Assessment of dental anxiety using the Child Drawing: Hospital scale and oral health-related quality of life in children diagnosed with Familial Mediterranean Fever

Background: The assessment of dental anxiety in pediatric patients is essential for achieving successful dental treatment as it may negatively impact oral health-related quality of life (OHRQoL). This cross-sectional clinical observational study aimed to compare dental anxiety levels, assessed using the Child Drawing: Hospital (CD:H) scale, and OHRQoL between children diagnosed with Familial Mediterranean Fever (FMF) at an early stage and healthy controls. Methods: This study included 37 children aged 8–12 years diagnosed with FMF and 37 healthy children as controls. Their behavior during dental examination was evaluated using the Frankl Behavior Rating Scale, and their anxiety was assessed at the end of the examination using drawings interpreted with the CD:H scale. Dental anxiety and fear were measured with the Dental Anxiety and Fear Scale (IDAF-4C), and OHRQoL was assessed using the Child Oral Health Impact Profile-Short Form 19 (COHIP-SF19). Decayed, missing, filled teeth (DMFT/dmft) indices of all children were recorded. Disease severity in children with FMF was determined using the Modified Pras Severity Score based on symptoms reported in the patient history. Data were analyzed using Jamovi, and statistical significance was defined as p < 0.05. Results: There were no statistically significant differences between children with FMF and healthy controls in CD:H, COHIP-SF19, IDAF-4C, DMFT/dmft, or Frankl scores (all p > 0.05). Frankl scores were negatively correlated with IDAF-4C scores (ρ = −0.355, p = 0.002). CD:H scores were negatively correlated with COHIP-SF19 scores (ρ = −0.241, p = 0.039). Among children with FMF, Pras severity scores were negatively correlated with Frankl scores (ρ = −0.341, p = 0.039). Conclusions: Children diagnosed with FMF showed similar levels of dental anxiety, stress, behavior, and OHRQoL compared with healthy controls. This study offers a novel perspective for future research on psychological and behavioral aspects of chronic pediatric conditions in dentistry.

Child Drawing: Hospital scale; Oral health-related quality of life; Dental anxiety; Familial Mediterranean Fever; Pediatric dentistry

[1] Ben‐Chetrit E, Touitou I. Familial Mediterranean fever in the world. Arthritis Care & Research. 2009; 61: 1447–1453.

[2] Eksi A, Molzan J, Savasir I, Güler N. Psychological adjustment of children with mild and moderately severe asthma. European Child & Adolescent Psychiatry. 1995; 4: 77–84.

[3] Claridge AM, J Powell O. Children’s experiences of stress and coping during hospitalization: a mixed-methods examination. Journal of Child Health Care. 2023; 27: 531–546.

[4] Gortmaker SL, Walker DK, Weitzman M, Sobol AM. Chronic conditions, socioeconomic risks, and behavioral problems in children and adolescents. Pediatrics. 1990; 85: 267–276.

[5] Van Dongen-Melman JE. Developing psychosocial aftercare for children surviving cancer and their families. Acta Oncologica. 2000; 39: 23–31.

[6] Klingberg G, Broberg AG. Dental fear/anxiety and dental behaviour management problems in children and adolescents: a review of prevalence and concomitant psychological factors. International Journal of Paediatric Dentistry. 2007; 17: 391–406.

[7] Armfield JM, Spencer A, Stewart JF. Dental fear in Australia: who’s afraid of the dentist? Australian Dental Journal. 2006; 51: 78–85.

[8] 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.

[9] Locker D, Shapiro D, Liddell A. Negative dental experiences and their relationship to dental anxiety. Community Dental Health. 1996; 13: 86–92.

[10] Klingberg G. Reliability and validity of the Swedish version of the Dental Subscale of the Children’s Fear Survey Schedule, CFSS-DS. Acta Odontologica Scandinavica. 1994; 52: 255–256.

[11] Bhatia MS, Goyal A. Anxiety disorders in children and adolescents: need for early detection. Journal of Postgraduate Medicine. 2018; 64: 75–76.

[12] Humphris G, King K. The prevalence of dental anxiety across previous distressing experiences. Journal of Anxiety Disorders. 2011; 25: 232–236.

[13] Clatworthy S, Simon K, Tiedeman ME. Child Drawing: Hospital—an instrument designed to measure the emotional status of hospitalized school-aged children. Journal of Pediatric Nursing. 1999; 14: 2–9.

[14] 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.

[15] 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.

[16] 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.

[17] Buldur B, Armfield J. 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.

[18] Armfield JM. Development and psychometric evaluation of the index of dental anxiety and fear (IDAF-4C+). Psychological Assessment. 2010; 22: 279–287.

[19] Sischo L, Broder H. Oral health-related quality of life: what, why, how, and future implications. Journal of Dental Research. 2011; 90: 1264–1270.

[20] Broder HL, McGrath C, Cisneros GJ. Questionnaire development: face validity and item impact testing of the child oral health impact profile. Community Dentistry and Oral Epidemiology. 2007; 35: 8–19.

[21] Frankl S. Should the parent remain with the child in the dental operatory? Journal of Dentistry for Children. 1962; 29: 150–163.

[22] Pras E, Livneh A, Balow JE III, Pras E, Kastner DL, Pras M, et al. Clinical differences between North African and Iraqi Jews with familial Mediterranean fever. American Journal of Medical Genetics. 1998; 75: 216–219.

[23] Makay B, Emiroğlu N, Unsal E. Depression and anxiety in children and adolescents with familial Mediterranean fever. Clinical Rheumatology. 2010; 29: 375–379.

[24] Fabris MA, Lange-Küttner C, Shiakou M, Longobardi C. Children’s drawings: evidence-based research and practice. Frontiers in Psychology. 2023; 14: 1250556.

[25] Altan H, Sonmezgoz E, Belevcikli M, Kasap T. Assessment of dental anxiety and fear levels of pediatric patients diagnosed with familial Mediterranean fever. Annals of Medical Research. 2022; 29: 831–835.

[26] Tong A, Lowe A, Sainsbury P, Craig JC. Experiences of parents who have children with chronic kidney disease: a systematic review of qualitative studies. Pediatrics. 2008; 121: 349–360.

[27] Ozen S, Demirkaya E, Erer B, Livneh A, Ben-Chetrit E, Giancane G, et al. EULAR recommendations for the management of familial Mediterranean fever. Annals of the Rheumatic Diseases. 2016; 75: 644–651.

[28] Custódio NB, Mathias FB, Cademartori MG, Goettems ML. Translation and cross-cultural adaptation of the “Child Drawing: Hospital” (CD:H) scale for paediatric dentistry in Brazil. Brazilian Research in Pediatric Dentistry and Integrated Clinic. 2023; 23: e210229.

[29] Malchiodi CA. Understanding children’s drawings. Guilford Press: New York. 2022.

[30] Sönmez AÖ, Sönmez HE, Çakan M, Yavuz M, Keskindemirci G, Aktay Ayaz N. The evaluation of anxiety, depression and quality of life scores of children and adolescents with familial Mediterranean fever. Rheumatology International. 2020; 40: 757–763.

[31] Cianetti S, Lombardo G, Lupatelli E, Pagano S, Abraha I, Montedori A, et al. Dental fear/anxiety among children and adolescents. A systematic review. European Journal of Paediatric Dentistry. 2017; 18: 121–130.

[32] Silva TMC, Alves LAC, Garrido D, Watanabe A, Mendes FM, Ciamponi AL. Health and oral health-related quality of life of children and adolescents with chronic kidney disease: a cross-sectional study. Quality of Life Research. 2019; 28: 2481–2489.

[33] Mohseni Homagarani Y, Adlparvar K, Teimuri S, Tarrahi MJ, Nilchian F. The effect of diabetes mellitus on oral health-related quality of life: a systematic review and meta-analysis study. Frontiers in Public Health. 2023; 11: 1112008.

[34] Makay B, Ünsal E, Arslan N. Quality of life of school-age children with familial Mediterranean fever: a preliminary study. Pediatric Rheumatology. 2008; 6: P206.