R E S E A R C H R E P O R T S
health trial w ith zin c-co n tain in g m o n o flu o ro p h o s-
p h a te dentifrices. J D ent Res 66(Special Issue) abstract
no. 164, 1987.
11. C onti, A., a n d others. Caries efficacy of tw o
fluoride dentifrices (1,000 vs 1,500 p p m F). J D ent Res
66(Special Issue) 66:258, abstract no. 1209, 258, 1987.
12. R adike, A.W. C riteria for d iagnosis of d ental
caries. In Proceedings o f the Conference o n C linical
T e stin g of C ariostatic A gents, C hicago, A m erican
D ental A ssociation, 1972, p p 87-88.
13. B ogopolsky, S.; A lbertini, H .; an d G oldberg,
W. E tude c lin iq u e d ’u n e pate (dentifrice) a h au te
ten eu r en fluoru res a M arseille. In V aillan t, J.M ., an d
Researchers asked 250 adults to respond to 25 dentist behaviors after receiving treatment.
Positive reactions were recorded in response to ten behaviors perceived to be associated
with anxiety reduction: specifically, empathy, friendliness, and communicativeness.
The dentist-patient relationship:
perceived dentist behaviors that reduce
patient anxiety and increase satisfaction
Norman L. Corah, P h D
Robert M. O ’Shea, P h D
G . Donald Bissell, D D S
Terrence J. Thines, D D S
Pauline Mendola
M a n a g in g p a tie n t a n x ie ty has
lo n g been a m ajor challenge for
the practicing dentist. A 1986
E m phasis re p o rt1 stressed th a t the den­
tist’s anxiety ab o u t the p atien t a n d the
p a tie n t’s anxiety about the dentist make
for a dental procedure that can be diffi­
cult for b o th of them . T he behaviors of
the d en tist in p atien t m anagem ent, p a r­
tic u la rly in c o m m u n ic a tin g w ith the
patien t, are considered im p o rta n t by m ost
ex p erts1 w ho stress b u ild in g rap p o rt by
u sin g various behavioral techniques to
p u t the p a tie n t at ease. Many dentists are
u n co m fo rtab le in d ea lin g w ith p a tie n t
anxiety a n d attem p t to avoid confronting
it.2 L ittle scientific research on the im pact
of specific dentist behaviors on p atient
anxiety is available.
Barm es, D., eds. Le P o in t Sur Le F lu r Sym posium ,
1982. In stitu t de S tom atologie et de C h iru rg ie M ax­
illo-Faciale, L a Salpetriere, Paris, 1984.
14. B arn au d , J., an d F in id o ri, C. Etude de l ’effica-
cite preventive d ’u ne pate a hau te teneur en fluorures.
J In t Assoc D ent C h ild 15(1):21-31, 1984.
15. G rain g er, R.M . A nalysis of caries increm ent by
ag e a n d to o th surface in flu o rid a te d a n d n o n ­
flu o rid ated p o p u la tio n s by electronic com puter. In
Jam es, P.; K önig, H .; H eld, H ., eds. Advances in fluo­
rin e research an d d e ntal caries p revention, voi 4.
L o n d o n , Perg am o n Press, 1966, p p 53-66.
16. B erm an, D.S., an d Slack, G .L . Caries experience
A recent em pirical study3 attem pted to
assess the relatio n sh ip between various
dentist behaviors, an d anxiety reduction
an d satisfaction of the patient. T h e d en ­
tist behaviors studied were narrow ed to
include only those perceived by the patient
as h av in g some im pact on them . Most
behaviors were associated w ith a m easure
of p atien t satisfaction; however, few were
associated w ith p atien t anxiety.
T hese in itial findings prom pted further
study of behaviors typically th o u g h t to
reduce p atien t anxiety. Researchers4 in ter­
viewed 60 ad u lt patients in a hospital
o u tp a tie n t clinic after dental treatm ent.
P atients were questioned ab o u t their n er­
vousness and how the dentist and assis­
ta n ts ) contribu ted to it. P atients were
also asked w hat they w ould do or say in
C orah-O thers : D E N T IS T -P A T IE N T R E L A T IO N S H IP ■ 73
re la tiv e to in d iv id u a l su sc e p tib ility . Br D ent J
135(2):68-70, 1973.
17. Jam es, P.M ., a n d others. A 3-year c linical trial
of a dentifrice c o n ta in in g 2% sodium m onofluoro-
p h o sp h ate . C om m u n ity D ent O ral E pidem iol 5(1 ):67-
72, 1977.
18. M itropoulos, C. DMFS(e) index for selection of
c lin ic al trial subjects. C om m u n ity D ent O ral E pide­
m io l 13(l):30-32, 1985.
19. A lm an, J.E . S tatistical an d e th ical considera­
tio n s in clinical trials. C om m unity D ent O ral E p i­
dem iol 8(5):267-272, 1980.
the d en tist’s place to ease p atien ts’ n er­
v o u sn ess. V erbal c o m m u n ic a tio n w as
often stressed by the patients. T hey gave
m ore th an 150 suggestions classified in to
12 categories. P atients frequently recom ­
m ended th at dentists: give in itia l ex p la­
n a tio n s of w h at was g o in g to h a p p e n
d u rin g the d ental procedure; give an in-
process e x p la n a tio n to let th e p a tie n t
know w hat is h a p p e n in g as it is g o in g
on; instruct the p atien t to be calm; w arn
the p a tie n t ab o u t p ain w hen it is likely to
occur; verbally su p p o rt the patient; try to
give the p atien t ways of lo o k in g at the
procedure in a less-threatening fashion
a n d p ro v id e c o a c h in g to m a k e th em
believe it is n o t as bad as they expect it to
be; provide distraction of atten tio n and
try to co m m unicate in ways th a t will
R E S E A R C H R E P O R T S

b u ild trust in the dentist. T hese resulting

suggestions led to the recasting of a list of Table 1 ■ Dentist behavior items (questionnaire).
d e n tis t b e h a v io r item s. T h e 25 item s D u rin g today’s visit, the d e n tis t. . .
developed are show n in T able 1.
1. w arned me w hen he felt the procedure m ig h t hurt.
Previous research5 show ed th a t 20% to 2. told me to be calm or to relax.
25% of the anxiety response to treatm ent 3. criticized my teeth or how I ’ve been tak in g care of them.
was determ ined by the p a tie n t’s general 4. m ade sure I was n u m b before w ork in g o n me.
anxiety ab o u t treatm ent w hen arriving at 5. show ed that he knew w h at I was feeling.
6. w orked quickly b u t d id n ’t rush.
the dental office. Therefore, it was deter­ was friendly to me.
7.
m in ed th a t it was necessary to assess the 8. encouraged me to ask q uestions a b o u t my treatm ent.
change in the p a tie n t’s anxiety that m ight 9. m ade me feel welcome.
be affected by the den tist’s behavior to 10. was p olite to me d u rin g my visit.
11. used w ords th a t were understandable in ta lk in g ab o u t m y dental care.
assess the relatio n sh ip appropriately.
12. told m e w h at he was g o in g to do before startin g to work.
T h is study attem pted to reassess a range 13. show ed that he p a id a tte n tio n to w hat I said.
o f d e n tist b eh av io rs—as perceived by 14. reassured me d u rin g the procedure.
p atien ts—to determ ine their role in reduc­ 15. asked d u rin g the procedure if I were h a v in g any discom fort.
in g p atien t anxiety and increasing satis­ 16. h a d a calm m anner.
17. asked d u rin g the visit if I were concerned or nervous.
faction. T h is investigation was conducted 18. gave m e a step by step e x p la n atio n of w h at he was d o in g as he d id it.
in large o u tp a tie n t dental clinics of two 19. show ed th a t he took seriously w h at I had to say.
h o sp itals to provide a potentially broad 20. was p a tie n t w ith me.
range of p atien t selection. A representa­ 21. carried o n casual conversation and sm all talk.
22. told me th a t if it started to h u rt, h e w ould relieve the pain.
tive response range was achieved from the
23. gave me m oral su p p o rt d u rin g the procedure.
clin ic’s diverse population. 24. let me know th a t h e ’d do everything he could to prevent pain.
25. smiled.
Methods and materials

O u tp atien ts were approached in the w ait­

in g room by a m em ber of the research
sta ff a n d asked to p a rtic ip a te . T h is
research assistant was identified clearly as
n o t b eing a dental clinic staff member.
P atients were n o t considered for p artici­
p atio n if they were present for a noninva-
sive procedure, were younger th an 18
years, o r were in severe pain. Patients
were offered $5 to participate; p articip a­
tion req u ired rem ain in g after they were
treated for 10 to 15 m inutes. O f the q u a li­
fied patients, less th a n 5% refused to
participate.
Before their dental procedures began,
p atients filled o u t the C orah D ental A nx­
iety Scale (DAS).6 After treatm ent, they
rated their anxiety on 7-point scales that
ranged from calm -relaxed to tense-upset.
T h ere were three scales labeled: before
treatm ent, d u rin g treatm ent, and now.
T h e three scales were presented together,
after treatm ent, for two reasons. First, it is
d ifficult to in te rru p t treatm ent to obtain
an anxiety rating. Therefore, an overall
ju d g m e n t of the experience seemed to be
preferable. Second, presenting the before,
d u rin g , a n d now scales together was
th o u g h t to encourage the patient into
m ak in g careful discrim inations of their
anxiety at the different points. T h e now
responses w hich were presented to enhance
anxiety d iscrim in atio n were n o t used in
analysis.
T h e respondents also answ ered a ques­
tio n n a ir e lis tin g 25 p o s s ib le d e n tis t
behaviors (Table 1), and com pleted the
D ental V isit Satisfaction Scale (DVSS).7
P atients responded to each of the 25 d en ­
tist behavior item s w ith yes or no to in d i­
cate w h e th e r th e d e n tis t sh o w ed th e
behavior; a question m ark was w ritten if
they were uncertain. For scoring purposes,
questio n m arks were always scored as a
negative response.
T h e DVSS w as d e s ig n e d to assess
respondents’ satisfaction w ith the dentist
in the context of a specific visit. Each of
ten item s has a L ik ert scale response for­
m at w ith five categories ran g in g from
strongly disagree to strongly agree. Items
are scored in a positive direction ran g in g
from one to five. T h e DVSS measures
satisfaction in three areas: inform ation-
c o m p re h e n sio n , u n d e rsta n d in g -a c c e p -
tance, a n d technical com petence. A total
satisfaction score is obtained from the sum
of the individual item scores. R eports of
the developm ent of the DVSS, in clu d in g
reliability and validity data, are available
elsewhere.7
A total of 250 dental p atients, 110 men
and 140 w om en, p articipated in the study.
T hey ranged in age from 18 to 75 years,
w ith a m edian of 30 years. M edian educa­
tion was h ig h school graduate, w ith a
range from co m pletion of th ird grade to
com pletion of 7 years of college. Fifty-six
percent of the sam ple were black an d 44%
were white. T h e d ental procedures for the
p atients o n the day of the interview were
extraction, 60%; restorations, 27%; end­
odontic treatm ent, 8%; an d other, 5%. T h e
classifications of the dentists providing
the service were staff m em bers, 6%; resi­
d en ts, 64%; a n d stu d e n ts, 30%. It was
estim ated th a t ap proxim ately 50% of the
clinic p o p u la tio n qualified for Medicaid
reim bursem ent.
Results
C orrelational analysis was used in this
study, w ith two m ajor dependent variables
of interest. T h e first was reduction in
anxiety from before treatm ent to d u rin g
treatm ent. T h is m easure was obtained by
subtracting anxiety d u rin g treatm ent from
anxiety before treatm ent. T h e ratings of
b o th anxiety an d dentist behaviors were,
of necessity, o b tain ed after treatm ent. T h e
other dependent variable was the total
satisfaction score from the DVSS. T h e
correlations between the perceived dentist
behavior item s an d these dependent vari­
ables are given in T ab le 2.
T e n of the 25 perceived dentist behav­
io r item s w ere co rrelated sig n ific an tly
(P < .05) w ith anxiety reduction. P atien t
anxiety reduction was linked to the per­
ception that the dentist was concerned for
the p a tie n t’s com fort, was em pathie, and
supportive (T able 2: item s 5, 15, 19, 23,
24). Anxiety red u ctio n was also linked to
the perception of a friendly, accepting,
an d reassuring d en tist (Table 2: item s 6,
7, 9, 16, 25). T h e change in anxiety scores
w as n o t asso cia te d w ith tr a it an x iety
before treatm ent—th a t is, w ith the DAS

74 ■ JADA, Vol. 116, Ja n u a ry 1988

 R E S E A R C H R E P O R T S

Discussion
Table 2 ■ Correlations between the dentist behavior items and patient anxiety
reduction and satisfaction (N = 250). A lth o u g h ten perceived dentist behaviors
were lin k ed to anxiety reduction, a subset
A nxiety T o tal
D entist behavior items red u ctio n satisfaction
of six behaviors ap p ear to be m ost in flu ­
ential. T h e m ost im p o rtan t behavior is
1. W arned m ig h t h u rt .08 .17*
2. T o ld m e to be calm .05 .07
the d en tist’s dedication to prevent pain .
3. C riticized teeth -.04 .03 M ost of the other behaviors—being friend­
4. M ade m e n u m b .09 .32+ ly, n o t ru sh in g , being calm , g iv in g m oral
5. Knew my feelings .16* .37+ support, an d p ro m isin g relief sh o u ld p ain
6. W orked quickly .19f .15*
o cc u r—can be viewed as p ro v id in g a
7. Was friendly .211 .20+
8. E ncouraged q uestions .09 .33+ behavioral context in su p p o rt of prevent­
9. W elcom ing .16* .29+ in g pain.
10. Polite .08 .32+ T h e patient-perceived dentist behaviors
11. Was u n d erstan d ab le -.03 .17* m ost associated w ith p atien t satisfaction
12. T o ld m e procedure .12 .23+
13. P aid atte n tio n to me .05 .23+
were those p o rtray in g em pathy, friendli­
14. R eassured me .11 .32+ ness, an d a calm an d com petent im age to
15. Asked a b o u t discom fort .15* .30+ the p atient. T w o items, h aving a calm
16. H a d calm m an n er .15* .34+ m an n er, an d dedication to prevent p ain ,
17. Asked a b o u t anxiety .07 .31+
are the only behaviors significant to b oth
18. O n g o in g e x p la n atio n .09 .24+
19. T o o k m e seriously .22+ .33+ d ependent variables. These scored behav­
20. P atien t w ith m e .03 .32+ iors are the sole lin k betw een anxiety an d
21. C onversation .11 .31+ satisfaction in this study, an d are consis­
22. Reassured a b o u t p a in -.01 .24+ ten t w ith o u r previous findings th a t no
23. M oral su p p o rt ,2 3 f .33+
24. Prevent p a in .25f .36+
s ig n ific a n t c o n n e c tio n ex ists b etw een
25. Smiled -18+ .36+ p a t ie n t s a tis f a c tio n a n d th e a n x ie ty
m easures.3
•P < .05. It is assum ed th a t b oth anxiety reduc­
tP<.01.
tio n a n d s a tis fa c tio n are im p o r ta n t
m ed iatin g variables leading to p atien t
scores (r = .12, P = NS). M ost of the d en ­ D entist behaviors, therefore, account for a com pliance w ith dental regim ens such as
tist behavior item s were related signifi­ statistically significant p art of the rela­ reg u lar visits an d preventive hom e care.3
cantly (P < .05) to the total satisfaction tionship w ith the two dependent variables. A careful assessm ent of this assum ed rela­
scores from the DVSS (Table 2). However, anxiety reduction a n d satisfac­ tio n sh ip has n o t been conducted. S u rp ris­
S eparate stepw ise m ultiple-regression tion is determ ined by factors other than in g results include the lack of association
analyses were conducted for each of the those assessed in this study for a num ber between anxiety reduction and satisfaction
two dependent variables. Variables were of dependent variables actually used in since it is com m only assum ed th at reduc­
retained in the analyses only if they co n ­ this study. in g p atien t anxiety should be satisfying
tributed significantly (P < .05) to the vari­ T here appears to be no relatio n sh ip to the patient.
an ce afte r a d ju s tm e n t (for p rev io u sly betw een th e assessm ent of satisfactio n T h e r e la tio n s h ip betw een p erceiv ed
extracted variables). T h e results of the (D V SS) a n d a n y of th e m e a su re s of dentist behaviors an d anxiety reduction
m ultiple regression analyses for the depen­ anxiety. F or ex am p le, the re la tio n sh ip has n o t yet been tested in a causal fashion,
dent variables are given in T able 3. betw een to ta l sa tisfac tio n a n d anxiety for exam ple, tra in in g dentists to use cer­
T h e results show n in T able 3 indicate before treatm ent, d u rin g treatm ent, and tain behaviors a n d then m easuring the
th at six perceived dentist behaviors con­ anxiety reduction are n ot significant. effects on their patients.
tributed significantly to anxiety reduction
w hile seven perceived dentist behaviors
Table 3 ■ Dentist behavior items accounting for most variation in anxiety reduction
co ntributed significantly to the total satis­ and dental visit satisfaction —stepwise multiple regression analyses.
faction score. O nly two items appear in
D ependent
b oth analyses: calm ness of the dentist,
variable D entist behavior item M ultip le r
an d reassurance concerning prevention of
A nxiety reduction 24 prevent p a in
pain. A ccording to the interviews, items
7 was friendly
co n trib u tin g to anxiety reduction often 6 w orked q u ick ly
include the d en tist’s prom ise to control 16 had calm m a n n e r
p ain and prevent discom fort, and provid­ 23 m oral su p p o rt
22 reassured a b o u t p a in .42
ing reassurance. T h e m ajor item s contrib­
u tin g to satisfaction appear to be friend­ T o ta l satisfaction score 5 knew my feelings
25 sm iles
liness, em pathy, and the general dem eanor
4 m ade me n u m b
of the dentist. 16 had calm m an n er
It sh o u ld be noted that dentist behav­ 17 asked a b o u t anxiety
io rs (T a b le 3) assessed in th is stu d y 24 prevent p a in
a c c o u n t for o n ly 18% of re d u c tio n in 2 told me to be calm .61

anxiety and 37% of p atien t satisfaction.

C orah-O thers : D E N T IS T -P A T IE N T R E L A T IO N S H IP ■ 75
R E S E A R C H R E P O R T S
Summary
T h is stu d y re la te s p erc eiv e d d e n tis t
behaviors to anxiety reduction in patients
d u rin g treatm ent, an d to satisfaction w ith
the dental visit. T h e sam ple consisted of
250 ad u lt p atien ts, 110 m en and 140
w om en, at tw o o u tp a tie n t h ospital dental
c lin ic s . Im m e d ia te ly a fte r tre a tm e n t,
p atien ts were asked to respond to a list of
25 dentist behaviors th o u g h t to be asso­
ciated w ith positive d entist-patient inter­
action. C riterion m easures obtained by
patien ts were self-ratings of anxiety d u r­
in g treatm ent a n d satisfaction measures
from the DVSS.
T en behaviors were significantly asso­
ciated w ith anxiety reduction. A stepwise
m u ltip le regression analysis w ith anxiety
reduction as the dependent variable in d i­
cated th a t to the patient, the d en tist’s
explicit dedication to prevent pain was
the m ost im p o rta n t dentist behavior, w ith
friendliness, w orking quickly, being calm,
76 ■ JADA, Vol. 116, Ja n u a ry 1988
and giving m oral su p p o rt, b eing im p o r­
tant auxiliary behaviors.
Most of the 25 dentist behaviors studied
were associated w ith p atien t satisfaction.
A stepwise m u ltip le regression analysis
indicated th a t the d en tist’s em pathy and
com m unicativeness were am o n g im p o r­
tant correlates of p atien t satisfaction. An
experim ental ap p ro ach to causal analysis
of anxiety reducing behaviors needs to be
studied.
-----------------------J l i O A ------------------------
T h e inform ed co n sen t of all subjects w ho p a rtic i­
pated in this study was obtained after the n atu re of
the procedures had been fully explained.
T h is research was supported, in part, by research
g ra n t no. DE 04494, N atio n al In stitu te of Dental
Research.
T h e au th o rs th an k the staff m em bers of the Buffalo
G eneral H o sp ital, a n d Deaconess H o sp ital Dental
C linics for th eir assistance w ith this project.
Dr. C orah is professor, behavioral sciences, School
of D ental M edicine; Dr. O ’Shea is associate professor,
social an d preventive m edicine, School of M edicine;
Dr. Bissell is associate professor, pu b lic h ealth d en tist­
ry; Dr. T h in e s is assistan t professor, oral m edicine;
an d Ms. M endola is research assistant, behavioral
sciences, School of D ental M edicine, State U niversity
of New Y ork at Buffalo, Squire H all, Buffalo, NY
14214. Address requests for reprints to Dr. C orah.
1. G iangrego, E. C o n tro llin g anxiety in the dental
office. JADA 113(5):728-735, 1986.
2. C orah, N .L .; O ’Shea, R.M.; an d Ayer, W.A.
D en tists’ m anagem ent of p atien ts’ fear an d anxiety.
JADA 110(5):734-736, 1985.
3. C orah, N .L .; O ’Shea, R.M.; and Bissell, G.D.
T h e d e n tis t-p a tie n t re la tio n sh ip : p ercep tio n s by
p atien ts of d entist behavior in relation to satisfaction
an d anxiety. JA D A 111 (3):443-446, 1985.
4. O ’Shea, R.M .; C orah, N .L .; an d T h in es, T .J.
D ental p a tie n ts’ advice on how to reduce anxiety. G en
D ent 34(1 ):44-47, 1986.
5. C orah, N .L. M ethodological needs an d behav­
io ral research w ith a d u lt d ental p atients. Anesthes
P ro g 33(1 ):46-49, 1986.
6. C orah, N .L. D evelopm ent of a dental anxiety
scale. J D ent Res 48:596, 1969.
7. C orah, N .L ., a n d others. D evelopm ent o f a
p a tie n t m easure of satisfaction w ith the dentist: the
dental visit satisfaction scale. J Behav Med 7(4):367-
373, 1984.