Journal of Clinical and Basic Research (JCBR)

Background and objectives: Dental anxiety refers to the fear associated with the idea of seeking dental care. It is the fifth most common cause of anxiety. The purpose of this study was to investigate efficiency of educational videos for reducing anxiety and fear in adult patients undergoing root canal treatment in private dental clinics.
Methods: This was a quasi-experimental study with a pretest-posttest design. The statistical population consisted of all patients referred to private dental clinics in Shiraz (Iran) during the summer of 2016. Overall, 50 subjects were selected via the convenience sampling method. The subjects were randomly divided into an intervention group (n=25) and a control group (n=25). Both groups responded to two anxiety and fear questionnaires. Then, the intervention group participated in a video training session, while the control group did not receive any training. Subjects in both study groups once again completed the questionnaires. Data were analyzed in the SPSS (version 22) using one-way analysis of covariance and at statistical significance of 0.05.
Results: After the intervention, the mean scores of fear and its components (avoiding dental treatment, physical symptoms caused by anxiety, and anxiety caused by dental stimuli) were significantly lower in the intervention group than in the control group (P<0.05).
Conclusion: Based on the findings, it can be concluded that the educational video on root canal treatment could help reduce anxiety and fear in adult patients.

Keywords: Educational video, Anxiety, Fear, Root canal treatment

Introduction
  Fear and anxiety from dental procedures have contributed to the avoidance of dental care. Dental anxiety refers to the fear associated with the idea of seeking dental care (1). It is the fifth most common cause of anxiety. This emotional state is sometimes indistinguishable from the actual threat that confronts us before the encounter occurs (2). According to Saatchi et al., the prevalence of dental anxiety is higher among women, regardless of education level (3). Previous studies have shown an inverse relationship between dental visits and anxiety (1-3). Dental anxiety can lead to dental health problems, such as dental caries (4-6). This problem is often accompanied with a poorer prognosis for restoration and more extractions because of delayed treatment (6). Moreover, the cost of further surgical treatment for the extraction site may be higher and such expenses disincentives patients further from seeking dental care. This may ultimately affect confidence and quality of life of patients (6). A combination of personal and environmental factors may contribute to the development of dental anxiety (5).
  Daokar et al. reported that dental anxiety not only affects patients' oral health, but also their daily lives. The authors claimed that audiovisual distraction techniques were effective in reducing dental anxiety (7). Benzodiazepines and sedatives that are widely used to treat anxiety, but these drugs often have several adverse effects and require a doctor's prescription (7,8). The non-pharmacological or complementary approaches for treating anxiety are typically free of side effects and can be used alone or in combination with other treatments (8,9)
  The American Academy of Pediatric Dentistry has recommended conducting further research regarding the development of non-pharmacological interventions (10). Music therapy, relaxation, desensitization, ceasing to think, and cognitive reconstruction can help decrease surgical anxiety (11). Adequate patient education and increasing knowledge about the surgical procedure and its complications and benefits
 
can reduce anxiety, postoperative complications, and length of hospital stay while speeding up the recovery process (10).
  To avoid negative experiences in patients and ensure quality care, it is critical for dentists to implement effective ways to help patients with dental anxiety overcome their fears. One way to control dental anxiety and fear in the waiting room is to use instructional videos and other forms of patient education (12).
  Adel Zakhary et al. demonstrated the beneficial effects of rehabilitation programs along with oral education in reducing dental anxiety (13). In another study, Zhang also showed that audiovisual distraction can effectively reduce dental anxiety among children (14).
  The main objective of the present study was to evaluate effects of educational videos on dental anxiety and fear of adult patients undergoing root canal treatment.
 
MATERIALS AND METHODS
  This was a quasi-experimental study with a pretest-posttest design. The study included all patients who were referred to private dental clinics in Shiraz (Iran) during the summer of 2016. The sample size was calculated as 45 at 95% confidence level and 80% test ability. After considering sample loss, 50 patients were randomly selected and then equally divided into an intervention group (n=25) and a control group (n=25).
  Demographic data were collected using a questionnaire. The patients also completed the dental anxiety scale (DAS) and the dental fear scale (DFS) at baseline and after the intervention. The intervention group watched an educational video, while the control group did not receive any training. The educational video for reducing dental anxiety was found on YouTube (available at: https://www.youtube.com/watch?v=QjHIzA4bHtM), translated and voiced by the researchers. Two clinical psychologists and four dentists approved the translated version of the video. The video was played for the subjects about 15 minutes before the dental denervation procedure.
  The DAS scale was originated by Shuurs & Hoogstraten (15) and is composed of four different dental conditions that include the feeling of being seen in a dental clinic, waiting for treatment in a dental office, shaving teeth, and scaling (16). It is one of the most widely used tools for measuring dental anxiety. The questionnaire examines patients' perceptions of the risk and threat of dental treatment and consists of five multiple-choice questions. The answers were scored from 1 (calmest) to 5 (most anxious). Accordingly, an overall score of less than nine, 9-11, 13-14, and 15-25 indicated low anxiety, moderate anxiety, high anxiety, and severe anxiety, respectively. The validity and reliability of the questionnaire have been verified (3). Pretest and posttest Cronbach's alpha values of the intervention group were 0.81 and 0.88, respectively. Pretest and posttest Cronbach's alpha values of the control group were 0.89 and 0.83, respectively.
  The DFS has been widely used to assess individuals' level of dental fear. It includes 20 questions under three categories: avoidance of dental treatment (two questions), physical symptoms caused by anxiety (five questions), and anxiety due to a dental stimulus (13 questions). Questions were related to the patients’ feeling about the treatment, possibility of avoiding dental examinations due to fear, approaching the clinic, and sitting in the waiting or on the dental chair are addressed in the questionnaire. The Likert scale was used to score the data from 1 to 5 based on the heart rate recorded during dental work. An overall DFS score of 60 or greater indicated fearful event.  A previous study indicated that the DFS has psychometric properties (18). In the present study, pretest and posttest Cronbach's alpha values of the intervention group were 0.91 and 0.86, respectively. Pretest and posttest Cronbach's alpha values of the control group were 0.85 and 0.89, respectively.
  Data were analyzed using the SPSS software (version 22). The data were described using mean, standard deviation, frequency, and percentage. Normality of data distribution and equality of variance were assessed using the Kolmogorov-Smirnov test and Levene's test, respectively. The collected data were analyzed using one-way analysis of variance and the. A p-value of less than 0.05 was considered statistically significant.
 
RESULTS
  (Table 1) presents the demographic characteristics of the subjects in both study groups.

Variables		Intervention group		Control group		P-value
		Frequency	Percentage	Frequency	Percentage
Gender	Female	18	72	19	76	0.723
	Male	7	28	6	24	0. 128
Marital status	Married	19	76	16	64	0. 427
	Single	6	24	9	36	0. 321
Age (years)	25-35	2	39	4	36	0. 112
	36-45	4	8	4	16	0. 154
	46-55	10	16	10	16	0. 675
	> 55	9	40	7	40	0. 456
Level of education	High school diploma and lower	16	64	15	60	0. 765
	Associate degree	5	20	5	20	0.546
	Bachelor's degree and higher	4	16	5	20	0. 234
Occupational status	Freelance	7	28	3	12	0. 354

 As shown in (table 2), the intervention did not significantly change anxiety scores related to dental denervation, fear of dental denervation, dental treatment avoidance, physical symptoms caused by anxiety, anxiety caused by dental stimuli (P>0.05). However, the posttest values of all variables were significantly lower in the intervention group compared with the control group (P<0.05).

Intergroup difference (posttest)	Intragroup difference (pretest vs. posttest)	Posttest	Pretest	Groups	Variable
		Mean ± SD	Mean ± SD
0.001	0. 236	8.12±2.82	11.44±3.54	Intervention	Anxiety caused by dental denervation
0.001	0. 206	10.2±2.71	11.05±2.64	Control
0.001	0. 321	33.76±25.11	44.08±17.4	Intervention	Fear of dental denervation
0.001	0. 651	42.67±13.62	43.18±15.12	Control
0.001	0. 533	3.37±1.69	4.4±1.21	Intervention	Dental treatment avoidance component
0.001	0. 243	4.26±1.02	4.31±1.23	Control
0.001	0. 187	8.44±2.25	11.02±3.3	Intervention	Component of physical symptoms caused by anxiety
0.001	0. 734	10.66±2.56	10.79±3.17	Control
0.001	0. 576	21.94±4.89	28.65±5.65	Intervention	Anxiety component created by dental stimuli
0.001	0. 322	27.73±5.01	28.06±4.49	Control

DISCUSSION
  In the present study, we evaluated the effects of an educational video on dental anxiety and fear among patients undergoing
 
root canal treatment. According to the results, the mean score of dental anxiety variables did not change significantly in the study groups. However, the posttest mean values of the variables were significantly lower in the intervention group. In many medical specialties, providing preoperative information could reduce anxiety and complaints among patients and increase positive outcomes. Moreover, providing information to patients can help prepare them for treatment by reduces anxiety levels (17-20). Our findings are in line with findings of some previous studies (6, 21, 22). 
  One of the most common reactions to a stressor is anxiety (19-22). Most people experience anxiety when facing stressful events. In fact, anxiety is a sporadic state of arousal after perceiving a real or imagined threat that is future-oriented and emotion-focused that can be an adaptive response. Stressful conditions occur, but a fundamental cause of anxiety is an irregular response to the stressful situation (23).
  In general, anxiety is classified by two main characteristics: mental characteristics (fear, difficulty concentrating, sadness, etc.) and physical symptoms (increased heart rate, shortness of breath, tremors, sweating, redness of the skin, and involuntary movements such as hand or face movement). There are several techniques for reducing stress, anxiety, and psychological problems. We assumed that an educational video could reduce anxiety by demonstrating that root canal treatment is not necessarily painful.
  The results showed that the mean scores of fear of denervation differed significantly between the groups after the intervention. This finding is consistent with findings of some previous studies (24-27). Mark (2017) concluded that some methods, such as adapting to body posture and relaxation, can reduce dental anxiety (24). Heidari et al. (2020) also reported a relationship between anxiety and unpleasant experience before dental appointment (27).
  In general, fear is a warning sign, and it is normal feel afraid when facing an external, definite, and conflict-free threat. A common reason for people's dental fear is denervation because the procedure can be painful. Using educational videos, dentists can minimize pain and reduce dental fear in patients (26).
Study limitations
  Limitations of the present study were the small sample size and lack of follow-ups. Moreover, we had no control over factors that may have influenced subjects’ answers to the questionnaire, such as problem-solving skills and resilience.
 
CONCLUSION
  Based on the findings, it can be concluded that the educational video on root canal treatment could help reduce anxiety and fear in adult patients.
 
ACKNOWLEDGMENTS
  This paper was derived from the results of an MSc thesis on Clinical Psychology approved by the Islamic Azad University, Shiraz Branch. The authors would like to express their gratitude to the staff of the dentistry clinics for cooperating in this study. 
 
DECLARATIONS
Funding
  The authors received no financial support for the research, authorship, and/or publication of this article.
 
Ethics approvals and consent to participate
  Informed consent was obtained from all participants after ensuring confidentiality of personal information.
 
Conflict of interest
The authors declare that there is no conflict of interest regarding publication of this article