https://orcid.org/0009-0008-7389-3512
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Abstract
Over fifteen percent of the global population experiences dental fear, and although evidence-based treatments exist, adoption of these treatments is almost non-existent. Informed by our prior research examining barriers to adopting face-to-face behavioral treatments in dental operatories, this study examined dentists’ responses to three stepped-care Cognitive Behavioral Therapy for Dental Fear (CBT-DF) formats that use technology. All approaches offer an automated component as the first step (a mobile app) and either an in-person, virtual reality (VR), or video telehealth session as the second step. This study aims to understand which of these approaches would most likely be adopted by private practice dentists and why. Eight focus groups/solo interviews with a total of 13 private practice dentists were conducted with the aim to assess barriers and facilitators to implementing three stepped-care approaches of CBT-DF. The qualitative data obtained from these interviews was coded and analyzed according to Rogers’ framework of innovation (relative advantage, compatibility, complexity, trialability, and observability). The results indicated that participants acknowledged the value of interventions to address dental fear, as they had personal experiences with fearful patients that impacted their practices. Participants responded positively to the automated component of treatment (the app) and were more wary of treatment options requiring office space and staff time (in-person VR and in-person mental health provider). The telehealth option received the most favorable response, although some doubts were expressed regarding relative efficacy and patient accountability. Thus, dissemination of an app-telehealth treatment model that allows dentists to serve as referral partners is promising, given dentists’ incentives to decrease patient fear while avoiding opportunity cost (e.g., occupied chairs and staff time).
Citation: Ochshorn J, Daly KA, Zaninovic V, Heyman RE, Smith Slep AM, Wolff MS (2025) Examining barriers and facilitators of dental fear treatment adoption: A qualitative study of practicing dentists. PLoS One 20(5): e0322884. https://doi.org/10.1371/journal.pone.0322884
Editor: Andrej M. Kielbassa, Danube Private University, AUSTRIA
Received: December 12, 2024; Accepted: March 28, 2025; Published: May 9, 2025
Copyright: © 2025 Ochshorn et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: This qualitative data was extracted from transcribed focus group interviews with dental professionals for the purposes of this study’s aims. Full focus group session transcriptions, which contain some potentially identifying information, will not be shared with any data depositories to protect participants’ privacy. Because of consent form restrictions, anonymized, redacted data can be requested via data.ftrg@nyu.edu and a data use agreement (as well as the final approved shared dataset) negotiated through NYU's Research and Compliance office. Data can be used for replication of authors’ aims, rather than original research, as per the study consent form.
Funding: Initials of the authors who received each award: RH, AS, MW Grant numbers awarded to each author: UG3DE029453 The full name of each funder: National Institute of Dental and Craniofacial Research URL of each funder website: https://www.nidcr.nih.gov/ Did the sponsors or funders play any role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript?: No.
Competing interests: The authors have declared that no competing interests exist.
Introduction
The dissemination and implementation of evidence-based interventions (EBIs) is a global public health priority [1]. The sluggish pace of adoption of EBIs across health policy and practice has served as the primary catalyst for the emergence and development of an entire discipline, implementation science [2]. Implementation science focuses on understanding the barriers and facilitators to the adoption and integration of scientific findings and evidence-based practices across systems [3] and provides a broad framework for contextualizing the phenomenon of dental fear, a major public health concern [4].
The prevalence of clinically significant dental fear among adults is 15.3% globally [5]. Among fearful individuals, anticipatory distress about dental visits often leads to avoidance of routine care which, over time, compromises oral health and increases the need for complicated and expensive dental procedures [5]. Dental fear is widespread and consequential, resulting in needless pain and suffering, oral and systemic health decline, and financial and social costs [6]. However, dental fear is also highly treatable; Cognitive Behavioral Therapy for Dental Fear (CBT-DF) has demonstrated efficacy across two dozen clinical trials with large effect sizes [7,8]. Yet, this highly effective treatment remains largely inaccessible to the millions of adults who could benefit from it [9]. Indeed, CBT-DF is rarely offered outside of a few specialty clinics worldwide, few mental health providers are trained in it, and dental practitioners are largely unaware of its existence [10].
Implementation science has been criticized for over-relying on researchers’ perceptions of healthcare practice rather than eliciting perspectives of actual full-time providers [11]. Thus, we have collaborated extensively with dentists and allied professionals to assess barriers to incorporating CBT-DF treatment. A previous study assessed responses from a focus group of dentists about providing CBT for dental fear via an evidence-based collaborative care model (i.e., embedding a mental health provider within a dental setting to provide psychological services when appropriate [9]). Although dentists were generally receptive to the concept of CBT-DF treatment, they expressed significant concerns regarding the financial and practical feasibility of using traditional evidence-based collaborative care [12] in dental settings [9]. Notably, traditional CBT-DF requires about three hours to administer in a dental chair within private practice or clinic settings [8]. We encountered hesitancy amongst dental providers regarding collaboration with mental health professionals directly in the dental home—especially if collaboration meant ceding significant chair time (otherwise available for dental procedures) and space (potentially disrupting workflow) to accommodate a mental health professional. Dentists cited the resulting loss of income as a significant concern [9]. It should be noted that although dentists may see this financial burden as a limitation, like other medical professionals, they have a responsibility to uphold ethical standards. Additionally, dentists questioned the feasibility of an in-chair intervention for their most fearful patients, noting the difficulties they have getting these patients to attend any dental visits [9].
Due to the COVID-19 pandemic, telehealth treatment options have become widespread, offering the possibility of innovative psychological treatment models that reduce logistical and cost barriers [13–15]. Moreover, a precedent existed for the development of technology-facilitated dental fear interventions. The dental fear treatment using computerized CBT [16], as well as mobile tools delivering exposure therapy [17], have been piloted by others with promising results. Informed by earlier research in this domain, we developed three different stepped-care (i.e., adaptive dosing) models of CBT-DF that we felt might address prior logistical and cost barriers identified by dental professionals.
Stepped-care intervention prioritizes parsimony, providing individuals with an initial low dose of treatment; if the patient does not benefit adequately [18–20], more intensive (or higher dose) interventions are administered. All three stepped-care models use technology to mitigate logistical and cost barriers and share the same first step (a self-administered CBT-DF mobile app accessed from smartphones at the participant’s convenience [21]). We believed that automating the foundational, lower-dose level would allow for significant reductions in costs (i.e., removing the scheduling complications and expense of a mental health provider, not requiring chair time) and increased feasibility (i.e., 24-hour availability whenever convenient for the patient, no disruption of practice workflow, accessibility to patients without current dental providers). The second step varied across models: (1) in-operatory treatment by a mental health provider, (2) remotely administered telehealth session with a mental health provider (eliminating practices’ space/cost concerns and allowing dentists to refer fearful patients externally), and (3) in-person virtual reality (VR) to administer the CBT-DF via immersive technology that eliminates the mental health provider (and obviates the need for practices to have a non-dental provider in their operatories).
Our previous work revealed dentists’ considerable concerns that cost, time, and logistics were barriers to welcoming comprehensive in-person, evidence-based psychological treatment in dental practices. In this paper, we updated the proposed CBT-DF approaches (i.e., technology-assisted) and used the Diffusion of Innovation Theory [22] as a framework for analyzing dentists’ reactions to the three proposed stepped-care models. Rogers et al. (1995) theorized that understanding how potential adopters perceive barriers and facilitators of an innovation can shed light on future disseminability. Based on the existing research, we hypothesize that most dentists will opt for the entirely virtual intervention that provides the least logistical barriers for their practice.
Methods
Participants and procedures
Participants were dentists in private practice (N = 13). This self-selected sample comprises dentists who volunteered to participate in an uncompensated Zoom focus group/interview. We solicited NYU-affiliated private-practice practitioners, including alumni, via email. Before participating in the focus groups/interviews, dentists signed written consent to participate in the study (NYU IRB#: IRB-FY2022–5951) and completed a demographic questionnaire that included questions related to professional dental experience (see Table 1). The recruitment period for this study began on 12/10/21 and ended on 5/10/22. Eight separate focus groups/interviews, ranging from 1 to 4 participants, were conducted to gauge the potential benefits and barriers of integrating each of our stepped-care approaches in private practice settings. All interview transcripts from the Zoom recordings were de-identified.
Each focus group/interview took place on Zoom and began with a description of the evidence-based CBT intervention we have adapted and an explanation of our stepped-care approach — an interactive mobile app plus either (a) an in-person one-on-one session with a mental health provider, (b) a telehealth one-on-one session with a fear specialist or (c) a virtual-reality device with custom dental fear treatment software. Participants were given a detailed description of each model as outlined in Table 2 and given opportunities throughout the interviews to ask clarifying questions. These focus groups/interviews were facilitated by either a clinical psychologist or a dental hygienist from our research team. All facilitators were trained, observed, and given a question guide to ensure accuracy and consistency.
Participants were asked about their experiences with fearful patients and their biggest issues in addressing dental fear. They were then asked about the challenges and benefits of each intervention, how it could be integrated into their practice, and how it compares to what they currently have in place. Toward the end of each discussion, participants were asked which of the three treatment approaches would be the best fit for their office. The average length of the interviews was approximately 40 minutes. Participants were interviewed until thematic saturation was obtained. For each discussion prompt, the facilitator ensured that each participant was given the opportunity to engage in conversation before moving on to the next prompt. Descriptions of the intervention models (Table 2) are provided below.
Data analysis
We conducted a multi-step thematic analysis using Braun and Clarke’s (2006) codebook thematic analysis approach [23] to qualitatively analyze the main themes from each focus group/interview. Our coders highlighted the key excerpts from each transcript and reduced each quote to its underlying theme. Two other researchers independently analyzed and grouped these themes according to a codebook we developed based on Rogers’ five attributes for predicting the rate of an innovation’s adoption/diffusion (relative advantage, compatibility, complexity, trialability, and observability [24]) along with their counterparts (disadvantage, incompatibility, usability, and lack of trialability/observability). Definitions of these drivers (Table 3) are provided below. Disagreements in coding were resolved via consultation and discussion among the full team.
Results
Themes were grouped according to Rogers’ five major attributes for predicting the rate of adoption [24], along with their supporting quotations. Expanded exemplars are presented in Table 4.
Dentists’ exposure to patient dental fear
Most dentists in the focus groups/interviews reported encountering patients who exhibited fear during their dental visits. Dentists believed fear often leads patients to avoid follow-up appointments, neglect their oral health, or opt for sedation and medication the dentists perceive as unnecessary. Some of the dentists discussed their experiences with patients whose fear stems from bad childhood experiences with dental work. One participant noted, “Most of our people who are really scared of dentists have been traumatized as a child.” Another dentist commented, “That childhood bad experience and that trauma can really stick with you.” It was also mentioned that parents can contribute to dental fear by modeling anxiety to their children. Dentists described different manifestations of fear they have witnessed, such as patients crying or shaking. One dentist described a patient who “is reluctant to open her mouth, and she just, she cries […]. She wants to try, she wants to, but for some reason, she just is very, very jittery.” Another dentist commented, “I have had patients who were so fearful that I either couldn’t continue treatment or like, oh, my gosh, I just want this patient out of my office because I just can’t do it. And it wastes so much time.” Only a few participants reported not having many experiences with fearful patients. One participant remarked, “I cannot say [I see] a lot of patients who have dental fear, but maybe they just hide it.” In addition, some dentists felt that the recent COVID-19 pandemic contributed to anxiety, both because of the need to remove masks at appointments and a general atmosphere of fear around transmission of viruses. Across focus groups/interviews, dentists expressed the ongoing difficulty of convincing fearful patients to return and receive necessary treatment, especially after an introductory consultation or initial exam.
Step 1: The App
The first step across the presented stepped-care models is Dental Fearless, a CBT-based mobile app containing psychoeducation about anxiety and dental procedures and evidence-based CBT strategies and skills [25]. The app consists of 5 modules (participants complete the introductory module and 1–4 of the topic-specific modules), each including psychoeducation, modeling, and practice. Throughout the app, users create personalized plans for managing their anxiety. Typically, the app takes 1–1.5 hours to complete.
Challenges.
Dentists in the focus groups/interviews discussed potential barriers to patients using the app in their practices. Identified factors primarily fell under Rogers’ (2003) relative disadvantage, incompatibility complexity, lack of trialability, and lack of observability. Relative disadvantage was repeatedly evoked across groups by the burden dentists assumed would be placed on staff to instruct patients in downloading and using the app. This burden is a time/cost concern, as it requires the attention of staff during working hours. In addition, dentists emphasized perceived incompatibilities on the patient’s end, specifically that patients may not have time to use the app. Participants agreed that their patients have busy schedules and felt that getting them to pursue the app on their own time may be difficult. Furthermore, participants discussed aspects of complexity when implementing this technology. The issue of accessibility came up multiple times, specifically concerning older or disabled patients. Some dentists fear this will place yet another burden on their staff if it becomes necessary to spend extra time training patients who are not familiar with using apps or have difficulty navigating the content. General skepticism toward the app was evident, demonstrating a lack of observability. Some dentists felt that presenting data on the efficacy of this intervention would increase the likelihood of implementation in practices.
Benefits.
Despite the previous shortcomings, participants overall agreed that the app is a convenient and useful intervention, particularly since it can be done outside of the dental office. Positive insights fell under Rogers’ relative advantage, compatibility, usability, trialability, and observability. The main relative advantage discussed by participants is that the app would not disrupt practice workflow, as it can be completed before appointments; this would also reduce likelihood of staff burden to facilitate it. Additionally, dentists felt the app data could have clinical utility for them; they discussed employing it as a screening tool for their offices to identify fearful patients (if permitted access to patient app data). Most dentists reported not having a standard fear screening method in place and thought the app could be a useful remedy. Many participants thought it would be easy to add a link to the app on their websites or integrate access into appointment scheduling processes. Participants also appreciated the possibility of separating severely fearful patients from moderately fearful ones using the app data.
Multiple dentists also mentioned anonymity as an aspect of compatibility on the patient’s end. Dentists responded positively to the privacy that accompanies the app versus assessing fear in person or via phone, citing that the app may encourage more honest answers and actual engagement with a fear intervention. Finally, participants emphasized the accessibility and engaging nature of this technology, coded under the usability attribute. Dentists agreed that apps are widely used, and most patients will likely be familiar and comfortable with the technology. Participants also commented on the interactive nature of the app, which they felt would garner engagement from their patients. One dentist remarked that the app would be far more effective than giving patients an informational pamphlet to read about dental fear.
Step 2: In-chair
The first intensive treatment option follows completion of the app and is conducted in a single, one-hour session in a dental chair with a trained mental health provider. This treatment relies on exposure techniques and other CBT techniques and is individualized to a patient’s specific fears.
Challenges.
Dentists identified many challenges with the in-person intervention. Concerns were expressed over financial feasibility, COVID considerations, organizational needs, time constraints, and limited chair availability. Participants expressed a concern over the time/cost inconvenience created by in-person sessions; this relative disadvantage was a recurring theme throughout the discussion of in-chair treatment. Identified challenges included finding space and time for psychological treatment, as most dentists agreed there are hardly ever available chairs during office hours. Furthermore, dentists felt that the pandemic had increased difficulties with patient attendance at regular in-person appointments, let alone for extra treatments. Some participants felt that while it may be possible to accommodate an in-chair intervention, it would be difficult and time-consuming. A minority of dentists voiced that they can already evaluate and treat fearful patients independently and thus have no need for this intervention. This sentiment was far less endorsed than logistical obstacles.
The main incompatibility discussed was patients’ time constraints. This theme recurred frequently, as an in-person intervention requires more effort on the patient’s end than a remote option would. Many participants discussed the difficulty their patients have in finding the time to come in person for basic oral healthcare appointments, which often require finding childcare or taking time off work. Again a few dentists felt the intervention was irrelevant to their clientele. One participant commented that even their fearful patients could come in and “tough it out” during their procedures. A further incompatibility was the embarrassment dentists worried their patients might feel in seeing a mental health specialist in a (more public) dental setting. This lack of privacy applied to dentists with practices that had open layout floorplans and did not have the spaces behind closed doors to host these sessions. For an in-person treatment especially, participants emphasized that lack of observability creates a barrier to implementation. Dentists reported wanting to know the intervention’s success rates and value before considering integrating such a treatment. Additionally, participants felt they would need more compelling evidence regarding the necessity for dental fear treatment among their patients before considering facilitating in-person CBT.
Benefits.
Although participants generally opposed the in-chair option, some identified benefits of in-person treatment. A relative advantage highlighted is CBT’s potential to replace or reduce unnecessary medication (taken for anxiety). Some dentists also thought the in-chair treatment could be more feasible at certain times of the day. A few participants expressed that this intervention, if successful, would pay off in the longer run, reducing inconveniences imposed, and time wasted, by fearful patients. An aspect of compatibility emphasized across the focus groups/interviews is that an in-chair session may be the most effective option. Despite setbacks of using office space, some participants emphasized the importance of an authentic environment, relative to simulated or telehealth alternatives, to produce desired effects from treatment. One dentist commented, “I understand the importance of sitting in the chair and going through the motion and desensitization.”
Step 2: Remote one-on-one telehealth
The second intensive treatment option is the remote one-on-one telehealth session, which would occur after the patient completes the app. This option allows patients to meet for one hour with a mental health provider over Zoom. Like the in-person option, the telehealth session also uses an exposure and other CBT approaches and is individualized to the patient’s fears.
Challenges.
Overall, focus group/interview participants were more receptive to this option compared with the in-person option. Challenges regarding the telehealth session were coded as, incompatibility, complexity, lack of trialability, and lack of observability. Some participants worried that a telehealth option may be less effective than in-person; dentists postulated that getting these patients into the actual dental chair is a necessary component of overcoming fear. Another aspect of incompatibility was dentists’ prediction that getting patients to show up for virtual appointments would be difficult. They suggested the accountability patients feel to show up is reserved for physical spaces/in-person appointments, and no-shows for telehealth would be frequent. One dentist commented that whereas the telehealth option seems more realistic than the in-chair option, they still don’t feel the need for any intervention — “I can usually manage most of my patients’ anxieties and fears with my present toolbox.” Some participants also voiced concern over the complexity of a telehealth intervention. One participant noted that it may be necessary for staff to act as a middle step to explain the intervention correctly and make patients comfortable with “a stranger who is not a dentist in a [virtual] dental office.” This added step for dental staff would create difficulty in treatment administration, burdening the practice.
Participants also highlighted the current lack of trialability and lack of observability. To integrate referral to a telehealth treatment into practice, participants expressed a need for data indicating treatment efficacy. They also requested the option to attend a mock session, allowing them to witness and evaluate the treatment process. In addition, some dentists stated that they would like to know how many patients would use this service and what types of patients would be most interested. One dentist noted that younger generations value mental health more than previous generations, so younger patients may be more inclined to receive treatment; others agreed.
Benefits.
Most participants found the telehealth treatment option more practical, financially feasible, and accessible than the in-person option. They felt that telehealth sessions would be easier to organize and place less burden on the dentist. A relative advantage that came up in multiple focus groups/interviews was the potential to reduce medications prescribed to manage patient anxiety. In addition, participants saw this option as an economic advantage. Since the telehealth sessions are done remotely, dentists wouldn’t have to worry about patients occupying dental chairs during office hours. An important aspect of compatibility emphasized was the convenience of telehealth treatment; participants agreed that this option would be more convenient, comfortable, and less stressful for their fearful patients. One dentist highlighted the advantage of being able to do the session from the comfort of one’s own home “as opposed to having to schlep into the dental operatory and do it there.” Participants also felt their patients would be more receptive to this option than an in-person one.
Step 2: Virtual reality
The third option for dental fear intervention involves private practices purchasing a virtual reality (VR) headset with custom dental fear treatment software. After completing the app, patients who still have moderate-to-severe dental fear would be scheduled for a one-hour VR session at the office (when an empty chair is available).
Challenges.
Several challenges were similar to those proposed regarding the in-chair sessions. Although the avenues for intervention are distinct, both require office space. A noteworthy relative disadvantage of using VR was the time and cost inconvenience. Some participants commented that the telehealth session, which can be done from a patient’s home, is more feasible than the VR, which requires coming into the office and using a dental chair. Participants emphasized the financial disadvantages of using VR in their practices due to the cost of using office space and the cost of the headset itself. One participant voiced that it would be unwise for a dentist to buy the VR headset and allow office space to be used unless they were confident there would be a financial return. Regarding incompatibility, multiple participants speculated that if they were going to cede office space, they would prefer to use it for the one-on-one session as opposed to the VR. Dentists expressed that the human connection from therapy may be missing with virtual reality and preferred models that involve direct patient care by a therapist. Additionally, as proposed with the in-chair option, participants were wary of time constraints on their patients’ end. Factors related to lack of observability were also prevalent in the discussion of VR. Participants noted that they would need to see evidence of success rates before considering purchasing anything. Participants also reiterated needing to know the percentage of patients who would use the VR treatment method. Participants expressed interest in understanding the VR treatment itself and getting a sense of how it might appear to patients. One dentist commented that it’s important to know what the procedure would be like and to have “the script” before deciding whether to implement it.
Benefits.
Despite challenges, several dentists supported the use of VR headsets, identifying factors related to relative advantage and compatibility. Participants discussed the potential financial advantages of VR. One participant mentioned that the cost of the VR headset is quite reasonable, especially compared with the other treatment options; the group felt this would be more financially feasible than paying for a therapist. Additionally, some participants noted that the treatment could pay off in the long run. One participant commented that if the success rates were high, it would certainly be worth the purchase. In addition to advantages on the practice’s end, participants also described the benefits of virtual reality from a patient’s standpoint. Aspects of this compatibility involve the popularity of VR technology and similar tech innovations, particularly among younger generations. Participants tended to agree that the VR intervention seemed interesting and would like to learn more about the software.
Discussion
This study was conducted to probe dentists’ attitudes toward three different models of dental fear treatment, all of which leverage technology to improve disseminability of CBT-DF, and each of which includes a dental practices’ participation to varying degrees. Consistent with current research [26,27], most dentists in our focus groups/interviews agreed that dental fear is an issue within their patient populations with observable negative effects on their patients’ oral health and their practices’ functioning. Dentists described experiences of fear leading to missed appointments or forcing them to stop work mid-procedure, both of which they felt were wastes of time, that sometimes had financial repercussions. The consensus that dental fear is an unresolved issue for practices facilitated some participant buy-in regarding the need to consider adoption of an intervention modality.
Results suggest that dentists are generally predisposed to the trialability of anxiety treatments for dental fear as summarized across the Rogerian themes (relative advantage, compatibility, complexity, trialability, and observability). Only a small minority of participants expressed the common misconceptions that fear is not an issue in their practices or that they can always identify and manage dental fear among their patients [10]. The development and adoption of behavioral health interventions that leverage technology (i.e., mobile apps, VR, telehealth) are novel interdisciplinary approaches that has recently served to increase collaborative care across different branches of medicine [25,28]. The growth of evidence-based, technology-delivered CBT is promising, particularly in fast-paced health settings [29,30]. Despite openness to such innovations, dentists expressed apprehension regarding feasibility.
Indeed, we found that most of the disadvantages on the dentist’s end were a result of using a dental chair (relative disadvantage; in-chair one-on-one), which was eliminated with the telehealth option. On the patient’s end (from a dentist’s perspective), the issue of time (commuting to a dentist’s office) was a consistent barrier for both in-person options (in-chair and VR), again making telehealth a preferred method (incompatibility; VR and in-chair one-on-one). Study results suggest the remotely administered telehealth option, with dental practices serving as referral partners, will be the most disseminable (relative advantage and compatibility; telehealth one-on-one). However, it is important to keep in mind the two main disadvantages of this option proposed by participating dentists: potential decrease in patient accountability and treatment effectiveness (incompatibility; telehealth one-on-one). Overall, these seemed like relatively minor concerns given the vast increase in accessibility and disseminability made possible by this approach. Patient accountability is a threat for both in-person and virtual options. Furthermore, rather than negatively impact attendance, as participants proposed, it is possible that the flexibility of telehealth leads to improved attendance (as suggested by recent research; [31]). Although an in-person exposure may more readily mimic a real dental session (i.e., using an actual dental chair, sights, and odors associated with dental procedures), telehealth exposures include other efficacious methods (e.g., imaginal techniques) and can be tailored to an individual patient’s dental fear via the use of precise sounds, images, and situational enactments. Although empirical inquiry in this domain is growing, more research on remotely administered exposure-based therapy for specific phobias is needed to (a) standardize effective protocols and then (b) test their efficacy relative to in-vivo.
Finally, the app itself (the first step of the intervention) was perceived by dentists as easy to implement, likely to promote engagement, and a familiar technology for most patients (relative advantage, compatibility, and usability; app). Participants were interested in using the app as a screening instrument which could influence the dentists’ approach and reduce problematic interactions (relative advantage; app). Universal fear assessment is considered best practice to appropriately tailor dental care for anxious patients [32].
Numerous studies exist on the efficacy of CBT-based interventions for dental fear [7,30,33], telehealth-adapted CBT treatments [34], and ways technology can be employed to facilitate mental health treatments across medical subspecialties [35]. This study furthers these lines of inquiry, considering dentists’ perspectives and opinions of different models of technology-facilitated psychological intervention from an implementation science perspective. Perceptions of the “characteristics of innovations” can determine how slowly or quickly they diffuse within a given system [24]. This qualitative research provides a lens through which to consider barriers to dissemination from a private practice standpoint. Despite the perceived advantages of in-person interventions, dentists found telehealth services more feasible for dentists and patients alike and believed other dentists were more likely to endorse them. Proposed considerations regarding practicality, workflow, chair time, and human connection may inform the development and adaptation of future models of psychological intervention for dental fear.
This study has several limitations. First, the sample size of this study is small (N = 13) and therefore not generalizable to all dentists. This is an exploratory study; consequently, we interviewed until arriving at thematic saturation. Future research is needed to replicate this research with a larger or more diverse sample. In addition, our sample is self-selected; therefore, it’s possible that the people who chose to participate already had an interest in the psychological well-being of their patients. With this in mind, it’s important to take into account the possibility of bias within this sample. Furthermore, although we could not tie specific quotes to dentists’ demographic information, and the sample size precludes making any generalizations of this nature, dentists’ age and gender may influence receptivity to behavioral health treatments [36]. This is a topic that warrants future research. Second, there was a miscommunication across several discussions regarding the financial repercussions of specific interventions. During multiple focus groups/interviews, participants seemed either under the impression that they would be responsible for paying the mental health provider who provided this treatment or were unclear about how the billing process would work (e.g., if this were something insurance would cover). This was not clarified explicitly by the interviewer, which likely resulted in the perception that certain cost barriers were greater than they would be. Although this misconception may have influenced the overall tenor of participant responses, its impact should be minimal given that all quotes related specifically to dental practices paying the mental health provider were excluded. Additionally, while we feel that Rogers’ lens was an appropriate choice for data analysis, we found little reference to factors indicative of trialability across discussions. The exception to this came up in a discussion of wanting to observe a “mock” session (trialability; telehealth one-on-one).
This research sheds some light on gaps in the field, namely, the disconnect between dentistry and mental health. We found that lack of observability came up frequently as a barrier to implementing any of these interventions within a practice. There was a general lack of awareness regarding the well-developed evidence base for CBT treatments for mental health difficulties generally and for dental fear specifically. This highlights the need for proper dissemination (i.e., marketing and education), which in turn has the potential to increase engagement. Social media has been shown as an effective way to spread information and awareness to the general population [37]. This gap also highlights the need for the diffusion of evidence-based dental fear treatment information via dental student education, conferences, and dental associations. It is recommended that future research explore the most effective means of communicating information and evidence-based approaches regarding dental fear among providers so that practice community can stay up to date.
This study highlights the accessibility of mobile-based applications and telehealth interventions for treating dental fear when compared with in-person options. These focus groups/interviews provide insight into the necessity of interventions that will not disrupt dental practice workflow. Eventually, app-based and telehealth treatments have the potential to be disseminated throughout private practice dental practices.
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