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ORIGINAL ARTICLE
Year : 2018  |  Volume : 16  |  Issue : 4  |  Page : 297-302

Social determinants of dental anxiety and utilization of oral health services among young adults in Mangalore City, India


1 Department of Public Health Dentistry, Himachal Institute of Dental Sciences, Paonta Sahib, Himachal Pradesh, India
2 Department of Public Health Dentistry, Manipal College of Dental Sciences, Manipal Academy of Higher Education, Mangalore, Karnataka, India

Date of Submission29-Mar-2018
Date of Acceptance11-Oct-2018
Date of Web Publication29-Nov-2018

Correspondence Address:
Dr. G Rajesh
Department of Public Health Dentistry, Manipal College of Dental Sciences, Manipal Academy of Higher Education, Mangalore, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jiaphd.jiaphd_80_18

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  Abstract 

Introduction: Dental anxiety is a known barrier to oral health-care utilization. The data on dental anxiety and oral health services utilization of young adults in India are scarce. Aim: The present study was conducted to assess the social determinants of dental anxiety and utilization patterns of oral health services among young adults aged 18–21 years in Mangalore city, India. Materials and Methods: A total of 575 young adults aged 18–21 years were selected from degree colleges in Mangalore city. Dental anxiety was assessed using the Modified Dental Anxiety Scale and utilization of oral health services was assessed using a questionnaire. Data were also collected on age, gender, and socioeconomic factors. Statistical analysis was done using Statistical Package for the Social Sciences software. Level of statistical significance was fixed at P < 0.05. Results: The prevalence of dentally anxious individuals was 81.2%. The mean dental anxiety score of respondents was 14.69 ± 4.29. Females reported a statistically higher dental anxiety than males (P = 0.004). Participants with past negative dental experience also showed greater dental anxiety scores (P = 0.04). Dental anxiety was found to be negatively correlated with age (P = 0.003) and father's occupation (P = 0.037). A total of 48 (8.3%) individuals visited a dentist twice a year, whereas 79 (13.7%) individuals had never visited a dentist. The total number of irregular visitors was 448 (77.9%), out of which 268 respondents (46.6%) visited a dentist only for emergency treatments. Dental anxiety scores and utilization of dental health services did not show a statistically significant association. Conclusions: There was a high prevalence of dental anxiety in this population of young adults. Females and individuals with past negative dental experience showed significantly higher dental anxiety. Age and father's occupation were also correlated with dental anxiety. Focus on the social determinants and measures to reduce dental anxiety and improve oral health utilization are needed.

Keywords: Dental anxiety, social determinants of health, young adult


How to cite this article:
Bhatt S, Rajesh G, Rao A, Shenoy R, Pai MB. Social determinants of dental anxiety and utilization of oral health services among young adults in Mangalore City, India. J Indian Assoc Public Health Dent 2018;16:297-302

How to cite this URL:
Bhatt S, Rajesh G, Rao A, Shenoy R, Pai MB. Social determinants of dental anxiety and utilization of oral health services among young adults in Mangalore City, India. J Indian Assoc Public Health Dent [serial online] 2018 [cited 2018 Dec 15];16:297-302. Available from: http://www.jiaphd.org/text.asp?2018/16/4/297/246364


  Introduction Top


Dental anxiety denotes a state of apprehension that something dreadful is going to happen in relation to dental treatment, coupled with a sense of losing control.[1] This anxiety associated with the dental treatment is a well-known problem for patients as well as for the dental health professionals.[2]

Studies have consistently shown that dental anxiety is associated with poor oral health outcomes, that is, those with high levels of dental anxiety were found to have poorer oral health status.[3],[4] Dental anxiety has also been found to be associated with reduced or irregular dental care utilization. This behavior may contribute to compromised oral health of such individuals.[5],[6] Dental anxiety, therefore, may be considered as a health-damaging behavior as it may prevent the patient from accessing essential dental care needed for maintaining optimal oral health.[7]

Individuals with dental anxiety are not a homogeneous group as there are several differences with regard to the onset, origin, and manifestations of dental anxiety.[8] According to the source of anxiety, dentally anxious individuals can be classified into two groups: exogenous and endogenous groups. In the exogenous group, dental anxiety is due to the conditioning through traumatic dental experiences.[9] Locker et al. found association between dental anxiety and negative experiences confirming the fact that dental anxiety can develop as a result of past negative experiences related to dental treatment.[10]

In the endogenous group, dental anxiety may originate in an inherent susceptibility to anxiety disorders, suggesting that all dentally anxious participants do not become fearful as a result of conditioning.[9] Locker et al. found that dental anxiety is a simple conditioned fear in younger participants, while in older participants, it is more likely to be related to generalized anxiety.[8]

Dental anxiety has also been observed to be associated with self-reported measures of oral health. In a study, dentally anxious individuals reported a poorer oral health as compared to nonanxious individuals. Dentally anxious individuals may have a bias in the way, they process the information causing them to perceive their oral health in a more negative way.[11]

Dental anxiety, thus, appears to be a complex of various inter-related factors, making it difficult to establish one factor as solely responsible. This indicates the presence of related social determinants. The social determinants of health are the conditions in which people are born, grow, live, work, and age.[12] These factors affect the oral health-related behavior and dental anxiety is one such aspect that has a negative impact on the oral health.

Results from previous studies suggest that younger adults are particularly vulnerable to onset and that dental anxiety may also arise during adolescence and adulthood. Furthermore, the prevalence of dental anxiety is most stable in young adults, making this a suitable age group for exploring dental anxiety.[13] Several investigators have estimated the prevalence and determinants of dental anxiety, but the majority of these studies are confined to western countries. Hence, socially determined factors associated with dental anxiety in western populations might not be the same in developing countries such as India.[14]

Moreover, there is no published data till date regarding the social determinants of dental anxiety in young adults and its association with utilization of oral health services in India. Hence, the present study aimed to assess the social determinants of dental anxiety and oral health-care utilization among young adults and ascertain the association between dental anxiety and utilization patterns of oral health services among young adults in Mangalore city, India. This study will also correlate the aforementioned factors with perceived oral health and past dental experiences in the Indian population.


  Materials and Methods Top


A cross-sectional questionnaire-based study was carried out among young adults aged 18–21 years in Mangalore city. Mangalore is the chief port city of the Indian state of Karnataka, with a population of 484,785 as per the 2011 census of India.[15]

The sample size was calculated using Stata/SE 10.0 (StataCorp, 2007, TX, StataCorp LP, USA) assuming mean dental anxiety as 7.04 and standard deviation as 3.4 which were based on the review of the literature.[5] The level of significance was fixed as 5%, and the power of the sample size was determined to be 90%. Based on these values, the sample size was estimated to be 575. The study began after approval from the Institutional Ethics Committee of Manipal College of Dental Sciences, Mangalore (Ref.:MCODS/198/2011).

For obtaining the data, a list of all the degree colleges in Mangalore city was obtained. There were nine colleges in Mangalore city offering degree courses. Out of these, three colleges were included conveniently according to permission granted by the heads of respective colleges. Therefore, convenient sampling was carried out to recruit participants for the study.

Inclusion criteria were as follows: regular college students, familiarity of study subjects with the English language, and availability during the study period. Students who had been admitted to hospital or suffered from major health/mental health problems in the last year, students with known systemic illness, students undergoing orthodontic treatment, and students who were undergoing treatment for known health/mental health problems were excluded from the study.

The study was conducted from August to September 2012. The students were contacted in the classrooms of their respective colleges at the end of the class. The students were explained about the purpose of the study and the questionnaires along with informed consent forms were distributed to them. The survey questionnaire included questions regarding frequency of dental visits, time since the last dental visit, main reasons for visiting the dentist, perceived oral and general health, and past dental experiences. Data on age, gender, and socioeconomic factors were also collected. The education and occupation of parents of the college students were classified according to criteria given in Kuppuswamy's socioeconomic status scale which is used to measure socioeconomic status of families in urban communities.[16] The process of completing the questionnaire was of 5–10 min duration.

The dental anxiety of the study participants was measured using the Modified Dental Anxiety Scale (MDAS), which is a modification of a self-reported assessment scale developed by Corah, the DAS.[17] It is a brief, 5-item questionnaire dealing with patient's subjective reaction to following questions: how anxious one feels: (1) the day before a dental appointment, (2) when in the waiting room, (3) waiting for the drilling of tooth, (4) scaling, and (5) a local anesthetic injection. There is a consistent answering scheme for each item ranging from “not anxious” (scored 1) to “extremely anxious” (scored 5). It is summed together to construct a Likert scale with a minimum score of 5 and a maximum of 25.[18]

The dentally anxious individuals were defined as participants with MDAS scores of more than 11, based on the conversion of Corah's DAS interpretation into MDAS scale. The case definition of dentally anxious individuals and the severity of dental anxiety was determined by converting interpretation of Corah's scale into MDAS scale using the formula 0.56 + (1.15 × DAS score) and is given as follows:[19]

  • <11 Not anxious
  • ≥11 Dentally anxious
  • 11–14 Moderately anxious
  • 15–18 Highly anxious
  • ≥19 Extremely anxious.


Statistical Package for the Social Sciences (SPSS for Windows, Version 16.0. Chicago, SPSS Inc.). Comparison of the dental anxiety with oral health-care utilization, age, sex, and socioeconomic determinants was done using Chi-square test, independent t-test, and one-way analysis of variance. Using these methods, variables were selected for correlation analysis and the level of significance was fixed at P < 0.05.


  Results Top


This study was conducted on a total of 575 participants, out of which 260 (45.2%) were men and 315 (54.8%) were women with age ranging from 18 to 21 years [Table 1].
Table 1: Relationship between dental anxiety and sociodemographic variables

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A total of 467 participants (81.2%) exhibited some level of dental anxiety with MDAS score of 11 or above. About 19% participants reported extreme dental anxiety with MDAS score of 19 and above, whereas about 33% of the participants reported high dental anxiety [Table 2]. The mean dental anxiety was calculated to be 14.7 ± 4.2 in this sample of young adults. Women reported a higher mean MDAS score (15.1 ± 4.0) as compared to men (14.1 ± 4.5), which was found to be statistically significant (P < 0.05) [Table 1]. Among other factors, the participants whose fathers were in professional occupation showed significantly lesser dental anxiety compared to other groups (P < 0.05) [Table 1], and a negative correlation was observed between the two groups [Table 3]. Rest of the sociodemographic factors were not significantly associated with the dental anxiety.
Table 2: Distribution of subjects according to dental anxiety, self-perceived general and oral health, dental attendance patterns, and past dental experiences

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Table 3: Correlation between dental anxiety and sociodemographic factors

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A total of 48 individuals (8.3%) visited the dentist twice a year (regular visitors), whereas 79 individuals (13.7%) had never visited a dentist (never visitors). The total number of irregular visitors was 448 (77.9%). When asked about the reason for the dental visit, about 46% of respondents mentioned that they visited a dentist only for emergency treatments [Table 2].

The individuals with a past negative dental experience showed higher mean dental anxiety (P < 0.05) as compared to those without any negative dental experience in the past [Table 4]. Other factors were not significantly associated with dental anxiety.
Table 4: Intra-group comparisons between dental anxiety and dental attendance patterns, past dental experience, and perceived general and oral health

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The dental anxiety scores were significantly correlated with age and father's occupation [Table 3]. Other sociodemographic factors were not found to be significantly correlated.

Age was significantly associated with perceived oral health. Participants with lower age reported better oral health than older participants. Women had perceived their general health to be better when compared to that of men (P < 0.05). Hindus were found to be more regular in their utilization of dental care than other religions. Furthermore, more number of Hindus perceived their general health to be better when compared to other religions (P < 0.05) [Table 5].
Table 5: Association of sociodemographic factors with dental anxiety, utilization patterns, perceived oral, and general health and past dental experiences

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Self-reported measures of oral health were significantly associated with perceived health. The utilization patterns of oral health services were significantly associated with past dental experiences, which were reported more by irregular visitors [Table 6].
Table 6: Association between various parameters among study subjects

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  Discussion Top


The present study was done to assess the social determinants of dental anxiety and its relationship with utilization patterns of dental health services among young adults in Mangalore city. This study is one of the 1st attempts to find out the association between dental anxiety and sociodemographic variables, utilization patterns of oral health services, perceived oral health, and past negative dental experiences in this sample of the Indian population.

In this study, 81.2% of the participants had some degree of dental anxiety (MDAS score ≥11). This is higher than the prevalence of dental anxiety reported previously in the literature. In a study, 50.2% of the participants were found to be dentally anxious,[20] whereas another study found 46% dentally anxious individuals in an adult Indian population,[14] supporting the hypothesis that dental anxiety is higher in the younger population.

Women reported a significantly higher mean dental anxiety score as compared to men. This finding was in agreement with various reported studies.[2],[14] Women, in general, are more likely than men to meet criteria for all anxiety disorders[21] and this might be the reason for higher levels of dental anxiety. More emotional stability among men has also been suggested as one of the reasons why women report higher dental anxiety.[22]

Among other sociodemographic factors, father's occupation was found to be significantly associated with dental anxiety. The participants whose fathers were in professional occupation had significantly lesser dental anxiety and a negative correlation was observed between the two variables. This observation might be related to the socioeconomic factors, a finding which is in agreement with studies which mention that dental anxiety is higher in the lower socioeconomic groups.[5],[23] Individuals from lower socioeconomic backgrounds experience higher levels of psychosocial stress[24] and are more likely to make behavioral or lifestyle choices that are damaging to health.[25] These factors might influence the way that a person perceives the dental treatment resulting in higher anxiety levels.

Dental anxiety was inversely correlated with age, confirming the findings from a systematic review on anxiety among children and adolescents which found that the prevalence of dental anxiety decreases with the increasing age.[1]

Utilization patterns of dental health services did not show statistically significant association with dental anxiety in this population of young adults, although the regular visitors showed lesser mean dental anxiety scores than irregular and never visitors. Similar findings were observed in another sample of Indian population where previous dental visits were not associated with dental anxiety.[14]

Among other variables, participants who reported negative dental experience in the past had a significantly higher mean dental anxiety scores as compared to those who did not confirming similar findings from previous studies.[14],[26] This indicates that previous negative or traumatic experiences related to dental treatment can be a significant predictor of dental anxiety.

Majority of the participants reported their oral health to be good to excellent. There was no significant association between dental anxiety and self-reported measures of health in this sample of the population. Younger study participants reported their overall oral health to be better in comparison to older participants. This seems logical as the oral diseases are cumulative in nature and their effect tends to accumulate over time. This might explain the better perceived oral health by younger age group in this population.

Female gender was associated with better self-reported measures of general health. This is in contrast to previous studies where women reported poorer health.[27] These differences can be due to different sociodemographic conditions in earlier studies.

Significant differences were observed in utilization patterns of Hindus and other religions. This is in agreement with a previous study done in Mangalore city.[28] Hindus also reported significantly better-perceived health as compared to others. The better utilization of dental services, in part, reflects a better attendance for general health care as well. This can lead to better overall health and thus better self-reported measures of health. However, causality of these associations can be explained better by longitudinal studies.

A significant association was observed between perceived oral health and perceived general health. Self-reported measures of health are basically the subjective interpretations of an individual's satisfaction with own health. Therefore, it seems reasonable to assume that people who report better oral health also perceive their general health as good.

Dental attendance patterns were found to be associated with past dental experiences. More irregular visitors reported having negative dental experiences in the past. This can be an indirect association as the past negative dental experience can result in dental anxiety[10] which in turn can lead to the development of avoidance behavior.

An inherent limitation of the present study is the cross-sectional design which does not give any insights into the causality. Longitudinal studies on a varied sample can give information about the causal relationship between dental anxiety and its social determinants. Representativeness of this study population should be considered with caution as sample was selected conveniently. The results of the study cannot be generalized to whole of the young adult population in India as the study was carried out in Mangalore city only. Furthermore, the study relies heavily on self-reported measures which are subjective in nature and can induce bias.

In this study, dental anxiety is seen to have a social gradient with various groups showing different anxiety levels. The high prevalence of dental anxiety clearly indicates the need for awareness toward dental treatment. The oral health education should be included in school curricula to familiarize the children with the importance of oral health in their learning phase. Creating a positive attitude toward dental treatment from an early age is essential to develop a regular attendance pattern and to reduce the incidences of negative dental experiences.


  Conclusions Top


A high prevalence of dental anxiety and a low dental attendance was reported in young adult population in Mangalore city, India. Females and individuals with past negative dental experience had a higher dental anxiety. Dental anxiety was seen to be correlated with age and father's occupation. Importance of understanding the social determinants and awareness toward dental treatment by means of oral health education in school curricula is essential to minimize this public health problem.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
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