Introduction

According to the most recent Adult Dental Health Survey,1 dental health across the UK is improving with 71% of dentate adults having no visible caries, compared with 54% in 1998. In this survey, 12% of adults were classified as having extreme dental anxiety and 61% attend for regular check-ups. Dental anxiety is a complex, multi-dimensional, multi-factorial characteristic. It has been shown to be associated with many different factors including personality types, age and gender.1,2 Previous bad experiences, together with how the bad experience is remembered, fear of pain, and general fears, such as fear of mutilation and suffocation, are significant factors for develo** dental anxiety.3,4,5

Dental anxiety is a major reason for avoidance of regular dental care,6,7,8 dental avoidance is also associated with social deprivation, low socioeconomic status, family attendance patterns, ethnicity, ability to pay for treatment and younger age.9,10,11,12,13 Those 'needing' treatment, as determined by a clinician, are less likely to seek regular care and more likely to only attend when experiencing problems.6,7,13

Qualitative research carried out by Finch et al. aimed to investigate the concept of barriers, or obstacles, to receipt of dental care.14 Cost and anxiety featured strongly in emerging patient-focused themes. However, there emerged a more complex, multifactorial concept involving physical barriers for patients, dentists perceiving inequalities of service provision, and society perception as a whole of insufficient political support from healthcare funding influencing the availability of dental services. The dentist-patient interaction was shown to be important and that barriers should be considered within a two-person framework (factors related to both dentist and patient).

It has been reported that dentally anxious patients visit the dentist less often and have higher numbers of decayed and missing teeth than non-anxious patients.6,15,16 The relationship between dental anxiety, dental avoidance and oral health has been described as a vicious cycle.6 Those who are anxious are more likely to delay treatment, attending only when they have a problem. This may require more complex treatment, which may in turn be a more traumatic experience, thus feeding back into maintaining their anxiety.

By develo** a greater understanding of co** strategies for anxious people, it may be possible to encourage more regular attendance patterns, so improving levels of oral health9

Miller describes a theory of how personality type affects information-seeking behaviour and influences co** strategies.17 Two personality types are described: 'monitors', people who seek information to cope with stress; and 'blunters', who avoid information when faced with a difficult situation. These two types may have different preferences and needs for anxiety management techniques and this suggests that different techniques will need to be employed for different people.

Although there has been little or no research linking Miller's personality types with preferences, research has been carried out investigating preferences for non-pharmacological approaches to manage general anxiety associated with chronic pain. This demonstrates that popular preferences include techniques such as biofeedback, yoga and hypnosis, whereas other techniques such as acupuncture and massage are less popular.18 To date, there would appear to be very little research investigating preferences for non-pharmacological management of dental pain and anxiety.

The use of complementary and alternative medicine (CAM) techniques as an adjunct to conventional medicine and for management of pain has increased. It is reported that up to 40% of adults and 12% children in the United States are using CAM for symptom management in chronic pain.19

Pharmacologically, dentally anxious patients say they would be more likely to visit the dentist if given a drug to make them feel less anxious.20 However, the numbers expressing a preference for sedation for dental treatment may be up to three times greater than those actually receiving it.20 Both high and low anxiety groups express interest in sedation, and this has been shown to increase if the treatment is perceived to be painful or unpleasant.21 Therefore, preferences for treatment may vary according to the individual and proposed treatment, and may not always be related to anxiety levels.

In general there has been little research addressing the factors that influence preferences for different anxiety management techniques, and the aim of this study was therefore to gain a greater understanding of the preferences for different anxiety management techniques of patients attending a dental access centre for emergency dental treatment and to ascertain the factors influencing such preferences.

Method

Study design

The work was designed as a cross-sectional study that combined observational and survey methods.

Sample

The study population involved patients attending for emergency appointments at Monkgate Dental Access Centre in York, UK, during the period October 2011 to January 2012. A required sample size of 200 was calculated to enable regression analysis to be applied to data.22 The established inclusion criteria were:

  • Not registered with a general dental practitioner

  • Aged 18 years or over

  • Currently experiencing pain

  • Self-referred

  • Able to comprehend/complete a questionnaire.

A consecutive sampling technique was used to include all patients fulfilling the inclusion criteria on allocated data collection sampling sessions, according to availability of the researcher. On allocated sessions, the researcher assessed attending patients from computer appointment diaries and identified potential participants.

Those meeting the inclusion criteria were approached by the researcher as they arrived for dental appointments and invited to participate. Those interested were given a verbal explanation and written participant information sheet. If they wished to proceed, written consent was obtained.

Questionnaires

The questionnaire was piloted for a period of two weeks before commencement of data collection; no modifications were necessary.

During the study period, questionnaires were given to consented participants by the researcher to be completed before their dental appointment.

The questionnaire included demographic information such as gender, age and employment status. Other topics covered by the questionnaire included information regarding participants pain history, dental history, preferences for treatment, reasons for not attending, dental anxiety levels and aetiology of dental anxiety, opinions on suggested management techniques to alleviate dental anxiety and demographic information.

Dental anxiety was measured using the previously validated Modified Dental Anxiety Scale (MDAS).23,24

Scores were converted to three levels of dental anxiety as described by Humphris et al.:23

  • Low: MDAS score of 5–11

  • Moderate: MDAS score of 12–18

  • High: MDAS score of 19–25.

Dental examination

During the emergency dental appointment, an oral health assessment was carried out using the following scores:

  • Poor: visible multi-sextant mature plaque or calculus accumulation and/or pronounced gingivitis

  • Fair: immature plaque accumulation and localised calculus deposits and/or mild gingivitis

  • Good: minimal plaque or calculus, healthy gingival condition.

Number of teeth, number of carious teeth and estimated number of unrestorable teeth (based on the subjective clinical experience of the examiner using cavity size and likelihood of pulp involvement as the two key indicators) were recorded.

All dental examinations were carried out by one operator (the researcher AH, a dentist by background) to exclude inter-examiner variability. The nature of the group meant that repeat attendance to measure intra-examiner reliability was not feasible. Following treatment, the researcher reviewed the patients' records to determine the treatment modality used for the participant during their emergency appointment, and what influenced this decision.

Ethical considerations

The project was reviewed and given a favourable opinion by National Research Ethics Service Committee North West Greater Manchester (reference number: 11/NW/0636).

Data analysis

Data were analysed using SPSS Statistics version 19 software. Frequency tables and cross tables were produced, means calculated and inferential tests such as chi-square and Spearman's correlation coefficient used. Binary logistic regression analysis was applied to test anxiety levels and preferences for treatment against predictor variables. A significance level of p <0.05 was used.

Results

During the investigation period, 200 patients took part in the study. Of the 211 patients that were approached, all agreed to participate, but 11 were excluded. Three participants were excluded because they were unable to sufficiently comprehend a questionnaire, seven had already filled out a questionnaire returning for another emergency appointment, and one wanted to complete the questionnaire at home. Of all respondents, 41.5% had visited Monkgate for an emergency appointment previously.

Means and frequencies

Table 1 demonstrates demographic frequencies and dental history for respondents in comparison to regional (Yorkshire) averages. In comparison to regional averages, the study population demonstrated a greater proportion of younger age groups, unemployed and exempt from payment. The study population also showed a greater number reporting a period of longer than two years since seeing a dentist, and receiving a filling or extraction. The ratio of males to females was very similar in both the study and population.

Table 1 Demographic frequencies and dental history for participants compared to Yorkshire averages
Full size table

Preferences for treatment

When asked about receiving a filling, 71.5% would accept local anaesthetic alone, with the remaining 28.5% preferring sedation or general anaesthetic. For an extraction, 23% would accept local anaesthetic alone, with 77% stating a preference for sedation or general anaesthetic.

A large proportion stated they would like to see a dentist regularly for check-ups (89.5%), with only 10.5% stating that they would not. Reasons for not attending selected from a pre-defined list included being unable to register (38.6%), anxiety (24.6%) and cost (25.1%).

Anxiety status

Table 2 gives frequency information on anxiety status for participants compared to regional averages.

Table 2 Frequencies of anxiety status for participants compared to Yorkshire averages
Full size table

Dental status

The mean number of teeth present (26.6) was similar to national averages (25.7) but the mean number of carious teeth (3.7) was greater than the national average (0.8).1 The mean number of unrestorable teeth was 1.9. Oral hygiene levels were compared to national averages; 48% were poor compared to a national average of 42.5%, 37% average compared to 39% nationally and 15% good compared to a national average of 18.5%.1

The mean pain score was 6.73 (SD 2.17) and mean anxiety score was 14.23 (SD 5.87).

Treatment pathway and outcome

Over half of respondents received treatment with local anaesthetic (60%), 5% were scheduled to have intravenous sedation (and were placed on a waiting list for this), 2% received no treatment and 33% received other treatment (including antibiotics, fillings with no local anaesthetic and dry socket management).

Pain (59.5%) and anxiety (36.5%) were the most frequent reasons for participants having a particular treatment or management outcome.

Consideration of non-pharmacological management techniques

Table 3 shows frequencies for how helpful respondents would consider different non-pharmacological techniques to be.

Table 3 Correlations between anxiety score with how helpful participants consider non-pharmacological anxiety management techniques to be
Full size table

Correlations with anxiety levels

Chi-square analysis and Spearman's correlation coefficient were used to test relationships between variables. No significant correlations were found between anxiety levels and number of teeth, number of carious teeth, number of unrestorable teeth or age. However, females were found to be significantly more likely to have high levels of anxiety (p <0.001).

Correlations with preferred anxiety management techniques

A number of correlations were positive and potentially clinically significant but were not statistically significant. These included positive correlations between high anxiety scores and how helpful respondents would consider anxiety management techniques to be (p = 0.13); low anxiety and a preference of local anaesthetic for extractions (p = 0.38); and high anxiety and poor oral hygiene levels (p = 0.71).

Table 3 demonstrates the correlations between anxiety levels and how helpful participants would consider different non-pharmacological techniques to be. A significant negative correlation was found between high anxiety scores and finding the following techniques helpful: tell show do technique (p = 0.001) and watching explanatory videos (p = 0.004).

Correlation of helpfulness scores between pairs of non-pharmacological management techniques were tested against value one, which represented 'very unhelpful' on the questionnaire. Large numbers of significant positive correlations between pairs were found, indicating that the same respondents may answer 'very unhelpful' to all suggestions (thus supporting the argument for sedation).

Factors influencing anxiety and preference for LA alone versus sedation

Binary logistic analysis was used to test low anxiety (versus high anxiety), preference for fillings under local anaesthetic (versus sedation or general anaesthetic) and preference for extractions under local anaesthetic (versus sedation or general anaesthetic) with predictor variables.

Tables 4a and 4b show the binary logistic regression analysis testing preferences for fillings and extractions under local anaesthetic (versus sedation or general anaesthetic) with predictor variables. No significant predictor variables were found for those who would prefer local anaesthetic for fillings or for extractions. Although findings did not reach a significant level, those who said they would prefer local anaesthetic for extractions were more likely to have had an extraction less than two years previously (p = 0.48) and have a pain score of less than five (p = 0.54) (Cox and Snell R2 = 0.063).

Table 4a Binary logistic regression analysis testing preference for treatment with local anaesthetic (versus sedation or general anaesthetic) for fillings against predictor variables
Full size table
Table 4b Binary logistic regression analysis testing preference for treatment with local anaesthetic (versus sedation or general anaesthetic) for extractions against predictor variables
Full size table

Binary logistic regression analysis of low anxiety (versus high anxiety) against predictor variables showed a significant relationship between those with low anxiety and the following characteristics: being male (p = 0.001), having seen a dentist less than two years previously (p = 0.05) and receiving a filling less than two years previously (p = 0.04) (Cox and Snell R2 = 0.197).

Discussion

The study shows the dental history, preferences for treatment, anxiety levels and aetiology in a group of irregular attenders. Relationships were analysed enabling conclusions to be drawn to support management strategies for this population. Before considering the implications of these results, it's necessary to consider the limitations of the study.

For practical reasons, this study collected data from a population of patients with the required characteristics who attended on specific days of the week within a given time period. This is not the ideal method of selecting respondents and may have introduced coverage bias; for example, patients attending on other days may have different emergencies, although experience suggests that this is not the case. However, the study population was similar to the regional population in terms of proportions of gender and employment status, except that there were greater proportions of unemployed and people who were exempt from payment. Nearly two-thirds of respondents were between 18–35 years of age, supporting previous findings that younger age groups attend the dentist less regularly.12,13 Overall, the representativeness may lead to problems with generalising the findings, but the regression analysis will account for some of this and so, although absolute findings may not be reliable, relative findings should be.

In addition, use of a structured survey may have introduced response bias and may have given a limited picture of views and opinions of the study population. Using a more qualitative approach in future studies would enable participants to expand on ideas rather than being prompted and given suggestions for responses.

An unexpected finding was that 60.5% of respondents had seen a dentist in the past two years, which although lower than the 78% of general attendance in the region, is not as much of a difference as one would expect. The explanation for the difference may be that 73.5% of respondents' last visit was for emergency treatment, whereas 70% of the regional population made a routine visit.

The proportion of respondents who were highly anxious is considerably higher than the findings of the Adult Dental Health Survey.1 Fear of pain was the most frequently reported reason for the cause of anxiety, as has previously been shown.3,5

Those with high levels of anxiety were significantly more likely to want help to overcome their anxiety. Although over 70% of patients thought that anxiety management would be helpful in reducing the amount of anxiety they felt, the proportion of patients who thought that suggested anxiety management techniques would be helpful was considerably lower. Very few had other suggestions as to how their anxiety could be overcome.

One of the most interesting findings was that respondents who were highly anxious were significantly more likely to consider either the dentist spending more time with them, or using a tell-show-do technique, to be unhelpful. This may be a result of personality differences described in the literature.2 Those attending access centres may be more likely to have an externalist personality type, and consider their anxiety to be the way that they are and that no action taken by them will change that. Personality type has been shown to influence co** strategies, dentally anxious non-attenders may be more likely to be a 'blunter', and avoid information when faced with the stress of a dental visit.17 They would rather ignore information that is being given to them and be told as little as possible. This would explain why the dentally anxious in the study population felt that watching explanatory videos would be very unhelpful. Some patients may prefer to get the visit over as quickly as possible, but long term this does not help to reduce anxiety levels or promote regular attendance.

The highly anxious tended to show poorer levels of oral hygiene. However, unlike other studies, there were no significant relationships found between anxiety levels and numbers of teeth present, decayed or unrestorable.6,15,16 This is surprising given the attendance patterns and current pain experience of this group.

Males were significantly more likely to have low anxiety, as were those who had visited a dentist or received a filling within two years, reinforcing the relationship between avoidance of care and high anxiety.6,7,8

Preferences for treatment varied according to the procedure, which is consistent with previous studies.20,21 Over three-quarters said they would prefer sedation or general anaesthetic for an extraction, compared to 20% and 30% respectively for scale and polish and fillings, suggesting that extractions are considered to be more unpleasant or anxiety evoking than other procedures.

Those stating a preference for local anaesthetic (rather than sedation or general anaesthetic) for extraction were more likely to have had an extraction in the previous two years, and have a pain score under five. Delaying treatment with the increased anticipation of how unpleasant the treatment may be could increase the demand to be sedated or asleep. Perhaps those who have had an extraction more recently remember the experience was not as unpleasant as they thought, whereas with time, the memory of how the experience was perceived is distorted in a negative way. People with a higher pain score were less likely to accept local anaesthetic for an extraction. This may be because the anticipation of an unpleasant experience is greater if the person is suffering greater levels of pain.

In conclusion, people attending the study access centre demonstrate a greater proportion of high dental anxiety than is seen nationally. Nearly 70% wanted help to overcome their anxiety but this was not supported with suggested ideas of non-pharmacological techniques. Moreover, there were few significant findings between these relationships suggesting that patients attending the centre may represent a group of people that consider themselves beyond help. This lends support for the use of sedation to allow such patients to have their treatment carried out. If services including non-pharmacological anxiety management techniques are being developed, some education about these would need to be included.

In the future, it may be helpful to investigate in more depth why anxious patients who do not attend a dentist regularly do not consider non-pharmacological management techniques to be helpful in reducing their anxiety levels. A greater understanding would help build strategies to encourage people to believe that they can overcome their anxieties.

Commentary

The patient attending a dental access centre is an excellent research participant for obtaining preference ratings. The patient will provide a context-sensitive opinion at the time of invitation. Hence, I read the Harding article with great interest, as there is an opportunity to inspect carefully what might help to alleviate patient distress when attending an emergency dental care service.

The levels of dental anxiety were indeed high with a third (33%) rating themselves on the MDAS assessment (cut off 19 or greater),1 and approximately three times higher compared to the representative sample reported in the Adult Dental Health Survey. On further questioning, the authors found that the anxiety level was negatively associated with a preference for 'tell-show-do' or 'explanatory videos'. That is, patients were less likely to consider explanation in the form of straightforward one-to-one dentist patient contact or a filmed presentation as a means to assist them receiving treatment in the ordinary way. In addition, respondents tended to request sedation as a means to manage their dental anxiety, particularly for extractions.

As Chair of the research arm of the European Association for Communication in Healthcare (EACH), I would suggest that further work is generated to explore these findings in greater depth. The implication of the authors' conclusions is that sedation should be an approach available to the dental service to offer to patients. My belief is that the patient may not be best served by this readiness to offer a pharmacological aid. Patients who opt for the sedation route fail to learn that they can cope with an extraction with local anaesthetic alone. In fact, the Harding study reveals some interesting results that support this, as the patients who reported an extraction in the past two years were more prepared to receive a further procedure of this nature 'under local' in the future.

Moreover, the study might have asked the patient whether they would prefer to receive a brief therapeutic intervention that included a more detailed assessment of their concerns and attention to their emotional reactions. Research instruments to investigate the consultation for the dental surgery are available2 and the next stage of this investigation would be to video the interaction of patient and staff to understand in greater detail the elements that predict successfully provided treatment and psychological outcome. This commentator looks forward to researchers rising to this important challenge!

Professor Gerry Humphris Professor of Health Psychology University of St Andrews

Author questions and answers

1. Why did you undertake this research?

Having worked at a dental access centre since 2004, I have always been struck by the levels of anxiety that this particular group suffer compared to other groups of patients. Providing intravenous sedation to enable the treatment to be carried out was one pathway available to these patients but this did not seem to encourage a more regular attendance pattern. There was some interest in develo** the service to include a more holistic approach to managing dental anxiety for access patients to improve their experiences, and hence enable to them to be able develop a more positive approach to regular dental care and reduce the barriers preventing this. Our services could then be developed as directed by the preferences and opinions of the patients. So this project aimed to gain a greater understanding of the needs and experiences of the patients attending the access centre so that improvements could be instigated in directions that were appropriate for the responses given by the patients themselves.

2. What would you like to do next in this area to follow on from this work?

To follow on from this work, I would like to design a qualitative project to develop and deepen some of the concepts and themes that emerged from this project. In particular, I would like to explore why the people that do not visit the dentist regularly, who visit for emergency treatment only, would appear (from the results of this study) to consider non-pharmacological management techniques to be unhelpful. A greater understanding of the beliefs and opinions of this group of people may enable us to develop our approach to them in a more acceptable way, ultimately increasing their trust in the dental profession and creating a more positive attitude to dentistry.