Discussion
phobia, anxiety, traumatic, PTSD, depression
EVENT, DISORDERS
In the present study comorbid symptoms of anxiety, depression or PTSD did not inhibit the treatment efficiency of two dentist-administered dental anxiety treatment methods. Nor did the treatment delivered coincide with an increase in symptoms of anxiety, depression, or PTSD in neither method. On the contrary, comorbid symptoms decreased during the dental anxiety treatment. Both dentist-administered CBT-treatment and Four Habits Model/midazolam-treatment proved to reduce dental anxiety effectively. The patients evaluated aspects relevant to the dentist-patient relationship to be the most important factors for treatment effect. The available emergency plan in case of acute psychological distress never had to be put into action.The use of validated instruments renders it possible to compare the present findings with findings in other relevant studies, while the standardized treatment protocols enhance reproducibility. Self-report measures are used in this study as well as in many comparable studies [Only one dentist treated all the patients. With this study design dentist variability could not influence the findings, which strengthens the inferences that can be drawn from the study. However, at the same time the study design limits the generalizability of the findings to other dentists. Yet, as both treatment methods were delivered with strict adherence to detailed treatment manuals, replication of treatments by other dentists is facilitated.The presence of drop-out and lost records could bias all repeated scores. The LOCF-design used to replace missing data is conservative and might underestimate study findings. It is a strength to the study that variability of the treatment effects over time was assessed.The symptoms of PTSD were measured only among patients that reported to have experienced a traumatic event and were removed from the questionnaire one year after treatment. This weakened the findings based on this variable.The present study confirms the presence of high comorbid symptomatology in patients with strong dental anxiety reported by Halonen et al. [The hypothesis “High score on comorbid symptoms (anxiety, depression, or PTSD) will not negatively affect the dental anxiety treatment effect measured by reduction in MDAS-score” was supported. No association was found between psychological symptoms and the effect of the dental anxiety treatment. This is in line with earlier studies on psychologist-administered or -assisted dental anxiety treatments [The hypothesis “No increase in symptoms of general anxiety, depression, or PTSD will be observed following systematic dental anxiety treatment administered by a dentist in a general dental practice” was supported. This finding contrasts with a recent systematic review in which Bürklein et al. In this paper it is recommended that when high levels of dental anxiety are associated with a long avoidance (> 2 years) a psychologist or psychiatrist should be consulted. This is justified by the authors due to the high frequency of other psychological disorders seen in patients with elevated dental anxiety. However, Bürklein et al. had no findings themselves, or reference to findings by other researchers, that support this recommendation [In the present study the dental anxiety treatment was followed by a decrease in the psychological symptom load. This leans support to previous findings on the effect of dental anxiety treatment on comorbid psychological symptoms. In a Swedish study comparing systematic desensitization by psychologist with sedation treatment in patients with severe dental anxiety (mean avoidance six years), positive generalization effects were reported [These findings support that dentist-administered treatments could safely serve as a cost-effective first line treatment of dental anxiety of differing severity. This could greatly increase access to treatment for patients in need. In the present study a second line treatment option involving a psychologist was available and referrals were made for about one third of the patients. Educating dentists to do first line treatments for dental anxiety should not be expected to eradicate the need for dental anxiety/dental phobia treatments by psychologist/psychiatrist. It may however relieve the pressure on such specialised services since a lower level of care appears to be satisfactory for the majority of the patients.The hypothesis “The patient-rated dentist-patient relationship will be of importance to the outcome of treatment by D-CBT and Four Habits/midazolam” was partially supported. Ceiling effects have been reported in relation to the Working Alliance Inventory as well as in other tools for measuring relationship/alliance [