Eye-Movement Therapy Effective in Dental Phobia

Laird Harrison

November 27, 2013

Patients can overcome dental phobia through a therapy in which they recall traumatic events while rapidly moving their eyes, researchers say.

After undergoing eye movement desensitization and reprocessing (EMDR) therapy, some patients are able to attend dental appointments for the first time in years, the researchers report in an article published online September 23 and in the December issue of the European Journal of Oral Sciences.

"It's quite efficacious," coauthor Ad de Jongh, PhD, a professor of anxiety and disorder at the University of Amsterdam in the Netherlands, told Medscape Medical News.

California psychologist Francine Shapiro, PhD, developed EMDR in 1987 after noticing that she processed traumatic memories differently when her eyes were moving rapidly. She began experimenting with a therapy in which she asked patients to describe a frightening experience while following the motion of her fingers with their eyes.

Since then several randomized controlled trials have established the therapy as an effective treatment for posttraumatic stress disorder, and evidence has mounted for its effectiveness in other forms of mental illness.

Many people have some fear of dental treatments, and between 2% to 4% of the general population has such paralyzing fear that they fit the diagnosis of dental phobia used in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision.

In a previous study, Dr. de Jongh and colleagues found that 87% of patients with high levels of dental anxiety reported a "horrific" event during a previous dental treatment. That made the researchers wonder whether EMDR might work for dental phobia.

To find out, they randomly assigned 16 German patients with dental phobia to three 90-minute EMDR sessions and 15 patients to a waitlist for the therapy. They excluded patients from the study if they had other serious mental illnesses.

Thirteen patients from the treatment group and 11 from the waitlist group were available for follow-up evaluation 4 weeks later.

The patients who had been treated improved significantly on the German versions of the Dental Anxiety Scale (DAS), the Dental Fear Survey, the Brief Symptom Inventory, the Impact of Event Scale Revised, the Dissociative Experiences Scale, and the Hospital Anxiety and Depression Scale for anxiety.

The differences between the 2 groups were striking. For example, the mean DAS score for the treated patients dropped from 18.2 (±1.6) to 12.2 (±2.9), a statistically significant change (P < .001). In contrast, the DAS score for the waitlist patients only declined from 18.2 (±1.8) to 17.9 (±1.2), which was not statistically significant (P = .75).

A patient scoring above 15 on the DAS is considered "highly anxious," those scoring between 13 and 14 are considered "moderately anxious," and those scoring below 13 are considered to have low or normal anxiety.

The researchers then administered EMDR to the patients on the waitlist and pooled the 2 groups to see how long the benefits of the treatment lasted.

Among the 12 patients from the pooled group available for evaluation after 3 months, dental anxiety and PTSD scores continued to decline. From a mean of 18.1 (±1.2) at baseline, the patients' DAS score dropped to 11.3 (±2.2) at 3 months.

The patients' dental anxiety seemed to stabilize after that. Among the 6 patients available at 12 months' follow-up, the mean score was 10.5 (±2.4). One patient tested at a high level of dental anxiety, 2 reached a moderate level, and the other 4 were low or normal.

Dental fear and impact of event (PTSD) scores followed a similar pattern, with significant improvement at 3 months that continued at 12 months. Changes in the other measures did not reach statistical significance.

The researchers also documented a change in the patients' behavior: Before treatment, the patients had avoided dental treatment for an average of about 4 years. Three months after the treatment, 12 of the 16 patients surveyed had visited a dentist. Of these, 7 received 1 or more restoration, 4 had root canal therapy, 4 had extractions, 3 had periodontal treatment, and 2 had their fixed prostheses renewed.

Following up a year after the treatment, the researchers found that 15 of the 18 patients they interviewed were receiving regular dental treatments.

Although the typical dentist cannot administer EMDR because it requires special training, dentists might help phobic patients more by referring them to this treatment than they would by administering sedatives, Dr. de Jongh said.

"The focus is not just on helping the patient during the appointment, but in the long-term," he said.

He said the size of the effect in this study was greater than the size of the effect reported in other studies on cognitive behavioral therapy, a standard psychotherapeutic for dental phobia.

Asked to comment, Stuart Tremlow, MD, a visiting professor of psychiatry at University College London in the United Kingdom, told Medscape Medical News that the study shows EMDR might be useful for a limited number of patients with dental phobia.

"It's a very well-done study in terms of design," he said. "It's a small study, but the effect size is very, very high."

Many patients will still find it more practical to use a sedative than to undergo three 90-minute sessions of EMDR. "I don't like giving people sedatives, but if you can take a milligram of [clonazepam], that's a hell of a lot easier than EMDR."

If someone is so afraid of seeing a dentist that general anesthesia is necessary, then Dr. Tremlow said he might recommend EMDR.

Dr. Tremlow also differed with Dr. de Jongh on the mechanism behind EMDR, which remains controversial.

Dr. de Jongh said evidence is mounting that the therapy works because a patient cannot simultaneously focus on the memory of the traumatic event and concentrate on the motion of the therapist's fingers. The effort to do both simultaneously causes the trauma to "lose its emotional charge," he said.

Dr. Tremlow believes EMDR and CBT both work the same way as talking about a difficult event to a priest or a close friend, which allows the patient to process the events in a limited way. The benefits are relatively transient, he believes.

To achieve more lasting results, Dr. Tremlow advocates psychoanalysis in which a patient spends a much longer time analyzing difficult emotional experiences.

The authors, Dr. Tremlow, and Dr. de Jongh have disclosed no relevant financial relationships.

Eur J Oral Sci. 2013;121:584-593. Abstract

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