Sample characteristics
Three Ss did not complete therapy; two dropped out after three appointments and one was satisfied with two consultations. The 30 Ss were demographically and psychometrically (Table
2) similar to those previously described for present specialist clinic [
27]. They received cognitive-behavioral therapy and limited dental treatments for a mean of 15.3 appointments (SD = 6.1).
Twelve Ss of the 30 had mentioned general anesthesia in initial interviewing, where 8 thought of it initially as a possible "quick fix" solution to their problems. Three had tried it as children and had negative experiences and therefore didn't think of it as a solution. One client had never tried it, but when a physician offered to refer him, he was too afraid. For 66.7% of Ss, self-reported age of onset was 12 yr. or less. Mean age of onset was 15.1 yr. (SD = 9.7; range = 5.5–43 yr.).
Although not usually chief complaints, incidence of embarrassment was substantial in this sampling. When asked about the condition of their teeth or effects on social relationships, all but three of the Ss expressed some degree of embarrassment about their dental fear problem or its consequences.
Chief complaints
Chief complaint at initial consultation for 9 Ss was pain, while 14 Ss cited "the whole process", referring to social aspects of the dental care situation and specifically named powerlessness or lack of control in the dental environment as the main problem. Seven Ss described co-morbid psychosocial dysfunction mostly related to general anxiety as a reason for seeking specialist treatment for dental anxiety, but none complained of depression at the time of interviews. Seven Ss had had previous psychiatric care. Nine patients described a generally discordant childhood, including 3 cases of sexual abuse. Moods disorders or depression was never a chief complaint among these subjects.
Thus, 47% of Ss expressed a sense of powerlessness about the whole dental situation as chief complaint, implying in relation to dentists or other personnel. Although several other Ss described feelings of a lack of control in the situation, it was secondary to other chief complaints or specific problems such as fear of anesthesia failure, panic attacks, choking or due to generally anxious feelings perceived as uncontrollable. Thus, the term "social powerlessness" was used in the following chief complaint analysis, since patients most often used the Danish terms for "powerless" or "powerlessness" to designate feelings of lack of control in relation to the dentist or staff. A qualitative analysis about chief complaints of feelings of social powerlessness was first undertaken in order to differentiate embarrassment from other possible types of social powerlessness. Then, analyses of both clinical and non-clinical manifestations specific to categories and characteristics of the phenomenology of embarrassment followed. English translations of all Danish transcript passages were checked among the three bilingual authors.
Social powerlessness as chief complaint associated with anxiety in dental care situations
In the present study, patient perceptions and descriptions about powerlessness in social interactions with the dentist were of two categories: 1) Social powerlessness associated with conditioned distrust of dentists' behaviors e.g. "I am afraid of how the dentist will do what he has to do and that I can't stop him." This could also include secondary embarrassment, since subjects' own behaviors or cognitions can seem out of control, e.g. "My reactions get so out of control sometimes that it's embarrassing." and 2) Social powerlessness primarily associated with embarrassment about anxiety, dental care neglect and treatment avoidance or appearance e.g. "I am afraid of what the dentist or others are thinking about me and how bad my teeth are or how long it has been since I had treatment." This did not preclude complaints of conditioned distrust of dentists in some cases, but these were secondary to the chief complaint or reason for seeking therapy. Case studies below illustrate the two types of social powerlessness.
Social powerlessness as conditioned distrust of dentist behavior
Descriptions of humiliating or physically traumatic events in an uneven power struggle with dentists filled this category of negative dentist behaviors as illustrated in the following case study.
Case #21 35 yr old day care mother (35 F) had last been to the dentist 7 years ago for emergency care. As a 10 yr old girl, she was forced against her will to have an operation to reposition an impacted canine tooth. The mother had accompanied her to the clinic and had originally given permission for the operation. But she protested at the last minute when she saw how frightened her daughter became. She was asked to leave the operatory and the operation was performed behind closed doors.
35 F: "And I remember that I screamed like a wild animal.. that I didn't want them to do it. So they just closed the door into the clinic, then in come a couple more assistants and I was held down here (shows on her arms and legs). Then they told me that I had a choice. Either I would lie still and they could get it over with quickly or I would be held down and it would take a long time. It was my choice. And that's how it was." (She cries.)
In this case, the resultant reaction was a dreadful anxiety about being entrapped and "forced" into treatment situations, akin to claustrophobia. Her presenting symptoms of crying whenever in the dental chair provoked embarrassment secondarily. The patient described her struggle to gain control over the irrational feelings of a perceived threat from not knowing what dentists might do.
35 F: "...normally I can say to myself, 'Just try it. It only takes 10 minutes... like going to the doctor and getting a gynecological checkup. Try to relax and breathe all the way down to your big toe and in about 2 minutes it will all be over.' What irritates me most (about at the dentist) is that you can't have control at all over what is happening. A wire just short circuits up in my head. It's horrible, really terrible."
RM: "You are just afraid that---?"
35 F: "Just suddenly he would pull out something or other (instrument).. "
Social powerlessness primarily associated with embarrassment
Feelings of powerlessness related to the embarrassment of revealing years of dental neglect to dentist and staff had developed as the main reason for dental treatment avoidance for this category, even though there may have been other reasons at the beginning of the avoidance history. Symptoms of embarrassment were also manifested outside clinical settings, indicating that complexities of shame and guilty conscience about avoiding treatment were not the only manifestations of this type of social powerlessness. Embarrassment was the main reason for seeking therapy, where other usually highly motivating factors such as pain, were not. These complexities are illustrated in the following case.
Case #3 A 36 yr old career business-woman (36 F) had avoided dental treatment 13 years and was embarrassed to admit it to her family and co-workers. Whereas 10 years ago her dental anxiety had been coupled to negative cognitions of dental procedures, it had now turned into something else. She tried to keep it a secret from family and co-workers, but had great difficulty, considering the toothache pains she experienced periodically. Since she could not face the problem without professional help, oral neglect led to a bad conscience and conflicts about her own image as mother and career woman since at home and work she was known as a "take charge" kind of person by her own description.
RM (first author): "What is the worst thing, when you think about going to the dentist?"
36 F: "Today it would perhaps have something to do with being embarrassed about the condition of my teeth. But 10 years ago they were not as bad as they are today. And I don't know if it is the (feelings of) powerlessness that made it so... but I simply couldn't foresee these consequences. I can't really explain it."
RM: " So it has come to that the embarrassment is actually the biggest barrier?"
36 F: " Yes. If you don't take care of your teeth, you get pain. And the pain, it really gets bad sometimes, where I need pain killers for it. Then I've often thought when I've had toothache, 'If I had (only) been to the dentist. It couldn't hurt more than this!' But from there to take the steps (dental visit), ... they are miles apart. "
RM: "So the anxiety is worse than the pain, in a way?"
36 F: Yes... yes!
This exemplifies the plight of many patients with phobic dental anxiety who have thoughts and feelings that the problem is bigger than themselves or their physical pain, and as in this case, was specifically related to embarrassment about getting started after a longer period of treatment avoidance.
Embarrassment phenomena and characteristics
The embarrassment category identified above as chief complaint (n = 9) manifested for Ss both at the dentist office when showing their mouths to dental personnel and having to admit to long periods of neglect and anxiety, as well as in general embarrassment or shame about dental neglect with inhibited smiling or dysfunctions in other social situations. Sixty-three percent of the sample described and were observed with symptoms of not being able to smile or laugh fully or had learned to cover their teeth with a hand, lip or tongue during social interactions. Blushing was also commonplace, especially at oral examinations. Other embarrassment phenomena, whether in clinical or non-clinical settings, were bad conscience/self-punishment, secrecy/taboo-thinking, poor self-image/esteem and in some cases, social withdrawal and personality changes. Six patients expressed feelings of inferiority based on their dentist avoidance and/or shame about their facial appearance and tended to avoid other people.
Bad conscience / self-punishment
Social circumstances for embarrassment were often linked to bad conscience about years of neglect where avoiding dental care was often seen as a sign of personal failure or inadequacy leading to self-punishment and associated poor self-image/esteem. The following case study exemplifies this:
Case #18 50 yr male (50 M) computer programmer was embarrassed about having avoided dental treatment for 26 yr and he described embarrassment characteristics as a personal failure in that regard:
50 M: " I feel as if I may have been punishing myself. I feel awful with the fact that I have not been able for that period of time to go regularly to the dentist. I think it is really bad of me. It is like a personal failure in some way that I wasn't able to take care of it."
RM: "So you see yourself as a rational human being and that was irrational?"
50 M: "Exactly. It is that that is my problem, because in my daily life I am used to thinking rationally and I can even criticize other people if they react so irrationally... since I do it also myself ... I don't know if I can say it is a double standard, but it is something like it. It gives cause for self-punishment. ..It's just too bad that I couldn't deal with it."
He went on to describe that his social inhibitions had lead him to a generally poor self-image.
Two subjects also indicated they felt embarrassed at the dentist because they might be "troublesome patients" for dentists. Neither subject experienced a high degree of embarrassment intensity.
Secrecy / taboo-thinking
Many patients had developed secrecy rituals that had to do with social taboos in talking about the topic of going to the dentist or the condition of their oral health. Taboo-thinking with rituals of secrecy both at work (11/30) and with family members (6/30) was observed and was associated with descriptions of bad conscience or poor self-esteem in patients (n = 11) who had been avoiding treatment for more than the mean number of years (12.7 yr) of treatment avoidance. This subgroup had mean 18.2 yr of avoidance. Some of these patients expressed fear that their teeth or mouths were being observed and were negatively evaluated by others. The following case study illustrates these relationships.
Case #8 51 yr old passenger ferry captain (51 M) who had avoided treatment for 23 years and who had carefully guarded his secret until recent events at his workplace:
51 M: "Clearly I haven't felt good about that I haven't done anything with my teeth for so many years. I just don't talk about it with anyone. That's the way it is."
RM: "Taboo?"
51 M: "Yes, because generally I am a very reasonable person and I don't want anyone to discover that I have a hard time with something."
RM: "But when someone talks about dentists?"
51 M: "I don't talk much about it."
RM: "In your social circle?"
51 M: "Yes, I keep my mouth shut. I hadn't even said anything to my wife about it. She has actually first now learned about it yesterday that I was coming here (therapy)."
RM: "So it's a secret?"
51 M: "It's a secret." (nodding confirmation).
RM: "And it is a secret that you want to get rid of?"
51 M: "Yes, of course I would like to get to the point where I can say like anyone else, 'Now I have also been to the dentist and everything is OK."
He continued to explain after treatment completion:
51 M: "(Now) I can talk freely about going to the dentist It had been taboo before. It affected me in relation to others... that I have had to hide something. I had always feared that someone (would say) 'When have you been to the dentist?' Therefore, if people started talking about the dentist, I changed the topic... because then I wouldn't get that question. And I would have been terribly embarrassed if I had to say 'It has been darn many years ago.' It has been like a symptom every single time I have opened my mouth, that one could see those two front teeth. So I thought, 'You must get them fixed!' I can tell you that it really is a load off my mind to be able to talk about going to the dentist.".
Poor self-image or self-esteem
As a symptom of embarrassment, poor self-image/esteem was cognitively manifested in two ways. Self-esteem problems were related to 1) job or professional image in which avoiding dental care and having bad teeth was not fitting to social status, which again returns to secrecy and taboo as in the example above or 2) how their children would see them or if a child would "catch" dental anxiety from them. The case of the ferry captain above is an example of self-esteem problems related mostly to career image. Here is an example of how phobic patients could worry about affecting their children:
Case #12 41 yr old quality control expert (41 M) who had avoided dental care for 12 years had never gotten over bad experiences that he had had with a dentist in his childhood. The many years of avoidance and neglect of painful dental conditions had set his beliefs about dentists and created a bad conscience that had affected his self-image and self-esteem. He stated in this regard:
"I hope that that (going to the dentist and having self-respect) can happen in the not too distant future, because it hurts like hell, especially since I have two small children to whom I try to explain about how important it is take care of their teeth. It wouldn't be very credible, and children can quickly sense such things about a person."
With analysis of these cases, self-image/self-esteem seemed to become an important driving concept for embarrassment/shame, i.e. the belief that "neglecting yourself" leads to poor self-esteem as related to societal norms and values. In other words, poor self-esteem was the result of a chronic condition of many years of neglect, secrecy, and feelings of shame and bad conscience. In many cases, the chronicity of the problem lead to social withdrawal and personality changes.
Social withdrawal and personality changes
Nine of the 30 Ss mentioned that they underwent changes in their personality as a result of long periods of time with dental neglect, bad conscience, poor self-image or self-esteem and social withdrawal. The following case report revealed that chronic dysfunctional embarrassment, and specifically fear of negative social evaluation associated with anxiety and avoidance, can lead to personality change.
Case #22 33 yr old factory worker (33 M) had experienced painfully traumatic root canal treatments on his two upper canine teeth as a 12 yr old child. His last emergency dental visit had been 7 years ago. He admitted to embarrassment and despair about the appearance of his teeth. It had affected his personality and eventually contributed to a divorce with his wife.
33 M: "... I don't know if you have noticed, but I don't smile so that you can see my teeth. My wife has nice teeth and is very happy and smiles a lot. She misses getting a smile from me once in a while. When we met about 14 years ago, I smiled a lot. I liked to tell jokes and make fun with people and laugh. But it has become less and less, where now I go more alone with myself."
RM: "Why do you think it is that you don't smile?"
33 M: "It's because my teeth are ugly and because I am missing teeth."
RM: "Are you saying that you are embarrassed about your teeth?"
33 M: "Yeah, I am a lot."
RM: "Do you think that you have undergone a change in your personality because of your embarrassment?"
33 M: "Yeah, it has been coming on as of about 6 to 8 years ago.... Actually, I am positive and happy, but I don't smile by showing my teeth... If someone tells a joke that I would laugh at, I really have to fight back doing it (laughing). So in that way, there are many times where I really don't listen carefully when someone tells a joke, since I can't allow myself to break out in a good laugh. I just can't allow myself. ... It is a sad state of affairs when you have to be embarrassed about your smile and to admit that you are afraid to go to the dentist. So I talked with my physician about sending a referral to your clinic."
Patients often first realized that they had undergone negative personality changes only after they had completed or nearly completed therapy. In contrast to how they had been before, they could sense an improved self-image and /or self-confidence they had acquired during therapy. The following case illustrates important reflections at exit interviews.
Case #24 44 yr old female day care mother (44 F) originally saw herself as a person with a "deep-dark secret" in which others could not "pass through" and she made all attempts to avoid contacts with new people, also hiding her teeth with both lips, hands and head gestures. She had suffered from a self-admitted inferiority complex about her mouth for over 20 years. Now she reflects upon the changes that had occurred for her at the conclusion of therapy.
44 F: "Yesterday when I sat and was talking with someone, I noticed she kept looking at my mouth. Then my hand went up (in front of my face) and I thought, 'OK, hello, I can still fall back into the old pattern!' This was a very, very good girlfriend. One who knows that I have been coming here (for therapy). I removed my hand again... Since we had removed what I thought everyone else was looking at (tarter buildup on front teeth), about which I was so embarrassed... I didn't have anything to be embarrassed about anymore. I told someone else a few days ago that I was having therapy here and had done so for 1 1/2 years because of my dental anxiety. I noticed that I was completely relaxed as I told it. A change had definitely occurred. I was a completely different person and I noticed the difference from before. It took a long time before I dared to tell anyone that I was in therapy for this, because it was embarrassing."
RM: "So in some way, has there occurred a personality change?"
44 F: "You bet. Yeah, I notice that I feel more free, because I don't have to think about covering my mouth. I do still have it a little bit yet. But you can't just snap your fingers and say it's gone! And I still wonder if I have bad breath."