A multi-layered barrier to oral health: a mixed methods exploration of dental anxiety

Abstract

Background

Dental anxiety is a prevalent psychological barrier that prevents many individuals from seeking routine dental care. This study aimed to assess the prevalence and predictors of dental anxiety and to explore the experiences of adult patients in a public dental hospital, providing insight into dental anxiety and its impact on treatment behaviors and clinician interactions.

Methods

The study employed an explanatory sequential mixed-method design, beginning with a quantitative phase involving 415 participants assessed using the Dental Fear Scale, followed by a qualitative phase with 12 participants selected via purposive sampling. Quantitative data were analyzed employing t-tests, ANOVA, and multinomial logistic regression. Qualitative data were analyzed via interpretative phenomenological analysis.

Results

Quantitative findings revealed moderate dental anxiety levels (mean score: 42.48 ± 18.02), with higher anxiety associated with female gender, older age (≥ 56 years), lower education, irregular dental visit attitudes, a history of dental trauma and complications, and attending for reasons such as orthodontic, pain, or surgery. Qualitative analysis identified four key themes: (1) anticipatory anxiety and bodily reactions, (2) emotional experiences during treatment, (3) past traumatic experiences and psychological residue, (4) relational expectations and anxiety reducing factors.

Conclusions

Dental anxiety is a multifaceted issue influenced by sociodemographic, behavioral, and psychological factors as well as by previous traumatic experiences. The study highlights the need for trauma-informed care, patient-centered communication, and individualized anxiety-reduction strategies in dental practice. Promoting regular preventive visits and addressing anxiety through empathetic, transparent interactions may improve oral health outcomes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12903-026-08393-5.

Background

Oral and dental health are a critical component of general well-being, significantly influencing individuals’ quality of life, nutritional status, and social functioning [1]. However, dental anxiety -defined as intense fear, stress, or avoidance associated with dental procedures- remains a prevalent psychological barrier that prevents many individuals from seeking routine dental care [1, 2]. This condition leads to postponed or neglected treatments, contributing to the deterioration of oral health and increased long-term treatment costs [1, 3].

Dental anxiety can be placed within general theories of fear acquisition from a more comprehensive psychological standpoint. According to theories of classical conditioning, fear arises from painful learning experiences when neutral stimuli are linked to pain or danger [4]. Dental anxiety may arise and remain as a result of early negative experiences, intrusive procedures, or vicarious learning. However, current research highlights that these mechanisms function within a biopsychosocial framework in which people’s reactions to dental treatment are jointly shaped by cognitive factors, emotional regulation, past trauma, social influences, and clinician-patient interactions [1, 2, 4].

Dental anxiety often originates in childhood and may persist into adulthood [5, 6], reinforced not only by negative dental experiences but also by broader traumatic exposures, including physical or sexual violence and abuse [7, 8]. Such experiences may heighten vulnerability in the dental context, where the subordinate and powerless body position in the dental chair can activate trauma-related memories and intensify anxiety responses [9]. Recent trauma research conceptualizes these reactions within stress-sensitization and threat-processing models, suggesting that repeated trauma exposure lowers the threshold for fear activation in later healthcare encounters [10, 11]. Studies show that survivors of violence may perceive dental procedures as invasive, threatening, or reminiscent of past abuse, leading to heightened anticipatory anxiety, dissociation, or physiological arousal during treatment [12]. Realist evaluations of specialized services for trauma-exposed individuals highlight how sensory triggers, bodily vulnerability, and perceived power asymmetries can reactivate traumatic memories, contributing to severe avoidance or defensive behaviors in dental settings [8]. Neurobiological mechanisms such as heightened amygdala reactivity and reduced prefrontal regulation exacerbate threat perception, while cognitive patterns including catastrophic thinking and selective attention to threat further amplify anxiety [11, 13]. These processes often manifest behaviorally as avoidance, hypervigilance, or heightened physiological arousal, with environmental triggers such as needles, drilling sounds, and perceived loss of control compounding psychological distress in dental settings [2, 5].

The consequences of untreated dental anxiety are multifaceted. Patients may avoid dental visits until emergencies arise, leading to more complex and costly interventions [14]. Additionally, dental anxiety impairs patient-clinician communication, undermines trust, and reduces treatment satisfaction [1, 15]. Evidence suggests that targeted interventions including empathetic communication, relaxation techniques, and patient-centered care, can mitigate anxiety and improve clinical outcomes [16, 17]. Given that some individuals with dental anxiety may have a history of abuse, an individually tailored and patient-centered approach becomes essential. Trauma-informed care is a framework that recognizes the widespread impact of trauma, emphasizes understanding patients’ trauma histories, and seeks to avoid re-traumatization by promoting safety, trustworthiness, collaboration, empowerment, and sensitivity to power dynamics within healthcare interactions [18, 19]. More recent healthcare literature positions trauma-informed care as a theoretically grounded approach rather than solely a clinical strategy, linking it to relational, ethical, and systems-level models of care delivery [20, 21]. Recent evidence emphasizes that trauma-informed care principles include creating a sense of safety, fostering trust, and supporting collaborative decision-making should guide clinical practice. Dentists should adopt a trauma-sensitive approach for the patients and demonstrate utmost consideration when treating survivors of abuse by building trusting relationships and jointly identifying coping strategies adapted to each patient’s specific needs [22, 23]. Taken together, the theoretical framework guiding this study integrates fear acquisition theories, contemporary biopsychosocial models, and trauma-informed care principles to support the formulation of the research questions and the interpretation of both quantitative and qualitative findings. Building on this framework, the study aimed to assess the prevalence and predictors of dental anxiety and to explore the experiences of adult patients attending a public dental hospital, with the goal of providing a comprehensive understanding of dental anxiety and examining its impact on treatment-related behaviors and clinician interactions.

Methods

Study design

This study employed an explanatory sequential mixed-method design, integrating both quantitative and qualitative approaches to comprehensively investigate dental anxiety in patients seeking dental care. The mixed-method approach enabled a multidimensional analysis by combining the statistical power of quantitative data with the depth and nuance provided by qualitative insights [24]. Initially, quantitative data were collected and analyzed, followed by qualitative data collection aimed at exploring and interpreting the earlier findings in greater detail. The qualitative phase was designed to complement, rather than replicate, routine clinical encounters and was conducted independently from standard dental care workflows.

Recruitment of participants

The quantitative study population comprised 139,914 patients who applied to Eskişehir Oral and Dental Health Hospital in 2024. Based on the single population proportion formula using Epi Info 7 (50% proportion, 95% CI, 5% margin of error), the minimum required sample size was determined to be 384. To strengthen subgroup analyses and improve estimation precision, the sample size was increased, and a total of 415 patients were selected through simple random sampling.

For the qualitative dimension, the sample was selected using purposive sampling based on the quantitative analysis results, comprising six patients with high dental anxiety levels and six with low dental anxiety levels. A total of 12 participants were interviewed; none refused or withdrew. Purposive sampling was used to recruit participants who could enable an in-depth exploration of dental anxiety mechanisms. Participants were included if they: (1) were aged 18 years or older, (2) completed the quantitative phase, (3) had a dental anxiety score falling within either the highest or lowest quartile of the distribution, and (4) were able to participate in an in-depth interview.

Data collection and procedures

All data collected face-to-face interviews conducted between May 2024 and October 2024. The hospital selected for this study is a public oral and dental health hospital serving the city as well as surrounding towns. One of the researchers is employed at this hospital, which facilitated building trust with patients. This trust was particularly important for the qualitative interviews, as it encouraged participants to communicate openly and share their experiences in depth. The combination of the hospital’s wide catchment area and researcher familiarity made it a suitable site for recruiting a representative and reliable sample for both quantitative and qualitative components. The quantitative assessments were conducted during routine outpatient visits and required approximately 10–15 min to complete.

Two primary instruments were utilized in the quantitative phase

Participant Information Form developed by researchers to collect demographic and oral health behavior data by researchers.

Dental Fear Scale (DFS)

The study utilized the DFS, originally validated by Fırat et al. (2006), which assesses dental fear across multiple dimensions, including fear of visiting the dentist, avoidance behaviors, somatic symptoms, and fear responses to various dental procedures. The scale consists of 20 items in a 5-point Likert format (1 = not at all to 5 = very much), yielding cumulative scores that allow classification of participants into low, moderate, high, or extreme anxiety groups [25, 26].

In the second phase, a semi-structured interview protocol was conducted with selected participants from both low- and high-anxiety groups. The protocol was developed based on prior literature, revised by expert review, and included 12 open-ended questions focused on emotional reactions, perceptions of dental treatment, anxiety triggers, and patient-provider communication. Qualitative interviews were scheduled in advance at mutually convenient times on days when participants were not undergoing any dental procedures, such as separate follow-up visits or non-treatment appointments. Table 1 details the participant characteristics.

Table 1.

Participant demographics

Participant	Age	Gender	Education	Tooth Brushing	Dental Visit Attitudes	Dental Trauma	Dental Complications	DFS* Score
P1	38	Male	University	Regular	Regular	No	No	20
P2	37	Female	University	Regular	Regular	No	No	20
P3	30	Female	High school	Regular	Regular	No	No	20
P4	45	Male	University	Regular	Regular	No	No	20
P5	39	Male	University	Regular	When necessary	Yes	No	20
P6	44	Female	University	Regular	Regular	No	No	20
P7	65	Female	Primary school	Irregular	When necessary	Yes	No	93
P8	64	Male	Primary school	Irregular	When necessary	No	Yes	90
P9	52	Female	Primary school	Irregular	When necessary	Yes	No	90
P10	65	Male	Primary school	Irregular	When necessary	Yes	No	88
P11	36	Male	High school	Irregular	When necessary	No	Yes	86
P12	51	Female	Primary school	Irregular	When necessary	No	Yes	85

*DFS Dental Fear Scale

All interviews were conducted in quiet and secure consultation rooms within the clinic. The interviews were audio-recorded and transcribed verbatim. The interviews were conducted in the participants’ native language. The transcripts were translated by a native English speaker residing in the country where the research was conducted, and a second translator performed a back-translation to assess potential loss of meaning. The interviews ranged in length from 40 to 60 min and were intentionally conducted separately from routine clinical care to ensure participant comfort, sustained engagement, and methodological rigor. Interview data were stored on an encrypted, password-protected drive, de-identified during transcription, and analyzed within a secure analysis software program.

Data analysis

Quantitative data were analyzed using SPSS 26.0. The distribution of data was evaluated via skewness and kurtosis values, both of which indicated normal distribution. Independent sample t-tests and one-way ANOVA were used to assess group differences, and Tukey’s post-hoc test was applied for subgroup comparisons. To examine the predictive power of various factors on anxiety group membership, multinomial logistic regression was performed [27, 28]. Variables in the multinomial logistic regression were selected in line with the study’s theoretical framework, capturing individual vulnerability, behavioral avoidance patterns, prior adverse experiences, and situational factors relevant to dental anxiety.

Qualitative data set was transferred to the analysis program MAXQDA-Plus Version 18 (VERBI GmbH, Berlin, Germany). Qualitative data were analyzed using Interpretative Phenomenological Analysis (IPA), following the methodological framework outlined by Smith (1996) and the procedural guidelines later systematized by Smith, Jarman and Osborn (1999). IPA was selected due to its idiographic commitment and its focus on understanding how participants make sense of their experiences. The analytic process involved several iterative stages: (1) repeated reading of each transcript to ensure immersion in the participant’s account; (2) detailed exploratory noting, including descriptive, linguistic, and conceptual comments; (3) development of emergent themes grounded in participants’ meaning-making; (4) clustering these themes into coherent superordinate structures; (5) treating each subsequent interview as an independent case to preserve idiographic depth; and (6) examining patterns of convergence and divergence across cases [29, 30]. Following the structured yet flexible IPA procedure ensured methodological transparency and analytic rigor in the qualitative component of the study.

Rigor

Rigor was enhanced through multiple strategies. First, an independent researcher who was not involved in the study conducted a separate analysis of the qualitative data, and discrepancies were resolved through team discussions. Two researchers and one external reviewer collaboratively refined the coding structure. Methodological triangulation was achieved using semi-structured interviews, field notes, and peer review, contributing to the depth and credibility of the findings. Transferability was supported by providing a clear description of the study context, participant characteristics, sampling procedures, and data collection settings. Reliability was further strengthened by coder triangulation and the application of Miles and Huberman’s (1994) formula, yielding an inter-coder agreement of 76%. The COREQ checklist guided the qualitative reporting process [31].

In addition, reflexivity was considered integral to qualitative analysis, acknowledging the active role of researchers in shaping data interpretation and the potential influence of their professional positions [32]. The first author was employed at the study hospital, which may have facilitated trust and participant openness, but also carried a risk of role-related assumptions or power dynamics. To address this, interviews were conducted independently of routine care, reflexive notes were maintained, and analytic decisions were discussed within a multidisciplinary research team. The second researcher, a doctoral-level psychiatric nurse and assistant professor with formal training in qualitative methods, and the third researcher, a psychiatrist and professor with extensive clinical and academic experience, contributed external and theoretical perspectives that supported analytic balance, critical reflection, and transparency in interpretation.

Results

In this study, quantitative data were collected from 415 participants who applied to a public dental hospital. Most of the sample consisted of females (62.9%), individuals aged between 36 and 45 years (36.9%), and those with middle income levels (79.8%). Educationally, a significant portion had completed high school (36.4%) or university (36.9%), indicating a relatively well-educated sample. Despite this, only 65.1% reported brushing their teeth regularly, and a mere 14.2% visited the dentist for routine check-ups. Most participants (71.1%) sought dental care only when symptoms necessitated it, predominantly due to pain (33.9%) or for general check-ups (29.3%) (Table 2).

Table 2.

Mean Dental Fear Scale Scores by Demographic and Clinical Variables (N=415)

Variables	N (%)	Dental for sale
		Mean±SD	t/F (p), post hoc
Groups			3.216 (0.013) e>b e>c
18-25a	48 (11.6)	42.21±16.53
26-35b	89 (21.4)	40.96±18.95
36-45c	153 (36.9)	39.99±16.74
46-55d	78 (18.8)	44.86±17.97
56 and upe	47 (11.3)	49.76±20.02
Gender			4.151 (0.000)
Female	261 (62.9)	45.73±18.60
Male	154 (37.1)	36.96±15.54
Income status			0.828 (0.438)
Low	59 (14.2)	39.85±19.38
Middle	331 (79.8)	43.03±17.73
High	25 (6.0)	41.40±18.67
Education			3.707 (0.012) a>d
Primarya	59 (14.2)	48.58±20.21
Middleb	52 (12.5)	42.69±16.23
Highc	151 (36.4)	42.97±16.82
Universityd	153 (36.9)	39.55±18.38
Tooth brushing			3.107 (0.046) a>c
Nonea	30 (7.2)	50.33±18.15
Irregularb	115 (27.7)	42.00±16.25
Regularc	270 (65.1)	41.80±18.57
Attitudes towards dental visits			5.458 (0.005)
When necessarya	356 (85.8)	44.32±18.21
Regularb	59 (14.2)	37.45±16.76
Dental trauma			5.032 (0.000)
Yes	70 (16.9)	53.57±20.90
No	345 (83.1)	40.23±16.52
Dental complications			2.651 (0.012)
Yes	36 (8.7)	51.67±22.13
No	379 (91.3)	41.60±17.36
Reasons for dental visit			3.551 (0.002) a>b d>b f>b f>e
Paina	141 (33.9)	46.50±18.55
Routine check upb	121 (29.3)	37.81±16.26
Gum complaintc	44 (10.6)	40.43±16.56
Surgeryd	26 (6.3)	45.73±15.14
Restorative procedurese	20 (4.8)	39.75±1990
Orthodonticf	18 (4.3)	53.88±21.23
Otherg	45 (10.8)	41.80±19.68

The DFS score among participants was 42.48 ± 18.02, indicating a moderate level of dental anxiety. As shown in Table 2, anxiety levels varied significantly by age, gender, education, oral hygiene habits, dental visit attitudes, clinical history, and reason for visit. Participants female and aged 56 and above had the highest anxiety levels. Similarly, individuals with primary education, irregular brushing habits, and symptom-driven dental attendance reported elevated anxiety levels. Notably, those with a history of dental trauma or complications had significantly higher scores than those without such experiences. Among reasons for dental visits, patients attending for orthodontic treatment, pain, or surgical procedures demonstrated the highest anxiety, compared to those visiting for routine check-ups.

Multinomial logistic regression analysis revealed several significant predictors of dental anxiety group membership (Fig. 1). Compared to individuals with moderate anxiety, those in the 26–35 age group had significantly lower odds of being classified as either low (Exp(β) = 0.336, p = 0.043) or high anxiety (Exp(β) = 0.325, p = 0.027), indicating a protective effect of younger age. Female gender was associated with a decreased likelihood of low anxiety (Exp(β) = 3.501, p < 0.001) and a markedly increased likelihood of high anxiety (Exp(β) = 4.273, p < 0.001). Clinical factors such as the history of dental trauma significantly increased the odds of both low (Exp(β) = 2.123, p = 0.046) and high anxiety (Exp(β) = 5.663, p < 0.001). Similarly, a history of dental complications increased the likelihood of high anxiety (Exp(β) = 2.291, p = 0.049). Moreover, patients who visited the dentist due to pain (Exp(β) = 3.771, p = 0.045), surgical procedures (Exp(β) = 3.213, p = 0.032), or orthodontic treatment (Exp(β) = 2.718, p = 0.041) were more likely to fall into the high-anxiety group, whereas those attending routine check-ups exhibited lower anxiety levels.

Fig. 1.

Predictors of High Dental Anxiety

Qualitative analysis revealed four themes that encapsulate the emotional, cognitive, and behavioral dimensions of dental anxiety. These are: (1) anticipatory anxiety and bodily reactions, (2) emotional experiences during treatment, (3) past traumatic experiences and their psychological residue, (4) relational expectations and anxiety reducing factors.

Qualitative phase

Qualitative analysis revealed four themes that encapsulate the emotional, cognitive, and behavioral dimensions of dental anxiety. These are: (1) anticipatory anxiety and bodily reactions, (2) emotional experiences during treatment, (3) past traumatic experiences and psychological residue, (4) relational expectations and anxiety reducing factors.

Theme 1. anticipatory anxiety and bodily reactions

The participants with high DFS scores reported experiencing intense anxiety well before arriving at the clinic. This anticipatory anxiety was accompanied by physical symptoms such as insomnia, palpitations, muscle tension, stomach discomfort, and even panic attacks. Participants described feelings of dread that sometimes began well before the appointment, extending into the days leading up to the visit.

“I get cold sweats in the waiting room. Even the smell makes my heart race.” (P7).

“I can’t sleep the night. My stomach cramps, my chest tighten as I think about it.” (P8).

“I try to convince myself not to go, even after I’ve made the appointment.” (P9).

“I start panicking the night before. I feel like I’m going to faint in the morning.” (P12).

Participants with low levels of dental anxiety, on the other hand, stated that they considered their dental visits as a normal part of their health routine and reported feeling relaxation and excitement.

“I go to the dentist regularly, this relaxes me.” (P3).

“I’m actually excited to get my cavity cleaned.“(P6).

Theme 2. emotional experiences during treatment

The dental chair functioned as a symbol of vulnerability. A range of emotions was reported-ranging from helplessness and panic to guarded calmness and trust. While some participants stated that their anxiety was reduced once the procedure began, others described being paralyzed with tension throughout.

“I feel comfortable when I sit on the chair. Something good is being done for my tooth.” (P3).

“Upon sitting down, I gain a sense of control.” (P5).

“The chair is a grave for me… I feel like crying. Once, I told the dentist, ‘I feel nauseous,’ and bolted.” (P8).

“I can’t stand the sound of the drill or the pressure in my mouth. I feel like I’m about to pass out from anxiety.” (P12).

The most difficult aspects of treatment were often injections, the sound and vibration of dental instruments, or prolonged procedures that triggered jaw fatigue, breathlessness, or gag reflexes.

“My mouth staying open for extended periods is the worst part” (P7).

“The needle feels like it’s drilling into my brain-unsetting. The needle alone stresses me out.” (P9).

Theme 3. Past Traumatic Experiences and Psychological Residue

Participants linked their current dental anxiety to earlier traumatic experiences, particularly those occurring in childhood. These included painful procedures without adequate anesthesia, poor communication, or perceived neglect. Such experiences were often described vividly and with emotional weight, suggesting long-lasting psychological effects. The patients described chaotic or dismissive treatment environments that heightened their sense of fear and helplessness, leading to entrenched avoidance behaviors.

“I didn’t experience anything very negative. I lost a tooth simply because I was not informed.” (P2).

“They pulled my teeth without numbing when I was a kid. I can still hear the sound in my head.” (P3).

“Once the dentist ignored me crying and just kept drilling. That memory makes me avoid check-ups even now.” (P9).

Theme 4. Relational Expectations and Anxiety Reducing Factors

It was expressed that the quality of communication between patients and dentists affects anxiety levels. Participants emphasized the importance of dentists providing detailed explanations regarding procedures, duration, instruments, and potential discomfort. Empathy, kindness, and non-judgmental language were highly valued. The majority emphasized that clear, step-by-step communication made them feel more in control. The role of auxiliary staff was also noted -both positively and negatively. A warm and calm team environment contributed to reassurance, whereas curt or indifferent behavior added to patients’ tension.

“Even the assistant saying, ‘you’re doing great’ helps a lot.” (P1).

“When the dentist explains step-by-step and talks gently, I feel like I’m in safe hands.” (P7).

“If the dentist smiles and tells me what’s coming, I can manage anything.” (P10).

“Knowing what will be done with the tools reduces my anxiety.” (P11).

“When the tool is in my mouth, I feel like I can’t breathe… When the doctor shouts, ‘Don’t close!’ it makes me panic.” (P12).

Despite their anxiety, participants described various coping strategies. It was expressed that familiarity with dental settings or personnel helps lower anxiety. Notably, the participants indicated that a calm and reassuring dentist could reduce their anxiety more effectively than any sedation. Others expressed a strong desire for more patient-centered care models that include optional sedation, music, shorter sessions, or information approaches. “Just explain everything with a smile” or “Ask me how I feel before you start” were common, reflecting patients’ need to feel seen and supported.

“When the dental assistant is at ease, I feel at ease too.” (P1).

“When they explain what they’re going to do beforehand, it puts me at ease.” (P4).

“Just put me to sleep. That’s the only way I’ll relax.” (P8).

“My anxiety drops when they describe what tools will be used and how they’ll work on my body.” (P11).

“First, I’d want them to have a normal, one-on-one conversation with me -not about teeth, just a simple ‘How are you? Are you doing well?“(P9).

Discussion

This study is interpreted within an analytical framework that integrates fear acquisition theories, contemporary biopsychosocial models, and trauma-informed care principles. Within this framework, dental anxiety is understood as a dynamic process shaped by conditioned fear responses, cognitive-emotional regulation, prior traumatic experiences, and relational factors embedded in the clinical encounter. Quantitative findings identify sociodemographic, behavioral, and experiential predictors of dental anxiety, while qualitative themes provide contextualized insight into how these factors are subjectively experienced, embodied, and negotiated by patients. By aligning statistical associations with lived experiences, this integrated framework enables a deeper interpretation of dental anxiety as both an individual psychological response and a relational phenomenon within dental care settings.

Quantitative results revealed significant age-related differences in dental anxiety. Patients aged ≥ 56 years exhibited the highest anxiety levels, likely due to negative experiences [33, 34], age-related pain sensitivity [35], and concerns about medical or financial burdens [2]. In contrast, the 26–35 age group showed lower anxiety, possibly reflecting better health literacy and preventive care awareness [1]. Our findings align with research linking aging to heightened dental anxiety through pain sensitization and traumatic recall [36, 37].

Female participants reported significantly higher dental anxiety than males, aligning with previous research highlighting the influence of hormonal, psychological, and social factors [38, 39]. Hormonal fluctuations such as estrogen and progesterone may heighten stress sensitivity in women [39]. Additionally, women tend to express anxiety more openly and show greater pain sensitivity, while men may underreport anxiety due to social norms [38]. Importantly, the higher prevalence of dental anxiety among women has also been linked to their disproportionate exposure to violence, particularly sexual abuse, which is significantly more common among women than men [7, 40]. Experiences of violence and interpersonal trauma can increase individuals’ sensitivity to dental procedures, particularly those involving close physical contact, reduced sense of control, or intrusion into personal space, and this sensitivity is further amplified by the vulnerable bodily position patients assume during dental appointments which together may intensify dental anxiety [8, 12, 22, 41, 42]. These findings underscore the need for trauma-informed and gender-sensitive approaches in dental care [43, 44].

Participants with lower education levels reported higher dental anxiety, supporting the role of health literacy in reducing anxiety [1]. When patients struggle to understand procedures, consent processes, or their rights, anxiety increases, consistent with evidence linking poor communication and limited comprehension to heightened dental anxiety [1, 45]. The studies show that under- and postgraduate dental education offers limited preparation for managing dental anxiety [46, 47]. Dental professionals require ongoing training and professional support to fulfil their care-taking responsibilities effectively [8]. This need is further reinforced by current legislation and ethical guidelines, which mandate that dental professionals provide clear, accessible, and psychologically safe care, particularly for patients [1, 8, 47].

This study highlights the key role of behavioral patterns in dental anxiety, particularly oral hygiene habits and dental visit attitudes. Regular brushing was associated with lower anxiety, suggesting a bidirectional relationship between oral hygiene and dental care. In contrast, symptom‑driven visits were correlated with higher dental anxiety, likely due to associations with pain and urgency of treatment [2, 33], reinforcing an avoidance cycle that exacerbates anxiety and oral health decline [48]. A history of dental trauma or complications strongly predicted elevated anxiety, supporting prior findings [49]. Negative experiences may create conditioned fear responses, where even stimuli (e.g., dental sounds) trigger distress [45], leading to treatment avoidance and worsening outcomes [50]. These results emphasize the need for trauma-informed care, especially for patients with past adverse experiences. Procedure type also influenced anxiety levels. Orthodontic treatment, surgeries, and pain-related visits elicited the highest anxiety while routine check-ups were linked to the lowest [2]. Pain drove anticipatory anxiety [1], whereas familiarity with preventive care appeared protective. These findings suggest that promoting regular dental visits, patient education, and gentle, anxiety-sensitive approaches could help mitigate dental anxiety and improve oral health compliance.

The qualitative findings of this study provided essential context and depth to the quantitative results, offering a more nuanced understanding of dental anxiety. Participants described a range of emotional and physiological responses, particularly anticipatory anxiety that began days before the dental appointment. This anxiety was often accompanied by insomnia, nausea, and panic, indicating a strong somatic component. Such reactions align with cognitive-behavioral theories of anxiety, where catastrophic thinking and loss of perceived control contribute to elevated physiological arousal [51, 52]. In contrast, patients with low anxiety associated dental care with preventive health behaviors and expressed greater emotional regulation, reinforcing the protective role of routine dental visits.

A prominent theme was the lasting impact of past dental trauma, particularly experiences from childhood. Participants often recalled painful procedures without proper anesthesia or consent, which contributed to long-term avoidance of dental care. These narratives support previous findings that early negative dental experiences can lead to fear conditioning and persistent anxiety in adulthood [53, 54]. Such traumatic memories not only shaped patients’ willingness to seek treatment but also influenced their emotional responses to clinical stimuli such as dental sounds, instruments, and the physical setting of the dental chair.

Communication between patients and dental professionals emerged as a key factor in moderating dental anxiety. Participants reported feeling safer and more in control when procedures were explained clearly, calmly, and step by step. Empathetic communication helped reduce anxiety and foster trust, while rushed or authoritarian approaches heightened anxiety. These findings echo the importance of the “Tell-Show-Do” protocol [55], while the observed variability in patients’ information preferences reinforce Donate-Bartfield et al.’s (2010) emphasis on communication personalization [56]. The significant impact of provider empathy and emotional attune aligns with Lin et al.’s (2017) relational model of dental care [57].

Coping strategies varied among participants but shared a common theme of seeking control over the dental experience. Some patients preferred continuity with a familiar dentist, while others requested sedation or used sensory distractions. The diversity in information preferences -ranging from a desire for detailed procedural knowledge to minimal explanation- highlighted the need for individualized care plans that consider psychological readiness and coping style. These insights illustrate how personalized approaches can reduce anxiety and improve treatment adherence.

Limitations

Several limitations should be acknowledged. First, cross-sectional design limits causal interpretations, and longitudinal studies are needed to examine the development and progression of dental anxiety over time. Second, the sample was drawn from an urban public oral and dental health hospital, which may limit the generalizability of the findings to other clinical settings. Future research should incorporate participants from solo practice environments to enhance transferability and capture setting-specific variations in dental anxiety. While validated instruments were used, the data collection process relied on self-reported measures, which may be influenced by participant bias and response tendencies. Additionally, the qualitative sample included low and high dental anxiety cases, which allowed clear contrasts but may have restricted variation, incorporating moderate or extreme cases might have revealed additional patterns. Finally, the study was conducted in a single geographical and cultural context, and differences in dental care systems or sociocultural norms may affect the applicability of results elsewhere.

Conclusions

This mixed-methods study provides comprehensive insights into nature and predictors of dental anxiety among adult patients. The analysis of quantitative data made evident to what extent and in which groups of patients’ dental fear occur, while the analysis of qualitative data disclosed how dental fear affects the attitude towards and experience of dental care. The findings indicate that dental anxiety is shaped not only by individual factors but also by prior care experiences and clinician-patient interactions. From a practice perspective, integrating psychological sensitivity into routine dental services, through communication-focused training, patient-centered care models, and supportive strategies for vulnerable groups, may reduce dental anxiety and improve engagement with dental care, ultimately contributing to better oral health outcomes.

Abbreviations

DFS

Dental Fear Scale

Authors’ contributions

**HAS: ** Conceptualization, methodology, formal analysis and investigation, writing - original draft preparation, funding acquisition, resources.**ND: ** Conceptualization, methodology, writing - original draft preparation, writing - review and editing, funding acquisition, resources.**EO: ** Conceptualization, methodology, writing - review and editing, funding acquisition, resources.All authors reviewed the manuscript.

Funding

Not applicable.

Data availability

Available to be requested from the corresponding author upon reasonable requests and compliance with data sharing agreements.

Declarations

Ethics approval and consent to participate

Prior to data collection, ethical approval was obtained from the University Ethics Committee (Approval No: 20.478.486/2029, dated: 11/10/2023) and the Provincial Health Directorate (Approval No: E-11202945-605-233491693, dated: 05/01/2024). The confidentiality and anonymity of the participants’ personal information were strictly maintained in accordance with the principles outlined in the Declaration of Helsinki. Before participation, all participants were provided with written and verbal information about the study, and informed consent was obtained. The pseudonyms were used to protect participant identities during qualitative reporting.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.