Abstract
Purpose: The COVID-19 pandemic interrupted dental care for individuals due to dental practice closures beginning in March 2020. The purpose of this study was to investigate the relationships between fear or stress related to COVID-19, dental anxiety and attending dental visits among adults in the United States (US).
Methods: A cross-sectional survey research design was used with a non-probability sample of adults residing in the US. Three validated scales, the COVID-19 Stress Scale (CSS), Fear of COVID-19 Scale (FCV-19S) and Modified Dental Anxiety Scale (MDAS), were used for the electronically delivered survey instrument. A crowdsourcing platform was used to recruit participants over the age of 18, residing in the US. Descriptive, correlation, and multiple regression tests were used for data analysis.
Results: A total of 308 participants opened the survey with a 97% completion rate (n=299). Time since the last dental visit was positively correlated with all measurement scale scores (p<0.01). Males had statistically significant higher scores on the CSS traumatic stress (p=0.002) and checking (p=0.001) sub-scales. Participants with bachelor and master’s degrees had significantly higher scores across FCV-19S and CSS subscales.
Conclusion: Individuals with dental anxiety were more likely to exhibit higher levels of fear and anxiety about COVID-19 transmission, resulting in delays in seeking dental care. Dental professionals should address patient concerns about the safety of dental settings and the infection control measures in place to prevent the transmission of COVID-19 in dental settings. Public health entities and professional organizations need to promote messaging about the measures in place to deliver safe oral health care.
- COVID-19
- coronavirus disease
- pandemic
- fear of COVID-19
- dental anxiety
- health-related behavior
- health care seeking behavior
Introduction
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a highly infectious respiratory virus with mild to severe symptoms and may lead to death.1,2 Coronavirus disease (COVID-19) was first reported in Wuhan, China in December of 2019 and was declared a global pandemic by the World Health Organization on March 11, 2020.3 As of January 2022, over 208 million cases of COVID-19 had been confirmed along with 5.5 million deaths worldwide.4
To slow the spread of infection during the initial surge of cases in the Spring of 2020, lockdown and quarantine were implemented worldwide including closure of dental offices except for emergency care.5 Temporary shutdowns and shortage of enhanced personal protection equipment (PPE) reduced access to professional dental care for patients.5 Additionally, the coronavirus pandemic has been shown to affect patients’ attitudes toward seeking dental treatment.6–11 Many individuals indicated feeling anxious or afraid to seek dental care due to the COVID-19 pandemic.6,7,9,11 Much of the initial research conducted early in the pandemic related to individuals’ willingness to seek dental care was done outside the United States (US) in countries including Brazil, Iran, and Spain. International studies reported 20 to 75% of individuals were willing to seek dental care from March 2020 to after the initial 2020 lockdowns.8,9 By August of 2020, fear of COVID-19 infection was at moderately high levels and there were still many unknowns and conflicting information about modes of transmission and vaccines were not yet available.12
Research suggests heightened anxiety induced by COVID-19 has influenced oral health.13–15 Dental fear has been linked to increased negative beliefs about seeking preventive oral health care.13,15 Furthermore, less frequent dental visits and poor patient-dentist relationships have been demonstrated to increase dental anxiety levels.13,15 Previous research suggests factors associated with higher levels of anxiety about dental visits during the COVID-19 pandemic include: being female, over age 60, higher COVID-19 fear scores, fear or perception of susceptibility to COVID-19, and not attending a dental visit in over six months.9,11,15,16 Reduction in the number of dental visits resulted in greater oral infections during COVID-19 pandemic, yet fewer people sought emergency dental care early in the pandemic.14,17 Furthermore, the types of dental emergencies changed from soft tissue lesions to infections, including acute pulpitis, periodontal diseases, and trauma.17,18
Declaration of the global COVID-19 pandemic resulted in closure of dental practices for routine care from March until early May of 2020.19,20 The rationale for the closure was twofold: concerns about minimizing risk of infection for dental providers and patients along with scarce resources to adjust office infection control protocols. As the pandemic grew more widespread, the Centers for Disease Control and Prevention (CDC), and Occupational Safety and Health Administration (OSHA) created interim guidelines for dental settings.19,21,22 In a recent survey of U.S dentists, about 75% reported following the CDC interim guidelines for PPE indicating compliance with the new guidelines.23 While infection control guidance and procedures may help patients feel more comfortable about receiving dental care during the COVID-19 pandemic; little is known about the patient’s perspective on these infection control practices. It may be important for dental practices to educate patients about the infection control guidelines being implemented. It may also be of value to share with patients the low reports of COVID-19 infection among dental providers to reassure them regarding the risk of contracting COVID-19 in the dental setting.23–25
As of mid-December 2021, the Health Policy Institute of the American Dental Association reported 38% of dental offices reported lower patient volumes than pre-pandemic levels.26,27 Due to the many unknowns regarding the virus at the time of the study and fears of being infected, patients may have developed negative feelings toward seeking professional dental care, impacting their dental visit patterns and consequently their oral health.11 A better understanding of these relationships may help dental professionals create protocols to improve patient confidence and compliance in seeking dental care. The purpose of this study was to examine the relationship among COVID-19 fears or stress, dental anxiety, and frequency of seeking dental care during the pandemic.
Methods
A cross-sectional survey design was used to explore COVID-19-related fears and stress and their relationship to seeking dental care in a non-probability sample of individuals in the US using a web-based survey. This studied was granted “exempt” status from the MCPHS Institutional Review Board (IRB 041221B). The study design and reporting were guided by the Checklist for Reporting Results of Internet E-Surveys (CHERRIES).28
Participants
A non-probability sample of adults was recruited using a crowdsourcing platform (Amazon MTurk; Seattle, WA, USA). The use of crowdsourcing for survey research allows for ease of access to a large and diverse population.29,30 The MTurk platform is one of the most researched types of non-probability sampling and more is known about the demographics and characteristics of the potential participants. Data collected through MTurk has been found to be either equivalent or superior to data collected using conventional non-probability sampling.29,30 Inclusion criteria were individuals aged 18 years and older and residing in the US.
A priori sample size estimation was conducted using G*Power 3.1.31 The following parameters were used: α=0.05 and β=0.8. Based on the previous work using the FCV-19S, CSS, and MDAS,32–34 this study used a medium effect size (f2=0.15) according to Cohen’s criteria.35 For the planned stepwise regression analysis with ten total predictors and seven tested predictors, the suggested minimum size was n=104 completed surveys.
Instrument
The survey instrument consisted of demographic questions and three validated scales for a total of 57 items. The instrument included: demographics (9 items); COVID-19 Stress Scale (CSS) (36 items);34 Fear of COVID-19 Scale (FCV-19S) (7 items);33 and Modified Dental Anxiety Scale (MDAS) (5 items).32 The technical functionality of the web-based survey (Qualtrics; Provo, UT, USA) was tested by three faculty members prior to submission for IRB approval.
The CSS was developed and validated in Canada and the US and contained five scales with a total of 36 items.34 The scales assessed COVID-19 related stress and anxiety symptoms and included items related to 1) danger and contamination fears, 2) fears about economic consequences, (3) xenophobia, 4) compulsive checking and reassurance seeking, and 5) traumatic stress symptoms.34 All CSS scales had excellent internal consistency reliability as all Cronbach’s alpha coefficients were >0.80.34 Response scales for the original CSS was a 5-point Likert scale ranging from not at all (0) to extremely (4) and never (0) to almost always (4). No cut-offs have been determined for this instrument, but higher scores indicate more COVID-19 stress. Total score may range from 35 to 252. For the current survey, the values for each response in the CSS were reassigned to 1 through 5, i.e., not at all (1) to extremely (5) so the scale values were consistent for the scales in the MDAS and FCV-19S.
The FCV-19S was a seven-item scale developed and validated in Iran to assess fear of COVID-19 among the general Iranian adult population.33 The FCV-19S exhibited strong psychometric properties and had high internal consistency reliability (Cronbach’s alpha 0.82).33 This scale used a 5-point Likert scale ranging from strongly disagree (1) to strongly agree (5). No cut-offs were identified, but total summed score indicates higher level fear of COVID-19.33 Total scores range from 7 to 35.
Lastly, the MDAS was a modification of the original 4-item Corah’s Dental Anxiety Scale with the addition of an item to measure possible anxiety induced by local anesthesia injections.32 The 5-item MDAS demonstrated high reliability and validity (Cronbach’s alpha >0.84).32 response scale was a 5-point Likert scale ranging from not anxious (1) to extremely anxious (5). The MDAS scores ranged from 5-25 (not anxious to extremely anxious). A score of 19 or above indicates high anxiety or possibly dental phobia.32
Procedure
The online crowdsourcing platform (MTurk) was used to include a diverse national sample. The platform has been extensively used by psychologists to perform tasks such as completing surveys, opinion polls and cognitive psychological studies.30,36,37 The survey was considered a HIT (Human Intelligence Task) available to MTurk users. There was a description of the task and invitation to participate with a link to the survey. Inclusion and exclusion settings in MTurk were used to target individuals for recruitment. Participants volunteered to take the survey and, in return, were compensated 50 cents for survey completion. Informed consent was required and only participants who provided consent were able to access the survey. The MTurk workers’ identity was anonymous and could not be connected to their survey responses.29 The survey settings did not allow participants to use the back button to change responses or take the survey more than once. Participants were given a reminder message if they skipped a question, Internet provider addresses were not recorded, and respondents were able to return to the site to complete the survey for 72 hours. Participants had the opportunity to withdraw from the survey at any time. The survey was opened to participants on May 28, 2021, and the desired sample size was reached after 2 hours at which time the survey was closed.
Data Analysis
Prior to data analysis, the percent of items completed and quality checks such as time for completion were evaluated to determine survey data to be included. Descriptive statistics were analyzed for the demographic variables and for each item and subscale from the FCV-19S, CSS, and MDAS including the frequencies for categorical variables, measures of central tendency, and spread for any continuous variables. When possible, the 95% CI and effect size for a given statistic were reported. To identify relationships between FCV-19S, CSS, and MDAS, each of the subscale scores were correlated with each other. Subscales from these instruments were considered ordinal for the purposes of this study. To identify differences in the mean FCV-19S, CSS, and MDAS scores across demographic variables, independent group t-tests were used for two group comparisons and one-way ANOVA for groups of three or more. The demographic category was used as the independent variable and the mean subscale score as the dependent variable for each individual test.
A stepwise regression was used to model the influence of COVID-19 fear, stress, and dental anxiety on time since last dental visit. To assess the individual influence of FCV-19S and CSS scores, the FCV-19S scores were entered into the model in step 1, CSS scores in step 2, and demographic covariates of interest in step 3. The R-square value of each model, F-statistic, and standardized betas weights of individual predictors were examined at each step. The critical cutoff alpha level for this study was p=0.05. Nonparametric statistical methods were used when the variables did not meet assumptions based on the normal distribution. All analyses were conducted using a statistical software program (SPSS version 26, IBM Corp; Armonk, NY, USA).
Results
Of the 308 participants who opened the survey link, 9 were excluded due to non-completion, 299 were retained (n=299) to yield a completion rate of 97%. The sample was 59.5% males (n=178) and 39.5% females (n=118) with a mean age of 39.7 years (18–70 years of age). Most participants identified as White (74.2%), followed by Asian (12.7%), Black/African American (9%), and Hispanic (5.4%).
The demographic questions included items pertaining to general health and COVID-19 vaccine status. The primary existing medical conditions reported by participants included smoking (32%), obesity (17%), type 2 diabetes (15%), cancer (12%) and cardiovascular disease (11%). When asked about time since their last dental visit, only about 20% had a visit in the last year with nearly half (49%) reporting visits for dental cleanings. Of those who reported being vaccinated for COVID-19, 74.5% (n=207) had completed dosage recommendations per the guidelines in May 2021. Demographic data are presented in Table I.
Sample demographics (n=299)
Measurements of COVID-19 fear showed the FCV-19S mean score was 2.85 on a scale of 1 to 5. The 75th percentile score was 27 out of a possible total score of 35 among participants. For the COVID-19 stress (CSS) subscales that included danger (D), economic consequences (SE), xenophobia (X), contamination (C), traumatic stress (T), and checking (CH), the mean scores were in the mid-range of the scale ranging from 2.82 on the D (danger) to 2.38 on the T (traumatic stress) subscale (Table 2). Scores for the MDAS range were from 5 (not anxious) to 25 (extremely anxious); the mean score for the participants was 15.55 (SD=5.12). For the MDAS, the 75th percentile score was 19 in this sample suggesting approximately 25% of the participants were in the extremely anxious category.
Scale and sub-scale descriptive statistics
Results demonstrated a strong positive correlation (p<0.01) among all MDAS, FCV-19S, and CSS subscales (Table III). In addition, time since the dental visit was positively correlated with all measurement scale scores (p<0.01), where longer periods of time since last dental visit (measured in years) were related to higher scale scores for dental anxiety, fear of COVID-19, and COVID-19 stress.
Correlation MDAS, FCV-19S, and CSS sub-scales
When comparing the relationship of FCV-19S, CSS, and MDAS with categorical demographic variables results indicated that males had a higher median traumatic stress score (2.83, p=0.004) and checking score (3.00, p=0.002) than females (1.67 and 1.92, respectively). For COVID-19 vaccination status outcomes, participants who had been vaccinated had higher median scale scores on all measurements. However, the correlation between COVID-19 vaccination status and MDAS was not statistically significant (p=0.07). Within the education variable, findings revealed bachelor’s and master’s degree holders had significantly higher scores (p<0.01) across many scales when compared with those with an associate degree, some college, or a high school education. In contrast, there were no statistically significant differences in scale scores across US regions. The regression model to assess predictive relationships of FCV-19S, CSS, and time since last dental visit found no variables reached statistical significance. Differences between FCV-19S, CSS, and MDAS and the sample demographics are shown in Table IV.
Difference between FCV-19S, CSS, and MDAS with categorical demographics
Discussion
Results from this study illuminate patients’ fear and anxiety toward dental care during the COVID-19 pandemic and may serve to assist dental professionals in improving the patients’ dental visit experience and increase compliance. Nearly one fourth of the participants in this study had an MDAS score at or above the cut-off for severe dental anxiety or possible dental phobia.32 A similar number of participants showed higher mean score than seen in the emerging literature on the fear of COVID-19 scale (FCV-19S).38
When analyzing the relationships between demographic variables and COVID-19 fear and anxiety, male participants had greater traumatic stress and checking scores on the COVID-19 Fear Scale when compared to females. Regarding gender, results from the current study were inconsistent with those in previous research, which has shown that females reported higher levels of fear of infection and mental distress when compared to males.7,9 Some studies have also suggested no gender differences despite having a larger sample of males than females as demonstrated in this study.11,33 However, much of the early research was conducted in March to May of 2020 and did not use the CSS, making comparisons difficult. This suggests more research with larger random samples using validated instruments like the CSS may be needed to understand the gender differences in fear and anxiety related to COVID-19 as this may impact dental visit attendance and long-term oral health outcomes.
Participants with bachelor’s or master’s degrees also had significantly higher scores across FCV-19S and CSS subscales which has not been previously reported in the literature. This strong pattern across the scales suggested those with higher education degrees tend to be more worried and fearful of COVID-19. Research conducted in Germany found while those with higher levels of education also had a higher level of worry, but did not have fear of COVID-19.39 The increased fear and anxiety about COVID-19 in those with graduate degrees may be related to searching for additional information from a variety of media sources (i.e. regular news, social media, online searching, and professional websites).40
Study participants who had been vaccinated displayed higher median scale scores on all measurements, indicating that those who were more stressed and fearful of COVID-19 were also more likely to be vaccinated against COVID-19. This finding has been noted in other studies, along with many other mitigating factors including the political environment.41,42
The strong positive correlations between all the scales (MDAS, CSS, and FCV-19) used in this study is a unique finding. The correlation suggests these instruments may be measuring the same dimension even though each instrument defines the variables differently, i.e. dental anxiety, COVID fear, and COVID stress. This finding needs further investigation with analysis of the psychometrics of the instruments.
Of interest for dentistry is the strong correlation of the MDAS with the measure of COVID-19 anxiety and fear, which may suggest that the COVID-19 pandemic will pose an additional barrier to individuals with dental anxiety needing dental care. Results in this study demonstrated that the longer it had been since the last dental visit was reflected in the higher scores across all scales. While the relationship was small, the pattern across all measurements suggested the participants who waited longer to go to the dentist were also individuals who were more worried and fearful of COVID-19.
This study had limitations. First, the cross-sectional design can only establish correlation between variables, not causation. Additionally, due to the nature of non-probability sampling, there is a risk of self-selection bias limiting generalizability. Although crowdsourcing has the potential to recruit a diverse sample, when comparing the demographic of the study sample to that of the 2021 US Census estimations, Hispanic (5.4% vs.18.5%) and Black (9% vs. 12.4%) populations were underrepresented, whereas Asian (12.7% vs. 5.9%) and White (74.2% vs. 60.1%) were overrepresented.43 Furthermore, the survey could not determine the participants’ history of anxiety pre-pandemic, which could have influenced their current dental anxiety. While there are limitations to crowdsourcing samples that could lead to poor data quality, such as inability to confirm that participants met inclusion criteria and the fact that some may have rushed through the survey. To manage this possible limitation, the time taken to complete the survey was assessed and anyone who took significantly below the mean time was removed from analysis.44
Conclusion
Much of the research regarding the impact of COVID-19 fear and anxiety regarding dental care was conducted early in the pandemic (March to May 2020). Results from this study contribute to what is known one year into the pandemic. Study findings revealed relationships among COVID-19 stress/fear, dental anxiety, and selected demographic variables including gender, level of education, and COVID-19 vaccination status. Identifying COVID-19 fear and anxiety and acknowledging patient fears may assist dental professionals in developing strategies to reduce dental anxiety. Dental practices and clinics need to strategize on ways to disseminate information about the protocols in place to keep patients safe. Public health entities and professional associations can also publicize the measures in place to help minimize patient fear and anxiety about returning for oral health care.
Acknowledgements
The authors would like to extend their thanks to Dr. Steven Taylor, University of British Columbia, Faculty of Medicine, Department of Psychiatry, for permission to use the COVID-19 Stress Scale for this research.
Footnotes
This manuscript supports the NDHRA priority area, Client level: Oral health care (Health promotion: treatments, behaviors, products).
- Received January 28, 2022.
- Accepted June 27, 2022.
- Copyright © 2022 The American Dental Hygienists’ Association
