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 Table of Contents  
Year : 2019  |  Volume : 6  |  Issue : 2  |  Page : 101-112

Dental anxiety at Riyadh Elm University Clinics

1 Department of Preparatory Health Sciences, Riyadh Elm University, Riyadh, Kingdom of Saudi Arabia
2 Dental Student, College of Dentistry, Riyadh Elm University, Riyadh, Kingdom of Saudi Arabia
3 Dental Intern, College of Dentistry, Riyadh Elm University, Riyadh, Kingdom of Saudi Arabia

Date of Web Publication19-Aug-2019

Correspondence Address:
Prof. Ashraf M. F. Kamel
Department of Preparatory Health Sciences, Riyadh Elm University, 517, King Fahad Road, Namuthageyah, P.O. Box 84891, Riyadh 11681
Kingdom of Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/sjos.SJOralSci_33_19

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Context: Anxious patients are difficult to manage and tend to avoid dental treatment.
Aim: The aim of this study is to explore dental anxiety (DA) among patients visiting Riyadh Elm University (REU) clinics.
Materials and Methods: Dental patients were first oriented about the purpose of the study and then signed consent before filling a ten-item quantitative DA questionnaire that included demographic variables of age, gender, and educational level. Responses were scored on a scale of 1–4 for each question, and an overall questionnaire score of 40 was obtained. Low anxiety was considered with at or below 15, moderate anxiety between 16 and 27, and high anxiety at or above 28. Statistical analysis was performed with frequencies and cross-tabulation by Chi-square and Student's t-test.
Results: Of 365 respondents, the majority (50.1%, n = 183) showed moderate anxiety followed by 104 participants (28.5%) showing high anxiety while only 78 participants (21.4%) exhibited low DA. Among the high DA group, 81% were female (n = 84) while 19% were male (n = 20) and this difference was statistically significant. High DA was recorded in patients aged 13–18 (25%) and 19–25 years (27%) compared to other age groups; however, the difference was statistically insignificant. Furthermore, schoolchildren demonstrated high DA (53%) compared to other educational levels, yet the difference was not statistically significant.
Conclusion: A considerable number of patients attending REU dental clinics exhibited DA that was more intense among female patients, younger age groups, and the less educated individuals.

Keywords: Dental anxiety, dental anxiety score, dental treatment, questionnaire

How to cite this article:
Kamel AM, Al-Harbi AS, Al-Otaibi FM, Al-Qahtani FA, Al-Garni AM. Dental anxiety at Riyadh Elm University Clinics. Saudi J Oral Sci 2019;6:101-12

How to cite this URL:
Kamel AM, Al-Harbi AS, Al-Otaibi FM, Al-Qahtani FA, Al-Garni AM. Dental anxiety at Riyadh Elm University Clinics. Saudi J Oral Sci [serial online] 2019 [cited 2022 Jul 1];6:101-12. Available from: https://www.saudijos.org/text.asp?2019/6/2/101/264763

  Introduction Top

Over the last decade, the increased public awareness of the significant impact of oral health on the quality of life, appearance, and self-confidence of an individual has increased the demand for dental services, with a proportional increase in the number of people who experience symptoms ranging from dislike to phobia regarding dental treatment.[1] These individuals find dental procedures so distressing that they experience acute anxiety symptoms, such as increased sympathetic nervous system output, uneasiness, apprehension, tension from anticipating danger, irritability, and avoidance when in a dental environment.[2]

Historically, patients have perceived dental procedures as painful and uncomfortable,[3] and this perception has continued.[4] It is a common problem both for the dental practitioners and for the patients and affects a significant proportion of people of all ages.[5] This often results in poor oral health by poor cooperation, irregular dental attendance, and complete avoidance of dental treatment.[6],[7],[8]

Anxiety has several possible meanings and may thus give rise to some uncertainty and ambiguity.[9] The American Heritage Science Dictionary defines anxiety as “a state of apprehension resulting from the anticipation of a threatening event or situation.”[10] Although the terms anxiety, fear, and phobia are used interchangeably, they differ categorically. Anxiety and fear both are distinguished from each other; in that case, the latter occurs in the presence of an observed threat.[11] Dental phobia is severe anxiety that is defined as “marked and persistent fear that is excessive or unreasonable cued by the presence or anticipation of a specific object or situation and characterized by the avoidance of dental treatments.”[12] Dental anxiety (DA) is defined as a patient's response to stress that is specific to dental situation.[13] It is ranked as the fourth among common fears and the ninth among intense fears.[14]

The prevalence of DA has been documented in many countries worldwide. Epidemiological studies based on the survey data have indicated that as many as 3%–7% of the population suffer from debilitating high levels of dental fear and avoidance.[8],[15],[16],[17] Furthermore, Gatchel et al.[18] indicated that 70% of patients visiting a dentist exhibited feelings of apprehension and 15% avoided dental visits due to their anxiety. In the United States, 45 million people suffer from dental fear [19] and up to 50% of the population has some form of DA [20] that were problematic in 3%–20% of the population.[21]

The prevalence of DA was reported to be 14.9% in Australia,[22] 12.5% in Canada,[23] 12.6% in Russia,[24] 13.5% in France,[15] and 30% in China.[25]

Not many studies have been conducted in Saudi Arabia on the prevalence of DA. A study conducted in Riyadh to assess dental fear and anxiety in adolescent females showed that 29% of the subjects had high levels of anxiety.[26] Al-Shammary et al.[27] reported that 11.8% of the surveyed subjects perceived dental treatment as a stressful procedure; 4.6% found dental treatment unpleasant and 6.2% found it painful while 5.2% of the subjects avoided visiting the dentist for fear of pain. In 2015, Al-Khalifa [28] concluded that the level of DA in Saudi patients was relatively higher (27.5%) than other studies with higher levels of DA reported in Jeddah (31.9%) compared to Dammam (22.7%).

The etiology of DA is poorly understood. The onset of DA is thought to originate in childhood, peak in early adulthood, and decline with age. Likewise, during childhood, the cause is usually a negative dental experience, and in adulthood, it is more likely due to general anxiety states.[29] In the investigations of DA since the 1960s, DA has been attributed to many factors including previous painful experience, learned attitudes toward dental services, personality characteristics, as well as attitudes of dentists and auxiliaries.[30] Dental patients tend to be moderately anxious at the beginning of a procedure and get more anxious, fearful, and depressed with time, complexity, and stage of treatment.[31]

The literature suggested that anxiety and dental pain were associated. For example, the pain was prevalent in patients reporting DA.[32] Other studies found that pain felt during dental injections was dependent on DA.[33] Psychological factors have an important influence on pain perception, both in clinical and experimental settings, and negative emotions, like anxiety, are known to increase pain perception.[4],[34]

Several researchers have concluded that DA varied among different social groups and tribes.[35] Age, sex, social status, and education level also significantly affected anxiety, with younger individuals and women showing higher levels of anxiousness.[22],[36],[37]

Avoidance of dental care, irregular dental attendance, and poor cooperation with care provider are considered the main outcomes of DA.[18] Approximately 25% of UK adults and 20% of US adults reported delays in visiting the dentist due to dental fear.[38],[39] Several study results from developed countries have shown that fearful dental patients avoid dental treatment, seek emergency dental care, postpone their dental visit, and have poor oral health and a greater number of missing and decayed teeth.[22],[40]

DA can cause a person to delay or avoid seeking dental health care despite being in need of treatment.[41],[42] Numerous studies correlated DA and its impact on the oral health-related quality of life and observed that avoidance of treatment by anxious patients is highly associated with a deterioration of their oral health-related quality of life.[29],[32],[43],[44],[45] This type of phobic or anxious behavior regarding dental practitioners and procedures could have negative consequences for the oral and psychological health of those affected. According to Todd and Walker,[46] nearly, 43% of people reported that they avoided going to a dentist unless they experience intense trouble with their teeth.

A study by Stouthard and Hoogstraten [47] revealed that 15% of the individuals regularly avoid dental care because of their anxiety.

The intensity and nature of DA vary from one individual to another. An extensive literature review revealed that several psychometric indexes have been developed to measure DA among patients.[48] It has been suggested that the adoption of formal psychometric measures would be of benefit for accurate assessment of a patient's DA from initial contact.[49]

Various scales have been composed to measure many aspects of DA such as Corah's dental anxiety scale (CDAS), modified dental anxiety scale (MDAS), Stouthard's dental anxiety inventory short form (DAI-S), and dental fear survey (DFS).[50] The DA scale commonly referred to as the CDAS index, developed by an American Psychologist Norman Corah in 1968,[22],[51] has been the most widely used. The MDAS, a modified version of the original CDAS, is commonly used and is considered more useful in the clinical setting for screening and diagnosing patients with DA.[52] The other advantages of the MDAS include its reliability, validity, and ability to be translated into different languages.[53],[54],[55],[56]

The literature indicates that DAS and MDAS constitute as research instruments in a majority, i.e. 31%, of research studies, and being fundamentally advanced, they are the most preferred tools by scientists all over the globe to measure fear and anxiety in a dental setting.[48]

Kleinknecht's DFS is one of the most frequently used measures of dental fear and has been used in the international epidemiological studies for over 30 years.[57],[58] It is a scale used in behavioral research studies, which present good stability, high reliability, and acceptable validity in diverse cultures and languages.[55],[59],[60],[61],[62],[63],[64],[65],[66]

Even though the MDAS and DFS were the most widely used instruments, some researchers used different questionnaires such as Bare and Dundes,[67] who used custom-made scales for DA so as to simplify the questionnaire to better suit the respondents.

Given that a considerable number of patients have demonstrated anxiety associated with dental visits in many centers worldwide, besides that, little is known about the prevalence and severity of DA in patients' seeking oral and dental health care at REU clinics whereas such information is valuable in providing high-quality oral health care. Therefore, the aim of this study was to measure the prevalence and evaluate the different factors influencing DA among patients attending the dental clinics of the College of Dentistry at REU and to customize a questionnaire to assess DA.

  Materials and Methods Top

This study was conducted at two REU dental clinics in Munisiya and Namouthajiyah Campuses in Riyadh, Kingdom of Saudi Arabia, from March 2018 to November 2018. The Namouthajiyah Campus is located in Riyadh city center, while the Munisiya Campus is in the east of Riyadh city; both dental clinics provide specialized oral health care. This research was registered in the research center of REU under registration number FUGRP/2018/75 and ethical approval was obtained from the institutional review board (IRB) at REU under the number of RC/IRB/2018/771.

Patients attending the dental clinics for dental treatment were provided with a questionnaire and were invited to complete it while in the waiting area. Patients who refused to give informed consent and those who were undergoing psychiatric therapy or suffering from generalized anxiety disorders or completely edentulous or were under pain were excluded from the study.

The aims and objectives of the study were explained to each patient, and informed written consent was obtained from the study subjects who agreed to participate. The participants were requested to fill demographic information about age, gender, and educational qualification. To assess their level of anxiety, the participants were asked to complete a DA questionnaire administered in the Arabic language by checking off a box or filling in a blank space on the questionnaire sheet provided. The used questionnaire consisted of the following ten questions:

Q1: If you had a previous visit to the dentist, how did you feel?

Q2: If your dental appointment is tomorrow for checkup or treatment, how do you feel?

Q3: How do you feel when you sit in the waiting area for your turn?

Q4: How do you feel when you sit in the dental chair before starting treatment?

Q5: How do you feel when you are in the dental clinic to clean your teeth?

Q6: What do you feel before taking anesthetic injection?

Q7: How do you feel when you see dental instruments?

Q8: How do you feel before the doctor extracts one of your teeth?

Q9: Are you worried about the final treatment result?

Q10: There is nothing to worry about when visiting a dentist.

In each question from 1 to 8, patients were asked to choose one answer from a four-choice Likert scale, including “comfortable,” “little comfortable” to “anxious” and “very anxious.” In questions 9 and 10, the choices ranged from “no” to “I'm not interested” to “sometimes” to “yes.” For each of the 10 questions, answers were scored on a scale of 1–4; thus, each question carried a possible minimum score of 1 (low anxiety) and a possible maximum score of 4 (high anxiety).

Summation of all answers produced a total score for the level of DA with a minimum score of 10 and a possible maximum total anxiety questionnaire score of 40 for the entire scale. Based on the total DA score, the patients were divided into three groups; Group 1 = low anxiety with total DA scores below the 25th percentile (score below 16), Group 2 = moderate anxiety with total DA scores between the 25th and 75th percentile (score between 16 and 27) and Group 3 = high anxiety with total DA scores above the 75th percentile (score at or above 28).[26]

Development of the questionnaire

Previous surveys designed to identify patients who were dentally anxious were reviewed in particular a similar study carried out on college students by Bare and Dundes [67] in the USA. The finalized questionnaire used in this study incorporated the five questions of the MDAS in addition to five additional questions regarding the patients' fears adopted from the dental fear survey.

The reliability of the questionnaire was analyzed using Cronbach's alpha [Table 1], which was found to be acceptable (0.89). The questionnaire was translated into Arabic language using forward and backward blind translation processes. The back-translated versions were reviewed by the authors, and the translated version was corrected along with the translators to eliminate any difference in the meaning between the original version and back-translated versions. The final back-translated version was piloted on an Arabic-speaking focus group to ensure the understanding of the questionnaire, the ease of answering the questions, and the time needed to fill out the questionnaire. Accordingly, final corrections were made to the translated Arabic version.
Table 1: Reliability of the used dental anxiety questionnaire

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The target sample size was determined by considering previous DA surveys in addition to a power analysis with the program package GPower (http:// www.gpower.hhu.de/en.html) to compute the sample size given an α = 0.05, power = 0.95, and a medium effect size of 0.5 when testing for significant differences in average responses between respondents in two independent groups. The results showed that a sample size of 176 patients (88 for each group) was needed and the total collected sample size in this study consisted of 365 respondents.

Statistical analysis

Data were entered and analyzed using a computer database/statistical software package SPSS version 22.0 (SPSS Inc., IBM Corp., Armonk, NY: USA). The mean total DA score was calculated for all the categorized variables. Descriptive statistics with frequencies were calculated and presented in three tables (age group, gender, and education level); cross-tabulation was also achieved using Chi-square tests and Student's t-test to compare the study groups based on age group, gender, and educational levels. Statistical significance was defined at P < 0.05.

  Results Top

In the present study, a total of 365 subjects participated, of which the majority 226 (62%) were female and 139 (38%) were male [Table 2]. The mean (±standard deviation [SD]) of the total DA score (out of 40) was 24.33 (±6.80) for female and 19.49 (±6.81) for male, and this difference was statistically significant [Table 3].
Table 2: Frequency and percentage of demographic variables according to gender, age, education level and mean±standard deviation of the age of respondents

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Table 3: Independent t-test of dental patient's responses according to gender, age, and education level

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Concerning the age groups, [Table 2] shows that the mean age and ± SD of the respondents were 27.82 years (±11.60). Among the 365 respondents, the majority (28.49%, n =104) belonged to the age group of 19–25 years, 22.47% (n = 82) belonged to the age group of 26–35 years, 20.55% (n = 75) belonged to the age group of 13–18 years, 15.62% (n = 57) belonged to the age group of 36–45 years, 8.49% (n = 31) belonged to the age group of ≥46 years, and only 4.38% (n = 16) belonged to the age group of 0–12 years [Table 2]. The mean (±SD) of the total DA score (out of 40) was 23.41 (±6.83) for the age group below 18 years and 22.18 (±7.29) for the age group above 18 years, and the difference was not statistically significant [Table 3].

With respect to the educational level, 57.26 % (n = 209) of participants had low education including both schoolchildren and uneducated participants, while 42.74% (n = 156) had a high education which included bachelor, diploma, and postgraduate degree holders in addition to university students [Table 3]. The majority (52.60%) were schoolchildren (n = 192), 26.58% had bachelor degrees (n = 97), 13.15% were university students (n = 48), 4.66% were uneducated (n = 17), while 2.47% had diploma degrees (n = 9) [Table 2]. The mean (±SD) of the total DA score (out of 40) was 22.57 (±6.89) for the low education group (school and uneducated) and 22.37 (±7.59) for the higher education group, and this difference was not statistically significant [Table 3].

The mean (±SD) of the total DA score (out of 40) was 22.48 (±7.19) [Table 3]. The majority (50.1%) of the respondents (n = 183) showed moderate anxiety (total DA score 16–27) followed by 104 participants (28.5%) showing high anxiety (total DA score 28–40) and only 78 participants (21.4%) exhibited low anxiety (total DA score 10–15) [Table 4].
Table 4: Frequency and percentage of the level of anxiety

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The mean and ±SD of the participants' responses to the DA score questionnaire are presented in [Table 5] together with the frequency (and percentage) of participants' responses according to their levels of anxiety. High anxiety responses were observed in question 8: “How do you feel before the doctor extracts one of your teeth?” (44.94%, n = 164) and in question 6: “What do you feel before taking anesthetic injection?” (30.42%, n = 111). In addition, moderate anxiety responses were observed in question 9: “Are you worried about the final treatment result?” (72.33%, n = 264) and in question 10: “There is nothing to worry about when visiting a dentist” (63.84%, n = 233), while low anxiety responses were observed in question 5: “How do you feel when you are in a dental clinic to clean your teeth?” (54.25%, n = 198) and in question 1: “If you had a previous visit to a dentist, how did you feel?” (41.65%, n = 152).
Table 5: Frequency, percentage, mean±standard deviation of participants responses according to the level of anxiety

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Independent t-test of dental patient's responses according to gender, age and education level is presented in [Table 3]. It was observed that compared to males, females were more anxious with statistical significance in question 1: “If you had a previous visit to the dentist, how did you feel?,” question 4: “How do you feel when you sit in the dental chair before starting treatment?,” question 5: “How do you feel when you are in a dental clinic to clean your teeth?,” question 7: “How do you feel when you see dental instruments?,” question 8: “How do you feel before the doctor extracts one of your teeth?,” and question 9: “Are you worried about the final treatment result?.”

Concerning the age groups, a statistically significant difference was only observed in question 6: “What do you feel before taking anesthetic injection?” while all other questions presented no statistically significant variation. Similarly, the educational levels' groups showed no statistically significant difference among them [Table 3].

The degree of DA differed according to the demographic characteristics such as gender, age, and level of education [Table 6]. Among the high anxiety group, 81% were female (n = 84) while 19% were male (n = 20) and this difference was statistically significant. The highest levels of anxiety were recorded in the age groups of 13–18 (25%) and 19–25 years (27%) when compared to the other age groups; however, the difference was statistically insignificant. Furthermore, schoolchildren group demonstrated the highest anxiety scores (53%) compared to the other educational levels, yet the difference was not statistically significant.
Table 6: Distribution of participant responses (frequency and percentage) by gender, age, and education level according to the overall anxiety score

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  Discussion Top

Despite the technological advances in modern dentistry, yet anxiety about dental treatment and fear of pain associated with it remained widespread.[68] DA afflicts a significant proportion of people of all ages from different social classes and results in poor oral health by avoiding dental treatment, irregular dental attendance, and/or poor cooperation with the dentist.[69]

To improve the quality of oral health care, dental practitioners need to assess their patients preoperatively for DA and use appropriate management techniques based on the outcomes of the assessment. In addition, dentists need to monitor their patients intraoperatively to ensure effective analgesia.

Many scales were developed to assess DA including CDAS,[36] MDAS,[70] Weiner's Fear Questionnaire, Dental Anxiety Inventory (DAI)[71] and short DAI,[7] DFS,[57] state-trait anxiety inventory,[72] and adolescents' fear of dental treatment cognitive inventory.[73] However, none of these existing instruments has been regarded as a gold standard as they have their own limitations.[74] Frequently, the two mostly used measures of overall dental fear in adults are the CDAS [36] and Kleinknecht's DFS.[57] The CDAS is considered as a simple, easy to score test which can be used by a dentist for dental visit associated anxiety, and the MDAS was developed to improve the psychometrics and content validity of the original CDAS by adding an item about receiving dental injection which was ranked high in terms of fear and anxiety.[5],[71] Even though the CDAS and MDAS are the often used measures, there are many studies that have used other recognized scales such as DFS and some studies, such as Bare and Dundes [67] being used custom-made scales for DA. Sousa et al. reported that researchers often adapt existing questionnaires to better fit the purpose of their study.[75] Hence, in the current research, through the pilot study, there were minor modifications of some of the items in the questionnaire to ensure better simplicity, comprehension, and easy responding by the patients attending REU clinics without affecting the reliability (having consistent measurements) and validity (measuring what it is supposed to be measured).

As a consequence of the presence of many methods in the literature to assess anxiety, there was always a difficulty in comparing the anxiety prevalence across the different studies.[76]

In the current study, both the MDAS and DFS were chosen as a basis for the questionnaire because the MDAS has been found to be reliable and valid in several samples from England, Scotland, Wales, Ireland, Finland Dubai, Brazil, and Turkey [53],[70],[77],[78],[79] and the DFS assessed a broader array of dental stimuli than the MDAS. Hence, the applied questionnaire in the current study consisted of five questions from the MDAS in addition to five more questions adopted from the DFS regarding patients' fears toward the treatment or the instruments. This questionnaire was confirmed to be internally reliable with a Cronbach's alpha of 0.889 for the application of the scale in patients attending the REU dental clinics.

In this studied population, DA was highly prevalent, where the percentage of highly anxious patients was 28.5%. This percentage correlated with numerous studies that have reported high DA levels in approximately 10%–20% of their participants.[29],[80],[81],[82]

This percentage correlated with previous studies such as Gaffar et al.,[83] who studied DA prevalence in adult patients attending the dental clinics at the University of Dammam, Saudi Arabia, and found that the prevalence of DA was 27% among the study sample. Similarly, our results correlated with Al-Khalifa,[28] who reported DA scores in Dammam and Jeddah, Saudi Arabia, as 22.7% and 31.9%, respectively, and Kirova et al.,[84] who found the percentage of people scoring high DA score of 29.9% in Bulgaria. Moreover, Coolidge et al.[55] reported the prevalence of DA to be 34% in the Greek version of the MDAS.

However, our results were high in comparison with the results from other countries such as the United Kingdom (11%),[81] Northern Ireland (19.5%),[85] Turkey (23.5%),[53] and Brazil (23%).[86]

The Scandinavian countries expressed the least prevalence of DA as of 3% in Finland,[85] 4.7% in Sweden,[87] and 4.2% in Denmark.[8]

In contrast, a high percentage of people with DA (48.3%) was reported in Jeddah, Saudi Arabia,[88] India (46%),[89] and Iran (58.8%).[90] A 39% prevalence of dental fear was reported by Quteish Taani among Saudi undergraduate students.[91]

Moreover, in a study to compare variations in DA among different populations, Schwarz and Birn [25] reported that the mean DA scores were significantly higher in the Chinese than in the Danish population. They attributed these variations to different sample sizes, different methodology, different mentalities, or different dental health care systems.

In the present study, it was obvious that female respondents showed a higher mean total DA score (out of 40) of 24.33 compared to male respondents who only scored 19.49 and this difference was statistically significant. This result was in agreement with the majority of the previous studies, reporting that females generally demonstrate higher levels of DA than their male counterparts.[79],[89],[90],[92],[93],[94],[95],[96]

Medical and psychological research on human response to pain stimuli had generally found that females report higher levels of anxiety and exhibit less tolerance for pain at given stimulus intensities than males.[5] In addition, females were more likely to self-report than males who would not express their fears as openly as females.[97] However and in contrast, our results disagreed with Thomson et al.[98] and Kumar et al.[99] This variation among different studies may be attributed to the cultural differences.

The results from this study showed that the mean DA score decreased with increasing age where younger patients showed higher DA level compared to their elder counterparts, but this variation was not statistically significant. This finding agreed with many previous studies.[2],[13],[43],[56],[95],[100],[101],[102],[103]

Locker and Liddell [104] correlated this reduction in anxiety with age to age-dependent cerebral deterioration, extinction or habituation, increased ability to cope with the experience and more exposure to systemic diseases and various therapies. Moreover, young individuals are more anxious about career and work issues which can be reflected as a higher level of DA. However, this finding was contrary to the findings of Tunc et al.,[53] Thomson et al.,[98] Nair et al.,[105] Saatchi et al.,[90] and Moore et al.,[8] who reported that the dental fear and anxiety were not affected by age.

The current study showed that the mean DA score decreased with increasing level of education where the less educated patients showed higher DA level compared to those with higher education levels. However, this variation was not statistically significant. These results agreed with several studies that showed such an inverse relationship between DA and the level of education and indicated that more highly educated patients presented fewer DA scores.[89],[92],[100],[106] This could be attributed to the ability of the more educated people to cope better and rationalize difficult situations rather than avoiding them. According to a report by Berggren and Meynert,[107] a low education level is among the primary reasons for dental fear and avoiding regular dental care. This may be due to the social distance between a highly educated dentist and the dental patient with little education, which results in the patient's embarrassment and worries about problems of communication in a physician–patient relationship.[108] In contrast, Saatchi et al.[90] stated that dental fear and anxiety were not affected by the education level and Al-Dosari [109] showed that 24% of noneducated individuals were fearful compared to 47% of those with a university degree in education.

In the current study, it was observed that the highest mean DA score (3.01 ± 1.10) was reported in response to the question asking about the feeling before tooth extraction followed by the question asking about local anesthetic injection (2.65 ± 1.14). In addition, it was found that the least mean DA score was seen in response to the question inquiring about feeling toward cleaning teeth (1.76 ± 0.97). These results indicated that DA is linked to the dental procedures that were assumed to cause more pain. These findings were consistent with the results of Moore et al.[8] and Humphris et al.,[85] who found that the dental anesthetic injection was the most anxiety-provoking item and that scaling and polishing were the least anxiety-provoking procedures.

Oosterink et al.[110] studied the anxiety-provoking capacity of 67 stimuli characteristics of the dental setting and reported that “invasive” surgical procedures were rated as the most anxiety-provoking compared to “noninvasive” dental procedures that were rated as the least anxiety provoking. Rodríguez Vázquez et al.[111] assessed the stress among the Spanish population seeking primary dental care and found that 10% of 804 patients experienced a high level of stress before undergoing dental extraction. Naidu and Lalwah [112] investigated a sample of adult West Indians and observed that half of the participants were extremely anxious for drilling of the tooth, local anesthetic injections, and tooth extraction. Similarly, Liau et al.[113] reported that the majority of patients (82.6%) were anxious toward dental extraction.

In a study of dental phobia among Saudis,[114] it was found that in a sample of men and women over 25 years, half of the dental phobics said their fear began following a traumatic experience, while 45% said the fear began after seeing someone fearful and in pain in the dental clinic. Men and women stated that their fear began at the age of 17 and 15 years, respectively. Seventy per cent of women reported fear more often than men with greater severity.

Brady et al.[115] found that 60% of all patients reported that they were “afraid it's going to hurt” where fear of the needle was reported to be the most anxiety-provoking stimulus followed by fear of the drill. This supports findings by other studies where fear of injections was found to lead the anxiety-provoking stimuli in the dental situation followed by the drill.[6],[116]

A significant percentage of anxious patients feared “feeling out of control” and “a negative experience” about their dental visit. Dickinson and Fiske [117] proposed a “traffic light system” of hand controls that allowed patients to have some control over the progress of their treatment. By explaining to a patient that they can signal to the dentist to stop at any time by raising their hand, the patient is likely to feel more in control of the situation and therefore able to better manage their anxiety.

Between 6% and 15% of the world's adult population suffers from avoidance of dental care due to high DA and phobia.[118] The high prevalence of DA is reflected in the high costs determined by the fact that people avoid the treatment and require it only in cases of emergency or when the necessary restorations are extremely expansive.[119]

Treating such anxious patients is stressful for the dentist, due to limited cooperation, thus requiring more treatment time and resources, ultimately resulting in an unpleasant experience for both the patient and the dentist.[120],[121] Eli suggested that a strained dentist–patient relationship dominated by severe anxiety resulted in misdiagnosis during vitality testing for endodontic therapy.[122] Therefore, it is necessary to measure the different aspects of DA so that a behavioral intervention could be implemented among such patients.

The limitations of the study include that the questionnaire was self-administered, with possible over or underestimation of the participants' responses. This could be overcome in the future research by asking the respondents verbally by an interviewer or via an open-ended question to elaborate what they thought each questionnaire item really meant. This approach allows the investigator to make sure that there is no confusion regarding the questionnaire statements.

  Conclusion Top

It was observed in this study that a considerable number of patients attending REU dental clinics exhibited DA. This anxiety was more intense among female patients, younger age groups and the less educated individuals. It could be possible that self-reported DA assessment measures can provide valuable information to the dentists interested in evaluating and reducing their patients' anxiety levels. Good dentist–patient communication by allowing patients to express their anxieties would enable the dental team to prevent and reduce many of the factors responsible for DA.


We are grateful to the patients visiting the dental clinics of the College of Dentistry, Riyadh Elm University, for their participation in the questionnaire. Furthermore, the authors' express sincere thanks and appreciation to Dr. Osama Al-Mugerien and the dental student Areej A. Al-Gahtani, who provided great help in facilitating data collection.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]

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