Dental fear, is defined as specific anxiety, with predisposition for negative experience in the dental surgery (1), this condition is common in dental practice. Dental fear represents normal emotional reaction to specific external threatening stimulus in the dental situation. Dental anxiety is a non-specific feeling of apprehension, where the child is evoked and prepared for something to happen, associated with abnormal conditions (2).
Dental fear may cause serious problems for patient and dentist, which lead to avoidance of dental care or disruptive behavior during treatment (3), and negatively affect treatment outcomes (4). Dental fear has a negative impact on the treatment outcome, because often leads to cancelled dental visits, may have a stressful influence on the dentist during a dental appointment, with detrimental consequences for the child oral health (5).
Etiology of dental fear and dental anxiety in children is multifactorial (6). The factors which play an important role in the onset of dental fear are: previous painful dental experiences, experience of dental trauma, child personality, parental dental fear, age, gender, and social background (7, 8). Previous traumatic experience has influence on a patient’s perception of the dental environment, related to fear of the unknown or injury. The effect of residual fears from past traumatic experiences, combined with the upcoming fears in a new dental situation, results as anticipatory anxiety (9). From previous painful experience, the child has enough time to create negative thoughts and expectations regarding the new dental intervention (10).
The prevalence of childhood dental fear, due to either methodological or cultural variables, shows considerable variations range between 3% to 43% (6, 11). Girls and younger children are more fearful than boys and older children.
The dental procedures have a different range according to the level of the fear they provoke in the child patient. The most painful dental procedures are: injection, drilling the tooth and periodontal procedures, which can evoke more dental anxiety in children (12). Child’s level of anxiety before procedure is closely related to their behavior during dental interventions (13).
The aim of this study was to evaluate dental anxiety among children with different measurement scales, with the aim of getting more precise and thorough estimations, as well as correlation between anxiety scale and aggression scale in children with/or without dental trauma.
Material and Methods
Patients. The study sample included 254 children experience with dental trauma (59.1% male), and 251 children without dental trauma (46.6% male), between 7 and 14 years, referred to the University Dentistry Clinical Center of Kosovo, at the Pediatric and Preventive Dentistry Department, in Prishtina, during 2015-2016.
Procedure. After referral to clinic, the children and their parents were asked to participate by completing Albanian translated version of the questionnaires. The children with trauma we have found in schools of five municipalities: Podujeva, Peja, Ferizaj, Gjilane and Kamenica. Children’s are referred to the University Dentistry Clinical Center of Kosovo for further evaluation. The questionnaires were completed by child at their first visit. As the younger children were not able to answer the questionnaire by themselves, the scale was adjusted to be answered by one of each child’s parents. All parents were well informed about the purpose of the study before signing the consent form.
Questionnaires. For psychometric measures we used: CDAS, PDAS, CFSS-DS, S-DAI, CMFQ, DVSS-SV and OAS (see table 1).
Statistical analysis. We used the IBM SPSS Statistics software (version 23) and Sigma Plot version 11.0 for analysis. The data were analyses regarding the questionnaire variables according to the gender, age and study groups (with and without dental trauma) and tested with the X2 test, Student’s t-test and one-way ANOVA. Pearson’s correlation coefficient was used to evaluate the validity of the measures and to study interrelationship between the tests used in assessing children’s anxiety and aggression. The predetermined significance levels were set at 0.05. Cronbach’s alpha was used to analyze internal consistency reliability.
The percentage of boys was higher in group with dental trauma (59.1% vs. 46.6%, Chi-test=7.35, df=1, p=0.007) (Table 2).
|Sex||With dental trauma||Without dental trauma|
Chi-square= 7.35 with 1 degrees of freedom (df). (P = 0.007)
The total mean age was higher in group with dental trauma (11.76+/-1.76 vs. 11.10+/-2.01, t-test=3.95, df=503, p<0.001). The significant difference in mean age were between males with dental trauma and females without dental trauma (p<0.001); also significant difference was between males with dental trauma and males without dental trauma (p<0.001) (Table 3 and Diagram 1).
MT = Male with dental trauma; MNT = Male without dental trauma; FT = Female with dental trauma; FNT= Female without dental trauma.
In children with dental trauma the higher Cronbach alpha coefficient were calculated for S-DAI (0.991), CFSS-DS (0.974), PDAS (0.968), and OAS (0.961); the lower Cronbach alpha values were computed for DVSS-SV (0.733). In children without dental trauma the higher Cronbach alpha coefficient were calculated for S-DAI (0.966), CFSS-DS (0.959), CDAS (0.914) and PDAS (0.906); the lower Cronbach alpha values were computed for OAS (0.815). All used test has satisfactory reliability and validity of the scale (Table 4).
|Questionnaire||With dental trauma||Without dental trauma|
|Cronbach alpha coefficients||Cronbach alpha coefficients|
** highly reliable; * reliable
Between the tests measuring children’s anxiety, in the group with dental trauma, the strongest correlation was between CFSS-DS and S-DAI (0.875). The Pearson’s correlation coefficients show a significant correlation at the 0.01 level between tested variables; the correlation is significant at the 0.05 level between PDAS vs OAS (r=0.123). The negative interrelation was found between the OAS and DVSS-SV (-0.037) (Table 5 and Diagram 2).
In the group without dental trauma, the strongest correlation was between CFSS-DS and CMFQ (0.906). The Pearson’s correlation coefficients show a significant correlation at the 0.01 level between majorities of variables measuring children’s anxiety. The negative interrelation was found between the OAS and variables measuring children’s anxiety: CFSS-DS, PDAS, CDAS, CMFQ, and S-DAI (r=-0.043, -0.04, -0.013, -0.05, -0.063, respectively), and also between CDAS vs DVSS-SV (r=-0.05) (Table 5).
The mean anxiety score was significantly higher in children with dental trauma compare to children without dental trauma for CFSS-DS (p=0.001), PDAS (p=0.042), CDAS (p=0.01), CMFQ (p<0.001), and S-DAI (p=0.048). The mean DVSS-SV score was significantly higher in children without dental trauma (p<0.001). The children with dental trauma had a higher mean aggression scale (OAS) than those without dental trauma (2.43+/-2.40 vs. 1.37+/-1.56, p<0.001). The girls had significantly higher mean anxiety score than boys in all used questionnaires. The mean aggression score was significantly higher for boys than girls in both compared groups (p<0.001, and 0.003, respectively) (Table 6).
* significant; #For total mean score t-test was used to compare means between groups with and without dental trauma
The Odds of the aggressive behavior in children with dental trauma (n=254) decrease for 0.95 when the value of the mean DVSS-SV scale is increased by 1 unit (OR=0.95, 95% CI 0.87 to 1.03, P=0.22), and increase for 1.04 when the means S-DAI score increased by 1 unit (OR=1.04, 95%CI 1.00 to 1.09, P=0.04). The odds of the aggressive behavior also increased for 1.04 when the mean score of CFSS-DS, PDAS, CDAS, and CMFQ increased by 1 unit, but not significantly (Table 7 and Diagram 3).
Dental anxiety is a serious problem with negative impact in oral health of children. Many measurement instruments have been proposed to assess dental fear and dental anxiety. To assess the true nature of dental anxiety is very difficult, because it is a complex multifactorial phenomenon (6). Child’s anxiety can be assessed with various measurement instruments, since different instruments might measure the different aspects of dental anxiety. Psychometric measures used for this purpose included several questionnaires. Child’s and parental dental anxiety can assessed by using the Child’s Fear Survey Schedule-Dental Subscale (CFSS-DS), the Corah Dental Anxiety Scale (CDAS, PDAS), and the Dental Anxiety Inventory-short version (S-DAI). Child’s fear of medical treatment can be measured by the Broome’s Child Medical Fear Questionnaire (CMFQ). Child’s aggression can be evaluated by the Overt Aggression Scale (OAS). Socioeconomic status can be evaluate by Hollingshead Index of Social Position (ISP index), and the child-dentist’s relationship can be evaluated by the Dental Visit Satisfaction Scale-Swedish Version (DVSS-SV) (1, 14-16). To provide more precise and thorough estimations for child’s dental anxiety is necessary to combine different scales.
The CFSS-DS consist of 15 items scored on 5-Likert scales (1=not afraid at all to 5= very afraid) with 15-75 minimal and maximal total score. It has been used in several countries. According to the report of Aartman et al (1), CFSS-DS was preferred, because measures dental fear more precisely, and covers more aspects of the dental situation. All used tests were found to be sufficiently reliable. The highest Cronbach alpha score were calculated for S-DAI (0.991), CFSS-DS (0.974), PDAS (0.968), and OAS (0.961). The mean CFSS-DS score for the patients with dental trauma in the present study (20.44+/-8.50) were in concordance with previous study, but was lower than the finding in Netherland (23.2) (17), Serbia (26.47) (18), and Croatia (23.4 for male and 29.9 for female) (19). In our study the mean score CFSS-DS for male was 19.23+/-6.30 and for female 22.17+/-10.72. The present study showed that mean anxiety score is significantly higher in girls than in boys (p=0.006). Our findings are similar to the findings of Ten Berge M et al (17), Maja L et al (18), Majstorovic et al (19), and Nakai et al (20). Some study had shown no significant difference in mean anxiety score between boys and girls (girl vs. boys mean CFSS-DS was 27.50+/-5.01, and 26.84+/-5.62, respectively) (21). According to the results of many authors, previous negative medical experiences at child create negative thoughts and expectations regarding the dental treatment, and so expressed higher dental fear and dental anxiety (10, 22).
The mean DVSS-SV score was significantly higher in children’s without dental trauma (36.36+/-3.07 vs. 35+/-3, p<0.001). The children with dental trauma has a higher mean aggression scale (OAS) than those without dental trauma (p<0.001). The present study also showed that the mean aggression score was significantly higher for boys than girls in both compared groups (p<0.001, and 0.003, (respectively). Similar results are obtained by Majstorovic M et al (19) according to which aggressive behaviors are present in dentally anxious children who have significant lower DVSS-SV score. Hakeberg et al (16) has found relationships between children’s satisfaction with dentist and their dental anxiety. Majstorovic M et al (23) also support Rachman’s theory, because they found that previous negative medical experience had significant influence on children’s dental anxiety and are more likely to show aggression behavior. Majstorovic M et al (24) in their study show that dental anxiety scores (mean CDAS, CFSS-DS and CMFQ score) and total internalizing problems were higher in girls, as well as anxiety/depression disorders.
The results of the CMFQ questionnaire in the children with dental trauma showed that child fear from medical intervention was strongly correlated with dental anxiety measured by CFSS-DS questionnaire (r=0.869), similarly as CDAS (r=0.841), S-DAI (r=0.832) and PDAS (r=0.775). Similar results were obtained for the group of patients without dental trauma. Majstorovic M et al (19) found that children with higher CMFQ, who are more afraid of doctors and medical intervention, are more dentally anxious; CMFQ score show significant correlation at the level 0.01 with SDAS (0.563) and S-DAI (0.515). Majstorovic M et al (25) indicated that the higher anxious score (CDAS=14.31) in children with highest fear from medical intervention (CMFQ=22.08). Majstorovic M et al (23) in his study, based on the linear regression analysis, found high correlation between previous traumatic medical experience and dental anxiety, in which dental fear depends on early negative medical experience.
In children’s with dental trauma significantly correlation was found between aggressive behavior (OAS) and dental anxiety level (Pearson’s correlation coefficients were 0.256, 0.249, 0.179, 0.161 and 0.123 for CFSS-DS, S-DAI, CDAS, CMFQ, and PDAS, respectively).The aggressive behavior is lower in dentally anxious children who have statistically significant higher DVSS-SV mean scores (r =-0.037). Similar results are obtained by Majstorovic M et al (23) in his study where aggression scale (OAS) shows significant correlation with the CDAS and the S-DAI mean score, as well as between the OAS score and DVSS-SV. Important factor which affect children’s cooperative behavior is unpleasant previous dental experience (26).
Standard questionnaires used in our study are reliable and valid psychometric instruments for evaluation of dental anxiety as well as behavior problems in children. These results are demonstrating that the mean anxiety score was significantly higher in children with dental trauma, as well as the girls and boys who are more afraid of medical interventions (CMFQ). Also the children with dental trauma, respectively boys had a higher mean aggression scale (OAS).
Significant correlation was found between dental anxiety level and children aggressive behavior. The aggressive behavior is lower in dentally anxious children who have statistically significant higher DVSS-SV mean scores. The odds of the aggressive behavior increased with increasing of mean score of each anxiety measurement scale, but not significantly, except for S-DAI score.