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Psychological Reports, 1990, 67, 371-377.

O Psychological Reports 1990

ANXIETY AND BLOOD PRESSURE PRIOR


TO DENTAL TREATMENT '
CARMEN BENJAMINS AND ALBERT H. B. SCHUURS

Department of Cariology and Endodontology, Academic Center for Dentiztry, Amsterdam


HENK ASSCHEMAN

JOHAN HOOGSTRATEN

Department of General Pathology


and Internal Medicine

Department of
Social Dentistry

Academic Center for Dentistry, Amzterdam


Summary.-In the present study dental anxiety and blood pressure were assessed
immediately prior to a dental appointment to assess the relationship between selEreported dental anxiety and blood pressure. Blood pressure was assessed by two independent methods, and the inte~hangeabllityof the blood-pressure measurement methods was also assessed. No relationshp was demonstrated among scores on three dental
anxiety questionnaires and blood-pressure values. The blood-pressure measurement
methods delivered comparable values lor diastolic and mean arterial blood pressure
only.

The prospect of a dental visit can evoke feelings of anticipation anxiety


(Weiner, 1980). Some patients appear to be extremely afraid of even a checkup, while others do not seem to be tense prior to the extraction of a tooth.
Given its anticipatory character, the strength of dental anxiety may be
assessed before the actual encounter with the dentist.
Anxiety may be assessed in three ways, i.e., psychologically, behaviorally
and physiologically. The results of these three assessment methods are not
highly associated. This lack in strength of relationship may be explained by
the differing times needed for the development of the cognitive, the physiological, and the behavioral signs of stress. Also, incomplete measures, such as
noncontinuous monitoring of physiological processes, may be misleading
(Burchfield, 1985). The behavioral signs of anxiety are, in contrast with children, rare in adults, therefore the psychological and physiological assessments
are to be preferred in studies involving adults (Melamed, 1979). Psychological signs of anxiety are registered by, among others, self-report inventories.
Among the physiologic signs of anxiety a rise in the systolic blood pressure is
mentioned (Hasset & Danforth, 1982).
In contrast to nonanxious dental patients, anxious ones are said to show
heightened blood pressure levels before treatment (Ge&b, Papp, & Tbth,
'The assistance of P C. Makkes and J. A. Kieft is gratefully acknowledged. Re uests for
reprints should be sent to Carmen Benjamins, Department of Cariology and ~ n d o j o n t o l o ~ ~ ,
Academic Center for Dentistry, Amsterdam, Louwesweg 1, 1066 EA Amsterdam, The
Netherlands.

372

C. BENJAMINS, ETAL.

1972). In other research, however, no significant relations were found


(Boelens & Rozema, 1984; Beck & Weaver, 1981; Goldstein, Diome, Sweet,
Gracely, Brewer, Gregg, & Keiser, 1982), which apparent discrepancy is
probably due to differences in research designs. First, the self-report questionnaire used in these studies was the state part of the State-Trait Anxiety
Inventory which has only a moderate (r= .48) correlation with the Dental
Anxiety Scale (Weisenberg, Kreindler, Schachat, & Werboff, 1974;
Weisenberg, Kreindler, & Schachat, 1975). The latter is specially designed
for the dental situation (Corah, 1969; Corah, Gale, & TJlig, 1978). Second,
the use of an intermittent registration method for the strongly fluctuating
blood-pressure signal may not reveal all the relevant changes.
The aims of the present study were to investigate (1) the relationship
between self-reported dental anxiety on the one hand and blood pressure as
assessed by a dlscrete (sphygmomanometer) and a recently developed noninvasive continuous ( ~ i n a ~ r e s method
~)'
on the other hand and (2) the
interchangeability of both blood-pressure measurement methods.

METHOD
Subjects

Patients originated from two clinics for dental care, namely, the clinic
for special dental care for extremely anxious patients and a university clinic
(UvATZ). Data were collected from 29 patients, just before dental treatment.
Three patients were excluded because they had an history of high blood
pressure and two because there was a technical failure or data were missing.
The data of 24 dental patients of mean age 32.5 yr. ( f 10.7) were used for
analysis. This group of patients included 10 men of mean age 30.5 yr.
( k 9 . 0 ) and 14 women of mean age 33.9 yr. ( + 11.8). Ten patients visited
the dentist for a checkup, 12 for restorative treatment, and three for extraction of a tooth. ALl patients were seen between 9 and 11 p.m. to adjust for
diurnal fluctuations in blood-pressure values.
Materials

~ i n a ~ r readings
es~
of systolic and diastolic blood pressure were taken for
10 min. from the left index finger according to instructions in the manual.

Before and after the Finapres readings systolic and diastolic blood pressure
were determined with a sphygmomanometer and cuff from the left upper
arm. The disappearance of the Korotkoff-sounds represented the diastolic
pressure. Next, all subjects completed three self-assessment inventories for
dental anxiety. First, the short version of the recently developed inventory
for fear of dental treatment, K-ATB (Stouthard, 1989), was administered.
'Ohmeda, Madison, WI, USA.

373

DENTAL ANXIETY AND BLOOD PRESSURE

This scale, which scores range from 9 (no anxiety) to 45 (extreme dental anxiety) has been proven v&d and reliable in some large scale studies
(Stouthard, 1989). The next questionnaire was the Dental Anxiety Scale, on
which scores range from 4 (no anxiety) to 20 (extreme dental anxiety) and
which has also been proven valid and reliable in large scale studies in the
United States (Corah, 1969; Corah, et a/., 1978) and in the Netherlands
(Eijkman & Orlebeke, 1975; Stouthard, 1989). Thereafter the patients were
presented a question to assess the duration of psychophysiological reactions
prior to a dental appointment (Schuurs, Duivenvoorden, Thoden van Velzen,
& Verhage, 1981). The scores range from one (a few days or longer before
the dental appointment) to seven (none at all). The scores were recoded so
that score of one represents a low and score of seven a high anxiety level.
The two sphygmomanometer pressure readings were combined to a
mean value because many people tend to respond with an heightened blood
pressure to the measurement itself. This mean value was also used in the
calculation of mean arterial pressure [Pmean = Pdia + 1/3(Psys - Pdia)]. The
values for systolic and diastolic pressures of a period of 30 sec. from the
Finapres reading were combined to a mean value which was also used to calculate mean arterial pressure. The 30-sec. period was extracted from the
record between time 3 min., 30 sec. and 4 min., 30 sec. This extraction of a
30-sec. period out of a 60-sec. period was done because the calibration cycles
in the recorded signal necessary to compensate for the influence of smooth
muscle tone in the arterial wall were unevenly spaced.

Table 1 shows the mean scores on the questionnaires and the Pearson
product-moment correlations between their scores. The correlations among
TABLE 1
MEANSCORESO N DENTALA ~ m Snc m , K-ATB A N D DURATIONOF
PSYCHOPHYSIOLOGICAL
REACTIONS
A N D T a m PWU~SON
PRODUCT-MOMENT
INTERCORRELATIONS
Dental
Anxiety

K-ATB*

Reacuons

Scale

Range
4-20
M SD
11.1 3.8
Dental Anxiety Scale
K-ATB
*K-ATB =Inventory for Fear of Dental Treatment.
tp < ,001.

Duration
Psychophy~iologicd

9-45
25.9 9.7
.94t

1-7
3.1k2.1
.83t
.80t

scores on the three questionnaires are high and significant. The respective
standard errors of the scores on the K-ATB and the Dental Anxiety Scale are
2.3 and 0.9. The internal consistency (Cronbach alpha) and the split-half re-

374

C. BENJAMINS, ET AL.

liability corrected for test length are .92 and .93 for the K-ATB and .93 and
.88 for the Dental Anxiety Scale.
Pearson coefficients did not reach significance for the association between the questionnaire scores and age. Sex was coded one for men and two
for women. Pearson correlation coefficients (Nunnally, 1967) indicated significant relationships with sex for the scores on the Dental Anxiety Scale
(r = -.45, p = .03) and the duration of psychophysiological reactions (r = -.48,
p = .02), but not for the K-ATB ( r = -.35, p = .09). Men tended to be somewhat more afraid than women.
The mean values for both blood-pressure measurement methods are
shown in Table 2. These blood pressure values were not related to age, sex,
or time of the day. The Pearson product-moment coefficients ranged from
-.32 to .36 (p>.05).
TABLE 2
MEANVALUESFORSPHYGMOMANOMETER
AND FINAPRES
BLOODPRESSURE

Sphygmomanometer
Systolic blood pressure
Diastolic blood pressure
Mean arterial blood pressure
Finapres
Systolic blood pressure
Diastolic blood pressure
Mean arterial blood ~ressure

SD

Range

119.9
75.3
90.2

11.2
7.8
7.8

99.0-139.0
60.5- 92.0
76.0-106.7

131.9
72.4
92.2

21.6
12.1
14.9

85.2-165.3
48.3- 97.4
60.6-116.3

These Pearson coefficients did not show an association between any of


the questionnaire scores on the one hand and any of the blood-pressure
values on the other hand. Correlations ranged from -.27 to .15 ( p > .05).
The sphygmomanometer and Finapres values differed significantly for systolic
blood pressure (paired t test; t = 2.99, p = ,007) but not for diastolic (t = 0.95,
p = .35) or for mean arterial pressure (t = -0.62, p = .54).

D~scussro~
The mean Dental Anxiety Scale score (11.2) is higher than the mean
scores 8.89 and 9.8 reported by other researchers in their studies with students (Corah, 1969; Corah, etal., 1978; Stouthard, 1989) and a score of 9.3
registered with inhabitants of a Dutch city (Schuurs, et al., 1985). Also, dental emergency patients scored 10.5 on the Dental Anxiety Scale (Weisenberg,
et a / . , 1974). The values for Cronbach alpha and the split-half reliability are
high. The internal consistency and reliability of both the K-ATB and the
Dental Anxiety Scale for this population are good. In this study we found a
mean score of 3.1 on the question concerning the duration of psychophysiological reactions, which is higher than the mean score of 2.3 found among

DENTAL ANXIETY AND BLOOD PRESSURE

3 75

patients of a Dutch town (Schum, et al., 1985), so it seems warranted to


conclude that the subjects in this study show somewhat more dental anxiety
than the respondents in the studies just cited. The relatively high questionnaire scores in this study are, of course, related to the participation of
subjects who were known to be highly anxious. The K-ATB, Dental Anxiety
Scale, and duration of psychophysiological reactions probably measure more
or less the same construct of dental anxiety. They may be differentially sensitive, however, to specific aspects of dental anxiety. The men in this study
appear to be somewhat more anxious than women, which contrasts with data
of other studies (Corah, et al., 1978; Schuurs, et al., 1985). The selectivity
of the sample may be responsible for this unexpected finding.
The values of the registered systolic and diastolic blood pressures, as
measured with both methods, fall within the range of standard values of a
population between 30 and 50 yr. of age (Boelens & Rozema, 1984).
No association was found between scores on the self-report questionnaires of dental anxiety and the blood-Pressure values just before a dental
visit. In case of the discrete (sphygmomanometer) method, this result is in
line with those reported elsewhere (GerCb, et al., 1972; Hasset & Danforth,
1982). The Finapres method has never been used to evaluate the relation between verbally reported dental anxiety and blood pressure. Despite the
capacity of this method to assess the fluctuations and therewith the range of
the blood-pressure signal more precisely, it only confirms prior data.
A significantly different systolic pressure was observed for the two
measurement methods. At the finger, pressure is 10 mmHg higher than the
pressure measured at the arm. Both the diastolic and mean arterial pressures
were more alike than in another study (Wesseling, et al., 1985), so the registration methods appear to be compatible only when used for assessment of
diastolic and mean arterial pressures.
The blood-pressure difference between arm and finger is the consequence of distortion of the pressure waveform (Brener & Kleinman, 1970)
and results in, among other things, an amplification of the pulse wave and
a small decrease in the mean arterial blood pressure. Amplification depends
on peripheral resistance, heart rate and age (Wesseling, Settels, Hoeven,
Nijboer, Butijn, & Dorlas, 1985). The range of the observed blood-pressure
values in the present study is much larger than the range reported by
Wesseling, et al. (1985). This difference may be related to measurement conditions. In the present study, the patients were awake but requested to keep
still while the patients in the study of Wesseling, et al. (1985) were anaesthetized and respired artificially. Respiratory manoeuvres as sighing, breath
holding, and speech result in heightening of the finger pressure through influence of the baroreflex on peripheral resistance (Brener & Kleinman, 1970;
Wesseling, et al., 1985).

376

C. BENJAMINS, ETAL.

In s u m m a r y , from t h e r e s u l t s of t h i s s t u d y i t is concluded t h a t no relat i o n s h i p e x i s t s between s e l f - r e p o r t e d d e n t a l a n x i e t y and blood p r e s s u r e . We


a d d , h o w e v e r , t h a t a n i n t e r e s t i n g line of f u r t h e r research seems a study
which c o r r e c t s for i n d i v i d u a l v a r i a t i o n s in physiological resting levels and act i v a t i o n , as is s u g g e s t e d b y Wilder (1962).
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Accepted August 3, 1990.

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