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RESEARCH REPORT |
1 Department of Clinical Dental Sciences, The University of Liverpool, School of Dentistry, Liverpool, UK L69 3GN; and
2 Academic Division of Clinical Psychology, School of Psychiatry and Behavioural Sciences, Rawnsley Building, University of Manchester, Manchester Royal Infirmary, Oxford Road, Manchester, M13 9WL, England;
*corresponding author, Y.M.Dailey{at}liverpool.ac.uk
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONMETHODSRESULTSDISCUSSIONREFERENCES |
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KEY WORDS: dental anxiety • anxiety management • communication • psychometrics
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONREFERENCES |
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Furthermore, in a recent survey of UK dentists who claimed special expertise in this area of dental practice, it was surprising how few routinely used psychometric measures of dental anxiety (Dailey et al., 2001b). Yet the adoption of these measures is generally recommended (Corah, 1986; Frazer and Hampson, 1988; Milgrom and Weinstein, 1993), and their use in specialized clinics (Aartman et al., 1998) and research studies (Weinstein et al., 1982; Berggren and Linde, 1984; Makkes et al., 1987; Moore, 1991; Johannson et al., 1993; Kaakko et al., 2000) has been widely reported. However, on reviewing the literature, we could find little evidence of the benefit of using psychometric measures of dental anxiety as part of routine case history and assessment within a primary care setting.
The aim of the study was therefore to determine the effect on patients' state anxiety (at the time of testing) by informing the primary care dentist about their patients' trait dental anxiety (dispositional affect toward dentistry) prior to treatment. The hypothesis tested was that informing the dentist about patients' dental anxiety levels before treatment would lead to a reduction in the patients' state anxiety. To improve the power of the study design, we noted, and controlled for, the age and gender of participants in the analysis phase.
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METHODS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONREFERENCES |
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The study was undertaken in eight general dental practices in North Wales and involved the patients of one male practitioner from each practice. We determined the sample size to detect a difference of 1.2 on the mean Spielberger state anxiety scale (Marteau and Bekker, 1992), with 
set at 0.05 and power at 80%. Each patient aged 18 years and over attending for his or her first dental treatment visit (subsequent to an initial examination appointment) was invited by the practice staff to take part. Each patient was given a written information sheet and consent form. Once consent was obtained, the patient was asked to complete, in the waiting room, the Modified Dental Anxiety Scale (MDAS)—a five-question instrument asking about the patient's underlying anxiety about specific dental procedures. Each question is scored from 1 (not anxious) to 5 (extremely anxious) (Humphris et al., 1995, 2000). Any patient scoring 5 on any one of the questions or accumulating a score of 19 or more, out of the maximum 25, was entered into the study.
Randomization
Each patient meeting these inclusion criteria was then allocated at random to an intervention or control group, via the member of the practice staff who opened the consecutive opaque and numbered envelope and read the assignment code. Randomization was generated prior to the start of the study by means of a computerized stratified block design. This ensured approximately equal numbers in the intervention and control groups within each practice.
Baseline Measurement
Prior to treatment, while each patient was in the waiting room, he or she completed the six-item Spielberger State Anxiety Inventory for state anxiety (STAI-S). The STAI-S is designed to assess patient state anxiety at the time the inventory is completed. The reliability of this measure has been reported to be high–Cronbach's alpha = 0.95 (Marteau and Bekker, 1992). There are six questions with scores of 1 to 4 per question.
Intervention
On moving to the surgery, the intervention group patients handed the dentist their completed MDAS screening forms, which the dentist initialed as confirmation of receipt. In contrast, those patients in the control group did not present the dentist with the completed MDAS but left theirs with the receptionist before entering the surgery. Before the study commenced, the dentists were instructed about the interpretation of the MDAS, but were given no further background information about the design of the study.
Follow-up Measurement
At the end of the treatment visit, the patients completed another STAI-S at the reception desk.
Data Analysis
The principle outcome measure was the change in STAI-S scores over the course of the visit from baseline (pre-treatment) to post-treatment. The questionnaires received were analyzed by means of a computer statistical package (SPSS V9.0, 1998). Summary statistics were calculated to include frequencies and, where appropriate, means and standard deviations. We calculated t tests to investigate differences between the groups. We performed univariate factorial analysis of covariance on the STAI-S change scores to test for the group effect, controlling for gender and age. P values equal to or less than 0.05 were considered statistically significant.
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RESULTS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONREFERENCES |
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. There were no significant differences between the intervention group and the control group for age (t = 0.919, df = 117, P = 0.36), the MDAS (t = -0.029, df = 117, P = 0.97), or the baseline STAI-S (t = -0.718, df = 117, P = 0.47).
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. In the control group, the changes in state anxiety ranged from –8 to 13 and were distributed evenly either side of the "no change" (0). In contrast, in the intervention group, the changes ranged from –11 to 12, and for 52 out of 60 patients, the change indicated a reduction in state anxiety. One outlying value in the intervention group showed a marked increase in state anxiety.
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONREFERENCES |
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This study has shown a significant effect on a patient's state anxiety on leaving the dental surgery when his/her pre-treatment assessment of dental anxiety is presented to the dentist. The effect was not trivial, and the results pose two areas of discussion. First, was the reduction in STAI-S reported in this paper of clinical rather than purely statistical significance? Second, what was responsible for the reduction in state anxiety in the intervention group?
A reduction of more than two raw scale points in the STAI-S would indicate a change in state anxiety equivalent to one-half of the baseline standard deviation. Therefore, assuming an approximately normal distribution, the proportion of patients who would score below the baseline mean would increase from 50% to 69%. Such a change would be considered to be clinically significant. Furthermore, a reduction of 0.6 in the mean STAI-S of a group of patients given information about cancer screening was considered to be of clinical importance (Wardle et al., 1999).
The effect on patient anxiety is interesting and requires explanation. Generally, the running of RCTs to test behavioral interventions is to be recommended (Stephenson and Imrie, 1998), although the design and implementation of such studies are challenging. Our intervention was straightforward (the supply of patients' dental anxiety information to the dentist) and simple to record compliance with the study protocol. However, several explanations exist to help understand the reported finding:
First, dentists would be aware that the visit was different, since anxiety data were being supplied to them in some cases. Their response may have been to concentrate on the patients' feelings more than their usual practice, or even to delay treatment.
Second, patients would also be aware of the change in the visit procedure. The intervention group supplied the details of their dental anxiety to the dentist. It is possible that the effect we have reported is due to patients believing that their dentist will treat them more favorably and with greater understanding of their dentally anxious state. The dentist may not change his behavior toward the patient in any way. Evidence for this effect in other fields is clear. For example, patients believing that they are consuming alcohol (when in fact they have been given a non-alcoholic drink) have been shown to reduce anxiety (Goldman et al., 1999; MacDonald et al., 2001). These studies are often well-controlled and provide an additional theoretical basis for the effect we have demonstrated in our study. Patient expectancy, a summary term for the beliefs patients hold about their treatment and highly dependent on the setting, can be considered in two forms. Patients may have been able to control their automatic negative thoughts associated with their dental visit with the knowledge that their dentist is formally aware of their dental anxiety level (Beck and Emery, 1985). In addition, patients may be assisted in thinking more positively toward the dentist—e.g., "the dentist knows that I am anxious about the drill and therefore he/she will take greater care of me" (Meichenbaum, 1985). Work conducted on individuals with social phobia found that the improvements in social anxiety from placebo were associated with an increase in positive thoughts, rather than a reduction in negative thoughts (Abrams et al., 2001). We have been impressed by patients' comments that they welcome the dental team having repeated reminders of their anxiety. This awareness may have boosted patients' beliefs, when they left the surgery, that the dentist cared about their feelings (Rankin and Harris, 1984; Liddell et al., 1990; Lahti et al., 1995).
Hence, our finding of reduced state anxiety in patients who reported their dental anxiety status to their dentist in comparison with those who did not convey this information could have been due to two phenomena, dentist behavior change or patient beliefs about the situation. A more complex design would be required to test both hypotheses that anxiety reduction was attenuated by either (i) dentist behavior/performance or (ii) patient expectancy. At the time of the study, we had concerns about the feasibility of undertaking any clinical trial in the primary care setting, together with the ability of ensuring adequate power. For these reasons, we implemented the "two-group" strategy. Further investigation is therefore needed, not only to confirm and determine what is responsible for the effect discovered, but also to determine if the reduction in anxiety has any longer-term consequences.
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ACKNOWLEDGMENTS |
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Received June 25, 2001; Last revision February 11, 2002; Accepted February 13, 2002
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REFERENCES |
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  L. J. Heaton, C. R. Carlson, T. A. Smith, R. A. Baer, and R. de Leeuw Predicting anxiety during dental treatment using patients'self-reports: Less is more J Am Dent Assoc, February 1, 2007; 138(2): 188 - 195. [Abstract] [Full Text] [PDF]
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