It is more than 30 years since I first started working as a psychologist in dentistry, and over that time there has been an increasing recognition of the role of psychology – not only in dentistry, but throughout healthcare. The terms ‘psychology’ and ‘behavioural science’ are often used interchangeably to refer to an approach to understanding human behaviour and thought – in this case in relation to oral and dental health. I will unapologetically continue this practice.

The original impetus for the post I took up in 1992 was the expansion of the UK undergraduate dental curriculum to five years, and the inclusion of social and behavioural sciences in the General Dental Council’s (GDC) guidance on dental curricula. The curriculum outlined by the GDC for undergraduate dentistry at that time centred around five broad topics: dentist/patient communication; changing behaviours related to oral health; anxiety management; pain management; and coping with personal stress.

In order to develop a programme of education I required a number of materials relevant to dentistry, which demonstrated how psychological theory and knowledge could better form the practice. Much of these were lacking.

Location, location, location

When I started as a lecturer in psychology in relation to dentistry, there was an existing body of research and education in the field of psychology and dentistry¹. Much of this drew on research conducted in medical settings, which was assumed to generalise dental settings. One example was the role of communication with patients, which was founded on theoretical models and empirical studies largely from medical settings. I have argued that the dental setting brings a particular set of expectations and practices associated with communication challenges. This includes – among other things – the high likelihood of some form of physical examination or treatment, negative perceptions of dentistry by patients, the fear of dentistry and (as typically mentioned by patients) dental examination precluding verbal communication by the patient.

In contrast, psychologists have long been interested in dental phobia as a model for the development and management of anxiety. So there was in existence a body of evidence on which to draw in developing teaching.

Facing down phobia

There are now more textbooks on the social and behavioural sciences in dentistry than had been available previously. A very positive development has been the general acceptance of the importance of including the social and behavioural sciences within dental textbooks, leading to greater integration of psychology into dental practice. These textbooks (such as that written by my colleagues at King’s College London – Scambler, Scott and Asimakopoulou – 2016²) benefit from the research undertaken by psychologists working in dentistry over the last few years.

Initially, I was offered a series of lectures in the pre-clinical component of the BDS, which was assessed by multiple-choice questions as part of an exam that incorporated many other subjects. I soon realised the limitations of this – in particular, the disconnect from clinical practice.

Over a period of years, I worked towards a course that ran throughout the five years of the BDS course, building upon theory and core skills taught in the early years to the more complex skills (working with dental-phobic patients, breaking bad news, dealing with complaints) in the final year. We were proud to be the first dental school to include a summative end-of-year exam that was composed solely of the assessment of communication. In 2008, our team of psychologists at KCL developed an NHS-based service for people with dental phobia. Using cognitive behavioural therapy, our goal is to enable patients with dental phobia to receive dental treatment without sedation. Approximately 93% of patients seen by the service achieved that goal³, with patients expressing high levels of satisfaction following their CBT treatment.

Additional benefits for patient care within the NHS Foundation Trust have been the identification and management of patients with significant psychological distress, including suicidality, within the dental institute. Our team of dental psychologists led on the development of the Trust policy on managing suicidal patients. Over time we have expanded the range of services we offer to include provision of therapy for individuals with chronic oro-facial pain and screening of patients for combined orthodontic/orthognathic treatment. In 2010, the Department of Health recommended CBT services be included in the commissioning of community dental services, citing the KCL model as an example.

An empathetic approach

Psychologists spend a great deal of their undergraduate education studying research methods, and have experience and knowledge of a wide range of research methods and analysis. Psychologists working in dentistry have been able to demonstrate the value of these skills in many areas, including epidemiological studies, interventional trials and descriptive methods such as surveys, focus groups and interview studies. My research has covered a broad range of areas, mirroring those early topics for teaching – the management of dental anxiety, the wellbeing of the dental team and interventions to enhance oral health behaviours. Recently I was a member of the team from the Behavioural, Epidemiological and Health Services Research group of the International Association for Dental Research that undertook a consensus-based approach to defining priorities for future development of social and behavioural sciences in dentistry⁴. They identified the following four key areas: behavioural and social theories and mechanisms related to oral health; the use of multiple and novel methodologies in social and behavioural research and practice related to oral health; development and testing of behavioural and social interventions to promote oral health; and dissemination and implementation research for oral health. This statement has been endorsed globally by more than 400 individuals and groups.

A testing ground for innovation

The areas identified are broad and reflect a growing maturity in the disciplines, demonstrating the broad understanding of the applicability of psychology to dental practice, as well as the value of dentistry as a topic of focus for psychologists. Behaviours associated with good oral health are multi-faceted, including those that are frequent and habitual (for example, toothbrushing), as opposed to those that are less widely established, such as inter-dental cleaning and behaviours with complex determinants, such as food choice.As such, explorations of the determinants of behaviour, and interventions to enhance positive behaviours, can be usefully tested in dentistry to inform wider theoretical and practical development in the field of psychology.

As a psychologist, I have been able to contribute to oral health through teaching, research and the provision of clinical services. The field has grown and is now widely acknowledged within dentistry. Possibly less well recognised is the opportunity provided by the field of dentistry to develop psychological and behavioural science.

References

1 Kent G and Blinkhorn AS. The psychology of dentistry. 1998, Wright, London.

2 Scambler S, Scott SE and Asimakopoulou K. Sociology and psychology for the dental team. 2016, Polity Press, Cambridge.

3 Kani E, Asimakopoulou K, Daly B, et al. Characteristics of patients attending for cognitive behavioural therapy at one specialist unit for dental phobia in the UK and outcomes of treatment. Brit Den J 2015; 219: 501–506.

4 McNeil DL, Randall, CR, Baker SR, et al. Consensus statement on future directions for the behavioural and social sciences in oral health. J Dent Res 2022; 101: 619–622.