IMPLEMENTATION OF MODIFIED DENTAL ANXIETY SCALE (MDAS) IN DENTAL

PATIENTS TO ASSESS IT’S EFFICIENCY IN REDUCING DENTAL ANXIETY

Eeshika Mitra, BDS

MPH Epidemiology Class of 2016

Texas A&M Health Science Center School of Public Health

ABSTRACTDental anxiety or phobia is the fear of receiving dental care and procedures, which may lead to hypertension during dental Office visits. Studies done in last four decades suggest that dental anxiety affects 29.2% of adults, which may prevent them from receiving any kind of dental treatment, hence affecting their general health. Four-hundred participants who are at least 21 years old, speak English or Spanish of either gender were enrolled in a randomized controlled clinical trial. The Modified Dental Anxiety Scale (MDAS), which has five questions, is used as an intervention to survey patients prior to and after routine dental care at two different dental clinics in Brazos Valley. Results of prior students using MDAS have been mixed, with some showing high reliability and construct validity while others show no significant effect of MDAS in reducing anxiety (p=0.2). The goal of this study is to assess if a simple questionnaire can make improve the patient/dentist relationship and decrease patient anxiety.

BACKGROUNDDental anxiety is recognized as one of the major causes of avoidance of dental visits or to have a regular check up.

EARLIER STUDIES: The reliability and validity of different scales and questionnaires and also the relation and its effect of socio-demographic characteristics on dental anxiety has been studied in the past. Also studies were performed to find out the relation of dental anxiety and its direct effect on oral health .Meta analytical studies of dental fear and behavioral interventions were conducted by Kvale et al.(7)

He used educational and cognitive approaches , the so-called “ iatrosedative “ technique and other informative education that has been tested.In a study conducted by Locker et al (8) where 272 adults aged 50yr and over completed the dental anxiety scale at baseline and after 3yrs of follow up showed a high degree of stability in the group. The mean DAS score at baseline was 7.6 and at follow up reduced to 7.4.The high levels of anxiety declined from 7% to 5.4%.

WHY THIS STUDY? The direct effect of a dental questionnaire to stabilize dental anxiety and of how it can help a dentist to provide an effective treatment has not been studied. Assessment of dental fear was first done by the Corah’s DAS(1969) which consisted of four questions. The MDAS has an additional question to the Corah’s scale .

ADVANTAGES OF MDAS OVER CORAH’S SCALE-While the Corah’s scale used an assortment of words (e.g tense , anxious)for their response categories ,the MDAS required interpreting or the direct translations of the various levels of anxiety into the native languages. The MDAS is translated in Hindi, Arabic,Finnish,Estonian,Russian and Arabic as published in a study by G.M. Humphris et al. (6)

The other types of dental anxiety measuring scales that were used are the 6- item Spielberg State anxiety scale which has four responses assigned with numerical values from 1-4.Among other methods to assess dental fear such as the Gatchell fear scale or the dental fear survey or any other kind of structured interview for assessing dental fear, the MDAS can be considered as a short and comprehensive questionnaire which is less time consuming and effective. The MDAS has a supplementary question about the patient’s anxiety to local anesthesia injection, which is a major focus of anxiety for many.

METHODSELIGIBILITY CRITERIA:

Survey will be done on 400 study subjects aged 21 years at least and will include men and women speaking English or Spanish at two different dental clinics in Brazos valley, Texas.

DATA COLLECTION METHODS:o Includes an informed consent that will be obtained from both control and intervention groups and a self complete questionnaire which includes the MDAS, prior to routine dental treatment.o The patients will be followed up for a period of 1 year.

SCORING CRITERIA:o MDAS has a total of 5 questions which ranges from ‘not anxious’ to ‘extremely anxious’ and each question is assigned a score in an increasing order from 1 to 5.o The entire scale has a possible minimum score of 5 and a maximum score of 25. A score that is recorded to be 13 or above is considered as a case of dental anxiety. o The following questions are included in the MDAS;

1) If you had to go to the dentist tomorrow, how would you feel?2) When you're waiting, in the dentist's waiting room, how do you feel?3) When you're in the dental chair, waiting for the dentist to prepare the engine to

work on your teeth, how do you feel?4) You are in the dental chair. While you're waiting for the dentist to get the

instruments to scrape your teeth (near the gum), how do you feel?5) How do you feel when a injection has to be given prior to a dental treatment.

-

A total of 200 controls and 200 belonging to the intervention group will be taken. Non participating patients history will be preserved and compared.

MDAS- 19 or over

DAS - 15 or over

CDAS- 12 or over

GATCHELL FEAR SCALE - 8

and over

(2)

Prevalance of dental anxiety using Corahs

dental scale

Ontario ,Canada

Seattle, USA

Sweden

Norway

DISCUSSIONMDAS should probably be considered in the dental treatment procedures to enhance relationship between patient and doctor and better efficacy of treatment.

More emphasis should be given in understanding the extent and reasons of dental anxiety and how it relates to poor oral health.These can provide important information regarding patients attitude toward different dental procedures and prevent adverse outcomes that may occur due to dental anxiety.

Also , the importance of training dentists in the management of dental anxiety, which could reduce the difficulties of delivering successful treatment can be assessed.

Compared to the Corah’s Dental scale which was a four question measure of dental anxiety, the scoring system for the MDAS is a much more simpler to evaluate

In addition to MDAS, the importance of psychological therapy or adjunctive anxiolytic medications can be used as good interventions. Behavioral intervention , systemic desensitization , cognitive therapy , video representaions , visual analogue scales or hypnosis can be adapted as additional techniques for conditioning patients with dental anxiety.

LITERATURE REVIEW Several samples from UK, Scotland ,Wales ,Ireland , Finland , Dubai, Brazil, and Turkey showed the MDAS to be reliable and valid.

Some of the other significant findings from other studies are as follows;

1) Testing the reliability and validity of the dental anxiety scales;The reliability and validity of the Dental Anxiety Scale DAS and the prevalence and the effect of socio-demographic characteristics on dental anxiety was estimated in a sample of 212 adults by Juliane Alvares Duarte Bonini Campos et al(2)

A total of 47.6% of the participants (CI 95% = 40.9 - 54.4) presented low levels of anxiety, 32.5% (CI 95% = 26.2 - 38.9) moderate levels, and 12.3% (CI 95% = 7.8 - 16.7) exacerbated levels. The convergent validity (AVE > 0.50 and CR > 0.70), and the internal consistency (α > 0.70) for DAS.

2) Study checking the dental anxiety prevalance.This study conducted by Sana Hawamdeh, Manal Awad (5) aimed to estimate the prevalence of dental anxiety and examine the socio-demographic associations of dental anxiety among a representative sample of UAE college populations .Students who visited their dentist more than two years ago had significantly higher MDAS scores compared with those who visited their dentist less than two years ago (t-test, P=0.02).

3) Studies conducted on anxiety levels based on sex and age differences:These are results are also taken from the same study (5) that was conducted by Sana Hawamdeh, Manal Awad Participants’ responses on the five-item MDAS indicated that there were no significant sex differences and that the highest MDAS scores for both males and females were for local injection anxiety [mean = 2.85 (SD: 1.47) and 2.98 (SD: 1.35)].

Additional Visual Analogue Scale

REFERENCES1. Astrom, A. N., Skaret, E., & Haugejorden, O. (2011). Dental anxiety and dental attendance among 25-year-olds in norway: Time trends from 1997 to 2007. BMC Oral Health, 11, 10-6831-11-10.2. Campos, Juliana Alvares Duarte Bonini, Presoto, C. D., Martins, C. S., Domingos, Patrícia Aleixo dos Santos, & Maroco, J. (2013). Dental anxiety: Prevalence and evaluation of psychometric properties of a scale.3. Court, H., Greenland, K., & Margrain, T. H. (2010). Measuring patient anxiety in primary care: Rasch analysis of the 6‐item spielberger state anxiety scale. Value in Health, 13(6), 813-819.4. Eitner, S., Wichmann, M., Paulsen, A., & Holst, S. (2006). Dental anxiety–an epidemiological study on its clinical correlation and effects on oral health. Journal of Oral Rehabilitation, 33(8), 588-593.5. Hawamdeh, S., & Awad , M. (2013). Dental anxiety: Prevalence and associated factors. European Journal of General Dentistry, 2(3), 270.6. Humphris, G., Freeman, R., Campbell, J., Tuutti, H., & D'souza, V. (2000). Further evidence for the reliability and validity of the modified dental anxiety scale. International Dental Journal, 50(6), 367-370.7. Kvale, G., Berggren, U., & Milgrom, P. (2004). Dental fear in adults: A meta‐analysis of behavioral interventions. Community Dentistry and Oral Epidemiology, 32(4), 250-264.8. Locker, D., & Liddell, A. (1995). Stability of dental anxiety scale scores: A longitudinal study of older adults. Community Dentistry and Oral Epidemiology, 23(5), 259-261.9. West Indian med. j. vol.59 no.5 Mona Oct. 2010 DENTAL FORUM Dental anxiety in a sample of West Indian adults. Ansiedad dental en una muestra de adultos de West Indies.RS Naidu; S Lalwah School of Dentistry, Faculty of Medical Sciences, The University of the West Indies, Trinidad and Tobag

Cut off Scores for different Anxiety Scales

Scoring for MDAS, taken from Humphris, G. et al. (2000)

MDAS Not

anxious

%

Fairly

anxious

%

Very

anxious

%

Extremely

anxious

%

If you went to the dentist tomorrow, how

would you feel?

When you're waiting, in the dentist's waiting

room, how do you feel?

If you were about to have a tooth drilled, how

do you feel?

You are in the dental chair. While you're

waiting for the dentist to get the instruments

to scrape your teeth (near the gum), how do

you feel?

If you were about to have a local anesthetic

injection to your gum, how do you feel?

If you were about to have an extraction (have

your teeth pulled), how do you feel?

30

41

11

53

9

10

15

17

14

11

14

20

13

16

26

7

21

24

12

5

22

2

32

28

PATIENTS FUFILLING THE REQUIRED

ELIGIBILITY CRITERIA

CONTROL Group (n=200)

Patients attending routine dental

checkup

Receive only informed consent and

no MDAS questionnaire prior to

dental treatment

Patients lost to follow up excluded

After 6 months

Followed up at the end of one year.

INTERVENTION Group (n=200)

Patients attending routine dental

checkup

Receive both informed consent and

MDAS questionnaire prior to dental

treatment

(MDAS Scores assessed)

Patients lost to follow up excluded

Scores assessed for dental anxiety by

the dentist in charge

A

L

L

O

C

A

T

I

O

N

I

N

T

E

R

V

E

N

T

I

O

N

A

N

A

L

Y

S

I

S

After 1 month

MDAS questionnaire given and assessed for

dental anxiety by the dentist in charge

Followed up at the end of one year.

Patients who completed trial, scores are

assessed for dental anxiety by the patients.Patients who completed trial, MDAS

questionnaire given and scores are assessed

for dental anxiety by the patients.

STUDY DESIGN