|Year : 2017 | Volume
| Issue : 2 | Page : 128-133
Prevalence of dental fear and its causes using three measurement scales among children in New Delhi
Anju Singh Rajwar, Mridula Goswami
Department of Pedodontics and Preventive Dentistry, Maulana Azad Institute of Dental Sciences, New Delhi, India
|Date of Web Publication||10-May-2017|
Anju Singh Rajwar
40-B, Pocket-B, Mayur Vihar Phase-2, New Delhi - 110 091
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Introduction: There is a great need for identifying fearful children, who often present problems in patient management, thus affecting the quality of dental care rendered to them. This study is unique in the way that dental fear was assessed through three fear scales as research has suggested the use of more than one scale because each scale has its own restrictions and is open to criticism. Aim: The aim of this study was to evaluate dental fear and anxiety (DFA) among children aged 3–14 years using three fear measurement scales. Methods: The study was conducted on children (3–14 years) who visited the Department of Pedodontics and Preventive Dentistry at Maulana Azad Institute of Dental Sciences, New Delhi. The DFA levels were measured using three fear measurement scales, i.e., facial image scale (FIS), dental fear scale (DFS), and children's fear survey schedule-dental subscale (CFSS-DS). The dental behavior was estimated using the Frankl's behavior rating scale (FBRS). Results: The prevalence of dental fear according to FIS was 14.3%, according to DFS was 22.6%, and according to CFSS-DS was 7.4%. In assessment of the behavior of children in the clinics through FBRS, it was observed that he maximum number of respondents (69.8%) showed Frankl's Rating 3 i.e. positive. In the DFS and CFSS-DS, the factor which caused most fear was “feeling the needle injected” and “injections,” respectively. Conclusion: Assessment of dental fear is an extremely useful tool for the dental practitioner, who can use it to customize the behavioral treatment and management for child patients.
Keywords: Children's fear survey schedule-dental subscale, dental fear, dental fear and anxiety, dental fear scale
|How to cite this article:|
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
|How to cite this URL:|
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 [serial online] 2017 [cited 2019 Dec 13];35:128-33. Available from: http://www.jisppd.com/text.asp?2017/35/2/128/206032
| Introduction|| |
Fear is a reaction to real or imagined threat and is considered to be an integral and adaptive aspect of normal development. Dental fear is a reaction to a known danger, which involves a fight-or-flight response when confronted with the threatening stimulus. Dental fear is a widespread phenomenon in children and poses a serious problem in rendering treatment to the child. Its etiology is complex and multifactorial with various factors being involved in the acquisition and development of dental fear in children. Dental fear in children does not only concern fear of pain or of invasive procedures but also entail separation from parents, confrontation with unfamiliar people and surroundings, and the experience of loss of control.
Anxiety is very similar to fear. It is formed of the same elements and functions the same way. Anxiety emotions are, however, more diffuse than specific fear and are attached to many different situations and events., In contrast to fear, anxiety may be felt even though the feared stimulus is not present. Dental fear and anxiety (DFA) poses a significant problem in patient management as such patients are more likely to avoid or delay seeking dental treatment and cancel dental appointments. This further leads to a vicious circle where the levels of dental anxiety are increased or reinforced as a result of greater disease prevalence and severity associated with delayed dental visiting.
This study was conducted in children in contrast to adults who have relatively limited communication skills and are less able to express their fears and anxiety. Their inability to cope with threatening dental stimuli often manifests as behavior management problems. Assessment of children based on their behavior is one of the most important skills for a pediatric dentist. Managing dental anxiety and fear forms a major aspect of child's dental care and considered to be the main barrier for successful completion of the dental treatment. Thus, early recognition and management of dental fear are imperative and the key to deliver effective dental treatment to the child patient.
Various measures have been developed in a bid to develop a uniform method of assessing and grading dental fear in children. Psychometric measures are easy to administer, inexpensive, flexible, and often result in continuous score ranges that can easily be compiled and processed statistically. Since each questionnaire has its own restrictions, and because they do not completely cover the concept of anxiety, the use of more than one questionnaire is advocated in research related to DFA assessment. Hence, in this study, three fear assessment scales were used to assess DFA, i.e., facial image scale (FIS), dental fear scale (DFS), and children's fear survey schedule-dental subscale (CFSS-DS) which makes it unique in comparison to other studies where fear assessment is through one or two scales.
To correlate, the DFA levels with the behavior in the dental setup Frankl's behavior rating scale (FBRS) was used, which is the most commonly used behavior rating scale by the dentist to categorize the child's behavior.
Assessment of the prevalence of dental fear, among children aged 3–14 years who will visit the Department of Pedodontics and Preventive Dentistry at Maulana Azad Institute of Dental Sciences, using three fear scales, i.e., FIS, DFS, and CFSS-DS.
- Assessment of the child's behavior pattern using the Frankl's behavior rating scale and to find out the association of dental fear with dental behavior
- Assessment of the factors which cause DFA in children
- Assessment of the impact of age and gender on the dental fear of the children.
| Methods|| |
A cross-sectional study was carried out in 420 children aged between 3 and 14 years who attended the Department of Pedodontics and Preventive Dentistry at Maulana Azad Institute of Dental Sciences, New Delhi.
The sample selection was done randomly and later divided into the following four groups:
- Group 1: Aged 3–5 years
- Group 2: Aged 6–8 years
- Group 3: Aged 8–11 years
- Group 4: Aged 12–14 years.
The inclusion criteria were all healthy children who visited the department for seeking dental care along with a parent. The exclusion criteria were patients with mental disabilities and sensory impairment and whose parents did not wish to participate in the study.
Parents and children were approached in the waiting room, to obtain their informed written consent to the participation in the present study, and at first, the FIS was applied and FIS score of the child was recorded. Children and their parents were not able to see the dentist ratings of FIS. The FIS comprises a row of five faces ranging from very happy (1) to very unhappy (5).
After the FIS, the DFS was applied to the children. The questionnaire of DFS was translated into Hindi (local language). The DFS is a twenty-question form, and the answers range from “not at all fearful” (20) to “very much afraid” (100). The parents were then asked to complete the questionnaire on behalf of their children since the younger children were not able to complete the questionnaire by themselves. Thereafter, the DFA levels were assessed by applying the CFSS-DS which is a 15-question form with a five-point response scale from 1 - “not afraid at all” to 5 - “very afraid.” Total score thus ranges from 15 to 75. The parents were asked to complete the questionnaire on behalf of their children.
The questionnaires were collected back and the child was then escorted to the operatory. The behavioral pattern of the child during treatment was determined by the dentist using the FBRS. The data obtained through the questionnaire were entered into Microsoft Office Excel Sheet 2007, and statistical analysis was carried out for the data. Data analysis was performed using the Statistical Package for the Social Science (v17.0, SPSS Inc., Chicago, USA). All statistical levels were made at P < 0.05.
| Results|| |
Out of the total 420 study respondents, 218 (51.9%) were males and 212 (48.1%) were females. The reliability and validity of the Hindi translated versions of DFS and CFSS-DS were checked using Cohen's Kappa statistics. Both the scales displayed a strong inter-rater reliability for each question. Internal consistency and reliability of the DFS and CFSS-DS questionnaire were assessed using Cronbach's alpha coefficient. Alpha values ≥0.70 were considered satisfactory. Cronbach's alpha value of 0.9992 was obtained for DFS and 0.9994 for CFSS-DS, which indicated high reliability.
- In FIS, the maximum respondents out of the sample population (41.9%) showed FIS score 2, i.e., happy as seen in [Table 1]. Since the choice of FIS 4 and 5 was considered to be indicative of dental fear in children, 14.3% of children were found to have dental fear according to FIS. There was a statistically significant difference in FIS scores among the four age groups using Pearson's Chi-square test (P = 0.0001). However, there was no statistical significant difference in FIS scores among males and females using Pearson's Chi-square test (P = 0.382)
- The mean DFS score for males was 29.92 ± 8.9 and for females was 32.88 ± 10.8 as shown in [Table 2]. It was observed that statistically significant difference between mean scores of males and females was seen after using Student's t-test (P = 0.02) as shown in [Table 2]. The maximum mean DFS scores were found in Group 2. However, no statistically significant difference was seen between the various groups (P = 0.151). The distribution of mean DFS scores with respect to gender and age group is represented by [Figure 1]. It shows the maximum DFS scores were seen in females in Group 2 (6–8 years)
|Figure 1: Mean dental fear scale scores with respect to age groups and gender|
Click here to view
- The mean CFSS-DS score for males was 21.67 ± 7.5 and for females was 23.71 ± 8.9 as shown in [Table 3]. It was observed that no statistical significant difference was seen between males and females and mean CFSS-DS scores using Student's t-test (P = 0.011) as shown in [Table 3]. It was observed that Group 3 (9–11 years) showed the highest CFSS-DS scores. The difference in mean CFSS-DS scores was calculated using one-way ANOVA. It was observed that maximum mean CFSS-DS scores were seen in Group 3; however, no statistically significant difference was seen between the various groups (P = 0.162). In CFSS-DS, scores ≥38 were considered under high-fear group. In our study, 7.4% children were under high-fear group whereas 92.6% were under low-fear group. The distribution of mean CFSS-DS scores with respect to gender and age group is represented by [Figure 2]. It shows the maximum CFS-DSS scores were seen in females in Group 3 (9–11 years)
|Table 3: Mean children's fear survey schedul-dental subscale with respect to gender|
Click here to view
|Figure 2: Mean children's fear survey schedule scores with respect to age groups and gender|
Click here to view
- The Frankl's ratings were recorded and it was observed that the maximum respondents (69.8%) showed Frankl's rating 3, i.e., positive as seen in [Table 4]. However, there was no statistically significant difference in Frankl's ratings among males and females using Pearson's Chi-square test (P = 0.033). A statistically significant difference was seen in Frankl's ratings among the four groups (P = 0.0001).
On the evaluation of DFS, it was found that the factor which caused the most fear was “feeling the needle injected” (38.8%), whereas in CFSS-DS, it was fear of “injections” (37.9%).
| Discussion|| |
This study was conducted to identify the presence of dental fear among children as it is considered to be the main barrier to successful completion of dental treatment of child patients. The need for assessing and addressing childhood DFA at an early stage should be emphasized to enable identification of children with high dental fear and consequently to prevent the negative consequences of high dental fear in them. The aim of this study was to evaluate the prevalence of dental fear in children and assess the various related factors and the impact of age and gender on the levels of dental fear.
A wide range of dental questionnaires for the assessment of dental fear is available. The availability of so many dental anxiety/fear questionnaires may be interpreted as representing dissatisfaction with the existing list. Furthermore, all the questionnaires are open to criticism. Each questionnaire has its own restrictions, and because they do not completely cover the concept of anxiety, the use of more than one questionnaire is advocated in research related to DFA assessment. Hence, in this study, we have used three fear assessment scales, along with correlation with a behavior rating scale which makes it unique in comparison to other studies.
The CFSS-DS is one of the most widely used scales for children and has better psychometric properties than other scales as it measures dental fear more precisely and covers more aspects of dental situations. The second most commonly used measure of dental anxiety and fear is the DFS. It was developed to provide information on a variety of specific stimuli that might elicit fear or avoidance response as well as the patient's specific and unique response to those stimuli. However, for clinical practice purpose, they are rather long questionnaire and their interpretation takes more time, and hence, FIS was used which can be employed even with young children and it becomes easier to assess them objectively through this scale. Furthermore, it takes very less time to administer. A strong positive correlation was found between the CFSS-DS and DFS scales in our study.
To classify the child behavior in the dental office, FBRS was used as it is the most widely used measure of classifying child behavior. It is one of the most reliable tools developed for behavior rating of children in dental sittings and correlates moderately well with questionnaires assessing dental anxiety and fear.
The prevalence of dental fear according to FIS in our study sample was found to be 14.3%. It was observed that the maximum response (41.9%) was seen for FIS score 2, i.e., happy. It was also reported that the age group of children between 12 and 14 years showed maximum response (54.5%) of FIS score 2. This may be explained due to the fact that as the cognitive ability develops with increasing age, the fear levels tend to reduce; hence, the older age group children were less fearful as compared to younger age group children. This finding was supported by a study done by Raducanu et al. where a significant decrease in fear levels was seen with advancement of age whereas no significant difference was observed between boys and girls with regard to age in a study conducted by Buchanan and Niven. With regard to gender, male respondents (41.3%) showed a higher frequency of FIS score 2 as compared to female respondents (42.6%). This implies that fear levels were more in females as compared to males; however, this difference was not statistically significant (P = 0.382). This observation was also supported by a study done by Raducanu et al. where dental fear in girls was reported to be 1.63 times greater than boys.
In the DFS, low fear was measured below the 25th percentile (below 24), moderate fear was measured between the 25th and the 75th percentile (24–53), and high fear was measured above the 75th percentile (above 53). Thus, the prevalence of high dental fear in children according to DFS in our study was found to be 22.6%.
The mean values of dental fear as measured with DFS scale were found to be higher in females as compared to male respondents. Statistically significant difference was found between mean score for males and females. It was also observed that the age group of 6–8-year-old children showed the highest mean values for dental fear. However, no statistically significant difference in fear levels within various age groups as measured with DFS was seen in our study. This was against the findings of the study by Raciene, who observed that as age increases the level of fear declines.
Children with CFSS-DS scores >38 were considered as dentally anxious, in accordance with Singh et al. and Klingberg. It was observed that 7.4% children were under high-fear group, whereas 92.6% were under low-fear group. The mean CFSS-DS values for females (21.67 ± 7.5) were higher than the males (23.71 ± 8.9); however, the difference was not found to be statistically significant (P = 0.011). This was not in accordance with the studies done by Nakai et al., Raadal et al., and Alvesalo et al., who reported higher dental fear levels in girls than in boys. Klingberg and Broberg  on the contrary found higher anxiety levels in boys than in girls. The findings of this study were, however, consistent with the findings of Singh et al., who found no significant difference in fear scores of girls and boys.
It was observed that the age group of 9–11 years showed the highest mean CFSS-DS scores (23.61 ± 8.585); however, no statistically significant difference was seen among the age groups (P = 0.162). The result was not similar to findings of Lee et al. that younger children express higher dental fear, but similar to Arapostathis et al. where mean scores were not related to age differences.
In assessment of the behavior of children in the clinics through FBRS, it was observed that the maximum rating (69.8%) for the respondents was FBRS 3, i.e., positive. This was consistent with the findings of Shinohara et al. who also reported the distribution of Frankl's rating 3 to be most frequent in his study. This could be due to the fact that the children were evaluated during a less invasive modality of treatment, i.e., oral prophylaxis. Furthermore, it could be due to the fact that children often tend to overestimate their fears; hence, the behavior ratings were positive.
In assessment of the various factors which caused the most fear in children, it was observed that according to DFS, the factors which caused the most fear was “feeling the needle injected,” followed by “seeing the anesthetic needle” and “how fearful are you of having your work done?“ followed by “vibrations of the drill.”
In CFSS-DS, the most feared item was “injections,” followed by “dentist” and then “doctors.” Thus, it may be concluded that the injections are the most feared item for the children. This was consistent with the findings of Nakai et al. who also reported injections to be one of the most feared items in his study. In a study done by Domoto et al., it was observed that injections and drilling were the most fear provoking stimuli.
The results of this study suggest that there is a need for further research to find better methods for understanding and improving the fears and behavior of children and adolescents when they visit dentists.
| Conclusion|| |
- The prevalence of high dental fear in children aged 3–14 years was 14.3% according to FIS, 22.6% according to DFS, and 7.4% according to CFSS-DS
- The maximum respondents (69.8%) showed Frankl's behavior rating 3, i.e., positive, which was corresponding to the low dental fear found in the study sample
- In the DFS, the factor which caused most fear was “feeling the needle injected” with the percentage of 38.8%, whereas in CFSS-DS, the factor which caused most fear was “injections” with percentage of 37.9%
- In the assessment of impact of age and gender on the dental fear levels, it was found that the level of dental fear declines as the age progresses and females were more fearful as compared to males as per the three scales used.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
King NJ, Hamilton DI, Ollendick TH. Children's Phobias: A Behavioural Perspective. Chichester, UK: John Wiley & Sons; 1988.
Ten Berge M. Dental Fear in Children: Prevalence, Etiology and Risk Factors. Thesis. Amsterdam: University of Academic Centre for Dentistry Amsterdam; 2001.
Freud S. Introductory Lectures on Psycho-Analysis. 1st
ed. London: Hogarth Press, the Institute of Psycho-Analysis; 1961.
Stein D, Hollander E. The American Psychiatric Publishing Textbook of Anxiety Disorders. 1st
ed. Washington, DC: American Psychiatric Pub.; 2002.
Armfield JM, Spencer AJ, Stewart JF. Dental fear in Australia: Who's afraid of the dentist? Aust Dent J 2006;51:78-85.
Armfield JM, Stewart JF, Spencer AJ. The vicious cycle of dental fear: Exploring the interplay between oral health, service utilization and dental fear. BMC Oral Health 2007;7:1.
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.
] [Full text]
Shinohara S, Nomura Y, Ide M, Idaira Y, Moriyasu K, Takahashi T, et al
. The classification of children by their behaviour for the dental treatment using cluster analysis. Pediatr Dent J 2005;15:191-4.
Sharma A, Tyagi R. Behavior Assessment of children in dental settings: A retrospective study. Int J Clin Pediatr Dent 2011;4:35-9.
Schuurs AH, Hoogstraten J. Appraisal of dental anxiety and fear questionnaires: A review. Community Dent Oral Epidemiol 1993;21:329-39.
Chellappah NK, Vignehsa H, Milgrom P, Lam LG. Prevalence of dental anxiety and fear in children in Singapore. Community Dent Oral Epidemiol 1990;18:269-71.
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;17:391-406.
Buchanan H, Niven N. Validation of a Facial Image Scale to assess child dental anxiety. Int J Paediatr Dent 2002;12:47-52.
Koenigsberg SR, Johnson R. Child behavior during sequential dental visits. J Am Dent Assoc 1972;85:128-32.
Raducanu AM, Feraru V, Herteliu C. Assessment of the prevalence if dental fear and its causes among children and adolescents attending a department of paediatric dentistry in Bucharest. OHDMBSC 2009;8:42-9.
Al-Madi E, AbdelLatif H. Assessment of dental fear and anxiety among adolescent females in Riyadh, Saudi Arabia. Saudi Dent J 2002;14:77-81.
Raciene R. Prevalence of dental fear among Vilnius pupils aged 12 to 15 years. Determining factors. Stomatol Balt Dent Maxillofac J 2003;5:52-6.
Singh P, Pandey RK, 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;28:151-5.
] [Full text]
Klingberg G. Reliability and validity of the Swedish version of the dental subscale of the children's fear survey schedule, CFSS-DS. Acta Odontol Scand 1994;52:255-6.
Nakai Y, Hirakawa T, Milgrom P, Coolidge T, Heima M, Mori Y, et al.
The children's fear survey schedule-dental subscale in Japan. Community Dent Oral Epidemiol 2005;33:196-204.
Raadal M, Milgrom P, Weinstein P, Mancl L, Cauce AM. The prevalence of dental anxiety in children from low-income families and its relationship to personality traits. J Dent Res 1995;74:1439-43.
Alvesalo I, Murtomaa H, Milgrom P, Honkanen A, Karjalainen M, Tay KM. The dental fear survey schedule: A study with Finnish children. Int J Paediatr Dent 1993;3:193-8.
Lee CY, Chang YY, Huang ST. Prevalence of dental anxiety among 5- to 8-year-old Taiwanese children. J Public Health Dent 2007;67:36-41.
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;18:374-9.
Domoto PK, Weinstein P, Melnick S, Ohmura M, Uchida H, Ohmachi K, et al.
Results of a dental fear survey in Japan: Implications for dental public health in Asia. Community Dent Oral Epidemiol 1988;16:199-201.
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4]