| Abstract|| |
Aims: To show the association between dental neglect and alexithymia among adult dental patients. Settings and Design: At times, certain individuals with dental neglect may experience trouble in communicating and/or understanding information, ability to identify, and describe their feelings termed as alexithymia. Hence, recognition of alexithymia in a dental setting is important, because it worsens the dentist–patient relationship, especially among patients who neglect their dental health. Materials and Methods: A cross-sectional survey was conducted among adult patients (≥20 years). Patients received a questionnaire assessing dental neglect [six-item Dental Neglect Scale (DNS)], alexithymia [20-item Toronto Alexithymia Scale (TAS-20)], and demographic profile. Statistical Analysis: Data were analyzed with standard statistical software (Statistical Package for the Social Sciences, version 22). P <0.05 was considered statistically significant. Results: A total sample of 1067 individuals comprising 553 (51.8%) females and 514 (48.2%) males with a mean age 35.33 ± 11.49 years participated in the study. Our findings showed that females had higher mean scores for both DNS and total TAS-20 and its factors. With increase in age and education, the mean scores of the DNS had significantly increased and mean scores of total TAS-20 and its factors had decreased with increase in age and education. Conclusion: The above study findings have supported the hypothesis that there is no association between dental neglect and alexithymia among adult dental patients.
Keywords: Alexithymia, dental neglect, dental patients, education, females
|How to cite this article:|
Nanamadri NK, Doshi D, Kulkarni S, Reddy MP, Srilatha A. Association between dental neglect and alexithymia among adult dental patients. Indian J Dent Res 2021;32:432-7
|How to cite this URL:|
Nanamadri NK, Doshi D, Kulkarni S, Reddy MP, Srilatha A. Association between dental neglect and alexithymia among adult dental patients. Indian J Dent Res [serial online] 2021 [cited 2022 Jun 27];32:432-7. Available from: https://www.ijdr.in/text.asp?2021/32/4/432/345425
| Introduction|| |
Alexithymia is regarded as stable personality trait and has emerged as a paradigm linking emotion with health. It is described as a multifaceted construct encompassing difficulty in identifying subjective emotional feelings and distinguishing between feelings and the bodily sensations of emotional arousal, difficulty describing feelings (DDF) to other people, an impoverished fantasy life, and a stimulus-bound, externally oriented cognitive style.,, Alexithymia might affect health by prompting unhealthy behaviors, for example, poor nutrition and poor maintenance of personal hygiene. It may be impeded by failure to experience or recognize potentially adaptive feelings such as fear, guilt, or even self-pride, and importantly, it is considered as a barrier to successful patient–clinician communication.,
Recently, dental research explored the association between alexithymia and its affect on oral health. Oral health is fundamental to general health and well-being and is one of the most costly diet and life style–related diseases. However, the cost of neglect is also high in terms of its financial, social, and personal impacts. A pilot study by Strauss et al. investigated dental neglect (DN) among American elders using a nine-item self-report scale which explored the three dimensions of self-care, service use, and general neglect. They showed that it is possible to objectively measure the hypothetical construct “DN” and examine its association with dental health.
The term “dental neglect” can be defined as the “behaviour and attitudes which are likely to have detrimental consequences for the individual's oral health.” DN is seen at each and every step of life with different reasons involved with it. Hence, recognition of alexithymia in a dental setting is important, because it worsens the dentist–patient relationship, especially among patients who neglect their dental health.
Several studies have linked alexithymia with oral health–related issues.,,,, Viinikangas et al. have concluded that some patients with dental anxiety among Finnish adult patients may have difficulties in identifying and describing their personal feelings in a dental setting. Pohjola et al. revealed that alexithymics are more likely to have dental fear than non-alexithymics, and Mattila et al. in their study showed that difficulties in emotional regulation (alexithymia) might be reflected in poor oral health–related quality of life. More recently, Stein et al. concluded that low oral health literacy was associated with alexithymia among adult dental patients at University Dental Clinic, Norway.
However, relationship between alexithymia and DN has not yet been established which might be the risk factors or screeners for poorer oral health outcomes. Hence, this study aimed to show the association between DN and alexithymia and we hypothesized that there is no association between DN and alexithymia.
| Materials and Methods|| |
Ethical clearance was obtained from the Institutional Review Board of Panineeya Institute of Dental Sciences and Research Centre and the study was conducted in accordance with the Declaration of Helsinki. Ethical approval obtained on 08-01-201 ECR/267/Indt/AP/2016 7. The study was conducted among the patients visiting Panineeya Institute of Dental Sciences and Hospital from February 2017 to May 2017. Participants who were 20 years of age and older and those willing to give the written informed consent were included.
A self-administered questionnaire in both English and vernacular language (Telugu) comprising three parts was used as a survey tool. The first part included the participants' demographic details such as age, gender, education, history of previous dental visit, and reason for the present dental visit. The second part assessed DN, using a modified six-item Dental Neglect Scale (DNS) by Thomson et al. Participants were asked to respond to the six items describing their dental behaviors. The responses ranged from “strongly disagree (1)” to “strongly agree (5)” on a 5-point Likert scale. Item no. 3, 4. and 6 were negatively recorded, hence reverse scored, to make the questions more aggregate and balanced in a positive/negative direction. The individual total score ranged from 6 (least DN) to 30 (most DN).
The third part assessed alexithymia with the 20-item Toronto Alexithymia Scale (TAS-20) by Bagby et al. These 20 items were divided into three factors: (a) difficulty identifying feelings (DIF: seven items – 1, 3, 6, 7, 9, 13, and 14); (b) DDF (five items – 2, 4, 11, 12, and 17); and (c) externally oriented thinking (EOT: eight items – 5, 8, 10, 15, 16, 18, 19, and 20). The items were rated on a 5-point scale ranging from “strongly disagree (1)” to “strongly agree (5)” with the total score ranging from 20 to 100. There are five items that are negatively recorded (items 4, 5, 10, 18, and 19). A score of 61 or more was defined as alexithymic. Although alexithymia is a dimensional construct, cut-off scores have been established permitting the categorization of respondents into alexithymic (<61), intermediate (52–60), and non-alexithymic (>51) groups.
Due to the complexity of the analysis, the five response categories were trichotomized as “disagree” (strongly disagree, moderately disagree), “neither disagree nor agree,” and “agree” (moderately agree, strongly agree). Statistical analysis was done using Statistical Package for Social Sciences Software (SPSS, Version 22.0; Chicago, IL, USA). Descriptive statistics was carried out for the demographic variables. Chi-square test was used to determine association between DN and alexithymia. DNS and TAS-20 mean scores were compared based on age, gender, education, history of previous dental visit, and reason for present dental visit carried out by t-test and Mann–Whitney U-test. The level of significance (P value) was set at P < 0.05. The validity and reliability of the questionnaire was tested using Cronbach's alpha.
| Results|| |
A total sample of 1067 individuals comprising 553 (51.8%) females and 514 (48.2%) males with a mean age 35.33 ± 11.49 years participated in the study. The majority of the participants, that is, about 72% belonged to 20–40 years age group and had university education [488 (45.7%)]. Around 39.7% of the participants had a history of previous dental visit with 36.3% visiting with a complaint of tooth pain [Table 1].
Out of six-item scale of DNS, the majority of the participants responded “agree” for four questions (DNS 1, 2, 4, and 6). Higher percentage of participants responded “disagree” for DNS 3 “I need dental care, but I put it off” (61.5%) and DNS 5 “I control snacking between meals as well as I should do” (63.8%).
Out of the 20-item TAS questionnaire, eight questions of TAS had a response of “agree” where a higher number of the participants (73.6%) responded “agree” for the item “It is difficult for me to reveal my innermost feelings, even to close friends” (TAS 17). However, the majority of the participants responded “disagree” for 10 items of TAS (TAS 3, 4, 6, 8, 9, 10, 12, 13, 16, and 19). On the other side, participants responded “neither disagree nor agree” for TAS 7 and TAS 18.
Except for gender, variables such as age, education, history of previous dental visit, and reason for present dental visit showed a statistical significant difference in the mean scores of DNS. A higher mean score of 21.62 ± 3.71 was noted among subjects age ≥60 years and lower mean score of 18.12 ± 4.08 was noted in subjects with no education [Table 2].
With respect to age, except for Factor 2, that is, “DDF,” all other factors, that is, total TAS-20, Factor 1 “DIF,” and Factor 3 “EOT” showed significantly higher mean scores among the subjects age ≤20 years, that is, TAS-20 (61.50 ± 11.49), Factor 1 (20.85 ± 6.31), and Factor 3 (24.4 ± 4.54). Females and subjects with no education had higher mean scores for all the factors, that is, TAS-20 and its factors. But statistical difference was observed only for factor 2 among females and for TAS-20, Factor 1, and Factor 2 among subjects with no education (P ≤ 0.05*) [Table 3].
|Table 3: Mean score comparison of TAS-20 and its factors based on variables|
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With regard to age, it was observed that odds of having TAS-20 and its factors had decreased with increase in age. Taking subjects with ≤20 years age group as reference population, subjects who belonged to 20–40 years age group were 0.86 times at risk of having Factor 1 “DIF.” On the other side, subjects who belonged to 40–60 years age group were at higher risk of having Factor 2 “DDF” [odds ratio (OR) =0.99], Factor 3 “EOT” (OR = 1.25), and total TAS-20 (OR = 0.61). Nonetheless, significant difference was observed only for TAS-20 and Factor 3 (P ≤ 0.05*). Based on gender, females had higher odds for TAS-20 and its factors compared with males. Considering the educational status, subjects with “no education” or “primary education” had higher odds of having total TAS-20 and its factors. However, only TAS-20 and Factor 3 were statistically significant (P = 0.008*). Subjects with DN were relatively at a higher risk of having Factor 2 (OR = 2.41) and Factor 3 (OR = 1.09) compared with Factor 1 and total TAS-20 [Table 4].
| Discussion|| |
DN, manifested in behaviors and/or attitudes related to the undervaluing of oral health, has been found to be a predictor of poor oral health in children and adults, measured by indices of caries, toothache, and number of teeth lost, among others. At times, certain individuals with DN may experience trouble in communicating and/or understanding information, ability to identify, and describe their feelings. One such personality trait, where an individual has difficulty in identifying, describing, and expressing the feelings, can be termed as alexithymia. Alexithymia is a concept that was originally developed in the field of psychosomatic medicine which literally means “no words for feelings.” Recognition of alexithymia among patients with DN is important, as it affects the dentist–patient relationship and thereby the treatment outcome. Hence, we conducted the study to explore the association between DN and alexithymia among adult dental patients.
Apart from DNS, Dental Indifference Scale (DIS) can also be used to assess the DN. But according to Jamieson and Thomson, the main critical issue of DIS was difficulty in deriving the scale scores, time-consuming, and difficulty in manipulating the data. On the other hand, DNS is easy to use in the dental healthcare setting, particularly for tasks such as identifying groups or individuals who might benefit from health promotion.
Likewise, alexithymia can be measured with questionnaires such as TAS-20, 40-item Bermond–Vorst Alexithymia Questionnaire (BVAQ-40), and Online Alexithymia Questionnaire. However, in 2005, Morera et al. had reported that BVAQ-40 was lacking internal consistency for some of the dimensions. Hence, they considered TAS-20 to be more economical than BVAQ-40 in terms of all dimensions. Till date, the most popular measure of alexithymia has been TAS-20. Therefore, in this study, alexithymia was assessed using TAS-20 questionnaire.
Female predominance of around 51.8% was observed in our study. Similar to these findings, a previous report by Viinikangas et al. among Finnish adult dental population attending the public health center showed female predominance of around 62.6%. In the same way, a study by Stein et al. among Norwegian population attending the University Dental Clinic showed 56% of female predominance. A possible reason for this could be females have a high aesthetic concern and have a better understanding about their oral health status. However, a practical reason by Shyagali TR et al. stated that as most of the Indian dental institutes/hospitals have the working hours between 8.00 am and 5.00 pm, males often face difficulty in arranging an appointment because of work.
An existing study by Thomson and Locker who carried a Dunedin Multidisciplinary Health and Development Study among young adults of Dunedin population had showed that males had higher mean score for DNS (13.65 ± 4.30). Also, a study conducted by McGrath et al. among the Hong Kong Chinese adults through a random telephone interview reported higher mean DNS (16.81 ± 3.62) among males. In contrast to this, we observed that the mean DNS score was high among females (19.57 ± 3.98) in our study. This must be due to the fact that though females are more concerned about their oral health status, they might be reluctant for dental treatment due to anxiety and fear. We also observed that females had higher mean scores for total TAS-20 (59.3 ± 10.56), Factor 1 “DIF” (19.52 ± 5.52), Factor 2 “DDF” (15.48 ± 4.03), and Factor 3 “EOT” (24.32 ± 4.36). However a, previous study by Parker et al. among undergraduate students from University of Germany showed that males had higher mean scores for TAS-20 (47.19 ± 10.24), Factor 1 (16.35 ± 5.29), Factor 2 (13.60 ± 4.22), and Factor 3 (17.25 ± 4.23). A possible reason for high TAS-20 mean scores among females in our study could be due to the reason that though females tend to share and express their feelings more often when compared with men, most of them express it only to their closed ones.
The findings of a previous study conducted by Onor et al., among healthy community-dwelling volunteers of IOWA state in U.S.A, showed that older adults had significantly higher mean scores for TAS-20 (37.05 ± 4.89) and its factors [“Factor 1” (11.95 ± 3.05), “Factor 2” (9.30 ± 2.07), “Factor 3” (15.80 ± 2.52)]. However, in our study, we noticed that total TAS-20 (53.46 ± 15.04) and its factors [“Factor 1” (16.51 ± 7.06), “Factor 2” (14.59 ± 5.43), “Factor 3”(22.35 ± 4.07)] decreased with increase in age. This might be because as people grow older, they become more oriented toward the present and consequently better able to regulate emotions. However, the unobserved variables such as occupation and socioeconomic status might have attributed effects on levels of alexithymia in young adults our study.
In this study, we observed that subjects with university education had significantly higher mean scores for DNS (20.44 ± 3.97). Similar findings were observed by Sarkar P et al. who conducted the study among different professional college students of Sri Aurobindo Institute of Indore city and observed that students of pharmacy college had high DNS (19.77 ± 3.94). Lack of proper oral health knowledge and insufficient time to visit a dentist could be the possible reason for DN. Hence, Singh et al. in their study reported the importance of dental health, which should be made clear through various campaigns and personal counselling.
Logistic regression model revealed that except for DNS, age, education, and history of present dental visit were significant predictors of total TAS-20 and Factor 3 “EOT.” However, a previous study by Stein et al. had showed that total TAS-20 and Factor 3 were significant predictors of Adult Health Literacy Instrument for Dentistry.
Limitations include bias caused by self reporting by patients, inability to arrive at a psychiatric assessment using questionnaire, and inability to generalize with entire population.
| Conclusion|| |
This study concluded there is no association between DN and alexithymia among adult dental patients. However, gender has modified the association between DN and alexithymia, that is, females who had higher mean score for DNS also had higher mean scores for TAS-20. This indicates that some female patients may have difficulties in identifying and describing their personal feelings in a dental setting and this might lead to cause DN among them. Obviously, additional research investigating the association between alexithymia and DN in a general population is needed. It may not be feasible to screen all patients for alexithymia, but if problems of DN are persistent among individuals, TAS-20 could be used as part of a more thorough psychological evaluation.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
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Conflicts of interest
There are no conflicts of interest.
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Dr. Nitya Krishna Nanamadri
Department of Public Health Dentistry, Panineeya Institute of Dental Sciences and Research Centre, Road No. 5, Kamala Nagar, Dilsukhnagar, Hyderabad - 500 060, Telangana
Source of Support: None, Conflict of Interest: None
[Table 1], [Table 2], [Table 3], [Table 4]