Download Developmental changes in dental anxiety in a normative population

Developmental changes in dental anxiety in
a normative population of Dutch children
M. MAJSTOROVIC*, J.S.J. VEERKAMP**
ABSTRACT. Aim The aim of this study was to ascertain age and gender related differences that contribute to dental
anxiety and to find relations with early onset of child dental anxiety in a population of 4-11 years old Dutch children.
Materials and methods The study was conducted among 2,865 patients (48.2% girls) aged between 4 and 11 years
old. The sample included a normative (n=2,153) and an anxious group of children (n=712), who were referred to
the Special Dental Care Clinic in Amsterdam because of manifested dental phobia. Children were divided into three
age groups (4-6, 7-9 and 10-11 years). Dental anxiety was assessed using the Children Fear Survey Schedule-Dental
Subscale. Three levels of dental anxiety were used: low (CFSS-DS = 15-25), moderate (CFSS-DS = 26-36) and high
(CFSS-DS above 37). Only children with CFSS-DS scores above 37 were considered dentally phobic. Statistics
Statistical analysis was performed in Statistics for Windows 10. Results In the total group a significantly higher level
of dental anxiety was found among girls (p=0.004; t=-3.262). There was a considerably lower number of dentally
phobic boys (7.1%) and girls (9.2%) in the older group compared with the younger (51.8%, 52.8% respectively). One
way Anova results revealed a statistically significant age related difference between the oldest and the youngest as
well as the middle-aged groups (p<0.001, p=0.001). In general dental anxiety was explained better in the younger
than in the older group. The regression analysis accounted for a higher percentage of the explained variance.
Conclusions The study confirmed the highest level of dental anxiety was present at 4 years of age and an overall
decrease in dental anxiety occurred as children became older. In different age groups, dental anxiety seems to be
related to different aspects of dentistry, indicating the causes shift from simple initial stimuli to more complex events.
KEYWORDS: Child dental anxiety, Development, Age aspects.
Introduction
Dental anxiety is multifactorial. Research aims at
many different aspects, with the purpose of creating
tools for practitioners to seek effective and individual
behavioural management strategies for different
child populations. In general though, many different
predisposing factors are involved in the aetiology of
dental fear, anticipated fear of pain seems to be of
great importance [Arntz et al., 1990]. Dental fear is
strongly related to invasive procedures and
associated conditioning processes, rather than to
social factors or the interactions between them
[Davey, 1989; Bedi et al., 1992; Veerkamp et al.,
1992; Milgrom et al., 1995]. Dentally anxious
*Department of Paediatric Dentistry, School of Dental medicine,
University of Zagreb, Croatia;
**Department of Cariology, Endodontology, Pedodontology,
Academic Center for Dentistry, Amsterdam, The Netherlands
E-mail: [email protected]
[email protected]
30
behaviour in children is associated more with direct
conditioning or vicarious learning, than with
psychological factors [Locker et al., 1999]. In
general an inverse relation with age seems to exist,
giving room to the assumption that the older one
becomes, the more time one has for good dental
experiences to neutralize aversive dental events
occurring at younger ages [Hagglin et al., 1996;
Liddell and Locker, 1997]. Females report higher
levels of dental fear, though the difference could not
be duplicated for young children [ten Berge et al.,
2002]. Some investigators have found that women
appear to be at a greater disadvantage than men in
perceived ability to cope with dental situations,
because of a greater desire to control [Liddell and
Locker, 1997].
It is assumed that a high level of dental fear, or
even phobia, might develop in early childhood. In
infancy, children are generally more fearful of
stimuli appearing immediately in their direct
surroundings or those related to a concrete stimulus,
while with increasing age their fears become more
EUROPEAN JOURNAL OF PAEDIATRIC
DENTISTRY • 1/2005
DENTAL ANXIETY IN DUTCH CHILDREN
associated with anticipatory events based on direct
experiences [Gullone, 2000]. Development into the
school years, especially between the ages of 6 and
12 years, coincides with the fears related to bodily
injury [King et al., 1989; Gullone and King, 1997;
Gullone, 2000].
Therefore, it might be hypothesised that different
aspects of dental treatment might evoke anxiety at
different age/developmental levels. As dental fear
seriously interferes with and negatively affects
dental treatment in young patients, the aim of this
study was to ascertain age and gender related
differences in factors contributing to dental anxiety
among a young child Dutch population aged 4-11
years and to find relations with early and late onset
of child dental anxiety.
Materials and methods
Subjects. The study was conducted among 2,865
patients (48.2% girls), whose age ranged from 4 to
11 years (mean 7.18). The patient sample included a
normative group (n=2,153) and an anxious group of
children (n=712), as the subject of the study focused
on examining dental anxiety among highly fearful
children. The normative group was formed by
randomly selected Dutch children who were regular
dental patients of the Academic Center for Dentistry
(ACTA) in Amsterdam. The anxious group was
formed of children who had been referred to the
Special Dental Care Clinic in Amsterdam because of
manifested dental phobia. Before filling in the
questionnaires the parents gave their written
approval for the study. Refusing an approval had no
influence on the treatment performed. The study was
part of the general ethical approval of the ACTA
research school IOT. To study the causative relation
between dental phobia and age, the children were
divided into three age groups: 4-6, 7-9 and 10-11
years old.
Methods. For the purpose of this study the
Children Fear Survey Schedule-Dental Subscale
(CFSS-DS) was used, a questionnaire which
measures specific dental fear [Cuthbert and
Melamed, 1982]. Since its development, the CFSSDS scale became quite a reliable instrument with an
acceptable validity in evaluating children’s dental
anxiety [Milgrom et al., 1995; ten Berge et al.,
2002]. The questionnaire consists of 15 items related
to various aspects of dental treatment, which can be
scored on a 5-point Likert scale varying from 1 (not
fearful at all) to 5 (dental phobic). The final scores
range from 15 to 75. As to the final and cut-off
EUROPEAN JOURNAL OF PAEDIATRIC
DENTISTRY • 1/2005
scores, different levels of dental anxiety have been
reported in the literature [Alvesalo et al., 1993;
Milgrom et al., 1995]. In this study, three levels of
anxiety were used: low (CFSS-DS = 15-25),
moderate (CFSS-DS = 26-36) and high (CFSS-DS
above 37). Highly anxious children who scored
above 37 on the CFSS-DS questionnaire were
considered dentally phobic.
Statistics. Statistical analysis was performed in
Statistics for Windows 10. Stepwise regression
analysis was performed to examine differences
regarding factors predicting dental anxiety for both
the youngest (4-6 years) and the oldest (10-11 years)
groups of children. Taking CFSS-DS question 1
(fear of dentists) as a dependant variable, the
sequence of CFSS-DS items was compared between
the groups. Cross-tabs were designed to represent
age related differences regarding dental anxiety.
One-way Anova analysis and the post-hoc
Bonferroni test were performed to represent age
related differences between each group. A graph was
designed to show age related differences in dental
anxiety mean scores for the whole sample. An
independent sample t test was used for the gender
related differences in dental anxiety.
Results
Children’s dental anxiety in relation to age and
gender. In the total group a significant difference in
dental anxiety regarding gender was found, girls
showing a higher level of dental fear than boys
(p=0.004; t=-3.262) (Table 1). Age related
differences for gender were indicative but not
significant. There was a considerably lower number
of dentally phobic boys in the oldest group (7.1%)
than in the youngest group (51.8%) and a
considerably lower number of dentally phobic girls
in 10-11 years old (9.2%) in comparison with 4-6
years old (52.8%) (Table 1).
One-way Anova results revealed a statistically
significant age related difference between the oldest
(10-11 years) and the youngest (4-6 years) groups
(p≤0.001) (Table 1). A significant age related
difference was found between the middle aged (7-9
years) and the oldest (10-11 years) groups (p≤0.001)
as well (Table 1).
The overall decrease in child dental anxiety is also
shown in Figure 1. The highest dental anxiety level
was present at the age of 4 years and slowly dropped
as children became older, showing a remarkable
tendency towards increasing again at the age of 11
years.
31
M. MAJSTOROVIC, J.S.J. VEERKAMP
Age related onset of factors predicting dental anxiety.
Taking fear of the dentists (CFSS-DS question 1) as
a dependant variable, stepwise regression analysis
revealed age related differences regarding factors
predicting dental anxiety in 4-6 and 10-11 years old
dentally anxious children (Table 2). For both the
younger and the older groups, fear of doctors
(dentists) (CFSS-DS question 2) was a significant
factor in predicting dental anxiety. Fear of the dentist
drilling (CFSS-DS question 8) was a statistically
significant predictor regarding dental anxiety only
for the older group (Table 2).
Fear of having had someone examine the mouth
(CFSS-DS question 4) was significantly related to
dental anxiety, but only for the younger children
(Table 2). In general, at a young age the nature of the
anxiety in dental situations seemed to be more
Gender (CFSS)
CFSS-DS scores
related to age (strangers, unknown situations) than
aspects specifically related to dental treatment.
The fear of having had someone put instruments in
the mouth (CFSS-DS question 11) was positioned on a
high sequential level, explaining a limited additional
percentage of the variance. It was a specific anxiety
provoking factor for both age groups (Table 2).
In the younger group, the most specific item
accounting for the highest percentage of the
explained variance was fear of people in white
uniforms (CFSS-DS question 14), while in the older
group it was fear of chocking (CFSS-DS question
12) (Table 2).
In general dental anxiety was better explained in
the younger than in the older group. The regression
analysis accounted for a higher percentage of the
explained variance (Table 2).
(N)
Age groups
A=4-6 yrs
**B=7-9 yrs
**C=10-11 yrs
Boys* (x=26.85)
Low=15-25
Moderate=26-36
High=37-75
Total
(554)
(227)
(226)
(1,007)
219 (39.5%)
95 (41.9%)
117 (51.8%)
431 (42.8%)
252 (45.5%)
102 (44.9%)
93 (41.2%)
447 (44.4%)
83 (15%)
30 (13.2%)
16 (7.1%)
129 (12.8%)
Girls* (x=28.30)
Low=15-25
Moderate=26-36
High=37-75
Total
(480)
(209)
(250)
(939)
163 (34%)
104 (49.8%)
132 (52.8%)
399 (42.5%)
237 (49.4%)
80 (38.3%)
95 (38%)
412 (43.9%)
80 (16.7%)
25 (12%)
23 (9.2%)
128 (13.6%)
*Statistically significant difference (t=-3.262, p=0.004) (Independent sample t test)
**Statistically significant difference with group A ( p< 0.001) (One-way Anova, Bonferroni post-hoc test)
TABLE 1 - Children’s dental anxiety dependant on age and gender in a normative population of Dutch children.
Age group 4-6 years
Age group 10-11 years
CFSSquestion
R Square
Beta
*P
CFSSquestion
R Square
Beta
*P
8
.588
2.896E-02
n.s.
8
.526
.227
.002
4
.701
-.111
.044
4
.655
-7.492E-02
n.s.
2
.718
-.283
.000
2
.681
-.205
.003
15
.726
-.266
.000
11
.692
-.210
.002
11
.729
-.262
.000
7
.697
-.141
.050
14
.730
-.234
.000
12
.702
-.178
.015
p≤0.05; Stepwise regression with Question 1 (fear for the dentist) as dependent variable. The numbers refer to the questions of the CFSS
TABLE 2 - Age related dental anxiety in a sequence of anxiety score items based on CFSS-DS scores in a normative Dutch child
population.
32
EUROPEAN JOURNAL OF PAEDIATRIC
DENTISTRY • 1/2005
DENTAL ANXIETY IN DUTCH CHILDREN
FIG. 1 - Children’s dental anxiety decreasing with age
(N=2,865).
Discussion
The results give evidence for a gradual decrease of
the level of dental phobia, as well as a decrease in the
number of dentally anxious children in different age
groups (Fig. 1).
The results are also in concordance with some
findings reporting on a general decrease of childhood
fears with increasing age [Ollendick and King, 1991;
Klingberg et al., 1994; Muris et al., 1996].
The high level of dentally anxious children in the
younger age group can be viewed from a
developmental perspective. Preschool children often
exhibit anxious behaviour due to attachment and
separation anxiety during the first visit, the latter
decreasing after a few dental visits as the child
becomes familiar with dental situations. The most
simple, direct fears disappear and are exchanged by
more complex events such as drilling, due to increased
ego strength and a child’s self esteem as he/she grows
older. It results in decreasing dental anxiety as well,
due to their decreasing constitutional vulnerability to
anxiety provoking stimuli. The higher level of the
explained variance in younger children might be
indicative in explaining a stronger role of a direct
conditioning pathway due to the limited cognitive
abilities. A stronger cognitively orientated mind might
be a mediator, but also plays an important role in the
further development of dental anxiety, without the
direct conditioning pathway being involved. Further
research on this item is definately needed.
The results of this study do not give support for the
overall decrease. Considering the number of dentally
phobic children still present in the older group and a
tendency towards raising the level of dental anxiety at
the age of 11 years, the results accounted for a change
in dental anxiety pattern entering adolescence (Fig. 1).
Some investigations have reported an increase in the
EUROPEAN JOURNAL OF PAEDIATRIC
DENTISTRY • 1/2005
prevalence of dental anxiety occurring among
preadolescents (9-12 years) and adolescents (15-18
years) [Murray et al., 1989; Thomson et al., 1997].
The difference in factors explaining dental anxiety
between the age groups might be due to a change in the
nature of dental anxiety as the child grows older. In the
youngest group dental anxiety seems to be merely a
matter of a straightforward cause-consequence relation
than the anticipation of a perceived pain of discomfort.
Apart from this, other factors might be involved in the
late onset of dental anxiety [Locker et al., 1999]. It is
important to further investigate and give evidence on the
psychopathological nature of true dental phobia in this
group of children, since they might represent the most
difficult dental patients regarding future dental
treatments.
Basically the nature of childhood dental fears seems
to depend on a child’s age [Ferrari, 1986]. In this study
it has been supported by the results of the stepwise
regression analysis.
Fears considering more general aspects of dental
treatment and those associated with medical situations
appear to be more anxiety provoking than other
procedures described by the CFSS-DS questionnaire
(Table 2). A higher percentage of the explained
variance in the younger group can be due to a higher
level of fears expressed by younger children. Dental
treatment experiences might be partly the source of
more general fears reported by some children as well
[Ollendick and King, 1991].
In contrast with other studies, these results indicate
that drilling is an aversive dental procedure significant
only for older children [Bernstein et al., 1979; Milgrom
et al., 1995] Some findings indicate that a conditioning
predisposition is stronger in younger and adolescent
children, while others agree that psychological factors
have a stronger impact on a later onset of dental anxiety
[Milgrom et al., 1995; Locker et al., 1999].
The age problem is intriguing. In adults it has been
found that females are generally more fearful than
males [Peretz and Zadik, 1994].
Moreover, some studies based on general findings,
widely represented in different cultures, have proved
that women are more prone to neurotic behaviour
involving anxiety, fear and worry. These findings may
be viewed in light of previous reports and explained
from a developmental aspect. With respect to dental
anxiety, it has been proved that at the age of 2-3 years,
girls exhibit more exploratory behaviour and appear
more secure than boys [Rousset et al., 1997]. It may be
indicated that this characteristic among females
appears sometime later after early childhood
[Klingberg et al., 1995].
33
M. MAJSTOROVIC, J.S.J. VEERKAMP
Conclusion
The results of the present study demonstrate that
dental anxiety in children between 4 and 11 years
decreases with increasing age and reports a difference
in dental anxiety with respect to gender. At different
age groups dental anxiety seems to be related to
different aspects of dental treatment, indicating the
causes shift from simple initial stimuli to more
complex events. From a developmental perspective
the decrease in children’s dental anxiety can be
explained by the increased cognitive abilities.
Nevertheless, the decrease is not linear over time and
possibly depends on other aspects like different
personality traits and conditioning processes, which
need to be investigated further.
References
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 Dec;3(4):193-8.
Arntz A, van Eck M, Heijmans M. Predictions of dental pain: the fear
of any expected evil, is worse than the evil itself. Behav Res Ther
1990;28(1):29-41.
Bedi R, Sutcliffe P, Donnan PT, McConnachie J. The prevalence of
dental anxiety in a group of 13- and 14-year-old Scottish children.
Int J Paediatr Dent 1992 Apr;2(1):17-24.
Berge ten M, Veerkamp JS, Hoogstraten J, Prins PJ. Childhood dental
fear in the Netherlands: prevalence and normative data.
Community Dent Oral Epidemiol 2002 Apr;30(2):101-7.
Bernstein DA, Kleinknecht RA, Alexander LD. Antecedents of dental
fear. J Public Health Dent 1979 Spring;39(2):113-24.
Cuthbert MI, Melamed BG. A screening device: children at risk for
dental fears and management problems. ASDC J Dent Child 1982
Nov-Dec;49(6):432-6.
Davey GC. Dental phobias and anxieties: evidence for conditioning
processes in the acquisition and modulation of a learned fear.
Behav Res Ther 1989;27(1):51-8.
Ferrari M. Fears and phobias in childhood: some clinical and
developmental considerations. Child Psychiatry Hum Dev 1986
Winter;17(2):75-87.
Gullone E, King NJ. Three year follow-up of normal fear in children
and adolescents aged 7-18 years. Br J Develop Psychol
1997;15:97-111.
34
Gullone E. The development of normal fear: a century of research.
Clin Psychol Rev 2000 Jun;20(4):429-51.
Hagglin C, Berggren U, Hakeberg M, Ahlqwist M. Dental anxiety
among middle-aged and elderly women in Sweden. A study of oral
state, utilisation of dental services and concomitant factors.
Gerodontology 1996 Jul;13(1):25-34.
King NJ, Ollier K, Iacuone R et al. Fears of children and adolescents:
a cross-sectional Australian study using the Revised-Fear Survey
Schedule for Children. J Child Psychol Psychiatry 1989
Sep;30(5):775-84.
Klingberg G, Berggren U, Noren JG. Dental fear in an urban Swedish
child population: prevalence and concomitant factors. Community
Dent Health 1994 Dec;11(4):208-14.
Klingberg G, Berggren U, Carlsson SG, Noren JG. Child dental fear:
cause-related factors and clinical effects. Eur J Oral Sci 1995
Dec;103(6):405-12.
Liddell A, Locker D. Gender and age differences in attitudes to dental
pain and dental control. Community Dent Oral Epidemiol 1997
Aug;25(4):314-8.
Locker D, Liddell A, Dempster L, Shapiro D. Age of onset of dental
anxiety. J Dent Res 1999 Mar;78(3):790-6.
Milgrom P, Mancl L, King B, Weinstein P. Origins of childhood
dental fear. Behav Res Ther 1995 Mar;33(3):313-9.
Muris P, Steerneman P, Merckelbach H, Meesters C. The role of
parental fearfulness and modeling in children’s fear. Behav Res
Ther 1996 Mar;34(3):265-8.
Murray P, Liddell A, Donohue J. A longitudinal study of the contribution
of dental experience to dental anxiety in children between 9 and 12
years of age. J Behav Med 1989 Jun;12(3):309-20.
Ollendick TH, King NJ. Origins of childhood fears: an evaluation of
Rachman's theory of fear acquisition. Behav Res Ther
1991;29(2):117-23.
Peretz B, Zadik D. Dental anxiety of parents in an Israeli kibbutz
population. Int J Paediatr Dent 1994 Jun;4(2):87-92.
Rousset C, Lambin M, Manas F. The ethological method as a means for
evaluating stress in children two to three years of age during a dental
examination. ASDC J Dent Child 1997 Mar-Apr;64(2):99-106.
Thomson WM, Poulton RG, Kruger E et al. Changes in self-reported
dental anxiety in New Zealand adolescents from ages 15 to 18
years. J Dent Res 1997 Jun;76(6):1287-91.
Veerkamp JS, Gruythuysen RJ, van Amerongen WE, Hoogstraten J.
Dental treatment of fearful children using nitrous oxide. Part 2:
The parent’s point of view. ASDC J Dent Child 1992 MarApr;59(2):115-9.
EUROPEAN JOURNAL OF PAEDIATRIC
DENTISTRY • 1/2005