Philip Weinstein

Origins of childhood dental fear

This study explored Rachmans theory of fear acquisition applied to fear of the dentist in a large sample of low income American primary school children. Children and their mother/guardians were interviewed or completed questionnaires in the home about fear acquisition and related concerns. A multivariate logistic regression model was evaluated in order to explore the relationship of direct conditioning and modeling variables to fear levels. Both direct conditioning and parent modeling factors were significant independent predictors of fear level even when controlling for gender, age and other sociodemographic and attitudinal factors.

Psychopathology and psychiatric diagnosis in subjects with dental phobia

Abstract To determine the diagnostic and psychopathologic characteristics of subjects with dental phobia, 73 subjects with dental phobia were systematically assessed using structured clinical interviews and multiple rating scales already validated as measures of dental phobia. Forty percent of the sample had a current Axis I diagnosis other than simple phobia, mostly anxiety (20%) or mood (16%) disorder. This subgroup had more Axis II diagnoses, functional impairment, generalized phobic avoidance, and somatization tendencies, higher harm avoidance scores on the TPQ, and more dental fear. Subgroupings based on the presence of an Axis II diagnosis, a lifetime Axis I diagnosis, multiple phobias, and type of dental fear yielded far fewer differences on the above diagnostic and psychometric measures. It remains to be seen whether using both DSM-III-R diagnoses and already validated dental fear classification schemes will improve treatment planning and outcome for these patients.

Adolescent dental fear and control: prevalence and theoretical implications.

This study examined the prevalence and etiology of dental fear in a large, representative sample of Singapore adolescents. Participants completed a questionnaire regarding fear of the dentist, dental beliefs and their most recent dental visit. The population prevalence of high dental fear was 115 fearful children per 1000 population (SE = 0.02). Children who reported painful treatment and perceived lack of control at the dentist were 13.7 times more likely to report high fear and 15.9 times less likely to be willing to return to the dentist or dental nurse. The etiology of severe clinical fear appears strongly related to direct conditioning in the presence of pain and vulnerability.

An Explanatory Model of the Dental Care Utilization of Low-Income Children

OBJECTIVES Factors related to the utilization of dental care by 5- to 11-year-old children from low-income households were investigated using a comprehensive multivariate model that assessed the contribution of structure, history, cognition, and expectations. The influence of dentist-patient interactions, psychosocial and health beliefs, particularly fear of the dentist, on utilization were investigated. METHODS Children were chosen randomly from public schools, and 895 mothers were surveyed and their children were interviewed in the home. Utilization was studied during the 1991-1992 school year, including a 6-month follow-up period after the interview. RESULTS The overall utilization rate was 63.2%, and the rate for nonemergent (preventive) visits was 59.9%. Utilization was unrelated to actual oral health status. Race and years the guardian lived in the United States were predictive of an episode of care. Preventive medical visits and perceived need were strong predictors of a visit to the dentist, as were beliefs in the efficacy of dental care. Mothers who were satisfied with their own care and oral health and whose children were covered by insurance were more likely to utilize childrens dental care. In contrast, child dental fear and absences from school for family problems were associated with lower rates of utilization. CONCLUSIONS Mutable factors that govern the use of care in this population were identified. These findings have implications for the design of dental care delivery systems for children and their families.

The use of nitrous oxide in the treatment of children: results of a controlled study

The sequential analysis of behavior has begun to show that the behavior of the dentist is a major influence on the fear-related behaviors of children, even when N2O is used. The moment-to-moment behaviors of the dentist influence the childs behaviors. Certain behaviors of dentists, such as distraction, appear to be effective especially when the N2O is being administered.

Additional psychometric data for the Spanish Modified Dental Anxiety Scale, and psychometric data for a Spanish version of the Revised Dental Beliefs Survey.

BackgroundHispanics comprise the largest ethnic minority group in the United States. Previous work with the Spanish Modified Dental Anxiety Scale (MDAS) yielded good validity, but lower test-retest reliability. We report the performance of the Spanish MDAS in a new sample, as well as the performance of the Spanish Revised Dental Beliefs Survey (R-DBS).MethodsOne hundred sixty two Spanish-speaking adults attending Spanish-language church services or an Hispanic cultural festival completed questionnaires containing the Spanish MDAS, Spanish R-DBS, and dental attendance questions, and underwent a brief oral examination. Church attendees completed the questionnaire a second time, for test-retest purposes.ResultsThe Spanish MDAS and R-DBS were completed by 156 and 136 adults, respectively. The test-retest reliability of the Spanish MDAS was 0.83 (95% CI = 0.60-0.92). The internal reliability of the Spanish R-DBS was 0.96 (95% CI = 0.94-0.97), and the test-retest reliability was 0.86 (95% CI = 0.64-0.94). The two measures were significantly correlated (Spearmans rho = 0.38, p < 0.001). Participants who do not currently go to a dentist had significantly higher MDAS scores (t = 3.40, df = 106, p = 0.003) as well as significantly higher R-DBS scores (t = 2.21, df = 131, p = 0.029). Participants whose most recent dental visit was for pain or a problem, rather than for a check-up, scored significantly higher on both the MDAS (t = 3.00, df = 106, p = 0.003) and the R-DBS (t = 2.85, df = 92, p = 0.005). Those with high dental fear (MDAS score 19 or greater) were significantly more likely to have severe caries (Chi square = 6.644, df = 2, p = 0.036). Higher scores on the R-DBS were significantly related to having more missing teeth (Spearmans rho = 0.23, p = 0.009).ConclusionIn this sample, the test-retest reliability of the Spanish MDAS was higher. The significant relationships between dental attendance and questionnaire scores, as well as the difference in caries severity seen in those with high fear, add to the evidence of this scales construct validity in Hispanic samples. Our results also provide evidence for the internal and test-retest reliabilities, as well as the construct validity, of the Spanish R-DBS.

Situation-specific child control : a visit to the dentist

This paper describes the development of the Child Dental Control Assessment (CDCA), a situationally-specific measure of control strategies for school-age children visiting the dentist. A pilot proceeded two definitive studies. In the pilot, the instructions and a battery of items were pretested. The first study was with 180 children and gathered data in a classroom setting to establish the psychometric characteristics of the instrument. Factor analysis, accounting for over 50% of the variance, suggested five scales: Dentist-Mediated Control, Active Coping, Cognitive Withdrawal, Reassurance, and Physical Escape. Internal consistency of the scales constructed from the factors ranged from 0.5 to 0.7. The highest standardized scale scores were for Reassurance and Dentist-Mediated Control. Younger children reported a greater need for Active Coping. In the second study in a clinical setting, children completed an assessment battery and were trained to use a signalling device. Higher CDCA scores for the Active Coping scale, but not the other scales, were associated with the use by subjects of a device to signal the dentist. The proposed measure allows assessment of individual differences among children of the same age as well as developmental differences between age groupings of children.

Pharmacokinetics of oral triazolam in children

The purpose of this study was to determine the pharmacokinetic behavior of triazolam in children. Nine healthy children, aged 6 to 9 years, received oral triazolam (0.025 mg/kg suspended in Kool-Aid, Kraft General Foods, Chicago, IL) before dental treatment. Plasma triazolam concentrations were measured by gas chromatography/mass spectrophotometry at approximately 5, 15, 30, 45, 60, 90, 120, 180, and 240 minutes. A one-compartment model with first-order absorption and varying parameters was used, and estimated concentration curves were obtained for each subject. The observed peak plasma concentration was 8.5 +/- 3.0 ng/mL (mean +/- SD). The observed time to peak plasma concentration was 74 +/- 25 minutes. Elimination half-life was 213 +/- 144 minutes. Substantial recovery from signs and symptoms of clinical sedation required 180 to 240 minutes. The long duration of effect and relatively slow elimination should be noted by clinicians concerned with patient safety.

Beliefs about professional ethics, dentist-patient communication, control and trust among fearful dental patients: the factor structure of the revised Dental Beliefs Survey.

The revised version of the Dental Beliefs Survey (DBS‐R), intended to measure three dimensions of the patient–dentist relationship as perceived by the patient, namely Ethics, Communication and Control, was tested in a confirmatory factor analysis. Five different models for the internal structure of the questionnaire were tested. The final model, a 5‐factor solution, basically including the 3 assumed dimensions as well as the re‐introduced dimension Trust covered in the first version of the DBS plus a global factor including all items, yielded an acceptable fit. This model also omits 4 items from DBS‐R, i.e. items 3, 11, 18, and 28. The reduced DBS‐R is recommended for clinical use when assessing the patients perception of the relationship to the dentist, including both trust and ethical behavior.

The anxiolytic effects of intravenous sedation using midazolam alone or in multiple drug techniques

This study examines four drug combinations (midazolam, midazolam-midazolam, fentanyl-midazolam, and fentanyl-midazolam-methohexital) in a placebo-controlled double-blind clinical trial of intravenous sedation. It tests the hypothesis that there is no difference between the anxiolytic effect of the four combinations when compared with a saline placebo. Subjects were 207 mildly anxious young adults having their third molars removed. Cognitive measures of anxiety increased from preoperative levels in the placebo and both midazolam groups (P < .05). The anxiety response remained the same in the fentanyl-midazolam and fentanyl-midazolam-methohexital groups (P > .05). The level of successful anxiolysis ranged from 24% in the placebo group to 74% in the barbiturate group. Using the log likelihood method, comparisons suggest that the drug groups (from midazolam alone to the methohexital combination) have increasingly positive anxiolytic effects even when controlling for the effects of dental fear and intraoperative pain. The fentanyl-midazolam group is 8.1 and the methohexital group is 9.0 times more likely to have had a favorable outcome than the placebo group. Additional analyses of behavioral measures of anxiety yielded parallel results. Global evaluations after surgery were related to the success of anxiolysis for subjects in the active drug conditions (P < .05).