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

1. Introduction

Dental anxiety is referred to as an anxious or worrisome emotional state occurring against unknown dangers that individuals feel against all kinds of dental procedures [1]. Dental anxiety is a prevalent condition that affects individuals across different age groups and geographical regions and is one of the most important factors in avoiding dental treatment. It also negatively affects the oral health-related quality of life in children and adults [1, 2]. There are many individual, environmental and dental factors that cause dental anxiety in children, such as previous traumatic dental experience, parental anxiety, age of the child. Identifying the etiology of dental anxiety and implementing preventive measures are of great importance for effective management [3, 4]. Dental caries, periodontal problems and tooth loss are more common in children with greater anxiety [5]. It has been reported that patients with greater dental anxiety have longer treatment sessions, postpone appointments, delay treatment and ultimately experience more complex problems [6]. There are many individual, environmental and dental factors that cause dental anxiety in children, such as previous traumatic dental experience, parental anxiety, age of the child [7].

To minimize or avoid the effect of dental anxiety on treatment, it is important to ensure that children’s behavior is properly managed [8]. Determining the pretreatment dental anxiety levels of individuals, especially children, who apply to the dentist allows the pediatric dentist to be prepared for the situations encountered during treatment and to decide on the appropriate management strategy [9]. Determining the level of dental anxiety in pediatric patients is highly important for successful treatment and should be accurately assessed in all its dimensions [10]. For this purpose, many different techniques are currently used, including behavior scoring and projective, psychometric and physiological methods [7].

With picture drawing, a projective technique, the level of fear and anxiety can be determined by depicting the object or creatures that may cause fear in the pictures drawn. Children can effectively convey their emotions through drawings. They can easily express their happiness, dreams, and unwanted emotions such as fear and anxiety through drawing [11]. The Child Drawing: Hospital (CD:H) Scale is one of the most widely used of these techniques and was developed by Clatworthy et al. [12] in the United States to measure the emotional state of hospitalized school-age children in 1999. This scale has recently been used in dentistry to assess dental anxiety during tooth extraction and restorative procedures [11, 13].

Psychometric tests are the most preferred tests due to their ease of application and differ according to the age at which they are applied. These methods are in the form of mutual questions and answers and are based on the child expressing himself or herself verbally [14]. The Index of Dental Anxiety and Fear (IDAF-4C+), a psychometric test, was developed by Armfield to eliminate the theoretical and practical limitations of previous dental fear scales. The IDAF-4C+ consists of 3 submodules analyzing dental anxiety, dental phobia and feared dental stimuli. This new scale is designed so that researchers can use the module related to the topic they will address [15]. Turkish validation of the IDAF-4C scale was performed by Buldur et al. [16] in 2018.

This study aimed to determine the dental anxiety levels of primary school students who underwent oral and dental health screening using the IDAF-4C and the Child Drawing: Hospital (CD:H) Scale and to evaluate the relationship between dental anxiety levels and dental treatment needs. In addition, the correlation between two different anxiety scales used in children was also evaluated.

2. Methodology

2.3 Study design

Children whose families permitted oral and dental health screening were asked to fill out a form containing demographic information (gender, dentist visit) and the IDAF-4C scale, which is used to evaluate dental anxiety and fear before screening. The dental examinations were performed by final-year dental students under the supervision of four licensed pediatric dentists. A dental mirror and explorer (probe) were used during the assessments, and all students wore gloves in accordance with infection control protocols. The screening focused on visual-tactile inspection to evaluate caries status and treatment needs.

The IDAF-4C scale consists of 8 questions and has been translated into many languages. The answers to the IDAF-4C scale, which uses a 5-point Likert scale, range from “disagree” (1) to “agree” (5) (Fig. 1, Ref. [16]). Higher scores indicate greater dental fear. After they were summed and averaged, the scores were evaluated as follows: “No or very little dental anxiety” (score range 1–1.5), “Low dental anxiety” (score range 1.51–2.5), “Average dental anxiety” (score range 2.51–3.5) and “High dental anxiety” (score >3.5) [15]. During the oral and dental health screening, the children’s caries risk groups and dental treatment needs were also recorded on the relevant form. Caries risk was determined according to American Academy of Pediatric Dentistry (AAPD) guideline “Caries-Risk Assessment and Management for Infants, Children and Adolescents” and Caries Management by Risk Assessment (CAMBRA) form was used [18]. It was given scores for each “yes” checked on the risk assessment form with a score of −1 for yes’s in column protective factors, and +2 and +3, respectively, for yes’s in columns risk factors, social/behavioral/medical and disease indicators. The caries risk level was determined based on the final total. Low = −8 to −2; Moderate = −1 to +2; High = +3 and/or more [19].

Fig. 1.The index of dental anxiety and fear (IDAF-4C) [16].

After the screening, the children were asked to provide a picture to evaluate anxiety during the oral and dental health screenings. For the pictures drawn, the statements “Your teeth were checked by the dentists today. I would like you to draw a picture with you and the dentist in it, thinking about the time you spent here today and what you experienced”. On a table and chair at an appropriate height, they were asked to draw on blank A4 paper with dry paints containing 8 basic colors. They were told that they could start when they were ready and stop drawing whenever they wanted, and their papers were collected when the drawing was finished (Fig. 2). The Child Drawing: Hospital (CD:H) Scale was used in the evaluation. According to the score calculated for each child, the anxiety level specified in the scale was obtained (Fig. 3, Ref. [12]). Anxiety levels based on the total score obtained in CD:H were as follows: 43 points or less, very low stress; 44–83 points, low stress; 84–129 points, average stress; 130–167 points, above average; and 168 points or above very high stress [12, 20]. The drawings included in the study were interpreted by two different observers.

Fig. 2.Sample pictures corresponding to varying levels of stress and their associated CD:H scores. (a) This picture indicates very low stress, and the CD:H score was 39. (b) This picture indicates low stress, and the CD:H score was 76. (c) This picture indicates the average stress, and the CD:H score was 116. (d) This picture indicates above average stress, and the CD:H score was 139.

Fig. 3.Children Drawing: Hospital (CD:H) rating scale [12].

3. Results

Parents of 853 children consented to participate in the study and the oral and dental health screening. A total of 156 children who agreed to draw were included in the study. However, 10 children who incompletely completed the IDAF-4C scale were excluded and the study was completed with 146 children. Of the 146 children in the study, 54 (37%) were girls, and 92 (63%) were boys. The children were 5th-grade students aged between 10 and 12. The number of those who had visited a dentist before was 126 (86.3%), and the number who had never visited a dentist was 20 (13.7%). When the caries risk group distribution of the children was analyzed, 64 children (43.8%) were in the high caries risk group (Table 1).

The mean IDAF-4C score of the children participating in the study was 2.15 ± 0.71. There was no significant difference between girls and boys (p = 0.735) among those who had visited a dentist before and those who had not visited a dentist before in terms of IDAF-4C scores (p = 0.948).

The agreement between the first observer (HA) and second observer (NG) on the Child Drawing: Hospital (CD:H) Scale was 0.998.

The median Child Drawing: Hospital (CD:H) score was 88 (min: 28–max: 145). There was a significant difference among the medians of the CD:H scores as a result of the evaluation by the dentist according to gender (p < 0.001). The median CD:H score of the girls was “low stress” (median: 63.5), and the median CD:H score of the boys was “average stress” (median: 99). No significant difference was found among the medians of the CD:H scores of students who had or had not visited a dentist before (p = 0.876) (Table 2).

According to the IDAF-4C score distributions, 67 (45.9%) of the 146 students who participated in the study were found to have low dental anxiety, and 42 (28.8%) were found to have average dental anxiety. It was observed that girls and boys, those who had visited a dentist before and those who had not, mostly showed “low dental anxiety” (Table 3).

When CD:H score distributions were evaluated, 67 (45.9%) and 55 (37.7%) children showed “average stress” and “low stress” values, respectively. “Low stress” scores were higher in girls, and “average stress” scores were greater in boys and in those who had visited a dentist before and those who had not (Table 4).

Correlation relationships shown in the heatmap: A significant relationship was found between gender and CD:H score. Male gender significantly increased the CD:H ratio (p < 0.001). No significant relationship was found between gender and the IDAF-4C score (p = 0.38). No correlation was found between the IDAF-4C anxiety scale and the CD:H anxiety scale. There was a significant relationship between dental treatment needs, caries risk group and anxiety scale score (Fig. 4).

Fig. 4.The correlation relationships are shown in a heatmap. CD:H and IDAF-4C were created to visualize the relationship between scale results and variables such as gender, frequency of dental visits, caries risk groups and treatment needs. The intensity of the colours used in the heatmap reflects the power of correlation. CD:H: Child Drawing: Hospital; IDAF-4C: Index of Dental Anxiety and Fear Scale.

4. Discussion

Children are often limited in verbalizing feelings and emotions due to cognitive development. When children cannot express certain emotions, a method is needed to reflect their feelings and expectations. For children with limited verbal skills, drawing is a universal way to convey emotions regardless of age, gender, socioeconomic status or ethnic origin [11]. This study, which aimed to measure the dental anxiety in children undergoing oral dental health screening by using the IDAF-4C, a psychometric method, and the CD:H scale, a projective method, found for the first time that children experienced an average level of anxiety during oral dental health screening in the school environment regardless of gender.

There are a limited number of studies that have assessed dental anxiety using the CD:H scale, which has been used in dentistry in recent years. These studies measured dental anxiety in children during procedures requiring local anaesthesia, such as tooth extraction, filling and root canal treatment [11, 17, 21]. The number of dental studies conducted in the Turkish population is rather low [13]. Turkish validation was also carried out by Özdemir et al. [20].

One of the most important personal factors in the occurrence of dental anxiety is the child’s gender, and differences have been observed between studies [16, 22, 23]. Onur et al. [13] reported that there was no significant difference between girls and boys when CD:H scores were evaluated according to gender, and that the mean scores of girls were considered “low stress” and those of boys were considered “average stress”. Some studies concluded that although there were no significant differences between girls and boys, boys had higher CD:H scores than girls [17, 21]. Similarly, in the present study, “low stress” was observed in girls and “average stress” was observed in boys. However, CD:H scores were found to be significantly higher in boys. Studies using the IDAF-4C scale have also reported different results between the sexes. In a study by Buldur et al. [16], girls were found to have significantly higher IDAF-4C scores than boys. Another study suggested that dental anxiety was independent of gender [24]. Büyükbayraktar et al. [25] reported that IDAF-4C scores were lower in girls, although this difference was not statistically significant. Similarly, the present study found no significant difference between the IDAF-4C scores of girls and boys. The fact that the anxiety levels of boys with low anxiety levels on the IDAF-4C scale increased on the CD:H scale may be because Turkish boys have more difficulty expressing their emotions through drawing than girls.

Important determinants of dental anxiety include caries risk group, level of treatment required, first dental visit and frequency of these visits. Many people with dental anxiety postpone treatment even if they are aware of the need for treatment or only have the teeth that cause pain treated. As a result, the number of active caries lesions and the incidence of caries increase [26, 27, 28]. Many studies have reported a significant relationship between dental anxiety and caries risk [28, 29]. Padmanabhan et al. [30] concluded that the prevalence and incidence of caries were highest in the group with the highest dental anxiety and that there was a significant relationship between them. Vlad et al. [31] concluded that the number of caries or missing teeth was greater in patients with high dental anxiety. In this study, similar to the literature, a positive correlation was found between the caries risk group, dental treatment needs and anxiety levels.

Many studies of dental anxiety have reported that people who rarely visit the dentist have significantly greater dental anxiety than those who visit the dentist more frequently [15, 16, 32]. In addition, Appukuttan et al. [33] reported that there was no relationship between dental experience and dental anxiety. This study revealed no significant differences in either the IDAF-4C score or the CD:H score between those who had previously visited a dentist and those who had never visited a dentist. The reason for this finding is that no invasive procedures were performed during the oral dental health screening, only the children’s teeth were examined.

Dental anxiety in children is also influenced by many environmental factors, such as the appearance of the dentist, the physical condition of the waiting room, the gender of the assistant, the waiting time, and the presence of toys, music or odours in the environment [34, 35, 36]. Shapiro et al. [37] investigated the effect of a sensory adapted Snoezelen environment on dental anxiety in children. The Snoezelen environment is characterised by a partially dimmed room with lighting effects, vibrating acoustic stimuli and deep pressure. The results showed that both behavioural and psychophysiological indicators of relaxation were significantly improved in the sensory-adapted environment (SDE) compared to a traditional dental environment. In a study by Jayakaran et al. [38] dental anxiety decreased when the clinical environment in which children were first examined was prepared with illustrated walls, pleasant smells, toys they liked, music and colours to make them feel good. In the present study, as the oral and dental health examinations were carried out in a familiar place where children felt more accessible, such as their neighbourhoods and schools, outside the dental clinic environment, we believe that they were minimally affected by environmental factors and that their dental anxiety levels may have been influenced by this situation.

As a result of the literature review, no study was found in which IDAF-4C and CD:H scales were used together. No correlation was found between the two scales in this study. The main reason for this finding is that the scales were developed using different methods. Projective methods (CD:H) assess anxiety by interpreting pictures drawn for a specific purpose and are the preferred scales for children under 6 years of age. In this way, it is possible to get an idea of the emotions hidden in the subconscious. It is also preferred for children who cannot express themselves verbally and whose mental development is not yet complete. Psychometric methods (IDAF-4C) are based on children’s verbal communication skills and are question and answer scales. It can be the first choice for children over 6 years of age. Differences in the method of administration, differences in emotional expression based on culture and gender, and differences in children’s communication skills may have caused the lack of correlation between the two scales.

Limitations of this study include its single-centre design, although it is a large-scale school survey. This study did not assess several known factors associated with dental anxiety, such as parental anxiety, previous negative dental experiences, socioeconomic status and family educational background. Furthermore, the lack of invasive procedures—as only oral examinations were performed—and the fact that these examinations were performed by fifth-year dental students may be considered limitations that could have influenced the measured levels of anxiety. In addition, as this study did not compare anxiety levels between the school environment and a traditional dental clinic environment, further research is needed to investigate potential differences.

5. Conclusions

According to the present study, drawings can reveal a significant amount of information about children’s emotional states, and children’s drawings are a proper nonverbal self-report technique for evaluating anxiety in the dental environment. At the same time, the IDAF-4C scale is also an easy-to-apply, useful, Children can effectively, and reliable option for assessing dental anxiety in children. Age and developmentally appropriate scales should be selected to assess children’s dental anxiety. The frequency of oral and dental health screening in school environments, where dental anxiety is thought to be lower, should be increased. This would allow early identification of children with dental anxiety, allowing for timely intervention and preventive measures.

Availability of data and materials

The data used to support the findings of this study can be made available upon request to the corresponding author.

Author contributions

NDŞ—Design; Data Collection and/or Processing; Analysis and/or Interpretation Literature Review; Writing; Critical Review. CBN—Design; Data Collection and/or Processing; Critical Review. AC—Design; Data Collection and/or Processing. HA—Design; Critical Review. All authors reviewed and revised drafts and approved the final version for submission.

Ethics approval and consent to participate

The ethical approval required for this study was obtained from Tokat Gaziosmanpaşa University Faculty of Medicine Clinical Research Ethics Committee (Approval No: 21-KAEK-277/Date: December 2021). Written informed consent was obtained from the children and their parents prior to the oral and dental health screening.

Acknowledgment

Not applicable.

Funding

This research received no external funding.

Conflict of interest

The authors declare no conflict of interest.