Evaluation of the Impact of Educational Status

on the Anxiety Levels of Patients Undergoing

Root Canal Therapy Using Modified Corah
Dental Anxiety Scale—A Cross-Sectional study

Hmoud Ali Algarni1 , Meshal Aber Al Onazi1 , Amjad Obaid Aljohani2 ,

Kumar Chandan Srivastava3(B) , Deepti Shrivastava4,5 , Merin Mathew6 ,
and Mohammed Ghazi Sghaireen6
1 Department of Operative Dentistry and Endodontics, College of Dentistry, Jouf University,
Sakaka, Saudi Arabia
{dr.hmoud.algarni,dr.meshal.alonazi}@jodent.org
2 Department of Prosthetic Dental Sciences, College of Dentistry, Jouf University, Sakaka,
Saudi Arabia
dr.amjad.johani@jodent.org
3 Department of Oral and Maxillofacial Surgery and Diagnostic Sciences, College of Dentistry,
Jouf University, Sakaka, Saudi Arabia
drkcs.omr@gmail.com
4 Department of Preventive Dentistry, College of Dentistry, Jouf University, Sakaka, Saudi
Arabia
5 Department of Periodontics, Saveetha Dental College and Hospitals, Saveetha Institute of
Medical and Technical Sciences, Saveetha University, Chennai 602105, India
6 Department of Prosthodontics, College of Dentistry, Jouf University, Sakaka, Saudi Arabia

{dr.merin.mathew,dr.mohammed.sghaireen}@jodent.org

Abstract. Background and Objective: Majority of dental procedures are inva-

sive in nature. Procedures such as injecting local anesthesia at the site of procedure,
raising a soft tissue flap, extraction or root canal therapy (RCT) are considered
invasive. These procedures have shown to increase anxiety among patients. Raised
levels of anxiety might result in complications and thus can affect the prognosis
of treatment. Hence, the aim of the current study was to evaluate the impact of
education on the anxiety level among the patients undergoing root canal therapy.
Materials & Methods: A cross-sectional study in a hospital setting was planned.
A total of 177 subjects who were planned to undergo RCT were included in the
study. Around ninety (90) subjects were included in non-educated group, whereas,
87 patients were recruited in educated study group. All subjects were asked to fill
the Modified Corah Dental Anxiety Scale (MDAS) before they undergo the RCT.
Results: Significantly (P < 0.05) higher number of educated subjects responded
“quiet” to the first three questions. Additionally, significantly (P < 0.05) higher
number of non-educated subjects displayed “very worried” response to the last two
questions of corah’s scale questionnaire. Level of education reported a significant
negative correlation with the anxiety level. Among the gender group, a greater
number of females displayed significantly (P < 0.05) “worried” response to all
questions compared to their male counterparts. On overall anxiety scale, male and

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2024

A. Badnjević and L. Gurbeta Pokvić (Eds.): MEDICON 2023/CMBEBIH 2023, 94, pp. 598–608, 2024.
https://doi.org/10.1007/978-3-031-49068-2_60
 Evaluation of the Impact of Educational Status on the Anxiety Levels 599

educated subjects reported to have significantly (P < 0.001) low level of anxiety
in comparison to their counterparts.
Conclusion: The level of education seems to influence the anxiety level, with
educated individuals coping better with the anxiety level prior to the RCT.

Keywords: Root canal therapy · Anxiety · Fear · Educational · Pain · Modified

Corah dental anxiety scale

1 Introduction
Anxiety can be defined as a group of feelings permeated by stress, fearful thoughts
and physical changes, such as sweating or high blood pressure, today anxiety events
are increased also caused by the effects of Covid-19 on the persons[1–7]. Nevertheless,
the influence of social media in modifying the environment needs to be considered
[8]. However, anxiety is considered normal and often healthy unless it is regular and
disproportionate. In later situation, it might be a medical condition and it can lead to
avoidance of non-fearful situation [9]. According to the study conducted by Kirova et al.,
it was found that the highest level of anxiety is between the age group of 25–26 years [10].
This could be explained by the impact of different psychological factors encountered in
this age group [11, 12]. Several researchers have found anxiety being more prevalent
among females. However, this difference among genders has been questioned clinically
[11, 13].
Dental anxiety (DA) reflects a combination of biochemical alterations in the body,
patient’s personal history, memory, and social state that causes a problem for both the
patient and the dentist. Some patients even consider visiting the dentist a source of fear,
phobia and anxiety, which affects the overall oral health to the point of causing also
linked symptoms as orofacial pain and possible Temporomandibualr disoders [14–19].
Nowadays, the treatment modalities in dentistry has expanded including periodontal
therapy, and endodontic treatment such as root canal therapy (RCT). With the advance-
ments in the technology the success rate of these modalities is high and thus has become
an integral part of the comprehensive oral care [20–26]. Although patients may be aware
of endodontic treatment, there awareness may be associated with lack of knowledge
about the details of the procedure, which leads to fear, anxiety and eventually avoidance
of the treatment [27, 28].
Many researchers have found that patient’s education will significantly decrease the
level of anxiety. Sghaireen MG et al., in his study found that patient’s education not only
decreases the level of anxiety but also encourage them before undergoing procedures for
dental implants [29]. Also, Camacho-Alonso F et al., found that the conventional face-
to-face verbal information is the best type of patient’s education prior to the placement
of dental implants[30, 31]. On the other hand, Stangvaltaite-Mouhat L et al., in his study
found that short educational videos will decrease the level of anxiety more than written
description obtained from the Saudi Endodontic Society [32, 33].
Currently, limited number of studies regarding the influence of education on the
anxiety levels of the patients’ undergoing root canal therapy. This prompted the current
study with an aim to assess the levels of DA among patients’ undergoing endodontic
treatment.
600 H. A. Algarni et al.

2 Material and Methods

2.1 Study Characteristics
A cross-sectional study was planned after getting the approval from the institutional
ethical committee. The study was conducted in accordance with the ethical guidelines
laid by the declaration of helsinki.

2.2 Sample Characteristics

The study was carried out in a hospital setting for duration of 3 months starting from
November 2021 to January 2022. Based on the treatment plan, the patients who were
eligible to undergo RCT were considered for the study. Subjects of age less than 18 years
or having any organic psychological disorder were excluded from the study. Any subjects
who were found to have any ongoing treatment for mental illness or had taken treatment
in recent past, or had discontinued treatment with residual disorder was also excluded
from the current study.

2.3 Sample Size Calculation

Sample size calculation was done using software—G Power 3.1.9.2 (Hein-
rich-Heine-Universität Düsseldorf, Germany). Chi square test between the two study
groups, with 1 degree of freedom and confidence interval of (α) 0.05 gave a sample size
of 147. Taking the attrition of the sample during the study into the account, a sample
size of 177 was considered.

2.4 Study Protocol

Based on the inclusion and exclusion criteria, the patients who were planned for the
RCT were considered for the study. The potential participants were informed about
the objectives of the study and were not compelled to participate in the study. Written
informed consent was taken from the patients who agreed for the study.
Patients were randomly allocated to the two study groups, with 90 patients in group
1 and 87 in group 2. Group I (Non-Educated): patients in this group were not informed
about the steps of the procedure other than the name of the procedure. Group II (Edu-
cated): Information imparted to the patients by an endodontist. Standardization was
assured by delivering the same written information involving all the details about the pro-
cedure. All participants were asked to fill the corah’s questionnaire before they undergo
the RCT.

2.5 Study Tool (Questionnaire)

The Modified Corah’s scale [11] was used to measure the extent of DA among patients
undergoing RCT. The scale has five questions, each with five options ranging from not
anxious at all (1 point) to severe anxious (5 points). These include the following. (1) If
you were going to your endodontist for RCT tomorrow, how would you feel? (2) If you
 Evaluation of the Impact of Educational Status on the Anxiety Levels 601

were at the endodontist office sitting in the waiting room, how would you feel? (3) If you
were about to have your tooth drilled, how would you feel? (4) If you were about to have
local anesthesia, how would you feel? (5) When the endodontist start pulp extirpation,
how would you describe your feeling?

2.6 Data Management

By adding the obtained scores of individual questions, the total scores were calculated
for every subject. Later, by using the Eq. (1), the total score was converted into a 3-point
ordinal scale as mentioned in study by Alduraywish et al. [34]
Maximum Value − Minimum Value
Class width(CW ) = (1)
Number of required class intervals
Every question had the minimum and maximum possible score of 1 and 5 respec-
tively. Thus, the least and highest possible score that can be attained was 5 and 25
respectively. Considering this, the anxiety levels were categorized into low (score ranging
5–11), moderate (12–18) and high (19–25) levels.

2.7 Data Analysis

Gathered data was expressed in number and percentages. Inferential analysis was carried
out using chi-square test at 95% confidence interval. For causal analysis, spearman
correlation was employed.

3 Results
The study consisted of a total sample of 177 subjects with 90 (50.8%) and 87 (49.2%)
subjects in non-educated and educated study groups respectively. Majority of subjects in
either group were in their middle age (31–50 years). The non-educated group included
majority of male (50.6%), whereas female subjects were more (63.3%) in the edu-
cated group. Both groups had majority (non-educated 85.1% versus 81.1% educated) of
subjects working in non- medical and paramedical sector (Table 1).
Responses to the questions were also analyzed between the genders. Significantly (P
< 0.05) higher number of male subjects responded to “Quite” response to the questions
1, 2 and 3, in contrast to female. However, higher number of female subjects (P < 0.05)
responded “very worried” when asked question number 4 and 5 (Table 3).
Later the study groups were assessed with the overall anxiety levels. The non-
educated subjects showed a significantly (P < 0.001) higher number of subjects (17.2%)
having an overall high level of anxiety compared to the educated subjects (6.7%). On
comparing among gender, female subjects reported to have significantly (P < 0.001)
higher number of subjects (20%) with high level of anxiety compared to their male
counterparts. On correlation analysis, educational level showed a significantly (P <
0.001) inverse relation with the anxiety, where subjects with higher educational level
display lower levels of anxiety (Table 4).
Other baseline variables such as age, and occupation reported with non-significant
variation in responses. However, significantly higher number of Saudi national subjects
was reported with “worried” behavior compared to non-Saudi (Table 5).
602 H. A. Algarni et al.

Table 1. Sample characteristics

Variable Study Group Total n = 177

Non-educated Educated 87 (49.2)
90 (50.8)
Age (Mean ± SD) Category 39.30 ± 13.784 40.86 ± 11.828 –
Age (In class Interval) 15–30 Years 28 (32.2) 24 (26.7) 52 (29.4)
31–50 Years 43 (49.4) 44 (48.9) 87 (49.2)
>50 Years 16 (18.4) 22 (24.4) 38 (21.5)
Gender Male 44 (50.6) 33 (36.7) 77 (43.5)
Female 43 (49.4) 57 (63.3) 100 (56.5)
Nationality Non-Saudi 11 (12.6) 12 (13.3) 23 (13)
Saudi 76 (87.4) 78 (86.7) 154 (87)
Occupation Medical 7 (8) 6 (6.7) 13 (7.3)
Para-medical 6 (6.9) 11 (12.2) 17 (9.6)
Others 74 (85.1) 73 (81.1) 147 (83.1)
Note SD- Standard deviation; Results are expressed in number (%) Table 2, describes the responses
of the subjects in either study groups to the 5 questions present in the corah’s scale for assessing
the anxiety level. On performing inferential analysis, significantly (P < 0.05) higher number of
the subjects in the educated group (56.7%, 41.1% and 36.7% respectively) responded to “Quiet”
behavior for question No. 1, 2 and 3 is comparison to non-educated group. Significantly higher
(P < 0.05) number of subjects (14.9% and 32.2% respectively) of non-educated group displayed
a “very worried” behavior in response to questions no. 4 and 5 in contrast to their contemporaries
in educated group (Table 2)

4 Discussion
Knowing and understanding the reasons for DA is an important factor in its management
and consequently improving the oral health. DA was negatively correlated to quality of
life with respect to social functioning, vitality and psychological well-being. This finding
indicates that the link between DA and perceived negative quality of life is multifaceted.
In 1954 Shoben EJ et al., reported that DA is an acquired rather than being inherent [35].
Accordingly, it is necessary to inform patients who are undergoing endodontic treatment
with detailed action steps which might be a causative factor for DA. The most common
factors for DA are either from a bad experience, through watching videos or from words
of friends and peers [8, 29, 30, 36].
Different methods were developed to assess and evaluate DA including: Dental
Anxiety Inventory, Kleinknecht’s DFS, Weiner’s Fear Questionnaire, state-trait anxiety
inventory, adolescents’ fear of dental treatment cognitive inventory and corah dental
anxiety scale(CDAS). In this study, the modified CDAS was used to assess the effect of
patient’s education on the level of anxiety as the CDAS is considered as simple, easy and
valid tool [37–39]. The survey contains five questions which test anxiety when patient
is undergoing endodontic treatment. A 5-point-scale answering scheme was devised for
 Evaluation of the Impact of Educational Status on the Anxiety Levels 603

Table 2. Descriptive Analysis of responses to various questions among study groups

Responses Question 1 Question 2 Question 3 Question 4 Question 5

Group Group Group Group Group Group Group Group Group Group
I II I II I II I II I II
Quiet 35 51 23 37 21 33 14 12 18 12
(40.2) (56.7) (26.4) (41.1) (24.1) (36.7) (16.1) (13.3) (20.7) (13.3)
A little 25 28 28 37 17 30 7 (8) 36 9 27
uncomfortable (28.7) (31.1) (32.2) (41.1) (19.5) (33.3) (40) (10.3) (30)
Tense 23 8 (8.9) 30 11 29 20 27 25 9 28
(26.4) (34.5) (12.2) (33.3) (22.2) (31) (27.8) (10.3) (31.1)
Anxiety 4 (4.6) 3 (3.3) 6 (6.9) 5 (5.6) 18 7 (7.8) 26 13 23 18
(20.7) (29.9) (14.4) (26.4) (20)
Very worried 0 0 0 0 2 (2.3) 0 13 4 (4.4) 28 5 (5.6)
about the (14.9) (32.2)
degree of
sweating or
fatigue
P value 0.015* 0.004** 0.005** 0.000*** 0.000***
Note * P < 0.05, ** P < 0.01, *** P < 0.001; Results are expressed in number (%); Group
I–Non-educated; Group II-Educated

Table 3. Descriptive and inferential analysis of responses to various questions among gender
group

Responses Question 1 Question 2 Question 3 Question 4 Question 5

Male Female Male Female Male Female Male Female Male Female
Quiet 47 39 (39) 41 19 (19) 40 14 (14) 20 6 (6) 27 3 (3)
(61) (53.2) (51.9) (26) (35.1)
A little 20 33 (33) 22 43 (43) 17 30 (30) 23 20 (20) 22 14 (14)
uncomfortable (26) (28.6) (22.1) (29.9) (28.6)
Tense 7 24 (24) 11 30 (30) 15 34 (34) 21 31 (31) 12 25 (25)
(9.1) (14.3) (19.5) (27.3) (15.6)
Anxiety 3 4 (4) 3 (3.9) 8 (8) 5 (6.5) 20 (20) 11 28 (28) 12 29 (29)
(3.9) (14.3) (15.6)
Very worried 0 0 0 0 0 2 (2) 2 (2.6) 15 (15) 4 (5.2) 29 (29)
about the
degree of
sweating or
fatigue
P value 0.014* 0.000*** 0.000*** 0.000*** 0.000***
Note * P < 0.05, *** P < 0.001; Results are expressed in number (%)

each question ranging from no anxiety to severely anxious and measured from 1 to
5, respectively. The level of anxiety is given by the sum of points of scale items. The
maximum score will be 25 representing sever anxiety and the minimum will by 5 points
604 H. A. Algarni et al.

Table 4. Comparative and correlation analysis of overall anxiety level among the study group
and gender

Overall anxiety levels Study group Gender group

Non-educated Educated Male Female
Mild Anxiety 27 (31) 56 (62.2) 53 (68.8) 30 (30)
Moderate Anxiety 45 (51.7) 28 (31.1) 23 (29.9) 50 (50)
High Anxiety 15 (17.2) 6 (6.7) 1 (1.3) 20 (20)
P value (Chi square test) 0.000*** 0.000***
P value (r) (Spearman correlation) 0.000*** (–0.316) 0.000*** (0.417)
Note * P > 0.05, ** P < 0.01, *** P < 0.001; Results are expressed in number (%); r-correlation
coefficient

Table 5. Inferential analysis of other independent variables with responses to the Questionnaire

Age Nationality Occupation

Question 1 0.261 0.937 0.339
Question 2 0.825 0.957 0.566
Question 3 0.621 0.444 0.848
Question 4 0.942 0.008** 0.501
Question 5 0.461 0.474 0.749
Overall 0.242 0.095 0.751
Note ** P < 0.01; Results are expressed in number (%)

representing no anxiety. Following Coolidge and Sghaireen patients were considered

severely anxious if the patients scored more than 19 points on the scale [29, 40].
In this study 21% of the whole sample were found to be severely anxious, 15% among
non educated group and only 6% among the study sample; indicating that educating
patients, assuring and explaining the steps of the procedure has a significant effect on
lowering their anxiety. These results concur with the results obtained by Sghaireen and
Lee et al. [29, 41]. On the contrary; Camacho-Alonso F et al. found that it depends on
the method of education as audio visual delivering method generated more anxiety than
conventional verbal information [30].
In the present study, females were found to be more anxious than males. This can be
linked to the fact that males are emotionally more stable than females [42–45]. These
findings are in accordance with other studies that found higher DA lever among female
[44, 45]. In the other hand, some other studies found that there is no difference between
the two genders. This conflict in the literature might be due to the culture differences
[46, 47]. Non-Saudi were less anxious than Saudi patients in both educated and the
non-educated group. These finding might be as a result of psychological, social pressure
and the insufficient educated programs.
 Evaluation of the Impact of Educational Status on the Anxiety Levels 605

Oral and dental health is a public health issue that is worsened by the increase
in DA levels, especially among children and women. Accordingly, the Saudi society
needs studies at the national level to determine the causes and methods of treating this
phenomenon also thanks to the use of new technologies [48].
Limitations of the study: Although the current study showed promising results, there
are few limitations as well. A multicenter study with a large sample size will make
the generalization of the results to a wide population. The DA from different dental
procedures can be compared.

5 Conclusion
Based on the results of the current study, the educational level of the patient might
influence in reducing the anxiety level before undergoing through a root canal therapy.

Acknowledgments. None.

Funding Statement. Self-funded.

Data Availability. The data set used in the current study will be made available on request from
Dr. Kumar Chandan Srivastava (drkcs.omr@gmail.com).

Conflicts of Interest. The author declares that there is no conflict of interest regarding the
publication of this paper.

List of Abbreviations

DA Dental Anxiety
CDAS Corah Dental Anxiety Scale
RCT Root Canal Therapy

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