Links Between Dental Anxiety and Preventive Dental Care: A Cross-Sectional Study in an Oral Surgery Practice

Abstract

Background/Objectives: Dental anxiety has been demonstrated to exert a significant influence on the frequency of treatment, the degree of patient compliance, and the long-term implications for oral health. The objective of this study was to evaluate the extent of dental anxiety experienced by patients attending an oral surgery practice in Germany. In addition, the study sought to assess their preventive dental behaviour and to explore any potential associations between anxiety levels and the utilisation of preventive care services. Methods: The present study comprised 102 consecutive adult outpatients from a private oral surgery practice. The assessment of dental anxiety was conducted using the Corah’s Dental Anxiety Scale (DAS). The behaviour of the subjects in relation to preventative dental care was measured using a series of six standardised items, including the frequency of tooth brushing, tartar removal, and professional tooth cleaning. The data analysis comprised descriptive statistics, chi-square (χ²) tests, multiple linear regression, and one-way analysis of variance (ANOVA). Results: The mean DAS score was 12.69 (SD = 3.36). According to the DAS classification system, 28.4% of patients reported low anxiety, 50.0% moderate anxiety, and 21.6% high dental anxiety. Regression analysis explained 10% of the variance in DAS scores (R² = 0.128, adj. R² = 0.100). The analysis revealed that age (β = −0.218, p = 0.035) and lower educational level (β = −0.357, p < 0.001) were associated with higher anxiety scores, whereas sex was not a significant predictor. Preventive dental behaviour, encompassing practices such as tooth brushing, professional tooth cleaning, and tartar removal, did not exhibit significant disparities across anxiety groups (all p > 0.05). Conclusions: While dental anxiety was prevalent among the patient sample, it did not exert a significant influence on preventive dental behaviours. However, patients with lower levels of education and younger age exhibited higher dental anxiety scores. These findings underscore the necessity for targeted educational and preventive strategies in patients with elevated dental anxiety.

1. Introduction

Dental anxiety is an aversive emotional state of apprehension in anticipation of dental treatment [1] and plays a key role in avoidance of care [2]. A “vicious cycle” occurs when anxiety leads to treatment delay, worsening oral health, feelings of shame, and further avoidance, with care sought only for acute pain [3,4]. This cycle reinforces both dental fear and anxiety intensity [4].

Patients with high dental anxiety often show poor oral health behaviours, such as infrequent brushing, unhealthy diet, and tobacco use, resulting in increased treatment needs [5]. A German study found dental anxiety was linked to less frequent brushing, calculus removal, professional cleaning, and electric toothbrush use, as well as lower oral health-related quality of life [6]. Some preventive measures, like flossing, mouthwash, or specific toothbrushes, were less affected by anxiety, yet avoidance still compromises hygiene and preventive care, worsening dental morbidity.

Extensive research has examined dental anxiety across adult clinical, student, and community populations worldwide [7,8,9,10,11]. German studies confirm that anxious patients exhibit poorer oral hygiene than non-anxious patients [12], highlighting the need for targeted education and awareness programs. Effective prevention requires that highly anxious patients understand the consequences of avoidance and the importance of timely caries prevention and early intervention. A large German study (N = 1549) found a strong correlation between dental anxiety and psychological distress, underlining its multifactorial nature [13].

Sociodemographic factors also play a role. Females consistently report higher dental anxiety than males [2], a pattern observed across age groups [7]. Among middle-aged and older women, both anxiety and dental attendance decline with age [10]. Women who maintained regular appointments despite anxiety showed better oral health outcomes, including greater tooth preservation, fewer caries, and more restorative treatments, compared to irregular attenders.

Clinical experiences are strongly correlated with dental anxiety. Painful procedures, traumatic expectations, and low perceived control increase anxiety [14,15], with needles, drills, and invasive treatments (e.g., subgingival scaling, deep probing, fillings, extractions, root canals) perceived as particularly painful by highly anxious patients [15]. Prior painful experiences lead patients to anticipate similar distress and a loss of control during subsequent procedures. Dental hygiene studies confirm that anxious patients expect more pain from probing, scaling, or vibrating sensations [9]. Regular attendance, however, may reduce anxiety through consistent exposure [16].

Dental anxiety poses challenges for clinicians, being associated with cancelled appointments, treatment avoidance, poorer oral health, and heightened pain perception [1,17,18,19]. A 2016 study described a sequential process in which behavioural, cognitive, and emotional factors shape appointment attendance: negative prior experiences influence expectations, predicting avoidance [20]. Memory distortions can exacerbate this, as anxious patients often recall dental pain as more severe than it was [21].

Taken together the review of the extant literature underscores the multifaceted impact of dental anxiety on oral health behaviour, treatment experience and psychological well-being. In light of the aforementioned background, the present study aims to investigate:

• The level of dental anxiety experienced by patients attending an oral surgery practice.
• The frequency of preventive dental behaviours, including tooth brushing, frequency of dentist visits, tartar removal and professional tooth cleaning.
• The relationship between dental anxiety and preventive dental care.

To our knowledge, this is one of the few studies in Germany that examines the relationship between dental treatment anxiety and preventive behaviour not in university dentistry but in a routine care practice.

2. Materials and Methods

2.1. Study Design and Setting

From December 2019 to June 2020, patients of an oral surgery practice located in the federal state of Saxony, Germany, were invited to participate in a cross-sectional survey. The inclusion criteria encompassed two key elements: firstly, sufficient proficiency in both spoken and written German, and secondly, no mental health issues. It is evident that no supplementary procedures were performed for the identification of psychiatric conditions. Furthermore, the presence of dental phobia or elevated levels of dental anxiety was not considered a basis for exclusion from the study. Prior to participation, written informed consent was obtained from all subjects. All data were collected anonymously and handled in accordance with data protection regulations.

A total of 150 patients were approached, and 102 patients (68.0%) provided written informed consent and were included in the study. The data collection process was conducted in the waiting area immediately prior to the patients undergoing their scheduled dental or oral surgical procedures. Each participant was requested to complete a structured paper-and-pencil questionnaire. This questionnaire included measures of dental anxiety and preventive dental care behaviour, along with sociodemographic items. The study was conducted in accordance with the STROBE guidelines [22].

2.2. Measures

2.2.1. Dental Anxiety Scale (DAS)

The assessment of dental anxiety was conducted utilising the Dental Anxiety Scale (DAS) [23,24], a widely employed self-report instrument for the evaluation of anxiety associated with dental treatment. The Dental Anxiety Scale (DAS) comprises four items which describe typical dental situations (e.g., sitting in the waiting room, undergoing drilling) and are each rated on a 5-point Likert scale ranging from 1 (low anxiety) to 5 (high anxiety). The potential range of scores is from 4 to 20 points. In a large international study, Corah et al. [25] reported a mean DAS score of 9.1 (N = 2103). In contrast, Tönnies et al. [24] found a substantially higher mean DAS score of 13.8 (N = 137) in a German sample. According to the classification proposed by Tönnies et al. [24], values exceeding 15 are indicative of high dental anxiety, values ranging from 11 to 15 are considered to represent moderate dental anxiety, and values below 11 are defined as low dental anxiety. The Dental Anxiety Scale (DAS) has repeatedly demonstrated good psychometric properties. The validity of the scale has been confirmed in several studies [23,24,25], with a test–retest reliability of rtt = 0.86 [23].

2.2.2. Preventive Dental Care

The objective of the study was to assess preventive dental care behaviour and attitudes towards oral health. In order to achieve this, participants were asked to respond to six standardised questions. Inspired by recommended preventive measures and examples from the literature [6], the study team designed the questions to cover both daily oral hygiene practices and self-perceived oral health. The specific questions posed are outlined below, with the response categories indicated within brackets:

• Tooth brushing frequency—“How many times a day do you brush your teeth? (never, once, twice, three times, four times, more often).
• Dental visit frequency—“How often do you visit the dentist each year?” (never, once, twice, three times, four times, more often).
• Tartar removal—“How often per year do you have tartar removed?” (never, once, twice, three times, four times, more often).
• Professional tooth cleaning—“How often per year do you have your teeth professionally cleaned?” (never, once, twice, three times, four times, more often).
• Self-rated dental condition—“When you think about your teeth, how would you describe their condition?” (poor, not so good, satisfactory, good, very good).
• Perceived self-efficacy—“How much can you do yourself to maintain or improve the health of your teeth?” (nothing at all, a little, some, a lot, very much).

The questions on dental care behaviour were evaluated statistically on an individual basis. A summary index, e.g., mean score, was not created, as the questions cover very different aspects in terms of content and, moreover, a higher value in one question does not always mean better behaviour (e.g., professional teeth cleaning four times or more a year is not necessary in most cases). In a total score, unfavourable preventive behaviour would be easily overlooked. For example, people who believe that their teeth are in “very good” condition but never brush their teeth could also receive an average total score.

2.3. Statistical Procedures

All statistical analyses were conducted using IBM SPSS Statistics, Version 30 (IBM Corp., Armonk, NY, USA). The Kolmogorov–Smirnov test was used to determine the normality distribution of the given data.

Multiple linear regression analysis was conducted in order to detect predictors of dental anxiety (DAS score). In this analysis, age, gender, and educational level were entered as independent variables, while the DAS score served as the dependent variable. In addition, one-way analysis of variance (ANOVA) was employed to verify the educational effects on anxiety scores. In order to analyse group differences in preventive dental care behaviour across anxiety categories, Chi-square (χ²) tests were performed. The magnitude of the observed effects was reported as Cramer’s V for χ² tests and η² for ANOVAs.

The level of significance was set at p ≤ 0.05 for all analyses. The internal consistency of the Dental Anxiety Scale (DAS) was evaluated by Cronbach’s α. An a priori power analysis was performed with G*Power 3.1 [26] to ensure adequate statistical power. Based on a medium effect size (Cohen’s ω = 0.50), α = 0.05, power = 0.95 (1 − β = 0.95), and 6 degrees of freedom, a minimum sample size of N = 84 was required for χ² analyses. For a multiple linear regression with three predictors, an effect size parameter of f² = 0.20, α = 0.05, and a desired power of 0.95 (1 − β = 0.95), the required sample size is N = 90.

The final sample size of N = 102 was therefore deemed sufficient to provide statistical power for all planned analyses.

3. Results

3.1. Participants

The final sample comprised N = 102 patients, of whom 60 (58.8%) were female and 42 (41.2%) were male. The age of the participants ranged from 18 to 77 years (M = 40.3, SD = 15.7). The sociodemographic characteristics of the sample (see

Table 1. Sociodemographic characteristics of the sample.

		N	%
Sex	female	60	58.8
	male	42	41.2
Marital status	single	35	34.3
	married	38	37.3
	relationship, not married	21	20.6
	divorced or separated	6	4.9
	widowed	1	1.0
Education	general qualification for university entrance	23	22.5
	secondary school	62	60.8
	lower secondary school	14	13.7
	other	3	2.9
Occupation	employed	71	69.9
	retired	10	9.8
	homemakers/others	21	20.6

) are broadly representative of the distribution of age, education, and employment status in the federal state of Saxony (Germany).

3.2. Distribution and Descriptive Statistics

In the present study, the Dental Anxiety Scale (DAS) demonstrated excellent internal consistency, with a Cronbach’s α of 0.871 (N = 102), which is consistent with previous research and validates its appropriateness for the present investigation. The Kolmogorov–Smirnov test demonstrated that the DAS scores of the study population followed an approximately normal distribution (D = 0.085, p = 0.064). The mean DAS score in the total sample was M = 12.69 (SD = 3.36; range 6–20).

Table 2. Dental anxiety score (DAS) according to demographic characteristics.

	DAS (M, SD)	DAS Level Low (<11) (N, %)	DAS Level Medium (11–15) (N, %)	DAS Level High (>15) (N, %)
Total sample	12.69 (3.36)	29 (28.4)	51 (50.0)	22 (21.6)
Sex
Male (N = 42)	12.41 (3.54)	14 (33.3)	20 (47.6)	8 (19.0)
Female (N = 60)	12.90 (3.24)	15 (25.0)	31 (51.7)	14 (23.3)
Age
<39 years (N = 52)	12.83 (3.64)	15 (28.8)	27 (51.9)	10 (19.2)
39 years and older (N = 50)	12.57 (3.38))	14 (28.0)	24 (48.0)	12 (24.0)
Education
lower secondary leaving certificate (N = 14)	14.71 (2.97)	1 (7.1)	8 (57.1)	5 (35.7)
secondary school leaving certificate (N = 62)	12.65 (3.25)	16 (25.8)	32 (51.6)	14 (22.6)
general qualification for university entrance (N = 23)	11.47 (3.38)	11 (47.8)	10 (43.5)	2 (8.7)

shows the demographic distribution of the study subjects according to dental anxiety (DAS) level.

3.3. Multiple Regression Analysis

In order to explore the influence of sociodemographic variables on dental anxiety, a multiple linear regression analysis was conducted. The dependent variable of this analysis was DAS score, with age, gender, and educational level used as predictors (see

Table 3. Multiple regression analysis for dental anxiety (DAS), predictors: age, gender, educational level (BETA = standardized regression coefficient, bold: significant results).

	Regression Coefficient B	Std. Error	Beta	T	Sig.
(Constant)	19.734	2.054		9.606	<0.001
Age in years	−0.047	0.022	−0.218	−2.138	0.035
Gender	−0.714	0.652	−0.106	−1.096	0.276
Educational Level	−1.974	0.562	−0.357	−3.512	<0.001

). The model demonstrated statistically significant predictive power (df = 3, F = 4.634, p = 0.005) and explained 10% of the variance (R² = 0.128; adjusted R² = 0.100). This finding indicates that, while the predictors account for a proportion of the variation in dental anxiety, a significant portion remains unexplained, suggesting the presence of additional influencing factors beyond the sociodemographic variables examined.

The strongest predictor of the outcome was education level (β = −0.357, p < 0.001). The findings of the study demonstrated a positive correlation between lower educational attainment and higher DAS scores. In contrast, higher education was found to be associated with lower anxiety levels. Furthermore, age exhibited a significant negative correlation (β = −0.218, p = 0.035), suggesting that subjects in the younger age group reported higher levels of dental anxiety compared to those in the older age group. The gender variable did not attain statistical significance (β = −0.106, p = 0.276), indicating that, in this particular sample, there was no systematic difference in reported DAS scores between men and women.

3.4. Educational Group Comparisons

In order to ascertain the impact of education on dental anxiety, a one-way analysis of variance (ANOVA) was conducted. Levene’s test indicated no violation of the homogeneity of variances assumption (F(df1 = 2, df2 = 99) = 0.13, p = 0.88). In this particular analysis, patients who did not possess a school leaving certificate (N = 3) were excluded on the basis that the group size was deemed to be inadequate. The analysis of variance (ANOVA) revealed significant differences among the three educational subgroups (F(df = 3) = 4.323, p = 0.016, η² = 0.083), indicating a medium effect size.

• Participants with a lower secondary leaving certificate reported the highest anxiety scores.
• Participants who had obtained a secondary school leaving certificate demonstrated lower levels of anxiety.
• The lowest scores were observed among participants who possessed a general qualification for university entrance.

These results corroborate the regression analysis by showing a discernible gradient: dental anxiety decreases with higher educational level. Conversely, the age effect observed in regression analysis could not be replicated in separate correlation analyses or group comparisons between different age categories and will therefore not to be discussed further. Consequently, the relationship between age and dental anxiety should be interpreted with a degree of caution.

3.5. Anxiety Group Classification According to Dental Anxiety Scale (DAS)

In accordance with the categorisation proposed by Tönnies et al. [24], patients were stratified into three distinct anxiety groups based on their scores in the Dental Anxiety Scale (DAS):

• Low anxiety (DAS < 11): N = 29 (28.4%).
• Moderate anxiety (DAS 11–15): N = 51 (50.0%).
• High anxiety (DAS > 15): N = 22 (21.6%).

Therefore, approximately 50% of the participants exhibited moderate anxiety, around 22% reported high anxiety, and around 28% of the sample demonstrated low anxiety levels.

3.6. Preventive Dental Care Behaviour

The analysis of preventive dental care behaviour was conducted separately for the three anxiety groups. The detailed results are presented in

Table 4. Preventive dental care behaviour in three groups with different levels of dental anxiety (Dental Anxiety Scale DAS, N, %, χ² Tests).

	How many times a day do you brush your teeth?
	Never	1×	2×	3×	4×	More Often
Total sample	0 (0)	13 (12.7)	84 (82.4)	4 (3.9)	1 (1)	0 (0)
DAS Low (<11) (N = 29)	0 (0)	3 (10.3)	24 (82.8)	2 (6.9)	0 (0)	0 (0)
DAS Medium (11–15) (N = 51)	0 (0)	4 (7.8)	45 (88.2)	1 (2.0)	1 (2.0)	0 (0)
DAS High (>15) (N = 22)	0 (0)	6 (27.3)	15 (68.2)	1 (4.5)	0 (0)	0 (0)
	χ2	df	p	Cramer’s V
	7.663	6	0.246	0.194
	How often do you visit the dentist each year?
	Never	1×	2×	3×	4×	More often
Total sample	1 (1)	38 (37.3)	36 (35.3)	11 (10.8)	3 (2.9)	13 (12.7)
DAS Low (<11) (N = 29)	0 (0)	10 (34.5)	11 (37.9)	3 (10.3)	0 (0)	5 (17.2)
DAS Medium (11–15) (N = 51)	1 (2)	16 (31.4)	20 (39.2)	5 (9.8)	3 (5.9)	6 (11.8)
DAS High (>15) (N = 22)	0 (0)	12 (54.5)	5 (22.7)	3 (13.6)	0 (0)	2 (9.1)
	χ2	df	p	Cramer’s V
	8.508	10	0.579	0.204
	How often a year do you have tartar removed?
	Never	1×	2×	3×	4×	More often
Total sample	0 (0)	72 (70.6)	27 (26.5)	2 (2)	0 (0)	1 (1)
DAS Low (<15) (N = 29)	0 (0)	21 (72.4)	6 (20.7)	2 (6.9)	0 (0)	0 (0)
DAS Medium (N = 51)	0 (0)	35 (68.6)	15 (29.4)	1 (2)	0 (0)	1 (2)
DAS High (>16) (N = 22)	0 (0)	16 (72.7)	6 (27.3)	0 (0)	0 (0)	0 (0)
	χ2	df	p	Cramer’s V
	6.628	6	0.357	0.18
	How often a year do you have your teeth professionally cleaned?
	Never	1×	2×	3×	4×	More often
Total sample	2 (2)	77 (75.5)	21 (20.6)	1 (1)	0 (0)	1 (1)
DAS Low (<15) (N = 29)	0 (0)	23 (79.3)	5 (20.7)	0 (0)	0 (0)	0 (0)
DAS Medium (N = 51)	2 (3.9)	37 (72.5)	11 (21.6)	0 (0)	0 (0)	1 (2)
DAS High (>16) (N = 22)	0 (0)	17 (77.3)	5 (22.7)	0 (0)	0 (0)	0 (0)
	χ2	df	p	Cramer’s V
	4.337	4	0.362	0.206
	When you think about your teeth, how would you describe their condition?
	Poor	Not so good	Satisfactory	Good	Very Good
Total sample	14 (13.7)	23 (22.5)	39 (38.2)	21 (20.6)	5 (4.9)
DAS Low (<15) (N = 29)	3 (10.3)	5 (17.2)	11 (37.9)	6 (20.7)	4 (13.8)
DAS Medium (N = 51)	6 (11.8)	13 (25.5)	20 (39.2)	12 (23.5)	0 (0)
DAS High (>16) (N = 22)	5 (22.7)	5 (22.7)	8 (36.4)	3 (13.6)	1 (4.5)
	χ2	df	p	Cramer’s V
	10.188	8	0.252	0.223
	How much can you do yourself to maintain or improve the health of your teeth?
	Nothing	Less	Something	Much	Very Much
Total sample	0 (0)	1 (1)	28 (27.5)	44 (43.1)	29 (28.4)
DAS Low (<15) (N = 29)	0 (0)	1 (3.4)	10 (34.5)	11 (37.9)	7 (24.1)
DAS Medium (N = 51)	0 (0)	0 (0)	11 (21.6)	24 (47.1)	16 (31.4)
DAS High (>16) (N = 22)	0 (0)	0 (0)	7 (31.8)	9 (40.9)	6 (27.3)
	χ2	Df	p	Cramer’s V
	4.578	6	0.599	0.15

.

• Tooth brushing frequency: In the overall sample, 82.4% of patients reported brushing their teeth twice a day, while 27.3% of individuals with high anxiety levels reported brushing only once a day. In this subgroup, only 68.2% of subjects reported brushing their teeth twice daily. This finding suggests a potential link between heightened anxiety levels and less consistent oral hygiene practices.
• Dental visits per year: In the total sample, 37.7% of patients reported visiting the dentist once per year and 35.3% twice per year. Conversely, among patients with high anxiety, 54.5% attended only once per year, and a mere 22.7% reported two annual visits. This finding suggests a potential link between anxiety and the avoidance of regular medical check-ups.
• Tartar removal: Across the total sample, 70.6% of subjects reported undergoing tartar removal on a yearly basis. The pattern exhibited a high degree of similarity in the highly anxious group (72.7%), indicating that this preventive measure was not significantly influenced by anxiety level.
• Professional tooth cleaning: 75.5% of the total group reported undergoing professional tooth cleaning at least once per year. This figure was compared to that of the highly anxious group, which reported a rate of 77.3%. This similarity indicates that professional cleaning is utilised consistently across anxiety groups, a phenomenon that may be attributable to the frequent recommendation of such cleaning methods by dentists.
• Self-rated dental condition: In the total sample, 25.5% described their dental condition as good or very good, whereas only 18.1% of patients with a high level of anxiety rated their oral health positively. Conversely, 45.4% of individuals with high anxiety described their condition as “poor” or “not so good,” compared to 36.2% of the total group. This finding suggests a tendency for patients with high levels of anxiety to perceive their dental health more negatively.
• Perceived self-efficacy: A majority of the total sample (71.5%) reported that they could do “a lot” or “very much” to maintain or improve the health of their teeth. In the group characterised by elevated anxiety, this figure was slightly lower (68.2%), indicating a modest reduction in perceived self-efficacy.

Notwithstanding the descriptive tendencies observed, the application of the χ² test did not yield any statistically significant differences between the groups with dental anxiety with regard to preventive dental care items.

4. Discussion

Dental anxiety is a multifactorial psychological construct that strongly influences oral health and well-being, often leading to avoidance of care and a cycle in which untreated conditions reinforce pre-existing fears [1,2,3]. This study examined the relationship between dental anxiety, preventive behaviour, and sociodemographic variables in oral surgery patients.

The mean Dental Anxiety Scale (DAS) score in our sample was 12.69 (SD = 3.36), consistent with previous German studies (e.g., 13.8; [24]), and higher than the original U.S. reference of 9.1 [25]. In our sample, 28.4% reported no anxiety, 50.0% moderate, and 21.6% high anxiety. The DAS has demonstrated high reliability, with Cronbach’s α = 0.871 in this study, corroborating previous findings [13].

Dental anxiety was negatively associated with educational level, aligning with prior evidence linking lower education to less favourable oral health behaviours and lower preventive service utilisation [8,27]. Age also influenced anxiety, while gender differences observed in earlier studies [10,12] were not replicated here.

Most participants (82.4%) brushed twice daily, 27.3% brushed once daily, 37.7% visited the dentist once per year, 35.3% twice, and 70.6% reported annual tartar removal. Annual professional cleaning was reported by 75.5%, and 25.5% rated their teeth as good or very good. A majority (71.5%) believed they could significantly influence their oral health.

Contrary to expectations, dental anxiety was not significantly associated with self-reported oral health attitudes. High anxiety appeared to influence behaviour more than attitudes, consistent with evidence linking negative experiences and anticipated pain to preventive avoidance [14,15].

Clinically, these findings highlight the importance of recognising and addressing dental anxiety, which is associated with missed appointments, reduced preventive care, and negative treatment expectations [18,19]. Anxiety-sensitive communication, behavioural management, and preventive programmes combining education, professional cleaning, fluoride, and behavioural interventions may benefit high-risk patients [27,28]. Sociodemographic factors should guide tailored strategies to facilitate early intervention and prevent progression of caries and periodontal disease [27,28].

4.1. Limitations

The present study is subject to several limitations. Firstly, the relatively small sample size and the recruitment from a single oral surgery practice restrict the generalizability of the findings. Secondly, the data were all based on self-report questionnaires, which are prone to reporting bias. The questions on preventive dental care were developed internally. Not all aspects of oral disease prevention, such as the use of fluoride and nutritional advice, could be covered. Objective indicators of oral health, such as the Periodontal Screening Index (PSI) or DMF-T, were not available for analysis. The data collection process was concluded in 2020; however, the analysis of the data was delayed by the onset of the Coronavirus pandemic.

Moreover, patients with pronounced dental anxiety avoid dental visits altogether, a phenomenon that is likely to have resulted in an underrepresentation of this group in the sample. Furthermore, the regression model accounted for a mere 10% of the variance in dental anxiety, indicating that other pertinent factors have yet to be considered.

Ultimately, the cross-sectional design precludes the possibility of causal inference. It is recommended that future research employs longitudinal designs in order to clarify causal mechanisms and to more accurately capture the long-term course of dental anxiety.

4.2. Conclusions

Dental anxiety is a widespread phenomenon. It is associated with lower levels of education and younger age. Preventive behaviour was not influenced by the level of fear in this study. These results underscore the need for early identification of anxious patients and prevention strategies, especially for vulnerable groups. Implementing systematic identification and treatment of dental anxiety as part of routine care can improve the use of preventive services, oral health and the general well-being of patients.