Khurram Parvez Sardar1 BDS, MDS
Iqra Sam Sam Ali Raza2 BDS
Mahira Shafi3 BDS
INTRODUCTION: The aim of this study was to evaluate the dental anxiety among patients attending Dental Outpatient Department at OJHA campus of Dow University of Health Sciences(DUHS).
METHODOLOGY: This study was conducted in oral diagnosis department of DUHS (OJHA Campus) for the tenure of six months .A total of 100 patients were included in thiscross sectional study according to two age groups.First group was between 18-30 years (n=74) and second group was >30 years (n=26).Patients were asked to complete a questionnaire based on two scales – Modified Dental Anxiety Scale (MDAS) and Dental Fear Survey (DFS).
RESULTS: The descriptive statistical analysis was engaged along with frequencies and percentages. The results showed that female participants scored higher dental anxiety (54.6%) compared to male patients (45.3%).Tooth pull attributed highest dental anxiety (71.80%) in Modified Dental Anxiety Scale and the Dental Fear Survey reveals that an increase heart rate is a highest outcome of dental anxiety(39.60%).
STATISTICAL ANALYSIS: Data was entered in statistical package for social sciences (SPSS version 20) and all quantitative and qualitative variables were analyzed by using the software. Chi square test was applied to observe the association of age and gender with tobacco and betal nut chewing by observing the expression of survivin. CONCLUSION: Female patients reported more dental anxiety thanmale patients and most fearful procedure as perceived by the respondents was tooth extraction.
KEY WORDS: Dental anxiety, Modified Dental Anxiety Scale, Dental Fear Survey, Tooth Pull.
HOW TO CITE: Sardar KP, Raza ISSA, Shafi M. Dental anxiety level in patients attending dental outpatient department at dow university of health sciences. J Pak Dent Assoc 2015;24(3):145-151.
Received: August 21 2015, Accepted: October 26, 2015
Anxiety is an unpleasant or overwhelming sense of apprehension and often marked by psychological signs (as sweating, tension, increase pulse).One of the major difficulties encountered by the clinician during dental care is anxiety which has been identified as a barrier to dental visits1.
Dental anxiety is defined as the response to situations in which the source of the threat to the individual is indefinable, indistinct or not immediately present. Anticipatory anxiety prior to dental procedures is commonly experienced. Dental anxiety is patient’s psychological state and response to the stressful environment of dental OPD such as dentist wearing gloves and masks, instruments, sight of needle, blood and the dental chair .It totally depends upon patient mind’s eye2.
Dental anxiety is a frequent problem among patients, it is a feeling that something terrible is going to happen in relation to dental treatment, it reflects biochemical changes in the body that result in losing control, increase heart rate and perspiration3. It is a common fear; approximately 6-15% of population suffers from high dental fear and avoidance worldwide. The onset of dental anxiety is thought to begin in the childhood, highly rise in adults and decreased with age. It is ranked fourth among common fears and ninth among intense fears3. Dental anxiety is a dilemma for the dental professionals as well because it renders treatment more difficult. Oral diseases are major health concerns and they may boost up by dental anxiety among dentally apprehensive patients4.
Dental anxiety, a problem for many adults and children, acts as a barrier to treatment, by avoiding and/or attending treatment irregularly or for visiting a dentist for emergencies only. Patient anxiety poses major management problems for the dental team, such as additional time required for treatment, missed appointments, and raised pain thresholds that’s why the management of dentally anxious patients is a major cause of stress for clinicians2,3.
A variety of factors associated with patients reporting of dental anxiety were previously reported.These include but are not limited to previous painful or traumatic dental experiences, fear of lack of control and type of personality to name a few3,4. Previous regional studies on this subject lack use of a validated questionnaire to measure the anxiety of patients in a dental setting. The objective of this study was to use Modified Dental Anxiety Scale (MDAS) and Dental Fear Survey (DFS) to quantify the fear and anxiety in a dental setting.
The cross-sectional study was conducted in Oral diagnosis department of at OJHA campus of Dow University of Health Sciencesfor a time period of 6 months. Total 100 patients were assessed. All patients of 18 years and above irrespective of gender that attended dental OPD were included in this study. The patients who were suffering from generalized anxiety disorder and who were physically disabled were excluded from the study.The sample contained two age groups which were assessed and compared. First group was (18-30 years) n=74 and second group was (>30 years) n=26.The descriptives of age and gender are presented in table no. 1.
Before oral history, examination and diagnosis, the patients were asked to self-assess their dental anxiety by answering a questionnaire containing measurements of Modified dental anxiety scale (MDAS)(appendix 1) and dental fear survey (DFS)(appendix 2)4. The questionnaire consisted of 20 questions asked in two different scales (Modified Dental Anxiety Scale and Dental Fear Survey)
Table 1: Descriptive statistics for age and gender
, began with a brief description of dental anxiety and the study purpose was to identify the factors that were intensifying /or alleviating dental anxiety. The respondents were specifically asked to what extent he or she experienced anxiety when visiting the dentist. A simplified 5-point-scale answering format was devised for each question ranging from not anxious to extremely anxious and measured in point from 1 to 5, respectively.
The survey also included questions in which respondents rated attributions for their anxiety such as feeling lack of control, perspiration, having heart beat and breathing rate faster and negative experience. Additional questions asked from the respondents to indicate what might enhance their anxiety in the dental OPD like stressful environment, smell in the dental OPD and so many people observing the respondents during their dental treatment.
Patients filled out the forms before their treatment in the waiting hall. Those patients who were uneducated and were unable to read and understand were helped by the facilitator.Data was analysed using SPSS version 19. Mean and standard deviation was calculated for quantitative variables where-as frequency and percentage was calculated for qualitative variables.
The results showed that dental anxiety level in male was 45.3% and in female was 54.64%.In younger participant i.e. (18-30 years) 79.5% and in older participants (>30years) 24.0%. Theseresults illustrate that female and the younger participants enclose high level of anxiousness than the counterpart, as shown in (Table 2).
Out of 48 male respondents 13.5% were extremely anxious, 17.6% were severely anxious, 17.6% were fairly anxious, 5.4% were slightly anxious and 10.8% were not anxious. Out of 52 female participants 28.4% were
Table 2: Incidence of dental anxiety among patients
extremely anxious, 16.2% severely anxious, 8.1% fairly anxious, 10.8% slightly anxious and 6.8% not anxious.
The highest percentage of anxiety is found with tooth pull(71.80%),however the level of anxiety get raised by the sight of injection(69.80), which is the second superior cause of anxiety. Other reasons which the dentist mostly ignores are the stressful and tensed environment of dental OPD which also rated high among respondents(63.60%). The patient also get apprehensive and maynot visit the dentist as they get influenced by the superfluous stories and bad experiences heard from their friends and relatives(62.60%). The drill i.e. the hand piece also found among the top fifth cause of anxiety, patient get panic by the sound of drill and feel more pain than the existing(60.80%).
The fear of dentist and dental treatment causes squeal of symptoms that the patient presents either during or before the procedure. In the dental fear index, most of the respondents presents with heart rate increase nearly every time during the dental treatment. Other symptoms such as nausea, aspiring foreign body, and breathlessness were less significant in our results (Graph 1).
Graph 1: Percentages of factors affecting dental anxiety in descending order
The present study confirms earlier research findings that younger persons show more dental fear than older ones and that women are more fearful than men. Study showed that female are more anxious to dental treatment than male this is because of the difference in brain chemistry of male and female, as the fright fight and flight response are more readily active in female than in male, partly as a result of action of estrogens and progesterone, female are more responsive to a particular stimulus. Another reason is that males tend to hide their fear due to their conventional gender role. One of the reasons female are more anxious about going to the dentist is due to traditional perception about ‘not going to the male dentist’ and going to the female dentist only.Secondly this study showed that showed that younger participants (18-30) scored higher dental anxiety than the older participants >30 years. The reason behind this is that the lack of experience of visiting the dentist and not knowing the procedure which is going to be performed5. Visiting a dentist is one of the rarest norms and it is routinely postponed until a serious symptom appears.According toa study, uneducated patients were dentally more anxious than the educated ones and patients who had no income and income less than ten thousand rupees were dentally more anxious than those who had higher income.Retired patients were dentally less anxious than the younger counter parts6.
The study showed highest dental anxiety was due to the fear of tooth extraction in patients attending DUHS OPD. Patients overestimate the pain they feel prior to the procedure7 as the root portion of the tooth is firmly locked in the socket so the dentist needs to expand the socket by applying optimum pressure. The anxiety during extraction occur due to the fact that the patient is unable to differentiate between pain and pressure because the local anaesthesia given only blocks the pain sensation but the nerve fibres that carry the pressure sensations are not blocked.
As far as fear of needle is concerned, similar proportion of male (49%) and female (52%) were found to be anxious. The needles are always the element of fear. Fear of needle includes fear of pain associated with injection, fear that the needle will slip, needle will break, and injection will not provide sufficient anaesthesia.
Stressful and tensed environment of the dental OPD affects patient before sitting in the dental chair.
Resultsrelated to stressful environment showed out of 48 male respondents 6.8% were extremely anxious, 14.9% severely anxious, 17.6% fairly anxious, 18.9% slightly anxious and 6.8% not anxious. Out of 52 female respondents 14.9% were extremely anxious, 24.3% severely anxious, 9.5% fairly anxious, 17.6% slightly anxious and 4.1% not anxious. The outcome of this stress would be either the patient walk away or returns back with the pessimistic observation.Patient perceive the tensed atmosphere of OPD, unfriendly behaviour of dentist, vision of unnecessary instruments, sight of blood, lack of positive relationship between dentist and patient9.
Superfluous stories heard by relatives and friends about dental treatment render people backing off visiting the dentist10.
Some people enclose painful encounters with the dental drill; thinking of the sound of the hand piece alone will make them anxious. According to our results the sound of dental drill has following perceptions. Out of 48 male participants 6.8% were extremely anxious, 10.8% severely anxious, 21.6 fairly anxious, 14.9% slightly anxious and 10.8% not anxious. Out of 52 respondents 2.7% were extremely anxious, 12.2% severely anxious, 5.4% fairly anxious, 21.6% slightly anxious and 28.4% not anxious11.
Smells are very powerful emotional triggers. This is because cells in the nose which process smell input send signals directly to the olfactory bulb, which is a part of the limbic system – an ancient part of the brain which is responsible for basic emotions like fear. Unpleasant smell in the dental office e.g. smells of eugenol, pulperyl, cresophane and others increase level of anxiety preoperatively12. Out of 48 male respondents 6.8% were extremely anxious to smell, 9.5% severely anxious, 20.3% fairly anxious, 18.9% slightly anxious and 9.5% not anxious. Out of 52 female respondents 9.5% were extremely anxious, 20.3% severely anxious, 10.8% fairly anxious, 20.3% slightly anxious and 9.5% not anxious. Many dentists do not explain the procedure which is going to perform in the patient’s mouth thus increases anxiety13. Out of 48 male respondents 4.1% were extremely anxious, 13.5% severely anxious, 25.7% fairly anxious, 18.9% slightly anxiousand 2.7% not anxious. Out of 52 female respondents 5.4% were extremely anxious, 13.5% severely anxious, 20.3% fairly anxious, 21.6% slightly anxiousand 9.5% not anxious. Other questions that are asked in this scale were aboutgoing to the dentist, sitting in the waiting room and procedure of teeth cleaning which showed least anxiety and most of the participants were not anxious14-15.
According to Dental Fear Survey out of n=48 male participants 47.9% and out of n=52 female respondents61.5% were having theirheart rate increased during dental procedure. Epinephrine used in the local anaesthesia cause sympathomimetic reactions such as apprehension, tachycardia and perspiration. Anxiety and sweating are interrelated with one another, the response that body made in danger, is a preventive response. Hyperhydrosis is common with patients having extreme anxiety. Out of n=48 male participants 50% and out of n=52 female participants 61.5% rated that they perspire during dental treatment15.
Anxiety leads to physiological and neuroendocrine changes which will affect digestive tract and one feels nauseated,out of n=48 male participants 45.8% and out of n=52 female respondents 50% reported nausea during treatment. Dental procedures involving isolation techniques such as placing rubber dam, cotton rolls, suction tips, mouth props etcmay result on unpleasant and nauseating experience.
Usually people anticipate more pain than they truly feel during the treatment which in response makes their muscle tense,breathing rate increase (hyperventilated) and become restless. Out of n=48 male participants
37.5% and out of n=52 female participants 51.9% expressed their anxiety by muscle stiffness. Out of n=48 male participants 41.6% and out of n=52 female participants
55.7% hyperventilated. Out of n=48 male participants 22.9% become restless and out of n=52 female participants 50% become restless.
The fear of dental treatment most commonly results in vasovagal syncope as quoted by many books, but according to our research the syncopal episode was minimal i.e. 8% participants from the total sample(n=100)reported faints during the treatment.But a fainting episode does not mean that he or she is anxious or feared of the dental treatment. Medical conditions such as hypotension, hypoglycaemia, cerebral ischemia, dehydration and diabetes should also be considered which may be alarming if not managed15,16.
The extent of fear that leads to cancellation of appointment was not significantly found in the study only 17% participants out of our samples reported cancelling their appointment because of fear of dentist and treatment.
Due to small sample size and limited location of the study the results cannot be generalized, but still the study may enhance the body of knowledge regarding patient’s apprehension, fear of visiting the dentist and assessed the different anxiety level in patients attending dental OPD (OJHA campus) DUHS.
Although this research assessed anxiety levels in relation to gender and age groups mainly, we recommend further studies to investigate actual causes of stress and anxiety and also develop methods to lower such untoward incidents.
Female gender, younger participants (18-30 age groups) tooth extraction were found to be related to increased level of dental anxiety.
Disclosure: None disclosed
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1.Assistant Professor Department of Science of Dental Materials Dr Ishrat-ul-Ebad Khan Institute of Oral Health Sciences, Dow University of Health Sciences.
2.House Officer DrIshrat-ul-Ebad Khan Institute of Oral Health Sciences Dow University of Health Sciences.
3.House Officer DrIshrat-ul-Ebad Khan Institute of Oral Health Sciences Dow University of Health Sciences.
Corresponding author: “Dr Khurram Parvez Sardar ” firstname.lastname@example.org