Temperamental reactivity and negative emotionality in uncooperative children referred to specialized paediatric dentistry compared to children in ordinary dental care

Background. Current treatment of children with dental behaviour management problems (DBMP) is based on the presupposition that their difficulties are caused by dental fear, but is this always the case? Objective. The aim of this study was to study temperamental reactivity, negative emotionality, and other personal characteristics in relation to DBMP in 8‐ to 12‐year‐old children. Methods. Forty‐six children referred because of DBMP (study group) and 110 children in ordinary dental care (reference group) participated. The EASI tempramental survey assessed temperamental reactivity and negative emotionality, the Child Behaviour Questionnaire internalizing and externalizing behaviour problems, and the Children's Fear Survey Schedule general and dental fears. Cluster analyses and tree‐based modelling were used for data analysis. Results. Among the five clusters identified, one could be characterized as ‘balanced temperament’. Thirty‐five per cent of the reference group compared to only 7% of the study group belonged to this cluster. Negative emotionality was the most important sorting variable. Conclusions. Children referred because of DBMP differed from children in ordinary dental care, not only in dental fear level, but also in personal characteristics. Few of the referred children were characterized by a balanced temperament profile. It is important to consider the dual impact of emotion dysregulation and emotional reactivity in the development of DBMP.     

Can parents and children evaluate each other’s dental fear?

Luoto A, Tolvanen M, Rantavuori K, Pohjola V, Lahti S. Can parents and children evaluate each other’s dental fear? Eur J Oral Sci 2010; 118: 254–258. © 2010 The Authors. Journal compilation © 2010 Eur J Oral Sci The aim of this study was to determine whether parents and their 11–16‐yr‐old children can evaluate each other’s dental fear. At baseline the participants were 11–12‐yr‐old children from the Finnish Cities of Pori (n = 1,691) and Rauma (n = 807), and one of their parents. The children and their parents were asked if they or their family members were afraid of dental care. Fears were assessed using single 5‐point Likert‐scale questions that included a ‘do not know’ option. Children and parents answered the questionnaire independently of each other. Background variables were the child’s and their parent’s gender. Parents’ and children’s knowledge of each other’s dental fear was evaluated with kappa statistics and with sensitivity and specificity statistics using dichotomized fear variables. All kappa values were < 0.42. When dental fear among children and parents was evaluated, all sensitivities varied between 0.10 and 0.39, and all specificities varied between 0.93 and 0.99. Evaluating dental fear among fearful children and parents, the sensitivities varied between 0.17 and 0.50 and the specificities varied between 0.85 and 0.94, respectively. Parents and children could not recognize each other’s dental fear. Therefore, parents and children cannot be used as reliable proxies for determining each other’s dental fear.     

Post‐trial costs,clinical outcomes,and dental service utilization after a randomized clinical trial for caries control among Finnish adolescents

Hietasalo P, Seppä L, Niinimaa A, Kallio J, Lahti S, Hausen H. Post‐trial costs, clinical outcomes, and dental service utilization after a randomized clinical trial for caries control among Finnish adolescents. Eur J Oral Sci 2010; 118: 265–269. © 2010 The Authors. Journal compilation © 2010 Eur J Oral Sci The aim of this study was to assess post‐trial treatment costs, clinical outcomes [decayed, missing or filled surfaces (DMFS) scores], and utilization of dental services among adolescents who had participated in a randomized clinical trial (RCT) in Pori, Finland, in 2001–2005. At baseline the children were 11–12 yr of age and had had at least one active initial caries lesion. The children in the experimental group (n = 250) had been exposed to multiple measures for caries control, while those in the control group (n = 247) had received standard dental care. During the post‐trial period (2005–2008), all participants received the standard dental care offered in public dental clinics in Pori. In both groups the costs of treatment procedures and outcomes for the post‐trial period were calculated for each adolescent. Information from patient records was available for 487 adolescents (former experimental n = 246, control n = 241). The mean total costs per adolescent were lower and the clinical outcome was better among the former experimental‐group participants. The differences in mean costs between the groups were statistically significant for preventive and restorative procedures. The utilization of dental services was significantly more regular among the former experimental‐group participants.     

Towards a better understanding of dental anxiety and fear: cognitions vs. experiences

Armfield JM. Towards a better understanding of dental anxiety and fear: cognitions vs. experiences. Eur J Oral Sci 2010; 118: 259–264. © 2010 The Author. Journal compilation © 2010 Eur J Oral Sci Traumatic dental experiences are associated with dental anxiety and fear. However, many people with no dental fear have had negative dental experiences, and some people with considerable fear fail to recall any traumatic incidents. This study aimed to determine whether dental fear was better explained by experiences or by cognitive perceptions of going to the dentist as being uncontrollable, unpredictable, dangerous, and disgusting. A random sample of 1,084 Australian adults (response rate = 71.7%) completed a mailed questionnaire with measures of dental fear, perceptions of going to the dentist, and dental experiences. Perceptions of uncontrollability, unpredictability, dangerousness, and disgustingness had strong bivariate associations with scores on the Index of Dental Anxiety and Fear (IDAF‐4C). Vulnerability‐related perceptions accounted for 46.3% of the variance in IDAF‐4C scores beyond that accounted for by demographic variables and five possible dental experiences comprising intense pain, considerable discomfort, gagging, fainting, and having a personal problem with the dentist. In contrast, dental experiences accounted for < 1% of the variance in IDAF‐4C scores beyond that accounted for by the four cognitive perceptions. Perceptions of uncontrollability, unpredictability, dangerousness, and disgustingness were superior predictors of dental fear compared with negative dental experiences.     

Anxiety and depressive disorders and dental fear among adults in Finland

Pohjola V, Mattila AK, Joukamaa M, Lahti S. Anxiety and depressive disorders and dental fear among adults in Finland.
Eur J Oral Sci 2011; 119: 55–60. © 2011 Eur J Oral Sci We studied the association between dental fear and anxiety or depressive disorders, as well as the comorbidity of dental fear with anxiety and depressive disorders, controlling for socio‐demographic characteristics, dental attendance, and dental health. Nationally representative data on Finnish adults, ≥ 30 yr of age (n = 5,953), were gathered through interviews and clinical examination. Dental fear was measured using the question: ‘How afraid are you of visiting a dentist?’ Anxiety and/or depressive disorders were assessed using a standardized structured psychiatric interview according to criteria presented in the Diagnostic and Statistical Manual of Mental Disorders (4th edition) (DSM‐IV).Those with depressive disorders, generalized anxiety disorder or social phobia more commonly reported high dental fear than did those without these disorders. When age, gender, education, dental attendance, and the number of decayed, missing, and restored teeth were considered, those with generalized anxiety disorder were more likely to have high dental fear than were participants with neither anxiety nor depressive disorders. The comorbidity of depressive and anxiety disorders also remained statistically significantly associated with dental fear; those with both depressive and anxiety disorders were more likely to have high dental fear than were those without these disorders. Our findings support the suggestion that some individuals may have a personality that is vulnerable to dental fear.     

Psychosocial concomitants to dental fear and behaviour management problems

BACKGROUND: Children with dental behavioural management problems (DBMP) form a heterogeneous group, where personal characteristics play significant roles. Attention to everyday life and family situation as additional background facets may help to better understand and treat these patients. AIM: This study describes everyday life and family situation in child/adolescent patients referred because of DBMP, as compared to patients in ordinary dental care. DESIGN: A study group of 230 referred patients (8-19 years old; 118 girls) was compared to a reference group of 248 same-aged patients (142 girls) without DBMP. Patients and parents were interviewed according to a semistructured protocol. RESULTS: Patients referred because of DBMP more often lived in low socioeconomic status families, had parents not living together, fewer leisure-time activities, and were assessed as doing worse in social interactions compared to the reference group. Half of the study group had personal professional support, and some had experienced interventions by the social authorities. Whether these findings apply also to children/adolescents with DBMP who are not referred to specialist care remains to study. CONCLUSIONS: Many children and adolescents referred because of DBMP have a burdensome life and family situation. This should be paid attention to in research and in clinical care.     

The relationship between dental anxiety and dental decay experience in antenatal mothers

Esa R, Savithri V, Humphris G, Freeman R. The relationship between dental anxiety and dental decay experience in antenatal mothers. Eur J Oral Sci 2010; 118: 59–65 . © 2010 The Authors. Journal compilation © 2010 Eur J Oral Sci
The aim of this study was to investigate the relationship between dental anxiety and dental decay experience among antenatal mothers attending Maternal and Child Health clinics in Malaysia. A cross-sectional study was conducted on a consecutive sample of 407 antenatal mothers in Seremban, Malaysia. The questionnaire consisted of participants' demographic profile and the Dental Fear Survey. The D_3cvMFS was employed as the outcome measure and was assessed by a single examiner (intraclass correlation = 0.98). A structural equation model was designed to inspect the relationship between dental anxiety and dental decay experience. The mean Dental Fear Survey score for all participants was 35.1 [95% confidence interval (34.0, 36.3)]. The mean D_3cvMFS score was 10.8 [95% confidence interval (9.5, 12.1)]. Participants from low socio-economic status groups had significantly higher D_3cvMFS counts than those from high socio-economic status groups. The path model with dental anxiety and socio-economic status as predictors of D_3cvMFS showed satisfactory fit. The correlation between dental anxiety and dental decay experience was 0.30 (standardized estimate), indicating a positive association. Socio-economic status was also statistically significantly associated with the D_3cvMFS count (β = 0.19). This study presented robust evidence for the significant relationship between dental anxiety and dental decay experience in antenatal mothers.     

Dental behaviour management problems: the role of child personal characteristics

International Journal of Paediatric Dentistry 2010; 20: 242–253 Aim. This study aimed to investigate the role of dental fear (DF) and other personal characteristics in relation to dental behaviour management problems (DBMP). Design. A study group of 230 patients (7.5–19 years old; 118 girls), referred because of DBMP, was compared to a reference group of 248 same‐aged patients (142 girls) in ordinary dental care. Patients and their parents independently filled in questionnaires including measures of fear and anxiety, behavioural symptoms, temperamental reactivity, and emotion regulation. Results. Study group patients referred because of DBMP differed from the reference group in all investigated aspects of personal characteristics. In the multivariate analyses, DF was the only variable with consistent discriminatory capacity through all age and gender subgroups. Aspects of anxiety, temperament, and behavioural symptoms contributed, but differently for different subgroups and at different levels of dental fear. Conclusions. Among older children and adolescents, DF deserves to be re‐established as the single most important discriminating variable for DBMP at clearly lower scores than commonly used. Further research should focus on the different patterns of DBMP development, considering various personal characteristics that may trigger, maintain, or exacerbate young patients’ vulnerability to DF and DBMP.     

Long‐term patterns of dental attendance and caries experience among British adults: a retrospective analysis

There is inconclusive evidence on the value of regular dental attendance. This study explored the relationship between long‐term patterns of dental attendance and caries experience. We used retrospective data from 3,235 adults, ≥16 yrs of age, who participated in the Adult Dental Health Survey in the UK. Participants were classified into four groups (always, current, former, and never regular‐attenders) based on their responses to three questions on lifetime dental‐attendance patterns. The association between dental‐attendance patterns and caries experience, as measured using the decayed, missing, or filled teeth (DMFT) index, was tested in negative binomial regression models, adjusting for demographic (sex, age, and country of residence) and socio‐economic (educational attainment, household income, and social class) factors. A consistent pattern of association between long‐term dental attendance and caries experience was found in adjusted models. Former and never regular‐attenders had a significantly higher DMFT score and numbers of decayed and missing teeth, but fewer filled teeth, than always regular‐attenders. No differences in DMFT or its components were found between current and always regular‐attenders. The findings of this study show that adults with different lifetime trajectories of dental attendance had different dental statuses.     

A multi‐country comparison of reasons for dental non‐attendance

The purpose of this study was to describe differences across countries with respect to the reasons for dental non‐attendance by Europeans currently 50 yr of age and older. The analyses were based on retrospective life‐history data from the Survey of Health, Ageing, and Retirement in Europe and included information on various reasons why respondents from 13 European countries had never had regular dental visits in their lifetime. A series of logistic regression models was estimated to identify reasons for dental non‐attendance across different welfare‐state regimes. The highest proportion of respondents without any regular dental attendance throughout their lifetime was found for the Southern welfare‐state regime, followed by the Eastern, the Bismarckian, and the Scandinavian welfare‐state regimes. Factors such as patients’ perception that regular dental treatment is ‘not necessary’ or ‘not usual’ appear to be the predominant reason for non‐attendance in all welfare‐state regimes. The health system‐level factor ‘no place to receive this type of care close to home’ and the perception of regular dental treatment as ‘not necessary’ were more often referred to within the Southern, Eastern, and Bismarckian welfare‐state regimes than in Scandinavia. This could be relevant information for health‐care decision makers in order to prioritize interventions towards increasing rates of regular dental attendance.     

Absence of lymphatic vessels in human dental pulp: a morphological study

Gerli R, Secciani I, Sozio F, Rossi A, Weber E, Lorenzini G. Absence of lymphatic vessels in human dental pulp: a morphological study. Eur J Oral Sci 2010; 118: 110–117. © 2010 The Authors. Journal compilation © 2010 Eur J Oral Sci Few and controversial data are available in the literature regarding the presence of lymphatic vessels in the human dental pulp. The present study was designed to examine morphologically the existence of a lymph drainage system in human dental pulp. Human dental pulp and skin sections were immunohistochemically stained with specific antibodies for lymphatic endothelium (D2‐40, LYVE‐1, VEGFR‐3 [vascular endothelial growth factor receptor‐3], and Prox‐1), with the pan‐endothelial markers CD31 and von Willebrand factor (vWF), and with the blood‐specific marker CD34. Several blood vessels were identified in human pulps and skin. Lymphatic vessels were found in all human skin samples but in none of the pulps examined. Western blotting performed on human dermis and on pulps treated with collagenase (to remove odontoblasts) confirmed these results. Transmission electron microscopy indicated that vessels which, by light microscopy, appeared to be initial lymphatic vessels had no anchoring filaments or discontinuous basement membrane, both of which are typical ultrastructural characteristics of lymphatic vessels. These results suggest that under normal conditions human dental pulp does not contain true lymphatic vessels. The various theories about dental pulp interstitial fluid circulation should be revised accordingly.     

Caries increment in children aged 3-5 years in relation to parents' dental attitudes: Oslo, Norway 2002 to 2004

Abstract – Objectives: To assess the relationship between parents’ dental attitudes and the caries increment in their children from the age of 3 to 5 years. Methods: Data based on parental questionnaires and dental examinations were collected from children participating in a follow‐up study from age 3 years (n = 354) in 2002 to 5 years (n = 304) in 2004. The children were categorized as western‐native (WN) and immigrants (IM). The items used were significantly related to caries experience in a multicentre study [ 1 Community Dent Health, vol. 21, pp. 121–30]. The responses to attitudinal items were weighted as positive if they would promote good dental health, and negative if not. Composite attitudinal variables relating to hygiene, diet and indulgence were calculated as a summation of the weighted responses to selected items. Regression analyses (bivariate and multiple) were performed to assess associations during the period between the attitudinal predictors/other control variables and caries increment (Δd_3‐5mfs). Results: Bivariate logistic regression analyses revealed that ‘Attitude to Diet’ and ‘Parental Indulgence’ were clearly related to caries increment. The more exposed children were to negative parental attitudes, the higher the OR. ‘Attitude to Diet’ also persisted in a multiple logistic regression model, showing a higher OR value than caries experience. ‘Immigrant Status’ was the most potent predictor of caries increment. Parents were found to be more indulgent among IM than among WN groups. Conclusion: Parental dental attitudes are clearly shown to be associated with caries increment in early childhood. The relationship is of such strength that it deserves to be taken into account in future preventive dental strategies.     

Dental anxiety, the parental family and regularity of dental attendance

A survey was carried out among 25-yr-old inhabitants of Amsterdam in order to study the relationship between regularity of dental attendance on the one hand and dental anxiety, dental upbringing of the respondents, dental behavior of the parents, education, sex, and the interactions between these independents, on the other. The data were analyzed hierarchically with regression analysis, the logistic approach. Dental anxiety, sex, dental upbringing and the interaction between education and anxiety, in that order, were found to be of importance for the prediction of regularity of dental attendance. Two other terms, though lacking substantial standardized regression coefficients, namely education and the interaction between education and dental upbringing, are also present in the model found. The prediction of one being a regular attender is satisfactory, but the classification of the irregular attenders is disappointing. The effect is discussed of the rather large non-response and attention is given to the effect of dental upbringing in regard to coping resources in the dental situation. It has to be concluded that other factors must be included to achieve an improvement of the classification of the irregular attenders. Dental anxiety, although of importance, cannot account for an adequate differentiation between regular and irregular attenders.     

Child dental fear as measured with the Dental Subscale of the Children’s Fear Survey Schedule: the impact of referral status and type of informant (child versus parent)

Gustafsson A, Arnrup K, Broberg AG, Bodin L, Berggren U. Child dental fear as measured with the Dental Subscale of the Children’s Fear Survey Schedule: the impact of referral status and type of informant (child versus parent). Community Dent Oral Epidemiol 2010; 38: 256–266. © 2010 John Wiley & Sons A/S Abstract – Objectives: The first aim of this methodological study was to investigate the agreement between self‐ratings of Children’s Fear Survey Schedule (CFSS‐DS). The second aim was to explore using differentiated cut‐off scores, and to compare these cut‐off scores with those commonly used. Methods: Three different data collections included study groups (n = 497) of children and adolescents who had been referred to specialized pediatric dentistry clinics, and reference groups (n = 499) of dental patients and children rating the analyses were limited to the Östergötland sample (n = 210 + 228). Patients and their accompanying parents (mainly mothers) were asked to fill in the CFSS‐DS independently. Cut‐off scores on the CFSS‐DS scale were determined using receiver‐operating characteristic analysis; patient–parent agreement was illustrated with Bland–Altman plots. Results: The patient–parent agreement was modest, particularly among those who were referred because of dental behaviour management problems (DBMP). Cut‐off scores differentiated by age and gender, suggested by exploration according to two different methods, were with few exceptions clearly below the standard cut‐off score. Conlusion: The validity of parental ratings of their children dental fear should be questioned, particularly in high‐fear populations. Self‐ratings should, as far as possible, be used to complement parental ratings. One consequence of using the standard cut‐off score is the risk of overlooking some patients needs for special attention. Further research is needed to establish and validate age‐and gender‐differentiated cut‐off scores on the CFSS‐DS.     

Differentiating regular from irregular dental attenders of either sex by linear discriminant analysis

Abstract The present article describes an attempt to improve the prediction of dental attendance, results by using an additional number of variables and performing discriminant analyses, clone separately for men and women, It appears that regular and irregular dental attenders might be discriminated on the basis of mathematically combined variables and interactions. The (number of) variables selected by the analysis to differentiate regular from irregular male attenders differ(s) from those selected for female attenders. About 80% of all respondents can be classified correctly, but this is largely due to the assignment of actual regulars to classified regulars. The use of differing sets of prior probabilities affects the classification results, namely, either the classification of the regulars or that of the irregulars improves. In the discussion attention is given to the seemingly contradictory results of the Mann- Whitney tests per variable on the one hand and the discriminant analyses on the other. In this connection, the finding that ‘education’ plays a different role for men than for women is discussed. The validity of the variable ‘last visit’ is dubious. It is concluded that when differentiating regulars from irregulars, a division of the respondents according to sex makes sense because of the (number of) variables associated with then- regular dental attendance. Furthermore, it seems warranted to say that the Classification of the irregulars fails because he reversed scores on the variables with which the regulars are classified don't contain all information needed for the prediction of irregular dental attendance. Lastly, notwithstanding the use of more variables in the present study, the results are not better than those in the previous one, in which just three factors were used.     

Relationship between age, dental status and regular dental care in Norway illustrated by a model

The purpose of this paper was to describe the relationship between age, dental status, and patterns of dental visits. Data from a national health survey of 11,014 persons in Norway 1975 were used. The model shows that though the absolute number of regular attenders decreased with increasing age their relative number among dentate persons increased with increasing age. Different examples of how the model may be used are described. Finally three explanations are given of the dental attendance pattern among Norwegian adults.     

Factors influencing the local planning of dental services

Findings from a survey of 796 high school children in four districts constituting a health administrative area were examined to ascertain the factors influencing their dental disease experience, treatment received and attendance pattern. In three of the four districts, over 60% of the children were regular attenders, enjoying the benefit of less active caries than irregular attenders. However, in the remaining district, much of which consisted of depressed, inner city areas undergoing re-development, only one third were regular attenders. Several local factors, such as availability and accessibility of services, probably influenced the numbers seeking regular care, but one of the most important appeared to be the level of provision in the salaried Community Dental Service. The implications of the findings for planning improvements in local services are discussed.     

Effectiveness of the school dental screening programme in stimulating dental attendance for children in need of treatment in Northern Ireland

The school dental screening programme has been in existence from the beginning of the 20th century yet its value in encouraging attendance among children with a dental health need is not fully established. OBJECTIVE: To evaluate the effectiveness of school dental screening in promoting dental attendance among children with a treatment need and to examine the relative importance of screening, social class and other factors in dental attendance. METHODS: Sixty-four participating schools were assigned to study and control groups using a stratified, blocked randomisation technique. The study group children received the standard school dental screening and the dental attendance of those with a positive screening result was assessed after 2 months by means of a questionnaire issued to the children's parents. The control group children were not, at this stage, screened, yet their parents received the same questionnaire assessing dental attendance over the 2-month period. However, only questionnaires from control group children who had a positive result at a subsequent screening were retained for analysis. RESULTS: A total of 2,321 children were screened, with 980 having a positive result. The mean dmft of those screening positive was 4.85. In all, 664 completed questionnaires were returned, giving a response rate of 67.8%. Dental attendance was reported among 45.5% of the study group (n=352) in the 2 months following screening. In the same period, 27.6% of the control group (n=312) claimed attendance. The effect was found to be significant among the high employed group (P<0.01) and the unemployed group (P<0.05). CONCLUSION: School dental screening was capable of stimulating dental attendance. The strong effect among the lowest socio-economic group shows that school dental screening may be used to decrease dental health inequalities.     

The association of individual characteristics and neighborhood poverty on the dental care of American adolescents

Objective: The purpose of this study was to explore the extent to which neighborhood poverty was associated with the utilization of dental care by American adolescents. Methods: To accomplish the study goals we conducted multilevel modeling analyses of two nationally representative data sets: National Longitudinal Study of Adolescent Health (Add Health) and the Early Childhood Longitudinal Study, Kindergarten Class of 1998‐1999 (ECLS‐K). Results: As hypothesized, neighborhood poverty predicted frequency of dental care in both studies (t = 6.06; P < 0.001; t = 2.44; P < 0.05). Even after accounting for individual level predictors such as household income, health insurance, and parental education, adolescents living in poor neighborhoods are less likely than their counterparts in non‐poor neighborhoods to utilize dental care. Conclusions: The findings from this study indicate that neighborhoods influence dental care utilization patterns in adolescents.