|Year : 2015 | Volume
| Issue : 2 | Page : 135-140
Prevalence of dental anxiety in two major cities in the kingdom of Saudi Arabia
Khalifa S Al-Khalifa
Division of Dental Public Health, Department of Preventive Dental Sciences, College of Dentistry, University of Dammam, Dammam, Kingdom of Saudi Arabia
|Date of Web Publication||6-May-2015|
Khalifa S Al-Khalifa
Division of Dental Public Health, Department of Preventive Dental Sciences, College of Dentistry, University of Dammam, P.O. Box 1982, Dammam 31441
Kingdom of Saudi Arabia
Source of Support: None, Conflict of Interest: None
Aims: The aim was to assess the level of dental anxiety in adult patients in two major cities in the Kingdom of Saudi Arabia and identify the etiological factors linked to this condition.
Settings and Designs: A cross-sectional study using a questionnaire.
Materials and Methods: A self-administered questionnaire based on the modified dental anxiety scale was distributed to dental patients who attended the dental clinics of the University of Dammam and King Abdulaziz University in Jeddah, respectively. The questionnaire included information about socio-demographic factors and other questions indicative of dental anxiety.
Results: A total of 132 forms was received from subjects in Dammam and 144 forms from Jeddah. The level of dental anxiety in patients was relatively higher (27.5%) than other studies. In this study, patients in Jeddah showed higher levels of dental anxiety than those in Dammam (31.9% vs. 22.7%). As expected, females demonstrated a higher level of anxiety than males (19.2% vs. 8.3%). Most of the participants who had severe dental anxiety thought a bad experience at the dentist was the main cause of their anxiety.
Conclusions: Dental anxiety was perceived as a problem in the sample examined. This was clearly seen irrespective of age, gender, social status, and/or place of residence. Patients' fear of dental treatment continues to pose a great threat to the dental profession. Dental professionals are encouraged to further assess the extent of this problem in order to find methods and techniques to help patients overcome it.
ملخص البحث :
عنيت هذه الدارسة المقطعية لتقييم الخوف والقلق من علاج الأسنان لدى المرضى البالغين بمدينتي جدة والدمام بالمملكة العربية السعودية، ولتحديد المسببات المحتملة لهذه الحالات. أجريت الدراسة باستخدام استبانه معايرة تم توزيعها على مراجعي عيادات الأسنان بجامعتي الدمام والملك عبدالعزيز. كان معدل الخوف والقلق من علاج الأسنان أعلى نسبيًا (%5.72) مما ورد في الدراسات الأخرى وكانت النسبة أعلى في جدة منها في الدمــــام (%9.13 مقابل (%7.22. وكانت المعدلات أعلى لدى الإناث مقارنة بالذكور. عزى المرضى الأكثر إصابة بالقلق خوفهم إلى تجربة سيئة مع طبيب الأسنان. خلصت الدراسة إلى أنه ينصح إجراء المزيد من الأبحاث لمعرفة مدى انتشار الخوف حتى يتم الحصول على وسائل لمساعدة المرضى للتغلب عليها.
Keywords: Dental anxiety, modified dental anxiety scale, prevalence, Saudi Arabia
|How to cite this article:|
Al-Khalifa KS. Prevalence of dental anxiety in two major cities in the kingdom of Saudi Arabia. Saudi J Med Med Sci 2015;3:135-40
|How to cite this URL:|
Al-Khalifa KS. Prevalence of dental anxiety in two major cities in the kingdom of Saudi Arabia. Saudi J Med Med Sci [serial online] 2015 [cited 2022 Nov 30];3:135-40. Available from: https://www.sjmms.net/text.asp?2015/3/2/135/156421
| Introduction|| |
The prevalence of dental caries in the Kingdom of Saudi Arabia (KSA) is considered among the highest globally. As dental caries affects dentition early in life, this in turn exposes patients to early dental treatment. Two studies conducted in the city of Jeddah reported the prevalence of dental caries in school children as 83% and 96%, respectively. , The consequences of the severity of dental caries have several outcomes of which dental anxiety to dental treatment was among the highest. As health professionals, we are faced with the enormous challenges of trying to meet the health demands of a growing population in KSA. Dental anxiety is known to be an obstacle toward receiving dental treatment. 
It has been estimated that 50% of the population in the United States (US) have some form of dental anxiety when going to the dentist.  Avoidance of dental care, irregular dental attendance, and poor cooperation with care provider are considered the main outcomes of dental anxiety. 
Various terms have been used to describe dental anxiety. Such as dental fear, dental phobia, odontophobia, and apprehensive patient. None of these terms have been adequately defined or made clearly distinctive. Sometimes, a more specific term like "dental injection phobia." is used. Some authors link pain with anxiety, but for many patients, dental anxiety is not the fear of pain.  In this study, the term "dental anxiety" is used to refer to all of the above-mentioned terms.
The prevalence of dental anxiety has been documented in many countries worldwide. In the US, between 3% and 20% of the population have levels of fear and anxiety about dental treatment that is considered problematic.  The prevalence of dental anxiety among Australians was reported to be 14.9%  while the levels in young adult population in Canada  and adolescents in Russia  were 12.5% and 12.6%, respectively. About 13.5% of the French population  and 30% of the Chinese population have some form of dental anxiety.  Few studies have been conducted in KSA on the prevalence of dental anxiety. A study conducted in Riyadh to assess dental fear and anxiety in adolescent females showed that 29% of the subjects had high levels of anxiety.  Al-Shammary et al. conducted a study in which 11.8% of the surveyed subjects perceived dental treatment as a stressful procedure; 4.6% found dental treatment unpleasant and 6.2% found it painful while 5.2% of the subjects avoided visiting the dentist for fear of pain. 
The purpose of this study was to assess the levels of dental anxiety in adult patients in two major cities in KSA (Dammam and Jeddah) and identify some etiological factors, namely, socio-demographic factors for developing dental anxiety.
| Materials and methods|| |
A self-administered questionnaire based on the modified dental anxiety scale (MDAS) was created.  The MDAS scale contains five multiple choice items dealing with the patient's subjective reaction to different dental situations. Each question has five scores ranging from "not anxious" to "extremely anxious" in an ascending order from one to five. Each question, thus, carries a possible maximum score of five with a possible total maximum score of 25 for the entire scale. Based on the severity of the MDAS score, the patients were divided into three groups; Group 1 = slightly anxious (MDAS scores below 11), Group 2 = moderately anxious (MDAS scores between 11 and 15) and Group 3 = extremely anxious (MDAS scores higher than 15). The questionnaire included information on socio-demographic factors such as sex, age, education, and income. Other questions that were indicative of dental anxiety such as experience from the first dental treatment as well as the type of treatment were also included in the questionnaire. Since the study was conducted in an Arabic speaking country, the corrected translation was achieved and pretested on a focus group.
A prior power analysis with the program package GPower 126.96.36.199 (http://www.gpower.hhu.de/en.html) was conducted to compute the needed sample size given an α = 0.05, power = 0.95 and a medium effect size of 0.5 when testing for significant differences in average responses between respondents in a comparison of the two groups. The results showed that a sample size of 176 patients (88 for each group) was needed. Accordingly, the sample size for this study consisted of 150 subjects for both Dammam and Jeddah cities (a total sample size of 300 subjects). The self-administered questionnaires were distributed to dental patients who attended the University of Dammam and King Abdulaziz University dental clinics in the cities of Dammam and Jeddah respectively. Eligibility criteria included being an adult (over the age of 18 years), medically and mentally fit and residing in either the cities of Dammam or Jeddah. Patients who were illiterate and/or non-Arabic speaking were not included in the study.
Statistical analysis was performed using the Statistical Package for the Social Sciences software (SPSS 17.0) (SPSS Inc., Chicago, IL, USA). Demographic data (city, gender, age, educational level, each of the parents' educational level and income) and other variables were computed. Bivariate analysis using Chi-squared test was performed. Variables that were significant in the bi-variable analysis level were included in the final model. Multivariate analysis using the analysis of variance (ANOVA) with MDAS as the dependent variable was also performed. For all statistical analysis, the level of significance was set at P < 0.05.
| Results|| |
Three hundred questionnaires were distributed to dental patients in the two cities equally. Twenty-four subjects were excluded from the data analysis because of incompleteness of data (response rate was 92%). A total of 132 forms was received from subjects in Dammam and 144 forms from Jeddah [Table 1]. There was an equal distribution of male and female patients in this study. The majority 59.4% (n = 164) of the sample was between 19 and 29 years old. With respect to educational level, 78.6% (n = 217) of the participants had university and/or postgraduate degree. The income levels were dominated 46% (n = 127) by subjects with a monthly income of <5000 Saudi Riyals ($1333). As for the MDAS scores, 42.0% (n = 116) of the subjects were categorized as slightly anxious. The most anxiety-provoking item was the feeling toward dental injection (mean score = 3.15) and the least anxiety-provoking item was the next dental visit (mean score = 2.03) [Table 2].
This study also attempted to assess other areas related to anxiety that were not covered by MDAS. When asked about how they felt after their first dental appointment, the majority 28.9% (n = 80) of slightly anxious participants had a positive feeling after the first appointment (mean = 2.42 ± 1.15). While moderately and extremely anxious patients were negative about their first dental appointment (data not shown here).
It was noticed in this study that the highest dental anxiety level was in patients who had root canal treatment as the first dental appointment (40.5%, n = 15 of 37), followed by restoration (35.0%, n = 35 of 100) while the lowest dental anxiety level was recorded with patients who had dental extraction (18.2%, n = 10 of 55). A bad experience at the dentist was recorded in 34.8% (n = 23) of extremely anxious group who had been seen by a dentist, while 36.4% (n = 32) reported other causes such as (cross infection, lack of confidence in the treatment quality and the qualification of the dentists) as the main causes of dental anxiety (data not shown here).
A t-test was performed for all socio-demographic factors with MDAS group as the dependent variable. The bivariate analysis revealed many significant associations (P < 0.05) between dental anxiety (MDAS) and socio-demographic variables, namely; gender, city, educational level, mother's education, and the first dental appointment [Table 3].
The one-way ANOVA analysis with MDAS groups as the dependent variable was performed. The final model was modified because of co-linearity between the variables in our study (city, gender, educational level, mother's education, and the first appointment). These variables were included in the final model with MDAS as the dependent variable. The first appointment variable was excluded from the final model because of its strong effect [Table 4].
|Table 4: Multivariate analysis with MDAS as the dependent variable with first appointment excluded from the final model|
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| Discussion|| |
The term "dental anxiety" is somewhat imprecise since various studies define and evaluate it differently. In this study, the extent (or level) of dental anxiety in dental patients residing in two major cities in KSA was effectively assessed using the MDAS. The MDAS, is a well-known dental anxiety scale (DAS) introduced by Humpris et al. It is similar to the original DAS, which includes an extra question about local anesthetic injections.  The MDAS as an instrument has high reliability and validity. 
Using the MDAS, the present study showed that dental anxiety scores in two major cities of KSA, Dammam and Jeddah (22.7%, 31.9%, respectively) were higher than what had been found in other cities around the world: 19.5% in Belfast; United Kingdom, 8% in Jyväskyla; Finland and 6.0% in Dubai; United Arab Emirates.  It is quite surprising, however, that the MDAS score in Dubai was much lower than the score in this study given that Dubai and the studied cities have a common cultural background. However, the difference might be explained by the fact that Dubai is now an international hub and has become a multicultural city.
Relating the social and demographic factors to MDAS results yielded some interesting findings. For example, females exhibited a higher level of dental anxiety than males (19.2% vs. 8.3%). The total MDAS scores of females were also higher than males. Medical and psychological research on human response to pain stimuli had generally found that females report higher levels of anxiety (they have lower thresholds) and exhibit less tolerance for pain at given stimulus intensities than males.  In addition, females were more likely to self-report, than males who would not express their fears as openly as females.  In our study, these differences were statistically significant and are therefore, in agreement with the findings of other studies. ,,,
In our study, there was an inverse relationship between the level of education and dental anxiety. This raises concerns on the awareness of the oral health in KSA in general, which is very low even in educated people. This relationship is in accordance with the study done by Al-Dosari, which showed that 24% of non-educated individuals were fearful compared to 47% of those with a university level of education.  Most of the studies showed an inverse relationship between the level of education and dental anxiety. For example, Hallstrom and Halling  found that the prevalence of dental anxiety was higher among individuals of lower education level. According to a report by Berggren and Meynert,  a low education level is among the primary reasons for not seeking regular dental care and dental fear. This may be due to the social distance between a highly educated dentist and the dental patient with little education which results in the patient's embarrassment and worries about problems of communication in a physician-patient relationship. 
According to Humphris et al.,  the feeling toward dental injection was the most anxiety-provoking item with a mean score of 2.45 ± 1.23, which was consistent with our study (mean score = 3.15 ± 1.39), and the least anxiety-provoking procedure was scaling and polishing with a mean score of 1.90 ± 1.35, which was different from our finding (feeling toward next dental visit - mean score = 2.03 ± 1.18). Owing to the fact that most patients in KSA visit the dentist in an emergency they do not see the dentist on a regular basis and are, therefore, not aware of the type of treatment required. This tends to create a sense of apprehension in our patient toward the dental treatment on the next dental visit.
When treatment is avoided, more invasive treatments such as root canals and extractions are eventually required, which tend to be more traumatic and anxiety-provoking than less invasive treatments.  When considering dental anxiety in relation to the various types of treatment, anxiety prior to root canal therapy was found to be the highest (mean = 14.0 ± 6.11), followed by restorative treatment (mean = 13.91 ± 5.12). The finding on root canal therapy as the most anxiety-provoking procedure is in agreement with Wong and Lytle.  This might be explained by the difference in the age of patients. In our study, >59.4% of the patients are younger than 29 years. Patients in this age group were more likely to benefit from the treatment of caries and its sequelae (filling and root canal therapy). 
In previous studies, ,,, patients mentioned that negative experiences were the primary reasons for dental fear. Furthermore, Berggren et al.  showed that dental anxiety in many cases may be attributed to previous traumatic experiences. Our study revealed that 34.8% (n = 23) of the extremely anxious group had had a bad experience at the dentist's while 36.4% (n = 32) reported other causes such as (cross infection, lack of confidence in the quality of treatment and the qualification of dentists) as the main causes of dental anxiety.
The findings of this study indicate that city, gender, and educational level variables strongly affected the level of dental anxiety. Thus, these variables were included in the final model with MDAS as the dependent variable.
In relation of the MDAS to the cities, Jeddah demonstrated a higher level of dental anxiety than Dammam (31.9% vs. 22.7%). We relate this difference to the nature of these cities and the people who live there.
The female participants showed a higher level of dental anxiety than the males according to their psychological properties (low thresholds) as mentioned earlier. Most of these were recorded in Jeddah making the level of dental anxiety there high. Thus, dentists are advised to make their appointment stress-free especially for females and use the modern technologies that make patients relax prior to treatment.
Dental treatment is somewhat new in KSA. Therefore, we recommend more dental educational programs on prevention and oral health care for all age groups in the community, ranging from persons with primary school education to the highly educated. As previous bad experience from treatment is the leading cause of anxiety, particular focus should be on this aspect of apprehension during dental training. Continuous education programs for dentists should encourage them to help patients to overcome their fear by giving them adequate explanation of the treatment procedures and providing them with proper pain management. Furthermore, dentists should make every effort to increase the awareness of prevention in dental care instead of restricting their work to treatment. Furthermore, they should take part and support programs on the promotion of oral health in their communities. The general practitioner should be capable of treating adults with mild forms of dental anxiety effectively. Treatments for moderate and severe dental anxiety often require more special interventions. In some countries, it is possible to refer such patients to dental fear clinics where the best management can be offered. This, of course, has to follow "evidence-based" guidelines in the dental practice.
| Limitations|| |
Few studies have been conducted in KSA on the prevalence of dental anxiety, which made a comparative analysis difficult. Besides, most of the studies done on the subject used MDAS as a measuring tool for dental anxiety, although MDAS showed a high degree of reliability and validity. The constraints of time and a small sample size created difficulties in conducting this study.
| Conclusion|| |
Dental anxiety was perceived as a problem in the sample examined. This was clearly seen irrespective of age, gender, social status, and/or place of living. Fear of dental treatment continues to put a great burden on all those who have anything to do with the dental profession, including the patients. Dental professionals have tried to assess the extent of this problem in order to find methods and techniques to help patients overcome it. Nonetheless, the problem persists.
Research often focuses on the highly anxious patients who refuse dental care since attendance at clinic can be used as a criterion for the outcome of the objective. Little attention has been given to questions on how to manage the majority of patients who routinely overcome their anxiety for the sake of maintaining their oral health. There is a need for high powered studies to examine strategies to make dental treatment less traumatic for these patients. To accomplish this, standardized and validated instruments are required.
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[Table 1], [Table 2], [Table 3], [Table 4]
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