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Research Article
Estimating the Need for Sedation in Patients with Dental Anxiety
and Medical Complexities Reporting to Tertiary Care Dental
Hospital Using the IOSN Tool
Beenish Abbas ,
1
Ayesha Maqsood,
2
Syeda Rabia Rahat Geelani,
2
Madeeha Sattar,
3
Majida Rahim,
4
and Zohaib Khurshid
5
1
Department of Pedodontics, Foundation University College of Dentistry, Islamabad, Pakistan
2
Department of Oral and Maxillofacial Surgery, Foundation University College of Dentistry, Islamabad, Pakistan
3
Department of Operative Dentistry, Islamabad, Pakistan
4
Department of Oral Medicine, Foundation University College of Dentistry, Islamabad, Pakistan
5
Department of Prosthodontics and Dental Implantology, College of Dentistry, King Faisal University, Al-Ahsa 31982,
Saudi Arabia
Correspondence should be addressed to Beenish Abbas; beenishabbas1982@gmail.com
Received 24 November 2021; Revised 8 March 2022; Accepted 18 March 2022; Published 26 April 2022
Academic Editor: Sivakumar Nuvvula
Copyright ©2022 Beenish Abbas et al. is is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Objectives. To provide consistent method for assessment of sedation need among patients undergoing dental treatment based on
specific risk factors that is dental anxiety, medical status, and treatment complexity of needed dental treatment using IOSN
(indication of sedation need) tool for assisting the clinician in decision making process. Methods. A total of 237 patients aged ≥12,
ASA I and II were enrolled in the study. A structured questionnaire comprising of three sections was distributed among the
participants. Section 1 comprises details about age, gender, literacy level, occupation, monthly income, and previous dental
treatment history. Section 2 is based on Modified Dental Anxiety Scale which is a questionnaire comprising of five questions
ranging from “not anxious” to “extremely anxious.” e third section was based on using the IOSN tool comprising three
components: MDAS (Modified Dental Anxiety Scale) rank score, Systemic Health (ASA status) rank score, and treatment
complexity rank scores. e total of three scores was then computed to determine the total rank score which suggested the
sedation need. History of past traumatic dental experiences was also inquired from each patient. Results. A total of 237 patients
aged ≥12, ASA I and II were enrolled in the study, out of which 56.1% were female. Statistical analysis was conducted by using the
IBM SPSS Statistics 23 software. Based on the MDAS score, 47/237 (19.8%) participants were found to be highly anxious related to
dental procedures. 34.6% of the participants showed to have a high sedation need while performing a dental procedure. e
sedation need was found to be significantly associated with the female gender with a significant pvalue of (p�0.016), higher
education status (p�0.016), and history of previous traumatic dental experience (p<0.001).Conclusion. A simple assessment
tool can enable clinicians in their decision making to identify patients in need for dental treatment under sedation based on
patient-specific risk factors such as past traumatic dental experiences. Need for sedation can be assessed by information on patient
anxiety level towards dental treatment, medical history, and complexity of planned dental treatment. e IOSN tool is a simple
and quick assessment tool that can be applied for preprocedural assessment of sedation need for dental treatment.
1. Introduction
Vicarious learning from anxious peers, past traumatic
dental experiences, and certain personality traits contribute
towards the development of lifelong behavior issues such as
dental anxiety and phobias which may necessitate the need
for sedation. Sedation is also indicated for patients
reporting with medical conditions which may aggravate
under a stressful environment like in angina patients,
anxiety and pain can increase the release of endogenous
catecholamines, thereby increasing the load on the car-
diovascular system. Similarly, asthmatic patients can
Hindawi
International Journal of Dentistry
Volume 2022, Article ID 5824429, 6 pages
https://doi.org/10.1155/2022/5824429
present with an acute episode of breathing difficulty in-
duced by stress [1].
Sedation is a safe and effective pharmacological behavior
management modality which can be used as an alternative to
more complex options such as general anaesthesia in certain
patients. In this pharmacological anxiety reduction protocol,
use of drugs causes depression of the central nervous system
enabling treatment to be carried out in a more relaxed
environment. At the same time, verbal contact with the
patient is maintained throughout treatment [1].
According to the treating clinician and patient per-
spective, sedation for complex dental treatment has been
gaining popularity in recent years, as patients are more
informed about the anxiety reduction treatment options
available. However, adhering to strict standard clinical
screening and individualized patient treatment needs is
essential to ensure good clinical practice [2]. To achieve this,
there is a need for an objective, comprehensive assessment
tool to evaluate the need for sedation as clinical decision
making is complicated. e tool should be useful in selecting
the right patient based on medical history, level of dental
anxiety, and complexity of dental treatment needed. is
aids in optimizing patient safety and setting guidelines for
adequate staff training [3].
is study aims to work on a simple assessment tool to
provide the minimum patient data set needed to establish
the need for sedation. Sociodemographic factors, past
traumatic dental experiences, and dental anxiety will be
assessed using a questionnaire based on a modified dental
anxiety scale. e American Society of Anesthesiologist
classification system will be used to assess the medical status
of the patient, and each patient will be assigned a score to
grade dental treatment complexity level. is novel assess-
ment tool does not take more than a few minutes of treating
clinicians’ time to provide comprehensive patient
assessment.
2. Methodology
e study was conducted after approval from the Ethical
Review Committee of the Foundation University College of
Dentistry, Islamabad, with ERC ref no. (FF/FUCD/632/
ERC001).
e minimum sample size required for this prospective
cross-sectional analytical study was 237, calculated by using
formula (n�[deff ∗np(1-p)]/[(d2/z21-α/2 ∗(n-1)+p∗(1-
p)]-open epi calculator), with 95% confidence level and 5%
margin of error [4]. A nonprobability consecutive sampling
methodology was employed and total (n�250) participants
enrolled in the study. Informed written consent was ob-
tained with the assurance of anonymity and confidentiality
from the participants before filling out the questionnaire.
Patients aged >12 years, irrespective of gender, were
recruited in the study. Nonconsenting participants, mentally
incapacitated patients with debilitating mental or physical
illness (ASA 3 and above) and/or already on any psychiatric
or chronic ailment treatments and patients with a history of
insomnia who were on sedatives were excluded from the
study.
A structured questionnaire comprising of three sec-
tions was distributed among all the study participants. e
questionnaire was designed both in Urdu and English
after validation and expert opinion on the subject. Section
1 (anxiety questionnaire to be completed by patient)
comprised the details such as patient age, gender, occu-
pation, monthly income, and past experience of traumatic
dental treatment. Section 2 is based on Modified Dental
Anxiety Scale which is a form of questionnaire comprising
of five questions in which range of each item is from “not
anxious” to “extremely anxious” assessed on following
occasions:
(i) Dental clinic visits.
(ii) While in the waiting room for dental treatment at
the dentist’s office.
(iii) Awaiting in the dental chair for tooth drilling.
(iv) Awaiting in the dental chair for teeth scaling.
(v) Awaiting in the dental chair for local anesthetic
infiltration.
Not anxious is given a score 1 and highly anxious is given
a score 5. e modified dental anxiety scale questionnaire
which is used to assess anxiety component of IOSN tool
provides the summed score between 5 to 25 which is then
converted to rank score of 1—4. ASA I patients were
assigned rank score 1, ASA II patients according to their
medical condition was rank scored as 2. ASA III patients
were allotted rank score 3. ird component of the IOSN
tool was related to treatment complexity of needed dental
treatment routine procedures such as scaling, and single
quadrant restorations were rank scored as 1. Intermediate
complexity procedures such as surgical extraction, scaling
with root planning, or two quadrant restorations were al-
lotted rank score 2. Complex dental procedures such as
periodontal surgery, surgical extraction with bone removal,
apicectomy posterior tooth, multiple quadrant restorative,
and multiple posterior endodontics. First component of the
IOSN tool was MDAS score; modified dental anxiety scale
score (5–9) indicating minimal dental anxiety was ranked
score as 1, MDAS score (10–12) indicating moderate patient
anxiety was given rank score 2. Likewise MDAS score
(13–17) indicative of high patient dental anxiety was
assigned rank score 3. Similarly, MDAS value of (18–25)
showing very high dental anxiety was rank scored as 4. e
second component of the IOSN tool comprised patient
medical status. Periodontal surgery was assigned a rank
score of 3. High complexity dental procedures were allotted
rank score 4. For each patient anxiety score, medical history
score and treatment complexity score was ranked and en-
tered in the IOSN tool and summative score of all three
components of the IOSN tool gives an overall score between
3 and 12 with lowest score 3 indicating minimal need for
sedation. (Figure 1)
2.1. Indicator of Sedation Need Tool
(i) Routine: scale, single rooted extraction of 1 or 2
teeth, small soft tissue biopsy, single quadrant
2International Journal of Dentistry
restorations, crown preparations, or anterior end-
odontic treatment.
(ii) Intermediate: scale and root planning, multirooted
tooth extraction, surgical extraction without bone
removal, apicectomy anterior tooth, 2 quadrant
restorative, and posterior endodontic treatment.
(iii) Complex: periodontal surgery, surgical extraction
with bone removal, apicectomy posterior tooth,
multiple quadrant restorative, and multiple poste-
rior endodontics.
(iv) High complexity: any treatment considered more
complex than above or are multiples of the above.
Statistical analysis was performed by the IBM SPSS
Statistics 23. Descriptive statistics were performed for age
and demographic data. A chi-square test was used to find a
statistically significant association between variables. A p
value of ≤0.05 was considered statistically significant.
3. Results
e data from 237 participants were considered for analysis
in this study. Out of 237, 104 (43.9%) males and 133 (56.1%)
females were in the study group. e majority of the par-
ticipants, 96 (40.5%) belonged to age group of 41–50 years,
while least, 47 (19.8%), were from 21 to 30 years age group.
Out of 237, 150 (63.2%) were unemployed including stu-
dents, housewives, and retired persons, while the remaining
87 (36.7%) were employed. 48 (20.3%) participants were
with no education, while 49 (20.7%) were graduates and 56
(23.6%) also had postgraduation. e demographic char-
acteristics of the study participants are summarized in Ta-
ble 1 in detail.
Experience of traumatic and fearful dental procedures
was reported by 90/237 (38.0%) of the participants. e
Modified Dental Anxiety Score (MDAS) was calculated to be
12.87 ±4.9 based on five anxiety assessment questions. Based
on MDAS score, 47/237 (19.8%) participants were found to
be experiencing very high anxiety related to dental proce-
dures as shown in Figure 2. e dental procedure anxiety
was significantly associated with female gender (p�0.016),
higher education status (p�0.012), and past traumatic/
fearful dental procedure (p<0.001). e majority of the
participants 127 (53.5%) reported to feel anxious a day
before going to the dentist for a dental procedure ap-
pointment (grade 2 and above on scale of 1–5). Similarly,
significant portion of participants, 133 (56.1%) said to feel
anxious while sitting in waiting room before getting a dental
procedure done. During the procedure, 189 (79.7%) re-
ported to have felt anxious before getting a tooth drilled
(grade 2 and above on scale of 1–5), 136 (57.3%) felt anxious
before getting scaling/polishing of tooth, while 202 (85.2%)
felt anxious before getting local anaesthesia injection in gum
(grade 2 and above on scale of 1–5), as depicted in Table 2.
In terms of medical and behavioral indicator rank score,
141 (59.5%) participants belonged to ASA grade 1, while the
remaining 96 (40.5%) belonged to grade 2. Concerning
treatment complexity score 24 (10.1%) participants under-
went routine procedures including scaling, single rooted
extraction of 1 or 2 teeth, small soft tissue biopsy, single
quadrant restorations, crown preparations, or anterior
endodontic treatment, whereas 191 (80.6%) participants
underwent intermediate procedures including scale and root
planning, multirooted tooth extraction, surgical extraction
without bone removal, apicectomy anterior tooth, 2 quad-
rant restorative, and posterior endodontic treatment.
Complex procedures including complex periodontal sur-
gery, surgical extraction with bone removal, apicectomy
posterior tooth, multiple quadrant restorative, and multiple
posterior endodontics were performed in only 22 (9.3%)
participants.
Table 1: Demographic characteristics of study participants
(n�237).
Demographic characteristics N (%)
Age groups
12–20 years 44 (22.3%)
21–30 years 47 (19.8%)
31–40 years 50 (21.1%)
41–50 years 96 (40.5%)
Gender Male 104 (43.9%)
Female 133 (56.1%)
Occupation
Student 66 (33.3%)
Housewife 82 (34.5%)
Private job 40 (16.9%)
Government job 25 (10.5%)
Self-employed 22 (9.3%)
Retired from army 2 (1.0%)
Monthly income (PKR)
Dependent 150 (63.3%)
20–30,000 22 (9.3%)
31–50,000 27 (11.4%)
>50,000 38 (16.0%)
Education
Less than primary 48 (20.3%)
Primary 46 (19.4%)
Secondary 38 (16.0%)
Graduate 49 (20.7%)
Postgraduate 56 (23.6%)
IOSN Tool
MDAS Rank
MDAS 5-9 MDAS
10-12
NDAS
13-17
MDAS
18-25
Medical &
Behavioral
Score
ASA I ASA II ASA III ASA IV
Treatment
Complexity
Score
Routine Intermediate Complex Highly
Complex
Figure 1: IOSN tool.
International Journal of Dentistry 3
e mean sedation need score based on mean dental
anxiety score (MDSA), medical and behavioral indicator
rank score, and complexity of dental procedure score was
calculated to be 5.83 ±1.35. It was found that 49 (20.7%)
participants had minimal need of sedation during dental
procedure, 106 (44.7%) had moderate need whereas 82
(34.6%) were found to have a high sedation need while
performing a dental procedure. e sedation need was found
to be significantly associated with female gender (p�0.034)
and history of previous traumatic dental experience
(p<0.001)as shown in Table 3.
4. Discussion
Various studies have been conducted locally and interna-
tionally, which evaluate the dental anxiety scale of the pa-
tient [5]. Recently published literature supported the need
for risk-based preprocedural assessment to make an ob-
jective decision of providing sedation. Keeping in view the
patient risk factors, preprocedural risk assessment to de-
termine the need for sedation is described as the minimum
standard of care as reported by Sutherland et al. [6].
Nowadays, patient-focused healthcare and decision
making are given prime importance. at is why the pa-
tient’s level of anxiety regarding dental treatment will help
the dentist reach a decision regarding the need for sedation.
e use of sedation enables the patient to have his required
dental treatment without finding it stressful [7]. Use of
sedation is variable among dentists, with some using it
injudiciously, whereas others are not using it at all.
e anxiety component of the IOSN Tool (Indicator of
Sedation Need Tool) was calculated using Modified Dental
Anxiety Scale (MDAS) as it is deemed as a very relevant and
brief tool [8].
Pretreatment compounding factors have positive influ-
ence on anxiety levels such as previous dental procedures
performed and environmental factors which are divided into
three categories including personal factors such as patient
age and mental status. Second important environmental
factor is external factors such as socioeconomic status,
education, and racial factors. Dental factors such as attitude
of dental team are also an important environmental factor to
consider towards patient anxiety [9]. Similarly, females
showed higher level of anxiety while giving local anaesthesia
and tooth being drilled compared to males [10]. Another
study supported that gender (females), age, and education
significantly affect dental anxiety [11]. Similarly, the results
of our study also found that dental procedure anxiety was
significantly associated with female gender (p�0.016).
Table 2: Frequency of participant responses to questions related to anxiety related to dental procedure (n�237).
Participant responses
1 2 3 4 5
Before going to dentist for treatment tomorrow, how do you feel? 110 (46.4%) 65 (27.4%) 44 (18.6%) 9 (3.8%) 9 (3.8%)
While sitting in waiting room before treatment, how do you feel? 104 (43.9%) 54 (22.8%) 53 (22.4%) 13 (5.5%) 13 (5.5%)
Before getting a tooth drilled, how do you feel? 48 (20.3%) 40 (16.9%) 35 (14.8%) 71 (30.0%) 43 (18.1%)
Before getting tooth scaled and polished, how do you feel? 101 (42.6%) 34 (4.3%) 59 (24.9%) 25 (10.5%) 18 (7.6%)
Before getting local anaesthesia in gum, how do you feel? 35 (14.8%) 34 (14.3%) 33 (13.9%) 35 (14.8%) 100 (42.2%)
Participant responses: 1, not anxious; 2, slightly anxious; 3, fairly anxious; 4, very anxious; 5, extreme anxious.
Table 3: Sedation need while performing dental procedure and its
association with past traumatic dental experience.
Categories of sedation need
Pvalue
Minimal
(n�49)
Moderate
(n�106)
High
(n�82)
Gender
Male 15 (30.6%) 45 (42.5%) 44 (53.7%) 0.034
Female 34 (69.4%) 61 (57.5%) 38 (46.3%)
Past traumatic dental experience
Yes 1 (2.0%) 47 (44.3%) 42 (51.2%) <0.001
No 48 (98.0%) 59 (55.7%) 40 (48.8%)
Bold shows Pvalue of less than .001 is considered statistically significant.
13.20% 23.30%
53.60% 59.60%
86.80% 76.70%
46.40% 40.40%
MINIMAL
ANXIETY
MODERATE
ANXIETY
HIGH
ANXIETY
VERY HIGH
ANXIETY
History of traumatic dental experience
No history of traumatic dental experience
Figure 2: Comparison of mean dental anxiety score (MDAS) classes with past traumatic dental experience.
4International Journal of Dentistry
Dental anxiety is stress-provoking both for patients and
dentist alike, leading to misdiagnosis and an unpleasant
treatment environment due to diminished patient cooper-
ation which may ultimately lead to poor oral, periodontal
health, and increased emergency attendance resulting from
avoidance of dental appointments as reported by Zinke et al.
[12]. Irregular dental visits leading to poor oral health is
associated with dental anxiety and phobias. Younger pa-
tients, females, and patients with previous unpleasant dental
experience were associated with increased MDAS scores.
Likewise, in our study, correlation has been established that
59.60% patients having past traumatic dental experiences
presented with very high dental anxiety [13, 14].
Demographic characteristics of our study participants
regarding their educational status show somewhat equal
distribution of participants regarding their education status,
with graduate and postgraduate being slightly high in
number. Higher the educational status, more was the anx-
iety, as seen in this study (p�0.012). Similar findings were
also observed in other studies [11, 15].
Based on MDAS (Modified Dental Anxiety Scale) score,
most of the participants in our study felt anxious while sitting
in a waiting room before getting a dental procedure done
(grade 2 and above on scale of 1–5), while it was closely
followed by 53.5% who felt anxious a day before going to
dentist. MDAS was selected to measure the dental anxiety
component of the IOSN tool and need for sedation because
this scale is simple and universally well accepted [16, 17].
e patients’ anxiety depends upon the dental procedure
he is undergoing. Our study suggests that quite a high pro-
portion of patients (42.2%) were extremely anxious while
getting local anaesthesia. Another study reported higher
anxiety scores in patients receiving local anaesthesia [18]. is
was contradictory to a study where most of the patients who
were having dental filling exhibited most anxiousness [19].
Recent study reported that patients with traumatic
dental event have higher scores of dental anxiety (p�0.028)
which leads to negative perceptiveness about dental treat-
ment and dentist [20]. Our study has a significant associ-
ation of dental anxiety with past traumatic dental experience
(p>0.001). In terms of traumatic and unpleasant past dental
experiences, younger the patient at the time of fearful dental
experience, higher are the chances of translating into more
anxious behavior owing to the emotional vulnerabilities of
adolescents and children. Another study reported significant
higher IOSN scores and need of sedation in 60.3% of patients
having unpleasant dental experiences. Patients who reported
previous traumatic dental experiences were 2.24 times more
likely to need sedation [21]. A recent study by Merdad and
El-Housseiny shows a significant association between
traumatic dental experience and poor oral health-related
quality of life had greater caries experience with more
avoidance behavior towards dental appointments [22].
While comparing the medical risk factors score, most
(59.5%) of the participants belonged to the group ASA Grade
I while the remaining (40.5%) belonged to Grade II. Another
recent study by Dziedzic et al. highlighted the crucial role of
the comprehensive assessment strategy in medically
compromised and special care patients for safe delivery of
conscious sedation as an alternative to general anaesthesia
for vulnerable patient group [23].
In our study, while applying the IOSN tool, 34.6% were
found to have a high sedation need while performing the
dental procedures. is was contradictory to a study which
found that only 2.4% of the patients showed a high need for
sedation when the IOSN tool was applied to their study
population [24].
More the complexity of dental procedure, more is the
need for sedation. at is why we see that in minor oral
surgical procedures such as third molar surgery, many of the
dentists prefer sedation [25]. Many methods for sedation are
being used for third molar impactions. All these methods
aim to achieve better patient outcomes in terms of pain
control as noted in other studies [26]. Also, patients pre-
senting with periodontal disease with higher anxiety levels,
while undergoing scaling and root planning treatments may
exhibit negative clinical outcomes. us, suggesting that
even for simpler procedures sedation can play an important
role to achieve better patient outcomes in terms of pain
control [27].
Preprocedural comprehensive patient evaluation is an
integral part of an up-to-date sedation practice. Detailed
evaluation of patient parameters is of utmost significance in
developing an individualized agreed-upon sedation plan that
reflects minimum standard of dental care with low risk of
complications. Research is lacking on the development and
application of a validated sedation scoring system to predict
requirement of sedation based on individual patient pa-
rameters which would further enhance shared decision
making between clinician and patients as it holds utmost
significance to enhance patient satisfaction [6]. e recent
pandemic has led to increasing demands on the hospitals
with deferral of general anaesthesia and hospital-based se-
dation. erefore, the use of dental sedation is the need of
hour to provide optimal dental services in dental clinics on
out-patient basis. In order to provide required support in
specialized dental care and to meet the current health care
needs, we need more trained personnel in the field of se-
dation [23].
e limitation of this study was a smaller sample size and
a wider age range, and the data were recruited from single-
hospital setting, thus lacking the generalizability. Similarly,
we applied this tool over a variety of the dental procedures,
some complex and some rather simple. e study lacks the
degree of variability because anxiety questionnaire score
revolves around dental treatment events and noncognitive
factor (traumatic dental event). is tool can be further
modified as it has certain limitations. It does not indicate the
level of sedation required for a particular patient, ranging
from mild sedation to general anaesthesia. is study was an
initial step towards applying this innovative tool for cal-
culating the need for sedation in dental patients. In future,
this could be used to carry out multicenter studies which will
help in further validation of this tool. is instrument could
be modified and applied for patients with special needs and
pediatric patients.
International Journal of Dentistry 5
5. Conclusion
A simple assessment tool can enable clinicians in their
decision making to identify patients in need for dental
treatment under sedation based on patient-specific risk
factors such as past traumatic dental experiences. Need for
sedation can be assessed by information on patient anxiety
level towards dental treatment, medical history, and com-
plexity of planned dental treatment.
Data Availability
e data used to support the findings of this study are
available on request.
Conflicts of Interest
e authors have no conflicts of interest to declare.
References
[1] J. D. O. Ara´ujo, C. D. C. Bergamaschi, L. C. Lopes,
C. C. Guimarães, N. K. De Andrade, and J. C. Ramacciato,
“Effectiveness and safety of oral sedation in adult patients
undergoing dental procedures: a systematic review,” BMJ
Open, vol. 11, no. 1, 2021.
[2] R. Shrivastava, “Conscious sedation : uses in medicine and
dental practice,” European Journal of Molecular & Clinical
Medicine, vol. 07, no. 10, pp. 3278–3288, 2020.
[3] R. Hazara, “Conscious sedation in dentistry: selecting the
right patient,” Dental Update, vol. 47, no. 4, pp. 353–359,
2020.
[4] A. M. White, L. Giblin, and L. D. Boyd, “e prevalence of
dental anxiety in dental practice settings,” Journal of Dental
Hygiene: JDH, vol. 91, no. 1, pp. 30–34, 2017.
[5] D. P. Appukuttan, P. K. Cholan, A. Tadepalli, and
S. Subramanian, “Evaluation of dental anxiety and its influ-
ence on dental visiting pattern among young adults in India: a
multicentre cross sectional study,” Annals of Medical and
Health Sciences Research, vol. 7, no. 6, pp. 393–400, 2017.
[6] J. R. Sutherland, A. Conway, and E. L. Sanderson, “Pre-
procedural assessment for patients anticipating sedation,”
Current Anesthesiology Reports, vol. 10, no. 1, pp. 35–42, 2020.
[7] L. Fiorillo, “Conscious sedation in dentistry,” Med, vol. 55,
no. 12, 2019.
[8] H. Kassem El Hajj, Y. Fares, and L. Abou-Abbas, “Assessment
of dental anxiety and dental phobia among adults in Leb-
anon,” BMC Oral Health, vol. 21, no. 1, pp. 1–10, 2021.
[9] R. Rafatjou, M. Ahmadpanah, B. Ahmadi, and M. Mahmoodi,
“Evaluation of dental anxiety and the role of concomitant
factors in their anxiety level in 9-12 years old children,”
Avicenna Journal of Dental Research, vol. 11, no. 2, pp. 53–60,
2019.
[10] M. L. Caltabiano, F. Croker, L. Page et al., “Dental anxiety in
patients attending a student dental clinic,” BMC Oral Health,
vol. 18, no. 1, pp. 48–8, 2018.
[11] E. Sinha, R. Rekha, and S. Nagashree, “Anxiety of dental
treatment among patients visiting primary health centers,”
Journal of Indian Association of Public Health Dentistry,
vol. 17, no. 3, p. 235, 2019.
[12] A. Zinke, C. Hannig, and H. Berth, “Comparing oral health in
patients with different levels of dental anxiety,” Head & Face
Medicine, vol. 14, no. 1, pp. 25–5, 2018.
[13] M. I. Fayad, A. Elbieh, M. N. Baig, and S. A. Alruwaili,
“Prevalence of dental anxiety among dental patients in Saudia
Arabia,” Journal of International Society of Preventive &
Community Dentistry, vol. 7, no. 2, pp. 100–104, 2017.
[14] S. Prakash, K. Kinikar, S. Kashyap, D. F. Swamy, P. Khare, and
B. Kashyap, “Evaluation of dental anxiety in patients un-
dergoing extraction of teeth,” vol. 5, no. 2, pp. 13–17, 2018.
[15] L. D. Seligman, J. D. Hovey, K. Chacon, and T. H. Ollendick,
“Dental anxiety: an understudied problem in youth,” Clinical
Psychology Review, vol. 55, pp. 25–40, 2017.
[16] I. A. Pretty, M. Goodwin, P. Coulthard et al., “Estimating the
need for dental sedation. 2. Using IOSN as a health needs
assessment tool,” British Dental Journal, vol. 211, no. 5,
pp. E11–E16, 2011.
[17] S. Yuan, S. J. Carson, M. Rooksby, J. McKerrow, C. Lush, and
R. Freeman, “Assessing sedation need and managing referred
dentally anxious patients: is there a role for the Index of
Sedation Need?” British Dental Journal, vol. 219, no. 12,
pp. 571–576, 2015.
[18] L. Dou, M. M. Vanschaayk, Y. Zhang, X. Fu, P. Ji, and
D. Yang, “e prevalence of dental anxiety and its association
with pain and other variables among adult patients with ir-
reversible pulpitis,” vol. 1–6, 2018.
[19] R. Bhola and R. Malhotra, “Dental procedures, oral practices,
and associated anxiety: a study on late-teenagers,” Osong
Public Health and Research Perspectives, vol. 5, no. 4,
pp. 219–232, 2014.
[20] C. Scandurra, R. Gasparro, P. Dolce, V. Bochicchio, B. Muzii,
and G. Sammartino, “e role of cognitive and non-cognitive
factors in dental anxiety: a mediation model,” European
Journal of Oral Sciences, vol. 129, no. 4, pp. 1–8, 2021.
[21] Y. Sirin, S. Yildirimturk, and N. Ay, “Do state-trait anxiety
and previous unpleasant dental experiences predict the need
for sedation in women having third molar surgery?” British
Journal of Oral and Maxillofacial Surgery, vol. 58, no. 5,
pp. 530–534, 2020.
[22] L. Merdad and A. A. El-Housseiny, “Do children’s previous
dental experience and fear affect their perceived oral health-
related quality of life (OHRQoL)?” BMC Oral Health [In-
ternet], vol. 17, no. 1, pp. 1–9, 2017.
[23] A. Dziedzic, M. Tanasiewicz, H. Abed, C. Dickinson, and
B. Picciani, “Are special care dentistry services prepared for a
global disruption in healthcare? A call for a wider promotion
of dental conscious sedation training,” Healthc, vol. 8, no. 4,
2020.
[24] P. Coulthard, C. M. Bridgman, L. Gough, L. Longman,
I. A. Pretty, and T. Jenner, “Estimating the need for dental
sedation. 1. e Indicator of Sedation Need (IOSN) - a novel
assessment tool,” British Dental Journal, vol. 211, no. 5,
pp. E10–E14, 2011.
[25] M. Melini, A. Forni, F. Cavallin, M. Parotto, and G. Zanette,
“Conscious sedation for the management of dental anxiety in
third molar extraction surgery: a systematic review,” BMC
Oral Health, vol. 20, no. 1, pp. 1–10, 2020.
[26] J. Alizargar, Sh M. Etemadi, N. Kaviani, S. F. V. Wu,
K. Jafarzadeh, and P. Ranjbarian, “Injection of lidocaine alone
versus lidocaine plus dexmedetomidine in impacted third
molar extraction surgery, a double-blind randomized control
trial for postoperative pain evaluation,” Pain Research and
Management, vol. 2021, 2021.
[27] Y. Liu, C. Zhang, J. Wu, H. Yu, and C. Xie, “Evaluation of the
relationship among dental fear, scaling and root planing and
periodontal status using periodontitis stages: a retrospective
study,” J Dent Sci [Internet, vol. 17, no. 1, pp. 293–299, 2021.
6International Journal of Dentistry
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