The Relationship etween Dental Anxiety Level and Patients’ Knowledge of the Procedure
Najlaa M. Alshathri1*, Bayan M. Dada1, Rowa M. Alghofaili1, Deema W. Altuwairq1, Ahmed Tawfig Gamal2
1BDS Riyadh Colleges of Dentistry and Pharmacy, Saudi Arabia
2Assistant Professor Department of Preventive Dentistry, Riyadh Colleges of Dentistry and Pharmacy, Supervisor, Saudi Arabia
Background and Aim: Patients avoids dental treatments due to fear and anxiety. Our aim is to determine the relationship between dental
anxiety level and patients’ knowledge of the procedure steps to be conducted, and to perceive the correlation between heart rate and
Material and Methods: A random sample of patients were divided in to two groups. The study group were shown a video describing
the dental procedure, after filling the Modified Dental Anxiety Scale (MDAS) questionnaire. The heart rates of the study group were
recorded four times with a pulse Oximeter; in the waiting area, while watching the video, on the dental chair and after the procedure.
The control group had their heart rates recorded three times; without watching videos.
Results: Increased heart rate were detected while watching the video, and when seated on the dental chair, the study group showed a
higher heart rate reading than the control group.
The study group showed a higher salivary cortisol level than the control.
Discussion: Salivary cortisol and heart rate can be reliable to confirm patient’s anxiety level.A positive relation found between MDAS
and both heart rate and salivary cortisol. Our study reviled increased dental anxiety among patients receiving detailed information about
Three different terms have been used concerning dental apprehension
in the literature:
Dental anxiety, fear and phobia of pain remain globally widespread
and are considered major barriers to dental treatment . Generally
fear is defined as an individual’s response to a real threatening
event or dangerous situation to protect his or her life, while
Specific phobia is an anxiety disorder classification that represents
unreasonable or irrational fear related to a specific object or situation
Fear is considered to be aroused by a real, immediately present,
specific stimulus (e.g. needles, drilling), whereas in the case of
anxiety, the source of the threat is unclear, ambiguous, or not immediately
present [4, 5].In1998 Canakci noted that a patient with a
high DAS (Dental Anxiety Score) would be more likely to present
a high pain response than a patient with a lower DAS. People
with high DAS exhibit more pain after dental treatment[7, 8]
A British study conducted in 2004, assessed the fear of dental pain
among 1,800 students, and found that 17% reported dental fear,
and 73% reported that oral health status affects quality of life.
In 2009 W. Al-Omari and M. Al-Omiri, concluded that the lack of
adequate dental health education may result in a high level of dental
anxiety among non-dental university students in Jordan. Another
study in 2011, involving 1,600 Saudi students, revealed that
22% displayed a high degree of dental fear. In the same year, a
different study was carried out in Pakistan, assessed discomfort
with regard to dental treatment among 503 university students, and
found that 21.6% of men and 24.0% of women reported negative
sensations in relation to dental treatment..
Anxiety related to dental treatment is a well-known phenomenon
that has been reported to cause 6% of the general population to avoid dental treatments.This avoidance of dental treatment, lead
to poorer oral health and oral health-related quality of life[14, 15].
Test of anxiety
The biological correlates of anxiety have not been widely examined,
but the social examination using questionnaires is often used
as a stress indicator. Stress related effects have been noted for
hematological indices such as red blood counts, hemoglobin ,
blood pressure, heart rate ,immunity in the form of natural killer
cells activity  and hormones such as cortisol .In addition, it
appears that there is disparity between social examination (self-reported)
and physiological stress that have not been correlated well
enough in the literature. This demonstrates the importance of utilizing
both social and physiological tests.
When the ANS (Autonomic Nervous System) gets activated, it
releases epinephrine and nor epinephrine from the adrenal medulla
.Upon activation of the hypothalamic-pituitary-adrenal axis,
cortisol is secreted from the adrenal cortex to the saliva and all
other body fluids. It was demonstrated in the past that salivary
cortisol increases in response to stress and anxiety, and that it also
presents an easy, noninvasive way of measuring stress. Cortisol
levels were shown to be higher in patients undergoing wisdom
teeth extractions and before emergency dental care. Similar to
alpha amylase, cortisol has a definite circadian rhythm .
In 2006, A.J.Van Wijk concluded that fear of pain for endodontic
treatment can be decreased significantly by providing positive information
about Endodontic treatment.A Saudi study found that
oral health knowledge will enhance oral health by transforming
knowledge into appropriate behaviors . In 2005, an Indian study
concluded that the impact of dental fear on oral health related quality
of life was significantly higher among non school going than
school going children, due to low socioeconomic status and lack of
awareness towards oral health and lack of dental visits .
The major objective of this study is to determine the relationship
between dental anxiety level and patients’ knowledge of procedure
steps to be conducted and to prove the correlation between salivary
cortisol level, and heart rate with dental anxiety.
Materials and Method:
A random sample of eighty patients between the ages of 20 to 50
years old who attended Riyadh Colleges of Dentistry & Pharmacy’s
dental clinic, were divided in to two groups, a study and control
group. The study group was shown a video describing the dental
procedure steps, after filling the Modified Dental Anxiety Scale
(MDAS) questionnaire. The study group participants’ heart rates
were recorded four times with a pulse Oximeter; in the waiting
area, while watching the video, on the dental chair before receiving
local anesthesia, and finally after the procedure. The control
group did not watch the video and had their heart rates recorded
three times: in the waiting area, on the dental chair and after the
procedure. A saliva sample was collected utilizing the method of
passive drooling. Participants were asked to allow the saliva to
pool at the floor of the mouth first, before ejecting it. Sample collection
was done over a maximum of 5 minutes; time and volume
of the samples were recorded. All the samples were stored at 5
degrees Celsius until the saliva cortisol analysis was performed in
the specialized laboratory. Any Patient with medical disorder, psychological disorder, under any pain or anxiety medication, smokers,
alcoholics, pregnant women and patients who refused to give
informed consent were excluded from the study.
The instrument of study used in this research will be based on
the Modified Dental Anxiety Scale (MDAS); which is a brief,
self-complete questionnaire consisting of five questions each with
a 5 category rating scale from ‘not anxious’ to ‘extremely anxious’,
It is the most well-known adult questionnaire designed to
assess dental anxiety.The original English version of the MDAS
questionnaire was translated by experienced bilingual professional
who was fluent in English (and for whom Arabic was her native
language) translated the questionnaire from English to Arabic. The
Arabic version of the MDAS had excellent internal consistency
and reliability (Alpha coefficients> 0.90). The scale was uni-dimensional,
and the percentage of patients with dental anxiety was
The Pulse Oximeter is a non-invasive method for monitoring a
person’s oxygen saturation and heart rate. Its most common (transmissive)
application mode, a sensor device is placed on a thin part
of the patient’s body, usually a fingertip. The device passes two
wavelengths of light through the body part to a photo detector.
It measures the changing absorbance at each of the wavelengths,
allowing it to determine the absorbance due to the pulsing arterial
blood alone, excluding venous blood, skin, bone, muscle, fat, and
nail polish (in most cases).
A saliva sample was collected at the same time range for both
groups utilizing the method of passive drooling, using 2-mL cryovials.
Participants were asked to allow the saliva to pool at the
floor of the mouth first, before ejecting it into the cryovials through
a short piece of straw. Samples collections were done over a maximum
of 5 minutes; time and volume of the samples were recorded.
The samples then were sent to the lab for salivary cortisol measurement.
Suggested in this study and the test were performed and
interpreted following instruction out lined in kit (Human Cortisol
ELISA Kit) MyBioSource, USA.
Principle of the test
The kit uses a double-antibody sandwich enzyme-linked immunosorbent
Assay (ELISA) to assay the level of Human Cortisol
(CORTISOL) in saliva. Human Substance Cortisol (CORTISOL)
of saliva were positively correlated assay procedure:
- Standard dilution: this test kit will supply one original Standard
reagent and dilution occurs according
to the instruction.
- The quantity of the plates depends on the quantities of to-betested
saliva and the standards.
- Inject saliva: Blank well: don’t add saliva and CORTISOL –
antibody labeled with biotin, Streptavidin-HRP, only Chromogen
solution A and B, and stop solution are allowed; other operations
are the same.
Standard wells: add standard 50µl, Streptavidin-HRP 50µl (since
the standard already has combined biotin antibody, it is not necessary to add the antibody); to be test wells: add saliva 40µl, and then
add both CORTISOL -antibody 10µl and Streptavidin-HRP 50µl.
Then seal the sealing membrane, and gently shaking, incubated 60
minutes at 37C0.
- Confection: dilute 30 times the 30×washing concentrate with
distilled water as standby.
- Washing: remove the membrane carefully, and drain the liquid,
shake away the remaining water.
- Add chromogen solution A 50µl, then chromogen solution B
50µl to each well. Gently mixed, incubate for 10 min at 37 C0 away
- Stop: Add Stop Solution 50µl into each well to stop the reaction
(the blue changes into yellow immediately).
- Final measurement: take blank well as zero, measure the optical
density (OD) under 450 nm wavelength which should be carried
out within 15min after adding.
- According to standards’ concentration and the corresponding
OD values, calculate out the standard curve linear regression equation,
and then apply the OD values of the saliva on the regression
equation to calculate the corresponding saliva’s concentration.
All the data were statistically analyzed with the IBM-SPSS ver.21
data processing software (IBM corp. Armonk, NY, USA). Oneway
ANOVA test were used to compare control & study group salivary
cortisol levels & heart rate differences in all stages. Cramer’s
Contingency Coefficient test was used to compare MDAS score
in both groups. While Pearson correlations were used to correlate
between salivary cortisol levels & heart rate on the dental chair,
and Spearman Rank Correlation were used to correlate between
MDAS, heart rate & salivary cortisol levels.
The result obtained showed that from the 80 volunteers who participated
in the research, 51 (63.75%) were female, and 29 (36.25%)
were male. The mean age was 31.35 for both groups (Fig.1, 2).
(Fig.1, 2) also shows the education level of our participants. All
of them followed this study’s inclusion criteria. Both groups had
a normal heart rate value in the waiting area. An increase in the
heart rate reading was found in the study group while watching the
video. Both groups showed a noteworthy higher HR on the dental
chair (P=0.36). While there was no significant difference in the HR
after the procedure (P=0.771).
Fig.1: Show’s Female and male level of education for control group
Fig.2: Show’s Female and male level of education for Study group
This study investigated the difference in cortisol level between the
control and study group; and found out that the mean value for salivary
cortisol level in the study group was higher than the control
group, even though it was statistically not significant (P value=
Table.1: Salivary cortisol levels for control and study groups
Prior to dental treatment; in the waiting area; both control and
study groups showed normal heart rate readings (< 90Beats/Minute).
While watching the video, the study group showed an increased
heart rate. When seated on the dental chair, both groups
displayed increased heart rate readings, however when compared
with the waiting area readings, the study group showed higher
readings than the control group (Table 2)(Fig.3).
Table.2: Patients heart rates during stages of treatment for both groups.
Figure 3: Shows heart rate values in both groups through different stages.
From the sample we have in this study, we can say that all salivary
cortisol level measurements for both groups were normally distributed,
also there were no significant statistical differences between
the groups means (±6.34). However, the study group had a higher
salivary cortisol level than the control, this difference is consider
unimportant statistically (Fig.4).
Figure 4: Salivary cortisol levels in study and control groups.
There is no relation between heart rate readings and salivary cortisol
levels within each group; moreover, ρControl and ρStudy are
estimated to be 0.000 and they are equivalent (Table 3). There is
no statistically significant relationship between the groups’ salivary
cortisol (control and study) and questionnaire result
Heart rate and salivary cortisol levels
Table 3: Heart rate and salivary cortisol levels relation in both groups.
The MDAS questionnaire was evenly distributed for both groups,
they were asked to answer the questions blindly (without knowing
which group they belonged to). As seen in the Bar chart (Fig.5)
both “Control” and “study” carry the same proportion when it
comes to the Questionnaire results: p Slightly anxious = 62.5%, π
other anxious level for each category = 9.375%.
Fig.5: Questionnaire results proportions in both groups
There is no statistically significant correlation relationship between
the salivary cortisol levels and questionnaire results for both
groups (control & study). Both “Control” and “Study” have a value
of ρsp =0.00 with salivary cortisol levels (Table 4, 5). Furthermore,
there is no statistically significant correlation relationship
between HR in the waiting area and the questionnaire results for
both groups (control & study). Both “Control” and “Study” have a
value of ρsp = 0.00 with HR in the waiting area (Table 6, 7).
Salivary cortisol levels and questionnaire results
Table 4: Salivary cortisol levels and questionnaire results for control group.
Salivary cortisol levels and questionnaire
Table 5:Salivary cortisol levels and questionnaire results for study group.
Heart rate in the waiting area and the questionnaire
Table 6: Heart rate in the waiting area and the questionnaire results in control group.
Heart rate in the waiting area and the questionnaire results
Table 7: Heart rate in the waiting area and the questionnaire results for study group
Emotional stresses increase the activity of the HPA (hypothalamic-pituitary-adrenal
axis), which results in an enhanced secretion
of adrenocortical hormones, and salivary cortisol is a reliable
measure for assessment of its activity . In stressful situations,
the sympathetic nervous system is responsible for the release of
epinephrine and norepinephrine, which causes the acceleration of
heart rate. In this study the mean value for cortisol level in the
study group was higher than the control group, even though it was
statistically not significant (P value= .163) that might be due to a
small sample size. Noriyasu Takai etal. participants also showed
an increase in cortisol level when shown a stressful video.
The lowest HR reading was recorded at the end of the procedure;
although the study group showed a lower reading than the control
group. A similar study was done in 2014 by S.C.Panie etal.
also found that the lowest heart rate recorded was after procedure,
while the highest was during implant placement . Another
study by J.C.Goylartetal etal. contradicted our findings, stating
that the heart rate did not change during the dental treatment in
relation to the anxiety level presented by the patients . That might be because of different methodology in their study they
used the “Dental Anxiety Scale”, aneroid sphygmomanometer and
a professional cardiologic stethoscope to measure the heart rate
and blood pressure, while in our study we used MDAS and pulse
oximeter to measure the heart.
Salivary cortisol levels and questionnaire results are compared for
both “Control” and “Study” groups and showed no statistically
significant correlation, although a positive relation was present between
both of them. In a disagreement with our result K.Kanegane
etal. stated that there was a tendency for negative association between
salivary cortisol and MDAS score. That might be due to
different saliva collection method, they asked their subjects to hold
a soft cotton roll in the mouth until it was saturated with saliva then
it was transferred to aplastic tube. Moreover, there is no statistically
significant correlation between heart rate in the waiting area and
questionnaire results for both groups.
Salivary cortisol level and heart rate can be reliable methods to
confirm patient’s anxiety level. A positive relation found between
anxiety scale and both heart rate and salivary cortisol, even though
the correlation between them is not detected. Our study reviled
increasing of dental anxiety among patients receiving detailed information
about the producers’ steps prior to their treatment.
Furtherer investigation with larger sample size is needed in the
future to determine the correlation between the heart rate and salivary
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