between the D component of DMF and age (Peretz et al., 1996). Factors that appear to contribute to the development of dental phobia are the expectation of pain, social and interpersonal factors, and uncertainty about the type of treatment (Berggren and Meynert, 1984). Anticipation of the dental visit was found to be more stressful among dental phobics (Gale, 1972; Kent, 1990).
    Two factors that, under normal circumstances, contribute to the utilization of dental services are the availability of a dentist and the patient’s community (urban versus rural, or large versus small cities) (Anderson, 1975; Kleiman, 1982; Friis-Hasche, 1990). These two factors are, of course, related since dentists are more likely to be available in urban centers.
    Communities may be categorized according to the U.S. census classification (Anderson, 1975) as follows: Standard Metropolitan Statistical Area (SMSA) are communities of 50,000 or more population, along with associated county and nearby counties which are judged by the Census to be socially and economically similar in nature, and non-SMSA communities are those communities with less than 50,000 population. The U.S. census classification fits the population pattern in Israel.
    The Israeli Defense Force (IDF) provides free dental treatment to all soldiers on duty, and has initiated a special clinic for the treatment of dental phobics, who could not be treated in the regular clinics. The techniques used for these patients were reported in a previous study (Peretz et al., 1996).
    The purpose of this study is to characterize differences in dental behavior between IDF dental phobic patients who reside in SMSA versus dental phobics who reside in non-SMSA.

Material and Methods

    The study population consisted of 41 patients who had been participating in a program for dental phobics organized by the Israeli Defense Force. Of the 41 patients, 31 were male and 10 were female. These patients had been referred to the special clinic by other dentists who could not provide dental care because of the high level of dental anxiety among these individuals. Each of the referred patients was required to complete the Corah’s Dental Anxiety Scale - DAS (Corah, 1969) prior to the visit. Corah’s scale comprises four multiple-choice questions dealing with the individual’s subjective reactions about 1) going to the dentist, 2) waiting in the dentist’s office, 3) waiting in the dental chair for fillings, and 4) waiting in the dental chair for scaling. For each of the four questions, candidates choose from five possible answers (1 through 5) with 5 indicating the most anxiety. Therefore, the maximum possible score was twenty. The mean DAS score of the 41 candidates was 19.3 ± 2.8 and therefore they fell within the range of dental phobics (Corah, 1978; Kent, 1984).
    The following variables were determined for each subject: age, age at the last dental visit, gender, location of residence, time since last routine dental visit, characterization of last visit by the subject, characterization of efforts to receive dental care over the last two years, reason for efforts to receive treatment, and the type of treatment received at last visit. Patients were divided into two groups: those who lived in communities of more than 50,000 population (SMSA) and those who lived in communities of less than 50,000 (non-SMSA). Since our previous report found that no statistical significance emerged when comparing the mean DAS scores of the men and women, the results were pooled into one group.
    The Student t-test was used to determine differences between urban and rural dwellers by age, time since last visit, and the age at the last visit. Chi-square analysis was conducted to analyze and compare urban versus rural for all other variables.


    The age range of the patients was 19-45 years. Table 1 illustrates mean age, time since the last routine visit, and the mean age at which they had their last routine dental treatment. There were no differences between both groups for these variables. Table 2 reports the characteristics of SMSA and non-SMSA patients with respect to the reason for seeking dental care over a 2-year period, and the remaining variables. The only difference between the two groups was that the SMSA dwellers were much more likely to seek care because of dental pain. There were no differences between SMSA and non-SMSA patients for the other variables.


    All patients scored high values on the DAS and were clearly categorized as dental phobics. They all recalled a traumatic dental visit as the source of their phobia. These “primal” visits occurred at least 6 years prior to their enrollment in the special dental phobia clinic and each subject described this experience in great detail. All of the subjects in this study were either children or young adolescents when the “primal” visit took place. Both groups described pain and fear as the two most important reasons why they avoided dental visits. This finding is not unexpected and supports previous reports on recollections of dental phobics (Liddell et al., 1990).
    There was no statistically significant difference of mean age at the last dental visit between the two groups. This finding was not in accordance with other studies which demonstrated greater utilization among SMSA residents (Kleiman, 1982). One explanation may relate to a “leveling of the playing field phenomenon”, i.e., the advantages of living in an urban community (e.g. the availability of more dentists) is neutralized by the special health behaviors of the dental phobic. Factors such as dentist availability may lose value among patients with significant behavioral differences. This suggestion may be supported by the high DMF found in the previous report of these patients (Peretz et al., 1996).
    There were, however, some motivational differences between the two populations. SMSA dwellers were more likely to have sought the services of a dentist because of pain over the past two years. One possible explanation might relate to differences in pain threshholds or at least a modified response to pain because of lowered access to care and less chance of having the pain relieved. It is also possible that non-SMSA dwellers were more stoic and less likely to complain about pain.
    The relative youthfulness of the phobics at their first phobic experience may be explained, at least in part, by the dentist’s lack of attention to adequate pain control and lack of administration of local anesthesia (Eli et al., 1997). The inability of the dentist to establish a sensitive and/or caring relationship with the patient could also contribute to the patient’s reaction (Lahti et al., 1992).
    Another important question emerges from our study: individual personality traits could have been the most definitive factor in developing severe dental anxiety, as some patients may undergo a traumatic dental experience but do not acquire an anxiety while others have the same experience and acquire an anxiety (Davey, 1989; Eli et al., 1997).
    Our study faces the limitation of a small population, and further research is obviously needed in a larger and more stratified sample of dental phobic patients in order to obtain a better characterization. Nevertheless, our findings underscore the need for proper behavioral and pain management during childhood.


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Correspondence: Dr. Benjamin Peretz, Department of Pediatric Dentistry, Hadassah Faculty of Dental Medicine, P. O. Box 12272, Jerusalem, Israel. Fax: 972-2-6435610. E-mail:

Accepted March 9, 1999
Electronic publication: September, 1999