|Year : 2019 | Volume
| Issue : 4 | Page : 345-349
The prevalence of dental anxiety and fear among 4–13-year-old Nepalese children
Nitin Khanduri1, Namrata Singhal2, Malay Mitra3
1 Department of Pediatric and Preventive Dentistry, Seema Dental College and Hospital, Rishikesh, Uttarakhand, India
2 Department of Oral Pathology, Institute of Dental Education and Advance Studies, Gwalior, Madhya Pradesh, India
3 Department of Pediatric and Preventive Dentistry, Guru Nanak Institute of Dental Science and Research, Kolkata, West Bengal, India
|Date of Web Publication||7-Nov-2019|
Department of Pediatric and Preventive Dentistry, Seema Dental College and Hospital, Rishikesh, Uttarakhand
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Aim: The aim of the study was to assess the prevalence of dental fear and anxiety among children aged 4–13 years using three fear scales, i.e., facial image scale (FIS), Nepalese version of Children's Fear Survey Schedule–Dental Subscale (CFSS-DS), and Modified Child Dental Anxiety Scale (MCDAS). Materials and Methods: The study was conducted on 300 children (4–13 years) who visited the Department of Pedodontics and Preventive Dentistry. The fear and anxiety levels were measured using three fear measurement scales, i.e., FIS, Nepalese version of CFSS-DS, and MCDAS. The dental behavior observed was rated according to the Frankl's Behavior Rating Scale (FBRS). Results: The prevalence of dental fear according to FIS was 11.9% as evident from children having FIS 4 and 5 scores. Dental fear with CFSS-DS ≥38 was identified in 49 children (21 [12.5%] male and 28 [21.21%] female). In assessment of the behavior of children in the clinics through FBRS, it was observed that the maximum number of respondents (70.6%) showed Frankl's rating 3, i.e., positive. Conclusion: The Nepalese versions of the CFSS-DS and the MCDAS are both reliable and valid scales for evaluating dental anxiety and fear in young children. Assessing dental anxiety and fear is useful, as behavior management can be designed accordingly for child patients.
Keywords: Children's fear survey schedule–dental subscale, dental fear and anxiety, modified child dental anxiety scale
|How to cite this article:|
Khanduri N, Singhal N, Mitra M. The prevalence of dental anxiety and fear among 4–13-year-old Nepalese children. J Indian Soc Pedod Prev Dent 2019;37:345-9
|How to cite this URL:|
Khanduri N, Singhal N, Mitra M. The prevalence of dental anxiety and fear among 4–13-year-old Nepalese children. J Indian Soc Pedod Prev Dent [serial online] 2019 [cited 2021 Mar 3];37:345-9. Available from: https://www.jisppd.com/text.asp?2019/37/4/345/270470
| Introduction|| |
Dental fear may be defined as an unpleasant emotion to stimuli during dental clinical practice which is perceived as threatening. Dental anxiety indicates excessive and unreasonable negative emotions experienced by selected vulnerable patients.
Dental fear and dental anxiety (DFA) have been closely related as both entities indicate the overwhelming discomfort that people (children and adults) experience in different dental situations. In most children, this fear will probably decrease with successive visits to the dentist and after becoming accustomed to the dental situation. What makes dental fear a serious problem for the pediatric dentist is its potential link with dental behavioral management problems.
DFA among children may render providing services difficult and even lead to an adverse outcome of the dental visit. Therefore, the identification of children with DFA before the dental visit is extremely important so that appropriate behavior management techniques can be employed (i.e., both pharmacological and nonpharmacological), allowing them to obtain an effective dental treatment. DFA in children may be measured using various methods, including behavioral rating scales, such as the Frankl's Behavior Rating Scale (FBRS), physiological measurements (e.g., heart rate and muscle tension), and psychometric assessments. The latter tools refer to a number of self-reported questionnaires that have been administered to measure DFA. Among psychometric tools, those most widely used in children are the 15-item Children's Fear Survey Schedule–Dental Subscale (CFSS-DS) and the 8-item Modified Child Dental Anxiety Scale (MCDAS).
Scherer and Nakamura introduced the fear survey schedule for children as an inventory for assessment for fear in children. Cuthbert and Melamed used this instrument in their research and modified it to assess dental fear.
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 MCDAS was developed by Wong et al. based on the Corah Dental Anxiety Scale. The MCDAS includes eight questions to assess dental anxiety about specific dental procedures. A 5-point Likert scale is used to assess dental anxiety with scores ranging from “relaxed/not worried” (1) to “very worried” (5). Total scores on the MCDAS range from 8 (little or no dental anxiety) to 40 (extreme dental anxiety).
The Facial Image Scale (FIS) comprises a row of five faces ranging from very happy to very unhappy (scores ranging from 1 to 5; 5 indicating the highest anxiety). Validation studies have shown that it is a suitable measure for assessing state child dental anxiety even in very young children.
This study was undertaken with the aim of:
- Assessment of the prevalence of dental fear among children aged 4–13 years who attended the Department of Pedodontics and Preventive Dentistry using three fear scales, i.e., FIS, Nepalese version of CFSS-DS, and MCDAS
- Assessment of the child's behavior pattern using the FBRS.
| Materials and Methods|| |
A cross-sectional study was carried out in 300 children aged between 4 and 13 years who attended the Department of Pedodontics and Preventive Dentistry of UCMS College of Dental Surgery, Nepal. Ethical clearance was obtained from the institutional review board. Written consent was obtained from the parents/caregiver to participate in the study after explaining them the study in detail.
- Children aged 4–13 years
- Children whose parents/guardians gave written consent to take part.
- Children with emergency (bleeding, swelling, dental trauma, and acute toothache)
- Children with systemic diseases
- Children with major disabilities and deficient psychological growth.
At first, the FIS was recorded in the waiting area where the patients were approached initially. FIS comprises a row of five faces ranging from very happy to very unhappy (scores ranging from 1 to 5; 5 indicating the highest anxiety). After the FIS, DFA levels were assessed by applying the Nepalese version of CFSS-DS and MCDAS.
The Nepalese version of CFSS-DS was used. Questions were translated to the Nepalese language, and then, responses were translated from Nepali to the English language. CFSS-DS consists of 15 items [Table 1] to be answered with a Likert scale ranging from 1 (not afraid at all) to 5 (very afraid). Consequently, the total score ranges between 15 and 75; a score of 38 or more has been associated with clinical dental fear.
The Nepalese version of MCDAS was used. It consists of eight questions [Table 2]. Questions were translated to Nepalese, and the responses were translated back to the English language. Each item was scored on a Likert scale from 1 (not afraid at all) to 5 (very afraid). The total score ranges between 8 and 40.
The behavior of all the 300 children enrolled in the study was also assessed using the FBRS considered during the treatment. The Frankl's scale consists of a 4-point scale, in which 1 represents “definitely negative” (i.e., the child cries forcefully and refuses treatment), 2 represents “negative” (i.e., the child is reluctant to accept treatment), 3 represents “positive” (i.e., the child accepts treatment but may be cautious), and 4 represents “definitely positive” (i.e., the child exhibits unique behavior and seems happy).
Statistical analysis was carried out for the data collected from the children. Data analysis was performed using the Statistical Package for the Social Sciences (version 22.0, SPSS Inc., Chicago, USA). All statistical levels were made at P < 0.05. Cronbach's alpha was used to compute the internal consistency.
| Results|| |
Of a total of 300 children who completed the questionnaires, 168 (56%) were male and 132 (44%) were female. The internal consistency and reliability of Nepalese translated versions of CFSS-DS and MCDAS questionnaires were assessed using Cronbach's alpha coefficient.
Cronbach's alpha value of 0.9694 was obtained for CFSS-DS and 0.9298 for MCDAS which indicated high reliability.
Facial image scale
[Table 3] shows the frequency and percentage of FIS. About 43.3% of children showed FIS 3. About 11.9% of children showed dental fear as FIS 4 and 5 scores are considered indicative of dental fear in children.
Children's fear survey schedule-dental subscale
The mean CFSS-DS score for males was 27.15 ± 9.92 and for females was 29.5 ± 12.45, as shown in [Table 4]. It was observed that no statistically significant difference was seen in mean CFSS-DS scores between males and females using Student's t-test (P = 0.698), as shown in [Table 4]. [Table 5] shows the mean CFSS-DS score in different age groups. The mean CFSS-DS score in the age group of 4–7 years was 31.71 ± 12.69 which was the highest among different age groups. The difference in mean CFSS-DS scores was calculated using one-way ANOVA. The mean difference was statistically significant between the various groups (P = 0.0001), as shown in [Table 5]. Dental fear with CFSS-DS ≥38 was identified in 49 children (21 [12.5%] males and 28 [21.21%] females). A total of 251 children (147 [87.5%] male and 104 [78.79%] female) had CFSS-DS <38.
|Table 4: Mean Children's Fear Survey Schedule-Dental Subscale with respect to gender|
Click here to view
|Table 5: Mean Children's Fear Survey Schedule-Dental Subscale with respect to age|
Click here to view
Modified child dental anxiety scale
The mean MCDAS score for males was 18.21 ± 6.29 and for females was 19.09 ± 6.7, as shown in [Table 6]. It was observed that no statistically significant difference was seen in mean MCDAS scores between males and females using Student's t-test (P = 0.243), as shown in [Table 6]. [Table 7] shows the mean MCDAS score in different age groups. The mean MCDAS score in the age group of 4–7 years was 20.24 ± 6.37 which was the highest among different age groups. The difference in mean MCDAS scores was calculated using one-way ANOVA. The mean difference was statistically significant between the various groups (P = 0.0009), as shown in [Table 7].
|Table 6: Mean Modified Child Dental Anxiety Scale with respect to gender|
Click here to view
[Table 8] represents the frequency of Frankl's behavior ratings which were recorded, and it was observed that 212 (70.6%) participants showed Frankl's rating 3 (positive), 49 (16.3%) showed Frankl's rating 2 (negative), 31 (10.4%) showed Frankl's rating 4 (definitely positive), and only 8 (2.7%) showed Frankl's rating 1 (definitely negative).
| Discussion|| |
Fear of dental treatment in children may lead to serious health problems, and it may persist into adolescence, which may cause troublesome behavior, during dental treatment. It becomes a topmost priority to identify such anxious children at the earliest so that such troublesome behavior can be prevented.
The development and expression of children's fear may be affected by cultural and social norms of behavior, and there may be considerable variations in dental care systems across cultures; normative data in each culture are needed. The present study assessed the dental fear and anxiety of children visiting the Department of Pedodontics and Preventive Dentistry using FIS, the validated Nepalese version of CFSS-DS, and MCDAS. In our population of young children, we found that the Nepalese version of the CFSS-DS and the MCDAS showed good internal consistency.
The FIS is quick and easy to administer in the dental waiting room. It took a very short time to administer, and the score is simply a reflection of the face chosen. The FIS gives immediate “state” feedback to the clinician in the dental waiting room and could allow the clinician to design appropriate treatment plans for their child patients.
The FIS also provided interesting results regarding the prevalence of child dental anxiety. The results reflected previous research: the majority of children have low levels of fear; however, a small but significant number shows higher levels. Only 11.9% of children chose either face four or five on the scale. The results are similar to study done by Bedi et al. This study has shown that most of the children were not anxious in the waiting room. This result is particularly encouraging as the study was carried out in a dental hospital where some of the children are referred specifically because of dental anxiety problems.
Dental fear with CFSS-DS ≥38 was identified in 49 children (21 [12.5%] males and 28 [21.21%] females). A score of more than or 38 represents high levels of dental fear, and these patients may present with serious behavior problems during dental treatment. However, dental fear for these young children may depend on specific circumstances, situations, and on temperamental factors. In other words, a fearful child does not always mean that the child will be an uncooperative one during dental treatment.,
The mean CFSS-DS score was 28.18 ± 11.21 which was similar to scores from previous studies ranging from 21.0 to 37.0., However, some studies had higher scores like done by Beena  and in Singapore (30.6).
The mean CFSS-DS score for males was 27.15 ± 9.92 and for females was 29.5 ± 12.45. The score is more in girls, but no significant differences in fear scores between boys and girls were found in the present study. A study by Akbay Oba et al. 2009 also found similar results. However, a study by Salem et al. in 2012 observed that girls showed significantly higher scores (33.92) (standard deviation [SD] = 12.3) than boys (30.57) (SD = 10.1) (t-test, P = 0.031, mean difference −3.353). However, the correlation between gender and child's general anxiety was not significant (t-test, P = 0.78).
The mean CFSS-DS score in the age group of 4–7 years was 31.71 ± 12.69, in the age group of 8–10 years was 26.63 ± 9.8, and in the age group of 11–14 years was 24.29 ± 9.63. In the present study, we found that as the age increased, dental fear decreased. Other studies which had similar results were done.,, However, Rantavuori et al. reported that dental fear was higher among 12- and 15-year old children than among younger ones. This decrease in dental fear with increasing age may be due to development of cognitive abilities and change in expression of fears, including dental fear with age., However, a cultural difference also cannot be overlooked.
The mean MCDAS score for males was 18.21 ± 6.29 and for females was 19.09 ± 6.7. The difference was not significant. Wong et al. observed in their study that girls indicated raised dental anxiety over the boys at all age groups.
The mean MCDAS score in the age group of 4–7 years was 20.24 ± 6.37 which was the highest among different age groups. The mean score in the age group of 8–10 years was 18.30 ± 6.21 and in the age group of 11–14 years was 16.11 ± 6.94. Here also, dental fear seems to decrease with increasing age and this is in agreement with the previous studies.,
The Nepalese versions of the CFSS-DS and MCDAS showed a good level of internal consistency, the Cronbach's alpha being 0.9694 for CFSS-DS and 0.9298 for MCDAS. Various other studies with different versions in other languages have reported alpha to range between 0.85 and 0.92. Ma et al., in 2015, examined the reliability and validity of the Chinese version of the CFSS-DS. In their study, the internal consistency (Cronbach's alpha) was 0.85. Nakai et al., in 2005, examined the reliability and validity of the Japanese version of the CFSS-DS. The Japanese version of the CFSS-DS showed good internal consistency (alpha = 0.91). As in most countries and cultures, also in Nepal, the most fearful and anxious aspects of the dental visit include the sight and the noise of the dentist drilling and receiving injections in the mouth. The test–retest reliability was also satisfactory for both CFSS-DS and MCDAS, being the answer to the same item questions of the scale, at different times, highly correlated and reproducible. The correlation coefficients (rsp = 0.86 for both CFSS-DS and MCDAS) was similar to those found for the same scales in other countries.
There were limitations of this study. The children were not enquired about their previous dental experience when questions were asked and answers were recorded. According to the previous studies done, a previous negative dental experience can lead to dental fear and anxiety.,
The relatively small sample size is not adequate to estimate prevalence satisfactorily, and the sample being from one institution does not represent the general population of Nepal aged 4–13 years.
| Conclusion|| |
The Nepalese versions of the CFSS-DS and the MCDAS are both reliable and valid scales for evaluating dental anxiety and fear in young children.
The mean CFSS-DS score in the age group of 4–7 years was 31.71 ± 12.69, and the mean MCDAS score in the age group of 4–7 years was 20.24 ± 6.37, which was highest among different age groups. In the present study, we found that as the age increased, dental fear decreased.
The mean CFSS-DS score for males was 27.15 ± 9.92 and for females was 29.5 ± 12.45, and the mean MCDAS score for males was 18.21 ± 6.29 and for females was 19.09 ± 6.7. The scores were not significant for both CFSS-DS and MCDAS.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Brogårdh-Roth S, Stjernqvist K, Matsson L, Klingberg G. Dental fear and anxiety and oral health behaviour in 12- to 14-year-olds born preterm. Int J Paediatr Dent 2010;20:391-9.
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.
Klaassen MA, Veerkamp JS, Aartman IH, Hoogstraten J. Stressful situations for toddlers: Indications for dental anxiety? ASDC J Dent Child 2002;69:306-9, 235.
Ma L, Wang M, Jing Q, Zhao J, Wan K, Xu Q. Reliability and validity of the Chinese version of the children's fear survey schedule-dental subscale. Int J Paediatr Dent 2015;25:110-6.
Goumans C, Veerkamp JS, Aartman IH. Dental anxiety and behavioural problems: What is their influence on the treatment plan? Eur J Paediatr Dent 2004;5:15-8.
Paglia L, Gallus S, de Giorgio S, Cianetti S, Lupatelli E, Lombardo G, et al.
Reliability and validity of the Italian versions of the children's fear survey schedule – Dental subscale and the modified child dental anxiety scale. Eur J Paediatr Dent 2017;18:305-12.
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.
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.
Bedi R, Sutcliffe P, Donnan P, Barrett N, McConnachie J. Dental caries experience and prevalence of children afraid of dental treatment. Community Dent Oral Epidemiol 1992;20:368-71.
Klingberg G, Broberg AG. Temperament and child dental fear. Pediatr Dent 1998;20:237-43.
Ten Berge M, Veerkamp JS, Hoogstraten J. The etiology of childhood dental fear: The role of dental and conditioning experiences. J Anxiety Disord 2002a; 16:321-9.
Akbay Oba A, Dülgergil CT, Sönmez IS. Prevalence of dental anxiety in 7- to 11-year-old children and its relationship to dental caries. Med Princ Pract 2009;18:453-7.
Beena JP. Dental subscale of children's fear survey schedule and dental caries prevalence. Eur J Dent 2013;7:181-5. [Full text]
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.
Salem K, Kousha M, Anissian A, Shahabi A. Dental fear and concomitant factors in 3-6 year-old children. J Dent Res Dent Clin Dent Prospects 2012;6:70-4.
Rantavuori K, Lahti S, Hausen H, Seppä L, Kärkkäinen S. Dental fear and oral health and family characteristics of Finnish children. Acta Odontol Scand 2004;62:207-13.
Versloot J, Veerkamp J, Hoogstraten J. Dental anxiety and psychological functioning in children: Its relationship with behaviour during treatment. Eur Arch Paediatr Dent 2008;9 Suppl 1:36-40.
Wong HM, Humphris GM, Lee GT. Preliminary validation and reliability of the modified child dental anxiety scale. Psychol Rep 1998;83:1179-86.
Tong HJ, Khong J, Ong C, Ng A, Lin Y, Ng JJ, et al
. Children's and parents' attitudes towards dentists' appearance, child dental experience and their relationship with dental anxiety. Eur Arch Paediatr Dent 2014;15:377-84.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]