(j) Anxiety and Blood Pressure Prior to Dental Treatment [1990]

8/17/2019 (j) Anxiety and Blood Pressure Prior to Dental Treatment [1990]

1/7

Psychological Reports 1990, 67, 371 377.

Psychological Reports 1990

A N X I E T Y A N D

BLOOD

PRESSURE PRIOR

TO DENTAL TR EATMENT

'

CAR MEN BENJAMINS AND ALBERT H. B. SCHUURS

Department of Cariology and Endodontology Academic Center for Dentiztry Amsterdam

H E N K A S S C H E M A N J O H A N H O O G S T R A T EN

Department of General Pathology Department of

and Internal Medicine Social Dentistry

Academic Center for Dentistry Amzterdam

Summary.-In the present study dental anxiety and blood pressure were assessed

immediately prior to a dental appointment to assess the relationship between selE-

reported dental anxiety and blood pressure. Blood pressure was assessed by two inde-

pendent methods, and the in te~ ha ng ea bll ity f th e blood-pressure measurement meth-

ods was also assessed. No relationshp was demonstrated among scores on three dental

anxiety questionnaires and blood-pressure values. The blood-pressure measurement

methods delivered comparable values lor diastolic and mean arterial blood pressure

only.

The prospect of a dental visit can evoke feelings of anticipation anxiety

(Weiner, 1980). Some patients appear to be extremely afraid of even a check-

up, while others do not seem to be tense prior to the extraction of a tooth.

Given its anticipatory character, the strength of dental anxiety may be

assessed before the actual encoun ter with th e d entist.

Anxiety may be assessed in three ways, i.e., psychologically, behaviorally

and physiologically. The results of these three assessment methods are not

highly associated. This lack in strength of relationship may be explained by

the differing times needed for the development of the cognitive, the physio-

logical, and the behavioral signs of stress. Also, incomplete measures, such as

noncontinuous monitoring of physiological processes, may be misleading

(Burchfield, 1985). The behavioral signs of anxiety are, in contrast with chil-

dren, rare in adults, therefore the psychological and physiological assessments

are

to be preferred in studies involving adults (M elamed , 19 79 ). Psychologi-

cal signs of anxiety are registered by, among others, self-report inventories.

Among the physiologic signs of anxiety a rise in the systolic blood pressure is

mentioned (Hasset Dan forth, 1982).

In contrast to nonanxious dental patients, anxious ones are said to show

heightened blood pressure levels before treatment (G e b, Papp, Tbth,

'The assistance of

C.

Makkes and J. A. Kieft is gratefully acknowledged. Re uests for

repr in ts should be sent to Carmen Benjamins, Depar tment of Car io logy and ~ n d o j o n t o l o ~ ~ ,

Academic Center for Dentistry, Amsterdam, Louwesweg 1 1066 EA Amsterdam, The

Netherlands.


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3 72

C.

BENJAMINS, ETAL .

1972). In other research, however, no significant relations were found

(Boelens Rozema, 1984; Beck Weaver, 1981; Goldstein, Diome, Sweet,

Gracely, Brewer, Gregg, Keiser, 1982), which apparent discrepancy is

probably due to differences in research designs. First, the self-report ques-

tionnaire used in these studies was the state part of the State-Trait Anxiety

Inventory which has only a moderate r= .48) correlation with the Dental

Anxiety Scale (Weisenberg, Kreindler, Schachat, Werboff, 1974;

Weisenberg, Kreindler, Schachat, 1975). The latter is specially designed

for the dental situation (Corah, 1969; Corah, Gale, TJlig, 1978). Second,

the use of an intermittent registration method for the strongly fluctuating

blood-pressure signal may not reveal all the relevant changes.

The aims of the present study were to investigate 1) the relationship

between self-reported dental anxiety on the one hand and blood pressure as

assessed by a dlscrete (sphygmomanometer) and a recently developed nonin-

vasive continuous ( ~ i n a ~ r e s ~ )ethod on the other hand and (2) the

interchangeability of both blood-pressure measurement methods.

METHOD

Subjects

Patients originated from two clinics for dental care, namely, the clinic

for special dental care for extremely anxious patients and a university clinic

(UvATZ). Data were collected from 29 patients, just before dental treatment.

Three patients were excluded because they had an history of high blood

pressure and two because there was a technical failure or data were missing.

The data of 24 dental patients of mean age 32.5 yr. 10.7) were used for

analysis. This group of patients included 10 men of mean age 30.5 yr.

(k9 .0) and 14 women of mean age 33.9 yr.

( +

11.8). Ten patients visited

the dentist for a checkup, 12 for restorative treatment, and three for extrac-

tion of a tooth. ALl patients were seen between 9 and 11 p.m. to adjust for

diurnal fluctuations in blood-pressure values.

aterials

~ i n a ~ r e s ~eadings of systolic and diastolic blood pressure were taken for

10 min. from the left index finger according to instructions in the manual.

Before and after the Finapres readings systolic and diastolic blood pressure

were determined with a sphygmomanometer and cuff from the left upper

arm. The disappearance of the Korotkoff-sounds represented the diastolic

pressure. Next, all subjects completed three self-assessment inventories for

dental anxiety. First, the short version of the recently developed inventory

for fear of dental treatment,

K-ATB

(Stouthard, 1989), was administered.

Ohmeda, Madison, WI,

USA


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DENTAL ANX IETY AND BLOOD PRESSURE

373

This scale, which scores range from 9 (no anxiety) to 45 (extreme dental anx-

iety) has been proven v d and reliable in some large scale studies

(Stouthard, 1989). The next questionnaire was the Dental Anxiety Scale, on

which scores range from

4

(no anxiety) to 20 (extreme dental anxiety) and

which has also been proven valid and reliable in large scale studies in the

United States (Corah, 1969; Corah,

t a / .

1978) and in the Netherlands

(Eijkman Orlebeke, 1975; Stouthard, 1989). Thereafter the patients were

presented a question to assess the duration of psychophysiological reactions

prior to a dental appointment (Schuurs, Duivenvoorden,

Thoden van Velzen,

Verhage, 1981). The scores range from one (a few days or longer before

the dental appointment) to seven (none at all). The scores were recoded so

that score of one represents a low and score of seven a high anxiety level.

The two sphygmomanometer pressure readings were combined to a

mean value because many people tend to respond with an heightened blood

pressure to the measurement itself. This mean value was also used in the

calculation of mean arterial pressure [Pmean = Pdia 1/3(Psys

-

Pdia)]. The

values for systolic and diastolic pressures of a period of 30 sec. from the

Finapres reading were combined to a mean value which was also used to cal-

culate mean arterial pressure. The 30-sec. period was extracted from the

record between time 3 min., 30 sec. and 4 min., 30 sec. This extraction of a

30-sec. period out of a 60-sec. period was done because the calibration cycles

in the recorded signal necessary to compensate for the influence of smooth

muscle tone

in

the arterial wall were unevenly spaced.

Table 1 shows the mean scores on the questionnaires and the Pearson

product-moment correlations between their scores. The correlations among

TABLE

1

MEANSCORES NDENTAL ~ m nc m , K-ATB N D DURATIONF

PSYCHOPHYSIOLOGICALEACTIONS

N D

T a m PW U~SONRODUCT-MOMENTNTERCORRELATIONS

Dental K-ATB Duration

Anxiety Psychophy~iologicd

cale eacuons

Range 4-20 9-45 1-7

M

SD

11.1 3.8 25.9 9.7 3. 1k 2. 1

Dental Anxiety Scale . 94 t . 83 t

K-ATB . 80 t

K-ATB =Inven tory for Fear

of

Dental Treatment.

tp 001.

scores on the three questionnaires are high and significant. The respective

standard errors of the scores on the K-ATB and the Dental Anxiety Scale are

2.3 and 0.9. The internal consistency (Cronbach alpha) and the split-half re-


4/7

3 74

C. BENJAMINS, ET AL.

liability corrected for test length are .92 and .93 for the K-ATB and .93 and

.88 for the Dental Anxiety Scale.

Pearson coefficients did not reach significance for the association be-

tween the questionnaire scores and age. Sex was coded one for men and two

for women. Pearson correlation coefficients Nunnally, 1967) indicated sig-

nificant relationships with sex for the scores on the Dental Anxiety Scale

r -.45, p .03) and the duration of psychophysiological reactions r -.48,

p

.02), but not for the K-ATB r = -.35, p .09). Men tended to be some-

what more afraid than women.

The mean values for both blood-pressure measurement methods are

shown in Table 2. These blood pressure values were not related to age, sex,

or time of the day. The Pearson product-moment coefficients ranged from

-.32 to .36 p> .0 5) .

TABLE 2

MEAN

VALUES

FOR

SPHYGMOMANOMETERND

FINAPRESLOOD

RESSURE

M

SD Range

Sphygmomanometer

Systolic blood pressure

119.9 11.2

99.0 139.0

Diastolic blood pressure 75.3 7.8 60.5 92.0

Mean arterial blood pressure 90.2 7.8 76.0 106.7

Finapres

Systolic blood pressure

131.9 21.6 85.2 165.3

Diastolic blood pressure 72.4 12.1 48.3 97.4

Mean arterial blood ~ressure 92.2 14.9 60.6 116.3

These Pearson coefficients did not show an association between any of

the questionnaire scores on the one hand and any of the blood-pressure

values on the other hand. Correlations ranged from

-.27 to .15

p >

.05).

The sphygmomanometer and Finapres values differed significantly for systolic

blood pressure paired test; 2.99,

p

,007) but not for diastolic t 0.95,

p .35) or for mean arterial pressure t -0.62, p .54).

D~scussro~

The mean Dental Anxiety Scale score 11.2) is higher than the mean

scores 8.89 and 9.8 reported by other researchers in their studies with stu-

dents Corah, 1969; Corah, et al ., 1978; Stouthard, 1989) and a score of 9.3

registered with inhabitants of a Dutch city Schuurs, et al., 1985). Also, den-

tal emergency patients scored 10.5 on the Dental Anxiety Scale Weisenberg,

et

a / .

1974). The values for Cronbach alpha and the split-half reliability are

high. The internal consistency and reliability of both the K-ATB and the

Dental Anxiety Scale for this population are good. In this study we found a

mean score of 3.1 on the question concerning the duration of psychophysio-

logical reactions, which is higher than the mean score of 2.3 found among


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DENT L NXIETY ND BLOOD PRESSURE

3 75

patients of a Dutch town Sc hu m, et

al.

1985), so it seems warranted to

conclude that the subjects in this study show somewhat more dental anxiety

than the respondents in the studies just cited. The relatively high question-

naire scores in this study

are

of course, related to the participation of

subjects who were known to be highly anxious. The K-ATB, Dental Anxiety

Scale, and duration of psychophysiological reactions probably measure more

or less the same construct of dental anxiety. They may be differentially sen-

sitive, however, to specific aspects of dental anxiety. The men in this study

appear to be somewhat more anxious than women, which contrasts with data

of other studies Corah, et

al.

1978; Schuurs, et

al .

1985). The selectivity

of the sample may be responsible for this unexpected finding.

The values of the registered systolic and diastolic blood pressures, as

measured with both methods, fall within the range of standard values of a

population between 30 and 50 yr. of age Boelens Rozema, 1984).

No association was found between scores on the self-report question-

naires of dental anxiety and the blood-Pressure values just before a dental

visit. In case of the discrete sphygmomanometer) method, this result is in

line with those reported elsewhere GerCb, et

al.

1972; Hasset Danforth,

1982). The Finapres method has never been used to evaluate the relation be-

tween verbally reported dental anxiety and blood pressure. Despite the

capacity of this method to assess the fluctuations and therewith the range of

the blood-pressure signal more precisely, it only confirms prior data.

A significantly different systolic pressure was observed for the two

measurement methods. At the finger, pressure is 10 mmHg higher than the

pressure measured at the arm. Both the diastolic and mean arterial pressures

were more alike than in another study Wesseling,

et

al. 1985), so the regis-

tration methods appear to be compatible only when used for assessment of

diastolic and mean arterial pressures.

The blood-pressure difference between arm and finger is the conse-

quence of distortion of the pressure waveform Brener Kleinman, 1970)

and results in, among other things, an amplification of the pulse wave and

a small decrease in the mean arterial blood pressure. Amplification depends

on peripheral resistance, heart rate and age Wesseling, Settels, Hoeven,

Nijboer, Butijn, Dorlas, 1985). The range of the observed blood-pressure

values

in

the present study is much larger than the range reported by

Wesseling, et

al .

1985). This difference may be related to measurement con-

ditions. In the present study, the patients were awake but requested to keep

still while the patients in the study of Wesseling, et

al.

1985) were anaes-

thetized and respired artificially. Respiratory manoeuvres as sighing, breath

holding, and speech result in heightening of the finger pressure through in-

fluence of the baroreflex on peripheral resistance Brener Kleinman, 1970;

Wesseling, et

al.

1985).


6/7

376 C. BENJAMINS, ETAL.

In

s u m m a r y ,

from

t h e r e s u l ts

of

t h i s s t u d y i t

is concluded

t h a t no

rela-

t i o n s h i p e x i s t s between s e l f- r ep o r te d d e n t a l a n x i e t y and blood p r e s s u r e . We

a d d , h o w e v e r , t h a t a n i n te r e s t i n g line

of

f u r t h e r research

seems

a

study

which

c o r r e c t s

for

i n d i v i d u a l v a r i a t i o n s

in

p h y s i o l o g i c a l

resting

levels

and

ac-

t i v a t i o n , as

is

s u g g e s te d b y

Wilder

1962).

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ROZEMA,F. R. 1984)

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BRENER,., W A N , . A. 1970 ) Learned control of decreases in systolic blood pressure.

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L.

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DENTAL ANXIETY AND BLOOD

PR SSUR

377

WILDER (1962) Basimetric a proach (law of initial values) to biological rhythms.

Annals

o

New

ork Academy ofsciences

98 1211-1228.

Accepted August 3 1990.

Documents

(j) Anxiety and Blood Pressure Prior to Dental Treatment [1990]