Fear and Anxiety in Patients Seeking Dental Care in the Makkah Region of Saudi Arabia

^*Correspondence: Afnan A Nassar, Department of Preventive Dentistry, Division of Public Health, Umm Al-Qura University, Mecca, Saudi Arabia, Email:

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Introduction

Dental fear and anxiety (DFA) is a general term that refers to all forms of fear and anxiety associated with dental practice [1,2]. Dental fear is a multifactorial problem rising from physiological, behavioral, and emotional responses to one or more intimidating stimuli in dental practice, such as drilling of teeth or the notice of injection. Intense fear is defined as dental phobia [3,4]. Dental anxiety (DA) occurs when a patient experiences tension regarding a specific dental practice and thereby avoids dental care [5,6]. This avoidance makes dental problems worse and increases the need for emergency visits. DA is severe problematic affecting people of altered age, genders and backgrounds [5,6]. Previous data reveal that 15% of the adult population are significantly affected by dental anxiety [1]. In Saudi Arabia, a study conducted on adults between 18 and 45 years old showed a prevalence of dental anxiety (70.5%) [7]. Other studies have shown that women probably experience more dental fear, specifically of dental pain, than men [8].

Cohen et al. reported that dental anxiety affects a person's life in various ways, such as constrained smiling, decreasing self-esteem, and functional restriction due to pain [9]. There is a significant relationship between DFA and avoidance of dental treatment [10].

Knowledge of the etiology of DFA can enable clinicians to improve oral health services for patients [11]; accordingly, several dental anxiety management strategies, including both pharmacological agents and combined methods, such as behavioral stimulation, have been used to reduce dental fear [12].

A review of the published dental literature revealed a lack of studies on dental fear among Saudi adults. Previous studies on dental fear in Saudi Arabia have mostly focused on a specific group of the population, for example, children or adolescents.

The aim of this study was to identify factors influencing dental fear and anxiety (DFA), as well as factors that help reduce such feelings, among Saudi adult patients in the Makkah region of Saudi Arabia.

Material and Methods

Ethical approval was taken from the ethical research committee at Umm Al-Qura University, Faculty of Dentistry, Makkah, Saudi Arabia (IRB number HAPO-02-K-012-2020-11-498). In this descriptive cross-sectional study, a self-administered electronic questionnaire was used to collect data using from patients aged 18 and older seeking dental treatment at different public and private dental clinics in Makkah. It took around five minutes to the whole questionnaire. Informed consent was acquired from all applicants who voluntarily responded to the questionnaire. Data were amassed between November 2020 and January 2021. This study aimed to collect data from 1000 respondents using a precision level of 5% and a confidence interval of 95%. The self-administered validated questionnaire was provided in Arabic and English and adapted from a previous study [13].

For validity and reliability purposes, a pilot study with 10 respondents was carried out.

The questionnaire was composed of 5 sections. The first section was related to the patient’s demographic information, such as age, gender, profession, educational level, income, and previous dental treatment. The second section was related to the level of fear the patient experienced regarding general dental procedures, such as anesthetic injection, tapping on sore teeth, or taking diagnostic X-rays. The third section was designed to elicit responses to the level of fear patients experienced regarding specific dental procedures, such as tooth drilling, tooth extraction, tooth preparation and impression, root canal treatment, sensitivity after bleaching, gingivectomy and implant insertion. The fourth section was related to factors that may help reduce dental fear, such as the reputation and appearance of the dentist, explanation of the dental procedure, appropriate attitude of dental personnel, the ambience and hygiene of the clinic and limiting the wait time. Categorical response options were provided for most questions (not at all, a little, moderate, a lot).

The last section was concerned with measuring anxiety and fear in patients using the Depression, anxiety and stress scale (DASS-21) [13]. Five Likert-scale response options were provided in this section (ranging from 0 =did not apply to me at all to 3=Highly applicable or applicable most of the time).

Descriptive statistics were used to analyze the demographics, responses about feelings regarding different dental procedures, and the DASS-21 scale to probe the levels of anxiety of the respondents. A chisquare test was accomplished to compare the levels of anxiety among the patients with age, gender, and level of education. Statistical analysis was done by the Statistical Package for the Social Sciences (Version 16, SPSS Inc., Chicago, IL, USA). A P value of <0.05 was reflected statistically significant.

Results

Demographic characteristics

A total of 631 respondents completed the questionnaire with a response rate of 63%; the demographic details of the respondents are shown in Table 1. We found that 33 years was the mean age of the respondents (SD=13.78). Most of the respondents were females (77.3%). The majority of the respondents had reached a bachelor's degree (62%), followed by a high school certificate (26%). Regarding past dental experience, 97% of the respondents had had previous dental treatment.

Table 1: Participantsâ?? demographic information

Level of fear of respondents regarding different dental procedures

The participants’ levels of fear when visiting dental clinics for general dental procedures are presented in Table 2. Most patients were comfortable while sitting in the waiting area or the dental chair, even for a long time, seeing different instruments, and taking X-rays, whereas 40.6% were highly anxious during local anesthesia injection. Patients' responses to certain dental procedures, for example, drilling of a tooth or preparation, tooth bleaching, or procedures of soft tissue, are shown in Table 3. The respondents found tooth extraction to be the most fearful procedure (53.1%), followed by root canal treatment (45.0%) and tooth drilling (37.4%). Surprisingly, most of the respondents were either moderately or “not at all” nervous about the tooth preparation procedure, tooth sensitivity after bleaching, and the dental implant procedure. In addition, the lowest fear level was reported for taking teeth impressions and laser therapy procedures.

Table 2: Level of fear among the patients visiting dental clinics for general dental procedures

Table 3: Level of fear among the patients visiting dental clinics for specific dental procedures.

Factors associated with DFA reduction

Factors that may be associated with reducing dental fear among patients are presented in Table 4. The analysis results displayed that dental fear was most reduced by the good reputation of the dentist (71.5%), followed by good ambience and hygiene of the clinic (66.2%), appropriate attitude of dental personnel (58%), good appearance of the doctor (47.2%), and explanation of the dental treatment by the dentist (44.4%). The gender of the doctor, good attitude of the receptionist, and a reduced wait time did not reduce dental fear.

Table 4: Factors that help to reduce dental fear.

DASS-21 scale

Depression, anxiety, and stress were shown by 56%, 70.8%, and 65.1% of the patients, respectively. The mean total results for the patients were 8.66 (SD ± 8.39) for depression, 10.51 (SD ± 9.78) for anxiety and 12.97 (SD ± 9.95) for stress, as displayed in Table 5. Females showed significantly higher grades of depression (p-value<0.030) and anxiety (p-value<0.001) than males, whereas there was no significant difference between the genders in the stress scores (p-value<0.524). Our results showed that respondents with a university degree had significantly higher depression, anxiety, and stress scores with a p-value <0.05 compared to those with a high school education level or lower.

Table 5: Presented percentages of depression, anxiety, and stress and DASS scores

Discussion

Our study focused on investigating dental fear and anxiety (DFA) among Saudi adults in the Makkah region.

The results found a higher level of DFA in females than males, which agrees with the finding of previous studies [14-16]. This difference could be explained by the ability of females to express their feelings about dental visits, unlike males, who may avoid dental treatment to prevent these feelings from arising. However, this difference does not always hold true, as in the case of Kanegane et al. who found no relationship between gender and anxiety [17].

Our findings also showed that highly educated patients had higher DFA scores than those with lower education levels. This result may have been acquired because patients with a high level of education possess the skills to search online about the expected results of treatment and smile design or may be related to the characteristics of our sample. However, it has been shown in other studies that dental anxiety is not affected by the education level of the patient [18,19].

The mean DFA was higher for patients below 40 years old than among older patients, and this result was in agreement with those of many studies in which a selfadministered questionnaire was used [19,20]. The inability of young people to cope and rationalize difficult situations may result in stress and fear.

DFA has several causes, and thus, is considered to be complex and multifactorial [21]. DFA appears to vary according to the type of treatment: higher DFA levels were found for injecting local anesthesia (40.6%), surgical procedures (53.1%) and endodontic procedures (45.0%) than restorative treatments, and this result was in dealing with those of other studies [19,22-24].

An analysis of the factors associated with DFA reduction showed that the good reputation of the dentist had the strongest influence on patients’ feelings. Patients may feel assured and confident when they trust the dentist’s skills and reputation, which can directly reduce DFA. By comparison, limiting the wait time before the appointment was not a significant factor in reducing dental anxiety and fear for our participants. This result is not matched with that of Gaffar et al. who found that dental anxiety increased with prolonged time in the waiting area [25]. Prolonged waiting is thought to provide a patient with more time to think about possible outcomes and ruminate on the worst-case scenario [25].

Various scales have been created to assess DFA. However, a gold standard has yet to be recognized, given that each of these scales has limitations. The DASS-21 is considered to be a simple and easy scoring test that can be used to help assess psychological status, including depression, anxiety, and stress.

The DFA levels observed in our sample (70%) were higher than those previously reported (31.9%) for the city of Jeddah by Al-Khalifa et al [26]. The significant reduction in the DFA levels for Jeddah compared to the level observed in this study may be explained by the large sample size and different scales used in our study.

Regarding technological advances in modern dentistry, anxiety about the dental procedures and fear of associated pain continues to influence a significant proportion of people universally of different ages and social levels, causing avoidance of dental treatment, infrequent attendance and/or reduced cooperation with the dentist [14].

Dental practitioners need to evaluate their patients preoperatively for DFA and use appropriate management techniques to provide higher-quality oral health care.

Conclusion

The present findings show that a considerable number of patients attending dental clinics exhibited DFA. Anxiety was more intense among female, young, and highly educated individuals. Tooth extraction was the most fearful procedure, whereas respondents experienced the lowest fear level during impression taking.

Limitations and Recommendations

Self-reported assessment measures can provide valuable information to dentists for evaluating and reducing patients’ anxiety levels. However, the results of a selfadministered questionnaire may over- or underestimate the actual DFA levels in a population. Therefore, future research studies with different designs, larger sample sizes, and different populations should be conducted to estimate the prevalence of DFA, and additional provocation and reduction factors for DFA should be investigated. In addition, the findings of this work may not be generalizable to male patients because the majority of our respondents were females.

Several recommendations can be made to reduce patient anxiety, such as good dentist-patient communication to enable patients to express anxiety, taking a thorough dental and mental history before starting treatment, and the use of relaxation techniques to help reduce DFA.

Data Availability

Data will be available on request.

Conflict of Interest

The authors declare that there are no disagreements of financial, concern or others.

Funding Statement

No funding for this research.

Acknowledgement

The authors would like to acknowledge the participants in the study for their time and involvement in the questionnaire.

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