Home About us Editorial board Search Ahead of print Current issue Archives Submit article Instructions Subscribe Contacts Login 
Visit old site
Home Print this page Email this page Small font size Default font size Increase font size
Users Online: 1091


 
 Table of Contents  
ORIGINAL ARTICLE
Year : 2015  |  Volume : 7  |  Issue : 1  |  Page : 13-18

Dental anxiety among adults: An epidemiological study in South India


Department of Periodontics, Sri Ramaswamy Memorial Dental College and Hospital, Chennai, Tamil Nadu, India

Date of Web Publication27-Jan-2015

Correspondence Address:
Devapriya Appukuttan
902, 38th Street, TNHB Colony, Korattur, Chennai - 600 080, Tamil Nadu
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1947-2714.150082

Rights and Permissions
  Abstract 

Background: Dental anxiety is a major barrier for dental care utilization. Hence, identifying anxious individuals and their appropriate management becomes crucial in clinical practice. Aim: The study aims to assess dental anxiety, factors influencing dental anxiety, and anxiety towards tooth extraction procedure among patients attending a dental hospital in India. Materials and Methods: The study sample consisted of 1,148 consecutive patients aged 18-70 years. The assessment tools consisted of a consent form, history form, a questionnaire form containing the Modified Dental Anxiety Scale (MDAS) which was used to assess the level of dental anxiety, and an additional question on anxiety towards dental extraction procedure. Results: Among the study group, 63.7% were men and 36.3% were women. Based on the MDAS score, 45.2% of the participants were identified to be less anxious, 51.8% were moderately or extremely anxious, and 3% were suffering from dental phobia. Mean MDAS total score was 10.4 (standard deviation (SD) = 3.91). Female participants and younger subjects were more anxious (P < 0.001). Subjects who were anxious had postponed their dental visit (P < 0.001). Participants who had negative dental experience were more anxious (P < 0.05). Notably, 82.6% reported anxiety towards extraction procedure. Significant association was seen between anxiety towards extraction procedure and the respondents gender (P < 0.05), age (P < 0.001), education level (P < 0.05), employment status (P < 0.001), income (P < 0.001), self-perceived oral health status (P < 0.05), and their history of visit to dentist (P < 0.05). Conclusion: Significant percentage of population was suffering from dental anxiety in this study population. A plethora of factors like age, gender, education level, occupation, financial stability, and previous bad dental experience influences dental anxiety to various levels. Extraction followed by drilling of tooth and receiving local anesthetic injection provoked more anxiety.

Keywords: Dental anxiety, Extraction, Modified Dental Anxiety Scale, Self-report, Tamil population


How to cite this article:
Appukuttan D, Subramanian S, Tadepalli A, Damodaran LK. Dental anxiety among adults: An epidemiological study in South India. North Am J Med Sci 2015;7:13-8

How to cite this URL:
Appukuttan D, Subramanian S, Tadepalli A, Damodaran LK. Dental anxiety among adults: An epidemiological study in South India. North Am J Med Sci [serial online] 2015 [cited 2020 Sep 20];7:13-8. Available from: http://www.najms.org/text.asp?2015/7/1/13/150082


  Introduction Top


Oral health has a significant impact on the quality of life, appearance, and self-esteem of a person. [1] Dental anxiety affects a significant proportion of people of all ages from different social classes. It remains to be a serious concern for both the dental practitioner and the patient for the provision of routine dental care on a day-to-day basis. [2] Modified Dental Anxiety Scale (MDAS) is commonly used to measure anxiety. This was modified from the original Corah's Dental Anxiety Scale (CDAS). Advantage of the MDAS is because of its brevity, it is simple, easy to complete, and can be used as a cost-effective instrument for population-based research. [3],[4] It has been found to be reliable and valid cross culturally, and has been translated into different languages. [5],[6],[7],[8] This scale includes a series of five questions to be presented to the participants and they are asked to rate the level of anxiety they would feel if they were in a particular dental situations.

Tooth extraction is said to provoke more anxiety and is perceived as a stressful experience due to physical and psychological impact. [9] Identifying anxious individuals can enable the dentist to anticipate patient's behavior and be better equipped with measures to help alleviate patient's anxiety.

The current study aims to measure and evaluate factors influencing dental anxiety using MDAS. Due to limited availability of published data concerning anxiety for extraction procedure and its associated sociodemographic variables, we aimed to assess the same among the adult patients attending a dental hospital in Chennai.


  Materials and Methods Top


The study was conducted from March 2012 to February 2013. Approval for the study was obtained from the institutional ethical committee of SRM Dental College and Hospital, Chennai. Convenience sampling was done and 1,148 consecutive patients aged 18-70 years, attending the Outpatient Department with varied dental problems were recruited. Only subjects who were native of Tamil Nadu with Tamil as their mother tongue were requested to participate in the study. The purpose of the study was explained to each patient and both written as well as verbal informed consent were obtained from those who agreed to participate. Those who refused to give informed consent, non-natives of Tamil Nadu or immigrants, those who were undergoing psychiatric therapy, suffering from Generalized Anxiety Disorders (GAD), and completely edentulous patients were excluded from the study.

The patients were asked to fill a history form which was used to obtain information on age, gender, educational qualification (categorized as incomplete/completed school, degree/diploma, postgraduation, and uneducated), occupation (choices were employed, unemployed, student, and retired from work), income (categorized as earning less than 10,000 Indian rupees; earning between 10,001 and 20,000 Indian rupees; more than 20,000 Indian rupees; and no income), details of previous dental visit, duration since the last visit to dentist (options were within last 6 months, last 6 months-1 year, before 1-2 years, and more than 2 years back), previous dental experience, self-perceived oral health status (choices given were excellent, good, fair, and poor), and postponement of dental treatment due to dental anxiety. To assess their level of anxiety the patients were asked to complete the MDAS administered in both Tamil and English language. In addition to MDAS, a question on anxiety towards dental extraction was included in the questionnaire as follows "How anxious would you feel, if you were about to have your tooth/teeth extracted?" and the patients were asked to choose the answer from Likert scale responses such as "not anxious, slightly anxious, fairly anxious, very anxious, or extremely anxious".

Statistical analysis

Data was analyzed using IBM version 20 software. Mean total MDAS score was calculated for all the categorized variables. Independent sample t-test and one-way analysis of variance (ANOVA) was done to compare mean total MDAS score between categories in a group. Spearman rank correlation was done to assess the strength of association between MDAS and anxiety towards extraction. Chi-square test was used to evaluate the association between anxiety towards extraction and the variables.


  Results Top


Among the 1,148 respondents, 63.7% were males and 36.3% were females. Mean age of the participants was 27.9 years (standard deviation (SD) =11.27) and it was seen that majority of the respondents belonged to age group ≤30 years (71.3%). Mean total score for dental anxiety on MDAS was 10.4 (SD = 3.91). Based on the MDAS score, 45.2% of the subjects were identified to be less anxious (5-9 total score), 51.8% were moderately or extremely anxious (10-18 total score), and 3% ≥19 total score) were suffering from dental phobia [Table 1].
Table 1: Shows descriptive statistics, mean total score MDAS, and statistical test

Click here to view


Descriptive statistics and the factors influencing anxiety, with the relevant statistical test - analysis of variance (ANOVA) and t-test (post hoc ANOVA not shown in Table) and P-values are shown in [Table 1]. Female participants were more anxious than their male counterparts (P < 0.001), further it was noticed that younger subjects were more anxious (P < 0.001) and post hoc showed a significant difference in anxiety level between the samples based on their age groups (P < 0.05). Among the respondents it was seen that students, unemployed, and uneducated participants reported more anxiety towards dental treatment procedures (P < 0.001), post hoc showed a significant difference in anxiety level between those who were employed and unemployed (P < 0.05). Evaluation of economic status with anxiety level revealed that respondents who had no income or were dependent on another family member financially were more anxious than those who were financially independent, there was highly significant variance (P < 0.001) among samples based on their income and post hoc showed a significant difference in anxiety between no income group and high income group (P < 0.05). It was also seen that extremely anxious subjects had postponed their dental visit (P < 0.001). Similarly, samples that had negative dental experience were more anxious and significant difference (P < 0.05) was seen in anxiety level between those who have had previous good or bad dental experience.

The mean, standard deviation, and median of the five anxiety-provoking stimuli were evaluated on MDAS. On analysis it was observed that 49.7% of the respondents were not anxious regarding their dental visit, 49% felt that they would not be anxious while sitting in the waiting room for their appointment, 76% felt that getting their tooth drilled or receiving local anesthetic injection would make them anxious, and 11.4% felt that they would be extremely anxious if they have to receive injection in their mouth. On assessment of extraction as an anxiety-provoking stimuli, it was seen that majority of the participants, that is, 82.6% reported anxiety and among them 18.7% felt that they would be extremely anxious if they have to extract their tooth. Spearman rank correlation analysis between MDAS and anxiety towards extraction procedure showed a highly significant correlation (P < 0.001) [Table 2]. Among the stimuli assessed in this study, it was identified that extraction followed by drilling of tooth and receiving local anesthetic injection provoked more anxiety in descending order.
Table 2: Frequency distribution (percentage), mean, median, and standard deviation of the questions assessed in
the study. Correlation between anxiety towards extraction and MDAS scale


Click here to view


Chi-square analysis was done for factors influencing anxiety concerning extraction of tooth. Significant association was seen with the respondents gender (P < 0.05), age group (P < 0.001), education level (P < 0.05), employment status (P < 0.001), and income (P < 0.001). The subjects self-perceived oral health status and their visit to dentist were also significantly associated (P < 0.05) with anxiety towards extraction. Analysis showed that increased anxiety for extraction was associated with higher mean total MDAS score, variance, and post hoc was also highly significant within the groups (P < 0.001) [Table 3].
Table 3: Association between anxiety towards extraction and the variables analyzed using chi-square test

Click here to view



  Discussion Top


Findings of the present study and from different states of India like Gujarat and Haryana indicate that there is a higher prevalence of dental anxiety among the Indian population when compared with that of Western countries. [10],[11],[12] This could be attributed to multiple factors like poor oral health awareness, ignorance about dental treatment procedures, superstitious and false beliefs about dental treatment, cultural differences, and views from members of the family (highly regarded in this society, hence any unpleasant dental experience will influence others attitude towards dental therapy). It was observed that among those who participated in the study, only 3% were suffering from dental phobia which was in agreement with the other Indian studies. [11],[13],[14] Dentally phobic individuals were considerably fewer in this population in comparison with industrialized countries like UK, Turkey, and North Ireland. [4],[5],[15]

Comparison between genders to evaluate the prevalence of dental anxiety showed that female subjects were more anxious than male counterparts, plausible explanation for such observation could be attributed to the fact that women usually admit their fears readily than men, have lower tolerance to pain, and exhibit higher level of neuroticism. [10],[11],[14],[16] It was seen that younger participants were more anxious, and with increasing age there seems to be a decrease in the level of anxiety; such a trend has been reported widely from several studies, [11],[16] but refuted by Tunc et al., [5] Thomson et al., [17] and Nair et al. [14] Decline in anxiety with age could be due to age-dependent cerebral deterioration, factors like extinction or habituation, adaptive resignation towards the inevitable, increased ability to cope with experience, ageing process itself, more exposure to debilitating diseases, and treatment. [18]

Subjects who were uneducated, unemployed, and financially dependent scored high on the anxiety scale; it could be argued that educated people cope better and rationalize a situation rather than avoiding it and also lower socioeconomic conditions leads to poor physical health, more psychological problems like depression and anxiety, less access to healthcare, and hence more fear and anxiety. [10] It is hypothesized that, anxious individuals and those with past negative dental experience usually postpone their visit to dentist, similar behavior was seen among this study population; thereby, concurring with the observations of Nicolas et al., [12] Acharya, [13] and Kumar et al. [19]

Oosterink and colleagues administered a questionnaire describing 67 potentially anxiety-provoking dental stimuli and their results indicated that invasive stimuli like surgical procedures were rated as the most anxiety-provoking and noninvasive stimuli were the least anxiety provoking. [20] Similar observation by Naidu and Lalwah [21] among a sample of West Indian adults indicated that half the participants were extremely anxious for drilling of tooth, injections, and extraction. Previous unpleasant experience with injections and extractions seemed to influence the anxiety levels. [21],[22],[23]

Dubey et al., in their study reported that prevalence of tooth loss is high among adults in India and over half of the general population had experienced tooth loss with greater prevalence of tooth mortality in rural, low socioeconomic status people when compared with urban residents. [24] Observational study by George et al., [25] among adults in Chennai showed 45.5% prevalence of permanent tooth loss, in addition people belonging to lower socioeconomic status had more number of missing teeth. In developing countries like India, more patients opt for tooth removal due to multiple factors like ignorance, lower socioeconomic status, time restraints, high cost for restoration of tooth, irregular and symptomatic dental visit, and poor oral health awareness. In clinical practice, it is not uncommon to encounter patients who interrupt extraction procedure despite adequate anesthesia, hence failure to identify anxiety leads to stressful and embarrassing situation for the dentist. Liau et al., [26] in their study reported that high anxiety, younger age, and traumatic dental history were correlated with greater increase in heart rate during the administration of local dental anesthesia for tooth removal. An astounding finding was that 82.6% of the subjects in this study were anxious regarding extraction procedure, this is in agreement with the findings of Nair et al., [14] Naidu and Lalwah, [21] Liau et al., [26] and among the stimuli assessed extraction had the highest rating.

Limitations of the study are cross sectional design, convenience sampling, and self-assessment questionnaire can be biased when eliciting responses and very few anxiety-provoking stimuli were assessed in this study.


  Conclusion Top


Thus, from the current study it can be concluded that dental anxiety was highly prevalent in this population; moreover, among the five anxiety-provoking stimuli assessed it was apparent that dental extraction provoked more anxiety followed by drilling of tooth and injection of local anesthetic agent. Summarily, this research work highlights crucial findings of importance in the field of dental anxiety which could be of significance to dental practitioners and researchers, thereby enabling them to pursue better patient management strategies and policy making.

 
  References Top

1.
McGrath C, Bedi R. The association between dental anxiety and oral health-related quality of life in Britain. Community Dent Oral Epidemiol 2004;32:67-72.  Back to cited text no. 1
    
2.
Eitner S, Wichmann M, Paulsen A, Holst S. Dental anxiety: An epidemiological study on its clinical correlation and effects on oral health. J Oral Rehabil 2006;33:588-93.  Back to cited text no. 2
    
3.
Corah NL. Development of a dental anxiety scales. J Dent Res 1969;48:596.  Back to cited text no. 3
    
4.
Humphris GM, Morrison T, Lindsay SJ. The Modified Dental Anxiety Scale: Validation and United Kingdom norms. Community Dent Health 1995;12:143-50.  Back to cited text no. 4
    
5.
Tunc EP, Firat D, Onur OD, Sar V. Reliability and validity of the Modified Dental Anxiety Scale (MDAS) in a Turkish population. Community Dent Oral Epidemiol 2005;33:357-62.  Back to cited text no. 5
    
6.
Appukuttan D, Datchnamurthy M, Deborah SP, Hirudayaraj GJ, Tadepalli A, Victor DJ. Reliability and validity of the Tamil version of Modified Dental Anxiety Scale. J Oral Sci 2012;54:313-20.  Back to cited text no. 6
    
7.
Coolidge T, Arapostathis KN, Emmanouil D, Dabarakis N, Patrikiou A, Economides N, et al. Psychometric properties of Greek versions of the Modified Corah Dental Anxiety Scale (MDAS) and the Dental Fear Survey (DFS). BMC Oral Health 2008;8:29.  Back to cited text no. 7
    
8.
Yuan S, Freeman R, Lahti S, Lloyd-Williams F, Humphris G. Some psychometric properties of the Chinese version of the Modified Dental Anxiety Scale with cross validation. Health Qual Life Outcomes 2008;6:22.  Back to cited text no. 8
    
9.
Rodriguez Vazquez LM, Rubinos Lopez E, Varela Centelles A, Blanco Otero AI, Varela Otero F, Varela Centelles P. Stress amongst primary dental care patients. Med Oral Patol Oral Cir Bucal 2008;13:E253-6.  Back to cited text no. 9
    
10.
Malvania EA, Ajitkrishnan CG. Prevalence and socio demographic correlates of dental anxiety among group of adult patients attending a dental institution in Vadodara city, Gujarat, India. Indian J Dent Res 2011;22:179-80.  Back to cited text no. 10
[PUBMED]  Medknow Journal  
11.
Marya CM, Grover S, Jnaneshwar A, Pruthi N. Dental anxiety among patients visiting a dental institute in Faridabad, India. West Indian Med J 2012;61:187-90.  Back to cited text no. 11
    
12.
Nicolas E, Collado V, Faulks D, Bullier B, Hennequin M. A national cross-sectional survey of dental anxiety in the French adult population. BMC Oral Health 2007;7:12.  Back to cited text no. 12
    
13.
Acharya S. Factors affecting dental anxiety and beliefs in an Indian population. J Oral Rehabil 2008;35:259-67.  Back to cited text no. 13
    
14.
Nair MA, Shankarapillai R, Chouhan V. The dental anxiety levels associated with surgical extraction of tooth. Int J Dent Clin 2009;1:20-3.  Back to cited text no. 14
    
15.
Humphris G, Freeman R, Campbell J, Tuutti H, D'Souza V. Further evidence for the reliability and validity of the Modified Dental Anxiety Scale. Int Dent J 2000;50:370-6.  Back to cited text no. 15
    
16.
Sanikop S, Agrawal P, Patil S. Relationship between dental anxiety and pain perception during scaling. J Oral Sci 2011;53:341-8.  Back to cited text no. 16
    
17.
Thomson WM, Locker D, Poulton R. Incidence of dental anxiety in young adults in relation to dental treatment experience. Community Dent Oral Epidemiol 2000;28:289-94.  Back to cited text no. 17
    
18.
Locker D, Liddell AM. Correlates of dental anxiety among older adults. J Dent Res 1991;70:198-203.  Back to cited text no. 18
    
19.
Kumar S, Bhargav P, Patel A, Bhati M, Balasubramaniyam G, Duraiswamy P, et al. Does Dental anxiety influence oral health related quality of life? Observations from a cross sectional study among adults in Udaipur district, India. J Oral Sci 2009;51:245-54.  Back to cited text no. 19
    
20.
Oosterink FM, de Jongh A, Aartman IH. What are people afraid of during dental treatment? Anxiety-provoking capacity of 67 stimuli characteristic of the dental setting. Eur J Oral Sci 2008;116:44-51.  Back to cited text no. 20
    
21.
Naidu RS, Lalwah S. Dental anxiety in a sample of West Indian adults. West Indian Med J 2010;59:569-72.  Back to cited text no. 21
    
22.
Brukiene V, Aleksejuniene J, Balciuniene I. Is dental treatment experience related to dental anxiety? A cross-sectional study in Lithuanian adolescents. Stomatologija 2006;8:108-15.  Back to cited text no. 22
    
23.
Ekanayake L, Dharmawardena D. Dental anxiety in patients seeking care at the university dental hospital in Sri Lanka. Community Dent Health 2003;20:112-6.  Back to cited text no. 23
    
24.
Dubey RK, Gupta DK, Shetty P. Current status of edentulousness in India: Systematic review. Chhattisgarh J Health Sci 2013;1:72-6.  Back to cited text no. 24
    
25.
George B, John J, Saravanan S, Arumugham IM. Prevalence of permanent tooth loss among children and adults in a suburban area of Chennai. Indian J Dent Res 2011;22:364.  Back to cited text no. 25
[PUBMED]  Medknow Journal  
26.
Liau FL, Kok SH, Lee JJ, Kuo RC, Hwang CR, Yang PJ, et al. Cardiovascular influence of dental anxiety during local anesthesia for tooth extraction. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2008;105:16-26.  Back to cited text no. 26
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3]


This article has been cited by
1 Dental anxiety and the effectiveness of local anesthesia
Hadi Esmaeili,Mohammad Malekzadeh,Davood Esmaeili,Farid Nikeghbal
Brazilian Journal of Oral Sciences. 2020; 19: e208127
[Pubmed] | [DOI]
2 Effect of Recreational Intervention on the Approach of Pediatric Patients in Dental Treatment: Analysis of Salivary Cortisol
Rúbia Zen,Lilian Rigo,Emanuela Gaviolli,Luiza Paloma S. Girotto,Debora N. Mário
Pesquisa Brasileira em Odontopediatria e Clínica Integrada. 2020; 20
[Pubmed] | [DOI]
3 Dental Phobia among Pregnant Women: Considerations for Healthcare Professionals
Muhammad Nazir,Muhanad Alhareky
International Journal of Dentistry. 2020; 2020: 1
[Pubmed] | [DOI]
4 Dental anxiety at Riyadh Elm University Clinics
AshrafM. F. Kamel,AhmadS Al-Harbi,FahadM Al-Otaibi,FahadA Al-Qahtani,AbdullahM Al-Garni
Saudi Journal of Oral Sciences. 2019; 6(2): 101
[Pubmed] | [DOI]
5 Comprehensive and esthetic rehabilitation for phobic patient “case report”
Razan Fahad AlEidan,Majed AlGhamdi
The Saudi Dental Journal. 2019;
[Pubmed] | [DOI]
6 Comparative assessment of dental anxiety among dental and pharmacy students in Paonta Sahib, Himachal Pradesh
Sumeet Bhatt,Ambika Gaur
Journal of Indian Association of Public Health Dentistry. 2019; 17(3): 230
[Pubmed] | [DOI]
7 Dental health status and oral health behaviours of patients with facial burn in Pakistan
Farooq Ahmad Chaudhary,Basaruddin Ahmad,Ulfat Bashir
BMC Oral Health. 2019; 19(1)
[Pubmed] | [DOI]
8 A cross-sectional study to assess the level of dental anxiety prevailing in undergraduate dental students in Riyadh Elm University
UmbreenNoor Muhammad,JulieSusan Rajan
Saudi Journal of Oral Sciences. 2019; 0(0): 0
[Pubmed] | [DOI]
9 The prevalence of dental anxiety and its association with pain and other variables among adult patients with irreversible pulpitis
Lei Dou,Margaret Maria Vanschaayk,Yan Zhang,Xiaoming Fu,Ping Ji,Deqin Yang
BMC Oral Health. 2018; 18(1)
[Pubmed] | [DOI]
10 Cross-Cultural adaption, validity and reliability of a Hindi versionof the Corah’s Dental Anxiety Scale
Meena Jain,Shourya Tandon,Ankur Sharma,Vishal Jain,Nisha Rani Yadav
Health Promotion Perspectives. 2018; 8(2): 120
[Pubmed] | [DOI]
11 Factors associated with dental anxiety in Brazilian children during the first transitional period of the mixed dentition
K. A. Barreto,L. D. K. T. Dos Prazeres,D. S. M. Lima,F. C. Soares,R. M. M. P. Redivivo,C. da Franca,V. Colares
European Archives of Paediatric Dentistry. 2017; 18(1): 39
[Pubmed] | [DOI]
12 A randomized control trial comparing the visual and verbal communication methods for reducing fear and anxiety during tooth extraction
Giath Gazal,Ahmed W Tola,Wamiq M. Fareed,Ahmad A. Alnazzawi,Muhammad S. Zafar
The Saudi Dental Journal. 2016;
[Pubmed] | [DOI]
13 Factors determining tooth extraction anxiety and fear in adult dental patients: a systematic review
I. Astramskaite,L. Poškevicius,G. Juodžbalys
International Journal of Oral and Maxillofacial Surgery. 2016;
[Pubmed] | [DOI]
14 Dental anxiety in patients with borderline intellectual functioning and patients with intellectual disabilities
Antonio Fallea,Rosa Zuccarello,Francesco Calì
BMC Oral Health. 2016; 16(1)
[Pubmed] | [DOI]
15 Changes induced by music therapy to physiologic parameters in patients with dental anxiety
Cynthia Mejía-Rubalcava,Jorge Alanís-Tavira,Hugo Mendieta-Zerón,Leonor Sánchez-Pérez
Complementary Therapies in Clinical Practice. 2015; 21(4): 282
[Pubmed] | [DOI]



 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
Abstract
Introduction
Materials and Me...
Results
Discussion
Conclusion
References
Article Tables

 Article Access Statistics
    Viewed2549    
    Printed62    
    Emailed2    
    PDF Downloaded545    
    Comments [Add]    
    Cited by others 15    

Recommend this journal