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J Am Dent Assoc, Vol 138, No 2, 188-195.
© 2007 American Dental Association
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CLINICAL PRACTICE

JADA Continuing Education

Predicting anxiety during dental treatment using patients’self-reports

Less is more



Lisa J. Heaton, PhD, Charles R. Carlson, PhD, Timothy A. Smith, PhD, Ruth A. Baer, PhD and Reny de Leeuw, DDS, PhD


   ABSTRACT
TOP
 ABSTRACT
DENTAL ANXIETY MEASURES
 SUBJECTS AND METHODS
 RESULTS
 DISCUSSION
 CONCLUSION
 REFERENCES
 
Background. Self-reported dental fear measures seldom are used in clinical practice to assess patients’ fears. This study examined how well dental fear measures predicted anxious behaviors displayed during dental treatment.

Methods. One hundred eight adult patients (54 percent female) in a periodontology clinic completed several paper-and-pencil demographic, dental fear and general anxiety measures before treatment. Dental practitioners, blinded to their patients’ responses, rated their patients’ anxiety during treatment on a series of 100-millimeter visual analog scales.

Results. Higher Dental Fear Survey scores, younger age, more invasive treatment type and previous avoidance of dental care because of a bad experience all were predictive of greater observed anxiety. Neither self-reported nor observed anxiety was affected by previous experience with a particular practitioner or treatment.

Conclusions. Dentists may assess patients’ anxiety quickly and accurately with the Dental Fear Survey or a similar measure, as well as by asking patients about their current dental attendance and previous dental experiences.

Key Words: Patient-dentist relationships; dental anxiety; anxiety measures; practice management; communication

Abbreviations: DAS: Dental Anxiety Scale • DFS: Dental Fear Survey • FPQ-III: Fear of Pain Questionnaire • M-C SDS: Marlowe-Crowne Social Desirability Scale • MDAS: Modified Dental Anxiety Scale • STAI: State-Trait Anxiety Inventory • STAI-S: State-Trait Anxiety Inventory-State • STAI-T: State-Trait Anxiety Inventory-Trait • VAS: Visual analog scale

Since the first study of dental anxiety by Shoben and Borland,1 the field of dental anxiety assessment has grown to include many measures for both adults and children. Largely self-reported in nature, these assessments usually ask respondents to indicate the level of anxiety they experience when encountering a particular aspect of dental treatment.

Depending on the measurement used, prevalence rates for extreme dental anxiety in the U.S. adult population range from 11 percent2 to 20 percent.3 A review of self-reported dental fear suggests that the prevalence of dental anxiety has not changed significantly in general adult or college samples since the 1950s.4 Dental anxiety appears to vary by type of treatment, with periodontic and endodontic patients reporting higher levels of anxiety than patients receiving restorative or prophylactic treatment.5–8


   DENTAL ANXIETY MEASURES
TOP
 ABSTRACT
 DENTAL ANXIETY MEASURES
SUBJECTS AND METHODS
 RESULTS
 DISCUSSION
 CONCLUSION
 REFERENCES
 
Evidence exists regarding the use of dental-specific anxiety measures as valuable clinical tools. Moore and colleagues9 found good reliability and validity for a number of dental anxiety measures when used with a sample of highly anxious subjects. Dailey and colleagues10 reported a significantly greater decrease in posttreatment 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.11 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 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,12–14 the impact of previous experience with a particular type of treatment or a specific dental provider has been a challenge to determine. Wong and Lytle8 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,15 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.16 It is unclear, however, whether the results from this homogeneous sample would generalize to a more heterogeneous dental school sample in the United States.

The purpose of this study was to determine which measures best predicted dentists’ ratings of subjects’ anxiety exhibited during dental treatment. We included both dental-specific measures (Modified Dental Anxiety Scale [MDAS],17 Dental Fear Survey [DFS],18 Gatchel’s 10-point single-item dental anxiety scale2) and general anxiety scales (State-Trait Anxiety Inventory [STAI],19 Fear of Pain Questionnaire-III [FPQ]20) to assess subjects’ anxiety. We hypothesized that including general anxiety measures would increase the predictive validity of the assessment battery.

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.


   SUBJECTS AND METHODS
TOP
 ABSTRACT
 DENTAL ANXIETY MEASURES
 SUBJECTS AND METHODS
RESULTS
 DISCUSSION
 CONCLUSION
 REFERENCES
 
Subjects. Subjects were adults (N = 108) seeking treatment in the graduate periodontology clinic at the University of Kentucky College of Dentistry, Lexington, between October 2003 and May 2004. The principal investigator (L.J.H.) recruited subjects if they were at least 18 years of age, arrived at least 15 minutes before their scheduled appointments to complete the questionnaires (unless otherwise approved by the treating dentist) and were not scheduled to receive sedation (either before or during the treatment session). The total sample consisted of 58 women and 50 men. The mean age of subjects was 52.4 years (standard deviation = 13.3 years), with a range between 19 and 82 years.

Methods. All study procedures were approved by the University of Kentucky’s Institutional Review Board before we began recruiting subjects. After registering with the reception staff for their scheduled appointments, subjects were recruited in the waiting area, where they completed the informed consent process (consisting of a brief explanation of the study, after which they read and signed an informed consent form) and received a questionnaire packet and a manila envelope. We distributed six different questionnaires to all of the subjects, as well as a demographic questionnaire at the front of each packet. We determined the order of the remaining six questionnaires via Latin Square (a method of reducing order effects by systematically changing the order in which the measures are presented). We chose the specific dental anxiety measures on the basis of their potential clinical utility and ease of use.

The principal investigator instructed subjects to complete the questionnaires, place them in the envelope (leaving it unsealed) and give the envelope to the dentist before undergoing treatment. Subjects were told that although clinicians would not see their questionnaire responses, they would complete a short form about the type of treatment performed that day, place the forms in the envelopes with the patients’ questionnaires and return them to the principal investigator. Subjects were debriefed after treatment. Specifically, they were told that their dentists had been making notes about how anxious they appeared during treatment, but that the dentists had not seen the subjects’ responses to the questionnaires. All subjects provided written permission for use of their data once debriefed.

Dentists completed an observational rating form (described below) for each subject completing the questionnaire packet. Each clinician wrote his or her initials at the top of the form, as well as a brief description of that day’s treatment. We did not include any information that could be used to identify the subject (such as name or date). The dentist then placed the form in the same envelope with the subject’s questionnaire packet and returned the entire packet for data entry and analysis.

Subject-completed measures. We used the MDAS,17 a five-item modification of Corah’s Dental Anxiety Scale (DAS),21 instead of the original DAS, because of its additional item about receiving dental injections. We included the DFS to provide a more extensive assessment of the dental anxiety construct than that provided by the MDAS.18 In addition, we included Gatchel’s 10-point single-item dental anxiety scale,2 which has been found to be an appropriate screening tool,22–24 as a concise indicator of dental anxiety.

Subjects completed the STAI to account for general levels of anxiety, as well as situationally specific anxiety levels reported before dental treatment.19 We also used the FPQ-III, a 30-item measure designed to assess anxiety related to various painful stimuli,20,25 to assess subjects’ fear of dental pain. Finally, we included the Marlowe-Crowne Social Desirability Scale (M-C SDS) to help evaluate whether subjects reported their fear honestly.26

Dentist-completed measures. Dentists (and one dental hygienist) completed ratings of subjects’ overall behavior during treatment, indicating the frequency (a rating of "0" indicates that the patient did not exhibit the behavior at all during treatment, while "100" signifies a behavior observed throughout the treatment session) of several anxiety-related behaviors on 10 100-millimeter visual analog scales (VAS) (Table 1Go). We included anxiety behaviors in an attempt to capture a wide range of possible behaviors seen during dental treatment. These behaviors included perspiring, showing muscle tension, having an increased respiration rate (taken from the DFS), trembling/shaking, showing facial signs of anxiety (such as the subject’s becoming pale or flushed), showing vocal signs (for example, crying, yelling), informing the dentist of anxiety, asking questions regarding the nature of or need for treatment, and interrupting treatment.


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  		TABLE 1 Dentists’ ratings of patients’ anxiety using 100-millimeter visual analog scales.*

 
Dentists also completed a 10th overall anxiety VAS item, in which they assessed subjects’ general levels of anxiety during the treatment sessions. We calculated each subject’s VAS anxiety score by averaging his or her dentist’s ratings on all 10 VAS items.

Practitioners also indicated the type of procedure completed that day (for example, surgery, periodontal maintenance treatment, initial examination) at the top of the rating form. We then categorized the procedures into one of four treatment types for analysis, in order of perceived invasiveness: examination/evaluation/postoperative follow-up, periodontal maintenance, scaling/root planing and periodontal surgery.

Before we recruited subjects, dentists reviewed the measures with the principal investigator to ensure that we included a comprehensive list of behaviors in the VAS ratings. The principal investigator instructed clinicians to consider each subject’s behavior during the entire treatment session and complete each VAS with regard to the mean number of behaviors observed during treatment. The clinicians and prinicipal investigator discussed the behaviors exemplifying each VAS scale (for example, "My patient showed increased muscle tension [such as gripping the arms of the chair]") so that we could calibrate all assessments of the specific behaviors measured on each of the scales.


   RESULTS
TOP
 ABSTRACT
 DENTAL ANXIETY MEASURES
 SUBJECTS AND METHODS
 RESULTS
DISCUSSION
 CONCLUSION
 REFERENCES
 
Table 2Go presents anxiety scores according to sex. Overall, women reported more anxiety on the dental-specific scales (MDAS, DFS, Gatchel’s scale) and on state anxiety (STAI-S) than did men (P < .05 for all scales). We found no sex differences with regard to trait anxiety (STAI-T), fear of pain (FPQ-III), social desirability (M-C SDS) or practitioners’ ratings of observed anxiety (P > .05 for all scales). Internal consistency, as measured by Cronbach’s alpha, was acceptable for all scales ({alpha} ≥ .84).


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  		TABLE 2 Anxiety scores, by sex.

 
Table 3Go (page 193) shows the relationship between demographic variables and anxiety measures. The results show that sex was related significantly to dental fear (MDAS, DFS, Gatchel’s scale) and state anxiety (STAI-S), with women reporting more anxiety on these scales than their male counterparts. Age was related negatively to practitioners’ anxiety ratings (P < .05), but not to any of the self-reported dental fear measures. Scores from all scales that assessed general anxiety (STAI-S, STAI-T and FPQ-III) and anxiety specific to the dental situation (MDAS, DFS, Gatchel’s scale, VAS ratings) were correlated significantly and positively with each other (P < .05 for all scales). Social desirability, as measured by the M-C SDS, was not correlated significantly with any dental anxiety measures, but it was correlated negatively with trait anxiety (STAI-T) (P < .05).


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  		TABLE 3 Bivariate correlations between anxiety and demographic variables.

 
The MDAS scores of subjects who previously had received the specific treatment scheduled for the day of the study (n = 62) did not differ from the scores of treatment-naive subjects (n = 39; t = –.357; P > .05). Clinicians did not rate inexperienced subjects as appearing more anxious than subjects experienced with the day’s treatment (t = –1.27; P > .05). Similarly, the MDAS scores of subjects who knew the dentist they were scheduled to see that day (n = 83) did not differ from scores of subjects who were not familiar with the treating clinician (n = 17; t = –.406; P > .05) (data were missing for eight subjects). The results showed a trend for clinicians to rate subjects with whom they were not familiar as being more anxious than subjects whom they had treated before (t = –1.98; P = .053).

Treatment type. We completed one-way analyses of variance to examine the effect of treatment invasiveness on self-reported and observed anxiety. We used the Bonferroni adjustment to control for the overall error rate. Subjects scheduled for surgery scored higher on the STAI-S (F3,98 = 4.25; P < .01) than did other subjects. In addition, practitioners rated patients who were scheduled for surgery or scaling/root planing as being more anxious than patients who were scheduled for periodontal maintenance treatment (F3,103 = 5.50; P < .01).

Stepwise linear regression. To assess which measures accounted for the most variance in practitioners’ VAS ratings, we performed a stepwise linear regression. The first block of the regression model consisted of age and treatment type entered in a stepwise manner. The second block consisted of the primary anxiety measures (MDAS, Gatchel’s scale, STAI-S, DFS, FPQ-III), also entered in a stepwise manner. We replaced missing values with variable means to account for all data cases. In the final block, we entered barriers to care and familiarity with the clinician, also in a stepwise fashion, to account for any remaining variance.

The resulting model, which predicted observed anxiety during treatment, consisted of more invasive treatment type, younger age, higher DFS scores and having avoided treatment previously owing to a bad experience (Table 4Go). This model accounted for 27 percent of the variance in VAS ratings.


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  		TABLE 4 Regression model of practitioners’ visual analog scale ratings.*

 

   DISCUSSION
TOP
 ABSTRACT
 DENTAL ANXIETY MEASURES
 SUBJECTS AND METHODS
 RESULTS
 DISCUSSION
CONCLUSION
 REFERENCES
 
Overall, we observed a significant relationship between self-reported and observed measures of dental anxiety, despite the overall low level of anxiety reported by subjects and observed by dentists. Although previous research on the concordance of these two types of measures in adults produced mixed results,27,28 our results suggest that these two types of anxiety assessment may be closely related. In particular, the DFS accounted for a significant amount of variance in dentists’ VAS ratings of subjects’ anxiety, more so than other dental fear measures (that is, MDAS, Gatchel’s scale). Kleinknecht and Bernstein29 and Johansson and Berggren30 found that the DFS represents accurately both the fearful appraisal of the dental situation, as well as physiological reactivity to dental treatment experienced by phobic subjects. Our results support the use of the DFS as an accurate predictor of anxiety observed during dental treatment.

Fearful behavior during dental treatment also was predicted by having had a bad experience during dental treatment (about which patients were asked on the questionnaire) and irregular dental attendance. Patients anxious about dental care often report having had a painful or traumatic dental experience,12–14 with more than two-thirds of one sample reporting that their fear began in childhood.3 Chanpong and colleagues31 reported that nearly 8 percent of people questioned in a large telephone survey had avoided dental care owing to fear, and the number jumped to nearly 50 percent for highly fearful people. Results from our study support the idea that previous dental experiences and avoidance of dental care may have an impact on patients’ current dental treatment, highlighting the importance of asking patients about their previous dental experiences.

Previous experience. Contrary to our expectations, subjects did not report any difference in anxiety with regard to previous experience with the specific treatment scheduled for that day or with the treating clinician. We might expect that patients who know what to anticipate from a dental situation would express less anxiety than other patients. The results of previous research in this area, however, have been mixed.8,15,32 While patients who are willing to receive treatment from residents in specialty training might be expected to have less dental fear, research has shown that patients treated in dental schools have fear levels comparable to those in the general population.33 By the time patients are referred for specialized treatment in a graduate dental program, they typically have had experience with many clinicians in the dental school. Receiving treatment from a new provider in the graduate program, therefore, might not lead to increased anxiety levels.

Study limitations. One limitation of our study is the small number of highly anxious subjects, as subjects generally reported experiencing less dental anxiety than that reported in earlier research.2,3 Dental patients seeking regular treatment often report lower levels of dental anxiety than other patients,4 because highly anxious people tend to seek dental care less frequently and, thus, often are not included in study samples.34,35 Furthermore, Kaakko and colleagues36 described difficulty in enrolling phobic people into dental anxiety studies.

The parameters of this study did not allow for assessment of dental anxiety in patients who declined to participate. It is possible that some people who refused to participate did so because of high levels of dental anxiety. In addition, we excluded from the study patients who received sedation, because their self-reports and clinicians’ observations made while patients are sedated would be unreliable. It is likely that many of the patients who opted for sedation before and during treatment did so as a result of fear. Excluding these patients certainly contributed to the low number of highly anxious patients in this sample, and it truncated the amount of variance in dental fear that we found. The small number of highly fearful patients in this study makes the significant relationship between reported and observed anxiety all the more noteworthy.

Previous research suggests that formal dental fear assessments are used rarely in clinical practice.11 Practitioners may worry that asking patients about anxiety might increase their fear of dental care. In fact, Corah37 reported that patient satisfaction improved when dentists inquired about their anxiety. He said, "If nothing else, asking about anxiety gives the patient permission to express concerns that are present. If the patient is not anxious, asking about anxiety will not produce it."

Practitioners also may be concerned about the time needed to administer a formal dental fear measure. Our study suggests that the DFS (a 20-item measure that is scored easily or simply scanned for areas of concern) accurately predicts patients’ anxiety during treatment. Practitioners who address these issues with their patients demonstrate concern and increase patients’ confidence and comfort (for example, dentists may allow more time with fearful patients and explain the procedures in greater detail). In fact, using a dental fear measure to assess patients’ concerns can expedite and simplify communication between dentists and patients by allowing patients to identify their concerns on paper before discussing them with their dentist.


   CONCLUSION
TOP
 ABSTRACT
 DENTAL ANXIETY MEASURES
 SUBJECTS AND METHODS
 RESULTS
 DISCUSSION
 CONCLUSION
REFERENCES
 
Our study results show that anxiety exhibited during dental treatment was predicted accurately with the brief DFS and items related to previous dental experiences, patient’s age and treatment invasiveness. Observed anxiety and self-reported anxiety were not related to previous experience with either the practitioner or the particular treatment. Dentists can assess patients’ concerns about dental care easily and quickly by reviewing their responses to a brief self-reported measure and by asking direct questions about previous dental care experiences.


   FOOTNOTES
 

Dr. Heaton is a senior fellow, University of Washington, Department of Dental Public Health Sciences, 1959 N.E. Pacific Street, Box 357475, Seattle, Wash. 98195-7475, e-mail "lheaton{at}u.washington.edu". Address reprint requests to Dr. Heaton.


Dr. Carlson is a professor, University of Kentucky, Departments of Psychology and Oral Health Sciences, Colleges of Arts and Sciences and Dentistry, Lexington.


Dr. Smith is a professor, University of Kentucky, Department of Behavioral Sciences, College of Medicine, Lexington.


Dr. Baer is a professor, University of Kentucky, Department of Psychology, College of Arts and Sciences, Lexington.


Dr. de Leeuw is an associate professor, University of Kentucky, Department of Oral Health Sciences, College of Dentistry, Lexington.


This investigation was supported by National Institutes of Mental Health training grant 5T32MH015730-25.


The authors thank the faculty, residents, staff and patients of the Periodontology Department, University of Kentucky, Lexington, for their participation in this study. In particular, they express appreciation to Dr. Mark Thomas, Dr. Holland Wright, Dr. Charles King, Dr. Charles Dyer, Dr. Terry Daniel, Dr. Brandon Frodge, Dr. Roger Robinson, Dr. Jennifer Taylor, Ms. Cheryl Huffman, Ms. Connie Thaxton and Ms. Terri McGlasson.


The authors also express their appreciation to Dr. Susan E. Coldwell for her valuable editorial contributions during preparation of the manuscript.


   REFERENCES
TOP
 ABSTRACT
 DENTAL ANXIETY MEASURES
 SUBJECTS AND METHODS
 RESULTS
 DISCUSSION
 CONCLUSION
 REFERENCES
 

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