Journal of Clinical Pediatric Dentistry. 2024; 48(1): 184-190. doi: 10.22514/jocpd.2024.020
Original Research

A study on related factors affecting dental fear in preschool children

Ruobing Peng1, Linhua Liu1, Youjian Peng1, Jun Li1, Tiantian Mao1,*,

1Department of Stomatology, Renmin hospital of Wuhan University, 430060 Wuhan, Hubei, China

*Corresponding Author(s):mtt6166@163.com (Tiantian Mao)

History Submitted: 24 August 2023 | Accepted: 17 October 2023 | Published: 03 January 2024
Copyright:  ©2024 The Author(s). Published by MRE Press.
This is an open access article under the CC BY 4.0 license (https://creativecommons.org/licenses/by/4.0/).

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Abstract

This study aims to examine the manifestations of dental anxiety (DA) and its influencing factors during dental visits among preschool children. The data of 166 preschool children who visited the Department of Dentistry of our hospital from April 2021 to April 2023 with oral problems were retrieved. Their DA performance was investigated using the Children’s Fear Survey Schedule-Dental Subscale (CFSS-DS). In addition, based on their general data and potential risk factor information, we performed logistic regression analysis to identify the factors influencing DA. Of the 166 questionnaires distributed, a total of 160 valid questionnaires were retrieved. The average CFSS-DS score was 35.57 ± 3.51 points. Sixty-six children had DA, resulting in an incidence rate of 41.25%. The top 5 items with the highest CFSS-DS scores were fear of needles, dentists, tooth extraction, drilling and oral anesthesia. When the 66 children with DA were classified into a DA group and a non-DA group, we observed significant differences in age distribution, dental experience, only child status, general anxiety symptoms, dental condition, family income and specific dental treatment procedures, particularly tooth extraction, between them (p < 0.05). Multivariate logistic regression analysis revealed that preschool children aged ≤4 years, those with prior dental experiences, single-child status, general anxiety symptoms, suboptimal dental health, family incomes below 100,000 yuan/year, and those undergoing specific dental procedures, such as tooth extractions, were independently associated with a higher risk of DA (p < 0.05). The incidence of DA in preschool children is high, and they exhibit substantial fear of needles, dentists, tooth extraction, drilling and oral anesthesia. Preschool children aged ≤4 years, with prior dental experiences, single-child status, the presence of general anxiety symptoms, suboptimal dental health, family incomes below 100,000 yuan/year, and those undergoing dental procedures, particularly tooth extraction, could be more predisposed to DA.

Keywords:Preschool age;Children;Dental anxiety;Influencing factors
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Cite this article

Ruobing Peng, Linhua Liu, Youjian Peng, Jun Li, Tiantian Mao. A study on related factors affecting dental fear in preschool children. Journal of Clinical Pediatric Dentistry. 2024; 48(1): 184-190. doi: 10.22514/jocpd.2024.020

1. Introduction

Dental anxiety (DA) is a prevalent psychological issue among children, characterized by significant fear and avoidance behaviors during dental visits, leading to children displaying reactions such as agitation, crying, avoidance or refusal to attend dental appointments [1, 2]. DA has become increasingly common in clinical practice, particularly among preschool children, which not only impacts the children and their parents but also adversely affects treatment outcomes and dentist procedures [3]. DA has not only a lasting negative influence on the oral health and quality of life of preschool children but also hinders routine oral examinations and treatments, delays the detection and management of oral diseases, and can even lead to a lasting fear toward dentists, inducing anxiety in these children and making future dental treatments more challenging [4, 5]. The causes of DA in preschool children are multifaceted, encompassing various factors at individual, environmental and family levels, making a comprehensive understanding of DA in preschool children and its contributing factors essential for the development of effective prevention and treatment strategies [6, 7]. While previous domestic and international studies have reported factors contributing to DA in children, such as age, educational level and family values, most of these studies have focused on specific factors, and comprehensive research on this topic remains limited [8, 9]. The Children’s Fear Survey Schedule-Dental Subscale (CFSS-DS) is a commonly used method for assessing DA in children. It includes 15 items related to dental fears, such as fear of dentists, pain and syringes. Ma et al. [10] reported that the Chinese version of CFSS-DS has good reliability and validity and was thus used in this study to evaluate DA in preschool children and analyze the various factors influencing it, with the goal of providing valuable insights for enhancing oral healthcare services for children.

2. Subjects and methods

2.1 Study subjects

The data of preschool children who presented with oral issues to our dental department between April 2021 and April 2023 were retrieved. The study inclusion criteria were: aged 1 to 6 years; requiring dental treatment for oral problems; parents or primary guardians provided consent for study participation by signing an informed consent form. The exclusion criteria were: presence of neurodevelopmental disorders such as autism, attention deficit hyperactivity disorder and others; had underlying general disorders that could potentially influence their dental procedures and experiences; children or parents who were unable to fully cooperate.

2.2 Investigation contents and methods

2.2.1 General data collection

General data was collected, including the children’s age, gender, dental history, only child status, guardian’s education, family income, dental treatment program, parental discipline, general anxiety symptoms and dental status. Their dental experience was assessed by determining whether the child had prior professional dental care. Parental discipline [11] was assessed using a questionnaire, which contained 10 questions, such as “When my child made a mistake, I would spend time discussing with him/her why this was wrong”, “When my child did not listen, I would give strict punishment”, etc., with each question having five choices (from “completely disagree” to “completely agree”), with the responses scored on a 1 to 5 scale. Scores ranging between 25 and 50 indicated a democratic parenting style, emphasizing communication and discussion, while scores ranging from 10 to 24 reflected an authoritative style, characterized by directives and regulations. General anxiety symptoms [12] were evaluated using the Generalized Anxiety Disorder 7-item (GAD-7) scale, with scores of 10 to 21 indicating the presence of such symptoms. Dental status [13] was classified as “good”, “fair” or “poor” based on deciduous dental caries index (DMFT) values of 0, 1 to 3 and over 3, respectively.

2.2.2 DA assessment

CFSS-DS [14] was used to evaluate the extent of dental treatment-related fear in children. The CFSS-DS scale assessed fear levels associated with dentists, syringes, drilling machines, pain, suffocation and dental tools, encompassing a total of 15 items. Each item received a score on a five-point scale, with 1 denoting “no fear at all” and 5 indicating “very fearful”. A CFSS-DS total score equal to or greater than 38 points was indicative of DA.

2.3 Outcome measures

The CFSS-DS score and occurrence of DA were counted, and logistic regression was used to analyze the independent influencing factors of DA in preschool children.

2.4 Statistical methods

Data analysis was performed using the SPSS v22.0 software (BMI company, Chicago, Il, USA). Continuous measurement data are presented as mean (± standard deviation), and group comparisons were performed using the t-test. Enumeration data are expressed as counts and percentages, and group comparisons were performed using the χ2 test. The rank sum test was used for grade data. In addition, a logistic regression model was used to analyze factors influencing the outcomes, and statistical significance was set at p < 0.05.

3. Results

3.1 Development of DA in children

A total of 166 questionnaires were distributed, and 160 valid responses were received. The mean CFSS-DS score was 35.57 ± 3.51 points, with 66 cases of DA, resulting in an incidence rate of 41.25%. The top five items with the highest CFSS-DS scores were related to the fear of needles, dentists, tooth extraction, drilling and oral anesthesia (Table 1).

Table 1.Top 5 items with the highest CFSS-DS score (x̄ ± s, n (%)).
ItemScore (points)Score ≥4 (rate)
Fear of needles3.80 ± 1.2070 (43.75)
Fear of dentists3.65 ± 1.1064 (40.00)
Fear of dentists3.58 ± 1.0358 (36.25)
Fear of drilling3.47 ± 0.9256 (35.00)
Fear of oral anesthesia3.40 ± 0.9852 (32.50)

3.2 Analysis of factors affecting the incidence of DA in children

Sixty-six children with DA were assigned to the DA group, while the remaining were in the non-DA group. Significant differences were observed in terms of age distribution, dental history, only child status, general anxiety symptoms and dental status between the DA and non-DA groups (p < 0.05). However, there was no significant difference in gender between the two groups (p > 0.05) (Table 2).

Table 2.Children factor comparison between the DA and non-DA groups (n (%)).
Associated FactorsDA group (n = 66)non-DA group (n = 94)Z/χ2p
Age
1–2 yr26 (39.39)24 (25.53)2.4820.013
3–4 yr27 (40.91)37 (39.36)
5–6 yr12 (18.18)33 (35.11)*
Sex
Male31 (47.00)51 (54.26)0.8240.364
Female35 (53.00)43 (45.74)
Dental experience
Yes47 (71.21)41 (43.62)11.930<0.001
No19 (28.79)53 (45.74)
Only child
Yes41 (62.12)42 (44.68)4.7240.030
No25 (37.88)52 (55.32)
General anxiety symptoms
Yes35 (53.03)21 (22.34)16.053<0.001
No31 (46.97)73 (77.66)
Dental status
Good15 (22.73)43 (45.74)*3.0470.002
Average33 (50.00)37 (39.36)
Poor18 (27.27)14 (14.89)
DA: dental anxiety. *Compared with DA group, p < 0.05.

3.3 Analysis of family/parent factors affecting the incidence of DA

Significant differences were observed in terms of family income and specific dental treatment procedures, particularly tooth extraction, between the DA and non-DA groups (p < 0.05). However, there was no notable distinction in guardian education and parental discipline between the two groups (p > 0.05) (Table 3).

Table 3.Comparison of family/parent factors between the DA and Non-DA groups (n (%)).
Associated factorsDA group (n = 66)Non-DA group (n = 94)Z/χ2p
Guardian education
College degree or above38 (57.58)55 (58.51)0.0140.906
College degree or below28 (42.42)39 (41.49)
Family income
≥100,000 yuan/year17 (25.76)40 (42.56)4.7700.029
<100,000 yuan/year49 (74.24)54 (57.44)
Dental treatment program
Conservative treatment20 (30.30)41 (43.62)7.6070.022
Tooth extraction29 (43.94)22 (23.40)*
Dental caries repair17 (25.76)31 (32.98)
Parental discipline
Democratic type31 (46.97)56 (59.57)2.4830.115
Authoritative type35 (53.03)38 (40.43)
DA: dental anxiety. *Compared with DA group, p < 0.05.

3.4 Multivariate logistics regression analysis of DA in preschool children

Multivariate logistic regression analysis revealed that preschool children aged ≤4 years, prior dental experiences, only child status, presence of general anxiety symptoms, fair/poor dental health, family incomes <100,000 yuan/year and those who had specific dental procedures, particularly tooth extraction, were independent risk factors for DA in preschool children (p < 0.05) (Tables 4 and 5).

Table 4.Logistics regression variable assignment.
VariableAssignment value
Age“5–6 yr” = 0, “≤4 yr” = 1
Dental experienceNo = 0, Yes = 1
Only childNo = 0, Yes = 1
General anxiety symptomsNo = 0, Yes = 1
Dental status“Good” = 0, “Average/poor” = 1
Family income“≥100,000 yuan/year”, “<100,000 yuan/year”
Dental treatment program“Conservative treatment/Dental caries repair” = 0, “Tooth extraction” = 1
Table 5.Multivariate logistics regression analysis of DA in preschool children.
FactorβSEWald χ2OR valuep value95% CI
Age ≤4 yr0.3560.10311.8761.4280.0011.164–1.751
Have dental experience0.4560.12214.0251.578<0.0011.261–1.975
Is the Only child0.3280.09910.9871.388<0.0011.144–1.681
Have general anxiety symptoms0.3710.10213.2581.450<0.0011.193–1.765
Dental status Average/poor0.3420.09712.4671.408<0.0011.168–1.698
Family income <100,000 yuan/year0.2940.0949.8061.3420.0021.112–1.618
Dental treatment program for tooth extraction0.4380.11315.0111.550<0.0011.251–1.924
SE: regression coefficient; OR: Odds Ratio; CI: Confidence Interval.

4. Discussion

Psychological issue among preschool children, significantly impacting their dental care experiences. This study investigated the DA levels and related influencing factors in 166 preschool children.

The CFSS-DS scale was used to evaluate the preschool children’s DA, which yielded a mean CFSS-DS score of 35.57 ± 3.51 points. We also observed that 66 participants exhibited DA, resulting in an incidence rate of 41.25%, which is consistent with previous reports [15, 16], supporting the overall high incidence of DA in this population. Analysis of the CFSS-DS score results revealed that the top five items most commonly eliciting DA were fear of needles, dentists, tooth extraction, drilling and oral anesthesia. To gain a deeper understanding of these manifestations, an in-depth analysis of their psychological mechanisms can enhance our comprehension of the factors contributing to DA in preschool children and provide valuable insights for the development of targeted interventions. The fear of needles may be related to children’s apprehension of pain, a common childhood experience. Additionally, needles are frequently associated with medical procedures like injections and blood collection, which can frighten children [17, 18]. Moreover, the sharp nature of needles may activate children’s innate sense of vulnerability and self-preservation, contributing to their fear [19]. The fear of dentists could be attributed to children’s unease around strangers and their unfamiliarity with medical environments. Unfamiliar medical professionals may induce restlessness and fear in children, and the medical setting itself is often unfamiliar, featuring various elements such as equipment, odors and sounds, which often intensify children’s anxiety [20, 21]. Fear of tooth extraction, drilling and oral anesthesia, which are often linked to the anticipation of discomfort and pain, typically involve physical sensations such as pressure, vibrations from dental drills, as well as the sensation of numbness from oral anesthesia. Children may anticipate discomfort and pain during these procedures, which can trigger their fear and reluctance [22, 23, 24].

In this study, a comprehensive statistical analysis of various potential influencing factors was conducted, which identified age, dental experience, only child status, general anxiety symptoms, dental status, family income and specific dental treatment procedures as significant contributors to DA in preschool children. Specifically, preschool children aged ≤4 years were found to be more susceptible to DA, which can be attributed to their relatively underdeveloped adaptability to novel environments and experiences during this developmental stage. Younger children may experience increased emotional distress when confronted with challenging situations, thereby increasing their likelihood of experiencing DA [25]. Moreover, preschool children with prior dental experiences exhibited a greater propensity for DA, which could be attributed to early dental encounters shaping memories of dentist-related fears, subsequently leading to apprehension and resistance during subsequent dental treatments, thereby underscoring the critical importance of fostering positive early dental experiences for children to enhance their overall oral health and future treatment experiences. Hence, emphasis should be placed on early oral health care and ensuring constructive early encounters with dental procedures [26]. For children visiting the hospital for the first time, it is essential to create a welcoming environment in collaboration with their parents. Children aged over 3 years can be encouraged to engage in simple communication. For those under 3 years, parents should provide comfort and whenever possible, avoid employing coercive measures. Alternatively, first-time patients can be placed behind children who are undergoing treatments successfully to alleviate tension through observation and demonstration. Additionally, providing health education to parents is valuable, emphasizing the importance of children’s oral health and encouraging prompt medical visits for mild conditions to prevent unfavorable dental experiences resulting from delayed treatment of worsening conditions. Rajeswari et al. [27] reported that active distraction using cognitive-behavioral play therapy during dental visits effectively reduced preoperative anxiety in children. However, further research is needed to determine the appropriate game content, timing and consideration of the child’s visit history and treatment efficiency.

Their home environment also plays an important role in the development of DA in preschool children [28, 29]. Our study revealed that only child status was associated with a higher likelihood of experiencing DA, which may stem from the fact that these children often receive more attention and protection within their families, potentially making them less adaptable to new experiences and unfamiliar environments. Furthermore, the close-knit family relationships and parenting styles in such households may impact a child’s emotional regulation skills and coping strategies, subsequently affecting their fear levels during dental visits [30]. Our present study indicates no substantial correlation between parental discipline and DA. However, it underscores the importance of nurturing independence and adaptability, particularly in children of only child status. Previous research suggested that only child status may be associated with a lack of opportunity for peer interaction and may exhibit a notable sense of “self-centeredness”. Therefore, placing such children in a group environment could be beneficial in fostering qualities such as sharing, cooperation, adherence to discipline, self-care abilities, the development of positive behavioral habits, and the prevention of personality deviations and behavioral issues [31]. The presence of general anxiety symptoms has been reported to be closely linked to the occurrence of DA in preschool children. Anxiety can increase children’s fear of dental visits and make them more sensitive to discomfort and pain during treatment, underscoring the importance of children’s emotional well-being and emphasizing the need for systematic screening and intervention for anxiety symptoms to reduce their fear of dental appointments [32]. The influence of dental status should not be underestimated. Our study revealed that children with fair or poor dental health were more likely to experience DA, as dental problems can cause pain or discomfort, exacerbating children’s anxiety about dental treatment, thereby highlighting the importance of oral health and the necessity of strengthening children’s oral care and early treatment to reduce discomfort and fear associated with dental issues [33]. Moreover, households with an annual income of less than 100,000 yuan were associated with a higher risk of DA development in preschool children. Low-income families may face financial pressures and resource limitations, making it challenging to provide high-quality dental care and treatment, which can increase the risk of fear and anxiety during dental visits [34]. Additionally, children requiring specific dental procedures such as tooth extractions are more likely to experience DA, as these procedures often involve greater pain and discomfort, leading to fear and resistance in children. For such cases, special interventions, including offering additional emotional support, employing gentle treatment techniques, and considering medication aids, can be implemented to alleviate fear and discomfort.

5. Conclusions

In conclusion, DA is prevalent among preschool children, with the most common triggers being fear of needles, dentists, tooth extraction, drilling and oral anesthesia. Children aged ≤4 years, with prior dental experiences, only child status, displaying general anxiety symptoms, with fair or poor dental health, families with an annual income less than 100,000 yuan, and those requiring specific dental procedures such as tooth extraction might be at higher risks of experiencing DA. Thus, targeted interventions can be tailored to address these high-risk factors, including the provision of emotional support, enhancing the image and behavior of dentists, adopting gentle treatment techniques, and delivering appropriate oral hygiene education.

Availability of data and materials

All data generated or analyzed during this study are included in this published article. The datasets used and/or analyzed during the present study are available from the corresponding author on reasonable request.

Author contributions

RBP and LHL—designed the study, completed the experiment and supervised the data collection. YJP—analyzed the data, interpreted the data. JL and TTM—prepare the manuscript for publication and reviewed the draft of the manuscript. All authors have read and approved the manuscript.

Ethics approval and consent to participate

Ethical approval was obtained from the Clinical Research Ethics Committee of Renmin hospital of Wuhan University (Approval no. AF/ZN 2-02/5.0). Parents or primary guardians provided consent for study participation by signing an informed consent form.

Acknowledgment

Not applicable.

Funding

This work was supported by the Key Laboratory Open Project of Hubei. (Grant No. 2021KFY029).

Conflict of interest

The authors declare no conflict of interest.

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