The psychosocial web of oral health: exploring the links between sense of coherence, dental anxiety and quality of life in adolescents

SOC and its role in fear perception and coping

Sense of Coherence (SOC), conceptualized by Antonovsky as a central component of the salutogenic model of health, represents a person’s ability to perceive life as structured, predictable, and meaningful [3]. It comprises three core dimensions: comprehensibility (the extent to which one perceives internal and external stimuli as understandable), manageability (the belief in one’s ability to cope with demands), and meaningfulness (the emotional investment in challenges faced) [2]. In the context of dental care, these components significantly shape how individuals perceive and respond to threatening or stressful stimuli, such as dental procedures or clinical environments. A person with a strong SOC is more likely to view dental treatment as understandable (comprehensibility), believe they have the internal or external resources to deal with it (manageability), and perceive it as a meaningful or worthwhile health-promoting activity (meaningfulness). As a result, such individuals are less prone to experience overwhelming fear or anxiety when facing dental situations [8], 10].

Furthermore, SOC influences coping mechanisms. Individuals with high SOC are more inclined to use active, problem-focused coping strategies, while those with low SOC may rely on avoidant or emotion-focused coping, which are often associated with higher dental anxiety and subsequent avoidance of care [18].

Empirical findings: is high SOC associated with reduced dental anxiety?

Several studies have examined the relationship between SOC and dental anxiety, and the majority of findings suggest an inverse association – that is, higher SOC is correlated with lower levels of dental anxiety. Lindmark et al. reported that older adults with strong SOC had reduced dental treatment-related anxiety and were more compliant with oral health care routines [19]. Carlsson et al., SOC found SOC to moderate the relationship between dental anxiety and oral health behaviors, suggesting that individuals with high SOC may be more resilient to anxiety-provoking experiences, including those related to dental care [1]. Empirical studies substantiate this theoretical role. Naveen et al. found that adult dental outpatients with higher SOC reported significantly lower dental anxiety levels, suggesting that SOC buffers against fear perception in clinical settings [8]. Consistently, de Oliveira et al., in a systematic review and meta-analysis, demonstrated an inverse association between SOC and dental fear across populations, concluding that higher SOC reduces the odds of experiencing dental anxiety [10]. Additional evidence from adolescent populations (da Costa et al.; Lock et al.; Junior et al.) further indicates that individuals with stronger SOC not only report lower psychosocial impacts of oral conditions but also engage in more adaptive perceptions of their oral health, reinforcing SOC’s role as a resilience factor [6], 13], 14].

The findings position SOC as a central psychological construct in moderating dental anxiety, functioning through mechanisms of coping, resource mobilization, and stress appraisal (Carlsson et al.; Knorst et al.; Mathisen et al.) [1], 11], 15].

While these studies support the buffering role of SOC, they are mostly cross-sectional in design, limiting causal interpretation. However, the consistency of the association across age groups and cultural contexts reinforces the potential of SOC as a psychological protective factor against dental anxiety. In sum, a strong Sense of Coherence appears to act as a psychological shield that not only lowers the perception of dental situations as threatening but also fosters adaptive coping behaviors. These findings underscore the importance of considering SOC in both research and clinical interventions aimed at reducing dental anxiety.

Studies examining more than two constructs together

Several studies have simultaneously investigated SOC, DA, and OHRQoL, often within general population samples or specific clinical subgroups: Bonanato et al. studied Brazilian schoolchildren and found that low SOC was associated with increased dental anxiety, which in turn negatively impacted OHRQoL [20]. Their path analysis suggested that dental anxiety partially mediated the relationship between SOC and OHRQoL Carlsson et al. incorporated all three variables and observed that individuals with stronger SOC not only reported lower dental anxiety but also demonstrated better OHRQoL, particularly in the psychological discomfort and disability domains. They proposed that SOC directly influences both anxiety and quality of life perceptions [1]. Shacham et al. investigated a moderated mediation framework, showing that OHRQoL mediated the association between DA and ageing anxiety, while subjective accelerated ageing further moderated this pathway – highlighting the complex, multifactorial nature of these constructs [12]. In pediatric contexts, Hegazi et al. (2024) confirmed that both child and parental DA contributed to reduced child OHRQoL, underscoring that these dynamics may be intergenerational^. [16] Despite methodological differences, these studies consistently support the notion that SOC influences both dental anxiety and OHRQoL, either directly or through mediating psychological variables.

Gaps in the literature

Despite growing interest in the psychosocial dimensions of oral health, several notable gaps remain in the current literature examining the relationship among Sense of Coherence (SOC), Dental Anxiety (DA), and Oral Health-Related Quality of Life (OHRQoL):

1. Limited Integration of Constructs in a Single Model: Most existing studies have investigated SOC, DA, and OHRQoL in isolation or in pairs, rather than exploring how all three constructs interact within a unified theoretical or statistical framework. As a result, the triangular relationship among these variables is poorly understood. Few studies employ models that examine mediating or moderating effects, such as SOC buffering the impact of DA on OHRQoL, which limits our ability to understand causal or indirect pathways.

2. Predominance of Cross-Sectional Designs: The majority of available research is cross-sectional, providing only a snapshot of the associations between these variables. This design limitation precludes inferences about causality or directionality. Longitudinal studies are urgently needed to clarify whether a strong SOC can prospectively reduce dental anxiety or preserve OHRQoL over time, or conversely, whether poor OHRQoL and high anxiety erode one’s SOC.

3. Over-Reliance on Self-Report Measures: While SOC, DA, and OHRQoL are inherently subjective constructs, there is an over-reliance on self-report questionnaires, which may be prone to bias. Few studies incorporate objective clinical measures of oral health or triangulate self-reported data with behavioral observations or physiological indicators of anxiety.

4. Underrepresentation of Diverse Populations: Research in this domain has largely focused on Western, adult populations, often neglecting children, adolescents, older adults, and culturally diverse groups. Given that SOC and DA may be shaped by cultural norms, socioeconomic context, and life-stage-related factors, this limits the generalizability of findings. There is also a lack of focus on vulnerable groups such as individuals with disabilities, migrants, or those with chronic health conditions.

5. Lack of Intervention-Based Research: Although theoretical models suggest that enhancing SOC or reducing dental anxiety could improve OHRQoL, intervention studies are scarce. There is little evidence on whether psychological interventions – such as cognitive-behavioral therapy, stress management training, or SOC-enhancing programs – lead to measurable improvements in both anxiety and perceived oral health outcomes.

6. Inconsistent Use of Measurement Tools: Studies vary widely in the tools used to assess SOC (e.g., SOC-13 vs. SOC-29), DA (e.g., MDAS, DAS, DFS), and OHRQoL (e.g., OHIP-14, GOHAI, COHIP), making it difficult to compare findings across studies. The lack of standardized, validated instruments across settings and populations hinders synthesis and meta-analysis.

In summary, although evidence supports meaningful relationships between SOC, DA, and OHRQoL, the field remains fragmented. More robust, interdisciplinary research is needed to clarify how these constructs interrelate, how they evolve over time, and how they can be effectively targeted through prevention and intervention strategies in clinical and community settings.