Home Print this page Email this page Small font size Default font size Increase font size
Users Online: 2156
Home About us Editorial board Search Ahead of print Current issue Archives Submit article Instructions Subscribe Contacts Login 

 Table of Contents 
Year : 2019  |  Volume : 8  |  Issue : 6  |  Page : 2036-2041  

Factors influencing anxiety levels in children undergoing dental treatment in an undergraduate clinic

Department of Paediatric and Preventive Dentistry, Saveetha Dental College and Hospitals, Saveetha Institute of Medical and Technical Sciences, Saveetha University, Chennai, Tamil Nadu, India

Date of Submission17-Mar-2019
Date of Decision19-Mar-2019
Date of Acceptance03-Apr-2019
Date of Web Publication26-Jun-2019

Correspondence Address:
Dr. Deepa Gurunathan
Department of Paediatric and Preventive Dentistry, Saveetha Dental College and Hospitals, Saveetha Institute of Medical and Technical Sciences, Saveetha University, 162, Poonamallee High Road, Chennai - 600 077, Tamil Nadu
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jfmpc.jfmpc_229_19

Rights and Permissions

Introduction: Dental anxiety is a kind of fear exerted due to threatening stimuli. Assessing a child's dental anxiety level is very important to perform a particular treatment. The aim of this study is to examine the various factors that determine the anxiety levels in children and evaluate their anxiety levels. Materials and Methods: A total of 50 children participated in the survey conducted. Each participant had fulfilled the inclusion and exclusion criteria to answer the questionnaire. It included questions regarding their habits, fears, and dental visit experience. Evaluation of their anxiety levels was done using the facial image scale (FIS) and the modified dental anxiety scale and was correlated with various factors using the Statistical Package for Social Science Software. Results: Female children are more anxious than male children toward dental treatment. About 38% were anxious and 16% refused while undergoing radiographic examination and showed significant anxiety levels (P = 0.012). About 16% of the population were highly uncooperative and were necessary to implement behavioral shaping techniques on them. It influences the FIS anxiety score before initiation of the treatment (P = 0.003). About 48% of children had maintained a good rapport with the dentist and showed strong significance with the child's anxiety (P = 0.025). Conclusion: Gender and behavior of the child while diagnosis and radiographic examination, implementation of behavioral shaping techniques, and rapport developed between child and dentist are all influencing factors of dental anxiety. The number of visits to the dental clinic, socioeconomic status, kind of amount of consumption of sugars, and type of treatment being done do not contribute to a child's anxiety level.

Keywords: Behavioral shaping techniques, dental anxiety, facial image scale, modified dental anxiety scale, threatening stimuli

How to cite this article:
Kothari S, Gurunathan D. Factors influencing anxiety levels in children undergoing dental treatment in an undergraduate clinic. J Family Med Prim Care 2019;8:2036-41

How to cite this URL:
Kothari S, Gurunathan D. Factors influencing anxiety levels in children undergoing dental treatment in an undergraduate clinic. J Family Med Prim Care [serial online] 2019 [cited 2021 Sep 24];8:2036-41. Available from: https://www.jfmpc.com/text.asp?2019/8/6/2036/261381

  Introduction Top

Dental anxiety is one of the primary emotions when entering the clinic and arises due to threatening stimuli, which aggravates the individual to respond in certain ways. This has been a potential problem in patient management. It leads to various psychological, cognitive, and behavioral consequences.[1] There are physiological symptoms like sweating, increase in pulse rate, blood pressure, and psychological symptoms like confusion, panic, and inability to concentrate.[2],[3] There are many patients who avoid or neglect treatment because of their fear to dental procedures. According to a survey conducted among 6000 people, 58% of the respondents delayed their dental treatment because of their fear. It is found that 80% of the Americans have some anxiety towards dental treatment while 5-14% of them exeperience intense dental anxiety. This makes their oral hygiene worsen leading to complications later.[4]

Apart from the adults, dealing with the anxiety levels of child is even more complicated. The dentists' appearance, environment of the clinic, and instrument make the child more anxious. The behavioral manifestations in the form of crying, screaming, and avoiding dental treatment decrease the efficiency of dental health service.[2] Various behavior shaping techniques including tell-show-do (TSD), positive reinforcement, effective communication, modeling and distraction are used to tackle children who are anxious and seem too uncooperative.[5] Studies have proved that fear of dental treatment in children may result in treatment management difficulties.[6] The behavioral management problems are also related to dental factors like earlier negative treatment experiences, injection, and drilling, which show negative emotional loads.[7],[8]

Physiological measures such as blood pressure, pulse rate, and psychological measures like modified child dental anxiety scale (MCDAS), Venham's picture test (VPT), and facial image scale (FIS) are used to assess the anxiety levels in children.[9] Various patterns to evaluate the anxiety in children are studied and factors such as age of the child, gender, number of dental visits, oral hygiene habits, and socioeconomic status contribute to this. The attitude of the dentist toward the patient is a major factor in deciding ones anxiety level and behavior.[10] For a good treatment, a good rapport between the two should be present creating positive impact.

This study aims to assess the various factors influencing the dental anxiety levels in children.

  Materials and Methods Top

Before the commencement of the study approval was obtained from the Saveetha Dental College institutional review board. The patients along with their guardians were invited to take up the survey. An informed consent was taken from the parent followed by distribution of the questionnaire. The questionnaire was developed and pretested among 10 other pair of children and parents. Modifications in questionnaire were done according to the requirements. A total of 50 children had been chosen for the study comprising 30 girls and 20 boys.

The inclusion criteria are as follows:

  1. Children of 6 to 10 age group
  2. Parents who are willing to take up the surgery
  3. Children who are in need of oral prophylaxis.

The exclusion criteria are as follows:

  1. Highly uncooperative patient
  2. Child having any kind of systemic diseases
  3. Children who are on regular medications
  4. Parents who deny taking up the survey.

The questionnaire was answered by the parents or guardians of the children. The children were also asked to grade anxiety level before and after the treatment using MDAS and FIS.

Facial image scale

The FIS involved the assessment of anxiety levels by making the child choose a particular facial expression before and after the treatment. The facial expressions range from a score of 1 to 5 with the following interpretations:

1- Very happy

2- Happy

3- Moderate

4- Unhappy

5- Very unhappy.

The FIS scores were correlated with the mean scores of:

  1. Rapport between child and dentist
  2. Implementation of behavioral shaping techniques.

Modified dental anxiety scale

The MDAS comprises a set of five standard questions to assess the anxiety levels of children ranging from not anxious to extremely anxious. This is one of the most reliable methods to measure dental anxiety. The following are the list of questions and interpretation of the scores:

The scores of all the five set of questions were added to obtain the total MDAS score. This total score was used to correlate the anxiety levels of children with the mean of the following factors:

  1. Gender
  2. Brushing habits
  3. Dietary habits
  4. Consumption of sugars
  5. Socioeconomic status
  6. Number of dental visits
  7. Child behavior while diagnosing and x-ray
  8. Type of treatment.

The data were tabulated and analyzed using the Statistical Package for Social Science Version 11.5. The independent sample t-test and Mann-Whitney test were performed for assessing the mean score differences along with the P value.

  Results Top

The number of participants obtained through the survey was 50. These participants were from the age group 6 to 10 years. The following are tables depicting the frequency of responses for every parameter and their correlation with the anxiety levels score. Gender has a significant value of P = 0.018. From [Table 1] and [Table 2], it is seen that 38% of children were anxious and 16% of them refused while undergoing radiographic examination and show significance with anxiety levels (P = 0.012). Other parameters such as brushing habits (P = 0.518), dietary habits (P = 0.119), consumption of sugars (P = 0.776), socioeconomic status (P = 0.351), number of dental visits (P = 0.497), treatment performed (P = 0.659) show no significance. From [Table 1] and [Table 3], we observe 16% of the population were highly uncooperative and were necessary to implement behavioral shaping techniques on them. It influences the FIS anxiety score before initiation of the treatment (P = 0.003). About 48% of the children had maintained a good rapport with the dentist and showed strong significance with the child's anxiety (P = 0.025).
Table 1: Frequency of responses for each parameter in percentage

Click here to view
Table 2: Correlation of parameters and MDAS (modified dental anxiety scale) score*

Click here to view
Table 3: Correlation of parameters and FIS (facial image scale) pre- and posttreatment score*

Click here to view

  Discussion Top

Dental anxiety in children is one of the major challenges faced in the field of dentistry. It poses a problem to the dentist as well as to the parent.[11] The early assessment of dental anxiety is very much important to facilitate the diagnosis and a guaranteed pleasant dental visit.[12] Avoidance of dental care can lead to more difficulty in behavioral management of the child and poor oral hygiene. According to certain studies, the prevalence of dental anxiety among children in the age of 5 to 10 years in India was found to be 6.3%.[13] Improper brushing and dietary habits contribute to the development of poor hygiene. In the study conducted, 80% of the children had brushed only once increasing risk of caries prevalence as shown in [Figure 1] and it was found that the brushing habit had no significance with the anxiety of children as shown in [Figure 2] (P = 0.518). Similarly, excess consumption of sugars by 54% of children [Figure 1]contributes to poor oral hygiene but has no significance with dental anxiety of children (P = 0.776).
Figure 1: Questionnaire

Click here to view
Figure 2: Facial image scale interpretation

Click here to view

According to certain studies, the age of the child is a factor having an impact on a child's anxiety level and that the cognitive ability of a child develops with increase in age and more understanding.[14] As shown in [Figure 1] the study comprised of 60% females and 40% males and influenced dental anxiety due to its strong significance with the MDAS score (P = 0.018). The children who had no siblings were comparatively more anxious than the ones who had an elder sibling being as role models for them. This is in concordance with a study by Aminabedi NA et al.[15] When stating about the socioeconomic status of each child, there is no significance with the anxiety levels in children. Another parameter to be considered is the type of treatment and the way it is being performed on the child: 50% underwent restorative treatment and 8% had undergone extraction and oral prophylaxis individually. According to a study, higher anxiety levels were noticed in children while performing an extraction due to the use of needles and while injecting. This being a painful procedure makes the child uncooperative. It was reported that local anesthesia injections increase the dental anxiety scores and the lowest score was linked to oral prophylaxis.[16],[17] This is not in concordance with result of this study because oral prophylaxis was related to higher anxiety levels. Secondary to injections, x-rays are considered to be a negatively rated procedure. Literature suggest that placement of the x-ray film can cause unpleasant sensations such as gagging making the child increase the anxiety levels and refuse treatment.[18] About 38% were anxious and 16% refused while radiographic examination. The behavior of the child while diagnosing and radiographic examination is a major factor influencing ones anxiety and the highest level is seen in children who refuse during the stage of diagnosis.

Children often require parent assistance while a treatment is being done. About 28% of the population had their parents by their side. This makes the child obey to the instructions given by the dentist more easily. Various behavioral shaping techniques such as TSD, live, and filmed modeling technique are some coping strategies for the child. About 38% of the children were being managed to make them comfortable and 16% of them were highly uncooperative indicating the necessity to implement various techniques. The implementation of behavioral shaping techniques is in correlation with evaluation of a child's anxiety before the treatment. Apart from the above-discussed factors that influence anxiety, both FIS and MDAS scores were useful in getting to know each individuals score and the manner in which each child has to be dealt with [Figure 2] and [Figure 3].[19] MDAS score is a more valid and reliable form of scale. This scale provides accurate information about the anxiety levels of children in the waiting room or while undergoing treatment such as oral prophylaxis, restorations which requires tooth drillling or usage of injections in extractions. Children tend to get more anxious due to the drilling sounds and the noise of other children shouting. It has been reported that the environment in the dental office also influences ones anxiety levels.[20] Various instruments which are used, the smell in the clinic, the communication of the dentist with the child and his/her attire plays a major role.[21],[22] A study indicates that regular outfits are preferred by children under the age of 8 years whereas children above the age of 8 years preferred white coat and surgical scrubs.[23] When stating about the kind of rapport developed between child and dentist, it has to be solely based on trust ensuring the best treatment. This sets up a treatment alliance and its seen that a child who has developed a good rapport with the dentist has lesser level of anxiety towards dental treatment.[24]
Figure 3: Modified dental anxiety scale

Click here to view

  Conclusion Top

The results indicate that gender, behavior of child while diagnosis and radiographic examination, behavioral shaping techniques before treatment, and rapport developed between child and dentist are influencing factors of dental anxiety. Children are highly anxious during oral prophylaxis and extractions. X-rays contribute to the anxiety levels in children. Other factors like socioeconomic status, number of siblings, type of treatment, amount of sugar consumption, and brushing habits do not influence a child's anxiety level. The environment, smell, and attire of dentist in the dental office are to be considered while dealing with children to create a positive impact.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Kritsidima M, Newton T, Asimakopoulou K. The effects of lavender scent on dental patient anxiety levels: A cluster randomised-controlled trial. Community Dent Oral Epidemiol 2010;38:83-7.  Back to cited text no. 1
Yuwannisa M, Runkat J, Indriyanti R. Dental anxiety level of children patient during dental treatment using CFSS-DS questionnaire. Padjadjaran J Dent 2013;25:1-9.  Back to cited text no. 2
Taylor S. Nature and measurement of anxiety sensitivity. J Anx Disorder 1996;10:425-51.  Back to cited text no. 3
Scott DS, Hirschman R. Psychological aspects of dental anxiety in adults. J Am Dent Assoc 1982;104:27-31.  Back to cited text no. 4
Bandura A, Menlove FL. Factor determining vicarious extinction symbolic modeling. J Pers Soc Psychol 1968;8:99-108.  Back to cited text no. 5
Van Wijk AJ, Hoogstraten J. Experience with dental pain and fear of dental pain. J Dent Res 2005;84:947-50.  Back to cited text no. 6
Klages U, Ulusoy Ö, Kianifard S, Wehrbein H. Dental trait anxiety and pain sensitivity as predictors of expected and experienced pain in stressful dental procedures. Eur J Oral Sci 2004;112:477-83.  Back to cited text no. 7
Jamieson LM, Thomson WM, McGee R. An assessment of the validity and reliability of dental self-report items used in a National Child Nutrition Survey. Community Dent Oral Epidemiol 2004;32:49-54.  Back to cited text no. 8
Sullivan C, Schneider PE, Musselman RJ, Dummett CO Jr, Gardiner D. The effect of virtual reality during dental treatment on child anxiety and behavior. ASDC J Dent Child 2000;67:193-6.  Back to cited text no. 9
Ten Berge M, Veerkamp JS, Hoogstraten J, Prins PJ. Childhood dental fear in the Netherlands: Prevalence and normative data. Community Dent Oral Epidemiol 2002;30:101-7.  Back to cited text no. 10
Merdad L, El-Housseiny AA. Do children's previous dental experience and fear affect their perceived oral health-related quality of life (OHRQoL)? BMC Oral Health 2017;17:47.  Back to cited text no. 11
Buchanan H, Niven N. Validation of a facial image scale to assess child dental anxiety. Int J Paediatr Dent 2002;12:47-52.  Back to cited text no. 12
Chhabra N, Chhabra A, Walia G. Prevalence of dental anxiety and fear among five to ten year old children: A behaviour based cross sectional study. Minerva Stomatol 2012;61:83-9.  Back to cited text no. 13
Rãducanu AM, Feraru V, Herteliu C, Anghelescu R. Assessment of the prevalence of dental fear and its causes among children and adolescents attending a department of paediatric dentistry in Bucharest. OHDMBSC 2009;8:42-9.  Back to cited text no. 14
Aminabadi NA, Sohrabi A, Erfanparast L, Oskouei SG, Ajami BA. Can birth order affect temperament, anxiety and behavior in 5 to 7-year-old children in the dental setting? J Contemp Dental Pract 2011;12:225-31.  Back to cited text no. 15
Al-Madi EM, AbdelLatif H. Assessment of dental fear and anxiety among adolescent females in Riyadh, Saudi Arabia. Saudi Dent J 2002;14:77-81.  Back to cited text no. 16
Humphris GM, Dyer TA, Robinson PG. The modified dental anxiety scale: UK general public population norms in 2008 with further psychometrics and effects of age. BMC Oral Health 2009;9:20.  Back to cited text no. 17
John MT. Dental anxiety is considerably associated with pain experience during dental procedures. J Evid Based Dent Pract 2013;13:29-30.  Back to cited text no. 18
Freeman R. Barriers to accessing and accepting dental care. Br Dent J 1999;18:81-4.  Back to cited text no. 19
Nirmala SV, Veluru S, Nuvvula S, Chilamakuri S. Preferences of dentist's attire by anxious and nonanxious Indian children. J Dent Child (Chic) 2015;82:97-101.  Back to cited text no. 20
Kamavaram Ellore VP, Mohammed M, Taranath M, Ramagoni NK, Kumar V, Gunjalli G. Children and parent's attitude and preferences of dentist's attire in pediatric dental practice. Int J Clin Pediatr Dent 2015;8:102-7.  Back to cited text no. 21
Asokan A, Kambalimath HV, Patil RU, Maran S, Bharath KP. A survey of the dentist attire and gender preferences in dentally anxious children. J Indian Soc Pedod Prev Dent 2016;34:30-5.  Back to cited text no. 22
[PUBMED]  [Full text]  
Ravikumar D, Gurunathan D, Karthikeyan S, Subbramanian EM, Samuel VA. Age and Environment Determined Children's Preference Towards Dentist Attire-A Cross-Sectional Study. Journal of clinical and diagnostic research. JCDR 2016;10:ZC16.  Back to cited text no. 23
Chandrapooja J, Selvarasu K. Behavioural management techniques in pediatric clinic. Int J Pharm Bio Sci 2016;6:10-5.  Back to cited text no. 24


  [Figure 1], [Figure 2], [Figure 3]

  [Table 1], [Table 2], [Table 3]

This article has been cited by
1 Laser acupuncture and intravascular laser irradiation of blood for management of pediatric dental anxiety
Celia R. G. Rangel,Sérgio L. Pinheiro
Journal of Oral Science. 2021;
[Pubmed] | [DOI]
2 A comparative evaluation of role of gender, age and socioeconomic status on perceived dental anxiety of 4-8 years old children using two scales
Sukhdeep Singh,Nikhil Grover,Dhirja Goel,Neha Awasthi,Deepak Khandelwal
International Journal of Oral Health Dentistry. 2021; 6(4): 287
[Pubmed] | [DOI]
3 Is dental anxiety associated with the behavior of sedated children?
Laércio Alves de AMORIM JÚNIOR,Vinícius Braudes Martins RODRIGUES,Luciane Rezende COSTA,Patrícia CORRÊA-FARIA
Brazilian Oral Research. 2021; 35
[Pubmed] | [DOI]
4 The Efficacy of Little Lovely Dentist, Dental Song, and Tell-Show-Do Techniques in Alleviating Dental Anxiety in Paediatric Patients: A Clinical Trial
Hira Abbasi,Muhammad Saqib,Rizwan Jouhar,Abhishek Lal,Naseer Ahmed,Muhammad Adeel Ahmed,Mohammad Khursheed Alam,Jes s L pez Herce
BioMed Research International. 2021; 2021: 1
[Pubmed] | [DOI]


Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

  In this article
   Materials and Me...
   Article Figures
   Article Tables

 Article Access Statistics
    PDF Downloaded379    
    Comments [Add]    
    Cited by others 4    

Recommend this journal