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The dentist-patient relationship: perceived dentist behaviors that reduce patient anxiety and increase satisfaction
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health trial w ith zin c-co n tain in g m o n o flu o ro p h o sp h a te dentifrices. J D ent Res 66(Special Issue) abstract no. 164, 1987. 11. C onti, A., a n d others. Caries efficacy of tw o fluoride dentifrices (1,000 vs 1,500 p p m F). J D ent Res 66(Special Issue) 66:258, abstract no. 1209, 258, 1987. 12. R adike, A.W. C riteria for d iagnosis of d ental caries. In Proceedings o f the Conference o n C linical T e stin g of C ariostatic A gents, C hicago, A m erican D ental A ssociation, 1972, p p 87-88. 13. B ogopolsky, S.; A lbertini, H .; an d G oldberg, W. E tude c lin iq u e d ’u n e pate (dentifrice) a h au te ten eu r en fluoru res a M arseille. In V aillan t, J.M ., an d
Barm es, D., eds. Le P o in t Sur Le F lu r Sym posium , 1982. In stitu t de S tom atologie et de C h iru rg ie M ax illo-Faciale, L a Salpetriere, Paris, 1984. 14. B arn au d , J., an d F in id o ri, C. Etude de l ’efficacite preventive d ’u ne pate a hau te teneur en fluorures. J In t Assoc D ent C h ild 15(1):21-31, 1984. 15. G rain g er, R.M . A nalysis of caries increm ent by ag e a n d to o th surface in flu o rid a te d a n d n o n flu o rid ated p o p u la tio n s by electronic com puter. In Jam es, P.; K önig, H .; H eld, H ., eds. Advances in fluo rin e research an d d e ntal caries p revention, voi 4. L o n d o n , Perg am o n Press, 1966, p p 53-66. 16. B erm an, D.S., an d Slack, G .L . Caries experience
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re la tiv e to in d iv id u a l su sc e p tib ility . Br D ent J 135(2):68-70, 1973. 17. Jam es, P.M ., a n d others. A 3-year c linical trial of a dentifrice c o n ta in in g 2% sodium m onofluorop h o sp h ate . C om m u n ity D ent O ral E pidem iol 5(1 ):6772, 1977. 18. M itropoulos, C. DMFS(e) index for selection of c lin ic al trial subjects. C om m u n ity D ent O ral E pide m io l 13(l):30-32, 1985. 19. A lm an, J.E . S tatistical an d e th ical considera tio n s in clinical trials. C om m unity D ent O ral E p i dem iol 8(5):267-272, 1980.
Researchers asked 250 adults to respond to 25 dentist behaviors after receiving treatment. Positive reactions were recorded in response to ten behaviors perceived to be associated with anxiety reduction: specifically, empathy, friendliness, and communicativeness.
The dentist-patient relationship: perceived dentist behaviors that reduce patient anxiety and increase satisfaction Norman L. Corah, P h D Robert M. O ’Shea, P h D G . Donald Bissell, D D S Terrence J. Thines, D D S Pauline Mendola
a n a g in g p a tie n t a n x ie ty has lo n g been a m ajor challenge for the practicing dentist. A 1986 E m phasis re p o rt1 stressed th a t the den tist’s anxiety ab o u t the p atien t a n d the p a tie n t’s anxiety about the dentist make for a dental procedure that can be diffi cult for b o th of them . T he behaviors of the d en tist in p atien t m anagem ent, p a r tic u la rly in c o m m u n ic a tin g w ith the patien t, are considered im p o rta n t by m ost ex p erts1 w ho stress b u ild in g rap p o rt by u sin g various behavioral techniques to p u t the p a tie n t at ease. Many dentists are u n co m fo rtab le in d ea lin g w ith p a tie n t anxiety a n d attem p t to avoid confronting it.2 L ittle scientific research on the im pact of specific dentist behaviors on p atient anxiety is available.
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A recent em pirical study3 attem pted to assess the relatio n sh ip between various dentist behaviors, an d anxiety reduction an d satisfaction of the patient. T h e d en tist behaviors studied were narrow ed to include only those perceived by the patient as h av in g some im pact on them . Most behaviors were associated w ith a m easure of p atien t satisfaction; however, few were associated w ith p atien t anxiety. T hese in itial findings prom pted further study of behaviors typically th o u g h t to reduce p atien t anxiety. Researchers4 in ter viewed 60 ad u lt patients in a hospital o u tp a tie n t clinic after dental treatm ent. P atients were questioned ab o u t their n er vousness and how the dentist and assis ta n ts ) contribu ted to it. P atients were also asked w hat they w ould do or say in
the d en tist’s place to ease p atien ts’ n er v o u sn ess. V erbal c o m m u n ic a tio n w as often stressed by the patients. T hey gave m ore th an 150 suggestions classified in to 12 categories. P atients frequently recom m ended th at dentists: give in itia l ex p la n a tio n s of w h at was g o in g to h a p p e n d u rin g the d ental procedure; give an inprocess e x p la n a tio n to let th e p a tie n t know w hat is h a p p e n in g as it is g o in g on; instruct the p atien t to be calm; w arn the p a tie n t ab o u t p ain w hen it is likely to occur; verbally su p p o rt the patient; try to give the p atien t ways of lo o k in g at the procedure in a less-threatening fashion a n d p ro v id e c o a c h in g to m a k e th em believe it is n o t as bad as they expect it to be; provide distraction of atten tio n and try to co m m unicate in ways th a t will
C orah-O thers : D E N T IS T -P A T IE N T R E L A T IO N S H IP ■ 73
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b u ild trust in the dentist. T hese resulting suggestions led to the recasting of a list of d e n tis t b e h a v io r item s. T h e 25 item s developed are show n in T able 1. Previous research5 show ed th a t 20% to 25% of the anxiety response to treatm ent was determ ined by the p a tie n t’s general anxiety ab o u t treatm ent w hen arriving at the dental office. Therefore, it was deter m in ed th a t it was necessary to assess the change in the p a tie n t’s anxiety that m ight be affected by the den tist’s behavior to assess the relatio n sh ip appropriately. T h is study attem pted to reassess a range o f d e n tist b eh av io rs—as perceived by p atien ts—to determ ine their role in reduc in g p atien t anxiety and increasing satis faction. T h is investigation was conducted in large o u tp a tie n t dental clinics of two h o sp itals to provide a potentially broad range of p atien t selection. A representa tive response range was achieved from the clin ic’s diverse population.
Table 1 ■ Dentist behavior items (questionnaire). D u rin g today’s visit, the d e n tis t. . . 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25.
w arned me w hen he felt the procedure m ig h t hurt. told me to be calm or to relax. criticized my teeth or how I ’ve been tak in g care of them. m ade sure I was n u m b before w ork in g o n me. show ed that he knew w h at I was feeling. w orked quickly b u t d id n ’t rush. was friendly to me. encouraged me to ask q uestions a b o u t my treatm ent. m ade me feel welcome. was p olite to me d u rin g my visit. used w ords th a t were understandable in ta lk in g ab o u t m y dental care. told m e w h at he was g o in g to do before startin g to work. show ed that he p a id a tte n tio n to w hat I said. reassured me d u rin g the procedure. asked d u rin g the procedure if I were h a v in g any discom fort. h a d a calm m anner. asked d u rin g the visit if I were concerned or nervous. gave m e a step by step e x p la n atio n of w h at he was d o in g as he d id it. show ed th a t he took seriously w h at I had to say. was p a tie n t w ith me. carried o n casual conversation and sm all talk. told me th a t if it started to h u rt, h e w ould relieve the pain. gave me m oral su p p o rt d u rin g the procedure. let me know th a t h e ’d do everything he could to prevent pain. smiled.
Methods and materials O u tp atien ts were approached in the w ait in g room by a m em ber of the research sta ff a n d asked to p a rtic ip a te . T h is research assistant was identified clearly as n o t b eing a dental clinic staff member. P atients were n o t considered for p artici p atio n if they were present for a noninvasive procedure, were younger th an 18 years, o r were in severe pain. Patients were offered $5 to participate; p articip a tion req u ired rem ain in g after they were treated for 10 to 15 m inutes. O f the q u a li fied patients, less th a n 5% refused to participate. Before their dental procedures began, p atients filled o u t the C orah D ental A nx iety Scale (DAS).6 After treatm ent, they rated their anxiety on 7-point scales that ranged from calm -relaxed to tense-upset. T h ere were three scales labeled: before treatm ent, d u rin g treatm ent, and now. T h e three scales were presented together, after treatm ent, for two reasons. First, it is d ifficult to in te rru p t treatm ent to obtain an anxiety rating. Therefore, an overall ju d g m e n t of the experience seemed to be preferable. Second, presenting the before, d u rin g , a n d now scales together was th o u g h t to encourage the patient into m ak in g careful discrim inations of their anxiety at the different points. T h e now responses w hich were presented to enhance anxiety d iscrim in atio n were n o t used in analysis. T h e respondents also answ ered a ques tio n n a ir e lis tin g 25 p o s s ib le d e n tis t behaviors (Table 1), and com pleted the 74 ■ JADA, Vol. 116, Ja n u a ry 1988
D ental V isit Satisfaction Scale (DVSS).7 P atients responded to each of the 25 d en tist behavior item s w ith yes or no to in d i cate w h e th e r th e d e n tis t sh o w ed th e behavior; a question m ark was w ritten if they were uncertain. For scoring purposes, questio n m arks were always scored as a negative response. T h e DVSS w as d e s ig n e d to assess respondents’ satisfaction w ith the dentist in the context of a specific visit. Each of ten item s has a L ik ert scale response for m at w ith five categories ran g in g from strongly disagree to strongly agree. Items are scored in a positive direction ran g in g from one to five. T h e DVSS measures satisfaction in three areas: inform ationc o m p re h e n sio n , u n d e rsta n d in g -a c c e p tance, a n d technical com petence. A total satisfaction score is obtained from the sum of the individual item scores. R eports of the developm ent of the DVSS, in clu d in g reliability and validity data, are available elsewhere.7 A total of 250 dental p atients, 110 men and 140 w om en, p articipated in the study. T hey ranged in age from 18 to 75 years, w ith a m edian of 30 years. M edian educa tion was h ig h school graduate, w ith a range from co m pletion of th ird grade to com pletion of 7 years of college. Fifty-six percent of the sam ple were black an d 44% were white. T h e d ental procedures for the p atients o n the day of the interview were extraction, 60%; restorations, 27%; end odontic treatm ent, 8%; an d other, 5%. T h e
classifications of the dentists providing the service were staff m em bers, 6%; resi d en ts, 64%; a n d stu d e n ts, 30%. It was estim ated th a t ap proxim ately 50% of the clinic p o p u la tio n qualified for Medicaid reim bursem ent. Results C orrelational analysis was used in this study, w ith two m ajor dependent variables of interest. T h e first was reduction in anxiety from before treatm ent to d u rin g treatm ent. T h is m easure was obtained by subtracting anxiety d u rin g treatm ent from anxiety before treatm ent. T h e ratings of b o th anxiety an d dentist behaviors were, of necessity, o b tain ed after treatm ent. T h e other dependent variable was the total satisfaction score from the DVSS. T h e correlations between the perceived dentist behavior item s an d these dependent vari ables are given in T ab le 2. T e n of the 25 perceived dentist behav io r item s w ere co rrelated sig n ific an tly (P < .05) w ith anxiety reduction. P atien t anxiety reduction was linked to the per ception that the dentist was concerned for the p a tie n t’s com fort, was em pathie, and supportive (T able 2: item s 5, 15, 19, 23, 24). Anxiety red u ctio n was also linked to the perception of a friendly, accepting, an d reassuring d en tist (Table 2: item s 6, 7, 9, 16, 25). T h e change in anxiety scores w as n o t asso cia te d w ith tr a it an x iety before treatm ent—th a t is, w ith the DAS
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Discussion Table 2 ■ Correlations between the dentist behavior items and patient anxiety reduction and satisfaction (N = 250). D entist behavior items 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25.
A nxiety red u ctio n
T o tal satisfaction
.08 .05 -.04 .09 .16* .19f
.17* .07 .03 .32+ .37+ .15* .20+ .33+ .29+ .32+ .17* .23+ .23+ .32+ .30+ .34+ .31+ .24+ .33+ .32+ .31+ .24+ .33+ .36+ .36+
W arned m ig h t h u rt T o ld m e to be calm C riticized teeth M ade m e n u m b Knew my feelings W orked quickly Was friendly E ncouraged q uestions W elcom ing Polite Was u n d erstan d ab le T o ld m e procedure P aid atte n tio n to me R eassured me Asked a b o u t discom fort H a d calm m an n er Asked a b o u t anxiety O n g o in g e x p la n atio n T o o k m e seriously P atien t w ith m e C onversation Reassured a b o u t p a in M oral su p p o rt Prevent p a in Smiled
.211 .09 .16* .08 -.03 .12 .05 .11 .15* .15* .07 .09 .22+ .03 .11 -.01 ,2 3 f .25f -18+
•P < .05.
tP<.01. scores (r = .12, P = NS). M ost of the d en tist behavior item s were related signifi cantly (P < .05) to the total satisfaction scores from the DVSS (Table 2). S eparate stepw ise m ultiple-regression analyses were conducted for each of the two dependent variables. Variables were retained in the analyses only if they co n tributed significantly (P < .05) to the vari an ce afte r a d ju s tm e n t (for p rev io u sly extracted variables). T h e results of the m ultiple regression analyses for the depen dent variables are given in T able 3. T h e results show n in T able 3 indicate th at six perceived dentist behaviors con tributed significantly to anxiety reduction w hile seven perceived dentist behaviors co ntributed significantly to the total satis faction score. O nly two items appear in b oth analyses: calm ness of the dentist, an d reassurance concerning prevention of pain. A ccording to the interviews, items co n trib u tin g to anxiety reduction often include the d en tist’s prom ise to control p ain and prevent discom fort, and provid ing reassurance. T h e m ajor item s contrib u tin g to satisfaction appear to be friend liness, em pathy, and the general dem eanor of the dentist. It sh o u ld be noted that dentist behav io rs (T a b le 3) assessed in th is stu d y a c c o u n t for o n ly 18% of re d u c tio n in anxiety and 37% of p atien t satisfaction.
D entist behaviors, therefore, account for a statistically significant p art of the rela tionship w ith the two dependent variables. However, anxiety reduction a n d satisfac tion is determ ined by factors other than those assessed in this study for a num ber of dependent variables actually used in this study. T here appears to be no relatio n sh ip betw een th e assessm ent of satisfactio n (D V SS) a n d a n y of th e m e a su re s of anxiety. F or ex am p le, the re la tio n sh ip betw een to ta l sa tisfac tio n a n d anxiety before treatm ent, d u rin g treatm ent, and anxiety reduction are n ot significant.
A lth o u g h ten perceived dentist behaviors were lin k ed to anxiety reduction, a subset of six behaviors ap p ear to be m ost in flu ential. T h e m ost im p o rtan t behavior is the d en tist’s dedication to prevent pain . M ost of the other behaviors—being friend ly, n o t ru sh in g , being calm , g iv in g m oral support, an d p ro m isin g relief sh o u ld p ain o cc u r—can be viewed as p ro v id in g a behavioral context in su p p o rt of prevent in g pain. T h e patient-perceived dentist behaviors m ost associated w ith p atien t satisfaction were those p o rtray in g em pathy, friendli ness, an d a calm an d com petent im age to the p atient. T w o items, h aving a calm m an n er, an d dedication to prevent p ain , are the only behaviors significant to b oth d ependent variables. These scored behav iors are the sole lin k betw een anxiety an d satisfaction in this study, an d are consis ten t w ith o u r previous findings th a t no s ig n ific a n t c o n n e c tio n ex ists b etw een p a t ie n t s a tis f a c tio n a n d th e a n x ie ty m easures.3 It is assum ed th a t b oth anxiety reduc tio n a n d s a tis fa c tio n are im p o r ta n t m ed iatin g variables leading to p atien t com pliance w ith dental regim ens such as reg u lar visits an d preventive hom e care.3 A careful assessm ent of this assum ed rela tio n sh ip has n o t been conducted. S u rp ris in g results include the lack of association between anxiety reduction and satisfaction since it is com m only assum ed th at reduc in g p atien t anxiety should be satisfying to the patient. T h e r e la tio n s h ip betw een p erceiv ed dentist behaviors an d anxiety reduction has n o t yet been tested in a causal fashion, for exam ple, tra in in g dentists to use cer tain behaviors a n d then m easuring the effects on their patients.
Table 3
■ Dentist behavior items accounting for most variation in anxiety reduction and dental visit satisfaction —stepwise multiple regression analyses. D ependent variable
D entist behavior item
M ultip le r
A nxiety reduction
24 7 6 16 23 22
prevent p a in was friendly w orked q u ick ly had calm m a n n e r m oral su p p o rt reassured a b o u t p a in
.42
T o ta l satisfaction score
5 25 4 16 17 24 2
knew my feelings sm iles m ade me n u m b had calm m an n er asked a b o u t anxiety prevent p a in told me to be calm
.61
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Summary T h is stu d y re la te s p erc eiv e d d e n tis t behaviors to anxiety reduction in patients d u rin g treatm ent, an d to satisfaction w ith the dental visit. T h e sam ple consisted of 250 ad u lt p atien ts, 110 m en and 140 w om en, at tw o o u tp a tie n t h ospital dental c lin ic s . Im m e d ia te ly a fte r tre a tm e n t, p atien ts were asked to respond to a list of 25 dentist behaviors th o u g h t to be asso ciated w ith positive d entist-patient inter action. C riterion m easures obtained by patien ts were self-ratings of anxiety d u r in g treatm ent a n d satisfaction measures from the DVSS. T en behaviors were significantly asso ciated w ith anxiety reduction. A stepwise m u ltip le regression analysis w ith anxiety reduction as the dependent variable in d i cated th a t to the patient, the d en tist’s explicit dedication to prevent pain was the m ost im p o rta n t dentist behavior, w ith friendliness, w orking quickly, being calm,
76 ■ JADA, Vol. 116, Ja n u a ry 1988
and giving m oral su p p o rt, b eing im p o r tant auxiliary behaviors. Most of the 25 dentist behaviors studied were associated w ith p atien t satisfaction. A stepwise m u ltip le regression analysis indicated th a t the d en tist’s em pathy and com m unicativeness were am o n g im p o r tant correlates of p atien t satisfaction. An experim ental ap p ro ach to causal analysis of anxiety reducing behaviors needs to be studied. -----------------------J l i O A -----------------------T h e inform ed co n sen t of all subjects w ho p a rtic i pated in this study was obtained after the n atu re of the procedures had been fully explained. T h is research was supported, in part, by research g ra n t no. DE 04494, N atio n al In stitu te of Dental Research. T h e au th o rs th an k the staff m em bers of the Buffalo G eneral H o sp ital, a n d Deaconess H o sp ital Dental C linics for th eir assistance w ith this project. Dr. C orah is professor, behavioral sciences, School of D ental M edicine; Dr. O ’Shea is associate professor,
social an d preventive m edicine, School of M edicine; Dr. Bissell is associate professor, pu b lic h ealth d en tist ry; Dr. T h in e s is assistan t professor, oral m edicine; an d Ms. M endola is research assistant, behavioral sciences, School of D ental M edicine, State U niversity of New Y ork at Buffalo, Squire H all, Buffalo, NY 14214. Address requests for reprints to Dr. C orah. 1. G iangrego, E. C o n tro llin g anxiety in the dental office. JADA 113(5):728-735, 1986. 2. C orah, N .L .; O ’Shea, R.M.; an d Ayer, W.A. D en tists’ m anagem ent of p atien ts’ fear an d anxiety. JADA 110(5):734-736, 1985. 3. C orah, N .L .; O ’Shea, R.M.; and Bissell, G.D. T h e d e n tis t-p a tie n t re la tio n sh ip : p ercep tio n s by p atien ts of d entist behavior in relation to satisfaction an d anxiety. JA D A 111 (3):443-446, 1985. 4. O ’Shea, R.M .; C orah, N .L .; an d T h in es, T .J. D ental p a tie n ts’ advice on how to reduce anxiety. G en D ent 34(1 ):44-47, 1986. 5. C orah, N .L. M ethodological needs an d behav io ral research w ith a d u lt d ental p atients. Anesthes P ro g 33(1 ):46-49, 1986. 6. C orah, N .L. D evelopm ent of a dental anxiety scale. J D ent Res 48:596, 1969. 7. C orah, N .L ., a n d others. D evelopm ent o f a p a tie n t m easure of satisfaction w ith the dentist: the dental visit satisfaction scale. J Behav Med 7(4):367373, 1984.
health trial w ith zin c-co n tain in g m o n o flu o ro p h o sp h a te dentifrices. J D ent Res 66(Special Issue) abstract no. 164, 1987. 11. C onti, A., a n d others. Caries efficacy of tw o fluoride dentifrices (1,000 vs 1,500 p p m F). J D ent Res 66(Special Issue) 66:258, abstract no. 1209, 258, 1987. 12. R adike, A.W. C riteria for d iagnosis of d ental caries. In Proceedings o f the Conference o n C linical T e stin g of C ariostatic A gents, C hicago, A m erican D ental A ssociation, 1972, p p 87-88. 13. B ogopolsky, S.; A lbertini, H .; an d G oldberg, W. E tude c lin iq u e d ’u n e pate (dentifrice) a h au te ten eu r en fluoru res a M arseille. In V aillan t, J.M ., an d
Barm es, D., eds. Le P o in t Sur Le F lu r Sym posium , 1982. In stitu t de S tom atologie et de C h iru rg ie M ax illo-Faciale, L a Salpetriere, Paris, 1984. 14. B arn au d , J., an d F in id o ri, C. Etude de l ’efficacite preventive d ’u ne pate a hau te teneur en fluorures. J In t Assoc D ent C h ild 15(1):21-31, 1984. 15. G rain g er, R.M . A nalysis of caries increm ent by ag e a n d to o th surface in flu o rid a te d a n d n o n flu o rid ated p o p u la tio n s by electronic com puter. In Jam es, P.; K önig, H .; H eld, H ., eds. Advances in fluo rin e research an d d e ntal caries p revention, voi 4. L o n d o n , Perg am o n Press, 1966, p p 53-66. 16. B erm an, D.S., an d Slack, G .L . Caries experience
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re la tiv e to in d iv id u a l su sc e p tib ility . Br D ent J 135(2):68-70, 1973. 17. Jam es, P.M ., a n d others. A 3-year c linical trial of a dentifrice c o n ta in in g 2% sodium m onofluorop h o sp h ate . C om m u n ity D ent O ral E pidem iol 5(1 ):6772, 1977. 18. M itropoulos, C. DMFS(e) index for selection of c lin ic al trial subjects. C om m u n ity D ent O ral E pide m io l 13(l):30-32, 1985. 19. A lm an, J.E . S tatistical an d e th ical considera tio n s in clinical trials. C om m unity D ent O ral E p i dem iol 8(5):267-272, 1980.
Researchers asked 250 adults to respond to 25 dentist behaviors after receiving treatment. Positive reactions were recorded in response to ten behaviors perceived to be associated with anxiety reduction: specifically, empathy, friendliness, and communicativeness.
The dentist-patient relationship: perceived dentist behaviors that reduce patient anxiety and increase satisfaction Norman L. Corah, P h D Robert M. O ’Shea, P h D G . Donald Bissell, D D S Terrence J. Thines, D D S Pauline Mendola
a n a g in g p a tie n t a n x ie ty has lo n g been a m ajor challenge for the practicing dentist. A 1986 E m phasis re p o rt1 stressed th a t the den tist’s anxiety ab o u t the p atien t a n d the p a tie n t’s anxiety about the dentist make for a dental procedure that can be diffi cult for b o th of them . T he behaviors of the d en tist in p atien t m anagem ent, p a r tic u la rly in c o m m u n ic a tin g w ith the patien t, are considered im p o rta n t by m ost ex p erts1 w ho stress b u ild in g rap p o rt by u sin g various behavioral techniques to p u t the p a tie n t at ease. Many dentists are u n co m fo rtab le in d ea lin g w ith p a tie n t anxiety a n d attem p t to avoid confronting it.2 L ittle scientific research on the im pact of specific dentist behaviors on p atient anxiety is available.
M
A recent em pirical study3 attem pted to assess the relatio n sh ip between various dentist behaviors, an d anxiety reduction an d satisfaction of the patient. T h e d en tist behaviors studied were narrow ed to include only those perceived by the patient as h av in g some im pact on them . Most behaviors were associated w ith a m easure of p atien t satisfaction; however, few were associated w ith p atien t anxiety. T hese in itial findings prom pted further study of behaviors typically th o u g h t to reduce p atien t anxiety. Researchers4 in ter viewed 60 ad u lt patients in a hospital o u tp a tie n t clinic after dental treatm ent. P atients were questioned ab o u t their n er vousness and how the dentist and assis ta n ts ) contribu ted to it. P atients were also asked w hat they w ould do or say in
the d en tist’s place to ease p atien ts’ n er v o u sn ess. V erbal c o m m u n ic a tio n w as often stressed by the patients. T hey gave m ore th an 150 suggestions classified in to 12 categories. P atients frequently recom m ended th at dentists: give in itia l ex p la n a tio n s of w h at was g o in g to h a p p e n d u rin g the d ental procedure; give an inprocess e x p la n a tio n to let th e p a tie n t know w hat is h a p p e n in g as it is g o in g on; instruct the p atien t to be calm; w arn the p a tie n t ab o u t p ain w hen it is likely to occur; verbally su p p o rt the patient; try to give the p atien t ways of lo o k in g at the procedure in a less-threatening fashion a n d p ro v id e c o a c h in g to m a k e th em believe it is n o t as bad as they expect it to be; provide distraction of atten tio n and try to co m m unicate in ways th a t will
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b u ild trust in the dentist. T hese resulting suggestions led to the recasting of a list of d e n tis t b e h a v io r item s. T h e 25 item s developed are show n in T able 1. Previous research5 show ed th a t 20% to 25% of the anxiety response to treatm ent was determ ined by the p a tie n t’s general anxiety ab o u t treatm ent w hen arriving at the dental office. Therefore, it was deter m in ed th a t it was necessary to assess the change in the p a tie n t’s anxiety that m ight be affected by the den tist’s behavior to assess the relatio n sh ip appropriately. T h is study attem pted to reassess a range o f d e n tist b eh av io rs—as perceived by p atien ts—to determ ine their role in reduc in g p atien t anxiety and increasing satis faction. T h is investigation was conducted in large o u tp a tie n t dental clinics of two h o sp itals to provide a potentially broad range of p atien t selection. A representa tive response range was achieved from the clin ic’s diverse population.
Table 1 ■ Dentist behavior items (questionnaire). D u rin g today’s visit, the d e n tis t. . . 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25.
w arned me w hen he felt the procedure m ig h t hurt. told me to be calm or to relax. criticized my teeth or how I ’ve been tak in g care of them. m ade sure I was n u m b before w ork in g o n me. show ed that he knew w h at I was feeling. w orked quickly b u t d id n ’t rush. was friendly to me. encouraged me to ask q uestions a b o u t my treatm ent. m ade me feel welcome. was p olite to me d u rin g my visit. used w ords th a t were understandable in ta lk in g ab o u t m y dental care. told m e w h at he was g o in g to do before startin g to work. show ed that he p a id a tte n tio n to w hat I said. reassured me d u rin g the procedure. asked d u rin g the procedure if I were h a v in g any discom fort. h a d a calm m anner. asked d u rin g the visit if I were concerned or nervous. gave m e a step by step e x p la n atio n of w h at he was d o in g as he d id it. show ed th a t he took seriously w h at I had to say. was p a tie n t w ith me. carried o n casual conversation and sm all talk. told me th a t if it started to h u rt, h e w ould relieve the pain. gave me m oral su p p o rt d u rin g the procedure. let me know th a t h e ’d do everything he could to prevent pain. smiled.
Methods and materials O u tp atien ts were approached in the w ait in g room by a m em ber of the research sta ff a n d asked to p a rtic ip a te . T h is research assistant was identified clearly as n o t b eing a dental clinic staff member. P atients were n o t considered for p artici p atio n if they were present for a noninvasive procedure, were younger th an 18 years, o r were in severe pain. Patients were offered $5 to participate; p articip a tion req u ired rem ain in g after they were treated for 10 to 15 m inutes. O f the q u a li fied patients, less th a n 5% refused to participate. Before their dental procedures began, p atients filled o u t the C orah D ental A nx iety Scale (DAS).6 After treatm ent, they rated their anxiety on 7-point scales that ranged from calm -relaxed to tense-upset. T h ere were three scales labeled: before treatm ent, d u rin g treatm ent, and now. T h e three scales were presented together, after treatm ent, for two reasons. First, it is d ifficult to in te rru p t treatm ent to obtain an anxiety rating. Therefore, an overall ju d g m e n t of the experience seemed to be preferable. Second, presenting the before, d u rin g , a n d now scales together was th o u g h t to encourage the patient into m ak in g careful discrim inations of their anxiety at the different points. T h e now responses w hich were presented to enhance anxiety d iscrim in atio n were n o t used in analysis. T h e respondents also answ ered a ques tio n n a ir e lis tin g 25 p o s s ib le d e n tis t behaviors (Table 1), and com pleted the 74 ■ JADA, Vol. 116, Ja n u a ry 1988
D ental V isit Satisfaction Scale (DVSS).7 P atients responded to each of the 25 d en tist behavior item s w ith yes or no to in d i cate w h e th e r th e d e n tis t sh o w ed th e behavior; a question m ark was w ritten if they were uncertain. For scoring purposes, questio n m arks were always scored as a negative response. T h e DVSS w as d e s ig n e d to assess respondents’ satisfaction w ith the dentist in the context of a specific visit. Each of ten item s has a L ik ert scale response for m at w ith five categories ran g in g from strongly disagree to strongly agree. Items are scored in a positive direction ran g in g from one to five. T h e DVSS measures satisfaction in three areas: inform ationc o m p re h e n sio n , u n d e rsta n d in g -a c c e p tance, a n d technical com petence. A total satisfaction score is obtained from the sum of the individual item scores. R eports of the developm ent of the DVSS, in clu d in g reliability and validity data, are available elsewhere.7 A total of 250 dental p atients, 110 men and 140 w om en, p articipated in the study. T hey ranged in age from 18 to 75 years, w ith a m edian of 30 years. M edian educa tion was h ig h school graduate, w ith a range from co m pletion of th ird grade to com pletion of 7 years of college. Fifty-six percent of the sam ple were black an d 44% were white. T h e d ental procedures for the p atients o n the day of the interview were extraction, 60%; restorations, 27%; end odontic treatm ent, 8%; an d other, 5%. T h e
classifications of the dentists providing the service were staff m em bers, 6%; resi d en ts, 64%; a n d stu d e n ts, 30%. It was estim ated th a t ap proxim ately 50% of the clinic p o p u la tio n qualified for Medicaid reim bursem ent. Results C orrelational analysis was used in this study, w ith two m ajor dependent variables of interest. T h e first was reduction in anxiety from before treatm ent to d u rin g treatm ent. T h is m easure was obtained by subtracting anxiety d u rin g treatm ent from anxiety before treatm ent. T h e ratings of b o th anxiety an d dentist behaviors were, of necessity, o b tain ed after treatm ent. T h e other dependent variable was the total satisfaction score from the DVSS. T h e correlations between the perceived dentist behavior item s an d these dependent vari ables are given in T ab le 2. T e n of the 25 perceived dentist behav io r item s w ere co rrelated sig n ific an tly (P < .05) w ith anxiety reduction. P atien t anxiety reduction was linked to the per ception that the dentist was concerned for the p a tie n t’s com fort, was em pathie, and supportive (T able 2: item s 5, 15, 19, 23, 24). Anxiety red u ctio n was also linked to the perception of a friendly, accepting, an d reassuring d en tist (Table 2: item s 6, 7, 9, 16, 25). T h e change in anxiety scores w as n o t asso cia te d w ith tr a it an x iety before treatm ent—th a t is, w ith the DAS
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Discussion Table 2 ■ Correlations between the dentist behavior items and patient anxiety reduction and satisfaction (N = 250). D entist behavior items 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25.
A nxiety red u ctio n
T o tal satisfaction
.08 .05 -.04 .09 .16* .19f
.17* .07 .03 .32+ .37+ .15* .20+ .33+ .29+ .32+ .17* .23+ .23+ .32+ .30+ .34+ .31+ .24+ .33+ .32+ .31+ .24+ .33+ .36+ .36+
W arned m ig h t h u rt T o ld m e to be calm C riticized teeth M ade m e n u m b Knew my feelings W orked quickly Was friendly E ncouraged q uestions W elcom ing Polite Was u n d erstan d ab le T o ld m e procedure P aid atte n tio n to me R eassured me Asked a b o u t discom fort H a d calm m an n er Asked a b o u t anxiety O n g o in g e x p la n atio n T o o k m e seriously P atien t w ith m e C onversation Reassured a b o u t p a in M oral su p p o rt Prevent p a in Smiled
.211 .09 .16* .08 -.03 .12 .05 .11 .15* .15* .07 .09 .22+ .03 .11 -.01 ,2 3 f .25f -18+
•P < .05.
tP<.01. scores (r = .12, P = NS). M ost of the d en tist behavior item s were related signifi cantly (P < .05) to the total satisfaction scores from the DVSS (Table 2). S eparate stepw ise m ultiple-regression analyses were conducted for each of the two dependent variables. Variables were retained in the analyses only if they co n tributed significantly (P < .05) to the vari an ce afte r a d ju s tm e n t (for p rev io u sly extracted variables). T h e results of the m ultiple regression analyses for the depen dent variables are given in T able 3. T h e results show n in T able 3 indicate th at six perceived dentist behaviors con tributed significantly to anxiety reduction w hile seven perceived dentist behaviors co ntributed significantly to the total satis faction score. O nly two items appear in b oth analyses: calm ness of the dentist, an d reassurance concerning prevention of pain. A ccording to the interviews, items co n trib u tin g to anxiety reduction often include the d en tist’s prom ise to control p ain and prevent discom fort, and provid ing reassurance. T h e m ajor item s contrib u tin g to satisfaction appear to be friend liness, em pathy, and the general dem eanor of the dentist. It sh o u ld be noted that dentist behav io rs (T a b le 3) assessed in th is stu d y a c c o u n t for o n ly 18% of re d u c tio n in anxiety and 37% of p atien t satisfaction.
D entist behaviors, therefore, account for a statistically significant p art of the rela tionship w ith the two dependent variables. However, anxiety reduction a n d satisfac tion is determ ined by factors other than those assessed in this study for a num ber of dependent variables actually used in this study. T here appears to be no relatio n sh ip betw een th e assessm ent of satisfactio n (D V SS) a n d a n y of th e m e a su re s of anxiety. F or ex am p le, the re la tio n sh ip betw een to ta l sa tisfac tio n a n d anxiety before treatm ent, d u rin g treatm ent, and anxiety reduction are n ot significant.
A lth o u g h ten perceived dentist behaviors were lin k ed to anxiety reduction, a subset of six behaviors ap p ear to be m ost in flu ential. T h e m ost im p o rtan t behavior is the d en tist’s dedication to prevent pain . M ost of the other behaviors—being friend ly, n o t ru sh in g , being calm , g iv in g m oral support, an d p ro m isin g relief sh o u ld p ain o cc u r—can be viewed as p ro v id in g a behavioral context in su p p o rt of prevent in g pain. T h e patient-perceived dentist behaviors m ost associated w ith p atien t satisfaction were those p o rtray in g em pathy, friendli ness, an d a calm an d com petent im age to the p atient. T w o items, h aving a calm m an n er, an d dedication to prevent p ain , are the only behaviors significant to b oth d ependent variables. These scored behav iors are the sole lin k betw een anxiety an d satisfaction in this study, an d are consis ten t w ith o u r previous findings th a t no s ig n ific a n t c o n n e c tio n ex ists b etw een p a t ie n t s a tis f a c tio n a n d th e a n x ie ty m easures.3 It is assum ed th a t b oth anxiety reduc tio n a n d s a tis fa c tio n are im p o r ta n t m ed iatin g variables leading to p atien t com pliance w ith dental regim ens such as reg u lar visits an d preventive hom e care.3 A careful assessm ent of this assum ed rela tio n sh ip has n o t been conducted. S u rp ris in g results include the lack of association between anxiety reduction and satisfaction since it is com m only assum ed th at reduc in g p atien t anxiety should be satisfying to the patient. T h e r e la tio n s h ip betw een p erceiv ed dentist behaviors an d anxiety reduction has n o t yet been tested in a causal fashion, for exam ple, tra in in g dentists to use cer tain behaviors a n d then m easuring the effects on their patients.
Table 3
■ Dentist behavior items accounting for most variation in anxiety reduction and dental visit satisfaction —stepwise multiple regression analyses. D ependent variable
D entist behavior item
M ultip le r
A nxiety reduction
24 7 6 16 23 22
prevent p a in was friendly w orked q u ick ly had calm m a n n e r m oral su p p o rt reassured a b o u t p a in
.42
T o ta l satisfaction score
5 25 4 16 17 24 2
knew my feelings sm iles m ade me n u m b had calm m an n er asked a b o u t anxiety prevent p a in told me to be calm
.61
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Summary T h is stu d y re la te s p erc eiv e d d e n tis t behaviors to anxiety reduction in patients d u rin g treatm ent, an d to satisfaction w ith the dental visit. T h e sam ple consisted of 250 ad u lt p atien ts, 110 m en and 140 w om en, at tw o o u tp a tie n t h ospital dental c lin ic s . Im m e d ia te ly a fte r tre a tm e n t, p atien ts were asked to respond to a list of 25 dentist behaviors th o u g h t to be asso ciated w ith positive d entist-patient inter action. C riterion m easures obtained by patien ts were self-ratings of anxiety d u r in g treatm ent a n d satisfaction measures from the DVSS. T en behaviors were significantly asso ciated w ith anxiety reduction. A stepwise m u ltip le regression analysis w ith anxiety reduction as the dependent variable in d i cated th a t to the patient, the d en tist’s explicit dedication to prevent pain was the m ost im p o rta n t dentist behavior, w ith friendliness, w orking quickly, being calm,
76 ■ JADA, Vol. 116, Ja n u a ry 1988
and giving m oral su p p o rt, b eing im p o r tant auxiliary behaviors. Most of the 25 dentist behaviors studied were associated w ith p atien t satisfaction. A stepwise m u ltip le regression analysis indicated th a t the d en tist’s em pathy and com m unicativeness were am o n g im p o r tant correlates of p atien t satisfaction. An experim ental ap p ro ach to causal analysis of anxiety reducing behaviors needs to be studied. -----------------------J l i O A -----------------------T h e inform ed co n sen t of all subjects w ho p a rtic i pated in this study was obtained after the n atu re of the procedures had been fully explained. T h is research was supported, in part, by research g ra n t no. DE 04494, N atio n al In stitu te of Dental Research. T h e au th o rs th an k the staff m em bers of the Buffalo G eneral H o sp ital, a n d Deaconess H o sp ital Dental C linics for th eir assistance w ith this project. Dr. C orah is professor, behavioral sciences, School of D ental M edicine; Dr. O ’Shea is associate professor,
social an d preventive m edicine, School of M edicine; Dr. Bissell is associate professor, pu b lic h ealth d en tist ry; Dr. T h in e s is assistan t professor, oral m edicine; an d Ms. M endola is research assistant, behavioral sciences, School of D ental M edicine, State U niversity of New Y ork at Buffalo, Squire H all, Buffalo, NY 14214. Address requests for reprints to Dr. C orah. 1. G iangrego, E. C o n tro llin g anxiety in the dental office. JADA 113(5):728-735, 1986. 2. C orah, N .L .; O ’Shea, R.M.; an d Ayer, W.A. D en tists’ m anagem ent of p atien ts’ fear an d anxiety. JADA 110(5):734-736, 1985. 3. C orah, N .L .; O ’Shea, R.M.; and Bissell, G.D. T h e d e n tis t-p a tie n t re la tio n sh ip : p ercep tio n s by p atien ts of d entist behavior in relation to satisfaction an d anxiety. JA D A 111 (3):443-446, 1985. 4. O ’Shea, R.M .; C orah, N .L .; an d T h in es, T .J. D ental p a tie n ts’ advice on how to reduce anxiety. G en D ent 34(1 ):44-47, 1986. 5. C orah, N .L. M ethodological needs an d behav io ral research w ith a d u lt d ental p atients. Anesthes P ro g 33(1 ):46-49, 1986. 6. C orah, N .L. D evelopm ent of a dental anxiety scale. J D ent Res 48:596, 1969. 7. C orah, N .L ., a n d others. D evelopm ent o f a p a tie n t m easure of satisfaction w ith the dentist: the dental visit satisfaction scale. J Behav Med 7(4):367373, 1984.