
==== Front
Heliyon
Heliyon
Heliyon
2405-8440
Elsevier

S2405-8440(24)12951-9
10.1016/j.heliyon.2024.e36920
e36920
Research Article
Exploring dental anxiety as a mediator in the relationship between mindfulness or self-compassion and dental neglect
Beltes Charalampos a
Giannou Kyriaki b
Mantzios Michail michael.mantzios@bcu.ac.uk
c⁎
a Aristotle University, Dental School, Thessaloniki, Greece
b De Montfort University, Faculty of Health and Life Sciences, Department of Psychology, Leicester, United Kingdom
c Birmingham City University, College of Psychology, Birmingham, United Kingdom
⁎ Corresponding author. Birmingham City University, Department of Psychology, Faculty of Business, Law and Social Sciences, Room C332, The Curzon Building, 4 Cardigan St., Birmingham, United Kingdom. michael.mantzios@bcu.ac.uk
29 8 2024
15 9 2024
29 8 2024
10 17 e3692027 2 2024
23 8 2024
23 8 2024
© 2024 Published by Elsevier Ltd.
2024

https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Dental anxiety and dental neglect are interconnected constructs with profound consequences for oral health and corresponding challenges for dental professionals. Meanwhile, other literature has indicated that mindfulness and self-compassion relate negatively to different forms of anxiety, and propose elements of potential interventions. This study aimed to explore the potential impact of dental anxiety as a mediator on the relationships between mindfulness or self-compassion and dental neglect. The results showed significant negative associations between mindfulness and self-compassion with dental anxiety and dental neglect. Mediation analyses supported the hypothesis that dental anxiety mediates the positive associations between mindfulness or self-compassion and dental neglect, providing preliminary evidence for the potential effectiveness of mindfulness and self-compassion interventions in addressing dental anxiety and dental neglect. Future research and potential clinical implications are discussed.

Keywords

Dental anxiety
Dental neglect
Mindfulness
Self-compassion
==== Body
pmc1 Introduction

Dental anxiety and dental neglect are prevalent issues and interconnected phenomena that have significant implications for oral health [[1], [2], [3]]. Dental anxiety refers to the fear and apprehension individuals experience in dental settings, while dental neglect refers to the persistent failure to seek dental care [4]. Research indicates that individuals with dental anxiety are more likely to neglect dental care [5,6], with dental anxiety and neglect coming together to form a vicious cycle that is hard to overcome for patients, researchers, and clinicians. In this short communication, we aimed to identify preliminary cross-sectional findings on the potential effectiveness of future mindfulness-based interventions on both dental neglect and dental anxiety.

Dental anxiety is a common occurrence, with approximately up to 20 % of adults and 40 % of children experiencing dental anxiety or fear [7]. Dental anxiety is not limited to specific demographic groups but is prevalent across various age groups, cultures, and socioeconomic backgrounds [5,8], with statistics on mild and severe anxiety offering a more distressing clinical picture [9,10]. One primary factor that further intensifies dental anxiety is former negative dental experiences, such as painful treatments, as well as fear of needles, the dental environment, and the sound and vibration of dental instruments [11]. Psychological factors, such as general anxiety and a tendency towards negative thinking, have also been linked to dental anxiety [[11], [12], [13]]. Dental anxiety has significant consequences for both the individual and the dental healthcare professionals [14]. Patients with dental anxiety pose challenges for dental professionals, as treating anxious patients can be time-consuming and challenging, as they tend to delay or avoid dental treatment, leading to a decline in oral health and an increased need for invasive and costly procedures [1,15,16]. Therefore, addressing dental anxiety is crucial not only for improving patient comfort, but also for enhancing the overall efficiency and effectiveness of dental care.

Separately from anxiety, and despite observed association to dental neglect can result in the progression of existing oral health problems, increased pain and discomfort, and compromised oral function [15,17]. Past reviews and population studies found that participants showed significant dental neglect across populations [[18], [19], [20]], while other literature showed a higher prevalence in specific populations, such as children, and individuals with low income and limited access to dental care [12,18,[21], [22], [23]]. Still, a lack of oral health literacy, negative dental experiences, and cultural beliefs toward oral health suggest the significance of the association between anxiety and neglect [21]. Several factors contribute to dental neglect, and Locker et al. [24] listed dental anxiety as a leading avoidance behavior and a common barrier to seeking dental care. Consequently, efforts to reduce dental neglect must also address the underlying dental anxiety, as both issues are deeply interconnected and mutually reinforcing.

The cyclical relationship between dental anxiety and dental neglect has profound consequences for oral health and has been studied over the past two decades. Quteish Taani [3] reported that approximately one-fifth of adults exhibited dental anxiety, and dental anxiety was associated with higher levels of dental neglect (see also 6). Individuals with dental anxiety are more likely to delay or avoid dental treatments, leading to a higher risk of dental caries, periodontal disease, and tooth loss [6,25,26]. Other literature identified that previous negative dental experiences, perceived lack of control, and anticipation of pain are factors that contribute to dental anxiety and subsequent dental neglect [3,11,27]. The psychosocial implications of dental anxiety and neglect can include reduced psychosocial well-being, including impaired self-esteem, social withdrawal, and reduced quality of life [12,18,21]. Significantly, the lack of preventive care and early intervention exacerbates oral health problems, resulting in increased pain, discomfort, and functional limitations [17], reinforcing avoidance and neglect. Therefore, this cyclical relationship underscores the need for comprehensive strategies to break the cycle of anxiety and neglect.

Researchers suggest education programs and community interventions to enhance oral health knowledge and access to dental care [17,27,28]. Improving communication skills among oral health professionals can alleviate dental anxiety and neglect [29,30], and a multidisciplinary approach, including interventions for anxiety symptoms, has been proposed [24,31]. Cognitive-behavioural therapy (CBT) is effective in reducing dental anxiety and increasing dental attendance [29,32]. CBT focuses on altering negative thoughts, teaching relaxation techniques, and gradual exposure to dental settings [33]; however, traditional treatments like CBT may not be cost-effective or scalable to meet the needs of those avoiding dental care [29]. Therefore, exploring alternative approaches is crucial in providing psychological support for common dental difficulties.

With an aim to identify alternative approaches, recent interest and literature in mindfulness-based interventions (MBIs) as anxiety treatments have been showing promise, offering cost-effective and single-session solutions [[34], [35], [36], [37]]. MBIs appeal to those averse to traditional treatments due to their non-stigmatizing nature [38], with practices that cultivate present-moment awareness and non-judgmental observation [39,40], and an enhancement of psychological flexibility and coping skills crucial for anxiety management [41]. They also reduce maladaptive processes like rumination and worry [42]. Moreover, mindfulness modulates emotional reactivity, enhancing emotion regulation and reducing anxiety responses [41,42]. Studies supported MBIs' efficacy across various anxiety disorders [43,44], and meta-analyses show moderate to large effects in reducing anxiety symptoms [45,46]. Acceptance and mindfulness-based interventions improve anxiety and depression outcomes through various mediators, including mindfulness skills and self-compassion [47]. These findings highlight the potential of MBIs to address dental anxiety, and thereby reduce dental neglect.

Interest has also been growing in self-compassion as a stand-alone MBI and anxiety treatment, enhancing psychological well-being and resilience [48]. Self-compassion interventions significantly reduce anxiety and depression symptoms [[49], [50], [51], [52], [53]], proposing an additional method to lead to health and wellbeing. Trials utilizing self-compassion have demonstrated reductions in anxiety symptoms and improved well-being [[54], [55], [56], [57]]. While traditionally practiced through meditation, MBIs include non-meditative approaches [58,59], creating some flexibility and adaptability to individual differences. Breathing interventions, like diaphragmatic breathing, show promise in reducing dental anxiety [60], although follow-up research is lacking, and importantly neglecting key aspects of mindfulness-based interventions. Continued research in these areas is essential to develop robust, scalable interventions that can effectively reduce both dental anxiety and neglect, and mindfulness and self-compassion may offer collectively or in isolation methods of treatment and care.

While mindfulness and self-compassion propose associations to, and are predictive of, several types of anxiety, and other research proposes a strong association between dental anxiety and dental neglect, mindfulness and self-compassion relating to and predicting dental neglect is a probable research hypothesis. If and once such potential associations were identified, the present research hypothesized that dental anxiety would be an explanatory factor of the association between mindfulness or self-compassion and dental neglect, to supply preliminary results that could support intervention development. Therefore, the aim of the present research was two-fold. First, it investigated the associations between dental anxiety and dental neglect, and potential associations with mindfulness and self-compassion. Second, it explored whether mindfulness and self-compassion predicted dental neglect, potentially through influencing dental anxiety.

2 Method

2.1 Participants

Four-hundred and seven undergraduate students were recruited through a university participant pool, of which 369 were female and 30 were male (eight participants did not provide information about their sex). Participants’ ages ranged from 18 to 56 years (M = 21.66, SD = 4.92). Two-hundred and ten participants stated their ethnicity as White, 82 as South Asian, 51 as Mixed, 47 as Black, four as Arab, two as Chinese and 11 did not provide information about their ethnicity. The inclusion criteria specified that participants should not have been diagnosed with any disorder within the past 12 months and should not have lost all of their teeth (which was not the case for any participants). According to Fritz and MacKinnon [61], a sample size of 368 participants would enable observations of an indirect effect of a small-sized alpha pathway coefficient (i.e., predictor to mediator) and a small-to-medium-sized beta pathway coefficient (i.e., mediator to criterion) at 80 % power using bias-corrected bootstrapping estimating procedures.

3 Materials

3.1 The Modified Dental Anxiety Scale (MDAS; Humphris et al., [62])

The MDAS includes 5 items that measure levels of dental anxiety (e.g., ‘If you went to your Dentist for TREATMENT TOMORROW, how would you feel?’). Responses are provided through a five-point Likert scale ranging from 1 (‘Not Anxious’) to 5 (‘Extremely Anxious’). Final summed scores range from 5 to 30, with a score of 23 or above indicating a highly dentally anxious patient or dentally phobic. Humphris et al. reported good reliability for MDAS (e.g., Cronbach's alpha, α = .72 for dental phobic patients and α = .90 for a community sample), with the MDAS in the present study similarly showing good reliability (Cronbach's α = .90; McDonald's omega, ω = .90).

3.2 The Dental Neglect Scale (DNS; Thompson and Locker, [63])

The DNS measures levels of dental neglect through 6 items (e.g., ‘I need dental care, but I put it off’). Response items range from 1 (‘Strongly Agree’) to 5 (‘Strongly Disagree’), with final summed scores indicating higher dental neglect. Thompson and Locker reported good reliability for the DNS (Cronbach's α of .71), which was replicated in the present study (Cronbach's α = .71; McDonald's ω = .71).

3.3 The Self-Compassion Scale (SCS; Neff, [48])

The 26-item SCS measures levels of self-compassion comprising the facets of Self-Kindness (e.g., ‘I'm kind to myself when I'm experiencing suffering.), Self-Judgment (e.g., ‘I'm disapproving and judgmental about my own flaws and inadequacies.’), Common Humanity (e.g., ‘I try to see my failings as part of the human condition.’), Isolation (e.g., ‘When I fail at something that's important to me, I tend to feel alone in my failure.’), Mindfulness (e.g., ‘When something upsets me I try to keep my emotions in balance.’) and Over-Identification (e.g., ‘When something painful happens I tend to blow the incident out of proportion.’). Responses range from 1 (‘Almost Never’) to 5 (‘Almost Always’) and mean final scores (after reverse scoring) indicate higher self-compassion levels. Neff (2003) reported good internal reliability for the SCS (Cronbach's α = .92). In the present study, the SCS similarly showed good internal reliability (Cronbach's α = .93; McDonald's ω = .94).

3.4 The Five Facet Mindfulness Questionnaire – Short Form (FFMQ-SF; Bohlmeijer et al., [64])

The 24-item FFMQ-SF, which corresponds to the original 39-item FFMQ [65], measures the five facets of mindfulness: observe (e.g., ‘I notice the smells and aromas of things’), describe (e.g., ‘I'm good at finding words to describe my feelings'), acting with awareness (e.g., ‘I am easily distracted’), non-judge (e.g., ‘I disapprove of myself when I have irrational ideas’) and non-react (e.g., ‘I watch my feelings without getting lost in them’). Responses are provided through a Likert scale ranging from 1 (‘never or rarely true’) to 5 (‘very often or always true’), with higher scores indicating higher levels of mindfulness. Bohlmeijer et al. reported good subscale reliability (Cronbach's alphas ranging from α = .73 to α = .91). The present study showed good internal reliability with Cronbach's α and McDonald's ω for total FFMQ-SF to be .83 and .81 respectively.

3.4.1 Procedure

Participants responded to a research advertisement placed exclusively on a university recruitment system in the West Midlands of the United Kingdom between 2022 and 2023. No other recruitment methods were employed. Participants read the participant information statement and continued with granting their consent for participation in the study. Then, participants filled in demographic information (i.e., age, sex and ethnicity) and completed the four self-report measures (i.e., MDAS, DNS, SCS, and FFMQ-SF). Participants were debriefed upon completion of the study. Ethical approval information is detailed in the declarations section.

3.4.2 Analysis

This study used Pearson's bivariate correlation to explore the relationships between variables. Next, mediation analyses were run to assess the impact of dental anxiety as a mediator on the relationships between mindfulness or self-compassion and dental neglect. Mediation analyses (Model 4) were carried out using the PROCESS macro [66] in SPSS version 28, with 5000 bootstrapped samples and bias-corrected 95 % confidence intervals.

4 Results

4.1 Bivariate correlations

Pearson's correlations confirmed the presence of previously reported associations, such as the positive correlation between dental anxiety and dental neglect and the positive correlation between mindfulness and self-compassion. The findings suggest that both mindfulness and self-compassion are negatively related to both dental anxiety and dental neglect (see Table 1).Table 1 Correlation results and corresponding descriptive statistics for the measured variables.

Table 1	FFMQ-SF	SCS	DAS	MDNS	M	SD	
FFMQ-SF	–				72.70	11.00	
SCS	.679**	–			77.90	21.55	
DAS	−.265**	−.173**	–		14.56	5.50	
MDNS	−.293**	−.199**	.255**	–	14.26	3.76	
Note. FFMQ-SF = Five Facet Mindfulness Questionnaire – Short Form; SCS = Self-Compassion Scale; MDAS = Modified Dental Anxiety Scale; DNS = Dental Neglect Scale; M = Mean; SD = Standard Deviation.

**. p < .001.

4.2 Mediation analyses

Table 2 displays the mediation analysis results for the potential mediating role of dental anxiety in the relationship between mindfulness and dental neglect. The indirect effect was supported (95 % CI = −.046 to −.008), confirming the hypothesis of dental anxiety mediating the positive association between mindfulness and dental neglect.Table 2 Mediation results of dental anxiety on the effect of mindfulness on dental neglect.

Table 2	Effect	SE	95%CI	
Lower	Upper	
Total effect	−.103	.024	−.150	−.057	
Direct effect	−.079	.024	−.123	−.033	
Indirect effect	−.024	.009	−.046	−.008	
Note. SE = Standard Error; 95%CI = 95 % Confidence Interval.

An additional mediation analysis explored the potential mediating role of dental anxiety in the relationship between self-compassion and dental neglect. The indirect effect was supported (95 % CI = .006 to .037), advocating the hypothesis of dental anxiety mediating the positive relationship between self-compassion and dental neglect (see Table 3, Fig. 1, Fig. 2).Table 3 Mediation results of dental anxiety on the effect of self-compassion on dental neglect.

Table 3	Effect	SE	95%CI	
Lower	Upper	
Total effect	−.035	.009	−.052	−.018	
Direct effect	−.028	.009	−.045	−.011	
Indirect effect	−.007	.003	−.014	−.003	
Note. SE = Standard Error; 95%CI = 95 % Confidence Interval.

Fig. 1 Parallel mediation using standardized regression coefficients to examine the interaction of mindfulness and dental neglect through dental anxiety. Note: ** = p < .0001, * = p < .001.

Fig. 1

Fig. 2 Parallel mediation using standardized regression coefficients to examine the interaction of self-compassion and dental neglect through dental anxiety. Note: ** = p < .0001, † = p = .0015.

Fig. 2

5 Discussion

The present research aimed to investigate the relationships between dental anxiety, dental neglect, mindfulness, and self-compassion. Specifically, the research focused on two main objectives. First, to analyse the correlations between dental anxiety, dental neglect, mindfulness, and self-compassion. Second, to explore whether mindfulness and self-compassion influence dental anxiety and, consequently, predict dental neglect. Understanding these relationships could provide valuable insights for developing effective interventions to improve oral health outcomes, and potentially explain the mechanisms behind mindfulness and self-compassion.

The findings reported in the study from correlations extend previous research by confirming the presence of established associations within the context of dental anxiety, dental neglect, mindfulness and self-compassion. Specifically, the positive correlation observed between dental anxiety and dental neglect supports prior research findings (e.g., 1; 3; 6). Similarly, the study replicated a positive correlation between mindfulness and self-compassion, corroborating previous research (e.g., [[49], [50], [51], [67]]). Of particular interest, the negative association of mindfulness and self-compassion to both dental anxiety and neglect proposed original findings, and potential for further examinations. Further assessment could explore the expectancy of mindfulness-based constructs and the well-known relationship to anxiety and anxiety-related disorders (e.g., 34; 26; 52; 55) to suggest a relative explanation for predicting dental neglect.

In particular, the investigation inquired into the potential mediating role of dental anxiety in the relationship between mindfulness or self-compassion and dental neglect. The results of the mediation analyses for mindfulness and self-compassion in predicting dental neglect were explained at least in part through the association with dental anxiety. Present findings replicate other similar research that has been conducted where the predictive value of self-compassion and mindfulness were mediated by anxiety (e.g., [[68], [69]]). While currently the knowledge is restricted to individual differences and trait constructs of mindfulness and self-compassion, the potential for future development of interventions proposes significant clinical implications.

Both mindfulness and self-compassion exhibit negative associations with dental anxiety and dental neglect, separately and in association. These results indicate that fostering mindfulness and self-compassion may hold promise in promoting favorable oral health behaviors by mitigating dental anxiety. Future investigations may benefit from exploring targeted interventions aimed at cultivating mindfulness and/or self-compassion as a means of alleviating dental anxiety and observing overall outcomes of oral health, as well as secondary outcomes such as the promotion of regular dental visits. Such future research will certainly address the common limitations found in cross-sectional studies and in research limited to university students, as in the present research, thereby enhancing its generalizability to the broader population. Present findings may also differ across older adult populations, and people who have suffered from psychological and/or dental difficulties, where clinical trials may be more decisive on the potential impact of mindfulness and/or self-compassion. Present findings are of clinical importance in that dental anxiety is a prevalent issue with substantial implications for both individuals and dental healthcare professionals. Future research should also focus on developing innovative, individualized, and patient-centered approaches that are possible and easily implemented through mindfulness-based practices.

In conclusion, findings reinforce established connections between dental anxiety and dental neglect, as well as mindfulness and self-compassion, aligning with prior research. Notable original contributions are negative associations linking mindfulness/self-compassion to dental anxiety and neglect. The mediation analyses suggest that dental anxiety may partly explain the relationship between mindfulness/self-compassion and dental neglect. While current knowledge focuses on individual differences and traits, the potential for future interventions to cultivate mindfulness and self-compassion holds promise for improving oral health behaviors by mitigating dental anxiety.

Consent for publication and ethical approval

Consent and ethical approval were obtained. Informed consent was obtained from all individual participants included in the study. This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Ethics Committee of the corresponding author's University (Reference Number: xx/4998/R(A)/2020/Feb/BLSS FAEC.

Funding

No funding supported the research or the preparation of this manuscript.

Data availability statement

Data will be available on request from the corresponding author.

CRediT authorship contribution statement

Charalampos Beltes: Writing – review & editing, Writing – original draft, Conceptualization. Kyriaki Giannou: Writing – review & editing, Writing – original draft, Methodology, Formal analysis, Conceptualization. Michail Mantzios: Writing – review & editing, Writing – original draft, Project administration, Methodology, Investigation, Formal analysis, Data curation, Conceptualization.

Declaration of competing interest

The authors have no relevant financial or non-financial interests to disclose.
==== Refs
References

1 Aydinoglu S.E.M.A. Arslan I. Are anxiety and the presence of siblings risk factors for dental neglect and oral health status in children? Arch. Pediatr. 28 2 2021 123 128 10.1016/j.arcped.2020.12.005 33455845
2 Eitner S. Wichmann M. Paulsen A. Holst S. Dental anxiety–an epidemiological study on its clinical correlation and effects on oral health J. Oral Rehabil. 33 8 2006 588 593 10.1111/j.1365-2842.2005.01589.x 16856956
3 Quteish Taani D.S.M. Dental anxiety and regularity of dental attendance in younger adults J. Oral Rehabil. 29 6 2002 604 608 10.1046/j.1365-2842.2002.00905.x 12071931
4 Kent G. Cognitive processes in dental anxiety Br. J. Clin. Psychol. 24 4 1985 259 264 10.1111/j.2044-8260.1985.tb00658.x 4074986
5 Berggren U. Carlsson S.G. Hakeberg M. Hägglin C. Samsonowitz V. Assessment of patients with phobic dental anxiety Acta Odontol. Scand. 55 4 1997 217 222 10.3109/00016359709115420 9298164
6 Skaret E. Raadal M. Berg E. Kvale G. Dental anxiety and dental avoidance among 12 to 18 year olds in Norway Eur. J. Oral Sci. 107 6 1999 422 428 10.1046/j.0909-8836.1999.eos107602.x 10625100
7 Humphris G. Dyer T. Robinson P.G. Rees N. The modified dental anxiety scale: UK general public population norms in 2008 with further psychometrics and effects of age BMC Oral Health 9 2019 20 10.1186/1472-6831-9-20
8 Tarrosh M.Y. Alhazmi Y.A. Aljabri M.Y. Bakri M.M.H. Al Shawkani H.A. Al Moaleem M.M. …Patil S. A systematic review of cross-sectional studies conducted in the Kingdom of Saudi Arabia on levels of dental anxiety between genders and demographic groups Med. Sci. Mon. Int. Med. J. Exp. Clin. Res. 28 2022 e937470 10.12659/MSM.937470
9 Kamin V. Fear, stress, and the well dental office NW. Dent. 85 2 2020 10 11
10 Nicolas E. Collado V. Faulks D. Bullier B. Hennequin M. A national cross-sectional survey of dental anxiety in the French adult population BMC Oral Health 7 2007 1 7 10.1186/1472-6831-7-12 17222356
11 Moore R. Birn H. Kirkegaard E. Brødsgaard I. Scheutz F. Prevalence and characteristics of dental anxiety in Danish adults Community Dent. Oral Epidemiol. 21 5 1993 292 296 10.1111/j.1600-0528.1993.tb00777.x 8222604
12 Armfield J.M. Heaton L.J. Management of fear and anxiety in the dental clinic: a review Aust. Dent. J. 58 4 2013 390 407 10.1111/adj.12118 24320894
13 Humphris G.M. King K. The prevalence of dental anxiety across previous distressing experiences J. Anxiety Disord. 25 2 2011 232 236 10.1016/j.janxdis.2010.09.007 20952156
14 Brahm C.O. Lundgren J. Carlsson S.G. Nilsson P. Corbeil J. Hägglin C. Dentists' views on fearful patients. Problems and promises Swed. Dent. J. 36 2 2012 79 89 22876395
15 Armfield J.M. Predicting dental avoidance among dentally fearful Australian adults Eur. J. Oral Sci. 121 2013 240 246 10.1111/eos.12036 23659256
16 Lin K.C. Behavior‐associated self‐report items in patient charts as predictors of dental appointment avoidance J. Dent. Educ. 73 2 2009 218 224 10.1002/j.0022-0337.2009.73.2.tb04657.x 19234078
17 Wong H.M. Bridges S.M. Ma K.W. Yiu C.K.Y. McGrath C.P. Zayts O.A. Advanced informatics understanding of clinician-patient communication: a mixed-method approach to oral health literacy talk in interpreter-mediated pediatric dentistry PLoS One 15 3 2020 e0230575 10.1371/journal.pone.0230575
18 Bhatia S.K. Maguire S.A. Chadwick B.L. Hunter M.L. Harris J.C. Tempest V. …Kemp A.M. Characteristics of child dental neglect: a systematic review J. Dent. 42 3 2014 229 239 10.1016/j.jdent.2013.10.010 24140926
19 Kiatipi M. Davidopoulou S. Arapostathis K. Arhakis A. Dental neglect in children: a comprehensive review of the literature J. Contemp. Dent. Pract. 22 2 2021 199 204 10.5005/jp-journals-10024-3019 34257183
20 McGrath C. Sham A.S.K. Ho D.K.L. Wong J.H.L. The impact of dental neglect on oral health: a population based study in Hong Kong Int. Dent. J. 57 1 2007 3 8 10.1111/j.1875-595X.2007.tb00111.x 17378343
21 Al Agili D.E. A systematic review of population-based dental caries studies among children in Saudi Arabia Saudi Dent J 16 3 2004 181 185 10.1016/j.sdentj.2012.10.002
22 Bilic S. Blomberg I. Burry K. Chong E. Yeung E. Ariyawardana A. Oral‐health‐related quality of life of dental patients: a hospital based study in far north Queensland, Australia J Investig Clin Dent 8 3 2017 e12216 10.1111/jicd.12216
23 Sarri G. Evans P. Stansfeld S. Marcenes W. A school-based epidemiological study of dental neglect among adolescents in a deprived area of the UK Br. Dent. J. 213 10 2012 E17 E19 10.1038/sj.bdj.2012.1042 23175099
24 Locker D. Thomson W.M. Poulton R. Psychological disorder, conditioning experiences, and the onset of dental anxiety in early adulthood J. Dent. Res. 80 6 2001 1588 1592 10.1177/00220345010800062201 11499519
25 Bernson J.M. Elfström M.L. Hakeberg M. Dental coping strategies, general anxiety, and depression among adult patients with dental anxiety but with different dental‐attendance patterns Eur. J. Oral Sci. 121 3pt2 2013 270 276 10.1111/eos.12039 23659261
26 Van Wijk A.J. Hoogstraten J. The Fear of Dental Pain questionnaire: construction and validity Eur. J. Oral Sci. 111 1 2003 12 18 10.1034/j.1600-0722.2003.00005.x 12558803
27 Aboud El Fadl R. Blair M. Hassounah S. Integrating maternal and children's oral health promotion into nursing and midwifery practice-a systematic review PLoS One 11 11 2016 e0166760 10.1371/journal.pone.0166760
28 Petersen P.E. Hunsrisakhun J. Thearmontree A. Pithpornchaiyakul S. Hintao J. Jürgensen N. Ellwood R.P. School-based intervention for improving the oral health of children in southern Thailand Community Dent. Health 32 1 2015 44 50 26263592
29 Aartman I.H. van Everdingen T. Hoogstraten J. Schuurs A.H. Appraisal of behavioral measurement techniques for assessing dental anxiety and fear in children: a review J. Psychopathol. Behav. Assess. 18 1996 153 171 10.1007/BF02229114
30 De Jongh A. Aartman I.H.A. Brand N. Trauma‐related phenomena in anxious dental patients Community Dent. Oral Epidemiol. 31 1 2003 52 58 10.1034/j.1600-0528.2003.00025.x 12542432
31 Lenk M. Berth H. Joraschky P. Petrowski K. Weidner K. Hannig C. Fear of dental treatment—an underrecognized symptom in people with impaired mental health Dtsch Arztebl Int 110 31–32 2013 517 10.3238/arztebl.2013.0517 24069071
32 Wide Boman U. Carlsson V. Westin M. Hakeberg M. Psychological treatment of dental anxiety among adults: a systematic review Eur. J. Oral Sci. 121 3pt2 2013 225 234 10.1111/eos.12032 23659254
33 Milgrom P. Mancl L. King B. Weinstein P. Origins of childhood dental fear Behav. Res. Ther. 33 3 1995 313 319 10.1016/0005-7967(94)00042-I 7726808
34 Arch J.J. Eifert G.H. Davies C. Vilardaga J.C.P. Rose R.D. Craske M.G. Randomized clinical trial of cognitive behavioral therapy (CBT) versus acceptance and commitment therapy (ACT) for mixed anxiety disorders J. Consult. Clin. Psychol. 80 5 2012 750 765 10.1037/a0028310 22563639
35 Singh S.K. Gorey K.M. Relative effectiveness of mindfulness and cognitive behavioral interventions for anxiety disorders: meta-analytic review Soc. Work. Ment. Health 16 2 2018 238 251 10.1080/15332985.2017.1373266
36 Blanck P. Perleth S. Heidenreich T. Kröger P. Ditzen B. Bents H. Mander J. Effects of mindfulness exercises as stand-alone intervention on symptoms of anxiety and depression: systematic review and meta-analysis Behav. Res. Ther. 102 2018 25 35 10.1016/j.brat.2017.12.002 29291584
37 Mantzios M. Giannou K. When did coloring books become mindful? Exploring the effectiveness of a novel method of mindfulness-guided instructions for coloring books to increase mindfulness and decrease anxiety Front. Psychol. 9 2018 56 10.3389/fpsyg.2018.00056 29441038
38 Kampmann I.L. Emmelkamp P.M. Hartanto D. Brinkman W.P. Zijlstra B.J. Morina N. Exposure to virtual social interactions in the treatment of social anxiety disorder: a randomized controlled trial Behav. Res. Ther. 77 2016 147 156 10.1016/j.brat.2015.12.016 26752328
39 Kabat-Zinn J. Wherever You Go There You Are 1994 Hyperion New York, NY
40 Bishop S.R. Lau M. Shapiro S. Carlson L. Anderson N.D. Carmody J. …Devins G. Mindfulness: a proposed operational definition Clin. Psychol. Sci. Pract. 11 3 2004 230 241 10.1093/clipsy.bph077
41 Roemer L. Williston S.K. Rollins L.G. Mindfulness and emotion regulation Curr Opin Psychol 3 2015 52 57 10.1016/j.copsyc.2015.02.006
42 Hoge E.A. Bui E. Marques L. Metcalf C.A. Morris L.K. Robinaugh D.J. Worthington J.J. Pollack M.H. Randomized controlled trial of mindfulness meditation for generalized anxiety disorder: effects on anxiety and stress reactivity J. Clin. Psychiatry 79 6 2018 17m11967 10.4088/JCP.12m08083
43 Evans S. Mindfulness-based cognitive therapy for generalized anxiety disorder Eisendrath S. Mindfulness-Based Cognitive Therapy 2016 Springer Cham 10.1007/978-3-319-29866-5_13
44 Goldin P.R. Gross J.J. Effects of mindfulness-based stress reduction (MBSR) on emotion regulation in social anxiety disorder Emotion 10 1 2010 83 91 10.1037/a0018441 20141305
45 Hofmann S.G. Sawyer A.T. Witt A.A. Oh D. The effect of mindfulness-based therapy on anxiety and depression: a meta-analytic review J. Consult. Clin. Psychol. 78 2 2010 169 183 10.1037/a0018555 20350028
46 Keng S.L. Smoski M.J. Robins C.J. Effects of mindfulness on psychological health: a review of empirical studies Clin. Psychol. Rev. 31 6 2011 1041 1056 10.1016/j.cpr.2011.04.006 21802619
47 Johannsen M. Nissen E.R. Lundorff M. O'Toole M.S. Mediators of acceptance and mindfulness-based therapies for anxiety and depression: a systematic review and meta-analysis Clin. Psychol. Rev. 94 2022 102156 10.1016/j.cpr.2022.102156
48 Neff K.D. Development and validation of a scale to measure self-compassion Self Ident. 2 3 2003 223 250 10.1080/15298860309027
49 Hussain M. Egan H. Keyte R. Strachan R. Tahrani A.A. Mantzios M. Exploring the association between self-compassion, mindfulness and mindful eating with eating behaviours amongst patients with obesity Nutr. Health 2022 02601060221094671 10.1177/02601060221094
50 Mantzios M. Egan H. Cook A. Jutley-Neilson J. O'Hara M. Wellbeing and the NSS: the potential of mindfulness and self-compassion for an enhanced student experience J. Furth. High. Educ. 44 3 2020 300 310 10.1080/0309877X.2018.1541970
51 Rizal F. Egan H. Cook A. Keyte R. Mantzios M. Examining the impact of mindfulness and self-compassion on the relationship between mental health and resiliency Curr. Issues Pers. Psychol. 8 4 2020 279 288 10.5114/cipp.2020.100792
52 Leary M.R. Tate E.B. Adams C.E. Batts Allen A. Hancock J. Self-compassion and reactions to unpleasant self-relevant events: the implications of treating oneself kindly J. Pers. Soc. Psychol. 92 5 2007 887 904 10.1037/0022-3514.92.5.887 17484611
53 Zessin U. Dickhäuser O. Garbade S. The relationship between self‐compassion and well‐being: a meta‐analysis Appl Psychol Health Well-Being 7 3 2015 340 364 10.1111/aphw.12051 26311196
54 Kearney D.J. Malte C.A. Storms M. Simpson T.L. Loving-kindness meditation vs cognitive processing therapy for posttraumatic stress disorder among veterans: a randomized clinical trial JAMA Netw. Open 4 4 2021 e216604 e216607 10.1001/jamanetworkopen.2021.6604 33861329
55 Egan S.J. Rees C.S. Delalande J. Greene D. Fitzallen G. Brown S. …Finlay-Jones A. A review of self-compassion as an active ingredient in the prevention and treatment of anxiety and depression in young people Adm Policy Ment Health Ment Health Serv Res 2021 1 19 10.1007/s10488-021-01170-2
56 Marsh I.C. Chan S.W. MacBeth A. Self-compassion and psychological distress in adolescents—a meta-analysis Mindfulness 9 2018 1011 1027 10.1007/s12671-017-0850-7 30100930
57 Dunne S. Sheffield D. Chilcot J. Brief report: self-compassion, physical health and the mediating role of health-promoting behaviours J. Health Psychol. 23 7 2018 993 999 10.1177/1359105316643377 27121978
58 Mantzios M. Tariq A. Altaf M. Giannou K. Loving-Kindness colouring and loving-kindness meditation: exploring the effectiveness of Non-meditative and meditative practices on state mindfulness and anxiety J. Creativ. Ment. Health 17 3 2022 305 312 10.1080/15401383.2021.1884159
59 Giannou K. Frowd C.D. Taylor J.R. Lander K. Mindfulness in face recognition: embedding mindfulness instructions in the face‐composite construction process Appl. Cognit. Psychol. 35 4 2021 999 1010 10.1002/acp.3829
60 Biggs Q.M. Kelly K.S. Toney J.D. The effects of deep diaphragmatic breathing and focused attention on dental anxiety in a private practice setting J. Dent. Hyg. 77 2 2003 105 113 12861790
61 Fritz M.S. MacKinnon D.P. Required sample size to detect the mediated effect Psychol. Sci. 18 3 2007 233 239 10.1111/j.1467-9280.2007.01882.x 17444920
62 Humphris G.M. Morrison T. Lindsay S.J. The modified dental anxiety scale: validation and United Kingdom norms Community Dent. Health 12 3 1995 143 150 7584581
63 Thomson W.M. Locker D. Dental neglect and dental health among 26‐year‐olds in the Dunedin Multidisciplinary Health and Development Study Community Dent. Oral Epidemiol. 28 6 2000 414 418 10.1034/j.1600-0528.2000.028006414.x 11106013
64 Bohlmeijer E. Ten Klooster P.M. Fledderus M. Veehof M. Baer R. Psychometric properties of the five facet mindfulness questionnaire in depressed adults and development of a short form Assessment 18 3 2011 308 320 10.1177/10731911114082 21586480
65 Baer R.A. Smith G.T. Hopkins J. Krietemeyer J. Toney L. Using self-report assessment methods to explore facets of mindfulness Assessment 13 1 2006 27 45 10.1177/1073191105283 16443717
66 Hayes A.F. Introduction to Mediation, Moderation, and Conditional Process Analysis: A Regression-Based Approach 2017 The Guilford Press New York
67 Giannou K. Lander K. Taylor J.R. Attentional features of mindfulness are better predictors of face recognition than empathy and compassion-based constructs Psychol. Rep. 126 3 2023 1481 1515 10.1177/00332941211061698 35113737
68 Quang A.M.T. Van Pham M. Mai T.T. Le G.N.H. Song G.A.N. Self-compassion and students' well-being among Vietnamese students: chain mediation effect of narcissism and anxiety J. Ration. Emot. Cogn. Behav. Ther. 40 3 2022 618 633 10.1007/s10942-021-00431-1
69 Chang X. Guo C. Zhou H. Liu L. Impact of rumination on sleep quality among patients with non-alcoholic fatty liver disease: a moderated mediation model of anxiety symptoms and resilience BMC Psychiatr. 23 1 2023 84 10.1186/s12888-023-04572-8
