A "phobia" is traditionally defined as "an irrational severe fear that leads to avoidance of the feared situation, object or activity" (even though the Greek word "phobia" simply means fear...). Exposure to the feared stimulus provokes an immediate anxiety response, which may take the form of a panic attack. The phobia causes a lot of distress, and impacts on other aspects of the individual's life, not just their oral health. Dental phobics will spend an awful lot of time thinking about their teeth or dentists or dental situations, or else spend a lot of time trying NOT to think of teeth or dentists or dental situations. Which is pretty hard in today's society, which is saturated with ugly reminders such as toothpaste commercials.

The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) describes dental phobia as a "marked and persistent fear that is excessive or unreasonable". It also assumes that the person recognizes that the fear is excessive or unreasonable. Conclusion? The DSM-IV criteria were obviously not decided upon by a representative group of dental phobics (read on to see why). Having said that, there is a new revised version coming out soon, so maybe the definition will have changed. You might be interested to learn that DSM-IV's predecessor, DSM-III, defined homosexuality as a mental disorder... I'd hazard a guess that most dental phobics would object to being labelled as suffering from a mental disorder.

This is not to say that dental phobia cannot co-occur with psychiatric disorder - of course it can. Dental phobia appears to be more common in people who suffer from another psychiatric disorder, notably Generalized Anxiety Disorder, agoraphobia, depression, and emetophobia. Research suggests that about 20% of dental phobics have a concurrent psychiatric disorder. The main problem in defining "dental phobia" is that there isn't just ONE type of dental phobia, but many types - some rational, and some which seem more "irrational".

Bracha and others (2006, HI Dental Journal) have suggested that the term dental phobia is typically a misnomer, for much the same reasons I'm outlining here (you can find the abstract of their article at the bottom of this page).

Whether the fear is "unreasonable", "excessive", or "irrational" is debatable... certainly not if you end up in the hands of the wrong dentist! Which, incidentally, is one of the reasons why people end up as dental phobics in the first place.

What are the most common causes of dental phobia?

• Bad experiences: Dental phobia is most often caused by bad, or in some cases horrific, dental experiences (studies suggest that this is true for about 80 -85% of dental phobias, but there are difficulties with obtaining representative samples). This not only includes painful dental visits, but also psychological behaviours such as being humiliated by a dentist.

• A history of abuse: Dental phobia is also common in people who have been sexually abused, particularly in childhood. A history of bullying or having been physically or emotionally abused by a person in authority may also contribute to developing dental phobia, especially in combination with bad experiences with dentists.

• Uncaring dentist: It is often thought, even among dental professionals, that it is the fear of pain that keeps people from seeing a dentist. But even where pain is the person's major concern, it is not pain per se that is necessarily the problem. Otherwise, dental phobics would not avoid the dentist even when in pain from toothache. Rather, it is pain inflicted by a dentist who is perceived as cold and controlling that has a huge psychological impact. Pain inflicted by a dentist who is perceived as caring is much less likely to result in psychological trauma (Weiner et al, 1999).

• Humiliation: Other causes of dental phobia include insensitive, humiliating remarks by a dentist or hygienist. In fact, insensitive remarks and the intense feelings of humiliation they provoke are one of the main factors which can cause or contribute to a dental phobia. Human beings are social animals, and negative social evaluation will upset most people, apart from the most thick-skinned individuals. If you're the sensitive type, negative evaluation can be shattering.

• Vicarious learning: Another cause (which judging by our forum appears to be less common) is observational learning. If a parent or other caregiver is scared of dentists, children may pick up on this and learn to be scared as well, even in the absence of bad experiences. Also, hearing other people's horror stories about visits to the psychodentist can have a similar effect.

• Preparedness: Some subtypes of dental phobia may indeed be defined as "irrational" in the traditional sense. People may be inherently "prepared" to learn certain phobias, such as needle phobia. For millions of years people who quickly learned to avoid snakes, heights, and lightning (and sharp objects, such as needles, which would not have been sterilized in those days, apart from giving you a nasty sting!) probably had a good chance to survive and to transmit their genes. So it may not take a particularly painful encounter with a needle to develop a phobia.

• Post-Traumatic Stress: Research suggests that people who've had horrific dental experiences (unsurprisingly) suffer from symptoms typically reported by people with post-traumatic stress disorder (PTSD). This is characterized by intrusive thoughts of the bad experience and nightmares about dentists or dental situations.