Determination of dental anxiety levels of primary school students evaluated at oral and dental health screening

Background: Determining the level of dental anxiety is crucial for the successful delivery of dental treatments in pediatric patients. Various dental anxiety scales have been developed and employed for this purpose. The aim of this study was to determine the dental anxiety levels of primary school students who underwent oral and dental health screening using The Index of Dental Anxiety and Fear Scale (IDAF-4C) and the Child Drawing: Hospital (CD:H) Scale. Methods: This study included 5th-grade students at primary schools who underwent oral and dental health screening. The children were asked to complete a questionnaire that included demographic information as well as the IDAF-4C scale. Visual-tactile inspection was performed to evaluate caries risk groups and treatment needs by final-year dental students under the supervision of four licensed pediatric dentists. The caries management by risk assessment (CAMBRA) form was used for caries risk assessment. Following the screening, the children were invited to draw pictures. Descriptive statistical methods and correlation analysis were used to assess the data. Results: Of the 146 children included in the study, 54 (37%) were girls and 92 (63%) were boys. There was no statistically significant difference in IDAF-4C or CD:H scores between children who had a previous dental visit and those who had not. While the CD:H score was significantly higher in boys, there was no significant difference in IDAF-4C scores between genders. Additionally, no correlation was found between the two anxiety scales. Conclusions: Both anxiety scales can be used reliably in paediatric populations. However, the child’s age and ability to express themselves should be carefully considered when selecting the appropriate scale. Regular screening programs should be expanded to allow early detection of dental problems and timely preventive measures.

Dental anxiety; Drawing; Oral and dental health; Primary school students

[1] Hoffmann B, Erwood K, Ncomanzi S, Fischer V, O’Brien D, Lee A. Management strategies for adult patients with dental anxiety in the dental clinic: a systematic review. Australian Dental Journal. 2022; 67: S3–S13.

[2] Winkler CH, Bjelopavlovic M, Lehmann KM, Petrowski K, Irmscher L, Berth H. Impact of dental anxiety on dental care routine and oral-health-related quality of life in a german adult population—a cross-sectional study. Journal of Clinical Medicine. 2023; 12: 5291.

[3] Šimunović L, Špiljak B, Radulović M, Vlahovljak A, Ostojić M, Krlev J, et al. Relationship between children’s and parents’ dental anxiety: a cross-sectional study on the six European countries. Dentistry Journal. 2022; 10: 209.

[4] Kvesić AJ, Hrelja M, Lovrić Ž, Šimunović L, Špiljak B, Supina N, et al. Possible risk factors for dental fear and anxiety in children who suffered traumatic dental injury. Dentistry Journal. 2023; 11: 190.

[5] Rodríguez ÓA, Laverde M, Rojas-Gualdrón DF, Cárdenas JM, Mejía JD, de Farias AL, et al. The level of dental fear and anxiety is higher in children with both severe Molar-Incisor Hypomineralisation and active dental caries lesions compared to children without these conditions. European Archives of Paediatric Dentistry. 2024; 25: 655–662.

[6] Couto BF, Couto GR, Sampaio F. Patient anxiety towards dental treatment: a scoping review. Revista Portuguesa de Estomatologia, Medicina Dentária e Cirurgia Maxilofacial. 2022; 63: 189–197.

[7] Uzel İ, Aydınel B, Ak AT. Evaluation of the risk factors of dental anxiety in children. The Journal of Pediatric Research. 2022; 9: 99–104.

[8] American Academy of Pediatric Dentistry. Behavior guidance for the pediatric dental patient. Pediatric Dentistry. 2018; 40: 254–267.

[9] Shankar A. Assessing dental anxiety among children in a dental clinic waiting room: an observational study. Journal of the Indian Society of Pedodontics & Preventive Dentistry. 2024; 42: 25.

[10] Dhar V, Gosnell E, Jayaraman J, Law C, Majstorović M, Marghalani AA, et al. Nonpharmacological behavior guidance for the pediatric dental patient. Pediatric Dentistry Journal. 2023; 45: 385–410.

[11] Shah RR, Bhattad MS, Chandak A, Kamble J. Assessment of dental anxiety during pulp therapy, restorations & extraction in 6- to 9-year-old children using drawings and questionnaire—a cross sectional study. Asian Journal of Medical Research & Health Sciences. 2024; 2: 9–13.

[12] Clatworthy S, Simon K, Tiedeman M. Child drawing: hospital manual. Journal of Pediatric Nursing. 1999; 14: 10–18.

[13] Guner Onur S, Tonguc Altin K, Demetgul Yurtseven B, Haznedaroglu E, Sandalli N. Children’s drawing as a measurement of dental anxiety in paediatric dentistry. International Journal of Paediatric Dentistry. 2020; 30: 666–675.

[14] Heima M, Stehli K. Reliability and validity of the dental anxiety question used with children. Anesthesia Progress. 2022; 69: 13–19.

[15] Armfield JM. Development and psychometric evaluation of the Index of Dental Anxiety and Fear (IDAF-4C+). Psychological Assessment. 2010; 22: 279–287.

[16] Buldur B, Armfield JM. Development of the Turkish version of the Index of Dental Anxiety and Fear (IDAF-4C+): dental anxiety and concomitant factors in pediatric dental patients. Journal of Clinical Pediatric Dentistry. 2018; 42: 279–286.

[17] Pala SP, Nuvvula S, Kamatham R. Expression of pain and distress in children during dental extractions through drawings as a projective measure: a clinical study. World Journal of Clinical Pediatrics. 2016; 5: 102–111.

[18] American Academy of Pediatric Dentistry. Caries-risk assessment and management for infants, children, and adolescents. Pediatric Dentistry. 2018; 40: 205–212.

[19] Featherstone JDB, Crystal YO, Alston P, Chaffee BW, Doméjean S, Rechmann P, et al. A comparison of four caries risk assessment methods. Frontiers in Oral Health. 2021; 2: 656558.

[20] Özdemir Çelik DS, Deniz E, Demir O, Altan H. Validation of child drawing hospital (CD: H) scale and the role of drawing in the evaluation of Dental anxiety. BMC Oral Health. 2025; 25: 274.

[21] Aminabadi NA, Ghoreishizadeh A, Ghoreishizadeh M, Oskouei SG. Can drawing be considered a projective measure for children’s distress in paediatric dentistry? International Journal of Paediatric Dentistry. 2011; 21: 1–12.

[22] Burns-Nader S, Hernandez-Reif M, Porter M. The relationship between mothers’ coping patterns and children’s anxiety about their hospitalization as reflected in drawings. Journal of Child Health Care. 2014; 18: 6–18.

[23] Wennström B, Nasic S, Hedelin H, Bergh I. Evaluation of the Swedish version of the Child Drawing: Hospital manual. Journal of Advanced Nursing. 2011; 67: 1118–1128.

[24] D’Alessandro G, Alkhamis N, Mattarozzi K, Mazzetti M, Piana G. Fear of dental pain in Italian children: child personality traits and parental dental fear. Journal of Public Health Dentistry. 2016; 76: 179–183.

[25] Çoban Büyükbayraktar Z, Doruk C. Dental anxiety and fear levels, patient satisfaction, and quality of life in patients undergoing orthodontic treatment: is there a relationship? Turkish Journal of Orthodontics. 2021; 34: 234–241.

[26] Soares FC, Lima RA, Salvador DM, de Barros MVG, Dahllöf G, Colares V. Reciprocal longitudinal relationship between dental fear and oral health in schoolchildren. International Journal of Paediatric Dentistry. 2020; 30: 286–292.

[27] Gao S, Lu J, Li P, Yu D, Zhao W. Prevalence and risk factors of children’s dental anxiety in China: a longitudinal study. BMJ Open. 2021; 11: e043647.

[28] Bhat PK, Shekar M, Jayachandra MY. Relationship between dental anxiety with dental caries and periodontal disease among army recruits in Bangalore city—a cross sectional study. Journal of Oral and Maxillofacial Pathology. 2022; 26: 126.

[29] Panda S, Quadri MFA, Hadi IH, Jably RM, Hamzi AM, Jafer MA. Does dental fear in children predict untreated dental caries? An analytical cross-sectional study. Children. 2021; 8: 382.

[30] Padmanabhan V, Islam MS, Habib M, Abdulaziz Z, Goud M, Chaitanya NC, et al. Association between salivary cortisol levels, dental anxiety, and dental caries in children: a cross-sectional study. Dentistry Journal. 2023; 11: 205.

[31] Vlad R, Stoica OE, Stoica AM, Monea M. Assessment of dental anxiety and the prevalence of dental caries in a group of 6–9 years old children. Acta Stomatologica Marisiensis Journal. 2020; 3: 18–23.

[32] Alkuwaiti E, Alshubaili R, AlZahrani N, Khusheim S, AlMunif R, Alharbi N, et al. Dental anxiety among physicians: relationship with oral problems, dental visits, and socio-demographic factors. Patient Preference and Adherence. 2023; 17: 1107–1116.

[33] Appukuttan DP, Tadepalli A, Cholan PK, Subramanian S, Vinayagavel M. Prevalence of dental anxiety among patients attending a dental educational institution in Chennai, India—a questionnaire based study. Oral Health and Dental Management. 2013; 12: 289–294.

[34] Bradt J, Dileo C, Shim M. Music interventions for preoperative anxiety. Cochrane Database of Systematic Reviews. 2013; 2013: CD006908.

[35] Fux-Noy A, Zohar M, Herzog K, Shmueli A, Halperson E, Moskovitz M, et al. The effect of the waiting room’s environment on level of anxiety experienced by children prior to dental treatment: a case control study. BMC Oral Health. 2019; 19: 294.

[36] Halonen H, Salo T, Hakko H, Räsänen P. Association of dental anxiety to personality traits in a general population sample of Finnish University students. Acta Odontologica Scandinavica. 2012; 70: 96–100.

[37] Shapiro M, Melmed RN, Sgan-Cohen HD, Eli I, Parush S. Behavioural and physiological effect of dental environment sensory adaptation on children’s dental anxiety. European Journal of Oral Sciences. 2007; 115: 479–483.

[38] Jayakaran TG, Rekha CV, Annamalai S, Baghkomeh PN, Sharmin DD. Preferences and choices of a child concerning the environment in a pediatric dental operatory. Dental Research Journal. 2017; 14: 183–187.