A Stepped-Care Approach to Treating Dental Fear: A Sequential, Multiple Assignment, Randomized Trial For Cognitive-Behavioral Treatment via Mobile App and Evidence-Based Collaborative Care

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PROJECT SUMMARY/ABSTRACT Dental fear affects over 53 million American adults. According to the U.S. Surgeon General, it leads to “needless pain and suffering, causing devastating complications to an individual's wellbeing, with financial and social costs that significantly diminish quality of life and burden American society.” Standard treatment — compassionate but ultimately counterproductive — includes anti-anxiety medication or more substantial anes- thesia, which (a) does nothing to reduce subsequent anxiety or avoidance, (b) leads to continued dental prob- lems, and (c) perpetuates the cycle of fear—>avoidance—>dental problems. Alternatively, cognitive-behavioral treatments (CBT) for dental fear have been developed, subjected to dozens of high-quality trials, and found to be efficacious. However, CBT has, almost exclusively, been offered only in a few specialty clinics worldwide as- sociated with universities and there is no disseminable model for integrating CBT into the workflow of dental practices. To fill this gap, we have created a stepped-care approach to dental fear treatment that can be implemented in private practice dental offices throughout the U.S. and is eminently scalable. Stepped-care in- volves starting with the least intensive option and progressing to more intensive options only when necessary. At the low end is a self-administered intervention: (a) a smartphone “app” that can be used privately in waiting rooms by an unlimited number of patients combined with (b) a paper-and-pencil “Pre-Game Plan” in which the patient records — to be reviewed with the dental staff prior to dental services — (1) pre-treatment fear levels, (2) the factor generating the most anxiety, (3) a stop-signal the patient will use to alert the dentist,(4) things the dental team can do to maximize this patient's comfort, and (5) a self-generated anxiety management plan. If patients are not in the “low fear” zone following their dental procedures, they may receive 1-hour (if still in moderate zone) or 2-hours (if still in severe zone) of dental fear CBT in their dentists' offices conducted by a collaborating mental health provider. In the first phase of this study, we will pilot test the approach with fearful patients (N»35,700) at two University dental centers. In the second phase, we will test the it in private dental practices (n = 100 volunteers from a pool of 10,000 practicing dentists in the metropolitan areas of Philadel- phia and New York [and the corridor between them] who graduated from dental school from either New York University or the University of Pennsylvania). The aims are to study factors influencing patients' and dentists' willingness to try stepped-care, to test the efficacy of the approach, to test the dosing of CBT interventions de- pending on patients' fear levels, and to test whether the way in which we believe CBT works (i.e., by helping patients disconfirm their beliefs regarding feared outcomes) is truly the active ingredient. Finally, we will develop dissemination materials for dentists and mental health providers on “How to Effectively Treat Dental Fear with a Stepped-Care Approach.”