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ORIGINAL ARTICLE
Year : 2020  |  Volume : 38  |  Issue : 3  |  Page : 222-231
 

Association between cognitive vulnerability, dental fear, and oral health status among schoolchildren in Bangalore city – A cross-sectional study


Department of Public Health Dentistry, Government Dental College and Research Institute, Bengaluru, Karnataka, India

Date of Submission15-Dec-2019
Date of Decision05-Feb-2020
Date of Acceptance21-Feb-2020
Date of Web Publication29-Sep-2020

Correspondence Address:
Dr. Santhiya Bairappan
Room No: 9, First Floor, Department of Public Health Dentistry, Government Dental College and Research Institute, Fort, Bengaluru - 560 028, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JISPPD.JISPPD_362_19

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   Abstract 


Context: Dental anxiety and fear is not only a psychological problem but also a dental health problem. It is important to understand how the cognitive elements influence child's dental anxiety/fear and interact with their oral health. Objective: This study was conducted among children to determine the association between cognitive vulnerability (CV) with dental fear and their oral health status. Settings and Design: A cross-sectional study was conducted among 500 schoolchildren aged 12–15 years in Bengaluru city. Methodology: The schools and participants were selected by cluster random and systematic random sampling method, respectively. Cognitive vulnerability and Index of Dental Anxiety and Fear (IDAF-4C+) were assessed by a self-administered questionnaire. Oral health status was recorded using the World Health Organization 2013 proforma for children. Statistical Analysis Used: Chi-square test, Student's t-test, Spearman's correlation, and multivariate hierarchical linear regression were used in this study. The statistical significance was considered at P < 0.05. Results: Nearly half of the study participants had cognitive perceptions, dental anxiety/fear, phobia, and stimulus toward dental treatment. Majority had dental caries and gingival bleeding. Cognitive vulnerability, dental anxiety/fear, phobia, and stimulus were independent of the age and gender and were associated with socioeconomic status. A significant correlation was found between participants' CV, IDAF-4C+, dental caries, and gingival bleeding. Cognitive vulnerability was a significant predictor of dental caries and gingival bleeding. Dental anxiety/fear and dental phobia were significant predictors of dental caries. Conclusion: Oral health status was significantly poorer and was associated with CV, dental anxiety/fear, phobia, and stimulus. Cognitive elements together with dental fear influenced oral health.


Keywords: Children, cognitive vulnerability, dental anxiety, fear, oral health


How to cite this article:
Bairappan S, Puranik MP, Shanbhag N. Association between cognitive vulnerability, dental fear, and oral health status among schoolchildren in Bangalore city – A cross-sectional study. J Indian Soc Pedod Prev Dent 2020;38:222-31

How to cite this URL:
Bairappan S, Puranik MP, Shanbhag N. Association between cognitive vulnerability, dental fear, and oral health status among schoolchildren in Bangalore city – A cross-sectional study. J Indian Soc Pedod Prev Dent [serial online] 2020 [cited 2020 Oct 30];38:222-31. Available from: https://www.jisppd.com/text.asp?2020/38/3/222/296640





   Introduction Top


Children and adolescents can present a series of oral diseases that may limit physical, social, and psychological well-being. Most children globally have signs of gingivitis. Dental caries is a major oral health problem in most industrialized countries and currently affects 60%–90% of schoolchildren as well as many adults. The increase in caries appears to occur primarily in vulnerable groups, especially children.[1] Dental pain is one of the main consequences of untreated dental caries.[2] Despite reductions in pain associated with dental visits and an increased awareness by dentists of the importance of building trusting relationships, dental fear remains a major issue for dental clinicians and their patients. Dental fear has long-term implications because it is both reasonably stable and difficult to assuage.[3] Dental fear and dental anxiety are often used indistinctly in the scientific literature, but they represent different progressive degrees of the same psychological condition.[4] Dental fear usually refers to a normal unpleasant emotional reaction to specific threatening stimuli occurring in situ ations associated with dental treatment, while dental anxiety is an excessive and unreasonable negative emotional state experienced by dental patients. Dental fear and anxiety can be associated with decreased oral health-related social and emotional well-being in children and adolescents. Noteworthy, the relationship between dental fear and poor oral health is probably bidirectional.[2] Dental fear is heterogeneous and can be classified into at least three separate factors: fear of invasive treatment or pain, losing control, and the experience of physical sensation.[2] Dentally fearful children show a higher incidence of untreated decay and have more teeth missing due to caries. Moreover, dental fear represents a barrier for accessing dental services and treatments, which may lead to worsening of one's oral status. Therefore, an understanding of the determinants of dental fear appears as an important target in preventive dentistry.[5]

Research analyzing the role of cognitive variables has offered an alternative to understand dental anxiety and fear in adults and children. According to these approaches, feared dental events trigger a person's negative appraisals of the situation, which will lead to fear-related emotional and behavioral responses.[6] The cognitive vulnerability (CV) model described by Armfield proposes that in dentally anxious patients, the exposure to dental stimuli or situation automatically and unconsciously triggers a vulnerability schema, based on previous learning experience influenced by personality traits or biological dispositions. The contents of this schema involve four interrelated perceptions of the dental event as being uncontrollable, unpredictable, potentially dangerous or harmful, and disgusting.[7] They appear to be strong predictors of children's dental fear. An immediate automatic affective response (fear) and a relatively slower cognitive assessment of the event are the two simultaneous processes that occur once the vulnerability schema is activated. A key point is that the vulnerability schema acts as a perceptual filter and guides the following interpretation of dental stimuli, thus favoring a biased handling of the dental-related information. The outcomes of these processes are the physiological, behavioral, emotional, and cognitive responses of the individual.[7]

It is important to further understand how cognitive elements may be operating in child's dental anxiety and how they could interact with dental visits and treatments.[8] A model has been suggested linking dental anxiety/fear, worsening of oral health status with impaired oral health-related quality of life that activates vulnerability schema. These variables are interdependent and form a vicious cycle.[9] Research on the interplay between the different cognitive elements involved in children and adolescents' dental fear has yet to be undertaken.[5]

There is a lack in scientific evidence relating measured CV with dental fear and oral health status. Hence, this study was conducted with the research question and hypothesis as:

Research question

Is there an association between children's CV, dental anxiety/fear, dental phobia, and stimulus with their oral health status?

Research hypothesis

There is an association between children's CV, dental anxiety/fear, dental phobia, and stimulus with their oral health status.


   Methodology Top


A cross-sectional study was conducted among schoolchildren aged 12–15 years attending government, aided, and private schools in Bengaluru city from June to September 2018. Ethical clearance was obtained from the Institutional Ethical Committee. The research was conducted in full accordance with the World Medical Association Declaration of Helsinki.[10] Informed consent and assent were obtained from parents and children after explaining the purpose and procedure.

The sample size was estimated based on the previous literature[11] considering dental caries prevalence (P) of 45%, statistical power of 80% with 95% confidence interval, and 10% margin of error (E)



The sample size obtained was 469 rounded off to 500 considering 5% of nonresponse rate. Children aged between 12 and 15 years were included. Children with mental or cognitive problems and those with conditions that make oral assessment difficult were excluded.

The sampling frame consisted of all government, aided, and private schools. They were further plotted into north and south zones on Bangalore map. A total of 12 schools (2 schools from each category and zone) were selected based on cluster random sampling method. Systematic random sampling was employed to select participants from each school with due representation for age and gender.

Data were collected using a structured questionnaire followed by clinical examination. Demographic profile and oral hygiene practices were recorded. Socioeconomic status was assessed using the modified Kuppuswamy classification (income updated based on the Consumer Price Index for June 2018).[12],[13] A self-administered questionnaire was applied to assess cognitive vulnerability (CV) and Index of Dental Anxiety and Fear (IDAF-4C+).

The dental CV questionnaire[14] covering four components of the CV schema with 3 items under each component was used. Four components were unpredictability, uncontrollability, dangerousness, and disgustingness of dental treatment-related events. The items were scored on a 4-point Likert scale, indicating their degree of agreement with each statement. The participants' total scores were obtained by adding their individual responses to the 12 items comprising a measure ranging from 1 to 4.

IDAF-4C+[15] developed by Armfield consists of three modules, namely (1) Dental Anxiety and Fear (fear module) (IDAF-4C) with four components of two items under each cognitive, behavioral, emotional, and physiological component; (2) Dental Phobia Module (IDAF-P) containing 5 items that measures avoidance, anxious anticipation, or distress in the feared situation(s) that interferes significantly with the person's normal routine, occupational (or academic) functioning, or social activities or relationships, or there is marked distress about having the phobia; and (3) Dental Stimulus Module (IDAF-S) with 10 items. The response formats included a 5-point Likert scale (range 1–5) for modules 1 and 3 and yes/no (1–2) options for module 2. A total score was calculated by adding participants' responses to the scale's items. Higher scores reflected a higher level of perceptions.

The cross-cultural validation of questionnaires was performed by means of forward- and back-translation (English to Kannada and Kannada to English) method with the help of linguistic experts. It was assessed for readability and comprehension. Internal consistency (α) was found to be good to excellent (CV [0.96], IDAF-4C+ [0.83], IDAF-4C [0.82], IDAF-P [0.81], and IDAF-S [0.85)].

Oral health status of the children was assessed using the World Health Organization 2013 oral health assessment form.[16]

The investigator was trained and calibrated for oral health examination with wide range of conditions. The kappa coefficient value (k) for intra-examiner reliability was 0.80–0.86 reflecting high degree of reliability.

The statistical analysis was done with the SPSS Version 22 software package (IBM Corporation, SPSS Inc., Chicago, IL, USA). Descriptive analysis with mean and standard deviation and percentage (proportion) was done for continuous and ordinal data, respectively. Inferential statistics were applied within the study group. The responses for CV and IDAF-4C+ were added and subjected for further analysis. The levels of CV, dental anxiety and fear, dental phobia, and dental stimulus were categorized into high/low based on total average score. Dental caries status was dichotomized into caries-free children (decayed, missing, and filled teeth [DMFT] = 0) and children with caries (DMFT >0). Gingival bleeding was dichotomized into present or absent.

Bivariate associations between CV, IDAF-4C+, and oral health status were analyzed using Chi-square test. Student's t-test was used to determine the significant difference among participants with or without caries/gingival bleeding for the components of CV and IDAF-4C+. A correlation between CV, IDAF-4C+, and oral health status (dental caries/gingival bleeding) was assessed using Spearman's correlation. Multivariate models adopted hierarchical linear regression analyses, which tested for the linear effect of one or more variables after controlling for all other variables. Two independent analyses were made with continuous (noncategorized) DMFT and gingival bleeding as a dependent variable, while the age, gender, SES, CV, and IDAF-4C + served as independent variables. Three models were employed in each analysis to check independently the effect of CV, dental anxiety and fear, dental phobia, and dental stimulus on DMFT and gingival bleeding. The statistical significance was considered at P < 0.05 with a 95% confidence interval.


   Results Top


In this study, participants' age ranged from 12 to 15 years, with a mean age of 13.58 ± 1.09 years with predominantly males (M:F = 57:43). Most of the parents were educated up to intermediate or posthigh school diploma (18.8%–27.4%), performed semiskilled to skilled occupations (10.8–35.4%), and had a family income per month up to Rs. 16483–21977 (35.2%). Majority belonged to upper- and lower-middle class (33.4%–36.2%) [Table 1].
Table 1: Distribution of study participants by demography and oral health status (n=500)

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Almost all the participants used toothbrush (97.6%) and toothpaste (88.2%) and cleaned teeth once daily (79.8%). Most of the study participants used soft (31.8%)-to-medium (27.2%) toothbrush in horizontal (45.6%) and circular direction (32.2%). About two-third of the study participants changed their brush in a period of 3–6 months. One-eighth of the participants used mouth rinses or tongue cleaner.

The prevalence of dental caries and gingival bleeding was 78% and 75%, respectively. The prevalence of dental erosion, dental traumatic injuries, very mild-to-moderate enamel fluorosis, and presence of oral mucosal lesions was 24.4%, 27%, 25.8%, and 11.6%, respectively. Majority of the participants required intervention ranging from preventive or routine treatment to immediate treatment (19.6%–48.6%) [Table 1].

With regard to CV perception, the mean score for all the items and components ranged from 2.18–2.55 and 6.94–7.34, respectively. These scores clustered around the midpoint of the response range for this scale. Considering this criterion as a reference, most of the study participants had moderate perceptions of CV [Table 2].
Table 2: Distribution of the study participants by cognitive vulnerability (n =500)

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The mean score for all the IDAF-4C items and components ranged from 2.8–3.06 to 5.75–6.05, respectively. Subscales pertaining to cognition and physiological components had means of <3.0. Behavioral component had crossed the mean score of 3.0, while the emotional component exhibited the mean score of ± 3.0 [Table 3]. The overall mean score of dental phobia was 7.17 ± 1.71 [Figure 1]. The mean score of each item of IDAF-4C + Stimulus Module varied from 2.39 to 2.52 [Figure 2].
Table 3: Distribution of the study participants by Index of Dental Anxiety and Fear-4C (n=500)

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Figure 1: Distribution of the study participants by Index of Dental Anxiety and Fear Phobia Module

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Figure 2: Distribution of the study participants by Index of Dental Anxiety and Fear Dental Stimulus Module

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Participants' CV perception was dichotomized based on the total average score of CV with >29.13 ± 10.09 as high and ≤29.13 ± 10.09 as low. Majority (60.8%) of the study participants had high CV. Participants aged 13 and 14 years and males belonging to lower- and upper-middle class had high CV. A statistically significant association was not found between CV, age, and gender, while a significant association was found with socioeconomic status [Table 4].
Table 4: Distribution of cognitive vulnerability and Index of Dental Anxiety and Fear-4C+ scores by age, gender, and socioeconomic status among study participants

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Participants' DAF was dichotomized based on the total average score of IDAF-4C with >23.71 ± 12.23 as high and ≤23.71 ± 12.23 as low. About 56.6% of the study participants had DAF. DAF was found high among 13–15 years and males with no significant association. Lower- and upper-middle-class participants had significantly high DAF (P = 0.03) [Table 4].

Dental phobia was dichotomized based on the total average score of IDAF-4C + Phobia Module with >7.17 ± 1.71 as high and ≤7.17 ± 1.71 as low. More than half of the study participants had high dental phobia. High dental phobia was more among 13 and 14 years of age group and among males with no significant association. High dental phobia was significantly more among lower- and upper-middle class.

Dental stimulus was dichotomized based on the total average score of IDAF-4C+ dental stimulus as high >24.57 ± 13.38 and as low ≤24.57 ± 13.38. More than half of the study participants had high dental stimulus. High dental stimuli were more among 13 and 15 years of age group and among males with no significant association. High dental stimuli were significantly more among lower- and upper-middle class [Table 4].

High CV had a statistically bivariate significant association with participants' caries experience and gingival bleeding. DAF was not significantly associated with participants' dental caries experience (P = 0.08) whereas significantly associated with gingival bleeding [Table 5].
Table 5: Distribution of cognitive vulnerability and Index of Dental Anxiety and Fear-4C+ by dental caries experience among study participants

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A statistical association was not significant between dental phobia and dental caries and gingival bleeding. Dental stimulus was not significantly associated with dental caries, whereas it was associated with gingival bleeding. A bivariate significant correlation was found between CV, IDAF-4C+, dental caries, and gingival bleeding [Table 5].

Age, gender, and socioeconomic status did not predict the DMFT and gingival bleeding. The unstandardized coefficient (B) value of CV, IDAF-4C and IDAF-P were 0.237 (P = 0.001), −0.083 (P = 0.003), and 0.332 (P = 0.003) respectively. and was significantly associated with DMFT. The multiple correlation coefficient ® 0.511, coefficient of determination (R2) 0.26, and adjusted R2 0.25 were statistically significant (P = 0.001) [Table 6]. Cognitive vulnerability was significantly associated with gingival bleeding with 0.116 (P = 0.001) unstandardized coefficient (B) and standardized coefficient of 0.306. The multiple correlation coefficient ® 0.316, coefficient of determination (R2) 0.1, and adjusted R2 0.087 were statistically significant (P = 0.001) [Table 6].
Table 6: Multivariate linear regression with Decayed, Missing, and Filled teeth and gingival bleeding as dependent variable

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   Discussion Top


Fear of dental treatment in children has been recognized as a source of a serious health problem. It may persist into adolescence and lead to an avoidance of seeking dental care or disruptive behavior during treatment.[6] People who are apprehensive about dental care often adopt a “cycle of avoidance” in which they consciously avoid visits to the dentist until they face a dental emergency, which can further strengthen their fear of dentistry.[17] Children who think that negative dental events are more likely and horrible or who appraise the dental treatment situation more negatively exhibit higher levels of dental fear and poorer oral health.[5]

The current study represented participants aged 12–15 years with a mean age of 13.58 ± 1.09 years with more proportion of males in upper- and lower-middle social class.

Dental CV is a sound measure for assessing negative beliefs and self-statements associated with dentists and dental treatment. It may be useful as a measure to facilitate negative cognitions that are involved in the development, maintenance, and exacerbation of psychological distress in dentally anxious individuals.[14] This study used a combined measure of CV, which reflects the person's global appraisals of dangerousness, uncontrollability, unpredictability, and disgustingness. In this study, uncontrollable perceptions toward dentistry are suggestive of their inability to control or terminate an encounter with dentist or dental events. Unpredictable perceptions toward dentistry were not in favor of unpredictability of dentists suggesting that dentists are patient and explain well about dental procedures before rendering dental treatment. Participants never showed perceptions of dangerousness toward dentistry indicative of uneventful treatment experiences. Participants did not perceive dental treatment or dental setting as disgusting representing participants' familiarity and concern toward dentistry. The perceptions of CV were moderate among the study participants which are suggestive of controllable and predictive nature of dentistry that is less dangerous and disgusting than generally perceived.

Age, gender, and socioeconomic status are important factors affecting child's vulnerability. Low income is associated with both poor oral and systemic health. Families with limited funds and social support may demonstrate less than adequate coping skills and choose less than healthy behaviors for themselves and their children.[1] In this study, CV was independent of the age and gender, while it was significantly associated with socioeconomic status. Lower socioeconomic status can create a situation where the child has a greater exposure to harmful environmental toxins.[1] A child's vulnerability leaves them unprotected, creating a greater probability of developing poor oral health.[1] In this study, CV was significantly associated with dental caries and gingival bleeding.

The IDAF-4C+ adopts a modular approach, allowing researchers or clinicians to select for the use of the modules of interest or relevance to them. IDAF-4C the eight-item core dental anxiety and fear module occupies the center point of the larger scale; the phobia module may be of use in those situations where a preliminary diagnosis of a psychological or psychiatric condition is desired. The stimulus module, in contrast, may aid where additional information about some of the important elements of an individual's dental fear is desired.[15]

Dental anxiety and fear acts as a barrier in receiving dental care by either reducing initial treatment seeking or causing missed or delayed appointments even after treatment has been sought. Catastrophizing and preoccupation, avoidance and escape, and specific physiological and disgust/vasovagal responses are the subareas of cognitive, behavioral, and physiological components of DAF, respectively.[15]

In this study, a higher proportion of participants exhibited cognitions pertaining to catastrophizing and preoccupation, avoidance and escape behaviors, emotions such as nervousness and fear, and disgust/vasovagal physiological responses regarding DAF. Participants expressed less DAF due to cognition and physiological factors and more DAF due to behavior while emotion contributing for both high and low DAF.

Dental fear is influenced by socioeconomic, demographic (gender, maternal schooling, and family income), and clinical variables (dental caries, gingival bleeding).[18]

In this study, 56.6% of the study participants had high DAF and was almost similar to a study (51.54%).[2] The prevalence of dental fear in this study was high compared to preceding studies (5.2%–49%).[5],[7],[8],[11],[17],[18],[19],[20] Dental fear scores decreased with increasing age and experience in a study.[20]

Girls tend to perceive a negative dental event in a more catastrophic way. Previous studies have shown some gender differences. Girls reported a statistically significant higher level of DAF than boys.[7],[17],[18],[20] On the contrary, a higher proportion of males in this study had high DAF (32.6%) than females. DAF was independent of the age and gender, whereas it was significantly associated with socioeconomic status.

The total dental caries experience of dentally anxious children was higher than their contemporaries.[18],[19],[20] It has been established from a number of studies that dentally anxious subjects avoid dental treatment whenever possible and prefer teeth to be extracted rather than restored. They are also more likely to present with decayed teeth. This appears to be an inevitable consequence of personal neglect and avoidance of dental care due to perceived anxiety acquired during childhood.[6] In this present study, nearly half of the participants had high DAF and dental caries experience compared to one-third of the participants having low DAF and dental caries experience. However, there was no statistically significant association between DAF and participants' dental caries experience (P = 0.08). This is similar to the previous study where total caries experience was higher in the fear group (44%).[19] In this study, 46.2% of the participants with high DAF had gingival bleeding, and the association was statistically significant.

Phobias result from a systematically biased interpretation of the danger associated with a stimulus.[21] It is a common anxiety disorder which causes a significant impairment to a person's normal routine, occupational or academic functioning, or social activities and relationships. Phobia module focused on functional impairment, distress about the level of dental fear, and the belief that the fear was excessive or unreasonable.[21],[22] Dental phobia was pertinent for the most of the participants in this study, and 52.2% exhibited high dental phobia. Dental phobia was independent of the age and gender. A higher proportion of lower- and upper-middle-class participants significantly had high dental phobia. Dental phobia was significantly not associated with dental caries and gingival bleeding.

Dental stimulus module (IDAF-S) focused on the stimuli assessing their extent of anxiety while visiting the dentist.[15] Participants exhibited anxiety to dental stimuli that ranged from little or somewhat. These dental stimuli were independent of the age, gender, and dental caries, whereas it was significantly associated with socioeconomic status and gingival bleeding.

Cognitive vulnerability was significantly correlated with DAF (ρ = 0.403) (P <0.001) and dental caries (ρ = 0.421) (P <0.001). Studies have shown a significant correlation with participants' CV and DAF (r = 0.44–0.55).[5],[7],[8],[9] This emphasizes the possible significance of cognitive elements as antecedents of dental fear in children and CV dimensions might play individual roles in triggering dental anxiety.[8] The present study was dissimilar to previous study where a significant association was absent with participants' CV and DMFT.[9] The magnitude of correlation ranges from little to low between CV and all other variables.

Previous research has not reported a significant association with participants' DAF and DMFT[9],[11],[17] and gingival bleeding.[17] Contrary to that in this study, DAF had shown a significant positive correlation with dental caries (ρ = 0.096) (P <0.05) and gingival bleeding (ρ = 0.114) (P <0.05). One study has shown a significant association with participants' DAF and DMFT (r = 0.14, P = 0.00).[8] DAF had a significant positive correlation with phobia and stimulus. Dental phobia was significantly correlated with dental stimuli and dental caries, whereas it was not significantly correlated with gingival bleeding.

Interaction between dental prevention beliefs and CV perceptions and age were found to be significant predictors of dental caries.[7] Dental fear has been evidenced to be a predictor of dental caries and may be a risk factor for untreated dental caries incidence.[8] In the current study, age, gender, and socioeconomic status did not predict the dental caries experience and gingival bleeding. After controlling for the effect of other variables, CV, fear module, and phobia module were found be significant predictors of dental caries with moderate level of prediction (R = 0.511) and explains 26% (R2 = 0.26) of the variability of DMFT. Hence, one-unit change in CV and phobia results in 0.23 (B = 0.23) and 0.33 (B = 0.33) times increase in dental caries, respectively, whereas one-unit change in fear module results in 0.083 (B = −0.083) times decrease in dental caries. After controlling for the effect of other variables, CV was found be a significant predictor of gingival bleeding with low level of prediction (R = 0.316) and explains 10% (R2 = 0.1) of the variability of gingival bleeding. Hence, one-unit change in CV results in 0.116 (B = 0.116) times increase in gingival bleeding.

The consequences of increased vulnerability and the development of dental disease contribute negatively to a child's well-being. The child may experience pain and suffer from caries formation, and this can then decrease oral intake, causing failure to thrive. The child may also experience lower self-esteem as a result of poor oral esthetics.[1]

The findings from this study fit neatly into the “vicious circle” framework that links children's dental fear and a worsening of their oral health status. This study contributes to this existing framework of the vicious circle by adding other psychosocial factors along with cognitive, behavioral, and emotional elements.[8] As expected from the “vicious circle” framework, in this study, cognitive perceptions and dental fear were associated with poor oral health, which is also consistent with previous research.[8]

This research has some relevant implications in dental practice. In order to reduce children's dental fear, two approaches seem to be necessary. First, it is important to promote the habituation of possible anxiety responses through the frequent exposure to dental events. This could be achieved by encouraging preventive treatments and regular checkups, not only because of their effects on children's oral health but also for their capacity to decrease dental anxiety levels. The second and complementary approach is a cognitive one. Children's expectations and belief of a probability of something bad and horrible will happen during a dental session and should be addressed in order to help them in reducing their potential anxiety. It is important for dental care professionals to be able to identify these negative thoughts and then be capable of reducing them by giving the children an idea about what is going to happen during sessions.

This study sheds light on the mechanisms involved in the early development of dental fear by analyzing the role played by cognitive elements together with dental fear and dental care experiences in this population. This study findings could be used in planning preventive programs, stressing the relevance of decreasing CV-related perceptions, and increasing children's awareness of the benefits of adequate dental care. Changing negative thoughts about dental visits and modifying erroneous oral health-related beliefs could lead to a more regular pattern of dental attendance, which in turn could result in a better oral health among children.

Dentists should be able to reduce child's perceptions of threat and disgust associated with dental treatments to improve the oral health and reduce dental anxiety among them. Other cognitive-behavioral techniques such as rational-emotive imagery, reality tests, or debate on irrational beliefs could be also applied to the change of disgust or harm-related cognitions. To ease dental fear among children, special attention is required by means of clinical risk assessment, early diagnostic tests/methods, parental/guardian education, oral hygiene instruction, pit and fissure sealants, and periodic dental checkups to prevent painful dental experiences and reduce the need for exhaustive dental procedures during childhood. Educational programs aiming to prevent oral health problems and promote adequate dental care habits not only have a positive effect on children's behavior and thoughts but also on their emotions.

This study has some limitations of any cross-sectional studies in determining causal effects. However, using prediction models and correlation analyses, an association was established between the variables. Social desirability bias in answering the questionnaire may be inherent in this study. In an effort to avoid this problem, participants were assured that all their data would be treated in an anonymous way.

Research using a longitudinal approach would be valuable to provide further evidence of the hypothesized relationships between variables. The design of strategies and techniques aiming to decrease children's vulnerability cognitions and enhance dental anxiety prevention should be explored. It is an undeniable fact that fears in dental setting are inherent.


   Conclusion Top


Participants had moderate perceptions of CV. Due to the multidimensional nature of dental anxiety/fear, the participants exhibited marked/higher dental anxiety/fear for behavioral component whereas cognition and physiological components contributed to lower dental anxiety/fear. Dental phobia was present and dental stimuli caused little or somewhat anxiety in most of the participants. More than three-fourth of the study participants experienced dental caries and gingival bleeding leading to poor oral health. The research hypothesis was accepted since a significant association existed between CV, dental anxiety/fear, dental phobia, and stimuli with oral health status among schoolchildren aged 12–15 years.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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    Abstract
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    References
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  2005 - Journal of Indian Society of Pedodontics and Preventive Dentistry | Published by Wolters Kluwer - Medknow 
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