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R E S E A R C H A R T I C L E Open Access
Effects of child characteristics and dental
history on dental fear: cross-sectional study
Mohammad A. Alshoraim
1
, Azza A. El-Housseiny
2,3
, Najat M. Farsi
2
, Osama M. Felemban
2*
, Najlaa M. Alamoudi
2
and Amani A. Alandejani
4
Abstract
Background: Dental fear (DF) is a challenging problem in dentistry. It is multifactorial in origin and many contributing
factors have been identified. The aim of the study was to assess dental fear among 12–15 years old Arabic speaking
children in Jeddah, Saudi Arabia and its relation to demographic variables, previous dental experience, and
child behaviour.
Methods: In this cross-sectional study, a total of 1522 boys and girls from middle schools in Jeddah, Saudi Arabia
participated in this study during the period of 2014 to 2016. The Children’s Fear Survey Schedule–Dental Subscale
(CFSS-DS) was used to assess DF. A parental questionnaire was used to record the children’s previous dental experience.
Children were examined for caries and the children’s behaviour was assessed during dental examination using Frankl
Behaviour Rating Scale. The associations between different variables and the CFSS-DS scores were analysed using t-tests,
ANOVA, and multiple linear regression analysis.
Results: The response rate of the questionnaires was 78.6%. The mean CFSS-DS score was 25.99 ± 9.3 out of a maximum
of 75. Bivariate analysis showed that younger children, girls, and public-school students were significantly more
fearful than older children, boys, and private school children, respectively (P< 0.001). Children who showed poor
behaviour during dental examination were significantly more fearful than those with good behaviour (P< 0.001).
Regression analysis showed that children who had significantly higher scores of dental fear were the children
who did not visit the dentist in the past year due to dental fear; who never visited the dentist or those who only
visited the dentist on pain; who were reported by parents as crying, screaming, or resistant during their previous
dental visit; and those who were described to be in pain during previous dental treatment. Dental caries showed
no significant association with DF.
Conclusions: This study confirms that DF is low among 12–15 years old Arabic speaking children in Jeddah,
Saudi Arabia. DF is associated with age, gender, school type, irregular patterns of dental visits, painful experiences
during previous dental visits and negative behaviours during dental examinations.
Keywords: Dental fear, Dental anxiety, Children’s fear survey schedule-dental subscale (CFSS-DS), Caries, Dental
behaviour
Background
Dental fear (DF) is a widely extended physiological, behav-
ioural, and emotional reaction to one or more threatening
stimuli in the dental practice [1]. DF and dental anxiety
(DA) are terms that are often mixed up in the literature;
thus, dental fear and anxiety (DFA) is used to describe all
kinds of fear and anxiety related to dentistry [1]. The use of
self-report scales is the most common and reliable method
of measuring DFA, and the Children’sFearSurvey
Schedule-Dental Subscale (CFSS-DS) is one of the most
commonly used scales [2]. This scale has been validated in
different populations with different languages [2].
DF is multifactorial in origin and many factors that affect
it have been identified [1]. One of these factors is the age
of the child, which has been associated with DF scores, al-
though this is a matter of debate. One previous study re-
ported that there was no effect of age on DF [3], while
* Correspondence: omfelemban@KAU.edu.sa
2
Paediatric Dentistry, Faculty of Dentistry, King Abdulaziz University, P.O. Box:
80200, Jeddah 21589, Saudi Arabia
Full list of author information is available at the end of the article
© The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Alshoraim et al. BMC Oral Health (2018) 18:33
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other studies found increased DF in older children com-
pared to younger ones [4,5]. DF cannot be considered to
be stable over time since other factors may decrease DF
with age such as treatment variables and subjective expe-
rience [6]. The sex of the child also has a significant effect
on DF severity [7]. Some studies showed significant differ-
ences in DFA between the two sexes [7–9], while other
studies found no significant differences [10–14].
Factors related to dental history, such as caries
experience, previous dental visits, dental visit patterns,
type of previous dental treatments, and behaviour
during dental treatment, and their relationship with DF
have been discussed in previous studies [6,13,15,16].
It has been suggested that prior dental visits can
decrease DF since this can eliminate negative thoughts
about dentistry [15].However,thetypeofdentaltreat-
ment the children received in their previous dental
visits plays a significant role in DF severity [6].
Among population-based studies in children, there is
still debate regarding the relationship between DF and
previous dental history. Thus, further investigation into
factors associated with DF is needed. The aim of the
study was to assess dental fear among 12–15 years old
Arabic speaking children in Jeddah, Saudi Arabia and
its relation to demographic variables, previous dental
experience, and child behaviour.
Methods
Study design
This is a cross-sectional study and the guidelines of
Strengthening the Reporting of Observational Studies
in Epidemiology (STROBE) were followed in reporting
this study [17].
Participants
The sample consisted of 1522 middle school-aged children
who were selected randomly from schools in Jeddah, Saudi
Arabia. A consent form was sent to parents, and the inclu-
sion criteria were as follows: aged between 12 and 15 years,
nativelanguagewasArabic,andsignedinformedconsent.
The population frame included all children registered in
middle schools in Jeddah according to Ministry of Edu-
cation, which included 115,689 children attending pub-
lic or private middle schools. The prevalence of DF in
the target population was hypothesized to be 20% ac-
cordingtopreviouspopulationbasedstudies[1], so the
percentage frequency of the outcome factor was set at
20% with ±2% confidence limits. The confidence level
was set at 95%, the significance level was set at 5%, and
the power was set at 85%. The resulting needed sample
size for the study was 1520 subjects.
The sampling method utilized a multistage stratified
random sample according to the four districts of Jeddah,
gender (male and female schools), and then according to
school type (private and public). Four schools were
chosen from each district: a male public school, a male
private school, a female public school, and a female
private school. The sampling procedure yielded a total of
16 school representative of the total number of schools
in Jeddah. For each school, one class from each grade
was randomly assigned (using the bowl method) to join
the study. Where there was a small number of students
in any selected class (less than 15), another class was
randomly selected. Where there was a small number of
students in the school (less than 150), all students in the
school were included in the study.
Ethical approval was received from the Research Eth-
ics Committee, Faculty of Dentistry, King Abdulaziz Uni-
versity, Jeddah, Saudi Arabia (number: 046–15).
The questionnaire
The study variables were assessed using two question-
naires. The first questionnaire was for the parents and
included the consent form as well as questions to inves-
tigate the different factors affecting DF. The factors
included: pattern of previous dental exposure, and the
child behaviour during those visits. The parents’ques-
tionnaire (Additional file 1) was adopted from a previ-
ous study questionnaire [18] developed based on the
literature. In this study, the selected questions were
revised by four experts in paediatric dentistry interested
in behaviour management of children. The second
questionnaire was the Arabic version of the CFSS-DS
[19], which was completed by children in order to
assess their DF level. The Arabic version of the CFSS-
DS is highly reliable in terms of both test-retest reliability
and internal consistency and shows good criterion validity
and moderate construct validity [20,21]. It has the same
15 items of the English version and each item was scored
on a five Likert scale ranging from 1 to 5. Higher scores
indicated higher dental fear. The scores of the 15 items
were added to get a total score for each child.
Study procedures
Multiple school visits were carried out during this study.
The study started in September 2014 and ended in June
2016. During the first visit, the questionnaires with consent
forms were distributed to the selected children. Subse-
quently, the examiners visited the schools again over a five-
month period for data collection. The examiners collected
the parent’squestionnairesfromstudents.andonlythose
with parental approval (i.e. signed informed consent form)
moved on to the second phase of the study, i.e. the child’s
questionnaire. The questionnaires were self-reported and
filled out directly by the children during school hours. On
collecting the child’s questionnaire, the questions were
inspected for completion for each child. In case of any
missing data, the child was asked to complete the
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questionnaire. After completing the child’squestionnaire,a
dental examination was carried out to assess the children
caries experience. The examination was carried out using
the Community Periodontal Index (CPI) probe (Screen
Probe Shepherd’s Hook 11.5 d722 pcwho-23, lot/ 981,766,
Nordent, USA) and a mirror using adequate lighting and
infection control measures. The index for decayed, missing,
or filled permanent teeth (DMFT) was recorded according
to the World Health Organisation (WHO) criteria [22,23].
Dental caries severity was categorized based on a modifica-
tion of the WHO criteria for dental caries severity into the
following: no caries (DMFT = 0), low caries (DMFT< 2.7),
moderate caries (DMFT = 2.7–4.4), and severe dental
caries (DMFT≥4.5) [23]. The examination was carried
out by two trained and calibrated examiners. The kappa
value for inter-examiner reliability was 0.93 and for the
intra-examiner reliability ranged from 0.8 to 1.00.
During the dental examination, the children’sbehaviour
was evaluated according to the Frankl Behaviour Rating
Scale [24] by two calibrated investigators to assess the rela-
tionship between DF and child behaviour. The classification
was dichotomized into two categories due to the low num-
bers in some categories. Negative behaviours included the
two categories of definitely negative and negative behav-
iours, while positive behaviour included the two categories
of positive and definitely positive behaviours. Kappa statis-
tic was calculated and its value for inter-examiner reliability
was 0.93 and it ranged from 0.83 to 1.00 for the intra-
examiner reliability. After the dental examination and be-
havioural assessment, a confidential report was sent to par-
ents to inform them about their child’s dental status and to
advise them to visit a dentist if needed.
Data analysis
Statistical analyses were carried out using SPSS version
18.0 (SPSS Inc., Chicago, II, USA). The significance level
was set at P< 0.05. For each child, the total fear score
was calculated by adding the fear score of each of the 15
items of the self-reported CFSS-DS, which ranged from
15 to 75, with higher scores indicating higher fear levels.
The associations between dental fear and demographic
variables, previous dental experience, caries experience,
and behaviour were analysed using independent t-tests
and one-way analysis of variances (ANOVA). When
significant effects were found using a one-way ANOVA,
a Tukey post-hoc test was used to determine significant
intergroup mean differences. A multiple linear regres-
sion analysis was used to evaluate significant predictors
of dental fear levels while controlling for potential
confounders.
Results
Theconsentformandparentquestionnairesweredistrib-
uted to 2000 children, out of which 1572 children returned
the consent form and the parent questionnaire. Thus, the
response rate for all children was 78.6%. Of those who
returned the consent form, 1522 participated in the study
(19 children refused to participate in the study, and 31
children were absent on the examination days).
There were 826 (54.27%) male participants and 696
(45.73%) female participants. There were 1027 (67.5%)
children from public schools and 495 (32.5%) children
from private schools. All children were aged between 12
and 15 years, with a mean age of 13.5 ± 1.05 years.
The results in Table 1show that the DF scores were
statistically significantly different among the different age
groups (P< 0.001). A post-hoc analysis indicated that 12-
year-old children had statistically significantly increased DF
scores compared to other age groups. The mean DF score
in girls was significantly higher than that in boys (P<
0.001). The mean DF score was also significantly higher
in children attending public schools compared to chil-
dren attending private schools (P< 0.001). Table 2
shows the scores for each item in the CFSS-DS of the
participants. The mean DF total score (CFSS-DS) for all
participants was 25.99 ± 9.31.
Regarding previous dental exposure, Table 3shows that
1340 (88%) of the parents reported that their children had
previous dental experience, while only 182 (12%) of the chil-
dren had no previous dental experience. There was no sig-
nificant difference in the mean DF scores between children
with previous dental experience and those without previous
dental experience (P= 0.230), or between those who visited
the dentist last year and those who did not (P= 0.931). The
reasonsfornotvisitingthedentistlastyearincludedmoney
issues, no pain, no time for treatment, not needed, and child
fear. A post-hoc analysis indicated that children who did
notvisitthedentistdueto“child fear”had the highest DF
scores compared to other causes (P<0.001). Parents were
asked about their children’s dental visit patterns, and the re-
sults show that the DF scores differ significantly among the
different patterns of dental visit (P< 0.001). Children who
visit the dentist only when theyhavepainshowsignificantly
increased DF scores compared to those who visit the dentist
on a regular basis (P<0.001).
Regarding previous dental treatment, Table 3shows a
non-significant difference in DF scores among children
who have experienced different dental treatments (oral
examination, local anaesthesia, extraction, filling, prophy-
laxis, and other) (P= 0.179). Children who cried during
their previous dental visits were significantly more fear-
ful compared to those who displayed other behaviours
(P< 0.001), except for screaming. Children who felt pain
during previous dental treatment had significantly
higher mean DF scores compared to those who did not
feel any pain or those who felt little pain (P< 0.001).
Upon dental examination, 232 (15.2%) children had
“no caries,”330 (21.7%) had “low caries,”418 (27.5%)
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children had “moderate caries,”and 542 (35.6%) children
had severe dental caries. For the total sample, children
with severe dental caries had the lowest mean DF score.
This score was significantly lower than that for children
who had no caries or who were classified as having low
caries (P< 0.001; Table 4).
Table 5indicates that the children displaying negative
behaviours during the dental examination had signifi-
cantly higher mean DF scores compared to the children
displaying positive behaviours (P< 0.001).
A multiple linear regression model was used to evaluate
the associations of the variables while controlling for
confounders (Table 6). The model showed that dental fear
score decreases by 0.62 for every year increase in age after
controlling for confounders. Females have a score of
dental fear of 5.36 higher than males after controlling for
confounders. Participants from private schools had a
dental fear score of 1.92 less than participants from public
schools. Children who did not visit the dentist last year
due to child fear had a score of dental fear higher by 4.57
compared to children who did not visit the dentist last
year because of no pain. Children who never visited a
dentist or those who only visit the dentist on pain had a
significantly higher dental fear score compared to children
who visit the dentist regularly. Children who were crying,
screaming, or resistant during their previous visit had
significantly higher score of dental fear compared to
children who were cooperative during their previous
dental visit. Children who had pain during previous dental
treatment had higher scores of dental fear compared to
those who did not have pain in the previous treatment
visit. Children whose behaviour was rated as negative
during dental examination had higher dental fear score by
5.73 compared to those who were rated as having positive
behaviour. Caries level was not associated with dental fear
after controlling for confounders.
Discussion
This is an observational and analytical cross-sectional
study designed to assess the severity of DF and associated
factors in children aged 12–15 years. The mean DF score
on the CFSS-DS for all children was 25.99 ± 9.31. This
resembles the score reported in a recent study among
children in Jeddah, Saudi Arabia [20]. This suggests a
low level of DF amongst children in this age group,
Table 2 CDSS-DS mean item scores for all children, boys and girls
Item Total (N= 1522)
Mean (SD) 95% CI
1.Dentists 1.61 (0.89) 1.5–1.6
2.Doctors 1.41 (0.76) 1.3–1.4
3.Injection 2.21 (1.22) 2.1–2.2
4.Somebody examining your mouth 1.38 (0.75) 1.3–1.4
5.Having to open your mouth 1.43 (0.78) 1.3–1.4
6.Having a stranger touch you 1.81 (1.07) 1.7–1.8
7.Having somebody look at you 1.43 (0.80) 1.3–1.4
8.The dentist drilling 2.42 (1.22) 2.3–2.4
9.The sight of the dentist drilling 2.16 (1.19) 2.1–2.2
10.The noise of the dentist drilling 2.04 (1.14) 1.9–2.1
11.Instruments in your mouth 1.93 (1.08) 1.8–1.9
12.Choking 2.29 (1.21) 2.2–2.3
13.Having to go to hospital 1.34 (0.75) 1.3–1.3
14.People in white uniforms 1.14 (0.52) 1.1–1.1
15.Dentist cleaning your teeth 1.39 (0.76) 1.3–1.4
Total 25.99 (9.31) 25.5–26.4
CFSS-DS children’s fear survey schedule–dental subscale, Ntotal number of children,
SD standard deviation, CI confidence interval
Table 1 Mean dental fear in relation to age, sex, and school type
Variables N (%) Mean (SD) 95% CI Min–Max Test value
(Pvalue)
Lower Bound Upper Bound
Age 12 312 (20.5) 27.96 (11.23) 26.71 29.21 15–74 F = 7.42
‡
(< 0.001*)
13 464 (30.5) 26.01(9.07
a
) 25.18 26.84 15–63
14 413 (27.1) 25.55 (8.47
a
) 24.73 26.37 15–65
15 333 (21.9) 24.63 (8.35
a
) 23.73 25.53 15–68
Sex Male 826 (54.3) 23.12 (7.12) 22.63 23.60 15–68 t= 193.16
†
(< 0.001*)
Female 696 (45.7) 29.39 (10.41) 28.62 30.17 15–74
School Type Public 1027 (67.5) 26.52 (9.75) 25.93 27.12 15–74 t= 10.55
†
(< 0.001*)
Private 495 (32.5) 24.87 (8.23) 24.14 25.60 15–69
Total 1522 (100) 25.99 (9.31) 25.52 26.45 15–74
Ntotal number of children, SD Standard deviation, CI Confidence interval
*Statistically significant (P< 0.05),
‡
Analysis of variance,
†
t-test
Means sharing the same alphabetical letter superscripts are not significantly different from each other (post -hoc, P≥0.05)
Means that have different alphabetical letter superscripts are significantly different from each other (post-hoc, P< 0.05)
Alshoraim et al. BMC Oral Health (2018) 18:33 Page 4 of 9
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according to the cut-off score of 32 that was used in
previous studies [3,25,26]. A straight forward comparison
with other studies is difficult because of different study
designs, sampling methods, different dental fear scales
used (e.g. CFSS-DS, Corah’s Dental Anxiety Scale (CDAS),
Modified Dental Anxiety Scale (MDAS), Short Dental
Fear Questionnaire (SDFQ), Dental Fear Survey (DFS),
Visual Analogue Scale (VAS), Facial Image Scale (FIS),
Smiley Face Program (SFP), and Short Version of the
Dental Anxiety Inventory (S-DAI)) and cultural and social
factors [1]. However, the score is higher than the scores re-
ported for Dutch children [3], and lower than the scores
reported for US children [12], Japanese children [8], and
Croatian children [27]. In addition, the difference in dental
fear between children in Arabic speaking countries and de-
veloped countries may be related to differences in the
organization of the dental health care systems [10]. While
developed countries emphasize on prevention, a high
number of children in this study only visit the dentist
when they are in pain.
This study showed that the most feared items reported
by the children were “dentist drilling,”“choking,”and
“injection.”These items were found to be the most feared
items among children with different rankings in different
studies [8,12,19,28]. The high scores on these items in
different cultures indicates that children have the same
Table 3 Mean dental fear scores in relation to dental history
Dental history variables N (%) Mean (SD) 95% CI Test value
(Pvalue)
Previous dental exposure Yes 1340 (88) 25.88 (9.1) 25.4–26.4 1.441
†
(0.230)
No 182 (12) 26.76 (10.6) 25.2–28.3
Dental visit in previous year Yes 843 (55.4) 26.00 (9.1) 25.4–26.6 0.007
†
(0.931)
No 679 (44.6) 25.96 (9.6) 25.2–26.7
Why didn’t your child visit dentist last year? Money 56 (4.3) 26.30 (9.8
a
) 23.7–28.9 7.53‡
(< 0.001*)
No pain 410 (26.9) 25.58 (9.1
a
) 24.7–26.5
No time 48 (3.2) 25.33 (9.2
a
) 22.6–28.0
Not needed 187 (12.3) 25.01 (8.1
a
) 23.8–26.2
Child fear 52 (3.4) 36.33 (14.2) 32.4–40.3
Frequency of dental visits Regular 130 (8.5) 24.34 (6.7
ac
) 23.2–25.5 7.161
‡
(< 0.001*)
With pain 1014(66.6) 26.76 (10.8
b
) 25.9–27.1
Sometimes 196 (12.9) 23.62 (6.6
c
) 22.7–24.5
Never 182 (12) 26.51 (9.7
ab
) 25.2–28.3
Previous dental treatment Examination 617 (40.5) 25.50 ± 8.8 24.8–26.2 1.52
‡
(0.179)
Anaesthesia 214 (14.1) 25.69 ± 8.3 24.6–26.8
Extraction 527 (34.6) 26.56 ± 9.7 25.7–27.4
Filling 659 (43.3) 25.56 ± 9.1 24.9–26.3
Prophylaxis 225 (14.8) 26.48 ± 10.1 25.1–27.8
Others 89 (6.4) 24.56 ± 7.7 22.9–26.1
Child behaviour during previous visit/s§ Crying 90 (5.9) 34.51 (11.3
a
) 32.1–36.9 32.5
‡
(< 0.001*)
Screaming 49 (3.2) 30.29 (12.3
ab
) 26.8–33.1
Resistant 373 (24.5) 28.00 (9.7
bc
) 27.0–29.0
Cooperative 738 (48.5) 24.12 (7.8
d
) 23.6–24.7
Happy 122 (8%) 22.83 (7.0
d
) 21.6–24.1
I don’t know 135 (8.9) 26.07 (9.9
dc
) 24.4–27.8
Pain during previous dental treatment/s§ Yes 456 (30) 28.82 (10.87
a
) 27.8–29.8 38.20
‡
(< 0.001*)
No 420 (27.6) 23.54 (7.97
b
) 22.8–24.3
A little 631 (41.5) 25.53 (8.35
c
) 24.9–26.1
Ntotal number of children, SD standard deviation, CI confidence interval
*Statistically significant (P< 0.05),
‡
Analysis of variance,
†
t-test
Means sharing the same alphabetical letter superscripts are not significantly different from each other (post -hoc, P≥0.05)
Means that have different alphabetical letter superscripts are significantly different from each other (post-hoc, P< 0.05)
§
15 (1%) of parents did not answer the question regarding the behaviour of their children
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concerns about specific dental procedures, even when the
overall DF severity is different [8]. The use of these three
items as screening tools was suggested by Cuthbert and
Melamed who developed the CFSS-DS [12].
Our results show that girls are significantly more
fearful than boys. Some studies support these findings
[7–9,20,29], while others do not [10–12,30]. It has
been suggested that girls are more fearful of the dentist
because of their tendency to show their feelings, unlike
boys who may deny their fear [7,27]. In addition, social
and cultural factors were identified to play at least partial
roles in this difference between fear levels in boys and girls
[31]. For example, while in some cultures it is socially
acceptable for girls to exhibit their fear, boys cannot [19].
Moreover, in some societies, such as Saudi Arabia,
there is complete separation between boys and girls
from an early school age, so they may not share the
same social factors affecting DF. The separation be-
tween male and female peer groups that takes place at
a late age in African populations was suggested to be
at least a minor factor in this finding [31].
Our data demonstrate a decrease in DF scores in older
children. These findings are supported by some previous
studies [10,12,28,29], while other studies do not
support this [4,5,8]. In previous studies, the decrease in
DFA that occurs over time could be related to the
increase in general competence as children grow up, and
maturation of cognitive controls and impulse control to
improve the personality of the child [1]. The relationship
between DF and age is not linear, as a weak negative
correlation was found [12]. Previous studies have
reported that age does not affect DF [8], no correlation
Table 4 Mean dental fear scores in relation to caries experience
in permanent teeth
Caries severity Total F Value
(Pvalue)
N (%) Mean (SD) 95% CI
No caries 232 (15.2) 27.91 (10.4
a
) 26.6–29.3 10.23‡
(< 0.001*)
Low caries 330 (21.7) 27.36 (9.3
ab
) 26.3–28.4
Moderate caries 418 (27.5) 25.96 (9.3
bc
) 25.1–26.9
Severe caries 542 (35.6) 24.51 (8.6
c
) 23.8–25.2
Total 1522 (100) 26.05 (9.3) 25.6–26.5
Ntotal number of children, SD standard deviation, CI confidence interval
*Statistically significant (P< 0.05),
‡
Analysis of variance
Means sharing the same alphabetical letter superscripts are not significantly
different from each other (post-hoc, P≥0.05)
Means that have different alphabetical letter superscripts are significantly different
from each other (post-hoc, P<0.05)
No caries DMFT = zero, low caries < 2.7, moderate caries ≥2.7 to ≤4.4,
severe caries≥4.5
Table 5 Mean dental fear scores in relation to behaviour during
dental examination
Behaviour N (%) Mean (SD) 95% CI Test value
(Pvalue)
Negative 517 (34) 29.37 (10.5) 28.4–30.3 110.39
†
(< 0.001*)
Positive 1005(66) 24.23 (8.1) 23.7–24.7
Total 1522 (100) 25.97 (9.3) 25.5–26.4
*Statistically significant (P< 0.05),
†
t-test
Negative behaviour includes definitely negative and negative behaviours
Positive behaviour includes positive and definitely positive behaviours
Table 6 Multiple linear regression model
Variable name Beta (SE) 95% CI p-value
Age −0.63 (0.22) −1.06 –0.20 0.004
Gender
Female 5.36 (0.45) 4.48–6.24 < 0.001*
Male ref ––
School
Private −1.923 (0.46) −2.83 –−1.02 < 0.001*
Public Ref ––
Why did you not visit the dentist last year
Money 1.29 (1.17) −0.100 –3.59 0.269
No time −0.31 (1.21) −2.70 –2.07 0.799
No need −0.80 (0.67) −2.12 –0.52 0.238
Child fear 4.57 (1.24) 2.13–7.00 < 0.001*
No pain Ref ––
Frequency of dental visits
On pain 2.23 (0.73) 0.80–3.65 0.002*
Sometimes 0.30 (0.89) −1.44 –2.05 0.732
Never 4.45 (1.04) 2.40–6.50 < 0.001*
Regular ref ––
Child behaviour during previous visit
Crying 6.12 (1.00) 4.16–8.07 < 0.001*
Screaming 3.50 (1.23) 1.09–5.92 0.005*
Resistant 1.81 (0.54) 0.75–2.86 0.001*
Happy −0.88 (0.82) −2.50 –0.74 0.286
Do not know 1.40 (0.85) −0.27 –3.08 0.100
Cooperative Ref ––
Pain during previous dental treatment
Yes 3.04 (0.63) 1.82–4.27 < 0.001*
A little 1.13 (0.57) 0.02–2.24 0.046*
No ref ––
DMFT
Low caries 0.42 (0.75) −1.06 –1.90 0.578
Moderate caries −0.03 (0.70) −1.41 –1.35 0.966
Severe caries −0.03 (0.70) −1.36 –1.31 0.970
No caries ref –
Behaviour during dental examination
Negative 5.73 (2.1) 1.61–9.84 0.006*
Positive ref
*Statistically significant (P< 0.05),
Alshoraim et al. BMC Oral Health (2018) 18:33 Page 6 of 9
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
[3,21] or a weak correlation [20] between DF and age,
or an increase in DF at an older age [5,32]. Similarly, for
3–15-year-old Finnish children, higher DF scores were
reported among 12–15-year-olds [4]. DF cannot be con-
sidered a stable factor with age since oral health status
and exposure to different social and cultural events seem
to affect the relationship between DF and age [6].
Our results show that 12% of the children in our
study had never visited the dentist before. These
children had higher DF scores compared to children
with previous dental experience, although the difference
was not significant. The association between DF and
having never been to the dentist has been confirmed
previously [15,33,34]. Children who had previously
visited the dentist had low DA, and they were also more
cooperative than children who had never visited the
dentist. This is because children who have never visited
the dentist usually have incorrect thoughts about dental
procedures [15]. In the present study, about two-thirds
of the children only visited the dentist owing to pain and
their DF score was significantly higher than that for chil-
dren who visit the dentist on a regular basis. This is in ac-
cordance with two longitudinal studies that found strong
associations between irregular dental visits and DA [13,
16]. Both studies suggested that visiting the dentist in an
irregular and symptomatic pattern is an indicator for
DA [13,16].
Children with a history of extraction had a higher score
of dental fear compared to those without history of extrac-
tion. Children who had dental fillings were less fearful than
children who had no history of dental fillings. The variation
in the degree of invasiveness between different restorative
techniques, as well as using atraumatic restorative methods,
might explain the lack of association between DF and
restorative treatment. However, most of the children
received more than one treatment during their previous
dental visits so the relationship between DF and any one
specific dental treatment was difficult to observe. In
general, it is recommended that children start with neutral
dental visits (e.g. oral examination, and prophylaxis) before
starting invasive treatment, since children who were
exposed to invasive treatment during their first dental
visit are more fearful [35].
Children whose parents reported them to be coopera-
tive during their previous dental appointments were
significantly less fearful compared to children who were
crying or screaming, and even children who showed
resistance behaviour during their previous dental visits.
Crying during previous dental treatment was previously
reported to be significantly positively related to DF [36].
Furthermore, children who showed uncooperative behav-
iour during the dental examination in the current study had
a significantly higher mean DF score compared to children
who were cooperative during the dental examination.
Paryab and Hosseinbor previously described uncooperative
behaviour as an indicator for DA, and high DA and bad
past dental experience as important factors in predicting
uncooperative behaviour in the dental clinic [14]. In
addition, it was reported that while 27% of children with
dental behaviour management problems (DBMP) have DF,
61% of fearful children have DBMP [37].
Our results also showed that children who felt pain
during previous dental treatment/s, even if the level was
low, had higher fear scores compared to others. This
significant relationship between pain and DF was also
confirmed recently [34].
The regression analysis in our study revealed that
caries level was not associated with dental fear after
controlling for confounders. This result is in agreement
with previous studies that showed no relationship
between dental caries and DF [30,38,39]. In contrast,
other studies demonstrated that fearful children have
more caries experience [4,13,15,29].
This study assessed DF and the factors associated with
it. However, the study has some limitations. One of these
limitations was the inability to investigate the causal rela-
tionship of the factors with DF. Thus, our results do not
provide definite information about the cause and effect
relationships. Therefore, our results regarding the factors
associated with DF must be treated with caution. Another
limitation of the study is the fact that the assessment of
behaviour during dental examination was carried out in
schools. Assessing behaviour during a dental examination
does not always identify the actual behaviour of the child
during dental treatment. However, children who do not go
to dentists because of DF are found within the school
environment. In this study, 3.4% of the participants had
not visited the dentist in the past year because of fear. In
general, one of the limitations of questionnaire studies is
the recall bias. However, to minimize recall bias in our
study, the parent’s questionnaire was sent home with the
children and the parents were given enough time to recall
and answer the questionnaires. In addition, the questions
were clear and asked about a recent period of time.
One strength of this study is that the children who
participated completed the questionnaire independently
in the school. Thus, it is known who provided the DF
score data, which increases the validity of the results.
This contrasts with different methodologies that allow
the children to complete the questionnaire at home; thus,
it is difficult to know who completed the questionnaire and
so the validity is affected.
Conclusion
DF is comparably low among 12–15 years old children in
Jeddah, Saudi Arabia. There were significant relationships
between DF and female sex, young age, going to public
schools, visiting the dentist in a symptomatic pattern,
Alshoraim et al. BMC Oral Health (2018) 18:33 Page 7 of 9
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
avoidance of the dentist because of fear, feeling pain
during previous dental visits, and poor behaviour during
the dental examination. There were no significant relation-
ships between DF and history of exposure to the dentist,
visiting the dentist within the last year, caries experience,
or type of treatment in previous dental visits. This study
confirms the importance of visiting the dentist regularly,
and the use of appropriate behavioural guidance and ef-
fective pain control during dental treatment to decrease
the probability of DF. Evaluation of the DF level of the
child before starting dental treatment, using an
appropriate scale such as the CFSS-DS, may help the
dentist to identify the behaviour of his/her patient and,
therefore, choose suitable behavioural guidance.
Additional file
Additional file 1: Parents’Questionnaire. (DOCX 15 kb)
Abbreviations
ANOVA: Analysis of variance; CFSS-DS: Children’s fear survey schedule-dental
subscale; CPI: Community periodontal index; DA: Dental anxiety;
DBMP: Dental behaviour management problems; DF: Dental fear; DFA: Dental
fear and anxiety; DMFT: Decayed, missing, filled permanent teeth;
WHO: World Health Organization
Acknowledgements
The authors would like to thank all the teachers who helped in distributing
the questionnaire and all the families who helped in completing the
questionnaire. We would also like to thank Editage (www.editage.com)
for language editing of the manuscript.
Funding
The study was not funded and was conducted and written by the authors.
Availability of data and materials
The participants consented for the authors to use their responses to conduct
this study only. It would be a violation of the consent to publicly share the
data. However, we will gladly consider sharing the data upon justifiable
requests form editors, reviewers, or researchers.
Authors’contributions
MA contributed to the acquisition and interpretation of the data and drafted
the manuscript. AAE formatted the concept and contributed to the design of
the study and critically revised and finalized the manuscript. NMF
contributed to the design of the study and critically revised and finalized the
manuscript. OMF contributed to the analysis and interpretation of the data;
participated in the writing of the manuscript; and critically revised the
manuscript. NMA contributed to the acquisition and interpretation of the
data and critically revised the manuscript. AAA contributed to the acquisition
of the data. All authors have read and approved the final manuscript.
Ethics approval and consent to participate
Ethical approval for the study was obtained from the Research Ethics
Committee of the Faculty of Dentistry, King Abdulaziz University (number:
046–15). All parents received a letter explaining the aims and procedures
of the study. Parents who agreed for their children to participate in the study
signed the consent to fill in the questionnaire and for their children
to be examined.
Consent for publication
Not applicable.
Competing interests
The authors have no conflict of interest to declare.
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
Author details
1
Ministry of Health, Jeddah, Saudi Arabia.
2
Paediatric Dentistry, Faculty of
Dentistry, King Abdulaziz University, P.O. Box: 80200, Jeddah 21589, Saudi
Arabia.
3
Paediatric Dentistry, Faculty of Dentistry, Alexandria University,
Alexandria, Egypt.
4
National Guard Hospital, King Abdulaziz Medical City,
Jeddah, Saudi Arabia.
Received: 15 November 2017 Accepted: 1 March 2018
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