This study aimed to evaluate anxiety levels in individuals with gingival recession and explore potential associations between anxiety and various etiological factors contributing to gingival recession. The results indicated varying levels of anxiety among participants, with a significant proportion experiencing mild to moderate anxiety. Notably, the MDAS scores revealed that only a small percentage of participants had high levels of dental anxiety. Furthermore, this study investigated the associations between different etiological factors of gingival recession and anxiety levels. There were significant differences in anxiety levels based on the etiology of gingival recession, particularly concerning anatomical anomalies and malpositioned teeth.
Dental anxiety is a prevalent issue globally, with sex and age emerging as significant factors associated with this condition28. In the study conducted by Türer et al.29, no significant relationship was found between the patient's age and the STAI score. Similarly, several studies have reported no significant correlation between age and dental anxiety30,31. On the contrary, another study identified a negative correlation between age and anxiety levels32. The level of anxiety in patients who underwent surgery for impacted wisdom teeth was not related to sex, age, or education level33. Arslan et al.34 reported that dental anxiety was not affected by age or education level and that the dental anxiety levels of females were greater than those of males. Further studies with larger sample sizes are needed to investigate the effect of various factors on dental anxiety. In Arslan et al.’s31 study, it was observed that dental anxiety was not affected by age or education level and that the dental anxiety levels of females were greater than those of males. In contrast to other studies, a statistically significant relationship was found between age and MDAS score, and MDAS score decreased with age. Also, a significant relationship was found among the STAI-S, STAI-T, and MDAS and gender. The anxiety levels of women were greater than those of men.
In the study in which the anxiety levels of thirty-five patients undergoing oral surgery were evaluated, 80% of the individuals’ parents lived together, and 34.3% of them responded yes to the question of whether they underwent surgery under local anesthesia. A total of 31.4% of the participants had previously undergone oral surgery, and 31.4% of the participants reported finding oral surgery frightening35. In this study, the rate of living with the family, the rate of undergoing surgery under local anesthesia, the rate of undergoing oral surgery, and the rate of fear of dental treatment were found to be higher compared to the other study.
Poor oral hygiene habits can cause gingival recession. Gingival recession is positively associated with the amount of abrasion (reflecting forceful brushing) and poor oral hygiene36. There was a positive association between tooth brushing frequency and gingival recession. Other potential risk factors were the duration of tooth brushing, brushing force, frequency of changing the toothbrush, brush (bristle) hardness, and tooth brushing technique 37. Marco et al.38 found no significant relationship between the MDAS score and the gingival index score in a study of five hundred people. Similarly, Singh et al.39 reported low pain perception and anxiety among participants during periodontal probing, with a very low correlation between bleeding on probing and both pain and anxiety. The study revealed that adolescents had a greater fear of dental care when they experienced gingival bleeding and tooth pain. Gingival bleeding is a symptom of early gingival disease, and dental pain is likely caused by advanced dental caries. These results suggested that it is necessary to have a program to reduce dental fear and anxiety as well as a program to prevent dental diseases through regular periodic screening and education40. Karahan et al.41 observed no significant relationship between oral hygiene habits and anxiety. Similar to the literature, this study did not find a significant relationship between oral hygiene habits and anxiety levels.
STAI-estimated anxiety is associated with the perception of pain following periodontal flap surgery, and females experience more pain after surgery; however, the amount of pain perception is not related to age22. In a study of one hundred and twenty oral surgery patients, no significant difference was found between the STAI-T and STAI-S scores when the surgical procedures were compared individually. There was also no significant difference in anxiety levels between patients scheduled for extractions due to previous dental treatments and those undergoing regular or surgical extractions23. In the study in which the effect of computer-assisted visual information on dental anxiety before periodontal surgery was determined by STAI-S and STAI-T scores for one hundred and fourteen people, there was no statistically significant difference between the groups in terms of the STAI-T score. In contrast, the STAI-S scores of the verbal and visual information groups were significantly greater than those of the verbal information only group. No significant difference was found for STAI-S or STAI-T score according to the type of surgery performed (frenectomy, gingivectomy, mucogingival, flap, implant, and sinus surgery)42. In a study investigating the effect of visual and written information on anxiety levels before and after periodontal surgery, the STAI score decreased in the postoperative period compared to the preoperative period29. In a study of 141 patients with gingivitis and periodontitis, the STAI scores were high in patients with gingivitis. Gingivitis was significantly more common in patients who had poor oral hygiene habits. The State-Trait Anxiety Inventory scores of the periodontal patients were significantly greater than those of the gingivitis patients. Patients with high state anxiety scores were more likely to have periodontitis43. Four hundred and fifty-six patients were analyzed, and a positive correlation was found between the STAI score and periodontal disease status44. In this study, participants with gingival recession generally had a low value of STAI high anxiety level and a high value of STAI low anxiety level values as a percentage.
In a study of three hundred dental students using the MDAS, higher anxiety levels were found in female dental students45. In a study involving 234 participants, 3.8% had high Modified Dental Anxiety Scale (MDAS) scores, with first-year students exhibiting higher levels of anxiety and fear than those in other grades. A significant correlation was found between anxiety levels and the frequency of dental visits, tooth brushing habits, and dental education. As students progressed in their education, gained clinical experience, and learned theoretical aspects of dentistry, their awareness increased, and their anxiety decreased 46. In contrast to these findings, the MDAS scores of five hundred dental students at all levels increased as the number of years at the university increased47. In the present study, which included one hundred and one people with peri-implantitis, peri-implant mucositis, and peri-implant status, no relationships were found among peri-implant status, dental anxiety, and quality of life. It was determined that the anxiety levels of the participants increased, and their quality of life decreased48. The anxiety and fear levels of the patients who underwent surgical procedures decreased, and patients without dental bridges experienced less pain after the procedure than patients with dental bridges. In patients with dental bridges, the STAI-S and MDAS scores were significantly greater, while the STAI-S and MDAS scores were significantly lower after 1 week. In general, MDAS scores were high49. Contrary to the data in this study, the MDAS score was generally not found to be high.
Montevecchi et al.50 individuals with low or no anxiety appear more prone to gingival recession when a thin periodontal phenotype is present. Conversely, those with high anxiety and poor oral hygiene seem less likely to develop buccal recession, suggesting that high anxiety may have a protective effect despite poorer oral hygiene habits. Correction of the malocclusion of the teeth with treatment resulted in a decrease in the STAI value51. In another study, higher anxiety levels were observed in individuals with malocclusion compared to healthy occlusion52. In this study, those with poor oral hygiene status had a lower MDAS, as in the study by Montevecchi et al. Also, it revealed a statistically significant correlation between the STAI-S and MDAS scores in patients with malpositioned teeth.
This study has several limitations. The cross-sectional design limited our ability to establish causality between etiological factors and anxiety levels. Longitudinal studies are warranted to elucidate the temporal relationship between these variables. Moreover, the study was conducted at a single institution, which may limit the generalizability of our findings to other populations. Future research involving larger and more diverse samples is needed to validate our results further.
As a result, malpositioned teeth, one of the etiologies of gingival recession, can worsen oral health and aesthetic problems and increase anxiety. Therefore, dentists and dental health professionals should consider not only patients' physical health but also their emotional and psychological needs. By identifying specific factors contributing to anxiety, dental professionals can develop targeted interventions to mitigate anxiety and improve patient care outcomes.
Acknowledgment
AJE Editing Services performed the English editing. I would like to thank Dr. Pınar SİVRİKAYA, a psychiatrist, for her support.