Managing Fear and Anxiety in Patients Undergoing Dental Hygiene Visits with Guided Biofilm Therapy: A Conceptual Model

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This research can be directly applied in the development of more efficient dental biofilm management techniques, enhancing the effectiveness of preventive dental care. Specifically, the insights from our study could be used to improve the protocols of Guided Biofilm Therapy, potentially reducing the anxiety associated with dental hygiene visits and improving patient outcomes.

Abstract

Fear and anxiety during dental visits are common issues that can lead to avoidance of appointments and deterioration of oral health. Effectively managing patients’ emotions during dental treatments is crucial to improving their experiences, increasing adherence to regular visits, and achieving better treatment outcomes. This study aimed to assess the levels of fear and anxiety in patients undergoing hygiene treatments utilizing Guided Biofilm Therapy (GBT) and identify factors that could reduce these negative emotions. A total of 247 patients were evaluated using standardized questionnaires (MDAS, STAI X1, STAI X2, and Gatchel), custom questions, and heart rate monitoring as a physiological stress indicator. Clinical factors, including dental status confirmed by AI-based radiographic analysis (Diagnocat system), as well as sociodemographic influences, were analyzed. Results indicated significant reductions in fear and anxiety after the procedure, as shown by both heart rate and questionnaire scores. Factors such as pain, the presence of caries, and implants were linked to higher anxiety, while strategies like avoiding visible needles and postprocedure interaction with staff were associated with lower stress levels. The findings underscore the importance of personalized care and emotional support to enhance patient experiences.

1. Introduction

1.1. Background and Significance of the Problem

Dental visits are often accompanied by emotions, including fear and anxiety [1,2,3], which may manifest as a state of dentophobia [4].

Scientific literature over the last decade describes dental anxiety as the fourth most common type of anxiety, confirming its prevalence in society [5]. Studies estimate that a high level of anxiety, including dentophobia, is recorded in 5–20% of the adult population [6,7].

Anxiety may be irrational, arising in response to an imagined threat or an exaggeration of stress factors, being excessive and unwarranted [8].

Among the causes of anxiety disorders, individual susceptibility, social factors, and environmental influences are noted.

The persistently high incidence of caries and periodontal diseases in Poland [9], along with increased life expectancy and improved quality of life [10], indicates that there is a growing need for dental treatment and for attending regular hygiene visits (professional teeth cleaning).

Thus, fear and anxiety about dental visits are common problems that can affect the frequency and quality of patient visits.

The ability to identify negative emotions in individuals attending dental hygiene visits can contribute to effectively directing the dental team’s actions to reduce the risk of experiencing fear, anxiety, and dentophobia. A review of the provides numerous publications analyzing anxiety experienced before dental treatment.

These studies indicate that dental anxiety can have various sources, including previous negative experiences, individual susceptibility to anxiety, social factors—such as familial and cultural attitudes toward dental care—and environmental influences, like the design of the dental clinic, the sounds of dental tools, and interactions with staff. It is important to note that this anxiety can lead to the avoidance of dental visits [11,12], which in turn contributes to the deterioration of oral health, including the development of caries and periodontal diseases. Furthermore, patients with high levels of anxiety often require more advanced treatment, which can intensify their anxiety, creating a vicious cycle [13].

Although most studies focus on anxiety associated with more invasive dental procedures, there is a growing interest in studying anxiety during routine hygiene visits. These visits, though less invasive, can evoke similar emotions. They may stem from fear of pain, discomfort, or negative evaluation by the dentist or hygienist.

However, there are few studies on the fear and anxiety experienced by patients before hygiene (preventive) visits, which should occur frequently to prevent the need for later interventional and therapeutic procedures.

Guided Biofilm Therapy (GBT) (Figure 1) is a modern and potentially more comfortable [14] method of dental prophylaxis that is gradually replacing traditional techniques. Given this shift, it is important to assess how GBT procedures impact patient anxiety levels. This study aims to explore the effect of GBT on reducing anxiety during hygiene procedures, focusing on how this innovative and more comfortable technique may improve patient experience and adherence to preventive care. By investigating the role of GBT in alleviating dental anxiety, we aim to contribute to better patient outcomes and overall oral health at a population level.

Guided Biofilm Therapy (GBT) technology is a modern preventive method that focuses on the removal of bacterial biofilm using specialized tools and techniques (Figure 2). The procedure involves eight defined steps performed by the clinician.

Traditional methods for removing dental deposits did not provide tools, agents, and the capability to remove biofilm, including subgingival biofilm, focusing solely on supragingival tartar. In contrast, GBT utilizes a minimally invasive, patented technology that combines the staining and removal of plaque, tartar, and deposits to effectively eliminate biofilm without damaging hard and soft tissues. This innovative approach is based on scientific findings that soft biofilm (Figure 3)—dental plaque—is the primary etiological factor in caries, gum and periodontal diseases [15,16], and also influences the progression of systemic diseases such as atherosclerosis, respiratory diseases, diabetes, and heart diseases [17].

In contrast to available studies that focused on anxiety management methods related to conventional preventive procedures, this study introduces an innovative approach through the use of Guided Biofilm Therapy. The knowledge gained could be particularly valuable, as GBT is increasingly being offered in dental practices.

In addition to assessing patient anxiety, accurate diagnosis of dental health status is crucial in understanding the clinical factors contributing to anxiety. For this purpose, we utilized the Diagnocat AI program, an advanced diagnostic tool that enhances the precision of radiographic analysis. The Diagnocat AI program is an advanced diagnostic tool based on artificial intelligence, used for analyzing radiographic images in dentistry. Diagnocat employs machine learning algorithms to automatically detect pathologies such as caries, periodontal issues, and abnormalities in bone structures, significantly enhancing the accuracy and efficiency of diagnoses. With integration into radiological systems, Diagnocat supports dentists by enabling rapid and precise diagnostic conclusions and monitoring treatment progress. The literature suggests that Diagnocat AI is an effective tool in clinical practices, enhancing diagnostic accuracy and aiding treatment planning. For instance, studies demonstrate that Diagnocat achieves high sensitivity (up to 92.3%) and specificity (up to 97.87%) in detecting periapical changes in radiograms [18,19]. The diagnostic accuracy for other qualitative features remains under-researched and underanalyzed, and is continually refined through ongoing machine learning.

Undoubtedly, dentists using Diagnocat can benefit from the ability to standardize measurements, reduce subjectivity, and ensure consistent diagnostic results [20]. However, it is emphasized that final diagnostic decisions should be made by the clinician, taking into account the full clinical context of the results, as was the case in the conducted study.

1.2. The Objectives of the Study Were

• To analyze the levels of fear and anxiety among patients attending dental hygiene visits,
• To analyze the relationships between anxiety and the factors studied,
• To attempt to identify key prognostic factors and develop a conceptual model.

2. Materials and Methods

The study was cross-sectional and prospective in nature. The protocol and subject matter were approved by the Bioethics Committee of Karol Marcinkowski Medical University in Poznań. Inclusion and exclusion criteria were established to ensure objectivity and a broad cross-section of the study population. Patients were consecutively included in the study who underwent oral hygiene procedures under the Guided Biofilm Therapy protocol from September 2023 to January 2024. These were patients of the multichair Kwiatek Dental Clinic in Poznań. Each patient’s procedure was carried out in accordance with uniform standards of admission and performed by three dental hygienists with comparable clinical experience.

2.1. Inclusion Criteria

The inclusion criteria for this study were:

• Aged 18 years and above,
• Ability to respond,
• Consent to participate in the study,
• Scheduled for an oral hygiene visit (hygiene treatment),
• Recent radiographs are available (as shown in Figure 4).

2.2. Exclusion Criteria

The exclusion criteria for this study included:

• Under 18 years of age,
• Inability to respond,
• Legally incapacitated individuals,
• Lack of consent to participate in the study.
• The study also considered differences between returning and new patients, as the literature suggests that returning patients may experience greater levels of anxiety. Although the study was cross-sectional and prospective in nature, a quasi-randomization process was implemented to minimize bias in patient selection. Patients were invited to participate in the study based on the order in which they scheduled their oral hygiene procedures, in accordance with the Guided Biofilm Therapy protocol. This order was determined based on the registration list, which prevented any preferential selection of patients by the clinic staff.
• In the study, steps were taken to minimize bias, including the standardization of procedures to ensure consistent treatment of patients and the analysis of results by independent researchers without access to personal data. Additionally, statistical analysis included adjustments for potential confounding factors, such as age, gender, and oral health status.

2.3. Sample Characteristics

A total of 277 individuals were invited to participate in the study; however, the lack of complete data at various stages of the research meant that the study was ultimately conducted on a group of 247 patients who attended the hygiene visits (Figure 4).

Clinical data regarding dental status were confirmed by clinicians and the Diagnocat system (Diagnocat Ltd., San Francisco, CA, USA), which analyzed panoramic radiographs (Figure 5).

Hygiene procedures (referred to in this study as “hygiene” or “procedure”) were performed using the Guided Biofilm Therapy (GBT) protocol with the AirFlow Prophylaxis Master device (EMS Dental, Switzerland) and a dedicated AirFlow nozzle (Figure 6A) and Piezon (Figure 6B), and in selected clinical situations, the PerioFlow nozzle.

2.4. Methods

2.4.1. Measures of Fear and Anxiety

The levels of fear and anxiety were measured using standardized questionnaires.

Dental Anxiety

Dental anxiety was measured using the Modified Dental Anxiety Scale (MDAS), which includes 5 questions related to emotions associated with the anticipation of a dental visit and planned procedures. Each question begins with the phrase “how would you feel?”, and the patient’s responses are categorized into 5 levels, each assigned a specific score: calm (1 point), slightly nervous (2 points), nervous (3 points), very nervous (4 points), and extremely nervous (5 points). The scores are summed, with the total score ranging from 5 to 25 points. The following interpretation is applied:

• 5 points: no anxiety,
• 6–10 points: low level of anxiety,
• 11–18 points: high level of anxiety,
• Above 19 points: very high level of anxiety, indicating that the patient may suffer from dentophobia.

The MDAS questionnaire, like its shorter version, DAS (Dental Anxiety Scale) (which excludes the question about drilling), is frequently used in anxiety studies [7] due to its validity and reliability [21], high internal consistency, and the variety of aspects addressed in its questions [22].

Trait and State Anxiety

In the present study, the State-Trait Anxiety Inventory (STAI) developed by S. Spielberger was utilized to assess the level of anxiety among participants, both as a currently experienced temporary state (situational anxiety, emotion) (STAI X1) and as a stable personality trait (STAI X2). This inventory is widely used in psychological and clinical research for diagnosing and monitoring anxiety.

As a frequently employed tool in numerous international studies, it has been adapted into over forty languages [23].

Both parts of the inventory consist of 20 questions each. The X-1 part, which assesses state anxiety, includes 20 questions of which 10 are directly formulated and 10 are indirectly formulated. The X-2 part, which assesses trait anxiety, also includes 20 questions, of which 13 are directly formulated and 7 are indirectly formulated. Patients respond in 4 categories, indicating the extent to which each statement applies to them. The responses are scored on a scale from 1 to 4, with the total score for each part of the STAI ranging from 20 to 80 points:

• 20–30 points: no anxiety
• 31–42 points: mild anxiety
• 43–53 points: moderate level of anxiety
• 54–80 points: high level of anxiety [24].

The Polish adaptation of the State-Trait Anxiety Inventory was described by Wrześniewski et al. [25].

Dental Fear

The 10-point Gatchel’s Dental Fear Scale was used to assess the feeling of fear both before and after the hygiene procedure. This scale consists of a single question in which the patient independently rates their fear related to dental treatment. The rating scale ranges from 1 to 10, where 1 indicates no fear and 10 represents the highest level of fear.

The Gatchel’s scale was chosen for its simple and easily understandable format for patients. In the literature, this type of questionnaire is widely utilized in research [26,27,28], with the consensus that a single question can provide valuable insights into the anxiety potential of the individual being assessed.

Fear Related to Hygiene Procedure

An author-developed question was used to assess the level of fear related to hygiene procedures, both before and after the procedure (Figure 7). The question asked patients to rate their experience of fear associated with the hygiene visit on a scale from 1 to 10, where 1 indicates no fear and 10 represents extreme fear.

This simple and direct approach was chosen to provide clear and useful data on patients’ fear related to hygiene procedures, serving as a tool for assessing emotional responses in this context.

Heart Rate

Additionally, the patient’s heart rate was measured before, during, and after the hygiene procedure, considering it a physical parameter of anxiety intensity. Heart rate can be regarded as a physical measure of anxiety feelings, as it is one of the physiological indicators that often changes in response to stress and anxiety. When a person experiences anxiety, their body enters a “fight or flight” mode, which can cause an increase in heart rate. Anxiety activates the autonomic nervous system, particularly the sympathetic system, which raises the heart rate in preparation for a rapid response to a perceived threat. Heart rate can be easily and noninvasively measured, making it a practical indicator in research and clinical assessments. An increase in heart rate is one of the somatic symptoms of anxiety that can be measured objectively, in contrast to subjective feelings and patient reports.

The measurement was performed using a Webber C356 finger pulse oximeter. The use of the same tool in all heart rate measurements in this study ensured consistency and comparability of results, eliminating variability associated with using different devices. Furthermore, it guaranteed uniform calibration and measurement accuracy, which is crucial for the reliability and validity of the study results. Heart rate was reported in units of beats per minute (bpm).

2.4.2. Clinical Factors

After the procedure, the patient assessed the pain experienced during the treatment using a Visual Analogue Scale (VAS). This is the most common and well-validated tool used for pain assessment. It is presented as a ruler marked with values from 0 to 10 cm (100 mm), and the patient indicates the degree of pain by placing a mark on this scale. The VAS is easy, understandable, and visual for the patient, making it a widely used method for assessing subjective pain sensations [29]. The results can be categorized as follows:

• 0: no pain,
• 1 to 25: mild pain,
• 26 to 50: moderate pain,
• 51 to 75: severe pain,
• 76 to 100: maximum pain.

The impact of clinical factors (e.g., oral health status, history of orthodontic treatment, health issues, regularity of dental visits), sociodemographic factors, and potential anxiety-reduction strategies—factors that could decrease the experience of negative emotions (fear, anxiety) from the patient’s perspective—were analyzed. These factors were categorized into three subcategories, asking the patient to evaluate which might reduce the experience of negative emotions (fear, anxiety).

Preprocedure factors:

• Positive recommendations/information from others,
• Belief in the professional care of the dental team,
• Positive and empathetic attitude of the staff,
• Calm atmosphere in the waiting room,
• Punctual admission to the treatment room.

During-procedure factors:

• Detailed information about what will be performed,
• Lack of detailed information about what will be performed,
• Pain-free procedures,
• No use of needles,
• Absence of tools in the field of view,
• Absence of sounds from working tools (e.g., wearing headphones during the procedure),
• Lack of characteristic dental office smells,
• Feeling of comfort in the dental chair,
• Possibility of using sedatives and painkillers.

Postprocedure factors:

• Possibility of contacting the clinic/dentist/hygienist,
• Ability to schedule a follow-up visit.

Each of these factors was rated by the patient in 4 categories corresponding to the following points: 0—definitely not, 1—probably not, 2—probably yes, 3—definitely yes.

An author-developed question was also created to assess the attitude of the dental hygienist, based on the VAS. This was important given that the procedures were performed by three different individuals.

A summary of the measurement tools used is provided in

Table 1. Measurement tools and study design.

Measure	Variable	Before Hygiene Procedure	After Hygiene Procedure
State-Trait Anxiety Inventory by S. Spielberger part X1	State anxiety	✔	✔
State-Trait Anxiety Inventory by S. Spielberger part X2	Trait anxiety	✔
MDAS—Modified Dental Anxiety Scale	Dental anxiety	✔
Gatchels’s 10-Point Dental Fear Scale	Dental fear	✔	✔
Author-developed question about the experience of fear before the hygiene visit	Fear related to the hygiene procedure	✔	✔
Medical documentation	Clinical factors	✔
	Heart rate	✔	✔
	Sociodemographic factors	✔
	Factors that may reduce the experience of anxiety in the patient’s assessment	✔
Author-developed questionnaire	Attitude of the dental hygienist		✔
VAS (Visual Analogue Scale)—scale for pain	Clinical factors—pain during the hygiene procedure		✔

.

2.4.3. Data Analysis

Statistical analyses were conducted using Statistica software, version 13. Descriptive statistics included mean values, standard deviation (SD), median, interquartile range, and 95% confidence interval (CI).

The following analyses were applied: chi-square test (Chi²), Spearman’s rank correlation, Student’s t-test, Friedman test, ANOVA (Analysis of Variance), Mann–Whitney U test, and Wilcoxon test.

The chi-square test was used for categorical variables such as gender and education level.

Spearman’s rank correlation was applied to evaluate relationships between nonparametric variables, like age and anxiety levels.

Student’s t-test was employed to compare mean anxiety scores between men and women.

The Friedman test and Wilcoxon test were used for repeated measures of anxiety and heart rate across different stages (before, during, and after the procedure).

ANOVA was applied to compare anxiety levels across multiple demographic groups.

Mann–Whitney U test was used for comparisons of nonparametric variables between groups.

Statistical significance was indicated by a p-value less than 0.05.

3. Results

3.1. Sociodemographic and Clinical Characteristics of the Study Population

Sociodemographic and clinical characteristics are presented in

Table 2. Sociodemographic and clinical characteristics of study participants.

Characteristic	Value
	Mean ± SD
Age [years]	43.52 ± 12.95
	n (%)
Gender
male	100 (59.5)
female	147 (40.5)
Education
primary/middle school	2 (0.8)
secondary	68 (27.5)
higher	177 (71.7)
First-time hygiene visit
yes	26 (10.5)
no	221 (89.5)
Orthodontic treatment in the past
yes	95 (38.5)
no	152 (51.5)
Dental visits in childhood
yes	223 (90.3)
no	24 (9.7)
Physical health problems
yes	68 (27.5)
no	179 (72.5)
Mental health problems
yes	18 (7.3)
no	229 (92.7)
Diagnosis of dentophobia
yes	0 (0%)
no	247 (100%)

.

Women comprised 59.5% of the patients, while 40.5% were men. Age categories were divided into: 18–34 years, 35–54 years, and over 55 years. The same classification was used in the studies by Sukuraman et al. [30]. The average age was 43.5 years (SD: 12.9), with the largest percentage of patients falling within the 35–54 years age group. Approximately 72% of patients had higher education, while 28% had secondary education. Two patients reported having primary and middle school education (for the purposes of the study, these were included in the “secondary” category for 26 patients (10.5%), this was their first hygiene visit in their lives, while the remaining patients were classified as returning patients (Figure 8).

The variable values are presented in

Table 3. Levels of fear, anxiety, and heart rate before and after the hygiene procedure.

Variable	Before Procedure (Mean ± SD)	During Procedure (Mean ± SD)	After Procedure (Mean ± SD)	Test Result	p-Value
Dental anxiety (MDAS)	8.5 ± 3.5	-	-	-	-
Trait anxiety (STAI X2)	45 ± 4.1	-	-	-	-
State anxiety (STAI X1)	45.8 ± 4.2	-	43.7 ± 4.1	t = 4.31	<0.001
Dental fear (Gatchel’s scale)	3.7 ± 2.4	-	3.0 ± 2.2	Z = 6.84	<0.001
Fear related to the hygiene procedure (author-developed question)	2.51 ± 2.0	-	2.04 ± 1.5	Z = 5.65	<0.001
Heart rate [bpm]	75.6 ± 8.6	74.0 ± 8.8	7.37 ± 7.9	ANOVA = 17.28	<0.001

Note: SD—standard deviation, t—Student’s t-test, Z—Wilcoxon signed-rank test, ANOVA—Friedman ANOVA.

.

3.2. Dental Anxiety

The factors influencing the level of dental anxiety (as measured by the MDAS scale) assessed before the hygiene procedure were examined (

Table 4. Variables associated with dental anxiety (MDAS scale).

Variable		Test Result	p Value
Gender—male		U = −2.43	0.0152
Frequency of dental visits		rs = −0.13	0.0431
Good oral hygiene self-assessment		rs = −0.21	0.0008
Absence of mental health issues		rs = −0.15	0.0171
Not taking medication		rs = −0.15	0.0179
Absence of traumatic dental experiences in the past		rs = −0.32	<0.0001
Number of carious lesions		H = 8.88	0.031
Factors that, in the patient’s opinion, could reduce negative emotions	Not using needles	H = 8.40	0.0384
	Absence of tools in the field of view	H = 21.92	0.0001
	Absence of sounds from working tools	H = 13.08	0.0045
	Absence of characteristic dental office smells	H = 14.49	0.0023
	Possibility of using sedatives and painkillers	rs = 0.17	<0.0001
Pain experienced during hygiene procedures		H = 26.40	<0.0001

Note: U—Mann–Whitney U test, H—Kruskal–Wallis ANOVA, r_s—Spearman’s rank correlation.

) (Figure 9 and Figure 10).

3.3. Trait Anxiety and State Anxiety

The results obtained in this study indicate that the differences between the mean values of STAI X1 before and after the procedure are statistically significant (Figure 11).

Moreover, state anxiety measured using the State-Trait Anxiety Inventory (STAI) did not show any correlation with the measures of dental fear and anxiety or with any clinical parameters. A correlation was found with education level—individuals with higher education levels exhibited higher anxiety levels as assessed by the STAI questionnaire (

Table 5. Variables showing a relationship with state anxiety (STAI X1) before and after the procedure.

Variable	State Anxiety (STAI X1)
	Test Result before the Procedure	p-Value before the Procedure	Test Result after the Procedure	p-Value after the Procedure
Trait anxiety (STAI X2)	rs = 0.14	0.0236	rs = 0.12	0.03
Education	Chi2 = 125.56	<0.001	Chi2 = 120.50	<0.001

Note: Chi²—Pearson’s chi-square, r_s—Spearman’s rank correlation.

).

Due to the lack of correlation between state anxiety measured by the STAI and the measures of dental fear and anxiety or clinical parameters, this aspect was not included in further analyses.

It can be observed that the measures of state anxiety (STAI X1) and trait anxiety (STAI X2) are positively correlated. Additionally, trait anxiety shows an association with gender (

Table 6. Variables showing a relationship with trait anxiety (STAI X2).

Variable		Trait Anxiety (STAI X2)
		Test Result	p-Value
State anxiety (STAI X1)		rs= 0.14	0.0236
Gender—male		Chi2 = 8.41	0.0149
Factors that, in the patient’s opinion, could reduce negative emotions	Not taking medication	Chi2 = 11.77	0.0028
		rs = −0.19	0.0028
	Absence of tools in the patient’s field of view	rs = 0.17	<0.0500
	Feeling of comfort in the dental chair	rs = 0.13	<0.0500

Note: Chi²—Pearson’s chi-square, r_s—Spearman’s rank correlation.

). Women exhibit higher levels of trait anxiety compared to men, as confirmed by both the chi² tests and Spearman’s rank correlation.

A weak negative correlation was also noted between trait anxiety levels (STAI X2) and medication use. The results of the chi-square tests and Spearman’s rank correlation indicate that this relationship is significant, although not very strong. The negative correlation suggests that individuals who do not take medication tend to have lower MDAS scores (indicating a lower level of anxiety).

The observed relationships are illustrated in Figure 12.

3.4. Dental Fear

3.4.1. Key Factors Influencing the Level of Dental Fear (Gatchel’s Scale)

In the conducted study, the average score for fear before the procedure was 3.7 (SD = 2.4), and after the procedure, it was 3 (SD = 2.2) (Figure 13).

In the conducted analysis, correlations between the level of dental fear on Gatchel’s scale and other examined parameters were assessed (

Table 7. Variables associated with dental fear (Gatchel’s scale) before and after the procedure.

Variable		Dental Fear (Gatchel’s Scale)
		Before the Procedure		After the Procedure
		Test Result	p-Value	Test Result	p-Value
Pain during the hygiene procedure		rs = 0.41	<0.0500	rs = 0.42	<0.0500
Factors that, in the patient’s opinion, could reduce negative emotions	Positive recommendations/information from others	rs = −0.07	NS	rs = −0.16	<0.0500
	Absence of tools in the field of view	rs = 0.22	<0.0500	rs = 0.13	<0.0500
	Absence of sounds from working tools	rs = 0.16	<0.0500	rs = 0.13	<0.0500
	Absence of characteristic dental office smells	rs = 0.19	<0.0500	rs = 0.16	<0.0500
	Possibility of using sedatives and painkillers	rs = 0.26	<0.0500	rs = 0.16	<0.0500
	Possibility of taking breaks according to the patient’s needs	rs = 0.15	<0.0500	rs = 0.05	NS
	Possibility of contacting the clinic/dentist/hygienist	rs = 0.14	<0.0500	rs = 0.08	NS

Note: r_s—Spearman’s rank correlation, NS—not statistically significant.

, Figure 14 and Figure 15).

3.4.2. Change in Dental Fear over Time

In 138 participants (56% of all subjects), no change was observed in the value of dental fear (Gatchel’s scale) when measured before and after the hygiene procedure.

In 109 participants (44% of all subjects), a change in the value of dental fear (Gatchel’s scale) was observed between the measurements before and after the hygiene procedure. Among this group, 16% experienced an increase in the indicated value, while 84% experienced a decrease. The Wilcoxon signed-rank test revealed that the decrease in Gatchel’s scale between the two time points was statistically significant (Z = 6.84, p < 0.0001) (

Table 8. Comparison of dental fear levels (Gatchel’s scale) before and after the hygiene procedure.

Variable	Test Result	p-Value
Dental Fear (Gatchel’s scale) before the procedure	Z = 6.84	p < 0.0001
Dental Fear (Gatchel’s scale) after the procedure

Note: Z—Wilcoxon signed-rank test.

).

3.5. Fear Related to the Hygiene Procedure

3.5.1. Key Factors Influencing the Level of Fear Related to the Hygiene Procedure

To assess the fear related to the hygiene procedure before and after the treatment, an author-developed question with a 1–10 scale, analogous to Gatchel’s scale, was used. Patients rated their feelings of fear both before the start of the hygiene procedure and after its completion. The average score for fear before the procedure was 2.5 (SD = 2.0), and after the procedure, it was 2.0 (SD = 1.5) (Figure 16).

In the conducted analysis, correlations between the level of fear related to hygiene procedures and other examined parameters were assessed (

Table 9. Variables associated with fear related to hygiene before and after the procedure.

Variable		Fear Related to Hygiene
		Before the Procedure		After the Procedure
		Test Result	p-Value	Test Result	p-Value
Pain during the hygiene procedure		rs = 0.48	<0.0500	rs = 0.56	<0.0500
Number of missing teeth replaced with implants		rs = −0.14	<0.0500	rs = −0.16	<0.0500
Factors that, in the patient’s opinion, could reduce negative emotions	Positive recommendations/information from others	rs = −0.23	<0.0500	rs = −0.26	<0.0500
	Belief in professional care	rs = −0.15	<0.0500	rs = −0.17	<0.0500
	Positive and empathetic attitude of the staff	rs = −0.08	NS	rs = −0.16	<0.0500
	Calm atmosphere in the waiting room	rs = −0.11	NS	rs = −0.15	<0.0500
	Punctual admission to the treatment room	rs = −0.06	NS	rs = −0.13	<0.0500
	Absence of in the patient’s field of view	rs = 0.24	<0.0500	rs = 0.18	<0.0500
	Feeling of comfort in the dental chair	rs = −0.13	<0.0500	rs = −0.18	<0.0500
	Possibility of using sedatives and painkillers	rs = 0.19	<0.0500	rs = 0.12	NS

Note: r_s—Spearman’s rank correlation, NS—not statistically significant.

, Figure 17 and Figure 18).

3.5.2. Change in Fear Related to the Hygiene Procedure over Time

In 156 participants (63% of all subjects), no change was observed in the value of fear related to the hygiene procedure when measured before and after the procedure.

In 91 participants (37% of all subjects), a change in the value of fear related to hygiene procedure was observed between the measurements before and after the procedure. Among this group, 21% experienced an increase in the indicated value, while 79% experienced a decrease. The Wilcoxon signed-rank test revealed that the decrease in fear related to hygiene procedures between the two time points was statistically significant (Z = 5.65, p < 0.0001) (

Table 10. Comparison of fear levels related to hygiene assessed before and after the procedure.

Variable	Test Result	p-Value
Fear related to hygiene before the procedure	Z = 5.65	p < 0.0001
Fear related to hygiene before the procedure

Note: Z—Wilcoxon signed-rank test.

).

3.6. Heart Rate

In the conducted study, statistically significant positive correlations were observed between the three heart rate measurements (

Table 11. Correlations between heart rate measurements before, during, and after the hygiene procedure.

Variable	Test Result: rs—Spearman’s Rank Correlation (p < 0.0500)
	Heart Rate before the Procedure	Heart Rate during the Procedure	Heart Rate after the Procedure
Heart rate before the procedure	1.00	0.54	0.46
Heart rate during the procedure	0.54	1.00	0.61
Heart rate after the procedure	0.46	0.61	1.00

).

The average heart rate before the hygiene procedure was 75.6 (SD = 8.6), during the procedure it was 74 (SD = 8.8), and after the procedure, it was 73.7 (SD = 7.9) (Figure 19).

3.6.1. Key Factors Influencing Heart Rate before, during, and after the Hygiene Procedure

In the conducted analysis, correlations between patient heart rate values and other examined parameters were investigated (

Table 12. Variables showing a relationship with heart rate values measured before, during, and after the procedure.

Variable		Heart Rate
		Before the Procedure		During the Procedure		After the Procedure
		Test Result	p-Value	Test Result	p-Value	Test Result	p-Value
Age [years]		rs = −0.11	NS	rs = −0.14	<0.0500	rs = −0.25	<0.0500
Number of missing teeth (not replaced)		rs = −0.08	NS	rs = −0.10	NS	rs = −0.19	<0.0500
Total number of missing teeth (including those replaced with implants)		rs = −0.10	NS	rs = −0.10	NS	rs = −0.18	<0.0500
Factors that, in the patient’s opinion, could reduce negative emotions	Positive recommendations/information from others	rs = 0.13	<0.0500	rs = 0.08	NS	rs = 0.11	NS
	Calm atmosphere in the waiting room	rs = 0.08	NS	rs = 0.08	NS	rs = 0.21	<0.0500
	Not using needles	rs = 0.06	NS	rs = 0.05	NS	rs = 0.13	<0.0500
	Absence of characteristic smells of the dental office	rs = 0.07	NS	rs = 0.05	NS	rs = 0.14	<0.0500
	Possibility of contacting the clinic/dentist/hygienist	rs = 0.15	<0.0500	rs = 0.01	NS	rs = 0.17	<0.0500

Note: r_s—Spearman’s rank correlation coefficient, NS—not statistically significant.

, Figure 20).

3.6.2. Heart Rate Changes over Time

The recorded decrease in heart rate during and after the hygiene procedure was statistically significant. The Friedman ANOVA test demonstrated that there are significant differences in the median heart rate between the three time points (before, during, and after the procedure) (

Table 13. Comparison of heart rate measurements before, during, and after the hygiene procedure.

Variable	Test Result	p Value	Degrees of Freedom
Heart rate before the hygiene procedure [bpm]	ANOVA = 17.28	<0.001	df = 2
Heart rate during the hygiene procedure [bpm]
Heart rate after the hygiene procedure [bpm]

Note: ANOVA—Friedman ANOVA, df—degrees of freedom.

). This indicates that at least one of these conditions differs significantly from the others in terms of heart rate.

Then, a comparison of mean ranks was conducted to precisely determine between which pairs of moments these significant differences occur. The obtained result allows us to conclude that a significant difference in heart rate exists only between the measurements taken before and after the procedure (

Table 14. Comparison of mean rank differences in heart rate measured before, during, and after hygiene.

Pairwise Comparison	Mean Rank Difference	p-Value
Heart rate before the hygiene procedure [bpm] vs. during the hygiene procedure [bpm]	0.2	NS
Heart rate before the hygiene procedure [bpm] vs. after the hygiene procedure [bpm]	0.4	<0.0500
Heart rate during the hygiene procedure [bpm] vs. after the hygiene procedure [bpm]	0.1	NS

Absolute differences between mean ranks are significant (approximately) if >0.215; NS—not statistically significant.

).

3.7. Inter-Relations of Parameters Measuring Fear and Anxiety

The relationships between various measures of fear and anxiety were examined, showing significant positive correlations between dental anxiety (MDAS) and dental fear before and after the hygiene procedure, as well as fear related to the hygiene visit. A detailed summary of these correlations can be found in

Table 15. Intercorrelations of variables measuring fear and anxiety.

Variable	Test Result: rs—Spearman’s Rank Correlation (p < 0.0500)
	Dental Anxiety (MDAS)	Dental Fear (Gatchel’s Scale) before Hygiene Procedure	Dental Fear (Gatchel’s Scale) after Hygiene Procedure	Fear Related to Hygiene before Procedure	Fear Related to Hygiene after Procedure
Dental anxiety (MDAS)	1.00	0.79	0.67	0.65	0.59
Trait anxiety (STAI X2)	NS	NS	NS	0.13	NS
Dental fear (Gatchel’s scale) before hygiene procedure	0.79	1.00	0.79	0.72	0.66
Dental fear (Gatchel’s scale) after hygiene procedure	0.67	0.79	1.00	0.57	0.73
Fear related to hygiene before procedure	0.65	0.72	0.57	1.00	0.79
Fear related to hygiene after procedure	0.59	0.66	0.73	0.79	1.00

Note; NS—not statistically significant.

.

Additionally, in this study, the question concerning the evaluation of the dental hygienist’s attitude during the hygiene procedure aimed at determining whether the operator’s demeanor could have influenced the outcomes. After analysis, it was found that the evaluation of the hygienists’ attitude did not significantly correlate with any of the measured indicators (such as heart rate, fear, or anxiety of the patients). This indicates that the hygienists’ demeanor during the procedure was consistent and did not influence the patients’ feelings, ruling out the possibility that the study results were altered by potential differences in the operators’ behavior.

3.8. First-Time Dental Hygiene Visit

It was observed that one of the factors associated with the level of anxiety was the fact that the patient was attending their first-ever dental hygiene appointment.

3.8.1. First-Time Dental Hygiene Visit and Changes in the Level of Dental Fear

The study analyzed the impact of a first-time dental hygiene visit on the level of dental fear, as measured by the Gatchel scale, both before and after the hygiene procedure (

Table 16. The mean values of dental fear on the Gatchel scale depending on the first-time hygiene visit.

Dental Fear (Gatchel’s Scale)	Mean
	First-Time Hygiene Visit	Subsequent Hygiene Visit
Before hygiene procedure	4.58	3.54
After hygiene procedure	3.19	3.01

).

The Friedman ANOVA test was applied to analyze repeated measurements in two groups: patients attending their first-ever dental hygiene visit and those undergoing a subsequent procedure of this type (

Table 17. Analysis of the impact of a first-time dental hygiene visit on changes in the level of dental fear.

Parameters	Test Result	p Value	Partial Eta-Squared	Observed Power (Alpha = 0.05)
First-time dental hygiene visit	F = 1.81	0.1802	0.007	0.268
Change in the level of dental fear (R1)	F = 48.88	<0.0001	0.166	1.000
Interaction: First-time dental hygiene visit × Change in the level of dental fear (R1)	F = 9.76	0.0020	0.038	0.875

Note: F—Test statistic used in Analysis of Variance (ANOVA) to assess the significance of differences.

).

These results indicate that both R1 (dental fear before and after the hygiene procedure) and the interaction between R1 and a first-time dental hygiene visit have a significant impact on the dependent variable. The fact that the hygiene visit was a first-time occurrence on its own does not have a significant effect; however, changes in dental fear differ significantly depending on this factor.

The chart (Figure 21) shows that the level of dental fear measured on the Gatchel’s scale decreases in both groups: patients who had their first-time hygiene visit and those who did not. However, these changes are more pronounced in the group of individuals who had their first-time hygiene visit.

3.8.2. First-Time Hygiene Visit and Changes in Fear Related to Hygiene Procedures

In the subsequent study, the impact of the first-time hygiene visits on the level of fear related to the hygiene procedure, assessed before and after the procedure, was analyzed (

Table 18. Mean values of fear related to hygiene procedures depending on the first-time hygiene visit.

Fear Related to Hygiene	Mean
	First-Time Hygiene Visit	Subsequent Hygiene Visit
Before procedure	3.77	2.36
After procedure	2.12	2.03

).

ANOVA test for repeated measures was applied to analyze two groups: patients who had a first-time hygiene visit and those who did not (

Table 19. Analysis of the effect of the first-time hygiene visit on changes in fear related to hygiene procedures.

Parameters	Test Result	p Value	Partial Eta-Squared	Observed Power (Alpha = 0.05)
First-time dental hygiene visit	F = 4.84	0.0288	0.019	0.591
Change in the level of fear related to hygiene procedure (R1)	F = 60.19	<0.0001	0.197	1.000
Interaction: First-time dental hygiene visit × Change in the level of fear related to hygiene procedure (R1)	F = 26.78	<0.0001	0.098	0.999

Note: F—F-statistic value used in the analysis of variance (ANOVA) to assess the significance of differences.

).

The results indicate that fear related to hygiene procedures before and after the treatment, as well as whether it was a first-time hygiene visit, have a statistically significant impact on the level of fear. The reduction in fear after the procedure is statistically significant for both individuals who had a first-time hygiene visit and those who did not. However, individuals who had a first-time hygiene visit started with a higher level of fear and experienced a greater reduction in fear compared to those who were undergoing a subsequent hygiene visit (Figure 22).

4. Discussion

4.1. Correlations between Fear and Anxiety Measures

There were strong correlations between the different measures of fear and anxiety used in the study, particularly those analyzing these emotions in the dental context. At the same time, the results suggest that despite the partial overlap of various measures of dental fear, there may be a need for further development and refinement of measurement methods in this area.

No correlation was found between situational anxiety (STAI X1) and measures of fear and anxiety related to dental aspects. Similar conclusions were reached by Eitner et al. in their studies [26].

Heart rate variability can be considered an indicator of anxiety: the mean heart rate decreased from before the procedure to after its completion, which may indicate initial anxiety that gradually diminished during and after the hygiene procedure. Statistically significant differences in heart rate values suggest that heart rate can be used as a physical indicator of the anxiety experienced by patients during dental procedures. The decrease in heart rate during and after the procedure may suggest that certain elements of the procedure or interventions used by the staff may have effectively reduced the patients’ anxiety.

4.2. The Impact of Fear and Anxiety on Pain Perception

A positive, strong correlation was noted between the pain experienced during the procedure and the assessment of fear and anxiety before and after the hygiene procedure. This can be explained by several psychological factors, from the anticipation of pain (expectation of pain can lead to a subconscious amplification of anxiety) to past experiences that shape the patient’s perception before the procedure. Additionally, patients with high levels of fear and anxiety may have a lowered pain threshold, causing them to feel pain more intensely. The presence of fear and anxiety, in turn, may itself amplify the sensation of pain, creating a vicious cycle. The expectation of pain before the procedure may not only raise the level of fear but also lead to a higher assessment of the pain during the procedure [21]. This mechanism can be explained by several interrelated psychological processes: the self-fulfilling prophecy effect, increased attention to pain stimuli, and the fact that anxiety lowers the pain threshold. Interestingly, Locker et al. consider fear of pain to be one of the key components of dental anxiety [27]. Clinicians should therefore pay attention to the emotional state of the patient before the procedure and consider anxiety management methods to reduce the pain experienced during the procedure.

4.3. Factors Influencing Fear and Anxiety

4.3.1. Sociodemographic Factors

Women exhibited higher levels of dental anxiety, consistent with reports in the available literature [7,28].

Individuals with higher levels of education exhibited higher values of situational anxiety. Higher education levels may be associated with greater professional and social demands, which can lead to higher levels of situational anxiety. Similar results were obtained in studies on the COVID-19 pandemic by Liu et al. [31]. However, further research is needed to better understand this relationship. It is important to consider cultural context, professional context, and individual differences in coping with stress and anxiety. Potential limitations of the study, related to the small number of patients with lower education levels, should also be considered.

Older patients exhibited lower heart rates both during and after the procedure, suggesting they may be less susceptible to stress related to dental procedures. Older individuals may have more experience coping with medical procedures, which reduces their fear and anxiety.

4.3.2. Clinical Factors

Mental health issues positively correlated with the level of anxiety.

Individuals taking medications experienced higher levels of anxiety, possibly due to their overall health condition.

Having dental implants reduced fear related to hygiene procedures.

Patients with more missing teeth appeared to be more relaxed after the procedure, as indicated by lower heart rates. It is possible that patients with missing teeth who opted for implants felt more confident and comfortable, which translated into better psychological well-being after the procedure.

A higher number of dental caries positively correlated with higher levels of dental anxiety. This finding is supported by several other publications on patient anxiety [26,32,33].

4.3.3. History of Dental Visits

Regular dental visits negatively correlated with various measures of anxiety, indicating that more frequent visits may help reduce anxiety.

Patients attending their first dental hygiene visit exhibited higher levels of anxiety both before and after the procedure compared to returning patients—these statistically significant differences highlight the need for special attention in managing anxiety in new patients. They also suggest that subsequent hygiene visits are associated with lower levels of negative emotions for the patient.

The first-time hygiene visit is associated with a higher initial level of fear but also with a more significant reduction in fear after the procedure.

Stressful dental experiences in the past correlated with higher levels of dental anxiety, which supports the model proposed by Wide et al. [13]. Similar conclusions were reached earlier by Scandurra et al. [34]. Beaton et al., in turn, include traumatic dental experiences in the group of exogenous, significant factors influencing patient anxiety [3].

4.3.4. Oral Hygiene

Good oral hygiene self-assessment reduces the level of dental anxiety. This finding is consistent with the results of other researchers [35]. In the study by Sullivan and Neish, individuals with better oral hygiene indicators had lower levels of dental anxiety [36].

4.3.5. Personality

A higher level of trait anxiety (STAI X2) increased the level of state anxiety (situational anxiety) on the STAI X1 scale.

4.3.6. Patient Preferences for Reducing Negative Emotions (Fear and Anxiety)

The importance of not using needles positively correlated with levels of fear and anxiety, indicating that patients with higher stress levels preferred to avoid needles. This is consistent with reports in the literature. In the study by Levin et al., the highest-rated anxiety was observed in relation to dental injections [37].

Reduction in sensory stimuli: factors such as the absence of tools in the field of view, the lack of sounds from working tools, and the absence of characteristic smells of the dental office were significantly associated with lower levels of anxiety and fear. This is supported by existing research on dental patients’ anxiety. Jeong-Woong et al. reported that noise generated by turbines and scalers was particularly stressful for patients, recommending the use of noise-canceling headphones during procedures [38]. The impact of sensory perceptions and their influence was also analyzed by Oosterink et al. [3] and Domoto et al. [39], reaching similar conclusions. This suggests that reducing sensory stimuli may be key to reducing negative emotions in patients. Patients who perceive these factors as important exhibit higher heart rates before and after the procedure, which may indicate their greater sensitivity to stress and the need for such interventions to reduce anxiety.

The possibility of using sedatives and analgesics was important to patients and positively correlated with measures of fear and anxiety. However, the study found that its importance decreased after the hygiene procedure. Before the procedure, patients may overestimate their need for sedatives and analgesics, especially if they experience high levels of fear and anxiety. However, after the procedure, when emotions subside, the importance of this factor becomes less significant. This may suggest that educating patients before the procedure about the actual course and level of discomfort during hygiene procedures could help reduce excessive concerns and decrease the perceived need for these agents. It also confirms lower levels of negative emotions in patients returning for subsequent hygiene visits. It is worth noting that according to literature reports, patients prefer nonpharmacological methods among anxiety management strategies [40].

The importance of preprocedure factors (belief in the professional care of the dental team, positive and empathetic attitude of the staff, calm atmosphere in the waiting room, punctual admission to the office) most often showed a negative correlation with measures of fear and anxiety.

Positive recommendations/information from others correlated with fear and anxiety before the procedure, but their importance seemed less significant after the procedure.

The possibility of taking breaks during the procedure and contacting the clinic/dentist or hygienist was important to the patient and correlated with the level of fear before the hygiene procedure. After the procedure, the significance of this preference was not observed. It seems important, therefore, to reassure the patient about this form of care before the procedure.

4.4. Conceptual Model

Based on the obtained results and analyzed relationships, a conceptual model for managing fear and anxiety in patients attending dental hygiene visits can be proposed (Figure 23).

4.5. Clinical Implications and Future Research Directions

The clinical implications of the conducted research include:

• Personalization of dental care: Developing patient anxiety and fear management strategies based on their previous experiences and individual responses.
• Optimization of clinical processes: Implementing effective technologies that simultaneously minimize patient discomfort.
• Reduction in sensory stimuli during dental visits.
• Increasing trust in dentists and dental hygienists: By better managing patient emotions.
• Enhancing the quality of dental services: Positive patient experiences and improved overall oral health.

These implications are crucial for reducing the avoidance of hygiene visits, which could contribute to better oral health and quality of life, strongly associated with dental fear and anxiety [41].

To summarize the conducted study, it is important to consider its limitations. One of the key limitations is the lower statistical power observed for certain variables, which may affect the ability to detect significant effects, particularly in cases where the sample size was smaller, or variability was higher. Additionally, the lack of a control group comparing GBT with traditional methods limits the conclusions we can draw regarding GBT’s potential to reduce anxiety or improve comfort. Although GBT was used in this study, its impact on anxiety reduction was not directly assessed.

The article identified some anomalies, such as unusual levels of anxiety and heart rate in patients, which may be due to individual differences or underlying medical conditions. However, these deviations did not affect the overall conclusions regarding the effectiveness of the therapy in reducing anxiety.

There is a clear need for further research to verify the long-term effects of fear and anxiety reduction strategies, as well as to conduct a cost-benefit analysis of implementing personalized interventions and new technologies. Future studies should focus on long-term outcomes and on identifying additional factors and their connections that may influence patient experiences during dental visits. It will also be valuable to expand the research sample to diverse demographic groups to determine whether the findings are universal and to understand how various cultural, social, and economic factors affect levels of fear and anxiety. Interdisciplinary research combining dentistry with psychology should also be considered, as it could provide more comprehensive strategies for managing patient emotions, taking into account different aspects of their mental and physical health. The potential significance of patient susceptibility to anxiety, which is frequently raised in foundational research on this topic, should not be overlooked [42].

In future studies, it would be beneficial to include more complex research designs, such as double-blind placebo-controlled trials, to more accurately assess the true impact of GBT on anxiety reduction and to limit the possibility of a placebo effect, which may have influenced anxiety reduction in patients regardless of the method used.

In future research, it would be valuable to consider testing modifications to the Guided Biofilm Therapy (GBT) protocol, such as integrating additional anxiety reduction techniques, including relaxation techniques, or the use of virtual reality technology. These studies could provide new data on their effectiveness in further reducing patient anxiety, contributing to the continued improvement of personalized patient care in the context of dental hygiene.

5. Conclusions

The study results highlight the necessity of a personalized approach to managing patients’ fear and anxiety during hygiene visits. Patients attending their first hygiene visit require special attention and support to mitigate negative emotions. While technologies such as Guided Biofilm Therapy (GBT) may have the potential to improve patient experiences, the current study did not directly assess its impact on reducing fear or anxiety. Personalized dental care, in line with the proposed conceptual model, remains essential to addressing these emotions effectively.

Dental anxiety is a complex and multidimensional phenomenon influenced by a variety of coexisting factors [43].

The variables analyzed in this article align with the groups of factors influencing dental anxiety, as described in the model proposed by Klingberg et al. According to this model, individual, dental, and external factors play key roles in shaping dental anxiety [44] (Figure 24).

The conceptual model for anxiety management involves identifying key factors that impact anxiety levels and implementing strategies aimed at its reduction. Regular dental visits, hygiene visits, patient education, psychological support, and an individualized approach to patient care are critical components of effective dental care.

Developing a patient anxiety management model and performing procedures using technologies like Guided Biofilm Therapy could be essential for improving the quality of dental care. Future research should focus on developing and implementing strategies to reduce patient anxiety, thereby enhancing their comfort and satisfaction with hygiene visits. Implementing these strategies may lead to improved patient comfort and increased effectiveness of hygiene procedures.