Prevalence of dental fear and its relationship with primary dental caries in 7-year-old-children

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Pediatric Dental Journal journal homepage: www.elsevier.com/locate/pdj

Research Paper

Prevalence of dental fear and its relationship with primary dental caries in 7-year-old-children Tong Minh Son a,1, Vo Truong Nhu Ngoc a,1, Phung Thi Tran a,1, Nga Phuong Nguyen a, Hang Minh Luong a, Ha-Thu Nguyen a, Kulbhushan Sharma b, Pham Van Tu c, Luu Song Ha d, Vu Ngoc Ha e, Pham Van Huy f,**, Deepak B. Thimiri Govinda Raj g, Dinh-Toi Chu h,* a

School of Dentistry, Hanoi Medical University, Hanoi, Viet Nam Institute of Basic Medical Sciences, Faculty of Medicine, University of Oslo, Norway c Faculty of Social Work, Hanoi National University of Education, Hanoi, Viet Nam d Vietnam Women's Academy, Hanoi, Viet Nam e Vietnam Academy of Social Sciences, Hanoi, Viet Nam f AI Lab, Faculty of Information Technology, Ton Duc Thang University, Ho Chi Minh City, Viet Nam g Institute of Cancer Research, Oslo University Hospital, Oslo, Norway h Faculty of Biology, Hanoi National University of Education, Hanoi, Viet Nam b

article info

abstract

Article history:

Background: Child's dental fear has been reported as one of the reasons that increase,

Received 1 September 2018

aggravate dental diseases and facilitate other oral diseases. This study is aimed to describe

Received in revised form

the type and prevalence of dental fear and to assess the relationship between cavities of

12 February 2019

primary teeth and dental fear in 7-year-old children at Phulam Primary School, Hanoi.

Accepted 9 April 2019

Methods: The sample comprised of 132 children aged 7 years. The questionnaire examined

Available online 24 April 2019

the profile of participants and assessed their dental fear using the Children's Fear Survey Schedule-Dental Subscale (CFSS-DS). Children have “dental fear” when the total CFSS-DS

Keywords:

score is greater than or equal to 38. By contrast, those without dental fear gain the total

Children

point which is less than 38. After completing the questionnaire, a dental examination was

Dental fear

undertaken according to the International Caries Detection and Assessment System

Primary dental caries

(ICDAS). Results: The prevalence of dental fear was 34.85%. Fear scores were highest for “Dentist drilling” (2.92 ± 1.47) and “Injections” (2.87 ± 1.53). In the univariate analysis, the odds of girls having dental fear were approximately equal to boys (OR ¼ 0.98, 95% CI ¼ 0.75-0.70). The odds of only children having dental fear were 1.6 times higher than others, but there were not significant. Dental fear was found to be no associated to sex, birth order and primary dental caries (p > 0.05).

* Corresponding author. ** Corresponding author. E-mail addresses: [email protected] (P. Van Huy), [email protected] (D.-T. Chu). 1 Co-first authors. https://doi.org/10.1016/j.pdj.2019.04.002 0917-2394/© 2019 Japanese Society of Pediatric Dentistry. Published by Elsevier Ltd. All rights reserved.

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Conclusion: Our findings demonstrated the status of 7-year-old children's dental fear at Phulam primary school, and found that primary dental caries had no correlation with child dental fear score. © 2019 Japanese Society of Pediatric Dentistry. Published by Elsevier Ltd. All rights reserved.

1.

Introduction

Dental fear is an emotional response to explicit or definite threat in situations related to dental treatment [1,2]. This issue may result in failure to provide suitable treatment procedure in dentistry which is susceptible to other oral diseases [3]. It has been reported that the proportion of child having dental fear (6.7e20%) was higher than that of adult (4e16%) [4]. This could be caused by the children having primitive perception, experiencing difficulties in self-regulation and language abilities as they are still developing these skills. The children are often taken to dental clinics or hospitals and have first dental experience between ages 6 and 7 as replacement of primary teeth begins and permanent teeth start to appear in the mouth at that time [5]. According the study conducted in Vietnam by Do et al., the prevalence of primary dentition caries of this age group was 84.9% which was significantly higher than the older group [6]. However, some children tend to delay or cancel dental appointments for the primary reason of dental fear, which can persist into adulthood [7,8]. This problem affects negatively on not only patients but also the dentists. When clinicians treat patients with dental fear, they experience increasing stress level, with more time-consuming treatments, rising costs and other difficulties encountered during their dental practice [9,10]. Many studies evaluated the variables which are able to influence dental fear such as age, gender, social context, and previous dental experiences [11]. The findings of Faezeh Ghaderi et al. also supposed that the birth order of children may affect dental behavior as it influences children's character [12]. However, till this day, no research on the dental fear of 7 year-old children has been conducted in Vietnam. It is of great importance that the dental expert has the ability to identify a child having dental fear and apply techniques which can reduce the pediatric fear in dental treatment [13]. In this study, in addition to the objective of assessing the degree of dental fear, we also investigated the association between cavities of primary teeth and dental fear in children at 7 years of age.

2.

Subjects and methods

We conducted a pilot study on a group of children at age 7 to examine the feasibility of research questionnaires for students in Vietnam. Then, across-sectional study was carried out from July to November 2016 at Phulam primary school in Hanoi, Vietnam.

2.1.

Participants

Inclusion criteria comprised 7-year-old children with physical well-being and having experience of dental visits. Exclusion criteria included mental disorders; the disagreement of child's parent's to participate in the study or suffering from the acute pain by oral diseases. A total of 132 children were purposely selected based on the above standards, the sample size was calculated according to the formula with 95% level of confidence, 56.52% of 7-year-old children having dental fear and margin of error of 9%.

2.2.

Questionnaire

The first questionnaire was about individual profile (age, sex, grade, birth order, and dental visits) and the second one was about the Children's Fear Survey Schedule-Dental Subscale (CFSS-DS) (CFSS-DS; Cuthbert and Melamed, 1982). This psychometric scale comprised 15 commonly dental fear situations that a local expert translated into Vietnamese and made a retranslation to control quality by another. Each question was scored 1 (not afraid), 2 (little afraid), 3 (fairly afraid), 4 (quite afraid) and 5 (very afraid). The sum of CFSS-DS scores had ranges between 15 and 75 points. The combined score greater than or equal to 38 was indicated as “having dental fear” [12,15].

2.3.

Procedure

The parents or guardians were provided information about the study and required to give signed consents and assured that participation was voluntary. Trained interviewers questioned the participants according to the research questionnaires. Then the children were examined for primary tooth decay using International Caries Detection and Assessment System (ICDAS). ICDAS 0 is “without primary dental caries” while ICDAS 1, 2, 3, 4, 5, 6 is “having primary dental caries”.

2.4.

Data analysis

Data processing was done using R software version 3.4.3 (free software). The proportion dental fear among the groups of gender and birth order was compared using Chi-square test. Mann-Whitney test was utilized to determine the substantial difference in mean scores of decayed, missing, and filled teeth (dmft) between two groups of gender and two groups of dental fear status. Pearson Correlation test was used to measure the relationship between CFSS-DS score and dmft. Analysis of association of the dental fear (dependent variable) with the

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mean fear scores for “having a stranger touch you” and “having somebody look at you” (Table 2). As observed in Table 3, there was no substantial difference between fear level and dmft with p > 0.05. The r value between CFSS-DS score and dmft was close to 0 (0.034) which indicated that there was no association between two variables. Table 4 shows the results of univariate and multivariate analyses for dental fear, gender, birth order and primary dental caries. In the univariate analysis, the odds of girls having dental fear were approximately equal to boys (OR ¼ 0.98, 95% CI ¼ 0.75-0.70). The odds of only child having dental fear were 1.6 times higher than others but were not significant.

independent variables: gender, birth order, dental caries was done using logistic regression models.

3.

Results

Of the 132 children examined, 46 children (27 boys and 19 girls) had dental fear (CFSS e DS  38) which account for 34.85% of total participants. The prevalence of only child (45.45%) was higher than that of middle child (36.84%), lastborn child (36.21%) and firstborn (29.55%). This result was not noticeably different with p > 0.05. As shown in Table 1, the mean CFSS e DS score was higher in the boys than the girls, but the difference was not statistically significant (p > 0.05). The highest scores were found in the cases: “the dentist drilling” (2.92 ± 1.47), “injections” (2.87 ± 1.53) and “choking” (2.61 ± 1.45) (Table 2). Mean scores according to 15 dental situations of CFSS e DS are given in Table 3. We found that there were some noticeably higher mean fear scores (p < 0.05) in girls compared to boys, including the

4.

Discussion

In the dental examination and treatment, clinical practitioners encounter many difficulties in approaching children. One of the crucial reasons for children's lack of cooperation with dentists is supposed to be dental fear. Determining the proportion of dental fear, exactly what the schoolchildren are

Table 1 e Fear scores according to gender. Gender

Boys Girls Total

Fearful (CFSS-DS  38)

CFSS-DS

Nonfearful CFSS-DS < 38

n

mean

n

mean

n

Mean

77 55 132

32.68 ± 12.04 33.22 ± 11.00 32.90 ± 11.58

27 19 46

45.96 ± 8.37 45.74 ± 5.64 45.87 ± 7.30

50 36 86

25.50 ± 6.15 26.61 ± 6.35 25.97 ± 6.22

Boys (n ¼ 77)

Girl (n ¼ 55)

Table 2 e Mean scores and standard deviation of CFSS-DS. Items 1 Dentists 2 Doctors 3 Injections 4 Somebody examine your mouth 5 Someone asks you to open your mouth 6 Having a stranger touch you 7 Having somebody look at you 8 Dental drilling 9 Sight of dental drilling 10 Noise of dental drilling 11 Someone put instruments in your mouth 12 Choking 13 Being asked to go to the hospital 14 People in white uniform 15 Having the dentist clean your teeth.

1.73 2.00 2.96 1.96 1.79 2.19 1.97 2.90 2.35 2.32 2.32 2.56 2.35 1.81 1.45

± 1.02 ± 1.31 ± 1.53 ± 1.16 ± 1.22 ± 1.23 ± 1.29 ± 1.47 ± 1.33 ± 1.38 ± 1.35 ± 1.46 ± 1.41 ± 1.17 ± 0.85

All (n ¼ 132)

1.78 ± 1.30 1.71 ± 1.13 2.75 ± 1.54 1.84 ± 1.01 1.62 ± 0.97 2.75 ± 1.49 2.55 ± 1.48 2.91 ± 1.48 2.35 ± 1.31 2.47 ± 1.33 2.44 ± 1.46 2.69 ± 1.45 2.16 ± 1.29 1.69 ± 1.12 1.49 ± 1.00

1.75 1.88 2.87 1.91 1.72 2.42 2.21 2.92 2.35 2.39 2.37 2.61 2.27 1.76 1.47

± 1.14 ± 1.24 ± 1.53 ± 1.10 ± 1.12 ± 1.37 ± 1.39 ± 1.47 ± 1.31 ± 1.36 ± 1.39 ± 1.45 ± 1.36 ± 1.15 ± 0.91

p 0.596 0.160 0.482 0.746 0.765 0.037* 0.011* 0.871 0.987 0.462 0.744 0.551 0.496 0.533 0.992

*p < 0.05.

Table 3 e Mean dmft according to fearful and nonfearful group. dmft Fearful (CFSS-DS 38) Nonfearful (CFSS-DS <38) Total p > 0.05.

dt

mt

ft

dmft

5.78 ± 2.94 6.15 ± 3.88 6.02 ± 3.57

0.15 ± 0.56 0.31 ± 1.05 0.26 ± 0.91

0.37 ± 0.77 0.47 ± 1.03 0.43 ± 0.94

6.30 ± 3.13 6.93 ± 4.19 6.71 ± 3.86

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Table 4 e Logistic regression of dental fear in the association to sex, birth order and primary dental caries. Covariates

Sex Boys Girls Birth Order Others Only child Dental caries Without primary dental caries Having primary dental caries

Univariate

Multivariate

OR (95%CI)

p

OR (95%CI)

p

Reference 0.98 (0.75e0.70)

0.951

Reference 1.02 (0.72e0.76)

0.960

Reference 1.63 (0.29e1.73)

0.444

Reference 1.63 (0.77e1.75)

0.445

Reference 1.65 (1.14e2.14)

0.528

Reference 1.7 (1.13e2.20)

0.530

afraid of when they have to visit dentists, also whether or not there is an association between dental fear and primary dental caries contributes to preventive dental services and improvement in the quality of dental treatment. Our study is the first report of the dental fear prevalence and its relationship with primary dental caries among 7-year-old children in Vietnam. Using CFSS-DS questionnaire we found 34.85% of the children having dental fear (CFSS-DS > 38), which were similar to the finding of Aylin et al. [14] for 7-year-old Turkey children (31.37%). In contrast, results from Beena et al. [15] for the similar study in an English secondary school were higher (56.52%). This may come from the distinctive study environment of the participants. We found that the difference in mean scores between boys and girls were not statistically significant. This result was in line with previous studies [14,16,17], but in contrast to other ones showing that CFSS-DS score in girls was higher than boys [18e20]. Our findings revealed that the worst feelings for children were “the dentist drilling”, “injection”, and “choking”. This was in accordance with reports shown by Beena 2013 [15], Aylin 2008 [14], and Nakai 2005 [21]. This result can be interpreted from the fact that in our culture, parents or guardians tend to use the sentence “taking children to a doctor for injection or to the dentist for tooth extraction” to threaten them. Therefore, the children are growing up with the awareness that these are bad or scary experiences. Although some previous studies indicated that dmft was significantly increased with the increase in CFSS-DS mean scores [22e24], our work revealed that dental fear had no correlation to dmft scores. This can possibly be explained by human physical variation and widely mixed reactions to dental treatment stimuli for each individual. In addition, further studies need to be performed with larger sample sizes, wider age groups and other geographic areas in Vietnam before researchers can draw any clear conclusions about that. In the univariate and multivariate analysis, the odds of only child having dental fear were 1.6 times higher than others but were not found significantly. This finding maybe due to the fact that the birth order plays an important role in personality traits and behavior. When a child has no siblings, she/he receives undivided attention from their parents and does not need to share with any new baby. They tend to be headstrong, antisocial and generally bratty, which may be the reason why they lack cooperation in dental situations. The

odds of children with primary dental caries having dental fear were 1.7 times higher than of children without primary dental caries. This could be explained by children having medical history involved tooth decay, these children are able to experience some dental treatments using injections, drilling or polishing, etc. If the intervention for approaching caries is not given in a thorough and conscientious way, it will become an unpleasant experience or act as the potential factor triggerin and aggravating dental fear. In this study, we found that a notable factor associated with dental fear was gender (OR ¼ 0.98, 95% CI ¼ 0.75-0.70). Dental fear could lead to uncooperative behaviors in patients requiring dental treatments, and avoiding dental attendance is one of them. It was reported that people involved in dental avoidance and precognition of fear would have more missing teeth than the rest [25,26]. Children's dental fear may lead to difficulties in controlling their behavior in dentistry situations, which could interfere treatment and become a challenge for pediatric dentists [27]. Some possible method to manage dental fear such as psychotherapeutic therapies, pharmacological interventions, or both methods in a combination. The selection for dental fear management will depend on the dentist's expertise and experience, clinical problems, the degree of dental anxiety as well as the patient characteristics [13]. Some techniques in behavior management including the use of non-verbal communication, tell-show-do, behavior shaping, and positive reinforcement can be helpful, and these techniques do not involve the use of drugs. However, in case children still refuse to cooperate with dentists, sedation could be used to reduce dental fear.

5.

Conclusion

The prevalence of dental fear in the studied subject at Phulam Primary School was 34.85%. The dentist drilling and injection were the greatest causes of fear in our study. We found that primary dental caries had no correlation with child dental fear score. However, to determine this subject comprehensively, it is essential to carry out further studies with different children groups and explore other psychological factors that have impacts on the children such as special needs, economic status, family background and past dental experiences.

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Ethical approval [2]

All procedures performed in the studies involving human participants were in accordance with the ethical standards of the School of Odonto-Stomatology's Ethical Committee (No. Ethics Committee Letter, Hanoi, 16/06/2016), Hanoi Medical University and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

[3]

[4]

Funding No funding was received.

Author contributions TMS, VTNN, PTT, NPN, HLM and HTN designed, performed experiments, and collected data and informed consents. PTT, NPN, VTNN, TMS, PVH, and TCD analyzed the data and interpreted results. PTT, NPN and DTC wrote the manuscript. DTC, DBTGR, KS and PVH edited the manuscript. All authors approved the final manuscript.

[5] [6]

[7]

[8]

[9] [10]

Conflict of interest [11]

All authors have no conflicts of interest or financial ties to disclose.

[12]

Acknowledgements

[13]

The authors sincerely thank the school authorities, teachers at Phulam Primary School, children and their parents for their enthusiastic participation in the study. We would also like to thank the interviewers who contributed to the data collection process. We also would like to thank our International colleagues at the Centre for Molecular Medicine Norway, Ms. Pham Minh Thuong (Faculty of English Language Teacher Education, University of Languages and International Studies, Hanoi, Vietnam), and Ms. Tran Uyen Ngoc (Nong Lam University, Ho Chi Minh, Vietnam) for checking and improving the English in the revised manuscript.

[14]

[15] [16]

[17]

[18]

Appendix A. Supplementary data

[19]

Supplementary data to this article can be found online at https://doi.org/10.1016/j.pdj.2019.04.002.

[20]

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