Anxiety among Patients Visiting for Periodontal Therapy in a Tertiary Care Dental Hospital: A Descriptive Cross-sectional Study

ABSTRACT Introduction: The aetiological factors of dental fear include negative information, witnessing or having a bad experience, and negative conditions related to periodontal treatment. Modified Dental Anxiety Scale Nepali version, is one of the tools used in epidemiological studies to measure dental anxiety in adults. The objective was to find out the prevalence of anxiety among dental patients visiting for periodontal therapy in a tertiary care hospital. Methods: This descriptive cross-sectional study was conducted among patients visiting for periodontal therapy from November 2020 to January 2021 at a tertiary care dental hospital. Ethical clearance from Institutional Review Committee (Reference no. 0311202001) was taken before the study. Convenient sampling was done. A standard questionnaire for dental anxiety was used for data collection after receiving informed consent from the participants. Data were entered and analyzed in Microsoft Excel Sheet. Descriptive data are presented as means, standard deviations, frequencies, and percentages. Results: Among a total of 311 participants visiting for periodontal therapy, 297 (95.49%) (92.57-97.42 at 95% Confidence Interval) were having anxiety. Among total patients, 113 (36.33%) were fairly anxious, 111 (35.69%) were slightly anxious, 62 (19.94%) very anxious and 11 (3.54%) were extremely anxious. Majority of males 54 (17.36%) were slightly anxious while most females 67 (21.54%) were fairly anxious. Mean Modified Dental Anxiety Scale-Nepali score of all the participants was 11.59±3.808. Extreme dental anxiety was observed in 11 (3.54%) participants 7 (2.25%) females; 4 (1.29%) males). Conclusions: The prevalence of anxiety among patients visiting for periodontal therapy in this study was found to be higher compared to other study done in similar setting.


INTRODUCTION
Dental anxiety persists among patients despite increased awareness about preventive approaches to oral diseases and innovations in pain reduction. 1,2 Studies have shown 13% of patients in dental college and 20.90% in dental clinics were severely anxious. 3 A telephone survey showed that 11.6% had high dental anxiety with female being more anxious. 4 This was similar to some studies 5,6 but not all. 7 The aetiological factors of dental fear include negative information, witnessing or having bad experience and negative condition related to periodontal treatment. 8 Lack of adequate dental health education may result in a high level of dental anxiety. 9 Although none of existing Free Full Text Articles are Available at www.jnma.com.np psychometric tests are regarded as gold standard, Corah's Dental Anxiety Scale (DAS), Modified Dental Anxiety Scale (MDAS), and Kleinknecht's Dental Fear Survey are most commonly used to measure dental anxiety in adults. 10 The objective was to find out the prevalence of anxiety among patients visiting for periodontal treatment in a tertiary care hospital. The mean MDAS-N score of all the participants was The mean MDAS-N score of all the participants was 11.59±3.808 (SEM = 0.216; minimum = 5; maximum = 21, Table 3).

METHODS
A cut-off value of 19 and above has been determined empirically 4 to indicate extreme dental anxiety that may require special attention. Extreme dental anxiety (MDAS-N ≥19) was observed in 11 (3.54%) of the 311 participants (Table 3). Among them, 7 (2.25%)  (Table 3). At the threshold value of 19 and above, a dental professional should consider using additional management approaches like relaxation, systematic desensitisation or adjunctive pharmacotherapy.

DISCUSSION
Dental anxiety can be predicted by cancellation of dental appointment(s), memorisation of poor dental practice, gender, and age. 5 Dental anxiety also varies with age, sex, and education. 12 The MDAS is the modification of the Corah's Dental Anxiety Scale, which also includes question about local anaesthetic injection. Levin, et al. have reported that patients suffering from chronic periodontitis had higher anxiety compared to control group patients. 13 The mean MDAS-N score of all participants was 11.59±3.808, this was similar to that reported by Faisal et al. (10.24±4.7). 14 In this study, high dental anxiety (MDAS-N ≥19) was observed in 11 (3.54%) of the 311 participants. Other study showed 13% of patients in dental college and 20.90% of patients in dental clinics were severely anxious. 3 One study reported that more than one third (36.9%) of the study population had DAS ≥15 (suggestive of highly anxious individuals). 15 Another study done by telephone survey 4 showed that 11.6% had high dental anxiety (DAS-N ≥19) while White, et al. 16 reported 6.82% patients with high dental JNMA I VOL 59 I ISSUE 239 I July 2021 anxiety. In this study, females were more anxious than males. Though most studies, 5,6 report females to be more anxious, a study in South India did not support for gender differences for anxiety. 7 In the present study, 0-19 years age group had highest mean score of 12.43±3.830 (Table 3) similar to other study which showed 54.1% had severe dental anxiety, 17 but Viinikangas, et al. study reported less score for older individuals. 18 The prevalence of anxiety was seen mostly in the 20-30-year age group (37.3%). 19 The anxiety level can be decreased by dental screening and education. 17 Medical and dental students were less anxious than arts and computer science students suggesting role of dental education in reducing dental anxiety. 20,21 In current study, participants were more anxious on the day before appointment than on the day during waiting for an appointment where as in Inamdar, et al. study, the level of anxiety while waiting for a dental treatment, increased a little as compared to the anxious anticipation of dental treatment a day earlier, approximately 10% of the individuals were more anxious. 15 In this study, MDAS score had been found the highest with local anaesthesia and tooth drilling where similar study done on students reported that students were anxious about tooth drilling and local anaesthetic injection. While anticipating a dental treatment for the next day, 35.3% of participants were not anxious. There were various levels of anxiety among the remaining 65.7%. Total of 64% of these respondents were extremely anxious to slightly anxious. Anxiety levels increased further when participants were asked about getting their tooth drilled and 89% of the respondents were anxious about getting their tooth drilled. 15 similarly, higher level of anxiety was found to be exhibited by participants for injection (55%), followed by scaling (45%) and tooth drilling (40%). 22 Local anaesthesia is given for other dental procedure and related to dental delayed dental visit. 23 High anxiety, younger age, and traumatic dental history were correlated with greater increases in heart rate during the administration of local dental anaesthesia. 24 dental education, psychotherapy might be helpful in reducing anxiety regarding local anaesthesia.
The mean MDAS-N score was highest (11.83±3.774) among bachelors and above education group, but the difference was minimal (Table 4). This may be due to more awareness for oral health and it is multifactorial which is governed by social, cultural rituals and education. Anxiety is present in other patient category(dyspepsia and irritable bowel syndrome). 25 No significant difference result have been found between death-related occupations (firemen, funeral personnel) and non-death related occupations (secretaries, accountants, teachers, etc.) measured by death related anxiety scale. 26 Limitations of the study include singlecentre study with small sample size.

CONCLUSIONS
The prevalence of anxiety among patients visiting fot periodontal therapy in this study was found to be higher compared to other study done in similar setting. Further studies with other modifying variables are needed to conclude this finding regarding dental anxiety in periodontal therapy and its reduction for patient comfort.