Dental Anxiety as a Multidimensional Phenomenon: A Mixed-Methods Study of Adult Dental Patients

Background Dental anxiety is a common barrier to dental care, but it is rarely examined as a multidimensional construct encompassing anticipatory, situational, procedural, physiological and relational components together. This study examined how these dimensions relate to one another and to patients' sociodemographic characteristics and dental attendance, and explored patients' own accounts of what makes dental care more or less anxiety-provoking. Methods A cross-sectional mixed-methods study was conducted with 135 adult dental patients recruited from a Brazilian public university dental clinic, primary care units and private practices; sample size was based on a pilot study (n = 50) and power calculations for detecting moderate Spearman correlations (α = 0.05, power = 0.80). Data were collected with a purpose-built questionnaire combining closed five-point Likert items, organized into five conceptual domains, and open-ended questions. Internal consistency was assessed with Cronbach's alpha. Associations between domains and between total anxiety score and visit frequency were examined with Spearman's correlation; gender differences were examined with the Mann-Whitney U test. Open-ended responses underwent thematic content analysis, with quantitative and qualitative findings subsequently integrated. Results Most participants were women (76.3%). Four of the five anxiety domains (anticipatory, situational, sensory/procedural, and modulating factors) showed adequate internal consistency (α = 0.72–0.86) and were strongly intercorrelated (ρ = 0.68–0.80, p < 0.001); the physiological-symptoms domain was retained descriptively but excluded from correlational analysis due to a strongly skewed distribution. The total anxiety score (range 5–25; median 12, IQR 8–18) was significantly higher among women (median 13) than men (median 9; Mann-Whitney U = 2271, z = 3.22, p = 0.0013, r = 0.28), and was not significantly associated with annual visit frequency (ρ = -0.087, p = 0.314). Thematic analysis of open-ended responses yielded eight categories, most prominently communication and procedural predictability, and the professional-patient relationship. Integrating both strands of data showed that communication- and relationship-related items were the most consistent link between the quantitative and qualitative findings, while appointment avoidance, mentioned qualitatively as a coping strategy, was not reflected in the quantitative visit-frequency data, a discrepancy attributable to sampling only patients who had, in fact, attended care. Conclusions In this sample, four of the five measured domains of dental anxiety showed strong intercorrelation, suggesting that anxiety may be expressed through closely related anticipatory, situational, procedural, and relational components, although this study did not perform a formal test of dimensionality such as factor analysis. Communication, procedural predictability and the quality of the professional-patient relationship emerged, in both the quantitative and qualitative data, as the factors most consistently associated with lower reported anxiety. These findings support prioritizing relational and communicational strategies in the clinical management of anxious adult patients, and caution against inferring true avoidance behavior from studies that, like this one, sample only patients already attending care.