Dental anxiety

Being frightened of the dentist is extremely common. It runs from mild dislike, through the kind of dread that occupies the week before an appointment, to a phobia that makes it impossible to pick up the phone at all. Dental practices encounter it every working day, it is a recognised phobia rather than a character flaw, and there is a great deal that can be done about it — most of which costs nothing and simply has to be asked for.

Where it comes from

Rarely from nowhere. The usual sources:

• A bad experience, often in childhood, and particularly one where pain was felt and not believed. Dentistry has changed enormously, but a memory formed at eight years old does not update itself.
• Loss of control. Lying back with the mouth open, unable to speak, while someone works in it. For many people this is the whole of it, and it has nothing to do with pain.
• Needles. A specific fear, and a common one.
• Gagging, or a fear of gagging, choking or not being able to breathe.
• Embarrassment — about the state of the mouth, about how long it has been, about having been told off before.
• The sensory detail: the sound of the drill, the smell, the light, the taste.
• Something else entirely. For some people the position in the chair, held still and unable to speak, resembles other experiences of being physically vulnerable. A practice can work around that if it knows, and it is a reasonable thing to mention without going into any detail at all.

Why it is worth tackling rather than managing

Avoidance does not keep the mouth in the state it was. Small problems become larger ones quietly, so the treatment eventually needed is more extensive than it would have been — which confirms the original fear and deepens the avoidance. That loop runs in one direction and gets harder to break the longer it runs.

There is a second loop around it. The longer the gap, the more embarrassing the gap feels, and the harder it becomes to end. So it is worth saying plainly: dentists see neglected mouths every day and are not shocked by them. A person who has not been for fifteen years is an ordinary new patient, not an exhibit, and nobody is going to be lectured. Any practice that does lecture is the wrong practice, and that is information rather than a verdict on the patient.

Choosing where to go

Say it when booking, in exactly those words — nervous patient, has not been for a long time, needs to take it slowly. What comes back is the most useful information available: a practice that is warm and unhurried about it on the telephone will be the same in the surgery, and one that is brisk and impatient will be that too.

Worth asking: whether they see nervous patients regularly, whether they offer a first appointment that is only a conversation, whether they offer sedation, and how much time they can allow. Many practices will book a first visit with nothing done at all — no instruments, the chair upright, a look in the mouth only if the patient wants one. That appointment is often the whole turning point, and it exists because practices know it works.

The practical measures that make the difference

An agreed stop signal. A raised hand, agreed before anything starts, that means stop now. Not being able to speak is a large part of what makes the chair feel uncontrollable, and knowing the work will halt on a signal removes much of that. It needs agreeing out loud rather than assumed.

Choosing how much to be told. Some people are calmer knowing exactly what is coming next; others find the commentary worse than the treatment. Either preference is fine and either can be asked for.

Timing. An early appointment leaves less of the day to spend dreading it. A short appointment is easier than a long one, and treatment can usually be broken into more, shorter visits.

Company. Bringing someone is reasonable at any age, and most practices will allow them into the surgery.

Distraction. Music or a podcast through headphones works well, and blocks the sound of the drill, which for many people is the worst part. Sunglasses deal with the light. Something to hold occupies the hands.

Breaks. Asking to stop halfway, sit up, rinse and have a minute is ordinary and is not a failure.

Relaxation and breathing techniques genuinely help in the chair, and are worth using — alongside the appointment, not as an alternative to making it.

Gagging, and needles

Both have practical answers and both are worth raising in advance rather than discovered mid-appointment.

For a strong gag reflex: sitting more upright, breathing through the nose, a smaller mirror, keeping the tongue down and forward, a salty taste on the tip of the tongue, and a numbing spray on the palate for impressions. Saying so at the start means the dentist works differently from the outset.

For needles: a topical anaesthetic gel is placed on the gum first and numbs the surface, which removes the sharp part. Not watching helps. And the sensation most people remember is usually the pressure of the anaesthetic entering the tissue rather than the needle itself, which is why giving it slowly makes a real difference — and is something that can be requested.

One thing worth knowing: discomfort during treatment is information the dentist needs, not a complaint. More anaesthetic can be given. Some people genuinely need more than the standard amount, or need a different technique, and that is physiology rather than weakness. Enduring it silently teaches the fear that the chair is a place where pain has to be tolerated, which is the opposite of what is wanted.

Sedation

Where the measures above are not enough, sedation makes treatment possible. It is not all one thing.

Inhalation sedation — a mixture of nitrous oxide and oxygen breathed through a small nosepiece — leaves the patient awake, able to respond and in control, but much less bothered by what is happening. It takes effect within minutes, is adjusted throughout, and wears off within minutes of stopping, so most people can go home unaccompanied. It is widely used for children and anxious adults, is very safe, and is probably the most under-asked-for thing in this article.

Oral sedation is a tablet taken before the appointment. It takes the edge off rather than transforming the experience, and requires someone to accompany the patient home.

Intravenous sedation goes deeper. The patient remains conscious and breathing independently — it is not a general anaesthetic — but is profoundly relaxed and usually remembers little or nothing of the appointment afterwards, which is often precisely the point. It requires an escort, no driving for the rest of the day, instructions about eating and alcohol, and recovery time. A great deal of treatment can be completed in one session this way.

General anaesthetic is carried out in hospital and reserved for particular circumstances. It carries risks of its own, which is why it is not the default route for anxiety however severe.

Availability varies, and sedation is frequently charged privately even within an NHS practice, so it is worth asking what is available and on what basis before committing to a plan.

Treating the phobia itself

Sedation makes treatment possible. It does not make the next appointment easier, and used on its own indefinitely it can entrench the belief that the chair is unsurvivable without it.

For a genuine phobia the treatment is psychological. Cognitive behavioural therapy for dental anxiety has good evidence behind it, works largely through graded exposure — approaching the situation in steps small enough to be manageable — and produces lasting change rather than a way around the problem. The combination that tends to work best is sedation to get the necessary treatment done, with psychological treatment in parallel to reduce the need for it next time.

Some areas have specialist dental anxiety services, and community dental services take referrals for severely anxious patients. The route in is a dentist or a GP — and for someone who cannot face telephoning a dental practice at all, the GP is the easier first call. Saying "I have not been able to go to the dentist for years and I need help with the fear, not just the teeth" is enough to start it.

Not passing it on

Dental fear is substantially learned, and children pick it up from the adults around them.

• Never use the dentist as a threat, or as the consequence of eating sweets.
• Avoid "it won't hurt" — it introduces the idea of hurting, and it is a promise that may not be kept. "They are going to have a look at your teeth" is better.
• Take children along to ordinary appointments from early on, so the surgery is a familiar room before anything needs doing in it.
• The first visit belongs in the first year, when there is nothing to treat.
• An anxious parent can say so and ask that their own reaction not be commented on in front of the child.

Inhalation sedation is common and well tolerated in children, and is a reasonable thing to ask about rather than something to be saved for a crisis.

See also dental check-ups, paying for dental care and why dental care matters.