Childrens dental anxiety in the United Kingdom in 2003

Nigel M. Nuttall
a,
*, Angela Gilbert
b
, John Morris
c
a
Dental Public Health & Health Psychology, University of Dundee, Dundee Dental Hospital & School,
Park Place, Dundee DD1 4HR, United Kingdom
b
Periodontology, University of Dundee, United Kingdom
c
Dental Public Health, The University of Birmingham, United Kingdom
1. Introduction
National surveys of Childrens Dental Health in the United
Kingdom began in 1973 with the rst England and Wales
study.
1
The 1973 survey made some assessment of the
occurrence or manifestation of dental anxiety in children,
with some exploration of how this was associated with
attendance behaviour and the role of other factors such as
social class, mothers reported anxiety and attendance
pattern. The assessment of the subjects anxiety was however
mostly based on a binary variable; whether the parent felt that
the child minded or did not mind going to the dentist,
supplemented by some questions on whether certain aspects
of dentistry were perceived as unpleasant and how the child
felt in the waiting room and behaved in the dental chair. No
questions relating to anxiety were asked in the 1983 and 1993
United Kingdom surveys. The topic was reintroduced in the
form of a more detailed question on dental anxiety in 2003.
The outline ndings have been reported: the majority of
childrenineachof four age groups (around75%) inthe 2003 UK
survey were reported as not being anxious about attending the
dentist andfewer than4%reportedsevere dental phobia.
3
This
paper is a secondary analysis to determine which factors are
associated with dental anxiety.
2. Methodology
Schools were sampled by obtaining lists of maintained and
independent schools from the relevant education depart-
j o ur na l o f d e nt i s t r y 3 6 ( 2 0 0 8 ) 8 5 7 8 6 0
a r t i c l e i n f o
Article history:
Received 14 June 2007
Received in revised form
21 May 2008
Accepted 30 May 2008
Keywords:
Dental anxiety
Children
Dental survey
a b s t r a c t
Background: The prevalence of dental anxiety among a representative sample of children in
the UK was determined in the Childrens Dental Health survey of 2003.
Aims: This paper is concerned with the extent to which children in the United Kingdom are
judged by a parent or carer to be behaviourally affected by dental anxiety and the factors
associated with this.
Method: The information was gathered by self-completion questionnaire distributed to the
parents of half of the sample of children who were also clinically examined in the dental
survey.
Results: Dental anxiety that was sufcient to disrupt dental attendance was reported for
around 34% of the four age groups surveyed (5, 8, 12 and 15 years of age). Childrens dental
anxiety was associated with parental dental anxiety; a greater experience of invasive dental
treatment and general anaesthetic; receipt of free school meals and social class.
Conclusions: Whilst these ndings do not necessarily indicate causal relationships, they do
conrm a number of co-factors associated with dental anxiety perhaps most importantly
that of anxiety with the experience of general anaesthetic for tooth extractions.
# 2008 Published by Elsevier Ltd.
* Corresponding author. Tel.: +44 1382 635999; fax: +44 1382 206321.
E-mail address: n.m.nuttall@dundee.ac.uk (N.M. Nuttall).
avai l abl e at www. sci encedi r ect . com
j our nal homepage: www. i nt l . el sevi er heal t h. com/ j our nal s/ j den
0300-5712/$ see front matter # 2008 Published by Elsevier Ltd.
doi:10.1016/j.jdent.2008.05.014
ments. Sampled schools were asked to participate in the
survey and those that agreed forwarded lists of children in the
eligible age groups at their school to the Ofce for National
Statistics, who led the consortium undertaking the survey.
These lists were used to randomly select an appropriate quota
of children for each school. The sample was divided equally
between children aged 5, 8, 12 and 15 on 31 August 2003.
The children in the selected schools were dentally
examined between October and December 2003. Trained
and calibrated dental examiners carried out the examinations
which followed a set procedure and used the same criteria for
all children within each age group, although some of the
clinical parameters measured varied between age groups.
The non-clinical information (e.g. anxiety) was to be
gathered by a questionnaire distributed to a 50% sub-sample
of the parents or carers of the 5480 children who had been
clinically examined. One completed questionnaire could be
returned for each child. Schools were unable to release the
home addresses of the sampled children, in compliance with
the UK Data Protection Act. Questionnaires were therefore
sent to the participating schools in stamped envelopes for the
school to address andpost to the parents/carers of the selected
children. Two reminder questionnaires were sent to non-
respondents, again via the school. Parents/carers were given
an alternative option of completing the questionnaire by
telephone and could use the same facility for assistance with
completing their questionnaire. One telephone interview was
carried out on request. The survey questionnaire gathered a
spectrum of socio-dental information in addition to dental
anxiety, including reported past dental experiences, self-
reported dental attendance behaviour and some demographic
factors.
Short questionnaire methods exist for self-reporting dental
anxiety,
4
however, the requirements of the UK surveys of
Childrens Dental Health are to enable parents to respond to
questions about their child rather than self-reporting. To
enable the respondents to answer on behalf of their children it
was considered necessary to develop a newquestion in which
the childs dental anxiety was anchored to an observable
behaviour. The questiononanxiety graded it onthe basis of its
behavioural impact regarding attending a dentist (Table 1)
rather than on a sliding scale of extent such as not at all
anxious through to very anxious which assumes the
respondent is able to have a degree of empathy about their
childs level of anxiety. The question had not previously been
tested.
The survey questionnaire was distributed to half of the
sample who took part in the survey. A total of 5480
questionnaires were distributed of which 3342 questionnaires
(61%) were nally returned. This response was lower than in
the 1993 survey when 84%of parents returned a questionnaire
in the UKas a whole. The drop inquestionnaire response since
1993, ranged from 12% in Scotland to 43% in Northern Ireland.
The overwhelming majority of the questionnaires that were
returned were completed by the parents of the participants
(91%) with help from the participant in a further 9% of cases.
5
3. Results
Thirty-four of the respondents (0.2%) gave no response to the
item about dental anxiety.
Table 1 shows the proportion of children in each of the
behavioural impact categories. Around three-quarters of
children in each age group were considered to be unaffected
by dental anxiety. Most of the remainder were consideredto be
anxious but not to the extent that they would avoid going to a
dentist. The three remaining categories concerned those who
were reluctant to go to a dentist or were non-attenders as a
result of their level of dental anxiety. This consists of children
who would only go to see a dentist if their parent or carer
insisted they attend; those who would only go if they had pain;
and those who were said to refuse to go. Less than 4%of all age
groups were considered to have their attendance behaviour
affected by dental anxiety in one of these three ways and most
of this group could be persuaded to attend by the insistence of
their parent or carer. Only 12% of children were so affected
that they were reported either not to attend a dentist or only to
go to a dentist when in pain.
Table 2 examines the childrens reported past dental
experiences, reported dental attendance behaviour and
some demographic factors that have previously been
considered to be associated with oral health status, in
comparison to whether their level of anxiety was considered
sufcient enough to make them reluctant attenders or non-
attenders. Children who were said to avoid going to a
dentist except when in pain or to refuse to go at all were
signicantly more likely to have experienced tooth extrac-
tion both with and without general anaesthetic; were
signicantly more likely to report having delayed a visit
to a dentist; were more likely to say they only attend a
dentist when in trouble and for the same to be true of their
Table 1 Parent/carers assessment
a
of their childrens experience of dental anxiety by age group
Age
group
Does not usually
get at all anxious
or worried
Gets anxious
or worried but
will still go to
the dentist
Gets anxious or
worried and will
only go to the
dentist if I insist
(% of age group)
Gets anxious or
worried and will
only go to the dentist
if he/she has any
pain in his/her mouth
Gets so anxious or
worried that he/she
refuses to go at all
5 years 77.8 18.5 2.5 0.9 0.3
8 years 75.3 21.9 1.9 0.7 0.3
12 years 71.7 25.6 1.2 0.9 0.6
15 years 75.3 22.2 1.6 0.7 0.4
a
In 9% of cases the questionnaire was completed or partly completed by the child.
j our na l of d e nt i s t r y 3 6 ( 2 0 0 8 ) 8 5 7 8 6 0 858
mother. There was also a relationship with social class and
with measures of deprivation; these extremely anxious
children were also signicantly more likely to come from
social class IV or V or to receive free school meals than
children who were not reported to be anxious.
Table 3 summarises the past treatment experience and
current dental caries experience of the children according to
their anxiety level. For 5 and 8 year olds, past treatment and
current disease are assessed in relation to the deciduous
dentition, whereas in 12 and 15 year olds only the permanent
dentition is considered. Children aged 12 or 15 who were said
to have some behavioural consequence as a result of their
anxiety were signicantly more likely to have experienced
tooth extraction, to have had teeth lled and to have current
decay than those who were not considered to be anxious.
Among 5 and 8 year olds, anxious children were signicantly
more likely to have some current decay in their deciduous
dentition than children of a similar age who were not
considered anxious.
4. Discussion
The prevalence of dental anxiety determined by questionnaire
will be dependent onthe questionused to elicit its grade. In the
North-West of England, 8.1% of 5-year-old children were
reported to be fairly anxious with a further 2.6% described
as veryanxious.
6
InItaly usinga broadlysimilar approachbut
with no neutral category as mid-point in the ve-point grading
scale, 15% of children aged 313 years were reported to be
afraid to some degree, 7% were fairly afraid and 5% were
very much afraid.
7
By contrast, in Finland, close to half of
children(4455%) aged3, 6, 9, 12or 15years oldwere reportedas
fearful of dental treatment in general or because of specied
dental procedures.
8
In the current study, less than 4%of all age
groupswereconsideredtohavehadtheir attendance behaviour
affected by dental anxiety and most of these children could be
persuaded to attend at the insistence of their parent or carer.
The UK survey ndings identify a number of factors which
have previously been identied as associated with dental
Table 2 Reported dental anxiety and past treatment experience, past attendance behaviour and social class/deprivation
of children aged 5 or 8 and 12 or 15 according to the behavioural impact of their dental anxiety, United Kingdom, 2003
5 and 8 years old 12 and 15 years old
Children for whom dental anxiety has
No
behavioural
impact
a
Some
behavioural
impact
a
No
behavioural
impact
a
Some
behavioural
impact
a
Has had GA and tooth extractions 7.1 31.8*** 14.6 35.5***
Has had tooth extractions 16.4 38.4*** 41.2 67.2***
Has had llings 30.5 34.1 50.1 82.3***
Household social classes IV and V 13.3 18* 12 20.4***
Receives free school meals 11.7 37.6*** 8.1 23***
Childs last visit over 1 year ago 5 21.2*** 8.4 25.8***
Mother: only attends dentist when having dental trouble 8.9 35.7*** 9.9 23.7***
Child: only attends dentist when having dental trouble 24.8 48.7*** 20.6 53.3***
Childs last visit was when having dental trouble 11.3 35.4*** 8.4 39.7***
Child has had a gap of over year between two visits in the past 9.3 32.9*** 10.1 21***
Child was aged over ve when rst went to a dentist 12.8 28.2*** 26.9 33.9
n 2575 86 2590 62
*Pearson Chi-square p < 0.05; ***Pearson Chi-square p < 0.01.
a
% of children with no/some behavioural impact.
Table 3 Dental status of children aged 5 or 8 and 12 or 15 according to the behavioural impact of their dental anxiety,
United Kingdom, 2003
5 and 8 years old 12 and 15 years old
Children for whom dental anxiety has
No behavioural
impact
a
Some behavioural
impact
a
No behavioural
impact
a
Some behavioural
impact
a
Permanent teeth missing due to decay 0 0.4***
Filled otherwise sound permanent teeth 0.8 1.8***
Obviously decayed permanent teeth 1.4 4***
Filled otherwise sound deciduous teeth 0.4 0.5
Obviously decayed deciduous teeth 1.6 3***
*Pearson Chi-square p < 0.05; ***Pearson Chi-square p < 0.01.
a
Average number of teeth affected.
j o ur na l o f d e nt i s t r y 3 6 ( 2 0 0 8 ) 8 5 7 8 6 0 859
anxiety such as a history of tooth extractions. These also
underscore previous ndings regarding the strength of
association between a childs anxiety and that of their parent
(mother).
6,9
The survey also identies an association between
childrens dental anxiety with a measure of deprivation (free
school meals) and social class. This association is difcult to
interpret andmay reect family andpeer attitudes to dentistry
or negative dental experiences associated with a higher risk
for dental caries combined with a greater likelihood of
irregular or symptomatic attendance, irrespective of anxiety
acquired through other routes. It is however of concern that
children from more deprived communities who are known to
experience more disease also have the additional barrier of a
greater likelihood of anxiety which affects attendance.
Previous ndings indicating no signicant relationship
between anxiety in 5 year olds and their history of restorative
treatment were also conrmed,
6
however, there was a
signicant relationship between anxiety and restorative
treatment experience among older children (12 year olds plus
15 year olds).
Whilst popular culture might lead us to anticipate
relatively high levels of reported dental anxiety in children,
these ndings suggest anxiety that is reported to affect dental
attendance is perhaps comparatively low (under 2% of each
age group). Nevertheless its signicance perhaps lies among
those children who were reported to be sufciently anxious
that their dental attendance was affected. These childrenwere
four times more likely to have experienced a General
Anaesthetic (GA) for dental procedures than children who
were not reported to be as anxious. The association of having
tooth extractions under GA with dental anxiety is not
straightforward to interpret in a cross-sectional survey,
6
nevertheless, it suggests that dental anxiety may have serious
ramications beyond those of dental care avoidance and
cooperation during treatment.
5. Conclusions
The UK survey of Childrens Dental Health in 2003 has
established a national baseline for the prevalence of dental
anxiety and conrms a number of associated factors, perhaps
most importantly that of the association with the experience
of general anaesthetic for tooth extractions.
Acknowledgements
The 2003 Childrens Dental Health Survey of the United
Kingdom was undertaken by a consortium comprising the
Ofce for National Statistics and the Dental Schools of the
Universities of Birmingham, Cardiff, Dundee and Newcastle
and the Dental Health Services Research Unit, Dundee who
received funding from the United Kingdom Health Depart-
ments. The views expressedinthis publicationare those of the
authors and not necessarily those of the HealthDepartment or
the Consortium.
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