|Year : 2013 | Volume
| Issue : 2 | Page : 82-86
Dental anxiety and behavioral problems: A study of prevalence and related factors among a group of Iranian children aged 6-12
M Paryab1, M Hosseinbor2
1 Department of Pediatric Dentistry, International Campus, Tehran University of Medical Sciences, Tehran, Iran
2 Department of Pediatric Dentistry, Zahedan University of Medical Sciences, Zahedan, Iran
|Date of Web Publication||26-Jul-2013|
Department of Pediatric Dentistry, Faculty of Dentistry, Tehran University of Medical Sciences, Mahan St., Zam Zam Street, Navabe Safavi Avenue, Tehran
Source of Support: Faculty of Dentistry, Zahedan University of
Medical Sciences, Conflict of Interest: None
| Abstract|| |
Purpose: The aims of this study were to assess the prevalence and also some related demographic and dental factors of dental anxiety and behavioral problems in school-aged children. Subjects and Methods: A total of 150 children of 6-12 years old were selected according to the inclusion criteria. Prior to the dental visit, the mothers were asked to answer a questionnaire of dental and demographic background and a Corah dental anxiety scale (CDAS). At the same time, a faces version of the modified child dental anxiety scale (MCDAS) was completed by the child. Next, the child was guided to the operating room. According to the treatment plan, local anesthesia solution was injected and the child's cooperative behaviors were quantified based on the Frankle index duration the injection stage. Analysis of Variance and Linear regression models were used for the statistical analysis. Results: The mean scores of the child's dental anxiety and cooperative behavior were 20.81 (±6.97) and 3.04 (±0.86), respectively. Forty four children (29.33%) had severe dental anxiety. Child's age and regular dental visit are predictive factors for the child's dental anxiety (P < 0.05). Dental behavioral problems had been identified in 43 children (28.67%). Unpleasant previous dental experience is an important factor affecting the child's cooperative behaviors (P < 0.05). Conclusion: High prevalence of severe dental anxiety may be seen in early years of school. It seems that general factors such as family factors have less impact on behavior of school aged children in a dental visit.
Keywords: Children, cooperative behavior, dental anxiety, predictive factor, prevalence
|How to cite this article:|
Paryab M, Hosseinbor M. Dental anxiety and behavioral problems: A study of prevalence and related factors among a group of Iranian children aged 6-12. J Indian Soc Pedod Prev Dent 2013;31:82-6
|How to cite this URL:|
Paryab M, Hosseinbor M. Dental anxiety and behavioral problems: A study of prevalence and related factors among a group of Iranian children aged 6-12. J Indian Soc Pedod Prev Dent [serial online] 2013 [cited 2020 Oct 29];31:82-6. Available from: https://www.jisppd.com/text.asp?2013/31/2/82/115699
| Introduction|| |
Children's dental anxiety is a natural developing emotion expected duo to meeting unfamiliar adults, strange sounds, and tastes, having to lie down and even pain.  Several personal, familial and environmental elements affect the severity of child's dental fears. ,, After the age 6, children acquire abilities in adjustments, independence and self-control.  However, some children have severe dental anxiety resulting in interruption of the dental treatment process. This anxiety possibly continues to adulthood. ,
Surveys from different areas of the world show that the prevalence of dental anxiety in children and adolescents varies from about 5% to nearly 20%. ,,,,,,,,,,,,,
The purpose of this study was to assess the prevalence of dental anxiety and behavioral problems and to investigate some associated demographic and dental background variables in a group of Iranian school-aged children.
| Subjects and Methods|| |
This cross-sectional investigation was approved by ethics committee of Zahedan University of Medical Sciences and involved 150 children among 6-12 years old registered at the pediatric clinic of Zahedan Dental School, in 2011. Children who did not need dental procedure using the local anesthesia and children with systemic disease, psychological disorder, and developmental problems were excluded from this study. The mothers had diploma and higher educational level. Prior dental visit, at the waiting room, the mothers were asked to answer a consent form and a two sectioned questionnaire. The first section of the questionnaire gathered information about the dental and demographic background of the child and family. The second section of the questionnaire had a Corah dental anxiety scale (CDAS).  At the same time, a faces version of the modified child dental anxiety scale (MCDAS) , was completed by the child, supervised by the dental assistance.
Next, the child was guided to the operating room. Examination was performed and required radiographies were obtained. According to the treatment plan, local anesthesia solution was injected and the child's cooperative behaviors were quantified based on the Frankle index  duration the injection stage. All of the dental procedures were performed by a pediatric specialist.
Descriptive statistics were produced and data analysis was performed using the Statistical Package for the Social Sciences-15 statistical Emperor Software. Analysis of variance and linear regression models were used for the statistical analysis. All statistical levels were made at 0.05.
| Findings|| |
A total number of 150 children, 66 boys and 84 girls were participated in this study. Most of the children were 6-7 years old (40.67%) [Table 1]. The mean scores of the child's dental anxiety and cooperative behavior during the local anesthesia injection were 20.81 (±6.97) and 3.04 (±0.86), respectively [Table 2].
|Table 2: Prevalence of dental anxiety and behavioral problems in children aged 6-12 years old|
Click here to view
According to the self-report measurement of anxiety (MCDAS), 44 children (29.3%) had severe dental anxiety and a high prevalence of severe dental anxiety was observed among children 6-7 years. The scores for each eight items of MCDAS showed "injections" had the highest rank with the 47% of the children answering "score 5." The items scoring next highest were "dental extraction" and "visiting the strangers," 46% and 27%, respectively.
Results of simple regression analysis for the child's dental anxiety have been shown in [Table 3]. The results of multiple regression analysis show that the child's age (P value: 0.006; beta coefficient: -1.032) and regular dental visit (P value: 0.045; beta coefficient: 2.273) are predictive factor for the child's dental anxiety.
|Table 3: Results of simple linear regression analysis for dental and demographic related factors for children's dental anxiety|
Click here to view
Dental behavioral problems (rating I and II of Frankle index) had been identified in 43 children (28.67%). Results of simple regression analysis for the child's cooperative behavior have been shown in [Table 4]. According to multiple regression analysis, child's prior dental experiences (P value: 0.07; odds ratio: 2.650) and dental anxiety (P value: <0.001; odds ratio: 1.170) are important factors affecting children behavior in a dental visit.
|Table 4: Results of simple linear regression analysis for dental and demographic related factors for children's cooperative behavior|
Click here to view
| Discussion|| |
Dental anxiety is one of the reasons why children avoid going to the dentist or express behavioral problems during a dental visit. If the child behavior problems are duo to general behavior and personality or related to fear of dental environment is an important issue in pediatric dentistry. There is a thin line in diagnosing between these two conditions.  A set of potential factors causes dental anxiety and behavioral problems. One of the most important factors in dental anxiety is the child's age. In children 3-6 years old, dental anxiety is as part of general anxiety.  When the child's age increases, changes in cognitive and socio-emotional characteristics, responsibilities, assimilating real, and self-control are acquired. Fear of separation from the parents, fear of strange situations and person, fear of bodily harm and general anxiety are reduced.  These abilities prepare the 6 years old children to enter the social environment such as school. It is expected that children older than 6 show little behavioral management problems in a dental visit. Our results showed that there is a high level of dental anxiety and behavior problems in school aged children. The prevalence of severe dental anxiety in children was 29.3% that is much higher than the findings in the same age children in Sweden (2.6%);  and Denmark (5.7%),  but is corresponded to the results obtained in Taiwanese children (28.3%)  and children from lower socio-economic families in Norway (19.5%). 
Comparison between age groups showed that the prevalence of severe dental anxiety in 6-7 years old children is higher than other age groups. High level of anxiety in early years of school has been shown in many studies.  No statistically significant difference in the prevalence of severe dental anxiety was found between boys and girls. This was consistent with Klingberg findings.  It is suggested that a study with a larger sample size and equal numbers of girls and boys in each age groups would be performed.
Irregular recall appointment was found as one of the most important predictive factors for severe dental anxiety in children. A total of 60% of children did not have regular recall dental visits. Irregular dental visits increases experience of pain and more treatment needs. The majority of studied children need a tooth extraction. Because of complicated treatment needs and awareness about the dental problems, children in this study showed a high level of dental anxiety. Bedi,  Skaret,  Raciene,  Lee,  and Oliveira  also emphasized on the importance of regular dental visits.
Parental dental anxiety, especially mothers, is another factor affects a child's dental anxiety. Females show more anxiety in comparison to men.  Influence of maternal anxiety on dental anxiety of children aged preschool  and after 6 , has been shown in previous studies. In Results of this study, no significant relationship between maternal dental anxiety and child's dental anxiety was found. It could be due to differences in methodology. Children completed the questionnaire under the supervision of dental assistant independent of their mother.
Cooperative behavior of the children during the injection of local anesthetic solution was also assessed. Injection of local anesthetic solution is one of the most anxiety-producing stimuli in the dental operatory. According to findings, high dental anxiety and previous negative dental experiences are important factors in predicting clinical behavior. Familial problems and acquired dental fear from familial members are less important in compare to child's dental experience and dental condition. Raddal,  Lee,  and Skaret  were also emphasized the importance of dental factors. They said that dental anxiety is a situational anxiety. However, in findings by Gustufson,  adolescent behavior problems in dental visits have been found as a part of more general behavior problems. Results about the behavioral problems showed Behavioral differences between boys and girls are reduced from age 6 as in the study by Peretz also found. 
It should be kept in mind that dental anxiety and behavioral problems of children during dental visits are influenced by several factors. In a cross-sectional study, causal relationship between a variable and a number of influential factors cannot be accurately assessed. One error is sampling error (selection bias). Children aged 6-12 years have more independence in decision-making. Some of them can avoid visiting the dentist duo to high anxiety and the reported prevalence of high dental anxiety could be lower than the actual prevalence. The studied children were a group of Iranian population; so the results cannot be generalized to other children with different cultures and socioeconomic conditions.
The other error occurs in the collection of information (information bias). It is duo to the parental anxiety or child's shaming in responding the questionnaire. Children may also express more anxiety because of awareness of dental problem.
According to the importance of dentally factors affecting anxiety and cooperative behavior of children in a dental visit, it is expected that informing the parents about the regular visits since birth, can improve a child's oral health-care and reduce the treatment needs of the children. Reduction of the negative dental experience in children prevent dental anxiety be increased in older ages.
| Conclusion|| |
High prevalence of severe dental anxiety may be seen in early years of school. It seems that general factors such as family factors have less impact on behavior of school aged children in a dental visit.
| Acknowledgment|| |
This study is based on a thesis to the graduate faculty, Faculty of Dentistry, Zahedan University of Medical Sciences, in partial fulfillment of the requirements for the M.S. degree.
| References|| |
|1.||Klingberg G, Raadal M, Arnrup K. Dental fear and behavior management problems. In: Koch G, Paulsen S, editors. Pediatric Dentistry: A Clinical Approach. 2 nd ed. Copenhagen: Munksagaard; 2009. p. 32. |
|2.||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. |
|3.||Folayan MO, Idehen EE, Ojo OO. The modulating effect of culture on the expression of dental anxiety in children: A literature review. Int J Paediatr Dent 2004;14:241-5. |
|4.||Arnrup K, Broberg AG, Berggren U, Bodin L. Lack of cooperation in pediatric dentistry: The role of child personality characteristics. Pediatr Dent 2002;24:119-28. |
|5.||Pinkham JR. Dynamic of changes. In: Pinkham JR, Casa Massimo PS, editors. Pediatric Dentistry-Infancy Through Adolescence. 4 th ed. Philadelphia: Elsevier Saunders; 2005. p. 469-71. |
|6.||Schwarz E. Dental anxiety in young adult Danes under alternative dental care programs. Scand J Dent Res 1990;98:442-50. |
|7.||Hakeberg M, Berggren U, Carlsson SG. Prevalence of dental anxiety in an adult population in a major urban area in Sweden. Community Dent Oral Epidemiol 1992;20:97-101. |
|8.||Bedi R, Sutcliffe P, Donnan PT, McConnachie J. The prevalence of dental anxiety in a group of 13- and 14-year-old Scottish children. Int J Paediatr Dent 1992;2:17-24. |
|9.||Klingberg G, Berggren U, Norén JG. Dental fear in an urban Swedish child population: Prevalence and concomitant factors. Community Dent Health 1994;11:208-14. |
|10.||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. |
|11.||Bergius M, Berggren U, Bogdanov O, Hakeberg M. Dental anxiety among adolescents in St. Petersburg, Russia. Eur J Oral Sci 1997;105:117-22. |
|12.||Skaret E, Raadal M, Berg E, Kvale G. Dental anxiety among 18-yr-olds in Norway. Prevalence and related factors. Eur J Oral Sci 1998;106:835-43. |
|13.||Peretz B, Efrat J. Dental anxiety among young adolescent patients in Israel. Int J Paediatr Dent 2000;10:126-32. |
|14.||Colares V, Richman L. Factors associated with uncooperative behavior by Brazilian preschool children in the dental office. ASDC J Dent Child 2002;69:87-91, 13. |
|15.||Wogelius P, Poulsen S, Sørensen HT. Prevalence of dental anxiety and behavior management problems among six to eight years old Danish children. Acta Odontol Scand 2003;61:178-83. |
|16.||Raciene R. Prevalance of dental fear among Vilnius pupils aged 12-15 years, determining factors. Stomatology Baltic Dent Maxillofac J 2003;5:52-6. |
|17.||Gustafsson A, Arnrup K, Broberg AG, Bodin L, Berggren U. Psychosocial concomitants to dental fear and behaviour management problems. Int J Paediatr Dent 2007;17:449-59. |
|18.||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. |
|19.||Lee CY, Chang YY, Huang ST. The clinically related predictors of dental fear in Taiwanese children. Int J Paediatr Dent 2008;18:415-22. |
|20.||Nuttall NM, Gilbert A, Morris J. Children's dental anxiety in the United Kingdom in 2003. J Dent 2008;36:857-60. |
|21.||Oliveira MM, Colares V. The relationship between dental anxiety and dental pain in children aged 18 to 59 months: A study in Recife, Pernambuco State, Brazil. Cad Saude Publica 2009;25:743-50. |
|22.||Corah NL, Gale EN, Illig SJ. Assessment of a dental anxiety scale. J Am Dent Assoc 1978;97:816-9. |
|23.||Howard KE, Freeman R. Reliability and validity of a faces version of the modified child dental anxiety scale. Int J Paediatr Dent 2007;17:281-8. |
|24.||Javadinejad S, Farajzadegan Z, Madahain M. Iranian version of a face version of the modified child dental anxiety scale: Transcultural adaptation and reliability analysis. J Res Med Sci 2011;16:872-7. |
|25.||Wright GZ, Stigers JI. Non-pharmacologic management of children's behaviors. In: Dean JA, Avery DR, McDonald RE, editors. Dentistry for the Child and Adolescence. 9 th ed. Louis: Mosby; 2011. p. 30. |
|26.||Holst A, Hallonsten AL, Schröder U, Ek L, Edlund K. Prediction of behavior-management problems in 3-year-old children. Scand J Dent Res 1993;101:110-4. |
[Table 1], [Table 2], [Table 3], [Table 4]