Journal of Indian Association of Public Health Dentistry

: 2019  |  Volume : 17  |  Issue : 3  |  Page : 235--245

Anxiety of dental treatment among patients visiting primary health centers

Ekta Sinha, R Rekha, SR Nagashree 
 Department of Public Health Dentistry, VS Dental College and Hospital, Bengaluru, Karnataka, India

Correspondence Address:
Dr. Ekta Sinha
Department of Public Health Dentistry, VS Dental College and Hospital, Bengaluru - 560 004, Karnataka


Background: Despite the advances in technology, dental materials, and increased oral health awareness, significant percentage of people suffer from dental anxiety. Dental anxiety is ranked fourth among common fears and ninth among intense fears. Aim: The aim was to assess the level of anxiety of dental treatment among patients in primary health centers (PHCs). Materials and Methods: The sample was made up of 100 patients from both genders over 18 years of age visiting PHCs for dental treatment, who were not suffering from any psychological limitation, between August and September 2017. Data collection was carried out through the administration of validated questionnaires by a calibrated researcher. A self-administered prevalidated questionnaire was used to evaluate the level of anxiety among the patients. The Modified Dental Anxiety Scale was used to evaluate the degree of anxiety among study participants. SPSS 21 was used, and data were analyzed using Chi-square test. Results: The prevalence of dental anxiety among study participants was found to be 94%. Females were found to be significantly more anxious than males. Higher level of anxiety was found to be exhibited by participants for injection (55%), followed by scaling (45%) and tooth drilling (40%). Relative influence of age, education, occupation, type of dental treatment, and previous dental visit were not significantly associated with dental anxiety. However, those participants who had past negative dental experience were found to be significantly more anxious. Conclusion: The study showed that dental anxiety was high among the participants. High level of anxiety was found to be exhibited by participants for injection, followed by scaling and tooth drilling. Level of anxiety is significantly associated with past traumatic dental experience, gender (higher level of anxiety was found to be among women), and low-income group (0–10 K) per month.

How to cite this article:
Sinha E, Rekha R, Nagashree S R. Anxiety of dental treatment among patients visiting primary health centers.J Indian Assoc Public Health Dent 2019;17:235-245

How to cite this URL:
Sinha E, Rekha R, Nagashree S R. Anxiety of dental treatment among patients visiting primary health centers. J Indian Assoc Public Health Dent [serial online] 2019 [cited 2022 Aug 17 ];17:235-245
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Full Text


Anxiety is often expressed as an imaginary threat to a vague, unpleasant feeling accompanied by the premonition that something undesirable is going to happen. It is defined as apprehension of danger and dread, accompanied by restlessness, tension, tachycardia, and dyspnea unattached to a clear unidentifiable stimulus.[1]

It can also be described as a reaction to a perceived danger that is known to the individual and is often characterized by feelings of tension, worried thoughts, apprehension, and physical changes such as increased blood pressure, nausea, and palpitation. On the other hand, fear is a biological response and a reaction to a known danger or threat.[2],[3] The terms anxiety, phobia, and fear are often used interchangeably in the literature, and differentiating one term from other is often complicated.

Despite the advances in technology, dental materials, and increased oral health awareness, significant percentage of people suffer from dental anxiety. Dental anxiety is ranked fourth among common fears and ninth among intense fears.[4] The prevalence of dental anxiety has been studied among various populations and cultures, and the study results from developed countries have shown that fearful dental patients avoid dental treatment, seek emergency dental care, postpone their dental visit, and have poor oral health-related quality of life and more number of missing and decayed teeth.[5],[6] The occurrence of dental anxiety has been attributed to factors such as personality characteristics, traumatic dental experience in childhood (conditioning experiences), vicarious learning from dentally anxious family members or peers, perception of body image, blood injury fears, and pain reactivity.[7],[8]

Dental anxiety is related to age, gender, educational qualification, socioeconomic status, and culture and varies from person to person. Identifying dentally anxious patients is crucial for management and treatment outcome.

There is little information on the direct impact that dental anxiety has on people's lives. A number of studies have indicated that people who are dentally anxious experience a greater amount of dental disease.[9],[10],[11],[12]

Little is understood of the natural history of dental anxiety.[13] Weiner and Sheehan (1990) have suggested that dentally anxious people could be classified into two groups: exogenous and endogenous, with respect to the source of their anxiety. In the former, dental anxiety is the result of conditioning through traumatic dental experiences or vicarious learning, whereas in the latter, it has its origins in a constitutional vulnerability to anxiety disorders, as evidenced by general anxiety states, multiple severe fears, and disorders of mood.[14]

Dental anxiety is often reported as a cause of irregular dental attendance, delay in seeking dental care, or even avoidance of dental care.[15] Mehrstedt et al.[16] and Crofts-Barnes et al.[17] have reported that those experiencing high levels of dental anxiety are among those with the poorest oral health-related quality of life. Dental anxiety varies in intensity from patient to patient. Several investigators have estimated the prevalence and determinants of dental anxiety, but majority of the studies have been mainly confined to populations from industrialized countries. There is evidence that the prevalence and characteristics of dental anxiety are influenced by culture.[15] Hence, factors that have been identified as responsible for dental anxiety in populations from industrialized countries may not be the same among population of developing countries such as India.

Dentally anxious individuals, because of their avoidant behavior, often have poorer dental health.[18],[19] In particular, those people who delay dental visiting for a prolonged time, even if experiencing considerable pain, might have extensive problems that require more complex and complicated treatment.

Prior to treatment, dentists should be able to detect patients' level of anxiety and fear, so they can use appropriate management options. Thus, several scales have been developed for this intention. One of them is Corah's Dental Anxiety Scale (CDAS).[20] This scale does not contain any question about local anesthetic injection, which is a major anxiety source for some patients.[21] The Modified Dental Anxiety Scale (MDAS) is established by Humphris et al.[22] based on the CDAS and comprises a question about local anesthetic injection. MDAS is the most accepted questionnaire for assessing dental anxiety in the UK.[23] It is valid and reliable and has good psychometric properties. Answering is easy, quick, not anxiety provoking, and therefore, suitable for clinical uses.[24],[25],[26] In younger children, vocabulary, understanding, and emotions are not fully developed, so using Dental Fear Scale and MDAS is limited to adults.[27]

Thus, this study was conducted to assess the level of anxiety toward dental treatment among adult study participants visiting primary health centers (PHCs) in Bengaluru.

 Materials And Methods

This cross-sectional study was conducted in Bengaluru. Convenience sampling was done as data were collected from the first 100 patients coming to the dental department of Shanthinagar and Sri Gandhadha Kavalu PHCs, during the month of study period, i.e., August and September 2017. Ethical clearance was obtained from the Institutional Committee of Vokkaligara Sangha Dental College and Hospital. Informed consent was obtained from the study participants prior to filling of the questionnaire, and complete anonymity and confidentiality were assured. All the patients aged ≥18 years, who visited PHC for any dental treatment during this period and were willing to participate, were included in the study. Patients with any serious physical anomaly or psychological limitations which will hinder in understanding the questionnaire were excluded from the study.

Structured questionnaire to record the demographic and socioeconomic data, previous dental visit as well as scores on anxiety scale regarding dental treatment were administered using MDAS to all the study participants designed both in Kannada and English languages.

Investigator personally administered the questionnaire to the participants and helped the participants with the questions where they faced difficulty in understanding. The questionnaire was used to collect the following information:

Sociodemographic information (age, sex, address, education, occupation, number of family members, and annual family income)Details of previous dental visits and treatments (five questions)Questions related to MDAS.[22] This scale includes five brief multiple choice questions and concerns patients' anxiety in the following situations:

Anticipating a visit to dental clinicWaiting in the dentist's office for treatmentWaiting in the dental chair for drilling of teethWaiting in the dental chair for scaling of the teethWaiting in the dental chair for receiving a local anesthetic injection (5 questions).

Details of dental fear (two questions).

Possible answers could range from “nonanxious” with a value of 1 to “extremely anxious” with a value of 5. The summation of values for all answers assembles a score for level of dental anxiety with a minimum of 5 and maximum of 25. Patients with scores of 0–10 were considered slightly/nonanxious. Scores from 11 to 14 were fairly anxious and scores from 15 to 25 were very anxious.

Statistical analysis

Data collected during the survey were entered into excel sheets and were subjected to statistical analysis. Statistical analysis was done by the IBM SPSS Statistics 21 (IBM, Chicago, USA, 2012) for descriptive data analysis. Descriptive statistics were done for demographic data and the questions related to attitude and comfort level, perception, and opinion on anxiety toward dental treatment. Chi-square test was used to find significant association between variables such as age, socioeconomic status and education, and gender with a few questions pertaining to details, perception, and attitude of the patients toward dental treatment, with significance levels at P ≤ 0.05.


The present study involved 100 participants. The study sample comprised 58 males and 42 females aged 18 years and above. The majority of the participants (45%) were 18–27 years old. Among the study participants, 46% were graduates and 30% of participants belonged to income group of Rs. 21–30 K per month [Table 1].{Table 1}

The prevalence of dental anxiety among the study population was 94%. Higher level of anxiety was exhibited by participants toward dental treatment procedures; majority of the participants were very anxious toward injection (55%), followed by scaling (45%) and tooth drilling (40%) [Table 2].{Table 2}

Of 100 participants, 71 had previously visited dentist. Twenty-three participants (32.4%) of the total participants who had previously visited dentist had traumatic experience.

Majority of the participants who had previous traumatic experience exhibited a higher level of dental anxiety, especially toward treatment procedures with 69.5% of participants being very anxious toward injection and scaling procedure, followed by 52.1% being very anxious when a tooth is being drilled. Dental anxiety was significantly associated with past traumatic experience [Table 3] ( P < 0.001).{Table 3}

Women demonstrated a significantly higher level of dental anxiety than men for treatment procedures [Table 4]. It was observed that there is a significant association between income and dental anxiety with study participants belonging to Rs. 0–10 K per month income group which showed a higher level of dental anxiety [Graph 1].{Table 4}[INLINE:1]


The prevalence of dental anxiety in the present study was found to be 94%, which suggests that despite the technological advances made in modern dentistry, anxiety associated with dental treatment was widespread in the study population. The prevalence was higher than that reported in studies done by do Nascimento et al. (23%),[28] Malvania and Ajithkrishnan (46%),[29] Madfa et al. (63%),[30] and Fotedar et al. (29%).[31] This difference can be attributed partly to the methodological differences or geographical variation.

About 9% of the participants claimed to visit the dentist on regularity. This figure is low compared with the figures reported in the developed countries (50%–72%).[32]

In a study conducted by do Nascimento et al.,[28] it was found that people with previous traumatic dental experiences showed higher levels of dental anxiety. This finding is consistent with the results of the present study as it has been seen that majority of the study participants who had previous traumatic experience were very anxious, and this association was found to be significant in all the five cases.

In the literature, although Kanegane et al. found no relationship between gender and dental anxiety,[33] many authors have shown that dental anxiety is more common in women.[34],[35],[36],[37] The result of our study is similar to the most recent reports that females demonstrate higher levels of dental anxiety than males. This difference may be explained by women being more able to express their feelings of fear. In addition, physiological conditions such as social phobia, panic, depression, stress, and fear are more common in females, and dental anxiety may be associated with such emotions.[35]

Patients with higher educational levels may have better oral health or visit the dentist more regularly.[32] In studies conducted by do Nascimento et al. and Humphris et al.[28],[36] and Erten et al., it is found that higher education leads to a reduction in dental anxiety.[36] However, in our study, differences in educational level did not influence the dental anxiety level as was the case in the studies of Kanegane et al. and Arslan et al.[33],[35]

The results of the study showed no statistically significant difference in anxiety levels between the age groups. Few of the studies done previously like Stabholz and Peretz, do Nascimento et al., Humphris et al., Appukuttan et al., and Marya et al. reported that age was strongly associated with dental anxiety and younger participants were more anxious than older ones.[27],28,[36],[37],[38] However, Malvania and Ajithkrishnan, Arslan et al., and Erten et al. found similar results with our study that age is not statistically associated factor with dental anxiety.[29],[35],[39] The result obtained in the present study might be due to the well-accepted fact that dentally anxious individuals are not a homogenous group but differ in terms of origin and manifestation of their fears of dental treatment.

It was observed that there is a significant association between income and dental anxiety which has not been shown earlier by any study. In the present study, participants belonging to Rs. 0–10 K income group showed a higher level of dental anxiety.

The present cross-sectional study has been conducted on a limited population who visited two public health centers, i.e., Shanthinagar and Srigandhakavalu PHCs during the study period. These patients had lower economical and educational levels; therefore, studies on larger populations are needed to reveal the prevalence and enormity of dental anxiety in the society. Furthermore, further studies with different designs should be accomplished to investigate different commencing factors of dental anxiety.


Findings of the study suggest that the prevalence of dental anxiety was high among the study participants. Among the various sociodemographic factors, gender, income, and past negative dental experience were significantly associated with dental anxiety. Although meticulous care has been taken to exclude the patients with psychological disorders which may influence the assessment of anxiety, some patients might have been missed out as reliability was based on the response of patients.

The development of dental anxiety could be prevented with pain control, behavior management, and consideration of patients as a whole. The inclusion of behavioral sciences in dental education and the integration of ethical considerations in the academic dental curriculum could help to improve the situation.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


1Sinan AY, Deniz O, Mustafa O, Serkan P. An assessment of dental anxiety in oral surgery patients. Gurhane Tip Dergisi 2002;44:395-8.
2Rubin JG, Slovin M, Krochak M. The psychodynamics of dental anxiety and dental phobia. Dent Clin North Am 1988;32:647-56.
3Chadwick BL. Assessing the anxious patient. Dent Update 2002;29:448-54.
4Kvale G, Berg E, Raadal M. The ability of Corah's dental anxiety scale and Spielberger's state anxiety inventory to distinguish between fearful and regular Norwegian dental patients. Acta Odontol Scand 1998;56:105-9.
5Gift HC, Atchison KA. Oral health, health, and health-related quality of life. Med Care 1995;33:NS57-77.
6Thomson WM, Stewart JF, Carter KD, Spencer AJ. Dental anxiety among Australians. Int Dent J 1996;46:320-4.
7Locker D, Shapiro D, Liddell A. Overlap between dental anxiety and blood-injury fears: Psychological characteristics and response to dental treatment. Behav Res Ther 1997;35:583-90.
8Seeman K, Molin C. Psychopathology, feelings of confinement and helplessness in the dental chair, and relationship to the dentist in patients with disproportionate dental anxiety (DDA). Acta Psychiatr Scand 1976;54:81-91.
9Hällström T, Halling A. Prevalence of dentistry phobia and its relation to missing teeth, alveolar bone loss and dental care habits in an urban community sample. Acta Psychiatr Scand 1984;70:438-46.
10Berggren U, Meynert G. Dental fear and avoidance: Causes, symptoms, and consequences. J Am Dent Assoc 1984;109:247-51.
11Locker D, Liddell A. Clinical correlates of dental anxiety among older adults. Community Dent Oral Epidemiol 1992;20:372-5.
12Hakeberg M, Berggren U, Gröndahl HG. A radiographic study of dental health in adult patients with dental anxiety. Community Dent Oral Epidemiol 1993;21:27-30.
13Thomson WM, Poulton RG, Kruger E, Davies S, Brown RH, Silva PA. Changes in self-reported dental anxiety in New Zealand adolescents from ages 15 to 18 years. J Dent Res 1997;76:1287-91.
14Locker D, Thomson WM, Poulton R. Onset of and patterns of change in dental anxiety in adolescence and early adulthood: A birth cohort study. Community Dent Health 2001;18:99-104.
15Ekanayake L, Dharmawardena D. Dental anxiety in patients seeking care at the university dental hospital in Sri Lanka. Community Dent Health 2003;20:112-6.
16Mehrstedt M, John MT, Tönnies S, Micheelis W. Oral health-related quality of life in patients with dental anxiety. Community Dent Oral Epidemiol 2007;35:357-63.
17Crofts-Barnes NP, Brough E, Wilson KE, Beddis AJ, Girdler NM. Anxiety and quality of life in phobic dental patients. J Dent Res 2010;89:302-6.
18Eitner S, Wichmann M, Paulsen A, Holst S. Dental anxiety – An epidemiological study on its clinical correlation and effects on oral health. J Oral Rehabil 2006;33:588-93.
19Armfield JM, Slade GD, Spencer AJ. Dental fear and adult oral health in Australia. Community Dent Oral Epidemiol 2009;37:220-30.
20Kelly M, Steele JG, Nuttal N, Bradnock G, Morris J, Nunn J, et al. Adult Dental Health Survey, Oral Health in the United Kingdom 1998. London: The Stationary Office; 2000.
21Lindsay SJ, Humphris G, Barnby GJ. Expectations and preferences for routine dentistry in anxious adult patients. Br Dent J 1987;163:120-4.
22Humphris GM, Morrison T, Lindsay SJ. The modified dental anxiety scale: Validation and United Kingdom norms. Community Dent Health 1995;12:143-50.
23Dailey YM, Humphris GM, Lennon MA. The use of dental anxiety questionnaires: A survey of a group of UK dental practitioners. Br Dent J 2001;190:450-3.
24Humphris GM, Freeman R, Campbell J, Tuutti H, D'Souza V. Further evidence for the reliability and validity of the modified dental anxiety scale. Int Dent J 2000;50:367-70.
25Humphris GM, Hull P. Do dental anxiety questionnaires raise anxiety in dentally anxious adult patients? A two-wave panel study. Prim Dent Care 2007;14:7-11.
26Newton JT, Edwards JC. Psychometric properties of the modified dental anxiety scale: An independent replication. Community Dent Health 2005;22:40-2.
27Peretz B, Efrat J. Dental anxiety among young adolescent patients in Israel. Int J Paediatr Dent 2000;10:126-32.
28do Nascimento DL, da Silva Araújo AC, Gusmão ES, Cimões R. Anxiety and fear of dental treatment among users of public health services. Oral Health Prev Dent 2011;9:329-37.
29Malvania EA, Ajithkrishnan CG. Prevalence and socio-demographic correlates of dental anxiety among a group of adult patients attending a dental institution in Vadodara city, Gujarat, India. Indian J Dent Res 2011;22:179-80.
30Madfa AA, Amran AG, Al-Sanabani FA, Alhajj MN, Al-Qudaimi NH, AL-Malahy NA, et al. Prevalence of dental anxiety and fear among medical students at university of Thamar. Am J Health Res 2015;3:5-9.
31Fotedar S, Bhardwaj V, Fotedar V. Dental anxiety levels and factors associated with it among patients attending a dental teaching institute in Himachal Pradesh. SRM J Res Dent Sci 2016;7:153.
32Woolgrove J, Cumberbatch G. Dental anxiety and regularity of dental attendance. J Dent 1986;14:209-13.
33Kanegane K, Penha SS, Munhoz CD, Rocha RG. Dental anxiety and salivary cortisol levels before urgent dental care. J Oral Sci 2009;51:515-20.
34Stabholz A, Peretz B. Dental anxiety among patients prior to different dental treatments. Int Dent J 1999;49:90-4.
35Arslan S, Erta E, Ülker M. The relationship between dental fear and sociodemographic variables. Erciyes Med J 2011;33:295-300.
36Humphris GM, Dyer TA, Robinson PG. The modified dental anxiety scale: UK general public population norms in 2008 with further psychometrics and effects of age. BMC Oral Health 2009;9:20.
37Marya CM, Grover S, Jnaneshwar A, Pruthi N. Dental anxiety among patients visiting a dental institute in Faridabad, India. West Indian Med J 2012;61:187-90.
38Appukuttan DP, Tadepalli A, Cholan PK, Subramanian S, Vinayagavel M. Prevalence of dental anxiety among patients attending a dental educational institution in Chennai, India – A questionnaire based study. Oral Health Dent Manag 2013;12:289-94.
39Erten H, Akarslan ZZ, Bodrumlu E. Dental fear and anxiety levels of patients attending a dental clinic. Quintessence Int 2006;37:304-10.