|Year : 2021 | Volume
| Issue : 1 | Page : 15-21
Prevalence of dental fear in children of 3–14 years visiting the OPD in Dental College, Lucknow, India
Ankita Singh, Anuradha Palshikar, Sugandha Agarwal, Shweta Singh
Department of Public Health Dentistry, Babu Banarasi Das College of Dental Sciences, Lucknow, Uttar Pradesh, India
|Date of Submission||10-Sep-2020|
|Date of Decision||18-Jan-2021|
|Date of Acceptance||18-Jan-2021|
|Date of Web Publication||16-Mar-2021|
Dr. Ankita Singh
Department of Public Health Dentistry, Babu Banarasi Das College of Dental Sciences, BBD University, Lucknow 226028, Uttar Pradesh.
Source of Support: None, Conflict of Interest: None
Introduction: Dental fear and anxiety pose a significant problem for the practice of dentistry, especially in children. Therefore, it is necessary to identify and quantify this anxiety, to implement, and to monitor the effectiveness of treatment interventions. Materials and Methods: A cross-sectional study was conducted on children in the age group of 3–14 years. The children who had sound health and visited outpatient department of a Dental College, Lucknow, India with their parents for dental care were considered for study purposes. Children’s dental fear and anxiety were measured by using three scales. Result: Out of the total 220 respondents, 118 (53.6%) were males and 102 (46.4%) females. The outcome of the study showed that the dental fear among children was 13.3%, 22.9%, 7.8%, respectively, in existence measured by the three scales, viz., (a) facial image scale (FIS), (b) dental fear scale (DFS), and (c) children’s fear survey schedule-dental subscale (CFSS-DS). About 70.2% of the children showed Frankl’s behavior rating of 3, i.e. positive. Conclusion: Dental fear and anxiety are the most common problems of children and because of this, they are afraid of undergoing any dental treatment. By using the above scale, we can know about those factors which can enhance their fear so that we can modify our treatment approach. Altering in a treatment modality not only leads the children to get the treatment done easily but also removes the fear for dental treatment in the future.
Keywords: Children, dental anxiety, dental fear, facial image scale, Frankl’s behavior rating scale
|How to cite this article:|
Singh A, Palshikar A, Agarwal S, Singh S. Prevalence of dental fear in children of 3–14 years visiting the OPD in Dental College, Lucknow, India. MGM J Med Sci 2021;8:15-21
|How to cite this URL:|
Singh A, Palshikar A, Agarwal S, Singh S. Prevalence of dental fear in children of 3–14 years visiting the OPD in Dental College, Lucknow, India. MGM J Med Sci [serial online] 2021 [cited 2021 Oct 21];8:15-21. Available from: http://www.mgmjms.com/text.asp?2021/8/1/15/311386
| Introduction|| |
Dental fear can be defined as a normal emotional reaction to one or more specific threatening stimuli within the dental situation, whereas dental anxiety refers to a state of apprehension that something terrible can happen during dental treatment, coupled with a sense of losing control. Dental phobia can be defined as a type of dental anxiety and is characterized by apparent situations, e.g. drilling, needle, injections, or dental situations in general.
Children’s uncooperativeness, especially in dentistry, has been conceptualized in different ways. Dental fear along with dental anxiety is often used to denote the early signs of dental phobia: an excessive or unreasonable fear or anxiety about the dental examination and treatment, which can affect daily living and result in the prolonged avoidance of dental treatment.
The reported prevalence of dental fear and anxiety (DFA) among children and adolescents in different countries ranged from 5% to 33%. Dental fear in children is not only about the fear of pain or invasive procedures but also about the separation from parents, confrontation with unfamiliar people and surroundings, and the experience of loss of control.
Many times adults, usually parents with dental fear and anxiety, may verbalize their fearful feelings in front of their children, creating a negative impression of dental treatment. Many children at an early school age begin to imitate their parents who are looked upon as models. They are very likely to internalize their parent’s values, belief, attitudes, and views, which would gradually become a part of their own belief system.
Children with fear and anxiety often try all means to avoid or delay dental treatment, resulting in deterioration of their oral health. This study was conducted in children in contrast to adults who have relatively very limited communication skills and they are less able to express their fears and anxiety. Managing dental fear and anxiety form a major aspect of a child’s dental care and are considered to be the main barrier for successful completion of dental treatment. Hence, in this study, three fear assessment scales, namely: (i) facial image scale (FIS), (ii) dental fear scale (DFS), and (iii) children’s fear survey schedule-dental subscale (CFSS-DS), were used to assess dental fear and anxiety.
The aim of this article is to assess the prevalence of dental fear among children in the age group of 3–14 years who visited the outpatient department (OPD) of a Dental College, Lucknow, India.
The objectives are as follows:
- Assessment of the factors which cause dental fear and anxiety in children using three scales.
- Impact of age and gender of children on dental fear.
- Children’s behavioral pattern by using Frankl’s behavior rating scale.
| Materials and methods|| |
A cross-sectional study was carried out on 220 children aged between 3 and 14 years who visited the OPD of Dental College, Lucknow, India. This study was conducted from July 2, 2019 to August 7, 2019. Before the start of the study, ethical clearance was obtained from the Institutional Ethical Committee. The sample selection was done using simple random sampling. The children were divided into four groups according to their age, viz., (i) 3–5; (ii) 6–8, (iii) 9–11, and (iv) 12–14 years.
The children of sound health who visited the OPD of a Dental College for taking dental care for the first time with their parents or guardians were considered for study purposes. Children suffering from any systemic disease, having any mental disabilities, and those parents who did not wish to participate in the study were excluded. Informed written consent was obtained from willing parents/guardians.
FIS was applied in the waiting room to assess the child’s dental anxiety as faces are considered to be an indicator of the feeling. The FIS comprises a row of five faces ranging from a very happy to sad face. The score of (1) was given to a very happy face and a score of (5) to a very sad face [Figure 1].
The questionnaire of DFS and CFSS-DS was translated from the English language to the Hindi language, i.e. forward-backward—the forward translation was done and a review of translation was done by the bilingual reviewer and discrepancies were ruled out and corrected. The reliability and validity were measured by using Cohen’s Kappa statistics. Both the scales showed strong inter-rater reliability. Internal consistency and reliability of the DFS and CFSS-DS questionnaire were assessed using Cronbach’s alpha coefficient (DFS=0.92 and CFSS-DS=0.99), indicating high reliability.
After recording the FIS, DFS was applied to the children. DFS was given by given by Kleinknecht–Klepac–Alexander and it comprised of 20 questions, with five options for each question and the answers range from never (1), once or twice (2), a few times (3), often nearly (4), and every time (5), as shown in [Table 1].
The parents of younger children were advised to assist them in fulfilling their questionnaires. Scores range from 20 to 100. A score of fear <24 indicates low, 24–53 indicates moderate, and >53 indicates high fear.
After DFS, the CFSS-DS developed by Cuthbert and Melamed consists of 15 items and each item can be given five different scores ranging from not afraid at all (1), very little (2), moderate (3), pretty much afraid (4), and very much afraid (5) as described in [Table 2]. Score ranges from 15 to 75. A score of 38 or more indicates fear.
All the questionnaires were collected back and the children were then taken to the operatory clinics for treatment. The behavioral pattern of each child during the treatment was determined by the first investigator using the FBRS [Table 3].
|Table 3: Frankl’s classification (Frankl’s behavior rating scale 1962)|
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The data collected through the questionnaires were entered into MS Excel. The statistical analysis was carried out using the Statistical Package for Social Sciences (SPSS) version 20.0 (IBM Corporation, Chicago, IL, USA). P < 0.05 was considered statistically significant.
| Results|| |
A total of 220 children participated in the study, out of which 118 (53.6%) were males and 102 (46.4%) females as shown in [Figure 2].
In FIS, 42.2% of the children showed a score of 2, i.e. happy as illustrated in [Table 4]. About 11.7% and 1.6% of the children showed a score of FIS 4 and 5, respectively, which indicates dental fear among children. FIS scores among the four age groups were found statistically significant (P = 0.0002). However, FIS scores among males and females were not found to be statistically significant using Pearson’s χ2 test (P = 0.352).
The mean DFS score for males was 30.94 ± 7.42 and for females was 33.96 ± 8.65 [Table 5]. A Student’s t-test was applied and a statistically significant difference had been observed between mean scores among males and females (P = 0.005). The maximum DFS scores had been found in the age group of 6–8 years. However, among the various age groups, there was no statistically significant difference found (P = 0.168). Mean dental fear scale scores concerning age groups and gender have been presented in [Figure 3].
|Figure 3: Mean dental fear scale scores concerning age groups and gender|
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The mean score for males and females has been found to be 22.48±7.65 and 24.62 ± 8.23, respectively [Table 6]. A statistically significant difference was found between male and female children and the mean CFSS-DS scores by using Student’s t-test were P = 0.0407 [Table 6]. It had been noticed that the children in the age group of 9–11 years had the highest CFSS-DS scores. It had been found that the maximum mean score of CFSS-DS was seen in group (iii), but there was no statistically significant difference observed among the various other groups (P = 0.182). Around 7.8% of the children lie in the high-fear group whereas 93.4% in the low-fear group. The CFSS-DS scores concerning age group and gender have been presented in [Figure 4]. It shows that the maximum score of CFSS-DS was seen in females that belong to the age group of 9–11 years (group iii).
|Table 6: Mean child fear survey schedule dental subscale concerning gender|
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|Figure 4: Child fear survey schedule scores according to age groups and gender|
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The majority of the children (70.2%) showed Frankl’s behavior rating 3, i.e. positive (+). Around 14.8% showed rating 2, i.e. negative (‒), 12.5% showed 4 which indicates definitely positive (++), and 2.5% showed rating 1 which means definitely negative (‒ ‒) [Table 7]. Statistically, a significant difference was seen in Frankl’s behavior ratings among males and females using Pearson’s χ2 test (P = 0.034). A statistically significant difference was observed among the four groups (P = 0.0002).
| Discussion|| |
This study was conducted to identify the presence of dental fear and anxiety among children as it is considered to be the main barrier to the successful completion of dental treatment in child patients. The need for assessing and addressing children’s dental fear and anxiety at an early stage should be emphasized to enable identification of those children who are having high dental fear and to prevent the negative consequences of high dental fear in them. Milgrom et al. suggest that, in the United States, more than 80% of the population fears dental treatment, and 20% avoids the dentist due to dental fear. Avoiding dental treatment due to fear and anxiety exacerbates problems related to the patient’s oral health. Also, treating such anxious patients tends to be both more difficult and more time-consuming.
The prevalence of dental fear according to FIS in our study was 13.3%. In our study, 42.2% of the children showed facial image scale 2, which was similar to the study conducted by Rajwar and Goswami and in contrast to the study conducted by Krishnappa et al. which shows that the most frequently chosen facial image on facial image scale was image no. 3 (n = 16, 30.76%), followed by images l and 4. It was also seen that the children between 12 and 14 years showed a maximum response to the FIS score of 2. This may be explained as the cognitive ability develops with increasing age, the fear levels tend to reduce; hence, the older aged children were less fearful when compared with younger age children. This observation was supported by a study done by Raducanu et al., in which a significant decrease in fear levels was seen as the age progresses whereas no significant difference was observed between boys and girls about the same age in a study conducted by Buchanan and Niven. About gender, male respondents (42.5%) showed a higher frequency of FIS score 2 when compared with female respondents (43.6%). This implies that fear levels were more in females when compared with males; however, this difference was not statistically significant (P = 0.352). Similar results were also obtained by a study done by Raducanu et al., in which dental fear is 1.63 times higher in girls when compared with boys. Many researchers have also reported that gender differences in anxiety scores further validate children’s dental anxiety assessment measures. When the anxiety rating scores were compared for gender differences, significant differences were not found in the present study. This observation is in agreement with the results found by previous researchers.,
In the DFS, low fear was measured below the score of 24, moderate fear was measured between the score (24–53), and high fear was measured above score 53. Thus, the prevalence of high dental fear in children according to DFS in our study was found to be 22.9%.
The mean values of dental fear as measured with the DFS scale were found to be higher in females when compared with males. A statistically significant difference was found between the mean score for males and females. It was seen that the 6–8-year-old children showed the highest mean values for dental fear. There was no statistically significant difference seen in fear levels within various age groups as measured with DFS seen in our study. Our result was similar to a study conducted by Raciene, who observed that as age increases the level of fear declines.
Children with CFSS-DS scores >38 were considered as dentally anxious, by Singh et al. and Klingberg. It was observed that 7.8% of the children were under the high-fear group, whereas 93.4% were under the low-fear group. The mean CFSS-DS values for females (24.62 ± 8.23) were higher than the males (22.48±7.65); however, the difference was found to be statistically significant (P = 0.0407) This was similar to the studies conducted by Nakai et al., Raadal et al., and Alvesalo et al., who also reported higher dental fear levels in girls than in boys. Klingberg and Broberg were, however, consistent with the findings of Singh et al. who found no significant difference in fear scores of girls and boys.
In our study, it was observed that the age group of 9–11 years showed the highest mean CFSS-DS scores; however, no statistically significant difference was seen among the age groups (P = 0.182). This was similar to a study conducted by Arapostathis et al., in which mean scores were not related to age differences but in contrast to a study conducted by Lee et al., that younger children express higher dental fear. In an assessment of the behavior of children in the clinics through FBRS, it was observed that the maximum rating (70.2%) for the respondents was FBRS 3, i.e. positive. This was similar to the findings of Shinohara et al., in which the most common rating was FBRS 3. This could be because the children were evaluated with a less invasive modality of treatment, i.e. oral prophylaxis or simple restoration.
In our study, the factors which cause the most dental fear in children according to DFS was “feeling the needle injected,” followed by “seeing the anesthetic needle” and “vibrations of the drill.”
The most feared item was “injections,” then “dentist,” and then “doctors” according to CFSS-DS. Thus, it can be said that injections are the most feared item among children. This was similar to the findings of Nakai et al., who also state that injections are the most feared items in their study. In a study done by Domoto et al., the most fear-provoking stimuli were injections and drilling.
| Conclusion|| |
Dental fear and anxiety was the most common problem of children and because of this, they are afraid of undergoing any dental treatment. By the above scale, it can be concluded that in DFS, the factor which caused most fear was “feeling the needle injected,” whereas in CFSS-DS, the factor which caused most fear was “injections.”
Among the children in the age group of 3–14, the prevalence of high dental fear was 13.3% (FIS), 22.9% (DFS), and 7.8% (CFSS-DS). The majority of the children (70.2%) showed Frankl’s behavior rating of 3, which denotes positive, thus indicating low dental fear in children. It had been found that while age increases the level of dental fear decreases among the children. It had been observed that the girls were found to be more fearful in comparison to boys as per the scales used in this study. There is a need for further research to find better methods for understanding and improving the fears and behavior of children when they visit dentists.
Limitation of the study
Frankl’s rating was recorded in children but the treatment modality was not the same for every child, for example, some undergone prophylaxis, restoration, pulpotomy, extraction, etc., so their response will be different.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
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.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Press; 1994.
Chhabra N, Chhabra A, Walia G Prevalence of dental anxiety and fear among five to ten year old children: A behaviour based cross sectional study. Minerva Stomatol 2012;61:83-9.
Ten Berge M Dental fear in children: Prevalence, etiology, and risk factors. Thesis. Amsterdam: The University of Academic Centre for Dentistry; 2001.
Gao X, Hamzah SH, Yiu CK, McGrath C, King NM Dental fear and anxiety in children and adolescents: Qualitative study using YouTube. J Med Internet Res 2013;15:e29.
Newman BM Development through life: A psychosocial approach. 6th ed. Pacific Grove, CA: Brooks/Cole Pub. Co; 1995.
Mungara J, Injeti M, Joseph E, Elangovan A, Sakthivel R, Selvaraju G Child’s dental fear: Cause related factors and the influence of audiovisual modeling. J Indian Soc Pedod Prev Dent 2013;31:215-20.
Sharma A, Tyagi R Behavior assessment of children in dental settings: A retrospective study. Int J Clin Pediatr Dent 2011;4:35-9.
Rajwar AS, Goswami M Prevalence of dental fear and its causes using three measurement scales among children in New Delhi. J Indian Soc Pedod Prev Dent 2017;35:128-33.
Kleinknecht RA, Klepac RK, Alexander LD Origins and characteristics of fear of dentistry. J Am Dent Assoc 1973;86:842-8.
Cuthbert MI, Melamed BG A screening device: Children at risk for dental fears and management problems. ASDC J Dent Child 1982;49:432-6.
Frankl SN, Shiere FR, Fogels HR Should the parent remain with the child in the dental operatory? J Dent Child 1962;29:150-63.
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.
Milgrom P, Fiset L, Melnick S, Weinstein P The prevalence and practice management consequences of dental fear in a major US city. J Am Dent Assoc 1988;116:641-7.
Krishnappa S, Srinath S, Vishwanath SK, Bhardwaj P, Singh R Evaluation of facial image scale and Venham picture test used to assess dental anxiety in children. JIPHD 2013;11:31-5.
Raducanu AM, Feraru V, Herteliu C Assessment of the prevalence of dental fear and its causes among children and adolescents attending a department of pediatric dentistry in Bucharest. OHDMBSC 2009;8:42-9.
Buchanan H, Niven N Validation of a facial image scale to assess child dental anxiety. Int J Paediatr Dent 2002;12:47-52.
Wong HM, Humphris GM, Lee GT Preliminary validation and reliability of the modified child dental anxiety scale. Psychol Rep 1998;83:1179-86.
Al-Madi E, Abdel-Latif H Assessment of dental fear and anxiety among adolescent females in Riyadh, Saudi Arabia. Saudi Dent J 2002;14:77-81.
Raciene R Prevalence of dental fear among Vilnius pupils aged 12 to 15 years. Determining factors. Stomatol Balt Dent Maxillofac J 2003;5:52-6.
Singh P, Pandey RK, Nagar A, Dutt K Reliability and factor analysis of children’s fear survey schedule-dental subscale in Indian subjects. J Indian Soc Pedod Prev Dent 2010;28:151-5.
Klingberg G Reliability and validity of the Swedish version of the dental subscale of the children’s fear survey schedule, CFSS-DS. Acta Odontol Scand 1994;52:255-6.
Nakai Y, Hirakawa T, Milgrom P, Coolidge T, Heima M, Mori Y, et al
. The children’s fear survey schedule-dental subscale in Japan. Commun Dent Oral Epidemiol 2005;33:196-204.
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.
Alvesalo I, Murtomaa H, Milgrom P, Honkanen A, Karjalainen M, Tay KM The dental fear survey schedule: A study with Finnish children. Int J Paediatr Dent 1993;3:193-8.
Arapostathis KN, Coolidge T, Emmanouil D, Kotsanos N Reliability and validity of the Greek version of the children’s fear survey schedule-dental subscale. Int J Paediatr Dent 2008;18:374-9.
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.
Shinohara S, Nomura Y, Ide M, Idaira Y, Moriyasu K, Takahashi T, et al
. The classification of children by their behavior for the dental treatment using cluster analysis. Pediatr Dent J 2005;15:191-4.
Domoto PK, Weinstein P, Melnick S, Ohmura M, Uchida H, Ohmachi K, et al
. Results of a dental fear survey in Japan: Implications for dental public health in Asia. Commun Dent Oral Epidemiol 1988;16:199-201.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]