Dental anxiety in first- and final-year Indian dental students

Chitta Chowdhury; Shahnawaz Khijmatgar; Avidyuti Chowdhury; Stewart Harding; Edward Lynch; Martin Gootveld

doi:10.1038/s41405-019-0017-9

Dental anxiety in first- and final-year Indian dental students

Chowdhury, Chitta; Khijmatgar, Shahnawaz; Chowdhury, Avidyuti; Harding, Stewart; Lynch, Edward; Gootveld, Martin 2019-10-16 00:00:00 BDJOpen www.nature.com/bdjopen ARTICLE OPEN Dental anxiety in ﬁrst- and ﬁnal-year Indian dental students 1,2 1 3 4 5 6 Chitta Ranjan Chowdhury , Shahnawaz Khijmatgar , Avidyuti Chowdhury , Stewart Harding , Edward Lynch and Martin Gootveld OBJECTIVES: The study aims to investigate dental anxiety in ﬁrst- and ﬁnal-year undergraduate dental students in India. DESIGN: Questionnaire Study Setting: BDS Students in four University dental colleges in India carried-out during 2013 and 2014. SUBJECTS (MATERIALS AND METHODS): The students (n = 614) were assessed using a pre-tested questionnaire. We estimated the level of dental anxiety by using the Modiﬁed-Dental-Anxiety-Scale (MDAS). ANCOVA and Mann–Whitney U, and Chi-squared contingency tests were employed to analyze the extensive dataset acquired. Univariate clustering analysis and principal component regression were also applied. Students had similar demographic and lifestyle patterns. INTERVENTIONS: Assessments of the level of dental anxiety amongst undergraduate dental students. MAIN OUTCOME MEASURES: Mean ± SD MDAS scores for ﬁrst- and ﬁnal-year Bachelor of Dental Surgery (BDS) students were 12.96 ± 4.00 and 10.54 ± 3.41, respectively. RESULTS: Six hundred and fourteen (n = 614) students from four dental colleges were included in this study. In total 77% were female (n = 478) and 23% were male (n = 136). The mean age of the ﬁrst- and ﬁnal-year students were 18.31 and 21.54 years, respectively. First-year BDS students had dental anxiety score (Mean ± SD 12.96 ± 4.00) compared to that of the ﬁnal year (10.54 ± 3.41), a difference which was very highly statistically signiﬁcant (p < 0.0001). CONCLUSION(S): Dental anxiety was moderately higher amongst ﬁrst year BDS students over that of ﬁnal-year students but it is lesser than the dental phobic threshold level. BDJ Open (2019) 5:15 ; https://doi.org/10.1038/s41405-019-0017-9 INTRODUCTION one or more painful dental procedures suffers from dental anxiety. Dental anxiety is often reported worldwide. The prevalence of Its etiology is therefore likely to be multi-factorial, which largely dental anxiety among the general population is between 3.9 and includes experience of a previous painful treatment combined 1 13–17 11%. Dental anxiety is a psychological feeling, which can partially with the particular personality traits of affected patients. In or completely prevent a person from receiving dental treatment. It this context, some of dental (BDS) students fall into this category. prevails in all age groups, but is most commonly observed among Previous studies have shown that a signiﬁcant number of BDS 2–4 young adults between 18 and 26 years of age. However, the students have a considerable amount of anxiety of receiving 18–21 prevalence rate among dental students is lower when compared dental treatments. However, effective communication has 3,4 to that of the general population. promoted the induction of a positive attitude towards dental Dental anxiety leads to negative attitudes towards receiving treatment in both Bachelor of Dental Surgery (BDS) students and 22,23 dental treatment; consequently, these students live with dental oral health professionals in general. Indeed, dental profes- 5–7 problems for prolonged periods. Indeed anxious dental patients, sionals play a crucial role in the management of dental 22,23 including dental students themselves, suffer more from dental anxiety. Therefore, an understanding of the level of dental diseases, simply because they cancel or delay their visit to a dentist, anxiety amongst dental students will provide a platform to work 7,8 and consequently complicate their disease condition. Therefore, from in order to explore if, and how exactly, this phenomenon a dentally anxious student is more unlikely to be able to maintain a signiﬁcantly impacts on the abilities of future cohorts of dental good quality of life, in view of their altered oral health status. professionals to effectively manage their patients. Also notable is There are several theories which attempt to explain the causes the conceivable hypothesis that anxiety experienced by dental of dental anxiety. Of these, unpleasant experiences whilst students is associated with oral health, poor dietary habits or 24–26 receiving dental treatment from a non-empathetic or ‘bullying’ indeed a higher body mass index (BMI). dentist appear to represent the primary cause of dental Hence, the aims of this study were to investigate the level of 10,11 anxiety. There are also speciﬁc stimuli such as the observation dental anxiety in BDS students, and also assess some possible of needles for local anesthetic injections, dental instruments, the inter-relationships with other variables such as age and gender, characteristic odor of a dental clinic, the use of rubber-dams, the former strongly correlated with student study year. Overall, together with noises from dental drills, which may all trigger the investigation was designed to determine if there are any dental anxiety, either singly, or two or more synchronously in signiﬁcant differences in dental anxiety between ﬁrst- and ﬁnal- 6,12 concern. Nevertheless, not every patient who has experienced year BDS students. 1 2 Department of Oral Biology & Genomic Studies, AB Shetty Memorial Institute of Dental Sciences, Nitte Deemed University, Mangalore 575018, India; Academic Dean, University 3 4 of Bolton City of London Dental School, Bolton, UK; Global Child Dental Health Task force, Kings College London, London, UK; Dean, University of Bolton City of London Dental 5 6 School, Bolton, UK; Biomedical and Clinical Research, School of Dental Medicine, University of Nevada, Las Vegas, USA and Institute of Health and Life Sciences, Health and Life Science, De Montfort University, The Gateway, Leicester LE1 9BH, UK Correspondence: Chitta Ranjan Chowdhury (crc.ob.cod@gmail.com) Received: 31 August 2018 Revised: 14 March 2019 Accepted: 15 March 2019 © British Dental Association/Macmillan Publishers Limited 2019 Dental anxiety in ﬁrst- and ﬁnal-year Indian dental students C.R. Chowdhury et al. Table 1. List of Modiﬁed Dental Anxiety Scale (MDAS) anxiety questionnaire Items Modiﬁed dental anxiety scale (MDAS) anxiety questionnaire 1 If you went to your dentist tomorrow, how would you feel? 1. Not anxious 2 If you were sitting in the waiting room, how would you feel? 2. Slightly anxious 3 If you were about to have a tooth drilled, how would you feel? 3. Fairly anxious 4 If you were about to have your teeth scaled and polished, how would you feel? 4. Very anxious 5 If you were about to receive a local anesthetic injection in your gum, how would you feel? 5. Extremely anxious MATERIALS AND METHODS applied was the Box–Cox transformation. These transformations The study received ethical approval from the Central Ethics and were further justiﬁed, since there was an extremely highly Research Committee of Nitte University. Data collection was signiﬁcant difference found between the variances of these performed during 2013 and 2014. The sample population was groups (F-test), i.e., that for ﬁrst-year students was much greater designed to include students from four dental schools located in than that for the ﬁnal-year cohort (p = 0.004). the state of Karnataka, India. These dental institutes included A.B. Application of these cube root- and Box-Cox-transformations Shetty Memorial Institute of Dental Sciences (ABSMIDS) of Nitte; effectively normalized both ﬁrst- and ﬁnal-year datasets (p = 0.278 Yenepoya Dental College (YDC), Yenepoya University; Manipal and 0.148 respectively for the former transformation, and 0.181 College of Dental Sciences (MCODS) of Manipal University; and and 0.242 respectively for the latter one). We therefore elected to A. J. Shetty Institute of Dental Sciences (AJSIDS), Rajiv Gandhi perform the ANOVA and ANCOVA (models 1 and 2 respectively) University of Health Sciences, Mangalore, Karnataka, India. The analyses on the cube root-transformed dataset described below. cohort group can be considered as a representative sample of its Moreover, these analyses were supported by that employing the category for the population of India. direct Mann-Whitney non-parametric U test for differences Dental anxiety level, along with related information was between the total anxiety scores of these two student groups collected from all participants recruited. The original English without consideration of the gender and age variables, which version of the Modiﬁed Dental Anxiety Scale (MDAS, Table 1) was were both found to be insigniﬁcant ‘within-BDS student year’ 27,28 employed, which is a ﬁve-item questionnaire containing groups via the ANCOVA analysis model 2 applied, as described questions about respondents’ level of anxiety whilst visiting a below. This non-parametric test employed 10,000 Monte-Carlo dental surgeon, with a response scale ranging from 1 (not anxious) simulations to compute its p value. to 5 (extremely anxious). The total scores ranged from 5 to 25. A Analysis-of-variance (ANOVA) was employed in model 1 in order score <11 is considered normal, whereas those lying between 11 to test for signiﬁcant differences between the total dental anxiety and 18 represent moderate anxiety. Scores >19 represents parameter (y ) between BDS study years, and ANCOVA was ijk extreme anxiety. The reliability of the English language version applied in model 2 to investigate the inﬂuence of genders and of the MDAS questionnaire had an internal consistency of 0.89, student ages ‘nested’ within these study years. The ﬁrst of these is and a test-retest value of 0.82. All the students were able to described by the mathematical model given in Eq. 1, where Y,G i j understand the English version of MDAS. The BDS course in the 4 and YG represent the student year, gender and student year x ij university participant sources is in the English language, and all gender interaction sources of variance respectively (all ﬁxed the BDS students in these cohort groups speak, read and write effects), µ the value of y in the absence of all these effects, and ijk English competently. e representing fundamental error. ijk y ¼ μ þ Y þ G þ YG þ e (1) i j ij ijk Questionnaire survey ijk In order to avoid any response bias, students were not provided with any prior information regarding dental anxiety prior to Since there was a strong positive correlation between year of commencing the study. The students were given 15 min to answer study and student age (Fig. 2), the latter variable was primarily a pre-printed questionnaire (Table 1). They were fully informed removed from the ANOVA model 1 employed. However, following about the voluntary nature of their participation and their rights as the establishment of a clear signiﬁcant difference between the volunteers to withdraw from this study at any point in time during two study year classiﬁcations, ANCOVA was also then applied to its course. Participant questionnaire respondents were invigilated test for differences ‘between-ages’ within each of the two study in order to ensure non-collusion and lateral discussion, and any years explored (Eq. 2), in which A and GA represent the age j ij form of cheating was prevented during participant completion of covariable and its interaction with the gender source of variation the questionnaire. (i.e., gender × age interaction effect). Questions related to oral hygiene frequency of dental visits, y ¼ μ þ G þ A þ GA þ e (2) j J ij ijk periodontal problems, and preference of dentistry as a career was ijk included in the questionnaire. The students were provided with the opportunity to request any further clariﬁcation. Chi-squared contingency table analysis was conducted in order to determine any associations between the numbers of male and Statistical analysis female students present in each year of study group, and this Tests for normality of the total anxiety score values for both involved 5000 Monte-Carlo simulations and a standard bootstrap student year classiﬁcations were performed by the Jarque–Bera interval of 100 samples. test. Evaluations of variance heterogeneity between these two Principal component regression (PCR) analysis was employed to student group classiﬁcations were performed by the F variance investigate the relationship between principal components ratio test. For the raw (untransformed) dataset, the distributions of formed from (1) strongly correlated student year and age the total anxiety scores for both groups demonstrated strong variables, and (2) genders alone. This model involved a minimum −4 −4 departures from normality (p = 0.004 and <10 for the ﬁrst- and consideration of 80% of the total variance, and a tolerance of 10 . ﬁnal-years respectively), and therefore data were transformed to Total anxiety score values and participant ages were standardized their cube root values (Fig. 1). A further data transformation (i.e., subtraction of their total variable mean values followed by BDJ Open (2019) 5:15 1234567890();,: Dental anxiety in ﬁrst- and ﬁnal-year Indian dental students C.R. Chowdhury et al. Fig. 2 Plot of total anxiety score versus age for ﬁrst- and ﬁnal-year Indian dental students (pink and blue respectively). The smaller number of datapoints visible than the total student participant sample size (n = 614) visible arises from their manifold level of overlap in the diagram. 95% conﬁdence ellipses for both sample groups are also indicated division of their sample standard deviations so that they both had means of 0 and unit variances) prior to PCR analysis. All statistical analyses, including two-sample t-tests, were performed using XLSTAT2014 and SPSS software. RESULTS For this study, all 614 students requested to participate responded to the questionnaire, i.e., a 100% response rate. The age of the sampled population ranged between 18 and 22 years, who were studying within the ﬁrst- and ﬁnal-years of their undergraduate BDS course. Mean ± 95% conﬁdence intervals (CIs) for the ages of the ﬁrst- and ﬁnal-year student participants recruited to the investigation were 18.31 ± 0.135 and 21.54 ± 0.116 years. This difference in mean ages was highly statistically signiﬁcant (p< −4 10 ), as expected (two-sample t-test). The gender-wise distribu- tion of the students was 136 (22.1%) male, and 479 (77.8%) female. The male-to-female (M:F) ratio of BDS students in India is ~20:80, and this index is common throughout this country, including Karnataka state. This is likely to be explicable to the students’ parents/guardians preference for their daughters to be dental or medical clinicians. Moreover, the study of dentistry in India represents the second-most popular choice of many female students who are not accepted to study medicine. There was no signiﬁcant difference between the mean ages of groups classiﬁed by gender i.e., 19.68 and 19.69 years for males and females respectively (two-sample t-test). A plot of total dental anxiety score versus age (Fig. 2) revealed clearly distinguishable clusterings for the ﬁrst- and ﬁnal-rear BDS students. Mean ± SD total anxiety score values for the ﬁrst- and ﬁnal-year students were 12.96 ± 4.00 and 10.54 ± 3.41 respectively Fig. 1 Normality distribution density plots of (a) the untransformed (95% conﬁdence intervals 12.54–13.38 and 10.12–10.93, (raw data) total dental anxiety scores for ﬁrst- and ﬁnal-year BDS respectively). students (green and blue respectively), and (b) following cube root The critical importance of the study year variable was also transformation of these datasets. Fitted normal distributions are demonstrated by linear regression analysis plots of untransformed depicted in red in (b). c Plots of cumulative relative frequency against total anxiety score against age, which was extremely statistically the cube root-transformed total dental anxiety scores for ﬁrst- and signiﬁcant for the entire total anxiety score response dataset ﬁnal-year BDS students (blue and green respectively), demonstrating an excellent ﬁt to a normal distribution curves (red) for both groups (Fig. 3), i.e., that comprising the ﬁrst- and ﬁnal-year students BDJ Open (2019) 5:15 Dental anxiety in ﬁrst- and ﬁnal-year Indian dental students C.R. Chowdhury et al. −4 combined (r = −0.24, p< 10 ). However, this relationship was not particular measure ‘between-genders-within-study-years’ for both at all signiﬁcant when these plots were performed for each study the ﬁrst- and ﬁnal-year BDS students. year separately (r = 0.040 and −0.039 only for ﬁrst- and ﬁnal-year ANOVA analysis of the complete dataset via model 1 demon- BDS students respectively). strated that there was a very highly signiﬁcant difference between −4 Scattergram plots of the total anxiety scores of males and the two years of study, i.e., ﬁrst- vs. ﬁnal years (p< 10 ). The females for both ﬁrst- and ﬁnal-year students (Fig. 4) clearly ‘between-genders’ and study year × gender interaction compo- conﬁrmed that there were no signiﬁcant differences in this nents of variation were not statistically signiﬁcant (p = 0.073 and 0.807, respectively), the latter indicating that particular combina- tions of gender and study year do not give rise to a non-additive (r = -0.244 effect model response. However, the ‘between-genders’ effect was close to statistical signiﬁcance. Thes ‘between-study year’ differ- ence was also found to be very highly signiﬁcant when tested by −4 the non-parametric two-tailed Mann–Whitney test (p< 10 ). Within sub-group analysis of the dataset according to model 2 (ANCOVA) revealed that student age exerted no signiﬁcant effects 15 in both study year groups (p = 0.443 and 0.616 for ﬁrst- and ﬁnal- year students respectively). Similarly, the gender and the age x gender interaction effects were also not found to be statistically signiﬁcant for both study years in this model. As expected, PCR analysis of the standardized raw dataset, which involved the prediction of anxiety scores from student year classiﬁcations, and students’ genders and ages, revealed that the best model attained comprised two major signiﬁcant principal components (PC1 and PC2). PC1 had very strong loadings from ﬁrst and ﬁnal course years (0.594 and −0.594 respectively) and 10 15 20 25 30 35 age (−0.554), whereas PC2 had strong loadings from gender (−0.844 and 0.844 for males and females respectively). These -5 results conﬁrm that, along with the fully expected strong AGE (year) correlation between student year of study and age, and that Fig. 3 Overall plot of total anxiety score versus student age for the gender was independent of (orthogonal to) these predictor combined ﬁrst- and ﬁnal-year BDS students (r = −0.244). Although variables when total anxiety score served as the dependent the negative correlation coefﬁcient observed is low, this relationship −4 variable. was very highly statistically signiﬁcant (p <10 ) in view of the very The sources of these study year-mediated differences were large sample size (n= 614), and demonstrates an age-dependent found to predominantly arise from the criteria monitored on decrease in the total anxiety score. 95% Conﬁdence intervals for both the mean regression values and individual observations are MDAS scale items 3, 4 and 5 (corresponding to anxiety induced by provided teeth-drilling, teeth scaling and polishing, and the receiving of Fig. 4 Scatterplots of total anxiety score for ﬁrst-year male and female, and ﬁnal-year male and female BDS students. Mean and median values are indicated BDJ Open (2019) 5:15 TOTAL ANXIETY SCORE TOTAL ANXIETY SCORE Dental anxiety in ﬁrst- and ﬁnal-year Indian dental students C.R. Chowdhury et al. Table 2. Enumeration distribution of dental anxiety according to year of study, and statistical signiﬁcance of associations found Question Anxiety Response First-Year (n) Final-Year (n) Total (n) χ p Value If you went to your dentist tomorrow, how would you feel? Not anxious 93 100 193 0.003 Slightly anxious 169 118 287 Fairly anxious 60 29 89 Very anxious 26 12 38 Extremely anxious 5 0 5 If you were sitting in the waiting room, how would you feel? Not anxious 92 87 179 0.004 Slightly anxious 140 112 252 Fairly anxious 74 44 118 Very anxious 32 15 47 Extremely anxious 15 1 16 If you were about to have a tooth drilled, how would you feel? Not anxious 32 53 85 <0.0001 Slightly anxious 102 113 215 Fairly anxious 81 54 135 Very anxious 84 31 115 Extremely anxious 50 8 58 If you were about to have your teeth scaled and polished, how would Not anxious 93 156 249 <0.0001 you feel? Slightly anxious 111 79 190 Fairly anxious 69 10 79 Very anxious 47 12 59 Extremely anxious 30 2 32 If you were about to receive local anesthetic injection in your gum, how would Not anxious 42 22 64 0.0004 you feel? Slightly anxious 82 77 159 Fairly anxious 70 75 145 Very anxious 94 64 158 Extremely anxious 64 21 85 local anesthesia respectively), and these are outlined below in (somewhat greater in ﬁnal-year students, although this was a Table 2. signiﬁcantly greater ‘unknown’ selection for ﬁrst-year students). The inﬂuence of year of study on student responses to Statistically signiﬁcant considerations found ‘between-genders’ individual MDAS anxiety questionnaire items was explored via χ were the identiﬁcation of bleeding gums whilst tooth-brushing contingency table analyses (Table 2). These analyses revealed that, (higher in males); time of tooth-brushing (signiﬁcantly more for with the exception of the ﬁnal item focused on local anesthesia, males when this regimen is performed after breakfast); previous ﬁnal-year BDS students exhibited a much lower level of anxiety experience of dental scaling (much higher in females); and the than the ﬁrst-year ones for all questionnaire items on the MDAS reception of oral health education (signiﬁcantly greater in females). questionnaire (p = <0.0001 to 0.004). For the question concerning Table 5 shows that there was a statistically signiﬁcant difference anesthesia, the percentage of ﬁrst-year students who recorded no in the total Level of dental anxiety (p< 0.001) between ﬁrst and signs of anxiety (12%) was approximately two-fold that of ﬁnal year students, but no signiﬁcant difference was detected for ﬁnal year students; conversely, however, the ﬁrst-year student Body mass index (BMI) (p> 0.05) between the two BDS degree group had a ca. twice the proportion of students (18%) than student groups. However, Table 6 shows that there was a those of ﬁnal-year ones who were extremely anxious about this signiﬁcant between-gender difference in BMI values, with males item. Virtually the same percentages of students in each study having a higher mean value than that of females (p < 0.001). year classiﬁcation were very anxious regarding this criterion However, no correlations were observed between the total dental (ca. 25%). anxiety level and BMI values. Notwithstanding, the gender qualitative variable was found to exert no effect whatsoever on anxiety response levels for all of the above MDAS anxiety questions (Table 3). DISCUSSION Table 4 provides data regarding the numbers of ﬁrst- and ﬁnal- Dental anxiety year BDS students responding positively or negatively to their In this study, the status of dental anxiety was monitored using the perceived oral health status and experiences, and all criteria tested MDAS scale, and related information was collected by using a pre- found a series of statistically signiﬁcant associations between tested, validated questionnaire. The level of dental anxiety was these qualitative enumeration variables and levels of anxiety (χ higher amongst ﬁrst-year BDS students over those of ﬁnal-year contingency table analyses). For the student years of study ones (Fig. 1). These results are consistent with previous studies 10,18,22,29–32 variable, these were the observation of bleeding gums during performed elsewhere. A probable reason for this is that tooth-brushing (higher in ﬁrst-year students); the previous ﬁnal-year students are more acclimatized with their clinical performance of dental scaling (much higher in ﬁnal-year students); settings and scenarios. Dental anxiety is a cause of poor patient the receiving of oral hygiene education (higher in ﬁrst-year (in this case dental student) compliance and negative attitudes students); and the early choice of dentistry as a career goal towards receiving dental treatment by the sufferers. Indeed, BDJ Open (2019) 5:15 Dental anxiety in ﬁrst- and ﬁnal-year Indian dental students C.R. Chowdhury et al. Table 3. Enumeration distribution of level of dental anxiety by gender, and statistical signiﬁcance of associations found Question Anxiety Response Male (n) Female (n) Total (n) χ p Value If you went to your dentist tomorrow, how would you feel? Not anxious 148 43 191 ns Slightly anxious 219 58 277 Fairly anxious 70 19 89 Very anxious 28 10 38 Extremely anxious 2 2 4 If you were sitting in the waiting room, how would you feel? Not anxious 138 38 176 ns Slightly anxious 197 55 252 Fairly anxious 96 22 118 Very anxious 32 14 46 Extremely anxious 10 6 16 If you were about to have a tooth drilled, how would you feel? Not anxious 67 18 85 ns Slightly anxious 163 50 213 Fairly anxious 103 32 135 Very anxious 92 22 114 Extremely anxious 45 12 57 If you were about to have your teeth scaled and polished, how would you feel? Not anxious 1 0 1 ns Slightly anxious 146 41 187 Fairly anxious 60 18 78 Very anxious 41 18 59 Extremely anxious 25 6 31 If you were about to receive local anesthetic injection in your gum, how would Not anxious 45 19 64 ns you feel? Slightly anxious 121 37 158 Fairly anxious 117 26 143 Very anxious 128 30 158 Extremely anxious 62 22 84 dentists ﬁnd it very difﬁcult to treat anxious patients, who may be dental surgery reception areas. Their responses revealed that the further afﬂicted by a series of oral diseases and oral health drilling of a carious tooth was a predominant cause of dental problems, since they delay or even terminate visits to dental anxiety, and this ﬁnding is also similar to that found in previous 35,36 surgeries. Notwithstanding, dental health education strategies and study reports. acclimatization to dental procedures can facilitate reductions in An improved knowledge of painless dental procedures, along stress levels; similar strategies could be utilized for anxious dental with education for oral hygiene maintenance through consistent students, in order to assist them in tackling their dental anxiety and personalized approaches, may assist patients to overcome at 33,34 problems. least some forms of dental apprehension. Indeed, a fully In view of the above observations, and the strong positive structured tutor-led awareness programme from the very start correlation of age with students’ year of study, the mean anxiety of dental undergraduate courses may serve as the best approach score also decreased with increasing age, as expected and noted for intervention. Dental anxiety can also be effectively managed at in. However, from our ANCOVA model 2 analysis performed, no an earlier stage by the enhancement of levels of awareness signiﬁcant differences were found between ages ‘nested’ within through the introduction of a motivational programme at both study year classiﬁcation groups. school and pre-university levels. Awareness of the positive It was also observed that there was an increased level of anxiety beneﬁts of dental treatment, delivered and learnt at an early in all the categories of the MDAS score system amongst ﬁrst- and stage in life, may facilitate reductions in dental anxiety responses. ﬁnal-year dental students. Speciﬁcally, ﬁrst-year students were Since generic approaches to such issues may be ineffective, a more anxious with MDAS items 3, 4 and 5 when compared to the more personalized strategy may be effective in diminishing the corresponding questionnaire responses of ﬁnal year ones (p < level of dental anxiety signiﬁcantly. However, in order to 0.001) (Table 2). The possible reason for this is that, ﬁnal year alleviate distressing dental anxiety experiences long-term, a students have more exposure to treatment procedures, and this time-framed follow-up with a sensitization process employing experience assists the process of dental treatment acclimatization. empowered reinforcement may be required. Indeed, the administration of local anesthetics and the drilling of teeth were associated with a higher level of anxiety. Indeed, 26.6% Oral health of ﬁrst-year students replied that they are very anxious during the The survey featuring a questionnaire on periodontal health drilling of teeth, and 18.1% conﬁrmed that they were extremely showed that oral health status was improved amongst ﬁnal year anxious about receiving a local anesthetic injection; this observa- students over that of ﬁrst year ones. A total of 26 (9.96%) students tion is in agreement with previous studies documented in the ﬁnal year explained that they experienced bleeding on 35,36 elsewhere. Approximately one-quarter (24%) of students were brushing, compared to 63 students (17.8%) experienced by those very anxious, and 14% were extremely anxious regarding the in the ﬁrst year of their BDS course (Table 4). This study also found prospect of receiving dental treatment, and these experiences that there was a signiﬁcant association between dental anxiety usually began whilst these subjects are awaiting such treatment in levels and oral hygiene in ﬁrst year students, and more commonly BDJ Open (2019) 5:15 Dental anxiety in ﬁrst- and ﬁnal-year Indian dental students C.R. Chowdhury et al. Table 4. BDS students’ oral health perception responses and statistical signiﬁcance (χ p values) according to year of study (top) and gender (bottom) Group X p Value First year N (%) Final year N (%) Spontaneously bleeding gums Yes 15 (4.9) 8 (3.06) 0.442 No 336 (95.1) 252 (96.5) Bleeding gums while brushing? Yes 63 (17.8) 26 (9.96) 0.006* No 288 (81.6) 235 (90.0) When do you brush? After breakfast 9 (2.5) 6 (2.2) 0.521 Before breakfast 337 (95.4) 245 (93.8) No deﬁnite time 5 (1.4) 7 (2.6) Scaling Done Yes 117 (33.1) 227 (86.9) <0.001* No 234 (66.2) 31 (11.8) Oral hygiene education received Yes 257 (72.8) 224 (85.8) <0.001* No 91 (25.7) 32 (12.2) Was dentistry your preferred career goal? Yes 292 (82.7) 234 (89.6) 0.007* No 20 (5.6) 12 (4.5) Don’t Know 35 (9.9) 9 (3.4) Gender X p Value Female N (%) Male N (%) Spontaneously bleeding gums Yes 19 (3.9) 4 (2.9) 0.593 No 455 (95.1) 129 (94.8) Bleeding gums while brushing? Yes 66 (13.8) 22 (16.1) 0.002* No 409 (85.5) 111 (81.6) When do you brush? After breakfast 8 (1.6) 7 (5.1) <0.001* Before breakfast 453 (94.7) 119 (87.5) No deﬁnite time 6 (1.2) 10 (7.3) Scaling Done Yes 267 (55.8) 66 (48.5) <0.001* No 10 (2.0) 70 (51.4) Oral hygiene education received No 86 (17.9) 41 (30.1) <0.001* Yes 383 (80.1) 95 (69.8) Yes 77 (16.0) 29 (21.3) Was dentistry your preferred career goal? Yes 407 (85.1) 112 (23.4) 0.423 No 28 (5.8) 8 (5.8) Don’t Know 30 (6.2) 13 (9.5) in females. These results concur with those of a further study. The frequency of dental visits for oral prophylaxis was higher Since the co-existence of dental anxiety and poor oral health- among ﬁnal-year BDS students than it was in ﬁrst-year ones: this is related quality of life (QoL) is not simply explicable, further especially evident among female students. This study also investigations are required to explore this. However, both oral demonstrated that a higher number of ﬁrst-year students received health-related QoL and dental anxiety are inter-dependent oral hygiene education than ﬁnal year ones, and hence despite phenomena, the former enhancing the latter’s levels. this deﬁcit, ﬁnal-year students had the scope required to apply BDJ Open (2019) 5:15 Dental anxiety in ﬁrst- and ﬁnal-year Indian dental students C.R. Chowdhury et al. this level of dental anxiety. Moreover, behavioral therapies and Table 5. Age, BMI and Anxiety Score among students in each distraction methods may also be effective in this context. study group Therefore, there is a major requirement for further investigations of the nature and level of anxiety amongst medical students in First year Final year p Value order to compare their anxiety proﬁles with those studying Mean SD Mean SD dentistry. Age 18.31 1.08 21.54 0.95 <0.001* BMI 22.09 4.01 21.63 3.84 0.182 ACKNOWLEDGEMENTS We thank Kathy Lewis, an expert in health promotion and protection and former Hon. Anxiety score 12.96 4.00 10.52 3.40 <0.001* Secretary of Institute of Health Promotion and Education, UK for her editing contribution in this manuscript. We are thankful to Dr TS Sanal of Nitte University Department Bio-statistics and Epidemiology for his statistical support. Many thanks to Professor Vathsala Blr of AJ Dental Institute, Mangalore; Professor Riaz Abdullah of Yenepoya Dental College, Mangalore and Professor Junaid Ahmed of Manipal College Table 6. Age, BMI and Anxiety Score by gender in each study group of Dental Surgery, Mangalore for their support in the study. Thanks to dental interns Yoga Naik and Dr Melanie for their involvement in entering data-information whilst Female Male t test value p Value they were placed in the department of Oral Biology and Genomic Studies of Nitte Mean SD Mean SD University AB Shetty Dental College. Age 19.69 1.89 19.68 2.00 0.06 0.953 BMI 21.58 3.77 23.08 4.33 3.65 <0.001* AUTHOR CONTRIBUTIONS S.K. and S.H.: manuscript preparation; A.C. and E.L.: manuscript editing; M.G.: Anxiety score 11.98 3.84 11.67 4.16 0.14 0.887 statistical support and editing. their learning based on clinical resources (such as patients based ADDITIONAL INFORMATION at hospital and community settings). This is undoubtedly Competing interests: The authors declare no competing interests. reinforced thorough their observations experienced during clinical placements. Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims Therefore, early implementation and reinforced dental aware- in published maps and institutional afﬁliations. ness, together with the implementation of an appropriate acclimatization process, can give rise to a signiﬁcant reduction 2,15 in dental anxiety; this has been observed in related studies. REFERENCES 1. Vermaire, J. H., Houtem, C. M., Ross, J. N. & Schuller, A. A. The burden of disease Dentistry as a career and dental anxiety of dental anxiety: generic and disease‐speciﬁc quality of life in patients with The majority of the dental students involved in this study revealed and without extreme levels of dental anxiety. Eur. J. Oral. Sci. 124, 454–458 that they had chosen dentistry as a career choice of their own (2016). accord. However, a small proportion of female students (5%) did 2. Todd J. E., Lader D. 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The management Attribution 4.0 International License, which permits use, sharing, of dental anxiety: time for a sense of proportion? Br. Dent. J. 213, 271–274 adaptation, distribution and reproduction in any medium or format, as long as you give (2012). appropriate credit to the original author(s) and the source, provide a link to the Creative 25. Tangade, P. S. et al. “Assessment of stress level among dental school students: an Commons license, and indicate if changes were made. The images or other third party Indian outlook.”. Dent. Res. J. 8, 95 (2011). material in this article are included in the article’s Creative Commons license, unless 26. Patil, S. et al. Prevalence of recurrent aphthous ulceration in the Indian Popula- indicated otherwise in a credit line to the material. If material is not included in the tion. J. ClinExp Dent. 6,36–40 (2014). article’s Creative Commons license and your intended use is not permitted by statutory 27. University of St Andrews [Internet]. Ruth Woodﬁeld | School of Management | regulation or exceeds the permitted use, you will need to obtain permission directly University of St Andrews. (cited 20186 Aug 2018). Available from: https://www.st- from the copyright holder. To view a copy of this license, visit http://creativecommons. andrews.ac.uk/dentalanxiety/ org/licenses/by/4.0/. 28. Giri, J., Pokharel, P. R., Gyawali, R. & Bhattarai, B. Translation and validation of modiﬁed dental anxiety scale: The Nepali Version. Int. Sch. Res. Not. 2017, © The Author(s) 2019 5495643 (2017). BDJ Open (2019) 5:15 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png BDJ Open Springer Journals http://www.deepdyve.com/lp/springer-journals/dental-anxiety-in-first-and-final-year-indian-dental-students-rQbjDWiiCt

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Publisher: Springer Journals
Copyright: Copyright © 2019 by The Author(s)
Subject: Dentistry; Dentistry
eISSN: 2056-807X
DOI: 10.1038/s41405-019-0017-9
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Abstract

BDJOpen www.nature.com/bdjopen ARTICLE OPEN Dental anxiety in ﬁrst- and ﬁnal-year Indian dental students 1,2 1 3 4 5 6 Chitta Ranjan Chowdhury , Shahnawaz Khijmatgar , Avidyuti Chowdhury , Stewart Harding , Edward Lynch and Martin Gootveld OBJECTIVES: The study aims to investigate dental anxiety in ﬁrst- and ﬁnal-year undergraduate dental students in India. DESIGN: Questionnaire Study Setting: BDS Students in four University dental colleges in India carried-out during 2013 and 2014. SUBJECTS (MATERIALS AND METHODS): The students (n = 614) were assessed using a pre-tested questionnaire. We estimated the level of dental anxiety by using the Modiﬁed-Dental-Anxiety-Scale (MDAS). ANCOVA and Mann–Whitney U, and Chi-squared contingency tests were employed to analyze the extensive dataset acquired. Univariate clustering analysis and principal component regression were also applied. Students had similar demographic and lifestyle patterns. INTERVENTIONS: Assessments of the level of dental anxiety amongst undergraduate dental students. MAIN OUTCOME MEASURES: Mean ± SD MDAS scores for ﬁrst- and ﬁnal-year Bachelor of Dental Surgery (BDS) students were 12.96 ± 4.00 and 10.54 ± 3.41, respectively. RESULTS: Six hundred and fourteen (n = 614) students from four dental colleges were included in this study. In total 77% were female (n = 478) and 23% were male (n = 136). The mean age of the ﬁrst- and ﬁnal-year students were 18.31 and 21.54 years, respectively. First-year BDS students had dental anxiety score (Mean ± SD 12.96 ± 4.00) compared to that of the ﬁnal year (10.54 ± 3.41), a difference which was very highly statistically signiﬁcant (p < 0.0001). CONCLUSION(S): Dental anxiety was moderately higher amongst ﬁrst year BDS students over that of ﬁnal-year students but it is lesser than the dental phobic threshold level. BDJ Open (2019) 5:15 ; https://doi.org/10.1038/s41405-019-0017-9 INTRODUCTION one or more painful dental procedures suffers from dental anxiety. Dental anxiety is often reported worldwide. The prevalence of Its etiology is therefore likely to be multi-factorial, which largely dental anxiety among the general population is between 3.9 and includes experience of a previous painful treatment combined 1 13–17 11%. Dental anxiety is a psychological feeling, which can partially with the particular personality traits of affected patients. In or completely prevent a person from receiving dental treatment. It this context, some of dental (BDS) students fall into this category. prevails in all age groups, but is most commonly observed among Previous studies have shown that a signiﬁcant number of BDS 2–4 young adults between 18 and 26 years of age. However, the students have a considerable amount of anxiety of receiving 18–21 prevalence rate among dental students is lower when compared dental treatments. However, effective communication has 3,4 to that of the general population. promoted the induction of a positive attitude towards dental Dental anxiety leads to negative attitudes towards receiving treatment in both Bachelor of Dental Surgery (BDS) students and 22,23 dental treatment; consequently, these students live with dental oral health professionals in general. Indeed, dental profes- 5–7 problems for prolonged periods. Indeed anxious dental patients, sionals play a crucial role in the management of dental 22,23 including dental students themselves, suffer more from dental anxiety. Therefore, an understanding of the level of dental diseases, simply because they cancel or delay their visit to a dentist, anxiety amongst dental students will provide a platform to work 7,8 and consequently complicate their disease condition. Therefore, from in order to explore if, and how exactly, this phenomenon a dentally anxious student is more unlikely to be able to maintain a signiﬁcantly impacts on the abilities of future cohorts of dental good quality of life, in view of their altered oral health status. professionals to effectively manage their patients. Also notable is There are several theories which attempt to explain the causes the conceivable hypothesis that anxiety experienced by dental of dental anxiety. Of these, unpleasant experiences whilst students is associated with oral health, poor dietary habits or 24–26 receiving dental treatment from a non-empathetic or ‘bullying’ indeed a higher body mass index (BMI). dentist appear to represent the primary cause of dental Hence, the aims of this study were to investigate the level of 10,11 anxiety. There are also speciﬁc stimuli such as the observation dental anxiety in BDS students, and also assess some possible of needles for local anesthetic injections, dental instruments, the inter-relationships with other variables such as age and gender, characteristic odor of a dental clinic, the use of rubber-dams, the former strongly correlated with student study year. Overall, together with noises from dental drills, which may all trigger the investigation was designed to determine if there are any dental anxiety, either singly, or two or more synchronously in signiﬁcant differences in dental anxiety between ﬁrst- and ﬁnal- 6,12 concern. Nevertheless, not every patient who has experienced year BDS students. 1 2 Department of Oral Biology & Genomic Studies, AB Shetty Memorial Institute of Dental Sciences, Nitte Deemed University, Mangalore 575018, India; Academic Dean, University 3 4 of Bolton City of London Dental School, Bolton, UK; Global Child Dental Health Task force, Kings College London, London, UK; Dean, University of Bolton City of London Dental 5 6 School, Bolton, UK; Biomedical and Clinical Research, School of Dental Medicine, University of Nevada, Las Vegas, USA and Institute of Health and Life Sciences, Health and Life Science, De Montfort University, The Gateway, Leicester LE1 9BH, UK Correspondence: Chitta Ranjan Chowdhury (crc.ob.cod@gmail.com) Received: 31 August 2018 Revised: 14 March 2019 Accepted: 15 March 2019 © British Dental Association/Macmillan Publishers Limited 2019 Dental anxiety in ﬁrst- and ﬁnal-year Indian dental students C.R. Chowdhury et al. Table 1. List of Modiﬁed Dental Anxiety Scale (MDAS) anxiety questionnaire Items Modiﬁed dental anxiety scale (MDAS) anxiety questionnaire 1 If you went to your dentist tomorrow, how would you feel? 1. Not anxious 2 If you were sitting in the waiting room, how would you feel? 2. Slightly anxious 3 If you were about to have a tooth drilled, how would you feel? 3. Fairly anxious 4 If you were about to have your teeth scaled and polished, how would you feel? 4. Very anxious 5 If you were about to receive a local anesthetic injection in your gum, how would you feel? 5. Extremely anxious MATERIALS AND METHODS applied was the Box–Cox transformation. These transformations The study received ethical approval from the Central Ethics and were further justiﬁed, since there was an extremely highly Research Committee of Nitte University. Data collection was signiﬁcant difference found between the variances of these performed during 2013 and 2014. The sample population was groups (F-test), i.e., that for ﬁrst-year students was much greater designed to include students from four dental schools located in than that for the ﬁnal-year cohort (p = 0.004). the state of Karnataka, India. These dental institutes included A.B. Application of these cube root- and Box-Cox-transformations Shetty Memorial Institute of Dental Sciences (ABSMIDS) of Nitte; effectively normalized both ﬁrst- and ﬁnal-year datasets (p = 0.278 Yenepoya Dental College (YDC), Yenepoya University; Manipal and 0.148 respectively for the former transformation, and 0.181 College of Dental Sciences (MCODS) of Manipal University; and and 0.242 respectively for the latter one). We therefore elected to A. J. Shetty Institute of Dental Sciences (AJSIDS), Rajiv Gandhi perform the ANOVA and ANCOVA (models 1 and 2 respectively) University of Health Sciences, Mangalore, Karnataka, India. The analyses on the cube root-transformed dataset described below. cohort group can be considered as a representative sample of its Moreover, these analyses were supported by that employing the category for the population of India. direct Mann-Whitney non-parametric U test for differences Dental anxiety level, along with related information was between the total anxiety scores of these two student groups collected from all participants recruited. The original English without consideration of the gender and age variables, which version of the Modiﬁed Dental Anxiety Scale (MDAS, Table 1) was were both found to be insigniﬁcant ‘within-BDS student year’ 27,28 employed, which is a ﬁve-item questionnaire containing groups via the ANCOVA analysis model 2 applied, as described questions about respondents’ level of anxiety whilst visiting a below. This non-parametric test employed 10,000 Monte-Carlo dental surgeon, with a response scale ranging from 1 (not anxious) simulations to compute its p value. to 5 (extremely anxious). The total scores ranged from 5 to 25. A Analysis-of-variance (ANOVA) was employed in model 1 in order score <11 is considered normal, whereas those lying between 11 to test for signiﬁcant differences between the total dental anxiety and 18 represent moderate anxiety. Scores >19 represents parameter (y ) between BDS study years, and ANCOVA was ijk extreme anxiety. The reliability of the English language version applied in model 2 to investigate the inﬂuence of genders and of the MDAS questionnaire had an internal consistency of 0.89, student ages ‘nested’ within these study years. The ﬁrst of these is and a test-retest value of 0.82. All the students were able to described by the mathematical model given in Eq. 1, where Y,G i j understand the English version of MDAS. The BDS course in the 4 and YG represent the student year, gender and student year x ij university participant sources is in the English language, and all gender interaction sources of variance respectively (all ﬁxed the BDS students in these cohort groups speak, read and write effects), µ the value of y in the absence of all these effects, and ijk English competently. e representing fundamental error. ijk y ¼ μ þ Y þ G þ YG þ e (1) i j ij ijk Questionnaire survey ijk In order to avoid any response bias, students were not provided with any prior information regarding dental anxiety prior to Since there was a strong positive correlation between year of commencing the study. The students were given 15 min to answer study and student age (Fig. 2), the latter variable was primarily a pre-printed questionnaire (Table 1). They were fully informed removed from the ANOVA model 1 employed. However, following about the voluntary nature of their participation and their rights as the establishment of a clear signiﬁcant difference between the volunteers to withdraw from this study at any point in time during two study year classiﬁcations, ANCOVA was also then applied to its course. Participant questionnaire respondents were invigilated test for differences ‘between-ages’ within each of the two study in order to ensure non-collusion and lateral discussion, and any years explored (Eq. 2), in which A and GA represent the age j ij form of cheating was prevented during participant completion of covariable and its interaction with the gender source of variation the questionnaire. (i.e., gender × age interaction effect). Questions related to oral hygiene frequency of dental visits, y ¼ μ þ G þ A þ GA þ e (2) j J ij ijk periodontal problems, and preference of dentistry as a career was ijk included in the questionnaire. The students were provided with the opportunity to request any further clariﬁcation. Chi-squared contingency table analysis was conducted in order to determine any associations between the numbers of male and Statistical analysis female students present in each year of study group, and this Tests for normality of the total anxiety score values for both involved 5000 Monte-Carlo simulations and a standard bootstrap student year classiﬁcations were performed by the Jarque–Bera interval of 100 samples. test. Evaluations of variance heterogeneity between these two Principal component regression (PCR) analysis was employed to student group classiﬁcations were performed by the F variance investigate the relationship between principal components ratio test. For the raw (untransformed) dataset, the distributions of formed from (1) strongly correlated student year and age the total anxiety scores for both groups demonstrated strong variables, and (2) genders alone. This model involved a minimum −4 −4 departures from normality (p = 0.004 and <10 for the ﬁrst- and consideration of 80% of the total variance, and a tolerance of 10 . ﬁnal-years respectively), and therefore data were transformed to Total anxiety score values and participant ages were standardized their cube root values (Fig. 1). A further data transformation (i.e., subtraction of their total variable mean values followed by BDJ Open (2019) 5:15 1234567890();,: Dental anxiety in ﬁrst- and ﬁnal-year Indian dental students C.R. Chowdhury et al. Fig. 2 Plot of total anxiety score versus age for ﬁrst- and ﬁnal-year Indian dental students (pink and blue respectively). The smaller number of datapoints visible than the total student participant sample size (n = 614) visible arises from their manifold level of overlap in the diagram. 95% conﬁdence ellipses for both sample groups are also indicated division of their sample standard deviations so that they both had means of 0 and unit variances) prior to PCR analysis. All statistical analyses, including two-sample t-tests, were performed using XLSTAT2014 and SPSS software. RESULTS For this study, all 614 students requested to participate responded to the questionnaire, i.e., a 100% response rate. The age of the sampled population ranged between 18 and 22 years, who were studying within the ﬁrst- and ﬁnal-years of their undergraduate BDS course. Mean ± 95% conﬁdence intervals (CIs) for the ages of the ﬁrst- and ﬁnal-year student participants recruited to the investigation were 18.31 ± 0.135 and 21.54 ± 0.116 years. This difference in mean ages was highly statistically signiﬁcant (p< −4 10 ), as expected (two-sample t-test). The gender-wise distribu- tion of the students was 136 (22.1%) male, and 479 (77.8%) female. The male-to-female (M:F) ratio of BDS students in India is ~20:80, and this index is common throughout this country, including Karnataka state. This is likely to be explicable to the students’ parents/guardians preference for their daughters to be dental or medical clinicians. Moreover, the study of dentistry in India represents the second-most popular choice of many female students who are not accepted to study medicine. There was no signiﬁcant difference between the mean ages of groups classiﬁed by gender i.e., 19.68 and 19.69 years for males and females respectively (two-sample t-test). A plot of total dental anxiety score versus age (Fig. 2) revealed clearly distinguishable clusterings for the ﬁrst- and ﬁnal-rear BDS students. Mean ± SD total anxiety score values for the ﬁrst- and ﬁnal-year students were 12.96 ± 4.00 and 10.54 ± 3.41 respectively Fig. 1 Normality distribution density plots of (a) the untransformed (95% conﬁdence intervals 12.54–13.38 and 10.12–10.93, (raw data) total dental anxiety scores for ﬁrst- and ﬁnal-year BDS respectively). students (green and blue respectively), and (b) following cube root The critical importance of the study year variable was also transformation of these datasets. Fitted normal distributions are demonstrated by linear regression analysis plots of untransformed depicted in red in (b). c Plots of cumulative relative frequency against total anxiety score against age, which was extremely statistically the cube root-transformed total dental anxiety scores for ﬁrst- and signiﬁcant for the entire total anxiety score response dataset ﬁnal-year BDS students (blue and green respectively), demonstrating an excellent ﬁt to a normal distribution curves (red) for both groups (Fig. 3), i.e., that comprising the ﬁrst- and ﬁnal-year students BDJ Open (2019) 5:15 Dental anxiety in ﬁrst- and ﬁnal-year Indian dental students C.R. Chowdhury et al. −4 combined (r = −0.24, p< 10 ). However, this relationship was not particular measure ‘between-genders-within-study-years’ for both at all signiﬁcant when these plots were performed for each study the ﬁrst- and ﬁnal-year BDS students. year separately (r = 0.040 and −0.039 only for ﬁrst- and ﬁnal-year ANOVA analysis of the complete dataset via model 1 demon- BDS students respectively). strated that there was a very highly signiﬁcant difference between −4 Scattergram plots of the total anxiety scores of males and the two years of study, i.e., ﬁrst- vs. ﬁnal years (p< 10 ). The females for both ﬁrst- and ﬁnal-year students (Fig. 4) clearly ‘between-genders’ and study year × gender interaction compo- conﬁrmed that there were no signiﬁcant differences in this nents of variation were not statistically signiﬁcant (p = 0.073 and 0.807, respectively), the latter indicating that particular combina- tions of gender and study year do not give rise to a non-additive (r = -0.244 effect model response. However, the ‘between-genders’ effect was close to statistical signiﬁcance. Thes ‘between-study year’ differ- ence was also found to be very highly signiﬁcant when tested by −4 the non-parametric two-tailed Mann–Whitney test (p< 10 ). Within sub-group analysis of the dataset according to model 2 (ANCOVA) revealed that student age exerted no signiﬁcant effects 15 in both study year groups (p = 0.443 and 0.616 for ﬁrst- and ﬁnal- year students respectively). Similarly, the gender and the age x gender interaction effects were also not found to be statistically signiﬁcant for both study years in this model. As expected, PCR analysis of the standardized raw dataset, which involved the prediction of anxiety scores from student year classiﬁcations, and students’ genders and ages, revealed that the best model attained comprised two major signiﬁcant principal components (PC1 and PC2). PC1 had very strong loadings from ﬁrst and ﬁnal course years (0.594 and −0.594 respectively) and 10 15 20 25 30 35 age (−0.554), whereas PC2 had strong loadings from gender (−0.844 and 0.844 for males and females respectively). These -5 results conﬁrm that, along with the fully expected strong AGE (year) correlation between student year of study and age, and that Fig. 3 Overall plot of total anxiety score versus student age for the gender was independent of (orthogonal to) these predictor combined ﬁrst- and ﬁnal-year BDS students (r = −0.244). Although variables when total anxiety score served as the dependent the negative correlation coefﬁcient observed is low, this relationship −4 variable. was very highly statistically signiﬁcant (p <10 ) in view of the very The sources of these study year-mediated differences were large sample size (n= 614), and demonstrates an age-dependent found to predominantly arise from the criteria monitored on decrease in the total anxiety score. 95% Conﬁdence intervals for both the mean regression values and individual observations are MDAS scale items 3, 4 and 5 (corresponding to anxiety induced by provided teeth-drilling, teeth scaling and polishing, and the receiving of Fig. 4 Scatterplots of total anxiety score for ﬁrst-year male and female, and ﬁnal-year male and female BDS students. Mean and median values are indicated BDJ Open (2019) 5:15 TOTAL ANXIETY SCORE TOTAL ANXIETY SCORE Dental anxiety in ﬁrst- and ﬁnal-year Indian dental students C.R. Chowdhury et al. Table 2. Enumeration distribution of dental anxiety according to year of study, and statistical signiﬁcance of associations found Question Anxiety Response First-Year (n) Final-Year (n) Total (n) χ p Value If you went to your dentist tomorrow, how would you feel? Not anxious 93 100 193 0.003 Slightly anxious 169 118 287 Fairly anxious 60 29 89 Very anxious 26 12 38 Extremely anxious 5 0 5 If you were sitting in the waiting room, how would you feel? Not anxious 92 87 179 0.004 Slightly anxious 140 112 252 Fairly anxious 74 44 118 Very anxious 32 15 47 Extremely anxious 15 1 16 If you were about to have a tooth drilled, how would you feel? Not anxious 32 53 85 <0.0001 Slightly anxious 102 113 215 Fairly anxious 81 54 135 Very anxious 84 31 115 Extremely anxious 50 8 58 If you were about to have your teeth scaled and polished, how would Not anxious 93 156 249 <0.0001 you feel? Slightly anxious 111 79 190 Fairly anxious 69 10 79 Very anxious 47 12 59 Extremely anxious 30 2 32 If you were about to receive local anesthetic injection in your gum, how would Not anxious 42 22 64 0.0004 you feel? Slightly anxious 82 77 159 Fairly anxious 70 75 145 Very anxious 94 64 158 Extremely anxious 64 21 85 local anesthesia respectively), and these are outlined below in (somewhat greater in ﬁnal-year students, although this was a Table 2. signiﬁcantly greater ‘unknown’ selection for ﬁrst-year students). The inﬂuence of year of study on student responses to Statistically signiﬁcant considerations found ‘between-genders’ individual MDAS anxiety questionnaire items was explored via χ were the identiﬁcation of bleeding gums whilst tooth-brushing contingency table analyses (Table 2). These analyses revealed that, (higher in males); time of tooth-brushing (signiﬁcantly more for with the exception of the ﬁnal item focused on local anesthesia, males when this regimen is performed after breakfast); previous ﬁnal-year BDS students exhibited a much lower level of anxiety experience of dental scaling (much higher in females); and the than the ﬁrst-year ones for all questionnaire items on the MDAS reception of oral health education (signiﬁcantly greater in females). questionnaire (p = <0.0001 to 0.004). For the question concerning Table 5 shows that there was a statistically signiﬁcant difference anesthesia, the percentage of ﬁrst-year students who recorded no in the total Level of dental anxiety (p< 0.001) between ﬁrst and signs of anxiety (12%) was approximately two-fold that of ﬁnal year students, but no signiﬁcant difference was detected for ﬁnal year students; conversely, however, the ﬁrst-year student Body mass index (BMI) (p> 0.05) between the two BDS degree group had a ca. twice the proportion of students (18%) than student groups. However, Table 6 shows that there was a those of ﬁnal-year ones who were extremely anxious about this signiﬁcant between-gender difference in BMI values, with males item. Virtually the same percentages of students in each study having a higher mean value than that of females (p < 0.001). year classiﬁcation were very anxious regarding this criterion However, no correlations were observed between the total dental (ca. 25%). anxiety level and BMI values. Notwithstanding, the gender qualitative variable was found to exert no effect whatsoever on anxiety response levels for all of the above MDAS anxiety questions (Table 3). DISCUSSION Table 4 provides data regarding the numbers of ﬁrst- and ﬁnal- Dental anxiety year BDS students responding positively or negatively to their In this study, the status of dental anxiety was monitored using the perceived oral health status and experiences, and all criteria tested MDAS scale, and related information was collected by using a pre- found a series of statistically signiﬁcant associations between tested, validated questionnaire. The level of dental anxiety was these qualitative enumeration variables and levels of anxiety (χ higher amongst ﬁrst-year BDS students over those of ﬁnal-year contingency table analyses). For the student years of study ones (Fig. 1). These results are consistent with previous studies 10,18,22,29–32 variable, these were the observation of bleeding gums during performed elsewhere. A probable reason for this is that tooth-brushing (higher in ﬁrst-year students); the previous ﬁnal-year students are more acclimatized with their clinical performance of dental scaling (much higher in ﬁnal-year students); settings and scenarios. Dental anxiety is a cause of poor patient the receiving of oral hygiene education (higher in ﬁrst-year (in this case dental student) compliance and negative attitudes students); and the early choice of dentistry as a career goal towards receiving dental treatment by the sufferers. Indeed, BDJ Open (2019) 5:15 Dental anxiety in ﬁrst- and ﬁnal-year Indian dental students C.R. Chowdhury et al. Table 3. Enumeration distribution of level of dental anxiety by gender, and statistical signiﬁcance of associations found Question Anxiety Response Male (n) Female (n) Total (n) χ p Value If you went to your dentist tomorrow, how would you feel? Not anxious 148 43 191 ns Slightly anxious 219 58 277 Fairly anxious 70 19 89 Very anxious 28 10 38 Extremely anxious 2 2 4 If you were sitting in the waiting room, how would you feel? Not anxious 138 38 176 ns Slightly anxious 197 55 252 Fairly anxious 96 22 118 Very anxious 32 14 46 Extremely anxious 10 6 16 If you were about to have a tooth drilled, how would you feel? Not anxious 67 18 85 ns Slightly anxious 163 50 213 Fairly anxious 103 32 135 Very anxious 92 22 114 Extremely anxious 45 12 57 If you were about to have your teeth scaled and polished, how would you feel? Not anxious 1 0 1 ns Slightly anxious 146 41 187 Fairly anxious 60 18 78 Very anxious 41 18 59 Extremely anxious 25 6 31 If you were about to receive local anesthetic injection in your gum, how would Not anxious 45 19 64 ns you feel? Slightly anxious 121 37 158 Fairly anxious 117 26 143 Very anxious 128 30 158 Extremely anxious 62 22 84 dentists ﬁnd it very difﬁcult to treat anxious patients, who may be dental surgery reception areas. Their responses revealed that the further afﬂicted by a series of oral diseases and oral health drilling of a carious tooth was a predominant cause of dental problems, since they delay or even terminate visits to dental anxiety, and this ﬁnding is also similar to that found in previous 35,36 surgeries. Notwithstanding, dental health education strategies and study reports. acclimatization to dental procedures can facilitate reductions in An improved knowledge of painless dental procedures, along stress levels; similar strategies could be utilized for anxious dental with education for oral hygiene maintenance through consistent students, in order to assist them in tackling their dental anxiety and personalized approaches, may assist patients to overcome at 33,34 problems. least some forms of dental apprehension. Indeed, a fully In view of the above observations, and the strong positive structured tutor-led awareness programme from the very start correlation of age with students’ year of study, the mean anxiety of dental undergraduate courses may serve as the best approach score also decreased with increasing age, as expected and noted for intervention. Dental anxiety can also be effectively managed at in. However, from our ANCOVA model 2 analysis performed, no an earlier stage by the enhancement of levels of awareness signiﬁcant differences were found between ages ‘nested’ within through the introduction of a motivational programme at both study year classiﬁcation groups. school and pre-university levels. Awareness of the positive It was also observed that there was an increased level of anxiety beneﬁts of dental treatment, delivered and learnt at an early in all the categories of the MDAS score system amongst ﬁrst- and stage in life, may facilitate reductions in dental anxiety responses. ﬁnal-year dental students. Speciﬁcally, ﬁrst-year students were Since generic approaches to such issues may be ineffective, a more anxious with MDAS items 3, 4 and 5 when compared to the more personalized strategy may be effective in diminishing the corresponding questionnaire responses of ﬁnal year ones (p < level of dental anxiety signiﬁcantly. However, in order to 0.001) (Table 2). The possible reason for this is that, ﬁnal year alleviate distressing dental anxiety experiences long-term, a students have more exposure to treatment procedures, and this time-framed follow-up with a sensitization process employing experience assists the process of dental treatment acclimatization. empowered reinforcement may be required. Indeed, the administration of local anesthetics and the drilling of teeth were associated with a higher level of anxiety. Indeed, 26.6% Oral health of ﬁrst-year students replied that they are very anxious during the The survey featuring a questionnaire on periodontal health drilling of teeth, and 18.1% conﬁrmed that they were extremely showed that oral health status was improved amongst ﬁnal year anxious about receiving a local anesthetic injection; this observa- students over that of ﬁrst year ones. A total of 26 (9.96%) students tion is in agreement with previous studies documented in the ﬁnal year explained that they experienced bleeding on 35,36 elsewhere. Approximately one-quarter (24%) of students were brushing, compared to 63 students (17.8%) experienced by those very anxious, and 14% were extremely anxious regarding the in the ﬁrst year of their BDS course (Table 4). This study also found prospect of receiving dental treatment, and these experiences that there was a signiﬁcant association between dental anxiety usually began whilst these subjects are awaiting such treatment in levels and oral hygiene in ﬁrst year students, and more commonly BDJ Open (2019) 5:15 Dental anxiety in ﬁrst- and ﬁnal-year Indian dental students C.R. Chowdhury et al. Table 4. BDS students’ oral health perception responses and statistical signiﬁcance (χ p values) according to year of study (top) and gender (bottom) Group X p Value First year N (%) Final year N (%) Spontaneously bleeding gums Yes 15 (4.9) 8 (3.06) 0.442 No 336 (95.1) 252 (96.5) Bleeding gums while brushing? Yes 63 (17.8) 26 (9.96) 0.006* No 288 (81.6) 235 (90.0) When do you brush? After breakfast 9 (2.5) 6 (2.2) 0.521 Before breakfast 337 (95.4) 245 (93.8) No deﬁnite time 5 (1.4) 7 (2.6) Scaling Done Yes 117 (33.1) 227 (86.9) <0.001* No 234 (66.2) 31 (11.8) Oral hygiene education received Yes 257 (72.8) 224 (85.8) <0.001* No 91 (25.7) 32 (12.2) Was dentistry your preferred career goal? Yes 292 (82.7) 234 (89.6) 0.007* No 20 (5.6) 12 (4.5) Don’t Know 35 (9.9) 9 (3.4) Gender X p Value Female N (%) Male N (%) Spontaneously bleeding gums Yes 19 (3.9) 4 (2.9) 0.593 No 455 (95.1) 129 (94.8) Bleeding gums while brushing? Yes 66 (13.8) 22 (16.1) 0.002* No 409 (85.5) 111 (81.6) When do you brush? After breakfast 8 (1.6) 7 (5.1) <0.001* Before breakfast 453 (94.7) 119 (87.5) No deﬁnite time 6 (1.2) 10 (7.3) Scaling Done Yes 267 (55.8) 66 (48.5) <0.001* No 10 (2.0) 70 (51.4) Oral hygiene education received No 86 (17.9) 41 (30.1) <0.001* Yes 383 (80.1) 95 (69.8) Yes 77 (16.0) 29 (21.3) Was dentistry your preferred career goal? Yes 407 (85.1) 112 (23.4) 0.423 No 28 (5.8) 8 (5.8) Don’t Know 30 (6.2) 13 (9.5) in females. These results concur with those of a further study. The frequency of dental visits for oral prophylaxis was higher Since the co-existence of dental anxiety and poor oral health- among ﬁnal-year BDS students than it was in ﬁrst-year ones: this is related quality of life (QoL) is not simply explicable, further especially evident among female students. This study also investigations are required to explore this. However, both oral demonstrated that a higher number of ﬁrst-year students received health-related QoL and dental anxiety are inter-dependent oral hygiene education than ﬁnal year ones, and hence despite phenomena, the former enhancing the latter’s levels. this deﬁcit, ﬁnal-year students had the scope required to apply BDJ Open (2019) 5:15 Dental anxiety in ﬁrst- and ﬁnal-year Indian dental students C.R. Chowdhury et al. this level of dental anxiety. Moreover, behavioral therapies and Table 5. Age, BMI and Anxiety Score among students in each distraction methods may also be effective in this context. study group Therefore, there is a major requirement for further investigations of the nature and level of anxiety amongst medical students in First year Final year p Value order to compare their anxiety proﬁles with those studying Mean SD Mean SD dentistry. Age 18.31 1.08 21.54 0.95 <0.001* BMI 22.09 4.01 21.63 3.84 0.182 ACKNOWLEDGEMENTS We thank Kathy Lewis, an expert in health promotion and protection and former Hon. Anxiety score 12.96 4.00 10.52 3.40 <0.001* Secretary of Institute of Health Promotion and Education, UK for her editing contribution in this manuscript. We are thankful to Dr TS Sanal of Nitte University Department Bio-statistics and Epidemiology for his statistical support. Many thanks to Professor Vathsala Blr of AJ Dental Institute, Mangalore; Professor Riaz Abdullah of Yenepoya Dental College, Mangalore and Professor Junaid Ahmed of Manipal College Table 6. Age, BMI and Anxiety Score by gender in each study group of Dental Surgery, Mangalore for their support in the study. Thanks to dental interns Yoga Naik and Dr Melanie for their involvement in entering data-information whilst Female Male t test value p Value they were placed in the department of Oral Biology and Genomic Studies of Nitte Mean SD Mean SD University AB Shetty Dental College. Age 19.69 1.89 19.68 2.00 0.06 0.953 BMI 21.58 3.77 23.08 4.33 3.65 <0.001* AUTHOR CONTRIBUTIONS S.K. and S.H.: manuscript preparation; A.C. and E.L.: manuscript editing; M.G.: Anxiety score 11.98 3.84 11.67 4.16 0.14 0.887 statistical support and editing. their learning based on clinical resources (such as patients based ADDITIONAL INFORMATION at hospital and community settings). This is undoubtedly Competing interests: The authors declare no competing interests. reinforced thorough their observations experienced during clinical placements. Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims Therefore, early implementation and reinforced dental aware- in published maps and institutional afﬁliations. ness, together with the implementation of an appropriate acclimatization process, can give rise to a signiﬁcant reduction 2,15 in dental anxiety; this has been observed in related studies. REFERENCES 1. Vermaire, J. H., Houtem, C. M., Ross, J. N. & Schuller, A. A. The burden of disease Dentistry as a career and dental anxiety of dental anxiety: generic and disease‐speciﬁc quality of life in patients with The majority of the dental students involved in this study revealed and without extreme levels of dental anxiety. Eur. J. Oral. Sci. 124, 454–458 that they had chosen dentistry as a career choice of their own (2016). accord. However, a small proportion of female students (5%) did 2. Todd J. E., Lader D. 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The management Attribution 4.0 International License, which permits use, sharing, of dental anxiety: time for a sense of proportion? Br. Dent. J. 213, 271–274 adaptation, distribution and reproduction in any medium or format, as long as you give (2012). appropriate credit to the original author(s) and the source, provide a link to the Creative 25. Tangade, P. S. et al. “Assessment of stress level among dental school students: an Commons license, and indicate if changes were made. The images or other third party Indian outlook.”. Dent. Res. J. 8, 95 (2011). material in this article are included in the article’s Creative Commons license, unless 26. Patil, S. et al. Prevalence of recurrent aphthous ulceration in the Indian Popula- indicated otherwise in a credit line to the material. If material is not included in the tion. J. ClinExp Dent. 6,36–40 (2014). article’s Creative Commons license and your intended use is not permitted by statutory 27. University of St Andrews [Internet]. Ruth Woodﬁeld | School of Management | regulation or exceeds the permitted use, you will need to obtain permission directly University of St Andrews. (cited 20186 Aug 2018). Available from: https://www.st- from the copyright holder. To view a copy of this license, visit http://creativecommons. andrews.ac.uk/dentalanxiety/ org/licenses/by/4.0/. 28. Giri, J., Pokharel, P. R., Gyawali, R. & Bhattarai, B. Translation and validation of modiﬁed dental anxiety scale: The Nepali Version. Int. Sch. Res. Not. 2017, © The Author(s) 2019 5495643 (2017). BDJ Open (2019) 5:15

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Published: Oct 16, 2019

References

The burden of disease of dental anxiety: generic and disease‐specific quality of life in patients with and without extreme levels of dental anxiety

Vermaire, JH; Houtem, CM; Ross, JN; Schuller, AA
Dental anxiety in adults in Bulgaria

Kirova, D; Atanasov, D; LalabonovaÍr; Janevska, S
Onset of and patterns of change in dental anxiety in adolescence and early adulthood: a birth cohort study

Locker, D; Thomson, WM; Poulton, R
Dental fear and anxiety in an older adult population

Locker, D; Liddell, A; Burman, D
The association between dental anxiety and oral health‐related quality of life in Britain

McGrath, C; Bedi, R
Dental fear and subjective oral impacts among adults in Finland

Pohjola, V; Lahti, S; Suominen‐Taipale, L; Hausen, H
The relationship between periodontal disease severity and state-trait anxiety level

Kesim, S; Unalan, D; Esen, C; Ozturk, A
The vicious cycle of dental fear: exploring the interplay between oral health, service utilization and dental fear

Armfield, JM; Stewart, JF; Spencer, AJ
Dental anxiety: a comparison of students of dentistry, biology, and psychology

Storjord, HP; Teodorsen, MM; Bergdahl, J; Wynn, R; Johnsen, JA
Psychological trauma exposure and trauma symptoms among individuals with high and low levels of dental anxiety

Jongh, A; Fransen, J; Oosterink-Wubbe, F; Aartman, I
The prevalence of dental anxiety across previous distressing experiences

Humphris, G; King, K
Psychosocial consequences of dental fear and anxiety

Locker, D
Why are people afraid of the dentist?

Beaton, L; Freeman, R; Humphris, G
Understanding children’s dental anxiety and psychological approaches to its reduction

Porritt, J; Marshman, Z; Rodd, HD
Prevalence of dental anxiety and fear among medical students at University of Thamar

Madfa, AA
Factors associated with dental anxiety and attendance in middle-aged and elderly women

Hägglin, C; Hakeberg, M; Ahlqwist, M; Sullivan, M; Berggren, U
Prevalence and correlates of dental anxiety in patients seeking dental care

Tellez, M; Kinner, DG; Heimberg, RG; Lim, S; Ismail, AI
Dental anxiety among university students and its correlation with their field of study

Al-Omari, WM; Al-Omiri, MK
What is the relationship between emotional intelligence and dental student clinical performance?

Victoroff, KZ; Boyatzis, RE
“Self-Reported Dental Fear among Dental Students and Their Patients.”

Serra-Negra, J
“Dental anxiety and its relationship with self-perceived health locus of control among Indian dental students.”

Acharya, S; Dattatreya Krishnarao, S
Dentists’ use of behavioural management techniques and their attitudes towards treating paediatric patients with dental anxiety

Strøm, K; Rønneberg, A; Skaare, AB; Espelid, I; Willumsen, T
The management of dental anxiety: time for a sense of proportion?

Newton, T; Asimakopoulou, K; Daly, B; Scambler, S; Scott, S
“Assessment of stress level among dental school students: an Indian outlook.”

Tangade, PS
Prevalence of recurrent aphthous ulceration in the Indian Population

Patil, S
Translation and validation of modified dental anxiety scale: The Nepali Version

Giri, J; Pokharel, PR; Gyawali, R; Bhattarai, B
Dental anxiety among university students and its correlation with their field of study

Al-Omari, WM; Al-Omiri, MK
Anxiety due to Dental treatment and procedures among University Students and its correlation with their gender and field of study

Sghaireen, MG; Zwiri, AMA; Alzoubi, IA; Qodceih, SM; AL-Omiri, MK
Prevalence and characteristics of dental anxiety in Danish adults

Moore, R; Birn, H; Kirkegaard, E; Brødsgaard, I; Scheutz, F
Self-reported dental fear among dental students and their patients

Serra-Negra, J
Dental anxiety in relation to mental health and personality factors.

Hägglin, C
Dental anxiety among a young adult Saudian population

QuteishTaani, DSM
Dental phobia among Saudis

Al-Khodair, I; Al-Balawi, S; Al-Khamis, H; Marks, I

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Dental anxiety in first- and final-year Indian dental students

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Dental anxiety in first- and final-year Indian dental students

Dental anxiety in first- and final-year Indian dental students

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