ORIGINAL RESEARCH |
https://doi.org/10.5005/jp-journals-10077-3249 |
Prevalence of Dental Fear and Anxiety and its Association with Behavior Using Three Fear and Anxiety Measurement Scales among Children in Faridabad
1-6Department of Pedodontics and Preventive Dentistry, Sudha Rustagi College of Dental Sciences & Research, Faridabad, Haryana, India
Corresponding Author: Tanya Kakkar, Department of Pedodontics and Preventive Dentistry, Sudha Rustagi College of Dental Sciences & Research, Faridabad, Haryana, India, Phone: +91 9953566725, e-mail: tanyakakkar96@gmail.com
Received on: 04 October 2022; Accepted on: 14 December 2022; Published on: 26 December 2022
ABSTRACT
Introduction: Dental fear and anxiety (DFA) start mostly at the beginning of childhood and persist through adolescence, and it can have a major influence toward the provision of dental services. For effective dental treatment, a good rapport between the pedodontist and the patient is the key, which helps in identifying anxious children.
Aim: The aim of the study was to assess the prevalence of DFA and its association with behavior, using three fear and anxiety measurement scales among children in Faridabad.
Materials and methods: A cross-sectional study was conducted on 400 children (3–14 years) who visited the Department of Pedodontics and Preventive Dentistry. The children were divided into three groups according to age, and DFA levels were assessed by three sets of questionnaires, namely: Modified Child Dental Anxiety Scale (MCDAS) faces version, Children’s Fear Survey Schedule-Dental Subscale (CFSS-DS), and Dental Fear Survey (DFS). The operator assessed the behavior of the children according to modified Frankl’s behavior rating scale (MFBRS).
Results: The prevalence of high dental fear in children aged 3–14 years was 63.8% according to MCDAS, 50.8% according to DFS, and 54% according to CFSS-DS. In the assessment of the impact of age on dental fear levels, it was found that the level of DFA decreases with an increase in age.
Conclusion: Assessment of DFA, along with behavior management, is the most vital tool in the hands of pediatric dentists, as it helps them to execute the required treatment plan in the most effective manner.
How to cite this article: Kakkar T, Saraf BG, Kalra G, et al. Prevalence of Dental Fear and Anxiety and its Association with Behavior Using Three Fear and Anxiety Measurement Scales among Children in Faridabad. J South Asian Assoc Pediatr Dent 2022;5(3):164-169.
Source of support: Nil
Conflict of interest: Dr. Gauri Kalra Yadav is associated as Associate Editor of this journal and this manuscript was subjected to this journal’s standard review procedures, with this peer review handled independently of the Editor-in-Chief and his research group.
Keywords: Behavior management of children, Children’s fear survey schedule-dental subscale, Dental fear and anxiety, Modified child dental anxiety scale
INTRODUCTION
Dental fear can be defined as a response to any familiar unpleasant state, mainly involving a fight or flight reaction when confronted with an external dangerous stimulus.1 While on the contrary, dental phobia or anxiety is characterized by marked apprehension and anxiousness during dental treatment. Dental fear in children tends to decrease as the child grows older.2 Moreover, other factors that can exaggerate fear and anxiety, especially in young patients, are separated from the mother/primary caregiver in the operator room, visiting unfamiliar places, meeting strange people, and lack of command.
However, evaluating fear and anxiety is essential for rendering dental treatment and instilling a positive attitude in young children. Different fear and anxiety assessing methods have been proposed to create a uniform way to analyze and grade dental fear in children. However, according to Aartman et al.,3 behavioral measures are not a suitable option for assessing dental fear; hence, psychometric measures should be used that result in score ranges that are continuous, easy to assemble, and process statistically. Though only one scale may not be sufficient to analyze DFA in young children, therefore, for reliable results, the use of numerous questionnaires is advocated.4
The psychometric method, namely the dental subscale of the CFSS-DS, is a popular psychometric scale that was developed by Cuthbert and Melamed in 1982.5 MCDAS6 was introduced in 1998 and dental fear scale developed in 1978 is also generally used for assessing DFA, and it is based on Corah’s dental anxiety scale. It has been proven to be a valid and reliable tool for the assessment of dental fear in children.
Realizing the need to predict the behavioral pattern of the child toward the treatment and its association with DFA, our study was planned to evaluate the prevalence of DFA in children and its correlation with the behavior of the child toward the treatment. To correlate fear and anxiety levels in children, an adaptation of Frankl’s behavior rating scale was introduced in the year 1991, namely MFBRS. This scale is a useful tool for research involving the behavior of children in the dental setting. It can be used to compare different treatment conditions and techniques.
MATERIALS AND METHODS
A cross-sectional observational study was conducted on 400 children of age-group 3–14 years, reporting to the Department of Pediatric and Preventive Dentistry following the principles of Strengthening the Reporting of Observational Studies in Epidemiology.
Children were divided into three groups.
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Group I: 3–6 years.
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Group II: 7–10 years.
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Group III: 11–14 years.
Children with the chronological age of 3–14-year-old and for whom parental consent was given were included in the study. Children who were mentally disabled or had a sensory impairment and for whom parental consent could not be obtained were excluded from the study.
Ethical clearance was obtained from the Institutional Ethical committee (SRCDSR/ACAD/2021/10441) before the conduction of the study. The purpose of the study was informed and explained through an information sheet to primary caregivers of the children, and the confidentiality of the findings of the study subjects was maintained. Informed written consent was taken from the child’s parents.
A pretested survey questionnaire was used to assess the children for their DFA. The questionnaire consisted of three sections. The first section included information regarding the demographic characteristics, that is, name, age, gender, etc., followed by their general health status. The other sections included three sets of questionnaires comprising three fear and anxiety measurement scales (MCDAS, CFSS-DS, and DFS), respectively. The aforementioned scales have been proven to be valid and reliable and have been cited to predict behavioral patterns in young children for effective treatment planning. The questions assessed the DFA of the participants. Before administering the survey, instructions were given on how to answer the survey questions according to fear assessment. The questions were translated into the native language for the ease of the participants (Figs 1 and 2). After filling out the questionnaire, the child was clinically examined, the parents were advised of the required treatment plan and counseled for preventive measures, such as maintenance of oral hygiene, proper brushing, and consumption of a sugar-free diet to be followed.
Fig. 1: Recording data from the child through DFA measuring scales
Fig. 2: Recording data from the child through DFA measuring scales
After the checkup, the child was taken to the operatory for the required treatment procedure. At that time, behavior of the child toward the ongoing treatment was assessed by the principal examiner (Fig. 3). Along with the principal examiner, a co-examiner also evaluated the behavior of the child and the rating was noted according to MFBRS (Fig. 4). The data obtained from the questionnaires were tabulated and entered into Microsoft Office Excel sheet 2007, further statistical analysis and inter-examiner agreement were analyzed using Statistical Package for the Social Sciences version 21, IBM Inc.
Fig. 3: Principal examiner recording MFBRS rating of the child during treatment
Fig. 4: Co-examiner recording MFBRS rating of the child during treatment
RESULTS
A total of 400 children aged 3–14 years from Faridabad, Haryana, India, were included, out of which 198 were males and 202 were females (n = 400). The mean MCDAS score among different groups was compared using the Kruskal–Wallis test, and the difference in the scores was found to be statistically significant (p-value < 0.05). The maximum MCDAS scores were seen in group I (20.78 ± 3.63), followed by group II (18.36 ± 3.07), and least in group III (16.410 ± 3.92), as seen in Table 1. The mean MCDAS score among males was (18.591 ± 4.59) and among females was (19.104 ± 3.37).
| N | Mean | Standard deviation (SD) | Minimum | Maximum | |
|---|---|---|---|---|---|
| Group I | 175 | 20.783 | 3.6355 | 9.0 | 27.0 |
| Group II | 108 | 18.361 | 3.0768 | 10.0 | 26.0 |
| Group III | 117 | 16.410 | 3.9264 | 9.0 | 26.0 |
| Total | 400 | 18.850 | 4.0290 | 9.0 | 27.0 |
| Chi-square value, pb-value | 97.70, 0.001*, sig | ||||
| pc–value | Group III < group II < group I | ||||
| Groups I and II | 0.001*, sig | ||||
| Groups I and III | 0.001*, sig | ||||
| Groups II and III | 0.001*, sig | ||||
bKruskal–Wallis test, pair-wise; cMann Whitney U test; Level of significance set at p ≤ 0.05; Sig, Significant
The bold value is the overall mean MCDAS score of study population was (18.850 ± 4.0290)
The overall mean CFSS-DS score of the study population was (37.120 ± 6.28). The mean CFSS-DS score among different groups was compared using the Kruskal–Wallis test and the difference in the scores was found to be statistically significant (p-value <0.05). Group I (42.086 ± 4.91) showed maximum CFSS-DS scores, followed by group II (38.611 ± 5.28), and least in group III (37.120 ± 6.28), as shown in Table 2. The mean CFSS- DS score among males was (39.68 ± 6.25) and among females was (39.70 ± 5.44).
| N | Mean | SD | Minimum | Maximum | |
|---|---|---|---|---|---|
| Group I | 175 | 42.086 | 4.9129 | 29.0 | 56.0 |
| Group II | 108 | 38.611 | 5.2894 | 24.0 | 50.0 |
| Group III | 117 | 37.120 | 6.2824 | 24.0 | 57.0 |
| Total | 400 | 39.695 | 5.8543 | 24.0 | 57.0 |
| Chi-square value, pb value | 56.194, 0.001*, sig | ||||
| pc-value | Group III, group II < group I | ||||
| Groups I and II | 0.001*, sig | ||||
| Groups I and III | 0.001*, sig | ||||
| Groups II and III | 0.018*, sig | ||||
bKruskal–Wallis test, pair-wise; cMann Whitney U test; Level of significance set at p ≤ 0.05; Sig, Significant
The overall mean DFS score of the study population was (53.240 ± 8.68) The mean DFS score among different groups was compared using the Kruskal–Wallis test and the difference in the scores was found to be statistically significant (p-value < 0.05). Group I (57.85 ± 7.006) showed the maximum DFS score, followed by group II (51.63 ± 7.11), and the least in group III (47.82 ± 8.65), as seen in Table 3.
| N | Mean | SD | Minimum | Maximum | |
|---|---|---|---|---|---|
| Group I | 175 | 57.851 | 7.0066 | 42.0 | 74.0 |
| Group II | 108 | 51.630 | 7.1193 | 27.0 | 73.0 |
| Group III | 117 | 47.829 | 8.6506 | 27.0 | 71.0 |
| Total | 400 | 53.240 | 8.6816 | 27.0 | 74.0 |
| Chi-square value, pb-value | 40.887, 0.001*, sig | ||||
| pc–value | Group III, group II < group I | ||||
| Groups I and II | 0.001*, sig | ||||
| Groups I and III | 0.001*, sig | ||||
| Groups II and III | 0.01*, sig | ||||
bKruskal–Wallis test, pair-wise; cMann Whitney U test; Level of significance set at p ≤ 0.05; Sig, Significant
The bold value is the overall mean DFS score of study population was (53.240 ± 8.68)
According to the MCDAS, the factor which caused the most fear was “having a tooth taken out,” (70.7%), and in CFSS-DS, the most fear-inducing factor was “injections” (88.5%). In DFS, the most fearful factor was “seeing the anesthetic needle,” with a percentage of 43.7%, as shown in Table 4.
| MCDAS | CFSS | DFS | |||
|---|---|---|---|---|---|
| Having a tooth taken out? | 70.7% | Injections | 88.5% | Seeing the anesthetic needle | 43.7% |
| Having an injection in the gum? | 71.5% | The dentist drilling | 63.75% | Feeling the injected needle | 39% |
| Being put to sleep to have treatment? | 20.55 | The sight of the dentist drilling | 48.2% | Seeing the drill | 39.25% |
| Hearing the drill | 47.25% |
During the evaluation of the behavior of the child through MFBRS, it was seen that most respondents (58.8%) had an MFBRS rating of three, that is, negative-positive (±), which correlates to sometimes uncooperative behavior, and also the child showed some evidence of unpronounced negative attitude in the study sample, as represented in Table 5.
| Situation | Rating 1: definitely negative (−) | Rating 2: negative (−) | Rating 3: negative positive (±) | Rating 4: positive (+) | Rating 5: definitely positive (++) | ||
|---|---|---|---|---|---|---|---|
| Situation 1 | Separation of the child from the parent | N | 7 | 56 | 84 | 172 | 81 |
| % | 1.8 | 14 | 21 | 43 | 20.3 | ||
| Situation 2 | First reaction of the child in dental setting | N | 7 | 84 | 56 | 172 | 81 |
| % | 1.8 | 21 | 14 | 43 | 20.3 | ||
| Situation 3 | Attitude toward the dental staff | N | 7 | 49 | 91 | 172 | 81 |
| % | 1.8 | 12.3 | 22.8 | 43 | 20.3 | ||
| Situation 4 | Behavior during the treatment | N | 56 | 7 | 235 | 102 | 0 |
| % | 14 | 1.8 | 58.8 | 25.5 | 0 | ||
| Situation 5 | Behavior after the treatment | N | 0 | 35 | 70 | 193 | 102 |
| % | 0 | 8.8 | 17.5 | 48.3 | 25.5 |
The bold values is 58.8% of the children rated MFBRS rating 3, i.e., (negative-positive)
DISCUSSION
Despite revolutionary and innovative behavior management techniques, fear and anxiety toward a dental procedure in children is a major obstacle that causes aversion to seeking treatment and hence, leads to adverse oral health problems. The prevalence of dental anxiety in 6–12-year-old children of Southern India was reported to be 84.4%, and 6.3% in North Indian children aged 5–10 years.7
First dental visit plays a vital role in determining the severity of fear and dental anxiety in a child and thereby guiding the pedodontist to improve behavior guidance approaches. An understanding of the development of dental anxiety and the risk factors associated with it would help the pedodontist in the implementation of appropriate behavior management strategies at the earliest, which will be beneficial for the child (Figs 5 to 7).8
Fig. 5: Dental fear scale
Fig. 6: CFSS-DS
Fig. 7: MCDAS
In our study, the maximum MCDAS scores were seen in the 3–6-year-old age-group (20.783 ± 3.6355) and were least in the 11–14-year-old age-group (16.410 ± 3.9264). A study conducted by Khanduri et al. showed similar results.6 According to findings, the reduction in dental phobia as age increases is due to the development of cognitive abilities and change in the expression of fear. Also, as age increases, the child has a better understanding of his surroundings, and hence, the level of dental fear decreases. This observation was supported by previous studies.1,6,9
Dental anxiety can be provoked by multiple stimuli, such as fear of the sight of blood or injections, gag reflex, the noise of dental instruments, and past dental experiences.10,11 In the present study, according to the MCDAS, the most fear-provoking stimuli in the children participating in the study was “having an injection in the gum” (71.5%).
The mean CFSS-DS score among males was (39.68 ± 6.25) and among females was (39.70 ± 5.44); in this study, however, the difference was found to be statistically insignificant. This was not in agreement with the findings of the studies were done by Nakai et al.12, Raadal et al.,13 and Alvesalo et al.14 Klingberg,15 on the contrary, found higher anxiety levels in boys than in girls. Differences might arise due to variances in the dental clinic setup and the environment of the dental operatory.
The maximum DFS scores were seen in 3–6-year-old children (57.85 ± 7.006) and least in the 11–14-year-old age-group (47.82 ± 8.65). This observation was per the observations of the research done by Raciene, who found out that with an increase in age, a decline in the level of fear is seen.16
During the behavior evaluation of the child through MFBRS, the interexaminer Kappa agreement was almost perfect. It was seen that most respondents (58.8%) showed an MFBRS rating of three, that is, negative-positive (±). A study conducted by Pandiyan and Hedge17 displayed that 83% of children showed positive behavior, and only 10% showed negative behavior when assessed through MFBRS. This could be because our study was based on assessing a child’s behavior on their first dental visit. However, Howitt and Stricker18 found that as a child gained experience in dental situations, he became familiar with the dental environment; hence his fear was less. Venham et al.19 also suggested a child’s conduct improved in subsequent dental visits.
The limitation of this study was that as the child was unaware of certain variables since it was his first dental visit, accurate results could not be obtained. The results of this study suggest that there is a need for further research to find better methods for understanding and improving the fears and behavior of children and adolescents when they visit pediatric dentists.
CONCLUSION
Our investigation suggests that the prevalence of dental phobia in the 3–6-year-old age-group was high compared to older age-groups, which shows they have been preoccupied with the fear of the unknown. Also, since our study was based on assessing DFA and the behavior of the child during the first visit, it is of great importance that the child must be given special consideration on his/her first visit, as it can have a great effect to achieve appropriate behavior and positive attitude during the treatment procedure.
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