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Table of Contents   
Year : 2012  |  Volume : 15  |  Issue : 1  |  Page : 51-55
Effect of 'Perceived control' in management of anxious patients undergoing endodontic therapy by use of an electronic communication system

1 Department of Conservative Dentistry and Endodontics, Gian Sagar Dental College & Hospital, Banur, India
2 Department of Conservative Dentistry and Endodontics, People's Dental College, Bhopal, India
3 Department of Conservative Dentistry and Endodontics, Government Dental College & Hospital, Nagpur, India
4 Department of Orthodontics & Dentofacial Orthopaedics, Gian Sagar Dental College & Hospital, Banur, India

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Date of Submission11-Mar-2011
Date of Decision15-Jun-2011
Date of Acceptance09-Jul-2011
Date of Web Publication4-Feb-2012


Background: From time immemorial, fear and anxiety have been associated with dental treatment. Coping with this fear and anxiety has been one of the most vexing problems with which the individual dentist, as well as the profession has had to contend. Hence this study was undertaken to evaluate a new technique for management of such anxious patients.
Aim: The aim of this study is to evaluate the efficacy of using 'Perceived control' for the management of anxious patients undergoing endodontic therapy.
Settings and Design: 'A communication device designed by the author and named as "Touch N' Tell" (Patent no: 234291, Government of India) was installed on the dental chair which helps to create an effective communiquι between the patient and dentist during the dental procedure.
Materials and Methods: Sixty anxious patients were selected using Modified Dental Anxiety Scale (MDAS), and were divided into two groups. For group A, the patients were treated along with the use of 'communication system' installed on the dental chair, whereas the patients were managed in a routine manner for Group B. The post operative MDAS scores were recorded for both the groups.
Statistical Analysis: The mean change in anxiety levels was calculated for both the groups. Statistical analysis was done using unpaired t-test.
Result and Conclusion: A significant decrease in the mean anxiety levels was observed in the group where 'communication system' was used as a measure of perceived control.

Keywords: Anxiety; dental treatment; perceived control

How to cite this article:
Singh H, Meshram G K, Warhadpande M M, Kapoor P. Effect of 'Perceived control' in management of anxious patients undergoing endodontic therapy by use of an electronic communication system. J Conserv Dent 2012;15:51-5

How to cite this URL:
Singh H, Meshram G K, Warhadpande M M, Kapoor P. Effect of 'Perceived control' in management of anxious patients undergoing endodontic therapy by use of an electronic communication system. J Conserv Dent [serial online] 2012 [cited 2023 Dec 4];15:51-5. Available from:

   Introduction Top

From time immemorial, fear and anxiety have been associated with dental treatment. Coping with this fear and anxiety has been one of the most vexing problems with which the individual dentist, as well as the profession has had to contend. [1],[2] Whatever be the etiology of the 'Anxiety' viz. unpleasant previous experience, stories of painful dentistry from siblings and parents, misleading information from media sources so on and so forth, the consequence is same; a psychologically afflicted personality who will not let himself be amenable to dental treatment. Many dentists literally throw up their hands in frustration when confronted with such patients while others empirically develop ways to solve their problems in an individual manner. Various suggestions for controlling the stress have been mentioned in dental literature, which can be broadly separated into three categories: 'Relaxation', 'Distraction' and 'Perceived control'. [3],[4],[5]

This study deals with management of anxious patients by the method of 'Perceived control', utilizing a "Self-designed communication device: TOUCH N' TELL" (Patent no: 234291, Government of India) installed on the dental chair which helps to create an effective communiqué between the patient and dentist during the dental procedure and provides the patient with a 'sense of control,' thus enabling him to overpower his fear and anxiety.

   Materials and Methods Top

This study was carried out in the Department of Conservative Dentistry and Endodontics, Government Dental College and Hospital, Nagpur. TOUCH N' TELL communication systemis unique in itself as it enables the patient to communicate with the dentist even after 'Rubber Dam' application during the treatment procedure with the help of visual signals and an audio alarm. It consists of 3 main parts: Monitor 1, Monitor 2 and wireless Remote Control [Figure 1]. Monitor 1 is attached to the arm of dental chair and is thus in the 'line of sight' of the patient seated on the dental chair. It is connected by a cable to Monitor 2. The Monitor 2 is placed in the "line of sight" of the Dentist who can visualize it without requiring any bodily movement [Figure 2]. A wireless Remote Control, given to the patient, enables him to operate the Monitor 1, which in turn is attached to Monitor 2, thus completing the circuit.
Figure 1: Communication system "Touch N Tell"

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Figure 2: "Touch N Tell" installed on dental chair and in use

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This communication device enables the patient to indicate the following five problems, which can be encountered intra-operatively:

  1. Feeling of pain.
  2. Feeling of giddiness.
  3. Excessive saliva collection in mouth causing a gag.
  4. Temporomandibularjoint (TMJ) pain due to prolonged mouth opening.
  5. To know how much time more the dentist is going to take to finish the treatment procedure.

Modified Dental Anxiety Scale [6] (MDAS - Humphris, 1995) was used to assess the anxiety levels of the patient both pre-operatively and post-operatively. It consists of 5 questions, each having 5 items. The patient was instructed to tick one item for each question, which he/she found appropriate. Total score of the scale is a sum of all five items, range of 5 to 25. For clinical purpose, the researchers have established that a cut-off MDAS score of 19 and above should be considered as a strong likelihood of patient being anxious for dental treatment. The form originally in English was translated in local language also for the patient's ease of understanding.

Sixty anxious patients, 50 female and 10 male were screened from the group of patients who had been advised molar endodontic therapy. This screening was done by asking the patients to fill MDAS, and those who scored 19 and above in the scale were included in the study. These anxious patients thus obtained for age range from 14 to 46 years were assigned randomly to two groups of 30, each having 25 female and 5 male patients.

One group acted as the Experimental group (Group A) and the other group acted as the Control group (Group B). The method of using TOUCH N' TELL was explained to the patients of group A prior to the start of treatment. Patients were then treated for their first appointment of molar endodontic therapy where in the access cavity preparation and pulp extirpation or debridement was performed with "TOUCH N' TELL" installed on the dental chair. The patients in Group B were treated similar to those in Group A; however, without the use of "communication system".Patients were recalled one week after the first appointment and were given MDAS. The scores obtained were noted and compared with those obtained pre-operatively.

   Observations and Results Top

Age distribution analysis was done for both the groups and when compared using paired t test, no statistically significant difference was found between the two, indicating an equal distribution of sample; making the groups comparable without a bias [Table 1]. The pre-operative scores of Experimental group were compared to the pre-operative scores of the Control, both for MDAS using paired t-test. No statistically significant difference was found between the pre-operative scores for both the groups again proving an equal and unbiased sample distribution, making the two groups comparable in all terms [Table 2]. The pre-operative and post-operative scores obtained in Experimental and Control group as per MDAS were recorded [Figure 3]a and b. Means of pre-operative and post-operative scores were also calculated for Experimental group and Control group with reference to Modified Dental Anxiety Scale [Table 3].
Table 1: Age distribution analysis of the study sample

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Table 2: Comparison between pre-operative scores of experimental and control group during the study

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Table 3: Means of pre-operative and post-operative scores of experimental group and control group during the study

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Figure 3a: Pre-operative and post-operative scores for Experimental group as per Modified Dental Anxiety Scale
Figure 3b: Pre-operative and post-operative scores for Control group as per Modified Dental Anxiety Scale

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The mean change in anxiety levels was analyzed. Unpaired t-testwas performed to compare the Experimental and the Control group [Table 4]. A highly significant difference (P<0.001) was found as per the scores obtained on MDAS. In overall, the results indicate a significant decrease in anxiety levels in the Experimental group wherein the "Communication Device" was used as a measure of "Perceived Control" as compared to the Control group in which the patients were treated in a routine manner without the use of communication device.
Table 4: Comparison of experimental and control group with reference to mean change in anxiety levels

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   Discussion Top

Perhaps nothing is more distressing to a dentist than not be able to manage an anxious patient visiting his dental office. Dental anxiety has been a worldwide problem and a universal barrier to oral health care services. [2],[3] Anxiety is defined as a reaction to unknown danger and the individual anticipates the worst even from relatively straight forward procedures. Patient anxiety during dental treatment has been of major concern to the dentists world over. [4],[5]

The reason for the anxiety towards dental treatment could be any: Fear acquired in the childhood through direct experience with painful treatment or vicariously through parents, friends or siblings which persists into adulthood; perceived dentist error during previous treatment; and, dislike of dentist's behavior and attitude or fear of needles and drills in general. [6],[7],[8] Whatever be the reason, the eventuality is a highly anxious patient who either avoids dental treatment or when visits dental office does not render himself so readily to the treatment. [9],[10]

From time immemorial, dentists either alone or in collaboration with psychologists have been trying to implement different measures for effective management of these 'Special Care' patients . [11],[12],[13],[14],[15]

Lazarus has elaborated on the importance of 'Perceived control' in situations that involve psychological stress. [16] According to the principle of 'Perceived control,' if an individual believes he has some control over what is happening to him in an undesirable environment, he will experience less stress. Logan et al., have also provided the evidence that in a dental setup, a low Perceived Control is most likely associated with the fear reactions. [17]

There are a number of reasons of the inherently stressful character of the dental operatory. First, the majority of patients believe that confrontation with aversive stimuli will occur. Second, one may never be certain when such a confrontation may occur. Finally, if such a confrontation is to occur, the patient generally feels helpless to do anything about it. [16]

Considering the gravity of situation, a Communication system 'TOUCH N' TELL' based on scientific principle of Perceived Control was designed by the author to enable the patient communicate with the dentist intra-operatively. The scientific basis of the parameters used in this study is partly based on the extensive research work of specialists who have enumerated the control related items desired by the patient intra-operatively such as 'use of stop signals' to indicate pain; and, rest breaks specifically and partly from the patient's response who have claimed their inability to stop the dentist in case it hurts or if they need a break or rest during the treatment procedure. [18]

Endodontic therapy was chosen as treatment option for this study for the fact that it has proven to be the most anxiety producing amongst various procedures of dental treatment. [19] In our evaluation method, using this unique communication system 'Touch N Tell' and keeping in mind that all other parameters were similar, the statistical result itself indicates the significant role played by the 'Perceived Control' in the form of Communication device TOUCH N' TELL in alleviating the anxiety of anxious dental patients. These results are similar to those obtained by Corah,[20] when he studied the 'Effect of perceived control on stress reduction in pedodontic patients'. However, our results are also in contrast to those of Corah[21] When he studied the 'Effect of perceived control on stress reduction in adult patients' where he found an increase in physiological arousal in his subjects. The explanation for this lies in the fact that in his study, the physiological arousal during local anaesthesia administration and during drilling was taken into account whereas in our study "the anxiousness of inability to communicate with the dentist after rubber dam application" was the criteria. This criterion is more dependent on psychological status of the patient rather that the physiological response of the patient to treatment steps. The two factors (physiological response and psychological make-up) need to be assessed separately as they have their own parameters; hence the difference in results.

With multiple etiological factors responsible for causing anxiety towards dental treatment, it is difficult to understand completely the psychological status of anxious patients. However, the use of 'perceived control' as per the results obtained in our study, can be stated to act as an efficient chair side behavior modification method, making the patient more comfortable during the treatment procedure by providing a 'sense of control' . Within the limits of sample size, this method seems to be competent enough in the management of anxious patients.

   References Top

1.Humphris GM, Morrison T, Lindsay SJ. The Modified Dental Anxiety Scale: Validation and United Kingdom norms. Community Dent Health 1995;12:143-50.  Back to cited text no. 1
2.Milgrom P, Weinstein P. Dental fears in general practice: New guidelines for assessment and treatment. Int Dent J 1993;43(3 Suppl 1):288-93  Back to cited text no. 2
3.Weiner AA. Dental anxiety: Differentiation, identification and behavioral management. J Can Dent Assoc 1992;58:580, 583-5.  Back to cited text no. 3
4.Corah NL, Gale EN, Illig SJ. Psychological stress reduction during dental procedures. J Dent Res 1979;58:1347-51.  Back to cited text no. 4
5.Armfield JM, Spencer AJ, Stewart JF. Dental fear in Australia: Who's afraid of the dentist? Aust Dent J 2006;51:78-85.  Back to cited text no. 5
6.Neverlien PO, Backer Johnson T. Optimism-pessimism dimension and dental anxiety in children aged 10-12 years. Community Dent Oral Epidemiol 1991;19:342-6.  Back to cited text no. 6
7.Wright GZ, Alpern GD. Variables influencing children's co-operative behavior at the first dental visit. ASDC J Dent Child 1971;38:124-8.  Back to cited text no. 7
8.Kleinknecht RA, Klepac RK, Alexander LD. Origins and characteristics of fear of dentistry. J Am Dent Assoc 1973;86:842-8.  Back to cited text no. 8
9.Sohn W, Ismail AI. Regular dental visits and dental anxiety in adult dentate population. J Am Dent Assoc 2005;136:58-66; quiz 90-1.  Back to cited text no. 9
10.Freidson E, Feldman JJ. The public looks at dental care. J Am Dent Assoc 1958;57:325-35.  Back to cited text no. 10
11.Corah NL, Gale EN, Illig SJ. The use of relaxation and distraction to reduce psychological stress during dental procedures. J Am Dent Assoc 1979;98:390-4.  Back to cited text no. 11
12.Dworkin SF, Chen AC, Schubert MM, Clark DW. Analgesic effects of nitrous oxide with controlled painful stimuli. J Am Dent Assoc 1983;107:581-5.  Back to cited text no. 12
13.Berggren U, Linde A. Dental fear and avoidance: A comparison of two modes of treatment. J Dent Res1984;63:1223-7.  Back to cited text no. 13
14.Kamin V. Fear, stress, and the well dental office. Northwest Dent 2006;85:10-1, 13, 15-8.  Back to cited text no. 14
15.Del Gaudio DJ, Nevid JS. Training dentally anxious to cope. ASDC J Dent Child 1991;58:31-7.  Back to cited text no. 15
16.Lazarus RS. Psychological Stress and the Coping Process. New York: McGraw-Hill; 1966.  Back to cited text no. 16
17.Logan HL, Baron RS, Keeley K, Law A, Stein S. Desired control and felt control as mediators of stress in a dental setting Health Psychol 1991;10:352-9.  Back to cited text no. 17
18.Milgrom P, Getz T, Weinstein P. Recognizing and treating fears in general practice. Dent Clin North Am 1988;32:657-65  Back to cited text no. 18
19.Udoye CI, Oginni AO, Oginni FO. Dental anxiety among patients undergoing various dental treatments in a Nigerian teaching hospital. J Contemp Dent Pract 2005;2:91-8.  Back to cited text no. 19
20.Corah NL. Effect of perceived control on stress reduction in pedodontic patients. J Dent Res 1973;52:1261-4.  Back to cited text no. 20
21.Corah NL, Bissell GD, Illig SJ. Effect of perceived control on stress reduction in adult dental patients. J Dent Res 1978;57:74-6.  Back to cited text no. 21

Correspondence Address:
Harpreet Singh
Mohindra Complex, Kheri Road, Patiala - 147 001, Punjab
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0972-0707.92607

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  [Figure 1], [Figure 2], [Figure 3]

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