175175 Dental Journal (Majalah Kedokteran Gigi) 2020 December; 53(4): 175–180 Research Report The relationship between dental fear, anxiety and sociodemography in Jakarta, Indonesia Lisa Prihastari,1 Rima Ardhani Iswara,1 Ghina Al Afiani,1 Fajar Ramadhan,1 Mega Octaviani,1 Willy Anugerah Hidayat,1 Muhammad Al Faqih1 and Ahmad Ronal2 1Department of Preventive and Dental Public Health, 2Department of Oral Medicine, Faculty of Dentistry, Universitas YARSI, Jakarta – Indonesia ABSTRACT Background: The anxiety associated with dental visits is one of the obstacles preventing dentists from improving oral health and is also a significant predictor of dental visit evasion, which is frequently observed in Indonesia. Purpose: To identify the level of dental fear and anxiety in the population of Jakarta, Indonesia and establish the relationship with sociodemographic factors. Methods: A cross-sectional method was used with a sample size of 1811 respondents aged 17–65 years old who were asked to complete the validated Indonesian versions of modified dental anxiety scale (MDAS) and dental fear scale (DFS) questionnaires. The data obtained was then analysed using nonparametric and chi-square tests. Results: The prevalence of subjects with moderate to high dental anxiety and fear was 16.3% (295 respondents) and 36.1% (654 respondents), respectively. The primary sources of dental fear and anxiety were dental drilling and anaesthesia before tooth extraction. The results of the nonparametric and chi-square tests show that both are significantly related to gender, age, educational status, income level, insurance and history of dental visits (p = < 0.05). Conclusion: Several sociodemographic factors are associated with dental fears and anxiety among the participants in Jakarta, Indonesia. Keywords: Dentist visit; dental fear and anxiety; sociodemography; Indonesia Correspondence: Lisa Prihastari, Department of Preventive and Dental Public Health, Faculty of Dentistry, Universitas YARSI, Kav. 13, Jl. Letjend Suprapto, Jakarta, 10510, Indonesia, lisa.prihastari@yarsi.ac.id INTRODUCTION The fear of dental care is a major obstacle to preventing problems related to dental and oral health, which are known to interfere with daily activities. Dental fear is a challenge for dentists because it complicates medical procedures and leads to irregular dental visits (and ultimately poor oral health).1–4 This type of fear, which can be defined as an emotional response to a threat or danger involving dental treatment, is a common phenomenon in dentistry.5,6 In Indonesia, a survey on dental fear and anxiety measured the prevalence of anxiety towards certain dental treatments: tooth extraction, dental fillings and oral hygiene; the results showed that around 20–30% of subjects felt fear and anxiety towards the treatments. There is limited data on the common causes of dental fear and anxiety in Indonesian society. However, research in other countries reports that the frequency of dental anxiety ranged from 5% to 20% and was higher in females.7,8 Furthermore, the prevalence of dental anxiety among children ranged from 6% to 20%, and in adolescents, this increased to 11%.6 The prevalence of dental anxiety varies from 4% to 30%.9 The percentage of dental care utilisation in Jakarta province is only 16.4%;10 therefore, it can be concluded that while Jakarta is the province with the fastest rate of progress and development in Indonesia, residents are less likely to participate in dental health care. The low number of dental visits or avoidance of dental treatment may both be a result of dental anxiety and fear. Several instruments have been developed to measure anxiety and fear related to dental care. One of the most common instruments is the dental anxiety scale (DAS). The DAS is widely used and has been updated by Dailey et al.11 to the modified dental anxiety scale (MDAS), which is more Dental Journal (Majalah Kedokteran Gigi) p-ISSN: 1978-3728; e-ISSN: 2442-9740. Accredited No. 32a/E/KPT/2017. Open access under CC-BY-SA license. Available at http://e-journal.unair.ac.id/index.php/MKG DOI: 10.20473/j.djmkg.v53.i4.p175–180 mailto:lisa.prihastari@yarsi.ac.id http://e-journal.unair.ac.id/index.php/MKG http://dx.doi.org/10.20473/j.djmkg.v53.i4.p175-180 176 Prihastari et al./Dent. J. (Majalah Kedokteran Gigi) 2020 December; 53(4): 175–180 concise and is both valid and reliable.6 It consists of five questions, with each question offering responses ranging from 1 to 5 (‘not anxious’ to ‘very anxious’, respectively). The minimum total score was 5 and the maximum was 25; 19 and above indicated high dental anxiety, which may require special attention from the dentist.12 The Kleinknecht’s Dental Fear Scale is the second most frequently used instrument, and it focuses on specific situations and procedures.13 The updated version contains 20 questions rated on a five-point scale where 1 is ‘no fear’ and five means ‘extreme fear’; hence, the total scores ranged from 20 to 100.14 The purpose of this study is to provide data on the prevalence of fear and anxiety levels associated with dental care in Indonesia – especially in the province of Jakarta – and identify the main causes of these and their relationship with sociodemography using the MDAS and DFS. Data on the prevalence of dental fear and anxiety is critical for Indonesian dentists and governments in order to see how much this will affect dental care and how to address this phenomenon. MATERIALS AND METHODS This study used an analytic cross-sectional design to determine the relationship between sociodemographic factors and the fear and anxiety levels towards dental care. The population included 17–65-year-old residents from the Thousand Islands and regions in the Jakarta province (Central, East, West, North and South Jakarta). The study was conducted from September to November 2017 following the review and approval of the research ethics protocol by the YARSI University Ethics Commission (certificate number 316/KEP-UY/BIA/XI/2017). The participants signed informed consent, and multistage cluster sampling was used: the sample was taken randomly up to the district level and in accordance with the proportion of the population of Jakarta with a total of 1811 respondents. The procedure was conducted by requesting permission from the relevant agencies and testing the validity and reliability of the MDAS and DFS questionnaires (0.844 and 0.935, respectively) using Cronbach alpha and a p value of < 0.05. The calculated r value is greater than r table for all question items from the two questionnaires using the Pearson product moment correlation test. The DFS and MDAS scoring, which initially consisted of a five-point scale, was converted into two-point scale for analysis in logistic regression. The scores in MDAS are divided as follows: 0–5 for not anxious, 6–10 for somewhat anxious, 11–14 for moderately anxious, 15–18 for highly anxious and 19–25 for extremely anxious. For DFS, the scores are divided as ≥ 60 for high dental fear, 34–59 for moderate fear, 21–33 for low fear and scores < 20 for no fear. The surveys were first calibrated by six interviewers then administered by researchers and extended for approximately two months. Furthermore, each respondent was asked to provide sociodemographic data consisting of age, region, sex, education level, income, questions related to health insurance and history of dental visits. The Indonesian versions of the DFS and MDAS were made available. The subjects’ ages were classified into 17–25, 26–35, 36–45, 46–55 and 56–65, and education level was divided into basic (elementary–junior high school), secondary (high school) and higher (higher education/university). Income level was categorised into non-income and income below and above the Jakarta UMR (regional minimum wage).15 The data obtained was analysed using SPSS software with a nonparametric test to compare the medians because the data did not have a normal distribution or chi-square values for proportions and binary logistic regression. RESULTS Based on sociodemographic status, the frequency distribution of research respondents is shown in Table 1. The data in Table 1 shows a gender variable characterised by 1012 male respondents (55.9%) and 799 female respondents (44.1%). In the age variable, the largest proportion was in the group of 17–25-year-olds (818 respondents, 45.2%) while the smallest was 37 respondents (2%) in the 56–65 age group. Table 1. Sociodemographic status of research subjects Variable N % Gender Male Female 1012 799 55.9 44.1 Region North Jakarta Central Jakarta East Jakarta West Jakarta South Jakarta Thousand Islands 300 201 414 404 382 110 16.6 11.1 22.9 22.3 21.1 6.1 Age of subject 17–25 years old 26–35 years old 36–45 years old 46–55 years old 56–65 years old 818 491 273 190 37 45.2 27.1 15.1 10.5 2.0 Level of Education Higher Education Secondary Education Basic Education 508 921 381 28.1 50.9 21.0 Income No income < Minimum wage ≥ Minimum wage 479 433 899 26.4 23.9 49.6 Insurance Yes No 1251 560 69.1 30.9 Ever been to dentist Yes No 1370 441 75.6 24.4 Total 1811 100.0 Dental Journal (Majalah Kedokteran Gigi) p-ISSN: 1978-3728; e-ISSN: 2442-9740. Accredited No. 32a/E/KPT/2017. Open access under CC-BY-SA license. Available at http://e-journal.unair.ac.id/index.php/MKG DOI: 10.20473/j.djmkg.v53.i4.p175–180 http://e-journal.unair.ac.id/index.php/MKG http://dx.doi.org/10.20473/j.djmkg.v53.i4.p175-180 177Prihastari et al./Dent. J. (Majalah Kedokteran Gigi) 2020 December; 53(4): 175–180 Table 2. Frequency of sources of fear in DFS questionnaire items Questions No Fear Some Fear Moderate Fear High Fear Extreme Fear Total The source of fear during treatment Promise to visit the dentist 1137 (62.8%) 519 (28.7%) 110 (6.1%) 24 (1.3%) 21 (1.2%) 1811 (100%) Approach the dentist’s clinic 1310 (72.3%) 391 (21.6%) 82 (4.5%) 19 (1.0%) 9 (0.5%) 1811 (100%) Sit in the dentist’s waiting room 1140 (62.9%) 526 (29.0) 112 (6.2%) 21 (1.2%) 12 (0.7%) 1811 (100%) Sitting in the dental care chair 898 (55.7%) 671 (37.1%) 184 (10.2%) 42 (2.3%) 16 (0.9%) 1811 (100%) Smell of the dental clinic 1307 (72.2%) 365 (20.2%) 96 (5.3%) 31 (1.7%) 12 (0.7%) 1811 (100%) Seeing the dentist enter the room 1133 (62.6%) 509 (28.1%) 132 (7.3%) 23 (1.3%) 14 (0.8%) 1811 (100%) The sight of syringe for anaesthesia 579 (32.0%) 667 (36.8%) 372 (20.5%) 113 (6.2%) 80 (4.4%) 1811 (100%) The feeling of injected syringe 554 (30.6%) 744 (41.1%) 309 (17.1%) 127 (7.0%) 77 (4.3%) 1811 (100%) Seeing the dental drill 623 (34.4%) 655 (36.2%) 347 (19.2%) 100 (5.5%) 86 (4.7%) 1811 (100%) The sound of the dental drill 636 (35.1%) 688 (38.0%) 321 (17.7%) 89 (4.9%) 77 (4.3%) 1811 (100%) The vibration of the dental drill 565 (31.2%) 714 (39.4%) 347 (19.2%) 100 (5.5%) 85 (4.7%) 1811 (100%) After the teeth cleaning process 1287 (71.1%) 381 (21%) 94 (5.2%) 32 (1.8%) 17 (0.9%) 1811 (100%) Table 3. MDAS and DFS nonparametric test results based on sociodemographic status Variable MDAS Median (Mean±SD) p value DFS Median (Mean±SD) p value Gender Male 9.00(9.85±4.08) 0.0001* 30.00(33.13±12.06) 0.0001*Female 10.00(10.86±4.12) 33.00(35.42±12.24) Region North Jakarta 9.00(10.02±3.77) 0.0001* 30.00(32.28±10.74) 0.0001* Central Jakarta 9.00(9.55±4.03) 31.00(33.25±11.81) East Jakarta 10.00(10.92±4.13) 33.00(35.65±12.44) West Jakarta 10.00(10.49±4.54) 31.00(34.86±13.27) South Jakarta 9.00(9.83±3.88) 31.00(33.09±11.38) Thousand Islands 11.00(11.13±4.06) 33.50(36.04±13.08) Age of subject 17–25 years old 10.00(10.51±4.09) 0.0001* 32.00(34.93±12.18) 0.0001* 26–35 years old 10.00(10.34±4.18) 32.00(34.47±12.07) 36–45 years old 9.00(10.06±4.05) 30.00(32.98±11.83) 46–55 years old 9.00(9.86±4.335) 29.50(32.40±12.86) 56–65 years old 9.00(9.08±3.507) 25.00(30.00±11.19) Education Higher Education 9.00(9.68±4.06) 0.0001* 30.00(32.92±12.31) 0.0001*Secondary Education 10.00(10.36±4.00) 31.00(34.51±12.13) Basic Education 10.00(10.98±4.41) 33.00(34.90±12.08) Income No income 10.00(10.74±3.99) 0.0001* 32.00(34.96±12.17) 0.0001*< Minimum wage 10.00(11.11±4.66) 33.50(36.64±13.59) ≥ Minimum wage 9.00(9.67±3.88) 30.00(32.50±11.21) Insurance Yes 9.00(9.77±3.98) 0.0001* 31.00(33.48±11.77) 0.0001*No 10.00(10.98±4.37) 33.00(35.63±12.97) Ever been to dentist Yes 9.00(9.91±3.86) 0.0001* 30.00(33.07±11.17) 0.0001* No 11.00(11.50±4.68) 34.00(37.48±14.43) Dental Journal (Majalah Kedokteran Gigi) p-ISSN: 1978-3728; e-ISSN: 2442-9740. Accredited No. 32a/E/KPT/2017. Open access under CC-BY-SA license. Available at http://e-journal.unair.ac.id/index.php/MKG DOI: 10.20473/j.djmkg.v53.i4.p175–180 http://e-journal.unair.ac.id/index.php/MKG http://dx.doi.org/10.20473/j.djmkg.v53.i4.p175-180 178 Prihastari et al./Dent. J. (Majalah Kedokteran Gigi) 2020 December; 53(4): 175–180 The sociodemographic data for the education variable showed that the highest proportion had a high school education (921 respondents, 50.9%), while 381 (21%) had a basic education. Furthermore, 899 respondents (49.6%) received income above the minimum wage (minimum wage in Jakarta is rupiah 3,648,035), and a majority (1251, 69.1%) also had either government (BPJS) or private insurance. A total of 1370 respondents (75.6%) have been to the dentist, while the remaining 441 (24.4%) have not. In this study, the levels of dental anxiety in 1811 respondents were as follows: high-level anxiety in 216 respondents (11.9%), extreme anxiety in 79 respondents (4.4%), moderate anxiety in 461 respondents (25.5%), low anxiety in 842 respondents (46.5%) and no anxiety in 213 respondents (11.8%). Moreover, the DFS questionnaire (Table 2) attributed the main source of fear to the sight and sensation of dental drills and anaesthesia (questions 7–11). This was indicated by the Likert scale, with scores of 4 (high fear) and 5 (extreme fear). The percentages of dental fear Table 4. The MDAS and DFS chi-square test results based on sociodemographic status Variable Dental Anxiety (%) Dental Fear (%) Not Anxious Somewhat Anxious Moderately Anxious Highly Anxious Extremely Anxious p value No Fear Low Fear Extreme Fear p value Gender Male 14.7 47.6 23.5 10.5 3.7 0.0001* 67.8 24.5 7.7 0.001 Female 8.0 45.1 27.9 13.8 5.3 58.9 31.0 10.0 Region North Jakarta 10.7 49.0 27.7 10.35 2.3 0.0001* 69.0 24.0 7.0 0.088 Central Jakarta 16.9 48.8 20.4 10.4 3.5 67.7 25.9 6.5 East Jakarta 6.8 44.9 30.0 13.0 5.3 58.7 31.6 9.7 West Jakarta 15.1 43.8 21.0 13.6 6.4 62.9 26.0 11.1 South Jakarta 13.9 49.2 22.8 11.3 2.9 64.9 28.3 6.8 Thousand Islands 4.5 41.8 37.3 10.9 5.5 62.7 25.5 11.8 Age of subject 17–25 years old 8.8 46.7 28.2 11.5 4.8 0.0001* 60.3 30.6 9.2 0.024* 26–35 years old 11.6 46.4 25.3 11.6 5.1 64.0 28.3 7.7 36–45 years old 15.0 46.2 22.0 13.9 2.9 67.4 23.1 9.5 46–55 years old 18.4 45.3 20.5 12.1 3.7 71.6 19.5 8.9 56–65 years old 21.6 51.4 18.9 8.1 0.0 78.4 16.2 5.4 Education Higher 14.2 53.0 19.5 9.4 3.9 0.0001* 70.7 22.2 7.1 0.003*Secondary 11.2 44.7 28.1 12.6 3.4 62.1 28.2 9.7 Basic 10.0 42.3 27.0 13.4 7.3 59.3 32.0 8.7 Income No income 7.5 45.1 29.4 13.4 4.6 0.0001* 60.3 29.4 10.2 0.0001*< Minimum wage 11.5 38.6 27.0 15.7 7.2 55.0 33.0 12.0 ≥ Minimum wage 14.1 51.1 22.6 9.3 2.9 70.1 23.6 6.3 Insurance Yes 10.5 41.3 24.3 18.0 5.9 0.0001* 57.3 31.6 11.1 0.0001* No 12.3 48.8 26.0 9.2 3.7 66.8 25.5 7.7 Ever been to dentist Yes 9.3 37.9 27.4 16.6 8.8 0.0001* 53. 3 33.1 13.6 0.0001* No 12.6 49.3 24.8 10.4 2.9 67.3 25.5 7.2 *p = < 0.05: significant Table 5. Binary logistic regression analysis with DFS and MDAS Variable MDAS DFS p value Odds ratio p value Odds ratio Gender 0.05 0.631 0.0001* 0.660 Age 0.253 0.621 0.008* 0.646 Education 0.017* 0.543 0.169 0.843 Income 0.780 1.080 0.507 0.925 Insurance 0.138 1.428 0.001* 1.411 Ever been to dentist 0.0001* 2.854 0.0001* 1.756 *p = < 0.05: significant; Nagelkerke R2 DFS = 0.05; Nagelkerke R2 MDAS = 0.066 Dental Journal (Majalah Kedokteran Gigi) p-ISSN: 1978-3728; e-ISSN: 2442-9740. Accredited No. 32a/E/KPT/2017. Open access under CC-BY-SA license. Available at http://e-journal.unair.ac.id/index.php/MKG DOI: 10.20473/j.djmkg.v53.i4.p175–180 http://e-journal.unair.ac.id/index.php/MKG http://dx.doi.org/10.20473/j.djmkg.v53.i4.p175-180 179Prihastari et al./Dent. J. (Majalah Kedokteran Gigi) 2020 December; 53(4): 175–180 in this study were as follows: high fear in 76 participants (4.2%), moderate fear in 693 participants (38.3%), low fear in 872 participants (48.2%) and no fear in 170 participants (9.4%). Bivariate analysis was performed to establish a relationship between gender, region, age, education, income, insurance and history of dental visits (independent variables) and MDAS and DFS (dependent variables). This analysis involved the use of nonparametric tests (Table 2) and chi-square tests (Tables 3 and 4). Table 3 shows the nonparametric test results obtained using the Mann-Whitney/Kruskal-Wallis tests and indicates a significant difference in MDAS and DFS scores in terms of all the variables. MDAS and DFS scores were higher for females (10.00[10.86±4.12]; 33.00[35.42±12.24]) than males (9.00[9.85±4.08]; 30.00[33.13±12.06]), and the age group of 17–25-year-olds scored the highest (10.00[10.51±4.09]; 32.00[34.93±12.18]). The scores declined with the subsequent increase in age groups. Furthermore, the education variables show higher MDAS and DFS scores in participants with lower levels of education (10.00[10.98±4.41]; 33.00[34.90±12.08]) and in those with no or low income below the minimum wage (10.00[10.74±3.99]; 33.50[36.64±13.59]). Individuals without insurance and those who had never visited a dentist indicated a higher level of fear and anxiety (11.00[11.50±4.68]; 34.00[37.48±14.43]). The chi-square test results in Table 4 showed significant differences in the gender variables: females had a higher proportion of moderate to extreme anxiety and fear towards dental care compared to males. This phenomenon is also higher among the age groups of 17–45-year-olds compared to individuals between 46 and 65 years old. This study also identified differences based on education level, income, insurance and history of dental visits. DISCUSSION Sociodemographic factors (gender, age, education, etc.) play a role in determining an individual’s fear and anxiety towards dental care.16 The gender variable in this study based on bivariate nonparametric and chi-square analysis of the MDAS and DFS scores had a p value of < 0.05, indicating the presence of statistically significant differences, with a higher mean score for females than males (Tables 4 and 5). This outcome was congruent with the studies conducted by Saatchi et al.14 and Fayad et al.7. Furthermore, physiological conditions in the nature of phobias, panic, stress, depression and fear are also more common in females; hence, there is a possibility that dental anxiety is related to these. Age is one of the factors commonly reported in various studies; although this study reported a significantly higher level of dental fear and anxiety in adolescents than in adults, this contradicts previous studies that found increased dental anxiety in adults 31–35 years of age and which decreased after 60+ years.8 Do Nascimento et al.17 found that the highest scores (found in the age group of 30–39- year-olds) were a result of the relationship between age, an individual’s experiences and views and their maturity level.18 This assumption is supported by the research conducted by Fayad et al.7 This study demonstrates that a person’s educational status (primary, secondary or higher) affects the level of fear and anxiety because of the significant differences based on the nonparametric and chi-square tests; the results of this study indicate that the higher a person’s education, the lower the level of dental fear and anxiety. These findings are consistent with other studies that associated a higher level of education to reduced anxiety related to dental care.7,17 An individual with a higher level of education is more likely to maintain better oral health and visit the dentist more frequently.8 This finding is contrary to other studies that reject the assumptions that stipulate the presence of a relationship.7,14 An assessment of the socioeconomic factors related to fear and anxiety towards dental care shows less fear among individuals with higher socioeconomic status. This is congruent with a study conducted by Armfield et al.18 in Australia, although other studies showed different results.17 The ability to pay for dental care or affiliated insurance premiums is directly related to an individuals’ job status, income and wealth.19 The results obtained from the bivariate analysis with nonparametric tests between MDAS and DFS scores with the coverage value showed a p value of < 0.05, which indicates a statistically significant difference between anxiety and fear between people who have insurance and those who do not; this may be because insurance can lower cost-related stress related to dental treatment. However, there are several types of insurance that have limited coverage, especially in terms of some dental procedures, so this can cause concern. There is a need for a broader level of insurance for someone with a higher level of fear, followed by a demand for more care needs. This study provides the same results as previous studies that reported a relationship between dental fear and individuals who have private insurance.18 The regularity of dental visits is considered another important contributor to fear and anxiety for dental care. In this study, the results of the bivariate analysis using nonparametric tests between MDAS and DFS scores showed a p value of < 0.05, which means that the difference is statistically significant between the MDAS and DFS scores of respondents who visited the dentist (MDAS: 9.00[9.91±3.86]; DFS: 30.00[33.07±11.17]) and those who never visited the dentist (MDAS: 11.00[11.50±4.68]; DFS: 34.00[37.48±14.43]). This was in line with the research conducted by Doganer et al.,20 which showed higher anxiety in participants evading dental treatment than those attending regular appointments. Therefore, patients with fear tend to keep their dental appointments only when necessary (e.g. when they can no longer endure the pain); they also avoid routine dental visits.20 Dental Journal (Majalah Kedokteran Gigi) p-ISSN: 1978-3728; e-ISSN: 2442-9740. Accredited No. 32a/E/KPT/2017. Open access under CC-BY-SA license. Available at http://e-journal.unair.ac.id/index.php/MKG DOI: 10.20473/j.djmkg.v53.i4.p175–180 http://e-journal.unair.ac.id/index.php/MKG http://dx.doi.org/10.20473/j.djmkg.v53.i4.p175-180 180 Prihastari et al./Dent. J. (Majalah Kedokteran Gigi) 2020 December; 53(4): 175–180 The chi-square test results between MDAS and DFS scores in relation to respondents’ visits to the dentist indicated the absence of statistically significant differences (p = > 0.05). Furthermore, the results show an absence of any possible influence on fear and anxiety towards dental care due to the higher proportion of respondents that regularly visit the dentist. This outcome was in contrast with the results of Svensson et al.,8 which demonstrated a significant difference between dental anxiety and the rate of visits. Based on the results and discussion, the percentages of dental fear and anxiety in the province of Jakarta were 4.2% (high fear), 38.3% (moderate fear), 4.4% (extremely anxious) and 25.5% (moderately anxious). In this study, several sociodemographic factors were confirmed to be related to dental fear and anxiety. In addition, nonparametric test results showed an association between gender, age and income level (p < 0.05), while the chi-square results confirmed a correlation between gender and dental anxiety (p < 0.05) as well as income level and dental fear (p < 0.05). The limitation of this study is that it cannot explain the relationship between sociodemographic factors and dental fear and anxiety, so further longitudinal research is required. 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