Journal of Indian Society of Pedodontics and Preventive Dentistry
Journal of Indian Society of Pedodontics and Preventive Dentistry
                                                   Official journal of the Indian Society of Pedodontics and Preventive Dentistry                           
Year : 2015  |  Volume : 33  |  Issue : 1  |  Page : 15--18

Correlation between dental anxiety, sense of coherence (SOC) and dental caries in school children from Bangalore North: A cross-sectional study

Deepak Viswanath, Anumula Vamsi Krishna 
 Department of Pedodontics and Preventive Dentistry, Krishnadevaraya College of Dental Sciences and Hospital, Bangalore, Karnataka, India

Correspondence Address:
Dr. Deepak Viswanath
Professor and Head, Department of Pedodontics and Preventive Dentistry, Krishnadevaraya College of Dental Sciences and Hospital, Bangalore, Karnataka 562157


Background: Very few publications report on the relationship between «SQ»salutogenesis«SQ», as measured by the concept of Sense of Coherence (SOC), and generally speaking an individual«SQ»s overall oral health- related quality of life (OHRQL). To add to this, there is even lesser information regarding the behavioral aspect of dental anxiety. Aim: The aim of the present study was to evaluate the relationship between dental anxiety, SOC and dental caries in school children from Bangalore North. Materials and Methods: The study had a sample of 529 children from various schools, age between 12-16 in Bangalore north. The study comprised of 17 questions which were handed over to them; and upon receival of the questionnaire the respective decayed, missing, filled tooth surfaces index (DMFS) score was checked which was then compared with dental anxiety and SOC. Statistical Analysis Used: One way analysis of variance (ANOVA) F-test and multiple comparison procedures (MCPs). Result: High dental anxiety predicted high dental caries index and low SOC predicted high dental caries index in association with advancing children«SQ»s age from 12-16 years. Conclusion: Dental anxiety had a direct relationship with dental caries and SOC had an inverse relationship with dental caries.

How to cite this article:
Viswanath D, Krishna AV. Correlation between dental anxiety, sense of coherence (SOC) and dental caries in school children from Bangalore North: A cross-sectional study.J Indian Soc Pedod Prev Dent 2015;33:15-18

How to cite this URL:
Viswanath D, Krishna AV. Correlation between dental anxiety, sense of coherence (SOC) and dental caries in school children from Bangalore North: A cross-sectional study. J Indian Soc Pedod Prev Dent [serial online] 2015 [cited 2021 Feb 25 ];33:15-18
Available from:

Full Text


The concept of 'salutogenesis', which is measured by Sense of Coherence (SOC) was theorized by Antonovsky in 1987, [1] where he discussed the issue of SOC specifically. The main concept of salutogenesis and SOC is to explain why some individuals stay healthy, especially after experiencing very high and long lasting stressful life situations, where as others experience disease and illness.

The last two decades have seen a vast number of publications that have revealed possible associations between SOC and different aspects of health and disease. [2] The findings from these publications have concluded that there is strong correlation between SOC and anxiety, physical activity, dietary activities and self-perceived health. [2] These findings are valid for SOC and oral health status. [3],[4],[5] Many authors have reported significant correlations between SOC, dental caries and oral health. [4],[6]

But the major drawback is that most of these publications are based from population studies from Finland, Sweden and Brazil. Dental anxiety and SOC were significant predictors of OHRQL as reported by Savolainen et al. [7]

A wide range of questionnaires are used to describe the dental anxiety in children; of which Corah's Dental Anxiety Scale, (DAS) is most commonly used as it is simple method for quantitative assessment and is also valid and reliable instrument. [8] Dental anxiety per se limits either partially or completely the utilization of oral health care services; [9] and this increases the prevalence of dental diseases. [10]

Therefore the present study was aimed to evaluate and assess the dental anxiety, SOC and dental caries in school children from Bangalore North, India as the previous studies have been done in western population and this is the first Indian study to document evidence on these three critical factors.

 Materials and Methods

Ethical approval was obtained from the ethical committee of Krishnadevaraya College of Dental Sciences and Hospital, Bangalore, India. And informed consent was obtained from each subject. The present study comprised 529 children between age groups of 12-16 belonging to four different schools from Bangalore North. The study was conducted during late January 2014 to early March 2014.

The survey included dental examination and self- related questionnaires that included global questions regarding socioeconomic status, oral health and function, SOC and dental anxiety. The questionnaire was in Kannada language (local language of Karnataka, questionnaire 1 and 2) which was given to the children in their respective schools. Each child was given half an hour time to fill the questionnaire. The decayed, missing, filled tooth surfaces index (DMFS) scoring was done for each child by a single examiner using disposable mouth mirror and probe under natural lighting in their respective schools.

Dental anxiety was measured using the modified Corah's Dental Anxiety Scale which consisted of four items that covered on anticipatory anxiety, physiological reactions and situational anxiety. [11] The responses were scored from 1 (no anxiety, relaxed) to 5 (high intensity of anxiety, very anxious).

SOC was measured with the shortened version of SOC questionnaire which consisted of nine items which are related to comprehensibility, manageability and meaningfulness. [1],[12] Each item was scored either 'Yes' or 'No' for the comprehensive SOC and a higher score indicated stronger SOC.

The data collected was then analyzed statistically with one way analysis of variance ANOVAF test and multiple comparison procedures (MCPs).


[Table 1] shows the mean dental anxiety scores in different age groups. The average dental anxiety scores of ages 12, 13, 14, 15 and 16 were 7.85, 9.81, 10.20, 10.05 and 10.00 respectively. It was seen that average anxiety scores significantly increased (P = 0.007) with advancing age. (Minimal variation in the mean scores of age groups 14, 15 and 16). The overall mean anxiety scale scores in 529 subjects was found to be 9.91 which accordingly to Corah's Dental Anxiety Scale, Revised (DAS-R) is categorized as having moderate anxiety levels along with specific stresses which can be discussed and managed.{Table 1}

DMFS score for ages 12, 13, 14, 15 and 16 were 1.00, 1.19, 1.19, 1.57 and 1.80 respectively [Table 2].The DMFS scores also showed constant significant increase (P = 0.015) with subsequent age-groups and an average DMFS scoreof 1.33 was seen in the same population.{Table 2}

From the above observations it was noted that anxiety score as well as DMFS scores, both showed significant increase with advancing age. Hence it can be safely concluded that a positive correlation was present between DMFS score and anxiety score, that is increased fear towards dental procedures lead to an overall increase in caries incidence.

Another set of observation drawn from the study [Table 3] were the SOC scores in age groups 12, 13, 14, 15 and 16 which were calculated to be 5.33, 4.55, 4.58, 4.25 and 4.22 respectively. These readings showed a highly significant decrease (P < 0.001) in SOC scores with increase in age(Minimal variation in the mean scores of age groups 13 and 14). The average SOC scores in the representing population were calculated to be 4.50.{Table 3}

As DMFS scores are increasing with increasing age, this makes relationship between DMFS and SOC to be inverse. In other words as the child enters teenage, it was seen his/her negative feelings towards the dental treatment was enhanced (as seen by decreasing SOC scores) along with increase in anxiety toward the same procedure which might have lead to avoidance of dental visits, resulting in overall increase in dental caries.


The psychological impact of dental anxiety and fear is well-documented and quality of life is increasingly acknowledged as a significant indicator of service needs and intervention outcomes in public health research and practice.

A very few publications in the scientific literature reported on the relationship between salutogenesis as measured by the concept of SOC and oral health- related quality of life (OHRQL). Even less information was found when the behavioral aspect of dental anxiety was added to the previous two concepts. Thus our study which correlated the dental anxiety, SOC and dental caries in children was the first of its kind ever conducted in India population.

The present study showed an increase in anxiety level and increase in caries frequency with advancing age. The results were in accordance with the reports of Lee CY, [13] Stenebrand A [14] and Rantavuori K, [15] This higher score among the older children is likely due to unpleasant experiences with the dental care. A greater frequency of caries and consequently greater number of invasive treatments may be a confounding factor in studies that affirm that anxiety scores increases with age. [16] But Klingberg G [17] reported that decrease in anxiety occurs as child matures probably due to losing the "fear of unknown".

As this study was conducted in rural areas, a possible explanation for increased dental fear, in rural areas may due to the different types of dental treatment received [18],[19] and or due to the differences in the type of dental service provided. [20],[21] For instance mobile dental units provide dental services to rural schools where as in urban schools; dental clinics are located within the school vicinity. Moreover, when asked over a third of rural adolescents were dissatisfied with dental services provided by the mobile dental units. [22]

This study also showed that as there is decline in the SOC scores there is an increase in the caries frequency with increase in age. This finding is in line with a recent oral health study in adolescents by Baker et al., [23] where, stronger SOC predicted better health perceptions.

According to the salutogenesis theory, SOC is shaped by three types of life experiences during the first decades of life, namely consistency, under-/overload balance and participation in socially valued decision-making. [1] Therefore it may be possible to strengthen SOC by early life interventions, with the former recently shown in a school program where changes in SOC were accompanied by improvements in tooth brushing behavior. [24] Therefore dental education for children should be started at early ages so that children would not develop negative relationship (low SOC) towards dental procedures, and to deliver a good dental care, the prevalence of dental anxiety should not be neglected in clinical practice, especially in pediatric dentistry.

Limitations of the study were that no comparison was made between genders and only a narrow age-group was selected for the study; also the present study was carried out in Bangalore North which is predominantly rural where the patients are not exposed to/unaware of preventive measures and most of these patients expressed a negative attitude towards general and dental health.


The conclusion from this study was that high dental anxiety predicted high dental caries index and low SOC predicted high dental caries index in association with advancing age. Thus dental anxiety had a direct relationship with dental caries and SOC had an inverse relationship with dental caries.


1Antonovsky A. Unraveling the mystery of health. How people manage stress and staywell. San Fransisco: Jossey-Bass; 1987.
2Eriksson M, Lindström B. Antonovsky´s sense of coherence scale and the relation withhealth: A systematic review. J Epidemiol Community Health 2006;60:376-81.
3Lindmark U, Hakeberg M, Hugoson A. Sense of coherence and oral health status in an adult Swedish population. Acta Odontol Scand 2011;69:12-20.
4Savolainen J, Suominen-Taipale A, Uutela A, Aromaa A, Harkanen T, Knuuttila M. Senseof coherence associates with oral and general health behaviours. Community Dent Health 2009;26:197-203.
5Freire MC, Sheiham A, Hardy R. Adolescents' sense of coherence, oral health status, and oral health-related behaviors. Community Dent Oral Epidemiol 2001;29:204-12.
6Bernabe E, Watt RG, Sheiham A, Suominen-Taipale AL, Uutela A, Vehkalahti MM, et al. Sense of coherence and oral health in dentate adults: Findings from the Finnish Health 2000 survey. J Clin Periodontol 2010;37:981-7.
7Johansson V, Axtelius B, Soderfeldt B, Sampogna F, Paulander J, Sondell K. Multivariate analyses of patient financial systems and oral health-related quality of life. CommunityDent Oral Epidemiol 2010;38:436-44.
8Corah NL. Development of a dental anxiety scale. J Dent Res 1969;48:596.
9Berggren U, Meynert G. Dental fear and avoidance: Causes, symptoms, and consequences. J Am Dent Assoc 1984;109:247-51.
10Locker D. Psychosocial consequences of dental fear and anxiety. Community Dent Oral Epidemiol 2003;31:144-51.
11Kleinknecht RA, Klepac RK, Alexander LD. Origins and characteristics of fear of dentistry. J Am Dent Assoc 1973;86:842-8.
12Langius A, Bjorvell H, Antonovsky A. The sense of coherence concept and its relation to personality traits in Swedish samples. Scand J Caring Sci 1992;6:165-71.
13Lee 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.
14Stenebrand A, Wide Boman U, Hakeberg M. Dental anxiety and temperament in 15-year olds. Acta Odontol Scand 2013;71:15-21.
15Rantavuori 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.
16Tickle M, Jones C, Buchannan K, Milsom KM, Blinkhorn AS, Humphris GM. A prospective study of dental anxiety in a cohort of children followed from 5 to 9 years of age. Int J Paediatr Dent 2009;19:225-32.
17Klingberg G, Broberg AG. Dental fear/anxiety and dental behavior management problems in children and adolescents: A review of prevalence and concomitant psychological factors. Int J Paediatr Dent 2007;17:391-406.
18Armfield JM, Stewart JF, Spencer AJ. The vicious cycle of dental fear: Exploring the interplay between oral health, service utilization and dental fear. BMC Oral Health 2007;7:1.
19Milsom KM, Tickle M, Humphris GM, Blinkhorn AS. The relationship between anxiety and dental treatment experience in 5-year-old children. Br Dent J 2003;194:503-6.
20Othman L, Jaafar N. A survey of customer satisfaction with the school dental service among 16-year-old schoolchildren in the district of Tawau, Sabah [monograph]. Kuala Lumpur, Malaysia: Oral Health Division, Ministry of Health and University of Malaya; 2004.
21Dayang Mariam AR, Ahmad A, Sujak SL, Noralaini I, Nooraini O, Fouziah G, et al. Refusal of dental treatment in the school dental service among primary schoolchildren. Int Dent J 2001;51:360.
22Othman N, Razak IA. Satisfaction with school dental service provided by mobile dental squads. Asia Pac J Public Health 2010;22:415-25.
23Baker SR, Mat A, Robinson PG. What psychosocial factors influence adolescents' oral health? J Dent Res 2010;89:1230-5.
24Ayo-Yusuf OA, Reddy PS, van den Borne BW. Longitudinal association of adolescents' sense of coherence with tooth-brushing using an integrated behavior change model. Community Dent Oral Epidemiol 2009;37:68-77.