Preliminary validation and reliability of the Modified Child Dental Anxiety Scale

The Abeer Children Dental Anxiety Scale (ACDAS) cross-cultural adaptation and validity of self-report measures in the Malaysian Children Context (MY-ACDAS)

BACKGROUND

The Abeer Children Dental Anxiety Scale (ACDAS) source language was developed and validated in an English-speaking country in the UK to measure dental anxiety among children. The ACDAS also included the child's cognitive assessment, as well as feedback from the parent or the legal guardian and a dental health professional (DHP). This is the first study to validate the application of the ACDAS in Malay or Bahasa Melayu for children aged 6-16 years.

AIM

To assess the Malay-translated version of the ACDAS, postadaptation into the local context and validation by the content and construct experts.

DESIGN

The English ACDAS was translated into Malay first through forward translation and then through backward translation. The prefinal translated version of the instrument was designed, with the participation of 61 children and 61 parents or legal guardians. Subsequently, a final cross-cultural adaptation of the instrument was then made for another group of participants and evaluated for validity and test-retest reliability among 144 children and 144 parents or legal guardians participating in the self-report feedback process at the Paediatric Dental Clinic, Faculty of Dentistry, Universiti Malaya, Kuala Lumpur, Malaysia. The cross-cultural adaptation of the instrument considered translating to Malaysian national language and adapting to its culture.

RESULTS

The Malay-translated ACDAS consisted of 19 items. The translated version of Malaysian-ACDAS (MY-ACDAS) achieved an acceptable agreement between six expert committee members with an internal consistency (Cronbach's alpha value, αconsistency) of 0.839. The test-retest reliability results of all participants support semantic and conceptual equivalence as an accepted construct validity between the children, parents and DHPs across the multicultural Malaysian population.

CONCLUSION

The MY-ACDAS is a valid and reliable scale for measuring dental anxiety among Malaysian children.

Development and validation of the Iranian version of the Children's Experiences of Dental Anxiety Measure (CEDAM)

OBJECTIVE

The aim of this study was to develop the Iranian version of the Children's Experiences of Dental Anxiety Measure (CEDAM) and evaluate its validity and reliability in assessing dental anxiety in children aged 9-16.

METHODS

The CEDAM was translated into Persian following the guidelines of the IQOLA project. A ‎sample of children completed the measure in a clinical setting, with a subgroup completing it ‎again to assess test-retest reliability. Concurrent criterion validity was evaluated by having all ‎participants complete the Modified Child Dental Anxiety Scale (MCDAS) alongside the ‎CEDAM. Construct validity was examined using exploratory and confirmatory factor ‎analyses.‎ RESULTS: The study included 275 children between the ages of 9 and 16. The Iranian version of CEDAM ‎exhibited excellent internal consistency with a Cronbach's ⍺ coefficient of 0.83. Test-retest ‎reliability was also high, with an intraclass correlation coefficient value of 0.96. Furthermore, there was a significant and ‎positive correlation between CEDAM and MCDAS scores (ρ = 0.72, p < .01). Exploratory ‎factor analysis identified two factors, and confirmatory factor analysis confirmed that the ‎instrument aligned well with the factor structure obtained from the exploratory analysis.‎ CONCLUSION: This study provides evidence supporting the validity and reliability of the Iranian version of ‎CEDAM as a valuable tool for evaluating dental anxiety in Persian-speaking children between ‎the ages of 9 and 16.‎.

Turkish version of the faces version of the Modified Child Dental Anxiety Scale (MCDASf): translation, reliability, and validity

OBJECTIVES

To cross-culturally adapt of MCDAS_f into Turkish and to evaluate reliability and validity of the Turkish version of MCDAS_f using explorative factor analysis (EFA), confirmatory factor analysis (CFA), and receiver operating characteristic (ROC) analysis to form a less time consuming and easy to understand tool for measuring dental anxiety.

MATERIALS AND METHODS

A total of 300 children (174 females, 126 males) aged 6-12 years who were recruited at the Department of Paediatric Dentistry in RTEU at the first visit participated in the present study. For the internal consistency reliability, Cronbach's alpha was calculated. Intraclass correlation coefficients (ICCs) were calculated for test-retest reliability (n=67). Construct validity was determined by comparing with the Venham Picture Test (VPT). The factor structure was examined using EFA. CFA was used for dimensionality. The cut-off points of the Turkish version of MCDAS_f were plotted using a ROC curve.

RESULTS

The Turkish version of MCDAS_f showed high internal consistency (0.703) and an excellent ICC value (0.827). Good correlations were found between the global scores of MCDAS_f and VPT (r=0.632). Three factors were identified from EFA and verified with CFA. Discriminant validity was supported by high scores of females and younger children (p<0.05). The cut-off point was assigned as >24.50. The area under the ROC curve (AUC) was 0.921 (95% CI: 0.873-0.969).

CONCLUSIONS

The Turkish version of the MCDAS_f is a reliable and valid scale that satisfied psychometric properties.

CLINICAL RELEVANCE

The Turkish version of MCDAS_f is a usable tool for the measurement of dental anxiety among Turkish speaking children.

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.

Impact of maternal and child dental anxiety on oral health-related quality of life of 5-6-year-old preschool children

BACKGROUND

There is a lack of evidence with regards to the association between both maternal and child dental anxiety and the mother's perception of her child's oral health-related quality of life (COHRQoL). The aim of this study was to investigate the association of maternal and child dental anxiety with COHRQoL and the effect of demographic factors as moderators in this relationship. In addition, the association between child's dental caries experience and the COHRQoL was also assessed.

METHODS

A cross-sectional study was conducted involving 1150, 5-6 year-old preschool children in Selangor, Malaysia. Mothers answered a questionnaire on socio-economic status, the Malay-Modified Dental Anxiety Scale to assess maternal dental anxiety, and the Malay-Early Childhood Oral Health Impact Scale to assess COHRQoL. Child's dental anxiety was assessed using the Malay-Modified Child Dental Anxiety Scale via a face-to-face interview prior to oral examination to assess dental caries. Data were analysed using structural equation modelling to assess the relationship between maternal and child dental anxiety and COHRQoL.

RESULTS

Overall, complete data on 842 mother-child dyads were analysed. The mean scores of total ECOHIS, the child impacts section (CIS), and the family impacts section (FIS) were 17.7 (SD = 4.9), 12.6 (SD = 3.7), and 5.1 (SD = 1.9), respectively. The mean dental anxiety scores for mothers and children were 11.8 (SD = 4.5) and 16.9 (SD = 4.3), respectively. Maternal dental anxiety was associated with the CIS (b = 0.08, p < 0.001), the FIS (b = 0.01, p = 0.001), and the total ECOHIS (b = 0.14, p < 0.001). Maternal education level, income, urban/rural location, and kindergarten type were moderators to the relationship. In addition, there was also a significant relationship between child's dental caries experience and COHRQoL (p < 0.001).

CONCLUSIONS

Maternal dental anxiety and child's dental caries experience have significantly impacted the COHRQoL, the CIS, and the FIS domains. Demographic factors such as maternal education, income, urban/rural location, and kindergarten type acted as moderators that can strengthen or weaken the relationship between maternal dental anxiety and COHRQoL of 5-6-year-old preschool children.

A case series analysing patients with dental anxiety: a patient-centered model based on psychological profiling

Anxiety and distress can jeopardize dental care experience of patients and may affect the clinical result. Although a wide range of sedation and analgesia techniques are currently available to relieve distress and pain during dental procedures, operative models to choose the most effective sedation-analgesic strategies are still insufficient.

This case series proposes a patient-centered model to optimize patients’ cooperation during dental care delivery. We describe how to achieve correct anaesthesia by using the least sedative procedure, accounting for the dental procedure needed and patient’s psychological profile.

Five patients were considered as paradigmatic to show the balance between patients’ subjective experiences and the clinical procedures: a patient with low stress, good compliance (case 1); a patient with moderate stress and reduction in compliance (case 2); anxious patient (case 3); a patient with acute anxiety and emotional distress (case 4); anguished patient (case 5).

A multimodal treatment of emotional and behavioural condition and a patient-centered model approach contributed to achieve the best patient satisfaction in the five cases detailed here.

Correlation of dental anxiety with oral health status and treatment needs among 12-year old indian school going children

Background and aim:

Dental anxiety is primarily associated with learning negative behaviour which may be attributed to the aggressive condition process during childhood and adolescence and is considered to be the main reason for avoiding dental care. Hence the present study aimed to assess the correlation of Dental Anxiety with Oral Health Status and Treatment Needs.

Methods:

Cross sectional study was carried out among 12-year old school going children of Hyderabad City, India. Dental anxiety was assessed using the Modified Child Dental Anxiety Scale (MCDAS). Oral Health Status and Treatment Needs were assessed using Gingival Index and Dentition status and treatment needs based on Basic Oral Health Survey. Multi-group analysis was done using Analysis of Variance. p<0.05 was considered statistically significant.

Results:

In the present study, females had higher significant total mean MCDAS score as compared to males (22.8±5.4 vs.19.66±6.0) (p=0.00001*). Study participants with no history of previous dental visits (21.55±5.6) showed a statistically higher significant total MCDAS score compared to their counterpart (p=0.006*). On the other hand, Decayed component (r=0.1335*) and overall DMFT (r=0.1384*) had a significant positive correlation with MCDAS score.

Conclusion:

The study concluded that there is a correlation between dental anxiety and dentition status and treatment needs among 12 year old children. (www.actabiomedica.it)

Dental fear association between mothers and adolescents-a longitudinal study

Aim

To assess the longitudinal association between adolescents’ and their mothers’ dental fear.

Study Design

A longitudinal questionnaire survey study.

Methods

A randomized sample of 12-year-old adolescents were selected from local Hong Kong schools. Adolescents and their mothers self-completed the Modified Dental Anxiety Scale (MDAS). The sociodemographic background of the mothers and the oral health habits of the adolescents were also collected and these measurements were repeated at 15- and 18-years-old. Non-parametric tests (Mann–Whitney U test/Kruskall Wallis test) were used to test associations between MDAS dental fear items and independent variables. Logistic regression (adjusted for family’s sociodemographic background and adolescent’s oral health habits) was performed to evaluate the longitudinal association between adolescents’ and mothers’ dental fear.

Results

A total of 212 mother-child pairs were recruited at baseline (12-year-old adolescents). In the first and second follow-ups (15- and 18-years-old), 195 and 182 mother-child pairs completed the survey. Significant associations between mother’s and child’s scores in “feeling about having their teeth scraped and polished”, “having teeth drilled”, and ‘having an injection in the gum’ were found when adolescents were 12- years-old (P < 0.01) and 18-years-old (P < 0.05), but not at 15-years-old.

Conclusion

Adolescents’ and mothers’ dental fear is associated at 12-years-old and 18-years-old, but not at 15-years-old, which is likely specific to the Hong Kong context but may be extrapolated to other industrialized countries with caution.

The association of socio-economic status, dental anxiety, and behavioral and clinical variables with adolescents' oral health-related quality of life

PURPOSE

It is not clear which factors hold more weight in predicting oral health-related quality of life (OHRQoL). Therefore, this study explored which component of factors (e.g., socio-economic status, clinical status or oral health behaviors, dental anxiety, oral health knowledge) has a better predictive value in different aspects (e.g., oral symptoms, functional limitations, social and emotional conditions) of adolescents' OHRQoL.

METHODS

Participants were randomly selected from Grade Two (S2) students within 12 secondary schools in Hong Kong. The independent variables include the following : socio-economic (monthly family income, parents' educational background), oral health behaviors (the frequency of brushing and having snacks like chocolate or biscuits), and oral health-related factors (oral health knowledge, dental anxiety, dental caries and bleeding index). Adolescents' OHRQoL was evaluated using the 16-item Child Perception Questionnaire (CPQ_11-14-ISF:16). Frequencies and means were used for data description. Different variables were analyzed as predictors of OHRQoL by multi-level linear regression analysis.

RESULTS

1207 adolescents (46.6% females) participated in this study. The mean total CPQ_11-14-ISF:16 was 14.2 (9.8). Mean scores of oral symptoms, functional limitations, and emotional and social well-being were 4.4 (2.8), 4.2 (2.8), 3.2 (3.1), and 2.4 (2.7), respectively. In the final model, adolescents with poorer oral health knowledge, higher dental anxiety levels, brushed their teeth less than once a day and consumed chocolates or biscuits more regularly as reported by a statistically worse OHRQoL (p < 0.05). In addition, gingival bleeding was a predictor of the oral symptom domain (β = 0.7, p = 0.027); the emotional well-being of adolescents whose father went to college had a better OHRQoL (β =  - 0.9, p = 0.014) and adolescents from the higher-income family had a statistically better social well-being (p = 0.015).

CONCLUSION

Our study indicates that adolescents with poorer oral health knowledge, higher dental anxiety levels, brushing their teeth less than once a day, or having a daily consumption of chocolate or biscuits had statistically worse OHRQoL. These findings can provide guidance for future oral health promotion in improving OHRQoL among adolescents.

Reliability and Validity of Scales for Assessing Child Dental Fear and Anxiety

Introduction

Children with high dental anxiety display uncooperative behavior during dental procedures. Different self-assessment questionnaires are in use to estimate the prevalence of dental fear and anxiety (DFA) in children but they need to be tested for reliability and validity in different populations.

Objectives

The aim of this study was to test the reliability and validity of two scales for the assessment of child dental fear and anxiety in a sample of Croatian children.

Material and Methods

The sample comprised 202 pairs consisting of children and their mothers (97 boys and 105 girls) aged 5 - 12 years. Two scales were used to assess children's DFA: the Children's Fear Survey Schedule - Dental Subscale (CFSS-DS) and the Modified Child Dental Anxiety Scale - face version (MCDAS-f). The Corah's Dental Anxiety Scale (CDAS) was used in the sample of children's mothers. The average scores of cooperative children and children with behavior management problem (BMP) were compared.

Results

Cooperative children displayed significantly lower CFSS-DS scores than children with BMP (M = 28. 46 vs. M = 39. 36; P < 0.001). The average MCDAS-f score was significantly higher in children with BMP than in cooperative children (M = 28. 07 vs. 20. 01; P < 0.001). The CFSS-DS showed high internal consistency (Cronbach's α = 0. 90), while internal consistency of MCDAS-f was good (α = 0. 73). The maternal CDAS showed good internal consistency (α = 0, 89). The correlations with other self-report measurements of DFS show good validity of all scales. The correlations between CFSS-DS and MCDAS-f were highly significant (r = 0.482; P < 0. 01) as well as the correlations of CFSS-DS and MCDAS-f with CDAS scores (r = 0.223; P < 0. 01 and r = 0.198; P < 0. 01, respectively.

Conclusion

The obtained results suggest that both the CFSS-DS scale and the MCDAS-f scale are reliable and valid scales for measuring dental fear and anxiety in children in a sample of Croatian children. The MCDAS-f scale has shown slightly lower internal consistency but it is suitable for use in young children. In addition, the MCDAS-f scale is simple to administer.

Best-practice prevention alone or with conventional or biological caries management for 3- to 7-year-olds: the FiCTION three-arm RCT

BACKGROUND

Historically, lack of evidence for effective management of decay in primary teeth has caused uncertainty, but there is emerging evidence to support alternative strategies to conventional fillings, which are minimally invasive and prevention orientated.

OBJECTIVES

The objectives were (1) to assess the clinical effectiveness and cost-effectiveness of three strategies for managing caries in primary teeth and (2) to assess quality of life, dental anxiety, the acceptability and experiences of children, parents and dental professionals, and caries development and/or progression.

DESIGN

This was a multicentre, three-arm parallel-group, participant-randomised controlled trial. Allocation concealment was achieved by use of a centralised web-based randomisation facility hosted by Newcastle Clinical Trials Unit.

SETTING

This trial was set in primary dental care in Scotland, England and Wales.

PARTICIPANTS

Participants were NHS patients aged 3-7 years who were at a high risk of tooth decay and had at least one primary molar tooth with decay into dentine, but no pain/sepsis.

INTERVENTIONS

Three interventions were employed: (1) conventional with best-practice prevention (local anaesthetic, carious tissue removal, filling placement), (2) biological with best-practice prevention (sealing-in decay, selective carious tissue removal and fissure sealants) and (3) best-practice prevention alone (dietary and toothbrushing advice, topical fluoride and fissure sealing of permanent teeth).

MAIN OUTCOME MEASURES

The clinical effectiveness outcomes were the proportion of children with at least one episode (incidence) and the number of episodes, for each child, of dental pain or dental sepsis or both over the follow-up period. The cost-effectiveness outcomes were the cost per incidence of, and cost per episode of, dental pain and/or dental sepsis avoided over the follow-up period.

RESULTS

A total of 72 dental practices were recruited and 1144 participants were randomised (conventional arm, n = 386; biological arm, n = 381; prevention alone arm, n = 377). Of these, 1058 were included in an intention-to-treat analysis (conventional arm, n = 352; biological arm, n = 352; prevention alone arm, n = 354). The median follow-up time was 33.8 months (interquartile range 23.8-36.7 months). The proportion of children with at least one episode of pain or sepsis or both was 42% (conventional arm), 40% (biological arm) and 45% (prevention alone arm). There was no evidence of a difference in incidence or episodes of pain/sepsis between arms. When comparing the biological arm with the conventional arm, the risk difference was -0.02 (97.5% confidence interval -0.10 to 0.06), which indicates, on average, a 2% reduced risk of dental pain and/or dental sepsis in the biological arm compared with the conventional arm. Comparing the prevention alone arm with the conventional arm, the risk difference was 0.04 (97.5% confidence interval -0.04 to 0.12), which indicates, on average, a 4% increased risk of dental pain and/or dental sepsis in the prevention alone arm compared with the conventional arm. Compared with the conventional arm, there was no evidence of a difference in episodes of pain/sepsis among children in the biological arm (incident rate ratio 0.95, 97.5% confidence interval 0.75 to 1.21, which indicates that there were slightly fewer episodes, on average, in the biological arm than the conventional arm) or in the prevention alone arm (incident rate ratio 1.18, 97.5% confidence interval 0.94 to 1.48, which indicates that there were slightly more episodes in the prevention alone arm than the conventional arm). Over the willingness-to-pay values considered, the probability of the biological treatment approach being considered cost-effective was approximately no higher than 60% to avoid an incidence of dental pain and/or dental sepsis and no higher than 70% to avoid an episode of pain/sepsis.

CONCLUSIONS

There was no evidence of an overall difference between the three treatment approaches for experience of, or number of episodes of, dental pain or dental sepsis or both over the follow-up period.

FUTURE WORK

Recommendations for future work include exploring barriers to the use of conventional techniques for carious lesion detection and diagnosis (e.g. radiographs) and developing and evaluating suitable techniques and strategies for use in young children in primary care.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN77044005.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 1. See the NIHR Journals Library website for further project information.

Use of an animated emoji scale as a novel tool for anxiety assessment in children

Background

Dental anxiety in children is a major barrier in patient management. If dental anxiety in pediatric patients is assessed during the first visit, it will not only aid in management but also help to identify patients who are in need of special care to deal with their fear. Nowadays, children and adults are highly interested in multimedia and are closely associated with them. Children usually prefer motion pictures on electronic devices than still cartoons on paper. Therefore, this study was conducted to evaluate a newly designed scale, the animated emoji scale (AES), which uses motion emoticons/animojis to assess dental anxiety in children during their first dental visit, and compare it with the Venham picture test (VPT) and facial image scale (FIS).

Methods

The study included 102 healthy children aged 4–14 years, whose dental anxiety was measured using AES, VPT, and FIS during their first dental visit, and their scale preference was recorded.

Results

The mean anxiety scores measured using AES, FIS, and VPT, represented as mean ± SD, were 1.78 ± 1.19, 1.93 ± 1.23, and 1.51 ± 1.84, respectively. There was significant difference in the mean anxiety scores between the three scales (Friedman test, P < 0.001). The Pearson's correlation test showed a very strong correlation (0.73) between AES and VPT, and a strong correlation between AES and FIS (0.88), and FIS and VPT (0.69), indicating good validity of AES. Maximum number of children (74.5%) preferred AES.

Conclusion

The findings of this study suggest that the AES is a novel and child-friendly tool for assessing dental anxiety in children.

On-line preparatory information for children and their families undergoing dental extractions under general anesthesia: A phase III randomized controlled trial

BACKGROUND

Family-centered interactive on-line games are increasingly popular in healthcare, but their effectiveness for preoperative preparation needs further research. www.scottga.org is the new on-line version of a proven nonweb-based game for children and parents/caregivers.

AIMS

The aim of this study was to evaluate if www.scottga.org improved children's anxiety and families' satisfaction compared with controls.

METHODS

In this phase III double-blind randomized controlled trial, children/parents/caregivers received (i) www.scottga.org, (ii) standard care, or (iii) a placebo hand-washing game. The intervention and placebo games were available online for home usage and provided again on the ward before surgery. All children were accompanied by parent/caregivers at induction and observed and scored using validated measures. Stratified randomization and generalized linear models were used. An intention-to-treat approach was adopted.

RESULTS

Overall, 52/176 children had baseline "psychological disturbance." Children's anxiety increased preinduction, but there were no differences between groups (Facial Image Scale: video-standard OR = 1.08, P = .82, 95% CI [0.56, 2.1]; video-placebo OR = 0.9, P = .77 95% CI [0.46, 1.8]). There were no differences in induction behavior (visual analog scale: video mean = 3.5; standard care mean = 3.5; placebo mean = 3.7: video-standard OR = 2.0, P = .42, 95% CI [-0.6, 1.3]; video-placebo OR = 1.53, P = .65, 95% CI [-0.8, 1.1]) or induction anxiety (modified Yale Preoperative Anxiety Scale: video-standard OR 1.02, P = .97, 95% CI [0.61, 2.6]; video-placebo OR 1.38, P = .49, 95% CI [0.87, 3.81]). Families favored the intervention regarding the "child handling the visit better" (Treatment Evaluation Inventory: video-standard OR = 12; 95% CI 4.7-32; P < .001; video-placebo OR = 8.2; 95% CI 3-22; P < .001) and "improving the child's ability to cope" (Treatment Evaluation Inventory: video-standard OR = 21; 95% CI 8-56; P < .001 and video-placebo OR = 13; 95% CI 5-34; P < .001).

CONCLUSION

Families believed that a video-game preparation helped their child's perioperative anxiety, but there were no objective measures of behavioral improvement associated with this intervention.

Evidence of pharmacological and non-pharmacological interventions for the management of dental fear in paediatric dentistry: a systematic review protocol

INTRODUCTION

Several techniques have been proposed to manage dental fear/dental anxiety (DFA) in children and adolescents undergoing dental procedures. To our knowledge, no widely available compendium of therapies to manage DFA exists. We propose a study protocol to assess the evidence regarding pharmacological and non-pharmacological interventions to relieve dental anxiety in children and adolescents.

METHODS AND ANALYSIS

In our systematic review, we will include randomised trials, controlled clinical rials and systematic reviews (SRs) of trials that investigated the effects of pharmacological and non-pharmacological interventions to decrease dental anxiety in children and adolescents. We will search the Cochrane Database of Systematic Reviews, the Cochrane Database of Abstracts of Reviews of Effects=, the Cochrane Central Register of Controlled Trials, PubMed, PsycINFO, Cumulative Index to Nursing and Allied Health Literature and the Web of Science for relevant studies. Pairs of review authors will independently review titles, abstracts and full texts identified by the specific literature search and extract data using a standardised data extraction form. For each study, information will be extracted on the study report (eg, author, year of publication), the study design (eg, the methodology and, for SRs, the types and number of studies included), the population characteristics, the intervention(s), the outcome measures and the results. The quality of SRs will be assessed using the A Measurement Tool to Assess Reviews instrument, while the quality of the retrieved trials will be evaluated using the Cochrane Handbook for Systematic Reviews of Interventions criteria.

ETHICS AND DISSEMINATION

Approval from an ethics committee is not required, as no participants will be included. Results will be disseminated through a peer-reviewed publications and conference presentations.

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.

Development and Testing of a Cognitive Behavioral Therapy Resource for Children's Dental Anxiety

Cognitive Behavioral Therapy (CBT) is an evidence-based treatment for dental anxiety; however, access to therapy is limited. The current study aimed to develop a self-help CBT resource for reducing dental anxiety in children, and to assess the feasibility of conducting a trial to evaluate the treatment efficacy and cost-effectiveness of such an intervention. A mixed methods design was employed. Within phase 1, a qualitative "person-based" approach informed the development of the self-help CBT resource. This also employed guidelines for the development and evaluation of complex interventions. Within phase 2, children, aged between 9 and 16 y, who had elevated self-reported dental anxiety and were attending a community dental service or dental hospital, were invited to use the CBT resource. Children completed questionnaires, which assessed their dental anxiety and health-related quality of life (HRQoL) prior to and following their use of the resource. Recruitment and completion rates were recorded. Acceptability of the CBT resource was explored using interviews and focus groups with children, parents/carers and dental professionals. For this analysis, the authors adhered to the Mixed Methods Appraisal Tool criteria. There were 24 families and 25 dental professionals participating in the development and qualitative evaluation of the CBT resource for children with dental anxiety. A total of 56 children agreed to trial the CBT resource (66% response rate) and 48 of these children completed the study (86% completion rate). There was a significant reduction in dental anxiety (mean score difference = 7.7, t = 7.9, df = 45, P < 0.001, Cohen's d ES = 1.2) and an increase in HRQoL following the use of the CBT resource (mean score difference = -0.03, t = 2.14, df = 46, P < 0.05, Cohen's d ES = 0.3). The self-help approach had high levels of acceptability to stakeholders. These findings provide preliminary evidence for the effectiveness and acceptability of the resource in reducing dental anxiety in children and support the further evaluation of this approach in a randomized control trial. Knowledge Transfer Statement: This study details the development of a guided self-help Cognitive Behavioral Therapy resource for the management of dental anxiety in children and provides preliminary evidence for the feasibility and acceptability of this approach with children aged between 9 and 16 y. The results of this study will inform the design of a definitive trial to examine the treatment- and cost-effectiveness of the resource for reducing dental anxiety in children.

Comparison of a New Auto-controlled Injection System with Traditional Syringe for Mandibular Infiltrations in Children: A Randomized Clinical Trial

Background:

Pain in the dental operatory can have a profound effect on the behavior of children.

Aim:

The aim of this study is to evaluate the pain perception while administering local infiltration, in children undergoing dental extractions, using a new auto-controlled injection system.

Materials and Methods:

Children in the age range of 6–10 years with teeth indicated for extraction were recruited and allocated to either Group I, computer-controlled injection system (auto system with special cartridge and compatible disposable 30-gauge, 10 mm needles), or Group II, traditional system (30-gauge, 10 mm needle and disposable traditional syringe). Local infiltration was administered and extraction performed after 3 min. The time of administration (TOA) of infiltrate was noted whereas anxiety and pain in both groups were assessed using the Modified Child Dental Anxiety Faces Scale simplified (MCDAS_(f)), pulse rate, Faces Pain Scale-Revised (FPS-R), and Face, Legs, Activity, Cry, Consolability (FLACC) Scale.

Results:

The TOA was high in computer group, compared to the traditional system (P < 0.001***); however, anxiety and pain were significantly less in computer group as reported in MCDAS_(f), pulse rate, FPS-R, and FLACC (P < 0.001***).

Conclusions:

Computer system created a positive and comfortable experience for the child, as well as the practitioner. The possibility of using buccal infiltration instead of inferior alveolar nerve block in children below 10 years was also demonstrated.

Protocol for a feasibility study of a self-help cognitive behavioural therapy resource for the reduction of dental anxiety in young people

Background

Childhood dental anxiety is very common, with 10–20 % of children and young people reporting high levels of dental anxiety. It is distressing and has a negative impact on the quality of life of young people and their parents as well as being associated with poor oral health. Affected individuals may develop a lifelong reliance on general anaesthetic or sedation for necessary dental treatment thus requiring the support of specialist dental services. Children and young people with dental anxiety therefore require additional clinical time and can be costly to treat in the long term. The reduction of dental anxiety through the use of effective psychological techniques is, therefore, of high importance. However, there is a lack of high-quality research investigating the impact of cognitive behavioural therapy (CBT) approaches when applied to young people’s dental anxiety.

Methods/design

The first part of the study will develop a profile of dentally anxious young people using a prospective questionnaire sent to a consecutive sample of 100 young people referred to the Paediatric Dentistry Department, Charles Clifford Dental Hospital, in Sheffield. The second part will involve interviewing a purposive sample of 15–20 dental team members on their perceptions of a CBT self-help resource for dental anxiety, their opinions on whether they might use such a resource with patients, and their willingness to recruit participants to a future randomised controlled trial (RCT) to evaluate the resource. The third part of the study will investigate the most appropriate outcome measures to include in a trial, the acceptability of the resource, and retention and completion rates of treatment with a sample of 60 dentally anxious young people using the CBT resource.

Discussion

This study will provide information on the profile of dentally anxious young people who could potentially be helped by a guided self-help CBT resource. It will gain the perceptions of dental care team members of guided self-help CBT for dental anxiety in young people and their willingness to recruit participants to a trial. Acceptability of the resource to participants and retention and completion rates will also be investigated to inform a future RCT.

A novel Chotta Bheem-Chutki scale for dental anxiety determination in children

Objective:

A potential problem in patient management in pediatric dentistry is dental anxiety among children. It is of paramount importance for pediatric dentists to identify an anxious child and review potential management options specific to every child. The aim of this study is to validate a newly devised Chotta Bheem–Chutki (CBC) pictorial scale and to compare this with Venham's pictorial scale (VPS) and facial image scale (FIS) to measure dental anxiety in young children during their first dental visit.

Materials and Methods:

One hundred children aged 4–12 years were randomly selected from our hospital outpatient department. Child's anxiety levels were measured using three different scales; the VPS, FIS, and the newly devised CBC pictorial scale. The scores were recorded by asking the children to choose the figure they identified with at that instant. The scores obtained from all the three scales were compared using student's t-test. Pearson correlation test was used to obtain correlation among the scales used in the study.

Results:

A strong correlation (0.778) was found between FIS and CBC scale. Moreover, a strong correlation (0.811) was found between VPS and CBC scale, indicating good validity of the CBC scale. Seventy five percent of the children found CBC scale to be the easiest among the three scales.

Conclusion:

The findings of this study suggest that CBC scale can be used as a new tool for dental anxiety assessment in children.

Variation in levels of anxiety to dental treatment among nonorphan and orphan children living under different systems

Background:

It is essential to understand the factors influencing the level of anxiety to dental treatment among different children as it can influence seeking dental care. Here, we assessed the impact of parental loss on dental anxiety among 6-13-year-old children.

Materials and Methods:

A total of 444 children within the age group 6-13 years were selected. Group 1 consisted of orphan children living in government-run orphanages, Group 2 consisted of orphan children taken care by a person with a motherly relationship, Group 3 consisted of abandoned children living in private organization and Group 4 consisted of children living with their parents. Dental anxiety was measured using children's fear survey schedule-dental subscale and modified faces version of modified child dental anxiety scale.

Results:

The highest number of anxious children were observed in Group 4 and the difference in the anxiety levels among the four groups was found to be highly statistically significant. Children living in government-run orphanages had least dental anxiety.

Conclusion:

All the orphans may not have the same anxiety levels and the environment of upbringing the orphans plays a significant role in the development of the anxiety.

Psychometric properties of the faces version of the Malay-modified child dental anxiety scale

BACKGROUND

To evaluate the psychometric properties of the faces version of the Modified Child Dental Anxiety Scale (MCDASf) Malay version in 5-6 and 9-12 year-old children.

METHODS

The MCDASf was cross culturally adapted from English into Malay. The Malay version was tested for reliability and validity in 3 studies. In the Study 1, to determine test-retest reliability of MCDASf scale, 166 preschool children aged 5-6 years were asked to rank orders five cartoons faces depicting emotions from 'very happy' to 'very sad' faces on two separate occasions 3 weeks apart. A total of 87 other 5-6 year-old children completed the Malay-MCDASf on two separate occasions 3 weeks apart to determine test-retest reliability for Study 2. In study 3, 239 schoolchildren aged 9-12 years completed the Malay-MCDASf and the Malay-Dental Subscale of the Children Fear Survey Schedule (CFSS-DS) at the same sitting to determine the criterion and construct validity.

RESULTS

In study 1, Kendall W test showed a high degree of concordance in ranking the cartoon faces picture cards on each of the 2 occasions (time 1, W = 0.955 and time 2, W = 0.954). The Malay-MCDASf demonstrated moderate test-retest reliability (Intraclass correlation coefficient = 0.63, p <0.001) and acceptable internal consistency for all the 6 items (Cronbach's alpha = 0.77) and 8 items (Cronbach's alpha = 0.73). The highest MCDASf scores were observed for the items 'injection in the gum' and 'tooth taken out' for both age groups. The MCDASf significantly correlated with the CFSS-DS (Pearson r = 0.67, p < 0.001).

CONCLUSIONS

These psychometric findings support for the inclusion of a cartoon faces rating scale to assess child dental anxiety and the Malay-MCDASf is a reliable and valid measure of dental anxiety in 5-12 year-old children.

Evaluating the risks of clinical research: direct comparative analysis

OBJECTIVES

Many guidelines and regulations allow children and adolescents to be enrolled in research without the prospect of clinical benefit when it poses minimal risk. However, few systematic methods exist to determine when research risks are minimal. This situation has led to significant variation in minimal risk judgments, raising concern that some children are not being adequately protected. To address this concern, we describe a new method for implementing the widely endorsed "risks of daily life" standard for minimal risk. This standard defines research risks as minimal when they do not exceed the risks posed by daily life activities or routine examinations.

METHODS

This study employed a conceptual and normative analysis, and use of an illustrative example.

RESULTS

Different risks are composed of the same basic elements: Type, likelihood, and magnitude of harm. Hence, one can compare the risks of research and the risks of daily life by comparing the respective basic elements with each other. We use this insight to develop a systematic method, direct comparative analysis, for implementing the "risks of daily life" standard for minimal risk. The method offers a way of evaluating research procedures that pose the same types of risk as daily life activities, such as the risk of experiencing anxiety, stress, or other psychological harm. We thus illustrate how direct comparative analysis can be applied in practice by using it to evaluate whether the anxiety induced by a respiratory CO2 challenge poses minimal or greater than minimal risks in children and adolescents.

CONCLUSIONS

Direct comparative analysis is a systematic method for applying the "risks of daily life" standard for minimal risk to research procedures that pose the same types of risk as daily life activities. It thereby offers a method to protect children and adolescents in research, while ensuring that important studies are not blocked because of unwarranted concerns about research risks.

Improving access to preparatory information for children undergoing general anaesthesia for tooth extraction and their families: study protocol for a Phase III randomized controlled trial

Background

Children can find anaesthesia induction especially distressing and postoperative psychological and physical morbidity are common. Preparation programmes for general anaesthesia (GA) are highly effective in reducing this distress. A Phase II study has already verified the effectiveness of a prototype preoperative GA-coping computer game to help children cope with induction in a dental GA setting. The biggest patient users of pediatric GA services in the UK are children who need to have teeth removed (estimated to be 100,000 yearly). Tooth decay is the most common disease in children worldwide. This study is a Phase III randomized controlled trial (RCT) and will evaluate the effectiveness of the new internet version of this game.

Methods/design

The Phase III RCT will use a double-blind three-armed design. The clinical trial will recruit up to 210 children and will compare the web-based game against standard care and another non-medical game. At least 53 patients in each group will be required for 90% statistical power. Distress will be assessed through an evaluation of the child’s behaviour during the visit and later parental reports of physical and psychological morbidity. The satisfaction of parents and children will be measured; the mode of usage of the web-based game will be automatically recorded and the impact on the service (for example, recovery time and throughput) will be reported.

The Phase III study primary outcome will measure: (1) patient experience: acceptance of anaesthetic induction, child cooperation and distress, reduction of peri- and postoperative morbidity, child and family satisfaction, and (2) service improvement: anaesthetic time and improvement in throughput. Measures will be administered at baseline, at the time of the GA treatment visit, and at 48 hours and one week postoperatively.

Discussion

This study aims to determine the effectiveness of an online GA-coping game for children and families undergoing tooth extraction under GA.

Trial registration

ISRCTN18265148 (registered 24 November 2013).

Behavioral changes in preschoolers treated with/without rotary instruments

BACKGROUND

Behavioral dentistry is an interdisciplinary science which needs to be learned, practiced, and reinforced in order to provide quality dental care in children.

AIM

To assess the anxiety experienced during dental treatment in preschool children with/without rotary instruments using behavioral scale.

STUDY AND DESIGN

Sixty pediatric patients of preschool age with bilateral occlusal carious lesions extending into dentin were selected for the study. Carious lesions were removed using conventional rotary instruments on one side and Papacarie - chemomechanical caries removal of approach on contra lateral side. Both cavities were restored with glass ionomer cement (Fuji IX). Anxiety scores were determined using 'Modified Child Dental Anxiety Scale' (Wong et al, 1998) during the various clinical stages of the treatment course.

RESULTS

Children experienced relaxed behavior when subjected to Papacarie method of caries removal compared to conventional method using rotary instruments.

CONCLUSION

This study helped us to provide behavioral measures and introduce children to dentistry in a nonthreatening setting.

Short communication: dental anxiety levels and outcomes of care: a preliminary report on experiences of a sedation assessment clinic

AIM

This was twofold: (1) to report on the type of paediatric patient referred to the sedation assessment clinic at the Glasgow Dental Hospital and School, and (2) to report on the level of anxiety.

METHODS

This was a two-part study. The first part was a retrospective review of case notes to evaluate referral pathways to and from the sedation assessment clinic with regard to a range of variables. The second part was a prospective clinical report of dental anxiety.

RESULTS

It was noted that 31 (67.4%) of patients were initially referred by their general dental practitioner, 7 (15.2%) by community dental surgeons and 8 (17.4%) by hospital dental surgeons. At the initial referral, 4 children (9%) showed symptoms of pain. The majority of patients were from lower social economic areas, as determined by DEPCAT score and exhibiting moderate to high anxiety levels. The children who were referred for general anaesthesia had the highest anxiety scores. Out of a total of 46 patients, five failed to complete treatment within the modality laid out for them at the assessment clinic.

CONCLUSIONS

(1) The patients attending the newly established sedation assessment clinic were mainly high caries risk, socially deprived patients and (2) that the majority of patients were dentally anxious, the most anxious appearing to have been referred for treatment under general anaesthesia.

Effect of psychological management techniques on specific item score change during the management of dental fear in children

The aim of the study is to determine how specific fear inducing items contribute to the overall dental fear level in Nigerian children. In addition, it looks at the specific changes that psychological management produces on each item and how variables like age, gender and type of treatment received contribute to these specific changes observed. The dental fear level of 75 children, who were attending the dental clinic for the first time were assessed pre and post-treatment using the short form of the dental subscale of the child fear survey schedule. During treatment, the children were managed using various forms of psychological management strategies. The effect of age and the gender of the children on the dental fear level were analyzed. The effect of the type of treatment received, categorized into either invasive or non-invasive, on the dental fear level was also determined. Results showed that with the use of psychological management strategies, dental fear level of the children decreased significantly post treatment (13.45 vs 12.59; p = 0.009). However, no statistically significant dijfference was noted in the dental fear scores based on age, gender and type of treatment received. On the other hand, the aggregate scores for each of the possible fear inducing items highlighted in the psychometric scale varied and so did the effectiveness of psychological techniques in significantly reducing dental fear scores for each of the items. Age, gender and type of treatment did have significant effect on the fear level changes that occur with specific items. It was concluded that although a significant change occurred in the dental fear level score of the child post management with psychological techniques, this does not necessarily translate to significant changes in the scores for each fear inducing item assessed by the psychometric scale. Age, gender and the type of treatment the child received also influence the change that could occur for each item. The dental fear level of the children decreased significantly post treatment (13.45 vs 12.59; p = 0.009).

The Richmond Agitation-Sedation Scale: validity and reliability in adult intensive care unit patients

Sedative medications are widely used in intensive care unit (ICU) patients. Structured assessment of sedation and agitation is useful to titrate sedative medications and to evaluate agitated behavior, yet existing sedation scales have limitations. We measured inter-rater reliability and validity of a new 10-level (+4 "combative" to -5 "unarousable") scale, the Richmond Agitation-Sedation Scale (RASS), in two phases. In phase 1, we demonstrated excellent (r = 0.956, lower 90% confidence limit = 0.948; kappa = 0.73, 95% confidence interval = 0.71, 0.75) inter-rater reliability among five investigators (two physicians, two nurses, and one pharmacist) in adult ICU patient encounters (n = 192). Robust inter-rater reliability (r = 0.922-0.983) (kappa = 0.64-0.82) was demonstrated for patients from medical, surgical, cardiac surgery, coronary, and neuroscience ICUs, patients with and without mechanical ventilation, and patients with and without sedative medications. In validity testing, RASS correlated highly (r = 0.93) with a visual analog scale anchored by "combative" and "unresponsive," including all patient subgroups (r = 0.84-0.98). In the second phase, after implementation of RASS in our medical ICU, inter-rater reliability between a nurse educator and 27 RASS-trained bedside nurses in 101 patient encounters was high (r = 0.964, lower 90% confidence limit = 0.950; kappa = 0.80, 95% confidence interval = 0.69, 0.90) and very good for all subgroups (r = 0.773-0.970, kappa = 0.66-0.89). Correlations between RASS and the Ramsay sedation scale (r = -0.78) and the Sedation Agitation Scale (r = 0.78) confirmed validity. Our nurses described RASS as logical, easy to administer, and readily recalled. RASS has high reliability and validity in medical and surgical, ventilated and nonventilated, and sedated and nonsedated adult ICU patients.