Effect of Dental Anxiety on Oral Health among the First-Time Dental Visitors: A Hospital-based Study

Abstract

Objective:

The objective was to assess dental anxiety and to find its association with oral health status and oral health-related quality of life (OHRQoL) among 20–40-year-old patients visiting Vokkaligara Sangha Dental College and Hospital.

Materials and Methods:

A single-center, hospital-based cross-sectional study was done among first-time dental visitors in the Department of Oral Medicine and Radiology, Vokkaligara Sangha Dental College and Hospital over a period of 8 months (July 14–February 18). The sample size was determined to be 700. Participants in the age group of 20–40 years were selected based on inclusion and exclusion criteria. Data were collected using Corah's Modified Dental Anxiety Scale, Oral Health Impact Profile-14 (OHIP-14), and clinical examination was done using the WHO oral health assessment form and OHI-S. Data were analyzed using Chi-square test and t-test. The associations found through bivariate analysis were entered as predictor variables into linear and binomial logistic regression models with high dental anxiety as the outcome variable.

Results:

The results of the study suggested that 56% of the study participants were having dental anxiety. Local anesthetic injection (80%) and fear of tooth drilling (60%) were the most anxiety-provoking stimulus. Analysis of OHIP-14 suggested that respondents perceiving oral health as affecting their life quality (very often/fairly often) in the past year were observed for items such as tension, difficulty to relax, irritability, difficulty in doing usual jobs, and totally unable to function because of oral problems. Dental anxiety was significantly associated with gender (odds ratio [OR] = 1.32), education (OR = 1.43), occupation (OR = 2.07), poor oral hygiene status (OR = 3.15), presence of dental caries (OR = 2.67), bleeding on probing (OR = 1.57), presence of periodontal pockets (OR = 2.64), clinical attachment loss (OR = 1.63), and OHRQoL (OR = 1.76). Stepwise linear regression model of independent variables (<0.05 variables included) explained dental caries as highest predictor (39%), followed by debris (22%), calculus (38%), mean OHIS (27%), mean OHIP-14 (29%), deep pocket (14%), and the least predictor was shallow pocket (9%).

Conclusion:

Dental anxiety was associated with poor oral health status seeking further attention to modify patients' behavior regarding improvement in oral health status.

INTRODUCTION

Anxiety is defined as an aversive emotional state anticipating a feared stimulus in future[1] with or without the presence of an immediate physical threat. Dental anxiety relates to the psychological and physiological variations of a nonpathological fear response to a dentist's appointment or treatment.[1] Dental anxiety is a universal phenomenon, since all over the world, approximately 25% of patients avoid dental visits and treatments, and approximately 10% reach phobic levels of anxiety.[2]

The prevalence of dental anxiety according to the published studies is between 11% and 91.2%, and this disparity is justified by the subjectivity of the diagnostic criteria, assessment methods, and sampling techniques. A study by Malvania and Ajithkrishnan et al.[3] reported a high prevalence of dental anxiety of 46% in a group of adult patients in India. The studies by Tang and Zhu,[4] Assuncão et al.,[5] Khraisat and AL-Olaimat[6] reported the prevalence of dental anxiety to be 61.3%, 72%, and 91.2%, respectively.

Levels of dental anxiety have been shown to be associated with poor clinical oral health status.[7] Dentally anxious people are reported to have more decayed teeth and surfaces,[8,9] more missing teeth,[1] fewer filled teeth,[1] gum problems,[10] and erosion[11] than the nonanxious people. Therefore, it is essential to assess dental anxiety among the population as this also causes management problems during dental treatment.

According to the research, the Indian population has a higher prevalence of dental anxiety than the Western population.[3,12] This could be due to a variety of factors, including poor oral health awareness, ignorance about dental treatment procedures, superstitions and false beliefs about dental treatment, cultural differences, and family members' perspectives (highly regarded in this society). Thus, it is critical to first identify dental anxiety, understand its nature, and its relationship with oral health status to improve the situation. As a result, the current study was carried out to assess dental anxiety and determine its relationship with oral health status.

MATERIALS AND METHODS

The present cross-sectional collected patients in the age group of 20–40 years, reporting to a dental college for the first time in South Bangalore were selected.

Patients on antianxiety therapy or any antipsychotic or neurotic drugs and those with any systemic diseases/medically compromised patients were excluded from the study. A convenient sample of 700 selected based on the following parameters (alpha = 5%, Prevalence [p] = 35% [0.35],13 precision level = 5%, and design effect = 2). Ethical approval from IRB and patient consent were obtained.

Pilot study

The pilot study was carried out with a convenience sample of 20 participants ranging in age from 20 to 40 years old in the Department of Public Health Dentistry at Vokkaligara Sangha Dental College and Hospital based on the inclusion and exclusion criteria. Test-retest reliability was conducted for Corah's Modified Dental Anxiety Scale (MDAS). The correlation coefficient for test-retest reliability of Corah's MDAS was 0.85 and which is a perfect agreement. The intraexaminer reproducibility was 0.87 for the WHO oral health assessment form and for OHIS, it was 0.93. Data collection included structured interview and clinical oral examination. Corah's MDAS.[14] Clinical oral examination included assessment of oral health status with the WHO basic oral health assessment form, 2013 and Oral Hygiene Index Simplified.[15]

Statistical analysis

Data were analyzed using the SPSS version 19.0 (SPSS Inc., Chicago, IL, USA), and the level of significance was set at P < 0.05. Descriptive statistics were performed to assess the frequencies of responses to the questionnaire items. Statistical analysis to find out the association between dental anxiety and oral health status was done using Chi-square test and Student's t-test. Regression analysis was also used to explain the effect of predictors on dental anxiety.

RESULTS AND DISCUSSION

To the best of the author's knowledge, this is the first study which assess dental anxiety among first-time “dental visitors.” The present cross-sectional study was conducted on a sample of 700 participants in the age group of 20–40 years. The previous published literature on the association between age and dental anxiety was inconsistent with a few studies reporting young people to be more anxious than older people; however, conflicting results with young adults having less anxiety than adults were also observed.[3,13] Thus, in this study, both age groups, i.e., 20–30 years and 31–40 years representative of young and adults, respectively, were selected to find the association of age with anxiety.

There was a considerable uncertainty surrounding the definition of complex emotional/behavioral responses such as anxiety and fear.[14] Anxiety is generally defined in modern psychological research as an aversive emotional state associated with an impending or anticipated encounter with a feared stimulus.[15] This definition is distinct from fear. At a more functional level, anxiety can be seen as priming an individual for a fear response.[16] In a nutshell, anxiety is an emotional state in anticipation of fear stimulus when stimulus is encountered, it turns into fear; hence, anxiety is best assessed among first-time dental visitors.

The present study thus included the first-time dental visitors, i.e., those who have not received any dental treatment in any manner or never visited a dentist. It is assumed that the presence of dental anxiety among patients may delay in seeking care and leading to further worsening of the oral condition. It may also render the treatment more complicated, influences patient–dentist relationship and obscure proper diagnosis. It is thus important to identify a patient with anxiety at the earliest visit for taking measures to ensure successful completion of course of care and preventing cancelling of appointments or delaying scheduled recalls.

A moderate anxiety level kept as 11–15 has been suggested and used in many studies.[3,17,18,19] Klingberg and Broberg[9] reported that normally adolescents are expected to experience mild/low anxiety. This anxiety only becomes a concern if it is “disproportionate to the actual threat and daily functioning becomes impaired,” a definition very similar to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Thus, in the present study, a score of <15 on anxiety scale was considered low anxiety and a score of 15 or above as high anxiety. The present study reported almost negligible participants with dental phobic levels (MDAS >19).

The prevalence of dental anxiety was found to be 56% in the present study. Literature in reporting prevalence of dental anxiety varies with range between 3% and 91.2%.[20]

The oral hygiene status of the patient is associated with dental anxiety. Anxious patients would avoid/delay dental treatment, which could affect the oral hygiene of the patients [Table 1]. Dental caries status was associated with dental anxiety (P < 0.05) could be explained by the same scenario of treatment delay/avoidance, whereas the root caries not found to be significant as the age criteria of study participants mainly belong to the middle age groups where chances of recession were minimal (P > 0.05).

Table 1.

Comparison of dental anxiety based on oral hygiene status

Category (n=700)	Response	Low anxiety MDAS <15 (n=306), n (%)	High anxiety MDAS ≥15 (n=394), n (%)	P (χ2)#
DI-S	Good	32 (28)	84 (72)	0.016* (8.220)
	Fair	84 (32)	181 (68)
	Poor	129 (40)	190 (60)
CI-S	Good	35 (30)	82 (70)	0.010* (9.186)
	Fair	84 (33)	172 (67)
	Poor	140 (43)	187 (57)
OHI-S	Good	32 (30)	77 (70)	0.011* (8.915)
	Fair	83 (31)	181 (69)
	Poor	136 (41)	191 (59)

*P<0.05 – Significant, ^# Chi-square statistics. MDAS: Modified Dental Anxiety Scale, OHI-S: Oral Hygiene Index-Simplified, DI-S: Debris Index Simplified, CI-S: Calculus Index Simplified

In the current study, older people reported less anxiety and painful experiences than their younger counterparts; this age-dependent waning in dental anxiety could be attributed to a general decline in anxiety with aging as well as increased exposure to other diseases and their treatment.[21] A person would be less likely to give attention to dental health when chronic lifestyle health problems starts to emerge during the fourth decade onward in life suggesting protective effect (odds ratio [OR] = 0.87) against dental anxiety in this age group [Table 2].

Table 2.

Comparison of dental anxiety based on dental caries and periodontal status

Category (n=700)	Response	Low anxiety MDAS <15 (n=306), n (%)	High anxietyMDAS ≥15 (n=394), n (%)	P (χ2)#
Decayed teeth	Absent	61 (69)	27 (31)	<0.0001* (26.818)
	Present	245 (40)	367 (60)
Number of decayed teeth	Absent	61 (69)	27 (31)	<0.0001* (255.113)
	1-2	188 (77)	55 (23)
	3 or more	57 (15)	312 (85)
Root caries	Present	7 (30)	19 (70)	0.137 (2.212)
	Absent	280 (42)	394 (58)
Bleeding on probing	Participants with healthy periodontium	195 (61)	124 (39)	<0.0001* (72.236)
	Participants with bleeding gums	111 (29)	270 (71)
Periodontal pocket	No pocket	85 (21)	317 (79)	<0.0001* (220.154
	Shallow pockets (4-5 mm)	207 (80)	53 (20)
	Deep pockets (>5 mm)	14 (63)	24 (37)

*P<0.05 – Significant, ^#Chi-square statistics. MDAS: Modified Dental Anxiety Scale

The present study reported a significant association of dental anxiety and gender, with females having higher dental anxiety than males. The risk observed was 1.32 times in females compared to males. The previous studies have suggested that females report more risk for dental anxiety than males[3,22,23,24] [Table 2].

Results of the study showed that oral hygiene status of majority of the participants was poor (46.7%). Bivariate association of oral hygiene status (debris and calculus) and severity of dental anxiety were statistically significant. Regression analysis also showed poor oral hygiene (debris and calculus) as a risk factor for anxiety (OR = 3.07 and 3.9). This observation is similar to the study by Kanaffa-Kilijanska et al.[25] Levin and Zini[26] also reported association with presence of calculus and dental anxiety. Although patients were following recommended aids for tooth brushing, majority brushed once a day and participants had no history of previous dental visits. Hence, participants were less likely to be aware of oral hygiene maintenance, which could reflect in their poor oral hygiene. Patients may be so embarrassed by their poor oral health/hygiene that they avoid going to the dentist for fear of being chastised [Table 2].

The literature supports the notion that people who are dentally anxious are more likely to have poor or worse oral health status than people who are less or not dentally anxious. It has been proposed that a cycle of anxiety, pain, guilt, and inferiority may prevent good oral hygiene and treatment [Table 2].

The prevalence of dental caries among the study participants was 87.4%. Among those with decayed teeth, a majority of them were in high dental anxiety group than the low anxiety group (P < 0.05). Regression analysis showed that the presence of three or more decayed teeth was at higher risk (OR = 2.67) for dental anxiety. Association between decay and anxiety has been reported by Delgado-Angulo et al. and Esa et al.[8,27] Eitner et al.[28] found that avoidance of dental treatment was highly correlated with anxiety scores and with increased caries morbidity. In general, dental anxiety has a negative effect on the utilization of dental services, as the present study participants visited their dentists for the first time, they were more likely to have more decayed teeth. This would appear to be the inevitable consequence of personal neglect and avoiding dental care as the result of anxiety. The series of events of anxiety delayed treatment worsening of condition could explain the presence of high caries in anxiety group [Table 2].

In the present study, linear regression explained the change in dependent variable dental anxiety by various independent predictors. Dental caries explain a major 39% change in high anxiety and other predictors noted were calculus (38%), OHI-S (27%), and debris (22%) undoubtedly explains how dental anxiety influences oral health status of an individual. In summary, the overall effect of dental anxiety appears to be multifaceted, such that the individual not only avoids their dental appointment but also tends to have poor oral health, and further dental anxiety is reinforced as a result of greater disease prevalence. This finding of the study supports the concept that dental anxiety is correlated with poor oral and periodontal health [Table 3].

Table 3.

Linear regression of predictors with high dental anxiety as dependent variable

Variable	Standard beta	SE	R	R 2	P
Dental caries	0.499	0.424	0.629	0.396	0.000*
Calculus	0.458	0.408	0.616	0.381	0.044*
Debris	0.462	0.305	0.473	0.224	0.036*
OHIS	0.416	0.104	0.527	0.278	0.023*
BOP	0.267	0.203	0.429	0.184	0.041*
Shallow pocket	0.242	0.224	0.308	0.095	0.044*
Deep pocket	0.188	0.144	0.382	0.146	0.040*

*P<0.05 – Significant. SE: Standard error

CONCLUSION

The study concluded that Dental anxiety is associated with oral hygiene, dental caries and periodontal status of the first time dental visitors.

Limitations

1. The cross-sectional survey design with its inherent drawback of establishing a cause-effect relationship, there is a need for longitudinal research covering wide groups of population

2. The participants who were visiting the dental hospital were selected for the study which may affect generalizability. Future studies in the general population would be required.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.