SRM Journal of Research in Dental Sciences

: 2016  |  Volume : 7  |  Issue : 3  |  Page : 153--157

Dental anxiety levels and factors associated with it among patients attending a dental teaching institute in Himachal Pradesh

Shailee Fotedar1, Vinay Bhardwaj1, Vikas Fotedar2,  
1 Department of Public Health Dentistry, Himachal Pradesh Government Dental College, Shimla, Himachal Pradesh, India
2 Department of Radiation Oncology, Regional Cancer Center, Indira Gandhi Medical College, Shimla, Himachal Pradesh, India

Correspondence Address:
Shailee Fotedar
Department of Public Health Dentistry, Himachal Pradesh Government Dental College, Shimla, Himachal Pradesh


Background: Dental anxiety is often reported as a cause of irregular attendance, delay in seeking dental care, or even avoidance of seeking dental care, resulting in a poor oral health-related quality of life. Aim: To assess the dental anxiety levels and factors associated with it among patients attending a dental teaching institute in Himachal Pradesh. Methods: A cross-sectional questionnaire study was conducted on a sample of 246 subjects. The dental anxiety was measured by Modified Dental Anxiety Scale. (MDAS). The questionnaire consisted of questions on various demographic factors, experience about dental treatments, and various questions as mentioned MDAS. Data were analyzed by SPSS package 16. Tests used were t-test and analysis of variance. A P < 0.05 was considered statistically significant. Results: The prevalence of dental anxiety was 29.2%. The mean dental anxiety score was 9.22. ± 4.5. Females, those residing in villages, those who had past negative dental history, and students were significantly associated with dental anxiety. On multiple logistic regression analysis, only gender and residence were the strong predictors of association. There was a strong association between dental anxiety and postponement of treatment. Conclusion: The anxiety levels are low among the present population as compared to other states of India. However, we should try to prevent the dental anxiety among patients as dental anxiety leads to postponement of treatment, which ultimately affects the oral health-related quality of life.

How to cite this article:
Fotedar S, Bhardwaj V, Fotedar V. Dental anxiety levels and factors associated with it among patients attending a dental teaching institute in Himachal Pradesh.SRM J Res Dent Sci 2016;7:153-157

How to cite this URL:
Fotedar S, Bhardwaj V, Fotedar V. Dental anxiety levels and factors associated with it among patients attending a dental teaching institute in Himachal Pradesh. SRM J Res Dent Sci [serial online] 2016 [cited 2021 Dec 9 ];7:153-157
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Anxiety and fear toward dental treatment are common problems frequently experienced by patients worldwide. Dental fear denotes a response to a real or active threat. It is usually brief, the danger is external, the stimulus is readily identified, and the unpleasant physiologic body feelings that are associated with this emotion pass as the danger passes. Anxiety is a subjective state of feelings. It may be defined as a state of unpleasant feelings combined with an associated feeling of impending doom or danger from within rather than from without.[1]

Little is understood of the natural history of dental anxiety.[2] Weiner and Sheehan (1990) have suggested that dentally anxious people could be classified into two groups, exogenous and endogenous, with respect to the source of their anxiety. In the former, dental anxiety is the result of conditioning via traumatic dental experiences or vicarious learning, while in the latter, it has its origins in a constitutional vulnerability to anxiety disorders as evidenced by general anxiety states, multiple severe fears, and disorders of mood.[3]

The prevalence of dental anxiety has been studied among various populations and cultures and study results from developed countries have shown that fearful dental patients avoid dental treatment, seek emergency dental care, postpone their dental visit, and when in the dental clinic, they sit on the edge of chair, keep fidgeting, pacing, show repetitious limb movement, have startled reaction to noise, have generalized muscle tension “white knuckle syndrome,” and show eye fixation like “deer in headlights.”[4],[5],[6] This in turn consequently contributes to the overall deterioration of individual oral health status. Hence, there is a veritable vicious circle that is dental anxiety leads to avoidance of dental appointments, increased dental problems, and consequently any actually applied dental treatment must out of necessity be a symptom-oriented one, which only further compounds patient's anxiety.[7],[8]

Despite the advances in technology, dental materials, and increased oral health awareness, a significant percentage of people suffer from dental anxiety. Dental anxiety is ranked fourth among common fears and ninth among intense fears.[9]

Various questionnaires have been used for the objective assessment of dental anxiety, but Modified Dental Anxiety Scale (MDAS) is more useful in a clinical setting for screening and diagnosing patients with dental anxiety, it was developed from Corah's Dental Anxiety Scale.[10] Completion of the questionnaire does not increase patient fear and has been shown to reduce state-trait anxiety in clinical settings.[11] It is simple and easy to complete and takes minimum time for completion.[12] It has been found to be reliable and valid, cross-culturally, and translated in different languages such as Spanish,[13] Greek,[14] Chinese,[15] Romanian,[16] and Turkish.[17]

Identifying anxious individuals can enable the dentist to anticipate patient's behavior and be better equipped with measures to help alleviate patient's anxiety. Various studies have been reported in the literature on the prevalence of dental anxiety and factors associated with it, but none has been conducted in Himachal Pradesh, India, so far. Hence, the present study was conducted to evaluate the levels of dental anxiety and factors associated with it among patients attending Himachal Pradesh Government Dental College, Shimla.


The present study was a cross-sectional questionnaire study. It was conducted from November 2014 to April 2015 on 246 subjects attending the Department of Public Health Dentistry, Himachal Pradesh Government Dental College, Shimla. A pilot study was undertaken which gave a prevalence rate of 23% for dental anxiety. The prevalence rate from pilot study was used to calculate the sample size which came out to be 228. Hence, the study was conducted on 246 subjects. Convenient sampling method was used. Informed consent was taken from the patients prior to the data collection. The inclusion criteria were to include subjects in the age group of 18–75 years and those who were willing to participate. The exclusion criteria were those who refused to give informed consent, those who were undergoing psychiatric therapy or suffering from Generalized Anxiety Disorders.

The questionnaire consisted of two sections. The first section consisted of demographic factors and dental information of patient, for example, age, gender, education qualification, residence, employment, past dental visit, past negative dental experience, and postponement of treatment due to anxiety. The second section had questions to reveal anxiety by using MDAS.[10] MDAS was used as an anxiety inventory to overcome the limitation of Corah's scale. In MDAS, there is an addition of item regarding respondent's feeling toward a local anesthetic injection, which was ranked almost as highly as the drill in terms of fear and anxiety. It is a brief five-item questionnaire and contains multiple choice questions dealing with subjective reaction about going to the dentist, waiting in the dental clinic for treatment, anticipating drilling, scaling, and local anesthetic injection. Each item has five responses scored from 1 to 5 and the responses range in an ascending order from “not anxious” to “extremely anxious.” In addition, the responses to each question are kept uniform in contrast to different sets of answers for each question employed in Corah's scale.[10] English version of MDAS has been used in the present study for which very good reliability and validity have been already demonstrated in various situations [12] and in the Indian population.[11]

The case definition of dentally anxious individual and severity of dental anxiety was determined by converting interpretation of Corah's scale into MDAS scale using the formula 0.56 + (1.15 × DAS score).[10],[18] The interpretation of MDAS scale based on this conversion is as follows: Score <11 - not anxious, 11–14 - moderately anxious, 15–18 - highly anxious, and >19 - extremely anxious.

Data were analyzed using SPSS 16 (SPSS 16 Inc., Chicago, IL) software. Reliability was calculated using Cronbach alpha which was 0.874. The independent t-test and one-way analysis of variance were used to study the difference in the groups based on their mean total anxiety score. Multiple logistic analysis was performed to know the factors independently associated with dental anxiety. A P < 0.05 was considered statistically significant.


Of the total population of 246, there were 122 (49.6%) males and 124 (50.4%) females. The mean age of the study was 37.14 ± 12.2.

The prevalence of dental anxiety among the study population was 29.2%. Based on the severity of dental anxiety, 15.9% were moderately anxious, 9.3% were highly anxious, and 3.7% were found to be extremely anxious. The mean of the questions 1, 2, 3, 4, and 5 in the MDAS was 1.47, 1.41, 1.98, 1.64, and 2.66, respectively. The mean dental anxiety score of the population was 9.22 ± 4.5 [Table 1].{Table 1}

Bivariate analysis has shown dental anxiety was significantly higher among females, people residing in cities, and those having past negative dental experience. There was statistically significant difference between the employee groups as well. The mean dental anxiety was highest among students followed by homemakers and lowest among retired personals [Table 2].{Table 2}

The multiple logistic regression analysis was done to know the factors independently associated with dental anxiety. Only the factors which were significantly associated in bivariate analysis were included in multiple logistic regression analysis. In this model, only the gender and residence were significantly associated and not the factors such as past negative dental history and employment [Table 3].{Table 3}


The present study assessed the levels of dental anxiety among the patients attending the Department of Public Health Dentistry, Himachal Pradesh Government Dental College, Shimla. The prevalence of dental anxiety was 29.2% which is <46% as was reported in Gujarat by Malvania and Ajithkrishnan [19] and 50.2% in Haryana by Marya et al.[20] and higher than 3% as reported by Appukuttan et al.[21] and Udoya et al.,[22] and 13.5% as reported by Nicolas et al.[23] The difference in prevalence rates could be due to geographical variations and cultures.

The mean of dental anxiety score (MDAS) for the population was 9.22 ± 4.5. This is similar to those reported by population of Karnataka,[24] Tamil Nadu,[21] Greece,[14] and Northwest England.[15] The mean anxiety score was highest for the local anesthetic injection. Similar results were reported by Humphris et al.,[25] Moore et al.,[26] and Appukuttan et al.[21]

Mean dental anxiety score was significantly higher among females as compared to males which is in agreement with several studies.[27],[28],[29],[30] This has already been explained by medical and psychological research on human responses to pain stimuli that women report higher levels of anxiety (they have lower levels of thresholds) and exhibit less tolerance for pain at given stimulus intensities than men.[31] It may also be that women are more likely to self-report, whereas men may not express their fear as openly as women.

MDAS was significantly higher among subjects from cities than villages which is in contrast to the findings from Malvania and Ajithkrishnan [19] and Nicolas et al.[23]

In the present study, there was statistically significant difference among the employment groups. The students had the highest mean MDAS followed by homemakers and retired employees had lowest MDAS, which is in contrast to the finding of Malvania and Ajithkrishnan.[19] Decline in anxiety among the retired could be due to factors such as extinction or habituation, adaptive resignation toward the inevitable, increased the ability to cope with experience, more exposure to debilitating diseases, and treatment.[32]

The present study shows a significant relation between past negative dental history and MDAS score which means the past negative dental experience is one of the factors in initiation of dental anxiety. This is in accordance with Acharya,[24] Moore et al.,[26] Malvania and Ajithkrishnan,[19] and other studies.[33],[34]

As already reported in other studies,[35],[36],[37] the present study also shows a significant relationship between dental anxiety and postponement of a dental visit. These results agree with the concept of avoidance of care proposed by Locker et al.[38]

Multiple logistic regression analysis has shown out of four variables which were significant in the bivariate analysis only gender and residence are independent factors associated with dental anxiety.


From the findings of the present study, it can be concluded that the prevalence of anxiety in the population was less than other states in India but higher than the Western countries. The anxiety levels were higher in females, those living in cities, among students as compared to retired personals and those who had a negative dental history. Among the various procedures, local anesthetic injection was the most common reason for anxiety. Gender and residence proved to be the strong predictors of dental anxiety. The limitations of the study are convenient sampling and cross-sectional design of the study. Hence, considering this as a start point, further longitudinal studies are recommended to understand the causal relationship among the population and then to manage dental anxiety in effective manner by various procedures such as pain control, behavior or by sedation. Rather, the dental anxiety should be prevented by focusing the patients in young age as early education in children has a positive influence on dental anxiety.

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Conflicts of interest

There are no conflicts of interest.


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