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Dental Anxiety and Its with Self-perceived Health Among Indian Dental Students
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pyrig ORIGINALoARTICLE N ot C for Pu bli cat ion Relationship te Locus of Control sse nc e
Shashidhar Acharyaa/Dattatreya Krishnarao Sangamb
Purpose: The objective of the present study was to assess dental anxiety and study its relationship with the perceived Health Locus of Control (HLC) among students in an Indian dental school. Methods: A total of 325 students returned completed history forms that consisted of the Multidimensional Health Locus of Control (MHLC) scale and the Modified Dental Anxiety Scale (MDAS). Results: ‘Fear of the needle’ was the greatest stimulus of dental anxiety with a mean score of 3.3, which was followed by ‘tooth drilling’ whose mean score was 2.7. There was also a statistically significant decrease in the mean scores for all of the MDAS items from 1st year to 4th year, except the item related to local anaesthetic injection, whose mean score remained high throughout. The mean scores of the three aspects of the MHLC scale (internal, chance and powerful others) were compared with respect to dental anxiety. The results showed that ‘internal’ was the most powerful of the three aspects of MHLC among all three anxiety groups. The mean ‘internal’ score for the low anxiety group was 4.4, which reduced to 4.1 for the high anxiety group. A statistically significant inverse correlation was also found between the ‘internal’ dimension of MHLC and dental anxiety. Conclusion: Perceived HLC was found to play an important role in predicting the dental anxiety among dental students. Key words: dental anxiety, dental students, Multidimensional Health Locus of Control Oral Health Prev Dent 2010; 8: 9–14.
he behavioural sciences have become an increasingly important component of dental education and research (General Dental Council, 1992; Kent and Croucher, 1998). Fear of clinicians and dentistry is a common and potentially distressing problem, both for the public and for dental practitioners. Dental anxiety or fear afflicts a significant portion of people of all ages and from different social classes
T
a
Department of Community Dentistry, Manipal College of Dental Sciences, Manipal University, Manipal 576104, India.
b
Biostatistics, Department of Community Medicine, J.J.M. Medical College and Hospital, Davangere, Karnataka, India.
Correspondence: Dr Shashidhar Acharya, 1-2-50 B, ‘Bhagyashree’ Kunjibettu, Udupi, Karnataka 576102, India. Tel: +0820 2527031. Email:
[email protected]
Vol 8, No 1, 2010
Submitted for publication: 28.04.08; accepted for publication: 28.07.08.
and often results in poor oral health by complete avoidance of dental treatment, irregular dental attendance or poor cooperation (Wardle, 1982; Moore et al, 1993; Aartman, 1998). Dental anxiety is based on several factors such as influence of the family and social environment, and general fearfulness, pain and traumatic or unpleasant experiences (Frazer and Hampson, 1988; Berggren et al, 1995; Bergdahl and Bergdahl, 2003). Other aetiological factors include perceptions of insensitive treatment or negative personality (Kleinknecht et al, 1973). Psychosocial factors play an important role in shaping attitude and behaviour. Dental health professionals are not blind to these psychosocial influences. Their health attitude and behaviour are equally affected by their life experience, including personal history and professional training. Indeed, the clinicians’ own health belief and attitude may 9
students in an Indian dental school.
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Locus of control refers to an individual’s generalised expectations concerning where control over subsequent events resides. In other words, who or what is responsible for what happens. It is analogous to, but distinct from, attribution. According to Weiner (1974, 1980), the ‘attribution theory assumes that people try to determine why people do what they do, that is, attribute causes to behaviour’. Julian Rotter’s original locus of control formulation (Rotter, 1966) classified generalised belief concerning who or what influences attitude, value and behaviour along a bipolar dimension from internal to external control. The notion of perceived locus of control is perhaps the most widely known of the psychological constructs associated with belief about control. The Health Locus of Control (HLC) model suggests that those who score high on the internal dimension, that is, who regard their health as largely within their own control, are likely to engage in a health-maintaining behaviour. Conversely, those who score high on the external dimension view their health as relatively independent of their behaviour and, accordingly, are more likely to engage in health-damaging behaviours than those with lower scores (Wallston et al, 1978). There is significant evidence that anxiety and depression are associated with an external locus of control (Joe, 1971; Strickland, 1977; Molinari and Khann, 1981; Burger, 1984; Dyal, 1984; Ganellen and Blaney, 1984), and that patients with major depression, social phobia, mixed anxiety depressive disorder and panic disorder also have significantly greater external locus of control scale scores as compared to a control group (Kennedy et al, 1998). Dental anxiety may be considered as a healthdamaging behaviour as it may prevent the patient from accessing essential dental care needed for maintaining optimal oral health. Hence, the rationale of the present study was that those with a low internal or a high external locus of control would show higher levels of dental anxiety. Although numerous studies have been done in various population groups, few studies have tried to assess dental
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influence the patients’ ability to comply with the dental health messages (Freeman, 1999). Dental health attitude and behaviour develop and change with age and lifestyle, as with any other aspect of health, and may play a role in shaping belief and anxiety towards health care in general and dental care in particular. Anxiety and belief about dental care may be offshoots of wider issues regarding the clinician’s previous experiences with health care.
pyrig No Co t fo r Pin particanxiety among the health care community, u ular the dental community. The objective of thebpreslica ent study was to assess dental anxiety and studytion ess among its relationship with the perceived tHLC e nc e
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MATERIALS AND METHODS The present study was carried out among students of the Manipal College of Dental Sciences, Manipal University, India. Prior permission was obtained from the dean for conducting this study, which is the standard procedure followed for the approval of research protocols in the author’s institution. Approval from the Ethical Committee of Manipal University was also obtained. The Modified Dental Anxiety Scale (MDAS) (Humphris et al, 1995) and the 18-item Multidimensional Health Locus of Control (MHLC) scale (Wallston et al, 1978; Wallston and Wallston, 1981) were distributed among the 372 undergraduate dental students. The original English language versions of both questionnaires were used, as a thorough knowledge of English was a prerequisite for entry into the course, and all of the students had an excellent knowledge of English. Of these, 325 returned completed forms, while 32 students refused to take part in the study. Incomplete forms were not included in further analysis. Other information such as age, sex and the year of study were also collected from the students. A brief overview of the MDAS and MHLC questionnaires is given below.
MDAS The five-item MDAS was developed by the modification of Corah’s Dental Anxiety Scale (DAS), where a fifth item asked the responses to administration of local anaesthetic, and by a change in the response format. This Likert scale had a scoring range of 5 to 25, with each item’s response ranging from 1 (no dental anxiety) to 5 (high dental anxiety). The modified scale has high levels of reliability and validity. Corah’s DAS is widely used, but has been criticised as exhibiting a range of total scores that are too narrow to be used effectively in clinical studies (Humphris et al, 1995). By increasing the number of possible responses from four to five and by introducing an additional item, the modified DAS, that is the MDAS, helps rectify this problem. The Indian version of the MDAS had been validated previously in another study (Acharya, 2008). Oral Health & Preventive Dentistry
A total of 325 students returned completed history forms that consisted of the MHLC scale and the MDAS as well as information about age, sex and year of study. The age of the study population ranged from 18 to 28. A total of 201 females and 124 males participated in the present study. The results of the present study showed that ‘fear of the needle’ was the greatest stimulus of dental anxiety with a mean score of 3.3, followed by ‘tooth drilling’ whose mean score was 2.7 (Table 1). A comparison of the mean scores of the MDAS items from 1st year to 4th year was done to assess the effect of dental education on dental anxiety. The results showed that there was a statistically significant decrease in the mean scores for all of the MDAS items including the mean MDAS score from 1st year to 4th year, with the exception of the item related to ‘local anaesthetic injection’, Vol 8, No 1, 2010
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Multiple intergroup comparisons (comparisons between different years of the course) were performed by Kruskal–Wallis analysis of variance followed by the Mann–Whitney test for groupwise comparisons. Spearman’s correlation analysis was performed to correlate the MDAS scores with the MHLC scores. A P value of 0.05 was considered statistically significant. All of the statistical analyses were performed using SPSS version 10.
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The 18-item MHLC scale (Wallston et al, 1978; Wallston and Wallston, 1981) is an excellent method for assessing health attitude and has been accepted by researchers as a concept for explaining behaviour. It consists of three six-item scales that also use the Likert format. The Internal HLC (IHLC) is the extent to which one believes that internal factors are responsible for health/illness. Powerful Others HLC (PHLC) is the belief that one’s health is determined by powerful others, and Chance HLC (CHLC) measures the extent to which one believes that health/illness is a matter of fate, luck or chance. Each subscale consisting of six questions has a scoring range from 6 to 36, with each item’s response ranging from 1 (strongly agree) to 6 (strongly disagree). There is no ‘total’ MHLC score for the questionnaire.
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MHLC scale
opyrig NAcharya/Sangam ot C for which remained high throughout the course. Pu The bli overall mean MDAS score also showed a statistica cally significant decrease from 1st year to 4th year tion te (Table 2). ss e n c e The study population was divided into three groups on the basis of their MDAS scores. Those with MDAS scores 5 to 10, 11 to 18 and 19 to 25 were classified into low anxiety, moderate anxiety and high anxiety groups, respectively. The mean scores of the three aspects of the MHLC scale (internal, chance and powerful others) were compared with respect to dental anxiety. The results showed that ‘internal’ was three most powerful of the three aspects of MHLC among all three anxiety groups. The mean ‘internal’ score was significantly less in the high dental anxiety group (Table 3). The MDAS scores were correlated with the three MHLC dimension scores, and the correlation coefficients of -0.113 (P = 0.041), 0.024 (P = 0.662) and 0.049 (P = 0.380) were obtained for internal, chance and powerful others, respectively. MDAS scores had a significant negative correlation with the ‘internal’ dimension of the MHLC.
DISCUSSION The present study was conducted to assess dental anxiety among students in an Indian dental school and to examine the relationship between dental anxiety and the perceived HLC among the dental students. The results of the present study showed that dental anxiety was a pertinent issue even among dental students. It was seen that ‘fear of the needle’ was the most important anxiety-producing stimulus, irrespective of the year of the course. Similar results were obtained by other investigators (Peretz and Mann, 2000). The dental anxiety scores for items dealing with ‘waiting in the dental office’, ‘anticipation of dental treatment’, ‘getting the tooth drilled’ and ‘getting the tooth polished’, with the exception of the ‘needle anxiety’, showed a statistically significant decline from the first year to the final years, indicating the effect of professional education and clinical experience that was acquired by the students throughout their dental course. This was also in agreement with previous research (Peretz and Mann, 2000). The second most powerful anxiety-inducing stimulus was fear of the drill, which, unlike fear of the needle, showed a sharp decline in the third and final years. An increased awareness and familiarity about the procedure 11
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Table 1 Student responses to the modified dental anxiety questionnaire
pyrig No Co t fo rP ub lica Extremely Mean tio n anxioust e s (SD)e s c en N (% %)
Items
Not anxious N (% %)
Slightly anxious N (% %)
Fairly anxious N (% %)
Very anxious N (% %)
1
If you were to go to your clinician for treatment tomorrow, how would you feel? If you were sitting in the waiting room (waiting for treatment), how would you feel? If you were about to have a tooth drilled, how would you feel? If you were about to have your teeth cleaned and polished, how would you feel? If you were about to have an injection in your mouth, above an upper back tooth, how would you feel?
122 (37.5)
127 (39.1)
60 (18.5)
11 (3.4)
5 (1.5)
1.9 (0.9)
106 (32.6)
104 (32.0)
74 (22.8)
28 (8.6)
13 (14.0)
2.2 (1.1)
55 (16.9)
108 (33.2)
76 (23.4)
57 (17.5)
29 (8.9)
2.7 (1.2)
184 (56.6)
84 (25.8)
34 (10.5)
16 (4.9)
7 (2.2)
1.7 (1.0)
28 (8.6)
70 (21.5)
74 (22.8)
66 (20.3)
87 (26.8)
3.3 (1.3)
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Table 2 Yearwise comparison of the mean scores for the MDAS items S. No.
Items
1
If you were to go to your clinician for treatment tomorrow, how would you feel? If you were sitting in the waiting room (waiting for treatment), how would you feel? If you were about to have a tooth drilled, how would you feel? If you were about to have your teeth cleaned and polished, how would you feel? If you were about to have an injection in your mouth, above an upper back tooth, how would you feel?
2 3 4 5
Overall mean (SD)
1st year mean (SD)
2nd year mean (SD)
3rd year mean (SD)
4th year mean (SD)
Significant difference
2.1 (0.9)
2.0 (1.0)
2.0 (1.0)
1.6 (0.7)
P = 0.001
2.5 (1.2)
2.3 (1.1)
2.3 (1.1)
1.9 (0.9)
P = 0.002
3.1 (1.3)
3.0 (1.2)
2.7 (1.1)
2.1 (0.1)
P < 0.001
2.1 (1.1)
2.0 (1.1)
1.6 (0.9)
1.2 (0.5)
P < 0.001
3.5 (1.4)
3.5 (1.3)
3.4 (1.4)
3.1 (1.2)
P = 0.25
2.6 (0.9)
2.5 (0.9)
2.4 (0.8)
2.0 (0.6)
P < 0.001
P u 0.05, statistically significant.
acquired by working on patients may explain this finding. The HLC model suggests that those who score high on the internal dimension, who regard their health as largely within their own control, are likely to engage in health-maintaining behaviour. 12
Conversely, those who score high on the external dimension view their health as relatively independent of their behaviour and, accordingly, are more likely to engage in health-damaging behaviours than those with lower scores (Wallston et al, 1978). Oral Health & Preventive Dentistry
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11–18 19–25 Significant difference
172 18 –
4.2 (0.8) 4.1 (0.8) P < 0.05
3.0 (0.8) 2.8 (0.8) P = 0.40 NS
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P u 0.05, statistically significant.
Dental anxiety can be a manifestation of the fear of losing control in the dental office, and this may result in a reduction of the Internal Locus of Control in an anxious person. It was observed that even though the Internal Locus of Control was the dominant aspect of HLC throughout the course years, it was the lowest among those who showed the highest levels of dental anxiety. Smith et al (1997) mentioned that an Internal Locus of Control may facilitate selection into higher status groups and occupations by fostering an increased sense of self-efficacy. Similarly, in the present study, where the occupation in question was dentistry, an increased Internal Locus of Control accompanied a concomitant decrease in dental anxiety. The present finding was again confirmed by the correlation analysis where a significant inverse correlation was obtained between the MDAS scores and the ‘internal’ scores. The results of the present study indicated that dental anxiety among dental students was an important issue that needs to be examined more thoroughly by the research community. Dental anxiety among dental students could have implications for their future practice, as it may adversely affect their ability to render quality dental care. It can also be concluded from the present study that a student’s HLC, arising out of his or her attitude and belief towards health in general, can play a major role in predicting dental anxiety. Efforts should be made by the dental teaching community to modify the Health Locus of Control as a means of controlling dental anxiety among dental students.
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4. Berggren U, Carlsson SG, Gustafsson J-E, Hakeberg M. Factor analysis and reduction of a Fear Survey Schedule among dental phobic patients. Eur J Oral Sci 1995;103: 331–338. 5. Burger JM. Desire for control, locus of control and proneness to depression. J Pers 1984;52:71–89. 6. Dyal JA. Cross-cultural research with the locus of control construct. In: Lefcourt HM (ed). Research with the Locus of Control Construct. Vol 3: Extensions and Limitations. New York: Academic Press, 1984:209–306. 7. Frazer M, Hampson S. Some personality factors related to dental anxiety and fear of pain. Br Dent J 1988;165: 436–439. 8. Freeman R. The determinants of dental health attitude and behaviour. Br Dent J 1999;187:81–84. 9. Ganellen RJ, Blaney PH. Stress, externality and depression. J Pers 1984;52:326–337. 10. General Dental Council. The First Five Years: The Undergraduate Dental Curriculum. London: General Dental Council, 1992. 11. Humphris GM, Morrison T, Lindsay SJ. The modified Dental Anxiety Scale: validation and United Kingdom norms. Community Dent Health 1995;12:143–150. 12. Joe VC. Review of the internal–external control construct as a personality variable. Psychological Reports 1971;28: 619–640. 13. Kennedy BL, Lynch GV, Schwab JJ. Assessment of locus of control in patients with anxiety and depressive disorders. J Clin Psychol 1998;54:509–515. 14. Kent G, Croucher R. Achieving Oral Health. Oxford: Wright, 1998:1–6. 15. Kleinknecht RA, Klepac RK, Alexander LD. Origins and characteristics of fear of dentistry. J Am Dent Assoc 1973;86:842–848. 16. Molinari V, Khann P. Locus of control and its relationship to anxiety and depression. J Pers Assess 1981;45: 314–319. 17. Moore R, Birn H, Kirkegaard E, Brødsgaard I, Scheutz F. Prevalence and characteristics of dental anxiety in Danish adults. Community Dent Oral Epidemiol 1993;21:292–296. 18. Peretz B, Mann J. Dental anxiety among Israeli dental students: a 4-year longitudinal study. Eur J Dent Educ 2000;4:133–137. 19. Rotter JB. Generalised expectancies for internal versus external control of reinforcement. Psychol Monogr 1966;80 (whole issue). 20. Smith PB, Dugan S, Trompenaars F. Locus of control and affectivity by gender and occupational status: a 14-nation study. Sex Roles 1997;36:51–57. 21. Strickland BR. Internal–external control of reinforcement. In: Blass T (ed). Personality Variables in Social Behaviour. Hillsdale, NJ: Erlbaum, 1977.
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pyrig No Co t fo 24. Wardle J. Fear of dentistry. Br J Med Psychol r P1982;55: ub 119–126. lica 25. Weiner B. Achievement Motivation and Attribution Theory. tio Morristown, NJ: General Learning Press, 1974. n te e 26. Weiner B. Human Motivation. New York: Holt,ssRinehart & c en
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Winston, 1980.
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