Research Article
ISSN: 2471 657X
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
*Corresponding author: Najlaa M. Alshathri, BDS, Riyadh Colleges of Dentistry and Pharmacy, Saudi Arabia. E-mail: Najlaa.alshathri@gmail.com
Citation: Najlaa M. Alshathri et al. (2017), The Relationship between Dental Anxiety Level and Patients’ Knowledge of the Procedure. Int J Dent & Oral Heal. 3:9, 105-115. DOI: 10.25141/2471-657X-2017-9.0092
Copyright: ©2017 Najlaa M. Alshathri et.al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited
Received Date: 31 October 2017; Accepted Date: 10 November, 2017; Published Date: November 30, 2017

Abstract:

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 dental anxiety.
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 the producers.

Introduction:

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 [1]. Generally fear is defined as an individual’s response to a real threatening event or dangerous situation to protect his or her life[2], while Specific phobia is an anxiety disorder classification that represents unreasonable or irrational fear related to a specific object or situation [3]

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[6]. 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[9]. 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[10]. Another study in 2011, involving 1,600 Saudi students, revealed that 22% displayed a high degree of dental fear[11]. 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.[12].

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[13].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 [16], blood pressure, heart rate [17],immunity in the form of natural killer cells activity [18] and hormones such as cortisol [19].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 [20].Upon activation of the hypothalamic-pituitary-adrenal axis, cortisol is secreted from the adrenal cortex to the saliva and all other body fluids[21]. 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[22]. Cortisol levels were shown to be higher in patients undergoing wisdom teeth extractions and before emergency dental care[23]. Similar to alpha amylase, cortisol has a definite circadian rhythm [21]. 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[24].A Saudi study found that oral health knowledge will enhance oral health by transforming knowledge into appropriate behaviors [25]. 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 [26]. 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 Questionnaire:

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[27].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 48.3% [15].

Physiological Test:

Pulse Oximeter

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)[28].

Salivary Cortisol

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:

  1. Standard dilution: this test kit will supply one original Standard reagent and dilution occurs according to the instruction.
  2. The quantity of the plates depends on the quantities of to-betested saliva and the standards.
  3. 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.
  4. Confection: dilute 30 times the 30×washing concentrate with distilled water as standby.
  5. Washing: remove the membrane carefully, and drain the liquid, shake away the remaining water.
  6. Add chromogen solution A 50µl, then chromogen solution B 50µl to each well. Gently mixed, incubate for 10 min at 37 C0 away from light.
  7. Stop: Add Stop Solution 50µl into each well to stop the reaction (the blue changes into yellow immediately).
  8. 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.
  9. 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.

Statistical Analysis:

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.

Results:

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= .163) (Table.1).


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

Discussion:

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 [29]. In stressful situations, the sympathetic nervous system is responsible for the release of epinephrine and norepinephrine, which causes the acceleration of heart rate[30]. 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.[22] 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 [31]. 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 [32]. 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[33]. 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.

Conclusion:

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.

Recommendation:
Furtherer investigation with larger sample size is needed in the future to determine the correlation between the heart rate and salivary cortisol level.

References:

  1. Yuzugullu, B., et al., Dental anxiety and fear: relationship with oral health behavior in a Turkish population. The International Journal Prosthodontics, 2014. 27(1): p. 50-3.
  2. Bay, E.J. and D.L. Algase, Fear and anxiety: a simultaneous concept analysis. Nursing Diagnosis, 1999. 10(3): p. 103-11.
  3. LeBeau, R.T., et al., Specific phobia: a review of DSM-IV specific phobia and preliminary recommendations for DSM-V. Depress and Anxiety, 2010. 27(2): p. 148-67.
  4. Milgrom P, W.P., Getz T, Treating fearful dental patients a patient management handbook. 1995(2nd ed).
  5. Aartman, I.H., et al., Self-report measurements of dental anxiety and fear in children: a critical assessment. ASDC journal of dentistry for children, 1998. 65(4): p. 252-8, 229-30.
  6. Canakci, C.F. and V. Canakci, Pain experienced by patients undergoing different periodontal therapies. Journal of the American Dental Association, 2007. 138(12): p. 1563-73.
  7. Maggirias, J. and D. Locker, Psychological factors and perceptions of pain associated with dental treatment. Community Dentistry and Oral Epidemiology’s, 2002. 30(2): p. 151-9.
  8. Sullivan, M.J. and N.R. Neish, Psychological predictors of pain during dental hygiene treatment. Probe, 1997. 31(4): p. 123-6, 135.
  9. McGrath, C.B., R, The association between dental anxiety and oral health-related quality of life in Britain Community Dentistry and Oral Epidemiology, 2004. 32: p. 67-72.
  10. Wael Mousa AL-OMARI, M.K.A.-O., DENTAL ANXIETY AMONG UNIVERSITY STUDENTS AND ITS CORRELATION WITH THEIR FIELD OF STUDY. Journal of Applied Oral Science, 2009. 17(3): p. 199-203.
  11. Abu-Ghazaleh, S.B.R., L.D.; Sonbol, H.N.; Aljafari, A.K.; Elkarmi, R.F.; Humphris, G., The Arabic version of the modified dental anxiety scale. Psychometrics and normative data for 15–16 years old. Saudi Medical Journal, 2011. 32: p. 725-729.
  12. Shaikth, M.A.K., A., Over dental anxiety problems among university students: Perspective from Pakistan. Journal of the College of Physicians and Surgeons --Pakistan. 2011. 21: p. 237-238.
  13. Kleinknecht R, B.D., The assessment of dental fear. Behavioral Therapy 1978. 9: p. 626-634.
  14. Eitner, S., et al., Dental anxiety--an epidemiological study on its clinical correlation and effects on oral health. Journal of Oral Rehabilitation, 2006. 33(8): p. 588-93.
  15. Jason M. Armfield, G.D.S. and, and A.J. Spencer, Dental fear and adult oral health in Australia, Community Dentistry and Oral Epidemiology, 2009. 37(3): p. 220-230.
  16. Maes, M.e.a., Influence of academic examination stress on hematological measurements in subjectively healthy volunteers. Psychiatry Research, 1998. 80: p. 201-212.
  17. Hughes, B.M., Academic study, college examinations, and stress: issues in the interpretation of cardiovascular reactivity assessments with student participants. Journal of Applied Biobehavioral Research, 2004. 9: p. 23-44.
  18. Borella, P.A., Rovesti, S., Pinelli, S., Vivoli, R., Solfrini, V., & Vivoli, G., Emotional stability, anxiety, and natural killer cell activity under examination stress. Psychoneuroendocrinology, 1999. 24: p. 613-627.
  19. Hellhammer, D.H., Heib, C., Hubert, W., & Rolf, L., Relationships between Slivery Cortisol Release and Behavioral Coping under Examination Stress. IRCS Medical Science. Psychology and Psychiatry, 1985. 13: p. 1179-1180.
  20. Nater U and R. N, Salivary alpha-amylase as a noninvasive biomarker for the sympathetic nervous system: current state of research. Psychoneuroendocrinology, 2009. 34: p. 486-496.
  21. Sadi, H., M. Finkelman, and M. Rosenberg, Salivary cortisol, salivary alpha amylase, and the dental anxiety scale. Anesthesia Progress, 2013. 60(2): p. 46-53.
  22. Takaia N, Y.M., Aragakia T, Etoa K, Uchihashia K, Nishikawa Y., Effect of psychological stress on the salivary cortisol and amylase levels in healthy young adults. Archives of Oral Biology, 2004. 49: p. 863-968.
  23. Miller, C.S., et al., Salivary cortisol response to dental treatment of varying stress. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontics, 1995. 79(4): p. 436-41.
  24. Van Wijk, A.J. and J. Hoogstraten, Reducing fear of pain associated with endodontic therapy. International Endodontic Journal, 2006. 39(5): p. 384-8.
  25. Wyne, A.H., et al., Oral Health knowledge and Sources of Information among male Secondary School Children in Riyadh. Saudi Dental Journal. 2005, 17.
  26. Goyal, A., et al., Impact of dental fear on oral health-related quality of life among school going and non-school going children in Udaipur city: A cross-sectional study. Contemporary Clinical Dentistry, 2014. 5(1): p. 42-8.
  27. Dailey YM, Humphris GM, and L. MA, The use of dental anxiety questionnaires: a survey of a group of UK dental practitioners. British Dental Journal, 2001. 190: p. 450-453.
  28. Brand TM , et al., Enamel nail polish does not interfere with pulse oximetry among normoxic volunteers. Journal of Clinical Monitoring and Computing 2002. 17(2).
  29. King SL, H.K., stress hormones: how do they measure up? Biological Research for Nursing, 2002. 4: p. 92-103.
  30. Seaward, B.L., Managing stress principles and strategies for health and well-being 5th edition ed.
  31. Pani, S.C., Assessment of the Impact of Stress and Anxiety on Pain Perception in Patients Undergoing Surgery for Placement of their First Dental Implant. Journal of Oral Health and Dental Management, June, 2014. 13 (2).
  32. Goulart, J.C.F., et al., Influence of anxiety on blood pressure and heart rate during dental treatment. The Revista Odonto Ciência, 2012. 27(1): p. 31-35.
  33. Kazue Kanegane, et al., Dental anxiety and salivary cortisol levels before urgent dental care. Journal of Oral Science, 2009. 51(4): p. 515-520.

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