|Year : 2013 | Volume
| Issue : 4 | Page : 215-220
Child's dental fear: Cause related factors and the influence of audiovisual modeling
Jayanthi Mungara, Madhulika Injeti, Elizabeth Joseph, Arun Elangovan, Rajendran Sakthivel, Girija Selvaraju
Department of Pedodontics and Preventive Dentistry, Ragas Dental College and Hospital, Chennai, Tamil Nadu, India
|Date of Web Publication||21-Nov-2013|
Department of Pedodontics and Preventive Dentistry, Ragas Dental College and Hospital, 2/102, East Coast Road, Uthandi, Chennai - 600 119, Tamil Nadu
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Delivery of effective dental treatment to a child patient requires thorough knowledge to recognize dental fear and its management by the application of behavioral management techniques. Children's Fear Survey Schedule - Dental Subscale (CFSS-DS) helps in identification of specific stimuli which provoke fear in children with regard to dental situation. Audiovisual modeling can be successfully used in pediatric dental practice. Aim: To assess the degree of fear provoked by various stimuli in the dental office and to evaluate the effect of audiovisual modeling on dental fear of children using CFSS-DS. Materials and Methods: Ninety children were divided equally into experimental (group I) and control (group II) groups and were assessed in two visits for their degree of fear and the effect of audiovisual modeling, with the help of CFSS-DS. Results: The most fear-provoking stimulus for children was injection and the least was to open the mouth and having somebody look at them. There was no statistically significant difference in the overall mean CFSS-DS scores between the two groups during the initial session (P > 0.05). However, in the final session, a statistically significant difference was observed in the overall mean fear scores between the groups (P < 0.01). Significant improvement was seen in group I, while no significant change was noted in case of group II. Conclusion: Audiovisual modeling resulted in a significant reduction of overall fear as well as specific fear in relation to most of the items. A significant reduction of fear toward dentists, doctors in general, injections, being looked at, the sight, sounds, and act of the dentist drilling, and having the nurse clean their teeth was observed.
Keywords: Audiovisual modeling, Children′s Fear Survey Schedule - Dental Subscale, dental fear
|How to cite this article:|
Mungara J, Injeti M, Joseph E, Elangovan A, Sakthivel R, Selvaraju G. Child's dental fear: Cause related factors and the influence of audiovisual modeling. J Indian Soc Pedod Prev Dent 2013;31:215-20
|How to cite this URL:|
Mungara J, Injeti M, Joseph E, Elangovan A, Sakthivel R, Selvaraju G. Child's dental fear: Cause related factors and the influence of audiovisual modeling. J Indian Soc Pedod Prev Dent [serial online] 2013 [cited 2019 Dec 7];31:215-20. Available from: http://www.jisppd.com/text.asp?2013/31/4/215/121815
| Introduction|| |
Dental fear among children is an issue of great concern to both dentists and their patients' parents. The etiology of a child's dental anxiety can be multifactorial. Various causes have been proposed which include direct or indirect influences of the past experiences of the child and his/her family members and peers. ,
A child's behavior pattern in any situation is governed by his/her inherited physical and mental endowment and, as he develops, by the conditioning he receives through contact with the environment. The former, except within certain narrow limits, cannot be altered. The latter can be controlled and developed, so the child will grow to have a well-adjusted personality suited to the situation.  Children have relatively limited communication skills and are less able to express their fears and anxieties. Children's inability to cope with threatening dental stimuli often manifests as behavior management problems. Early recognition and management of this dental fear is the key to delivering effective dental treatment to the child patient.
The behavioral sciences have become an increasingly important component of dental education and research. One component of this has been the application of psychological methods to the study of behavior and attitudes relevant to health, illness, and health care - in particular, fear of dentists and dentistry as well as of dental pain. One psychometric scale that is widely used in pediatric dentistry research is the Children's Fear Survey Schedule - Dental Subscale (CFSS-DS), presented by Cuthbert and Melamed.  The scale helps in identification of specific stimuli which provoke fear in children with regard to the dental situation. Knowledge of fear-provoking stimuli, in turn, helps in planning the appropriate behavior management strategies for the child.
There are a number of non-pharmacological or psychological techniques that aim to manage patient behavior. Some methods aim to improve the communication process, while others are intended to eliminate inappropriate behavior or reduce anxiety. Most recommended techniques for modifying child behavior during dentistry have involved various forms of pre-exposure to the dental setting and procedures. One such technique, modeling, is based on the Social Learning Theory, which emphasizes the importance of observing and imitating the behaviors, attitudes, and emotional reactions of others. Bandura established that modeling or learning by observation worked not only for acquisition of new behaviors but also for reducing undesirable behavior. One of the primary principles of this technique is Vicarious Extinction, wherein "fearful and avoidant behavior can be extinguished vicariously through observation without any adverse consequences accruing to the performer." Hence, this technique allows for "learning without performance," and thus, the child learns to eliminate fearful behavior without incurring the aversive consequences of such behavior. ,,
The success of modeling in reducing dental fear and anxiety has been well documented in the past; despite this, it has not been widely practiced as a routine behavior management technique.  In addition, most of the research on this subject dates back to two or three decades ago, ,,,,, and there is little published literature on the effectiveness of this technique from recent times.
With this background, this study was undertaken to assess the degree of fear provoked by various stimuli in the dental office and to evaluate the effect of audiovisual modeling on dental fear of children as assessed by the CFSS-DS.
| Materials and Methods|| |
This clinical study was conducted in the Department of Pedodontics and Preventive dentistry, Ragas Dental College and Hospital, Chennai, after getting approval from the Institutional Review Board and Ethics Committee. This trial was conducted in accordance with the principles of the Declaration of Helsinki to compare the effect of audiovisual modeling with a video unrelated to dentistry and no video exposure on the dental fear of children between 5 and 9 years of age of both the genders. The study was conducted for a period of 9 months from March 2011 to November 2011.
Ninety children between 5 and 9 years of age with no prior dental treatment done and who were accompanied by their parents were randomly selected and included. Children with mental subnormality, physical disabilities, systemic illnesses, intraoral or extraoral swellings, and acute dental symptoms, and those not accompanied by parents or whose parents were unable to understand and complete the CFSS-DS were excluded from this study.
Children's dental fear was assessed by the parents using the parental version of the 15-item CFSS-DS. 
The children were distributed into one of two groups after age and gender matching to ensure similar distribution of children in both groups: Group I, children undergoing filmed modeling (n = 45) or group II, children not exposed to any film (n = 45). Each child was evaluated over two dental visits for their fear levels and to assess the influence of audiovisual modeling on the fear levels of the children according to the CFSS-DS.
The psychometric scale used to assess dental fear in the present study was CFSS-DS [Table 1], which is a modification of the CFSS by Cuthbert and Melamed to include specific dental fear items as one of its subscales. The scale consists of 15 items related to various aspects of dental treatment, such as drilling or injections. Each item can be scored on a Likert 5-point scale from 1 (not afraid at all) to 5 (very afraid). Total scores thus range from minimal 15 to maximal 75. Scores above 38 indicate significant dental fear. 
During the first visit, baseline fear ratings were obtained by using the parents' version of the CFSS-DS [Table 1], hence the questions were aimed at the parent. For non-English speaking parents, each situation in the 15-item scale was first explained in the local language prior to their rating. This was followed by examination and treatment planning, after which oral prophylaxis was carried out for each child. The examination and prophylaxis procedures carried out during the initial as well as the second sessions of the first visit were similar for the two groups.
During the second visit, according to the groups ascertained, the children were allowed either to view the modeling film (group I) or were not shown the film (group II), after which restorative treatment was carried out for all of them.
At the end of the second visit, the parent completed the CFSS-DS (parental version) for the second time. The data obtained from the fear ratings were tabulated and subjected to statistical analysis using SPSS software (version 11).
| Results|| |
[Table 2] shows the distribution of children in the two groups based on gender. There was no significant difference in the distribution of males and females between the two groups (P > 0.05).
On comparing between sessions [Table 3], using paired Student's t-test, there was a highly significant improvement in the mean CFSS-DS score in Group I in the final session (P < 0.01). In group II, an increase in the final mean CFSS-DS score compared with the initial score indicated a slight increase in fear in this group; however, this difference was not statistically significant (P > 0.05).
|Table 3: Comparison of the mean fear scores (CFSS-DS) between the study groups during the experimental period|
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There was no statistically significant difference in the overall mean CFSS-DS scores between the two groups during the initial session (P > 0.05). However, in the final session, a statistically significant difference was observed in the overall mean fear scores between the groups (P < 0.01). A significant improvement was seen in group I, while no significant change was noted in case of group II.
In group I, the most feared items in descending order prior to audiovisual modeling were injections, choking, the sight, sounds, and act of the dentist drilling, doctors, being touched by a stranger, having their teeth cleaned, and dentists, which were followed by having someone put instruments in their mouth, having someone examine the mouth, having to go to the hospital, and people in white uniforms. Having to open the mouth and having somebody look at them were the least fear-provoking items among these children [Table 4]a.
Audiovisual modeling resulted in a significant reduction of overall fear as well as specific fear in relation to most of the items. A highly significant reduction of fear was observed toward dentists, doctors in general, injections, being looked at, the sight, sounds, and act of the dentist drilling, and having the nurse clean their teeth (P < 0.001). Significant reduction in fear toward having somebody examine the mouth and having someone put instruments in patient's mouth was also seen (P < 0.05).
In group II, the most fearful stimuli were injections, choking, the sight, sounds, and act of the dentist drilling, having their teeth cleaned, and doctors, which were followed by having someone put instruments in their mouth, dentists, having to go to the hospital, and people in white uniforms. Having to open the mouth and having somebody look at them were the least fear-provoking items among these children similar to group I [Table 4]b.
During the second visit, the children belonging to group II who did not receive audiovisual modeling showed no significant reduction either in the overall mean fear or in the specific fear toward individual items, when compared to the initial visit. On the contrary, a slight increase in fear was observed toward the sight and noise of the dentist drilling, choking, having to go to the hospital, and people in white uniforms, but this difference was not statistically significant (P > 0.05).
| Discussion|| |
Dental fear in patients still poses a significant problem for the practice of dentistry. It is often initiated in childhood and responsiveness to fear varies between children and adults due to cortical immaturity and emotional conditioning received from parents and contact with the environment.  Fear of the unknown provokes anxiety in the dental clinic. In children with no previous dental experience, fear may be to the uncertainty they feel about what awaits them after the initial appointment check-up. Alleviating a child's anxiety about dental treatment is important not only in mitigating the immediate fear but also in preventing apprehension continuing into adulthood.  Filewich and colleagues have reported that highly fearful patients required approximately 20% more chair-side time than did less fearful patients, highlighting the concern for dentists to learn and utilize various management techniques to relieve fear and anxiety of patients, not only for the patient's sake but also for the potential economic impact. 
Although it is important to develop new techniques for reducing fear and anxiety and improving behavior, it may also be fruitful to promote those promising techniques that already possess an initial research base, but have not received enough support or attention to be incorporated into daily dental practice, such as modeling.  Although previous studies report the successful use of modeling in reduction of anxiety as well as behavior management problems, there are very few reports about the influence of modeling in the present scenario, wherein children are exposed to a multitude of influences through other means such as various forms of mass media, in addition to their own dental and medical experiences. These factors influence both the child's initial perception as well as responses to the dental situation. The present study was undertaken to determine the efficacy of audiovisual (filmed) modeling in reducing dental fear in present-day pediatric dental patients.
Many measurement techniques have been proposed to assess dental fear and anxiety and dental behavior management problems: Behavioral ratings, psychometric scales, physiological measures, and projective techniques. Two broad types of measurement techniques are most frequently used in research: (i) observation of the child's reaction/behavior by dentist or other person during dental treatment (behavioral ratings) and (ii) reports of anxiety made by the child him/herself or by the accompanying parent (most often the mother) using psychometric scales. Self-reports are most often used when studying adolescents, while parental reports are normally used with children under 13 years of age.  The CFSS-DS consists of 15 items scored on Likert-type scales ranging from 1 (not afraid at all) to 5 (very afraid) with 15-75 as the possible total score range. It has been used in Croatia,  Denmark,  Finland,  Japan,  the Netherlands,  Norway,  Singapore,  Sweden,  and in the USA,  and mainly in larger patient samples. In a report by Aartman et al. comparing properties of different self-report measures, it was concluded that CFSS-DS was preferred as it has better psychometric properties, measures dental fear more precisely, covers more aspects of the dental situation, and since normative values are available. Several studies also show high test - retest reliability for the CFSS-DS. Regarding validity (mostly evaluated as comparisons with behavioral ratings or congruence with other psychometric measures for child dental fear, and a few comparisons with physiological measures), there was more variation but several reports of moderate to good correlations. Today the test is mainly used in two versions: A self-report by the child him/herself and a parental version. Research has indicated that parental ratings of child dental fear have a good correlation with other measures. , Using parental ratings, scores equal to or exceeding 37, 38, or 39 have been correlated to clinical assessments of Dental Fear and Anxiety [DFA] when comparing CFSS-DS in children with DFA (usually patients referred to specialist pediatric dentists) and non-anxious children and, thus, are used as cut-offs for dental anxiety. ,,,, The advantage of this scale over others is that it helps in identifying specific situations that provoke fear and quantifies the severity of fear provoked by each situation.
The most feared items among this study population according to the baseline CFSS-DS scores recorded during the first visit were getting injections and fear of choking, followed by the dentist drilling and the noise of the dentist drilling. Similar results have been reported in previous studies conducted in other countries including Singapore, Denmark, Greece, and Sweden. In the present study, the modeling group showed a significant reduction in fear (P < 0.01) both in the overall scores as well as in individual items [Table 3] and [Table 4]a. However, in group II, there was a slight increase in the overall score and increase or no change was observed when the items were analyzed individually [Table 3] and [Table 4]b.
When the effects of exposure to the modeling film and no video exposure on fear extinction were compared, the children in group I showed a significant reduction in fear while, on the contrary, the children who were not exposed to any video showed a slight increase in fear, although this increase was not statistically significant (P > 0.05).
The reduction of fear in group I may be due to the observation of a filmed model who depicted positive behavior during dental treatment and was, in turn, verbally and materially reinforced for cooperation in the modeling film. Exposure to the modeling film may have familiarized the children to the sights, sounds, and procedures that they will be subjected to. Hence, the threat of the unknown was reduced or eliminated among these children, which might have reduced their anxiety and negative responses toward an unfamiliar situation by fear extinction, while the children in group II did not receive any pre-exposure prior to being subjected to an unfamiliar dental procedure.
| Conclusion|| |
- The results of this study show that the most feared items among the study population were injections, choking, the sight, sounds, and act of the dentist drilling, doctors, being touched by a stranger, and having their teeth cleaned. Having to open the mouth and having somebody look at them were the least fear-provoking items among these children.
- Audiovisual modeling had a significant influence on the child's overall fear as well as individual responses toward the common fear-evoking stimuli in the dental situation.
- The CFSS-DS is helpful in evaluating the overall dental fear as well as identifying specific fear-provoking stimuli.
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[Table 1], [Table 2], [Table 3], [Table 4]