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Year : 2021  |  Volume : 19  |  Issue : 1  |  Page : 27-31

Dental anxiety and sense of coherence among outpatient department patients of a dental college in Chhattisgarh: A correlational study

Department of Public Health Dentistry, Rungta College of Dental Sciences and Research, Bhilai, Chhattisgarh, India

Date of Submission13-Jul-2020
Date of Decision13-Oct-2020
Date of Acceptance17-Feb-2021
Date of Web Publication31-Mar-2021

Correspondence Address:
N Naveen
1154, 25th Main 3rd Cross, J P Nagar 1st Phase, Bengaluru - 560 078, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jiaphd.jiaphd_143_20

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Context: The term “dental anxiety” (DA) refers to the feeling of uneasiness one undergoes during their appointment. Sense of coherence (SoC) is known to be capable of strengthening resilience and developing a subjectively positive state of health. There have been scarce studies showing the association between these two variables. Aim: The present study correlates DA and SoC among patients visiting outpatient department for the first time of a dental college in Chhattisgarh. Materials and Methods: A cross-sectional, questionnaire study was conducted among 400 participants. SoC and DA were measured using Antonovosky's Modified DA Scale and SoC Scale (SoC 13), respectively. The Chi-square test and Pearson's correlation coefficient were used. The analysis was done using the SPSS software version 16.0. Results: Out of 400 participants, the mean age was 37.5, where the number of male participants was high (male = 265 and female = 135). 44.8% of the study participants were slightly anxious. DA according to the age and gender was found to be statistically insignificant (P ≤ 0.896), (P ≤ 0.171), respectively. The overall SoC among the study population was low and a statistically significant association between SoC and age (P ≤ 0.046) was seen. A statistically significant association was found between SoC and gender (P ≤ 0.001). The results stated that SoC is inversely proportional to DA (r = −0.97). Conclusions: The present study reflects that DA and SoC have inverse correlation.

Keywords: Chhattisgarh, correlation, dental anxiety, outpatient department patients, sense of coherence

How to cite this article:
Naveen N, Pradhan A, Singh S, Borkar P. Dental anxiety and sense of coherence among outpatient department patients of a dental college in Chhattisgarh: A correlational study. J Indian Assoc Public Health Dent 2021;19:27-31

How to cite this URL:
Naveen N, Pradhan A, Singh S, Borkar P. Dental anxiety and sense of coherence among outpatient department patients of a dental college in Chhattisgarh: A correlational study. J Indian Assoc Public Health Dent [serial online] 2021 [cited 2022 Dec 3];19:27-31. Available from: https://www.jiaphd.org/text.asp?2021/19/1/27/312637

  Introduction Top

Anxiety is an emotion describing a person's reaction toward situations that they might consider stressful, dangerous, or not favorable. Dental anxiety (DA) is a multidimensional and complex concept, but it can be explained simply as anxious thoughts about getting dental treatment. This anxiety tends to create fear in the patient as a result of which they avoid seeking oral health care. Any patient-seeking dental treatment in a dental clinic/institution for the 1st time is anxious about how they are going to be treated. Apart from this DA can also be due to various reasons such as the fear of pain, sight of blood, noise of dental instrument, and dental experiences shared by other people who have already visited a dentist.[1]

Sense of coherence (SoC) is a global orientation that is part of the Salutogenesis theory given by Antonovsky in 1979, it expresses the extent to which one has pervasive and enduring, tough dynamic, feeling of confidence that one's environment is predictable that things will work out as well as reasonably can be expected. It has three components: Comprehensibility, manageability, and meaningfulness.[2] This concept explains different people's different perceptions toward life situations and stressors, the people who have a high SoC have a better perception toward situations and tend to react better, when under stress or under unfavorable situations. It is one's internal ability to identify their own internal and external environment and to create a positive balance between both. A person acquires the level of SoC before the age group of 30 years, and it remains relatively stable after that age.[3]

The SOC has also been associated with several general and oral health behaviours, such as dietary habits, alcohol consumption, drug recovery, and physical activity.[4] One of the studies in Finland has determined that people with low SoC are more anxious toward dental treatment as compared to people with high SoC.[5] Many studies have been conducted in India assessing DA, its impact on oral habits and disease and the association of SoC, DA, and oral health. No such study to our best knowledge has been carried out to correlate DA and SoC in adult patients of outpatient department (OPD) of Dental college of Chhattisgarh. The research hypothesis of the study is to assess an association between DA and SoC among the adult patients of OPD of Dental college of Chhattisgarh. Hence, the study was conducted to correlate DA and SoC, with an objective to assess age and gender related DA and SoC among the adult patients of OPD of Dental college of Chhattisgarh.

  Materials and Methods Top

Study setting and participants – the study was conducted among patients visiting the OPD of a dental college in Chhattisgarh for the first time during the months of 1 July–August 30, 2019. The data collection was done following the proper research protocol. The ethical approval was taken from the Institutional Review Board. The sample size was derived from the prevalence of a previous study[1] using the Cochrane's formula:

Where N = Sample size,

Z = Z statistic for a level of confidence,

P = Expected prevalence or proportion

D = Precision

On putting values, we get required sample of 381 which was rounded off to 400.

The participants were selected using the convenient sampling methods and those who gave consent after properly explaining the study were taken as participants. The sample selection was done on the basis of inclusion and exclusion criteria.

Inclusion criteria

  1. Attending the dental college/dentist OPD for the 1st time
  2. Patients who gave consent
  3. Patients above 18 years of age
  4. Patients who were properly able to understand and answer the questionnaire.

Exclusion criteria

  1. Patients who came for subsequent treatment
  2. Patients who refused to participate
  3. Patients who were mentally challenged.

A pilot study was conducted to assess validity and reliability of questionnaire. Thirty patients were included in the pilot study, where Modified DA Scale (MDAS) to assess DA[6] and SoC-13 questionnaire was taken for SoC.[7] The pilot study was done to check the feasibility of the study and validity of the questionnaire. The average time for the data collection was calculated to be 8–10 min for each subject, and on an average, 5–8 patients were interviewed daily (excluding Saturday, Sunday, and general holidays). All the information regarding the survey and doubts were clarified by the investigator whenever necessary.


The tools used for the study consisted of a questionnaire divided into three parts:

  • Part 1 – Demographic details (name, age, and gender education)
  • Part 2 DA (MDAS)
  • Part 3 SoC (SoC 13).

The questionnaire consisted of 18 questions related to DA and SOC. All the questions were translated to the local language (Hindi) and given to study participants. Before the questionnaire was handed over to the study participants, the questionnaire was checked for the language translation (so it will convey the same meaning as original). The Hindi questionnaire was given to a group of 10 experts in the language of Hindi (who were fluent with English also) to check if the Hindi questionnaire conveyed the same meaning as the English one. They found that the Hindi questionnaire was satisfactory. The forward translation was given to a group of 10 people who were expert in the English language (who were fluent with Hindi) they also found the questionnaire to be conveying the same meaning in both languages. An expert in the subject of PHD was given the questionnaire to check for the relevance of the questions for the present study. He also found the questionnaire to be relevant and satisfactory. The kappa value for the present questionnaire was 0.8.

In the present study, MDAS has been taken to assess DA. It consists of five questions in comparison to four questions present in the original Corah's DA Scale. Advantage of the MDAS is because of its brevity, it is simple, easy to complete, and can be used as a cost-effective instrument for population-based research, and there is no change in the assessment of overall DA. It has been found to be reliable and valid cross culturally and has been translated into different languages. Each question has five response options from “not anxious” to “extremely anxious” resulting in a total score range of 0–20. Higher score represents high DA.[8]

The SoC Questionnaire-13 was used to measure the SoC. The 13-item version of Antonovsky's original 29-item SOC questionnaire was used to measure SOC. The short version consists of 13 items related to the three inter-related SOC components: comprehensibility (five items), manageability (four items), and meaningfulness (four items). This instrument measures how people stay well, function in promoting health, and can manage problems in the everyday life.[4] The item scores are added to obtain subset total scores. Each item was scored on a unitary scale, the Likert scale, which ranged from −2 to +2 options from Strongly Disagree to Strongly Agree. This gives a total range from −26 to 26 points. A higher score indicates a stronger SoC.

Data entry and compilation

The data obtained in the present study were compiled and organized systematically. All the collected data were entered in the Microsoft office excel sheet 2007 version and coding was done for all the variables. The final data set was exported to the Statistical Package for the Social Sciences (SPSS) software version 16.0 (SPSS Pvt Ltd, Chicago, IL, USA).

Statistical analysis

The data obtained were analyzed using the SPSS software version 16.0 for the descriptive analysis and statistical tests of significance. The mean, standard deviations, and proportions (% of participants) were calculated for each parameter, Chi-square test was applied to check the association between age and gender with DA and SoC and Pearson's correlation coefficient was used to assess correlation between DA and SoC.

  Results Top

Sociodemographic details

The total number of participants was 400. Out of which, 265 (66.2%) were males and 135 (33.8%) were females. The study participants 161 (40.2%) were in between the 20 and 30 years of age. Seventy-six (19%) were between the age group of 31 and 40 years. Eight-nine (22.2%) were of the age range of 41–50 years. Forty-one (10.2%) participants were of age range of 51–60 years and 33 (8.2%) participants were of 61 and above years of age. A majority of sample was high school pass outs (25%), whereas minimum study participants were illiterate (3%).

Distribution of dental anxiety

In the present study, 44.8% of the participants were slightly anxious, whereas only 13.2% were very anxious. Among the male participants, 44.53% of them were slightly anxious and 12.5% of them were very anxious. Among the female participants, 45.19% of them were slightly anxious and 38% of them were very anxious. When overall DA was assessed between the gender, it was found that there was no statistically significant difference (P = 0.17) seen.

Distribution of sense of coherence

Low SoC was found among the participants (80.5%). A statistically significant association between gender and SoC was seen (P = 0.001) [Table 1], where females had higher SoC (22.96%) when compared to males.
Table 1: Gender wise comparison of sense of coherence among study samples

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Lowest SoC was seen among the age group of 31–40 years (88.16%) and a statistically significant association (P = 0.046) [Table 2] was found among age and SoC.
Table 2: Age wise comparison of sense of coherence among study samples

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Correlation of dental anxiety and sense of coherence

There is an inverse relation between SoC and dental anxiety, (r = −0.97), (P = 0.01) [Table 3].
Table 3: Correlation between dental anxiety and sense of coherence

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  Discussion Top

DA is characterized by anxious thoughts about dentistry and fear reactions in the dental treatment situation. The fear of dental treatment describes a psychological reaction pattern which can be termed as DA or dental fear. DA affects a significant proportion of people of all ages and social classes. It remains to be a serious concern for both dental practitioner and patient for the provision of routine dental care on a day-to-day basis.[6] SOC has been suggested to be highly applicable concept in the public health area because a strong SOC is stated to decrease the likelihood of perceiving the social environment as stressful. This reduces the susceptibility to the health damaging effect of chronic stress by lowering the likelihood of repeated negative emotions to stress perception.[9]

The present study evaluated that majority of participants were slightly anxious (44.8%), overall DA is low among the population but males have lower DA as compared to females, which was not statistically significant (P = 0.171). The reason for this could be more pain tolerance of women when compared to men, and also in the study sample, the number of women was less as compared to men. The results of this study were contradicted by the study done by Devapriya et al. which stated that female participants were more anxious than their male counterparts (P < 0.001)[6] this could be due to different type of population.

The lowest level of DA was seen among the age group of 20–30 years (63.98%) which increased with the increase in age; the reason for this could be that with the advancement of age a person's ability to judge a situation and reaction toward it also increases as their level of experience increases. Overall DA was found to be low among the participants but no significant association of DA with age was seen (P = 0.896). Similar results were given by Marya et al. which stated that the anxiety levels of younger age groups were significantly higher than the older age groups (51–60 and above 60 years).[9]

SoC among the study participants was seen to be low, the reason for this can be the low education level of participants as most of the study participants have passed their high school examination so, their level of understanding and perception toward life stresses could be low which might have a role in the development of their SoC. Lowest SoC was seen among the age group of 31–40 years (88.16%) and increases as the age increases, a statistically significant association (P = 0.046) was seen among age and SoC. Similar results were given by Ahmed et al., where the mean SOC scores increased with increasing age, participants belonging to 51–55 years of age group had highest mean SOC (48.22).[10] The reason for this could be that with increase in age people were able to cope up more effectively with tension and external and internal resources, find solutions, and resolve tension in a health promoting manner.

A statistically significant association between gender and SoC was seen (P = 0.001) where females had slightly higher SoC (22.96%) when compared to males (17.4%). The results given by Volanen et al.[11] stated that SoC levels are not gender specific, they are based on individual levels which have contradicted the results of the current study. The reason behind this could be their level of understanding and perception toward life stresses could be low which might have a role in the development of their SoC.

An inverse correlation was seen between sense of coherence and DA (P ≤ 0.001) which was in accordance with the studies conducted by Jaakkola et al. (odds ratio = 2.5, 95% confidence interval = 1.4–4.4).[7] The reason could be that DA is associated with avoidance of dental treatment and a negative attitude or fear toward dental treatment while SoC have a role in re-shaping this behavior, it will help a person to understand or to cope with good dental habits and a positive dental attitude, so they are inversely correlated as SoC helps in shaping a positive behavior while high DA ends to develop a more negative attitude toward dental treatment.

  Conclusion Top

Thus, the study concluded that as the SoC increased the level of DA decreased and vice versa, this was found in our population. Maximum DA was seen among the age group of 20–30 years, it is also observed that females have a high level of anxiety when compared to males. Hence, we can state that SoC is inversely related to DA, so Soc may be a relevant framework which might enable a better understanding of factors related to individual's behavior toward the dental treatment.


The SOC is a resource that enables people to manage tension, to reflect about their external and internal resources, which can be used as a tool for patients having a high level of DA. Hence, a clinician or dentist should always be looking forward to the signs of DA among their patients. Following the theory of SOC, this should be done by helping patients succeed in dealing with stressors/events regarding their oral health by means of increasing comprehensibility, manageability, and meaningfulness.


  • The study has been conducted only in the single hospital
  • The type of patients might vary in the government and private hospital
  • The sample size could be larger for better generalizability.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Jeddy N, Nithya S, Radhika T, Jeddy N. Dental anxiety and influencing factors: A cross-sectional questionnaire-based survey. Indian J Dent Res 2018;29:10-5.  Back to cited text no. 1
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Mittelmark MB, Sagy S, Eriksson M, Bauer G, Pelikan JM, Lindstrom B, et al. The Hand Book of Salutogenesis. AG Switzerland: Springer International Publishing; 2017.  Back to cited text no. 2
Feldt T, Leskinen E, Koskenvuo M, Suominen S, Vahtera J, Kivimäki M. Development of sense of coherence in adulthood: A person-centered approach. The population-based HeSSup cohort study. Qual Life Res 2011;20:69-79.  Back to cited text no. 3
Savolainen J, Suominen-Taipale AL, Hausen H, Harju P, Uutela A, Martelin T, et al. Sense of coherence as a determinant of the oral health-related quality of life: A national study in Finnish adults. Eur J Oral Sci 2005;113:121-7.  Back to cited text no. 4
Viswanath D, Krishna AV. Correlation between dental anxiety, Sense of Coherence (SOC) and dental caries in school children from Bangalore North: A cross-sectional study. J Indian Soc Pedod Prev Dent 2015;33:15-8.  Back to cited text no. 5
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Devapriya A, Sangeetha S, Anupama T, Kumar DL. Dental anxiety among adults: An epidemiological study in South India. North Am J Med Sci 2015;7:13-8.  Back to cited text no. 6
Jaakkola S, Rautava P, Saarinen M, Lahti S, Mattila ML, Suominen S, et al. Dental fear and sense of coherence among 18-yr-old adolescents in Finland. Eur J Oral Sci 2013;121:247-51.  Back to cited text no. 7
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Marya CM, Grover S, Jnaneshwar A, Pruthi N. Dental anxiety among patients visiting a dental institute in Faridabad, India. West Indian Med J 2012;61:187-90.  Back to cited text no. 9
Ahmed SI, Sudhir KM, Reddy VC, Kumar RV, Srinivasulu G, Deepthi A. Impact of sense of coherence on oral health among bus drivers: A cross-sectional study. J Int Soc Prev Community Dent 2018;8:145-52.  Back to cited text no. 10
Volanen SM, Lahelma E, Silventoinen K, Suominen S. Factors contributing to sense of coherence among men and women. Eur J Public Health 2004;14:322-30.  Back to cited text no. 11


  [Table 1], [Table 2], [Table 3]

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