Evaluation of Dental Fear and Anxiety in Displaced Persons in Bosnia and Herzegovina.

INTRODUCTION: In Bosnia and Herzegovina, apart from domicile population, there is a certain number of displaced persons. Most of them are situated in the area of Canton Tuzla. These persons are generally at risk of and being watched for various diseases, including the disease of the orofacial area. Dental fear and anxiety (DFA) is also inevitably present in displaced persons, with higher prevalence compared with general population. Therefore, the aim was to evaluate the DFA presence and the most common reasons for dental fear and anxiety in displaced persons in our country. PATIENTS AND METHODS: 310 interviewed persons were included in this study, aged 35 to 44 years, from several cities of Canton Tuzla. They were divided in the group of displaced persons (n=153), and the group of domicile inhabitants (n=157). The study participants were interviewed about the DFA presence, as well as about the risk factors for DFA, which was subsequently evaluated by the Modified Corah's Dental Anxiety Scale.
RESULTS: A high prevalence of DFA presence was determined in the total sample (38.71%), and particularly in the displaced persons group (57.52%). The results showed that displaced persons rarely visited dentists, mainly when it was necessary (odontalgia), with stronger reactions to factors that could cause DFA appearance.
CONCLUSION: Displaced persons are regarded as one of the highest risk groups for prevalence of DFA. This could be mainly due to poor oral health status, rare dental office visits and the urgent need for dental treatment, which could lead to vicious circle of mutual strengthening between bad oral health and DFA appearance.

Introduction

Populations are developing and changes in their structural characteristics are under the influence of various factors. Population migration depends on natural and mechanic movement of inhabitants, and mutual correlation between various combinations of natural and mechanic movement acts directly to the changes in total number of inhabitants ().

In Bosnia and Herzegovina (B&H), apart from domicile population, there is still a relatively large number of displaced persons who were forced to leave their homes, mostly due to war. A displaced person in B&H is by definition a citizen of B&H who is placed in B&H but was expelled from or left its original residence after 30th of April 1991 due to war and fear of being pursued or executed because of race, religion, nationality, belonging to certain social group or political opinions, and could not safely and proudly come back to former residence, and also decided not to permanently stay in another residence voluntarily ().

It was stated in the United Nations High Commissioner for Refugees Report that there were about 43.3 millions of forcedly displaced persons worldwide at the end of 2009, which was the largest number of pursued and expelled persons since mid-90's of 20th century ().

The first comprehensive official registry of displaced persons in B&H was announced at the end of 2000, with 183, 555 displaced families and 556, 214 displaced persons (). According to the data of the Ministry of Displaced Persons and Refugees of the Federation of B&H, the displaced person status was approved for 50, 541 individuals (). The greatest number of displaced persons in B&H was within the area of Canton Tuzla, with 13.74% out of its total number in our country ().

The oral health status of all age groups of B&H citizens is among the worst in Europe (, ). According to the statistical data of the Institute for Public Health of the Federation of B&H, the leading oral disease in the population of the people older than 19 years in the period from 2005 up to 2008 was dental caries, with 33-41% involvement in total (-). Also, displaced persons belonged to a risk group for appearances of various kinds of illnesses in general, even in the orofacial area ().

Dental fear and anxiety (DFA) is omnipresent clinical dental phenomenon in about one fifth of the general population. The causes for appearance are various but they are generally divided into direct and indirect experiences. Direct ones are the most often reasons for DFA appearance in persons, and most of them said that their DFA appeared after traumatic, hard and/or painful dental experience (). The DFA was also inevitably present in displaced persons who had previous caries experience (as the best example of poor oral health status), and also previous experience with the direct stressors for the DFA appearance that were higher than those in general population (). Generally, and especially in displaced persons, the individual with DFA presence will seek for dental assistance only when there are urgent needs for it such as odontalgia, dental trauma, swelling and/or abscess in the orofacial area, etc. Persons with DFA presence, who experienced dental fear during dental procedures, developed the avoiding cycle, where they did not want to visit the dentist unless there was an urgent need for dental intervention and invasive procedures, which could only strengthen their DFA ().

Based on above mentioned facts, we wanted to evaluate the presence of DFA and factors for DFA appearance in displaced persons in Canton Tuzla, in B&H.

Patients and methods

Participants

The participants in the study were adult inhabitants of Canton Tuzla, B&H, aged between 35 and 44 years. This age group is the standard age group for surveillance of oral health conditions in adults, according to the criteria of World Health Organization (). During the research that took place in the period between March and November of 2011, 410 persons were interviewed. After their selection, according to the inclusive criteria for the participation in the study that were applied, there were 310 participants left in the study in total.

Inclusive criteria for the participation in the study were physically and mentally healthy persons belonging to the age group between 35 and 44 years, with absence of odontalgia or some other urgent dental interventions, or any other serious systemic diseases.

The study participants were divided in two groups. The first, the control group (n=157) comprised individuals who were domicile inhabitants, factory workers in the area of study research. In the second, the study group (n=153) there were displaced persons from collective accommodation centers from the area of study research. The study has been conducted in several cities of Canton Tuzla: Živinice, Tuzla, Banovići, Gračanica, Kladanj, Srebrenik and Kalesija, according to the principles of Helsinki declaration (), and also approved by the Ethics Committee of Faculty of Dentistry with Clinics of Sarajevo University. The aim of the study and its content were explained to every participant and their informed consent was obtained prior to the commencement of research.

Methods

The study research has been performed in two parts simultaneously in the first and second group of participants. In the first study part, the DFA presence in participants was evaluated by the Modified Corah's Dental Anxiety Scale (MCDAS). This psychometric instrument was used for evaluation of DFA presence in adults. It comprised five dental situations and answers to them were ranged by Likert scale and expressed in values from 1 to 5. The total scale score was 25, and the cut off score for DFA presence was 17. The higher MCDAS values were related to stronger DFA presence (). The second part of the study research was the evaluation of the presence of main factors causing (or could cause) the DFA appearance: pain, local dental anesthesia administration, negative experience, transmitted opinion of other persons, loss of control during dental treatment, sounds and noise within dental office setting, and behavior of the dentist and dental staff. The frequency of dental visits and reasons for dental office visiting were also determined.

Statistical analysis

The Kolmogorov-Smirnov test was used for determination of data distribution normality. Although it was showed that data were asymmetrically distributed, the t-test for arithmetic means equality and the F-test for variances equality were also used.

Descriptive statistical results were represented in standard ways, by frequencies, percentages, arithmetic means and standard deviations. They are presented in tables.

The existence of statistically significant differences between study research variables was determined by the χ2 and Mann-Whitney test. All statistical analyses were performed with significance level of p ≤ 0.05, using the SPSS® Statistics 17.0 statistical software for Windows operative system.

Results

The average age of respondents was 40.19 years ± 3.60 years, while in the displaced persons group it was 40.44 years ± 3.52 years, and in the domicile inhabitants group it was 39.94 years ± 3.68 years. There were also 64.52% of female and 35.48% of male respondents. In the displaced persons group, there were 75.82% of female and 24.18% of male participants, while in the domicile inhabitants group there were 53.50% of female and 46.50% of male participants.

According to the average scores of answers to MCDAS scale questions, the fifth question regarding local dental anesthesia caused the highest feeling of DFA (M=3.14, SD=±1.49), while the fourth question about teeth scaling and polishing caused the lowest feeling of DFA (M=2.31, SD=±1.17) in study participants. The same situation was in the displaced persons group with somewhat higher average scores (M=3.65, SD±1.43; M=2.65, SD=±1.08, respectively), and also in the domicile inhabitants group with somewhat lower average scores (M=2.64, SD±1.38; M=1.97, SD=±1.15, respectively).

The statistically significant differences were determined to each of five questions of the MCDAS scale, between the answers of the displaced persons group and the domicile inhabitants group, with χ2 = 30.934, p < 0.0005; Mann-Whitney U = 7963.000, p<0.0005 for the first question; χ2 = 26.074, p < 0.0005; Mann-Whitney U = 8516.500, p < 0.0005 for the second question; χ2 = 43.015, p < 0.0005; Mann-Whitney U = 7213.000, p < 0.0005 for the third question; χ2 = 36.569, p < 0.0005; Mann-Whitney U = 7797.000, p < 0.0005 for the fourth question, and χ2 = 43.160, p < 0.0005; Mann-Whitney U = 7406.000, p < 0.0005 for the fifth question. According to the above mentioned results, a significantly larger number of displaced persons stated that they felt DFA in each of these five MCDAS scale situations described by questions compared with domicile inhabitants. Besides, displaced persons obtained significantly higher average scores of answers to each of five MCDAS scale questions compared to domicile inhabitants. Also, the same situation repeated with the MCDAS scale itself (Table 1), where similar statistically significant differences were determined (χ2 = 58.928, p < 0.0005; Mann-Whitney U = 6958.500, p < 0.0005), in a way that significantly larger number of displaced persons stated to feel DFA in total MCDAS scale compared to domicile inhabitants. In addition to that, the displaced persons obtained significantly higher average scores of answers to MCDAS scale questions in total compared to domicile inhabitants.

Table 1

Distribution of total values from MCDAS scale given by participants

MCDAS scale (points)	Displaced		Domicile		Total
	n	%	n	%	n	%
5	7	4.58	25	15.92	32	10.32
6	4	2.61	12	7.64	16	5.16
7	4	2.61	8	5.10	12	3.87
8	7	4.58	10	6.37	17	5.48
9	4	2.61	8	5.10	12	3.87
10	5	3.27	6	3.82	11	3.55
11	6	3.92	14	8.92	20	6.45
12	9	5.88	12	7.64	21	6.77
13	4	2.61	10	6.37	14	4.52
14	4	2.61	6	3.82	10	3.23
15	7	4.58	10	6.37	17	5.48
16	4	2.61	4	2.55	8	2.58
17	10	6.54	5	3.18	15	4.84
18	10	6.54	5	3.18	15	4.84
19	14	9.15	3	1.91	17	5.48
20	15	9.80	4	2.55	19	6.13
21	9	5.88	4	2.55	13	4.19
22	17	11.11	3	1.91	20	6.45
23	8	5.23	2	1.27	10	3.23
24	3	1.96	1	0.64	4	1.29
25	2	1.31	5	3.18	7	2.26
Total	153	100.00	157	100.00	310	100.00

The DFA presence was determined in 120 study participants, which was prevalence of 38.71%. In the displaced persons group, the DFA prevalence was 57.52%, and in the domicile inhabitants group it was 20.38%., which was statistically significant (χ2 = 45.037, je p < 0.0005), hence the displaced persons showed significantly higher prevalence of DFA presence.

Significantly greater number of domicile study participants visited annually dental offices more often than the displaced persons (χ2 = 45.285, je p < 0.0005). Also, a significantly greater number of domicile study participants visited the dentist more often for regular check-ups than the displaced persons (χ2 = 28.457, je p < 0.0005). Yet, numerous study participants stated that toothache or pain in the orofacial area constituted the most common reasons for dental emergency, which was more evident in displaced persons.

Possible factors for the DFA presence and appearance are presented in Table 2. The leading factors in the displaced persons group were as follows: pain during dental treatment, local dental anesthesia administration and various smells in dental office. In the domicile inhabitants group, similar factors played an important role: pain and negative experiences during dental treatment, local dental anesthesia administration and various smells in dental office. The statistically significant differences were determined in answers to these dentally stressful factors (χ2 = 16.827, p = 0.032), where the displaced persons group of study participants reacted more strongly to these factors compared to the domicile inhabitants group.

Table 2

Most frequent factors that cause DFA in participants

Factors	Displaced		Domicile		Total
	n	%	n	%	n	%
Pain during procedure	78	37.32	58	29.90	136	33.75
Anaesthesia	39	18.66	24	12.37	63	15.63
Sound of an instrument	13	6.22	18	9.28	31	7.69
Smells in the dental office	30	14.35	22	11.34	52	12.90
Experiences of others	11	5.26	8	4.12	19	4.71
Dental personel attitude	5	2.39	8	4.12	13	3.23
Loss of control during procedure	1	0.48	0	0.00	1	025
Negative experiences during procedures	20	9.57	33	17.01	53	13.15
Total	209	100.00	194	100.00	403*	100.00

*Total does not match the number of participants as some gave multiple answers

Discussion

There were the two (local dental anesthesia, tooth drilling) out of the three most significant invasive factors that could most frequently cause the DFA appearance in MCDAS scale design. This was also confirmed by the study results in the total sample, as well as in the displaced persons group and the domicile inhabitants group of study participants. Numerous studies about the causes of DFA presence and appearance were based on factors which could cause pain during dental treatment. Accordingly, the most stressful dental factors are those having the potential for harming the integrity and normal functioning of one's body and those causing the pain during dental treatment ().

The DFA prevalence in the total sample, as well as in the sample groups was high. Among all mental diseases, dental anxiety and fear disorder (DFA) has been described as one of the most frequent kinds of fears and anxieties (). In the study conducted in Canton Sarajevo, the DFA related to dental interventions was found in 36.7% of participants with lower education level, and in 16% of participants with higher educational level, which corresponds to the age group of participants of the present study (). The scores were lower compared to the above presented results, which was also similar to the results of the studies carried out by other authors who investigated into this particular field (-). Also, the displaced persons belonged to the risk group for incidence of many kinds of (oral) diseases, which could inevitably lead to higher DFA appearance and prevalence, compared to average population (). Lider et al. investigated the association between some traumatic experiences (not related to dental situations) during the lifetime period and the DFA, and showed that women, who suffered some negative experience during the period of their childhood, could have extremely high levels of DFA presence (). This could be in agreement with the results of the study including displaced persons, where more than 75% of participants were women who had been forcibly expelled from their homes.

Study participants rarely visited the dentist compared to the recommendations for oral health prevention. Also, a great number of study participants, especially those belonging to the displaced persons group, did not have any annual dental visits. In the study conducted in 1996, statistically significant differences were found, where 38% of displaced persons had annual dental visit, compared to the 55% of domicile population (). These findings were also confirmed by other studies, where oral health status correlated with the educational level as one of the displaced persons determinant ().

The results of various studies have shown that study participants go rarely for regular dental check-ups. Dental visits are mostly related to reasons such as some urgent needs, or odontalgia. In the study conducted in 1996, more than 30% of participants aged from 35 to 44 years, from the displaced and domicile group, stated that odontalgia was the main reason for their dental visits. (). High frequency of odontalgia is not unusual finding in poor oral health status, which was typical of both populations, especially of displaced persons (). Even 41.7% of participants in the study conducted in Canton Sarajevo decided for tooth extraction as final dental treatment ().

The leading dental factor for the DFA appearance was pain during dental treatment, in the total sample, and in the study groups of participants. Similar studies showed that painful stressors and fear of pain were the main reasons for DFA appearance (, ). In one study conducted in Germany, 67% of study participants stated that painful experience during dental treatment was the main reason of DFA presence, which was followed with the fear of local dental anesthesia administration (). Various types of noise and smells in dental offices were also included in the group of stressful dental factors for the DFA appearance, especially in children who started avoiding the dentist, which might lead to minor dental problems becoming major ones (, ).

Conclusions

Displaced persons belonged to the risk group with high DFA prevalence. The factors for the DFA appearance and presence in this group were identical to those related to the average population. However, displaced persons had stronger reactions to them. Possible reasons for this could be that this specific population of individuals had lower average indices of oral health status, and worse behavior patterns related to the frequency of dental visits and the reasons for dental visiting. All of this could lead to strengthening of vicious circle, where poor oral health status mutually anticipated the DFA appearance and presence.