Abstract
Objectives: We evaluated associations between changes in dental anxiety and oral health-related quality of life (OHRQoL) in parents of the FinnBrain Birth Cohort Study. Methods: Two-year dental anxiety trajectories measured with Modified Dental Anxiety Scale from gestational weeks (gw) 14 and 34, and 3 and 24 months after birth were used. OHRQoL was measured with the Oral Health Impact Profile 14-item questionnaire at gw34 and 4 years. Changes in the OHRQoL sum and dimension scores according to dental anxiety trajectories were analyzed with the Jonckheere–Terpstra test separately for mothers (n = 998) and fathers (n = 513). Results: Overall, OHRQoL decreased in all dental anxiety trajectory groups except the High decreasing group in mothers and in fathers. The decline in the overall OHRQoL was greatest in the Stable high trajectory group for both parents. In fathers, OHRQoL increased considerably but not statistically significantly in the High decreasing trajectory group. The changes in OHRQoL dimensions Psychological discomfort and Handicap differed according to dental anxiety trajectories for both of mothers and fathers, and also for the dimension Psychological disability for mothers. Conclusions: These findings highlight the need for targeted interventions in treating high dental anxiety and in preventing the increase in dental anxiety to improve oral health outcomes such as OHRQoL.
Keywords: dental fear, anxiety, oral health-related quality of life
1. Introduction
The WHO Quality of Life (QoL) group has defined QoL as “individuals’ perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns” [1]. It has been included into health research and services to incorporate important patient perspective. Oral health-related quality of life (OHRQoL) is a multidimensional construct that evaluates patients’ oral health, functional well-being, emotional well-being, expectations and satisfaction with care and sense of coherence [2,3]. Those with common oral health problems such as caries, periodontal disease and missing teeth report poorer OHRQoL [4,5,6,7]. Dental anxiety is another common oral health-related problem [8,9] which leads to irregular attendance [10]. Patients with high dental anxiety and irregular dental attendance have a four-times-higher risk of poor OHRQoL in comparison with those who have lower levels of dental anxiety or who attend dentist regularly [11]. Additionally, post childhood irregular dental visiting patterns have been associated with lower OHRQoL in adulthood [12].
Numerous studies consistently reported that higher dental anxiety has been related to poorer OHRQoL among adults and adolescents [13,14,15,16,17,18,19]. Differences between those with high dental anxiety and low dental anxiety have been found especially in psychological, social and handicap dimensions of OHRQoL showing that those with high dental anxiety experienced embarrassment and dissatisfaction with life in general more often [14].
According to our knowledge, so far, there are few longitudinal studies on the association between changes in dental anxiety and OHRQoL. A small study of 35 patients with high dental anxiety showed that a reduction in dental anxiety was associated with an improvement in OHRQoL, and that reduction in dental anxiety, rather than improved oral health, predicted an improved OHRQoL [20]. This suggests that decreasing dental anxiety might have a direct positive effect on OHRQoL. However, the association between changes in dental anxiety and OHRQoL needs to be confirmed in larger samples at the population level.
Thus, the aim of this study was to analyze whether the trajectories of changes in dental anxiety are associated with the changes in the OHRQoL and its dimensions in the parents of the FinnBrain Cohort Study. We hypothesize that stable high dental anxiety is associated with stable poor OHRQoL, and decreased dental anxiety with the improvement of OHRQoL.
2. Materials and Methods
This longitudinal study is a secondary analysis of the longitudinal data from the FinnBrain Birth Cohort Study (http://www.finnbrain.fi/), which prospectively studies the effects of environment and genes on children’s brain development and health [21]. The participants of the study were recruited after ultrasonography appointments that are offered free of charge to every pregnant woman in Finland by municipal maternity clinics during the first trimester of the pregnancy. Expecting mothers and their partners who participated the appointments in the South-Western Hospital District and the Åland Islands in Finland in 2011–2015 were invited to participate the study. Mothers were asked to invite those partners (later called fathers) who did not participate the appointment. The Ethics Committee of the Hospital District of Southwest Finland has approved the study protocol (14.6.2011 ETMK: 57/180/2011 § 168). Written informed consent was obtained from all participants.
Of the 5790 pregnant mothers visiting the recruitment site and invited to the study, 3808 mothers and 2623 fathers expecting decided to participate [21]. The parents selected the mode of questionnaire they preferred. The data for this study were collected by paper or electronic questionnaires between gestational week (gw) 14 and at 4 years after childbirth. The trajectory solution for dental anxiety between gw14 and 24 months after childbirth was obtained for 3201 mothers and 2068 fathers. Of those with the trajectory solution, 1039 mothers (27% of participants) and 513 fathers (20% of participants) returned the OHRQoL questionnaires at both time points, gw34 and 4 years. Regarding the mothers, 41 did not meet the inclusion criteria (did not answer the questions concerning OHRQoL). Thus, the total numbers included in the analysis was 998 mothers and 513 fathers. To justify the use of the same trajectory groups, we ensured that this sample population was similar enough with the original population for which the trajectories were calculated. We calculated means, standard deviations and 95%CIs of the Modified Dental Anxiety Scale (MDAS) scores from non-imputed data in each time point and according to the trajectory groups for those with information available at all measurement points (mean, SD) and for those with information available at least in one measurement point (95%CI). Parents’ background information on age and education were collected during pregnancy. In this study, educational level was divided into three levels: low (compulsory, vocational or secondary level, 12 years of schooling), medium (polytechnics) and high (university degree).
Dental anxiety was measured with validated Finnish version of MDAS which consists of five questions for self-rating dental anxiety [22,23,24,25]. The questions in the MDAS were as follows: (1) If you went to your dentist for treatment tomorrow, how would you feel? (2) If you were sitting in the waiting room (waiting for treatment), how would you feel? (3) If you were about to have a tooth drilled, how would you feel? (4) If you were about to have your teeth scaled and polished, how would you feel? (5) If you were about to have a local anesthetic injection in your gum, above an upper back tooth, how would you feel? Each question was rated on a five-point scale ranging from 1 (not anxious) to 5 (extremely anxious); summated scores ranged from 5 to 25. The MDAS was measured on following four points: at gestational weeks (gw) 14 and 34, and 3 and 24 months after birth. Dental anxiety trajectories (four for mothers and five for fathers) that were identified using latent growth mixture modeling and reported in a previous study from the same population were used [26].
The OHRQoL was measured by the validated Finnish translation of Oral Health Impact Profile 14 (OHIP-14) questionnaire at gw34 and 4 years [27,28]. It contains 14 questions about the frequency of adverse impacts during the preceding month of the following five-point scale ranging from 0 (never) to 4 (very often). The severity sum score was calculated as sum of the ordinal responses. Lower scores indicated a better OHRQoL. The severity sum change score was calculated by extracting the 4-year score from gw34 score, negative scores indicating deteriorating OHRQoL. Correspondingly, sum and change scores were calculated for the seven dimensions of OHRQoL, that is, Functional limitation, Physical pain, Psychological discomfort, Physical disability, Psychological disability, Social disability and Handicap.
The cross-tabulations and descriptive statistics were used for examination of age, education, dental anxiety trajectories, severity and dimension scores for mothers and fathers. The OHIP-14 severity scores at gw34 and 4 years were compared in each trajectory group with Wilcoxon rank sum test. The association between dental anxiety trajectories and change between gw34 and 4 years in the OHIP-14 severity scores by total and dimensions was analyzed with the Jonckheere–Terpstra test separately for mothers and fathers using the ascending order based on the dental anxiety level at 24 months. The corresponding effect sized were calculated using the matched-pairs rank biserial correlation coefficient. The statistical analyses were processed with SPSS Statistics for Windows (Version 29.0., IBM Corp: Armonk, NY, USA). The p-values of <0.05 were considered to be indicative of the statistical differences.
3. Results
The comparison showed sufficient similarity between the groups (Table 1). There were no systematic differences in the mean dental anxiety levels between the original sample used to calculate dental anxiety trajectories and the sample used in this study as the 95% confidence intervals overlapped largely.
Table 1.
Dental anxiety levels (mean, standard deviation, 95% CI) for the original dental anxiety trajectories data and for data from the sample included in this study (non-imputed values). Number and percentages for those with information available at all measurement points a and for those with information available at least in one measurement point b.
| Trajectories | Total n (%) | Gestational Week 14 | Gestational Week 34 | 3 Months | 2 Years | |||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Original | Sample | Original | Sample | Original | Sample | Original | Sample | Original | Sample | |||
| Mothers | n = 3201 | n = 998 | ||||||||||
| Stable low | 960 (30.0) a | 2583 (80.7) b | 826 (82.8) | mean (SD) | 8.9 (2.8) | 8.7 (2.7) | 8.7 (2.7) | 8.6 (2.6) | 9.1 (2.9) | 8.9 (2.7) | 9.1 (2.9) | 9.0 (2.8) |
| 95% CI | 8.8–9.0 | 8.5–8.9 | 8.6–8.8 | 8.4–8.8 | 9.0–9.2 | 8.7–9.1 | 8.9–9.3 | 8.8–9.2 | ||||
| High decreasing | 30 (0.9) a | 89 (2.8) b | 23 (2.3) | mean (SD) | 18.6 (3.5) | 17.6 (3.5) | 14.6 (3.5) | 14.7 (2.7) | 13.4 (3.2) | 13.9 (3.1) | 10.5 (2.6) | 10.5 (2.5) |
| 95% CI | 17.8–19.3 | 16.1–19.1 | 13.9–15.4 | 13.6–15.7 | 12.6–14.1 | 12.6–15.2 | 9.6–11.3 | 9.4–11.6 | ||||
| Moderate increasing | 76 (2.4) a | 169 (5.3) b | 67 (6.7) | mean (SD) | 12.6 (2.9) | 12.2 (3.0) | 14.2 (3.4) | 13.7 (3.6) | 17.2 (3.4) | 16.6 (3.7) | 17.7 (2.9) | 17.6 (2.7) |
| 95% CI | 12.1–13.0 | 11.5–13.0 | 13.7–14.8 | 12.9–14.6 | 16.6–17.7 | 15.7–16.7 | 17.1–17.7 | 16.9–18.3 | ||||
| Stable high | 99 (3.1) a | 360 (11.2) b | 82 (8.2) | mean (SD) | 19.9 (3.0) | 19.4 (3.0) | 19.9 (3.1) | 19.8 (3.2) | 20.4 (2.9) | 20.3 (3.0) | 19.6 (3.7) | 19.6 (3.4) |
| 95% CI | 19.6–20.2 | 18.8–20.1 | 19.6–20.3 | 19.1–20.5 | 20.0–20.8 | 19.7–21.0 | 18.9–20.2 | 18.8–20.5 | ||||
| Fathers | n = 2068 | n = 513 | ||||||||||
| Stable low | 457 (14.3) a | 1657 (80.1) b | 425 (79.5) | mean (SD) | 7.6 (2.1) | 7.4 (2.1) | 7.6 (2.3) | 7.5 (2.2) | 7.8 (2.4) | 7.7 (2.4) | 7.7 (2.4) | 7.6 (2.4) |
| 95% CI | 7.5–7.7 | 7.2–7.6 | 5.6–9.6 | 7.3–7.7 | 7.6–7.9 | 7.5–7.9 | 7.5–7.9 | 7.4–7.9 | ||||
| High decreasing | 7 (0.2) a | 33 (1.6) b | 4 (0.3) | mean (SD) | 19.1 (2.7) | 19.7 (4.5) | 13.7 (6.0) | 11.8 (7.3) | 12.6 (5.6) | 12.3 (8.4) | 9.5 (2.8) | 8.3 (3.4) |
| 95% CI | 18.2–20.0 | 14.6–24.8 | 11.3–16.0 | 4.6–18.8 | 10.1–15.2 | 2.8–21.2 | 7.5–11.5 | 4.9–11.6 | ||||
| Stable moderate | 65 (2.0) a | 228 (11.0) b | 51 (12.5) | mean (SD) | 14.4 (1.8) | 14.6 (2.2) | 13.5 (3.1) | 13.4 (2.8) | 13.4 (2.6) | 13.2 (2.5) | 12.5 (3.1) | 12.7 (3.2) |
| 95% CI | 14.2–14.6 | 14.0–15.2 | 13.0–14.0 | 12.6–14.1 | 12.9–13.8 | 12.5–13.9 | 11.8–13.2 | 11.8–13.7 | ||||
| Moderate increasing | 20 (0.6) a | 80 (3.9) b | 23 (5) | mean (SD) | 11.1 (2.4) | 10.3 (1.4) | 14.1 (3.1) | 13.7 (2.6) | 16.1 (2.5) | 16.0 (2.3) | 16.2 (2.5) | 15.9 (2.1) |
| 95% CI | 10.6–11.6 | 9.7–10.9 | 13.4–14.8 | 12.6–14.8 | 15.5–16.7 | 15.0–16.9 | 15.2–17.1 | 14.8–16.9 | ||||
| Stable high | 10 (0.3) a | 70 (3.4) b | 10 (2.6) | mean (SD) | 21.7 (2.3) | 21.3 (2.4) | 21.6 (2.6) | 21.4 (2.0) | 22.7 (2.4) | 21.9 (2.4) | 22.4 (2.0) | 21.7 (2.3) |
| 95% CI | 21.2–22.3 | 19.8–22.8 | 20.8–22.4 | 20.2–22.6 | 21.8–23.5 | 20.4–23.4 | 21.4–23.4 | 20.0–23.4 | ||||
Table 2 presents the distribution of the participants according to their OHRQoL, age and education. Both mothers and fathers experienced an increase in the severity of OHIP-14 scores over the 4-year period, indicating a decline in OHRQoL. Mothers experienced approximately 0.5 points greater deterioration in OHRQoL than fathers during the study period. The OHRQoL tended to decrease according to most OHIP-14 dimensions for both mothers and fathers. The change was greatest in Physical Pain and Psychological Discomfort dimensions.
Table 2.
Distribution of the participants according to their oral health-related quality of life (OHIP-14), age and education at gw34 and 4 yr time points.
| Mothers | Fathers | ||
|---|---|---|---|
| n = 998 | n = 513 | ||
| Age | Mean (SD) | 31.1 (4.28) | 33.1 (3.51) |
| Education | Low, n (%) | 284 (28.5) | 197 (38.5) |
| Medium, n (%) | 279 (27.9) | 160 (31.1) | |
| High, n (%) | 435 (43.6) | 156 (30.4) | |
| OHIP-14 gw34 | Severity score, mean (SD) | 1.50 (3.2) | 1.98 (4.2) |
| OHIP-14 4 yr | Severity score, mean (SD) | 2.20 (4.0) | 2.23 (4.1) |
| Change in OHIP-14 | Severity score, mean (SD) | −0.71 (4.4) | −0.24 (4.5) |
| OHIP-14 dimensions gw34 | Functional limitation, mean (SD) | 0.08 (0.4) | 0.18 (0.6) |
| Physical pain | 0.59 (1.1) | 0.76 (1.3) | |
| Psychological discomfort | 0.39 (0.9) | 0.46 (1.1) | |
| Physical disability | 0.07 (0.5) | 0.10 (0.5) | |
| Psychological disability | 0.21 (0.7) | 0.23 (0.7) | |
| Social disability | 0.07 (0.4) | 0.11 (0.5) | |
| Handicap | 0.09 (0.5) | 0.14 (0.6) | |
| OHIP-14 dimensions 4 yr | Functional limitation, mean (SD) | 0.70 (0.4) | 0.14 (0.6) |
| Physical pain | 0.84 (1.4) | 0.87 (1.3) | |
| Psychological discomfort | 0.63 (1.3) | 0.59 (1.2) | |
| Physical disability | 0.09 (0.5) | 0.08 (0.4) | |
| Psychological disability | 0.33 (0.9) | 0.26 (0.8) | |
| Social disability | 0.07 (0.4) | 0.12 (0.5) | |
| Handicap | 0.17 (0.6) | 0.17 (0.6) |
OHIP-14 = Oral Health Impact Profile 14; gw34 = gestational week 34; 4 yr = 4-year time point.
Table 3 shows the OHRQoL (OHIP-14 severity) at two time points (gw34 and 4-year follow-up) and the change in OHRQoL according to different dental anxiety trajectories among mothers and fathers. Negative change in OHIP-14 severity scores indicated a slight but statistically significant decrease in OHRQoL, in all except one trajectory group in mothers and in two groups in fathers. The OHRQoL differed according to dental anxiety trajectories in mothers at both time points and in fathers at 4 years. The difference in the OHRQoL change between dental anxiety trajectory groups was statistically significant in mothers and fathers. OHRQoL decreased most in mothers and fathers in the Stable high trajectory groups. In mothers, OHRQoL decreased second most in the Moderate increasing trajectory group. In fathers, there was a considerable increase in OHRQoL in the High decreasing trajectory group, but the difference was not statistically significant. In mothers, the effect sizes were medium, except for the Stable low group for which it was small. In fathers, the effect size varied more. For the Stable high group, the effect size was large; for the Moderate increasing group, medium; and for other groups, small or not calculatable.
Table 3.
Oral health-related quality of life (OHIP-14 severity) at two time points and the change in it according to dental anxiety trajectories.
| Trajectories | n (%) | Severity Mean (SD) | ||||
|---|---|---|---|---|---|---|
| gw34 | 4 Yr | Change | p-Value * | rc *** | ||
| Mothers | 998 | 1.50 (3.3) | 2.20 (4.0) | −0.71 (4.4) | <0.001 | 0.310 |
| Stable low | 826 (82.8) | 1.33 (3.1) | 1.88 (3.6) | −0.55 (4.1) | <0.001 | 0.273 |
| High decreasing | 23 (2.3) | 1.35 (2.2) | 2.48 (3.2) | −1.13 (3.9) | 0.254 | 0.314 |
| Moderate increasing | 67 (6.7) | 2.46 (3.6) | 3.91 (4.5) | −1.45 (4.6) | 0.006 | 0.446 |
| Stable high | 82 (8.2) | 2.38 (4.9) | 3.95 (6.5) | −1.57 (6.0) | 0.007 | 0.428 |
| p-value | 0.006 ** | |||||
| Fathers | 513 | 1.98 (4.2) | 2.23 (4.1) | −0.24 (4.5) | 0.005 | 0.186 |
| Stable low | 425 (79.5) | 1.75 (3.7) | 1.87 (3.4) | −0.12 (4.3) | 0.067 | 0.014 |
| High decreasing | 4 (0.3) | 5.50 (8.0) | 2.00 (2.4) | 3.50 (7.0) | 0.317 | n.a. |
| Stable moderate | 51 (12.5) | 3.33 (6.9) | 4.12 (6.2) | −0.78 (5.7) | 0.112 | 0.294 |
| Moderate increasing | 23 (5) | 1.83 (3.3) | 2.39 (2.5) | −0.57 (3.3) | 0.220 | 0.358 |
| Stable high | 10 (2.6) | 4.10 (5.7) | 7.60 (8.7) | −3.50 (4.6) | 0.030 | 0.861 |
| p-value | 0.403 ** | |||||
OHIP-14 = Oral Health Impact Profile 14; gw34 = gestational week 34; 4 yr = 4-year time point; * Wilcoxon signed-rank test, difference between time points; ** Jonckheere–Terpstra test, difference in change between dental anxiety trajectory classes; *** matched-pairs rank biserial correlation coefficient.
Table 4 presents the change in the scores of the seven dimensions of OHIP-14 according to dental anxiety trajectories. Of the dimensions, the changes in Psychological discomfort and Handicap differed according to dental anxiety trajectories in both of mothers and fathers, and in Psychological disability in mothers. In mothers, the decrease in OHRQoL (negative change score) was the greatest in the Stable high trajectory groups for Psychological disability and Handicap dimensions, and for Psychological discomfort, the decrease was highest in the Moderate increasing trajectory group and second highest in the Stable high trajectory group. In fathers, the decrease in the Psychological discomfort and Handicap dimensions of OHRQoL were highest in the Stable high trajectory group, but increase was observed in the High decreasing group.
Table 4.
The mean change in oral health-related quality of life (OHIP-14) dimensions according to dental anxiety trajectories.
| Change in the Mean (SD) | ||||||||
|---|---|---|---|---|---|---|---|---|
| Dental Anxiety Trajectories | n (%) | Functional Limitation | Physical Pain | Psychological Discomfort | Physical Disability | Psychological Disability | Social Disability | Handicap |
| Mothers | 998 (100) | 0.01 (0.5) | −0.25 (1.6) | −0.24 (1.3) | −0.02 (0.6) | −0.12 (1.0) | −0.00 (0.6) | −0.08 (0.7) |
| Stable low | 826 (82.8) | 0.01 (0.5) | −0.22 (1.5) | −0.20 (1.2) | −0.02 (0.6) | −0.10 (0.2) | 0.01 (0.6) | −0.04 (0.6) |
| High decreasing | 23 (2.3) | −0.04 (0.2) | −0.43 (2.1) | −0.26 (1.3) | 0.13 (0.7) | −0.04 (0.6) | −0.13 (0.7) | −0.35 (0.8) |
| Moderate increasing | 67 (6.7) | 0.03 (0.4) | −0.37 (1.9) | −0.55 (1.5) | 0.06 (0.7) | −0.33 (1.3) | −0.06 (0.6) | −0.22 (0.8) |
| Stable high | 82 (8.2) | −0.07 (0.9) | −0.48 (1.9) | −0.41 (2.0) | −0.06 (0.6) | −1.59 (0.04) | −0.64 (0.1) | −0.83 (0.3) |
| p-value | 0.637 | 0.131 | 0.034 | 0.104 | 0.046 | 0.078 | <0.001 | |
| Fathers | 513 (100) | 0.04 (0.7) | −0.11 (1.5) | −0.13 (1.3) | 0.02 (0.6) | −0.03 (0.8) | −0.006 (0.7) | −0.03 (0.7) |
| Stable low | 425 (82.8) | 0.04 (0.6) | −0.08 (1.5) | −0.07 (1.2) | 0.01 (0.6) | −0.03 (0.8) | 0.005 (0.6) | 0.01 (0.6) |
| High decreasing | 4 (0.8) | 0.00 (0.8) | 1.25 (1.9) | 0.50 (1.7) | 0.50 (1.0) | 0.50 (1.7) | 0.75 (2.2) | 0.00 (0.8) |
| Stable moderate | 51 (9.9) | 0.10 (0.9) | −0.23 (1.7) | −0.41 (1.3) | 0.12 (0.7) | −0.14 (0.8) | 0.04 (0.8) | −0.25 (0.8) |
| Moderate increasing | 23 (4.5) | 0.00 (0.7) | −0.35 (1.5) | −0.48 (1.3) | 0.09 (0.4) | 0.22 (0.6) | 0.04 (0.4) | −0.09 (0.6) |
| Stable high | 10 (1.9) | −0.10 (0.7) | −0.80 (1.6) | −0.70 (1.5) | −0.40 (1.0) | −0.60 (0.7) | −0.70 (1.1) | −0.20 (0.6) |
| p-value | 0.523 | 0.965 | 0.126 | 0.804 | 0.005 | 0.346 | 0.019 | |
p-values for Jonckheere–Terpstra test.
4. Discussion
The OHRQoL decreased most in the Stable high dental anxiety trajectory groups in both parents. The changes in the OHRQoL dimensions Psychological disability and Handicap differed according to dental anxiety trajectories for both parents, the decrease being greatest in the Stable high trajectory groups.
A previous longitudinal study [20] demonstrated that reductions in dental anxiety led to improvements in OHRQoL, whereas improvements in oral health (rated by dentists or patients) did not show a consistent association with OHRQoL improvement. Other studies reporting changes in dental anxiety over several time points [26,29] did not include OHRQoL, and the studies with changes in OHRQoL did not include dental anxiety. In a Finnish nationally representative longitudinal survey, the mean OHIP-14 severity improved from 2000 to 2011 from 2.90 to 2.41 (p = 0.197) in men and from 2.41 to 1.98 (p = 0.004) in women of similar age with this age group [30], while in this study, the OHRQoL declined. In general, after treatment of the most common oral problems caries and periodontal disease, the improvement in OHRQoL has been moderate [31,32], but not statistically significant [33].
In most of the cross-sectional studies, those with high dental anxiety have reported a lower OHRQoL than those with low dental anxiety [13,14,15,16,17,18,19] even in a nationally representative population when adjusted for age, gender, education, remaining teeth, and dental visits [14]. These findings from cross-sectional studies align with our present findings, where those in the Stable low dental anxiety group reported a better OHRQoL at both time points than those in other trajectory groups. On the other hand, the OHRQoL in our study was better even in the Stable high anxiety group than in highly dentally anxious Dutch patients (4.0 in mothers and 7.6 in fathers and 30.5 in Dutch patients) [34]. In a previous study among adults in Finland, the greatest differences between those with high and low dental anxiety were found in psychological, social, and handicap dimensions of OHIP-14 [14]. These findings are in concordance with those of the present study, where the greatest decrease in the OHRQoL was seen in Psychological Disability and Handicap dimensions. Dental anxiety has tended to show a strong effect on psychosocial impact measured with the Handicap dimension [35], but an even greater effect on the Psychological discomfort, Psychological disability, Physical pain, Social disability and Physical disability dimensions in those with high dental anxiety [34]. The improvements in these dimensions were also greater than in the Handicap dimensions in another study [35].
The large sample size and rather long follow-up periods in addition to the use of valid and reliable methods were the strengths of this study. On the other hand, different follow-up periods for the dental anxiety trajectories and changes in the OHRQoL can be considered as a limitation. However, dental anxiety had been shown to be rather stable in adulthood over 11 years [8], and thus, those with stable high dental anxiety especially could be likely to remain so until the 4-year measurement point. The use of the trajectory solution obtained from a larger sample can be consider as a limitation as this needs to be applied with a caution [36,37]. As the High decreasing group among fathers was already small in the largest sample, this led to very small number of fathers in the decreasing high dental anxiety trajectory group in this study population [26]. However, the MDAS scores in this study and the original study population were rather similar even though those staying in the study over four years were more often older and had higher education. As this group was originally selected partly based on clinical relevance, the current finding of an improvement in their OHRQoL looks promising but needs to be confirmed in another larger sample.
5. Conclusions
The findings of this study emphasize the impact of dental anxiety and its changes on changes in OHRQoL over time among mothers and fathers. They also suggest gender differences in these changes. It also highlights the need for targeted interventions both in treating high dental anxiety and in preventing the increase in dental anxiety to improve oral health outcomes. The interventions include efficient basic dental anxiety management techniques, such as building trust, providing control (such as cognitive or behavioral), using a tell–show–do method and relaxation strategies (such as muscle or breathing relaxation) [38], are useful to reduce and prevent the development of dental anxiety. Further research is needed in other populations and on the effects of these dental anxiety management interventions on changes in OHRQoL.
Author Contributions
Conceptualization, L.Y., A.S. and S.L.; methodology, A.S., E.-L.K., S.L. and E.L.; formal analysis, A.S. and E.-L.K.; data curation, A.S. and E.-L.K.; writing—original draft preparation, L.Y., A.S. and S.L.; writing—review and editing, K.P., E.-L.K., V.P., M.O., L.K., H.K. and E.L.; supervision, S.L.; project administration, L.K. and H.K.; funding acquisition, L.K. and H.K. All authors have read and agreed to the published version of the manuscript.
Institutional Review Board Statement
This study was conducted according to the guidelines of the Declaration of Helsinki and approved by The Intermunicipal Hospital District of Southwest Finland, which granted ethical clearance for the FinnBrain Cohort Study in 14 June 2011 (approval cade: ETMK:57/180/2011 § 168, approval date: 14 June 2011).
Informed Consent Statement
Written informed consent was obtained from all subjects involved in the study. All participants gave signed informed consent for the study.
Data Availability Statement
Data are not available due to restrictions related to privacy and ethical issues. The datasets presented in this article are not readily available because of restrictions based on EU GDPR and local legislation. Requests to access the datasets should be directed to L.K.
Conflicts of Interest
The authors declare no conflicts of interest.
Funding Statement
This study was funded by the Research Council of Finland (grant #253270 and grant #264363), Signe and Ane Gyllenberg Foundation, Finnish Medical Foundation and State Research Grants.
Footnotes
Disclaimer/Publisher’s Note: The statements, opinions and data contained in all publications are solely those of the individual author(s) and contributor(s) and not of MDPI and/or the editor(s). MDPI and/or the editor(s) disclaim responsibility for any injury to people or property resulting from any ideas, methods, instructions or products referred to in the content.
References
- 1.Skevington S.M., Lotfy M., O’Connell K.A. The World Health Organization’s WHOQOL-BREF quality of life assessment: Psychometric properties and results of the international field trial. A report from the WHOQOL group. Qual. Life Res. 2004;13:299–310. doi: 10.1023/B:QURE.0000018486.91360.00. [DOI] [PubMed] [Google Scholar]
- 2.Palo K., Tolvanen M., Karlsson H., Karlsson L., Lahti S. Is the oral health-related quality of life associated with quality of life among pregnant Finnish families: A cross-sectional study. Acta Odontol. Scand. 2021;79:523–527. doi: 10.1080/00016357.2021.1906441. [DOI] [PubMed] [Google Scholar]
- 3.Sischo L., Broder H.L. Oral health-related quality of life: What, why, how, and future implications. J. Dent. Res. 2011;90:1264–1270. doi: 10.1177/0022034511399918. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Masood M., Newton T., Bakri N.N., Khalid T., Masood Y. The relationship between oral health and oral health related quality of life among elderly people in United Kingdom. J. Dent. 2017;56:78–83. doi: 10.1016/j.jdent.2016.11.002. [DOI] [PubMed] [Google Scholar]
- 5.Ortíz-Barrios L.B., Granados-García V., Cruz-Hervert P., Moreno-Tamayo K., Heredia-Ponce E., Sánchez-García S. The impact of poor oral health on the oral health-related quality of life (OHRQoL) in older adults: The oral health status through a latent class analysis. BMC Oral Health. 2019;19:141. doi: 10.1186/s12903-019-0840-3. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Geevarghese A., Baskaradoss J.K., Sarma P.S. Oral Health-Related Quality of Life and Periodontal Status of Pregnant Women. Matern. Child Health J. 2017;21:1634–1642. doi: 10.1007/s10995-016-2255-y. [DOI] [PubMed] [Google Scholar]
- 7.Ferreira M.C., Dias-Pereira A.C., Branco-de-Almeida L.S., Martins C.C., Paiva S.M. Impact of periodontal disease on quality of life: A systematic review. J. Periodontal Res. 2017;52:651–665. doi: 10.1111/jre.12436. [DOI] [PubMed] [Google Scholar]
- 8.Liinavuori A., Tolvanen M., Pohjola V., Lahti S. Changes in dental fear among Finnish adults: A national survey. Community Dent. Oral Epidemiol. 2016;44:128–134. doi: 10.1111/cdoe.12196. [DOI] [PubMed] [Google Scholar]
- 9.Svensson L., Hakeberg M., Boman U.W. Dental anxiety, concomitant factors and change in prevalence over 50 years. Community Dent. Health. 2016;33:121–126. [PubMed] [Google Scholar]
- 10.Liinavuori A., Tolvanen M., Pohjola V., Lahti S. Longitudinal interrelationships between dental fear and dental attendance among adult Finns in 2000–2011. Community Dent. Oral Epidemiol. 2019;47:309–315. doi: 10.1111/cdoe.12458. [DOI] [PubMed] [Google Scholar]
- 11.Boman U.W., Wennström A., Stenman U., Hakeberg M. Oral health-related quality of life, sense of coherence and dental anxiety: An epidemiological cross-sectional study of middle-aged women. BMC Oral Health. 2012;12:14. doi: 10.1186/1472-6831-12-14. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Crocombe L.A., Broadbent J.M., Thomson W.M., Brennan D.S., Poulton R. Impact of dental visiting trajectory patterns on clinical oral health and oral health-related quality of life. J. Public Health Dent. 2012;72:36–44. doi: 10.1111/j.1752-7325.2011.00281.x. [DOI] [PubMed] [Google Scholar]
- 13.Samami M., Farrahi H., Alinia M. The relationship between dental anxiety and oral health literacy with oral health-related quality of life. BMC Oral Health. 2024;24:567. doi: 10.1186/s12903-024-04359-7. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Pohjola V., Lahti S., Suominen-Taipale L., Hausen H. Dental fear and subjective oral impacts among adults in Finland. Eur. J. Oral Sci. 2009;117:268–272. doi: 10.1111/j.1600-0722.2009.00631.x. [DOI] [PubMed] [Google Scholar]
- 15.Pakpour A.H., Lin C.Y., Kumar S., Fridlund B., Jansson H. Predictors of oral health-related quality of life in Iranian adolescents: A prospective study. J. Investig. Clin. Dent. 2018;9:e12264. doi: 10.1111/jicd.12264. [DOI] [PubMed] [Google Scholar]
- 16.Ng S.K., Leung W.K. A community study on the relationship of dental anxiety with oral health status and oral health-related quality of life. Community Dent. Oral Epidemiol. 2008;36:347–356. doi: 10.1111/j.1600-0528.2007.00412.x. [DOI] [PubMed] [Google Scholar]
- 17.McGrath C., Bedi R. The association between dental anxiety and oral health-related quality of life in Britain. Community Dent. Oral Epidemiol. 2004;32:67–72. doi: 10.1111/j.1600-0528.2004.00119.x. [DOI] [PubMed] [Google Scholar]
- 18.Sukumaran I., Taylor S., Thomson W.M. The prevalence and impact of dental anxiety among adult New Zealanders. Int. Dent. J. 2020;71:122–126. doi: 10.1111/idj.12613. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19.Carlsson V., Hakeberg M., Wide Boman U. Associations between dental anxiety, sense of coherence, oral health-related quality of life and health behavior—A national Swedish cross-sectional survey. BMC Oral Health. 2015;15:100. doi: 10.1186/s12903-015-0088-5. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20.Vermaire J.H., de Jongh A., Aartman I.H. Dental anxiety and quality of life: The effect of dental treatment. Community Dent. Oral Epidemiol. 2008;36:409–416. doi: 10.1111/j.1600-0528.2007.00416.x. [DOI] [PubMed] [Google Scholar]
- 21.Karlsson L., Tolvanen M., Scheinin N.M., Uusitupa H.-M., Korja R., Ekholm E., Tuulari J.J., Pajulo M., Huotilainen M., Paunio T. Cohort profile: The FinnBrain birth cohort study (FinnBrain) Int. J. Epidemiol. 2018;47:15a–16j. doi: 10.1093/ije/dyx173. [DOI] [PubMed] [Google Scholar]
- 22.Humphris G.M., Freeman R., Campbell J., Tuutti H., D’Souza V. Further evidence for the reliability and validity of the Modified Dental Anxiety Scale. Int. Dent. J. 2000;50:367–370. doi: 10.1111/j.1875-595X.2000.tb00570.x. [DOI] [PubMed] [Google Scholar]
- 23.Humphris G., Crawford J.R., Hill K., Gilbert A., Freeman R. UK population norms for the modified dental anxiety scale with percentile calculator: Adult dental health survey 2009 results. BMC Oral Health. 2013;13:29. doi: 10.1186/1472-6831-13-29. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24.Newton J.T., Edwards J.C. Psychometric properties of the modified dental anxiety scale: An independent replication. Community Dent. Health. 2005;22:40–42. [PubMed] [Google Scholar]
- 25.King K., Humphris G. Evidence to confirm the cut-off for screening dental phobia using the Modified Dental Anxiety Scale. Soc. Sci. Dent. 2010;1:21–28. [Google Scholar]
- 26.Lahti S., Kataja E.L., Suominen A., Palo K., Ogawa M., Kallio A., Räikkönen O., Pohjola V., Rantavuori K., Karlsson L., et al. Two-Year Trajectories of Dental Anxiety in Parents and Their Association with Parents’ and Children’s Oral Healthcare Procedures in FinnBrain Birth Cohort Study. Dent. J. 2024;12:72. doi: 10.3390/dj12030072. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 27.Lahti S., Suominen-Taipale L., Hausen H. Oral health impacts among adults in Finland: Competing effects of age, number of teeth, and removable dentures. Eur. J. Oral Sci. 2008;116:260–266. doi: 10.1111/j.1600-0722.2008.00540.x. [DOI] [PubMed] [Google Scholar]
- 28.Allen P.F. Assessment of oral health related quality of life. Health Qual. Life Outcomes. 2003;1:40. doi: 10.1186/1477-7525-1-40. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 29.Thomson W.M., Broadbent J.M., Locker D., Poulton R. Trajectories of dental anxiety in a birth cohort. Community Dent. Oral Epidemiol. 2009;37:209–219. doi: 10.1111/j.1600-0528.2009.00473.x. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 30.Torppa-Saarinen E., Suominen A.L., Lahti S., Tolvanen M. Longitudinal pathways between perceived oral health and regular service use of adult Finns. Community Dent. Oral Epidemiol. 2019;47:374–380. doi: 10.1111/cdoe.12478. [DOI] [PubMed] [Google Scholar]
- 31.Shanbhag S., Dahiya M., Croucher R. The impact of periodontal therapy on oral health-related quality of life in adults: A systematic review. J. Clin. Periodontol. 2012;39:725–735. doi: 10.1111/j.1600-051X.2012.01910.x. [DOI] [PubMed] [Google Scholar]
- 32.Yeh D.Y., Kuo H.C., Yang Y.H., Ho P.S. The Responsiveness of Patients’ Quality of Life to Dental Caries Treatment—A Prospective Study. PLoS ONE. 2016;11:e0164707. doi: 10.1371/journal.pone.0164707. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 33.Baiju R.M., Peter E., Varghese N.O., Anju P. Patient Reported Outcome Assessment of Periodontal Therapy: A Systematic Review. J. Clin. Diagn. Res. 2017;11:zc14–zc19. doi: 10.7860/JCDR/2017/28505.10343. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 34.Vermaire J.H., van Houtem C.M., Ross J.N., Schuller A.A. The burden of disease of dental anxiety: Generic and disease-specific quality of life in patients with and without extreme levels of dental anxiety. Eur. J. Oral Sci. 2016;124:454–458. doi: 10.1111/eos.12290. [DOI] [PubMed] [Google Scholar]
- 35.Su N., van Wijk A., Visscher C.M. Psychosocial oral health-related quality of life impact: A systematic review. J. Oral Rehabil. 2021;48:282–292. doi: 10.1111/joor.13064. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 36.Hickendorff M., Edelsbrunner P.A., McMullen J., Schneider M., Trezise K. Informative tools for characterizing individual differences in learning: Latent class, latent profile, and latent transition analysis. Learn. Individ. Differ. 2018;66:4–15. doi: 10.1016/j.lindif.2017.11.001. [DOI] [Google Scholar]
- 37.Herle M., Micali N., Abdulkadir M., Loos R., Bryant-Waugh R., Hübel C., Bulik C.M., De Stavola B.L. Identifying typical trajectories in longitudinal data: Modelling strategies and interpretations. Eur. J. Epidemiol. 2020;35:205–222. doi: 10.1007/s10654-020-00615-6. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 38.Armfield J.M., Heaton L.J. Management of fear and anxiety in the dental clinic: A review. Aust. Dent. J. 2013;58:390–407; quiz 531. doi: 10.1111/adj.12118. [DOI] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
Data are not available due to restrictions related to privacy and ethical issues. The datasets presented in this article are not readily available because of restrictions based on EU GDPR and local legislation. Requests to access the datasets should be directed to L.K.