Introduction
Dental anxiety is highly prevalent in Western societies and remains a public health concern that poses a significant challenge to oral health care. The impact of dental anxiety is far-reaching, affecting large numbers of people across a wide demographic spectrum, from young children to the elderly. Given the magnitude of the problem, it is necessary for oral health professionals to have a comprehensive understanding of the prevalence of dental anxiety and the factors that may exacerbate it. The ability to understand the prevalence of different levels of dental anxiety is an essential component in enabling oral health professionals to tailor their approach, resulting in more accessible and less traumatic dental care for each patient.
According to Jöhren and Margraf-Stiksrud (2012), dental anxiety encompasses all psychological and physiological manifestations of varying but non-pathological fear of dental treatment or related stimuli (Jöhren & Margraf-Stiksrud 2012). Dental phobia, on the other hand, is a pathological condition characterised by active avoidance of dental treatment. In addition, phobic patients generally show increased anxiety towards dentists, have more frequent traumatic experiences, and have a heightened fear of needles and injections in particular (Enkling et al. 2006). Both groups - dental anxiety and dental phobia - are common in dental clinics. Their anxious behaviour has a significant impact on the dentists treating them, consuming more treatment time and potentially complicating treatment procedures, leading to distressing experiences for both patient and practitioner (Armfield & Heaton 2013).
In particular, patients who avoid dental appointments for long periods of time, even when experiencing significant dental pain, may have serious dental problems requiring complex and challenging treatments (Armfield & Heaton 2013). The act of avoiding scheduled appointments is a clear indicator of dental anxiety, as seen in 82% of self-identified highly anxious patients (Lenk et al. 2013). A study by McGrath & Bedi found that 73% of participants felt that their quality of life was affected by their avoidance behaviour and the resulting dental problems (Beaton et al. 2014). In addition, non-anxious patients typically have 1 to 2 teeth in need of treatment, while those with dental phobia have an average of 8 to 9 teeth affected (Wannemueller et al. 2011). Those with dental phobia fear tooth extraction more than restorations and often have more missing teeth than conservatively treated teeth (Armfield et al. 2009).
With a prevalence of 60-80% demonstrating some form of fear or concern about dental treatment, encountering a patient with dental anxiety in a routine dental practice is not an outlier (de Jongh & ter Horst 1993, Enkling et al. 2006). However, the prevalence of dental anxiety varies in different populations. A recent systematic review of global studies reported an overall prevalence of dental fear and anxiety in adults of 15.3%, with higher prevalence in women and younger adults (Silveira et al. 2021). In a representative sample of adults in Gothenburg, Sweden, the prevalence of high dental anxiety was 6.7% as measured by the Fear Scale (FS) and 5.4% as measured by the Corah Dental Anxiety Scale (DAS) (Hakeberg et al. 1992). Furthermore, in a study of dental patients in private dental practices, the prevalence of moderate to high dental anxiety was 19% (White et al. 2017). Finally, in a systematic review of studies worldwide, the overall pooled prevalence of dental anxiety in children and adolescents was 23.9% (Grisolia et al. 2021).
Recent research on the prevalence of dental anxiety includes additional studies around the world, each aimed at understanding the prevalence of dental anxiety in their respective regions. The prevalence of dental anxiety varies in different populations. A study comparing dental anxiety between men and women found that the overall prevalence of dental anxiety was 18%, with women having a higher prevalence of 22.9% compared to men at 13.1% (Dadalti et al. 2021). Among school children, the prevalence of dental fear and anxiety was found to be 50.4% in boys and 71.28% in girls (Dadalti et al. 2021). A study of orthodontic patients found that 65% had moderate anxiety, 25% had mild anxiety and 9% had severe to extreme anxiety. (Acharya et al. 2021). The prevalence of dental anxiety in the New Zealand adult population was reported to be 13.3% (Sukumaran et al. 2020). These findings highlight the importance of addressing dental anxiety in different age groups and populations to improve oral health outcomes.
Despite this large amount of data from several countries, it remains difficult to obtain a consistent global picture due to the variability in the methods used, the populations studied and the definitions of dental anxiety. To date, there hasn't been a comprehensive study of the prevalence of dental anxiety in the Swiss population. This lack of data has made it difficult to develop individually tailored interventions and has hindered the ability to compare the Swiss prevalence of dental anxiety with global trends.
Therefore, the main aim of this study was to determine the prevalence of different levels of dental anxiety in Switzerland. Using national surveys conducted by the Swiss Dental Association (SSO), the aim was to collect information on the level of dental anxiety in two representative samples of the Swiss population in 2010 and 2017. In addition, these statistics were to be related to both demographic and socio-economic factors in order to identify patterns of dental anxiety in Switzerland. These findings may provide a basis for future targeted interventions in Switzerland to improve access to dental care, particularly for people with dental anxiety.
Materials and methods
The Swiss Dental Association (SSO) conducted surveys with standardised questions approximately every ten years since 1980. Since 2010, these questionnaires were augmented with additional questions on the general perception of the dental profession by the Swiss population. These allowed a deeper understanding of factors such as trust in the dentist, image of the profession, dental anxiety, the subjective condition of one's own teeth and the reasons for visiting the dentist.
In both 2010 and 2017, the survey was commissioned by the Swiss Dental Association (SSO) and carried out by a professional market research company. Stratified sampling was used to facilitate comparisons between the three main language regions of Switzerland. The survey questionnaire covered topics related to the use of dental services, individual perceptions and dental anxiety, and was available in German, French and Italian.
Selection of participants
Participants were selected on a quota basis, taking into account factors such as language region, type of residence (urban or rural), age and gender. Participants were selected on the basis of demographic criteria such as age, gender, language region, urban or rural residence, and educational and occupational status. This ensured a representative sample of the Swiss population. Prior to the survey, the questionnaires were tested and validated for clarity in the three main Swiss languages (German, French and Italian) under laboratory conditions. In Switzerland, conducting a survey using a questionnaire does not require approval from the Ethics Commission. The surveys followed the guidelines of the ESOMAR Codex of Opinion Polls and the principles of the Association of Swiss Market and Social Research (VSMS-ASMS).
Interviews with participants
Specific questions were discussed and answered in interviews lasting approximately 45 minutes. These interviews were conducted in the participants' homes by professional interviewers. Data were collected simultaneously and digitally using portable computers, following the CAPI (Computer-Assisted Personal Interviewing) method. A total of 1129 questionnaires were analysed in 2010 and 1111 in 2017.
All participants were asked the single-item dental fear question "Are you afraid of going to the dentist?" with possible responses ranging from 1 to 4, i.e. "not at all", "a little", "quite a lot", or "very much". This item has previously been shown to be reliable and valid and has been used in several other national studies of dental anxiety (Neverlien 1990, Neverlien & Backer Johnsen 1991). Dental satisfaction was assessed by the question "Are you generally satisfied with your dentist?" with possible responses of "Not satisfied", "Less satisfied", "Satisfied" and "Very satisfied". In addition, trust in the dentist was assessed by the question "Do you trust your dentist?" with possible responses of "Very little trust", "Little trust", "A lot of trust" and "Very much trust", while self-reported oral health status was assessed by the question "What is your current oral health status?" with possible responses of "Poor", "Fair", "Good" and "Very good". Finally, the importance of appearance was assessed by asking "How important is your appearance to you?" with possible responses of "not important", "not very important", "important" and "very important".
Statistical analysis
Statistical analyses were performed using RStudio (version 2023.06.1, R Core Team [2023]. R Core Team (2023). R: A Language and Environment for Statistical Computing. R Foundation for Statistical Computing, Vienna, Austria. <https://www.R-project.org/>).
Descriptive statistics were generated to provide counts, frequencies, means and standard deviations for the two survey years 2010 and 2017. Differences between these years were assessed using Pearson's chi-squared test of independence for categorical variables and the Welch two-sample t-test for continuous variables. For non-parametric data, the Wilcoxon Mann-Whitney U test was used, and the effect size r of the difference was quantified. To further investigate differences in satisfaction with the dentist between the two years, a Bayesian statistical approach was applied using the JAGS (Just Another Gibbs Sampler) software through the RJAGS package in R.
Individual anxiety group and cumulative percentage prevalences of dental anxiety were calculated. To increase the accuracy and reliability of these prevalence estimates, the Wilson score confidence interval for a proportion was included. A logistic regression analysis was performed to examine the relationship between different predictors and dental anxiety. The dependent variable chosen was "dental anxiety", characterised by levels of anxiety categorised as "quite a lot" and "severe". For model optimisation, both Nagelkerke’s and McFadden’s pseudo R-squares were evaluated to determine the most explanatory model. The magnitude of gender differences in anxiety levels was quantified using Cramer's V for both survey years. Cochran-Armitage trends were calculated to identify potential relationships between levels of anxiety and socio-economic variables. The significance level was set at p=0.05.
Results
A total of 2240 individuals were surveyed, 1129 in 2010 and 1111 in 2017. Table 1 provides a demographic overview of the participants in the two surveys. The overall gender distribution was almost equal in both surveys, with 49.7% male and 50.3% female (p = 0.7656). The mean age for the entire cohort was 43.5 (±16.0) years with no statistically significant difference between both surveys (p = 0.2882). The majority of participants in both years spoke German (63.7%), followed by French (27.2%) and Italian (9.1%). The language region was consistent in both surveys, with the majority originating from German-speaking Switzerland. There were no statistically significant differences in language, household size, and regional distribution between the two surveys. Differences in the type of agglomeration were observed between the two surveys. In particular, there was a statistically significant decrease in participants from rural communities in the 2017 survey compared to 2010 (p = 0.0029) (Table 1).
In terms of socio-economic variables, no noticeable shifts in educational levels were found between 2010 and 2017 (Table 2). However, professional activity and purchasing power classes differed in 2010 and 2017, reaching statistical significance (Table 2). While trust in the dentist and subjective oral health education didn't differ between the two surveys, a small increase in satisfaction with the dentist was found with a Bayesian estimated difference of DELTA = 0.07 (CI: 0.02 - 0.12). Although this increase reached a statistically significant difference (p = 0.0028), its effect size remained small at r = 0.0646 (Table 2).
Table 3 presents the prevalence of dental anxiety between the two surveys. In 2010, 21.3% (CI: 19.0-23.7) reported higher levels of anxiety (either “a quite a lot” or “very much”). Including mild anxiety (“a little”), a total of 49.3% (CI: 46.4-52.2) reported some level of anxiety. In 2017, dental anxiety appears to have decreased, with only 13.3% (CI: 11.4-15.4) reporting higher, and 41.9% (CI: 39.1-44.9) reporting some level of anxiety (Table 3). In 2010, 6.7% (CI: 5.3-8.3) of women had a very high level of anxiety and 29.0% (26.4-31.7) had some level of anxiety. In 2017, anxiety decreased among women, with only 4.8% (CI: 3.7-6.2) reporting very high levels of anxiety (Table 3). Among men in 2017, a total of 2.5% (CI: 1.7-3.6) reported very high levels of anxiety and 20.4% (CI: 18.1-22.8) reported some level of anxiety. In 2017, anxiety decreased among men, with only 1.9% (CI: 1.2-2.9) reporting very high levels of anxiety (Table 3).
In both years 2010 and 2017, the main triggers for dental anxiety included personal experiences of pain, fear of needles, concerns about high costs, and treatment received during primary school dental care (Fig. 1, A). Interestingly, while a small percentage of participants (2.1% in 2010 and 2.9% in 2017) abstained from seeking dental care, their primary reasons included financial constraints, anxiety, and the perceived complexity of the treatment plan (Fig. 1, B). Concerning the reasons for the last dental appointment, the primary motivations for most dental visits were general check-ups, followed by specific problems such as toothache (Fig. 2, C). Table 4 reveals the logistic regression analysis predicting higher levels of dental anxiety (“quite a lot” and “a lot”) based on confounding factors. Women reported to suffer more likely from dental anxiety than men, reaching statistical significance (p < 0.0001). On the other hand, higher levels of education (p < 0.0001), trust in the dentist (p = 0.0005), and satisfaction with the dentist (p = 0.0489) emerged as statistically significant predictors of less dental anxiety (Table 4). Further trends of the levels of anxiety and their predictors are presented in Figure 2. Across the two survey years, female participants consistently reported higher levels of dental anxiety than males, reaching statistical significance (2010: p < 0.0001, 2017: p = 0.0003) (Fig. 2, A). There was no observable trend in dental anxiety across age groups (Fig. 2, B). However, the data revealed statistically significant trends in both survey years with anxiety levels and the levels of satisfaction with their dentist (2010: p < 0.0000, 2017: p < 0.0000) (Fig. 2, C) and trust in the dentist (2010: p = 0.0014, 2017: p = 0.0005) (Fig. 2, D). Further trends were found between dental anxiety and education (2010: p = 0.0027, 2017: p = 0.4626), economic status (2010: p = 0.0019, 2017: p = 0.0342) and perceived oral health (2010: p < 0.0001, 2017: p < 0.0001) (Fig. 2, E-G).
>Discussion
The present study surveyed a total of 2240 participants in 2010 and 2017 to examine the trends and predictors of dental anxiety in the Swiss population. Demographically balanced, the study revealed a significant decrease in dental anxiety from 2010 to 2017. However, no factors were found to be associated with this decrease. Dental anxiety remained higher among women. The main reasons for anxiety in both genders were identified as personal experience of pain, fear of needles, concerns about high costs, and negative experiences during primary school dental care. The study highlighted the importance of trust in the dentist, satisfaction with the dentist, and higher education as protective factors against dental anxiety. Interestingly, no significant trends were observed across different age groups. Lower levels of dental anxiety were found to correlate with higher levels of education, economic status, and perceived oral health. These findings may have important implications for understanding and treating dental anxiety. They could help formulate effective strategies to reduce anxiety and improve dental care uptake, particularly in high-risk groups.
Comparable anxiety levels found in the present study underscore the universal nature of dental anxiety across different societies and cultures. Our findings of 21.3% in 2010 and 13.3% in 2017 resonate with research conducted on adults worldwide, where “quite a lot” and “very much” dental anxiety was recently estimated at 15. 3% (Silveira et al. 2021), and in the New Zealand adult population with a prevalence of 13.3% (Sukumaran et al. 2020). However, our study goes beyond mere reporting of prevalence rates by tracing a marked decrease in dental anxiety in the Swiss population between 2010 and 2017. Despite significant changes in the dental profession and increasing knowledge about the effects of dental anxiety, Armfield (2010) reported that the level of dental anxiety hasn't decreased significantly in recent decades (Armfield 2010). However, the marked decrease in dental anxiety in the present study, characterized as “quite a lot” and “very much”, from 21.3% in 2010 to 13.3% in 2017, presents a compelling aspect. The majority of studies, including those cited above, typically represent a cross-sectional view of dental anxiety prevalence at a specific point in time. Consequently, the present study has shed light on a critical, yet under-explored, dimension of dental anxiety including its evolution over time. It is worth noting that despite the observed decrease in dental anxiety from 2010 to 2017, the underlying causal factors for this decrease remain elusive. The multifactorial nature of dental anxiety suggests the possibility of various interacting reasons, but our comprehensive analysis did not yield any conclusive determinants for the observed decrease. This lack of identifiable causes emphasises the complexity of dental anxiety as a psychosocial phenomenon and underlines the need for further longitudinal research to elucidate the complexities of its evolution over time.
Gender
The differences in dental anxiety levels between men and women in the present study reflect the global trend. It corroborates the findings of the above and other studies which have consistently reported higher levels of dental anxiety in women (Silveira et al. 2021, Sukumaran et al. 2020). Similarly, this study shows a higher prevalence of dental anxiety in women (8.6%) compared to men (4.8%). In comparison, Dadalti and co-workers (2021) found that women had a higher prevalence of 22.9% compared to men at 13.1% (Dadalti et al. 2021). Our study thereby further highlights the persistent gender differences in dental anxiety and the need for future gender-specific intervention strategies.
Age
As pointed out by previous studies, the role of age as a determinant of dental anxiety, as demonstrated by various studies, represents an interesting dimension for analysis (Cianetti et al. 2017, Enkling et al. 2006). As recently seen in a longitudinal study in China, the prevalence of dental anxiety among children aged 5-12 years was reported to be 11.59%, with age as a significant determinant (Gao et al. 2021). This age-related variation in dental anxiety highlights the potential influence of developmental aspects, such as cognitive and emotional maturity, on how dental anxiety is experienced and managed.
In addition, the high prevalence and significant health impact of dental anxiety compared to other specific anxieties and phobias highlights the critical need for more research in this area (Armfield 2008). Given its prevalence and impact on health outcomes, dental anxiety warrants attention not only from a dental health perspective, but also from a broader public health and psychological perspective.
Looking more closely at different age groups, a longitudinal study of young adults in New Zealand found an annualised incidence rate of dental anxiety of 2.1% over an eight-year period (Thomson et al. 2000). In the United Kingdom, a high prevalence of dental anxiety of 11.2% was observed among university students (Humphris & King 2011). This suggests that the transition to adulthood doesn't necessarily reduce dental anxiety, highlighting the need for ongoing interventions throughout adolescence and early adulthood.
Interestingly, however, unlike these studies, the present study did not find a significant effect of age on dental anxiety. This discrepancy may be due to various factors, such as cultural, societal, or methodological differences, and warrants further investigation. It highlights the complex, multi-factorial nature of dental anxiety and emphasises the need for a more nuanced understanding of the age-related dynamics at play. This may involve exploring different age-related variables, such as life-stage-specific stressors, exposure to dental care, or societal attitudes towards dental health. The absence of age as a significant determinant in our study adds a valuable perspective to the existing literature and encourages further exploration of the multifaceted phenomenon of dental anxiety.
Education
The relationship between education and dental anxiety is multi-faceted, with varying results in different regions and populations. Our study found a statistically significant inverse relationship: higher levels of education correlated with lower levels of dental anxiety. This contrasts with a Pakistani study, which found that higher levels of education were associated with increased dental anxiety (Siraj et al. 2020), while a Caribbean study found no significant effect of education on dental anxiety (Reid et al. 2020).
The contextual nature of this relationship becomes clear when specific educational settings are examined. A Saudi Arabian study found that dental students had the lowest levels of dental anxiety compared to medical and nursing students (Al Jasser et al. 2019), suggesting that specific educational exposure may influence dental anxiety. Socio-economic factors, including education, play an important role in dental anxiety. Lower levels of education, unemployment or financial dependency are associated with higher levels of dental anxiety (Appukuttan et al. 2015). The impact of these interrelated factors highlights the need for a comprehensive, multidisciplinary approach drawing on health education, health economics and psychology to effectively address dental anxiety. The impact of dental anxiety goes beyond personal discomfort and often leads to avoidance of dental care and consequent deterioration in oral health (Armfield et al. 2007, De Jongh et al. 2011). This highlights the critical need for targeted educational programmes as part of strategies to manage dental anxiety and improve oral health outcomes. The results of our study add an important perspective to the literature and highlight the potential role of education in addressing dental anxiety and its wider implications for dental health and well-being.
Strengths of the study
The present study has several strengths that contribute to the understanding of dental anxiety in the Swiss population. First, the large sample size of 2240 participants, representative of the demographic and socioeconomic distribution of the Swiss population, increases the generalisability of the findings. The use of stratified sampling to ensure representation from the three main linguistic regions of Switzerland further strengthens the external validity of the study. Second, the longitudinal design of the study, with data collected in 2010 and 2017, allows for the examination of trends over time. This is a major advantage over cross-sectional studies, as it provides insights into the evolution of dental anxiety in the population. The ability to track changes in dental anxiety over seven years provides a more dynamic understanding of the observations. Thirdly, the use of validated and reliable measures to assess dental anxiety, trust in the dentist, satisfaction with the dentist, and self-reported oral health status ensures the accuracy and consistency of the data collected. The use of the single-item dental fear question, which has been validated in previous studies, further strengthens the reliability of the findings. Finally, the extensive statistical analysis, including logistic regression and trend analysis, allows a robust examination of the relationships between different predictors and dental anxiety.
Limitations of the study
Despite its strengths, the study has several limitations that should be taken into account when interpreting the results. First, the study relies on self-reported measures, which are subject to response bias. Participants may under-report their level of dental anxiety due to social desirability bias or over-report due to recall bias. This could potentially lead to an underestimation or overestimation of the prevalence of dental anxiety. Moreover, the study does not take into account potential confounding variables that could influence dental anxiety. Factors such as previous traumatic dental experiences, general anxiety disorder or other psychological conditions could potentially influence levels of dental anxiety, and these were not controlled for in the study. Thirdly, the cross-sectional design of the study allows for the examination of trends over time but does not allow for the establishment of causal relationships. The observed associations between dental anxiety and factors such as trust in the dentist, satisfaction with the dentist and level of education are correlational and do not necessarily imply causality. Finally, the focus of the study on the Swiss population may limit the generalisability of the findings to other cultural or geographical contexts. Cultural factors may significantly influence perceptions of dental care and levels of dental anxiety, and these were not examined in the present study.
Conclusion
In conclusion, this study provides evidence of an overall decrease in dental anxiety in the Swiss population from 2010 to 2017. The results indicate that higher levels of education, satisfaction with dental services and trust in the dental profession are significantly correlated with lower levels of dental anxiety. However, women consistently reported higher levels of anxiety than men in both survey years. Overall, this study reveals an encouraging trend towards improving perceptions of the dental profession in Switzerland. It underscores the importance of fostering trust and satisfaction in dental care relationships to tackle dental anxiety and thus make a positive contribution to public oral health.