Background While there is increasing evidence for the relevance of psychosocial variables such as dental fear or psychological attachment in dentistry, much less is known about the mechanisms that determine the strength of those associations. One potential moderator is the occurrence of a comorbid chronic disease such as psoriasis, which is linked to relevant disease parameters such as periodontal inflammation. The aim of the study was to test a moderation model of the relationship between dental fear, psychological attachment and psoriasis on periodontal health. Methods A total of 201 patients (100 with psoriasis, 101 without psoriasis) were included in a questionnaire-based, cross-sectional study. Dental status was measured with the Community Periodontal Index (CPI), dental fear was measured with the Hierarchical Anxiety Questionnaire (HAQ), and psychological attachment was measured with the Relationship Questionnaire (RQ). In addition to the examination of main effects, bootstrapping-based analyses were conducted to test the moderating influence of psychological attachment on the association between CPI and dental fear, gain moderated by group (with vs. without psoriasis). Results Controlling for several covariates, higher CPI scores were associated with higher levels of dental fear only in individuals without psoriasis under conditions of higher levels of psychological attachment anxiety and lower levels of attachment avoidance. Conclusion In individuals without psoriasis, psychological attachment can moderate the association between periodontal health and dental fear. This may provide a useful framework for reducing dental fear through interventions on the level of the dentist-patient relationship.

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Psoriasis is a chronic inflammatory disease associated with risk factors such as obesity, tobacco smoking and significant comorbidity including diabetes or periodontitis. 1 Depression, bipolar mood disorder, anxiety, psychosis, cognitive impairment, personality disorders, eating disorders and suicidal ideation have been linked to psoriasis. 2 Because psoriasis does not manifest on mucosal surfaces, the oral cavity is rarely inspected during routine dermatological investigations. Attachment theory provides a model for predicting how individuals use interpersonal relationships to manage distress, relating to stress management skills, health behaviour, adherence to medical treatment and patient-physician interaction across the lifespan. 3 Different attachment styles can be distinguished: secure, fearful, preoccupied and dismissing, whereas the last three styles are grouped into an insecure style. Secure individuals trust others to be available in times of distress and seek proximity to others when needed. Insecure individuals are either uncomfortable relying on and getting close to others in times of need, or view themselves as insufficient with respect to self-regulatory competence, struggling for proximity and attention. Attachment insecurity may narrow health-related regulatory strategies, serve as a distal risk factor concerning stress regulation, and it is directly linked to chronic somatic health conditions. Dental fear describes the 'proximal' anxiety-related reaction to common patients' experiences in dentistry, leading to avoidance of interventions and ultimately poor dental status. 4 Psychological attachment is related to chronic diseases but also to oral health parameters, 5 and dental fear is linked to health behaviour relevant for dentistry. As patients with psoriasis have a higher risk for a poor oral health status, 6 we investigated differences in dental fear and psychological attachment in patients with and without psoriasis as well as associations between those variables and dental/psoriasis disease indices in the group of patients with psoriasis. Within the context of a questionnaire-based cross-sectional survey, psoriasis severity (PASI), dental fear (Hierarchical Anxiety Questionnaire, HAQ 8) and psychological attachment (Relationship Questionnaire, RQ 91) were assessed in a sample of 201 patients with and without psoriasis (100/101) in addition to the analysis of their oral health status. 8 In a first step, we tested a possible difference of the sum scores of the HAQ between individuals with vs. without psoriasis, while controlling for the covariates age, smoking, body mass index (BMI) and decay-missing-filled index