Dental Investigations

Copyright 2015 Medical University, Plovdiv doi: 10.1515/folmed-2015-0029 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 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 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, Medical University, Plovdiv; Tel: +359 888 608 406; E-mail: lalabonova@abv.bg 116 3, Hristo Botev, Blvd., 4002 Unauthenticated Plovdiv, Bulgaria

Impact of Dental Anxiety on the Decision to Have Implant Treatment INTRODUCTION Throughout their life people may lose, for various reasons, part or all of their teeth and this may cause serious physiological and psychological problems. The dental defects acquired during such a process have a negative impact on their eating and speaking behaviour and, in some individuals, can even trigger depressive conditions. The restoration of such defects can be done with fixed or removable dental constructions. Dental implants are increasingly used in modern dentistry as anchors for prosthetic restorations. 1 What treatment a patient chooses to have depends on their level of information capacity, physical health, financial potential and, last but not least, on their level of dental anxiety. Anxiety is a term which designates a state that may involve experiencing irrational psychological sensations of uneasiness, apprehension and agonising anticipation or may be accompanied by some somatic manifestations such as palpitation, dyspnea, and sweating. 2,3 Anxiety and pain are essentially multidimensional. They are capable of suppressing many bodily functions. This becomes a risk factor in many diseases and rehabilitation processes. It is therefore important to identify them and assess their level. Use of standard instruments provides a good opportunity to compare data from test groups, experimental manipulations and therapies. In Bulgaria dental anxiety has been studies only by a few researchers. 2,4-6 Various scales have been proposed to measure dental anxiety, the most appropriate being that developed by N. Corah the Dental Anxiety Scale (DAS) in 1969. This scale is simple, short, and has good psychometric properties. 7-10 AIM In this study we aimed at investigating the impact of dental anxiety on the decision to choose dental treatment with implants used as anchors of prosthetic restorations. MATERIALS AND METHODS The study included 174 patients that were referred to us for dental implant treatment because of partial or total loss of teeth. These patients underwent a careful examination to assess their oral and general health status we found no contraindications that might preclude the chosen treatment. They were informed about the stages of the implant treatment (both the surgical and the prosthetic stages), the time that it was going to take and the cost of the treatment. The patients completed the questionnaire for assessment of the dental anxiety proposed by Norman Corah which is an established assessing modality widely recognised in the literature because of its brevity, accessibility and simplicity. It contains four items with five options each. The number of a question corresponds to the points awarded for this question. The maximum score a patient may have is 20. The anxiety assessment score is as follows: 8 points the level of anxiety is normal; 9-12 points there is a moderate anxiety, 13-14 points severe anxiety, 15-20 points - extremely severe anxiety bordering on phobia. Individuals that score 13 points and higher are considered high level anxiety people. At the second dental visit, the patients either chose to have restorations with dental implants as abutments or refused to have it because of anxiety or for other reasons. And these other reasons include: the long-term treatment which did not satisfy the patient, the high cost of the treatment, inability to go through all stages of the surgical procedure because of living abroad. Statistical Analysis In the study we used descriptive, parametric, nonparametric, correlation and graphic analyses. The distribution normality of the variables was analysed using graphic analysis and the Kolmogorov- Smirnov test for all patients and for the subgroups. The Student-Fisher t-test and analysis of variance were used to analyse quantitative parameters that had normal or near normal distribution at level of significance p < 0.05, dispersion analysis (ANOVA) was used to test the null hypothesis for any statistically significant differences between the studied parameters in the respective groups of patients, and Bonferroni test - to make comparison between more than two groups. For variables that had abnormal distribution we used the Mann-Whitney test; the Kruskal-Wallis test was used to compare two or more independent samples if the variables did not have normal distribution. The results are presented as relative percentages, mean and standard error. The statistical analysis was performed using SPSS v. 17 and MS Office Excel 2003. RESULTS Fear of dental treatment is known to be a result of the action of various factors. In the present study we investigate dental anxiety as a factor in choosing 2015 Medical University, Plovdiv Unauthenticated 117

C. Lalabonova dental implant treatment in which the implants are used as abutments for the prosthetic reconstruction. The study included 174 patients: 88 (506%) men and 86 (30.7%) women; they were allocated to 3 groups according to the choice they made of a dental treatment: Group 1: this included patients that opted to be treated with dental implants for abutments; group 2: patients that refused to have implant treatment because of dental fear; group 3: in this group we placed the patients that refused treatment for other reasons. The level of anxiety of the participant was assessed using N Corah s scale: 1 no anxiety, 2 moderate anxiety, 3 severe anxiety, 4 extremely severe anxiety (phobia). The distribution of patients by sex and age, total and by groups is presented in Table 1. The gender and age of patients were not correlated with significant differences in the level of anxiety (U = 3712.50, P = 0.82 and F = 0.79, P = 0.82, respectively). The distribution of patients by level of anxiety is presented in Fig. 1. The distribution of patients by the treatment they chose was as follows: 40.8% opted to be treated with dental implants, 24.1% refused to have the treatment because of dental fear; 35.1% refused to have implant treatment for other reasons (Table 1). The level of anxiety is associated with the specific choice of treatment and this is supported by the average correlation we found (r s = 0.398, P = 0.000). The level of anxiety according to the choice the patient has made is presented in Figs 2, 3, and 4. Of the patients in group 1, 61% showed no anxiety and 39% showed moderate level of dental anxiety. The analysis of the results suggested that patients that decided to have the dental implant treatment were the low-level anxiety patients. The distribution of patients by anxiety in group 2 was as follows: 7% had moderate anxiety, 69% showed severe anxiety and 24% showed to have extremely severe anxiety. The analysis of the results suggested that 93% of the patients that refused treatment because of fear were high-level anxiety patients. The distribution of anxiety in group 3 was as follows: 23% showed no dental anxiety, 46% showed moderate anxiety, 25% had severe anxiety and 6% displayed extremely severe anxiety. The analysis of the results suggested that the group of patients that refused treatment for reasons other than those in groups 1 and 2 was heterogenous with all kinds of anxieties. Table 1. Characteristics of the study contingent Parameters Sex U = 3467.50, P = 0.31 (NS) Group 1 Group 2 Group 3 Total n % Sp n % Sp n % Sp n % SP Men 38 53.5 23 54.8 27 44.3 88 50.6 5.92 7.68 6.36 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 3.79 118 2015 Medical Unauthenticated University, Plovdiv

Impact of Dental Anxiety on the Decision to Have Implant Treatment severe 44; 25% extremely severe 14; 8% anxiety-free; 57; 33% moderate 59; 34% Figure 1. Distribution by level of anxiety. moderate 28; 39% anxiety free; 43; 61% Figure 2. Level of anxiety and treatment (group 1, n = 71). extremely severe 10; 24% moderate 3; 7% severe 29; 69% Figure 3. Level of anxiety and treatment (group 2, n = 42). DISCUSSION The relevant literature recognises that high-level anxiety patients are those that score 13 points or more than 13 points in this scale. The present study found that 33% of the study participants were high-level anxiety patients. A study on dental anxiety in Bulgaria 11 has found that 29.9% of general Bulgarian population show severe dental anxiety this percentage is considerably higher than that reported in the literature. 12. There is a great variety 2015 Medical University, Plovdiv Unauthenticated 119

C. Lalabonova extremely severe 4; 6% anxiety free; 14; 23% severe 15; 25% moderate 28; 46% Figure 4. Level of anxiety and treatment (group 3, n = 61). of methods and drugs that have been proposed to manage this high anxiety in our population. 13-15 The severe dental anxiety we found in this study for 33% of the participants is a little higher than the results found for general Bulgarian population. But we assume that the results of the two studies are similar because our study sample was rather small. The choice patients make of a treatment method affects the level of their dental anxiety. Those that opted for dental implant treatment were low-level anxiety patients that scored 13 or less than 13 points in DAS (Fig. 2). This result is important because anxiety, which is potentially able to trigger many negative changes in the body, cannot be a risk factor in the healing processes of dental implants. Those that refused to have dental implant treatment were 24.1% of those that wanted to have the treatment. Their level of anxiety was primarily of severe or extremely severe degree (high-level anxiety patients) (Fig. 3). The dental anxiety experienced by patients refusing dental implant treatment for other reasons included all kinds of anxieties (Fig. 4). The reason was that the refusal was made on account of unacceptable treatment duration or because of high treatment cost. CONCLUSIONS The decision to have dental implant treatment is very much affected by the level of dental anxiety of the patient. A high level of anxiety suppresses the body functions and this can be quite a risk factor in some treatment modalities. High-level anxiety patients do not choose dental implant treatment. Patients that make the decision to have this type of treatment tend to show low level dental anxiety. The low level anxiety in such cases is beneficial because it eliminates a risk factor which would otherwise interfere with the osseointegration processes. Familiarity with the problem of dental anxiety and the possibility of finding ways of dealing with it by dental specialists are crucial factors in motivating patients to choose the most appropriate treatment modality. REFERENCES 1. Peev T, Filchev A. [Prosthetic dental medicine.] Sofia: Eko-Print; 2008; p 272 (Bulgarian). 2. Ilieva E, Lalabonova Ch. [Stress and dental treatment.] Physicalna medicina, rehabilitacia, zdrave 2005;4(2):12-16 (Bulgarian). 3. Madzhirova N. [Childhood complexes.] Plovdiv: Poligrafia; 1996; p 173 (Bulgarian). 4. Kirova D, Lalabonova Ch. [The attitude of dental practitioners to treatment induced anxiety.] Scientific works of Bulgarian Scientists Union. 2009;12:139-43. (Bulgarian). 5. Kirova D, Kirilov G, Atanassov D. [Saliva cortisol as an anxiety biomarker in dental treatment.] Endocrinologia 2011;16(1):29-40. (Bulgarian). 6. Kirova DG. Dental anxiety among dental students. J of IMAB 2011;17(2):137-9. 7. Kirova D. [Psychological assessment of dental anxiety.] Dentalna Medicina 2010;1:67-70. (Bulgarian) 8. Corah NL, Gale EN, Illig SJ. Assessment of a dental anxiety scale. J Am Dent Assoc 1978;97(2):816-9. 9. Corah NL, O, Shea RM, Skeels DK. Dentists perceptions of problem behaviors in patients. J Am Dent Assoc 1982;104(6):829-33. 10. Corah N. Development of a Dental Anxiety Scale. J 120 2015 Medical Unauthenticated University, Plovdiv

Impact of Dental Anxiety on the Decision to Have Implant Treatment Dent Res 1969;48(4):596. 11. Kirova D, Atanasov D, Lalabonova Ch, Janevska S. Dental anxiety in adults in Bulgaria. Folia Medica 2010;52(2):49-56. 12. Kirova D, Todorova V, Cholakova R. [Dental anxiety.] Dentalna Medicina 2010;1:71-74. (Bulgarian) 13. Kirova D. [Modern research of the properties and use of valerian.] Savremenna stomatologia 2010;1:30-8. (Bulgarian) 14. Kirova D, Lalabonova Ch. Use of valerian drug preparations in dental practice. Journal of IMAB-Annual Proceeding (Scientific Papers) 2009;2:109 12. 15. Lalabonova Ch, Staneva M, Dobreva D. Pain, stress, anxiety and psychotherapeutic modalities for their management in dental practice. J IMAB 2005;2:31 3. 2015 Medical University, Plovdiv Unauthenticated 121