Clinical implications of panic symptoms in dental phobia

Clinical implications of panic symptoms in dental phobia

Journal of Anxiety Disorders 28 (2014) 724–730 Contents lists available at ScienceDirect Journal of Anxiety Disorders Clinical implications of pani...

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Journal of Anxiety Disorders 28 (2014) 724–730

Contents lists available at ScienceDirect

Journal of Anxiety Disorders

Clinical implications of panic symptoms in dental phobia Carrie M. Potter a , Dina G. Kinner a , Marisol Tellez b , Amid I. Ismail c , Richard G. Heimberg a,∗ a

Adult Anxiety Clinic, Department of Psychology, Temple University, 1701 North 13 Street, Philadelphia, PA 19122, USA Department of Pediatric Dentistry and Community Oral Health Sciences, Kornberg School of Dentistry, Temple University, 3223 North Broad Street, Philadelphia, PA 19140, USA c Kornberg School of Dentistry, Temple University, 3223 North Broad Street, Philadelphia, PA 19140, USA b

a r t i c l e

i n f o

Article history: Received 28 February 2014 Received in revised form 21 June 2014 Accepted 21 July 2014 Available online 12 August 2014 Keywords: Dental anxiety Dental phobia Specific phobia Panic Oral health-related quality of life

a b s t r a c t The occurrence of panic symptoms in various anxiety disorders has been associated with more severely impaired and difficult-to-treat cases, but this has not been investigated in dental phobia. We examined the clinical implications of panic symptoms related to sub-clinical and clinically significant dental phobia. The sample consisted of 61 patients at a university dental clinic who endorsed symptoms of dental phobia, 25 of whom met criteria for a formal diagnosis of dental phobia. Participants with dental phobia endorsed more panic symptoms than did those with sub-clinical dental phobia. In the total sample, greater endorsement of panic symptoms was associated with higher dental anxiety, more avoidance of dental procedures, and poorer oral health-related quality of life. Among those with dental phobia, certain panic symptoms exhibited associations with specific anxiety-eliciting dental procedures. Panic symptoms may serve as indicators of clinically significant dental phobia and the need for augmented treatment. © 2014 Elsevier Ltd. All rights reserved.

Dental anxiety is increasingly recognized as a major public health concern, as it affects 10–20% of adults in the United States (Doerr, Lang, Nyquist, & Ronis, 1998; Locker, Liddell, & Shapiro, 1999; Milgrom, Fiset, Melnick, & Weinstein, 1988; Sohn & Ismail, 2005) and leads to underutilization of dental care and poor oral health (Berggren & Meynert, 1984; Hakeberg, Berggren, Carlsson, & Grondahl, 1993; Ng & Leung, 2008; Thom, Sartory, & Jöhren, 2000; Thomson, Stewart, Carter, & Spencer, 1996). It is also associated with low oral health-related quality of life, such as problems with sleep and impaired social and occupational functioning (Berggren, 1993; Cohen, Fiske, & Newton, 2000; Kaufman, Bauman, Lichtenstein, Garfunkel, & Hertz, 1991; Kent, Rubin, Getz, & Humphris, 1996). Although the terms “dental anxiety” and “dental phobia” are often confounded in the literature, the diagnosis of dental phobia (i.e., specific phobia of dental procedures) represents a subset of dental anxiety in that it not only involves anxiety about dental procedures but also requires interference or distress

∗ Corresponding author at: Adult Anxiety Clinic of Temple, Department of Psychology, Temple University, 1701 North 13th Street, Philadelphia, PA 19122, USA. Tel.: +1 215 204 1575; fax: +1 215 204 5539. E-mail addresses: [email protected] (C.M. Potter), [email protected] (D.G. Kinner), [email protected] (M. Tellez), [email protected] (A.I. Ismail), [email protected] (R.G. Heimberg). http://dx.doi.org/10.1016/j.janxdis.2014.07.013 0887-6185/© 2014 Elsevier Ltd. All rights reserved.

related to the anxiety and avoidance of dental procedures (Gordon, Heimberg, Tellez, & Ismail, 2013). As the majority of the published studies on dental anxiety have not included a diagnostic assessment, there is a dearth of available data comparing correlates of dental anxiety and dental phobia; however, given the interference component of dental phobia, individuals who meet criteria for dental phobia likely experience heightened problems with quality of life and physical health. Although one of the major concerns regarding dental phobia is avoidance of dental care, many dentally phobic individuals who attend appointments experience significant distress and exhibit poor compliance with dental procedures (ter Horst & De Wit, 1993). Furthermore, patients with high dental anxiety are more likely to be referred for sedation during dental treatment, which is an expensive and potentially hazardous technique (Boyle, Newton, & Milgrom, 2009). Developing effective psychological interventions for dental phobia has important public health implications, such as a potential reduction in overutilization of emergency dental care and sedation (Kanegane, Penha, Borsatti, & Rocha, 2003), calling for a better understanding of this condition and informed directions for treatment. A major change introduced in the DSM-5 is that panic attacks can now be used as a clinical specifier across disorders to indicate potentially more severe and difficult-to-treat cases (American Psychiatric Association [APA], 2013; Batelaan et al., 2012; Craske et al., 2010); however, there is a lack of research examining the

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prevalence and clinical implications of panic symptoms in dental phobia. Although panic attacks are the defining feature of panic disorder, they are often associated with other anxiety disorders, particularly specific phobia (Kessler et al., 2006). Data from the National Comorbidity Survey Replication indicate that 21.1% of individuals who experience panic attacks, but who do not meet criteria for panic disorder, have a specific phobia, which is the highest rate of co-occurrence between panic attacks and an anxiety disorder other than panic disorder (Kessler et al., 2006). Of the specific phobias, dental phobia may be among the most highly associated with panic attacks. In a sample of 59 individuals with both panic disorder with agoraphobia and specific phobia, dental phobia was one of the two most commonly endorsed phobias, with 40.7% of individuals meeting diagnostic criteria (Starcevic & Bogojevic, 1997). Although panic attacks appear to be associated with dental phobia, more data are needed documenting the prevalence of panic symptoms and attacks in dental phobia to clarify the degree to which panic is a component of this disorder. Examining the occurrence and intensity of panic symptoms associated with dental phobia will also help inform the debate about whether it is appropriate to categorize dental phobia as a subtype of blood-injection-injury (BII) phobia (i.e., phobia of blood, injury, needles, and invasive medical procedures), as it is classified in DSM-5 (APA, 2013; van Houtem et al., 2013). One of the major defining features of BII phobia is that, unlike other specific phobias, it involves a biphasic physiological response to phobia-related stimuli (Öst, Sterner, & Lindahl, 1984; Ritz, Meuret, & Ayala, 2010). Whereas individuals with other types of phobia typically exhibit increased heart rate and blood pressure when they encounter phobia-related stimuli, individuals with BII phobia exhibit an initial increase followed by a subsequent sharp decrease in heart rate and blood pressure, which can lead to vasovagal fainting (Öst et al., 1984). Existing research on cardiac response in dental phobia suggests that the biphasic response pattern may not apply, as individuals with dental phobia who are exposed to phobia-related stimuli (e.g., shown pictures of dental treatment procedures) typically exhibit an acceleration in heart rate that is not followed by a deceleration (e.g., Leutgeb, Schafer, & Schienle, 2011). Examining dental phobia-related panic symptoms can help further determine whether or not dental phobia appears to involve the biphasic physiological response pattern that is indicative of BII phobia, as some panic symptoms are suggestive of this response (e.g., fainting). Clarifying which panic symptoms are the most relevant to dental phobia will help address the question of whether or not dental phobia should be considered a subtype of BII phobia. The presence and severity of panic symptoms among patients with dental phobia has several important clinical implications. First, the presence of panic in various anxiety and mood disorders has been associated with greater disorder severity and comorbidity, as well as poorer treatment response (Feske et al., 2000; Frank et al., 2000, 2002; Goodwin & Hoven, 2002; Goodwin & Roy-Byrne, 2006; Hinton et al., 2008; Jack et al., 1999; Roy-Byrne et al., 2000). These findings support the use of panic attacks as a clinical specifier across most disorders, as introduced in DSM-5 (APA, 2013). Panic symptoms in dental phobia may also serve as clinical indicators of complex cases in need of more comprehensive assessment and intervention. However, no existing studies have examined the clinical correlates of panic symptoms in dental phobia, so it is unclear if panic attacks should be used as a clinical specifier for dental phobia. Second, panic symptoms may be differentially associated with various anxiety-eliciting dental procedures (e.g., drilling/filling, X-rays), suggesting specific treatment targets for different presentations of dental phobia. For instance, individuals who primarily fear oral X-rays may experience panic attacks characterized by choking sensations, whereas individuals who fear other types of dental procedures may exhibit a

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different constellation of panic symptoms. There is some evidence that panic symptoms are differentially associated with variations in anxiety pathology (Rachman et al., 1987; Rapee et al., 1992), but this has not been examined in dental phobia. Third, examining the prevalence of panic in dental phobia can inform the importance of targeting panic symptoms in therapy for this disorder. Most existing empirically supported therapies for dental phobia do not directly address panic symptoms (Gordon et al., 2013); however, incorporating techniques such as interoceptive exposure, an empirically supported treatment for panic symptoms in panic disorder (Craske et al., 1991), might improve the efficacy of therapy for dental phobia. Dental phobia-related panic symptoms may serve as an additional barrier to receiving dental care, as patients who exhibit high physiological arousal (e.g., high blood pressure) at the beginning of a dental appointment can be denied treatment because they are at increased risk for experiencing cardiovascular complications during dental procedures (Brand et al., 1995; Little, 2000). Therefore, if panic is prevalent in dental phobia, targeting panic symptoms in therapy for dental phobia could improve phobic individuals’ access to dental care. Further studies examining the presence and implications of panic symptoms in dental phobia are needed to clarify if panic symptoms are an important aspect of dental phobia to address in assessment and treatment. As a preliminary step toward evaluating the presence and implications of panic symptoms in dental phobia, the present investigation tested the following hypotheses among a group of individuals with varying levels of dental phobia symptoms: (1) individuals with clinically significant dental phobia would endorse more panic symptoms than those with sub-clinical dental phobia, (2) experiencing higher numbers of panic symptoms would be associated with greater self-reported dental anxiety, greater avoidance of dental procedures, and poorer oral health-related quality of life, and (3) different panic symptoms would be associated with specific anxiety-eliciting dental procedures. 1. Method 1.1. Participants The current sample was comprised of 61 adults (59.0% female; Mage = 40.89, SD = 12.98, range = 19–69) seeking dental care at various clinics within Temple University’s Kornberg School of Dentistry in north Philadelphia, PA. The racial/ethnic composition of the present sample was generally consistent with that of north Philadelphia (United States Census Bureau, 2010): approximately 50.8% of participants identified as black, 37.7% identified as white/Caucasian, 3.3% identified as Asian or Pacific Islander, and 8.2% identified as other. The primary inclusion criterion for the present investigation was endorsement of symptoms of dental phobia during the diagnostic interview, the Anxiety Disorders Interview Schedule for DSM-IV (ADIS-IV; Brown et al., 1994). Of 120 individuals screened, 65 met this criterion. However, four of these individuals were missing data on panic symptoms and were therefore excluded from all analyses, resulting in a total sample of 61 participants. 1.2. Measures Semi-structured diagnostic interview. The ADIS-IV (Brown et al., 1994) is a semi-structured clinical interview for assessing DSM-IV (APA, 1994) criteria for current anxiety, depressive, somatoform, and substance use disorders. The ADIS-IV has demonstrated good to excellent inter-rater reliability for the diagnosis of all assessed disorders (’s = .56–.81; Brown et al., 2001), with the exception of dysthymic disorder ( = .31). All diagnosticians

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were advanced doctoral students or research assistants who were trained to strict reliability standards established by Brown et al. (2001). For the present investigation, only the specific phobia module of the ADIS-IV was administered to assess the presence and severity of a current diagnosis of dental phobia and of dental phobia-related panic symptoms. Details regarding the assessment and computation of each of these variables are provided below. Dental phobia. Dental phobia was assessed using the specific phobia module of the ADIS-IV. Interviewers have demonstrated excellent inter-rater reliability for the principal diagnosis of specific phobia in a mixed sample of anxiety disorder patients ( = .86; Brown et al., 2001). In the present study, participants were only interviewed about phobia of dental procedures. Interviewers assessed participants’ anxiety and avoidance of dental procedures, as well as their distress and impairment due to dental phobia symptoms and assigned a clinician’s severity rating (CSR) for dental phobia that ranged from 0 (none) to 8 (very severe); a CSR of 4 or above indicates that the participant met criteria for diagnosis. In order to improve diagnostic validity, the phobia module includes a question that assesses whether participants are afraid of dental procedures because they are afraid of having an unexpected panic attack. Any participants who endorsed this item were asked further probing questions to determine whether their dental phobia was better accounted for by panic disorder; if so, they were not given a diagnosis of dental phobia. A random sampling of ten interviews was reviewed by reliability coders who were not informed about the diagnoses derived by the original interviewer. There was 90% ( = .78) agreement with the original determination of the presence or absence of a diagnosis of dental phobia. For the one case in which the original interviewer and reliability coder differed in their assessment of the presence of dental phobia, they assigned CSRs within one point of each other, one just at the diagnostic threshold (4) and the other just below (3). Interviewer ratings of the presence of a diagnosis of dental phobia, as well as CSRs for those who met diagnostic criteria for dental phobia, were used in the present analyses. Panic symptoms. Participants’ dental phobia-related panic symptoms were also assessed using the specific phobia module of the ADIS-IV. During the interview, participants were asked if they usually experience the DSM-IV symptoms of a panic attack when they encounter dental procedures and how intensely each symptom is experienced. Interviewers explained that panic symptoms that occurred in anticipation of, during, or following dental procedures qualified. Interviewers then rated each of the panic symptoms on a scale of 0 (none) to 8 (very severe); a rating of 4 or above denotes clinical significance. The DSM-IV panic symptom “fear of losing control or going crazy” is administered as two separate items on the ADIS-IV, so a total of 14 panic symptoms was assessed. In the present analyses we examined endorsement of clinically significant panic symptom (CSR ≥ 4) by including total number of clinically significant panic symptoms endorsed (possible range = 0 – 14) and endorsement of specific panic symptoms (yes/no) in analyses. Dental anxiety. Dental anxiety was measured using the Modified Dental Anxiety Scale (MDAS; Humphris et al., 1995), a 5-item self-report measure that assesses fear of dental procedures, including drilling, scaling and polishing (i.e., cleaning), and local anesthetic injections. Sample items include, “If you went to your dentist for treatment tomorrow, how would you feel?” and “If you were about to have your tooth drilled, how would you feel?” Items are rated on a 5-point Likert-type scale ranging from 1 (not anxious) to 5 (extremely anxious). The total score ranges from 5 to 25; a score of 19 or above indicates high dental anxiety (Humphris et al., 1995; King & Humphris, 2010). The MDAS has demonstrated good internal consistency (˛ = .89) and test–retest reliability (r = .82, interval

unspecified; Humphris et al., 1995). In the present analyses, the MDAS total score (˛ = .89) was used to index global dental anxiety, and three individual item scores were used to assess anxiety specifically related to drilling, scaling and polishing, and injections. Oral health-related quality of life. Oral health-related quality of life was measured using the Short-Form Oral Health Impact Profile (OHIP-14; Slade, 1997), a 14-item self-report measure that assesses the impact of oral conditions on individuals’ wellbeing. The OHIP-14 evaluates the consequences of oral conditions across multiple dimensions, including physical pain, psychological discomfort, physical disability, psychological disability, social disability, and handicap. Sample items include, “Has your diet ever been unsatisfactory because of problems with your teeth, mouth, or dentures?” and “Have you ever been self-conscious because of your teeth, mouth, or dentures?” Items are rated on a 5-point Likerttype scale ranging from 0 (never) to 4 (very often). Higher OHIP-14 scores indicate greater impact of oral conditions, thus poorer oralhealth-related quality of life. The OHIP-14 has demonstrated good reliability, construct and discriminant validity, and internal consistency (Slade, 1997; Steele et al., 2004). In the present analyses, the OHIP-14 total score (˛ = .93) was used to index global oral healthrelated quality of life. 1.3. Data analytic plan First, descriptive characteristics of participants were evaluated with regard to dental phobia, panic symptoms, dental anxiety, and oral health-related quality of life. Second, a series of independent samples t-tests was conducted to compare dental anxiety, oral health-related quality of life, and endorsement of clinically significant panic symptoms (CSR ≥ 4) between those with sub-clinical and clinically significant dental phobia. Third a series of bivariate correlations was conducted among endorsement of clinically significant panic symptoms, dental anxiety, avoidance of dental procedures (as assessed by the ADIS-IV), and oral health-related quality of life. These correlations were examined both among the total sample and the sub-group of individuals with a diagnosis of dental phobia. Fourth, among the clinically significant dental phobia sub-group, a series of bivariate correlations was conducted among endorsement of specific clinically significant panic symptoms and anxiety ratings of specific dental procedures (drilling, scaling and polishing, and injections). 2. Results 2.1. Participant characteristics Table 1 provides descriptive characteristics of participants who did/did not meet criteria for clinically significant dental phobia. Among the total sample of participants (N = 61), all of whom endorsed some degree of dental phobia symptoms, participants received dental phobia CSRs that ranged from very mild (CSR = 1; n = 7) to severe/very severe (CSR = 7; n = 3), with a median CSR of mild/moderate (CSR = 3). The most common anxiety-eliciting dental procedures participants mentioned during diagnostic interviews were injections (n = 24), tooth extractions (n = 11), drilling (n = 7), and root canals (n = 3). Over half (57.4%) of the total sample endorsed at least one clinically significant panic symptom, and almost one-fifth (16.4%) of the sample endorsed four or more clinically significant panic symptoms, one of the DSM-5 criteria for a panic attack (APA, 2013). The most commonly endorsed clinically significant panic symptoms were cardiac sensations (32.8%), nausea/stomach distress (19.7%), sweating (18.0%), and trembling/shaking (13.1%). Please see Table 2 for further information regarding frequency of endorsement of each of the DSM-5 panic

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Table 1 Descriptive data and comparisons between sub-clinical and clinically significant dental phobia groups.

Dental phobia CSR Clinically significant panic symptoms Cardiac sensations Sweating Trembling/shaking Shortness of breath Choking Chest pain Nausea/abdominal distress Dizziness/faintness Derealization/depersonalization Paresthesias Chills/hot flushes Fear of losing control Fear of going crazy Fear of dying Total # clinically significant panic symptoms MDAS total score OHIP total score

Sub-clinical dental phobia (n = 36)

Clinical dental phobia (n = 25)

M

M

SD

t

p

SD

2.03

0.65

5.24

1.09

13.17

<.001

0.22 0.06 0.03 0.06 0.06 0.00 0.14 0.00 0.03 0.00 0.03 0.00 0.00 0.00 0.61 14.19 18.42

0.42 0.23 0.17 0.23 0.23 0.00 0.35 – 0.17 – 0.17 0.00 0.00 0.00 0.96 4.07 10.17

0.48 0.36 0.28 0.20 0.12 0.08 0.28 0.16 0.12 0.17 0.20 0.08 0.08 0.12 2.72 19.08 30.52

0.51 0.49 0.46 0.41 0.33 0.28 0.46 0.37 0.33 0.38 0.41 0.28 0.28 0.33 2.34 4.28 10.99

2.08 2.89 2.63 1.60 0.89 1.45 1.30 2.14 1.28 2.15 2.00 1.45 1.45 1.81 4.27 4.51 4.42

.043 .007 .014 .119 .375 .161 .201 .043 .209 .043 .055 .162 .161 .083 <.001 <.001 <.001

Note. CSR = Anxiety Disorders Interview Schedule for DSM-IV Clinician Severity Rating; MDAS = Modified Dental Anxiety Scale; OHIP = Short-Form Oral Health Impact Profile. CSR and ratings of panic symptoms are on a 0–8 scale, with higher scores representing greater severity. Significant between-group comparisons appear in bold print.

symptoms in the total sample and the clinically significant dental phobia subgroup. Of the total sample, 25 participants received a dental phobia CSR of four or above, indicating that they met criteria for a diagnosis of dental phobia. In this group, CSRs ranged from moderate (CSR = 4; n = 9) to severe/very severe (CSR = 7, n = 3), with a median CSR of moderate/severe (CSR = 5). Over three-quarters (76.0%) of participants in this group endorsed at least one clinically significant panic symptom, and one-third (33.0%) endorsed four or more clinically significant panic symptoms. The most commonly endorsed clinically significant panic symptoms in this group were cardiac sensations (48.0%), sweating (36.0%), trembling/shaking (28%), and nausea/stomach distress (28%, see Table 2). 2.2. Comparisons between sub-clinical and clinically significant dental phobia groups Table 1 provides comparisons on the variables of interest between the sub-clinical and clinically significant dental phobia groups. Compared to participants with sub-clinical symptoms of dental phobia, those who met criteria for a formal diagnosis of dental phobia exhibited significantly higher levels of dental anxiety and

significantly worse oral health-related quality of life. Participants with a diagnosis of dental phobia also endorsed more clinically significant panic symptoms than did those with sub-clinical symptoms of dental phobia. In terms of individual clinically significant panic symptoms, those with a diagnosis of dental phobia were significantly more likely to endorse cardiac sensations, sweating, trembling/shaking, dizziness/faintness, and paresthesias (numbness and tingling sensations) than were those with sub-clinical dental phobia symptoms. 2.3. Correlates of panic symptoms in the total sample and the dental phobia subgroup In the total sample, endorsement of a greater number of clinically significant panic symptoms was associated with dental anxiety (r = .49, p < .001), avoidance of dental procedures (r = .31, p = .015), and poorer oral health-related quality of life (r = .49, p < .001). Among participants who met diagnostic criteria for dental phobia, endorsement of a greater number of clinically significant panic symptoms was associated with poorer oral health-related quality of life (r = .62, p < .001) but was only modestly associated with dental

Table 2 Frequency of endorsement of dental phobia-related panic symptoms among the total sample and clinically significant dental phobia subgroup. Total sample (N = 61)

Cardiac sensations Sweating Trembling/shaking Shortness of breath Choking Chest pain Nausea/abdominal distress Dizziness/faintness Derealization/depersonalization Paresthesias Chills/hot flushes Fear of losing control Fear of going crazy Fear of dying

Clinical dental phobia (n = 25)

Frequency

Percentage

Frequency

Percentage

20 11 8 7 5 2 12 4 4 4 6 2 2 3

32.8 18.0 13.1 11.5 8.2 3.3 19.7 6.6 6.6 6.6 9.8 3.3 3.3 4.9

12 9 7 5 3 2 7 4 3 4 5 2 2 3

48.0 36.0 28.0 20.0 12.0 8.0 28.0 16.0 12.0 16.0 20.0 8.0 8.0 12.0

Note. Frequency = number of people who endorsed experiencing each panic symptom at a clinically significant level (clinician severity rating ≥4). Percentage = percentage of sample who endorsed experiencing each panic symptom at a clinically significant level.

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anxiety (r = .39, p = .057) and was not associated with avoidance of dental procedures (r = .17, p = .405). However, higher dental anxiety was significantly correlated with greater endorsement of clinically significant cardiac sensations (r = .48, p = .016) and sweating (r = .52, p = .007). In terms of associations between specific panic symptoms and anxiety related to specific dental procedures, the panic symptom of sweating was associated with anxiety related to both drilling and injections (r’s > .41, p’s < .041), whereas the panic symptom of cardiac sensations was specifically associated with anxiety related to drilling (r = .45, p = .025). There were no significant associations between clinically significant panic symptoms and anxiety related to scaling and polishing.

3. Discussion The present findings are generally consistent with our hypotheses about the associations between panic symptoms and dental phobia. As predicted, individuals who met criteria for a diagnosis of dental phobia reported experiencing more clinically significant panic symptoms related to dental procedures than did those with sub-clinical dental phobia. Specifically, this group was more likely to endorse the occurrence of cardiac sensations, sweating, trembling/shaking, dizziness/faintness, and paresthesias. This finding suggests that assessing for the presence and symptom composition of panic attacks may help determine whether an individual is experiencing dental phobia at a clinical level. It is noteworthy that the panic symptoms dizziness/faintness and paresthesias were associated with a diagnosis of dental phobia, as these symptoms have been found to be more prevalent in individuals with panic disorder than in those with specific phobia (Rapee et al., 1992). It is possible that the symptoms of dental phobia overlap more with panic disorder than is the case for other specific phobias or that dental phobia is more highly comorbid with panic disorder than are other specific phobias, and this is worthy of future research attention. The association of dizziness/faintness with dental phobia also suggests that some individuals with dental phobia may exhibit the biphasic physiological response to dental procedures that often results in vasovagal fainting (Öst et al., 1984), and this is another important direction for future research. It would be interesting to examine the specific fears endorsed by individuals with dental phobia who do/do not experience fainting when they encounter dental procedures to see if fainting is associated with more typical BII phobia-related fears (e.g., fear of receiving an injection) as opposed to dental procedure-specific fears (e.g., fear of losing teeth). Future studies comparing endorsement of panic symptoms across different anxiety disorders are also needed to evaluate which symptoms are more or less related to dental phobia. This line of future work will help clarify how the assessment of panic symptoms can improve the differential diagnosis of dental phobia and other highly associated anxiety disorders, such as social anxiety disorder (Moore et al., 2004), and whether dental phobia appears to involve the same type of physiological arousal as other subtypes of BII phobia (van Houtem et al., 2013). Also consistent with our expectations, in the total sample, experiencing more dental phobia-related panic symptoms was associated with greater dental anxiety, avoidance of dental procedures, and poorer oral health-related quality of life. However, only the associations between panic symptoms and dental anxiety and poor oral health-related quality of life held among the subset of participants who met diagnostic criteria for dental phobia. It is possible that the small size of the clinically significant dental phobia group did not provide enough power to detect a more moderate association between dental phobia-related panic symptoms and avoidance of dental procedures, and future studies examining this relationship among larger samples of individuals with a diagnosis of dental

phobia are needed. Restricted range of scores may also have been a problem on some measures in the dental phobia group, although a number of relationships were quite robust. Still, the observed associations between panic symptoms, dental anxiety, and poor oral health-related quality of life in the clinically significant dental phobia group suggest that individuals with dental phobia who experience panic symptoms represent more severe and complex cases. Our findings support the use of panic attacks as a clinical specifier for dental phobia as is recommended in DSM-5 (APA, 2013). It is noteworthy that in both the total sample and the clinically significant dental phobia subgroup, those with panic symptoms were more likely to experience oral health-related impairment (as assessed by the OHIP-14), such as difficulties with speaking, eating, or sleeping. There are a number of ways that dental phobia-related panic symptoms may serve as a barrier to dental care and place individuals at increased risk for experiencing problems related to poor oral health. Our finding that panic symptoms were related to avoidance of dental procedures in the total sample suggests that individuals who experience dental phobia-related panic symptoms may be more likely to avoid dental procedures, which may lead to greater oral health impairment. Another reason that individuals who experience dental phobia-related panic may receive inadequate dental care is that many dental procedures cannot be safely performed on individuals who exhibit increased physiological arousal (Brand et al., 1995; Little, 2000). Dentists routinely measure patients’ blood pressure before and during invasive dental procedures, such as placement of dental implants, and stop procedures if patients exhibit high blood pressure or sudden changes in pressure (Little, 2000). Given that panic symptoms are marked by elevated physiological arousal, patients who experience dental phobia-related panic may be more likely to be denied dental care and therefore at increased risk for experiencing subsequent oral health-related impairment. Since over three-quarters of the clinical dental phobia group reported experiencing at least one clinically significant panic symptom, addressing dental phobia-related panic may be an important component of treatment for many individuals and may improve anxious individuals’ access to dental care. Future work on clinical interventions for dental phobia should examine if individuals with dental phobia who experience panic symptoms benefit from interoceptive exposure (Craske et al., 1991) to the physical and cognitive symptoms experienced in anticipation of or during dental procedures, and if incorporating interoceptive exposure into therapy reduces physiological arousal during dental treatment and improves delivery of care. Our hypothesis that panic symptoms would be associated with specific anxiety-eliciting dental procedures among the clinically significant dental phobia subgroup was partially supported. Of the three procedures assessed by the MDAS (drilling, injections, and scaling and polishing), cardiac sensations were associated with anxiety related to drilling, and sweating demonstrated associations with anxiety related to both drilling and injections. These findings provide very preliminary evidence that dental phobia-related panic symptoms may vary depending on the procedure in question, perhaps because different dental procedures evoke distinct physical sensations. For example, oral X-rays involve placing a piece of film in the mouth and therefore may be more likely to induce feelings of choking than receiving a filling would. It is important to further examine associations between specific anxiety-eliciting dental procedures and panic symptoms to inform potential treatment targets for dental phobia. It is possible that individuals with dental phobia who experience anxiety related to different procedures may benefit from different exposure exercises that address distinct panic symptom profiles. The current study has a number of strengths and limitations that should be considered in interpreting the findings. Our study included a diagnostic interview, which allowed us to examine

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associations between panic symptoms and dental anxiety among individuals who met DSM-IV criteria for dental phobia. A limited number of published studies on dental anxiety have included a diagnostic assessment of dental phobia (Gordon et al., 2013), and the present study is an addition to that literature. However, only 25 participants met criteria for dental phobia, which limited the sample size of the clinical group. Further, as we only administered self-report measures and the specific phobia module of the ADIS-IV, we were unable to examine or control for psychiatric comorbidity and our measures were limited to self-report and clinician ratings. Additionally, the specific phobia module of the ADIS-IV does not include questions regarding the timing of panic symptoms, so we were unable to examine whether panic symptoms occurred in anticipation of, during, or after dental procedures. Future studies examining panic and dental anxiety in larger clinical samples that include a comprehensive diagnostic assessment and other types of measurement (e.g., behavioral, physiological) are necessary. Our sample was comprised of individuals seeking dental care at a university clinic who exhibited symptoms of dental phobia, many of whom met criteria for clinically significant dental phobia and had a history of avoidance of dental procedures. However, our findings may not generalize to individuals who completely avoid dental treatment, and future studies should examine correlates of dental phobia among this group. Another limitation of the present study is that anxiety related to specific dental procedures was assessed using single items on the MDAS. Future studies should build off of our preliminary findings on the associations between panic symptoms and specifically feared dental procedures by including more detailed assessments that measure anxiety related to a wider range of dental procedures. The present findings provide preliminary evidence that most individuals with clinically significant dental phobia experience dental anxiety-related panic symptoms, illustrating the need for targeting them in the treatment of dental phobia. Assessing panic symptoms among individuals with dental phobia appears to be clinically useful in making diagnoses and identifying more severe cases that may necessitate augmented treatment. Conflicts of interest The authors of this manuscript do not have any direct or indirect conflicts of interest, financial or personal relationships or affiliations to disclose. Acknowledgements Portions of this paper were presented at the 2013 annual meeting of the Association for Psychological Science in Washington DC, and the presentation was supported in part by a Building Bridges Award from the National Institute of Dental and Craniofacial Research to Carrie M. Potter. This research was supported in part by a grant from the Pennsylvania Department of Health to Marisol Tellez (grant number 100054871). References American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Press. Batelaan, N. M., Rhebergen, D., de Graaf, R., Spijker, J., Beekman, A. T. F., & Penninx, B. W. J. H. (2012). Panic attacks as a dimension of psychopathology. Journal of Clinical Psychiatry, 73, 1195–1202. http://dx.doi.org/10.4088/JCP.12m07743 Berggren, U. (1993). Psychosocial effects associated with dental fear in adult dental patients with avoidance behaviours. Psychology and Health, 8, 185–196. http://dx.doi.org/10.1080/08870449308403178 Berggren, U., & Meynert, G. (1984). Dental fear and avoidance: Causes, symptoms, and consequences. Journal of the American Dental Association, 109, 247–251.

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