Dental caries, age and anxiety: factors influencing sedation choice for children attending for emergency dental care

OBJECTIVES: The aim of the study was to examine how physical (dental caries) and psychosocial (age, dental anxiety and dental health behaviour) factors, associated with child and parent, influenced dentists' sedation choice when a child presents in pain. METHODS: 600 parents whose children were aged between 5 and 11 years took part: 200 attended for routine dental care (RDC); the remaining 400 attended as emergency patients and were offered either dental general anaesthesia (DGA) or relative analgesia (RA). The subjects were approached and invited to take part. The researcher was blind as to the child's pattern of dental attendance and the type of sedation offered. All parents and children completed self-reported ratings of dental anxiety. The children's teeth were examined to determine past and present dental caries experience. RESULTS: The results showed that children who were offered DGA had greater experience of dentinal caries, were younger and dentally anxious. The children offered RA were older, had a higher frequency of brushing their teeth with fluoride toothpaste and were also dentally anxious. Discriminant analysis showed that 2 canonical functions provided clear categorisation of the three treatment groups. Function 1 was a physical (dental caries) factor, which was related to the child's experience of dentinal caries. Function 2 was a psychosocial factor, which was related to the child's age, dental anxiety and frequency of tooth brushing. A greater proportion of the variance in the treatment offered was explained by Function 1, suggesting that the most important factor in the decision to offer DGA was dentinal caries. Function 2 was of lesser importance. CONCLUSIONS: The findings have implications for the type of sedation offered to children presenting for emergency care. These children may not otherwise receive treatment and the need to provide less anxiety provoking forms of sedation must be promoted. By doing so, parents who have only brought their children when in pain may take advantage of RDC and the treatments offered to prevent and control dental caries and anxiety in their children.     

Evaluation of the ability of dental clinicians to rate dental anxiety

The aim of this study was to evaluate the ability of dental clinicians to rate dental anxiety. A total of 104 clinicians from 24 public dental clinics in the Region of Östergötland, Sweden, examined 1,128 adult patients undergoing their regular dental examination. The patients rated their dental anxiety using the Modified Dental Anxiety Scale and a Visual Analogue Scale. After the examination, the clinicians rated the patients’ levels of dental anxiety on a Visual Analogue Scale. The correlation (r_s) between the clinicians’ and patients’ ratings of dental anxiety was 0.45. Among highly dentally anxious patients, there was no correlation between clinicians’ and patients’ ratings. Dental clinicians rated dental anxiety lower than their patients did, especially if the patients were highly anxious. The ability of clinicians to rate dental anxiety was better when the clinician was older and the patient was older. There was an inverse association between clinicians’ confidence and their ability to rate a patient's dental anxiety. In conclusion, clinicians are unsuccessful in identifying a dentally anxious patient without the concurrent use of patient self‐assessment tools. A Visual Analogue Scale is a suitable screening tool in general practice for detection of dental anxiety.     

Development of the Gagging Problem Assessment: a pilot study

Summary  An accepted management strategy for gagging problems appears not to exist. A reliable and valid instrument is needed to develop an evidence based treatment for this clinical problem. The aim of this pilot study was to evaluate the reliability and validity of a newly developed measurement tool for dental gagging: the Gagging Problem Assessment (GPA). An experimental group ( n  =   13) comprising individuals with gagging problems, and a control group ( n  =   12) that had received dental care without gagging, completed a questionnaire focused on general health aspects and dental anxiety and the patient part of the GPA. The dentist part consisted of tests with increasing intrusiveness. This part was completed by two dentists. Statistical analyses concerned inter-rater reliability (Cohen's κ ) , reliability of the questionnaire (Cronbach's α , Pearson correlation coefficient) and the statistical difference between the GPA and two dental anxiety questionnaires (Mann–Whitney U- test, α  = 0·05). Within the limits of this study, the findings suggested that dental gagging warranted the development of a diagnostic and evaluative instrument. Gagging appeared to be a specific problem that cannot be interpreted as some form of dental anxiety. The GPA proved to be a reliable questionnaire to assess the presence of gagging problems, with a satisfying inter-rater reliability ( κ  = 0·64; s.d. = 0·16). Significant differences were noted between the experimental group and the control group. This pilot study will be followed by a confirmation study with a larger sample size, evaluated according to recently formulated quality criteria for measurement properties of health status questionnaires.     

Clinical correlates of dental anxiety among older adults

Most studies of the relationship between dental anxiety and oral health status have used subjective rather than clinical indicators of oral health. In this paper we examine differences between older adults who are and are not dentally anxious using a broad range of clinical measures. The data show that dentally anxious individuals were more likely to be edentulous, and among the dentate, had more missing and fewer filled teeth. As a result, dentally anxious dentate subjects were more likely to need prosthodontic treatment. They were also more likely to need immediate treatment for the relief of pain and infection and periodontal care. There was evidence to suggest differences in patterns of dental treatment between those who were and were not dentally anxious and some evidence consistent with the hypothesis that aging influences the relationship between dental anxiety and oral health status.     

The acceptability of the use of sedation in the management of dental anxiety in children: views of dental students

The aim of the present study was to determine the views of dental students concerning the acceptability of the use of sedation in the management of dentally anxious children. Dental students in Trinidad (n = 100) were asked to rate the acceptability of vignettes describing the management of a young teenager with dental anxiety. The vignettes varied systematically along two dimensions: nature of intervention for anxiety (sedation vs. the use of relaxation training and rewards) and outcome of the intervention (good vs. poor). Ratings of acceptability were made using a standardized questionnaire measure. The data were analysed using analysis of variance (ANOVA). There were significant main effects of nature of intervention (F = 5.54; P < 0.05) and outcome of intervention (F = 298.01; P < 0.001), though the students' year of study did not influence ratings. None of the interaction terms were significant. Sedation was viewed as a less acceptable intervention than relaxation and rewards. Interventions associated with good outcomes were seen as more acceptable than interventions associated with poor outcomes. It is concluded that dental students' perceptions of the acceptability of interventions for use with dentally anxious patients are related to the effectiveness of the intervention. Sedation, regardless of the outcome, is seen as less acceptable than the use of rewards and relaxation.     

Psychological disorders and dental anxiety in a young adult population

OBJECTIVES: It has been suggested that some individuals who are fearful or anxious about dental treatment have a constitutional vulnerability to anxiety disorders as evidenced by the presence of multiple fears, generalized anxiety or panic disorders. This paper compares the prevalence of psychological disorders among dentally anxious and non-anxious groups drawn from the general population. METHODS: Data were obtained as part of a birth cohort study when study members were aged 18 years. They were assessed using the Dental Anxiety Scale (DAS) and the Diagnostic Interview Schedule (DIS). The disorders diagnosed by the DIS were major depressive episode, dysthymia, generalized anxiety disorder, panic disorder, agoraphobia, social phobia, simple phobia, obsessive compulsive disorder, conduct disorder, cannabis and alcohol dependence. RESULTS: Overall, 12.5% of study members had DAS scores of 13 or more and were considered to be dentally anxious. Those who were dentally anxious were more likely than the non-anxious to be diagnosed with one or more psychological disorders (55.0% vs. 42.3%). However, those with DAS scores of 13 or 14 (moderately dentally anxious) were broadly similar to the non-anxious in terms of their psychological profile. This excess prevalence of psychological disorder was largely accounted for by high rates of disorder among those with DAS scores of 15 or more (highly dentally anxious). The highly anxious were more likely than the non-anxious to have a diagnosis of conduct disorder, agoraphobia, social phobia, simple phobia or alcohol dependence. Odds ratios ranged from 2.8 to 5.0 after controlling for the effects of gender. The data also suggested that dentally anxious individuals with psychological disorders were more likely to maintain their anxiety over time. CONCLUSIONS: In this population of young adults, high rates of psychological disorder were characteristic of those with high levels of dental anxiety. Psychological disorder was related to the maintenance of dental anxiety over time.     

Dental caries and changes in dental anxiety in late adolescence

Little is known about changes in dental anxiety with ageing and their association with changes in oral health. This study examined the relationship between changes in dental caries experience and dental anxiety from 15 to 18 years of age among adolescent participants in the Dunedin Multidisciplinary Health and Development Study. Dental anxiety was estimated using the Corah Dental Anxiety Scale (DAS), and individuals with a DAS score of 13 + were identied as being dentally anxious. Dental examinations were performed on 649 individuals at ages 15 and 18, and a DMFS score was computed for each. Caries prevalence among those who were dentally anxious at both 15 and 18 years was signicantly higher than for those who were not at either age. Regression analysis revealed that dental anxiety predicted caries incidence between ages 15 and 18 years. Dental anxiety is likely to be a signicant predictor of dental caries experience, and may be a risk factor for dental caries incidence.     

Structural relationships of dental anxiety, mood, and general anxiety

The aim of this study was to explore the structural relationships between dental anxiety, mood, and general anxiety among 220 dentally anxious patients who participated in a clinical study. A structural equation modeling analysis (SEM) was applied by using the LISREL program on the hypothesized latent variables dental anxiety, mood, and general anxiety, which were measured by means of several psychometric tests. The final model showed that mood and general anxiety had positive factor loadings on dental anxiety. However, the impact of the general anxiety latent variable was not significant as compared with the mood factor. Another finding was that the residual variance for the latent variable dental anxiety was 0.68, indicating that a major portion of the variance is still unexplained by the tested variables. In conclusion, this study showed a relationship between dental anxiety, general anxiety, and mood among dentally anxious patients.     

Dental anxiety and quality of life: the effect of dental treatment

Abstract – Objective: The aim of the present study was to determine the association between dental anxiety and quality of life (QoL) and to test the hypothesis that treatment of highly anxious patients would significantly enhance QoL. Material and methods: Subjects were 35 highly anxious dental patients of a Dutch dental fear clinic who were assessed on dental trait anxiety (DAS and S‐DAI) and QoL (oral health‐related QoL with the use of OHIP‐14, dental anxiety‐related QoL with the SADAS, and general aspects of QoL using Global Assessment of Functioning, while five different aspects of life satisfaction were quantified on a VAS‐scale) both prior to and after treatment (an average of six sessions of 45–60 minutes each). Also, both objective (DMFT and dentists’ judgement) and subjective (patients’ judgement) indices of oral health status were recorded. Results: Higher dental anxiety was significantly associated with lower OH‐QoL as indexed by the OHIP‐14 (r = 0.51–0.56, P < 0.01). Treatment was associated with marked improvement on oral health status, reduction of dental anxiety, and improvements regarding a variety of aspects of QoL (all Ps < 0.001). Reduction of dental anxiety, rather than improved oral health, was found to predict enhanced OH‐QoL. Conclusion: The results underline the importance of applying effective treatment methods for dentally anxious patients, not only with the purpose to alleviate their dental anxiety and to improve their oral health, but also because it contributes to an enhancement of their QoL.     

Structural relationships of dental anxiety,mood, and general anxiety

The aim of this study was to explore the structural relationships between dental anxiety, mood, and general anxiety among 220 dentally anxious patients who participated in a clinical study. A structural equation modeling analysis (SEM) was applied by using the LISREL program on the hypothesized latent variables dental anxiety, mood, and general anxiety, which were measured by means of several psychometric tests. The final model showed that mood and general anxiety had positive factor loadings on dental anxiety. However, the impact of the general anxiety latent variable was not significant as compared with the mood factor. Another finding was that the residual variance for the latent variable dental anxiety was 0.68, indicating that a major portion of the variance is still unexplained by the tested variables. In conclusion, this study showed a relationship between dental anxiety, general anxiety, and mood among dentally anxious patients.     

Do dental anxiety questionnaires raise anxiety in dentally anxious adult patients? A two-wave panel study.

OBJECTIVE: To test whether or not dentally anxious patients attending the dentist for an appointment become more anxious when completing a dental anxiety questionnaire. BASIC RESEARCH DESIGN: Patients were initially screened to include only those who were dentally anxious. A pre- and post-test was planned with the completion of the Modified Dental Anxiety Scale (MDAS) questionnaire as the intervention. CLINICAL SETTING: Two dental access centres in the North West of England. PARTICIPANTS: Initially, 583 patients were screened. Of these, 182 (31%) were found to be dentally anxious and were recruited into the study. MAIN OUTCOME MEASURES: State-Trait Anxiety Inventory Scale Short Form. RESULTS: State anxiety did not change with the completion of the MDAS questionnaire in either designated dental phobics (MDAS >or=19) or those classified as non-phobics (MDAS <19). CONCLUSIONS: The MDAS can be used to assess dental anxiety without raising anxiety in patients with or without self-reported dental phobia.     

A prospective study of dental anxiety in a cohort of children followed from 5 to 9 years of age

Background.  The development of dental anxiety in children is poorly understood.
Aims.  The aims of this study were to measure changes in dental anxiety over time and to examine the relationship between anxiety, dental care, and other factors.
Design.  A prospective cohort study of children in the north-west of England followed from 5 to 9 years of age. The participants were clinically examined and their parents completed the same questionnaire at 5 and 9 years.
Results.  The majority (54.3% N  = 38) of participants who were anxious at 5 years were no longer anxious at 9 years, but a large proportion of children who were anxious at 5 remained anxious at 9 years of age (45.7% N  = 32). During the follow-up period, a larger proportion of children developed anxiety (11.7% N  = 85) than the proportion of children who were reported as being anxious at baseline (8.8% N  = 70). At 9 years of age, dental anxiety was significantly associated with girls; parental anxiety; a history of extraction; and irregular, asymptomatic dental visiting. These factors were also significantly associated with dental anxiety at 5 years old.
Conclusions.  Dental anxiety was cumulative in the study population over time, and its development influenced by multiple variables. Results suggest that adverse conditioning and vicarious learning are both important in the development of this condition.     

Work stress inventory for dental assistants: development and psychometric evaluation

Objectives: The purposes of this study were to develop a work stress inventory for dental assistants (WSI-DA) in Jordan and examine its psychometric properties and to describe potentially stressful work-related conditions related to the profession of dental assistance in Jordan. Methods: A total of 542 dental assistants working in private dental clinics in Jordan participated in this study. The stages of instrument development included selecting an initial item pool, choosing the best items, deciding on the questionnaire format, pretesting the instrument, and determining its reliability and validity. An initial set of 55 items was selected and categorized into nine hypothetical categories. Further testing and using factor analysis ended with a 35-item, nine-scale instrument. The raw score for each scale was calculated by adding the responses for individual items and then transformed to 0-100 scales. The item-level validity, item internal consistency, item discriminant validity, and Cronbach's alpha were assessed. Results: Nine factors had eigenvalues greater than one. The nine factors accounted for 78.7 percent of the total variability in the 35-item questionnaire. All item–scale correlations were greater than the recommended correlation of 0.40. Except patient's suffer scale (Cronbach's alpha  =  0.56), all other scales demonstrated acceptable internal consistency with Cronbach's alpha exceeding the minimum standard of 0.7 and ranging from 0.71 to 0.87. Test–retest reliability showed acceptable reliability in all nine scales and ranged from 0.61 to 0.92. Conclusions: The 35-item, nine-scale WSI-DA demonstrated acceptable validity and reliability when used among dental assistants in Jordan .     

Dental fear and anxiety in an older adult population

A random sample of 580 people aged between 50 and 89 yr completed a questionnaire containing two measures of dental fear and anxiety. One of these was Corah's Dental Anxiety Scale (DAS) and the other a scale derived from the Structured Interview for Assessing Dental Fear (SIADF). The mean score on the DAS was 7.8, and 8.4% of subjects were classified as dentally anxious. There were no differences in mean DAS scores by sex but significant differences by age, with younger individuals having higher scores (P less than 0.0001). The edentulous had significantly higher scores than the dentate (P less than 0.001). Scores on the SIADF scale were higher among younger individuals (P less than 0.0001), the edentulous (P less than 0.01) and women (P less than 0.05). Older adults who were dentally anxious were less likely to report a regular source of dental care and a dental visit in the previous year and more likely to report having avoided or delayed dental treatment. Possible explanations of higher dental anxiety scores among younger persons and the edentulous are reviewed.     

The use of dental anxiety questionnaires: a survey of a group of UK dental practitioners

AIM: To determine the frequency of use of dental anxiety assessment questionnaires and factors associated with their use in a group of UK dental practitioners. METHOD: A postal questionnaire to all 328 dentists whose names appear in the British Society for Behavioural Sciences in Dentistry Directory. Information collected for each practitioner included gender, year of qualification, type of practice in which anxious dental patients were treated, treatment used to manage anxious dental patients, type and frequency of use of dental anxiety assessment indices. RESULTS: Questionnaires were returned from 275 (84%) practitioners. 269 were analyzed. Only 54 practitioners (20%) used adult dental anxiety assessment questionnaires and only 46 (17%) used child dental anxiety assessment questionnaires. Male practitioners were more likely to report questionnaire use in comparison with females (P< 0.05), when treating dentally anxious adults (26% v 14%). In addition, practitioners providing intravenous sedation were more likely to use an adult dental anxiety questionnaire (P < 0.04) than those who did not use intravenous sedation (29% v 15%). The type of treatment provided had a significant association with the use of child dental anxiety. Those providing general anaesthesia (P = 0.03) and hypnosis (P = 0.01) for dentally anxious children were more inclined to use a questionnaire. CONCLUSION: The use of pre-treatment dental anxiety assessment questionnaires was low in this group of dentists. Male practitioners and those providing intravenous sedation, general anaesthesia or hypnosis seem more likely to use dental anxiety assessment questionnaires.     

Influence of repression upon the measurement of dental anxiety

Using a non-linear, multivariate analysis, the resistance against admitting to being dentally anxious was studied. Dental anxiety was found to be repressed by a subgroup, among them more men than women, of a sample, who also repressed the feeling of low self esteem about tooth loss. Based on the results, regular and irregular dental attenders can be separated almost perfectly. The relationship with other anxiety measurements, i.e. Corah's Dental Anxiety Scale and three components discernible in Weiner's Anticipation Anxiety Level Chart, was studied.     

Trajectories of dental anxiety in a birth cohort

Abstract – Objective: To examine predictors of dental anxiety trajectories in a longitudinal study of New Zealanders. Methods:  Prospective study of a complete birth cohort born in 1972/73 in Dunedin, New Zealand, with dental anxiety scale (DAS) scores and dental utilization determined at ages 15, 18, 26 and 32 years. Personality traits were assessed at a superfactor and (more fine‐grained) subscale level via the Multidimensional Personality Questionnaire at age 18 years. Group‐based trajectory analysis was used to identify dental anxiety trajectories. Results:  DAS scores from at least three assessments were available for 828 participants. Six dental anxiety trajectories were observed: stable nonanxious low (39.6%); stable nonanxious medium (37.9%); recovery (1.6%); adult‐onset anxious (7.7%); stable anxious (7.2%) and adolescent‐onset anxious (5.9%). Multivariate analysis showed that males and those with higher DMFS at age 15 years were more likely to be in the stable nonanxious low trajectory group. Membership of the stable nonanxious medium group was predicted by the dental caries experience at age 15 years. Participants who had lost one or more teeth between ages 26 and 32 years had almost twice the relative risk for membership of the adult‐onset anxious group. Personality traits predicted group membership. Specifically, high scorers (via median split) on the ‘stress reaction’ subscale had over twice the risk of being in the stable anxious group; low scorers on the traditionalism subscale were more likely to be members of the recovery trajectory group; and high scorers on the ‘social closeness’ subscale had half the risk of being in the stable anxious group. Dental caries experience at age 5 years was also a predictor for the stable anxious group. Membership of the late‐adolescent‐onset anxious group was predicted by higher dental caries experience by age 15 years, but none of the other predictors was significant. Conclusion:  Six discrete trajectories of dental anxiety have been observed. Some trajectories (totalling more than 90% of the cohort) had clear associations with external influences, but others were more strongly associated with characteristics such as personality traits. A mix of both influences was observed with only the stable anxious dental anxiety trajectory.     

Attitudes to dental hygienists: evaluation of the Dental Hygienist Beliefs Survey in a Swedish population of patients and students

Abstract:  Objectives: The aim was to evaluate and test the psychometric properties of the Dental Hygienist Beliefs Survey (DHBS) in a Swedish sample of different patient groups and students. It was hypothesized that negative dental hygienist beliefs would discriminate between fearful and non-fearful study groups. The DHBS was distributed together with the revised Dental Beliefs Survey (DBS-R) and the Dental Anxiety Scale (DAS). The study sample included 394 subjects (130 students, 144 general dental patients, 90 periodontal patients and 30 patients on a waiting list for dental fear treatment). The results verified that the DHBS discriminates well between dentally fearful and non-fearful study groups. The DHBS had high internal consistency (Cronbach's α  = 0.96−0.98) in all the groups. The correlation between the DHBS and the DBS-R was high ( ρ  = 0.82, P  < 0.001). Furthermore, the DHBS correlated significantly with the DAS, as well as with a low but significant correlation to age (more negative attitudes in younger age groups) and gender (more negative attitudes amongst women). Regression analysis showed that gender and the DHBS items: 23, 16 and 28, i.e. items related to feeling helpless, worries/fears not being taken seriously and fear about 'bad news' possibly preventing treatment, were the most important predictors of dental fear. The results suggest that the DHBS may be a valid and reliable scale to use in order to assess patient's specific attitudes to dental hygienists. However, the psychometric properties including test–retest analysis and the underlying factor structure of the DHBS need to be further explored.     

Reliability and validity of the short version of the Dental Anxiety Inventory

The present study focused on a newly developed questionnaire to assess dental anxiety. The short version of the Dental Anxiety Inventory (S-DAI) contains nine items of the Dental Anxiety Inventory (DAI), which was designed to take into account three situations that may evoke dental anxiety, four time elements in which dental anxiety may be provoked, and three reactions. The aim was to assess the validity and reliability of the S-DAI in a sample of highly anxious dental patients applying for treatment at a dental fear clinic in the Netherlands. Three hundred and twenty-one patientslled out several questionnaires assessing dental anxiety (S-DAI, DAS, and a 10-point Likert-scale) and psychological complaints. Total mean score on the S-DAI for women (mean=40.5, s =5.7) was some-what higher than for men (mean=38.8, s =6.9) ( t (306)=2.35; P =0.019). Cronbach's α for the present sample was 0.88. Correlations with other measures of dental anxiety were 0.73 with the DAS ( P < 0.001) and 0.69 ( P < 0.001) with the 10-point scale. The results indicated that the S-DAI has good reliability and construct validity. It was concluded that the S-DAI is easy to administer in general dental practices and dental fear clinics and has satisfactory psychometric qualities.