Dental Investigations

ORIGINAL ARTICLES Dental Investigations

IMPACT OF DENTAL ANXIETY ON THE DECISION TO HAVE IMPLANT TREATMENT Christina K. Lalabonova* Department of Maxillofacial Surgery, Faculty of Dental Medicine, Medical University, Plovdiv, Bulgaria

ВЛИЯНИЕ СТОМАТОЛОГИЧЕСКОЙ ТРЕВОЖНОСТИ НА ВЫБОР ИМПЛАНТОЛОГИЧЕСКОГО ЛЕЧЕНИЯ Христина К. Лалабонова* Кафедра челюстно-лицевой хирургии, Факультет стоматологии, Медицинский университет, Пловдив, Болгария ABSTRACT Introduction: Dental implants are increasingly used in modern dentistry as anchors for prosthetic restorations. Anxiety is a complex phenomenon which can become a risk factor for suppression of many functions of the body. Aim: The aim of this study was to investigate the effect dental anxiety exerts on the choice of method of treatment by patients wanting to have dental implants. Materials and methods: The study included 174 patients that were referred to us for dental implants placement because of partial or total loss of teeth. Their dental anxiety was measured using the Dental Anxiety Scale (DAS) proposed by Norman Corah. The patients decided to have or refused to have treatment with dental implants either because they had dental anxiety or gave other reasons. Results: Distribution of patients by level of anxiety was as follows: 33% were anxiety free, in 34% the dental anxiety was moderate, 25% had severe anxiety, and 8% experienced an extremely severe anxiety. Dental fear was given as a reason for refusal of treatment by 24.1% of the patients wanting to have dental implants. Of the patients wanting to have dental implants, 40.8% decided to proceed with the treatment; these patients exhibited low dental anxiety. Conclusion: The decision to have dental treatment with implants is affected by the patient’s level of dental anxiety. Only those with low level of dental anxiety decide to proceed with such a treatment. The mild anxiety some patients experience is beneficial as it eliminates a risk factor that may hinder the process of osseointegration. Key words: anxiety, dental anxiety, treatment, dental implants, implants Folia Medica 2015; 57(2): 116-121 Copyright © 2015 Medical University, Plovdiv РЕЗЮМЕ Введение: В современной стоматологической медицине всё чаще применяются стоматологические имплантаты в качестве опор для протетических восстанавливаний. Многомерная в своей сущности тревожность является фактором риска для подавления многих функций организма. Цель: Целью настоящей работы является исследование влияния стоматологической тревожности на выбор метода лечения пациентами, которые желают установление стоматологических имплантатов. Материал и методы: Объектом исследования стали 174 пациента, обратившиеся за помощью по поводу лечения частичной или полной потери зубов при помощи стоматологических имплантатов. Оценка стоматологической тревожности осуществилась при помощи DAS шкалы Norman Corah. Пациенты выбирали имплантологическое лечение или отказывались от него по причине стоматологической тревожности или по другим причинам. Результаты: Распределение участников в зависимости от степени тревожности следующее: у 33% отсутствует тревожность, у 34% наблюдается умеренный уровень тревожности, у 25% проявляется сильный уровень тревожности, у 8% установлен исключительно сильный уровень тревожности. 24.1% из числа желающих установить стоматологические имплантаты отказываются от лечения по причине страха. Выбравшие лечение при помощи стоматологических имплантов пациенты составляют 40.8% с низким уровнем тревожности. Заключение: Выбор пациентом лечения с установлением стоматологических имплантатов зависит от уровня тревожности. Данное заключение является благоприятным фактом, так как устраняет один из факторов риска, который может привести к подавлению процессов остеоинтеграции. Ключевые слова: тревожность, стоматологическая тревожность, лечение, стоматологические имплантаты, имплантаты Folia Medica 2015; 57(2): 116-121 © 2015 Все права защищены. Медицинский университет, Пловдив

Article’s history: Received: 25April 2014; Received in a revised form: 27 Oct 2014; Accepted: 18 Feb 2015 *Correspondence and reprint request to: C. Lalabonova, Department of Maxillofacial Surgery, Faculty of Dental Medicine, Medi- cal University, Plovdiv; Tel: +359 888 608 406; E-mail: [email protected] 116 3, Hristo Botev, Blvd., 4002 Plovdiv, Bulgaria Impact of Dental Anxiety on the Decision to Have Implant Treatment

INTRODUCTION (both the surgical and the prosthetic stages), the Throughout their life people may lose, for various time that it was going to take and the cost of the reasons, part or all of their teeth and this may cause treatment. The patients completed the questionnaire serious physiological and psychological problems. for assessment of the dental anxiety proposed by The dental defects acquired during such a process Norman Corah which is an established assessing have a negative impact on their eating and speak- modality widely recognised in the literature because ing behaviour and, in some individuals, can even of its brevity, accessibility and simplicity. trigger depressive conditions. The restoration of It contains four items with five options each. such defects can be done with fixed or removable The number of a question corresponds to the points dental constructions. Dental implants are increasingly awarded for this question. The maximum score a used in modern dentistry as anchors for prosthetic patient may have is 20. The anxiety assessment restorations.1 score is as follows: ≤ 8 points – the level of anxi- What treatment a patient chooses to have depends ety is normal; 9 - 12 points – there is a moderate on their level of information capacity, physical anxiety, 13 - 14 points – severe anxiety, 15 - 20 health, financial potential and, last but not least, points - extremely severe anxiety bordering on on their level of dental anxiety. phobia. Individuals that score 13 points and higher Anxiety is a term which designates a state that are considered high level anxiety people. may involve experiencing irrational psychological At the second dental visit, the patients either sensations of uneasiness, apprehension and agonis- chose to have restorations with dental implants as ing anticipation or may be accompanied by some abutments or refused to have it because of anxi- somatic manifestations such as palpitation, dyspnea, ety or for other reasons. And these other reasons and sweating.2,3 include: the long-term treatment which did not Anxiety and pain are essentially multidimen- satisfy the patient, the high cost of the treatment, sional. They are capable of suppressing many inability to go through all stages of the surgical bodily functions. This becomes a risk factor in procedure because of living abroad. many diseases and rehabilitation processes. It is Statistical Analysis therefore important to identify them and assess In the study we used descriptive, parametric, non- their level. Use of standard instruments provides parametric, correlation and graphic analyses. The a good opportunity to compare data from test distribution normality of the variables was anal- groups, experimental manipulations and therapies. ysed using graphic analysis and the Kolmogorov- In Bulgaria dental anxiety has been studies only Smirnov test for all patients and for the subgroups. 2,4-6 by a few researchers. The Student-Fisher t-test and analysis of variance Various scales have been proposed to measure were used to analyse quantitative parameters that dental anxiety, the most appropriate being that had normal or near normal distribution at level of developed by N. Corah – the Dental Anxiety Scale significance p < 0.05, dispersion analysis (ANOVA) (DAS) in 1969. This scale is simple, short, and was used to test the null hypothesis for any statis- 7-10 has good psychometric properties. tically significant differences between the studied parameters in the respective groups of patients, and AIM Bonferroni test - to make comparison between more In this study we aimed at investigating the impact than two groups. For variables that had abnormal of dental anxiety on the decision to choose dental distribution we used the Mann-Whitney test; the treatment with implants used as anchors of pros- Kruskal-Wallis test was used to compare two or thetic restorations. more independent samples if the variables did not have normal distribution. The results are presented MATERIALS AND METHODS as relative percentages, mean and standard error. The study included 174 patients that were referred The statistical analysis was performed using to us for dental implant treatment because of partial SPSS v. 17 and MS Office Excel 2003. or total loss of teeth. These patients underwent a careful examination to assess their oral and general RESULTS health status – we found no contraindications that Fear of dental treatment is known to be a result of might preclude the chosen treatment. They were the action of various factors. In the present study informed about the stages of the implant treatment we investigate dental anxiety as a factor in choosing

Folia Medica 2015; 57(2): 116-121 © 2015 Medical University, Plovdiv 117 C. Lalabonova dental implant treatment in which the implants are (Table 1). The level of anxiety is associated with used as abutments for the prosthetic reconstruction. the specific choice of treatment and this is sup-

The study included 174 patients: 88 (506%) ported by the average correlation we found (rs = men and 86 (30.7%) women; they were allocated 0.398, P = 0.000). to 3 groups according to the choice they made of The level of anxiety according to the choice the a dental treatment: Group 1: this included patients patient has made is presented in Figs 2, 3, and 4. that opted to be treated with dental implants for Of the patients in group 1, 61% showed no abutments; group 2: patients that refused to have anxiety and 39% showed moderate level of dental implant treatment because of dental fear; group 3: anxiety. The analysis of the results suggested that in this group we placed the patients that refused patients that decided to have the dental implant treatment for other reasons. The level of anxiety of treatment were the low-level anxiety patients. the participant was assessed using N Corah’s scale: The distribution of patients by anxiety in group 1 – no anxiety, 2 – moderate anxiety, 3 – severe 2 was as follows: 7% had moderate anxiety, 69% anxiety, 4 – extremely severe anxiety (phobia). showed severe anxiety and 24% showed to have The distribution of patients by sex and age, total extremely severe anxiety. The analysis of the and by groups is presented in Table 1. results suggested that 93% of the patients that The gender and age of patients were not cor- refused treatment because of fear were high-level related with significant differences in the level of anxiety patients. anxiety (U = 3712.50, P = 0.82 and F = 0.79, The distribution of anxiety in group 3 was P = 0.82, respectively). as follows: 23% showed no dental anxiety, 46% The distribution of patients by level of anxiety showed moderate anxiety, 25% had severe anxiety is presented in Fig. 1. and 6% displayed extremely severe anxiety. The The distribution of patients by the treatment analysis of the results suggested that the group of they chose was as follows: 40.8% opted to be patients that refused treatment for reasons other treated with dental implants, 24.1% refused to than those in groups 1 and 2 was heterogenous have the treatment because of dental fear; 35.1% with all kinds of anxieties. refused to have implant treatment for other reasons

Table 1. Characteristics of the study contingent

Group 1 Group 2 Group 3 Total Parameters n % Sp n % Sp n % Sp n % SP Sex U = 3467.50, P = 0.31 (NS) Men 38 53.5 23 54.8 27 44.3 88 50.6 5.92 7.68 6.36 3.79 Women 33 46.5 19 45.2 34 55.7 86 49.4 Total 71 40.8 42 24.1 61 35.1 174 100 Age F = 1.13, P = 0.29 (NS) Mean ± SE 47.18 ± 1.55 46.40 ± 1.91 50.95 ± 1.55 48.32 ± 0.96 Min 24 26 25 24 Max 79 73 75 79 Level of anxiety F = 98.22, P = 0.00 Mean ± SE 1.39 ± 1.56 3.17 ± 1.91 2.15 ± 1.58 2.09 ± 0.07 Min 1 2 1 1 Max 2 4 4 4

extremely severe anxiety; 14; 8% anxiety-free; 57; 33% severe anxiety; 44; 25%

moderate anxiety; 59; 34% Figure 1. Distribution by level of anxiety.

moderate anxiety; 28; 39%

anxiety free; 43; 61%

Figure 2. Level of anxiety and treatment (group 1, n = 71).

extremely severe moderate anxiety; anxiety; 3; 7% 10; 24%

severe anxiety; 29; 69%

Figure 3. Level of anxiety and treatment (group 2, n = 42).

DISCUSSION high-level anxiety patients. A study on dental anxi- 11 The relevant literature recognises that high-level ety in Bulgaria has found that 29.9% of general anxiety patients are those that score 13 points Bulgarian population show severe dental anxiety – this percentage is considerably higher than that or more than 13 points in this scale. The present 12 study found that 33% of the study participants were reported in the literature. . There is a great variety

extremely severe anxiety; anxiety free; 4; 6% 14; 23%

severe anxiety; 15; 25%

moderate anxiety; 28; 46%

Figure 4. Level of anxiety and treatment (group 3, n = 61). of methods and drugs that have been proposed to of treatment tend to show low level dental anxiety. manage this high anxiety in our population.13-15 The The low level anxiety in such cases is beneficial severe dental anxiety we found in this study for because it eliminates a risk factor which would oth- 33% of the participants is a little higher than the erwise interfere with the osseointegration processes. results found for general Bulgarian population. But Familiarity with the problem of dental anxiety and we assume that the results of the two studies are the possibility of finding ways of dealing with it by similar because our study sample was rather small. dental specialists are crucial factors in motivating The choice patients make of a treatment method patients to choose the most appropriate treatment affects the level of their dental anxiety. Those that modality. opted for dental implant treatment were low-level anxiety patients that scored 13 or less than 13 points REFERENCES in DAS (Fig. 2). This result is important because 1. Peev T, Filchev A. [Prosthetic dental medicine.] anxiety, which is potentially able to trigger many Sofia: Eko-Print; 2008; p 272 (Bulgarian). negative changes in the body, cannot be a risk factor 2. Ilieva E, Lalabonova Ch. [Stress and dental treat- in the healing processes of dental implants. Those ment.] Physicalna medicina, rehabilitacia, zdrave that refused to have dental implant treatment were 2005;4(2):12-16 (Bulgarian). 24.1% of those that wanted to have the treatment. 3. Madzhirova N. [Childhood complexes.] Plovdiv: Their level of anxiety was primarily of severe or Poligrafia; 1996; p 173 (Bulgarian). extremely severe degree (high-level anxiety pa- 4. Kirova D, Lalabonova Ch. [The attitude of dental tients) (Fig. 3). The dental anxiety experienced by practitioners to treatment induced anxiety.] Scientific patients refusing dental implant treatment for other works of Bulgarian Scientists Union. 2009;12:139- reasons included all kinds of anxieties (Fig. 4). The 43. (Bulgarian). reason was that the refusal was made on account 5. Kirova D, Kirilov G, Atanassov D. [Saliva cortisol of unacceptable treatment duration or because of as an anxiety biomarker in dental treatment.] Endo- crinologia 2011;16(1):29-40. (Bulgarian). high treatment cost. 6. Kirova DG. Dental anxiety among dental students. CONCLUSIONS J of IMAB 2011;17(2):137-9. 7. Kirova D. [Psychological assessment of dental anxi- The decision to have dental implant treatment is ety.] Dentalna Medicina 2010;1:67-70. (Bulgarian) very much affected by the level of dental anxiety of 8. Corah NL, Gale EN, Illig SJ. Assessment of a dental the patient. A high level of anxiety suppresses the anxiety scale. J Am Dent Assoc 1978;97(2):816-9. body functions and this can be quite a risk factor 9. Corah NL, O, Shea RM, Skeels DK. Dentists’ percep- in some treatment modalities. High-level anxiety tions of problem behaviors in patients. J Am Dent patients do not choose dental implant treatment. Assoc 1982;104(6):829-33. Patients that make the decision to have this type 10. Corah N. Development of a Dental Anxiety Scale. J

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