One sign of strong fear is strong physical reactions that occur as soon as one finds oneself in the threatening situation, or, in acute cases, even as soon as one thinks about them. Reactions may include, for example, increased heart rate, sweating, trembling, muscle tension, nausea and feelings of powerlessness. In addition, anxiety-related thoughts begin to emerge: the fear of losing control at the dentist’s office, of fainting, of having a drug intolerance or of not being able to endure the treatment. The people afflicted also often interpret the physical reactions accompanying great fear as something dangerous. Seen objectively, these thoughts are unrealistic, yet they are experienced by the people afflicted as something highly threatening. Shame also plays a role when the patients have failed for years to go to the dentist and their teeth are already badly damaged. From these experiences of physical reactions and thoughts of catastrophe, avoidance behavior develops. For example, fleeing from the situation of fear - the visit to the dentist - or avoiding it altogether. People with dental anxiety who do manage to have a dental procedure performed only endure it with extreme tension and a massive sense of fear. And in this way they repeatedly continue to experience a visit to the dentist’s office as something that is simply frightening. This creates a vicious cycle of fear that can be described as a boosting process. A number of things can trigger the vicious cycle of fear, for example the thoughts of an upcoming dental appointment, the sight of a needle, the sound of a drill or the typical smell of a dentist’s office. Avoidance behavior lessens the fear for the time being and the people afflicted consider it to be the only possibility for avoiding or dealing with the fear.