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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 6  |  Issue : 2  |  Page : 42-49

Pretreatment assessment of anxiety levels among patients undergoing surgical and nonsurgical therapy – A cross-sectional study


1 HOD, DAPMRV Dental College, Bengaluru, Karnataka, India
2 Postgraduate Student, DAPMRV Dental College, Bengaluru, Karnataka, India
3 Reader, Department of Periodontology, DAPMRV Dental College, Bengaluru, Karnataka, India
4 Private Practitioner, Patnam, Bihar, India

Date of Submission31-May-2020
Date of Acceptance02-Jul-2020
Date of Web Publication31-Oct-2020

Correspondence Address:
Dr. Surya Suprabhan
CA-37, 24th Main, JP Nagar, ITI Layout, 1st Phase, Bengaluru - 560 078, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijohr.ijohr_12_20

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  Abstract 


Aim: The aim of this study is to evaluate the comparison of pretreatment anxiety levels among patients undergoing nonsurgical and surgical periodontal therapy. Materials and Methods: A total of 100 patients were included in the study. In Group A, 50 patients undergoing nonsurgical periodontal therapy for the first time were included, whereas in Group B, 50 patients undergoing surgical periodontal therapy for the first time were included. Matching was done with respect to age and gender for both the groups. Just before the procedure, a questionnaire form containing modified dental anxiety score was used to check anxiety levels. Once the patient had marked the score, total score was calculated. The collected data were tabulated and analyzed statistically using the independent student t-test. Results: There was no significant difference in the pretreatment anxiety levels between both the test groups. Pretreatment anxiety was more among females in both groups compared to males. Conclusion: In this study, there was no statistical difference between both the test groups. However, there are some studies which show that surgical group is less anxious than nonsurgical group; hence, a larger sample size is needed to confirm these findings. Further studies are needed to address the dental anxiety levels in different populations' age wise and gender wise, which will help dental-care providers to better manage their patients.

Keywords: Anxiety, periodontitis, pretreatment


How to cite this article:
Suchetha A, Suprabhan S, Darshan B M, Sapna N, Apoorva S M, Khawar S. Pretreatment assessment of anxiety levels among patients undergoing surgical and nonsurgical therapy – A cross-sectional study. Indian J Oral Health Res 2020;6:42-9

How to cite this URL:
Suchetha A, Suprabhan S, Darshan B M, Sapna N, Apoorva S M, Khawar S. Pretreatment assessment of anxiety levels among patients undergoing surgical and nonsurgical therapy – A cross-sectional study. Indian J Oral Health Res [serial online] 2020 [cited 2021 Jun 15];6:42-9. Available from: https://www.ijohr.org/text.asp?2020/6/2/42/299698


  Introduction Top


Dental anxiety (DA) is considered one of the main reasons for avoidance of dental care and the resultant deteriorating oral health. Many people will seek dental care only when they have a dental emergency, such as a toothache or dental abscess. Anxieties or fears usually result from direct experience and conditioning, or vicariously through information.[1] Little is understood of the natural history of DA.[2] Weiner and Sheehan (1990) have suggested that dentally anxious people could be classified into two groups: exogenous and endogenous, with respect to the source of their anxiety. In the former, DA is the result of conditioning through traumatic dental experiences or vicarious learning, while in the latter; it has its origins in a constitutional vulnerability to anxiety disorders, as evidenced by general anxiety states, multiple severe fears, and disorders of mood.[3] DA is often reported as a cause of irregular dental attendance, delay in seeking dental care, or even avoidance of dental care.[4]

DA varies in intensity from patient to patient. There are different factors that can cause DA such as stress due to school work, college work, job, relationships, and substance-induced anxiety. Mehrstedt et al.[5] and Crofts-Barnes et al.[6] have reported that those experiencing high levels of DA are among those with the poorest oral health-related quality of life. Objective assessment of DA can be done using anxiety questionnaires such as Corah's DA Scale (CDAS), Modified DA Scale (MDAS), dental fear survey (DFS), State Trait Anxiety Scale (STAI), General Geer Fear Scale, and Getz Dental Belief Survey.[7],[8],[9],[10],[11],[12],[13]

The practice among dentists to screen and evaluate the fear or anxiety of the patient before dental treatment is not common. However, with evaluation of anxiety, we can begin building the preventive programs and by understanding how they persist, we can develop more effective treatment programs. So far, only a few research papers have been published on the prevalence of DA and factors influencing DA among the Indian population.[14],[15],[16] Hence, this study aims to evaluate the pretreatment DA among patients undergoing surgical and nonsurgical periodontal therapy using MDAS.[17]


  Materials and Methods Top


The Ethical clearance for the study was obtained from the ethical committee and review board of the institution. A total of 100 patients were included in the study. In Group A, patients undergoing nonsurgical periodontal therapy for the first time were included, whereas in Group B, patients undergoing surgical periodontal therapy for the first time were included.

The inclusion criteria included age group was between 35 and 50 years for both the sexes, Study groups had equal number of male and female participants. Matching was done with respect to age and gender for both the groups, patients included in Group A had not undergone any sort of periodontal treatment before, whereas in patients included in Group B, patients had not undergone periodontal surgical therapy before.

The exclusion criteria included patients who were/are undergoing psychiatric therapy, patients who were/are taking antianxiety drugs, patients suffering from generalized anxiety disorders, and pregnant and lactating patients.

Fifty patients were included in each group. A consent form [Annexure 1] and patient information sheet were provided to the patients of both the groups after a brief explanation about the study and its purpose. The selected patients were seated on the dental chair for the procedure. Just before the procedure, a questionnaire form containing MDAS [Annexure 2] was used to assess anxiety levels. All the patients were given the questionnaire in a printed form. Once the patient had marked the score, total score was calculated.

Statistical analysis used

Data were analyzed using the version 19.0; SPSS Inc., Chicago, IL, USA. Independent student t-test was done to compare mean total MDAS score between both the groups at 95% confidence interval. The level of significance will be set at P < 0.05.


  Results Top


  1. Gender distribution [Table 1] and [Graph 1] – A total of 50 patients were included in each group. Each group had equal number of male and female patients (25 each)
  2. Age distribution [Table 2] and [Graph 2] – Of the selected 100 patients, in Group A, mean age distribution was 40.48 years (range 35–50 years), whereas in Group B was 41.16 years (range 35–50 years)
  3. Intergroup assessment of anxiety [Table 3] and [Graph 3] – The mean value of anxiety levels using MDAS among Group A patients were 11.18, whereas for Group B, it was 10.38. The mean difference in MDAS was 0.8 which was statistically insignificant with P = 0.38
  4. Intragroup assessment of anxiety levels genderwise [Table 4] and [Table 5] and [Graph 4] and [Graph 5] – The mean value of anxiety levels using MDAS among male patients were 9.52, whereas for female patients, it was 12.84. The mean difference in MDAS was 3.32 which were statistically significant with P = 0.01. The mean value of anxiety levels using MDAS among male patients was 8.76, whereas for female patients, it was 12. The mean difference in MDAS was 3.24 which were statistically significant with P = 0.004
  5. Intergroup assessment of anxiety levels among males [Table 6] and [Graph 6] – The mean value of anxiety levels using MDAS among Group A male patients were 9.52, whereas for Group B male patients, it was 8.76. The mean difference in MDAS was 0.76 which was statistically insignificant with P = 0.49
  6. Intergroup assessment of anxiety-females [Table 7] and [Graph 7] – The mean value of anxiety levels using MDAS among Group A female patients were 12.84, whereas for Group B female patients, it was 12. The P = 0.52. The mean difference in MDAS was 0.84 which was statistically insignificant with P value (0.52).
Table 1: Gender distribution

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Table 2: Age distribution

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Table 3: Inter group assessment of anxiety levels using modified dental anxiety score

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Table 4: Intra group assessment of anxiety levels using modified dental anxiety score among males and females in Group A

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Table 5: Intra group assessment of anxiety levels using modified dental anxiety score among females in Group B

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Table 6: Inter group assessment of anxiety levels using modified dental anxiety score among males of both the groups

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Table 7: Inter group assessment of anxiety levels using modified dental anxiety score among female of both the groups

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  Discussion Top


Psychosocial factors such as anxiety and stress have been shown to impact wound healing and pain perception.[18],[19],[20] However, the connection between the body and mind is a topic of much controversy. The current theory suggests that psychosocial factors induce the activation of the peripheral sympathetic system and adrenal medulla. When stimulations are sustained, they can result in the release of glucocorticoids and mineral corticoids, which have direct effects on cellular physiology, leading to reduced wound healing and immune response.[21] DA affects a significant proportion of people of all age groups from different socioeconomical classes and remains to be serious concern for both the dentist and the patient for seeking dental health care.[22]

The etiology of DA depends on the age of onset; likewise, during childhood, the cause is usually a negative dental experience, and in adulthood, it is more likely due to general anxiety states. DA can cause a person to delay or avoid seeking dental health care despite being in need of treatment.

Several questionnaires and rating scales have been developed for such purpose. Objective assessment of DA can be done using anxiety questionnaires such as Corah's Dental Anxiety Scale (CDAS), Modified Dental Anxiety Scale (MDAS), Dental Fear Survey (DFS), State Trait Anxiety Scale (STAI), General Geer Fear Scale and Getz Dental Belief Survey. The MDAS, a modified version of the original CDAS, is commonly used to measure anxiety for community-based research and is easy to compare responses. The advantages of the MDAS include its reliability, validity, and ability to be translated into different languages.[23],[24]

The MDAS is a simple, valid, and good predictor of patients' distress in the dental operatory. Knowledge of a patient's anxiety before the treatment can be an aid to the dentist in two ways. He can become aware of what to expect from the patient, and he can take measures to help alleviate the anxiety of the patient. The MDAS requires very little time approximately 3–5 min and can be done easily in the waiting area. More importantly, the process of completion does not raise the patient's anxiety level. MDAS has been translated into different languages, namely, Arabic, Chinese, Greek, Romanian, Spanish, Tamil, Turkish, and Italian. It has a good cross-cultural reliability and validity.[23]

In the present study, equal number of male and female patients was included in each group. Mix gender within study groups was advocated, since this was considered the best approach to equality for a research.[25] Hossinifard et al. in 2005 found that the prevalence of anxiety in adolescents was 8.4%, and there was a significant correlation between some demographic variables such as gender.[26] There are many studies which show that anxiety disorders are more prevalent among women than men.[27],[28],[29]

In nonsurgical periodontal therapy patients, the mean age group was 40.48 years (age range was 35–50), whereas in the periodontal surgical group, the mean age of the patients was 41.16 years (age range was 35–50). In this study, patients with similar age groups were considered to avoid bias.[30]

A small age group of people (35–50) was selected for the study. It is said that the mean anxiety score reduced with increasing age which is in agreement with the studies of McGrath and Bedi,[31] Ng and Leung,[32] Acharya,[33] Yuan et al.,[11] Appukuttan et al.,[23] and Settineri et al.[34] Younger patients were more anxious compared to their elder counterparts. However, several other studies[13],[35],[36] contradicted the trend occurring widely among younger patients. Locker and Liddell[37] correlated this reduction in anxiety with age to age-dependent cerebral deterioration, extinction or habituation, increased ability to cope with experience, and more exposure to systemic diseases and treatment. Hence, only middle age group patients were selected for the study.

There were no significant differences between the pretreatment anxiety levels between the nonsurgical and surgical periodontal patients. This finding can be because of the smaller sample size. But according to a study done by Kloostra et al.,[38] it is said that nonsurgically treated periodontal patients had higher levels of psychosocial distress than surgically treated patients on the day of treatment. This finding contradicted the expectation that surgical treatment may evoke stronger reactions than nonsurgical treatment. One possible explanation for this finding might be that patients presenting for surgery might have received nonsurgical treatment previously and therefore, might have spent more time with the clinician before the day of the surgical treatment. These multiple encounters with the doctor may have increased their familiarity and trust in the doctor, which in turn may have reduced the anxiety, depression, and stress of patients on the day of the treatment. According to a study done by Patel et al.,[39] the results showed that patients with periodontal disease who decided against recommended surgical treatment and instead, received nonsurgical treatment had higher general and DA than patients who decided to have surgical treatment. Positive communication and good rapport between a provider and a patient can reduce a patient's anxiety and stress and thus need to be crucial components of a patient-centered approach to providing surgical and nonsurgical treatment.

In nonsurgical periodontal group, the mean value obtained on MDAS among males was 9.52, whereas for females, it was12.84. In periodontal surgical group, the mean value obtained on MDAS among males was 8.76, whereas for females, it was 12. When the values were compared between males and females, the difference in the values were found to be statistically significant in both the groups. DA was greater among females compared to males. This can be explained by the fact that males are more emotionally stable than females.[40] These findings corroborated the results from previous studies that showed higher levels of anxiety among females.[41]

It has been reported earlier that females are more responsive to a particular stimulus (like fear of the needle) than males which could be the reason for higher anxiety levels reported by females.[42] Another reason for this trend could be that males tend to hide their fears due to their conventional gender role which has been reported earlier by Pierce and Kirkpatrick.[43]

However, the most appropriate reason for this could be attributed to neuroticism which is governed by the characteristics of being anxious, angry, and jealous and which has been reported higher in females by several studies.[44],[45]

There was no statistically significant difference in anxiety levels on using MDAS in males between nonsurgical and surgical group. There was no statistical significance difference in anxiety levels on using MDAS in females between nonsurgical and surgical group.


  Conclusion Top


Many research studies have shown that anxiety, stress, and depression have a clear relationship with patients' responses to surgical and nonsurgical treatment. It can be concluded that pretreatment anxiety is more among females in both groups compared to males. However, there was no difference between the anxiety levels among the surgical and nonsurgical periodontal treatment groups. And also, while evaluating the response forms, it was seen that most of the patients were anxious about local anesthetic injection. Further studies are needed to address the DA levels in different populations-age wise and gender wise, which will help dental care providers to better manage their patients. And also a larger sample size is needed to confirm these findings. More information should emerge in this field since specialties in dentistry are becoming more available to the public, and none has given adequate attention regarding patient management prior to and during specific dental treatments. The development of DA could be prevented with pain control, behavior management, and consideration of patient as a whole. The inclusion of behavior sciences in dental education and the integration of ethical considerations in the academic dental curriculum could help to improve the situation.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.


  Annexures Top


Annexure 1

Department of Periodontics, D.A P.M.R.V. Dental College, Bangalore

Consent Form

I, ______________________________ aged about _________years, by my own volition, hereby give my consent to be a part of the clinical study conducted by Dr. Surya Suprabhan, Department of Periodontics, D.A.P.M.R.V Dental College and Hospital, Bangalore.

I have been informed in detail, in the language known to me, about the procedure to be carried out, its advantages and possible disadvantages.

Patient's Signature: ___________

Name (in block letters): ______________

Address: ________________

Tel No: ______________________

WITNESS: ________________

Signature: _____________________

Name: _____________________

Address: ___________________

Phone number: _____________________

Attending doctor's signature: _____________


  Annexure 2 Top


Annexure 2: The modified dental anxiety scale (MDAS)

Name:_________________ Date: ____________

Age: ____________

Sex: _______________

Directions: Can you tell us how anxious you get, if at all, with your dental visit? Read each question and then mark the statement that indicates how you feel right now, that is, at this moment. There is no right or wrong answers. Do not spend too much time on any statement but give the answer which seems to describe your present feelings best

  1. If you went to your dentist for treatment tomorrow, how would you feel?


    1. Not anxious
    2. Slightly anxious
    3. Fairly anxious
    4. Very anxious
    5. Extremely anxious.


  2. If you were sitting in the waiting room (waiting for treatment), yow would you feel?


    1. Not anxious
    2. Slightly anxious
    3. Fairly anxious
    4. Very anxious
    5. Extremely anxious.


  3. If you were about to have a tooth drilled, how would you feel?


    1. Not anxious
    2. Slightly anxious
    3. Fairly anxious
    4. Very anxious
    5. Extremely anxious.


  4. If you were about to have your teeth scaled and polished, how would you feel?


    1. Not anxious
    2. Slightly anxious
    3. Fairly anxious
    4. Very anxious
    5. Extremely anxious.


  5. If you were about to have a local anaesthetic injection in your gum, how would you feel?


    1. Not anxious
    2. Slightly anxious
    3. Fairly anxious
    4. Very anxious
    5. Extremely anxious.


Instructions for scoring The Modified Dental Anxiety Scale (Remove this section below before copying for use with patients).

Each item scored as follows: 1 = Not anxious 2 = Slightly anxious 3 = Fairly anxious 4 = Very anxious 5 = Extremely anxious.

Total score is a sum of all fine items, range 5–25: Cut-off is 19 or above which indicates a highly dentally anxious patient, possibly dentally phobic

 
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]



 

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Abstract
Introduction
Materials and Me...
Results
Discussion
Conclusion
Annexures
Annexure 2
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