Peter Jöhren

Comparison between one-session psychological treatment and benzodiazepine in dental phobia

To compare the effects of a single session of psychological treatment and acute administration of benzodiazepine, 50 dental phobic patients were allocated either to psychological treatment, benzodiazepine, or no treatment for anxiety. Psychological treatment consisted of stress management training and imaginal exposure to phobic stimuli with homework assignments. Benzodiazepine was administered 30 min before dental treatment. Both treatment conditions led to less anxiety during dental surgery than did the control condition. Phobic patients in the benzodiazepine condition showed a relapse after dental treatment, whereas those in the psychological treatment condition showed further improvement until the follow-up 2 months later. Of the latter group, 70% continued dental treatment; only 20% and 10% returned in the benzodiazepine and control conditions, respectively.

Dental anxiety in a representative sample of residents of a large German city

In a demographic survey, 300 residents of a German city were questioned to determine the prevalence of dental anxiety. The correlation between the amount of dental anxiety and the age, sex, and education of the subjects was examined and the reasons for avoiding dentist’s appointments, the duration of this avoidance, and what the subjects desire from future dental treatment. The Hierarchical Anxiety Questionnaire (HAQ) was used to measure the amount of dental anxiety. The average level of anxiety was 28.8±10.1 according to the HAQ. Young people were more afraid than older people (p=0.007), and women were more anxious than men (p=0.004). Of the women, 72% go to the dentist regularly, but only 60% of the men do (p=0.020). A painful experience while receiving dental treatment was given by 67% as the main reason for their dental anxiety, followed by a fear of needles (35%). The people wished for the most accurate information available about the dental treatment they receive (69%), followed by a compassionate dentist (62%), and treatment that is free of pain (62%). Of the people, 11% [95% CI: (7.5%; 14.5%)] suffer from dental phobia. All dental phobics were able to state the cause of their fear and more urgently wished for help from the dentist in overcoming their anxiety than the non-phobics (p=0.030). To satisfy the needs of the phobic patients, it appears necessary to screen the phobics out of the group of all patients and then offer them adequate therapy, or refer these patients to specialised treatment centres.

Predictors of behavioral avoidance in dental phobia: The role of gender, dysfunctional cognitions and the need for control

Abstract Dental anxiety and the related avoidance of dental treatment can result in severe impairment of health. We investigated the influence on avoidance behavior of phobic severity, gender, characteristics related to generalized anxiety and depression, such as dysfunctional cognitions and sensitivity of bodily symptoms, as well as personality traits of self-efficacy and locus of control. Forty-eight dental phobics were given an initial assessment and avoidance behavior was determined by the degree of observance of three subsequent dental appointments. Principal component analysis revealed separate factors for trait and phobic anxiety as well as for avoidance and dysfunctional cognitions. Women showed a higher degree of avoidance than men. Regression analysis revealed a high desire for control over dental treatment combined with a low level of perceived control as the only significant predictor variable of avoidance. The results suggest that avoidance behavior in dental phobia could be reduced by extending patients’ control over treatment conditions.

Internal bacterial colonization of implants: association with peri‐implant bone loss

OBJECTIVES The aim of the present longitudinal study was to investigate bacterial colonization of the internal implant cavity and to evaluate a possible association with peri-implant bone loss. METHODS A total of 264 paper point samples were harvested from the intra-implant cavity of 66 implants in 26 patients immediately following implant insertion and after 3, 4, and 12 months. Samples were evaluated for Aggregatibacter actinomycetemcomitans, Fusobacterium nucleatum, Porphyromonas gingivalis, Prevotella intermedia, Treponema denticola, and Tannerella forsythia as well as total bacterial counts by real-time PCR. Bone loss was evaluated on standardized radiographs up to 25 months after implant insertion. For the statistical analysis of the data, mixed effects models were fitted. RESULTS There was an increase in the frequency of detection as well as in the mean counts of the selected bacteria over time. The evaluation of the target bacteria revealed a significant association of Pr. intermedia at 4 and 12 months with peri-implant bone loss at 25 months (4 months: P = 0.009; 12 months: P = 0.021). CONCLUSIONS The present study could demonstrate a progressive colonization by periodontopathogenic bacteria in the internal cavities of two-piece implants. The results suggest that internal colonization with Pr. intermedia was associated with peri-implant bone loss.

Mental retrieval of treatment context in dental phobia.

BACKGROUND The effect of mental retrieval of an exposure session was investigated during a follow-up examination in dental phobia patients. METHOD The exposure session took place at the psychology unit and the follow-up a week later at the dental clinic prior to dental treatment while patients were seated in the dental chair. During exposure, individuals with dental phobia (N = 72) were shown a video of a dental appointment, after which they were instructed to imagine themselves receiving dental treatment. During follow-up half of the participants received instructions to mentally retrieve the exposure session and the other half were asked to recall everyday activities. Before and after exposure treatment, and after mental retrieval, participants were shown three dental instruments while heart rate (HR) and avoidance and subjective units of discomfort (SUD) were recorded. RESULTS Questionnaires of phobic anxiety administered before and after treatment indicated significant improvement. Mental retrieval of treatment was moderately superior to the control condition with regard to avoidance. Over 80% of patients underwent the subsequent dental treatment session. Those not adhering showed initially more dysfunctional cognitions and more desire for control. CONCLUSION There is some evidence that retrieval of treatment context may have a moderately beneficial effect on avoidance.

Genome-wide expression and response to exposure-based psychological therapy for anxiety disorders

Exposure-based psychological treatments for anxiety have high efficacy. However, a substantial proportion of patients do not respond to therapy. Research examining the potential biological underpinnings of therapy response is still in its infancy, and most studies have focussed on candidate genes. To our knowledge, this study represents the first investigation of genome-wide expression profiles with respect to treatment outcome. Participants (n=102) with panic disorder or specific phobia received exposure-based cognitive behavioural therapy. Treatment outcome was defined as percentage reduction from baseline in clinician-rated severity of their primary anxiety diagnosis at post treatment and 6 month follow-up. Gene expression was determined from whole blood samples at three time points using the Illumina HT-12v4 BeadChip microarray. Linear regression models tested the association between treatment outcome and changes in gene expression from pre-treatment to post treatment, and pre-treatment to follow-up. Network analysis was conducted using weighted gene co-expression network analysis, and change in the detected modules from pre-treatment to post treatment and follow-up was tested for association with treatment outcome. No changes in gene expression were significantly associated with treatment outcomes when correcting for multiple testing (q<0.05), although a small number of genes showed a suggestive association with treatment outcome (q<0.5, n=20). Network analysis showed no association between treatment outcome and change in gene expression for any module. We report suggestive evidence for the role of a small number of genes in treatment outcome. Although preliminary, these findings contribute to a growing body of research suggesting that response to psychological therapies may be associated with changes at a biological level.

Die modulierte Schreckreaktion bei Zahnbehandlungsphobie

Zusammenfassung. Theoretischer Hintergrund: Die Zahnbehandlungsphobie ist eine spezifische Phobie, die mit Vermeidung der Zahnbehandlung und dadurch schwerwiegenden Folgen fur die Zahngesundheit einher geht. Zahnarzte gaben an, Zahnbehandlungsphobiker nur ungern behandeln zu wollen, wobei einer der Grunde die erhohte Schreckhaftigkeit dieser Patienten war, die das Unfallrisiko bei der Behandlung erhoht. Fragestellung: Kann bei Zahnbehandlungsphobikern bei phobiebezogenen Hintergrundreizen eine uberhohte modulierte Schreckreaktion nachgewiesen werden? Methoden: 90 Zahnbehandlungsphobikern und 30 Kontrollprobanden wurden Zahnbehandlungsgerausche und – als Kontrollbedingung – Vogelgesang dargeboten, wobei nach jeweils drei von ihnen ein Schreckreiz erfolgte. Zusatzlich zur EMG-Lidschlussreaktion auf den Schreckreiz, wurden die Herzratenreaktion (HR) und die elektrodermale Aktivitat (EDA) auf die Hintergrundreize erfasst. Ergebnisse: Zahnbehandlungsgerausche wurden von beiden Gruppen als angsterregender einge...

Separate and combined effects of genetic variants and pre-treatment whole blood gene expression on response to exposure-based cognitive behavioural therapy for anxiety disorders

Abstract Objectives: Exposure-based cognitive behavioural therapy (eCBT) is an effective treatment for anxiety disorders. Response varies between individuals. Gene expression integrates genetic and environmental influences. We analysed the effect of gene expression and genetic markers separately and together on treatment response. Methods: Adult participants (n ≤ 181) diagnosed with panic disorder or a specific phobia underwent eCBT as part of standard care. Percentage decrease in the Clinical Global Impression severity rating was assessed across treatment, and between baseline and a 6-month follow-up. Associations with treatment response were assessed using expression data from 3,233 probes, and expression profiles clustered in a data- and literature-driven manner. A total of 3,343,497 genetic variants were used to predict treatment response alone and combined in polygenic risk scores. Genotype and expression data were combined in expression quantitative trait loci (eQTL) analyses. Results:Expression levels were not associated with either treatment phenotype in any analysis. A total of 1,492 eQTLs were identified with q < 0.05, but interactions between genetic variants and treatment response did not affect expression levels significantly. Genetic variants did not significantly predict treatment response alone or in polygenic risk scores. Conclusions: We assessed gene expression alone and alongside genetic variants. No associations with treatment outcome were identified. Future studies require larger sample sizes to discover associations.

Dental phobia is no contraindication for oral implant therapy

OBJECTIVES Dental phobia is a psychological disease and a possible contraindication for implant therapy. The study aimed to show that implant therapy in dental-phobic patients (DP, test group) after adequate psychological and dental pretreatment (PDPT) is successfully possible and results in a similar implant prognosis as in nonfearful patients (NF, control group). METHOD AND MATERIALS 15 DP with PDPT and 15 NF were treated with dental implants and were re-evaluated 2 to 4 years after denture-mounting regarding: alteration of dental anxiety (Hierarchical Anxiety Questionnaire [HAQ], Visual Analog Scale [VAS]), patient satisfaction and compliance, implant success, and peri-implant health. Statistical tests of non-inferiority DP versus NF were performed with Hodges-Lehmann estimators and respective one-sided 97.5% confidence intervals of Moses, and pairwise testings with Mann-Whitney test. RESULTS The DP test group rated its anxiety significantly lower at follow- up than at baseline (PHAQ < .001). However, at follow-up, anxiety was still higher in DP than in NF (PHAQ = .046; PVAS < .001). Implant success at follow-up was 100%. Oral health was equally good in DP and NF patients. At follow-up, all patients were satisfied with implant therapy, but compliance was better for NF (100%) than for DP (73% dental checkup; 67% dental hygienist). CONCLUSION Implant therapy can be successfully performed in DP patients with PDPT as phobia is not negatively influenced by the invasive implant therapy. However, motivation for professional maintenance programs remains challenging.

DNA methylation of FKBP5 and response to exposure-based psychological therapy

Differential DNA methylation of the hypothalamic‐pituitary‐adrenal axis related gene FKBP5 has recently been shown to be associated with varying response to environmental influences and may play a role in how well people respond to psychological treatments. Participants (n = 111) received exposure‐based cognitive behavioural therapy (CBT) for agoraphobia with or without panic disorder, or specific phobias. Percentage DNA methylation levels were measured for the promoter region and intron 7 of FKBP5. The association between percentage reduction in clinical severity and change in DNA methylation was tested using linear mixed models. The effect of genotype (rs1360780) was tested by the inclusion of an interaction term. The association between change in DNA methylation and FKBP5 expression was examined. Change in percentage DNA methylation at one CpG site of intron 7 was associated with percentage reduction in severity (β = −4.26, p = 3.90 × 10−4), where a decrease in DNA methylation was associated with greater response to therapy. An interaction was detected between rs1360780 and changes in DNA methylation in the promoter region of FKBP5 on treatment outcome (p = .045) but did not survive correction for multiple testing. Changes in DNA methylation were not associated with FKBP5 expression. Decreasing DNA methylation at one CpG site of intron 7 of FKBP5 was strongly associated with decreasing anxiety severity following exposure‐based CBT. In addition, there was suggestive evidence that allele‐specific methylation at the promoter region may also be associated with treatment response. The results of this study add to the growing literature demonstrating the role of biological processes such as DNA methylation in response to environmental influences.