Association between children’s dental anxiety and parental acceptance of dental general anesthesia: a cross-sectional study

1. Introduction

Children’s dental anxiety (CDA) refers to a feeling or anticipation that something will happen, combined with a sense of losing control of dentistry. CDA may lead to behaviour management problems [1] and there existed a valid demonstrable path of association between parental socioeconomic status, dental anxiety, childhood dental anxiety, oral health behaviors and children’s oral health-related quality of life (OHRQoL) [2]. The prevalence of CDA varies from 6.3% [3] to 93.8% [4] based on differences in age, region, culture and evaluation method. In 2019, the prevalence of CDA in children aged 3–12 years was nearly 55% in Chongqing, China [5]. When treating children with behaviour management problems caused by CDA, practitioners tend to consider non-pharmacologic behavioral management techniques (BMTs) in advanced [6], through which about 80% of pediatric patients could be cooperative in previous study [7]. If such strategy proves to be unsuccessful, conscious sedation and dental general anaesthesia (DGA) can be considered.

DGA is a controlled state of unconsciousness in which protective reflexes are lost [8]. It is the practitioner’s compelled way to treat a child’s dental problem when other options are insufficient. CDA has been demonstrated to be the most common self-reported and parent-reported factor leading to DGA [9, 10]. However, less was known about the association between CDA and parental acceptance of DGA. Understanding this association is critical to practitioners because childhood is a developmental period marked by biopsychosocial immaturity, with children holding a minimal role, conversely, parents play a major role in decision making at treatment [11]. However, some studies suggest that children should be encouraged to participate in healthcare decisions, because they desire voicing their preferences and choosing how treatments are administered to them [12, 13]. Especially for children’s dental behaviour, there was a valid demonstrable path of association among parenting style, parental economic status, dental anxiety, childhood dental anxiety, oral health behaviors, and dental caries and dental visit behaviour [14]. Therefore, when a child is recommended to undergo DGA, how a child’s emotion particularly CDA influences parents’ decision is essential to explore.

DGA was first brought to mainland China in 1999 [15], which led to low parental acceptance and was primarily affected by parent’s DGA cognition [16]. Some findings concerning parental acceptance and educational level, culture background, and socioeconomic status are controversial [17, 18]. Although these studies show some insights into CDA between the parental acceptance of DGA, some gaps remain in understanding. Firstly, whether parents of children with higher CDA were more likely to accept DGA requires further assessment. Secondly, DGA is commonly recommended to children with high CDA, so the factors influencing the acceptance of DGA by parents of children with high CDA warrants exploration.

The present study aimed to test the hypothesis that parents of children with high CDA were more likely to accept DGA than parents of children with medium CDA. Gaining such knowledge can help practitioners provide advice and intervention from parents and children’s perspectives, which may mitigate the negative effects of CDA on children’s oral health.

2. Materials and methods

3. Results

A total of 743 (98.15%) of all parent-child couples completed the questionnaire; the other 14 couples were excluded from data analysis, owing to missing more than two questions. Table 1 shows the characteristics of the participants in this study. More than half of the children were girls (52.62%) and from single-child families (57.07%). The population of children aged 7–12 years was twice that of children who aged 3–6. The majority of caregivers (86.68%) were parents. More than two-thirds of the pediatric patients in the research visited a dentist more than one time. Only less than 10% of the children had a GA experience. More than two-thirds of the respondents were mothers, 64.06% of whom reported providing a permissive parenting style to their children. Approximately, half of the parents in this survey had a bachelor’s degree. Over half of the families had a monthly annual household income of more than >¥10,000. More than one-third of parent(s) had never heard of DGA before participating in the survey. Except for the mother’s occupation, no statistically significant difference was found in the demographic characteristics.

Significant differences existed between dental anxiety level and children’s ages and their visit time(s) (p < 0.05). The share of children scoring the lowest anxiety level in 7–12 years (53.8%) was significantly higher than that in 3–6 years (42.4%). Moreover, the proportion of children with the highest CDA level was 42.79% on the first visit, which was much higher than the proportion on the second visit (22.22%) and more visit(s) (22.11%). These data revealed that children’s age and visit time(s) were strongly correlated with CDA level (Fig. 1).

Fig. 1.Distribution of Children’s dental anxiety (n = 743). Note: 1—None anxiety; 2—Mile to moderate anxiety; 3—Severe anxiety. *: The difference was significant.

The distributions of parental answers to their DGA knowledge were described in Table 2. Among the six answers regarding the complications of DGA for children, the percentages of correct answers ranged from 10.23% to 24.76%. About 40.38% of respondents chose the answer “I do not know”, and only 5.25% answered all questions correctly. Regarding the risks of DGA, only 14.54% parents believed that DGA cannot irreversibly damage the brain. Notably, 89.91% knew that the child may have conditions such as pain when they received DGA. The total scores for DGA knowledge ranged from 0 to 9, with a mean of 2.341 and a standard deviation of 1.826. The proportion of score 1–2 was the most concentrated (52.76%).

Further analysis on parental knowledge scores were shown in Fig. 2. The mean score of mothers was higher than that of fathers. A higher respondents’ education level corresponded with a higher mean score. The mean score of the respondents with the lowest monthly income had the lowest mean score of parental knowledge.

Fig. 2.Mean score of DGA knowledge of parents. *: The difference was significant.

CDA levels, children’s experience of GA, and DGA knowledge of parents in parental acceptance of DGA were shown in Table 3. In Model 1, parents whose children with medium CDA were less likely to accept DGA compared with parents whose children had high CDA (OR1 = 0.58; 95% CI: 0.36–0.94). After adding the DGA knowledge score of parents, dental visits, parents’ having heard of DGA and children’s experience of GA, smaller likelihoods of reluctance were found (OR2 = 0.56; OR3 = 0.55; p < 0.05) in models 2 and 3. In all models, parents who had higher DGA knowledge scores (OR3 = 1.23; 95% CI: 1.12–1.35), who had heard of DGA (OR3 = 1.52; 95% CI: 1.03–2.25), and whose children had experience of GA were more likely (OR3 = 7.34; 95% CI: 3.98–13.52) to accept DGA.

The analysis results of influencing factors on parental acceptance of DGA whose children had high CDA are presented in Table 4. Interestingly, the parents whose children with GA experience (OR = 18.78; 95% CI: 4.52–78.05) were more likely to accept DGA. Other factors including higher DGA knowledge score of parents (OR = 1.03; 95% CI: 0.85–1.24), parents’ having heard of DGA (OR = 1.46; 95% CI: 0.66–3.27), and more dental visits (>3) of children (OR = 0.85; 95% CI: 0.36–2.00) were not significant. Moreover, girls’ parents (OR = 2.77; 95% CI: 1.27–6.09), fathers with clerical or skilled occupation (OR = 3.59; 95% CI: 1.08–11.93), and parents with higher household income (OR = 11.69; 95% CI: 1.46–93.93) were more likely to accept DGA. However, mothers whose occupations were clerical or skilled workers (OR = 0.28; 95% CI: 0.10–0.80) and freelance work or others (OR = 0.13; 95% CI: 0.03–0.53), were less likely to accept DGA even though their children were reported to have high CDA.

4. Discussion

More than one-third of parents had never heard about DGA before in this study, which was similar to the previous study [24]. Surprisingly, the mean score of mothers was significantly higher than that of fathers, either because mothers might have acquired some knowledge of GA during pregnancy or delivery period [25] or highlights that in Chinese domestic and medical concerns of the child are still mostly provided by the female caregiver [26], which was the same in Germany [11]. A larger cohort with more male participants in the future may give better understanding of parental acceptance of DGA.

Furthermore, despite only sevoflurane-based DGA did not affect neurocognitive function in children adversely [27], a common misunderstanding that more than 85% parents insisted the DGA irreversibly damage children’s brain. Positively, 90% of parents understood the postoperative complications of DGA, though they may feel confused about the specific items, which may be beneficial to reduce conflicts between practitioners and parents. These results indicated that practitioners should minimise or even eliminate the risk of adverse events by following AAPD (the American Academy of Pediatric Dentistry) guidelines [28] to promote parents’ confidence in DGA, in addition to increasing public awareness and cognition of CDA and DGA.

Parents of children with medium CDA were less likely to accept DGA than parents of children with high or no CDA in this study. The reason may be that parents of children with medium CDA believe their child’s compliance should improve with age and increased visits. As a result, the parents of these children with medium CDA may prefer non-pharmacological BMT to pharmacological BMT [29] and may result in some children neither cooperate via BMT nor receive dental treatment under DGA timely, leading to more severe oral disease eventually [30]. For practitioners, to reduce this vicious cycle, delaying (or deferral) treatment in uncooperative children especially for those without urgent treatment needs. In support of this conjecture, alternative treatment options like nitrous oxide inhalation sedation have been shown to be more accepted by parents than GA [29]. The use of fluoride and frequent control plaque removal and minimally invasive treatment methods (such as non-restorative caries management and indirect pulp coverage) by dentists may meet the expectations of these families.

Among parents of children with high CDA, the results suggested that children’s GA experience was significantly associated with parental acceptance of the DGA, rather than the parents’ DGA knowledge and parents’ having heard of CDA. This may be because they have known the benefits of the DGA beforehand [11]. Higher household income was more likely to promote parental acceptance of the DGA. It was suggested for policy-makers that DGA’s partial inclusion should be in the scope of medical reimbursement to reduce medical costs for some low-income families.

Emotional factors influencing parental perception of GA have been discussed in several studies [30, 31]. Interestingly, children’s gender may also be associated with parental DGA acceptance in children with high CDA. The results showed that parents of high CDA girls were more likely to accept the DGA than parents of high CDA boys, which may be related to parents’ perception that boys may be braver. To some extent, it was suggested that when parents of children with high CDA made a decision on whether or not to accept the DGA, the daughter’s emotion may affect the parents more than the son’s.

Another interesting finding was a difference between fathers and mothers of children with high CDA in deciding on their children’s DGA: fathers with clerical or skilled occupations were more likely to accept DGA than mothers with the same occupations. This finding was similar to previous research that parents may consider differently when making DGA decisions for their children [32]. Fathers may be more sensible to think that DGA was the appropriate way to relieve the pain of children with high CDA. When recommending DGA to parents whose children were uncooperative owing to high CDA, practitioners should focus on parental acceptance, especially low-income families, and boys’ parents with non-skilled occupations. Non-pharmacological BMT should be tried/applied for children with high CDA before considering DGA or attempting to convince parents to choose DGA. If CDA does not resolve DGA is for sure indicated.

However, considering the limitations of this cross-sectional study, the results should be interpreted with caution. Firstly, the cross-sectional design cannot explain the causal relationship between CDA and parental acceptance of DGA. Future prospective research studies are needed to validate these findings. Secondly, owing to the large sample size of this work, the presence of CDA was reported by parents, which may cause an inaccurate determination of CDA. If possible, the children themselves should evaluate CDA. Thirdly, the acceptance of DGA was assessed through questionnaires, which may have caused recall bias. The dichotomy of parental acceptance may reduce the sensitivity of the results. Additionally, it was hard to check the oral health status of the child, which may affect parental awareness and acceptance of DGA. Further targeted surveys are necessary in the future.

5. Conclusions

Further education on DGA was considered to be necessary. Parents of children with medium CDA were less likely to accept DGA than those with high or no CDA. Among parents of children with high CDA, mothers with freelance work and families with low household income were less likely to accept DGA than others. These might be a potential barrier to dental practitioners. When recommending DGA to parents whose children were uncooperative due to medium or high CDA, dental practitioners should be flexible in their implementation following AAPD guidelines.

Availability of data and materials

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Author contributions

WWL and LND—study design. LND—data collection, funds collection. TTW—statistical analysis. JDH and ZC—data interpretation. LND and TTW—manuscript preparation. JDH, YJY, LND and TTW—literature search. All authors contributed to the article and approved the submitted version.

Ethics approval and consent to participate

The studies involving human participants were reviewed and approved by Stomatological Hospital of Chongqing Medical University was obtained (CQHS-IRB-2021-29). Written informed consent to participate in this study was provided by the participants’ legal guardian/next of kin. Guidelines documented in the Helsinki-2013 Declaration of experiments on humans were adopted for this study. Informed consent was obtained from the participants and their legal guardians. Prior to signing the consent form, all participants were informed that they could withdraw from this study at any stage without any penalty; and were invited to ask questions.

Acknowledgment

The authors thank all the children and their parents who participated in this study.

Funding

This study received funding from Chongqing Health Commission medical scientific research project (2016MSXM047).

Conflict of interest

The authors declare no conflict of interest.