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 Table of Contents  
Year : 2018  |  Volume : 9  |  Issue : 3  |  Page : 56-63

Can the Fear of the Chair be Worsened by Dental Appointments?

1 Department of Preventive Dentistry, Lagos State University College of Medicine, Ikeja, Lagos, Nigeria
2 Department of Preventive Dentistry, Lagos State University Teaching Hospital, Ikeja, Lagos, Nigeria

Date of Web Publication31-Oct-2018

Correspondence Address:
Afolabi Oyapero
Department of Preventive Dentistry, Faculty of Dentistry, Lagos State University College of Medicine, Ikeja, Lagos State
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/denthyp.denthyp_39_18

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Introduction: Limitations in dental access and challenges associated with service delivery often necessitates the usage of an appointment system in patient care. This research aimed to determine the association between levels of dental anxiety in dental patients and dental treatment appointment at the Lagos State University Teaching Hospital (LASUTH). Materials and Methods: A descriptive study at a tertiary hospital in Lagos State. A systematic sampling method was used to enlist 149 study patients in four clinical dental departments in LASUTH, whereas sociodemographic, clinical history, and anxiety-related data were collected using a structured interviewer-administered questionnaire. Visual analog scale (VAS) was used to assess inconvenience, whereas the Modified Dental Anxiety Scale (MDAS) was used for anxiety assessment. Data entry and analysis was performed using Statistical Package for Social Sciences version 20, P value of <0.05 was considered significant. Results: The mean age of the respondents was 25.3 ± 6.8; 53% had never had a dental visit and majority felt inconvenient by the length of dental appointment (62.7%; mean VAS = 5.95 ± 2.72); higher levels of inconvenience was significantly associated with levels of anxiety (MDAS—13.96 ± 4.8; P = 0.010). At baseline, age group ≤20 years (MDAS—15.21 ± 4.0; P = 0.026), female gender (MDAS—14.44 ± 4.8; P = 0.042), and primary level of education (MDAS—0.029; P = 15.25 ± 4.7) were significantly associated with high levels of anxiety. At baseline, 14.8% had high dental anxiety (MDAS scores of ≥19), and this increased to 18.1% on the treatment appointment day. Conclusion: Dental appointments appear to be associated with impact on anxiety levels. MDAS can be used as a screening tool to identify anxious patients to determine which treatment approach to adopt and possibly give shorter appointments.

Keywords: Anxiety, anxiety scale, patient appointment

How to cite this article:
Oyapero A, Edomwonyi A, Adeniyi AA. Can the Fear of the Chair be Worsened by Dental Appointments?. Dent Hypotheses 2018;9:56-63

How to cite this URL:
Oyapero A, Edomwonyi A, Adeniyi AA. Can the Fear of the Chair be Worsened by Dental Appointments?. Dent Hypotheses [serial online] 2018 [cited 2023 Jun 2];9:56-63. Available from:

  Introduction Top

There are many factor that influence healthcare seeking behaviors. These can be grouped as those enabling professional health care or hampering it. Using Aday and Andersen’s framework for the study of access to medical care, Scheutz and Heidmann[1] explored determinants of utilization of dental care among 20 to 34-year olds. They found that in Denmark the following factors were associated with irregular use of dental services: age, sex, exercise habits, costs, and dental anxiety.[1] Anxiety, which can be seen as a demotivating factor for seeking healthcare, is used to denote responses to situations in which the source of the threat to the individual is not well defined, ambiguous or not immediately present. Dental anxiety signifies a state of trepidation that something dreadful is going to happen in relation to dental treatment, and it is often associated with a sense of losing control.[2] Dental phobia is severe sort of dental anxiety characterized by marked and persistent anxiety in relation either to clearly discernible objects such as drills or injections or the dental environment in general, which causes significant distress or interferes with social functioning.[2] Excessive fear of dental treatment procedures or associated stimuli often leads to avoidance of dental treatment resulting in more extensive treatment problems including pain, or endurance of dental procedures with intense fear.[3]

Those with dental anxiety predictably have poorer oral health habits and oral health problems,[4],[5] with many studies observing poorer self-reported[6],[7] or clinically determined oral health among them.[4],[5] When dental health was measured with the numbers of decayed, restored, or missing teeth to determine between dental fear and oral health, greater numbers of decayed teeth are found among people with dental anxiety.[4],[5] Similarly, other studies observed more missing teeth[4],[5],[8] and fewer restored teeth[4],[5] among those with severe dental anxiety. Avoidance of dental treatment due to dental anxiety not only situates the oral health of a patient at risk but also poses a severe threat to his/her general health, and the patient can suffer from a number of serious medical conditions, such as septicemia, sepsis, sinusitis, and osteomyelitis of the facial skeleton.[9]

It is well documented that dental anxiety has an impact on dental attendance. The most obvious consequence is avoidance of dental care, with dental anxiety correlating positively with the length of intervals between dental visits and frequent use of emergency care.[7],[10],[11] In addition, Gatchell et al.[12] showed that 70% of patients visiting the dentist demonstrated feelings of apprehension, and 15% avoid dental clinics due to anxiety. Dental anxiety can thus be a vicious cycle resulting in embarrassment, avoidance of dental settings, and deterioration in oral health.[13]

It is however distressing that when patients finally summon courage to attend the clinic for treatment, they often have their treatments deferred and often obtain a treatment appointment, especially in public health facilities. This may be due to the workload that the clinic has administrative lapses or systemic ineffectiveness and inefficiency. There is a possibility that this waiting period may further exacerbate the level of dental anxiety experienced by the patient. Although there are more comprehensive measures which allow for the more specific identification of aspects of the individual’s dental anxiety, the Modified Dental Anxiety Scale (MDAS) provides a simple, easy-to-use screening tool. It has been found to be acceptable both to patients and the dental team.[14] The aim of this study was to determine if there is any association between anxiety levels of patients and dental appointments at a tertiary hospital in Lagos State [Lagos State University Teaching Hospital (LASUTH)].

  Materials and Methods Top

Study design

A descriptive study of dental patients at LASUTH was conducted by means of an interviewer-administered questionnaire that was pretested. LASUTH is the Lagos State Government-owned tertiary health institutions, and it is a foremost referral centre, caring for the health needs of most residents of Lagos State and its environs.

Ethical considerations

The procedure for this study was presented to the LASUTH Health Research and Ethics Committee and written approval was acquired (LREC. 06/10/854). Participation was voluntary for all patients, and they were informed that they were free to decline to enlist and to withdraw from the study. Written informed consent was obtained from all the participants.

Sample selection

The sample size was calculated using a formula for descriptive studies: N = Zpq/d2. Using the prevalence of 8% for high dental anxiety (HDA) from a reference study,[15] a sample size of 113 was determined. The sample was however increased to 149 by dividing the sample size by 0.8 to make provision for 20% attrition. The study participants included patients referred to the Departments of Preventive Dentistry, Restorative Dentistry, Oral and Maxillofacial Surgery and Child Dental Health at the LASUTH Dental Centre from the Oral Diagnosis Unit. A systematic random sampling method was performed with initial classification into four clinical departments and consequent selection of respondents on each clinic day using the appointment register for each clinic day as the sampling frame. The sampling interval for each department (Preventive Dentistry: 3, Restorative Dentistry: 4, Oral and Maxillofacial Surgery: 4, and Child Dental Health-Orthodontics: 3) was determined based on the number of patients booked on each day, and patients were methodically selected using this interval as they obtained their appointment date.

Inclusion and exclusion criteria

Those enlisted in the study were patients who were 18 years or older that presented in the clinic with a dental ailment and obtained an appointment for any routine dental procedure. Those excluded were who had tumors and severe maxillofacial injuries that would require general anesthesia, who had a known anxiety disorder, patients with uncontrolled systemic comorbid conditions, and who refused to give their informed consent.

Data collection and data collection tool

Two interviewer-administered questionnaires were used for data collection. The first questionnaire was used at baseline when the patients received their appointment after they gave an informed consent, whereas the second one was administered on the treatment appointment day. The first questionnaire comprised closed-ended question which obtained sociodemographic information; dental history and utilization of dental services by study patients; and the MDAS section that measured dental anxiety. Sociodemographic information taken included gender, age, marital status, education, occupation, and the income level of respondents. Dental history of the sample determined their pattern of attendance, reason for dental visit, and appointment duration. For each of the MDAS questions in that segment, the respondent’s anxiety level when visiting the dentist was rated on a five-point Likert scale with scores ranging from 1 to 5.

The second questionnaire determined the self-help practices the patients resorted to while awaiting their appointment, reassessed their level of anxiety using the MDAS, and also determined the level of inconvenience caused by the appointment using the visual analog scale (VAS). The 10-cm-long line or VAS, which has a minimum score of 0 and a maximum score of 10, was used to determine the inconvenience the patients experienced during the waiting time for the dental appointment.

Modified Dental Anxiety Scale (MDAS)

The MDAS is a five-item self-report measure designed and previously validated by Humphries et al.[16] to assess levels of anxiety associated with an upcoming dental visit, the dentist’s waiting room, tooth drilling, teeth scaling, and local anesthetic injection. Responses are rated with a five-point scale, ranging from Not Anxious (score of 1) to Extremely Anxious (score of 5) and then summed to produce a total score. The MDAS has empirically devised cutoff points where scores above a certain level indicate the possibility of dental anxiety, as follows: 5 to 9 = not dentally anxious, 10 to 18 = moderate dental anxiety, and 19 to 25 = HDA.[16]

Data analysis

Data were analyzed using frequency distribution tables will be generated for all variables and measures of central tendency and dispersion will be computed for numerical variables. Because the data were normally distributed—determined by the Shapiro–Wilk test, descriptive statistics including means, standard deviations (SDs), and percentages were used to summarize the demographic variables and health-related behavior of the study sample. The Chi-square test was used to determine the level of association between categorical variables, and for the comparison of means between groups, the analysis of variance was used. Differences and associations were considered statistically significant where the associated P values are equal to or less than 0.05.

  Results Top

One hundred and forty-nine patients with mean age of 25.3 ± 6.8 and age range between 18 and 68 years who kept their treatment appointment were included in the final analysis. The highest proportion of patients (42; 28.2%) was in the ≤20 years age category, and there were more females (82; 55.0%) enrolled in the study. The majority of participants (52; 34.9%) were students, whereas 95 (63.8%) had tertiary level of education; 66 (44.3%) earned less than 20,000 naira monthly. Majority of the respondents had never visited a dentist before. Thirty-five (33.4%) respondents visit the dentist every 6 months, whereas 18 (12.1%) do so annually [Table 1].
Table 1: Sociodemographic characteristics of the study population

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Using the VAS, with the score of 10 cm corresponding to being extremely inconvenient, the mean VAS score was 5.95 ± 2.72, whereas the highest proportion of the respondents (32; 21.5%) were moderately inconvenient, whereas 25 (16.8%) were very inconvenient. The patient who felt very inconvenient had significantly higher mean MDAS scores (13.96 ± 4.8; P = 0.010) [Table 2].
Table 2: How respondents felt when they were given a dental appointment

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Tooth extraction (31.5%) was the most scheduled treatment, whereas root canal treatment (8.1%) and orthodontic treatment (8.1%) were the least. Majority (46; 30.9%) of patients waited for 2 h before being attended to, whereas 6% had to wait for more than 5 h before being seen. The highest proportion (98; 65.8%) of the dental appointments was within a month, though 3.4% had to wait for more than 6 months. During the waiting time, most (81; 54.4%) of the patients did nothing, whereas others resorted to the use of warm saline mouthwash (16.8%), self-medication (11.4%), and consultation of a chemist (8.7%) [Table 3].
Table 3: Type and duration of appointment and patients’ self-care practices during waiting period

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Overall 14.8% of the sample indicated very HDA with total scores above the 19 and above. Over 26% of the sample had moderate anxiety, whereas 59.1% had minimal or no anxiety. The drilling and local anesthetic injection items attracted the highest anxiety ratings in the study sample, with the highest mean MDAS scores (3.03 and 3.09, respectively) in both domains. Sitting in the waiting room elicited the least anxiety response with the lowest mean MDAS scores elicited (2.42) [Table 4].
Table 4: Baseline level of dental anxiety among the respondents shown by the MDAS

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Association between the overall mean (SD) MDAS scores and all the sociodemographic variables was statistically significant (P < 0.05) at baseline. Patients aged ≤20 years (15.21 ± 4.0; P = 0.026) and females (14.44 ± 4.8; P = 0.042) had significantly higher mean (SD) anxiety scores. Similarly, students (14.98 ± 4.2; P = 0.012), respondents with primary education (15.25 ± 4.7; P = 0.029), those who earned less than 20,000 naira monthly (13.86 ± 5.0; P = 0.008), and those with no previous dental visit (14.88 ± 3.7; P = 0.011) had higher mean MDAS scores as well as a greater proportion of respondents with extreme anxiety (MDAS scores ≥19) than their counterparts [Table 5].
Table 5: Association between the MDAS scores of the patients at baseline and their sociodemographic variables

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Association between the overall mean (SD) MDAS scores and all the sociodemographic variables were also statistically significant (P < 0.05) on the treatment appointment day. Patients aged ≤20 years (17.14 ± 3.1; P = 0.014) and females (16.12 ± 4.8; P = 0.011) had significantly higher mean (SD) anxiety scores. Similarly, students (16.67 ± 5.1; P = 0.011), respondents with primary education (16.64 ± 4.4; P = 0.023), those who earned less than 20,000 naira monthly (15.46 ± 5.2; P = 0.012), and those with no previous dental visit (15.24 ± 2.5; P = 0.021) had higher mean MDAS scores as well as a greater proportion of respondents with extreme anxiety (MDAS scores ≥19) than their counterparts. There was an increase in the mean MDAS scores of the respondents as well as an increase in the number of respondents with high level of anxiety (27; 18.1%) [Table 6].
Table 6: MDAS scores of the study participants on the treatment appointment day

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  Discussion Top

Dentistry is a form of health care that is extremely emotive. Dental anxiety is the fear of dental treatment or certain aspects of it, and it a situation-specific trait anxiety with a disposition to experience anxiety in dental settings. There was no loss to follow-up among our study patients possibly due to the affordable fees charged by the teaching hospital that has a subsidized payment plan and also probably due to the central location of the hospital in Lagos Metropolis. Although the response to this study was satisfactory, we cannot rule out the possibility of differences between the study sample and the population from which they were drawn necessitating some caution in the generalization of the results. A major limitation of the study was its cross-sectional design which makes it impossible to establish temporal relationships. Thus, although the results tend to support the existence of a vicious cycle in relation to dental fear, no information is available on the temporal sequence of events. To determine causality, a longitudinal study design is required.

The highest percentage of study patients was below 20 years of age, and the ages of participants were unequally distributed with about 53% of the sample aged below 30 years. This is may not be surprising because majority of the participants were scheduled for procedures which are to mainly to treat the sequelae of dental caries (root canal therapy, extractions, and fillings) and orthodontic treatment which are mainly requested by patients in this age bracket. More than half of the study patients had never had dental visits, and only a few had regular dental check-up. This further illustrates the fact that despite the high need for dental treatment, dental service use remains low and is often prompted by oral symptoms such as pain, and the need for curative treatment, highlighting the importance of preventive interventions and oral health promotion.

The prevalence of HDA in this study population was 14.8% at baseline. The prevalence of HDA is reported to vary depending on population studied and the method of measurement. A recent review, considering children and adolescents from 15 different populations, has estimated a prevalence of dental anxiety ranging from 5.7% to 19.5%.[17] Another contemporary review of current literature by Folayan et al.,[18] identified a worldwide dental anxiety prevalence ranging from 3% to 43%. An assortment of sociodemographic, behavioral, and psychosocial factors has been related to dental anxiety. Respondents of age group ≤20 years and students had the highest mean MDAS scores. Dental anxiety often peaks in adolescence and declines with age. Thus, older people have lower scores on dental anxiety measures than younger individuals, particularly after 50 years of age.[19]

In the present study, females also reported greater levels of dental anxiety than males as previously documented. This outcome is consistent with previous literature suggesting that females are more likely to be diagnosed with anxiety and phobia-related problems,[20] because they are more responsive to specific stimuli such as fear of the needles, whereas they also display more anxiety-related characteristics such as anger, self-consciousness, hostility, and introspection. The male gender in contrast tends to hide their fears due to their conventional gender roles.

The relationships between dental anxiety and other demographic variables such as income level and education have not been fully elucidated. In our study, respondents with primary education and those that earned less than 20,000 naira monthly had higher mean MDAS scores as well as a greater proportion of respondents with extreme anxiety than their counterparts. Although some studies have demonstrated that higher levels of dental anxiety are associated with low income and education,[21],[22],[23] patients with lower income customarily have increased oral disease experience and encounter more barriers to accessing dental care. Taken in combination with other variables, it would be expected that being female, having a low income, or education can be linked with higher levels of dental anxiety, and this combination has been confirmed in a study by Doerr et al.[24]

Consistent with numerous studies in the field of dental anxiety, patients who used dental care infrequently reported higher levels of dental anxiety than patients those that do so every 6 months or annually.[3],[25] An association between dental fear and dental attendance has been found in many previous studies; those with high dental fear are more likely to visit a dentist irregularly and on a problem-oriented basis rather than for regular check-ups. Even if anxious dental patients attend regular dental visits, they are likely to avoid necessary follow-up appointments to complete the required dental treatment.[26] A decision to put off dental visits may result in a short-term reduction of anxiety, but this changes over time as the likelihood of invasive treatment increases due to dental neglect. Drawing these factors into a model, Berggren and Meynert[27] suggested that fearful dental patients are often caught in a vicious cycle that accounts for the maintenance of dental fear as their treatment need increases.

Our study aimed to observe if any association exist between anxiety levels in patients from their first visit to the treatment appointment day. There was an increase in the mean MDAS scores of the respondents across all domains explored on their treatment appointment day. The proportion of respondents with HDA had increased to 18.1% on the treatment appointment day from 14.8% at baseline. For patients who experience dental anxiety, the impact on their appointment day can be debilitating, resulting either in an inability to comply with required treatment, culminating in further avoidance behavior.[28] Although causality cannot be established, this finding is significant. Outpatient clinics have a threshold capacity where service supply meets up with demand and eventually forming an infinite backlog where demand exceeds service supply. Gupta and Denton[29] distinguished between a direct waiting time that the patient experiences while waiting in the clinic and an indirect waiting time which is the sequence between appointment booking and receiving treatment. These waiting times can have a direct bearing on the patient’s anxiety-related experiences as observed in this study.

Our findings have obvious public health and service consequences for oral health, because most patients in Nigeria access oral health services from public facilities that utilize appointment systems. Some of these health institutions are however ineffectually managed due to infrastructural deficits and inadequate dental material supplies that result in prolonged and failed appointments. Because these deficiencies may have a direct bearing on the level of dental anxiety experienced by patients, it may be suitable to ensure that quality control standards on dental appointments are established and enforced. Primary oral healthcare services should also be made available for basic procedures to ameliorate challenges with current appointment systems. It is also important that the dental profession, in addition to providing ways to alleviate dental anxiety, also identifies who present with HDA at their first visit to establish qualitative and responsive care.[30] The appropriate screening of dental anxiety and fear by dental practitioners is a fundamental first step in managing patient anxiety. Simple psychological inventories such as the MDAS, which is a structured, psychometrically valid scale, can be used as a means of identifying dentally anxious patients and thus give them prompt treatment or shorter appointments.

  Conclusion Top

Majority of the study patients felt inconvenient by the length of dental appointment, and higher levels of inconvenience were significantly associated with levels of anxiety. At baseline, patients ≤20 years, females, and patients with a primary level of education had significantly higher levels of dental anxiety. At baseline, 14.8% of patients had HDA which increased to 18.1% on the treatment appointment day. Because the appointment systems in public oral health facilities are associated with some deficiencies that may have a direct bearing on dental anxiety, it may be appropriate to ensure that quality control standards on dental appointments are established and enforced. MDAS, which contains five items, is reliable and quick to administer, can be used as a screening tool to identify anxious patients to determine which treatment approach to adopt and possibly give shorter appointments where required.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Scheutz F, Heidmann J. Determinants of utilization of dental services among 20- to 34-year-old Danes. Acta Odontol Scand 2001;59:201-11.  Back to cited text no. 1
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Schuller AA, Willumsen T, Holst D. Are there differences in oral health and oral health behavior between individuals with high and low dental fear? Community Dent Oral Epidemiol 2003;31:116-21.  Back to cited text no. 4
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Klingberg G, Broberg AG. Dental fear/anxiety and dental behaviour management problems in children and adolescents: A review of prevalence and concomitant psychological factors. Int J Paediatr Dent 2007;17:391-406.  Back to cited text no. 17
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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]

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