Anticipating Tooth Extraction: Patient Experiences of a Communication-Sensitive Clinical Moment in Pakistan

Anticipating Tooth Extraction: Patient Experiences of a Communication-Sensitive Clinical Moment in Pakistan | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Anticipating Tooth Extraction: Patient Experiences of a Communication-Sensitive Clinical Moment in Pakistan Aamna Mansur, Nasir Ali, Sana Murtaza, Hafizah Sumayya Shaukat, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9061076/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 9 You are reading this latest preprint version Abstract Objective Tooth loss is a major public health concern, yet the period between the recommendation for extraction and the procedure remains underexplored. This study explored how adults in southern Khyber Pakhtunkhwa (KP), Pakistan, experience the anticipatory phase of non-emergency tooth extraction and how patient–dentist communication shapes emotional responses, social interpretations and coping behaviours during this period. Methods A qualitative study informed by phenomenological principles was conducted at the Institute of Dental Sciences Kohat, the only public-sector dental hospital in southern KP, Pakistan. Fifteen patients were purposively recruited using maximum variation sampling. Semi-structured interviews were conducted in Urdu or Pashto, audio-recorded, transcribed verbatim and translated into English. Data were analysed using reflexive thematic analysis following Braun and Clarke’s six-phase framework, with interpretation conceptually informed by the Common-Sense Model of Self-Regulation. Results Analysis revealed three interrelated themes characterising the anticipatory phase of tooth extraction: ( 1 ) perceived threat and identity disruption, ( 2 ) coping and behavioural self-regulation, and ( 3 ) clinical communication as a determinant of emotional readiness. Conclusion The anticipatory phase before tooth extraction was experienced as an emotionally and socially significant period that is rarely addressed in routine public-sector dental care. Fear, stigma, and concerns about appearance and social judgement, particularly among women, were prominent, while clear and empathetic clinician communication emerged as essential. These findings suggest the need for brief, culturally responsive pre-extraction counselling, locally appropriate educational and audio-visual materials, and stronger communication training, feedback, and evaluation systems to support more patient-centred care in resource-constrained settings. Tooth extraction patient-dentist communication anticipatory anxiety qualitative research oral health behaviour Pakistan Introduction Globally, in 2019, 3.5 billion people were affected by oral diseases, which are consistently identified as the most common non-communicable health issues worldwide ( 1 ). Evidence indicates that around 2.3 billion people suffer from untreated dental caries in their permanent teeth, whereas severe periodontal disease, a leading cause of tooth loss, impacts nearly 1 billion adults worldwide ( 2 ). Although substantial advances have been made in preventive and restorative dentistry, and tooth loss is largely preventable, it continues to represent a significant public health concern worldwide ( 3 ). The burden is especially pronounced in low- and middle-income countries, where restricted access to preventive services, under-resourced oral health systems, and financial barriers frequently lead to higher levels of edentulism and periodontal disease, contributing to a global economic loss estimated at approximately 234 billion dollars in 2021 ( 4 ). Pakistan, an LMIC, faces a considerable burden of dental caries, with a recent systematic review and meta-analysis estimating a pooled prevalence of around 57% in the population ( 5 ), while evidence from regional studies indicates substantial variation in periodontal disease prevalence, with estimates of approximately 37% in Punjab, 40% in Sindh, 20% in Khyber Pakhtunkhwa, and 3% in Baluchistan ( 6 ). Moreover, the World Health Organization recommends that countries allocate at least 6% of GDP to health; however, historical data from Pakistan indicate that, on average, only about 1.12% of GDP is spent on the health sector annually ( 7 ). These broader structural constraints within the health system leave limited resources for oral healthcare, resulting in high out of pocket expenditure, restricted access to preventive and restorative services, and delayed care seeking, which ultimately leads many individuals to rely on tooth extraction ( 8 , 9 ). In such a context, tooth loss reflects broader systemic and socio-economic constraints rather than purely clinical decisions; evidence from Pakistan indicates that untreated dental disease leading to delayed care contributes to around 63% of extractions, while periodontal disease accounts for approximately 26% ( 10 ). Similarly, evidence from Pakistan suggests that patients’ experiences and meanings attached to tooth loss are closely intertwined with socio-economic circumstances, where affordability constraints and levels of oral health awareness often shape decisions surrounding dental extraction ( 11 , 12 ). These epidemiological patterns underscore the importance of understanding tooth loss through a subjective lens in resource-constrained contexts. Qualitative research suggests that tooth loss extends far beyond functional impairment, as the mouth represents one of the most prominent physical features of the human body ( 13 ). A meta-synthesis has identified several key experiential domains associated with tooth loss, including compromised oral functioning, diminished social status and self-esteem, and the ongoing coping strategies individuals adopt in response to tooth loss ( 14 ). However, the majority of studies included in the synthesis were conducted in the Global North, with limited evidence from the Global South. Given that socio-cultural norms, gender dynamics, financial constraints, healthcare systems, dietary patterns, and oral hygiene practices differ substantially in these settings, the transferability of existing findings to LMIC contexts remains uncertain ( 14 , 15 ). While the psychosocial consequences following tooth loss have been well documented in the literature, considerably less attention has been directed towards the period before a prescribed extraction, which remains insufficiently explored in dental research ( 14 , 16 ). A qualitative study conducted in Northern Ireland reported that patients experience a distinct phase after being informed that their teeth must be removed, highlighting the interval between the clinical recommendation and the procedure itself ( 17 ). Another way to understand this distinct phase is through dental anxiety, which often peaks before treatment. Anticipatory anxiety, reflected through both subjective experiences and physiological indicators, suggests that the pre-treatment period represents a meaningful psychological stage rather than merely a waiting time before the procedure ( 18 , 19 ). This anticipatory phase may influence patients’ psychological responses to dental treatment, as research indicates that preoperative dental anxiety commonly occurs before tooth extraction and may affect the consent process while also shaping coping behaviours ( 19 ). The Common-Sense Model of Self-Regulation (CSM) provides a dynamic and multi-tiered conceptual framework for comprehending the anticipatory processes associated with individuals' perceptions, behaviours, and cognitive processes linked to their self-management of health threats, which are influenced by prior beliefs, socio-cultural contexts, and information obtained from healthcare professionals ( 20 ). The CSM proposes that individuals develop cognitive and emotional representations of illness based on personal experiences and communication with healthcare professionals during clinical encounters, and these perceptions subsequently guide coping responses and health related behaviours ( 20 ). Applying the CSM to anticipatory tooth loss therefore extends beyond clinical necessity to the sociocultural context of Pakistan, where hierarchical and patriarchal norms shape patient-dentist communication and influence how patients interpret extraction recommendations and regulate their cognitive and emotional responses. By conceptualising anticipation through the lens of the CSM, this study explores how adults awaiting non-emergency tooth extraction in a public-sector dental hospital in southern Khyber Pakhtunkhwa province of Pakistan experience patient-dentist communication during the anticipatory phase, and how such communication shapes emotional responses, social interpretations, coping strategies, and behavioural adaptation. Methods Study design This study employs a qualitative phenomenological approach to explore how adults awaiting non-emergency tooth extraction experience patient-dentist communication during the anticipatory phase prior to treatment. A phenomenological approach is particularly suited when the aim is to explore the lived experiences of patients in relation to a specific phenomenon, including their beliefs, attitudes, decision-making processes, and the meanings individuals assign to dental encounters ( 21 ). This study was informed by a relativist ontological position ( 22 ), recognising that patients’ experiences of dental treatment and clinician communication are shaped by individual beliefs, social contexts, and prior experiences. Epistemologically, the study adopted a qualitative interpretive approach aimed at understanding how participants make sense of their experiences within their social context rather than relying solely on numerical measures or predefined outcomes ( 23 ). More broadly, qualitative dental health research using a phenomenological perspective has demonstrated that understanding communication processes can help identify interactional challenges and inform improvements in clinical practice and patient safety, which quantitative methods may overlook ( 24 , 25 ). Participant recruitment Participants were recruited through purposive sampling from individuals who self-referred after being informed about the study. A study information leaflet describing the purpose of the study, procedures involved, and the voluntary nature of participation was made available within the dental hospital. To ensure accessibility, the leaflet was provided in local languages Pashto and Urdu. Patients who had been advised to undergo non-emergency tooth extraction and were interested in participating were invited to contact the researcher (AM) directly via telephone or email. Individuals who contacted the researcher were provided with further information about the study, and an interview was arranged at a time and place convenient for the participant. All participants preferred to be interviewed in a private room within the dental hospital prior to their extraction appointment. Before the interview commenced, participants were given the opportunity to ask questions, and approximately 10 minutes were allocated for clarification and discussion. The researcher explained the written informed consent process, including permission for audio-recording of the interview. Written informed consent was obtained from all participants prior to data collection. Participants were eligible for inclusion if they were adults aged 18 years or older who had been advised to undergo a non-emergency tooth extraction. Individuals requiring emergency dental treatment or those with severe cognitive impairment that could affect meaningful participation in an interview were excluded from the study. Data collection Data collection and interviews were conducted at the Institute of Dental Sciences, Kohat, between July and August 2025. Kohat is located in the southern belt of Khyber Pakhtunkhwa and is strategically positioned as a link between the northern and central regions of the province. The Institute of Dental Sciences serves as the only public sector dental hospital for a socioeconomically diverse catchment population from the surrounding districts. The southern divisions of Khyber Pakhtunkhwa, including Bannu Division, Dera Ismail Khan Division, and Kohat Division, represent densely populated and predominantly rural regions of the province. These divisions have estimated populations of approximately 2.66 million in Bannu Division, 2.80 million in Dera Ismail Khan Division, and 3.21 million in Kohat Division, collectively representing a population of approximately 8.67 million people ( 26 ). A semi-structured interview topic guide was developed by a multidisciplinary research team comprising experts and consultants in prosthodontics (AM, SM, NA), an experienced qualitative researcher and dental public health professional (MIK), dental public health trainees (HSS, SSB), and a maxillofacial surgeon (MK). The topic guide (Supplementary File 1) was developed through expert input from the research team and a comprehensive review of the existing literature. All interviews were conducted by the principal investigator (AM), a prosthodontist trained in qualitative interviewing techniques with prior experience in patient communication. Interviews were conducted in a private consultation room within the dental hospital to ensure participant comfort and confidentiality and were carried out in the local language ( Pashto or Urdu ). Prior to the interviews, participants were given the opportunity to ask questions about the study. Participants were informed about anonymisation and confidentiality procedures, and each participant was assigned a unique identification code to protect their identity. All participants provided written informed consent and consented to the audio recording of the interviews. Only the interviewer and the participant were present and each interview lasted approximately 20–30 minutes. The interviewer (AM) recorded field notes and reflective observations following each interview. Data saturation was reached after the fifteenth interview, at which point no new themes or insights emerged and data collection was discontinued ( 27 ). The research team held bi-monthly meetings throughout the study to discuss progress, emerging insights, and interpretations of the data. Data analysis The interviews were conducted in the local language (Pashto) and transcribed verbatim by the researcher (AM) in English. In line with the descriptive phenomenological approach, a thematic analysis of the data was adopted following the method of Sundler et al. (2019), which emphasises that research conducted through a phenomenological lens requires the researcher to remain reflective ( 28 ). The method proposes an iterative, meaning-oriented process that remains faithful to the lived essence of the experience rather than superficial categories ( 28 ). To support the qualitative analysis, the software package ATLAS.ti (version 1.9) was used to facilitate the storage of transcripts, adding comments or memos, highlighting segments of text or meaning units, writing analytic memos, grouping codes into patterns or themes, and using the network view to guide the thematic structure (29). First, the researcher remained neutral and set aside preconceived notions, writing a reflection note to acknowledge personal assumptions about the phenomenon. The research team members (AM and MIK) read the interview transcripts in their entirety to develop an understanding of the participants’ overall narratives. The researchers (AM and MIK) analysed smaller units of the transcripts. Specific meaning units closely related to the phenomenon were identified and extracted, after which the researchers returned to the full transcripts to determine whether these meaning units illustrated the overall experience. Subsequently, the meaning units were clustered into groups that explained the overall experience across participant accounts. The themes derived were then synthesised into a comprehensive description of the phenomenon to capture the essential meaning of the experience. The themes were presented using participants’ own words and experiences, supported by thick illustrative quotes. To minimise subjective bias, the research team (AM, NA, SM, HSS, MK, SSB, MIK) met regularly to reach consensus and ensure the reliability of the themes identified. The study is reported in accordance with the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist (Supplementary File 2). Results A total of 15 participants were included in the study. Most were female (n = 12) and aged 31–45 years (n = 10). The majority had higher secondary education or above (n = 10), while four had primary–secondary education and one had no formal schooling. Most participants resided in semi-urban areas (n = 11), with four from rural settings. Regarding clinical characteristics, posterior teeth were scheduled for extraction in ten cases, while five involved anterior teeth. Most participants had no previous extraction experience (n = 13), indicating that the procedure represented a first-time extraction for the majority. Table 1 Participant Characteristics (N = 15) Characteristic Category, n Gender Female ( 12 ), Male ( 3 ) Age (years) 18–30 ( 3 ), 31–45 ( 10 ), 46–60 ( 2 ) Education level No formal schooling ( 1 ), Primary–secondary ( 4 ), Higher secondary and above ( 10 ) Residence Semi-urban ( 11 ), Rural ( 4 ) Tooth region scheduled for extraction Anterior ( 5 ), Posterior ( 10 ) Previous extraction experience Yes ( 2 ), No – first-time extraction ( 13 ) Marital status Married ( 6 ), Single ( 5 ), Widowed ( 4 ) Employment Housewife ( 5 ), Informal sector workers ( 5 ), Students ( 3 ), Professionals ( 2 ) During the analysis of the participants' experiences, three interrelated themes emerged: 1) Emotional and social meanings of anticipated tooth loss; 2) Coping, faith, and behavioural adaptation during the waiting period; and 3) Clinical communication shaping emotional readiness for extraction. Theme 1: Emotional and Social Meanings of Anticipated Tooth Loss The first experience discovered was the intense emotional reactions upon learning that tooth extraction was required, followed by emerging anxiety after the clinical recommendation. These reactions were not limited to concerns about procedural pain; rather, the loss of a tooth encompassed not only the proper functioning of the mouth but also an irreversible bodily change, which influenced participants’ uncertainty about the outcome of the procedure. This essence was reflected across several key dimensions: bodily integrity and irreversible loss, threat to identity and self-image, social visibility and stigma, gendered vulnerability, and anticipatory behavioural withdrawal. Therefore, when asked about the meaning attributed to anticipatory tooth loss, the majority of participants expressed a traditional and somewhat fatalistic view, closely linked to anxiety and fears related to irreversible bodily change and uncertainty about the outcome of the procedure. “ The thought of undergoing anaesthesia and having a tooth extraction makes me nervous although I have undergone C-section, extraction feels worse .” (ID-4) “ I was very scared and anxious……...worried about the pain and the outcome .” (ID-5) When questioned about tooth extraction, many participants attached symbolic meaning to tooth loss beyond the removal of a diseased tooth. The prospect of losing a permanent body part generated feelings equivalent to shock, sadness, and a loss of control over one’s body. “ I didn't want to get it extracted. I wanted to explore other options… I was concerned about losing a part of my body and the potential impact on my other teeth .” (ID-1) “ I felt shock first, then sadness. I kept thinking, ‘Once a tooth is gone, it never comes back.’ I felt old suddenly. I also blamed myself for not coming earlier. Deep down, I felt fear-not just of pain, but of losing a part of myself.” (ID-11) Participants had a strong sense of how anticipated tooth loss disrupted their identity and self-image. They shared that extraction may be associated with ageing, personal failure, or loss of confidence, reflecting the deep attachment to natural teeth and the perceived threat posed by their loss. “ My first thought was aging. I immediately associated extraction with getting old. I felt a sudden drop in confidence, like I was losing something that defined me. ” (ID-9) “ Everyone teases me, I feel like I’m aging, like my personality is gone .” (ID-9) “ Extraction felt like deterioration rather than treatment. ” (ID-14) Participants expressed that anticipatory tooth loss had a deep social impact, as tooth loss could lead to negative perceptions of being observed and judged by others in society, particularly in relation to their appearance, social identity, and confidence. “ I worry that people will notice my missing tooth and judge me.” (ID-6) “ I avoid gatherings sometimes because I don’t feel confident… even at family events I stay quiet .” (ID-11) All the women participants noted that gender expectations intensified during the anticipatory phase of tooth loss. The thought of losing a tooth was described in relation to socio-cultural gender norms surrounding appearance and marital relationships with spouses, which amplified their fear and emotional distress. “ My family makes fun of me. My husband jokes about marrying again because of my teeth .” (ID-2) “ In our society, a woman’s appearance matters a lot. Missing teeth can make you feel embarrassed .” (ID-11) “ Front tooth loss is shameful for women… people look at your mouth first.” (ID-15) Participants expressed that perceived socio-cultural pressures led them to withdraw from social gatherings and interactions during the anticipatory phase. Anticipatory social stigma led women to navigate and internalise behavioural changes, including avoiding social gatherings or becoming self-conscious during conversations even before the extraction took place. “ I avoid social gatherings and prefer staying at home. I don’t feel comfortable facing people anymore .” (ID-6) “ I avoid hard foods and chew on one side only. I speak less and feel conscious all the time .” (ID-6) “ I avoid gatherings sometimes because I don’t feel confident.” (ID-11) “ I cover my mouth while speaking .” (ID-15) Theme 2: Coping, Faith and Behavioural Adaptation During the Waiting Period Despite experiencing considerable emotional distress, suffering, insecurities, and the challenges associated with awaiting extraction, participants described actively seeking ways to regulate their emotions and maintain psychological stability. Spirituality emerged as a central coping mechanism, allowing individuals to frame the experience within a broader religious, spiritual, and existential perspective, shaping their beliefs, values, and understanding of life’s challenges. “Life is full of challenges, and tooth extraction is just one of them.” (ID-3) “ I believe Allah tests His servants but also loves them. I try to stay positive and patient .” (ID-6) “ I just pray to Allah that everything goes well. I'm grateful for my overall health, and I try to be patient .” (ID-4) Participants adopted several coping strategies to regulate emotional distress while awaiting extraction. Faith-based reflections and spiritual coping provided hope, strengthened faith, and helped participants accept the inevitability of treatment while fostering a sense of protection, belonging, and emotional resilience. In addition, participants used personal strategies such as private reflection, prayer, meditation, cognitive reframing, and support from religious communities to manage feelings of guilt, worry, and sadness during the waiting period. “ I try to stay quiet. I pray. Sometimes I cry alone.” (ID-2) “ I try to rationalize it. I tell myself it’s common. I distract myself with work .” (ID-9) “ On the outside, I look calm. Inside, there’s guilt and worry .” (ID-13) Alongside emotional coping, participants also described behavioural adjustments prior to extraction, including increased awareness of oral health practices, changes in dietary habits, and modifying chewing patterns to manage discomfort and protect the affected tooth. “ It's made me more conscious about taking care of my teeth. I've increased my brushing frequency and I'm more mindful of my sugar intake.” (ID-1) “ I chew on one side and avoid hard foods. I’m constantly aware of my mouth .” (ID-13) “ I already avoid hard foods and eat carefully.” (ID-12) Theme 3: Clinical Communication Shaping Emotional Readiness for Extraction A central theme across all participants’ accounts was that the quality of clinician–patient communication played a critical role in shaping emotional responses and readiness to accept tooth extraction, suggesting that this interaction helps in managing patients’ doubts, addressing emotions, and enhancing self-management. Many participants described that when explanations were brief or purely procedural, the interaction felt dismissive, with several interruptions, limited attention, and non-existent non-verbal communication strategies, leaving them uncertain about the necessity of the procedure. “The doctor just said the tooth wasn’t serving any purpose… no one really counseled me.” (ID-2) “ At that time, there was no proper explanation, just ‘this tooth must come out.’ That memory still stays with me.” (ID-11) “ The dentist focused on the technical side .” (ID-9) On the other hand, some participants expressed that limited counselling and limited consultation time, along with a lack of acknowledgement of their emotional concerns and well-being, intensified feelings of anxiety and vulnerability during the anticipatory phase of treatment. Consequently, many participants stated that they wished they had received greater encouragement and emotional support from dentists. Participants suggested that clear communication, reassurance, and a more compassionate tone could improve their experience and strengthen patients’ perception of control over their condition. They recommended that dentists speak gently, tactfully explain treatment options, demonstrate emotional intelligence, and recognise the human element and emotional concerns associated with tooth loss, rather than focusing solely on the procedural and clinical aspects of care. “ They should speak gently and ask about patients’ feelings, not just focus on the teeth.” (ID-6) “ They should listen more. Explain gently. Ask about emotions, not just teeth .” (ID-11) “ Doctors should be empathetic and understanding, taking the time to explain treatment options and procedures clearly.” (ID-4) “ Speak kindly and reassure.” (ID-15) On the contrary, some participants noted that this pattern was not universal and was shaped by healthcare system structures. In their view, private dental practices were financially driven and action-oriented, whereas public hospitals involved longer waiting times but offered better communication. “Private care is fast but profit-driven… government doctors are slower but more caring.” (ID-3) Discussion This study provides insight into how adults awaiting non-emergency tooth extraction interpret and respond to the anticipatory phase of treatment within the context of patient–dentist communication. Interpreted through the Common-Sense Model, participants constructed cognitive and emotional representations of anticipated tooth loss that shaped their coping responses and behavioural adaptations. Tooth extraction was interpreted not merely as a clinical intervention but as a perceived threat to bodily integrity, identity, and social appearance. These illness representations generated emotional responses such as fear and anxiety, which were subsequently regulated through coping strategies including faith-based reflection and behavioural adjustments. Patient-dentist communication played a key role in shaping these representations and influencing emotional readiness for treatment. Participants did not perceive extraction as a routine clinical procedure; rather, it was interpreted as a threat to bodily integrity, identity and social belonging, with fear extending far beyond expected pain and revealing teeth to be a symbols of identity, self-worth and physical wholeness. Previous literature highlights a bidirectional relationship between tooth loss and psychological distress, with tooth loss associated with grief, anxiety, restlessness, fear of irreparable damage, shame, and depression ( 30 ). A large cross-sectional study using data from the National Health and Nutrition Examination Survey 2007–2020 reported a significant association between depression (7.4%) and tooth loss (58%), partly mediated by lifestyle factors (41.691%) and systemic immune-inflammation index (3.289%), suggesting behavioural and biological pathways linking psychological distress and tooth loss ( 31 ). Our findings are consistent with this literature; however, our study adds to and extends prior research by demonstrating that these feelings emerge before extraction, during the anticipatory period. In this study, gendered socio-cultural norms were expressed in relation to tooth loss, as teeth were symbolically linked to beauty, attractiveness, and marital stability, particularly among women. Our findings are consistent with previous evidence from South Asia (Lukacs, 2011), which recognises the numerous socio-cultural gender norms and expectations that shape dietary patterns and health behaviours, particularly those surrounding women’s bodies and health, contributing to higher rates of dental caries and tooth loss among women compared with men ( 32 ). These findings highlight the need for dental professionals to recognise the anticipatory phase of extraction as an emotional period, during which pre-emptive steps should be taken to discuss post-extraction restorative options. Effective, culturally informed communication should be central to this process, as it may help reduce anxiety and prevent treatment avoidance. Participants in this study reported that emotional distress required active self-regulation, beginning with finding motivation or becoming hopeful, which was often interpreted through the lens of spirituality and expressed through both religious beliefs and more general reflections. The findings from our study add to the existing body of literature on spirituality, which is widely recognised as a coping mechanism in chronic illness contexts, particularly in relation to mental health and cancer ( 33 , 34 ). However, limited evidence exists regarding the role of spirituality in the context of tooth extraction or tooth loss. Evidence from South Asian settings suggests that many Muslim individuals hold strong beliefs that Islamic spiritual teachings shape interpretations of illness, functioning both as a perceived causal explanation and as a healing or coping resource ( 35 ). Interestingly, in this study participants reported that behavioural adaptation also began prior to extraction, including dietary modification and improved oral hygiene in anticipation of tooth loss. Our findings extend the existing literature from LMICs, which has largely conceptualised behavioural adaptation as occurring only after tooth extraction or tooth loss ( 36 , 37 ). Therefore, this study highlights the anticipatory phase as an important communicative window, where effective clinician-patient dialogue may support oral health promotion by addressing patients’ concerns, offering preventive counselling, and encouraging positive oral health behaviours before extraction. In the present study, clinical communication emerged as a central determinant shaping how participants interpreted and emotionally processed the need for extraction; when communication was brief or limited to procedural explanations, anxiety intensified and perceived controllability diminished, with participants reporting that dentists often used these communication skills insufficiently. Similar barriers have been reported in Asian healthcare settings, where public sector doctors often have limited time for patient communication due to heavy patient loads and the need to reduce waiting times, particularly in systems where consultations occur without scheduled appointments ( 38 ). These findings may be partly explained by the study by Matusitz and Spear (2015), which compared doctor-patient communication styles in the United States with those in Asian settings including Pakistan, Japan, and Thailand, reporting that communication in these contexts tends to be more authoritative and physician-led, with doctors dominating the interaction while patients assume a more passive listening role, reflecting paternalistic approaches to care and more structured communication patterns shaped by broader cultural values influencing clinical encounters ( 39 ). Nevertheless, these findings reinforce the importance of established standards in clinical communication, including the effective use of verbal and non-verbal cues, discussion of treatment options through shared decision-making, and the use of open-ended questions, underscoring the need for these competencies to be developed from undergraduate training and embedded into routine clinical practice. Implications for practice, policy and research The study shows that the period before tooth extraction in a public-sector dental hospital in southern Khyber Pakhtunkhwa is associated with significant emotional and social concerns among patients, yet this stage is rarely addressed in routine care. In high-volume outpatient settings in LMIC public hospitals, limited consultation time often results in brief, procedure-focused discussions rather than patient-centred communication that supports trust and reassurance. Simple, low-cost interventions such as brief pre-extraction counselling by the treating dentist, waiting-area educational materials in the local language, tele-dentistry support, and task-shifting communication to dental assistants, auxiliary staff, or dental public health professionals may improve patient understanding and emotional readiness without increasing work-load. Similar approaches have been reported in dental public health services in comparable settings, use of visual aids, tele-dentistry, educational materials where proposed as strategies for counselling and patient education to enhance patient communication and oral health literacy in low-resource settings ( 40 – 42 ). Given that many participants expressed anxiety about visible tooth loss particularly women concerned about appearance, marital relationships, and social judgement communication should explicitly acknowledge these concerns. In the sociocultural context of southern Khyber Pakhtunkhwa, where family reputation and social perceptions are highly valued, addressing such anxieties at the anticipatory phase may help reduce stigma and strengthen trust between dentists and patients. Public sector hospitals may develop policies that incorporate patient-centred communication guidelines that address these socio-cultural concerns directly. Evidence from randomized trials shows that audiovisual educational tools can significantly reduce fear associated with tooth extraction compared with verbal counselling alone ( 43 ). Integrating such visual education material within dental clinics and waiting areas may support patient understanding while also helping normalise tooth extraction as a routine treatment rather than a socially stigmatising event. From a clinical training perspective, although dental curricula in Pakistan include communication skills training, greater emphasis is needed on evaluating these competencies in clinical practice. Public-sector hospitals could adopt validated assessment tools to identify clinicians requiring additional support in patient communication. Furthermore, incorporating patient feedback mechanisms would allow institutions to assess communication practices in relation to culture-specific expectations surrounding patient–doctor interactions and strengthen patient-centred care. For research, future work should extend beyond a single tertiary institution. Comparative analyses between public and private clinics in Khyber Pakhtunkhwa could clarify whether differences in communication reflect structural conditions rather than anecdotal variation. There is also a need to explore clinicians’ perspectives in this region, particularly how workload, institutional pressures, and time constraints shape communication practices. In addition, policy-oriented evaluations examining how institutional guidelines, training programmes, and patient feedback systems influence clinician–patient communication would provide valuable system-level insights. Finally, longitudinal research investigating whether anticipatory distress predicts post-extraction satisfaction, prosthesis uptake, or avoidance of future dental care could generate clinically actionable evidence. Strengths and weaknesses of the study This study has several important strengths. First, it focuses on the anticipatory phase of tooth extraction, an aspect of dental care that has received limited attention in existing literature. Much of the research on tooth loss has concentrated on post-extraction experiences, prosthetic rehabilitation, or clinical outcomes. By contrast, this study captures the period before the procedure, revealing how patients construct meanings around impending tooth loss, experience anxiety, and begin behavioural or emotional coping strategies prior to treatment. Second, the study provides contextually grounded insights from southern Khyber Pakhtunkhwa, a region with distinct social and demographic characteristics. Located near the Afghanistan–Pakistan border, the area hosts a substantial population of migrants and refugees following the conflicts of the 1990s and is characterised by considerable socioeconomic diversity across semi-urban and rural communities. Examining patient experiences within this setting helps illuminate how broader structural and sociocultural factors shape perceptions of anticipatory tooth loss. Third, the research was conducted in the only public-sector dental hospital serving southern Khyber Pakhtunkhwa, which functions as a key referral centre for surrounding rural districts. As a high-volume facility providing care to a large proportion of underserved rural populations, the setting offers valuable insights into real-world public dental services in the Global South. Consequently, the findings contribute to understanding how patient experiences and dentist–patient communication unfold within routine public-sector dental care environments. However, several limitations should be acknowledged. The study was conducted in a single public-sector institution, and therefore the findings may not fully reflect experiences in private dental clinics or other regions of Pakistan where service structures and patient populations may differ. In addition, the qualitative design prioritises depth and contextual understanding rather than statistical generalisability, and the findings should therefore be interpreted as analytically transferable rather than representative of all patient experiences. The participant sample also included a higher proportion of women, which may have shaped the prominence of gender-related perspectives reported in the findings. Furthermore, interviews were conducted by a female consultant prosthodontist; although efforts were made to establish rapport, the interviewer’s clinical role and the hierarchical dynamics common within South Asian healthcare settings may have influenced how participants expressed their views or the extent to which they disclosed sensitive concerns. Conclusion This qualitative study highlights that the anticipatory phase before tooth extraction in a public-sector dental hospital in southern Khyber Pakhtunkhwa, Pakistan is experienced as an emotionally and socially meaningful period, yet these concerns are rarely addressed within routine dental care. Participants described fear, stigma, and concerns about appearance and social judgement, particularly among women, while emphasising the importance of clear and empathetic communication from clinicians. The findings suggest that integrating brief, culturally responsive pre-extraction counselling, locally appropriate educational materials and audio-visual aids, alongside strengthened communication training, patient feedback mechanisms, and communication evaluations of dental staff within public-sector hospitals, may help acknowledge these concerns and support more patient-centred communication in resource-constrained settings. Declarations Competing Interests: The authors declare that they have no competing interests related to this study. Consent for participate All participants provided written informed consent before participating in the study. Consent for publication Not Applicable Human Ethics and Consent to Participate Ethical clearance for this study was obtained from the Ethics Review Committee, Institute of Public Health and Social Sciences (IPH&SS), Khyber Medical University (Reference: KMU/IPHSS/Ethics/2025/AP/264, approved on 25-04-2025). In this research study, the researchers assured confidentiality and anonymity during data collection and the publication of results in accordance with the Declaration of Helsinki. Funding This study was supported by a student research grant from the Office of Research, Innovation and Commercialization (ORIC), Khyber Medical University. The funding body had no role in the study design, data collection, analysis, interpretation of results, decision to publish, or preparation of the manuscript. Author Contribution (AM) contributed to the conceptualisation of the study, conducted data collection, and carried out the initial analysis and drafting of the manuscript. (NA), (SM), and (MK) contributed to transcription and critical revision of the manuscript. (HSS) contributed to data interpretation and manuscript review. (SSB) contributed to data analysis and manuscript preparation. (MIK) supervised the study and contributed to conceptualisation, methodology, and critical revision of the manuscript. All authors read and approved the final manuscript. Acknowledgement We sincerely thank all participants who generously gave their time to participate in the interviews and share their experiences for this study. Data Availability Available upon request. References Denis F, Clement C. Oral Health: A Major Global Public Health Concern. J Clin Med [Internet]. 2025 Jun 1 [cited 2026 Mar 6];14(12):4101. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC12194110/ Bernabe E, Marcenes W, Hernandez CR, Bailey J, Abreu LG, Alipour V et al. Global, Regional, and National Levels and Trends in Burden of Oral Conditions from 1990 to 2017: A Systematic Analysis for the Global Burden of Disease 2017 Study. J Dent Res [Internet]. 2020 Apr 1 [cited 2026 Mar 6];99(4):362–73. Available from: https://pubmed.ncbi.nlm.nih.gov/32122215/ Shrivastava SRBL, Bobhate PS, Kukde M. 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Available from: https://www.jumdc.com/index.php/jumdc/article/view/1009 Leventhal H, Phillips LA, Burns E. The Common-Sense Model of Self-Regulation (CSM): a dynamic framework for understanding illness self-management. J Behav Med [Internet]. 2016 Dec 1 [cited 2026 Mar 6];39(6):935–46. Available from: https://pubmed.ncbi.nlm.nih.gov/27515801/ Groenewald TA, Phenomenological Research Design Illustrated. : Int J Qual Methods [Internet]. 2016 Nov 29 [cited 2022 Sep 8];3(1):42–55. Available from: https://journals.sagepub.com/doi/ 10.1177/160940690400300104 Denzin NK, Lincoln YS, Giardina MD. Disciplining qualitative research. Int J Qual Stud Educ [Internet]. 2006 Nov 1 [cited 2024 Nov 6];19(6):769–82. Available from: https://www.tandfonline.com/doi/abs/10.1080/09518390600975990 Smith JA, Osborn M. Interpretative Phenomenological Analysis. In: Doing Social Psychology Research. 2008. Vasthare R, Lim AYR, Bagga A, Nayak PP, Bhat B. S S. The phenomenological approach in dentistry - a narrative review. Int J Qual Stud Health Well-being [Internet]. 2024 [cited 2026 Mar 6];19(1):2341450. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC11028029/ Kenny KP, Chauhan A, Pavitt S, Foy R, Day PF. Qualitative research in dental traumatology—A narrative review. Dent Traumatol [Internet]. 2024 Aug 1 [cited 2026 Mar 6];40(4):357–65. Available from: /doi/pdf/10.1111/edt.12935 Ullah K, Ahmed N, Waseem D, Ismail M. Population Distribution of Cities in Khyber Pakhtunkhwa and ZIPF`s Law. J Asian Dev Stud. 2025;14(3):474–87. Guest G, Namey E, Chen M. A simple method to assess and report thematic saturation in qualitative research. PLoS One [Internet]. 2020 May 1 [cited 2022 Feb 17];15(5):e0232076. Available from: https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0232076 Sundler AJ, Lindberg E, Nilsson C, Palmér L. Qualitative thematic analysis based on descriptive phenomenology. Nurs Open [Internet]. 2019 Jul 1 [cited 2024 Nov 10];6(3):733. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC6650661/ Smit B, Scherman V. Computer-Assisted Qualitative Data Analysis Software for Scoping Reviews: A Case of ATLAS.ti. Int J Qual Methods. 2021;20. Sinha N, Mishra B. Tooth Loss, Anxiety and Depression: A Viewpoint. Cent India J Med Res. 2025;4(01):13–5. Hao Y, Yuan Z, Zhu Y, Li S, Gou J, Dong S et al. Association between tooth loss and depression mediated by lifestyle and Inflammation- a cross-sectional investigation. BMC Public Heal 2024 241 [Internet]. 2024 Sep 27 [cited 2026 Mar 7];24(1):2627-. Available from: https://link.springer.com/article/ 10.1186/s12889-024-20065-z Lukacs JR. Gender differences in oral health in South Asia: metadata imply multifactorial biological and cultural causes. Am J Hum Biol [Internet]. 2011 May [cited 2026 Mar 7];23(3):398–411. Available from: https://pubmed.ncbi.nlm.nih.gov/21448908/ Lucchetti G, Koenig HG, Lucchetti ALG. Spirituality, religiousness, and mental health: A review of the current scientific evidence. World J Clin cases [Internet]. 2021 Sep 16 [cited 2026 Mar 7];9(26):7620–31. Available from: https://pubmed.ncbi.nlm.nih.gov/34621814/ Bai M, Lazenby M. A systematic review of associations between spiritual well-being and quality of life at the scale and factor levels in studies among patients with cancer. J Palliat Med [Internet]. 2015 Mar 1 [cited 2026 Mar 7];18(3):286–98. Available from: https://pubmed.ncbi.nlm.nih.gov/25303461/ Hussain NO. An exploration of spiritual healing methods amongst the south-asian muslim community in the north of England. J Hist Archaeol Anthropol Sci [Internet]. 2018 Mar 2 [cited 2026 Mar 7];3(2). Available from: https://www.researchgate.net/publication/327863476_An_exploration_of_spiritual_healing_methods_amongst_the_south-asian_muslim_community_in_the_north_of_England Nono D, Bagenda G, Okullo I, Rwenyonyi CM. Exploring lived experiences with tooth loss among fully edentulous patients attending Makerere University Dental Hospital, Kampala, Uganda. BMC Oral Heal 2024 241 [Internet]. 2024 Nov 7 [cited 2026 Mar 7];24(1):1355-. Available from: https://link.springer.com/article/ 10.1186/s12903-024-05150-4 Zelig R, Jones VM, Touger-Decker R, Hoskin ER, Singer SR, Byham-Gray L et al. The Eating Experience: Adaptive and Maladaptive Strategies of Older Adults with Tooth Loss. JDR Clin Transl Res [Internet]. 2019 Jul 1 [cited 2026 Mar 7];4(3):217–28. Available from: https://www.researchgate.net/publication/331436947_The_Eating_Experience_Adaptive_and_Maladaptive_Strategies_of_Older_Adults_with_Tooth_Loss Sun N, Rau PLP. Barriers to improve physician–patient communication in a primary care setting: perspectives of Chinese physicians. Heal Psychol Behav Med [Internet]. 2017 Jan [cited 2026 Mar 7];5(1):166–76. Available from: https://www.tandfonline.com/doi/pdf/ 10.1080/21642850.2017.1286498 Matusitz J, Spear J. Doctor-Patient Communication Styles: A Comparison Between the United States and Three Asian Countries. J Hum Behav Soc Environ. 2015;25(8):871–84. Nayak SU, Raja KP, Pal A, Pai K, Shenoy R, Teledentistry. A new oral care delivery tool among Indian dental professionals - a questionnaire study. F1000Research [Internet]. 2022 [cited 2026 Mar 8];11. Available from: https://pubmed.ncbi.nlm.nih.gov/36249998/ Chaudhry A, Ahmad N. Evaluation of the Impact of Audio-Visual Aids in Reducing Dental Patients’ Fear in Pakistan. J Univ Coll Med Dent [Internet]. 2023 Jun 6 [cited 2026 Mar 8];2(2):43–6. Available from: https://journals.uol.edu.pk/jucmd/article/view/2375 Hussain SA, Khanum N. Effects of Exposure to Animated Videos of Dental Procedures on Patient’s Anxiety and Decision-Making: An Experimental Study. Qlantic J Soc Sci Humanit. 2024;5(4):188–97. Gazal G, Tola AW, Fareed WM, Alnazzawi AA, Zafar MS. A randomized control trial comparing the visual and verbal communication methods for reducing fear and anxiety during tooth extraction. Saudi Dent J [Internet]. 2016 Apr 1 [cited 2026 Mar 8];28(2):80. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC4957266/ Additional Declarations No competing interests reported. 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14:28:19","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":19977,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementaryfile1.docx","url":"https://assets-eu.researchsquare.com/files/rs-9061076/v1/f321efc48bfd169a84db1c88.docx"},{"id":106726679,"identity":"0cdcb73c-86e5-48d8-8f7c-a78e9192a720","added_by":"auto","created_at":"2026-04-12 18:37:01","extension":"doc","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":71680,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementaryfile2.doc","url":"https://assets-eu.researchsquare.com/files/rs-9061076/v1/93a5253b362fa6ebdbdfcfee.doc"}],"financialInterests":"No competing interests reported.","formattedTitle":"Anticipating Tooth Extraction: Patient Experiences of a Communication-Sensitive Clinical Moment in Pakistan","fulltext":[{"header":"Introduction","content":"\u003cp\u003eGlobally, in 2019, 3.5\u0026nbsp;billion people were affected by oral diseases, which are consistently identified as the most common non-communicable health issues worldwide (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Evidence indicates that around 2.3\u0026nbsp;billion people suffer from untreated dental caries in their permanent teeth, whereas severe periodontal disease, a leading cause of tooth loss, impacts nearly 1\u0026nbsp;billion adults worldwide (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Although substantial advances have been made in preventive and restorative dentistry, and tooth loss is largely preventable, it continues to represent a significant public health concern worldwide (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). The burden is especially pronounced in low- and middle-income countries, where restricted access to preventive services, under-resourced oral health systems, and financial barriers frequently lead to higher levels of edentulism and periodontal disease, contributing to a global economic loss estimated at approximately 234\u0026nbsp;billion dollars in 2021 (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003ePakistan, an LMIC, faces a considerable burden of dental caries, with a recent systematic review and meta-analysis estimating a pooled prevalence of around 57% in the population (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e), while evidence from regional studies indicates substantial variation in periodontal disease prevalence, with estimates of approximately 37% in Punjab, 40% in Sindh, 20% in Khyber Pakhtunkhwa, and 3% in Baluchistan (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Moreover, the World Health Organization recommends that countries allocate at least 6% of GDP to health; however, historical data from Pakistan indicate that, on average, only about 1.12% of GDP is spent on the health sector annually (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). These broader structural constraints within the health system leave limited resources for oral healthcare, resulting in high out of pocket expenditure, restricted access to preventive and restorative services, and delayed care seeking, which ultimately leads many individuals to rely on tooth extraction (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). In such a context, tooth loss reflects broader systemic and socio-economic constraints rather than purely clinical decisions; evidence from Pakistan indicates that untreated dental disease leading to delayed care contributes to around 63% of extractions, while periodontal disease accounts for approximately 26% (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Similarly, evidence from Pakistan suggests that patients\u0026rsquo; experiences and meanings attached to tooth loss are closely intertwined with socio-economic circumstances, where affordability constraints and levels of oral health awareness often shape decisions surrounding dental extraction (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). These epidemiological patterns underscore the importance of understanding tooth loss through a subjective lens in resource-constrained contexts.\u003c/p\u003e \u003cp\u003eQualitative research suggests that tooth loss extends far beyond functional impairment, as the mouth represents one of the most prominent physical features of the human body (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). A meta-synthesis has identified several key experiential domains associated with tooth loss, including compromised oral functioning, diminished social status and self-esteem, and the ongoing coping strategies individuals adopt in response to tooth loss (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). However, the majority of studies included in the synthesis were conducted in the Global North, with limited evidence from the Global South. Given that socio-cultural norms, gender dynamics, financial constraints, healthcare systems, dietary patterns, and oral hygiene practices differ substantially in these settings, the transferability of existing findings to LMIC contexts remains uncertain (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). While the psychosocial consequences following tooth loss have been well documented in the literature, considerably less attention has been directed towards the period before a prescribed extraction, which remains insufficiently explored in dental research (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). A qualitative study conducted in Northern Ireland reported that patients experience a distinct phase after being informed that their teeth must be removed, highlighting the interval between the clinical recommendation and the procedure itself (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Another way to understand this distinct phase is through dental anxiety, which often peaks before treatment. Anticipatory anxiety, reflected through both subjective experiences and physiological indicators, suggests that the pre-treatment period represents a meaningful psychological stage rather than merely a waiting time before the procedure (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). This anticipatory phase may influence patients\u0026rsquo; psychological responses to dental treatment, as research indicates that preoperative dental anxiety commonly occurs before tooth extraction and may affect the consent process while also shaping coping behaviours (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe Common-Sense Model of Self-Regulation (CSM) provides a dynamic and multi-tiered conceptual framework for comprehending the anticipatory processes associated with individuals' perceptions, behaviours, and cognitive processes linked to their self-management of health threats, which are influenced by prior beliefs, socio-cultural contexts, and information obtained from healthcare professionals (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). The CSM proposes that individuals develop cognitive and emotional representations of illness based on personal experiences and communication with healthcare professionals during clinical encounters, and these perceptions subsequently guide coping responses and health related behaviours (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). Applying the CSM to anticipatory tooth loss therefore extends beyond clinical necessity to the sociocultural context of Pakistan, where hierarchical and patriarchal norms shape patient-dentist communication and influence how patients interpret extraction recommendations and regulate their cognitive and emotional responses.\u003c/p\u003e \u003cp\u003eBy conceptualising anticipation through the lens of the CSM, this study explores how adults awaiting non-emergency tooth extraction in a public-sector dental hospital in southern Khyber Pakhtunkhwa province of Pakistan experience patient-dentist communication during the anticipatory phase, and how such communication shapes emotional responses, social interpretations, coping strategies, and behavioural adaptation.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design\u003c/h2\u003e \u003cp\u003eThis study employs a qualitative phenomenological approach to explore how adults awaiting non-emergency tooth extraction experience patient-dentist communication during the anticipatory phase prior to treatment. A phenomenological approach is particularly suited when the aim is to explore the lived experiences of patients in relation to a specific phenomenon, including their beliefs, attitudes, decision-making processes, and the meanings individuals assign to dental encounters (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). This study was informed by a relativist ontological position (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e), recognising that patients\u0026rsquo; experiences of dental treatment and clinician communication are shaped by individual beliefs, social contexts, and prior experiences. Epistemologically, the study adopted a qualitative interpretive approach aimed at understanding how participants make sense of their experiences within their social context rather than relying solely on numerical measures or predefined outcomes (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). More broadly, qualitative dental health research using a phenomenological perspective has demonstrated that understanding communication processes can help identify interactional challenges and inform improvements in clinical practice and patient safety, which quantitative methods may overlook (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eParticipant recruitment\u003c/h3\u003e\n\u003cp\u003eParticipants were recruited through purposive sampling from individuals who self-referred after being informed about the study. A study information leaflet describing the purpose of the study, procedures involved, and the voluntary nature of participation was made available within the dental hospital. To ensure accessibility, the leaflet was provided in local languages Pashto and Urdu. Patients who had been advised to undergo non-emergency tooth extraction and were interested in participating were invited to contact the researcher (AM) directly via telephone or email.\u003c/p\u003e \u003cp\u003eIndividuals who contacted the researcher were provided with further information about the study, and an interview was arranged at a time and place convenient for the participant. All participants preferred to be interviewed in a private room within the dental hospital prior to their extraction appointment. Before the interview commenced, participants were given the opportunity to ask questions, and approximately 10 minutes were allocated for clarification and discussion. The researcher explained the written informed consent process, including permission for audio-recording of the interview. Written informed consent was obtained from all participants prior to data collection.\u003c/p\u003e \u003cp\u003eParticipants were eligible for inclusion if they were adults aged 18 years or older who had been advised to undergo a non-emergency tooth extraction. Individuals requiring emergency dental treatment or those with severe cognitive impairment that could affect meaningful participation in an interview were excluded from the study.\u003c/p\u003e\n\u003ch3\u003eData collection\u003c/h3\u003e\n\u003cp\u003eData collection and interviews were conducted at the Institute of Dental Sciences, Kohat, between July and August 2025. Kohat is located in the southern belt of Khyber Pakhtunkhwa and is strategically positioned as a link between the northern and central regions of the province. The Institute of Dental Sciences serves as the only public sector dental hospital for a socioeconomically diverse catchment population from the surrounding districts. The southern divisions of Khyber Pakhtunkhwa, including Bannu Division, Dera Ismail Khan Division, and Kohat Division, represent densely populated and predominantly rural regions of the province. These divisions have estimated populations of approximately 2.66\u0026nbsp;million in Bannu Division, 2.80\u0026nbsp;million in Dera Ismail Khan Division, and 3.21\u0026nbsp;million in Kohat Division, collectively representing a population of approximately 8.67\u0026nbsp;million people (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e A semi-structured interview topic guide was developed by a multidisciplinary research team comprising experts and consultants in prosthodontics (AM, SM, NA), an experienced qualitative researcher and dental public health professional (MIK), dental public health trainees (HSS, SSB), and a maxillofacial surgeon (MK). The topic guide (Supplementary File 1) was developed through expert input from the research team and a comprehensive review of the existing literature.\u003c/p\u003e \u003cp\u003eAll interviews were conducted by the principal investigator (AM), a prosthodontist trained in qualitative interviewing techniques with prior experience in patient communication. Interviews were conducted in a private consultation room within the dental hospital to ensure participant comfort and confidentiality and were carried out in the local language (\u003cem\u003ePashto or Urdu\u003c/em\u003e).\u003c/p\u003e \u003cp\u003ePrior to the interviews, participants were given the opportunity to ask questions about the study. Participants were informed about anonymisation and confidentiality procedures, and each participant was assigned a unique identification code to protect their identity. All participants provided written informed consent and consented to the audio recording of the interviews. Only the interviewer and the participant were present and each interview lasted approximately 20\u0026ndash;30 minutes.\u003c/p\u003e \u003cp\u003eThe interviewer (AM) recorded field notes and reflective observations following each interview. Data saturation was reached after the fifteenth interview, at which point no new themes or insights emerged and data collection was discontinued (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). The research team held bi-monthly meetings throughout the study to discuss progress, emerging insights, and interpretations of the data.\u003c/p\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003eThe interviews were conducted in the local language (Pashto) and transcribed verbatim by the researcher (AM) in English. In line with the descriptive phenomenological approach, a thematic analysis of the data was adopted following the method of Sundler et al. (2019), which emphasises that research conducted through a phenomenological lens requires the researcher to remain reflective (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). The method proposes an iterative, meaning-oriented process that remains faithful to the lived essence of the experience rather than superficial categories (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eTo support the qualitative analysis, the software package ATLAS.ti (version 1.9) was used to facilitate the storage of transcripts, adding comments or memos, highlighting segments of text or meaning units, writing analytic memos, grouping codes into patterns or themes, and using the network view to guide the thematic structure (29).\u003c/p\u003e \u003cp\u003eFirst, the researcher remained neutral and set aside preconceived notions, writing a reflection note to acknowledge personal assumptions about the phenomenon. The research team members (AM and MIK) read the interview transcripts in their entirety to develop an understanding of the participants\u0026rsquo; overall narratives. The researchers (AM and MIK) analysed smaller units of the transcripts. Specific meaning units closely related to the phenomenon were identified and extracted, after which the researchers returned to the full transcripts to determine whether these meaning units illustrated the overall experience.\u003c/p\u003e \u003cp\u003e Subsequently, the meaning units were clustered into groups that explained the overall experience across participant accounts. The themes derived were then synthesised into a comprehensive description of the phenomenon to capture the essential meaning of the experience. The themes were presented using participants\u0026rsquo; own words and experiences, supported by thick illustrative quotes. To minimise subjective bias, the research team (AM, NA, SM, HSS, MK, SSB, MIK) met regularly to reach consensus and ensure the reliability of the themes identified. The study is reported in accordance with the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist (Supplementary File 2).\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 15 participants were included in the study. Most were female (n\u0026thinsp;=\u0026thinsp;12) and aged 31\u0026ndash;45 years (n\u0026thinsp;=\u0026thinsp;10). The majority had higher secondary education or above (n\u0026thinsp;=\u0026thinsp;10), while four had primary\u0026ndash;secondary education and one had no formal schooling. Most participants resided in semi-urban areas (n\u0026thinsp;=\u0026thinsp;11), with four from rural settings.\u003c/p\u003e \u003cp\u003eRegarding clinical characteristics, posterior teeth were scheduled for extraction in ten cases, while five involved anterior teeth. Most participants had no previous extraction experience (n\u0026thinsp;=\u0026thinsp;13), indicating that the procedure represented a first-time extraction for the majority.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eParticipant Characteristics (N\u0026thinsp;=\u0026thinsp;15)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCategory, n\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGender\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e), Male (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge (years)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18\u0026ndash;30 (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e), 31\u0026ndash;45 (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e), 46\u0026ndash;60 (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEducation level\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo formal schooling (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e), Primary\u0026ndash;secondary (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e), Higher secondary and above (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eResidence\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSemi-urban (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e), Rural (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTooth region scheduled for extraction\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAnterior (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e), Posterior (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePrevious extraction experience\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e), No \u0026ndash; first-time extraction (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMarital status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMarried (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e), Single (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e), Widowed (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEmployment\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHousewife (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e), Informal sector workers (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e), Students (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e), Professionals (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e During the analysis of the participants' experiences, three interrelated themes emerged: 1) Emotional and social meanings of anticipated tooth loss; 2) Coping, faith, and behavioural adaptation during the waiting period; and 3) Clinical communication shaping emotional readiness for extraction.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eTheme 1: Emotional and Social Meanings of Anticipated Tooth Loss\u003c/h2\u003e \u003cp\u003eThe first experience discovered was the intense emotional reactions upon learning that tooth extraction was required, followed by emerging anxiety after the clinical recommendation. These reactions were not limited to concerns about procedural pain; rather, the loss of a tooth encompassed not only the proper functioning of the mouth but also an irreversible bodily change, which influenced participants\u0026rsquo; uncertainty about the outcome of the procedure. This essence was reflected across several key dimensions: bodily integrity and irreversible loss, threat to identity and self-image, social visibility and stigma, gendered vulnerability, and anticipatory behavioural withdrawal.\u003c/p\u003e \u003cp\u003eTherefore, when asked about the meaning attributed to anticipatory tooth loss, the majority of participants expressed a traditional and somewhat fatalistic view, closely linked to anxiety and fears related to irreversible bodily change and uncertainty about the outcome of the procedure.\u003c/p\u003e \u003cp\u003e\u0026ldquo;\u003cem\u003eThe thought of undergoing anaesthesia and having a tooth extraction makes me nervous although I have undergone C-section, extraction feels worse\u003c/em\u003e.\u0026rdquo; (ID-4)\u003c/p\u003e \u003cp\u003e\u0026ldquo;\u003cem\u003eI was very scared and anxious\u0026hellip;\u0026hellip;...worried about the pain and the outcome\u003c/em\u003e.\u0026rdquo; (ID-5)\u003c/p\u003e \u003cp\u003eWhen questioned about tooth extraction, many participants attached symbolic meaning to tooth loss beyond the removal of a diseased tooth. The prospect of losing a permanent body part generated feelings equivalent to shock, sadness, and a loss of control over one\u0026rsquo;s body.\u003c/p\u003e \u003cp\u003e\u0026ldquo;\u003cem\u003eI didn't want to get it extracted. I wanted to explore other options\u0026hellip; I was concerned about losing a part of my body and the potential impact on my other teeth\u003c/em\u003e.\u0026rdquo; (ID-1)\u003c/p\u003e \u003cp\u003e\u0026ldquo;\u003cem\u003eI felt shock first, then sadness. I kept thinking, \u0026lsquo;Once a tooth is gone, it never comes back.\u0026rsquo; I felt old suddenly. I also blamed myself for not coming earlier. Deep down, I felt fear-not just of pain, but of losing a part of myself.\u0026rdquo;\u003c/em\u003e (ID-11)\u003c/p\u003e \u003cp\u003eParticipants had a strong sense of how anticipated tooth loss disrupted their identity and self-image. They shared that extraction may be associated with ageing, personal failure, or loss of confidence, reflecting the deep attachment to natural teeth and the perceived threat posed by their loss.\u003c/p\u003e \u003cp\u003e\u0026ldquo;\u003cem\u003eMy first thought was aging. I immediately associated extraction with getting old. I felt a sudden drop in confidence, like I was losing something that defined me.\u003c/em\u003e\u0026rdquo; (ID-9)\u003c/p\u003e \u003cp\u003e\u0026ldquo;\u003cem\u003eEveryone teases me, I feel like I\u0026rsquo;m aging, like my personality is gone\u003c/em\u003e.\u0026rdquo; (ID-9)\u003c/p\u003e \u003cp\u003e\u0026ldquo;\u003cem\u003eExtraction felt like deterioration rather than treatment.\u003c/em\u003e\u0026rdquo; (ID-14)\u003c/p\u003e \u003cp\u003eParticipants expressed that anticipatory tooth loss had a deep social impact, as tooth loss could lead to negative perceptions of being observed and judged by others in society, particularly in relation to their appearance, social identity, and confidence.\u003c/p\u003e \u003cp\u003e\u0026ldquo;\u003cem\u003eI worry that people will notice my missing tooth and judge me.\u0026rdquo;\u003c/em\u003e (ID-6)\u003c/p\u003e \u003cp\u003e\u0026ldquo;\u003cem\u003eI avoid gatherings sometimes because I don\u0026rsquo;t feel confident\u0026hellip; even at family events I stay quiet\u003c/em\u003e.\u0026rdquo; (ID-11)\u003c/p\u003e \u003cp\u003eAll the women participants noted that gender expectations intensified during the anticipatory phase of tooth loss. The thought of losing a tooth was described in relation to socio-cultural gender norms surrounding appearance and marital relationships with spouses, which amplified their fear and emotional distress.\u003c/p\u003e \u003cp\u003e\u0026ldquo;\u003cem\u003eMy family makes fun of me. My husband jokes about marrying again because of my teeth\u003c/em\u003e.\u0026rdquo; (ID-2)\u003c/p\u003e \u003cp\u003e\u0026ldquo;\u003cem\u003eIn our society, a woman\u0026rsquo;s appearance matters a lot. Missing teeth can make you feel embarrassed\u003c/em\u003e.\u0026rdquo; (ID-11)\u003c/p\u003e \u003cp\u003e\u0026ldquo;\u003cem\u003eFront tooth loss is shameful for women\u0026hellip; people look at your mouth first.\u0026rdquo;\u003c/em\u003e (ID-15)\u003c/p\u003e \u003cp\u003e Participants expressed that perceived socio-cultural pressures led them to withdraw from social gatherings and interactions during the anticipatory phase. Anticipatory social stigma led women to navigate and internalise behavioural changes, including avoiding social gatherings or becoming self-conscious during conversations even before the extraction took place.\u003c/p\u003e \u003cp\u003e\u0026ldquo;\u003cem\u003eI avoid social gatherings and prefer staying at home. I don\u0026rsquo;t feel comfortable facing people anymore\u003c/em\u003e.\u0026rdquo; (ID-6)\u003c/p\u003e \u003cp\u003e\u0026ldquo;\u003cem\u003eI avoid hard foods and chew on one side only. I speak less and feel conscious all the time\u003c/em\u003e.\u0026rdquo; (ID-6)\u003c/p\u003e \u003cp\u003e\u0026ldquo;\u003cem\u003eI avoid gatherings sometimes because I don\u0026rsquo;t feel confident.\u0026rdquo;\u003c/em\u003e (ID-11)\u003c/p\u003e \u003cp\u003e\u0026ldquo;\u003cem\u003eI cover my mouth while speaking\u003c/em\u003e.\u0026rdquo; (ID-15)\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eTheme 2: Coping, Faith and Behavioural Adaptation During the Waiting Period\u003c/h3\u003e\n\u003cp\u003e Despite experiencing considerable emotional distress, suffering, insecurities, and the challenges associated with awaiting extraction, participants described actively seeking ways to regulate their emotions and maintain psychological stability. Spirituality emerged as a central coping mechanism, allowing individuals to frame the experience within a broader religious, spiritual, and existential perspective, shaping their beliefs, values, and understanding of life\u0026rsquo;s challenges.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Life is full of challenges, and tooth extraction is just one of them.\u0026rdquo; (ID-3)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e\u0026ldquo;\u003cem\u003eI believe Allah tests His servants but also loves them. I try to stay positive and patient\u003c/em\u003e.\u0026rdquo; (ID-6)\u003c/p\u003e \u003cp\u003e\u0026ldquo;\u003cem\u003eI just pray to Allah that everything goes well. I'm grateful for my overall health, and I try to be patient\u003c/em\u003e.\u0026rdquo; (ID-4)\u003c/p\u003e \u003cp\u003e Participants adopted several coping strategies to regulate emotional distress while awaiting extraction. Faith-based reflections and spiritual coping provided hope, strengthened faith, and helped participants accept the inevitability of treatment while fostering a sense of protection, belonging, and emotional resilience. In addition, participants used personal strategies such as private reflection, prayer, meditation, cognitive reframing, and support from religious communities to manage feelings of guilt, worry, and sadness during the waiting period.\u003c/p\u003e \u003cp\u003e\u0026ldquo;\u003cem\u003eI try to stay quiet. I pray. Sometimes I cry alone.\u0026rdquo;\u003c/em\u003e (ID-2)\u003c/p\u003e \u003cp\u003e\u0026ldquo;\u003cem\u003eI try to rationalize it. I tell myself it\u0026rsquo;s common. I distract myself with work\u003c/em\u003e.\u0026rdquo; (ID-9)\u003c/p\u003e \u003cp\u003e\u0026ldquo;\u003cem\u003eOn the outside, I look calm. Inside, there\u0026rsquo;s guilt and worry\u003c/em\u003e.\u0026rdquo; (ID-13)\u003c/p\u003e \u003cp\u003e Alongside emotional coping, participants also described behavioural adjustments prior to extraction, including increased awareness of oral health practices, changes in dietary habits, and modifying chewing patterns to manage discomfort and protect the affected tooth.\u003c/p\u003e \u003cp\u003e\u0026ldquo;\u003cem\u003eIt's made me more conscious about taking care of my teeth. I've increased my brushing frequency and I'm more mindful of my sugar intake.\u0026rdquo;\u003c/em\u003e (ID-1)\u003c/p\u003e \u003cp\u003e\u0026ldquo;\u003cem\u003eI chew on one side and avoid hard foods. I\u0026rsquo;m constantly aware of my mouth\u003c/em\u003e.\u0026rdquo; (ID-13)\u003c/p\u003e \u003cp\u003e\u0026ldquo;\u003cem\u003eI already avoid hard foods and eat carefully.\u0026rdquo;\u003c/em\u003e (ID-12)\u003c/p\u003e\n\u003ch3\u003eTheme 3: Clinical Communication Shaping Emotional Readiness for Extraction\u003c/h3\u003e\n\u003cp\u003e A central theme across all participants\u0026rsquo; accounts was that the quality of clinician\u0026ndash;patient communication played a critical role in shaping emotional responses and readiness to accept tooth extraction, suggesting that this interaction helps in managing patients\u0026rsquo; doubts, addressing emotions, and enhancing self-management. Many participants described that when explanations were brief or purely procedural, the interaction felt dismissive, with several interruptions, limited attention, and non-existent non-verbal communication strategies, leaving them uncertain about the necessity of the procedure.\u003c/p\u003e \u003cp\u003e\u0026ldquo;The doctor just said the tooth wasn\u0026rsquo;t serving any purpose\u0026hellip; no one really counseled me.\u0026rdquo; (ID-2)\u003c/p\u003e \u003cp\u003e\u0026ldquo;\u003cem\u003eAt that time, there was no proper explanation, just \u0026lsquo;this tooth must come out.\u0026rsquo; That memory still stays with me.\u0026rdquo;\u003c/em\u003e (ID-11)\u003c/p\u003e \u003cp\u003e\u0026ldquo;\u003cem\u003eThe dentist focused on the technical side\u003c/em\u003e.\u0026rdquo; (ID-9)\u003c/p\u003e \u003cp\u003e On the other hand, some participants expressed that limited counselling and limited consultation time, along with a lack of acknowledgement of their emotional concerns and well-being, intensified feelings of anxiety and vulnerability during the anticipatory phase of treatment. Consequently, many participants stated that they wished they had received greater encouragement and emotional support from dentists.\u003c/p\u003e \u003cp\u003e Participants suggested that clear communication, reassurance, and a more compassionate tone could improve their experience and strengthen patients\u0026rsquo; perception of control over their condition. They recommended that dentists speak gently, tactfully explain treatment options, demonstrate emotional intelligence, and recognise the human element and emotional concerns associated with tooth loss, rather than focusing solely on the procedural and clinical aspects of care.\u003c/p\u003e \u003cp\u003e\u0026ldquo;\u003cem\u003eThey should speak gently and ask about patients\u0026rsquo; feelings, not just focus on the teeth.\u0026rdquo;\u003c/em\u003e (ID-6)\u003c/p\u003e \u003cp\u003e\u0026ldquo;\u003cem\u003eThey should listen more. Explain gently. Ask about emotions, not just teeth\u003c/em\u003e.\u0026rdquo; (ID-11)\u003c/p\u003e \u003cp\u003e\u0026ldquo;\u003cem\u003eDoctors should be empathetic and understanding, taking the time to explain treatment options and procedures clearly.\u0026rdquo;\u003c/em\u003e (ID-4)\u003c/p\u003e \u003cp\u003e\u0026ldquo;\u003cem\u003eSpeak kindly and reassure.\u0026rdquo;\u003c/em\u003e (ID-15)\u003c/p\u003e \u003cp\u003eOn the contrary, some participants noted that this pattern was not universal and was shaped by healthcare system structures. In their view, private dental practices were financially driven and action-oriented, whereas public hospitals involved longer waiting times but offered better communication.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Private care is fast but profit-driven\u0026hellip; government doctors are slower but more caring.\u0026rdquo; (ID-3)\u003c/em\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study provides insight into how adults awaiting non-emergency tooth extraction interpret and respond to the anticipatory phase of treatment within the context of patient\u0026ndash;dentist communication. Interpreted through the Common-Sense Model, participants constructed cognitive and emotional representations of anticipated tooth loss that shaped their coping responses and behavioural adaptations. Tooth extraction was interpreted not merely as a clinical intervention but as a perceived threat to bodily integrity, identity, and social appearance. These illness representations generated emotional responses such as fear and anxiety, which were subsequently regulated through coping strategies including faith-based reflection and behavioural adjustments. Patient-dentist communication played a key role in shaping these representations and influencing emotional readiness for treatment.\u003c/p\u003e \u003cp\u003e Participants did not perceive extraction as a routine clinical procedure; rather, it was interpreted as a threat to bodily integrity, identity and social belonging, with fear extending far beyond expected pain and revealing teeth to be a symbols of identity, self-worth and physical wholeness. Previous literature highlights a bidirectional relationship between tooth loss and psychological distress, with tooth loss associated with grief, anxiety, restlessness, fear of irreparable damage, shame, and depression (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). A large cross-sectional study using data from the National Health and Nutrition Examination Survey 2007\u0026ndash;2020 reported a significant association between depression (7.4%) and tooth loss (58%), partly mediated by lifestyle factors (41.691%) and systemic immune-inflammation index (3.289%), suggesting behavioural and biological pathways linking psychological distress and tooth loss (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). Our findings are consistent with this literature; however, our study adds to and extends prior research by demonstrating that these feelings emerge before extraction, during the anticipatory period.\u003c/p\u003e \u003cp\u003eIn this study, gendered socio-cultural norms were expressed in relation to tooth loss, as teeth were symbolically linked to beauty, attractiveness, and marital stability, particularly among women. Our findings are consistent with previous evidence from South Asia (Lukacs, 2011), which recognises the numerous socio-cultural gender norms and expectations that shape dietary patterns and health behaviours, particularly those surrounding women\u0026rsquo;s bodies and health, contributing to higher rates of dental caries and tooth loss among women compared with men (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). These findings highlight the need for dental professionals to recognise the anticipatory phase of extraction as an emotional period, during which pre-emptive steps should be taken to discuss post-extraction restorative options. Effective, culturally informed communication should be central to this process, as it may help reduce anxiety and prevent treatment avoidance.\u003c/p\u003e \u003cp\u003eParticipants in this study reported that emotional distress required active self-regulation, beginning with finding motivation or becoming hopeful, which was often interpreted through the lens of spirituality and expressed through both religious beliefs and more general reflections. The findings from our study add to the existing body of literature on spirituality, which is widely recognised as a coping mechanism in chronic illness contexts, particularly in relation to mental health and cancer (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). However, limited evidence exists regarding the role of spirituality in the context of tooth extraction or tooth loss. Evidence from South Asian settings suggests that many Muslim individuals hold strong beliefs that Islamic spiritual teachings shape interpretations of illness, functioning both as a perceived causal explanation and as a healing or coping resource (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e). Interestingly, in this study participants reported that behavioural adaptation also began prior to extraction, including dietary modification and improved oral hygiene in anticipation of tooth loss. Our findings extend the existing literature from LMICs, which has largely conceptualised behavioural adaptation as occurring only after tooth extraction or tooth loss (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e). Therefore, this study highlights the anticipatory phase as an important communicative window, where effective clinician-patient dialogue may support oral health promotion by addressing patients\u0026rsquo; concerns, offering preventive counselling, and encouraging positive oral health behaviours before extraction.\u003c/p\u003e \u003cp\u003e In the present study, clinical communication emerged as a central determinant shaping how participants interpreted and emotionally processed the need for extraction; when communication was brief or limited to procedural explanations, anxiety intensified and perceived controllability diminished, with participants reporting that dentists often used these communication skills insufficiently. Similar barriers have been reported in Asian healthcare settings, where public sector doctors often have limited time for patient communication due to heavy patient loads and the need to reduce waiting times, particularly in systems where consultations occur without scheduled appointments (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e). These findings may be partly explained by the study by Matusitz and Spear (2015), which compared doctor-patient communication styles in the United States with those in Asian settings including Pakistan, Japan, and Thailand, reporting that communication in these contexts tends to be more authoritative and physician-led, with doctors dominating the interaction while patients assume a more passive listening role, reflecting paternalistic approaches to care and more structured communication patterns shaped by broader cultural values influencing clinical encounters (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e). Nevertheless, these findings reinforce the importance of established standards in clinical communication, including the effective use of verbal and non-verbal cues, discussion of treatment options through shared decision-making, and the use of open-ended questions, underscoring the need for these competencies to be developed from undergraduate training and embedded into routine clinical practice.\u003c/p\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eImplications for practice, policy and research\u003c/h2\u003e \u003cp\u003eThe study shows that the period before tooth extraction in a public-sector dental hospital in southern Khyber Pakhtunkhwa is associated with significant emotional and social concerns among patients, yet this stage is rarely addressed in routine care. In high-volume outpatient settings in LMIC public hospitals, limited consultation time often results in brief, procedure-focused discussions rather than patient-centred communication that supports trust and reassurance.\u003c/p\u003e \u003cp\u003eSimple, low-cost interventions such as brief pre-extraction counselling by the treating dentist, waiting-area educational materials in the local language, tele-dentistry support, and task-shifting communication to dental assistants, auxiliary staff, or dental public health professionals may improve patient understanding and emotional readiness without increasing work-load. Similar approaches have been reported in dental public health services in comparable settings, use of visual aids, tele-dentistry, educational materials where proposed as strategies for counselling and patient education to enhance patient communication and oral health literacy in low-resource settings (\u003cspan additionalcitationids=\"CR41\" citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e Given that many participants expressed anxiety about visible tooth loss particularly women concerned about appearance, marital relationships, and social judgement communication should explicitly acknowledge these concerns. In the sociocultural context of southern Khyber Pakhtunkhwa, where family reputation and social perceptions are highly valued, addressing such anxieties at the anticipatory phase may help reduce stigma and strengthen trust between dentists and patients. Public sector hospitals may develop policies that incorporate patient-centred communication guidelines that address these socio-cultural concerns directly. Evidence from randomized trials shows that audiovisual educational tools can significantly reduce fear associated with tooth extraction compared with verbal counselling alone (\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e). Integrating such visual education material within dental clinics and waiting areas may support patient understanding while also helping normalise tooth extraction as a routine treatment rather than a socially stigmatising event.\u003c/p\u003e \u003cp\u003eFrom a clinical training perspective, although dental curricula in Pakistan include communication skills training, greater emphasis is needed on evaluating these competencies in clinical practice. Public-sector hospitals could adopt validated assessment tools to identify clinicians requiring additional support in patient communication. Furthermore, incorporating patient feedback mechanisms would allow institutions to assess communication practices in relation to culture-specific expectations surrounding patient\u0026ndash;doctor interactions and strengthen patient-centred care.\u003c/p\u003e \u003cp\u003eFor research, future work should extend beyond a single tertiary institution. Comparative analyses between public and private clinics in Khyber Pakhtunkhwa could clarify whether differences in communication reflect structural conditions rather than anecdotal variation. There is also a need to explore clinicians\u0026rsquo; perspectives in this region, particularly how workload, institutional pressures, and time constraints shape communication practices. In addition, policy-oriented evaluations examining how institutional guidelines, training programmes, and patient feedback systems influence clinician\u0026ndash;patient communication would provide valuable system-level insights. Finally, longitudinal research investigating whether anticipatory distress predicts post-extraction satisfaction, prosthesis uptake, or avoidance of future dental care could generate clinically actionable evidence.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eStrengths and weaknesses of the study\u003c/h2\u003e \u003cp\u003eThis study has several important strengths. First, it focuses on the anticipatory phase of tooth extraction, an aspect of dental care that has received limited attention in existing literature. Much of the research on tooth loss has concentrated on post-extraction experiences, prosthetic rehabilitation, or clinical outcomes. By contrast, this study captures the period before the procedure, revealing how patients construct meanings around impending tooth loss, experience anxiety, and begin behavioural or emotional coping strategies prior to treatment. Second, the study provides contextually grounded insights from southern Khyber Pakhtunkhwa, a region with distinct social and demographic characteristics. Located near the Afghanistan\u0026ndash;Pakistan border, the area hosts a substantial population of migrants and refugees following the conflicts of the 1990s and is characterised by considerable socioeconomic diversity across semi-urban and rural communities. Examining patient experiences within this setting helps illuminate how broader structural and sociocultural factors shape perceptions of anticipatory tooth loss.\u003c/p\u003e \u003cp\u003eThird, the research was conducted in the only public-sector dental hospital serving southern Khyber Pakhtunkhwa, which functions as a key referral centre for surrounding rural districts. As a high-volume facility providing care to a large proportion of underserved rural populations, the setting offers valuable insights into real-world public dental services in the Global South. Consequently, the findings contribute to understanding how patient experiences and dentist\u0026ndash;patient communication unfold within routine public-sector dental care environments.\u003c/p\u003e \u003cp\u003eHowever, several limitations should be acknowledged. The study was conducted in a single public-sector institution, and therefore the findings may not fully reflect experiences in private dental clinics or other regions of Pakistan where service structures and patient populations may differ. In addition, the qualitative design prioritises depth and contextual understanding rather than statistical generalisability, and the findings should therefore be interpreted as analytically transferable rather than representative of all patient experiences. The participant sample also included a higher proportion of women, which may have shaped the prominence of gender-related perspectives reported in the findings. Furthermore, interviews were conducted by a female consultant prosthodontist; although efforts were made to establish rapport, the interviewer\u0026rsquo;s clinical role and the hierarchical dynamics common within South Asian healthcare settings may have influenced how participants expressed their views or the extent to which they disclosed sensitive concerns.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis qualitative study highlights that the anticipatory phase before tooth extraction in a public-sector dental hospital in southern Khyber Pakhtunkhwa, Pakistan is experienced as an emotionally and socially meaningful period, yet these concerns are rarely addressed within routine dental care. Participants described fear, stigma, and concerns about appearance and social judgement, particularly among women, while emphasising the importance of clear and empathetic communication from clinicians. The findings suggest that integrating brief, culturally responsive pre-extraction counselling, locally appropriate educational materials and audio-visual aids, alongside strengthened communication training, patient feedback mechanisms, and communication evaluations of dental staff within public-sector hospitals, may help acknowledge these concerns and support more patient-centred communication in resource-constrained settings.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003eCompeting Interests:\u003c/h2\u003e \u003cp\u003eThe authors declare that they have no competing interests related to this study.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eConsent for participate\u003c/h2\u003e \u003cp\u003e All participants provided written informed consent before participating in the study.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eConsent for publication\u003c/h2\u003e \u003cp\u003eNot Applicable\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eHuman Ethics and Consent to Participate\u003c/h2\u003e \u003cp\u003eEthical clearance for this study was obtained from the Ethics Review Committee, Institute of Public Health and Social Sciences (IPH\u0026amp;SS), Khyber Medical University (Reference: KMU/IPHSS/Ethics/2025/AP/264, approved on 25-04-2025). In this research study, the researchers assured confidentiality and anonymity during data collection and the publication of results in accordance with the Declaration of Helsinki.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eThis study was supported by a student research grant from the Office of Research, Innovation and Commercialization (ORIC), Khyber Medical University. The funding body had no role in the study design, data collection, analysis, interpretation of results, decision to publish, or preparation of the manuscript.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003e(AM) contributed to the conceptualisation of the study, conducted data collection, and carried out the initial analysis and drafting of the manuscript. (NA), (SM), and (MK) contributed to transcription and critical revision of the manuscript. (HSS) contributed to data interpretation and manuscript review. (SSB) contributed to data analysis and manuscript preparation. (MIK) supervised the study and contributed to conceptualisation, methodology, and critical revision of the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eWe sincerely thank all participants who generously gave their time to participate in the interviews and share their experiences for this study.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eAvailable upon request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eDenis F, Clement C. Oral Health: A Major Global Public Health Concern. J Clin Med [Internet]. 2025 Jun 1 [cited 2026 Mar 6];14(12):4101. 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Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://pmc.ncbi.nlm.nih.gov/articles/PMC4957266/\u003c/span\u003e\u003cspan address=\"https://pmc.ncbi.nlm.nih.gov/articles/PMC4957266/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-oral-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ohea","sideBox":"Learn more about [BMC Oral Health](http://bmcoralhealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ohea/default.aspx","title":"BMC Oral Health","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Tooth extraction, patient-dentist communication, anticipatory anxiety, qualitative research, oral health behaviour, Pakistan","lastPublishedDoi":"10.21203/rs.3.rs-9061076/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9061076/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eObjective\u003c/h2\u003e \u003cp\u003eTooth loss is a major public health concern, yet the period between the recommendation for extraction and the procedure remains underexplored. This study explored how adults in southern Khyber Pakhtunkhwa (KP), Pakistan, experience the anticipatory phase of non-emergency tooth extraction and how patient\u0026ndash;dentist communication shapes emotional responses, social interpretations and coping behaviours during this period.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA qualitative study informed by phenomenological principles was conducted at the Institute of Dental Sciences Kohat, the only public-sector dental hospital in southern KP, Pakistan. Fifteen patients were purposively recruited using maximum variation sampling. Semi-structured interviews were conducted in Urdu or Pashto, audio-recorded, transcribed verbatim and translated into English. Data were analysed using reflexive thematic analysis following Braun and Clarke\u0026rsquo;s six-phase framework, with interpretation conceptually informed by the Common-Sense Model of Self-Regulation.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eAnalysis revealed three interrelated themes characterising the anticipatory phase of tooth extraction: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) perceived threat and identity disruption, (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) coping and behavioural self-regulation, and (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) clinical communication as a determinant of emotional readiness.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThe anticipatory phase before tooth extraction was experienced as an emotionally and socially significant period that is rarely addressed in routine public-sector dental care. Fear, stigma, and concerns about appearance and social judgement, particularly among women, were prominent, while clear and empathetic clinician communication emerged as essential. These findings suggest the need for brief, culturally responsive pre-extraction counselling, locally appropriate educational and audio-visual materials, and stronger communication training, feedback, and evaluation systems to support more patient-centred care in resource-constrained settings.\u003c/p\u003e","manuscriptTitle":"Anticipating Tooth Extraction: Patient Experiences of a Communication-Sensitive Clinical Moment in Pakistan","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-10 14:28:16","doi":"10.21203/rs.3.rs-9061076/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"221134359647529757813352224775694258386","date":"2026-04-08T08:08:54+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"86295617535081745508371552270135567664","date":"2026-04-08T05:52:07+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"101192705672442031733696075793601153582","date":"2026-04-08T05:48:26+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"50956677918220325174600424579575193723","date":"2026-04-06T12:05:26+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-06T05:22:29+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-04-02T06:43:06+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-03-20T10:09:41+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-03-19T21:16:59+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Oral Health","date":"2026-03-19T21:08:27+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-oral-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ohea","sideBox":"Learn more about [BMC Oral Health](http://bmcoralhealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ohea/default.aspx","title":"BMC Oral Health","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"96aebd17-b3cf-4cd5-9c6a-f026a7be01f7","owner":[],"postedDate":"April 10th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-10T14:28:16+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-10 14:28:16","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9061076","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9061076","identity":"rs-9061076","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}