Patterns of dental anxiety in children after sequential dental visits.
Abstract: AIM: To determine whether gradually exposing Brazilian children to the dental environment would decrease their levels of dental anxiety over a 14.5-month period. STUDY Design And Methods: The study was carried out on 302 children of both genders, aged 6-7 years old. Dental anxiety was assessed using the Facial Image Scale (FIS) at five time points: 1) before an epidemiological examination; 2) before the first treatment session; 3) before the second treatment session; 4) before the first evaluation session 5) before the second evaluation session. STATISTICS: ANOVA, Student-t tests and ANCOVA were used to analyse the data. RESULTS: There was a statistically significant decrease in levels of dental anxiety between time points 1 and 5. Eighty-nine percent of the children with FIS score 1 or 2 at baseline had the same scores at the last time point, whereas 82% of children with FIS score 4 or 5 at baseline had a FIS score of 1 or 2 at the last time point. CONCLUSION: A gradual exposure of children to the dental environment in sequential dental visits of different natures in a school premise decreased their levels of dental anxiety over a 14.5-month period.

Key words: Dental anxiety, facial image scale, dental caries, restorative treatment, paediatric dentistry.
Article Type: Report
Subject: Children (Health aspects)
Anxiety (Risk factors)
Anxiety (Research)
Dental care (Health aspects)
Dental hygiene (Health aspects)
Mouth (Care and treatment)
Mouth (Health aspects)
Authors: de Menezes Abreu, D.M.
Leal, S.C.
Mulder, J.
Frencken, J.E.
Pub Date: 12/01/2011
Publication: Name: European Archives of Paediatric Dentistry Publisher: European Academy of Paediatric Dentistry Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2011 European Academy of Paediatric Dentistry ISSN: 1818-6300
Issue: Date: Dec, 2011 Source Volume: 12 Source Issue: 6
Topic: Event Code: 310 Science & research
Product: Product Code: E121920 Children
Geographic: Geographic Scope: Brazil Geographic Code: 3BRAZ Brazil
Accession Number: 277106791
Full Text: Introduction

Dental anxiety can be defined as a feeling of apprehension about dental treatment, which is not necessarily connected to a specific external stimulus [Folayan and Fatusi, 2005]. It is a common and potentially distressing problem, both for the public and for dental professionals. Many studies have described dental anxiety as an adaptative process, which could be initiated during childhood and would decrease over time [Venham et al., 1977; Folayan and Idehen, 2004; Folayan and Fatusi, 2005]. However, sometimes this feeling can carry on into adulthood, and becomes a serious health problem. Dental anxiety may lead to avoidance of dental care, increasing the risk of caries lesion development and oral diseases [Vassend, 1993; Milsom et al., 2003; Taani et al., 2005; Wigen et al., 2009]. Poor oral health can cause disturbances in social life and negatively affect work performance.

It can also initiate a depression process, as self-esteem and self-confidence are also profoundly reduced in affected individuals [Cohen et al., 2000].

Dental anxiety has been a matter of concern for many years. However, its aetiology is still not completely understood [Townend et al., 2000; Klinberg, 2008]. Studies have demonstrated that previous negative dental experience, especially when involving pain and an irregular pattern of dental visits are related to the development of dental anxiety [Berggren and Meynert, 1984; Vassend, 1993; Abrahamsson et al., 2002; Milsom et al., 2003; Oliveira and Colares, 2009]. Another risk factor for the development of dental anxiety is the use of drills and needles during dental treatment [Louw et al., 2002; Schriks and van Amerongen, 2003; Kuscu and Akyuz, 2008].

It is generally accepted that dental anxiety is predominantly initiated during childhood [Milsom et al., 2003]. Therefore, it is necessary that professionals understand how this phenomenon begins, in order to try to prevent its occurrence. A gradual exposure to the dental environment and to dental procedures has been shown to successfully minimise dental anxiety development in young adults and adolescents [Murray et al., 1989; Peretz and Mann, 2000; Klaassen et al., 2008]. However, very few longitudinal studies on dental anxiety in young children exist. Venham et al. [1977] studied the responses of children during sequential dental visits. Analysis of four different behaviour dimensions, including dental anxiety, showed that the negative behaviour decreased as the children became familiarised with the dental environment and treatment provided. Surprisingly, the self-reported dental anxiety did not change over six dental visits.

A recent study which followed a cohort of children from 5 to 9 years of age showed an increase in the prevalence of dental anxiety from 8.8% at age 5 to 14.6% at age 9 [Tickle et al., 2009]. Unfortunately, the authors did not specify what kind of dental intervention those children were submitted to during the four years between the two dental anxiety assessments. Nor did they closely follow the studied cohort. Therefore, these results are not useful for explaining and understanding the changes in dental anxiety over time.

In light of these considerations, investigating the effect of sequential dental visits on the state of dental anxiety in children would aid the understanding of a dentally anxious individual development. The present study seeks to determine whether gradually exposing children to the dental environment will decrease their levels of dental anxiety.

Materials and methods

Study population and sampling procedure

The sample for the present investigation resulted from an oral health epidemiological survey of 6- and 7-yr-old children attending 6 public schools in Paranoa, a city near to Brasilia, the capital of Brazil. This survey forms part of a major study assessing the cost-effectiveness of three different dentine carious lesion treatment approaches in children. These were conventional, ART and ultra-conservative. The sampling procedure was based on the caries experience of the children, assessed according to the ICDAS II criteria [Pitts, 2004]. The inclusion criterion for children was the presence of two or more dentine carious lesions in primary molars, without pulp involvement or pain. This was a requirement for conducting the main study on the cost-effectiveness of the three dental treatments.

This study was approved by the Research Ethics Committee of the Brasilia Medicine School, reference 081/2008. Children's parents or guardians signed individual informed consent forms, and also answered a question about whether it was their child's first dental visit. Children whose parents declined to sign the consent form were excluded from the study.


During the epidemiological examination, each child was first submitted to an assessment of the Visible Plaque Index (VPI) and the Gingival Bleeding Index (GBI), by one of three trained and calibrated examiners. The same examiner then brushed the child's teeth in order to improve the visualisation of the tooth surfaces, and performed a dental examination, using a mirror, a CPITN probe and the three-way syringe. The examiner also used cotton rolls to clean and dry the tooth surface when necessary.


The treatment sessions were performed by three well-trained paediatric dentists who applied the dental treatments to primary and permanent teeth. In order to test one of the aims of the major study, the treatment was divided in two parts. During the first session one class II cavity was performed according to one of the treatment approaches. The remaining restorations were carried out during the second session. The three different treatment approaches used were:

Conventional treatment: It involved the use of the drill and burs to perform amalgam restorations. Local anaesthesia was administered when requested by the children. Caries-prone pits and fissures of permanent molars received resin-based sealants.

Atraumatic Restorative Treatment (ART): ART restorations followed the protocols developed for this approach [Frencken et al., 1996]. Local analgesia was administered when requested by each child. Caries-prone pits and fissures in permanent molars were sealed with a high-viscosity glass-ionomer cement according to the ART approach.

Ultra-conservative treatment: Hand excavators were used to clean large cavities in primary molars by removing soft carious tissue. Medium-sized cavities in single and multiple tooth surfaces in primary molars were enlarged with a hatchet instrument, to facilitate easy cavity cleaning. Small cavities in primary teeth and all cavities in permanent molars were restored according to the ART approach. The cavity size was defined as follows. One half of the occlusal surface was taken as a reference. Three sizes were distinguished; small (covering <1/3 of half the tooth surface), medium (covering between 1/3 and 2/3 of half the tooth surface) and large (covering >2/3 of half the tooth surface). Permanent molar pits and fissures were not sealed. Children received special training in brushing their teeth, including plaque removal from inside the opened cavities and from the permanent molars, with a toothbrush and fluoridated toothpaste. This special tooth brushing was supervised by dental assistants during all schooldays, for the whole study period.

Intervention--Treatment evaluation

The effectiveness of the three treatment approaches was evaluated at 8.5 and 14.5 months after epidemiological examination by two independent, external and calibrated paediatric dentists. To perform the evaluation they used a mirror with an intra-oral light attached, a CPITN probe, the three-way syringe and cotton rolls. Children had their teeth brushed by a dental assistant before the first and second evaluation sessions.

Dental anxiety evaluation

The Facial Image Scale (FIS) [Buchanan and Niven, 2002], which is shown in Figure 1, was used to assess state dental anxiety. It comprises a row of five faces ranging from 'very unhappy' to 'very happy' and numbered from 5 to 1 and aims to assess state anxiety. Each child was asked to point to the face which they felt most closely depicted their feelings at that moment.


Dental anxiety of the children was assessed and recorded at five time points (fig. 2) in a 14.5-month period, as follows: 1) before the start of the epidemiological examination (FIS EPI); 2) before the start of the first treatment session (FIS Tx-1); 3) before the start of the second treatment session (FIS Tx-2); 4) before the start of the first evaluation session (FIS Ev-1) and 5) before the start of the second evaluation session (FIS Ev-2).


In accordance with the protocols for the FIS application, each child was approached outside the examination/treatment/evaluation room by a trained assistant before the start of each session, without being aware of the procedures that were to follow. At all stages of the study, which were performed on the school premises, examiners, assistants, operators and evaluators were blinded to the outcomes of the FIS application.

Statistical analysis

The data were entered into a database, checked for errors and analysed, using SAS software (version 9.2). The dependent variable was the dental anxiety score (FIS). The independent variables were gender, first dental visit (yes/no), history of extraction (yes/no), DMFT and dmft scores (low (0-3), medium (4-6), and high ([greater than or equal to] 7)), treatment approach, and time points (1 = start, 2 = 2 months, 3 = 2.5 months, 4 = 8.5 months and 5 = 14.5 months).

Effects of time points were tested using a mixed model (ANOVA) where time point was a fixed and children a random factor. The differences between the separated time points were calculated, using Student-t tests within the model. An ANCOVA model was used on each of the time points in testing the effects of the other independent variables. The statistically significant level was set at [alpha] = 5%.



Disposition of subjects

The initial sample consisted of 302 children (166 boys and 136 girls), with a mean age of 6.8 years (SD [+ or -] 0.4), ranging from 6-7 years of age. There was no loss-to-follow up of children up to time point 3. At time points 4 and 5, the loss-to-follow up was 7.9% and 14.2%, respectively (Figure 2). There was no statistically significant difference in baseline FIS scores between the longitudinally-followed children and the loss-to-follow-up group (p > 0.05).

The effect of time points on dental anxiety

The mean and standard deviation of the FIS scores at the five time points are presented in Table 1. The mixed model showed an effect of time points on the FIS scores (p < 0.0001). The results of the Student-t tests showed that the dental anxiety of the children at time point 1 was statistically significantly higher than at time points 2 to 5. There was no statistical difference in the children's dental anxiety between time points 2 and 3, and between time points 4 and 5. All the other comparisons of the time points were statistically significantly different. The difference in the mean FIS scores between time point 1 and time point 5 was 0.6. The pattern of FIS scores of the children over the five time points is illustrated in Figure 3. Eighty-nine percent of the children with FIS score 1 or 2 at baseline had the same scores at the last time point, whereas 82% of children with FIS score 4 or 5 at baseline had a FIS score of 1 or 2 at the last time point.

The effect of other variables on dental anxiety

There were no effects of gender, first dental visit, history of extraction, DMFT, dmft or treatment approach on the dental anxiety scores of the children at each of the five dental visits.


The primary purpose of this study was to investigate the effect of sequential dental visits on children's dental anxiety over a 14.5-month period. This investigation provides information on how acquired experiences, regarding aspects of oral health, can influence the level of dental anxiety in a child during follow-up visits. Of importance is the selection of the appropriate instrument to assess dental anxiety. Self-report scales were given preference, as the study was conducted on school premises, in the absence of the parents. In view of the young age of the study group, the picture scales were considered most appropriate. The Facial Image Scale (FIS) was developed and validated to assess state anxiety in individuals from 3-to 18-years old [Buchanan and Niven, 2002]. This scale was used in the current investigation as it is simple and easy to handle and takes less than one minute to be completed [Olumide et al., 2009]. The same well-trained assistants performed this task during all five time points, ensuring that the established protocols for dental anxiety assessment were strictly followed.

In using a self-reporting measurement technique, only the cognitive component of the dental anxiety construct was covered [Aartman et al., 1998]. Considering this limitation of the FIS, the study outcomes should be treated with caution, as there are other aspects of dental anxiety that were not assessed.

The main outcome of this study was a decrease in the children's levels of dental anxiety over time, which was not affected by any of the independent variables. The fact that the dental history of the children had no effect on their self-reporting of dental anxiety was a surprise, as it was expected that having a previous history of extraction would have increased the level of dental anxiety [Milsom et al., 2003]. It is interesting to notice that between time points 2 and 3, in which children received restorative treatment, there was no statistically significant decrease in levels of dental anxiety. The same is true for time points 4 and 5, in which the children only had their restorations and sealants evaluated. Dental anxiety decrease occurred after the epidemiological survey and after the 2nd restorative session, which suggests that it may be related to increased familiarity with the dental environment and the dental procedures.

This outcome differs from that of Tickle et al. [2009], who reported an increase in dental anxiety prevalence. The difference between the present study and the one conducted by Tickle may be the absence of frequent contact with the dental environment in the latter. In contrast, during the 14.5-month period of the present investigation, the same dental team was present at the school premises. Very few children moved from a low to a high FIS score, the reverse was seen more often.

The outcomes of the present investigation are also not in line with that of Venham et al. [1977], carried out more than 30 years ago. In their study, although the behaviour of the children improved after six dental visits, the self-reported dental anxiety remained unchanged over time. This difference might be explained by the different measurement instruments used Venham Picture Test and Facial Image Scale--and also by the different nature of the dental visits.

In the Venham study the first dental visit involved a prophylaxis performed with a rotary hand-piece, which some children could have considered threatening. However, in the present investigation the dental treatment of the children gradually evolved from an epidemiological examination, a totally noninvasive procedure, to a first restorative session, in which only one tooth was treated, and then to a second standard restorative session. This flow of events may have positively influenced the study outcome, as it has been proposed that meeting the dentist on a non-threatening occasion, in order to get accustomed to the professional and the practice environment, works well in engendering acceptance by children of invasive treatment and in controlling dental anxiety [Chapman and Kirby-Turner, 1999].

Another interesting outcome of the present investigation was the positive effect that the invasive treatment had on the children, as they experienced a statistically significant decrease in levels of dental anxiety, even after the restorative sessions. This was a surprise, as it known that local analgesia and burs are often identified as anxiety-provoking parts of dental treatment [Rafique et al., 2008].

It is important to note that the dental treatment of the children in the present study was performed by paediatric dentists, who have special skills and are well-trained in behaviour management techniques, such as 'tell-show-do' [Lyons, 2009]. This may be a reason for the decrease in the children's levels of dental anxiety, and also for the fact that none of the children refused to undergo dental treatment in any the five dental visits. One could hypothesise that, in the hands of general dental practitioners, the outcomes could be different. Further investigation might clarify this point.

Furthermore, friends at school may also have been a factor in the observed decrease in levels of dental anxiety, as it is obvious that they talked to each other about what happened during the dental visits and thus influenced each other, which does not occur when children visit a dentist in a private practice environment. Furthermore, measuring dental anxiety on the school premises might have had a positive influence on the level of dental anxiety of the children, as the environment is regarded by them as less threatening than a dental clinic.

The outcomes of the present investigation show that a mixture of non-invasive dental treatments in a school setting reduced the levels of dental anxiety in this group of Brazilian children. As the choice of the study area was done selectively, the external validity may not be very high. At best, the outcomes can only be extrapolated to other communities in Brazil sharing the characteristics of the study population in this research.


In conclusion, a gradual exposure of children to the dental environment in sequential dental visits of different natures in a school premise caused a decrease in their levels of dental anxiety over a 14.5-month period.


The authors thank Dr RG de Amorim for providing the treatment and the dental assistants for their skillful contributions. We are grateful to FAP-DF (Fundacao de Apoio a Pesquisa do DF), Brazil, and to the Radboud University Nijmegen Medical Centre, the Netherlands (institutional funds), for financially supporting the study. The authors declare that they have no conflict of interest.


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D.M. de Menezes Abreu *, S.C. Leal **, J. Mulder ***, J.E. Frencken *

* Department of Global Oral Health, *** Department of Preventive and Restorative Dentistry, College of Dental Sciences, Radboud University Nijmegen Medical Centre, The Netherlands, ** Department of Dentistry, School of Health Sciences, University of Brasilia, Brazil.

Postal address: D.M. de Menezes Abreu. Rua 35 Sul Lote 9 Apto. 1204--Ed. Del Fiori Solarium, Aguas Claras 71931-180--Brasilia/DF, Brazil.

Table 1. Mean and standard deviation
(SD) of dental anxiety scores (FIS)
by time point.


1) Fis EPI     302   2.3    1.2
2) Fis Tx-1    302   2.0    1.0
3) Fis Tx-2    302   1.9    1.0
4) Fis Ev-1    278   1.7    0.8
5) Fis Ev-2    259   1.7    0.9

N=number of children; EPI=epidemiological
examination; Tx-1=first treatment session;
Tx-2=second treatment session; Ev-1=first
evaluation session; Ev-2=second evaluation
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