EfficacyofAudiovisualDistractionintheReductionof

DentalAnxietyDuringEndodonticTreatment

UniversityofMichiganGraduateEndodontics
VincentMDeNitto,DMD

CommitteeMembers
G.RexHolland,BSc,BDS,PhD(Chair)
PatriciaBauer,DDS,MS
MathildePeters,DMD,PhD
JosephHimle,PhD
ThomasBraun,PhD

Introduction
Anxietyisacommonreasonmanypatientsgivefornotvisitingadentist.Anxiety
canariseasaconditionedresponsetoapreviouspainfulortraumaticexperience
withadentistorcanresultfromnegativebeliefsandperceptionsofdental
situationsrenderingpatientsparticularlysensitivetothereceptionand
communicationtheyreceivefromdentalstaffandtotheoutcomeofdental
treatment(1).Duringadentalvisit,manypatientswillnormallyexperiencesome
typeoftensionorfear,withsomepatientsexperiencingmoderatetosevereanxiety.
IntheUnitedStatesalone,ithasbeenestimatedthatapproximately80%ofthe
populationhassomeanxietyaboutdentaltreatmentandthat5to14%havean
extremedegreeofdentaltreatmentanxiety(2).Severalstudiessupportthe
hypothesisthatpainorfearofpainisaprimarysourceofthisanxiety,aswellas
beingamajorobstacletoseekingdentalcare(3).Anxiouspatientsfeelmorepain
duringinjectionsoflocalanesthesiaandoflongerdurationthanlessanxious
patients(4).
Nocurrentdataexistsregardingtheprevalenceofrootcanaltreatment.
Howeveritisestimatedthatthemajorityofadultsundergooneormorerootcanal
treatmentsduringtheirlifetime(8).Rootcanaltreatmentisawellacceptedand
beneficialtreatmentfordiseasesofthedentalpulp.Anxietyinpatientsundergoing
rootcanaltreatment,asinmostpatientsundergoinginvasivemedicalprocedures,
maybeduetoconcernsaboutthephysicaldiscomfortcausedbytheprocedure
itself.A1991studybyWongandLytleshowedthatrootcanaltherapyandoral
surgerywerefoundtobethemostanxietyprovokingtreatments(5).Thirtyfive

percentofparticipantsinthestudystatedthattheyhadheardthatrootcanal
therapywasthemostunpleasantdentalprocedurewhereas29%statedoral
surgerytreatmenthadtheworstreputation.However,53%ofpatientsactually
experiencingoralsurgerytreatmentstatedthatanoralsurgeryprocedurewasthe
mostunpleasanttreatmentwhereasonly17%ofpatientsexperiencingrootcanal
therapystatedthesame.
Greatadvancementshavebeenmadeinthetreatmentofdentalanxiety,
includingtheuseoforalmedications,nitrousoxide,andmusicdistraction(8).
Unfortunately,notalltherapiesarefullyeffectiveandnotallpatientsrespond
equallytoalltherapies.Thisstudywilltestanewtreatmentmodalityforthe
reductionofendodonticrelateddentalanxiety.Theaimofthestudyistodetermine
ifanaudiovisualdevicewornduringendodontictherapycanreducethepre
treatmentanxietyfeltbyapatient.Ifsuccessful,thisfindingcouldalterthewaythat
endodonticassociatedanxietyismanagedandmayallowmorepeoplewithhigh
anxietytofinallyvisitadentistinpeace.Wealsodecidedtoexamineiftherewas
anycorrelationbetweendentalknowledgeandchangesindentalanxiety.Ifitis
shownthatpatientswithagreaterdentalknowledgetendtohavealargerdecrease
intheirdentalanxiety,thenacasemaybemadeforprovidingpatientswithmore
informationregardingtheirprocedurebeforetreatment.Thiscanbeaccomplished
byhavingpatientswatchaninformativemovieabouttheprocedureorbyutilizing
moderntechnologysuchastheAppleiPadtohelpbettereducatethem.

LiteratureReview/Rationale
CausesofDentalAnxiety
Thereasonforthedevelopmentofdentalrelatedanxietyisstillyettobe
determined.However,threemainaspectshavebeensuggested:(i)direct
conditioningtoaversiveencountersinthedentaloffice,(ii)vicariouslearning,
throughrolemodels,suchasfamily,peersandsociety,and(iii)psychodynamicand
personalityaspects,i.e.specifictraitsthatwhenpresent,increasethepatients
pronenessforapprehensioninthedentalsetting(12).
A1954studybyShobenandBorland(11),soughttoproveanetiologybehind
dentalfear.Transcriptsofinterviewsconductedwith15selfreportedfearful
patientsand15nonfearfulpatientswerescoredforpresenceorabsenceof11
factors,5ofwhichwerebroadpersonalitydispositions.Fearfulandnonfearful
groupsdidnotdifferinthefrequencyofscoredhighanxiety,troublewithauthority
figures,emphasisonappearance,emphasisonorality,ordependency.Infact,the
twopatientgroupsdifferedinonly2ofthe11factors:fearfulpatientsmore
frequentlyreportedahistoryoftraumaticdentalexperiences(directconditioning)
andmorefrequentlynotedunfavorableattitudestowarddentistryamongfamily
members(vicariouslearning).
MethodsofMeasuringDentalAnxiety
Thereareawiderangeofmethodologicalapproachesandtechniquescurrently
availabletostudybehaviorandattitudesrelevanttohealth,illnessandhealthcare
including,fearofdentists,dentistryanddentalpain.Thisincludesavarietyof
methodologicalapproachesandtechniques,especiallythroughtheuseof

questionnairesandbehavioralmeasures.Someofthemanysubjectivemethods
usedformeasuringdentalanxietyincludetheCorahdentalanxietyscale(13)the
Spielbergerstatetraitanxietyinventory(15),thevisualanalogscale(18,19),and
theKleinknechtdentalfearsurvey(26).
Unlikesubjectivemeasures,whichrelyonpatientstoprovideananswer,
objectivemeasuresallowaninvestigatortocollectdatawithoutthepossibilityof
bias.Objectivemeasuresincludebloodpressure,pulserate,pulseoximetry,finger
temperature,andgalvanicskinresponse.
SubjectiveMethods
In1969,Dr.NormanCorahdevelopedaquestionnairetomeasuretherelative
anxietyofdentalpatients(13).Today,theCorahDentalAnxietyScale(DAS)isone
ofthemostwidelyusedpsychometricinstrumentsforthemeasurementofdental
fear.Thescalecontainsfourmultiplechoiceitemsdealingwiththepatient's
subjectivereactionsaboutgoingtothedentist,waitinginthedentist'sofficeforthe
procedure,andanticipationofdrillingandscaling.Pointsareassignedforthe
patientschoices,withpointsrangingfromonetofivepoints.Totalscoresrange
from4to20,with13andaboveregardedasdentallyanxious.TheDAShas
undergonenumerousteststoconfirmitsvalidity.Ina1978study,Dr.Corahhimself
demonstratedtheDAStobeareliable,valid,andusefulmeasureofdentalanxiety
(14).Morerecently,theabilityoftheDAStodistinguishbetweenfearfulandregular
Norwegiandentalpatientswasassessed(15).Theresultsshowedthat90%ofthe
fearfulpatientsand85%oftheregularpatientswerecorrectlyassignedtothe
appropriategroups.ItwasthusconcludedthatwhenusedonaNorwegian

population,theDASisavalidinstrumentfordistinguishingfearfulpatientsamong
thoseregularlyattendingfordentaltreatment.
TheSpielbergerStateTraitAnxietyInventory(STAI)distinguishesbetween
anxietyasageneralaspectofpersonality(traitanxiety)andanxietyasaresponseto
aspecificsituation(stateanxiety).Thequestionnairecontains20itemsforwhich
theindividualrateshowtheygenerallyfeel.Thescorerangesfrom20to80.
AccordingtoaBrazilianvalidationstudy(16),subjectswereconsideredtohave
highorlowtraitanxietyiftheirscoresweregreaterthan49orlessthan33,
respectively.A2009studybyFuentesandothers(17),investigatedarelationship
betweendentalanxietyandtraitanxiety.Itwasfoundthatpatientswithhighdental
anxietytendedtopresentwithhightraitanxiety,buthightraitanxietyseemednot
topredisposetohighdentalanxiety.IntheNorwegianstudymentionedpreviously
(15),distinguishingbetweenfearfulandregularNorwegiandentalpatients,the
STAIwasalsoevaluated.Theresultsshowedthat80%ofthefearfulpatientsand
79%oftheregularpatientswerecorrectlyassignedtotheappropriategroups.The
authorsconcludedthatalthoughnotdevelopedspecificallyforthispurpose,the
STAImightstillbeavalidmeasureusedtodistinguishbetweenfearfulandnon
fearfulpatients.
AthirdwayoftenusedtomeasuredentalanxietyisthroughtheuseofaVisual
AnalogScale.FirstdescribedbyFreydalmostninetyyearsago(1923),theVisual
analogscaleisasimple,selfadministeredmeasureforsubjectivephenomena.
TheVisualAnalogScaleforAnxiety(VASA)isrepresentedusingacontinuumwith
"notatallanxious"and"veryanxious"attheleftandrightextremesrespectively.

Thefollowingwritteninstructionsareincluded,Pleaseputacrossontheline
shownbelowtoindicatehowyoufeelrightnow.Amarkattheextremeleftend
wouldindicatethatyouarefeelingnotatallanxious.Amarkattheextremeright
endwouldindicatethatyouarefeelingthemostanxiousyoucouldeverimagine.A
marknearthecenterwouldindicatethatyoufeelmoderatelyanxious.TheVASA
hasbeenusedinseveralstudiestomeasurethedegreeofanxietyinbothanxiety
disorderpatientsandhealthycontrolsubjects(18,19).Ithasproventobeavalid
methodforthemeasurementofanxietyandishighlysensitiveforchange.
Objectivemethods
Anxietyisoftenthoughtofasadirectcausalrelationshipofhighbloodpressure
butstudieshavenotshownanylongtermdirectlinkbetweenhighbloodpressure
andanxiety(27).However,eventhoughanxietydoesnotcausepersistenthigh
bloodpressure,itcanandoftendoescausetemporaryspikesinbloodpressure.
Althoughthehighbloodpressureisnotpersistent,thesespikesdohavethe
potentialtoseverelydamageapatientsvascularsystem(27).
Anextremelyaccuratemethodusedtomeasuredentalanxietyisthroughthe
measurementofagalvanicskinresponse(20).Asopposedtoquestionnaires,which
relyonpatientsexpectedtruthfulness,galvanicskinconductanceisnotreliantona
patientsveracity.Galvanicskinresponsetakesadvantageoftheelectricalchanges
inducedbyminuteamountsoffluidfromepidermalsweatglandsreleased
secondarytoanxiety.Sweatontheskinprovidesalowresistancepathwayfor
electriccurrent,whichisthenrecorded.Severalinvestigatorshaveused
psychophysiologicalmeasurementssuchasgalvanicskinresistance(GSR),asused

inpolygraphtesting,toquantitatelevelsofanxietyinpatients.Theuseofgalvanic
skinresponsehasbeenvalidatedasanaccuratemethodinmeasuringdental
anxiety.Ina2003studybyCapraraetal(20),galvanicskinconductancewasused
toobjectivelymeasureapatientsdentalanxiety.Theauthorsconcludedthatthere
wasastatisticallysignificantcorrelationfoundbetweenskinconductanceand
dentalanxietyinallcases.
TreatmentModalitiesforDentalAnxiety
Therehavebeenavarietyofapproachesusedinanattempttorelieve
endodonticrelatedanxietyorphobia.Anoftenusedmethodinvolvesthe
administrationofanoralsedativetoapatientpriortotheappointment(9).Theuse
oforalmedicationformanagementofanxietyisaconvenient,inexpensive,andwell
establishedtechniqueforthemanagementofmildanxiety.Byfar,thebestclassof
drugsusedforthispurposeisthebenzodiazepines.Thesedrugsprovidespecific
reliefofanxietywithoutdepressingcardiopulmonaryfunction.Theyalsohavethe
fewestsideeffectswhencomparedtootherclassesofsedatives(9).
Anothermethodtorelieveendodonticanxietyistheuseofnitrousoxide.Nitrous
oxidehasbeenusedforanesthesiaindentistrysinceDecember1844,whereHorace
Wellsmadethefirst1215dentaloperationswiththegasinHartford,CT(25).Its
debutasagenerallyacceptedmethod,however,camein1863,whenGardner
QuincyColtonintroduceditmorebroadlyatalltheColtonDentalAssociationclinics,
thathefoundedinNewHavenandNewYorkCity(25).Althoughtheexact
mechanismofactionisnotfullyunderstood,itisbelievedtobetrifoldandincludes
analgesia,anxiolysis,andanesthesia.Aswithoralsedatives,nitrousoxideisbest

suitedforpatientswithmildtomoderateanxiety.
Athirdmethodthathasbeenusedtorelieveendodonticanxietyistoprovide
patientsabouttoundergoendodontictreatmentwithpositiveinformationrelating
toendodontictherapy.InastudybyvanWijk&Hoogstraten(10),itwasshownthat
fearofpainfromendodontictreatmentcouldbedecreasedsignificantlyby
providingpositiveinformationpriorthetreatment.Thepositiveinformationgiven
tothepatientwasaboutapreviousstudywherepeoplewhoexperiencedrootcanal
treatmentpersonallywere4to5timesmorelikelytodescribetheprocedureas
painless.Thistechniqueallowsthepatienttobemoreateasebeforeandduring
treatment,decreaseavoidancebehaviorandmakedecisionsregardingtreatment
choice,basedoncommonsenseratherthanfearfulexpectations
Othertherapiesusedinanattempttorelieveendodonticrelatedanxietyinclude
relaxationtechniquesandmusicdistraction(6,7,8).Laietal,showedthatmusic
distractioncoulddecreasetheprocedurerelatedanxietyofpatientsundergoing
endodontictreatment(8).HoweverinarecentstudybyLahmannetal,which
lookedatdentalanxietyingeneral,relaxationexerciseswereshowntobemore
effectivethanmusicdistractioninhighlyanxiouspatients(7).Accordingtothe
study,onepossibleexplanationforthisphenomenonisthat,toacertainextent,
usingrelaxationexercisesallowsthepatienttocontrolhisorherownperceptionof
stress,therebyachievingreducedpainsensitivity.Thesefactorsdonotapplyto
musicdistraction,whichoperatesonaprincipleofoveralldistractionbymasking
fearenhancingnoisesduringtreatment(7).Musicdistractionstillprovedtobe
beneficialinreducingstateanxietyincomparisonwithnointervention,withits

greatesteffectamongsubjectswithmoderateanxiety(7).
Recentlyanewapproachhasgainedpopularitytohelprelieveanxietyrelatedto
endodonticsthatincorporatesavisualaswellasanaudiocomponent(6).
Audiovisualdistraction(A/Vdistraction)allowsapatienttousetwooftheirsenses
tohelpfurthertheirdistractionpotential.Arecentstudycomparedaudioand
audiovisualdistractiontechniquesinmanaginganxiouspediatricpatients(6).Inthe
study,childrenpresentingfortheirfirstdentalvisitswereseparatedintothree
groups:notreatment,listenedtomusicthroughheadphones,orwatchedtelevision.
Theauthorsconcludedthattheaudiovisualdistractiontechniquewasmore
effectiveinmanaginganxiouspediatricpatientsascomparedtotheaudio
distractiontechniqueandnormaldentalsetup(nodistractiontechniquesused).
DentalanxietyisanextremelycommonproblemintheUnitedStates,affecting
millionsofAmericans(28).Morespecifically,anxietyrelatedtoendodontictherapy
canbeespeciallydebilitating(28).Treatmentoptionssuchasnitrousoxideor
benzodiazepinemedicationsaretremendouslyeffectiveforalargepercentageofthe
population,butasadentalprofession,weshouldalwayslooktoreduceourpatients
anxietyinanonpharmacologicmannerwheneverpossible.Oneoptionthathas
beenshowntobeareliablealternativetopharmacologicmethodsismusic
distraction(8).Anothernonpharmacologicalternativeusedintreatinganxietyis
throughtheuseofanaudiovisualdistractiondevice.Thismethodhasbeenalready
beenshowntobeextremelyeffectiveinpediatricpatients,buthasyettobetested
inthetreatmentofendodonticrelateddentalanxiety.Theobjectiveofthisstudyis
toinvestigate1.Ifendodonticrelateddentalanxietycanbereducedbytheuseofan

audiovisualdevicewornbythepatientduringtreatmentand2.Ifanincreased
dentalknowledgehasanyinfluenceonthisreduction.Wehypothesizedthatthere
wouldbeagreateranxietyreductionintheaudiovisualgroupversusthecontrol
groupandthatahigherdentalknowledgewouldalsoleadtoreducedanxietylevels.

II.MaterialsandMethods

Thestudywasdesignedasaprospective,randomized,singleblinded
controlledtrialandhadtheapprovaloftheUniversityofMichiganInstitutional
ReviewBoard.
Atotalof60patientsrequiringendodontictherapywererecruitedforthis
study.AllworkwascompletedintheGraduateEndodonticClinicattheUniversityof
MichiganSchoolofDentistry.Patientshadtobeabovetheageof18,freeofany
systemichealthproblemspreventingthemfromundergoingendodontictreatment,
andhadselfreportedanxietyaboutrootcanaltreatment.Exclusioncriteriawere:
patientsalreadytakingantianxietyorpsychotropicmedications,patientswithany
visualorauditorydeficits,andpatientswhocouldnotcommunicateefficientlydue
toilliteracyorlanguagebarriers(nonEnglishspeakingpatients).
PatientsreferredtotheGraduateEndodonticClinicwerecontactedpriorto
schedulingtheirappointmentandinformedaboutaresearchprojectongoinginthe
clinicconcerningpatientswhoareanxiousaboutundergoingendodontictherapy.
Treatmentwasexplainedinsimpleterms.Ifafterthisdialoguethepatientagreedto
participateinthestudy,theywereenrolled.Patientswerescheduledforfullhalf
dayblocksoftime,toensureadequatetimetoperformallrequiredtreatmentand
datacollection.
Newpatientswereinstructedtoarriveearlytocompleteanynecessary
paperwork.Afterbeingseated,allpatientsunderwentathroughreviewoftheir
medicalhistoryaswellasanendodonticexamination.Thisconsistedofany
radiographsrequired,aswellasintraandextraoralexaminations.Oncetheneed

forendodontictherapywasconfirmed,consentformstoperformarootcanaland
consenttoparticipateintheresearchprojectwereexplainedandthensignedbythe
patient.Uponsigningtheresearchconsentform,acopyoftheformwasgiventothe
patienttotakehome.Patientswerethenanesthetizedandwhilewaitingforthe
anesthesiatotakeeffect,thepatientwasaskedtocompleteaquestionnaire
administeredonaniPad(Apple;Cupertino,CA,USA)usingQualtricsonlinesurvey
software(www.qualtrics.com).
Theadministeredquestionnaireconsistedofthreeparts.Thefirstwasthe
CorahDentalAnxietyScale(AppendixA)(13).Thescalecontainsfourmultiple
choiceitemsdealingwiththepatient'ssubjectivereactionsaboutgoingtothe
dentist,waitinginthedentist'sofficefortheprocedure,andanticipationofdrilling
andscaling.Pointswereassignedforthepatientschoices,withpointsrangingfrom
onetofivepoints.Totalscoresrangedfrom4to20with13andaboveregardedas
dentallyanxious.ThesecondportionofthequestionnairewastheDental
KnowledgeQuestionnaire(AppendixB)(21).Thisquestionnaireconsistsof15
questionsregardinggeneraldentalknowledge,withsubscalesofteethandgums,
rootcanalprocedures,andfearofdentalpain.Thelastpartofthequestionnaire
giventothepatientwasAppendixC.Thisportionofthequestionnairewascreated
bytheinvestigatorinanattempttoidentifytheinfluencesofpatientsanxiety.
Patientswereaskedtoconsidervariousinfluences,suchasfamily,
friends/acquaintances,mediaandprevioustraumaticdentalexperiences,andscore
themindependentlyonascalefrom0to10(0=noinfluence,10=highly
influential).

Uponcompletionofthequestionnaires,thetoothundergoingrootcanal
therapywastestedtocheckitslevelofanesthesia.Thiswasdonethroughtheuseof
arefrigerantspray(HygenicEndoIce,Coltene/Whaledent;Switzerland)placedona
cottonpellet.Thepelletwasthenplacedonthetoothandifasharpsensationwas
notfelt,thepatientwasdeterminedtobeadequatelyanesthetized.Afterrubber
damisolation,thevideoeyewear(VuzixWrap310XL;VuzixCorporation,Rochester,
NY,USA)wasplacedonthepatientandattachedtothepreviouslymentionediPad.
Awirelesspulseoximeter(OxiPulse,Phoenix,AZ),whichmeasuredthepatients
bloodoxygensaturationandpulserate,wasthenplacedonthepatientsindex
finger,monitored,andrecordedeveryfifteenminutesthroughouttherootcanal
procedure.
Beforetherootcanalprocedurebegan,thepatientwasassignedbyadental
assistant,throughtheuseofarandomizationsheet,intoeitheranintervention
group,inwhicharelaxationmovie(Solemnity,CedarLakeDVD,Milwaukee,WI)was
watchedandlistenedtobythepatientthroughouttherootcanalprocedure,ora
controlgroup,inwhichnothingwasturnedonandthevideoeyewearremained
blank.Therandomizationsheetwascreatedbyoneofthestudyteammembers(TB)
andtheprimaryinvestigatorwasblindeduntilafterthedatacollectionhadbeen
completed.Thisensuredtheprimaryinvestigatorremainedunbiasedthroughout
thedatacollectionphase,asallpatientsappearedthesamewiththeeyewear
present.
Immediatelybeforethestartoftherootcanal,thepatientwasaskedtoassigna
numbertothelevelofanxietytheywerefeeling.Therangeofanxietylevelsgiven

wasfrom010,with0beingnoanxietyand10beingmaximumanxiety.Thepatient
thenunderwenttheendodonticprocedurescheduled.Everyfifteenminutesthe
patientwasaskedtoreassesstheiranxietylevelandagainassignittoascorefrom
010.Datawascollectedforatotalof90minutes(sixreadings).
Uponcompletionoftheendodontictreatment,thevideoeyewearandpulse
oximeterwereremovedandtheModifiedCorahDentalAnxietyScalewasre
administered.Thepatientwasinstructedtoanswerthequestionnaireasifthey
weregoingtohaveanotherrootcanaltomorrowandwouldhavethesameanxiety
reducinginterventiontheyhadjustreceived(videoornothing).Thedifference
betweenthefirstscaleandthesecondscalewasanalyzed.
Apairedttestwasusedtoassessthesignificanceofchangesovertimeineach
treatmentgroup,whileatwosamplettestwasusedtodirectlycomparedifferences
betweentheaudiovisualandthecontrolgroups.APearson'scorrelationwasuseto
determineiftherewasanycorrelationbetweenchangesinanxietyanddental
knowledge.Pvalues<.05wereconsideredsignificant.

III.Results:
Demographics
Werandomlyassigned60subjectsintooneoftwogroups,audiovisualor
control(Table1).Intheaudiovisualgroup,19subjectswerefemaleand11were
male,whileinthecontrolgroup,17subjectswerefemaleand13weremale.When
lookedatbyage,theaudiovisualgrouphad8subjectsbetween1830yearsold,9
between3150,9between5170and4abovetheageof70.Thecontrolgroup
had5subjectsbetween1830,11between3150,11betweenage5170,and3
abovetheageof70.Asforrace,26oftheaudiovisualsubjectswereCaucasian,3
wereAfricanAmerican,and1classifiedasother.Thecontrolgrouphad24
Caucasiansubjects,5AfricanAmericansubjects,and1classifiedasother.

MeanChangesinAnxietybetweenGroups
Graph1andTable2summarizethemeanchangesinanxietybetweenthetwo
treatmentgroupsover90minutes.Themeanreportedpreoperativeanxietyscore
fortheaudiovisualgroupwas5.73(1.96)andthecontrolgroupwas6.03(2.04).
Thedifferencebetweenthesescoreswasnotsignificant(P>0.05).Themean
reportedpostoperativeanxietyscorefortheaudiovisualgroupwas1.67(1.49),
whilethecontrolgroupwas4.30(1.86).Thisdifferencewassignificant(P<0.001).
Themeanchangefrompreoperativetopostoperativeanxietyscoreforthe
audiovisualgroupwas4.07(1.75)andthecontrolgroupwas1.73(1.75).This
differencewassignificant(P<0.001).

MeanDentalAnxiety

MeanChangeinAnxietyoverTime
9.00
8.00
7.00
6.00
5.00
4.00
3.00
2.00
1.00
0.00

ControlGroup
AudiovisualGroup

15

30

45

60

75

90

Time

Graph1.MeanChangeinAnxietyoverTime(withstandarddeviations)

ChangeinDentalAnxietybasedonGender
Whenmeanchangeindentalanxietywasexaminedbasedongender
differences,femalepatientsshowedanapparentlargerdecreaseintheirdental
anxietythanmalepatients(Table3).Femalepatientsintheaudiovisualgroup
showeda4.32(1.97)pointdecreasefrompreoperativetopostoperativedental
anxietyscore.Malepatientsinthesamegroupshoweda3.64(1.64)pointdecrease
intheirdentalanxiety.Thisdifferencewasnotsignificant(P=0.32).Femalepatients
inthecontrolgroupshoweda2.24(1.59)pointdecreaseintheirdentalanxiety
frompreoperativetopostoperative.Malepatientsinthesamegroupshowedonly
a1.08(1.86)pointdecreaseintheirdentalanxiety.Thisdifferencewasalsonot
significant(P=0.073).
MeanChangeinPulseOximetryandPulse
Themeanchangeinoxygensaturationfrompreoperativetopostoperative
forpatientsintheaudiovisualgroupwas0.24(2.35)(Table4).Themeanchangein

thepulseoximetryforthecontrolgroupwas0.30(1.97).Whencompared,no
significantdifferencewasfound(P>0.05)
Themeanchangeinpulsefrompreoperativetopostoperativeforpatientsin
theaudiovisualgroupwas2.66(6.07),whilethecontrolgroupexhibitedachange
of4.77(6.40).Whencompared,nosignificantdifferencewasfound(P>0.05).
CorahDentalAnxietyScores
Table5summarizesthemeantotalchangefrompreoperativetopost
operativefortheCorahDentalAnxietyscores.ThemeanpreoperativeCorahDental
Anxietyscorefortheaudiovisualgroupwas12.5(3.28)andthepreoperative
CorahDentalAnxietyscoreforthecontrolgroupwas14.5(2.73).Thisdifference
wassignificant(P=0.01).ThemeanpostoperativeCorahDentalAnxietyscorefor
theaudiovisualgroupwas8.5(3.28).ThemeanpostoperativeCorahDental
Anxietyscoreforthecontrolgroupwas11.5(3.28).Thedifferencebetweenthe
twopostoperativescoreswasalsoconsidereddifferent(P=0.001).Thedifference
betweenthepreoperativeandpostoperativeCorahDentalAnxietyscoresforthe
audiovisualgroupwas3.97(2.84).Thisdifferencewassignificant(P<0.001).The
differencebetweenthepreoperativeandpostoperativeCorahDentalAnxiety
scoresforthecontrolgroupwas3.03(3.12).Thisdifferencewasalsoconsidered
significant(P<0.001).However,whenthesedifferenceswerecompared(3.97vs.
3.03),nosignificancewasfound(P>0.05).

CorrelationbetweenChangeinAnxietyandDentalKnowledge
Whenchangeindentalanxietywascorrelatedwithdentalknowledge(Table
6),asscoredfromtheDentalKnowledgeQuestionnaire,itwasshownthattherewas
anapparentpositivecorrelationforpatientsintheaudiovisualgroup,whileforthe
controlgrouptherewasanapparentnegativetoalmostnocorrelation.Thismeant
thatpatientsintheaudiovisualgroupwithahigherdentalIQtendedtohavea
greaterdecreaseintheiranxiety.ThePearsonCorrelationCoefficientforthe
audiovisualgroupwas0.16(P=0.39)howeverthisvaluewasnotsignificant.The
PearsonCorrelationCoefficientforthecontrolgroupwas0.06(P=0.74).This
valueisnotsignificant.TheseresultsaresummarizedinGraph2.

CorrelationofChangeinAnxietywithDentalKnowledge

ChangeinDentalAnxiety

ControlGroup

AudiovisualGroup

4
3
2
1
0
0

10

12

14

1
2
DentalKnowledge
Graph2.CorrelationofChangeinAnxietywithDentalKnowledge

InfluencesofDentalAnxiety
Thelargestinfluenceondentalanxietywaspatientsprevioustraumaticdental
experiences(Table7).Subjectsintheaudiovisualgroupmarkedanaverageof6.6(
2.19)outof10,whilethoseinthecontrolgroupmarkedanaverageof6.4(2.74).
Thepatientsfamilyandfriends/acquaintanceswereequallyinfluentialincausing
patientsanxiety.Theaudiovisualgrouphadameanfamilialinfluenceof3.5(2.19)
andfriends/acquaintances3.4(2.19).Thecontrolgrouphadameanfamilial
influenceof3.9(3.28),withfriends/acquaintancesat4.0(2.74).Theleast
influentialfactorinpatientsanxietywasthemedia.Theaudiovisualgroupmarked
anaverageof2.4(2.19)andthecontrolgroupa3.4(2.19).

IV.Discussion:
Personalvideoeyewearisaportablevideoentertainmentsystemthathasthe
potentialofprovidingarelaxedenvironmentduringdentaltreatment.Incontrastto
traditionalaudiovisualprogramsthatusealargetelevisionmonitorabovethe
patientschair,thissystemincludesalightweighteyeglasssystemthathasabuiltin
televisionmonitoralongwithstereoearphones.Patientsfocustheirattentiononthe
relaxationvideoinsteadofanxietyinducingdentalequipment(syringe,drill,
endodonticfiles,rubberdam)ornoises.Themusicinthevideocomingthroughthe
earphonesnotonlyshieldsthedrillingnoise,butalso,enhancestherelaxationfelt
bythepatient.Ithasbeenreportedpreviouslythatsuchanaudiovisualsystemis
beneficialinthereductionoffearandpainforbothadultsandchildrenundergoing
dentalprophylaxisandrestorativeprocedures(22,23).
Althoughsimilarstudieshavebeenperformed,thisis,toourknowledge,the
firststudythatteststheuseofvideoeyewearinthereductiondentalanxietyon
patientsundergoingarootcanaltreatment.In2008,Laiandcolleagues(8)studied
theeffectsofmusiconstateanxietyinpatientsundergoingrootcanaltherapy(state
anxietyreflectsatransitoryemotionalstateorconditionofthehumanorganism
thatischaracterizedbysubjective,consciouslyperceivedfeelingsoftensionand
apprehension,andheightenedautonomicnervoussystemactivity(8)).Subjectsin
themusicgrouplistenedtoselectedsedativemusicusingheadphonesthroughout
therootcanaltreatmentprocedure,whilepatientsinthecontrolgroupwore
headphonesbutwithoutthemusic.Thesubjectsheartrate,bloodpressureand
fingertemperatureweremeasuredpriortotreatmentandduringtreatmentevery

10minutesuntiltheendoftherootcanaltreatmentprocedure.Theresultsshowed
thatthesubjectsinthemusicgrouphadasignificantincreaseinfingertemperature
andadecreaseinanxietyscoreovertimecomparedwiththecontrolgroup.
Prabhakarandcolleaguesconductedanothersimilarstudyin2007.Inthe
studyanaudioonlydevicewascomparedtoanaudiovisualdeviceinreducing
dentalanxietyinpediatricpatients.Sixtychildrenweredividedinto3groupsof
twentychildrenapiece,withthefirstgroupactingasacontrol.Thesecondgroup
listenedtomusicthroughtheuseofheadphoneswhilethethirdwasshownan
audiovisualpresentationthroughatelevisionthroughouttheentirevisit.All
childrenhadtheirpulseandoxygensaturationmeasuredthroughouttheprocedure.
Theresultsshowedthattheaudiovisualdistractiontechniquewasmoreeffectivein
managinganxiouspediatricdentalpatientsascomparedtotheaudiodistraction
techniqueandthenormaldentalsetup(control).Theresultsalsoindicatedthat
therewasadecreaseintheoxygensaturationasthepulserateincreased,albeitnot
statisticallysignificant.
Inourstudy,audiovisualdistractiondidnothaveafavorableeffectonpulse
rateorpulseoximetryforthesubjectsundergoingrootcanaltreatment.Patientsin
bothgroupstendedtoshowpulseratesandoxygensaturationlevelsthatdidnot
varysignificantlyfrompretreatmenttoposttreatment.Thus,itispossiblethat
personalvideopreferenceneedstobeconsideredwhenselectingaudiovisual
interventionforsubjects.However,doingsowouldhavechangedthefocusofthe
trialtoaddressingwhattypeofvideoiseffective,ratherthanansweringthemore
straightforwardquestionofwhetherornottheuseofastandardizedaudiovisual

devicecanassistinreductionofrootcanaltreatmentrelatedanxiety.Theresult
howeverisnotallthatsurprising,asa2003studybyBartfieldetal(24)foundthat
changesinheartratedidnotcorrelatewithpainandanxietyinpatientsundergoing
IVplacement.
Therewasalsonosignificantdifferenceinthemeanreductionofdental
anxietywhencomparingthepretreatmentandposttreatmentCorahDental
Anxietyscores(P>.05).However,whencomparingthepreoperativeandpost
operativescoresgivenbythepatientwhileundergoingtherootcanaltherapy,the
resultsshowedthatbothgroupshadadecreaseinanxietyover90minutes,withthe
audiovisualgrouphavingasignificantlygreaterdecreasethanthecontrolgroup(P
<.001).Themostlikelyreasontheselfreportedanxietyscoressignificantly
decreasedovertime,whilethescoresfromtheCorahAnxietyscaledidnotshowa
significantdecreasefrompreoperativetopostoperativeisbecausetheself
reportedanxietyscoresarearealtimerepresentationofwhatthepatientisfeeling
atthatverymoment.Thisgivesthemostaccuratescoreofdentalanxiety.Patients
takingtheCorahDentalAnxietyquestionnairemustanswerquestionsabouthow
theywouldfeeliftheywereplacedintocertainsituations.Patientsmaytendtoover
orundervaluehowtheywouldfeelbecausetheywerenotactuallyinthemoment.
Patientsmayalsoforgetwhattheyhadoriginallyansweredonthepreoperative
CorahDentalAnxietyquestionnaireandalsooverorunderscoretheirpost
operativequestionnaire.Althoughoursamplesizewasadequate,tocompletely
eliminatethistypeoferror,alargersamplesizewouldberequired.
Dentalanxietyisamultidimensionalcomplexphenomenon,andnoonesingle

variablecanexclusivelyaccountforitsdevelopment(29).Thereareanumberof
factorsthathaveconsistentlybeenlinkedwithagreaterincidenceofdentalanxiety,
including:personalitycharacteristics,fearofpain,pasttraumaticdental
experiences,particularlyinchildhood(conditioningexperiences),andtheinfluence
ofdentallyanxiousfamilymembersorpeerswhichelicitfearinaperson(vicarious
learning)(29).Inourstudythegreatestfactorinfluencingpatientsdentalanxiety
wasfoundtobeprevioustraumaticdentalexperienceswithameanratingof6.47
(2.47)outof10.Familymembersandfriends/acquaintanceswereequally
influentialincreatingdentalanxietywithscoresof3.72(2.73)and3.68(2.51)
outoften,respectively.Theleastinfluentialfactor,asscoredbythepatients,was
themedia,receivinga2.93(2.20)outoften.
Inourstudy,weattemptedtofindacorrelationbetweendentalknowledge
andreductionsindentalanxiety.TodothisweusedtheDentalKnowledge
Questionnaire(DKQ)(21).Themeannumberofcorrectanswersforourtotalpatient
populationwas7.55(2.16).Thepatientsintheaudiovisualgrouphadslightly
higherscoresontheDKQ(7.83vs.7.27),howeverthedifferencewasnotsignificant
(P>.05).Whencomparedtoreductionindentalanxiety,anapparentpositivetrend
wasseenfortheaudiovisualgroup,indicatingthatpatientswithahigherdental
knowledgewhohadtheaudiovisualintervention,tendedtohaveagreater
reductionintheirdentalanxiety.Incontrast,thecontrolgroupshowedanapparent
negativecorrelation,althoughneitherofthecorrelationsprovedsignificant.
Perhapswithalargersamplesize,thedifferencebetweenthetwocorrelations
wouldbecomesignificant.

StudyLimitations
Itisimportanttonotethattheparticipantsinthisstudyselfreportedtheir
dentalanxiety,withactualscoresrangingfrommildtosevere.Allpatientswere
askedtocompleteapretreatmentCorahDentalAnxietyQuestionnaire,even
thoughtherewasnospecificscorethatwasrequiredtoparticipateinthestudy.Had
weonlyincludedpatientswhoscoreda13orabove(indicatingmoderateanxiety),
thestudywouldhavebeenfurtherstandardized.
Anotherissuethatcouldbeaddressedinfuturestudiesisifpatientsshouldbe
allowedtochoosethevideotheywatch.Videosspecificallydesignedforrelaxation
purposesshould,intheory,workforeveryone,butinrealitydont.Afewpatientsin
thestudycommentedaftertheirtreatmentthattheydidnotcareforthevideoand
wouldhavelikedtheopportunitytochoosethevideotheyhadwatched.Afollowup
studyshouldbeperformed,allowingpatientstochoosefromaselectionofvideos.
Perhapstheresultswillbeofgreatermagnitude,sincethepatientwouldchoosea
videotheyenjoyedwatching,furtheraddingtotheirrelaxationandultimately
decreaseinanxiety.Thepatientpopulationwouldthereforehavetobeincreased
significantlytoaccountfortheextravariables.
Anothercautionwithrespecttotheinterpretationofthisstudyisthatblinding
ofthesubjectswasnotpracticable,whichmightpotentiallyresultinbias.Since
patientsknewwhichtreatmentgrouptheywereapartof,theymayhaveratedtheir
anxietyscorewithwhattheybelievedwascorrect(i.e.overscoringanxiety
reductionforpatientsintheaudiovisualgrouporunderscoringanxietyreduction
forpatientsinthecontrolgroup)insteadofwhattheyactuallyfelt.

V.Conclusions

Boththeaudiovisualandcontrolgroupsshowedareductioninanxietyover90
minuteswiththeaudiovisualgroupshowingastatisticallygreaterreduction
thanthecontrolgroup.

Therewasanapparentpositivecorrelationbetweendentalknowledgeand
reductionindentalanxietyintheaudiovisualgroup,whiletherewasan
apparentnegativecorrelationinthecontrolgroup.Neitherstatisticwas
statisticallysignificant.

Patientsstatedthatprevioustraumaticdentalexperienceswerethegreatest
influenceintheirdentalanxiety.Familialinfluences,friends/acquaintances,and
lastlythemediafollowedthis.

Additionalresearchinvolvinglargergroupsisneededtoconfirmtheresultsof
thispreliminarystudy.

VI.Tables

TreatmentGroup

Male

Gender
Female

Audiovisual
11
Control
13
Table1.PatientDemographics

1830

19
17

8
5

Age
3150
9
11

5170

70+

Caucasian

9
11

4
3

26
24

Race
African
American
3
5

AudiovisualGroup
MeanAnxiety
Standard
Changefrom
Score
Deviation
Baseline
0
5.73
1.96
n/a
15
4.03
1.97
1.70
30
3.20
2.09
2.53
45
2.70
1.84
3.03
60
2.30
1.64
3.43
75
1.87
1.73
3.87
90
1.67
1.49
4.07
Table2.MeanChangeinAnxietyover90minutes
Time

Time
0
15
30
45
60
75
90

MeanAnxiety
Score
6.03
5.70
5.27
5.03
4.67
4.43
4.30

ControlGroup
Standard
Deviation
2.04
2.22
2.02
2.20
1.97
1.96
1.86

Changefrom
Baseline
n/a
0.33
0.77
1.00
1.37
1.60
1.73

TreatmentGroup

MeanChangeinAnxiety
Audiovisual
StandardDeviation
MeanChangeinAnxiety
Control
StandardDeviation
Table3.GenderDifferencesinChangeinAnxiety

Gender
Male
3.64
1.97
1.08
1.86

Gender
Female
4.32
1.64
2.24
1.59

pvaluefordifference
0.324

0.073

TreatmentGroup

Audiovisual
Control
Mean
0.24
0.30
ChangeinPulseOximetry
StandardDeviation
2.35
1.97
Mean
2.66
4.77
ChangeinHeartRate
StandardDeviation
6.07
6.40
Table4.MeanChangeinPulseOximetryandHeartRate
Outcome

pvaluefordifference
0.345

0.198

Outcome

Timepoint

TreatmentGroup
Audiovisual
Control
MeanScore
StandardDev.
MeanScore
StandardDev.
3.4
0.55
3.9
0.55
2.5
1.09
3.1
1.09
2.8
1.09
3.7
1.09
2.0
1.09
2.9
1.09
3.4
1.09
3.8
1.09
2.1
1.09
3.1
1.09
2.9
1.09
3.2
1.09
1.9
0.55
2.5
1.09
12.5
3.28
14.5
2.74
8.5
3.28
11.5
3.28

CorahAnxiety
Pretreatment
Question1
Posttreatment
CorahAnxiety
Pretreatment
Question2
Posttreatment
CorahAnxiety
Pretreatment
Question3
Posttreatment
CorahAnxiety
Pretreatment
Question4
Posttreatment
CorahAnxiety
Pretreatment
Total
Posttreatment
Table5.CorahDentalAnxietyScores

TreatmentGroup
PearsonCorrelationCoefficient
Audiovisual
0.16
Control
0.06
Table6.CorrelationofChangeinAnxietywithDentalKnowledge

pvalue
0.39
0.74

Other
1
1

AnxietyInfluenceQuestion#
Q1
Q2
Q3
Q4
Table7.InfluencesofAnxiety

TreatmentGroup
Audiovisual
Mean
StandardDev.
Mean
3.5
2.19
3.9
3.4
2.19
4.0
2.4
2.19
3.4
6.6
2.19
6.4

Control
StandardDev.
3.28
2.74
2.19
2.74

VII.Figures

Figure.1.SubjectundergoingRootCanalwhilewearingvideoeyewear

Figure2.VideoEyewear

VIII.Appendices
AppendixA

CorahDentalAnxietyScale

1.Ifyouhadtogotothedentisttomorrow,howwouldyoufeelaboutit?
a)Iwouldlookforwardtoitasareasonablyenjoyableexperience.
b)Iwouldn'tcareonewayortheother.
c)Iwouldbealittleuneasyaboutit.
d)Iwouldbeafraidthatitwouldbeunpleasantandpainful.
e)Iwouldbeveryfrightenedofwhatthedentistmightdo.

2.Whenyouarewaitinginthedentist'sofficeforyourturninthechair,howdoyou
feel?
a)Relaxed.
b)Alittleuneasy.
c)Tense.
d)Anxious.
e)SoanxiousthatIsometimesbreakoutinasweatoralmostfeelphysicallysick.

3.Whenyouareinthedentist'schairwaitingwhilehegetshisdrillreadytobegin
workingonyourteeth,howdoyoufeel?
a)Relaxed.
b)Alittleuneasy.
c)Tense.
d)Anxious.
e)SoanxiousthatIsometimesbreakoutinasweatoralmostfeelphysicallysick.

4.Youareintheendodontist'schairtohaveyourrootcanal.Whileyouarewaiting
andthedentistisgettingouttheinstruments,whichhewillusetoperformtheroot
canal,howdoyoufeel?
a)Relaxed.
b)Alittleuneasy.
c)Tense.
d)Anxious.
e)SoanxiousthatIsometimesbreakoutinasweatoralmostfeelphysicallysick.

***Pointsareassignedforthesubject's(S's)choices,withonepointforan(a)choice
tofivepointsforan(e)choice.Totalscoresrangedfrom4to20.(13andaboveis
regardedasdentallyanxious)***

AppendixB

DentalKnowledgeQuestionnaire

1. Whatisanidealangletoholdyourtoothbrushwhenbrushingyourteeth?

a)Abouta90degreeangle
b)Abouta45degreeangle
c)Abouta25degreeangle
d)Abouta65degreeangle

2. Rootcanaltreatmentissuccessfulaboutwhatpercentofthetime?

a)85%
b)90%
c)95%
d)98%

3. Whatisonereasonthatdentistsreferpatientsforrootcanaltreatment?

a)Therootofatoothhasbecomediseasedandneedstobereplacedwithan
implant.
b)Therootofthetoothhasbecomedecayedandneedstoberemovedand
replacedwithafilling.
c)Thereisinflamedtissueand/oraninfectioninsideatooththatneeds
treatment.
d)Acavityinsideatoothneedstobetreated.

4. Whatsensationsaremostpeoplelikelytoexperiencewhenanestheticis
administeredduringrootcanaltreatment?

a)Sharporstabbing
b)Pinchingorpressing
c)Flashingorthrobbing
d)Penetratingorpiercing

5. Howlongdoesitusuallytakefortheanesthesiausedinrootcanaltherapyto
beginworking?

a)Immediately

b)Within10minutes

c)Within5minutes

d)Within15minutes

6. Whatisthefinalstepingoodtoothbrushingtechnique?

a)Brushyourtongue
b)Brushtheinsideportionsofyourcheeks
c)Brushyourgums
d)Brushyourteethagainwithfreshtoothpaste

7. Howlongdoesittaketocompleterootcanaltreatment?

a)24appointments
b)13appointments
c)35appointments
d)Only1appointment

8. Whenyoufirststartflossingeveryday,howlongshouldyouexpectyourgums
tobesore?

a)Forthefirst5days
b)Forthefirst10days
c)Forthefirst2days
d)Forthefirst7days

9. Whenisthemostdiscomforttypicallyexperiencedduringrootcanaltreatment?

a)Beforetreatmentevenbegins
b)Whentheinfectedpulpisremoved
c)Duringtheadministrationofanesthesia
d)Duringdrillingtheinfectedtooth

10. Whattotallengthofdentalflossshouldyoufirstpulloutwhenflossing?

a)About24inches
b)About10inches
c)About14inches
d)About18inches

11. Whatisthematerialcalleddeepinsideteeththatcontainsbloodvessels,nerves,
andlymphaticvessels?

a)Enamel
b)Dentin
c)Gingiva
d)Pulp

12. Whereisnumbnesspresentoncetheanesthesiausedforrootcanaltherapyhas
beenadministered?

a)Immediatelysurroundingtheinfectedtooth
b)Withinthepulpoftheinfectedtooth
c)Inthetissuesurroundingtheinfectedtooth
d)Inthetissueandteethsurroundingtheinfectedtooth

13. Whatsensationsmightyouexperienceduringrootcanaltreatment?

a)Scraping

b)Pulling

c)Probing

d)Vibration

14. Howoftenshouldyoureplaceyourtoothbrush?

a)Everymonth
b)Every2months
c)Every34months
d)Every56months

15. Whatshouldyoudoifyouexperiencepostoperativediscomfortinthe2to4
daysafterrootcanaltreatment?

a)Callyourdentistafterthe5thday
b)Callyourdentistafterthe4thday
c)Callyourdentistimmediately
d)Callyourdentistafterthe7thday

Citation:Sorrell,J.T.,McNeil,D.W.,Gochenour,L.L.,&Jackson,R.Evidencebased
patienteducation:knowledgetransfertoendodonticpatients.JournalofDental
Education,2009;73,12931305.
Subscales
Teeth&GumsSubscale:1,6,8,10,14
RootCanalProcedureSubscale:2,3,7,11,15
FearofDentalPainSubscale:4,5,9,12,13

*Permissiongrantedbytheauthorstoreproduceforclinicalandresearchpurposes.

AppendixC

Q1:Towhatdegreehasyourfamilyinfluencedyouranxiety?

||||||||||
12345678910
NoInfluence

Extremely

Influential

Q2:Towhatdegreehaveyourfriendsand/oracquaintancesinfluencedyour
anxiety?

||||||||||
12345678910
NoInfluence

Extremely

Influential

Q3:Towhatdegreehasthemediainfluencedyouranxiety?

||||||||||
12345678910
NoInfluence

Extremely

Influential

Q4:Towhatdegreehaveprevioustraumaticdentalexperiencesinfluencedyour
anxiety?

||||||||||
12345678910
NoInfluence

Extremely

IX.RawData
CorahDentalAnxietyQuestionnaire

Ifyouhadtogotothe
dentisttomorrow,how
wouldyoufeelaboutit?

Patient01Preop
Patient01Postop
Patient02Preop
Patient02Postop
Patient03Preop
Patient03Postop
Patient04Preop
Patient04Postop
Patient05Preop
Patient05Postop
Patient06Preop
Patient06Postop
Patient07Preop
Patient07Postop
Patient08Preop
Patient08Postop
Patient09Preop
Patient09Postop
Patient10Preop
Patient10Postop
Patient11Preop
Patient11Postop
Patient12Preop
Patient12Postop
Patient13Preop
Patient13Postop
Patient14Preop
Patient14Postop
Patient15Preop
Patient15Postop
Patient16Preop
Patient16Postop
Patient17Preop
Patient17Postop
Patient18Preop
Patient18Postop
Patient19Preop
Patient19Postop
Patient20Preop
Patient20Postop
Patient21Preop
Patient21Postop
Patient22Preop
Patient22Postop
Patient23Preop
Patient23Postop
Patient24Preop
Patient24Postop
Patient25Preop
Patient25Postop
Patient26Preop
Patient26Postop
Patient27Preop
Patient27Postop
Patient28Preop

4
1
4
1
3
3
4
2
4
2
5
4
4
3
3
3
3
1
3
1
4
2
4
3
3
2
4
4
3
3
4
3
5
5
2
3
3
3
5
4
2
1
4
3
3
3
4
2
3
1
3
1
4
3
4

Whenyouarewaiting
inthedentist'soffice
foryour/turninthe
chair,how/doyou
feel?
2
1
3
2
2
2
4
1
4
2
5
4
3
2
2
2
2
1
2
2
4
2
5
2
2
1
2
3
2
2
3
2
4
4
4
5
2
1
3
4
1
1
3
2
2
1
4
2
2
1
2
1
4
4
3

Whenyouareinthe
dentist'schairwaiting
whilehegetshisdrill
readytobegin
workingonyourt...
3
1
3
2
3
3
4
2
4
2
5
3
4
2
3
2
3
1
2
2
4
3
5
2
2
2
3
3
2
2
4
1
4
4
5
3
2
2
4
4
2
1
4
2
2
1
3
2
3
1
3
1
4
4
4

Youareinthe
dentist's/chairto
haveyourteeth
cleaned./Whileyou
arewaiting
3
1
4
1
3
2
3
2
4
1
4
2
2
2
2
2
1
1
2
2
4
2
4
2
3
2
4
3
3
2
4
1
4
4
3
4
2
2
2
2
1
1
4
2
2
1
2
1
3
1
3
2
2
2
3

Patient28Postop
Patient29Preop
Patient29Postop
Patient30Preop
Patient30Postop
Patient31Preop
Patient31Postop
Patient32Preop
Patient32Postop
Patient33Preop
Patient33Postop
Patient34Preop
Patient34Postop
Patient35Preop
Patient35Postop
Patient36Preop
Patient36Postop
Patient37Preop
Patient37Postop
Patient38Preop
Patient38Postop
Patient39Preop
Patient39Postop
Patient40Preop
Patient40Postop
Patient41Preop
Patient41Postop
Patient42Preop
Patient42Postop
Patient43Preop
Patient43Postop
Patient44Preop
Patient44Postop
Patient45Preop
Patient45Postop
Patient46Preop
Patient46Postop
Patient47Preop
Patient47Postop
Patient48Preop
Patient48Postop
Patient49Preop
Patient49Postop
Patient50Preop
Patient50Postop
Patient51Preop
Patient51Postop
Patient52Preop
Patient52Postop
Patient53Preop
Patient53Postop
Patient54Preop
Patient54Postop
Patient55Preop
Patient55Postop
Patient56Preop
Patient56Postop
Patient57Preop
Patient57Postop
Patient58Preop
Patient58Postop
Patient59Preop
Patient59Postop
Patient60Preop
Patient60Postop

3
5
3
3
3
4
3
5
3
4
3
3
3
4
5
3
3
3
3
4
3
4
4
3
2
3
3
3
1
3
2
3
3
4
4
4
3
4
4
3
3
4
2
3
1
3
3
4
3
4
3
4
4
4
3
4
3
4
4
4
4
4
3
4
3

2
5
4
2
2
4
3
4
4
4
4
2
2
5
3
3
2
3
2
5
4
4
4
2
1
2
2
2
1
4
2
2
3
5
5
3
2
3
3
4
4
5
2
3
1
3
3
4
2
5
2
4
4
4
2
4
2
2
3
2
3
4
3
4
4

2
5
2
3
3
5
4
4
4
4
4
3
2
5
3
4
3
3
3
5
5
4
4
2
1
2
1
2
1
3
3
3
3
5
5
5
3
4
3
4
4
3
2
2
1
3
4
5
2
5
3
4
4
4
3
5
2
3
2
2
4
5
3
4
4

2
2
2
3
2
5
3
4
2
4
4
2
2
3
3
3
2
3
3
5
5
2
1
2
1
2
2
2
1
2
2
4
2
5
5
3
3
4
3
3
4
2
2
2
1
4
3
4
2
4
2
3
3
3
2
5
3
2
2
3
3
4
2
4
2

DentalKnowledgeQuestionnaire,Questions17

Patient01
Patient02
Patient03
Patient04
Patient05
Patient06
Patient07
Patient08
Patient09
Patient10
Patient11
Patient12
Patient13
Patient14
Patient15
Patient16
Patient17
Patient18
Patient19
Patient20
Patient21
Patient22
Patient23
Patient24
Patient25
Patient26
Patient27
Patient28
Patient29
Patient30
Patient31
Patient32
Patient33
Patient34
Patient35
Patient36
Patient37
Patient38
Patient39
Patient40
Patient41
Patient42
Patient43
Patient44
Patient45
Patient46
Patient47
Patient48
Patient49
Patient50
Patient51
Patient52
Patient53
Patient54
Patient55
Patient56
Patient57
Patient58
Patient59
Patient60

Question1
1
2
1
1
1
2
1
2
1
2
2
1
2
2
2
4
2
3
2
2
2
1
2
2
2
1
1
2
3
2
2
1
2
3
2
1
2
2
1
2
3
2
3
2
1
2
1
2
2
1
2
2
2
2
2
2
1
2
2
2

Question2
4
3
1
3
4
3
3
3
4
3
3
3
4
2
3
4
3
1
2
1
4
3
3
4
4
4
1
1
2
2
3
4
1
4
2
1
2
1
3
3
1
2
2
4
3
2
3
1
3
1
3
1
1
2
3
3
2
4
2
2

Question3
3
3
3
2
3
3
2
3
3
3
2
3
3
3
2
2
3
3
3
3
3
2
3
2
3
2
3
2
2
2
3
1
3
2
3
2
3
3
3
2
2
3
2
3
3
3
3
3
2
1
3
3
3
3
3
3
4
3
3
3

Question4
2
1
4
4
1
2
2
2
4
2
2
2
4
1
2
2
2
2
1
2
1
1
4
1
2
2
4
2
2
2
2
2
2
2
2
2
2
2
2
2
1
1
2
2
1
2
1
4
2
4
2
1
4
3
1
4
2
1
4
2

Question5
4
2
3
2
2
3
3
3
2
3
2
3
2
3
3
1
3
4
3
2
3
2
4
3
3
2
4
2
2
3
4
1
2
2
4
2
2
2
2
2
2
1
3
2
3
2
2
2
4
2
1
4
3
1
2
4
2
4
2
2

Question6
1
1
1
1
1
1
3
3
1
1
1
1
1
1
1
1
1
3
1
1
1
1
1
3
4
3
1
1
1
1
1
3
1
1
1
1
2
1
3
3
1
3
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1

Question7
2
2
2
2
2
2
2
2
2
2
2
2
2
2
1
4
1
1
1
2
1
2
4
4
3
2
2
1
1
2
2
4
2
2
4
4
2
1
2
2
2
2
4
4
1
2
2
4
2
2
1
2
2
1
1
1
2
2
2
2

DentalKnowledgeQuestionnaire,Questions815

Patient01
Patient02
Patient03
Patient04
Patient05
Patient06
Patient07
Patient08
Patient09
Patient10
Patient11
Patient12
Patient13
Patient14
Patient15
Patient16
Patient17
Patient18
Patient19
Patient20
Patient21
Patient22
Patient23
Patient24
Patient25
Patient26
Patient27
Patient28
Patient29
Patient30
Patient31
Patient32
Patient33
Patient34
Patient35
Patient36
Patient37
Patient38
Patient39
Patient40
Patient41
Patient42
Patient43
Patient44
Patient45
Patient46
Patient47
Patient48
Patient49
Patient50
Patient51
Patient52
Patient53
Patient54
Patient55
Patient56
Patient57
Patient58
Patient59
Patient60

Q8
3
3
1
3
3
4
3
3
1
3
4
3
2
3
1
3
1
3
1
1
3
3
3
1
3
3
3
1
3
3
1
1
3
4
2
3
1
3
1
4
1
1
4
4
1
1
3
3
3
3
4
4
3
1
3
4
3
3
3
3

Q9
3
4
1
3
2
2
1
1
3
1
1
3
3
1
4
1
2
3
1
1
3
3
2
1
1
3
3
1
1
2
1
4
1
4
1
3
1
2
3
4
3
3
3
4
3
4
3
3
4
4
2
4
4
1
3
1
4
1
3
2

Q10
3
2
2
3
4
2
4
3
3
3
1
3
2
3
3
2
3
2
4
4
2
3
2
4
3
4
3
3
1
2
1
2
4
3
4
2
2
2
3
3
3
3
2
1
3
4
2
4
2
3
4
4
1
4
3
4
2
1
3
2

Q11
4
4
3
1
4
4
4
2
4
2
4
4
4
4
4
1
4
4
4
2
4
4
4
4
4
2
4
4
4
2
4
4
4
4
4
4
4
4
4
4
3
4
4
4
4
4
4
4
4
4
3
4
4
4
4
4
2
4
4
4

Q12
4
3
4
4
4
4
4
4
4
4
2
4
4
4
4
1
4
3
4
1
4
4
4
4
1
4
3
4
3
4
4
4
4
4
4
4
3
1
4
3
4
1
1
3
3
4
4
4
4
3
3
1
3
4
4
4
2
4
3
4

Q13
1
3
4
3
3
4
1
3
4
4
4
3
3
4
4
4
3
4
4
4
3
1
3
3
4
1
1
4
4
4
3
4
3
4
4
1
4
3
1
2
3
4
4
3
4
3
1
4
3
4
4
1
3
4
4
1
3
1
3
3

Q14
1
1
3
3
3
3
2
3
3
3
3
3
2
4
3
1
2
4
3
2
3
3
3
2
3
2
2
1
2
1
3
3
3
2
3
4
1
2
3
2
4
3
2
1
1
2
2
2
3
1
1
3
3
1
3
4
2
4
1
1

Q15
2
2
3
3
3
4
2
3
3
3
3
1
2
3
3
3
3
3
2
1
3
3
3
3
2
3
3
3
2
3
3
3
3
3
3
3
3
2
1
2
3
3
2
3
3
2
4
1
3
2
2
3
3
3
3
3
1
1
4
2

AppendixCData

Towhatdegreehas
your/family

Patient01
Patient02
Patient03
Patient04
Patient05
Patient06
Patient07
Patient08
Patient09
Patient10
Patient11
Patient12
Patient13
Patient14
Patient15
Patient16
Patient17
Patient18
Patient19
Patient20
Patient21
Patient22
Patient23
Patient24
Patient25
Patient26
Patient27
Patient28
Patient29
Patient30
Patient31
Patient32
Patient33
Patient34
Patient35
Patient36
Patient37
Patient38
Patient39
Patient40
Patient41
Patient42
Patient43
Patient44
Patient45
Patient46
Patient47
Patient48
Patient49
Patient50
Patient51
Patient52
Patient53
Patient54
Patient55
Patient56
Patient57
Patient58

8
7
3
1
5
8
1
1
2
6
8
1
4
3
2
1
1
1
7
1
1
4
1
5
5
2
1
3
1
6
2
1
9
3
7
7
1
3
9
3
2
6
3
1
1
1
3
6
9
1
9
4
1
5
6
3
1
4

Towhatdegreehave
yourfriendsand/or
acquaintances
1
7
5
4
7
2
1
1
8
6
3
1
5
1
2
9
1
2
5
1
1
5
3
7
7
8
1
3
1
3
5
1
7
3
3
2
5
2
3
3
2
7
3
1
1
2
3
3
7
1
9
1
1
5
7
5
1
7

Towhatdegreehas
themediainfluenced
youranxiety?
2
8
3
1
1
1
5
1
1
3
1
1
1
1
2
4
1
1
5
1
1
3
1
3
8
2
4
5
1
3
6
1
5
3
9
1
5
3
6
5
1
5
3
1
9
2
2
3
3
2
3
1
1
7
4
1
1
3

Towhatdegreehave
previoustraumatic
dentalexperiences
9
7
7
7
9
2
6
7
5
6
8
8
7
9
2
1
9
6
9
5
1
8
5
1
7
4
9
6
1
4
7
6
7
6
9
7
5
8
7
6
3
8
7
7
1
9
9
9
9
3
9
8
9
8
7
9
5
7

Patient59
Patient60

3
9

3
7

2
3

9
9

ReportedAnxietyThroughoutRootCanalTherapy

Patient01
Patient02
Patient03
Patient04
Patient05
Patient06
Patient07
Patient08
Patient09
Patient10
Patient11
Patient12
Patient13
Patient14
Patient15
Patient16
Patient17
Patient18
Patient19
Patient20
Patient21
Patient22
Patient23
Patient24
Patient25
Patient26
Patient27
Patient28
Patient29
Patient30
Patient31
Patient32
Patient33
Patient34
Patient35
Patient36
Patient37
Patient38
Patient39
Patient40
Patient41
Patient42
Patient43
Patient44
Patient45
Patient46
Patient47
Patient48
Patient49
Patient50
Patient51
Patient52
Patient53
Patient54
Patient55
Patient56
Patient57
Patient58
Patient59
Patient60

Treatment
Group
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3

Preop
Anxiety
8
3
5
7
5
7
9
3
7
5
5
5
3
4
9
8
3
6
4
3
5
4
8
6
4
8
5
8
7
8
4
2
5
8
4
6
6
10
10
5
8
6
6
5
4
5
7
5
5
4
5
3
8
5
8
7
5
7
8
10

15min

30min

45min

60min

75min

90min

4
1
3
6
3
4
7
1
6
7
2
2
3
1
8
7
3
5
3
2
5
3
6
5
4
3
2
6
5
4
5
3
4
6
2
5
6
10
10
4
8
5
5
5
4
4
9
7
5
4
4
2
8
5
8
5
4
7
8
9

2
0
3
3
1
2
7
0
6
5
2
0
2
1
5
7
2
4
1
3
3
2
6
5
2
5
4
6
5
2
5
3
4
5
2
4
5
10
8
4
7
5
3
5
3
5
7
8
5
4
4
2
7
5
5
5
4
7
8
9

2
0
3
2
0
1
6
0
5
5
5
0
2
1
3
6
2
4
1
3
2
1
5
4
2
3
2
5
4
2
4
3
4
5
1
4
5
9
10
5
5
5
2
3
2
6
8
8
5
5
3
2
5
5
5
5
4
7
8
8

2
0
2
2
0
1
5
0
5
5
2
0
2
1
3
5
2
4
1
2
2
1
5
3
1
2
2
4
4
1
4
3
3
5
1
4
5
9
9
4
4
5
2
3
2
4
7
6
5
5
3
2
5
5
5
5
4
7
6
8

1
0
2
1
0
0
5
0
5
5
1
0
1
0
2
5
1
4
0
2
1
1
4
3
1
2
1
4
3
1
4
2
4
5
1
4
5
9
7
3
4
5
1
3
1
5
6
7
5
5
3
2
5
5
3
5
4
7
6
7

1
0
2
1
0
0
4
0
4
5
1
0
1
0
2
4
1
4
0
2
1
1
4
2
1
2
1
2
3
1
4
2
3
5
1
4
5
9
4
4
4
5
1
3
1
5
6
6
5
5
3
2
5
5
3
5
4
7
6
7

PulseOximitry

Patient01
Patient02
Patient03
Patient04
Patient05
Patient06
Patient07
Patient08
Patient09
Patient10
Patient11
Patient12
Patient13
Patient14
Patient15
Patient16
Patient17
Patient18
Patient19
Patient20
Patient21
Patient22
Patient23
Patient24
Patient25
Patient26
Patient27
Patient28
Patient29
Patient30
Patient31
Patient32
Patient33
Patient34
Patient35
Patient36
Patient37
Patient38
Patient39
Patient40
Patient41
Patient42
Patient43
Patient44
Patient45
Patient46
Patient47
Patient48
Patient49
Patient50
Patient51
Patient52
Patient53
Patient54
Patient55
Patient56
Patient57
Patient58
Patient59
Patient60

Pre
operative
98
97
97
96
96
91
96
97
97
93
95
95
95
88
96
98
96
93
97
98
91
93
94
95
96

98
95
95
95
95
96
94
97
98
98
98
96
96
98
94
93
95
93
94
96
94
92
94
94
92
95
96
99
93
98
98
95
96
93

15min

30min

45min

60min

75min

90min

97
92
97
97
97
89
98
94
97
90
97
92
95
87
95
99
93
96
97
97
90
95
96
93
96

98
97
94
95
96
96
98
96
97
98
98
98
94
95
95
92
97
94
96
94
93
94
95
95
93
96
94
93
92
98
97
94
97
92

96
91
96
95
96
88
96
92
95
92
99
92
94
88
96
98
91
96
93
96
90
95
96
94
97

96
97
97
95
94
95
97
97
96
96
98
96
94
96
94
91
97
92
95
95
95
97
96
94
93
96
96
96
90
96
98
93
98
93

97
94
97
96
96
88
96
91
94
92
97
94
94
86
96
98
94
97
96
96
90
97
95
93
96

96
97
97
97
92
95
97
93
96
98
99
96
94
97
94
93
95
94
93
94
95
94
96
92
94
96
95
95
90
95
97
95
97
92

98
92
97
97
96
86
96
91
96
92
97
97
95
84
96
98
95
96
97
95
90
96
95
93
96

97
97
96
96
94
93
96
97
97
98
98
95
95
98
94
92
97
94
94
94
95
95
95
94
95
97
93
94
93
97
96
93
97
93

97
91
97
97
95
86
96
93
96
93
98
96
95
92
95
97
93
97
95
95
91
97
96
94
96

97
96
97
95
93
97
96
96
97
98
98
98
95
98
96
94
97
95
96
97
98
95
96
96
95
96
93
93
90
97
97
93
97
93

98
91
98
97
95
87
95
92
95
94
97
95
94
89
97
98
93
98
97
96
90
96
95
94
97

96
97
97
96
95
96
97
98
96
98
98
99
95
98
96
93
97
92
95
95
97
97
95
96
94
96
94
95
92
96
96
93
98
92

Pulse

Patient01
Patient02
Patient03
Patient04
Patient05
Patient06
Patient07
Patient08
Patient09
Patient10
Patient11
Patient12
Patient13
Patient14
Patient15
Patient16
Patient17
Patient18
Patient19
Patient20
Patient21
Patient22
Patient23
Patient24
Patient25
Patient26
Patient27
Patient28
Patient29
Patient30
Patient31
Patient32
Patient33
Patient34
Patient35
Patient36
Patient37
Patient38
Patient39
Patient40
Patient41
Patient42
Patient43
Patient44
Patient45
Patient46
Patient47
Patient48
Patient49
Patient50
Patient51
Patient52
Patient53
Patient54
Patient55
Patient56
Patient57
Patient58
Patient59
Patient60

Preop
68
82
78
71
82
69
75
70
58
81
86
63
69
63
84
90
81
67
85
91
84
55
75
67
71

68
94
82
92
70
99
92
82
83
94
84
95
91
72
61
83
85
71
68
80
52
78
76
60
94
62
72
74
94
65
83
99
64
80

15min
71
96
82
67
79
67
76
71
60
83
86
66
80
57
76
86
77
59
89
90
82
54
77
64
72

55
94
76
86
72
89
107
72
76
80
73
93
87
56
62
82
83
70
67
79
51
75
80
58
88
54
73
67
86
63
88
88
74
75

30min
68
85
82
65
73
65
77
71
58
81
80
71
79
58
79
85
80
54
77
85
82
51
77
68
70

64
90
74
79
76
92
90
66
81
82
76
86
86
60
62
82
78
72
70
78
47
73
78
57
87
56
76
70
82
59
82
86
69
78

45min
68
94
79
73
74
61
74
68
66
82
88
63
81
58
81
91
69
55
85
86
80
46
78
64
68

59
96
73
83
72
89
82
69
67
81
68
83
89
66
61
79
75
68
71
61
53
70
78
55
86
57
75
72
83
56
84
91
74
76

60min
65
81
78
66
72
56
75
66
64
80
84
61
80
60
82
92
70
56
80
85
81
51
80
60
75

60
95
75
84
73
88
80
64
68
78
62
86
85
73
60
73
75
64
68
64
50
72
79
56
86
56
74
73
82
60
85
100
67
75

75min
66
87
77
68
75
54
76
68
63
81
83
62
78
63
76
90
72
55
81
86
80
60
77
61
72

68
96
72
78
74
89
82
62
69
80
64
88
88
65
59
72
74
64
70
75
53
77
81
56
89
58
73
70
78
62
81
92
70
78

90min
70
79
74
66
73
52
80
67
67
83
81
60
80
62
80
91
73
56
83
91
82
61
74
64
70

62
90
73
80
72
87
90
65
70
82
72
84
86
64
57
70
73
75
67
82
52
76
83
59
90
60
70
71
81
59
78
98
72
75


X.References:

1. AbrahamssonKH,BerggrenU,HakebergM,CarlssonSG.Theimportanceof
dentalbeliefsfortheoutcomeofdentalfeartreatment.EurJOralSci2003;
111:99105.
2. ScottDS,HirschmanR.Psychologicalaspectsofdentalanxietyinadults.JAm
DentAssoc1982;104:2731.
3. ArntzA,vanEckM,HeijmansM.Predictionofdentalpain:thefearofany
expectedevil,isworsethantheevilitself.BehavResTher1990;28(1):29
41.
4. vanWijkAJ,HoogstratenJ.Anxietyandpainduringdentalinjections.JDent
2009;37:7004.
5. WongM,LytleWR.Acomparisonofanxietylevelsassociatedwithrootcanal
therapyandoralsurgerytreatment.JEndod1991;17:4615.
6. PrabhakarA,MarwahN,Raju,O.Acomparisonbetweenaudioand
audiovisualdistractiontechniquesinmanaginganxiouspediatricdental
patients.JournalofIndianSocietyofPedodonticsandPreventiveDentistry
2007;25(4):177182.
7. LahmannC,SchoenR,HenningsenP,RonelJ,MuehlbacherM,LoewT,TrittK,
NickelMandDoeringS.BriefRelaxationVersusMusicDistractioninthe
TreatmentofDentalAnxiety:ARandomizedControlledClinicalTrial.JADA
2008;139:31724.

8. LaiHL,HwangMJ,ChenCJ,ChangKF,PengTC,ChangFM.Randomized
controlledtrialofmusiconstateanxietyandphysiologicalindicesinpatients
undergoingrootcanaltreatment.JClinNurs2008;17:265460.
9. SaxenMA,NewtonCW.Managingtheendodonticpatientwithdisabling
anxietyorphobia.JournaloftheIndianDentalAssoc.1999;78:213.
10. vanWijkAJ,HoogstratenJ.Reducingfearofpainassociatedwithendodontic
therapy.IEJ2006;39:384388.
11. ShobenEJandBorland,L.Anempiricalstudyoftheetiologyofdentalfears.J
ClinPsychol1954;10:171174.
12. EliI,UzielN,BlumensohnR,BahtR.Modulationofdentalanxiety:theroleof
pastexperiences,psychopathologictraitsandindividualattachment
patterns.BrDentJ2004;196(11):689694.
13. CorahNL.Developmentofadentalanxietyscale.JDentRes1969;48:596.
14. CorahNL,GaleEN,IlligSJ.Assessmentofadentalanxietyscale.JAmDent
Assoc1978;97:816819.
15. KvaleG,BergE,RaadalM.TheabilityofCorah'sDentalAnxietyScaleand
Spielberger'sStateAnxietyInventorytodistinguishbetweenfearfuland
regularNorwegiandentalpatients.ActaOdontolScand1998;56:105109.
16. GorensteinC,AndradeL.ValidationofaPortugueseversionoftheBeck
DepressionInventoryandtheStateTraitAnxietyInventoryinBrazilian
subjects.BrazJMedBioRes1996;29:453457.
17. FuentesD,GorensteinC,HuLW.Dentalanxietyandtraitanxiety:an
investigationoftheirrelationship.BrDentJ2009;206:E17.

18. HornblowAR,KidsonMA.Thevisualanaloguescaleforanxiety:avalidation
study.AustNZJPsychiatry1976;10(4):33941.
19. vanDuinenM,RickeltJ,GriezE.ValidationoftheelectronicVisualAnalogue
ScaleofAnxiety.ProgressinNeuroPsychopharmacology&Biological
Psychiatry32(2008)10451047.
20. CapraraHJ,EleazerPD,BarfieldRD,ChaversS.ObjectiveMeasurementof
PatientsDentalAnxietybyGalvanicSkinReaction.JOE2003;29(8):493
496.
21. Sorrell,JT,McNeil,DW,Gochenour,LL,Jackson,R.Evidencebasedpatient
education:knowledgetransfertoendodonticpatients.JournalofDental
Education,2009;73,12931305.
22. FrereCL,CroutR,YortyJ,McNeilDW.Effectsofaudiovisualdistraction
duringdentalprophylaxis.JAmDentAssoc2001;132:10318.
23. RamD,ShapiraJ,HolanG,MagoraF,CohenS,DavidovichE.Audiovisual
videoeyeglassdistractionduringdentaltreatmentinchildren.Quintessence
Int2010;41:6739.
24. BartfieldJM,JanikasJS,LeeRS.Heartrateresponsetointravenouscatheter
placement.AcadEmergMed.2003;10:10058.
25. GoerigM,SchulteamEschJ.HistoryofNitrousOxidewithspecialreference
toitsearlyuseinGermany.BestPractice&ResearchClinicalAnesthesiology.
2001;15:313338.
26. KleinknechtRA.TheAssessmentofDentalFear.BehaviorTherapy.1978;9:
626634.

27. http://highbloodpressure.about.com/od/prevention/f/anxietybp.htm
28. PeretzBandMoshonovJ.Dentalanxietyamongpatientsundergoing
endodontictreatment.JOE.1998;24:435437.
29. HmudRandWalshLJ.Dentalanxiety:causes,complicationsand
managementapproaches.JMinIntervinDent.2009;2:6778.