Identification of dental anxiety

Dental anxiety is common, and dental clinicians can use several different techniques to manage its symptoms. However, before giving any anxiety-alleviating treatment, the dental staff must first understand that their patient is indeed suffering from dental anxiety. This thesis aims to enhance our understanding of how dental anxiety is identified.

Study I aimed to assess how dental clinicians rate dental anxiety. One hundred four clinicians from 24 public dental clinics in Östergötland, Sweden, evaluated 1,128 adult patients returning for routine check-ups. Patients expressed their levels of dental anxiety on the Modified Dental Anxiety Scale and a Visual Analog Scale. The clinicians assessed the patients' anxiety levels using a Visual Analog Scale. The correlation (rs) between the anxiety ratings given by the clinicians and those provided by patients was found to be 0.45. Notably, among patients with high dental anxiety, no correlation was observed between the ratings of the clinicians and those of the patients. Generally, the clinicians tended to rate dental anxiety lower than their patients, particularly in cases of high anxiety.

Study II aimed to identify, describe, and develop concepts regarding how dental professionals perceive dental anxiety. Eleven semi-structured interviews were performed with public dental clinicians in Östergötland, Sweden. A purposive and theoretical sampling method was employed, and theoretical saturation was achieved after eight interviews. The recorded interviews were transcribed verbatim. Classical grounded theory was utilized for data analysis through a method known as constant comparative analysis. The primary finding (the core category) was The clinical eye, which refers to clinicians recognizing behaviors that may indicate dental anxiety based on their knowledge, experiences, or intuition. This core category includes five categories: Sympathetic activation, Patient- reported anxiety, Controlling behaviors, Avoidance, and Accomplishment. Initially, there is often doubt about whether a specific behavior is a result of dental anxiety. To gain more certainty, clinicians must recognize a stressor within the dental environment by observing a behavioral change during the anticipation, presence, or removal of that stressor.

Study III aimed to understand how patients experience the dental staff identifying them as dentally anxious. Semi-structured interviews were performed with ten people who considered themselves to be dentally anxious. The methodology was consistent with that of Study II, reaching theoretical saturation after eight interviews. The core category that emerged was hope for Fingerspitzengefühl from dental staff, which refers to an intuitive understanding of a situation and the appropriate response. This concept also encompasses tact and sensitivity from the dental staff. The dentally anxious were reluctant to confide their dental anxiety to the staff due to embarrassment and guilt, thus placing the responsibility for noticing on the staff. The participants hoped that the dental staff would detect their anxiety, acknowledge their feelings of embarrassment, and take meaningful steps to help alleviate their distress.

Study IV aimed to adapt the English version of the Modified Dental Anxiety Scale (MDAS) for use in Sweden and to validate it within the Swedish context. The process followed recommended guidelines for cross-cultural adaptation and validation. Field testing of the Swedish MDAS (MDAS-S) involved 246 adults attending routine dental check-ups and seven individuals diagnosed with dental phobia. The MDAS-S scores were significantly higher (p < 0.001) in the group with dental phobia compared to the group undergoing regular check- ups. Additionally, the MDAS-S was correlated with several known factors associated with dental anxiety, indicating good validity. The MDAS-S demonstrated good reliability, with Cronbach's Alpha values ranging from 0.880 to 0.909. A test-retest conducted on 37 individuals revealed an Intraclass Correlation Coefficient of 0.956. Confirmatory factor analysis supported the existence of a two-factor model, suggesting that the MDAS-S measures anticipatory dental anxiety and treatment-related dental anxiety, although with a shared variance of 78%. Overall, the MDAS-S appears validated as a screening tool for assessing dental anxiety among Swedish adults.

List of scientific papers

I. Evaluation of the ability of dental clinicians to rate dental anxiety. Höglund M, Bågesund M, Shahnavaz S, Wårdh I. Eur J Oral Sci. 2019 Oct;127(5):455-461. https://doi.org/10.1111/eos.12648

II. Dental clinicians recognizing signs of dental anxiety: a grounded theory study. Höglund M, Wårdh I, Shahnavaz S, Berterö C. Acta Odontol Scand. 2023 Jul;81(5):340-348. https://doi.org/10.1080/00016357.2022.2154263

III. Dental professional recognition of dental anxiety from a patient perspective: a grounded theory study. Höglund M, Wårdh I, Shahnavaz S, Berterö C. Acta Odontol Scand. 2024 Dec 18;83:696-701. https://doi.org/10.2340/aos.v83.42447

IV. Cross-cultural adaptation and validation of the Swedish version of the Modified Dental Anxiety Scale. Höglund M, Göranson E, Wårdh I, Larsson P. Acta Odontol Scand. 2024 Dec 16;83:666-671. https://doi.org/10.2340/aos.v83.42436