|Year : 2013 | Volume
| Issue : 3 | Page : 175-179
The relationship between dental anxiety in children, adolescents and their parents at dental environment
Cristiane Meira Assunção1, Estela Maris Losso2, Roberto Andreatini3, José Vitor Nogara Borges de Menezes4
1 Department of Surgery and Orthopedics, Federal University of Rio Grande do Sul, Porto Alegre, RS, Brazil
2 Department of Dentistry in Childhood, Positivo University, Curitiba, PR, Brazil
3 Department of Pharmacology, Federal University of Paraná, Curitiba, PR, Brazil
4 Department of Stomatology, School of Dentistry, Federal University of Paraná, Curitiba, PR, Brazil
|Date of Web Publication||11-Sep-2013|
Cristiane Meira Assunção
R. Equador, No. 60, Bacacheri 82510-120, Curitiba, PR
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Purpose: The aim of the present study was to compare trait anxiety and dental anxiety among children, adolescents and their parents. Materials and Methods: A cross-sectional study was conducted involving 100 patients from the Pediatric Dentistry Clinic of the Federal University of Parana (Brazil) between the ages of 8 and 17 years (mean age: 10.3; standard deviation: 2.03) and their parents, who responded to Corah's Dental Anxiety Scale (DAS) and the Trait Anxiety Scale. The data were analyzed using the Mann-Whitney test, analysis of variance and both Pearson's and Spearman's correlation coefficients. Results: Ninety percent of children and adolescents and 76% of the parents had moderate anxiety based on the DAS score. Seventy-four percent of children and adolescents and 72% of the parents had moderate anxiety based on the Trait Anxiety Scale score. The trait anxiety and dental anxiety scores were correlated among the adults (rs = 0.64) and children (r = 0.52), whereas no correlation between scores was found among the adolescents. Associations were also found between children's trait anxiety and the dental and trait anxiety of their parents (both r = 0.43). Conclusions: A moderate degree of dental anxiety was prevalent among the children, adolescents and parents who took part in this investigation, with correlations demonstrated between some trait anxiety and dental anxiety scores.
Keywords: Children, dental anxiety, parents
|How to cite this article:|
Assunção CM, Losso EM, Andreatini R, de Menezes JN. The relationship between dental anxiety in children, adolescents and their parents at dental environment. J Indian Soc Pedod Prev Dent 2013;31:175-9
|How to cite this URL:|
Assunção CM, Losso EM, Andreatini R, de Menezes JN. The relationship between dental anxiety in children, adolescents and their parents at dental environment. J Indian Soc Pedod Prev Dent [serial online] 2013 [cited 2021 Jan 16];31:175-9. Available from: https://www.jisppd.com/text.asp?2013/31/3/175/117977
| Introduction|| |
Dental anxiety is defined as "an abnormal fear or dread of visiting the dentist for preventive care or therapy and unwarranted anxiety over dental procedures" and may have psychological, cognitive and behavioral consequences.  Dental anxiety can prevent patients from cooperating fully during dental treatment.  Moreover, anxious people tend to overestimate pain and discomfort caused by dental treatment and may also postpone or miss appointments, with negative consequences for their oral health and often having to incur more complex interventions, thereby entering a vicious cycle that tends to intensify anxiety with regard to treatment. 
Dental anxiety is a common problem that affects people of all ages and appears to develop mostly in childhood and adolescence. Childhood dental anxiety is not only distressing for the child and family but is also associated with poor oral health outcomes and an increased reliance on costly specialist dental services.  Thus, the frequency of dental diseases and unpleasant dental experiences is greater among children with more anxious and uncooperative behavior in comparison to non-anxious children. 
Dentists need to understand the anxiety and its repercussions in dental care and need to know how to identify behavior that indicates anxiety so that a relationship of trust may be established with the patient for the implementation of strategies aimed at minimizing the anxiety caused by dental treatment.  Questionnaires or scales constitute the most common means of assessing dental anxiety. ,
The prevalence of dental anxiety among children varies according to the methodology employed and the age of the subjects. A study with Taiwanese children aged 5-8 years found a 20.6% prevalence rate of dental anxiety.  Dental anxiety can be considered a common condition, affecting approximately 9% of children and adolescents in Europe and in countries such as Australia, Canada and the United States. 
The aim of the present study was to measure anxiety in children and parents through the application of the same scales (Trait Anxiety Scale and Corah's Dental Anxiety Scale [DAS]) and determine possible associations between these scores and gender, age, household income, schooling and previous experience with dental treatment.
| Materials and Methods|| |
A cross-sectional clinical study was carried out involving the administration of anxiety scales and a questionnaire. This study received approval from the Human Research Ethics Committee of the Health Sciences Department of the Federal University of Paranα, Brazil (CAAE: 0055.0.088.091-08).
Patients treated at the Pediatric Dentistry Clinic of the Federal University of Paranα in the second semester of 2010 were invited to take part in this study. To participate, the children and adolescents needed to be accompanied by their parents during the dental appointment. All participants needed to be literate. Parents who agreed to participate signed a statement of informed consent and filled out the anxiety scales and questionnaires.
Approximately 180 children and adolescents were treated at the Pediatric Dentistry Clinic of the Federal University of Paranα during the data collection period. One hundred twenty-six were literate, but 16 were not accompanied by their parents. The scales and questionnaires of eight pairs of parents and children were excluded due to incomplete answers or having been filled out improperly. Although no risk was involved in participating in the study, two parents refused to do so.
A sample composed of 100 children and adolescents aged 8-17 years (mean age: 10.3 ± 2.03 years) was selected among the patients regularly attending the Pediatric Dentistry Clinic.
Corah's DAS is composed of four items addressing aspects of dental treatment, with five response items.  Torriani et al. have recently performed the cross-cultural adaptation of the DAS for use on children and concluded that this instrument is very acceptable and representative of reactions of dental anxiety and can therefore be administered to Brazilian children. 
Some scales employed in studies on general anxiety (not specific to dental treatment) may be useful to conduct a broad evaluation of the individual who will undergo dental treatment. The State-Trait Anxiety Inventory (STAI) is made up of 2 scales, each with 20 items, the scores of which range from 1 to 4 points. The State Anxiety Scale assesses how an individual is feeling at the moment and the Trait Anxiety Scale assesses how the individual generally feels. While the score of the Trait Anxiety Scale is relatively stable, the State Anxiety Scale varies due to anxiogenic stimuli. 
Both the DAS and STAI are reliable, validated instruments that have been consolidated in the dental literature and adapted to the Brazilian population. ,,,,,
Filling out the scales
The scales were filled out in a dental care environment during the period in which the patients were treated at the Pediatric Dentistry Clinic of the Federal University of Paranα. The scales were completed during the first dental appointment to avoid the influence of invasive procedures on the anxiety scores. A single researcher explained the objectives and procedures to the participants, who filled out the scales manually in approximately 10 min. Children and adolescents, answered the questionnaires separately from their parents to avoid interferences.
The data obtained on the questionnaires and scales were analyzed with the aid of the Statistical Package for the Social Sciences (SPSS® , Version 15.0, Chicago, USA). Pearson's and Spearman's correlation coefficients were calculated to determine possible correlations between the scores obtained on the different anxiety scales. Associations between anxiety scores and socioeconomic status and previous dental experiences were determined using the Mann-Whitney test, Duncan's test and analysis of variance. The level of significance was set to 5% (P ≤ 0.05).
| Results|| |
Forty-five of the pediatric participants were male, 55 were female, 73% were children aged between 8 and 11 years and 27% were adolescents aged 12 and 17 years. 
The majority (87%) was accompanied by their mothers during the dental appointment. With regard to parents' schooling, 32% had completed elementary school, 46% had completed high school and 22% had obtained a university degree. Half of the families that participated in the study reported having a monthly income of US$778 or less (equivalent to 2.5 times the Brazilian minimum wage); 28% were classified as low income, 50% were classified as medium income and 22% were classified as high income.
[Table 1] displays the frequency data on trait anxiety and dental anxiety among the children, adolescents and their parents. A significant positive correlation was found between trait anxiety and dental anxiety scores among the parents (rs = 0.64) as well as among the children (r = 0.52). The data also demonstrate a significant moderate association (rs = 0.43) between trait anxiety in children and both the trait anxiety and dental anxiety scores of their parents. In contrast, no association was found between the anxiety level of adolescents and that of their parents [Table 2].
|Table 1: Trait and dental anxiety frequency distribution among children, adolescents and their parents (n=200)|
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|Table 2: Correlation coefficients between parents' and children's trait and dental anxiety scores (n=100) Pearson's (r) and Spearman's (rs) correlation coefficients|
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Parents' schooling was not significantly associated with trait anxiety or dental anxiety scores (P > 0.05). A significant difference in dental anxiety scores (children/adolescents and parents) was found between low and medium income families (P < 0.05, Duncan's test). Moreover, a tendency toward a significant difference in the dental anxiety scores of the children/adolescents was found between high and medium income families (P = 0.06, Duncan's test).
Both the trait anxiety and dental anxiety scores were higher among the female gender, but this difference was non-significant (P ≥ 0.05, Mann-Whitney test) [Figure 1].
|Figure 1: Distribution of trait and dental anxiety scores in accordance with gender (n = 100)|
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[Table 3] displays the variables associated with dental anxiety and trait anxiety.
|Table 3: Frequency distribution of the studied variables and association with trait and dental anxiety (n=100)|
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| Discussion|| |
Dentists must consider the multifactor etiology of anxiety to gain a better understanding of pediatric patients and their families. Indeed, the assessment of anxiety should be part of the dental evaluation of children and adolescents.
Choosing assessment tools that are validated for the Brazilian population enables the identification of individuals with anxiety. ,, Corah's DAS has proven valid and reliable and is relatively free of bias in its response options.  The differentiation between general anxiety and dental anxiety is important. However, this differentiation is not always made in investigations into dental anxiety.  The application of the Trait Anxiety Scale was a strategy for distinguishing general anxiety from dental anxiety, despite being applied in a clinical setting, which could have led to the overlap of both conditions.  The combination of these 2 scales allows the investigation of anxiety regarding dental care and highlights anxious traits in children and adolescents that may arise in their behavior during dental care.
The decision to use the same scales for all subjects was based on the fact that the scores would allow a better comparison between parents and children/adolescents. This strategy has been proven effective in previous studies. 
The positive correlation between trait anxiety and dental anxiety scores of the parents (rs = 0.64) and children (r = 0.52) demonstrate that individuals with anxious behavior in general situations may also exhibit dental anxiety.
The decision to select literate children who could fill out the scales themselves was made to ensure results that are more compatible with the thoughts and feelings of children and adolescents since parents' reports regarding their children's anxiety are not considered reliable.  In the present study, the children, adolescents and parents were all able to fill out the scales without great difficulties.
In the present study, anxiety was not associated with gender, which is an agreement with findings reported in previous investigations. , However, a number of studies report higher anxiety scores among girls in comparison to boys. ,,,,,
The literature also reports divergent findings regarding the relationship between age and anxiety level. Some authors report data that point to a decrease in anxiety as a child matures due to losing the "fear of the unknown".  Others report higher scores among older children, likely due to unpleasant previous experiences with dental care. ,, A greater frequency of caries and consequently, a greater number of invasive treatments may be a confounding factor in studies that affirm that anxiety scores increase with age.  In the present study, no significant differences in the level of dental anxiety were found between children and adolescents.
In some studies, factors related to the family, such as household income and parents' schooling, are reported to have no influence on anxiety scores. , In the present investigation, however, differences were found between low and medium income families, with higher scores among lower income families. This result is in agreement with findings described in a previous study, in which a lower socioeconomic status proved to be an important factor related to dental anxiety. 
The children and adolescents were most often accompanied by their mothers during dental care (87%). Maternal dental anxiety is likely to be associated with the avoidance of dental treatment, which could prevent children/adolescents from receiving appropriate dental care.  This aspect gains further importance when considering the fact that women exhibit higher levels anxiety than men and are generally in charge of accompanying their children in health-related matters.
The tendency toward an association between the need for invasive treatment and the anxiety scores of children and adolescents regarding dental treatment (P = 0.08) demonstrates that, even with the progress gained in minimally invasive dentistry, the use of local anesthesia remains closely associated with unpleasant experiences regarding dental treatment and dental anxiety. ,
Fear reported by other family members is one of the factors most often associated with dental fear and anxiety in children.  Indeed, negative attitudes and experiences transmitted by mothers and their opinions regarding dental treatment are considered etiological factors of dental fear and anxiety in children. ,, A previous study found that children whose mothers exhibited a moderate or high level of dental anxiety were more likely to have untreated dental caries in comparison to children whose mothers had a low degree of dental anxiety. 
Previous studies report no association between parent's and children's DAS scores, , whereas other found that parents' anxiety was associated with their children's anxiety. , In the present study, associations were found between the children's trait anxiety scores and both the trait anxiety and dental anxiety scores of their parents. This finding indicates that the parents had an influence on their children's anxiety level, but this influence was not strongly associated with dental anxiety. In contrast, no association was found between the adolescents' anxiety and that of their parents, indicating that other factors should be further investigated in this age group, such as previous experiences with dental care, the prevalence of caries and access to oral health programs.
A significant association was found between dental anxiety and parents' reports that their children had cried during previous dental appointments (P = 0.02). Other authors also report higher dental anxiety scores among children who reacted by crying or with fear in previous dental appointments. 
To offer more humanized dental care, the prevalence of dental anxiety should not be overlooked in clinical practice, especially in pediatric dentistry. Strategies for the assessment, prevention and control of dental anxiety should be implemented to allow better treatment for children, adolescents and their parents. It is possible to conduct a simple, efficient evaluation of anxiety in the routine of a pediatric dental clinic with the use of validated tools. An adequate approach regarding children and adolescents with dental anxiety can assist in establishing a good dental experience and a trusting relationship between pediatric dentists, patients and parents.
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[Table 1], [Table 2], [Table 3]