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Reducing Patients' State Anxiety in General Dental Practice: A Randomized Controlled Trial
1 Department of Clinical Dental Sciences, The University of Liverpool, School of Dentistry, Liverpool, UK L69 3GN; and Correspondence: *corresponding author, Y.M.Dailey{at}liverpool.ac.uk
Anxiety assessment by questionnaire provides information for the dentist and may also confer a psychological benefit on patients. This study tested the hypothesis that informing dentists about patients' dental anxiety prior to commencement of treatment reduces patients' state anxiety. A randomized controlled trial was conducted involving eight General Dental Practitioners in North Wales. Participants included patients attending their first session of dental treatment, and accumulating a score of 19 or above, or scoring 5 on any one question, of the Modified Dental Anxiety Scale (MDAS). Patients (n = 119) completed Spielberger's state anxiety inventory (STAI-S) pre- and post-treatment and were randomly allocated to intervention (dentist informed of MDAS score) and control (dentist not informed) groups. Intervention patients showed greater reduction in mean change STAI-S scores (F[1,119] = 8.74, P < 0.0001). Providing the dentist with information of the high level of a patient's dental anxiety prior to treatment, and involving the patient in this, reduced the patient's state anxiety.
Key Words: dental anxiety • anxiety management • communication • psychometrics
In a four-year follow-up study of dentally anxious patients who had been successfully managed in a special dental clinic and referred back to a general dental practitioner, it was noted that a continuing concern among the patients was that the dentist would eventually "forget" or "overlook" their anxiety (Crawford et al., 1997; Dailey et al., 2001a). 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.
Study Sample Human subjects participated in the study after providing informed consent to a protocol that was reviewed and approved by the three Research Ethics Committees in North Wales.
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
Randomization
Baseline Measurement
Intervention
Follow-up Measurement
Data Analysis
Overall, 291 patients completed the MDAS screening form, of whom 123 satisfied the inclusion criteria and were allocated to intervention and control groups (intervention = 63, control = 60). Four patients (three males and one female) did not entirely complete the pre-treatment STAI-S questionnaire. Thus, complete data were obtained for 119 patients (females = 65.5%, males = 34.5%, mean age = 41.30, SD = 13.9). Sixty patients comprised the intervention group and 59 patients the control group. Mean scores (SD, range and confidence intervals) for both the pre-treatment STAI-S and the MDAS are shown in Table 1  . 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).
The intervention and control groups' mean change STAI-S scores (standard error and confidence intervals) are shown in Table 2 . 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.
A test of homogeneity of variance (Levene's) showed that the scores obtained for each group showed similar variance (F[3,115] = 1.27, P = 0.25). Univariate factorial analysis of covariance showed that the group effect was significant (F [1,119] = 8.74, P < 0.0001), with adjustments for gender and age.
There is anecdotal evidence that practitioners worry about giving their patients dental anxiety assessment questionnaires. They believe that the questions would focus the patient unnecessarily upon "specific anxiety-provoking events", thus harming the dentist-patient relationship. The results of this study indicate that these concerns are unjustified. Furthermore, dentists may worry that discussion of patient's fears may take too much time. The study was undertaken in busy National Health Service practices. This system of care discourages lengthy discussion or counseling. The completion of the MDAS took seconds rather than minutes, while the dentists assured us that no additional surgery time was necessitated if a patient presented an MDAS to them. A strength of the present study was that the patients completed the questionnaires themselves. No assistance from the practice staff was allowed. Hence, the "assessor" was not influenced by the research staff, thereby removing systematic bias from this source. 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.
Internal financial and material support was received from the first author's Department. The authors are grateful to the General Dental Practitioners and patients who participated in the study. Received for publication June 25, 2001. Revision received February 11, 2002. Accepted for publication February 13, 2002.
Journal of Dental Research, Vol. 81, No. 5,
319-322 (2002) This article has been cited by other articles:
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ABSTRACT
INTRODUCTION
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) (
