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06 May 2022: Clinical Research  

COVID-19: Another Cause of Dental Anxiety?

Marija Nikolić1ABCDEF*, Aleksandar Mitić1ABE, Jelena Petrović2ABCD, Dragana Dimitrijević2ABCD, Jelena Popović1ABDE, Radomir Barac1ABE, Ana Todorović3ABE

DOI: 10.12659/MSM.936535

Med Sci Monit 2022; 28:e936535



BACKGROUND: Fear has always been closely linked to dentistry but it could be intensified by the objective risks imposed by the pandemic. The objective of this study was to determine the profile of the frightened dental patient during the COVID-19 pandemic and determine measures taken by dentists to reduce fear and increase security among their patients.

MATERIAL AND METHODS: An anonymous online survey was conducted between March 15 and April 15, 2021. The respondents were 2060 adult citizens of the Republic of Serbia. In addition to demographic data, data related to the COVID-19 pandemic, dental fear, and attitudes and fear of dental interventions during the ongoing pandemic were compiled. The data were analyzed using descriptive statistics: the chi-square test and Pearson’s coefficient.

RESULTS: Seventy percent of the respondents felt some level of fear of the ongoing pandemic, 50% felt fear of going to a dentist during the pandemic, 20% considered a dental office a hotspot for the transmission of SARS-CoV-2, and 43% would visit their dentist only in the case of emergency.

CONCLUSIONS: The COVID-19 pandemic has affected the attitudes and behavior of people pertaining to visits to dental offices. Identifying frightened patients and their opinions and fears at this challenging time would make it easier for dentists to include protocols in their everyday practice to increase a sense of security among their patients, such as implementing preventive measures in front of the patients, ensuring an empty waiting room, and providing telephone consultations.

Keywords: COVID-19, Dental Anxiety, Dentistry, Adult, Dentists, Humans, Pandemics, SARS-CoV-2, Surveys and Questionnaires


Dentistry has always been related to anxiety and pain. Dental fear and anxiety are important characteristics that contribute to the avoidance of dental treatment [1,2]. Dental fear or anxiety affects approximately 36% of the population, of which approximately 12% have extreme fear [3,4].

While anxiety is a state that precedes facing a threatening stimulus, fear is a reaction that occurs when that stimulus is spotted and leads to a fight or flight response. Consequently, anxiety related to the idea of visiting a dentist for preventive care or dental procedures is called dental anxiety, and the reaction to threatening stimuli in the dental environment is called dental fear [5]. In dental practice, it is not necessary to separate these 2 terms, which in the broadest sense represent the fear of anything that has to do with dentistry. Therefore, it is convenient to use the umbrella term: dental fear and anxiety [6]. The overpowering and irrational fear of dentistry is also known as odontophobia, which leads to the complete avoidance of the dentist and is classified as a phobia in the Diagnostic and Statistical Manual of Mental Disorders-IV and the International Statistical Classification of Diseases and Related Health Problems [7].

The etiology of dental anxiety is multicausal and very complex. The etiological factors are mostly either endogenic, such as genetics, personality type, and intelligence or exogenic (or conditioning experience), such as role models, the media, and previous experience [6].

The emergence of the SARS-CoV-2 virus has changed the world, from individual lives to global functioning. Care for one’s own health and life and the lives of loved ones, fear of pandemic consequences, and daily disturbing images coming from around the globe have had an impact on mental health [8]. For a long time, this problem was not the focus of the scientific community, since the preservation of life came first. However, over time, studies emerged which confirm the negative impact of the pandemic on mental health [9,10]. If we could identify the concerns and fears of potential patients at this challenging time, we might be able to better meet their needs [10].

It is believed that a dental office, and dentistry as a high-risk profession, are hotspots for the transmission of contagious diseases [11,12]. It is not possible to completely exclude the risk of getting infected in a dental office [13]. A dental intervention precludes 2 basic recommendations for the prevention of the spread of COVID-19: social distancing and wearing protective masks. Direct contact with a patient is required (60 cm and less), and most interventions include the use of rotating instruments with the production of aerosol, which not only potentially endangers those present, but could contaminate surrounding surfaces [12,14]. The highly contagious nature of SARS-CoV-2 presents a risk for dental office employees and patients, especially because asymptomatic carriers can also transmit the virus [15]. Dentists have always taken care about the prevention of contagious diseases. However, in this new pandemic, the situation may require the implementation of additional preventive measures, especially since the SARS-CoV-2 virus has been around longer than expected [14].

The duration of the pandemic has taught us to live with the virus, and dental care is available again, but the fear has not disappeared. The ever-present dental fear has been assigned a new exogenic etiological factor; namely, fear of contracting the SARS-CoV-2 virus in a dental office, which became a challenge for dentists and their patients.

The aims of this study were to determine the profile of the frightened dental patient during the COVID-19 pandemic and determine the measures which, when implemented by dentists, could decrease fear and increase a sense of security among their patients.

Material and Methods


An online survey was conducted between March 15 and April 15, 2021. It was distributed via online channels and social media. The research included a sample of 2060 adult citizens from the Republic of Serbia (35% male, 65% female). The representative sample was calculated using a 95% confidence level and error margin of 3%. Available statistical data on the population from 2021 indicated that the representative sample size for the defined criteria was a minimum of 1067 respondents (data from the Statistical Office of the Republic of Serbia) [16].


Participation in the survey was anonymous and voluntary, and the respondents could stop participating at any phase. They were informed about the study and gave their consent prior to the beginning of the survey. The study was conducted in accordance with the Helsinki Declaration and with previous approval from the Ethics Committee of the Faculty of Medicine-University of Niš, Serbia (approval no: 12-2213-2/3). The online study design was chosen owing to its simplicity and lack of social contact, which is recommended during a pandemic.


The survey questions were designed based on the study objectives, according to the Stehr-Green steps for developing a questionnaire [17]. The expert assessment of the questionnaire was performed by 2 university professors from the relevant field of dentistry who were not involved in the study, and the evaluation of the question construction (eg, avoiding ambiguity and suggestibility) was conducted by 2 experienced experts in questionnaire construction. In accordance with their suggestions, and after a pilot study, a definitive version of the questionnaire was formed using the Google Forms platform. Reliability was determined based on the value of the Cronbach Alpha test, which was 0.801. Twenty closed-ended questions were grouped into 4 sections: section 1, demographic data (2 questions); section 2, COVID-19-related information (6 questions); section 3, fear of dental interventions unrelated to the pandemic (3 questions); and section 4, fear of dental interventions during the pandemic (9 questions).

The degree of determined fear is not a clinical assessment but an individual’s self-assessment that dictates a person’s fear-driven behavior, which is why it was considered more relevant to this study. The respondents rated fear of the dentist, fear of visiting the dentist in a pandemic, and fear of a pandemic using a 5-point Likert scale (0, I do not feel fear; 1, I am slightly scared; 2, I am quite scared; 3, I am very scared; 4, I am extremely scared).

The number of questions in the questionnaire was limited to 20, because owing to the set goals of the study (such as determining the profile of a frightened dental patient during a pandemic), the authors decided that the central data processing method should be a correlation analysis which, when working on a large number of questions, would provide a certain amount of data in the results that would exceed the amount of data that are usually presented in a single scientific paper. The questions are shown in Table 1.


The Statistical Package for the Social Sciences (SPSS, version 22.0) software was used for descriptive statistical analysis. The chi-square test was used to show statistical significance of the obtained data with the level of statistical significance set at P<0.01. Pearson’s coefficient was used to find the correlation between the responses (level of significance P<0.01).


Seventy percent of the respondents felt some level of fear of the COVID-19 pandemic. Most described the extent of this fear as mild (48%). Almost 60% of the respondents had not contracted COVID-19 up until the beginning of the survey, while others had had symptoms but had not been tested (14%) or had tested positive to the virus and recovered (26%). At the time of the survey, 31.5% of the respondents had been vaccinated. Most evaluated the epidemiological situation as unfavorable (74%) and had reduced their activities to a minimum (60%). Ten percent of the respondents avoided information about the pandemic because it upset them, while 20% tried to keep up with the current global information.

A total of 49.5% of respondents felt some level of dental fear. Most described the extent of that fear as mild (32.5%), then strong (5%) and extreme (2%). Only 8% of the respondents feared that they could contract a disease (other than COVID-19) during a dental intervention, but 27% experienced a distressing sense of powerlessness and lack of control in a dental office.

Approximately 20% of the respondents considered a dental office a hotspot for the transmission of COVID-19, while 43% of them would only go there in an emergency. Most (80%) would not cease ongoing treatment, irrespective of the COVID-19 pandemic.

Most (70%) of the respondents felt safer when the dentist implemented preventive measures in their presence and 50% felt safer when there were no other patients in the waiting room. The possibility of telephone consultations during a pandemic was considered desirable by 76% of the respondents. Approximately 14% stated that a waiting room with chairs evenly spaced apart, containing disinfectant, and without the presence of other people or magazines seemed distressing. Irrespective of the beginning of mass vaccination and the fact that many people recovered from the virus, 26.5% of the respondents still did not feel safe in a dental office.

Statistical analyses showed that the responses which reflected fear of dental interventions during the pandemic (section 4 of the survey) differed based on demographic data (section 1), COVID-related information (section 2), and data regarding fear of dental interventions unrelated to COVID-19 (section 3).

The statistical analysis showed a statistically significant positive correlation between fear of COVID-19 and fear of going to a dental office during the COVID-19 pandemic (correlation coefficient=0.460, P<0.01) and going to a dental office only in an emergency/urgency (correlation coefficient=0.292, P<0.01). All other correlations are presented inTables 2–6.



An online study is recommended during a pandemic owing to the lack of social contact and simplicity. However, the required access to the internet is a possible reason why there were few elderly respondents (65+ years) in the studied population. The cross-sectional design of the study had its limitations since it was not possible to determine a cause-and-effect relationship. Although the size of the sample was representative, this was still a convenience sample with potential bias.

Collecting data such as whether someone had been vaccinated, had had the disease, kept activities to a minimum, and assessed the epidemiological situation were not in themselves the goal of the research because these data change from day to day and they can reflect the situation at only a given moment. These data were collected because they reflected the fear and discomfort of patients caused by the pandemic and were current regardless of the moment in time. The aim of the research was not to determine the proportion of people who were vaccinated or contracted the disease, but to determine the attitudes and behaviors of people who belong to these groups when it came to visiting the dentist in a pandemic.

To the best of our knowledge, this is the first study that deals with the fear of dentists during the pandemic in Serbia and that gives practical recommendations to dental professionals on how to behave to positively influence the fear of their patients. The length of the pandemic, with all the changes it has brought, such as the number of infected people, the availability of vaccines, and new strains of the virus, but also the habituation of people to the situation, imposes the need for further research.


One of the basic objectives of treating dental anxiety is to diminish or remove the cause of fear among patients so that they could be motivated for long-term repeat visits [5]. The pandemic as an exogenic factor cannot be removed, and therefore it is important to know the profile of the frightened dental patient during the pandemic, as well as what increases fear and what increases a sense of security. Our results showed that the individual most afraid of a dental intervention during the COVID-19 pandemic is an elderly adult who has not had the disease, is vaccinated, has reduced activities to a minimum, and is regularly informed about the current situation around the world. Implementing preventive measures in front of the patient, ensuring an empty waiting room, and enabling telephone consultations increase a sense of security. Knowing this, it is easier for dentists to identify a frightened patient and to implement certain protocols in their daily practice because they can view the dental intervention during the COVID-19 pandemic through the eyes of a frightened patient. In this way, dentists would give their patients’ fear as much importance as they do the success of the intervention.


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