Original Article Dental subscale of children’s fear survey schedule and dental caries prevalence Beena J. P.1 1Department of Pedodontics and Preventive Dentistry, Correspondence: Dr. Beena J.P., AECS Maaruti College of Dental Sciences and Research Email: [email protected] Centre, Bangalore, India ABSTRACT Objective: To assess the level of fear of dental procedures among 6‑12 year school children and correlate the prevalence of dental caries with their dental fears scores. Materials and Methods: The study sample of 444 school children, comprising of 224 girls and 220 boys in the age group of 6‑12 years old from a private English medium school were selected. Each student was asked to independently complete a Children’s Fear Survey Schedule – Dental Subscale (CFSS-DS) questionnaire. Children having a score of ≥ 38 were included in the ‘‘dental fear’’ group while those scoring <38 were placed in the ‘‘without dental fear’’ group. All dental examinations were performed in the classroom. Results: Fear scores were highest for ‘‘Injections,’’ (3.76 ± 0.68) ‘‘Choking,’’ (3.48 ± 0.63) and ‘‘Dentist drilling’’ (2.88 ± 0.69). The overall mean score of CFSS‑DS in our study was 37.0 ± 8.89, mean score of DMFT and DMFS were 0.58 ± 0.74 and 0.73 ± 1.09, respectively. Mean score of deft and defs were 4.40 ± 2.34 and 7.28 ± 5.49, respectively. Conclusion: The study showed the prevalence of dental fear in 6‑12 year old children and there was no statistically significant co‑relation between the level of dental fear and dental caries in these children. Key words: Children, dental caries, dental fear, prevalence INTRODUCTION cycle. This problem may lead to neglect of dental care and therefore represents a problem to dentists and Dental fear in children has an overwhelming effect patient’s alike.[3,4] on their conduct which includes them to a have preconceived notion that the dental treatment will be Therefore, it is of great importance that the dental of a painful nature. Dental fear hampers their ability health professional is able to identify children who to cope with clinical setting of a dental clinic, which in have dental fear and apply appropriate pediatric turn leads to failure to seek timely dental treatment. management techniques at the earliest age possible.[5,6] The etiology of dental fear in children is multifactorial. Fear of the dentist has been ranked fourth among Dental fear has been related to personality, increased common fears.[1] Dental fear in children has been general fears, and previous painful dental experiences, recognized in many countries as a public health parental dental fear, age, and gender.[7,8] Girls and problem.[2,3] younger children are most often reported as more fearful than boys and older children.[8,9] Prevalence Dental fear has been also reported as one of the most estimates of childhood dental fear vary considerably, important reasons for avoidance and negligence of from 3 to 43% in different populations.[9] These regular dental care. Neglect of dental care may lead differences in prevalence estimates may be due to dental decay and pain that usually results in a visit to several parameters, such as methodological or to the dentist which in turn increases the patient’s cultural variables in the populations surveyed.[9] original dental fear and thereby completing a vicious Dental fear scales have been used widely as a reliable How to cite this article: Beena JP. Dental subscale of children’s fear survey schedule and dental caries prevalence. Eur J Dent 2013;7:181-5. Copyright © 2013 Dental Investigations Society. DOI: 10.4103/1305-7456.110166 European Journal of Dentistry, Vol 7 / Issue 2 / Apr-Jun 2013 181 Beena: Children’s fear survey and dental dental caries tool to ascertain the level of dental fear in children Consent for conducting examination was obtained so as to customize the various behavior management from all the parents and school authority. The techniques and treatment plan based on the score. study was approved by the Ethical Committee for Hence, making the child’s first dental experience an Research. uneventful and pleasant one. Children’s fear survey schedule was developed by Scherer and Nakamura. The CFSS‑DS consists of 15 items related to different It consists of 80 items on a 5‑point likert scale. It aspects of dental treatment which were scored as has been demonstrated to have high reliability and follows: Not afraid = 1; a little afraid = 2; fairly validity for measuring dental fear in children. The afraid = 3; quite afraid = 4; and very afraid = 5. cumbersome nature of the questionnaire designed to Total scores thus ranged from 15 to 75. Seventy‑five be filled by the child patient has limited its use despite indicating maximal fear [Table 1]. Children with established validity report.[10] The Dental Subscale CFSS‑DS ≥38 were defined as dentally anxious.[17] of Children’s Fear Survey Schedule (CFSS‑DS) The questionnaire was administered to the children developed by Cuthbert and Melamed [4,11] consists in the classroom by teacher after explanation under of 15 items and each item can be given five different the Pediatric dentist’s supervision. The children scores ranging from “not afraid at all (1)” to “very were not allowed to discuss with each other and much afraid (5).” The CFSS‑DS has a total score any doubts were clarified by a translator to their range of 15 to 75 and a score of 38 or more has been native language and then back to English for quality associated with clinical dental fear.[11‑13] It can be used control. The survey took on an average 15 min to to differentiate patients with high and low dental complete. fears. Its reliability and validity have been aptly Dental examination demonstrated.[14‑16] All dental examinations were conducted in school by There are limited data correlating the level of dental two trained and calibrated examiner. The diagnostic fear among children and dental caries. criteria used for caries were the same as those published by the WHO.[18] All decay‑missing‑filling The aim of this cross sectional study was: teeth (DMF‑T and DMF‑S) were registered in • To assess the level of fear of dental procedures among permanent teeth, only decay, extracted filled 6‑12 year school children and correlate the prevalence teeth (def‑t and def‑s) were registered in deciduous of dental caries with their dental fears scores. teeth. • To describe the gender distribution of these Caries prevalence data were collected using deft children according to level of dental fear. and DMFT by the same trained and calibrated • Compare the mean DMFT, DMFS and deft, defs examiner, according to the criteria of the World Health with CFSS‑DS <38 and CFSS‑DS ≥38 according to Organization (WHO). Examination was conducted their age group. by seating the child on a chair, using a disposable MATERIALS AND METHODS mouth mirror and probe and flash light was used to illuminate the oral cavity. White spot lesions were reported as normal and not recorded in deft or DMFT The study sample of 444 school children, comprising analyses. 224 girls and 220 boys in the age group of 6‑12 years old from a private English medium school with The data obtained through the questionnaires were moderate to high socioeconomic status were selected. analyzed using Chi‑Square test and Mann‑ Whitney U test. Inclusion criteria Children above 6 years of age with good health and who had not received any dental treatment before Table 1: Gender distribution according to CFSS-DS but had visited a dental clinic with a parent and were score familiar with all the dental procedures. CFSS-DS Male Female χ2 P value n % n % Exclusion criteria <38 117 53.18 119 53.13 Children below 6 years of age, with medical condition ≥38 103 46.82 105 46.88 0.000 0.990 and who had sought dental treatment before. Total 220 100 224 100 182 European Journal of Dentistry, Vol 7 / Issue 2 / Apr-Jun 2013 Beena: Children’s fear survey and dental dental caries RESULTS age group children between those whose CFSS‑DS was <38 and those whose CFSS‑DS was ≥38 (P < 0.05). A total of 444 children were examined (males 220 Similarly significant difference was noted in 9 year and 224 females). Dental fear with CFSS‑DS ≥38 age group children with respect to deft (P < 0.01) and was identified in 208 children [103 (46.82%) male defs scores (P < 0.01) shown in Table 4. Statistically and 105 (46.88% female]. A total of 236 children significant difference in mean DMFT, DMFS scores [117 (53.18%) male and 119 (53.13%) female] had were noted in the 7 year age group children whose CFSS‑DS <38. There was no statistically significant CFSS‑DS was ≥38 (P < 0.05). Similarly significant difference between gender distribution and difference was noted in the 10 year age group with CFSS‑DS (P > 0.05) as seen in Table 1. Mean score respect to CFSS‑DS ≥38 and DMFT, DMFS scores and for CFSS‑DS questionnaire is given in Table 2 with also in the 12 year age group CFSS‑DS ≥38 and DMFS no statistically significant difference in the mean score (P < 0.05) shown in Table 5. score between boys and girls except for questions 10 (P < 0.01) and 14 (P < 0.05) which were ‘‘The DISCUSSIONS noise of dentist drilling’’ and ‘‘People in white uniform,’’ respectively. Fear scores were highest for Associations between children’s dental fear and oral ‘‘Injections’’ (3.76 ± 0.68), ‘‘Choking,’’ (3.48 ± 0.63) and health status have been reported.[4,19,20] Dental fear ‘‘Dentist drilling’’ (2.88 ± 0.69). has been reported to be associated with a range of adverse behavioral and dental health characteristics. The overall mean score of CFSS‑DS in our study was Studies of children and adults have shown that 37.0 ± 8.89, mean score of DMFT and DMFS were dental fear is associated with less favorable self‑care 0.58 ± 0.74 and 0.73 ± 1.09, respectively. Mean score behavior, avoidance of dental care, and also with of deft and defs were 4.40 ± 2.34 and 7.28 ± 5.49, poorer health outcomes.[19] The Dental Subscale of respectively. There was no statistically significant the Children’s Fear Survey Schedule (CFSS‑DS) is a difference in the mean scores between the males well‑known psychometric scale that was developed and females for any of the parameters mentioned in 1982 for assessing dental fear in children. It has been above (P > 0.05) Table 3. Statistically significant shown to have good reliability‑validity, and recently difference in mean defs was noted in the 6 year has been used in several countries and translated into several languages.[21,22] Community‑based and other large studies conducted in schools or clinics Table 2: Comparison of mean scores of CFSS-DS typically rely on questionnaire data to assess the between males and females prevalence of dental fear. School‑based samples offer Question Overall Males Females P value the advantages of faster data collection (because the Q1 2.45±0.74 2.5±0.72 2.41±0.77 0.267 children can be surveyed in groups) and better Q2 2.46±0.74 2.5±0.72 2.42±0.77 0.302 representation of children of that locale (because Q3 3.76±0.68 3.78±0.67 3.74±0.70 0.456 even dental avoiders are likely to attend Q4 2.18±0.72 2.13±0.71 2.23±0.72 0.170 school).[21] CFSS‑DS is used to register differences in dental fear between experimental and control Q5 2.43±0.77 2.42±0.79 2.44±0.76 0.662 groups to select fearful and non‑fearful children Q6 2.36±0.94 2.31±0.91 2.41±0.98 0.367 from a larger reference population and to estimate Q7 1.67±0.72 1.67±0.71 1.66±0.74 0.841 the prevalence of dental fear in children.[9,22] CFSS‑DS Q8 2.88±0.69 2.90±0.72 2.86±0.67 0.618 has been shown to be better in some situations than Q9 1.93±0.99 1.93±1.01 1.93±0.97 0.910 other scales such as the Venham Picture Test and the Dental Anxiety Scale.[23] Q10 2.36±0.75 2.46±0.75 2.27±0.74 0.001* Q11 2.86±0.75 2.91±0.71 2.82±0.80 0.105 Q12 3.48±0.63 3.52±0.63 3.44±0.62 0.215 Table 3: Comparison of different parameters between males and females Q13 2.35±0.67 2.33±0.66 2.37±0.69 0.656 Parameter Overall Males Females P value Q14 1.77±0.69 1.69±0.67 1.85±0.71 0.018* CFSS-DS 37.0±8.89 37.0±8.78 37.0±9.02 0.990 Q15 1.86±0.74 1.84±0.79 1.89±0.70 0.323 DMFT 0.58±0.74 0.62±0.78 0.54±0.70 0.378 *denotes significant difference, Mean score for CFSS-DS questionnaire is DMFS 0.73±1.09 0.80±1.16 0.67±1.01 0.294 given in Table 2 with no statistically significant difference in the mean score deft 4.40±2.34 4.43±2.34 4.37±2.36 0.789 between boys and girls except for questions 10 (P<0.01) and 14 (P<0.05) which were ‘‘The noise of dentist drilling’’ and ‘‘People in white uniform,’’ respectively defs 7.28±5.49 7.50±5.66 7.06±5.34 0.566 European Journal of Dentistry, Vol 7 / Issue 2 / Apr-Jun 2013 183 Beena: Children’s fear survey and dental dental caries Table 4: Comparison of mean deft and defs with CFSS‑DS <38 and CFSS‑DS ≥38 according to their age group Age CFSS-DS <38 CFSS‑DS ≥38 P value CFSS-DS <38 CFSS‑DS ≥38 P value (Years) n deft n deft n defs n defs 6 30 4.40±2.54 42 4.76±2.29 0.534 30 6.20±3.84 42 10.48±7.62 0.029* 7 30 4.46±2.81 39 4.71±2.27 0.749 30 6.06±4.44 39 9.07±6.13 0.500 8 29 4.82±2.47 36 5.05±2.21 0.665 29 6.55±4.06 36 8.61±5.34 0.130 9 32 3.31±1.95 28 3.35±1.61 0.009* 32 4.62±3.34 28 4.57±3.02 0.008* 10 - - - - - - - - - - 11 - - - - - - - - - - 12 - - - - - - - - - - *: Statistically significant difference was noted in the 10 year age group with respect to CFSS-DS ≥38 and DMFT, DMFS scores and also in the 12 year age group CFSS-DS ≥38 and DMFS score (P < 0.05). Table 5: Comparison of mean DMFT and DMFS with CFSS-DS <38 and CFSS-DS ≥38 according to their age group Age CFSS-DS <38 CFSS‑DS ≥38  P value CFSS-DS <38 CFSS‑DS ≥38  P value (Years) n DMFT n DMFT n DMFS n DMFS 6 - - - - - - - - - - 7 30 0.10±0.40 39 0.46±0.91 0.026* 30 0.13±0.57 39 0.68±1.39 0.034* 8 29 0.20±0.55 36 0.30±0.52 0.231 29 0.34±0.97 36 0.47±0.94 0.232 9 32 0.50±0.62 28 1.14±1.07 0.755 32 0.50±0.62 28 1.42±1.47 0.807 10 34 0.50±0.61 26 1.03±0.66 0.002* 34 0.50±0.61 26 1.42±1.27 0.001* 11 38 0.65±0.70 20 0.80±0.52 0.296 38 0.76±0.99 20 0.95±0.88 0.221 12 43 0.69±0.70 17 1.00±0.61 0.102 43 0.79±0.96 17 1.47±1.32 0.035* *: Statistically significant difference was noted in the 10 year age group with respect to CFSS-DS ≥38 and DMFT, DMFS scores and also in the 12 year age group CFSS-DS ≥38 and DMFS score (P < 0.05). The mean CFSS‑DS score in the present study present study showed no significant correlation was 37.0 ± 8.89 which is similar to findings in between dental fear and DMFS‑defs scores similar to Singapore (30.6),[2] Canada (for Chinese children, 31.9)[15] studies.[3,26,27] Some studies have found that DMFT‑dfs and China (35.7)[24] and much higher than findings in increased significantly with increasing CFSS‑DS Turkey (28.7),[25] USA (28.7)[11] and the mean score values[4,14,19,20] A probable explanation is that the caries was higher than the findings in Finland (22.1),[14] experience of anxious individuals in some studies Sweden (23.1),[17] and the Netherlands (23.2).[9] is not markedly worse than that of non‑anxious counterparts, but the negative dental health attitudes No statistically significant difference in fear and behavior of the former suggested that their dental scores between boys and girls in our study. Some health might have deteriorated over the time.[19] prevalence studies have shown that girls score Dental anxiety is a serious problem which negatively higher on the CFSS‑DS,[2,9] while others have found affects the oral health of children and adults. Early no difference.[15,22,24] detection of the causes of fear is very important in the solution of the problem. It is recognized that Children in the present study were most afraid children who witness fear in their parents are likely of ‘‘injections,’’ ‘‘choking,’’ and ‘‘Dentist drilling’’ to acquire that outlook and as a result experience which similar to reports from other studies where painful experiences at an early age and that this is ‘‘choking,’’ ‘‘injections,’’ and ‘‘have somebody put an important factor related to the problem. To reduce instruments in your mouth’’ were the most feared the level of dental fear among children, attention items.[2,5,9,20,21] This suggests that apprehension for needs to be paid to the use of epidemiologic concepts particular dental items may be constant among of clinical risk ascertainment using caries activity various cultures even though the total fear score tests and early intensive preventive efforts such as varied. fissure sealants, routine oral health examinations, oral hygiene instructions and parental education to Kruger, et al.[19] stated that dental fear is likely to prevent the child from experiencing pain, and reduce be a significant predictor of dental caries and may the need for injections at a very early age.[2] This can be a risk factor for incidence of dental caries. 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