“Dental anxiety and potentially traumatic events” “A cross-sectional study based on the Tromsø Study: Tromsø 7”

doi:10.21203/rs.3.rs-426613/v1

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Research Article

“Dental anxiety and potentially traumatic events” “A cross-sectional study based on the Tromsø Study: Tromsø 7”

https://doi.org/10.21203/rs.3.rs-426613/v1

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published 23 Nov, 2021

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Background The objectives of the study were to describe the prevalence of high dental anxiety and the possible associations between dental anxiety and potentially traumatic life events in an adult population.

Method The study is based on cross-sectional questionnaire data from the 7th wave of the Tromsø Study, a study of the adult general population in the municipality of Tromsø carried out in 2015–2016. The Modified Dental Anxiety Scale was used to measure dental anxiety across potentially traumatic events, oral health, dental attendance (avoidance) and current mental health symptoms (Hopkins Symptom Checklist). Individuals with high and low dental anxiety scores were compared to investigate differences in the distribution of potentially traumatic events, current mental health symptoms, avoidance, sex and oral health, and hierarchical multivariable regression was used to study the influence of traumatic events on dental anxiety.

Results High dental anxiety was reported by 2.9% of the sample and was most prevalent among women and in the youngest age groups. Individuals with high dental anxiety reported more current mental health symptoms, and they were more likely to report poorer oral health and more irregular dental visits compared to individuals with no or lower dental anxiety scores. Concerning traumatic life events, the reporting of painful or frightening dental treatment showed the biggest difference between those with high dental anxiety and low dental anxiety scores (a moderate effect). The hierarchical regression model indicated that reporting sexual abuse, traumatic medical treatment in hospital and childhood neglect significantly predicted dental anxiety in the step they were entered in, but only sexual abuse remained a significant individual contributor after controlling for current mental health symptoms.

Conclusions The prevalence of high dental anxiety was lower than expected (2.9%), but dentally anxious individuals expressed a high burden of mental health symptoms, poor oral health and the avoidance of dental care. The regression analysis indicated that experiences with sexual abuse can also affect dental anxiety levels in the absence of generalised symptoms of anxiety and depression.

Dentistry

Dental Anxiety

Dental Fear

Psychological Distress

Psychological Trauma

Sexual Trauma

Oral Health

Dental Health Surveys

Epidemiology

Public Health Dentistry

The Tromsø Study

Dental anxiety: prevalence, severity, aetiology

Individuals with high dental anxiety are often unable to utilise standard dental health services adequately [1, 2]. As a consequence, dental professionals in general practice rarely encounter these patients, and without specialised care, dentally anxious individuals will have more missing teeth and fewer filled and sound surfaces due to a lack of adequate dental treatment [3, 4]. High dental anxiety extends beyond the aversive emotional response that interferes with dental treatment; it may include flashbacks, nightmares, intrusive images, difficulties sleeping, irritability and impaired concentration, even if dental treatment is not imminent [5, 6]. Consequently, high dental anxiety often leads to reduced oral health-related quality of life [7-10] and has demonstrated comorbidity with generalised anxiety and depression disorders [11, 12]. The prevalence of high dental anxiety among adults is reported to be between 3.9% and 15.5% [9, 11, 13-20], depending on the measurements used and cut-off levels. Dental anxiety levels are reported to be higher among women and in younger age groups [13].

The aetiology of dental anxiety is likely multifactorial. Conditioning theories, focusing on the development of a generalised fear response in the dental setting from previous painful and/or traumatic dental treatments [21, 22], are generally accepted as central to the acquisition of high dental anxiety, but are an inadequate explanation in many respects [23, 24]. The experience and processing of a potentially traumatic or aversive event in a dental setting depend on many factors, including life history [25]. Nonetheless, pain is an important factor in conditioning experiences for developing and maintaining dental anxiety [26-28]. Besides, dental anxiety is an important predictor for reporting and expecting pain during dental treatment [29-32], implying that it might be more difficult to achieve dental treatment without pain in anxious individuals. A dentally anxious individual will both expect and report more pain during dental experiences compared to a non-anxious individual [33].

Potentially traumatic events

Potentially traumatic events (PTEs) are highly stressful and threatening events, such as exposure to violence, sexual abuse or neglect in childhood. Several studies have pointed to the negative impact of adverse childhood experiences on multiple health outcomes [34, 35], and similar associations with the development of oral disease may also be expected [36]. The brain reacts differently to traumatic events depending on sex, age, the possession of particular genotypes, personality characteristics, coping strategies, the nature of the trauma and the relationship to the perpetrator [22, 37]. In other words, the emotional load from aversive life events and the nature and timing of them are important in terms of how individuals respond and move forward after such events. Individuals with high dental anxiety have shown trauma-related symptoms similar to those of people suffering from posttraumatic stress disorder (PTSD) [5, 38]. Traumatic life events inflicted by others, like sexual or physical assault, are reported by 10% to 30% of the general population [39, 40]. These traumatic events, in particular, impact interpersonal relationships and can have severe consequences for the mental health and interpersonal functioning of the individuals that are affected [41].

PTEs and dental anxiety

There are limited population studies concerning dental anxiety and PTEs outside the dental setting, and the evidence regarding whether or not there is an association in the general population is contradictory [5, 22, 42, 43]. However, studies on selected subgroups of the population indicate that victims of torture and violence and sexually abused women have a higher prevalence of dental anxiety compared to the general population [5, 44, 45]. Mental health symptoms are a measure of clinical importance with regard to the long-term effects of PTEs and dental anxiety but have, to our knowledge, not been taken into consideration when examining the association between traumatic events and dental anxiety. There are several hypotheses as to how traumas outside the dental clinic can influence dental anxiety. Situations, feelings and other cues from a traumatic experience in the past might be generalised to the dental treatment situation, following a broader conditioning pattern through traumatic coupling [46]. Also, a dental treatment situation is intimate and can leave patients with a sense of a lack of control and helplessness, which could potentially evoke reactions related to the past traumatic experience [5, 45]. A history of abuse and neglect is associated with difficulties in interpersonal relationships, the increased likelihood of depression and anxiety disorders and substance abuse [47, 48]. This burden might increase such patients’ vulnerability to developing dental anxiety. It is possible to hypothesise that general anxiety disorders might be extended to include anxiety towards dental treatment, or that potentially negative or painful dental experiences have a larger impact when mental health is compromised [49]. In other words, it could be the mental health symptoms that follow traumatic experiences that are central when it comes to the development of dental anxiety. It is a reliable finding that psychiatric disorders are associated with dental anxiety and that symptoms of depression and anxiety are predictive of dental anxiety over time [50]. Hence, symptoms of depression and anxiety could intermediate the association between traumatic events and dental anxiety. Since a dental treatment situation is arguably a highly relational, intimate and interpersonal circumstance [46], it comes as no surprise that dental experiences are inevitably coloured by the interpersonal relationship between the dental caregiver and the recipient [51-54]. Regarding sexual abuse, there is evidence indicating a more direct conditioning pattern. For instance, sexually abused women that had experienced oral penetration as part of the abuse reported higher dental fear than sexually abused women without experiences of oral penetration [45]. A recent qualitative study indicated that dental anxiety in survivors of sexual abuse was trauma-driven, in which their anxiety reactions were triggered by their traumatic abuse and not their negative dental experiences (traumatic coupling) [46]. Studies have indicated that the response to triggers is overwhelming to the point of blurring previous memories of abuse and the current experiences in the dental chair [55]. Nonetheless, there is limited research on how traumatic events involving interpersonal relationships influence dental anxiety in the general population. Moreover, current mental health symptoms have not yet, to our knowledge, been considered in research on dental anxiety and traumatic events.

The objectives of the present study are to investigate the associations between dental anxiety, oral health and mental health symptoms, as well as the potential influence of different PTEs on dental anxiety in the general population. The specific aims are as follows:

To describe the prevalence of high dental anxiety within a large population-based study of individuals aged 40 and above in Northern Norway (the Tromsø 7 study).
To analyse the influence of PTEs on dental anxiety when controlling for sex, age, oral health, dental attendance (avoidance) and current mental health symptoms.
To analyse the mediating effect of current mental health symptoms on the relationship between potentially traumatic events and dental anxiety.

Study population and design: The Tromsø Study

The Tromsø Study [56] is a repeated population health survey. This study used data collected from the 7^th survey of the Tromsø Study, in which all adults registered in Tromsø municipality aged 40 or above were invited to participate (32,591 in total). The registration and examination of participants took place from 2015 to 2016. In total, 21,083 residents (10,009 men and 11,074 women) took part in the study, which resulted in a participation rate of 65%. The participants answered questionnaires about several different health topics and received a physical health examination. In the present study, only the questionnaire data were used. Detailed information on the questionnaires and study data are provided through the Tromsø Study web resource [https://uit.no/research/tromsostudy] [57]. Every project in the Tromsø Study is obliged to follow the EU's General Data Protection Regulation and the Personal Data Act (Norwegian law). All participants gave informed consent. This present study only retrieved anonymised data. The Regional Committee of Medical and Health Research Ethics (reference number 2018/1352/REK nord) approved the present study in July 2018. It is confirmed that all methods in the present study were carried out in accordance with the stated guidelines and regulations.

Measures

Age and education

Age was divided into 8 categories each spanning 5 years (40–44, 45–49, etc.), where the last age group was 75 years old and above. Education was categorised into high (university or college) and low (primary and secondary school).

Dental anxiety

Dental anxiety was measured using the Modified Dental Anxiety Scale (MDAS) [14]. The MDAS is a five-item scale, with response options ranging from “not anxious” to “extremely anxious”, yielding a score from 5–25. This variable was dichotomised in the chi-square analysis with a recommended cut-off value of 19 [15](55). The MDAS had a Cronbach’s alpha of 0.932 (N = 20,197) and a mean inter-item correlation of 0.743.

Current mental health symptoms

The current mental health symptoms of the study participants were measured using the 10-item Hopkins Symptom Checklist (HSCL-10), validated for use in epidemiological studies as an indicator of symptoms of depression and anxiety during the last two weeks [58]. Each question is answered based on 4 responses, ranging from “not bothered” to “very bothered”, providing a score between 10 and 40. An average score of 1.85 or higher on the HSCL-10 indicates symptoms of mental illness [58]. The Cronbach’s alpha of the HSCL-10 was 0.866 (N = 19,824), and it had a mean inter-item correlation of 0.413.

Oral health

Oral health was assessed with a single question: “How do you consider your oral health to be?” The participants selected one out of five response options to this question: “excellent”, “good”, “neither good nor bad”, “bad” or “very bad”. The scores were dichotomised in the bivariate analyses. Good (0) included the responses “excellent” and “very good”, while bad (1) comprised “neither good nor bad”, “bad” and “very bad”. In the hierarchical multivariable regression, the Likert format response was used as a continuous variable, assuming that the distances between the answers were reasonably equal and meaningful. Both visual inspection and the low values of skewness and kurtosis indicated that these items could be treated as numerical. Also, the regression was run with the dichotomised variable, which yielded the same result.

Avoidance

Dental attendance patterns were measured by the item, “Do you go to the dentist regularly?”, where participants could indicate their attendance patterns by choosing one of six alternatives: “at least once a year”, “every year”, “every second year”, “less than once every two years”, “only for acute problems” and “never”. This variable was dichotomised to indicate the avoidance of dental treatment, in which yes (0) included the response alternatives “at least once a year”, “every year”, “every second year” and ”less than once every two years”, and no (1) included the response alternatives “only for acute problems” and “never”.

Potentially traumatic events (PTEs)

A list of eleven potentially traumatic life events was included in the Tromsø 7 Study with four response options (no; yes, before the age of 18; yes, after the age of 18; yes, in the last year). In this study, events were included that had the potential to affect interpersonal relationships: painful or threatening dental treatment, painful or threatening medical treatment in hospital, childhood neglect, violence, sexual assault, bullying or witnessing someone close being a victim of violence or sexual assault. The answers were dichotomised into 0 = no and 1 = yes to avoid deflated effect sizes after assuring that the direction of the effects was the same regardless of the timing of the event.

Analyses

All the analyses were performed using IBM Statistical Package for the Social Sciences (SPSS) Statistics version 26 (IBM Corp., Armonk, NY, USA). Chi-square tests for independence were used to explore the relationship between the dichotomised MDAS and the independent variables used in the analysis. Hierarchical multivariable regression was used to assess the ability of selected traumatic life events (sexual abuse, violence, bullying, witness, childhood neglect, painful or threatening medical treatment at the hospital) to predict levels of dental anxiety when controlling for sex, age, self-assessed oral health, the avoidance of dental treatment and painful or threatening dental treatment. The demographic control variables, sex and age, were entered in the first step, followed by the known predictors of dental anxiety from the dental setting in the second step and all the traumatic life events listed above in the third step. To assess how HSCL-10 influenced the model and the effect of the predictors on dental anxiety, it was entered in the final step. Preliminary analyses on the assumptions for linear regression indicated issues with the normal distribution. When inspecting the outliers, all of them reported a higher dental anxiety level than predicted by the model; however, they are a natural part of the population and were therefore not removed or transformed for the current analysis. Hence, the distribution of the test statistics was empirically derived through bootstrapping with 1,000 bootstrap samples. Simple mediation analyses were performed using the PROCESS macro in SPSS [59]. Analysing the dataset with regard to missing values disclosed that 2.4% of all the values were missing, 9.6% of all the subjects had incomplete data and there were missing values in all but two variables (sex and age). The items that made up our variable for measuring mental health symptoms (HSCL-10) had the most missing data (6%), followed by the MDAS (4.2%), avoidance (2.3%) and oral health (2.0%). All the PTEs had the same number of missing values (1.1%). The Little’s MCAR (Missing Completely At Random) test was significant, which indicated that data were not missing completely at random. To evaluate the impact of the missing data on the continuous variables (HSCL-10, MDAS and oral health), the variables were compared with a version of themselves where the missing values were replaced by the series mean using a paired sample t-test. However, since the standard error of the difference was zero, it was not possible to perform any of these analyses. A comparison with the original dataset and the dataset with imputation of missing data was also performed, using both regression and expectation-maximisation techniques. The differences between the variables in the two datasets were minimal and limited to deviations in the second decimal. Finally, a regression analysis was performed by replacing the missing values with multiple imputations, which yielded similar results as the analysis of the original data. The differences were limited to decimal levels in the unstandardised regression coefficient, and there were no differences in β when rounded up to the first decimal place. Based on these findings, the analyses were performed on the original data without any imputation with the pairwise exclusion of missing data.

Almost half of the participants in this study reported higher education levels, and 30% had more than 4 years of university education. Over 94% of the participants specified their nationality as Norwegian, 2.8% as Sami and 1.9% as Kven, and 4.2% felt they belonged to another ethnicity. Most of the participants fell in the second age group (45–49), which constituted 15.6% of the population under study. The age groups with the least participants were the oldest (70–74 and 75+), representing 8.1% and 8.2% of the population, respectively.

The mean sum score of the MDAS was 7.7, with a median of 6. The prevalence of highly anxious (MDAS ≥ 19) participants in this study was 2.9%. The mean value of the MDAS among the highly anxious was 21.7, and the median was 21. Current psychological symptoms were indicated by 8.7% of the participants (10.7% of the women compared to 6.5% of the men). The majority reported good oral health (54.9%), and women scored their oral health a little higher than men, with 58.9% having good or excellent oral health compared to 50.6% of the men. The avoidance of dental health services was reported by 10.2%, with fewer avoiders being observed among women (7.8%) than among men (12.8%). Nearly a quarter of the population under study (23.8%) had experienced one or more traumatic and/or painful dental experiences, with little difference between the sexes (females: 23.7%, males: 23.8%).

Associations of dental anxiety with age, education, income and oral health

Spearman’s correlation showed that dental anxiety scores significantly declined with age; rs (n = 20,195) = -0.25, p < 0.001, and comparing the youngest (MDAS; median = 7) and the oldest (MDAS; median = 5) groups with a Mann-Whitney U test revealed a medium to large effect; U = 3476217, z = 226.92, p < 0.001, r = 0.4. The proportions of highly anxious individuals were also significantly higher in the younger age groups (Fig. 1).

There was a minimal difference in dental anxiety scores across education levels, with differences in the MDAS means being less than 0.4 (participants with a primary and/or an upper secondary education reported a mean MDAS score of 7.6, and participants with a college or a university education reported a mean MDAS score of 7.7). Dental anxiety levels varied somewhat but inconsistently across the different groups of household income, but when dichotomising above and below the national median of household income that year [60], the difference in dental anxiety means was insignificant (participants both above and below the national median of household income had a mean MDAS of 7.68).

As shown in Table 1, chi-square tests for independence (with Yates’ continuity correction) indicated a significant difference in individuals with high and low dental anxiety scores and oral health. Dentally anxious individuals were more inclined to report very bad oral health (71.7%) compared to individuals with lower dental anxiety scores (11.9%). Furthermore, among the dentally anxious, 39.9% never went to the dentist or only went for acute problems versus 9% among those with lower dental anxiety levels (Table 1). There were also significant associations between high or low dental anxiety scores between the sexes and current mental health symptoms (Table 1). No significant differences were found for dental anxiety between different ethnicities. When repeating this analysis separately for the sexes, anxious men reported significantly poorer oral health (90.2% reported very bad oral health) compared to anxious women (61.1% reported very bad oral health). More anxious (MDAS ≥ 19) women (69.6%) than anxious men (41.2%) reported going to the dentist regularly.

Chi-square tests of independence were used to test the proportion of traumatic experiences in the high and low dental anxiety groups and the strength of the associations between the two (Table 2). There were significant differences in dental anxiety for all the traumatic events, and the effect sizes were small and highest for traumatic and/or painful dental experiences (phi = 0.18).

Predicting dental anxiety from PTEs

The results of this analysis are given in Tables 3a and 3b. The control variables entered in steps 1 and 2 in Table 3b explained most of the variance in dental anxiety (23.1%). In the final model, the only traumatic life event entered in step 3 that remained a significant contributor to the model was sexual abuse; B = 0.220, SE = 0.086, β = 0.017, p = 0.011. All the control measures entered in the two first stages remained statistically significant (p < 0.001).

As it is well known that experiencing traumatic events may increase the risk of mental health symptoms [61, 62], and there is a relationship between mental health symptoms and dental anxiety [11, 63], the mediating effect of mental health symptoms was investigated in three separate simple mediation models. The predictor variables of sexual abuse, childhood neglect and traumatic medical treatment in the hospital were tested with the HSCL-10 as the mediator and the MDAS as the outcome (Fig. 1). All the other covariates from the regression model were included in these analyses. Mental health symptoms mediated the effect of the three traumatic events investigated, but sexual abuse had a larger direct effect on dental anxiety than an indirect one, hence the continued significant effect in our hierarchical regression model. The effects of childhood neglect and traumatic medical treatment were fully mediated through current mental health symptoms (HSCL-10) (Fig. 2).

To our knowledge, this is the first study to investigate the association between dental anxiety and PTEs while considering mental health symptoms and self-reported oral health.

The present study investigated dental anxiety in the adult population (> 40 years old) in Tromsø and in accordance with the stated objectives, this population expressed a lower prevalence of dental anxiety than expected [9, 11, 13, 16, 64]; however, this study confirmed previously reported associations between dental anxiety and sex, age, dental attendance, previously traumatic or painful dental treatments and oral health [13, 16, 20, 65].

This study also found that the following potentially traumatic events outside the dental setting had a significant impact on our hierarchical regression model at the stage they were entered: sexual abuse, painful or scary medical treatment at the hospital and childhood neglect. Of these, only sexual abuse remained a significant predictor after controlling for current mental health symptoms. Furthermore, the mediation analysis provided evidence that current mental health symptoms seem to mediate the effect of traumatic or painful medical treatment in hospital, sexual abuse and neglect in childhood on dental anxiety. However, sexual abuse was only partially mediated.

The results of this study indicate that reporting sexual abuse has a direct significant influence on dental anxiety in the general population. In other words, the experience of sexual abuse appears to impact dental anxiety in individuals irrespective of whether the same individuals are experiencing generalised mental health problems (e.g. depression, anxiety). This could point to sexual abuse experiences being somehow directly conditional on dental anxiety [46], but also clarifies the lack of conscious awareness of the link between sexual abuse and dental anxiety, which might be evident in some survivors of sexual abuse [45]. Evidence shows that many aspects of dental treatment can trigger memories and flashbacks from sexual abuse within the concept of trauma coupling [46, 54, 66]. Crossing lines of intimacy in the dental setting can be difficult in itself, but the oral cavity may have been violated directly, which could make the dental setting even more challenging [45, 67]. Dental treatment requires touching the face and head of the patient, inserting fingers in the oral cavity, using water spray and rubber gloves and relying on the patient’s ability to keep their mouth open during certain procedures. Furthermore, being in a reclined position with dental health professionals leaning over and intruding into one’s personal space can trigger feelings associated with losing control and being trapped [67]. Remaining motionless, not having the ability to speak and not seeing what the dentist is doing also may echo feelings of being violated all over again [55, 66]. The dental personnel’s reassurances can also trigger memories since perpetrators often do this as well as a means of justifying their actions or controlling the situation. This might include telling victims to keep calm, that it will not hurt and that it will be over soon [68]. Survivors of sexual abuse have reported persistent problems with dental treatment despite the processing and mental resolving of the abuse in other aspects of their lives [55], which could indicate that exposure to the dental setting, with all its triggers, is especially important for these individuals.

The regression analysis underlines the importance of traumatic dental treatment, oral health and the avoidance of dental treatment as predictors of dental anxiety. However, it is worth noting that most of the variance in dental anxiety is unaccounted for in this model, which points to the fact that there is more to explaining variance in dental anxiety than the factors included in the current model. One aspect that was not controlled for was personality factors, such as neuroticism, which are considered an important predictor of health in general [69], and dental anxiety specifically [12, 63]. Another factor that was not considered was oral health-related quality of life, which evidence shows is often impaired in dentally anxious individuals [70]. Oral health affected by dental anxiety and subsequent avoidance behaviour may affect the oral health-related quality of life and lead to social isolation and the presentation of symptoms related to depression and general anxiety [71, 72]. Dental anxiety has a multifactorial aetiology; hence, effect sizes for the single variables are not expected to be high. Identifying these variables is important, but they must be considered as a part of a set of variables to be able to understand the clinical variations in the population.

The avoidance of dental treatment is much more prevalent among anxious individuals compared to the rest of the population. Still, 60% of the dentally anxious participants reported going regularly to the dentist, and 89.8% of all the participants in this study reported a regular attendance pattern. This is higher than the numbers reported in a population study including adults from the whole of Troms County, where 77.7% of the entire population under study reported similar regular attendance [73]. The private sector provides the majority of dental care for the adult population in Norway without any public involvement concerning the geographical distribution of dental clinics or fees for dental services. That could be problematic with regard to the provision of equal health care, making accessibility and personal economy more predictive of regular dental attendance than other factors [74]. Thus, the adult population in Tromsø, a city with a high density of private clinics, will perhaps have better access to dental health care compared to more rural areas. Also, individuals with a dental phobia who chose not to participate in this study would probably be more inclined to use avoidance as a strategy than the phobic participants that participated in this study, which would influence the reported attendance pattern. Note that the reporting of regular dental treatment includes the option “less than once every two years”, an alternative that could be considered to be more irregular.

There is some controversy in terms of performing mediation analyses on cross-sectional data since the order of occurrence of reported measures is unknown in an individual’s life. The HSCL-10 measures current symptoms (the last two weeks), and it is reasonable to assume that traumatic life events most likely happened sometime previous to the last two weeks in these types of studies. Similarly, the MDAS is also a current measure, which makes it impossible to pinpoint the onset of dental anxiety in the past. Even though the order of events can be stipulated or hypothesised, causal effects cannot be ascertained, and the direction of correlation in the mediation analyses is probably, to some extent, bidirectional. Current mental health symptoms might affect reported traumatic events [75], and high dental anxiety could influence current mental health symptoms. Nevertheless, there is a well-documented link between traumatic life events and mental health. Having experienced trauma increases the likelihood of developing mental health disorders, like PTSD, depression and anxiety [76–79]. There is also convincing evidence concerning the higher prevalence of psychological disorders among highly dentally anxious individuals [23] and the role of psychological disorders in the maintenance of dental anxiety. It could be argued that some traumatic life events might affect dental anxiety as a result of causing increased vulnerability in an individual. That is, the psychological consequences of traumatic experiences might increase susceptibility to dental anxiety and poorer oral health.

There was a low prevalence of highly anxious participants in this study compared to previous investigations, as only 2.9% of the participants scored over the cut-off value of 19 for high dental anxiety. This could be interpreted as a result of a continuous decline in dental anxiety in the adult population [13] or reflect differences in the measures used to classify high dental anxiety. Still, the possibility of issues with the representativeness of individuals with high dental anxiety in the study population cannot be ruled out, especially considering that some of the participants were to undergo a thorough clinical dental examination. This could, to some extent, hinder recruitment among highly dentally anxious individuals due to the avoidance behaviour that characterises the phobic disorder [80]. This is the obvious pitfall of all population studies in the field. However, the questionnaire data used were collected independently of the dental examination, so the dentally anxious could participate in the study while declining the oral examination. Also, if considering the possible bias of representativeness, it can be inferred that the associations in all the bivariate analyses are supported by the existing literature, and including a larger portion of dentally anxious individuals would probably enhance rather than lower the effect sizes of the correlations observed.

Self-reported measures without any clinical markers are problematic and can give rise to bias. Recall bias is often an issue in epidemiological research, and the reporting of traumatic life events can be over- or underreported due to such bias. This can affect the association between reported traumatic events and health-related outcomes, here dental anxiety and current mental health symptoms. Studies have shown that the effect of adverse childhood experiences is present in adult health, despite people not recalling or failing to report such events [75, 81]. Adverse or traumatic life events can be useful and important to individuals when they are trying to make sense of their health problems [81, 82]. Hence, traumatic events could be more relevant to individuals that struggle with mental health problems, and traumatic dental treatment experiences could be more accessible to individuals with dental anxiety. People that are in good health without current problems tend to “forgive and forget” adverse events in their past [83], adding to the risk of underestimating the associations of interest.

The findings of this study show that survivors of sexual abuse can experience challenges in terms of receiving dental treatment regardless of whether their history of sexual abuse affects their current mental health status. Dental personnel should integrate this knowledge into their daily practices, recognise signs of sexual abuse, avoid re-traumatisation and refer patients to specialists in the field.

PTE Potentially traumatic events

MDAS Modified dental anxiety scale

PTSD Posttraumatic stress disorder

HSCL-10 Hopkins symptom checklist

SPSS IBM Statistical package for the social sciences

MCAR Missing completely at random

Ethics approval and consent to participate

All participants in Tromsø 7 gave informed consent. Every project in the Tromsø Study is obliged to follow the EU's General Data Protection Regulation and the Personal Data Act (Norwegian law). The responsible research institution must assess the need to implement the Data Protection Impact Assessment and research processing personal data has to notify the Norwegian Centre for Research Data. This current study only retrieved anonymised data. The Regional Committee of Medical and Health Research Ethics (reference number 2018/1352/REK nord) approved the present study in July 2018. It is confirmed that all methods were carried out in accordance with the stated guidelines and regulations.

Consent for publication

Not applicable

Availability of data and materials

Researchers affiliated with approved research institutions can apply for access to research of the Tromsø Study's material, available from The Tromsø Study [https://uit.no/research/tromsostudy]. All projects applying for data in the Tromsø study must have their own approval from the Regional ethics committee (REK).

Competing interests

The authors declare that they have no competing interests

Funding

The Norwegian Directorate of Health, through Troms and Finnmark County

Authors' contributions

All authors have read and approved the final manuscript.

HN as first author, contributed in planning the study, performed all statistical analyses, drafted and wrote the manuscript.

J-AKJ planned the study, contributed in statistical analyses, interpretations of data, contributed in writing and substantively revised the manuscript.

TW contributed in planning the study, contributed in writing and substantively revised the manuscript.

KR contributed with the statistical analyses, interpretation of data and revised the manuscript.

CEAW contributed in the conception of the study and revised the manuscript.

JT contributed in the conception of the study and revised the manuscript.

Acknowledgements

The publication charges for this article have been funded by a grant from the publication fund of UiT The Arctic University of Norway.

Authors' information

Not included

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Table 1 The distribution of low and high dental anxiety in key variables

VariablE		n	% low dental anxiety	% high dental anxiety	ꭓ2^a	*phi*^b
Sex		20197
	Female (0)	10583	52	66.6	47.63^*	-0.05
	Male (1)	9614	48	33.4
Total count			19614	583
current mental health symptoms		19415
	HSCL < 1.84	17729	91.8	75.7	170.74^*	0.09
	HSCL ≥ 1.85	1686	8.2	24.3
Total count			19197	562
Avoidance^c		20144
	Never, only for acute problems (0)	3249	9.0	39.9	602.69^*	0.17
	Goes regularly (1)	16895	91	60.1
Total count			19565	579
ORAL HEALTH^d
	Excellent (0)		88.1	28.3	323.69^*	0.31
	Very bad (1)		11.9	71.7
Total count		3506	3393	113

Legend: Frequency of high (≥ 19) and low (< 19) dental anxiety scores (MDAS) according to sex, mental health symptoms, dental attendance (avoidance) and oral health

^aYates’ correction for continuity; Chi-square test of independence

^bPhi coefficient (effect size: 0.10 for small effect, 0.30 for medium effect, 0.50 for large effect [Cohen’s criteria 1988])

^cDo you go to the dentist/experience dental care regularly? 0 = no, never or only for acute problems 1 = yes, often, yearly, every other year or less than once every two years

^dComparing high and low evaluations of one’s own oral health

^*p < 0.001

Table 2 The proportion of reported PTEs in the high and low dental anxiety groups

Trauma	MDAS ≥ 19	MDAS < 19	ꭓ2^a	phi^b	OR	95% CI
Any trauma	82.3	51.4	212.23^*	0.10	4.4	3.54 – 5.44
Dental trauma^c	69.0	22.7	660.49^*	0.18	7.6	6.32 – 9.04
Sexual abuse^d	20.8	9.2	85.21^*	0.07	2.6	2.09 – 3.16
Violence^e	26.4	15.2	53.60^*	0.05	2.0	1.66 – 2.42
Bullying^f	32.1	21.1	39.77^*	0.05	1.8	1.48 – 2.11
Witness^g	16.6	9.1	37.39^*	0.04	2.0	1.60 – 2.50
Medical trauma^h	20.6	10.6	57.38^*	0.05	2.2	1.78 – 2.69
Failure of careⁱ	13.0	6.7	34.58^*	0.04	2.1	1.64 – 2.69

Legend: The proportion of reported PTEs in the high and low dental anxiety groups and the strength of the associations (odds ratios) between traumatic events and anxiety level

^*p < 0.001

^aYates’ correction for continuity; Chi-square tests of independence

^bPhi coefficient (effect size: 0.10 for small effect, 0.30 for medium effect, 0.50 for large effect (Cohen’s criteria 1988))

^cReceived painful or terrifying medical treatment at the dentist

^dBeen exposed to sexual abuse, i.e. sexual actions against your will

^eBeen exposed to violence (for example, hit, kicked, beaten, robbed or threatened with a firearm)

^fBeen called negative things, marginalised, threatened or bullied by schoolmates, fellow students or coworkers over a long period of time

^gWitnessed someone close to you being exposed to violence or sexual abuse

^hReceived painful medical treatment when hospitalised due to sickness or serious injury

ⁱFailure of care in childhood, i.e. not having received the necessities of food, clothing, protection and care/love from parents/caregivers

Table 3a Model summary of the hierarchical regression analysis with the MDAS as the dependent variable

	ΔF(df1,df2)	ΔR²
Model 1	646.68^* (2,19012)	0.064
Model 2	1374.83^* (3,19009)	0.167
Model 3	8.63^* (6,19003)	0.002
Model 4	341.72^* (1,19002)	0.014

Legend: ^*p < 0.001

Table 3b Hierarchical regression with the MDAS as the dependent variable

		B	SE Bⁱ	β	Sig.ⁱ	CI 95%ⁱ Lower Upper
Step 1	Constant	9.58	0.07		0.001	9.45	9.72
	Sex	-1.08	0.05	-0.14	0.001	-1.18	-0.97
	Age	-0.36	0.01	0.20	0.001	-0.38	-0.34
Step 2	Constant	11.38	0.14		0.001	11.10	11.67
	^aOral health	-0.67	0.03	-0.16	0.001	-0.73	-0.61
	^bAvoidance	1.91	0.12	0.15	0.001	1.67	2.15
	^cPain dentist	2.55	0.07	0.30	0.001	2.4	2.67
Step 3	Constant	11.20	0.15		0.001	10.91	11.49
	^dNeglect	0.23	0.11	0.02	0.042ⁱⁱⁱ	0.01	0.45
	^eViolence	0.01	0.08	0.00	0.881	-0.15	0.17
	^fSexual abuse	0.38	0.10	0.03	0.001	0.19	0.58
	^gBullying	0.09	0.07	0.01	0.215	-0.05	0.22
	^hWitness	0.09	0.10	0.01	0.391	-0.12	0.28
	ⁱHospital pain	0.21	0.09	0.02	0.025ⁱⁱⁱ	0.04	0.41
Step 4	Constant	9.36	0.18		0.001	8.98	9.73
	^jHSCL-10	1.25	0.09	0.13	0.001	1.09	1.42

Legend: ⁱConfidence intervals (CI) and standard errors (SE) are based on 1000 bias-corrected and accelerated bootstrap samples

ⁱⁱStandardised coefficients

ⁱⁱⁱLost their significant contribution in the last model (see figure on mediation)

^aSelf-reported oral health (Likert format)

^bAvoidance: 0 = goes regularly to the dentist, 1 = never goes or only for acute dental pain

^cReceived painful or terrifying medical treatment at the dentist

^dFailure of care in childhood, i.e. not having received the necessities of food, clothing, protection and care/love from parents/caregivers

^eBeen exposed to violence (for example, hit, kicked, beaten, robbed or threatened with a firearm)

^fBeen exposed to sexual abuse, i.e. sexual actions against your will

^gBeen called negative things, marginalised, threatened or bullied by schoolmates, fellow students or coworkers over a long period of time

^hWitnessed someone close to you being exposed to violence or sexual abuse

ⁱReceived painful medical treatment when hospitalised due to sickness or serious injury

^jHopkins Symptom Checklist: current mental health symptoms

No competing interests reported.

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“Dental anxiety and potentially traumatic events” “A cross-sectional study based on the Tromsø Study: Tromsø 7”

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