Self-assessed oral health, cognitive vulnerability and dental anxiety in children: testing a mediational model

The Relationship between Dental Fear and Anxiety, General Anxiety/Fear, Sensory Over-Responsivity, and Oral Health Behaviors and Outcomes: A Conceptual Model

Dental fear and anxiety (DFA) is common across the lifespan and represents a barrier to proper oral health behaviors and outcomes. The aim of this study is to present a conceptual model of the relationships between DFA, general anxiety/fear, sensory over-responsivity (SOR), and/or oral health behaviors and outcomes. Two rounds of literature searches were performed using the PubMed database. Included articles examined DFA, general anxiety/fear, SOR, catastrophizing, and/or oral health behaviors and outcomes in typically developing populations across the lifespan. The relationships between the constructs were recorded and organized into a conceptual model. A total of 188 articles were included. The results provided supporting evidence for relationships between DFA and all other constructs included in the model (general anxiety/fear, SOR, poor oral health, irregular dental attendance, dental behavior management problems [DBMP], and need for treatment with pharmacological methods). Additionally, SOR was associated with general anxiety/fear and DBMP; general anxiety/fear was linked to poor oral health, irregular attendance, and DBMP. This model provides a comprehensive view of the relationships between person factors (e.g., general anxiety/fear, SOR, and DFA) and oral health behaviors and outcomes. This is valuable in order to highlight connections between constructs that may be targeted in the development of new interventions to improve oral health behaviors and outcomes as well as the experience of DFA.

Modelling health belief predictors of oral health and dental anxiety among adolescents based on the Health Belief Model: a cross-sectional study

Background

A vicious cycle exists between dental anxiety, oral health behaviors and oral health status. Based on previous research, psychological factors of the Health Belief Model (HBM) are associated with oral health behaviors and oral health, and are likely involved in this cycle. However, little is known about the relationship between HBM factors and dental anxiety of adolescents. The purpose of this cross-sectional study was to investigate the relationship between health belief factors, oral health and dental anxiety based on the constructs of the HBM.

Methods

1207 Grade 2 students from 12 secondary schools in Hong Kong were randomly selected and measured for the decayed, missing and filled permanent teeth (DMFT) index. Data for oral health behaviors, HBM constructs and dental anxiety were collected using questionnaires. The hierarchical entry of explanatory variables into logistic regression models estimating prevalence odds ratios (POR) were analyzed and 95% confidence intervals (95% CI) for DMFT and dental anxiety were generated. Path analysis was used to evaluate the appropriateness of the HBM as predictors for oral health behaviors, DMFT and dental anxiety.

Results

Based on the full model analysis, individuals with higher perceived susceptibility of oral diseases (POR: 1.33, 95% CI: 1.14–1.56) or girls or whose mother received higher education level were likelier to have a DMFT≥1, while those with higher perceived severity (POR: 1.31, 95%CI: 1.09–1.57), flossing weekly, DMFT≥1 or higher general anxiety level statistically increases the possibility of dental anxiety. The results from path analysis indicated that stronger perceived susceptibility, greater severity of oral diseases, less performing of oral health behaviors and a higher score of DMFT were directly related to increased dental anxiety level. Other HBM variables, such as perceived susceptibility, self-efficacy beliefs, cues to action and perceived barriers, might influence dental anxiety through oral health behaviors and caries status.

Conclusions

Clarifying the propositional structures of the HBM may help the future design of theory-based interventions in reducing dental anxiety and preventing dental caries.

Supplementary Information

Supplementary information accompanies this paper at 10.1186/s12889-020-09784-1.

Prevalence of Dental Fear and Anxiety among Russian Children of Different Ages: The Cross-Sectional Study

OBJECTIVE

 Children's dental fear may lead to an avoidance of seeking dental care or disruptive behavior during treatment. The study was aimed to evaluate the prevalence and scores of dental fear and anxiety (DFA) among Russian children of different ages with an experience of dental treatment.

MATERIALS AND METHODS

 The cross-sectional study included 371 children aged 2 to 17 years. Study participants were divided into three groups according to their age: 112 "preschool children" aged 2 to 5 years, 137 "school children" aged 6 to 11 years, and 122 "adolescents" aged 12 to 18 years. The questionnaires were distributed at reception areas of the dental clinic to parents of children aged 2 to 5 years and to the older children themselves.

STATISTICAL ANALYSIS

Data analysis was performed using SPSS version 15.0. The parametric tests were used (one-way ANOVA, Student's t-test, and Pearson's correlation) because of the expected sample of more than 100 observations. The chi-square test was used for categorical variables.

RESULTS

The data have shown that 93.8% of the Russian child population visiting dental offices suffer mostly from moderate (11.85) levels of DFA. DFA was more often revealed in girls and among the youngest children aged 2 to 5 years.

CONCLUSIONS

 According to the obtained results, children were more afraid of "tooth drilling" and an "injection of local anesthetic" than other factors mentioned in the questionnaires. Fear of dental treatment is common among Russian children, and the factors associated with it differ with the gender and age of the child.

What sensitivities matter in dental anxiety? Investigating sensitivity to anxiety, pain, and disgust

Dental anxiety affects many people worldwide and interferes with oral health. Beyond emotional distress, avoidance of dental care visits can lead to serious dental and health consequences. Although emerging research implicates anxiety, pain, and disgust sensitivities in the etiology and maintenance of dental anxiety, no studies to date have concurrently investigated the unique contribution of these vulnerabilities in dental anxiety. As a step toward elucidating salient mechanisms of dental anxiety, the present study investigated the aggregate contribution of anxiety, pain, and disgust sensitivities in dental anxiety, after controlling for relevant covariates. In this study, participants (N = 717; 71.3% female) included an unselected sample of undergraduate students who completed a battery of online questionnaires. Consistent with community rates, 12% of this sample reported high levels of dental anxiety. The hierarchical regression model revealed anxiety and disgust sensitivities were positively associated with dental anxiety symptoms when adjusting for other model variables. Results highlight the roles of anxiety and disgust sensitivities in dental anxiety and indicate the potential benefit of targeting these emotional sensitivities through routine screenings and treatments for dentally anxious patients.

Psychological Intrusion - An Overlooked Aspect of Dental Fear

Dental fear/anxiety is a widely recognised problem affecting a large proportion of the population. It can result in avoidance and/or difficulty accepting dental care. We believe that psychological intrusion may play a role in the aetiology and maintenance of dental fear for at least some individuals. In this narrative review we will take a developmental perspective in order to understand its impact across the lifespan. We will consider the nature of 'self,' parenting styles, the details of intrusive parenting or parental psychological control, and briefly touch upon child temperament and parental anxiety. Finally, we draw together the supporting (largely unrecognised) evidence available in the dental literature. We illustrate the paper with clinical examples and discuss possibly effective ways of addressing the problem. We conclude that psychological intrusion appears to play an important role in dental fear, for at least some individuals, and we call for detailed research into the extent and exact nature of the problem. A simple means of identifying individuals who are vulnerable to psychological intrusion would be useful for dentists.

The role of cognitions in short-term temporal changes in dental fear among Australian adults

OBJECTIVES

To determine if temporal changes in dental fear over a 4-month period are predicted by changed cognitive vulnerability-related perceptions of going to the dentist.

METHODS

Australian adults (n = 484) completed mailed questionnaires at baseline and follow-up, containing measures of dental fear, cognitive vulnerability-related perceptions, dental services received, and possible aversive experiences during the study period. Change in dental fear was the main outcome measure, categorized as decreased (Fear^- ), unchanged (Fear⁰ ), and increased (Fear⁺ ).

RESULTS

Across the study period, 15.5 percent of people had Fear^- , 73.4 percent had Fear⁰ , and 11.1 percent had Fear⁺ . In a multinomial logistic regression, after controlling for participant gender, income, time since last dental visit at baseline, dental fear at baseline and experiencing an aversive event, increased vulnerability-related perceptions were significantly associated with Fear⁺ (OR = 2.83, P < 0.001) while decreased vulnerability-related perceptions were associated with Fear^- (OR = 0.17, P < 0.001).

CONCLUSIONS

This study found, across a relatively short 4-month period, that increased vulnerability-related perceptions of visiting the dentist predicted increased dental fear while decreased vulnerability-related perceptions predicted decreased dental fear. More appropriate study designs, such as longitudinal designs, and longer follow-up periods are needed to determine the possible causal nature of these associations.

Dental anxiety: An understudied problem in youth

Dental anxiety and dental phobia typically emerge during childhood; the associated avoidance of dental care can result in oral health problems and is associated with lower quality of life. In this review, we discuss the definition of dental phobia and dental anxiety and issues related to their differentiation. We then review the literature on dental anxiety and dental phobia, including its prevalence, assessment, and sequalae. Moreover, we provide a synthesis of findings on the etiology and maintenance of dental phobia and propose a comprehensive cognitive behavioral model to guide further study. We also present a systematic qualitative and a quantitative review of the treatment literature, concluding that although we have made strides in learning how to prevent dental anxiety in youth, the methods effective in preventing anxiety may not be equally effective in treating youth with dental phobia. We propose a multidisciplinary approach, including those with expertise in pediatric anxiety as well as pediatric dentistry, is likely required to move forward.

Evaluation of children's dental anxiety levels at a kindergarten and at a dental clinic

This study evaluated the dental anxiety levels of preschool children at a kindergarten and at a dental clinic. The anxiety levels of ninety 4-6-year-old (4.99 ± 0.81) preschool children were evaluated according to pulse rates, the facial image scale (FIS), the Venham picture test (VPT), and the Frankl behavior rating scale. The children's mothers were asked to complete the state-trait anxiety inventory (STAI) forms 1 and 2 (STAI 2 and STAI 2). The sample t-test, Mann-Whitney U test, and Pearson's correlation test were used. A statistically significant difference was observed between the children's pulse rates when measured at the dental clinic and those when measured at the kindergarten (p < 0.001). Although the results were not statistically significant, more negative facial expressions were observed in the children at the dental clinic than in those at the kindergarten when assessed using FIS and VPT (p = 0.090 and p = 0.108, respectively). There was a statistically significant correlation between the transient anxiety levels (STAI 1) of mothers and the VPT scores of their children evaluated at the dental clinic (r = 0.506, p < 0.001). The continuous anxiety level of the mothers of males was found to be significantly higher (p = 0.033) than that of the mothers of females (STAI 2). Although the children had been informed about dentistry and were introduced to a dentist at the kindergarten, their anxiety levels seemingly increased as they arrived at the dental clinic. The significant increase observed in the children's pulse rates was a physical indicator that their anxiety levels had increased. It can be concluded that the children felt more anxious at the dental clinic that at the kindergarten.

Cross-Cultural Adaptation of Kannada Version of Modified Dental Anxiety Scale Among an Adult Indian Population

BACKGROUND

Dental anxiety is one of the most common barriers in seeking dental care. In order to overcome this barrier dentist need to screen patients to successfully help in treatment. A scale is thus needed to measure dental anxiety which is socially & culturally acceptable.

AIM

This study aimed to assess the Cross cultural adaptation and validity of the Kannada translation of the Modified Dental Anxiety Scale (MDAS-K).

MATERIALS AND METHODS

A test-retest was conducted on 30 patients visiting a dental institution to assess the reliability of MDAS- K. A cross-sectional survey of 301 patients was conducted in different departments at a dental institution to test the psychometric properties of MDAS-K. The assessment tool consisted of a proforma containing socio-demographic, non socio- demographic variables, MDAS-K and Visual analogue scale (VAS).

STATISTICAL ANALYSIS

Reliability was assessed using Cronbach's alpha, inter-item Spearman's correlation. Independent t-test, ANOVA and post hoc Bonferroni were used to analyse dental anxiety in the psychometric constructs.

RESULTS

The internal consistency of MDAS-K was good with Cronbach's alpha of 0.83. The test-retest reliability for MDAS K had a good correlation of 0.901. The psychometric variables established the construct validity of MDAS-K.MDAS-K also showed good convergent validity with VAS score. The anxiety levels differed in patients visiting different dental departments.

CONCLUSION

The high reliability and validity of the MDAS-K supports its cross cultural adaptation and indicates that it can be a valuable tool for dental practioners in quantifying anxiety among patients and provide quality dental care.

Dental fear and expected effectiveness of destructive coping as predictors of children's uncooperative intentions in dental settings

AIM

To explore the mechanisms by which some children select disruptive behaviours to cope with stressful dental events. In particular, the relationships between dental fear, expected effectiveness of destructive coping, and intentions of displaying uncooperative behaviours were analysed.

DESIGN

Participants were 170 children who filled out a questionnaire survey. Descriptive statistics by gender and group age as well as comparisons of means were calculated. Spearman's rho correlation coefficients and binary logistic regression analysis were used to test hypotheses of the relationships among variables.

RESULTS

Both dental fear and the expected effectiveness of destructive coping strategies were significantly associated with children's uncooperative intentions at the dentist. In addition, children who strongly endorsed the effectiveness of destructive coping strategies had a higher probability of uncooperative intentions as dental fear increased. In contrast, this relationship was not statistically significant among children who did not expect negative behaviours to be effective.

CONCLUSIONS

Children's expectations about the effectiveness of destructive coping behaviours can help explain variations in the use of these strategies in stressful dental situations. Dental fear as well as children's inadequate expectancies about coping alternatives should be explored and targeted to prevent and modify uncooperative behaviour intentions at the dentist.

From public mental health to community oral health: the impact of dental anxiety and fear on dental status

Dental fear is a widely experienced problem. Through a “vicious cycle dynamic,” fear of dental treatment, lower use of dental services, and oral health diseases reinforce each other. Research on the antecedents of dental anxiety could help to break this cycle, providing useful knowledge to design effective community programs aimed at preventing dental fear and its oral health-related consequences. In this regard, frameworks that analyze the interplay between cognitive and psychosocial determinants of fear, such as the Cognitive Vulnerability Model, are promising. The onset of dental fear often occurs in childhood, so focusing on the child population could greatly contribute to understanding dental fear mechanisms and prevent this problem extending into adulthood. Not only can public mental health contribute to population health, but also community dentistry programs can help to prevent dental fear. Regular dental visits seem to act in a prophylactic way, with dental professionals playing an important role in the regulation of the patients’ anxiety-related responses. Both public mental health and community dentistry could therefore benefit from a multidisciplinary approach to dental fear and oral health.

Applying the Cognitive Vulnerability Model to the analysis of cognitive and family influences on children's dental fear

Negative experiences, cognitions, and family variables are involved in the etiology of child dental fear, but previous research has frequently considered them separately. This study uses the Cognitive Vulnerability Model to explore the influence of negative dental experiences and family members on children's dental anxiety. The participants were 185 children who completed a questionnaire comprising measures of dental fear and cognitive vulnerability-related perceptions. Measures were obtained for 88 of the participants' fathers and for 97 of the participants' mothers. Cognitive vulnerability perceptions had the strongest association with children's dental fear (β = 0.40), explaining 14-21% of the variance in dental fear scores beyond that explained by other variables. Furthermore, vulnerability perceptions mediated the relationship between negative dental experiences and dental fear. Children's dental fear and cognitive vulnerability perceptions were significantly associated with those of their fathers (r = 0.23 and r = 0.40, respectively) and mothers (r = 0.28 and r = 0.35, respectively). Moreover, fathers' (β = 0.24) and mothers' (β = 0.31) levels of cognitive vulnerability significantly predicted the children's levels of dental fear. The Cognitive Vulnerability Model offers a framework to understand child dental fear. Furthermore, this cognitive approach may help explain why some children develop dental fear problems after suffering a negative dental experience and how dental anxiety is passed on from parents to children.

The moderating role of dental expectancies on the relationship between cognitive vulnerability and dental fear in children and adolescents

OBJECTIVE

Recently, cognitive approaches have been successfully applied to the understanding of child dental anxiety. Our study aimed to analyze the interplay between cognitive variables and their associations with dental fear. In particular, we proposed that the observed relationship between dental treatment-related cognitive vulnerability (i.e., uncontrollability, unpredictability, dangerousness, and disgustingness appraisals) and dental fear is moderated by the expectancies of the probability and aversiveness of negative events during dental treatments.

METHODS

A questionnaire survey was conducted with data obtained from 179 participants (8-18 years, 55.9% female) who attended 12 randomly selected educational establishments in Madrid (Spain).

RESULTS

Dental fear was associated with an irregular pattern of dental visits. As expected, cognitive vulnerability was strongly linked to dental anxiety. For those children who expected a lower likelihood of negative dental events or appraised them in a less aversive way, the relationship between cognitive vulnerability and fear was attenuated.

CONCLUSIONS

As dental fear and oral health are connected, the prevention and reduction of dental fear among children and adolescents might be a worthwhile target for public health interventions. Our study sheds some light on how this could be achieved, that is, by modifying the children's vulnerability appraisals as well as their fearful dental expectancies.