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The Science of Dental Care-related Fear & Anxiety

There is broad agreement that dental care-related fear and anxiety represents a tax on both patient and practice.  Successfully managing fear & anxiety can have measurable impact on patient wellbeing, health outcomes and on key practice performance metrics including productivity, case acceptance, active patients, marketing expense, and patient lifetime & practice value. 

On the subject of Dental Fear & Anxiety in “Behavioral Dentistry1,” McNeil and Randall offer useful definitions:

Fear: an immediate onset distressing emotional response to treatment-related stimuli typically characterized by physiological responsivity, feelings of apprehension, dismay and avoidance.

Anxiety: a more cognitively involved emotional response to stimuli or experiences associated with treatment.  Anxiety entails negative thoughts and worries about exposure to evocative stimuli that can occur distally in time – in advance of, or at the point of care.

Further, fears and anxiety about treatment are related but distinct states existing on a continuum, caused by unique individual factors and experiences, and manifest in diverse ways before and at the point of care whether associated with regular oral maintenance or more invasive operative procedures.  

The Operatory-Patient Transaction

As patients enter the operatory there is an implicit person-environment transaction – an assessment that guides the patient’s perception of their ability to cope with what’s going to happen – of the demands of the situation and the the resources (physical, psychological) needed to meet them.  Anxious patients bring a diversity of potential thoughts and emotions fueled by experience, conditioning and bias: embarrassment for their looks, shame for delaying care, worry about costs, uncertainty about staff and/or procedures, expectations for pain/discomfort, etc..  Add environmental factors like equipment, sounds, smells as well as the feelings of vulnerability & powerlessness induced by the chair, and the demands of competing stimuli placed on attentional resources can stress an individual’s capacity.  Over the course of the treatment session, unmitigated attentional stress is will create measurable negative physiological and behavioral effects that will shape their experience. 

McNeil and Randall suggest that assessing how a patient perceives practitioners and aspects of the treatment experience and then targeting an appropriate intervention to change mis-perceptions will reduce fear and anxiety (interventions include behavioral, cognitive, educational, and pharmacological). These reductions correlate with a patient’s renewal of openness to communications, a shift in the need to control, and improved perceptions of trust and professional judgement.

OperatoryTV is a behavioral intervention: a relaxation therapy delivered through distraction designed for the 75% of patients that present dental care-related fear and anxiety.  

Stress Mitigation Theories

OperatoryTV works to reduce anxiety in 90%* of anxious patients by relieving treatment-related attentional fatigue, restoring attentional capacity, and allowing a shift towards a more positively-toned emotional state.

Physiological Stress Response & Recovery

The Autonomic Nervous System (ANS) functions without conscious control to regulate  organ systems controlling heart rate, blood pressure, respiration, digestion, and sexual arousal.   The sympathetic system (“fight or flight”) is the branch of the ANS responsible for the body’s mobilization in response to stressful events.  Its activation enables increases in energy expenditure and inhibits digestion.  In contrast, the parasympathetic system of the ANS (“relax and renew”) influences recovery from stressful events by slowing down heart rate, dilating blood vessels, activating digestion, and storing energy. 

Environmental Psychology

Psychological theories account for the effects of stress on cognition, specifically on the cognitive process of attention allocation.  Stressful stimuli can overload our limited resources to focus attention – to prioritize, choose and concentrate attention on what we believe is important (a process that also inhibits competing stimuli).  Environmental psychology theorizes that physical environment plays a role in stress arousal and recovery. 

Environments can strain our attentional capacities for focus, or elicit a calming response that supports a recovery of our ability to focus. 

Stress Reduction & Attention Restoration Theories

In her review of the research into restorativeness, Berto2 offers a useful framework to understand these seminal theories advanced by Robert Ulrich and Rachel & Stephen Kaplan that test the effect of natural environments on stress and restoration.  Ulrich’s3 landmark study (Stress Reduction Theory – SRT) showed that surgical patients’ physiological recoveries were faster and with fewer complications and lower analgesic intakes when their hospital windows overlooked trees rather than brick walls.  Building on SRT, Kaplans’4 theory of Attention Restoration (ART) shows that natural environments can provide physiological, emotional, and attentional relief and restoration from environmental stressors.  Centering on the distinction between attention types, voluntary (directed) and involuntary (effortless), Kaplan’s found that giving one’s attention to natural environments is effortless – requiring minimal cognitive resources to achieve focus.  In contrast, directed attention (i.e. while in the chair) requires a greater focus and effort to inhibit competing stimuli, which, over time, leads to mental fatigue.  Mental fatigue increases the probability that an individual experiences a stress response due to the cognitive overload, and to the depletion of the attentional resources needed to cope.  Most significantly, when effortless attention is engaged, the demands on a depleted directed attentional capacity are diminished, allowing for restoration.  

Theoretical Mechanisms Underlying Attention Restoration

Attention Restoration theorizes natural environments are conducive to our involuntary attention engagement – it is “softly fascinating.”  When nature effortlessly captures our attention, the executive system that regulates directed attention gets to rest, pessimistic thoughts are blocked, and negative emotions are replaced by positive ones5. In addition to fascination, nature is characterized by restorative properties which work together with fascination.  Renewal of depleted attentional capacity occurs with a physical and/or psychological “being-away” from demands on directed attention, a sense of “extent”, i.e., of being in a large enough world where “coherence” and “scope” are perceived in the environment, and “compatibility” between one’s inclinations and the environmental demands4,6,7.

Measuring the Effects of Natural Environments

Physiological Effects

Ulrich measured the physiological effects of natural environments to show that exposure to natural stimuli (independent of the type of exposure: plants, posters, slides, video, VR or views) reduces symptoms related to psycho-physiological stress, and has a direct restorative influence that is quicker and more complete than exposure to non-natural environmental (urban) stimuli8.  His research recorded the parasympathetic response (cortisol levels, heart rate and skin conductance response, pulse transit time, cardiac response, partial thromboplastin time) within the initial minutes of recovery.  Other studies have shown that unstressed subjects exposed to natural landscapes have greater brain electrical activity in the alpha frequency range.  High alpha amplitude is associated with low levels of physiological arousal and wakeful relaxation, whereas low alpha amplitude is associated with high levels of arousal and feelings of anxiety.  EEG studies identify tranquility as an outcome of viewing natural settings9.

Natural environments trigger the parasympathetic response of “relax & renew” minimizing physiological symptoms of stress and allowing greater tolerance of pain and positive emotions contributing to a faster recovery from treatment.

Behavioral Effects

People with directed attentional fatigue will display behaviors caused by weary minds.  Inability to focus and loss of inhibition will limit patience and endurance4 and manifests in negative emotions, irritability, impulsiveness, impatience, reduced tolerance for frustration, insensitivity to interpersonal cues, decrease altruistic behaviors, reduced performance, and increased likelihood of taking risks.10,61-64, 11  The inability to renew attentional capacity aggravates mental fatigue and can also damage mood, work performance and interpersonal relationships.  

Exposure to natural settings have restorative influences on emotional dimensions: positive affects (cheerfulness, enthusiasm, energy), anger and aggression, and fear12,13,14.  Kuo and Sullivan15 in their studies of urban environments measured lower levels of aggression and violence in apartment residents located near nature than those located overlooking urban areas.  Loss of inhibition through attentional fatigue leads to negative affects; while exposure to nature enhances the senses of community and belonging.

Moreover, exposure to the pleasant stimuli of natural environments through distraction can not only elicit positive emotional states, but can improve pain control and patient’s satisfaction with procedures16,17.  Further, exposure to nature offers individuals the opportunity to establish a level of control through “temporary escape”18.

The case for the mitigation of attentional fatigue is strong and central to patient experience.  Unmitigated fatigue can lead to negative stress response behaviors that, in the short-term effect mood, performance and social interactions. Reducing attentional fatigue restores adaptive resources, leaving patients with renewed capacity to function.

A Durable Stress Mitigation Solution

Intelligent Design

OTV has been designed around the science underlying attention restoration.  Using high-resolution images as a proxy for a real environment, patients choose one of four one-hour gallery “escapes” based on individual preference: a walk in the mountains, on a beach, under the sky, and through a garden.  Each gallery image is selected based on sensual value, sequentially organized for coherence, and delivered via Roku and practice wifi in 12-second intervals accompanied by an original ethereal music composition similar to those used in guided imagery.

Relief, Restore, Repeat

Three out of four patients will present some level of anxiety as they enter the operatory.  In varying degrees, they will find an inability to muster sufficient resources needed to cope with treatment.  The dangers (real or imagined) that drive your patient’s sympathetic response are complex, individual and magnified by their perceived vulnerability and loss of control.  While in the chair, the focus required by directed attention is mentally fatiguing.  By offering patients an escape that is softly fascinating, aligned with individual preferences, rich and coherent, a restorative effect on mental fatigue and attentional capacity can be achieved. The objective of OTV is to address the operatory-patient transaction and flip the paradigm to the parasympathetic rest-and-renew response; to gradually change the threat perception of your operatory from the “House of Pain” into a more restorative environment that leaves patients with the perception and memory of a better treatment experience.  One worth talking about.

OTV Works

OTV has been tested in commercial dental practices since November 2019*.  Self-reported patient responses have revealed the following:

  1. 76% of patients report some level of pre-treatment anxiety.
  2. 90% of anxious patients exposed to OTV report a reduction in treatment related anxiety.
  3. 96% of exposed patients report being “drawn into” the setting on OTV.
  4. 92% of patients want to explore the setting.
  5. 88% of patients report experiencing the feeling of “being away” in the setting.
  6. 62% of exposed patients report an increase in the likelihood of referral because of OTV.

OTV is a durable and science-based stress mitigation solution for the majority of anxious patients.  Easy to activate on existing TVs in your operatories, OTV is different from every directed-attention TV entertainment option you offer patients.



  1. Mostofsky, D.I.; Fortune, F. Behavioral Dentistry, Second Edition.  Wiley Blackwell 2014.  Chapter 12 167-168 
  2. Berto, R. The Role of Nature in Coping with Psycho-Physiological Stress. Behav. Sci. 2014 4, 394-409
  3. Ulrich, R.S. View through a window may influence recovery from surgery. Science 1984, 224, 420–421. 
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  9. Hunter M.D., Eickhoff S.B., Pheasant R.J., Douglas M.J., Watts G.R., Farrow T.F., Hyland D., Kang J., Wilkinson I.D., Horoshenkov K.V., et al. The state of tranquility: Subjective perception is shaped by contextual modulation of auditory connectivity. Neuroimage. 2010;53:611–618.
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  11. Kaplan, R. The role of nature in the context of workplace. Landsc. Urban Plan. 1993, 26, 193–201
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  13. Zuckerman, M. Development of a situation-specific trait-state test for the prediction and measurement of affective responses. J. Consult. Clin. Psychol. 1977, 45, 513–523. 
  14. Ulrich, R.S. Visual landscape and psychological well-being. Landsc. Res. 1979, 4, 17–23.
  15. Kuo F.E., Sullivan W.C. Aggression and violence in the inner city: Impacts of environment via mental fatigue. Environ. Behav. 2001;33:543–571. 
  16. Diette, G.B.; Lechtzin, E.; Haponik, E.; Devrotes, A.; Rubin, H.R. Distraction therapy with nature sights and sounds reduces pain during flexible bronchoscopy. Chest 2003, 123, 941–948. 
  17. Miller, A.C.; Hickman, L.C.; Lemasters, G.K. A distraction technique for control of burn pain. J. Burn Care Rehabil. 1992, 13, 576–580.
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