Conquering dental fear through use of a mobile app

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A novel mobile application developed by researchers from NYU College of Dentistry and Penn School of Dental Medicine offers a home-based solution for alleviating dental anxiety through cognitive behavioural therapy and mindfulness techniques. (Image: David Song/NYU)

Dental fear is estimated to affect nearly one-third of adults globally, and the condition leads to avoidance of dental visits and has negative implications for oral and systemic health. In a recent study, researchers from the New York University (NYU) College of Dentistry and Penn School of Dental Medicine introduced Dental FearLess, an innovative mobile health app and optional one-on-one psychological session that aims to help users get back into the dental chair. The study found that the app offered a stepped-care approach to the cognitive behavioural therapy (CBT) of dental fear that could have a significant impact, and the researchers are currently recruiting US-based participants for a clinical trial. In this interview, Dr Kelly Daly, NYU research scientist and project director for Dental FearLess, explained why we need a new approach to treating the condition and how new technologies can help.

Dr Daly, what can you tell us about dental fear and how it manifests?
We know that dental fear causes people discomfort, impairment and suffering and that the condition is extremely common. About one in five people experience moderate to severe fear. Dental fear, or dental anxiety, can manifest in a breadth of physiological and cognitive symptoms. Having dental fear can mean anything from being apprehensive and ruminating for the week or weeks prior to a dental appointment and being miserable and struggling through it to absolute terror and avoidance of the dentist altogether. Like other major fears and anxieties, dental fear causes bodily responses such as sweating, a quickened heart rate, faster breathing and panic attacks. It can also provoke catastrophic thoughts. Those who suffer from the condition may think things like “The dentist is going to accidentally hit a nerve and paralyse me”, “I’m going to pass out and humiliate myself” or “The pain will be unbearable. I can’t handle this.” People experience fear and anxiety to the degree that they avoid the dentist altogether and tend to only receive emergency oral care. Emergency appointments, of course, are more intensive and painful than routine treatment, and fearful people take this as confirmation that they were right all along—that seeing a dentist is a negative, painful experience. This just perpetuates the avoidance, and the cycle continues.

Over time, we know that dental fear is associated with oral health decline, overall poorer systemic health and lower quality of life.

Why did the research team opt for a mobile app supported by video consultation?
Interestingly, there is an incredibly successful treatment for dental fear: a CBT treatment that has over two dozen studies demonstrating its efficacy. It is helpful; however, only a handful of specialty clinics worldwide offer this intervention, and very few people receive it. Mental health practitioners are not trained to provide the treatment, and patients and dentists often do not even know that it exists.

As the requisite skills for CBT for dental fear are very different from the ones that dentists learn at university, clinicians must receive secondary CBT training or have a close partnership with a trained mental health provider in order to provide this therapy. A limited number of dentists have been successfully trained, and these tend to be clinicians working in specialty clinics in collaborative atmospheres that have a large mental health focus. Another major accessibility barrier is that the treatment traditionally requires about 3 hours of chair time, meaning that dental teams cannot see other patients and provide billable treatment while the CBT is being administered.

So, we have a population who really needs this treatment, and we have a treatment that does work; however, no one gets it. Few are trained to provide it, it is extremely hard to access, and it is cost ineffective.

The past decade has taught us that a lot of CBT—at least at a foundational level—can be automated. Apps can successfully teach evidence-based skills to challenge distorted thinking, behaviour skills to adaptively confront fears and physiological techniques to regulate emotions. In addition, they can provide psycho-education about how anxiety is maintained and about the object of the fear itself. One example is the demystifying of dental tools, such as needles, which can become somewhat less scary to patients if they understand that their design is functional. Translating what works from in-person treatment to an app made sense to us as a way to disseminate some of these foundational skills and techniques to people who suffer from dental fear.

The Dental FearLess app is an adaptive treatment intervention and offers an optional one-on-one psychological session. (Image: David Song/NYU)

How does the optional video consultation build on the user’s experience with the app?
The app delivers a sort of foundational version of CBT for dental fear, and we think that people with mild to moderate dental fear could use it to learn skills and create a plan that will sufficiently change the relationship they have with the dentist. However, as with any other fears or phobias, there is a spectrum. People with more severe cases of fear, especially those who have experienced a dental or medical trauma, will likely require further help. So, for people who remain at moderate fear or above after having used the app, we provide a one-on-one virtual video session with a mental health provider that is specifically tailored to this person’s individual fears.

For example, I had a case in which someone had a medical procedure go wrong several years earlier, and she had experienced facial paralysis on the left side for several months as a result. She was terrified of letting anyone near her mouth and had not been to a dentist since this incident. So, our session incorporated coping skills and techniques that she learned from the app and focused on helping her to practise confronting her fear. The model itself is an adaptive treatment intervention that is used across different medical specialties, the idea being to treat people with dental fear with the lower “dose” and see how they do. Those who do not sufficiently respond then receive an additional “dose”.

How do the study results compare with those of existing evidence-based CBT treatment?
In general, CBT treatments for specific fears and phobias produce incredible results, and they can be produced remarkably quickly, especially when compared with those aimed at treating conditions like post-traumatic stress disorder or depression. What is really promising is that we found that the performance of our entirely virtual treatment was really close to that seen in in-person CBT for dental fear. In our pilot study, half of the participants were no longer fearful after completing the intervention.

The best part for us has been actually hearing from participants after they go to that first post-intervention dental appointment. It has been incredibly rewarding to receive personal emails thanking us and explaining how participants are no longer worried about passing this on to their children or that they have finally been able to receive desperately needed oral care to relieve chronic pain.

Much of what we are doing with our research is focused on exposure. 

What can you tell us about the potential to add virtual reality (VR) technology to the app?
Research psychologists have for some time been exploring the delivery of treatment via VR. Much of what we are doing with our research is focused on exposure—the sights and sounds in the app and the entire one-on-one virtual experience are designed to simulate a dental office.

Essentially, the premise of modern CBT is the idea that people conquer fears and phobias not just by being exposed and getting used to them but by disconfirming that the awful things they are convinced are going to happen actually will or by disconfirming their own inability to tolerate the fear. The company that we worked with to produce the Dental FearLess app specialises in VR-based technology for psychotherapy. We realised that it could be used to create a real-time dental visit that includes the characters and stimuli that evoke someone’s fears but also give him or her the chance to practise some of the strategies learned in the app. The participant could be exposed virtually to the thing they are most afraid of while actively applying a different approach—a sort of dress rehearsal for practising learned techniques and starting to confront their fear, albeit in a fictitious dental office setting.

We hope that VR technology might offer a viable alternative to the one-on-one individualised treatment session, as this would not require a mental health provider, or that it might increase the appeal of the app to a different subset of people with dental fear. Across the board, the goal is to get people to approach their actual dental visit differently—for many, it means making it into the office for the first time in years—and to test out whether the evidence-based approaches they have learned in the app make a difference. We know for the vast majority they really do.

Do you feel that Dental FearLess has the potential to increase equity of access to oral care?
This is a complex question. I think there are so many systemic biases and barriers that really complicate the vision of equitable access to oral healthcare, be they financial or geographic in nature or related to health literacy. I know that some individuals who had faced a number of these barriers found Dental FearLess empowering, reporting that it gave them a better sense of what treatment should look like, what they were entitled to ask and understand, and the coping skills required to manage their fear so that they felt like actual partners in their care. I found that incredibly heartening. I think that the work we are doing is definitely a step in the right direction when it comes to increasing equity of access, and I cannot think of a better contribution than empowering people to participate in their own healthcare.

Editorial note:

The study, titled “Leveraging technology to increase the disseminability of evidence-based treatment of dental fear: An uncontrolled pilot study”, was published online on 19 December 2023 in the Journal of Public Health Dentistry, ahead of inclusion in an issue. For information about the clinical trial, visit the project website.

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