Abstract
Dental anxiety (DA) and generalized anxiety (GA) significantly impact patients’ quality of life, influencing their social interactions, job performance, self-esteem, self-confidence, and overall oral health. Previous literature showed that females have a higher probability of experiencing psychological burdens compared with males. This study aimed to examine the correlation between GA and DA among females. This is a cross-sectional study that utilized the online survey study design using Qualtrics software in Jordan and Saudi Arabia in 2024. The convenience sampling technique was employed in this research. The correlation between GA and DA scores was examined using the Pearson correlation coefficient test. Multiple logistic regression analysis was conducted to identify predictors of severe DA. A total of 1858 females were involved in this study. The prevalence of severe anxiety (a total score of 15 and above) among the study sample was 24.2%. The mean DA score among the study participants was 12.6 (standard deviation = 5.1) out of 25. Around 38.2% of the study sample showed moderate level of DA. A total of 16.0% of the study sample showed high level of DA. A moderately positive correlation was identified between Generalized Anxiety Disorder-7 score and Modified Dental Anxiety Scale score (r = 0.270; 95% confidence interval = 0.226–0.316; P value < .001). Females with a monthly income of 1500 to 2000 dollars were at a lower likelihood of experiencing severe DA level (P < .05). DA and GA were significant burdens among female study samples in Saudi Arabia and Jordan. Anxiety-minimizing and coping techniques can be considered by dentists while dealing with female patients. Educational campaigns should promote the importance of oral health and decrease public fear of dental visits.
Keywords: anxiety, dental anxiety, dental phobia, generalized anxiety
1. Introduction
Fear and anxiety are among the biggest obstacles of receiving proper dental care.[1] Dental anxiety (DA) is a complex, multifactorial condition that affects individuals of all age groups.[2,3] The most common causes are a previous experience of pain during or after visiting dentists, along with negative interactions or observations involving the dentists.[4] DA and generalized anxiety (GA) significantly impact patients’ quality of life, influencing their social interactions, job performance, self-esteem, self-confidence, and overall oral health.[5,6]
The prevalence of DA varies widely across different populations, ranging from 2.6% to 29.9%.[7,8] DA prevalence also differs by age and gender[3,9]; for example, Alshuaibi et al found that among school-age children, the prevalence was approximately 50% in boys and 70% in girls.[3] High level of DA is significantly associated with negative oral health outcomes. Patients with severe anxiety are at greater risk of having more decayed teeth, missing teeth, gum issues, fewer filled teeth, and tooth erosion compared with those without anxiety.[10,11]
Although the prevalence of DA is high, the specific factors predicting anxiety levels remain unclear. Studies suggested that demographic factors like age, gender, and education level play a role[12]; for instance, females are more likely to experience pain and anxiety during dental visits, while males hide their pain due to cultural behaviors.[13] Generally, older adults tend to be less anxious and expressive about their pain in dental visits compared with young individuals.
However, the relationship between GA and DA is less frequently studied compared with other factors. Both DA and GA similarly impact oral healthcare negatively, suggesting a need for greater efforts to understand how GA might influence DA.[14–16] Previous literature showed that females have a higher probability of experiencing GA compared with males.[16] In our previous research that examined the complex interplay between DA, GA, dental neglect, and oral health-related quality of life among the general public in Saudi Arabia and Jordan, we identified that GA significantly predicted DA.[16] However, the previous research did not examine gender-specific predictors of DA nor the correlation between GA and DA. Therefore, the aim of this study was to examine the correlation between GA and DA among females. This study hypothesized that GA is correlated with DA among females. Furthermore, we hypothesized that females’ sociodemographic characteristics could predict their severe DA status.
2. Methods
2.1. Study design and population
This is a cross-sectional study that utilized the online survey study design using Qualtrics software (Qualtrics, LLC, Provo). This study was conducted in Jordan and Saudi Arabia in 2024 (between September and November). The study population for this research was adult females from the general community. The inclusion criteria were females aged 18 years and older. Besides, the participants should be currently living in 1 of the 2 countries.
2.2. Sampling technique
In order to recruit the participants for this study, a convenience sampling technique was applied. The social media platforms (Instagram, WhatsApp, and Facebook) were used to invite and recruit eligible study participants. The survey link was administered in the Arabic language along with the invitation letter showing the inclusion criteria for the study. The study participants were informed about their right to participate in the study on a voluntary basis and that they are free to withdraw. Before participating in this study, all respondents gave their informed consent.
2.3. Study instruments
This research utilized previously validated tools to achieve the study aim of examining the link between GA and DA. The Generalized Anxiety Disorder (GAD)-7 and Modified Dental Anxiety Scale (MDAS) were used in this study.[17,18] The scoring scale and scale severity categories were mentioned extensively in previous literature.[6,18] A GAD-7 score between 5 and 9 indicates mild anxiety, between 10 and 14 indicates moderate anxiety, and above 15 indicates severe anxiety. The MDAS comprises 5 items that utilized 5-point Likert scale ranges between “not anxious” and “extremely anxious” with an individual’s item score that ranges between 1 and 5. The maximum score is 25, and a cutoff of 19 or above indicates a highly dentally anxious patient.
2.4. Questionnaire piloting
A piloting study was conducted on 40 participants to examine the questionnaire clarity and understandability. Before the distribution of the study questionnaire tools, we also checked the clarity of the questionnaire tools by an expert panel of 2 oral health researchers. They confirmed the items’ clarity and suitability for achieving the study aim.
2.5. Statistical analysis
The Statistical Package for Social Science Software version 31 (IBM Corp., Armonk) analyzed the data for this study. Mean and standard deviation (SD) presented continuous variables. The correlation between GA and DA scores was examined using the Pearson correlation coefficient test. Predictors of severe DA were identified using multiple logistic regression analysis, which was identified as DA score of 19 and above based on the original questionnaire. The significance level was assigned as P < .05.
2.6. Sample size
The estimated minimum required sample size for our study population was 385 females from each country, using an SD of 0.5, a confidence interval of 95%, and a margin of error of 5%.
2.7. Ethical approval
The Scientific Research Ethics Committee at Isra University approved this study (SREC/24/09/114).
3. Results
A total of 1858 females were involved in this study. The age group 24 to 30 years contributed for 15.4% of the study sample. Single contributed to the majority of the participants (84.7%). Bachelor’s degree holders contributed to 56.0% of the participants. Around one-third of the study participants (47.5%) reported that their family monthly income level is <$700. Around 43.2% of the participants reported that they are unemployed. A total of 14.4% reported that they are smokers. Comorbidities history was reported by 9.3%. For further details, refer to Table 1.
Table 1.
Participants’ demographic characteristics.
| Overall (N = 1858) | Jordan (n = 1522) | Saudi Arabia (n = 336) | ||||
|---|---|---|---|---|---|---|
| Frequency | Percentage | Frequency | Percentage | Frequency | Percentage | |
| Age (yr) | ||||||
| 18–23 | 1479 | 79.6% | 1332 | 87.5% | 147 | 43.8% |
| 24–30 | 286 | 15.4% | 167 | 11.0% | 119 | 35.4% |
| 31–40 | 61 | 3.3% | 18 | 1.2% | 43 | 12.8% |
| 41–50 | 21 | 1.1% | 4 | 0.3% | 17 | 5.1% |
| 51–60 | 8 | 0.4% | 0 | 0.0% | 8 | 2.4% |
| 61 and older | 3 | 0.2% | 1 | 0.1% | 2 | 0.6% |
| Marital status | ||||||
| Single | 1574 | 84.7% | 1396 | 91.7% | 178 | 53.0% |
| Married | 248 | 13.3% | 116 | 7.6% | 132 | 39.3% |
| Divorced | 29 | 1.6% | 9 | 0.6% | 20 | 6.0% |
| Widowed | 7 | 0.4% | 1 | 0.1% | 6 | 1.8% |
| Education level | ||||||
| Diploma or lower | 739 | 39.8% | 642 | 42.2% | 97 | 28.9% |
| Bachelor’s degree | 1040 | 56.0% | 822 | 54.0% | 218 | 64.9% |
| Higher education | 79 | 4.3% | 58 | 3.8% | 21 | 6.3% |
| Family monthly income level | ||||||
| <$700 | 883 | 47.5% | 819 | 53.8% | 64 | 19.0% |
| $700–$1500 | 528 | 28.4% | 465 | 30.6% | 63 | 18.8% |
| $1500–$2000 | 220 | 11.8% | 132 | 8.7% | 88 | 26.2% |
| >$2000 | 227 | 12.2% | 106 | 7.0% | 121 | 36.0% |
| Employment status | ||||||
| Retired | 43 | 2.3% | 22 | 1.4% | 21 | 6.3% |
| Unemployed | 803 | 43.2% | 689 | 45.3% | 114 | 33.9% |
| Working in healthcare sector | 83 | 4.5% | 26 | 1.7% | 57 | 17.0% |
| University student | 781 | 42.0% | 705 | 46.3% | 76 | 22.6% |
| Working in other sectors | 148 | 8.0% | 80 | 5.3% | 68 | 20.2% |
| Smoking status | ||||||
| Smoker | 268 | 14.4% | 217 | 14.3% | 51 | 15.2% |
| Comorbidities history | ||||||
| Yes | 173 | 9.3% | 142 | 9.3% | 31 | 9.2% |
3.1. Anxiety status profile
3.1.1. GAD status
The prevalence of severe anxiety among the study sample was 24.2%. Table 2 shows the distribution of anxiety status among the study sample.
Table 2.
Generalized anxiety status of the study sample (N = 1858).
| Variable | Frequency | Percentage |
|---|---|---|
| GAD-7 diagnosis based on score distribution | ||
| Minimal anxiety (scored <5) | 426 | 22.9% |
| Mild anxiety (scored 5–9) | 548 | 29.5% |
| Moderate anxiety (scored 10–14) | 435 | 23.4% |
| Severe anxiety (scored >15) | 449 | 24.2% |
GAD = generalized anxiety disorder.
3.1.2. DA status
The mean DA score among the participants was 12.6 (SD = 5.1) out of 25, indicating moderate DA level among the participants. Around 38.2% of the participants showed moderate DA level. A total of 16.0% of the study sample showed high DA level, see Figure 1. Table 3 shows DA status for the study participants.
Figure 1.
Distribution of dental anxiety classification.
Table 3.
Dental anxiety status.
| Variable | Frequency | Percentage |
|---|---|---|
| Low dental anxiety (a score of 5–11) | 851 | 45.8% |
| Moderate dental anxiety (a score of 12–18) | 710 | 38.2% |
| High dental anxiety (a score of 19–25) | 297 | 16.0% |
3.2. Correlation between GA and DA
Pearson correlation coefficient showed a moderately positive correlation between GAD-7 score and MDAS score (r = 0.270; 95% confidence interval = 0.226–0.316; P value < .001).
3.3. Predictors of severe DA
Multiple logistic regression analysis identified that females with a monthly income of 1500 to 2000 dollars were at a lower likelihood of experiencing severe DA level (P < .05), Table 4. Multicollinearity was examined utilizing the variance inflation factor, which was lower than 2. The regression model demonstrated adequate goodness of fit (P value = .767).
Table 4.
Predictors of severe dental anxiety.
| aOR (95% CI)* | P value | |
|---|---|---|
| Age (yr) | ||
| 18–23 (reference category) | 1.0 | |
| 24–30 | 1.34 (0.87–2.07) | .180 |
| 31–40 | 0.98 (0.41–2.32) | .958 |
| 41–50 | 0.31 (0.04–2.55) | .277 |
| 51–60 | 0.90 (0.09–9.15) | .931 |
| 61 and older | 4.13 (0.36–47.99) | .257 |
| Marital status | ||
| Single (reference category) | 1.0 | |
| Married | 1.02 (0.64–1.62) | .940 |
| Divorced | 1.08 (0.33–3.53) | .903 |
| Widowed | 1.30 (0.14–12.42) | .822 |
| Education level | ||
| Diploma or lower (reference category) | 1.0 | |
| Bachelor degree | 0.93 (0.69–1.25) | .625 |
| Higher education | 0.75 (0.36–1.54) | .430 |
| Family monthly income level | ||
| <$700 (reference category) | Reference | |
| $700–$1500 | 0.75 (0.56–1.02) | .067 |
| $1500–$2000 | 0.50 (0.31–0.81) | .005 |
| >$2000 | 1.07 (0.72–1.59) | .751 |
| Employment status | ||
| Retired (reference category) | 1.0 | |
| Unemployed | 1.17 (0.47–2.91) | .742 |
| Working in healthcare sector | 0.79 (0.25–2.52) | .688 |
| University student | 1.50 (0.59–3.80) | .396 |
| Working in other sectors | 1.16 (0.42–3.21) | .774 |
| Smoking status | ||
| No (reference category) | 1.0 | |
| Yes | 1.05 (0.73–1.50) | .792 |
| Comorbidities history | ||
| No (reference category) | 1.0 | |
| Yes | 0.94 (0.60–1.47) | .792 |
| Constant | 0.17 (0.00–0.00) | .000 |
aOR = adjusted odds ratio, CI = confidence interval.
The multivariate regression analysis controlled for age, marital status, education level, family monthly income level, employment status, smoking status, and comorbidities history.
4. Discussion
The prevalence of severe anxiety among our study sample was 24.2%. A similar study in Lebanon assessing DA with the same tool revealed that 31.1% of the participants experienced anxiety,[19] while a study in Nigeria found that 10% of the participants had a severe anxiety level of DA.[20] Another study conducted among children showed a higher prevalence, with 54.1% experiencing severe DA,[1] and a separate study indicated that 19.2% of individuals were exceptionally anxious regarding dental care.[10] These variations in anxiety levels across studies might result from differences in assessment tools, study methodologies, and sample characteristics.
In our study, the mean DA score among participants was 12.6 (SD = 5.1) out of 25, which indicates a moderate level of DA. Approximately 38.2% of the study sample showed moderate level of DA. A total of 16.0% of the study sample showed high level of DA. Similar to our findings, 2 other studies reported comparable DA scores, with total DA mean scores of 10.1 (4.78) and 12.62 (4.73).[19,20] In another study, approximately 17% of individuals were dentally anxious, and 21.2% of individuals were highly anxious.[10] These similarities may be attributed to shared sample characteristics and the use of similar assessment tools. Our results showed that the enrolled sample had a moderate level of DA, which is significantly associated with the number of clinical conditions. Previous studies indicated that DA is associated with traumatic dental experience, feelings of embarrassment, losing control in a dental chair, mistrust of a dentist, or an imagined fear based on anecdotal instances, which can all contribute to anxiety.[12,21]
The Pearson correlation coefficient revealed a moderately positive correlation between GAD-7 score and MDAS score (r = 0.270; 95% confidence interval = 0.226–0.316; P value < .001), indicating that as the GA level increases, the level of DA tends to increase. Similar to our findings, a study reported that the DA was significantly correlated with GAD (r = 0.240, P ≤ .001).[22] Another study indicated that there was a positive and significant relationship between total anxiety scores and DA.[23] This similarity in the correlation coefficient may be explained by the fact that GA tends to heighten DA. Clinically, people who suffer from GA may also have increased DA because of a similar psychological mechanism. DA is a significant psychological issue that has a negative impact on patients’ physical health. Fear and anxiety associated with dentistry may be psychiatric disorders in and of themselves. Numerous studies on this topic can be found in the literature.[16] In addition, prior research revealed an association between DA and overall psychological well-being as well as general psychological disorders.[24]
Dental care can often provoke phobias and anxiety, with the discomfort experienced during dental procedures potentially exacerbating both depression and anxiety. Furthermore, individuals with mental health disorders, particularly anxiety, might have an elevated risk of dental issues. For example, anxiety disorders are significantly associated with a 2.7 times higher risk of experiencing tooth loss compared with individuals without anxiety.[25]
Multiple logistic regression analysis identified that females with an income level of $1500 to $2000 were predictors of a lower likelihood of experiencing severe DA level (P < .05). Two different previous studies showed females are at a higher risk of developing DA compared with males.[19,20] However, other research indicated that monthly income is not a significant predictor of anxiety.[22] These contrasting findings may be due to variations in sample characteristics across studies. Several studies reported that females are at higher risk of developing DA compared with males, with a higher prevalence rate during pregnancy.[26,27]
In this study, there is a significant correlation between general and DA. Clinically, this finding highlights the importance of mental health factors in the dental treatment plans. Furthermore, including anxiety screening and management in the treatment plans might reduce avoidance behavior and enhance the overall oral health. Future research should investigate the effect of implanting of anxiety management interventions such as behavioral therapy in reducing DA, which, in turn, might improve the dental care and oral health.
This study emphasizes how important it is for dentists to take their patients’ mental health into account when providing complete dental care. To find patients who are more likely to have DA, dentists are advised to perform regular anxiety screening in their initial patient evaluations. Anxiety level can also be decreased by creating a calm atmosphere in the clinic with features like soft lighting, soothing music, and sympathetic conversation. Educating dental professionals on how to identify and manage anxiety can improve patient satisfaction and treatment compliance, which might ultimately lead to better oral health outcomes.
There were several potential limitations to this study, with the first relating to the study design; self-reported questionnaires are at high risk of bias due to overestimating or underestimating their oral health and anxiety level. Second, factors such as previous dental experience and cultural attitude toward dental care were not controlled, which may affect the accuracy of the dental care anxiety level. The use of the convenience sampling technique increases the possibility of having selection bias. Furthermore, this study is prone to sample size instability as most participants were recruited from Jordan, and there were differences in the demographic characteristics between the 2 countries. Other confounding factors, such as frequency of dental visits, previous dental traumas, and specific dental phobias, remain unassessed. Finally, this study focuses on general and dental care without accounting for other factors such as specific dental phobias that might also affect the DA level.
5. Conclusions
DA and GA were significant burdens among our female study sample in Saudi Arabia and Jordan. Anxiety-minimizing and coping techniques can be considered by dentists while dealing with female patients. Educational campaigns should promote the importance of oral health and decrease public fear of dental visits. Future longitudinal studies are recommended to examine behavioral and interventional approaches such as virtual reality in reducing DA and GA among patients referring to dental clinics.
Author contributions
Investigation: Abdullah S. Bin Rahmah, Mohammed I. Alsaif, Hamdan Alamri, Abdallah Y. Naser.
Resources: Abdullah S. Bin Rahmah, Mohammed I. Alsaif, Hamdan Alamri, Abdallah Y. Naser.
Conceptualization: Abdullah S. Bin Rahmah, Mohammed I. Alsaif, Abdallah Y. Naser.
Data curation: Mohammed I. Alsaif, Abdallah Y. Naser.
Formal analysis: Mohammed I. Alsaif, Abdallah Y. Naser.
Funding acquisition: Abdullah S. Bin Rahmah, Mohammed I. Alsaif.
Methodology: Abdullah S. Bin Rahmah, Mohammed I. Alsaif, Abdallah Y. Naser.
Project administration: Mohammed I. Alsaif, Abdallah Y. Naser.
Software: Mohammed I. Alsaif, Abdallah Y. Naser.
Supervision: Abdullah S. Bin Rahmah, Mohammed I. Alsaif, Abdallah Y. Naser.
Validation: Abdullah S. Bin Rahmah, Mohammed I. Alsaif, Abdallah Y. Naser.
Visualization: Abdullah S. Bin Rahmah, Mohammed I. Alsaif, Abdallah Y. Naser.
Writing – original draft: Abdullah S. Bin Rahmah, Mohammed I. Alsaif, Abdallah Y. Naser.
Writing – review & editing: Abdullah S. Bin Rahmah, Mohammed I. Alsaif, Hamdan Alamri, Abdallah Y. Naser.
Abbreviations:
- DA
- dental anxiety
- GA
- generalized anxiety
- GAD
- generalized anxiety disorder
- MDAS
- Modified Dental Anxiety Scale
- SD
- standard deviation
Informed consent was obtained from all subjects involved in the study.
The Scientific Research Ethics Committee at Isra University approved this study (SREC/24/09/114).
The authors have no funding and conflicts of interest to disclose.
The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.
How to cite this article: Bin Rahmah AS, Alsaif MI, Alamri H, Naser AY. Association between dental anxiety and generalized anxiety among females in Saudi Arabia and Jordan: A cross-sectional study. Medicine 2026;105:15(e48279).
ASBR and MIA contributed to this article equally.
Contributor Information
Abdullah S. Bin Rahmah, Email: arahmah@ksu.edu.sa.
Hamdan Alamri, Email: h.alamri@qu.edu.sa.
Abdallah Y. Naser, Email: abdallah.naser@iu.edu.jo.
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