Dental Anxiety Among Patients Attending A Periodontal Clinic: A Cross Sectional Analysis

Dental Anxiety Among Patients Attending A Periodontal Clinic: A Cross Sectional Analysis
Abdul Razaq Malik1 , Syed Akhtar Hussain Bokhari2 , Agha Mohammad Suhail3 , Mian Farrukh Imran4 , Syed Ameer Hamza5

1. Associate Professor Margalla College of Dentistry, Rawalpindi
2. Professor University Medical & Dental College, Faisalabad
3. Associate Professor University Medical & Dental College, Faisalabad
4. Associate Professor University Medical & Dental College, Faisalabad
5. House Officer University College of Dentistry, Lahore
Corresponding author: “Prof Dr S Akhtar Hussain Bokhari ”

How to CITE:

Malik AR, Bokhari SAH, Suhail AM, Imran MF, Hamza SA. Dental Anxiety Among Patients Attending A Periodontal Clinic: A Cross Sectional Analysis. J Pak Dent Assoc 2014; 23(3):112-116


Dental anxiety and fear are significant factors that deter patients from having dental care at a proper time. No study has reported its status in Pakistan. The aim of this study was to investigate dental anxiety among patients attending a periodontal clinic in a dental hospital in Pakistan.


All patients attending the periodontal clinic in Margalla dental hospital during 1st to 30th June 2013 were interviewed for their dental anxiety status. Dental anxiety was assessed through Corah’s dental anxiety scale (Q1-4). Five response levels of anxiety were compared among genders and age-groups. Chi-square test and regression analysis were applied for statistical association of the variables at the level of 0.050.


Two hundred subjects with a mean age of 39.2± 15.0 participated in this study. The highest percentage of the participants (44%) were in lowest income group (Rs. 5000/-), 41% were in service and 84.5% of the subjects were from urban locations. Females were found to be significantly (p>0.004) more dentally anxious than males. Subjects age-groups (>/<34 years) showed no statistical (>0.059) difference for anxiety levels. In step wise regression analysis, only gender showed significant association with all the dental anxiety scales (p<0.041). Correlation analysis showed significant association of gender with Q1, 3, and 4 and age with Q3 and Q4.


Dental anxiety was prevalent among majority of the study participants and showed a significant association with female gender, but no statistically significant relationship was noted with the other demographic factors in this study sample.


Dental Anxiety, Corah’s Dental Anxiety Scale, Periodontal Patients.


Depression and anxiety are known to be risk factors that cause a range of diseases and conditions1. Dental fear has been suggested as a conditioned reaction to previous negative dental experiences and unpleasant dentist contacts2. Anxiety of dental treatment is an insurmountable factor that may lead to irregular dental attendance behavior, and avoidance of care and is associated with poor oral health.

High dental anxiety is inversely related to oral health1. Higher numbers of decayed teeth, lower numbers of filled teeth and higher counts of missing teeth are associated with high dental anxiety3, 4.

Dental anxiety has been reported to lead to avoidance behavior and cause delay in regular or necessary dental treatment5 and this also negatively affects dental health6. The prevalence and consequences of dental anxiety have been explored and its impact on dental health status has been reported previously7. There is psychosocial impact of dental anxiety on daily livelihood and physiological, cognitive, behavioral, health, and social impacts of dental anxiety have been identified8. An association between dental anxiety / fear with gender and age has been observed2,9. No data on dental anxiety has been reported from Pakistan. This study was conducted to explore the status of dental anxiety among patients attending a periodontal clinic and to assess its association with demographic variables of age and gender, education, income, occupation and residential location.


Patients attending the Periodontology department of Margalla College of Dentistry Hospital, Rawalpindi, Pakistan were invited to participate in the study. All patients, who gave a verbal consent, were recruited by convenient sampling technique over a period of one month (1st-30th June 2013). A structured questionnaire was prepared to record demographic variables. Dental anxiety was measured using the Corah’s Dental Anxiety Scale (DAS) [10], which consisted of 5 items covering ‘relaxed, a little uneasy, tense, anxious, and very anxious’.

Responses were recorded against four questions: 1) if you had to go to the Dentist tomorrow, how would you feel about it?; 2) When you are waiting in the Dentist’s office for your turn, how do you feel?; 3) When the dentist’s gets his drill ready to begin working, how do you feel?; 4) when the dentist gets his instruments ready to scrap your teeth around the gums, how do you feel? Demographic variables of age, gender, education, income, occupation and residential location of the respondents were assessed. The response for the 4 questions were compared among genders and age-groups (>/<34 years) and Chi-squire test was applied for statistical significance that was set at p<0.050. Stepwise linear regression with backward elimination method was applied to observe the association of dental scales as dependant variables with all the demographic variables as independent variables. Data was analyzed using SPSS version 16. Ethical approval of the study was obtained from dental college research review committee.


Two hundred patients were recruited during the one month period. Demographic variables showed that females were higher in number than the males (%). Mean age of the patients was 39.2± 15.0 years. The mean age was 41.1± 15.9 years for the males and 37.8± 14.2 years for the females. 58% participants were <34 years old, while 44% subjects were in lowest income group (Rs. 5000/-), 41% were in service and 84.5% subjects from urban location. (Table 1)

Sixty one percent of the males and 37% of the females selected the response uneasy to Q1 (having to visit the dentist). For the same question 48% subjects of the higher age group felt uneasy. This difference was found to be statistically significant (p=0.014) among genders while it was statistically insignificant (p=0.715) among the age groups. No statistically significant differences were found among the genders and different age groups with regards to Q2 and 3. Statistically significant differences were found among genders (p= 0.004) for the patients’ response to teeth scraping for the anxious category and insignificant among the age groups (p=0.080) (Table 2). Dental anxiety scale questions were also analyzed for their statistical association with demographic variables of occupation, education, income and location; however no association was observed (p>0.130) (data not shown). Stepwise linear regression

with DAS as dependant variable and age, gender, education, income, occupation and location as independent variables showed significant (p<0.41) relation of gender with Q1, 2, 3 and 4 (Table 3). Correlation analysis showed significant association of gender with Q1, 3, 4 and age with Q3 and 4 (Table 4).


The results of this study showed that highest percentage of patients did have anxiety level of uneasy. The anxiety score for the four questions was significantly higher in females as congruent with another study11 however there was an insignificant difference between different age groups11. Moderate to severe anxiety regarding dental treatment was observed in 25% of the patients in Brazil, and the degree of anxiety was higher among females, over the age of 20 years;12 this corresponds with our findings of anxious to severe anxious status of periodontal patients. A regional study by Malvania et al. (2011) has reported that 46% of the participants were anxious about dental procedures and females were significantly more anxious as compared to males13 . In that study, subjects from villages significantly showed higher anxiety levels to those living in city. These findings are not concordant with those of our study.

Different age groups did not show statistically significant difference when compared for dental anxiety levels11. In the current study, subjects of age group >34 years revealed high anxiety scores which disagree with what was reported by another study that reported higher anxiety scores for the subjects aged 20 years and below14. However our results were similar to the results reported by Stabholz et al. (1999) who reported that anxiety of higher level among subjects in the age group 35-44 years15. High dental anxiety is associated with irregular dental care with large odds ratios (ORs)1. As compared to males, females have higher dental anxiety that is also observed in the current study but females also exhibit better compliance with dental visits; have better oral hygiene2.

The reported observation that higher anxiety levels are associated with low level of education as compared to individuals with higher level of education; the probable explanation for this trend may be that higher education provides the individual with better tools to cope with stressful situations like anxiety. Less educated patients had high anxiety scores9 and in another study gender, education and fear were reported significant predictors of dental anxiety that create hindrance in seeking dental care for the presenting complaint16, but this aspect was not explored in the current study.

Regression analysis of the data of this study revealed a significant association of ‘anxiety’ with gender and age. An association between Corah’s Dental Anxiety Scale (DAS) scores and decayed, missing, and filled surfaces (DMFS) status in young men with relatively low level of dental caries has been observed17.

Dental anxiety has also shown association with impact of oral health related quality of life (OHQoL) in a study in Britain, higher scores of dental anxiety were observed among those with worst OHQoL18; however we have not observed QoL in our study. Therefore, it is suggested that dentists should help patients to establish a realistic expectation of pain and minimize fear-related dental avoidance in order to reduce the irregular utilization behaviors by patients2. Treatment of fearful dental patients is recognized as a professional stressor and requires an understanding by the dentist of patience, empathy, and skill in behavior management19, 20. Dental anxiety plays a negative role in a person’s oral health and interferes with effective dental interventions. That is why dental fear and poor dental utilization behaviors reinforce each other2. This study augments observations of other epidemiological studies on dental anxiety and
demographic variables21-24.


Dental anxiety is prevalent among majority of study participants and showed a significant association with female gender, but no relationship was noted with the age-groups in this study sample. No association was observed between DAS and demographic variables of education, income, occupation and location in regression analysis (also by all the used tests).


1. Boman UW, Wennstrom A, Stenman U, Hakeberg M. Oral health-related quality of life, sense of coherence and dental anxiety: an epidemiological cross-sectional study of middle-aged women. BMC Oral Health 2012,12:14-18
2. Meng X, Heft MW, Bradley MM, Lang PJ. Effect of fear on dental utilization behaviors and oral health outcome. Community Dent Oral Epidemiol 2007; 35:292- 301
3. Ha¨gglin C, Berggren U, Hakeberg M, Ahlqwist M. Dental anxiety among middle-aged and elderly women in Sweden. A study of oral state, utilization of dental services and concomitant factors. Gerodontology 1996;13:25-34.
4. Schuller AA, Willumsen T, Holst D. Are there differences in oral health and oral health behavior between individuals with high and low dental fear? Community Dent Oral Epidemiol 2003;31:116-121
5. Schuurs AHB, Duivenvoorden HJ, Thoden van Velzen SK, Verhage F. Three factors predicting irregular versus regular dental attendance: a model fitting to empirical data. Community Dent Oral Epidemiol 1980;8:413-419.
6. Berggren U, Meynert G. Dental fear and avoidance: causes, symptoms, and consequences. J Am Dent Assoc 1984;109:247-251.
7. Ng SKS, Stouthard MEA, Leung WK. Validation of a Chinese version of Dental Anxiety Inventory. Community Dent Oral Epidemiol 2005;33:107-114.
8. Cohen SM, Fiske J, Newton JT. The impact of dental anxiety on daily living Br Dent J 2000;189:385-390
9. Acharya S. Factors affecting dental anxiety and beliefs in an Indian population. J Oral Rehabil 2008;35:259-267
10. Kumar S, Bhargav P, Patel A, Bhati M, Balasubramanyam G, Duraiswamy P and Kulkarni S. Does dental anxiety influence oral health-related quality of life? Observations from a cross-sectional study among adults in Udaipur district, India. J Oral Sci 2009;51:245-254
11. Sanikop S, Agrawal P, Patil S. Relationship between dental anxiety and pain perception during scaling. J Oral Sci 2011;53:341-348
12. Carvalho RW, Falcão PG, Campos GJ, Bastos Ade S, Pereira JC, Pereira MA, et al. Anxiety regarding dental treatment: prevalence and predictors among Brazilians. Cien Saude Colet. 2012;17:1915-1922.
13. Malvania EA, Ajithkrishnan CG. Prevalence and socio-demographic correlates of dental anxiety among a group of adult patients attending a dental institution in Vadodara city, Gujrat, India. Indian J Dent Res 2011;22:179-180
14. Udoye CI, Oginni AO, Oginni FO. Dental anxiety among patient undergoing various dental treatments in a Nigerian teaching hospital. J Contemp Dent Pract 2005;6:91-98.
15. Stabholz A, Peretz B. Dental anxiety among patients prior to different dental procedures. Int Dent J 1999;49:90-94
16. Ekanayake L, Dhamawardena D. Dental anxiety in patients seeking care at the university dental hospital in Srilanka. Community Dent Health 2003;20:112-116
17. Cohen ME. Dental anxiety and DMFS status: association within a US naval population versus differences between groups. Community Dent Oral Epidemiol 1985;13:75-78.
18. McGrath CM, Bedi R. The association between dental anxiety and oral health-related quality of life in Britain. Community Dent Oral Epidemiol 2004;32:67-72.
19. O’Shea RM, Corah NL, Ayer WA. Sources of dentists’ stress. J Am Dent Assoc 1984;109:48-51.
20. Corah NL, O’Shea RM, Ayer WA. Dentists’ management of patients’ fear and anxiety. J Am Dent Assoc 1985;110:734-736.
21. Nicolas E, Collado V, Faulks D, Bullier B, Hennequin M. A national cross-sectional survey of dental anxiety in the French adult population. BMC Oral Health 2007; 7 12-19
22. Enkling N, Marwinski G, Jaehren P. Dental anxiety in a representative sample of residents of a large German city. Clin Oral Investig 2006;10: 84-91.
23. Woodmansey KF. The prevalence of dental anxiety in patients of a university dental clinic. J Am Coll Health 2005;54:59-61.
24. Fredrikson M, Annas P, Fischer H, Wik G. Gender and age differences in the prevalence of specific fears and phobias. Behav Res Ther 1996;34:33-39.