Introduction
Dental anxiety in children present a challenge to the child, parents and the dental team. This, in turn, leads to difficulty in behaviour management, avoidance of dental care, and poor oral health outcomes [1]. The assessment of dental anxiety is necessary in order to overcome these problems and facilitate diagnosis and treatment while also guaranteeing a pleasant dental visit [2].
It has been reported that dental anxiety among children is influenced by many factors. As indicated by the relevant literature, various studies have been conducted to evaluate the impact of specific factors on dental anxiety [3-6].
This article presents a review of the investigated factors which affect dental anxiety and provides an insight into the possible explanations on the influence of these factors.
1) Age
The age of the child is considered one of the factors which has a substantial impact on dental anxiety among children [4]. There is almost total agreement in the literature that younger children tend to be more anxious in the dental office compared to older children [5-7].
This is believed that it results from fear of the unknown therefore abandonment among younger children. Child’s cognitive ability develops with increasing age, thus resulting in more awareness and understanding [8]. As such, dental anxiety is more prevalent in those of a younger age, and declines as children become older.
In contrast, other reports have found no difference in the severity of dental anxiety between age groups [9-11].
Interestingly, certain other reports concluded that dental anxiety increases with age [3,12]. This could be explained by the possibility of other factors arising, such as having more previous painful dental experiences [4].
2) Gender
Evidence regarding differences in dental anxiety between boys and girls has been inconsistent. Most investigators reported higher levels of dental anxiety among girls [5-7,13].
On the contrary, certain other studies reported that there were no differences between both genders regarding dental anxiety [3,9,14,15]. In contrast, it has been reported that dental anxiety is more prevalent in boys [16].
These observations may be attributed to various factors, such as the cultural background of the population being studied, the structure of the anxiety scales used, the real differences in anxiety levels between genders, the willingness to acknowledge anxiety feelings, or combinations of these factors [13,17].
3) Education and Socioeconomic Status
The education level of parents and the social class of the child’s family have long been considered as the factors that affect the dental anxiety level of children [18].
Children from low socioeconomic families and low educational levels tend to experience more dental anxiety [7]. This could possibly be due to decreased dental awareness in low socioeconomic and educational level in families, thus it means that dental anxiety increases [19].
On the other hand, it has been reported that high education level is associated with severe dental anxiety [4]. One explanation offered is that children from families with a higher income can more easily access information on dental procedures [4].
Certain other studies reported a very weak association regarding these factors [20,21], or no association between the dental anxiety of children and the various educational levels [22,23].
4) Ethnicity and Culture
Ethnicity and cultural background may influence the level of dental anxiety. In Arab cultural background, it has been suggested that boys are expected to act like men and to be brave [13,24]. On the other hand, in African culture, endurance to stress usually manifest as self-control and self-repression [25]. However, in American or European cultures, children can more easily express their anxiety and feelings [3].
5) Number of Siblings
In literature, dental anxiety level has been found to be associated with increased number of siblings [1,18]. This is more especially in preschool children from larger families, with three or more siblings [18].
The explanation for this could be that children with more number of siblings might be exposed to information about their siblings’ dental treatments or they could observe their siblings displaying anxious behaviour during dental treatments [26].
On the contrary, a study by Aminabadi NA et al., showed that a single child in a family had higher dental anxiety compared to children with siblings [27]. In regard to birth order, they found that in children with siblings, the first-born child had increased dental anxiety [27].
6) Previous General Anaesthesia
Dental treatment under General Anaesthesia (GA) is a significant emotional event in the dental history of children. This is considered a traumatic experience for children, due to the stressful procedure of anaesthesia induction, and the post operative consequences following treatment under GA [28].
The GA experience is deemed to contribute to dental anxiety, both in the short and long term. Most investigations reported that dental anxiety is positively associated with a previous GA experience; there exists more dental anxiety in children who have had previous GA dental treatment [29,30].
In contrast, a few reports concluded that there is no change in children’s dental anxiety levels following treatment under GA [31,32]. This is possibly due to the fact that most of the children studied were already highly anxious [28,33].
7) Dental Caries
In literature, the association between dental caries and dental anxiety has been investigated [3,5,15]. This association could be true in both directions. Indeed, this means that high caries prevalence in a child may lead to increased anxiety towards visiting a dentist, and the presence of dental anxiety may lead to avoidance of dental check-ups, which would result in an increased prevalence of dental caries [29,30].
Most previous studies found that dental anxiety is related to caries prevalence and is considered a risk factor for dental caries [3,5,15,34].
However, a few studies reported that dental anxiety is not related to dental caries prevalence, and is rather influenced by other factors [35,36].
8) Parental/Maternal Anxiety
The literature has also reported a positive association between children’s dental anxiety and parental, particularly maternal, anxiety [37-39].
Children who see dental anxiety in their parents, or learn about it through stressful information provided by parents, are more likely to develop a reflection and similar attitude, thus resulting in the development of dental anxiety [17].
However, there is a suggestion that this contribution could only affect the first dental visit, after which the child’s own experience and the dentist’s influence tend to have more significant weighting [40].
On the contrary, several studies concluded that there is no relationship between the dental anxiety of the child and that of the parents [33,41].
9) Dental Procedures
Specific dental procedures are associated with dental anxiety. Indeed, the child’s dental anxiety may be influenced by the type of dental treatment proposed at a specific dental visit [21,42].
Patients who expect operative procedures and extractions exhibit higher anxiety [17]. It has also been reported that local anaesthesia injections increase the dental anxiety scores [20]. The lowest dental anxiety levels have been linked to oral prophylaxis [17].
10) Previous Dental and Medical Experiences and Frequency of Dental Visits
It has been reported that dental anxiety is related to previous dental experience. High levels of dental anxiety are expected among children on their first visit to the dentist [13,17]. Dental anxiety in children would then decrease with more dental visits, hence having experienced more dental treatments [42].
Additionally, this is possibly due to the fact that previous dental experience establishes a dentist-patient trust, and the children become older and mature with subsequent dental visits [17,42].
Children who have experienced specific dental treatment will likely be less anxious about that particular treatment [5], and infrequent dental visits and long intervals between visits have been found to be positively correlated with dental anxiety [42,43].
Conversely, Peretz B and Mann J, reported that dental anxiety in all children who have experienced dental procedures in the past is higher than in children who have not [44]. This could be because the children studied already knew that they would have an unpleasant dental session [5,15,20,40]. In contrast, many studies reported that prior dental experience is not associated with dental anxiety and has no influence on it [11,20,45]. More painful or invasive dental procedures will likely lead to negative experience of dental treatment and the development of dental anxiety [17,30].
In addition, children who had negative experiences associated with medical treatment and exposed to invasive medical procedures have shown to be more anxious about dental treatment [46].
11) Clinical Environment
The influence of the dental office environment on dental anxiety has also been investigated. Indeed, it has been reported that higher dental anxiety is associated with anxiety from the drilling sound, followed by long waits in the waiting room [20,47]. Additionally, the noise of other children undergoing dental procedures in the dental office can lead to anxiety in children waiting for their turn [47].
It has also been shown that dental anxiety results from the shape of the dental instruments, and the smell of the atmosphere, in addition to the association with the dentist’s attire and gender [48-50].
12) Personal Traits, General Anxiety and Psychological Status
Dental anxiety is related to the personal traits of children. It has been reported that higher dental anxiety is positively associated with high trait-state and general anxiety [7,37,42].
A positive relationship has been reported between dental anxiety and psychological status that includes psychiatric disorders and depressive disorders, which lead to higher dental anxiety [7,37,42].
Conclusion
Dental anxiety is multifactorial, and is far more complex than can be explained by a single contributing factor. The differences presented in this article may be due to several parameters, such as methodological or cultural variables in the investigated populations. Further investigations in this area are recommended.
[1]. Merdad L, El-Housseiny AA, Do children’s previous dental experience and fear affect their perceived oral health-related quality of life (OHRQoL)? BMC Oral Health 2017 17:4710.1186/s12903-017-0338-928093086 [Google Scholar] [CrossRef] [PubMed]
[2]. Buchanan H, Niven N, Validation of a facial image scale to assess child dental anxiety Int J Paediatr Dent 2002 12:47-52.10.1046/j.0960-7439.2001.00322.x11853248 [Google Scholar] [CrossRef] [PubMed]
[3]. Akbay Oba A, Dülgergil CT, Sğnmez IS, Prevalence of dental anxiety in 7- to 11-year-old children and its relationship to dental caries Med Princ Pract 2009 18:453-57.10.1159/00023589419797921 [Google Scholar] [CrossRef] [PubMed]
[4]. Busato P, Garbín RR, Santos CN, Paranhos LR, Rigo L, Influence of maternal anxiety on child anxiety during dental care: cross-sectional study Sao Paulo Med J 2017 135:116-22.10.1590/1516-3180.2016.02772810201628423066 [Google Scholar] [CrossRef] [PubMed]
[5]. Kakkar M, Wahi A, Thakkar R, Vohra I, Shukla AK, Prevalence of dental anxiety in 10-14 years old children and its implications J Dent Anesth Pain Med 2016 16:199-202.10.17245/jdapm.2016.16.3.19928884153 [Google Scholar] [CrossRef] [PubMed]
[6]. Shim YS, Kim AH, Jeon EY, An SY, Dental fear & anxiety and dental pain in children and adolescents; a systemic review J Dent Anesth Pain Med 2015 15(1):5310.17245/jdapm.2015.15.2.5328879259 [Google Scholar] [CrossRef] [PubMed]
[7]. Talo Yildirim T, Dundar S, Bozoglan A, Karaman T, Dildes N, Acun Kaya F, Is there a relation between dental anxiety, fear and general psychological status? Peer J 2017 5:e297810.7717/peerj.297828229019 [Google Scholar] [CrossRef] [PubMed]
[8]. Rãducanu AM, Feraru V, Herteliu C, Anghelescu R, Assessment of the prevalence of dental fear and its causes among children and adolescents attending a department of paediatric dentistry in Bucharest OHDMBSC 2009 8:42-49. [Google Scholar]
[9]. Rajwar AS, Goswami M, Prevalence of dental fear and its causes using three measurement scales among children in New Delhi J Indian Soc Pedod Prev Dent 2017 35:128-33.10.4103/JISPPD.JISPPD_135_1628492191 [Google Scholar] [CrossRef] [PubMed]
[10]. Arapostathis KN, Coolidge T, Emmanouil D, Kotsanos N, Reliability and validity of the Greek version of the children’s fear survey schedule-dental subscale Int J Paediatr Dent 2008 18:374-79.10.1111/j.1365-263X.2007.00894.x18284471 [Google Scholar] [CrossRef] [PubMed]
[11]. Agarwal M, Das UM, Dental anxiety prediction using Venham Picture test: a preliminary cross-sectional study J Indian Soc Pedod Prev Dent 2013 31:22-24.10.4103/0970-4388.11239723727738 [Google Scholar] [CrossRef] [PubMed]
[12]. Rantavuori K, Tolvanen M, Hausen H, Lahti S, Seppå L, Factors associated with different measures of dental fear among children at different ages J Dent Child. 2009 76:13-19. [Google Scholar]
[13]. El-Housseiny AA, Merdad LA, Alamoudi NM, Farsi NM, Effect of child and parent characteristics on child dental fear ratings: analysis of short and full versions of children’s fear survey schedule-dental subscale Oral Heal Dent Manag 2015 14:757 [Google Scholar]
[14]. Singh P, Pandey R, Nagar A, Dutt K, Reliability and factor analysis of children’s fear survey schedule-dental subscale in Indian subjects J Indian Soc Pedod Prev Dent 2010 28:15110.4103/0970-4388.7378821157045 [Google Scholar] [CrossRef] [PubMed]
[15]. Saatchi M, Abtahi M, Mohammadi G, Mirdamadi M, Binandeh ES, The prevalence of dental anxiety and fear in patients referred to Isfahan Dental School, Iran Dent Res J (Isfahan) 2015 12:248-53. [Google Scholar]
[16]. Klingberg G, Broberg AG, Dental fear/anxiety and dental behaviour management problems in children and adolescents: a review of prevalence and concomitant psychological factors Int J Paediatr Dent 2007 17(1):391-406.10.1111/j.1365-263X.2007.00872.x17935593 [Google Scholar] [CrossRef] [PubMed]
[17]. Al-Madi EM, AbdelLatif H, Assessment of dental fear and anxiety among adolescent females in Riyadh, Saudi Arabia Saudi Dent J 2002 14:77-81. [Google Scholar]
[18]. Abanto J, Vidigal EA, Carvalho TS, Sá SNC DE, Bğnecker M, Factors for determining dental anxiety in preschool children with severe dental caries Braz Oral Res 2017 31:e1310.1590/1807-3107bor-2017.vol31.001328099579 [Google Scholar] [CrossRef] [PubMed]
[19]. Soares FC, Lima RA, Barros MVG, Dahllğf G, Colares V, Development of dental anxiety in school children: A 2-year prospective study Community Dent. Oral Epidemiol 2017 45:281-88.10.1111/cdoe.1229028266046 [Google Scholar] [CrossRef] [PubMed]
[20]. Humphris GM, Dyer TA, Robinson PG, The modified dental anxiety scale: UK general public population norms in 2008 with further psychometrics and effects of age BMC Oral Health 2009 9:2010.1186/1472-6831-9-2019709436 [Google Scholar] [CrossRef] [PubMed]
[21]. Yildirim TT, Evaluating the relationship of dental fear with dental health status and awareness J Clin Diagn Res 2016 10:ZC105-09.10.7860/JCDR/2016/19303.821427630944 [Google Scholar] [CrossRef] [PubMed]
[22]. López-Jornet P, Camacho-Alonso F, Sanchez-Siles M, Assessment of general pre and postoperative anxie in patients undergoing tooth extraction: a prospective study Br J Oral Maxillofac Surg 2014 52:18-23.10.1016/j.bjoms.2013.01.00423357053 [Google Scholar] [CrossRef] [PubMed]
[23]. Ekanayake L, Dharmawardena D, Dental anxiety in patients seeking care at the University Dental Hospital in Sri Lanka Community Dent. Health 2003 20:112-16. [Google Scholar]
[24]. El-Housseiny A, Farsi N, Alamoudi N, Bagher S, El Derwi D, Assessment for the children’s fear survey schedule-dental subscale J Clin Pediatr Dent 2014 39:40-46.10.17796/jcpd.39.1.ml4h38626g66p75025631725 [Google Scholar] [CrossRef] [PubMed]
[25]. Ingman KA, Ollendick TH, Akande A, Cross-cultural aspects of fears in African children and adolescents Behav Res Ther 1999 37:337-45.10.1016/S0005-7967(98)00108-9 [Google Scholar] [CrossRef]
[26]. Porritt J, Marshman Z, Rodd HD, Understanding children’s dental anxiety and psychological approaches to its reduction Int J Paediatr Dent 2012 22(1):397-405.10.1111/j.1365-263X.2011.01208.x22221141 [Google Scholar] [CrossRef] [PubMed]
[27]. Aminabadi NA, Sohrabi A, Erfanparast LK, Oskouei SG, Ajami BA, Can birth order affect temperament, anxiety and behavior in 5 to 7-year-old children in the dental setting? J Contemp Dent Pract 2011 12:225-31.10.5005/jp-journals-10024-103922186855 [Google Scholar] [CrossRef] [PubMed]
[28]. Hosey MT, Macpherson LMD, Adair P, Tochel C, Burnside G, Pine C, Dental anxiety, distress at induction and postoperative morbidity in children undergoing tooth extraction using general anaesthesia Br Dent J 2006 200:39-43.10.1038/sj.bdj.481312316415835 [Google Scholar] [CrossRef] [PubMed]
[29]. Howard KE, Freeman R, Reliability and validity of a faces version of the modified child dental anxiety scale Int J Paediatr Dent 2007 17:281-88.10.1111/j.1365-263X.2007.00830.x17559456 [Google Scholar] [CrossRef] [PubMed]
[30]. Haworth S, Dudding T, Waylen A, Thomas SJ, Timpson NJ, Ten years on: Is dental general anaesthesia in childhood a risk factor for caries and anxiety? BDJ 2017 222:299-304.10.1038/sj.bdj.2017.17528232699 [Google Scholar] [CrossRef] [PubMed]
[31]. Klaassen MA, Veerkamp JSJ, Hoogstraten J, Young children’s oral healthrelated quality of life and dental fear after treatment under general anaesthesia: a randomized controlled trial Eur J Oral Sci 2009 117:273-78.10.1111/j.1600-0722.2009.00627.x19583755 [Google Scholar] [CrossRef] [PubMed]
[32]. Klaassen MA, Veerkamp JSJ, Hoogstraten J, ental treatment under general anaesthesia: the short-term change in young children’s oral-health-related quality of life Eur Arch Paediatr Dent 2008 9:130-37.10.1007/BF0326262418793595 [Google Scholar] [CrossRef] [PubMed]
[33]. Balmer R, O’Sullivan EA, Pollard MA, Curzon MEJ, Anxiety related to dental general anaesthesia: changes in anxiety in children and their parents Eur J Paediatr Dent 2004 5:9-14. [Google Scholar]
[34]. Rantavuori K, Lahti S, Hausen H, Seppå L, Kårkkåinen S, Dental fear and oral health and family characteristics of Finnish children Acta Odontol Scand 2004 62:207-13.10.1080/0001635041000158615513417 [Google Scholar] [CrossRef] [PubMed]
[35]. Taani DQ, El-Qaderi SS, Abu Alhaija ESJ, Dental anxiety in children and its relationship to dental caries and gingival condition Int J Dent Hyg 2005 3:83-87.10.1111/j.1601-5037.2005.00127.x16451387 [Google Scholar] [CrossRef] [PubMed]
[36]. Vignehsa H, Chellappah NK, Milgrom P, Going R, Teo CS, A clinical evaluation of high- and low-fear children in Singapore ASDC J Dent Child 1990 57:224-28. [Google Scholar]
[37]. D’Alessandro G, Alkhamis N, Mattarozzi K, Mazzetti M, Piana G, Fear of dental pain in Italian children: child personality traits and parental dental fear J Public Health Dent 2016 76:179-83.10.1111/jphd.1212726613212 [Google Scholar] [CrossRef] [PubMed]
[38]. Cagiran E, Sergin D, Deniz MN, Tanattı B, Emiroglu N, Alper I, Effects of sociodemographic factors and maternal anxiety on preoperative anxiety in children J Int Med Res 2014 42:572-80.10.1177/030006051350375824501165 [Google Scholar] [CrossRef] [PubMed]
[39]. Patel H, Reid C, Wilson K, Girdler NM, Inter-rater agreement between children’s self-reported and parents’ proxy-reported dental anxiety Br Dent J 2015 218:E610.1038/sj.bdj.2015.9825720913 [Google Scholar] [CrossRef] [PubMed]
[40]. Townend E, Dimigen G, Fung D, A clinical study of child dental anxiety Behav Res Ther 2000 38:31-46.10.1016/S0005-7967(98)00205-8 [Google Scholar] [CrossRef]
[41]. Ten Berge M, Veerkamp JSJ, Hoogstraten J, Prins PJM, Childhood dental fear in relation to parental child-rearing attitudes Psychol Rep 2003 92:43-50.10.2466/pr0.2003.92.1.4312674255 [Google Scholar] [CrossRef] [PubMed]
[42]. Pekkan G, Kilicoglu A, Hatipoglu H, Relationship between dental anxiety, general anxiety level and depression in patients attending a university hospital dental clinic in Turkey Community Dent Health 2011 28:149-53. [Google Scholar]
[43]. Klages U, Kianifard S, Ulusoy O, Wehrbein H, Anxiety sensitivity as predictor of pain in patients undergoing restorative dental procedures Community Dent. Oral Epidemiol 2006 34:139-45.10.1111/j.1600-0528.2006.00265.x16515678 [Google Scholar] [CrossRef] [PubMed]
[44]. Peretz B, Mann J, Dental anxiety among Israeli dental students: a 4-year longitudinal study Eur J Dent Educ 2000 4:133-37.10.1034/j.1600-0579.2000.040308.x11168477 [Google Scholar] [CrossRef] [PubMed]
[45]. Peretz B, Nazarian Y, Bimstein E, Dental anxiety in a students’ paediatric dental clinic: children, parents and students. Int J Paediatr Dent 2004 14:192-98.10.1111/j.1365-263X.2004.00545.x15139954 [Google Scholar] [CrossRef] [PubMed]
[46]. Hollis A, Willcoxson F, Smith A, Balmer R, An investigation into dental anxiety amongst paediatric cardiology patients Int J Paediatr Dent 2015 25:183-90.10.1111/ipd.1211124916764 [Google Scholar] [CrossRef] [PubMed]
[47]. Muppa R, Bhupatiraju P, Duddu M, Penumatsa NV, Dandempally A, Panthula P, Comparison of anxiety levels associated with noise in the dental clinic among children of age group 6-15 years Noise Health 2013 15:190-93.10.4103/1463-1741.11237123689302 [Google Scholar] [CrossRef] [PubMed]
[48]. Nirmala SVSG, Veluru S, Nuvvula S, Chilamakuri S, Preferences of dentist’s attire by anxious and nonanxious Indian children J Dent Child (Chic) 2015 82:97-101. [Google Scholar]
[49]. Kamavaram Ellore VPK, Mohammed M, Taranath M, Ramagoni NK, Kumar V, Gunjalli G, Children and parent’s attitude and preferences of dentist’s attire in pediatric dental practice Int J Clin Pediatr Dent 2015 8:102-07.10.5005/jp-journals-10005-129326379376 [Google Scholar] [CrossRef] [PubMed]
[50]. Asokan A, Kambalimath H, Patil R, Maran S, Bharath K, A survey of the dentist attire and gender preferences in dentally anxious children J Indian Soc Pedod Prev Dent 2016 34:3010.4103/0970-4388.17550726838145 [Google Scholar] [CrossRef] [PubMed]