267267 Dental Journal (Majalah Kedokteran Gigi) 2025 September; 58(3): 267–272 Original article Prevalence of dental anxiety and its association with mental health among adults in Kuantan, Malaysia Farah Natashah Mohd1, Abdul Hadi Said2, Nurul Ruziantee Ibrahim3, Nur Afirah Maluin4, Nabila A. Rahaman4 1Special Care Dentistry Unit, Department of Oral Maxillofacial Surgery and Oral Diagnosis, Kulliyyah of Dentistry, International Islamic University of Malaysia, Kuantan, Malaysia 2Department of Family Medicine, Kulliyyah of Medicine, International Islamic University Malaysia, Pahang, Kuantan, Malaysia 3Oral Pathology and Oral Medicine Unit, Kulliyyah of Dentistry, International Islamic University Malaysia, Kuantan, Malaysia 4Dental Officer, Ministry of Health Malaysia. ABSTRACT Background: There is a limited number of studies on the prevalence of dental anxiety among the general population in Malaysia and its association with mental health. Purpose: This study aimed to assess the prevalence of dental anxiety and its association with mental health. Methods: This cross-sectional study was conducted among 474 adults attending a public hospital in Kuantan, Malaysia. Participants were required to answer validated, self-administered questionnaires that used the Modified Dental Anxiety Scale (MDAS) and Depression Anxiety and Stress Scale (DASS). Data were analyzed using chi-square and Mann-Whitney tests. Multiple logistic regression was used to determine the relationship between dental anxiety and other variables. Results: A total of 461 respondents completed the questionnaire, with a response rate of 97.3%. The prevalence of dental anxiety among respondents was very high (93.1%). We found that females were 2.3 times more likely to have dental anxiety than males. Meanwhile, an increase in age by one year reduced the likelihood of having dental anxiety by 3%. However, no significant association was found between dental anxiety and mental health. Conclusion: The majority of adults in Kuantan were found to have dental anxiety. Female and younger patients were more likely to have dental anxiety. Our study failed to find any association between dental anxiety and mental health. Keywords: dental anxiety; depression; mental health; anxiety; stress Article history: Received 6 April 2024; Revised 27 June 2024; Accepted 16 July 2024; Online 27 May 2025 Correspondence: Abdul Hadi Said, Department of Family Medicine, Kulliyyah of Medicine, International Islamic University Malaysia, Pahang, Kuantan, Malaysia. Email: abdulhadi@iium.edu.my INTRODUCTION Anxiety can be defined as a universal adaptive reaction to a dangerous stimulus.1 This natural response may be abnormal when it is out of proportion to the level of threat or when there are unacceptable symptoms regardless of the level of threat.2 One of the categories is specific phobias, which include fears of dentistry, in which the patient might have a vasovagal response and faint upon seeing blood, injury, or an injection.1 Dental anxiety refers to a condition in which the patient will have an overwhelming sense of fear, feeling threatened by any dental treatment or doubting their ability to cope with it.3 Meanwhile, dental phobia is a severe type of dental anxiety that can be illustrated by apparent and constant anxiety about dental-related objects or situations.3 It is known that dental anxiety can worsen oral health because anxious people tend to avoid dental treatment. They are usually irregular dental attendees who visit a dentist only when there are problems and tend to delay or cancel the appointment. As a result, their dental problems can progress extensively to become a dental abscess or may cause one of the following: cellulitis, Ludwig’s angina,4 septicemia, sepsis, sinusitis, or osteomyelitis of the face,5 which may then compromise their general health. Hence, these conditions will require more complex dental treatment needs, which will likely be more invasive and painful. Consequently, their poor oral health could also affect them psychologically and socially due to the embarrassment of their oral status and reduced self-confidence.6 Despite the continuous advances made in dental-care services, dental anxiety remains a barrier to dentists, Copyright © 2025 Dental Journal (Majalah Kedokteran Gigi) p-ISSN: 1978-3728; e-ISSN: 2442-9740. Accredited No. 158/E/KPT/2021. Open access under CC-BY-SA license. Available at https://e-journal.unair.ac.id/MKG/index DOI: 10.20473/j.djmkg.v58.i3.p267–272 mailto:abdulhadi@iium.edu.my https://e-journal.unair.ac.id/MKG/index https://doi.org/10.20473/j.djmkg.v58.i3.p267-272 268 Mohd et al. Dent. J. (Majalah Kedokteran Gigi) 2025 September; 58(3): 267–272 preventing treatment from being carried out successfully. In addition, anxious patients were reported to be one of the most stressful situations for a dentist. The dentist–patient relationship may be affected, leading to unclear diagnoses that further worsen the patient’s oral health.7 Studies from a different population in Pakistan have shown around a 20% prevalence of dental anxiety, while severe dental anxiety, which includes dental phobia and avoidance of dental care, shows a prevalence of 5%.6 Individuals’ sociodemographic backgrounds are shown to be related to dental anxiety. This includes young age, female gender, low education level, poor general health,4 psychological disorders, and personality or psychological traits.6 However, dental anxiety among the general population in Malaysia has rarely been explored, as most studies have focused on undergraduate students, and another study by Esa et al.8 was conducted on pregnant women. A study by Gunjal et al.7 found that 60% of the dental undergraduate students in one of the dental schools in Malaysia have a moderate to high anxiety level. This highlights the significance of this research, as no study has been conducted among the general population in Malaysia as yet. Furthermore, one study found general anxiety and depression to be related to oral health status and dental behavior.9 People with depression were found to have certain habits that could put them at high risk of caries activity. These include ignorance of self-care, high consumption of carbohydrates and sugary meals, smoking more cigarettes than the average smoker, reduced salivary secretion associated with consumption of antidepressant medication, dry mouth sensation, and a lower frequency of daily toothbrushing.9 Findings from another study showed that those who experience anxiety during dental treatment were more likely to have psychiatric disorders than those who do not. Hence, patients with dental anxiety tend to be generally anxious.10 The authors of this study were interested in finding the association between dental anxiety and mental health problems such as depression, anxiety, and stress disorder. Thus, this research aimed to assess the prevalence of dental anxiety among the general population in Kuantan and its association with their sociodemographic profiles and mental health. MATERIALS AND METHODS A cross-sectional study was conducted among adults attending Sultan Ahmad Shah Medical Centre (SASMEC) in Kuantan, Malaysia, from February to August 2019. Ethical approval was obtained from IIUM Research Ethics Committee (IREC 2019-013), and permission letters were sent to the Research Unit of SASMEC before conducting the research. The total sample size was calculated using a single proportion formula with 50% chosen prevalence (CL of 95%) while considering a 20% nonresponse rate. The total sample size calculated was 465 participants. Participation in this study was voluntary, and consent was obtained from all participants. Using a purposive sampling method, the questionnaires (in hard-copy version) were distributed to 474 adults who attended SASMEC during our study period. Written consent was obtained prior to the commencement of the questionnaires. Participants were given 15–20 minutes to complete the questionnaire in a dedicated room that is separate from the general waiting area, and they were allowed to leave at any point during the session. The collected questionnaires were checked for completeness. Participants were also given the opportunity to ask whether they had any queries about the questions on the questionnaire. The inclusion criteria were adults aged 18 years old and above who had no known active psychotic disorder, such as schizophrenia and delusional disorder (as they may not have been able to answer the questionnaire appropriately), as well as having no learning disabilities. Meanwhile, the exclusion criteria were those who were illiterate as well as staff and students from the dental department. A structured questionnaire with four sections was used throughout this study. It consisted of the Modified Dental Anxiety Scale (MDAS), the Depression Anxiety and Stress Scale (DASS), and a sociodemographic profile. Dental-related anxiety was assessed using the MDAS, and the results were categorized into four groups: not anxious, low anxiety, moderate anxiety, and extreme anxiety (dental phobic).11 This modified version of Corah’s Dental Anxiety Scale by Humphris et al.12 includes questions on local anesthesia. This scale has been translated into and validated in the Malay language.11 Meanwhile, the DASS, which consists of 21 items, was used to assess the level of general anxiety, depression, and stress. Each measure was divided equally into seven questions. The questions were translated into Malay and validated, showing high internal consistency.13 The MDAS and DASS questionnaires are two well-known questionnaires commonly used in Malaysia. They were translated into and validated in Malay many years ago. Hence, we did not perform any further validation or pilot test prior to this study. Information regarding sociodemographic background, including age, gender, education, and occupation, was collected in the last section of the questionnaire. Every section included both English and Malay versions. The IBM Statistical Package for the Social Sciences (SPSS) software version 24.0 was used for data and statistical analysis. The participants’ responses were coded into numbers; thus, no sensitive information was included in the data analysis. Univariate analysis was performed for categorical and continuous data input, including all sociodemographic backgrounds, MDAS, and DASS results. Bivariate analysis using the chi-square test was conducted to determine the association between MDAS and DASS as well as the sociodemographic profile. Initially, the MDAS score was categorized into four groups: not anxious (0–5), low anxiety (6–10), moderate anxiety (11–18), and extreme anxiety or phobic (19–25).12 Meanwhile, the DASS scores Copyright © 2025 Dental Journal (Majalah Kedokteran Gigi) p-ISSN: 1978-3728; e-ISSN: 2442-9740. Accredited No. 158/E/KPT/2021. Open access under CC-BY-SA license. Available at https://e-journal.unair.ac.id/MKG/index DOI: 10.20473/j.djmkg.v58.i3.p267–272 https://e-journal.unair.ac.id/MKG/index https://doi.org/10.20473/j.djmkg.v58.i3.p267-272 269Mohd et al. Dent. J. (Majalah Kedokteran Gigi) 2025 September; 58(3): 267–272 were categorized into five groups for each psychological symptom: normal, low, moderate, high, and extreme. Next, we recoded the four levels of the MDAS into two groups, which were normal (no dental anxiety) and dentally anxious, which includes low, moderate, and extreme. The five levels of the DASS were also regrouped into two groups, which were “No” (no symptoms of depression/stress/anxiety at all) and “Yes” (at least a low level of depression/stress/anxiety). These three psychological symptoms were then analyzed through bivariate analysis to assess their association with dental anxiety. The Mann-Whitney test was used, as the results were not normally distributed. Results with p<0.05 were considered statistically significant. Multiple logistic regression analysis was performed to find the true association between the variables while adjusting for possible confounding factors. RESULTS A total of 474 questionnaires were distributed, and 461 were returned, making the response rate 97.3%. Five questionnaires were excluded because they were incomplete. There were almost equal numbers of male and female participants, with 201 male participants (43.2%) and 261 female participants (56.1%). The respondents were aged between 18 and 74 years old, with a mean age of 36.9 years old. Table 1 summarizes the frequency distribution of the participants’ sociodemographic profile. Table 2 illustrates that only 6.9% of the participants are not anxious at all when having dental treatments, while 93.1% have anxiety toward dental procedures that ranges from low to extreme dental anxiety/dental phobic. Table 3 shows the DASS scores; more than 50% of respondents had a normal score, indicating that they did not have any symptoms of depression, anxiety, or stress. A summary of the association between dental anxiety and sociodemographic factors is presented in Table 4. Interestingly, there were significant associations between dental anxiety and the participants’ age and gender. Apart from these two factors, no other factors exhibited any significant association with dental anxiety. A multiple logistic regression (Table 5) was used to further determine the relationship gender and age have with dental anxiety. Females were 2.3 times more likely to have dental anxiety than males. In terms of age, as age increased by one year, the likelihood of having dental anxiety decreased by 3%. Table 1. Sociodemographic profile of respondents Variables Variables / Category Study population distribution n (%) Gender Male 201 (43.2) Female 260 (56.1) Mean age (in years) ± SD 36.87 ± 12.6 Employment status Nonprofessional 161 (35.2) Professional 93 (20.4) Unemployed 203 (44.4) Monthly gross income < RM 1000 143 (30.8) RM1001-RM3000 132 (28.4) RM3001-RM5000 95 (20.4) > RM5001 85 (18.3) Educational level Primary school 5 (1.3) Secondary school 106 (23.0) Tertiary (diploma and higher) 342 (25.8) Dental attendance Regular 153 (32.9) Irregular 308 (66.1) Last dental visit Within 6 months 153 (32.9) More than 6 months previous 166 (35.7) More than 2 years previous 142 (30.5) Table 2. Level of dental anxiety among respondents (MDAS) n (%) Variables MDAS score n % Not anxious 32 6.9 Low anxiety 187 40.2 Moderate anxiety 205 44.1 Extreme anxiety / dental phobic 38 8.2 Table 3. Levels of depression, anxiety, and stress among respondents (DASS) Variables Depression n (%) Anxiety n (%) Stress n (%) Normal 344 (74.0) 244 (52.5) 278 (59.8) Low 47 (10.1) 51 (11.0) 134 (28.8) Moderate 44 (9.5) 102 (21.9) 40 (8.6) High 10 (2.2) 31 (6.7) 9 (1.9) Extreme 12 (2.6) 35 (7.5) 1 (0.2) Copyright © 2025 Dental Journal (Majalah Kedokteran Gigi) p-ISSN: 1978-3728; e-ISSN: 2442-9740. Accredited No. 158/E/KPT/2021. Open access under CC-BY-SA license. Available at https://e-journal.unair.ac.id/MKG/index DOI: 10.20473/j.djmkg.v58.i3.p267–272 https://e-journal.unair.ac.id/MKG/index https://doi.org/10.20473/j.djmkg.v58.i3.p267-272 270 Mohd et al. Dent. J. (Majalah Kedokteran Gigi) 2025 September; 58(3): 267–272 DISCUSSION The present study found that the prevalence of dental anxiety among the adult population in Kuantan is markedly high, with 93.1% of respondents having low to extremely high dental anxiety. However, in this study, no direct comparison could be made with local studies. Nevertheless, this result is comparable with previous studies conducted in one of the local universities in which non-dental students had high dental anxiety.4,7 As explained by Gunjal et al.,7 in Malaysia, non-dental students lack dental knowledge and awareness and have fewer dental visits. Hence, more dental information should be circulated among the general population to increase their dental awareness. Our study also found that female respondents were more likely to have dental anxiety compared to males. A similar result pattern was observed in a previous study, which described that being female was one of the main factors associated with having dental phobia.5,14,15 One of the reasons behind this could be that males have a higher tendency to shield themselves from fear and anxiety due to people’s perceptions of their gender role.5 Furthermore, females are said to be easily affected by a stimulus and to simply express their emotions.5,15 Different age groups may exhibit different levels of dental anxiety. In the present study, younger people had a higher tendency for dental anxiety than older people. This result is in concordance with other studies, which observed a significant reduction in dental anxiety as the age increased, especially after reaching 50 years old.16,17 Mohammed et al.17 suggested that older patients are exposed to other chronic and more severe diseases, which may change their perceptions toward pain and health care. Studies have proved that fears and phobia may reduce with age due to deterioration of cerebral function and adaptive endurance toward imminent events.17 Nevertheless, this fact is still controversial, as some other studies have not shown any relationship between the factors.15,18 Higher education level may affect an individual’s perception of dental care and routine oral hygiene practice.19 However, this study showed no significant correlation between dental anxiety and education level. This result is complementary to other studies, which exhibited the same results.15,20 Thus, it cannot be reliably concluded that a higher education level assures better dental behavior and perceptions of dental care. A decent socioeconomic status may provide better access to dental health care. Logically, this should be reflected in more desirable dental behavior and perception. Yet our study demonstrates no significant association between monthly income and dental anxiety, and this is corroborated by other studies.20 Dental visits/attendance and dental anxiety were not shown to be significantly correlated in the current study. Table 4. Factors associated with dental anxiety using the Mann-Whitney test Sociodemographic profile MDAS p-valueNormal n (%) Dentally anxious n (%) Gender Male 21 (10.6) 178 (89.4) 0.008Female 11 (4.2) 250 (95.8) Median age (IQR) 41 (19.0) 34 (18.0) *0.005 Race Malay 27 (6.4) 397 (93.6) 0.273Non-Malay 4 (11.8) 30 (88.2) Non-Muslim 4 (13.8) 25 (86.2) Occupation Professional 6 (6.5) 87 (93.5) 0.344Nonprofessional 14 (8.8) 146 (91.3) Unemployed 10 (4.9) 193 (95.1) Monthly income < 3k 15 (5.5) 259 (94.5) 0.224> 3k 15 (8.4) 164 (91.6) Education level Primary 0 (0.0) 5 (100) 0.078Secondary 12 (11.3) 94 (88.7) Tertiary 18 (5.3) 324 (94.7) Mother’s education level Primary 9 (6.7) 125 (93.3) 0.211Secondary 9 (4.7) 183 (95.3) Tertiary 10 (10.1) 89 (89.9) Dental attendance Regular 14 (9.2) 139 (90.8) 0.192Irregular 18 (5.9) 289 (94.1) * Mann-Whitney test Table 5. Multiple logistic regression table on factors associated with dental anxiety Category B Wald Exp (B) 95% C.I p-value Lower Upper Gender Male (reference) Female 0.833 4.483 2.301 1.064 4.978 0.034 Age -0.028 3.930 0.972 0.946 1.000 0.047 Constant 3.309 25.029 27.358 0.000 Copyright © 2025 Dental Journal (Majalah Kedokteran Gigi) p-ISSN: 1978-3728; e-ISSN: 2442-9740. Accredited No. 158/E/KPT/2021. Open access under CC-BY-SA license. Available at https://e-journal.unair.ac.id/MKG/index DOI: 10.20473/j.djmkg.v58.i3.p267–272 https://e-journal.unair.ac.id/MKG/index https://doi.org/10.20473/j.djmkg.v58.i3.p267-272 271Mohd et al. Dent. J. (Majalah Kedokteran Gigi) 2025 September; 58(3): 267–272 According to a previous study, people who visit the dentist infrequently have greater levels of dental anxiety.21 High levels of dental anxiety were also found to be the main cause of tooth loss, treatment cancellation, and missed dental appointments. The results of this earlier study may be strongly tied to the participants’ individual dental experiences, wherein pleasant dental experiences may have reduced the likelihood of developing dental anxiety and vice versa. However, because we did not evaluate participants’ prior dental experiences in the current study, we were unable to propose an explanation for this relationship. Nevertheless, our findings showed that the regularity of dental visits/attendance did not affect participants’ levels of dental anxiety. Further study is necessary to assess their personal dental experiences and involve a larger sample size. By acknowledging the factors contributing to dental anxiety, dental practitioners should be able to predict and recognize those who are more likely to have fears and anxiety in the dental chair. This is crucial in determining and modifying the dental approach to deliver successful dental treatment. Previous studies have found that mental health problems such as depression, anxiety, and stress have a significant correlation with dental perception.9,10 A person who was found to have these psychological symptoms also had a significant level of dental anxiety.9,10 Nonetheless, a noteworthy finding from our research indicates that there is no correlation between any of these mental health issues and dental anxiety. This could be because previous studies used different methods in assessing depression, anxiety, and stress rather than the DASS questionnaire. The study by Pekkan et al.10 used Beck’s depression inventory and Beck’s anxiety inventory to evaluate depression and anxiety. Furthermore, the prevalence of depression, anxiety, and stress in our study was relatively low, making the statistical analysis not strong enough. We suggest future researchers conduct a larger-scale study using randomized sampling and a variety of questionnaires to further establish this relationship. For now, perhaps it is unnecessary to be overly worried about this possible association. Dental practitioners may continue managing dental problems related to dental anxiety without being concerned about their patients’ mental health. The high frequency of dental anxiety, particularly in younger women, should be made known to dentists. The Ministry of Health Malaysia has also been actively promoting oral health to the public via social media and outreach programs. However, those with dental anxiety might not be attending the programs because of their fear. Dental professionals should, therefore, prepare for alternative behavioral management techniques, such as conscious sedation, desensitization, or the use of technology in the office (e.g., a TV with headphones). It is encouraging to learn that most Kuantan adults do not suffer from psychological issues. The limitation of this study was that it used a nonrandom sampling method. This reduces the ability to generalize the results of this study to the larger population. Nevertheless, the strength of this study is that it is the first survey on dental anxiety among the general adult population in Malaysia that comprises a comprehensive socioeconomic background and adequate sample size. For future research, we advise using a randomized sampling method and including different locations in Malaysia to provide a more accurate representation of the adult population. It is also advisable to include dental procedure lists that may affect levels of dental anxiety. There was a high prevalence of dental anxiety in Kuantan’s general adult population. Younger and female respondents showed higher levels of dental anxiety. Therefore, it is imperative that all dentists are made aware of these findings. Furthermore, our research indicates that dental anxiety is a distinct issue associated with dental procedures rather than being a component of psychological issues. 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BMC Oral Health. 2023; 23(1): 1–10. Copyright © 2025 Dental Journal (Majalah Kedokteran Gigi) p-ISSN: 1978-3728; e-ISSN: 2442-9740. Accredited No. 158/E/KPT/2021. Open access under CC-BY-SA license. Available at https://e-journal.unair.ac.id/MKG/index DOI: 10.20473/j.djmkg.v58.i3.p267–272 https://e-journal.unair.ac.id/MKG/index https://doi.org/10.20473/j.djmkg.v58.i3.p267-272