Predicting Anxiety Among Patients in LPU Clinical Dispensary

Predicting Anxiety Among Patients In LPU Clinical Dispensary During Dental Treatment: Towards Student’s Clinical

Performance Enhancement

By: Maribel D. Mayuga-Barrion, D.D.M., M.A.T.

Dental anxiety is very common in dental procedures. Anxiety can come

from many different sources. Most of the time, patients become anxious during

tooth extraction and other dental procedures that needs needle injection of

anesthetic solution. Patients also differ in degree of anxiety.

Reasons for anxiety are as different as people, but some are more

common than others. The most common sources is a past bad experience. This

is most often from childhood experiences before modern anesthesia and

techniques. Another source is phobias of the sights and sounds of the dental

office. Many patients do not like the sounds of drills but unfortunately, they are a

necessity. Some patients are simply afraid of needles, and this is very

understandable.

One of the primary reasons that most people avoid visiting the dentist and

seeking dental care, is dental anxiety. Whether this stems from a previous bad

experience, the media, or friends who have told them horror stories, the result is

that they neglect to maintain their dental health by avoiding visits to the dentist,

and in turn create more problems.

As we know, the key factor for good oral hygiene is prevention – stopping

problems before they arise. Unfortunately, phobic patients who suffer from

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severe anxiety do not visit the dentist for regular care. This results in more

complex problems.(www.floss.com)

Like reasons for anxiety, degrees also differ from person to person. Some

folks are simply a bit nervous anytime they walk into a dental office. They can

have slightly elevated blood pressures once they pull into the parking lot which

goes down as fast as they exit the front door.(Eddelmen, 2012)

Other patients get uncomfortable when they see a needle or hear the drill.

Many patients are nervous about the anesthetics. Some patients can be so

uncomfortable that they have an increased risk for stroke or heart attack due to

the spike in blood pressure that anxiety can produce. Many of these patients

avoid dental work altogether which only worsens their problems later

Other patients, with severe dental fear, cannot sit still when the dentist is

working which endangers them due to the instruments in close proximity to the

face/eyes/mouth. This also makes work extremely difficult for the dentist not

allowing him to do a good job.

According to Dr. Neipris, (2010), it's common to feel some anxiety about

going to the dentist. A phobia is a much stronger feeling. People with dental

phobia are terrified of seeing a dentist. They may never see a dentist, even when

they are suffering from bleeding gums or a broken tooth. What's more, there is no

clear boundary between dental anxiety and a phobia.

You may have dental anxiety or phobia if: the thought of going to the

dentist makes you ill, you have trouble sleeping the night before a dental visit,

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you feel like crying when you have to see a dentist, you panic when objects are

placed in your mouth during a dental exam.

Bad experiences, usually reaching back to childhood, are a major source

of dental anxiety. Keep in mind, though, that dental care has improved

dramatically over the last 20 years. Pain-free treatments and techniques other

than drilling are commonplace today.

Sitting in the dental chair - just like flying in an airplane - is a situation

where you have little control over what is going to happen. It's common to

be anxious about that.

If you haven't seen a dentist in a while, you may be embarrassed about

the appearance of your teeth. You may become self-conscious and insecure and

you may avoid smiling. In extreme cases, a person's personal and professional

lives may start to suffer. (Neipris, 2010).

It is very important to have a dentist who understands your fears, takes

them seriously, and works with you to overcome them.

If you fear pain, ask for a topical anesthetic to minimize the discomfort of

cleanings and minor gum treatments. A local anesthetic numbs your mouth

completely for a few hours and blocks out all pain.

If the sound of the dentist's tools bothers you, bring a music player with

you to the appointment and wear headphones. Music also helps in different

relaxation techniques. Guided imagery can take your mind off the things going on

around you. Imagine yourself in a pleasant place. For example, imagine the feel

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of the gentle breeze on your face and the sound of ocean waves breaking

against the shore.

Most importantly, get regular checkups. You'll become familiar with the

dentist and you'll be able to catch problems early, before they become major.

Little is known about the anxiety of patients experience before attending

for dental treatment. The aim of this study is to determine, in dentally phobic

patients.

Self-reported dental fear measures seldom are used in clinical practice to

assess patients’ fears. This examined how well dental fear measures predicted

anxious behaviors displayed during dental treatment.

One of the most prevalent fears is the fear of dentistry. According to the

Diagnostic and statistical manual of mental disorders (DSM-IV), severe dental

anxiety should be considered a specific phobia. This is defined as a clinically

significant anxiety provoked by exposure to a specific feared object or situation,

often leading to avoidance behavior and/or significantly interfering with the

person’s normal routines, occupational functioning, social activities or

relationships (DSM-IV, 1994). Thus, dental fear is a widespread problem, which

can have significant impact on the individual’s health and daily life. It has been

suggested that dental anxiety creates its own vicious circle in which the phobic

patients’ inability to accept dental treatment leads to a real or perceived

deterioration of oral health, which in each turn can create feelings of shame, guilt

and inferiority, subsequently reinforcing fear and anxiety (Berggren, 1994).

Moore et al. (1991) proposed that feelings of powerlessness and embarrassment

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in the dental situation were important social determinants in the acquisition and

maintenance of dental anxiety. They referred to the “vicious circle” suggesting

that with the passing time of avoidance, social conflicts reinforce anxiety and

result in further avoidance of dental care. In addition, it has been proposed that

the social factors appear to contribute strongly to the maintenance of dental fear ,

especially in long-term avoiders (Berggren, 1994). Berggren found that a majority

of dental phobic patients felt that they had to curtail their social relations, and

many reported widespread negative social life effects. This included family

relations and perceived social support and provides further support to the vicious

circle (Berggren, 1993).

With the aforementioned, the researcher believes that dental anxiety

causes patients to refuse dental treatments that lead to deterioration of their oral

health. Student clinicians had difficulties in handling anxious patients. Thus, the

researcher had an idea of conducting this research to investigate the patient’s

anxiety during dental treatments so that it can help the student clinicians to

improve their clinical practice and to render dental services to patients without

anxiety.

Furthermore, the researcher believed that this study will have significant to

the patients, clinicians and clinical instructors by providing an insight in

increasing the emphasis of anxiety management in health education. On the

other hand, student clinicians would have more insights on how to be more

responsible for the anxiety their patients experience and would have better

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understanding on the role of anxiety management to enhance their clinical

performance.

Objectives of the Study

In this study, the researcher was anchored by the following objectives: 1)

to determine the respondents’ profile in terms of age, gender, frequency of

dental visit, and type of patient whether dental phobic or not; 2) to determine the

dental anxiety of patients in LPU dental dispensary; 3) to identify the causes and

severity of anxiety of the patients in LPU dental dispensary; 4) to determine if

there is a significant difference between the respondents’ demographic profile

and their level of anxiety; and lastly, 5) to propose a program that will help the

patients cope with dental anxiety and a program that will enhance the students’

clinical performance.

Conceptual Framework

Figure 1

Profile of the Patients

- Age - Gender - Frequency of

Dental Visit - Type of Patient

Anxiety -Level

- Causes -Severity

Proposed Action

Plan

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Dental anxiety is a multidimensional complex phenomenon, and no one

single variable can exclusively account for its development. A number of factors

that have consistently been linked with a greater incidence of dental anxiety,

including: personality characteristics, fear of pain, past traumatic experiences

particularly in childhood, blood-injury fears and the influence of dentally anxious

family members or peers which elicit fear in a person.

Fear of pain has been linked strongly to the development of dental anxiety

and to avoidance of dental treatment. Highly anxious patients tended to

overestimate the pain experienced when asked to recall it.

The restorative dentistry procedures deliver the most potent triggers for

dental anxiety, namely, the sight, sound and vibrational sensation of rotary dental

drills, coupled with the sight and sensation of a dental local anesthetic injection.

It is for this reason that anxious patients who must undergo restorative

procedures are often managed using the “4S” rule (sight, sound, sensations, and

smell), which aims to reduce the triggers of stress. A patient’s expectation of

experiencing pain, being hurt, and choking or gagging during treatment can also

act as a major trigger for dental anxiety.

It is also important to recognize other factors which can trigger anxiety or

increase it. Aspects of dentist-patient interactions are particularly important.

These include statements made by the operator, in particular when they are

angry or if they make comments. Furthermore, dentally anxious patients have

complained that dentists made them feel guilty for being anxious.

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The period of time spent waiting for dental treatment is cited commonly by

patients as being anxiety-provoking, as it increases the time to think about what

will happen, and to ponder the worst-case outcomes. This emphasizes the need

for support staff in the dental practice to be aware of an anxious patient and to

actively take measures to reduce their concerns.

Literature Review

In the field of dentistry, knowledge and technical skills are not the only

prerequisites for good practice. An ability to communicate effectively with patient-

in particular, to use active listening skills, to gather and impart information

effectively, to handle patient emotions sensitively, and to demonstrate sympathy,

rapport, ethical awareness, and professionalism—is crucial. Among the benefits

noted when dentists/clinicians demonstrate effective communication skills are

increased patient satisfaction, improved patient adherence to dental

recommendations, decreased patient anxiety, and lower rates of formal

complaints and malpractice claims. (Hannah, et. al 2004)

Dental Anxiety or Dental Fear

Dental fear refers to the fear of dentistry and of receiving dental care. A

severe form of this fear (specific phobia) is variously called dental phobia,

odontophobia, dentophobia, dentist phobia, or dental anxiety. However, it has

been suggested not to use the term "dental phobia" for people who do not feel

their fears to be excessive or unreasonable and resemble individuals with post-

http://en.wikipedia.org/wiki/Fear

http://en.wikipedia.org/wiki/Dentistry

http://en.wikipedia.org/wiki/Dental_care

http://en.wikipedia.org/wiki/Specific_phobia

http://en.wikipedia.org/wiki/Post-traumatic_stress_disorder

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traumatic stress disorder, caused by previous traumatic dental experiences.

(Bracha, et. Al, 2006)

Dental anxiety is common and affects people of all ages. There are

different levels of dental anxiety, ranging from slight nervousness to a severe

phobia (an out-of-proportion fear that makes you steer clear of certain situations).

Being nervous about going to the dentist affects people in different ways.

Some people are anxious about specific aspects of dental treatment. Others may

dislike being in close contact with someone they don't know very well. Many

people had unpleasant experiences as a child and are frightened that these will

be repeated. However, nervous or fearful one is when having dental treatment,

there are a number of things one can do to help you overcome your anxiety.

There are also different levels of dental anxiety, ranging from slight

nervousness to a severe phobia (an out-of-proportion fear that makes you avoid

a certain situation). However anxious one may be, it's likely there will be ways of

dealing with the problem one step at a time.

The first step is to get in touch with one’s dentist and talk about his/her

anxiety. It is important to remember that he or she will understand if the patient is

anxious about having treatment.

One way of finding a supportive dentist is by word of mouth. One may be

able to get a recommendation from friends or family. Or one could make some

phone calls to find out which dentists in your area specialize in treating people

with anxiety. When one call, be open about one’s worries so that the staff can

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arrange the support he/she needs. One may be able to book an appointment with

his/her dentist just to discuss all the worries he/she has.

According to Rocha (2010), one of the difficulties encountered by the

clinician during dental care is the fear that some patients express with respect

to procedures which will take place during their visit. Coming to their dental

appointments may represent a major problem for these patients.

Fear is a primary and powerful emotion which alerts us about imminent

danger, with respect to an object or situation. When danger is recognized, the

individual reacts with a set of behavioral and neurovegetative responses which

are accompanied by a disagreeable sensation.

When danger is not evident, but presents itself in a vague and persistent

manner, or when signs of imminent danger are not consciously perceived, it is

denominated a state of apprehension, in which the existence of anxiety may be

verified. It is not consciously controlled, that is, people do not have the capacity

to interrupt it. Anxiety also aggravates psychological suffering caused by pain.

Childhood is the critical period for the development of anxiety.

Approximately one fourth of the adult American population regularly avoids

dental treatment due to traumatic experiences which occurred during this period.

(Anderson, 1997). People who suffer from intense dental fear are known to be

more difficult patients among dentists and dental students. (Kaakko, et. Al, 1999)

Almost 7% of the general population state they suffer from intense fear of

dentistry, while another 13% state they feel some degree of fear. In Brazil, there

is a 15% prevalence of dental anxiety. (Rocha, 2010)

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While assessing a short version of the Dental Anxiety Inventory,

Aartman(1998) found that highly anxious dental patients were most anxious

about tooth extraction, followed by drilling.

Rosa & Ferreira, (1997) also stated there was an association between fear

and poor oral health. This could be the result of less frequent attendance to

dental services by patients who fear treatment.

Usually, patients who suffer from dental anxiety wait longer periods of time

before scheduling an appointment and often cancel it. Among the major reasons

given for avoiding dental visits are costs (75.4%) and fear (36.9%) of treatment.

Twenty-three percent of the people who did not regularly attend dental services,

stated that fear was the reason for non-attendance. (Haugejorden, et. Al, 2000)

According to Milgrom et al (1998), patients under forty years old may be

1.5 times more anxious than those over forty. Another finding mentioned in the

literature is that women tend to report higher levels of anxiety than men.(Liddel,

1997)

In emergency dental services, both in private and in dental school clinics,

the reason for attendance is, in the majority of cases, a complaint of pain.

Clinical practice suggests that levels of anxiety and fear among emergency

patients coming to a clinic are greater than in the general population.

Since a delay in seeking care may be due to dental anxiety or fear, this

study proposed to assess the frequency of anxious patients attending a dentistry

school’s emergency clinic, associating anxiety to the undertaken procedure,

time elapsed since the last visit to the dentist, time since the symptoms

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appeared, previous history of trauma and socio-economic characteristics of the

sample. (Haugejorden, et. Al, 2000)

Persons with special health care needs due to physical and cognitive

impairment can be at increased risk for dental disease which can be attributed

to, as well as exacerbate, existing medical conditions. This study assessed the

nature of perceived barriers to obtaining oral health care among a special-needs

population and the influence of these factors (in particular, fear and anxiety) on

utilization of dental services. A total of 27.9% of the sample reported fear/anxiety

about dental visits, with approximately half of those reporting to be very nervous

or “terrified”. There was an inverse relationship between the frequency of dental

visits and the proportion of respondents reporting themselves as very nervous or

terrified, and between the perception of oral health status and the level of dental

fear/anxiety (P < 0.001). A large difference was reported between patient

preference for pharmacologic modalities for anxiety control and those received

at dental visits, with 40% of the youngest age group indicating that they would

go to the dentist more frequently if sedation or general anesthesia were offered.

The levels of self-reported fear/anxiety and the high proportion of respondents

indicating an unmet need for adjunctive anesthesia services suggest that

fear/anxiety acts as a barrier to dental care among this special-needs group

which could be ameliorated with greater use of these services. (Dionne, et. Al,

2008)

The 1998 Adult Dental Health Survey (Kelly et al., 1998) found that 64% of

respondents were nervous about some form of dental treatment, and 49% were

http://jdr.sagepub.com/content/89/3/302.full#ref-13

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anxious about simply going to the dentist. This fear can then lead to avoidance of

dental treatment (Mellor, 1992), dental neglect (Hakeberg et al., 1993), and a

reduced general quality of life (Locker, 2003; McGrath and Bedi,

2004; Mehrstedt et al., 2004). Eventually, dental neglect can lead to pain, when

many patients seek treatment. This is often undertaken at a referral hospital

under conscious sedation.

Conscious sedation is a technique used to reduce anxiety while

undertaking dental treatment. However, little is known about the patient’s anxiety

in the period before attending for treatment under sedation. A study of Cohen,

et.al, (2000) discusses the impact of dental anxiety on quality of life in the days

leading up to treatment; however, due to the fact that the data are qualitative, the

frequency or severity of these quality-of-life effects is not reported. More

objective research is required to assess anxiety and quality of life in anxious

dental patients.

When fears arise that are considered out of proportion to the demands of

the situation, cannot be explained or reasoned away, are beyond voluntary

control, and lead to avoidance of the feared situation, then a phobia is said to

exist (Marks, 1969). The aims of this study were to determine, in phobic dental

patients scheduled to undergo dental treatment under conscious sedation, (a) the

temporal relationship of experienced anxiety levels in the days prior to the dental

procedure, and (b) the level of disruption to daily life activities

Little is known about the anxiety patients experience before attending for

dental treatment. The aim of this study was to determine, in dentally phobic








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patients, the temporal relationship of pre-operative anxiety levels, and the

disruption to daily life caused by this. Twenty-four phobic and 19 comparison

(non-phobic) dental patients were recruited. Four validated questionnaires were

used to assess anxiety and quality of life, which each patient completed for 5

days prior to, and on the day of, treatment. Those in the experimental group were

found to have significantly greater levels of dental and general anxiety, and a

significantly lower quality of life compared with those in the comparison group.

Significant temporal relationships were found with all of the questionnaires.

Dental and general anxiety scores were significantly correlated with quality-of-life

measures. This study suggests that phobic dental patients are experiencing

significant increased anxiety, and significant negative quality-of-life effects, in this

period.

Phobic dental patients are experiencing significant increased anxiety, and

significant negative quality-of-life effects, before attending for dental treatment.

It is estimated that as many as 75% of US adults experience some degree

of dental fear, from mild to severe. Approximately 5 to 10 percent of U.S. adults

are considered to experience dental phobia; that is, they are so fearful of

receiving dental treatment that they avoid dental care at all costs. Many dentally

fearful people will only seek dental care when they have a dental emergency,

such as a toothache or dental abscess. People who are very fearful of dental

care often experience a “cycle of avoidance,” in which they avoid dental care due

to fear until they experience a dental emergency requiring invasive treatment,

which can reinforce their fear of dentistry. (Armfield, JM, et.al 2007)

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Women tend to report more dental fears than men, and younger people

tend to report being more dentally fearful than older individuals. People tend to

report being more fearful of more invasive procedures, such as oral surgery, than

they are of less invasive treatment, such as professional dental cleanings,

or prophylaxis. (Stabholz, et.al 1999)

Dental phobia is the serious, often paralyzing fear of seeking dental care.

It has been reliably reported that 50% of the American population does not seek

regular dental care. An estimated 9-15% of all Americans avoid much needed

care due to anxiety and fear surrounding the dental experience.

In terms of your dental health and overall well-being, this can have serious

ramifications. Besides chronically infected gums and teeth which can affect your

medical status, your ability to chew and digest can be seriously compromised.

Without healthy gums and teeth, your speech can be affected as well. Your self

confidence can be compromised if you are insecure about your breath and smile.

This can lead to serious limitations in both your social and business

environments. (Nicholas, et. al., 2008)

Causes of Dental Anxiety

It has been found that there are two main causes of dental fear in patients:

Direct Experiences and Indirect Experiences.

Direct experience is the most common way people develop dental fears.

We’ve found that a majority of people report that their dental fear began after a

traumatic, difficult, or painful dental experience. These reasons of course are not

the only explanations of dental anxiety. Another contributing factor is simply the

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perceived manner of the dentists as “impersonal”, “uncaring”, “Uninterested” or

“cold” whereas dentists who are perceived as warm and caring actually

counterbalance the fear caused by painful procedures.

Indirect experience can include vicarious learning, mass media, stimulus

generalization, helplessness and perceived lack of control. Through vicarious

learning one may develop an anxiety simply by hearing of other peoples painful

and traumatic experiences at their dentist’s office. Mass media has negative

portrayal of dentistry in television shows and children’s cartoons. (Dental Fear

Central, 2007)

Stimulus generalization is another indirect experience causing a patient to

develop a fear as a result of a previous traumatic experience in a non-dental

context. A major contributor of stimulus generalization is a patient’s traumatic

experience at hospitals or general practice doctors that wear white coats and

have antiseptic smells throughout their practices. A way that a lot of dental

practicioners have been combating this perception is by wearing clothing that

isn’t so “lab coatish”.

Helplessness and perceived lack of control occurs when a person believes

that they have no means of influencing a negative event. Research has shown

that a perception of lack of control leads to fear whereas a perception of having

control lessens fear greatly. For example, a dentist that tells a patient to raise

their hand during a procedure to signal pain so that the dentist or hygienist can

stop during the procedure will generate a much less fearful and anxious patient

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thus creating a more pleasant general experience influencing the patient to

continue to come back for additional treatment.

Dental phobias and anxiety stem from various sources. These can lead to

a strongly conditioned fear response. The following are the most common origins

of dental fear:

1. Previously painful or negative experiences during visits to a

dentist’s office. This can even include careless comments made by a dentist or

hygienist during a past examination.

2. A severe discomfort with feeling helpless and/or out of control in the

dental situation.

3. A sense of embarrassment of your dental neglect and fear of

ridicule and/ or belittlement when you present to the dental office.

4. Scary anecdotes of negative dental experiences learned vicariously

from family and friends.

5. Negative, menacing portrayals of dentists in movies, TV,

newspapers and magazines.

6. A sense of depersonalization in the dental process, intensified by

today’s necessity for the use of barrier precautions, such as masks, latex gloves

and shields.

7. A general fear of the unknown.

The first thing you can do is to realize that your dental fear can be overcome.

Fear is a learned behavior which, therefore, can be unlearned. Patient-centered

behavior modification that treats you as a whole person, not as a set of teeth can

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help you overcome your fears. This will obviously take a team approach between

you and your dentist and his/her staff. Communication is the key. You must feel

comfortable expressing your fears and concerns and have a sense that you are

being listened to. If you feel that the Dr. and/or staff is not genuinely concerned

and listening, then absolutely feel comfortable with seeking out referrals to other

offices.

Specific questions that explore the main categories of dental anxiety will

provide a wealth of information to both the dentist and the often the patient that

will facilitate treatment. The main categories of dental anxiety include: specific

anxieties, generalized reactions, mistrust and catastrophe.

Specific anxieties related to dentistry include questioning about the

individual components that cause anxiety. Needles are often a specific concern

for anxious patients. Problems with needles can include the inability to accept a

dental injection (needle phobia); fainting when a needle is used (Blood Injury

Injection phobia); fear of the needle including fear of pain associated with the

injection; fear that the needle will slip or move or break; fear that the needle will

not provide sufficient anaesthesia and there will be pain. Other specific fears

include fear of the drill. This includes fear of the noise, vibration or pain

associated with the drill if there is insufficient local anaesthetic. Insufficient local

anaesthetic resulting in pain during dental treatment is a common fear. Often the

patient has experienced pain during dental treatment. They have either not

informed the dentist or have informed the dentist and been told that they have

had sufficient local anaesthetic and treatment has continued despite their pain. It

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is common that with additional local anaesthetic or additional time following the

administration of local anaesthetic that profound anaesthesia can be obtained

eliminating pain during treatment. (Buchanan, et. al, 2007)

Generalized anxiety assessment begins by asking about sleep

disturbances the night before a dental appointment. This gives a better indication

of the level of anxiety associated with dental treatment. An assessment of the

body’s reactions to dental anxiety that a person experiences while in the dental

chair provides additional information about the extent of dental anxiety. Body

reactions can include pounding heart, sweaty palms, shaking, butterflies in the

stomach and nausea. Treatment can be tailored to address these specific

reactions.

Mistrust is a different faucet of dental anxiety that also needs to be

explored. Sometimes a patient has been inappropriately spoken to by a dentist,

hygienist or other member of staff. Remarks about a patient’s dental condition or

at home dental care or simply a condescending attitude can make a patient feel

embarrassed or ashamed. Additionally, if there have been problems during

dental treatment such as pain, unexpected changes to the dental treatment

required, or errors or omissions on the dentists behalf can make a patient very

wary of future dental treatment.

Catastrophising is a type of thought process that can undermine a

patient’s ability to accept dental treatment. Thoughts or beliefs that involve

catastrophic events can paralyze a dental patient. For example some patients

hold the belief that they may have a heart attack during dental treatment or may

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suffer a serious allergic reaction, be unable to breath or may die as a result of

dental treatment.

The discussion of these different categories of dental treatment usually

identifies the specifics of the patient’s dental anxiety. Anxiety may involve only

one category of dental anxiety or may involve elements of a number or all of the

categories of dental anxiety. Once the specifics of dental anxiety have been

identified specific tools and pathways are used to address the anxiety. (Levitt,

2012)

Severity of Dental Anxiety

Many people have a high level of anxiety and avoid visiting the dentist.

This can cause future dental problems. It is important to note, however, that

many new, wonderful products and procedures are available that can make the

dental visit a pleasant experience. (www.floss.com)

According to a recent study in the British Dental Journal (2011), dental

phobia is initiated by a bad experience that unknowingly has become associated

with dentistry.

The study has found that despite the advancement of modern techniques

and the use of very effective anesthetics, patients still seem to maintain the same

level of anxiety as they did years ago. The proportion was shown to be the same

today as it was in the 1930′s,

Dr. Freeman of Queens University Dental School in Belfast (2012), wrote

the article and explains that if all dental phobia were related to painful

experiences from a patient’s life, the condition should have gotten better over the

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years because of all the advanced techniques available today. This however is

not the case and it suggests that dental phobia is brought on by outside

experiences which are then related to dental experiences.

There are some techniques for relaxation that a dentist can put into

practice for people with such trauma. Patients may be given sedation and be

informed about pain control and they may be given the advantage of being able

to control their own pain by stopping and starting treatment using hand signals.

Evidence exists regarding the use of dental-specific anxiety measures as

valuable clinical tools. Moore and colleagues found good reliability and validity for

a number of dental anxiety measures when used with a sample of highly anxious

subjects. Dailey and colleagues reported a significantly greater decrease in post

treatment anxiety for patients whose dentists knew their pretreatment dental

anxiety scores in comparison with subjects whose dentists did not know their

scores. Consequently, self-reported dental anxiety measures can provide

valuable information to clinicians interested in evaluating and reducing their

patients’ anxiety levels.

The use of formal dental anxiety measures in general clinical practice,

however, is limited. A survey of British dentists who identified themselves as

specifically treating anxious people revealed that only 20 percent of the sample

used dental anxiety assessments with their adult patients; fewer than 17 percent

used them with pediatric patients. In a PubMed search of the literature, we found

no comparable studies of providers in the United States. The authors who

surveyed the British dentists speculated that dentists may worry that rapport with

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patients could suffer by focusing on previous negative dental experiences. In

addition, practitioners may avoid the use of such measures owing to perceived

time constraints for patients within the clinical practice, lack of familiarity with the

measures, or an assumed burden regarding scoring and interpreting the results

of complicated formal measures. Thus, the use of dental anxiety assessments

primarily has been limited to research purposes and, in general, has not

extended to clinical practice.

Previous research using dental-specific measures found that, although a

painful or traumatic prior dental experience commonly has been reported among

people with dental anxiety, the impact of previous experience with a particular

type of treatment or a specific dental provider has been a challenge to determine.

Wong and Lytle reported less self-reported anxiety with regard to treatment for

patients who previously had undergone endodontic treatment or oral surgery

than for patients who had not undergone such treatment. Peretz and Moshonov

(2007), however, found no difference in dental anxiety between endodontic

patients experienced with this type of treatment and naive patients.

The relationship between familiarity with the treating practitioner and fear,

too, is equivocal. One study suggested that previous "harsh and painful" dental

treatment from "poorly qualified dentists" increased dental anxiety in a sample of

people living on a kibbutz. It is unclear, however, whether the results from this

homogeneous sample would generalize to a more heterogeneous dental school

sample in the United States.

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The purpose of this study was to determine which measures best

predicted patients’ ratings of subjects’ anxiety exhibited during dental treatment.

We included both dental-specific measures (Modified Dental Anxiety Scale

[MDAS], Dental Fear Survey [DFS], Gatchel’s 10-point single-item dental anxiety

scale2) and general anxiety scales (State-Trait Anxiety Inventory [STAI], Fear of

Pain Questionnaire-III [FPQ] to assess subjects’ anxiety. We hypothesized that

including general anxiety measures would increase the predictive validity of the

assessment battery. (www.bda-findadentist.org.uk, 2011)

In addition, we expected that a patient’s familiarity with the specific

treatment and the clinician would affect both self-reported and observed anxiety.

Specifically, we predicted that subjects who had undergone the treatment

scheduled for the day of the study would report lower anxiety levels than

treatment-naive subjects. Similarly, we predicted that subjects who were familiar

with the dentist who was scheduled to treat them would report experiencing less

anxiety than subjects who had not been treated by the dentist.

A limitation of the research on dental anxiety is that there is a lack of

studies describing dental fear with the patients, own words and from their

perspective. Most previous research has been performed using psychometric

instruments modified from general psychology and adapted to the field of dental

anxiety. However, there is always a risk that valuable information is lost when

using quantitative instruments. (www.mind.org.uk, 2009)

http://www.bda-findadentist.org.uk/

http://www.mind.org.uk/

24

Method

Research Design

The study will use the descriptive research design with the combination of

content analysis of documents and related materials. The respondents of the

study will be the patients in the dental dispensary unit of the LPU-Batangas,

College of Dentistry who receive dental treatments from dental clinicians.

Subjects

Patients who received dental treatments in the dental dispensary unit of

LPU College of Dentistry in SY 2011-2013 had a total population of 234. Using

the Slovin’s formula with 7% margin of error, one hundred nine (109)

respondents were randomly selected to answer the questionnaires and predict

the level, severity and causes of their anxiety.

Instruments

The researcher utilized the following instruments and data gathering

techniques in conducting the study, particular in collecting the data.

Survey data were collected from dental patients in Lyceum of the

Philippines University- Batangas, College of Dentistry. Prior to their

administration, the questionnaire and research methodology will be reviewed and

approved by the Research Department of the university.

A modified version of the Dental Anxiety Survey (MDAS) will be used in

this study. The Cohra’s Dental Anxiety Scale (CDAS) was modified by adding a

fifth question relating to local anaesthetics as it is a major cause of anxiety for

25

many individuals. The answer options were also modified so that the same

options were available for all five questions, and they were rephrased to be in a

more clear order of anxiety. The MDAS is now the most frequently used dental

anxiety questionnaire in the United Kingdom.

Each item scored as follows:

1= Not anxious

2= Slightly anxious

3= Fairly anxious

4= Very anxious

5= Extremely anxious

Total score is a sum of all five items, range 5 to 25: Cut off is 19 or above

which indicates a highly dentally anxious patient, possibly dentally phobic.

( www.sitalchauhan.pwp.blueyonder.co.uk/dentalanxiety)

Data Collection Procedures

In determining the instrument’s validity, the researcher will present the

questionnaire she constructed to her colleagues and dean for comments and

suggestions. The researcher will include all the suggestions in modifying the said

questionnaire for further improvement. Dry-run of the questionnaire will also be

conducted and the necessary revisions will be made for more clarity and

exactness before finally administering the survey.

For the research design of this study, the questions will be revised so that

they will be applied to the clinical and didactic aspects of dental school training.

26

To accomplish this task, questions that pertain to dental training will be changed

to reflect a neutral health care setting. The essential purpose of the question will

remain intact.

Data Analysis

The research questions, methods, and appropriate statistical design for

this study are: ANOVA, t-test, Pearson's r correlation and descriptive statistics

will be used to answer the research questions.

ANOVA and individual t-test will be used to determine the differences exist

by gender, by age, by race, and by year in school for perceived levels of stress,

sources of stress and for methods of managing stress.

Pearson’s r correlation will be used to know if there is a relationship

between the major sources of stress and the levels of perceived stress among

college students.

It will also be used to know if there is a relationship between the amount of

stress perceived by college students and the amount of time they spend involved

in stress reducing or relaxing activities.

Descriptive Statistics includes means, standard deviation, ranges and

percentage. These will also be used to determine the major sources of stress the

college students perceive and the methods they actively participate in to reduce

stress.

27

Results and Discussion

This presents an analysis of the data collected according to the methods

and procedures described in the Method. This analysis includes a reiteration of

the purpose of the study and the results of the demographic data collected on the

sample of dental patients in the clinical dispensary of Lyceum of the Philippines

University who responded to the survey.

Table 1

Percentage Distribution of the Respondents’ Profile

Profile Variables Frequency Percentage (%)

Age

14-18 years old 47 43.10 19-25 years old 34 31.20 26-35 years old 9 8.30 36-45 years old 9 8.30 46-60 years old 8 7.30 61-70 years old 2 1.80

Sex

Male 60 55.00 Female 49 45.00

Frequency of Dental Visit

Every month 14 12.80 Every 6 months 16 14.70

Once a year 70 64.20 If only needed 9 8.30

Never - -

Type of Patient

Dental Phobic 40 36.70 Not Phobic 69 63.30

As seen from the table 1, majority of the respondents belonged to age

range of 14-18 years old range (43.10%) whereas for gender or sex, majority

who avail of the clinic’s services are males (55%). This is because women are

28

more afraid than men in terms of dental problems. Further, younger people are

more afraid than older ones.

Table 2 Level of Anxiety

Level of Anxiety Weighted

Mean Verbal Interpretation Rank

1. The proposed treatment will not work.

1.07 Moderately Anxious 2

2. I will disappoint my dentist because of my teeth.


3. The dentist will not be happy about my teeth


4. I will not have enough time to talk about the proposed treatment.

0.47 Not Anxious 17

5. The dentist does not share my concern about my teeth.


6. The dentist does not care about me as a person.


7. The dentist is in a hurry while treating me.


8. I could feel some pain during the treatment.


9. I think that my face will stay frozen. 0.60 Moderately Anxious 13 10. Comments are made during the procedure.


11. I should have brushed my teeth more regularly.


12. Something will go wrong during the procedure.


13. The dentist/operator is expecting too much from me.


14. I am not convinced that the treatment is really required.


15. I spend too much time in the waiting area.

0.49 Not Anxious 16

16. The dentist is often late in relation to my appointment.

0.17 Not Anxious 20

17. I am afraid or not eased to ask questions.

0.28 Not Anxious 19

18. The dentist always gives me bad news.


19. I can’t ask questions because they will know I don’t understand.

0.37 Not Anxious 18

20. The dentist doesn’t tell me what is happening during treatment.


Composite Mean 0.67 Moderately Anxious

Legend: 0.01 – 0.49 = Not Anxious; 0.50 – 1.49 = Moderately Anxious; 1.50 – 2.49 =

Anxious; 2.50 – 3.00 = Extremely Anxious

29

Marya, CM, et. al (2012) supports the analysis. Their study mentioned that

age factor was seen to be significantly related to dental anxiety. The anxiety

levels of younger age groups ('less than 20' and 20-30 years) were significantly

higher than the older age groups (51-60 and 'above 60' years). The anxiety levels

of the 51-60-year age group were significantly lower than the other age groups.

Kanegane, et. al (2009), also stated that older patients have often

undergone more dental care in their lifetime, possibly facilitating habituation and

enabling favorable reevaluation of the experience.

In a study of Moore, et. al., 2002, women were better regular attenders

than men. Specialist treated regular attenders were significantly less anxious and

had more positive beliefs.

Majority of the respondents only seek dental treatments once a year

(64.20%) and they are not dental phobic (63.30%).

This only showed that patients that came in the dental dispensary of LPU

College of Dentistry were already educated with regards to proper oral care and

they were already familiar with different dental treatments.

As shown in Table 2, the level of anxiety of patients varies on moderately

to not anxious. Feeling or experiencing pain during dental treatment ranked first

with a weighted mean of 1.17 followed by the fear or worry of not working the

proposed treatment with a weighted mean of 1.07. The dentist is in a hurry while

30

treating also made the patients moderately anxious with a weighted mean of

1.06.

These were followed by the thought of something that may go wrong

during the procedure (1.04), brushing teeth more regularly (0.80), disappointing

the dentist (0.79), comments made during the procedure (0.75), dentist will not

be happy about the patients’ teeth (0.71), dentist does not share concern on

patients’ teeth(0.70), and giving bad news by the dentist (0.67).

Other variables like dentist expecting too much from patients with a mean

of 0.65, dentist does not care about patients as a person (0.62), thinking that the

face will stay frozen (0.60), not being convinced that the treatment is really

required (0.54), and dentist does not tell what is happening during treatment

(0.52) also made the respondents moderately anxious.

People fear what they do not understand and they also, logically, dislike

pain. If someone has had one or more painful past experiences in a dental office

then their fear is completely rational and they should be treated supportively.

(Dental Fear Central, 2004)

Sufferers from fear of pain, in terms of dental health, are unable to visit

dentists because of a prior painful memory when these patients were young.

Fearful patients remember the visit as a particularly painful one. This memory

manifests later in life as an unconscious desire not to visit the dentist resulting in

dental appointments being constantly delayed or missed entirely.

31

Most people prefer not to suffer pain. For dental phobics, however, just the

mere idea of pain is far worse than the actual pain itself. Ironically, because

these patients are unable to regularly visit dentists, they suffer almost constant

pain from their neglected teeth.

It is important to note that the fear of pain from visits to the dentist is often

from memories of long ago. These memories tend to become warped over time.

Modern dental practices have reduced the pain involved in dental procedures

from what they were even as recently as a decade ago.

People afflicted with this type of phobia often do not receive suitable levels

of dental care. By not having any sense of relationship with the dentist, these

people are unable to articulate fears or get any kind of professional reassurance.

By staying away from dentist, these patients further increase fears since nobody

is able to provide information that will counterbalance the imaginations and are

stuck with a mental picture of the dentist based on painful childhood memories.

www.dentalfearcentral.org, (2010)

According to the study of Kanegane, et. al, (2003), fear is a primary

emotion that indicates that a dangerous situation was recognized, leading the

individual to concentrate all his attention on this event. Anxiety represents a fear

which was transferred from a real to an imaginary situation, resulting from similar

facts or that recall a previous situation.

Once patient seats on the dental chair, they were already anxious and

different thoughts came to their minds. The level of anxiety increased when these

http://www.dentalfearcentral.org/

32

patients feel any discomforts and pain, and will thought that the proposed

treatment will not work because of the severity of the case. Phobic patients were

also anxious if they feel or see that the dentists were in a hurry in doing the

treatment because they were afraid that the said treatment may fail or the dentist

may hurt or injured them.

Table 3.1

Causes of Dental Anxiety with Regards to Pre-operative Procedure

Pre-Operative Procedure Weighted Mean Verbal

Interpretation Rank

1. I think I have a problem with my teeth. 1.15 Slightly Anxious 1 2. I think that I have to go to the dentist 1.08 Slightly Anxious 2 3. I call to make an appointment. 0.64 Slightly Anxious 11.5 4. I arrive at the dental office 0.72 Slightly Anxious 10 5. I am in the waiting room. 0.59 Slightly Anxious 15 6. I smell various odors in the dental office.

0.49 None 18

7. I heard sounds of instruments in the dental office.

0.64 Slightly Anxious 11.5

8. I sit in the dental chair. 0.94 Slightly Anxious 7 9. The dentist examined my teeth. 1.04 Slightly Anxious 4 10. I don’t understand what the dentist is explaining a needle is used to freeze me

0.46 None 20

11. I feel numbness in my mouth from freezing.


12. I feel the scratching on my teeth by the instrument.


13. The drill is making high pitch sound. 0.95 Slightly Anxious 5.5 14. The dental instruments are used in my mouth.

1.07 Slightly Anxious 3

15. I think I could choke during dental instrument.


16. The rubber dam is used. (because I am afraid to choke or gag.)

0.48 None 19

17. I realize that I will not see the work being done in my mouth.


18. I feel the vibration of the drill. 0.91 Slightly Anxious 8 19. I hear the staff converse during the procedure


20. During treatment, I am afraid to move because of the precision of the work done by the dentist.


Composite Mean 0.76 Slightly Anxious

33

Legend: 0.01 – 0.49 = None; 0.50 – 1.49 = Slightly Anxious; 1.50 – 2.49 = Very Anxious; 2.50 – 3.00 = Extremely Anxious

Table 3.1 showed that the thought of having problems with their teeth

(1.15), going to the dentists (1.08), and the dental instruments that are being

used in their mouth (1.07) were the top three causes of dental anxiety with

regards to preoperative procedures which obtained a rating of “slightly anxious.”

Other causes like examination of teeth by the dentist (1.04), scratching of

instruments on teeth (0.95), high pitch sound of drills (0.95), sitting in the dental

chair (0.94), feeling of vibration of drill (0.91), being afraid to move because of

the precision of the work done by the dentist during treatment (0.77), and arriving

at the dental office (0.72) made also the respondents slightly anxious.

According to Levitt (2012), the thought of going to dentists to have dental

treatments make patients already anxious. Thoughts or beliefs that involve

catastrophic events can paralyze a dental patient.

Sometimes a patient has been inappropriately spoken to by a dentist,

hygienist or other member of staff. Remarks about a patient’s dental condition or

at home dental care or simply a condescending attitude can make a patient feel

embarrassed or ashamed.

Some people have had painful encounters with the dental “drill”. Thinking

of the sound alone will make patients feel very anxious. Many people are scared

of the sight of instruments being put into the mouth. Many people find that

having a better look at “the drill” aka the handpiece, and having it demonstrated

on finger, takes a lot of the fear away. Or else, some people find that simply

closing the eyes works while receiving dental care. On the other hand, there are

34

people who like to see exactly what is going on, in which case he can ask his

dentist to show him what he is doing with the help of mirrors.

Table 3.2

Causes of Dental Anxiety During Dental Treatments

During Dental Treatments Weighted Mean Verbal

Interpretation Rank

1. Sound or vibration of the drill 1.06 Slightly Anxious 11.5 2. Not being numb enough 1.02 Slightly Anxious 13 3. Dislike the numb feeling 1.26 Slightly Anxious 2 4. Injection 1.25 Slightly Anxious 3 5. Probing to assess gum disease 1.38 Slightly Anxious 1 6. The sound or feel of scraping during teeth cleaning.


7. Gagging, for example during impressions of the mouth


8. X-rays 0.47 None 26 9. Rubber dam 0.76 Slightly Anxious 23 10. Jaw gets tired 1.06 Slightly Anxious 11.5 11. Cold air hurts teeth 0.95 Slightly Anxious 14 12. Not enough information about Procedures


13. Root canal treatment 1.24 Slightly Anxious 4 14. Extraction 1.23 Slightly Anxious 5 15. Fear of being injured 1.19 Slightly Anxious 6 16. Panic attacks 1.08 Slightly Anxious 8.5 17. Not being able to stop the dentist 0.83 Slightly Anxious 20 18. Not feeling free to ask questions 0.84 Slightly Anxious 18 19. Not being listened to or taken seriously


20. Being criticized, put down, or lectured to


21. Smells in the dental office 0.52 Slightly Anxious 25 22. I am worried that I may need a lot of dental treatment


23. I am worried about the cost of the dental treatment


24. I am worried about the number of appointments and treatment; time away from work, or the need for child care or transportation


25. I am embarrassed about the condition of my mouth.


26. I don’t like feeling confined or not in control


Composite Mean 0.97 Slightly Anxious

Legend: 0.01 – 0.49 = None; 0.50 – 1.49 = Slightly Anxious; 1.50 – 2.49 = Very Anxious; 2.50 – 3.00 = Extremely Anxious

35

Many people equate the sound of the drill with pain. The logic behind this

is simple: if he had a painful dentistry experience in the past which was

accompanied by the sound of a dental tool, he has come to associate the sound

with pain. Just hearing the sound may evoke a “perception” of pain.

www.dentalfearcentral.org. (2010)

The causes of dental anxiety during dental treatment vary mainly on

slightly anxious having a composite mean of 0.97 as shown in Table 3.2. Among

the causes given, probing to asses gum disease (1.38), dislike the numb feeling

(1.26) and injection (1.25) were the top three causes of dental anxiety.

Root canal treatment, extraction, fear of being injured, cost of dental

treatment, sound or feel of scraping during teeth cleaning, panic attacks, and the

need of having lots of dental treatment were also noted as causes of anxiety

during dental treatment with a weighted mean of 1.24, 1.23, 1.19, 1.17, 1.08,

1.08, and 1.07 with a verbal interpretation of “slightly anxious”.

Levitt (2012), stated that patients were slightly anxious in probing their

gums maybe because they had no idea about the procedure and they were

afraid that their gums may be injured or bleeds. Needles are often a specific

concern for anxious patients. Problems with needles can include the inability to

accept a dental injection.

The fear of the needle including fear of pain associated with the injection;

fear that the needle will slip or move or break; fear that the needle will not provide

sufficient anaesthesia and pain increases the patient’s anxiety.


36

Table 4 Difference of Responses on the Level of Anxiety When Grouped According

to Profile Variables

Profile Variables Fc p-value Interpretation

Age 1.467 0.207 Not Significant Sex 0.664 0.417 Not Significant

Frequency of Visit 2.215 0.091 Not Significant Type of Patient 7.865 0.006 Significant

Legend: Significant at p-value < 0.05

Based from the result, only type of patient shows significant difference

since the obtained p-value of 0.006 is less than 0.05 level of significance, thus

the null hypothesis of no significant difference on the level of anxiety when

grouped according to profile variables (type of patient) is rejected. This means

that the level of anxiety of both phobic and not phobic differs.

According to Armfield, et.al (2007), phobic dental patients experience

significant increase in anxiety, and significant negative quality-of-life effects,

before attending to dental treatment.

People who are very fearful of dental care often experience a “cycle of

avoidance,” in which they avoid dental care due to fear until they experience a

dental emergency requiring invasive treatment, which can reinforce their fear of

dentistry.

However, other variables do not show significant difference and implies

that whatever if the respondents’ age, sex and how long they visit the dentist,

their level of anxiety do not varies.

37

Conclusions

Based on the data analyses the following conclusions were drawn:

1. Sex, age and the frequency of dental visit appear to be important factors

linked to dental anxiety, with males being particularly common within the dentally

anxious group in the population.

2. Patients receiving dental treatments in the Clinical Dispensary of the

College of Dentistry were slightly anxious of the different dental procedures.

3. Dental anxiety is a multidimensional complex phenomenon, which is

influenced by characteristics like fear of pain, past traumatic dental experiences

in childhood, and dentally anxious family members or peers.

4. Severe dental anxiety is a major barrier to seeking professional dental

care, and the implications of this in terms of dental disease are significant in

terms of deterioration of their dentition, and a range of psychosocial problems.

5. Observed anxiety and self-reported anxiety were not related to previous

experience with either the patient or the particular treatment.

Recommendations

Based on the findings of the study, the following recommendations were

given:

1. Dental clinicians, clinical instructors and school administration may continuously

provide dental education and extend programs to the community in order for them to be

aware of the oral diseases that they may experience because of their anxiety.

2. A continuous study and upliftment of skills and knowledge must be acquired by

dental clinicians to be able to share and render the best dental service to their patients.

38

3. The dental clinicians should establish good rapport with their patients for efficient

treatment.

4. Dental clinicians should acquire good communication skills so they can explain

well the procedures, treatments, dental materials that will be used in the treatment as

well as the cost of the said treatment to their patients.

5. The dental dispensary of LPU College of dentistry should be equipped with

Virtual Reality- like glasses that provide both visual and auditory distraction by allowing

the patients to view videotapes through these glasses while having dental work done.

6. Clinicians should provide patients with walkman, books and magazines while

they are waiting in the dental dispensary to relax their minds and lessen their anxiety.

39

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Documents

Predicting Anxiety Among Patients in LPU Clinical Dispensary