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335 © 2024 Journal of International Oral Health | Published by Wolters Kluwer - Medknow
Address for correspondence: Dr. Nawwal Alwani Mohd Radzi,
Centre of Population Oral Health and Clinical Prevention Studies,
Faculty of Dentistry, Universiti Teknologi MARA (UiTM),
Sungai Buloh, Selangor 47000, Malaysia
E-mail: nawwal@uitm.edu.my
Review Article
Relationship Between Dental Anxiety, Dental Utilization, and
Oral Health-Related Quality of Life: A Systematic Review
Azizi Ab Malek1,2, Nawwal Alwani Mohd Radzi1, Muhd Firdaus Che Musa3, Amirul Faiz Luai1,4
1Centre of Population Oral Health and Clinical Prevention Studies, Faculty of Dentistry, Universiti Teknologi MARA (UiTM), Sungai Buloh, Selangor, Malaysia, 2Training
Management Division, Ministry of Health, Putrajaya, Malaysia, 3Department of Pediatric Dentistry and Dental Public Health, Kulliyyah of Dentistry, International Islamic
University Malaysia, Kuantan Pahang, 4Dental Public Health Unit, Department of Family Oral Health, Faculty of Dentistry, Universiti Kebangsaan Malaysia (UKM),
Kuala Lumpur, Malaysia
Abstract
Aim: No comprehensive synthesis of dental anxiety (DA), dental utilization (DU), oral health-related quality of life (OHRQoL), and
their relationships have been examined despite various systematic investigations being done on their prevalence and interventions
individually. Therefore, this review aims to systematically review the status and relationship between DA, DU, and OHRQoL among
adult groups. Materials and Methods: Data collection spanned 6 months, from 1 July to 31 December 2023, involving eight databases.
Only cross-sectional (CS) studies with adult participants aged 15–64 years, conducted globally, published in English, and available as
full-text articles by December 31, 2023, were included. Two reviewers screened the titles and abstracts and assessed the full-text articles.
All studies were CS. The risk of bias was evaluated using the Joanna Briggs Institute’s Critical Appraisal Checklist for Analytical
CS studies. The quality of evidence for each measured factor was assessed using the Grading of Recommendations Assessment,
Development, and Evaluation methodology. Results: The initial search yielded 3333 studies. The 22 final studies included 13 high-
quality studies with over 80% and nine fair studies with 50% and 79% scored. None of the studies scored below 50%. A negative
link between DA and DU was identified in 15 of 16 studies with 35,846 participants aged 22.19–50.21 years. Six studies on DA, DU,
and OHRQoL included 22,845 participants aged 15–55 years, mostly in their late and mid-fifties. Four of six verified Berggren and
Meynert’s (1984) vicious cycle theory’s high association between DA, DU, and OHRQoL. Conclusions: A 22-study review reveals
a strong association between DA, DU, and OHRQoL. Most moderate to high-quality studies emphasized a negative correlation
between DA and DU, which affected OHRQoL.PROSPERO registration number CRD42023455219.
Keywords: Anxiety, Dental Fear, Dental Public Health, Dental Visits, Quality of Life
Received: 07-Jun-2024, Revised: 09-Aug-2024, Accepted: 21-Aug-2024, Published: 29-Oct-2024.
IntroductIon
The term “dental anxiety” (DA) refers to a negative
psychological response to the stress that is, caused by
visits to the dentist.[1] This global health issue affects
oral health and quality of life (QoL) in all ages and
countries.[2]
Moving beyond the terminology, DA, fear, and phobia
are frequently used interchangeably.[3] When confronted
with a threatening stimulus, dental fear is a “fight-or-
flight” response to a recognized danger. On the other
hand, DA is a response to an unknown threat, and
dental phobia is essentially the same as fear, only much
more substantial.[3] Moreover, DA can develop during
childhood, adolescence, adulthood, or later.[1] Younger
adults are more anxious compared with older people.[4]
On the other hand, one study reported that DA begins
in childhood, peaks in early adulthood, and fades with
age.[5] The association between age and the severity of
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DOI:
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How to cite this article: Ab Malek A, Mohd Radzi NA, Che Musa
MF, Luai AF. Relationship between dental anxiety, dental utilization
and oral health-related quality of life: A systematic review. J Int Oral
Health 2024;16:335-49.
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Ab Malek, et al.: Relationship between DA, DU, and oral health-related QoL
336 336 Journal of International Oral Health ¦ Volume 16 ¦ Issue 5 ¦ September-October 2024
DA is still unclear in the literature, and researchers have
offered contradicting outcomes.[6]
Despite the advancements in oral healthcare technologies,
heightened knowledge, and enhanced dentistry school
curriculum, DA among adults has remained prevalent,
exhibiting different rates across countries and cultures
over the past five decades.[7] Several studies conducted in
Western and European countries have reported prevalence
rates of DA ranging from 4.0% to 37%.[8-11] Conversely,
it was shown that this condition varied from 2.0% to
20.8% among Asian adults.[12] Several local investigations
undertaken in Malaysia have shown a significantly higher
prevalence of DA, ranging from 90% to 99% among
young adults.[13] However, comparing the prevalence
of a particular phenomenon between countries or over
time is not possible due to the differences in measuring
methodologies, various cut-off points, and complex cross-
cultural evaluations.[14,15]
Beyond its prevalence, DA causes missed appointments,
dentist avoidance, and treatment non-adherence.[16] People
with anxiety had worse dental health,[17] whereas poor
oral health lowers QoL.[18] The DA cycle suggested in 1984
illustrated how these components relate.[19] Additionally,
two small-scale studies conducted in Malaysia have
indicated a consistent correlation between higher levels of
DA and an increased prevalence of oral disorders.[20]
Oral health-related QoL (OHRQoL) is a sociodental
indicator that measures how an individual’s QoL is
affected by the context of oral health. A higher DA score
is correlated with a lower OHRQoL, with extreme anxiety
levels predicting poor OHRQoL.[21] This correlation has
been observed globally across various countries, such as
India[18] and Sweden.[22] Despite several systematic reviews
(SRs) on prevalence and therapies, no comprehensive
synthesis of DA, dental utilization (DU), and OHRQoL
has been conducted. This review tried to bridge this gap
and comprehensively explore the relationship between
DA, DU, and OHRQoL.
At the same time, we propose a conceptual framework
[Figure 1] built on a hypothesis that DA acts as a
mediator, influencing patients’ perceptions of dental visits
and, consequently, impacting their OHRQoL. This review
also aids in consolidating the evidence on the intricate
relationship among DA, DU, and OHRQoL in adult
populations. By doing so, not only it contributes to the
understanding of these dynamics but also strengthens
the proposed conceptual framework. Therefore, this SR
aims to systematically review the status and relationship
between DA, DU, and OHRQoL among adult groups and
summarize the available evidence. It is important to note
that this review adheres to the term “DA” as specified by
Minja and Kahabuka[2] study.
MaterIals and Methods
This SR adheres to the Preferred Reporting Items for
Systematic Reviews and Meta-Analyses (PRISMA)
checklist and justification.
Selection of studies
Data collection spanned 6 months, from July 1, 2023, to
December 31, 2023, and was conducted in two phases:
screening the titles and the abstracts and selecting the full-
text articles. Two reviewers (AAM and NAMR) selected
the studies from the screened titles and abstracts. Two
reviewers (AAM and MFCM) independently assessed
all the full-text articles, and disagreements were resolved
Figure 1: The interplay between dental anxiety, dental utilization, and oral health-related quality of life
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Journal of International Oral Health ¦ Volume 16 ¦ Issue 5 ¦ September-October 2024 337
through discussion. Final option judgments were
unanimous among the three reviewers (AAM, NAMR,
and MFCM). Data were extracted and quality assessed
in the included studies. The three reviewers extracted
the data. Quality assessments were conducted by two
reviewers (AAM and AFL).
Type of studies
This SR examined DA, DU, and OHRQoL using only
cross-sectional (CS) studies. The selection was based
on the research question and SR objectives. The CS
studies were chosen over randomized controlled trials or
other observational designs because they can investigate
associations between variables at a specific time. Since our
goal was to examine the relationship between DA, DU,
and OHRQoL, the CS approach allowed us to collect
data on all three variables simultaneously, providing more
generalizable insights into the link between these variables
across diverse populations.
Inclusion and exclusion criteria
Studies conducted in different countries worldwide,
published in English, from their starting date to December
31, 2023 and available full-text articles were included in
the present SR. Any publications containing the keyword
“DA” were reviewed concerning the concepts of “DU”
and “OHRQoL.” The study participants were adults aged
15–64 years.
Search strategy
The search strategies were framed according to the
PICOTS system.[23]
➣ Population (P): Adults aged 15–64 years.
➣ Intervention (I): DA.
➣ Comparator (C): Not applicable.
➣ Outcomes (O): DU and OHRQoL.
➣ Timing (T): From commencement to December 31,
2023.
➣ Study design (S): CS study.
Based on Medical Subject Headings (MeSH), a search
strategy consisting of all possible synonyms for key search
phrases was developed. Truncation, wildcard characters,
and Boolean operators were incorporated into the search
string. The details of the search string used for each
database are shown in Appendix 1.
Data extraction
The data extraction activity includes three reviewers:
AAM, NAMR, and MFCM. Reviewers were matched
with specific papers using data extraction forms [Appendix
2]. All disputes were deliberated. The data extraction
forms were piloted and adjusted in three studies before
screening. Authors, year of publication, country of origin,
search engine, participant data, age, sample size, measuring
instruments, and summary were retrieved from each study.
The outcomes were keyed into an Excel spreadsheet.
Quality assessment tool
The retrieved studies were exported to Mendeley reference
manager software to eliminate duplicates. Methodological
quality and risk of bias (ROB) were independently
assessed using the Joanna Briggs Institute’s (JBI) Critical
Appraisal Checklist for Analytical CS Studies[24] by two
reviewers (AAM and AFL). Any discrepancies were
resolved by the third reviewer (MFCM).
The JBI tool consists of eight domains and questions of
methodological concepts, including participant selection,
confounding factors, outcome validity, and reliability. The
responses to each question were: “Yes,” “No,” “Unclear,”
and “Not applicable.” A score of 1 was given for answering
“Yes,” and a score of 0 was assigned for both “No” and
“Unclear.” Hence, the highest score was 8. The overall
scores for each paper were computed as percentages, and
the quality of each study was rated as good (80%–100%),
fair (50%–79%), or low (<50%).[25] The last section of the
checklist presented the overall appraisal of “include,”
“exclude,” or “seek further information.”
Quality of evidence
Next, the quality of evidence (QoE) for each measured
factor was evaluated in three studies using the Grading
of Recommendations Assessment, Development, and
Evaluation (GRADE) methodology. The GRADE
system categorizes evidence into four levels: very low,
low, moderate, and high. Moreover, QoE derived from
observational data initially begins at a low level. The
following aspects were assessed by two reviewers (AAM
and AFL): ROB, inconsistency, indirect evidence,
imprecision, and publication bias. Disputes were resolved
through consensus, involving a third reviewer (NAMR)
when needed.
results
Description of the included studies
The initial search retrieved 3333 articles from PubMed,
Scopus, Web of Science, Cochrane Library, ScienceDirect,
LILACS, ProQuest, and Springer databases. A total of
3248 studies were shortlisted after 85 duplicates were
removed. Next, 39 full-text studies were further shortlisted
to establish eligibility, and ultimately, 22 studies were
included in the final review [Figure 2]. Sixteen studies
investigated the link between DA and DU, whereas
six examined the relationship between DA, DU, and
OHRQoL. These studies overall involved 58,691 subjects.
Characteristics of included studies
Four of the 22 studies were conducted in the United
Kingdom, two in India, two in Sweden, one each in the
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United States, Germany, and New Zealand, three in Saudi
Arabia, one each in Finland, Norway, Jordan, Kuwait,
China, Turkey, Australia, and Virginia. Sample sizes
ranged from 100 to 11,382, with 58,691 15- to 64-year-old
participants. Appendix 3 summarizes all study findings.
Quality assessment
Of the 22 studies assessed, 13 were high-quality, with over
80%, whereas 9 were fair, with 50% and 79%. None of the
studies was rated below 50%. Table 1 shows each study’s
quality ratings. Although the 22 final articles varied in quality
levels, none was excluded based on poor quality [Figure 3].
QoE for DA, DU, and OHRQoL
Table 2 illustrates the QoE associating DA, DU, and
OHRQoL. The overall certainty of evidence determined
using the GRADE was high because 75% of the studies
were moderate to high-quality on the JBI Critical
Appraisal Checklist, with scores ranging from 4 to 8,
and bias was rated “no serious limitations.” Only one
study gave effect estimates on either side of the line of
no effect and did not correlate DA and DU. Therefore,
there was no notable disagreement. All 22 studies had a
sample that fully represented the review question and “no
serious limitation” for imprecision, avoiding indirectness.
A thorough literature review eliminated publication bias.
Studies revealed no conflicts of interest.
Included studies for a relationship between DA and DU
After a rigorous quality assessment, 16 studies involving
35,846 individuals emerged as key contributors to
unraveling this complex association. The average ages were
22.19–50.21 years, with standard deviations showing age
variation within each group. The sample was heterogeneous
due to participants aged 30 and older, 25–35, 18–65, and
15 years and older. Age categories such as 17–20 and
30–45 years added to our awareness of the study’s wide
demographic makeup, reinforcing the importance of these
studies in investigating the complicated interplay between
DA and DU.
Figure 2: The PRISMA 2020 flow diagram illustrates the sequential steps involved in identifying, screening, assessing eligibility, exclusion, and
inclusion of studies
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Six studies employed the Modified Dental Anxiety
Scale (MDAS) to assess DA,[30,35,36,40,42,43] two used
Corah’s Dental Anxiety Scale (DAS),[39,41] and one
each utilized the DA questionnaire (DAQ), fear of
pain questionnaire, dental fear survey (DFS), and
Index of Dental Anxiety and Fear (IDAF-4C+).
Four studies relied on a single question to gauge
DA.[33,34,37,38] Despite variations in measurement tools,
all studies assessed DU. As outcome measures, the
selected studies focused on dental visit frequencies,
care behaviors, regularity, avoidance factors, DU, and
attendance patterns.
Table 1: Summary of the quality appraisal for the included studies using the JBI critical appraisal checklist for analytical cross-
sectional studies
Included studies JBI quality assessment criteria Overall appraisal: include/
exclude/seek further info
Score
percentage (%)
Comments
(high/fair/low)
Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q8
1 Heidari et al. (2015)[26] N Y Y Y N N Y Y Include 62.5 Fair
2 Kumar et al. (2009)[18] Y Y Y Y Y Y Y Y Include 100 High
3 Boman et al. (2012)[27] Y Y Y Y Y Y Y Y Include 100 High
4 Carlsson et al. (2015)[22] Y Y Y Y N Y Y Y Include 87.5 High
5 Winkler et al. (2023)[28] U N Y Y N N Y Y Include 50.0 Fair
6 Sukumaran et al. (2020)[29] Y Y Y U Y Y Y Y Include 87.5 High
7 AlRatroot et al. (2022)[30] Y Y Y Y Y Y Y Y Include 100 High
8 Gaffar et al. (2014)[31] Y Y Y Y N Y Y Y Include 87.5 High
9 Meng et al. (2007)[32] Y Y Y Y Y Y Y Y Include 100 High
10 Pohjola et al. (2007)[33] Y U Y Y Y Y Y Y Include 87.5 High
11 Astrom et al. (2022)[34] Y Y Y Y Y Y Y Y Include 100 High
12 Alkuwaiti et al. (2023)[35] Y Y Y Y U U Y Y Include 75.0 Fair
13 Shahid and Freeman (2019)[36] Y Y Y Y U U Y Y Include 75.0 Fair
14 Obeidat et al. (2014)[37] Y Y Y Y Y Y Y Y Include 100 High
15 Al-Shammari et al. (2007)[38] Y Y U N Y Y Y Y Include 75.0 Fair
16 Mellor (1992)[39] Y Y Y Y Y Y Y Y Include 100 High
17 Bhola and Malhotra (2014)[40] YYYYNA NA Y Y Include 75.0 Fair
18 Woolgrove (1986)[41] Y Y Y Y U U Y Y Include 75.0 Fair
19 Yu et al. (2021)[42] YYYYNA NA Y Y Include 75.0 Fair
20 Yüzügüllü et al. (2014)[43] Y Y Y Y U U Y Y Include 75.0 Fair
21 Wiener (2017)[44] Y Y Y Y Y Y Y Y Include 100 High
22 Armeld (2013)[3] Y Y Y Y Y Y Y Y Include 100 High
Y = yes, N = no, U = unclear, NA = not applicable. Q1 = Were the criteria for inclusion in the sample clearly dened? Q2 = Were the study subjects
and the setting described in detail? Q3 = Was the exposure measured validly and reliably? Q4 = Were objective, standard criteria used for measurement
of the condition? Q5 = Were confounding factors identied? Q6 = Were strategies to deal with confounding factors stated? Q7 = Were the outcomes
measured validly and reliably? Q8 = Was appropriate statistical analysis used?
20
20
21
20
12
14
22
22
1
1
1
4
2
1
1
1
1
4
4
2
2
0510 15 20 25
Q1= Were the criteria for inclusion in the sample clearly
defined?
Q2= Were the study subjects and the setting described in
detail?
Q3= Was the exposure measured in a valid and reliable
way?
Q4= Were objective, standard criteria used for
measurement of the condition?
Q5= Were confounding factors identified?
Q6= Were strategies to deal with confounding factors
stated?
Q7= Were the outcomes measured in a valid and reliable
way?
Q8= Was appropriate statistical analysis used?
Number of studies
YesNo UnclearN/A
Figure 3: Overview of the results using the JBI Critical Appraisal Checklist for analytical cross-sectional studies on the 22 selected articles
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Notably, 16 studies included in the review were CS
[Appendix 4]. A survey in 2022 demonstrated that routine
dental attendance within a year reduced DA,[30] whereas
in 1992, another survey reported that people who had
not been to the dentist in over a year had more DA than
those who had recently.[39] Additionally, one study in 2014
revealed that anxious patients postponed dental visits,
with a higher percentage reporting intervals of more
than 2 years between their last dental visit.[43] Besides, DA
was also noted to hinder preventive dental visits among
Jordanian adults.[37,38] In a similar vein, DA was found to
prevent more than 30% of the sample from seeking dental
care.[41]
After controlling for sociodemographic and general health
factors, it was demonstrated that DA and fear of dental
pain negatively affected DU and oral health outcomes.[32]
One study highlighted appointment cancelation rates as
fear-based and cost-related dental avoidance.[34] Another
study found that DA, communication issues, and treatment
costs were barriers to dental care, with DA mediating the
relationship between perceived need and extended dental
visits.[36] However, a study conducted among patients in the
University of Dammam Interns’ Dental Clinics in Saudi
Arabia in 2014 reported no association between irregular
dental visits and DA.[31]
Included studies for examining the relationship between
DA, DU, and OHRQoL
Six selected studies examined the relationship between
DA, DU, and OHRQoL. All six studies employed reliable
measures to assess DA, including the MDAS,[26] DAS,[18]
DFS,[27] DAQ,[22] and Corah’s DAS[29] [Appendix 5]. The
number of participants was 22,845, aged between 15 and
55 years, concentrating in their late teens and mid-fifties.
Four studies examined DU using dental attendance
and visiting practices.[18,22,26,27] One study used dental
appointments to quantify DU,[28] whereas another one
employed oral health services.[29] In terms of OHRQoL,
three studies utilized Oral Health Impact Profile-14
(OHIP-14),[26,27,29] one used OHIP-5 (OHIP-5),[22] another
used OHRQoL-UK[18] and one employed German OHIP
(OHIP-G5).[28] Despite the different scales used, all were
validated and reliable.
Four studies discovered a robust correlation between DA,
DU, and OHRQoL.[18,22,27,29] They confirmed a strong
correlation between DA, DU, and OHRQoL, as proposed
in the vicious cycle theory by Berggren and Meynert.[19]
DA was found to vary considerably by dental visiting
habits and affected OHRQoL even after controlling for
other variables.[18] Besides, high DA and irregular dental
care were reported to be almost four times more likely to
trigger poor OHRQoL.[27] Indeed, high DA was associated
with low OHRQoL and irregular dental attendance.[22]
These four CS national surveys supported the vicious cycle
of DA by showing substantial relationships between high
DA, avoidance of dental care, and health consequences.
Moreover, dentally anxious New Zealand adults have
been found to have greater oral disease experience and
visited the dentist less in the past year.[29] DA in 35- to
54-year-olds had the highest OHIP-14 impacts and lower
OHRQoL.[29]
Two more studies revealed a direct relationship between
DA and OHRQoL.[26,28] It was immediately associated with
DA and OHRQoL rather than following the cycle from
DU to OHRQoL. Illustrating these deviations in 2015,
Heidari et al.[26] found significant differences between
phobias and non-phobias scores in OHIP-14 and oral
impact on daily performance scores. People with phobia
scored higher. A substantial correlation exists between
higher DAS and OHIP-G5 scores, which decreased the
total OHRQoL.[28]
dIscussIon
To our knowledge, this is the first SR of the relationship
between DA, DU, and OHRQoL. An important
novelty was introduced in this study, given that no
previous SR in Malaysia or worldwide has examined
these relationships in such detail. DA, as predicted and
indicated by the vicious cycle of DA, has an impact on
DU and subsequently impacts OHRQoL. For instance,
the majority of patients with DA in this SR had an
independent negative effect on DU behaviors.[32,36,45] This
conclusion has been derived from our comprehensive
SR, taking into account potential confounding variables
that could influence it, including age, sociodemographic
parameters, and cost.
Table 2: Quality of evidence
Outcomes Participants (n) No. of
studies
GRADE factors
Risk of
bias
Inconsistency Indirectness Imprecision Publication
bias
Overall quality
Dental
utilization
35,846 16 √ x √ √ √ High
OHRQoL 22,845 6 √ √ √ √ √ High
For GRADE factors: √ = no serious limitations, x = serious limitations, For overall quality of evidence = very low, low, moderate, high, OHRQoL=oral
health-related quality of life
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There were some limitations in this SR. Most of the
studies in the analysis were CS, making causality
findings unfeasible due to potential bias and inaccurate
representation of causal links. Recall bias was another
drawback of these CS studies. However, considering the
nature of the review question, these limitations may be
acceptable for this SR. The studies’ various instruments
may have influenced the outcomes and caused
heterogeneity. Nevertheless, all studies used CS-adapted
questionnaires to evaluate DA, DU, and OHRQoL with
suitable psychometric characteristics, indicating that all
instruments used were accurate and reliable.
Relationship between DA and DU
This SR discovered compelling evidence supporting
a substantial correlation between DA and DU.
Approximately 15 out of 16 studies found a negative
correlation between DA and DU, in which only one
disagreed. There was no correlation between irregular
dental visits and DA, and they found that time, money, and
distance to dental clinics caused irregular dental visits.[31]
The present SR found that DA delayed dental visits. One
study discovered that DA delayed dental appointments
in a comparable SR.[46] They reported that postponing a
dentist appointment due to DA increased the probability
of future DA.[46]
Building on this, an association between DA and visiting
patterns was highlighted.[17] High DA reduces dental
visits, causing dental problems. Thus, DA increases
problem visits and social and functional impairment.[17]
This finding suggests that DA may be a component in
a cycle of dental disadvantage, with dentally anxious
individuals avoiding dental care, exacerbating their dental
problems.[17] In particular, these findings link DA and DU,
reinforcing our SR’s emphasis on the intricate interplay
between psychological factors and dental behavior.
Furthermore, our SR corroborates the findings of three
surveys,[30,39,43] aligning with the vicious cycle of dental
fear explored in 2007.[17] The conclusion emphasizes the
importance of examining dental visit frequency and
timing to understand the intricate relationship between
DA and DU. To extend our perspective, we can draw
comparisons with the study undertaken in 1998,[47] which
identified that dental fear and anxiety decreased dental
appointment frequency and increased the perception of
poor oral health. Our SR supports this same viewpoint.
Although they focused on special-needs populations, our
focus on adult groups underscores a common theme: DA
avoids or postpones dental visits.
Relationship between DA with DU and OHRQoL
The present SR includes six studies on DA, DU,
and OHRQoL. Four studies suggested a significant
relationship between DA, DU, and OHRQoL.[18,22,27,29] This
corroborated the self-perpetuating pattern as indicated in
1984.[19] Building upon these findings, the remaining two
studies in our SR highlighted a direct link between DA
and OHRQoL, indicating that individuals with increased
DA levels experienced poor OHRQoL. Interestingly, this
observation challenges the vicious cycle concept suggested
in 1984.[19]
To further understand the significance of our findings,
it is essential to acknowledge the broader societal
consequences of DA. Our comprehensive SR illustrates
the complex correlation between DA, DU, and OHRQoL,
revealing that addressing DA extends beyond well-being.
It impacts public health and dental prevention.
conclusIons
A comprehensive analysis of 22 studies provides
compelling evidence of a significant association between
DA, DU, and OHRQoL. Subsequently, it supports and
strengthens the conceptual framework proposed with the
hypothesis that DA acts as a mediator, influencing adult
patients’ perceptions of dental visits and, consequently,
impacting their OHRQoL. Most moderate to high-quality
studies emphasize a negative correlation between DA and
DU. Tackling these concerns is crucial for formulating
strategies to mitigate DA, ultimately fostering proactive
dental care and enhancing public health outcomes.
Further investigations in this field are recommended.
Acknowledgements
The authors express their heartfelt gratitude to all
individuals, institutions, and organizations whose invaluable
contributions and support were instrumental in the
completion of this systematic review. We also extend our
sincere thanks to the government officials and acknowledge
the Director-General of the Ministry of Health, Malaysia,
for granting permission to publish this work.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
Author contributions
Azizi Ab Malek: Contributed to conception and design,
data acquisition, analysis, and interpretation, drafted
and critically revised the manuscript, gave final approval,
and agreed to be accountable for all aspects of work
ensuring integrity and accuracy. Nawwal Alwani Mohd
Radzi: Contributed to conception and design, data
acquisition, and interpretation, drafted and critically
revised the manuscript, gave final approval, and agreed to
be accountable for all aspects of work ensuring integrity
and accuracy. Muhd Firdaus Che Musa: Contributed
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to conception and design, data acquisition and analysis,
drafted and critically revised the manuscript, gave final
approval, and agreed to be accountable for all aspects of
work ensuring integrity and accuracy. Amirul Faiz Luai:
Contributed to design and data analysis, drafted and
critically revised the manuscript, gave final approval, and
agreed to be accountable for all aspects of work ensuring
integrity and accuracy.
Ethical policy and Institutional Review Board Statement
Not applicable.
Patient declaration of consent
Not applicable.
Data availability statement
All pertinent data for the study is either contained
inside the publication or provided as supplementary
information.
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appendIx 1: lIterature search: search strIng
PubMed search string
(“Dental Anxiety/complications”[MeSH]) AND “Young
Adult”[Mesh]) OR (“Dental Anxiety/complications”[MeSH])
AND “oral health”[MeSH]) OR (“Dental Anxiety/
complications”[MeSH]) AND “dental utilization”[MeSH])
OR (“Dental Anxiety/complications”[MeSH]) AND
“dental utilization”[MeSH] AND “adult”[MeSH]) OR
(“Dental Anxiety/complications”[MeSH]) AND “dental
utilization”[MeSH] AND “oral health related quality of
life”[MeSH]).
Scopus search string
TITLE-ABS-KEY (“dental anxiety” AND “dental
utilization”) OR TITLE-ABS-KEY (“dental anxiety”)
AND (“dental utilization” OR “dental utilization”)
AND (“oral health” OR “oral health-related quality of
Life”) OR TITLE-ABS-KEY (“dental anxiety”) AND
(“dental utilization” OR “dental utilization”) AND (“oral
health-related quality of Life”) OR TITLE-ABS-KEY
(“dental anxiety”) AND (“dental utilization” OR “dental
utilization”) OR TITLE-ABS-KEY (“dental anxiety”)
AND (“oral health-related quality of Life”).
Web of Science search string
((ALL=(dental anxiety)) AND ALL=(dental utilization
OR dental utilization)) AND ALL=(oral health related
quality of life) OR (((((ALL=(dental anxiety)) OR
ALL=(dental fear)) OR ALL=(dental phobia)) AND
ALL=(dental utilization)) OR ALL=(dental utilization))
AND ALL=(oral health related quality of life) OR
((ALL=(dental anxiety OR dental phobia OR dental
fear)) AND ALL=(dental utilization OR dental utilization
OR dental visit*)) AND ALL=(oral health related quality
of life) OR (ALL=(dental anxiety OR dental fear OR
dental phobia)) AND ALL=(dental utilization OR dental
utilization OR dental visit*) OR ((ALL=(dental anxiety
OR dental fear OR dental phobia)) AND ALL=(dental
utilization OR dental utilization OR dental visit*)) AND
ALL=(adult*) OR (ALL=(dental anxiety OR dental
fear OR dental phobia)) AND ALL=(oral health related
quality of life) OR ((ALL=(dental anxiety OR dental
fear OR dental phobia)) AND ALL=(oral health related
quality of life)) AND ALL=(adult*).
Cochrane Library search string
#1 Dental anxiety OR dental fear OR dental phobia in
All Text AND dental utili* OR dental visit*
#2 Dental anxiety OR dental fear OR dental phobia in
All Text AND dental utili* OR dental visit* in All
Text AND adult*
#3 Dental anxiety OR dental fear OR dental phobia in
All Texts AND oral health-related quality of life.
Science Direct search string
(“dental anxiety” OR “dental fear” OR “dental phobia”
AND “dental visit” OR “dental utilization” OR “dental
utilization”) OR (“dental anxiety” OR “dental fear”
OR “dental phobia” AND “dental visit” OR “dental
utilization” OR “dental utilization” AND “oral health-
related quality of life” OR “OHRQoL”) OR (“dental
anxiety” OR “dental fear” OR “dental phobia” AND
“dental visit” OR “dental utilization” OR “dental
utilization” AND “adult”).
LILACS search string
(dental anxiety) AND (dental visit*)
(dental anxiety) AND (oral health-related quality of life)
(dental anxiety) AND (dental visit*) AND (oral health-
related quality of life).
ProQuest search string
adult* and dental anxiety and dental utilization and
OHRQoL
“dental anxiety” OR “dental fear” OR “dental phobia”
AND “dental visit*” AND “oral health-related quality of
life.”
Springer search string
“dental anxiety and utilization” OR “dental anxiety and
oral health-related quality of life” OR “dental anxiety and
utilization and oral health-related quality of life.”
appendIx 2: data extractIon forM
Study title:
Authors and year of publication:
Database
Study design
Participants
Sample size
Range, mean, age
Dental anxiety measure
Outcomes measure: dental utilization
Outcomes measure: OHRQoL
Response rate
Aim/objective
Results and reading
Summary of results
Recommendations
Notes
onlIne suppleMental appendIx
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appendIx 3: descrIptIon of the studIes Included In thIs systeMatIc revIew
No Author, year,
setting
Title Study
design
Participants,
sample size
(N)
Range,
mean age
(years)
DA
measure
Outcomes
measure (DU
and OHRQoL)
Summary of results
Dental anxiety
Dental utilization and OHRQoL
1 Heidari et al.
2015, London
Oral health
status of non-
phobic and
dentally phobic
individuals;
a secondary
analysis of the
2009 Adult
Dental Health
Survey
CS The adult
population
in England,
Wales, and
Northern
Ireland, N =
11,380
16–55 MDAS Dental
attendance
Self-rated oral
and general
health
• OHIP-14
• OIDP
There were signicant differences
(P < 0.001) between the phobic
group’s and non-phobic group’s
Oral Health Impact Prole-14
(OHIP) and Oral Impacts on
Daily Performance (OIDP)
scores with phobic participants
having generally higher scores.
Participants reporting dental
phobia are mostly females,
irregular attendees, and have
a greater treatment need with
increased caries levels.
2 Kumar et al.
2009, India
Does dental
anxiety
inuence oral
health-related
quality of life?
Observations
from a cross-
sectional study
among adults in
Udaipur district,
India
CS Individuals
aged
15–54 years
living in
Udaipur
district, N =
1324
15–54 DAS Dental visiting
habits
OHQoL-UK(W)
DA had a signicant inuence on
OHQoL, with people with high
DA being 2.34 times more likely
to present poor OHQoL than
those having low anxiety.
Those who never visited a dentist
had an odds ratio of 1.62 for
poor OHQoL relative to those
who had visited a dentist within
the last 12 months.
Subjects who never visited a
dentist reported signicantly
higher mean DAS than those
who had been to a dentist within
the last 12 months.
DA differed signicantly with age
and dental visiting practices and
had a signicant impact on oral
health-related quality of life after
controlling for other variables.
3 Boman et al.
2012, Sweden
Oral health-
related quality
of life, sense
of coherence
and dental
anxiety: An
epidemiological
cross-sectional
study of middle-
aged women
CS Women in
Gothenburg,
Sweden, N =
500
38–50 DFS Dental visiting
habits
OHIP-14
High DA was found to be
strongly associated with irregular
dental care, indicating that
individuals with high levels of
DA were more likely to avoid or
delay dental appointments. The
odds of having poor OHRQoL
were almost four times higher for
individuals with high DA and
irregular dental care compared to
those with lower levels of these
behavioral factors. High DA
predicted low OHRQoL.
4 Carlsson et al.
2015, Sweden
Associations
between dental
anxiety, sense of
coherence, oral
health-related
quality of life
and health
behavior: – A
national Swedish
cross-sectional
survey.
CS Individuals
aged 19 years
or above were
randomly
selected using
the national
SPAR registry,
N = 3500
53.4 ± 17.5 DAQ Dental care
attendance:
• Regular:
yearly and once
every other year
• Irregular: less
often than every
other year, only
acutely or never
dental care
• OHIP-5
High DA was related to low
OHRQoL and irregular dental
attendance patterns.
This cross-sectional national
survey gives support to the
signicant associations between
high DA, avoidance of dental
care, and health-related
outcomes, which may further
reinforce the model of a vicious
circle of dental anxiety.
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No Author, year,
setting
Title Study
design
Participants,
sample size
(N)
Range,
mean age
(years)
DA
measure
Outcomes
measure (DU
and OHRQoL)
Summary of results
Dental anxiety
5 Winkler et al.
2023, Germany
Impact of
Dental Anxiety
on Dental Care
Routine and
Oral-Health-
Related Quality
of Life in a
German Adult
Population – A
Cross-Sectional
Study
CS Adults in
Technical
University of
Dresden, N =
2666
45.5 ± 18.2 DAS Dental
appointments
OHIP-G5
Higher DAS scores were
found to be strongly
associated with greater
OHIP-G5 scores, thus leading
to a substantial decline in
overall OHRQoL.
The ndings of this study
unveil a signicant correlation
between elevated DAS scores
and reduced frequency of tooth
brushing; calculus removal and
appointments for professional
teeth cleaning.
6 Sukumaran
et al. 2020, New
Zealand
The Prevalence
and Impact of
Dental Anxiety
Among Adult
New Zealanders
CS Adults from
New Zealand
who took
part in the
2009 New
Zealand Oral
Health Survey
(NZOHS), N =
3475
18 years or
older
Corah’s
DAS
Utilization of
oral health
services.
OHIP-14
Those who were dentally
anxious had greater oral
disease experience and were
less likely to have visited a
dentist within the previous 12
months. They also had poorer
oral health-related quality of
life, with the highest prevalence
of OHIP-14 impacts observed
in dentally anxious 35- to
54-year-olds.
DA is an important contributor
to poor oral health and
care avoidance among New
Zealanders.
Dental utilization
7 AlRatroot et al.,
2022, Saudi
Arabia
Dental Anxiety
Amongst
Pregnant
Women:
Relationship
with Dental
Attendance
and Socio-
demographic
Factors.
CS Pregnant
women visiting
prenatal clinics
in major
hospitals and
primary health
care centers
in Dhahran,
Khobar, and
Dammam
cities in the
Eastern
Province of
Saudi Arabia,
N = 825
29.08 ± 5.18 MDAS WHO Oral
Health Survey
for
Adults: patterns
of dental
attendance
Routine dental attendance and
dental visits during 1 year were
related to reduced DA.
The multiple logistic regression
analysis showed signicantly
increased odds of experiencing
moderate to extreme dental
anxiety among pregnant women
who visited the dentist after 1
year or never.
The participants who
performed routine dental visits
demonstrated lower dental
anxiety scores than those who
visited the dentist for pain,
treatment, or consultation.
8 Gaffar et al.,
2014, Saudi
Arabia
The prevalence,
causes, and
relativity of
dental anxiety in
adult patients to
irregular dental
visits.
CS Patients
attending the
Interns’ Dental
Clinics in the
University
of Dammam,
Kingdom of
Saudi Arabia,
N = 1025
22.19 ± 14.70 Dental
Anxiety
Question
(DAQ)
Regularity of
dental visits and
related causes.
Irregular dental visits were not
related to dental anxiety.
9 Meng et al. 2007,
USA
Effect of fear on
dental utilization
behaviors and
oral health
outcome.
CS Adults in
Florida, USA,
N = 504
49.4 FPQ-III Dental care
utilization
behaviors
Dental fear and FDP have
independent negative effects
on dental utilization behaviors
and oral health outcomes after
controlling for other socio-
demographic and general health
factors.
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No Author, year,
setting
Title Study
design
Participants,
sample size
(N)
Range,
mean age
(years)
DA
measure
Outcomes
measure (DU
and OHRQoL)
Summary of results
Dental anxiety
10 Pohjola et al.
2007, Finland
Association
between dental
fear and dental
attendance
among adults in
Finland.
CS Adults in
Finland, N =
6986
Age 30 and
older
Single
question
“How
afraid are
you of
visiting a
dentist?”
Dental visits
frequency
Reducing dental fear would
increase the number of regular
attendees, especially among
older age groups.
11 Åstrøm et al.
2022, Norway
Exploring
avoidance of
dental care due
to dental fear
and economic
burden – A
cross-sectional
study in a
national sample
of younger
adults in
Norway.
CS Norwegian
adults, N =
9052
25–35,
30.1 ± 3.2
Two indicators
of dental
avoidance
behavior
were utilized
as outcome
measures:
a. Ever
canceled dental
appointment due
to dental fear.
Ever avoided
ordering dental
appointments
due to dental
fear?
14.7%, 30.5%, and 37.7%
conrmed canceled appointments
due to fear, avoided ordering
appointments due to fear, and
avoided visiting the dentist due
to cost.
Avoiding dental care due to
fear and economic burden was
more and less common among
participants with respectively,
frequent and seldom use of dental
care.
Dental fear has been dened as a
universal factor inuencing dental
avoidance across age groups.
12 Alkuwaiti et al.
2023, Saudi
Arabia
Dental Anxiety
Among
Physicians:
Relationship
with Oral
Problems,
Dental Visits,
and Socio-
Demographic
Factors.
CS Physicians
in Dhahran,
Khobar,
Dammam, and
Qatif cities in
the Kingdom
of Saudi
Arabia, N =
377
24–68,
40.13 ± 10.45
MDAS Oral Health
Questionnaire
for Adults by the
WHO.
Dental anxiety can deter
individuals from seeking regular
dental care, leading to more oral
health problems.
13 Shahid and
Freeman, 2019,
UK
What is the
function of
psychosocial
factors in
predicting length
of time since last
dental visit? A
secondary data
analysis.
CS Adults in
England, Wales
and Northern
Ireland, N =
11,382
50.21 ± 18.27 MDAS Dental visits
frequency
DA, communication, and
treatment costs acted as barriers to
accessing dental care.
Dental anxiety acted as a mediator
in the relationship between the
perception of need and the
increased time interval between
dental visits.
14 Obeidat et al.
2014, Jordan
Factors
inuencing
dental care
access in
Jordanian
adults.
CS Jordanian
adults, N = 650
18–65 Reasons
for not
visiting or
irregularly
visiting
dentists
Utilization of
dental services.
Patterns
of dental
attendance.
Dental fear was identied as a
signicant barrier to regular dental
attendance in Jordanian adults.
15 Al-Shammari
et al. 2007,
Kuwait
Barriers
to seeking
preventive
dental care by
Kuwaiti adults.
CS Kuwaiti
nationals
18 years of
age or older
recruited from
all six districts
(Capital,
Ahmadi,
Hawalli, Jahra,
Farwaniya,
and Mubarak),
N = 2400
18–70,
33.4 ± 9.0
Dental fear
is one of
the reasons
for not
visiting the
dentist
Dental visit
history.
Reasons for
not visiting the
dentist
Dental fear is a signicant barrier
to seeking preventive dental visits.
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348 348 Journal of International Oral Health ¦ Volume 16 ¦ Issue 5 ¦ September-October 2024
No Author, year,
setting
Title Study
design
Participants,
sample size
(N)
Range,
mean age
(years)
DA
measure
Outcomes
measure (DU
and OHRQoL)
Summary of results
Dental anxiety
16 Mellor, 1992,
England
Dental anxiety
and attendance
in the North-
west of England.
CS Workers from
three different
workplaces in
the North-west
of England, N
= 300
17–64, 33.8 Corah DAS Time interval
since last dental
check-up
There was a signicant association
between dental anxiety and dental
attendance, with those who had
not visited the dentist in more
than a year being more likely to
be anxious or highly anxious than
those who had a check-up in the
last year.
17 Bhola and
Malhotra, 2014,
India
Dental
procedures,
oral practices,
and associated
anxiety: A
study on
late-teenagers.
CS Indian college
students (50
males and
50 females)
of Delhi
University, N
= 100
17–20 MDAS Frequency of
dental visits
The irregularity in dental visits
was found to be interdependent
with the degree of anxiety, as
higher anxiety reinforced fewer
visits.
There is a strong correlation
between dental anxiety and the
frequency and regularity of
dental visits among Indian college
students.
18 Woolgrove, 1986,
London
Dental anxiety
and regularity
of dental
attendance.
CS Casual patients
at Birmingham
Dental
Hospital, N
= 386
30 Corah DAS Frequency of
dental visits
Reasons for not
attending the
dentist
DA is a major barrier to seeking
dental care, with over 30% of the
sample admitting to avoiding or
delaying dental visits due to fear.
19 Yu et al. 2021,
China
The Prevalence
of Dental
Anxiety
Associated with
Pain among
Chinese Adult
Patients in
Guangzhou.
CS Dental adult
patients in
Guangzhou,
China, N = 183
30–45 MDAS Frequency of
dental visits
The relationship between dental
anxiety and dental visits is
signicant, and the frequency
of dental visits is strongly
associated with the MDAS score.
Patients who suffer from DA
are more likely to postpone or
neglect dental treatment, leading
to the deterioration of their oral
health.
20 Yüzügüllü et al.
2014, Turkey
Dental Anxiety
and Fear:
Relationship
with Oral
Health Behavior
in a Turkish
Population.
CS Patients at
Baskent
University,
Faculty of
Dentistry,
in Ankara,
Turkey, N =
500
32.97 ± 13.11 MDAS
DFS
Frequency of
dental visits
Reason for the
last dental visits
Fearful patients were more likely
to have a delayed pattern of dental
visits, with a higher percentage of
last visiting a clinician at intervals
of more than 2 years.
21 Wiener, 2017,
Virginia
Dental Fear
and Delayed
Dental Care in
Appalachia-
West Virginia.
CS Adults over the
age of 18 years
in a university
dental clinic in
Appalachia-
West Virginia,
N = 140
18–60 DFS Frequency of
dental visits
The prevalence of dental fear was
high in the study population, and
dental fear was the only signicant
variable associated with delayed
dental care.
22 Armeld, 2013,
Australia
What goes
around comes
around:
Revisiting the
hypothesized
vicious cycle of
dental fear and
avoidance.
CS Dentate
Australians
aged 15 and
above, N =
1036
Aged 15+,
43.5
IDAF-4C+ Reason for
visiting a dental
professional
Dental fear often leads to
avoidance or delay in seeking
dental care.
Individuals with moderate to high
dental fear are more likely to avoid
or delay dental visits because of
fear or dislike.
CS = cross-sectional, DA = dental anxiety, OHRQoL = oral health-related quality of life, MDAS = Modied Dental Anxiety Scale, DAQ = Dental Anxiety
Question, VAS-A = Visual Analog Scale for Anxiety, DFS = Dental Fear Scale, IDAF-4C+ = Index of Dental Anxiety and Fear, DAS = Dental Anxiety Scale,
FDP = fear of dental pain, FPQ-III = Fear of Pain Questionnaire III, OHIP-14 = Oral Health Impact Prole-14, OHIP-5 = Five-Item Version of the Oral
Health Impact Prole, OHIP-G5 = German Oral Health Impact Prole
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Journal of International Oral Health ¦ Volume 16 ¦ Issue 5 ¦ September-October 2024 349
appendIx 4: dIstrIbutIon and characterIstIcs of the 16 Included studIes on the relatIonshIp between
da and du
appendIx 5: dIstrIbutIon and characterIstIcs of the sIx Included studIes on the relatIonshIp of da
wIth du and ohrQol
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