Muinelo-Lorenzo ORIGINAL ARTICLE et al
Haemodynamic Response and Psychometric Test Measuring Dental Anxiety in a Spanish Population in Galicia Juan Muinelo-Lorenzoa/Jose Otero Sanfeliúb/Santiago Vivas Alegrec/Fátima López Lombardíad/Xosé Luis Otero Cepedae/Maria Mercedes Suarez-Cunqueirof Purpose: To evaluate haemodynamic changes during dental checkups and preventive treatments and establish the relationship between haemodynamic parameters and psychometric tests. Materials and Methods: Seventy-one paediatric patients (39 boys and 32 girls ages 6 to 14 years, mean age 8.04) scheduled to receive dental procedures fulfilled the inclusion criteria for this prospective study. Anxiety was measured at three time points by using the following haemodynamic parameters: heart rate (HR), systolic and diastolic blood pressure (SBP and DBP) and oxygen saturation (SaO2). The Children’s Fear Survey Schedule Dental Subscale (CFSS-DS) and the Facial Image Scale (FIS) were used as psychometric tests before and after child attendance, respectively. Results: Variations in HR and BP during dental procedures were statistically significant while SaO2 values were not. The highest mean HR, SBP and DBP values were obtained during dental procedures, while the lowest SBP and DBP were recorded at baseline. HR and BP changes (r = 0.32, P < 0.01) were statistically correlated. The most anxious children based on both CFSS-DS and FIS scales also had the highest mean HR. Changes in BP and oxygen saturation parameters were found to have no relationship with anxiety groups in either scale. Conclusions: Dental checkups and preventive treatments cause significant changes in HR and BP. However, the CFSS-DS questionnaire does not adequately predict these changes. Key words: dental anxiety, dental checkups, dental fear, haemodynamic changes, prevention Oral Health Prev Dent 2014;1:3-12
Submitted for publication: 29.05.12; accepted for publication: 30.10.12
doi: 10.3290/j.ohpd.a30605
D
espite advances in the field of dentistry, many patients still fear a visit to their dentist. A review involving populations in different countries
a
Researcher, Department of Stomatology, School of Medicine and Dentistry, Santiago de Compostela, Spain.
b
Medical Staff, Dental Care Unit of Villalba, Galician Health Service Primary Care Network (SERGAS), Lugo, Spain.
c
Researcher, Department of Digestive Diseases, León University Hospital, León, Spain.
d
Postgraduate Student in Esthetic Dentistry, Private Practice in Esthetic Dentistry, Lugo, Spain.
e
Professor, Department of Biostatistics, School of Medicine and Dentistry, Santiago de Compostela, Spain.
f
Professor, Department of Stomatology, School of Medicine and Dentistry, Santiago de Compostela, Spain.
Correspondence: Prof. M. Cunqueiro, Department of Stomatology, School of Medicine and Dentistry, Entrerrío, St. Santiago de Compostela, 15782 Spain. Tel: +34-88-181-2437, Fax: +34-981-562-226. Email:
[email protected],
[email protected]
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found that the prevalence of dental fear (DF) and anxiety (DA) ranged from 5.7% to 19.5% (Klingberg and Broberg, 2007). Anxiety is a multidimensional reaction characterised by a variety of physiological, cognitive, emotional and behavioural responses (Lang and Cuthbert, 1984; Kendall, 2006). Escape-avoidance is the most common behavioural reaction. Wogelius and Poulsen (2005) found that 37.7% of children avoid at least one dental appointment and 17.7% avoid two or more. In addition, children often fail to cooperate during treatment, thereby inhibiting proper oral maintenance. Anxiety in children may lead to postponed treatment and deterioration of oral health. The need for more invasive treatments can produce greater pain, which acts as negative feedback (Tickle et al, 2009). Poor oral health status and subsequent fear of negative evaluations is an important causal pathway that contributes to the perpetuation of anxiety and fear (Armfield et al, 2007).
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By quantifying the level of anxiety caused by routine dental visits at early ages, we can better determine whether earlier non-invasive experiences act as a positive reinforcement for lifelong dental care. Several psychometric tests have been used in child populations (Newton and Buck, 2000). Nevertheless, none of these scales can be considered as a gold standard. The most widely used psychometric scale in paediatric dentistry research is the Children’s Fear Survey Schedule Dental Subscale (CFSS-DS) (Cuthbert and Melamed, 1982). Several studies based on CFSS-DS have been conducted to estimate prevalence, potential clinically related predictors, risk factors and symptoms, as well as to evaluate changes due to experiences or treatment over time (Ten Berge et al, 2002; Klingberg and Broberg, 2007). However, it has been argued that this scale lacks adequate theoretical psychological underpinnings and does not take into account various aspects and components of anxiety response (Armfield, 2010). Another useful scale is the Facial Image Scale (FIS) (Buchanan and Niven, 2002), which provides immediate pre-treatment feedback that can help the clinician to adjust treatment plans to the needs of their paediatric patients. Measurements of physiological changes have been postulated as an objective means of measuring DA (Folayan et al, 2004). Cardiovascular changes induced by DA have been widely reported (Brand et al, 1995; Schriks and van Amerongen, 2003; Liau et al, 2008). Questionnaires have been used in a number of studies to analyse the association between anxiety scales and haemodynamic changes. In particular, some authors have reported positive results in adults using the DAS scale (Brand et al, 1995; Liau et al, 2008). Unfortunately, previous research on physiological changes and DA in children did not use scales (West et al, 1983), had poorly explained methods (Rosenberg and Katcher, 1976) or were based on behavioural rating scales (Schriks and van Amerongen, 2003; Rayen et al, 2006). However, the only method for properly assessing the cognitive component of anxiety is selfreported questionnaires (Beck, 1985), but little is known regarding how they relate to haemodynamic changes in children. The aim of this study was two-fold: first, to evaluate the haemodynamic changes before, during and after dental checkups and preventive dental treatments; second, to establish the relationship between haemodynamic parameters and patient scores on the CFSS-DS and FIS.
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MATERIALS AND METHODS This prospective study was carried out in two Dental Care Units of the Public Health Service Primary Care Network (SERGAS) of Galicia, a region in the northwest of Spain. Ethical approval for the study was obtained from the Galician Ethics Committee of Clinical Research (Ref: 2011/375) and written consent was obtained from all parents and children over 12 years of age.
Participants A total of 73 consecutive patients were enrolled in this study. Two patients were excluded because they were under pharmacological treatment. The data of 71 patients (39 boys and 32 girls) aged 6 to 14 (mean 8.04, SD = 1.90) were used for analysis. The sample was divided into two age groups: a younger group which consisted of 47 children aged 6 to 8 years (66.2%), and an older group of 24 children aged 9 to 14 (33.8%). The inclusion criteria were: 6 to 14 years of age; attended dental appointments for checkups or preventive treatment such as sealants, fluoride treatments, dental prophylaxis; previous experience with dentist. The exclusion criteria were: existence of cardiovascular pathology or systemic disease; existence of psychological or psychiatric pathology or disability.
Measurements DA/DF were measured by using haemodynamic parameters (heart rate, HR; blood pressure, BP; oxygen saturation, SaO2), the CFSS-DS and the FIS. Haemodynamic changes were evaluated using a Dinamap V100 monitor (GE Healthcare; Madrid, Spain). We only took into consideration BP values within the 95% percentile of normal values accepted by the Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents of the American Academy of Pediatrics (AAP, 2004). The CFSS-DS consisted of 15 items scored on a Likert-type scale ranging from 1 (not afraid at all) to 5 (very afraid) with a total score ranging from 15 to 75. Participants were divided according to their CFSS-DS scores into three groups: no or low anxiety (< 32), borderline anxiety (32–39) and high anxiety (> 39). Out of 71 children in the sample, a total
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of 56 completed the CFSS-DS. The children without previous experience with the dental turbine could not do so. The FIS consisted of 5 facial expressions ranging from very happy to very unhappy. The children were asked to select which face best mirrored their feelings during the procedure, where a score of 1 was given for the most positive facial expression and a score of 5 for the most negative. No assistance was allowed from parents, only the researcher’s explanations were used. Children were divided into 2 groups according to their FIS score: no or low anxiety (< 3) and high anxiety (≥ 3).
physiological parameters at the three time points. Independent sample t-tests were used to determine differences in haemodynamic parameters between gender, age and treatment groups. The comparative studies of haemodynamic parameters at each stage among the CFSS-DS groups and the FIS groups were also performed using one-way ANOVA. Pearson’s correlation coefficients were calculated to test for association between all quantitative variables. Results were considered to be statistically significant at P < 0.05.
RESULTS Procedure Initial measurements were taken in an area adjacent to the treatment room. All patients were seen between 9 a.m. and 12 p.m. to avoid diurnal fluctuations in BP values. Specifically, physiological parameters were taken at the following three time points: • At baseline. After waiting for 5 min in the adjacent room, two consecutive measurements of HR, BP and SaO2 were taken with an interval time of 2 min. Immediately afterward, instructions for the CFSS-DS were given for about 5 min and then the researcher read each item aloud to the child for an answer. After 2 to 5 min, the child proceeded into the treatment room. • During dental procedure. Two consecutive measurements of HR, BP and SaO2 were taken with an interval time of 2 min. The first measurement was made when treatment started. All procedures were conducted within a range of 4 to 8 min. • After dental procedure. Two minutes after completing the procedure, two consecutive measurements of HR, BP and SaO2 were made at an interval of 2 min. Finally, the FIS was applied, where participants had to choose a single facial expression to describe how they felt during the dental procedure. We used the FIS at the end of the procedure so that we could assess how the child coped with the treatment.
Statistical analysis Statistical analysis was performed with SPSS (version 17.0; Chicago, IL, USA) for Windows. Variables were expressed as mean and 95% confidence interval. Repeated-measures of variance (ANOVA) were used to analyse the significance of changes in
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Regarding the reason for attendance, 28 children (39.4%) attended for dental checkups and 43 (60.6%) for preventive treatment.
Heart rate The global mean HR was 79.99 (95% CI: 76.89– 83.09) bpm. No statistically significant difference in this value (average of the three stages baseline, during the procedure and after the procedure) was found between boys (77.48 [73.78–81.17] bpm) and girls (83.05 [77.81–88.28] bpm) (t = 1.81, P > 0.05). However, a significant difference was found with respect to age between the younger group (83.16 [79.19–87.13] bpm) and the older group (73.79 [69.65–77.92] bpm) (t = 3.00, P < 0.01). Also, the average baseline HR differed significantly between boys and girls (t = 2.08, P < 0.05). Regarding type of procedure, the mean HR was 79.83 (73.75–85.90) bpm for dental checkups and 80.10 (76.61–83.58) for preventive treatments, which was not statistically significant (t = -0.85, P > 0.05). Table 1 shows HR values over time.
Systolic blood pressure The global mean SBP was 104.51 (102.25– 106.77) mmHg. Distributed by gender, the mean SBP was 105.29 (102.15–108.43) mmHg for boys and 103.49 (100.08–106.90) mmHg for girls, which was not statistically significant (t = -0.76, P > 0.05). Regarding age, the global mean SBP was 102.24 (99.48–104.99) mmHg in the younger age group and 108.59 (105.21–111.97) mmHg in the older age group (t = -2.73, P < 0.01). Table 1 shows SBP values over time. Differences in SBP
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between subsequent time points were statistically significant (P < 0.05). No significant difference was found between measurements at baseline and the final time point. Regarding type of procedure, the global mean SBP for dental checkups was 102.37 (99.74–104.99) mmHg and for preventive treatments was 105.70 (102.41–108.99) mmHg (t = -1.37, P > 0.05).
Diastolic blood pressure The global mean DBP was 62.96 (61.02–64.89) mmHg. Distributed by gender, the mean DBP was 62.03 (59.54–64.52) mmHg for boys and 64.19
(61.05–67.32) mmHg for girls, which was not statistically significant (t = 1.07, P > 0.05). Regarding age, the global mean DBP was 62.16 (59.66– 64.65) mmHg for the younger group and 64.40 (61.21–67.58) mmHg for the older group (t = -1.07, P > 0.05). Table 1 shows DBP values over time. Differences in DBP between subsequent time points were statistically significant (P < 0.05). A statistically significant difference was also found between measurements at baseline and the final time point (P < 0.01). Regarding type of procedure, the global mean DBP for dental checkups was 59.93 (57.89– 61.96) mmHg and for preventive treatments was 64.65 (61.86–67.43) mmHg (t = -2.34, P < 0.05).
Table 1 Comparison of the haemodynamic parameters at baseline, during and after the procedures Comparison of each pair of moments
Mean
95% CI
Heart rate (n = 71) Baseline
79.57
76.07–86.03
During procedure
81.73
78.46–84.99
After procedure
78.68
75.59–81.76
Systolic BP (n = 71) Baseline
102.85
100.12–105.58
During procedure
106.32
103.95–108.69
After procedure
104.37
101.93–106.81
Diastolic BP (n = 71) Baseline
60.48
58.13–62.82
During procedure
65.61
63.46–67.75
After procedure
62.80
60.81–64.78
Mean arterial P (n = 71) Baseline
74.66
72.33–76.98
During procedure
79.24
77.20–81.28
After procedure
77.01
78.06–78.95
Oxygen saturation (n = 71) Baseline
97.99
97.81–98.16
During procedure
98.05
97.82–98.27
After procedure
98.12
97.98–98.26
Baseline vs during procedure
During vs after procedure
Baseline vs after procedure
Pa
Pa
Pa
0.022*
0.000*
0.408
0.001*
0.044*
0.153
0.000*
0.002*
0.006*
0.000*
0.001*
0.018*
0.567
0.444
0.095
*P < 0.05; a Repeated–measures ANOVA.
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Mean arterial blood pressure The global mean arterial blood pressure (MAP) was 76.86 (74.93–78.78 mmHg. With respect to gender, the MAP was 76.50 (73.93–79.06) mmHg for boys and 77.34 (74.25–80.42) mmHg for girls, which was not statistically significant (t = 0.41, P > 0.05). Distributed by age, the mean MAP was 75.59 (73.14–78.03) mmHg for the younger group and 79.13 (75.99–82.26) mmHg for the older group (t = -1.73, P > 0.05). Table 1 shows MAP values over time. Differences in MAP between all time points were statistically significant (P < 0.05). With respect to type of procedure, MAP was 74.08 (70.47–77.68) mmHg for dental checkups and
78.41 (75.55–81.26) mmHg for preventive treatments (t = -2.57, P < 0.05). Pearson’s analysis revealed a significantly positive correlation between changes in HR and SBP (r = 0.32, P < 0.01), between changes in SBP and MAP (r = 0.755, P < 0.001) and between SBP and DBP (r = 0.506, P < 0.001) comparing baseline to during the procedure. Pearson’s analysis between HR and PAM (r = 0.229, P > 0.05) and between HR and DBP (r = 0.185, P > 0.05) did not show significance.
Table 2 Average systolic blood pressure, diastolic blood pressure (BP, in mmHg), O2 saturation (%) and heart rate (in beats per min) of patients in different anxiety groups at the three moments CFSS-DS score at baseline No anxiety (39) (n = 8)
Mean
95% CI
Mean
95% CI
Pa
Heart rate (Pb for group x time = 0.285) Baseline
76.97
72.51–81.42
78.54
67.31–89.76
81.87 66.43–97.30
0.699
During procedure
78.93
74.74–83.11
81.66
71.24–92.07
82.37 71.74–92.99
0.717
After procedure
75.12
71.61–78.62
82.04
70.40–93.68
82.00 69.03–94.96
0.179
b
Systolic BP (P for group x time = 0.356) Baseline
104.18 100.77–107.59
100.20
93.40–106.99
103.06 87.36–118.75
0.599
During procedure
107.55 104.33–110.77
106.37
99.14–113.59
106.56 93.81–119.31
0.936
After procedure
104.19 101.30–107.08
103.12
96.21–110.03
107.81 92.15–123.47
0.619
Diastolic BP (Pb for group x time = 0.288) Baseline
60.47 57.09–63.84
58.41
53.63–63.18
64.06 52.73–75.38
0.467
During procedure
65.32 62.05–68.58
66.70
61.87–71.52
65.93 54.54–77.31
0.915
62.29 59.25–65.32
63.33
58.87–67.78
65.37 56.03–74.70
0.671
After procedure b
Mean arterial BP (P for group x time = 0.255) Baseline
75.04 71.91–78.16
72.34
67.36–77.31
77.06 64.68–89.43
0.559
During procedure
79.40 76.36–82.43
79.93
75.00–84.85
79.47 68.05–90.88
0.986
76.25 73.50–78.99
76.59
71.67–81.50
79.52 69.05–89.98
0.636
After procedure b
Oxygen saturation (P for group x time = 0.189)
a
Baseline
98.05 97.75–98.34
98.04
97.75–98.32
97.81 97.31–98.30
0.719
During procedure
98.22 98.04–98.39
98.08
97.54–98.61
97.25 95.27–99.22
0.064
After procedure
98.19 98.00–98.37
98.29
97.87–98.70
97.75 97.04–98.45
0.143
b
one-way ANOVA, repeated-measures ANOVA.
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Oxygen saturation
Anxiety and fear (CFSS-DS)
The global mean SaO2 was 98.05% (97.90%– 98.19%). There was no statistically significant difference with respect to gender, SaO2 was 98.10% (97.96%–98.23%) in boys and 98.00% (97.70%– 98.29%) in girls (t = -0.64, P > 0.05). There was a significant difference with respect to age; SaO2 for the younger group was 97.93% (97.74%–98.11%) and for the older group 98.29% (98.04%– 98.53%) (t=-2.27, P < 0.05). Table 1 shows the mean value of SaO2 at different time points (P > 0.05). No statistically significant differences were found between dental checkups and preventive treatments (t = 0.19, P > 0.05).
The CFSS-DS result for internal consistency assessed using Cronbach’s alpha was _ = 0.83. The mean score for CFSS-DS was 28.8 (SD = 8.3). Regarding gender, CFSS-DS was 29.0 (SD = 8.8) for girls and 28.6 (SD = 7.9) for boys. The younger age group presented higher scores (29.8 [SD = 9.2]) on the questionnaire than did the older group (27.3 [SD = 6.8]). A total of 36 children (64%) showed no or low anxiety, 12 children (21.4%) presented borderline anxiety and 8 children (14.3%) showed high anxiety. Table 2 shows the haemodynamic changes by anxiety group over time. There were no significant differences in any of these parameters.
Table 3 Average systolic blood pressure, diastolic blood pressure (BP, in mmHg), O2 saturation (%) and heart rate (in beats per min) of patients in different anxiety groups at the three moments FIS score after procedure No anxiety (
