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Table of Contents   
EPIDEMIOLOGICAL WORK  
Year : 2019  |  Volume : 30  |  Issue : 2  |  Page : 300-304
Evaluation of anxiety levels and their characteristics in dental care: Cross-sectional study


1 Department of Dentistry, Faculdade Meridional (IMED), Passo Fundo, RS, Brazil
2 Department of Dentistry, Federal University of Sergipe, Aracaju, Brazil
3 Post-Graduation Program in Sciences Applied to Health, Federal University of Sergipe, Lagarto, SE, Brazil
4 Department of Preventive and Community Dentistry, School of Dentistry, Federal University of Uberlândia, Uberlândia, Minas Gerais, Brazil

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Date of Web Publication29-May-2019
 

   Abstract 

Context: Anxiety is defined as an emotion produced by a set of feelings and physical changes. Many patients are afraid of some procedures involved in dental therapy. Aim: The objective of this study was to verify the anxiety of patients regarding the visits to dental clinics of a higher education institution, as well as to observe the moment of greatest anxiety. Settings and Design: It is a cross-sectional observational study including 94 patients from the dental clinics of an educational institution in a city of southern Brazil. Materials and Methods: The Corah Dental Anxiety Scale, composed of four questions, was used to evaluate the dental anxiety levels of all patients. The sample universe included registered patients under treatment in the clinics of the studied institution, from August to November of 2016. We included only healthy patients over 18-year old who were subjected to surgical and nonsurgical procedures. Statistical Analysis: The data were analyzed through descriptive statistic to verify the frequency distribution of all variables. Pearson's Chi-square test, at 5% significance level and 95% confidence interval, was used to evaluate the association between the dependent variable (dental treatment anxiety) and the independent variables (demographics), aided by the SPSS software 20.0. Results: It was found that most of the participants were not anxious (69.1%) and the moment of greatest anxiety reported was before local anesthesia. In addition, statistics showed no correlation among gender, age group, and type of procedure performed. It was possible to conclude that the level of anxiety of the patients regarding the dental care performed in the clinics of the studied institution was low for both surgical and nonsurgical procedures. Conclusion: This survey revealed that the moment of greatest anxiety for the patients was before the anesthetic procedure, and gender, age, and type of procedure did not influence the level of anxiety felt by the patient.

Keywords: Dental anxiety, dental fear, manifest anxiety scale

How to cite this article:
Piano RP, Vieira WA, Sousa-Silva J, Paranhos LR, Rigo L. Evaluation of anxiety levels and their characteristics in dental care: Cross-sectional study. Indian J Dent Res 2019;30:300-4

How to cite this URL:
Piano RP, Vieira WA, Sousa-Silva J, Paranhos LR, Rigo L. Evaluation of anxiety levels and their characteristics in dental care: Cross-sectional study. Indian J Dent Res [serial online] 2019 [cited 2019 Aug 22];30:300-4. Available from: http://www.ijdr.in/text.asp?2019/30/2/300/259219

   Introduction Top


Anxiety is defined as an emotion produced by a set of feelings (stress, worried thoughts, constant fear) and physical changes (increase or decrease of blood pressure and sweating).[1] Some of the types of anxiety described in the literature are generalized anxiety disorder, social anxiety, and panic disorder.[2] The International Classification of Diseases (ICD-10) characterizes anxiety as a neurotic disorder, often related to contexts of stress.[3] The symptoms may vary, but the ones that most stand out are (a) apprehension – concerns and continuous nervousness and premonitions; (b) motor stress – restlessness, tremors, and inability to relax; and (c) autonomic hyperactivity – lightheadedness, sweating, dizziness, and headaches.[3]

In the early 21st century, anxiety was the most common mental health problem worldwide.[4] In a recent survey from the World Health Organization, around 264 million people in the world present some type of anxiety, which is an increase of 19.4% from 2005.[5] In Brazil, >18 million people suffer from anxiety, that is 9% of the population.[5]

In the dental environment, anxiety is a recurring emotion.[6] Scientific evidences report that the levels of anxiety increase significantly even in simple procedures.[7] The anxiety related to dental treatment is connected to factors such as previous traumatic experiences[8] or the negative influence of close people.[9] This situation represents a complication for dental treatment, for both executing the procedure and its success,[10] provided that the higher the patient anxiety, the higher the sensitivity to painful stimuli.[11]

The fear of dental care presents in all age groups and if the patient is not properly handled, this fear may continue throughout the life of the individual.[12] Hence, the impact of such condition on the oral health of the patient is negative, considering that when patients relate the dental office to bad experiences they tend to avoid frequent visits.[13] Thus, knowing the level of anxiety of patients and their expectations for the treatment becomes vital to a safer and more comfortable service.

The topic of fear and anxiety during dental procedures needs to be researched, as the positive results of the procedures will depend on the patient's perception and collaboration. Many patients are afraid of some procedures involved in dental therapy. The researches performed in dental clinics are important because they reflect the patients' real perception. However, there are still few studies in the literature that involve patients in clinics in Brazil.[9],[11],[14] This study was conducted to improve the development of treatment strategies for anxious dental patients.

Therefore, this study aimed to verify the anxiety of patients regarding the visits to dental clinics of a higher education institution, as well as to observe the moment of greatest anxiety and correlate it to the type of procedure, gender, and age of participants using a questionnaire adapted from the Corah Scale. The authors accepted the following hypotheses: 1) the higher rate of anxiety would appear before anesthesia and before intervention; 2) there is a correlation between anxiety and gender of the patient; 3) there is a correlation between age and level of anxiety; and 4) there is a correlation between the type of procedure and the level of anxiety.


   Methods Top


Ethical research criteria

The Research Ethics Committee of a higher education institution approved this study under report #2.014.444 (CAAE 65086116.8.0000.5319). The study was conducted according to every ethical and legal guideline. All participants signed the Informed Consent Form. A Location Authorization Form was used to access the dental clinic.

Study design and participants

This study has a quantitative approach and cross-sectional design. The research was performed in clinics of a higher education institution located in the city of Passo Fundo, which is located in the North region of the state of Rio Grande do Sul, Brazil. From the 496 cities of the state, Passo Fundo is among the most populous ones, and it is the largest city in the North region of Rio Grande do Sul. According to the estimate of the Brazilian Institute of Geography and Statistics (IBGE)[15] of 2017, the city has 198,799 inhabitants, ranking it as one of the densest cities of the state. The economy is focused on agriculture and commerce; the city also has a solid university education and it is considered a reference for health care.

The sample universe included patients registered and under treatment in the clinics of the studied institution, from August to November of 2016. We included only healthy patients over 18-year old, who were subjected to surgical and nonsurgical procedures. Exclusion criteria consisted of patients on their first visit, syndromic patients, pregnant women, patients under psychological treatment or using anxiolytics, and patients unable to answer the questionnaire. The final sample included 94 participants.

Data collection

The questionnaire was self-administered by the patients in the waiting room of the dental clinics. Patients answered a questionnaire after dental procedures such as third molar extractions, endodontics, restorations, and periodontal treatments.

The tool used was the Corah Dental Anxiety Scale,[16] which assesses the manifestations of dental anxiety and allows identifying the level of anxiety by adding the answers given to its multi-item questions. The Corah Dental Anxiety Scale was developed by Corah in 1969[16] and validated in Brazil.[17]

This scale consists of a questionnaire with four questions with five possible answers, in an ascending scale from 1 (relaxed) to 5 (almost physically ill), resulting in a range of values between 4 and 20: “How did you feel in the day prior to the procedure?”; “In the waiting room, before being called in, how did you feel?”; “In the dental chair, waiting for the anesthetic procedure, how did you feel?”; and “After being anesthetized, waiting to initiate the procedure, how did you feel?” Each question has five answer choices and each alternative received a score (1–5). To interpret the level of anxiety, patients whose total sum is lower than 5 points are considered very little anxious; from 6 to 10 points, slightly anxious; from 11 to 15 points, moderately anxious; and totals higher than 15 points are considered extremely anxious.[14]

First, data were analyzed with descriptive statistic to verify the frequency distribution of all variables. Later, Pearson's Chi-square test, at 5% significance level and 95% confidence interval, was used to assess the association between the dependent variable (dental treatment anxiety) and the independent variables (demographics), aided by the SPSS® software (Statistical Package for the Social Sciences), version 20.0 (IBM, Armonk, New York, USA). The independent demographic variables were gender, age group, and surgical or nonsurgical dental procedures. The dependent variable of dental treatment anxiety was obtained by ranking the levels of anxiety of the Corah Scale in only two categories. The first category included only the “little anxious” level, the second joined all the other anxiety levels (slightly, moderately, and extremely anxious).


   Results Top


Along the research, 94 patients were seen in the dental clinics of the higher education institution studied, both for surgical and nonsurgical procedures. Most of the participants were women (61.7%) and the predominant age group was 31–50 years (41.5%), followed by patients over 50-year old (33%) and under 30-year old (25.5%). Most of the participants received nonsurgical procedures (84%).

[Table 1] describes the questions that compose the Corah questionnaire, as well as the distribution of answers given by the research participants. As for the distribution of anxiety levels of the patients assessed by the Cora Scale, our study identified 69.1% of patients who were little anxious, 21.3% slightly anxious, 8.5% moderately anxious, and 1.1% extremely anxious.
Table 1: Frequency distribution of answers for the variables of the Corah dental anxiety scale

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[Table 2] presents the bivariate relations between the dependent variable and the independent variables (gender, age group, dental procedures). There was no statistically significant relation between the variables analyzed (P > 0.05).
Table 2: Inferential analysis between the variable of anxiety and demographic variables of patients

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   Discussion Top


This study sought to assess the previous level of anxiety of patients for dental treatment, in both surgical and nonsurgical procedures. The results showed a low level of anxiety reported by patients who visited the dental clinic of a higher education institution in the South region of Brazil. The first hypothesis proposed was confirmed, while the others were denied by the results of this study.

Anxiety is measured with different scales and, consequently, the subjectivity of answers is a factor that contributes to the great variation of results found in the literature. The Corah Scale was the tool selected to assess the levels of anxiety in this study, for being a validated instrument,[16] which is globally promoted and provides reliable results.[7],[17],[18] Since the 1970s, the Corah Scale is known as an instrument to assess the manifestations of dental anxiety and it is a method promoted in several countries for being easily reproducible and for allowing to objectively identify level of anxiety.[16]

As for sample characterization, the female gender prevailed in our study. Scientific evidences affirm that women are more prone to suffer from anxiety than men.[19],[20],[21],[22] The global ratio of women for men who suffer from anxiety is 1.9:1.[22] Some of the reasons for the high level of anxiety of women are the pressure for motherhood, fear of rape, and their family role.[20],[22] Regarding dental treatment anxiety, a study[17] showed significant statistical difference between genders, in which women presented superior results to men. Some justifications say that women are used to be more worried about dental procedures than men[17] and that they express their feelings and fears more easily.[23] However, our study showed neither much percentage difference between genders nor correlation between gender and dental treatment anxiety (P = 0.426), corroborating the study by Medeiros et al.,[11] which also showed no difference for anxiety between genders.

This study presented a great age variation, from young adults to elderly people. A recent systematic review[22] concluded that the age group that suffers most from anxiety is the elderly, especially because of health limitations. Regarding dental treatment anxiety, a justification for greater anxiety in older adults is related to childhood traumas. Studies affirm that childhood traumas may go on through the patient's entire life.[24] Our study, however, presented the lowest rates of anxiety among older patients and the highest ones among younger patients, similar to other studies.[25],[26] These results may be related to a potential low frequency of young people in dental offices, which provides less knowledge on procedures, in addition to the memory of childhood traumas being more recent. However, the result of our study did not show correlation between patient age and dental treatment anxiety (P = 0.648).

As for the type of procedure, our study showed that most of the patients subjected to surgical procedures presented higher rates of anxiety. However, scientific evidences have shown that even in nonsurgical therapies of endodontic treatments, the patients will present high rates of anxiety.[27] Moreover, the study by Lin et al.[28] concluded that there is correlation between the type of procedure and the level of anxiety, similar to the results of our study (P = 0.128). One possible reason would be that some procedures – either surgical or nonsurgical – are more feared than others and one of the factors for this is the presence of anesthesia.[9]

This study verified that anxiety peaked while patients waited for anesthesia (10.6%). The research conducted by Medeiros et al.[11] reported that the puncture with the anesthetic needle and the more invasive clinical procedures, such as oral surgeries, for instance, are more stressful procedures. The study also emphasizes that anesthesia could be among the most painful procedures. Scientific evidences prove the relationship between the level of anxiety and the pain felt by the patient during the dental procedure,[28] which would consequently increase the anxiety condition.

The method for sample selection may have presented limitations regarding generalization; however, the authors considered that it satisfactorily represented the opinion of patients who attended in the clinics of the studied institution.

The results presented in the aforementioned researches corroborate the results presented in our study and show not only that the rate of anxiety of the general population is low but also that anxiety, even low rates of it, is often observed in individuals seeking dental care. Thus, the professional should be aware of the level of anxiety of patients to set proper care protocols and provide more comfort and predictability to the procedure performed.


   Conclusion Top


Therefore, our study concluded that the level of anxiety of patients regarding the dental care performed in the clinics of the institution studied, for both surgical and nonsurgical procedures, was low. The moment of greater anxiety for patients was before the anesthetic procedure, when they are already in the dental chair. Moreover, this study showed no relation between gender, age, and type of procedure to the level of anxiety felt by the patient. However, our results should be interpreted with caution and further studies are required for more clarification on the subject.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

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27.
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Correspondence Address:
Dr. Lilian Rigo
Department of Dentistry, Faculdade Meridional (IMED), Av. Major Joào Schell, 1121, Annes, CEP - 99020020, Passo Fundo, RS
Brazil
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijdr.IJDR_325_18

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