PUBLIC HEALTH AND MANAGEMENT
STUDY REGARDING THE ANXIETY LEVEL OF PATIENTS FROM THE EMERGENCY DENTAL OFFICE WITHIN THE EMERGENCY ROOM OF MOBILE EMERGENCY SERVICE FOR RESUSCITATION AND EXTRICATION (UPU-SMURD) SIBIU
CRISTIAN ALEXANDRU ȚÂNȚAR1, ADRIAN MARIAN ROȘAN2, CARMEN DANIELA DOMNARIU3
1PhD Candidate “Lucian Blaga” University of Sibiu, 2“Babeș-Bolyai” University, Cluj-Napoca 3“Lucian Blaga” University of Sibiu
Keywords: Abstract: Our study is based on identifying the level of anxiety as state and trait of patients presenting at questionnaire, dental the Emergency Dental Office from the County Clinical Emergency Hospital of Sibiu. The tool used is the anxiety, STAI, UPU state-trait anxiety inventory (STAI). The results show an increase in the level of state anxiety at the same SMURD, dental time with the increase of the education level, while the level of trait anxiety is slightly lower in those with emergency room higher education than the rest. In males, the level of state anxiety regarding the dental interventions and the level of trait anxiety was significantly associated with the age of the respondents. State anxiety scores regarding dental interventions have positively associated with anxiety scores as a personal trait. Over 70% of STAI-STAIT and STAI-TRAIT values were above the average and significantly higher than the validated average values for the Romanian population.
INTRODUCTION disadvantage of this method is that it does not provide Anxiety is an affective disorder, expressed by fear, information about the patient’s specific fears. Many feeling of restlessness and all these are usually felt without a real questionnaires have been proposed to fill the gaps left by the reason to provoke it. Anxiety affects the whole human body DAS. One of these is the Hierarchical Anxiety Questionnaire triggering a somatic, psychological and behavioural response. (HAQ). Anxiety expressed over a short period of time at Previous studies of various social categories of moderate intensity is not always harmful, having the role of patients targeting countries like England and Germany shows creating the body’s adaptation to a particular situation or that dental anxiety is not evenly distributed in terms of gender, increasing the efficiency of an activity. Long term anxiety at age or social status or level of education.(11) high intensity level can be a very damaging thing. A person Thus, younger patients have a higher level of anxiety suffering from generalized anxiety usually develops a particular than the elderly.(10) Female patients have a higher level of type of mental functioning. The person develops excessive and dental anxiety than men. The level of education is a factor that exacerbated worries about reality and fears without objective greatly affects anxiety. The prevalence of dental anxiety reasons.(1) according to studies in Australia is 16.4%, being more Dental anxiety is quite widespread in the population of exacerbated in the female population aged 40-64.(12) many countries (2), with varying degrees of intensity.(3,4) According to a study led by Abrahamsson, Berggren, Terms such as dental anxiety or dental phobia are not used Hallberg and Carlsson in 2002, the population in the consistently in the literature, and the limit between the two terms Scandinavian countries suffered from dental anxiety in is difficult to define. However, a net differentiation between percentages ranging from 7 to 10%. It seems, according to the dental anxiety and pathological dental phobia should be made. same study, that fear is set in childhood, it shows a peak of Dental anxiety is the term used to describe a more or less intense intensity around the age of 30-40 years and after this, it feeling with psychological and physiological variations of fear gradually decreases. According to the same study, there are linked to a dentist’s appointment or things related to dental three things that can reduce patients’ anxiety when presenting to treatment without being pathological. Pathological dental phobia the dentist: correct information of the patient regarding is characterized by avoidance of dental treatment due to a pre- intervention and diagnosis, lack of intraoperative pain and the existing anxiety.(5,6) Dental anxiety and dental phobia are physician’s empathy towards the patient.(12) usually present in the dental office and have an important A study conducted in Spain, in 2009, concludes that influence on the treatment provided by the dentist.(7,8) Anxiety patients of a dento-alveolar surgery service with a high level of expressed before going to the dental office usually leads to the trait anxiety had a postoperative deficiency healing, as well as lack of preventive dental treatments leading to the absence of the most complications and accidents during surgery, and last ideal oral health.(9) but not least, surgery duration was longer than in the other Several ways to measure these patients’ conditions patients in the study who were with a low trait-anxiety level.(13) have been proposed. One of the most commonly used in As for Romania, there are several studies applied on dentistry is the English dental anxiety scale (DAS).(10) A big different samples. A cross-sectional study that was applied to a
1Corresponding author: Cristian Alexandru Ţânţar, Str. Ştefan cel Mare, Nr. 75 B, Ap. 5, Sibiu, România, E-mail: [email protected], Phone: +40744 369508 Article received on 27.06.2017 and accepted for publication on 28.08.2017 ACTA MEDICA TRANSILVANICA September 2017;22(3):1-5
AMT, vol. 22, no. 3, 2017, p. 1 PUBLIC HEALTH AND MANAGEMENT group of 282 participants achieved a value of 10.3% and an average of 41.39 (SD = 8.30) and men 40.78 (SD = 7.21).(17) average age of 31-50 years in which the participants showed the The scale has 40 items that are rated on a four-point Likert scale. highest value of anxiety.(14) It has two subclasses, one for the state with 20 statements that However, another screening performed, this time, on a evaluates how the subject, “now at this time”, feels and, the trait group of 1680 Romanian citizens (using the Corah Dental subscript contains 20 statements about how the patient feels “in Anxiety Scale or DAS) indicated that anxiety was present in general”. The scale provides a score for each of the two 38.04% of the participants.(14) The age and type of patients subscales.(18) presenting in the dental emergency service in Romania is the The questionnaire was applied to a group of 60 same as the groups of patients with the highest incidence of patients who addressed the UPU service of the Sibiu County dental anxiety in various international studies.(15,16) Clinical Emergency Hospital in the dental emergency room with We have identified the level of anxiety in patients various complaints. The study was conducted between presenting in the dental emergency office because we believe September and October 2016 on the sample described above they are part of the group of patients who usually do not appear with inclusion and exclusion criteria. The mean age of in the private dental office, due to the presence of marked respondents to our questionnaire was M = 34.20 (SD = 12.33, anxiety. min = 18, max = 68) years. Of those who participated in the study were about 47% males (Mage = 35.29, SD = 11.09) and PURPOSE 53% females (Mage = 33.25, SD = 13.42), 42% belonged to the Our study aims to trace state and trait anxiety using rural area (Mage =33.00,SD=10.86) and 58% of the urban area Spielber’s State-Trait Anxiety Inventory (STAI, Spielberger, (Mage = 35.06, SD = 13.37). With regard to the level of 1985) in a group of patients who presented to the emergency education that respondents had, 50% had completed high school, dental office within the Emergency Room of Mobile Emergency 33% had higher education, 15% only 8 grades, and 1,7% were Service for Resuscitation and Extrication (UPU-SMURD) Sibiu, with no studies. for a two-month period, in 2016. Inclusion criteria included all patients who wanted to Using the results of this study, we aim at drawing a fill out this questionnaire, were over 18 years old and did not profile of the patient presenting to the County Emergency have clinical psychiatric disorders. Exclusion criteria included Dental Office and find some of the reasons for addressability. patients aged below 18 who had recalcitrant, verbal or physical We make the following prediction; that there will be correlations aggressive behaviours during the emergency treatment, or between the level of anxiety as state and trait and their simply did not wish to fill out the questionnaire. All functional consequences on the presentation to the emergency questionnaires were filled out by the patients after the dentist dental office, according to socio-economic status, age, and level had done the emergency treatment. The study observed the of education. ethical norms of the scientific research, the research being approved by the Ethics Commission of Sibiu County Clinical MATERIALS AND METHODS Emergency Hospital. This study represents the analysis of the results from Data analysis was performed using the IBM SPSS the application of a self-administered anxiety questionnaire to Statistics 20 and Microsoft Office Excel 13 software packages. the patients who have addressed the emergency dental office For the continuous variables, the normality criterion was within the Emergency Room of Mobile Emergency Service for checked using the Kolmogorov-Smirnov test and the values of Resuscitation and Extrication (UPU-SMURD) Sibiu, during the central tendency and distribution (average, standard September 2016-October 2016. The tool used was the deviation, minimum, maximum, coefficients of symmetry and questionnaire “State-Trait Anxiety Inventory” (STAI; kurtosis). In order to compare the scores for the two genders and Spielberger, 1985). the origin environment, the Student t-test was used and the The STAI test has been developed specifically to correlations between the gender scores and origin environment identify and differentiate anxiety as a state of this moment from scores were achieved using the Pearson correlation coefficient, a trait feature (Oei, Evans and Cook, 1990). STAI is a scale of the level of significance considered being p<0.05.(19,20,21) anxiety widely used in psychology, applied both in practice and in research. Over time, it has been applied to various social RESULTS AND DISCUSSIONS categories: from students, adults to soldiers and imprisoned The distribution of STAI-State scale scores through people. A great deal has proven in its use in patients in various which dental anxiety was operationalized had the following clinical trials.(17) characteristic values: minimum = 31, maximum = 54, M = After following treatment in the dental emergency 44.43, median = 45, SD = 5.44, Skewness = - 0.76, Kurtosis = room, patients were invited to fill out STAI (State Trait Anxiety 0.15 (figure no. 1). Inventory) questionnaires to help assess anxiety symptoms. In relation to the maximum score that a respondent The STAI questionnaire consists of two self-assessing could get, the average of scores for the entire sample indicated a scales, independent of each other, which assess the anxiety as moderate level of anxiety over dental interventions. 56% of state (STAI-S) and anxiety as trait (STAI-T). STAI-S defines respondents scored higher than 44. The value of the skewness the state of the subject at the time of filling out the questionnaire coefficient indicated a slight asymmetry to the right (negative), (hours, days); it expresses the magnitude of the phenomenon which indicates the tendency of the scores to move towards the and monitors the evolution over time. STAI-T defines the slightly elevated values range. The difference between the general background (which is the structure of the person) and average scores obtained by the female respondents and the shows a tendency to see stressful events as dangerous and to act average scores among the male respondents was not significant by increasing state anxiety. Trait anxiety can be altered by (M women = 44.53, SD women = 5.22, M men = 44.32, SD men = 5 , psychological interventions or medication. 77, t = -0.14, p = 0.883). The average of the scores obtained by The used questionnaires are validated for application rural respondents is slightly higher than the average of scores on the population of Romania. Valid averages for the Romanian among urban respondents (M rural = 45.48, SD rural = 5.52, M urban population are for STAI-Trait, 42.11 (SD = 7.04) for women and = 43.69, SD urban = 5.33; T = 1.258, p = 0.214). 40.16 (SD = 8.33) for men. For STAI-State, women have an The distribution of STAI-Trait scores - where anxiety AMT, vol. 22, no. 3, 2017, p. 2 PUBLIC HEALTH AND MANAGEMENT was a pre-existing condition, had the following characteristic values: minimum = 31, maximum = 58, M = 44.72, median = 44.5, SD = 6.66, Skewness = 0.18, Kurtosis = -0.80.
Figure no. 1. Distribution of values obtained for STAI-State and STAI-Trait
The average of the scores obtained by rural respondents is slightly higher than the average of scores among urban respondents (M rural = 45.04, SD rural = 7.57, M urban = 44.49, SD urban = 6.03 T = 0.315, p = 0.754) (figure no. 3).
Figure no. 3. Distribution of values obtained for STAI-State Trait according to the origin environment
In relation to the maximum score that a respondent could get, the average of scores for the entire sample indicated a moderate level of anxiety over dental interventions. 50% of respondents scored higher than 44. The average scores obtained by female respondents is higher than the average scores among male respondents (M women = 46.06, SD women = 6.88, M men = 43.18, SD men = 6.17; T = - 1.69, p = 0.095) (figure no. 2).
Figure no. 2. Distributions of values obtained for STAI-State related with gender
No significant association was found between the anxiety level as state and the respondents’ age (r = 0.066; p = 0.614) The scores for state anxiety have positively associated with trait anxiety scores: (r = 0.443, p <0.000). In males, the level of anxiety of dental interventions as state and anxiety as trait was significantly associated with the respondents’ age (r = 0.361, p = 0.059, r = 0.472, p = 0.011). In females, the level of anxiety of dental interventions as state and anxiety as trait did not significantly associate with the respondents’ age (r = -0.171, p = 0.350, r = -0.038, p = 0.836). There is a negative trend between age and anxiety status
as a condition (figure no. 4). AMT, vol. 22, no. 3, 2017, p. 3 PUBLIC HEALTH AND MANAGEMENT
Figure no. 4. STAI-state and STAI-trait age-related There is an increase in the level of anxiety as state tendencies in males with the increase of the schooling level and the level of anxiety as trait is slightly more sacrificed in those with higher education than the rest (8 grades: M STAI_state = 41.44 (SD = 6.32), M STAI_trait= 4 (SD = 6.32) M men = 43.18; SD men = 6.17; t = - 1.69; p = 0.095) (figure no. 5).
Figure no. 5. Distribution of STAI-State and STAI-Trait values according to the level of education
Figure no. 4 STAI-state and STAI-trait age-related tendencies in females
The average values obtained for STAI-State and STAI-Trait were compared with the validated average values for the Romanian population. In the female gender, it is observed that the mean values obtained in STAI-State and STAI-Trait (Mstate = 44.53, SD = 5.22, Mtrait = 46.06, SD = 6.88) are significantly higher (p = 0.002, p =0.003) than the validated average values. In the male gender, it is observed that the mean values obtained in the STAI-State (Mstate = 44.53, SD = 5.22, Mtrait = 43.18, SD = 6.17) are significantly higher (p = 0.003, p = 0.015) than the validated mean value. Regarding STAI-State values, 21.7% of patients had anxiety below average and 78.3% above average. The values obtained for STAI-Trait registered 28.3% below the average and 71.7% above the average.
CONCLUSIONS Pre-existing anxiety level (STAI-Trait results) is more homogeneous across the group of patients studied than the level of anxiety as state. If the most of responding patients have recorded rather high scores of anxiety as a trait, then we can draw certain characteristics of the patients presenting in the UPU dental emergency office. We can conclude that the most of patients presenting in the dental emergency office are patients who do not regularly go to the dentist because they suffer from dental AMT, vol. 22, no. 3, 2017, p. 4 PUBLIC HEALTH AND MANAGEMENT phobia or anxiety marked as trait, probably caused by previous Székely M. Comparative Study Regarding Activity of dental incidents or simply based on wrong information taken Emergency Dental Offices în Tîrgu Mures and Oradea. from the community. Acta Medica Marisiensis. 2015;61(2):120-123. Both pre-existing anxiety and lack of education have 17. Pita HD, Levine EL, Muşat S, Ispas D. Validarea led to negligence, and this has contributed to the acute, painful chestionarului de măsurare a emoţiilor ca stare și trăsătură dental pathologies, which only amplify anxiety and confirm to (Mest-Ro) la baschetbaliste. Psihologia resurselor umane. the patient the reasons of the phobia already installed by 2006;4(2):16-26. developing a vicious circle. 18. Vrasti R. Măsurarea Sănătătii Mentale .Măsurarea With regard to the male patients present in the study, anxietății.(România); 2008.p1- the trend of the values of state and trait anxiety is to increase 30.http://www.vrasti.org/evaluarea anxietatii.pdf. with the age of the patients present in the study, whereas the 19. Mocan I. SPSS Introducere în analiza datelor, Ed. Univ. female patients tend to decrease the level of anxiety as state and „Lucian Blaga” Sibiu, ISBN 973 – 739 – 189 – 6; 2005. p. to evolve constantly in terms of anxiety as trait. 9-100. 20. Maniu I. Tehnici de analiză a datelor: statistica, Ed. Univ. REFERENCES „Lucian Blaga” Sibiu, ISBN 978 – 606 – 12 – 0891 – 3; 1. Cojocaru V, Tüdös S, Predoiu R, Coli E, Coli D. Study 2014. p. 93-98. regarding the impact of trait anxiety on intersegmental 21. Popa EM, Hunyadi D, Muşan M, Maniu I, Brumar B, coordination and topographical memory in junior football Stoica E. Manual de inițiere în birotică, Ed. Univ. „Lucian players .Procedia - Social and Behavioral Sciences. Blaga” Sibiu ISBN 978 – 973 – 739 -388 -3; 2007. 2015;187:124-129 22. Astramskaite ̇I, Poskevicius L, Juodzbalys G. Factors 2. Milgrom P, Fiset L, Melnick S,Weinstein P. The determining tooth extraction anxiety and fear in adult prevalence and practice management cosequences of dental dental patients: a systematic review. Int. J Oral Maxillofac. fear in a major US city. J Am Dent Assoc. 1988;116:641-7. Surg. 2016;45:1630-1643. 3. Agras S, Sylvester D, Oliveau D The epidemiology of 23. Humphris GM, Freeman R, Campbell J, Tuutti H, D’Souza common fears and phobia. Compr Psychiatry. V. Further evidence for the reliability and validity of the 1969;10:151-156. Modified Dental Anxiety Scale. International Dental 4. Malamed SF Pain and anxiety control in dentistry. J Calif Journal. 2000;50:367-370. Dent Assoc. 1993;21:35-39. 5. Jöhren P, Margraf-Stiksrud J. Zahnbehandlungsangst und Zahnbehandlungsphobie bei Erwachsenen. Stellungnahme der DGZMK. Deutsch Zahnärztl Z. 2002;57:9-10. 6. Slovin M. Managing the anxious and phobic dental patient. N Y State Dent J. 1997;63:36-40. 7. Gatchel RJ, Ingersoll BD, Bowman L, Robertson MC, Walker C. The prevalence of dental fear and avoidance: a recent survey study. J Am Dent Assoc. 1983;107:609-610. 8. Hakeberg M. Dental anxiety and health. Thesis, University of Gotenburg, Sweden; 1992. 9. Hakeberg M, Gustafsson JE, Berggren U, Carlsson SG Multivariate analysis of fears in dental phobic patients according to a reduced FSS-II scale. Eur J Oral Sci. 1995;103:339-344. 10. Corah NL. Development of a dental anxiety scale. J Dent Res. 1969;48:596-02. 11. Jöhren P.Validierung eines Fragebogens zur Erkennung von Zahnbehandlungsangst. Zahnärzteblatt. 1999;108:104- 114. 12. Abrahamsson KH, Berggren U, Hallberg L, Carlsson SG. Dental phobic patients’ view of dental anxiety and experiences in dental care: A qualitative study, Scandinavian Journal of Caring Sciences. 2002;16(2):188- 196.
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