ORIGINAL Prathima ARTICLE et al
Assessment of Anxiety Related to Dental Treatments Among Patients Attending Dental Clinics and Hospitals in Ranga Reddy District, Andhra Pradesh, India Vedati Prathimaa/M. Shakeel Anjumb/P. Parthasarathi Reddyc/A. Jayakumard/ M. Mounicae Purpose: To assess the levels of dental anxiety among patients anticipating dental treatments in dental clinics/hospitals of Ranga Reddy district. Materials and Methods: A cross-sectional study was conducted among a representative sample of 1200 subjects (at least 18 years old) in dental clinics/hospitals which were selected from a list obtained through systematic random sampling. The data were collected using a pre-tested and calibrated questionnaire consisting of the Modified Corah Dental Anxiety Scale (MDAS) to assess anxiety levels. Results: The majority (52.4%) of subjects showed a low level of anxiety. Females (11.44 ± 4.41) were found to have higher mean MDAS scores than males, and the highest mean MDAS scores were found among 18- to 34-year-olds (11.28 ± 4.67) (P < 0.05). Significant differences were found among subjects anticipating different treatments, with higher MDAS scores for extraction (11.25 ± 5.4), followed by examination, root canal treatment, gum surgery, scaling, restoration and others, e.g. orthodontic treatment, restoration with crowns, bridges and dentures (7.79 ± 3.80). The highest mean MDAS scores were found among subjects who were apprehensive due to ‘past difficult experience in dental treatments’, followed by ‘drill’ and ‘injection’, with the lowest scores among subjects indicating ‘other reasons’ (7.82 ± 3.84). Conclusion: The present data show that anxiety levels are higher in patients who have to undergo extractions than those who must be fitted with dentures. Thus, dental health care providers should pay more attention to patients’ anxiety levels associated with different types of treatment. Key words: dental anxiety, dental treatments, modified dental anxiety scale Oral Health Prev Dent 2014;12:357-364 doi: 10.3290/j.ohpd.a31660
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ehaviour is the collection of conative (e.g. walking, swimming), cognitive (e.g. thinking, reasoning, imagining) and affective (e.g. feeling happy,
a
Assistant Professor, Department of Public Health Dentistry, Army College of Dental Sciences, Andhra Pradesh, India.
b
Professor, Department of Public Health Dentistry, Sri Sai College of Dental Surgery, Andhra Pradesh, India.
c
Professor and Head of Department, Department of Public Health Dentistry, Sri Sai College of Dental Surgery, Andhra Pradesh, India.
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Professor, Department of Periodontics, Sri Sai College of Dental Surgery, Andhra Pradesh, India.
e
Associate Professor (Reader), Department of Public Health Dentistry, Sri Sai College of Dental Surgery, Andhra Pradesh, India.
Correspondence: Dr. V.Prathima, Army College of Dental Sciences, ACDS Nagar, Jawahar Nagar, Secunderabad, India, 500087. Tel: +91-986-642-4751. Email: [email protected]
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Submitted for publication: 23.01.12; accepted for publication: 02.03.13
sad, angry, etc) activities. Cognitive and affective activities lead to the development of responses and reactions. One such reaction or emotional response is anxiety, which begins with a biological arousal in specialised subcortical areas of the brain. Anxiety is thus described as a diffuse, unformulated uneasiness and intense apprehension that is usually reflected in a characteristic combination of visceral-motor disturbances and skeletal tensions. These symptoms are often anticipatory in nature, a reaction to an unknown danger; i.e. they are often felt when a stimulus is not present or readily identifiable. If these reactions are present throughout life, it is termed trait anxiety. However, it may develop as a response to a particular situation or activity and is then called state anxiety (Corah, 1988).
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The source of anxiety may be found not only within the individual’s personality but also outside it, for instance, in dental environments. The prevalence of dental anxiety is estimated to be approximately 5% to 30% in the general population (Thomson et al, 2009). This anxiety-provoking environment can exist before, during and after the dental treatment. The multireligious Indian society, with its different cultures and extremely diverse thinking, harbours a variety of taboos, mores and personal beliefs which may affect respondents’ views. However, an Indian study reported that 4.7% of dental patients had a high level of dental anxiety (Acharya, 2008). The literature has shown that the aetiology of dental anxiety is a multidimensional phenomenon, and stimuli (real or imaginative) can contribute to the development of dental anxiety (Neverlien et al, 1991). The stimulus can be acquired from role models (family, peers and society), unpleasant previous dental experience, environmental factors (e.g. examination room, appearance and noise of equipment, unpleasant odour), fear of injections and high-speed instruments. On the other hand, one study (Eli et al, 1997) also states that several individual personality traits such as neuroticism, health locus of control, hostility and psychological and somatic lack of well-being intervene between stimuli and response. Dental anxiety in the general population was found to be associated with age, gender, education and socioeconomic status (Eli et al, 1997; de Jongh et al, 2003; Oktay et al, 2009). The Dental Anxiety Scale (DAS) is a widely-used trait anxiety measure designed to assess a patient’s tendencies to appraise dental treatment situations as dangerous and threatening. It is a four-item measure developed by Corah in 1988, based on the premise that a generalised notion of trait anxiety will never be meaningful unless it is associated with a specific area of potential threat. It is a scale mainly useful in clinical contexts; it takes little time to perform (< 5 min), has high reliability and predictive validity and yields a sufficient amount of information. Despite its common usage, there were limitations; to overcome these, the modified dental anxiety scale (MDAS) was developed by Humphris et al in 1995. It differs from DAS by addition of a fifth item that asks about responses to administration of local anaesthetic and by a standard response format. It has high levels of reliability and validity (Newton and Buck, 2000).
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The study by Corah (1988) considered dental anxiety as one of the major variables associated with patient compliance (regular visits or check ups, etc) and a reason for abandoning treatment, which may cause poor oral hygiene (Corah 1988), affect the patient-dentist relationship and impair proper diagnosis of the actual dental problem. Only a few studies have reported anxiety in association with various dental treatments, e.g. filling, scaling, crown preparations, extraction, periodontal surgery and endodontic treatment. The anxiety scores of patients were reported to be highest related to extraction, followed by scaling, periodontal surgery, root canal treatment, crowns and finally fillings (Stabholz et al, 1999). In light of the above, the present study was conducted to assess the levels of anxiety associated with dental treatments among patients attending dental clinics and hospitals in Ranga Reddy district in the state of Andhra Pradesh, India.
MATERIALS AND METHODS A cross-sectional study was conducted among a sample of 1200 patients attending dental clinics or hospitals of Ranga Reddy district. A systematic random sampling technique was used to select the dental clinics (indivdually-owned practice and group practice) and dental hospitals (multispecialty and dental wing in a general hospital) from the list obtained from Indian Dental Association Deccan Branch and The District Health and Medical Office respectively. A design effect of three was assumed for cluster sampling, since the data were obtained from the practices and hospitals. Patients older than 18 waiting in the reception area were included in the study. Those who reported a history of psychological illness, were presently on medication or were physically handicapped were excluded from the study. Ethical clearance was obtained from Sri Sai College of Dental Surgery, Vikarabad. Informed consent was obtained from subjects. The data were collected using the prepared questionnaire which comprised (i) demographic details, (ii) patients’ previous dental visits and their experiences and (iii) the Modified Corah Dental Anxiety Scale (MDAS). The original English version was translated to Telugu and Hindi languages twice independently, first by persons with an excellent command of their respective languages and second by professional translators. Both translations were merged into one version and
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back translation of the questionnaire was done as quality control. Cronbach’s _ was computed to check the internal consistency, and test-retest reliability of the translated questionnaires was performed (Cronbach’s _ = 0.85, Spearman’s correlation 0.78). Explanations were given to illiterate subjects (17.2%) about the objectives and content of the questionnaire in their local language and their responses were entered appropriately.
Modified Dental Anxiety Scale This self-rating instrument is a 5-item scale and each question has five scores ranging from relaxed to very anxious. The total score is a sum of all five items and can thus range from 5 to 25. Each question thus carries a possible minimum score of 5 with a total possible maximum score of 25 and a minimum score of 5 for the entire scale. The subjects were distributed according to each item and the mean was calculated based on three scoring criteria, i.e. 5–10 was considered as low anxiety, 11–18 as moderate anxiety and 19–25 as high anxiety.
Statistical analysis The collected data were entered into Microsoft Excel 2007 (Redmond, WA, USA) and subjected to statistical analysis using SPSS version 15.0 (Chicago, IL, USA). The quantitative data were summarised using means and standard deviations, while qualitative data were summarised using percentages. The t-test, Mann-Whitney U-test and one-way ANOVA were used to determine significant differences between the means of anxiety associated with different variables. Tukey’s post-hoc least significant difference (LSD) test was used on significant F-test variables to explore differences among means associated with anxiety. To investigate the importance of variables responsible for anxiety, logistic regression analysis was carried out.
RESULTS This cross-sectional study was conducted on 1200 patients, of which 1.9% (23) patients had no knowledge regarding dentistry or had never seen the dental instruments and were excluded from the study because they were unable to answer the
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questionnaire. Among the remaining 1177 patients, 49.60% (584) were males and 50.40% (593) were females. They were categorised into four age groups: 18–34, 35–44, 45–64 and > 64 years old. Most of the participants were between 18 and 34 (56.1%) and the least number were in the age group > 64 years (4%). A majority of the participants belonged to the upper middle class (42.23%) and a minority (3.82%) had a low socioeconomic status. The distribution of subjects in relation to socioeconomic status was classified based on Kuppuswamy’s socioeconomic status (SES) scale (Kuppuswamy, 1976). This scale includes educational status, occupational status and family income per score (income per month in Rupees is divided in to seven ranges in Kuppuswamy’s scale; these ranges change every year according to the census and each are assigned a score). In the present study, the scores were based on the 2007 census. The total of these scores is used to form SES categories: upper class (26–29), upper middle class (16–25), lower middle class (11–15), upper lower class (5–10) and lower class (< 5). Nearly 65.3% of the participants were from urban areas. They were distributed among three levels of anxiety: low (5–10), moderate (11–18) and high (19–25). 52.4% belonged to the low-anxiety level, 43.2% to the moderate and 4.4% belonged to the high-anxiety level. Among the total number of subjects, the levels of anxiety were highest (24%) in those who were waiting for extraction and lowest for denture (1.5%) treatment. The total mean MDAS score for 1177 subjects was 10.51 (± 4.56). A higher mean MDAS score was recorded in females (11.44 ± 4.41) than in males (9.57 ± 4.52); this difference was found to be significant (P < 0.05). The highest anxiety score was found between ages 18–34 (11.28 ± 4.67). As age increased thereafter, the anxiety scores decreased. The difference in the levels of anxiety among the different age groups was found to be significant (P < 0.05). A higher mean MDAS score was found among subjects of the lower middle class (10.96 ± 4.4) followed by subjects of the lower class (10.76 ± 5.24), upper lower class (10.69 ± 5.4), upper middle class (10.32 ± 4.1) and lastly upper class (8.93 ± 2.82). These differences were also found to be significant (Table 1). The MDAS score was found to be significantly higher among subjects who were making their first visit to the dentist (12.07 ± 4.3) as compared to other subjects who had visited the dentist previously (Table 2).
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Table 1
Mean MDAS scores of subjects in relation to sociodemographic variables Variable
% (n)
Mean MDAS score
Gender Males Females
49.6% 50.4%
9.5 ± 4.52 11.44 ± 4.41
Age groups (years) 18–34 35–44 45–64 > 64
56.1% 16.9% 23% 4%
11.28 ± 4.67a 10.06 ± 4.15b 9.38 ± 4.32bc 8.19 ± 3.64cd
Socioeconomic status Upper class Upper middle class Lower middle class Upper lower class Lower class
4.7% 42.2% 23.2% 26% 3.82%
8.93 ± 2.82 10.32 ± 4.1 10.96 ± 4.4 10.69 ± 5.4 10.76 ± 5.2
Residential area Urban Rural
65.3% 34.7%
10.07 ± 4.7 10.75 ± 4.4
P-value 0.012*
0.0001**
0.027**
0.016***
*Mann-Whitney U-test; **one-way ANOVA; ***t- test. Values having the same superscript letters are not significantly different at P > 0.05 using post-hoc ANOVA with LSD.
Table 2
Mean MDAS scores of subjects in relation to previous visit to dentist and their experience Variable
%
Mean MDAS score
P-value
First visit Yes No
25.8 74.2
12.07 ± 4.3 9.97 ± 4.5
Previous no. of visits Once Twice Thrice More than 3 times
25.6 29.3 18.1 27
10.81 ± 5.13ab 10.60 ± 4.54ab 9.23 ± 4.2cd 9.07 ± 3.9cd
0.0001**
Visit to a dentist Regularly (once in 6 months/1 year) Occasional check-up When in pain or trouble Never
10.3 8.2 56.5 25
8.57 ± 3.47a 9.89 ± 4.25bc 10.34 ± 4.71bc 11.92 ± 4.30d
0.0001**
0.0001*
** One-way ANOVA; *t-test. Values having the same superscripts (a,b,c,d) are not significantly different at P > 0.05 using post-hoc ANOVA with LSD.
Table 3 shows the highest MDAS score among subjects waiting for extraction (11.25 ± 5.4), followed by examination (10.67 ± 4.41), root canal treatment (10.59 ± 4.41), gum surgery (10.57 ± 2.94), scaling (10.45 ± 4.17), restoration (10.27 ± 4.2) and others, e.g. orthodontic treatments (9.43 ± 3.22), crowns (9.37 ± 4.45), bridges (9.36 ± 3.82) and dentures (7.79 ± 3.80). As evident from Table 4, a significant association exists between anxiety levels of
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the subjects anticipating different dental treatments. The highest anxiety levels of patients waiting for ‘extraction’ was found to be significantly associated with subjects waiting for ‘restoration’, ‘crown’, ‘denture’ and ‘bridge’ treatments. Anxiety levels of the subjects waiting for ‘gum surgery’ and others, e.g. ‘orthodontic treatments’ were found not to be associated with any other treatments.
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Table 3
Distribution of study subjects based on levels of anxiety in relation to treatments they were anticipating Treatment
No. of subjects
Percentage
Mean ± SD
Examination
144
12.2%
10.67 ± 4.41
Scaling
202
17.2%
10.45 ± 4.17
Restoration
164
13.9%
10.27 ± 4.20
Extraction
278
24.0%
11.25 ± 5.40
Root canal treatment
225
19.0%
10.59 ± 4.41
Denture
19
1.5%
7.79 ± 3.80
Crown
54
4.5%
9.37 ± 4.45
Bridge
47
4.0%
9.36 ± 3.82
Gum surgery
21
1.7%
10.57 ± 2.94
Others
23
2.0%
9.43 ± 3.22
1177
100.0%
10.51 ± 4.56
Total F= 2.52, df= 9, P = 0.007.
Table 4
Association of anxiety levels of the study subjects anticipating different treatments
Treatment
Examination Scaling Restoration
Examination
Scaling
Restoration
Extraction
Root canal treatment
Denture
Crown
Bridge
Gum surgery
Others
NS
NS
NS
NS
**
NS
NS
NS
NS
NS
NS
NS
**
NS
NS
NS
NS
**
NS
**
NS
NS
NS
NS
NS
**
**
**
NS
NS
**
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
Extraction Root canal treatment Denture Crown Bridge Gum surgery
NS
**Statistically significant; NS not statistically significant using Tukey’s post-hoc ANOVA with LSD.
From high to low, the following mean MDAS scores were recorded for subjects apprehensive about ‘all the aspects stated below’ (14.03 ± 5.39) followed by ‘any combinations of above’ (14.03 ± 5.39), ‘past difficult experience in dental treatments’ (12.58 ± 4.43), ‘fear of drill’ (11.91 ± 4.52), ‘fear of injection’ (11.33 ± 3.56), ‘well aware of the experience of those close to them in relation to dental treatments’ (10.13 ± 4.30), ‘stories heard about dental proced-
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ures’ (9.71 ± 4.04) and lastly among subjects indicating ‘other reasons’ (7.82 ± 3.84) (Fig 1). Table 5 presents results from logistic regression analysis to predict those at a cut-off of 11 or above on the MDAS with the following variables: age group, sex, socioeconomic status, area of residence, first visit to a dentist and number of previous visits. The independent variables found strongly related to dental anxiety were age, sex, area of residence and visit-
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Mean anxiety levels
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16 14 12 10 8 6 4 2 0
Mean
Past difficult experience
Well aware of experiences of someone close to you
Stories about dental procedures
Drill
Injection
Any combinations of above
All the above
Others
12.58
10.13
9.71
11.91
11.33
13.59
14.03
7.82
Fig 1 Distribution of study subjects based on levels of anxiety in relation to apprehension
Table 5
Logistic regression to predict those at cutoff of 11 or above on the MDAS with various variables Dependent variable: anxiety (yes = 0; no = 1, 2, 3, 4) Independent variable
Lower limit
Upper limit
P-value
2.861 1.533 1.252
1.249 0.638 0.533
6.554 3.685 2.941
0.013* 0.339 0.606
0.479
0.350
0.656
0.0001*
Socioeconomic status Lower class (0) Middle class (1) Upper class (2)
1.939 1.392
0.829 0.622
4.535 3.112
0.126 0.421
Residential area Rural (0) Urban (1)
0.563
0.397
0.797
0.001*
First visit Yes (0) No (1)
8.092
1.215
53.9
0.031*
No. of previous visits Once (0) Twice (1) Thrice (2) More than 3 times (3)
1.472 1.387 0.851
0.950 0.916 0.523
2.282 2.100 1.385
0.084 0.122 0.517
0.52 1.09 1.18
0.17 0.37 0.4
1.5 3.1 3.1
0.2 0.8 0.7
Age groups 18–34 (0) 35–44 (1) 45–64 (2) > 64 (3) Gender Female (0) Male (1)
Visit to the dentist Never been (0) When in pain or trouble (1) Occasional check-up (2) Regularly (once in 6 months/1yr) (3)
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Odds ratio
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ing a dentist for the first time. Gender and area of residence were found to have the strongest impact on anxiety scores. Upon comparison of the age groups, only subjects 35–44 years old were noted to be at higher risk of having dental anxiety. Those who had never visited a dentist had a significantly higher risk of having anxiety when compared to those who had previously visited a dentist.
DISCUSSION In the present study, assessment of anxiety through a questionnaire was found to be advantageous, firstly because questionnaires are fast and inexpensive to administer and score and secondly, they have high face validity making them appropriate for patients and research subjects to engage in (Coolidge et al, 2008). Cultural adaptation is a process by which a questionnaire developed for one specific country can be adapted for use in other countries. The translated version of MDAS was reliable with a Cronbach’s alpha of 0.85, which was acceptable. However, in a study conducted by Acharya (2008), it was found to be slightly less (0.78). In the present study, the level of high dental anxiety in the sample was 4.4%, which was slightly more than in the study conducted by Acharya (2008), i.e. 2.2%. This difference might be due to the difference in study settings (university vs private clinics). Similar findings were found in a study done by Locker et al (1991) with 4.4% high anxiety and Moore et al (1993) with 4.2%. In contrast, greater percentages of high anxiety were found in studies conducted by Humphris et al (2009) with 11%, Ofori et al (2009) with 13.4% and Yuan et al (2008) with 8.7% of subjects having a high level of anxiety. The different Indian cultures may be the reason for this wider difference between India (Acharya, 2008) and other countries, or it might be due to the attitudes stemming from modifiable sociodemographic factors such as age, sex, education, socioeconomic status and apprehension due to various aspects of dental treatment, as was demonstrated in the present study. In the present study, the basis for higher anxiety levels found in females than males may possibly be due to personality and psychological state, as men may not express their fears as openly as women. These finding were in agreement with the findings of Acharya (2008), Humphris et al (2009) and Yetkin et al (2008).
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The current study showed the highest anxiety scores among subjects of the 18–34 age group. This finding was in agreement with the studies conducted by Humphris et al (2009) and Yuan et al (2008) but not with the study conducted by Thomson et al (1996), in which the age group 35–44 years had the highest anxiety score. The onset of dental anxiety is thought to originate in childhood, which peaks in early adulthood and declines with age. The onset in childhood is usually ascribed to averse dental experiences, vicarious influences or conditioning via sources of information (Thomson et al, 1996). Thomson et al (2000) stated that a marginal increase in dental anxiety between the ages of 15 and 18 years (adolescence/early adulthood) may perhaps be due to physiological and psychological changes of puberty and the likelihood that older children experienced more invasive treatments. It has also been reported that anxiety tends to decrease with age, suggesting that it might be due to a cohort effect reflecting differences in historical and cultural experiences between the age groups surveyed, as well as greater past exposure to various diseases and treatments (Stabholz et al, 1999). Although there was a decrease in anxiety levels in older adults in this study, there was increasing need for dental care among them. The present study shows the highest anxiety levels among the lower middle class and lower class and the lowest among upper SES subjects. This might be due to an indirect effect, as ethnic minorities or people with a low SES tend to visit the dentist infrequently and hence have less dental treatment modality awareness. Anxiety levels were found to be high in subjects who had a bad dental experience, which influences the next visit as well. In a series of experimental studies, more patients in the anxious group reported that they suffered from memories of earlier dental events than did patients in the low-anxiety group (de Jongh et al, 2003). The present study findings were in agreement with the study conducted by Acharya (2008), whereas in a study conducted by Ofori et al (2009), past dental experience did not have any impact on anxiety levels. The highest MDAS score was found among subjects who were anticipating an extraction and the lowest for denture treatment. The reason for high levels of anxiety in relation to extraction might be due to both injection and blood phobias. The lowest anxiety score for denture treatment might be due to the painless treatment procedure. In this
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study, ‘waiting for an examination’ was found to be the second most frequent reason for anxiety. This seemingly counterintuitve observation may possibly be explained by a general phobia towards dentists at the first visit, since patients fear that examination and diagnosis of the problem will be followed by interventions such as root canal treatments. The present study is in agreement with the study conducted by Stabholz et al (1999), where the highest anxiety levels were found in patients waiting for extraction, followed by scaling, periodontal surgery, root canal treatment, crown preparation and lastly filling. In contrast, in a study conducted by Udoye et al (2005), high levels of anxiety were found among patients waiting for root canal treatment, followed by extraction, filling and lastly scaling.
CONCLUSION The study concludes that nearly 50% of the total sample had a low anxiety level. Female subjects of the youngest age group, lower middle socioeconomic status, those who resided in rural areas and who had never been to the dentist were found to have highest mean anxiety level. Subjects who were anticipating extractions were found to have the highest anxiety score, followed by examination, root canal treatment etc. Subjects who were apprehensive due to ‘past difficult experience in dental treatments’ were found to have the highest mean anxiety score, followed by ‘drill’ and ‘injection’. Government and health agencies should take a step forward through mass media to put an end to dental patients’ fears and dismantle the myths or beliefs regarding dental treatment among the general public. As this is also an onus for the private practitioners, the dental professional associations should offer psychological training to dental-care providers, so they can overcome patients’ fear and anxiety through an improved doctor-patient relationship and application of psychologically helpful techniques (distraction, imagery, relaxation and breathing techniques).
ACKNOWLEDGEMENTS We acknowledge Dr. Vishnuvardhan Rao, statistician, for compiling the data and performing the statistical analysis.
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REFERENCES 1. Acharya S. Factors affecting dental anxiety and beliefs in an Indian population. Journal of Oral Rehabilitation 2008;35:259–267. 2. Coolidge T, Arapostathis KN, Emmanouil D, Dabarakis N, Patrikiou A, Economides N, Kotsanos N. Psychometric properties of Greek versions of the Modified Corah Dental Anxiety Scale (MDAS) and the Dental Fear Survey (DFS). BMC Oral Health 2008;8:2–12. 3. Corah NL. Dental Anxiety: Assessment, reduction and increasing patient satisfaction. Dent Clin North Amer 1988;32:779–790. 4. De Jongh A, Aartman IHA, Brand N. Trauma- related phenomena in anxious dental patients. Community Dent Oral Epidemiol 2003;31:52–58. 5. Eli I, Uziel N, Baht R, Kleinhauz M. Antecedents of dental anxiety: learned responses versus personality traits. Community Dent Oral Epidemiol 1997;25:233–237. 6. Humphris GM, Dyer TA, Robinson PG. The modified dental anxiety scale: UK general public population norms in 2008 with further psychometrics and effects of age. BMC Oral Health 2009;9:20. 7. Kuppuswamy B. Manual of Socioeconomic Status (Urban), ed 1. Delhi: Manasayan, 1981. 8. Locker D, Liddell A, Burman D. Dental fear and anxiety in an older adult population. Community Dent Oral Epidemiol 1991;19:120–124. 9. Moore R, Birn H, Kirkegaard I, Scheutz F. Prevalence and characteristics of dental anxiety in Danish adults. Community Dent Oral Epidemiol 1993;21:292–296. 10. Neverlien PO, Backer Johnsen T. Optimism-pessimism dimension and dental anxiety in children aged 10-12yrs. Community Dent Oral Epidemiol 1991;19:342–346. 11. Newton TJ, Buck DJ. Anxiety and pain measures in dentistry: a guide to their quality and application. J Am Dent Assoc 2000;131:1449–1457. 12. Ofori MA, Adu-Ababio .F, Nyako EA, Ndanu TA. Prevalence of dental fear and anxiety amongst patients in selected dental clinics in Ghana. Health Educ J 2009;68:130–139. 13. Oktay EA, Koqak, Sahinkesen G, Topqu FT. The role of age, gender, education and experiences on dental anxiety. Gulhane Tip Dergisi 2009;51:145–148. 14. Stabholz A, Peretz B. Dental anxiety among patients prior to different dental treatments. Int Dent J 1999;49:90–94. 15. Thomson WM, Broadbent JM, Locker D, Poulton R. Trajectories of dental anxiety in a birth cohort. Community Dent Oral Epidemiol 2009;37:209–219. 16. Thomson WM, Judy F Stewart, Carter KD, Spencer JA. Dental anxiety among Australians. Int Dent J 1996;46:320–324. 17. Thomson WM, Locker D, Poulton R. Incidence of dental anxiety in young adults in relation to dental treatment experience. Community Dent Oral Epidemiol 2000;28:289–294. 18. Udoye CI, Oginni AO, Oginni FO. Dental anxiety among patients undergoing various dental treatments in a Nigerian teaching hospital. J Contemp Dent Pract 2005;6:91–98. 19. Yuan S, Freeman R, Lahti S, Lioyd-Williams F, Humphris G. Some psychometric properties of the Chinese version of the Modified Dental Anxiety scale with cross validation. Health Quality Life Outcomes 2008;6:1–19.
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Assessment of Anxiety Related to Dental Treatments Among Patients Attending Dental Clinics and Hospitals in Ranga Reddy District, Andhra Pradesh, India Vedati Prathimaa/M. Shakeel Anjumb/P. Parthasarathi Reddyc/A. Jayakumard/ M. Mounicae Purpose: To assess the levels of dental anxiety among patients anticipating dental treatments in dental clinics/hospitals of Ranga Reddy district. Materials and Methods: A cross-sectional study was conducted among a representative sample of 1200 subjects (at least 18 years old) in dental clinics/hospitals which were selected from a list obtained through systematic random sampling. The data were collected using a pre-tested and calibrated questionnaire consisting of the Modified Corah Dental Anxiety Scale (MDAS) to assess anxiety levels. Results: The majority (52.4%) of subjects showed a low level of anxiety. Females (11.44 ± 4.41) were found to have higher mean MDAS scores than males, and the highest mean MDAS scores were found among 18- to 34-year-olds (11.28 ± 4.67) (P < 0.05). Significant differences were found among subjects anticipating different treatments, with higher MDAS scores for extraction (11.25 ± 5.4), followed by examination, root canal treatment, gum surgery, scaling, restoration and others, e.g. orthodontic treatment, restoration with crowns, bridges and dentures (7.79 ± 3.80). The highest mean MDAS scores were found among subjects who were apprehensive due to ‘past difficult experience in dental treatments’, followed by ‘drill’ and ‘injection’, with the lowest scores among subjects indicating ‘other reasons’ (7.82 ± 3.84). Conclusion: The present data show that anxiety levels are higher in patients who have to undergo extractions than those who must be fitted with dentures. Thus, dental health care providers should pay more attention to patients’ anxiety levels associated with different types of treatment. Key words: dental anxiety, dental treatments, modified dental anxiety scale Oral Health Prev Dent 2014;12:357-364 doi: 10.3290/j.ohpd.a31660
B
ehaviour is the collection of conative (e.g. walking, swimming), cognitive (e.g. thinking, reasoning, imagining) and affective (e.g. feeling happy,
a
Assistant Professor, Department of Public Health Dentistry, Army College of Dental Sciences, Andhra Pradesh, India.
b
Professor, Department of Public Health Dentistry, Sri Sai College of Dental Surgery, Andhra Pradesh, India.
c
Professor and Head of Department, Department of Public Health Dentistry, Sri Sai College of Dental Surgery, Andhra Pradesh, India.
d
Professor, Department of Periodontics, Sri Sai College of Dental Surgery, Andhra Pradesh, India.
e
Associate Professor (Reader), Department of Public Health Dentistry, Sri Sai College of Dental Surgery, Andhra Pradesh, India.
Correspondence: Dr. V.Prathima, Army College of Dental Sciences, ACDS Nagar, Jawahar Nagar, Secunderabad, India, 500087. Tel: +91-986-642-4751. Email: [email protected]
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Submitted for publication: 23.01.12; accepted for publication: 02.03.13
sad, angry, etc) activities. Cognitive and affective activities lead to the development of responses and reactions. One such reaction or emotional response is anxiety, which begins with a biological arousal in specialised subcortical areas of the brain. Anxiety is thus described as a diffuse, unformulated uneasiness and intense apprehension that is usually reflected in a characteristic combination of visceral-motor disturbances and skeletal tensions. These symptoms are often anticipatory in nature, a reaction to an unknown danger; i.e. they are often felt when a stimulus is not present or readily identifiable. If these reactions are present throughout life, it is termed trait anxiety. However, it may develop as a response to a particular situation or activity and is then called state anxiety (Corah, 1988).
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The source of anxiety may be found not only within the individual’s personality but also outside it, for instance, in dental environments. The prevalence of dental anxiety is estimated to be approximately 5% to 30% in the general population (Thomson et al, 2009). This anxiety-provoking environment can exist before, during and after the dental treatment. The multireligious Indian society, with its different cultures and extremely diverse thinking, harbours a variety of taboos, mores and personal beliefs which may affect respondents’ views. However, an Indian study reported that 4.7% of dental patients had a high level of dental anxiety (Acharya, 2008). The literature has shown that the aetiology of dental anxiety is a multidimensional phenomenon, and stimuli (real or imaginative) can contribute to the development of dental anxiety (Neverlien et al, 1991). The stimulus can be acquired from role models (family, peers and society), unpleasant previous dental experience, environmental factors (e.g. examination room, appearance and noise of equipment, unpleasant odour), fear of injections and high-speed instruments. On the other hand, one study (Eli et al, 1997) also states that several individual personality traits such as neuroticism, health locus of control, hostility and psychological and somatic lack of well-being intervene between stimuli and response. Dental anxiety in the general population was found to be associated with age, gender, education and socioeconomic status (Eli et al, 1997; de Jongh et al, 2003; Oktay et al, 2009). The Dental Anxiety Scale (DAS) is a widely-used trait anxiety measure designed to assess a patient’s tendencies to appraise dental treatment situations as dangerous and threatening. It is a four-item measure developed by Corah in 1988, based on the premise that a generalised notion of trait anxiety will never be meaningful unless it is associated with a specific area of potential threat. It is a scale mainly useful in clinical contexts; it takes little time to perform (< 5 min), has high reliability and predictive validity and yields a sufficient amount of information. Despite its common usage, there were limitations; to overcome these, the modified dental anxiety scale (MDAS) was developed by Humphris et al in 1995. It differs from DAS by addition of a fifth item that asks about responses to administration of local anaesthetic and by a standard response format. It has high levels of reliability and validity (Newton and Buck, 2000).
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The study by Corah (1988) considered dental anxiety as one of the major variables associated with patient compliance (regular visits or check ups, etc) and a reason for abandoning treatment, which may cause poor oral hygiene (Corah 1988), affect the patient-dentist relationship and impair proper diagnosis of the actual dental problem. Only a few studies have reported anxiety in association with various dental treatments, e.g. filling, scaling, crown preparations, extraction, periodontal surgery and endodontic treatment. The anxiety scores of patients were reported to be highest related to extraction, followed by scaling, periodontal surgery, root canal treatment, crowns and finally fillings (Stabholz et al, 1999). In light of the above, the present study was conducted to assess the levels of anxiety associated with dental treatments among patients attending dental clinics and hospitals in Ranga Reddy district in the state of Andhra Pradesh, India.
MATERIALS AND METHODS A cross-sectional study was conducted among a sample of 1200 patients attending dental clinics or hospitals of Ranga Reddy district. A systematic random sampling technique was used to select the dental clinics (indivdually-owned practice and group practice) and dental hospitals (multispecialty and dental wing in a general hospital) from the list obtained from Indian Dental Association Deccan Branch and The District Health and Medical Office respectively. A design effect of three was assumed for cluster sampling, since the data were obtained from the practices and hospitals. Patients older than 18 waiting in the reception area were included in the study. Those who reported a history of psychological illness, were presently on medication or were physically handicapped were excluded from the study. Ethical clearance was obtained from Sri Sai College of Dental Surgery, Vikarabad. Informed consent was obtained from subjects. The data were collected using the prepared questionnaire which comprised (i) demographic details, (ii) patients’ previous dental visits and their experiences and (iii) the Modified Corah Dental Anxiety Scale (MDAS). The original English version was translated to Telugu and Hindi languages twice independently, first by persons with an excellent command of their respective languages and second by professional translators. Both translations were merged into one version and
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back translation of the questionnaire was done as quality control. Cronbach’s _ was computed to check the internal consistency, and test-retest reliability of the translated questionnaires was performed (Cronbach’s _ = 0.85, Spearman’s correlation 0.78). Explanations were given to illiterate subjects (17.2%) about the objectives and content of the questionnaire in their local language and their responses were entered appropriately.
Modified Dental Anxiety Scale This self-rating instrument is a 5-item scale and each question has five scores ranging from relaxed to very anxious. The total score is a sum of all five items and can thus range from 5 to 25. Each question thus carries a possible minimum score of 5 with a total possible maximum score of 25 and a minimum score of 5 for the entire scale. The subjects were distributed according to each item and the mean was calculated based on three scoring criteria, i.e. 5–10 was considered as low anxiety, 11–18 as moderate anxiety and 19–25 as high anxiety.
Statistical analysis The collected data were entered into Microsoft Excel 2007 (Redmond, WA, USA) and subjected to statistical analysis using SPSS version 15.0 (Chicago, IL, USA). The quantitative data were summarised using means and standard deviations, while qualitative data were summarised using percentages. The t-test, Mann-Whitney U-test and one-way ANOVA were used to determine significant differences between the means of anxiety associated with different variables. Tukey’s post-hoc least significant difference (LSD) test was used on significant F-test variables to explore differences among means associated with anxiety. To investigate the importance of variables responsible for anxiety, logistic regression analysis was carried out.
RESULTS This cross-sectional study was conducted on 1200 patients, of which 1.9% (23) patients had no knowledge regarding dentistry or had never seen the dental instruments and were excluded from the study because they were unable to answer the
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questionnaire. Among the remaining 1177 patients, 49.60% (584) were males and 50.40% (593) were females. They were categorised into four age groups: 18–34, 35–44, 45–64 and > 64 years old. Most of the participants were between 18 and 34 (56.1%) and the least number were in the age group > 64 years (4%). A majority of the participants belonged to the upper middle class (42.23%) and a minority (3.82%) had a low socioeconomic status. The distribution of subjects in relation to socioeconomic status was classified based on Kuppuswamy’s socioeconomic status (SES) scale (Kuppuswamy, 1976). This scale includes educational status, occupational status and family income per score (income per month in Rupees is divided in to seven ranges in Kuppuswamy’s scale; these ranges change every year according to the census and each are assigned a score). In the present study, the scores were based on the 2007 census. The total of these scores is used to form SES categories: upper class (26–29), upper middle class (16–25), lower middle class (11–15), upper lower class (5–10) and lower class (< 5). Nearly 65.3% of the participants were from urban areas. They were distributed among three levels of anxiety: low (5–10), moderate (11–18) and high (19–25). 52.4% belonged to the low-anxiety level, 43.2% to the moderate and 4.4% belonged to the high-anxiety level. Among the total number of subjects, the levels of anxiety were highest (24%) in those who were waiting for extraction and lowest for denture (1.5%) treatment. The total mean MDAS score for 1177 subjects was 10.51 (± 4.56). A higher mean MDAS score was recorded in females (11.44 ± 4.41) than in males (9.57 ± 4.52); this difference was found to be significant (P < 0.05). The highest anxiety score was found between ages 18–34 (11.28 ± 4.67). As age increased thereafter, the anxiety scores decreased. The difference in the levels of anxiety among the different age groups was found to be significant (P < 0.05). A higher mean MDAS score was found among subjects of the lower middle class (10.96 ± 4.4) followed by subjects of the lower class (10.76 ± 5.24), upper lower class (10.69 ± 5.4), upper middle class (10.32 ± 4.1) and lastly upper class (8.93 ± 2.82). These differences were also found to be significant (Table 1). The MDAS score was found to be significantly higher among subjects who were making their first visit to the dentist (12.07 ± 4.3) as compared to other subjects who had visited the dentist previously (Table 2).
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Table 1
Mean MDAS scores of subjects in relation to sociodemographic variables Variable
% (n)
Mean MDAS score
Gender Males Females
49.6% 50.4%
9.5 ± 4.52 11.44 ± 4.41
Age groups (years) 18–34 35–44 45–64 > 64
56.1% 16.9% 23% 4%
11.28 ± 4.67a 10.06 ± 4.15b 9.38 ± 4.32bc 8.19 ± 3.64cd
Socioeconomic status Upper class Upper middle class Lower middle class Upper lower class Lower class
4.7% 42.2% 23.2% 26% 3.82%
8.93 ± 2.82 10.32 ± 4.1 10.96 ± 4.4 10.69 ± 5.4 10.76 ± 5.2
Residential area Urban Rural
65.3% 34.7%
10.07 ± 4.7 10.75 ± 4.4
P-value 0.012*
0.0001**
0.027**
0.016***
*Mann-Whitney U-test; **one-way ANOVA; ***t- test. Values having the same superscript letters are not significantly different at P > 0.05 using post-hoc ANOVA with LSD.
Table 2
Mean MDAS scores of subjects in relation to previous visit to dentist and their experience Variable
%
Mean MDAS score
P-value
First visit Yes No
25.8 74.2
12.07 ± 4.3 9.97 ± 4.5
Previous no. of visits Once Twice Thrice More than 3 times
25.6 29.3 18.1 27
10.81 ± 5.13ab 10.60 ± 4.54ab 9.23 ± 4.2cd 9.07 ± 3.9cd
0.0001**
Visit to a dentist Regularly (once in 6 months/1 year) Occasional check-up When in pain or trouble Never
10.3 8.2 56.5 25
8.57 ± 3.47a 9.89 ± 4.25bc 10.34 ± 4.71bc 11.92 ± 4.30d
0.0001**
0.0001*
** One-way ANOVA; *t-test. Values having the same superscripts (a,b,c,d) are not significantly different at P > 0.05 using post-hoc ANOVA with LSD.
Table 3 shows the highest MDAS score among subjects waiting for extraction (11.25 ± 5.4), followed by examination (10.67 ± 4.41), root canal treatment (10.59 ± 4.41), gum surgery (10.57 ± 2.94), scaling (10.45 ± 4.17), restoration (10.27 ± 4.2) and others, e.g. orthodontic treatments (9.43 ± 3.22), crowns (9.37 ± 4.45), bridges (9.36 ± 3.82) and dentures (7.79 ± 3.80). As evident from Table 4, a significant association exists between anxiety levels of
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the subjects anticipating different dental treatments. The highest anxiety levels of patients waiting for ‘extraction’ was found to be significantly associated with subjects waiting for ‘restoration’, ‘crown’, ‘denture’ and ‘bridge’ treatments. Anxiety levels of the subjects waiting for ‘gum surgery’ and others, e.g. ‘orthodontic treatments’ were found not to be associated with any other treatments.
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Table 3
Distribution of study subjects based on levels of anxiety in relation to treatments they were anticipating Treatment
No. of subjects
Percentage
Mean ± SD
Examination
144
12.2%
10.67 ± 4.41
Scaling
202
17.2%
10.45 ± 4.17
Restoration
164
13.9%
10.27 ± 4.20
Extraction
278
24.0%
11.25 ± 5.40
Root canal treatment
225
19.0%
10.59 ± 4.41
Denture
19
1.5%
7.79 ± 3.80
Crown
54
4.5%
9.37 ± 4.45
Bridge
47
4.0%
9.36 ± 3.82
Gum surgery
21
1.7%
10.57 ± 2.94
Others
23
2.0%
9.43 ± 3.22
1177
100.0%
10.51 ± 4.56
Total F= 2.52, df= 9, P = 0.007.
Table 4
Association of anxiety levels of the study subjects anticipating different treatments
Treatment
Examination Scaling Restoration
Examination
Scaling
Restoration
Extraction
Root canal treatment
Denture
Crown
Bridge
Gum surgery
Others
NS
NS
NS
NS
**
NS
NS
NS
NS
NS
NS
NS
**
NS
NS
NS
NS
**
NS
**
NS
NS
NS
NS
NS
**
**
**
NS
NS
**
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
Extraction Root canal treatment Denture Crown Bridge Gum surgery
NS
**Statistically significant; NS not statistically significant using Tukey’s post-hoc ANOVA with LSD.
From high to low, the following mean MDAS scores were recorded for subjects apprehensive about ‘all the aspects stated below’ (14.03 ± 5.39) followed by ‘any combinations of above’ (14.03 ± 5.39), ‘past difficult experience in dental treatments’ (12.58 ± 4.43), ‘fear of drill’ (11.91 ± 4.52), ‘fear of injection’ (11.33 ± 3.56), ‘well aware of the experience of those close to them in relation to dental treatments’ (10.13 ± 4.30), ‘stories heard about dental proced-
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ures’ (9.71 ± 4.04) and lastly among subjects indicating ‘other reasons’ (7.82 ± 3.84) (Fig 1). Table 5 presents results from logistic regression analysis to predict those at a cut-off of 11 or above on the MDAS with the following variables: age group, sex, socioeconomic status, area of residence, first visit to a dentist and number of previous visits. The independent variables found strongly related to dental anxiety were age, sex, area of residence and visit-
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Mean anxiety levels
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16 14 12 10 8 6 4 2 0
Mean
Past difficult experience
Well aware of experiences of someone close to you
Stories about dental procedures
Drill
Injection
Any combinations of above
All the above
Others
12.58
10.13
9.71
11.91
11.33
13.59
14.03
7.82
Fig 1 Distribution of study subjects based on levels of anxiety in relation to apprehension
Table 5
Logistic regression to predict those at cutoff of 11 or above on the MDAS with various variables Dependent variable: anxiety (yes = 0; no = 1, 2, 3, 4) Independent variable
Lower limit
Upper limit
P-value
2.861 1.533 1.252
1.249 0.638 0.533
6.554 3.685 2.941
0.013* 0.339 0.606
0.479
0.350
0.656
0.0001*
Socioeconomic status Lower class (0) Middle class (1) Upper class (2)
1.939 1.392
0.829 0.622
4.535 3.112
0.126 0.421
Residential area Rural (0) Urban (1)
0.563
0.397
0.797
0.001*
First visit Yes (0) No (1)
8.092
1.215
53.9
0.031*
No. of previous visits Once (0) Twice (1) Thrice (2) More than 3 times (3)
1.472 1.387 0.851
0.950 0.916 0.523
2.282 2.100 1.385
0.084 0.122 0.517
0.52 1.09 1.18
0.17 0.37 0.4
1.5 3.1 3.1
0.2 0.8 0.7
Age groups 18–34 (0) 35–44 (1) 45–64 (2) > 64 (3) Gender Female (0) Male (1)
Visit to the dentist Never been (0) When in pain or trouble (1) Occasional check-up (2) Regularly (once in 6 months/1yr) (3)
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Odds ratio
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ing a dentist for the first time. Gender and area of residence were found to have the strongest impact on anxiety scores. Upon comparison of the age groups, only subjects 35–44 years old were noted to be at higher risk of having dental anxiety. Those who had never visited a dentist had a significantly higher risk of having anxiety when compared to those who had previously visited a dentist.
DISCUSSION In the present study, assessment of anxiety through a questionnaire was found to be advantageous, firstly because questionnaires are fast and inexpensive to administer and score and secondly, they have high face validity making them appropriate for patients and research subjects to engage in (Coolidge et al, 2008). Cultural adaptation is a process by which a questionnaire developed for one specific country can be adapted for use in other countries. The translated version of MDAS was reliable with a Cronbach’s alpha of 0.85, which was acceptable. However, in a study conducted by Acharya (2008), it was found to be slightly less (0.78). In the present study, the level of high dental anxiety in the sample was 4.4%, which was slightly more than in the study conducted by Acharya (2008), i.e. 2.2%. This difference might be due to the difference in study settings (university vs private clinics). Similar findings were found in a study done by Locker et al (1991) with 4.4% high anxiety and Moore et al (1993) with 4.2%. In contrast, greater percentages of high anxiety were found in studies conducted by Humphris et al (2009) with 11%, Ofori et al (2009) with 13.4% and Yuan et al (2008) with 8.7% of subjects having a high level of anxiety. The different Indian cultures may be the reason for this wider difference between India (Acharya, 2008) and other countries, or it might be due to the attitudes stemming from modifiable sociodemographic factors such as age, sex, education, socioeconomic status and apprehension due to various aspects of dental treatment, as was demonstrated in the present study. In the present study, the basis for higher anxiety levels found in females than males may possibly be due to personality and psychological state, as men may not express their fears as openly as women. These finding were in agreement with the findings of Acharya (2008), Humphris et al (2009) and Yetkin et al (2008).
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The current study showed the highest anxiety scores among subjects of the 18–34 age group. This finding was in agreement with the studies conducted by Humphris et al (2009) and Yuan et al (2008) but not with the study conducted by Thomson et al (1996), in which the age group 35–44 years had the highest anxiety score. The onset of dental anxiety is thought to originate in childhood, which peaks in early adulthood and declines with age. The onset in childhood is usually ascribed to averse dental experiences, vicarious influences or conditioning via sources of information (Thomson et al, 1996). Thomson et al (2000) stated that a marginal increase in dental anxiety between the ages of 15 and 18 years (adolescence/early adulthood) may perhaps be due to physiological and psychological changes of puberty and the likelihood that older children experienced more invasive treatments. It has also been reported that anxiety tends to decrease with age, suggesting that it might be due to a cohort effect reflecting differences in historical and cultural experiences between the age groups surveyed, as well as greater past exposure to various diseases and treatments (Stabholz et al, 1999). Although there was a decrease in anxiety levels in older adults in this study, there was increasing need for dental care among them. The present study shows the highest anxiety levels among the lower middle class and lower class and the lowest among upper SES subjects. This might be due to an indirect effect, as ethnic minorities or people with a low SES tend to visit the dentist infrequently and hence have less dental treatment modality awareness. Anxiety levels were found to be high in subjects who had a bad dental experience, which influences the next visit as well. In a series of experimental studies, more patients in the anxious group reported that they suffered from memories of earlier dental events than did patients in the low-anxiety group (de Jongh et al, 2003). The present study findings were in agreement with the study conducted by Acharya (2008), whereas in a study conducted by Ofori et al (2009), past dental experience did not have any impact on anxiety levels. The highest MDAS score was found among subjects who were anticipating an extraction and the lowest for denture treatment. The reason for high levels of anxiety in relation to extraction might be due to both injection and blood phobias. The lowest anxiety score for denture treatment might be due to the painless treatment procedure. In this
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study, ‘waiting for an examination’ was found to be the second most frequent reason for anxiety. This seemingly counterintuitve observation may possibly be explained by a general phobia towards dentists at the first visit, since patients fear that examination and diagnosis of the problem will be followed by interventions such as root canal treatments. The present study is in agreement with the study conducted by Stabholz et al (1999), where the highest anxiety levels were found in patients waiting for extraction, followed by scaling, periodontal surgery, root canal treatment, crown preparation and lastly filling. In contrast, in a study conducted by Udoye et al (2005), high levels of anxiety were found among patients waiting for root canal treatment, followed by extraction, filling and lastly scaling.
CONCLUSION The study concludes that nearly 50% of the total sample had a low anxiety level. Female subjects of the youngest age group, lower middle socioeconomic status, those who resided in rural areas and who had never been to the dentist were found to have highest mean anxiety level. Subjects who were anticipating extractions were found to have the highest anxiety score, followed by examination, root canal treatment etc. Subjects who were apprehensive due to ‘past difficult experience in dental treatments’ were found to have the highest mean anxiety score, followed by ‘drill’ and ‘injection’. Government and health agencies should take a step forward through mass media to put an end to dental patients’ fears and dismantle the myths or beliefs regarding dental treatment among the general public. As this is also an onus for the private practitioners, the dental professional associations should offer psychological training to dental-care providers, so they can overcome patients’ fear and anxiety through an improved doctor-patient relationship and application of psychologically helpful techniques (distraction, imagery, relaxation and breathing techniques).
ACKNOWLEDGEMENTS We acknowledge Dr. Vishnuvardhan Rao, statistician, for compiling the data and performing the statistical analysis.
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REFERENCES 1. Acharya S. Factors affecting dental anxiety and beliefs in an Indian population. Journal of Oral Rehabilitation 2008;35:259–267. 2. Coolidge T, Arapostathis KN, Emmanouil D, Dabarakis N, Patrikiou A, Economides N, Kotsanos N. Psychometric properties of Greek versions of the Modified Corah Dental Anxiety Scale (MDAS) and the Dental Fear Survey (DFS). BMC Oral Health 2008;8:2–12. 3. Corah NL. Dental Anxiety: Assessment, reduction and increasing patient satisfaction. Dent Clin North Amer 1988;32:779–790. 4. De Jongh A, Aartman IHA, Brand N. Trauma- related phenomena in anxious dental patients. Community Dent Oral Epidemiol 2003;31:52–58. 5. Eli I, Uziel N, Baht R, Kleinhauz M. Antecedents of dental anxiety: learned responses versus personality traits. Community Dent Oral Epidemiol 1997;25:233–237. 6. Humphris GM, Dyer TA, Robinson PG. The modified dental anxiety scale: UK general public population norms in 2008 with further psychometrics and effects of age. BMC Oral Health 2009;9:20. 7. Kuppuswamy B. Manual of Socioeconomic Status (Urban), ed 1. Delhi: Manasayan, 1981. 8. Locker D, Liddell A, Burman D. Dental fear and anxiety in an older adult population. Community Dent Oral Epidemiol 1991;19:120–124. 9. Moore R, Birn H, Kirkegaard I, Scheutz F. Prevalence and characteristics of dental anxiety in Danish adults. Community Dent Oral Epidemiol 1993;21:292–296. 10. Neverlien PO, Backer Johnsen T. Optimism-pessimism dimension and dental anxiety in children aged 10-12yrs. Community Dent Oral Epidemiol 1991;19:342–346. 11. Newton TJ, Buck DJ. Anxiety and pain measures in dentistry: a guide to their quality and application. J Am Dent Assoc 2000;131:1449–1457. 12. Ofori MA, Adu-Ababio .F, Nyako EA, Ndanu TA. Prevalence of dental fear and anxiety amongst patients in selected dental clinics in Ghana. Health Educ J 2009;68:130–139. 13. Oktay EA, Koqak, Sahinkesen G, Topqu FT. The role of age, gender, education and experiences on dental anxiety. Gulhane Tip Dergisi 2009;51:145–148. 14. Stabholz A, Peretz B. Dental anxiety among patients prior to different dental treatments. Int Dent J 1999;49:90–94. 15. Thomson WM, Broadbent JM, Locker D, Poulton R. Trajectories of dental anxiety in a birth cohort. Community Dent Oral Epidemiol 2009;37:209–219. 16. Thomson WM, Judy F Stewart, Carter KD, Spencer JA. Dental anxiety among Australians. Int Dent J 1996;46:320–324. 17. Thomson WM, Locker D, Poulton R. Incidence of dental anxiety in young adults in relation to dental treatment experience. Community Dent Oral Epidemiol 2000;28:289–294. 18. Udoye CI, Oginni AO, Oginni FO. Dental anxiety among patients undergoing various dental treatments in a Nigerian teaching hospital. J Contemp Dent Pract 2005;6:91–98. 19. Yuan S, Freeman R, Lahti S, Lioyd-Williams F, Humphris G. Some psychometric properties of the Chinese version of the Modified Dental Anxiety scale with cross validation. Health Quality Life Outcomes 2008;6:1–19.
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