Aminabadi 2017
Aminabadi 2017
Aminabadi 2017
Objective: Dental anxiety, fear and phobia have different etiology, response patterns, time courses, and
intensities that justify a clear distinction between these constructs. Differentiation of dental anxiety, fear or
phobia in practice is a critical prerequisite for developing and implementing effective treatment for children.
The aim of this study was to investigate whether current researches in the pediatric dentistry appropriately
discriminate the central construct of dental anxiety, fear and phobia. We also highlighted the specific
methodological issues in the assessment of these issues in pediatric dentistry. Study design: A systematic
search was conducted in Pubmed/medline and Scopus for articles which assessed dental anxiety, fear or
phobia in children. Results: 104 research papers were included in the review that had made a distinction
between dental anxiety, fear and phobia and had not used them interchangeably. Only five studies used
different clinical measures or cut-offs to discriminate between dental anxiety, fear and phobia. Conclusion:
The dental literature appears unable to capture and also measure the multi-sided construct of dental anxiety,
fear and phobia and, therefore, there was a tendency to use them interchangeably.
D
understanding of the child’s problem using a proper screening scale.
isruptive behavior, and anxiety- and fear-related reactions Dental fear, anxiety, phobia and behavior management problems
are frequent encounters in pediatric dentistry and have (DBMP) are different concepts related to each other, but not iden-
major implications for the child, dental team and public tical, and can involve different physiological, cognitive, emotional
health service providers 1, 2. Dental anxiety, fear or phobia make and behavioral components. Besides, a child specifically afraid of
the dental treatment time-consuming, costly and demanding for the injections or drilling may need a different management approach than
clinician and the child, and have a strong negative impact on treat- a child mostly afraid of unknown people and an unfamiliar setting
ment outcome 1, 3. 4, 5
. Thus, the question of who is at risk for these problems, which
methods would be most useful for which patients and delivered by
which professionals are a number of critical issues that needs to be
addressed in order to ensure the effectiveness of any treatment 6, 7.
Dental anxiety and fear vary across a continuum from very mild
From Tabriz University of Medical Sciences, Tabriz, Iran. anxiety and fear to severe and debilitating dental phobia 5. Children
*Naser Asl Aminabadi, Professor, Department of Pediatric Dentistry, Faculty with low or moderate fear or anxiety can be effectively managed
of Dentistry. by establishing a trusting relationship, good communication skills,
**Marzieh Shokravi, Assistant Professor, Department of Pediatric Dentistry,
empathy, careful treatment and some basic non-pharmacological
Faculty of Dentistry.
***Zahra Jamali, Associate Professor, Department of Oral Sciences, Faculty approaches. On the other hand, highly anxious/fearful or phobic
of Dentistry. children may require specific pharmacological support in addition
****Sajjad Shirazi, Research Fellow and Lecturer, Dental and Periodental to the use of behavior guidance strategies (i.e. behavioral guid-
Research Centre. ance techniques, nitrous oxide sedation, intravenous sedation, and
general anesthesia) 5, 6, 8-10.
Send all correspondence to:.
Sajjad Shirazi Therefore, a brief review of the more clinically oriented concep-
Dental and Periodontal Research Center, Faculty of Dentistry, Tabriz tions may help to set some theoretical basis to understand and differ-
University of Medical Sciences, Golgasht AVE, Tabriz, East Azerbaijan, entiate these phenomena in practice which is a critical prerequisite
Iran. for studying and understanding the nature, prevalence and conse-
Phone:+989144114086.
quences of these common problems. Any definition should enable
E-mail: s.shirazi.tbzmed88@gmail.com.
The Journal of Clinical Pediatric Dentistry Volume 41, Number 6/2017 doi 10.17796/1053-4628-41.6.1 399
Barriers and Drawbacks of the Assessment of Dental Fear, Dental Anxiety and Dental Phobia in Children
the clinician to identify an individual within the domain that the obtain information from their patients which can be highly variable
definition addresses. between dentists and from one patient to another 20.
Anxiety represents a state when a child is evoked and prepared Accordingly, the various problems surrounding the issue led
for something to happen. It is not attached to an object, rather it is us to ask the question of who should be considered to be dentally
a generalized response to an unknown threat or internal conflict and anxious, fearful or odontophobic? In addition, considering method-
is associated with more abnormal conditions 8, 11. Specifically, dental ological issues with measurement of dental anxiety, fear and phobia;
anxiety is defined as the response to a stressful stimulus that is specific the question is raised whether current studies in pediatric dental liter-
to the dental context and its recognition should be established by ature appropriately measure and discriminate the central construct
reference to its origin. Dental anxiety is considered as an affective of dental anxiety, fear and phobia which may significantly affect the
expression of a normal anxious state or as a pure and specific psycho- result of any given investigation. Furthermore, given the fact that
pathological condition. The practitioner should differentiate what is the definition and construct of dental anxiety, fear and phobia are
linked to a state condition (dental anxiety) from psychiatric disorder fundamentally different; is there any study that differentiated dental
(Such as generalized anxiety or trait anxiety) 12-14. anxiety, fear and phobia based on the conceptual and theoretical
Fear, on the other hand, is a reaction to a known, specific and real underpinnings of each particular construct? Therefore, this works
external threatening stimulus 11. Dental fear is a normal emotional comprehensively reviews the principal issues and methodological
reaction to threatening stimuli in the dental situation 8, 13. It can arise pitfalls that are relevant to the assessment of dental anxiety, fear and
because of particular events like past trauma in the dental surgery phobia in children. Particularly, we will analyze which measures
(previous learning) or during other medical procedures (the gener- are used to assess each of the constructs, the degree of overlap in
alization of fear) 15. A practitioner should recognize that the fear of assessment of these distinct constructs, and the appropriateness of
new and potentially threatening things and situations is a normal the measures used to assess each of the constructs.
reaction for children 8, 16. Avoidance reduces fear in children. There- There is a relatively new and ongoing discussion in the behav-
fore, the first response to a feared object or stimulus is to avoid or ioral dentistry community about the need to study and address
escape the fearful situation 15. In other words, the psychological and dental fear and anxiety as related but distinct emotions. We hope
biological responses accompanying anticipation of encountering that the results of this review help researchers, clinicians, psychol-
the fearful stimulus or situation can be termed the anxiety response. ogists, service providers and epidemiologists to correctly recognize
But, the consequences of encountering the stimulus or situation can and assess dental anxiety, fear and phobia when undertaking studies.
be termed the fear response. At a more functional level, anxiety can This paper will outline the steps that are needed to be taken in
be seen as preparing an individual for a fearful situation 17. subject selection, measurement, and study design in order to create
Phobia is more likely to be developed in children with exagger- scientifically sound outcomes. The field of dental anxiety and fear
ated fear responses that persist even in safe settings 15. Dental phobia and their assessment in dental patients will be reconsidered with
represents a severe and special form of dental fear and is a persistent dissemination of present research findings which can be incorpo-
fear of clearly discernible, circumscribed objects or situations in rated into research in all related fields of dental fear and anxiety.
dental setting 5, 17. According to the criteria of DSM-V, dental phobia
is characterized by marked and persistent fear of clearly discernible MATERIALS AND METHOD
situations or objects which is unproportional to the dental situation, Search strategy
is unadaptive and is not age or stage appropriate, cannot be explained A systematic search was conducted by a professional librarian
or reasoned away, is beyond voluntary control, and leads to avoid- with skills in informatics by searching electronic databases Pubmed/
ance of necessary dental treatment or enduring treatment only with MEDLINE and Scopus for English language peer-reviewed articles
dread 8. Although one of the major criteria regarding dental phobia published between 1986 and June 2015 using the search terms
is the avoidance of dental care, many children are not allowed to ((“dental anxiety” OR “dental phobia” OR “dental fear” OR “odon-
avoid even if they would wish to 15. Dentally phobic children who tophobia” OR “dental distress” OR “dental stress” OR “dentist
attend the dental appointments experience significant distress and phobia” OR” dent* anxiety” OR “dent* phobia” OR “dent* fear”))
exhibit poor compliance with dental procedures 19. AND (“infant” OR “child” OR “adolescent” OR “children” OR
Therefore, the differences in etiology, response patterns, time “young” OR “young person” OR “minor” OR “paediatric” OR
courses, and intensities seem to justify a clear distinction between “pediatric”)). To ensure completeness, functional search characters
dental anxiety, fear and phobia. Dental practitioners should be were used to search for word variations, ‘‘dent*’’ was used to obtain
efficient at detecting the presence of dental anxiety, fear, phobia results containing ‘‘dentist’’, dentists’’ and ‘‘dental’’. A database of
or DBMP. It is therefore recommended to use a structured and the first search results was created and subsequent search results
psychometrically valid scale during clinical assessment 20. The were entered and duplicate entries were removed.
importance of any measure of child dental anxiety, fear and phobia After searching the databases, some pediatric and valid jour-
is to give the clinicians and researchers the means to assess the nals in this field including the International Journal of Paediatric
subjective experience of dental fear and anxiety in an objective and Dentistry, Pediatric Dentistry, The Journal of Clinical Pediatric
consistent manner, and also to identify the relevant characteristics Dentistry, European Archives of Paediatric Dentistry, Journal of
of the anxiety/fear-inducing situation 16. A recent survey reported Dentistry for Children, and Community Dentistry and Oral Epide-
that the use of scales in clinical practice is limited and only 17% of miology were also hand searched. In addition, the reference lists of
dentists used child anxiety assessment questionnaires. Indeed, most selected articles were manually searched in order to complement the
dental practitioners attempt to subjectively evaluate the patients or search database.
400 doi 10.17796/1053-4628-41.6.1 The Journal of Clinical Pediatric Dentistry Volume 41, Number 6/2017
Barriers and Drawbacks of the Assessment of Dental Fear, Dental Anxiety and Dental Phobia in Children
• Use of only physiological measures (i.e heart rate etc.) as Titles and abstracts screened
N=5798
study was obtained for verification. A third reviewer conducted a Non-English papers= 11
random check of approximately 10% of titles and abstracts to check Participants had
medical / mental Total articles that did not used the
reliability of initial screening. All papers that passed the abstract disabilities= 5 terms dental anxiety, fear and
screening were retrieved in their complete forms, and data extraction Used the terms
phobia exchangeably
reliability and validity. Seven of the studies were conducted in more than one setting
In the second stage, we sought those studies that differentiated (Appendix 1).
dental anxiety, fear and phobia.
The Journal of Clinical Pediatric Dentistry Volume 41, Number 6/2017 doi 10.17796/1053-4628-41.6.1 401
Barriers and Drawbacks of the Assessment of Dental Fear, Dental Anxiety and Dental Phobia in Children
Discrimination between dental anxiety, dental fear CFSS-DS was widely used as a proxy measure of children’s dental
and dental phobia fear and anxiety. There were 18 (17%) studies in which it was filled
Dental fear, anxiety and phobia were studied in 24, 77 and three in by parents to assess their children’s dental fear and/or anxiety.
studies respectively. Six (5%) of these 104 studies included different The MCDAS, DFS and Venham’s Rating of Clinical Anxiety were
clinical measures or cut-offs to discriminate between dental anxiety, other scales by which parents/raters rated the children’s dental
fear or phobia. Only three (2.5%) studies provided a credible ratio- anxiety or fear (Table 2 and 4) (Appendix 1).
nale for differentiation of dental anxiety from dental fear using two
different scales. In these studies, the Child’s Fear Survey Sched- Use of measures in children of different ages
ule-Dental Subscale (CFSS-DS) was used for dental fear and Clin- The participants in the included studies were categorized
ical Anxiety Rating Scale (CARS), Venham Picture Test (VPT), into three age groups of 3-6, 6-12 and 12-18 years old. The most
Visual Analoug Scale (VAS) and State Trait Anxiety Inventory for frequently used measure type for 3-6-year old children were picto-
Children (STAIC-S) for dental anxiety. One study differentiated rial scales. They were used in 21 (20%) studies of which the VPT
dental anxiety from blood and injection phobia using Dental fear was the most common scale used in seven (6%) studies. Psycho-
scale (DFS), and Injection Phobia Scale and Mutilation question- metric scales were used in 16 (15%) studies and were second widely
naire for Blood injury fear and phobia, respectively. There were used measure types and parental version of CFSS-DS was in the first
also two (1%) studies that differentiated dental anxiety from dental rank. Behavioral rating scales were used in 8 (8%) studies.
phobia using a cut-off point. They used Modified dental anxiety In children aged 6-12 years psychometric tests followed by
Scale (MDAS) and Modified child dental anxiety scale (MCDAS) pictorial scales were the most common scale types used for the
for dental anxiety with a cut-off score above which children were assessment of dental anxiety and fear. They were used in 53 (50%)
considered to have dental phobia (Table 1) (Appendix 1 A). and 34 (33%) studies, respectively. Child and parental version of
CFSS-DS were largely used in this age group. Behavioral rating
Assessment measures scales were used in seven (6%) studies.
In the included studies, two self-styled tools and 24 established In 12-18-year-old age group, the same trend as previous age
scales were used to assess dental anxiety, one scale was used to range was observed. Psychometric tests were used in 39 (38%)
assess dental fear and two scales were used to assess injection studies and followed by pictorial scales that were used in 13 (13%)
phobia and blood phobia. One self-styled tool and four established studies. Interestingly, behavioral rating scales were not used in these
measures were used to assess either dental anxiety or fear. Of the children (Table 4) (Appendix 1).
established scales, nine were psychometric tests, 10 were pictorial
scales and four were of behavior rating scales. Eight other types of Screening for children’s background psychological
scales were also used in the studies which were not dentally specific problems
(Table 2). As it is shown in Table 2, same measures were used for Of the 104 included studies, only 18 (17%) studies had screened
different constructs. The most widely used scale was the CFSS-DS and excluded those children with anxiety or other childhood-related
which was used to assess both dental anxiety and dental fear (in 40 disorders. Most of the reviewed studies did not report whether they
studies, 38%). MCDAS, DFS and CARS were also used to assess controlled for probable psychological problems in the included chil-
both dental anxiety and fear. The VPT was the second most used dren (Appendix 1).
measure (in 13 studies, 12.5%) followed by the MCDASF (in 11
Using various techniques for reduction of dental
studies, 10.5%) (Appendix 1).
anxiety or fear
Time of assessment There were 19 (18%) studies which had incorporated different
Dental fear was most widely assessed at places other than dental scales as outcome measures of the effects of different interventions
environment (15 studies, 62%), before treatment (11 studies, 45%) on children’s dental anxiety. These interventions included virtual
and after treatment (5 studies, 20%) respectively. Dental anxiety reality, video modeling, ART, audiovisual distraction, preoperative
was most widely assessed prior dental treatment (47 studies, 57%), information, viewing positive images, WAND and EDA. No study
at places other than dental environment (26 studies, 31%), during aimed at evaluating possible techniques for reduction or treatment
treatment (21 studies, 25%) and after treatment (18 studies, 21%) of dental fear or phobia (Appendix 1).
(Table 3) (Appendix 1).
Use of scales for treatment planning
Using parents/raters to assess children’s dental fear/ None of the included studies attempt at using dental anxiety
anxiety and fear scales to identify children with different treatment needs to
The use of proxy in the assessment of child’s dental fear was establish tailored treatment plan and choose appropriate treatment.
common and parents’ rating of their children’s dental fear was
Cut-off
largely used in the included studies (9 studies, 38%). Dentists were
In the included studies and among the scales incorporated, only
used to assess children’s dental fear in three (12%) studies. Chil-
CFSS-DS, MCDASf, CARS, MDAS, CDAS, DFS and MCDAS
dren’s self reports were used in 17 (70%) studies. However, dental
were used with cut-points. Each of these measures was applied with
anxiety was mostly assessed using children self reports (78 studies,
different cutoffs which are shown in Table 5 and Appendix 1.
95%). Parental and dentists’ rating of children’s dental anxiety were
used in 19 (23%) and 15 (18%) studies respectively. In overall,
proxy method was mostly used in children aged 6-12 years. The
402 doi 10.17796/1053-4628-41.6.1 The Journal of Clinical Pediatric Dentistry Volume 41, Number 6/2017
Barriers and Drawbacks of the Assessment of Dental Fear, Dental Anxiety and Dental Phobia in Children
DISCUSSION have not been established, and the use of these scales for diagnostic
In order to establish a reasonable relationship between etiology purposes is problematic 21. In addition, dental phobia has previously
and clinical consequences of dental anxiety, fear and phobia, it is been considered to be a phobia of the dentist. However, the dentist
important to interpret these constructs at a formal theoretical level. has been found to be one of the least fear-evoking aspects of the
First, if dental anxiety, fear and phobia are different, they should dental situation. This may have led to significant under-reporting of
have different underlying conditions and be caused by different the incidence of dental phobia in the literature 21.
precipitating events. Second, activation of dental anxiety fear
or phobia should have different consequences or cause different Dental fear/anxiety vs. dental behavioral manage-
behaviors. If these two conditions are met, then dental anxiety, fear ment problems (DBMP)
and phobia would be valuable and not redundant constructs. Other- DBMP denote to externalizing behavioral problems related to
wise, there is little value in having these separate constructs 18. The the dental situation. Children with DBMP may or may not have
present study provides an extensive review of the studies attempt at behavior management problems in other situations 22. DBMP repre-
measuring dental anxiety, fear and phobia in children. Our findings sent uncooperative and disruptive behaviors resulting in the delay of
can provide insights for researchers and clinicians who intend to treatment or rendering the treatment impossible 8.
evaluate children’s dental anxiety, fear or phobia and may fill the The distinction between dental fear/anxiety and DBMP is
existing knowledge gap about the methodological and theoretical important. DBMP are likely to be identified more easily by the
issues in this field. practitioners than dental fear/anxiety. The presentation of dental
All together, there were 104 studies that at least apparently made fear/anxiety may vary from uncooperative behavior to being more
a distinction between dental anxiety, fear and phobia and did not passive and silent during the treatment, reflecting the differences
use them interchangeably. None of them have explicitly aimed to in personality characteristics and etiology 8, 23. It has been shown
differentiate dental anxiety, fear and phobia. While different clinical that there is an overlap in the symptoms of dental fear/anxiety and
measures or cut-off points were used in five studies to discriminate DBMP 22. Thus, dental anxiety and fear are likely to be missed if
these constructs, the issues have not been successfully captured and the dentist only focuses on child cooperation or behavior during
defined. Surprisingly, of 34 studies in which dental fear, anxiety the treatment. Moreover, although DBMP is the defining feature of
and phobia were clearly defined, 13 studies failed to adhere to these dental anxiety and fear, it is often associated with other disorders
conceptual principles throughout the text and fell into the pitfall of particularly specific phobias 19.
using these concepts interchangeably. It has been noted that most referrals in pediatric dentistry are
Therefore, the dental literature appears to lack a clear under- based on DBMP 22. Therefore, in order to conduct a study related to
standing of the concepts of dental anxiety, fear and phobia. There dental fear/anxiety in children screening should be targeted toward
was a tendency to ignore them empirically considering the subjec- dental fear/anxiety rather than inclusion of individuals based on a
tive and multidimensional nature of these conditions. While a single characteristic namely uncooperative behavior. Most aspects
distinction between fear and anxiety is made in both clinical and of children’s behavior in the dental environment are core aspects of
preclinical psychology 11, 18, there is no consistency in the dental clinical child psychology, and consequently theories and measures
literature to characterize these constructions practically and beyond developed within that field have a strong potential to enrich studies
their subjective status. This deficiency has led to the current discrep- of dental fear/anxiety and DBMP 22.
ancy and uncertainty in the clinical dental literature in which no
One measure for different constructs
clear distinction could be made between the different causes and
As our review demonstrates, various measures were used to
differences of fear versus anxiety and the responses they are intend
assess the level of dental anxiety or fear. The most striking result
to generate in the dental setting. In order to enable the investigators
of this review is that same scales were used for different constructs
to compare and integrate the results of different investigations; clear,
and vice versa. Considering the conceptual shortcomings of exciting
consistent and theory based definitions of dental anxiety, fear and
measures, it is difficult to explicitly say that which scale measure
phobia should be provided.
what identical construct. Beside, typically each instrument asks
Dental phobia different questions based on various conceptual foundations, and
Although one study used a scale for assessment of blood and the determination of dental anxiety, fear and phobia is derived from
injection phobia, none of the reviewed studies have included a diag- different ranges of possible answers. Consequently, the nature of
nostic assessment of dental phobia. Consequently, they might have generated scores and possible interpretation of conditions is rather
failed to identify children with dental phobia. In addition, we did not dependent on issues such as scale construction and construct
find any scale that has been designed for, or at least has considered, coverage, item weighting, placement of cut-points and measure-
the detection of dental phobia based on specific diagnostic criteria. ment error 24. Therefore, the level of agreement and concordance
Current scales either could not differentiate dental anxiety from among different dental anxiety and fear scales should be assessed in
fear. The use of cut-offs is naive and cannot differentiate dental fear, order to interpret the results correctly and with a sufficient amount
anxiety and phobia from each other. Therefore, it is not surprising of certainty. However, even with high association between the
that the correlates of dental anxiety, fear and phobia is lacking in the scales, the use of different scales could result in identifying basi-
current available data 17. Despite the recommended use of self-re- cally different people in the same study with the same population.
port measures to identify children who need special attention, and It has been shown that the existing measures are inconsistent with
to assess symptom severity as well as treatment effects, the perfor- only fair to moderate agreement in terms of classifying individual
mance of self-report scales as a diagnostic tool for dental phobia children as having high dental anxiety or fear 17, 24.
The Journal of Clinical Pediatric Dentistry Volume 41, Number 6/2017 doi 10.17796/1053-4628-41.6.1 403
Barriers and Drawbacks of the Assessment of Dental Fear, Dental Anxiety and Dental Phobia in Children
Because dental anxiety and fear can be measured for different In addition, equalizing the cut-points used to define dental
purposes (e.g. clinical, service organization, survey or research), anxiety or fear across different scales that might result in more
choosing the correct scale as an appropriate outcome measure comparable results has remained controversial and has been
is essential. In addition, considering the fact that dental anxiety, largely ignored. However, in the absence of a gold standard,
fear and phobia are fundamentally different constructs and may identification of dental anxiety or fear is largely dependent on the
have different emotional, behavioral, cognitive and physiological content and the nature of the scale adopted to categorize the study
components and response systems, one measure would never participants which might fundamentally affect the outcomes of any
be appropriate for various purposes. Therefore, measurement of investigation 24.
dental anxiety or fear should combine behavioral, self-report and Therefore, there is still a need to further improve our under-
physiological methods because neither the children’s behavioral standing of the use of cut-off scores in epidemiological and clinical
responses nor physiological responses are sufficient indices for studies, as well as to establish and validate cut-off points differen-
their anxiety or fear 25. Direct scaling or self-report techniques can tiated by age, gender and informant (child’s self-report or report by
provide qualitative and quantitative estimates of anxiety or fear. accompanying parent). Unfortunately, there is currently no research
Behavioral and physiological techniques can be used in a repeated about the possible gender or age differences in the interpretation of
time sampling sequence throughout a clinical session to provide particular items in the dental fear and anxiety scales 24. Cognitive
a comprehensive pattern of how anxiety parameters change interviewing techniques that ask children to verbalize their thoughts
throughout the situation 16. whilst responding to questionnaire items, could be used to test
how children of different ages are able to understand and complete
Cut-off measures of dental anxiety and fear 1. However, previous reports
Classification of children as having predefined amount of dental support the use of age differentiated cut-off scores for both screening
anxiety or fear (i.e. high, medium or low) by means of cut-points and clinical purposes. Lower cut-off scores has been suggested for
and categorizing continuous scale scores has been a dominant older children compared to younger children 26.
theme in the literature. Our review, surprisingly, revealed that Knowledge of the sensitivity and specificity of different ranges
different cut-points were adopted on an identical scale to define of scores will allow different applications based on the context for
dental anxiety or fear. The CFSS-DS, MCDASf, CARS, CDAS, which the scales are used. The aim of any given study should be
MCDAS, DFS and MDAS were used with different cut-points to considered when choosing cut-offs to evaluate dental fear/anxiety.
measure the same issue. The use of different cut-points can alter the Lower cut-off scores are suitable where diagnostic sensitivity is
sensitivity and specificity of scales which in turn affects prevalence the primary goal and also false positives are not a major concern.
estimates and other related outcomes. Different cut-points on a scale However, using standard cut-offs appears to apply too strict criteria
may impact the interpretation of outcomes and affect the associa- (high specificity) for dental anxiety or fear leading to an underes-
tions between dental anxiety/fear and individual factors like age timation of the prevalence of these problems in epidemiological
and gender. Besides, the selection of cut-points is a fundamentally studies. Furthermore, from a clinical perspective, a cost-effective
arbitrary exercise which exacerbates the discrepancy in the use of individualized treatment strategy based on differential diagnosis
cut-points to determine dental anxiety or fear 24. of dental fear/anxiety is of great importance for both the patients
In epidemiological studies, one reason for the wide range of and the practitioners. Thus, the focus should be on specificity using
estimated prevalence of dental anxiety and fear in child populations score levels near to standard cut-off point which might have high
might be related to the fact that the prevalence estimates would sensitivity and be more responsive to influences of age, gender, and
differ considerably depending upon the cut-point used to define a purpose of the study 24, 26.
case of (high) dental fear or anxiety. It might also be an artifact of
differences between the scales in terms of what they measure and Utilizing proxy method for assessment of children’s
how they measure dental anxiety and fear. Different prevalence dental fear and anxiety
estimates may also be due to the differences related to culture, Based on the results reported in the reviewed studies, the proxy
study design and sampling methods 17, 22, 24. Therefore, these results method was mostly used in children aged 6-12 years. Previous
cannot be directly compared with each other since it is not clear research has revealed that children aged eight years and older can
whether these estimates reflect real differences among populations reliably report all aspects of their health. On the other hand, children
or whether they are methodological variations in origin. On the as young as three and four are capable to effectively communicate
other hand, the interchangeable use of the terms of dental fear and their emotional and physical experiences such as pain 1, 26, 27, and
anxiety in the literature makes the implications and interpretation Children older than five are considered to be capable of reporting
of any given result much more problematic. As a result, it remains their fears and anxieties using questionnaires 28. However, the reli-
to be determined whether the mentioned construct is truly captured. ability of parental reports has been questioned since the parents’
Consequently, the scientific value of reporting prevalence estimates assumption of their child’s dental fear and anxiety is far from its
or any interpretation based on cut-points might be questionable. real feature and often inappropriate 27. The agreement between
The use of distinct definitions and appropriate measurement tools children’s self-report and parental report of their children’s level of
will clearly influence estimates of the prevalence of these constructs dental anxiety\fear has been reported to be only poor to moderate
and judgment of any given finding. Besides, reporting measures of regardless of using different types of questionnaires and different
central tendency (i.e. mean, median, mode) and the distribution of statistical methods to assess inter-rater agreement 28.
scores would solve many of the problems discussed here and allow In our included studies, the use of proxy method in the assess-
for the comparability of scores from different studies 24. ment of children’s dental fear was common and the parents’ rating
404 doi 10.17796/1053-4628-41.6.1 The Journal of Clinical Pediatric Dentistry Volume 41, Number 6/2017
Barriers and Drawbacks of the Assessment of Dental Fear, Dental Anxiety and Dental Phobia in Children
of their children’s dental fear was largely used. However, dental anxiety might affect their response to these interventions compared
anxiety was mostly assessed using children’s self-reports, and proxy to non-anxious ones, only two studies have included children with
report was not widely used. On the other hand, different respon- high dental anxiety, and only in these studies a significant reduc-
dents such as parents, clinicians or children themselves were used tion in dental anxiety was observed. It is, therefore, possible that
in questionnaire-based assessment of children’s dental anxiety and the remaining studies have encountered the floor effect problem
fear. However, research on child psychology and psychopathology and have failed to observe any actual benefits that might have
has shown that the agreement between informants (i.e. parent, occurred following an intervention, because they included partici-
teacher, clinicians) on children’s problems and dysfunctions are pants without (or low levels of) dental anxiety. Therefore, studies
not compatible with the children’s own perceptions 26, 27. The agree- on dental fear and anxiety should consider floor effect problem and
ment has been reported to be weaker for internalizing (i.e. anxiety attempt to differentiate children with and without dental anxiety/fear
or depression) as compared with externalizing problems. This before any intervention is applied. Besides, all of these 19 studies
pattern may be explained by the fact that externalizing problems failed to capture the differential effect of treatment modalities on
are more easy to characterize by observers (i.e. parents, clinicians pre-operative dental anxiety considering the fact that none of these
and teachers) than internalizing or emotional problems 26. Therefore, studies included an appropriate control group (i.e. with different
the current reliance on parental ratings of children’s dental anxiety level of dental anxiety).
and fear is seriously undermined. For children 8 years of age and A consensus has not been achieved on the gold standard for
older, self-ratings should be considered as an essential and primary assessing dental anxiety and fear in children underwent different
tool of assessment of dental anxiety and fear. However, for younger therapeutic interventions. However, practitioners should select a
children and those unable to fill out a questionnaire the use of a measure which assess the specific component of dental anxiety/fear
proxy, preferably parent-reported method, is of primary importance. that is being manipulated 1. For instance, if pharmacologic or relax-
In addition, using dentists’ clinical observations for assessing ation procedures are being studied, assessment of the physiological
children’s dental anxiety/fear is not reliable. It has been noted that responses may be appropriate.
there is only poor to moderate agreement when dentists’ ratings are
compared to the child’s own rating of anxiety or fear using different Screening for possible existing disorders
scales 1. While children with dental anxiety and fear may be more The practitioners should be able to recognize and deal with
likely to exhibit negative emotional and behavioral reactions dental patients who may suffer any psychiatric disorders in order to
within the dental environment, some children do not display overt enhance patient’s compliance and treatment. Children’s personality
presentations of anxiety and fear. On the other hand, behavioral or psychological problems might interact with dental anxiety/fear
reactions such as DBMP might be interpreted as manifestations of and exacerbate their disruptive behaviors in reaction to aversive
dental anxiety and fear 1. Furthermore, a clinical diagnosis of dental events or stimuli 32. Of the 104 included studies, only 17 studies had
fear and anxiety may be difficult to establish in children who have screened the children with anxiety disorders or other childhood-re-
developed coping mechanisms. This may cause some bias in their lated disorders. Neuropsychiatric disorders constitute a substantial
subjective assessment as the rater might equate a child’s dental fear group of diagnoses affecting up to 5% of the child population.
and anxiety with the ability to accept treatment 29. Therefore, it is important that practitioners are appropriately trained
to use of screening tools of possible coexisting disorders. Specifi-
Scales for treatment planning cally, children at risk of developing internalizing disorders including
Ideally, dental fear and anxiety scales are designed to aid practi- anxiety, depression and psychosomatic problems tend to score high
tioners in choosing appropriate patient management techniques and on measures of dental fear/anxiety. Moreover, there might be a
treatment modalities. Unfortunately, none of the reviewed studies relationship between DBMP and externalizing disorders such as
used dental anxiety and fear scales to identify children with different Oppositional Defiant Disorder and Conduct Disorder 33. It is also
needs and establish or choose an appropriate treatment plan. Appar- likely that children with neuropsychiatric disorders exhibit dental
ently, identification of treatment needs for children are often based fear/anxiety or DBMP as part of their diagnosis 22. These children
on the subjective assessment of children’s behaviors by dentists. need special attention to overcome the challenges that they are faced
Our results highlight an important issue that the practitioners should in dental environment.
avoid grouping child patients with different level of dental fear
and anxiety into one universal category. The treatment plan should Time of assessment
be chosen based on the level of child’s dental fear/anxiety and its The time point at which dental anxiety/fear is measured can
underlying reasons, and child characteristics including age, temper- affect the outcomes. It is also important to consider the time frame of
ament and developmental stage. However, deciding which interven- the assessment in order to evaluate the dynamic process of change 7.
tions are appropriate for which patients and under what conditions Based on our results, dental fear was most widely assessed at places
is rarely addressed in the literature. Therefore, preoperative use of other than dental environment (15 studies), before treatment (11
these scales would provide a quick impression of dental anxiety/ studies) and after treatment (5 studies). In addition, dental anxiety
fear level and differentiate their symptoms in order to provide more was most widely assessed prior dental treatment (47 studies), at
tailored treatment options 17, 30, 31. places other than dental environment (26 studies), during treatment
On the other hand, little attention has been directed to the effects (21 studies) and after treatment (18 studies). Practitioners should
of interventions on child dental anxiety/fear. Only 19 studies incor- keep in mind that pretreatment assessment of a child at home or
porated scales as outcome measures of different methods for reduc- waiting room is more likely to capture the child’s anxiety rather than
tion of children’s dental anxiety. While children’s level of dental fear. Moreover, filling a dental fear questionnaire before treatment
The Journal of Clinical Pediatric Dentistry Volume 41, Number 6/2017 doi 10.17796/1053-4628-41.6.1 405
Barriers and Drawbacks of the Assessment of Dental Fear, Dental Anxiety and Dental Phobia in Children
may give false results as the child may experience anticipatory that the anticipation of dental situations might be more important to
anxiety prior to treatment that would be expressed through the ques- the anxious patient than the actual dental experience. Nevertheless,
tionnaire instead of the fear relating to the dental procedure at the assessment of previous aversive experience needs to be extended
moment. However, the use of preoperative questionnaires is ques- with more comprehensive and detailed methodology in the future.
tioned especially in the dental situation since it is necessary to know The exact strength and nature of experiences, the number, and the
why or when a child is over stimulated or unable to cope with an combination of the experiences seem to have stronger associations
invasive dental treatment 32. On the other hand, applying measures with dental fear.
immediately after treatment might capture the child’s dental fear.
However, concurrent factors such as pain experience and dental General anesthesia and other pharmacologic
environment may confound the child’s response. Besides, a lower approaches in children with dental fear and anxiety
score would also be expected several hours after treatment 20. Surprisingly, our results showed that none of the included
Another problem relates to the use of single questions that leave studies have used a scale to identify children who need general
the interpretation of fear and anxiety to the child. There were three anesthesia. This could result in an overutilization of general anes-
studies in the included articles that had used only one single ques- thesia in child dental patients probably because of inaccurate diag-
tion to assess dental anxiety in children. It has been argued that this nosis of the conditions. Ideally, only children suffering high dental
method easily leads to the inclusion of general concerns or worries anxiety or fear or those with diagnosed dental phobia should be
in children’s responses 21. Assessment of anxiety after treatment referred to general anesthesia. The National Consensus Develop-
is questionable since children who recovered after treatment may ment Conference on Anesthesia and Sedation in the Dental Office
rate the treatment procedure more positively than they actually noted that “behavioral approaches are often overlooked as effective
felt. Besides, it is not fully clear that changes in the psychological mechanisms for relieving patient apprehension,” and suggested that
responses are related to changes in anxiety/fear or to a general sedation and general anesthesia may be unnecessary in situations
arousal state. Therefore, because the timing of measurement may when psychological and behavioral approaches are effective 7.
have influenced the results rather than treatment efficacy, future
Methodological issues
studies should attempt to standardize the assessment periods over
Focus on methodological issues in measuring dental anxiety or fear
the course of the treatment and follow-up. Use of a control group
is rarely discussed. Different measurement techniques for assessing
with no treatment allows for the evaluation of the changes observed
dental anxiety and fear including behavioral, projective, physiologic
through repeated measurement 7.
and psychometric methods are employed in children. Besides, each of
In addition, dental fear/anxiety scores might be higher in chil-
these core principle techniques requires a different set of tools.
dren in the school compared with children in clinical settings. This
Interestingly, inter-correlations between these different techniques
difference in levels of fear/anxiety is possibly related to the fact that
are low. Considering that dental anxiety and fear are a multidimen-
phobic or highly fearful/anxious children are less likely to attend
sional constructs, this poor correlation can be expected because
dental treatment, but they can be included to study in school-based
theoretically each measurement technique captures a distinct part of
samples. In addition, many of the children undergoing dental treat-
the construct 17. Furthermore, the correlation between measures that
ment may be recall patients who may have been coped with the
tap the same part of the construct can also never be high because
situation. School samples offer the advantages of faster and easier
different scales of same construct ask different questions and
data collection because the children can be surveyed in groups. In
cover different contents, and their determination of dental anxiety
addition, school-based sample is assumed to be more representa-
or fear is based on different answers 13, 30. Consequently, not only
tive because even dental avoiders are likely to attend school. On
it demonstrates that the use of more than one questionnaire and/
the other hand, most private practice patients have a long-standing
or measurement instruments is necessary, but it also highlights
relationship with their dentists which might result in less anxiety,
the overwhelming errors in substituting of the scales. Each ques-
whereas clinic patients would soon drop out if they were anxious
tionnaire has its own restrictions and do not completely cover the
about the situation.
concept of anxiety/fear 30.
Previous dental experience In addition, intervention studies should consider the age, coping
The effect of confounding variables including previous expe- repertoire, and level of initial dental fear/anxiety as they interact
rience of medical and dental treatment, anticipated treatment to be with the effectiveness of interventions in children. In addition, the
undertaken and whether the participants knew what treatment they majority of researchers investigating dental anxiety and fear in chil-
could expect should be taken into account 34. dren have used heterogeneous samples which make it difficult to
Anxiety is an unspecific feeling that requires no prior experience compare the results across different studies to determine the most
of the anticipated situation. In the case of dental anxiety, there is effective treatment strategies. Although randomized assignment is
a feeling of apprehension of possible pain, discomfort or danger often suitable to control for such variations, matching the groups
during dental treatment even when there is not a prior experience. in terms of age and previous experience seems more important.
In addition, there is a negative relationship between frequency of Besides, the standardization of outcome measures would facilitate
dental visits and dental anxiety and fear. A higher dental anxiety has between-subject comparisons. The use of multivariate analysis
been reported in children with no previous dental visits 35. On the could allow for the evaluation of factors which may contribute to the
other hand, some studies have shown a strong associations between prediction of favorable outcomes. The co-variation among measures
dental anxiety/fear and negative dental experiences 36. It appears and across time periods of assessment would allow a better under-
standing of fear modification 7.
406 doi 10.17796/1053-4628-41.6.1 The Journal of Clinical Pediatric Dentistry Volume 41, Number 6/2017
Barriers and Drawbacks of the Assessment of Dental Fear, Dental Anxiety and Dental Phobia in Children
The use of statistical techniques to evaluate changes in clinical differences in anxiety/fear symptoms that need to be considered 1, 13.
studies is controversial. It is generally mentioned that statistical The theoretical foundations of existing measures of dental fear
significance in such designs may not have any practical signifi- and anxiety and the way they relate to the current conceptualiza-
cance. However, the current statistical advances make it possible tion of disorders of emotion should be considered. Ideally, these
to perform a profile analysis of concordance and de-synchrony instruments should all be based on explicit theoretical foundations
between different measures of dental anxiety and fear. Multiple and demonstrate good psychometric properties. Unfortunately, this
regression techniques would allow evaluating which measures most is not the case 17. Therefore, a lack of precise understanding and
strongly predict which behaviors. The use of time series sequential conceptual clarity in defining the core terms of anxiety, fear and
analysis also allows examining the causal correlates between behav- phobia; a failure to consider the various aspects or components
iors of the practitioner and patient. of their response system; and the weak conceptual and theoretical
Of further note, most of the studies in our review addressing the underpinnings of the existing scales are the most significant prob-
issue of prevalence were not based on large, representative and popu- lems with measuring dental fear, anxiety and phobia. Although there
lation-based samples. It is necessary to move from convenience to is an overall consensus on these issues in the psychological litera-
representative samples to understand potential differences in preva- ture, it appears that they are rarely addressed in dental literature 17.
lence of dental anxiety/fear between cultures and within cultures Interestingly, the majority of current scales were predominantly
over time and across dental practices. In addition, it is important validated in schools, not in the clinical setting considering that
to distinguish between dental anxiety and dental fear if the aim is the child’s response could be different in a clinical situation. They
to accurately study them. Therefore, inclusion of a referred patient almost lack a report on the state of previous dental experience and
sample is not ideal as most referrals are based on DBMP. In addi- the parent’s expectation of the child’s behavior. Most scales only
tion, most of the reviewed studies were comparative or correlational provide an overall estimate of perceived discomfort without under-
which have their intrinsic limitations. No extensive randomized standing the causes of this anxiety/fear. Current scales only include
controlled studies have been conducted among child dental patients the most commonly feared items (injections, extraction) without
considering the differential diagnosis of dental anxiety/fear/phobia considering other common dental procedures which might evoke
and their specific management techniques. As a consequence, it anxiety/fear. In addition, the external validity or generalizability is
is not clear whether treatments were appropriate for the patients’ almost lacking in the existing scales 25.
problem or even the outcomes were related to their characteristics. It has been argued that current scales of dental fear/anxiety
Moreover, longitudinal studies can describe patterns of change and fail to encompass new knowledge of the factors that contribute to
establish the direction and extent of assumed causal relationships as dental anxiety and fear, particularly the role of negative thoughts
well as risk predictors and age effects related to dental fear/anxiety. in the maintenance of dental fear/anxiety. The scales are generally
The principal disadvantage of this design is sample drop-outs over based on the behavioral manifestations of anxiety/fear or have used
time which can result in unrepresentative findings and compromise nonverbal tools such as pictures. In most cases, numerical estimates
a study’s external validity 37. of anxiety/fear scores are obtained by differentially weighing the
specific anxiety/fear behaviors and scoring their frequency. Behav-
Quality of current measures ioral approaches to anxiety/fear measurement may be operationally
Current dental anxiety and ⁄or fear scales are different in nature and objectively defined and a variety of external raters can be
and measure widely varying constructs using different methods. trained to use consistent criteria in assessing children’s distress
Unfortunately, it has been argued that the conceptual and theoret- behaviors 16. However, physiological and cognitive responses have
ical underpinnings of the existing dental anxiety and fear scales are been relatively ignored because children may not have a fully devel-
weak. In addition, each instrument asks different questions, and its oped ability to recognize and interpret the physiological and cogni-
determination of dental anxiety, fear and phobia is based on different tive manifestations of anxiety/fear. It is assumed that these scales
answers 1, 17(Porritt, et al., 2013). Therefore, it is important to address measure anxiety/fear-related stimuli rather than anxiety/fear itself 38.
the more fundamental question of what we are actually measuring In addition, pictorial measures are rapidly administered, reliable
or perhaps not measuring using the current dental fear and anxiety and understandable to a broad age range. However, this technique
scales because any understanding of the nature, consequences and has questionable reliability and validity due to difficulties in the
possible treatment of these conditions is dependent upon the scale interpretation of stories and the standardization of scoring. Only a
that is used to measure the construct 24. weak correlation between drawing a picture and age, physiological
Summarizing the existing literature, we found the apparent lack response and behavior ratings has been establish. Its use is also
of a comprehensive psychometric scale for dental fear, anxiety and limited because an expert is required to carry out the interview and
phobia. Content validity and developmental validity of measures score the tests 39.
of dental anxiety and fear for children is questionable. In addition,
the majority of existing scales do not fulfill the ideal statistical or How to choose an appropriate scale?
clinical criteria which are required for psychometric scales 25. A In order to choose an appropriate measure, the investigator or
number of the measures used to assess children’s dental anxiety clinician should assess the instrument first to see whether the scale
and fear had been developed to assess dental anxiety/fear in adults. is valid and reliable. Appropriateness and acceptability of the instru-
Therefore, psychometric quality of these scales is questionable ment for the study should also be considered. Choice of a particular
particularly when used with children. Although current evidence measure will depend on the purpose of the study and the particular
suggests a considerable overlap between the presentation of anxiety/ aspect of dental fear/anxiety that will be assessed. It will also be
fear among children and adults, clearly there are developmental determined by the type of information the researcher, healthcare
The Journal of Clinical Pediatric Dentistry Volume 41, Number 6/2017 doi 10.17796/1053-4628-41.6.1 407
Barriers and Drawbacks of the Assessment of Dental Fear, Dental Anxiety and Dental Phobia in Children
408 doi 10.17796/1053-4628-41.6.1 The Journal of Clinical Pediatric Dentistry Volume 41, Number 6/2017
Barriers and Drawbacks of the Assessment of Dental Fear, Dental Anxiety and Dental Phobia in Children
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Barriers and Drawbacks of the Assessment of Dental Fear, Dental Anxiety and Dental Phobia in Children
APPENDIX
Number of studies used each scale
Table 1- Characteristics of studies which used different clinical Scale
For dental For dental For dental
measures or cut-offs to discriminate between dental
anxiety fear phobia
anxiety, fear and phobia
Pictorial scales
Test for each construct MCDASF (Modified Child
Reference
Dental fear Dental anxiety Dental phobia Dental Anxiety Scale- 11
Karibe et al. 37 CFSS-DS STAIC-S Face Version)
410 doi 10.17796/1053-4628-41.6.1 The Journal of Clinical Pediatric Dentistry Volume 41, Number 6/2017
Barriers and Drawbacks of the Assessment of Dental Fear, Dental Anxiety and Dental Phobia in Children
The Journal of Clinical Pediatric Dentistry Volume 41, Number 6/2017 doi 10.17796/1053-4628-41.6.1 411
Barriers and Drawbacks of the Assessment of Dental Fear, Dental Anxiety and Dental Phobia in Children
CFSS-DS
High anxiety=38
Anxious> 36
Dental fear≥38
Dental fear≥39
High dental fear or phobia ≥39
Low anxious<32
Dental anxiety>32
Dental anxiety and fear ≥39
High dental fear ≥38
Dental anxiety>32, dental fear>38
dental anxiety≥39
Around 24.5= fear
Borderline anxious >32
32< dental fear
High fear >37
High anxiety >29
MCDASf
High anxiety>22
Severe anxiety ≥26
25-32 = very anxious, 33-40 = extremely anxious
Anxious >19, highly fearful>31
State anxiety > 19, severe phobic disorder > 31
CARS
7= anxiety
4-5= anxiety
MDAS
High anxiety≥19
High dental fear =19–25
Anxiety≥13, phobia >19
High dental fear 19–25
CDAS
Highly anxious≥15
Moderate anxiety: 9–12, high anxiety: 13–14, severe anxiety ≥15
High anxiety≥13
MCDAS
Anxious>19, Highly fearful>31
Dental phobia >31
DFS
Dental anxiety>59
Dental anxiety>60
412 doi 10.17796/1053-4628-41.6.1 The Journal of Clinical Pediatric Dentistry Volume 41, Number 6/2017
Table S1- Data extraction table for included studies
Area
in the
article
assessed
N
(y)
Age
place
Cut off
design
Author
Country
definition
Report by:
Intervention
Test(s) used
differentiated
Waiting room/
fear
Operation room
First experience
Type of treatment
phobia
anxiety
Place of evaluation:
Time of assessment
psychological health
assessment of background
(Honkala 2014) 1 Kuwait 1-a single- 2-high 745 13-15 * Cross School No Yes N/I Child - - - - N/I
(Aminabadi Iran CARS - 100 7-12 * Cross Clinic No No Yes Dentist During pulpotomy Operation - N/I
(Peretz 2013) 8 Israel 1-DAS - 130 7-18 * Cross Clinic No No No Child Before Various Waiting - N/I
2-DFS sectional
(Jaakkola 2013) Finland. Modi- High dental 777 18 * Cross Home Yes No N/I Child - - - - N/I
9
fied Dental fear =19–25 sectional
Anxiety Scale
(Aminabadi Iran 1-CARS 1-(7) 128 4-6 * cross clinic No No Yes 1-Dentist 1-During Injection/ Operation - N/I
2013) 10 2-VSS 2- 2- Dentist 2- Before restoration
3-FRS 3-(6) 3- Dentist 3- During
Barriers and Drawbacks of the Assessment of Dental Fear, Dental Anxiety and Dental Phobia in Children
in the
article
assessed
N
(y)
Age
place
Cut off
design
Author
Country
definition
Report by:
Intervention
Test(s) used
differentiated
Waiting room/
fear
Operation room
First experience
Type of treatment
phobia
anxiety
Place of evaluation:
Time of assessment
psychological health
assessment of background
(Roshan 2012) India Modified - 60 5-7 * RCT Clinic/ No No N/I Dentist Before/ ART Operation - N/I
(Sjogren 2010) Sweden. CFSS-DS Dental 32 7-9 * RCT Clinic No No No Parent Before/ Extraction Waiting - N/I
27
fear≥38 After
(Al-Jundi 2010) Jordan Global Mood - 118 2-12 * Cross Clinic No No No Dentist Before/ General Waiting - N/I
28
Score sectional After anesthesia
Barriers and Drawbacks of the Assessment of Dental Fear, Dental Anxiety and Dental Phobia in Children
in the
article
assessed
N
(y)
Age
place
Cut off
design
Author
Country
definition
Report by:
Intervention
Test(s) used
differentiated
Waiting room/
fear
Operation room
First experience
Type of treatment
phobia
anxiety
Place of evaluation:
Time of assessment
psychological health
assessment of background
(Olumide 2009) UK FIS 50 8-12 * RCT Clinic Yes No N/I Child Before N/I Waiting Leaflet N/I
30
(Tahmassebi UK VPT - 38 3-10 * RCT Clinic No No Yes Child Before/ Injection Operation Wand Yes
(Nuttall 2008) 38 UK Single 3342 5-15 * Cross Home No No N/A Parent - - - - N/I
question sectional
(Versloot 2008) Nether- CFSS-DS on low 128 4-11 * Cross Clinic No No No Parent During Injection N/A - N/I
39
lands. behalf anxious<32 sectional
(Versloot 2008) Canada CFSS on dental 147 4-11 * RCT Clinic No No No Parent - Injection - - N/I
40
behalf anxiety>32
(Lee 2008) 41 Taiwan 1-CFSS-DS 1- 247 2-10 * Cross Clinic Yes Yes No 1-Child 1-Before N/A N/A - Yes
2-CARS 2- 4-5 * sectional 2-Dentist 2-During
(Vika 2008) 42 Norway 1-DFS 1-dental 1385 18 * Cross school N Yes N/A Child - - - - N/I
2-Injection anxiety ≥60 * sectional
Phobia Scale
3- Mutilation
questionnaire
for Blood
injury fear and
phobia
Barriers and Drawbacks of the Assessment of Dental Fear, Dental Anxiety and Dental Phobia in Children
in the
article
assessed
N
(y)
Age
place
Cut off
design
Author
Country
definition
Report by:
Intervention
Test(s) used
differentiated
Waiting room/
fear
Operation room
First experience
Type of treatment
phobia
anxiety
Place of evaluation:
Time of assessment
psychological health
assessment of background
(Kuscu 2008) 43 Turkey 1-CFSS-DS/ 1-dental 41 9-13 * RCT Clinic No No N/A Child Before Injection Operation - Yes
(Leong 2007) 50 UK VPT - 54 2-6 * RCT Clinic No No N /A Child Before/ Extraction Waiting - N/I
After
(Lee 2007) 51 Taiwan CFSS-DS on dental 3597 5-8 * Cross School Yes No N/A Parent - - - - Yes
behalf anxiety≥39 sectional
(Gazal 2007) 52 Syria MCSFS - 201 2-12 RCT Clinic No No No Dentist Before/ General Operation - N/I
After Anesthesia
(Ramos-Jorge Brazil modified VPT - 118 4-5 * Cross Clinic No No Yes Child N/A Examina- - - N/I
2006) 53 sectional tion
(Cohen 2006) 54 USA 1-Children - 44 3-7 * Cross Clinic No No 25 yes 1-Child 1-Before Injec- 1-Opera- Yes
anxiety sectional 2-Parent /During/ tion-resto- tion
in the
article
assessed
N
(y)
Age
place
Cut off
design
Author
Country
definition
Report by:
Intervention
Test(s) used
differentiated
Waiting room/
fear
Operation room
First experience
Type of treatment
phobia
anxiety
Place of evaluation:
Time of assessment
psychological health
assessment of background
(Marwah 2005) India 1-VPT - 40 4-8 * Cross Clinic No No Yes 1-Child 1-Before/ Various - Music N/I
59
2-CARS sectional 2-Dentist After distraction
2-During
(Folayan 2004) Nigeria CFSS-SF - 74 8-13 * Cross Clinic No No N/I child Before / Various Waiting Behavior Yes
69
sectional After manage-
ment
(Wogelius 2003) Denmark CFSS-DS anxiety >38 1493 6-8 * Cross home Yes No No Parent - - - - Yes
70
sectional
(Folayan 2003) Nigeria 1-short form of - 81 8-13 * Cross Clinic No No Yes Child Before - Waiting - Yes
71
DFSS-DS sectional
(McComb 2002) USA Modified - 76 39-71mth * Clinic No No No child Before / various - - N/I
72
CFSS-DS after
(Aitken 2002) 73 USA 1-VPT 45 4-6 * RCT Clinic No No Yes 1-Child 1-Before/ Restor- - Music N/I
2-MCAS 2- high 2-Parent After ative distrac-
anxiety>20) 2- Before/ tion/
After Behavior
Barriers and Drawbacks of the Assessment of Dental Fear, Dental Anxiety and Dental Phobia in Children
in the
article
assessed
N
(y)
Age
place
Cut off
design
Author
Country
definition
Report by:
Intervention
Test(s) used
differentiated
Waiting room/
fear
Operation room
First experience
Type of treatment
phobia
anxiety
Place of evaluation:
Time of assessment
psychological health
assessment of background
(Peretz 2000) 74 Israel 1-DAS - 104 12-18 * Clinic No NoNo Child Before - Waiting - N/I
in the
article
assessed
N
(y)
Age
place
Cut off
design
Author
Country
definition
Report by:
Intervention
Test(s) used
differentiated
Waiting room/
fear
Operation room
First experience
Type of treatment
phobia
anxiety
Place of evaluation:
Time of assessment
psychological health
assessment of background
(Hollis 2015) 88 UK MCDASF - 106 8-16 * Case Clinic No No No Child - - Clinic - N/I
control
(Patel 2015) 89 - MCDASF MCDASF ≥19 132 7-16 * Prospective Clinic No No - Child Before - Dental - N/I
assessment of background
psychological health
N/I
N/I
N/I
N/I
N/I
Intervention
positive
viewing
images
2-ART
-
Place of evaluation:
Waiting room/
school
Home
Operation room
N/I
-
-
examina-
examina-
Type of treatment
Resto-
ration
tion
tion
-
-
Time of assessment
After
After
-
Report by:
Parent
Child
Child
Child
Child
First experience
Yes
No
No
No
no
differentiated
No No
clinic/ No No
School No No
No No
definition
N
school
Home
home
place
clinic
follow-up
sectional
design
Cohort
Cross
study
RCT
Area phobia
assessed
anxiety
in the
*
article fear
Mean age *
*
10 years
Age
(y)
5-17
4-11
6-7
old
:11
N
518
597
322
-
high anxiety
Cut off
-
-
CFSS-DS
CFSS-DS
CFSS-DS
Test(s) used
VPT
VPT
(Freeman 2007) Scotland
Nether-
Turkey
Country
USA
land
(Raadal 2002)
(Topaloglu-Ak
(Guelmann
(ten Berge
Author
2007) 101
2005) 102
2002) 104
100
103
420 doi 10.17796/1053-4628-41.6.1 The Journal of Clinical Pediatric Dentistry Volume 41, Number 6/2017
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