Changes in symptoms of anxiety, depression, and PTSD in an RCT-study of dentist-administered treatment of dental anxiety

(2023) 23:415 Hauge et al. BMC Oral Health https://doi.org/10.1186/s12903-023-03061-4 BMC Oral Health Open Access RESEARCH Changes in symptoms of anxiety, depression, and PTSD in an RCT‑study of dentist‑administered treatment of dental anxiety Mariann Saanum Hauge1,2*†, Tiril Willumsen1 and Bent Stora3† Abstract Background Educating dentists in treatment methods for dental anxiety would increase the patients’ access to treatments that are important to their oral health. However, to avoid adverse effects on comorbid symptoms, involvement by a psychologist has been considered necessary. The objective of the present paper was to evaluate whether a dentist could implement systematized treatments for dental anxiety without an increase in comorbid symptoms of anxiety, depression or PTSD. Methods A two-arm parallel randomised controlled trial was set in a general dental practice. Eighty-two patients with self-reported dental anxiety either completed treatment with dentist-administered cognitive behavioural therapy (D-CBT, n = 36), or received dental treatment while sedated with midazolam combined with the systemized communication technique “The Four Habits Model” (Four Habits/midazolam, n = 41). Dental anxiety and comorbid symptoms were measured pre-treatment (n = 96), post-treatment (n = 77) and one-year after treatment (n = 52). Results An Intention-To-Treat analysis indicated reduced dental anxiety scores by the Modified Dental Anxiety Scale (median MDAS: 5.0 (-1,16)). The median scores on the Hospital Index of Anxiety and Depression (HADS-A/D) and the PTSD checklist for DSM-IV (PCL) were reduced as follows: HADS-A: 1 (-11, 11)/HADS-D: 0 (-7, 10)/PCL: 1 (-17,37). No between-group differences were found. Conclusions The study findings support that a general dental practitioner may treat dental anxiety with Four Habits/ Midazolam or D-CBT without causing adverse effects on symptoms of anxiety, depression or PTSD. Establishing a best practice for treatment of patients with dental anxiety in general dental practice should be a shared ambition for clinicians, researchers, and educators. Trial registration The trial was approved by REC (Norwegian regional committee for medical and health research ethics) with ID number 2017/97 in March 2017, and it is registered in clinicaltrials.gov 26/09/2017 with identifier: NCT03293342. Keywords Dental anxiety, CBT, Midazolam, Communication, Anxiety, Depression, PTSD, Sedation † Mariann Saanum Hauge and Bent Storå shared first authorship. *Correspondence: Mariann Saanum Hauge Full list of author information is available at the end of the article © The Author(s) 2023. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativeco mmons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Hauge et al. BMC Oral Health (2023) 23:415 Background Dental anxiety has a high prevalence, and this combined with a high impact on oral health, constitutes a serious public health challenge [1]. In a 2021 meta-analysis the global estimated prevalence of dental anxiety was 15.3% (95% CI 10.2–21.2) [2], meaning that general practicing dentists are required to handle anxious patients nearly on a daily basis. Cognitive behavioural therapy (CBT) is recognized as the treatment of choice for specific phobias, including the most severe form of dental anxiety, dental phobia [3]. A concern for adverse reactions in patients if this sort of treatment (involving exposure) is applied by a dentist without support from a psychologist or a psychiatrist has been raised. Both the severity of the condition as well as common psychiatric comorbidities that could complicate treatment have been proposed as arguments against CBT treatment by dentists [4, 5]. In evidently, dentists do recurrently expose their dental anxiety patients to their fears through regular dental treatment. In a study investigating how an invasive dental treatment (wisdom tooth removal) affected patients, pain and frequency of previous traumatic experiences were found to increase the risk for the development of symptoms of anxiety and post-traumatic stress following the procedure [6]. Although dental treatment may carry a risk for psychological adverse effects, it is difficult to find evidence that justify a concern for adverse reactions following dentist-administered dental anxiety treatments. Contrarily, favourable findings have been reported in the few studies that do exist on the subject [7–9]. Vassend and colleagues even found positive effects on general distress after dentist administered treatments of dental anxiety of varying severity [10]. The daily management of patients with dental anxiety in general dental practices often includes the use of sedatives [11]. A hesitancy towards conscious sedation as part of dental anxiety treatment is endorsed by reports revealing no positive long-term effects on dental anxiety levels [12]. Performing conscious sedation in an optimal manner requires good relational skills as argued by Woolley in 2016 [13]. In line with this, studies that systematically combine conscious sedation with basic skills for patient management generate more promising long-term effects, including stable reductions in dental anxiety [14–16]. The evidence-based communication model “The Four Habits Model” [17] is an example of a method that has proved to be a helpful tool also in combination with sedation treatment [7]. Awareness of the importance of adequate communication and functional dentist-patient relationships for treatment outcome in dentistry is growing [18]. Still, reports on how dentists’ relational skills affect the outcome of Page 2 of 11 dental anxiety treatments are few. Clinical communication skills, including empathetic skills, have been identified as important when dental students interact with fearful patients [19]. Yuan et al. proposed that effective patient-dentist interaction may reduce dental anxiety and shame and thus function as a driver for regular dental visiting [20]. Since empathy has been shown to be particularly important to (...truncated)