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BRITISH DENTAL JOURNAL VOLUME 194 NO 9 MAY 10 2003 503
The relationship between anxiety and dental
treatment experience in 5-year-old children
K. M. Milsom,
1
M. Tickle,
2
G. M. Humphris
3
and A. S. Blinkhorn
4
Objectives To examine the relationship between dental anxiety, dental
attendance and past treatment history in 5-year-old children after
taking into account confounding influences.
Methods A cross sectional study of all 5-year-old children living in
Ellesmere Port and Chester. All children were clinically examined and
dmft and its components were recorded. A postal questionnaire was sent
to parents of participating children to identify whether children attended
the dentist on a regular asymptomatic basis or only when experiencing
problems. Additionally parents were asked to judge whether they and
their child were anxious about dental treatment. The socio-economic
status of the family was measured using the Townsend Material
Deprivation Index of the electoral ward in which they resided. The
bivariate relationships between anxiety and reported attendance, caries
experience, past extraction and restoration history were assessed using
chi-square and t-tests. Multiple logistic regression analyses were used to
identify predictors for dental anxiety.
Results A total of 1,745 children received both a clinical examination
and a questionnaire and 1,437 parents responded, a response rate of
82.3%. One in ten parents (10.8%) judged their child to be dentally
anxious. Anxious children had significantly (p<0.001) more caries
experience (dmft 2.58 vs 1.12). Multiple logistic regression analyses
confirmed that anxious children were more likely to be irregular
attenders (OR 3.33, 95% CI 2.22, 5.00), have anxious parents (OR 1.60,
95% CI 1.09, 2.36), and to have undergone dental extraction in the past
(OR 3.50, 95% CI 2.10, 5.85), after controlling for gender and socio-
economic status. A past history of restoration was not a significant
predictor of anxiety after controlling for other factors.
1
Consultant in Dental Public Health, Department of Dental Research and Development,
Halton Primary Care Trust, Moston Lodge, Countess of Chester Health Park, Liverpool Road,
Chester,
2
*Senior Lecturer\Consultant in Dental Public Health, Department of Dental
Medicine and Surgery, Manchester University Dental Hospital,
3
Reader in Clinical
Psychology, Department of Clinical Psychology, School of Psychiatry and Behavioural
Sciences, University of Manchester,
4
Professor of Oral Health, Department of Dental
Medicine and Surgery, Manchester University Dental Hospital.
*Correspondence to: M. Tickle, Senior Lecturer\Consultant in Dental Public Health,
Department of Dental Medicine and Surgery, Manchester University Dental Hospital,
Higher Cambridge Street, Manchester M15 6FH
Email: martin.tickle@man.ac.uk
Refereed paper
Received 12.07.02; Accepted 10.10.02
© British Dental Journal 2003; 194: 503–506
Conclusions Dental anxiety is a fairly common condition in 5-year-old
children in the North West of England. It is closely associated with a
symptomatic, irregular attendance pattern, a history of extraction and
having a dentally anxious parent. The cause and effect dynamics of these
relationships need to be determined.
INTRODUCTION
A debate about how best to provide dental care for young children
with caries in the primary dentition has been initiated by the pub-
lication of several recent research papers.
1,2,3,4
It seems that many
general dental practitioners (GDPs) are providing care according to
a philosophy which can be described as ‘reluctant intervention’.
This model of care is very different to that advocated in guidance
issued by the British Society of Paediatric Dentists (BSPD).
5
The
reasons why many GDPs hesitate to provide care in accordance
with BSPD guidance are probably multiple. One possible reason is
that GDPs may be concerned that performing aggressive clinical
interventions on young children may cause dental fear and anxi-
ety. Any such concerns are well founded, as dental anxiety is a
serious problem that has long term effects because it is stable and
difficult to alleviate.
6
Rachman
7
proposed three pathways leading to the acquisition
of child fears. They include: direct conditioning through some
traumatic experience, or two indirect pathways, referred to as
vicarious experiences or threatening information. Some reports
have claimed that dental anxiety, resistant to casual management,
develops from the infrequent experience of major or traumatic
dental treatment.
8
Children who attend irregularly and sympto-
matically are likely to have more caries than regularly attending
children, and crucially are more likely to have extractions.
9
Given
the well-documented traumatic nature of extractions performed
under general anaesthesia
10
it is likely that this group of irregular
attenders is at greater risk of developing dental anxiety. Frequent
asymptomatic visits with no aversive experiences appear to pre-
vent the development of an anxious response to dental attendance.
This process is termed ‘latent inhibition’.
8,11
The evidence for this
effect has been limited to retrospective reports in the dental
field.
12,13
Indirect evidence can be retrieved from studies that show
children with high levels of dental anxiety have received more
extensive dental treatment,
14,15,16
however the literature is equiv-
ocal, as the opposite relationship has also been found. Possibly, the
most important study in this field is the longitudinal survey of
● Dentally related anxiety occurs in about 10% of the population of 5-year-old children and is related
to irregular attendance, traumatic treatment procedures and the anxiety of the child’s parents.
● Children who are sporadic attenders, usually present in pain and therefore often require an
extraction and extraction is associated with anxiety. This pattern of attendance and care can set
up a vicious cycle leading to long lasting dental anxiety problems.
● To prevent anxiety, we must break this cycle by making the dental visiting experience easier for
parents and more pleasant for children, but also by providing effective public health measures to
prevent dental caries.
● In measuring the outcomes of dental treatment provided to children, we must measure not only
clinical dental factors such as the longevity of restorations, perhaps more important is the need
to measure the impact of the treatment on the patient’s quality of life.
IN BRIEF
RESEARCH
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504 BRITISH DENTAL JOURNAL VOLUME 194 NO 9 MAY 10 2003
Murray et al.
17
who followed a sample of 9-year-old children for
three years. Those children who did not receive invasive treatment
were more likely to be dentally anxious. However, an important
caveat included in this report was that the anxiety response fol-
lowing dental treatment was attenuated when the child had a
record of past regular asymptomatic dental visits. This would sup-
port the latent inhibition hypothesis raised earlier.
In attempting to gain an understanding of the initiation and
development of dental anxiety, two factors: attendance behaviour
and past treatment history seem to be of prime importance. If we are
to avoid dental anxiety it is also important to see if the relationships
reported by Murray et al.
17
in 9-year-old children exist in younger
age groups. Against a background of high caries prevalence in
young children and the frequent use of extractions to deal with the
condition, a study was undertaken in the North West of England, the
aim of which was to examine the relationship between dental anxi-
ety, dental attendance and past treatment history in 5-year-old chil-
dren after taking into account confounding influences.
METHOD
A whole population survey of 5-year-old children in Chester and
Ellesmere Port was undertaken. Children were examined according
to national criteria developed by the British Association for the
Study of Community Dentistry.
18
Three trained and calibrated
examiners collected data on dmft and its components. These data
were recorded electronically in the field. The Townsend Material
Deprivation Score
19
of the electoral ward of residence of each child
was attached to each record by reference to the subject’s home
postcode. This area measure of deprivation was used as a proxy
measure of the socio-economic status of each child.
The parents of all children included in the study were sent a
questionnaire designed to measure the child’s dental anxiety. The
questionnaire asked parents to indicate:
• If their child attended the dentist on a regular asymptomatic
basis or if they attended only when experiencing symptoms.
• Whether or not their child was frightened or anxious in relation
to dental treatment.
• Whether or not they themselves were frightened or anxious in
relation to dental treatment.
Both single item questions about anxiety employed a five point
rating scale with verbal anchors ranging from very relaxed to very
frightened about dental treatment. Children were dichotomised
according to their anxiety status, subjects were classified as being
anxious about dental treatment if their parents indicated that they
were either fairly or very frightened. Those children whose parents
described their children as being very or fairly relaxed, or that they
were neither relaxed nor frightened, were classified as non-anxious.
Questionnaires were sent out in three stages to increase
response. The parents of all subjects were included in the first
mailing and non-responders were successively targeted in the sec-
ond and third stages. Answers to each question were compared
from the three stages to detect for possible non-response bias. Each
questionnaire was marked with the child’s unique study identifica-
tion number to enable the data collected by questionnaire to be
linked to the clinical data.
Bivariate relationships between categorical variables were
analysed using cross-tabulations and chi-square tests, t-tests were
used for continuous variables. A multiple logistic regression model
was fitted, for the child assessed as being anxious / not anxious as
the dependent variable. This model included: regular asymptomatic
attendance / irregular symptomatic attendance, gender, Townsend
Index, anxious / non anxious parent and ever / never had an extrac-
tion. A second model was constructed replacing the independent
variable ever / never had an extraction with ever / never had a fill-
ing. In this last analysis children who had previously had an extrac-
tion were excluded from the analysis.
RESULTS
A total of 1,745 children received both a clinical examination and
a questionnaire to their home address and 1,437 parents respond-
ed, an 82.3% response rate. Some 89.8% (N=1,291) of children
were reported by their parents as having visited the dentist in the
past year. Table 1 examines the prevalence of child anxiety as
reported by their parents, and shows that three quarters of all par-
ents asked (76.8%) felt that their children were either very relaxed
or fairly relaxed about dental treatment. One in ten parents (10.7%)
classified their children as being anxious (fairly or very frightened)
and one in nine parents (12.5%) felt that their children were nei-
ther anxious nor relaxed about dental treatment.
A series of bivariate analyses were completed prior to the
logistic regression analyses. These demonstrated that children
classed as anxious had significantly more dental caries experi-
ence than children who were perceived to be relaxed about den-
tal care (dmft=2.58 vs dmft=1.12, p<0.001). The association
between child anxiety and the child’s dental visiting behaviour
was also statistically significant. Children judged by their parents
to be anxious were more likely to have an irregular, symptomatic
visiting pattern than children who were classified as non-anx-
ious (χ
2
=58.2, dof 1, p<0.001). The relationship between extrac-
tion and anxiety was also explored prior to multivariate analysis.
The epidemiological examination showed that 115 (8%) of chil-
dren had one or more extractions in the past. In the question-
naire, parents were asked if their child had received an extraction
under local or general anaesthetic, 29 reported that their child
had been treated under local anaesthetic and 65 reported that
their child had previously undergone a general anaesthetic for
extractions. This represents an under-reporting (N=94 vs N=115)
of the epidemiological findings. Chi square tests were used to
determine the relationship between anxiety and both types of
patient management techniques. The tests showed that children
who had extractions performed under either a local or general
anaesthetic were significantly (local anaesthetic χ
2
= 12.71,
dof=1, p<0.001, general anaesthetic χ
2
= 48.68, dof=1, p<0.001)
more likely to be anxious than children who had no history of
extraction. The tests also showed that similar proportions of chil-
dren treated under local (31%) and general anaesthetic (37%)
suffered from dental anxiety. Following the results of these
analyses children who had a history of extraction were aggregat-
ed. The relationship between child anxiety and extraction history
(measured epidemiologically) showed that 5-year-old children
reported as being anxious by their parents were significantly
(χ
2
=43.6, dof 1, p<0.001) more likely to have had an extraction
than non anxious children. In fact, 21.9% (n=33) of anxious 5-
year-olds had a history of extraction compared with 6.4% (n=80)
of children classified as non-anxious.
A further analysis, excluding the children who had undergone
extraction, looked at the relationship between anxiety and
whether or not the subject had a restoration in the past. This
analysis showed that having a restoration in the past had no sig-
nificant association with anxiety status of the child (χ
2
=0.78, dof
1, p=0.38).
Table 1 Parentally reported levels of anxiety towards dental treatment of
5-year-old children.
Frequency Pe rcent
Very relaxed 567 40.4
Fairly relaxed 511 36.4
Neither relaxed or anxious 176 12.5
Fairly anxious 114 8.1
Very anxious 37 2.6
Total 1,405* 100.0
* 32 records missing due to item non-response
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BRITISH DENTAL JOURNAL VOLUME 194 NO. 9 MAY 10 2003 505
the strong association between major or traumatic treatment
interventions and dental anxiety.
8,14,15,16
In light of these obser-
vations perhaps extraction should be considered very much as a
treatment of last resort. For very young children or the child who
is already dentally anxious, a wait and watch approach by the
dentist may have much to recommend it.
It is more difficult to explain why no relationship was found
between dental anxiety and a history of restorative treatment.
One explanation could be that the restorative approach adopted
by the majority of GDPs is atraumatic for children. At present
we have no in-depth understanding of the processes employed
by GDPs for the restoration of carious primary teeth. For exam-
ple, how often is local anaesthesia used and how is the mechani-
cal preparation of teeth approached; is hand instrumentation
rather than use of an air rotor the norm? If local anaesthetic
(and therefore an injection) and use of an air rotor are avoided
(through the application of hand instrumentation) the restora-
tive procedure may well be less traumatic for the child than the
procedures required to undertake an extraction either under
local or general anaesthetic. This possible regimen may reflect a
holistic approach by GDPs keen to reduce levels of anxiety at
the expense of fastidious cavity preparation. The BSPD recom-
mends the use of a vital pulpotomy followed by fitting a pre-
formed crown for the treatment of primary teeth with two sur-
face caries,
5
procedures which require an injection and use of
the air rotor. And yet in England and Wales in 2001, NHS fees
for only 4,255 preformed crowns for the treatment of primary
teeth were claimed by GDPs.
23
These statistics suggest that the
majority of GDPs are providing dental care according to a less
invasive philosophy than that recommended by BSPD, which
may account for the findings of no association between anxiety
and restorative history.
The data from this study demonstrate that there is a very
strong link between irregular attendance and dental anxiety in
young children, even after controlling for past treatment experi-
ence. These results add support to the notion of latent
inhibition;
8,11
that regular asymptomatic dental visits have a
cumulative effect and prevent development of dental anxiety. In
this way children learn to associate positive or neutral effects
with asymptomatic dental visits. Against a background of unre-
markable dental visits, an occasional unavoidable aversive expe-
rience is psychologically less negative.
The link between extraction and reported dental anxiety
amongst 5-year-old children has been demonstrated in this
study, as has the link between reported irregular symptomatic
dental attendance and anxiety, but the nature of these relation-
ships is unclear. Does extraction lead to the creation of dental
anxiety in children, or is it the case that inherently anxious chil-
dren undergo extraction under general anaesthesia because their
anxiety prevents alternative treatment options? Are anxious
children less likely to be regular attenders because they have an
intrinsic anxiety (irrespective of whether they have attended a
Two multivariate logistic regression analyses were performed
to identify which variables predict anxiety in children. The
results are presented in Tables 2 and 3. Table 2 shows that chil-
dren who had anxious parents were one and a half times more
likely to be anxious than those whose parents judged themselves
not to be anxious about dental treatment. Children who were
classed as irregular, symptomatic attenders at the dentist were
3.3 times more likely to be anxious than children who attended
regularly. This was after controlling for socio-economic status
and gender, both of these variables were shown to have no asso-
ciation with anxiety. The other important predictor of anxiety
was a history of extraction. Children who had an extraction in
the past were three and a half times more likely to be anxious
than children who had not experienced this type of treatment.
Interestingly, when this independent variable was replaced with
a history (or not) of fillings, no significant association was found
between restoration experience and anxiety (Table 3). The signif-
icant, independent relationships between the dependent variable
and attendance patterns and parental anxiety remained.
DISCUSSION
In this population of 5-year-olds, dental anxiety was relatively
common, 10.7% of parents reported that their child was either
fairly or very anxious about dental care. The multivariate analy-
ses demonstrated that parents’ levels of dental anxiety had a
consistent, independent influence on their child’s dental anxiety.
Some clinical studies have indicated that there is an association
between child and maternal dental anxiety, that is modelling or
an example of vicarious experience.
20
Although when parents
are invited to comment on the possible causes, no attribution
which focuses on parental transfer of anxiety could be found.
21
In a community representative survey in Seattle, USA of 5–11-
year-old children (N=895), it was found in a multiple logistic
regression model that the influence of parental modelling (ie
dentally fearful parent) on the child’s independently derived
dental anxiety score was significant.
14
That is, children who had
a dentally anxious parent were twice as likely to be anxious
when compared with children who had non-fearful parents. This
result held true when controlling for dental health status (a proxy
measure of direct conditioning). However, as in the study report-
ed here, direct conditioning was found to be the strongest predic-
tor of child dental anxiety status.
Children who had a history of extraction were three and a half
times more likely to be anxious than children who had no experi-
ence of this form of treatment. The results of this study and sur-
veys of general anaesthesia provision
22
conducted at the time
this study was undertaken (1999/2000) show that general anaes-
thesia was commonly employed to manage young children
undergoing extractions. We also know that extraction under
general anaesthesia is a traumatic process for young children.
10
Therefore it is not surprising that the results of this study agree
with the findings of others in the literature which demonstrate
Table 2 Results of a logistic regression analysis for the dependent variable
anxious/not anxious with independent variables including ever/never had
an extraction.
Dependent variable: anxious/not anxious as reported by parent
95% CI for Odds ratio
Independent variables Odds ratio Lower Upper
Regular asymptomatic/
irregular symptomatic attender 3.33 2.22 5.00
Gender 1.31 0.90 1.90
Townsend Index 0.99 0.94 1.04
Anxious parent/
non anxious parent 1.60 1.09 2.36
Ever/never had an extraction 3.50 2.10 5.85
Table 3 Results of a logistic regression analysis for the dependent variable
anxious/not anxious with independent variables including ever/never had a
filling.
Dependent variable: anxious/not anxious as reported by parent
95% CI for Odds ratio
Independent variables Odds ratio Lower Upper
Regular asymptomatic/
irregular symptomatic attender 4.50 2.70 7.50
Gender 1.27 0.80 2.02
Townsend Index 0.99 0.94 1.06
Anxious parent/
non anxious parent 1.78 1.1 2.88
Ever/never had a filling 1.16 0.57 2.34
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506 BRITISH DENTAL JOURNAL VOLUME 194 NO 9 MAY 10 2003
dentist in the past) which acts as a barrier to attendance, or does
a past history of symptomatic attendance associated with
unpleasant treatment experiences have the effect of creating
anxious children? Cross-sectional studies cannot answer these
questions. Longitudinal studies are required to provide us with a
more complete understanding of the causal relationship between
dental care and dental anxiety if we are to prevent this distress-
ing psychological condition in the future.
The basis of non-threatening dental care should be preven-
tion, which ought to form the cornerstone of any long-term care
strategy for the dental care of children. The preventive messages
are well understood
24
and the fact that 60% of 5-year-olds are
caries free
25
suggests that dental decay can be prevented. How-
ever, for prevention to work in practice, regular attendance by
children is necessary and dentists should be adequately remuner-
ated for undertaking this time consuming work. Dietary advice
and preventive interventions such as the topical application of
fluorides are advocated for children with active caries
5
and such
non-invasive approaches can do much to build confidence in
anxious children and their parents.
It is important that the value of primary teeth is recognised,
but we must not lose sight of the fact that they are temporary
structures and as a consequence may need to be managed some-
what differently to the permanent dentition. Most of all, the den-
tal profession needs to remember that the patient’s long term
well-being should be our overriding concern. Anxious children
have greater dental disease levels than their non-anxious peers.
If we wish to convert these dentally needy children into preven-
tively-minded, asymptomatic adult dental attenders, we have to
be able to offer them positive dental experiences. With this in
mind, the dental care of the young child should be approached
holistically and the desire to eradicate dental caries should be
carefully considered against the possible psychological conse-
quences of invasive dental treatment.
CONCLUSIONS
Dental anxiety is a fairly common condition in 5-year-old chil-
dren in the North West of England. It is closely associated with a
symptomatic, irregular attendance pattern, a history of extrac-
tion and having a dentally anxious parent. The cause and effect
dynamics of these relationships need to be determined through
longitudinal studies if we are to have a firm evidence base for
preventing and alleviating this distressing psychological condi-
tion.
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