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.     

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.     

The relationship between temperament and fearfulness in adult dental phobic patients

BACKGROUND: Temperament has been associated with dental fear (DF) and dental behavioural management problems (DBMP) in children, but little is known about what role temperament plays in the aetiology of DF. Thus, measures of temperament suitable for use among children, adolescents, and adults would be of value for longitudinal and family studies of DF, where relations between children's and parent's ratings are investigated. AIM: Our aim was to explore the adapted EASI (emotionality, activity, sociability, and impulsivity) in adult patients, and to evaluate the instrument in comparison with established measures of DF and general emotional reactions in adults. DESIGN: The subjects were 230 adult patients applying for treatment for DF and 41 nonfearful patients (reference group). Questionnaires investigated temperament (general and DF) and general anxiety and depression. RESULTS: The previously described factor structure of the EASI among children was confirmed and the adapted EASI had acceptable psychometric qualities. Emotionality correlated with DF and with measures of general psychological distress. No differences were found in mean scores of EASI dimensions between DF group and the reference group, which was in contrast with studies in children. CONCLUSIONS: The adapted EASI seem promising for use in future longitudinal and familial studies of development of DF and DBMP.     

Dental fear/anxiety and dental behaviour management problems in children and adolescents: a review of prevalence and concomitant psychological factors

OBJECTIVES: The objectives of this article were to examine the literature published from 1982 to 2006 and to evaluate prevalence of dental fear and anxiety (DFA) and dental behaviour management problems (DBMP) in children and adolescents, and their relationships to age, sex, general anxiety, temperament, and general behavioural problems. METHODS: A broad search of the PubMed database was performed using three combinations of search terms. RESULTS: A large proportion of the identified articles could not be used for the review owing to inadequate endpoints, measures or poor study design. Thirty-two papers of acceptable quality were identified and reviewed. The prevalence of both DFA and DBMP were estimated to 9%, with a decrease in prevalence with age. DFA/DBMP were more frequent in girls. DFA/DBMP were related to general fear and both internalizing and externalizing behavioural problems, although these relationships were not clear-cut. Temperament was related to both DFA and DBMP but with different temperamental characteristics, while general behavioural problems mainly correlated with DBMP. CONCLUSIONS: DFA/DBMP are common, and several psychological factors are associated with the development of these problems. In order to better understand these relationships, a number of issues concerning design of research and measurement of DFA/DBMP have to be dealt with.     

Possible predictors of discontinuation of specialized dental treatment among children and adolescents with dental behaviour management problems

Gustafsson A, Broberg AG, Bodin L, Berggren U, Arnrup K. Possible predictors of discontinuation of specialized dental treatment among children and adolescents with dental behaviour management problems. Eur J Oral Sci 2010; 118: 270–277. © 2010 The Authors. Journal compilation © 2010 Eur J Oral Sci This study aimed to identify potential predictors of non‐attendance among children and adolescents with dental behaviour management problems (DBMP). A group of 179 patients, 7.5–19 yr of age, was grouped into 56 ‘non‐attenders’ (discontinued treatment, missed appointments, or ≥ 20% cancellations) and 123 ‘attenders’. In addition to data from an introductory interview and dental recordings, baseline data from psychometric measures of fear and other personal and parental characteristics were included in logistic regression analyses and tree‐based modelling. The non‐attenders had higher scores on impulsivity and sociability and lower socio‐economic status (SES) than the attenders, and they lived more often in single‐parent families. Logistic regression analyses and tree‐based modelling point to SES and parental anxiety as important predictors for non‐attendance within this group of children and adolescents. To predict, and possibly to prevent, non‐attendance among children and adolescents referred for specialized dental care because of DBMP, we must consider their lives and family situations as well as their personal characteristics and oral health status. Further research should focus on whether the observed associations between non‐attendance and factors such as personal characteristics, family and psychosocial factors, and previous dental experiences, also hold for those who remain in regular dental care.     

Factors affecting dental fear in French children aged 5–12 years

International Journal of Paediatric Dentistry 2010; 20: 366–373 Background. While dental anxiety is often correlated with prior negative dental experience, prevention of dental anxiety should in theory include early exposure to the dental setting. Objective. We set out to evaluate factors affecting dental fear in French children. Methods. Dental fear was evaluated using a visual analogue scale (DF‐VAS) in a group of 1303 French children (681 boys and 622 girls) aged 5–11 years (mean: 8.12 years, SD: 1.42 years). Indicators of caries and oral hygiene were evaluated on dental examination. Indicators of well‐being related to oral health, dental experience, and oral health education were collected via a structured interview. Results. Dental fear was scored low in 75.7% (DF‐VAS 0–3), moderate in 16.7% (DF‐VAS 4–6), and high in 7.6% (DF‐VAS 7–10). DF‐VAS decreased statistically with experience of a prior dental visit. Children who had at least one decayed tooth presented a higher level of dental fear than those with no decay, while children with fillings were significantly less anxious than those without previous dental care. Conclusions. This study shows that for children aged 5–12 years, prior experience of the dental setting can act as a positive component of dental fear.     

Lack of cooperation in pediatric dentistry--the role of child personality characteristics

PURPOSE: This study aimed to investigate fear, temperament, behavioral symptoms and verbal intelligence in a study group of uncooperative child dental patients, partly in comparison with a reference group of ordinary child dental patients. A second aim was to explore a hypothesis of heterogeneity by searching for subgroups within the study group. METHODS: Parents of 86 study group children (36 aged 4-to 7- years and 50 aged 8- to 12-years) and 117 reference group children (8- to 12-years) answered a questionnaire concerning dental and general fear, temperament and general behavior. Study group children performed a vocabulary test to measure verbal intelligence. Data were analyzed with a variable-based and a person-based approach. RESULTS: In addition to dental fear, a higher level of impulsivity most clearly discriminated study group from reference group children. Cluster analyses revealed four different fear and personality subgroups within the study group. CONCLUSIONS: Uncooperative child dental patients constitute a heterogeneous group. Subgroups with different fear, temperament and behavior problem profiles can be identified. These subgroups could be presumed to benefit from different treatment regimens, which should be further investigated.     

牙科畏惧症在经历拔牙术患者中的流行状况研究

目的:探索牙科畏惧症的成因,并采取相应的措施来防治牙科畏惧症.方法:通过现况调查研究,随机收集颌面外科门诊200个行拔牙治疗的病例,通过一般资料量表及牙科焦虑量表(DAS),分析导致牙科畏惧症的相关因素.结果:本组患者DAS≥13,共21人(10.5％).经历拔牙术的患者DAS评分与性别、性格、拔牙类型、拔牙经历、周围人拔牙经历及疼痛耐受程度有关(P＜0.05).结论:应针对拔牙患者牙科畏惧症的具体因素进行心理或医疗干预,以缓解牙科畏惧症.     

Common use of a Fear Survey Schedule for assessment of dental fear among children and adults

BACKGROUND: Little is known about children with dental fear (DF) in a long-term perspective. Measures of DF suitable for use among children, adolescents, and adults would be of value for longitudinal and family studies. AIM: Our aim was to explore the DF subscale of the Children's Fear Survey Schedule (CFSS-DS) in highly fearful adult dental patients. DESIGN: The subjects were 230 adult patients applying for treatment for severe DF at a specialized DF clinic. Questionnaires investigated background data, general fear and DF, and general anxiety and depression. Reference data were obtained from 36 nonfearful patients on a subset of questionnaires. RESULTS: The fearful group reported high levels of DF on all measures and at a level similar to children with severe DF. The DF measures clearly differed between the fearful and reference groups. A factor analysis revealed a three-factor structure (fear of dental treatment, medical treatment, and of strangers and choking), which explained 68% of the variance. CONCLUSION: The CFSS-DS appears suitable for use in studies of adult populations. The results indicated that some areas of DF (physiology, avoidant behaviour, anticipatory anxiety), areas of importance among adult patients, are not assessed by the CFSS-DS. Studies of adults should therefore also include established adult measures of DF.     

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.     

Psychosocial and dental factors in the maintenance of severe dental fear

The aim was to study the relationship between psychosocial factors and dental status in adult subjects with severe dental fear (DF). A consecutive sample of 148 adults (mean age 36.1 yrs, range 21-69 yrs) referred for dental fear treatment was investigated using an intake questionnaire on dental attendance and history, psychometric questionnaires on dental fear, general anxiety and depression and a radiographic examination. The subjects had a mean DFMT (Decayed, Filled, Missed Teeth) score of 18.6 (SD = 5.6). A deterioration in dental status defined as the presence of root remnants was present in 57% of the subjects and was related to the negative consequences of dental fear, general anxiety and depression. Most subjects (84%) reported clinical levels of general anxiety and 46% reported clinical levels of depression. In conclusion, subjects with severe DF often suffer from psychosocial consequences and distress.This is even more marked if their dental status has deteriorated.The findings support a biopsychosocial vicious circle understanding of the maintenance of DF.     

Dental behavioural management problems and dental caries prevalence in 3- to 6-year-old Swedish children born preterm

Background.   Today, most children born preterm survive without major impairments. But high frequencies of cognitive and behavioural difficulties arise. Studies on dental behavioural management problems (DBMP) in these children are lacking. In addition, studies on caries prevalence are few and inconclusive.
Aim.   This study aims to compare the frequency of behavioural problems and poor compliance with dental treatment in preschool children born preterm with those born full-term. The prevalence of caries was also studied.
Methods.   The study group included 187 children born between 23 and 32 weeks of gestation. The control group constituted full-term children matched by age, sex, immigrant background, and dental operator. DBMP, number of dental visits, missed appointments, and caries between ages 3 and 6 were noted.
Results.   At age 3, but not at age 6, the prevalence of DBMP at clinical examinations was significantly higher in preterm children compared with the control group. Of the children who received dental treatments during preschool years, preterm children displayed significantly more DBMP. No significant difference in dental visits or in caries prevalence was found. Preterm children, however, missed significantly more dental appointments.
Conclusion.   Children born preterm display a higher prevalence of DBMP at dental examinations and treatments during preschool years.     

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目的    探讨心理行为诱导对牙科畏惧症（dental anxiety, DA）患儿的临床疗效。方法    对2009年2月至2010年7月在济南市口腔医院门诊就诊的398例3～12 岁口腔疾患儿童,采用儿童焦虑调查表-牙科分量表（children’s fear survey schedule-dental subscale, CFSS-DS ）进行分析比较,并将筛选出的316例DA 患儿随机分为试验组和对照组。试验组在进行常规口腔治疗的同时,采用心理行为诱导;对照组仅进行常规口腔治疗。结果      试验组治疗后,DA 程度明显下降（P＜0.01）,男孩DA 程度的下降较女孩更显著（P＜0.05）。结论    心理行为诱导治疗DA患儿效果明显,有利于提高临床治疗效率与治疗质量。     

大学生中牙科恐惧症与人格焦虑症的相关性研究

目的　探讨牙科恐惧症(DF)与人格焦虑症(PA)的相关关系。方法　采用人格焦虑量表和Corah问卷等对成都市1 975名1~3年级的大学生进行人格焦虑症和牙科恐惧症的调查,并对调查数据进行统计分析。结果　 DF与PA、重度DF与PA均相关(χ2分别为3·97、6·23,P<0·05);DF分值与15问分值及副反应分值均相关(r分别为0·913、0·409,P=0·000)。结论　DF与PA具有相关性。     

Behavioural and emotional problems in children referred to a centre for special dental care

This study was conducted among 203 children (103 boys) referred to a centre for special dental care because of a high level of dental fear. It was undertaken to explore to what extent behavioural and emotional problems co-exist in these children compared with children of a Dutch norm group. The children's parents filled out the parental version of the Child Behaviour Checklist (CBCL), before their first appointment at the centre. The behavioural and emotional problems of the children were assessed by this CBCL, and the mean scores of the children in the study were compared with the mean scores of the norm group. The mean scores on all scales, except on the subscale 'sex problems', of the children with a high level of dental fear proved to be significantly higher than the mean scores of the norm group (P< or =0.001). The results indicated that children referred to a special dental care centre not only suffer from high dental fear but also have problems in several other behavioural and emotional areas. These problems appear to be heterogeneous; they were found in several specific problem areas, both external and internal.     

Treatment outcome in subgroups of uncooperative child dental patients: an exploratory study

Objectives. The principal aims of this study were to evaluate the treatment outcome in subgroups of uncooperative child dental patients and to test the validity of these subgroups, which were based on fear and personality characteristics. Design. An exploratory, intervention study using quantified questionnaire, interview and observation data. Sample and methods. Eighty‐six 4 to 12‐year‐old uncooperative child dental patients (of whom 81 were divided retrospectively into four subgroups) and their accompanying parents were followed up during treatment at a specialist paediatric dental clinic in Sweden. Treatment was based on behaviour management techniques, supported by nitrous oxide/oxygen sedation if necessary. At baseline, parents answered a questionnaire including questions on child dental and general fear, temperament and behaviour, and parental dental fear, emotional stress, locus of control, parenting efficacy and attitudes to dental care, some of which were repeated post‐treatment. The treating dentist rated child behaviour according to the acceptance of a maximum of 14 treatment steps at each visit. Results. Approximately 90% of all children managed to undergo the dental treatment. Child dental fear and parental emotional stress decreased during treatment. Externalizing, impulsive children showed lower acceptance. In fearful, inhibited children, integrated use of sedation appeared to facilitate acceptance. Validity of the subgroups characterized as ‘fearful, extrovert, outgoing’, ‘fearful, inhibited’ and ‘externalizing, impulsive’ was supported, while heterogeneity within the group of ‘non‐fearful, extrovert, outgoing’ children made validation difficult. Conclusion. Fear and personality characteristics may serve as diagnostic aids when planning treatment of uncooperative child dental patients. Controlled outcome studies using differentiated treatment methods for children with different fear and personality profiles are needed.     

Do traumatic events have more impact on the development of dental anxiety than negative,non‐traumatic events?

The importance of exposure to traumatic events for the development of dental anxiety has not been investigated. The aim of the present study was to test the hypotheses that individuals who reported having been exposed to a traumatic event [that is, fulfilling Criterion A of the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM‐5), for post‐traumatic stress disorder (PTSD)] as the cause of their dental anxiety would report significantly higher levels of dental anxiety, typical trauma‐related (PTSD) symptoms, and greater disturbance of memories involving these events than those who reported being exposed to non‐traumatic events. Patients of a specialized dental fear clinic (n = 90) were divided into those who reported a traumatic event that initiated their dental trait anxiety and those who did not. The two groups did not differ in their severity of dental anxiety and number of PTSD symptoms, but the memories of those who had been exposed to traumatic events were significantly more vivid than the memories of those in the reference group. Length of time since the event took place did not play a role. Hence, traumatic events are remembered more vividly, but do not seem to initiate more severe forms of dental anxiety than other events.     

Dental anxiety among young adolescent patients in Israel

Aim. To evaluate adolescents’ dental anxiety using self‐reported questionnaires previously given to adults. Sample and method. One hundred and four patients (42 boys, 62 girls) aged 12–18 years who attended their paediatric dentist completed a questionnaire in the waiting room. The survey consisted of three sections: sociodemographic information for the children, a dental anxiety scale (DAS), and a dental fear survey (DFS). Results. The scores of the girls were higher than the boys in every DAS item as well as in the total score. Girls showed higher DFS scores than boys in most items. The most anxiety‐provoking stimuli were feeling and seeing the needle. In the most anxiety provoking stimuli, among the boys who reported higher DFS scores (categories 3, 4, 5), the DAS scores were higher than the scores of the girls. As the stimulus became less anxiety‐provoking, such as sitting in the dental chair, the DAS scores of the girls in these categories were higher than boys. Significantly more girls’ responses were in categories 3, 4 and 5 in the items dealing with the needle and the drill, while no significant difference was observed among the boys and girls regarding sitting in the dental chair. Conclusions. It is concluded that individual personality traits may be the final factor to indicate those who will eventually develop higher dental anxiety, and those who will not. The difference could be also in the conditioning process and learned responses (male and female education) that these individuals have experienced in life.     

Developmental changes in dental anxiety in a normative population of Dutch children.

AIM: The aim of this study was to ascertain age and gender related differences that contribute to dental anxiety and to find relations with early onset of child dental anxiety in a population of 4-11 years old Dutch children. MATERIALS AND METHODS: The study was conducted among 2,865 patients (48.2% girls) aged between 4 and 11 years old. The sample included a normative (n = 2,153) and an anxious group of children (n = 712), who were referred to the Special Dental Care Clinic in Amsterdam because of manifested dental phobia. Children were divided into three age groups (4-6, 7-9 and 10-11 years). Dental anxiety was assessed using the Children Fear Survey Schedule-Dental Subscale. Three levels of dental anxiety were used: low (CFSS-DS = 15-25), moderate (CFSS-DS = 26-36) and high (CFSS-DS above 37). Only children with CFSS-DS scores above 37 were considered dentally phobic. STATISTICS: Statistical analysis was performed in Statistics for Windows 10. RESULTS: In the total group a significantly higher level of dental anxiety was found among girls (p = 0.004; t = -3.262). There was a considerably lower number of dentally phobic boys (7.1%) and girls (9.2%) in the older group compared with the younger (51.8%, 52.8% respectively). One way Anova results revealed a statistically significant age related difference between the oldest and the youngest as well as the middle-aged groups (p < 0.001, p = 0.001). In general dental anxiety was explained better in the younger than in the older group. The regression analysis accounted for a higher percentage of the explained variance. CONCLUSIONS: The study confirmed the highest level of dental anxiety was present at 4 years of age and an overall decrease in dental anxiety occurred as children became older. In different age groups, dental anxiety seems to be related to different aspects of dentistry, indicating the causes shift from simple initial stimuli to more complex events.     

Psychobiological personality dimensions in two environmental-illness patient groups

The aim of the present study was to investigate the psychobiological personality dimensions in two subgroups of patients with environmental illness (EI). Fifty-nine patients, 34 women and 25 men (aged 32–69 years), were referred for symptoms allegedly caused by abnormal sensitivity to either dental fillings (DF; n=26) or electromagnetic fields (EMF; n=33). For the evaluation of personality, the Swedish 238-item version of the Temperament and Character Inventory (TCI) was used. Compared with a control group, the EMF group scored higher on the temperament dimension Persistence. The DF group scored higher on the TCI subscales Harm Avoidance (fatigability and asthenia) and Self-Directedness (self-acceptance). Women scored higher than men did on the Novelty Seeking and Reward Dependence (RD) dimensions in the DF group and on RD in the control group, indicating an inherited gender difference. No differences were found between men and women in the EMF group. Our results indicate that the high level of persistence found in the EMF group and the high level of fatigability and asthenia in combination with high self-acceptance found in the DF group represent vulnerable personalities. No significant differences were found between the two patient groups, indicating that these groups are quite similar regarding personality. This vulnerability can be expressed as various mental and somatic symptoms, which can be interpreted as EI symptoms by the affected individual.